Irritable bowel syndrome is one of the most common disorders seen in medical practice today. During a typical week, the average family practitioner or internist will see more patients who have irritable bowel syndrome (IBS) than patients who have asthma, diabetes, hypertension, or cardiovascular disease. To help put this into perspective, consider that approximately 15 percent of adult Americans have symptoms of IBS, which translates to approximately 45 million adult Americans having recurring symptoms of abdominal pain, discomfort, bloating, distention, and either constipation or diarrhea (or both). This helps to explain why the aisles in your local pharmacy or drugstore are packed with over-the-counter medications designed to treat digestive problems.
Although IBS is common, the condition remains poorly understood. Lack of understanding of this prevalent, complex disorder is pervasive among family members and coworkers of people who have IBS as well as insurers, health care plans, the public at large, and even some physicians. People misunderstand IBS on many different levels. For example, some people believe that IBS is an uncommon disorder and that the attention paid to it occurs only because of the actions of a very small but vocal group of people who have IBS. On the contrary, multiple large population-based research studies have shown that up to 15 percent of adult Americans have IBS.
Another common misconception is that IBS affects only young women. In fact, nothing could be further from the truth. Irritable bowel syndrome is an equal opportunity disorder. It does not discriminate based on age, sex, race, or nationality. Some insurance companies and health care providers believe that IBS is nothing more than an annoyance and that it should not even be considered a medical problem. It is well documented, however, that from a patient’s perspective, this common disorder significantly affects patients’ quality of life on a daily basis.
Finally, some people mistakenly argue that IBS is a new problem that has appeared in response to the stresses of an industrialized society or that it is a problem manufactured by pharmaceutical companies solely to improve their revenue. But multiple studies have clearly shown that IBS is found throughout the world and is not just limited to Western societies. Irritable bowel syndrome exists in rural areas, underpopulated areas, and nonindustrialized societies. Irritable bowel syndrome is not new; it likely has been present for thousands of years, if not longer. In this book, I address these common misconceptions and provide answers to common questions about IBS using the most recent data from scientific studies performed around the world.
Although irritable bowel syndrome is now a relatively familiar term, the disease was given a number of different names in the past. Some of these are colorful (spastic colitis), while others are somewhat pejorative (nervous colitis), and still others are simply misnomers (mucus colitis, unstable colitis, and inflammatory colitis). These terms are misleading, confusing, and often distressing to people who have IBS. People who receive a diagnosis using one of these old-fashioned terms may be worried that they are receiving a different diagnosis of a more severe disorder rather than IBS. For example, the term “mucus colitis” may lead someone to think that they have ulcerative colitis or Crohn’s disease, both of which are inflammatory bowel diseases (see Chapters 7, 8, and 12). For these reasons, such older labels should not be used, and anyone who is diagnosed with one of these labels should ask his or her doctor for a different diagnosis.
Despite the variety of names and labels for IBS, the disease has remained the same over the years. Noted English physician W. Cumming published a description of IBS more than 150 years ago that seems remarkably similar to our current description. In an 1849 passage taken from the London Gazette, he described IBS in the following manner: “The bowels are at one time constipated, at another time lax, in the same person. How the disease has two such different symptoms I do not profess to explain.”
There is significant confusion over this common medical problem, and a host of unanswered questions remain. What, then, is IBS? Irritable bowel syndrome is a common, chronic (meaning that it continues for a long time or recurs frequently) disorder of the gastrointestinal tract. Characteristic symptoms include abdominal pain or discomfort, in association with disordered bowel habits consisting of either constipation or diarrhea (or alternating symptoms of both, in many cases). Other common symptoms include bloating, gassiness, abdominal distention, passage of mucus with a bowel movement, significant straining during a bowel movement, or the very urgent need to have a bowel movement. Although these symptoms are well recognized, they are not specific to IBS; other medical conditions can cause these or similar symptoms, too. The following story of a young woman referred for the evaluation of chronic gastrointestinal symptoms illustrates the misconceptions and misperceptions that surround this common medical problem.
Meredith is a 29-year-old woman referred by her family practitioner for a second opinion. She explained that her problems first began in college. Every several months she would have several days of lower abdominal cramps and diarrhea. The diarrhea was loose and watery but never bloody. It seemed to be associated with significant bloating and distention of her abdomen. Her friends often joked that during these episodes she looked six months pregnant. She attributed these episodes to a viral illness on one occasion, food poisoning on another, and overly rich food on a third occasion.
