A very mumsnet question- apologies

Blaendulais

strtdv said:

The above advice is wrong. Colonoscopy is unnecessary in the majority of cases in your age group. It's not your GP "fobbing you off", it's them not sending you for an unnecessary procedure which has a 1 in 800 chance of perforating your colon.

A 35 year old male needs a decent history taken, a physical examination and a couple of blood tests unless there are particular alarm symptoms. As I've said, IBS isn't a diagnosis of exclusion, it has clear diagnostic criteria.

If your symptoms or the blood tests suggest something other than IBS then it's reasonable to have a look at your colon but to go straight in with a scope would be unwise and unnecessary.

Are you a medic? If you are you should be ashamed of the nonsense you have written. A blood test is useless here what on earth would it show - ignorance

MattBanshee

I had what I thought was IBS, but turned out to be entirely lactose-related. Try cutting out dairy completely?

bbill335

strtdv said:

The above advice is wrong. Colonoscopy is unnecessary in the majority of cases in your age group. It's not your GP "fobbing you off", it's them not sending you for an unnecessary procedure which has a 1 in 800 chance of perforating your colon.

A 35 year old male needs a decent history taken, a physical examination and a couple of blood tests unless there are particular alarm symptoms. As I've said, IBS isn't a diagnosis of exclusion, it has clear diagnostic criteria.

If your symptoms or the blood tests suggest something other than IBS then it's reasonable to have a look at your colon but to go straight in with a scope would be unwise and unnecessary.

I'm sorry, but this is a dangerous thing to say. Endoscopic examination is vital in forming an accurate diagnosis of bowel problems because of so many different ailments (with different treatments) presenting in similar ways.

By this reasoning, you shouldn't drive anywhere because there's a chance you'll crash and die. Don't leave the house because you might get stabbed by a madman. Ignore the blood pouring from your bum hole because a colonoscopy might perforate your bowel.

Philly_Q

A lot of quite contradictory and strongly-expressed opinions in the last few posts.  I think a couple of you should be clarifying if you are doctors or medically trained.

bbill335

Philly_Q said:

A lot of quite contradictory and strongly-expressed opinions in the last few posts.  I think a couple of you should be clarifying if you are doctors or medically trained.

I'm no medical professional, but I am an experienced patient. I've had several endoscopies, more than I care to remember. None have been remotely pleasant and there is a recovery period. Don't always expect to go back to work the afternoon after, but you might be fine. There is a risk but the best way to solve the mystery of what's been going on in my guts has been to have a good old fashioned look with a camera. They can take biopsies to analyse what's going on in the tissue. There's no getting around the fact that it will give the most detailed picture as to what's going on. To scare away someone who could need one, who would have to consent to the procedure, is to potentially jeopardise their diagnosis.

merlin

Stop eating gluten, ALL gluten. That worked for me. 
If your guts don't clear up after a week or two then remove lactose, eggs, alcohol, all nightshades (aubergine, tomatoes, peppers, chillies and potatoes), tea, coffee, chocolate from you diet. 

If it clears up then add one item back at a time. It's more than likely to be gluten, lactose and eggs....but try them all. 

Plukky

What's you weight like?
My "IBS" disappeared when I lost 3 stone.

ThorpyFX

Plukky said:

What's you weight like?
My "IBS" disappeared when I lost 3 stone.

overweight at the moment......

ennspek

ThorpyFX said:

Plukky said:

What's you weight like?
My "IBS" disappeared when I lost 3 stone.

overweight at the moment......

But look dreamy!

Hope you get it sorted mate.

strtdv

Blaendulais said:

Are you a medic? If you are you should be ashamed of the nonsense you have written. A blood test is useless here what on earth would it show - ignorance

I am indeed.

A blood test is the initial investigation of choice for coeliac disease (anti Transglutaminase, Endomysial, and Gliadin Antibodies), which is the most common "organic" cause of abdominal symptoms in a 35 year old male.
In a female you'd consider doing an ultrasound pelvis and a Ca125 blood test to look for ovarian cancer, but that clearly isn't needed here.
A blood test will also tell you if an inflammatory bowel condition is likely too, as CRP and ESR are likely to be elevated. In combination with a faecal test called Calprotectin, you can basically exclude an inflammatory bowel problem without going anywhere near an endoscope.
You would also routinely do a blood count and iron profile to make sure the patient wasn't iron deficient (as this would be an indication for both gastroscopy and colonoscopy)
Helicobacter is common, and can be diagnosed on Gastroscopy, but that's the top end, not the bottom, and a simple breath test is as effective.

I'm not saying that a colonoscopy isn't ever necessary, but if someone in their 30's presents with IBS symptoms and has a negative coeliac screen and a couple of other routine blood tests, and no immediate family history of bowel cancer, then invasive investigation simply isn't indicated. There are clear guidelines from the British Society of Gastroenterologists to this effect.

