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Irritable Bowel Syndrome

(IBS)

• Irritable bowel syndrome (IBS) implies that your bowels are "irritable". This is a clinical diagnosis for many patients with intestinal problems after no abnormality is found on various blood, stools, x ray or scope tests of the bowel. In spite of the normal tests, the patient continues to have tummy pains as well as irregular bowels as constipation and/or diarrhea. Frequently, the patient is led to believe that there is something wrong with his/her brain. Is this true? Well, yes and no!

• No, it's not your brain in the skull. Recent research indicates that intestines are controlled by its own network of interconnected nerve cells. These connections and their "messages" are affected by neurochemical transmitters, which are similar to the ones found in the "big brain". Unlike the brain in the skull, which is the major part of central nervous system (CNS), our intestines are controlled by an essentially autonomous enteric nervous system (ENS).

• Think of this system of two brains in the body as the federal government , which only has a peripheral control over how any state government, in this case ENS, conducts its routine business in its own state (bowels)! However, the two brains do interact in a lot of ways, perhaps a lot more so in IBS, thus affecting each other. For example, mental stress can "worsen" IBS, whereas inability to find a satisfactory solution to IBS increases stress.

• Prevalence: Irritable Bowel Syndrome, also known as spastic colon, is a common disorder affecting as many as 20% of the population, more so among women than men. Since it is a clinical diagnosis, the prevalence figures vary depending upon the definition of IBS used. Contrary to the popular myth, IBS does occur in elderly persons, although the prevalence is somewhat lower (11 percent).

• Although only about 10% of IBS patients actually seek medical attention, it accounts for about 3 million physician visits and over 2 million prescriptions in the U.S. annually. It is the seventh leading diagnosis amongst all physicians and these patients utilize $300 per year of health care cost more than their non-IBS counterparts.

• What causes Irritable Bowel Syndrome?  Our knowledge of this very common disorder is rudimentary. While the cause of IBS is unknown, a bio-psychosocial model has been proposed. It results from various combinations and permutations of abnormal movements of the intestines, heightened sensitivity and perception, psychological distress, and in some cases physical and sexual abuse.

• Clinical features of Irritable Bowel Syndrome: It is a chronic condition characterized by remissions and relapses. While tummy pains and cramps is a feature common to all IBS, the patients are usually classified based on their predominant irregularity of bowel habit, i.e. diarrhea predominant, constipation predominant, or diarrhea alternating with constipation. Stress and food are common triggers for onset of symptoms. Pain is relieved by defecation. There may be a feeling of bloating, distention and incomplete evacuation.

• Blood in stools, weight loss and nocturnal defecation are characteristically not associated with Irritable Bowel Syndrome (IBS).

• Other conditions that may mimic Irritable Bowel Syndrome (IBS) include lactose intolerance, diverticulosis, medication-induced diarrhea or constipation, chronic intestinal infections, Crohn's disease, thyroid and other hormonal problems, and last but not the least, tumors both inside and outside the intestines.

• Diagnosis of Irritable Bowel Syndrome: In simple terms, Irritable Bowel Syndrome may be described as a heterogeneous and multidimensional disorder, a catch-all name for multiple disorders affecting the gut, after no abnormality can be found by doing a variety of tests. These tests usually include blood counts, comprehensive medical profile, thyroid tests, and stool studies for infection. Structural abnormality of colon is diagnosed by the scope exam of the colon, usually a flexible sigmoidoscopy or colonoscopy. A lactose hydrogen breath test is frequently employed to exclude lactose intolerance. Additional digestive or psychological tests are performed based on individual situation.

• Management: A good patient physician relationship and trust as well as patient education is of paramount importance. Unrealistic goals of a "cure", at least at this time, would only lead to increasing frustration and be counterproductive.

• Use of medications is based on patient's symptoms. Diarrhea-predominant patients should use high fiber diet and avoid sugar free candies, gums, and high fructose fruits like apple and grape juice. Loperamide (Imodium) and diphenoxylate with atropine (Lomotil) are frequently used. Lomotil can be habit forming!

• Review of diet/fluid and medication intake is especially important in constipation predominant patients. Many medications are constipating, i.e. heart and blood pressure medications, painkiller narcotics etc. High fiber intake is usually prescribed to most IBS patients especially the constipation predominant. Raw bran or over the counter products like Metamucil may help. Make sure you drink plenty of water/fluids during the day. Milk of magnesia is frequently used as a "gentle laxative". Tegaserod (Zelnorm) has been approved by the FDA and is helpful in select cases.

• Spasm-reducing medicines like hyoscyamine (Cystospaz, Levsin), dicyclomine (Bentyl) as well as combinations of multiple medications (Donnatal) are used for tummy cramps. Narcotics for pain can be counter productive and should be avoided. Avoid chronic use of antidiarrheals as well as laxatives in IBS.

   

  Treatment of increased gas and bloating can also be frustrating in some patients. While doctors try a few measures, and some over the counter drugs (simethicone or Beano) to take care of the gas problems, there are no good and effective drugs to take care of the problem. Avoid pastries, pretzels, legumes, berries, apples, prunes, raisins, bananas, baked beans, cabbage, celery, broccoli and other cruciferous vegetables.   Are you chewing a lot of gum? Sugarless gum with the sorbitol causes gas. Sorbitol is present as an artificial sweetener in many sugar free products. Carbonated beverages are full of gas. Many medicines slow the gut and may cause gas to be trapped in the bowel for prolonged periods because of slow movements, causing tummy cramps.   Low doses of tricyclic antidepressants (imipramine, desipramine) raise the pain threshold and lessen tummy cramps. They are helpful in all types of IBS especially in diarrhea predominant. Psychotherapy and hypnosis are helpful. IBS classes using multidimentional group approach comprising of a nurse, dietician, physical and behavioral therapists have been shown to be of benefit. Alterenate & complementary medicine: Americans are increasingly opting for this approach out of frustration with the mainstream medicine and studies show that some of these are beneficial. For example, a randomized controlled study published in Journal of American Medical Association (1998) showed that Chinese herbal medicine is is effective for treatment of IBS. Novel therapies: Many exciting new pharmaceutical compounds including  prucalopride are under investigation, and it appears that after decades of no good drug for IBS, the Food and Drug Administration is likely to approve 1-2 drugs in the next 12-18 months.  Alosetron (Lotronex) was approved by FDA for female IBS-diarrhea patients but the company withdrew the drug in late 2000 because of severe complications and deaths.