Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is not a specific disease with a single specific cause, rather it is the name given to describe the condition involving abnormal pattern of bowel habits often with other associated problems, such as abdominal pain, bloating and gas. Irritable bowel syndrome is a common disorder which tends to begin in people before the age of thirty. Symptoms can fluctuate or be chronic and persistent.

What Causes IBS?

The cause of irritable bowel syndrome is not known at this time. It is considered a "functional" disorder, referring to abnormal function of the gastrointestinal tract rather than a "structural" disorder where there is actual change in the underlying tissue, for example, an ulcer or infection. Thus, when the colon is examined by colonoscopy or barium enema x-ray, it appears normal. IBS is felt to represent disordered motility of the intestinal tract, essentially viewed as "spasm". Normally, the intestinal tract functions silently without our awareness of its actions. Food that has been eaten progressively makes it way down the GI tract and is slowly absorbed. The muscular layers within the intestine propel the material in a forward/downward direction. In IBS, intestinal contractions are sensed and cause pain much like a spasm of muscle in the calf would cause a painful "charley horse". If the contractions are overly active, material may be propelled forward too fast to be absorbed properly and diarrhea may result. On the other hand, spasms or contractions that are stationary and do not propel forward could cause constipation, bloating, gaseousness and pain.

Patients often ask if IBS is caused by stress or emotional factors. It is important to point out that the symptoms of IBS are "not in your head", and that IBS is not caused by stress alone. Certainly, people under stress or other emotional factors can experience worsening of symptoms.

What is the Brain-Gut Axis?

There are connections between the brain, the nervous system and the gastrointestinal tract. These connections take two forms. There are direct nerve fibers, essentially the way our body is electrically wired, that connect the brain with most of our body including the gastrointestinal tract. The second mechanism involves hormones which are chemical substances that are released in one part of the body, then travel through the blood stream to cause an effect elsewhere in the body. Specific to IBS, there have been several hormones isolated that fulfill this role (CCK, bombesin and others). After traveling through the blood, specific receptor sites within the GI tract are found where the hormones bind and cause stimulation of gut function. Many factors (stress, emotions, diet and others) may stimulate the brain to discharge nerve fibers or release hormones. The brain-gut access is one mechanism that helps us explain the way IBS symptoms are produced.

What Triggers IBS?

Since we do not know the specific cause of IBS, it can be difficult to identify triggering events in some people. Clearly, stress and emotional factors can bring out symptoms in many people with IBS. The brain-gut axis discussed above may account for this relationship. Dietary factors can play a role, particularly foods that have a stimulating effect on bowel function, such as caffeine, chocolate, alcohol, tobacco and fatty foods. It can be difficult to isolate a specific food in all patients that will trigger IBS. This is an area where each person needs to examine their diet individually to seek out triggering substances. Often, a "Diet Dairy" can be used to keep a log of symptoms, foods, emotional and other factors that may be reviewed from time to time looking for patterns in an attempt to find items and situations that could be avoided or changed.

What are the Symptoms of IBS?

Irritable bowel syndrome usually involves abnormal frequency and consistency of bowel movements. This may be seen as chronic or intermittent diarrhea, constipation, or commonly constipation alternating with diarrhea. Patients will often begin their morning "bathrooming" with firm pellet-like stools which then become loose and then watery. Abdominal pain, bloating and gas may be seen as part of IBS. Symptoms that are NOT due to IBS alone and often merit a physician’s attention and evaluation include weight loss, fever, blood with bowel movements and persistent severe pain.

How is IBS Treated?

Successful treatment of IBS often utilizes a multi-step approach. With greater understanding of what is causing the problems in your body and why it is occurring, this often helps to isolate triggering events and avoid them.

Diet

Proper diet can play an important role in treatment of irritable bowel syndrome. There is not a standard "IBS diet" for every patient. General recommendations can be made and then each patient needs to individualize their dietary therapy. Foods which stimulate bowel motility can contribute to spasm, pain, and diarrhea. These include caffeine, chocolate, alcohol, spicy foods, fried and fatty foods. While fruits and vegetables can produce gas and bloating, a diet low in fiber tends to be more constipating. It is important to try to eat three balanced meals daily. Avoidance of meals (for example in a patient who is trying to lose weight or is always on the run) can offset the digestive cycle and can lead to symptoms. Every person may have individual susceptibility to food substances or even food additives contained within processed or packaged foods. Keeping a "diet diary" which may be reviewed periodically may help identify foods which repeatedly bring on symptoms.

Stress/Exercise/Lifestyle

Stress and emotional factors can trigger symptoms. Often, it may be difficult to identify the specific situation or event responsible. A conscious effort to reflect on these issues may be required to gain insight into one’s emotional status. Methods to reduce stress can include regular exercise (this also helps to promote digestive function), try to spend a few minutes at the end of the day to relax and reflect, meditation, and sometimes seeking the assistance of a mental health professional. The use of a heating pad or warm bath can be soothing.

Medications

Some medications can potentially worsen inflammatory bowel disease. For example, medications that are constipating (anti-hypertensive medications, pain medications and many others) should be reviewed. Antispasmodic agents to treat the underlying spasm include dicyclomine (Bentyl), hyoscamine (Levsin), Donnatal and others. Sometimes medications that are antidepressants also have a beneficial effect on irritable bowel symptoms. Serotonin receptor antagonists are a new class of medications that block a chemical mediator (serotonin) that stimulates gut motility and secretions. Lotronex, the first medication available in this class, was taken off the market in December 2000 after a few patients experienced severe side effects. 

Tegaseride (Zelnorm) is now available for patients (mainly women have been studied) with constipation-predominant IBS. We are currently involved in clinical studies of other medications in this class that have not shown serious side effects.

For additional information, call (513) 872-4549 or email, info@ccrstudy.com

Antidepressant medications can be helpful for patients with anxiety and/or depression.  These medications also have a role to treat some types of pain.

Is Fiber the Answer for IBS?

For a long time, doctors and IBS-related publications touted the importance of fiber . Although a proper diet that is high in fiber can benefit many patients with IBS and a fiber supplement likewise can be helpful, this is not a solution for every patient! The following analogy may help to describe how fiber may be helpful in some patients. Consider a tube of toothpaste when it is full and how easy it is to squeeze out an aliquot of toothpaste. When the toothpaste container is nearly empty, however, it requires significantly more squeezing and straining to eke out even a few drops of toothpaste. Similarly in the empty bowel, the extra pressure and force attempting to push small bits of stool or liquid can cause pain and bloating. By "filling up the tube" with fiber bulk, considerably less pressure is required and thus less painful. This benefit is not seen in all patients particularly those who suffer from constipation. In this circumstance where the colon has little motility, by filling up the tube with fiber merely leads to excess bloating and gas.

The IBS Diary

This is an example of a diary that can be kept. Fill the blanks in on a daily basis and periodically review the diary sheets in an attempt to identify factors that may have triggered symptoms.

Date: ______________ Day of the Week: _______________

Number of Hours of Sleep Last Night: ___________________

Quality of Sleep Last Night: ___________________________

Work Schedule: ____________________________________

Breakfast: _________________________________________

Lunch: ___________________________________________

Dinner: ___________________________________________

Snacks: ___________________________________________

Caffeine: _____________________

Alcohol: _____________________

Tobacco: ____________________

Today’s stresses: ________________________________

Today’s exercise: _____________________________________

Related Sites

International Foundation for Functional Gastrointestinal Disorders, http://www.iffgd.org

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