Telling someone they're being "fobbed off" by their GP because they're not referring them straight for endoscopy isn't helpful.
The GP may take a history and blood tests and then feel that the referral is warranted, and that's nothing to be alarmed at either, as the vast majority of causes of this sort of problem in this age group are benign, but going in with the expectation that you need a colonoscopy and everything else is second rate care is nonsense (and part of the reason the NHS wastes so much money on pointless investigations).

Grunfeld

strtdv said:

...As I've said, IBS isn't a diagnosis of exclusion, it has clear diagnostic criteria.

@strtdv ; Here's a genuine question:  I get that IBS has clear diagnostic criteria but my understanding -- and this is not my speciality -- was that the pathology and aetiology of IBS was still obscure and therefore diagnosis was a bit of a dustbin after confirming symptoms and signs x, y, and z, and excluding other causes.

Any clarification totally appreciated.

TimmyO

ThorpyFX said:

Does anyone here suffer from IBS? If so, how did it start and how do you stop it?

its really starting to annoy me! 

This is a very weak Mumsnet question - try something more along the lines of "I've been fucking my husbands friend on and off, this is totally all down to him right? Validate me hun" 

ThorpyFX

TimmyO said:

ThorpyFX said:

Does anyone here suffer from IBS? If so, how did it start and how do you stop it?

its really starting to annoy me! 

This is a very weak Mumsnet question - try something more along the lines of "I've been fucking my husbands friend on and off, this is totally all down to him right? Validate me hun" 

Yeah, apologies I've really let myself down! 

Blaendulais

strtdv said:

Blaendulais said:

Are you a medic? If you are you should be ashamed of the nonsense you have written. A blood test is useless here what on earth would it show - ignorance

I am indeed.

A blood test is the initial investigation of choice for coeliac disease (anti Transglutaminase, Endomysial, and Gliadin Antibodies), which is the most common "organic" cause of abdominal symptoms in a 35 year old male.
In a female you'd consider doing an ultrasound pelvis and a Ca125 blood test to look for ovarian cancer, but that clearly isn't needed here.
A blood test will also tell you if an inflammatory bowel condition is likely too, as CRP and ESR are likely to be elevated. In combination with a faecal test called Calprotectin, you can basically exclude an inflammatory bowel problem without going anywhere near an endoscope.
You would also routinely do a blood count and iron profile to make sure the patient wasn't iron deficient (as this would be an indication for both gastroscopy and colonoscopy)
Helicobacter is common, and can be diagnosed on Gastroscopy, but that's the top end, not the bottom, and a simple breath test is as effective.

I'm not saying that a colonoscopy isn't ever necessary, but if someone in their 30's presents with IBS symptoms and has a negative coeliac screen and a couple of other routine blood tests, and no immediate family history of bowel cancer, then invasive investigation simply isn't indicated. There are clear guidelines from the British Society of Gastroenterologists to this effect.

Telling someone they're being "fobbed off" by their GP because they're not referring them straight for endoscopy isn't helpful.
The GP may take a history and blood tests and then feel that the referral is warranted, and that's nothing to be alarmed at either, as the vast majority of causes of this sort of problem in this age group are benign, but going in with the expectation that you need a colonoscopy and everything else is second rate care is nonsense (and part of the reason the NHS wastes so much money on pointless investigations).

So am I chief. Fobbed off is what I have seen as a Consultant many time. Indeed I have family experience of my Dad being fobbed off by GPs with clear cancer of the skin and clear Inflammatory Bowel.

Risk management and Governance within General Practice in the UK is not well developed

I'd think before you treat someone as a simpleton.

As you know and I do seeing many cases of sepsis and Inflammation CRP WCC and CRP can be absolutely normal

By the way the commonest cause of organic abdominal symptoms in a 35 year old is constipation.  Many many more times so than Coeliac

strtdv

Grunfeld said:

strtdv said:

...As I've said, IBS isn't a diagnosis of exclusion, it has clear diagnostic criteria.

@strtdv ;;;; Here's a genuine question:  I get that IBS has clear diagnostic criteria but my understanding -- and this is not my speciality -- was that the pathology and aetiology of IBS was still obscure and therefore diagnosis was a bit of a dustbin after confirming symptoms and signs x, y, and z, and excluding other causes.

Any clarification totally appreciated.

This certainly was widely regarded to be true, and care still needs to be exercised when diagnosing IBS as the last thing you want to do is miss something like an ovarian cancer, which often presents with bloating as the only symptom.
However, a modified version of the Rome criteria is now widely used among gastroenterologists, and is slowly making its way into GP land, and IBS is very much not a diagnosis of exclusion. You simply need to do a couple of basic tests to exclude a couple of things, rather than an exhaustive list of investigations, provided the patient meets certain inclusion criteria (under the age of 50 for a start).

