Management of IBS The most impoant steps are to make a positive diagnosis and reassure the patient. Many people are concerned that they have developed cancer. A cycle of anxiety leading to colonic symptoms, which fuher heighten anxiety, can be broken by explaining that symptoms are not due to a serious underlying disease but instead are the result of behavioural, psychosocial, physiological and luminal factors. In individuals who fail to respond to reassurance, treatment is traditionally tailored to the predominant symptoms. Dietary management is effective for many patients. Up to 20% may benefit from a wheat-free diet, some may respond to lactose exclusion, and excess intake of caffeine or aificial sweeteners, such as sorbitol, should be addressed. A more restrictive, 'low-FODMAP' diet, supervised by a dietitian, with gradual re-introduction of different food groups, may help some patients, as may a trial of a gluten-free diet. Probiotics, in capsule form, can be effective if taken for several months, although the optimum combination of bacterial strains and dose have yet to be clarified. Patients with intractable symptoms sometimes benefit from several months of therapy with a tricyclic antidepressant, such as amitriptyline or imipramine (10-25 mg orally at night). Side-effects include dry mouth and drowsiness but these are usually mild and the drug is generally well tolerated, although patients with features of somatisation tolerate the drug poorly and lower doses should be used. It may act by reducing visceral sensation and by altering gastrointestinal motility. Anxiety and affective disorders may also require specific treatment . The 5-HT4 agonist prucalopride, the guanylate cyclase-C receptor agonist linaclotide, and chloride channel activators, such as lubiprostone, can be effective in constipation- predominant IBS. Trials of anti-inflammatory agents, such as ketotifen or mesalazine, and the antibiotic rifaximin may be considered in some patients with difficult symptoms but are best prescribed only after specialist referral. Psychological interventions, such as cognitive behavioural therapy, relaxation and gut-directed hypnotherapy, should be reserved for the most difficult cases. A range of complementary and alternative therapies exist; most lack a good evidence base but are popular and help some patients . Most patients have a relapsing and remitting course. Exac- erbations often follow stressful life events, occupational dissatisfaction and difficulties with interpersonal relationships. Ref Davidson edition23rd pg 826