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Dr. Robert D. Fusco, Medical Director    
Irritable Bowel Syndrome

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You are just on your way to work and again it happens - another attack of crampy abdominal pain. You dash off to the bathroom and have a burst of diarrhea. What is wrong? Last week you were constipated, now you are having diarrhea. Was it something you ate? Why does this keep happening to you? Is it serious?

You Are Not Alone

Well, if you are like 25 million other Americans, you may be suffering from an episode of Irritable Bowel Syndrome (IBS). Also known as spastic colon, nervous bowel, mucous colitis, functional bowel disorder, and its aptly named British term, "intestinal hurry," IBS is one of the most common digestive disorders seen in medical practice today. Only the common cold leads to more time lost from work and school. But, most IBS sufferers suffer in silence. Most people don't like to talk about their bowel problems with others - sometimes not even with their doctor - and would be surprised to learn that their recurrent attacks of lower abdominal cramps, and alternating diarrhea and constipation even have a name, let alone treatment. Because of this fear and embarrassment, many individuals suffer and worry needlessly. Although the symptoms of IBS can be quite distressing, most symptoms can be relieved with proper medical attention.

What Is IBS?

Irritable bowel syndrome, as the name implies, is not a disease, but rather a syndrome - a set of symptoms that occur together. IBS is what doctors call a "functional" ailment. It is not caused by any physical or structural abnormality. In fact, an operation performed on the abdomen would reveal a perfectly normal-appearing small intestine and colon. Despite much research, IBS is still rather poorly understood, but most researchers feel that it is simply a "malfunction" of the digestive tract. Although the symptoms may be distressing, IBS is not a serious health threat, and it doesn't lead to any significant complications. It is not associated with inflammatory bowel diseases such as ulcerative colitis or Crohn's disease. It does not require surgery and it does not lead to cancer. You don't die from IBS. It doesn't threaten your life, only your lifestyle, and usually only temporarily, whenever the symptoms are distressing.

What Are The Symptoms?

These vary greatly from individual to individual, but typically include some combination of lower abdominal pain, bloating, excess gas, increased mucus in the stools, alternating diarrhea and constipation, and an urgent need to have a bowel movement. While most healthy adults may have an occasional bout of diarrhea or "nervous stomach," those with IBS experience these complaints more frequently and more severely.

If present, the abdominal pain usually worsens soon after eating and is relieved by having a bowel movement or the passage of gas. Classically, sleep is uninterrupted, but patients may awaken early in the morning with an immediate urge to have a bowel movement. They tend to have frequent bowel movements during the course of the morning, yet still have a sense of incomplete evacuation. Mysteriously, this diarrhea may give way to prolonged periods of constipation with hard, dry stools that are usually described as "marble-like" or "pencil-thin." There may be much straining and a lot of gas. All of these symptoms may correct themselves only to return when the individual least expects it - usually at an inconvenient time such as before an important occasion. . Who Gets IBS? Anyone can. IBS now affects one in five of all adults and it tends to run in families. All races are susceptible. For unknown reasons, it usually first appears in late adolescence or early adulthood, and women seem to develop it four times as often as men. But, this may only reflect the fact that in most Western societies, women tend to visit physicians more often than men do. In India, where men seek medical care more frequently than women, the sexual predominance is reversed.

What Causes IBS?

Nobody knows for sure. Despite decades of extensive research, our knowledge of why IBS occurs is still incomplete. However, medical researchers have discovered that sufferers of IBS have a measurable disturbance of intestinal motility - gut movements that propel stool. In IBS, the bowel is a little "out of sync" and does not contract normally. Instead, the gut squeezes in a disorganized, and at times violent, manner. These contractions may be terribly exaggerated and sustained, lasting for long periods of time and may lead to diarrhea or constipation - or both. These disorganized contractions can also lead to intestinal spasms and cause bouts of abdominal pain, just as a cramp of your calf muscle causes pain. In addition, air may accumulate behind these localized contractions, causing the bowel to swell; bloating and gas production can then occur. Contrary to popular belief, the symptoms of IBS are not in your head. They are in your gut.

What About Stress?

That is not to say that stress and other emotional factors do not play a role in IBS. Most of us have had firsthand experience with the effects of emotions on our digestive tracts. Intense anger or anxiety, for instance, may increase intestinal contractions and trigger bowel movements and loose stools. Many studies have shown that IBS is often linked with psychological distress. By some estimates, over 50% of people with IBS have also sought treatment for anxiety, depression, or obsessive-compulsive disorder. There is also evidence linking IBS with psychological trauma such as prior physical or sexual abuse. Thus, while IBS is a disruption of the natural motion of the bowel muscle, emotional factors may worsen the symptoms,

How Is IBS Diagnosed?

