Pulse September 2017
Irri
tab
le b
ow
el s
yn
dro
me
Pro
fess
or
Ing
var
Bja
rnaso
n, c
on
sult
an
t g
ast
roen
tero
log
ist,
off
ers
his
qu
ick g
uid
e t
o d
iag
no
sin
g a
nd
man
ag
ing
IBS
Fe
atu
res:
Recu
rren
t ab
do
min
al p
ain
or
dis
co
mfo
rt a
t le
ast
th
ree d
ays
a m
on
th in
th
e p
ast
th
ree m
on
ths
plu
s tw
o o
f th
e fo
llow
ing
:•
Imp
rovem
en
t w
ith
defa
ecati
on
• C
han
ge in
fre
qu
en
cy o
f b
ow
el o
pen
ing
s •
Ch
an
ge in
fo
rm o
r ap
peara
nce o
f st
oo
l (d
iarr
ho
ea-c
on
stip
ati
on
)
Th
ere
are
vari
ou
s su
b-c
ate
go
ries
of IB
S a
sso
cia
ted
wit
h h
yp
erm
ob
ility
sy
nd
rom
es
(Eh
lers
Dan
los)
, IB
S d
evelo
pin
g fo
llow
ing
fo
od
infe
cti
on
syn
dro
mes
(po
st-i
nfe
cti
ou
s IB
S)
etc
. So
me p
ati
en
ts, e
specia
lly t
ho
se o
n s
tati
ns
an
d
retr
ovir
als
, ass
ocia
te t
heir
IBS
-lik
e s
ym
pto
ms
wit
h t
reatm
en
t. A
t p
rese
nt,
tr
eatm
en
t fo
r th
e s
ym
pto
ms
exp
eri
en
ced
acco
rdin
g t
o t
he ‘c
au
se’ o
f IB
S d
o n
ot
dif
fer
an
d a
re t
ailo
red
, ap
art
fro
m w
ith
dra
win
g m
ed
icati
on
th
at
may c
on
trib
ute
to
sym
pto
ms.
Dif
fere
nti
al d
iag
no
sis
• S
ho
rt h
isto
ry: f
oo
d in
fecti
on
s, d
ivert
icu
litis
, ap
pen
dic
itis
, salp
ing
itis
• Lo
ng
er
his
tory
: in
flam
mato
ry b
ow
el d
isease
, div
ert
icu
lar
dis
ease
, co
lore
cta
l can
cer, d
iab
eti
c d
iarr
ho
ea (
inclu
din
g d
iarr
ho
ea d
ue t
o m
etf
orm
in),
sid
e-e
ffects
of m
ed
icati
on
, pan
cre
ati
c in
suffi
cie
ncy,
co
elia
c d
iseae, e
nd
om
etr
iosi
s, p
eri
od
p
ain
s etc
.•
Bew
are
of any p
ati
en
t w
ith
‘red
flag
sym
pto
ms’
(p
r b
leed
ing
, weig
ht
loss
, ab
no
rmal s
cre
en
ing
test
s etc
.). I
BS
can
mim
ic a
ny g
ast
roin
test
inal d
isease
Ass
oc
iate
d s
ym
pto
ms
– th
ese
ma
y b
e c
on
tin
uo
us
or
inte
rmit
ten
t
Intestinal
• A
bd
om
inal b
loati
ng
or
dis
ten
sio
n•
Feelin
g o
f in
co
mp
lete
evacu
ati
on
of st
oo
ls•
Mu
cu
s in
sto
ol
• S
pecifi
c fo
od
into
lera
nces
Extra-intestinal
• H
ead
ach
es
• M
usc
ula
r co
mp
lain
ts, i
nclu
din
g fi
bro
myalg
ia•
No
n-i
nfl
am
mato
ry jo
int
an
d b
ack p
ain
• M
en
stru
al i
rreg
ula
riti
es
• U
rin
ary
tra
ct
sym
pto
ms,
pain
on
vo
idin
g, i
ncre
ase
d fre
qu
en
cy o
f vo
