Sunday, June 30, 2002		Fitness

Coping with a common gastrointestinal disorder
B. K. Sharma

THIS is gastrointestinal disorder characterised by change in bowel habits or abdominal pain and flatulence without any defined structural changes in the gut. The doctors call it irritable bowel syndrome (usually written as IBS) and has been referred to by various names like spastic colitis, irritable colon and mucus colitis. Recently, one of my patients suffering from this disease referred to it as "intestinal nervousness". That sums it all. The disorder is very common, distressingly persistent and frustrating, both for the patient and the doctor. However, it is benign and associated with a normal life span. Notwithstanding its benign nature, it causes a lot of distress and implies poor quality life and absenteeism from work with enormous economic implications.

No recognised pathology

As the name suggests, the disease is functional in nature without any recognised pathology, inflammation or associated infection. The main features are variable combinations of constipation, diarrhoea, pain or discomfort in the abdomen and flatulence. The hallmark of the disease is the associated of the symptoms with defaecation or an alteration in bowel habit. All these symptoms are very non-specific and common. Therefore, a criteria was defined for the diagnosis of this syndrome at a conference of experts in 1992. The basic criterion is the presence of abdominal discomfort or pain which is relieved with defaecation and/or associated with change in frequency of the stool or change in consistency and form of the stool. The stool may be semi-solid or watery, hard or lumpy in appearance and there may be undue straining or urgency during bowel movement, feeling of incomplete evacuation, abdominal bloating and sometimes, passing of mucus along with the stool. The presence of blood in the stool is not a feature of this disease.

Abdominal pain is more often localised to the lower abdominal area, mostly on the left side, but can be in the middle or right side. Pain may be dull or constant with a feeling of cramps. Pain is more often present in the morning, is made worse by emotional stress and eating and is usually absent during sleeping hours. Constipation or diarrhoea may be present in the same patient on alternative pattern. But some patients may have predominant constipation whereas others may have diarrhoeal illness. In cases of constipation, in the beginning it may be episodic but gradually becomes chronic and patients start using laxative on their own. Besides constipation there is a sensation of incomplete evacuation and repeated attempts are made to pass the stool, which sometime gives a false impression of diarrhoea. In the other group, the diarrhoea may be a predominant symptom with 2-3 semi-solid or watery stools of relatively small volume (as compared to infective diarrhoea). Eating or emotional stress may aggravate the diarrhoea.

Flatulence or bloating, what is commonly referred to as ‘gas’, is a frequent occurrence and gives an uncomfortable feeling and the patient tries to pass out the gas by belching, which may, in fact, worsen the bloating. There is no evidence that there is excessive amount of gas in the intestine in these patients. But perhaps increased sensitivity of the colon to the pressure is responsible for this feeling.

As the name suggests, the symptoms are predominantly localised to the large intestine or colon, but sometimes may occur in the upper gastrointestinal tract, suggesting that other parts of the gut may also be involved. There may be epigastric pain, dyspepsia, nausea or vomiting and heart-burn. Functional symptoms like headache, backache and painful menses are often associated with this syndrome.

There are no well-defined physical changes or pathology seen in the colon and, therefore, the researchers have been looking for areas of abnormality like motility disorder, abnormal pain threshold in the intestine or in the brain. Although still not completely understood, the role of the central nervous system is being studied and is suggested, by its association with emotional disorders, stress and therapeutic response to the drug that acts on the brain. Very interesting observations have been made by studying blood flow to various areas of the brain with positron emission tomography, which shows different response of certain parts of the brain in patients of irritable bowel syndrome as compared to normal ones.

This indeed poses problem to the physicians because no physical abnormalities have been defined and diagnosis is based on clinical features and ruling out the known organic diseases. When a patient is seen for the first time, particularly an old patient, it is imperative to rule out serious diseases which may have similar signs and symptoms and may be missed with disastrous results. These include various infective disorders of the colon, inflammatory diseases of the intestine, various varieties of cancers, malabsorption, vascular diseases of the gut and psychiatry disorders like anxiety and depression which may superficially seem like irritable bowel syndrome. Thyroid disorders can mimic the syndrome very closely. Pertinent investigation in a patient is left to the judgement of the attending physician as only few of these disorders would be required to be excluded in a given patient.

Having rules out the underlying known illnessness and making the diagnosis with reasonable certainty, the physicians need to explain the nature of the illness and its long-term outcome. A good physician-patient relationship with non-judgemental attitude goes a long way to relieve the distress of the patient. Its relation to the emotional aspect should be explained to the patient. The fear of infective disorder or cancer of the colon should be particularly dealt with to avoid repeated investigations and "doctor shopping" by these patients.

The principles of medical treatment vary with the kind of presentation of the syndrome in a given person. Dietary counselling is the most important beginning. Although no single dietary ingredient has been suggested for this disease, every patient has his own known trigger for his or her diarrhoea. That may be milk, fish, egg, legumes or a particular vegetable. The important thing is to encourage the patient to eliminate any food item that appears to aggravate his syndrome, irrespective of its known scientific basis. In patients with constipation, high-fibre diet or stool bulking agents are the main treatment. Fibre has water-holding action in the colon and adds to the bulk of the stool. It also increases the speed of the colonic passage. The Indian diet is fairly rich in fibre, but because of self-imposed restrictions by many patients, this may be supplemented with bran, isabgol husk, full bran cereal or raw bran may be encouraged.

Here again, individual preference is important. In case of diarrhoea presentation, patient should be advised not to take recourse to antibiotics every time there is loose motion. The drugs which slow the intestine motility like Imodium or Lomotil (after medical advice) are helpful. The intake of the drug should be timed with the anticipated time of diarrhoea which may be early morning or after a meal. For relief of pain, antispasmodic drugs are helpful and can be taken according to the severity and frequency of the pain on the advice of a doctor. Flatulence or bloating is relieved by the physical activity. The patient should be advised against making repeated attempts to expel gas and that actually ends up in swallowing more air and a continuous cycle of belching may start. Drugs like Simethicon and activated charcoal may help symptomatically.

In view of the strong psycho-social nature of this disease, various anti-anxiety and anti-depressant drugs have been used and are helpful depending upon the total picture of the patient. Relaxing techniques like yoga and meditation are helpful.