The Dutch College of General Practitioners (NHG) Practice Guideline

This NHG Practice Guideline is a translation of the Dutch guideline. It is specifically written for Dutch general practitioners in the Dutch enviroment. The advice which is given may therefore not be in accordence with the views of general practitioners in other countries.

NHG Practice Guideline 'Irritable bowel syndrome'   

Van der Horst HE, Meijer JS, Muris JWM, Sprij B, Visser FMPB, Romeijnders ACM, Boukes FS

 

INTRODUCTION   

The NHG Practice Guideline 'Irritable bowel syndrome' provides guidance for the diagnosis and management of irritable bowel syndrome in adult patients. The term spastic colon is less suitable because it suggests an incorrect cause for the condition.

The irritable bowel syndrome (IBS) is present if the patient has had intermittent or continuous abdominal pain for a longer period of time, accompanied by one or more of the following: a feeling of bloating or abdominal distension, a variable defecation pattern, passage of mucus without blood in the faeces, flatulence, and tenderness in the area of the colon during abdominal palpation.1 The diagnosis can usually be established without supplementary investigations. However, a prerequisite for the diagnosis is the exclusion of other disorders, so that if inflammatory bowel disease or colorectal malignancy is suspected, supplementary investigations are always indicated. Supplementary investigations are also necessary to exclude a colorectal malignancy with sufficient certainty in elderly patients who present with the complaints for the first time. There is no specific age limit for this purpose, in view of the gradually increasing incidence of colorectal malignancies with age.

In the general population, irritable bowel syndrome has a prevalence of 15-20% in women and 5-20% in men. Only one-third of those with complaints corresponding with irritable bowel syndrome seek medical help. Dutch morbidity records reveal large differences. Per 1,000 patients per year the incidence varies from 4 to 13 and the prevalence from 6 to 20. The syndrome is more prevalent among women than among men, occurs mainly between the ages of 15 and 65, and often causes long-term complaints.2 A pathophysiological substrate for irritable bowel syndrome has never been demonstrated.

Irritable bowel syndrome can be diagnosed and managed adequately by the general practitioner. Referral to a specialist for diagnosis can be useful, but as far as therapy is concerned, the internist or gastroenterologist has no more options than the general practitioner. The aim of the practice guideline is to improve the efficacy of diagnosis and management and to aid the patient in coping with complaints that are often long-term.

 

Background   

The diagnosis 'irritable bowel syndrome' was initially established by the exclusion of organic causes, but eventually diagnostic criteria were developed which define it as a distinct syndrome. A pathophysiological substrate has never been demonstrated, although many hypotheses have been investigated: lack of dietary fibre, disrupted intestinal motility, visceral hyperalgesia, changed cerebrovisceral perception, induction due to gastroenteritis, food allergy, and psychogenic causes. Despite extensive research, conclusive evidence is lacking and none of these hypotheses have diagnostic or therapeutic consequences.3

Patients with irritable bowel syndrome often have non-colonic complaints as well, such as nausea, dyspepsia, tiredness, and dysuria. Patients with irritable bowel syndrome who seek the help of a general practitioner more often are troubled by anxiety, depression, or stress than do those with or without irritable bowel syndrome who do not consult a general practitioner. In psychological terms, patients with irritable bowel syndrome who seek the help of a general practitioner do not differ from those with organic intestinal conditions. The greater a patient's anxiety and tendency to attribute the complaints to a physical abnormality, the more often he will visit the general practitioner.4

 

DIAGNOSTIC GUIDELINES   

The symptoms of irritable bowel syndrome overlap with those of such abdominal conditions as colorectal malignancy, inflammatory bowel disease (Crohn's disease, ulcerous colitis), diverticulitis, and genital conditions (pelvic inflammatory disease, endometriosis). The routine application of supplementary investigations for colorectal malignancy or other organic disorders is, however, not recommended.5

In patients with symptoms of abdominal pain which could be associated with irritable bowel syndrome, the general practitioner determines whether there is reason to suspect an organic cause. In addition, he enquires about complaints and symptoms which support the diagnosis of irritable bowel syndrome and he gives attention to factors which can affect the prognosis, such as avoidance behaviour, anxiety for certain conditions, and dysfunctioning as a result of the complaints.

 

History   

The general practitioner enquires about:

The general practitioner also enquires about:

The general practitioner forms an impression about:

 

Physical examination   

The aim of the physical examination is to reassure the patient and to detect possible organic complaints.11

The general practitioner examines the abdomen by inspection, auscultation, and palpation, giving particular attention to the area where the pain occurs.

The general practitioner performs a digital rectal examination when he suspects:

The general practitioner performs a digital vaginal examination when he suspects a disease of the internal genitalia. Guidelines for supplementary investigations for gynaecological causes of  the complaints are beyond the scope of this guideline.

 

Supplementary investigations   

Supplementary investigations are focused on differentiating between irritable bowel syndrome and inflammatory bowel disease or colorectal malignancy. The characteristics of other conditions considered in differential diagnosis are described briefly in the section on 'Evaluation'.

In younger patients without indications of another disease and in older patients with complaints for many years, supplementary investigations are not meaningful and are therefore not recommended. If there are doubts about the presence of inflammatory bowel disease or colorectal malignancy in these patients, limited additional laboratory tests are sufficient: ESR, total leucocytes, and Hb. If the results of all of these laboratory tests are normal, the diagnosis of irritable bowel syndrome is more likely.12

 

If  inflammatory bowel disease is suspected, as when

or if a colorectal malignancy is suspected, as in

the general practitioner requests laboratory tests (ESR, total leucocytes, and Hb) and requests a sigmoidoscopy, followed  by a colon x-ray if the result of sigmoidoscopy is normal, or refers the patient without delay to an internist or gastroenterolgist.14 Testing faeces for occult blood is not recommended because it has no added value.15

 

Also for patients with persistent complaints or who are anxious despite treatment, the general practitioner can consider the above-mentioned laboratory tests and imaging investigations.

 

For  patients with abdominal complaints and a history of colorectal carcinoma in a first-degree relative<45 years of age or in two first-degree relatives  irrespective of age,7 the general practitioner discusses supplementary investigations with the internist or gastroenterologist.

 

Evaluation   

If there has been intermittent or continuous abdominal pain for a longer period of time and one or more of the following complaints or findings:

the diagnosis 'irritable bowel syndrome' is established, provided that there are no indications for other conditions. In the majority of cases this requires no additional tests or examinations.

In older patients who have complaints for the first time, or if  inflammatory bowel disease or colorectal malignancy is suspected (see ‘Supplementary investigations’), the diagnosis is established only if the supplementary investigations are not abnormal.

