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What’s Wrong with Your Gut? Diagnosing Irritable Bowel Syndrome First in a two-part series on IBS by Wenda Reed

I used to receive compliments for being so slender.

I thought to myself, “You’d be skinny too if you lived on rice and applesauce seven or eight days out of each month.” I thought I’d rather be fat than endure agonizing stomach pain and abdominal cramping with bouts of diarrhea or constipation.

I suffered from digestive problems diagnosed as Irritable Bowel Syndrome (IBS) for 20 years. I don’t suffer from them anymore. My path from pain to a cure involved many detours through diagnostic tests, drugs, diets and treatment options. In the end, my naturopath discovered through a stool test that I did not make adequate amounts of pancreatic and hydrochloric digestive acids. I began taking enzymes with every meal, and now I can eat anything, have regular bowel movements and have no more abdominal problems than the average person.

Is that the answer for anyone with IBS? Unfortunately, no. The National Institutes of Health (NIH), the Mayo Clinic and other experts estimate that 20 percent of the population may suffer from IBS. It seems to affect more women than men, although some doctors believe that women are just more likely to visit a doctor. There is nothing structurally wrong with the gut, but it doesn’t function properly. It reacts with cramping, gas, bloating and bowel elimination problems when subjected to foods, stress, diseases or other factors that generally don’t bother other people.

Beyond that, there are hundreds of causes or triggers for individual symptoms and, therefore, numerous treatment options. Google “treatment for IBS” and you’ll get 1,050,000 options — some of them are completely bogus, but many of them work for somebody.

Colleen Prisock of Bellevue has suffered from IBS for 20 years and found limited help from tweaking her diet and using laxatives, enemas, fiber supplements and antacids. A breakthrough occurred when her naturopath did a blood test to identify an allergy to eggs and a stool test indicating that there were no good bacteria in her gut. She stays off eggs and dairy products (because she is lactose intolerant), took medicines to clear up yeast in her digestive system, and takes probiotics (beneficial bacteria). She still has some bloating, but is doing much better.

Although most people are diagnosed with IBS as young adults, Seattle resident Heather Van Vorous had symptoms when she was 9 — summarily dismissed as “all in her head” by her pediatrician — and was diagnosed at 15. Her description of her symptoms is graphic: “Imagine someone setting their hand on fire, then plunging it into your lower abdomen to try and rip your guts out.”

Anti-spasmodic drugs and fiber did not provide complete relief, and so she began experimenting to develop an “IBS diet.” It involves strict limits on fat and the inclusion of soluble fiber (found in oatmeal, pasta, rice, potatoes and white bread) with every meal or snack. She is careful with her intake of insoluble fiber (the rough fiber found in fresh fruits and vegetables) and has eliminated coffee, carbonated beverages and alcohol. Peppermint is soothing for her, and she has developed her own line of “tummy teas” and IBS products.

“IBS is a highly personalized problem. What works for you may not work for others and vice versa,” Van Vorous says.

So if you are suffering from abdominal pain and constipation and/or diarrhea, where do you start?

GET AN ACCURATE DIAGNOSIS

A diagnosis of IBS is generally made only after any other possible causes have been eliminated and a variety of structural or “organic” conditions ruled out.

Craig Pepin, M.D., a gastroenterologist with the Polyclinic in Seattle, begins with a detailed medical and family history to see if there’s inflammatory bowel disease such as ulcerative colitis or Crohn’s disease, colon cancer, ulcers or other conditions in the family.

A blood workup can screen for anemia, infections, thyroid problems or inflammation in the digestive system, as well as celiac disease, a diagnosis Pepin says is often overlooked or improperly labeled IBS. (Celiac disease is a digestive disease that damages the small intestine and interferes with the absorption of nutrients from food. People who have celiac disease cannot tolerate gluten, a protein in wheat, rye and barley. It can be accurately detected through a blood test.)

If a patient has diarrhea, Pepin will look for an infection or parasites in the digestive system. He will check to see if lactose intolerance (the inability to digest significant amounts of lactose, the major sugar found in milk) is causing nausea, cramps, bloating, gas and diarrhea. If constipation is the primary symptom, he will look at electrolyte and calcium levels, which can be corrected.

