Episode Transcript
[00:00:00] Speaker A: Welcome to ingest, the podcast series designed for primary care and brought to you by the Primary Care Society for Gastroenterology. My name is Charlie Andrews. I'm a GP with an extended role in gastroenterology based near Bath. Ingest is an educational podcast where I speak to specialists in gastroenterology and we discuss a variety of different topics that we commonly encounter in primary care in the uk. In this episode, I'm speaking to Professor Anton Emanuel, who is a consultant gastroenterologist and professor of neurogastroenterology at University College Hospital London. His research includes gut neurophysiology and the study of the causes and management of functional disorders of the gut. So it seems particularly appropriate to be discussing with him the diagnosis of irritable bowel syndrome.
[00:00:51] Speaker B: So, Anton, thank you so much for joining me on the podcast today. It's a pleasure to have you here.
[00:00:56] Speaker C: Thank you, Charlie. No, it's my pleasure. I really enjoy doing podcasts because it gives you a chance to present information in a way other than the written, which always ends up being slightly more narrow in form than you want it to be. So thank you for the invitation.
[00:01:09] Speaker A: Well, great.
[00:01:10] Speaker B: Thanks for being here. And we're going to be talking about ibs, which is such a huge topic, and we're dividing this into two episodes. So we have another episode coming out in a month or so which is going to be looking at more at the management of ibs. So today we're going to be looking a bit more at kind of the background of ibs. We're going to look at some of the challenges of diagnosis and how to communicate with patients.
So to kick us off, could you give us a bit of background about ibs? So, you know, what is it, how common is it? And I know that an area where you have specialist knowledge and interest is around the causes and why some people develop it and others don't.
[00:01:47] Speaker A: Would you be able to give us.
[00:01:48] Speaker B: A bit of a background to ibs?
[00:01:51] Speaker C: Yeah, no, thanks for that. So, yes, in essence, in my interest in this, I'm a neurologist originally who became a gastroenterologist during training. And so my interest in this is in terms of how this fits into that family of so called functional disorders where organs look normal but symptoms are present. And obviously that's a big issue for us in neurology, it's a big issue for us in gastroenterology. And so therefore that's the sort of the framework almost for my view on what IBS is that, number one and most importantly has to be answered. IBS is a pain condition. You can't have ibs. In terms of the label of ibs, you can have a functional problem. But specifically to label somebody's ibs, they have to have pain. It's not discomfort, it's not bloating, it's not, you know, occasional ache. It's pain. They have to have pain. So that's number one. And that's all been codified in the various classifications. So it's a pain syndrome. Number two, there has to be bowel dysfunction. There has to be either some increased or reduction in frequency which may be chronic or episodic.
That's number two.
Number three, and most importantly, there has to be a temporal relationship between those two things. There has to be a relationship in time between the pain getting worse with the bowel getting centers getting worse or bowel getting less problematic and the pain getting less. In other words, there has to be some temporal relationship. All the other things that people think of, like bloating or stress relationships or loss of mucus per rectum, those things are optional extras. They're not core to the diagnosis. The core things are those three things. And sorry to be repetitive, it's number one, pain. Number two, altered bowel function. Number three, a temporal relationship. Without those three things, you don't have ibs. You may have another functional syndrome. And that's important because phenotyping this carefully means you identify those people who have functional constipation or slow transit constipation or rectal evacuation difficulty or chronic diarrhea. Those are different things which won't get better with the embedded IBS treatments that you'll hear about next podcast.
[00:04:02] Speaker B: Fantastic.
[00:04:03] Speaker A: And how common is ibs?
[00:04:05] Speaker C: So if you use those definitions, as opposed to the previous more woolly ones, but these accepted definitions for the last 15 years, you will see that the population prevalence onto a huge range of severities. But forgetting severity, just the prevalence of the condition, it's about realistically 8 to 12% depending on which country you're in and who does the survey, et cetera. But just that presence of those three mandatory symptoms, it's about 1 in 10 people roughly. And it's interesting, we tend to think of this as being a woman's condition, and that is certainly the case in western populations and maybe driven by our culture or something. We may talk about more in time, but certainly in sub Saharan African populations and some of the Far east populations, it's as prevalent, if not more prevalent in men than in women. So I don't think there's necessarily a biological reason why women are more infected in the uk, but maybe, but there's least importantly a social reason around why women present more often.
