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Irritable Bowel Syndrome

Irritable bowel syndrome affects about 300 people per 100,000. These disorders are affecting 10,000 to 30,000 people per 100,000. So, you can see that it is just orders of magnitude more common which helps explain why they are such a part of our practice.

The symptom criteria developed by Manning, Heaton, and Thompson back in 1979 had been used for some time - six very specific symptoms, and the idea here is that the more symptoms you have the more likely you are to have IBS. Now the Rome group took this a bit further and tried to create even more specific symptom criteria, and these are the criteria that are now being used.

That is, the pain has to be in some way associated with the bowels. One of the reasons I think IBS gets a bad rap is that all abdominal pain gets called IBS, and I think mentally I find it helpful to try to split off functional abdominal pain from IBS. That just gives abdominal pain a bad rap - understand that. Altered chronic bowel habits. So you have to have one criteria here, and then usually two of these five in order to meet a criteria for IBS, and these are just the symptoms that we are all used.

Now many proposed risk factors exist for IBS and I certainly do not want to go through all of these, but certainly psychiatric and psychological issues, previous diarrheal illness, and familial aggregation I think is an exciting area. If we look at the pathogenesis of IBS, it really serves as a model for much of the functional disorders. Is it abnormal motility, visceral perception, psychological distress, or some sort of environmental factor. Now there are true motor problems in IBS - clustered contractions, heightened gastrocolic reflex, giant amplitude contractions in the colon, so those do exist. There is also altered visceral perception.

Now our approach to IBS is very similar to the approaches you have heard so far, but we would like to assess the predominant symptom, do a limited screen for organic disease and interface therapeutic trials in a diagnostic process.

Shifting gears then to the diarrhea group - again the issue is if there is anything simple that we can do to try to take care of this and certainly sugar-free gums, and sorbitol - many of the medications that come in the syrup form have sorbitol in them, and so we need to be careful about that, and reviewing the medications - does the patient have reflux and take a lot of Mylanta or other magnesium antacid. Are they are on some sort of prokinetic, and I would also add to this, in the diabetic group Metformin which is an issue with diarrhea.

In the gas/bloat - again the simple things first. Now one of the issues that always comes up, especially in the patient with "severe" IBS is do they have an obstruction. And, so it is very helpful - although you hate to have these people go to the emergency room when they are acutely ill - to get some sort of abdominal flat plate to make sure that you are not dealing with an intermittent bowel obstruction just because that is something you can fix and you want to know about. The other issue with the predominantly pain group is, is this a form of abdominal wall pain. Is the pain always there. Does it never go away. Does it get worse more with stretching and reaching and straining as opposed to being related to their bowels, and so we want to check their abdominal wall, have them flex their muscles, see if the tenderness increases or decreases. There is not great sensitivity and specificity on this , but at least if they have abdominal wall pain we can focus on injection therapy or the like and move away from this focus on their bowels. Once they have had that initial screen we can think about a therapeutic trial usually of Dyclonine.

Now where it is true that if they have anxiety or depression it is important to treat that, and I try to avoid getting into this fight over which is more important. You have to say you do have anxiety, you do have depression - we have to treat that. You also have your bowel problem - we have to take care of that, but at least get this treated. Somatization is a challenge and if the patient has a bona fide personality disorder you are really in trouble.