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Sheri L. Sanderson is the mother of three children, including one with gluten sensitivities. Her cookbook is the result of personal need---wanting to offer her family gluten-free meals that look and taste just as good as those she made before the change in diet. In addition to many years of... Read more

The Specific Carbohydrate Diet: a carbohydrate plan for those with IBS

Diabetes Medical Library                         main "Disorders" page

Irritable bowel syndrome

We are currently working on our own article about IBS and diabetes that is informative and easy to read.

For now, we refer you to the following article cut from Wikipedia.com.  It is not all that lay-friendly, but contains thorough information about IBS.  


From Wikipedia, the free encyclopedia.

In medicine (gastroenterology), irritable bowel syndrome (IBS) or spastic colon is a group of functional bowel disorders which are fairly common and make up 20–50% of visits to gastroenterologists. There are three forms, dependent on which symptom predominates: diarrhea-predominant (IBS-D), constipation-predominant (IBS-C) and IBS with alternating stool pattern (IBS-A). An important new IBS subtype, post-infectious IBS (IBS-PI), is drawing much clinical investigation.

 

Features

Symptoms of IBS are abdominal pain or discomfort associated with changes in bowel habits in the absence of any apparent structural abnormality. The pain is typically relieved by defecating.

There appears to be an overlap of IBS with stress, chronic pelvic pain, fibromyalgia and various mental disorders (in a small minority). While no good explanation for this phenomenon exists, it does strengthen the view that there is a neurological and psychological component to IBS.

Hormones play a role in IBS that is not yet fully understood. Menstruation frequently triggers or exacerbates IBS symptoms (Heitkemper, 2003), while pregnancy and menopause can either worsen or improve symptoms. Hormone replacement therapy is associated with an increased risk of developing IBS (Maturitas, 2003).

Diagnosis

Diagnostic criteria

In 1978 Manning et al., found, from questionaire data, that IBS sufferers reported four common symptoms. The Manning Criteria was established to distinguish organic causes for symptoms from those of IBS. In 1992 the Rome I Criteria was established by a multinational committee of specialists, which further refined the Manning Criteria. In 1998 the Rome Working Team proposed changes to the definition and diagnostic criteria for IBS to reflect new research data, and to improve clarity.

The diagnosis of Irritable Bowel Syndrome has relied on a diagnosis of exclusion. Because the symptoms of IBS share the symptoms of so many other intestinal illnesses, it sometimes takes years before a correct diagnosis is made to exclude the obvious, and not so obvious, conditions which present symptoms similar to IBS.

Physicians rely on a variety of procedures and laboratory tests to confirm a diagnosis. The Rome II Criteria, however now defines markers which allows professionals to diagnose IBS after a careful examination of a sufferers medical history and physical abdominal examination which looks for any 'red flag' symptoms.

Red Flag symptoms which are NOT typical of IBS:

  • Pain that awakens/interferes with sleep
  • Diarrhea that awakens/interferes with sleep
  • Blood in your stool (visible or occult)
  • Weight loss
  • Fever
  • Abnormal physical examination

According to the Rome II consensus conference of the American Gastroenterological Association and international medical societies on functional bowel disorders, the diagnosis of IBS can be made when the following criteria are fulfilled:

At least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has 2 of 3 features:

  1. Relieved with defecation; and/or
  2. Onset associated with a change in frequency of stool; and/or
  3. Onset associated with a change in form (appearance) of stool.

Symptoms that cumulatively support the diagnosis of IBS

  • Abnormal stool frequency (for research purposes, “abnormal” may be defined as greater than 3 bowel movements per day and less than 3 bowel movements per week);
  • Abnormal stool form (lumpy/hard or loose/watery stool);
  • Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation);
  • Passage of mucus;
  • Bloating or feeling of abdominal distention.

