32
CHAPTER 7
Irritable bowel syndrome Dr Eric Beck, BSc, FRCP Dr Brian Hurwitz, MSc, MRCP MRCGP
Advice from: Ms Karen Hyland, SRD
SUMMARY 1. Irritable bowel syndrome is a functional disorder of the lower intestinal tract affecting approximately 10% of the population and causing a wide range of symptoms. 2. Most cases of irritable bowel syndrome can be diagnosed in general practice on the basis of the presenting history and clinical examination but some patients may need to be referred to a gastro-enterologist for further assessment including sigmoidoscopy and barium enema. 3. The clinical picture may include symptoms of abdominal pain and/or distension and altered bowel habit. Nausea, dyspepsia, gynaecological or bladder symptoms are also common. About a third of patients may give a family history of recurrent abdominal pain. 4. Clinical signs include general anxiety, scars on the abdomen (from previous laparotomies for severe abdominal pain), a palpable and tender left colon or generalized abdominal tenderness, and loud borborygmi. 5. Absolute indications for a specialist assessment are: * weight loss * rectal bleeding * onset of symptoms after the age of 40 * a mass. Even in the absence of any of these findings referral is frequently necessary to allay patient anxiety and reinforce the diagnosis. 6. Blood tests are usually non-contributory. Stool specimens should be sent if diarrhoea is a feature. 7. A full explanation emphasizing the benign and often recurrent nature of the condition should be given to help patients understand the nature of their symptoms. Only after review of liJe.style and advice about diet have been provided should drug therapy be tried.
Introduction Functional disorders of the gut can be divided into those with symptoms that derive mainly from the upper gastro-intestinal tract, now called non-ulcer dyspepsia, and those with symptoms referable mainly to the lower gastro-intestinal tract, the irritable bowel syndrome. Point prevalence studies show that approximately 10% of the population can be classified as suffering from irritable bowel syndrome, which comprises almost 50% of new referrals to gastro-enterology outpatients.
Such a high prevalence emphasizes the importance of effective diagnosis and management at primary health care level and the need for appropriate referral. A small change in the threshold of referral could have very large consequences for outpatient clinics.
Definition Irritable bowel syndrome encompasses a wide variety of possible symptoms and signs in which there is no demonstrable organic pathology after gastro-enterological investigation. The symptoms involved may range from abdominal discomfort or pain, often accompanied by a disturbance of bowel habit or a feeling of bloatedness, to nausea and regurgitation. Extra-abdominal symptoms may include frequency of micturition, headache and malaise. In a large majority of patients, a positive diagnosis can be made on history and examination alone, but in a small percentage, referral for outpatient investigation will be required, either to reinforce the diagnosis and reassure the patient, or to exclude other possible causes of the symptoms. Most patients presenting to outpatients are in their third or fourth decades and have had symptoms for an average of five years. However, there is a wide variation and some patients appear to have had similar symptoms since childhood and may give a long history of 'grumbling appendix', 'abdominal migraine' or 'bilious attacks' - a paediatrician has noted that "little belly achers grow into big ones!". Women outnumber men by about 2 to 1 and are said to have predominantly more symptoms of the constipation variety than male patients (Lennard-Jones, 1983). How to make a positive diagnosis There is often a family history (in approximately 30% of patients) and symptoms tend to cluster around certain systems: ABDOMINAL SYMPTOMS
Lower gastro-intestinal
(a) Altered bowel habit, for example diarrhoea, often in the mornings though never disturbing sleep. The moming rush frequently gives rise to a fear of going out because of incontinence. Direct questioning frequently reveals feared or actual incontinence, and some patients describe not being able to tell in advance whether they have an urge to pass flatus or faeces. The urgency experienced forces patients to
33 plan their journeys with a toilet route in mind. A feeling of incomplete defaecation (tenesmus) is often described. In other patients, loose pellet stools, or constipation, may be the predominant symptoms, and in others, constipation may alternate with diarrhoea. (b) Distension, for example wind, rumbling, a feeling of bloatedness usually without signs of clinical distension. (c) Pain can be dull or sharp, often relieved by defaecation though it can be aggravated by it. Sited most commonly in the left iliac fossa or right iliac fossa, it can sometimes radiate outside the abdomen from the left upper quadrant into the chest or back, or from the iliac fossa into the anterior thigh. Anecdotally, it has always been thought to worsen with, or be precipitated by stress, though good studies to substantiate this association are difficult to find.
