Irritable Bowel Syndrome and The Invisible Enemy

Valley of the Kings Egypt (Dr. Noorali Bharwani)
Valley of the Kings Egypt (Dr. Noorali Bharwani)

COVID-19 has caused significant stress and anxiety among the general population. Individuals with a history of irritable bowel syndrome (IBS) will have aggravation of symptoms.

IBS is a common medical condition that affects the large intestine. It is a chronic condition that requires long term management. Unfortunately, the pathology and physiology of IBS is not fully understood.

Usually, only a small number of people with IBS have severe symptoms. Some people can manage to control their symptoms by managing diet, make lifestyle changes and controlling stress.

More severe symptoms can be treated with medication and counseling. But management of IBS is not always easy. IBS is a relapsing and remitting disorder in which the predominant bowel habit and symptoms can change over time. It is like COVID-19 except IBS is usually not life threatening.

We don’t know what causes IBS. But we know stress aggravates the symptoms.

Good news is IBS does not cause changes in bowel tissue or increase your risk of colorectal cancer.

The most recent review on this subject was published in the Canadian Medical Association Journal (CMAJ March 16, 2020 – An approach to the care of patients with irritable bowel syndrome).

IBS is a disorder of gut – brain interaction leading to abdominal pain with a change in frequency or form of bowel habit. Forty per cent of patients referred to a gastroenterologist have IBS.

IBS affects four per cent of men and eight per cent of women in Canada, with a peak incidence in ages 18 – 34 years. It can occur in patients with other medically unexplained conditions, such as fibromyalgia and depression or anxiety. Symptoms typically vary in frequency and intensity, and are often aggravated by stress. It is very disruptive to an individual’s work schedule and life style.

When a person has symptoms suggestive of IBS, the burden falls on the physician to make sure other conditions like inflammatory bowel disease (IBD), celiac disease, bile acid diarrhea and carbohydrate malabsorption (e.g. lactose intolerance) are not missed.

Patients who need further investigations are those whose first presentation of symptoms are at age 50 or after, has weight loss, has rectal mass or bleeding, and has family history of colon and rectal cancer.

Diagnosis relies on the identification of chronic typical symptoms characterized by abdominal pain, bloating and change in frequency or form of bowel habit.

The clinical management of IBS can be challenging. The CMAJ article says physician should establish positive therapeutic relationship with patients, underpinned by patient education. That is key to optimizing clinical outcomes. You cannot cure the problem but managing the bothersome symptoms is the mainstay of IBS treatment.

While several management options exist, none of them are effective to cure the problem. They can provide some symptomatic relief. For more information visit: The IBS Network.

In conclusion, IBS is a common disorder characterized by chronic abdominal pain that is associated with a change in frequency or form of bowel habit. The underlying cause is incompletely understood. Therefor treatments are based on symptom management. That include education and reassurance, dietary modifications and pharmaceutical interventions, largely directed toward improving the most bothersome symptoms.

This brings us to the current situation of dealing with the invisible enemy (COVID-19) and the stress it is causing. This is having negative physical and mental effect on our body. Best thing is to do what the experts say and hope for the best.

Manage your stress by doing meditation, yoga, and establish network with friends and family. There are many options available online. Be creative. Be safe and take care.

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Irritable Bowel Syndrome a Significant Problem for Some

Irritable bowel syndrome (IBS) is the most common chronic intestinal disorder. The symptoms are due to disturbance in the movement and sensation of the bowel. The person is otherwise well but presents with chronic or recurrent abdominal pain, change in bowel habit (constipation and/or diarrhea) and bloating.

Literature suggests at least 15 percent of the population has this condition. I feel that almost everybody has some element of irritable bowel syndrome.

IBS affects twice as many women as men and usually begins in early adult life. Although IBS can cause much distress, it does not lead to life-threatening illness. It is also called spastic colon. IBS is not like other conditions. There are no definite abnormalities to find in a patient with IBS and there are no tests to confirm the diagnoses.

IBS is a complex condition that affects a person’s psychology (emotional and behavioural characteristics). A physician treating this condition must have a good understanding of the problem. He should be able to dedicate time and energy to help his IBS patients.

IBS is considered to be a functional disorder of the gastrointestinal tract. But there is high incidence of psychiatric disorders in patients with IBS – panic disorder, major depressive disorders, and phobias.

Patients have to realise that they may need psychological treatment for a physical condition. And having irritable bowel does not mean a person is mentally ill. Antidepressants and medications that inhibit anxiety have been shown to be effective in IBS. But these drugs have to be used with care.

Stress-induced anxiety can make symptoms of IBS worse. The source of stress can be internal (from within your own body) or external (from your environment). IBS patients experience higher levels of anxiety and fatigue than do healthy people.

Management of IBS can vary from simple to complex. First, you have to see a doctor and get some basic investigations done to rule out any other illness like infection in the bowel, cancer, ulcerative colitis, Crohn’s disease and celiac disease. Anemia, rectal bleeding and loss of weight are not symptoms of IBS. This may suggest inflammatory bowel disease (IBD) or cancer of the bowel.

There is no cure for IBS. However, controlling the diet and emotional stress usually relieves the symptoms. Sometimes symptoms come and go. Some medicines may also help.

In more severe cases, like treatment-resistant IBS, psychotherapy has been proven to be useful. But there is no evidence to suggest that psychotherapy is beneficial in patients with mild IBS.

