34 HOW TO TREAT : IRRITABLE BOWEL SYNDROME
34 HOW TO TREAT : IRRITABLE BOWEL SYNDROME
1 SEPTEMBER 2023 ausdoc . com . au been studied include CBT , behavioural therapy , psychodynamic psychotherapy and mindfulness-based therapy .
CBT is the best examined approach . Conceptually , CBT in IBS involves : first , education about the stress / anxiety response and its relationship to gut symptoms ; second , building insight into cognitive and behavioural responses to symptoms and / or fear of symptoms ; and third , modifying these responses to decrease the distress related to IBS , and decrease the physical reactivity to stress . 47
Psychotherapy has the added benefit of treating coexisting psychological comorbidity . Multiple meta-analyses have demonstrated the superiority of CBT over placebo for the management of gut
46 , 48 symptoms .
Patients do not always find it intuitive that CBT is prescribed for the treatment of the gut symptoms of IBS . Even if a clinician strongly believes a psychologically based treatment may be helpful , the patient requires motivation to attend treatment and to understand the link between their symptoms and their psychological state . Patients who feel ‘ coerced ’ into psychological therapy are unlikely to attend or benefit from it .
Patients being treated for IBS with CBT should expect to attend approximately 8-12 sessions ; however , many require ongoing therapy if there is added psychological complexity , such as significant prior trauma .
Gut-directed hypnotherapy
Gut-directed hypnotherapy is another form of psychologically based therapy . It involves patients being placed into a state of hypnosis where they are led through a series of gut-focussed imagery and hypnotic suggestions .
Clinicians may often regard gut-directed hypnotherapy as an alternative treatment ; however , there is an abundance of high-quality studies of this therapy . The first randomised controlled trial on severe refractory IBS and the effects of hypnotherapy versus psychotherapy and placebo was published in the Lancet in 1984 . 49 The patients treated with hypnotherapy showed a dramatic and significant improvement in all features compared with the group treated with psychotherapy and placebo .
Gut-directed hypnotherapy is ideally performed by a psychologist and usually involves one session a week for 7-12 weeks .
Hypnotherapy delivered by telehealth may be as effective as in-person hypnotherapy . 50 Gut-directed hypnotherapy produces effective control of gastrointestinal symptoms in IBS in more than 70 % of patients , with most maintaining symptom control after five years . 51
Head-to-head clinical trials have shown hypnotherapy to be as effective as a low-FODMAP diet . 52 There are practical limitations to this therapy . Adequately trained gut-directed hypnotherapists are few and far between , and there are long waiting times to receive therapy . Many patients find committing to one hour of hypnotherapy weekly for seven weeks or longer logistically challenging . Costs can be prohibitive , as many patients may not be able to access Medicare rebates for this therapy .
Multidisciplinary clinics
Patients often present with multiple contributors to their symptoms , including gross dietary restrictions ,
How to Treat Quiz . severe psychological comorbidity ( including prior trauma ) and abnormal toileting behaviours . These complex patients may have multiple GP , healthcare and hospital presentations . A multidisciplinary team approach can be helpful in these more challenging cases .
A 2020 Australian randomised controlled trial demonstrated that patients with IBS who were referred to a public hospital had superior improvements in symptoms , psychological health and quality of life when treated in a multidisciplinary clinic ( gastroenterologist , psychiatrist , physiotherapist , dietitian and gut hypnotherapist ) compared with a gastroenterologist-only clinic . 53 A longer term follow-up of this study demonstrated significantly fewer visits to GPs if patients were managed in a multidisciplinary clinic compared with a gastroenterologist-only clinic . 54 These public-hospital clinics operate in many Australian capital cities .
CASE STUDIES
Case study one
ALISON , 20 , presents to her GP complaining of 18 months of difficulty passing stools , associated with abdominal pain and bloating . She passes small infrequent stools that are “ pencil-like ” in appearance . She spends longer than 30 minutes on the toilet , and on most occasions “ strains ” to have an effective bowel
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1 . Which THREE form part of the definition of IBS ? a Chronic functional gastrointestinal condition . b Related to unintended weight loss . c Characterised by abdominal discomfort . d Associated with altered bowel habits .
2 . Which TWO statements regarding diet in IBS are correct ? a FODMAPs lead to intestinal distention with pain , bloating and diarrhoea . b FODMAPs are well-absorbed fermentable carbohydrates . c The role of fibre in IBS is clearly delineated . d There are likely to be other food-related pathophysiological mechanisms causing symptoms in IBS .
3 . Which THREE statements regarding the psychological and emotional state and IBS are correct ? a Anxiety and stress only result in inhibition of colonic motor function . b Patients with perfectionistic personality profiles may have poor tolerance of minor gastrointestinal symptoms . c The bidirectional relationship of the gut-brain axis can lead to a perpetuation of symptoms . d Anxious patients may perceive symptoms in the gastrointestinal tract at a lower symptom threshold .
4 . Which THREE may be causes of maladaptive defecatory behaviours ? a Medications . b Faecal incontinence . c Anal fissures . d A history of sexual assault .
