Irritable Bowel Syndrome

By: Dr Himanshu Gul Mirani

Emergency Physician, Urgent Care Centre

Irritable bowel syndrome (IBS) is a very common and distressing condition, making the sufferers yearn for freedom to eat; with flare-ups not only draining them physically but also mentally. Called ‘spasmodic colon’, it can be a nightmare for the sufferers. They are constantly under threat, not knowing what may trigger the next acute episode. It’s particularly an issue for people travelling abroad often, as the options with food being available become limited.

The condition

Its characterised by varied presentations, with pain in lower abdomen associated with bloating sensation being a predominant condition. Although in reality there abdomen is not truly increased in size to the extent perceived by the patient, the subjective sense of discomfort often brings them to the medical facility for treatment.

Altered bowel habits are another common complaint of IBS. There is characteristic history of alternating episodes of increased frequency of passing stools with constipation. Stools aren’t voluminous, but there is a sensation of incomplete evacuation, with ‘squirting’ of small amount of stool each time. Stools are often laced with mucous.

Described by the patient as diarrhoea, careful history reveals that often these episodes of increased stool frequencies are confined to a particular part of the day, usually mornings, wherein most efforts to evacuate the gut are made, concentrated over a span of around half to one hour.

Some people come with complaints of intractable acidity/ indigestion/ heartburn (dyspepsia).  Described as functional dyspepsia, these people find no relief from anti-acidity drugs and their other tests like endoscopies of the upper gut are normal.

There are a few associated complaints that help as pointers to IBS. Stress, panic disorder, type A personality character trait, sexual dysfunctions, sexual abuse specially in childhood – all these are linked with IBS.

Diagnosis

‘Bristol Stool Scale’ may help the patients to describe their stools. ‘Rome III criteria’ is often quoted to label an individual as a case of IBS. It is diagnosed if the symptom complex of recurrent abdomen pain or discomfort, along with altered bowel habits remains for at least 6 months and cannot be attributed to any other pathology. Two out the following three features must be present on at least 3 days of the last 3 months viz. ;

-    Pain relieved by bowel movement

-    Onset of pain related to change in stool frequency

-    Onset of pain related to change in appearance of stool

Decoding the problem

The patients of IBS have lower pain threshold to rectal distension than other people.  This has been studied by noting the volume to which the rectal balloon needs to be inflated to elicit pain. IBS patients experienced pain at a lower balloon volume than others.

These patients on PET scan evaluation seemed to have altered blood flow in the brain to the sensation of gut distension and that might also be a cause for the perceived altered sensation.

In an interesting study to understand the stress response, arithmetic problems were given to IBS patients along with non-sufferers as controls. Patients of IBS had an altered response compared to non-sufferers, as reflected by altered EEG patterns in such individuals.

Apart from these, there are many differences at molecular level in the gut physiology that seem to work in an altered manner in these patients making them prone to the IBS symptoms.

Workup

There is no gold standard test for the diagnosis of IBS. A detailed history along with the tests that rule out any other disease condition, point to the diagnosis of IBS.

Some of the common tests done to rule out other causes are –

•    Stool routine examination with cultures

•    Stool osmolarity and electrolytes

•    Colonoscopy with biopsies

•    Contrast radiological evaluation of the gut

•    May need small bowel biopsies too

Lifestyle and dietary modifications for IBS

There are certain foods that trigger IBS acute episode. Most of the patients can identify what foods triggered the onset of pain and symptoms. But there are some foods that are routinely incriminated to precipitate an acute event. Some of them are high fat, low fibre foods; carbonated drinks; large meals; refined cereals & excessive alcoholic or caffeine intake.

Eating small and frequent meals, oats, wheat bran, fruits and vegetables, more of plant fibre, linseeds along with regular exercise and stress management helps IBS patients.

Treatment

The management of such patients calls for extensive counselling so that they understand the disease condition and gain enough insight to deal with the ordeal.

Better targeted therapy is expected for IBS in future as the molecular mechanics are being decoded.

Pharmacological management along with lifestyle modifications and psychiatric help go a long way to help these individuals.

Drug therapy is guided by the predominant symptom.  IBS patients are grossly categorized based on their predominant presenting symptom as:

1.) Constipation predominant

2.) Diarrhoea predominant

3.) Pain predominant

Source: www.urgentcare.co.in, one of the Best Hospitals in Delhi.