Transcript Using this template

Irritable bowel syndrome
in adults
Implementing NICE guidance
2008
NICE clinical guideline 61
What this presentation covers
Background
Key priorities for implementation
Costs and savings
Discussion
Find out more
Background
Irritable bowel syndrome (IBS) has a prevalence of
10-20% in the general population
It is a chronic, relapsing and often life-long disorder
The people most commonly affected are those aged
20–30 years
It is twice as common in women as in men
Initial assessment
Consider assessment for IBS if any of these symptoms
have been present for at least 6 months
• Abdominal pain or discomfort
• Bloating
• Change in bowel habit
Initial assessment:
‘red flag’ indicators
Refer to secondary care if any of these indicators present
Ask
• Unintentional and unexplained weight loss
• Rectal bleeding
• A family history of bowel or ovarian cancer
• Bowel habit change for > 6 weeks in person over 60 years
Assess/examine
• Anaemia
• Abdominal masses
• Rectal masses
• Inflammatory markers for inflammatory bowel disease
Initial assessment:
establishing the diagnosis
Consider IBS diagnosis only if the person has abdominal
pain that is relieved by defaecation or associated with
altered bowel frequency or stool form, and at least two
symptoms from:
• altered stool passage
• abdominal bloating, distension, tension or hardness
• symptoms made worse by eating
• passage of mucus
Initial assessment:
establishing the diagnosis
Take the following factors into account to facilitate effective
consultation
• People should be asked open questions to establish
symptoms, 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 the
cultural, ethnic and communication needs of people for
whom English is not a first language or who may have
cognitive and/or behavioural problems or disabilities
Bristol Stool Form Scale
Reproduced
by
kind
permission of Dr K W Heaton,
Reader in Medicine at the
University of Bristol. 2000
Norgine Ltd.
Diagnostic tests
In people who meet the IBS diagnostic criteria, the
following tests should be undertaken to exclude other
diagnoses:
• full blood count (FBC)
• erythrocyte sedimentation rate (ESR) or
plasma viscosity
• c-reactive protein (CRP)
• antibody testing for coeliac disease
(endomysial antibodies [EMA]
or tissue transglutaminase [TTG])
Diagnostic tests
The following tests are not necessary to confirm a
diagnosis where IBS diagnostic criteria are met:
• ultrasound
• rigid/flexible sigmoidoscopy
• colonoscopy; barium enema
• thyroid function test
• faecal ova and parasite test
• faecal occult blood test
• hydrogen breath test (for lactose intolerance and
bacterial overgrowth).
Clinical management of IBS:
dietary and lifestyle advice
People with IBS should be given information that
explains the importance of self-help in effectively
managing their IBS
Clinical management of IBS:
dietary and lifestyle advice
Healthcare professionals should review the fibre intake
of people with IBS, adjusting (usually reducing) it while
monitoring the effect on symptoms
If symptoms persist after following lifestyle/dietary
advice, consider referral to a dietitian
Clinical management of IBS:
pharmacological therapy
Advise people with IBS how to adjust their doses of
laxative or antimotility agent
Healthcare professionals should consider low-dose
tricyclic antidepressants (TCAs) as second-line
treatment, recommended only for their analgesic effect
Costs
per 100,000 population
Recommendations with significant costs
Reduction in unnecessary diagnostic tests
Costs (£ per year)
– 17,200
Increased referral to dietitian
2,600
Increased prescribing of low-dose antidepressants
31,600
Increased referral to psychological interventions
3,500
Estimated net cost of implementation
20,500
Discussion
What does our primary care IBS pathway look like?
Where do our local protocols need updating to reflect all
the recommendations in the guideline?
How can we manage the expectations of clinicians and
patients about the use of tests to diagnose IBS?
When should psychological interventions be considered?
Are we offering ineffective treatments for IBS?
For example, reflexology, acupuncture.
Find out more
Visit www.nice.org.uk/cg061 for:
•
•
•
•
Other guideline formats
Costing report and template
Audit support
Algorithm for diagnosis and management of IBS
within primary care
• IBS dietary information resource