IBS is one of the most miserable complaints, and little is understood about it. Controlling symptoms involves a combination of lifestyle changes and medication

Irritable bowel syndrome (IBS) is a common disorder of the intestines that causes much misery in both men and women. It affects different people in different ways but usually leads to abdominal discomfort or pain, bloating and changes in bowel habits. The abdominal pain or cramping can be a dull ache over one area of the colon, or several areas, and for some it can be intolerable and without relief. Constipation and diarrhoea (or bouts of both) can be experienced by sufferers. If you have IBS, you may feel the urge (perhaps accompanied by cramps) to move your bowels but have to strain do so. Sometimes, individuals with IBS pass mucus with their bowel movements.

One third of people in the UK have occasional symptoms of IBS and one in ten have symptoms that are severe enough to require medical attention. Although the syndrome can affect both sexes it is women who are more likely to see their doctor about their symptoms. IBS can affect people of all ages but tends to begin between the ages of 15 and 40. While there is no cure, you often can control symptoms through diet, stress management and medicines.

What causes IBS?
The exact cause of IBS is not well understood although it seems to be due to an increased sensitivity of the bowel. Women with IBS seem to have more symptoms during their periods, suggesting that reproductive hormones may play a role.

‘Syndrome’ refers to a collection of symptoms, not just one or two. In fact, IBS isn’t a disease – it is considered a ‘functional disorder’ because there is no sign of disease. It can strike otherwise healthy people. The causes are multiple: biological, psychological and social factors can all contribute to symptoms.

The good news is that the syndrome does not cause permanent harm to the intestines, it doesn’t lead to intestinal bleeding and it doesn’t cause cancer or inflammatory bowel diseases (such as Crohn’s disease or ulcerative colitis). Moreover, if you have IBS, you may not suffer all the time: some people can go for weeks or months with no symptoms. Others may experience symptoms daily. Also, it is possible – by paying attention to the triggers of your symptoms – that you can modify your diet, make lifestyle changes to reduce stress and use medication to reduce the symptoms.

Depression and anxiety disorders can aggravate IBS but, despite this, the symptoms are real and have a physiological basis. IBS has been called by many names, including colitis, mucous colitis, spastic colon, spastic bowel and functional bowel disease. Some of these terms are inaccurate. Colitis, for instance, means inflammation of the large intestine. IBS, however, does not cause inflammation and should not be confused with another more serious disorder, ulcerative colitis.

How is it diagnosed?
If you see your doctor with symptoms that may be due to IBS, he or she will first take a detailed history, asking specifically about change in bowel habit and any abdominal pains. There is a wide range of symptoms that may occur in IBS but sufferers usually complain of one or more of the following:

• Abdominal pain, often colicky in nature, which may be relieved on opening the bowels. Pain may be worse when there is constipation, and for women it may vary according to their menstrual cycle.
• Abdominal discomfort with a feeling of being bloated with clothing feeling tight and uncomfortable; there may be an excess of flatulence with an easing of the symptoms on passing wind or belching. Although nausea may be a feature it is unusual for there to be vomiting.
• Change in bowel habit that may result in constipation, diarrhoea or an alternation between the two. No two people have the same bowel habit so the most important point here is that there is a change to the normal pattern for that person. There may be an urgency to open the bowels, or straining to pass a motion as well as a feeling that the bowel has not properly been emptied. An unpleasant condition called ‘proctalgia fugax’, or sudden sharp pains in the lower bowel, are a relatively common feature of IBS.
• Some women experience seemingly unrelated symptoms, such as fatigue, lower-back pain or urinary-tract pain.

It’s important to remember that everyone suffers from an occasional bowel disturbance. A normal bowel movement is one that is formed but not hard, contains no blood, and is passed without cramps or pain. Changes in bowel habits don’t necessarily indicate IBS. If you have IBS, such disturbances are uncomfortable, painful, chronic and recurrent.

Psychological symptoms
IBS manifests more than just physical symptoms. You may suffer stress, depression, anxiety and frustration, at least in part because IBS can be embarrassing and not easy to talk about. A common source of anxiety relates to the need to be near a toilet when the feeling of urgency develops.