Upper gastro-intestinal Symptoms include: nausea, regurgitation, dyspepsia which can be related to food, and delayed gastric emptying. NON-ABDOMINAL SYMPTOMS
Gynaecological On direct questioning, it may become clear that one of the above abdominal symptom patterns worsens pre-menstrually or the patient suffers from dyspareunia or dysmenorrhoea (Whorwell et al., 1986). Bladder detrusor instability This results in urinary frequency and incomplete emptying. Mental state Anxiety may precipitate symptoms and both depression and anxiety may in part be caused by bowel symptoms. Anxiety which can be global and vague in nature, or specifically focused on bowel symptoms, may be a marked feature with physical signs (see below). Headache and malaise are common accompaniments. In patients with a previous history of psychiatric problems, the appearance of symptoms of irritable bowel syndrome can be part and parcel of an illness behaviour pattern (Creed and Guthrie, 1982).
The most helpful signs are those to be found in the abdomen but they are not as confirmatory as the sigmoidoscopic findings, which include a normal mucosa, colonic spasm and excess pressure waves. Insufflation of air may reproduce the abdominal symptoms and this is the best diagnostic test available at present. If there is any doubt about the diagnosis, or the patient is not reassured by your explanation and treatment of the condition, then referral for outpatient sigmoidoscopy is indicated. If new symptoms occur that are not obviously a part of the typical pattern of irritable bowel syndrome, refer
Indications for referral Abolute indications for referral are: * weight loss * rectal bleeding * fever * onset of symptoms over the age of 40 (mostly, though not always, due to diverticulosis - 'the irritable bowel syndrome of the over 40s'. * a mass. Whether the patient has already been referred for specialist assessment or not, it should be remembered that any change of symptoms should be re-evaluated on its merits and not automatically credited to irritable bowel syndrome.
Differential diagnosis General differential diagnosis: * Endometriosis * Ulcerative colitis, Crohn's disease * Infective diarrhoea * Malabsorption, for example coeliac disease * Thyrotoxicosis. Predominant site of abdominal pain It can also be helpful to consider the differential diagnosis according to the predominant site of the abdominal pain: * Right lower quadrant: Crohn's disease, appendicitis * Right upper quadrant: gallstones * Epigastrium: peptic ulcer, oesophagitis, pancreatic disease * Left upper quadrant: cardiac disease * Left lower quadrant: diverticular disease.
SIGNS
General appearance The following signs are not uncommon: tremor, bitten fingernails, sweating, anxiety, tachycardia, hyper-reflexia if pronounced, check T4. There is a definite positive association with smoking and nicotine stains may be obvious. -
Abdomen Signs include: scar(s), palpable (tender) left colon, generalized tenderness, loud borborygmi. The abdomen may seem to bulge outwards though frequently this is due to the patient lying with an arched back. A tender right colon should arouse suspicion that irritable bowel syndrome is not the cause though occasionally it is associated with this sign.
General practitioner investigations Full blood count and erythrocyte sedimentation rate (ESR) are useful tests. Anaemia, leucocytosis or a high ESR preclude the diagnosis (unless there is some other concurrent cause). Patients with diarrhoeaal symptoms should have stool cultures to rule out parasites and pathogens as a cause of the complaint.
Pathogenesis There is a demonstrable disordered motility and function of the gut the causes of which are unknown (Swarbrook et al., 1980). Sometimes a specific factor such as lactose intolerance can be identified after outpatient investigation.
