Management Of Functional Gastrointestinal DisordersⅡ

Management 

The general and initial approach

Once you have diagnosed an FGID, it is important to put a label on it, as patients often complain that they do not have a diagnosis or that ‘nobody knows what is causing their symptoms’, and then to explain in simple language what FGIDs are; information sheets or online resources can be very useful. To manage patient expectations, it is useful to reiterate the incurable nature of FGID and to explain that the aim of management is not to remove symptoms completely or return the patient to ‘normal’, but to give them more control over their symptoms so that the GI symptoms do not dominate their life.

Click to laxatives for constipation

It is helpful when managing these patients to address the bio-psycho-social factors, in reverse: 

> Social/lifestyle factors: diet, exercise, sleep, and ingestion of caffeine, alcohol and other medication 

> Psychological factors: presence of stress, anxiety, low mood and history of eating disorders 

> Biological factors: physiological abnormalities and medication side effects which are contributing to symptoms

The heterogeneity of FGID makes it difficult to design an algorithm to fit all patients, however, using a biopsychosocial approach and identifying factors which may have triggered symptoms and which ones are maintaining them enables the clinician to focus on modifying these factors as part of a personalised management plan. Integrated multidisciplinary clinical care (eg gastroenterologist, nurse, dietitian and psychologist) appears to be superior to gastroenterologist-only care in terms of improving symptoms, psychological state, quality of life and cost of treating functional gastrointestinal disorders, so this should be offered where possible.12

Specific management 

Lifestyle advice 

Exercise 

Exercise can improve bowel function, improve transit time (in females) and, therefore, help with constipation.13 It can also reduce stress, improve mood and lead to better sleep, all of which impact GI symptoms. In a randomised controlled trial (RCT), increased physical activity was associated with a greater reduction in IBS symptom severity scores.14 Patients should be advised to do 20–30 minutes of exercise 3–5 times per week, even if this is just walking.

Sleep 

Sleep disturbances are associated with both upper and lower GI symptoms and worse QOL.15 Sleep disturbances can be initial (anxiety preventing the onset of sleep), middle (typically broken sleep) and late (early morning awakening (can be a sign of depression)). Digital technology (eg ‘Fitbits’ and phone apps) can measure sleep patterns and quality, and then advise interventions to improve this (eg Sleepio app). Patients should be advised on sleep hygiene. If a drug is needed, benzodiazepines should be avoided but melatonin (3 mg nocte) can be used. This has been shown to reduce abdominal pain and rectal hypersensitivity but not bloating or overall IBS symptom scores.16

Phone apps 

Apps can be useful for tracking lifestyle factors and monitoring changes to them. There are hundreds of healthcare apps available so it can be difficult to know what to recommend. Apps which are listed on the NHS Apps Library or ORCHA  have been reviewed and can be more confidently recommended. We tend to recommend Sleepio for sleep and Headspace for mindfulness. Bowelle helps track symptoms in IBS. Zemedy is an IBS self-management app that uses a cognitive behavioural therapy (CBT) approach. The Monash University Low FODMAP Diet™ App helps users identify foods with high fermentable oligo-, di-, and monosaccharides and polyols (FODMAP) content and is useful for patients who are on the low FODMAP diet (further details follow later).

Stimulants and depressants 

Caffeine increases diarrhoea, alcohol worsens reflux symptoms and heavy use is associated with increased risk of functional dyspepsia.17 Both caffeine and alcohol can lead to disrupted sleep, so these should be minimised and not taken late at night in symptomatic individuals. 

Cannabis misuse, with direct causative links to vomiting syndromes, has latterly been replaced by internet-bought cannabidiol and other plant derivatives. Even if the patient experiences none of the commonly associated GI side effects, such as vomiting and diarrhoea, there is an association with anxiety, fatigue, somnolence, risk of dependence and the potential for drug interactions, so this should not be recommended.18,19

Diet and nutrition 

Eating behaviours 

In FGID, symptoms are frequently associated with food intake, so dietary assessment and optimisation should be part of the initial management strategy. Patients can be asked to keep a food diary to identify foods which trigger symptoms and to identify eating behaviours, however, the possibility of reporting bias should be noted. 

IBS is associated with irregular dietary patterns and reduced diet quality and diversity (ie not having the recommended range and quantity of particular food groups), so education about how to eat as well as what to eat is important.20,21 The National Institute for Health and Care Excellence (NICE) has a useful information sheet for an ‘IBS diet’ which focuses on eating small regular meals, avoiding insoluble fibre, fatty foods, gas-producing foods and caffeine.

