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Supporting community patients withirritable bowel syndrome (IBS)

Isobel Mason

Irritable bowel syndrome (IBS) is associated with a significantimpairment of quality of life. Due to the nature of its symptoms, therole of the nurse is central to the care of patients who may have IBS.The often embarrassing symptom profile means that patients mayrely on nurses to provide psychological and physical support inhelping them to improve their symptoms. In this article, the authordiscusses the management of patients with irritable IBS, includingthe optimal delivery of care for patients and the role of communitynurses in dealing with this chronic condition. JKEYWORDS:Continence m Irritable bowel syndrome s Chronic conditions

Irritable bowel syndrome (IBS)is a chronic, relapsing and oftenlife-long disorder affecting 10.5%of the UK population (Wilson etal, 2004). It is twice as commonin women as in men, and mostcommonly presents in people agedbetween 20 and 30 years (NationalInstitute for Care and HealthExcellence [NICE], 2008).

In the UK, IBS is esfimated tocost the NHS over £200 millionper year (Akehurst et al, 2002), andrepresents a major proportion of thegastrointestinal cases in both primaryand secondary care (Thompson etal, 2000). As IBS is very common,cost-effective management of thecondition is important.

The diagnostic criteria for IBSinclude any person who exhibits thefollowing symptoms for more thansix months (NICE, 2008):• Abdominal pain or discomfort• Bloating• Change in bowel habit.

To diagnose IBS safely, it isimperafive that alarm, or red-fiagsymptoms for other gastrointestinaldiseases are ruled out (NICE, 2008).These alarm symptoms may indicateother serious gastrointestinal diseasessuch as colon cancer, coeliac disease,ulcerative colitis or Crohn's diseaseand need medical assessment. Alarmsymptoms include (NICE, 2008):• Unintentional weight loss• Rectal bleeding• Family history of bowel or

ovarian cancer• Change in bowel habit to looser

stools for longer than six weeks inpersons over 60 years of age.

CLASSIFICATION

There are three acknowledgedsubtypes of IBS, which are basedon the presence of abdominalpain in addition to the dominantbowel symptoms that pafients mayexperience (NICE, 2008):

• Constipation predominant(IBS-C)

• Diarrhoea predominant (IBS-D)• A mixture of the two (IBS-M).

One-third of patients with IBS arethought to have IBS-C, suffering fromchronic abdominal pain, bloating andconstipation (Rao et al, 2012).

OUALITY OF LIFE

IBS is associated with a significantlyimpaired quality of life (Akehurst etal, 2002) {Table 1). Due to the natureof the syniptoms, the role of nurses iscentral to the care of patients with thecondition. The embarrassing symptomprofile means that pafients may relyon nurses to provide psychological andphysical support, in helping them toimprove their symptoms.

WHAT CAUSES IBS?

The cause of IBS is currentlyunknown (NICE, 2008). However,common explanations include:• Visceral hypersensitivity: higher

than normal sensation of painin the internal organs (viscera)can result in more painful bowelmovements (Delvaux, 2002)

• Post infective: this involvescontinued gastrointestinalsymptoms following a resolvedgastrointestinal infection or courseof antibiotics (NICE, 2008)

• Dietary intolerance (NICE, 2008)• Stress and life events may also

cause/exacerbate symptoms of IBS(Table 1) (NICE, 2008).

Table V. Impact of IBS on patient quality of life

Isobei Mason. Nurse Consultant, Gastrocnterology,Royal Free London NHS Foundation Trust, London

IBS reduces quality of life (Akehurst ef al, 2002)

IBS is a leading cause of work absenteeism (Hulisz, 2004)

IBS can cause significant disability, affecting patients physically and psychologically(Sainsbury and Ford, 2011)

IBS can have an emotional impact, with symptoms including depression, frustration, embarrassment andanxiety (Sainsbury and Ford, 2011)

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DIAGNOSIS AND MANAGEMENT

One of the main aims of IBSmanagement is to provide aposifive diagnosis fo rule ouf anyofher gasfroinfesfinal cause of fhesympfoms (NICE, 2008).Thosewifh'red flag'indicators should bereferred fo secondary care for furtherinvesdgafion such as endoscopy(NICE, 2008).

