Salt ibs book by Ohio Gastro Group

IBS Irritable Bowel Syndrome A Gastroenterologist Answers Your Questions Author: William B. Salt II, M.D. Cover design: Susan Edison, Edison Design Illustrations: William B. Salt II, M.D. Photography and editing: Susan S. Salt ÂŠ William B. Salt II, M.D. Parkview Publishing http://www.IBSAnswersForYou.com This is PDF version 1.01 of the ebook prepared exclusively for patients of Ohio Gastroenterology Group, Inc. Version 1.01. All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form, or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the prior written permission of both the copyright holder and the publisher of this book. Purchase only authorized editions. 1

Sanibel, Florida

This book is not intended as a medical manual. The information provided is designed to assist you in making informed decisions regarding your health. It cannot serve as a substitute for consultation with a medical doctor. The author and publisher recommend that you be aware of your condition and seek competent medical help before you begin any health program, including making dietary changes and undertaking an exercise plan. 2

Table of Contents

Going deeper

Dedication Foreword Introduction Case Presentations 1) What Is It? 2) What Causes It? 3) How Can I Get Well? 4) IBS-D (Diarrhea) 5) IBS-C (Constipation) 6) Belching and “Gas” Afterword About the Author Updates Resources Biopsychosocial Models “IBS”

Dedicated to You, the Patient Nerita Beach Sanibel, Florida

Finding your way

This PDF version of the ebook is prepared exclusively for you, a patient of Ohio Gastroenterology Group, Inc. The ebook is available in online bookstores, including Amazon, Apple, and Barnes and Noble. Consult the authorâ&#x20AC;&#x2122;s website for more information: www.IBSAnswersForYou.com If you have IBS, this ebook will answer three questions: What is it? What causes it? How can I get well? However, IBS is one of over 30 Functional GI Disorders (FGIDs), including heartburn that does not respond to treatment with powerful acid reducing drugs and dyspepsia/epigastric upper abdominal pain unresponsive to ulcer treatment. IBS and FGIDs are all interrelated and commonly occur together. They share common causes. Therefore, this ebook will help if you suffer with any FGID.

Foreword Life is difficult. M. Scott Peck, M.D. opens The Road Less Traveled with this great truth. While beautiful and mysterious, life is also complicated. We have pain and symptoms, negative thoughts and memories of old hurts, stress, and emotional distress. As many as 1 in 5 of us has IBS, and life has a lot to do with causing it. By contrast, the disease of IBS makes life even more difficult. It’s a vicious circle. Life

IBS I’m a M.D. gastroenterologist in a group of 36 (Ohio Gastroenterology Group in Columbus, Ohio) with 35 years of experience caring for patients with IBS while teaching both medical students and doctors in training. I’m going to answer your IBS questions in this book. You’ll become an “IBS expert,” so you can work effectively with your doctor and other caregivers to get better. Join me on a short journey through the pages of this book. It will change your life. It’s go time! 7

Introduction Larry & Buck Salt

Letâ&#x20AC;&#x2122;s go!

On your IBS journey, you’ll want to keep in mind:

• IBS involves your entire body: GUT (gastrointestinal tract or GI tract), HEAD (mind/brain), and their CONNECT (intercommunications).

• You have two brains: one in your HEAD and one in your GUT.

• Your two brains are in 24/7 communication with one another through the CONNECT; they are both independent and interdependent.

• IBS is a disease — it’s a disturbance of how your body and brains function and work together.

• Medical tests do not detect this disturbance, or “dysfunction.”

• IBS often occurs with other diseases. • You can get better by changing both brains with your mind AND by applying the latest medical treatment.

Case Presentations

Nerita Beach Sanibel, Florida

Beautiful Mysterious Complicated

Anne (name changed to protect confidentiality) is a 26 year old woman referred to the Ohio Gastroenterology Group IBS Clinic with â&#x20AC;&#x153;IBS.â&#x20AC;? She began having symptoms sometime in high school, with cramping pain in her lower abdomen associated with diarrhea. The diarrhea is often loose and even watery brown. Both diarrhea and pain are often triggered by eating and unrelated to specific foods. She feels better following defecation. While she does not awaken from sleep with diarrhea, urgency can be very distressing, and she prefers to know the location of the bathroom wherever she may go. She has not lost any weight or noticed blood in the stool. She suffers from abdominal bloating and even distention, which is abdominal enlargement that worsens throughout the day. She has had blood tests and even a colonoscopy by another gastroenterologist showing no cause for her distressing symptoms, which very much interfere with the quality of her life. Her physical examination is normal. Author comment: Anne describes the typical symptoms of IBS-D (diarrhea), which is the first of two main IBS subtypes.

John (name changed to protect confidentiality) is a 35 year old man referred to the Ohio Gastroenterology Group IBS Clinic with constipation. He has been suffering with constipation much of his life, but the problem has worsened over the past several years. He has cramping abdominal pain in the middle and lower abdomen that worsens each day he has not had a bowel movement, and he can sometimes go as long as 10 days without one. He feels better following defecation. The stools are hard and often difficult to pass, so it is often necessary for him to strain hard. He has not lost any weight or noted rectal bleeding. He has had blood tests and even a colonoscopy by another gastroenterologist showing no cause for the distressing symptoms, which very much interfere with the quality of his life. His physical examination is normal. Author comment: John describes the typical symptoms of IBS-C (constipation), which is the second of two main IBS subtypes.

Sandy (name changed to protect confidentiality) is a 47 year old woman referred to the Ohio Gastroenterology Group IBS Clinic with abdominal pain, diarrhea, and heartburn. She has symptoms consistent with IBS-D (diarrhea), but she also has heartburn and upper abdominal pain that may or may not be related to eating, and which do not improve with powerful acid reducing medications. Her symptoms developed suddenly following an acute food-related bacterial gastroenteritis. She had not recalled this until she was asked specifically about how the symptoms began. She has had blood tests and even endoscopy and colonoscopy by another gastroenterologist showing no cause for her distressing symptoms, which very much interfere with the quality of her life. Her physical examination is normal. Author comment: Sandy describes the typical symptoms of IBS-D (diarrhea), which are also associated with upper digestive symptoms unexplained by testing and unresponsive to treatment. Her symptoms began suddenly following food-borne GI infection. She did not realize that all of her symptoms are interrelated and share a common cause. 13

Jennie (name changed to protect confidentiality) is a 55 year old woman referred to the Ohio Gastroenterology Group IBS Clinic with abdominal pain, diarrhea, and heartburn. Her symptoms are similar to those that Sandy describes, but she also has fatigue, widespread pain, headaches, and a painful bladder. She has seen several specialists and been diagnosed with fibromyalgia, tension headaches, and interstitial cystitis. She has had blood tests and even endoscopy and colonoscopy by another gastroenterologist showing no cause for her distressing symptoms. All of her symptoms very much interfere with the quality of her life. Her physical examination is normal. Author comment: Jennie describes the typical symptoms of IBS-D (diarrhea), which are also associated with upper digestive symptoms unexplained by testing and unresponsive to treatment. She has many other troublesome symptoms and diagnoses and did not realize that they are all interrelated and share a common cause.

Chapter 1

What Is It? Sanibel, Florida

Text Text

Collecting information 15

Welcome! You’re going to learn that IBS is a real disease that involves the whole of you. You’ll understand how doctors define IBS, know what the symptoms are, learn about other related diseases, and appreciate how the diagnosis of IBS is made. Sections in Chapter 1 What is IBS? IBS Involves Your Whole Body The Biopsychosocial Model of IBS Definition of IBS GUT Anatomy Functional GI Disorders (FGIDs) Functional Symptom Syndromes Normal Bowel Movement Frequency and Amount Abdominal Pain and/or Discomfort Bowel Movement Form (Consistency) Other Common Symptoms Abdominal Wall Pain Diary Diagnosis 16

IBS Involves Your Whole Body See yourself in Figure 1.1.

Figure 1.1 The target is your GUT (GI tract). The red circle is your HEAD (mind/brain). The arrows are your CONNECT (their communication systems). A good part of your problem resides in your GUT. This is the basis for GUT therapy, which can reduce spasm and sensation of the GI tract with dietary changes, enzyme supplements, and medications. Triggers within the GUT can be managed, such as bile salts and bacteria that live there.

But your HEAD plays an equally important role in causing the pain and symptoms of IBS. This is the basis for HEAD therapy, which can reduce heightened pain and symptom sensitivity in the brain, negative thoughts and effects of old hurts, harmful stress, and emotional distress. CONNECT therapy is directed to the communication systems between your HEAD and GUT.

The Biopsychosocial Model of IBS Now see that YOU are a complex system (Figure 1.2). THOUGHT

HEAD

Conscious Subconscious Memory

SENSITIVITY

Pain & Symptoms

STRESS

CONNECT EMOTION Depression Anxiety

GUT

YOU

Gender Nature/Nurture Figure 1.2 The Biopsychosocial Model of IBS Doctors explain the disease of IBS (and all diseases) with a model that integrates the body (bio), the mind/ brain (psycho), and your relationship with the world, including other people (social). (The spiritual dimension will not be discussed in this book.) Even though YOU are complicated, you can and you will understand this model by the time youâ&#x20AC;&#x2122;ve finished your journey here. IBS cannot be understood any other way. 19

Definition of IBS The medical diagnosis of IBS is based upon symptoms of abdominal pain and/or discomfort associated with bothersome bowel symptoms: diarrhea, constipation, or both. IBS symptoms are recurrent at least 3 days per month in the last 3 months. Furthermore, symptoms must have an onset at least 6 months prior to the diagnosis of IBS. The pain and symptoms of IBS are not imagined or all in your head. IBS is not a psychiatric or psychological diagnosis, even though emotional distress can be associated and require treatment. IBS is a functional symptom syndrome. “Functional” refers to how the body works. When doctors say a symptom or collection of symptoms (a “syndrome”) is functional, they mean “dysfunction” or disturbance of how the body works. Disease is dysfunction. Pain and symptoms are the expression. IBS is a real disease. Medical tests are normal with functional diseases, such as IBS. Blood tests, x-rays, endoscopies, and scans don’t show the dysfunction. 20

GUT Anatomy The GI tract (GUT) extends from the throat to the anus and is about 30 feet in length (Figure 1.3).

Figure 1.3 The GUT IBS affects the colon, which is shaped like a horseshoe. The arrow points to the sigmoid colon. The colon is about 3 feet long and is the lower part of the GUT. The digestive contents passed down from the small intestine are liquid. The colon absorbs fluid, making the waste solid and storing it. The sigmoid colon is the most common location of IBS pain, because it is the most muscular portion. 21

Functional GI Disorders (FGIDs) IBS is the most common functional symptom syndrome of the GUT. Gastroenterologists call these symptom syndromes, “Functional GI Disorders” (FGIDs). You can learn more about the FGIDs at the Rome Foundation website: www.RomeCriteria.org (Figure 1.4). Or click “Rome III Diagnostic Criteria” circled in red on the left menu.

Figure 1.4 www.RomeCriteria.org Rome Foundation Website Functional GI Disorders (FGIDs)

The symptoms of FGIDs can involve any location of the GUT from the top to the bottom (Figure 1.5).

Figure 1.5 FGIDs can affect the GUT anywhere from the throat (top red arrow) to the rectum and anus (bottom red arrow).

Gastroenterologists describe over 30 FGIDs, the most common of which are listed below:

• Globus (lump in the throat) • Chest pain (like heart angina) • Heartburn (not responsive to treatment with strong acid reducing drugs) • Belching • Rumination (regurgitation not caused by acid reflux) • Dyspepsia or epigastric pain (pain or discomfort in the middle of the upper abdomen often related to eating not caused by acid or ulcer) • Abdominal bloating/distention (distention is abdominal enlargement) • Biliary (attacks of severe upper abdominal pain without gallstones) • Nausea • Vomiting • IBS • Constipation (without pain) • Abdominal pain (without bowel dysfunction) • Rectal pain

The FGIDs are all interrelated and commonly co-occur. Most IBS patients have more than one FGID. One of the most common combinations of FGIDs is heartburn (not responsive to treatment with strong acid reducing drugs), dyspepsia/epigastric pain not caused by acid or ulcer, and IBS (Figure 1.6).

FGIDs Heartburn

Dyspepsia

IBS

Figure 1.6 Functional GI Disorders (FGIDs) often co-occur, with the three most common in combination shown here. 25

Functional Symptom Syndromes Any part of the body can express the pain and symptoms of a functional symptom syndrome. They are often called “somatic” syndromes, with the term referring to the body. Specialists in almost every area of medicine define at least one of these dysfunctional syndromes, the most common of which are listed below:

• FGIDs (IBS is the most common) • Fibromyalgia (widespread pain and fatigue) • Fatigue • Headaches • TMJ (temporomandibular joint disorder) • Myofascial pain (pain that can occur anywhere in muscles and soft tissues) • Irritable larynx syndrome (chronic cough, lump in the throat, muscle spasm in the throat, hoarseness, throat clearing, voice dysfunction) • Chronic low back pain • Interstitial cystitis (painful bladder syndrome) • Chronic pelvic pain • Dysmenorrhea • Multiple chemical sensitivity • Multiple medication sensitivity 26

The FGIDs are functional symptom syndromes, which are similarly interrelated (Figure 1.7).

Functional Symptom Syndromes FGIDs HA

IC IBS

LBP FM

Figure 1.7 FGIDs are functional symptom syndromes. The most common symptom syndromes are represented here: HA = headaches; CF = chronic fatigue; FM = fibromyalgia; LBP = low back pain; IC = interstitial cystitis. 27

Functional symptom syndromes often occur together (Figure 1.8).

Functional Symptom Syndromes FGIDs IBS FM

Figure 1.8 Functional symptom syndromes often occur together because they all share common causes (Chapter 2). As many as one half of IBS patients also have fibromyalgia (FM). 28

Normal Bowel Movement Frequency and Amount The normal bowel movement frequency is from 3 stools each day to 3 per week (Figure 1.9).

Range 3/day

Normal # stools/day

3/week

Figure 1.9 Normal bowel movement frequency In developed countries, the normal amount of stool per bowel movement is about 7 ounces (Figure 1.10).

Figure 1.10 The normal amount of stool in a bowel movement would not quite fill an 8 ounce glass. 29

Abdominal Pain and/or Discomfort Abdominal pain and discomfort may or may not mean the same thing to you (some patients don’t consider the abdominal symptom to be pain). If possible, try to determine whether abdominal pain and discomfort are the same or different symptoms. Remember, the pain or discomfort of IBS is associated with bowel dysfunction. So your abdominal pain or discomfort is associated with two or more of the following:

• Improvement after a bowel movement • Change in stool frequency (either more or less often than normal, which is 3 a day to 3 per week)

• Change in stool form (appearance) or consistency (either loose or hard) Abdominal pain or discomfort without bowel dysfunction is not IBS. A diagnosis of IBS cannot be considered in a patient with chronic and recurrent abdominal pain unless bowel dysfunction is associated.

The pain of IBS is usually located in the left lower quadrant (LLQ) of the abdomen. Recall that this is the location of the sigmoid colon (Figure 1.11).