The following conditions are also considered in differential diagnosis:

The management of the these conditions considered in differential diagnosis is beyond the scope of this practice guideline.

 

MANAGEMENT GUIDELINES  

If a patient with irritable bowel syndrome is only moderately inconvenienced by the symptoms and is not particularly anxious, giving an explanation, reassurance, and advice during a single consultation is usually sufficient.

If the patient is seriously anxious about the complaints, a step-by-step approach during several consultations will be necessary. The basis of management is behavioural therapy, with the aim of reassuring the patient and reducing the inconvenience caused by the complaints.17 The general practitioner first devotes attention to the anxiety and then gives an explanation of the nature and prognosis of irritable bowel syndrome, tailored to the patient's situation. If necessary, he informs the patient about diagnostic tests to exclude other possible conditions. In giving information, the general practitioner avoids suggesting somatic attributions (incorrect somatic explanatory models by the patient). The general practitioner provides information and recommendations about self-treatment specific to the patient's needs. Drug therapy is not recommended.  

 

Information   

The general practitioner tells the patient that no satisfactory explanation for the symptoms of irritable bowel syndrome has been found. There is not an increased risk of developing serious intestinal diseases.18 Sometimes the symptoms seem to develop as a consequence of an severe intestinal infection or a period of considerable stress.3 The symptoms are often prolonged, occur in episodes, and are generally variable in nature. How the symptoms will proceed in an individual case cannot be predicted.

Some theoretical explanations for the persistence of the complaints are:

 

Non-pharmacological therapy   

The general practitioner provides information about possibilities for self-care, linking this to information from history taking. Depending on the findings, one or more of the following recommendations can be given.

Aim to eliminate unnecessary worries

Anxiety can play an important role in maintaining the complaints. A vicious circle can develop when complaints lead to anxiety, hence worsening of the complaints, more anxiety, etc. Discussing the anxiety reduces the complaints.19 The general practitioner explores the anxiety, ascertains which questions are bothering the patient, and whether the information provided is sufficient.

Aim to reduce avoidance behaviour20

Sometimes patients avoid a whole host of activities for fear that the symptoms will occur, without this being medically necessary. Avoidance behaviour makes the prognosis less favourable. The general practitioner discusses the undesirability of avoidance behaviour and encourages the patient to continue his normal activities as much as possible. See also the NHG Practice Guideline 'Anxiety disorders'.

Aim to resolve stressful factors and achieve a more congenial environment

There is a correlation between stress and help-seeking behaviour in patients with irritable bowel syndrome.4 Tensions and complaints can negatively influence each other. Although the effectiveness of this point has not been demonstrated, it is logical to discover how tensions have arisen and what can be done—and by whom—to resolve them. The general practitioner ascertains whether the partner or others in the patient's immediate environment may play a role in the persistence of complaints. He discusses with the patient whether changes are desired and how the patient can broach the subject.21

Habits: eating pattern, nutrition, and physical exercise

Although abnormal nutritional, eating, and exercise habits have some connection with abdominal complaints, the effects of interventions directed towards these habits are hypothetical and have not been substantiated. The beneficial effect of a fibre-rich diet on abdominal complaints has also not been adequately demonstrated.22 If the symptoms seem to be associated with irregular eating habits, changing to regular mealtimes according to healthy eating guidelines is recommended  These guidelines, together with advice to take in sufficient liquids, are also recommended for constipation and diarrhoea. In patients who do not engage in sufficient physical activity, and especially those who are troubled by constipation, the general practitioner recommends extra physical exercise, such as walking or cycling for half an hour each day.

Drug therapy   

No medications are recommended for the treatment of irritable bowel syndrome, because not one medication has been demonstrated to be effective.23

 If constipation is prominent and the aforementioned recommendations provide insufficient benefit, the general practitioner recommends adopting a fibre-rich diet or a bulk-former (such as psyllium), with generous intake of liquids. An alternative is the prescription of a laxative such as lactulose (15-30 ml once daily) or magnesium sulphate (10-30 g once daily).24

 

Follow-up   

After the diagnostic examination has been completed and the explanation and recommendations have been given, there is no medical need for follow-up consultations. The patient is requested to make a new appointment if:

 

Referral   

The patient is referred:

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The currently used diagnostic criteria for irritable bowel syndrome (IBS), named the ‘Rome criteria', are:

At least 3 months of continuous or recurrent symptoms of the following:

abdominal pain or discomfort

relieved with defecation, or 

Associated with a change in frequency of stool, or

Associated with a change in consistency of stool

Two of more of the following, at least on one-fourth of occasions or days:

Altered stool frequency (for research purposes altered may be defined as more than three bowel movements each day or less than three bowel movements each week), or 

Altered stool form (lumpy/hard or loose/watery stool), or

Altered stool passage (straining, urgency, or feeling of incomplete evacuation), or

Passage of mucus, or

Bloating or feeling of abdominal distention

The ‘Rome criteria’ have been drawn up on the basis of an internal consensus and are used in particular for research purposes. The definition of irritable bowel syndrome used in the Dutch version of this practice guideline is a translation of the inclusion criteria for IBS in the ICPC-2. An important difference from the Rome criteria is the absence of the time criterion.2 Drossman et al. advised the differentiation of subtypes of IBS on the basis of symptoms, with a different treatment for each subtype. The subtypes are abdominal pain with mainly constipation, abdominal pain with mainly diarrhoea, and abdominal pain with mainly bloating and flatulence.3 However, the added value of this differentiation has not been demonstrated by means of comparative research. In a study of 3,022 persons in the general population, Talley et al. distinguished four subtypes on the basis of a changed defecation pattern: mainly constipation, mainly diarrhoea, mainly alternating constipation and diarrhoea, and insufficiently frequent complaints about defecation. They concluded that the distinction was probably artificial, because there was no difference among subgroups on many points, such as onset of the complaints, health care utilization, other symptoms (including abdominal pain), or effect on daily activities.4

  1. Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Müller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut 1999;45(Suppl 2):II43-7.
  2. WONCA International Classification Committee. The International Classification of Primary Care, second edition, (ICPC-2). Oxford: Oxford University Press, 1998.
  3. Drossmann DA, Whitehead WE, Camiliera M. Irritable bowel syndrome: a technical review for practice guideline development. Gastroenterology 1997;112:2120-37.
  4. Talley NJ, Zinsmeister AR, Melton LJ, et al. Irritable bowel syndrome in a community: symptom subgroups, risk factors, and health care utilization. Am J Epidemiol 1995;142:76-83.

