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IBS management in the community

IBS management in the community

Irritable Bowel Syndrome & Causes

Irritable bowel syndrome is a disorder of the lower gastrointestinal tract. It is a chronic, relapsing and often life-long condition with a multifactorial cause. Symptoms usually affects patients between 20 to 30 years old, with women being twice as likely to be affected. It is a common condition, affecting around 16% of adults in the UK. (Rutter, 2017)

Irritable Bowel Syndrome does not have a singular cause, many factors including environmental and genetic contribute to the disease. Some include:

  • Abnormal gastrointestinal immune function.
  • Changes in intestinal microbiota.
  • Altered gut motility.
  • Central pain processing of afferent gut signals can become abnormal and contribute to IBS – visceral hypersensitivity.
  • IBS can be caused by a combination of these factors.
  • Symptom presentation can be influenced by the psychological state, as stress and/or depression influences the brain-gut axis.

Risk Factors

  • Genetics
  • Enteric infection
  • Gastrointestinal Inflammation
  • Diet
  • Drugs
  • Psychosocial factors (NICE, 2021)

Clinical Features

  • Abdominal discomfort/pain – cramping in the lower/mid abdomen. Passing stool can relieve abdominal pain
  • Altered bowel habits – diarrhoea, constipation or alternating of these.
  • Stool with visible mucous
  • Bloating
  • There may be mild tenderness of the right or left lower quadrant of the abdomen (BMJ, 2021).

Red flags associated with diarrhoea require referral to a doctor and consist of the following:

  • If the pain in the abdomen is severe
  • Blood in the stool
  • Unintentional or unexplained weight loss
  • A family history of gastrointestinal cancer, IBD or coeliac disease
  • If the patient is over 45 years or under 16 with recent changes in bowel habits
  • Waking up from sleep with the need to defecate.

Differential Diagnosis (questions to ask the patient)

  1. Is the patient under 16 years old?
    • Yes = IBS is unlikely in this age group, refer the patient for further examination
    • No = Ask further questions
  2. Is the patient over 45 years old with recent change in bowel habits?
    • Yes = Refer for further investigation
    • No = Ask further questions
  3. Does the patient have a history of alternating diarrhoea and constipation?
    • Yes = Ask further questions
    • No = Ask if patient has lower abdominal pain and check for other causes
  4. Are these symptoms due to medication the patient is taking?
    • Yes = Speak with prescriber and suggest alternative medication
    • No = Ask further questions
  5. Does the patient have flare-up of symptoms during major life events?
    • Yes = Ask further questions
    • No = Likely to be IBS, refer to rule out other causes
  6. Does the patient have any associated symptoms such as bloating and wind?
    • Yes = This likely IBS, provide advice and treatment
    • No = Likely to be IBS, refer to rule out other causes

Treatments

The first stage in treatment is to identify psychological factors such as stress which contribute to symptoms. Provide advice on avoidance and healthy coping mechanisms.

The diet of the patient is also studied, discussed with patient, and altered as appropriate to control symptoms – eating healthy and balanced meals regularly, removing suspected trigger foods for a couple of weeks before reintroducing. Having more or less fibre depending on if diarrhoea or constipation is dominant. The FODMAP diet has also shown promise in alleviating symptoms of IBS in patients and can be recommended alongside the advice of a dietician. 

Encourage the patient to drink enough water, around 8 cups daily (Rutter, 2017).

Antispasmodics:

Hyoscine Butylbromide

  • Mechanism:  Prevents the contraction of smooth muscles in the gut by binding to muscarinic receptors (M3). This prevents acetylcholine from binding and activating receptors. This reduces spasms and pain (DrugBank, 2021).
  • Indication: Symptomatic relief of irritable bowel syndrome (NICE, 2021)
  • Side-effects/Cautions:
    • Dry mouth, dizziness, drowsiness, palpitations
    • Constipation, nausea and vomiting
    • Headaches(NICE, 2021)
    • Not suitable for patients with glaucoma, myasthenia gravis or a blocked bowel.
    • Not suitable for pregnant or breast-feeding women(emc, 2021)
  • Evidence: A study looked at the effect of hyoscine on both aspects of motility – electrical and biomechanical. Hyoscine was shown to reduce both indexes by 50.9% and 36.5% respectively. This showed that hyoscine is an effective treatment for IBS as it reduces motility, which is what causes intestinal spasms (Madileine F Américo, 2009).

