Irritable Bowel Syndrome
Do you have frequent bouts of constipation alternating with diarrhea? Have you periodically experienced abdominal pain, gas, painful cramping, bloating, nausea, and loss of appetite for no apparent reason? If so, you may have irritable bowel syndrome (IBS).
Doctors describe IBS as a functional disorder, meaning that there's a problem in bowel function that appears to be unrelated to organic disease. Those of us afflicted by the malady might be more apt to call it "dysfunctional," however. Its symptoms range from annoying and embarrassing to downright disabling: Some people afflicted with chronic diarrhea are so worried about getting to a bathroom on time that they withdraw from normal social activities.
But although IBS can cause considerable discomfort, it doesn't cause permanent intestinal damage or lead to serious illness. The other good news is that it may respond well to stress reduction measures and changes in diet and exercise.
What are the symptoms of irritable bowel syndrome?
Lined with muscles and nerves, the colon is an active organ that contracts and relaxes to push along digested material. When it's running smoothly, it's easy to ignore -- just the way everyone would prefer it.
In some people, however, the colon can become extremely sensitive, leading to the collection of symptoms known as irritable bowel syndrome. Small contractions or gas can cause cramps and pain in the lower abdomen. The pain often appears after a meal and goes away after a bowel movement. The colon may go into spasms, causing diarrhea during the daytime (people with IBS rarely suffer from diarrhea during the night). Conversely, the spasms may hamper the normal movement of waste, causing constipation. Some patients experience mostly diarrhea and others mostly constipation; many alternate between the two extremes.
Other common symptoms include bloating, mucus in the stool, urgent bowel movements, straining during bowel movements, or a feeling of incomplete emptying after a bowel movement. All the symptoms of irritable bowel syndrome tend to come and go, but often flare up in times of stress.
Up to one in five adults in the United States experiences irritable bowel syndrome at some point in their lives. Two-thirds of all people who seek medical help for the syndrome are women. The majority of people with IBS continue to experience the symptoms off and on, but up to 30 percent get rid of it entirely.
What causes irritable bowel syndrome?
Most people with irritable bowel syndrome seem to have perfectly healthy digestive systems. Most likely, your doctor could order a slew of tests and exams and still find nothing wrong with your colon. But that doesn't mean the problem is "all in your head." While stress can make your symptoms worse and may contribute to the condition, something else probably set the problem in motion.
Unfortunately, nobody's sure what that "something else" may be. Experts speculate that people with the syndrome may have a glitch in their nervous systems that makes the lining of the intestines extra sensitive to the presence of certain foods or to swelling and distention. Others believe that in some people, inflammation may leave the lining of the intestines more sensitive. People affected by IBS also produce certain brain chemicals called neurohormones in higher quantities than people who don't have the malady, and some researchers think that there may be a communication breakdown between the nerves and the muscles in the colon.
What can aggravate my symptoms?
In many people, symptoms can flare up or worsen during times of emotional stress, which can cause spasms of the colon. Many things in your diet can also contribute to the condition, including alcohol, dairy products, caffeine, fatty foods, and -- in some people -- gas-producing foods (such as beans, cabbage, nuts, and broccoli), the artificial sweetener sorbitol, and chocolate. Nicotine is another common culprit.
How is irritable bowel syndrome diagnosed?
Doctors can usually diagnose irritable bowel syndrome just by taking inventory of a patient's symptoms. Your doctor or a specialist in digestive disorders (gastroenterologist) may also want to check your blood or stool for other possible causes of the symptoms, such as parasitic infections or diabetes.
Because some symptoms of IBS resemble those of colon cancer, your doctor may want to do tests to rule that out, particularly if you are over 50 or have a history of colon cancer in the family. He or she may begin by testing your stool for occult, or hidden, blood. (Colon cancer -- but not IBS -- can cause internal bleeding, which in turn can lead to blood in the stool.) Some patients may also need to have their colons examined with the aid of a barium enema x-ray, colon scan, or endoscope to rule out colon cancer and other diseases.
How is irritable bowel syndrome treated?
There's no single treatment for coping with irritable bowel syndrome. You'll need to work with your doctor to find an individual approach that works best for your symptoms.
If you suffer from diarrhea, constipation, or both, your doctor may recommend an over-the-counter fiber supplement such as Metamucil, which contains a vegetable powder called psyllium. These fiber supplements absorb water, and so make stools bulkier (helping with your diarrhea) and softer (helping with constipation by making the stools easier to pass). The package labels often describe the supplements as "fiber laxatives," but they're actually not laxatives. (Just be sure to take them with one, and preferably two, 8-ounce glasses of water, or they may actually cause constipation.) Some people have found that mixing the fiber powder with fruit juice and ice makes it much more palatable.
Your doctor may also recommend a change in diet. Many people feel better after cutting back on fat, alcohol, and caffeine. Some people with chronic IBS may also need to stop eating salads and raw vegetables, according to Gary Gitnick, chief of the division of digestive diseases at University of California at Los Angeles. Among other things, raw vegetables can cause gas and diarrhea in people with sensitive digestive systems.
