Thread by @john_damianosMD

Here are the new @BritSocGastro guidelines for #IBS in @Gut_BMJ! I'll summarize in 🧵 ⬇️⬇️⬇️!

😖💩🦠🧠🥦🍞💊

#GITwitter #GI #gut #braingut #motility #DGBI #FGID #microbiome #probiotics #MedTwitter #MedEd

gut.bmj.com/content/early/…

🧑‍⚕️-😷
Doctor-patient communication
🧑‍⚕️A strong 🧑‍⚕️-😷 relationship is fundamental to the management of #IBS
😷Patients want their 🧑‍⚕️ to ⬆️empathy, support and information about the nature of IBS, diagnosis, and treatment options

DIAGNOSIS
🩸New pt: CBC, CRP or ESR, celiac serology and, if <45 w diarrhea, fecal calprotectin
➕Make POSITIVE diagnosis based on @RomeFoundation criteria
➡️Refer to #GI when: diagnostic doubt, pt w symptoms that are severe or refractory to 1stline tx,or when pt wants specialist

DIAGNOSIS
❌Colonoscopy unless🚩features OR #IBS-D with atypical features that may suggest microscopic colitis (female,≥50, autoimmune disease,nocturnal or severe, watery diarrhea, duration of 💩 <12 months, weight loss or use of potential precipitating 💊 inclu NSAIDs & PPIs

DIAGNOSIS
💩If atypical feature (as above) or a prior cholecystectomy, consider 23-seleno-25-homotaurocholic acid scanning or serum 7α-hydroxy-4-cholesten-3-one to exclude bile acid diarrhea (#BAD)

😢Not in U.S.A. 🇺🇸

DIAGNOSIS
🚽If coexisting signs of defecatory disorder or fecal incontinence, consider anorectal physiology tests (to assess if biofeedback warranted)
❌testing for exocrine pancreatic insufficiency
❌breath testing for #SIBO
❌testing for carbohydrate intolerance

#IBS

DIAGNOSIS
🧑‍🎓NAME the diagnosis #IBS
🧑‍🎓Explain as a DISORDER OF GUT-BRAIN INTERACTION
🧑‍🎓Explain how diet, stress, cognitive, behavioral, emotional responses to symptoms, and infections can contribute to brain-gut dysfunction

TREATMENT
🚴‍♀️Exercise
❌IgG elimination diet
🍞⬆️Soluble fiber (eg ispaghula), watch out for insoluble fiber (eg wheat bran) which can ⬆️symptoms
🥦⬇️FODMAP diet is 2nd line, in conjunction w RD, and with gradual reintroduction of foods
❌Gluten free
💊✅#probiotics but❓strain

TREATMENT
💊✅loperamide for diarrhea, but may ⬆️abdominal pain, bloating, nausea, & constipation, so start lo and go slow
💊✅certain antispasmodics, but may⬆️dry mouth, visual disturbance, & dizziness
💊✅peppermint oil, but may⬆️#GERD
💊✅PEG for #constipation, but may⬆️pain

2nd line TREATMENT
💊EXPLAIN why we use neuromodulators
💊✅TCAs
💊✅SSRIs
💊✅Eluxadoline for #IBS-D (❌in sphincter of Oddi d/o, cholecystectomy, alcohol dependence, pancreatitis, severe liver impairment)
💊✅Serotonin modulators alosetron and ramosetron or ondansetron IBS-D

2nd line TREATMENT
💊✅Rifaximin #IBS-D
💊✅Linaclotide IBS-C (⚠️most effective secretagogue!), may➡️diarrhea
💊✅Lubiprostone IBS-C (less likely to➡️diarrhea)
💊✅Plecanatide IBS-C
💊✅Tenapanor IBS-C
💊✅Tegaserod IBS-C

PSYCHOLOGICAL THERAPY
🧠Consider when symptoms have❌improved after 12 months of 💊 OR earlier if patient wants
🧠✅CBT
🧠✅gut-directed hypnotherapy

#IBS

SEVERE/REFRACTORY #IBS
💩Consider alternate diagnoses & appropriate w/u
💩Multidisciplinary care (RD, #gastropsych)
💩avoid iatrogenesis w opioids, unnecessary surgery, unproven/unregulated diagnostic/therapeutic approaches incentivized by💰or reputation
💩combo neuromodulators

Postlude on #probiotics:
Signals found for
🦠combination probiotics
🦠Lactobacilli
🦠Bifidobacteria
🦠Escherichia

"Variations in study design, strain&species of probiotic used&heterogeneity btw studies make it difficult to give specific recommendations. However, it is reasonable to advise pts...to take...for up to 12 weeks, & to discontinue treatment if there is no improvement in symptoms."

That's all, folks! What do you think of these #IBS guidelines?

@IBS_Maastricht @KewinSiah @umfoodoc @MarkPimentelMD @SultanMahmoodMD @AndrewOngML @LindaNguyenMD @JohannahRuddy @IBSpatient @TuesdayNightIBS @drjshapiro @MTPapaD @TennysonMD @magnushallandMD