Communication skills: Explaining Irritable Bowel Syndrome (IBS)
Irritable bowel syndrome (IBS) is a common, functional bowel disorder, which consists of multiple non-specific abdominal complaints including abdominal pain, bloating, diarrhoea or constipation.
‘Functional’ disorders are those for which there is no known organic cause for symptoms.
While IBS in isolation is not dangerous, its symptoms can have a significant psychological burden for patients. Therefore careful and sensitive explanation is a key aspect to initiating treatment (not to mention functional disorders come up frequently in exams!).
A challenging OSCE scenario could involve trying to explain the diagnosis of IBS to a patient who has undergone relevant tests for other causes of their abdominal symptoms (e.g. for inflammatory bowel disease or coeliac) which have all been negative. Sometimes patients remain worried about other causes of their symptoms, so as long as the essential tests have been carried out it is important to reassure them, acknowledge their ongoing symptoms, and work with them to try to explore the management options.
- Good afternoon, my name is John Smith, I am a final year medical student and I have been asked to talk to you about your diagnosis of IBS. Is this alright?
- ‘Before I begin, can you tell me what you know about IBS? Are there any specific things that are worrying you that we can address now?
- Allow patient to talk continuously without interruption
- Once the patient has finished, suggest that in the first instance you would like to give an overview explanation of what IBS is and then perhaps you can address their questions as you go along.
Ensure patient understanding through each stage of the consultation and look out for verbal and non-verbal queues. Better marks will be given for addressing concerns in a more ‘natural’ way, not just by asking at the end!
- IBS is a common disorder of the bowel for which the cause is currently unknown.
- It is known as a functional disorder, and this means people develop symptoms though we can’t find anything physically wrong on blood tests and other investigations.
- It can affect anybody at any age, but comes on most commonly in young adults
- The symptoms of IBS vary from person to person and may change over time.
- The commonest symptoms include abdominal pain, bloating, diarrhoea or constipation or a mixture of the two.
- The abdominal pain can be anywhere in the tummy, vary in severity and is often relieved by opening the bowel.
- Other symptoms include needing to rush to the toilet (particularly after meals) and the feeling of incomplete emptying of the bowel after a motion.
- Along with bowel symptoms, many people experience other symptoms including back pain, muscle aches and irritable bladder.
- All of the symptoms of IBS can take their toll psychologically and some people can feel anxious or depressed.
- Currently, there is no available test that can diagnose IBS. Your doctor will ask you questions about your symptoms to see if they fit with a diagnosis of IBS and will also ask questions to make sure there is no other cause of your symptoms that fits.
- However, you doctor will also do some basic tests to help rule out other causes of your symptoms that wood be treated differently. These including checking the iron levels in your blood, checking for coeliac disease and also sending off a sample of stool to rule out Inflammatory Bowel Disease (Crohn’s or UC).
- Occasionally, if your doctor is concerned, s/he may refer you for further investigations such as an endoscopy. This will not diagnose IBS but will help to rule out other causes, particularly if you develop symptoms later in life (e.g. over age of 50)
- Currently we don’t know for certain the cause of IBS. One theory is that the muscles and nerves, which control how the food is squeezed through the intestines, are overactive in people with IBS. This can result in diarrhoea, constipation and abdominal pain. The over activity of the nerves may also result in people with IBS having increased sensitivity to the pain caused when the gut is bloated by constipation.
- This over activity may be linked with emotional stress, as many people find there symptoms start or are made worse by stressful life events.
- Some people with IBS feel that their symptoms started after a bout of gastroenteritis, so another theory is that changes in the gut movement/squeezing may be triggered by a change in the normal bacteria of the gut.
- Currently there is no cure for IBS, but the symptoms can be greatly improved in many people.
- The symptoms often vary greatly over time and may be influenced by psychological, dietary and lifestyle factors.
General measures: Managing stress may be of benefit. Try to identify things that cause stress and try to avoid these triggers. Exercise has been shown to relieve symptoms of IBS.
Dietary measures: Maintaining a regular meal schedule is important in reducing symptoms. Try to drink plenty of fluid, but avoid excessive coffee, fizzy drinks and alcohol as these can make symptoms worse. If diarrhoea is a major problem, then avoidance of foods high in insoluble fibre (e.g. bran) is recommended, as well as avoiding excessive fresh fruit and artificial sweeteners. Soluble fibres (oats, nuts, seeds, ispaghula) can improve symptoms for some people. If diet is a big contributor to your symptoms, then your doctor can refer you to a dietician. The dietician may offer more complex diet plans, such as the new ‘FODMAP diet’, which avoids foods high in fermentable sugars. In reality, finding the right diet for you may be trial and error, but the most important thing is to work closely with your doctor to find the solution.
Medications: Anti-spasm medications may be used to reduce abdominal pain as well as laxatives or anti-diarrhoeal medications depending on whether you are suffering mainly from constipation or diarrhoea respectively. Peppermint oil is another option for bloating and has few side effects.
Drugs that are used for anxiety/depression are sometimes used at low doses in IBS and in some people help to alleviate symptoms. As we discussed above, nerve hyperexcitablity is thought to one of the causative factors in IBS. Some of these drugs, for example amitriptyline, have an effect of nerve transmission. In addition, they may also have improve emotional/psychological stress, which can worsen IBS symptoms
If emotional stress is a big factor, then your doctor may refer you for talking therapies to help you deal with this, and this may also help your symptoms of IBS.
- The symptoms of IBS tend to come and go. In some people it will go away completely but in the majority it will persist in the long term. Treatments are directed at symptoms as they arise, rather than cure.
- However, IBS is not considered to be dangerous and does not lead on to more dangerous problems with the bowel such as cancer or inflammatory bowel disease.
- Ask if they have any further specific questions or concerns.
- Recommend written patient information leaflet (patient.co.uk for example)
- Offer the opportunity to come back for another appointment to answer any further questions.
- http://patient.info/health/irritable-bowel-syndrome-leaflet
- http://www.uptodate.com/contents/irritable-bowel-syndrome-the-basics
