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Irritable bowel syndrome (IBS)
Kok-Ann Gwee, Uday C Ghoshal*
Associate Professor, National University of Singapore, and *Associate Professor, Dept.
of Gastroenterology, SGPGI, Lucknow, India
Story of a patient
her bowels completely. Recently she
Mrs L is a 42-year old working mother
underwent colonoscopy, and after this
of
been
proved to be normal, her doctor gave
experiencing central abdominal pain
her a diagnosis of irritable bowel
and bloating from time to time in the
syndrome.
past 3 years. Her symptoms are usually
What is IBS?
worse after meals, especially if the food
IBS is a condition where the patient
is oily. Pain used to get relieved after
experiences
passing stools. She did not lose weight.
discomfort that arises from either the
She did not observe blood in her stools.
small or large intestines in the absence
In the past she had consulted numerous
of significant disease in these areas. The
doctors, had numerous blood tests,
pain or discomfort may be located
ultrasound scan of the abdomen and an
anywhere in the abdomen including the
endoscopic assessment of the stomach.
upper abdomen and gastric region. Other
Two years ago she had surgery to
symptoms associated with IBS include
remove her gallbladder when a gallstone
bloating, loose motions, constipation and
was found on the ultrasound scan.
incomplete bowel movements. As the
Although not severely constipated, she
symptoms of IBS overlap with those of
would experience difficulty in clearing
other intestinal diseases such as colitis,
three
children
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who
has
abdominal
pain
or
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diverticular disease, stomach ulcers and
and anaemia, it is not always necessary
even cancers of the digestive system, it
to undertake any tests.
is important to consider these before
How common is it and who is at risk?
making a diagnosis.
Estimates from around the world suggest
What tests are required to make a
that 5-20% of the population have IBS.
diagnosis?
In a recent study from Mumbai the
As there is no specific test for IBS, tests
prevalence was estimated to be 7.5%.
are usually carried out to exclude
Young adults between ages of 20 and 40
intestinal
those
years appear to be most at risk. Although
mentioned above. These tests comprise
in the west women appear to be more
blood tests, stool examination and either
prone to IBS than men, in Asian
a colonoscopy or a barium enema. In
communities men and women appear to
people over the age of 45, in those with
be equally at risk.
alarm symptoms such as weight loss,
What are the symptoms of IBS?
blood in the stools or fever, and people
All
with a family history of bowel cancer, it
exclusive to IBS and it is important to
is important to have these tests before
check
making a diagnosis of IBS. However, if
assuming that they are due to IBS. A
the patient is young and healthy, and has
patient does not require all the symptoms
been experiencing these symptoms for a
to be present all the time for a diagnosis
year or longer without any signs of
of IBS.
diseases
such
as
the
above
with
a
symptoms
doctor
first
are
not
before
deteriorating health such as weight loss
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•
•
Crampy abdominal pain, often
•
abdominal
pain,
either low or under the right
passage of flatus
lower ribs which does not always
Alteration
in
bowel
habit
get better on opening the bowels;
or
or pain under the left ribs
constipation
alternating)
(splenic flexure syndrome) and
Bloating and (painful) swelling
when the pain is bad it may
of the abdomen
ascend to the left armpit.
Rumbling noises (borborygmi)
•
and excessive passage of wind
•
Right-sided
relieved by defecation and / or
(diarrhea,
•
•
Increased gastro-colic reflex, this
Sensation of incomplete bowel
movement
•
Mucus with stool
is an awakening of the childhood
Other symptoms that are frequently
reflex where food in the stomach
associated include: indigestion, belching,
stimulates
colonic
activity,
nausea, headaches, dizziness, ringing in
resulting in the need to open the
the ears, fibromyalgia, backache, passing
bowels.
urine frequently, tiredness or even
•
Urgency - a need to rush to the
chronic fatigue, shortness of breath,
toilet and incontinence (if a toilet
anxiety and depression
isn't nearby)
Why do people get IBS?
•
A sharp pain felt low down
People may develop IBS for a number of
inside the rectum (proctalgia
reasons including food poisoning and
fugax)
repeated or prolonged use of antibiotics.
People who have recently been through
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an emotional life event and those who
blamed on the lack of fibre in the diet.
worry easily over various symptoms also
However, dietary assessments usually
appear to be more prone to developing
show that IBS patients consume similar
IBS. In the past, IBS was frequently
levels of fibre as people without IBS.
Fig. 1. Factors increasing symptoms of IBS
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Some patients with IBS however, appear
less important than drugs for treatment
to be intolerant of dairy products and
of IBS.
certain grains such as wheat. Alcohol,
There are many ways to cope with stress.
coffee, oily food and spices may
Here are some suggestions that can help
aggravate IBS symptoms. People with
you get started.
IBS may also experience worsening of
• Practice Relaxation Exercises.
their symptoms in times of stress, when
• Breathe.
they lack sleep, and during the menstrual
• Meditate or pray.
period.
• Examine your beliefs and
Relationship with stress and life style
attitudes.
factors
• Develop your sense of humor.
Symptoms of IBS many wax and wane
• Make time for your hobbies.
over period of time. For example, a very
• Exercise.
serious examination, problems at work
place, difficult times in family life, and
Is there any relationship between milk
even a happy event, such as getting
ingestion and symptoms of IBS?
married or receiving a promotion can
Many patients with IBS experience
make
behave
increase in symptoms of IBS while on
differently, perhaps making underlying
milk. This is due to intolerance to lactose,
IBS symptoms worse.
