Table 13.1. Excerpt from an IBS Diary
When people consult a health care provider about symptoms they are experiencing, the provider tries to find the underlying cause (etiology) of the symptoms. A cardinal rule in medicine is that the most effective treatment for any medical condition treats the underlying cause rather than just the symptoms. If the originating condition (the etiology) is successfully treated, the disease will normally be cured and the symptoms resolve.
Unfortunately, the cause of irritable bowel syndrome remains unknown, so treatment cannot take this ideal approach but instead must focus on improving symptoms. This is a critical concept to understand, since at present we are not able to cure patients of IBS. While research on the causes of IBS continues, health care providers must concentrate their efforts on treating symptoms and improving patients’ quality of life and ability to cope with a chronic medical problem.
How should treatment for IBS be initiated? Some general rules apply to all patients who have irritable bowel syndrome. First, successful management of the disease requires that the treating physician be well educated in the etiology, pathophysiology, and treatment of people who have IBS. Although this seems obvious, many people receive treatment from health care providers who do not actually know a great deal about IBS. It is important that patients find a provider who is intimately familiar with this disorder and has up-to-date information. New medical information becomes available every day, and it is difficult for any physician to remain current in every medical condition. If you are working with a physician who still believes that depression or anxiety is the cause of IBS or that the symptoms you are experiencing are “all in your head,” then you would do well to search for a health care provider whose knowledge and understanding of IBS are more current.
Second, find a health care provider who is interested in treating patients who have IBS. Again, this seems an obvious point to make, but physicians are no different from anybody else. They have likes and dislikes. Some providers enjoy treating patients who have migraine headaches, while others do not. Some enjoy treating patients who have diabetes, while others do not. To maximize the likelihood of obtaining relief of your IBS symptoms, it is important to find a provider who not only has a current working knowledge of this problem but who also enjoys working with individuals who have IBS.
Specifically, find a health care provider who recognizes that, for most patients, IBS is a chronic disorder. Some physicians feel more comfortable treating people who have conditions that are acute and short lived rather than chronic in nature. Because IBS is a chronic disorder, both patient and physician need to accept the fact that they will be working together to manage the disease over the long term. If your provider is used to treating conditions that are short lived, then he or she may try to employ “quick fixes” that may not be helpful to you in the long run. You may want to ask friends, coworkers, and relatives about physicians they know who are experienced at treating this disorder (remember, since more than one in seven adults have IBS, it’s fairly easy to find someone who has similar symptoms).
The treatment of IBS begins with the first interview and physical examination, which will usually establish a relationship of mutual interest and confidence between the patient and the physician. During this time, the physician should take a thorough history, paying special attention to the details of all contributing factors. These factors include diet, exercise, current and past medical history, surgical history, family history of medical problems, allergies and adverse drug reactions, medications, drug and alcohol use, emotional health, professional and interpersonal relationships, and the fears and concerns of the patient. Getting a thorough history is a big step toward determining whether the symptoms are caused by an organic problem or are all due to IBS. In addition, a thorough history is often reassuring to the patient, because it indicates that the doctor is taking the complaints seriously.
After taking an exhaustive history, the physician should perform a thorough physical examination. As discussed in Chapter 7, this part of the initial evaluation clarifies that there is not an organic cause for the symptoms, such as an ulcer, an infection, or a cancer in the colon or rectum. Many patients are reassured if no evidence of an organic disease is found during the physical exam.
If it looks likely that IBS is causing the symptoms, the health care provider should then explain to the patient the mechanisms that produce symptoms of IBS. This is a good time for an exchange of concerns and ideas between patient and physician. Questions can be answered and information verified. Although time in the initial appointment may have run out and a follow-up visit may need to be scheduled, the provider should next explain to the patient what to expect in the upcoming weeks and what to anticipate in the future, describing the natural history of IBS (see Chapter 5). The patient and physician should discuss the patient’s hopes and expectations. The treatment goals of people who have IBS vary dramatically, depending on which symptoms bother them most. For example, some patients want to focus their treatment on constipation, while other patients are most eager for relief of bloating. This discussion should also include expectations about diagnostic testing, the benefits and side effects of medications, the possible need for referral to other physicians, and the timing of follow-up visits and phone calls.
