Irritable Bowel Syndrome

August, 2006

Irritable Bowel Syndrome (IBS), sometimes called spastic colon, irritable colon, or nervous stomach, is a functional disorder of the bowel. It is marked by abdominal pain, and associated with changes in bowel habit (either in frequency, urgency, or characteristics). A precise cause is unknown, but faulty interaction between the gut, brain, and central nervous system seems to result in the bowel becoming over-reactive (Characteristics of IBS, 2006).

Additionally, the pain receptors in many IBS patients’ guts are unusually sensitive (Irritable Bowel Syndrome, 2006). Stress and diet don’t cause IBS, but they can trigger symptoms.

Many people develop IBS after a bacterial infection in the intestinal tract (gastroenteritis). This condition is referred to as post-infectious IBS. As many as 78% of people with IBS have an overgrowth of intestinal bacterial (Pimentel, Chow, and Lin, 2000).

The major symptom of IBS is a change in the patient’s bowel function -- usually diarrhea, constipation, or alternating between the two. Other symptoms include bloating, abdominal fullness, flatulence, nausea, and reflux (where stomach contents “back up”). Some people experience exhaustion or chest pain that is not cardiac--related. Depression is prevalent in IBS patients.

People with IBS often have a lower quality of life. IBS can affect sleep, sexual functioning, business and personal obligations, and social life. IBS is further complicated by comorbidity with other conditions, such as fibromyalgia, Chronic Fatigue Syndrome (CFIDS), and thyroid disease.

Incidence and Costs
IBS is more common than diabetes, asthma, heart disease, or hypertension (Adams and Benson, 1991). It affects between 20%-22% of Americans, 60%-65% of whom are women (Characteristics of IBS). Up to 70% of those meeting the diagnostic criteria for IBS do not seek treatment (Irritable Bowel Syndrome, 2002). Annual U.S. direct medical costs are estimated at $1.35 billion annually (Inadomi, Fennerty & Bjorkman, 2003), with 3.5 million office visits and 2.2 million prescriptions filled (Sandler, 1990).

Indirect costs, amounting to $205 million, include frequent absenteeism (Inadomi, Fennerty & Bjorkman). One study estimated that IBS patients are absent from work or school three times more often than their non-IBS counterparts (Drossman, Li, et al, 1993). Authors of another study concluded that 25% of those with IBS worked fewer hours, and 20% changed their work schedule because of the condition (Hungin, Tack, 2002).

Diagnosis and Medical Treatment
Since there are no conclusive diagnostic tests, IBS is a diagnosis of exclusion. This means that the doctors usually rule out other possible causes of the symptoms. Medication is geared toward reducing or relieving symptoms. Prescriptives include antispasmodics, antidiarrhetics, laxatives, bulking agents, and prokinetic agents (to move food quickly through the bowel). If a patient is depressed or has severe pain that doesn’t respond to other treatment, two other classes of drugs (SSRIs and low-dose tricyclic antidepressants) are used.

Complementary Treatment
Early studies indicate that peppermint oil and Chinese herbal medicine warrant further study (Jailwala, Imperiale, and Kroenke, 2000), as do Slippery elm, fenugreek, devil's claw, tormentil and wei tong ning (Langmead, Dawson, et al, 2002). The results of one well-designed trial demonstrated that Chinese herbal medicine was significantly effective in improving symptoms, and quality of life (Bensoussan, Talley, et al, 1998).

Other non-pharmaceutical treatment includes patient education, diet modification (including identification and avoidance of food triggers), and mind-body therapies.

Mind-Body Approaches
There is a strong mind-body component to IBS, and emotions have been shown to affect gut motility (Salt and Neimark, 2002; Whorwell, Houghton, et al, 1991) and patient perception, as illustrated in the study where hypnotically induced anger and excitement increased the motility of the colon, while happiness reduced motility (Houghton, Calvert, et al, 2002).

The literature supporting mind-body therapies is compelling. Relaxation (Blanchard, Greene, and Scharff, 1993; Keefer and Blanchard, 2001, 2002; Voirol and Hipolito, et al, 1987) and biofeedback (Leahy, Clayman, et al, 1998) have shown success in improving symptoms and preventing relapse. One approach (relaxation, therapy, and medication) was effective in two-thirds of patients who had not responded to medication alone (Guthrie, Creed et al, 1992).

Another combination regimen (progressive muscle relaxation, thermal biofeedback, cognitive therapy, education) had a 50% success rate, maintained four years later (Schwarz, Taylor, et al, 1990). Meditation was able to affect improvements that were maintained a year later (Keefer and Blanchard, 2002).

Confirming the power of the mind-body connection, placebo, positive suggestion, and positive expectation were effective in reducing both the sensory and motor components of the gastric response in IBS patients (Simren, Ringstrom, et al, 2004). Placebo and positive suggestion increased the effectiveness of lidocaine in reducing pain (Vase, Robinson, et al, 2003).

Recent reviews of the literature confirmed the efficacy of hypnosis (Hussain and Quigley, 2006; Tan, Hammond, and Joseph, 2005; Whitehead, 2006). Hypnosis uses relaxation, suggestion, and imagery for its effects (Palsson, undated). Its positive effects may be due to changes in colorectal sensitivity and improved psychological factors (Simren, 2006).

Hypnosis has been shown to improve symptoms (Palsson, Turner, et al, 2002), even in severe refractory cases (Barabasz A, Barabasz M, 2006; Forbes, MacAulay, and Chiotakakou-Faliakou, 2000; Francis and Houghton, 1996; Galovski and Blanchard, 1998; Houghton, Heyman, and Whorwell, 1996; Roberts, Wilson, et al, 2006), and in cases where psychotherapy has failed (Whorwell, Prior, and Faragher, 1984). Improvements can be sustained at long-term (Gonsalkorale, Miller, et al, 2003; Gonsalkorale & Whorwell, 2005).

Both the Forbes et al. and the Galovsky et al. studies used gut-directed suggestion, and the results showed significant symptom improvement. Forbes specifically looked at the effect of therapeutic suggestions on audiotape and found them effective. The Houghton et al. study results showed “profound” improvement in physical symptoms (pain bloating and bowel habit). People also felt that their quality of life was better, and that they felt more in control of their situation. They lost less time at work and needed fewer doctor’s office visits than the control group (Houghton, Heyman & Whorwell).

Researchers of one review paper reported that, in 19 of 22 studies reviewed, psychotherapy was superior to medication (Svedlund, 2002). In another study, patients receiving therapy improved, while patients receiving medication deteriorated (Svedlund, Sjodin, et al, 1983). A large-scale British study (250 patients) confirmed that hypnosis significantly improved not only symptoms, but also depression, anxiety, and quality of life (Gonsalkorale, Houghton, & Whorwell, 2002).

An at-home pre-scripted hypnosis was also effective, but not as effective as one-on-one hypnosis (Palsson, Turner, & Whitehead, 2006). Both individual and group hypnosis sessions proved effective (Harvey, Hinton, et al, 1989).

Mind-body techniques are effective in not only reducing IBS’s physical symptoms, but also in lifting depression and/or improving quality of life (Blanchard, Radnitz, et al, 1987; Gonsasalkorale, Toner, & Whorwell, 2004; Houghton Heyman & Whorwell, 1996; Read, 1999).

A very low-cost guided imagery program can improve patients’ abilities to cope with IBS pain, reduce or eliminate its symptoms and/or recurrences, reduce office visits, absenteeism and, in some cases, medications. These benefits can be long-lasting. It may improve patients’ quality of life and symptoms, even in difficult IBS cases.

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