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Irritable Bowel Syndrome

In November, our guest expert in Le Club's Ask the Expert segment was Jeffrey Roberts, MSEd, BSc, President and Founder of the Irritable Bowel Syndrome Association.

The IBS Association is a patient advocate organization dedicated to helping educate those who are living with IBS by providing accurate treatment information and increasing awareness about IBS.

Jeffrey has testified to the United States Food and Drug Administration (FDA) several times on behalf of IBS patients and has appeared on the Discovery Channel, in Canadian Living Magazine, Today's Dietitian, and has been cited by the Washington Post, USA Today, Reuters, Associated Press, New York Times, Globe and Mail, and CBC Online.

Jeffrey coordinates the activities of the IBS Self Help and Support Group website, a 20,000 member IBS community, as well as a monthly IBS Support Group meeting at the Mount Sinai Hospital in Toronto.

He is in the process of co-authoring a book related to the IBS Self Help and Support Group.

Here are Jeffrey’s answers to your questions about Irritable Bowel Syndrome (IBS).

 

Q: Can IBS be caused by hypoglycemia?


A: Despite the advancement in the many theories as to the cause of IBS, research does not indicate that it is caused by or associated with hypoglycemia.  Current research suggests, that although there is no direct connection to diet, modifications in one's diet for mild or moderate IBS may benefit from the elimination of some trouble foods. These troubled foods could perhaps also be associated with hypoglycemia, but there is no direct connection with IBS.

 

 


Q: Why do I sometimes have issues with constipation for weeks, then am suddenly struck with explosive, runny bowel movements? How can I prevent this?

A: It is not altogether unusual for an individual with constipation predominant IBS to have this pattern. The Rome II Criteria (a margin that physicians use to diagnose IBS) indicates a pattern of fewer than three hard or lumpy bowel movements a week and the possibility of one of loose, watery stools or more than three bowel movements per day. This cyclical pattern is classic IBS. Additionally, for women, it is not usual for diarrhea to proceed around menstruation.

New prescription medication,which modulates the passage of stool in the gut, is now available for sufferers of this pattern.

 



Q:  Are there any surgeries being done in Ontario to correct IBS?  If so, what?


A: IBS is classified as a Functional Bowel Disorder, which is characterized by abdominal pain and changes in bowel habits which are not associated with any abnormalities seen on clinical testing.  Since no abnormality is present no surgical procedure is warranted.

 



Q:
 Are there any medications that make a difference?


A. Medication therapy is best used in IBS patients with moderate to severe symptoms which do not respond to education and dietary modifications. However, there is no medication which provides effective treatment of the multiple symptoms of IBS sufferers.  Therefore, first line treatment has traditionally been aimed at treating the most bothersome symptoms. That being said, a new physician-prescribed therapy for constipation predominant IBS, Zelnorm (tegaserod), has recently been introduced. It has been shown to effectively treat the multiple symptoms of IBS-C (constipation predominant).  Clinical studies with tegaserod indicate it improves symptoms and function in patients over a 12-week treatment course.

Available only in the US, Lotronex (alosetron) has the opposite effect of Zelnorm. It is for IBS-D (diarrhea predominant) sufferers and it regulates the motility in the gut thereby slowing down the movement of stool along with reducing diarrhea and abdominal pain.

Additionally, the anticholinergic (pain relief) and diarrhea or constipation side effects of antidepressants have effectively treated many IBS sufferers. A complete medication listing for IBS is located at ww.ibsgroup.org/main/medications.shtml.

 



Q: I was recently UNDIAGNOSED after 20 yrs with IBS & would like to know why. I had a scope, due to having some new symptoms. I am back and forth to the bathroom with diarrhea up to 10 times some days before I even eat.

Other times I am constipated for days on end with no relief. When the internist did my scope he said I had an unremarkable bowel but he diagnosed me with ulcerative rectal proctitis. I have researched this and there are THREE ways to have this condition. 1. Crohn's 2. Colitis 3. STD (I KNOW I do not have that!!)

 He did no biopsy to rule out any of the three, and I have found out that he should have. But to undiagnose me with IBS when I have suffered for 20 years seems strange. I also have severe chronic fibromyalgia and some chemical sensitivity. Please help!

A: There are no physical findings or diagnostic tests that confirm the diagnosis of IBS. Therefore, diagnosis involves identifying certain symptoms consistent with the disorder and excluding other medical conditions that may have similar symptoms.  Sometimes this can take years.  There are also individuals who have a combination of IBS along with Crohn's disease, ulcerative colitis, fibromyalgia or others.  I am not aware of any research studies which indicate that having IBS undiagnosed leads to worse or prolonged IBS.