Treating IBS is not a straightforward matter. Many patients and physicians mistakenly believe that there is a single therapy usable by all patients who have IBS. There are several reasons why no single treatment plan or medication can be used. First, there are three well-recognized subtypes of IBS (diarrhea predominant, constipation predominant, and IBS with mixed symptoms of alternating diarrhea and constipation). Each of these subtypes needs to be treated differently. Also, individual symptoms within each type vary widely. In a large group of people who have IBS and diarrhea, the frequency of diarrhea will vary significantly. Therefore, some patients may require only changes in diet, while others may require a combination of changes in diet and the use of several medications. The tremendous differences in patients’ goals for therapy are another reason a single treatment can’t apply to everyone. Finally, people differ in their response to specific therapies. While one patient may respond very well to a particular medication, another with virtually identical symptoms may not respond at all. Thus, the patient and physician must work together to find the best treatment for that individual’s symptoms.
That being said, as with the treatment for other common diseases, the physician should still adhere to several common principles of treatment: patient education, providing guidelines on diet and exercise, and instituting medical (medicine) therapy, if appropriate. Along the way, the doctor should try to work with the patient to identify specific goals, so that an individualized treatment plan can be developed for that patient. Unlike some other medical problems, surgery is never a treatment for IBS symptoms. Finally, any treatment plan should include routine follow-up appointments. These scheduled follow-up appointments are critical in the treatment of IBS, because they allow both the patient and the physician time to carefully review the response to the current therapy, make changes in the treatment program if necessary, and identify further goals and endpoints. In addition, because advances continue to be made in the field of IBS treatment, routine follow-up appointments allow your health care provider to keep you up to date on research efforts involving diet, behavioral therapy, medications, and complementary and alternative therapies.
Probably, before you get around to consulting a health care provider about your symptoms, you will have received treatment suggestions from friends, family, coworkers, or even your pharmacist. You may also have read about treatment of IBS on the Internet or in magazines and books. Some of this information may be dated or incorrect, or it may not apply to you. Bring this information with you to your first appointment, along with a list of questions and concerns, so you can make your visit efficient and worthwhile (for more on this topic, see Chapter 23). Another approach that is useful to many people is keeping a diary of symptoms and daily routines to share with their physician. Diary entries can sometimes pinpoint precipitating (causal) or worsening factors (see Table 13.1 for a sample diary entry).
A characteristic of IBS is that the symptoms tend to occur in patterns. Some people have extremely good powers of recall and can accurately report their symptom patterns and bowel patterns to their physician. Other people have more difficulty recalling activities, meals, and symptoms, especially if they occurred more than a few days ago. Even people with the best of memories, however, can benefit from keeping a record of symptoms, ideally on a daily basis, during the course of a month. Although a month seems like a long time to write down all of this information, a shorter diary may not be as helpful or as accurate, because symptoms of IBS typically wax and wane over the course of about a month. Patients should record abdominal pain (location, intensity, and length of each painful episode), constipation, bloating, and/or diarrhea. Pain can be rated on a 0-to-10-point scale, with 0 being the absence of pain and 10 being the worst pain ever experienced. The number of bowel movements per day should be noted, along with their consistency. All of this information is important, and reporting it all to your doctor would be impossible without a written record. Many of us can’t remember what we had for dinner two nights before a doctor’s appointment, so it’s unrealistic to try to recall the amount of bloating or the number of bowel movements from a month ago. Along with symptoms, individuals should also record significant occurrences of the day, such as stressful events at home, school, or work (meetings, presentations, financial discussions). Other information to record would be exercise, travel, diet, and responses to medication.
The information recorded in an IBS diary, in addition to being very useful to the treating physician, can help a patient uncover clues about what might be triggering symptoms. Clare’s experience, and a week from her diary, illustrate how this works.
