Irritable bowel syndrome (IBS), a chronic disorder that affects the stomach and the intestines, is fairly common, occurring in up to 11.2% of the population worldwide and about 4.2-7.5% in India, as per various estimates. But since the symptoms—which can range from mild enough to be annoying to severe enough to interfere with daily life—aren’t life threatening, many people don’t feel the need to get themselves diagnosed.
“IBS is a chronic digestive system condition. Its primary symptoms are abdominal pain and changes in bowel habits (constipation and/ or diarrhoea). IBS is the most commonly diagnosed gastrointestinal condition and is second only to the common cold as a cause of absence from work,” says Dr Sushrut Singh, additional director, gastroenterology and hepatobiliary sciences, Fortis Hospital, Noida.
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There are several myths associated with the disorder, one of them being stress as a causal factor for IBS. But is it really a myth? Recent research from the University of Missouri School of Medicine in the US has established a link between IBS and mental health challenges. The research highlights the need for health professionals to evaluate and treat associated psychiatric co-morbidities in IBS patients to improve their overall health and quality of life.
The study looked at more than 1.2 million IBS patient hospitalisations from 4,000 US hospitals over a three-year period and found that more than 38% had anxiety, and more than 27% had depression. Both figures were double the rate of anxiety and depression found in those without IBS. The prevalence of psychiatric problems including anxiety, depression, bipolar disorder, suicidal attempt/ ideation, and eating disorders was significantly higher in the IBS patient population when compared to the general adult population. “One possible explanation is the so-called brain-gut axis. We have long suspected that dysfunction of the brain-gut axis is bidirectional, such that IBS symptoms influence anxiety and depression, and on the other hand, psychiatric factors cause IBS symptoms. Medical professionals need to treat both ends of the axis,” Zahid Ijaz Tarar, lead researcher, assistant professor of clinical medicine, University of Missouri Health Care, was quoted as saying by the News Medical website.
The exact cause of IBS is unknown, but some common factors that appear to play role include severe gastrointestinal infection, irregular muscle contractions, changes in gut microbiota, and poor coordination between the intestine and the nervous system, says Dr Vikas Singla, director and head—gastroenterology, Max Hospital, Saket, New Delhi. “The bidirectional communication along the gut–brain axis is being extensively studied. The complex interaction between the gut and the brain has a role to play in IBS and aggravation of symptoms. Several psychosocial aspects of IBS are poorly understood. Association of certain disorders like depression and anxiety may be noted in some patients with IBS,” adds Singla.
IBS patients often go through more daily and lifetime stressful events than normal people. They complain about increased anxiety, depression, phobias, and somatisation. “Thus, the co-morbidity of IBS and psychological distress are not uncommon, and the prevalence of at least one psychiatric disorder in IBS patients typically ranges from 40% to 60%. Sometimes, this has been reported as high as 80%, especially depression and anxiety,” says Dr Pramod Kadam, consultant laparoscopic and robotic surgeon, Ruby Hall Clinic, Pune.
IBS may also be linked to major life traumas like disruption of a close relationship, marital separation, break-ups, etc, or traumatic experiences during childhood like maladjusted relationships, severe illness or death of a parent, or abuse—be it physical, sexual or emotional. “These studies strongly and clearly suggest that psychological or psychosocial stressors can lead to the development of IBS,” adds Kadam.
However, Kadam clarifies that stress is not the primary cause of IBS. “Stress often triggers symptoms of IBS; so, it’s common for people to believe that the former causes the latter. Stress, however, can trigger or worsen symptoms of IBS. If you find your IBS flares when you face undue stress, we can help you explore relaxation techniques such as meditation, yoga, cognitive behaviour therapy, and hypnosis,” he adds.
There are several other myths associated with IBS. Many people believe that IBS is associated with cancer or it may give rise to inflammatory bowel disease. “However, in reality, IBS is not an autoimmune disorder and will not give rise to colon cancer or irritable bowel disease (IBD),” explains Singla of Max Hospital.
Similarly, Singh of Fortis Hospital lists the frequent myths associated with the disorder such as “it’s an untreatable disorder” (fact: easily manageable with lifestyle modification, dietary modification and medicines), “symptoms remain the same for everyone” (fact: symptoms might change even for a patient from time to time, like constipation alternating with diarrhoea), “it may lead to inflammatory bowel disease” (fact: it does not, both are completely different diseases); and “colon cancer” (fact: no associated risk).
So, can IBS be prevented? “There is no such defined way to avoid it but certainly after this occurs it can be controlled by avoiding high-fat intakes like milk, butter, etc. Medically, antispasmodic and anti-psychotic medicines are recommended by doctors,” says Dr Sanjay Gupta, senior consultant, internal medicine, Paras Hospitals, Gurugram.
Treatment options for IBS include lifestyle and dietary modifications for mild to moderate symptoms that do not impair the quality of life. “For worse symptoms, therapies including dietary modifications like exclusion of gas-producing food, lactose avoidance, gluten avoidance, higher inclusion of soluble fibre and reduction of soluble fibre have been found to help,” says Kadam of Ruby Hall Clinic.
While antibiotics should not be routinely recommended in a one-size-fits-all approach to all patients, a few, like rifaximin can help. Probiotics, too, are similar and cannot be routinely recommended, although they have been found to aid in improvement of symptoms. “A few antidepressants slow intestinal transit time, which may help those suffering from IBS-D (IBS with predominant diarrhoea),” adds Kadam.
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According to Singla of Max Hospital, the initial treatment plan should include patient education and reassurance. “The benign nature of the disease should be conveyed to the patient. Though there is no one-time cure for IBS, the symptoms can be effectively managed. The choice of treatment depends mainly on the predominant symptom. First-line pharmacological treatments include fibre and osmotic laxatives for constipation, opioids for diarrhea, antispasmodics for pain. Management of associated psychological disorders also forms an important aspect,” he says.
Adequate management of IBS requires a multidisciplinary team approach involving the physician, dietician and psychologist. “In clinical settings, dietary restriction of short-chain fermentable carbohydrates (the low fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP diet) is gaining popularity to manage the symptoms of IBS,” adds Singla.