PHYSICAL & HISTORY ASSESSMENT

A complete history and relevant examination are required when diagnosing IBS, with limited use of diagnostic tests. It is a diagnosis based on clinical symptoms. Exclude alarm features as listed above. The presence of alarm features should prompt consideration of a referral to a Gastroenterologist.

 

 

INVESTIGATIONS

A CBC should be performed in all patients presenting with IBS symptoms to rule out anemia that may require further investigation.

Symptoms of celiac disease often overlap with IBS, particularly diarrhea and bloating. Celiac serology is recommended and can be performed as anti-tTG IgA. This test should always be done simultaneously with a serum IgA level; IgA deficiency can cause false-negative anti-tTG tests.

 

 

GENERAL PRINCIPLES OF IBS TREATMENT

Developing a therapeutic relationship with the patient at the time of diagnosis is the foundation of effective long-term management. It is essential to provide reassurance by acknowledging the patient’s symptoms and offering a continued assessment of treatment response. It is helpful to discuss what factors may have contributed to the individual patient’s IBS and how those factors may be treatment targets. Discussion of the role of the gut-brain axis can help frame a patient’s understanding of their illness and treatment plan. It is important to set realistic treatment goals in the management of IBS.

All patients with IBS will benefit from lifestyle and dietary modifications. If available, patients should be connected with resources for dietary modification, exercise (yoga has shown to be beneficial), stress reduction strategies, and psychological counselling, if appropriate.

 

 

DIETARY

A trial of soluble fibre (e.g. psyllium, guar gum) and not insoluble fibre (e.g. wheat) may be helpful. It has been shown to bulk stool formation, alter the production of gas from fermented products, and change the composition of the gut microbiome.

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The low FODMAP diet has been shown to be effective in improving overall IBS symptoms, bloating, and stool form (in IBS-D only). If available, refer the patient to a Registered Dietician to trial the low FODMAP diet. If a Registered Dietician is not available, the patient can be directed to access the resources listed below. Emphasize to the patient that this is not a lifelong diet. Instead, it is used to determine trigger foods that may contribute to symptoms. The patient can trial the low FODMAP diet for 4 to 6 weeks to determine if it reduces IBS symptoms. The patient then must move on to the reintroduction phase. During the reintroduction phase, the patient should keep a food diary to track restarted food items and their symptoms (Appendix 2). The patient should reintroduce one food item over three days to determine if it causes symptoms. When the patient can identify trigger foods, reassure the patient they do not have to completely stop eating the food item (especially if it is something they enjoy eating), but simply be more mindful of its effects on their GI symptoms and reduce its intake. Please note that this type of elimination may not be appropriate for all patients with IBS.

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OVER-THE-COUNTER OPTIONS

There are effective over-the-counter options for managing abdominal pain. Peppermint oil in delayed-release capsules has shown to alleviate symptoms of abdominal pain, bloating, and a sense of urgency. Ingesting pure peppermint oil has shown to increase acid reflux symptoms. The encapsulated form is released in the small bowel to reduce this risk.

Antispasmodic medications have also proven to help alleviate abdominal pain and cramps.

Probiotics are another option as there is growing research regarding the relationship between IBS and the gut microbiome. The two commonly researched strains for IBS are lactobacillus and bifidobacterium. Overall, probiotics were statistically superior to placebo in reducing abdominal pain, bloating, and flatulence. As the evidence for probiotics is still emerging, patients should be advised to limit their trial period to one month. If there is no effect on their IBS symptoms, treatment should be discontinued.

 

PSYCHOLOGICAL

It is important to assess any stressors that may trigger IBS symptoms. During the assessment, inquire if the patient’s IBS symptoms started within 6 to 12 months of a stressful event. Childhood trauma has also been associated with IBS and should be addressed if appropriate. A referral to a psychologist specializing in cognitive behavioural therapy (CBT) or gut-directed hypnotherapy has shown to be effective in teaching patients relaxation techniques to manage their symptoms.

 

  

PHARMACOLOGICAL MANAGEMENT

Pharmacological options can complement conservative therapies to optimize IBS symptom control.

The use of neuromodulators/antidepressants has been shown to improve IBS symptoms. Other pharmacological options can be considered to address symptoms but may not improve overall IBS symptoms. Emphasize to patients that symptom control is based on multiple variables (lifestyle, diet modification, medication, etc.) and that treatment is individualized.