RUQ

LUQ

RLQ

LLQ

Figure 1.11 The most common location of IBS pain is the LLQ. But IBS pain can be located anywhere in the belly or involve the entire abdomen. Pain can be referred into the pelvis and back. The pain can even be referred into the chest and upper thighs. 31

The abdominal pain is usually colicky, coming and going in a cramping fashion. It can last for a few minutes or for hours. But the abdominal pain can be constant. Its character can be dull, aching, sharp, or burning. Pain often occurs after eating. Diarrhea or loose stools are often associated with pain triggered by meals. Abdominal pain can occur in sudden â&#x20AC;&#x153;attacks.â&#x20AC;? These episodes can be so severe that the patient decides to visit a doctor immediately or go to the emergency room. When associated with constipation, the pain commonly becomes increasingly severe each day without having a bowel movement and is relieved after having a bowel movement. When associated with diarrhea, the pain often worsens around the time of bowel movement but is usually relieved following defecation. Research shows that pain is a symptom experienced with more significant intensity or severity than is discomfort. When describing abdominal pain to your doctor, itâ&#x20AC;&#x2122;s more helpful to rate the intensity (severity) of the pain than to describe the frequency (how often it occurs). 32

It helps your doctor to better understand your IBS if you describe your pain based upon new government guidance on IBS for industry and researchers. Rate your â&#x20AC;&#x153;worst abdominal pain over the past 24-hoursâ&#x20AC;? on a 10 point scale, with 0 = no pain and 10 = very severe pain (Figure 1.12). 1 2 3 4 5 6 7 8 9

NONE 0

Range of your worst abdominal pain over the past 24-hours

SEVERE 10

Figure 1.12 Record the number daily for at least one week. Then compute the weekly average. Note that if you had pain all day rated about a 3 but that if the intensity of the pain reached a 6 for a short period of time, then your worst abdominal pain over the past 24-hours would be 6. For example, your daily worst abdominal pain over the past 24-hours was 4+6+8+5+7+6+6 = total of 42. Divide 42 by 7 days in the week = 6. So the weekly average of your worst abdominal pain over the past 24-hours is 6. 33

Bowel Movement Form (Consistency) The Bristol Stool Form Scale can help both you and your doctor understand what your bowel dysfunction is like (Figure 1.13). Type 1

Separate hard lumps, like nuts (hard to pass)

Type 2

Sausage-shaped but lumpy

Type 3

Like a sausage but with cracks on the surface

Type 4

Like a sausage or snake, smooth and soft

Type 5

Soft blobs with clear-cut edges

Type 6

Fluffy pieces with ragged edges, a mushy stool

Type 7

Watery, no solid pieces; entirely liquid

Figure 1.13 The Bristol Stool Form Scale

Other Common Symptoms Most patients with IBS report symptoms that are not part of the formal definition. Belching and “gas” include air expelled from the mouth and abdominal bloating, abdominal distention (enlargement), loud abdominal noises, and excessive flatulence or farting (Chapter 6). Meal triggered symptoms, including abdominal pain, “gas,” and diarrhea are commonly described by patients suffering with IBS (Figure 1.14).

Treat? or Trigger?

Treat? Or trigger?

Figure 1.14 At least one half of IBS patients experience symptoms that occur during or after meals. 35

Mucus is a white stringy substance similar to thick saliva normally made by the colon lining. IBS patients often misinterpret mucus in or on the stool as pus or infection. Menstruation often triggers IBS pain and diarrhea. IBS is often associated with painful menstruation syndrome (dysmenorrhea). Both are functional symptom syndromes. Fatigue is the most common non-GUT symptom that patients with IBS report. Autonomic nervous system symptoms include shortness of breath, fast heart rate (tachycardia), dizziness (low blood pressure), feeling sweaty (diaphoresis), and nausea. The autonomic nervous system is involved with GUT function. Abdominal cramping, bowel changes, nausea, and vomiting are related to autonomic nervous system dysfunction in the GUT.

Abdominal Wall Pain (AWP) Many patients with IBS also have abdominal pain originating in the abdominal wall. Some patients with this problem are incorrectly diagnosed with IBS, even though they do not have associated bowel dysfunction. AWP commonly involves the right upper quadrant (RUQ) of the abdomen (Figure 1.15).

RUQ

LUQ

RLQ

LLQ

Figure 1.15 Abdominal wall pain (AWP) often occurs in the right upper quadrant (RUQ) of the abdomen. The liver and gallbladder are located under the ribs just above the RUQ, so AWP frequently leads to imaging with ultrasound, CT scan, or MRI.

AWP may or may not be close to an old surgical scar. It also may be located at the outer edge of the abdominal muscle (rectus abdominis). The pain is usually sharp and there is often extreme tenderness upon gentle stroking or pinching of the skin over the area of pain. The tenderness on abdominal examination is typically sharply localized to a very small area (the size of a quarter or fifty cent piece), but it can be more broadly distributed. AWP can be aggravated by wearing tight clothing and gaining weight. Triggers include changing body position, standing, lifting, stretching, or coughing. Relief may be found by sitting, lying, or pressing on the affected area. A diagnostic clue to AWP on physical examination of the abdomen is called the Carnette test, where the tenderness continues or increases with tensing of the abdominal wall by elevating the head and shoulders or raising the legs. Click here to see a video of the Carnette test. AWP can be caused by localized myofascial pain (muscle tension), nerve entrapment, or hernia. It can be treated with properly placed anesthetic/steroid injection, physical therapy, and sometimes with surgery. Diabetics can develop severe AWP called, â&#x20AC;&#x153;thoracolumbar radiculopathy.â&#x20AC;? 38

Diary Patients and doctors donâ&#x20AC;&#x2122;t have much time to spend together. This limitation commonly interferes with the diagnostic process. Now you know how to accurately describe your pain and bowel symptoms. Keeping a symptom diary will also help your doctor comprehend and understand what you are experiencing. As you will soon discover, you and your doctor are going to try to subtype your IBS based upon the predominant bowel dysfunction, because successful and appropriate IBS treatment depends upon it. Hereâ&#x20AC;&#x2122;s how to keep a daily symptom diary for at least one week, where you record abdominal pain, stool frequency, stool consistency, and then your overall IBS symptom assessment at the end of each week.

• Record your “worst abdominal pain over the past 24-hours” each day. Compute the weekly average.

• Record your daily stool frequency. • Record your daily stool consistency (refer to the Bristol Stool Form Scale).

• Determine your overall (global) IBS symptom assessment at the end of each week:

‣ Very severe ‣ Severe ‣ Moderate ‣ Mild ‣ None

Diagnosis The foundation of IBS diagnosis is recognition of the characteristic pain and symptoms that meet the Rome III Diagnostic Criteria (C1, page 889 of the PDF). Doctors are increasingly encouraged to make a symptom-based diagnosis of IBS based upon these criteria, as long as symptoms and findings that raise concern about presence of a disease masquerading as IBS are absent. (You will learn about these “Red Flags” shortly.) However, the reality in clinical practice is that most primary care specialists are not familiar with Rome criteria, and few gastroenterologists use them. The criteria may not distinguish IBS from several diseases and conditions that mimic or trigger IBS. Furthermore, they may not identify coexisting diseases. The gastroenterologists of the Ohio Gastroenterology Group use a comprehensive and customized “state of the art” method to establish the diagnosis of IBS in our IBS Clinic. This method includes consideration of the following:

• Confirmation that Rome III symptom-based criteria are met

• Recognition of sudden onset • Effect of antibiotics • Classification by subtype • Recognition of associated FGIDs • Recognition of heightened sensitivity to pain and symptoms

• Acknowledgement of stress • Screen for emotional distress and negative thoughts • Identification of “red flags” • Consideration of

“differential diagnoses”

• “IBS Plus” other diseases

Confirmation that Rome III symptom-based criteria are met Recall that the pain/discomfort of IBS must be associated with bowel dysfunction and have been present for 6 months. Recognition of sudden onset Research confirms that many patients with IBS-D or IBS-C and other FGIDs, such as heartburn and dyspepsia/epigastric pain report the sudden onset of their symptoms following the GI â&#x20AC;&#x153;flu,â&#x20AC;? gastroenteritis, or suspected food poisoning. Patients may not recall this unless the doctor asks about it. While a specific infectious cause may be found on stool culture (nontyphoid Salmonella, Campylobacter, Shigella, or Yersinia enterocolitica), the culprit is commonly not identified. A clue is that one or more other people also became sick around the same time. Effect of antibiotics Some IBS-D patients benefit by antibiotics, while others find that their symptoms are worsened by them. If symptoms are strongly affected by antibiotics, small intestinal bacterial overgrowth may be present, which many be treatable.

Classification by subtype Two main IBS subtypes are determined based upon the predominant bowel dysfunction: IBS-D (diarrhea) and IBS-C (constipation). Treatment is based upon this classification. Three other subtypes may also be recognized. IBS-D (diarrhea)

• Diarrhea is the troublesome symptom. • Constipation is not a troublesome symptom. • Abdominal pain intensity (severity) is 3 or greater. • Stool form (consistency) is either a Bristol Stool Form 6 or 7 (which is loose or watery) at least twice a week.

• Bowel function is irregularly irregular in frequency and form. Bowel frequency commonly varies from day to day. Bowel form commonly varies in the average week with 3 or more different stool forms based upon The Bristol Stool Form Scale.

IBS-C (constipation)

• Constipation is the troublesome symptom. • Diarrhea is not a troublesome symptom. • Abdominal pain intensity (severity) is 3 or greater. • There are fewer than 3 complete spontaneous bowel movements per week (without laxatives).

• Stool form is usually but not invariably hard (Bristol Stool Form 1 or 2). IBS-M (mixed) Stool form varies from loose to hard over hours to days. Treatment guidelines for IBS-M are not clear, but stress, emotional distress, and diet are often symptom triggers. IBS-A (alternating) Stool form changes over weeks to months, most commonly from IBS-D to IBS-C. IBS-PI (post-infectious) Approximately 25% of patients diagnosed with IBS report the sudden onset of the disease following an acute GI infection.

Recognition of associated FGIDs As you have learned, most patients diagnosed with IBS also suffer from one or more FGID. The most common FGIDs that occur with IBS are functional heartburn that does not respond to strong acid reducing drugs and dyspepsia/epigastric pain not caused by acid or ulcer.

Recognition of heightened sensitivity to pain and symptoms As you will soon understand, most patients suffering with IBS also have central nervous system (CNS) dysfunction, which amplifies sensations and feelings originating in the body and GUT. This dysfunction is called, “central sensitivity” represented in Figure 1.16, which will appear in several later illustrations.

Figure 1.16 The speaker with a high volume control setting represents “central sensitivity,” which increases sensation to pain and symptoms in the body and GUT. There are no tests for central sensitivity outside of research centers. However, heightened sensitivity to pain and symptoms can be easily recognized by the following (the more present, the greater the likelihood that central sensitivity is present): 47

• Chronic pain anywhere or widespread • Functional GI disorder (FGID) diagnosed • Functional symptom syndrome diagnosed • Fatigue • Memory and concentration problems (“brain fog”) • Insomnia • Sensitivity to foods, medications, chemicals, light, sound, odors

• Family history of chronic pain, FGIDs, or functional symptom syndromes

• Abuse history (physical, emotional, sexual)

Acknowledgement of stress Life is difficult. Life is stressful. These are universal life truths for everyone. Science confirms the body and brain are constantly damaged by stress and that much of it occurs without our conscious awareness. Stress triggers and exacerbates IBS pain and symptoms. While there are many “stress tests” available, what’s most important is that you accept the fact that life is stressful and hurts you (Figure 1.17).

Figure 1.17 “The Stress Ball” While in college years ago, my daughter Shelley once confided, “Dad, I’m such a ‘stress ball!’” She created this illustration. 49

Screen for emotional distress and negative thoughts The Ohio Gastroenterology Group IBS Clinic uses a screening tool to help identify psychosocial problems commonly faced by patients suffering with FGIDs. The questionnaire screens for anxiety, depression, suicidal ideas, pain severity, impairment, impaired coping, and abuse. Click here to review the Rome III Psychosocial Alarm Questionnaire for the Functional GI Disorders (FGIDs).

Identification of “red flags” The diagnosis of IBS is based upon absence of certain history, symptoms, or findings called, “red flags” (Figure 1.18).

Figure 1.18 “Red flags” raise concern that a disease is present that either mimics, co-occurs with, or aggravates symptoms of IBS.

Red flag history

• Onset over age 50 • Symptoms progressively worsening • Vomiting • Weight loss • Blood in the stool • Diarrhea that is constant or occurs during the night • Flushing that is dry • Family history of colorectal cancer • Family history of inflammatory bowel disease • Family history of celiac disease

Red flag test results

• Complete blood count: anemia, inflammation, and cancer)

• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): inflammation

• Stool calprotectin: inflammation • Comprehensive metabolic panel (CMP) with many tests, including:

‣ Albumin: low with inflammation, malabsorption, cancer

‣ Total protein: high with inflammation ‣ AST and ALT: most common elevation caused by fatty liver

‣ Alkaline phosphatase: elevation comes from either bone or liver disease

‣ Bilirubin: most common cause of elevation is a harmless condition (Gilbert’s syndrome) Note: certain alternative evaluations have not been validated or shown to be helpful, such as stool testing for dysbiosis and small intestinal bacterial overgrowth.

Consideration of â&#x20AC;&#x153;differential diagnosesâ&#x20AC;? Testing for several diseases and disorders may be necessary before a diagnosis of IBS can be established, because they can be mistaken for IBS. Furthermore, new research shows that several conditions commonly trigger or aggravate IBS symptoms. The most common of these are malabsorption of bile acids and carbohydrates, non-celiac gluten sensitivity, and small intestinal bacterial overgrowth.

IBS-D (diarrhea) Recall that the symptoms are commonly triggered by eating and that actual diarrhea must be present (Figure 1.19).

Type 6

Fluffy pieces with ragged edges, a mushy stool

Type 7

Watery, no solid pieces; entirely liquid

Figure 1.19 Stool form (consistency) in IBS-D is either a Bristol Stool Form 6 or 7 at least twice a week.

• Inflammatory bowel disease or IBD (Crohn’s disease and ulcerative colitis) is usually diagnosed with colonoscopy, but scans, x-rays, and/or small intestinal capsule endoscopy (a tiny swallowed camera) may be needed.

• Celiac disease is an intestinal injury caused by gluten in wheat, barley, and rye resulting in impaired absorption of nutrients and fat (malabsorption). The diagnosis is based upon blood tests and duodenal biopsies at endoscopy. 55

• Microscopic colitis is different than IBD. Diagnosis is made with colonoscopy and biopsies, because there are no visible changes in the colon lining.

• Colon and rectal cancer (CRC) affects at least 150,000 Americans each year. The red flag symptom of rectal bleeding or hidden (occult) blood in the stool may or may not be present. Diagnosis is usually made with colonoscopy.

• Fat malabsorption caused by intestinal or pancreatic disease is detected with a stool test for increased fecal fat.

