The Sensitive Gut

Overview

DO YOU EXPERIENCE FREQUENT STOMACHACHES
OR EXCESSIVE GAS AFTER EATING?
DOES EATING A SIMPLE MEAL LEAVE YOU
WITH A FEELING OF HEARTBURN?
DO CONSTIPATION AND DIARRHEA PLAGUE YOUR LIFE?

If you answered yes to any of these questions, you might be suffering from a gastrointestinal disorder. As many as one in ...

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Overview

DO YOU EXPERIENCE FREQUENT STOMACHACHES
OR EXCESSIVE GAS AFTER EATING?
DOES EATING A SIMPLE MEAL LEAVE YOU
WITH A FEELING OF HEARTBURN?
DO CONSTIPATION AND DIARRHEA PLAGUE YOUR LIFE?

If you answered yes to any of these questions, you might be suffering from a gastrointestinal disorder. As many as one in four people experience these troublesome symptoms, and they don't get the problem adequately diagnosed and treated.

In The Sensitive Gut, readers will learn that the root causes of these symptoms are often a group of disorders -- reflux disease, dyspepsia, irritable bowel syndrome (IBS), food allergies, or other conditions. The causes of these disorders are not fully understood, but their effects are quite real.

This valuable guide explains each of these disorders and, more important, describes how they are diagnosed and treated. You will learn:

• how heartburn is exacerbated by high-fat foods, onions, garlic, alcohol, and coffee

• how cauliflower and chewing gum can trigger IBS

• how to determine whether you have dyspepsia or an ulcer

• which oral laxatives seem to be the most effective and produce the fewest side effects

• and much more...

Besides suggesting eating plans to soothe and minimize symptoms, The Sensitive Gut also evaluates new alternative approaches such as relaxation response training, hypnosis, and biofeedback. Finally, lists of questions are included to help readers make the most of their time with their doctors.

A reassuring and practical guide to managing common intestinal distress, The Sensitive Gut can improve the quality of life for millions of Americans.

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Editorial Reviews

Library Journal
With the help of medical doctor Neimark, Salt has updated and improved his excellent book on Irritable Bowel Syndrome (IBS) (LJ 10/15/97). This second edition preserves Salt's clear writing and lively illustrations while completely revising the format. Instead of eight steps on learning to live with IBS, now there are seven steps, which put greater emphasis on choices and action. A nice addition is a chapter on journaling as a mind/spirit health tool, and helpful symbols scattered throughout indicate that more detailed information on a subject is available on the publisher's web site. This book is essential, even for libraries that own the first edition. The Sensitive Gut also deals with irritable bowel syndrome, but it includes other functional gastrointestinal disorders as well: heartburn, dyspepsia, excessive gas, and constipation. It carries the powerful creditability of Harvard Medical School, but its textbook-like format may scare off many potential readers. This is unfortunate, as the language is very clear and easy to understand. The book's conversational tone makes the explanation of the digestive system's mechanics one of the most entertaining yet concrete descriptions available. This guide also discusses the mind/gut connection and alternative medicine options, but since it covers a broader scope than Salt's book, there is less depth in most areas. This is a nice addition to larger collections but is not an essential purchase. KellyJo Houtz Griffin, Eatonville, WA Copyright 2001 Cahners Business Information.
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Product Details

  • ISBN-13: 9780743215046
  • Publisher: Free Press
  • Publication date: 1/28/2001
  • Edition description: Original
  • Pages: 224
  • Product dimensions: 5.60 (w) x 8.40 (h) x 0.60 (d)

Meet the Author

Harvard Medical School is a center of medical expertise composed of dozens of affiliated hospitals, clinics, research foundations, and publication centers. Throughout its history, Harvard's doctors have made important medical breakthroughs, including the discovery of anesthesia, the first human organ tranplantation (Nobel Prize), and the discovery of the polio virus (Nobel Prize).

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Read an Excerpt

Chapter 4: Irritable Bowel Syndrome

Man should strive to have his intestines relaxed all the days of his life.

— Moses Maimonides

Another common disorder of the intestines is irritable bowel syndrome (IBS). Its myriad of unpleasant symptoms affect tens of millions and have no known cause nor effective remedy.

Irritable bowel syndrome is probably the number-one reason why people see gastroenterologists, accounting for as many as 3.5 million physician visits and 2.2 million prescriptions per year. It accounts for an estimated 28 percent of patients seen by gastroenterologists and up to 12 percent of patients seen in primary-care offices.

The cost of all of this in dollars and cents is staggering. Studies have estimated the toll for caring for IBS patients at more than $8 billion in the United States alone. A Seattle study pegged the cost of caring for IBS sufferers at $4,044 per patient during the year in which they were diagnosed, a figure that is 35 percent higher than the average spent on treatment of patients with other illnesses.

For patients and doctors alike, irritable bowel syndrome is probably the most challenging of all functional gastro-intestinal (GI) disorders. A recent study found that patients with IBS have a significantly lower quality of life than persons without the syndrome and that the illness is seriously underdiagnosed. In fact, only 4 percent of study participants who met the criteria for having IBS had been diagnosed with the condition by a physician.

Medical historians credit John Howship, of St. George's Infirmary in London, with providing the first scientific description of IBS, in an 1830 article entitled "Spasmodic Stricture of the Colon as an Occasional Cause of Confinement of the Bowels." His theory was that the abdominal pain and altered bowel habits of IBS sufferers stem from colonic dysmotility or spasm of the colon. Through the years, the condition has been called by many names — spastic colon, spastic bowel, colitis, mucous colitis, and functional bowel disease among them. None of these is quite accurate, however, hence the catchall term irritable bowel syndrome.

Today, IBS affects 10 to 22 percent of otherwise healthy adults. While it is thought to affect both sexes nearly equally, men and women may actually suffer from different symptoms. In any case, women are three to five times more likely to see a doctor for the problem than are men.

About 70 percent of patients who see physicians for IBS are considered to have "mild" symptoms, and their lives are minimally impacted. About 25 percent are said to have "moderate" symptoms, which may cause them to miss work occasionally. And roughly 5 percent of patients suffer from "severe" symptoms that considerably affect their daily lives. Symptoms usually begin in young adulthood, though they can occur in children as well.

The causes of irritable bowel syndrome are obscure. Many believe it stems from an abnormality in the contractions of the muscles of the colon, which can result from any of several factors, including distension or stretching, food residues, intestinal hormones, and stress. They may all combine to induce an abnormality in the rhythm of the bowels. On the other hand, some experts think the problem is primarily psychological in origin. Still others believe IBS to be a heightened sensitivity to stress. Whatever the cause, IBS remains quite real to the millions who suffer its symptoms.

Despite frustrating and sometimes debilitating symptoms that keep sufferers preoccupied with the toilet, most sufferers don't consult a doctor. There may be good reason not to; the cost of seeking out care may be high, and the drugs used to treat IBS not only are expensive, but also offer scarce evidence of effectiveness. And, in some cases, IBS patients are liable to undergo unnecessary surgeries. Many simply try to cope on their own, tolerating the symptoms or attempting to alleviate them by avoiding certain foods, taking over-the-counter remedies or herbal preparations, or trying stress-reduction techniques.

What Is Irritable Bowel Syndrome?

Symptoms of irritable bowel syndrome usually begin to appear when a patient is anywhere between his or her twenties and forties. In a typical situation, you're a relatively healthy person, then one day you begin to suffer intermittent cramps in the lower abdomen. You have to move your bowels often, much more often than usual. And when you have to go, you have to get to a toilet right away.

Your stools are loose, watery, and possibly contain mucus — stuff you've never seen before in a bowel movement. Sometimes, you feel bloated and full of gas.

The cramps are relieved by a bowel movement (often diarrhea). After a while, however, the cramps return, but this time when you try to go to the bathroom, nothing happens. You're constipated.

Back and forth it goes: diarrhea, constipation, and pain and bloating in between.

