by Dr. Adnan Butt MCPS family medicine, MRCGP [international]

1. IRRITABLE BOWEL
SYNDROME
Dr. Adnan Butt
MCPS family medicine, MRCGP [international]

2. Learning objectives

3. Learning objectives
■ To identify IBS

4. Learning objectives
■ To identify IBS
■ To manage IBS

6. Facts and figures

7. Facts and figures
■ Chronic, relapsing, remitting condition

8. Facts and figures
■ Chronic, relapsing, remitting condition
■ Unknown cause

9. Facts and figures
■ Chronic, relapsing, remitting condition
■ Unknown cause
■ Lifetime prevalence >20%

10. Facts and figures
■ Chronic, relapsing, remitting condition
■ Unknown cause
■ Lifetime prevalence >20%
■ Female > male (2.5:1)

11. Facts and figures
■ Chronic, relapsing, remitting condition
■ Unknown cause
■ Lifetime prevalence >20%
■ Female > male (2.5:1)
■ Any age

12. Facts and figures
■ Chronic, relapsing, remitting condition
■ Unknown cause
■ Lifetime prevalence >20%
■ Female > male (2.5:1)
■ Any age
■ >50% still have symptoms 5 years after treatment !

13. Facts and figures
■Chronic, relapsing, remittingcondition
■ Unknown cause
■ Lifetime prevalence >20%
■ Female > male (2.5:1)
■ Any age
■ >50% still have symptoms 5 years after treatment !

14. Symptoms and Diagnosis

15. Symptoms and Diagnosis
■A, B, C

16. Symptoms and Diagnosis
■ A, B, C
■A= may be relieved by defecation or made worse by eating

17. Symptoms and Diagnosis
■ A, B, C
■ A = may be relieved by defecation or made worse by eating
■B= distention, tension, or hardness

18. Symptoms and Diagnosis
■ A, B, C
■ A = may be relieved by defecation or made worse by eating
■ B = distention, tension, or hardness
■C= passage of mucus, straining, urgency, or incomplete evacuation

19. Associated symptoms
■ Lethargy
■ Nausea
■ Backache
■ Bladder symptoms

20. Differential diagnosis
■ IBD
■ Coeliac disease
■ Colonic carcinoma
■ PID
■ Endometriosis
■ GI infection
■ Thyrotoxicosis

21. Investigations

22. Investigations
■Diagnosis of exclusion

23. Investigations
■ Diagnosis of exclusion
■ Coeliac disease = ?

24. Investigations
■ Diagnosis of exclusion
■ Coeliac disease = ?
■ Thyrotoxicosis = ?

25. Investigations
■ Diagnosis of exclusion
■ Coeliac disease = ?
■ Thyrotoxicosis = ?
■ PID = ?

26. Investigations
■ Diagnosis of exclusion
■ Coeliac disease = ?
■ Thyrotoxicosis = ?
■ PID = ?
■ GI infection = ?

27. Investigations
■ Diagnosis of exclusion
■ Coeliac disease = ?
■ Thyrotoxicosis = ?
■ PID = ?
■ GI infection = ?
■ Colonic cancer = ?

28. Referral

29. Referral
■ Suspicion of cancer

30. Referral
■ Suspicion of cancer
■ Hyperthyroidism

31. Referral
■ Suspicion of cancer
■ Hyperthyroidism
■ Endometriosis

32. Referral
■ Suspicion of cancer
■ Hyperthyroidism
■ Endometriosis
■ Coeliac disease

33. Referral
■ Suspicion of cancer
■ Hyperthyroidism
■ Endometriosis
■ Coeliac disease
■ Patient is unhappy to accept a diagnosis of
IBS, despite explanation

35. Treatment – lifestyle changes

36. Treatment – lifestyle changes
■ Reassurance

37. Treatment – lifestyle changes
■ Reassurance
■ Stress management

38. Treatment – lifestyle changes
■ Reassurance
■ Stress management
■ Exercise

39. Treatment – lifestyle changes
■ Reassurance
■ Stress management
■ Exercise
■ Diet

40. Treatment – lifestyle changes
■ Diet :

41. Treatment – lifestyle changes
■ Diet :
1. Diary

42. Treatment – lifestyle changes
■ Diet :
1. Diary
2. Regular meal timings

43. Treatment – lifestyle changes
■ Diet :
1. Diary
2. Regular meal timings
3. Drink >8 cups of fluids; restrict tea, coffee, alcohol, fizzy drinks

