32 HOW TO TREAT : IRRITABLE BOWEL SYNDROME
32 HOW TO TREAT : IRRITABLE BOWEL SYNDROME
1 SEPTEMBER 2023 ausdoc . com . au
Source : Department of Gastroenterology , Monash University . Table reproduced with permission from Monash University ( monashfodmap . com ).
Figure 5 . High and low FODMAP alternatives .
of cancer and is associated with a lower risk of colorectal cancer and cancer-specific mortality . 27
Complementary testing in patients with IBS
There are a range of complementary tests that may be used by patients with IBS that are of questionable utility . Breath testing for lactose , fructose malabsorption and SIBO are notoriously unreliable . 30
Australian studies have shown that repeating these tests two weeks later yielded a different result in 30 % of patients . 31
Patients who report symptoms after particular foods are better directed to a dietitian for dietary modification and a management plan .
Stool microbiome and metabolite testing may be undertaken by patients , usually on the advice / insistence of an alternative practitioner , such as a naturopath . These tests are not standardised , often not performed by accredited laboratories , and the clinical utility of actioning treatment based on these results has not been examined .
MANAGEMENT
PATIENTS currently treated for IBS can expect symptom improvement , and many may experience resolution of their symptoms .
Individualise the treatment , targeting pathophysiological contributors unique to each patient ’ s symptoms while also considering patient treatment preferences .
The treatments for IBS include diet , antispasmodics , probiotics , antibiotics , physiotherapy , gut-directed hypnotherapy , antidepressants ( neuromodulators ) and psychotherapy .
An approach to the consultation
Only a proportion of those with IBS consult a medical professional . 32 There are many reasons why patients with IBS consult their doctor . These include a need for reassurance that there is no sinister pathology , seeking an explanation for the condition , or a request for treatment . It is important for the doctor to understand the patient ’ s motivation for seeking help .
During the consultation , address patient concerns and provide an explanation about the condition . It is also important to explain that IBS does not lead to the development of other gastrointestinal pathology ( for example , malignancy ) or mortality . Ensure all patients are treated with empathy and avoid dismissing their concerns . An interesting trial in patients with IBS demonstrated the role of an empathic practitioner . Patients were randomised to “ waiting list ( observation ), placebo acupuncture alone , or placebo acupuncture with a patient-practitioner relationship augmented by warmth , attention and confidence ”. 33 Despite patients not receiving a recognised treatment for IBS , those who attended an empathetic practitioner achieved significantly greater symptom improvements compared with the other two groups .
Dietary treatments for IBS
There are many dietary strategies available for the treatment of IBS , and dietary approaches are popular with patients .
However , dietary treatment should be avoided in unmotivated patients and those with disordered eating behaviours ( such as an already
Figure 6 . FODMAP tracking app .
self-imposed highly restricted diet ) and eating disorders . The two commonly practised diets for IBS are a low-FODMAP diet and the NICE diet , the latter also referred to as “ traditional dietary advice ”. 6 , 34
Source : Department of Gastroenterology , Monash University . Images reproduced with permission from Monash University ( monashfodmap . com ). Download the Monash University FODMAP Diet App for a comprehensive food guide containing the
FODMAP ratings and serving sizes for hundreds of different foods and beverages . Available on iOS and Android .
A LOW-FODMAP DIET The most popular prescribed diet for IBS is a low-FODMAP diet ( a diet low in fermentable fructose , fructans , oligosaccharides , disaccharides , monosaccharides and polyols ). 35 The diet involves two phases : first , a restriction phase , and second , a reintroduction phase . During the restriction phase , patients reduce foods which are high in FODMAP content . In the reintroduction phase , patients