Irritable bowel syndrome in adults: diagnosis and management of

881 Pages·2008·5.64 MB·English

clinical practice guidelines
National Collaborating Centre for Nursing and Supportive Care
Irritable bowel syndrome
in adults: diagnosis and
management of irritable
bowel syndrome in
primary care
Commissioned by the National Institute for
Health and Clinical Excellence (NICE)
F E B R U A R Y 2 0 0 8
National Collaborating Centre for Nursing and Supportive Care

Clinical practice guideline

Irritable bowel syndrome in adults: diagnosis
and management of irritable bowel syndrome
in primary care

Commissioned by the National Institute for Health and Clinical Excellence

February 2008

Irritable bowel syndrome: full guideline Page 1 of 556
National Collaborating Centre for Nursing and Supportive Care
This guideline was developed by the National Collaborating Centre for Nursing and Supportive
Care (NCC-NSC) on behalf of the National Institute for Health and Clinical Excellence (NICE).
The guideline was commissioned and funded by NICE, and developed in accordance with NICE
processes and methodologies.

Based at the Royal College of Nursing, the NCC-NSC is a partnership of organisations brought
together for the purposes of supporting the development of NICE clinical practice guidelines. The
partnership is comprised of representatives from the following organisations:

• Centre for Evidence-Based Medicine, University of York
• Clinical Effectiveness Forum for Allied Health Professions
• Healthcare Libraries, University of Oxford
• Health Economics Research Centre, University of Oxford
• Royal College of Nursing
• UK Cochrane Centre.

Disclaimer
As with any clinical practice guideline, the recommendations contained in this guideline may not
be appropriate in all circumstances. A limitation of a guideline is that it simplifies clinical decision-
making (Shiffman 1997). Decisions to adopt any particular recommendations must be made by
practitioners in the context of:

• available resources
• local services, policies and protocols
• the circumstances and wishes of the patient
• available personnel and devices
• clinical experience of the practitioner
• knowledge of more recent research findings.
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Contents Page
National Collaborating Centre for Nursing and Supportive Care 2
Disclaimer 2
Guideline development group membership and acknowledgements 5
Terminology 8
Abbreviations 8
Glossary 10
1 EXECUTIVE SUMMARY 27
2 PRINCIPLES OF PRACTICE 32
2.1 Person-centred care 32
2.2 A collaborative interdisciplinary approach to care 32
2.3 Organisational issues 32
2.4 Background 33
2.5 Clinical need for the guideline 33
2.6 Management issues 35
3 SUMMARY OF GUIDELINE RECOMMENDATIONS 36
4 AIMS OF THE GUIDELINE 41
4.1 Who the guideline is for 41
4.2 Groups covered by the guideline 41
4.3 Groups not covered by the guideline 41
4.4 Health care setting 41
4.5 Diagnosis and management interventions covered by the guideline 42
4.6 Interventions not covered by the guideline 42
4.7 Guideline development group 42
5 METHODS USED TO DEVELOP THE GUIDELINE 44
5.1 Summary of development process 44
5.2 Clinical effectiveness review methods 45
5.3 Cost effectiveness review methods 59
5.4 Submission of evidence 73
5.5 Formulating recommendations 73
6 DIAGNOSIS 76
7 DIET AND LIFESTYLE 128
7.1 General dietary and lifestyle advice 135
7.2 Physical activity 136
7.3 Fibre 145
7.4 Probiotics and prebiotics 168
7.5 Aloe vera 191
7.6 Exclusion diets 199
8 PHARMACOLOGICAL INTERVENTIONS 212
8.1 Laxatives 214
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8.2 Antimotility agents 260
8.3 Antispasmodics 291
8.4 Antidepressants 314
8.5 Adverse effects: pharmacological interventions 349
8.5.1 Adverse effects: antispasmodics, antimotility agents and laxatives 349
8.5.2 Adverse effects: tricyclics and selective serotonin re-uptake inhibitors 369
9 PSYCHOLOGICAL INTERVENTIONS 374
9.1 Relaxation 377
9.2 Biofeedback 381
9.3 Evidence to recommendation: relaxation and biofeedback 388
9.4 Psychotherapy 388
9.5 Cognitive behavioural therapy (CBT) 407
9.6 Hypnotherapy 441
9.7 Indirect comparison of psychological interventions 458
9.8 Evidence to recommendation: psychotherapy, CBT and hypnotherapy 463
10 COMPLEMENTARY AND ALTERNATIVE THERAPIES 465
10.1 Reflexology 467
10.2 Acupuncture 471
10.3 Herbal medicines 481
11 PSYCHOSOCIAL INTERVENTION: PATIENT INFORMATION AND
SUPPORT GROUPS 507
11.1 Support groups and self-help 509
11.2 Patient information 515
11.3 Evidence to recommendation: psychosocial and patient information 520
12 RECOMMENDATIONS FOR RESEARCH 521
13 IMPLEMENTATION OF THE GUIDELINE 524
14 RELATED NICE GUIDANCE 525
15 UPDATE OF THE GUIDELINE 525
16 REFERENCES 526
APPENDIX A Registered stakeholders
APPENDIX B Search strategies and searched databases
APPENDIX C Tables of included studies
APPENDIX D Quality assessment of studies
APPENDIX E Tables of excluded studies
APPENDIX F Grading the evidence
APPENDIX G Literature review of prognostic resource use and quality of life data
APPENDIX H PSA parameters
APPENDIX I Bristol Stool Form Scale
APPENDIX J General Practice Physical Activity Questionnaire