[00:05:12] Speaker B: One in ten, that's an awful lot.
[00:05:14] Speaker C: I don't want yourself or colleagues to roll their eyes. I'm sure you won't, Charlie, but oh God, if it's that common, how do you call it a disorder? And I think the thing is that there's a huge range of severity. There's IBS patients we think of and can bring to mind instantly who are the ones who are absolutely miserable with their symptoms. Just life daily is a, is a trial and then there are those, and that's a small group of that. Again, ostimates vary, but that probably represents no more than 5 or 10% of that. 10%. The vast majority of patients have milder symptoms, which are a nuisance level. So I think it's important not to think that I or anyone else walking around saying that 1 in 10 people are out there in the depths of IPS agony. It's just the prevalence by symptoms, but severity is that much smaller group.
[00:06:05] Speaker B: So it's that broad spectrum. And a number of them won't present to us, but some certainly will and we need to have an understanding of how to approach those patients, how to support them as best we can. Can you give us any information about the sort of the underlying causes of ibs? Now, I know that it's not fully understood, but where are we at with understanding why some people develop it and others don't?
[00:06:28] Speaker C: So I'll try not to make this too much of a personal viewpoint, but it'll be informed by what I see the evidence as, of course, like any presentation. So I think it's very clear that it is definitely a disorder of the so called gut brain axis. So the people listening will know that the gut is the second most nervous organ in the body after your brain. There are 100 million neurons in your gut, which is more than there are in your spinal cord, interestingly. And that connection is both at a conscious level, so that the desire to eat, the desire to open one's bowels, the knowing when you've had enough to eat, knowing when you finished in the toilet, those things are the sensory part of that mechanism, which is voluntary, but there's a huge involuntary autonomic part of that as well. So there's this complex voluntary, involuntary sensory and motor domain of this. And so the core theory around this is that this is a problem, like a lot of functional pain syndromes which IBS is one of, as I say, is that it's a problem of how the afferent traffic of information from the organ, in this case the gut as a whole, goes to your brain. And I keep saying the word gut and for me the word gut refers to anything from your mouth down to your anus. So it isn't exclusively colon, exclusively small bowel.
Ibs, as you know, and as you implied earlier on, is a spectrum with functional dyspepsia and non cardiac chest pain and all those other syndromes. They're part of the same continuum and they all relate to that same thing about how there's a sort of an altered afferent processing, if you want to put it in very neurological terms, how those afferent sensory information from your gut gets perceived by your brain. And therefore things that we think about like stress or like smoking or like diets or whatever else, menstrual cycle, that influence that, you can see that as you know, we are all familiar idea that smoking alters afferent traffic, that during menstrual cycle we get heightened sensation from different parts of our body. So those, those other things that we tend to think of as being the cause of ibs, they mechanistically, pathophysiologically, we're talking about an alteration of that nerve axis, that brain gut nerve access.
And then in more severe cases, what's clear, that kind of one percentage of the population I mentioned earlier on who have much more chronic symptoms, their problem is that afferent transport, but also the part around the cortical perceptional part. So not only is it the nerves going up, but it's also how the brain signals that. And that's why the interplay with other functional conditions then comes into its own in those patients where psychiatric comorbidity is often more present. It's often exacerbated by the social factors and that kind of becoming a patient and all the vortex of problems that occur. So that's a very complicated answer, but essentially a brain gut axis issue which is related to alternate afferent processing. In more severe cases, central processing of that afferent information and all the things that are associations to it, diet, smoking, whatever else, are working through that nerve signaling process.
[00:09:48] Speaker B: Thank you, that's a really helpful answer. And the gut brain axis is something that we, you know, having an understanding of enables us to communicate this diagnosis to patients much better.
So thank you, that's a really helpful one. And it also ties in with some of the treatment options as well. That we'll explore in the next podcast. I know that there are different types of ibs. Could you just outline them for us?
