IBS: Irritable Bowel Syndrome

The truth about the trouble down under.

During her twenties, when Rebecca Spencer was getting ready for a first date, she had more on her mind than selecting an outfit to complement her curly red hair and spitfire personality. She found herself worrying about what type of restaurant her date would take her to and, specifically, what food would be on the menu.

“I was always anxious about going to dinner with someone new,” says Spencer, who at 36 is now married and expecting her second child. “I worried whether I would have access to a bathroom and stressed over what I could order that wouldn’t give me diarrhea.”

Spencer says she has long suffered from what she describes as a “nervous stomach.” In college she developed vicious cycles of diarrhea and constipation in response to certain foods and hormones — a hallmark of a common condition affecting the large intestines, known as irritable bowel syndrome (IBS). It is estimated that IBS affects up to 15 percent of the United States population, making it the most common intestinal disorder for which a patient is referred to a gastroenterologist.

Although it can appear at any age, IBS often begins in the teens or early adulthood and is twice as common in women as men. Some IBS sufferers have constipation, others have diarrhea, and many experience both. Though IBS is considered a lifelong condition and has no cure, it does not tend to worsen over time, cause ongoing inflammation or increase the risk for colorectal cancer. Over time, IBS may improve as patients learn to avoid triggers and control stimulating factors, such as diet and stress.

WHAT CAUSES IBS?

The exact cause of IBS is unknown and may vary from person to person. Sometimes IBS can occur after an
infection, but there can be other external triggers. It’s theorized that the signals between the intestines and the brain become more active during stressful times, causing the intestines to squeeze and contract more. Certain foods, hormonal shifts and some antibiotics may trigger symptoms and pain.

“Many of my IBS symptoms are directly tied to hormones,” says Spencer. “Even when I developed a diet and medication regimen to help reduce the number of painful bouts of IBS I experienced, I still would have an episode the weekend before my menstrual cycle. It was like clockwork.”

Curtis Weaver, MD, a gastroenterology fellow at the University of Rochester/Strong Memorial Hospital in Rochester, New York,
explains that many theories exist about the exact cause of IBS, and studies are continuously being funded to learn more about the condition.

“It is likely that what we consider to be IBS is really a number of different conditions with different causes,” says Dr. Weaver. “As we learn more about the underlying etiologies, we hope to improve the treatments.”

SYMPTOMS

IBS may cause abdominal pain and cramping, excessive gas, mucus in the stool, bloating, constipation and diarrhea. Typically, pain relief is often reported following a bowel movement. Most symptoms can be managed without medication, but it’s important to seek medical treatment when symptoms interfere with daily life.

“In general, most cases of IBS can be diagnosed and treated by the patient’s primary care physician,” says Dr. Weaver. “A patient may be referred to a gastroenterologist if the patient has severe symptoms, symptoms that do not respond to basic treatment or ‘red flag’ symptoms, such as unintentional weight loss, blood in the stool, fever or chills.”

Spencer was referred to a gastroenterologist when she received an IBS diagnosis from her primary care doctor. She was prescribed a medication to help prevent diarrhea, but she could not tolerate the side effects. So, through trial and error, she discovered a regimen of supplements that has proven to be highly effective in preventing constipation and avoiding diarrhea — painful IBS episodes she compares to labor pains.

“It’s violent,” says Spencer. “It’s like my intestines are twisting, and I feel intense sharp, stabbing and cramping pain. I would feel it begin in my right lower abdomen, and relief would only come after the 30- minute episode of diarrhea had ended.” For Spencer and many others like her, painful diarrhea is a dramatic ending to a several-day period of constipation.

For Spencer, episodes of diarrhea would always occur after a meal. Her symptoms are controlled now, but she previously experienced painful diarrhea twice a week, with constipation between bouts. She says the constipation was uncomfortable and led to painful hemorrhoids.