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Data on the prevalence of irritable bowel syndrome in the general population and the percentage of persons who seek medical help have been taken from the review article by Drossman et al.1 In some studies the prevalence in men and women in the general population is the same.2 However, in other population studies and in morbidity records in Dutch general practice, the male:female ratio is 1:2.1, 3, 4 There are also striking differences in findings among the National Study, the Transition Project, and the CMR. In the CMR, irritable bowel syndrome was found to occur predominantly in young adults. Other studies found the prevalence and incidence in 15-year-old persons to be the same as in the CMR, but a decrease was found only after the age of 74.3-5 Talley et al. investigated the clinical progression of the irritable bowel syndrome in a random sample of 1,021 people in the general population. Of the 18% of the population with irritable bowel syndrome, 38% had no complaints after 12-20 months.2

  1. Drossmann DA, Whitehead WE, Camiliera M. Irritable bowel syndrome: a technical review for practice guideline development. Gastroenterology 1997;112:2120-37.
  2. Talley NJ, Weaver AL, Zinsmeister AR, Melton LJ. Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders. Am J Epidemiol 1992;136:165-77.
  3. Van der Velden J, De Bakker DH, Claessens AAMC, Schellevis FG. Een nationale studie naar ziekten en verrichtingen in de huisartspraktijk. Basisrapport; Morbiditeit in de huisartspraktijk [A national study of diseases and procedures in general practice. Foundation report; Morbidity in general practice]. Utrecht: Nivel, 1991.
  4. Okkes IM, Oskam SK, Lamberts H. Van klacht naar diagnose [From complaint to diagnosis]. Bussum: Coutinho, 1998.
  5. Written Communication Van de Lisdonk E. CMR periode 1992-6 [CMR period 1992-1996].

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The nutritional fibre deficiency hypothesis is based on the observation that Africans have few functional abdominal complaints or problems with constipation and their faecal volume is large due to fibre-rich food.1 However, Nyhlin et al. found no difference in dietary fibre content between a group of 128 referred patients with irritable bowel syndrome and a control group.2

Research on abnormal intestinal motility assumes a disorder of the intrinsic activity of the intestinal smooth muscle and has mainly concentrated on contractility in the small intestine and colon. The intestine has two types of smooth muscle: circular muscles which contract tonically over short segments and contract slowly in phase over larger segments to ensure the propulsion of the intestinal contents, and longitudinal muscles which have a smaller role, providing the pumping function. Motility is investigated by measurements of pressure and the transit time. Gorard and Farthing reviewed studies of this subject and found inconsistent results and shortcomings in methodology. No conclusions can be drawn about the significance of abnormal intestinal motility in the irritable bowel syndrome.3

The visceral hyperalgesia hypothesis has its origins in the observation that gas insufflation of the colon and balloon distension of the rectum produced more pain in patients with irritable bowel syndrome than in other patients. Many of the arguments for visceral hyperalgesia are derived from animal experiments and similarities in symptoms between inflammatory and functional intestinal disorders, such as irritable bowel syndrome.4 In recent years attention has been given to the role of 5-hydroxytriptamine-3 receptors. A change in these receptors as a consequence of infections, stress, or other agents could lead to a permanent change in the perception of physiological stimuli in the intestine. Selective 5-HT3 antagonists are currently being investigated in clinical trials in referred patients.5, 6 Thus far, the visceral hyperalgesia hypothesis has ed to no practical applications in diagnosis or treatment.

The changed cerebrovisceral perception hypothesis assumes that in patients with irritable bowel syndrome there are changes in the central nervous system. Orr et al. carried out a case-control study in 10 patients with irritable bowel syndrome and found that they had more and longer periods of REM sleep.7 In an even smaller group, Silverman et al. observed a difference in cerebral activity in a certain part of the brain after balloon distension of the rectum .8 These studies involved very small patient groups. The hypothesis has no consequences for everyday practice.

The  post-gastroenteritis hypothesis is, however, supported by research. Neal et al. interviewed 544 patients who had had a bacterial gastroenteritis. One quarter of them still had an altered defecation pattern 6 months later and 7% had developed IBS.9 Rodriguez et al. carried out a comparative study in 318 patients from general practice who had a bacterial gastrointestinal complaint and a control group from the general population. IBS was found one year later in 4.4% of the gastroenteritis patients, compared with 0.3% of the control group.10

The scientific basis for a role of a specific food allergy or a food intolerance is too meagre to justify a place in the management of IBS. In the study by Nanda et al., half of the patients with irritable bowel syndrome had fewer complaints after 3 weeks on a strict elimination diet.11 A food allergy or intolerance could be considered in patients with pronounced and persistent diarrhoea.

No causal connection has been demonstrated between psychological factors and irritable bowel syndrome.12 Drossman et al. investigated the relation between stress and the defecation pattern and abdominal pain in 135 people with irritable bowel syndrome and 654 people without abdominal complaints. Seventy-two percent of those with complaints and 54% of the control group reported that stress had led to a change in their faeces. For abdominal pain the percentages were 84 and 67, respectively.13 In contrast, Suls et al. found that in patients with irritable bowel syndrome who had both abdominal complaints and stress on a daily basis, the two were not significantly correlated.14 There is also too little scientific basis for a relation between abdominal complaints and sexual abuse or physical violence in the past. From a study in the Australian population, Talley et al. concluded that although there was a correlation between irritable bowel syndrome and sexual abuse, it was more likely the neuroticism which arose as a result of the abuse than the abuse itself.15 The working group concludes that psychological factors might not influence the onset of the symptoms so much as the persistence of abdominal complaints. It therefore advises that the general practitioner be prepared to consider a possible link with serious trauma.