34 In this case, the diagnosis of lactose intolerance is the one that applies, not irritable bowel syndrome, which remains an idiopathic disease. (Long-term lactose intolerance requires referral to a dietitian for therapeutic dietary advice.) On the other hand, cases of irritable bowel syndrome frequently arise following infective diarrhoea months or years previously, where symptoms persist long after the disappearance of the causative agent. These patients should be identified as suffering from one of the well recognized variants of irritable bowel syndrome. There is no demonstrable allergic basis to irritable bowel syndrome as there is in coeliac disease. There have been frequent suggestions that irritable bowel syndrome is caused by food intolerance although allergic mechanisms are probably not the explanation (Jones and Hunter, 1986). If patients are unconvinced of any specific foods which upset them it is unlikely that elaborate exclusion diets will reveal hitherto undiscovered causes in a particular individual. Treatment Effective treatment rarely results from drugs alone and time spent talking and explaining the nature of the condition will be repaid in lower prescription rates. Make sure you ascertain what the patient's view of the likely cause of the symptoms is, so that you can meet their anxieties appropriately. Emphasizing the common and benign nature of irritable bowel syndrome and outlining current ideas about causation in terms of 'hyper-irritability' are often reassuring. "Your gut is doing what everyone else's does but more so." Likening the exacerbation of symptoms by stress to exambutterflies or exam-diarrhoea is often a helpful analogy. The prognosis is generally good with a third of patients being symptom free at 5 years and a further 50% reporting some, or considerable, improvement. (Women with diarrhoea for over two years appear to be in a prognostically poor group.) Treatment is aimed at breaking the vicious circle of bowel symptoms provoking anxiety and this in turn worsening the symptoms. Review of lifestyle
Discuss regular food intake, stopping smoking and methods of stress reduction. Diet Offer general advice about healthy diet backed up with written materials including the importance of ingesting more fluid if fibre intake is to be increased (for leaflet see Appendix). Evidence for an allergic component is unproven but any foods that the patient seems intolerant towards should obviously be avoided (Jones and Hunter, 1986). Refer to local dietitians for appropriate dietary assessment and advice especially if the patient appears to have food intolerance.
Medication Because the placebo response is about as therapeutic as any of the drugs on offer at the moment, avoid building up false hopes in the patient. Stress that medication produces symptomatic relief not a cure. The available drugs fall into several different categories:
Anti-spasmodics: * dicyclomine 10-20 mg tds (anticholinergic side-effects) * mebeverine 135 mg i-ii tds * peppermint oil capsules i-ii tds (warn patient of peppermint-smelling stools). Anti-diarrhoeaals: * codeine phosphate * loperamide. Fibre and bulking agents: * Ispaghula husk or fybogel plus extra fluids (the use of unprocessed natural bran is not generally recommended). Tranquillizers: are best avoided, except for short specific reasons. Pro-kinetics: are especially useful for upper gastrointestinal symptoms: * metoclopramide * domperidone (much more expensive).
Complementary/alternative medicine Hypnotherapy is reported to be effective in the right hands (Whorwell, 1991). There is no evidence that the approach of food allergists is successful and significant nutritional deficiencies can result from very restricted diets - please refer patients whose diets are inadequate to the dietitian. Follow-up There is no need to review these patients regularly once the nature of their condition has been explained to them and an appropriate treatment regimen instituted. Hospital clinics commonly discharge patients with irritable bowel syndrome with an open invitation to return if their symptoms worsen or if any new symptoms arise. This is a sensible policy which can also be followed in general practice. Audit points 1. Proportion of patients with practice diagnosis of irritable bowel syndrome who are subsequently referred for specialist
gastro-enterological investigation. 2. Proportion of patients with practice-based diagnosis of irritable bowel syndrome who are given a different diagnosis following gastro-enterological referral and investigation. 3. What is the average delay between the patients' presenting symptoms ascribable to irritable bowel syndrome and diagnosis of the condition? 4. What are the three most common reasons for referring patients with a practice diagnosis of initable bowel syndrome for specialist gastro-enterological assessment? References Creed F H and Guthrie E (1982) Psychological factors in the irritable bowel syndrome. Gut 28, 1307-18. Jones V A and Hunter J 0 (1986) Food intolerance. In Recent Advances in Gastroenterology. Vol. 6. Ed. Pounder R E. Edinburgh, Churchill Livingstone. pp. 281-300. Lennard-Jones J E (1983) Functional gastro-intestinal disorders. New England Journal of Medicine 308, 431-5.
