People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Diagnosis and management of irritable bowel syndrome (IBS) can be frustrating, both for people presenting with IBS symptoms and for clinicians. Both parties need to understand the limitations of current knowledge about IBS and to recognise the chronic nature of the condition.
Confirming a diagnosis of IBS is a crucial part of this guideline. The primary aim should be to establish the person's symptom profile, with abdominal pain or discomfort being a key symptom. It is also necessary to establish the quantity and quality of the pain or discomfort, and to identify its site (which can be anywhere in the abdomen) and whether this varies. This distinguishes IBS from cancer‑related pain, which typically has a fixed site.
When establishing bowel habit, showing people the Bristol Stool Form Scale (see appendix I of the full guideline) may help them with description, particularly when determining quality and quantity of stool. People presenting with IBS symptoms commonly report incomplete evacuation/rectal hypersensitivity, as well as urgency, which is increased in diarrhoea‑predominant IBS. About 20% of people experiencing faecal incontinence disclose their incontinence only if asked. People who present with symptoms of IBS should be asked open questions to establish the presence of such symptoms (for example, 'tell me about how your symptoms affect aspects of your daily life, such as leaving the house'). Healthcare professionals should be sensitive to the cultural, ethnic and communication needs of people for whom English is not a first language or who may have cognitive and/or behavioural problems or disabilities. These factors should be taken into consideration to facilitate effective consultation.
Healthcare professionals should consider assessment for IBS if the person reports having had any of the following symptoms for at least 6 months:
Abdominal pain or discomfort
Bloating
Change in bowel habit. [2008]
All people presenting with possible IBS symptoms should be assessed and clinically examined for the following 'red flag' indicators and should be referred to secondary care for further investigation if any are present:
signs and symptoms of cancer in line with the NICE guideline on suspected cancer: recognition and referral
inflammatory markers for inflammatory bowel disease. [2017]
This recommendation has been withdrawn. [2017]
A diagnosis of IBS should be considered only if the person has abdominal pain or discomfort that is either relieved by defaecation or associated with altered bowel frequency or stool form. This should be accompanied by at least 2 of the following 4 symptoms:
altered stool passage (straining, urgency, incomplete evacuation)
abdominal bloating (more common in women than men), distension, tension or hardness
symptoms made worse by eating
passage of mucus.
Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS, and may be used to support the diagnosis. [2008]
In people who meet the IBS diagnostic criteria, the following tests should be undertaken to exclude other diagnoses:
full blood count (FBC)
erythrocyte sedimentation rate (ESR) or plasma viscosity
c‑reactive protein (CRP)
antibody testing for coeliac disease (endomysial antibodies [EMA] or tissue transglutaminase [TTG]). [2008]
The following tests are not necessary to confirm diagnosis in people who meet the IBS diagnostic criteria:
ultrasound
rigid or flexible sigmoidoscopy
colonoscopy; barium enema
thyroid function test
faecal ova and parasite test
faecal occult blood
hydrogen breath test (for lactose intolerance and bacterial overgrowth). [2008]
People with IBS should be given information that explains the importance of self‑help in effectively managing their IBS. This should include information on general lifestyle, physical activity, diet and symptom‑targeted medication. [2008]
Healthcare professionals should encourage people with IBS to identify and make the most of their available leisure time and to create relaxation time. [2008]
Healthcare professionals should assess the physical activity levels of people with IBS, ideally using the General Practice Physical Activity Questionnaire (GPPAQ; see appendix J of the full guideline). People with low activity levels should be given brief advice and counselling to encourage them to increase their activity levels. [2008]
Diet and nutrition should be assessed for people with IBS and the following general advice given.
Have regular meals and take time to eat.
Avoid missing meals or leaving long gaps between eating.
Drink at least 8 cups of fluid per day, especially water or other non‑caffeinated drinks, for example herbal teas.
Restrict tea and coffee to 3 cups per day.
Reduce intake of alcohol and fizzy drinks.
It may be helpful to limit intake of high‑fibre food (such as wholemeal or high‑fibre flour and breads, cereals high in bran, and whole grains such as brown rice).
