The Angry Gut

douleur-abdominaleThere is a condition that affects between 5 and 20% of the global population. It is characterised by abdominal pain and changes in bowel movement. It is more prevalent in under-50s, women, people with a history of mood disorder and during stressful times. It may have a family predisposition. There is currently no specific test to make a diagnosis and no known cure despite the condition being common.
Now, what would you do if someone literally steps on your toes? Lash out with your tongue (or fist), swear under your breath or simply walk away? In like manner, when the bowel is irritated, it can go loose, shut down or grumble along.

What is Irritable Bowel Syndrome (IBS)?
IBS is a functional disorder of the intestines characterised by one or more of the following symptoms:

  1. Abnormal bowel movement
    • Diarrhoea [IBS-D or Diarrhoea predominant]
    • Constipation [IBS-C ]
    • Alternating diarrhoea or constipation [IBS-M or mixed type]
  2. Abdominal pain, cramp or discomfort
  3. ‘Gas’ – bloating, abdominal distension or flatulence
  4. Associated conditions – Mood disorders, chronic fatigue, chronic pelvic pain, etc.
Why IBS?
No one really knows. New areas are being explored to have a better understanding of what goes on within the gut and the brain-gut axis in IBS.
Suffice it to say that there is a complex interaction between the individual’s genes and the environment. The following factors have been implicated in IBS:
  • Diet (food intolerance and sensitivity).
  • Psychological factors (stress, coping, abuse, depression, anxiety).
  • Changes in peristalsis – the movement of the muscles of the gut.
  • The cells of the intestines being hypersensitive.
  • Alterations in nerve signals between the gut and the brain.
  • The population of the ‘good’ and ‘bad’ bacteria in the intestines.
  • Changes to the way the immune system responds to an infection.[i]
  • Levels of serotonin, a chemical messenger in the body that is largely present in the gut.
 How is IBS diagnosed?
IBS is a functional disorder. There are currently no tests to make a diagnosis. Investigations to check the structure of the intestines and biochemical parameters are normal. Ironically, it is the absence of abnormalities despite symptoms that clinches the diagnosis. Most recently, researchers have found that breath samples can distinguish people with and without IBS[ii]. This may be used in future to aid diagnosis.  Until then, IBS is diagnosed from the patient’s medical history along with normal test results.A group of scientific experts meet to review the diagnosis and treatment of gut disorders every few years. Their most recent advice for the diagnosis of IBS is in the Rome IV Criteria[iii] published in June 2016.

Diagnostic criteria for IBS:

  1.  Recurrent abdominal pain, occurring on average, at least one day per week in the last three months, and associated with two or more of the following:
    1. Related to defaecation
    2. Associated with a change in frequency of stool.
    3. Associated with a change in form (appearance) of stool.

Criteria fulfilled for the last three months with symptom onset at least six months prior to diagnosis

Rarely, some of the symptoms above may be early warning signs for ovarian, colon or rectal cancer. If someone you know has unintentional weight loss, black or bloody stool or altered bowel persisting for six or more weeks, you should get a doctor’s opinion urgently.

How is IBS treated?
As stated earlier, there is no cure. The goal of management is to alleviate symptoms. Where triggers exist, the first step is to avoid them.

General lifestyle advice:

  • Increased physical activity where practicable
  • Food diary, avoidance of foods which consistently (not occasionally) trigger bloating
  • Time management, adequate sleep
  • Probiotics (e.g. bacteria and yeast added to yoghurt) may help restore changes in the ‘good bacteria’ of the intestines when the balance is upset following illness or treatment with antibiotics. These can be tried for 1-2 months and discontinued if no subjective improvement in symptoms.
  • Peppermint oil from peppermint plant which has a calming effect on the intestines
  • Dietary fibre: The general idea is to increase soluble fibre (e.g. oats, ispaghula) or decrease insoluble fibre (e.g. bran) and see what works for you.
  • Single food avoidance / exclusion diets; special FODMAP[iv] diets under dietitian supervision
  • Treating diarrhoea symptom:
    1. Anti-motility drugs – Loperamide is usually recommended
  • Constipation
    1. Laxative – preferably bulk-forming laxative
  • Abdominal pain or discomfort
    1. Paracetamol, anti-spasmodics e.g. Buscopan; avoid Ibuprofen
  • Mood disorders / Psychological factors e.g. stress and anxiety may adversely affect nerve signals from the gut to the brain. These can be treated with:
    1. Psychological therapies
    2. Medications for anxiety or depression

The laid-back patient is less likely to walk into a consulting room with distressing symptoms of IBS. Many IBS sufferers have associated psychological challenges, from the mild and intermittent stress triggered by life events e.g. menstruation, preparing payrolls, headlines and deadlines to more chronic anxiety, depression and painful conditions.

In summary, patients with an internal locus of control who understand the symptoms of IBS, obtain a supply of relevant medicines for symptom control, soon become expert patients. They experience minimal disruption in their daily living. At the other end of the spectrum are patients almost crippled by IBS, who keep coming back to request more prescriptions, tests and referrals, anxious that doctors are missing something, despite the array of normal test results over several years. If you suffer from IBS, where you fall along this continuum will ultimately determine how you respond to the angry gut.

Last line: There are further sources of information about IBS. The IBS Network is a good place to start.

Interesting video:

Doctor Hector
KayHector Consulting Ltd

[i] Magnud Haland & Yuri Santo. Irritable bowel syndrome: new and emerging treatments.