idin
g•
Sexu
al d
ysf
un
cti
on
• T
ired
ness
Inv
est
iga
tio
ns
• In
vasi
ve in
vest
igati
on
s are
usu
ally
un
necess
ary
befo
re s
tart
ing
tre
atm
en
t in
p
rim
ary
care
, pro
vid
ed
th
at:
• F
ull
blo
od
co
un
t is
no
rmal
• B
asi
c b
ioch
em
istr
y, in
clu
din
g C
RP
an
d E
SR
, is
no
rmal
• F
aecal c
alp
rote
cti
n is
no
rmal
• S
too
l mic
rob
iolo
gy m
icro
sco
py a
nd
cu
ltu
res
may b
e in
dic
ate
d
• S
eru
m t
ran
sglu
tam
inase
sh
ou
ld b
e u
nd
ert
ake
n fo
r all
pati
en
ts
NB
Th
ese
test
s sh
ou
ld b
e n
orm
al i
n IB
S, b
ut
there
are
many r
easo
ns
why t
est
resu
lts
are
so
mew
hat
ab
no
rmal:
1 E
SR
an
d C
RP
are
no
t G
I sp
ecifi
c.
2 A
calp
rote
cti
n v
alu
e le
ss t
han
20
0 (
no
rmal l
ess
th
an
60
) d
oes
no
t au
tom
ati
cally
req
uir
e in
vasi
ve in
vest
igati
on
– 15
% o
f p
ati
en
ts w
ith
IBS
have
slig
htl
y rais
ed
calp
rote
cti
ns
Sept 2017 IBS pull-out flowchart_v3Y.indd 4 23/08/2017 19:51
Pulse September 2017
This Pulse chart has been commissioned and produced completely indepenently of any commercial or outside influence
Re
ferr
al t
o s
pe
cia
list
ga
stro
en
tero
log
y c
en
ters
• B
ear
in m
ind
th
at
mo
st g
ast
roen
tero
log
ists
co
nsi
der
that
man
ag
em
en
t o
f IB
S
sho
uld
be G
P-l
ed
wit
hin
pri
mary
care
• G
ast
roen
tero
log
ists
are
hap
py t
o in
vest
igate
pati
en
ts w
ith
IBS
bu
t o
nly
a few
h
osp
itals
have d
ed
icate
d IB
S t
reatm
en
t clin
ics.
• T
he m
ost
severe
ly a
ffecte
d p
ati
en
ts w
ith
IBS
may b
en
efi
t fr
om
refe
rral t
o t
hese
d
ed
icate
d c
linic
s
Co
nv
en
tio
na
lL
axati
ves
(fib
re, o
smo
tic a
gen
ts,
stim
ula
nts
, etc
.), c
on
stip
an
ts
(lo
pera
mid
e, c
od
ein
e p
ho
sph
ate
, etc
.),
an
tisp
asm
oti
cs
(meb
everi
ne,
bu
sco
pan
), p
ep
perm
int,
am
itri
pty
line
or
oth
er
an
tid
ep
ress
an
ts, a
nxio
lyti
cs
Mo
de
rn d
ay
– m
ult
ifa
cto
ria
l ap
pro
ac
hD
ieta
ry a
dv
ice –
co
nsi
der
lacto
se fre
e d
iet,
glu
ten
fre
e d
iet,
low
FO
DM
AP, e
limin
ati
on
die
t w
ith
re-i
ntr
od
ucti
on
of fo
od
s.•
Lo
w F
OD
MA
PS
an
d a
wh
eat
free d
iet
help
mo
stly
in p
ati
en
ts w
ith
blo
ati
ng
an
d d
iarr
ho
ea
• D
air
y fre
e d
iet
is n
ot
ind
icate
d fo
r IB
S p
ati
en
ts w
ith
co
nst
ipati
on
, bu
t m