Ovarian cancer and endometriosis might also mimic the symptoms of IBS.

The Digestive Diseases Information Clearinghouse (a division of the NIH) identifies these red flags that are NOT symptoms of IBS:

• New onset of symptoms after age 50
• Blood in the stools
• Recurrent vomiting
• Weight loss
• Fever
• Pain that awakens the patient at night and interferes with sleep

If you have any of those symptoms, you should have a colonoscopy to check for colon cancer, inflammatory bowel disease, ulcers or other conditions, Pepin says.

My diagnosis of IBS came after traditional blood, urine and stool tests came back normal. I was treated for the intestinal parasite giardia; I had my gall bladder removed; and my gastroenterologist gave me an endoscopy to check for structural problems in the esophagus, stomach and small intestine. Symptoms continued and there was no structural abnormality, so I was given the IBS label. It felt like a catchall diagnosis with no clear direction for improvement.

Twenty years ago, Prisock was told she had “spastic colon” — an older term for IBS. She figured that diagnosis meant “We don’t know why (you have abdominal symptoms), but we’re going to call it this.” Van Vorous agrees: “IBS is coined by the medical establishment to mean, ‘I don’t know what’s wrong with you,’” she says.

In 1988, at the 13th International Congress of Gastroenterology in Rome, Italy, a group of physicians created “the Rome Criteria” to more accurately define and diagnose IBS. The guidelines have been updated twice, most recently in 2006. After you have been screened for other diseases, you should be diagnosed with IBS if:

• You have had abdominal pain or discomfort for at least 12 weeks out of the previous 12 months. The 12 weeks do not have to be consecutive.

• The abdominal pain or discomfort has two of the following three features: It is relieved by having a bowel movement; and/or once the symptoms start, there is a change in how often you have a bowel movement; and/or once the symptoms start, there is a change in the form of the stool or the way it looks.

• Other symptoms support the diagnosis, including abnormal stool frequency (more than three bowel movements per day or fewer than three bowel movements per week); abnormal stool form (lumpy/hard or loose/watery); abnormal stool passage (straining, urgency, or feeling of incomplete evacuation); bloating or feeling of abdominal distention.

Stephen Wangen, N.D., a former IBS sufferer and director of the IBS Treatment Center in Seattle, agrees that the most important part of diagnosing IBS is to rule out other diseases, but he does not find the Rome Criteria particularly helpful. “If you have digestive problems, get help, even if you don’t exactly meet the criteria,” he advises. “IBS is a catchall for any number of digestive problems, so it can be difficult to figure out the cause.”

DO TRADITIONAL MEDICINES AND FIBER SUPPLEMENTS HELP?

Some traditional medicines and fiber supplements help some people to varying degrees. They may provide enough relief to manage symptoms successfully.

Van Vorous maintains a Web site on IBS, and has found that many of those who contact her have been treated like hypochondriacs and had their complaints dismissed. She says her doctor offered her little help after diagnosis beyond prescribing drugs to reduce spasms in the colon and Metamucil to add fiber and keep stools moving smoothly. She finds soluble fiber supplements (such as Citrucel, Benefiber and/or Fibercon) extremely helpful when taken daily, but they were not enough to remove all of her symptoms.

Most IBS experts recommend soluble fiber, although Pepin says it doesn’t matter if fiber is soluble or insoluble. The supplements work for both diarrhea and constipation and result in less gas and bloating. The fiber absorbs water and forms a gel when mixed with liquid, helping food move smoothly through the gut.

My own family doctor was kind and sympathetic, but didn’t know what to do to help. When I was being treated for depression — partly because of the pain of IBS — we discovered that Imipramine, a tricyclic antidepressant developed in the 1950s, helped the IBS symptoms as well as the depression. This is partly because these types of antidepressants have an anti-spasmodic effect, according to Monica Jarrett, Ph.D., R.N., a professor at the University of Washington, who helps conduct studies on management of IBS for the UW School of Nursing. After the depression lifted, I continued on a lower dose of Imipramine for years.

