Irritable Bowel Syndrome

In this episode of PodMD, experienced Gastroenterologist and Hepatologist Dr Matt Kitson will be discussing the topic of IBS, including what IBS is, symptoms of the condition, the benefits of managing it well, its likelihood of reoccurrence and more.

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Matt Kitson

    Dr Matt Kitson is an experienced Gastroenterologist and Hepatologist whose private practice is based in Glen Iris, Melbourne. He completed Gastroenterology training in 2011 and was awarded a PhD by Monash University in 2015. Dr Kitson is a consultant at the Alfred Hospital and Senior Lecturer at Monash University. He also provides specialist medical services to Gippsland in regional Victoria and is involved in providing endoscopy and Gastroenterology training for Pacific Island doctors.

    Today, we’ll be discussing the topic of IBS.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Matt, thanks for talking with us on PodMD today.

    Matt: Thank you for having me.

    Question 1
    The topic of today’s discussion is Irritable Bowel Syndrome, also commonly known as IBS. Matt, can you give us a rundown of what IBS actually is?

    Matt: So irritable bowel syndrome is a very common functional Gastrointestinal disorder the gut is macroscopically and microscopically normal, but patients get significant symptoms. It’s probably present in about 15% of people and tends to be more common in females. It’s quite a heterogeneous condition and symptoms can vary quite significantly between patients. It’s a diagnosis of exclusion and in the top of my mind the main conditions I want to exclude before diagnosing irritable bowel syndrome is the presence of celiac disease, inflammatory bowel disease, or any gastrointestinal malignancy. Acute gastrointestinal infections whether they’re bacterial or viral, a really common trigger of IBS, and it’s very common for those symptoms to persist long after the infection has resolved. And a key factor in the development of these symptoms is the presence of visceral hypersensitivity, so the gut has its own nervous system, and if the innovation of the gut is incredibly sensitive, then patients are much more likely to develop the symptoms of IBS.

    Question 2
    What kind of symptoms would a patient with IBS typically present with?

    Matt: It’s very common for patients with IBS to have either lower abdominal pain or bloating. Distention is often present, and patients can commonly be troubled by excessive flatus. An altered bowel habit is almost universally present where there’s either a change in stool frequency change in stool form, or a mixture of both. These symptoms need to be present for at least three months, and it’s very common for patients to also complain of mucus in their stools. There’s four specific types of irritable bowel syndrome and I find that a Bristol Stool chart is incredibly helpful in identifying which subtype patients have. There’s Constipation predominant, irritable bowel syndrome, diarrhoea predominant irritable bowel syndrome, a mixed irritable bowel syndrome where patients fluctuate between Constipation, diarrhoea, and then an unclassified irritable bowel syndrome for patients that don’t meet any of those criteria. Certain foods or stress and anxiety are really common triggers, and exacerbating factors are patient symptoms.

    Question 3
    What are the benefits of this condition being diagnosed and managed well?

    Matt: Even though it is a functional gastrointestinal disorder, it being managed well can have a significant improvement in a patient quality of life. It’s really important to exclude other significant gastrointestinal disorders, and sometimes this can be done non-invasively and in other patients they might require a gastroscopy and a colonoscopy, depending on their age and symptoms and blood results.

    Once we’ve excluded significant gastrointestinal problems, quite often patients are actually quite relieved and have a piece of mind, and we can reassure them that the symptoms that they’re experiencing are not causing any harm to their gut. The other key thing about the management of IBS is that the patient feels empowered to manage those symptoms that they’re experiencing as well.

    Question 4
    What are the different treatment options currently available for IBS?

    Matt: To manage IBS well requires a multidisciplinary management with the involvement of a dietitian and potentially also the involvement of a psychologist. Sensitivity to fodmap’s is often present, and a low fodmap diet is the first line management. It results in improvement in symptoms in about 70% of patients, I point my patients in the direction of the Monash Fodmap app which is an incredibly useful tool and often refer them to a dietitian with expertise in the management of IBS. The standard approaches and elimination phase of a low fodmap diet, which is followed for about four to six weeks and then followed by a rechallenge phase of fodmaps. And a patient in a low fodmap diet fibre Supplementations really important, and I tend to prefer a sterculia based fibre supplements such as Normafibe over a selenium based fibre supplement such as Meta Musil as it tends to be better tolerated in patients with IBS. It’s really important to have a nutritionally adequate diet when patients are following an exclusion diet. And that’s why involvement of a dietitian in their management is so important. It’s also really important to identify patients who have a history of an eating disorder as going on an exclusionary diet may well cause more harm than good in these patients. The good thing about IBS is that there’s more than one option in the management of this condition.

