Despite its high prevalence in this country, irritable bowel syndrome (IBS) is poorly understood and often dismissed as trivial. As a result, many patients are left to suffer in silence. What can pharmacists do to help?

Learning objectives

After reading this feature you should:
• Be able to recognise the symptoms of IBS
• Know which symptoms require referral
• Be able to provide self-care advice.

 

Irritable bowel syndrome (IBS) costs the NHS £200m annually in the UK1 yet, according to the charity The IBS Network, diagnostic tests are usually negative and treatment ineffective.2 So how can pharmacy teams help identify and support sufferers?

The disease is a chronic remitting and relapsing condition that can occur throughout a sufferer’s life.

Symptoms include abdominal pain or discomfort and changes in bowel habit (constipation, diarrhoea, or both), as well as bloating. While some people have intermittent symptoms, for others the condition becomes chronic and more difficult to treat.

Prevalence is estimated to be between 10 and 20 per cent, mainly affecting people in their 20s and 30s – but recent trends indicate it is also significantly prevalent in older people.3

Symptoms and diagnosis

There are no investigations or tests that can confirm the presence of IBS, so it should be considered in people who have had any of the following symptoms for six months or more4:
• Abdominal pain or discomfort
• Bloating
• Change in bowel habit.

A diagnosis of IBS can be confirmed if the pain or discomfort is eased when passing a stool, or if it is associated with altered bowel frequency and the person has at least two of the following symptoms:
• Straining, urgency or incomplete evacuation
• Abdominal bloating, distension, tension or hardness
• Symptoms made worse by eating
• Passage of mucus.

The presence of additional symptoms such as lethargy, nausea, backache and headache, will also support the diagnosis of IBS. While there are no tests to confirm a diagnosis of IBS, tests may be undertaken to exclude other conditions (e.g. coeliac disease).

Differential diagnosis

Coeliac disease is an autoimmune disorder caused by the body’s response to gliadin, a component of gluten found in wheat, barley and rye. Gliadin causes the intestines to become inflamed, leading to symptoms of diarrhoea, bloating, abdominal pain and tiredness.

With so many similarities between the symptoms of coeliac disease and IBS, careful questioning is required when patients present in the pharmacy with gastrointestinal symptoms to help identify which patients need to be referred and which (after diagnosis by the GP) can be safely treated in the pharmacy. It is also important to consider that patients who have self-diagnosed IBS may in fact be suffering from coeliac disease.

“It is now widely recognised that the symptoms of coeliac disease are very similar to those of IBS and may explain why some people take years to get a proper diagnosis,” says Juvela marketing manager Claire Monks.

“Getting the correct diagnosis is key, both for the patient and commissioners, as the longer diagnosis is delayed the longer people will feel unwell and incur repeated visits to their GP, and the greater the risk of other costly long-term complications such as coeliac disease-related osteoporosis.”

Unlike IBS, the diagnosis of coeliac disease involves a blood test to identify the presence of antibodies, after which a gut biopsy may be carried out.

Causes of IBS

The cause of IBS and the pathophysiology of the symptoms are unknown but it is believed that the normal digestive process is somehow altered and that there may be increased sensitivity of the GI tract.4,5

While other causes such as gastroenteritis, antibiotics, inflammation and family history have been proposed, there is no evidence to support any of them, but a number (stress, antibiotics and gastroenteritis) are known to aggravate the condition.

Quality of life

Irritable bowel syndrome can have a negative effect on quality of life, impacting physically, psychologically and socially to the extent that the health of those with IBS is poorer than that of the general population.6

Diarrhoea-predominant IBS has been shown to significantly affect the health-related quality of life of patients, with co-morbid depression, anxiety, decreased intimacy and lost working days.

Bloating also has a significant impact on patients, with data suggesting that they use it as a key element in gauging the success of treatment, independent of other symptoms.7 Treating bloating should therefore be an important consideration.

People with severe IBS symptoms can suffer depression and anxiety that can lead to a vicious cycle of stress, symptoms and management. Relieving stress may reduce the frequency and severity of attacks, so relaxation techniques such as meditation and breathing exercises may be useful. In some cases counselling or cognitive behavioural therapy may be required.

