Conquering Irritable Bowel Syndrome 9781607952510, 9781607951735

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CONQUERING IRRITABLE BOWEL SYNDROME 2nd Edition Professor Nicholas J. Talley MD (NSW), PhD (Syd.), FRACP, FAFPHM Pro Vice-Chancellor, Dean (Health), and Professor University of Newcastle Callaghan, NSW, 2308, Australia Adjunct Professor of Medicine and Consultant Mayo Clinic Rochester, Minnesota, USA Adjunct Professor of Medicine University of North Carolina Chapel Hill, North Carolina, USA Foreign Guest Professor Karolinska Institute Stockholm, Sweden

2012 People’s Medical Publishing House–USA Shelton, Connecticut

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People’s Medical Publishing House-USA 2 Enterprise Drive, Suite 509, Shelton, CT 06484 Tel: 203-402-0646 Fax: 203-402-0854 E-mail: [email protected] © 2012 PMPH-USA, Ltd. 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 the publisher. 12 13 14 15/PMPH/9 8 7 6 5 4 3 2 1 ISBN-13 978-1-60795-173-5 ISBN-10 1-60795-173-8 eISBN-13 978-1-60795-251-0 Printed in Spain by Rololito Lombardo. Editor: Linda H. Mehta; Medical Writer/Copyeditor: Jennifer Cobb; Typesetter: diacriTech; Cover designer: Mary McKeon Library of Congress Cataloging-in-Publication Data Data on file. Sales and Distribution Canada McGraw-Hill Ryerson Education Customer Care 300 Water St Whitby, Ontario L1N 9B6, Canada Tel: 1-800-565-5758 Fax: 1-800-463-5885 www.mcgrawhill.ca Foreign Rights John Scott & Company International Publisher’s Agency P.O. Box 878 Kimberton, PA 19442, USA Tel: 610-827-1640 Fax: 610-827-1671 Japan United Publishers Services Limited 1-32-5 Higashi-Shinagawa Shinagawa-ku,Tokyo 140-0002 Japan Tel: 03-5479-7251 Fax: 03-5479-7307 Email: [email protected] United Kingdom, Europe, Middle East, Africa McGraw Hill Education

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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated.The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.

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CONTENTS Foreword 

v

by Eamonn M. M. Quigley

Foreword

vii

by Nancy J. Norton

Preface Acknowledgments

ix xi

Chapter 1. What Is Irritable Bowel Syndrome? Chapter 2. Causes and Diagnosis of IBS Chapter 3. Diet and Exercise—Key Helpers in the Battle! Chapter 4. The Mind-Body Connection: How We Can Heal Ourselves Chapter 5. Can I Just Take a Pill? Over-the-Counter Drugs and Herbs Chapter 6. Prescription Drug Treatments for IBS—­ Evidence for What Works! Chapter 7. Defeat IBS: A Summary

1 13

121 137

Glossary of Terms References Index

149 157 169

39 73 99

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FOREWORD That irritable bowel syndrome (IBS) is common in Europe, North America and Australasia has been known for decades; that it is a truly global affliction that can severely disrupt the lives of some of its sufferers is relatively new information but one that has transformed the perception of IBS among health care providers and the general public alike. The great news for those who suffer from IBS is that it is now (long overdue you will say!) being taken seriously by medical scientists and researchers as well as pharmaceutical companies. While considerable progress has been made, and continues to be pursued, in defining the cause(s) of IBS and towards developing effective and safe treatments, the diagnosis and management of IBS continues to be a challenge in the real world. In the meantime, the IBS sufferer often feels isolated and even abandoned by the medical fraternity who all too often under-appreciate the impact of a given sufferer’s symptoms and make scant effort to address them. Unfortunately, recourse is often sought from “alternative” approaches, some of which may not only be unproven and ineffective but even potentially harmful but proliferate thanks to the internet and social media. This is where this book by Professor NicholasTalley is, in my opinion, an invaluable source of information and help. In reading through the book I am continually struck by the pertinence and immediate relevance of the issues addressed.This should come as no surprise given that the author has dedicated much of his immensely productive research career towards understanding IBS as it occurs in the community and world-wide. The questions posed cut to the very quick of an IBS sufferer’s concerns and the responses provided are concise, accurate and, invariably, practical and achievable. No attempt is made to “dumb down” the science behind IBS; the latest data on research on IBS whether in relation to its occurrence and presentation or to the many factors that may contribute to its causation and aggravation are discussed in some detail but presented in a most accessible format. At the very least, the IBS sufferer

v

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should see from this that real and concerted effort is being made in attempting to unravel the many mysteries of IBS! The IBS sufferer (and those who care from them) will glean much helpful information from the sections that deal with how one can cope with and manage IBS symptoms on a day-to-day basis. Controversies, such as the role of allergy in IBS, are confronted head on and opinions which are always backed up by data and science presented in a very understandable and readily implemented manner. As a clinical gastroenterologist whose practice is dominated by IBS and related disorders, I found a wealth of useful information here which I look forward to applying to my management strategies. Research in IBS has thrown up some unexpected findings in recent years and I am sure that there will be many more surprises ahead; more importantly, there is genuine optimism that more successful therapies for IBS are on the horizon. Regardless of future developments, the information in this book will remain invaluable to the IBS sufferer as she or he copes with the varied symptoms of this common disorder. —Eamonn M. M. Quigley, MD, FRCP, FACP, FACG, FRCPI University College Cork, Cork, Ireland

vi   Foreword

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FOREWORD As an advocate for patients with chronic gastrointestinal disorders such as irritable bowel syndrome (IBS), I am pleased that Nicholas Talley has written a 2nd edition of his book, Conquering Irritable Bowel Syndrome. I have known Dr. Talley for over 20 years as a tireless, uncompromising, compassionate teacher, investigator, and physician. He brings all those skills to this book, broadening understanding in a way that is of benefit to anyone interested in IBS. Over the past few decades, we have seen significant progress made in understanding the characteristics of irritable bowel syndrome (IBS) and recognizing the impact this prevalent condition has on individuals, healthcare systems, and societies. Increasing interest has led to discoveries of several different ways by which multiple symptoms of IBS may develop. Yet despite this progress, people with IBS often find it difficult to receive a diagnosis and effective treatment. While the dedicated efforts of those searching to understand IBS and most effectively treat patients are moving us forward, these investigators and clinicians remain relatively few in the field of medicine. Despite its high occurrence, funding of medical research into IBS remains limited. Many physicians are not well trained in recognizing and treating IBS. IBS challenges both patients and physicians. Multiple symptoms can vary from person to person, and even change from day to day in an individual. Multiple factors can influence the onset and severity of symptoms. Results from standard clinical tests appear normal. These are features that can make IBS more difficult to understand. Clearly, IBS is a complex condition. But that does not mean it cannot be managed. Complexity has been described as,“The things within things” [Alice Munro]. Approaching IBS management one “thing” at a time makes it less daunting and more doable. And in this book, Dr. Talley offers a host of ideas and information that will help those with IBS manage the condition, on their own and in partnership with their care provider.

vii

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Conquering Irritable Bowel Syndrome provides comprehensive, practical information “from A to Z” on symptoms and medical treatments. At the same time, Dr. Talley informs us on the broader subjects of health care, drug development, clinical trials, and selftreatment. He also explains how to find help from qualified providers and how to effectively work with your doctor or care provider. Dr. Talley has spent many years dedicated to working for and with IBS patients. He provides personal insights into caring for his IBS patients and explains the importance of the physician–patient partnership. He offers hope in a very real way, with touches of humor that we all can appreciate. He lets us know that his work as a gastroenterologist is very personal for him, and that comes through meaningfully in this book. Dr. Talley has captured what so many people with IBS are searching for—a clear explanation of what IBS is and is not, what they can expect as they look for relief of their symptoms, and ways to find that relief. So many patients feel that their doctors just don’t understand or appreciate the impact of IBS on their lives. Dr. Talley clearly understands. In this book he offers guidance to help those with IBS find ways to navigate the many aspects that touch on their chronic condition and to improve their quality of life. Once again, he has provided a must-read book for anyone who has IBS. —Nancy J. Norton, President and Founder International Foundation for Functional Gastrointestinal ­Disorders (IFFGD) Milwaukee, WI July, 2012