In the absence of alarmsymptoms, IBS can be confirmedwith some simple investigations toexclude more serious disease suchas colon cancer, coeliac disease,ulcerative colitis or Crohn's disease.These include blood tests such asfull blood count (FBC), C-reacfiveprofein (CRP) and coeliac antibodies(tissue transglutaminase [tTG])(NICE, 2008).

Only 19% of pafierrfs arediagnosed af fheir firsf consulfafionand 56% of patients may requireup fo five cor-\sulfations before adiagnosis is confirmed (Hunginef al, 2003). IBS can be difficulf fodiagnose because if can presenfwith inconsistent symptoms thatmimic organic disease. Patients mayrequire extensive investigation andconsultation before a final diagnosisis reached.

IBS accour-\fs for 20-50% ofreferrals fo gasfrointestinal clinicswithin secondary care, and it isestimated that up to 50% of fhosediagnosed wifh IBS are referredto hospital for ofher tests, suchas endoscopy (British Society ofGastroenterology, 2013).

Pafients are often fearful fhatthey have conditions such asinflammatory bowel disease (IBD)or cancer. Some studies have shownthat this fear is often still presenteven at the end of consulfafions,which may confribute to patientsreturning so often (Thompson et al,2000). This is why reassurance andexplanation from all clinicians is soimporfanf (Thompson ef al, 2000).

'Patients are often fearful thatthey have conditions such asinflammatory bowel diseaseor cancer'

CURRENT PHARMACOLOGICALTREATMENT OPTIONS

Most currenf freafments are aimed atrelieving individual symptoms (NICE,2008). Many of these are targetedat treating either diarrhoea orconstipation and have varying levelsof success depending on the patientand the nature of fheir IBS. This canmean fhaf pafienfs offen receivemulfiple freatments for differenfsympfoms (NICE, 2008).

New treatments for IBS canimprove pafienfs'qualify of ufe byfargefing specific symptoms includingabdominal pain, bloafing andconsfipafion. As such, they representa welcome development in themanagement of fhe condifion (Table 2).

DIETARY AND LIFESTYLE ADVICE

The chronic nature of IBS requires

Table 2: Treatments for IBS symptoms

Dominant symptom

]M\/discomfort

Constipation

Diarrhoea

Treatment options (NICE, 2008)

• Antispasmodics (e.g. mebeverine)• Trycylic antidepressants (e.g. amitryptiline)

• Guanylate c}'clase-c agonists (GCCA) (e.g.

linaclotide)

• Laxatives, for example Movicol® (Norgine)/

Fybogel® (Reckitt Benckiser) (lactulose is not

recommended)

• GCCA (e.g. linaclotide)

• Antimotility (e.g loperamide)

• Büe salt absorber (e.g. cholestyramine)

good basic informafion about dietaryand lifesfyle adjusfmenfs. Self-managemenf is also sfressed.

NICE (2008) provides cleargeneral advice abouf dief :• Have regular meals and fake fime

fo eat• Avoid missing meals and long

gaps between eating• Resfricf fea and coffee fo fhree

cups per day• Limit high-fibre foods

(wholemeal, cereals high in bran,brown rice)

• Those suffering from hloafingshould fry oafs and linseed (up foone tablespoon per day).

There is some evidence thatprobiofics can improve fhesympfoms of IBS (Nikfar ef al, 2008),and NICE guidance recommendsfhaf pafienfs fry a four-week course.The reasons for probiofic efficacyare unclear, buf may relate to arebalancing of normal gut flora.However, NICE does not specifywhich particular strain of probioficshould be used (NICE, 2008).

COMPLEMENTARY THERAPIES

As wifh many chronic illnesses,patients often seek outcomplementary therapies to helpthem manage their symptoms.However, in the case of IBS fhereis liftle, or no, published evidencefor fhese. Indeed, NICE guidancerecommends that acupuncture andreflexology are not to be encouraged(NICE, 2008).