• Diverticular disease of the colon Diverticulosis of the colon (small outpouches) becomes increasingly common with aging. Inflammation is a complication of diverticulosis called, “diverticulitis.” Subsequently, symptoms of IBS-D can develop or persist even if the inflammation has healed. Diagnosis is made with colonoscopy and CT scan.

• Bile acid malabsorption (BAM) occurs in at least one of every three patients otherwise diagnosed with IBSD and is a common cause of symptoms triggered by eating. Since there’s no test for BAM available to doctors outside of research centers, diagnosis requires a treatment trial with a bile acid binding drug for diagnosis.

• Carbohydrate malabsorption Certain carbohydrates in the diet can be fermented by the GUT bacteria, resulting in gas symptoms. Diagnosis is based upon hydrogen breath testing and assessing response to dietary treatment.

• Non-celiac gluten sensitivity (NCGS) This recently recognized disorder is considerably more common than is celiac disease. Diagnosis requires testing to exclude celiac disease and a dietary treatment trial, since a medical test for NCGS is not available.

• Small intestinal bacterial overgrowth (SIBO) can contribute to IBS symptoms. Diagnosis of SIBO depends upon either a hydrogen breath test, treatment trial, or both.

IBS-C (constipation) Recall that there are fewer than 3 complete spontaneous bowel movements per week (without laxatives) in IBS-C and the stool form is usually hard (Figure 1.20).

Type 1

Separate hard lumps, like nuts (hard to pass)

Type 2

Sausage-shaped but lumpy

Figure 1.20 The stool form in IBS-C is usually but not invariably hard (Bristol Stool Form 1 or 2).

• Diverticulosis of the colon (small outpouches) becomes increasingly common with aging. Inflammation is a complication called, “diverticulitis.” Subsequently, symptoms of IBS-C can develop or persist even if the inflammation has healed. If inflammation persists or inflammation from scar tissue develops, blockage can occur. Diagnosis is made with colonoscopy, CT scan, and barium enemia.

• Inflammatory bowel disease or IBD (Crohn’s disease and ulcerative colitis) is usually associated with diarrhea, but some patients are constipated. IBD is usually diagnosed with colonoscopy, but scans, xrays, and/or small intestinal capsule endoscopy (a tiny swallowed camera) may be needed.

• Functional constipation is a (FGID) that can co-occur with IBS-C. There are three main types: 1. Normal transit (stool movement through the colon is normal) 2. Slow transit (stool movement through the colon is slow) 3. Obstructed defecation (stool evacuation from the rectum and anus is difficult). Decreased stool frequency and/or difficulty evacuating stool from the rectum are the bothersome symptoms, rather than abdominal pain and discomfort. As with IBSC, the stool is not necessarily hard. Obstructed defecation is the most important type of functional constipation to recognize, since it can be treated. 59

The most common type of functional constipation that occurs along with IBS-C is obstructed defecation, with the following symptom clues:

‣ Straining to defecate ‣ Incomplete rectal emptying ‣ Sense of anorectal blockage ‣ Need for applying pressure between or within the vagina and rectum

‣ Actual direct evacuation of the stool from the rectum with the fingers These symptoms may or may not be present, and special testing is necessary to diagnose obstructed defecation:

‣ Digital rectal examination (DRE) ‣ Rectal balloon expulsion A good screening test for obstructed defecation is inability to defecate a rectal balloon inflated in the rectum within a short period of time (Figure 1.21).

Figure 1.21 The rectal balloon expulsion catheter is used to screen for functional obstructed defecation.

â&#x20AC;Ł Anorectal manometry This test involves inserting a special soft balloon into the rectum to evaluate the function and coordination of anal sphincters and pelvic floor muscles. Anorectal manometry requires very sophisticated equipment to record and analyze the results.

â&#x20AC;Ł Sitzmarks Colonic Transit Diagnostic Test This test involves swallowing a small capsule that contains 24 tiny soft rings which can be seen on a plain x-ray of the abdomen (Figure 1.22).

Figure 1.22 The Sitzmarks capsule The plain abdominal x-ray is taken 5 days later to determine the location and extent of elimination of the rings.

Interpretation is based upon the extent of elimination of the rings and their location if retained (Figures 1.23 - 1.25).

Figure 1.23 If 5 or less markers remain, colonic transit is probably normal.

Figure 1.24 If most rings are scattered about the colon, slow colon transit is likely. 63

Figure 1.25 If most rings are gathered in the rectum and sigmoid colon, functional obstructed defecation is likely.

“IBS Plus” other diseases As you have learned, IBS commonly co-occurs with other functional GI disorders (FGIDs), such as heartburn unresponsive to treatment and functional symptom syndromes, such as fibromyalgia. Most patients and many doctors don’t know that IBS commonly co-occurs with other GI (GUT) diseases. The author calls this co-occurrence, “IBS Plus” (Figure 1.26).

Other Diseases

IBS Figure 1.26 “IBS Plus” IBS commonly co-occurs with several diseases, such as diverticular disease of the colon, inflammatory bowel disease, and celiac disease.

It’s important to recognize “IBS Plus,” so the IBS can be treated and the other disease isn’t over-treated or mistreated. A common example is shown in Figure 1.27.

IBS

IBD

Figure 1.27 An example of “IBS Plus” is IBS + IBD. IBD is Inflammatory Bowel Disease (Crohn’s disease and colitis). In the example of IBS+IBD, the disease activity and inflammation of IBD may not explain symptoms of diarrhea and abdominal pain, which are more related to the co-occurring IBS. Medical testing may be required to evaluate for disease activity and inflammation in order to avoid unneeded IBD treatment. Now you’re ready to learn what “causes” IBS and why it’s commonly associated with functional GI disorders (FGIDs) and functional symptom syndromes.

Chapter 2

What Causes It? Nerita Beach Sanibel, Florida

Examining

What causes IBS? You’re ready to discover answers to this second question. Here’s a hint: Note the “s” in the word, “causes.” There’s more than one cause of IBS, other functional GI disorders (FGIDs), and functional symptom syndromes. It’s complicated, but you can and you will understand! Sections in Chapter 2 What Causes It? IBS Involves Your Whole Body You Have Two Brains It’s More Than a Feeling Anatomy and Physiology Dysfunction is Responsible Symptom Syndromes Revisited: Central Sensitivity Syndromes Functional GI Disorders (FGIDs) Revisited “IBS Plus” Other Diseases The Causes of IBS The Biopsychosocial Model Revisited 68

IBS Involves Your Whole Body You were introduced to this key concept in the first chapter (Figure 2.1).

Figure 2.1 The target is your GUT (colon of your GI tract). The red circle is your HEAD (mind/brain). The arrows are your CONNECT (their communication systems).

You Have Two Brains Thereâ&#x20AC;&#x2122;s a brain in your HEAD and an equally important second brain in your GUT (Figure 2.2).

Brain

CONNECT

Second Brain

Figure 2.2 Both brains developed from the same origin and have the same nerve cells and chemical messengers. They are independent but interdependent and in constant communication with one another. 70

This “second brain” is located within the GUT lining from top to bottom. Both brains developed from the same origin when you were growing within your mother’s womb until they separated into your two brains. So the brains in your HEAD and GUT contain the same nerve cells and chemical messenger molecules, such as serotonin and norepinephrine. Your brains are independent, with your second brain controlling GUT function, including digestion. However, they are also interdependent in a 24/7 dialogue with one another via the CONNECT, which includes both the nervous system and the chemical messengers. Your second brain enables you to “feel” the inner world of your gut and it’s contents, including food, ingested substances, and resident bacteria.

It’s More Than a Feeling You know your HEAD brain affects your GUT second brain. For example, most of us experience “butterflies” in the stomach when excited or stressed. But we may not know what stressor causes a sudden attack of abdominal cramping and diarrhea accompanied by anxiety in a panic attack. The HEAD can perceive stress and express bodily and GUT symptoms without conscious awareness of the stressor. You may not be aware that your GUT brain does a whole lot more than handle breakdown of food, digestion, absorption, and both storage and elimination of stool. The 2 main “vagus” nerves connecting your two brains transmit 90% of information from the GUT to the brain, rather than the other way around. Your second brain affects your state of mind (both thoughts and emotions) and plays a key role in IBS, FGIDs, and other functional symptom syndromes, such as fibromyalgia. Much of your mental state is influenced by GUT feelings. These inner feelings actually affect both your thoughts and emotions, with or without your conscious awareness of them. This is the basis for sayings, such as, “My gut instinct tells me... .”

Medical science has confirmed that mental illness involves both the physical brain as well as the mind within the HEAD. For example, antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) increase serotonin levels in the brain, where 5% of the body’s serotonin is located. But 95% of serotonin is located in the GUT brain. In part, IBS-D arises because of excess serotonin in the GUT. So IBS is in part like “mental illness” of the second brain. Your GUT feelings, the food you eat, the substances you ingest, and the bacteria residing in your GUT affect your entire body. Again, most of what’s happening occurs without your conscious awareness.

Anatomy and Physiology To answer the important second question of this chapter, you need to know a little bit about how your two brains communicate with one another and whatâ&#x20AC;&#x2122;s going on within and between them. They talk through the CONNECT, which is shown in Figure 2.3.

Figure 2.3 The CONNECT between the two brains is represented by the red arrows: central nervous system (CNS), autonomic nervous system (ANS), and chemical messenger system (CMS).

Your central nervous system (CNS) is the first of three CONNECT systems (Figure 2.4).

Brain

Vagus Nerves

Spinal Cord

Figure 2.4 The central nervous system (CNS) of the CONNECT includes the brain, spinal cord, and two large vagus nerves. Information exchange between your two brains is a two-way and 24/7 ongoing process. Most of the time, you’re not aware of the discussion that’s going on. For example, you’re not usually aware of your gut feelings, even though there’s a lot going on within your GI tract all of the time.

Your autonomic nervous system (ANS) is the second of three CONNECT systems (Figure 2.5).

Brain

Vagus Nerves

Spinal Cord

Figure 2.5 The autonomic nervous system (ANS) of the CONNECT is located within the brain and spinal cord and includes two vagus nerves. The ANS is also located within the GUT brain, which lines the GI tract The ANS functions automatically, controlling breathing, heart rate, sweating, blood pressure, and digestive function. Symptoms of ANS dysfunction are very commonly associated with IBS.

The autonomic nervous system (ANS) includes two branches that balance one another, much like a teeter totter (Figure 2.6).

Brain

Vagus Nerves

Sympathetic

Spinal Cord

Parasympathetic

Figure 2.6 The autonomic nervous system (ANS) of the CONNECT includes two main branches. The sympathetic nervous system functions as the “accelerator,” which is the “fight, flight, freeze” reaction in response to stress. The parasympathetic nervous system is the “brake” and “relaxer.” 77

Your chemical messenger system (CMS) is the third of three CONNECT systems (Figure 2.7).

Receptor (Lock)

Cell Figure 2.7 The chemical messenger system (CMS) of the CONNECT includes chemical messengers, which are like tiny keys that float throughout the body in the bloodstream and fluids. All cells in the body have thousands of tiny receptors like locks on the surface. When the correct lock and key combination occurs, the function of the cell is changed, for better or worse. Examples of these chemical messengers are serotonin, norepinephrine, and histamine.

Dysfunction is Responsible Recall that the term, â&#x20AC;&#x153;dysfunctionâ&#x20AC;? refers to abnormal function of how the body works. This dysfunction involves interactions of your body and two brains. It cannot be detected by medical testing outside of research centers. But the pain and symptoms are real. Your HEAD, CONNECT, and GUT are all in this. See yourself with two brains in Figure 2.8 and focus upon your HEAD first.

Your World (Environment) Physical Social Manmade

Cell

Figure 2.8 The brain in the HEAD responds to the world through the five senses: sight, hearing, smell, taste, and touch. 79

Now look at your second brain in the GUT in Figure 2.9. Itâ&#x20AC;&#x2122;s your sixth sense!

Your World (Environment) Physical Social Manmade Figure 2.9 The second brain in the GUT is a sixth sense responding to the world: food, ingested substances, and gut contents. The little brain in your GUT responds to chunks of the external environment (your world), which is the food and substances that you ingest. Your second brain independently controls the functions of your GUT while interdependently communicating with your brain. Other GUT contents, including bile acids, enzymes, and resident bacteria also participate in the responses made by your second brain. 80

To help you understand the causes of IBS, FGIDs, and functional symptoms, picture a transmission tower sending signals to a radio shown in Figure 2.10.

Figure 2.10 Central Sensitivity The transmission tower silently sends information through airwaves 24/7 to a radio located within the red oval.

A speaker with a high volume control setting broadcasts loudly with distortion in Figure 2.11.

Figure 2.11 Central Sensitivity The radio broadcasts sound through a speaker. The volume control setting is turned high, resulting in sound that is loud and even distorted. You were introduced to the speaker earlier. It represents, â&#x20AC;&#x153;central sensitivity.â&#x20AC;? 82

YOU are like this radio tower, radio, and speaker (Figure 2.12).

Feelings Pain Symptoms Figure 2.12 Central Sensitivity All parts of the body, including the GUT silently transmit feelings to the mind/brain in response to the environment. After these feelings are processed, they are broadcasted and may be experienced. The dysfunction of central sensitivity amplifies and distorts them, so they are felt as pain and symptoms. 83

Now picture your colon and its second brain as a radio tower transmitting feelings to a radio in your head shown in Figure 2.13.

Figure 2.13 The brain in the GUT silently transmits feelings and sensation (including pain) 24/7 to the SENSITIVITY system (red oval) of the brain in the HEAD. This communication through the CONNECT occurs 24/7 without your conscious awareness. You donâ&#x20AC;&#x2122;t yet experience these feelings. 84

With help from other systems in your mind/brain you will soon study, the SENSITIVITY system in your HEAD “broadcasts” your colon’s GUT feelings as pain and symptoms through a speaker. The speaker dial has a high volume control setting, which represents dysfunction, called “central sensitivity” (Figure 2.14).

IBS

Central Sensitivity

Cell

Figure 2.14 The dysfunction of “central sensitivity” results in heightened sensation to IBS pain and symptoms originating in the colon. Furthermore, there is increasing evidence that dysfunction of the small intestine occurs in IBS, particularly when symptoms include “gas,” with abdominal bloating, distention, and flatulence. 85

Remember that your second GI brain lines the entire GUT. So it’s not only your colon sending hidden signals to your brain. All locations of your GUT transmit their feelings, which is why the pain and symptoms of the dysfunctional GI disorders (FGIDs) can originate from any location in your GI tract, from the top (throat) to the bottom (rectum and anus). Central sensitivity also explains why patients with IBS commonly have one or more additional FGIDs (Figure 2.15).

FGIDs

Central Sensitivity Cell Figure 2.15 The dysfunction of “central sensitivity” results in heightened sensation to FGID pain and symptoms originating from any location of the GUT. 86

All of the tissues and organs of your body are sending hidden signals to your brain. Your whole body can be seen as a radio tower silently transmitting bodily feelings to the brain in your HEAD. Central sensitivity helps explain how you can have unexplained pain and symptoms anywhere in your body. The new name for dysfunctional symptom syndromes, including FGIDs and IBS is central sensitivity syndromes (CSS), shown in Figure 2.16.

