Irritable bowel syndrome in adults

Short Text

Diagnosis and management of irritable bowel syndrome in primary care

Introduction

This pathway covers the diagnosis and management of irritable bowel syndrome in adults (18 years and older) in primary care.
Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders, with a prevalence estimated at between 10% and 20%. People present to primary care with a wide range of symptoms, some of which overlap with other gastrointestinal disorders.
Key elements of management are:
  • establishing a positive diagnosis
  • identifying symptoms that require prompt referral and
  • working in a long-term partnership with the person with irritable bowel syndrome.

Source guidance

The NICE guidance that was used to create the pathway.
Irritable bowel syndrome in adults. NICE clinical guideline 61 (2008)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Important information about diagnosing irritable bowel syndrome

Confirming a diagnosis of irritable bowel syndrome is crucial. The primary aim should be to establish the person's symptom profile, with abdominal pain or discomfort being a key symptom. It is also necessary to establish the quantity and quality of the pain or discomfort, and to identify its site (which can be anywhere in the abdomen) and whether this varies. This distinguishes irritable bowel syndrome from cancer-related pain, which typically has a fixed site.
When establishing bowel habit, showing people the Bristol stool form scale may help them with description, particularly when determining quality and quantity of stool. People presenting with irritable bowel syndrome symptoms commonly report incomplete evacuation/rectal hypersensitivity, as well as urgency, which is increased in diarrhoea-predominant irritable bowel syndrome. About 20% of people experiencing faecal incontinence disclose their incontinence only if asked. People who present with symptoms of irritable bowel syndrome should be asked open questions to establish the presence of such 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. These factors should be taken into consideration to facilitate effective consultation.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

17 December 2013 Minor maintenance update.
11 June 2013 Minor maintenance update.
19 October 2012 Minor maintenance update.

Supporting information

Glossary

Cognitive behavioural therapy
C-reactive protein
Endomysial antibodies
Erythrocyte sedimentation rate
Full blood count
Selective serotonin reuptake inhibitor
Tricyclic antidepressant
Tissue transglutaminase

Person reporting any of the following symptoms for at least 6 months: abdominal pain or discomfort, bloating, or a change in bowel habit

Person reporting any of the following symptoms for at least 6 months:
  • Abdominal pain or discomfort
  • Bloating
  • Change in bowel habit

Follow-up

Follow-up

Follow-up

Agree follow-up with the person based on symptom responses to interventions. This should form part of the annual patient review.
Investigate or refer to secondary care if 'red flag' symptoms appear during management and follow-up.
For more information about 'red flag' symptoms, see looking for 'red flag' indicators for referral to secondary care in this pathway.

Source guidance

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Referral for psychological interventions

Referral for psychological interventions

Referral for psychological interventions

For people whose symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory irritable bowel syndrome), consider referring for:
  • CBT
  • hypnotherapy
  • psychological therapy.

Source guidance

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Looking for 'red flag' indicators for referral to secondary care

Looking for 'red flag' indicators for referral to secondary care

Looking for 'red flag' indicators for referral to secondary care

Ask all people with possible irritable bowel syndrome symptoms if they have any of the following 'red flag' indicators and refer them to secondary care for further investigation if they have.
  • Unintentional and unexplained weight loss.
  • Rectal bleeding.
  • A 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.
Assess and clinically examine all people with possible irritable bowel syndrome symptoms and refer to secondary care if any of the following 'red flags' are found:
  • anaemia
  • abdominal masses
  • rectal masses
  • inflammatory markers for inflammatory bowel disease.
Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer in line with NICE's pathway on ovarian cancer.
See referral for suspected cancer (NICE clinical guideline 27) for detailed referral criteria where cancer is suspected.
NICE has also produced a pathway on colorectal cancer.

Source guidance

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Patient experience in adult NHS services pathway

View the 'Patient experience in adult NHS services overview' path

Paths in this pathway

Pathway created: October 2012 Last updated: December 2013

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