 


Q: I have IBS and I seem to be getting more and more constipated.  Sometimes I can go for up to three days without a bowel movement — is this normal?  I know what foods will irritate my symptoms, but sometimes even eating fibre or taking laxatives doesn't help.  Can IBS symptoms lead to other serious intestinal problems?


A: There is no definition for 'normal' when it comes to the number of bowel movements an individual should have per day or per week.  In terms of IBS, the consistency of the stool and the presence of abdominal pain are the most notable features that a physician will look for when making the diagnosis of IBS.  With constipation predominant IBS, hard lumpy stools with straining, a feeling of incomplete passage and a bloated feeling are common.  A diagnosis of IBS, though greatly impacting on one’s quality of life, does not lead to more serious intestinal problems or a predisposition for any types of digestive malignancies.

Some individuals find that adding additional fibre or taking laxatives can relieve their constipation predominant IBS. For moderate to severe IBS, these measures may not be enough and actually too much fibre could contribute to an increase in discomfort due to impaction and severe constipation.

 


Q:  My father has recently been diagnosed with IBS and also has Ankylosing Spondylitis. I have Ankylosing Spondylitis and have recently been having lower GI troubles. My symptoms included times where I'm constipated and bloated, followed by cramping and loose stools. I have noticed a trend that I get GI flare ups at the same times as I get inflammation flare ups with my Ankylosing Spondylitis.  Is there a connection between IBS and Ankylosing Spondylitis?


A: Ankylosing Spondylitis is usually a complication of Inflammatory Bowel Disease (IBD), one of Crohn’s disease or ulcerative Colitis.  IBD is characterized by visible inflammation of the digestive system and is a different illness than IBS; however, it is possible to have the co-morbidity of IBS along with IBD even when there is no active disease.  There is no research which shows any relationship between IBS and Ankylosing Spondylitis.  That being said, in order to confirm that you are not suffering from IBD versus IBS, a clinical work-up is required.

 



Q: I am a 59-year-old female with IBS. I have a long colon according to my doctor. Is there a link between IBS and having a long colon?  Also is there any medication to relieve the cramps and spasms? Thank you.


A: Having a long colon is not a characteristic in the diagnostic criteria for IBS.

The diagnosis of Irritable Bowel Syndrome has relied, in the past, on a diagnosis of exclusion. Because the symptoms of IBS share the symptoms of so many other intestinal illnesses, it sometimes takes years before a correct diagnosis is made to exclude the obvious, and not so obvious, conditions which present symptoms similar to IBS.

Physicians rely on a variety of procedures and laboratory tests to confirm a diagnosis. The Rome II Criteria, however, is now used to define markers. This allows professionals to diagnose IBS after a careful examination of a sufferer's medical history and physical abdominal examination, which looks for any 'red flag' symptoms.

Red Flag symptoms which are NOT typical of IBS:

  • Pain that awakens/interferes with sleep
  • Diarrhea that awakens/interferes with sleep
  • Blood in your stool (visible or occult)
  • Weight loss
  • Fever
  • Abnormal physical examination

The Rome II Criteria states:

The diagnostic criteria of Irritable Bowel Syndrome always presumes the absence of a structural or biochemical explanation for the symptoms and is made only by your health care professional. Irritable Bowel Syndrome can be diagnosed based on at least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has two out of three features:

  1. Relieved with defecation; and/or
  2. Onset associated with a change in frequency of stool; and/or
  3. Onset associated with a change in form (appearance) of stool.

Relief from the symptoms of cramps and spasms can sometimes be found by dietary modification, for mild symptoms.  Common foods which may contribute to causing the symptoms are caffeine, alcohol, fat and fructose and other sweeteners.  There is some anecdotal evidence that antispasmodics or antidepressants bring some relief to many sufferers with severe symptoms, because they provide pain relief and/or diarrhea or constipation side effects.

 


Q:  In my situation, diet is a big factor.  I was diagnosed with Crohn's disease which is a little more severe than IBS, however from the same family.  Could you make some suggestion as to a proper diet to follow?  I also have high cholesterol and am taking lipitor to keep that under control. Is there a specific diet to follow for these problems?


A: Although Crohn's Disease, a form of IBD, is different than IBS, it is not unusual for IBD and IBS to share dietary concerns.  However, there is no evidence that digestion of food is different in those with IBS compared to those without IBS. Although the exact cause of IBS is not known, there are factors that appear to aggravate symptoms or make a person feel worse.

While dietary factors do not cause IBS, they may aggravate symptoms in some persons. Increased intestinal muscle reactivity and/or heightened sensitivity in IBS can cause the bowel to over-respond to stimuli. Even a normal event such as the act of eating itself (and not a particular food) may aggravate symptoms at times.