“Antidepressants at low doses seem to work well for many patients — tricycline antidepressants the most, SSRI’s (selective serotonin reuptake inhibitors such as Paxil, Celexa and Zoloft) not as much,” Pepin says. SSRI’s are a newer class of antidepressants, so their effects on IBS have not been as well measured. Scientists believe they may block pain messages from the brain to the intestines and that the messages are somehow modulated by serotonin (most of the serotonin in the body is in the gut). Jarrett and her fellow researchers at the UW are looking at ways that genetics affect serotonin levels and their effects on the bowels.

My doctor’s second line of defense was the anti-spasmodic drug, Bentyl. Anti-spasmodics reduce the movement of the intestines by controlling the smooth muscles on the wall of the gut. They don’t work as a preventative, but are used when you have active symptoms. Bentyl did help during flare-ups, but took a while to work and left me groggy and tired and unable to work — not to mention the dry mouth.

There are very few prescription medications for IBS. Zelnorm for IBS with constipation was removed from the market because it was linked to heart attack and strokes. Lotronex is approved only for women with severe diarrhea-predominant IBS that does not respond to other treatments. Amitiza is a new drug for women with IBS with constipation, but it is used sparingly because it causes other gastrointestinal symptoms.

Over-the-counter medicines like Imodium to slow down diarrhea, or laxatives or enemas to ease constipation can sometimes be too harsh for people whose bowels are ultrasensitive. Imodium was a disaster for me, causing cramping and pain so severe that I had to spend 24 hours in the emergency room.

In the end, even with the help of the antidepressants and anti-spasmodic, I was still suffering from pain, occasional diarrhea and nausea for quite a few days each month.

Prisock had a similar experience. She could not tolerate antidepressants, but used laxatives and enemas to relieve constipation, along with fiber supplements, which either did not work well or caused painful side effects. As indigestion and acid reflux began causing problems, she started “loading up on Nexium and Tums.” They helped for a while, and then stopped working.
“You just self-treat, not really knowing what’s causing the IBS; it’s very frustrating,” Prisock says. “You try to suffer through it.’’

For many of us who have been diagnosed with IBS and tried to find relief through traditional medicine, our question is: Now what?

Next month: Can alternative medicine help? Is there such a thing as a cure for IBS? How do we manage diet and stress to reduce symptoms?

Wenda Reed is a Seattle-area health writer and a former IBS sufferer.

RESOURCES

Heather Van Vorous’s Web site includes her own story, along with a comprehensive list of treatments and causes from two decades of research, written as a friend talking to a friend. Find links to support groups and message boards, sales of “Heather’s Tummy Teas” and other products, and her book, Eating for IBS Diet & Cookbook. www.helpforibs.com (1-866-640-4942 for retail orders).

The IBS Treatment Center Web site (Dr. Stephen Wangen) walks readers through the workings of the digestive system, causes for IBS and the center’s approach to finding a cure. Visitors can buy Wangen’s books, The Irritable Bowel Syndrome Solution and Healthier without Wheat at www.ibstreatmentcenter.com or by phone at 206-264-1111 or 1-888-546-6283.

The National Digestive Diseases Information Clearinghouse, part of the National Institutes of Health, gives readers the ABC’s of IBS from symptoms and causes to diagnosis and treatment. www.digestive.niddk.nih.gov/ddiseases/pubs/ibs/.

The Mayo Clinic’s Web site has short answers on symptoms, causes, risk factors, tests, complications, treatments and drugs, prevention, lifestyle and home remedies, coping and support and alternative medicine. www.mayoclinic.com/health/irritable-bowel-syndrome/DS00106.

International Foundation for Functional Gastrointestinal Disorders Web site is a gold mine of information on IBS, other functional disorders, and conditions with similar symptoms, from celiac disease and diverticulitis to food allergies and gastrointestinal infections. The nonprofit organization summarizes current studies and advocates for more research dollars. www.iffgd.org or 1-888-964-2001 for a free information packet.

©2009 Caliope Publishing Company