APPENDIX K Declarations of interests
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Guideline development group membership and acknowledgements

Mr Jonathan Blanchard-Smith
Patient/carer representative
IBS Network

Dr Ian Bullock
Director
NCC-NSC

Dr Jamie Dalrymple
Medical Practitioner, Drayton & St Faith's Medical Practice, Norwich
Primary Care Society for Gastroenterology

Ms Sarah Davis
Senior Health Economist
NCC-NSC

Ms Jackie Eastwood
Specialist Pharmacist in Gastroenterology, St. Mark’s Hospital, Harrow
Royal Pharmaceutical Society of Great Britain

Dr Charles Foster
Senior Researcher, University of Oxford
Health Promotion Research Group, British Heart Foundation

Dr Jenny Gordon
Research and Development Fellow
NCC-NSC

Mrs Jenny Gough
Nurse Consultant, Camden Primary Care Trust, London
Royal College of Nursing

Professor Elspeth Guthrie
Professor of Psychological Medicine and Medical Psychotherapy, Manchester Royal Infirmary
Royal College of Psychiatrists

Dr Miranda Lomer
Consultant Dietitian in Gastroenterology, King’s College London
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British Dietetic Association

Ms Marion Saunders
Patient/carer representative

Ms Theresa Shaw (Chair)
Chief Executive
Foundation of Nursing Studies

Dr Richard Stevens
General Practitioner, East Oxford Health Centre
Royal College of General Practitioners

Dr Maggie Westby
Senior Research and Development Fellow
NCC-NSC

Professor Peter Whorwell
Professor of Medicine and Gastroenterology, Wythenshawe Hospital, Manchester
British Society of Gastroenterology

Dr Mary Wilson
Nurse Specialist, Westwood Hospital, North Humberside
Royal College of Nursing

Staff at the NCC-NSC who contributed to this guideline:

Dr Anayo Akunne
Health Economist

Ms Nahara Martinez-Gonzales
Systematic Reviewer

Mr Paul Miller
Information Specialist

Ms Emma Nawrocki
Administrator

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Mr Edward Weir
Centre Manager

The NCC-NSC would like to thank the following people for their assistance with developing
this guideline:

Dr Yoon Loke

Dr Giok Ong

Dr Jacoby Patterson

Dr Joanne Lord

The NCC-NSC also acknowledges the expert opinions of the following people:

Kevin Whelan
Nutritional Sciences Division, King’s College London

Professor E Quigley

Yvonne McKenzie, Liane Reeves, Annabel Drake, Anna Brian, Carolyn Johnstone, Adele
Nichol, Kristina Zaremba
Gastroenterology Specialist Group of the British Dietetic Association

Scottish Nutrition and Diet Resources Initiative (SNDRi)

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Terminology
Where the term ‘carer’ is used, this refers to unpaid carers as opposed to paid careworkers.

Abbreviations
ARR: Absolute relative risk

BNF: British National Formulary

CAM: Complementary and alternative medicine

CBT: Cognitive behavioural therapy

CEAC: Cost-effectiveness acceptability curve

CI: Confidence interval

CRP: C-reactive protein — used mainly as a marker of inflammation

ESR: Erythrocyte sedimentation rate — a non-specific measure of inflammation that is commonly
used as a medical screening test

EMA: Anti-endomysium antibodies — inflammatory markers used in the diagnosis of coeliac
disease

FBC: Full blood count

FOB: Faecal occult blood

GDG: Guideline development group

GI: Gastrointestinal

GP: General practitioner

GRADE: Guidelines, Recommendations, Assessment, Development, Evaluation

HRQoL: Health-related quality of life

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IBD: Inflammatory bowel disease — a general term for any disease characterised by inflammation
of the bowel. Examples include colitis and Crohn's disease. Symptoms include abdominal pain,
diarrhea, fever, loss of appetite and weight loss

IBS: Irritable bowel syndrome

IBS-A: Irritable bowel disease with alternating symptoms of diarrhoea and constipation

IBS-C: Irritable bowel disease with constipation as the primary bowel dysfunction

IBS-D: Irritable bowel disease with diarrhoea as the primary bowel dysfunction

ICER: Incremental cost-effectiveness ratio

LY: Life-year

NHS: National Health Service

NICE: National Institute for Health and Clinical Excellence

NNT: Number needed to treat

OR: Odds ratio

PCT: Primary care trust

PEG: Polyethylene glycol (macrogol)

PSA: Probabilistic sensitivity analysis

PSS: Personal social services

QALY: Quality-adjusted life-year

RCT: Randomised controlled trial

RR: Relative risk

SSRI: Selective serotonin re-uptake inhibitors

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