Supportive Symptoms of IBS:

  1. Fewer than three bowel movements a week
  2. More than three bowel movements a day
  3. Hard or lumpy stools
  4. Loose (mushy) or watery stools
  5. Straining during a bowel movement
  6. Urgency (having to rush to have a bowel movement)
  7. Feeling of incomplete bowel movement
  8. Passing mucus (white material) during a bowel movement
  9. Abdominal fullness, bloating, or swelling

Diarrhea-predominant: 1 or more of 2, 4, 6 and none of 1, 3, or 5; or: 2 or more of 2, 4, or 6 and one of 1 or 5. (3. Hard or lumpy stools do not qualify.) Constipation-predominant: 1 or more of 1, 3, 5 and none of 2, 4, or 6;or: 2 or more of 1, 3, or 5 and one of 2, 4 or 6.

Differential diagnosis

The diagnosis of a functional bowel disorder always presumes the absence of a structural or biochemical explanation for the symptoms. This can be excluded via:

Initial screening only requires a history and physical exam, as well as a full blood count, electrolytes, renal function, and an erythrocyte sedimentation rate. Additional testing is done when when there is a poor response to treatment.

While these modalities may be employed to rule out other causes of abdominal symptoms, they are not necessary to make a diagnosis of IBS. Depending on local practice, many doctors avoid overdiagnosing if the history is clearly suggestive of a functional bowel disorder.

Diagnostic tests

A diagnostic test for IBS via assessment of colonic/rectal hypersensitivity using a barostat is currently being discussed. However, sensitivity and specificity are not yet high enough to render the method widely applicable.

Pathophysiology

IBS is highly prevalent in the Western world, but despite the advancement of many theories, no clear cause has yet been established. Increasing prevalence in developing countries suggests some possibile links to diet and cultural factors (Gwee, 2005). Evidence of visceral hyperalgesia (increased sensitivity to noxious stimuli in the gut) includes perception of pain from distention of a rectal ballon at smaller volumes than in normal patients. However somatic sensitivity testing, such as in controlled pressure on the nails of the hand show that IBS patients have greater pain tolerance than normal patients. The association of IBS with stress is less clear, but studies have shown that there is a high likelyhood of reports of previous physical and sexual abuse in IBS patients. Socially stressful situations seem to play a role in the presence of symptoms but are not known to actually affect the underlying disease.

Onset of IBS after an episode of enteritis has been described (partially after use of antibiotics). In these cases, a prolonged immune reaction may be the cause. Patients with IBS after a viral illness may have a self limited course of only 3 to 6 months duration.

IBS is widely regarded as a conglomeration of disorders with similar symptoms but a different etiology (root cause). As with many other medical conditions, there is a lot of speculation about causes, including in the field of alternative medicine.

Stress

Stress—feeling mentally or emotionally tense, troubled, angry, or overwhelmed—stimulates colon spasms in people with IBS. The colon has a vast supply of nerves that connect it to the brain. These nerves control the normal rhythmic contractions of the colon and cause abdominal discomfort at stressful times. People often experience cramps or "butterflies" when they are nervous or upset. But with IBS, the colon can be overly responsive to even slight conflict or stress. Stress also makes the mind more tuned to the sensations that arise in the colon and makes the stressed person perceive these sensations as unpleasant (NIH, 2003).

Some evidence suggests that IBS is affected by the immune system, which fights infection in the body. The immune system is also affected by stress. For all these reasons, stress management is an important part of treatment for IBS. Stress management comprises:

  • stress reduction (relaxation) training and relaxation therapies, such as meditation
  • counseling and support
  • regular exercise such as walking or yoga
  • changes to the stressful situations in your life
  • adequate sleep

Treatment

One of the most important therapeutic measures is reassuring the patient that she has no fatal or otherwise threatening disease, as this is the major concern of patients seeking medical help. Dietary advice may be given and medication is an option in most forms.

Halpert et al (2006), developed and fielded a questionnaire to identify patients’ perceptions about IBS, their preferences on the type of information they need, as well as educational media and expectations from health care providers. Responses from patients with IBS revealed misperceptions about IBS developing into other conditions, including colitis, malnutrition and cancer. The survey found IBS patients were most interested in learning about foods to avoid (60 percent), causes of IBS (55 percent), medications (58 percent), coping strategies (56 percent), and psychological factors related to IBS (55 percent). The respondents indicated that they wanted their physician to be available via phone or e-mail following a visit (80 percent) and have the ability to listen (80 percent), provide hope (73 percent) and support (63 percent).

