irritable bowel syndrome
Doctor Information
Jenna Marcus, age 26
No PMH or current medication
No known allergies
Last consultation 2 weeks ago:
Seen by Dr Philips
Complains of abdo pain and bloating, thinks might have food poisoning as went to a bbq. However has had similar pains before and occasional loose stool. Suggested increase fluid intake, to do stool sample and have bloods. Review in two weeks.
Stool microscopy:
Microscopy negative
Virology negative
Bloods:
Hb 12.7
Wcc 5.8
Plt 208
Na 137
K 3.5
Urea 7.0
Creat 78
LFT NAD
TFT NAD
CRP < 5
Coeliac screen negative
No PMH or current medication
No known allergies
Last consultation 2 weeks ago:
Seen by Dr Philips
Complains of abdo pain and bloating, thinks might have food poisoning as went to a bbq. However has had similar pains before and occasional loose stool. Suggested increase fluid intake, to do stool sample and have bloods. Review in two weeks.
Stool microscopy:
Microscopy negative
Virology negative
Bloods:
Hb 12.7
Wcc 5.8
Plt 208
Na 137
K 3.5
Urea 7.0
Creat 78
LFT NAD
TFT NAD
CRP < 5
Coeliac screen negative
Patient Information
Jenna Marcus, age 26
History: You have come for your results - you have been having these pains in your belly and feeling really bloated. You had a poo sample done and some blood test in case it was food poisoning.
If you are given the results straight away you want to know what could be causing your symptoms. Otherwise you can provide the following information if asked: The pain is in the lower parts of your belly and feels crampy. It is not all the time and never wakes you up from sleep. You cant really link it to any foods, but after a night of drinking you definitely get the pains the next day. You also get bloating, which is a bit embarrassing because you sometimes look pregnant! It also makes you pass wind or belch which is awful. On the bad days, you get diarrhoea, which is not all day but often in the morning. There is no blood in the poo and it flushes easily. You have no nausea or vomiting, no heartburn or weight loss. Some days you feel absolutely fine, and others you are doubled over.
You are a law graduate who has recently started the LPC which is a one year course that will allow you to get a training contract. It is intense and full of exams. You are coping with the workload but conscious that your stress levels are pretty high. Now you think about it, some of the worst days have been when you have had coursework or presentations, and the symptoms can last a few days after that. You have not taken anything for the pain but you did use immodium before your last presentation and it helped.
You live with two flatmates in town. You have never smoked, and you go out once a week to clear your head, and usually drink a few vodka red bulls. Up until this point, your health has been fine and you take no regular tablets and have no allergies.
Ideas: you think your symptoms might be related to stress but sometimes they are so severe it does make you wonder whether something more serious is going on
Concerns: apart from the possibility of something serious, you are worried about completing your LPC as the symptoms are always on days when there is something important happening
Expectations: to find something in your tests that will explain things, and to be offered a treatment
History: You have come for your results - you have been having these pains in your belly and feeling really bloated. You had a poo sample done and some blood test in case it was food poisoning.
If you are given the results straight away you want to know what could be causing your symptoms. Otherwise you can provide the following information if asked: The pain is in the lower parts of your belly and feels crampy. It is not all the time and never wakes you up from sleep. You cant really link it to any foods, but after a night of drinking you definitely get the pains the next day. You also get bloating, which is a bit embarrassing because you sometimes look pregnant! It also makes you pass wind or belch which is awful. On the bad days, you get diarrhoea, which is not all day but often in the morning. There is no blood in the poo and it flushes easily. You have no nausea or vomiting, no heartburn or weight loss. Some days you feel absolutely fine, and others you are doubled over.
You are a law graduate who has recently started the LPC which is a one year course that will allow you to get a training contract. It is intense and full of exams. You are coping with the workload but conscious that your stress levels are pretty high. Now you think about it, some of the worst days have been when you have had coursework or presentations, and the symptoms can last a few days after that. You have not taken anything for the pain but you did use immodium before your last presentation and it helped.
You live with two flatmates in town. You have never smoked, and you go out once a week to clear your head, and usually drink a few vodka red bulls. Up until this point, your health has been fine and you take no regular tablets and have no allergies.
Ideas: you think your symptoms might be related to stress but sometimes they are so severe it does make you wonder whether something more serious is going on
Concerns: apart from the possibility of something serious, you are worried about completing your LPC as the symptoms are always on days when there is something important happening
Expectations: to find something in your tests that will explain things, and to be offered a treatment
Examination Findings
Pulse 87
Blood pressure 128/69
Abdomen soft and non tender, no palpable mass
No renal angle tenderness
Blood pressure 128/69
Abdomen soft and non tender, no palpable mass
No renal angle tenderness
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently, or use instruments proficiently |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Manages risk effectively, safety netting appropriately . Encourages the patient to participate in appropriate health promotion and disease prevention strategies Follow-up arrangements and safety netting are adequate |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions to refer is inappropriate. Follow-up arrangements are absent or disjointed Unable to enhance patient’s health perceptions and coping strategies |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centred approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation. |
Management
Explanation: Irritable bowel syndrome (IBS) is a common disorder that affects the gut. The symptoms can be quite variable - tummy pain, cramps, bloating, diarrhoea, constipation. Blood tests, stool tests, and cameras inside the bowel come back normal. We think it is caused because your bowels are more sensitive to small things compared to someone who does not have IBS. Some people find certain foods or periods of stress can trigger their symptoms. We try and focus our treatments on the specific symptoms that you are experiencing.
