IBS or IBD: a N.I.C.E. Way to Tell

1. IBS or IBD: a N.I.C.E. Way to Tell

2. Dr Stephen Grainger Honorary Consultant Gastroenterologist King George and Queen’s Hospitals

3. Disclosures I have received payment from: Almirall speaking at meetings British Medical Journal reviewing Action Sets AP&T reviewer IBD Registry consultant adviser McKesson UK consultant adviser

4. Why is it difficult? Diagnosing GI symptoms can be challenging: Few symptoms, many conditions Lack of in-depth knowledge

5. Prevalence of GI conditions in the UK Incidence per CCG = national incidence/number of CCGs. Incidence per GP = incidence per CCG/100.

6. Case study: Kate Kate W* is 36 and works as a personal assistant in a busy office. Over the past 12 months, she has consulted five other GPs in your practice for symptoms of anxiety, headache, abdominal pain, and constipation. *All patient names are fictional

7. Case study: Kate When you see Kate, she explains that she has abdominal discomfort and frequent bloating. She does not pass stools very frequently and usually finds that she has to strain. She describes her stools as ‘hard,’ and finds that her symptoms are relieved by having a ‘good’ bowel movement.

8. Case study: Kate When asked how long she has been having symptoms, Kate explains that she has had them intermittently for 10 years, but has never received a satisfactory diagnosis or management plan.

9. An important part of GI diagnosis is eliminating organic disease Need to eliminate the possibility of organic disease: Check for alarm features

10. Alarm features Alarm features from NICE and BSG guidelines

11. Differential diagnoses

12. Case study: Kate Questioning reveals that Kate does not have any alarm features. From her notes, you can see that the results of previous investigations have been unremarkable, and therefore her history does not indicate cause for concern.

13. Case study: Kate You can be fairly confident of a functional diagnosis for Kate.

14. Case study: Janet • Janet S presented aged 30 with altered bowel habit: she used to open her bowels 2-3 times a day, but now goes up to 6 times a day with looser stools. • She has lost 3kg over the past three months and has abdominal pain on most days.

15. Case study: Janet • On questioning, her doctor discovers that Janet’s father recently passed away.

16. Case study: Janet

17. Case study: Janet • Janet’s GP ordered a full set of blood tests,the results of which were: Haemoglobin: 12.1 White blood count: 5.6 Platelet count: 414 Erythrocyte sedimentation rate: 12

18. Case study: Janet • Janet’s only abnormality was a slightly elevated platelet count. • Janet’s GP thought that her symptoms could be an acute reaction to the stress of losing her father, and asked her to return for a follow-up appointment in a month's time to re-check her blood tests.

19. Case study: Janet • Janet did not attend her appointment. • She returned a year later and explained that she had forgotten her last appointment as she was busy arranging her father’s funeral.

20. Case study: Janet • She still had episodic loose stools and abdominal pain. So far, she had managed her symptoms with over the counter loperamide, but she was worried that they hadn’t disappeared with time.

21. Case study: Janet Janet’s GP repeated her blood tests, andfound that her platelet count was still elevated (420). Janet’s GP decided to refer her to a gastroenterologist for further investigation.

22. Case study: Janet In secondary care, Janet’s blood tests were repeated. It was found that her CRP level was now high (20), as well as her platelets.

23. Janet was diagnosed with Crohn’s disease A colonoscopy was performed, which confirmed that Janet had Crohn’s disease.

24. Calprotectin and lactoferrin may help to distinguish IBS from IBD Faecal calprotectin Inflammatory marker Useful to determine which patients require endoscopy for IBD Faecal lactoferrin Inflammatory marker Useful for discriminating IBD from IBS patients and healthy subjects

25. 71/94 81/94 170/189 31/31 20/20 79/91 30/30 True positives True negatives BMJ July, 2010

26. Faecal Calprotectin

28. Need for referral Patients with alarm features need to be referred. It is important to have a lower referral threshold for people with colorectal cancer risk factors.

29. Colorectal cancerrisk factors Age >65 years Diet Obesity Lack of exercise Alcohol intake Smoking Family history Related conditions

30. Case study: Alan • Alan F is well known at his doctor’s surgery and presented at age 53 with intermittent diarrhoea (three months’ duration). • The doctor noted that his age and sex may indicate cause for concern, but since no other worrying features were present and his blood count was normal, he asked Alan to return in a month’s time to review his symptoms.

31. Case study: Alan

32. Case study: Alan • When Alan returned, he still had abdominal pain and diarrhoea. • Since Alan still did not have any worrying symptoms and his repeat full blood count was normal, he agreed with his GP to try pharmacological treatment (loperamide).

33. Case study: Alan • The doctor issued clear instructions for Alan to come back to the surgery for further investigation in six weeks if his symptoms persisted or if any other symptoms developed.

34. Case study: Alan • Six weeks later, Alan returned with painless rectal bleeding. A rectal exam revealed a haemorrhoid, but this did not sufficiently explain the bleeding and Alan’s GP referred him for urgentcolonoscopy. • Alan was found to have Dukes’ stage A annular adenocarcinoma of the sigmoid colon.

35. Alan was diagnosed with early stage bowel cancer Alan did not initially need referral, however, an alarm feature became apparent later. Due to the advice of his doctor to return if his symptoms changed, Alan was referred and his cancer diagnosed at an early stage. This is an example of safety netting.

36. NICE IBS Diagnostic Criteria1 Patients exhibiting any of the following symptoms for at least six months in the absence of red flags: Abdominal pain/discomfort Bloating Change in bowel habit • 1. NICE clinical guideline 61: irritable bowel syndrome in adults, 2008.

37. Specific examination findings: To exclude organic diagnosis: Abdominal masses/obstruction/enlarged liver2 Perianal/rectal examination As reassurance of absence of organic diagnosis: Carnett’s sign

38. Certain tests are recommended Non-invasive tests can also exclude the possibility of an organic diagnosis: Full blood count Erythrocyte sedimentation rate/C-reactive protein Ca 125 Coeliac serology + serum IgA Faecal calprotectin

40. Which patients need to be referred? Alarm features Genuine uncertainty about diagnosis Concerns are not allayed after multiple consultations

41. Secondary care investigations for IBS *Including biopsy.

42. Agreeing an IBS diagnosis: Explanation Helps to relate symptoms to the underlying disorder and the approaches to treatment Worries Reassurance can only come when the patient’s concerns are addressed Goals Set realistic goals to avoid patient dissatisfaction

43. Symptoms can be induced by stress

44. Symptoms can be induced by diet

45. The doctor may be the most important drug This is particularly important in IBS: Chronic and relapsing condition Long-term consultation pattern

46. Pharmacological management should be tailored to symptoms Aim is symptomatic relief of the most troublesome symptom, rather than cure. Different subtypes require different management strategies: IBS with constipation IBS with diarrhoea IBS mixed

47. Summary of management options in IBS PAIN Antispasmodics Linaclotide (IBS-C) Antidepressants TCAs SSRIs  BOWELS Laxatives osmotic stimulant fibre ? Linaclotide (IBS-C) BLOATING Probiotics Linaclotide (IBS-C)  BOWELS Antimotility agents  FODMAPs *Not licensed for IBS.