Diagnosis and management of irritable bowel syndrome: a guide for the generalist

Ecushla C Linedale and Jane M Andrews
Med J Aust 2017; 207 (7): . || doi: 10.5694/mja17.00457
Published online: 2 October 2017



  • Irritable bowel syndrome (IBS) and other functional gastrointestinal disorders (FGIDs) are so prevalent they cannot reasonably have their diagnoses and management based within specialty care. However, delayed diagnosis, lengthy wait times for specialist review, overinvestigation and lack of clear diagnostic communication are common.
  • The intrusive symptoms of IBS and other FGIDs impair patient functioning and reduce quality of life, and come with significant costs to individual patients and the health care system, which could be reduced with timely diagnosis and effective management.
  • IBS, in particular, is no longer a diagnosis of exclusion, and there are now effective dietary and psychological therapies that may be accessed without specialist referral.
  • The faecal calprotectin test is widely available, yet not on the Medical Benefits Schedule, and a normal test result reliably discriminates between people with IBS and patients who warrant specialist referral.


  • 1 University of Adelaide, Adelaide, SA
  • 2 Royal Adelaide Hospital, Adelaide, SA


Competing interests:

Jane Andrews has worked as a speaker, consultant and advisory board member for Abbott, AbbVie, Allergan, Celgene, Ferring Pharmaceuticals, Takeda Pharmaceuticals, MSD, Shire, Janssen, Hospira and Pfizer; and has received research funding from Abbott, AbbVie, Ferring Pharmaceuticals, MSD, Shire and Janssen.

