Challenging the diagnosis of IBS
7th May 2017
The Hippocratic Post
Doctors often find it challenging to make a positive diagnosis of Irritable Bowel Syndrome (IBS), which affects at least one in five people at some point in their lives.
The symptoms of IBS, including pain, bloating and altered bowel habits, have significant overlap with a number of other conditions including Inflammatory Bowel Disease (IBD) and coeliac disease. Diagnosis is made more difficult by the fact that there is no definitive test to confirm the diagnosis.
As a consequence, many people seeking medical help with IBS symptoms are waiting years for a firm diagnosis.
This delay can have serious long-term consequences for their mental and physical health. According to a recent survey, a third of respondents based in the UK had to visit their GP at least five times before diagnosis and 44 per cent of sufferers report delayed diagnosis and treatment has impacted their quality of life.
IBS is more common amongst women although roughly a third of sufferers are men. Half of sufferers develop symptoms before they reach 35. Lifestyle change is often important in managing the condition, although a range of medications is available for specific symptoms.
The first, most important thing is for clinicians to ensure that they take a full history. This, combined with examination, has always been the corner stone of medical diagnosis.
The first, most important thing, is for clinicians to ensure that they take a full history. This, combined with examination, has always been the corner stone of medical diagnosis.
It is important to make sure that “red flags” such as rectal bleeding and rapid unexplained weight loss, a strong family history of colon or ovarian cancer, or persistent new symptoms in patients over 50 years old are identified. The presence of red flags should lead to the consideration of alternative diagnoses and referral.
The next step is to undertake a number of investigations including blood tests to exclude coeliac disease and anemia. People should also have a test to exclude inflammatory conditions such as Crohn’s disease or colitis; this may be a blood or stool test or both. If all these tests are negative and there are no “red flags” the diagnosis of IBS can be made with a high degree of certainty.
Treating IBS often starts with dietary and lifestyle changes. We know that around 40 per cent of people with IBS can identify triggers in their diet, which make their symptoms worse. When I talk with patients with IBS, I ask them to talk me through their eating habits, what they eat and how often throughout the day. Very often, they do not space meals out evenly and drink significant quantities of caffeinated drinks and/or alcohol. FODMAP foods (Foods containing Fermentable, Oligo-, Di-, Mono-saccharides and Polyols (FODMAPs) can provoke symptoms. They can be found in a range of different foods: like onions, garlic and cruciferous vegetables like cauliflower and broccoli, ferment in the gut and are often implicated in bloating and pain. All these things can lead to gut irritation and poor function.
Stress is another factor, which plays a part. There is a very complex interaction between the brain, spinal cord and the gut which all play their part in this condition. Exercise can improve function of the bowel and is an important factor in helping to regulate bowel function. I suggest that people with IBS try and take 20 minutes out of their day to simply relax and wind down. Many of us really struggle with lifestyle change so it is very important to approach this in a constructive and supportive way.
Having identified any lifestyle factors that may be making things worse it is worth considering medicines. Medication and drugs are rarely the whole answer to resolving symptoms. Broadly drugs can be used to alter the sensitivity or motility of the gut or to impact the pathways of communication between the gut, the brain and the spinal cord. Medicines like Imodium are often used for diarrhea, whereas anti-spasmodics like buscopan are used for abdominal cramps. Aperients like movicol or laxido may help constipation. Sometimes tricyclic’s like amitriptyline can be useful for pain.
IBS is a debilitating condition and people who suffer from this syndrome do need to be given the help they need at the earliest possible opportunity after their symptoms have arisen. Doctors are in the vanguard of diagnosis and have a hugely important role to play in ensuring that IBS is managed in a timely and appropriate way.
For more information on IBS visit the national charity, The IBS Network, which supports people living with IBS.