  1. Tytgat G. De rol van voedingsvezels in de gastroenterologie: ‘fact of fancy’ [The role of dietary fibre in gastroenterology: 'fact or fancy']. Ned Tijdschr Geneeskd 1989;133:1926-9.
  2. Nyhlin H, Ford MJ, Eastwood J, et al. Non-alimentary aspects of the irritable bowel syndrome. J Psychosom Res 1993;37:155-62.
  3. Gorard DA, Farthing MJ. Intestinal motor function in irritable bowel syndrome. Dig Dis 1994;12(2):72-84.
  4. Mayer EA, Gebhart GF. Basic and clinical aspects of visceral hyperalgia. Gastroenterology 1994;107:271-93.
  5. Goldberg PA, Kamm MA, Setti-Carraro P, Van der Sijp J, Roth C. Modification of visceral sensitivity and pain in irritable bowel syndrome by 5-HT3 antagonism (ondansetron). Digestion 1996;57:478-83.
  6. Delvaux M, Louvel D, Mamet JP, Campos-Oriola R, Frexinos J. Effect of alosetron on responses to colonic distension in patients with irritable bowel syndrome. Aliment Pharmacol Ther 1998;12:849-55.
  7. Orr WC, Crowell MD, Lin B, et al. Sleep and gastric function in irritable bowel syndrome: derailing the brain-gut axis. Gut 1997;41:390-3.
  8. Silverman DHS, Munakata JA, Ennes H, et al. Regional cerebral activity in normal and pathological perception of visceral pain. Gastroenterology 1997;112:64-72.
  9. Neal KR, Hebden J, Spiller R. Prevalence of gastrointestinal symptoms six months after bacterial gastroenteritis and risk factors for development of the irritable bowel syndrome: postal survey of patients. BMJ 1997;314:779-82.
  10. Garcia Rodriguez LA, Ruigomez A. Increased risk of irritable bowel syndrome after bacterial gastroenteritis: cohort study. BMJ 1999;318:565-6.
  11. Nanda R, James R, Smith H, Dudley CRK, Jewell DP. Food intolerance and the irritable bowel syndrome. Gut 1989;30:1099-104.
  12. Smith RC, Greenbaum DS, Vancouver JB, et al. Psychological factors are associated with health care seeking rather than diagnosis in irritable bowel syndrome. Gastroenterology 1990;98:293-301.
  13. Drossman DA, Sandler RS, McKee DC, Lovitz AJ. Bowel patterns among subjects not seeking health care. Use of a questionnaire to identify a population with bowel dysfunction. Gastroenterology 1982;83:529-34.
  14. Suls J, Wan CK, Blanchar EB. A multi-level data analytic approach for evaluation of relationships between daily life stressors and symptomatology: the case of irritable bowel syndrome. Health Psychol 1994;13:103-13.
  15. Talley NJ, Boyce P, Jones M. Identification of distinct upper and lower gastrointestinal symptom groupings in an urban population. Gut 1998;42:690-5.

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Drossman et al. found more psychological abnormalities in a group of 72 patients who had IBS for which they sought medical help than in two control groups. One control group consisted of 82 IBS patients who did not seek medical help and the other control group consisted of 84 persons without IBS complaints. Other complaints, such as nausea, dyspepsia, tiredness, and dysuria, were also more prevalent among those who sought medical help.1  Donker et al. compared 53 IBS patients in general practice with 10,787 persons in the general population. Complaints such as nausea, stomach-ache, tiredness, dizziness, and sweating were also significantly more prevalent in the IBS group, as were anxiety, sleeping disorders, irritability, and apathy.2 In a random sample of 48 patients with irritable bowel syndrome, half of whom had consulted their general practitioner about this complaint and half of whom had not, the severity of the complaints and anxiety about the complaints explained 85% of the variation between the groups. Half of those who had consulted their general practitioner were anxious that the complaints had a serious cause, compared with 2 of the 24 persons who had not consulted their general practitioner. Ten of the 24 persons in the first group were afraid that they had cancer, compared with 1 person in the second group.3 Bleijenberg et al. carried out psychological tests in 308 patients who had been referred to the outpatient clinic with abdominal complaints. Eighty-one were found to have organic disorders and the remainder were diagnosed as having functional abdominal complaints. There were no differences between these groups in scores for depression, anxiety, self-confidence, neuroticism, and problem-solving ability.4 Smith et al. carried out psychological tests in 97 patients who had been referred with abdominal complaints and a changed defecation pattern. An organic disorder was found in 30 of them and the remainder were considered to have IBS. No differences in the scores for anxiety, depression, lack of social support, somatization, and abnormal sickness behaviour were found between these two groups. However, in the entire group the scores were significantly higher than in the general population. It is assumed that the presence of anxiety, depression, or stress does not so much promote the onset of IBS as provide an important explanation for the help-seeking behaviour.3, 5 In a study with a follow-up period of 5 years in 75 referred patients with irritable bowel syndrome, those who had a high score on the anxiety scale at the start of the study were more inconvenienced by their complaints 5 years later. The 28 patients who reported an improvement after 5 years had a low score on the anxiety scale at the start of the study.6 In a study by  Dulmen et al. in 120 referred patients with irritable bowel syndrome, those who ascribed their complaints to a physical abnormality subsequentially visited the general practitioner more often for their abdominal complaints.7

  1. Drossman DA, McKee DC, Sandler RS, et al. Psychosocial factors in irritable bowel syndrome. A multivariate study of patients and non patients with irritable bowel syndrome. Gastroenterology 1988;95:701-8.
  2. Donker GA, Foets M, Spreeuwenberg P. Patients with irritable bowel syndrome: health status and use of health care services. Br J Gen Pract 1999;49:787-92.
  3. Kettell J, Jones R, Lydeard S. Reasons for consultation in irritable bowel syndrome: symptoms and patient characteristics. Br J Gen Pract 1992;2:459-61.
  4. Bleijenberg G, Fennis JFM. Anamnestic and psychological features in diagnosis and prognosis of functional abdominal complaints: a prospective study. Gut 1989;30:1076-81.
  5. Smith RC, Greenbaum DS, Vancouver JB, et al. Psychological factors are associated with health care seeking rather than diagnosis in irritable bowel syndrome. Gastroenterol 1990;98:293-301.
  6. Fowlie S, Eastwood MA, Ford MJ. Irritable bowel syndrome: the influence of psychological factors on the symptom complex. J Psychosom Res 1992;36:169-73.
  7. Van Dulmen AM, Fennis JFM, Mokkink HGA, Bleijenberg G. The relationship between complaint-related cognitions in referred patients with irritable bowel syndrome and subsequent health care seeking behaviour in primary care. Fam Pract 1996;13:12-7.

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Using score models, attempts have been made to distinguish patients with abdominal complaints caused by organic factors from those with irritable bowel syndrome. Starmans et al. investigated the value of six score models in a group of 933 patients in general practice and 370 patients in outpatient clinics, all of whom had non-acute abdominal complaints. The external validity was not sufficient for any of the score models and so they could not be used. Some of the separate items in the score models did, however, have a certain value: the feeling of incomplete evacuation after defecation, alternating constipation and diarrhoea, and a visibly bloated abdomen were indications for a non-organic cause of the abdominal complaints, whereas age >60 years, the occurrence of colon carcinoma in first-degree relatives, and passage of blood during defecation indicated an organic disorder.1 In a group of 933 patients in general practice, Muris et al. found that male sex, advanced age, epigastric pain, non-specific pain, nocturnal pain, passage of blood during defecation, no alleviation of the pain after defecation, and leucocytosis correlated with an organic disorder. The following five factors correlated with the presence of a malignancy: male gender, advanced age, non-specific pain, weight loss of >1 kg in 4 weeks, and an ESR of 20 mm/hr.2

  1. Starmans R, Muris JWM, Fijten GH, et al. The diagnostic value of scoring models for organic and non-organic gastrointestinal disease, including the irritable bowel syndrome. Med Decis Making 1994;14:208-16.
  2. Muris JWM, Starmans R, Fijten GH, et al. Non-acute abdominal complaints in general practice: diagnostic value of signs and symptoms. Br J Gen Pract 1995;45:313-6.