You're probably suffering from irritable bowel syndrome, a catchall term for this mixed bag of symptoms, the most frequently reported of which is pain or discomfort in the abdomen, rather than a name for a solitary, specific complaint.

It's a common disorder with no known cause. People with IBS generally feel their pain subside after a bowel movement or passing gas. But they also may feel that they haven't fully emptied their rectum after a movement. While some patients may have daily episodes or continuous symptoms, others experience long symptom-free periods. These patterns may raise the question as to whether someone actually has irritable bowel syndrome as opposed to the occasional bowel complaints that may be considered part of the bowel's normal response to stress.

Sometimes, these bouts of bowel irregularities begin when one is about to undertake a stressful endeavor, such as taking a big exam or going out on a first date. "Nervous stomach" is what some would call it.

Whether it is IBS usually depends on frequency. The formal criterion for diagnosis is that symptoms have occurred during any three months of the previous twelve.

Fortunately, there is no organic basis for IBS. And doctors do not believe IBS is a forerunner of any more serious diseases, such as ulcerative colitis, Crohn's disease, or stomach cancer. But for the significant percentage of the population that experiences IBS, that's little comfort. They are suffering. If doctors can find nothing wrong, why are they suffering?

Doctors say that the irritable bowel is a disorder in the functioning of the intestinal tract. Some suspect disturbances in the functioning of nerves or muscles in the gut lay at the root; others believe abnormal processing of gut sensations in the brain may hold the key to at least some cases. Because no organic cause can be found, IBS often has been thought to be caused by emotional conflict, stress, or some other psychological factor. While such factors may worsen symptoms, however, researchers suggest that other factors are also at work.

Motility and Transit

Because the spasmodic pain associated with IBS seems to emanate from the colon, numerous investigators have searched for the condition's cause in irregularities in the way food makes its way through this part of the gastrointestinal tract. Findings, however, have been inconsistent.

Colon motility (contractions of intestinal muscles and movement of its contents) is controlled by nerves, hormones, and electrical activity in the colon muscle. The electrical activity acts like a pacemaker and is similar to the mechanism that regulates heartbeat.

Movement of the colon propels the contents slowly back and forth, but mainly in the direction of the rectum. A few times a day, strong contractions move down the colon, pushing the contents ahead, resulting in a bowel movement.

Some researchers have found that the colon muscle of a person with IBS begins to spasm after only mild stimulation. The colon seems to be more sensitive and reactive than usual, they found, so it responds strongly to stimuli that would not affect other people. Sometimes, the spasms lead to diarrhea, other times to constipation. Other researchers, however, counter with studies showing that colonic motor activity is no different for IBS patients than for anyone else.

Some studies have suggested that diarrhea is associated with rapid small-intestinal transit and constipation with slow transit. In addition, there are studies that have shown that clustered contractions — short bursts of muscle activity separated by long rest periods — occur more often in the small intestines of IBS patients than other people and may be associated with abdominal pain. Still other studies, though, have found these contractions to be just as frequent in healthy people without symptoms. In short, studies have shown no consistent motility pattern in patients with IBS. While it appears that motility plays a role in IBS pain, that exact role remains a mystery.

Perception

Another possible explanation for irritable bowel syndrome's bothersome symptoms is that people with IBS have a heightened awareness of the inner workings of their gut. In several well-known experiments in which balloons were inflated in the sigmoid colon, rectum, and small intestine, IBS patients usually had a much lower threshold for pain than healthy volunteers. Scientists believe that the lower threshold for internal pain may be related to the dispatch of nerve signals from the gut to the brain.

Indeed, people with IBS may just be more sensitive to a variety of ailments, perhaps their entire bodies are hyperreactive. People with irritable bowel complaints may also have more headaches, palpitations, chest tightness, shortness of breath, and chronic fatigue than the general population. They might feel pain more intensely, complain more about colds; some researchers even surmise that they suffer more anxiety and depression than other people and, when questioned, are more likely to regard themselves as being "sick."

Hormone and Dietary Factors

Hormones produced in the GI tract, such as cholecystokinin, which stimulates gallbladder contractions after a meal, and motilin, which helps regulate bowel motility, have been suspected of triggering IBS symptoms, but studies have not been definitive. Researchers have also found that women with IBS may have more symptoms during their menstrual periods, suggesting that reproductive hormones can increase IBS symptoms.

Certain medicines — such as antacids, antibiotics, beta blockers, and narcotics — and foods may trigger spasms in some people. Sometimes the spasm delays the passage of stool, leading to constipation. Chocolate, dairy products, or large amounts of alcohol are frequent offenders in these cases. Some people simply can't tolerate certain dietary substances such as lactose (a sugar found in milk), fructose (a sugar found in fruit and used as a sweetener), and sorbitol (an artificial sweetener) and develop bloating and diarrhea as a result. In addition, though caffeine causes loose stools in many people, it is more likely to affect those with IBS.

Sometimes, bran may increase IBS symptoms. Wheat flour, too, is a culprit in some cases. On the other hand, some believe lack of fiber in the diet may contribute to IBS, but not everyone with IBS improves on a high-fiber diet. Some may even feel worse.

Fats can also contribute to IBS symptoms. Fat in any form (animal or vegetable) is a strong stimulant of colonic contractions after a meal. Many foods contain fat, especially meats, poultry skin, dairy products, vegetable oil, and margarine and shortening.

Stress

Many experts are convinced that there is a strong psychological component to irritable bowel syndrome, and stress is known to stimulate colonic spasms in people with IBS. The process is not completely understood, but scientists point out that the colon is controlled partly by the nervous system. Some studies have shown significantly higher stress levels among people with IBS compared to healthy individuals. And stress reduction or relaxation training or counseling has helped to relax IBS symptoms in some people.

But even this theory is not ironclad, as there are many people — with and without IBS — who manifest gut reactions to stressful life events. The bad effects stress has on IBS may be no different from those it has upon any other disorder of the body.

Psychological Factors

Despite the influence of emotions, there is no evidence that IBS is a completely imaginary complaint; the symptoms are real and troublesome enough in many cases to warrant attention. Yet there is one school of thought claiming that nearly all cases of IBS are psychological in nature, that the symptoms are merely the mind's attempt to take its focus off emotional problems that, if dwelled upon, could be even more upsetting to the person than the gastrointestinal distress. All of this remains in the theoretical realm, however.

It is a fact, though, that studies conducted at medical centers have found considerably more psychiatric problems among IBS patients than among healthy people or those with structural bowel diseases. Between 42 and 61 percent of patients with functional bowel disorders who are seen in gastrointestinal clinics also have a current psychiatric diagnosis — usually anxiety or depression, according to a report by Dr. Douglas A. Drossman of the University of North Carolina. But most patients do not see the psychiatric symptoms as being as important as their physical symptoms.

Despite this disturbing fact, many experts feel that formal psychiatric care is not needed for most IBS patients, nor has it proved especially helpful. On the other hand, some sessions with a good therapist may help patients manage their illness better. And such sessions could uncover and treat a problem with depression, for example, which may be either a cause or a result of the patient's IBS.

Psychiatric disorders frequently associated with severe IBS include trauma from childhood abuse, depression, anxiety, phobia, and somatization, a condition in which psychological stresses manifest as physical complaints. Sometimes, the onset of IBS symptoms is preceded by a life-threatening event or a major crisis such as a divorce or a loved one's death.

Although it is important to attend to the emotional problems of those suffering from IBS, it appears that a person's psychological state is not the only factor to be considered when trying to determine the origin of the irritable gut. That said, however, there is some evidence that antidepressants may be useful in treating IBS. The reasons are not clear why. It may be that when patients feel less depressed, they complain less about their bowels. Or it may prove that the drugs used to treat depression actually have additional beneficial effects on gut function.

