The National Institute for Health and Clinical Excellence (NICE) has released new guidelines for the diagnosis and management of Irritable Bowel Syndrome that for the first time emphasize proactive diagnosis.
Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders in developed countries with prevalence estimated at between 10% and 20%. Currently the diagnosis of IBS is based on the 'Rome III' diagnostic criteria. These criteria state that in order for a diagnosis of IBS to be given a patient must satisfy the following:
At least 3 months, with onset at least 6 months previously, of recurrent abdominal pain or discomfort associated with 2 or more of the following features:
- It is relieved with defecation, and/or
- Onset is associated with a change in frequency of stool, and/or
- Onset is associated with a change in form (appearance) of stool.
Due to the general nature of these symptoms (which can occur in numerous other conditions) IBS is often only diagnosed after a lengthy process of elimination during which the patient may undergo a number of unnecesary and often invasive tests to rule out other diseases.
The new guidelines from NICE, the independent organisation which provides guidance on the promotion of good health and the prevention and treatment of ill health in the UK, seek to address this situation with clear guidelines on how to rule out other diseases in the simplest way and make a positive diagnosis of IBS based on this and the patient's symptoms.
To this end it is recommended that patients who meet the Rome III criteria have blood taken and looked at for full blood count (FBC), erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), and antibodies used to diagnose c(o)eliac disease; endomysial antibodies (EMA) and tissue transglutaminase (TTG). As well as celiac disease, these markers are enough to rule out the presence of the level of inflammation which would be present in inflammatory bowel disease (IBD).
The inclusion of celiac disease testing will be welcomed by many as those with this condtion have often been misdiagnosed with IBS in the past due to lack of routine screening for antibodies. If patients test positive for EMA and/or TTG they must remove all sources of gluten from their diet but can expect rapid improvement in their condition.
The guidelines also recommend that certain tests are NOT needed to rule out other conditions and make the diagnosis of IBS. These tests include the more invasive, time-consuming and expensive such as colonoscopy, sigmoidoscopy, and ultrasound.
The guidelines emphasise the need to make a diagnosis as soon as possible, identify symptoms that may require a quick referrel to a specialist, and develop a long-term partnership with the patient to maximise the chances of successful management. They also include the need to make patients aware of the large role that self-help strategies can play in successfully managing IBS
In terms of guidelines on treatment NICE conducted an evaluation of current evidence and produced recommendations for the management of IBS. The recommendations include dietary modification with an emphasis on reducing irritants such as fizzy drinks and coffee, increasing water intake, reducing insoluble fibre intake (e.g. bran) which can irritate the intestinal lining, and making sure to eat regular meals and actually sitting down and taking time to eat rather than eating on the move.
If these dietary guidelines don't ease the patient's symptoms then it is recommended that they be referred to a dietician who can work with the patient on excluding specific foods which may be causing a problem. This is in line with research which shows that IBS symptoms are often exacerbated by specific foods with the most common including wheat and dairy products.
Guidelines on medication remain similar to those used now and include the use of antispasmodics, antimotility drugs (for diarrhea) and laxatives (for constipation). In the event that these medications don't bring benefit then low-dose antidepressants in the tricyclic and SSRI classes are advised.
Recommendations that will be welcomed by many include techniques for stress reduction including hypnotherapy and cognitive behavioural therapy (CBT). It is well known that stress exacerbates IBS symptoms due to the strong gut-brain connection so these interventions can be very beneficial.
On the back of a number of studies showing beneficial results with probiotics the new NICE guidelines suggest if an IBS patient wants to try them then this should not be discouraged.
When it comes to complementary and alternative medicine (CAM) treatments NICE looked at acupuncture and reflexology and decided there was not enough evidence to recommend their use. This may come as a surprise to many patients who have derived benefit from these and other CAM therapies. Herbal medicine faired a little better with NICE concluding that some herbal remedies, from both Western and Traditional Chinese Medicine, may be effective treatments.
The NICE guidelines are published in a document called 'Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care'.
To read the full document and summaries of the main points visit the NICE website.
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