Irritable Bowel Syndrome IBS

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Irritable Bowel Syndrome (IBS)

• Dietary Management
• Faten Dekki

2
Topics

• Prevalence, Symptoms, Criteria
• Causes
• Management and Treatment

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Prevalence

• Affects up to 20 of Western Populations
• Most Commonly 20 to 30 Year Olds
• Twice as Common in Women as in Men
• Accounts for up to a Third of Referrals to a
  Gastroenterologist and 12 of GP Visits
• 11-13 Adults Present with IBS, But Estimated
  that Only 25 of Those with the Condition Seek
  Help

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Symptoms

• According to NICE Guidelines
• Abdominal Pain or Discomfort
• Bloating
• Change in Bowel Habit
• But Some Overlap with Other Disorders
• Red Flag Indicators

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Red Flag

• Alarming Features Include
• Unintentional weight loss
• Rectal bleeding
• Family history of bowel or ovarian cancer
• Bowel habit change gt 6 weeks in over 60s
• Anaemia, abdominal/rectal masses, IBD
• Symptoms Must Be Urgently Investigated First
• Possible Indicators of e.g. Inflammatory Bowel
  Disease, Colorectal Carcinoma

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Rome Diagnostic Criteria

• Abdominal Pain or Discomfort that is either
  Relieved by Defecation or Associated with Altered
  Bowel Frequency or Stool Form
• and
• Two or More of the Following
• Altered stool frequency, form, or passage
• Abdominal bloating or feeling of distension
• Symptoms made worse by eating
• Passage of mucus

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Diagnostic Tests

• Diagnoses to Exclude First
• FBC (Full Blood Count)
• ESR (Erythrocyte Sedimentation Rate)
• CRP (C-Reactive Protein)
• EMA (Endomysial Antibodies) for Coeliac Disease

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Possible Causal Contributors (1)

• Exact Cause Remains Unknown
• No Known Structural or Anatomical Explanation
• Several Mechanisms Have Been Proposed
• No single mechanism

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Possible Causal Contributors (2)

• Altered bowel motility
• Visceral hypersensitivity
• Psychological factors
• Imbalanced neurotransmitters
• Altered intestinal flora
• Increased cytokine production
• Poor general diet/balance of fibre
• Large consumption of irritants
• Food Intolerance
• Genetic/psychological

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Management of IBS

• No Universally Agreed Approach
• After Diagnosis, Treatment May Combine
• Treatment of GI Symptoms
• Medication
• Dietary Treatment
• Treatment of Psychological Symptoms
• Coping with stress, reassurance
• Medication for anxiety and depression

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Management of IBS

• Oxford Approach
• Step 1 (GP)
• Lifestyle
• Step 2 (GP)
• Adjust Diet According to Symptoms
• Step 3 (Dietitian)
• Consult Dietitian
• Exclusion Diet (Dietitian) (Step 4)

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Step 1 - Management of IBS

• Assess Lifestyle
• Skipping meals
• Eating in a hurry
• Eating ready meals and take-aways
• Tea/coffee consumption
• Exercise
• Recommend Lifestyle Change
• Diet
• Exercise

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Step 2 - Management of IBS

• Adjust Diet According to Symptoms
• Reduction in some foods
• Regular intake of other foods

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Step 3 Management of IBS

• Meal Pattern, Emotional State when Eating,
  Nutritional Content
• Fibre Content
• Resistant Starch
• Caffeine Tea/Coffee/Fizzy Drinks
• Sorbitol and Fructose

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Step 3 - Other Dietary Components

• Probiotics
• Continuing research
• Dose and specific strain are important factors
• Four weeks considered minimum intervention
• Alcohol
• Moderation
• Linseeds
• Useful in constipation, alternating constipation
  and diarrhoea, wind and bloating

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Exclusion diets

• Excludes dairy, wheat, corn, yeast, processed
  food
• Includes rice and soya substitutes, meat, chicken
  fish, non-citrus fruit, and vegetables
• Basic diet followed for 2 weeks
• Patients keep detailed food and symptom record
• If no improvement in 2 weeks, patient returns to
  normal diet

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Exclusion diets

• If Symptom Relief Occurs, Foods Slowly
  Reintroduced
• One at a time
• 2 day intervals
• Moderate portions
• If Symptoms Recur after Reintroduction, Food
  Excluded until Symptoms Stabilised
• Reintroduction of other Foods Continues

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Summary

• Patient presents to GP with typical symptoms
• Eliminate organic causes (red flags)
• Investigate other causes further
• Diagnose IBS
• GP advises steps 1 and 2
• GP refers to dietitian (step 3)
• Exclusion diet (if needed)

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Resources and References

• NICE Guideline 61- released in 2008
• www.nice.org.uk/nicemedia/pdf/IBSFullGuideline.pdf
  
• JAMA, October 15, 2008 Vol 300, No. 15
• Gut 2007 561770-1798. doi 10.1136/gut.2007.1194
  46
• BMJ 2008337a2313 doi10.1136/bmj.a2313
• N ENGL J MED 20083581692-9