Best Management Of Irritable Bowel SyndromeⅠ

Abstract 

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction that can have a considerable impact on quality of life. Following diagnosis, timely and evidence-based management is vital to the care of patients with IBS, aiming to improve outcomes and enhance patient satisfaction. Good communication is paramount, and clinicians should provide a clear explanation of the disorder, with a focus on exploring the patient’s own beliefs about IBS, and a discussion of any concerns they may have. It should be emphasized that symptoms are often chronic and that treatment, while aiming to improve symptoms, may not relieve them completely. Initial management should include simple lifestyle and dietary advice, discussion of the possible benefit of some probiotics, and, if this is unsuccessful, patients can be referred to a dietician for consideration of a low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet. Antispasmodics and peppermint oil can be used first-line for the treatment of abdominal pain. If patients fail to respond, central neuromodulators can be used second-line; tricyclic antidepressants should be preferred. Loperamide and laxatives can be used first for treating diarrhea and constipation, respectively. Patients with constipation who fail to respond to laxatives should be offered a trial of linaclotide. For patients with diarrhea, the 5-hydroxytryptamine-3 receptor agonists alosetron and ramosetron appear to be the most effective second-line drugs. Where these are unavailable, ondansetron is a reasonable alternative. If medical treatment is unsuccessful, patients should be referred for psychological therapy, where available, if they are amenable to this. Cognitive behavioral therapy and gut-directed hypnotherapy are the psychological therapies with the largest evidence base.

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Introduction 

Irritable bowel syndrome (IBS) is one of the most common disorders of gut-brain interaction, with a population prevalence of between 5% and 10%.1 2 The cardinal symptoms are abdominal pain, related to defaecation, associated with a change in the frequency or form of stools.3 Symptoms are chronic, often severe, and have a substantial impact on quality of life.4 More than 80% of patients will consult their general practitioner (GP),5 and the majority are managed successfully in this setting.6 However, some patients, particularly those who fail to respond to first-line treatment, or those in whom there is any diagnostic uncertainty, for example, older patients in whom underlying organic pathology may need to be excluded, will be referred to secondary care. Managing patients with IBS accounts for approximately 25% of a gastroenterologist’s time in the outpatient clinic,7 and the associated costs of investigation and treatment are considerable.8 When reviewing any patient with IBS, the first consideration should be the requirement for any further investigation. We have previously written about the importance of adopting a rational approach, which prioritizes making a diagnosis on clinical grounds in the majority of cases, following a limited number of essential investigations, for example, routine blood, including coeliac serology.9 Exhaustive investigation is not only undesirable, but unnecessary, as tests are frequently normal, and this is likely to make patients feel that the cause of their symptoms has been missed, rather than providing reassurance.10 Indeed, taking a rational approach to investigation, and making an early diagnosis, are key components of recommendations calling for physicians to standardize the care of patients with IBS, to improve the quality of care overall, and to enhance patient satisfaction.11 The next step is to start treatment in a timely fashion, ideally during the first consultation if the diagnosis is secure and on July 4, 2023, by the guest. Protected by copyright relevant limited diagnostic tests to exclude another condition have already been performed in primary care. However, there is a recognition that confidence in managing IBS will vary among physicians, depending on expertise.

Figure 1 Suggested algorithm for the management of irritable bowel syndrome. CBT, cognitive behavioral therapy; FODMAP, fermentable oligosaccharides, disaccharides, monosaccharides, and polyols; IBS, irritable bowel syndrome; SSRI, selective serotonin reuptake inhibitor; TCA, a tricyclic antidepressant; 5-HT3, 5-hydroxytryptamine-3. *As per the NICE IBS dietary advice sheet, consider ispaghula husk. +Tricyclic antidepressants should be the first choice, starting at a dose of 10mg at night, and titrating slowly (e.g. by 10mg per week) according to response and tolerability. Continue for at least 6 months if the patient reports a symptomatic response. ‡Review efficacy after 3 months of treatment, and discontinue if no response.

