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Irritable bowel syndrome: the latest thinking Marianne Williams Irritable bowel syndrome (IBS) is a chronic and debilitating condition effecting over 10% of the UK population with a higher preponderance among adult Caucasian females. It places a significant economic burden on the NHS with annual cost projections ranging from £45 to £200 million. Misdiagnosis is common and is reflected in the high prevalence of gastrointestinal-related surgery within this cohort, and it is essential to obtain a detailed case history to ensure correct treatment. National guidelines now recommend diet as the first line approach, with research repeatedly advocating the use of the low FODMAP diet, particularly for those with diarrhoea dominant or mixed IBS. However, specialist dietetic support is essential to ensure nutritional adequacy and prevent the use of unnecessary or highly restrictive diets. Where access to dietitians may be limited, dietetic departments are now able to recommend technology, such as dietitian-led webinars, mobile phone apps and YouTube videos to increase patient access to reliable information.
Irritable bowel syndrome Diagnosis Diet
rritable Bowel Syndrome (IBS) is a chronic and debilitating functional gastrointestinal disorder, which has a significant impact on quality of life and effects approximately 10% of the UK population (Wilson et al, 2004). As set out in the ROME IV criteria, IBS is characterised by: Abdominal pain Bloating Change in bowel habit in the absence of any overt mucosal abnormality (Drossman, 2016). IBS is non life-threatening and its pathogenesis remains poorly understood (Maxion-Bergemann et al, 2006; Parkes et al, 2010).
Marianne Williams, NHS and private specialist allergy and irritable bowel syndrome (IBS) dietitian
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It is more commonly seen in Caucasians, with a significantly higher prevalence in women, making IBS the digestive disease with the greatest preponderance among females. IBS appears to increase in later adulthood and it is not considered a disease of childhood (Everhart and Rhul, 2009). The condition is divided into subgroups, with one third of cases presenting with IBS with diarrhoea (IBS-D), one third IBS with constipation (IBS-C) and one third to half of cases being diagnosed with both diarrhoea and constipation, known as mixed IBS (IBS-M)(Quigley et al, 2015).
The burden of IBS The condition places a notable burden on the National Health Service (NHS), both in terms of financial cost and strain on primary and secondary care (Thompson, 2000; Maxion-Bergemann et al, 2006; Soubieres et al, 2015). Despite the National Institute for Health
and Care Excellence (NICE) and British Society of Gastroenterology guidelines recommending that IBS management should take place within primary care (Spiller et al, 2007; NICE, 2008; 2015), patients with IBS are frequently referred to secondary care despite a low probability of pathology. Indeed, it is the commonest cause of referral to gastroenterologists in the developed world, with around half of IBS patients being referred for endoscopic investigation (Parkes et al, 2010; Soubieres et al, 2015). Research shows that IBS patients incur 51% more costs per year than a control group, with more outpatient visits and higher medication costs, with spending steadily increasing year-on-year (Longstreth, 2003), and annual cost projections ranging from £45.6 to £200 million in the UK (Canavan et al, 2014). Costs are often exacerbated at a primary care level, where research suggests that general practitioners (GP) still see IBS as a diagnosis of exclusion, often due to uncertainty about diagnosis and in the belief that negative diagnostic tests are useful. (Bellini et al, 2005; NICE, 2008; Spiegel, 2010). This is compounded by the fact that the condition can Table 1: NICE recommendations for the treatment of IBS (NICE, 2015 Diet and lifestyle Medications, such as antispasmodics, laxatives,
loperamide, linaclotide. Follow up people taking linaclotide after three months. Secondline medication treatment using tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) If diet and medication have failed to help
symptoms within 12 months, consider psychological intervention such as cognitive behavioural therapy (CBT), hypnotherapy and/ or psychological therapy
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have a significantly detrimental impact on quality of life and patients can lack confidence in their IBS diagnosis, with 50% considering the diagnosis to be a ‘catch all’ (Spiegal, 2009). The resulting uncertainty and anxiety inevitably leads to a demand for further tests, with patients concerned that their symptoms may develop into cancer, colitis or may shorten their life expectancy (Halpert et al, 2007; Spiller and Garsed, 2009).
