THE ENIGMA OF IBS-IRRITABLE BOWEL SYNDROME.
Irritable bowel syndrome (IBS) is the most important misunderstood gastrointestinal disease because it is extremely common and its symptoms are exceptionally varied.
The presence of so many different manifestations in every patient suggest that we may be dealing with more than one disease that we, doctors, “throw in a basket” and for convenience call it “Irritable Bowel Syndrome” or “IBS”.
Not knowing what to call something is always difficult. Sometimes medical doctors may be pressured by insurance companies to “code” symptoms with a number, and this issue does not help. Other times patients feel pressure by their family members, mother, sister, and ever friends, neighbors, etcetera, who ask them “What did the doctor said you have?” “Does the doctor give you a final diagnosis?”. These questions make matters worse because the patient suppose to “know” or “have” a “real diagnosis”, so the people around them can look it up in the internet! Please, do not get me wrong, I truly want my patients to know what is exactly going on with them; however, there are times I cannot find the exact “label” to their ailments when all the X-rays, CT scans, MRIs, endoscopies, colonoscopies, etc. come back “normal”.
Since I started my practice, I have resisted labeling every patient with these symptoms as simply IBS; I prefer to use the words chronic constipation and lower abdominal pain, or chronic diarrhea and abdominal pain, or intermittent cramping with loose stools, bloating and nausea, painful abdominal distention, etcetera.
It is worth mentioning that loose stools and diarrhea are not synonymous; in order to have diarrhea, in addition to loose stools patients have to excrete a minimum amount of stool. The normal weight of total daily stool is approximately 200 grams in Western societies, and can be even 300 grams when high fiber diet is ingested. Also, in general, three or more bowel movements are considered abnormal. Patients who have a weak anorectal sphincter (anorectal incontinence) and may not be able to hold their stool and this is not diarrhea –although they are not immune to having diarrhea, anorectal incontinence should not be confused with chronic diarrhea.
IBS patients can become an easy prey of multiple remedies sold as “natural”, such as “colon cleansers”, products containing laxatives of the anthraquinone family such as Aloe, Senna, Cascara Sagrada, Chinese teas, etcetera; which can be toxic to the colon and cause severe chronic constipation. Early in its use the will cause more stools in patients with chronic constipation, but in the long run they will quit working leaving the patient with a “soggy” colon with weak muscle wall that will retain more gas and cause more abdominal distention –sometimes a feeling patients refer as “I am so distended that I feel pregnant”. Other patients are victims of other deceiving practices such as regular enema treatments (glamorously called “colonics”) that are offered with the promise that “at least the patient will have a colon free of toxins”, one of the saddest scams I have ever seen.
The solution is a very individualized plan for each patient that includes a diet designed for each patient, exercise, a meditation program, counseling by reputable people -not the vitamin store or the supermarket “nutrition specialist” that are no more that trained salespeople who make a living by following instructions from their employers, nonmedical individuals who have very little knowledge about evidence based medicine. These people are not bad intentioned human beings, they are merely trying to make a living; they may mean “good”, but meaning good is not enough when dealing with patients that really need evidence-based medical care. Very frequently I see these people recommending the chronic use of “natural” laxatives that are a “dead-end” in the management of IBS.
Counseling is directed to underlying issues. Most patients are normal in every way except for their belly problems. Some patients overdo certain things such as worrying, catastrophizing, while others may have of distorted self-image, compulsive behavior such as overeating, , etcetera. Many patients have anxiety/depression, substance abuse and other issues that will benefit from medications such antidepressants and/or psychiatric care.
IBS patients are NOT crazy, their pains and symptoms are real; but sometimes they can be so overwhelming that patients need to acquire coping skills that will allow them to face and “walk long” with their discomfort while they get better. Although there is a solution, here is no quick cure for IBS, it seems that a great number of my patients eventually “outgrow” it, or learn to cope with it.
We live in a society that demands instant gratification, and IBS does not respond to this approach, it is a chronic problem that demands a long-term solution. IBS demands patience, self-consideration, self-kindness, and self-forgiveness. Consequently, these patients need to be seen by capable physicians who understand the complexity of the disease.