Assessment: Diagnosis of IBS is usually based upon the ROME III criteria listed below:
C1. Irritable Bowel Syndrome Diagnostic criterion*
Recurrent abdominal pain or discomfort** at least 3 days/month in the last 3 months associated with two or more of the following:
* Criterion fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis
** “Discomfort” means an uncomfortable sensation not described as pain. In pathophysiology research and clinical trials, a pain/discomfort frequency of at least days a week during screening evaluation is recommended for subject eligibility
While there is no diagnostic test to confirm IBS, you should consider performing a full blood tests including CRP and Coeliacs screen to exclude other causes of similar symptoms. Remember that if the patient is a female to consider this being a presentation of ovarian cancer, or in the older individual of this being a presentation of bowel cancer. To distinguish between inflammatory causes and IBS, NICE does recommend the use of Faecal Calprotectin, however this test is not widely available, and is currently still very expensive.
Your history should still exclude red flags such as weight loss, rectal bleeding, anaemia, and look at potential triggers in their diet and lifestyle. It is important to ask specifically about physical activity in addition to their current psychological condition. Specifically looking for underlying stress, anxiety or depression.
General advice with diet: Make time for relaxation. Advise regular physical activity. Increase fluid intake (8 cups of water per day) and reduce carbonated, caffeinated or alcoholic drinks. Usually fibre content needs to be reduced to help with pain and bloating, or switch from insoluble fibre (brown bread, bran, wholemeal foods) to soluble fibre (oats). If bloating is an issue, again oats can help, or also linseed or peppermint. Peppermint capsules can be purchased over the counter in most pharmacies or supermarkets. There is a very good diet sheet on patient.co.uk for patients with irritable bowel syndrome. Often keeping a food diary can help identify possible triggers, however most people with suspected IBS will probably have thought of this already, and may come in stating that certain foods appear to aggravate them.
There is now increasing evidence for the low-FODMAP diet in the treatment of IBS. The term FODMAP is an acronym, deriving from "Fermentable, Oligo-, Di-, Mono-saccharides And Polyols. By reducing foods that are high in the afore mentioned ingredients, then a reduction in symptoms should be seen. Please see the image below for a quick visual representation of foods that should be avoided, as well as foods that should be encouraged.
Assessment: Diagnosis of IBS is usually based upon the ROME III criteria listed below:
C1. Irritable Bowel Syndrome Diagnostic criterion*
Recurrent abdominal pain or discomfort** at least 3 days/month in the last 3 months associated with two or more of the following:
- Improvement with defecation
- Onset associated with a change in frequency of stool
- Onset associated with a change in form (appearance) of stool
* Criterion fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis
** “Discomfort” means an uncomfortable sensation not described as pain. In pathophysiology research and clinical trials, a pain/discomfort frequency of at least days a week during screening evaluation is recommended for subject eligibility
While there is no diagnostic test to confirm IBS, you should consider performing a full blood tests including CRP and Coeliacs screen to exclude other causes of similar symptoms. Remember that if the patient is a female to consider this being a presentation of ovarian cancer, or in the older individual of this being a presentation of bowel cancer. To distinguish between inflammatory causes and IBS, NICE does recommend the use of Faecal Calprotectin, however this test is not widely available, and is currently still very expensive.
Your history should still exclude red flags such as weight loss, rectal bleeding, anaemia, and look at potential triggers in their diet and lifestyle. It is important to ask specifically about physical activity in addition to their current psychological condition. Specifically looking for underlying stress, anxiety or depression.
General advice with diet: Make time for relaxation. Advise regular physical activity. Increase fluid intake (8 cups of water per day) and reduce carbonated, caffeinated or alcoholic drinks. Usually fibre content needs to be reduced to help with pain and bloating, or switch from insoluble fibre (brown bread, bran, wholemeal foods) to soluble fibre (oats). If bloating is an issue, again oats can help, or also linseed or peppermint. Peppermint capsules can be purchased over the counter in most pharmacies or supermarkets. There is a very good diet sheet on patient.co.uk for patients with irritable bowel syndrome. Often keeping a food diary can help identify possible triggers, however most people with suspected IBS will probably have thought of this already, and may come in stating that certain foods appear to aggravate them.
There is now increasing evidence for the low-FODMAP diet in the treatment of IBS. The term FODMAP is an acronym, deriving from "Fermentable, Oligo-, Di-, Mono-saccharides And Polyols. By reducing foods that are high in the afore mentioned ingredients, then a reduction in symptoms should be seen. Please see the image below for a quick visual representation of foods that should be avoided, as well as foods that should be encouraged.
Further information that can be printed for patients - can be found here made at the Stanford University
Medications suitable for IBS: Alongside dietary / lifestyle modifications, medication can be used as required depending on the predominant symptoms. For example antispasmodics such as buscopan or mebeverine are good for cramps, diarrhoea can be treated with laxatives (bulk-forming if possible e.g. isphagula or movicol - avoid lactulose). Loperamide is good for diarrhoea.
If treatment doesnt respond to the above measures, then consider using a low dose tricyclic antidepressant such as amitriptyline, or an SSRI like citalopram.
Medications suitable for IBS: Alongside dietary / lifestyle modifications, medication can be used as required depending on the predominant symptoms. For example antispasmodics such as buscopan or mebeverine are good for cramps, diarrhoea can be treated with laxatives (bulk-forming if possible e.g. isphagula or movicol - avoid lactulose). Loperamide is good for diarrhoea.
If treatment doesnt respond to the above measures, then consider using a low dose tricyclic antidepressant such as amitriptyline, or an SSRI like citalopram.