Irritable Bowel Syndrome

Irritable Bowel Syndrome Overview

Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder of unknown cause. Common symptoms include abdominal cramping or pain, bloating and gassiness, and altered bowel habits.

Irritable bowel syndrome has also been called spastic colon, functional bowel disease, and mucous colitis. However, IBS is not a true "colitis." The term colitis refers to a separate group of conditions known as inflammatory bowel disease (IBD).

Irritable bowel syndrome is not contagious, inherited, or cancerous. It is estimated that 20% of adults in the U.S. have symptoms of IBS. It occurs more often in women than in men, and the onset occurs before the age of 35 in about half of the cases.

Irritable Bowel Syndrome Causes

The cause of irritable bowel syndrome is currently unknown. IBS is thought to result from an interplay of abnormal gastrointestinal (GI) tract movements, increased awareness of normal bodily functions, and a change in the nervous system communication between the brain and the GI tract. Abnormal movements of the colon, whether too fast or too slow, are seen in some, but not all, people who have IBS.

Irritable bowel syndrome has also developed after episodes of gastroenteritis.

It has been suggested that IBS is caused by dietary allergies or food sensitivities, but this has never been proven.

Symptoms of irritable bowel syndrome may worsen during periods of stress or menses, but these factors are unlikely to be the cause that leads to the development of IBS.

Irritable Bowel Syndrome Symptoms

Irritable bowel syndrome affects each person differently. The hallmark of IBS is abdominal discomfort or pain. The following symptoms are also common:

• Abdominal cramping and pain that are relieved with bowel movements
• Alternating periods of diarrhea and constipation
• Change in the stool frequency or consistency
• Gassiness (flatulence)
• Passing mucus from the rectum
• Bloating
• Abdominal distension

The following are NOT symptoms or characteristics of IBS (but should still be brought to the attention of a physician since they may be signs and symptoms of other conditions):

• Blood in stools or urine
• Black or tarry stools
• Vomiting (rare, though may occasionally accompany nausea)
• Pain or diarrhea that interrupts sleep
• Fever
• Weight loss

When to Seek Medical Care

If a person has any of the symptoms of IBS as discussed previously, or if a person with known IBS has unusual symptoms, a health care practitioner should be consulted. Go to a hospital emergency department if problems are severe and/or come on suddenly.

Irritable Bowel Syndrome Diagnosis

Irritable bowel syndrome can be a very difficult diagnosis to make. IBS is called a diagnosis of exclusion, which means a doctor considers many other alternatives first, performing tests to rule out other medical problems. Some of these tests may include laboratory studies, imaging studies (such as a CT scan or small intestinal X-rays), or a lower GI endoscopy (colonoscopy). An endoscopy is a procedure in which a flexible tube with a tiny camera on one end is passed into the GI tract while the patient is under conscious sedation.

• A combination of history, physical examination, and selected tests are used to help diagnose irritable bowel syndrome.
• No single blood test or x-ray study confirms a diagnosis of IBS.

Irritable Bowel Syndrome Treatment

Irritable Bowel Syndrome Self-Care at Home

Many people may have already modified their diets before seeing a doctor. Temporarily avoiding dairy products may help assess whether symptoms of lactose intolerance are mimicking those of irritable bowel syndrome. Persons who avoid dairy products should exercise and consider taking calcium supplements.

• Certain foods, such as cruciferous vegetables (cauliflower, broccoli, cabbage, brussels sprouts) and legumes (beans) may worsen bloating and gassiness.
• Dietary fiber may lessen symptoms.
• Individuals with IBS should drink plenty of water, and avoid soda, which may cause gas and abdominal discomfort.
• Eating smaller meals may lessen the incidence of cramping and diarrhea.
• Low fat and high carbohydrate meals such as pasta, rice, and whole grain breads may help IBS symptoms (unless the affected individual has celiac disease).

Medical Treatment

Most people with irritable bowel syndrome have problems only occasionally. A few may experience long-lasting problems and require prescription medications.