Why some people with IBS go to the doctor and others don't is also a good question, though it appears that those who do seek care may be experiencing more discomfort. It may be that psychosocial factors influence this decision, too: attitudes toward illness and pain are important factors and may date back to behaviors learned in childhood. It appears that IBS sufferers are more prone to chronic illness behavior and that this behavior may be learned. Chronic illness behavior is a term describing the depression and discouragement that often accompany life with chronic illness, and it may include the inability to sleep, weight loss, undernourishment, or the inability to hold a job. Some doctors see such behaviors as an involuntary response to living with chronic illness, but others look upon chronic illness behavior as no more than patients "acting ill" in order to secure some secondary gain, such as the attention of a spouse or child.

Diagnosing Irritable Bowel Syndrome

Since there are no tests for irritable bowel syndrome, the illness must be diagnosed entirely by the symptoms being experienced by the patient and a limited number of tests to exclude the likelihood of an organic disease. Fortunately, a positive diagnosis usually can be made on the first visit to a doctor.

The doctor must take a complete medical history that includes a careful description of symptoms. A physical exam and laboratory tests likely will also be done, and a stool sample will probably be tested for evidence of bleeding. In some cases, the doctor may also perform diagnostic procedures such as endoscopy (specifically sigmoidoscopy) and possibly take X rays to find out if there is any evidence of disease such as colitis, colon cancer, or inflammatory bowel disease.

At this stage as few costly, invasive tests as possible are used to determine whether a patient is suffering from a specific, identifiable "organic" condition or irritable bowel syndrome. To accomplish this, experts in the treatment of gastrointestinal illnesses have developed a specific set of criteria to identify people with irritable bowel syndrome. A person is strongly suspected to have the syndrome if he or she has experienced abdominal pain or discomfort on a continuous or recurring basis for a total time of at least three of the previous twelve months, along with two of the following three additional features:

  • The abdominal pain or discomfort is relieved with a bowel movement
  • The onset of the pain is associated with a change in the frequency of stool
  • The onset of the pain is associated with a change in the consistency of stool

In addition, the following symptoms are not considered essential for diagnosis, but if present are considered support for the diagnosis. They may also be used to identify certain types of IBS.

  • Abnormal stool frequency (more than three bowel movements per day or less than three per week)
  • Abnormal stool form (unusually hard or loose stool more than one out of every four times)
  • Abnormal stool passage (straining, urgency, or the feeling of incomplete evacuation more than one in four times)
  • Passage of mucus more than once in every four defecations
  • Bloating or the sensation of having a distended abdomen more than one out of every four days

In questioning the patient about symptoms and performing a clinical exam, the physician should assess the total picture, including the nature and timing of pain, bowel habits, and other complaints. IBS symptoms can vary widely; pain can range from mild to intense, but it rarely interferes with normal eating and usually does not awaken a person during the night.

An attempt should be made to correlate symptoms with specific foods and medications, with particular emphasis on the consumption of milk products (to rule out lactose intolerance) and foods and beverages that contain fructose or sorbitol. Patients may need to keep food diaries for a few weeks to see if they can identify foods that provoke symptoms.

At the same time, it is especially important to consider emotional and psychological triggers for a patient's symptoms. Physicians will want to know what prompted the visit and will want to ask about the patient's lifestyle and stress level. After all, it's not unusual for traumatic life events, such as divorce or the loss of a job, to wreak havoc on the bowels and psyche. The doctor must also try to establish that the patient has no serious mental disturbance. A referral to a mental-health professional may be indicated in some cases.

Doctors must also make sure to exclude the presence of organic diseases. To this end, they will ask questions about the pain being experienced:

  • To where does the pain radiate? Pain caused by gallstones, for example, may radiate to the chest, while some ulcers may cause pain that radiates to the back. While patterns of pain for IBS are not so easily definable, the most frequently reported symptom is pain or discomfort in the abdomen that is poorly localized, migratory or variable in nature, and usually relieved by defecation.
  • Is the pain steady or cyclical? Ulcer pain tends to be cyclical. It is relieved by eating but may come back in the middle of the night. By contrast, pain caused by cancer tends to be continuous.
  • Is there cramping? Cramps may signal intestinal obstruction.

Other symptoms that accompany the pain may offer clues as to the cause of a patient's discomfort, too. If there is pain in the lower abdomen and a change in bowel movements, an abnormality in the large intestine may be present. A combination of pain and fever can signal inflammation (such as diverticulitis), which requires immediate medical attention.

Another major diagnostic clue is any bleeding in the digestive tract. People with IBS can have rectal bleeding, but it's usually due to trivial causes — internal hemorrhoids, for example — and never to IBS alone. Bright-red blood comes from the lower digestive tract, while black, tarry blood comes from the upper portion of the tract. If there is bleeding, more tests must be performed to determine the cause.

A physical exam will also be performed. During the exam, the physician will look for tenderness in the abdomen. If it is located in the lower right part, it may signal appendicitis; in the upper right part, inflammation of the gallbladder or liver. The doctor will also check for masses caused by tumors, large cysts, or impacted stool.

A digital rectal exam is also usually part of the exam. In the exam, the doctor feels for masses in the rectum and, in males, the prostate. If a serious disorder is suspected, more tests will be ordered immediately.

Additional tests may include a complete blood count and erythrocyte sedimentation rate test, which measures the speed at which mature red blood cells settle; it can be used to screen for inflammatory disease. If the hemoglobin, white count, erythrocyte sedimentation rate, and temperature are normal and the patient's symptoms are typical of IBS, no further tests may be needed.

For patients with persistent diarrhea, stool samples will be examined for infectious agents that include intestinal parasites. Occasionally, the doctor may arrange for a three-day stool collection to check for excess fecal fat content (more than seven grams of fat per day) or weight (more than 200 grams of feces per day), neither of which is consistent with a diagnosis of IBS. Either may be an indicator instead of an organic problem such as inflammatory bowel disease, malabsorption, or even cancer.

And despite efforts to avoid expensive tests, a patient's age or atypical symptoms may persuade the doctor to conduct even more diagnostic procedures, such as sigmoidoscopy or colonoscopy.

A flexible sigmoidoscopy may be performed to check for tumors, particularly in people over the age of forty, or inflammatory bowel disease. The procedure, which permits observation of the rectum and sigmoid colon through a viewing tube and can be used to take a tissue sample, may be performed in the doctor's office with no anesthesia. Such a test, while somewhat uncomfortable, can also provide a measure of relief to the patient. In any patient over age forty, a colonoscopy or barium enema, may also be ordered to rule out colon cancer.

When it comes to tests, common sense should prevail: not every patient with a gut problem should get every test, especially because, unfortunately, no test can confirm IBS. Thus, patients should discuss each option carefully with the doctor before proceeding with any course of testing or treatment. Aggressive investigation may uncover an alternative diagnosis, or it may provide reassurance to patients and doctors that a potentially serious illness has not been overlooked.

The physical exam will usually not reveal anything other than perhaps a mildly tender abdomen in a patient with IBS. And lab tests are generally normal in IBS patients.

Despite the long list of possible tests, however, remember that an experienced gastroenterologist will likely be able to make a preliminary determination as to whether IBS is the problem on hearing the patient's initial story.

Managing Irritable Bowel Syndrome

If you think that diagnosing IBS is tricky, wait until you try managing it. Diagnosis is only the beginning — the real quandary is figuring out a way to live with it.

While there may be comfort in knowing that the condition is benign, the relief probably won't last long because you'll soon find out that the prognosis for IBS sufferers can mean years — maybe a lifetime — of bowel distress.

If doctors knew what caused this group of symptoms, treatment would be easier and aimed at providing comfort and eliminating those causes. But that is not yet the case. As a result, treatment is directed at individual symptoms, and the process is somewhat hit-or-miss and complete relief is sometimes difficult to obtain. The frustration this can induce has sent many IBS sufferers into the world of alternative or complementary therapies to try such remedies as hypnosis, biofeedback, or herbs, with varying degrees of success.

Accordingly, the management of IBS requires a great deal of understanding between doctor and patient. When a patient has a clear-cut organic disease, such as an ulcer, the treatment plan is not a matter of debate. In contrast, the proper treatment of functional disorders such as irritable bowel syndrome is not so clear.