[00:10:11] Speaker C: Yes, of course. So again, the grey beards who sit around tables and discuss this have been persuaded by clinicians and I'd like to think of myself as being one of those rather than part of the grey beard, despite evidence, have moved this to being something which is much more around patient symptoms rather than being the theoretical ways we should classify ibs. This is a very symptomatic thing. And so we have this notion that you have essentially four subtypes, but I think that's probably over boxing it. But broadly speaking, the boxes are ibs, which is constipation predominant, ibs, which is diarrhea predominant, ibs, which is of a mixed type. And then a small group. You always need a kind of a idiopathic. So there's an unknown IBSU group. But essentially what that refers to is this question of how often do you have pain and how severe is that pain in relationship to your particular bowel patterns. If you just have, say, infrequent or difficult bowel opening without pain, then you have functional constipation. Whereas if it's with pain, you're in that box of IBS C. If you just have diarrhea, it's a chronic or functional diarrhea. So you have this notion of the pain defining ibs, as I keep saying, but it's also then related to the type of bowel function and then accepting that there's a group who mix. Now, one of the important things, if I may just make a small plea, there's a temptation to often think that people are often labeled as mixed. And if you look at the series that have emerged from primary care historically, they've put IBSM mixed as being the largest group. What actually transpires often. And this is a plea therefore, for sort of that thing about a slightly more careful history is actually what people's problem is primarily constipation, but then whatever, through accumulation or dietary manipulation or over the counter laxative, they then get this period of explosive diarrhea to void and then the cycle begins again. And so they get channeled in as mixed when actually it's more of an IBS C. So actually the inverted commas, rarer IBS C, when you do the history taking and diary keeping, which is very dull, in a kind of formal trial, you actually find IBS C, the constipation predominant group, are slightly more prevalent. So and the point about that being to ask those questions. So the way I tend to ask it, and maybe I'm jumping to something you will cover later on. Charlie, is there one about asking patients when they say, oh, it's all over the place, Doc, Sometimes it's this, sometimes that I'd say, so if I asked you a difficult question and asked you, could you say that your bowel is generally slow and then speeds up, or do you say is generally speeds up and then sometimes slows down, which would you say? And I would say when I ask the question that way, a lot of people, most people defer to that first formulation. It's slow and then sometimes speeds up because of what I've done or whatever. And it's very few who actually say, I just can't tell you. It just alters completely randomly by anything I do from one to the other. That true IBSM actually is a smaller population.
[00:13:18] Speaker B: Something that's really come across as we've been talking is that relationship with pain. It really feels like that's the sort of that key thing. And it's been really helpful you clarifying that if there's not pain but there's constipation, this is a slightly different picture. This is a functional constipation picture, but that pain seems to really sit at the heart of it, which is really helpful to keep on reiterated. So I think that's great. Thinking about diagnosis overall, it feels like the diagnosis of IBS can be quite challenging in primary care.
And I was trying to think of some of the reasons why that might be and I've got things like missing more worrying things, so missing cancers and things like that. So people get quite worried about making a diagnosis of IBS because they might miss something.
Difficulty with making a positive diagnosis when IBS is seen as a diagnosis of exclusion can feel quite hard for some primary care clinicians.
This is really my list, I have to say, potentially.
[00:14:18] Speaker A: It could also potentially feel like it's.
[00:14:19] Speaker B: A fob off diagnosis for a patient as well, that patients have this sort of, there's a stigma around IBS potentially and that if a GP is giving them that diagnosis, they may think, well, you're really just saying this is all in my head. That's really taking it down to the most basic level.
[00:14:34] Speaker C: Yeah.
[00:14:35] Speaker B: And then the other things sort of concern about missing mimics. So things like SIBO or bile acid diarrhea.
[00:14:43] Speaker A: So it feels like there are quite.
[00:14:44] Speaker B: A few challenges around making the diagnosis and I thought it'd be really helpful just to hear what your thoughts are around that. What do you do you hear about these challenges?
[00:14:54] Speaker A: What are your thoughts?
