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Irritable bowel syndrome

 

What Is Irritable Bowel Syndrome?

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders that physicians see. Yet until recently, it was also one of the least talked about conditions. IBS is characterized by abdominal pain or cramping and changes in bowel function ó including bloating, gas, diarrhea and constipation ó not something most people like to discuss. Whatís more, for many years IBS was considered a psychological rather than a physical problem.

An estimated 35 million Americans have irritable bowel syndrome. It ranks second only to the common cold as a cause of lost work time and accounts for about 3 million physician visits in the United States every year.

Fortunately, unlike more serious intestinal diseases such as ulcerative colitis and Crohnís disease, IBS doesnít cause inflammation or changes in bowel tissue or increase your risk of colorectal cancer.

Signs and Symptoms

Symptoms of IBS vary widely from one person to another and often occur with many other diseases. Among the most common symptoms are:

Like many people, you may have only mild symptoms of IBS. Or you may have intermittent symptoms that can sometimes be disabling. In some cases, you may have severe symptoms that donít respond well to medical treatment.

For most people, IBS is a chronic condition, although there will likely be times when symptoms are worse and times when symptoms improve or even disappear completely.

Causes

The walls of the intestines are lined with layers of muscle that contract and relax as they move food from your stomach through the intestinal tract to the rectum. Normally, these muscles contract and relax in a coordinated rhythm. But if you have IBS, the contractions are stronger and last longer than normal. Food is forced through your intestines more quickly, causing gas, bloating and diarrhea. In some cases, however, the opposite occurs. Food passage slows, and stools become hard and dry.

No one knows exactly what causes IBS. Some researchers think IBS is caused by changes in the nerves that control sensation or muscle contractions in the bowel. Others believe the central nervous system may affect the colon. And because women are two to three times more likely than men to have IBS, researchers believe that hormonal changes also play a role. For many women, symptoms are worse during or around their menstrual periods.

For reasons that still arenít clear, if you have IBS you probably react strongly to stimuli that donít bother other people. Triggers for IBS can range from gas or pressure on your intestines to certain foods, medications or emotions. Chocolate, milk and alcohol might cause constipation or diarrhea, for instance. And the least bit of stress might send your colon into spasms.

In fact, if youíre like most people with IBS, you probably find that symptoms are worse or more frequent during stressful events, such as a change in your daily routine or family arguments. But while stress may aggravate symptoms, it doesnít cause them.

Sometimes another illness, such as an acute episode of infectious diarrhea (gastroenteritis) can trigger IBS. Antibiotic use also may be a factor because antibiotics disrupt the normal bacterial flora living ing in your bowel. Excessive use of laxatives and even some antidiarrheal medications may contribute to the problem as well.

If you experience cramping and bloating occur mainly after eating dairy products or sugar-free gum or candies, the problem may not be irritable bowel syndrome. Instead, your body may not be able to tolerate the sugar (lactose) in dairy products or the artificial sweetener sorbitol.

Risk Factors

Many people have occasional symptoms of IBS, but youíre more likely to have IBS if youíre young and female. IBS typically begins in adolescence or young adulthood. Although many older adults have irritable bowel syndrome, about 30 percent of people notice a reduction in symptoms as they get older. Overall, two to three times as many women as men have the condition.

When To Seek Medical Advice

Although approximately one in five American adults have symptoms of IBS, fewer than half seek medical help. Yet itís important to see your doctor if a change in your bowel habits lasts longer than a week to 10 days or if you have any other symptoms of IBS.

Your doctor may be able to help you find ways to relieve symptoms as well as rule out other, more serious colon conditions, such as ulcerative colitis, Crohnís disease and colon cancer. He or she can also help you avoid possible complications from symptoms such as chronic diarrhea.

Screening And Diagnosis

A diagnosis of IBS depends largely on a complete medical history and physical exam. Your doctor may also recommend conducting several tests, including stool studies to check for infection or malabsorption problems. He or she may perform a flexible sigmoidoscopy ó a test that examines the lower part of the colon (sigmoid) with a flexible, lighted tube (sigmoidoscope).

In some cases, your doctor may perform a colonoscopy, a diagnostic test in which a small, flexible tube is used to examine the entire length of the colon. These tests help rule out more serious conditions such as ulcerative colitis, Crohnís disease and colorectal cancer.

You may also have tests to determine whether youíre lactose intolerant. Lactase is an enzyme needed to digest the sugar found in dairy products. If you lack this enzyme, you may have symptoms similar to those caused by IBS, including abdominal pain, gas and diarrhea.

Because there are usually no physical signs of disease in IBS, diagnosis is often a process of elimination. To help in this process, researchers have developed diagnostic criteria, known as Rome criteria, for IBS and other functional gastrointestinal disorders ó conditions in which the bowel appears normal but doesnít function normally.