Dr Anton Emmanuelle, consultant gastroenterologist at University College Hospital London and medical director of Core, a charity that funds research into digestive disorders, explains the personal impact of IBS.

“Sufferers face significant difficulties on a daily basis, which impact upon their lives. They often can’t eat, for instance, without cramping and pain, which means they might not be comfortable eating in public, so it affects their social lives.

“Even when they do go out, they might not be able to leave home without going to the bathroom many times beforehand, as they are anxious that they might need to go urgently when they are out. There is measurable, quantifiable data that this negative effect on quality of life is as important as for an organic illness, such as rheumatoid arthritis or renal failure.”

Ewa Gabzdyl, a medicines management pharmacist with NHS Sheffield Clinical Commissioning Group and a member of The IBS Network advisory board, agrees. “IBS can affect all aspects of a person’s life: their relationships, their work and their self-esteem. People with IBS may be wracked with abdominal pain, affected by bloating, or urgently need to use the toilet without any notice.

“Shame is often associated with the condition, with IBS being described as one of society’s last taboos. Sufferers often dread leaving their home for fear of faecal incontinence. If they do venture out, they have to meticulously plan where all the toilets are on their journey and at their destination. Meals out can be a nightmare, as they are not able to control all ingredients used and a lot of what they eat upsets their sensitive bowels.

“Equally, constipation may be a constant source of discomfort and frustration. Intimate relationships can suffer as a result of an IBS diagnosis, with sufferers unable to be intimate for fear of a return of symptoms.

“A combination of these factors and the social stigma attached to anything relating to the toilet, means that IBS can be a very isolating condition. Key to people’s effective management of their condition is accurate information, advice and support.”

When to refer

People with IBS symptoms and any of the following red flag signs should be referred urgently:
• Unintentional and unexplained weight loss
• Rectal bleeding
• A family history of bowel or ovarian cancer
• A change in bowel habit to looser and/or more frequent stools persisting for more than six weeks in people aged over 60 years.

Treatment options

Treatment of IBS involves addressing the most predominant symptoms, which may involve using a combination of drugs to keep those symptoms under control.

Stomach pain caused by muscle spasms, for example, can be treated with antispasmodics such as peppermint oil, alverine citrate or mebeverine. These act on the intestinal smooth muscle, causing it to relax. Other muscle relaxants (e.g. hyoscine) are likely to cause antimuscarinic side-effects so are better used as a second-line option.

Laxatives, such as ispaghula, will help relieve constipation associated with IBS, and are preferable to lactulose, which may exacerbate bloating. For those unable to take bulk-forming laxatives, alternatives include stimulant preparations like senna, or osmotic laxatives containing macrogol.

Diarrhoea symptoms can be treated with antimotility drugs, such as loperamide.

The aim with using laxatives and antimotility drugs is to adjust the dose as required to control symptoms and produce a soft, well-formed stool.

If the steps mentioned above fail to control symptoms, NICE advises using tricyclic antidepressants. The starting dose of 5-10mg (equivalent of amitriptyline) should be taken at night and increased to 30mg if necessary. If this is ineffective, selective serotonin reuptake inhibitors (SSRIs) can be used.

Additional treatment options include interventions such as cognitive behavioural therapy (CBT), hypnotherapy and psychological therapy. While these are thought to be helpful, clear guidance is not yet available on when they should be used. Treatments that are not recommended include aloe vera, probiotics, acupuncture, reflexology and herbal medicine.

Lifestyle interventions

NICE guidance suggests that adjusting a number of lifestyle factors can help manage the symptoms of IBS.3

Stress is known to aggravate IBS, with around half of sufferers saying that it contributes to their symptoms.4 Identifying sources of stress and trying to manage them, as well as finding time to relax, may be useful. While evidence for such an approach is lacking, some patients report that they find it beneficial.

Increasing physical activity can help improve gastric emptying and speed up transit time. It is recommended that adults undertake at least 30 minutes of moderate exercise, such as cycling or fast walking, at least five days a week, as well as strength exercises on two or more days a week that work all of the major muscle groups.

However, this exercise can be less formal and can include dancing or climbing the stairs at home. If the predominant symptom is diarrhoea, then increasing exercise levels may not be appropriate.

