NICE report

For UK healthcare professionals only

In February 2008, the National Institute for Health and Clinical Excellence (NICE) published updated guidance on the diagnosis and management of irritable bowel syndrome (IBS) in primary care. The guideline provides advice on the care of patients over the age of 18 years, outlining the support, treatment and advice services that they should be offered. It also looks at when patients should be referred for specialist evaluation. A few of the main recommendations are summarized here. Please read the full guideline for further details.

Diagnosis of IBS

  • A diagnosis of IBS should be considered if a patient reports having abdominal pain or discomfort, bloating or a change in bowel habit for at least 6 months.
  • Weight loss, rectal bleeding, family history of bowel or ovarian cancer, and change in bowel habit to looser/more frequent stools in a person over 60 years are “red flags” warranting further investigation.
  • Patients should be given information about IBS that explains the importance of self-help (e.g. general lifestyle, physical activity, diet, symptom-targeted medication).
  • The importance of making a positive diagnosis is central to the NICE guidance and recommendations are made on the diagnostic tests that can help make a differential diagnosis.

Treatment of IBS

  • The cause of IBS has not been established and treatment is targeted at symptom control.
  • Symptoms vary among individuals (and even in the same individual over time) and therefore a combination of different treatments may be necessary to achieve effective relief.
  • Clinical management includes dietary and lifestyle advice.

A review of the patient’s fibre intake is important, as is encouraging the ingestion of soluble (e.g. oats) over insoluble (e.g. bran) fibre.

  • Decisions about pharmacological management should be based on the nature and severity of symptoms.

The choice of single or combination medication is determined by the predominant symptom/s. Antispasmodic agents should be considered and taken alongside dietary and lifestyle advice.

  • Laxatives (not lactulose) and anti-diarrhoeal agents (loperamide) may be used.

Patients should be advised on how to adjust the doses to achieve the best clinical response.

  • Low-dose tricylic antidepressants (TCAs) should be reserved for second-line treatment if antispasmodics, laxatives or loperamide have not helped.

Selective serotonin reuptake inhibitors should only be considered if TCAs have proven ineffective.

  • Psychological therapies should be considered, including cognitive behavioural therapy and hypnotherapy.

The use of acupuncture and reflexology should not be encouraged.

Referral and follow-up

  • The extent of follow-up should be agreed in partnership with the patient and be part of the annual review.
  • Any red flag symptoms emerging should prompt further investigation and, if necessary, referral to secondary care.

Reference

National Institute for Health and Clinical Excellence (NICE). Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care. Clinical guideline CG61. London: NICE (February 2008). Click here to go to the NICE guidance on IBS.