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August 28, 2015

Irritable Bowel Syndrome

At one time or another, nearly everyone has some constipation, diarrhea, uncomfortable bloating sensations, feelings of excessive "gassiness" and upset stomach associated with generalized discomfort in the abdomen. However, about one in 10 people have some or most of these symptoms on and off for long periods of time, sometimes nearly lifelong. IBS can begin at any age, though seems most commonly to develop during teen years through early adulthood. Both genders are affected, though in the US the symptoms bring more women than men to medical attention. IBS is a worldwide problem, affecting all ethnic groups.

When tests do not show damage, disease, infection or growths in the digestive organs, what clinicians then diagnose are called "functional" disorders of the digestion. This means that the digestion doesn't function comfortably or quite normally, yet no disease results from it, and no obvious damage to the organs seems to cause it. When the lower bowel (colon) is the primary area that malfunctions over time, the term "irritable bowel disorder" or "irritable bowel syndrome" (IBS) is often used. Other common names for this--such as spastic colon, nervous colon, mucus colitis for example--can mean the same thing. These names focus on symptoms that some people have but others don’t. The word "syndrome" means a set of symptoms that are common to groups of people, who have a condition that acts in similar ways and is treated with similar remedies.

Causes

IBS comes from a mix of hypersensitive nerve endings in the intestine, abnormal contraction patterns, and from brain center feedback on how the gut works. There are factors related to past infections, very subtle ongoing inflammation, possibly altered “barrier function” (the “leaky gut” idea, whereby certain substances normally not absorbed in health can be absorbed and trigger subtle immune or inflammatory or other nerve-mediated function changes)…and other aspects clearly related to stress. The result is a variety of chronic symptoms, food sensitivities and bowel function changes. The role of abnormal amounts of bacteria in the small intestine is sometimes major.

Signs & Symptoms

Symptoms of irritable bowel syndrome include:

  • Changes in bowel movement patterns—diarrhea or constipation, sometimes both, often feelings of incomplete evacuation.
  • Bloating and excess gas.
  • Pain, mostly in the lower abdomen but sometimes other locations including back.
  • Mucus in stools, but not bleeding unless bleeding is due to hemorrhoids or other causes

An IBS disorder can cause a lot of distress, discomfort, and may interfere with normal activities, but it doesn't do physical harm internally, no matter how often or how long symptoms act up. In this way it is like a chronic headache tendency--it can sometimes be bad, but in most people is minor or intermittent. IBS doesn’t lead to cancer, or to IBD (inflammatory bowel diseases).

Screenings & Diagnostic Tests

It all depends on the situation. People don't need special tests on a regular basis once we're sure they have IBS, but people should have routine tests to detect polyps and cancers once they get to age 50, just like anyone else. Typically some tests are done when IBS is suspected, to help confirm there aren't other disorders or more medically serious diseases, and find other things that can cause similar symptoms. This can involve some simple tests on blood (CBC, chemistries, thyroid tests are common; sometimes we test for a malabsorption disorder due to a wheat allergy called celiac disease); and simple tests from stool samples (for hidden bleeding, or for infections).

At some point, many people are asked to have imaging tests if we strongly believe there may be alternative causes of abdominal pain—ultrasound or CAT scans. Sometimes colonoscopy is very important, most commonly for the “routine” preventive tests for 50-up individuals, sometimes to evaluate for other possible diseases. This is much more likely important to evaluate persistent diarrhea where the pattern seems unusual for IBS and where inflammatory bowel diseases (IBD or microscopic colitis) are suspected.

Some people with IBS also have a lot of upper digestive symptoms (called non-ulcer dyspepsia) and may need tests run related to the esophagus, stomach, duodenum (UGI endoscopy exam) or gallbladder (ultrasound test, usually). When we strongly suspect SIBO (small intestine bacterial overgrowth), we will sometimes do a “lactulose breath test"

MOST INDIVIDUALS WITH IBS THOUGH DO NOT NEED MORE THAN A CAREFUL MEDICAL HISTORY, PHYSICAL EXAM AND MAY NOT NEED ANY TESTS NOT ALREADY DONE FOR PRIMARY CARE CHECKUP PURPOSES.

We have a very strong ability to accurately diagnose IBS without special tests, so most typically treatment is started, and testing is done only if symptoms don’t improve or behave as we would expect. The important thing to realize is that NEW symptoms from IBS shouldn't be taken for granted or assumed to be IBS without discussing it with your doctor. If bleeding or fever or new types of abdominal pain occur, ALWAYS see your doctor about it.

Unexplained changes in bowel habit that last for weeks or are getting steadily worse, if clearly different than the usual pattern a person runs with their IBS, also needs attention.

Treatment

Most importantly, being sure of the diagnosis--which many times physicians can tell by symptoms alone, with just a few simple tests to be sure there are no warning signs of other ailments. Being sure of the diagnosis should relieve anxiety about what else might be wrong inside--this adds a lot of mental stress, so a person with IBS should understand what IBS is and that it has a good outlook. Treatment has several aspects:

Diet:

This emphasizes good nutrition principles: well balanced, regular meals which aren't rushed, good fluid intake (over a quart a day of liquids), and low fat. This means about 30% of calories from fats, which is also healthy for the heart and circulation. Many Americans consume much more fat and less fiber than they should. Look at the information on fiber to understand this better.

