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IBS: treating the patient rather than the disease

Nick Read
MA MD FRCP
Physician and Psychotherapist
Claremont Hospital
Sheffield
Medical Adviser to the Gut Trust

Irritable bowel syndrome (IBS) was invented by doctors in the 1970s to provide a definitive diagnosis for bowel symptoms that could not be explained by any obvious pathological disease. It is a medically unexplained illness. Further refinement of the diagnosis by a succession of committees meeting in Rome, established positive diagnostic criteria, which, it was claimed, would facilitate research and streamline medical practice by reducing unnecessary investigations. So IBS became a diagnosis by consensus of medical experts, the definition changing with every committee meeting (see Box 1).

[[Box 1 IBS]]

But who is going to bother to remember the mantra of Rome when confronted by a patient in a busy surgery? The best the doctor or practice nurse can do is to make sure that there are no red flag symptoms, such as rectal bleeding, weight loss or fever, that might denote a treatable structural change in the bowel, and prescribe medications to quell the most dominant symptoms.

Patients with IBS frequently present with symptoms that resemble other medically explained illnesses: 60% of people with IBS have criteria for functional dyspepsia; 30% have chronic fatigue; and 20% have irritable bladder. The pattern of symptoms is extremely variable and unpredictable.

Given the extensive overlap, it is not surprising that most medically unexplained illnesses share the same epidemiology. They tend to be more common in women than men, in the young than the old and in those who are anxious or depressed about something going on their lives. Symptoms can in some ways act like a barometer, sensing and reflecting what is happening in the person's life.

Physiology
The key feature of IBS was originally thought to be an exaggeration of contractile activity of the colon. Then researchers discovered that when they distended a balloon in the rectum, patients with IBS were more likely to report discomfort at lower levels of distension.1 Patients with IBS also demonstrate enhanced visceral sensitivity and reactivity in other parts of the gastrointestinal tract. Heightened sensitivity is a feature of other unexplained illnesses.2

Causes of IBS
Many have been suggested, but in recent years, research has focused on food intolerance or allergy, infection, and a mind/gut disorder.

Foods allergy and intolerance
The symptoms of IBS are often triggered by eating a meal, but this is probably explained by the fact that sensitive guts tend to react to whatever is put in them and whatever makes them tense (food and mood). Despite the protestations of some nutritionists, the scientific evidence for food allergy is unconvincing. People with IBS have food intolerance - usually the combination of physiological sensitivity of the bowel and worries about the effects of certain foods. People with IBS can be very suggestible. Popular articles on food allergies may make them nervous of certain foods and the fear can then exacerbate their symptoms. Case histories suggest that specific food intolerances arise because the bowel becomes conditioned to react adversely to the contents of a particular meal, during which they may have received devastating news or had a blazing row.

Postgastroenteritis IBS
A small proportion of people develop IBS for the first time after a bout of gastroenteritis. There is no evidence of lingering infection, but they do tend to have a mild inflammation of intestine. Postinfectious IBS is much more likely if the person is anxious, depressed and has experienced difficult life situations at the time of the original illness. It is as if the symptoms and signs of the original illness have been recruited to express the unresolved situation.3

A change in colonic flora
The colon is packed full of anaerobic bacteria that salvage unabsorbed carbohydrate and protein by fermentation. An attack of food poisoning, the administration of broad spectrum antibiotics, colonic irrigation and even stress can reduce healthy bacterial populations and encourage the overgrowth of more pathogenic species. The suggestion that this may cause symptoms of IBS is unproven, but restoration of beneficial populations of colonic bacteria with probiotics or live yoghurts has become a popular (though unproven) means of preventing and treating IBS.

A mind-gut disorder
There is strong association between emotional upset and IBS.4,5 Not only are patients with moderate to severe IBS abnormally anxious and depressed but they have also experienced more traumatic life events and difficult life situations. IBS is frequently instigated by a traumatic life event or something that reminds the patient of a previous trauma. Physiological studies have demonstrated how emotional tension can sensitise the gut.

When something happens to us, surges in the autonomic nervous system cause us to feel it in our bodies, as a tension in the muscles, a quickening of the heart, a queasiness in the stomach like hunger, or a cramping in our bowels like we want to go to the toilet. We deal with these feelings by contextualising them and experiencing them as emotions. Then if we resolve the emotion, the feelings go away.

But if we cannot acknowledge what has happened to us or we cannot resolve it, then the feelings stay in the body producing chronic symptoms. Often but not always, individuals will consult a doctor and receive a diagnosis of IBS where they achieve a life of their own as a medical disease which has to be treated by the doctor. Working as a psychotherapiest with IBS patients, I recognise that the symptoms frequently seem to convey the meaning of what has happened.6 So the grief that cannot be expressed might find visceral expression as difficulty in swallowing or constipation, the fear or anger that cannot be contained may come out as diarrhoea, the shame as incontinence. These symptoms may slowly fade away as life moves on, only to recur when a combination of events unlocks the memory and rekindles the symptoms. But if the feeling can be brought to mind, contextualised and the emotion resolved, the symptoms will go away.

Practical management of IBS
The medical model tends to see the patient's illness as a specific disease with a definite pathology, aetiology and treatment. Specific diagnosis is the key to the whole process. IBS and other unexplained illnesses are not like that. They are not so much diseases as disorders, visceral expressions of personal disharmony. In times past all of these would have been subsumed into a single holistic diagnosis such as hysteria, hypochondriasis, melancholy or neurasthaenia. The challenge therefore is not so much to treat the symptoms, although that can help, but to treat the whole person; taking into account their life situation, their diet and lifestyle and the symptoms and anxieties they suffer from.