Some people with moderate to severe symptoms (including unpredictable pain, urgency and perhaps even bowel incontinence) find that IBS can affect many aspects of their lives, from the most public (including the ability to work, attend social events and travel) to the most private (including relationships with friends, family and sexual partners).

Moreover, IBS can be a vicious circle, since stress can lead to more symptoms due to what researchers call the ‘mind-gut’ connection. The colon is partly controlled by the nervous system, and when areas of the brain that are excited by stress are overwhelmed, it can affect the gastrointestinal tract, causing pain and other symptoms; the increased pain can cause further anxiety. Psychological treatment may be called for, particularly when the symptoms are severe enough to impair quality of life.

Psychological treatment, in addition to medical treatment, can break the vicious circle of pain to anxiety to pain. Stress management counselling, hypnotherapy and psychotherapy have all been used in the treatment of both the physical and psychological symptoms of IBS.

Examination and investigations
After asking you about your symptoms your doctor will examine you, paying particular attention to the abdomen. There may be tenderness, especially in the lower left where the last part of the colon lies. He may also hear loud or gurgling bowel sounds.

There are no specific tests for IBS; diagnosis is based on the pattern of symptoms, together with physical examination and tests that rule out other causes. Most of the investigations that are performed in cases of IBS are actually to rule out more serious and potentially harmful conditions, such as ulcerative colitis and bowel cancer. (For instance, bleeding, raised temperature, weight loss and persistent severe pain are not symptoms of IBS and may indicate other, more serious conditions.)

In younger patients, who are less likely to have other bowel diseases, the doctor may not carry out many investigations after the initial history and examination. If the patient is older there is a greater need to rule out serious bowel conditions and so the doctor will probably arrange more tests. These may include:

• Blood tests to check general health and to exclude certain other medical conditions
• X-ray examinations of the bowel, such as a barium enema, which shows up the shape of the large bowel by passing a special dye through the back passage
• Endoscopy of the large bowel – a ‘sigmoidoscopy’ or, for older patients, a ‘colonoscopy’; these procedures involve viewing the colon through a flexible tube inserted through the anus
• A pelvic examination to rule out ovarian tumours and cysts or endometriosis, which may display symptoms similar to IBS
• Testing a stool sample for evidence of bleeding; your doctor may take a sample during a rectal examination, or you may be asked to take a sample yourself

Treatment of IBS
There is no single effective treatment for IBS. For some people all that is needed is reassurance from their doctor that their symptoms, though unpleasant, will not have serious effects upon their health.

Your doctor can also help you to determine if there are ‘trigger factors’ which bring on your symptoms, perhaps a particular food or a stressful situation. Avoiding these triggers may enable you to control your symptoms without the need for medication. If you do have treatment the form it takes will depend upon your symptoms.

Some of the areas your doctor might discuss with you are:

Diet – traditional therapies have included dietary fibre, especially for treatment of symptoms of constipation. Fibre decreases the transit time through the colon and decreases the pressure in the colon. Increasing your consumption of fresh fruits and vegetables, whole grains and bran may also help; your doctor may suggest a soluble fibre supplement.

However, some recent research indicates that increased fibre can make symptoms worse for some IBS patients. This is because bacteria in the colon can break down fibre, producing gas, which may be uncomfortable for people with oversensitive nerves in the colon.

Discuss this with your doctor, it may be to your benefit to avoid certain forms of fibre, particularly gas-forming foods. But there’s no conclusive proof that eliminating certain foods will eliminate your symptoms.

In IBS, your bowel becomes sensitive to stimuli. The potential for abnormal colon/bowel function exists for everyone, but a trigger also must be present to cause symptoms. Identifying your triggers and avoiding them can help prevent the symptoms. Certain foods such as caffeine, dairy products, chocolate, nicotine, alcohol and high-fat food can all trigger an attack. Some common sense guidelines are:

• Eat at regular hours, chew food slowly and thoroughly and avoid large or high-fat meals or excess caffeine
• Drink six to eight cups of liquid daily, including fruit and vegetable juices and water
• Get regular physical activity
• Avoid delaying the urge to have a bowel movement
• Avoid straining during a bowel movement; try to relax and take your time