Diagnosing & Managing Irritable Bowel Syndrome(IBS)

It is estimated that 10-20% of the world’s population suffers from IBS, or irritable bowel syndrome (Geriatrics, 2005). Women are affected more frequently than men. About 70% of IBS sufferers experience mild symptoms, while 25% experience moderate to severe symptoms. Whether you are male or female, young or old, and symptoms are mild, moderate or severe, IBS can adversely affect quality of life.
What is IBS?
IBS is a functional disorder of the intestines characterized by abdominal discomfort or pain accompanied by a change in bowel habits- diarrhea, constipation or a combination of the two. “Functional” means that an organ’s functional ability is altered, but its structure remains intact. IBS does not cause visible or detectable damage to the intestines and does not shorten the life span of individuals who suffer from it (Marks, 2011). Although it cannot be “seen”, its effects are very real. The pain caused by IBS can be quite severe, and alterations in bowel habits can be distressing. Patients with IBS may experience periods of remission (when the disorder is causing no symptoms) and exacerbations (when they are experiencing full-blown symptoms).
What Causes IBS?
Unfortunately, researchers have yet to determine the exact cause of IBS. There are three main schools of thought as to factors that affect IBS symptoms. The first is that there may be an abnormality in gut motility: “Altered GI motility includes distinct aberrations in small and large bowel motility…small bowel dysmotility manifests in delayed meal transit in patients prone to constipation and in accelerated meal transit in patients prone to diarrhea” (Lehrer, 2012). Another theory is that individuals with IBS are hypersensitive to colonic movement and distention. “Enhanced perception of normal motility and visceral pain characterizes irritable bowel syndrome. Rectosigmoid and small bowel balloon inflation produces pain at lower volumes in patients than in controls. Notably, hypersensitivity appears with rapid but not with gradual distention” (Lehrer, 2012). Dysregulation of the brain-gut axis has also been postulated to be a possible cause of IBS: “This biopsychosocial disorder involves dysregulation of the nervous system, altered intestinal motility, and increased visceral sensitivity. All of these result from dysregulation of the bidirectional communication between the gut with its enteric nervous system and the brain (the brain-gut axis)” (Mach, 2004).
How is IBS Diagnosed?
At one point, IBS was diagnosed by excluding all other possible causes of the patient’s symptoms, a “diagnosis of exclusion”. This meant that patients were forced to endure numerous unpleasant tests to rule out diseases such as colon cancer, ulcerative colitis and Crohn’s disease. Beginning in 1989, the Rome criteria, achieved through a consensual process of experts in gastroenterology, have been the gold standard in diagnosis of IBS. The latest criteria (Rome lll) were established in 2006.
The Rome lll criteria state that IBS can be diagnosed in any patient who has experienced abdominal pain or discomfort for at least 3 months out of the past 12 months (not necessarily consecutive) that was accompanied by at least 2 out of the following 3 criteria:
Relieved with defecation, and/orr
Onset was accompanied by a change in the frequency of stool, and/orr
Onset was accompanied by a change in the appearance (form) of stoolr
Supportive symptoms that may be used to strengthen the diagnosis of IBS include having more tha
3 stools a day or less tha
3 stools per week, mucus in the stool, abdominal bloating and abnormal stool passage (i.e. having to strain to pass stool). Four subtypes of IBS are recognized: IBS-C (constipation is predominant), IBS-D (diarrhea is predominant), IBS-A (diarrhea and constipation alte
ate) and IBS-U (no subtype identified).
In addition to these criteria, it is recommended that patients have a complete blood count, chemistry panel and ESR (erythrocyte sedimentation rate) done. When blood results and physical exam are normal, and when no “red flag” symptoms are present (pain that awakens from sleep, blood in stool, weight loss, fever and diarrhea that interferes with sleep), there is a >95% accuracy rate in using Rome lll criteria to diagnose IBS (Medscape Gastroenterology, 2006).
Management of IBS
There is no cure for IBS. No single drug can target the symptoms of IBS. Furthermore, evidence supporting the use of drugs to treat IBS is limited and conflicting (Rx Files, 2008).