35 Swarbrook E T, Hegarty J E, Bat L et al. (1980) Site of pain from the irritable bowel. Lancet 2, 443-6. Whorwell P J (1991) Use of hypnotherapy in gastrointestinal disease. British Journal of Hospital Medicine 45, 27-9. Whorwell P J, McCallum M, Creed F H et al. (1986) Alimentary tract and pancreas. Non-colonic features of irritable bowel syndrome. Gut 27, 37-40.
APPENDIX
High Fibre Diet Your aim is to eat normally but to increase the amount of bulk or fibre in your diet. Fibre will help to keep your bowel muscles healthy and working normally. Increase your fibre intake by including the following foods in your diet: * Bread Wholemeal, any made from whole wheat or whole rye flour of 100% extraction. * Flour Wholemeal, ie wholewheat or whole rye of 100% extraction. Made with wholemeal flour, oatmeal, or * Cakes and biscuits rolled oats, dried fruit and nuts. Wholegrain crispbreads, eg Ryvita, wholemeal biscuits, oatcakes, digestives. All Bran, Weetabix, Shredded Wheat, * Breakffast cereals muesli, porridge oats, bran flakes. * Rice and Try brown rice and wholewheat spaghetti or macaroni. pasta * Fruit, nuts, All kinds in generous amounts, with as pulses and much as possible eaten raw, including vegetables skins. Especially peas, sweetcorn, beans, lentils and jacket potatoes. When increasing the amount of fibre in your diet you should also make sure you drink plenty of fluid (8-10 cups/day). Natural processed bran is not advised for most people. Source: Bloomsbury and Islington Health Authority.
CHAPTER 7
Irritable bowel syndrome Dr Eric Beck, BSc, FRCP Dr Brian Hurwitz, MSc, MRCP MRCGP
Advice from: Ms Karen Hyland, SRD
SUMMARY 1. Irritable bowel syndrome is a functional disorder of the lower intestinal tract affecting approximately 10% of the population and causing a wide range of symptoms. 2. Most cases of irritable bowel syndrome can be diagnosed in general practice on the basis of the presenting history and clinical examination but some patients may need to be referred to a gastro-enterologist for further assessment including sigmoidoscopy and barium enema. 3. The clinical picture may include symptoms of abdominal pain and/or distension and altered bowel habit. Nausea, dyspepsia, gynaecological or bladder symptoms are also common. About a third of patients may give a family history of recurrent abdominal pain. 4. Clinical signs include general anxiety, scars on the abdomen (from previous laparotomies for severe abdominal pain), a palpable and tender left colon or generalized abdominal tenderness, and loud borborygmi. 5. Absolute indications for a specialist assessment are: * weight loss * rectal bleeding * onset of symptoms after the age of 40 * a mass. Even in the absence of any of these findings referral is frequently necessary to allay patient anxiety and reinforce the diagnosis. 6. Blood tests are usually non-contributory. Stool specimens should be sent if diarrhoea is a feature. 7. A full explanation emphasizing the benign and often recurrent nature of the condition should be given to help patients understand the nature of their symptoms. Only after review of liJe.style and advice about diet have been provided should drug therapy be tried.
Introduction Functional disorders of the gut can be divided into those with symptoms that derive mainly from the upper gastro-intestinal tract, now called non-ulcer dyspepsia, and those with symptoms referable mainly to the lower gastro-intestinal tract, the irritable bowel syndrome. Point prevalence studies show that approximately 10% of the population can be classified as suffering from irritable bowel syndrome, which comprises almost 50% of new referrals to gastro-enterology outpatients.