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The study of  Muris et al. found that weight loss of >1 kg in 4 weeks was correlated with the presence of a malignancy.1 This finding has not been confirmed by other studies. The working group has decided to adopt the limit of 3 kg of unintended weight loss per month for suspicion of carcinoma. This is with the assumption that normal physiological fluctuations in weight can exceed 1 kg. Dieticians use the percentage of body weight that has been lost as the measure of clinically important weight loss, taking the normal limits to be 5% within a month and 10% within 6 months.2 This is in reasonable agreement with the work group's choice.

  1. Muris JWM, Starmans R, Fijten GH, et al. Non-acute abdominal complaints in general practice: diagnostic value of signs and symptoms. Br J Gen Pract 1995;45:313-6.
  2. Verheul-Koot M, Huitema S. Bepalen van de voedingstoestand [Determining the nutritional state]. In: Bleichrodt RP, Van Mourik JB (eds). Enterale voeding [Enteral nutrition]. Enschede: University of Twente, 1995;13-31.

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About 5% of all patients with a colorectal malignancy have a hereditary form, most often hereditary nonpolyposis colorectal cancer (HNPCC) or familial adenomatous polyposis (FAP). These conditions can be demonstrated by DNA analysis in more than the half of the cases. For HNPCC the risk of developing a colorectal carcinoma is 80% and the average age of onset is 40 years. Furthermore, there is an elevated risk of developing other carcinomas, especially endometrial carcinoma. Virtually 100% of patients with FAP develop a carcinoma, at the average age of 40 years. For both of these conditions regular follow-ups are recommended, and in patients with FAP a preventative colectomy is recommended at about the age of 20 years. 'Familial intestinal cancer' occurs in 10% of all patients with a colorectal malignancy. This means that the same condition occurs in different family members, but without a clear hereditary pattern as found for HNPCC and FAP.1, 2 The risk of developing a colon carcinoma is 1:50 for someone who has no relatives with colon carcinoma. If a first-degree relative has a colorectal malignancy, the risk is 3-4 times greater, i.e., about 1:17. If the age of onset in the relative was <45 years, the risk is 4-5 times as great, or about 1:10, and if 2 first-degree relatives are affected, the risk is 6 times as great, or 1:6.3, 4 Vasen et al. have suggested that colonoscopy should be performed regularly in persons who have a first-degree relative who developed colorectal carcinoma before the age of 45 or two first-degree relatives with colorectal carcinoma regardless of the age of onset.3 However, this is not yet a general policy among gastroenterologists.

  1. Menko FH, Griffioen G, Wijnen JTh, Tops CMJ, Fodde R, Vasen HFA. Genetica van darmkanker. I. Non-polyposis- en polyposisvormen van erfelijke darmkanker [Genetics of colorectal cancer. I.  Non-polyposis and polposis forms of hereditary colorectal cancer]. Ned Tijdschr Geneeskd 1999;143:1201-6.
  2. Menko FH, Griffioen G, Wijnen JTh, Tops CMJ, Fodde R, Vasen HFA. Genetica van darmkanker. II. Erfelijke achtergrond van sporadische en familiaire darmkanker [Genetics of colorectal cancer. II.  Genetic background of sporadic and familial colorectal cancer]. Ned Tijdschr Geneeskd 1999;143:1207-11.
  3. Vasen HFA, Nagengast FM, Griffioen G, Kleibeuker JH, Menko FH, Taal BG. Periodiek colonoscopisch onderzoek bij personen met een belaste familieanamnese voor colorectaal carcinoom [Periodic colonoscopic examinations of persons with a positive family history for colorectal cancer]. Ned Tijdschr Geneeskd 1999;143:1211-4.
  4. Houlston RS, Murday V, Harocopos C, Williams CB, Slack J. Screening and genetic counselling for relatives of patients with colorectal cancer in a family cancer clinic. BMJ 1990;301:366-8.

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Otte et al. found that 19 of 69 patients with irritable bowel syndrome also had diverticulosis and there was no difference in symptomatology and prognosis between those with and those without diverticulosis.1 The prevalence of colon diverticulosis increases with age. At autopsy, almost 50% of persons older than 60 years have diverticula, mainly in the sigmoid. However, 80-90% of persons with diverticulosis are asymptomatic.2, 3 Only a few develop complications such as a diverticulitis, which is an inflammation extending through the wall of one or more diverticula, causing pericolitis. In more than 90% of cases the inflammation occurs in the sigmoid.2 The diagnosis is established on the basis of the following findings: pain in the left lower half of the abdomen, usually a change in defecation, fever, tenderness during palpation, and sometimes an infiltrate, an elevated ESR, and leucocytosis.3 However, these findings seem to have only moderate diagnostic value, analogous to those for diagnosing appendicitis.2, 3 The risk of complications of diverticulitis, such as perforation, peritonitis, or obstructive ileus, has been estimated to be 5-20%.2 If there are signs of peritonitis the patient should be referred. About 25% of patients who have had acute diverticulitis develop a recurrence.3

  1. Otte JJ, Larsen L, Andersen JR. Irritable bowel syndrome and symptomatic diverticular disease-different diseases? Am J Gastroenterol 1986;81:529-31.
  2. Lagro-Janssen ALM, Lisdonk van de EH. Diverticulosis en diverticulitis {Diverticulosis and diverticulitis]. Huisarts Wet 1991;34:422-5.
  3. De Boer HHM. Acute diverticulitis [Acute diverticulitis]. Ned Tijdschr Geneeskd 1989;133:1733-6.

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In pelvic inflammatory disease, pain in the lower abdomen is usually the most important complaint and it can be associated with fever or general malaise. See the NHG Practice Guideline 'Pelvic inflammatory disease'.

Dekker JH, Veehof LJG, Heeres PH, Hinloopen RJ, Van den Berg G, Burgers JS. NHG-Standaard Pelvic inflammatory disease [NHG Practice Guideline 'Pelvic inflammatory disease'. In: Thomas S, Geijer RMM, van der Laan JR, Wiersma Tj. NHG-Standaarden voor de huisarts deel II [NHG Practice Guidelines for the general practitioner part II]. Utrecht: Bunge, 1996;230-6.

