The following blog is a summary of key learning points from a talk given at Digestive Health and Wellbeing: The Patient Journey. Click here to learn more about the event or click here to visit the health care professional portal.

Meet the speaker:

Dr Adam Farmer MBBS studied at University College London, Barts Hospital, The London School of Medicine and Dentistry and Harvard Medical School, USA. His primary clinical interests include functional gastrointestinal disorders such as irritable bowel syndrome (IBS), abdominal pain, bloating, heartburn and reflux, diarrhoea, constipation and digestive symptoms arising from diabetes and Ehlers-Danlos syndrome. Widely considered an international expert in clinical gastroenterology, Adam has been awarded two prestigious prizes for his work:

Dr Adam Farmer
  • American Neurogastroenterology and Motility Society Young Investigator Prize, 2020
  • European Gastroenterology Rising Star Award, 2018

Secondary care in digestive health

Adam’s presentation discusses the clinical approaches to dealing with patients with unexplained digestive symptoms in the absence of obvious pathophysiology. He takes a closer look at the kind of patients who appear in secondary care with benign GI disorders but severe unexplained symptoms, as well as how to systematically approach these patients. Adam then discusses the treatments commonly available and the signs to escalate for further testing.

Summary points

Red flag features in IBS typically include age over 50 years, short history of symptoms, documented weight loss, nocturnal symptoms, male sex, family history of colon cancer, anaemia, rectal bleeding and recent antibiotic use. The Rome IV criteria outlines 30 adult disorders and 12 paediatric disorders related to Functional gut disorders, gut and the brain in neurogastroenterology.

  • Functional gut disorders make up around 35% of new referrals to gastroenterology clinics (Shivaji & Ford, 2014)
  • The implications of functional gut disorders are significant in the UK, with a prevalence of 10-20% (Philpott et al., 2011)
  • Functional gut disorders make up 3% of primary care referrals and up to 40% of gastroenterology referrals in secondary care (Thompson et al., 2000)
  • Cause significant morbidity and lower quality of life (Jamali et al., 2012) and has a heavy economic burden (Sandler et al., 2002)

The gut-brain axis is central to functional gut disorders due to the influence of the stress response, whether that be via psycho-social stress or physiological stress response to pain or discomfort. Functional gut disorders are regulated by the gut-brain axis, which is increasing appreciation for the central role of the gut microbiota. When something goes wrong in the gut-brain axis, there can be visceral pain hypersensitivity. Patients with IBS tend to be more sensitive to pressure than non-IBS individuals. IBS patients are often not given a positive diagnosis and not having a formal diagnosis can cause unnecessary stress or anxiety in patients. One challenge is that doctors are often not sure on the exact diagnosis, and there are multiple factors to consider, for instance, ruling out cancer.

Gut-Brain Axis

Healthcare practitioners should be mindful of wording and avoid phrases like ‘it’s nothing serious’. This can be demeaning to patients when they have been suffering symptoms for years. How we speak to patients without a clear diagnosis is important. The doctor-patient relationship is one of the most fundamental facets when dealing with chronic conditions. It’s important to consider how patients think doctors operate, particularly in only considering symptoms and not underlying cause. Some patients struggle to accept that while symptoms affect their life, it is from a benign history – they may have been affected for much longer without realising. Patients may also feel they are being diagnosed with a psychological disorder when prescribed antidepressants, but with lack of communication, they have not realised that this medication has an important role in rewiring the gut-brain axis.

IBS is a very common disorder with far-reaching implications, including a significant impact on quality of life, work and social life, and individuals may wait a long time to get a formal diagnosis. Often, patients are not satisfied with the support they get. Importantly for healthcare professionals, coeliac disease and IBS have similar symptoms – which can easily lead to confusion and delay in diagnostics. One of the most useful screening tests is faecal calprotectin, a biomarker which can spot underlying inflammatory bowel disease by detecting inflammation in the bowels. In addition, the Rome Criteria have a good clinical application for diagnosing IBS. Sub-classification is important for deciding on the correct treatment and route forward for the patient, which may indicate whether dietary management or pharmacological interventions will prove more useful.

Click here to visit the Bimuno HCP learning portal, which includes Adam’s presentation.

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