Introduction
Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by abdominal pain or discomfort and altered bowel habits in the absence of detectable structural abnormalities.
In 2006, the Rome II criteria for the diagnosis of IBS were revised . IBS symptoms tend to come and go over time and often overlap with other functional disorders such as fibromyalgia, headache, backache, and genitourinary symptoms. Severity of symptoms varies and can significantly impair quality of life, resulting in high health care costs. Advances in basic, mechanistic, and clinical investigations have improved our understanding of this disorder and its physiologic and psychosocial determinants. Altered gastrointestinal (GI) motility, visceral hyperalgesia, disturbance of brain-gut interaction, abnormal central processing, autonomic and hormonal events, genetic and environmental factors, and psychosocial disturbances are variably involved, depending on the individual. This progress may result in improved methods of treatment.
Diagnosis of IBS 1
ROME III DIAGNOSTIC CRITERIA. Functional Bowel Disorders. Irritable Bowel Syndrome
Recurrent abdominal pain or discomfort** at least 3 days/month in last 3 months associated with two or more of the following:
. Improvement with defecation
. Onset associated with a change in frequency of stool
. Onset associated with a change in form (appearance) of stool
* Criterion fulfilled for the last months with symptom onset at least months prior to diagnosis
**“Discomfort” means an uncomfortable sensation not described as pain. In pathophysiology research and clinical trials, a pain/discomfort frequency of at least days a week during the screening evaluation is recommended for subject eligibility.
ROME II DIAGNOSTIC CRITERIA . Functional Bowel Disorders. Irritable Bowel Syndrome
At least 12 weeks, which need not be consecutive,in the preceding 12 months of abdominal discomfort
or pain that has two out of three features:
. Relieved with defecation; and/or
. Onset associated with a change in frequency of stool; and/or
. Onset associated with a change in form (appearance) of stool.
Symptoms that Cumulatively Support the Diagnosis of Irritable Bowel Syndrome– Abnormal stool frequency (for research purposes “abnormal” may be defined as greater than bowel movements per day
and less than bowel movements per week);– Abnormal stool form (lumpy/hard or loose/watery stool);– Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation);– Passage of mucus;
– Bloating or feeling of abdominal distension. Irritable bowel syndrome (IBS), also known as spastic colon is a functional disorder which is thought to be caused by emotional instability. Young men and women who have deep-seated, unresolved emotional problems are prone to get the condition. The large intestine is sensitive and reacts to mental stress. The slightest provocation can cause the large bowel to contract violently and go into spasm. The bowel secrete large quantities of mucus which appear in the stool.
IBS is characterized by abdominal discomfort, flatulence, irregular bowel movements, with alternating diarrhea and constipation. Women with irritable bowels syndrome may notice symptoms during their menstrual period. Symptoms get worse from eating certain foods such as animal fat, refined flour products, meat, raw fruits and vegetables.
Prevalence of IBS 2
Population-based studies estimate the prevalence of IBS at 10–20% and the incidence of IBS at 1–2% per year. Of people with IBS, approximately 10–20% seek medical care. An estimated 20–50% of gastroenterology referrals relate to this symptom complex. The prevalence, demography and clinical features are different among countries
Most patients with IBS in India are middle-aged men, and have a sense of incomplete evacuation and mucus with stools. Abdominal pain or discomfort is frequent but not universal. Importantly, stool frequency was similar irrespective of whether the patients felt having constipation or diarrhea. Most (90%) non-complainant subjects had 1 or 2 stools per day; symptoms complex suggestive of IBS was present in 4.2% of community subjects.
The prevalence, demography and clinical features of irritable bowel syndrome in
Western countries India
Prevalence 10–20% 4.2–7.9%
Sex Female > male Male > female
Age More common in young More common in young
Socioeconomic status Inversely related Inversely related
Clinical features lower abdominal symptoms upper abdominal symptoms
Etiology
The etiology of IBS is uncertain but is likely to be multifactorial [2].
Dysregulation of brain-gut axis,- involving abnormal function in the enteric, autonomic and/or central nervous system (CNS).2 A number of mechanisms have been described in the etiology of IBS as summarized below. Visceral Hypersensitivity It is an important mechanism for abdominal pain in IBS. It is caused by heightened sensitivity of both peripheral and CNS due to inflammatory and non inflammatory agents.
Abnormal Gut Motility -A cardinal feature of IBS is change in bowel pattern which is due to abnormality of gut motility. Sympathetic and parasympathetic nerves control the function of enteric nervous system via a variety of mediators and receptors such as serotonin. Activation of 5-HT3 and 5-HT4 receptors enhances gut motility while inhibition of 5-HT3 delays transit time. Gut motility is also regulated by psychogenic, somatic and immune stress.
