Rational Investigations in IBS

Reassurance is an interesting concept in modern medicine. I remember my blood pressure creeping up at the sight of an advert on the tube a few years back for a health check involving a ‘whole body MRI scan,’ fuming over the willingness of this private healthcare provider to offer false assurance of alleviating any anxiety regarding a lurking, thus far undetected deadly disease (ie cancer) that needs treatment before it’s too late.

This approach to healthcare makes me angry for 3 reasons: first, it is making money out of people’s worries, in the full knowledge that injudicious ‘screening tests’ performed without due basis (ie at risk population, specific disease with an available intervention, acceptable and effective test) are not value for money; second, it fuels further unnecessary investigations when non-specific lumps and bumps of uncertain significance are revealed, demonstrating the shades of grey in medical diagnostics when the public expect binary clarity; third, and linked to this, investigations are a very poor cure of our health anxiety, and likely even perpetuate it.

Leaving aside financial incentives in medical investigations (a discussion for another day!), it is the second and third point I wish to focus on here in reflecting on the excellent review from Black and Ford on Rational Investigations in Irritable Bowel Syndrome published in this month’s issue of FG. For many of us working in general gastroenterology clinics, IBS can be a difficult and dissatisfying disease to manage, producing consultations from which all parties often leave unsatisfied. A contributing factor to this is how we approach the health anxiety often associated with this condition. Suffering from significant symptoms of pain and altered bowel habit that are impacting their quality of life, patients worry that they are being fobbed off by a label of IBS while a sinister underlying pathology has been missed. This is compounded by perceived ineffectiveness of treatments offered for their disabling symptoms.

The misstep we often make at this point as the managing doctor is to over endless cycles of (often repeated) investigations in an effort to placate and reassure our patient, a practice made worse by reduced continuity if they are seen by registrar who changes on each visit. The current review helpfully tackles this practice. Black and Ford address head-on the fact that unnecessary and repeated investigations for IBS are not only a waste of NHS resources, but merely accentuate and perpetuate a patient’s anxiety and underlying belief that the real, dangerous cause of their symptoms has been missed.

Rather than being a ‘diagnosis of exclusion,’ it is a positive diagnosis that may be made through a good quality history, clinical examination and limited, targeted investigations (that may not even require an endoscopy). Therefore, once the diagnosis has been reached, a far greater proportion of the consultation time may be spent on explanation, advice and tailored treatments, many of which have a growing evidence base to support their use. These points came out in our twitter debate on function disease last year, with summary points also published in the journal.

Therefore, I highly commend reading this concise and well applied review (this issue’s Editor’s choice, also discussed in the Frontline Gastroenterology podcast). Who knows, you may save your hospital a lot of MRI small bowels while improving patient satisfaction!

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