[00:14:55] Speaker C: No, Charlie, you're absolutely right. You've summarized that. I can visualize the slide you'd be writing and I agree with every line of it. You're absolutely right. I mean, I know that it is a lot easier for me to diagnose IBS in my setting after patients have seen two or three clinicians in primary care and after they've had tests done and where I can do more tests. So I absolutely. This notion that some of my peers go around saying, oh, it's a diagnosis exclusion, come on, just do it, that's for the birds. Frankly, I think the notion that we would have the temerity to be without all the defense as that I've mentioned in primary care, making confident diagnosis is just nonsense. So yeah, I think what we can rely on, and in a practical way, having talked about this abstract way, the practical thing I would say is this. I think it's fair to say that societies like the British Society of Gastroenterology and the European gastroenterologist societies and even the fda, they've produced these kind of diagnostic formulations which say if the symptoms are like this and it becomes a very reductivist. But essentially things talk about pain, the absence of alarm features, and you've done the following tests, then you can, you can then not investigate further. So it's not almost, it's not, it's not necessarily saying you can diagnose IBS because that comes back to be a clinical diagnosis. So I still believe it's a clinical diagnosis, but I believe the level at which you exclude, in other words, how much testing do you do before you say I'm excluded? I think we have to rely on what the great beards, as I say, have done again. And just to say these level of testing is enough. So as you mentioned, diarrhea is just about the most common presentation. So having a fecal calprotectin, which is how it's presented in your organization when it's below 50 or as a negative or whatever that is assuring for the diarrhea patients, but it's only helpful for diarrhea patients. If you have a patient who's got constipation type symptoms and the carpatectin is value in offering you assurance, or if you get a positive patient with constipation gets a carpetectin of 100, you've got a real dilemma. You've now got a borderline number and how do you pursue that? Do you repeat it? And if you Repeat it. What level do you worry? But I would say capotectin should really be only be using diarrhea patients. That's very well borne out by literature, not just a personal view.
Then the, the kind of routine blood testing. How diagnostically predictive is that? So if you have a negative set of bloods including thyroid function and calcium and celiac, if those bloods are negative in a person with typical IBS symptoms, how often do you get an organic disease within five years? There's good data on this from good surveys and it's of the order of about 0.2 to 0.5%. So it's very rare, probably less. And that's probably less than the incidence of new organic GI pathology in the community. So these tests have a screening value as well. So I think at that level of confidence we can say, look, I think if the experts have said this, I've taken a careful list of symptoms, I've done the expert recommended tests, they're negative. Your symptoms are persistent or fluctuating without any alarm features having developed, then I think at that point you can make a diagnosis. But I would not being kind to say somebody's got a fibromyalgia and pelvic pain and they come along with new belly ache and diarrhea and I'm going to label them as ibs.
That is not the right thing to do. People's comorbidities should not be part of that diagnostic schedule at the start. It should be based purely on their gut symptoms. And then at the point where in my view the tests are negative, then that formulation comes in of their other morbidity, their psychological or social challenges. Those things then come in at that point. So for me, that, that sequencing of information, obviously you take it in one go, but diagnostically I wouldn't personally want to use that information until I've got the assurance of negative.
Basic workup is that that's really helpful.
[00:19:03] Speaker B: And that workup very much fit well, that is the BSG guidance really talks about those initial screening, careful history screening, blood tests, fecal can protect him when relevant. And actually that's really helpful about not doing it on patients who are constipated. Really useful as well.
So really helpful advice around testing.
[00:19:22] Speaker A: I'm going to.
[00:19:23] Speaker C: Can I jump to the thing that you said, the third thing you said there? I'll come to the middle one, as per. I'd like to talk about a bit more about. But the part about missing other comorbidities, treatable comorbidities. So I think the following things would be true. So what are they? Microscopic colitis. That is a diagnosis primarily of older women. So 85, 90% of cases are number one. Number two, and this is the key one for getting the demography is that it has to be watery diarrhea. Diarrhea which is a bit porridgey, a bit sloppy, but sometimes no, it's watery diarrhea. And incontinence is not invariable but incredibly common. So microscopic and I should say car protection is often negative there. It isn't helpful. It's borderline elevated. So that's one comorbidity we don't want to miss. Bile acid malabsorption. There isn't always a history of some sort of biliary surgery, gallbladder surgery or small bowel disease. We know that about a third of patients with bias amount absorption don't have those comorbidities. Obviously if they have that, then that should make one think. But the hallmark symptom there is of episodic discoloured diarrhea. So they will get almost invariably in the course of a week, at least one of their stools or more will be altered color mustardy yellow or orangey or a bit of green or like a goose poo or baby's meconium type stool. Occasional stools will be like that, sometimes much more frequent. But that should be the the thing that makes us think about that. And then there may be a statory element to it of difficulty to flush away. Third differential that we may miss is the one around pancreatic insufficiency. So again the antecedent history around biliary disease or drinking alcohol.