igh
t h
elp
dia
rrh
oea a
nd
blo
ati
ng
Pro
bio
tics
– S
ym
pro
ve, A
lign
, VS
L-3
(u
np
roven
effi
cacy in
IBS
).•
Pro
bio
tics
help
wit
h a
bd
om
inal p
ain
an
d d
iarr
ho
ea/c
on
stip
ati
on
• D
iffe
ren
t ty
pes
of p
rob
ioti
cs
have d
iffe
ren
t b
en
efi
ts a
nd
need
to
be t
ailo
red
to
sym
pto
ms
Psy
chia
tric
an
xie
ty/s
tre
ss –
red
ucti
on
, lifest
yle
man
ag
em
en
t b
y C
BT
• R
eco
mm
en
ded
(N
HS
) n
um
ber
of C
BT
sess
ion
s is
10
, alt
ho
ug
h m
ost
IBS
pati
en
ts w
ith
mo
dera
tely
severe
an
xie
ty w
ill
ach
ieve m
axim
um
ben
efi
t fr
om
20
-40
sess
ion
sC
om
mo
n s
en
se –
eat
reg
ula
rly,
eat
slo
wly
, take
exe
rcis
e, m
ain
tain
hig
h fl
uid
inta
ke, c
ut
do
wn
on
alc
oh
ol,
co
ffee a
nd
tea.
Fo
llo
w u
p•
Revie
w y
earl
y t
o a
ssess
:•
Lif
est
yle
issu
es
– st
ress
, an
xie
ty, e
tc.
• E
nco
ura
ge m
od
era
tio
n o
f caff
ein
e a
nd
alc
oh
ol i
nta
ke, s
mo
kin
g, e
tc.
• C
on
sid
er
rep
eati
ng
calp
rote
cti
n t
est
fo
r re
ass
ura
nce in
th
e v
ery
an
xio
us
pati
en
ts c
on
cern
ed
ab
ou
t n
ew
sym
pto
ms
– d
o n
ot
get
overe
xcit
ed
ab
ou
t m
ildly
ele
vate
d le
vels
of 5
0-2
00
mcg
/g
• S
up
ple
men
tary
tre
atm
en
t fo
r extr
a-i
nte
stin
al c
om
pla
ints
• D
irect
pati
en
ts t
o IB
S s
up
po
rt g
rou
ps
that
are
access
ible
via
th
e in
tern
et
Pro
fess
or In
gvar
Bja
rnas
on is
a c
onsu
ltan
t gas
troe
nte
rolo
gist
at K
ing’
s C
olle
ge H
ospi
tal
Tre
atm
en
t •
A h
olis
tic a
pp
roach
is im
po
rtan
t•
Th
e v
ari
ou
s fo
rms
of IB
S –
co
nven
tio
nal I
BS
, po
st-i
nfe
cti
ve IB
S, I
BS
ass
ocia
ted
w
ith
hyp
erm
ob
ility
syn
dro
mes
– are
all
treate
d in
th
e s
am
e w
ay
• A
realis
tic e
xp
ecta
tio
n is
to
an
ticip
ate
a 7
0%
imp
rovem
en
t in
70
% o
f p
ati
en
ts.
Th
ere
is a
bso
lute
ly n
o c
ure
.
• Ta
ilor
the t
reatm
en
t to
th
e s
ym
pto
ms
• P
ati
en
ts w
ith
IBS
an
d m
ult
iple
un
exp
lain
ed
sym
pto
ms
freq
uen
tly t
hin
k t
hat
they h
ave t
he ‘l
eaky g
ut’
syn
dro
me, w
here
by in
cre
ase
d in
test
inal p
erm
eab
ility
is
po
stu
late
d t
o a
llow
ab
sorp
tio
n o
f b
acte
rial t
oxin
s. T
his
is a
myth
an
d in
test
inal
perm
eab
ility
test
ing
can
co
nfi
rm t
his
Sept 2017 IBS pull-out flowchart_v3Y.indd 5 23/08/2017 19:51