After college she worked for a consulting firm. This was a stressful job and she had little free time for exercise or relaxing social activities. Several times a month, she would have three to four days of lower abdominal cramps and pain. The pain would generally start shortly before an episode of diarrhea, and she noted that she would often have to run to the bathroom because the urge to have a bowel movement was so strong and forceful. The cramps and lower abdominal discomfort would eventually subside, but each episode left her feeling exhausted. Her friends suggested that she might be lactose intolerant (unable to break down and digest the major sugar in milk products; see Chapter 10). However, even after she eliminated milk and cottage cheese from her diet, her symptoms continued. Meredith mentioned her symptoms to her gynecologist at her next routine office visit. After examining her, he told her he could find nothing wrong and that it was probably “just stress.”
During the next year, her symptoms did not change significantly but did occur more frequently. It was now common for her to have three to four days in a row of lower abdominal pain and discomfort associated with significant bloating and distention. Although she had always been slender, Meredith had to buy new clothes with elastic waistbands, because many of her clothes felt tight on the days when she was bloated. She began to plan her errands and social events more carefully, because sometimes the urge to go to the bathroom came on so suddenly that she was afraid she would have an accident. Meredith tried a variety of over-the-counter medications without any relief. One friend told her that she probably was not digesting her food properly and that enzyme supplements would help her. She tried these for a month, but they did not seem to help. Another friend told her that she wasn’t getting enough fiber in her diet. Meredith became a strict vegetarian and eliminated all animal products from her diet. This only seemed to make the bloating worse. Another friend told her that her symptoms sounded just like her aunt, who had celiac disease (an allergy to wheat products; see Chapter 10).
After researching the topic online, Meredith thought that her symptoms could be the result of a wheat allergy, so she eliminated all wheat products from her diet, which was very hard to do. After two months without any improvement in her symptoms, she abandoned this strict wheat-free diet. Meredith next tried acetaminophen and a variety of over-the-counter anti-inflammatory medications in an attempt to help with the lower abdominal pain, but none of them alleviated her symptoms, and most of them upset her stomach. Out of frustration, she finally made an appointment to see her family practitioner.
Dr. Berkes listened to Meredith’s story, carefully examined her, and reassured her that everything was normal. She ordered some simple laboratory tests, all of which yielded normal results. She told her that this was really “nothing to worry about” and said that maybe she was just overly stressed and a little anxious. She suggested that an exercise program and stress management might be helpful.
Meredith joined a health club, started yoga, and even learned to meditate, but her symptoms continued. The next time she discussed her chronic problem with several of her friends, they told her that all of her complaints were common symptoms of ulcerative colitis, an inflammatory bowel disease. This greatly concerned her, especially after one friend described how her brother needed multiple surgeries to help with his inflammatory bowel disease. The next day, Meredith called her family practitioner and told her that she was concerned that she had inflammatory bowel disease and wanted to see a specialist in stomach and bowel disorders. Dr. Berkes reassured her that her symptoms did not sound worrisome, but she agreed that seeing a gastroenterologist would be a good idea.
In my office, Meredith described her symptoms: lower abdominal cramps and discomfort; sudden urges to go to the bathroom; loose, watery bowel movements; and feelings of being very bloated and distended. She said she was concerned that she had inflammatory bowel disease and was also worried that she might have ovarian cancer (she had visited several websites that described abdominal discomfort and bloating as common signs of ovarian cancer).
I reviewed her history carefully. Her weight had been stable for the first five years of her symptoms, and during the last three years, she had actually gained eight pounds. The character of her pain and discomfort had not changed, although the episodes were now more frequent. A recent test of her complete blood count (CBC) was normal, and Meredith had never been anemic. She stated that no one in her family had a history of ovarian cancer, inflammatory bowel disease, celiac disease, or any type of cancer in the gastrointestinal tract. Meredith had not been camping or traveling, had not been taking antibiotics, and had been drinking water that came from the city water supply (all of these factors decreased the likelihood that she had developed diarrhea due to an infection in her colon). She did admit that she had problems with mild insomnia and that she felt stressed at work. I performed a complete physical examination and did not find anything abnormal.
