Irritable Bowel Syndrome: Management

A 28-year-old woman is diagnosed with constipation predominant irritable bowel syndrome. She occasionally experiences spasms of pain in the left iliac fossa.
Which one of the following is LEAST likely to help her symptoms?
A. Mebeverine
B. Ispaghula
C. Methylcellulose
D. Sterculia
E. Lactulose

Answer:
E. Lactulose

Discussion: NICE recommend avoiding lactulose in the management of IBS

The management of irritable bowel syndrome (IBS) is often difficult and varies considerably between patients.

NICE issued guidelines in 2008

First-line pharmacological treatment - according to predominant symptom 
 pain: antispasmodic agents
 constipation: laxatives but avoid lactulose
 diarrhoea: loperamide is first-line

Second-line pharmacological treatment 
 low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin re uptake inhibitors.

Other management options 
 psychological interventions - if symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS), consider referring for cognitive behavioural therapy, hypnotherapy or psychological therapy
 complementary and alternative medicines: 'do not encourage use of acupuncture or reflexology for the treatment of IBS'

General dietary advice 
 have regular meals and take time to eat
 avoid missing meals or leaving long gaps between eating
 drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas
 restrict tea and coffee to 3 cups per day
 reduce intake of alcohol and fizzy drinks
 consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
 reduce intake of 'resistant starch' often found in processed foods
 limit fresh fruit to 3 portions per day
 for diarrhoea, avoid sorbitol
 for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).