Irritable Bowel Syndrome – Suffering in Silence.
Do I have IBS?
Well, simply because you’ve asked the question, almost certainly yes! But don’t overlook Coeliac disease, Inflammatory Bowel Disease or Bowel Cancer.
Irritable Bowel Syndrome (IBS) is diagnosed using criteria based on symptoms, and by ruling out other conditions that may mimic IBS such as Inflammatory bowel or Coeliac Disease.
The diagnosis is based on symptoms. It is important to see The GP and not to self-diagnose IBS because other conditions may cause similar symptoms. The formal diagnosis is made with the assistance of The “Rome Criteria.” The Rome III criteria were updated to Rome IV in 2016 and the key features are:
Recurrent abdominal pain on average at least 1 day a week in the last 3 months associated with two or more of the following:
- Related to defecation
- Associated with a change in a frequency of stool
- Associated with a change in form (consistency) of stool.
Symptoms must have started at least 6 months ago.
IBS does not cause weight loss, diarrhoea at night, vomiting, bleeding or anaemia.
The longer the history, the more likely IBS is the cause. During “IBS Days”:
- The discomfort is often relieved by opening your bowels – although this criteria was removed in Rome IV.
- There is often a change in bowel habit – change in consistency of bowel motions and/or change in how often you go. This may include diarrhoea or constipation, or both, at different times.
- There is often bloating.
Everyone has an opinion about IBS just because it is so common. However, IBS may be almost trivial in one person to extremely debilitating in another.
Do I need any tests?
Some blood tests are often suggested to help rule out other conditions:
- CRP / ESR: Inflammatory Bowel Disease – for Ulcerative Colitis / Crohns
- Anti Tissue Transglutamase Antibody (or other serology test) – for Coeliac Disease
There’s a new faeces test (faecal calprotectin) that also helps to rule out inflammatory bowel disease in someone with diarrhoea & symptoms that might indicate inflammatory bowel disease. In Australia, The faecal calprotectin test is not medicare rebable (cost under $100) and a positive test will still require the need a colonoscopy – so it has its pros and cons depending on individual circumstances. In The UK, Calprotectin testing is being made available on the NHS for GP requesting in some areas.
Someone in their 40’s who appears to have developed IBS for the first time may well need a colonoscopy. Bowel Cancer can present as the new onset of diarrhoea. QLD Health gastro referral guideline suggests a colonoscopy when bowel habit has changed for at least 6 weeks over the age of 40 but the age cut-off between guidelines vary enormously. The UK NICE cancer care pathway updated in 2015 recommends a colonoscopy over the age of 60 if there is a change in bowel habit. You Doctor will discuss the risk of bowel cancer with you, and a change in bowel habit is only one indicator along with others.
IBS symptoms developing for the first time in older people may need further tests to exclude diagnoses such as microscopic colitis or ovarian carcinoma.
Thankfully, the treatment for Irritable Bowel Syndrome has moved on a lot from in the past and there are a range of treatment options.
What is the Cause of IBS?
The term “gut-brain interface” is helpful because it changes the way we look at IBS. The way that pain is processed in The nervous system is as important as bowel itself.
- The bowel itself is more sensitive and active. This is reflected by the term “sensitive bowel” although that’s not the whole story.
- The bowel sends an abnormal number of pain signals to the nervous system.
- Pain is processed by the Central Nervous System in an abnormal way.
Living with Irritable Bowel Syndrome & Lifestyle
There’s Irritable bowel, and there’s Irritable bowel. IBS can be a minor nuisance. IBS can also be a major block to leading a normal life with experiences like rushing to the toilet in a meeting, abdominal cramps in the car, or feeling bloated all the time.
IBS can’t be officially cured although the symptoms may well be helped enormously with attention to some of treatments suggested.
Understanding the nature of the condition is helpful – it’s easier to live with something that you understand rather than are fearful of.
Physical Activity can reduce the symptoms of IBS. People who don’t do regular exercise are most likely to benefit from increasing their activity levels. A good quality study of 102 people with IBS found that people who exercised for around half an hour 3-5 times per week had reduced IBS symptoms.
Attention to stress management may be helpful – even if this doesn’t help the IBS then at least it might make the IBS easier to live with. Relaxation exercises are often beneficial.
Diet for irritable bowel syndrome
It’s best to limit fibre in the insoluble form eg. corn bran, corn syrup, wheat bran, & bran as a supplement. Insoluble fibre is fermented by bacteria in the large intestine & exacerbates symptoms such as bloating.
It is best to have fibre in soluble form such as oats (porridge), nuts & seeds. IBS with constipation if often helped with Ispagula Husk (Fybogel). Golden linseed may also help.
Keeping a food diary is helpful. Note that the food may not be linked to the symptom until the following day.
Most people with IBS have heard of The FODMAP diet. The results can be dramatic. The FODMAP component are different types of carbohydrate that may not be broken down in the small intestine and end up in the colon causing bloating and diarrhoea. Fructose (in sweet fruit) is one the of five FODMAPs and intolerance to pears, apples, watermelon and so on are a common issue. So a good starting point is not to eat more than 3 portions of sweet fruit (including fruit drinks) per day.
Artificial sweeteners such as sorbitol or xylitol can trigger symptoms. These sweeteners are another FODMAP called “polyols.” It’s surprising how often diarrhoea can go away on stopping diet fizz or sweeteners in coffee.
Some people find their bloating and diarrhoea improve on a wheat-free diet. Wheat contains fructans which is another FODMAP carbohydrates. As long as coeliac disease has been excluded previously then it’s reasonable to try without wheat for a few weeks to see if this improves your symptoms before embarking on the more complicated low FODMAP diet.
Getting the idea on FODMAP? There are five FODMAP carbohydrates in total, and we’ve touche on three already (Fructose, Polyols and Fructans). The other two are lactose (dairy) and galactantans (beans, lentils, chickpeas etc).
It takes a couple of months to go through the full FODMAP elimination diet and it can be hard to tell the wood through the trees. Seeing a dietician can be very helpful as can a look at the FODMAP monash website. The official FODMAP diet is available for both Android & IOS.
For a simple start to FODMAP, eliminate sweet fruit, artificial sweeteners and dairy for a week.
It is also helpful to avoid food very high in fat such as fried chips / burgers.
Constipation or diarrhoea need treatment. Loperamide (Imodium) often helps manage diarrhoea.
For constipation, various laxatives are helpful such as fybogel, but it’s best to avoid lactulose. The aim is the appearance of a soft and well formed stool. Take a look at the very useful Bristol Stool Chart to identify your stool types. Bowel motions that are constipated (types 1 to 3) may require laxatives whereas motions that are loose (type 5 or 6) may require anti-motility medication. Type 4 stool (“like a sausage or snake, smooth and soft”) is the type to aim for!
Prescription-only medication for IBS symptoms may be prescribed by your GP. Options include Endep (Amitryptyline), and possibly SSRIs. Both originally came out to treat depression. Endep is nowadays rarely prescribed for depression and is, in any case, only an antidepressant in high doses – not the much lower doses used to treat IBS. Endep has a variety uses – from migraine prevention to treatment of neuropathic pain. Anti spasmodic medication is also available on prescription (such as mebeverine or hyoscine butylbromide).
Other IBS Treatments
Iberogast is a herb. A recent IBS review indicates that there is some evidence of its benefit at a dose of 20 drops in half a glass of water three times per day.
There is also evidence that Probiotics may be useful and they do need to be tried for at least 4 weeks.