  • 1. Cremonini F, Talley NJ. Irritable bowel syndrome: epidemiology, natural history, health care seeking and emerging risk factors. Gastroenterol Clin North Am 2005; 34: 189-204.
  • 2. Halder SL, Locke GR, Schleck CD, et al. Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study. Gastroenterology 2007; 133: 799-807.e1.
  • 3. Talley NJ. Functional gastrointestinal disorders as a public health problem. Neurogastroenterol Motil 2008; 20 Suppl 1: 121-129.
  • 4. Spiegel BM. The burden of IBS: looking at metrics. Curr Gastroenterol Rep 2009; 11: 265-269.
  • 5. Enck P, Dubois D, Marquis P. Quality of life in patients with upper gastrointestinal symptoms: results from the Domestic/International Gastroenterology Surveillance Study (DIGEST). Scand J Gastroenterol Suppl 1999; 231: 48-54.
  • 6. Fullerton S. Functional digestive disorders (FDD) in the year 2000—economic impact. Eur J Surg 1998; 164(S12): 62-64.
  • 7. Nellesen D, Yee K, Chawla A, et al. A systematic review of the economic and humanistic burden of illness in irritable bowel syndrome and chronic constipation. J Manag Care Pharm 2013; 19: 755-764.
  • 8. Longstreth GF, Wilson A, Knight K, et al. Irritable bowel syndrome, health care use, and costs: a US managed care perspective. Am J Gastroenterol 2003; 98: 600-607.
  • 9. Rome Foundation. Rome IV collection, 2016. Raleigh: Rome Foundation; 2016. (accessed July 2017).
  • 10. Locke GR, Zinsmeister AR, Fett SL, et al. Overlap of gastrointestinal symptom complexes in a US community. Neurogastroenterol Motil 2005; 17: 29-34.
  • 11. Chang JY, Locke GR, McNally MA, et al. Impact of functional gastrointestinal disorders on survival in the community. Am J Gastroenterol 2010; 105: 822-832.
  • 12. Knott VE, Holtmann G, Turnbull DA, et al. M1253 patients’ satisfaction with specialist gastroenterologist consultation for irritable bowel syndrome (IBS) and health care utilisation: exploring the role of patient expectations. Gastroenterology 2009; 136: A-382.
  • 13. Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterology 2006; 130: 1480-1491.
  • 14. Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review. Am J Gastroenterol 2002; 97: 2812-2819.
  • 15. Spiegel BM, Farid M, Esrailian E, et al. Is irritable bowel syndrome a diagnosis of exclusion? A survey of primary care providers, gastroenterologists, and IBS experts. Am J Gastroenterol 2010; 105: 848-858.
  • 16. Hungin AP, Molloy-Bland M, Claes R, et al. Systematic review: the perceptions, diagnosis and management of irritable bowel syndrome in primary care — a Rome Foundation working team report. Aliment Pharmacol Ther 2014; 40: 1133-1145.
  • 17. National Institute for Care and Excellence. Irritable bowel syndrome in adults: quality standard [QS114]. 2016. London: NICE; 2016. (accessed Feb 2016).
  • 18. Talley NJ, Boyce PM, Jones M. Predictors of health care seeking for irritable bowel syndrome: a population based study. Gut 1997; 41: 394-398.
  • 19. Levy RL, Korff M, Whitehead WE, et al. Costs of care for irritable bowel syndrome patients in a health maintenance organization. Am J Gastroenterol 2001; 96: 3122-3129.
  • 20. Patel RP, Petitta A, Fogel R, et al. The economic impact of irritable bowel syndrome in a managed care setting. J Clin Gastroenterol 2002; 35: 14-20.
  • 21. Halpert A, Drossman D. Biopsychosocial issues in irritable bowel syndrome. J Clin Gastroenterol 2005; 39: 665.
  • 22. Manning AP, Thompson WG, Heaton KW, Morris AF. Towards positive diagnosis of the irritable bowel. Br Med J 1978; 2: 653-654.
  • 23. Mearin F, Lacy BE. Diagnostic criteria in IBS: useful or not? Neurogastroenterol Motil 2012; 24: 791-801.
  • 24. Spiller R, Camilleri M, Longstreth GF. Do the symptom-based, Rome criteria of irritable bowel syndrome lead to better diagnosis and treatment outcomes? Clin Gastroenterol Hepatol 2010; 8: 129-136.
  • 25. Mikocka-Walus A, Turnbull D, Moulding N, et al. Psychological comorbidity and complexity of gastrointestinal symptoms in clinically diagnosed irritable bowel syndrome patients. J Gastroenterol Hepatol 2008; 23(7 Pt 1): 1137-1143.
  • 26. Lacy BE, Mearin F, Chang L, et al. Bowel disorders. Gastroenterology 2016; 150: 1393-1407.e5.
  • 27. Clinical Insights Steering Committee. Differentiating IBS and IBD, 2013. Melbourne: Crohn’s and Colitis Australia; 2014. (accessed May 2017).
  • 28. Choosing Wisely Australia [website]. Sydney: 2016. (accessed Dec 2016).
  • 29. Royal Australasian College of Physicians. Evolve: evaluating evidence, enhancing efficiencies. Sydney: RACP. (accessed May 2017).
  • 30. Turvill J. High negative predictive value of a normal faecal calprotectin in patients with symptomatic intestinal disease. Frontline Gastroenterol 2011; 3: 21-28.
  • 31. National Institute for Health and Care Excellence. Faecal calprotectin diagnostic tests for inflammatory diseases of the bowel. Diagnostics guidance [DG11]. London: NICE; 2013. (accessed Sept 2016).
  • 32. Zayyat R, Appleby RN, Logan RPH. Can we improve the negative predictive value of faecal calprotectin for the diagnosis of IBS in primary care? Gut 2011; 60(Suppl 1): A49-A50.
  • 33. Williamson KD, Steveling K, Holtmann G, et al. Clinical triage for colonoscopy is useful in young women. Intern Med J 2015; 45: 492-496.
  • 34. Lau MSY, Ford AC. Do lay people accept a positive diagnosis of irritable bowel syndrome? Gastroenterology 2015; 149: 252-253.
  • 35. Collins J, Farrall E, Turnbull DA, et al. Do we know what patients want? The doctor-patient communication gap in functional gastrointestinal disorders. Clin Gastroenterol Hepatol 2009; 7: 1252-1254, 4.e1-e2.