Central Sensitivity Syndromes (CSS)

Central Sensitivity Cell

Figure 2.16 The dysfunction of â&#x20AC;&#x153;central sensitivityâ&#x20AC;? results in heightened sensation to all bodily pain and symptoms. 87

Symptom Syndromes Revisited: Central Sensitivity Syndromes This term, central sensitivity syndromes (CSS) is relatively new. Most doctors will not be familiar with it as the name for functional symptom syndromes, which you learned about in the first chapter and are listed below:

• FGIDs (IBS is the most common) • Fibromyalgia (widespread pain and fatigue) • Fatigue • Headaches • TMJ (temporomandibular joint disorder) • Myofascial pain (pain that can occur anywhere in muscles and soft tissues) • Irritable larynx syndrome (hoarseness, throat clearing, voice dysfunction, chronic cough) • Chronic low back pain • Interstitial cystitis (painful bladder syndrome) • Chronic pelvic pain • Dysmenorrhea • Multiple chemical sensitivity • Multiple medication sensitivity

Functional GI Disorders (FGIDs) Revisited Most of the causes of IBS are also causes of the other FGIDs (Figure 2.17).

Figure 2.17 The functional GI disorders (FGIDs) share similar causes, which is why they so commonly co-occur. Recall that the more than 30 FGIDs can affect the GUT anywhere from the top (throat) to the bottom (rectum and anus). Furthermore, most patients with IBS have more than one FGID. For example, IBS commonly cooccurs with other FGIDS, such as functional heartburn that does not respond to strong acid reducing drugs, dyspepsia or epigastric pain, and nausea.

“IBS Plus” Other Diseases You were introduced earlier to the concept of the common co-occurrence of IBS with other GUT diseases, such as diverticular disease of the colon, inflammatory bowel disease, or IBD (Crohn’s disease and ulcerative colitis), and celiac disease. This is called “IBS Plus.” It’s important to recognize “IBS Plus,” so the IBS can be treated and the co-occurring disease isn’t over-treated or mis-treated.

The Causes of IBS The dysfunction that causes IBS involves complex systems of your body (bio), your mind/brain (psycho), and your relationship with the world, including other people (social). This can only be understood with the biopsychosocial model (Figure 2.18). THOUGHT

HEAD

Conscious Subconscious Memory

SENSITIVITY

Pain & Symptoms

STRESS

CONNECT EMOTION Depression Anxiety

GUT

YOU

Gender Nature/Nurture Figure 2.18 The Biopsychosocial Model of IBS

See yourself (YOU) in Figure 2.18 as the causes of IBS are described. As you learn about each cause, you can click on YOU to review and study your biopsychosocial model above as needed:

• Complex adaptive systems • Gender • Nature/Nurture • Central sensitivity • Cellular inflammation • HEAD • CONNECT • GUT

YOU Complex adapative systems A complex adaptive system has a large number of components that interact and adapt or learn collectively in response to the changing environment. From their interaction comes emergence of something that is not a property of any component of the system. For example, your brains are complex adaptive systems (Figure 2.19).

Interaction

BRAIN CELLS

THOUGHT

Interaction Figure 2.19 Brain cells (neurons) cannot think, but both brains are complex adaptive systems composed of billions of neurons whose interactions result in the emergence of thought. As Aristotle taught, â&#x20AC;&#x153;The whole is greater than the sum of its parts.â&#x20AC;? You are a big complex adaptive system composed of many smaller interacting such systems. Your two brains interact. Pain and symptoms emerge from their dysfunction. 93

YOU Gender Gender refers to differences in dysfunction and disease in women and men. In general, women are more pain sensitive than are men, but the reasons for this are not understood. More women than men consult with doctors about functional symptom syndromes, IBS, and FGIDs. YOU Nature/Nurture Nature/nurture refers to the effects of both heredity (genetics) and early life experience. Both equally influence pain and symptom expression by their effects on the volume control involving central sensitivity (figure 2.20).

Nature (heredity/genetics) Nurture (early life experience) Figure 2.20 Nature and nurture equally affect central sensitivity.

Studies clearly show that IBS, FGIDs, and CSSs can run in families. Heredity is one factor, likely influencing genes and function of HEAD, GUT, and their CONNECT. The influence of nurture in the household is equally important, such as serious illness of self or other family member, relationship difficulties, divorce, and financial difficulties. A history of abuse (physical, emotional, and/or sexual) can strongly influences the expression of pain and symptoms with greater severity, stress reactivity, emotional distress, and poorer daily function and coping ability.

YOU Central sensitivity Your sensitivity to pain and symptoms depends upon your central volume control setting (Figure 2.21).

Sensitivity to Pain

Low

High

Figure 2.21 An individualâ&#x20AC;&#x2122;s sensitivity to pain and symptoms depends upon where he or she is located on a bell-shaped curve of the population. Gender, nature, and nurture affect your pain sensitivity. Some people have a low setting. Many people have a high volume control setting. This is why IBS, FGIDs, and dysfunctional symptom syndromes (central sensitivity syndromes) are so common. 96

YOU Cellular inflammation You canâ&#x20AC;&#x2122;t feel the damage being done to the cells of your body, GUT, and brains by inflammation, because itâ&#x20AC;&#x2122;s happening at the subconscious level. This cellular dysfunction underlies chronic diseases, including obesity, heart, diabetes, hypertension, cancer, IBS, FGIDs, and central sensitivity syndromes (Figure 2.22).

Cell Figure 2.22 Chronic inflammation damages the cells of the body, GUT, and both brains. It is a cause of all diseases. The damage caused by chronic inflammation can kill you (such as by diabetes, heart attack, and stroke). 97

YOU HEAD The causes of IBS, FGIDs, and central sensitivity symptom syndromes arenâ&#x20AC;&#x2122;t all in your HEAD. But your HEAD matters. Four mind/brain systems are involved (Figure 2.23). THOUGHT

HEAD

Conscious Subconscious Memory

SENSITIVITY

STRESS

CONNECT EMOTION Depression Anxiety

GUT

Figure 2.23 Four mind/brain systems in the HEAD are involved with the causes of IBS, FGIDs, and central sensitivity syndromes. The ovals overlap, which emphasizes the systems communicate with and affect one another. Nature/nurture can increase pain and symptom sensitivity, negative cognition, stress reactivity, and susceptibility to emotional distress. 98

SENSITIVITY Your volume control setting and SENSITIVITY to the pain and symptoms of IBS, FGIDs, and central sensitivity syndromes are affected by the other three mind/brain systems. Much of what’s happening occurs without your conscious awareness. THOUGHT This mind/brain system includes both conscious and subconscious thought and memory. Negative thoughts and memories of old hurts (conscious and subconscious) can increase pain and symptom sensitivity. For example, catastrophic thinking (“I’ll never get well!”) and/or memory of emotional, physical, or sexual abuse can increase pain and symptom experience, stress responsiveness, emotional distress, and ability to cope.

STRESS The damage done by chronic stress is called, “allostatic load,” which causes dysfunction and physical injury to both brains. Many patients with IBS, FGIDs, and central sensitivity functional symptom syndromes have increased sensitivity and reactivity to stressors. The pain and symptoms are commonly exacerbated by stressors, which comes in many forms:

• Psychosocial stress and distress • Early life stressors ‣ Injury ‣ Institutionalization ‣ Abuse (physical, emotional, sexual) • Painful bodily disorder, (such as IBS and arthritis) • Physical trauma (such as auto accident or injury) • Combat • Infections 100

EMOTION In many patients with IBS, FGIDs, and central sensitivity functional symptom syndromes, psychological disorders coexist. This co-occurrence is called, “comorbidity.” Psychological distress increases pain and symptom sensitivity and reduces ability to cope. Some patients cannot recognize psychosocial difficulties, and this impairment can develop early in life. The most common psychiatric comorbidities include:

• Depression (including dysthymia) • Anxiety disorders (panic and generalized anxiety disorders)

• Somatoform disorders (hypochondriasis and somatoform disorder)

• Phobic disorders

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YOU CONNECT Recall the CONNECT includes the central nervous system (CNS), autonomic nervous system (ANS), and the chemical messenger system CMS (Figure 2.24).

ANS Sympathetic

Parasympathetic

Figure 2.24 CONNECT dysfunction commonly involves imbalance in the autonomic nervous system (ANS). ANS dysfunction can result in symptoms of abdominal cramps, diarrhea, nausea, rapid heart rate, dizziness, faintness, and feeling sweaty. Chemical messengers may not function correctly. For example, dysfunction involving histamine can cause abdominal cramping, nausea, diarrhea, and flushing (face and chest turning red). 102

YOU GUT Itâ&#x20AC;&#x2122;s important to understand a little normal GUT anatomy and physiology before learning about GUT dysfunction as another cause of IBS and FGIDs (Figure 2.25).

HEAD

CONNECT

GUT Figure 2.25 The GUT includes a second brain and is a sixth sense. Your GUT responds to chunks of the environment in the food and substances that you eat. GUT contents of bile acids, enzymes, and resident bacteria are also involved.

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Your GI tract (GUT) is 30 feet long (the colon is about 3 feet in length). Amazingly, the total surface area of the GUT is about the size of a football field! Figure 2.26 explains how this is possible. The inside lining (mucosa) has many folds visible to the eye The gut is a long tube (about 30 feet)

Very tiny villi on vill require an electron microscope to see Tiny villi of the lining require a microscope to see Gut cells

Figure 2.26 The GUT has a surface area about the size of a football field.

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Research shows that many patients suffering with IBS have abnormalities in their GUT itself, which can require special research techniques to detect. These findings usually cannot be shown with regular tests, such as lab tests, x-rays, scans, and scopes. The role these findings associated with dysfunction play in causation of pain and symptoms is not yet clear and is the subject of considerable research.

• Increased GUT leakiness (“permeability”) The GUT is normally permeable to permit absorption of nutrients and to allow secretion of digestive juices. There is no single diagnosis of “leaky gut syndrome.” However, alterations in permeability can be found in some diseases, including IBS and IBD.

• Microscopic inflammation in GUT lining • Activation or alteration of certain chemical messengers

• Changes in immune cells and their chemical messengers

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Remember to picture your colon as a transmission tower silently sending your GUT feelings 24/7 to the radio in the SENSITIVITY system of your mind/brain. However, your GUT also directly causes dysfunction (Figure 2.27).

BACTERIA

SENSITIVITY

MOTILITY (Spasm)

Figure 2.27 There are three main types of GUT (colon) dysfunction that contribute to the causes of IBS. 106

All three fundamental types of GUT dysfunction are treatment targets:

• Sensitivity The second brain in the GUT also has a SENSITIVITY system, where dysfunction results in increased sensitivity to GUT pain and symptoms. This high volume control setting in the GUT brain is called, “visceral sensitivity.” The term, “visceral” refers to internal abdominal organs.

•

Motility affects GUT and colon contraction and movement of content forward. Dysfunction of motility includes spasm (pain) and altered movement (too fast—diarrhea; too slow—constipation). This involves dysfunction of the autonomic nervous system.

•

GUT bacteria (the “microbiome”) Hundreds of different bacteria live in the GUT. This “microbiome” plays an important role in both digestive as well as overall health. Dysfunction of the microbiome, called “small intestinal bacterial overgrowth” (SIBO) can cause or contribute to the symptoms of IBS.

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As there are stressors that trigger dysfunction in the mind/brain of the HEAD, stressors trigger dysfunction in the second brain of the GUT (Figure 2.28).

Figure 2.28 GUT Stressors

• Diet • Ingested substances • Infections • Medications and antibiotics • Inflammation • Bile acids • Gut bacteria (microbiome) • Menstruation 108

GUT pain and symptoms are themselves stressors that affect your HEAD, which in turn can worsen them. It’s another vicious circle (Figure 2.29).

HEAD

GUT

IBS Figure 2.29 GUT pain and symptoms stress the HEAD. The HEAD worsens pain and symptoms. It’s vicious circle. At both the conscious and subconscious level, IBS pain and symptoms stress the four mind/brain systems. They “mess with your HEAD,” increasing pain and symptom sensitivity, negative thoughts, stress reactivity, and depression/anxiety. In turn, your HEAD then worsens pain and symptoms not only in your GUT, but also in your whole body. 109

The Biopsychosocial Model Revisited Now you see that the complex systems dysfunction that causes IBS also causes other FGIDs and central sensitivity syndromes (Figure 2.30). THOUGHT

HEAD

Conscious Subconscious Memory

SENSITIVITY

Pain & Symptoms

STRESS

CONNECT EMOTION Depression Anxiety

YOU GUT

Gender Nature/Nurture Figure 2.30 The Biopsychosocial Model of Functional GI Disorders (FGIDs) and Central Sensitivity Syndromes Disease is dysfunction. Pain and symptoms are the expression anywhere in the GUT and body. The target now includes the entire GI tract, and the whole body is enclosed in a red rectangle. 110

Chapter 3

How Can I Get Well? Key West, Florida

Finding balance

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You will know how to get well with IBS. It’s likely that you decided to embark on the journey of reading this book, because you’ve been overwhelmed by information (and misinformation) regarding IBS and chronic pain. But you’ve studied the important and relevant information here, placed it in context, and now you understand. This is knowledge, and knowing the answers to the first two questions here is therapeutic. It validates your symptom experience and empowers you to take charge of your health. You’re ready to know your treatment opportunities. The answers to the third question, How can I get well? are provided for you in the next 4 chapters. Wisdom is application of knowledge. There’s usually no one way to get better. You’re going to need to explore “HEAD,” “CONNECT,” and “GUT” therapeutic options with your doctor and caregivers. My colleague, Rick Edgin, says you’re going to need to “tinker” to find what works best for you. He’s right. Everyone is unique. A lot of trial and error may be necessary.

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Sections in Chapter 3 How Can I Get Better?

IBS Involves Your Whole Body HEAD Change your brains Self-care Diary Start here, right now Medication Antidepressants Anticonvulsants Miscellaneous drugs Sleep Opioids (narcotics) and non-steroidal antiinflammatory drugs (NSAIDs) CONNECT GUT

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IBS Involves Your Whole Body To get well, you have to see the biopsychosocial “big picture” of the whole YOU (Figure 3.1). THOUGHT

HEAD

Conscious Subconscious Memory

SENSITIVITY Pain & Symptoms

STRESS

CONNECT EMOTION Depression Anxiety

GUT

YOU

Gender Nature/Nurture Figure 3.1 Getting well with IBS requires a biopsychosocial therapeutic approach involving HEAD, CONNECT, and GUT.

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HEAD HEAD therapy targets heightened pain and symptom sensitivity in the brain, negative thoughts and effects of old hurts, emotional distress, and harmful stress by using mind-body management, which may also include medication (Figure 3.2).

Figure 3.2 HEAD Therapy for IBS

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Change your brains Stress, emotional distress, and the mind can make life and living with IBS more or less difficult. Science confirms stress management and therapeutic mind/ body approaches can improve dysfunction of all 4 mind/brain systems by reducing sensation of pain (SENSITIVITY), fostering positive cognitions and dealing with old hurts (THOUGHT), decreasing stress reactivity (STRESS), and improving mood (EMOTION). Look at Figure 3.3. THOUGHT

HEAD

SENSITIVITY

Conscious Subconscious Memory

STRESS

CONNECT EMOTION Depression Anxiety

GUT

Figure 3.3 There are two brains to change (blue arrows).

