Key priorities for implementation

IBS is one of the most common gastrointestinal disorders, with people presenting to primary care with a wide range of symptoms. People present with other gastrointestinal disorders. 
 
The NICE guideline presents a series of key priorities for implementation for the attention of health care professionals, with key elements of management being:

These represent a significant change from current practice, where diagnosis has been predominantly by exclusion of diseases, often leading to unnecessary investigations and referrals.

The key priorities for implementation appear below and can also be found in the quick reference guide (currently unavailable - see NICE website). There is also an accompanying algorithm. 

For information about other materials to support the implementation of the guideline see guideline resources. A glossary of selected terms used in the guideline is also available. 

The key priorities for implementation are:

Initial assessment

Health care professionals should consider assessment for IBS if the person reports having had any of the following symptoms for at least six months:

All people presenting with possible IBS symptoms should be asked if they have any of the following ‘red flag’ indicators and should be referred to secondary care for further investigation if any are present:*

All people presenting with possible IBS symptoms should be assessed and clinically examined for the following ‘red flag’ indicators and should be referred to secondary care for further investigation if any are present:*

A diagnosis of IBS should be considered only if the person has abdominal pain or discomfort that is either relieved by defaecation or associated with altered bowel frequency or stool form. This should be accompanied by at least two of the following four symptoms:

Diagnostic tests

In people who meet the IBS diagnostic criteria, the following tests should be undertaken to exclude other diagnoses:

The following tests are not necessary to confirm diagnosis in people who meet the IBS diagnostic criteria:

Dietary and lifestyle advice

People with IBS should be given information that explains the importance of self-help in effectively managing their IBS. This should include information on general lifestyle, physical activity, diet and symptom-targeted medication.

Health care professionals should review the fibre intake of people with IBS, adjusting (usually reducing) it while monitoring the effect on symptoms. People with IBS should be discouraged from eating insoluble fibre (for example, bran). If an increase in dietary fibre is advised, it should be soluble fibre such as ispaghula powder or foods high in soluble fibre (for example, oats).

Pharmacological therapy

People with IBS should be advised how to adjust their doses of laxative or antimotility agent according to the clinical response. The dose should be titrated according to stool consistency, with the aim of achieving a soft, well-formed stool (corresponding to Bristol Stool Form Scale type 4).

Health care professionals should consider tricyclic antidepressants (TCAs) as second-line treatment for people with IBS if laxatives, loperamide or antispasmodics have not helped. TCAs are primarily used for treatment of depression but are only recommended here for their analgesic effect. Treatment should be started at a low dose (5–10 mg equivalent of amitriptyline), which should be taken once at night and reviewed regularly. The dose may be increased, but does not usually need to exceed 30 mg.**

* See 'Referral guidelines for suspected cancer' NICE clinical guideline 27, for detailed referral criteria where cancer is suspected.

** At the time of publication (February 2008) TCAs did not have UK marketing authorisation for the indication described. Informed consent should be obtained and documented.