Giving the symptoms of IBS a name doesn't end the problem, but accurate diagnosis is an important first step in treatment. It is your doctor's responsibility to determine if your particular symptoms are caused by IBS. Abdominal pain or a persistent change in bowel habits can sometimes reflect a more serious digestive disorder. So before the diagnosis of IBS can be made, all other diseases that may reasonably cause the same symptoms must be excluded. Your doctor will want to take a thorough medical history, do a physical examination, and may also wish to perform additional laboratory tests and x-rays or a special "scope" test in which your doctor looks directly into the bowel using a flexible viewing tube to exclude more serious disorders before making a diagnosis of IBS.

How is IBS treated?

Although medical researchers know that IBS is due to a "malfunction" of the digestive tract, they have not yet uncovered a specific "cure." IBS must be considered a chronic long-term disorder similar to high blood pressure. As you know, there is no cure for high blood pressure, but treatment is available to control the problem. The same is true for IBS. There is no cure, but with proper treatment, bowel habits can usually be stabilized, abdominal cramping lessened, and attacks of urgency reduced. If you have IBS, it is important that you work with your doctor to create an individual treatment program. Since every case is different, it may take some time and "trial and error" until it can be determined which treatment regimen works best for you. Surgery is never indicated.

If your symptoms are transient and only occasionally appear during periods of stress, no special treatment may be needed. However, those with more severe and persistent symptoms may need additional treatment. No one therapy resolves all symptoms in all patients, but the following are usually effective:
  • Lifestyle Changes Often this means recognizing and dealing better with stress. Our "high tech" world now runs at a faster pace making stress an almost normal part of modern life. Understand that you may never completely catch up and be on top of things, and accept that that's all right. Make it a point to spend some regular time relaxing and enjoying life despite all that needs done. Be sure to get an adequate night's sleep and exercise regularly.

  • Diet
    Eating smaller meals more frequently, or eating smaller portions of food at mealtimes may also help to alleviate symptoms. Eating foods that are low in fat and high in carbohydrates (pasta, rice, bread, cereal, fruit and vegetables), and foods that are high in protein and low in fat (skinless chicken and turkey, fish and low fat dairy products such as skim milk and low fat cheese) can also be beneficial. If diarrhea is the major problem, eliminating foods that have a laxative effect, such as fruit, fruit juice and dairy products is often advised. Avoid tobacco, and excessive use of caffeine and alcohol.

  • Fiber
    Most patients find that a high fiber diet is helpful in controlling IBS, particularly in those patients with constipation. Increasing dietary fiber adds bulk to the stool. Larger stools are also softer and easier to eliminate. Fiber can be added with whole grain breads and cereals and by getting 5 servings daily of fruits and vegetables. For those on the go, over-the-counter fiber supplements such as Metamucil and Citrucel are acceptable.

  • Medications
    Patients whose symptoms are more frequent and severe often require more aggressive treatment. In these cases, special prescription medications may be ordered by your doctor. Since all drugs have the potential for side effects, it is best to limit drug treatment to control severe flare-ups. Of course, if any drug is prescribed for you, you should always take it exactly as prescribed. These may include medications to suppress abdominal cramps, diarrhea and urgency. Even though depression may not be present, low dose antidepressants such as imipramine and amitryptiline at bedtime seem to reduce sensitivity to abdominal pain.

  • Psychotherapy
    If stress seems to play a major role, psychotherapy is sometimes suggested. Psychotherapy can often provide assistance in coping with a chronic illness and uncover any emotional triggers that may be present.
The Future

IBS is a chronic, life-altering disorder that can have a significant impact on daily functioning and overall well-being and costs the US healthcare system more than $29 billion annually in direct and indirect costs. It is the second leading cause of workplace absenteeism after the common cold and affects up to 1 in 5 Americans. Currently, there is no single effective therapy to treat the multiple symptoms of IBS.

At this time, your best hope for the future will come from a self-examination of the way you live, the problems and situations that cause you stress, and your eating habits. In some cases medication is helpful. If you suffer from IBS, you cannot expect immediate results. However, with self-knowledge and awareness of the problem, you can make adjustments in your lifestyle to minimize the inconvenience that IBS may cause. If you have any questions, see your doctor.

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