The caveat is that there are a variety of "red flag" symptoms which would warrant further investigation, which is why a doctor taking a good history is so important. IBS for instance generally doesn't cause weight loss, so if this is present it would usually warrant further investigation. Similarly, tropical sprue can present with very similar symptoms so a travel history is relevant.

You are quite correct though in saying that the pathology and aetiology is still obscure. I suspect that in the next 20 years or so, so called "functional" disorders will become better understood and treatments specifically for them will be developed, as the current method of trying to treat individual symptoms is obviously frustrating for patients.
At the moment the trend is to divide IBS into constipation predominant and diarrhoea predominant.
The diarrhoea predominant tends to be investigated more as there's a higher index of suspicion for inflammatory bowel disease, although I suspect in future the faecal calprotectin stool test (basically a stool test for evidence of bowel inflammation, it's found in neutrophil white blood cells) will further reduce the number of invasive investigations.

strtdv

@Blaendulais my comment was not aimed at you in particular, no offence was intended. This is a general forum made up predominantly of non-healthcare professionals, so I was trying to stick to general terms and avoid too much jargon. 

I'm sorry for whatever experience you had with your dad.

You are quite right, risk management and governance in general practice can be very hit and miss, and I agree that if you feel you are being fobbed off by your GP then a second opinion either in the form of a GP you trust, or a Gastroenterology referral are absolutely the way to go.

However, I stand by what I have said regarding the place of colonoscopy in the investigation of IBS, and I believe there is both evidence and guidelines to back what I have said in that regard.

Blaendulais

strtdv said:

@Blaendulais my comment was not aimed at you in particular, no offence was intended. This is a general forum made up predominantly of non-healthcare professionals, so I was trying to stick to general terms and avoid too much jargon. 

I'm sorry for whatever experience you had with your dad.

You are quite right, risk management and governance in general practice can be very hit and miss, and I agree that if you feel you are being fobbed off by your GP then a second opinion either in the form of a GP you trust, or a Gastroenterology referral are absolutely the way to go.

However, I stand by what I have said regarding the place of colonoscopy in the investigation of IBS, and I believe there is both evidence and guidelines to back what I have said in that regard.

No worries! 

Grunfeld

strtdv said:

....IBS is very much not a diagnosis of exclusion. You simply need to do a couple of basic tests to exclude a couple of things, rather than an exhaustive list of investigations....

You are quite correct though in saying that the pathology and aetiology is still obscure. I suspect that in the next 20 years or so, so called "functional" disorders will become better understood and treatments specifically for them will be developed, as the current method of trying to treat individual symptoms is obviously frustrating for patients.

Cheers!  I hear what you’re saying, I misunderstood you initially because of different assumptions packed into our everyday work-related use of “exclusion”:  a doctor’s exclusion of certain diagnoses naturally assumes the option of ordering tests and procedures, which may not be without some risk and distress, therefore you wouldn’t want to request any unnecessary investigations.  Makes total sense.
As a therapist I can’t order investigations nor do I diagnose, so in order to treat someone I need that history with no red flags or anything suspicious -- and if there is I pack them off to their doctor and write. 

With IBS I invariably pick it up as an incidental problem within a history for something else.  If I’m wearing my physio hat in the NHS I’ll probably just focus on the presenting problem.  Wearing my hypnotherapy hat we’ll explore it.  That’s when I’m confirming the inclusion criteria, and I’m excluding any obvious physical factors such as diet and exercise problems, checking they’ve seen their GP about it, and basically I’m looking for yellow flaggy stuff and psychological factors which could be driving these very real physical symptoms. 

The NICE recommendations for the use of hypnotherapy with IBS suggest hypnotic psychological treatments which are primarily “mechanistic” — and these have proved to be very successful in the treatment of IBS symptoms.  That approach however does nothing to specifically address any underlying psychological causes.  So in practice the therapists and doctors using hypnosis for patients with IBS tend not to solely use the NICE recommended approach. 

I do agree that better understanding is needed.  I suspect some of what’s now called IBS will be found to be driven by an organic pathology and the remainder will genuinely be driven so much by psychological factors that you could say it was caused by them.  (And then, no doubt, the hunt will be on for a material cause of those!) 

=====
EDIT:  Coincidentally with the timing of this topic I've just got an email flagging up a book coming out in January 2017:
Prof. Peter Whorwell, Take Control of Your IBS
Whorwell is one of the big names in IBS and had a huge hand in developing the initial NICE guidelines.  I've pre-ordered my copy!

strtdv

@Grunfeld you should have a chat with a neurologist I know! He could talk for hours about the separation of psychiatry and neurology (which in his view is nonsense, he just views psychiatry as poorly understood neurology)!

Hootsmon