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Antibiotics, calcium antagonists, antidepressants, diuretics, codeine, and morphine can cause abdominal complaints such as those occurring in irritable bowel syndrome. These complaints can also be caused by milk in patients with lactose intolerance, artificial sweeteners, 'diet products' (sorbitol or aspartame), and alcohol. Although caffeine and nicotine seem to influence intestinal transit time, there has been no research demonstrating a link between these substances and irritable bowel syndrome.

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In a study of 254 patients with chronic abdominal pain who visited the general practitioner, Bellentani et al. found that among findings in the physical examination, only the 'visibly distended abdomen' occurred more often in patients with irritable bowel syndrome than in those with organic disease.1 No other studies are known to have demonstrated that a specific finding in the physical examination supports the diagnosis of irritable bowel syndrome. Positive criteria for the diagnosis of irritable bowel syndrome originate from the history and physical examination. The working group is of the opinion that the value of a physical examination in patients with symptoms of irritable bowel syndrome is mainly its reassuring effect, if the physician takes note of the complaints by examining the place where the pain occurs. Futher more, a general orientation takes place with respect to other disorders.

Bellentani S, Baldoni P, Petrella S, et al. A simple score for identification of patients at high risk of organic diseases of the colon in the family doctor consulting room. Fam Pract 1990;7:307-12.

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Kruis et al. investigated the value of a score model for the diagnosis of IBS in 399 patients with symptoms of abdominal pain, flatulence, and changed defecation. Among a large number of laboratory tests they found that the ESR, leucocytes, and haemoglobin, if normal, were sufficient to support the diagnosis of IBS.1 In a study of 933 general practice patients with non-acute abdominal complaints, Muris et al. found that these three tests have a diagnostic value for distinguishing between functional abdominal complaints and abdominal complaints due to an organic disorder. Regression analysis revealed that only two are necessary, the ESR as an indicator of the presence of a malignancy and the leukocyte count as an indicator of other organic abnormalities. However, this study was concerned with 'all non-acute abdominal complaints' and the diagnoses were verified retrospectively by review of the medical records.2 Hence the working group has decided not to limit the laboratory tests to these two determinations but to adopt the recommendations of  Kruis et al. The American Gastroenterological Association advises the routine performance of extensive blood tests; faecal examinations for occult blood, amoebae, and parasites; and in patients >50 years of age, either sigmoidoscopy together with an x-ray of the colon or colonoscopy. However, in the absence of scientific evidence, the added value of these tests and examinations in general practice is unknown.3

  1. Kruis W, Thieme CH, Weinzierl, Schüssler P, Holl J, Paulus P. A diagnostic score for the irritable bowel syndrome. Gastroenterology 1984;87:1-7.
  2. Muris JWM, Starmans R, Fijten GH, et al. Non-acute abdominal complaints in general practice: diagnostic value of signs and symptoms. Br J Gen Pract 1995;45:313-6.
  3. Anonymous. American Gastroenterological Association medical position statement: irritable bowel syndrome. Gastroenterology 1997;112:2118-9.

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There is a certain overlap in complaints between the irritable bowel syndrome and colorectal malignancy. If there are no suspicious findings, the patient’s age is used to decide whether to carry out supplementary investigations to exclude colorectal malignancy. The incidence of colorectal malignancy per 1,000 patients per year is 0.08 at age 40-44 years, 0.61 at age 55-59 years, and 3 at age 75-79 years.1 The incidence is therefore very low and increases slowly with age. The working group is of the opinion that a specific age limit for supplementary investigations cannot be justified on the basis of the incidence of colorectal malignancies with respect to age. There are also no scientifically justified guidelines for gastroenterologists on this point (written communication from Prof. AJPM Smout). The working group has decided to recommend supplementary investigations in 'older patients' who have complaints for the first time.

  1. Visser O, Coebergh JWW, Schouten LJ, Van Dijck JAAM. Incidence of cancer in the Netherlands 1995. Utrecht: Vereniging van Integrale Kankercentra, 1998.

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Sigmoidoscopy is thought to detect 70% of colorectal malignancies.1 If no abnormalities are found during sigmoidoscopy, radiographic examination of the colon is requested to assess the part that cannot be reached by the sigmoidoscope. An important advantage of colonoscopy over radiographic examination is that if there is a visible abnormality, a biopsy can be taken directly or a polypectomy can be performed. The specificity of the investigation is therefore high, virtually 100%, but colonoscopy also gives rise to more complications. The mortality due to colonoscopy is estimated to be from 1:2000 to 1:5000, whereas for a radiographic examination it is 1:50,000.2 Studies have shown the combined sensitivity of sigmoidoscopy and a radiographic examination to be equivalent to that of a colonoscopy: 90% or more 3-5 The working group's recommendation of sigmoidoscopy followed by an x-ray, if necessary, is based on the following considerations: 1) the sensitivity of the investigations is similar,. 2) colonoscopy has a very high specificity but gives rise to more complications, 3) colonoscopy cannot be requested directly by the general practitioner, and 4) colonoscopy can be more uncomfortable for the patient.

  1. Lieberman D. Endoscopic screening for colorectal cancer. Gastroenterol Clin North Am 1997;26:71-83.
  2. Smith C. Colorectal cancer. Radiologic diagnosis. Radiol Clin North Am 1997;35:439-56.
  3. Jensen J, Kewenter J, Asztely M, et al. Double contrast barium enema and flexible rectosigmoidoscopy: A reliable diagnostic combination for detection of colorectal neoplasm. Br J Surg 1990;77:270-2.
  4. Kewenter J, Brevinge H, Engaras B, et al. The yield of flexible sigmoidoscoy and double-contrast barium enema in the diagnosis of neoplasms in the large bowel in patients with a positive hemoccult test. Endoscopy 1995;27:159-63.
  5. Rex D, Weddle R, Lehman G, et al. Flexible sigmoidoscopy plus air-contrast barium enema versus colonoscopy for suspected lower gastrointestinal bleeding. Gastroenterology 1990;98:855-61.

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The diagnostic value of various tests for occult blood in the faeces for the purpose of detecting colorectal malignancy was investigated in about 8,000 persons aged 50 years or over in the general population. If the test was positive, a colonoscopy was performed. The sensitivity of the best test was 79.4 %, the specificity was 86.7%, and the positive predictive value 2.5%.1 In 439 patients referred for suspected colorectal malignancy on the basis of blood in the faeces, pain in the lower abdomen, a changed defecation pattern, weight loss, or anaemia, the sensitivity, specificity, and positive predictive value were  69.2 %, 73.2%, and 7.3%, respectively.2 Starmans et al. discussed the diagnostic value of testing faeces for occult blood for the purpose of screening and as a result of complaints. Literature on this subject from 1980 to 1993 was assessed. No statement could be made about the place of the hemoccult test in screening. Its diagnostic value was high in patients referred to an outpatient clinic and in patients with a colon carcinoma, but this does not clarify the place of the test in persons with complaints examined in general practice.3 The working group has decided not to recommend testing faeces for occult blood because it has little added value in the diagnosis of colorectal malignancies and because imaging remains necessary if the test is negative.

