Delfini IBS 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 III Criteria) – Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following
1. Improvement with defecation
2. Onset associated with a change in frequency of stool
3. Onset associated with a change in form (appearance) of stool
Criteria must be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.
Discomfort is defined as an uncomfortable sensation not described as pain. Pain or discomfort frequency is of at least 2 days a week during screening evaluation for subject eligibility for research studies.
- (23) Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. 2006 Apr;130(5):1480-91.PMID: 16678561. [Note: Print version of the IBS Guideline Resource Information & Algorithm refers to Rome II criteria in this place in the algorithm, but lists all Rome Criteria on page 9)

NOTE 1

Establish rapport (8, 9, 10) — NOTE 1
History and PE
Alarm symptoms or signs - BOX A?

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