• A common treatment for IBS is the addition of fiber to the diet. This theoretically expands the inside of the digestive tract, reducing the chance it will spasm as it transmits and digests food. Fiber also promotes regular bowel movements, which helps reduce constipation. Fiber should be added gradually, because it may initially worsen bloating and gassiness.
• Stress may cause IBS "flares." Doctors may offer specific advice on reducing stress. Regularly eating balanced meals and exercising may help reduce stress and problems associated with irritable bowel syndrome.
• Smoking may worsen symptoms of IBS, which gives smokers another good reason to quit.
• Since many patients with irritable bowel syndrome report food intolerances, a food diary may help identify foods that seem to make IBS worse.
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Medications

• Antispasmodic medicines, such as dicycomine (Bemote, Bentyl, Di-Spaz) and hyoscyamine (Levsin, Levbid, NuLev), are sometimes used to treat symptoms of irritable bowel syndrome. Antispasmodic medicines help slow the action of the digestive tract and reduce the chance of spasms. They may have side effects and are not for everyone. Other treatment plans are available, depending on symptoms and condition.
• Antidiarrheal medicines, such as loperamide (Imodium), a kaolin/pectin preparation (Kaopectate), and diphenoxylate/atropine (Lomotil), are sometimes used when diarrhea is a major feature of IBS. Do not take these on a long-term basis without first consulting a doctor.
• Antidepressants may be very effective in smaller doses than those typically used to treat depression. Imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Pamelor), and desipramine (Norpramin) are some commonly used medicines that may alleviate irritable bowel syndrome symptoms. Some other antidepressants are more commonly prescribed when depression and IBS coexist.
• The following medications are typically reserved for patients with symptoms that do not improve with the above treatments:
• Lubiprostone (Amitiza) is a type of laxative used to treat irritable bowel syndrome with constipation in women who are at least 18 years of age. It is a capsule taken orally, twice a day with food. It is used to relieve stomach pain, bloating, and straining; and produce softer and more frequent bowel movements in people who have chronic idiopathic constipation.
• Alosetron (Lotronex) is a restricted drug approved only for short-term treatment of women with severe, chronic, diarrhea-predominant IBS who have failed to respond to conventional IBS therapy. Fewer than 5% of people with irritable bowel syndrome have the severe form, and only a fraction of people with severe IBS have the diarrhea-predominant type. Alosetron was removed from the United States market but was reintroduced with new restrictions approved by the FDA in 2002. Physicians must be registered with the pharmaceutical manufacturer in order to prescribe the medication. Serious and unpredictable gastrointestinal side effects (including some that resulted in death) were reported in association with its use following its original approval. The safety and efficacy of alosetron has not been sufficiently studied in men; therefore, the FDA has not approved the drug for treatment of IBS in men.
• Tegaserod (Zelnorm) was a medication used to treat IBS but was removed from the market in 2008 due to increased risk of heart attack, stroke, and ischemic colitis.

Irritable Bowel Syndrome Diet and Lifestyle Changes

Diet and lifestyle changes are important in decreasing the frequency and severity of IBS symptoms.

The first thing your doctor may suggest is to keep a food diary. This will help you figure out foods that trigger your symptoms.

• Limit foods that contain ingredients that can stimulate the intestines and cause diarrhea, such as:
  • Caffeine
  • Alcohol
  • Dairy products
  • Fatty foods
  • Foods high in sugar
  • Artificial sweeteners (sorbitol and xylitol)
• Some vegetables (cauliflower, broccoli, cabbage, brussels sprouts) and legumes (beans) may worsen bloating and gassiness and should be avoided.
• Dietary fiber may lessen symptoms of constipation.
• Drink plenty of water, and avoid carbonated drinks such as soda, which may cause gas and discomfort.
• Eat smaller meals and eat slowly to help reduce cramping and diarrhea.
• Low fat, high carbohydrate meals such as pasta, rice, and whole-grain breads may help (unless you have celiac disease).

In addition to dietary changes, there are some healthy habits that may also help reduce IBS symptoms.

• Maintain good physical fitness to improve bowel function and help reduce stress.
• Stop smoking for overall good health.
• Avoid coffee and chewing gum.
• Reducing or eliminating alcohol consumption may help.
• Stress management can help prevent or ease IBS symptoms.
  • Use relaxation techniques: deep breathing, visualization, yoga
  • Do things you find enjoyable: talk to friends, read, listen to music

Irritable Bowel Syndrome Prevention

Follow the diet and lifestyle recommendations as outlined above, and as discussed with your physician. Avoiding triggers is the best way to prevent symptoms of IBS.

Gastrointestinal Endoscopy Introduction

Gastrointestinal Endoscopy Introduction

With the procedure known as gastrointestinal endoscopy, a doctor is able to see the inside lining of your digestive tract. This examination is performed using an endoscope-a flexible fiberoptic tube with a tiny TV camera at the end. The camera is connected to either an eyepiece for direct viewing or a video screen that displays the images on a color TV. The endoscope not only allows diagnosis of gastrointestinal (GI) disease but treatment as well.