viii   Foreword

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PREFACE Cramps or pain in the stomach, feelings of bloating or even swelling up like a balloon, rushing to the toilet because of diarrhea, or not being able to go at all; these are some of the symptoms of the irritable bowel syndrome (IBS). Up to one in five people worldwide are troubled by typical IBS symptoms, and most have not seen a doctor about them. In some cases the complaints are minor, but in others IBS unfortunately rules their lives. IBS costs taxpayers billions of dollars each year due to medication use and consultations with doctors or alternative therapists. Many doctors don’t know much about it and many dismiss IBS as being “in their head.” Huge numbers of people suffer with IBS. Yet, many find treatment is often ineffective or temporary, and their symptoms return. Diets are often tried, but can make some symptoms worse. Other sufferers are advised to self-treat when certain medicines make the symptoms worse, but how can they know the best way to do this? New drugs have hit the market very recently claiming to be helpful, but are they safe and effective? Many seek alternative care. But is this approach always safe, and does it work? Thankfully there is a quiet revolution going on that looks promising. First, new ways of evaluating whether treatments really work (so-called evidence-based medicine) are being applied with surprising results in IBS! Second, alternative therapies are finally being placed under the scientific microscope. Indeed, some of these do seem to be useful, while others have been found utterly useless. And we have discovered new dietary approaches that really work to relieve symptoms. Third, brand new medicines have finally arrived and can help. And finally, there are intriguing hints IBS has a cause, which means that possible cures may be within our reach. Knowledge is power; those troubled with IBS need to take control by understanding the problem and its potential solutions. This book aims to help empower people who suffer with IBS as well as their families. What is IBS? Why do some people get the

ix

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disease? What can be done about it now that truly works? Take control and read on. I am very grateful to all the patients who have taught me so much about the problem and the struggle to manage it. I thank the men and women who have written to me about their IBS and allowed me to quote their words; all of you have inspired me to work tirelessly to beat IBS. —Nicholas J. Talley July, 2012

x   Preface

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ACKNOWLEDGMENTS I would like to thank the many people who have helped me prepare this book on IBS. My colleagues and patients continue to educate me about the very human condition of IBS.You are all an inspiration. My grandfather (Dr Niklos Tallyai-Roth) and father (Dr ­Nicholas Alexander Talley) are my role models. Their story of dedication, ­persecution, betrayal and triumph, which I told in part in the 1st ­edition, reminds me why I strive every day to serve my patients and the community as a physician. Jennifer Cobb from Cobb Medical Writing provided expert writing and editing assistance for this new edition. Finally I must thank my wife and children for their love and support, without whom my work would not be possible. —Nicholas J. Talley

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Chapter

1 WHAT IS IRRITABLE BOWEL SYNDROME? I could write a book myself about what I went through with IBS, but I’m on the other end of my life being 81 years old. —An IBS sufferer

Do you wake up in the morning feeling fine but a few minutes or hours later you start to feel a gnawing discomfort or pain in your lower stomach? There may be waves of discomfort followed by relief, or it may be more constant. You might feel the need to go to the bathroom to move your bowels, and when you do, the discomfort or pain may be relieved, but only for a little while. Do you feel a sudden urge to run to the toilet, or try to go more frequently because you feel constipated or plugged up? You may need to strain excessively and only be able to pass very hard small stools, if anything. Or perhaps you may have very loose and frequent stools, or the pattern may change without your knowing why. Perhaps you have noticed a white slimy material (mucus) on top of the stool. Maybe you have noticed that your stomach feels full of gas and sometimes even swells up, as if you were pregnant. Al-though you might not have shared your experience with anyone, perhaps because you feel embarrassed, if you have some of these types of 1

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2   Conquering Irritable Bowel Disease

symptoms you may be suffering from irritable bowel syndrome (IBS). (See Table 1-1 for stories of others who suffer from IBS.)

Table 1-1.

PATIENT STORIES First Date Diarrhea Sarah is an attractive 19-year-old girl who met Carl in college. She remembered on their first date having to find the bathroom every place they went. She was nervous and ended up moving her bowels, which helped relieve her cramping abdominal pain. Even more embarrassingly, she would stain her underpants with a small amount of brown liquid stool. When she drank alcohol, this sometimes made her whole problem worse. She and Carl had fallen in love, but she was terrified of any intimacy because of embarrassment about her problem.

Gassing the Train Simone is 51 and is particularly worried about her problem with gas. She experiences abdominal pain and swelling at times associated either with constipation or diarrhea. In addition, she nosily passes excess gas at the most inappropriate times. She works for a large company and is still hoping to go up the ladder but is terrified in meetings that she will pass gas and embarrass herself. Particularly on the train, she has an urgent need to find a toilet associated with passing gas and must step off the train to relieve herself.

Pseudo Pregnant Susan is a 38-year-old mother of two children who complains bitterly about abdominal swelling.When she gets up in the morning her abdomen is flat but soon after lunch her tummy begins to swell.This can take some hours to settle and happens irregularly. She often experiences abdominal discomfort improved by a bowel movement. Sometimes she also feels constipated, which she describes as feeling incompletely empty after passing stool as if she hasn’t properly delivered the contents. Sometimes she sees some white slimy material on top of her stool. The main problem though remains the swelling. She has taken photos with her cell phone to show her husband and her doctor who seem amazed. Sometimes, when she goes shopping, despite the swelling, she feels people look at her oddly.

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Chapter 1 - What Is Irritable Bowel Syndrome?   3

The Squirter Peter is a 48-year-old high-flying executive under considerable stress as his company shares are plummeting and the pressure to outperform the market is mounting. Peter describes terrible urgency, causing him to race to the bathroom as soon as he feels the need to go. If he isn’t near a bathroom, he will leak a tiny amount of liquid stool into his underpants. He often needs to spend twenty minutes several times in the morning sitting on the toilet trying to clear his bowels before he drives to work. Even though he gets up earlier to allow time for his bowels, he still may need to stop on his drive to move his bowels again. Peter knows every bathroom between home and work on his commute. He never is constipated but often has pain with the diarrhea His symptoms are improved when he starts to pass the stool. He often feels a bit nauseated but never vomits. Not only are his symptoms interfering with his work, but his wife feels most unhappy because of Peter’s mood swings. Peter blames these mood swings on his bowels but doesn’t know what to do about the problem.

The Strainer Heather is a 24-year-old model. She is thin and fit but her life style is disturbed by bowel dysfunction. Heather needs to sit on the toilet and must strain excessively to have a bowel movement. She only has a bowel movement once or twice per week. Sometimes she sees white slimy material on the stool and she often feels incompletely empty after going but never has diarrhea. Heather does not eat a lot and wants to stay thin for her modeling profession. With her irregular diet and frequent nausea, she is very afraid she might have a serious disease.

IBS—A COMMON PROBLEM Everywhere I went I had to know where the bathroom was—how far I was from the bathroom. —An IBS sufferer

IBS remains a relatively mysterious, often hidden problem. Until recently, no one understood that it affects at least one in ten people worldwide. In 1980, Grant Thompson and Ken Heaten were

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4   Conquering Irritable Bowel Disease

among the first to report the prominence of IBS, publishing a large survey of 301 volunteers from England. They found that in people who were otherwise healthy, symptoms related to the bowel were amazingly common. Most had not even consulted a doctor for the problem.1 It is striking that only about one-third of the population had absolutely no stomach or bowel complaints. Apparently, it can be abnormal to have absolutely no trouble with your bowels (but most of us would be happy to be so “super normal”)! IBS has been known by several names over the years, including spastic colitis and mucous colitis. The term “colitis” means inflammation in the colon, but obvious inflammation was thought to be absent in IBS, so these terms have not been in vogue for many years. You will see later there is an element of “colitis” or inflammation in some people with IBS, but it is quite subtle and had not been seen in IBS until recently. As we have learned more about IBS, the definition has changed from a broad, all-encompassing, unexplained abdominal condition, to a more specific classification described below. But, IBS does not explain all stomach and bowel symptoms. It is a part of a large group of unexplained chronic gut problems. Although IBS may not produce obvious changes in the structure of the bowel, the symptoms are real. This is thought to be due to enhanced sensitivity of the bowel combined with abnormalities in the way the bowel moves its contents. Infection and inflammation play a role in setting off IBS symptoms. These concepts will be discussed later in this book. The number of people suffering with these symptoms appears to be remarkably constant from year to year. However, in some people, their symptoms might wane over time, while other people might be developing their symptoms for the first time. The ­people losing and developing symptoms balance each other, which accounts for the stability of the number of people in the community with IBS each year. It is interesting that, while some bowel symptoms decline with older age, IBS is still common ­(Figure 1-1). But in the elderly, IBS is often misdiagnosed as another disease, like diverticulosis, which refers to “pockets” in the large bowel.