Management of IBS poses a big challenge to a physician. Many drugs are available in the market for use in IBS. But none of them have proven benefits. Some of them may act as placebo. Smooth muscle relaxants tend to help relieve abdominal pain with or without relief of other symptoms. Loperamide (Imodium) is beneficial in patients who have diarrhoea as a predominant symptom. Psyllium and other higher fibre diets are useful for patients with constipation.

Current treatment of IBS includes advice on high fibre low fat diet, smooth muscle relaxant, agents to stop diarrhoea or bloating and psychotherapy or psychoactive drugs to take care of depression or anxiety.

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Traveler’s Diarrhea Can Cause Irritable Bowel Syndrome

Have you already planned a winter holiday? Besides getting your passport and appropriate currency, you need to think of getting your vaccinations updated and take actions to prevent traveler’s diarrhea (TD).

TD hits your system when you consume contaminated food and water. It occurs during or shortly after travel, most commonly affecting persons traveling from an area of more highly developed hygiene and sanitation to a less developed one. Food and water may be contaminated with bacteria, parasites or viruses. A similar but less common syndrome is toxic gastroenteritis, caused by ingestion of pre-formed toxins.

Studies have shown bacteria are responsible for approximately 85 per cent of TD, parasites about 10 per cent, and viruses five per cent. On average, 30-50 per cent of travelers to high-risk areas will develop TD during a one to two-week stay.

TD is generally self-limited and lasts 3-4 days even without treatment, but persistent symptoms may occur in a small percentage of travelers. Any diarrhea associated with fever and blood in the toilet requires medical attention.

Infectious diarrhea can have a long term effect on our system resulting in arthritis, Guillain-Barré syndrome (a reversible condition that affects the nerves in the body), and irritable bowel syndrome (IBS). IBS may occur in up to 30 per cent of persons who contracted travelers’ diarrhea or infectious diarrhea. Research is going on to determine if post-infectious IBS can lead to inflammatory bowel disease.

IBS is a complex disorder clinically characterized by abdominal pain and altered bowel habit. Its causative mechanisms are still incompletely known. It could be a person’s genes, psychosocial factors, changes in gastrointestinal motility and hypersensitivity of certain organs in the body.

TD can be self-limiting benign condition or may result in serious sequalae. So it is no rocket science to conclude that we should try and prevent TD by taking necessary preventive measures. Travelers should remember to wash their hands with soap and water prior to eating or meal preparation.

Eat foods that are freshly cooked and served piping hot and you should avoid water and beverages diluted with non-potable water. Foods like salads are washed in non-potable water. You should avoid that. Raw or undercooked meat and seafood and raw fruits and vegetables should be avoided. Safe beverages include those that are bottled and sealed or carbonated. Consumption of food or beverages from street vendors poses a particularly high risk.

What kind of medications can you use as prophylaxis against TD?

Studies from Mexico have shown Pepto-Bismol (taken on arrival at the destination as either two oz. of liquid or two chewable tablets four times per day) reduces the incidence of TD from 40 to 14 per cent, says one research paper. You should make sure that Pepto-Bismol is compatible with other medications you take. There is no conclusive evidence that use of probiotics is helpful.

E. coli is the most common type of bacteria which causes TD. Use of oral Dukoral vaccine (two weeks and one week before travel) provides protection against E. coli diarrhea for three months.

Use of prophylactic antibiotics has been demonstrated to be quite effective in the prevention of TD. Studies have shown that attacks of diarrhea are reduced from 40 per cent to 4 per cent by the use of antibiotics. But it is becoming difficult to decide which antibiotic to use as bacteria tend to develop resistance to antibiotics. For this and other reasons, prophylactic antibiotics should not be recommended for most travelers.

Three months before you travel, you should visit your family doctor and local public health nurse and discuss your travel plans. They will provide you with the most advanced information on how to have a healthy and happy holiday.

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Irritable Bowel Syndrome

Some time ago I received a letter from one of the readers. It had multiple questions. So here are the questions and appropriate answers.

Q. Please describe irritable bowel syndrome (IBS). Is it constipation or diarrhea?

Irritable bowel syndrome is the most common chronic intestinal disorder. The symptoms are due to disturbance in the movement and sensation of the bowel. The person is otherwise well but presents with chronic or recurrent abdominal pain, change in bowel habit (constipation and/or diarrhea) and bloating.

Literature suggests at least 15 percent of the population has this condition. I feel that almost everybody has some element of irritable bowel syndrome.

It affects twice as many women as men and usually begins in early adult life. Although IBS can cause much distress, it does not lead to life-threatening illness. It is also called spastic colon.

Q. What can you do for it?

First, you have to see a doctor and get some basic investigations done to rule out any other illness like infection in the bowel, cancer, ulcerative colitis, Crohn’s disease, and celiac disease. Anemia, rectal bleeding and loss weight are not symptoms of IBS.

There is no cure for IBS. However, controlling the diet and emotional stress usually relieves the symptoms. Sometimes symptoms come and go. Some medicines may also help.

IBS is like arthritis of the gut. Just as in arthritis, your doctor may have to try more than one medication to control your symptoms.

Q. Early in spring, I had diarrhea for two weeks. Things settled down a lot since. I have a lot of gas and grumbling. Could this be due to stress?

That is quite possible. Stress plays a significant negative role in many of our illnesses. But before you blame everything on stress, you should talk to your doctor and let him decide the cause of your “back door trots”.

The subject of irritable bowel syndrome has been covered in these columns previously. These columns are available on my web site: www.nbharwani.com. Or you can pick up a copy of the relevant article from my office.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!