Irritable Bowel Syndrome (IBS)
– A disorder of mind and gut interrelation.
“It is more important to know what sort of Person has the disease than to know what sort of disease a person has”
– Hyppocrates
IBS is a unique disease entity in itself. It not only has physiological component but involves psychological component also that has its major impact in the manifestation of this disease. The medical management of patients with IBS is still unsatisfactory. Doctors are still taught that IBS is diagnosis of exclusion and patients readily sense that they are being told that nothing is really wrong with them. Many people soon realise that the medication they are being offered has little role to play. This mood of negativity once established further worsens the condition and is difficult to dispel.
IBS is best regarded as a complex of symptoms without a single cause. Disordered gut motility, visceral hypersensitivity, intestinal inflammation, and genetic and environmental factors have been suggested as being causative factors. In some cases, a well defined point of onset of syndrome symptoms seems to exist, such as after gastrointestinal infection but the most plausible view is that the symptoms of IBS are an integrated response to a variety of complex interactions combining biological and psychological factors. The concept of IBS is a disorder of brain – gut interaction with physical and psychological components, which places the emphasis on the perception of symptoms and their impact rather than on the symptoms themselves.
The psychological profiles of patients presenting with IBS are well characterised and about half of them have been found to have a demonstrable psychiatric disorder. Whether these abnormalities are cause of effect of is debated but since most of the diseases are psychosomatic in origin therefore it is more prudent to consider it while dealing with this disease because the patients with IBS are clearly more likely to have depression and abnormal behaviour patterns, including anxiety, sensitivity and somatisation. More specifically some patients develop maladaptive behaviour regarding eating and defecation which reinforces the magnitude of symptoms and their impact on quality of life. Moreover, concurrent psychiatric disorders are associated with poor outcome in irritable bowel syndrome.
The main problem a clinician is faced with is how to diagnose an IBS. For this Rome III criteria have been devised:
Symptoms of abdominal discomfort or pain, for three days a month in the past three months, associated with two or more of the following three features:
o Relieved by defection.
o Onset associated with a change in frequency of stool.
o Onset associated with a change in consistency (form or appearance) of stool.
Criteria fulfilled for the past three months, with onset of symptoms at least six months before diagnosis.
Treatment:
Growing evidence supports the use of antidepressants for IBS, but the mechanism of action of these drugs in the disorder remains unclear. Their beneficial effect is independent of mood or anti-cholinergic effects on the gut, which can be important in encouraging patients to accept their use. Clearly, although their antidepressant action is likely to be important in patients with a coexisting disorder, a separate and key action may be to influence psychological pathways leading to reduced somatisation and a reduced tendency to regard gut sensation as indicating illness.
Tricyclic antidepressants: They seem to be more useful when the main symptoms are pain and diarrhoea. Evidence suggests that a low dose of tricyclic antidepressant e.g. daily doses of amitriptyline as low as 10 mg are efficacious as, and produce fewer side effects than, conventional doses.
Selective serotonin reuptake inhibitors: They are thought to be more helpful in constipation and pain or bloating symptoms. e.g. Paroxetine (Tab Parotine 10 mg BD or according to response)
Cognitive behaviour therapy: It shows patients how events, thoughts, emotions, actions, and physiological responses are interlinked; the perception of sensation and the patients’ thoughts are of particular importance. It is most appropriate for those patients who are considerably distressed by their symptoms, are open to the idea that psychological factors play some role in their difficulties, and are willing to participate in this therapeutic approach. Cognitive behaviour therapy is as effective as antidepressant therapy and its benefit lasts longer.
Combining cognitive behaviour therapy and antidepressants can produce the best response.
Along with this the symptomatic treatment of the symptoms should also follow.
- If it is constipation predominant then encourage high roughage diet and Isapghol with milk or Lactulose (Gush or Ree-Lax 10 gm or 15 ml) as a single dose and adjusted according to patients response).
- If it is diarrhoea predominant then advice to avoid legumes and excessive dietary fibre along with Loperamide (Cap Eldoper) 2 – 8 mg daily.
In both the above conditions Cap. Syncrospas 100 mg tds (max duration in one go = 6 weeks) should also be added.