Identifying IBS

Constipation and diarrhoea are two of the commonest conditions encountered in pharmacy, so there is an opportunity to identify people who may have IBS but aren’t aware of it.

“Pharmacists can help to identify the three core features of IBS: pain, discomfort and altered bowel habit, and the temporal relationship between them,” says Dr Emmanuelle. However, if IBS is suspected, “patients need to be referred to their GP to confirm the diagnosis because it is important to check that it isn’t something else like, for example, coeliac disease or thyroid related”.

Dr Emmanuelle stresses that, even if someone has been diagnosed with IBS, it is still important to be aware of other alarm symptoms. “IBS is so prevalent, but it doesn’t mean [a patient] does not have another condition.”

Through careful questioning and awareness of red flag symptoms, pharmacists can reassure people or refer urgently to their GP where appropriate. It is possible that, while talking to patients who suspect they have IBS, it might become apparent they have coeliac disease, which again requires referral to the GP to confirm the diagnosis.

Ewa Gabzdyl agrees that careful questioning is all-important but says that once a diagnosis is made, pharmacy staff can help patients self-manage their condition by providing advice about appropriate treatments, which ones to avoid and what lifestyle changes may need to be made to support the management of their symptoms.

“It is also important to provide advice about avoiding faddish diets, the importance of eating regularly and keeping a diary for two weeks to record bowel symptoms and eating habits to help identify foods that cause diarrhoea, for example.

“Signposting to other healthcare professionals for further information, such as dieticians, support networks and groups such as The IBS Network, will ensure people with IBS receive the help they need to manage their symptoms better.”

Healthy eating tips

Healthy eating tips that can be passed on to IBS sufferers include:
• Have regular meals and take time to eat
• Avoid missing meals or leaving long gaps between eating
• Drink at least eight cups of fluid per day, especially water or other non-caffeinated drinks (e.g. herbal teas)
• Restrict tea and coffee to three cups per day
• Reduce intake of alcohol and fizzy drinks
• Limit the intake of high-fibre food, such as wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice
• Reduce the intake of starch that resists digestion in the small intestine and reaches the colon intact. This is often found in processed or re-cooked foods
• Limit fresh fruit to three portions a day (a portion should be approximately 80g)
• People with diarrhoea should avoid sorbitol, an artificial sweetener found in sugar-free sweets (including chewing gum) and drinks, and in some diabetic and slimming products
• People with wind and bloating may find oats (such as oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day) helpful.

Source: NICE

 

References
1. Canavan C, West J and Card T (2014). Review article: The economic impact of
irritable bowel syndrome. Alimentary Pharmacology & Therapeutics, 40 (9), 1023-34
2. The IBS Network: theibsnetwork.org/ news/campaigns
3. Irritable bowel syndrome in adults: diagnosis and management.
NICE guidelines [CG61]
4. NICE Clinical Knowledge Summaries. Irritable bowel syndrome
5. NHS Choices: Irritable bowel syndrome
6. Mönnikes H. Quality of life in patients with irritable bowel syndrome. J Clin Gastroenterol. 2011 Aug; 45 Suppl: S98-101. ncbi.nlm.nih.gov/pubmed/21666428
7. Neri L and Iovino P. Laxative inadequate relief survey (LIRS) group. Bloating is associated with worse quality of life, treatment satisfaction, and treatment responsiveness among patients with constipation-predominant irritable bowel syndrome and functional constipation. Neurogastroenterol Motil. 2016
Apr; 28(4): 581-91
8. King’s College London. FODMAPS FAQ
9. NHS Choices: Escherichia coli

Useful information

• CORE is a charity that supports medical research into digestive diseases and provides evidence-based information. It has a patient leaflet on IBS. See: corecharity.org.uk
• IBS Network is a charity that supports people with IBS. See: theibsnetwork.org
• Coeliac UK offers a range of support tools for patients and healthcare professionals. See: coeliac.org.uk
• FODMAP diets. See: kcl.ac.uk/lsm/research/divisions/dns/projects/fodmaps/faq.aspx

Irritable bowel syndrome can have a big negative effect on a sufferer's quality of life

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