nhsManagers.net | Briefing | 28 February 2018

Medicine for Managers

Dr Paul Lambden BSc MB BS BDS FDSRCSEng MRCS LRCP DRCOG MHSM FRSM

The syndrome can result in almost any symptom of which the bowel is capable; abdominal pain and cramps, bloating, discomfort, diarrhoea or constipation, excessive wind or nausea.

Sometimes people may notice mucus in the stool and there may be a feeling of not having finished a bowel movement.

Less common symptoms include headache, tiredness, poor appetite, muscle pain, heartburn, backache and irritable bladder.

The symptom that it does not cause is bleeding from the back passage and if that occurs, it should be investigated as a matter of urgency.

 For many who suffer the symptoms, they

are mild and intermittent, but for a relatively small number of people the symptoms are severe and more persistent. For many control of symptoms can be achieved by management of their diet, lifestyle and stress (good luck with that) but for those who suffer more it may be necessary to use medication and

counselling.

However severe the symptoms, the bowel remains completely undamaged and unchanged by the condition.

The bowel appears completely normal to the naked eye, on colonoscopy and when examined under the microscope.

Irritable bowel does not predispose to any other disease nor does it increase the risk of colo-rectal cancer.  

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only and should not be regarded as an endorsement of their use.

Irritable bowel After last week’s ‘tummy ache’ this week probably the most common causes. Irritable bowel syndrome is a disorder which results in an ill-defined group of symptoms which are not associated with any disease or structural abnormality of the bowel itself. The name ‘irritable bowel’ or ‘irritable colon’ is enough to make one feel embarrassed about the disorder but the names are, I suppose, an improvement on the former ‘spastic colon’.

It is estimated that the syndrome affects about 20-25% of the population, most commonly first appears in early adulthood and affects women twice as frequently as men.

It is much more common in the Western world than in developing countries, fuelling suspicions that it is stress which is a primary cause.  

The cause of irritable bowel is unclear. The disturbance in the function is associated with overactivity of the muscles of the large bowel resulting in spasm.

Many reasons have been offered for this overactivity of the nerves or muscles in the gut. They include:

• Food intolerances • Excessive alcohol consumption • Emotional stress • Antibiotic use.

The suggestion is that the antibiotic kills the normal gut organisms (the good bacteria), which exert a protective effect on the bowel and which may result in the overgrowth of bacteria.

These interlopers are antibiotic resistant and may affect the bowel function through release of toxins or other effects. It is known that irritable bowel symptoms start following a bout of gastro-enteritis in about one in six people who experience symptoms.

Some irritable bowel sufferers have increased numbers of immune system cells in their intestines and it is the immune response which results in the functional bowel disturbances.

The walls of the large bowel are lined with layers of muscle that alternately relax and contract as they move food through the digestive tract.

It is contractions that are stronger than normal and which last longer (spasm) that

result in the formation of gas, bloating and diarrhoea. Weak intestinal contractions may result in slower transit of bowel contents with the production of hard, dry stools.  

Some suggest that it is in fact the nervous control of the gut, rather than the muscles themselves, that result in the disturbances in function.

It is postulated that the electrical activity between the brain and the intestine is in some way dysfunctional resulting in the gut over-reacting to normal digestive processes.

Other opinion is that the condition occurs as a result of clinical or sub-clinical infection which results in destruction of the normal gut bacteria and their replacement by an overgrowth of more harmful bacteria which in some way generate a hostile bowel environment.

This hypothesis informs some types of treatment for the condition.

Other possible ‘triggers’ for the disease include

• Food. Some foods undoubtedly aggravate the condition, e.g wheat, dairy products and carbonated drinks.

• Hormones. Women are twice as likely to have the condition as men which has led to suggestions of female hormones might be implicated and trigger episodes.

• Stress. We pretty much all have stress and many IBS sufferers say that periods of stress increase the symptoms.

Diagnosis

There are no tests to confirm the diagnosis of irritable bowel because there is no specific abnormality to identify. The diagnosis is usually made by exclusion when other possible diseases (such as

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only and should not be regarded as an endorsement of their use.

colitis, coeliac disease, gut infections, malignancy, ulcers, etc.) have been excluded.

For that reason it is always expedient to take a blood sample for a full blood count (to exclude anaemia which may suggest bleeding), an ESR (to exclude inflammation which does not occur with irritable bowel) and antibodies for coeliac disease.  

It may also be worthwhile to keep a diary of the symptoms to see whether there is any association between the symptoms and particular activities.

It may also be helpful to assess the effectiveness of dietary change or the use of medication on the symptoms.

If there is weight loss, rectal bleeding or persistent pain, the condition must not be assumed to be irritable bowel and medical assistance should be sought.

Treatment.

The treatment of irritable bowel is empirical. There are a range of suggested treatments, each of which works for a proportion of patients.

For many, antispasmodic drugs are effective and may control the pain adequately. It is often helpful to take antispasmodics before meals.

Commonly used drugs include mebeverine (Colofac), hyoscine and peppermint oil (Colpermin).

They can be used as required during flares-up of the symptoms. A healthy diet and increased dietary fibre may help. It is also recommended to drink at least eight cups of fluid a day but to reduce tea and coffee to a maximum of three cups daily.

Eating smaller meals more frequently may also relieve the symptoms. Sorbitol (an artificial sweetener) should be avoided. Some sufferers identify one or more

specific food intolerances and control the symptoms by not eating them.

Probiotics (which contain ‘good’ bacteria) such as live yoghurts, some cheeses and milk drinks may restore normal gut flora in patients where the normal balance has been disturbed. 

Stress seems to aggravate the  condition in many people and so relief of stress may reduce the symptoms, although, of course, that may be very difficult to achieve.

Sometimes a tricyclic antidepressant such as amitriptyline may produce good results. In others relaxation techniques, stress counselling and even psychotherapy have been helpful. This is often difficult to achieve. 

Relief of constipation by the use of added fibre or diarrhoea, by the use of an anti-diarrhoeal, may ease the symptoms and may also make the management of the problem simpler.  

A newer technique, still under evaluation, and with insufficient evidence to know how effective it is, is the transplantation of faecal material (unpleasant though it may sound) from a healthy non-IBS sufferer into someone with irritable bowel.

The theory underpinning the work is to introduce a microbial culture which will proliferate in the gut and suppress and destroy any bacteria which might be implicated in the genesis of irritable bowel.

Early results have suggested that up to 35% of sufferers are improved or ‘cured’ by the therapy and results appear to be sustained. However, the studies are small and the disorder is not easy to evaluate because of its intermittent symptom nature.  

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only and should not be regarded as an endorsement of their use.

Treatments often ease the symptoms without eliminating them but any reduction in pain or functional disturbance may improve the quality of life. 

Overall, the nature of irritable bowel syndrome is that its symptoms wax and wane and there are periods of remission and exacerbation in many patients which are unpredictable. In some patients the symptoms ultimately disappear altogether.

The wide variation in symptoms and effective treatments suggest that the condition is multifactoral and the important linking factor is that irritable bowel is distressing and inconvenient but not serious.

Symptoms such as weight loss and rectal bleeding are not a feature of irritable bowel and necessitate consultation with a doctor.

Sufferers can be reassured that the disorder is not associated with any other diseases, such as cancer, does not lead to bowel obstruction and does not have any effect on lifespan.

paullambden@compuserve.com

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only and should not be regarded as an endorsement of their use.