  1. Allison JE, Tekawa IS, Ransom LJ, Adrain AL. A comparison of fecal occult-blood tests for colorectal-cancer screening. N Engl J Med 1996;334:155-9.
  2. Niv Y, Sperber AD. Sensitivity, specificity and predictive value of fecal occult blood testing (hemoccult II) for colorectal neoplasia in symptomatic patients: a prospective study with total colonoscopy. Am J Gastroenterol 1995;90:1974-7.
  3. Starmans R, Muris JWM, Fijten GH, Pop P, Crebolder HFJM, Knottnerus JA. Testen op bloed in de faeces. De diagnostische waarde van de tests op occult bloed in de faeces bij screening en naar aanleiding van klachten [Testing for blood in the faeces. The diagnostic value of tests for occult blood in the faeces for screening and as a result of complaints]. Huisarts Wet 1994;37:57-65.

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Lactose intolerance is due to the lack of lactase, the enzyme formed in the small intestine for the splitting of lactose, the most important sugar in milk. Lactase activity is high prior to weaning in most of the world population, but it decreases gradually after weaning. After the age of 5 the tolerance to milk is greatly decreased (except in Caucasians) and the consumption of too much milk causes symptoms similar to those of irritable bowel syndrome: abdominal pain, cramps, bloating, nausea, flatulence, and sometimes diarrhoea. In Caucasians (including the people of northern Europe), there is no decrease in lactase activity and the tolerance to milk remains high. Secondary lactase deficiency occurs in gastroenteritis, Giardia lamblia infection, and bacterial overgrowth, after irradiation and after chemotherapy.

Rings EHHM, Van ‘t Hoff BWM, Grand RJ, Büller HA. Lactose-intolerantie. I. Klinische aspecten, diagnostiek en therapie [Lactose intolerance. I. Clinical aspects, diagnostics and therapy]. Ned Tijdschr Geneeskd 1991;135:742-6.

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Within a year after the first consultation, about half of the patients do not return to the general practitioner. Those with prolonged complaints benefit most if the inconvenience and anxiety caused by the complaints are removed as effectively as possible. Various investigators have developed a method termed 'effective reassurance'. This consists of several steps which can be taken consecutively in patients with persistent anxiety. The first two steps have been incorporated in this practice guideline.

Van der Horst HE. Irritable bowel syndrome in general practice. How effective is patient education and counselling? [thesis]. Amsterdam: Free University of Amsterdam, 1997.

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There are no indications that patients with irritable bowel syndrome, irrespective of the duration of their complaints, have a higher risk than the general population of serious gastrointestinal diseases. In the study by Owen et al., 112 referred patients with a diagnosis IBS were re-evaluated after about 30 years. The study revealed that the prognosis for IBS is good and that it is unlikely that an organic gastrointestinal disorder will arise from IBS.

Owens DM, Nelson DK, Talley NJ. The irritable bowel syndrome: long-term prognosis and the physician-patient interaction. Ann Intern Med 1995;122:107-12.

 note 19    terug naar tekst  

In an intervention study in general practice in 179 patients with irritable bowel syndrome, Van der Horst found that if general practitioners gave explicit attention to the nature of the patient's anxiety, then the anxiety about complaints after both one and two years was significantly lower than in a control group which had received the so-called usual care.1 In a study in 110 referred patients with irritable bowel syndrome, Van Dulmen et al. found that after 6 months the abdominal complaints decreased if during the consultations, the physician gave attention to the patients’ anxiety and concern about their complaints. Thirty-one percent of the patients reported an improvement and 12% reported that the complaints had disappeared.2

  1. Van der Horst HE. Irritable bowel syndrome in general practice. How effective is patient education and counselling? [Thesis]. Amsterdam: Free University of Amsterdam, 1997.
  2. Dulmen AM van, Fennis JFM, Bleijenberg G. Betere prognose van functionele buikklachten door aandacht voor psychische factoren [Improved prognosis of functional abdominal complaints by attending to psychic factors]. Ned Tijdschr Geneeskd 1998;142:641-5.

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In her intervention study in 179 patients with irritable bowel syndrome in general practice, Van der Horst found that patients with whom unwanted avoidance behaviour was discussed had a significant decrease in this behaviour after one and two years  compared with controls for whom the general practitioner provided the so-called usual care.1 Van Dulmen et al. found that cognitive behavioural therapy for the 'unlearning' of avoidance behaviour had a favourable effect on the complaints in 25 patients with irritable bowel syndrome, who received eight 2-hour sessions of group therapy, compared with 20 patients who 'were on the waiting list'. During the therapy, attention was also given to stopping avoidance behaviour. Both in the short term and after a two-year follow-up, patients in the intervention group had significantly fewer complaints and exhibited less avoidance behaviour.2

  1. Van der Horst HE. Irritable bowel syndrome in general practice. How effective is patient education and counselling? [thesis]. Amsterdam: Free University of Amsterdam, 1997.
  2. Van Dulmen AM, Fennis JFM, Bleijenberg G. Cognitive-behavioral group therapy for irritable bowel syndrome: effects and long-term follow-up. Psychosom Med 1996;58:508-14.

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By confirming the illness role or indeed ignoring the complaints, persons in the patient's environment can play a symptom-confirming role. Drossman has described a conceptual model for people with irritable bowel syndrome in which one of the factors determining how this behaviour develops is the attitude of family and friends to the patient's complaints.1 In his book about somatic fixation, Grol described the so-called external cycle: a person's symptoms can play such a role in his relationships with others in his environment that a process of somatic fixation is strengthened.2 Although no studies have been found in which the influence of the environment on the symptoms of patients with irritable bowel syndrome has been investigated, it seems worthwhile to give attention to this if the patient seems to be dissatisfied with attitudes about his complaints in his immediate environment.

  1. Drossman DA. Illness behaviour in the irritable bowel syndrome. Gastroenterol Internat 1991;4:77-81.
  2. Grol RPTM. Huisarts en somatische fixatie [The general practitioner and somatic fixation]. Utrecht: Bohn, Scheltema & Holkema, 1983.