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Chapter 1 - What Is Irritable Bowel Syndrome?   5

Percent rome II IBS

15

10

5

0

Female

Male non-visceral: IBS > IBS_FM

Somatic > non-somatic: IBS_FM > IBS

3 2.5 2 1.5 1 0.5 0

Crosshairs at: 4, 10, 34

Crosshairs at: 6, 20, 34

Figure 2-5. In IBS, the part of the brain called the amygdala is important in pain processing. The drug alosetron decreases blood flow in area in response to stretching the colon with a balloon.This may mean the drug reduces pain by signaling the brain. Reprinted, with permission from Elsevier, from Chang L. Brain responses to visceral and somatic stimuli in irritable bowel syndrome: a central nervous system disorder? Taken from Gastroenterology Clinics of North America 2005;34:271-9; used with permission.

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Chapter 2 - Causes and Diagnosis of IBS   23

therefore, by other factors that influence brain activity. Some of these factors must include early life experiences, as well as any problems with stress, which are so common in the community. If a person happens to be more sensitive to the processing of unpleasant stimuli, this may lead to repeated negative thoughts, or increased anxiety and depression, and worsened bowel symptoms, setting off a vicious circle (more bad signals to the brain cause more stress which in turn causes more bad signals to reach the brain causing yet even more stress). Blocking the cycle can help bring relief. And we have ways to interrupt this awful cycle. There is a link between stress and bowel problems. And it is clear that at least in some cases, addressing both the bowel problems and the stress can be really helpful. Abnormal processing of signals reaching the brain may explain why certain drugs (such as antidepressants) as well as psychological treatments (such as hypnotherapy or relaxation techniques) are effective in some people with IBS. These treatments will be discussed in later chapters.

ABNORMAL BOWEL RESPONSES Overwhelming evidence exists that people with IBS have a more sensitive gastrointestinal tract. If you have IBS, you are more likely to feel distention in your bowels compared with people who do not have IBS.7-9 This means the brain is more likely to be overwhelmed with signals from the bowel, possibly leading to the disease. Drugs that block bowel sensitivity have now been developed, and some are available as will be discussed later. In the past, bowel spasms were considered to be an important part of IBS. Researchers thought that these spasms could explain the pain of the condition. A large number of studies investigated whether the muscle functions of the bowel are abnormal in IBS.10,11 However, the results of these studies have been inconsistent. Perhaps muscle function in the bowel, although not normal, is not the major cause of IBS. For people with IBS, the speed of movement through the bowel tends to vary from day to day and week to week, so abnormalities in muscle function are not particularly consistent in IBS.12

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24   Conquering Irritable Bowel Disease

SEXUAL AND PHYSICAL ABUSE If you have been abused as a child or an adult, you might have a higher risk of developing IBS.13,14 In a U.S. community study, forty percent of women and ten percent of men reported a history of some type of abuse, a frighteningly high rate.14 Certainly, only some people with IBS ever have a history of any type of abuse, but reported abuse is about twice as common in people who have developed IBS than in people who don’t have IBS. If you have been abused, or feel that you may have been abused, this is worth discussing with your physician. Sometimes revealing the experience and talking it over can be very helpful in terms of learning to manage your IBS. Not everyone who has been abused wants to talk about it, and that is understandable, but please consider seeking the counsel of your physician about this. If the events are still intruding into their lives in a major way, consider that people who have undergone any abuse often benefit from formal counseling. There is nothing to be ashamed about. Speak to your doctor if you are worried about any of this in your life.

SHORT-TERM BOWEL CHANGES Many things can lead to short-term changes in your bowels. For women, if you are pregnant or if it is just before your period, you  may notice constipation or diarrhea, and this is normal. If you  have had a hysterectomy, you may sometimes have shortlived bowel symptoms, although some people do develop IBS after a hysterectomy. After eating something upsetting, many people who do not have IBS can develop a short case of diarrhea. People with IBS typically feel their symptoms get worse after they eat certain foods, although this highly variable. If you have been traveling, you may develop diarrhea or even constipation (particularly the latter if you are afraid to use some of the terrible public toilets that exist in the world). Of course, traveler’s diarrhea is usually a short-term problem. For some people, however, an episode of food poisoning or even a minor gastrointestinal infection will lead to long-term IBS.

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Chapter 2 - Causes and Diagnosis of IBS   25

If you have been forced to go to bed or have lost weight, you may become constipated. This may have nothing to do with IBS. And, of course, if you are particularly nervous, as before a job interview or an examination, then diarrhea is common, although it usually settles once the stress goes away. People with IBS, however, don’t have a complete settling of their bowel function after a particular stress. They tend to experience symptoms intermittently, whether or not there is active stress in their lives. Certainly, stress may make it much worse, which is why treating stress can help.

IS IBS COMMON? YES! AM I ONE OF THE FEW? NO! I feel cheated in my diagnosis…. I feel as though it is a “default” diagnosis when no other condition is evident…. I feel that a condition as severe and pervasive as mine could not simply be IBS. —An IBS sufferer

You definitely are not alone if you suffer with IBS or a related condition. In the United States, at least ten percent of the population has IBS. And maybe two-thirds have stomach or bowel problems that come and go. Indeed, if you do not suffer with any gastrointestinal complaints—ever—you are probably a little abnormal (but lucky)!15 The good news is, IBS is not life threatening and does not mean that you are more likely to develop cancer or inflammatory bowel disease. Actually, you have less of a risk of developing colon cancer if you suffer from IBS (but this doesn’t mean you should avoid colon cancer screening if needed).16 Some risks do come from the tests or treatments offered to people with IBS.You’ll learn about these issues next.

TO BE TESTED OR NOT TO BE TESTED? I have had every test known to mankind and some of them twice. —An IBS sufferer

Your doctor can make a positive diagnosis of IBS without tests in most cases.17 If you do agree to medical tests, then usually, if you

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26   Conquering Irritable Bowel Disease

Table 2-1. Symptoms of a more serious condition—if yes, get tested • Weight loss without dieting (especially if you have lost 7 pounds or more) • Any difficulty swallowing especially if it is getting worse • Evidence of bleeding (e.g. blood in the stools) • Fatty stools (pale, very smelly, difficult to flush away bowel movements) • Repeated vomiting • Repeated fevers with your stomach or bowel symptoms • First onset at age 40 years or older • Symptoms wake you from sleep • Very severe diarrhea • Strong family history of cancer of the colon or bowel have the typical symptoms of IBS, the tests will confirm that you have IBS, and not some other sinister condition. However, some other symptoms are more concerning.These are listed in Table 2-1. If you have any of these symptoms, then you should see your doctor and be tested for other conditions. A major concern that many people have is the high rate of colon cancer in the United States. Screening is currently recommended for anyone fifty years old or older, regardless of symptoms. Colon cancer can begin even before you have any symptoms. Some of the first warning features can be bowel symptoms and abdominal pain or discomfort. Other features of concern include a clear-cut change in bowel habits not beginning until after forty years of age. These changes may include, for example, going from normal bowel function to diarrhea or constipation, or a sudden unexplained switch from diarrhea to constipation, or vice versa. People with a higher risk of colon cancer include those with a family history of colon cancer, a diagnosis of longstanding ulcerative colitis or Crohn’s disease, or a known colon polyp. If you have any of these, then you should discuss screening tests with your doctor. Colon cancer screening includes different types of tests. President Obama had his colon cancer screening examination in 2010 by CT X-ray (called virtual colonoscopy), refusing sedation in order

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Chapter 2 - Causes and Diagnosis of IBS   27

to avoid handing over his presidential power. However, the experts suggest that passing an actual “camera” (or colonoscope) into the bowel remains the best method of finding cancer or pre-cancer lesions like polyps.

A BLOOD TEST FOR IBS—THE FUTURE IS NOW One possible way to diagnose IBS in the very near future may be a special blood test developed for IBS. One such test has in fact been developed, but because it was not as useful as hoped it is little used now.18 This test is currently being refined. A new test is based on exciting emerging information including the fact that both genes and inflammation play a role in IBS.19 If nothing else, this tells you there is hope for all IBS sufferers—IBS is a real disease. It can be measured, and, therefore, one day it will be cured.