Autonomic Nervous System Dysfunction -There appears to be an imbalance resulting from increased sympathetic and decreased parasympathetic activity. Vagal and adrenergic dysfunctions are associated mainly with constipation and diarrhea, respectively.
Small Intestine Bacterial Overgrowth -Up to 84% patients with IBS have been found to have small intestinal bacterial overgrowth (SIBO). Antibiotic treatment with nonabsorbable antibiotics, e.g. rifaximin leads to clinical improvement of IBS. Two studies suggest the prevalence of SIBO to be 11% in India. However, villous atrophy with bacterial overgrowth (tropical enteropathy) is also common in India. It is presently unclear whether SIBO is the cause or effect of IBS. Microscopic Inflammation Microscopic inflammation has been documented in some patients. This concept is important because IBS has previously been considered to have no demonstrable pathologic alterations. Immuno histochemical studies reveal mucosal immune system activation in a subset of patients with diarrhea-predominant IBS.
Postinfectious Irritable Bowel Syndrome– Posti nfectious IBS affects 10% of IBS patients. This subtype is consequent to previous bacterial gastroenteritis and raises the importance of bacterial infections in causation of IBS. A longer duration of the diarrheal episode, younger age, female sex, bloody stools, depression, etc. increases the risk of development of IBS. Interestingly, some studies in India suggest a protective effect of previous exposure to amebic infection. Food Intolerance and Allergy Hypersensitivity reactions lead to mast cell degranulation with production of local and systemic proinflammatory leukotrienes and histamine which act on smooth muscles. Sugar and gluten intolerance have also been implicated but seem to be unlikely cause of IBS although may contribute to bloating.
Psychosocial Factors -Emotions affect gut motility and patients with history of physical or sexual abuse, loss and separation during childhood, and conflicting maternal relationship are all associated with development of IBS. Genetic Factors There is some evidence to suggest a genetic factorin causation of IBS. One study found that 33% of patients with IBS had a positive family history. Also, first-degree relatives are twice likely to have IBS
PROGNOSIS [2]
Irritable bowel syndrome is a chronic relapsing disorder characterized by recurrent symptoms of variable severity. The life expectancy, however, remains similar to that of the general population. Clinicians should inform and reassure patients, because the knowledge may help allay undue fears. IBS does not increase the mortality or the risk of inflammatory bowel disease or cancer. The principal associated physical morbidities of IBS include abdominal pain and lifestyle modifications related to altered bowel habits. Absenteeism from work resulting in lost wages is more frequent in patients with IBS. IBS is purely a functional disorder of the intestinal wall muscles. There is no pathological evidence of any visible disease within the colon.
Normally, muscles lining the intestines contract rhythmically forcing the food out of the bowels. In IBS, the contractions are either too strong (fast) or slow, resulting in diarrhea or constipation respectively.
There are numerous theories (altered nervous signals, hormonal etc) explaining this faulty mechanism. However there is no tangible evidence supporting the same.
Common triggers of IBS are [3]: (These trigger off an attack of IBS and aren’t the cause of IBS)
Stress: Emotional factors such as grief, shock, anxiety, nervousness and anticipation
Food: Dairy products, egg yolk, oily/fried foods, red meat, alcohol, coffee, fats,beverages, chocolates
Drugs: Certain medicines may precipitate an attack of IBS
Infections: Gastroenteritis or infection within the digestive tract
Psychology and IBS
IBS is nearly always associated with psychological problems. Stress, fear, anger, grief, and obsession can cause hyperactivity of the nerve impulses controlling muscle action. When any muscle is irritated or overworked, it will go into spasm.