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Medical science has confirmed that the function and actual structure of the brains can be changed for the better at any age with the mind. Keep the following in your mind:

• State of mind affects your whole body well-being through your brains.

• Thoughts and emotions change the activity of genes in nerve cells, which alters pathways in the brain.

• Your brain can be nurtured and trained to transform your life through self-awareness and conscious intention.

• There are many ways to manage stress, including conscious breathing, exercise, and mind/body techniques. Here’s a simple mind/body technique. Do you feel the shoe on your left foot? You probably didn’t until you read the question. If you were hurting, it’s likely that your shift in bodily attention resulted in reduction of the intensity and distress of the pain. You can learn mind/ body techniques like this one on your own. You can work with a health care professional to learn others, such as:

117

• Relaxation training reduces autonomic sympathetic nervous system arousal and stress reactivity. Examples include mindful breathing and meditation, (which can also be done during exercise) and yoga.

• Cognitive behavior therapy (CBT) changes maladaptive thoughts contributing to depression and anxiety, which in turn can aggravate IBS symptoms.

• Hypnosis is an intervention that uses a special mental state of enhanced receptivity to suggestion to facilitate therapeutic psychological and physiological changes.

• Biofeedback is a form of behavior training. It uses continuous visual or auditory feedback of physical activity to enable patients to learn how to voluntarily control those bodily functions.

• Psychotherapy in all forms can help. One example is existential psychotherapy, which explores life, pain, and symptoms relative to four basic conflicts that drive human behavior - both adaptive and maladaptive. These four ultimate concerns are death, freedom, existential isolation, and meaninglessness.

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Self-care Answering the third question of this book involves committing your whole being to getting better and healthy. Write your self-care plan down and modify it as needed (Figure 3.4).

Mind/Brain

Spirit

Body

Figure 3.4 A self-care plan can be simple, but it is most effective when written. This sample can be replicated and used.

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Diary Scientific research clearly shows that writing your observations, plans, and progress down can be very beneficial in management and treatment of IBS, FGIDs, and central sensitivity syndromes. Keeping a diary will help you:

• Accept responsibility and take control for your own health.

• Clarify your vision so you can begin to picture yourself getting better and healthier.

• Transform intention into action. • Partner with your doctor in a shared decisionmaking relationship.

• Document what does and doesn’t work, since successful management often requires trial and error and more than one treatment.

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Start here, right now Youâ&#x20AC;&#x2122;ve learned that you are stressed and inflamed, right down to your cells (Figure 3.5). The damage is occurring without your awareness.

Cell Figure 3.5 Stress and inflammation damage the body and brains subconsciously, which contributes to the pain and symptoms of IBS, FGIDs, and central sensitivity symptom syndromes. This silent injury hurts you by contributing to central sensitivity, which amplifies your pain and symptoms. It can even kill you (like with heart disease). Hereâ&#x20AC;&#x2122;s what every one of us must do to reduce stress and inflammation:

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• Eat an anti-inflammatory diet, beginning with breakfast. One example of an anti-inflammatory diet is the Mediterranean diet. The main goal is to keep blood sugar low and stable, which reduces the inflammatory effects of insulin spikes).

‣ Eat complex carbohydrates, mainly vegetables and fruits (you’ll learn to avoid triggering foods later).

‣ Limit saturated fats and eat omega-3 fats (consider taking omega-3 supplements).

‣ Try to eat 25 - 30 grams of protein with meals. Most people aren’t eating enough protein while placing too much emphasis on carbohydrates.

• Exercise regularly. There is clear, scientific evidence of benefit for IBS and overall health. Walk 10,000 steps/day and/or take a brisk 30 + minute walk on most days. Consider including strength training.

• Achieve and maintain a healthy weight. • Get adequate rest and sleep.

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Medication Several types of drugs, including certain antidepressants can favorably affect all four mind/ brain systems by turning the central (mind/brain) volume control for pain and symptoms down (SENSITIVITY), reducing the stress response (STRESS), and improving depression and anxiety (EMOTION). This can clear the way for positive thoughts, intentions, and constructive action (THOUGHT). Definitions Two terms are important to understand HEAD Down drug therapy.

• “Off-label” therapy refers to the common practice of prescribing an FDA (Food and Drug Administration) approved drug for an unapproved disease (such as IBS) or unapproved age group, dose, or form of administration.

• “Augmentation” therapy refers to the use of a combination of drugs from different classes in low doses rather than one drug at a maximal dose. Augmentation “combo” therapy is intended to optimize synergistic and beneficial effects while minimizing the potential for dose-dependent side effects. 123

Treatment strategy Keep the following in mind if you elect to try medication:

â&#x20AC;˘ Start low, go slow, consider combo. This means starting treatment with a low dosage and gradually increasing dosage if needed. An alternative to using high doses of a single drug is to combine medications in lower doses to increase the benefits and decrease side effect potential (augmentation therapy).

â&#x20AC;˘ Be patient Studies show that many patients give up on a medication within the first week. It may take several weeks for the drug or drugs to work. If side effects do occur, they often diminish or disappear over time. A given drug is not effective or tolerated by everyone. Treatment often includes trial and error.

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Antidepressants The common association of emotional distress (depression and anxiety) with chronic pain and symptoms, including IBS confuses and frustrates both patients and doctors. Remember that the four mind/ brain systems of SENSITIVITY, THOUGHT, STRESS, and EMOTION overlap and talk, sharing chemical messengers and nerve pathways (Figure 3.6).

Antidepressant

Figure 3.6 Antidepressants can relieve pain, clear the way for positive thoughts, lift mood, relieve anxiety, and reduce stress reactivity.

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Sensitivity to pain and symptoms is also more â&#x20AC;&#x153;sensitiveâ&#x20AC;? to these antidepressants than is emotional distress. Therefore, antidepressant drug doses lower than are necessary to treat depression and anxiety are commonly prescribed off-label to relieve pain and symptoms of IBS, other functional GI disorders (FGIDs), and other central sensitivity syndromes. Full dosing may be necessary if significant depression and anxiety co-occur. Note that antidepressants have an FDA Black Box Warning of increased risk of suicidality in children, adolescents, and young adults less than 24 years of age suffering with major depressive or other psychiatric disorders. Physiologic dependency (not addiction) can occur with antidepressants, which requires gradual tapering of dosage to reduce the possibility of withdrawal symptoms.

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Serotonin norepinephrine reuptake inhibitor antidepressants (SNRIs) These antidepressants increase brain levels of two chemical messengers: serotonin and norepinephrine. Affecting the â&#x20AC;&#x153;nâ&#x20AC;? chemical messenger, norepinephrine is particularly important in reducing central sensitivity and heightened pain and symptom sensation. SNRI tricyclic antidepressants (TCAs) TCAs were the first antidepressants, which are rarely used for this purpose now because of the emergence of better antidepressants. Furthermore, high doses of TCAs were necessary to treat depression, which were associated with adverse side effects. Doctors have used TCAs off-label in low dosage for many years to reduce the pain and symptoms of dysfunction. Examples of these TCAs are nortriptyline (brand name is Pamelor); desipramine (brand name is Norpramin); amitriptyline (brand name is Elavil); and doxepin (also available as Silenor for treating insomnia). Cyclobenzaprine (brand name is Flexeril) is approved as a muscle relaxant, even though it is essentially an SNRI TCA. It also has sedating properties that can help with sleep.

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The risk of side effects with TCAs is greatly reduced by using very low doses. Furthermore, second generation TCAs (nortriptyline or desipramine) are associated with lower likelihood of side effects. Potential TCA side effects include sedation, constipation, rapid heart rate, urinary retention, dry mouth, insomnia or nightmares, agitation, and weight gain. Cardiac arrhythmias that could be life-threatening are very rare in low dose TCA therapy. An EKG or cardiology consult may be recommended in the elderly or for patients with a history of heart disease or a family history of arrhythmias or sudden death.

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SNRI antidepressants for fibromyalgia and also IBS As you now know, IBS and fibromyalgia commonly occur together. Both are functional symptom syndrome central sensitivity syndromes, with similar brain amplification of pain and symptoms. Two SNRI drugs are approved for fibromyalgia and can be used off-label for treatment of IBS and other central sensitivity syndromes. Both drugs are currently being tested in research trials for IBS treatment. Cymbalta Cymbalta is an antidepressant also used to treat anxiety. In addition to fibromyalgia, the drug is approved for treatment of chronic low back pain, which is also a central sensitivity syndrome). The most common side effects of Cymbalta are nausea, headache, dry mouth, and constipation. Savella Savella is an SNRI antidepressant approved for treatment of fibromyalgia but not studied for antidepressant use. Savella has relatively more norepinephrine than serotonin effects. The most common side effect is nausea.

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Other SNRI antidepressants Two other SNRI antidepressants are venlafaxine (generic name; original brand name was Effexor) and Pristiq (no generics available). Selective serotonin reuptake inhibitor antidepressants (SSRIs) SSRIs increase brain levels of the chemical messsenger, serotonin. Unlike SNRIs, SSRIs do not affect brain levels of norepinephrine. While SSRIs can be effective for off-label treatment of IBS pain and symptoms, the evidence for benefit is stronger for SNRIs that affect norepinephrine levels in the brain and for anticonvulsant drugs. Regardless, SSRIs can have a beneficial effect on overall well-being and any anxiety or depressive symptoms associated with IBS. They can be effective components of augmentation therapy in IBS pain and symptom reduction. Potential side effects of SSRIs are usually mild and include nausea, diarrhea, sexual dysfunction (decreased libido and delayed orgasm), anxiety, nervousness, tremor, insomnia, and nightmares.

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Available SSRI antidepressants include fluoxetine (brand names are Prozac and Sarafem), paroxetine (brand name is Paxil), sertraline (brand name is Zoloft), citalopram (brand name is Celexa), and escitalopram (brand name is Lexapro). SSRIs may also have beneficial GUT therapy direct GI effects. Since diarrhea can be a side effect of SSRIs, they can be helpful in the treatment of IBS-C (constipation). Paroxetine may be the best choice for IBS-D (diarrhea), because it is the least likely SSRI associated with the side effect of diarrhea.

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Anticonvulsants Anticonvulsants can be as effective as SNRIs in the relief of chronic pain, including the pain of fibromyalgia and as off-label treatment of IBS. Lyrica Lyrica is approved for treatment of fibromyalgia. The drug is currently being studied as a treatment for IBS and can be used off-label. The two most common side effects of Lyrica are dizziness and sleepiness, which may lessen or resolve with time. A less common side effect is swelling of hands, legs, and feet. Gabapentin Gabapentin is the generic name of Neurontin. Gabapentin is similar to Lyrica, but it is not FDAapproved for fibromyalgia.

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Miscellaneous Drugs Three other drugs can be considered. Mirtazepine The original brand name of this drug was Remeron. Mirtazepine is a tetracyclic antidepressant. It can also be effective off-label as a hypnotic for sleep, antiemetic, and appetite stimulant. When used off-label in treatment of IBS, the main benefit of mirtazepine may be in augmenting the benefit of the antidepressant and anti-anxiety effects of other drugs, such as TCAs or SNRIs or when symptoms of nausea or vomiting or low body weight are present (such as with a co-existing eating disorder). Buspirone The original brand name of this drug was BuSpar. Buspirone is a non-benzodiazepine anti-anxiety agent that can augment the effect of antidepressants. Buspirone may be helpful off-label in treatment of IBS when functional GI disorders dyspepsia and/or epigastric pain are associated.

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Atypical antipsychotic drugs These drugs were initially approved for the treatment of schizophrenia, bipolar disorder, and as augmentation to treat depression. One example is quetiapine (Seroquel). Atypical antipsychotics can be considered in off-label treatment of IBS and FGIDs with or without associated emotional distress (depression and/or anxiety) when symptoms are severe, significantly interfere with quality of life and function (missing work), and fail to respond to other GUT Up and HEAD Down treatment and management, including combination therapy with an SNRI or SSRI together with a TCA. The atypical antipsychotic drug can be added to an SNRI or TCA in augmentation therapy. Collaboration with a psychiatrist is usually advisable.

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Sleep Poor sleep can amplify the pain and symptoms of IBS, FGIDs, and central sensitivity syndromes by adversely affecting all four mind/brain systems. Treatment considerations for insomnia include anticonvulsants (Lyrica or gabapentin), giving the higher amount at night; doxepin as the SNRI drug, which is FDA-approved as a hypnotic: Silenor); cyclobenzaprine; the atypical antidepressant trazadone; the hypnotic zolpidem (brand name is Ambien); and the hypnotic zalepion (brand name is Sonata).

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Opioids (narcotics) and non-steroidal antiinflammatory drugs (NSAIDs) Opioids and NSAIDs are usually not effective in treatment of IBS, FGIDs, and related central sensitivity syndromes. Both opioids and NSAIDs can have serious side effects. Opioid (narcotic) risks Opioids can eventually worsen pain and cause GI symptoms of nausea, vomiting, abdominal bloating, distention, and constipation. They can even simulate bowel obstruction (called the â&#x20AC;&#x153;narcotic bowel syndromeâ&#x20AC;?). Narcotics can lead to dependency and addiction. Tramadol is an analgesic that can be considered in treatment, because it also has SNRI effects. However, tramadol does have opioid effects. Patients and doctors may not be aware that tramadol can result in dependency and addiction. NSAID risks NSAIDs can cause pain, ulceration, and bleeding anywhere in the GUT, most commonly the stomach and duodenum. NSAIDs can even cause strictures (scar tissue) to form in the small intestine, which can result in blockage.

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CONNECT Now you understand the role of dysfunction involving your central nervous system, autonomic nervous system, and chemical messenger system (Figure 3.7).

Figure 3.7 Connect Therapy for IBS Your state of mind affects your entire body, including your brains through the CONNECT. This is why you can get better with self-awareness, conscious intention, a self-care plan, and with drugs if needed.

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GUT You’ve come a long way on your journey and have part of the answers to the third question, How can I get well? You’re ready to learn about GUT therapy options (Figure 3.8).

Figure 3.8 GUT Therapy for IBS GUT therapy helps the whole you by breaking the vicious cycle of GUT pain and symptoms “messing with your HEAD,” which in turn worsens pain and symptoms in your GUT and whole body. So successful treatment of GUT pain and symptoms can reduce central sensitivity, which reduces pain and symptoms of associated central sensitivity syndromes. It can also reduce stress sensitivity, negative thinking and memory recall, and depression/anxiety. 138

GUT therapy is discussed in following chapters: Chapter 4: IBS-D (diarrhea) Chapter 5: IBS-C (constipation) Chapter 6: Belching and “Gas”

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Chapter 4

IBS-D (Diarrhea) Break free

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GUT Therapy: IBS-D (Diarrhea) Getting well with IBS-D includes determining goals, bowel retraining, considering psyllium fiber supplements, dietary changes, enzyme therapy, treatment directed to dysfunction of the GUT bacteria (microbiome), and medication. Sections in Chapter 4 IBS-D (Diarrhea) Goals Bowel Retraining Psyllium Diet FODMAPS Wheat and Gluten Uncommon Dietary Approaches Enzymes Supplements Small Intestinal Bacterial Overgrowth (SIBO) Medication

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Goals Reasonable goals in treating IBS-D include:

• No more than 3 complete bowel movements on most days

• Minimal urgency to defecate • The weekly average of your “worst abdominal pain over the past 24-hours” rated 2 or less If bowel function improves and abdominal pain and discomfort continue despite GUT therapy described in this chapter, HEAD therapy can help.