Misdiagnosis Is Common The chronic symptoms of IBS tend to occur intermittently for periods of several days and patients often describe suffering with ‘flare ups’ or ‘attacks’ of symptoms. Symptoms can mimic several conditions. Indeed, abdominal pain is the most common gastrointestinal symptom leading to outpatient visits (Longstreth and Tieu, 2016), with IBS being just one of the possible diagnoses. Research suggests that IBS is frequently diagnosed as diverticulitis, as both conditions can present with pain and tenderness over the left colon (Longstreth and Tieu, 2016). In fact, misdiagnosis is common and is reflected in the high prevalence of cholecystectomy, appendectomy and hysterectomy in this patient cohort (Longstreth and Yao, 2004; Longstreth, 2007). IBS patients can exhibit almost identical gut symptoms to those with other conditions, such as coeliac disease, non-coeliac gluten sensitivity (NCGS) and food allergy. Indeed, around 16–22% of coeliac patients are initially wrongly diagnosed with IBS (Card et al, 2013; Somerset Clinical Commissioning Group, 2013). IBS NICE guidelines (2015) stress that patients suffering with IBStype symptoms for longer than six months should have a coeliac blood test to rule out the condition. Unfortunately, there are no tests yet available for the relatively newly recognised condition NCGS, but as with coeliac disease, these patients often exhibit extraintestinal symptoms which are not a feature of IBS, e.g. foggy headedness, joint pains, mouth ulcers, hair loss, headaches/migraines in relation to
eating gluten. This highlights the importance of taking a detailed case history if IBS is to be diagnosed correctly.
‘The chronic symptoms of IBS tend to occur intermittently for periods of several days and patients often describe suffering with ‘flare ups’ or ‘attacks’ of symptoms. Symptoms can mimic several conditions. Indeed, abdominal pain is the most common gastrointestinal symptom leading to outpatient visits (Longstreth and Tieu, 2016), with IBS being just one of the possible diagnoses.‘
Additionally, community nurses should consider food allergy as a differential diagnosis for IBS-type symptoms. Those who are suffering with allergy, which only affects the gastrointestinal tract, are often exhibiting ‘non-IgE’ allergy for which there are no allergy tests (Holgate et al, 2012). Food removal and reintroduction is the gold standard for diagnosis in these cases (NowakWegrzyn et al, 2015). These patients will often have a significant personal or family history of atopy, normally starting in infancy or childhood. However, allergy does not always follow the rules and is a complex area requiring specialist knowledge. If allergy is suspected, referral to an appropriately trained dietitian and/or nurse is essential to ensure nutritional adequacy and appropriate treatment (Walsh et al, 2016). An essential part of IBS diagnosis is the assessment of stool form, passage and frequency. It is recognised that IBS patients commonly misinterpret their stools and may complain of ‘diarrhoea’ when referring to frequent passage of formed stools. Equally, patients may use the term ‘constipation’ in reference to the act of defecation and not the infrequency (Quigley et al, 2016). As stool habit is likely to determine treatment options, it
is vital that a careful assessment is made without the use of antidiarrheals or laxatives. Using image-based tools with patients, such as the Bristol Stool Chart, can be extremely helpful with his process.
