Managing patients with irritable bowel syndrome in general practice: How to promote and reinforce self-care activities

https://doi.org/10.1016/S0738-3991(98)00053-6Get rights and content

Abstract

In this paper the development and implementation of a set of guidelines for the management of irritable bowel syndrome (IBS) patients in primary care is presented. The guidelines are based on the knowledge that has emerged from research in the past decade on factors that influence the course and prognosis of IBS. These include lifestyle factors, avoidance behaviour and reaction patterns from family and friends. The guidelines contain elements of psychotherapeutic techniques that have been found to be successful in outpatients with IBS. They comprise instructions to promote and reinforce self-care activities. The guidelines have been applied in daily practice by a group of Dutch general practitioners and various aspects of the feasibility of the guidelines are discussed.

Introduction

General practitioners (GPs) encounter one or two patients with irritable bowel syndrome (IBS) each week in their surgery. Approximately 40% of IBS patients consult their GP more or less regularly for a number of years because of their IBS symptoms 1, 2, 3. GPs are often frustrated by these patients who have refractory complaints and repeatedly request tests or a referral to a specialist 4, 5. The question of how to develop a successful strategy for the management of IBS (i.e. acceptable and profitable for both doctor and patient) has been addressed by several authors who concentrated mainly on outpatients with IBS 5, 6, 7, 8, 9In this paper we present a set of guidelines for GP management of IBS patients. First, we briefly review the knowledge of the pathophysiology and management of IBS that has emerged from studies carried out in the last decade including systematic reviews. Next, we extensively describe our guidelines which, taking into account this knowledge, were developed in dialogue with two experts in the field of IBS1. We also comment on certain aspects of the feasibility of the guidelines which have been applied in daily practice by a number of GPs.

Section snippets

IBS: definition, pathophysiology and therapeutic considerations

According to the definition developed by an international working panel, IBS is `a functional gastrointestinal disorder attributed to the intestines and associated with symptoms of pain and disturbed defecation and/or symptoms of bloatedness and distension' [7]. The pathophysiological mechanism of IBS is still unclear 5, 7. However, many authors have reported on factors that can possibly influence the course of the complaints and/or the health-care-seeking behaviour in patients with IBS. The

Guidelines for the management of IBS patients in general practice

The guidelines we propose for the management of IBS patients in primary care combine the Drossman approach with elements of health-promoting behaviour and self-care: after exploration of the patient's worries and beliefs about the symptoms, and enquiring about the self-care activities and limitations resulting from the complaints, the GP should reassure the patient and provide adequate information regarding the complaints. Subsequently, the GP turns to seven so-called self-care activities that

Training GPs in the application of the guidelines

In order to assess the feasibility of the guidelines, 19 GPs were trained during a 3-h session in the application of the guidelines. They were asked to read the booklet for patients before attending the meeting. The training was given by the first author, and the programme of the session consisted of:

  • explanation and theoretical justification of the guidelines

  • role-playing to practise the application of the guidelines

  • discussion of the problems the GPs anticipated in applying the guidelines

During

Discussion

Starting from some basic principles of a good therapeutic relationship — namely the exploration of a patient's problems, feelings and beliefs, and appropriate reassurance — we have combined knowledge of factors that have proved to be of influence on the course and prognosis of IBS with elements of successful psychotherapeutic techniques used in IBS, to develop a comprehensive set of guidelines for the management of IBS patients in primary care. Our aim was to simplify some elements of useful

References (31)

  • D.A. Drossman

    Illness behaviour in the irritable bowel syndrome

    Gastroenterol Int

    (1991)
  • W.G. Thompson et al.

    Functional bowel disease and functional abdominal pain

    Gastroenterol Int

    (1992)
  • W.G. Thompson

    Irritable bowel syndrome: pathogenesis and management

    Lancet

    (1993)
  • E. Guthrie et al.

    A randomised controlled clinical trial of psychotherapy in patients with refractory irritable bowel syndrome

    Br J Psychiatry

    (1993)
  • R. Johnsen et al.

    Associations between symptoms of irritable colon and psychological and social conditions and lifestyle

    Br Med J

    (1986)
  • Cited by (11)

    • Intervening on cognitions and behavior in irritable bowel syndrome: A feasibility trial using PDAs

      2011, Journal of Psychosomatic Research
      Citation Excerpt :

      The feedback was focused on IBS complaints, catastrophizing thoughts, dysfunctional cognitions, and avoidance behavior, and was mainly based on cognitive–behavior therapy. A protocol to standardize the feedback was developed based on existing literature (e.g., Refs. 19,39) including an informative book on IBS for patients, written by a consortium of Dutch IBS experts [40]. For pragmatic reasons, the protocol was divided into five sets of topics which were structured in a hierarchical way, with the first set of topics (cognitions, emotions, and activities) as the most important to intervene on.

    • Interface between Primary Care and Secondary Care

      2013, Irritable Bowel Syndrome: Diagnosis and Clinical Management
    • Patient education for people with irritable bowel syndrome

      2011, European Gastroenterology and Hepatology Review
    View all citing articles on Scopus
    View full text