According to these criteria, you must have certain symptoms before a doctor diagnoses IBS. The most important are abdominal pain, and diarrhea or constipation lasting at least 3 months. You also need to have at least two of the following symptoms one-fourth or more of the time:

A change in the frequency or consistency of your stool. For example, you may change from having one normal, formed stool every day to several loose stools. Or you may have only one hard stool every 3 to 4 days.

Straining, urgency or a feeling that you canít empty your bowels completely.

Mucus in your stool.

Bloating or abdominal distension.

Complications

Both diarrhea and constipation can aggravate hemorrhoids. In addition, symptoms of IBS can interfere with your work, your relationships with friends and family and your ability to live your life to the fullest. At times, you may feel discouraged or depressed.

Treatment

Because itís still not clear what causes IBS, treatment focuses on the relief of symptoms so you can live your life as fully and normally as possible.

In most cases, you can successfully control mild symptoms of IBS by learning to manage stress and making changes in your diet and lifestyle. But if your symptoms are moderate or severe, you may need more help than lifestyle changes alone can offer.

For moderate symptoms of IBS, your doctor may suggest fiber supplements such as psyllium or methylcellulose and over-the-counter (OTC) medications such as loperamide (Imodium) to help control diarrhea or constipation. In some cases, you may be given drugs that affect certain activities of the nervous system (anticholinergics) to relieve painful bowel spasms. If so, follow-up with your doctor is very important.

If your symptoms include pain and depression, your doctor may recommend a tricyclic antidepressant or a selective serotonin reuptake inhibitor (SSRI). These medications help relieve depression as well as inhibit the activity of neurons that control the intestines. For diarrhea and abdominal pain, your doctor may suggest tricyclic antidepressants such as imipramine (Tofranil, Norfranil) and amitriptyline (Elavil). Side effects of these drugs include drowsiness, dry mouth and constipation. Selective serotonin reuptake inhibitors such as fluoxetine (Prozac, Sarafem) or paroxetine (Paxil) may help if youíre depressed and have pain and constipation. But sometimes SSRIs may not help. In that case, you may have better results from counseling. If you have severe IBS, itís important to receive ongoing treatment and support from your physician.

In November 2000, the Food and Drug Administration (FDA) approved the first medication specifically for the treatment of moderate to severe symptoms of IBS in women. Alosetron (Lotronex) is a nerve receptor antagonist thatís supposed to relax the colon and slow the movement of waste through the lower bowel. But Lotronex was pulled from the market in late November 2000 at the urging of the FDA. The drug has been linked to an intestinal inflammation known as ischemic colitis. It may also be responsible for as many as six deaths. If you're taking Lotronex or have taken it in the past, talk to your doctor.

Researchers continue to look for better ways to manage IBS. The following drugs may be available within the next 5 years:

5HT-4 antagonists.

These medications, which stimulate the movement of waste through your colon, should help treat constipation and pain.

Kappa-opioid agonist (fedotozine).

A synthetic narcotic that resembles an opiate, this drug is designed to reduce intestinal pain.

Alpha

-2-adrenergic agents. These drugs work to normalize bowel function and relieve pain.

Prevention

Anyone can experience digestive upset from worry or anxiety. But if you have IBS, stress-related symptoms such as abdominal pain and diarrhea tend to occur with greater frequency and intensity. Finding ways to deal with stress can be extremely helpful in preventing or alleviating symptoms:

Counseling.

In some cases, a health care professional such as a psychologist or psychiatrist can help you learn to reduce stress by looking at how you respond to events in your life and then working with you to modify or change that response.

Biofeedback.

This stress-reduction technique helps you reduce muscle tension and slow your heart rate with the help of a machine. Youíre then taught how to produce these changes yourself. The goal is to help you enter a relaxed state so you can cope more easily with stress. Biofeedback is usually taught in hospitals and medical centers.

Regular exercise, yoga, massage or meditation.

These can all be effective ways to relieve stress. You can take classes in yoga and meditation, or practice at home using books or tapes.

Progressive relaxation exercises.

These help you relax every muscle in your body, one by one. Start by tightening the muscles in your feet, then concentrate on slowly letting all of the tension go. Next, tighten and relax your calves. Continue until every muscle in your body, including those in your eyes and scalp, is completely relaxed.

Deep breathing.

Most adults breathe from their chests. But you become calmer when you breathe from your diaphragm, the muscle that separates your chest from your abdomen. When you inhale, allow your belly to expand with air; when you exhale, your belly naturally contracts. Deep breathing can also help relax your abdominal muscles, which may lead to more normal bowel activity.

Hypnosis.

Studies show that hypnosis may reduce abdominal pain and bloating. A trained professional teaches you how to enter a relaxed state and then guides you as you imagine your intestinal muscles becoming smooth and calm.

Other techniques.

Set aside at least 20 minutes a day for any activity you find relaxing ó listening to music, reading, playing computer games or just soaking in a warm bath.

