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CLINICAL: CHRONIC ILLNESS


symptom severity. Reduction in primary care consultations.


ESTABLISHING THE DIAGNOSIS Patients may present in primary care with differing symptom profiles, most commonly “diarrhoea predominant”, “constipation predominant” and alternating symptoms of these. Clinical management in primary care will very much depend on the presenting symptoms. Different symptom types may have differing prognoses and this will assist the healthcare professional in determining the type and urgency of investigations and subse- quent management. IBS most commonly affects people between the ages of 20-30


years and is more common in women than men. The prevalence of the condition in the general population is estimated to lie some- where between 10 and 20%. Recent trends indicate that there is also a significant prevalence of IBS in older people; therefore, IBS diagnosis should be a consideration when an older person presents in primary care with unexplained abdominal symptoms. The true prevalence of IBS in the whole population may be


higher than estimated, because it is thought that many people with IBS do not actively seek out medical advice; NHS Direct online data4


suggest that 75% of people using this service rely on


self-care and self-medication. In England and Wales, the number of people consulting for IBS is extrapolated at between 1.6 and 3.9 million.5 Evidence suggests that age and race have no consistent effect


on the incidence of symptoms. Appropriate action should be taken to facilitate effective consultation. Causes of IBS have not been adequately defined, although gut hypersensitivity, disturbed colonic motility, post-infective bowel dysfunction or defective anti-pain system are possible causes.1


Stress commonly aggra-


vates the disorder and around half of IBS outpatients attribute the onset of symptoms to a stressful life event. Lactose, gluten or other food intolerance is also identified as an antecedent. Colonic flora may be abnormal in IBS patients.7


Patients with IBS tend to alter


their diet to alleviate symptoms of IBS, often this is self-directed, or guidance is sought from inadequately qualified nutritionists. Excluding individual foods or complete food groups can readily lead to inadequate nutrient intake and ultimately malnutrition. In ad- dition, symptoms remain unresolved, leading to further inappropri- ate dietary restriction. Primary Care: initial assessment; consider assessment for IBS if


any of these symptoms have been present for six months: Abdominal pain. Bloating. Change in bowel habit.


Ask about: Any unintentional and unexplained weight loss. Rectal bleeding. Family history of bowel or ovarian cancer. Bowel habit change for over 6 weeks in a patient over 60 years of age.


Assess and examine: Anaemia. Abdominal masses. Rectal masses. Inflammatory markers for inflammatory bowel disease.


CLINICAL MANAGEMENT OF IBS; DIETARY AND LIFESTYLE ADVICE Many patients attending the practice with IBS, with or without diagnosis, will have spent time in trying to alleviate their symptoms in a variety of ways. Most commonly, this will have been trial and error with their diet. Patients 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. Healthcare professionals should try to encourage patients with


IBS to identify and make the most of their available leisure time to create relaxation time. Physical activity levels of patients should be assessed using the General Practice Physical Activity Question- naire. (See Appendix J NICE Guidance 2008).6


Patients with low


activity levels should be given brief advice and counselling to encourage them to increase their activity levels. Diet and nutrition should be assessed for patients with IBS and


the following general advice given: Have regular meals and take time to eat. Avoid missing meals or leaving long gaps between eating. Drink at least eight cups of fluid a day, especially water or other non-caffeinated drinks, for example herbal teas. Restrict tea and coffee to three cups per day. Caffeine can act


ESTABLISHING THE DIAGNOSIS The use of diagnostic criteria has merged over the last three decades, with leading GI specialists such as Manning and Kruis leading the way. Such diagnostic criteria were forerunners to a consensus process amongst leading clinicians which became known as the Rome process. Rome 111 is the latest iteration and builds on the validated work from authors, in particular the Manning criteria.1 Patients should be asked open questions to establish symp-


toms, for example, “tell me about how your symptoms affect aspects of your daily life, such as leaving the house.” Healthcare professionals should be sensitive to cultural, ethnic


and communication needs of people for whom English is not their first language or who may have cognitive and or behavioural problems or disabilities. You should consider IBS diagnosis only if the patient has abdomi- nal pain that is relieved by defaecation or associated with altered bowel frequency or stool form and at least two symptoms from the following: Altered stool passage. Abdominal bloating, distension, tension or hardness. Symptoms made worse by eating. Passage of mucus.


Diagnostic Tests: Full blood count. Erythrocyte sedimentation rate or plasma viscosity. C-reactive protein. Antibody testing for celiac disease. Endomysial antibodies or tissue transglutiminas.


Patients are likely to be referred to a secondary care specialist if symptoms are atypical (for example, patients over 40 years with change in bowel habit and/or rectal bleeding), or if GI or ovarian cancer is suspected.


48 Nursing in Practice March/April 2012


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