A more sensitive bowel implies that anything that goes on inside the bowel is more likely to be felt as symptoms of pain or bloating or nausea, wind, needing to go to the loo or just funny feelings.
Q. How common is it - and who gets it?
A. We all experience bowel pain and upset from time to time. That is not abnormal, but about 1 in 5 people get these symptoms with sufficient frequency (greater than 3 times a week) to be diagnosed as IBS. It is a spectrum. Some people have it so badly, they rarely have a day without pain, and do not dare to go out of their houses for fear of getting 'caught short'. It is more common in women than men and can occur throughout the life cycle, but is more likely to take place in young people, so pressurised by the pace of life that they are struggling to cope. My experience suggests that there is another peak in prevalence at the time of the menopause, associated with children leaving home, parental illness, loss of role etc.
Q. How is it diagnosed?
A. It is a symptomatic diagnosis. Anybody who has experienced frequent bouts of bowel upset, either diarrhoea or constipation, associated with abdominal pain or bloating, for more than a few months may be suspected of having IBS. The presence of other symptoms, such as anxiety, depression, tiredness, nausea, indigestion, muscle aches and pains, make the diagnosis more likely.
Q. Is it linked to stress?
A. Most definitely. Attacks of IBS are frequently triggered by life changes, such as feeling overworked and undervalued, upsetting arguments, having your purse stolen, a car accident. People with IBS tend to react to the normal ups and downs of life with their bowels. Many people report that their IBS started for the first time after a particularly upsetting event, like for example a parent dying, becoming unemployed or the breakdown of a key relationship.
People with IBS also tend to have been more likely than other people to have suffered from a tense, unhappy and sometimes traumatic childhood.
Psychological factors have an enormous influence on this condition. Ongoing emotional tension is the commonest reason for bowel senstivity in this condition.
Q. Is it linked to diet?
A. Yes. If the gut is sensitive, anything that goes in it will give rise to symptoms. This is why so many patients with IBS report that their symptoms are caused by so many different foods. It's not the food as much as the sensitive gut that is at fault here. Of course some foods affect all of us more than others. We are all more likely to experience gut upset if we eat very hot spicy foods, and experience gassy symptoms if we eat a lot of fruit and fibre. Not surprisingly, patients with the sensitive gut of IBS get a lot more symptoms from these foods.
Finally and very importantly, if the food has a particular emotional significance, i.e. the meat that dad always used to make us eat, the horrible greens that we had to eat as children, sitting down to traumatic family meals, the fish one of my patients was eating when her husband announced he was leaving her, then eating the same food will cause emotional upset which will cause areas of gut to go into spasm and becaome very senstive and give rise to symptoms.
Q. What treatments are available and how do doctors select which one to try?
A. Drug treatments are limited. There are antispasmodics, that can reduce the strength of bowel contraction and hence (in theory) reduce pain caused by bowel spasm. There are several available. They include colofac, spasmanol, buscopan and peppermint oil derivatives such as colpermin. There are drugs that treat diarrhoea and urgency (loperamide, lomotil and codeine phosphate) and drugs that treat constipation (lactulose, dulcolax, senna and fybogel).
Unfortunately drugs that alter bowel function tend to cause other symptoms. For example, fybogel and lactulose may help constipation but make the pain, the distension, bloating and gassy symptoms worse. Antidiarrhoeal agents may relive the diarrhoea but often at the expense of causing pain. Patients often do not tend to take these drugs for very long.
Q. Are there any alternative approaches that have been proven to help?
A. Hypnotherapy and counselling/psychotherapy can be very useful for patients with severe IBS. The evidence is very good. Other treatments are less well proven, but should not be dismissed because of lack of 'evidence'. They work at the level of the person, their efficacy depends on how much the patient believes in them.
Aromatherapy, acupuncture, herbal remedies, reflexology, massage, can all be very useful in IBS. The patient feels understood, calmed and looked after. Exponents of these alternative treatments have time to care and that is very therapeutic for people whose condition is so related to how much many of them struggle to cope with life.
Q. What dietary changes do you suggest?
A. It is impossible to be prescriptive on this, but I tend to ask patients which foods they find upset them and work with that. If they are senstive to everything, then clearly excluding all the foods that upset them could cause severe malnutrition, but a judicious reduction of those spicy or high fibre foods that are likely to stimulate the gut more would be helpful. I tend to focus on encouraging the patient to find space in his or her life to eat in a relaxed manner with family and friends - make it an enjoyable rather than a frazzled experience.
Q. Are food intolerances anything to do with it?
A. Yes, but there are rarely specific and often have to do with the meaning of food and emotional tension (see answer to Q 5)
Q. And what do you think of the theory that probiotics help?
A. I'm not convinced, but perhaps we should wait and see. There are some hints that the diarrhoea caused by emotional tension may reduce the beneficial bacteria from the gut and clear the way for harmful species to grow, but we're a long way from showing that is really an important mechanism in IBS. Probiotics are being marketted by much hype. If the patients believe in this, it may help.
The therapeutic power of confidence, faith and belief (the placebo effect) is very powerful in patients with IBS. Doctors need to take this more seriously, and harness its power to enhance any biological therapeutic efforts. I just don't like the idea of companies making a lot of money out of this, by making out it has an established and specific action.
Q. Are there any exciting developments in the pipeline?
A. I thing that this next century will be the time when we will really begin to understand how the emotional tension caused by our ever more rapidly changing, complex and overcrowded lifestyle with increasing restriction on time to relax and enjoy life is impacting on our health to cause a spectrum of disease like IBS. We will realise that IBS is just one of a spectrum of diseases that are becoming increasingly common and include asthma, ME, fibromyalgia, unexplained indigestion, migraine, premenstrual syndrome and so on.
Perceptions and times, they are a'changing!
Professor Nick Read is a consultant Gastroenterologist and a Psychoanalytical psychotherapist. He has recently been appointed as Professor of Integrated Medicine at the University of Sheffield. He has worked with patients with IBS, functional dyspepsia, eating disorders, obesity, chronic abdominal pain, disorders of defaecation since 1972.
His quest to undersatnd IBS has led him through academical appointments in Human Physiology, for 14 years, Human Nutrition for 9 years, and Psychotherapeutic Studies. His employer is the Department of General Practice.
He also writes a regular column ( gut agony uncle) for Gut Reaction, the journal of the IBS Network, and is currently writing a book on "How modern life makes us ill".
