Sunday, 19 September 2021

IBS: it's a gut feeling

IBS: it's a gut feeling

THIS typical patient story may sound familiar.

“Doctor, I’m someone who has always had a bit of a ‘funny tummy’, it’s worse when I’m stressed and I tend to have a period of a few days of irregular stool habit and then everything goes back to normal. It seems to run in the family.”

If it does sound familiar then you could have irritable bowel syndrome, or IBS, not to be confused with IBD (inflammatory bowel disease) which is a serious condition.

IBS is a common condition, with up to 15 per cent of the population thought to suffer from it. It is characterised by recurrent abdominal pain and bloating relieved by opening the bowels and also a change in bowel habit.

For some this may mean constipation while for others, the opposite. These changes are noted for a few days each month and for most there are periods of “normality” between these episodes.

It is important to note that these symptoms can sometimes be a sign of something serious. As you get older, the risk of developing IBS decreases and after the age of 50 it is very unlikely to develop. Any persistent change in bowel habit or blood in the stool, not attributable to haemorrhoids, should be discussed with your GP.

So what causes it? There seems to be no one reason and people respond differently to different treatments with varying levels of success.

Factors that have been found to be relevant include diet, psychological influences such as anxiety and stress, changes in the way the gut moves food along the intestines, hypersensitivity of the gut, differences in the natural bacteria found in the gut and sometimes even as an immune response after an infection.

Put more simply, people with IBS have a gut that is hypersensitive. Certain foods and strong emotions can upset it, causing it to either try to squeeze food along faster through the gut or slow it down, causing tummy pain and a change in bowel habit.

To make things more difficult, it is what we doctors call a diagnosis of exclusion. This means that there is no specific test we can carry out to confirm that you have IBS but talking to you and getting a clear history of your symptoms is often enough.

So how can we treat it? Firstly, understand the condition. It can be helpful to realise that your collection of symptoms has a name and how it works. This in itself can help ease anxiety which can help improve symptoms made worse by emotion.

Dietary advice: different foods can upset the gut in different ways. Some sugars encourage water to stay in the gut and move the food along quickly like a laxative. Other foods stimulate the gut to pass food along more quickly, for example, caffeine. Foods which ferment in the gut increase gas, causing abdominal pain, bloating and flatulence.

The British Dietetic Association reviewed 30 dietary studies into foods and supplements used in the treatment of IBS. There was no definitive answer for a cure but instead some low-grade evidence for the use of probiotics and a reduction in fermentable carbohydrates. In those with IBS prone to constipation, a three-month trial of ground linseed was shown to be helpful.

Reducing fermentable carbohydrates has the most evidence for reducing the bloating and flatulence symptoms of IBS but what does it mean?

Anyone who has consulted me about IBS will have heard me use the term FODMAPs. This stands for (wait for it) Fermentable oligosaccharides, disarrcharides, monosaccharides and polyols, a group of poorly digested carbohydrates that change gut motility and cause bloating.

It’s important to note that it’s not every carbohydrate, just some, so there is no need to remove carbohydrate from your diet completely. The last thing anybody needs is to cut out large food groups from their diet and end up with nutritional deficiencies and a deterioration in health.

Start by keeping a food diary to identify your specific triggers and visit for a list of FODMAPS.

The evidence for probiotics gives no clear guidance on specifically what and how much but in general probiotics can help with symptoms such as bloating, abdominal pain and constipation (but have not shown to improve loose stool). I have anecdotal evidence from patients for SymproveTM but whatever you choose, make sure your probiotic has either lactobacillus or bifidobacterium in.

Fibre is a useful treatment in those with predominantly constipation with abdominal pain but should be avoided in those with bloating and fluctuance. In those with loose stool, anti-diarrhoeal tablets maybe helpful in the short term.

Stress management is important. In particular, look for triggers of stress and try to put positive coping strategies in place to deal with these before they affect your bowel.

Antispasmodic medication helps to reduce the squeezing activity of your gut, alleviating cramps and slowing the rate of travel through the gut. Buscopan and Colofac can be bought over the counter. Colpermin (peppermint oil) works differently to these two but can also reduce pain.

There are limited studies on the effect of exercise but a 2011 trial of 100 patients who tried to have 20 to 60 minutes of physical activity three to five times a week showed substantial improvement in symptoms and less worsening of symptoms over time. Exercise decreases pain, encourages a healthy regular bowel habit, reduces stress and improves gas transit through the bowel.

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