• Current endoscopes are derived from a primitive system created in 1806-a tiny tube with a mirror and a wax candle. Although crude, this early instrument allowed a first view into a living body.
• The GI endoscopy procedure may be performed on either an outpatient or inpatient basis. Through the endoscope, a doctor can evaluate several problems, such as ulcers or muscle spasms. These concerns are not always seen on other imaging tests.
• Endoscopy has several names, depending on which portion of your digestive tract your doctor seeks to inspect.
  • Colonoscopy: This procedure enables the doctor to see ulcers, inflamed mucous lining of your intestine, abnormal growths and bleeding in your colon, or large bowel.
  • Enteroscopy: Enteroscopy is a recent diagnostic tool that allows a doctor to see your small bowel. The procedure may be used in the following ways:
    • To diagnose and treat hidden GI bleeding
    • To detect the cause for malabsorption
    • To confirm problems of the small bowel seen on an x-ray
    • During surgery, to locate and remove sores with little damage to healthy tissue
  
  
• Doctors do have other diagnostic tests besides GI endoscopy, including echography to study the upper abdomen and a barium enema and other x-ray exams that outline the digestive tract. Doctors can study the stomach juices, stools, and blood to learn about GI functions. But none of these tests offers a direct vision of the mucous lining of the digestive tube.
• Endoscopy has little value for people with the following conditions:
  • Severe coronary artery disease and acute or recent heart attack
  • Uncontrolled high or low blood pressure
  • Shock
  • Massive upper GI bleeding
  • Acute peritonitis (inflammation of certain tissues in your abdomen)
  • Injuries of the cervical spine
  • Perforation of organs of the upper GI tract
  • A history of respiratory distress
  • Severe coagulopathy, a disease in which you continue bleeding because of inadequate clotting in your blood
  • Recent upper GI tract surgery
  • Long-standing and stable inflammatory bowel diseases (except for watching cancers)
  • Chronic irritable bowel syndrome
  • Acute and self-limiting diarrhea
  • Bloody or tarry stools with a clear source of the bleeding
  • Pregnancy in second or third trimester
  • History of severe chronic obstructive pulmonary disease
  • Recent colon surgery or past surgery of your abdomen or pelvis resulting in internal adhesions
  • Acute diverticulitis
  • Tear in a blood vessel in your abdomen
  • Sudden colon inflammation
  • Acute inflammation of the sac that lines your abdomen
  • Noncorrectable coagulopathy, a disease in which you continue bleeding due to inadequate clotting factors in your blood
  • Massive gastrointestinal bleeding

Risks

• Upper GI endoscopy (EGD): Although rare, bleeding and puncture of your esophagus or stomach walls are possible during EGD. Other complications include the following:
  • Severe irregular heartbeat
  • Pulmonary aspiration - When material, either particulate (food, foreign body) or fluid (gastric contents, blood, or saliva), enters from your throat into your windpipe
  • Infections and fever that come and go
  • Respiratory depression, a decrease in the rate or depth of breathing, in people with severe lung diseases or liver cirrhosis
  • Reaction of the vagus nerve system to the sedatives
• Lower GI endoscopy (colonoscopy, sigmoidoscopy, enteroscopy): Although uncommon (less than 1.5% of cases), possible complications of colonoscopy and sigmoidoscopy include the following:
  • Local pain
  • Dehydration (due to excess of laxatives and enemas for bowel preparation)
  • Cardiac arrhythmias
  • Bleeding and infection
  • Hole in your colon
  • Explosion of combustible gases in your colon (certain gases are produced within the bowel) during removal of polyps
  • Respiratory depression usually due to oversedation in people with chronic lung disease

Gastrointestinal Endoscopy Preparation

• Upper endoscopy
  • The doctor will explain the test to you, including the possibility of biopsy and risks such as the need to remove polyps or other surgical procedures.
  • The doctor will ask you to sign a consent form agreeing to the procedure. At the same time, you must inform the endoscopy team of any medications you may be taking and any allergies or bad reactions you have had to previous tests.
  • Wear clothing that is easily removed.
  • Remove all dentures and eyeglasses prior to beginning an upper endoscopy. For colonoscopy, dentures can be left in.
  
  
• EGD
  • Stop taking any medications, such as aspirin and sucralfate (Carafate), used to treat ulcers, that could cause false readings on tests.
  • People who have had cardiac valve replacement or blood vessel graft should receive antibiotics to prevent infection.
  • Do not eat or drink anything for 8-10 hours before your examination to allow a valid examination of the upper GI tract and to lower the risk of vomiting.
  • You will be given a topical anesthetic before the test to numb your throat to prevent gagging.
  