What is known is that there is a strong mind-body association in IBS. It is estimated that approximately 50 to 90% of individuals suffering from IBS also suffer from co-morbid mental health disorders, such as depression and anxiety (Rx Files, 2008). Recent treatment modalities have shifted from the use of drugs to control symptoms to the use of psychological therapies to help patients manage their symptoms more effectively and improve quality of life. Cognitive behavior therapy, relaxation therapy and hypnotherapy have all been used successfully to treat symptoms of IBS, acknowledging that the physical symptoms are very real but patients can learn to control these symptoms.
Cognitive Behavioral Therapy (CBT)
The Canadian Psychological Association (2009) describes cognitive behavioral therapy in the treatment of IBS:
“…incorporates a number of steps aimed at changing behavior to improve health and coping. It often involves providing information to ensure a better understanding of the illness…teaching strategies to change thinking patterns that can contribute to strong physical and emotional reactions, teaching skills to deal with challenging or stressful situations that can trigger the gut, and goal-setting to establish optimal health habits. CBT typically includes relaxation therapy”.
A study of self-administered CBT in the treatment of moderate to severe IBS, where CBT was administered by a therapist or by the patients themselves using a program designed for home use, found that both CBT versions were significantly superior in the percentage of participants reporting adequate relief and improvement of symptoms, with participants reporting significantly improved quality of life and IBS severity (Lacker et al, 2008).
Hypnotherapy
“Hypnotherapy uses mental imagery and hypnosis instructions to specifically reduce gut sensations and develop a state of calmness and relaxation” (Canadian Psychological Association, 2009). Hypnotherapy has been used successfully to combat the symptoms of IBS, as shown in the following statement from a literature review of studies involving hypnotherapy in IBS (Tan et al, 2005):
“…hypnosis consistently produces significant results and improves the cardinal symptoms of IBS in the majority of patients, as well as positively affecting non-colonic symptoms. When evaluated according to the efficacy guidelines of the Clinical Psychology Division of the American Psychological Association, the use of hypnosis with IBS qualifies for the highest level of acceptance as being both efficacious and specific”.
In terms of effective treatment for IBS, “evaluation studies have shown that psychological treatments can lead to greater improvement than the usual medical treatment” (Canadian Psychological Association, 2009).
Irritable bowel syndrome is a complex and common condition resulting in distressing symptoms of abdominal pain and altered bowel habits. Although most people suffer from a mild form of the disorder, a small number suffer from moderate to severe symptoms that can affect quality of life negatively. Studies regarding medications to treat IBS are few and conflicting; however, there is evidence that psychological therapy, such as hypnotherapy and CBT, can effectively reduce the severity and frequency of IBS symptoms.
Referencesr
Ehrenpreis, E. (2005). Irritable bowel syndrome: 10% to 20% of older adults have symptoms consistent with diagnosis. Geriatrics, 60(1); p. 25-28.
Marks, J. MedicineNet.com Irritable Bowel Syndrome. Updated Jan 2011. http://www.medicinenet.com/irritable_bowel_syndrome/page13.htm
Lehrer, J. Medscape. Irritable Bowel Syndrome. Updated Jan 2012. http://emedicine.medscape.com/article/180389-overview#a0104
Mach, T (2004). The brain-gut axis in irritable bowel syndrome- Clinical aspects. Med Sci Monit, 10(6); p. 125-131.
Medscape Gastroenterology (2006). From Rome to Los Angeles — The Rome III Criteria for the Functional GI Disorders. http://www.medscape.org/viewarticle/533460
RxFiles (2008). Irritable Bowel Syndrome (IBS). Saskatchewan Health Region. http://www.rxfiles.ca/rxfiles/uploads/documents/GI-IBSyndrome.pdf
Canadian Psychological Association (2009). “Psychology Works” Fact Sheet- Irritable bowel syndrome. http://www.cpa.ca/psychologyfactsheets/irritablebowelsyndrome/
Lacker, J., Jaccard, J., Krasner, S., Katz, L., Gudleski,G., & Holroyd, K (2008). Self-administered cognitive behavior therapy for moderate to severe irritable bowel syndrome: Clinical efficacy, tolerability, feasibility. Clinical Gastroenterology and Hepatology, 6(8); p. 899-906.
Tan, G., Hammond, D. & Joseph, G (2005). Hypnosis and irritable bowel syndrome: a review of efficacy and mechanism of action. Am J Clin Hypnosis, 47(3); p. 161-178.