OTHER TESTS TO CONSIDER Sometimes your doctor may consider simple medical tests to make sure there is no other explanation for the problem (Table 2-2). Blood tests for anemia, thyroid function, and especially celiac disease may be considered. Anemia (or low hemoglobin) can occur with bleeding from the bowel that may not have been noticed. Since thyroid problems may be an underlying cause of some forms of constipation or diarrhea, your doctor might decide to check your thyroid function. Celiac disease is an allergy to certain proteins in wheat, rye, and barley products. Celiac disease typically causes diarrhea and bloating, but sometimes it can even cause constipation. It is treated by eating a special gluten-free diet for life. Celiac disease is more common in those with IBS-type symptoms. About one in twenty people with IBS-type symptoms may have celiac disease, so your doctor may order a blood test for this.17 Other allergy tests usually don’t help rule out or diagnose IBS. Several techniques are currently used to examine and diagnose diseases of the colon. The colonoscopy exam, as mentioned before, involves passing a camera into the bowel and is considered a safe way to examine the entire colon. The short endoscope can also be used

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28   Conquering Irritable Bowel Disease

Table 2-2. Laboratory investigations for suspected IBS

Representative Tests

Conditions Being Screened for

Useful but not essential: Hematology, ESR, and CRPa Chemistry panel Thyroid function testing Antigliadin, antiendomysia, or tissue transglutaminase ­antibodies Other tests (not routine): Stool test for blood Flexible sigmoidoscopy Stool studies (microscopy, microbiology) Colonoscopy or barium enema (≥ 50 years of age) Hydrogen breath test Colonic transit study Pelvic floor study (anorectal mamometry)

Anemia, inflammation Liver dysfunction, kidney ­disturbance Thyroid dysfunction (under or over active thyroid) Celiac disease Bleeding from cancer or bad inflammation Colitis, cancer Infection (if diarrhea) Colitis, cancer Lactose intolerance, excess bacteria small bowel Slow colon (causing severe constipation) Muscle problem around the anus (causing severe ­constipation)

ESR, erythrocyte sedimentation rate; CRP, C-reactive protein.

a

to look at the lower part of the colon (flexible sigmoidoscopy). A number of X-ray techniques are also used. The traditional approach used barium, which is a thick white paste that allows the lining of the bowel to be seen properly when an X-ray is taken. More advanced approaches, such as the CT X-ray virtual colonoscopy used on President Obama, can image the colon and reconstruct it very realistically—as if a scope had been passed through it. However, this does require radiation exposure and can miss large polyps in the colon. Colonoscopy (Figure 2-6) is a safe test. Unlike X-rays it can confirm whether a cancer is present (Figure 2-7). But like all medical tests, it too can sometimes miss things. Since it is invasive, it has the potential for complications (like the rare event of tearing the colon), even in the very best hands. So it is very important for you,

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Chapter 2 - Causes and Diagnosis of IBS   29

Figure 2-6. Colonoscopy.

Cancer in the large bowel

Virtual colonoscopy

Figure 2-7. Example of images obtained by virtual colonoscopy. Reproduced with permission from Fenlon HM, Nunes DP, Schroy PD III, et al. A comparison of virtual and conventional colonoscopy for the detection of ­colorectal polyps. N Engl J Med. 1999;341:1496-503.

with your doctor, to consider the potential risks and benefits of any test you are going to have done. In striving to help, medicine can still be harmful in the 21st century. Rarely, other serious diseases can mimic IBS. Of major concern in middle-aged women is ovarian cancer, but this is rare. Check with

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30   Conquering Irritable Bowel Disease

your doctor and discuss the possibilities. Most serious diseases can be ruled out by your doctor, if need be.

MEASURE YOUR BELLY? Bloating (feeling swollen) and visible swelling of the abdomen is common in IBS, especially for some women. You can look pregnant! Some patients photograph themselves swollen to prove it’s real to their skeptical doctors. We can now objectively measure visible abdominal swelling in IBS with a machine called the bloatometer (Figure 2-8), developed by Dr. Peter Whorwell and colleagues in England.20 You put a belt with electric probes on the abdomen and record the signals over twenty-four hours. Using the machine,

Figure 2-8. Photograph of a subject wearing the equipment. A, the belt; B, data ­logger; and C, mercury tilt switches. Insert shows a close up of the belt revealing the wire sewn in a zig zag fashion and connected to an oscillator (D), which is secured under the belt. Taken from Lewis MJ, Reilly B, Houghton LA, Whorwell PJ20; used with permission from Gut.

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Chapter 2 - Causes and Diagnosis of IBS   31

we can see clearly that swelling occurs more often later in the day, and goes away at night. So belly swelling is real in IBS, not imagined! No need to photograph it anymore.

LOOK AT YOUR STOOL? People often shy away from looking at their stools, but not all. American toilets are particularly well designed to look at the contents delivered, while in some parts of the world toilets seem designed to better hide their output. The British seem to have a particular interest in their bowel function, so trust a team in Britain to come up with a scale for grading the stools! In case you are interested, there are seven grades based on looking in the toilet bowel (Figure 2-9). This is called the Bristol stool form scale. It is

Figure 2-9. Bristol stool form scale. (1) Separate, hard lumps like nuts (difficult to pass); (2) sausage-shaped but lumpy; (3) like a sausage but with cracks on its surface; (4) like a sausage or snake, smooth and soft; (5) soft blobs with clear-cut edges (passed easily); (6) fluffy pieces with ragged edges, a mushy stool; (7) liquid stool.

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remarkable because: (1) it can be graded by anyone (patient or doctor), (2) it measures real and important changes in the stool, and (3) the stool types relate to the time it takes for food to move through the bowel.21 The stool appearance tells you about bowel function. And bowel function is haywire in IBS!

HOW WE GOT TO ROME Doctors are rightly concerned about correctly diagnosing their patients. No one wants to miss any patients with cancer. But no patient wants to be told that they have cancer when they really don’t. As stated before, similar symptoms can have different causes. But doctors are asking whether it is possible to know which patient has what disease based on symptoms alone. We now know a number of symptoms are much more common in IBS than in people who have some kind of other structural (or what is called organic) explanation for their problem. Organic can mean inflammation (like in ulcerative colitis or Crohn’s disease) or cancer. In a study in Britain, patients who reported (1) relief of pain with a bowel movement, (2) more frequent bowel movements when their pain began, (3) looser bowel movements when their pain began, (4) visible abdominal swelling, (5) feeling that they have not completely emptied their bowel, and (6) mucus (white slimy stuff) in the stools were much more likely to have IBS than some other explanation.22 In those with IBS, over 90% had two or more of these six symptoms. The six symptoms that this group of researchers identified are now known as the Manning criteria, named after the first author. In the medical literature, you will often see reference to the Manning criteria when a diagnosis of IBS is being considered. Typically, the Manning criteria refer to three or more of these six symptoms in any combination. If you have these symptoms, you are much more likely to have IBS instead of cancer or another serious disease.

THE BEST TEST: THE ROME CRITERIA Since the Manning criteria, more studies have been performed in which typical IBS symptoms that help to differentiate it from other gastrointestinal diseases are reported. An international group of

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Chapter 2 - Causes and Diagnosis of IBS   33

experts have now recommended the use of a set of helpful symptoms to diagnose IBS, called the Rome criteria.The Rome criteria allow your doctor to make a positive diagnosis of IBS without any other tests. Even though you may not think about answering a few questions the same way you think about a blood test or a colonoscopy, research is finding that the best test for an accurate diagnosis of IBS is this: just three simple questions.23 Assuming you have longstanding abdominal pain and diarrhea or constipation (or both): 1.  Is your pain made better by going to the toilet and moving your bowels? 2. Do you have harder or looser stools when your pain begins? 3. Do you have more frequent or less frequent stools when your pain begins? If you answered “yes” to two of three, then you have hit the jackpot—it’s pretty clear it’s IBS. (The actual chances are more like 80%—nothing in life, and especially medicine, is 100% certain.) You may well also have other typical IBS symptoms like bloating. Not all doctors know about the Rome criteria, but the message is spreading. I was very fortunate to be a part of creating the Rome classification system for all the unexplained gastrointestinal disorders, including IBS. The field has become standardized, and there have been substantial advances in part because of this new classification approach. So in this chapter we have come full circle, from symptoms to tests and back to symptoms again. Yes, if you have IBS symptoms and you fit the Rome criteria, your doctor may still feel you need a few simple tests to make sure it’s nothing else (like celiac disease). But equally, your doctor can be pretty sure it’s IBS if you fulfill the Rome criteria. And so can you (but please don’t self-diagnose—see your doctor to be sure).