Common foods which may contribute to causing the symptoms are caffeine, alcohol, fat and fructose (and other sugary sweeteners).  Some foods are gas producing (e.g., beans, cabbage, legumes, cauliflower, broccoli, lentils, Brussels sprouts) and eating too much of these may cause increased gas, which can be associated with symptoms of bloating.  In general the low-fat diet for cholesterol should be okay for Crohn’s  Disease or IBS since high fat meals can increase the gastro-colic reflex that can bother some people.

 


Q:  Does IBS ever resolve on its own, or is it a lifelong condition?  What lifestyle changes are most effective in treating/managing the condition?

A: IBS is an illness that waxes and wanes overtime.  Its unpredictable nature is very troublesome for sufferers and has an impact on their quality of life.  Some do find that IBS symptoms appear to resolve on their own with modification of lifestyle and diet.

Stress contributes to the anxiety associated with the unpredictable nature of IBS.  Cognitive behavioural therapy and hypnosis have shown, through clinical studies, to be effective for helping to modify lifestyle and outlook on coping with IBS.  Many clinical therapists, psychologists and hypnotherapists are aware of how effective this can be.

 



Q: Hello Mr. Roberts. I am in need of assistance as I have been suffering for years with acute constipation with mild intermittent diarrhea. This is excruciatingly painful, uncomfortable and embarrassing. Presently, I take 1 tsp Metamucil daily and once in a while Zelnorm, and also need to use enemas, which provide instant relief.  My family doctor says I have a lazy bowel. Firstly, does the use of enemas have any long term effect and secondly, what can I do to ease the daily discomfort?  I am a very healthy, fit female with no pertinent medical problems. I lead a very healthy lifestyle and have a healthy diet. Any comments or suggestions you can provide are greatly appreciated.

A: Constipation is one of the most frequent GI tract complaints in Western countries. There are millions visits to the physician for constipation annually in North America, with hundreds of millions of dollars spent on laxatives and other treatments.

Many find the use of enemas helpful for intermittent relief of the symptoms of constipation yet many worry that they will become dependent on them or that over the long run they will harm themselves or require them more often.  A recent global study, prepared by a manufacture of enemas reported: "Constipation sufferers should be reassured that they will not become dependent on laxatives. Clinical studies and extensive experience show that laxatives, such as bisacodyl and sodium picosulphate, are not addictive and can be trusted as safe and effective treatments."

A review by the American Journal of Gastroenterology found that: "At recommended doses, stimulant laxatives are unlikely to be harmful to the colon. Although some patients with chronic constipation depend on laxatives for satisfactory bowel function, this is not the result of prior laxative intake. Tolerance to stimulant laxatives is uncommon; there is no evidence of "rebound constipation" after stopping laxative intake, and there is no potential for addiction even though laxatives may be misused."

Relying on laxatives for satisfactory relief of constipation is likely not a long term solution.  Diet and exercise seem to play a positive role in relieving symptoms of constipation.  Zelnorm, a physician prescribed medication, has shown to have an excellent safety profile.  Long term studies regarding its use for longer than the initial 12-week course have been positive for constipation predominant IBS sufferers.  Zelnorm also is now prescribed for chronic constipation sufferers.  A discussion with your physician, about its continuous use, may provide more reliable relief from this product.

 



Q:  What are some drug-free options for relieving IBS attacks and are there any over the counter items that should be included in my diet as an IBS sufferer?

A: Several drug-free options are available for IBS sufferers.  Both cognitive behavioural therapy with or without medication have clinically shown to benefit sufferers.  Hypnotherapy, by someone trained in a specific IBS protocol, has also been clinically beneficial.  Peppermint oil capsules act as a smooth muscle relaxant for the bowel and may provide relief from abdominal pain and feeling bloated.

Recent studies about the use of probiotics, in particular, Bifidobacterium infantis and Lactobacillus acidophilus, have shown that they may provide multiple symptom relief of IBS.  With probiotics it is important to only rely on specific clinically studied concentrated formulas.  Seek vendors using evidence based studies.

 



Q: I have a few questions:  Is there research about the link between emotions and IBS/colitis?  What are your suggestions about diet and ulcerative colitis?  Different things I read say different things and it is confusing.  Thanks!!

A: Stress is a factor in our lives and it contributes to the anxiety associated with the unpredictable nature of IBS.  However, there are no research studies that indicate stress causes IBS; however it is understood that IBS causes stress as a result of the reduced quality of life of a sufferer.

It is not entirely clear how stress, anxiety, and IBS are related or which one comes first but studies show they tend to co-exist. The most common mental condition suffered by people with IBS is generalized anxiety disorder.  Although psychological problems such as anxiety do not cause IBS, people with IBS may be more sensitive to emotional troubles. Stress and anxiety may make the mind more aware of spasms in the colon.  Stress management is an important tool for an IBS sufferer.  Some people use relaxation techniques such as deep breathing or visualization, where they imagine a peaceful scene. Others reduce stress by doing something enjoyable.