Gitnick, a gastroenterologist who has treated thousands of people with irritable bowel syndrome and other functional GI disorders, believes that most people can get rid of the syndrome -- or at least keep it under control -- through lifestyle changes alone. To figure out what foods may be playing havoc with their digestion, he encourages keeping a food and mood diary for several weeks. The key, he writes in a recent book, is to write down your symptoms and what you were doing before the symptoms started. Keep track of your mood, the cause of any stress, and also everything that goes into your mouth, including food, drink, and even candies and chewing gum. Then look for patterns. If something seems to start trouble over and over, consult your doctor to determine whether you should try to avoid it. In his book, Gitnick recounts that one IBS patient who had begun suffering from mysterious daily attacks of diarrhea was able to trace them back to the sugar-free gum sweetened with sorbitol that she chewed every day. Once she cut out the gum, her diarrhea disappeared entirely.
Foods that affected Gitnick's patients with IBS include cabbage, coleslaw, beans, nuts, fresh unpeeled fruits, beverages that contain caffeine, carbonated beverages, foods containing sorbitol like diet candies and gum, and bran cereals. Of course, the symptoms vary from person to person, and what bothers some patients won't affect others. The key is to look for repeating patterns.
Regular daily exercise is also helpful, particularly if you suffer from constipation. And if your bouts of irritable bowel syndrome seem to go hand-in-hand with stress and anxiety, you may need some help relaxing and coping with difficult feelings. Some doctors can recommend relaxation techniques or places you can get counseling, if necessary.
What if lifestyle modifications aren't working?
If your symptoms are out of control and aren't responding to lifestyle changes, your doctor may prescribe medication -- at least for a short while.
For severe pain, a physician may prescribe an antispasmodic agent. The drugs hyoscyamine (Levsin) and dicyclomine (Bentyl) can all ease pain and diarrhea by relaxing the colon. Your doctor may also prescribe an antidepressant that sometimes acts as a pain reliever, even if you aren't depressed.
The drug alosetron hydrochloride (Lotronex) was re-approved with restrictions by the U.S. Food and Drug Administration (FDA) in 2002, after previously being pulled off the market after a number of deaths were reported in association with its use. It's intended only for women with severe IBS who have not responded to conventional therapy and whose primary symptom is diarrhea. However, it should be used with caution as it can have serious side effects, such as severe constipation or decreased blood flow to the colon. For this reason, its distribution requires both doctors and patients to be registered in a risk management program which tracks patients and ensures they are informed of the drug's risks.
Another drug approved only for women who have severe IBS and haven't yet found the right treatment is Lubiprostone (Amitiza). This drug -- for women with IBS and constipation -- increases fluid secretion in the small intestine which helps to get the bowels moving.
A drug that was approved by the FDA for treating women with IBS -- tegaserod maleate (Zelnorm) -- was removed from the market in 2007 because safety studies found an increased risk of heart attack, stroke and heart/chest pain. Zelnorm is intended for patients suffering from severe constipation. It is now only available in emergency situations (those that are either life-threatening or require hospitalization) and requires special FDA authorization before it can be shipped by the manufacturer.
Over-the-counter medications may be useful, too. The drug loperamide (Imodium A-D) may help relieve diarrhea. If you have constipation, you can safely take over-the-counter fiber supplements. Activated charcoal tablets can help relieve gas. Ask your doctor which types will work for you.
Remember, though, that lifestyle modifications are generally the best method to finding long-lasting relief. Getting regular exercise, changing your diet, reducing stress, and cutting out nicotine may not only help alleviate irritable bowel syndrome, but make you healthier and more energetic in general.
National Digestive Diseases Information Clearinghouse. Irritable Bowel Syndrome. September 2007. http://digestive.niddk.nih.gov/ddiseases/pubs/ibs/
Gitnick, Gary MD, Freedom from Digestive Distress: Medicine-Free Relief from Heartburn, Gas, Bloating, and Irritable Bowel Syndrome. Three Rivers Press, New York.
Heitkemper, M. and M. Jarrett. It's not all in your head: Irritable bowel syndrome. American Journal of Nursing. January 2001. 101(1): 26-32.
Rome II: A multinational consensus document on functional gastrointestinal disorders. Gut: An International Journal of Gastroenterology and Hepatology. Supplement No. II, vol. 45.
Shen, B. and E. Soffer. The challenge of irritable bowel syndrome: Creating an alliance between patient and physician. Cleveland Clinic Journal of Medicine. March 2001. 68(3): 224-234.
Food and Drug Administration (FDA). FDA Approves Restricted Marketing of Lotronex. June 7, 2002.
Food and Drug Administration (FDA). Zelnorm (tegaserod maleate) Information. April 2, 2008.
Mayo Clinic. Irritable Bowel Syndrome. July 2009. http://www.mayoclinic.com/health/irritable-bowel-syndrome/DS00106