Reduce intake of 'resistant starch' (starch that resists digestion in the small intestine and reaches the colon intact), which is often found in processed or re‑cooked foods.
Limit fresh fruit to 3 portions per day (a portion should be approximately 80 g).
People with diarrhoea should avoid sorbitol, an artificial sweetener found in sugar‑free sweets (including chewing gum) and drinks, and in some diabetic and slimming products.
People with wind and bloating may find it helpful to eat oats (such as oat‑based breakfast cereal or porridge) and linseeds (up to 1 tablespoon per day). [2008]
Healthcare professionals should review the fibre intake of people with IBS, adjusting (usually reducing) it while monitoring the effect on symptoms. People with IBS should be discouraged from eating insoluble fibre (for example, bran). If an increase in dietary fibre is advised, it should be soluble fibre such as ispaghula powder or foods high in soluble fibre (for example, oats). [2008]
People with IBS who choose to try probiotics should be advised to take the product for at least 4 weeks while monitoring the effect. Probiotics should be taken at the dose recommended by the manufacturer. [2008]
Healthcare professionals should discourage the use of aloe vera in the treatment of IBS. [2008]
If a person's IBS symptoms persist while following general lifestyle and dietary advice, offer advice on further dietary management. Such advice should:
include single food avoidance and exclusion diets (for example, a low FODMAP [fermentable oligosaccharides, disaccharides, monosaccharides and polyols] diet)
only be given by a healthcare professional with expertise in dietary management. [new 2015]
Decisions about pharmacological management should be based on the nature and severity of symptoms. The recommendations made below assume that the choice of single or combination medication is determined by the predominant symptom(s).
Healthcare professionals should consider prescribing antispasmodic agents for people with IBS. These should be taken as required, alongside dietary and lifestyle advice. [2008]
Laxatives should be considered for the treatment of constipation in people with IBS, but people should be discouraged from taking lactulose. [2008]
Consider linaclotide for people with IBS only if:
optimal or maximum tolerated doses of previous laxatives from different classes have not helped and
they have had constipation for at least 12 months.
Follow up people taking linaclotide after 3 months. [new 2015]
Loperamide should be the first choice of antimotility agent for diarrhoea in people with IBS. [2008]
People with IBS should be advised how to adjust their doses of laxative or antimotility agent according to the clinical response. The dose should be titrated according to stool consistency, with the aim of achieving a soft, well‑formed stool (corresponding to Bristol Stool Form Scale type 4). [2008]
Consider tricyclic antidepressants (TCAs) as second‑line treatment for people with IBS if laxatives, loperamide or antispasmodics have not helped. Start treatment at a low dose (5 mg to 10 mg equivalent of amitriptyline), taken once at night, and review regularly. Increase the dose if needed, but not usually beyond 30 mg. At the time of publication (February 2015), TCAs and selective serotonin reuptake inhibitors (SSRIs) did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information. [2015]
Consider SSRIs for people with IBS only if TCAs are ineffective. At the time of publication (February 2015), TCAs and SSRIs did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information. [2015]
Take into account the possible side effects when offering TCAs or SSRIs to people with IBS. Follow up people taking either of these drugs for the first time at low doses for the treatment of pain or discomfort in IBS after 4 weeks and then every 6 to 12 months. At the time of publication (February 2015), TCAs and SSRIs did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information. For guidance on safe prescribing of antidepressants (such as TCAs and SSRIs) and managing withdrawal, see NICE's guideline on medicines associated with dependence or withdrawal symptoms. [2015]
Referral for psychological interventions (cognitive behavioural therapy [CBT], hypnotherapy and/or psychological therapy) should be considered for people with IBS who do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (described as refractory IBS). [2008]
The use of acupuncture should not be encouraged for the treatment of IBS. [2008]
The use of reflexology should not be encouraged for the treatment of IBS. [2008]
Follow‑up should be agreed between the healthcare professional and the person with IBS, based on the response of the person's symptoms to interventions. This should form part of the annual patient review. The emergence of any 'red flag' symptoms during management and follow‑up should prompt further investigation and/or referral to secondary care. [2008]