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Guideline Resource Info & Algorithm
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IBS Guideline Resource Kit
 Introduction
 Guideline Resource Info & Algorithm
 Info for Patients & Clinicians
 The Science
Implementation Tips
 Impact Assessment
Delfini Evidence & Usability Scale
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Downloads
Introduction [PDF]
Guideline Resource Information & Algorithm [PDF]
Information for Patients & Clinicians [PDF]
The Science: Treatment [PDF]
The Science: Diagnosis [PDF]
The Science: Communications [PDF]
Implementation Tips [PDF]
Impact Assessment Template [Excel]

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BOX A
Colon cancer screening, other screening issues and routine testing of patients are not covered in this guideline, nor are patients meeting these criteria:

GUIDELINE EXCLUSIONS Patients with these alarm symptoms, signs, diagnoses require individual management (2):

- Age: Onset age 50 or older
- Any change in progression or in expected pattern of symptoms
- Unintended weight loss >5-10 lbs.
- Anorexia
- Vomiting
- GI bleeding
- Nocturnal symptoms
- Fever
- Any signs of infection
- Other diseases of the colon (e.g., colitis)
- Anemia
- Any abnormal findings upon exam

NOTE 1

 


“EXPLICIT" EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE RESOURCE KIT
Irritable Bowel Syndrome (IBS)

Original March 2003
Updates —

  • 07/06: Herbal Preparations
  • 04/07: Medication Withdrawal

Legal Information & Disclaimers
These materials are not meant to replace the clinical judgment of any health care professional or establish a standard of care. The information contained in this document may not be appropriate for use in all circumstances. Decisions to utilize this information must be made by consumers and health care professionals in light of individual circumstances.

Before prescribing any medication, review full prescribing information such as from the Physicians Desk Reference, DrugStore.Com or other source.

Delfini Group, LLC, MAKES AND USER RECEIVES NO WARRANTY EXPRESS OR IMPLIED ABOUT THIS WORK AND ALL WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE ARE EXPRESSLY EXCLUDED

GUIDELINE RESOURCE INFORMATION & ALGORITHM SECTION CONTENTS

Treatment Information
Suggestions for Using   •   Algorithm   •   Key Points   •   Details of Treatment Options [PDF]
Algorithm Notes   =   IBS Definition & Description   •   Criteria for Diagnosis   •   Establishing Rapport   •   Diagnostic Testing

Science
Scientific References    •   Delfini Evidence & Usability Scale   (Use BACK to return from the scale)

About the Guideline
Guideline Documentation


GUIDELINE RESOURCE INFORMATION
Suggestions for Using

The following guideline materials (including the algorithm, key points, notes and associated information and decision-aids) were designed primarily for primary care physicians and other clinicians who diagnose and manage IBS in adult patients.

These materials may also be useful to professionals who plan and implement clinical quality improvement projects.

It should be emphasized that although the materials may be useful “as is,” we recommend that each organization create information and decision aids that meet local needs.


                        IRRITABLE BOWEL SYNDROME (IBS) GUIDELINE ALGORITHM

ADULTS WITH TYPICAL IBS SYMPTOMS (and without GUIDELINE EXCLUSIONS - BOX A):

  • IBS Definition: Abdominal discomfort associated with altered bowel habits.
  • IBS Diagnosis Criteria: Symptom-based criteria for IBS (ROME II Criteria) – At least 12 wks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has 2 of these 3 features –
    1. Relieved with defecation, and/or
    2. Onset associated with a change in frequency of stool, and/or
    3. Onset associated with a change in form (appearance) of stool.

NOTE 1

  • Establish rapport (8, 9, 10) — NOTE 1
  • History and PE
  • Alarm symptoms or signs - BOX A?
 No


  Yes
Individual Management
  • Perform hematocrit to rule out anemia. Other routine diagnostic testing (e.g., thyroid function tests, stool tests, colonic visualization) may not be required in the work-up for IBS (11)
  • For other diagnostic tests see NOTE 2
  

TREATMENT OF IBS

  • Should be based on the type and severity of symptoms.
  • There is insufficient evidence to prioritize treatment strategies.
  • Patients should be provided with information about the condition along with self-care options and physician-directed options.
  • Options include change in diet, over-the-counter preparations, prescription medications and behavioral interventions.

