Monday, October 31, 2011

Irritable Bowel Syndrome

I was working in the gastrointestinal clinic at the county hospital when I went into see a new patient referral.  I’ll call her Jane.  She was in her mid-30s. 
“Hi, I’m Sharon and I’m a PA in the clinic.  How can I help you?”
“I’m Jane and my physician referred me due to my having gassy abdominal pain with constipation that won’t go away.”
“Okay, what work-up have you had so far for it?”
“My physician has done an x-ray of my abdomen which just showed that I had a lot of stool present.  He’s also told me to take a lot of fiber, which just made my bloating worse.”
“Okay, well let’s start with your family history then, any history of cancer in any of your relatives?”
“No, none.”
“Any history of cancer in yourself?”
“Have you had any rectal bleeding?”
“How about any other symptoms related to your abdomen, such as acid reflux, diarrhea, a feeling of fullness, etc?”
“Sometimes I get diarrhea, it only last for 2-3 days, then it’s gone and my constipation is back.  I also have occasional reflux, which I take some over the counter zantac for, which relieves it.”
“How long have you had these symptoms?”
“For about a year or so.”
“What medications are you on?”
“I take a blood pressure medication, lisinopril.  My occasional zantac for my acid reflux.  And then I take over the counter miralax when my constipation gets really bad and I feel all bloated up.”
“Does the miralax work for you?”
“Yes, I usually have to take two doses though before I get relief.”
“Okay, once the miralax works, is your abdominal pain gone, or is it still there?”
“No, once the miralax works, I have relief of my gassy pain and bloating.  But then the cycle just starts all over again.  A couple of days later I’m all constipated again, with lots of gas and bloating.”
“So when you have constipation, are you able to pass any bowel movement or do you just feel plugged up?”
“I can pass a small amount, but I have to really push to get it out, and then it’s only a small amount.”
“Does your symptoms ever wake you up at night?”
“Okay, well then how about any drug allergies?”
“Any weight loss?”
I quickly scanned through her patient chart and saw that her blood counts were normal as was her electrolytes. 
“Okay, I see that your labs are normal which your primary care physician drew on you a while back. So
then let me listen to your chest, feel your abdomen and I’ll go over what we’ll do for you.”
The patient’s physical exam was normal which included her abdominal exam which did not show any tenderness to palpation.

At this point the most likely diagnosis for this patient was irritable bowel syndrome (IBS).  This is a clinical diagnosis.  The patient did not have any ‘red flags’ i.e. rectal bleeding, pain awakening her at night, weight loss, abnormal blood counts and she had the typical constellation of alternating diarrhea with constipation history.  She also complained of gassy pain with a feeling of bloating which was relieved with passage of her stool.  If the patient had any ‘red flags’ then this would have necessitated her receiving a more complete work-up which could consist of having a flexible sigmoidoscopy (a procedure where a scope is put up the patient’s rectum and the inside walls of the patient’s lower colon is inspected). 
If the patient had mostly diarrhea alternating with some constipation then the work-up would have consisted of doing stool studies (to rule out infectious diarrhea) and/or studies to make sure she didn’t have celiac disease (a gluten sensitivity). 

“Okay, what I want you to try first is to increase your their water/fluid intake to at least 72-84 fluid ounces a day.  I also want you to stop all diet soda intake which has an artificial sweetner that most people don’t handle very well and gives patients gas.  You can try a lactose free and ‘gas-free’ diet.  Lactose is found in milk products and can cause gas in patients who are lactose intolerant.  There are many foods (mostly vegtables and some fruits) which can cause gas formation, I’ll give you a list before you leave the clinic.”
“Okay, now about the fiber supplement.  You probably tried taking the fiber too fast.  Fiber helps move food along the GI tract in a smooth fashion.  But for those patients who have IBS we tell them to increase their fiber intake very slowly so as to not cause additional gas.  Generally we advise patients  to begin with taking 1 teaspoon every day for 3 days, then increase by ½ teaspoon every 3 days until they are at 1 tablespoon 3 times a day.  Then you can switch over to the fiber tablets or cubes every day.  I want you to get your fiber intake up to 30 grams a day and stay there.   With the additional fiber intake and fluid intake this helps to relieve the constipation symptoms by allowing the system to regulate itself.”
“Are you with me so far?”
“I think so, are you going to write this all down for me?”
“Sure.  I’m going to give you information on the foods that can cause gas, as well as our fiber schedule to take home with you.” 
“Exercise is another benefit for patients.  Exercise helps to increase the motility of the GI tract, which then helps with proper regulation.  So I want you to try to walk 30 minutes 3 times a week.  Can you do this?” I asked.
“I can try.”

Patients can also be given anti-spasmotics if they are complaining of spastic abdominal pain.  If the patient’s IBS is severe then these patients can also be given anti-depressants which work on the nerve endings in the GI tract and decrease the pain sensations.   An alternative to prescription medication is for patients to try taking peppermint oil 187 mgs 3 times a day and this has shown symptoms improvement in more than 50% of patients.

“Okay, well it’s going to take you a couple of weeks to get your fiber intake up to the full dose of 30 grams a day.  It will also take you some time to see whether going on a lactose free and gas-free diet makes any difference in your symptoms.  So I want you to take the miralax only if you absolutely have to, otherwise stay with the plan regarding the change in your diet and exercise.  Schedule yourself to come back in and be seen by the GI clinic in 6-8 weeks and we’ll see how you are then.”
I retrieved the information on the necessary food changes as well as the fiber schedule and gave them to her. 

Two months later Jane was back in clinic.  I went into see her.
“Hi, Jane how are you?”
“I’m better.  I stopped all of my diet soda intake and that helped.  Stopping all of my milk products didn’t do anything for me.  I found one or two of the vegtables caused me a problem such as broccoli and cauliflower, so I don’t eat them anymore.  And I followed your instructions on fluid intake and also about the fiber intake.  I slowly worked up to 30 grams of fiber after 6 weeks and I’ve noticed that has helped.  I’ve only had to take one dose of miralax in the last two weeks since I’ve been on the full dose of fiber intake.  And I’m trying to walk several times a week.”
“Sounds great.  How’s your pain and gas symptoms?”
“Almost gone. “
“Alright, I’m glad to hear it.  Well it sounds as though you’re finally on the right track.  I don’t think we need to see you again then.  Keep up the good work.  If you by chance find that you need some additional help you can also take some peppermint oil three times a day, which comes over the counter and that has been shown to be effective in over 50% of the patients who take it.   I’m glad to see you’re doing so well.”


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