TALK TO YOUR DOCTOR FIRST As far as working with your doctor. That’s a laugh…. Easy money earned and not interested in how you feel. No bedside manners at all. —An IBS sufferer

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34   Conquering Irritable Bowel Disease

Unfortunately, some people don’t get a satisfactory answer, but finding a good physician to work with you is essential. If your symptoms are worrying you, it is wise to see a doctor to receive an accurate diagnosis. This will also give you some peace of mind about the condition. Get a second opinion if you are still worried or dissatisfied. Institutions like the Mayo Clinic are staffed by specialists for diagnosing and treating IBS, so consider this option too if you are still worried. Self-diagnosis is sometimes difficult and certainly not recommended. To help you prepare for your doctor’s visit, consider a few things your doctor will want to know: 1.  When did your symptoms begin? 2. What exactly are your symptoms? 3. Have there been any recent changes in your symptoms? 4. What medications are you taking now or have you taken in the past? Take a full list including over-the-counter medicines and herbals with you. 5. Have you had any bowel tests in the past? Bring copies of all the tests and X-rays with you. Keeping a diary for two weeks of your symptoms, including when they occurred and the relationship to meals or bowel movements is helpful (Table 2-3). On the other hand, detailed records can add little; bringing a box load of material from the internet also won’t usually help or impress your doctor.

SUMMING UP AND MOVING FORWARD It is clear that IBS is a real condition with genuine abnormalities that can be observed in careful studies. Many investigators are examining how genetics, infection, bacteria, the bowel, and the brain are all involved in IBS. Much more will be learned about the causes of IBS, which will lead to more sensible interventions for the condition. The findings in the last few years are very exciting and suggest we will be able to do much more for IBS in the near future. Yet much can be done right now as you will find later in this book.

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Time

Stool Passed (hard, soft, normal)

Snacks

Dinner

Lunch

Breakfast

DIET: BEVERAGES & FOODS List items and times

Date

Example of a symptom diary for IBS

Table 2-3.

Bloating

Stress

Any Medications

EXERCISE List: walk, run, bike, other — and times

Abdominal Pain

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36   Conquering Irritable Bowel Disease

Once you receive a diagnosis of IBS, what’s next? You can and should take control of this problem to treat it effectively. This is what the rest of this book is about. Make the journey with me as we explore the mysterious and complex bowel, and discover what you can do to gain control and relief.

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s ABC

LEARN YOUR ABCs TO GAIN CONTROL AND RELIEF

Function, not the structure, of the gastrointestinal tract is disordered. Negative test results do not mean there is no disease. Genetic causes for IBS are likely. IBS runs in families. Be Happy, because the next chapters are all about effective treatments! Infection and Inflammation as well as bacteria are important factors contributing to the development of IBS.

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Chapter

3 DIET AND EXERCISE— KEY HELPERS IN THE BATTLE! Everything from oatmeal and fruit to a regular dinner causes pain and bloating. I rarely feel motivated to exercise or have the energy. I dread every bowel movement. —An IBS sufferer

NORMAL DIGESTION Digestion is the complicated process of breaking up the food we eat into little parts that can be easily absorbed through the gastrointestinal tract into the bloodstream. Among the many tools the body uses to digest food are: muscles of the bowel that assist by grinding the food into smaller pieces, and special chemicals called enzymes that attack the food by enhancing chemical reactions. These ­chemical reactions break the food into three major components: carbohydrates, protein, and fat.

39

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Many different types of enzymes are made in different parts of the gastrointestinal tract to assist in digestion. For example, salivary glands in the mouth release enzymes to break down carbohydrates and fats. Enzymes from the pancreas enter the gastrointestinal tract to break down carbohydrates, proteins, and fats. After the food has been broken into these smaller pieces, it enters the bloodstream. Most digestion does not occur in the stomach but in the small intestine. Understanding the processes can help you plan how best to use diet to treat IBS. Sugars, also called carbohydrates or starches, are a major part of our diet. Examples include milk sugar (lactose) and table sugar (sucrose). An enzyme called amylase begins the process of digestion of sugar. Another enzyme involved in sugar digestion is lactase. Some people do not make enough lactase to properly digest the sugar found in milk. The lactose is not broken down and can drag water from the cells into the bowel itself, causing diarrhea with bloating and excess gas. A majority of people of Asian, American Indian, and African descent will have a problem with drinking milk because they have lactase deficiency (or lactose intolerance, discussed later in this chapter). About one in six people in the United States of European descent also have lactase deficiency. Some people with lactase deficiency are misdiagnosed as having IBS. In the large intestine, bacteria live quite comfortably in huge amounts, further breaking down carbohydrates not absorbed by the small intestine. Their actions lead to the production of excess gas (carbon dioxide and oxygen). Some bacteria in the colon (the “stink bugs”) release methane gas or sulfur-containing gases. Gas is important in causing IBS symptoms in some people. Another major part of our diet is protein. In the stomach, protein digestion begins with enzymes called pepsins. They work best in the stomach’s acidic environment. The smaller proteins are further digested in the small intestine by enzymes secreted from the pancreas. Digestion of proteins takes a lot of time and work. Final digestion of these proteins occurs in several stages in the small intestine. The third major component of our diet is fat. The body digests most of our fat in the small intestine through the secretion of an enzyme called lipase from the pancreas. Bile from the gallbladder

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Chapter 3 - Diet and Exercise—Key Helpers in the Battle!   41

is also secreted into the small bowel to help break down a familiar type of fat called cholesterol. Part of the bile is absorbed along with the fat into the bloodstream. But another part of the bile (called bile salts) continues to travel through the small bowel until it reaches the end, where it is taken up for recycling. Some of these bile salts can “spill over” into the colon, however, causing diarrhea.This is more likely if you have had your gallbladder removed. Since the gallbladder’s job is to store and release bile only when a meal is eaten, without a gallbladder, bile will be released continuously into the small intestine. These bile salts can be removed by certain drugs, helping control diarrhea in some people with IBS. Without the enzyme lipase, diarrhea occurs, and fat is not absorbed by the body. In this case, the stools are typically white colored, large in volume, and very difficult to flush away. They are also very smelly and contain oil droplets. This condition is called steatorrhea. The weight-loss drug orlistat (Xenical™) blocks lipase to limit fat absorption and often causes diarrhea or fatty stools. Another major part of our diet is water. Even though you don’t realize it, your gastrointestinal tract secretes a large amount of fluid into the bowel to help with the digestive process. About 7 L (1.8 gallons) comes from the bowel (1 L is about 1/4 of a gallon). In addition, you normally drink about 2 L (1/2 gallon) a day of fluid. However, you only excrete about 200 mLs of fluid (1/20 of a gallon) in the bowel motions. By far, most of the fluid in the bowel is typically reabsorbed in the small intestine and colon. When traveler’s diarrhea is a big problem, leading to dehydration, a treatment of salt and water (electrolyte solutions) will increase absorption of water in the small bowel. This treatment is intended to limit the dangers of severe dehydration. Laxatives, however, such as magnesium sulfate, limit the reabsorption of water and salt and can cause diarrhea. As we come to the end of the digestive tract, we are left with the parts of food that the body is not able to use (stool), including inorganic materials, undigested plant fibers, and bacteria. The brown color of stool is due to pigmentation from the bile broken down by bacteria in the intestine. This is also why it smells! Much of the stool is composed of normal secretions from the bowel,

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42   Conquering Irritable Bowel Disease

­ owever, so even if you starve yourself you will still pass some stool. h But eventually, if you eat nothing you will usually become constipated. People with anorexia nervosa, an eating disorder, often are constipated. As a colorectal surgical colleague of mine used to muse, “If you don’t eat, you won’t poop!” Movement through the colon is accomplished by contractions of muscle from one portion of the colon towards the anus. These are called high-amplitude propagated contractions (HPACs). There are other muscle contractions in the colon that mix the contents and help absorption of fluids and nutrients. There is also a relationship between the stomach and the colon called the gastrocolic response. When you get up in the morning and have breakfast, you will often feel the urge to go to the toilet soon afterwards (the “breakfast rush”).This is the gastrocolic response in action! Some people with IBS may have an exaggerated gastrocolic response, which might explain why their symptoms are worse in the mornings after eating. When the rectum fills with stool, muscle contractions near the anus are automatically stimulated, signaling the desire to “go” in healthy persons. The muscle around the rectum that prevents leakage of stool is called the anal sphincter. An anatomy professor once asked, “Why is the anal sphincter considered to be the smartest muscle in the body?” A quick medical student replied, “Because it is the only one that knows the difference between solid, liquid, and gas.” You can voluntarily relax a part of the anal sphincter that is called the external sphincter. Relaxing this muscle is important for passing stool (called defecation), while contracting it can block stool up, despite the person having the urge to go. The other part of this muscle, the internal anal sphincter is not under voluntary control. Instead, it is controlled by the nervous system, to keep the sphincter contracted or relaxed. Tensing other muscles, such as those in the abdomen, often called “straining,” can also help empty the rectum. Multiple factors can affect bowel function including voluntarily squeezing shut the external anal sphincter when it should be relaxed, which can contribute to worsening constipation in some people. This thankfully can be unlearned by biofeedback, as discussed later in the book, substantially improving constipation in some people (even curing it).