Fig. 1 shows
the principal sugar component of milk.
factors, which increase symptoms of IBS.
Lactose is a chemical substance which
Patients must pay attention to these
contains glucose and galactose. In
factors as relieving these factors are no
human small intestine, lactose is
anyone’s
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bowels
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Shanti Patient Related Education And Directions (SPREAD))
Fig. 2. Methods of testing for lactose (major constituent of milk) intolerance.
supposed to be broken down into its
This leads to development of symptoms
components (glucose and galactose) by
such as bloating, flatulence, diarrhea and
an enzyme called lactase. Though lactase
constipation. If you experience increase
is present in the small bowel in adequate
in symptoms with milk, it is good
quantity in most infants, many of us lose
practice to stop all milk and milk
this enzyme during adulthood. In these
products for a few weeks and see if
individuals, lactose is not broken down
symptoms of IBS decreases significantly.
to glucose and galactose by lactase;
If so, it is advisable to stop milk and
therefore,
is
milk containing foods for sometimes
fermented by the bacteria residing inside
according to advice of doctor. Following
the intestine, which produce gases like
this, the patient can reintroduce a
hydrogen and methane.
measured amount for example half a
undigested
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lactose
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Shanti Patient Related Education And Directions (SPREAD))
glass of milk with food, and increase
treatment
gradually until symptoms reoccur. In this
improvement is not related to treatment
way a patient is able to determine his or
of amebiasis but may be related to
her threshold. If you want to be sure
killing of bad bacteria in excess of
whether you have lactose intolerance or
normal in your intestine, which is known
not before undertaking life-long dietary
as small bowel bacterial overgrowth. If
modification such as complete avoidance
you have experienced such response to
of milk and milk products, you may ask
treatment with metronidazole, it is
your doctor to get lactose hydrogen
advisable to get yourself tested for small
breath test or lactose tolerance test done.
bowel
This is a simple and cheap test on your
glucose hydrogen breath test before you
breath air or blood. However, it may not
take treatment with antibiotics to kill
be widely available and hence, you need
these bad bugs. To know more about
to go to a tertiary referral centre to get
breath
this test done.
preparation of motility and breath tests
Sometimes symptoms of IBS might
chapter in this website.
respond
How is IBS treated?
to
treatment
with
of
bacterial
test,
amebiasis,
overgrowth
you
may
go
this
using
through
metronidazole tablet, what does it
Contrary to what many doctors and
mean?
patients think, IBS can be effectively
You might have experienced short-
treated. Results from various centres
lasting improvement in your symptoms
report major improvement in symptoms
after
metronidazole.
in as many as 85% of patients within 6
Though metronidazole is useful in
months of treatment. For the majority of
treatment
with
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patients there is no requirement for
abdominal pain and urge for bowel
elaborate tests, restrictive diets, or
movement after coffee, oily and spicy
treatment with a large number of
foods should avoid or reduce the intake
medications. Treatment usually consists
of these substances.
of a combination of simple diet and
It is important to pay attention to the
lifestyle adjustments, together with 2 or
effects of stress and lifestyle factors.
3 medications to be taken for 6-12 weeks.
Patients should set aside enough time in
The type of medications used to treat
the morning for breakfast and bowel
IBS will be determined by the type of
movement, and to be on time for their
symptoms bothering the patient. For
afternoon and evening meals. Patients
example, antispasmodics are used to
should also ensure that they get enough
treat abdominal pain, prokinetics are
rest, and in particular get a good night’s
used to treat constipation and bloating,
rest.
and anti-diarrhoeal agents are used to
symptoms
treat diarrhoea. The use of a low dose
abdominal pain. Patients should examine
anti-depressant medication can be very
the underlying reasons for anxiety, and
effective for pain even in the absence of
discuss these with a close friend, family
depression.
member or counsellor. Regular exercises
The use of fibre supplement such as
and relaxation techniques such as yoga
ispaghula or psyllium may help to soften
and meditation can help a patient to cope
stool in constipation, but cereal fibre
better with stress.
such as bran could aggravate bloating in
Experience and studies suggest that good
some patients. Patients who develop
results are achieved when the doctor
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Anxiety
will
such
as
often
aggravate
diarrhoea
and
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Shanti Patient Related Education And Directions (SPREAD))
takes a compassionate interest in the
flatulence are due to the gallstones. In
patient and is able to provide a clear
fact, the majority of people with
explanation of the condition and the
gallstones will never experience any
requirements
Simply
symptoms. Female patients should also
telling patients that there is nothing
be careful not to jump to the conclusion
wrong with them and dismissing their
that they have a disease in the pelvis
condition as a consequence of stress,
when they experience pain in the lower
does not help.
abdomen.
Surgical treatment is not indicated for
endometriosis and fibroids in the pelvis
IBS, and it is important to be aware that
frequently do not cause any discomfort
IBS patients often do worse after surgery
or pain, women should pay particular
than patients without IBS. Patients
attention to any changes in their bowel
should be aware that just because
pattern as this could be an indicator that
gallstones
the pelvic pain is from the bowel and
are
of
treatment.
found
it
does
not
necessarily mean that symptoms like
As
adhesions,
cysts,
could be due to IBS.
upper abdominal pain, bloating and
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