The Management of Irritable Bowel Syndrome: The Viewpoint of Italian General Practitioners in Activity and in Training

  

    

    
GPs (n=170) 
    
ITGPs (n=64) 
    
P    Value 
  
  

    
Knowledge of IBS is considered satisfactory (%)
    
79 (46.5) 
    
45 (70.3) 
    
0.002 
  
  

    
An update on IBS is considered useful (%)
    
64 (37.6) 
    
28 (43.8) 
    
n.s. 
  
  

    
GPs: General Practitioners; ITGPs: in-Training    General Practitioners; IBS: Irritable Bowel Syndrome. 
  

Table 6: Educational needs regarding IBS.

Discussion

The results of this survey provide important information on the attitude of both Italian GPs and ITGPs in managing IBS. The two groups are, obviously, markedly different in terms of age, seniority, and gastroenterology specialization. Moreover, most of the GPs are males, whereas among ITGPs there is a greater prevalence of females. This reflects the Italian situation where there is a higher number of female ITGPs than male ITGPs.

The knowledge of the RC for IBS among GPs is low, although it is increasing if compared to the results of a survey we carried out in 2005 (47.6% vs. 35.7%). Also their use in clinical practice by those who know the RC has increased (76.5% vs. 60%) [10]. However, these results are comparable to those obtained by similar studies carried out in different countries. These confirm that the knowledge and the routine use of these criteria are widespread only among gastroenterologists with a particular aptitude for managing functional digestive disorders [11-15]. On the other hand, the criteria are scarcely known and used in primary care where most patients are diagnosed and treated [9,11,14-16].

IBS positive diagnostic criteria are largely based on expert opinion and not on high quality evidence. Very few data report their applicability in primary care [17] and very few studies attempted to validate a positive diagnostic strategy for IBS in primary care. Begtrup et al. showed that a positive strategy was not inferior to an exclusion strategy, with lower direct costs and less use of health resources, and yet with similar effects on symptoms and patients’ satisfaction [18]. However, at present, worldwide, the diagnosis of IBS still largely remains an exclusion diagnosis for GPs [15,19,20]. It is a complex procedure requiring a non negligible amount of time and high costs [19].

On the contrary, there is a higher percentage of ITGPs, more recently graduated, who are more familiar with the RC than the GPs, demonstrating that the awareness of the RC has been constantly increasing in recent years. Hence, even if among those familiar with the RC the percentage of GPS and ITGPs using them in clinical practice is not significantly different, the RC end up being used more by ITGPs than GPs (respectively 54.7% vs. 36.5%; p=0.017).

In addition, the knowledge of the BS is more widespread among ITGPs, but the GPs use it more frequently than the ITGPs in their clinical practice, probably because they find the BS rapid and easily understandable by patients due to its visual immediacy.

As expected, more GPs with a gastroenterological specialization are familiar with both the RC and BS than other colleagues, but this does not imply a significant difference in their use in clinical practice.

A large number of the respondents feel that other symptoms should be added to the definition of IBS (63% of GPs and 44.7% of ITGPS) in order to achieve a correct clinical picture of IBS patients. Both GPs and ITGPs would like to include abdominal bloating (80.4% of GPs and 95.2% of ITGPs) among the diagnostic criteria for IBS. With a lower percentage they think that also abdominal discomfort (43.1% of GPs and 45% of ITGPs), present in RC III but eliminated from the new RC IV, is an important symptom. GPs with a gastroenterological specialization would like to include bloating among diagnostic IBS criteria more frequently (p=0.018) than GPs without gastroenterological specialization. The degree of seniority and the number of patients under their care do not seem to make any difference among the GPs, together with gender, which does not influence any choice of either GPs or ITGPs.

As reported in our previous survey, abdominal pain and changes in the frequency of bowel movements are symptoms frequently used in clinical practice by GPs [10]. Based on our results, it seems that ITGPs use them even more frequently than GPs. Abdominal bloating, which had been considered an important symptom for the diagnosis of IBS also by 78.6% of the GPs who participated in the 2005 survey [10], is still frequently used both GPs and ITGPs with no significant difference between them.

Bloating is considered as only an additional diagnostic criterion by RC, although it is often reported as the most bothersome symptom by patients and GPs [21], and is the third most frequent IBS symptom according to GPs and gastroenterologists [11].

In the NICE guidelines, bloating was only a supportive element [22] but in the 2015 revision it became one of the basic symptoms [23] and the Consensus development using nominal group technique created for European primary care gastroenterology identifies the defining features of IBS in: alteration of bowel habits, bloating and abdominal pain (or discomfort or annoyance) [24]. Abdominal bloating in IBS is associated with increased symptoms and pain severity, somatization, depression, fibromyalgia, and altered dietary fluid composition. Recognizing and addressing these factors in the diagnosis and management of patients with IBS may improve clinical outcome [25]. It is interesting to underline that regarding abdominal bloating even younger doctors (ITGPs) have the same opinion as their older colleagues (GPs), whereas ITGPs seem to pay more attention to defecatory problems because they use defecatory urgency as a diagnostic symptom more frequently than GPs.