    So the next thing to consider is whether a patient might benefit from gut directed hypnotherapy. If they don’t respond to a low fodmap diet, or are they not appropriate for that. In diarrhoea predominant irritable bowel syndrome it’s worthwhile trialling a 2 week course of rifaximin in patients who don’t respond to a low fodmap diet, this medication isn’t PBS listed, but a two week course costs about $100. Other potential options in patients who don’t improve with the above measures include trial of a Kiwi fruit extract such as Phloe and also trial of either peppermint tea or peppermint oil or mentec. As Peppermint is the smooth muscle relaxant and can significantly improve abdominal pain and cramping. is also a herbal supplement which has some evidence in use in IBS. In patients who have more refractory symptoms, and especially where pain is present, I consider use of a tricyclic antidepressants such as amitriptyline or an SSRI such as mirtazapine, and I tend to try this for at least 6 to 8 weeks to see if it resolves in, results in significant improvement in symptoms. In patients that are really troubled by refractory Constipation, other options that we can use our proclapride and linaclotide, although neither of these medications are currently PBS listed.

    Question 5
    Further to the treatment options you just mentioned, has there been much progress in the field in regards developments for IBS treatment?

    Matt: So those red flags to keep in the top of your mind are things like large volume diarrhoea, watery diarrhoea, nocturnal diarrhoea, greasy stools, presence of rectal bleeding or Molina. Unexplained weight loss, onset of these sorts of symptoms that are classic for IBS in a patient. Above the age of 50 is also a red flag. And then on routine blood testing if anaemia or iron deficiency is present needs to be further investigated and the other thing to keep in the back of your mind is what is the family history of the patient and if there’s a family history of inflammatory bowel disease, colorectal cancer or celiac disease, these patients will often need referral to Gastroenterologist for consideration of gastroscopy or colonoscopy. Again, to reiterate, celiac disease, inflammatory bowel disease, and malignancy are the key conditions that need to be excluded before a diagnosis of irritable bowel syndrome can be made. In terms of further investigations, a faecal calprotectin is an incredibly useful non-invasive test, and this will have a Medicare rebate from November and this is helpful to assess for inflammatory bowel disease. I would encourage all patients to be checked for Celiac serology and some patients will require gastroscopy and colonoscopy to further evaluate.

    Question 6
    Is IBS likely recur after treatment?

    Matt: IBS is a condition that patients will have to manage in the long term, and the symptoms of IBS can certainly be exacerbated by dietary lapses with fodmap intake or during periods of stress and anxiety, and during the COVID pandemic I’ve certainly noted a lot of my patients have had a significant exacerbation of their symptoms.

    Question 7
    When should a GP refer?

    Matt: I think it’s really important to involve a gastroenterologist in the management of these patients if any of those red flag symptoms that I mentioned in to present as often these patients will require further evaluation with the GASTROSCOPY and colonoscopy. The other subgroup of patients that it’s really important to involve a gastroenterologist in management are when either fodmaps or fibre aren’t working.

    Question 8
    Apart from often being involved in initial diagnosis, how is the GP involved in the treatment of IBS?

    Matt: As IBS is a condition that patients are going to need to manage in the long term, having a good relationship with their GP is incredibly important, and many patients may present to their GP if their symptoms flare up, whether due to dietary lapses or stress and anxiety. The other key thing to remember is the uh, a diagnosis of irritable bowel syndrome doesn’t exclude the development of other gastrointestinal conditions down the track, and so you need to be on the lookout if there’s a significant change in the pattern of symptoms and also patients with IBS also require routine bowel cancer screening from the age of 50 onwards and often GPs or the first port of call for a discussion about bowel cancer screening with patients.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on IBS.

    Matt: So the first key take home message is that IBS is a diagnosis of exclusion and the key conditions that need to be excluded are celiac disease, inflammatory bowel disease and the presence of gastrointestinal malignancy.

    The second key take home point is that IBS is a condition that requires multidisciplinary management. There are many treatment options available, whether it’s dietary, psychological, or pharmacotherapy, but we need to take a holistic view of the management of these patients

    and the 3rd and final take home point is that when IBS is managed well, it can result in a significant improvement in the quality of life of patients.

    Thanks for your time and the insights you’ve provided.

    Matt: Thank you for having me

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.