Dr Obasi Emmanuel is a consultant gastroenterologist in the Department of Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State. He tells ALEXANDER OKERE about the management and treatment of irritable bowel syndrome
What is irritable bowel syndrome?
Irritable bowel syndrome is a functional gastrointestinal disorder characterised by abdominal pain, altered bowel habit (constipation, diarrhoea, or both), and related to defecation (may be relieved or worsened by defecation) in the absence of specific and unique organic pathology. In the past, IBS was considered a diagnosis of exclusion but currently, its diagnosis is made using standardised criteria and it may co-exist with organic pathologies.
Is it a common disorder?
It is relatively a common disorder; population-based studies estimated its prevalence at 10 to 20 per cent. The average Nigerian national prevalence of IBS is 12.2 per cent based on a report from a Nigeria national study and with the estimated population of Nigeria in 2022 of 215,133, 539, according to United Nations data, it can be extrapolated that over 20 million Nigerians are suffering from the IBS.
Is it a genetic disorder?
It is not purely a genetic disorder. Results from most studies on the role of genetic factors in developing IBS are limited and inconclusive, but increasing evidence points to at least a small hereditary component of IBS. Relatives of patients with IBS are almost three times more likely to develop IBS; a greater concordance of IBS in monozygotic than dizygotic twins.
What are the signs and symptoms?
The signs and symptoms include abdominal pain, altered bowel habits, the passage of clear or white mucus (mucorrhea), epigastric discomfort or pain (dyspepsia), nausea, vomiting and sexual dysfunction. Others are dyspareunia (feeling of pain during sexual intercourse) and loss of libido, urinary frequency, and urgency, menstrual pain, fibromyalgia (muscular pain), headache, backache, joint pain, impaired sleep, chronic fatigue, dizziness, palpitations, anxiety and depression.
Abdominal pain must be present for the diagnosis of IBS. The pain often is poorly localised, diffused without radiation, and can occur in any part of the abdomen, although it more typically is located in the left lower abdomen. It waxes, wanes, and may be aggravated by eating. The pain may be either aggravated or relieved by defecation, and its onset is associated with an increase or decrease in stool frequency or with looser or harder stools. Exacerbation of pain by life events or difficult life situations is common. Patients with IBS experience constipation and diarrhoea, or a mixture of these symptoms. This has led to an attempt to classify IBS patients according to their predominant symptom – IBS with constipation, which variably results in complaints of hard stool of narrow calibre; diarrhoea, small volumes of loose stool with evacuation preceded by urgency or frequent defecation; or mixed stool pattern.
Those with the constipation-predominant type of IBS usually complain of the hard stool of narrow calibre, painful or infrequent defecation. While those with the diarrhoea-predominant type usually pass small volumes of loose stool, with evacuation preceded by urgency or frequent defecation.
Can IBS be easily identified based on the colour, texture and shape of one’s stool?
The Bristol Stool Form Scale can be used to classify subtypes of IBS based on the texture and shape of one’s stool when a patient has fulfilled other IBS criteria. Type 1 is a stool with separate hard lumps like nuts. Type 2 is sausage-shaped but lumpy. Type 3 looks like a sausage but with cracks on the surface. Type 4 looks like a sausage or a snake; it is smooth and soft. Type 5 is soft blobs with clear-cut edges. Type 6 looks like fluffy pieces with ragged edges, and a mushy stool, while Type 7 is watery. Types 1 and 2 suggest IBS with constipation, types 1 and 6 suggest IBS with mixed stool pattern, while types 6 and 7 suggest IBS with diarrhoea.
How is irritable bowel syndrome different from diarrhoea?
Diarrhoea alone does not qualify as IBS. Characteristic abdominal pain and its relationship with defecation must be present. Diarrhoea may be one of the symptoms of some specific types of IBS.
When should a person with irritable bowel syndrome see a doctor?
A person with irritable bowel syndrome should see a doctor immediately. A consultation with a gastroenterologist (doctors who specialise in the treatment of gastrointestinal diseases) is usually necessary since the symptoms are usually persistent.
There are arguments as to how regular one should defecate in a week. What is your expert view on that?
Defecating once or twice per day and not less than three times per week is considered normal if the stool consistency is normal. Note that stool consistency is very important as passage of hard or loose stool irrespective of the frequency is considered abnormal.
Is defecating once in three days a course for concern and should people who experience this see a doctor?
Yes, defecating three or fewer times per week is considered abnormal, thus, pooping once in three days can be considered constipation, especially if the stools are hard in consistency, which may be caused by low fibre diets, IBS-D, primary or secondary causes such as mechanical obstruction, drugs such as paracetamol, aluminium-containing antacids, anticholinergics, calcium supplements and diuretics. Such patients should see a doctor for evaluation, health education and management.
What are the causes of irritable bowel syndrome?
