HOW TO TREAT 33 systematically reintroduce foods to determine which FODMAP foods retrigger symptoms .
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HOW TO TREAT 33 systematically reintroduce foods to determine which FODMAP foods retrigger symptoms .
There are several common mistakes in the application of a low- FODMAP diet . Often patients misinterpret a ‘ low ’ FODMAP diet as a ‘ no ’ FODMAP diet and needlessly exclude foods .
Patients may not be aware of the re-introduction phase and therefore remain on an unnecessarily restricted diet .
The low-FODMAP diet should ideally be administered by a dietitian , who can tailor dietary plans specifically for the patient and correctly supervise the reintroduction phase .
TRADITIONAL DIETARY ADVICE The UK ’ s National Institute for Health and Care Excellence ( NICE ) diet is less restrictive than the low- FODMAP diet . Two randomised controlled trials found the NICE diet to be as effective as the low FODMAP diet as well as better tolerated by patients . 8 , 36
The NICE diet includes adopting healthy , sensible eating patterns such as having regular meals , never eating too little / too much and maintaining adequate hydration . The diet also involves reducing the intake of alcohol , caffeine and fizzy drinks ; and fatty or spicy processed foods ; restricting fresh fruit to a maximum of three pieces per day ; reducing fibre and other commonly consumed gas-producing foods ( for example , beans , bread , sweeteners ); and addressing any perceived food intolerances ( such as dairy products ). 8
Over-the-counter therapies
ANTISPASMODICS Antispasmodics , such as mebeverine and hyoscine , can be used for the symptoms of abdominal pain and discomfort . Randomised controlled trials have demonstrated modest benefits compared with placebo . 37
PROBIOTICS Many probiotic strains have been examined for the treatment of IBS . Several systematic reviews and meta-analyses have concluded that probiotics are likely to provide symptom benefit greater than placebo . 38 Because of the number of strains of probiotics available in Australia , and the varying doses , it is not clear which preparation will be of benefit to patients . 39
There are limited adverse effects associated with probiotics , so clinicians are unlikely to harm patients by prescribing them .
PEPPERMINT OIL Peppermint oil is thought to act as an antispasmodic via smooth muscle calcium channel antagonism . Meta-analyses have demonstrated that peppermint oil significantly reduces symptoms compared with placebo . 40
Antibiotics
Randomised controlled trials on antibiotics have demonstrated benefit in treating the symptoms of IBS . 41 However , the magnitude of symptom reduction is modest . 41
The mechanism of action in achieving symptom improvement is not understood and should not be misinterpreted as a comorbid diagnosis of SIBO . The best studied antibiotic is the minimally absorbed
A
B
Figure 7 . Functional magnetic resonance imaging in a representative healthy control , and a constipated ( IBS-C ) and diarrhoeic ( IBS-D ) irritable bowel syndrome ( IBS ) patient during painful rectal distension without ( top row ) and with painful heterotopic stimulation ( bottom row ) at sections through the anterior cingulate ( A ) and insula cortex ( B ). The anterior cingulate and insula cortices are encircled . Clusters with significant differences from baseline are depicted as colour-coded values ( see z scale bar ).
rifaximin . A two-week course of rifaximin has been shown to reduce symptoms of bloating and pain in patients with IBS . 41
Patients may have a relapse in symptoms after treatment with rifaximin and may benefit from having repeated courses . Rifaximin is not PBS-listed for the treatment of IBS .
Pelvic floor physiotherapy , biofeedback and gut behavioural retraining
Abnormal defecation mechanics and toileting behaviours are prevalent among patients with IBS and may be the sole explanation for symptoms in
17 , 42 some patients . Health professionals who typically treat this are pelvic floor physiotherapists or continence nurses within a hospital continence clinic . The treatment involves education about proper toileting technique , timing of bowel actions and correct interpretation of rectal symptoms .
Patients may need education on how to relax their pelvic floor muscles , or alternatively , improve anal
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Figure 8 . Anal fissure . sphincter tone with exercises . When these conservative measures fail , physiotherapists may use a technique called anorectal biofeedback . 43 Anorectal biofeedback is based on operant conditioning techniques and uses instruments such as electromyography ( EMG ) sensors or a rectal balloon ( attached to a catheter or string ) to guide a patient to effectively co-ordinate the pelvic floor and the anal sphincter musculature during defaecation .
Patients often react to this form of biofeedback ( a simulated bowel action of sorts ) with trepidation , but it is often the most direct method to demonstrate to them what is wrong with how they defecate .
Gut pelvic floor physiotherapy , including anorectal biofeedback , typically occurs over 4-6 sessions , and patients can expect positive outcomes in more than 70 % of cases
44 , 45
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Antidepressants
A network meta-analysis compared soluble fibre , antispasmodic drugs , peppermint oil and gut-brain neuromodulators ( antidepressants ) for treating IBS . Peppermint oil was noted to be first for efficacy when assessing global symptoms , with tricyclic antidepressants ranked first for efficacy when abdominal pain was used as the outcome measure . 40 Note that antidepressants can be used in IBS for the treatment of gastrointestinal symptoms , even in the absence of a coexisting mood disorder .
Antidepressants ( tricyclic or SSRIs ) are highly effective for treating gastrointestinal symptoms . Counselling patients on the use of these medications is critical to their success .
Advise on the possible side effects , such as drowsiness in the first week of administration from tricyclic antidepressants , and that they may see symptom improvement typically between four and six weeks after drug initiation .
Explaining the rationale for their use is extremely important ; this includes an explanation that the medications are not used for the management of psychological symptoms , and that their use does not imply that the condition is “ all in the head ”.
Clarifying that the medication is being used ‘ off label ’ and using the term ‘ neuromodulators ’ may limit any perceived stigma regarding taking an antidepressant .
The most commonly used neuromodulators are tricyclic antidepressants ( amitriptyline or nortriptyline ). There are numerous randomised controlled trials demonstrating their efficacy as superior to placebo . 46 Amitriptyline or nortriptyline doses for patients with IBS can range from 10mg to 50mg at night . SSRIs are also efficacious but are only modestly superior to placebo . 46
Tricyclic antidepressants often cause constipation , and SSRIs are associated with diarrhoea ; it may therefore be helpful to tailor the neuromodulator to address the predominant symptom profile , using tricyclic antidepressants for IBS-D and SSRIs for IBS-C .
Psychological therapies
Many forms of psychotherapy are effective in the management of gastrointestinal symptoms of IBS . The forms of psychotherapy that have