Patients need to educate themselves about IBS and receive adequate information from their physicians so they can learn to manage the syndrome and regain control over their lives. At least one study found that strong communication between doctor and patient reduced the number of IBS follow-up visits.

What is known about IBS is that something has disrupted the automatic functioning of the bowel, and the first task in management is to search for possible irritants coming from outside or arising from within the body. The natural place to start is with something consumed — foods, beverages, or drugs, for example.

Common sense should prevail in treating IBS, and so the first step should be the easiest: dietary measures.

Patients should eliminate likely food triggers — caffeine, sorbitol-containing gum or beverages, dairy products, alcohol, apples and other raw fruits, fatty foods, and gas-producing vegetables like beans, cabbage, and broccoli — to see if symptoms subside. Some call it "eating bland."

Should milk be found to be a problem, lactose-intolerant individuals can take supplements of the enzyme lactase if they can't always (or don't want to) avoid milk. There are also a host of lactose-free milk products on the market.

The most common dietary recommendation for IBS sufferers is adding fiber to increase the stool's bulk and speed the movement of contents through the gastrointestinal tract. The refined diet of the Western world, which is low in fiber, has been compared to the fiber-rich diets of much of the rest of the world, and our low fiber content has been blamed by some for the high rates of IBS in America. This connection, however, has not been proven, and a high-fiber diet does not always improve bowel symptoms. Still, many clinical trials have shown that bulking up on fiber does seem to relieve constipation and ease abdominal pain. It may even alleviate diarrhea.

To increase fiber intake, doctors usually recommend bran or a fiber supplement, such as psyllium or methylcellulose, available in many products found in supermarkets or drugstores. Fiber should be introduced gradually, however, because too much too soon can cause excessive gas, cramping, and bloating.

For some people, these dietary measures may be all that is needed to reduce symptoms and calm the belly. One study noted improvement in most patients who follow these recommendations, but many patients continue to have flare-ups after an initial response to therapy.

When Problems Persist

There are certain occasions when doctors will consider the use of drug therapy for patients who continue to experience symptoms troublesome enough to impair daily function. While these drugs can't cure irritable bowel syndrome, they may help to ease symptoms.

To date, despite dozens of scientific trials, no drug has proven to be generally effective against IBS — yet data show that one-third to one-half of patients with functional complaints actually improve on placebo. In any case, there are times when the doctor may want to prescribe drugs for specific indications such as diarrhea, cramping, or pain.

Anticholinergics Drugs such as atropine and related agents, like dicyclomine (Bentyl), hyoscyamine (Levsin), and chlordiazepoxide (Librax), may relieve mild abdominal pain because as antispasmodics they reduce bowel spasms. People who often experience cramps after eating may obtain some relief if they take the antispasmodic medications before meals. The idea is to ensure maximum anticholinergic effect at the time symptoms are expected, while allowing minimum exposure to side effects.

Antidepressants Amitriptyline (Elavil) and desipramine (Norpramin) may sometimes be prescribed for patients who have diarrhea-predominant IBS. These tricyclic antidepressants should be used at low doses, however, and should be used only by patients who have diarrhea-predominant IBS, as they can cause constipation. The newer selective-seratonin-reuptake inhibitors (SSRIs), such as sertraline (Zoloft), may be helpful in treating abdominal pain in patients who suffer primarily from constipation-related IBS. Another SSRI, paroxetine (Paxil), may be used to treat abdominal pain in diarrhea-predominant IBS because of its anticholinergic antidiarrheal effect.

A Mayo Clinic study found that patients with gastrointestinal disorders taking antidepressants had no significant demonstrable changes in gastrointestinal motility. However, the patients did have a significant improvement in their gastrointestinal-symptom ratings and significant improvement in their overall sense of well-being.

Another study, from Belgium, looked at the effects of the SSRI citalopram on the physiology of the colon and found that when patients had balloons inflated in their colons, there was a slight relaxation of the colon. This was followed by an intravenous dose of citalopram. Patients reported a reduction of discomfort. The findings led the researchers to conclude that the drug may reduce visceral hypersensitivity by relaxing the colon.

Current research is focusing more on the gut-brain connection, which appears to play a role in IBS. Serotonin-like medications are among those being investigated. However, the first of these to be approved, alosetron (Lotronex), which works on the serotonin type III receptor, was a disaster and was pulled from the market just a year after winning FDA approval. The FDA urged Lotronex be taken off the shelves after receiving reports of three deaths and dozens of serious side effects in patients using the drug. In most of the reported cases, patients developed ischemic colitis, a potentially life-threatening inflammation of the large intestine that can occur when blood flow to that area of the gastrointestinal tract is blocked. In some cases, the drug caused constipation so severe that surgery was needed to unblock their intestines. One patient needed her colon removed.

Lotronex was the first new drug in decades for treatment of IBS and had been approved only for treatment of women whose main IBS problem was diarrhea.

Loperamide (Imodium) and diphenoxylate (Lomotil) These medications are generally recommended for patients whose main complaint is diarrhea. Loperamide, available over the counter, reduces the secretion of fluid by the intestine. Diphenoxylate, available by prescription only, helps to slow down intestinal contractions. It is related to codeine and contains atropine as well. Doctors generally favor preparations that don't contain codeine or other narcotics, because they may have adverse nervous-system effects, including sedation, drowsiness, and confusion.

Beyond Drugs

Herbal remedies and other alternative or complementary therapies — as well as behavior techniques and psychotherapy — are being used frequently by patients with IBS when standard therapies don't work. One recent study conducted at the Royal London School of Medicine in England questioned 225 patients with intestinal problems. Of those with IBS, half were using complementary therapies. Most of these remedies are used to address the psychological components of the disorder.

Research shows that any of several stress-reducing techniques taught by psychologists or other specially trained medical professionals can help some patients. People should consider cost and availability in their community when choosing which ones to try, and should also know that there is little evidence available to prove the effectiveness of herbal remedies.

Among the most popular approaches are the following:

Relaxation-response training and meditation Simple and easy to learn, this technique helps reduce nervous-system activity and relaxes muscles. Meditation, including transcendental meditation (TM), has been shown to be very helpful in lowering blood pressure, for example. Similarly, the technique can help relax the intestinal muscle.

Yoga Some forms of yoga, the ancient Indian spiritual discipline that seeks to bring the body and mind into balance, have proven valuable to some IBS sufferers. Yoga, like meditation, can help the patient induce a form of self-relaxation. The ancient tradition, which emphasizes special breathing exercises, recognizes the intimate connection between the breath and the nervous system. The yogis believe that if one can learn to control the breath, he or she can learn to control, or at least influence, how he or she feels both emotionally and physically.

Hypnosis Hypnotherapy was strongly associated with improved IBS symptoms by one study presented in 2000 by researchers at the Eastern Virginia Medical School in Norfolk. About 85 percent of study participants who were given hypnosis sessions and audiotapes at home reported improvement in all IBS symptoms after fourteen weeks. Significant improvement was found in abdominal pain, bloating, stool consistency, and other involuntary body activities. After the course of hypnotherapy, the autonomic nervous system was less easily stimulated. The researchers theorized that the calming effect of hypnosis may have contributed to the improvement in symptoms.

Acupuncture One study of twenty-seven patients who received acupuncture treatments three times per week for two weeks found improvements in their quality of life and gastrointestinal-symptom scores. The results were the same as those observed among a comparison group that received relaxation training. However, the patients who received the acupuncture were more likely to see their pain reduction persist over the course of a four-week follow-up.

Biofeedback A mind/body technique in which participants see and realize their body's response to stimuli such as pain, biofeedback's proponents believe that it helps people modify their body's responses to these stimuli. With visual devices and easy instructions, patients can be taught how to alter such apparently automatic responses as the skin's temperature, for example, by altering the flow of blood to it. Some patients who have lost control of their bowels have been trained to better control them using biofeedback techniques to change the sphincter muscle's ability to contract. In one study, conducted at the University of Tennessee in Memphis, a biofeedback technique developed by NASA as a therapy for motion sickness was found to be effective for constipation. Study participants said that their symptoms — nausea, vomiting, abdominal pain, and gas — improved after just three sessions. Some say the technique works especially well for cramping.