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There is little hard research evidence about the 'necessary' level of fibre in the diet. In a retrospective study, 100 patients referred to an outpatient clinic with IBS were interviewed about the effect of adding extra fibre to the diet. More than half of the patients found that adding extra fibre had an unfavourable effect on most complaints, with the exception of constipation.1 The recommendation to follow guidelines for a healthy diet is based on a consensus within the working group.

Although it has certainly not been established that physical exercise has a positive effect on irritable bowel syndrome symptoms, intestinal transit time may be related to constipation. In a crossover study in 10 healthy volunteers, Oettlé showed that an hour of physical exercise per day (cycling or jogging) led to a shorter intestinal transit time.2

  1. Francis CY, Whorwel PJ. Bran and the irritable bowel syndrome: time for a reappraisal. Lancet 1994;344:39-40.
  2. Oettlé GJ. Effect of moderate exercise on bowel habit. Gut 1991;32:941-4.

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In a review published in 1988, Klein analysed 43 studies of the efficacy of pharmaceuticals on irritable bowel syndrome. These trials involved a broad range of pharmaceuticals: spasmolytics, anticholinergics, antidepressants, bulk-formers (including psyllium), dopamine antagonists, loperamide, and anxiolytics. In the majority of these trials, the treatment period was less than 8 weeks, which, in view of the chronic character of irritable bowel syndrome, is much too short. He concluded that  the majority of the studies contained serious methodological shortcomings and that even in the better trials not a single drug was convincingly shown to be effective.1 However, on the basis of a meta-analysis, Poynard et al. found that several spasmolytics (including mebeverine) had a clinical effect.2 Yet with regard to this analysis, the Geneesmiddelenbulletin stated that no reliable conclusions can be drawn from  unvalidated studies and rejected Poynard's conclusion.3 After the analysis of several new studies, the conclusion of the Geneesmiddelenbulletin has not changed and it advises against the use of mebeverine.4

The working group concludes that drug therapy should not be recommended for irritable bowel syndrome, due to the lack of qualitatively good efficacy studies.

Recent drugs are the 5-HT3-antagonists, including alosetron. Camilleri et al. investigated the efficacy of this drug in 647 women with irritable bowel syndrome in a randomized, placebo-controlled study with a follow-up of 3 months. Women who, in addition to abdominal complaints, mainly suffered from constipation were excluded from the study. There were many withdrawals: 24% of the alosetron group (especially due to constipation) and 16% of the placebo group. In the intention to treat analysis, 41% of the women in the alosetron group and 29% of those in the placebo group obtained sufficient alleviation of the abdominal complaints.5 5-HT 3-antagonists are not registered in the Netherlands for irritable bowel syndrome and the working group is of the opinion that there is insufficient clarity about their efficacy.

In a meta-analysis the effect of antidepressants on functional abdominal complaints, among others, was investigated. Eight trials were found in which antidepressants were prescribed for irritable bowel syndrome, the majority in referred patients. In all of the studies improvement was achieved in one of the following: general functioning, frequency of defecation, score lists of symptoms, pain, or contractions of the rectosigmoid. The working group considers these results as yet to be inadequate to justify the prescription of antidepressants for patients with irritable bowel syndrome in general practice.6

Finally, the above-mentioned data were confirmed in a recent review on the efficacy of drug therapy of irritable bowel syndrome. Seventy trials were included in the analysis. Only certain smooth muscle relaxants were effective in reducing the pain, but these were generally drugs which are registered in neither the US nor the Netherlands for use for the irritable bowel syndrome. Bulk-formers only reduce constipation and not pain; the place of psychotropic drugs, including antidepressants, is not yet clear; and further research on the 5-HT3-antagonists is required.7

  1. Klein KB. Controlled treatment trials in the irritable bowel syndrome: a critique. Gastroenterology 1988;95:232-41.
  2. Poynard T, Naveau S, Mory B, et al. Meta-analysis of smooth muscle relaxants in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 1994;8:499-510.
  3. Anonymous. Middelen bij het prikkelbare-darmsyndroom [Medicines for irritable bowel syndrome]. Geneesmiddelenbulletin 1996;30:48-9.
  4. Anonymous. Mebeverine (Duspatal®) bij een prikkelbare darm [Mebeverine (Duspatal®) for irritable bowel syndrome]? Geneesmiddelenbulletin 1998;32:133-4.
  5. Camilleri M, Northcutt AR, Kong S, Dukes GE, McSorley D, Mangel AW. Efficacy and safety of alosetron in women with irritable bowel syndrome: a randomised, placebo-controlled trial. Lancet 2000;355:1035-40.
  6. O’Malley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract 1999;48:980-90.
  7. Jailwala J, Imperiale F, Kroenke K. Pharmacologic treatment of the irritable bowel syndrome: a systematic review of randomized controlled trials. Ann Intern Med 2000;133:136-47.

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In the placebo-controlled crossover study by Snook et al. on the effect of fibre-rich nutritional products in 80 patients with irritable bowel syndrome, there was no improvement in symptoms.1 In a similar study in 28 patients, Lucey et al. found that both a fibre-rich diet and a placebo led to improvement.2 In a retrospective study in 100 patients, a fibre-rich diet resulted in even more complaints.3 Longstreth et al. found no difference between the effect of  psyllium and a placebo in 77 patients with irritable bowel syndrome.4 The working group is of the opinion that for the treatment of irritable bowel syndrome, no general advice about a fibre-rich diet or other bulk-formers such as  psyllium is appropriate. However, there is a place for these if constipation is a prominent problem. In a systematic review Tramonte et al. concluded that both bulk-formers and laxatives have a modest effect on chronic constipation.5 The choice of laxatives in this practice guideline has been taken from the Farmacotherapeutisch Kompas [Pharmacotherapeutic Compass].6

  1. Snook J, Shephard HA. Bran supplementation in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 1994;8:511-41.
  2. Lucey MR, Clark ML, Lowndes J, et al. Is Bran efficacious in irritable bowel syndrome? A double-blind placebo-controlled crossover study. Gut 1987;28:221-5.
  3. Francis CY, Whorwel PJ. Bran and the irritable bowel syndrome: time for a reappraisal. Lancet 1994;344:39-40.
  4. Longstreth GF, Fox DD, Youkeles L, et al. Psyllium therapy in the irritable bowel syndrome. Ann Intern Med 1981;95:53-6.
  5. Tramonte SM, Brand MB, Mulrow CD, et al. The treatment of chronic constipation in adults. J Gen Intern Med 1997;12:15-20.
  6. Van der Kuy A (ed). Farmacotherapeutisch Kompas [Pharmacotherapeutic Compass]. Amstelveen: Ziekenfondsraad, 1999

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