Irritable Bowel Syndrome: 10-Minute Consultation

Primary care
10-minute consultation
BMJ: first published as 10.1136/bmj.330.7492.632 on 17 March 2005. Downloaded from http://www.bmj.com/ on 21 September 2018 by guest. Protected by copyright.
Irritable bowel syndrome
William E Cayley Jr
University of A 35 year old woman with longstanding “loose bowels”

Wisconsin
Department of
reports an increasing incidence over two years of pain- Manning criteria for diagnosing irritable bowel
Family Medicine, ful abdominal cramps and “rumblings,” with frequent syndrome
Eau Claire Family loose stools and occasional leakage. Her work is stress-
Medicine
ful, and she worries that her bowel problems may affect Diagnose irritable bowel syndrome if ≥ 3 are present:
Residency, 617 West
Clairemont, Eau her job performance. • Abdominal pain
Claire, WI 54701, • Relief of pain on defecation
USA
• Increased stool frequency with pain
William E Cayley Jr
assistant professor • Looser stools with pain
What issues you should cover • Mucus in stools
[email protected]
Characteristics—Irritable bowel syndrome consists of • Feeling of incomplete evacuation
The series is edited
by general abdominal pain and intermittent diarrhoea, constipa-
“Red flag” signs
practitioners Ann tion, or bloating. Possible contributing factors include Evaluate further if the patient is aged > 50 or has:
McPherson and
stress or anxiety, visceral hypersensitivity, altered bowel • Weight loss
Deborah Waller
(ann.mcpherson@ motility, neurotransmitter imbalances, and inflamma-
• Blood in stools
dphpc.ox.ac.uk) tion. No single mechanism explains all cases, and no
• Anaemia
The BMJ welcomes specific dietary causes are known. Symptoms usually
contributions from • Fever
begin before the age of 50, and up to 20% of the popu-
general
practitioners to the lation may be affected.
series Diagnosis—Differential diagnoses include inflamma-
tory bowel disease, colorectal polyps or cancers, malab- tion, and cognitive behaviour therapy. Comorbid
BMJ 2005;330:632 sorption (lactose intolerance or coeliac disease), psychiatric illness should be treated.
infectious diarrhoea, and thyroid dysfunction.
Although irritable bowel syndrome is often considered
a diagnosis of exclusion, validated criteria allow What you should do
positive diagnosis without extensive testing. The x Does she meet the Manning criteria? (What are the
Manning criteria (see box) have been studied the most, nature and duration of abdominal complaints? Is there
and the presence of three of the six criteria is 66% to pain? Is it relieved with defecation or associated with
90% sensitive and 61% to 93% specific for a diagnosis changes in stool form or frequency? Is there faecal
if no red flag signs are present. Although many doctors urgency or incontinence or a feeling of incomplete
usually obtain a full blood count, electrolyte and evacuation?) Ask about weight loss, intestinal bleeding,
thyroid stimulating hormone concentrations, and and fever. Ask about dietary fibre and food
erythrocyte sedimentation rate, evidence indicates that intolerances and about any family history of intestinal
only the full blood count is always needed. Determin- disease or malignancy. Ask about work or family stress,
ing whether the predominant symptoms are diarrhoea, any history of abuse, depression, or anxiety, and the
pain, or constipation can help guide management. effect of symptoms on her daily life.
Management—Reassurance and explanation are impor- x Check whether she seems to be in good health and
tant, and some experts suggest reducing dietary fat, whether she has lost any weight. Perform abdominal
alcohol, and caffeine intake. Evidence supports and rectal examinations. A full blood count will rule
increased dietary fibre for constipation, drugs for spe- out anaemia. Further testing at this point is probably
cific symptoms, and multicomponent behaviour unnecessary for patients aged under 50 who meet the
therapy, including education, coping strategies, relaxa- Manning criteria and have no red flag signs.
x Explain the syndrome and reassure her that it doesn’t
Useful reading represent serious disease or a greater risk of malignancy.
Consider asking her to reduce dietary fat, alcohol, and
Holten KB, Wetherington A, Bankston L. Diagnosing the patient with caffeine and other dietary triggers that aggravate symp-
abdominal pain and altered bowel habits: is it irritable bowel toms. Evidence supports treatment for specific predomi-
syndrome? Am Fam Physician 2003;67:2157-62 nant symptoms: bulking agents (wheat bran, psyllium)
for constipation, loperamide for diarrhoea (initially 2 mg
Holten K. Irritable bowel syndrome: minimize testing, let symptoms
four times daily as needed), and tricyclic antidepressants
guide treatment. J Fam Pract 2003;52:942-50
for pain (starting with scheduled amitriptyline 25 mg at
Jones J, Boorman J, Cann P, Forbes A, Gomborone J, Heaton K, et al. bedtime). The risk of severe side effects make the two
British Society of Gastroenterology guidelines for the management of new serotonergic drugs for the syndrome (alosetron and
the irritable bowel syndrome. Gut 2000;47 (suppl II):ii1-19 tegaserod) inappropriate for initial management.
Explore life stresses that trigger symptoms, and consider
Viera AJ, Hoag S, Shaughnessy J. Management of irritable bowel relaxation or cognitive therapy.
syndrome. Am Fam Physician 2002;66:1867-74, 1880
Self help websites for patients are listed on bmj.com
632 BMJ VOLUME 330 19 MARCH 2005 bmj.com

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Primary care

University of A 35 year old woman with longstanding “loose bowels”

632 BMJ VOLUME 330 19 MARCH 2005 bmj.com

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