Mebeverine

  • Mechanism: This drug is a synthetic anticholinergic, it reduces spasms through the contribution of multiple mechanisms such as decreasing ion channel permeability, local anaesthetic effect and changing water absorption, however the exact mechanism of action is not known (emc, 2020).
  • Indication: Symptomatic relief of irritable bowel syndrome (NICE, 2021)
  • Side-effects/Cautions:
    • Skin reactions - Angioedema, face oedema and urticaria
    • Hypersensitivity – allergic reactions possible
  • Evidence: Clinical trials have shown mebeverine to be safe and effective in treating IBS, however these trials were not placebo controlled. In placebo-controlled studies, mebeverine has not shown statistically superior effectiveness in comparison to placebo (Annaházi, 2014).

Alverine

  • Mechanism: Acts directly on the smooth muscle of the intestine. It decreases sensitivity of contractile proteins to calcium and selectively inhibits 5-HT1a receptors. It is an antispasmodic, causing relaxation of smooth muscles leading to reduced pain and cramps (emc, 2020).
  • Indication: Symptomatic relief of GI disorders including irritable bowel syndrome (NICE, 2021)
  • Side-effects/Cautions:
    • Dizziness, headache, nausea
    • Signs of an allergic reaction such as itching, swollen lips/tongue or breathing difficulties.
    • Not suitable for pregnant or breastfeeding patients.
    • Not suitable for patients with obstruction of the gut.
    • Not suitable for patients with allergies to Alverine
  • Evidence: Studies have shown that using Alverine for treating symptoms of IBS lead to a slight improvement of symptoms after 12 weeks. These results were not statistically superior to the placebo group. Evidence suggests that using Alverine with simethicone is significantly more effective in treating IBS (Wittmann, 2010).

Peppermint oil

  • Mechanism: Causes a reduction of influx of calcium ions, this leads to relaxation of intestinal smooth muscle and reduction in contractions (DrugBank, 2021).
  • Indication: Relief of abdominal colic and distension, particularly in IBS (NICE 2021)
  • Side-effects/Cautions:
    • Stop using this medicine if you experience any signs of an allergic reaction; rash, headache, bradycardia, shaking or loss of coordination.
    • Heartburn or acid reflux.
    • Nausea and vomiting
    • Burning sensation in the mouth (McNeil Products Ltd, 2021).
  • Evidence: In a systematic review and meta-analysis looking at the effect of peppermint oil in the treatment of IBS, it was concluded that peppermint oil was more effective than placebo in treating IBS (Ford A C, 2008).

References

Annaházi, A. R. (2014). Role of antispasmodics in the treatment of irritable bowel syndrome. World journal of gastroenterology, 6031-6043.

BMJ. (2021). Irritable bowel syndrome: History and exam. Retrieved from BMJ Best Practice: https://bestpractice.bmj.com/topics/en-gb/122/history-exam

DrugBank. (2021). DrugBank Online. Retrieved from Butylscopolamine: https://go.drugbank.com/drugs/DB09300

DrugBank. (2021). Peppermint oil. Retrieved from DrugBank Online: https://go.drugbank.com/drugs/DB11198

emc. (2020). Alverine Citrate 120 mg Hard Capsules. Retrieved from Medicines.org: https://www.medicines.org.uk/emc/product/11542/smpc

emc. (2020). Mebeverine 135mg film-coated tablets. Retrieved from medicines.org: https://www.medicines.org.uk/emc/product/2315/smpc

emc. (2021). Buscopan 10 mg Tablets. Retrieved from medicines.org: https://www.medicines.org.uk/emc/files/pil.1775.pdf

Ford A C, T. N.-O. (2008). Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis. BMJ.

Madileine F Américo, J. R. (2009). Electrical and mechanical effects of hyoscine butylbromide on the human stomach: a non-invasive approach. Physiological Measurement, 363.

McNeil Products Ltd. (2021). Colpermin IBS Relief Capsules; Peppermint Oil. Retrieved from Medicines.org: https://www.medicines.org.uk/emc/files/pil.1076.pdf

NICE. (2021). Hyoscine Butylbromide. Retrieved from BNF.NICE: https://bnf.nice.org.uk/drug/hyoscine-butylbromide.html

NICE. (2021). Irritable Bowel Syndrome: What causes irritable bowel syndrome? Retrieved from NICE.CKS: https://cks.nice.org.uk/topics/irritable-bowel-syndrome/background-information/causes/

Rutter, P. (2017). Irritable Bowel Syndrome (IBS). In P. Rutter, Community Pharmacy: Symptoms, Treatments and Diagnosis (pp. 187-191). Eslevier.

Wittmann, T. P. (2010). Clinical trial: the efficacy of alverine citrate/simeticone combination on abdominal pain/discomfort in irritable bowel syndrome--a randomized, double-blind, placebo-controlled study. Alimentary pharmacology & therapeutics, 615-624. 

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