But again that hallmark clay sandy stool episodically with a very sort of fragrant odor. People mention that occasion, that's bring the hallmark. And a PR will often, even with if it sound reporting will often show a pale stool. And then the fourth thing is bacterial overgrowth. Bacterial overgrowth has become for me a bit of analysis declaring our own personal preference. I don't believe it's nearly as prevalent as everyone or sorry as some of the marketing would tell you it is.
I think it's definitely there. The hallmark symptoms for me that make me think about it and where our diagnostic yield is much more positive is that people describe altered taste or altered breath odor episodically occurring at the time their symptoms are worse if the symptoms are episodic rather than chronic. Bacterial overgrowth is a waxing and waning thing. It isn't a chronic thing.
If bulborygmi are quite prominent alongside the bloating. Not just a bloated tummy, but it's noisy. I'm in a quiet room, Doc, and everyone turns around to look at me. Those are the two things that make me think about bacterial overgrowth much more. And then you ask me about the question about this kind of dustbin of a diagnosis. Oh, you're just saying it's IBS to get out of your room, doctor. And I absolutely hear that and I think. And maybe we'll talk about that a bit more and I'll pause that thought about how we communicate with patients.
[00:22:21] Speaker B: That's so helpful, what you just talked about, because one of the things that I was hoping that we could talk about more was thinking about that history taking, because careful history taking is going to be vital here. And you've just given us so many useful things that we can pick out and ask about. So obviously we've got the symptoms that we need to try and elicit, but we can also pick out some of those differentiating questions that you've just given us. So that's really, really helpful.
[00:22:45] Speaker A: Do you have any other sort of.
[00:22:47] Speaker B: Useful differentiating questions that you sometimes ask people when you're approached by a patient with possible ibs?
[00:22:54] Speaker C: So thanks for that. I mean, beyond those details of the bowel type I mentioned, I often then will ask them about their sort of drug consumption terms of laxatives. I think it's surprising to me. Maybe this is working in London and it's different for listeners who are not in a metropolitan setting. The prevalence of drug misuse, I don't mean just prescribed drugs, but the sort of more casual use of recreational drugs. And all of these have the simple mimetics, the cocaine and all that have a very profound constipating effect, the effect of cannabinoids in terms of upper GI symptoms, but also lower GI in terms of both constipation. So getting a history on that in exploring it in as gentle a way as possible. So using the word drugs in its wider sense is a way of I often get into patients and, and sometimes I say, oh, I don't use any drugs, doctor or oh, what do you mean? And if somebody says to me what do I mean? And I say about drugs? I say, oh, I say there's a whole range of drugs, isn't there? There's a prescribed drugs and sometimes there's things we're exposed to in the community and so on. So I think I would say, and maybe this is experience of somebody in a tertiary center probably A third of patients I see have got a significant contribution from a drug history. Not necessarily the sole cause, but it's certainly a part of it.
In terms of the other bits around differentiation I haven't talked about, and I tend to avoid talking about, except in very rare cases, things around past personal life. So traumatic histories in their childhood or any of those, because although they are actually more present, it's often a bit of a hornet's nest that's set up, which you can't necessarily deal with. You know, CAM services are so stretched that often asking about these things, they're not having anywhere to go, is the worst thing you can do. So it may well be a comorbidity if the patient raises it. I'm sure it's always. It's normal to be empathic and understand it and explore that, but do I ever explore it myself? I'd almost say that's something I'd like to say. I don't even. That's as a tertiary specialist with the access to good psychological support in my unit. So I'm wary about that. It isn't diagnostically a clue. It doesn't say, oh, because you've had that experience, that means you are definitely an IBS patient. Because we know lots of people who have those experiences don't go on to get stuff. And lots of people with organic disease have had those experiences. So there's some negative things I've said there along the positive signs of our history taking, but I hope that's of some value as well in the formulation.
[00:25:22] Speaker A: Yeah, no, very helpful.
[00:25:25] Speaker B: And I'm sure that quite a lot of diagnoses are made in primary care, but we also know that a lot of patients with IBS or with IBS type symptoms will end up in secondary care outpatient clinics.
[00:25:37] Speaker C: Yes.
[00:25:39] Speaker B: With your secondary care hat on.
[00:25:40] Speaker A: Do you have any learnings from that?
[00:25:42] Speaker B: Anything that you've learned about the sort of patients that you see sort of common pitfalls that maybe you could sort of relay to our primary care colleagues who are listening things that you've noticed over your time working in secondary care and receiving these patients, as it were, and seeing them?