I explained to Meredith that she had irritable bowel syndrome. Her long-standing symptoms of bloating, abdominal distention, and abdominal cramps and spasms preceding loose, watery bowel movements were fairly classic symptoms. Meredith had brought a long list of questions to her appointment that she wanted answered. The two questions at the top of her list were short but difficult ones: “Why me?” and “Why now?” Meredith also wanted to know if her IBS would turn into some other disease, like colon cancer. I answered her questions as best I could and reassured her that she was not alone with her symptoms. I told her that IBS is a common, chronic disorder that affects many women and men. I explained the natural history of the disorder (see Chapters 4 and 5) and gave her some written information as well.
When I asked Meredith what her worst symptom was, she said it was the urgency to go to the bathroom and the loose, watery bowel movements. She was less concerned about the abdominal pain and the bloating because, she said, she had “just learned to live with it.” I advised Meredith to lower the amount of fiber in her diet, as her very high fiber diet was probably making her symptoms of bloating and diarrhea worse. I also advised her to avoid caffeine and fructose-containing liquids, because these can cause diarrhea and fecal urgency in some people who have IBS. We discussed a special diet called a low-FODMAP (Fructans, Oligodisaccharides, Disaccharides, Monosaccharides, and Polyols) diet, which excludes foods that may cause excessive fermentation in the gastrointestinal tract (see Chapter 15). Because Meredith didn’t want to change too many things in her diet at once, she instead decided to schedule more regular meals and routine trips to the bathroom so that she wouldn’t be afraid of having an accident when she felt the sudden urge to go to the bathroom. We agreed that she would take half an Imodium (loperamide) tablet each day after breakfast and again after dinner and would track her symptoms for the next four weeks, at which point she would return for an office visit.
When Meredith returned, she had a mixed report. She felt better overall. She had fewer episodes of diarrhea and some days even felt a little bit constipated after taking just the two half-tablets of Imodium each morning and evening. However, on two different days she had noted some blood in the toilet after having a bowel movement, and she feared that she might have colon cancer because her mother had told her that blood in the stool was a common sign of colon cancer. She also reported that the abdominal pain was becoming more of an issue. I reassured Meredith that colon cancer, although a significant medical problem in the United States, was unlikely in a young woman who was not anemic and did not have a family history of colon cancer. However, I also told her that it is not normal to have bleeding and that the best thing to do would be to schedule a colonoscopy to examine her colon and determine where the bleeding had come from. In addition, we agreed that she would start taking a low dose of a new medication, desipramine, each night before bedtime. This medication, one of a class of medications called tricyclic antidepressants (TCAs), is commonly used to treat abdominal pain in people who have IBS. In addition, this medication would likely improve her insomnia (see Chapter 17).
Meredith had her colonoscopy three weeks later. As expected, it was completely normal, except for a small internal hemorrhoid, which was likely the source of bleeding. She reported that her abdominal pain wasn’t gone, although it was much better on the desipramine. In addition, she was sleeping better, and she felt more rested and better able to cope with some of the daily stressors in her life. Meredith was reassured by her normal colonoscopy and encouraged that by taking some simple medications, her symptoms had dramatically improved after many years of suffering from pain, bloating, and diarrhea. We discussed a few more ideas regarding diet and exercise, and I increased her dose of desipramine. She called back four weeks later to say that she felt dramatically better.
Like Meredith, people who have IBS have many questions about their condition. They are concerned that their symptoms indicate a very serious or life-threatening disease, such as colon or ovarian cancer. They worry that their symptoms may continue and evolve into a more serious disease, like inflammatory bowel disease. People who have IBS are often concerned that they will pass the condition on to their children. In addition, they are frustrated that they have not been able to get their symptoms under control by changing their diet or by using simple medications available over the counter. Finally, many people who have IBS feel confused, because they have been given contradictory, misleading, or even incorrect advice from family members, friends, nurses, and physicians.
This book seeks to answer questions, correct misperceptions, and alleviate concerns of people who have IBS and their family members and friends. In short, the goal of this book is to make sense of IBS.
• IBS is one of the most common medical conditions seen in primary care practice today.
• IBS is one of the most common reasons for a person to be referred to a specialist in digestive disorders (a gastroenterologist).
• IBS is found worldwide. It affects men and women of all ages, nationalities, races, and religions.
• IBS is not a new disorder but is now more widely recognized and more commonly diagnosed than it was in the past.
• People who have IBS characteristically suffer from lower abdominal pain or discomfort in association with either constipation or diarrhea (or both).