Irritable bowel syndrome

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Irritable bowel syndrome (IBS) refers to a complex disorder of the lower intestinal tract. It is mainly characterized by a pattern of symptoms that is often worsened by emotional stress. [1] It can occur at any age but often begins in adolescence or early adulthood. About 20% of population suffer from this. In western countries the female predominance is noticed, but studies in India and other Asian countries reveal that there is a balanced occurrence or male predominance. It is often misunderstood with inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis.

Contents

Prevalence

Recent studies point out that the prevalence is increasing in Asian countries, probably due to the westernisation of the diet and increased psychological stress (Irritable Bowel Syndrome in Developing Countries - A Disorder of Civilization or Colonization?, Neurogastroenterol Motil. 2005, Jun;17(3):317-24). As per some literatures from western countries the prevalence rate in those countries is about 15-20% of adults. There is a lack of evidence to show clear status of prevalence of IBS in India. However, one study conducted in a small area of Pune reveals that the overall prevalence is 33% in which the male female ratio is 5.3:1 (A Search for Unhappy Abdomen: Prevalence of Irritable Bowel Syndrome in General Population, Medical Journal of Armed Forces in India, 1998 April; 54(2): 123-7). Some other studies state that the presentation of symptoms found in patients of Asia seems to be different from western countries, like greater frequency of upper abdominal pain and defecatory symptoms perceived as being less bothersome.

Causes and pathophysiology

There are many possible causes for the development of the symptoms of irritable bowel syndrome and underlying pathophysiological mechanism. The importance of these varies from individual to individual. In 50% of patients psychological disturbances like anxiety, depression, somatisation and neurosis are identified. Such mental symptoms are important for homoeopaths in treating the case. In modern opinion many consider these mental symptoms separately and often refer them to the psychiatrist.

Some IBS symptoms surfaces in patients with lower threshold for abdominal visceral pain, or lower volumes of colonic gas insufflations or colonic balloon inflation when compared with controls in experimental studies. Differentiating these causes is often helpful in the selection of the remedy. There may be a problem with muscle movement in the intestine or a lower tolerance for stretching and movement of the intestine. A number of myoelectrical and motor abnormalities in the colon and small intestine have been identified. These are correlated in some cases with the episodes of abdominal pain and emotional stress.

Recent studies reveal that immune reaction also plays a significant role in IBS. These studies identified association of cytokines and secretary products in tissues taken from IBS patients with inflammation due to immune reaction. It supports the vitality theory. It is also identified that some protozoal infections occur more frequently in IBS patients. The syndrome can also be triggered by low fibre diet, acute gastrointestinal infection and use or abuse of laxatives.

Symptoms

(a) Anxiety, depression and IBS

IBS is a chronic condition and definite diagnosis is made if symptoms are present for more than 3 months. Usually patients present clear abdominal symptoms. Thorough clinical investigation is to be made to identify the link between mental symptoms and physical symptoms. In IBS physical symptoms are usually worse due to mental cause. Mental symptoms usually presented by these patients are of anxiety and depression. Hypersensitivity is another factor where tolerance even to a slight pain is poor.

(b) Gastrointestinal symptoms of IBS

Gastrointestinal symptoms of IBS are either diarrhoea predominant (IBS-D), constipation predominant (IBS-C) or with alternating stool pattern (IBS-A). In some patients it is an acute onset which usually develops after infectious illness with fever, abuse of antibiotics, lowering of vitality, vomiting and acute diarrhoea. Though there may be number of symptoms, three common and primary symptoms are 1) abdominal pain, 2) abdominal distension and bloating, and 3) variable bowel habits – more frequent and loose stools, or constipation. Abdominal pain is usually intermittent. The type of pain is colicky or cramping, which is felt in the lower abdomen and may be relieved by defecation. It is usually worse 1-2 hours after meals and does not occur at night or interfere with sleep. Abdominal distension and bloating worsen through out the day, but it is not due to excessive intestinal gas. The bowel habit is variable; most of the patients have alternate between the episodes of diarrhoea and constipation. In choice of medicine it is also important to know that what patient means by saying constipation or diarrhoea. Sometimes patient may use constipation as a general term for meaning hard or small stools with straining and reduced frequency. Many patients report firm stool in the morning followed by progressively looser movements. Mucous is commonly seen with the stool. Despite all these symptoms as reported, usually patients do not loose weight. Many of the patients have other functional symptoms like dyspepsia, frequent urination, headache, backache and chronic fatigue syndrome.

Pathological investigations for IBS

Tests reveal no problem. Usually laboratory investigations are done to find out whether presence of symptoms is due to other disease. The routine blood count, serum albumin, ESR and stool occult blood test are not altered in IBS. In patients with diarrhoea, thyroid function test, and stool examination for ova and parasites are helpful to rule out other causes. Generally hospitals conduct barium enema and colonoscopy in older patients to exclude colorectal cancer. Younger patients with persistent diarrhoea may perhaps require endoscopy to look for inflammatory bowel disease (Crohn's disease or ulcerative colitis) if IBS therapy fails.

Differential diagnosis

Usually celiac disease, intestinal infectious diseases, food allergies, lactose intolerance and parasites are wrongly diagnosed as IBS. Proper case history, triggering factor and stool examination are helpful to rule out these conditions.

