Do you have recurrent abdominal pain and diarrhoea? And to make matters worse, do they alternate with periods of constipation?
Let’s be really honest here: Over the past year (12 months, if you want to be really specific), have you had abdominal pain or discomfort for at least 12 weeks? If yes, did it happen along with altered stool passage or altered stool form? Did defecation give you relief?
Chances of you nodding in affirmation are greater if you are a woman, or are above 45 years of age. Irritable Bowel Syndrome (IBS) is a disorder characterised by abdominal pain or discomfort, with altered bowel habits – in the absence of organic disease (which involves or affects physiology or body organs).Alarming Patients with typical IBS symptoms may also exhibit so called ‘alarm’ features that increase concern of organic disease:
- Rectal bleeding.
- Weight loss.
- Iron deficiency anaemia.
- Nocturnal symptoms – when these symptoms happen at night.
- Family history of selected organic disease including colorectal cancer, Inflammatory Bowel Disease (IBD) and coeliac disease.
Usually, it is recommended that patients who exhibit alarm features undergo further investigation to rule out organic disease. Researchers are yet to discover any specific cause for IBS. One theory is that people who suffer from IBS have a colon or large intestine that is particularly sensitive and reactive to certain foods and stress. The immune system, which fights infection, may also be involved.
What to Watch Out For?
- Pain: The intensity, location and timing of abnormal discomfort or pain in patients with IBS are highly variable. The pain may be so intense as to interfere with daily activities. Pain is most often described as crampy or achy, though sharp, dull and gas like pains are also reported.
- Constipation: Predominant IBS patients report stools that are hard or pellet-like, are difficult to pass, and are associated with a sensation of incomplete faecal evacuation.
- Diarrhoea: Patients mostly pass it soft or loose above the normal daily volume, which may occur after eating or during stress. Passage of faecal mucus is reported by 50 per cent of patients.
- Symptoms referable to other organs are also frequently reported by IBS patients. Large subsets have associated heartburn, early satiety, nausea, vomiting and dyspepsia (indigestion). High incidences of genitourinary dysfunction (severe uterine pain during menstruation, impotence, higher urinary frequency, and incomplete urinary evacuation), low back pain, headache, fatigue, insomnia and impaired concentration have been observed in individuals with IBS.
- Abnormal psychiatric features, including major depression, somatisation disorder (varied physical symptoms that have no identifiable physical origin), anxiety disorder, panic disorder, hostility, hypochondriasis (excessive preoccupation or worry about having a serious illness) and phobias are reported in up to 80 per cent of individuals with IBS.
Fact Finding Mission
Your gastroenterologist makes a positive diagnosis of IBS, based on your symptoms and the absence of alarm features. Extensive investigations to exclude most possibilities are not only expensive but have the danger of reinforcing abnormal illness behaviour in patients. Traditional screening tests – even though inexpensive – can be reassuring for both the patient and the physician if found negative or normal. These include a full blood count, kidney and liver function testing, thyroid function testing and evaluation of fresh stool samples for parasites.
- Sigmoidoscopy (the minimally invasive medical examination of the large intestine from the rectum through the last part of the colon) or colonoscopy (endoscopic examination of the colon and the distal part of the small bowel with a camera on a flexible tube passed through the anus) may be performed, especially in those older than 45 years.
- Biopsy (removal of cells or tissues for examination) of the colon during lower endoscopy is indicated in some patients with predominant diarrhoea to rule out microscopic colitis as a cause of symptoms.
- Upper endoscopy – examining the upper part of the gastrointestinal tract for reflux or dyspeptic symptoms like chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating – is also done
- Coeliac disease serology is obtained in individuals with possible coeliac disease. And if it they do, an endoscopic small intestinal biopsy is indicated.
Therapeutic trial of treatment is given on the basis of the severity of symptoms before investigations are performed in people without alarm symptoms.
- If patients do not respond to a therapeutic trial of treatment, then further intervention is required. If they are constipation predominant, and have infrequent bowel movements, then a colon transit study is suggested.
- If patients give a history of digital evacuation (the polite term for pushing out stuck faeces with the fingers) during defecation or symptoms of obstructive defecation or if the rectal examination suggests poor pelvic floor relaxation, your doctor will have to measure the pressure in your anal canal (anorectal manometry) with balloon expulsion studies.
- In diarrhoea predominant patients, 24-hour stool for fat, a trial of cholestyramine (which binds bile in the gastrointestinal tract to prevent its reabsorption), hydrogen breath tests for small bowel bacterial overgrowth, fructose (a simple fruit sugar) and sorbitol (a sugar alcohol that the human body metabolises slowly) intolerance are performed.
- Rectal sensory function is performed in a subgroup of patients.
- In those whom pain is the predominant symptom, abdominal X-rays, small bowel enema ultrasonography and CT, MRI scans of the abdomen are also done.
How Good Are Your Chances?
For some individuals, education and dietary advice is sufficient. However, most patients receive medications to reduce their symptoms. Some affected persons will be refractory to any treatment and are considered for psychological therapies. IBS usually persists in a waxing and waning fashion for many years. Patients are likely to report good outcomes in the following cases:
- those who are male.
- those with a brief history of symptoms.
- those with acute onset of IBS.
- those who exhibit predominant constipation.
- those who have a good initial response to treatment.
- those who can ingest food
- Changes in diet can be recommended for selected patients with IBS.
- Reducing fat content may decrease abdominal discomfort evoked by lipids.
- Increasing fibre content in the diet on consuming a fibre supplement upto 10-15 gm/day (Psylinum, Polycarbophil or Methylcellulose) may improve bowel function in constipated IBS patients. Fibre supplements, may take several weeks to work though, and may produce gaseous symptoms if large quantities are ingested rapidly. Go slow!
- Low gas diets have been devised to reduce bloating and excess flatulence (farts, in common parlance) in patients with IBS.
- Some patients with diarrhoea and excess gas may respond well to exclusion of dairy products or fruit and soft drinks that contain poorly absorbed sugars (fructose and sorbitol).