Such a high prevalence emphasizes the importance of effective diagnosis and management at primary health care level and the need for appropriate referral. A small change in the threshold of referral could have very large consequences for outpatient clinics.
Definition Irritable bowel syndrome encompasses a wide variety of possible symptoms and signs in which there is no demonstrable organic pathology after gastro-enterological investigation. The symptoms involved may range from abdominal discomfort or pain, often accompanied by a disturbance of bowel habit or a feeling of bloatedness, to nausea and regurgitation. Extra-abdominal symptoms may include frequency of micturition, headache and malaise. In a large majority of patients, a positive diagnosis can be made on history and examination alone, but in a small percentage, referral for outpatient investigation will be required, either to reinforce the diagnosis and reassure the patient, or to exclude other possible causes of the symptoms. Most patients presenting to outpatients are in their third or fourth decades and have had symptoms for an average of five years. However, there is a wide variation and some patients appear to have had similar symptoms since childhood and may give a long history of 'grumbling appendix', 'abdominal migraine' or 'bilious attacks' - a paediatrician has noted that "little belly achers grow into big ones!". Women outnumber men by about 2 to 1 and are said to have predominantly more symptoms of the constipation variety than male patients (Lennard-Jones, 1983). How to make a positive diagnosis There is often a family history (in approximately 30% of patients) and symptoms tend to cluster around certain systems: ABDOMINAL SYMPTOMS
Lower gastro-intestinal
(a) Altered bowel habit, for example diarrhoea, often in the mornings though never disturbing sleep. The moming rush frequently gives rise to a fear of going out because of incontinence. Direct questioning frequently reveals feared or actual incontinence, and some patients describe not being able to tell in advance whether they have an urge to pass flatus or faeces. The urgency experienced forces patients to
33 plan their journeys with a toilet route in mind. A feeling of incomplete defaecation (tenesmus) is often described. In other patients, loose pellet stools, or constipation, may be the predominant symptoms, and in others, constipation may alternate with diarrhoea. (b) Distension, for example wind, rumbling, a feeling of bloatedness usually without signs of clinical distension. (c) Pain can be dull or sharp, often relieved by defaecation though it can be aggravated by it. Sited most commonly in the left iliac fossa or right iliac fossa, it can sometimes radiate outside the abdomen from the left upper quadrant into the chest or back, or from the iliac fossa into the anterior thigh. Anecdotally, it has always been thought to worsen with, or be precipitated by stress, though good studies to substantiate this association are difficult to find.
Upper gastro-intestinal Symptoms include: nausea, regurgitation, dyspepsia which can be related to food, and delayed gastric emptying. NON-ABDOMINAL SYMPTOMS
Gynaecological On direct questioning, it may become clear that one of the above abdominal symptom patterns worsens pre-menstrually or the patient suffers from dyspareunia or dysmenorrhoea (Whorwell et al., 1986). Bladder detrusor instability This results in urinary frequency and incomplete emptying. Mental state Anxiety may precipitate symptoms and both depression and anxiety may in part be caused by bowel symptoms. Anxiety which can be global and vague in nature, or specifically focused on bowel symptoms, may be a marked feature with physical signs (see below). Headache and malaise are common accompaniments. In patients with a previous history of psychiatric problems, the appearance of symptoms of irritable bowel syndrome can be part and parcel of an illness behaviour pattern (Creed and Guthrie, 1982).
The most helpful signs are those to be found in the abdomen but they are not as confirmatory as the sigmoidoscopic findings, which include a normal mucosa, colonic spasm and excess pressure waves. Insufflation of air may reproduce the abdominal symptoms and this is the best diagnostic test available at present. If there is any doubt about the diagnosis, or the patient is not reassured by your explanation and treatment of the condition, then referral for outpatient sigmoidoscopy is indicated. If new symptoms occur that are not obviously a part of the typical pattern of irritable bowel syndrome, refer
Indications for referral Abolute indications for referral are: * weight loss * rectal bleeding * fever * onset of symptoms over the age of 40 (mostly, though not always, due to diverticulosis - 'the irritable bowel syndrome of the over 40s'. * a mass. Whether the patient has already been referred for specialist assessment or not, it should be remembered that any change of symptoms should be re-evaluated on its merits and not automatically credited to irritable bowel syndrome.