There is a lot of conflicting information about diet and IBS because people often respond in different ways to diet.   Much of the time diet recommendations are based on anecdotal evidence rather than systematic review which can lead to very conflicting advice. Additionally some safe food lists are made based on nutritional theories rather than data, and the theories may or may not be valid.

 



Q:  What is and what causes IBS? I believe that my 25-year-old daughter is suffering from IBS. If she is lucky she may have a bowel movement once a week. I believe she eats correctly (lots of fruit and veggies). However, she does eat a lot of cheese and pasta with cheese which I have told her to cut back on. She bought a bowel cleanser from the health food store.  Is this healthy? What can she do or take to help alleviate this problem with constipation? Her family doctor doesn't seem to concerned, should she be? Any info on this would be greatly appreciated.

A: Researchers continue to investigate the cause of IBS; however, the cause remains unknown. Recent studies have concentrated on the motility of the gut. Current medications to help relieve symptoms have been focused on these areas.  Zelnorm for IBS-C, helps to regulate the motility of the gut by adding more serotonin to the gut.  This seems to increase the rate that the gut moves stool along thereby reducing constipation and abdominal pain.

Evidence about the effectiveness of non-medication treatments for constipation are anecdotal.  These treatments include modifications of diet, an increase in fibre and liquids, exercise and the occasional laxative.

Bowel cleansers are not usually a remedy prescribed to relieve the symptoms of IBS.  Since the mechanism of IBS seems to be related to a regulation of the gut, temporarily removing the stool may provide some immediate symptomatic relief.  However, in the long run, symptoms will likely reappear when new stool is present.

If you suspect your daughter has a problem with constipation, speak with your doctor about further evaluation initially using a non-invasive test such as a SitzMark test.  This test is a bowel transit study that objectively measures the severity of the constipation, and it helps to establish the primary cause of the constipation. In the SitzMark test, radio-opaque markers are swallowed and the doctor observes where the markers are after 3-5 days.

The presence of more than 25 percent of the markers in the colon at day 5 is indicative of a positive test. Markers evenly spread throughout the colon are consistent with slow transit constipation.  A negative SitzMark test with fewer than 25 percent of the markers on day 5 is suggestive of normal transit constipation or a patient who is not compliant with the instructions regarding no laxative use during the testing.

 



Q: I have been reading that probiotics can help with irritable bowel syndrome. Apparently there is a probiotic called "Align", which is only available in the US at the moment. Studies have shown that it does reduce the gas and bloating associated with IBS. Do you know if it might be available in Canada soon, or are there other probiotics that might be of help?

A: I have partly answered your question about probiotics in one of the questions above. To summarize, recent studies about the use of probiotics, in particular Bifidobacterium infantis and Lactobacillus acidophilus, have shown that they may provide multiple symptom relief of IBS.  With probiotics it is important to only rely on specific clinically studied concentrated formulas.  Seek vendors using evidence based studies.

Align, which is manufactured by Proctor and Gamble, is only available at this time via the internet in the US. Several clinical studies specifically studying the active probiotic in Align, namely Bifidobacterium infantis, have shown very promising results at relieving multiple IBS symptoms.  Another probiotic, VSL #3, available in the US and Canada, is a highly potent concentrated cocktail of beneficial bacteria.  In the last year a clinically controlled study with VSL#3 and IBS has shown positive outcome for IBS sufferers. 

 



Q: I eat a fairly healthy diet, and my bowel movements are very regular, occurring daily.  However, most mornings I experience the following problem.  About 15 - 30 minutes after awaking and moving around, I have an almost uncontrollable urge to go to the bathroom.  The result can vary from a regular bowel movement to almost diarrhea.  At times, this episode may recur within an hour.  However, it does not occur at any other time of the day.  Is this a symptom of IBS?

A: When colon activity is measured in normal people, it is found that the most active time of the day for the colon is right around the time you wake up.  There are additional increases in activity after meals, which may also be a problematic time for some people.

Patients prone to diarrhea predominant IBS find that the first stool in the morning is usually normal in consistency. However, a great deal find subsequent urgent bowel movements which become more watery and mucoid, and are associated with intestinal cramps, rectal urgency and bloating. Symptoms are relieved with the passage of stool but often quickly return.

Some patients get up early each day or do not leave their home in the morning until the diarrhea comes under control. It is thought that the urgency each morning is from the amplified hypersensitivity of the waking bowel.  IBS sufferers have much more sensitivity to the normal muscle contractions in the bowel and this has a greater tendency to force an emptying of the bowel.

IBS patients are evaluted by the Rome II criteria as long as no Red Flag symptoms are noted (see one of the earlier questions for Rome II and Red Flag symptoms); however, symptoms such as urgent diarrhea should be followed up by a physician to rule out other illnesses with similar symptoms.

 

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