What to do with suspected IBS in Under 2 Minutes

Irritable bowel syndrome (IBS) affects 20% of the population. The diagnosis should be considered in patients with at least a six month history of:

  •  Abdominal pain or discomfort
  •  Bloating
  •  Change in bowel habit


  • Consider diagnosing IBS if abdominal pain or discomfort is:
  •  Relieved by defaecation or
  •  Associated with altered bowel frequency or stool form

and at least two of the following:

  • Altered stool passage (straining, urgency, incomplete evacuation)
  •  Abdominal bloating, distension, tension or hardness
  •  Symptoms made worse by eating
  •  Passage mucous
  • Lethargy, nausea, backache and bladder symptoms may be used to support diagnosis.

“Red Flag” indicators (refer to secondary care (Specialist GI Unit ) if present):

  • Unintentional and unexplained weight loss
  • Rectal bleeding
  •  Any family history of bowel or ovarian cancer
  • In people aged over 60, a change in bowel habit lasting more than 6-weeks with looser and/or more frequent stools.
  •  Anaemia
  • Abdominal masses
  •  Rectal masses
  •  Inflammatory markers for inflammatory bowel disease

If symptoms suggest ovarian cancer, undertake appropriate examination and referral Investigations to exclude other diagnoses. Investigate/refer as appropriate if abnormal:

  • Full blood count (FBC)
  • Erythrocyte sedimentation rate (ESR)
  • C-reactive protein (CRP)
  • Anti-body testing for Coeliac Disease (Tissue Transglutaminase – TTG)

What next and when:
Provide information about self-help covering lifestyle, physical activity, diet and symptom targeted medication. Arrange follow up to assess response and re-assess “red flags”.
First line pharmacological treatment

  • Choose single or combination medication based on predominant symptom(s).
  •  antispasmodic agents
  •  laxatives for constipation (not lactulose)
  • loperamide for diarrhoea
  • Advise people to adjust doses according to response, shown by stool consistency.
  • Aim for soft well formed stool (Bristol Stool Form Type 4 )bristol stool type,faeces chart,bristol stool chart type,meyers scale,bristol stool scale ibs

Second line pharmacological treatment
Consider tricyclic antidepressants(TCAs)

Start at a low dose (5-10 mgs equivalent of amitriptyline) taken at night and review regularly. The dose may be increased (but should not exceed 30 mgs)
Consider selective serotonin reuptake inhibiters (SSRIs) only if TCAs are ineffective or contraindicated. Take into account the possible side effects of TCAs and SSRIs if prescribing for the first time.
Referral for psychological interventions:

People whose symptoms do not respond to pharmacological treatments after 12-months and who develop a continuing symptom profile (refractory IBS) consider referring for:
cognitive behavioural therapy (CBT) & hypnotherapy psychological therapy

Source: Sister Lynette Byatt (specialist sister) and Dr Ewen Cameron (Consultant), Department of Gastroenterology, Addenbrooke’s Hospital
Date16/4/10 Review April 2011