44. Treatment – lifestyle changes
■ Diet :
1. Diary
2. Regular meal timings
3. Drink >8 cups of fluids; restrict tea, coffee, alcohol, fizzy drinks
4. Decrease intake of high fiber foods

45. Treatment – lifestyle changes
■ Diet :
1. Diary
2. Regular meal timings
3. Drink >8 cups of fluids; restrict tea, coffee, alcohol, fizzy drinks
4. Decrease intake of high fiber foods
5. Decrease intake of processed foods

46. Treatment – lifestyle changes
■ Diet :
1. Diary
2. Regular meal timings
3. Drink >8 cups of fluids; restrict tea, coffee, alcohol, fizzy drinks
4. Decrease intake of high fiber foods
5. Decrease intake of processed foods
6. For bloating, consider oats and linseeds

47. Treatment – lifestyle changes
■ Diet :
1. Diary
2. Regular meal timings
3. Drink >8 cups of fluids; restrict tea, coffee, alcohol, fizzy drinks
4. Decrease intake of high fiber foods
5. Decrease intake of processed foods
6. For bloating, consider oats and linseeds
7. For diarrhea, avoid sorbitol

48. Treatment – lifestyle changes
■ Diet :
1. Diary
2. Regular meal timings
3. Drink >8 cups of fluids; restrict tea, coffee, alcohol, fizzy drinks
4. Decrease intake of high fiber foods
5. Decrease intake of processed foods
6. For bloating, consider oats and linseeds
7. For diarrhea, avoid sorbitol
8. For exclusion diet, refer to dietician

50. Treatment – pharmacological

51. Treatment – pharmacological
■ Probiotics – try a 4 week trial

52. Treatment – pharmacological
■ Probiotics – try a 4 week trial
■ Fibre/bulking agents – ispaghula huskVs bran

53. Treatment – pharmacological
■ Probiotics – try a 4 week trial
■ Fibre/bulking agents – ispaghula huskVs bran
■ Antispasmodics

54. Treatment – pharmacological
■ Probiotics – try a 4 week trial
■ Fibre/bulking agents – ispaghula huskVs bran
■ Antispasmodics
■ Antidiarrheal preparation – loperamideVs codeine phosphate

55. Treatment – pharmacological
■ Probiotics – try a 4 week trial
■ Fibre/bulking agents – ispaghula huskVs bran
■ Antispasmodics
■ Antidiarrheal preparation – loperamideVs codeine phosphate
■ Antidepressants –TCAVs SSRI

56. Treatment – pharmacological
■ Probiotics – try a 4 week trial
■ Fibre/bulking agents – ispaghula huskVs bran
■ Antispasmodics
■ Antidiarrheal preparation – loperamideVs codeine phosphate
■ Antidepressants –TCAVs SSRI
■ Psychotherapy – reserve for resistant cases

57. Case study
■ Mr. X is a 33 year old engineer. He comes to you complaining of changes in bowel
habits, mostly loose stools for the last 8 months. He tells you that his belly remains
tight most of the time since ages and often causes pain. He has never understood
what causes this problem.
■ Which of the following would make diagnosis of IBS very likely?

58. Case study
■ Mr. X is a 33 year old engineer. He comes to you complaining of changes in bowel
habits, mostly loose stools for the last 8 months. He tells you that his belly remains
tight most of the time since ages and often causes pain. He has never understood
what causes this problem.
■ Which of the following would make diagnosis of IBS very likely?
■ A) age
■ B) loose stools
■ C) tight belly
■ D) belly pain

59. Case study
■ Correct answer = D – belly/abdominal pain

61. Take home message
■ Don’t shy away from investigations in IBS
■ Proper counselling of patients

63. References
■ Oxford Handbook of GP (4th edition)
■ Current MDT (2017)