Herbal remedies A number of herbs and other natural substances are being used by a growing portion of patients in pursuit of relief from IBS symptoms. Among the most popular substances are St. John's wort, fish oils, flaxseed oil, aloe vera juice, and a variety of Chinese herbs. Unfortunately, there are few studies to gauge the effectiveness of any of these remedies. A new product, however, made from fish protein, was found in one study to significantly reduce some IBS symptoms.

Psychotherapy Experts disagree on whether formal psychoanalysis is helpful in combating IBS. However, talking things out with an experienced and realistic therapist may help patients reduce stress and provide coping skills that improve mental health and associated physical ailments. In a 1983 Swedish study, IBS patients who combined medical treatment with individual psychotherapy showed more short-term and long-term improvement than those who had only medical therapy. A possible benefit of psychotherapy may be the discovery by the patient that he or she is depressed and that the depression is either a cause or result of IBS.

The important thing to remember throughout all searches for diagnoses and remedies is that every IBS patient is unique and that treatments should be tailored to the specific symptoms and needs of each individual. The good news is that IBS poses no threat to your life — with the right attitude and therapy techniques, patients can learn to live with irritable bowel syndrome while experiencing a minimum of interruption to their daily lives.

Copyright © 2000, 2001 by the President and Fellows of Harvard College

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Table of Contents

Contents

Introduction

1

How the Gut Works

2

Gastroesophageal Reflux Disease

3

Functional Dyspepsia

4

Irritable Bowel Syndrome

5

Diseases with Symptoms Similar to Irritable Bowel Syndrome

6

Constipation

7

Diarrhea

8

Excessive Gas

9

Food Allergies and Intolerances

10

Psychological Factors

11

The Aging Gastrointestinal Tract

12

The Rome Criteria

13

Good Gut Hygiene: Some Concluding Thoughts

Appendix

Drugs Used to Treat Functional Gastrointestinal Disorders

Glossary

Resources

Index

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First Chapter

Chapter 4: Irritable Bowel Syndrome
Man should strive to have his intestines relaxed all the days of his life.

-- Moses Maimonides

Another common disorder of the intestines is irritable bowel syndrome (IBS). Its myriad of unpleasant symptoms affect tens of millions and have no known cause nor effective remedy.

Irritable bowel syndrome is probably the number-one reason why people see gastroenterologists, accounting for as many as 3.5 million physician visits and 2.2 million prescriptions per year. It accounts for an estimated 28 percent of patients seen by gastroenterologists and up to 12 percent of patients seen in primary-care offices.

The cost of all of this in dollars and cents is staggering. Studies have estimated the toll for caring for IBS patients at more than $8 billion in the United States alone. A Seattle study pegged the cost of caring for IBS sufferers at $4,044 per patient during the year in which they were diagnosed, a figure that is 35 percent higher than the average spent on treatment of patients with other illnesses.

For patients and doctors alike, irritable bowel syndrome is probably the most challenging of all functional gastro-intestinal (GI) disorders. A recent study found that patients with IBS have a significantly lower quality of life than persons without the syndrome and that the illness is seriously underdiagnosed. In fact, only 4 percent of study participants who met the criteria for having IBS had been diagnosed with the condition by a physician.

Medical historians credit John Howship, of St. George's Infirmary in London, with providing the first scientific description of IBS,in an 1830 article entitled "Spasmodic Stricture of the Colon as an Occasional Cause of Confinement of the Bowels." His theory was that the abdominal pain and altered bowel habits of IBS sufferers stem from colonic dysmotility or spasm of the colon. Through the years, the condition has been called by many names -- spastic colon, spastic bowel, colitis, mucous colitis, and functional bowel disease among them. None of these is quite accurate, however, hence the catchall term irritable bowel syndrome.

Today, IBS affects 10 to 22 percent of otherwise healthy adults. While it is thought to affect both sexes nearly equally, men and women may actually suffer from different symptoms. In any case, women are three to five times more likely to see a doctor for the problem than are men.

About 70 percent of patients who see physicians for IBS are considered to have "mild" symptoms, and their lives are minimally impacted. About 25 percent are said to have "moderate" symptoms, which may cause them to miss work occasionally. And roughly 5 percent of patients suffer from "severe" symptoms that considerably affect their daily lives. Symptoms usually begin in young adulthood, though they can occur in children as well.

The causes of irritable bowel syndrome are obscure. Many believe it stems from an abnormality in the contractions of the muscles of the colon, which can result from any of several factors, including distension or stretching, food residues, intestinal hormones, and stress. They may all combine to induce an abnormality in the rhythm of the bowels. On the other hand, some experts think the problem is primarily psychological in origin. Still others believe IBS to be a heightened sensitivity to stress. Whatever the cause, IBS remains quite real to the millions who suffer its symptoms.

Despite frustrating and sometimes debilitating symptoms that keep sufferers preoccupied with the toilet, most sufferers don't consult a doctor. There may be good reason not to; the cost of seeking out care may be high, and the drugs used to treat IBS not only are expensive, but also offer scarce evidence of effectiveness. And, in some cases, IBS patients are liable to undergo unnecessary surgeries. Many simply try to cope on their own, tolerating the symptoms or attempting to alleviate them by avoiding certain foods, taking over-the-counter remedies or herbal preparations, or trying stress-reduction techniques.


What Is Irritable Bowel Syndrome?

Symptoms of irritable bowel syndrome usually begin to appear when a patient is anywhere between his or her twenties and forties. In a typical situation, you're a relatively healthy person, then one day you begin to suffer intermittent cramps in the lower abdomen. You have to move your bowels often, much more often than usual. And when you have to go, you have to get to a toilet right away.

Your stools are loose, watery, and possibly contain mucus -- stuff you've never seen before in a bowel movement. Sometimes, you feel bloated and full of gas.

The cramps are relieved by a bowel movement (often diarrhea). After a while, however, the cramps return, but this time when you try to go to the bathroom, nothing happens. You're constipated.

Back and forth it goes: diarrhea, constipation, and pain and bloating in between.

You're probably suffering from irritable bowel syndrome, a catchall term for this mixed bag of symptoms, the most frequently reported of which is pain or discomfort in the abdomen, rather than a name for a solitary, specific complaint.

It's a common disorder with no known cause. People with IBS generally feel their pain subside after a bowel movement or passing gas. But they also may feel that they haven't fully emptied their rectum after a movement. While some patients may have daily episodes or continuous symptoms, others experience long symptom-free periods. These patterns may raise the question as to whether someone actually has irritable bowel syndrome as opposed to the occasional bowel complaints that may be considered part of the bowel's normal response to stress.

Sometimes, these bouts of bowel irregularities begin when one is about to undertake a stressful endeavor, such as taking a big exam or going out on a first date. "Nervous stomach" is what some would call it.

Whether it is IBS usually depends on frequency. The formal criterion for diagnosis is that symptoms have occurred during any three months of the previous twelve.

Fortunately, there is no organic basis for IBS. And doctors do not believe IBS is a forerunner of any more serious diseases, such as ulcerative colitis, Crohn's disease, or stomach cancer. But for the significant percentage of the population that experiences IBS, that's little comfort. They are suffering. If doctors can find nothing wrong, why are they suffering?

Doctors say that the irritable bowel is a disorder in the functioning of the intestinal tract. Some suspect disturbances in the functioning of nerves or muscles in the gut lay at the root; others believe abnormal processing of gut sensations in the brain may hold the key to at least some cases. Because no organic cause can be found, IBS often has been thought to be caused by emotional conflict, stress, or some other psychological factor. While such factors may worsen symptoms, however, researchers suggest that other factors are also at work.