Self-Care

In many cases, simple changes in your diet and lifestyle can provide relief from symptoms of IBS. Although your body may not respond immediately to these changes, your goal is to find long-term, not temporary, solutions:

Experiment with fiber.

When you have IBS, fiber can be a mixed blessing. Although it helps reduce constipation, it can also make diarrhea, gas and cramping worse. The best approach is to gradually increase the amount of fiber in your diet over a period of weeks. If your symptoms are the same or worse, tell your doctor. You may also want to talk to a dietitian. If you take a fiber supplement, such as psyllium powder, Metamucil or Citrucel, be sure to introduce it gradually and drink at least 8 to 10 glasses of water every day to minimize gas, bloating and constipation. If you find that taking fiber helps your symptoms, use it on a regular basis for best results.

Avoid problem foods.

If certain foods make your symptoms worse, donít eat them. Common culprits include alcohol, chocolate, caffeinated beverages such as coffee and sodas, medications that contain caffeine, decaffeinated coffee, spicy foods, fruit juices, raw fruits and vegetables, fatty foods, dairy products, beans, broccoli, cabbage and other gassy foods and sugar-free sweeteners such as sorbitol or mannitol. For a few people, fats such as butter and margarine or foods high in fat such as mayonnaise, nuts, cream, ice cream and red meat may also aggravate symptoms. Be careful that your diet doesnít become too restricted, though. If you need help, talk to a dietitian.

Eat at regular times.

Donít skip meals, and try to eat about the same time each day to help regulate bowel function. If you have diarrhea, you may find that eating small, frequent meals makes you feel better. But if youíre constipated, eating larger amounts of high-fiber foods may help move food through your intestines.

Take care with dairy products.

If youíre lactose intolerant, try substituting yogurt for milk. Or, use an enzyme product such as Lactaid or Dairy Ease to help break down lactose. Consuming small amounts of milk products or combining them with other foods to slow digestion may also help. In some cases, though, you may need to eliminate dairy foods completely. If so, be sure to get enough protein, calcium and B vitamins from other sources.

Drink plenty of liquids.

Try to drink at least 8 to 10 glasses of fluids a day. Water is best. Alcohol and beverages that contain caffeine stimulate your intestines and can make diarrhea worse, while carbonated drinks produce gas.

Exercise regularly.

Exercise helps relieve depression and stress, stimulates normal contractions of your intestines and can help you feel better about yourself. Aim for 30 minutes of exercise most days. If youíve been inactive, start slowly and gradually increase the amount of time you exercise.

Use antidiarrheal medications and laxatives with caution.

If you try over-the-counter antidiarrheal medications, such as Imodium or Kaopectate, use the lowest dose that helps. In the long run, these medications can cause worse problems if you donít use them appropriately. The same is true of laxatives. If you have any questions about them, check with your doctor.

Coping Skills

Living with IBS presents daily challenges. Your symptoms may be painful or embarrassing and may seriously affect the quality of your life. These suggestions may help you cope more easily:

Learn as much about IBS as you can.

Talk to your doctor, look for information on the Internet, read books and pamphlets. Being informed about your condition can help you take better charge of it.

Identify the factors that trigger IBS.

This is a key step both in managing your condition and helping you feel you have control of your life.

Seek out others with IBS.

Talking to people who know what youíre going through can be very reassuring. Try Internet chat rooms or IBS support groups in your community. Your doctor may be able to refer you to a support group or you may find one listed on the Internet or in your local paper.

Donít hesitate to seek counseling.

Specialists in behavioral medicine can help you understand and manage the effects of stress.

Complementary And Alternative Medicine

The following nontraditional therapies may help relieve symptoms of IBS:

Acupuncture.

In 1998, the National Institutes of Health (NIH) issued a long-awaited statement on acupuncture. Among other benefits, NIH researchers found that acupuncture could provide significant relief from chronic pain. Although the NIH didnít study the effects of acupuncture on other symptoms of IBS, some people have found that acupuncture can relax muscle spasms and improve bowel function. If youíd like to try acupuncture, ask for a referral from someone you know who has had these treatments or contact the National Acupuncture and Oriental Medicine Alliance at 253-851-6896. Keep in mind that you may not experience immediate effects from nontraditional therapies and may require more than one session.

Herbs.

Peppermint is a natural antispasmodic that relaxes smooth muscles in the intestines. A study published in the Journal of Gastroenterology reported that 110 people with IBS who took one enteric-coated peppermint capsule 15 to 30 minutes before meals for 1 month noted a significant improvement in bloating, diarrhea and abdominal pain. Be sure to use enteric-coated capsules, not uncoated capsules or peppermint tea, which may actually make symptoms worse. Peppermint may also aggravate heartburn. Before taking any herbs, check with your doctor to be sure they wonít interact or interfere with other medications you may be taking.