The new ‘Controversies In…’ series for the Frontline Gastroenterology Twitter debates addressed the difficult area of functional gastrointestinal disorders, facilitated by the former editor-in-chief Anton Emmanuel. Key topics discussed included distinguishing functional dyspepsia from genuine gastroparesis, when we should investigate for bile acid malabsorption, the current treatments for constipation-predominant irritable bowel syndrome and, importantly, how to manage consultations with complex patients presenting with functional bowel disease. The debate generated over a million impressions on twitter and this article aims to summarise the key educational points from the event.
- functional bowel disorder
- irritable bowel syndrome
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As part of our re-launch of the #FGdebate, we were joined by our previous editor-in-chief Anton Emmanuel to answer your questions and discuss challenging aspects of managing functional gastrointestinal disorders (FGIDs). This article will summarise the main points covered in the event, which generated widespread engagement and over a million impressions on Twitter.
Are diagnostic tests for gastroparesis clinically useful and how should they be interpreted?
The discussion opened with evaluating the utility of available tests for gastroparesis. A major point to come through was the poor discrimination in current diagnostic tests between gastroparesis and functional dyspepsia (FD). Approximately, 25%–35% of patients with FD will have some delayed gastric emptying,1 but this alone is insufficient to label as gastroparesis. Therefore, tests such as gastric emptying scintography should be used judiciously, focused on patients with comorbidities relaying increased risk of gastroparesis such as diabetes, previous abdominal surgery and chronic opioid use.
How do we manage a consultation with a frustrated patient who has already tried multiple treatments without success?
It was clear from the contributions that clinicians find it challenging knowing how to manage and structure consultations for patients with FGIDs. It was recommended that 30 min is a minimum requirement for new patient consultations, in which listening to the patient’s story is of paramount importance. Communication should involve an honest discussion about prognosis and managing expectations about the lack of ‘magic bullet’ cures. Care should be taken over ordering excessive tests, which have often already been done in the past, as this can perpetuate a false sense of hope about treatment goals and delay positive steps towards managing symptoms.
However, it was emphasised that much can be gained by explaining the rationale for treatments clearly and revisiting previously ‘failed’ treatments that may not have been administered properly. A good example of this was the use of neuromodulators, which have a strong evidence base when dosed appropriately and given in the right combinations.2 Cognitive behavioural therapy and hypnotherapy also have a good evidence base (box 1).3–5
Managing a difficult consultation
Patient concern: ‘None of the treatments work because they’re for people with mental illness’.
Reframe understanding: ‘They are centrally acting analgesics used at lower doses than psychiatrists with few side effects’.
Be familiar with available drug indications, doses, side effects and combinations, and non-pharmacological treatments (eg, cognitive behavioural therapy, hypnotherapy).
Adapted from Sperber & Drossman AP&T 2011
All agreed that a clinical psychologist is a vital resource in a specialist functional bowel disorder (FBD) clinic, but availability is scarce due to funding restrictions.
Is small intestinal bacterial overgrowth under-diagnosed?
There was strong disagreement with data from some studies suggesting a high prevalence of small intestine bacterial growth in IBS-D, due to the limitations of hydrogen breath testing. The general view was that diagnosis should only be considered in at-risk groups such as scleroderma, previous abdominal surgery and jejunal diverticulosis.
Should we investigate patients with irritable bowel syndrome with diarrhoea for bile acid diarrhoea?
Bile acid diarrhoea is present is about a third of patients with irritable bowel syndrome with diarrhoea (IBS-D), and eminently treatable with sequestrants (eg, questran and colesevelam). Symptoms that point to this as an underlying cause include profuse watery diarrhoea, urgency and nocturnal symptoms, ±bloating. It is some clinician’s practice to treat empirically but confirming the diagnosis with a 75-selenium homocholic acid taurine (SeHCAT) scan was encouraged as patients find the treatment difficult to tolerate, and it can interfere with the absorption of other medications and fat-soluble vitamins.
What are the recommended treatments for IBS-D?
Once the diagnosis is confirmed and alternative causes of chronic diarrhoea have been excluded, the first-line treatment is loperamide, which can most easily be gently titrated using the syrup preparation to avoid excessive swings to constipation. There are four drugs that show small but significant improvements in IBS-D based on Food and Drug Administration (FDA) trial endpoints (alosetron, ramosetron, eluxadoline and rifaximin), although none are available currently in the UK. For patients with pain and bloating as part of the IBS-D symptom complex, a low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet may be beneficial, although this needs proper dietitian support to assist in structured reintroduction of food groups. A careful history (absence of pain temporally associated with altered bowel function) and examination (presence of paradoxical puborectalis contraction on attempted voiding) should eliminate the concern that the diarrhoea is related to IBS with constipation (IBS-C) or overflow from idiopathic constipation.
Are there options for patients with IBS-C refractory to linaclotide?
Forest plot data show significant benefit of five drugs verses placebo for IBS-C based on FDA trial endpoints (linaclotide, tenapanor, lubiprostone and plecanatide), but the effect size is smaller than for hypnotherapy6 and only linaclotide is available in the UK. Linaclotide and lubiprostone are agents acting on intestinal chloride channels and are more specific agents than laxatives. Prucalopride can be an effective agent and can overcome the constipating effect of low dose tricyclic antidepressents. For severely refractory patients, there is benefit to stopping all treatments and reassessing using a focused symptom-based approach.
Should we be funding more clinical trials in IBS?
Clinical trials are not the only answer in improving the management in IBS, mainly because trial populations in tertiary centres are very different from the vast majority who are only seen in primary care. Of all patients with IBS, only 20% will consult a general practitioner (GP), and 3% will end up in specialist centres. Conversely, tertiary centre patients make up 85% of clinical trial cohorts. Therefore, data obtained from such studies may not be applicable to the unseen majority in the community.
One example cited of useful clinical trials in IBS was debunking the myth that it is an inflammatory condition, through two large trials showing no improvement with 5-aminosalicylic acid (5-ASAs).7 8
Is there a role for faecal microbiota transplantation in functional bowel disease?
IBS is a multifactorial disease and a gut dysbiosis might contribute to the severity of symptoms. Could faecal microbiota transplantation (FMT) have a positive effect in patients with IBS? To date, there is no good evidence that altering the gut microbiota is enough to obtain clinical improvement in IBS. There is one borderline positive randomised controlled trial on patients with moderate to severe IBS published in Lancet9 and another one by a Danish group published in Gut showing placebo arm had significantly greater improvement in IBS than treatment with FMT capsules.10 Let us watch this space, as various larger trials are ongoing. In the meantime, we should advise patients to avoid unregulated homemade faecal microbiota transplants.
Standard dietary advice or low FODMAP diet?
Low in FODMAPs diet is increasingly recommended for patients with IBS. Up to third of patients suffering from pain and bloating will benefit from it. There is no value of low FODMAPs for IBS-C. The limitation of microbiota diversity, short-chain fatty acids with low FODMAP is a worry.11 12 Many patients referred to the specialist clinics have already tried low FODMAP diet and there is no good data to support a second attempt, although the quality of low FODMAP diet patients follow at home can be questionable as this is often based on the information found on internet rather than robust dietary recommendations given by a gastrointestinal dietitian. The UK National Institute for Health and Clinical Excellence guideline recommends standard dietary advice in management of IBS. A study conducted by the Nutritional Sciences Division King’s College in London showed that low FODMAP diet appears to be more effective than standard dietary advice for symptom control in IBS.13
Contributors JBM, MW and AE wrote the manuscript and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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