Motility and Transit

Because the spasmodic pain associated with IBS seems to emanate from the colon, numerous investigators have searched for the condition's cause in irregularities in the way food makes its way through this part of the gastrointestinal tract. Findings, however, have been inconsistent.

Colon motility (contractions of intestinal muscles and movement of its contents) is controlled by nerves, hormones, and electrical activity in the colon muscle. The electrical activity acts like a pacemaker and is similar to the mechanism that regulates heartbeat.

Movement of the colon propels the contents slowly back and forth, but mainly in the direction of the rectum. A few times a day, strong contractions move down the colon, pushing the contents ahead, resulting in a bowel movement.

Some researchers have found that the colon muscle of a person with IBS begins to spasm after only mild stimulation. The colon seems to be more sensitive and reactive than usual, they found, so it responds strongly to stimuli that would not affect other people. Sometimes, the spasms lead to diarrhea, other times to constipation. Other researchers, however, counter with studies showing that colonic motor activity is no different for IBS patients than for anyone else.

Some studies have suggested that diarrhea is associated with rapid small-intestinal transit and constipation with slow transit. In addition, there are studies that have shown that clustered contractions -- short bursts of muscle activity separated by long rest periods -- occur more often in the small intestines of IBS patients than other people and may be associated with abdominal pain. Still other studies, though, have found these contractions to be just as frequent in healthy people without symptoms. In short, studies have shown no consistent motility pattern in patients with IBS. While it appears that motility plays a role in IBS pain, that exact role remains a mystery.

Perception

Another possible explanation for irritable bowel syndrome's bothersome symptoms is that people with IBS have a heightened awareness of the inner workings of their gut. In several well-known experiments in which balloons were inflated in the sigmoid colon, rectum, and small intestine, IBS patients usually had a much lower threshold for pain than healthy volunteers. Scientists believe that the lower threshold for internal pain may be related to the dispatch of nerve signals from the gut to the brain.

Indeed, people with IBS may just be more sensitive to a variety of ailments, perhaps their entire bodies are hyperreactive. People with irritable bowel complaints may also have more headaches, palpitations, chest tightness, shortness of breath, and chronic fatigue than the general population. They might feel pain more intensely, complain more about colds; some researchers even surmise that they suffer more anxiety and depression than other people and, when questioned, are more likely to regard themselves as being "sick."

Hormone and Dietary Factors

Hormones produced in the GI tract, such as cholecystokinin, which stimulates gallbladder contractions after a meal, and motilin, which helps regulate bowel motility, have been suspected of triggering IBS symptoms, but studies have not been definitive. Researchers have also found that women with IBS may have more symptoms during their menstrual periods, suggesting that reproductive hormones can increase IBS symptoms.

Certain medicines -- such as antacids, antibiotics, beta blockers, and narcotics -- and foods may trigger spasms in some people. Sometimes the spasm delays the passage of stool, leading to constipation. Chocolate, dairy products, or large amounts of alcohol are frequent offenders in these cases. Some people simply can't tolerate certain dietary substances such as lactose (a sugar found in milk), fructose (a sugar found in fruit and used as a sweetener), and sorbitol (an artificial sweetener) and develop bloating and diarrhea as a result. In addition, though caffeine causes loose stools in many people, it is more likely to affect those with IBS.

Sometimes, bran may increase IBS symptoms. Wheat flour, too, is a culprit in some cases. On the other hand, some believe lack of fiber in the diet may contribute to IBS, but not everyone with IBS improves on a high-fiber diet. Some may even feel worse.

Fats can also contribute to IBS symptoms. Fat in any form (animal or vegetable) is a strong stimulant of colonic contractions after a meal. Many foods contain fat, especially meats, poultry skin, dairy products, vegetable oil, and margarine and shortening.

Stress

Many experts are convinced that there is a strong psychological component to irritable bowel syndrome, and stress is known to stimulate colonic spasms in people with IBS. The process is not completely understood, but scientists point out that the colon is controlled partly by the nervous system. Some studies have shown significantly higher stress levels among people with IBS compared to healthy individuals. And stress reduction or relaxation training or counseling has helped to relax IBS symptoms in some people.

But even this theory is not ironclad, as there are many people -- with and without IBS -- who manifest gut reactions to stressful life events. The bad effects stress has on IBS may be no different from those it has upon any other disorder of the body.

Psychological Factors

Despite the influence of emotions, there is no evidence that IBS is a completely imaginary complaint; the symptoms are real and troublesome enough in many cases to warrant attention. Yet there is one school of thought claiming that nearly all cases of IBS are psychological in nature, that the symptoms are merely the mind's attempt to take its focus off emotional problems that, if dwelled upon, could be even more upsetting to the person than the gastrointestinal distress. All of this remains in the theoretical realm, however.

It is a fact, though, that studies conducted at medical centers have found considerably more psychiatric problems among IBS patients than among healthy people or those with structural bowel diseases. Between 42 and 61 percent of patients with functional bowel disorders who are seen in gastrointestinal clinics also have a current psychiatric diagnosis -- usually anxiety or depression, according to a report by Dr. Douglas A. Drossman of the University of North Carolina. But most patients do not see the psychiatric symptoms as being as important as their physical symptoms.

Despite this disturbing fact, many experts feel that formal psychiatric care is not needed for most IBS patients, nor has it proved especially helpful. On the other hand, some sessions with a good therapist may help patients manage their illness better. And such sessions could uncover and treat a problem with depression, for example, which may be either a cause or a result of the patient's IBS.

Psychiatric disorders frequently associated with severe IBS include trauma from childhood abuse, depression, anxiety, phobia, and somatization, a condition in which psychological stresses manifest as physical complaints. Sometimes, the onset of IBS symptoms is preceded by a life-threatening event or a major crisis such as a divorce or a loved one's death.

Although it is important to attend to the emotional problems of those suffering from IBS, it appears that a person's psychological state is not the only factor to be considered when trying to determine the origin of the irritable gut. That said, however, there is some evidence that antidepressants may be useful in treating IBS. The reasons are not clear why. It may be that when patients feel less depressed, they complain less about their bowels. Or it may prove that the drugs used to treat depression actually have additional beneficial effects on gut function.

Why some people with IBS go to the doctor and others don't is also a good question, though it appears that those who do seek care may be experiencing more discomfort. It may be that psychosocial factors influence this decision, too: attitudes toward illness and pain are important factors and may date back to behaviors learned in childhood. It appears that IBS sufferers are more prone to chronic illness behavior and that this behavior may be learned. Chronic illness behavior is a term describing the depression and discouragement that often accompany life with chronic illness, and it may include the inability to sleep, weight loss, undernourishment, or the inability to hold a job. Some doctors see such behaviors as an involuntary response to living with chronic illness, but others look upon chronic illness behavior as no more than patients "acting ill" in order to secure some secondary gain, such as the attention of a spouse or child.


Diagnosing Irritable Bowel Syndrome

Since there are no tests for irritable bowel syndrome, the illness must be diagnosed entirely by the symptoms being experienced by the patient and a limited number of tests to exclude the likelihood of an organic disease. Fortunately, a positive diagnosis usually can be made on the first visit to a doctor.

The doctor must take a complete medical history that includes a careful description of symptoms. A physical exam and laboratory tests likely will also be done, and a stool sample will probably be tested for evidence of bleeding. In some cases, the doctor may also perform diagnostic procedures such as endoscopy (specifically sigmoidoscopy) and possibly take X rays to find out if there is any evidence of disease such as colitis, colon cancer, or inflammatory bowel disease.

At this stage as few costly, invasive tests as possible are used to determine whether a patient is suffering from a specific, identifiable "organic" condition or irritable bowel syndrome. To accomplish this, experts in the treatment of gastrointestinal illnesses have developed a specific set of criteria to identify people with irritable bowel syndrome. A person is strongly suspected to have the syndrome if he or she has experienced abdominal pain or discomfort on a continuous or recurring basis for a total time of at least three of the previous twelve months, along with two of the following three additional features:

  • The abdominal pain or discomfort is relieved with a bowel movement
  • The onset of the pain is associated with a change in the frequency of stool
  • The onset of the pain is associated with a change in the consistency of stool

In addition, the following symptoms are not considered essential for diagnosis, but if present are considered support for the diagnosis. They may also be used to identify certain types of IBS.