DELFINI INFORMATION QUALITY RATINGS

Grade A - Useful Scientific Evidence B - Possibly Useful U - Uncertain Usefulness
Treatment Options for IBS
Abdominal
Pain
Constipation
Diarrhea
Gas &
Bloating
Dietary Change
Herbal Preparations
STW 5 (9 herbs sold under the name IberogastAA, Steigerwald Arzneimittelwerk GmbH, Darmstadt, Germany; distributed in the United States by Enzymatic Therapy, Green Bay, WI [independent health food stores] and PhytoPharmica, Green Bay, WI [pharmacies and healthcare professionals]). STW 5 contains bitter candytuft plant (a.k.a. clown’s mustard; Iberis amara L., Brassicaceae), German chamomile flower (Matricaria recutita L., Asteraceae), peppermint leaves (Mentha x piperita L., Lamiaceae), caraway fruit (Carum carvi L., Apiaceae), licorice root (Glycyrrhiza glabra L., Fabaceae), lemon balm leaves (Melissa officinalis L., Lamiaceae), celandine herb (i.e., aerial parts of Chelidonium majus L., Papaveraceae), angelica root and rhizome (Angelica archangelica L., Apiaceae), and milk thistle fruit (Silybum marianum [L.] Gaertn. Asteraceae).		      
Bulking Agents (Bulking Agents (IBS symptoms may initially worsen)
Psyllium
Wheat bran
Corn fiber
Calcium polycarbophil
Ispaghula husk
Antispasmodics (e.g. anticholinergics)
Dicyclomine
Hyoscyamine
Anti-diarrheals
Imodium (loperamide)
Lomotil (diphenoxylate hydrochloride 2.5 mg with atropine sulfate 0.025mg)

Range to
Gas-X, Mylicon (simethicone)
Tricyclic Antidepressants, (TCAs) e.g. –
Nortriptyline (e.g., Pamelor)
Desipramine (e.g., Norpramin)
Amitriptyline (e.g., Elavil)
Doxepin (e.g., Sinequan)
Caution is advised when using TCAs in IBS patients with constipation
SSRIs (selective serotonin reuptake inhibitors) e.g. –
Fluoxetine (e.g., Prozac)
Paroxetine (e.g., Paxil)
     
Serotonin Receptor Antagonists for Diarrhea
Lotronex (alosetron)

(urgency)

See cautions.
Behavioral Health Interventions
Grade B for certain individual symptoms

DETAILS ABOUT TREATMENT OPTIONS
For a complete listing of treatment options and for details about specific treatments, go to the accompanying Delfini Information & Decision Aid for Adult Patients and Clinicians [PDF].

KEY POINTS ACCOMPANYING ALGORITHM

a. Irritable Bowel Syndrome (IBS) is defined as “abdominal discomfort associated with altered bowel habits” (2). IBS is characterized by chronic and/or recurrent symptoms which may be in combination: abdominal pain, discomfort, altered bowel habits, episodes of diarrhea and/or constipation.

b. IBS is a common condition with a prevalence of 10%-15% in North America.

c. There is good scientific evidence that physicians who develop good rapport, based on positive engagements, with IBS patients, and who provide relevant, valid and, when possible, quantitative information about management options are likely to improve patient health outcomes (8, 9, 10).

d. There is insufficient evidence to conclude that, beyond history and physical examination, any diagnostic testing (e.g., blood tests, stool tests, radiological or endoscopic interventions) improves patient health outcomes in patients with IBS (11).

e. In managing IBS, patients should be provided with information about the condition along with self-care options and physician-directed options. Options include change in diet, over-the-counter preparations, prescription medications and behavioral interventions. The evidence on these options varies widely.

f. Alosetron has been associated with some serious adverse events, some fatal. Be sure to carefully review the most current prescribing information on this agent.

Details about IBS management and treatment options, along with the strength of the scientific evidence for each option, are found in the accompanying Delfini Information & Decision Aid for Adult Patients and Clinicians [PDF].


 

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