Expert Interview on Irritable Bowel Syndrome

Prof. Susan L. Lucak, MD, is associate director of the Center for Intestinal Dysfunction and a gastroenterologist at Columbia-Presbyterian Medical Center in New York. She also holds a chair in clinical medicine at Columbia University’s College of Physicians and Surgeons in New York. Dr. Lucak: Irritable bowel syndrome is the most common gastrointestinal disorder in the United States, affecting 15 to 20 percent of Americans. In Westeropa, it’s about 15 percent of the population. The condition manifests as abdominal pain or discomfort associated with diarrhea (more than three bowel movements per day) or constipation (fewer than three bowel movements per week), or alternating diarrhea and constipation in the same person. The symptoms may seem insignificant, but they can become quite severe and affect the quality of life of those affected. People with irritable bowel syndrome often miss school or work because of symptoms of the condition.

What causes IBS?

We do not know the exact cause of irritable bowel syndrome. Most experts suspect a dysfunction of the nervous gastrointestinal system (the autonomic intramural nervous system of the intestines, also called: “second brain“) as the basis for the disease. This network is as complex in structure as our brain. It is responsible for the control of gastrointestinal functions such as perception of pain in the intestinal area, intestinal movement and secretion of digestive juices. People with IBS tend to have increased pain sensitivity, increased intestinal activity, and increased secretion of digestive juices into the intestines. The nervous system of the intestine is connected to the brain by nerve cells in both directions. Stress or emotional problems that affect the human brain are therefore also transmitted to the intestines. Accordingly, increased stress can result in increased irritable bowel syndromes.

Who is at risk for developing irritable bowel syndrome?

In the United States, women are two to three times more likely to be affected by irritable bowel syndrome than men. In India, it’s the other way around – six times more men. There is no uniform distribution across the globe, and it is not easy to explain the pattern. Presumably, people in different cultures have their own understanding of preventive medical care. The gender difference in terms of occurrence of irritable bowel syndrome needs to be studied in more detail.

How does the affected person know if he or she has IBS? What are the specific characteristics?

IBS symptoms report repeatedly and at regular intervals. Features of the disease include abdominal pain or discomfort that improves after bowel movements. Diarrhea, constipation, or the occurrence of constipation alternating with diarrhea are also associated with the disease. Further, symptoms include flatulence, a feeling of incomplete evacuation after defecation, and mucus mixed with the stool.

How is the diagnosis made?

IBS is diagnosed based on clinical symptoms, according to the ROME II guidelines. These include abdominal pain or discomfort that improves after bowel movements, diarrhea or constipation, or alternating constipation and diarrhea for three months within a year, not necessarily for three consecutive months.

How is IBS treated?

In the past, people treated only the symptoms of the disease. People did this because they did not know the cause of IBS. During the last two decades, we have been able to gain deeper insights into the nervous system of the internal organs. The independent, “second brain” lies at the root of the problem of irritable colon. In addition, serotonin, a neurotransmitter present in large quantities, plays an important role in the function of this autonomic nervous system. In fact, 95 percent of the serotonin present in the body is localized in the gastrointestinal tract.

What causes the most stress for people with IBS?

Life for people with IBS is inherently stressful because symptoms come on abruptly. Abdominal pain can be severe and interfere with daily life. People with the condition need to continually check on the nearest public restrooms, as they may lose rectal control (fecal incontinence) when they experience diarrhea and urge to defecate. If constipation is the main problem, patients may experience bloating or pain.They need a lot of time on the toilet to push and empty their bowels. All this affects the quality of life. Often, patients also suffer in silence because it is not appropriate to speak publicly about the symptoms. Often, sufferers withdraw from their environment, are forced to stay away from school or work, or avoid social occasions. All of this leads to great stress for some patients.

Can you please name some of the side effects that result from the treatment of IBS?

The anticholinergic medications for mild forms of IBS can result in drowsiness, dry mouth, mild dizziness, and constipation. The tricyclic antidepressants, on the other hand, are accompanied by similar side effects as the anticonvulsant medications. They can also trigger significant weight gain.

To what extent do psychological factors play a specific role in IBS?

For some patients, psychological factors can play a very important role. Because the “first brain” is connected to the “second,” the intestines reflect what is going on in the head. Stress in itself does not trigger IBS, but it can make symptoms worse. Measures against anxiety attacks, depression and other psychological abnormalities should be given in combination with treatment tailored to the intestines in order to achieve a more holistic improvement in the state of health. Hypnosis, biofeedback, cognitive behavioral therapy, and psychodynamic therapy have been shown to be curative when used appropriately. In recently published studies, it became apparent that combined treatment of both psychological and gastrointestinal factors resulted in improved overall health.

So is there a mind-body connection?

In a sense there is, yes. I call it headgut interaction.

What happens to patients who want to be treated alternatively rather than conventionally?

Alternative treatments are being used around the world for IBS patients, and they seem to be quite effective. I don’t have any experience with them myself. However, I did learn about the Ayurvedic treatment method in India. It includes buttermilk enema, massage and steam therapy, and meditation among other elements. The emphasis is placed on maintaining health and is directed at treating the body and mind. I consider alternative treatment methods to be very effective and think that individuals should find out about them beforehand.

Do IBS patients need to change their diet?

Many people think their gut functions according to the food it is fed. There is no specific diet for IBS. In general, I recommend that my patients eat a high-fiber diet to increase stool volume and make stool easier to pass. To make the whole digestive passage more fluid, it helps to drink six to eight glasses of water a day. I also recommend low-fat diets, as high-fat foods tend to increase bowel motility and thus are more likely to cause cramping and pain in the abdominal area. It is important to know if the patient has lactose intolerance to exclude lactose (milk sugar) from the diet. Some patients have specific food intolerances; they should avoid the foods in question.

Is there anything we can do to avoid getting IBS?

Since we do not know the cause of IBS, we do not know how to prevent it. In the case of postinfectious IBS, at least we can prevent acute gastrointestinal disease. In practice, this is difficult to realize. As for the psychological side of IBS, one would have to ask how to avoid stress in life or how to prevent the negative sides of life. Here I would like to mention something important. IBS is not just a symptom, but a broad clinical picture. There are probably many factors that lead to the different symptoms of IBS. If we can better understand these factors, we can better prevent IBS. The disease was first described in 1849. We can still learn a lot about it!

What is the prognosis for people with IBS?

There is no cure for IBS, but with targeted treatment directed at the internal organs and brain, the disease can be managed. Patients treated in this way can already live much better lives.