The causes of IBS are not clearly known but are avidly researched. Postulated causes include abnormal colonic transit profiles, post-infectious IBS-colonic muscle hyperactivity, immunologic and neural alterations of the small and large intestines that may persist after gastroenteritis, abnormal central neuronal mechanisms, abnormal glutamate activation of N-Methyl-D-aspartate receptor, activation of nitric oxide synthase, activation of neurokinins receptors and induction of calcitonin gene-related peptide, limbic system abnormalities that mediate emotions, and hypothalamic corticotropin-releasing factors in response to stress. Others are increased intestinal permeability in IBS-D, alteration in the intestinal biome and dietary intolerance.
How do muscle contractions in the intestine cause IBS?
Patients with IBS-diarrhoea usually have increased high-amplitude propagated contractions, which is an enhanced gastrocolic reflex, or rectal hypersensitivity and accelerated transit time. IBS-constipation may be secondary to increased segmental (non-propulsive) contractions, decreased high-amplitude propagated contractions, or reduced rectal sensation and delayed transit time.
Food and stress are said to be triggers. Is that true?
Yes.
Which types of food trigger IBS and how?
High fermentable oligo-, di-, and mono-saccharides and polyols diets, which are present at high levels in some fruits like apples, cherries and peaches; artificial sweeteners, legumes and green vegetables like broccoli, sprouts, cabbage and peas are fermentative, generating a high amount of gas such as methane and hydrogen sulphide that are responsible for symptoms of abdominal bloating, excessive belching and flatulence, and they also possess osmotic effects, which may result in the passage of loose stool.
Who is at risk of irritable bowel syndrome?
Those at risk are the female gender, individuals with pre-existing psychological issues, such as anxiety, depression, or hypochondriasis. The best-accepted risk factor for IBS is post-infectious gastroenteritis caused by protozoal, bacterial, and viral gastroenteritis. Others are affluent childhood environments, previous antibiotic use, food intolerance, IBS aggregates in families, perinatal factors such as young maternal age, caesarean section, and low birth weight.
Does IBS have psycho-social effects on the sufferer?
Yes, it does. Psychiatric conditions such as depression, anxiety and somatisation (psychological distress represented by physical symptoms) often occur in IBS.
What are the various medical tests a person with IBS may undergo?
Extensive medical tests are not often required in patients with straightforward IBS except in the presence of alarm symptoms, which are symptoms that may suggest complications or the presence of very serious diseases such as cancer, vomiting of blood, unexplained weight loss, unexplained vomiting, progressive difficulty with swallowing, IBD, celiac disease, evidence of low blood level, a family history of malignancy, and new-onset symptoms in older age (50 years of age). Medical tests may also be required to rule out other possible background illnesses or causes of the symptoms, especially in atypical presentation.
Other tests are hydrogen breath testing to identify lactose intolerance or SIBO; bile salt malabsorption, detected by SeHCAT scan, has been proposed to explain IBS-D symptoms in some patients although until recently, many of the studies examining this issue were retrospective; celiac serology testing, colonoscopy, biopsy and histologic studies may help in diagnosing microscopic colitis in patients with suspected IBS-D. If any red flags are absent, the patient who responds to an empiric trial of therapy for IBS does not require any further diagnostic evaluation, other than celiac serology. Those who fail to respond should undergo more extensive evaluation, depending on the predominant symptoms.
Is irritable bowel syndrome curable?
Yes. In some cases, IBS patients have spontaneous improvement and resolution of symptoms over time, but in the majority of patients, it is usually a relapsing disorder.
How can it be treated?
It is important first to educate patients and then to actively reassure them. Patients typically want to understand why their symptoms have occurred; they also want to obtain the validation that their symptoms are real. High-soluble fibre diet can be helpful against constipation and abdominal bloating and gas fibre supplements should begin at a low dose and a low FODMAP diet improved significantly abdominal pain, bloating, stool frequency, and consistency, as well as urgency.
Patients should eat small, regular meals. Exercise enhances GI transit and has been shown to improve symptoms of IBS. Psychological treatments, hypnotherapy and cognitive behavioural therapy provide long-term efficacy in patients with refractory symptoms. Treatment with drugs depends on the type of IBS.
Are there certain types of food a person with IBS should avoid so as to reduce the symptoms?
A person with IBS should avoid high fermentable oligo-, di-, and monosaccharides and polyols diets as they may exacerbate symptoms in some patients with IBS because of their fermentation and osmotic effects. They should also avoid insoluble fibre, fatty foods and caffeine.
Are there modern treatment options researchers are currently working on?
Yes, there are. Some drugs act on pain receptors and target visceral hypersensitivity. Some target motility and inflammation. Other modern treatment options researchers are working on include bile acid sequestrants, bile acid transporter inhibitors and pancreatic enzyme supplements, but RCTs are sparse.
Copyright PUNCH.
All rights reserved. This material, and other digital content on this website, may not be reproduced, published, broadcast, rewritten or redistributed in whole or in part without prior express written permission from PUNCH.
Contact: [email protected]