Differential diagnosis General differential diagnosis: * Endometriosis * Ulcerative colitis, Crohn's disease * Infective diarrhoea * Malabsorption, for example coeliac disease * Thyrotoxicosis. Predominant site of abdominal pain It can also be helpful to consider the differential diagnosis according to the predominant site of the abdominal pain: * Right lower quadrant: Crohn's disease, appendicitis * Right upper quadrant: gallstones * Epigastrium: peptic ulcer, oesophagitis, pancreatic disease * Left upper quadrant: cardiac disease * Left lower quadrant: diverticular disease.
SIGNS
General appearance The following signs are not uncommon: tremor, bitten fingernails, sweating, anxiety, tachycardia, hyper-reflexia if pronounced, check T4. There is a definite positive association with smoking and nicotine stains may be obvious. -
Abdomen Signs include: scar(s), palpable (tender) left colon, generalized tenderness, loud borborygmi. The abdomen may seem to bulge outwards though frequently this is due to the patient lying with an arched back. A tender right colon should arouse suspicion that irritable bowel syndrome is not the cause though occasionally it is associated with this sign.
General practitioner investigations Full blood count and erythrocyte sedimentation rate (ESR) are useful tests. Anaemia, leucocytosis or a high ESR preclude the diagnosis (unless there is some other concurrent cause). Patients with diarrhoeaal symptoms should have stool cultures to rule out parasites and pathogens as a cause of the complaint.
Pathogenesis There is a demonstrable disordered motility and function of the gut the causes of which are unknown (Swarbrook et al., 1980). Sometimes a specific factor such as lactose intolerance can be identified after outpatient investigation.
34 In this case, the diagnosis of lactose intolerance is the one that applies, not irritable bowel syndrome, which remains an idiopathic disease. (Long-term lactose intolerance requires referral to a dietitian for therapeutic dietary advice.) On the other hand, cases of irritable bowel syndrome frequently arise following infective diarrhoea months or years previously, where symptoms persist long after the disappearance of the causative agent. These patients should be identified as suffering from one of the well recognized variants of irritable bowel syndrome. There is no demonstrable allergic basis to irritable bowel syndrome as there is in coeliac disease. There have been frequent suggestions that irritable bowel syndrome is caused by food intolerance although allergic mechanisms are probably not the explanation (Jones and Hunter, 1986). If patients are unconvinced of any specific foods which upset them it is unlikely that elaborate exclusion diets will reveal hitherto undiscovered causes in a particular individual. Treatment Effective treatment rarely results from drugs alone and time spent talking and explaining the nature of the condition will be repaid in lower prescription rates. Make sure you ascertain what the patient's view of the likely cause of the symptoms is, so that you can meet their anxieties appropriately. Emphasizing the common and benign nature of irritable bowel syndrome and outlining current ideas about causation in terms of 'hyper-irritability' are often reassuring. "Your gut is doing what everyone else's does but more so." Likening the exacerbation of symptoms by stress to exambutterflies or exam-diarrhoea is often a helpful analogy. The prognosis is generally good with a third of patients being symptom free at 5 years and a further 50% reporting some, or considerable, improvement. (Women with diarrhoea for over two years appear to be in a prognostically poor group.) Treatment is aimed at breaking the vicious circle of bowel symptoms provoking anxiety and this in turn worsening the symptoms. Review of lifestyle
Discuss regular food intake, stopping smoking and methods of stress reduction. Diet Offer general advice about healthy diet backed up with written materials including the importance of ingesting more fluid if fibre intake is to be increased (for leaflet see Appendix). Evidence for an allergic component is unproven but any foods that the patient seems intolerant towards should obviously be avoided (Jones and Hunter, 1986). Refer to local dietitians for appropriate dietary assessment and advice especially if the patient appears to have food intolerance.