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Bowel Retraining Either initially or after completing this chapter and getting better with treatment, you may be able to retrain your bowel to regularly empty more completely and predictably. Sit on the toilet for about 15 minutes daily and try to completely empty the rectum. Many people with IBS-D donâ&#x20AC;&#x2122;t spend enough time on the toilet and must return soon several times. Since eating stimulates colonic activity, the best time to do this is 10 to 20 minutes after a meal and preferably after breakfast. Realize that coffee is a bowel stimulant. Donâ&#x20AC;&#x2122;t strain to have a bowel movement. If you are not successful, go on about your life. Be patient. Bowel retraining can take several weeks.

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Psyllium Psyllium is a unique, natural, non-gluten, nonfermentable fiber that is not absorbed. It promotes a soft but solid stool form. While psyllium is most commonly helpful in management of IBS-C, some patients with IBS-D can benefit by taking a psyllium fiber supplement. If psyllium triggers or aggravates symptoms, it can always be discontinued. Click here for details on how to take psyllium supplements, which is discussed in Chapter 5: IBS-C (Constipation).

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Diet Over one half of IBS-D patients suspect that eating triggers symptoms immediately or up to 2 hours later. Some patients report certain specific food triggers. Historically, caffeine, alcohol, fat, and fiber have been considered to be dietary triggers with little scientific evidence to support the observation. Meals are complex mixtures of many dietary components, and the timing of symptom onset following ingestion can vary, which makes identification of the dietary culprit difficult. Food and ingested substances donâ&#x20AC;&#x2122;t cause IBS. Instead, certain food intolerances increase the likelihood and intensity of food responses, which trigger symptoms. In many patients with IBS, the gut is so responsive and sensitive that eating anything triggers symptoms. Keep four things in mind regarding diet and IBS. First, research confirms that eating an anti-inflammatory diet, such as the Mediterranean type diet, dramatically reduces cellular inflammation and is important for overall health. Eating an anti-inflammatory diet may also reduce sensitivity in both the GUT and HEAD brains.

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Second, certain carbohydrates arenâ&#x20AC;&#x2122;t digested normally in many patients with IBS, which results in fermentation, gas formation, and dysfunction that can trigger IBS pain and symptoms. Reduction or elimination of these carbohydrates can help to relieve IBS symptoms. Third, wheat and gluten can trigger IBS symptoms. Youâ&#x20AC;&#x2122;ll soon see how and why. Fourth, certain food chemicals and substances can be IBS triggers. However, very little is understood about this.

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FODMAPS Certain sugars, carbohydrates, and fiber in foods are fermentable by the GUT bacteria. FODMAPS is an acronym for Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And PolyolS. Developed by Dr. Sue Shepherd, a low FODMAPS diet avoiding the most common FODMAPS carbohydrates has been scientifically shown to help around 75% of patients with IBS-D and “gas.” Dietary therapy should be tried for at least one month. Consider working with a dietitian and/or consulting Resources. The most important FODMAPS to restrict and avoid are:

• Fructo-oligosaccharides (fructans) Wheat and rye (in large amounts), onions, garlic (in large amounts), artichokes, asparagus, inulin (note that wheat contains both gluten and fructans)

• Galacto-oligosaccharides (GOS) Legume beans, lentils, chickpeas

• Lactose Milk, ice cream, soft unripened cheeses

• Fructose Honey, apple, mango, pear, watermelon, high fructose corn syrup (HFCS) 147

• Polyols Apples, pears, stone fruits, mushrooms, prunes, sugar-free mints/gums with sweeteners ending in “ol” Certain foods can inhibit carbohydrate digestive enzymes (glucosidases): spicy foods, onions, garlic, corn, and peppers. Wheat and Gluten Wheat contains poorly absorbed carbohydrates that can trigger IBS symptoms, which is why wheat restriction is a component of the low FODMAPS diet. Celiac disease (celiac sprue) Gluten is the protein in wheat, barley, and rye responsible for celiac disease (CD) or celiac sprue. Gluten damages the GUT lining through an immune response in genetically susceptible individuals. CD affects 1 in 100 people in the US and is considered in the differential diagnosis of most patients with IBS-D and/or “gas.” CD can rarely be associated with constipation. CD is associated with impaired absorption, but some patients are overweight or obese. Many people with CD are undiagnosed, because it does not necessarily cause GUT symptoms.

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Non-celiac gluten sensitivity Even more common than celiac disease is non-celiac gluten sensitivity (NCGS), which is driving the multibillion dollar gluten-free food industry. NCGS may influence GI symptoms through another type of immune activation or alterations in intestinal leakiness or permeability. Gluten can trigger GUT symptoms in some IBS patients who do not have celiac sprue, including loose stool and diarrhea (often after eating), and/or â&#x20AC;&#x153;gasâ&#x20AC;? (abdominal bloating, distention, and flatulence). Eating a gluten free diet can result in significant benefit of IBS symptoms. Some patients with NCGS have non-GI symptoms regardless of whether they have IBS. These symptoms include fatigue (the most common), headache, attention deficit/hyperactivity disorder, depression, and dizziness.

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Distinguishing CD from NCGS can be difficult The symptoms of both can be similar, and some patients seeking diagnosis have been eating a gluten free diet, which can cause falsely normal testing for celiac sprue. Only patients with celiac sprue have abnormal duodenal biopsies, which are obtained with endoscopy. Celiac antibody blood tests can be positive in patients with either celiac sprue or NCGS. Celiac genetic blood testing (HLA-DQ2/DQ8) is positive in virtually all patients with celiac disease. Negative results exclude celiac disease. But 1 of every 3 people in the United States has positive celiac genetics and most donâ&#x20AC;&#x2122;t have CD. They can have CD without symptoms (+ duodenal biopsy), potential CD (negative biopsy), or NCGS (negative biopsy). New research shows that most patients with NCGS have positive celiac genetic blood testing.

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Diagnosis and treatment of NCGS After testing for CD in IBS-D patients, a 2 - 4 week trial of a gluten free diet is necessary to diagnose NCGS, since no diagnostic blood testing is available and duodenal biopsies are normal. It is not necessary to be as careful avoiding gluten in NCGS as it is in CD, since GUT injury and malabsorption do not occur. If IBS and gas symptoms are relieved or improved and a gluten free diet is continued, consultation with a dietitian is advisable. Eating a gluten free diet can be difficult and result in certain nutritional deficiencies. Uncommon Dietary Approaches Dietary triggering or exacerbation of symptoms may persist despite the low FODMAPS diet, trial of glutenfree eating, and restriction of coffee, caffeine, alcohol, and fiber. In this case, it is likely that the GUT is hypersensitive to even normal amounts of digestive tract content. Additional dietary approaches to consider include a trial of a very low fat diet, very low carbohydrate diet, and an elimination diet.

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Very low fat diet (VLFD) While some IBS patients find that fat triggers symptoms, a VLFD has not been studied as dietary treatment, as has eating a low FODMAPS diet. Very low carbohydrate diet (VLCD) A VLCD for IBS-D was shown to be beneficial in one study. It is rarely used and difficult, requiring doctor supervision and collaboration with a dietitian. Elimination diet (ED) There is no research using an ED to treat IBS-D, restricting common food allergens (wheat, cowâ&#x20AC;&#x2122;s milk, soy, eggs, fish, shellfish, peanuts, and nuts), specific chemical substances in foods (naturally occurring or added; salicylates, benzoates, penicillin, yeast, and tartrazine), and restrictions on the use of personal hygiene products and medications that contain these chemicals. If an ED is considered, both an allergist and dietitian should be be involved.

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Enzyme Supplements Four enzyme supplements may help digest certain triggering carbohydrates, which can reduce IBS-D symptoms and â&#x20AC;&#x153;gas.â&#x20AC;? Lactase (beta-galactosidase) Lactase is the enzyme that digests lactose (milk sugar). Lactase treated milk can be purchased. Lactase enzyme supplements are available without prescription. Alpha amylase Alpha amylase is contained in pancreatic enzyme medications used to treat certain pancreatic diseases. These drugs require a prescription and can be used offlabel as a treatment alternative. Two such drugs are Zenpep and Creon. Alpha amylase containing products can be purchased without a prescription and identified on the web by searching the National Institutes of Health Dietary Supplement Label Database.

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Beano (alpha-galactosidase) Beano is a dietary supplement that breaks down polysaccharide and oligosaccharide carbohydrates in foods, especially raffinose. Beano can help prevent gas and abdominal discomfort from beans, vegetables, and whole grains. It is necessary to take Beano before eating as a preventative. Xylose isomerase Fructose is broken down by xylose isomerase. One brand name of a product containing xylose isomerase is Fructosin. Small Intestinal Bacterial Overgrowth (SIBO) (refer to Resources for details of SIBO) SIBO refers to alterations in the types, numbers, and/or location of GUT bacteria. Hundreds of different bacteria live in the GUT. This “microbiome”) plays an important role in both digestive as well as overall health, even though it is not yet understood. SIBO can be associated with several GUT diseases, including IBS-D, IBS-C, and “gas” (abdominal bloating, distention, noisy bowel sounds, and flatulence). SIBO can be treated.

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Diagnosis of IBS-D/SIBO Hydrogen breath testing following ingestion of a nonabsorbed carbohydrate called lactulose supports diagnosis of SIBO (Figure 4.1).

Lactulose (Carbohydrate)

Hydrogen Gases are measured in the breath

Methane

Figure 4.1 Small intestinal bacteria break lactulose down into one or both of two colorless gases, depending upon the types and numbers of bacteria. Elevated levels of hydrogen are evidence of IBS-D/SIBO. Detection of methane is found in 1/3 of people and can be associated with constipation, which will be discussed in the next chapter. Hydrogen breath testing is not perfect. It may not always detect SIBO. Furthermore, a positive test for SIBO does not assure that treatment will be effective. A caveat: SIBO cannot be diagnosed with stool tests. Some laboratories make misleading claims that â&#x20AC;&#x153;dysbiosisâ&#x20AC;? can be detected by stool testing. 155

Treatment of IBS-D/SIBO without medication It may not be necessary to treat SIBO with drugs. The low FODMAPS diet Avoiding or restricting the most common carbohydrates fermented by the intestinal bacteria is the foundation of IBS/SIBO treatment. The diet restricts certain artificial sugars, including Splenda. Dietary therapy should be tried for at least one month. PPI acid reducers Stomach acid kills most ingested bacteria, and there is evidence that reduction of stomach acid secretion by strong acid reducing drugs called, proton pump inhibitors PPIs) can promote SIBO. Examples of PPIs include Prilosec (generic name is omeprazole), Nexium, and Prevacid (generic name is lansoprazole). Furthermore, new studies show that many patients with chronic heartburn can reduce dosage or frequency of PPIs or switch to much less potent acid reducing drugs called H2RAs (histamine-2 receptor antagonists). Examples of H2RAs include cimetidine (brand name is Tagamet), ranitidine (brand name is Zantac), and famotidine (brand name is Pepcid).

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Motility dysfunction Altered intestinal function promotes SIBO (Figure 4.2).

MMC

Figure 4.2 The migrating motor complex (MMC) of the small intestine is like a broom and â&#x20AC;&#x153;housekeeper of the gut,â&#x20AC;? cleaning the small intestine every 90 to 120 minutes during fasting by sweeping contents (including bacteria) into the colon. Dysfunction of the MMC occurs in most patients with IBS, which can result in small intestinal bacterial overgrowth (SIBO). The MMC is deactivated by eating and stress. So avoidance of snacking, stress management, and exercise can help reduce SIBO. 157

Antibiotics While some IBS-D patients benefit by antibiotics, others find that their symptoms are worsened by them. Antibiotics are generally overused and should only be taken when necessary. Probiotics These are microorganisms that may confer a health benefit on the host. Lactic acid bacteria and bifidobacteria are the most common types of microbes used in probiotics. Very little is known about using probiotics to manipulate GUT bacteria for health. Over 500 different bugs live in the GUT, and it is unlikely that any one probiotic will prove to be of benefit in treating and preventing SIBO. â&#x20AC;&#x153;Probiotics: A Consumer Guide for Making Smart Choicesâ&#x20AC;? is available by the International Scientific Association for Probiotics and Prebiotics, or ISAPP (www.ISAPP.net). The guide advises that there are five criteria consumers should consider when selecting a probiotic: probiotic strain, proof, packaging, quality, and quantity. Use of probiotics to treat IBS/SIBO is trial and error, and they should be taken for at least one month before a judgement is made about response to treatment. 158

Based upon research, 4 probiotics may help improve IBS symptoms:

• Activia yogurt (constipation) www.Activia.com • Align www.AlignGI.com • Florastor www.Florastor.com • VSL#3 www.VSL3.com Opioids or narcotics These drugs can cause or contribute to SIBO by causing dysfunction of motility and peristalsis. Treatment of IBS-D/SIBO with Xifaxan Xifaxan is a unique antibiotic that has been found to be the most effective antibiotic treatment for IBS-D/SIBO, and it will be approved by the FDA in the near future. Xifaxan is not absorbed, so the risk of side effects is minimal. Meanwhile, many gastroenterologists prescribe Xifaxan off-label for IBS-D/SIBO. Xifaxan is a 550 mg tablet taken three times a day by mouth (around 8 am, 2 pm, and 8 pm) for a total of 10 to 14 days. (Treatment is 14 days in research, but 10 days can be effective and reduce cost.) It does not matter if Xifaxan is taken on an empty stomach or with food. 159

Relapse of IBS-D/SIBO If IBS-D/SIBO responds to treatment, symptoms can return up to 9 months later. Relapse soon after discontinuation of treatment can be a clue that the differential diagnoses of IBS-D may need to be reconsidered. Reduction of relapse risk In addition to following treatment of IBS-D/SIBO without medication, the likelihood of relapse can be reduced with two drugs taken in low dosage at bedtime that promote the intestinal housekeeper wave, or MMC.

â&#x20AC;˘ Erythromycin While this drug is an FDA-approved antibiotic, it is used here off-label for itâ&#x20AC;&#x2122;s effects on the MMC. Erythromycin is taken in low dosage (50 to 62.5 mg) daily at bedtime. A convenient way to take erythromycin is to split a 250 mg tablet with a pill cutter into 4 equal pieces and take one piece at bedtime each night. Side effects of erythromycin with this regimen are uncommon and include nausea, abdominal pain, and diarrhea. Potentially serious and unpredictable allergic reactions can occur with erythromycin, as they can with any antibiotic.