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Chapter 3 - Diet and Exercise—Key Helpers in the Battle!   43

FIBER: DOES IT HELP IBS? The second day of a diet is always easier than the first. By the second day you’re off it. —Jackie Gleason

People with IBS, especially when constipated, may benefit from increasing the fiber in their diet. Let me tell you why. First, fiber is any food reaching the large intestine without being broken down and absorbed by the body. There are a number of vegetable products we humans are not built to digest. Second, increasing fiber increases stool bulk. It can keep the stools soft if they have been hard, because the undigested material pulls water from the bowel into the stool itself; or, it can sometimes help people with loose stools to firm them up, although this is variable.Third, fiber reduces the amount of pressure that the bowel uses to move its content through. This possibly reduces the pain of IBS for some people, although this benefit is not large.1,2 Eating lots of fiber can have all sorts of potential health benefits. There is some evidence that high-fiber diets reduce colon cancer and heart disease, although this is not conclusive.The American and European diet is traditionally low in fiber, further aggravated by the fast-food industry, which serves generally low-fiber diets that are instead high in carbohydrates and fat (all bad). When eating more fiber, which can help some people with IBS, make sure you change your diet gradually. Sudden large increases in dietary fiber will make you feel bloated and gassy. However, by very slowly increasing the amount of fiber in your diet, building it up over several weeks, you will more likely tolerate the changes and be able to test whether it helps or not. When considering adding fiber to your diet, it is helpful to know that there are two types: (1) insoluble fiber and (2) soluble fiber. They each come from different sources of food. Insoluble fiber is present in wheat bran, whole grains, and some vegetables, while soluble fiber can be found in dried beans and peas, oats, and some fruits and vegetables. Soluble fiber helps reduce cholesterol and blood sugar levels, which is useful in people who suffer with high cholesterol or diabetes.

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Both soluble and insoluble fiber foods are effective for helping people with constipation. IBS is different than having constipation alone. Clinical trials for people with IBS show that fiber may help constipation but do little for pain.2

INCREASE FIBER, BUT SLOWLY If you have IBS with constipation as a major symptom, it is worthwhile to try increasing fiber first. I recommend soluble fiber. This is simpler than other diet treatments. However, it is important to add fiber in a sensible way. Eating too much fiber may make your symptoms worse! It is recommended that people eat between 20 and 30 grams of fiber a day. This is about twice the fiber found in a normal ­American or European diet! But eating more than 50 grams of fiber a day just doesn’t help, so don’t try to eat too much fiber. The best way to increase fiber is to have a well-balanced diet, eating more whole-grain breads and cereals, vegetables, fruits, dried beans, and peas. Eating regularly scheduled meals that each contain some fiber-enriched foods can promote healthy bowel function throughout the day. This is especially what you need when you have IBS. Again, start off increasing the fiber very slowly. If you eat too much fiber too quickly when your body is not used to it, you are more likely to have bloating and gas, which will not help you. So consider introducing a small amount of high-fiber foods with each meal. Increase this amount every week until you reach adequate levels of fiber each day. Adding fiber to your diet will take some work. The fiber content of the food table (Table 3-1) will help you. You should increase your fiber by no more than about 3 grams of fiber daily each week. It will take you about 5 to 6 weeks to increase your fiber to a total of 25 to 30 grams per day if you are currently eating a typical diet. The food labels on many foods provide the amount of fiber, so try looking at these carefully. Simple suggestions include soups, salads, or main dishes containing dried peas or beans, lentils, or whole grains. Try eating brown rice or whole-wheat pasta as side dishes. Or you could add them to your soups or casseroles. Add raw vegetables if you like them. Eat plenty of dried fruit. Substitute your potato chips and

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Chapter 3 - Diet and Exercise—Key Helpers in the Battle!   45

Table 3-1. Fiber content of foods

2-3 GRAMS OF FIBER PER SERVING: Grain products One serving of a grain product is ½ cup or 1 average piece unless otherwise specified. Barley, cooked Bran muffin Bread or roll, 100% whole   wheat Bulgur, cooked Cheerios™ (1 cup) Crispbread, whole grain   (for example, Ry-Krisp™)   (2 pieces) Granola Grape-Nut Flakes™ (1 cup) Life™ (1 cup) Muesli

Oat bran cereal, cooked Oatmeal, cooked Popcorn, popped (2-3 cups) Wheat bran (2 tablespoons) Hot wheat cereal (for ­example,   Ralston ™, Maltex™,  Wheatena™) Wheat flakes (for example,  Wheaties™, Total™) (1 cup) Wheat germ (2 tablespoons) Whole wheat spaghetti or ­  macaroni, cooked

Vegetables and fruits One serving of a vegetable or fruit is ½ cup cooked, 1 cup raw, or 1 average piece unless otherwise specified. Artichokes Tomato sauce or paste Bamboo shoots Wax beans Beets Apple Broccoli Apricots, fresh (4-5) Brussels sprouts Banana Carrots Blueberries Cauliflower Cherries Corn Dried fruit (1/4 cup) Cucumber (1 large) Figs, canned Green beans Figs, fresh (2) Greens Kiwi (Continued)

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Table 3-1.  (Continued) Kohlrabi Parsnips Peas, green Potato Rutabaga Spinach Squash, winter (for example, butternut, buttercup) Sweet potato Tomato (1 large)

Mango Nectarine Orange Papaya Prunes, cooked or canned Nuts (1/4 cups) Peanut butter (2 tablespoons) Snack seed kernels (1/4 cut)

4-6 GRAMS OF FIBER PER SERVING: Grain products Bran flakes (1 cup) Chex™ wheat or multibran (1 cup) Corn Bran™ (1 cup) Grape-Nuts™ (1/2 cup) Raisin bran (1 cut) Shredded wheat (1 cup bite size or 2 biscuits)

Vegetables and fruits One serving of a vegetable or fruit is ½ cup cooked, 1 cup raw, or 1 average piece unless otherwise specified. Avocado Bakes beans Dried beans (for example, navy, pinto, kidney, lima, soybeans), cooked or canned Lentils, cooked Dried peas, cooked Pumpkin Vegetable protein burger Blackberries Figs, dried (1/4 cup)

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Chapter 3 - Diet and Exercise—Key Helpers in the Battle!   47

Pear, fresh Raspberries Strawberries

OVER 6 GRAMS OF FIBER PER ­SERVING: Bran cereals (for example, All-bran™, Fiber One™, 100% Bran™, Bran Buds™) (1/2 cup).

candies for popcorn. Don’t eat too many cakes or cookies, but try eating desserts containing fruit or bran muffins. Experiment to get the best flavor as well as the best-tolerated combination. An inexpensive way to add fiber is unprocessed wheat bran. Simply sprinkle 1 tablespoon on your hot or cold cereal. If you are tolerating the increased bulk without problems, then the following week you can add 2 tablespoons and the third week, 3 tablespoons. Adding bran cereal or unprocessed wheat bran to many other foods can be a simple place to start. Foods to consider include breads and muffins, cookies and cakes, as well as meatloaves and casseroles. Substitute a cup of white flour for 7/8 of a cup of coarsely ground or a cup of finely milled wheat flour. Unfortunately, the most recent evidence shows that wheat bran does not help many typical IBS symptoms, with the exception of constipation.3 Indeed, wheat bran makes some people worse, so I generally avoid this approach. When you add more fiber, you must also remember to drink plenty of fluid. Fiber pulls more liquid out into your bowel; therefore, you need to drink enough fluid or you may aggravate rather than relieve your symptoms of constipation. You should drink at least eight to ten 8-ounce glasses of liquid each day. This liquid should not contain caffeine. Unfortunately, caffeine-containing drinks are dehydrating. Water, however, is excellent (and tap water is still best in most Western countries—don’t waste your money on bottled water if good tap water is available)! Remember that eating fiber should be one part of a balanced diet. Although they contain no fiber, fish, poultry, and meat have other essential nutrients including protein. Unfortunately, desserts and sweets, as well as high-fat foods, have lots of extra calories but

