Professor Ingvar Bjarnason MD, MSc, FRCPath, FRCP, DSc is a consultant physician and gastroenterologist at Bupa Cromwell Hospital and Professor of Digestive Diseases at King’s College Hospital.
Abdominal bloating, abdominal pain, rumbling or a gurgling noise (borborygmus), a change in bowel habits, constipation and or diarrhoea, incomplete evacuation, post-prandial urgency to defaecate, tiredness, lack of initiative, pelvic floor pain, food intolerances, etc. Do these symptoms sound familiar? If so, is your first thought whether this represents IBS, inflammatory bowel or coeliac disease, or some more sinister gastrointestinal pathology? Almost certainly!
IBS is one of the most common disorders of the digestive system in the UK. About one in six people have occasional symptoms of the disease. Women are more likely to get IBS than men, as well as to have more severe symptoms.
We are all familiar with the dilemma of how aggressively and thoroughly we should be investigating patients with these symptoms. No one wants to miss a significant pathology such as colitis or colorectal cancer that may present with similar symptoms, but neither do we want to subject patients to unnecessary, invasive and sometimes painful investigations, which by themselves carry risks of complications. However, there have been significant advances in the non-invasive and positive diagnosis of IBS and certainly by taking a co-ordinated approach to medical, dietary and lifestyle-psychiatric treatments or changes, we are now realistically approaching a goal of getting IBS patients 70 percent better.
Making an accurate diagnosis of IBS
Diagnostic symptomatology can be assessed by the ROME III criteria, which stipulates that given a patient with recurrent abdominal pain or discomfort at least three days a month in the last three months, associated with two or more of the following:
- improvement with defaecation
- onset associated with a change in frequency of stool
- onset associated with a change in form (appearance) of stool
– and no red flag symptoms (PR bleeding, anaemia, significant weight loss, etc) – then there is a good probability of the patient having IBS. However, the certainty of the IBS diagnosis can be improved four-fold with some simple non-invasive investigations that are now available at Bupa Cromwell Hospital. These include:
- intestinal absorption-permeability test (abnormal in most small bowel disease)
- faecal calprotectin, which is a uniquely sensitive measure for intestinal inflammation and virtually raised in all patients with untreated IBD and most patients with colonic disease
- quantitative intestinal disaccharidase test (establishes lactase or sucrase deficiency and predicts the response to dietary treatment)
- wireless capsule enteroscopy
Given a positive ROME III symptom score and normal faecal calprotectin, ± intestinal permeability, ± capsule enteroscopy there is almost no other possible diagnosis than IBS, especially in patients under 50 years of age. By employing these criteria most patients do not require colonoscopy, CT colonography, CT or MRI-enterography or duodenal biopsy.
When to refer patients
IBS is a lifelong disease, frequently associated with extra-intestinal symptoms (fibromyalgia, interstitial cystitis, menstrual irregularities, sexual dysfunction, headaches, hyperventilation, tachycardia, anxiety and depression, etc.) each of which may otherwise require symptomatic treatment. Given that an integrated approach to IBS treatment by enthusiasts yields a much better outcome, it is better to refer to the specialist sooner rather than later, so that a comprehensive treatment schedule can be formulated. An important consideration is that endometriosis can mask under the umbrella of IBS so a close collaboration with a gynaecologist is essential, especially for patients with pelvic pain.
Modern approach to IBS treatment
The mainstay of IBS treatments is changing rapidly. Having made the diagnosis from the above tests it is important to address the principal symptoms and their possible treatments.
The conventional treatments of bulking agents (for constipation), opioid receptor antagonists (for diarrhoea), antispasmodics (mebeverine and buscopan, peppermint preparations) and antidepressants (for pain) are well tested and largely ineffective and certainly not evidence-proven. As a result many patients seek alternative treatments, most of which are equally unproven.
The first treatment is the consultation where the specific and most problematic symptoms are elucidated and discussed. Gynaecologic referral may be made, depending on symptoms and it is useful to exclude endometriosis in women as investigation and treatments may differ significantly.
Because of its location Bupa Cromwell Hospital attracts a number of very driven professional individuals that are under undue stress in their jobs. My first consultation therefore always explores underlying lifestyle issues and anxieties about the symptoms. With the investigational results to hand, I try to reassure the patient that the symptoms are functional. A minority of patients then express a wish to proceed to invasive investigation, such as gastroscopy. If endoscopy/colonoscopy/ERCP, etc, is required then the Cromwell provides these services quickly and at a level par excellence.
Psychiatric and lifestyle issues
Anxiety and worry (at times approaching panic attacks), sleeping disturbances and lifestyle issues are best addressed by a dedicated psychiatrist who more often than not manages to treat these symptoms by one of the various forms of CBT and by other non-pharmacologic measures (depending on symptoms and severity).
It is important for a dietitian to assess specific food sensitivities. Many patients have already identified common foodstuff such as tomatoes and cucumber, but there are many others causing abdominal pain, diarrhoea, etc. Many place these symptoms in the context of “food allergy” which is actually a very rare occurrence in adults. There are extensive panels of specific serologic antibodies for a wide variety of foodstuff available but their impact on clinical decision-making is still being evaluated.
The most common offending food contributing to IBS symptoms, especially abdominal bloating, is wheat. A consultation with a dietitian with an information sheet on how to avoid dietary wheat is helpful for many patients with bloating (a very common and problematic symptom in women) and is relatively simple to adhere to.
More recently a low FODMAP (stands for Fermentable, Oligorong>ligo-, Di- and Mono-saccharidesccharides and Polyolsng>olyols) diet is used to describe a regime largely excluding fermentable short-chain carbohydrates. The advantage of this treatment is that it is not particularly restrictive in the amount of food that the patients can eat and after three months of adherence patients can often successfully re-introduce the sugars to their diet without detriment to symptoms. A low FODMAP diet has been shown to be particularly effective for bloating. This diet has undergone (open-labelled) trials and shows great promise. It requires a 45-60 minute consultation with a specialist dietitian, again available at Bupa Cromwell Hospital.
The Candida diet (starch, wheat and mould-free) is reserved for the extremely rare patient and few can adhere to this diet in the long-term.
Of the hundreds of probiotics that are available over the counter only a few have undergone rigorous clinical trials. All of the probiotics differ in their bacterial composition and the results from a trial using one of these cannot be extrapolated over to the other as the outcomes depend on the amount of bacterial principal delivered, their viability and their specific strains. The probiotic VSL-3 has shown some promise in patients with IBS although its main use may be in pouchitis.
However a probiotic called Symprove (a liquid mixture of live bacteria) has just shown itself to be significantly better in reducing IBS symptom severity in a double-blind, placebo-controlled trial. The main effect is on abdominal pain and bowel habits.
Bupa Cromwell Hospital is in a unique position as it provides all of the non-invasive diagnostic tests needed to confidently diagnose IBS, without resorting to colonoscopy or imaging procedures other than ultrasound in the vast majority of cases. Furthermore, by taking an integrated and individualised approach to the treatment of IBS through bringing together a dedicated team of experts, we are achieving increasingly greater symptom relief in patients with IBS with great potential for improvement in their quality of life.