UNM COC:  Your Healthcare Primer for Long Term Care

 
Irritable Bowel Syndrome

Sharon Witemeyer MD (Pediatrician)

Definition

Irritable Bowel Syndrome (IBS) is a disorder of the intestinal tract motility (contraction of intestinal muscles and movement of its contents) that causes cramping lower abdominal pain, gas, bloating and changes in bowel habits.

Introduction

It is estimated that 35 million Americans (20-25% of otherwise healthy individuals) suffer from irritable bowel syndrome. In America IBS is much more common in women than it is in men, but in India it is much more common in men that in women. In Africa the incidence is about equal between the sexes. It is the most common diagnosis gastroenterologists make and one of the top ten reasons people visit their PCP every year. IBS is not a life threatening condition but for some involved individuals it can be extremely disabling.

IBS is called a functional disorder because there is no sign of abnormality when the colon is examined. The colon is about 6 feet long and lies between the small intestine and the rectum. Its job is to reabsorb water and salts from the intestinal fluids before the stool is passed out of the anus as a bowel movement. Nerves, hormones and electrical activity of the colon muscle control colon motility. The cause of IBS is unknown. However, the most recent theories suggest that defects in this "enteric (intestinal) nervous system" cause the colon of individuals with IBS to be more sensitive and reactive than usual. They respond more strongly to normal and abnormal stimuli than most people.

Symptoms of IBS include:

1. Cramping lower abdominal pain that may be mild to severe

2. Gassiness and bloating

3. Changes in bowel habits that may be diarrhea, constipation or a mixture of both diarrhea and constipation. Mucus may be passed with the stool.

Symptoms of IBS do NOT include:

1. Bleeding

2. Fever

3. Weight loss

4. Persistent severe pain

5. Persistent diarrhea or severe constipation

6. Family history of intestinal cancer, inflammatory bowel disease or celiac disease is also a "red flag" to physicians to look for another cause of symptoms.

The most common triggers for onset of symptoms of IBS are diet and stress. Common foods that seem to be associated with IBS include:

1. Foods high is fat (butter, oil, margarine, whole milk, avocados, meats, poultry skins)

2. Dairy products

3. Caffeine, chocolate and alcohol

4. Foods that contain sorbitol (an artificial sweetener)

5. Beans, cabbage and some fruits and juices (apple and grape juice, bananas, raisins)

6. Nuts

Not everyone with IBS is troubled by all of these foods. It is a good idea to keep a journal noting what foods seem to cause distress. Discuss the findings with the doctor or a registered dietitian who can suggest changes in the diet. Some ideas for modifying the diet include:

1. Eating smaller meals or smaller portions at meals

2. Eating meals that are low in fat, high in carbohydrates like pasta, rice, whole-grain breads and cereals, fruits and vegetables.

Stress is also a common trigger. Changes in daily routine, travel, or attending social events are such stressors. Women with IBS may have more symptoms during the menstrual periods.

Diagnosis

The diagnosis of IBS is made when the doctor has excluded other diseases. The doctor will take a careful history and do a complete physical examination that will include a rectal exam. A stool specimen will be checked for evidence of bleeding. Blood tests will be drawn that include a complete blood count (CBC), serum electrolytes (salts), and liver function tests (LFTs). Other tests that may be done are X-rays (barium enema) and endoscopy (viewing the colon through a flexible tube inserted through the anus.)

Treatment

No one specific treatment is available for IBS. Doctors who are familiar with this condition recommend a 7- step approach to management. These are the steps:

1. Education

2. Reassurance

3. Dietary modification (See above)

4. Fiber

5. Symptomatic treatment

6. Psychological/behavioral options

7. Realistic goals.

Helping individuals understand the nature of the condition and reassuring them that it is neither life threatening nor will it lead to other more serious gastrointestinal disease (like cancer or Crohn’s Disease) is the starting point. As shown above, food is a frequent trigger for IBS symptoms. Keep a food and symptom journal and use the information to modify the diet with the help of the physician or dietitian. It is often difficult for individuals with a developmental disability to get adequate fiber in their diets. Ask the doctor if a fiber supplement might be beneficial.

Medications for IBS are all directed toward relief of symptoms.

1. Pain management – Antispasmodics (anticholinergics, peppermint oil), Opioid-like Agents (Dextromethorphan, Trimebutine)

2. Diarrhea – Imodium, Cholestyramine. The FDA has removed Lotronex (alosetron) from the market because of reports of acute ischemic colitis.

3. Constipation – Fiber (Metamucil, Fiberall), Laxatives

Stress is often a trigger for IBS symptoms. Many individuals respond to psychological/behavioral treatments including:

1. Cognitive-behavioral therapy

2. Interpersonal psychotherapy

3. Hypnosis

4. Relaxation techniques

5. For individuals with depression or with an anxiety component, antidepressant or antianxiety medications may be prescribed. Antidepressants may also be helpful for pain control.

Finally it is important for patient and doctor to set realistic goals. They need to focus on health rather than illness, improved function rather than cure.

Emergency Situations – What can go wrong?

IBS is a chronic condition that can cause a good deal of annoyance, distress and discomfort. However, IBS is not life threatening, and it does not cause permanent harm to the individual or the internal organs. If an individual has severe vomiting, severe and persistent abdominal pain, bleeding, weight loss, or severe and persistent diarrhea or constipation it is NOT irritable bowel syndrome. The presence of those symptoms suggest some other potentially much more serious problem. The individual’s PCP should be notified and arrangements made to evaluate the individual in a timely manner.

Conclusion

Irritable Bowel Syndrome (IBS) is a common disorder of the intestinal tract motility (contraction of intestinal muscles and movement of its contents) that causes cramping lower abdominal pain, gas, bloating and changes in bowel habits. It is called a functional disorder because no abnormality is found when the intestine is examined. The diagnosis is made when the doctor has ruled other diseases. It is annoying, uncomfortable, distressing, occasionally even debilitating but it is not life threatening. It is not associated with other more serious gastrointestinal conditions (like cancer or Crohn’s Disease.) Diet and stress are common triggers for symptoms of IBS. Treatment aims at dietary modifications, medications that treat symptoms and psychologic/behavioral approaches.

References

Koval, George, MD "The Pathophysiology of Irritable Bowel and Managing IBS: A Treatment Strategy for Success" presented 9-16-00 in Albuquerque, NM, sponsored by Medical World Conferences, supported by Glaxo Wellcome, Inc.

Sharon Witemeyer MD (Pediatrician)