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What is Irritable Bowel Syndrome

IBS is a syndrome of abdominal symptoms for which no organic cause can be found. It is thought to be due to an abnormal brain-gut axis


What will you find in a history of Irritable Bowel Syndrome

Diagnostic criteria:
Recurrent abdominal pain S (Commonly LLQ) T(Early morning rush) A(Worse on eating) R(Defecation), for at least 1 day of each week, lasting more than 3 months, associated with 2 of:
Relief on defecation
Altered stool form - Constipation and diarrhoea (Can be either and may alternate)
Altered bowel frequency – Increased or decreased frequency, can alternate. Associated with urgency, tenesmus

Other Symptoms not diagnostic - Abdominal bloating/distension, Mucous in stool, Symptoms worsen with stress, gastroenteritis or menstruation, “Early morning rush”

Risk Factors:

Specific Questions to ask:
Features that make IBS less likely and require referral - Weight Loss, Nocturnal Symptoms, Rectal Bleeding, Worsening symptoms, Fever, Steatorrhea, Age > 60, Family history of bowel or ovarian cancer, Anaemia, raised inflammatory markers
Assess for risk factors – Stress, Onset after a gastroenteritis

Colorectal cancer – Weight loss, constitutional symptoms
Crohns or UC – Systemic response with raised inflammatory markers
Coeliac Disease – May president similarly, exclude with anti-tissue transglutaminase
Gastroenteritis – Inflammatory response, exclude with stool cultures if signs like fever etc
Diverticular Disease
Thyroid Abnormalities – May have other symptoms of thyroid problems, exclude with bloods
Anxiety – May precipitate IBS
Ovarian Cancer/PID – Abdominal discomfort and bloating, may have urinary or vaginal symptoms, rule out with Ca-125


What will you find on examination of IBS?

Examination: Most commonly a completely normal examination
Possible mild tenderness in lower quadrants (commonly LLQ)


What investigations will you order in suspected Irritable Bowel Syndrome

Investigations: There is no diagnostic test for IBS, so investigations are used to rule out differentials.
Stool cultures (send multiple samples)– Only if infection suspected, to rule out infective causes.
Test any stool sent for C. Diff

FBC – to assess any raised WBC (indicating infection) or for any anaemias (suggesting blood loss/malabsorption)
CRP/ESR - Should be normal, if raised think something else
Coeliac Screen - To rule out coeliac
Ca-125 – to rule out ovarian cancer
TSH - If other features of hyper/hypothyroidism

Colonoscopy – Only If red flags present

Special Tests:
Faecal calprotectin – to rule out IBD
Faecal Occult blood – If cancer suspected
Can try lactose free diet for 1 week with lactase supplement, to see if the patient is lactose intolerant


What is the treatment of irritable Bowel Syndrome

Regular meals
Lots of fluid
Reduced alcohol and fizzy drinks
Ensure a heathy diet
Adjust fibre foods – more in constipation, less in diarrhoea
If diet plays key role in symptoms, consider dietician referral
Consider CBT as can have big psychological impact

Medical: There is no cure, so medication is used for symptom management
Constipation - Consider ispaghula (laxative) after attempting dietary changes
Diarrhoea - Consider loperamide (anti diarrhoeal) after attempting dietary changes
Bloating - Mebeverine (Antispasmodic)
Patients may require antidepressants if it is having a big effect on their life