Medication Because the placebo response is about as therapeutic as any of the drugs on offer at the moment, avoid building up false hopes in the patient. Stress that medication produces symptomatic relief not a cure. The available drugs fall into several different categories:
Anti-spasmodics: * dicyclomine 10-20 mg tds (anticholinergic side-effects) * mebeverine 135 mg i-ii tds * peppermint oil capsules i-ii tds (warn patient of peppermint-smelling stools). Anti-diarrhoeaals: * codeine phosphate * loperamide. Fibre and bulking agents: * Ispaghula husk or fybogel plus extra fluids (the use of unprocessed natural bran is not generally recommended). Tranquillizers: are best avoided, except for short specific reasons. Pro-kinetics: are especially useful for upper gastrointestinal symptoms: * metoclopramide * domperidone (much more expensive).
Complementary/alternative medicine Hypnotherapy is reported to be effective in the right hands (Whorwell, 1991). There is no evidence that the approach of food allergists is successful and significant nutritional deficiencies can result from very restricted diets - please refer patients whose diets are inadequate to the dietitian. Follow-up There is no need to review these patients regularly once the nature of their condition has been explained to them and an appropriate treatment regimen instituted. Hospital clinics commonly discharge patients with irritable bowel syndrome with an open invitation to return if their symptoms worsen or if any new symptoms arise. This is a sensible policy which can also be followed in general practice. Audit points 1. Proportion of patients with practice diagnosis of irritable bowel syndrome who are subsequently referred for specialist
gastro-enterological investigation. 2. Proportion of patients with practice-based diagnosis of irritable bowel syndrome who are given a different diagnosis following gastro-enterological referral and investigation. 3. What is the average delay between the patients' presenting symptoms ascribable to irritable bowel syndrome and diagnosis of the condition? 4. What are the three most common reasons for referring patients with a practice diagnosis of initable bowel syndrome for specialist gastro-enterological assessment? References Creed F H and Guthrie E (1982) Psychological factors in the irritable bowel syndrome. Gut 28, 1307-18. Jones V A and Hunter J 0 (1986) Food intolerance. In Recent Advances in Gastroenterology. Vol. 6. Ed. Pounder R E. Edinburgh, Churchill Livingstone. pp. 281-300. Lennard-Jones J E (1983) Functional gastro-intestinal disorders. New England Journal of Medicine 308, 431-5.
35 Swarbrook E T, Hegarty J E, Bat L et al. (1980) Site of pain from the irritable bowel. Lancet 2, 443-6. Whorwell P J (1991) Use of hypnotherapy in gastrointestinal disease. British Journal of Hospital Medicine 45, 27-9. Whorwell P J, McCallum M, Creed F H et al. (1986) Alimentary tract and pancreas. Non-colonic features of irritable bowel syndrome. Gut 27, 37-40.
APPENDIX
High Fibre Diet Your aim is to eat normally but to increase the amount of bulk or fibre in your diet. Fibre will help to keep your bowel muscles healthy and working normally. Increase your fibre intake by including the following foods in your diet: * Bread Wholemeal, any made from whole wheat or whole rye flour of 100% extraction. * Flour Wholemeal, ie wholewheat or whole rye of 100% extraction. Made with wholemeal flour, oatmeal, or * Cakes and biscuits rolled oats, dried fruit and nuts. Wholegrain crispbreads, eg Ryvita, wholemeal biscuits, oatcakes, digestives. All Bran, Weetabix, Shredded Wheat, * Breakffast cereals muesli, porridge oats, bran flakes. * Rice and Try brown rice and wholewheat spaghetti or macaroni. pasta * Fruit, nuts, All kinds in generous amounts, with as pulses and much as possible eaten raw, including vegetables skins. Especially peas, sweetcorn, beans, lentils and jacket potatoes. When increasing the amount of fibre in your diet you should also make sure you drink plenty of fluid (8-10 cups/day). Natural processed bran is not advised for most people. Source: Bloomsbury and Islington Health Authority.
