Irritable bowel syndrome in adults Implementing NICE guidance

Irritable bowel syndrome in adults Implementing NICE guidance 2008 NICE clinical guideline 61

What this presentation covers Background Key priorities for implementation Costs and savings Discussion Find out more

Background Irritable bowel syndrome (IBS) has a prevalence of 10 -20% in the general population It is a chronic, relapsing and often life-long disorder The people most commonly affected are those aged 20– 30 years It is twice as common in women as in men

Initial assessment Consider assessment for IBS if any of these symptoms have been present for at least 6 months • Abdominal pain or discomfort • Bloating • Change in bowel habit

Initial assessment: ‘red flag’ indicators Refer to secondary care if any of these indicators present Ask • Unintentional and unexplained weight loss • Rectal bleeding • A family history of bowel or ovarian cancer • Bowel habit change for > 6 weeks in person over 60 years Assess/examine • Anaemia • Abdominal masses • Rectal masses • Inflammatory markers for inflammatory bowel disease

Initial assessment: establishing the diagnosis Consider IBS diagnosis only if the person has abdominal pain that is relieved by defaecation or associated with altered bowel frequency or stool form, and at least two symptoms from: • altered stool passage • abdominal bloating, distension, tension or hardness • symptoms made worse by eating • passage of mucus

Initial assessment: establishing the diagnosis Take the following factors into account to facilitate effective consultation • People should be asked open questions to establish symptoms, for example, ‘tell me about how your symptoms affect aspects of your daily life, such as leaving the house’ • Healthcare professionals should be sensitive to the cultural, ethnic and communication needs of people for whom English is not a first language or who may have cognitive and/or behavioural problems or disabilities

Bristol Stool Form Scale Reproduced by kind permission of Dr K W Heaton, Reader in Medicine at the University of Bristol. 2000 Norgine Ltd.

Diagnostic tests In people who meet the IBS diagnostic criteria, the following tests should be undertaken to exclude other diagnoses: • full blood count (FBC) • erythrocyte sedimentation rate (ESR) or plasma viscosity • c-reactive protein (CRP) • antibody testing for coeliac disease (endomysial antibodies [EMA] or tissue transglutaminase [TTG])

Diagnostic tests The following tests are not necessary to confirm a diagnosis where IBS diagnostic criteria are met: • ultrasound • rigid/flexible sigmoidoscopy • colonoscopy; barium enema • thyroid function test • faecal ova and parasite test • faecal occult blood test • hydrogen breath test (for lactose intolerance and bacterial overgrowth).

Clinical management of IBS: dietary and lifestyle advice People with IBS should be given information that explains the importance of self-help in effectively managing their IBS

Clinical management of IBS: dietary and lifestyle advice Healthcare professionals should review the fibre intake of people with IBS, adjusting (usually reducing) it while monitoring the effect on symptoms If symptoms persist after following lifestyle/dietary advice, consider referral to a dietitian

Clinical management of IBS: pharmacological therapy Advise people with IBS how to adjust their doses of laxative or antimotility agent Healthcare professionals should consider low-dose tricyclic antidepressants (TCAs) as second-line treatment, recommended only for their analgesic effect

Costs per 100, 000 population Recommendations with significant costs Reduction in unnecessary diagnostic tests Costs (£ per year) – 17, 200 Increased referral to dietitian 2, 600 Increased prescribing of low-dose antidepressants 31, 600 Increased referral to psychological interventions 3, 500 Estimated net cost of implementation 20, 500

Discussion What does our primary care IBS pathway look like? Where do our local protocols need updating to reflect all the recommendations in the guideline? How can we manage the expectations of clinicians and patients about the use of tests to diagnose IBS? When should psychological interventions be considered? Are we offering ineffective treatments for IBS? For example, reflexology, acupuncture.

Find out more Visit www. nice. org. uk/cg 061 for: • • Other guideline formats Costing report and template Audit support Algorithm for diagnosis and management of IBS within primary care • IBS dietary information resource