On World Irritable Bowel Syndrome (IBS) Day (April 19), and in accordance with IBS Awareness Month, we spoke with Dr Kevin Barrett, general practitioner in Rickmansworth, Hertfordshire, UK, and primary care commissioner as well as chair of the Primary Care Society of Gastroenterology. He was the Royal College of General Practitioners (RCGP) and Crohn’s and Colitis UK lead clinical champion for the 2017–2020 Inflammatory Bowel Disease Spotlight Project.
Please tell us more about irritable bowel syndrome (IBS) and its causes. What distinguishes it from inflammatory bowel disease (IBD), and why shouldn’t these two be confused with another?
Irritable bowel syndrome is a functional bowel disorder which means there is no (as yet) identifiable pathology. It is common and affects up to 1 in 10 of the population. IBS can usually be divided into diarrhoea-predominant (IBS-D), constipation-predominant (IBS-C) or mixed, and it is likely to be a cluster of conditions with similar symptoms rather than one disease entity alone. Inflammatory bowel disease is an uncommon (approximately 1 in 140 people) multi-system inflammatory disease that appears to be triggered by a combination of genetic susceptibility and an unidentified environmental trigger. IBD follows a relapsing-remitting course and can affect the skin, eyes, joints and liver as well as the bowel. Crohn’s disease and ulcerative colitis are the two main subtypes of IBD. Neither IBD or IBS have a known cure but there are treatments that can help both diseases. It is important to make a correct diagnosis as the symptoms can also overlap with colorectal cancer, ovarian cancer, endometriosis, coeliac disease, microscopic colitis and other pelvic or gastrointestinal conditions.
Which modes of treatment are available for IBS?
Lifestyle change is the cornerstone of treatment for IBS wherever possible. Relaxation and finding ways to de-stress are important. Eating regularly and avoiding known trigger foods are a good starting point. Reducing fibre intake (while still aiming to achieve the recommended 30 g/day for adults) can make a difference. Dieticians may be available to help, particularly when guiding patients through the low-FODMAP elimination and re-introduction pathway. Antispasmodic medications can be of benefit, and medication for constipation or diarrhoea can help. Sometimes antidepressant medications are used as the gut has similar receptors to those in the brain, and psychological therapies such as cognitive behavioural therapy (CBT) can have high success rates.
From your experience, what are the do’s and don’ts when dealing with patients suffering from IBS?
The key is not to assume that there is a one-size-fits-all approach or to promise that the first treatment one recommends will work. A trial-and-error approach is needed, and it is important to explain that some patients’ symptoms have different triggers, hence the reason for having a wide range of therapies available to use. Building trust and a positive rapport is important. It is, however, vital that enough investigations are undertaken to exclude other pathology, and to review new symptoms that develop, as patients may have more than one gastrointestinal disease.
In your opinion, what can patients with IBS do themselves to alleviate their symptoms, to possibly change their lifestyle, and to improve their quality of life? Where can they find help?
There are a great deal of myths about IBS and an enormous number of diet books and internet articles about IBS which shows that many patients are affected and that they may have lost faith in traditional medical therapies. In order to maintain trust, it is important to signpost patients to reputable sources of information such as The IBS Network. Talking to others about their symptoms is important as IBS can cause anxiety in social situations and affect work, relationships and social lives.
How has the current Covid-19 pandemic made an impact on your work as a doctor? From your point of view, how has it changed the lives of your patients since last year?
Covid-19 has had an impact on all our lives; immunosuppressed patients with IBD have had to shield and had stricter restrictions on their lives than the majority, stress for all has been higher and this has led, unsurprisingly, to an increase in IBS-type symptoms. Many patients have been reluctant to seek health advice for worrying symptoms because of the fear of contracting Covid-19 from healthcare environments, and the change to a remotely delivered healthcare service has widened the divide between the IT-savvy and those unable to access technology. Endoscopy waiting times have soared and there has been an increase in the proportion of cases of colorectal cancer detected at a late stage. It’s not all bad news though; there are signs of greater collaboration between primary and secondary care which can only be a good thing for patients.
On a personal note, what made you want to become a gastroenterologist and/or general practitioner when starting your career?
When I went to medical school I wasn’t sure what kind of doctor I wanted to be. I was attracted to general practice because of the variety and the ability to look after patients over decades. Gastroenterology was something I was exposed to at an early stage of medical school, and it has cropped up time and time again over my career. I also like to champion the underdog, and gastroenterology doesn’t get the interest or funding like the glamorous specialities of cardiology or diabetes, but we have all known the impact the gastrointestinal symptoms can have on our lives.
Dr Barrett, many thanks for the interview!