[00:26:00] Speaker C: It's a trick. This is probably a question I was dreading in some ways most. But I'm glad we have a chance to ask it because I think it's one where I can't give you a simple glib answer, like a glib but a simple evidence based answer. My impression is that a lot of these patients come in through the endoscopy route. So Patients who've coming along for either a first or more often a second or third procedure because symptoms have marginally changed or they've persisted in a way that somebody's worried or they're seeing a different person in primary care who didn't necessarily have all the information available to them because of our IT or whatever. And so they end up being seen in having a negative endoscopy of upper or lower sort, then being said, oh well, you know, I've been senior before, I'll send you to the clinic. So I think there's that routine and then how do we tackle that? I think, I don't know, I guess naive. I hope that system working, moving to ICSS would allow this amongst people in the vanguard areas in which we actually integrated care. I think that's probably a slightly naive pipe dream of mine because it's so the pressures on the system are so great at creating a pathway which avoids, minimizes. That is going to be hard. But I think that minimizing second and third endoscopies or CT scans is a helpful thing.
I think there is that element that you colleagues in primary care experience way more than we do in secondary tertiary care where I'm based. It's that the patients who are incredibly persistent, who are where there's multiple other problems in their lives and they'll present this and it almost becomes, I can understand having lots of friends and relatives in how it becomes easy to think, oh, okay, yeah, okay, that has changed a bit. Let's put you through this pathway again or let's send you up. So my belief, and this is not intended to sound patronizing, my apologies if it is, is that the quality of diagnosis made in primary care is unbelievably sound. Most of the patients who end up in secondary care, the additional benefit that they get from us is vanishingly small, especially if we just regard it as a. Oh, well, I'll put you through the investigation route once again. Yeah, it's all normal. Here's a diet sheet or here's. Here's a website with psychological help. Goodbye, don't come back. So I don't think we do a good job in secondary care with these patients. In the main there are honorable exceptional units, but mostly they get come in, they get come. And so if you ask me the question, the reason I dreaded the question is because I come across as being patronizing. But I think the quality of diagnosis that's made is high. And I've worked also, I should say, in other countries, I've Worked in the States for a while, I've worked in France for a while. And it's the quality of what we get in with functional labels is much higher in the uk.
The challenges of those patients who do end up are often the ones who have greatest other challenge, the other social or psychological morbidity or other diseases, fibromyalgia or chronic fatigue, where that burden is super additive. And hospital care tends to just abandon those patients, say, well, go and see a rheumatologist, go and see a gynecologist. And in primary care that's even harder because you've got even less access to those colleagues. I think there is that group of patients which, you know, functional medical symptoms or whatever you want to call it.
But I think that that's the heartache part of things. I don't think I would ever want to be sitting in front of GP saying, oh, well, you could do better by not sending these to us because I think I recognize the pressures that attend before somebody comes to us.
[00:29:33] Speaker A: Last part of the podcast is just.
[00:29:35] Speaker B: About how do we communicate the diagnosis to patients? We know that it's really important that they are on board with and understand their diagnosis.
[00:29:45] Speaker A: So how do you approach that?
[00:29:46] Speaker B: How do you explain to patients? Can you give us some tips?
[00:29:51] Speaker C: Thank you. So I alluded to, but didn't go into detail consciously when you were saying patients often leave a room feeling, oh, I've just been given the same old, same old diagnosis. So what I will do and again bear in mind that I see patients at a certain end of the spectrum, but I think this holds the universe earlier in the spectrum is to say to patients, okay, so let me explain what this disease is. I know we hear a lot about ibs, and you probably got friends who said they got ibs, but let me try and explain to you what goes on with the disease. And I give them a kind of an explanatory module. I learned from Palli Hangan, who you may know is a professor of primary care in Northeast England and the value of that as a concept. And I've used that ever since. All diseases I look after, but giving somebody an explanatory model. So for ibs, I may talk about, you know, the nerve and the brain and the gut is being like a system of traffic lights. And sometimes the traffic lights get a bit out of sync or screwy or some roadworks put in. And when that happens, then traffic builds up behind it and then suddenly the lights go green, everything shoots through, but then out of control and then Suddenly everything has to go and halt again and a new lane and the M25 gets put in. I give analogies which I try to explain how the control system has gone wrong. And so without making it seem like here's a single target, like we have in inflammatory bowel disease or cancer or whatever, I tend to talk about here is the mechanism that's gone wrong as it implies it isn't usually a single traffic like it's a multiplicity of things that have happened in that. So therefore I can't cure this, you can't cure this, but what we can do is change how we manage this. So there's bits that you can do to help yourself and you may have already begun that process by looking at your diet and observing that it's worse with this and better with that. You may have observed that it's worse when you're during your cycle or just before. You may have observed that it's worse when you before your exams or when you're having an argument with your spouse. You try and link it to things that they've observed themselves or if they haven't then almost opening up doors for them to think oh, maybe I'll think of as a link next time.
