Document type

n/a

Place

South and West Hertfordshire

Output type

Clinical Pathways

Pathway

Irritable Bowel Syndrome Pathway | SWH

Irritable Bowel Syndrome (IBS)

Initial presentation A person reports having any of the following symptoms for at least 6 months:
• Abdominal pain or discomfort
• Bloating
• Change in bowel habit.
• Change in bowel habit. 

In people who meet the diagnostic criteria:
• Carry out the following tests to exclude other diagnoses:
-Ca125 for ovarian cancer in any woman of 50 or over who has experienced symptoms within the last 12 months
-Full blood count (FBC)
-Erythrocyte sedimentation rate (ESR) or plasma viscosity
-C-reactive protein (CRP)
-Antibody testing for coeliac disease;
tissue transglutaminase (TTG) or endomysial antibodies (EMA)
- Faecal calprotectin
Do not do the following tests to confirm diagnosis of IBS:
-Ultrasound -Rigid/flexible sigmoidoscopy
-Colonoscopy; barium enema
-Thyroid function test
-Faecal ova and parasite test
-Faecal occult blood
- Hydrogen breath test (for lactose intolerance and bacterial overgrowth)

 

Positive diagnostic criteria for IBS
•Consider diagnosing IBS only if the person has abdominal pain or discomfort that is:
-relieved by defaecation OR associated with altered bowel frequency or stool form AND at least two of the following:
-altered stool passage (straining, urgency, incomplete evacuation)
-abdominal bloating (more common in women than men),
distension, tension or hardness
-symptoms made worse by eating -passage of mucus
•Lethargy, nausea, backache and bladder symptoms may be used to support diagnosis. 

 

Treatment options
1. Diet advice – see Fodmap and Lifestyle advice Page Healthy Lifestyle Landing Page
2. First line pharmacological treatment options
3. Second line pharmacological options See below for more detailed information 

 

Referral for psychological interventions For people whose symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS), consider referring for:
- Cognitive behavioural therapy (CBT)
- Psychological therapy
You may wish to advise your patient of the benefit of hypnotherapy in IBS (this is recommended in NICE CG61), but please note that this is not funded by the NHS in Hertfordshire.

 

Follow-up
• Agree follow-up with the person based on symptom responses to interventions.
This should form part of the annual patient review.
• Investigate or refer to secondary care if ‘red flag’ symptoms appear during management and follow-up 

 

See ‘Referral guidelines for suspected cancer’, NICE NG12, for detailed referral criteria where cancer is suspected.
2 In certain situations the daily dose of loperamide required may exceed 16mg, an out of licence dose. Informed consent should be obtained and documented.
3TCAs and SSRIs do not have UK marketing authorisation for the indications described. Informed consent should be obtained and documented