Transcript Is it IBS or IBD- A N.I.C.E way to tell

IBS or IBD: a N.I.C.E. Way to Tell
Dr Stephen Grainger
Honorary Consultant Gastroenterologist
King George and Queen’s Hospitals
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
Why is it difficult?
Diagnosing GI symptoms can be challenging:
• Few symptoms, many conditions
• Lack of in-depth knowledge
Prevalence of GI conditions in the UK
Incidence per CCG = national incidence/number of CCGs.
Incidence per GP = incidence per CCG/100.
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
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.
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.
An important part of GI diagnosis is
eliminating organic disease
Need to eliminate the possibility of organic disease:
• Check for alarm features
Alarm features
Alarm features from NICE and BSG guidelines
Differential diagnoses
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.
Case study: Kate
You can be fairly confident of a functional
diagnosis for Kate.
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.
Case study: Janet
On questioning, her doctor discovers that
Janet’s father recently passed away.
Case study: Janet
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
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.
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.
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.
Case study: Janet
Janet’s GP repeated her blood tests, and
found that her platelet count was still elevated
(420).
Janet’s GP decided to refer her to a
gastroenterologist for further investigation.
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.
Janet was diagnosed with
Crohn’s disease
A colonoscopy was performed, which confirmed
that Janet had Crohn’s disease.
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
71/94
81/94
170/189
31/31
20/20
79/91
30/30
True positives
True negatives
BMJ July, 2010
Faecal Calprotectin
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.
Colorectal cancer
risk factors
• Age >65 years
• Smoking
• Diet
• Family history
• Obesity
• Related conditions
• Lack of exercise
• Alcohol intake
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.
Case study: Alan
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).
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.
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 urgent colonoscopy.
Alan was found to have Dukes’ stage A annular
adenocarcinoma of the sigmoid colon.
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.
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.
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
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
Which patients need to be referred?
• Alarm features
• Genuine uncertainty about diagnosis
• Concerns are not allayed after multiple consultations
Secondary care investigations for IBS
*Including biopsy.
Agreeing an IBS diagnosis:
Explanation
disorder
Helps to relate symptoms to the underlying
and the approaches to treatment
WorriesReassurance can only come when the patient’s
concerns are addressed
Goals
Set realistic goals to avoid patient dissatisfaction
Symptoms can be induced by stress
Symptoms can be induced by diet
The doctor may be the
most important drug
This is particularly important in IBS:
• Chronic and relapsing condition
• Long-term consultation pattern
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
Summary of management options in IBS
PAIN
BLOATING
Antispasmodics
Probiotics
Linaclotide (IBS-C)
Linaclotide (IBS-C)
Antidepressants
TCAs
SSRIs
 BOWELS
Laxatives
osmotic
stimulant
fibre ?
Linaclotide (IBS-C)
*Not licensed for IBS.
 BOWELS
Antimotility agents
 FODMAPs