In general, treatment is targeted at addressing a patient’s most troublesome symptoms, be that abdominal pain, diarrhea, constipation, or bloating. Although several factors have been implicated in the pathophysiology of IBS, including the gut-brain axis, alterations in the microbiome, genetic factors, and visceral hypersensitivity, there is currently no role in using these to guide therapy in routine practice. Moreover, it is likely that, even among patients with the same symptoms, the underlying pathophysiology responsible for them will vary. Consequently, although treatments may be designed to address theoretical pathophysiological abnormalities, there is no way to assess response through objective measurement of these and, instead, the clinician must rely on patient-reported symptom response to determine treatment success. 

This review aims to provide physicians with a practical, comprehensive, and evidence-based framework for treating IBS (Figure 1). It will focus on the importance of good communication, the role of dietary and lifestyle advice, and second-line dietary strategies. First-line and second-line drug treatments will be evaluated, as will newer second-line treatments targeting abnormal stool form specifically. Finally, the place of psychological therapies in IBS will also be discussed. One problem with randomized controlled trials (RCTs) of therapies is that, in most IBS treatment trials, active drugs are compared with a placebo, rather than with each other. Therefore, the absence of head-to-head treatment comparisons makes it difficult to understand the relative efficacy of drugs, which is important when doctors and patients are choosing treatments. Network meta-analysis can circumvent this problem, to some extent, by providing the likelihood of which treatment is likely to be the most efficacious in each clinical scenario, and the findings from these types of evidence synthesis will be discussed, where available (Table 1).

Table 1 Summary of evidence from trial-based meta-analyses and network meta-analyses concerning the efficacy of drugs for IBS

Natural Herbal Medicine For Relieving Constipation-Cistanche 

Cistanche is a genus of parasitic plants that belongs to the family Orobanchaceae. These plants are known for their medicinal properties and have been used in Traditional Chinese Medicine (TCM) for centuries. Cistanche species are predominantly found in arid and desert regions of China, Mongolia, and other parts of Central Asia. Cistanche plants are characterized by their fleshy, yellowish stems and are highly valued for their potential health benefits. In TCM, Cistanche is believed to have tonic properties and is commonly used to nourish the kidney, enhance vitality, and support sexual function. It is also used to address issues related to aging, fatigue, and overall well-being. While Cistanche has a long history of use in traditional medicine, scientific research on its efficacy and safety is ongoing and limited. However, it is known to contain various bioactive compounds such as phenylethanoid glycosides, iridoids, lignans, and polysaccharides, which may contribute to its medicinal effects.

Wecistanche's cistanche powder, cistanche tablets, cistanche capsules, and other products are developed using desert cistanche as raw materials, all of which have a good effect on relieving constipation. The specific mechanism is as follows: Cistanche is believed to have potential benefits for relieving constipation based on its traditional use and certain compounds it contains. While scientific research specifically on Cistanche's effect on constipation is limited, it is thought to have multiple mechanisms that may contribute to its potential to relieve constipation. Laxative Effect: Cistanche has long been used in Traditional Chinese Medicine as a remedy for constipation. It is believed to have a mild laxative effect, which can help promote bowel movements and induce constipation. This effect may be attributed to various compounds found in Cistanche, such as phenylethanoid glycosides and polysaccharides. Moistening the Intestines: Based on traditional use, Cistanche is considered to have moisturizing properties, specifically targeting the Intestines. Promoting hydration and lubrication of the Intestines may help soften tools and facilitate easier passage, thereby relieving constipation. Anti-inflammatory Effect: Constipation can sometimes be associated with inflammation in the digestive tract. Cistanche contains certain compounds, including phenylethanoid glycosides and lignans, that are believed to have anti-inflammatory properties. By reducing inflammation in the intestines, it may help improve bowel movement regularity and relieve constipation.

Christopher J Black ,1,2 Alexander Charles Ford 1