5 . Which TWO features are required to make a positive diagnosis of IBS ? a Condition unresponsive to laxatives . b Characteristic symptoms . c An absence of red flags . d No abnormal findings on colonoscopy .
6 . Which THREE are red flags that warrant further investigation ? a Recent change in bowel habit in people over 50 years of age . b Unintentional weight loss . c Evidence of iron deficiency anaemia on blood testing . d Family history of IBS .
7 . Which TWO dietary interventions may assist in managing IBS ? a Low-FODMAP diet . b Traditional dietary advice . c Intermittent fasting . d Anti-inflammatory diet .
8 . Which THREE medication classes may assist in managing IBS ? a Antispasmodics . b Peppermint oil .
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• RACGP points are uploaded every six weeks and ACRRM points quarterly . movement . Almost all her bowel movements leave her with a sense of incomplete emptying . The pain and bloating are partially relieved with bowel movements .
Alison also says she is passing urine frequently and has occasional dyspareunia . There is no history of preceding illness or triggering event .
Alison admits that during school camps , when she was a teenager , she would frequently defer a bowel action until she came home , up to a week later .
Her examination reveals a soft abdomen without organomegaly
Multiple meta-analyses have shown the superiority of CBT over placebo for the management of gut symptoms .
IRRITABLE BOWEL SYNDROME
or masses . Perianal examination reveals a poorly relaxing pelvic floor .
Alison ’ s GP recognises that she has pelvic floor dyssynergia contributing to her IBS-C and would benefit from seeing a pelvic floor physiotherapist .
After three appointments with a pelvic floor physiotherapist , Alison is now able to open her bowels every second day with a complete sense of emptying without any additional straining . Her bloating and discomfort have also resolved .
Case study two
Steph , 27 , works in marketing for a multinational corporation that sells beauty products and is an aspiring social media influencer . She presents to her GP complaining about abdominal pain and bloating associated with mixed loose and hard stools . Steph is
c Prebiotics . d Antibiotics .
9 . Which TWO statements regarding the treatment of IBS are correct ? a Abnormal defecation mechanics and toileting behaviours may be an explanation for symptoms in some patients . b Tricyclic antidepressants and SSRIs are equally efficacious . c Dietary treatments should be avoided in patients with eating disorders . d SSRIs can often cause constipation .
10 . Which THREE statements regarding the treatment of IBS are correct ? a Gut-directed hypnotherapy is an alternative treatment with little evidence to support its use . b Multidisciplinary care improves symptoms , psychological health and quality of life . c Psychotherapy is effective in the management of gastrointestinal symptoms of IBS . d Hypnotherapy is as effective as a low-FODMAP diet . distressed by the “ painful bloating ” and visible distention and says , “ I look nine months pregnant .” Bowel actions partially relieve the abdominal pain .
Steph has tried to control her symptoms with a low-FODMAP diet ( self-administered using a low- FODMAP smartphone app ), and although there were initial improvements , she has maintained a strict ( no ) FODMAP diet with persisting symptoms . She avoids eating on days when she is delivering presentations at work or when she is having staged photos for social media .
Examination reveals a BMI of 18.5kg / m 2 with a soft non-tender abdomen without masses or signs of organomegaly .
Blood tests and calprotectin are normal , and despite the GP ’ s reassurance that there is no sinister pathology to explain her symptoms , Steph wants to be prescribed treatment . The GP explains that the low-FODMAP diet is unlikely to help her symptoms further and that diet therapy needs to be relaxed ; he refers her to a dietitian to oversee the ‘ reintroduction ’ phase of the diet .
The GP also refers Steph to a gut-directed hypnotherapist who , over eight sessions , successfully treats the symptoms of bloating , distention and abdominal pain . The gut-directed hypnotherapist incorporates CBT techniques during sessions to address perfectionist traits and body image concerns .
Case study three
Arjun , a 28-year-old investment banker , presents to his GP complaining of two years of diarrhoea ( he describes loose , frequent stools ) associated with abdominal pain . He consults the GP after speaking to an old high-school friend who is a doctor and who advises that the most likely diagnosis is IBS . He is not concerned about missed pathology but does want better control of his symptoms , which can disturb his work . His examination reveals a soft abdomen with no masses or organomegaly .
Arjun declines the low-FODMAP diet as he is an avid ‘ foodie ’ and does not want dietary restrictions . He also declines gut-directed hypnotherapy as he is unlikely to be able to commit to weekly sessions with a gut hypnotherapist over eight weeks .
After starting six weeks of a careful introduction and escalation of nortriptyline from 10mg to 25mg , Arjun notices that he now opens his bowels once a day without pain .
CONCLUSION
IBS is a highly prevalent condition in primary and secondary care . There are many causes , including dietary and psychological factors .
GPs are ideally placed to treat IBS , as they are familiar with a patient ’ s psychosocial context and dietary patterns . The GP can make a positive diagnosis of IBS early , even before receiving the results of basic non-invasive testing .
GPs should feel empowered to diagnose and treat IBS , without a gastroenterologist , as there are now a multitude of effective treatments available for this condition .
References Available on request from howtotreat @ adg . com . au