There is good evidence for the roleof hypnotherapy, however (Houghtonet al, 1996). Specialist gut-directedhypnotherapy uses visuaUsafionand deep relaxation targeted atthe bowel. Studies have shown itto be beneficial, nof only reducingsymptoms, but also improvirig qualityof life (Houghton et al, 1996).

THE ROLE OF COMMUNITYNURSES IN IBS

Nursing support is important in themanagement of IBS. Many patientsfeel that their illness is not takenseriously enough by clinicians(British Society of Gasfroenferology,

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Five-minute test

Answer the following questionsabout this topic, either to test the

new knowledge you have gained orto form part of your ongoing practice

development portfolio.

1 -What is irritable bowel syndrome(IBS)?

2 - Name some of the commonsymptoms of IBS.

3 - What are some of the reasons forthe development of IBS?

4 - Name some of the potentialtreatment options for IBS.

5 - Wliy is self-care so important?

2013). Although the condition is notlife-threatening and will not shortenlife expectancy, it is a lifelongcondition that has a serious effecton quality of life (Longstreath andThompson, 2006).

A strong nurse-patientrelationship can help nurses to shareclear information with patients, assistthem in setting management goalsand evaluate adherence to treatmenton an ongoing basis (British Societyof Gastroenterology, 2013).

As a flrst-line option, patientswith IBS are usually advised to tryand treat their symptoms by alteringtheir diet and increasing their fibreintake. However, if the patient hasdiarrhoea, flatulence or abdominalbloating, a high-fibre diet can actuallyworsen these symptoms.

In many cases, altering diet isineffective at relieving patients'symptoms, and this leads to repeatvisits to primary care professionalsand referrals to secondary care tocomplete investigations, excludeother organic diseases and confirmthe diagnosis of IBS.

The focus on reducing secondarycare referrals has been prompfedby increasing waiting times and

the move to manage long-termconditions closer to the patient'shome (Department of Health [DH],2012). There are real opportunities tooptimise IBS management here, andgaining a positive diagnosis for IBS inprimary care is possible. Primary careprofessionals, such as communitynurses, have the benefit of greaterfamiliarity with the patient andprevious consultations to refer to andthey can view symptoms in context,rather than in isolation. For example,where patients have developedconstipation, community nurses areable to view this change in bowelhabit with reference to an individual'smedication history, dietary changesand mobility, etc.

Supporting patients to self-care, using clear, validated patienteducation materials wül lead to agreater acceptance of IBS as a chroniccondition. Self-management oflong-ferm conditions such as IBS isacknowledged to be a fundamentalpart of helping patients live withongoing symptoms and nursescan take a lead in this, using theirrelationship with patients to helpthem manage their condition.

Encouraging patientsto sett-careThe IBS Network provides dedicatedsupport to people living with IBS inthe UK. The Network aims to helpthem, their families and carers tomanage their IBS and achieve animproved quality of life. While theNetwork's online resource (http://www.theibsnetwork.org) includesfacf-sheets and other information,it has also developed a self-caremanagement programme thatmembers can access online. Thereis an interactive programme for themanagement of IBS, which consists of12 modules that have been adaptedfor individual study, or which can beused by self-help groups. The self-help module includes:• Have I got IBS: what is IBS; what

else could it be?• How do I know if if is anything

more serious?• What are the causes of IBS?• Diet: food allergy, intolerance,

food and mood, pre- andprobiotics

• Stress: reducing fear and panic.

KEY POINTS

i

IrritäbleDowel syndrome (IBS)is a chronic, relapsing and oftenlife-long disorder.

IBS is twice as common inwomen, and most commonlypresents in people aged between20 and 30 years.

IBS is associated with asignificant impairment of qualityof life.

A strong nurse-patientrelationship can help the nurseto share clear information with

tthe patient, assist them in settingmanagement goals and evaluatepatient adherence.managing anger/despair,psychological therapies

• Medical: when to see a doctor,medical treatments

• Therapies: hypnotherapy,counselling and psychotherapy,nutrition, and herbal therapy

• Symptom management:constipation, diarrhoea, bloating,abdominal pain, symptom tracker,bowel-directed relaxation module.