Clare is a 28-year-old woman who has had symptoms of irritable bowel syndrome for nearly 5 years. Her symptoms are mostly frequent, watery bowel movements with significant feelings of urgency before them. She has intermittent lower abdominal discomfort on most days. The discomfort increases to pain before an episode of diarrhea and generally eases afterwards. On some occasions, the sense of urgency has come on so suddenly that she has had to leave a meeting or social event and rush to the bathroom. She has been concerned that she might even have an accident. She had tried over-the-counter medications, including fiber products and Pepto-Bismol, without relief. She has used Imodium intermittently, and this seems to help to some degree. One of her friends told her that she probably had a wheat allergy, so she stopped using all wheat products for several weeks, but this did not seem to improve her symptoms.
Clare went to see Dr. Englar, her new primary care physician, who recorded a thorough history and performed a physical examination. Because Clare’s symptoms had generally been stable for so long, she had not lost weight, and no one in her immediate family had a history of colorectal cancer, inflammatory bowel disease, or celiac disease, Dr. Englar told Clare that she probably had IBS with diarrhea. She suggested that they continue the evaluation by having some simple lab tests (CBC, TSH, and ESR) done on a sample of Clare’s blood. Stool cultures seemed unnecessary; it was unlikely that this was a viral, bacterial, or parasitic infection, since the symptoms had lasted for five years and Clare used only city water or bottled water, did not camp, and had not traveled outside of the country recently. They discussed starting a medication for IBS with diarrhea, but Clare wanted to avoid medications, if possible.
Clare raised the issue of whether stress could be playing a role in the symptoms and also asked about the effect of diet. Dr. Englar suggested that a good way to identify whether stress or diet was playing a role in Clare’s symptoms would be to keep a daily diary for a month and then return for a follow-up visit to review the behavior of Clare’s symptoms. Clare agreed that this was a reasonable approach. A sample of Clare’s diary is shown as Table 13.1.
When Clare returned for her follow-up appointment, she and Dr. Englar carefully reviewed the diary. Two points came to light almost immediately. It seemed that Clare consistently had more frequent or looser bowel movements after consuming dairy products. Also, the amount of milk product she took in seemed to make a difference. If she ate just a small amount (like one slice of pizza), then she did fine. However, if she ate large amounts or multiple dairy products (pizza and ice cream), diarrhea always followed. Dr. Englar felt that this was pretty good evidence that Clare also had some degree of lactose intolerance (discussed in Chapter 10).
The diary also revealed that Clare’s symptoms were always worse on Mondays and on days when things were especially hectic at work. It was also interesting that Clare’s symptoms were consistently better on weekends. Dr. Englar asked Clare how her symptoms were when she was on vacation, and Clare realized that her symptoms were always the least troublesome during vacations. Clare admitted that she found her job stressful, and she could see from the diary that her symptoms always got worse during times of stress.
Clare and Dr. Englar discussed these two findings and formulated a plan that focused on dietary changes and stress management. Clare agreed to keep a diary for another two months while following the plan and then to review the diary together and see if these strategies improved her symptoms.
This case story highlights the value of keeping a diary. It allowed Clare to readily pinpoint two contributing factors to her IBS symptoms—stress and excess lactose intake. Not every individual will so easily identify precipitating factors or events, and many people find keeping a daily diary to be a nuisance or outright burdensome. However, this safe, easy, and cheap method produces positive results for many people.
• The focus of treating patients who have IBS is to improve symptoms and quality of life. Caring for the patient is the preeminent goal, since we can’t cure the disorder at present.
• Find a health care provider who is both interested in treating patients who have IBS and knowledgeable about the disorder.
• All people who have IBS are unique. Thus, different treatment strategies need to be employed for different patients. There is no single pathway that can be used to treat all individuals who have IBS.
• Use a symptom diary to track symptoms to try and identify factors or events that might precipitate or worsen symptoms.