Diet and IBS Research has shown that patients predominantly seek advice on diet and the role of food in their condition, with many reporting an exacerbation of symptoms after eating (Halpert et al, 2007). Historically, there seemed to be limited evidence for the involvement of diet in IBS. However, in the last decade there has been a dramatic increase in research investigating food and its effect on IBS symptoms, with a greater emphasis on the need for specialist dietetic intervention. As long ago as 2008, NICE guidelines for IBS noted that if diet is considered to be a major factor in symptoms, then a patient ‘should be referred to a dietitian for advice and treatment’. In 2015, these guidelines were updated to include further dietary management, which noted single food avoidance and exclusion diets making specific mention of the low FODMAP diet (low fermentable oligo-di-mono-saccharides and polyols diet), with the proviso that this advice should ‘only be given by a healthcare professional with expertise in dietary management’. The British Dietetic Association (BDA) reviewed their published dietary guidelines for IBS in 2016 giving two avenues of treatment under the guidance of a dietitian (McKenzie et al, 2016a): 1. First line — looking at healthy eating/lifestyle, recognised dietary triggers and lactose intolerance 2. Second line — revolving around the use of the low FODMAP diet. From a community nurse perspective, healthy eating and lifestyle can be addressed by encouraging regular meal patterns, taking time over meals, chewing food thoroughly and not eating
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too late at night. Ensuring an appropriate intake of alcohol and caffeine, and limiting the intake of ready-made/processed high fat foods can also be encouraged. Often, these simple changes can lead to an improvement in symptoms. If necessary, patients can then be referred to an NHS dietitian for more specialist dietary advice, such as a low lactose or low FODMAP diet.
Advice for those with IBS-D or IBS-M: The Low FODMAP Diet BDA second-line advice revolves around the low FODMAP diet. But, what is this diet? The low FODMAP diet has absolutely nothing to do with allergy or the immune system and is instead a diet to reduce the effects of gut fermentation. FODMAPs are fermentable dietary carbohydrates. Some of these carbohydrates can cause an osmotic effect, leading to increased water delivery into the small intestine. This could lead to distressing loose stools in some people, or alternatively could be helpful in those with constipation, e.g. prunes contain the FODMAP ‘sorbitol’ , making them a useful natural laxative. FODMAPs are also fermented by the bacteria in the colon leading to gas production, bloating and abdominal pain in some patients. The low FODMAP diet is supported by a number of good quality randomised control trials (RCTs), with research consistently showing that 50–80% of patients report symptomatic relief (Staudcher et al, 2012; Halmos et al, 2014; Hustoft et al, 2017; McIntosh et al, 2017; Staudacher et al, 2017). Patients follow the diet for 4–8
To gain an overall understanding of the low FODMAP diet, patients and healthcare professionals may find this video useful: www.youtube.com/ watch?v=Z_1Hzl9o5ic
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weeks and are then guided through a reintroduction process. A recent long-term study looking at patients post reintroduction, showed that 70% of patients maintained improvement after 6–18 months, and, with the guidance of a dietitian, nutritional status was not compromised. The FODMAP reintroduction process after 4–8 weeks is absolutely essential, as research is now suggesting that the low FODMAP diet can alter gut bacteria. It is still not clear if these bacteria effects are short-term, negative to health, or sustained once reintroduction is started. A recent RCT indicated that taking a particular probiotic alongside the diet may ameliorate these negative effects, but more research is needed before probiotics can be standardly recommended alongside the low FODMAP diet (Staudacher et al, 2017). The effects on gut bacteria and the complexity of the FODMAP intervention mean that it is vital that dietetic advice is sought for IBS patients wanting to follow this diet. However, in areas where referral to a NHS or private FODMAP dietitian may be limited, patients can use the excellent UK mobile phone FODMAP app produced by King’s College London: www. kcl.ac.uk/innovation/business/ support/ipandlicensing/casestudies/ FODMAP.aspx . This app also has several associated videos that help guide patients through the process, although ideally the app should be used in conjunction with a dietitian.
Is the low FODMAP diet useful for constipation dominant patients?
In effect, the diet is removing nature’s laxatives by eliminating many of the foods that cause water to be drawn into the small intestine. Hence, for constipation dominant patients, this diet may not be the best option. However, research shows that even despite the physiological effects of the low FODMAP diet, some IBS-C patients can benefit if they have dedicated dietetic management to ensure that they are consuming plenty of fluid
The laxative lactulose acts as a FODMAP causing osmotic changes in the small intestine and fermentation in the large intestine and should be avoided in IBS patients as it is highly likely to make their symptoms worse (NICE, 2008). and alternative fibre (de Roest et al, 2013). It may be necessary to incorporate the use of laxatives as part of their treatment programme (Rao et al, 2015).