  • Abnormal stool frequency (more than three bowel movements per day or less than three per week)
  • Abnormal stool form (unusually hard or loose stool more than one out of every four times)
  • Abnormal stool passage (straining, urgency, or the feeling of incomplete evacuation more than one in four times)
  • Passage of mucus more than once in every four defecations
  • Bloating or the sensation of having a distended abdomen more than one out of every four days

In questioning the patient about symptoms and performing a clinical exam, the physician should assess the total picture, including the nature and timing of pain, bowel habits, and other complaints. IBS symptoms can vary widely; pain can range from mild to intense, but it rarely interferes with normal eating and usually does not awaken a person during the night.

An attempt should be made to correlate symptoms with specific foods and medications, with particular emphasis on the consumption of milk products (to rule out lactose intolerance) and foods and beverages that contain fructose or sorbitol. Patients may need to keep food diaries for a few weeks to see if they can identify foods that provoke symptoms.

At the same time, it is especially important to consider emotional and psychological triggers for a patient's symptoms. Physicians will want to know what prompted the visit and will want to ask about the patient's lifestyle and stress level. After all, it's not unusual for traumatic life events, such as divorce or the loss of a job, to wreak havoc on the bowels and psyche. The doctor must also try to establish that the patient has no serious mental disturbance. A referral to a mental-health professional may be indicated in some cases.

Doctors must also make sure to exclude the presence of organic diseases. To this end, they will ask questions about the pain being experienced:

  • To where does the pain radiate? Pain caused by gallstones, for example, may radiate to the chest, while some ulcers may cause pain that radiates to the back. While patterns of pain for IBS are not so easily definable, the most frequently reported symptom is pain or discomfort in the abdomen that is poorly localized, migratory or variable in nature, and usually relieved by defecation.
  • Is the pain steady or cyclical? Ulcer pain tends to be cyclical. It is relieved by eating but may come back in the middle of the night. By contrast, pain caused by cancer tends to be continuous.
  • Is there cramping? Cramps may signal intestinal obstruction.

Other symptoms that accompany the pain may offer clues as to the cause of a patient's discomfort, too. If there is pain in the lower abdomen and a change in bowel movements, an abnormality in the large intestine may be present. A combination of pain and fever can signal inflammation (such as diverticulitis), which requires immediate medical attention.

Another major diagnostic clue is any bleeding in the digestive tract. People with IBS can have rectal bleeding, but it's usually due to trivial causes -- internal hemorrhoids, for example -- and never to IBS alone. Bright-red blood comes from the lower digestive tract, while black, tarry blood comes from the upper portion of the tract. If there is bleeding, more tests must be performed to determine the cause.

A physical exam will also be performed. During the exam, the physician will look for tenderness in the abdomen. If it is located in the lower right part, it may signal appendicitis; in the upper right part, inflammation of the gallbladder or liver. The doctor will also check for masses caused by tumors, large cysts, or impacted stool.

A digital rectal exam is also usually part of the exam. In the exam, the doctor feels for masses in the rectum and, in males, the prostate. If a serious disorder is suspected, more tests will be ordered immediately.

Additional tests may include a complete blood count and erythrocyte sedimentation rate test, which measures the speed at which mature red blood cells settle; it can be used to screen for inflammatory disease. If the hemoglobin, white count, erythrocyte sedimentation rate, and temperature are normal and the patient's symptoms are typical of IBS, no further tests may be needed.

For patients with persistent diarrhea, stool samples will be examined for infectious agents that include intestinal parasites. Occasionally, the doctor may arrange for a three-day stool collection to check for excess fecal fat content (more than seven grams of fat per day) or weight (more than 200 grams of feces per day), neither of which is consistent with a diagnosis of IBS. Either may be an indicator instead of an organic problem such as inflammatory bowel disease, malabsorption, or even cancer.

And despite efforts to avoid expensive tests, a patient's age or atypical symptoms may persuade the doctor to conduct even more diagnostic procedures, such as sigmoidoscopy or colonoscopy.

A flexible sigmoidoscopy may be performed to check for tumors, particularly in people over the age of forty, or inflammatory bowel disease. The procedure, which permits observation of the rectum and sigmoid colon through a viewing tube and can be used to take a tissue sample, may be performed in the doctor's office with no anesthesia. Such a test, while somewhat uncomfortable, can also provide a measure of relief to the patient. In any patient over age forty, a colonoscopy or barium enema, may also be ordered to rule out colon cancer.

When it comes to tests, common sense should prevail: not every patient with a gut problem should get every test, especially because, unfortunately, no test can confirm IBS. Thus, patients should discuss each option carefully with the doctor before proceeding with any course of testing or treatment. Aggressive investigation may uncover an alternative diagnosis, or it may provide reassurance to patients and doctors that a potentially serious illness has not been overlooked.

The physical exam will usually not reveal anything other than perhaps a mildly tender abdomen in a patient with IBS. And lab tests are generally normal in IBS patients.

Despite the long list of possible tests, however, remember that an experienced gastroenterologist will likely be able to make a preliminary determination as to whether IBS is the problem on hearing the patient's initial story.


Managing Irritable Bowel Syndrome

If you think that diagnosing IBS is tricky, wait until you try managing it. Diagnosis is only the beginning -- the real quandary is figuring out a way to live with it.

While there may be comfort in knowing that the condition is benign, the relief probably won't last long because you'll soon find out that the prognosis for IBS sufferers can mean years -- maybe a lifetime -- of bowel distress.

If doctors knew what caused this group of symptoms, treatment would be easier and aimed at providing comfort and eliminating those causes. But that is not yet the case. As a result, treatment is directed at individual symptoms, and the process is somewhat hit-or-miss and complete relief is sometimes difficult to obtain. The frustration this can induce has sent many IBS sufferers into the world of alternative or complementary therapies to try such remedies as hypnosis, biofeedback, or herbs, with varying degrees of success.

Accordingly, the management of IBS requires a great deal of understanding between doctor and patient. When a patient has a clear-cut organic disease, such as an ulcer, the treatment plan is not a matter of debate. In contrast, the proper treatment of functional disorders such as irritable bowel syndrome is not so clear.

Patients need to educate themselves about IBS and receive adequate information from their physicians so they can learn to manage the syndrome and regain control over their lives. At least one study found that strong communication between doctor and patient reduced the number of IBS follow-up visits.

What is known about IBS is that something has disrupted the automatic functioning of the bowel, and the first task in management is to search for possible irritants coming from outside or arising from within the body. The natural place to start is with something consumed -- foods, beverages, or drugs, for example.

Common sense should prevail in treating IBS, and so the first step should be the easiest: dietary measures.

Patients should eliminate likely food triggers -- caffeine, sorbitol-containing gum or beverages, dairy products, alcohol, apples and other raw fruits, fatty foods, and gas-producing vegetables like beans, cabbage, and broccoli -- to see if symptoms subside. Some call it "eating bland."

Should milk be found to be a problem, lactose-intolerant individuals can take supplements of the enzyme lactase if they can't always (or don't want to) avoid milk. There are also a host of lactose-free milk products on the market.

The most common dietary recommendation for IBS sufferers is adding fiber to increase the stool's bulk and speed the movement of contents through the gastrointestinal tract. The refined diet of the Western world, which is low in fiber, has been compared to the fiber-rich diets of much of the rest of the world, and our low fiber content has been blamed by some for the high rates of IBS in America. This connection, however, has not been proven, and a high-fiber diet does not always improve bowel symptoms. Still, many clinical trials have shown that bulking up on fiber does seem to relieve constipation and ease abdominal pain. It may even alleviate diarrhea.