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little or no fiber. So I would advise you to avoid these treats as much as you can. Although many experts used to say that there are few advantages to fiber supplements, aside from convenience, many people seem to prefer this approach. Clinical trials show some benefit with fiber supplements, or bulking agents, in IBS, so here the experts were wrong when the evidence came in.3 We will cover fiber supplements in detail in Chapter 5. It is reasonable to try them, understanding that it will also cost you more than just adding high-fiber foods to your diet. The fiber supplements work best for people with more constipation than diarrhea. Still, they can help firm up loose stools in some people with diarrhea too. One last word on fiber. Not everyone benefits from increased fiber, and some IBS sufferers may even be intolerant of it (or get worse). So if a high-fiber diet fails, don’t despair—there are more diet options as described below.

EXCESS GAS? DIET CAN HELP My diet has given me back my life, and I would be very happy if it could help anyone else. —An IBS sufferer

Flatus, or passing gas out the rectum (called passing gas or less elegantly, a fart), can be an awful problem for some people. Normally, we all expel gas around thirteen times a day (and less than twenty times is considered normal)! This was learned by counting flatus episodes in the laboratory (a memorable experiment).4 Remember, though, while you may be aware of passing gas, many around you truly won’t notice. Farting for entertainment remains part of popular culture, and not just by children. “Mr Methane” (Paul Oldfield) from Britain has made a living as a professional performing flatulist. An iPhone app that simulates farting was the top-selling download in 2008. In other cultures, passing gas is less well tolerated. In 2011, George Chaponda, the Minister of Justice from Malawi (in southeast Africa), tried to make public farting illegal, but there was such a reaction by the press (who could not help themselves with their headlines) that he had to back down (which led to this notable headline— “Chaponda: Oops I goofed, you can fart!”).

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Chapter 3 - Diet and Exercise—Key Helpers in the Battle!   49

While swallowing air and producing gas in the bowel is normal (everyone does it), some people have a tendency to swallow more air as they eat. Others seem to be greater gas producers.This may in part relate to the different compositions of bacteria present in the bowel. Indeed, in a normal colon there is an enormous mass of bacteria. These bacteria act like a factory with gas as one of their byproducts. A number of foods are linked to increased gas production in the intestine. However, different foods affect people in different ways. It may take a lot of trial and error to find the foods that are important for you to avoid. Listed below are some common gas-causing foods (Table 3-2).

Table 3-2. Gas-forming foods • Legumes and certain vegetables baked beans kohlrabi dried beans lentils lima beans onions Broccoli dried peas Brussels sprouts radishes Cabbage rutabagas Cauliflower sauerkraut Cucumbers • Excessive amounts of fruit or fruit juice The following fruits and fruit juices are more likely to cause gas: prunes prune juice apples apple juice raisins grape juice bananas • Bran • Dairy products milk ice cream cream ice milk

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Baked beans are a typical example of gas-producing foods. Some people consider it a joke and take great pleasure after consuming them in expelling gas through the mouth or later from the other end. People with gas trouble don’t think it’s funny, however, and don’t want to deal with this issue. So, cutting out beans and the other legumes and vegetables that are particularly gas forming can be helpful. Fruits and fruit juices can also produce a lot of gas, especially prunes and prune juice as well as grape and apple juice. All high-fiber products produce more gas, creating a real problem for those trying to increase the fiber in their diet. Consider the list of less gassy fiber-containing foods listed below (Table 3-3).

Table 3-3. Less Gassy Fiber-Containing Foods

Fruits

Vegetables

Grain products

Apricots, fresh Berries Nectarines Oranges, fresh Peaches, fresh Pears Pineapple Plums, fresh

Asparagus Beans, green or wax Beets Carrots Corn Greens Okra Peas, green Potatoes (with skin) Spinach Sweet potatoes Pumpkin Tomatoes Winter squash

Barley Bread, whole wheat Cereals, whole grain,   such as: Cheerios®, Granola,   Oat Squares®,   Ralston® Grapenuts® Maltex®, Shredded Wheat®, Total®, MiniWheats®, Muesli(x), Wheat Chex®, Wheaties®, Wheatena®, Nutri Grain® Flat breads & ­Crispbreads Whole grain, such as: Kavli® and Wasa® Pasta, whole wheat Popcorn Rice, Brown or wild Ry Krisp®

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Chapter 3 - Diet and Exercise—Key Helpers in the Battle!   51

If you have a particular problem with flatus, a special diet may help. High-flatus foods include beans, brussels sprouts, onions, celery, carrots, raisins, bananas, wheat germ, and fermentable fiber. Eating pork can result in the release of very smelly gases occasionally. Avoid these, then! Try a low-flatus diet instead. This includes eating meat, fowl, fish, and eggs as sources for protein. Other lowflatus foods are gluten-free bread, rice bread, and rice. Some vegetables, such as lettuce and tomatoes and some fruits, such as cherries and grapes, are considered less “gassy.” If the diet works, you can then re-introduce each potential high-flatus food excluded week by week, and see whether the gas returns. If it does, continue to avoid that food but reintroduce another food product, and so on until you hit on the right mix. See a dietician for help if you are having trouble. Beano™ (alpha galactosidase, a sugar-digesting enzyme) is available over the counter; it can reduce the production of gas from baked beans. Take 3-10 drops or 2-3 tablets just before eating. Beano™ is broken down by heat and will not work if added to food that is then cooked.You shouldn’t use Beano™ if you have the very rare disease called galactosemia (where your body can’t make use of a sugar called galactose in milk). Again it is important to emphasize that each person will vary from others in response to particular foods. Dairy products such as milk, ice cream, ice milk, and cream could produce a feeling of excess gas, particularly in someone with lactose intolerance. And even for those without lactose intolerance, these products are sometimes associated with gassy feelings that can improve when the food is eliminated from the diet. Even if you have lactose ­intolerance, you can moat likely have at least 1/2 cup of dairy product at a time without any major problems. Yogurt, cheese, and cottage cheese usually don’t cause any problems. Artificial sweeteners such as sorbitol and mannitol can also cause problems with excess gas. This type of sweetener is found in sugar-free gums, diet candies, and diet drinks. Some people take a lot of diet products every day. I’ve known patients who drink 6 to 12 cans of Diet Coke or Pepsi a day, such that the caffeine load also causes trouble. Other artificial sweeteners such as Aspartame or Saccharin (e.g., in Tab) don’t tend to cause the same problem with excess gas, diarrhea, and bloating.

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52   Conquering Irritable Bowel Disease

Another group of gas-producing foods are those that contain a high amount of fat. Fried foods, rich sauces and gravies, fatty meals, and rich pastries all contain lots of fat. Indeed, the average diet is full of fat! Many people don’t really appreciate just how extremely high the fat content of the items offered by fast-food outlets often are, but excess fat can cause gas and bloating in some people. Highfat foods slow stomach emptying, which can worsen feelings of indigestion if this is a problem for you. Reduce fat if you can, and the gas problem may improve. Products that have chlorophyll (like Derifil or Nullo) can reduce the odor from flatus. A charcoal cushion that you can buy is also used for this purpose. In 1998, Chester “Buck” Weimer from Colorado created and patented underpants (air-tight ones) that included a charcoal filter for gas. (He won the Ig-Nobel prize—an American parody of the famous Nobel Prize—for his “discovery.”) Others have produced an activated-charcoal panty insert for the same purpose, but I’m not convinced sales are brisk. If diet fails even with the help of a dietician, other medical therapies have the potential to reduce gas (like a probiotic or an antibiotic like rifaximin). These are discussed later in this book.