Certain types of fiber may be a problem--too much wheat bran, beans, cabbage, onions--can release more gas or not digest comfortably. (see brochure on Fiber, and discussion of soluble, insoluble fiber types). Some IBS patients do better with smaller amounts of gluten (wheat protein) products (breads, pastas). Some with bloating or pain as the predominant symptom get benefit from a broader restriction of gluten along with other foods that seem to ferment extensively by bowel bacteria—these foods are referred to as “FODMAPS” (see our separate brochure and Low FODMAP Diet materials).

Some people with IBS and should try to get much higher fiber intake; some get more gas, bloat or diarrhea and need to restrict the more gas-producing forms of fiber. Also, many adults don't digest milk too comfortably (they don’t absorb lactose sugar well and it produces gas, bloat and/or diarrhea); however, adults shouldn't give up dairy products without thinking about other sources of calcium and protein. Furthermore, solid cheese and yogurt usually digest quite well in people with lactose intolerance; and many adults can take lactose products if treated with enzymes (like Lactaid milk) or if taken with Lactase enzyme pills.

What diet approach is best for you? Your clinician will help you decide based on your individual experience with foods, symptom pattern and many times treatment trials of one or another dietary approach.

Stress Management:

This is a major reason IBS acts up, and needs to be recognized and dealt with. Adequate sleep, exercise, recreation and enjoyable pleasurable activities are the main keys. There are lots of ways people manage strong or chronic stress, and methods that work for one person may not work for another. Meditation, massage, tai chi exercise, listening to relaxation or music tapes etc all work for some people.

Sometimes, small amounts of medicines used to help anxiety and depression disorders can be very helpful in IBS when it is not responding well to other treatment—even if you aren’t depressed or unusually anxious. A form of therapy called “cognitive behavioral therapy” done by referral to psychologists or other therapists can be very helpful for some people who can’t get pain under good control; likewise, “mindfulness” seems very effective as a program to manage symptoms and stress. These teach people methods to reduce & control pain and reduces the distress feelings people experience when the gut “acts up.” It is clear that diet and lifestyle modifications are the MOST effective ways of dealing with IBS for MOST people.

Medicines:

Some are simple things like fiber supplements, mainly for those with predominant constipation (IBS-C)--forms of psyllium (like Metamucil, Konsyl, PerDiem), methylcellulose (Citrocel) or pectin fiber (Benefiber), which digest comfortably when used properly and add more fiber for the colon to work with. This relaxes the colon and makes the contractions calmer and more effective. However, some people tolerate the fiber supplements poorly, and other approaches to constipation are used.

Acacia powder may be better tolerated if other forms are not. IBS patients with diarrhea often get more symptoms when they use fiber supplements. Relaxant herbal teas (mint, chamomile) and heat applied to the abdomen are helpful.

Other medicines very useful include a group called antispasmodics--such things as dicyclomine (brand Bentyl), hyoscyamine (Levsin, Levsinex,), belladonna (Donnatal), clindex (Librax). These relax intestinal contractions or spasm, make the intestine less sensitive to the stretch inside it. Sometimes anti-gas medicines--simethicone (GasX, Mylicon) can help gas disperse or break up easier. Peptobismol has a good antispasm and antidiarrhea effect, as does enteric peppermint extract. Some people with IBS with a lot of diarrhea get good benefit from diphenoxylate (Lomotil and others) or loperamide (Imodium and others, OTC).

FOR MOST PEOPLE, the GENERIC FORMS OF THESE MEDICINES WILL WORK QUITE WELL AND ARE MUCH CHEAPER THAN BRAND NAMES.

We mentioned low doses of drugs which (in high dose) are used to treat depression—several types are helpful in IBS, including older drugs called tricyclics (nortriptyline for example); or newer ones called SSRI’s or NSRI’s (generics for Prozac; Lexapro; Effexor; and similar).

Drugs that are focused on improving the abnormal gut motility are under development; some have come gone (Cisapride, Zelnorm) because of side effects observed after they were in broad use. A drug caused alosetron (Lotronex) is sometimes used for stubborn IBS diarrhea, but has to be supervised very carefully to use it safely. Newer drugs for stubborn IBS constipation include Amitiza (luboprostone) and Linzess (linaclotide) can help by increasing the fluid within the intestine, improving motility and reducing gut sensitivity, and can be quite useful but are quite expensive. Newer drugs are under development. Treatments for SIBO (small intestine bacterial overgrowth) involve 1 or combinations of specialized antibiotics for 10-14 days, sometimes followed by low dose of “motility” drugs taken at nightlong term.

Complementary therapies:

We do frequently suggest certain probiotics, oral products that are highly concentrated freeze-dried but live “healthy bacteria”or yeasts, since there is some good medical evidence they can helpl some IBS-C patients those with bloating. We sometimes use certain herbal compounds.

Some individuals will benefit from acupuncture, and certainly massage and other therapies can be very helpful for stress reduction. Many products are touted through Internet and other sources that have no good evidence behind them. We just encourage any of our patients with IBS to discuss approaches they would like to try so we can review them for safety, for medical evidence and give precautions where appropriate.

What medical followup do I need? This will vary considerably. In some cases, a single visit may be enough to assess the problem and advise good solutions, with followup “as needed” or through your referring physician. In other cases, several visits may be needed to do an evaluation, get tests done, try different treatments and then see “as needed.” Those with more severe conditions are naturally seen more regularly and for longer periods of time. We refer where appropriate to other specialists (e.g. gynecologists if we suspect a pelvic organ disorder), or to therapists if we feel cognitive-behavioral therapy or other psychological approaches may be needed.

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