The course aims to helpindividuals to understand and self-manage their IBS.

CONCLUSION

Community nurses can playa major role in improving themanagement of people with IBS inthe community setting.

Firstly, it is important to recognisethe recommendations from bofhNICF and the British Society ofGastroenterology, which stipulatethat the management of mostpatients with IBS can take placewithin a primary care environmentand does fall wifhin the communitynursing remit (NICE 2008; BritishSociety of Gastroenterology, 2013).

It is also important to enable apositive diagnosis by recognising thechronic nature of IBS and supportingpatients to self-manage, answeringquestions and directing them to self-management resources.

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Enhancing IBS services, includingproviding access to specialistand practice nurses, GPs witha special interest or secondarycare gastroenterology services, isalso vital, as is developing localpathways in partnership withsecondary and primary care servicesto assist in triaging referrals andhelp with symptom management.

Ensuring confinuity of care, aswell as providing advice and supportfor people with IBS can help themovercome the burden of the condifion.Helping pafients achieve a betterquality of life should be a specific aimof community nurses.

Finally, community nurses shouldaim to take an active role in themanagement of IBS patients bydeveloping care pathways, which takeinto account new treatments. jCN

ACKNOWLEDGEMENTS

All views expressed are the viewsoflsobel Mason, who received anhonorarium from Almirallforher involvement.

REFERENCES

Akehurst RL, Brazier JE, Mathers N, etal (20Ü2) Health related qualit\' oflife and cost impact of irritable bowelsyndrome in a UK primary care setting.Pharmacoeconomics 20(7): 455-62

British Society of Gastroenterology (2013)IBS Functional Symptoms. Availableonline at http://www.bsg.org.uk/cunical/commissioning-report/ibs/functional-symptoms.html [accessed 2 Januarv', 2014]

DH (2012) Living with Long-term Conditioiis;a policy framework. Available at: http://www.dhsspsni.gov.uk/living'longterm-conditions.pdf (accessed 22 January, 2014)

Delvaux M (2002) Role of visceral sensitivityin the pathophysiology of irritable bowelsyndrome. Cut 51(1 suppl): S67-S71

Houghton LA, Heyman DJ, Whorweü PJ(1996) Symptomatology, quality of lifeand economic features of irritable bowelsyndrome-the effect of hypnotherapy.Aliment Pharmacol Tljer 10(1): 91-5

Hulisz D (2004) The burden of ülnessof irritable bowel syndrome: currentchallenges and hope for the future./Manag Care Pharm 10(4): 299-309

Hungin APS, Whorwell PJ, Tack J, MearingF (2003) The prevalence, patterns andimpact of irritable bowel syndrome: an

international survey of 40,000 subjects.Aliment Pharmacol Ther 17: 643-50

Longstreath G, Thompson WG(2006) Functional bowel disorders.Castroenterology 130:1480-91

NICE (2008) Irritable Bowel Syndrome inAdults. NICE, London

Nikfar S, Rahimi R, Rahimi F, DerakhshaniS, AbdoUahi M (2008) Efficacy ofProbiotics in irritable bowel syiidrome: Ameta-analysis of randomized controlledtrials. Dis Colon Rectum 51:1775-80

Rao S, Lembo AJ, Shiff SJ, et al (2012) A12-week, randomized, controlled trialwith a 4-week randomized withdrawalperiod to evaluate the efficacy and safetyof linaclotide in irritable bowel syndromewith constipation. Am J Castroentcrol107(11): 1714-24

Sainsbury A, Ford A (2011) Treatment ofirritable bowel syndrome: beyond fibreand antispasmodic agents. Therap AdvCastroenterol 4{2): 115-27

Thompson WG, Heaton KW, Smyth GT,et al (2000) Irritable bowel syndromein general practice: prevalence,characteristics and referral. Cut 46: 78-82

Wilson S, Roberts L, Roalfe A, Bridge P(2004) Prevalence of irritable bowelsyndrome: a community survey. BrJCenPrac 54: 495-502

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