There is a strong link between IBS on the one hand, and anxiety and depression on the other hand. However, it is unclear which one comes first.. According to Dr. Wang (Consultant, Department of Gastroenterology & Hepatology, Singapore General Hospital (SGH), Psychological disorders can affect the way we perceive discomfort coming from the intestinal tract4. A study carried out by SGH found that almost half of 345 IBS patients screened from November 2010 to October 2011 had psychological disorders. The most common psychological disorder associated with IBS is anxiety, followed by depression. After screening all severe IBS patients for psychological disorders when a psychological disorder is found the patients are referred to a psychiatrist or psychologist for intervention. Understanding this condition can give patients the reassurance to live with this condition4. It is becoming, increasingly accepted that the enteric nervous system (sometimes called the ‘second’ or ‘little’ brain due to its extensive intraconnected neural network) is exquisitely monitored and modulated by the central nervous system, although most of this processing is not conscious. As proposed that enhanced responsiveness of central stress circuits to exteroceptive (psychosocial) as well as interoceptive (visceral) stressors is a plausible pathophysiologic model for IBS5. Illustration in enhanced output of the Emotional Motor System or EMS can explain the cardinal symptoms of IBS. Altered autonomic balance results in altered bowel habits, stress-induced hyperalgesia results in abdominal pain and discomfort and enhanced activation of ascending arousal systems result in hyper vigilance towards sensory stimuli. In addition to the hyper-responsiveness of the EMS to actual stressors, conditioned fear responses and cognitive factors play an important role in the chronicity of IBS symptoms. For example, selective attention to an increased threat appraisal of visceral sensations and conditioned GI symptom-related fear may maintain symptoms in the absence of actual stressors5. As readers of this journal are well aware, central and peripheral systems are in constant interplay and affective and cognitive actions have peripheral consequences including changes in motility and peripheral immunity, which in turn provide important feedback to the brain that helps shape ongoing mental activity. In general, IBS patients show altered perception of visceral events that is characterized by hyper vigilance, hypersensitivity and increased autonomic arousal.. GI symptom-specific anxiety may be an especially important variable leading to increased pain sensitivity, hyper vigilance and poor coping. Mild psychological stress increases visceral perception in IBS patients but not in healthy controls and IBS symptoms are exacerbated following stressful life events. We have also recently shown that visceral-specific anxiety appears to be particularly important in IBS and may be the primary element in mediating the impact between changes in symptom severity and changes in quality of life in IBS sufferers. Recent brain imaging findings have now begun to show the central circuitry that may underlie many of the observations described above. For example, patients with IBS during visceral stimulation show increased activation in the anterior cingulate cortex, area involved in vigilance and discomfort during physical and social situations.
Of particular relevance to the understanding of mind/Body psychologic therapies applied to IBS is the development of specific mind/Body themes that have emerged from the research literature described above. These include the following5:
- The presence of an increased stress response, especially an increased stress response associated with viscerally related events.Life stress can stimulate colon spasms, resulting in abdominal discomfort at stressful times. Whereas people might experience ‘butterflies’ or cramps when they are nervous or upset, a person with IBS will experience a higher level of distress, as their colon can be overly responsive to the smallest amount of conflict or stress. Whether through progressive muscle relaxation, meditation, yoga, counseling or changes to the stressful situations we face daily, reducing the level of stress in one’s life can have a positive effect. In addition to life stress for those with IBS, visceral sensations and the context in which these sensations occur can be an anxiety producing experience. For patients with urgency and diarrhea, the anticipation of not making it to the bathroom on time can be unbearable. How an individual’s symptoms are perceived, evaluated, and acted upon can determine illness behavior. The slightest amount of abdominal pain can lead to catastrophizing the experience and can result in increased anxiety and possibly more symptoms. Anxiety can serve as part of a vicious cycle that involves a trigger (physical symptom such as abdominal pain), a reaction (anxiety) and a belief (‘I am going to have diarrhea and miss my appointment’). Certain symptoms can cause more anxiety than others; for example, dining at a restaurant and experiencing severe gas pain might cause a person so much anxiety that they get up and leave. Similar mechanisms may also occur with sensations associated with constipation such as bloating.
- Poor or inappropriate coping responses to GI-related events.Patients with IBS may develop hyper vigilance to visceral sensations as well as avoidance of many pleasurable activities for fear of triggering symptoms. Poor coping responses, in part due to catastrophic beliefs and a poor sense of control over symptoms, play a critical role in mediating the relationship between affective states such as depression, severity of symptoms (e.g. pain) and real life limitations caused by IBS
- Psychosocial fears and isolation; including low self-esteem, depression and social withdrawal.IBS can take its toll on friendships, marriages, employment and one’s sex life. People with IBS can become pre-occupied with fears of soiling themselves in public and as a result, isolate themselves and only venture out when necessary. If employed, many are afraid to eat while at work out of fear that they might become incapacitated with pain and/or multiple bowel movements. Shame and guilt, as well as anger, are common emotions described by those with IBS, as they are relegated to keeping their disorder a secret out of embarrassment. As the isolation is compounded, many patients with IBS develop depression and anxiety, which serves to further complicate the presentation of IBS.
Cognitive activity plays an important role in modulation of limbic activation via cortico-limbic interactions and behaviors such as avoidance may perpetuate arousal responses by negating normal inhibition in these circuits.
Psychologic Treatments Applied To IBS
Three types of psychologic treatment modalities have received the most attention in the literature to date. These include several forms of cognitive behavioral therapy (CBT), a brief form of insight-oriented psychotherapy, and a gut-directed form of hypnotherapy.