There is no specific treatment for IBS. The essence of successful management is to work with the patient to find an explanation for their illness that they can identify with and a treatment that makes sense. Drugs may help to relieve some symptoms but can make others worse. For example, while antispasmodic drugs such as mebeverine (Colofac; Solvay) or alverine citrate (Spasmanol; Norgine) may take the edge off abdominal cramps, they might tend to make constipation worse. And while bulk laxatives, such as ispaghula (eg, Fybogel; Britannia) may loosen the bowels, women may suffer more discomfort from bloating and abdominal distension. Loperamide (eg, Imodium; Janssen-Cilag) is an excellent drug for diarrhoea, but it tends to increase abdominal cramping. It is as if their frustrated bowels have to have their way, one way or another. Which brings us back to treating the whole person; body, mind and meaning!

Antidepressants can help to calm the emotional tension, which is wrenching the gut out of kilter, but they too have side-effects. Tricyclic antidepressants, such as amitriptyline tend to be constipating while SSRIs such as paroxetine (eg, Seroxat; GlaxoSmithKline) can make the bowels loose.

Diet can help, especially for people who are convinced that their diet is at fault. Common sense advice on reducing fat intake, adjusting the type and amount of dietary fibre, reducing intake of coffee and avoiding hot spices, is useful. Cutting down on foods that consistently make the symptoms worse would seem sensible, but patients should be cautioned against obsessive restriction because that might risk nutritional deficiency. Diet is not a life sentence. As life and symptoms improve, restrictions can be relaxed.

Complementary therapies are useful, such as hypnotherapy, homoeopathy, therapeutic massage and reflexology. They offer both the time and space to understand the patient and plausible treatment methods that can provide a focus of confidence and healing.

Confidence and healing are crucial. Not everybody is going to identify connections between their illness and particular life events or situations. The link may have been established so early in childhood when emotional competence was emerging out of bodily reaction, that it is inaccessible. And even if they could remember, reliving the memory will just make things worse. Often management is more a matter of advising the patient on ways to calm the emotional tension - using methods that suit them - relaxation tapes, hypnosis, massage, meditation and exercise.  

What can you do as a practice nurse?
As a practice nurse, you can listen to your patients' stories and may be able to help them make connections between their illness and what is happening in their lives, but your input is likely to be more supportive, offering advice on diet and lifestyle as well as the benefits and side-effects of drugs (see Box 2). You should encourage a balanced and enjoyable lifestyle with regular patterns of work, eating, exercise, sleep, going out, time to reflect, frequent holidays, practices that induce relaxation (such as massage and meditation) and the importance of emotional resources (friends, family, pets, activities). All of these and more are included in The Gut Trust's new "Self-management programme". It may be more expedient for you to work with groups of people with IBS using the programme as a resource.

[[Box 2 IBS]]

Self-management programme for IBS
The NHS just does not have the resources to look after the vast number of people with IBS. Self-management holds the key. The Gut Trust has developed a comprehensive self-management programme for patients with IBS and the health workers who look after them. Published both on the web and in hard copy, it can be used for individual study or as a course book for groups. It not only provides information about IBS, but also gives advice on how to manage symptoms and live with IBS. The course consists of 11 modules (see Box 3). The first four modules provide information, the next section gives advice on management and the final section describes what health professionals and complementary therapists can do to help the patient. Information is power and control and permits a more equal dialogue with health professionals. The programme is supported by relevant factsheets, numerous case histories and interactive exercises.

[[Box 3 IBS]]

NICE guidelines
This year the National Institute for Health and Clinical Excellence (NICE) also published evidence-based guidelines for IBS.7 These endorse the importance of self-management, encourage exercise, regular eating patterns, probiotics, fluid intake (at least eight cups of fluid a day), soluble fibre such as ispaghula (Fybogel) rather than the insoluble wheatbran, and the use of hypnotherapy and cognitive behavioural therapy rather than acupuncture and reflexology. They are Good Housekeeping guidelines for doctors and nurses, but are not intended for self-management since they regard IBS as a discrete illness rather than the individual visceral expression of what is happening in a patient's life.

"It is much more important to know what sort of patient has the disease than what kind of disease the patient has" - Dr Caleb Hillier Parry (1755-1822), physician to the spa city of Bath.

References
1. Delvaux M. Role of visceral sensitivity in the pathophysiology of irritable bowel syndrome. Gut 2002;51:67-71.
2. Yunnus MB. Central sensitivity syndromes: a unified concept for fibromyalgia and other similar maladies. J Indian Rheumatol Assoc 2000;8:27-33.
3. Gwee KA, Leong YL, Graham JC, et al. The role of psychological and biological factors in post infective gut dysfunction. Gut 1999;44:400-6.
4. Creed F. Relationship between IBS and psychiatric disorder. In: Camilleri M, Spiller R, editors. Irritable bowel syndrome: diagnosis and treatment. Edinburgh: WB Saunders; 2002.
p. 45-54.
5. Bennett EJ, Kellow JE. Relations between chronic stress and bowel symptoms.  In: Camilleri M, Spiller R, editors. Irritable bowel syndrome: diagnosis and treatment. Edinburgh: WB Saunders; 2002. p. 27-36.
6. Read NW. The meaning of illness and the purpose. In: Read NW, editor. Sick and tired; healing the illnesses doctors cannot cure. London: Phoenix; 2006. p. 118-38.
7. National Institute for Health and Clinical Excellence. Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care. CG61. London: NICE; 2008.

Resources
The Gut Trust
W: www.theguttrust.org

Further reading
Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care.
NICE Clinical Guidelines (CG61) 2008
W: www.nice.org.uk

Sick and Tired; Healing the Illnesses Doctors Cannot Cure
By Nick Read. Published by in London by Phoenix, 2006.