Expert interview on irritable bowel syndrome

Prof. Dr. med. Susan L. Lucak is Deputy Director of the Center for Intestinal Dysfunction and Gastroenterologist at the Columbia-Presbyterian Medical Center in New York. She also has a clinical medicine chair at the College of Physicians & Surgeons, Columbia University, New York. Dr. Lucak: Irritable bowel syndrome is the most common gastrointestinal disease in the US, affecting 15 to 20 percent of Americans. In Westeropa it is about 15 percent of the population. Suffering manifests itself in abdominal pain or discomfort associated with diarrhea (more than three bowel movements per day) or constipation (less than three bowel movements per week), or alternately diarrhea and constipation in the same person. The symptoms may seem insignificant, but can be severe and affect the quality of life of those affected. People with IBS are often absent at school or at work because of symptoms of the disease.

What causes IBS?

We do not know the exact cause of the irritable bowel. Most experts suspect a dysfunction of the nervous gastrointestinal system (the autonomic, intramural nervous system of the viscera, also called "second brain") as the basis for the disease. This network is structurally as complex as our brain. It is responsible for the control of gastrointestinal functions such as perception of pain in the intestinal area, intestinal movement and secretion of digestive juices.

People with irritable bowel syndrome tend to be more sensitive to pain, increased bowel activity, and increased secretion of digestive juice into the gut. The nervous system of the intestine is connected to the brain by nerve cells in both directions. Stress or emotional problems that affect the human brain are also transmitted to the intestines. Increased stress can therefore lead to increased irritable bowel syndrome.

Who is at risk of developing irritable bowel syndrome?

In the US, women are two to three times more likely to be affected by irritable bowel syndrome than men. In India it is the other way round - there are six times more men there. There is no uniform distribution on earth, and it is not easy to explain the pattern. Presumably, people in different cultures have their own understanding of medical care. The gender difference regarding the appearance of the irritable bowel needs to be examined more closely.

How does the affected person know if he or she is suffering from irritable bowel syndrome? Which are the specific characteristics?

IBS symptoms will be reported repeatedly and at regular intervals. Disease features include abdominal pain or discomfort, which improves after a bowel movement. Also, diarrhea, constipation or the appearance of constipation alternating with diarrhea are associated with the disease. Further, bloating, feeling of incomplete emptying after defecation, and mucus added to the stool are among the symptoms.

How is the diagnosis made?

The diagnosis IBS is made according to the ROME II guidelines due to clinical symptoms. These include abdominal pain or discomfort that improves after bowel movement, diarrhea or constipation, or alternately constipation and diarrhea during three months within a year, not necessarily for three consecutive months.

How is IBS treated?

In the past, only the symptoms of the disease were treated. This was done because one did not know the cause of irritable bowel syndrome. During the last two decades, we have been able to gain deeper insights into the nervous system of the internal organs. The independent, "second brain" is at the root of the problem of the irritable colon. In addition, serotonin, a large-scale neurotransmitter, plays an important role in the function of this autonomic nervous system. In fact, 95 percent of serotonin in the body is localized in the gastrointestinal tract.

What causes the greatest stress to people with IBS?

Life for people with IBS is in itself stressful as the symptoms appear suddenly. The abdominal pain can be very strong and affect daily life. Those affected must keep informed about the nearest public toilets, as they may lose control of the rectum in case of diarrhea and urgency (faecal incontinence). If constipation is the main problem, patients may feel bloated or in pain. They need a lot of time on the loo to squeeze and drain their bowels. All this affects the quality of life.

Often, patients also suffer from breastfeeding because it is not appropriate to speak publicly about the symptoms. Often, those affected withdraw from their environment, are forced to stay away from school or work, or avoid social events. All this leads to great stress in some patients.

Could you please list some of the side effects of treating IBS?

The anticholinergic drugs for mild forms of IBS can cause drowsiness, dry mouth, mild dizziness and constipation. The tricyclic antidepressants, however, are accompanied by similar side effects as the anticonvulsant drugs. You can also trigger a significant weight gain.

To what extent do psychological factors play a special role for IBS?

For some patients, psychological factors can play a very important role. Because the "first brain" communicates with the "second, " the intestines reflect what's going on in the head. Stress does not trigger any IBS, but it can aggravate the symptoms. Measures to combat anxiety attacks, depression and other psychological abnormalities should be combined with the bowel-matched treatment to achieve a more holistic improvement in health.

Hypnosis, biofeedback, cognitive behavioral therapy and psychodynamic therapy have proven to be beneficial when used appropriately. Recent studies have shown that combined treatment of psychological and gastrointestinal factors led to an improved overall condition.

Is there a connection between body and mind?

In a way, yes. I call it head-intestine interaction.

What happens to patients who do not want to be treated conventionally but as alternatives?

Alternative treatments are used worldwide in IBS patients, and they appear to be quite effective. I myself have no experience with it. But I got to know the Ayurvedic treatment method in India. It includes Buttermilcheinlauf, massage and steam therapy and, among other elements and meditation. Emphasis is placed on the maintenance of health and is focused on the treatment of body and mind. I think alternative treatments are very effective and think that the individual should be informed in advance.

Do IBS patients need to change their diet?

Many people think that their bowels function according to the food that is given to them. There is no specific diet for IBS. In general, I recommend that my patients eat a high fiber diet to increase their stool volume and make the stool more easily passable. To make the whole digestive passage more fluid, it helps to drink six to eight glasses of water daily.

I also recommend a low-fat diet, as high-fat food leads to increased bowel movements and thus more likely to spasmodic symptoms and pain in the abdominal area.

It is important to know if the patient is suffering from lactose intolerance to exclude lactose (milk sugar) from the diet. Some patients have specific food intolerances; they should avoid the food.

Can we do something to prevent IBS?

Since we do not know the cause of IBS, we also do not know how to prevent it. In the case of post-infectious IBS, one can at least prevent acute gastrointestinal disease. In practice this is difficult to realize. As far as the mental side of irritable bowel syndrome is concerned, one would have to ask oneself the question of how to avoid stress in life or how to prevent the negative side of life.

Here I would like to mention something important. IBS is not just a symptom, but a broad disease picture. There are probably many factors that lead to the different symptoms of IBS. If we learn to understand these factors better, we can better prevent IBS. The disease was first described in 1849. We can still learn a lot about it!

What is the prognosis for persons with IBS?

There is no cure for IBS, but the disease can be managed through targeted treatment directed to the internal organs and the brain. Patients treated in this way can already lead a much better life.

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