Damian, a 33 year old with known IBS, comes to see you for a review. He has a longstanding history of abdominal discomfort and constipation. He infrequently has the urge to open his bowels, and can go days without passing stools which are sometimes hard. He feels intermittently bloated. He has had no rectal bleeding and no weight loss, and has no significant family history.Damian works in IT and has a very sedentary lifestyle. At his previous review, you discussed his diet. At this consultation he reports that he has followed your advice and feels better in many respects. However, he has seen no change in his bowel movements. He tried taking senna tablets which he bought over the counter. This seems to have caused Damian further abdominal pain.Which one of the following is the most appropriate next step?Start Damian on a low dose tricyclic antidepressantSuggest that he increases the amount of fibre in his dietPrescribe lactulosePrescribe a macrogol laxative

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