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â&#x20AC;˘ Resolor (generic name is prucalopride) This drug is approved for treatment of constipation and IBS-C in many other countries and will likely soon become available in the United States. Until then, health insurance will not pay for Resolor. It can be obtained through Canadian pharmacies. A low dose of Resolor (1/2 mg) is taken at bedtime. Potential side effects include headache, nausea, diarrhea, and abdominal pain. Retreatment If IBS-D/SIBO responds to treatment with Xifaxan, it can be used again effectively. Research shows that retreatment with Xifaxan is effective up to 8 times.

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Treatment of IBS-D/SIBO with alternative antibiotics Other antibiotics have been reported to be effective, but they have not been formally studied as has Xifaxan. Furthermore, there is no research that favors one over another. Unlike Xifaxan, most other antibiotics are absorbed. One exception is neomycin, with less than 3% absorption. Antibiotics include risk of side effects and allergy and may result in Clostridium difficile infection. Antibiotics can also contribute to the development of bacterial resistance, which has not been a problem associated with Xifaxan to date. It is usually necessary to combine two antibiotics that are effective against different types of bacteria (aerobic and anaerobic). Several antibiotics can used: amoxicillin-clavulanate, cephalexin, ciprofloxacin, doxycycline, metronidazole, neomycin, norfloxacin, tetracycline, and trimethoprim-sulfamethoxazole. As with Xifaxan, relapse is common, and periodic retreatment may be necessary. Rotation of several antibiotics may help to reduce bacterial resistance.

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Medication Several medications are available for the treatment of IBS-D. Imodium This is the brand name of loperamide, which is available in generic form and can be purchased without prescription. Treatment of IBS-D can result in improvements in stool consistency, stool form, and urgency. Loperamide is not sedating, non-addictive, and safe to use during pregnancy and lactation. Loperamide in 2 mg dosage can be taken as needed or regularly as often as four times a day. A doctor may recommend even higher doses. Side effects are uncommon unless constipation occurs. Loperamide has the added advantage of tightening the anal sphincter muscle, which can be helpful if fecal incontinence is also present.

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Diphenoxylate-atropine This antidiarrheal is available by prescription as the generic of the original brand name, Lomotil. It is an opiate that has never been formally studied as treatment for IBS-D. However, gastroenterologists know that it can be effective. Because diphenoxylate is an opioid, it can be habitforming and associated with side effects, including constipation, sedation, dizziness, and dry mouth. Atropine is an anticholinergic drug added to diphenoxylate to reduce potential for abuse, which is consequently very uncommon. Lotronex This is the only FDA-approved drug available for the treatment of IBS-D. Lotronex can improve global symptoms (quality of life), abdominal pain, bloating, and diarrhea (both stool frequency and urgency). Lotronex can be considered as off-label treatment in men. It was effective during research trials, but not enough men were included for the studies to achieve statistical significance.

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Risks of Lotronex include severe constipation, which is why the drug should be used only for more severe cases of IBS-D that have not responded to treatment. A rare form of colitis (ischemic colitis) is another potential side effect. Lotronex is a very helpful IBS-D drug when used appropriately. It is important for both the patient and doctor to understand that diagnostic criteria for IBS-D should be met and that constipation is not a symptom. Bile acid sequestrants (BAS) At least one third of patients diagnosed with IBS-D have bile acid diarrhea (BAM), which can be very effectively treated. Since a test for BAM is not available outside of research centers, the diagnosis is based upon response to treatment. BAM symptoms are commonly triggered by eating. They are related to GUT mishandling of livermanufactured bile acids which are necessary to absorb fat. Normally, these bile acids are reabsorbed in the lower small intestine (ileum) and reused by the liver. In BAM, the bile acids are not reabsorbed properly and enter the colon where they cause dysfunction. This commonly occurs after cholecystectomy and Crohnâ&#x20AC;&#x2122;s disease. 165

BAS used to lower cholesterol bind bile acids and can be prescribed off-label to relieve IBS-D symptoms related to BAM. These drugs include cholestyramine (powder), colestipol (tablets and powder), and Welchol (tablets). They are not absorbed and have very little potential to cause systemic side effects. Cholestyramine and colestipol (less likely Welchol) interfere with absorption of some drugs and vitamins, which should be taken at least one hour beforehand. Potential GUT side effects of bile acid sequestrants include constipation, nausea, and â&#x20AC;&#x153;gasâ&#x20AC;? symptoms. When effective, BAS work within the first 1 - 2 weeks and then must be continued indefinitely. The optimal time of treatment is at bedtime, and most patients with BAM require dosing twice daily. Some patients with BAM are very sensitive to BAS. For example, only one pill of colestipol or Welchol taken daily may be adequate. If constipation occurs after treatment is initiated, dosage can be lowered to achieve satisfactory symptom relief. Welchol may have three advantages in treating IBS-D associated with BAM, because it is less likely to interfere with absorption of other medications, research has shown benefit, and it may be effective when the other two drugs are not. 166

Antispasmodics Antispasmodics can improve intermittent abdominal pain and discomfort, particularly if triggered following meals. They are unlikely to relieve diarrhea. Examples of generic antispasmodics requiring prescription include dicyclomine and hyoscyamine. Potential side effects of antispasmodic drugs can include sedation, dizziness, dry mouth, and constipation. Peppermint has been used for digestive symptom relief for centuries. It has been shown to have antispasmodic effects, which can relieve IBS pain. Most products have an enteric coating that prevents the peppermint from dissolving in the stomach where it can cause heartburn. Peppermint containing antispasmodics do not require a doctorâ&#x20AC;&#x2122;s prescription. One such product is called, CompleteReliefÂŽ.

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Antispasmodics with anti-anxiety drug Two antispasmodics also include an anti-anxiety drug. They have the same potential side effects of antispasmodics and greater likelihood of causing drowsiness. Donnatal Donnatal is the brand name for a drug that includes antispasmodics (belladonna alkaloids) and phenobarbital. Phenobarbital is a barbiturate that has sedative and anti-anxiety effects. It is rarely used for these purposes now. Librax Librax is the brand name of a drug now discontinued but available in generic form. It includes an antispasmodic (clidinium) and a benzodiazepine antianxiety drug (chlordiazepoxide). The original brand name of chlordiazepoxide was Librium, which is related to diazepam (original brand name was Valium). Antidepressants If needed to treat depression/anxiety or reduce pain sensitivity, SNRIs may be helpful in off-label treatment of IBS-D as direct GUT therapy because of the common side effect of constipation. If SSRIs are used, paroxetine is less likely than others to cause diarrhea. 168

Chapter 5

IBS-C (Constipation) St. John New Brunswick Canada

Stones and rocks 169

GUT Therapy: IBS-C (Constipation) Getting well with IBS-C involves determining goals and prioritizes improving bowel function by following new constipation management guidelines. Associated obstructed defecation requires treatment. Two drugs are available to treat IBS-C, which may also be amenable to treatment if SIBO is associated. Sections in Chapter 5 IBS-C (Constipation) Goals Remove the Hard Stool Plug Bowel Retraining Program AGA Guidelines Psyllium fiber supplements Osmotic agents Laxatives Prunes Obstructed Defecation Medication Small Intestinal Bacterial Overgrowth (SIBO) 170

Goals Reasonable goals in treating IBS-C include:

• At least 3 complete bowel movements each week, which are comfortable and do not require hard straining

• The weekly average of your “worst abdominal pain over the past 24-hours” rated 2 or less

• Initial emphasis is directed to improving bowel function The abdominal pain and discomfort of IBS-C usually become increasingly severe on each consecutive day without a bowel movement as the colon fills up with stool. So the abdominal pain and discomfort can be expected to be relieved as bowel function improves. But if bowel function improves and abdominal pain and discomfort continue despite GUT therapy described in this chapter, HEAD therapy can help.

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Remove the Hard Stool Plug Think of your colon as being “blocked” by a hard glob of stool. If you add psyllium fiber to your diet and begin other treatments, which will be discussed in the next sections, your success may be jeopardized, as stool “piles up” behind the blockage. Begin by removing the “plug” with laxatives, enemas, or even a colonoscopy prep. You can use whatever works for you. This way you begin your program with a “clean” colon. Bowel Retraining Program Think of this as behavioral modification for you and your colon. Either initially or after completing this chapter and getting better with treatment, you may well be able to retrain your bowel to empty regularly more completely and predictably. You’re going to improve bowel function, with the expectation that your abdominal pain and discomfort will then respond. Current medications can be continued as prescribed. The method for retraining includes:

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• Sit on the toilet for about 15 minutes daily and try to completely empty the rectum.

• The best time to do this is 10 to 20 minutes after a meal with coffee.

• Don’t strain to have a bowel movement. • If you are not successful, go on about your life. • If you don’t have a bowel movement in 2 to 3 days, insert a suppository into the rectum (Dulcolax or Fleet) 30 minutes after eating. It may eventually be possible to discontinue the use of the suppositories.

• Be patient. Bowel retraining can take several weeks.

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AGA Guidelines New guidelines for the management of chronic constipation, including IBS-C were published by the American Gastroenterological Association in 2013. Treatment of constipation is initially focused upon improving bowel function with psyllium fiber supplements, osmotic agents, and laxatives. While dietary guidelines call for most people to eat 25 to 35 grams or more of fiber/day, most eat only about 15 grams/day. Some with IBS-C donâ&#x20AC;&#x2122;t benefit from fiber or find that it makes them worse. However, the potential benefit of using psyllium fiber is commonly underestimated by both patients and doctors. The keys are to understand what psyllium fiber supplements are and know how to use them.

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Psyllium fiber supplements Psyllium (ispaghula) is a unique, natural, non-gluten, soluble fiber that is not absorbed. There is scientific evidence that psyllium fiber supplements (but not insoluble dietary fiber, such as wheat bran) improve bowel symptoms in IBS-C and chronic constipation. There are additional benefits to taking psyllium daily. Clinical studies have shown that 7 grams of soluble fiber from psyllium taken daily as part of a heart healthy diet low in saturated fat and cholesterol may reduce the risk of heart disease by lowering LDL “bad” cholesterol. Psyllium helps maintain low blood sugar levels, which is anti-inflammatory. Because it is filling, psyllium can also reduce appetite, which helps with weight control. Two main psyllium fiber supplements In the United States, two main psyllium fiber supplements are available by brand and in generic equivalents.

• Metamucil (3.4 grams of psyllium per teaspoonful) • Konsyl (6.0 grams of psyllium per teaspoonful)

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How to take psyllium fiber supplements

• Begin with 3.4 to 7 grams of a psyllium fiber supplement taken every day with meals (taking it intermittently won’t help).

• As dosage is increased, it is best to take psyllium more than once each day.

• Increase the dosage gradually over several weeks to achieve the goals.

• Most people need 15 to 20 grams/day, but 30 to 40 grams/day and even more may be necessary.

• Be patient, because it can take several weeks to respond to psyllium fiber supplements.

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Psyllium and “gas” If “gas” (abdominal bloating, distention, and/or flatulence) seems to increase with psyllium therapy, it commonly diminishes with regular daily use over time. Psyllium fiber supplements are usually not directly responsible for “gas.” Chapter 6 provides more information on management of “gas.” Sometimes “gas” can be reduced by switching to an alternative fiber supplement. Examples include methylcellulose (brand name: Citrucel; generics available,) calcium polycarbophil (brand name: Fibercon; generics available), and Benefiber. Osmotic agents These products soften hard stool and can be taken as often as daily. Osmotic agents are not absorbed. Polyethylene glycol (PEG) is available as Miralax without prescription (generics are available). The dosage of PEG is 17 grams (one capful) dissolved in a glass of water 1 - 2 times a day. An alternative osmotic agent is a magnesium osmotic, such as Milk of Magnesia. The dose is 1 - 2 tablespoons taken 1 - 2 times a day.

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Laxatives The new AGA constipation guidelines confirm the safety of using stimulant laxatives and that they can be taken either intermittently or even regularly and daily if needed.

•

Bisacodyl (brand name: Dulcolax) is a stimulant laxative available without prescription that can be used as often as daily, either as a 10 mg suppository rectally or as one to three 5 mg tablets orally.

• An alternative laxative that can be taken as often as daily is senna (brand name is Senokot). The dose ranges from 2 tablets once a day to 4 tablets twice a day.

• A suppository (Dulcolax or Fleet) can be used 30 minutes after eating to potentiate meal stimulated colonic contraction. Prunes Prunes contain a natural laxative in the peeling. Each medium sized prune contains 1/2 gram of soluble fiber. Prunes also contain sorbitol, which can be beneficial as an osmotic agent. However, sorbitol is a FODMAP, so there is a risk of aggravating IBS symptoms of abdominal pain, discomfort, and “gas” with prunes.

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Obstructed Defecation Based upon the AGA constipation guidelines, if you fail to respond to psyllium, osmotic agents, and laxatives, then you and your doctor will consider further evaluation to determine if you have both IBS-C and functional obstructed defecation. If a defecatory disorder (obstructed defecation) is identified, then you can consider pelvic floor retraining. The concept is similar to the bowel retraining program described here for IBS-C. However, pelvic floor retraining is more sophisticated and youâ&#x20AC;&#x2122;ll need professional help. It involves biofeedback and pelvic floor relaxation training therapy. Research confirms that symptoms improve in more than 70% of patients with defecatory disorders using pelvic floor retraining. The method can be used to train patients to relax pelvic floor muscles during straining and to correlate relaxation and pushing to achieve defecation. Then the non-relaxing pelvic floor is gradually suppressed and normal coordination is restored. Emphasis is placed upon appropriate coordination of abdominal and pelvic floor motion during evacuation. Several sessions may be necessary (for example, 6 sessions lasting 30 - 60 minutes at 2 weekly intervals). 179

Medication Several drugs can be helpful in treatment of IBS-C. SSRIs If IBS-C is present and an antidepressant is advisable, SSRIs may be preferable. They can potentiate direct GUT therapy because of their common side effect of diarrhea. Amitiza Amitiza is approved for treatment of IBS-C in women and chronic functional constipation in adults. The most common side effects of Amitiza are nausea, diarrhea, and headache. Nausea is less likely to occur if Amitiza is taken with food. Occasional patients experience a sensation of chest tightness and shortness of breath within one hour of taking Amitiza. These symptoms usually go away within three hours but may recur with repeated use. The safety of Amitiza in pregnancy is not established. It is necessary to be patient taking Amitiza. Side effects can resolve over time. Furthermore, relief from abdominal pain, discomfort, and bloating may take several weeks.

