4 October 2017

Confidence key to earlier IBS diagnoses

Clinical Gastro

The medical system is failing sufferers of irritable bowel syndrome (IBS), and GPs should be encouraged to diagnose the condition more confidently to prevent patients from floundering in uncertainty and confusion.

That’s the picture painted by a narrative review in the Medical Journal of Australia which found delayed diagnosis, repeat consultations, over-investigation and unclear communication between doctors and with patients were rife.

“The condition does not appear to be generally well handled within the health care system, which leads to frustration and dissatisfaction in patients and doctors alike,” wrote the authors, Professor Jane Andrews, who heads the Inflammatory

Bowel Disease service of the Royal Adelaide Hospital, and Dr Ecushla Linedale (PhD), a clinical researcher at the RAH Department of Gastroenterology.

That IBS was traditionally a diagnosis of exclusion was a possible explanation, the authors said. But the publication of the Manning criteria – a six-point diagnostic algorithm that allows a positive diagnosis of IBS – meant this was no longer the case.

“We’ve come into a more positive diagnosis, and maybe some doctors or specialists are uncomfortable with that,” Dr Linedale said.

Some GPs still lacked confidence to definitively diagnose IBS themselves, she said. In her recently completed PhD, Dr Linedale studied referrals to RAH for functional gut disorder symptoms and found the majority of GPs were only looking for a second opinion or confirmation.

But she stressed that it was “not a GP problem, per se”, saying the health system didn’t afford GPs the time nor financial recompense required to get an IBS diagnosis and reassure patients.

“The gist of our article is that GPs can be confident that IBS is a safe and secure diagnosis, and they really do need to give the diagnosis rather than referring patients on,” Dr Linedale said.

Diagnosing IBS also requires patients to meet a time criteria of six months, meaning infection would likely have resolved and other pathology progressed, the authors said. After clinical alarms are excluded a physical examination, including a digital rectal examination, can often produce a firm diagnosis without the need for further tests.

Doctors should clearly tell patients if their collection of symptoms were indicative of IBS, explain the condition, and also explain that there were effective new treatments such as psychological therapy and the Low FODMAP Diet, “which do help a large proportion of patients”, Dr Linedale said. The review also suggested pharmacological treatment options including loperamide, antispasmodics and probiotics.

“We’re hoping with this article that by highlighting the issues, GPs and specialists can begin thinking about the way they communicate this diagnosis and perhaps address some of the uncertainty in the language they’re using.”

Dr Linedale also fingered specialists, saying the RAH letter study found gastroenterologists often used unclear diagnostic language – “possible that this patient might have IBS,” or “fits the pattern of IBS,” instead of clearly stating “this patient has IBS”.

“We were a bit surprised at the lack of clarity, because if GPs aren’t given a clear diagnosis it’s very difficult for patients to then own that diagnosis,” Dr Linedale said. “A clear diagnosis gives patients the option to progress straight to effective management.”

Professor Andrews criticised health officials for failing to subsidise the faecal calprotectin test, which she called “highly valuable”, as a negative result excludes inflammatory bowel disease and significantly favours an IBS diagnosis.

The test could preclude the need for more invasive and expensive investigations such as colonoscopy or scans, she said.

Professor Andrews, who has been campaigning for the test to be funded in her capacity as a member of the board of the Gastreoentological Society of Australia, said after four years of consideration, MSAC had still not reached a decision. “I’ve found the whole process incredibly frustrating,” she said.

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