In a study on Psychosocial factors in the irritable bowel syndrome, a multivariate study of patients and non patients with irritable bowel syndrome. It was conclude that the psychological factors previously attributed to the IBS are associated with patient status rather than to the disorder per se. These factors may interact with physiologic disturbances in the bowel to determine how the illness is experienced and acted upon6. Among patients consulting for IBS, symptoms of psychological distress are common, and more than half of these patients are found to have a psychiatric diagnosis in addition to bowel dysfunction. Many investigators have therefore concluded that IBS is a psycho physiologic disorder and proposed that patients with IBS be treated with psycho logic techniques. However, recent studies suggest that this association may be spurious; persons in the community who have symptoms of IBS but do not consult a doctor have no more psychological symptoms than persons without bowel symptoms. This indicates that psychological symptoms do not cause bowel symptoms, but, instead, influence which persons with bowel symptoms will consult a physician. The bowel symptoms and the psychological symptoms that coexist in most patients with IBS may be best thought of as comorbid conditions.. Psychologic treatments that reduce the level of their psychologic distress also frequently reduce the frequency and severity of complaints about bowel symptoms. Controlled trials show psychiatric treatment approaches to be superior to medical management alone. It may appear paradoxical that psychologic treatments aimed at the management of emotions are so frequently found to reduce bowel symptoms7.
IBS study in homoeopathy– A recently concluded meta-analysis (Peckham EJ et al, 2013) reflected that the pooled analysis of two small studies (Rahlfs VW et al, 1976, 1979) suggested a possible benefit for clinical homeopathy, using the remedy asafoetida, over placebo for people with constipation-predominant IBS8. Another small study (Owen D et al, 1990) found no statistically difference between individualised homeopathy and usual care. However, the authors warranted cautious interpretation on account of low quality of reporting in these trials, small number of participants, high or unknown risk of bias, short-term follow-up and sparse data. The authors also encouraged further high quality, adequately powered RCTs to assess the efficacy and safety of clinical and individualised homeopathy compared to placebo or usual care9. One three-armed pragmatic RCT is already ongoing on IBS (Peckham EJ et al, 2012)10.
References/ Bibliography
1 Comparison Table of Rome II and Rome III Adult Diagnostic Criteria,
2.Irritable Bowel Syndrome: chapter 56, The Indian Scenario, Rajesh Upadhyay, Aesha Singh, )
3. Irritable Bowel Syndrome ,(http://www.homeoconsult.com/irritable_bowel_syndrome.php)
4.Can Anxiety or Depression Cause Irritable Bowel Syndrome (IBS)?, Anjana Motihar Chandra for Health Xchange, with expert input from the Department of Gastroenterology & Hepatology, Singapore General Hospital (SGH), a member of the SingHealth group.(http://www.healthxchange.com.sg/healthyliving/SpecialFocus/Pages/Management- and Treatment- for-Irritable-Bowel-Syndrome-IBS.aspx)
5. Mind/Body Psychological Treatments for Irritable Bowel Syndrome,Bruce D. Naliboff, 1,2,3 Michael P. Fresé,1,2,3 and Lobsang Rapgay, Evid Based Complement Alternat Med. 2008 Mar; 5(1): 41–50,Published online 2007 May 17. doi: 10.1093/ecam/nem046(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2249749/)
6.A multivariate study of patients and non patients with irritable bowel syndrome Gastroenterology,1988 Sep;95(3):701-8, Psychosocial factors in the irritable bowel syndrome. Drossman DA1, McKee DC, Sandler RS, Mitchell CM,Cramer EM, Lowman BC, Burger ALL,,(http://www.ncbi.nlm.nih.gov/pubmed/3396817)
7. Gastroenterol Clin North Am. 1991 Jun;20(2):249-67.,Psychologic considerations in the irritable bowel syndrome., Whitehead WE1, Crowell (http://www.ncbi.nlm.nih.gov/pubmed/2066151)
8.Homeopathy for treatment of irritable bowel syndrome ,Cochrane Database Syst Rev.2013 Nov 13;11:CD009710. doi: 10.1002/14651858.CD009710.pub2.,Peckham EJ1,Nelson EA, Greenhalgh J, Cooper K, Roberts ER, Agrawal A (http://www.ncbi.nlm.nih.gov/pubmed/24222383)
9.Homeopathy for IBS? Published Monday 18 November 2013,(http://edzardernst.com/2013/11/homeopathy-for-ibs-
10.A protocol for a trial of homeopathic treatment for irritable bowel syndrome., Emily J Peckham, Clare Relton, Jackie Raw, Clare Walters, Kate Thomas, and Christine Smith ,BMC Complement Altern Med. 2012; 12: 212.,, Published online 2012 Nov 6.,doi: 10.1186/1472-6882-12-212,PMCID: PMC3517481, (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3517481/)
Authors
- Dr Rupali Bhaduri M.D.(HOM),R.A. (H) CRU Siliguri
- Dr Anjan Roy lecturer M.D.(HOM) RVHMC and Hospital, Udaipur , Rajasthan