Dietary restriction 

There is evidence for symptom improvement following a reduction in lactose and high-starch and sugary foods and drinks, so these can be reduced if appropriate.20 The identification that consumption of foods high in FODMAP can exacerbate symptoms of IBS because of fermentation and osmotic effects (bloating/pain and diarrhoea, respectively) has led to the use of a low FODMAP diet as a dietary intervention for IBS, particularly in IBS-D.22 

However, this diet runs the risk of being overly restrictive and the long-term effects on nutrition and the colonic microbiome are unclear, so this must be implemented by a trained dietitian.23 In two RCTs in Sweden and the USA, there was a similar reduction (40–50%) in IBS symptom scores in both a ‘low FODMAP diet’ and an IBS/NICE diet.24,25 

Thus, in the absence of dietetic support for the former, it is useful for a clinician to provide generic dietary advice in the clinic based on NICE guidance. The evidence for a gluten-free diet is less clear-cut. While minimising gluten intake is associated with a reduction in abdominal pain, it is unclear whether this is because gluten is a high-FODMAP food.26 Patients can be asked to reduce their gluten intake if this is felt to be helpful but there is no clear evidence for restricting this completely

Fibre 

Soluble fibre – psyllium or spatula husk (eg fybogel) – is cheap and useful for symptoms of IBS, particularly in IBS-C. This should be started at a low dose and increased slowly. There is no evidence for insoluble fibre or for bran, both of which can exacerbate pain and bloating.

Probiotics 

Patients with FGID have altered microbiota, and this will be increased if patients have been on long-term or recurrent antibiotics. Microbial alteration with probiotics can be trialled and there is growing evidence for this. A meta-analysis demonstrated that probiotics improve global IBS symptom scores as well as individual symptoms of abdominal pain, bloating and flatulence.28 Probiotics can improve stool consistency and frequency in both IBS-D and IBS-C but this is not as clear-cut as its effect on pain and bloating.29 

Combination probiotics are more likely to be beneficial but there is no consistent data to suggest what that combination should be, nor what the dose should be.30 Although the long-term effect of probiotics on the microbiota is unknown, they are generally safe so trialling them for 2–3 months can be considered early on in the treatment of IBS-D and possibly IBS-C. There is no evidence to recommend faecal microbiota transfer, prebiotics (dietary supplements that result in specific changes in the composition and/or activity of the GI microbiota) or synbiotics (a mixture of probiotics and prebiotics that act synergistically to promote the growth and survival of beneficial organisms) at the current time.

Psychopathology: identification and psychological treatment 

Although it may not be constructive to medicalise stress and distress by imposing diagnoses of anxiety and clinical depression, it is important to identify these as they are treatable and improving them will lead to an improvement in GI symptoms and QOL. The use of simple questionnaires (such as the hospital anxiety and depression scale) is a quick and easy way to identify this in an outpatient setting. Treatment is with pharmacological agents or with psychotherapy, both of which are effective treatments for FGID.31

Anxiety 

Several symptoms of anxiety are similar to those in FGID (eg diarrhoea, vomiting, abdominal cramps and nausea) and patients with multiple functional syndromes often have an element of health anxiety. GI-specific anxiety can be measured by the visceral sensitivity index (VSI) and this is the best predictor of IBS symptom severity

Depression 

It is important not to blame the GI disorder on low mood but to explain how mood will contribute to GI symptoms and how it is treatable. Urgently refer patients with current suicidal ideation or plans to mental health professionals. For others, consider the role of psychotherapy versus pharmacotherapy for treating low mood. As a general rule, unless there is suicidal ideation, we would consider psychotherapy (further details follow later) as a first line before medication.

Eating disorders and disordered eating 

Although FGID is not typically associated with eating disorders, the presence of meal-related symptoms can lead to disordered eating and, in severe cases, the development of food phobias. This is due to the conditioned pairing of an unpleasant GI symptom (eg abdominal pain) with specific foods which can then lead to avoidant restrictive food intake disorder (ARFID) which is an emerging category of eating disorders.32

Psychotherapy 

A meta-analysis has confirmed that psychological therapies including CBT, gut-directed hypnotherapy, dynamic psychotherapy, and relaxation and mindfulness therapy are effective treatments for FGID (number needed to treat (NNT) 3–6).30 Which of those is chosen will be determined by the availability of local services. CBT is probably the easiest type of therapy to access (via Improving Access to Psychological Therapies (IAPT)) and most effective with an NNT of 3, meaning at least one in three referrals to CBT will experience a significant reduction in symptoms.31 

The success of psychotherapy may be dependent on the expertise of the therapist; in some studies, psychotherapy delivered in specialised centres appears to have a better outcome.33 However, CBT and mindfulness are effective even when delivered via the Internet which will improve access to psychological therapies.34,35 Psychotherapy can be time-consuming, usually delivered over 12–14 weekly sessions. However, the effects appear to be long-lasting and relatively free of side effects, so this form of therapy should be considered in willing patients.36–39 A meta-analysis has confirmed that antidepressants are also effective treatments for IBS, equally effective to psychotherapy when patients are compliant with them.31,40 The use of antidepressants for treating symptoms of FGID is discussed later.

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 ageing, 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 contains 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.