Advice for those with IBS-C Fluid
Fluid helps the stools to remain slippery and therefore easier to pass. Much of the fluid that we consume is absorbed back into the body and this absorption will occur even if fluid intake is low. Therefore, if the patient is not drinking enough, their stools are likely to become hard and difficult to pass. Hence, patients need to consume between 1.5 to 2 litres of non-caffeinated fluid per day.
Gradually increase fibre intake but be aware that sudden increases in fibre can actually make symptoms worse for some patients. Wholegrains, oats, vegetables, pulses, nuts, seeds and fruit can help soften stools and should be increased gradually using a variety of sources and with sufficient fluid intake. Adding a tablespoon of brown or golden linseeds (whole or ground) to food can also help soften stools but this must be taken along with an extra 150ml water per tablespoon, and the full benefit may take up to six months (McKenzie et al, 2016a). Contrary to old advice, wheat bran is no longer recommended for IBS as it can aggravate symptoms.
Physical activity on a daily basis, e.g. walking regularly, can stimulate the bowel and help it to keep working effectively.
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Diary-free or lactose?
A low lactose is completely different from a dairy-free diet, which is only appropriate when treating dairy allergy. A dairy-free diet does not allow any dairy from a mammal and relies solely on plant-based alternatives. However, in IBS it is only necessary to reduce, rather than eliminate, the use of high lactose dairy foods, such as milk and yogurt. Hence in IBS, those on a low lactose diet can continue to eat dairy foods such as butter, cream and most cheese (King’s College and Guys and St Thomas’ NHS Foundation Trust, 2017).
Finally, as an adjunct to these suggestions, toilet positioning is also important (Barrie, 2016) and you may wish to discuss details with your local continence service.
Should IBS patients use a dairy or gluten-free diet? Understandably, patients frequently self-prescribe in an effort to help their symptoms, with many patients unnecessarily following highly restrictive diets for many months with no guidance on suitable alternatives, supplementation, or when to stop the diet. We commonly see the use of ‘dairyfree’ or ‘gluten-free’ diets, both of which are inappropriate for IBS and are unnecessarily over-restrictive (McKenzie et al, 2016a; Skodje et al, 2017). Without professional dietary guidance, the concern is that the use of restrictive diets can potentially compromise nutritional status, increasing the likelihood of comorbidities such as osteoporosis, anaemia and deficiencies in vitamins, minerals and fibre (Skypala et al, 2015).
Probiotics in IBS While there is ongoing discussion regarding the use of probiotics alongside the use of the low
FODMAP diet, patients are also keen to know if probiotics in general are helpful in reducing IBS symptoms. The use of probiotics in IBS was looked at in detail in a recent systematic review (McKenzie et al, 2016b). The overall conclusion was that probiotics were, ‘unlikely to provide substantial benefit to IBS symptoms’. However, as with the NICE guidelines, individuals who wish to try a probiotic should not be discouraged from doing so, and are advised to try one product at a time for a minimum of four weeks at the manufacturers’ recommended dose and to monitor effects.
