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In matters of abdominal symptoms, the most prevalent symptom is abdominal pain. Of course, acute symptoms can represent any number of disorders, including appendicitis, stomach ulcer, gallbladder disease, peptic ulcer, hepatitis and the list goes on and on. Consider the pain that keeps coming and going over several months–If it is associated with a change in bowel habits over the same period of time, it could well be Irritable Bowel Syndrome (IBS).
First of all, it is a real disorder. Although it doesn’t have biochemical or structural abnormalities like many of the acute disorders, it is every bit as real. It is one of the most common reasons why patients seek medical care, occurring in about 1 in 10 patients. Twice as many women as men are usually affected. It causes many billions of dollars in terms of medical treatments, absenteeism, and loss of productivity at work.
Let’s say you go to the doctor because your abdomen has been bothering you for over three months now. When you think back on it, you’ve had similar symptoms since you were 19 or 20. Now you are in your third or fourth decade, and it seems to be worse. You have these uncomfortable cramps which are relieved somewhat by defecation. Your bowels are irregular. There may be intermittent constipation or there may be diarrhea, or both. You haven’t lost weight, had fevers, or noticed blood in your stool. These symptoms are what doctors call alarm symptoms. Still, you have a lot of worry. Somewhere in the back of your mind you think, “Is it cancer?”
The first thing the doctor needs to do is to listen very carefully to how you describe what’s been going on. He will probably interject questions to look for any directing symptoms. This will be especially true if you are over 50, when certain diagnostic tests such as colonoscopy might be indicated. As you talk about the discomfort and the irregular bowel movements, a clear picture starts to form in the physician’s mind. He can say with relative certainty that you may have this problem. Now the big problem is to convince you that he knows what he is talking about. He suggests that you allow him to prescribe specific therapy to see if relief might be obtained. At this point, no, you don’t need a CT scan, colonoscopy, MRI, or ultrasound. You need treatment. Other tests can be done later if you’re not getting better. No, you are not a hypochondriac. You have what is known as a Functional Bowel Disorder.
What are the treatments? Well, absorbable fiber-like psyllium has been found to be of great benefit; non-absorbable fiber-like bran can actually make the condition worse. Motility agents like loperamide can cut down on the frequency of stools, but don’t help the pain. It is very interesting that certain anti-depressants like tricyclics or SSRI’s can significantly help in ways not related to their anti-depressant effects. Another finding is that probiotics can help irritable bowel syndrome. In related diarrhea, certain non-absorbable antibiotics have been found to be effective. There are some newer classes of drugs which specifically address IBS. Alosetron can help diarrhea-prone patients, but care has to be taken because it can cause ischemic colitis. Tegaserod can be effective in treating IBS-associated constipation, but care has to be taken because it can have cardiovascular side effects. One of the newest agents is lubiprostone, which acts as a chloride channel activator, causing the bowel to secrete more fluid, and effectively treating IBS constipation symptoms.
Another interesting treatment which has been shown to be highly effective is psychotherapy. This is not to say that “it’s all in your head,” but there are complex mind-body hook-ups which benefit from this. Cognitive behavioral therapy and hypnotherapy have been found to be effective, but relaxation therapy has not.
There have been a lot of clinical trials with over-the-counter medications. One of the effective treatments for cramps and discomfort is enteric-coated peppermint oil capsules. Peppermint has been used all the way back to the early Greeks for abdominal discomfort problems and nausea. Absorbable psyllium fiber is available over the counter and is effective for irregularity. Certain antispasmodics like hyoscine are available and have been found to be effective for cramps.
No, it’s not all in your head. It is a specific diagnosis for which there are specific treatments. In order to get to the bottom of your abdominal problem, you have to talk very candidly with your doctor about your health. Get over your embarrassment of talking about bowel movements: Everybody “poops.” It may not be possible to make your symptoms completely resolve, but life can certainly be a lot more comfortable if all the symptoms are properly addressed.
John Drew Laurusonis M.D.
Doctors Medical Center