Conditions that accompany IBS

Some studies have identified some conditions that frequently associated with or occurred in IBS patients. A study with 97,593 individuals with IBS identified headache, fibromyalgia and depression are the co-morbidities of IBS. [2] Many researches have suggested that IBS and inflammatory bowel disease (IBD) are inter-related diseases. As per some reports IBS is a type of low-grade IBD. A 3 year study found that patients diagnosed as IBS were 16.3 times more likely to develop IBD during the study period. [3] Another recent study has reported a statistically significant link between IBS, migraine headaches and endometriosis. [4]

Management

The aim of treatment is to relieve symptoms acutely and to reduce the episodes where advice and reassurance also play important role. Changes in diet helps relieve symptoms. Increasing dietary fibres and avoiding items that stimulate the intestines may also be helpful. Other possible treatments may include anxiety-reducing measures, regular exercise and counselling (in cases of severe anxiety or depression). A study conducted by professionals comprising from different field indicates a beneficial effect of yogic intervention in diarrhoea predominant IBS. [5]

CAM therapies for irritable bowel syndrome

In randomized double blind trials IBS shows a vere high response rate of about 30%-40% to placebos[6]. Therefore alternative treatments that are able to harness the placebo effect can be useful in its treatment.

Acupuncture and acupressure

Acupuncture is useful for the treatment of IBS as a method to harness the placebo effect [7]. For that purpose is not important where exactly needles are placed, as sham acupuncture is just as effective as real acupuncture. If there is an additional effect other than the placebo, then it is of insufficient clinical relevance to justify de novo investment in provision of acupuncture services to hospital patients with IBS[8].

Ayurveda

Herbal remedies

Homeopathy

Homeopathic medicines for abdominal pain of IBS.

Aegle marmelos: Abdominal colic with indigestion and constipation; no desire for food; wind comes out with loud noise, worse in the afternoon; associated amoebic and bacillary dysentery may or may not be present. Arsenicum album: Pains in the abdomen, with unbearable anxiety and restlessness; suitable for office goers, those who are perfectionists; burning in the abdomen, with heat and thirst; tenesmus as in dysentery, constant burning and pressure in the rectum and anus; ineffectual urging to stool; frequent diarrhoea, with violent tearing cutting pains in the intestines; while fully conscious, sometimes discharges of faeces and urine unaware. Belladonna: Melancholy with grief and discouragement; nervous anxiety and restlessness; dread of all exertion and motion; violent colic with constipation, which allows no rest; shootings in left side of the abdomen, on coughing, on sneezing, and on being touched; painful distended abdomen, very sensitive to the touch; diarrhoea with stools of mucus; evacuations whitish like chalk, or greenish; thin, green stools, with frequent micturition and perspiration. Colocynthis: Suitable for irritable persons who easily angered; colic causing patient bend double, sometimes with nausea and vomiting, sometimes with diarrhoea, sometimes with passing great quantities of gas; pains often extend into chest and pelvis; sensation as if stones were being ground together in the abdomen. Iris versicolor: Low-spirited, discouraged and easily vexed persons; great depression with headache; fear of an approaching illness; colic worse by bending forward and better by discharge of flatulence; cutting pain in the lower part of abdomen; fetid flatulence; sharp griping pains in the bowels. Natrum phosphoricum: Fears of bad news and on waking; irritable; sharp cutting in hypochondria and left iliac region; flatulence worse after eating; colic as from wind pressing on bladder, causing frequent inclination and urging to stool; colicky pains worse walking; diarrhoea with colic; fears to pass flatus as faeces would escape; after coitus (man) urging to stool and urination. Nux vomica: Very useful in effects of mental strain at night, especially when it results in irritability and great nervous sensitiveness; suitable to persons who becomes angry easily, of sedentary habits, or those who sit up late at night; indescribable anxiety with nausea, vomiting and trembling; colic with pressure upward causing shortness of breath, and downward causing desire for stool; colic, with constipation and frequent desire for stool; indicated in constipation when there is repeated ineffectual urging to stool; diarrhoea consisting of frequent small evacuations; constant feeling as if there were more to be evacuated; dysentery, especially after the administration of allopathic remedies, with disordered stomach, morning aggravation and discharge of bloody mucus. Pulsatilla: Suitable for women of weeping tendency; likes sympathy; spasmodic pain at bottom of hypogastrium or around the navel with pressure on rectum penetrating into pelvis; colic and labour-like pains in pregnant women; colic with chilliness, while the menstruation is suppressed; hard distension of abdomen especially in epigastrium.

References

  1. MedlinePlus Medical Encyclopedia Irritable Bowel Syndrome
  2. Cole JA, Rothman KJ, Cabral HJ, Zhang Y, Farraye FA, "Migraine, fibromyalgia, and depression among people with IBS: a prevalence study", BMC gastroenterology 2006 Sep 28; 6:26
  3. García Rodríguez LA, Ruigómez A, Wallander MA, Johansson S, Olbe L, "Detection of colorectal tumor and inflammatory bowel disease during follow-up of patients with initial diagnosis of irritable bowel syndrome" Scand. J. Gastroenterol. 2000 Mar;35(3):306-11
  4. Tietjen GE, Bushnell CD, Herial NA, Utley C, White L, Hafeez F, "Endometriosis is associated with prevalence of comorbid conditions in migraine" Headache 2007 Jul-Aug;47(7):1069-78
  5. Yogic Versus Conventional Treatment in Diarrhoea - Predominant Irritable Bowel Syndrome: A Randomised Control Study, Applied Psychophysiology and Biofeedback; Volume 29, Number 1 / March 2004
  6. Systematic review: Complementary and alternative medicine in the irritable bowel syndrome. Aliment Pharmacol Ther. 2006 Feb 15;23(4):465-71.Click here to read
  7. http://www.wjgnet.com/1007-9327/11/4040.asp Acupuncture for irritable bowel syndrome: A blinded placebo-controlled trial
  8. http://www.wjgnet.com/1007-9327/11/4040.asp Acupuncture for irritable bowel syndrome: A blinded placebo-controlled trial
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