So creating that idea of an explanatory model which doesn't just explain their symptoms and the pathophysiology, but also gives them a chance to understand how self management could help with this.
Not overstating self management, in other words, recognizing that there's a certain amount that they can do but that there is no evidence to support buying expensive at this stage, particular probiotics that if simple dietary things that they've experimented with haven't helped, including I generally would advise the kind of bsg, low fiber, low fat diet, low fodmap diets are very hard to adhere to long term because they're so restricted in what is available. But low fat, low fiber works just as well.
Having an go with those things, looking at the contribution from recognizing that you can't necessarily remove stress, but stress will be one thing that triggers it. Almost recognizing that and not therefore panicking about oh my God, my pain's bad, makes you more stressed, makes the situation whole reciprocating cycle trying to break that. So using that growth, so using the explanation of a mechanism to then segue into the options of self care, but not overstating that and then that then allows me to segue into the idea of psychological factors being of some importance in that and how much one wants to explore that and how much of that can be done by oneself and the limited availability of things we have elsewhere. But some of the mindfulness things undoubtedly help us. Two or three big trials now showing that some of the stuff on online hypnotherapy has been shown to be effective in a couple of big studies. So there's some of those things that can be done if people can engage with them.
And then, and only then do I ever mention drugs. And that's even for me working in a tertiary setting where patients are expecting to come in there and be given fecal transplants or, you know, electrical stimulation of their gut or something. And I mentioned drugs very much as the sort of the last of last lines of this, let alone all our weird research stuff, which I keep completely away from them by and large. So my, my point about telling that narrative is almost to say it's to tell a story rather than give them a diagnosis. So I hope I've brought you for a journey there. But to think of you as a patient. I was talking to you, but that's how I am with the patients basically tell the story of their causation, of what they can do to help the traffic and not drive at a busy time, of how they can recognize other things that are contributing to this. Keep using analogies. For me, that works. And then the backup help online or from doctors and drugs as a third line.
[00:34:32] Speaker B: That was really helpful model. And I really like the idea of thinking of these analogies to try to make it understandable for patients and then linking it with their social and psychological state and what's going on with them. I think that sounds really powerful and it allows you to, as you said, segue into some of those treatments which you want to be focusing on more than the medication side. I think that's a really nice model and really helpful. So it's certainly things I'm going to take away. And I always hear lots of different analogies about how to explain the cause of ibs. And that's a really helpful one. We are coming to the end, Anton, and this is the opportunity where I give you the opportunity just to sort of give us your take home messages, things that you'd really like our audience to leave today's discussion with the things.
[00:35:22] Speaker C: I guess I would be really invested in. I know this may sound the same old hat from a neurologist, but the detail of the history is really important in terms of the particular symptoms. The adjuvant information around their personal situation is worth collecting. But in that diagnostic phase, bear in mind that each time a patient comes to you, it's a new consultation. Yes, it's informed by their past, but they have new symptoms. You also have to press the reset button. And how to hold that tension between old information and new information is obviously one of the great skills in primary care, but for me, that's unbelievably important in functional disease, especially ibs. So holding that tension of what is the new symptom, specifically, what is it in terms of the kind of diarrhea, the timing of the diarrhea, any aspects of it which are concern, the constipation, is it more to do with evacuation, is it more to do with bloating, is it straining or gas? Or is it having to use a finger or take a funny position? Those things indicate whether this is more pelvic floor problem or a transit problem. So that investing the detail of that, of the symptoms for me is really the key message I would be obsessed about whilst keeping the antecedent stuff there.
Again, talking from my own personal experience, I would say thinking about contemporaneous drug use is kind of a big deal, which is often forgotten about, which is a contributor. So it almost helps explain people that, okay, you're not going to get better whilst this carries on, then it's your choice what you do with that information.
