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Irritable Bowel Syndrome
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Irritable Bowel Syndrome.

Dr.Barin Bose MS,FACRSI, FAIS.

Consultant Surgeon and Coloproctologist.

Jabalpur Hospital and Research Centre.

Jabalpur (M.P.)

The irritable bowel syndrome (IBS) is the most common of all the digestive disorders, affecting nearly everyone at one time or the another and accounting for up to 50% of patients referred to a gastroenterologic practice. Although chacterized as a disorder of bowel moility, in many patients it is an exaggeration of normal physiologic response. IBS is one of the most common functional gastrointestinal disorder characterized by chronic abdominal pain or disorder, which is associated with change in stool frequency and /or form.

Numerius terms have been used to describe the syndrome, they are -

• Irritable bowel syndrome.
• Irritable colon syndrome.
• Spastic bowel syndrome.
• Spastic colitis.
• Mucous colitis.
• Splenic flexure syndrome.
• Functional bowel syndrome.
• Psychophysiologic bowel disease.
• Nervous bowel.

But of all these Irritable bowel syndrome seems to be he most appropriate term. Tearms that include the word colon or colitis are inaccurate because the condition is not limited to the colon and inflammation is not a feature. Further more use of the term colitis leads to confusion with ulcerative colitis.

Pathogenesis - The cause and pathogenesis of IBS remain obscure. Never the less, clinical and laboratory evidence indicate that it is most likely a disorder of bowel motility. Constipation and abdominal cramps are prominent complaints of many patients with IBS. These symptoms could be explained on the basis of hypertonic segments of the bowel which slows down the transit by increasing the resistance to passage of feces. On the other hand it is possible that patients with diarrhea have a hypototile bowel, which would decrease resistance to passage of feces or that they simply have an increase in peristaltic contractions. Both number of mast cells and their mediators have been shown to be increased in the intestinal mucosa of patients with IBS. This increased mast cells in the intestinal mucosa could be due to hypersensitivity to foods . It is a gastrointestinal disorder in which a disturbed brain gut axis has been thought to have a role.

Diagnosis

Clinical Presentation – Patients with IBS typically complaints of crampy abdominal pain and constipation.In some patients chronic constipation is punctuated by brief episodes of diarrhea. A minority of patients have only diarrhea. Symptoms usually have been present for months to years, and it is common for patients with IBS to have consulted several physicians about their complaints and to have undergone one or more gastrointestinal evaluation, but without any releaf . Patients correlate symptoms with emotional stress.Stools are mixed with excessive mucous discharge but blood is never present unless the IBS is associated with haemorrhoids.

Abdominal cramps are a feature but they are releaved temporarily by defecation. Bowel movements are clustered during the morning or may occur through out the day but rarely the patient is awakened at night .

Rome III has subdivided IBS into –

• IBS with constipation (IBS-C)
• IBS with diarrhea (IBS-D)
• IBS mixed type (IBS – M)
• IBS unsubtyped (IBS – U)

These subtype are based on the stool consistency which can be determined by Bristol Stool Scale Form.

Two dimensional display of the 4 possible IBS subtypes according to bowel form at a particular point in time. IBS – C IBS with constipation ;

IBS – D IBS with diarrhea ; IBS - M mixed IBS ; IBS – U unsubtyped IBS.

The Bristol Stool Form Scale –

1. Separate hard lumpy like nuts ( which are difficult to pass).
2. Sausage shaped but lumpy.
3. Like a sausage but with cracks on its surface.
4. Like a sausage or snake , smooth and soft.
5. Soft blobs with clear – cut edges (which are passed easily)
6. Fluffy pieces with ragged edges, a mushy sool.
7. Watery , no solid pieces, entirely liquid.

Features suggestive of Irritable Bowel Syndrome –

Characteristic Features –

• Constipation or diarrhea or both.
• Crampy abdominal pain.
• Mucous in stools.
• Symptoms related to stress.
• Body weight is stable or increasing.
• Healthy appearance.
• Chronic symptoms.

Uncharacteristic Features –

• Anorexia.
• Weight loss.
• Rectal bleeding.
• Fever.
• Nocturnal diarrhea.
• Recent onset of symptoms.

Physical Examination – Patients generally appears healthy, although they may be somewhat tense or anxious. If abdominal pain is a prominent symptoms, voluntary guarding may be present, sometimes a tender sigmoid colon is palpable. A digital rectal examination is important to rule out non IBS disorders.

Diagnostic Studies : Because of the diagnosis of IBS is largely one of exclusions, a number of clinical and laboratory studies should be performed to rule out other treatable disorders.

Routine tests such as a complete blood count , an ESR and stool test for occult blood are done in all patients. If the patient complaints of diarrhea, the stool should be examined for leucocytes, ova, parasites and bacterial pathogens. A flexiable sigmoidoscopic examination and a double contrast barium enema should be performed in all patients.

Additional diagnostic studies such as ultrasound abdomen for gall stones. Barium meal and follow through to rule out Crohn’s disease. Serum amylase is to be don’t to rule out pancreatitis. A lactose tolerance test may be necessary to confirm lactose deficiency in some patients.

Treatment

1. Emotional support – It includes reassurance and stress reduction . Making a diagnosis of IBS is sufficient in some patients to alleviate anxiety about their symptoms. In patients who suffers from cancer phobia are relieved to learn that they are cancer free. However most patients with IBS experience no releaf from reassurance. Many patients carry the diagnosis of IBS for years and continue to experience distressful symptoms despite supportive reassurance , diet and drug therapy. Psychotherapy is feasible and effective in two third of patients with IBS who do not respond to standerd medical treatment. Judicious use of tricyclic antidepressants can be used.
2. Diet and fibre therapy : There is no need for bland of highly restrictive diet in the treatment of IBS. But patients should avoid food that they find causes symptoms.If lactose contaning foods produces cramps and diarrhea , these should be eliminated from the diet. Patients with abdominal pain and constipation should be given high residue diet and fibre supplementation in diet. Increase fibre in the diet gives symptomatic releaf to patients.
3. Stool softner and laxatives : Should be judiciously in the treatment of the constipated form of IBS.
4. Antidiarrheal agents : Patients with diarrhea should be given antidiarrheal agents eg Lomotil. The use of pre and probiotics in the treatment of IBS is controversial.
5. Antispasmodics : Unfortunately drug therapy of IBS often is empiric. Patients with abdominal pain and constipation may be benefited from antispasmodic drugs. Dicyclomine hydrochloride , 10 to 20 Mgs three to four times a day can be used.
6. Tegaserod and Alosetron : Only two drugs are specifically indicated in IBS . Tegaserod in constipation prominent IBS and Alosetron in diarrhea predominant IBS. Except for these two drugs the treatment of IBS is symptomatic.

Alosetron : This drug is a nerve receptor antagonist that is supposed to relax the colon and slow the movement of waste through the lower bowel. But the drug was removed from the market just nine months after its approval when it was linked to at least four deaths and severe side effects in 197 people. In June 2002, when the Food and Drug Administration (FDA) decided to allow alosteron to be sold again – but with restrictions . The drug can be prescribed only by doctors enrolled in a special program and is intended for severe cases of

diarrhea - predominant IBS in women who haven’t responded to other treatments.