Diet

There is no evidence that digestion of food or absorption of nutrients is different in those with IBS compared to those without IBS. However, the very act of eating can provoke an over-reaction of the gastrocolic response in those with IBS due to their heightened visceral sensitivity, and this can lead to abdominal pain, diarrhea, and/or constipation. Although the exact cause of IBS is not known, there are dietary factors that appear to aggravate symptoms or make a person feel worse. While dietary factors do not cause IBS, they often aggravate symptoms.(IFFGD, 2004).

Definitive determination of dietary issues can be accomplished by testing for the physiological effects of specific foods. The ELISA food allergy panel can identify specific foods to which a patient has a reaction. Other testing can determine if there are nutritional deficiencies secondary to diet that may also play a role.

There are a number of diet changes a person with IBS can make to prevent the over-reaction of the gastrocolic reflex and lessen pain, discomfort and bowel dysfunction. Having soluble fiber foods and supplements, substituting soy or rice products for dairy, being careful with fresh fruits and vegetables that are high in insoluble fiber, and eating regular small amounts can all help to lessen the symptoms of IBS (Van Vorous 2000). Foods and beverages to be avoided or minimized include red meat, oily or fatty (and fried) products, dairy (even when there is no lactose intolerance), solid chocolate, coffee (regular and decaffeinated), alcohol, carbonated beverages (especialy those also containing sorbitol) and artificial sweeteners (Van Vorous 2000). Several of the most common dietary triggers are well-established by clinical studies at this point; research has shown that IBS patients are hypersensitive to fats, insoluble fibers, and fructose (Caldarella, 2005; Whorwell, 1994; Young Choi, 2003). It also appears that some foods are more difficult for the gut as evidenced by elevated food-specific IgG4 antibodies being present (Kumar, 2005), while others increase colonic contractions, which may be painful, due to increased visceral sensitivity in IBS sufferers (Mayer, 2004).

Medication

Medications may consist of stool softeners and laxatives in constipation-predominant, and antidiarrheals (loperamide) in diarrhea-predominant IBS for mild symptoms. The use of antispasmodic drugs (e.g. anticholinergics such as hyoscine) has not shown conclusive beneficial results due to a large number of individuals who respond to the placebo effect; however, in general, although the cause is unknown, the placebo effect remains higher than normal for sufferers of IBS for all medications.

Low dosage of tricyclic and SSRI antidepressants have shown to be the most widely prescribed medications for helping to relieve symptoms of visceral sensitivity (pain) and diarrhea or constipation respectively. Newer drugs include alosetron, a selective 5-HT3 antagonist for IBS-D, which is only available for women in the United States under a restricted access program, due to severe risks of side-effects if taken mistakenly by IBS-A or IBS-C sufferers. Cilansetron, also a selective 5-HT3 antagonist, is undergoing further clinical studies in Europe for IBS-D sufferers. In 2005, Solvay Pharmaceuticals withdrew Cilansetron from the United States regulatory approval process after receiving a "not-approvable" action letter from the FDA requesting additional clinical trials. Tegaserod, a selective 5-HT4 antagonist for IBS-C, is available for relieving IBS constipation in women and chronic idiopathic constipation. The USA FDA has issued two warnings about the serious consequences of Tegaserod. In 2005, Tegaserod was rejected as an IBS medication by the European Union; however, it is available in some other countries.

Enteric coated peppermint oil capsules have been shown to relieve IBS symptoms in adults and children (Hadley, 2005), but they are contraindicated in patients with the comorbidity of gastroesophageal reflux disease.