So that is important. And then trying to sort of counsel them through a story of the diagnosis rather than say, yeah, I've diagnosed you having ibs, that's a positive diagnosis. Here's a piece of paper which tells you what to do next. Because that, for a patient's point of view says, well, I've got a diagnosis. I don't really know what that means. I know everyone seems to have it and I know epidotic on a diet, but that isn't a cure and where does that leave me? So I think trying to tell that I keep using the word formulation and I'm a strong believer in that in consultation, that you take the patient's symptoms and translate that into a model of what they understand and then translate that into how that model helps treat them. So it gives them a sort of a couple of backup options.
That storytelling is what I'm obsessed about in all this. So listen to their history and then tell your story with it.
[00:37:44] Speaker B: Brilliant.
[00:37:45] Speaker A: Thank you so much.
[00:37:46] Speaker B: That is really helpful. Learning points. I've had a. I've really enjoyed talking to you and learning more about IBS and the diagnosis and exploring some of those challenges. I've got lots of little take homes from this, so And I'm sure that our audience will have taken huge amounts of really useful information from your. From this talk. You're a wealth of knowledge around ibs. So thank you so much for joining me. Thank you.
[00:38:07] Speaker C: All the very best, Charlie.
[00:38:09] Speaker A: Thank you very much. Well, that was a real tour de force from Anton there. I mean, he really knows his stuff about irritable bowel syndrome and really gave us a great discussion about lots of different topics. And we segued into lots of different areas, which I hope that you will have found really interesting and which I certainly felt really enhanced my understanding of irritable bowel syndrome diagnosis.
As with all of my episodes, I try and pull out a few key learning points, but there were so many there. It's very difficult to do that. But one of my key messages from earlier on in the episode was around pain, that this really is a pain syndrome and that you need to have the presence of pain in association with those symptoms, such as change to the bowel habit, in order to start to make that diagnosis of irritable bowel syndrome. My second take home was about having a real structure and taking a systematic approach to diagnosis. So really digging down to the details of the symptoms, going through your investigations in a careful and systematic way, and really only later, that's when you start considering the comorbid state and whether that may be having an impact on how the patient is presenting with symptoms. And really it feeds into that management that we were talking about. So the having a scheme for describing the condition to the patient in a way that they understand and that allows you to explore some of those comorbid factors such as anxiety and stress, that can feed into the symptoms of irritable bowel syndrome.
My final take home was around the negative predictive value of normal blood tests. That is, normal blood tests such as thyroid function tests, calcium celiac blood tests, all the tests that we're advised to do by the BSG guidelines, these have a very strong negative predictive value for organic disease and so can really help us to feel more confident in making a diagnosis of irritable bowel syndrome. And Anton quoted a number of 0.2 to 0.5% organic disease pickup in patients who have normal initial screening blood test for irritable bowel syndrome.
So that brings the episode to an end. I really hope that you've enjoyed it and learned something from this episode. Today I would really encourage you to have a look at the guidelines. The BSG have some fantastic guidelines around the diagnosis and management of irritable bowel syndrome. They're very clear and they have really helpful flowcharts in there, which we referred to during this episode. So I'd really encourage you to have a look at that and we'll make sure there's a link to that in our show. Notes As I mentioned before, this is part one of two episodes on irritable bowel syndrome. The second will be coming out in the next couple of months and that one's going to be looking at the management of irritable bowel syndrome. So we're going to take it to that next step, start looking at some of the evidence base behind some of the medications and dietary aspects that we can offer patients to help them with their symptoms.
So all that's left for me to say now is thank you so much for listening. I really hope you've enjoyed this episode. I certainly picked out some really useful things that are going to help me adapt and change some of my practice.
If you've enjoyed this episode, please check out some of our other episodes on the podcast. We have episodes coming up on pediatric gastrointestinal problems and as I said, a second episode on irritable bowel syndrome management. So lots of things to look forward to over the next few months. If you've enjoyed this episode, remember to click follow and then you'll get an update. Whenever we bring out a new episode, and if you want to, please do leave feedback for us. We always find it really helpful. Or you can visit the Primary Care Society for Gastroenterology website and get in touch with us if you have ideas about new episodes or there's anything else that you want to let us know about. Thank you very much.
