NICE Guidance: irritable bowel syndrome in adults

Sep 8, 2017

Irritable bowel syndrome in adults: diagnosis and management [CG61]

Last updated: April 2017 | www.nice.org.uk/guidance/cg61 
In April 2017, recommendation 1.1.1.2 was updated in line with more recent guidance on recognition and referral for suspected cancer. This recommendation is dated [2017]. Recommendation 1.1.1.3 was removed as it was no longer needed after the changes to recommendation 1.1.1.2.

Recommendations

This guideline includes recommendations on:

Key priorities for implementation

The following recommendations were identified as priorities for implementation in the 2008 guideline and have not been changed in the 2015 update.

Initial assessment

  • Healthcare professionals should consider assessment for IBS if the person reports having had any of the following symptoms for at least 6 months:
    • Abdominal pain or discomfort
    • Bloating
    • Change in bowel habit. [2008]
  • 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:
    • Passage of mucus.
    • Symptoms made worse by eating
    • Abdominal bloating (more common in women than men), distension, tension or hardness
    • Altered stool passage (straining, urgency, incomplete evacuation)

Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS, and may be used to support the diagnosis. [2008]

Diagnostic tests

  • In people who meet the IBS diagnostic criteria, the following tests should be undertaken to exclude other diagnoses:
    • Full blood count (FBC)
    • Erythrocyte sedimentation rate (ESR) or plasma viscosity
    • C‑reactive protein (CRP)
    • Antibody testing for coeliac disease (endomysial antibodies [EMA] or tissue transglutaminase [TTG]). [2008]
  • The following tests are not necessary to confirm diagnosis in people who meet the IBS diagnostic criteria:
    • Ultrasound
    • Rigid/flexible sigmoidoscopy
    • Colonoscopy; barium enema
    • Thyroid function test
    • Faecal ova and parasite test
    • Faecal occult blood
    • Hydrogen breath test (for lactose intolerance and bacterial overgrowth). [2008]

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. [2008]
  • Healthcare 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). [2008]

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). [2008]
  • Consider tricyclic antidepressants (TCAs) as second‑line treatment for people with IBS if laxatives, loperamide or antispasmodics have not helped. Start treatment at a low dose (5–10 mg equivalent of amitriptyline), taken once at night, and review regularly. Increase the dose if needed, but not usually beyond 30 mg.[1][2015]

Read more

 Read the full guideline here.