Among GPs, those with a gastroenterological specialization recognize abdominal pain even more frequently as a pivotal symptom. As reported above, gender does not influence any choices among both GPs and ITGPs. Among GPs, neither seniority nor number of patients under their care seems to influence any choice.

As regards the pathogenetic hypotheses, alterations of intestinal motility and psychological factors remain the most frequently considered causes, as detected in our previous investigation [10]. This is without any difference between GPs and ITGPs, but also other factors (e.g. gut dysbiosis and infections, visceral hypersensitivity, and food allergy/intolerance) are considered among the most frequent pathophysiological mechanisms. These data confirm the results data coming from previous studies showing broad areas of uncertainty among GPs about the etiology of IBS [26]. Most GPs give importance to psychological factors and stress [9,15,19,26,27], but there is a nonunequivocal opinion regarding the role of other possible factors [15,21,27]. As a matter of fact, IBS pathogenesis is one of the most debated and controversial issues in the gastroenterological field and many different, sometimes conflicting, hypotheses have been put forward [6].

With regard to the reasons for referring the patients to a gastroenterologist, the GPs report different motivations (i.e. the difficulty of management, the need for an in-depth diagnostic pathway and the need to reassure the patient). The proportion of GPs requiring specialist consultation varies widely between countries, with differing motivations (probably due to the different organization of the local National Health System) [15,28-30]. As reported by Mujagic et al., a specialist referral can be useful to reassure patients whose symptoms partially respond to the GP’s therapy and/or to improve patients’ satisfaction [9]. In one study published in 1997, male and older doctors referred patients to a gastroenterologist more than female and younger doctors [31], whereas in our previous survey no difference was observed regarding specialist referral between older and younger doctors and between male and female doctors [10].

In the present survey GPs reported more frequently than ITGPs that factors inducing a specialist consultation were the patient's request and the difficulties in management. This data must be read together with the evaluation of satisfactory patient management obtainable according to the ITGPs in more than 50% of patients and for GPs only in about 40%. It is a quite different result from that obtained (62.7%) in our previous investigation [10]. Particularly, the referral to a gastroenterologist due to a patient’s request is reported in highly variable percentages [10,32]. A study recently carried out in Spain has shown that IBS patients would prefer to be referred to a gastroenterologist more frequently than their GPs usually do so, even if the same study highlighted that there was no difference in the frequency of patients satisfied with the care provided by their GP or by the gastroenterologist [33]. The patients perceived reluctance by GPs in asking for a gastroenterological consultation [33]. Indeed, referral is a sensitive topic for GPs, involving emotionally charged interactions and relationships with patients, colleagues, specialists and supervisors. Consequentially, the decision to refer or not is influenced by multiple environmental, personal and clinical factors which dynamically interact and affect the decision-making process [9,34].

Finally, as far as training needs are concerned, the ITGPs, recently graduated, believe that their personal knowledge of IBS is satisfactory more frequently than the GPs, even if the percentage of respondents who deem a specific professional update to be useful is around 40%, without differences between GPs and ITGPs. Compared to our previous investigation [10], the percentage of GPs considering their knowledge sufficient is remarkably similar, but the percentage of the GPs regarding a professional update as useful has more than tripled. Among GPs no correlation between seniority of degree and number of patients was observed regarding these variables, but GPs with a gastroenterology specialization consider more often that they have a satisfactory knowledge of IBS.

The results of this survey clearly show that it is mandatory to constantly update the knowledge of GPs and ITGPs about IBS. There is still a gap between the indications provided by the experts, i.e. national and international guidelines, and local practice. This gap has persisted over the years, probably indicating an insufficient communication between the various professional healthcare figures. Gastroenterologists do not fully convince GPs and perhaps GPs, conversely, fail to adequately express the reality they face every day, together with their needs and requirements. It could also be highly desirable to develop common guidelines in order to share management paths between gastroenterologists and GPs. This could reduce the number of unnecessary diagnostic tests and gastroenterological consultations, resulting in a higher rate of patients’ satisfaction, and enabling an alternative and more effective allocation of health expenditure. This aim could be more easily achieved if also ITGPs, the younger doctors still in training to become GPs, were actively involved.

Acknowledgement

The authors are grateful to the following GPs of the Italian Group for Primary Care Gastroenterology (GIGA-CP) for their valuable help in carrying out the study: Alessandra Belvedere, Alberto Bozzani, Giovanni Casella, Maurizio Mancuso, Luigi Napoli, Enzo Pirrotta, Riccardo Scoglio, Enzo Ubaldi and to Chris Powell for the language revision of this paper.

Conflicts of Interest Statement

The authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

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