It’s time I took a good look at the NICE guidelines for the diagnosis and treatment of IBS in the UK. NICE is the National Institute for Clinical Excellence, and its job is to basically provide guidance to NHS doctors and nurses on various medical issues.
Now, this may well sound bone-crunchingly dull, but these guidelines are the gold standard for IBS treatment and so we need to take them seriously. If NICE says that IBS is caused by unhappy childhoods and over-bearing mothers then we’re all in a lot of trouble.
The latest version of the IBS guidelines was published in February 2008. I should really have had a look at the guidelines when they came out, but I do try to watch at least eight hours of television a day for personal reasons, which eats into my time rather, plus I’m always wary about reading this kind of stuff because it might get me in a strop. Who knows what unadulterated drivel I might find in there – IBS all a figment of our imaginations? A mild disorder easily treated with peppermint? Who can say.
But let’s dive in anyway and see what we get. There are three different versions of the guidelines: one incredibly long version, one slightly long version, and a brief idiot’s guide, and I’m gonna concentrate on the two shorter versions because of my aforementioned telly-watching commitments. It should be noted that these guidelines are for GPs in primary care, rather than gastroenterologists, who presumably should know what the hell they’re doing anyway.
The guidelines start by describing what diagnostic tests should be used if IBS is suspected. The emphasis is on making a positive diagnosis, rather than the traditional diagnosis of exclusion. So, patients should NOT have a colonoscopy, sigmoidoscopy, ultrasound, or thyroid function test, for example.
In fact, the only tests recommended are a full blood count (checking for anemia and lots of other stuff), an erythrocyte sedimentation rate (ESR) test (for inflammation and autoimmune diseases), a c-reactive protein test (mainly looking for inflammatory bowel diseases) and an antibody test for celiac disease.
This seems to be in line with current IBS thinking worldwide, which has moved away from the exclusion diagnosis idea, and I think it’s probably true to say that fewer patients are having colonoscopies as a matter of routine just because they present with IBS-type symptoms. On the other hand, there are plenty of IBSers who have never been near a test for celiac disease.
I’m quite surprised to see that a ‘hydrogen breath test for lactose intolerance or bacterial overgrowth’ is listed among the tests that should not be performed. I guess this shows that Dr Mark Pimentel’s theories of small bacterial overgrowth are famous enough to be mentioned, but not established enough to be recommended.
The guide includes general diagnostic criteria, and these are based on the standard Rome Criteria – abdominal pain/discomfort, change of bowel habit, pain relieved by defecation etc. The only unusual thing here was the list of possible supporting symptoms: lethargy, nausea, backache and bladder symptoms. You don’t usually see bladder symptoms listed as a possible factor in IBS, but I guess there are lots of IBSers with bladder problems too.
So, now we’re all nice and diagnosed, the guide moves on to treatment advice, starting with some lifestyle and diet tips. These are quite basic but generally useful. Some slightly airy-fairy stuff about encouraging patients to ‘make the most of their leisure time’ is backed up by more solid suggestions like referring patients to a dietician for advice on exclusion diets and advising patients to avoid aloe vera as a treatment (some aloe products can be strong laxatives, although aloe supplement manufacturers often say their products have had these bits removed).
Most exciting of all though – you might want to sit down for this – is the fact that the guide advises patients to avoid insoluble fiber such as bran. Can you believe it? It actually tells us to eat LESS bran, when for thousands of years the standard (and often only) advice for IBS sufferers was that they should stuff their face with All-bran, often with fantastically painful results. Hurray! Hurrah! Plus it also advises that soluble fiber is much better for us than the insoluble kind, which I’m sure you all knew anyway.
The guide does seem to take this a little far at one point, recommending that we reduce our intake of both bran cereals and any other high fiber food like brown rice (do sufferers really have problems with brown rice?!) but the basic message is soluble fiber good, insoluble fiber bad, bran awful, which is just what I like to see.
I’m also very pleased to see the mention of sorbitol, an artificial sweetener that, along with some other sweeteners, can produce dramatic laxative effects. Other tips such as drinking lots of water and cutting down on caffeine and alcohol are difficult to argue with, although limiting fresh fruit to three portions a day is a bit of an unusual one, but I guess that’s because fruit in large quantities can cause diarrhea as easily as sweeteners, so fair enough.
On the drug front, NICE recommends anti-spasmodics, laxatives (but not Lactulose, that syrupy-sweet liquid stuff) and Imodium to start with, progressing to tricyclic anti-depressants such as amitriptyline for their painkilling effects, or SSRIs if the tricylics don’t work. Again, nothing to argue with there. (Where’s all the fun stuff telling me that I need a damn good talking to and a trip to the psychiatrist? Honestly.)
Acupuncture and reflexology are specifically mentioned as treatments that should not be used, and I don’t know why these two in particular have been singled out. I mean, maybe lots of patients ask for acupuncture, but reflexology is an advanced form of foot massage – who on earth thinks that it could treat IBS apart from reflexologists? Anyway, don’t try it, apparently.
Also included is the suggestion that if a patient has not responded to treatment after 12 months then they should be referred for CBT, hypnotherapy or ‘psychological therapy’. I would agree with the hypno, as there are studies to show it can be good for IBS, and I believe that CBT can be helpful if you have diarrhea that is set off by situations such as being stuck in traffic, as it can help train the brain to chill out and behave itself.
I’m not sure what is meant by psychological therapy, which is probably good as I don’t expect I’d approve. (In fact I’ve just checked the longer version of the guidelines and it seems like ‘psychological therapy’ means a trip to the good old psychiatrist’s office after all. I knew they’d try and sneak that in somewhere.)
But still, it’s tough to get too animated about a guide that says try plenty of physical treatments for a year and then look into some of the psychological stuff if you need to.
So – that was amazingly painless! I have to say that if the Great British IBS public are getting this kind of treatment from their doctors then that would constitute an impressive leap forward from the attitudes of old.
In my own history of GP visits I have been prescribed Lactulose, undergone sigmoidoscopy, thyroid function and ultrasound tests, been given absolutely no dietary advice whatsoever and never even had it mentioned to me that anti-depressants can be used for IBS.
Now, my last GP visit was almost 10 years ago now, so hopefully things have changed since then, and GP care has now metamorphosed into the kind of caring, sensible, evidence-based approach found in these guidelines. Let’s hope so!
(The NICE guidelines are available as PDFs here.)
