Introduction
Irritable bowel syndrome (IBS) is a highly prevalent disorder. According to Rome IV, the diagnosis relies on the presence of abdominal pain in association with a change in stool consistency or frequency. Guidelines recommend minimal testing to exclude other diseases, while advising on therapeutic options. However, the actual application of these guidelines into practice needs confirmation.
Aims & Methods
This study aims to assess the management of IBS by general practitioners (GP) and gastro-enterologists (GE) in their daily practice. Methods: Belgian GP and GE completed an online vignette-based survey between January and July 2022. Apart from data about years of experience, participants indicated their preferred diagnostic modality or therapeutic option for eight cases of diarrhoea-predominant IBS. Cases varied in age (25, 48 and 65 years), cardinal symptom (pain, discomfort, or diarrhoea) and availability of test results (none, limited to biochemistry and ultrasound, or extensive including endoscopy), while stressing out the prolonged duration of the symptoms and the absence of red flags. Frequencies were compared by Chi-square. The main determinants to the diagnosis of IBS were assessed by logistic regression.
Results
Sixty-four gastroenterologists and 31 general practitioners completed the survey. When considering pain and discomfort as cardinal symptoms in a young patient, 87.4% and 84.1% of participants diagnosed IBS, which decreased to 58.3% with diarrhoea. The diagnosis of IBS dropped to 26.8% for a patient of 65 years. In those cases, GP less frequently diagnosed IBS (all p<0.05), except with diarrhoea as cardinal symptom (p=0.78). According to logistic regression, diagnosing IBS was related to patient age, cardinal symptom, availability of prior test results and specialty, and only borderline related to the experience of the practitioner (p<.001, R²=.293). Even when diagnosing IBS, 89.5% ordered one or more additional tests (77.9% biochemistry, 59.3% stool culture and parasites, 60.5% faecal occult blood testing, 17.4% breath testing, 12.8% imaging, 9.3% endoscopy). Upon normal results, 57% would not order further investigations. Both GP and GE opted for spasmolytics (62.3%) and dietary interventions (28.3%) as the preferred first-line treatment for IBS. Second-line treatment consisted of referral to a specialist or colleague (19.4%), dietary intervention (22.6%), neuromodulators (19.4%) and spasmolytics (14.5%). In second-line, GP favoured referral (61.1%) and dietary intervention (22.2%), while GE preferred neuromodulators (27.3%) and spasmolytics (18.2%). No GP initiated modulators. Similar figures were obtained in third-line.
Conclusion
In Belgium, abdominal pain or discomfort are equivalent cardinal symptoms when diagnosing IBS. Diarrhoea as cardinal symptom, older age and absence of prior testing lowered the preference for IBS, especially in GPs. Even when diagnosing IBS, healthcare providers order a large variety of tests. Spasmolytics and dietary interventions are favoured in first-line. Upon failure, only GE prescribe neuromodulators, while GP opt for referral. Future education of GP and GE should focus on harmonising the diagnostic approach and medical treatment of IBS with existing guidelines.
Disclosure
Consultancy for Truvion Healthcare
