health

Irritable Bowel Syndrome

Cramping abdominal pains, bloating, diarrhoea or conversely bouts of constipation: these are all common symptoms of Irritable Bowel Syndrome (IBS).  It’s a pretty common problem thought to affect 10-15% of the population with only 10-20% of sufferers ever going to see their GP.  It’s far more likely to occur in women than men (2:1 ratio female to male sufferers) and commonly affects people in their 20s and 30s.

I’ve been driven to write about it because these are symptoms I see every day in General Practice and have personally suffered with and I’ve found that once it’s been diagnosed it can almost be… dismissed.

“It’s just IBS.  No need to worry”.

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Unfortunately there are studies which show that, although IBS doesn’t limit the length of peoples lives, the quality of the lives sufferers lead can be impaired causing psychological issues and financial losses through missed time at work.

Case: Laura

Last month my friend Laura started to develop severe cramps in her stomach.  She felt sick, bloated and she started having bouts of diarrhoea.  This was unusual for her: she’s very healthy and is rarely off work.  She’s also self-employed so any time she does need to take off is unpaid.  So she took some antacids and just powered through it.  Her pain continued.  It was so bad one night that she called 111 and was advised to go to A&E.  It was December and we were in the grips of yet another winter crisis for the NHS: the hospitals were full to the brim and the staff overworked.  They assessed her and told her it was probably gastritis.  Take some Omeprazole and see your GP.

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The pain continued.  She could barely eat over Christmas.  The pain was intermittent: she’d have periods of time where she thought she was better and go into work only for the pain to come on quickly and be so severe she’d have to return home.  She went to her GP who was very thorough.  She’d been diagnosed with IBS in her early 20s but never had any advice or testing for other things.  He wasn’t particularly happy about this “we should really make sure it isn’t any thing else”.  He arranged for a blood test (including a test for Coeliac’s Disease which is a gluten-allergy) and stool tests to check for a bug called H Pylori which can cause gastritis and another called a faecal calprotectin (to check for inflammation).

Off she went again, waiting for the results of the tests.  On my advice she’d started trying to track her symptoms to see if they were associated with any specific foods.  The blood tests and stool tests were all normal and she’d realised that her symptoms were worse every time she ate anything containing dairy.

What causes IBS?

Ok this is another syndrome where we don’t fully understand the processes involved but it is likely to be linked to a number of factors.

  • Genetics: no specific gene has been identified but twin studies suggest this has a role.

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  • Diet: this includes intolerances and sensitivity to certain foods and up to 90% of people suffering with IBS report certain food triggers
  • Infection: some people seem to develop IBS after gastroenteritis due to changes in the normal constituents of the gut due to the immune-response and normal bacteria which make up the gut flora.
  • Psychological factors: psychological stress due to anxiety or depression can alter the functioning of the bowel.  This is due to the presence of the “brain” around the gut (a complex neurological system which exists around the gastrointestinal system).

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  • Medications: such as antibiotics

How is IBS diagnosed?

This is tricky.  There is no definitive test to confirm the presence of IBS: it’s made by looking at the pattern of symptoms and, if necessary, ruling out other causes.  Laura’s GP was correct: her symptoms were quite severe so it was worth making sure that she was tested appropriately.  But to be honest, this may not always be appropriate and it does depend on the pattern of symptoms and how certain the doctor seeing the patient is about the diagnosis.

I personally think a symptom diary can be invaluable.  Cutting out whole food groups at random always seems to be en vogue but it can lead to deficiencies which can endanger health and wellbeing.  Keeping a diary can help to identify any patterns of symptoms and make it easier to see if certain food groups trigger them.

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If testing is recommended I would always advise being checked for a gluten allergy (Coeliacs Disease) because it can cause similar symptoms.  Before this blood test is carried out you should make sure you’ve been eating wheat for at least 2 weeks otherwise it may be negative even if the disease exists.

Diet and lifestyle

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The most popular treatment option for sufferers of IBS (according to the BMJ) is the low FODMAP diet.  The term FODMAP relates to a new dietary class comprising of fermentable oligosaccharides, disaccharides, monosaccharides and polyols: a list of foods which ferment and thus are poorly absorbed.  This includes common foods such as:

  • Fruits (apples, cherries, peaches and nectarines)
  • Artificial sweeteners (sorbitol, xylitol and mannitol)
  • Vegetables and legumes (including broccoli, Brussels sprouts, cabbage and peas)
  • Most lactose-containing products

This diet is restrictive which can make it difficult to stick to.  Evidence from the trials shows that even short term adherence to the diet can lead to better gut health.  The longest duration of the diet in these trials seemed to be 6 weeks but even sticking to it for as little as 3 can be beneficial.

Ideally this diet should be adopted under the guidance of a dietician but there is a good factsheet from the IBS Network.

The NICE guidance also advises that probiotics purchased over the counter may have some benefit but the evidence from trials is limited and the probiotic should be tried for between 4-6 weeks.

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Exercise and regular physical activity are also advised in the management of IBS.  Theoretically, regular activity reduces bloating and gas retention and it is known that regular exercise reduces stress levels.  There have been some small trials which show that there was a significant reduction in IBS symptoms in patients who undertook a regular exercise programme compared to those who did no exercise.

Medications

There are no specific medications for IBS at present but the choice of medications should be based on the nature and severity of the symptoms.  The different medications can either be used in isolation or combination:

  • Antispasmodics such as Meberverine Hydrochloride or Peppermint Oil for abdominal cramps as required
  • Laxatives (but not Lactulose) for constipation symptoms.  The specific laxative Linaclotide can be prescribed for moderate-severe constipation in IBS if:
    • constipation has persisted for more than 1 year
    • all the other types of laxatives have been tried and failed
  • Anti-motility agents such as Loperamide for diarrhoea-type symptoms
  • Antidepressant medication can be tried if laxatives, antispasmodics or anti-motility agents have not worked.
    • Tricyclic Antidepressants (TCAs) such as Amitriptyline.  As with its use in migraine this would not be used to treat a suspected depression but for its neuropathic painkilling effects.
    • Selective Serotonin Re-uptake inhibitors (SSRIs) such as Citalopram or Fluoxetine if treatment with a TCA has been ineffective or poorly tolerated.

Cognitive Behavioural Therapy (CBT)

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Use of psychological therapies such as CBT has been advised for many years now, but uptake of such treatment is low, possibly because of the stigma associated with suffering with a “mental health disorder”.  The studies show that there can be some benefit from CBT in the initial stages following treatment but the benefits are vary according to the practitioner providing the treatment, the patients adherence to the treatment and the number of sessions which are provided.  This is still advised in the NICE guidance for IBS which does not respond to lifestyle changes or medications.

What next?

If none of the above is beneficial a referral to a gastroenterologist should be made to confirm whether or not IBS is indeed the diagnosis and for guidance on further management.

For more information please see:

The gut and liver disease charity CORE

The IBS Network

The Association of UK Dieticians factsheet on IBS and diet

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