  • 36. Linedale EC, Chur-Hansen A, Mikocka-Walus A, et al. Uncertain diagnostic language affects further studies, endoscopies, and repeat consultations for patients with functional gastrointestinal disorders Clin Gastroenterol Hepatol 2016; 14: 1735-1741.
  • 37. Linedale EC, Shahzad M, Mikocka-Walus A, et al. Referrals to a tertiary hospital: a clinical snapshot of patients with functional gastrointestinal disorders and effectiveness of primary care management. United European Gastroenterol J 2016; 3(5 Suppl 1): 484.
  • 38. Harkness EF, Grant L, O’Brien SJ, et al. Using read codes to identify patients with irritable bowel syndrome in general practice: a database study. BMC Fam Pract 2013; 14: 183.
  • 39. Stone L. Blame, shame and hopelessness: medically unexplained symptoms and the ‘heartsink’ experience. Aust Fam Physician 2014; 43: 191-195.
  • 40. Dalrymple J, Bullock I. Diagnosis and management of irritable bowel syndrome in adults in primary care: summary of NICE guidance. BMJ 2008; 336: 556-558.
  • 41. Hu LY, Ku FC, Lu T, et al. Risk of cancer in patients with irritable bowel syndrome: a nationwide population-based study. Ann Epidemiol 2015; 25: 924-928.
  • 42. Hsiao CW, Huang WY, Ke TW, et al. Association between irritable bowel syndrome and colorectal cancer: a nationwide population-based study. Eur J Intern Med 2014; 25: 82-86.
  • 43. Adeniji OA, Barnett CB, Di Palma JA. Durability of the diagnosis of irritable bowel syndrome based on clinical criteria. Dig Dis Sci 2004; 49: 572-574.
  • 44. Owens DM, Nelson DK, Talley NJ. The irritable bowel syndrome: long-term prognosis and the physician-patient interaction. Ann Intern Med 1995; 122: 107.
  • 45. Youn YH, Kim HC, Lim HC, et al. Long-term clinical course of post-infectious irritable bowel syndrome after shigellosis: a 10-year follow-up study. Neurogastroenterol Motil 2016; 22: 490.
  • 46. Nørgaard M, Farkas DK, Pedersen L, et al. Irritable bowel syndrome and risk of colorectal cancer: a Danish nationwide cohort study. Br J Cancer 2011; 104: 1202.
  • 47. Olafsdottir LB, Gudjonsson H, Jonsdottir HH, et al. Stability of the irritable bowel syndrome and subgroups as measured by three diagnostic criteria – a 10-year follow-up study. Aliment Pharmacol Ther 2010; 32: 670-680.
  • 48. Madisch A, Holtmann G, Plein K, et al. Treatment of irritable bowel syndrome with herbal preparations: results of a double-blind, randomized, placebo-controlled, multi-centre trial. Aliment Pharmacol Ther 2004; 19: 271-279.
  • 49. Ford AC, Quigley EM, Lacy BE, et al. Effect of antidepressants and psychological therapies, including hypnotherapy, in irritable bowel syndrome: systematic review and meta-analysis. Am J Gastroenterol 2014; 109: 1350-1365; quiz 66.
  • 50. Liu JP, Yang M, Liu YX, et al. Herbal medicines for treatment of irritable bowel syndrome. Cochrane Database Syst Rev 2006; (1): CD004116.
  • 51. Moayyedi P, Quigley EM, Lacy BE, et al. The effect of fiber supplementation on irritable bowel syndrome: a systematic review and meta-analysis. Am J Gastroenterol 2014; 109: 1367-1374.
  • 52. Marsh A, Eslick EM, Eslick GD. Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. Eur J Nutr 2016; 55: 897-906.
  • 53. Enck P, Junne F, Klosterhalfen S, et al. Therapy options in irritable bowel syndrome. Eur J Gastroenterol Hepatol 2010; 22: 1402-1411.
  • 54. Lackner JM, Mesmer C, Morley S, et al. Psychological treatments for irritable bowel syndrome: a systematic review and meta-analysis. J Consult Clin Psychol 2004; 72: 1100-1113.
  • 55. Ford AC, Talley NJ, Schoenfeld PS, et al. Efficacy of antidepressants and psychological therapies in irritable bowel syndrome: systematic review and meta-analysis. Gut 2009; 58: 367-378.
  • 56. Prior A, Colgan SM, Whorwell PJ. Changes in rectal sensitivity after hypnotherapy in patients with irritable bowel syndrome. Gut 1990; 31: 896-898.
  • 57. Whorwell PJ, Houghton LA, Taylor EE, et al. Physiological effects of emotion: assessment via hypnosis. Lancet 1992; 340: 69-72.
  • 58. Gonsalkorale WM, Houghton LA, Whorwell PJ. Hypnotherapy in irritable bowel syndrome: a large-scale audit of a clinical service with examination of factors influencing responsiveness. Am J Gastroenterol 2002; 97: 954-961.
  • 59. Whorwell PJ, Prior A, Faragher EB. Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. Lancet 1984; 2: 1232-1234.
  • 60. Vidakovic-Vukic M. Hypnotherapy in the treatment of irritable bowel syndrome: methods and results in Amsterdam. Scand J Gastroenterol Suppl 1999; 230: 49-51.
  • 61. Calvert EL, Houghton LA, Cooper P, et al. Long-term improvement in functional dyspepsia using hypnotherapy. Gastroenterology 2002; 123: 1778-1785.
  • 62. Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol 2010; 25: 252-258.
  • 63. Halmos EP, Power VA, Shepherd SJ, et al. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology 2014; 146: 67-75.
  • 64. Shepherd SJ, Lomer MCE, Gibson PR. Short-chain carbohydrates and functional gastrointestinal disorders. Am J Gastroenterol 2013; 108: 707-717.
  • 65. Barrett JS, Gearry RB, Muir JG, et al. Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon. Aliment Pharmacol Ther 2010; 31: 874-882.
  • 66. O’ Keeffe M, Lomer MC. Who should deliver the low FODMAP diet and what educational methods are optimal: a review. J Gastroenterol Hepatol 2017; 32 Suppl 1: 23-26.
  • 67. Barrett JS. How to institute the low-FODMAP diet. J Gastroenterol Hepatol 2017; 32 Suppl 1: 8-10.
  • 68. Tuck C, Barrett J. Re-challenging FODMAPs: the low FODMAP diet phase two. J Gastroenterol Hepatol 2017; 32 Suppl 1: 11-15.
  • 69. Ford AC, Lacy BE, Talley NJ. Irritable bowel syndrome. N Engl J Med 2017; 376: 2566-2578.


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