Brain-Gut and other

Gut-directed or gut-specific hypnotherapy or self-hypnosis is one of the most promising areas of IBS treatment. Current research shows that symptom reduction/elimination from IBS hypnotherapy can last at least five years (Gonsalkorale 2003). There is a strong brain-gut component to IBS, and cognitive therapy may improve symptoms in a proportion of patients in conjunction with antidepressants (Kennedy et al, 2005). Ongoing investigational research also involves relationships to food allergies (as measured through blood antibody analysis), poor bacterial balance and the increase of probiotics (Quigley, 2005), parasites, scar tissue that affects bowel motility, and bacterial overgrowth (Pimentel, 2000), as a cause of symptoms.

Epidemiology

Point prevalence is 10 - 20% of the general population of Western countries with a much higher lifetime prevalence. Prevalence is similar in India, Japan and China. IBS is less common in Thailand and rural South African areas. In Western countries, but not in India or Sri Lanka, females have a greater risk of developing IBS.

Of the persons who have symptoms of IBS, only a proportion seeks medical help. However, there is not yet a predictor known for who will seek medical help and who will not.

Prognosis

IBS is not fatal nor is it linked to the development of other serious bowel diseases. However, due to the chronic pain, discomfort, and other symptoms, work absenteeism, social phobias, and other negative quality-of-life effects can be common in more serious cases. Individuals who find a caring primary caregiver and/or sufficient self-help options should be able to develop a successful treatment program for their symptoms and lead normal lives.

Reference

  • Caldarella, M. Visceral Sensitivity and Symptoms in Patients with Constipation- or Diarrhea-predominant Irritable Bowel Syndrome (IBS). The American Journal of Gastroenterology, Volume 100 Issue 2 Page 383 - February 2005.
  • Choi, Y. Fats, Fructose May Contribute to IBS Symptoms. ACG 68th Annual Scientific Meeting: Abstract 21, presented Oct. 13, 2003; Abstract 547, presented Oct. 14, 2003.
  • Gonsalkorale WM. Long term benefits of hypnotherapy for irritable bowel syndrome. Gut. 2003 Nov;52(11):1623-9.
  • Gwee KA. Irritable bowel syndrome in developing countries--a disorder of civilization or colonization? Neurogastroenterol Motil. 2005 Jun;17(3):317-24. PMID 15916618
  • Halpert, A., Thomas, A., Hu, Y., Morris, C., Bangdiwala, S., Drossman, D., A survey on patient educational needs in irritable bowel syndrome and attitudes toward participation in clinical research. J Clin Gastroenterol. 2006 Jan;40(1):37-43. PMID 16340632.
  • Hadley, S. Treatment of Irritable Bowel Syndrome. Am Fam Physician 2005;72:2501-6.
  • Irritable Bowel Syndrome Self Help and Support Group, (2005). Diagnostic Criteria. Retrieved on Dec. 4, 2005 from http://www.ibsgroup.org/main/diagnosis.shtml
  • Kennedy T, Jones R, Darnley S, Seed P, Wessely S, Chalder T. Cognitive behaviour therapy in addition to antispasmodic treatment for irritable bowel syndrome in primary care: randomised controlled trial. BMJ 2005;331:435. PMID 16093252.
  • National Institutes of Health, 2003. Irritable Bowel Syndrome. Publication No. 03–693 April 2003.
  • Pimentel M, Chow EJ, Lin HC. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome. Am J Gastroenterol 2000;95:3503-3506.
  • Quigley EM. The use of probiotics in functional bowel disease. Gastroenterol Clin North Am. 2005 Sep;34(3):533-45, x
  • Thompson WG, Longstreth GL, Drossman DA et al. (2000). Functional Bowel Disorders. In: Drossman DA, Corazziari E, Talley NJ et al. (eds.), Rome II: The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment. A Multinational Consensus. Lawrence, KS: Allen Press. ISBN 0965683729.
  • Van Vorous, Heather. Eating for IBS. 2000. ISBN 1569246009. Excerpted with author's permission at Help for Irritable Bowel Syndrome (see IBS Diet Section)
  • Whorwell, PJ. Bran and irritable bowel syndrome: time for reappraisal. Lancet. 1994 Jul 2;344(8914):39-40.

 

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