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Gut 56:1770-1798 doi:10.1136/gut.2007.119446
  • Guidelines

Guidelines on the irritable bowel syndrome: mechanisms and practical management

  1. R Spiller1,
  2. Q Aziz2,
  3. F Creed3,
  4. A Emmanuel4,
  5. L Houghton5,
  6. P Hungin6,
  7. R Jones7,
  8. D Kumar8,
  9. G Rubin9,
  10. N Trudgill10,
  11. P Whorwell11
  1. 1
    Wolfson Digestive Diseases Centre, University of Nottingham, Nottingham, UK
  2. 2
    Department of Gastroenterology, St Barts and Royal London Hospital, London, UK
  3. 3
    University Department of Psychiatry, Manchester Royal Infirmary, Manchester, UK
  4. 4
    Digestive Disorders Institute, University College Hospital, London, UK
  5. 5
    Neurogastroenterology Unit, Wythenshawe Hospital, Manchester, UK
  6. 6
    Centre for Integrated Research, University of Durham, Durham, UK
  7. 7
    Department of General Practice and Primary Care, Kings College London, London, UK
  8. 8
    Department of Surgery, St George’s Hospital, Tooting, London, UK
  9. 9
    University of Sunderland, Sunderland, UK
  10. 10
    Sandwell General Hospital, West Bromwich, UK
  11. 11
    University Hospital of South Manchester, Manchester, UK
  1. Professor R C Spiller, The Wolfson Digestive Diseases Centre, University Hospital, Nottingham NG7 2UH, UK; robin.spiller{at}nottingham.ac.uk
  • Revised 20 April 2007
  • Accepted 1 May 2007
  • Published Online First 8 May 2007

Abstract

Background: IBS affects 5–11% of the population of most countries. Prevalence peaks in the third and fourth decades, with a female predominance.

Aim: To provide a guide for the assessment and management of adult patients with irritable bowel syndrome.

Methods: Members of the Clinical Services Committee of The British Society of Gastroenterology were allocated particular areas to produce review documents. Literature searching included systematic searches using electronic databases such as Pubmed, EMBASE, MEDLINE, Web of Science, and Cochrane databases and extensive personal reference databases.

Results: Patients can usefully be classified by predominant bowel habit. Few investigations are needed except when diarrhoea is a prominent feature. Alarm features may warrant further investigation. Adverse psychological features and somatisation are often present. Ascertaining the patients’ concerns and explaining symptoms in simple terms improves outcome. IBS is a heterogeneous condition with a range of treatments, each of which benefits a small proportion of patients. Treatment of associated anxiety and depression often improves bowel and other symptoms. Randomised placebo controlled trials show benefit as follows: cognitive behavioural therapy and psychodynamic interpersonal therapy improve coping; hypnotherapy benefits global symptoms in otherwise refractory patients; antispasmodics and tricyclic antidepressants improve pain; ispaghula improves pain and bowel habit; 5-HT3 antagonists improve global symptoms, diarrhoea, and pain but may rarely cause unexplained colitis; 5-HT4 agonists improve global symptoms, constipation, and bloating; selective serotonin reuptake inhibitors improve global symptoms.

Conclusions: Better ways of identifying which patients will respond to specific treatments are urgently needed.

Footnotes

  • Conflicts of interest: Professor Aziz has received remuneration for consultancy advice to Novartis and Mundi Pharma, and has received research funding from GlaxoSmithKline (GSK) and Pfizer Pharmaceuticals. Professor Creed has received remuneration for consultancy advice to Eli Lilley and Company. Dr Emmanuel has been reimbursed for travelling and conferences by GSK and Novartis and has received research funding from GSK. Dr Houghton has received remuneration for advice and speaking (Novartis, Solvay, Clasado), together with financial support for the conduct of physiological research from Novartis, GSK, and Pfizer. Professor Hungin has received remuneration for speaking and consulting from GSK, Novartis, and AstraZeneca, and research funding from Novartis. Professor Jones has received remuneration for speaking and consulting from Novartis, Solvay, Astra-Zeneca, and GSK. Professor Rubin has received remuneration for consultancy advice to Novartis and Tillots Pharma, and has received research funding from Novartis. He has shares in GSK. Professor Spiller has received remuneration for consultancy advice and received research support from Novartis Pharmaceuticals and GSK. He has also acted on an advisory board for Solvay Pharmaceuticals. Dr Trudgill has received remuneration for consultancy advice to Astra-Zeneca and Ferring. Professor Whorwell has received remuneration for advice and his department has received financial support from Novartis, GSK, Pfizer, Solvay, Rotta Research, Proctor and Gamble, Astellas, and Tillots.

  • Abbreviations:
    CBT
    cognitive behavioural therapy
    CCK
    cholecystokinin
    CRF
    corticotropin releasing factor
    CRH
    corticotrophin releasing hormone
    EMA
    endomysial antibodies
    fMRI
    functional magnetic resonance imaging
    HPA
    hypothalamo-pituitary-adrenal
    IBS
    irritable bowel syndrome
    IBS-C
    constipation predominant IBS
    IBS-D
    diarrhoea predominant IBS
    IBS-M
    IBS with mixed bowel pattern
    MMC
    migrating motor complex
    NNT
    number needed to treat
    PIT
    psychodynamic interpersonal therapy
    RCT
    randomised controlled trial
    SSRI
    selective serotonin reuptake inhibitor