DIAGNOSING IBS

If someone suspects IBS is responsible for ongoing bouts of constipation and/or diarrhea, a visit to the doctor is recommended.

“Someone with IBS-like symptoms that affect or impair their normal activities should see a doctor in order to receive an initial diagnosis and to rule out other causes for the symptoms,” says Dr. Weaver.

There is no definitive test for IBS, which is often diagnosed based on medical history and a physical exam. In some cases, a battery of tests may be performed to rule out other conditions that are directly testable. Doctors may also use what is known as the Rome III criteria to more accurately pinpoint a diagnosis.

“In order to fit the criteria for IBS,” says Dr. Weaver, “a patient must have abdominal pain or discomfort at least three days out of a month for at least three months, associated with at least two of the following: improvement in pain with passage of stool, onset of pain associated with change in frequency of stools, or onset of pain associated with change in form and/or appearance of stool. Depending on the symptoms and the patient’s medical history, the patient’s physician may also check blood work or imaging studies, or refer the patient to a specialist to evaluate and rule out other possible causes of the patient’s symptoms.”

IBS RELIEF

For Spencer, preventing IBS episodes is a matter of taking Colace, a stool softener, along with a fiber
supplement such as Fibercon or Metamucil. The fiber helps to bulk up her stool, making diarrhea less common, and increasing dietary fiber helps prevent constipation. Spencer says she also has learned to eliminate certain foods.

“I avoid heavy dairy, heavy cheeses and greasy, fatty foods,” she says.

For people like Spencer who experience consecutive days of constipation, a new drug received FDA approval in August 2012. It provides relief by encouraging more frequent bowel movements and may ease associated abdominal pain. Linzess, developed by Ironwood Pharmaceuticals and Forest Laboratories, Inc., comes in capsule form and is taken once daily on an empty stomach.

“I think it’s well recognized that these patients are suffering and that there’s a need for more effective therapy,” says Thomas McCourt, chief commercial officer with Ironwood Pharmaceuticals. “I think what we’re seeing
[with Linzess] is a tremendous opportunity to improve both the abdominal pain as well as the constipation.” Other commonly prescribed medications for IBS include antidiarrheal or antispasmodic drugs, as well as some classes of antibiotics.

DIET & LIFESTYLE

Most IBS symptoms can be controlled with diet and lifestyle changes. Certain foods trigger IBS flare-ups, and stress is definitely considered to be an overriding roadblock to wellness. A few lifestyle changes and awareness of triggers can result in significant improvement.

“Keeping a record of foods eaten, with symptoms noted, may allow someone to figure out which foods are more problematic for them,” says Sandra Meyerowitz, MPH, registered dietitian and owner of Nutrition Work in Louisville, Kentucky. “Although this can be time-consuming, it would be a worthwhile exercise to decrease the constipation [and other symptoms] and possibly reveal some trigger foods.”

People with IBS, especially those with constipation, should avoid starchy foods and caffeine, according to Meyerowitz, and choose a diet rich in whole grains, fresh fruits, vegetables, beans, nuts and seeds. She also places an emphasis on increasing fiber and fluids.

In addition to changing her diet and adding the right supplements, Spencer has learned that an active lifestyle is mandatory for reducing stress and for keeping her bowels regular.

“The key is to stay regular so you don’t set yourself up to get constipated, which then causes painful diarrhea,” says Spencer.

“Above all else,” she adds, “don’t be embarrassed to talk to your doctor. Your physician’s input can be an invaluable resource to regaining a full and active life where you make the decisions for the day, not your bowels!”

Dr. Weaver agrees that prevention is key to IBS control.

“Once the diagnosis of IBS is made, prevention is definitely the best treatment,” says Dr. Weaver. “Dietary changes to avoid specific triggers, adding fiber supplements and regular physical activity can all help to prevent acute exacerbations of symptoms. Also, recognizing that symptoms are often related to stress and anxiety allows patients to learn certain relaxation techniques and coping mechanisms to avoid acute episodes.”