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Linzess Linzess is approved for treatment of IBS-C and chronic functional constipation in adults. Linzess works directly upon the GUT by increasing fluid secretion and movement (motility and peristalsis) and by reducing the activity of pain sensitive nerves. The risk of systemic side effects with Linzess are minimal, because the drug is not absorbed and works directly on the GUT. The main side effect risk is diarrhea. It is not known if Linzess will harm unborn babies. It is also not known if Linzess passes into breast milk. The effect of Linzess on bowel function occurs within the first week or so after initiation of treatment, which can result in reduction of pain and discomfort. However, the direct effect of Linzess on decreasing pain and symptom sensitivity on the GUT can take several weeks. It is necessary to be patient taking Linzess for two reasons. First, if diarrhea occurs, the drug is working. Diarrhea is likely to resolve with time as the GUT becomes accustomed to the drug. Second, the abdominal pain, discomfort, and bloating relief may not be fully realized for several weeks. 181

Resolor This is the brand name for prucalopride, which is approved for IBS-C in many countries and will likely be FDA approved in the United States in the near future. It can be obtained through Canadian pharmacies; however, health care insurance will not pay for Resolor without FDA approval. The dosage of Resolor is 1 to 2 mg by mouth daily with or without food. Potential side effects of Resolor include headache, nausea, diarrhea, and abdominal pain.

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Small Intestinal Bacterial Overgrowth IBS-C can be associated with SIBO ((BS-C/SIBO), which may respond to off-label treatment with a unique antibiotic called, Xifaxan. A 10 to 14 day course of Xifaxan 550 mg is taken by mouth three times a day COMBINED with 500 mg of neomycin sulfate by mouth twice a day. For details on diagnosis and treatment of SIBO, refer to Chapter 4 and Resources. Neomycin is a poorly absorbed antibiotic, so side effects are rare (nausea, vomiting, and diarrhea). Serious reactions are extremely rare and include injury to the kidneys and ears (impaired hearing and/or impaired balance) that can be permanent (primarily associated with chronic kidney disease and/or long term use over months). A less studied off-label alternative to neomycin sulfate is metronidazole 250 mg, which is taken orally three times a day for two weeks COMBINED with Xifaxan. Metronidazole is an absorbable antibiotic. Possible side effect risks include nausea, vomiting, diarrhea, indigestion, metallic taste, and furry tongue. Other side effects are possible, but they are rare.

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Chapter 6

Belching and “Gas”

Disney World Orlando, Florida

Stones and rocks

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GUT Therapy: Belching and “Gas” Most patients with IBS report troublesome symptoms with belching and/or “gas,” even though these symptoms are not a formal component of the disease definition of IBS. It’s first necessary to distinguish belching from “gas” (abdominal bloating, abdominal distention, noisy bowel sounds, and/or flatulence and farting), because treatments are quite different. If belching and “gas” persist despite GUT therapy directed to the predominant IBS subtype and the advice offered in this chapter, HEAD therapy can help.

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Sections in Chapter 6 Belching and “Gas” Belching or “Eructation” Treatment of Belching “Gas” Abdominal bloating Abdominal distention Noisy intestinal sounds or “audible borborygmi” Flatulence or farting Malodorous flatulence (smelly gas) Treatment of “Gas”

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Belching or “Eructation” This is the audible (you and others can hear it) escape of air from the esophagus into the mouth. There are two types of belch: the gastric belch and supragastric belch. Gastric belch This belch is the escape of swallowed air from the stomach back into the esophagus and mouth. This is the result of normal function (reflexes) and occurs 25 to 30 times a day. A gastric belch may or may not be audible. Supragastric belch “Supra” means above, so this belch involves the esophagus, which is above the stomach. The swallowed air in the esophagus immediately escapes into the mouth. Supragastric belches are not the result of a reflex. Instead, they are the consequence of learned behavior. The diaphragm is the breathing muscle that separates the chest from the abdomen. When the diaphragm contracts, it creates a negative pressure in the chest and the esophagus, which “suctions” air into the esophagus, where it is belched into the mouth by straining. A few patients ingest air into the esophagus by contracting the muscles at the base of the tongue and throat. 187

Supragastric belching is most commonly associated with stress and anxiety. Remember, much of what’s happening occurs without your conscious awareness. Supragastric belching usually stops during speaking and does not occur during sleep. Supragastric belching can be associated with GERD (gastroesophageal reflux). GERD symptoms of heartburn and regurgitation are usually present, and the associated symptom of belching usually responds to GERD treatment. Rarely, supragastric belching can be associated with heart disease, ulcer, gallstones, or pancreatic disease. Supragastric belching is a learned behavior. It is the symptom of an FGID (“functional excessive belching”).

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Treatment of Belching The easiest way to â&#x20AC;&#x153;unlearnâ&#x20AC;? supragastric belching is to become aware of and then understand what is happening and accept that abnormal gas production in the stomach or upper intestine is not the cause. Then supragastric belching can be controlled or stopped by breathing through the mouth rather than nose, which reduces swallowing (of air). A pencil or pen placed laterally in the back of the mouth helps with this, because opening the mouth virtually prevents swallowing. Controlled abdominal breathing through the mouth is a mind/body relaxation technique that diverts attention and elicits relaxation and calming. Placing a hand or both hands over the upper abdomen can help you learn abdominal breathing. If belching does not eventually stop, then consultation with a speech therapist or cognitive behavioral specialist is the next step.

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“Gas” Symptoms include abdominal bloating, abdominal distention, noisy abdominal and intestinal sounds, and flatulence (farting). Abdominal bloating Bloating is a sense of pressure or fullness in the abdomen. Abdominal bloating usually involves the entire abdomen, but some patients can localize the symptom to one or more areas of the belly. Bloating is the symptom of a FGID (“functional bloating”). Abdominal distention Distention is actual enlargement of the abdominal girth. Both abdominal bloating and distention are commonly triggered by eating and can fluctuate through the day. Bloating and distention are usually minimally present upon awakening and become worse as the day progresses. Noisy intestinal sounds or “audible borborygmi” Loud gurgling, rumbling, and growling sounds coming from the belly can be very embarrassing. Waves of contractions, called peristalsis cause movement of fluids and gas through the small intestines, which is what causes the sounds.

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Flatulence or farting The average number of farts passed from the colon daily is around 14, but many patients with IBS consider farting to be bothersome and/or embarrassing, regardless of number (Figure 6.1).

Range 7

Average # farts/day = 14

Figure 6.1 Normal daily flatulence The amount of gas expelled each day normally ranges from 1 to 4 pints. Part of it comes from swallowed air. The major source of gas is fermentation of ingested carbohydrates by the GUT bacteria: hydrogen, oxygen, nitrogen, carbon dioxide, and, in about one-third of people, methane, which is colorless and odorless). Malodorous Flatulence When farts have a bad smell, they contain hydrogen sulfide, which is produce by fermentation of certain sulfur-containing foods by GUT bacteria. Treatment of â&#x20AC;&#x153;gas,â&#x20AC;? including excessive, bothersome, and or smelly flatulence is discussed in the next section. 191

Treatment of “Gas” “Gas symptoms often respond to improvement of bowel function, which is a treatment goal for GUT therapy of IBS-D and IBS-C. Emphasis is then placed upon reducing and correcting carbohydrate maldigestion and malabsorption:

• Diet: Low FODMAPS • Diet: Wheat and Gluten Restriction • Diet: Malodorous Flatulence Avoid sulfur-containing foods, including red meat (the prime offender), cruciferous vegetables (broccoli, cabbage, brussels sprouts, and cauliflower), garlic, dried and sulfured fruit (e.g., apricots), certain aromatic spices, and beer (for unexplained reasons).

• Enzyme Supplements • Small Intestinal Bacterial Overgrowth (SIBO) IBS-D

• Small Intestinal Bacterial Overgrowth (SIBO) IBS-C

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Afterword

Captiva, Florida

Itâ&#x20AC;&#x2122;s go time!

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You’ve come full circle in your journey to find IBS answers. You see the whole picture: IBS is disease that involves the whole you. You know what IBS is, what causes it, and your treatment opportunities. If you apply HEAD, CONNECT, and GUT therapy,” you can get well. To take charge of your health, “be your own doctor,” and work effectively with your doctors and caregivers, you’ll want to study portions of this book carefully. It will continue to be your IBS resource. The e-book version will be updated periodically. Check the website regularly for IBS news: www.IBSAnswersforYOU.com. You can find additional IBS help that I recommend in Resources. Being healthy is an active process. It takes work. It really is “go” time. It’s time to take care of yourself.

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About the Author

Itâ&#x20AC;&#x2122;sYou never goare time!

alone

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I received my M.D. degree from The Ohio State University in 1972 and completed training in internal medicine and gastroenterology at Vanderbilt University Hospitals in 1977, where I also served as a Chief Resident in Medicine. In 2012, following a three year retirement, I returned to practice with the Ohio Gastroenterology Group, where I had been a founding partner. Life is beautiful and mysterious, but it’s also difficult and complicated for everyone. Life and IBS are truly a vicious circle, and it’s increasingly difficult to find the knowledge lost in information and misinformation overload, particularly in the hurried patient - doctor relationship. I wrote this book for our patients at the Ohio Gastroenterology Group and for you. I’m confident you’ll find the help you need to see the whole picture of you, get better, and become healthier than you’ve ever been.

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Updates This PDF of the ebook is version 1.01. It will be updated periodically. Check here first to learn what has changed. Check the website regularly for news, updates, and errata: www.IBSAnswersForYOU.com

Eager to learn 197

Resources Umbrella Girl German Village Columbus, Ohio

Donâ&#x20AC;&#x2122;t forget your shoes

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Resources Click here to see a list of the most common functional GI disorders (FGIDs). IBS Support Groups International Foundation for Functional Gastrointestinal Disorders (IFFGD) IFFGD was founded by Nancy and Bill Norton in 1991 to help people suffering with functional GI disorders. Rome Foundation The mission is â&#x20AC;&#x153;To improve the lives of people with functional GI disorders.â&#x20AC;? Irritable Bowel Syndrome Self Help and Support Group was founded by Jeffrey D. Roberts in 1987 and is the first and largest on-line community for sufferers of irritable bowel syndrome.

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Resources Patient-Physician Relationship Douglas Drossman, M.D., is a gastroenterologist and authority on IBS, FGIDs, and the biopsychosocial model (This author has been profoundly influenced by Dr. Drossman’s work.) Clifton K Meador, M.D., writes books about the effects of mind on body. (This author was Dr. Meador’s student while training at Vanderbilt University Hospitals. He considers Dr. Meador to be his most important medical role model and the inspiration for his personal and professional interest in the mind/brain — body relationship.) Here is an inspirational story of the importance of the patient—doctor relationship told by gastroenterologist, John Pandolfino, M.D., of Northwestern University.

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Resources Low FODMAPS Diet Sue Shepherd, Ph.D., dietician, (developed the low FODMAPS diet) Patsy Catsos, M.S., R.D., (website and book,Â IBS -- Free at Last) Gina Casagrande, M.S., R.D., L.D., in Columbus, Ohio Dietitians Patsy Catsos, provides a directory of Registered Dietitians who have identified themselves as capable of assisting clients with low FODMAPS diets. Functional Heartburn John Pandolfino, M.D., is a world renowned gastroenterologist and esophageal expert at Northwestern University who studies and treats patients suffering with functional heartburn. (The author and his esophageal expert colleague at the Ohio Gastroenterology Group, John Castor, M.D., appreciate the recent opportunity to spend time in the Northwestern GI laboratory and study with Dr. Pandolfino.) 201

Resources Small Intestinal Bacterial Overgrowth (SIBO) Mark Pimentel, M.D., is a gastroenterologist doing pioneering research regarding the role of SIBO in IBS and other FGIDs. He is the author of A New IBS Solution. (This author appreciates his personal conversation with Dr. Pimentel intended to provide the latest recommendations for treatment of IBS/SIBO in this book and by the Ohio Gastroenterology Group.) Dr. Pimentel and the Ohio Gastroenterology Group utilize hydrogen breath testing to diagnose SIBO provided by Commonwealth Laboratories, Inc. Click here to see a short video about how SIBO breath testing is done. Click here to see Dr. Pimentel’s treatment algorithm for IBS/SIBO utilized by the Ohio Gastroenterology Group. K. Scarlata, dietician, “Small Intestinal Bacterial Overgrowth - What to Do When Unwelcome Microbes Invade.” Today’s Dietitian. April, 2011 (Vol 13) No. 4 P 46.

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Resources Psychology and Psychiatry Barbara Bolen, Ph.D., is a clinical psychologist in New York with special interest and expertise in IBS. She serves as the Guide to Irritable Bowel Syndrome for About.com. Peter Zafirides, M.D., is a psychiatrist in Columbus, Ohio with special expertise in chronic pain and existential psychotherapy. He provides helpful information on his website (Dr. Zafirides was one of this author’s “star” students). David D Clarke, M.D., is a gastroenterologist with a helpful website and book about “Stress Illness” (central sensitivity symptom syndromes). Howard Schubiner, M.D. has a website, book, and program for Mind Body Syndrome (central sensitivity syndromes) based upon the work of John Sarno M.D. M. Scott Peck, M.D., (book) The Road Less Traveled: A New Psychology of Love, Traditional Values, and Spiritual Growth. (This author considers this book to be one of the best self-help books ever written.) 203

Resources Central Sensitivity Muhammad B Yunus, M.D., is a rheumatologist at the University of Illinois at Peoria, IL who pioneered the concept of central sensitivity and central sensitivity symptom syndromes. D. J. Clauw, M.D., is a University of Michigan rheumatologist who researches and advances the concept of central sensitivity and â&#x20AC;&#x153;chronic multisymptom illnesses,â&#x20AC;? which are central sensitivity symptom syndromes. Manuel Martinez-Lavin, M.D., is a rheumatologist and fibromyalgia expert in Mexico who researches and writes about fibromyalgia, stress, central sensitivity, and chronic pain. Stress Bruce S. McEwen, Ph.D., is a neuroscientist at The Rockefeller University in New York and one of the worldâ&#x20AC;&#x2122;s leading experts on the damaging effects of stress on the brain and body. He advances the concept of allostasis and allostatic load and emphasizes the resiliency and adaptability of the brain to change. 204

Resources Change Your Brains Superbrain (2012), is a new book by best-selling author and physician, Deepak Chopra, M.D., and Harvard neuroscientist, Rudolph E. Tanzi, Ph.D., explaining how the brain and body can be changed for the better by the mind with increased self-awareness and conscious intention.

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THOUGHT

HEAD

Conscious Subconscious Memory

SENSITIVITY

Pain & Symptoms

STRESS

CONNECT EMOTION Depression Anxiety

GUT

YOU

Gender Nature/Nurture Figure 1.2 and 2.18 The biopsychosocial model of IBS ÂŠ William B. Salt II, M.D.

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THOUGHT

HEAD

Conscious Subconscious Memory

SENSITIVITY

Pain & Symptoms

STRESS

CONNECT EMOTION Depression Anxiety

YOU GUT

Gender Nature/Nurture Figure 2.30 The Biopsychosocial Model of Functional GI Disorders (FGIDs) and Central Sensitivity Syndromes ÂŠ William B. Salt II, M.D.

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“IBS” by Reese Knickle (the author’s granddaughter)

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IBS Irritable Bowel Syndrome A Gastroenterologist Answers Your Questions

William B. Salt II, M.D. This PDF version of the ebook is prepared exclusively for patients of the Ohio Gastroenterology Group, Inc. The ebook is available in online bookstores, including Amazon, Apple, and Barnes and Noble. Consult the authorâ&#x20AC;&#x2122;s website for more details: www.IBSAnswersForYou.com

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