  
• Colonoscopy or sigmoidoscopy
  • Your rectum and colon should be cleaned of all fecal matter. Even a small amount of feces can reduce reliability of the test.
  • You will change your diet prior to the test-no fibers or foods with small seeds for 5-6 days before the examination. You will drink liquids such as tea, fruit juices, and clear broth.
  • You may be given laxatives 12-15 hours before the test. You will be asked to drink up to 4 liters (about 4 qt) of a special cleansing solution to clean out the colon. Several medications are available for bowel cleansing, including polyethylene glycol 3350 (GoLYTELY, NuLYTELY). Other laxatives to cleanse the bowel, such as magnesium citrate (Citroma) or senna (X-Prep), may also be prescribed.
  • You may be given 1 or 2 little enemas 2-3 hours before the procedure.
  • The doctor may perform a rectal examination to detect narrowings, polyps or abnormal growth, or hidden bleeding from your lower intestine.

During the Procedure

• Upper GI endoscopy
  • You will be placed on your left side and have a plastic mouthpiece placed between your teeth to keep your mouth open and make it easier to pass the tube.
  • The doctor lubricates the endoscope, passes it through the mouthpiece, then asks you to swallow it. The doctor guides the endoscope under direct visualization through your stomach into the small intestine.
  • Any saliva you have will be cleared using a small suction tube that is removed quickly and easily after the test.
  • The doctor inspects portions of the linings of your esophagus, stomach, and the upper portion of your small intestine and then reinspects them as the instrument is withdrawn.
  • If necessary, biopsies and removal of foreign bodies and polyps may be performed.
  • The procedure usually is completed within 10-15 minutes. Any surgical procedures will require several minutes, depending on the type.
  
  
• Lower GI endoscopy
  • You will be placed on your left side with your hips back, flexed beyond your abdominal wall.
  • The doctor lubricates the endoscope and inserts it into your anus and advances it under direct vision.
  • You may be asked to change position during the procedure to assist moving the endoscope. The doctor will study your colon and rectum walls and reinspect them as the endoscope is withdrawn. If necessary, surgeries may be performed.
  • You may feel uneasiness and abdominal pain. The procedure usually takes 15-20 minutes. Any surgeries will require additional time, depending on the type.

After the Procedure

• If you have been sedated, you will be moved to a recovery area to wake up.

• Once sedation has worn off, before you are discharged from medical center, you will be given instructions and told to call your doctor if complications develop.

• You should have someone there to take you home. You should not drive a car or use other machinery or drink alcohol for at least a day. You may feel drowsy.

• At home, it would be best to have a light meal and rest for the remainder of the day.

When to Seek Medical Care

If any of the following symptoms develop, you should call your doctor.

• Any unexplained and chronic abdominal or chest pain, even heartburn
• Vomiting or reflux
• Swallowing difficulties or pain on swallowing
• Bleeding in your esophagus
• Nausea
• Indigestion
• Weight loss
• Anemia
• Any long-standing and unexplained changes in bowel habits
• Abdominal pain
• Diarrhea
• Black or tarry stools or bleeding through your rectum

Gastrointestinal Tract Cancer and Digestive Endoscopy

Endoscopy is very important to detect early cancers developing from the mucous coverings in either the upper or lower tracts of the digestive tube. Colon cancers can develop if intestinal polyps are not removed. Polyps can grow until they become a cancer.

Several studies report that growth of these polyps may take as long as 10 years. People who are at low risk for cancer, or even have no symptoms, should schedule a colonoscopy every 3-5 years after age 50 years. Those who are high-risk should begin regular screening prior to age 40 years. The following conditions can put you at high risk for cancer.

• HP (Helicobacter pylori) infections: H pylori bacteria are thought to cause gastric tumors. People who test positive for H pylori should be scheduled for an EGD every 1-2 years to detect early signs of cancer.
• Bowel inflammatory diseases
• Ulcerative colon inflammation
• Family or personal history of GI cancer or cancer in other organs
• Family history of developing glandlike polyps
• People with gastroesophageal reflux disease, especially those who smoke and drink regularly and complain of chronic heartburn, are at high risk for a cancer of the esophagus-a dramatic and deadly disease. Cancer stems from chronic injury of the gastric juice on the mucous lining of your esophagus.
• Changes in the lining of your esophagus (Barrett's esophagus) may be detected early in a person with chronic heartburn only by means of EGD, because this first change is detectable only by direct vision. These people should be scheduled for an EGD once or twice a year.