How do you access a specialist IBS dietitian? The need for more access to specialist dietetic services has become clear over recent years, particularly with the success of the low FODMAP diet and its incorporation into national guidelines. In the author’s locality (Somerset), the first UK NHS dietetic-led community gastroenterology clinic was set up in 2012 with a county-wide IBS pathway specifically for use by healthcare professionals in primary care (Williams et al, 2016). The aim was to reduce referrals into secondary care by giving GPs and community and general practice nurses (GPNs) an alternative and effective referral route. Today, there are similar clinics set up or planned across many parts of the UK. Some are based in secondary care, while others are established in primary care. Additionally, each year King’s College London are continuing to train significant numbers of UK dietitians in the FODMAP diet which will steadily increase access to specialist IBS dietitians. King’s College London produce a list of FODMAP trained dietitians in both the NHS and in private practice which is available on their website: /www.kcl.ac.uk/lsm/Schools/lifecourse-sciences/departments/ nutritional-sciences/projects/ fodmaps/faq.aspx. (Note: Once you have accessed this page, click on the yellow/orange box on the right-
hand side of the screen to find the list of trained dietitians.) The author’s team have recently introduced the use of webinars for first-line IBS advice, which may represent a more practical method of treating large numbers of patients within a sizable rural county. Early data from these webinars show that patients are finding them easy to use, with 100% of attendees stating that they are likely to recommend the webinars to friends. Surveys before and after attending the webinars clearly show that the webinars are improving patient education and patients report that they are keen to join the evening sessions as they can gain reliable information from specialist dietitians in the comfort of their own home, without having to take time off work. Vitally, patients can re-watch the session afterwards whenever they wish. Those that
Gluten or fructan free?
Confusion over the use of ‘glutenfree diets’ often occurs due to the similarity in gut symptoms between IBS, coeliac disease and non-coeliac gluten sensitivity (NCGS), with only the latter two requiring a gluten-free diet. In fact, in IBS it is thought to be the carbohydrate, ‘fructans’, in wheat, barley and rye that can cause symptoms and not the protein, ‘gluten’ (Skodje et al, 2017). However, IBS patients will often use ‘gluten-free food’ simply because these foods are free from wheat, barley and rye and are therefore free of ‘fructans’. Unlike coeliac disease, IBS patients do not need to be as regimented in their avoidance, i.e. they do not need to worry about cross-contamination, they can have some foods containing barley malt extract and they are allowed to consume some foods containing ‘spelt’, which is an old-fashioned variety of wheat (King’s College and Guys and St Thomas’ NHS Foundation Trust, 2017).
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register for the webinar but are unable to attend on the night are automatically sent a complete video of the session. These Somerset IBS webinars have now been showcased in the newly published NHS England document, ‘Transforming gastroenterology elective care services’, as an example of selfmanagement support for long term conditions (NHS England, 2017).
Summary IBS can have a significantly detrimental impact on quality of life and UK health economics. Misdiagnosis is common, so taking a detailed case history is essential to ensure correct care. The last decade has seen the development of robust recommendations for the dietary treatment of IBS, although research shows that the most effective and safest results are achieved with input from a specialist dietitian. The low FODMAP diet is now a recognised form of intervention, although reintroduction of FODMAP eliminated foods is essential to avoid negative effects on gut microbiota. Access to specialist dietitians and dietetic-led IBS clinics is steadily increasing and new technologies such as webinars, mobile phone apps and Utube videos can be recommended by healthcare professionals and have the potential to further improve patient access to accurate and reliable IBS information. JCN
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Revalidation Alert Having read this article, reflect on:
Rao SS, Yu S, Fedewa A (2015) Systematic review: dietary fibre and FODMAPrestricted diet in the management of constipation and irritable bowel syndrome. Aliment Pharmacol Ther 41(12): 1256–70
Why allergy testing is of no use for IBS Your knowledge of the different subgroups of IBS
Skodje GI, Sarna VK, Minelle IH, Rolfsen KL, Muir JG, Gibson PR, et al (2017) Fructan, rather than gluten, induces symptoms in patients with self-reported non-celiac gluten sensitivity. Gastroenterology pii: S0016– 5085(17)36302-3 [Epub ahead of print]
Types of diet that might be helpful for someone with IBS Why referral to a specialist dietitian is advisable and how to access them The different treatment approaches according to the type of IBS.
Skypala IJ, Venter C, Meyer R, deJong NW, Fox AT, Groetch M, et al (2015) The development of a standardised diet history tool to support the diagnosis of food allergy. Clin Transl Allergy 5: 7
Then, upload the article to the free JCN revalidation e-portfolio as evidence of your continued learning: www.jcn.co.uk/revalidation
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