management of irritable bowel syndrome

Appropriate management of irritable bowel syndrome (IBS) involves a combination of lifestyle, dietary, pharmacological, and psychological approaches tailored to the individual's symptoms.

• Initial management: Provide information emphasizing self-help, including general lifestyle advice, physical activity encouragement, and dietary modifications such as regular meals, adequate fluid intake (at least 8 cups/day), limiting caffeine to 3 cups/day, reducing alcohol and fizzy drinks, and adjusting fibre intake by reducing insoluble fibre and considering soluble fibre like ispaghula powder or oats ¹.
• Dietary advice: Avoid sorbitol-containing products in diarrhoea-predominant IBS; consider oats and linseeds for bloating; and if symptoms persist, offer further dietary management such as low FODMAP diet under expert supervision ¹.
• Pharmacological treatment: Use antispasmodics as needed for pain; laxatives (excluding lactulose) for constipation; loperamide as first-line for diarrhoea; titrate doses to achieve soft, well-formed stools (Bristol Stool Form Scale type 4) ¹. Consider linaclotide for chronic constipation unresponsive to laxatives after 12 months ¹.
• Second-line pharmacotherapy: Consider low-dose tricyclic antidepressants (5–10 mg at night, up to 30 mg) if symptoms persist despite initial treatments; SSRIs may be considered if TCAs are ineffective, with informed consent and monitoring for side effects ¹.
• Psychological interventions: For refractory IBS (symptoms persisting >12 months despite pharmacological treatment), consider referral for cognitive behavioural therapy, hypnotherapy, or psychological therapy ¹.
• Follow-up: Agree on follow-up based on symptom response; monitor for any new 'red flag' symptoms requiring further investigation or referral ¹.
• Complementary therapies: Avoid acupuncture, reflexology, and aloe vera as treatments for IBS ¹.