Update information March 2017 Recommendation 1.1.1.2 in the short version was updated by NICE with more recent guidance on recognition and referral for suspected cancer. Recommendation 1.1.1.3 in the short version was removed as it was no longer needed after the changes to recommendation 1.1.1.2. February 2015 NICE has made new recommendations relating to the clinical management (dietary and lifestyle advice, and pharmacological therapy) of people with IBS. The recommendations and evidence in sections 3, 7.6, 8.4, 8.5.2 and 9.1 of this guideline that have been highlighted in grey have been stood down and replaced. New recommendations on dietary and lifestyle advice, and pharmacological therapy, can be found in the irritable bowel syndrome in adults update CG61.1. September 2012 A recommendation in this guideline (see pages 28 and 37) has been partially updated by recommendation 1.1.2.1 in 'Ovarian cancer' (NICE clinical guideline 122, 2011).
The National Institute for Health and Clinical Excellence (‘NICE’ or ‘the Institute’) commissioned the National Collaborating Centre for Nursing and Supportive Care (NCC-NSC) to develop guidelines on irritable bowel syndrome (IBS). This follows referral of the topic by the Department of Health and Welsh Assembly Government. This document describes the methods for developing the guidelines and presents the evidence and consensus based recommendations. It is the source document for the NICE (abbreviated version for health professionals); Understanding NICE Guidance, and; Quick Reference Guide versions of the guidelines which will be published by NICE. The guidelines were produced by a multidisciplinary guideline development group and the development process was undertaken by the NCC-NSC.
The main areas examined by the guideline were during the:
- IBS Positive Diagnosis
- Red flags for suspected cancer and other morbidities
- IBS Management focussed on lifestyle advice relating to diet and physical activity, drug and psychological therapies.
- Referral and follow-up.
This guideline covers areas relevant to the diagnosis and management of IBS reflecting the complete patient journey, from the person presenting with IBS symptoms, positive diagnosis and management, targeted at symptom control. The guideline incorporates Cochrane reviews, published NICE clinical and public health guidance, Health Technology Assessment reports, systematic and health economic reviews produced by the National Collaborating Centre for Nursing and Supportive Care. Recommendations are based on clinical and cost effectiveness evidence, and where this is insufficient, the GDG used all available information sources and experience to make consensus recommendations using nominal group technique.
The care pathway reflects a logical sequencing to what is, in effect, tracking the progress of the patient from entry to primary care through to lifestyle adaptation and therapeutic intervention, enabling the person with IBS to learn to live with this chronic condition. The partnership that the person with IBS forms with their primary care clinician/team is key to this being a positive experience where shared decision making feature strongly in aiming for symptom control. This sequencing has enabled the Guideline Development Group (GDG), supported by the technical team, to look at the evidence reviews, understand the clinical context and consider the patient voice when shaping guidance. Patient experience is at the heart of development. Evidence published after June 2007 was not considered.
Healthcare professionals should use their clinical judgement and consult with patients when applying the recommendations. Recommendations aim to reduce variations in practice, thus improving patient outcomes related to both the diagnosis and continuous management of IBS. This guidance is intended to be the source document for primary care local policy development. Its success is dependent on the primary health care team and patients working in partnership in implementing key recommendations. The algorithm provides healthcare professionals, patients and carers to visualise the care pathway, summarising clinical and cost effective evidence and consensus decisions.
Key recommendations
The key recommendations were identified by the GDG as the recommendations that are the priorities for implementation. (The numbering corresponds to the abbreviated (NICE) version of the guideline).
- 1.1.1.1.
Healthcare professionals should consider assessment for IBS if the person reports having had any of the following symptoms for at least 6 months:
- Abdominal pain or discomfort
- Bloating
- Change in bowel habit.
- 1.1.1.2.
All people presenting with possible IBS symptoms should be asked if they have any of the following “red flag” indicators and should be referred to secondary care for further investigation if any are present (see ‘Referral guidelines for suspected cancer’, NICE clinical guideline 27, for detailed referral criteria where cancer is suspected):
- 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 6 weeks in a person aged over 60 years.
- 1.1.1.3.
All people presenting with possible IBS symptoms should be assessed and clinically examined for the following “red flag” indicators and should be referred to secondary care for further investigation if any are present (see ‘Referral guidelines for suspected cancer’, NICE clinical guideline 27, for detailed referral criteria where cancer is suspected).
- Anaemia
- Abdominal masses
- Rectal masses
- Inflammatory markers for inflammatory bowel disease.
If there is significant concern that symptoms may suggest ovarian cancer, a pelvic examination should also be considered.
- 1.1.1.4.
A diagnosis of IBS should be considered only if the person has abdominal pain or discomfort that is either relieved by defaecation or associated with altered bowel frequency or stool form. This should be accompanied by at least two of the following four symptoms:
- 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.
Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS, and may be used to support the diagnosis.
- 1.1.2.1.
In people who meet the IBS diagnostic criteria, the following tests should be undertaken to exclude other diagnoses:
- Full blood count (FBC)
- Erythrocyte sedimentation rate (ESR) or plasma viscosity
- C-reactive protein (CRP)
- Antibody testing for coeliac disease (endomysial antibodies [EMA] or tissue transglutaminase [TTG]).
- 1.1.2.2.
The following tests are not necessary to confirm diagnosis in people who meet the IBS diagnostic criteria:
- 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).
- 1.2.1.1.
People with IBS should be given information that explains the importance of self-help in effectively managing their IBS. This should include information on general lifestyle, physical activity, diet and symptom-targeted medication.
- 1.2.1.5.
Healthcare professionals should review the fibre intake of people with IBS, adjusting (usually reducing) it while monitoring the effect on symptoms. People with IBS should be discouraged from eating insoluble fibre (for example, bran). If an increase in dietary fibre is advised, it should be soluble fibre such as ispaghula powder or foods high in soluble fibre (for example, oats).
- 1.2.2.4.
People with IBS should be advised how to adjust their doses of laxative or antimotility agent according to the clinical response. The dose should be titrated according to stool consistency, with the aim of achieving a soft, well-formed stool (corresponding to Bristol Stool Form Scale type 4).
- 1.2.2.5.
Healthcare professionals should consider tricyclic antidepressants (TCAs)** as second-line treatment for people with IBS if laxatives, loperamide or antispasmodics have not helped. TCAs are primarily used for treatment of depression but are only recommended here for their analgesic effect. Treatment should be started at a low dose (5–10 mg equivalent of amitriptyline), which should be taken once at night and reviewed regularly. The dose may be increased, but does not usually need to exceed 30 mg.
The IBS algorithm demonstrates the importance of positive diagnosis in providing an effective platform for both the person presenting with IBS symptoms and primary care clinician to work towards symptom control. It importantly identifies red flag symptoms, meaning in practice that the person would leave this guideline and be referred to secondary/tertiary care for further investigation. The emergence of any of the ‘red flags’ during management and follow up should prompt referral for further investigation and/or referral into secondary care.
IBS Algorithm (PDF, 65K)
Footnotes
- **
At the time of publication (February 2008) TCAs did not have UK marketing authorisation for the indications described. Informed consent should be obtained and documented.
Publication Details
Copyright
Publisher
Royal College of Nursing (UK), London
NLM Citation
National Collaborating Centre for Nursing and Supportive Care (UK). Irritable Bowel Syndrome in Adults: Diagnosis and Management of Irritable Bowel Syndrome in Primary Care [Internet]. London: Royal College of Nursing (UK); 2008 Feb. (NICE Clinical Guidelines, No. 61.) 1, Executive summary, key recommendations and IBS algorithm.