To increase fiber intake, doctors usually recommend bran or a fiber supplement, such as psyllium or methylcellulose, available in many products found in supermarkets or drugstores. Fiber should be introduced gradually, however, because too much too soon can cause excessive gas, cramping, and bloating.

For some people, these dietary measures may be all that is needed to reduce symptoms and calm the belly. One study noted improvement in most patients who follow these recommendations, but many patients continue to have flare-ups after an initial response to therapy.

When Problems Persist

There are certain occasions when doctors will consider the use of drug therapy for patients who continue to experience symptoms troublesome enough to impair daily function. While these drugs can't cure irritable bowel syndrome, they may help to ease symptoms.

To date, despite dozens of scientific trials, no drug has proven to be generally effective against IBS -- yet data show that one-third to one-half of patients with functional complaints actually improve on placebo. In any case, there are times when the doctor may want to prescribe drugs for specific indications such as diarrhea, cramping, or pain.

Anticholinergics Drugs such as atropine and related agents, like dicyclomine (Bentyl), hyoscyamine (Levsin), and chlordiazepoxide (Librax), may relieve mild abdominal pain because as antispasmodics they reduce bowel spasms. People who often experience cramps after eating may obtain some relief if they take the antispasmodic medications before meals. The idea is to ensure maximum anticholinergic effect at the time symptoms are expected, while allowing minimum exposure to side effects.

Antidepressants Amitriptyline (Elavil) and desipramine (Norpramin) may sometimes be prescribed for patients who have diarrhea-predominant IBS. These tricyclic antidepressants should be used at low doses, however, and should be used only by patients who have diarrhea-predominant IBS, as they can cause constipation. The newer selective-seratonin-reuptake inhibitors (SSRIs), such as sertraline (Zoloft), may be helpful in treating abdominal pain in patients who suffer primarily from constipation-related IBS. Another SSRI, paroxetine (Paxil), may be used to treat abdominal pain in diarrhea-predominant IBS because of its anticholinergic antidiarrheal effect.

A Mayo Clinic study found that patients with gastrointestinal disorders taking antidepressants had no significant demonstrable changes in gastrointestinal motility. However, the patients did have a significant improvement in their gastrointestinal-symptom ratings and significant improvement in their overall sense of well-being.

Another study, from Belgium, looked at the effects of the SSRI citalopram on the physiology of the colon and found that when patients had balloons inflated in their colons, there was a slight relaxation of the colon. This was followed by an intravenous dose of citalopram. Patients reported a reduction of discomfort. The findings led the researchers to conclude that the drug may reduce visceral hypersensitivity by relaxing the colon.

Current research is focusing more on the gut-brain connection, which appears to play a role in IBS. Serotonin-like medications are among those being investigated. However, the first of these to be approved, alosetron (Lotronex), which works on the serotonin type III receptor, was a disaster and was pulled from the market just a year after winning FDA approval. The FDA urged Lotronex be taken off the shelves after receiving reports of three deaths and dozens of serious side effects in patients using the drug. In most of the reported cases, patients developed ischemic colitis, a potentially life-threatening inflammation of the large intestine that can occur when blood flow to that area of the gastrointestinal tract is blocked. In some cases, the drug caused constipation so severe that surgery was needed to unblock their intestines. One patient needed her colon removed.

Lotronex was the first new drug in decades for treatment of IBS and had been approved only for treatment of women whose main IBS problem was diarrhea.

Loperamide (Imodium) and diphenoxylate (Lomotil) These medications are generally recommended for patients whose main complaint is diarrhea. Loperamide, available over the counter, reduces the secretion of fluid by the intestine. Diphenoxylate, available by prescription only, helps to slow down intestinal contractions. It is related to codeine and contains atropine as well. Doctors generally favor preparations that don't contain codeine or other narcotics, because they may have adverse nervous-system effects, including sedation, drowsiness, and confusion.

Beyond Drugs

Herbal remedies and other alternative or complementary therapies -- as well as behavior techniques and psychotherapy -- are being used frequently by patients with IBS when standard therapies don't work. One recent study conducted at the Royal London School of Medicine in England questioned 225 patients with intestinal problems. Of those with IBS, half were using complementary therapies. Most of these remedies are used to address the psychological components of the disorder.

Research shows that any of several stress-reducing techniques taught by psychologists or other specially trained medical professionals can help some patients. People should consider cost and availability in their community when choosing which ones to try, and should also know that there is little evidence available to prove the effectiveness of herbal remedies.

Among the most popular approaches are the following:

Relaxation-response training and meditation Simple and easy to learn, this technique helps reduce nervous-system activity and relaxes muscles. Meditation, including transcendental meditation (TM), has been shown to be very helpful in lowering blood pressure, for example. Similarly, the technique can help relax the intestinal muscle.

Yoga Some forms of yoga, the ancient Indian spiritual discipline that seeks to bring the body and mind into balance, have proven valuable to some IBS sufferers. Yoga, like meditation, can help the patient induce a form of self-relaxation. The ancient tradition, which emphasizes special breathing exercises, recognizes the intimate connection between the breath and the nervous system. The yogis believe that if one can learn to control the breath, he or she can learn to control, or at least influence, how he or she feels both emotionally and physically.

Hypnosis Hypnotherapy was strongly associated with improved IBS symptoms by one study presented in 2000 by researchers at the Eastern Virginia Medical School in Norfolk. About 85 percent of study participants who were given hypnosis sessions and audiotapes at home reported improvement in all IBS symptoms after fourteen weeks. Significant improvement was found in abdominal pain, bloating, stool consistency, and other involuntary body activities. After the course of hypnotherapy, the autonomic nervous system was less easily stimulated. The researchers theorized that the calming effect of hypnosis may have contributed to the improvement in symptoms.

Acupuncture One study of twenty-seven patients who received acupuncture treatments three times per week for two weeks found improvements in their quality of life and gastrointestinal-symptom scores. The results were the same as those observed among a comparison group that received relaxation training. However, the patients who received the acupuncture were more likely to see their pain reduction persist over the course of a four-week follow-up.

Biofeedback A mind/body technique in which participants see and realize their body's response to stimuli such as pain, biofeedback's proponents believe that it helps people modify their body's responses to these stimuli. With visual devices and easy instructions, patients can be taught how to alter such apparently automatic responses as the skin's temperature, for example, by altering the flow of blood to it. Some patients who have lost control of their bowels have been trained to better control them using biofeedback techniques to change the sphincter muscle's ability to contract. In one study, conducted at the University of Tennessee in Memphis, a biofeedback technique developed by NASA as a therapy for motion sickness was found to be effective for constipation. Study participants said that their symptoms -- nausea, vomiting, abdominal pain, and gas -- improved after just three sessions. Some say the technique works especially well for cramping.

Herbal remedies A number of herbs and other natural substances are being used by a growing portion of patients in pursuit of relief from IBS symptoms. Among the most popular substances are St. John's wort, fish oils, flaxseed oil, aloe vera juice, and a variety of Chinese herbs. Unfortunately, there are few studies to gauge the effectiveness of any of these remedies. A new product, however, made from fish protein, was found in one study to significantly reduce some IBS symptoms.

Psychotherapy Experts disagree on whether formal psychoanalysis is helpful in combating IBS. However, talking things out with an experienced and realistic therapist may help patients reduce stress and provide coping skills that improve mental health and associated physical ailments. In a 1983 Swedish study, IBS patients who combined medical treatment with individual psychotherapy showed more short-term and long-term improvement than those who had only medical therapy. A possible benefit of psychotherapy may be the discovery by the patient that he or she is depressed and that the depression is either a cause or result of IBS.


The important thing to remember throughout all searches for diagnoses and remedies is that every IBS patient is unique and that treatments should be tailored to the specific symptoms and needs of each individual. The good news is that IBS poses no threat to your life -- with the right attitude and therapy techniques, patients can learn to live with irritable bowel syndrome while experiencing a minimum of interruption to their daily lives.

Copyright © 2000, 2001 by the President and Fellows of Harvard College

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