REDUCE BELCHING AND SWALLOWING AIR If you have a problem with burping or belching repeatedly, you are swallowing air. Your body alone cannot produce enough air in the bowel to cause repetitive belching. The only explanation for a burping problem is that it is due to swallowing air and then burping it back up. This can be a quite an unconscious act, so you don’t realize you are swallowing excess air. If you are aware that you may be doing this, then consciously try not to swallow air—this may help. After you eat, remaining in an upright position can relieve this gas problem. It is important to avoid frequent or repetitive swallowing when you eat. Eating slowly can help here. Remember, don’t gulp your food down or frequently sip through a straw. There are foods that contain lots of air such as whipped creams and drinks that are carbonated, so often it is helpful to limit these, too. Giving up smoking, avoiding

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Chapter 3 - Diet and Exercise—Key Helpers in the Battle!   53

chewing gum or tobacco, and not sucking on hard candies can all reduce the amount of air that you swallow. If you must smoke (but please don’t—it really is a way to help nudge yourself to an early death), avoid drawing long on cigarettes, cigars, or pipes. Sometimes ill-fitting dentures can lead to increased air swallowing; if you have this difficulty, see your dentist. Regular exercise seems to help some people with this problem, although the reasons are not obvious aside from stress reduction. Treating constipation can also help excess burping and gas, perhaps because constipation triggers the stomach to empty more slowly. Some people swallow air as part of a nervous habit. Sometimes excess belching occurs when you are under particular stress. Reducing stress can be helpful here. Many therapies that are helpful in reducing stress are discussed in Chapter 4. It may take a series of sessions with an experienced psychologist to learn how to control such a habit, and in difficult cases this is worth considering. A special technique called belly breathing (or more technically, diaphragmatic breathing training) seems to help some people with excess burping to limit air swallowing they can’t otherwise stop (Figure 3-1). The therapist will work with you to do exercises during and after eating. For example, sit up straight and place one hand on your chest and one on your stomach (above your belly button). Slowly breathe in through pursed lips (to slow down your breathing). As you slowly breathe in, push out your stomach and feel your stomach expand with your hand. Practice until you can do this when eating repeatedly without thinking too

Figure 3-1. Diaphragmatic breathing.

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54   Conquering Irritable Bowel Disease

much. This exercise does not help oxygen get in any better as some alternative practitioners preach (utter nonsense!), but it can help repeated belchers.5,6

LACTOSE INTOLERANCE (LACTASE DEFICIENCY) I was fearful of eating out and when I did, I took my own food—my friends were very kind about it. —An IBS sufferer

Do you have bloating or cramping abdominal pain, excessive gas, or diarrhea? If you do, then these symptoms might be explained in part by lactose intolerance. There is an enzyme in the intestine called lactase that is essential for the body to break down lactose, or milk sugar. The problem is that if lactase is no longer present in the body, then undigested lactose remains in the small intestine, dragging water into it and leading to excessive frothy liquid in the bowel. Lactose intolerance, or lactase deficiency, happens to most people naturally! People of African and Latin descent are typically lactase deficient by the time they are adults. However, even if you are lactase deficient, you still can tolerate some milk products. At least a half cup of milk or other high-lactose food at any one time won’t usually cause any problems if you are lactase deficient. But drinking more than a cup of milk in this situation will cause symptoms. For this reason, people with lactase deficiency can tolerate small amounts of lactose throughout the day. It is also better if you take the lactose-containing food with other foods at the same time. So, you don’t have to miss out on your ice cream treat or milk shake as long as you don’t take too much in at a time. Yogurt is better tolerated than other milk products because it contains bacteria, which will digest part of the lactose anyway.Yogurt with an active culture present is usually the best tolerated, but frozen yogurt may also be quite acceptable to your bowel. A list of lactose-free and low-lactose foods is summarized below (Table 3-4). Remember, nobody needs to be on a completely lactose-free diet, even if they have lactase deficiency.

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Table 3-4. Lactose-free and low-lactose foods

THE FOLLOWING FOODS ARE ­LACTOSE-FREE AND MAY BE USED AS DESIRED: Bread made without milk, dry-milk solids or whey (Italian bread) Broth-based soups Cereal and crackers Non-dairy creamers Desserts made without milk, dry-milk solids or whey Fruits and vegetables Plain meat, fish, poultry and peanut butter Special foods such as cottage cheese that are labeled “lactose-free”

LOW-LACTOSE FOODS Most people tolerate the amount of lactose in the following lowlactose foods: Aged and processed cheeses (aged cheddar or Swiss, processed American, etc.) Breads containing milk, dry-milk solids or whey Butter or margarine Commercially-prepared foods containing dry-milk solids or whey Milk treated with lactase enzyme* Sherbet *Dairy Ease™ or Lactaid™ enzyme can be purchased in liquid or tablet form and can aid in the digestion of milk and milk products. Follow the directions on the package.

A list of high-lactose foods to avoid if you are intolerant of lactose is listed in Table 3-5. If you are lactase deficient and highlactose foods cause symptoms, consider purchasing the enzyme, lactase in tablet or liquid form (e.g. Lactaid, Dairy Ease). The tablet

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56   Conquering Irritable Bowel Disease

Table 3-5. High-lactose foods to consider avoiding if you have true lactose intolerance and symptoms

Food

Serving Size

Cheese food or spread* Cottage cheese Dry cottage cheese Ricotta cheese Dry milk (whole, non-fat, buttermilk) Evaporated milk Half and half Ice cream or ice milk Milk (whole, skim, 1%, 2%, chocolate milk, ­buttermilk) Chip dip or potato topping Sour cream Sweet acidophilus milk Sweetened-condensed milk White sauce

2 ounces ¾ cup 1 cup ¾ cup 2 tbsp. ¼ cup ½ cup ¾ cup ½ cup ½ cup ½ cup ½ cup 3 tbsp. ½ cup

*Labeled as such. Lactose content is higher than that of aged cheese and processed cheese because whey powder and/or dry-milk solids are included.

form is chewed before eating lactose products, or the liquid form can be added to milk. Lots of people with IBS will have lactase deficiency.Your doctor can test you for lactose intolerance in many different ways, such as a blood test or a breath test. Another way is to test a small amount of tissue from the small intestine through an endoscope. This is totally painless because the bowel lining has no pain fibers. If your symptoms persist despite trying a low-lactose diet for two weeks, this almost certainly means that lactose deficiency is not the cause of your symptoms and you can go back to eating a sensible diet that does include some lactose.

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Chapter 3 - Diet and Exercise—Key Helpers in the Battle!   57

FOOD INTOLERANCE: A REAL PROBLEM IN IBS! Just psychosomatic, say most of the textbooks…. Undeterred, I sought more information…. Finally, Eureka! One article stood out…. It suggested IBS can be caused by food intolerance…. Other books and papers echoed these findings…. Since there is not a test for food intolerance, one has to learn what to avoid by use of an elimination diet and a food diary. —An IBS sufferer

To clarify what I mean by food intolerance, I will pose a question: Could a food allergy be your problem? Many people believe it is in IBS! But a food allergy causing IBS is very, very rare. A true food allergy would result in symptoms such as swelling around the mouth or, even more serious, breathing problems when eating a particular food. A peanut allergy is a classic example, which is why many airlines, if you are lucky, only serve pretzels in coach now (saving the airlines big money). I hate pretzels almost as much as I hate flying coach. Almost all people who have IBS do not have true food allergy, and testing for food allergy is almost always unhelpful. Some people who are tested will be found to have an allergy, but if the offending food is eliminated, IBS symptoms usually don’t disappear. However, there is some recent evidence that people with IBS have specific problems caused by certain types of food.This is called food intolerance.7 The explanation for this observation remains unclear. A large number of different foods that have been implicated are listed in Figure 3-2. But it remains unclear whether eliminating them would be beneficial. A key clinical trial suggests that food intolerance may be significant in some people with IBS.8 In this study, the investigators examined the participants’ immune response to various types of food. On the basis of the test results, the investigators divided the participants into two groups. The first group received a modified diet, where the foods that caused an immune response were removed from the diet. The second group received a “sham diet,” where some foods not causing an immune response were removed.

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58   Conquering Irritable Bowel Disease Food intolerance: Common food items incriminated by patients with IBS (n = 189) 35

Percentage

30 25 20 15 10 5

M ilk ni on s C he es e O

e

at

W

he

r

la t

ho

co

rt

tte

Bu

C

e fe

gu

of

Yo

C

s

gs

Eg

s

ut N

itr u

C

ye Te a

R

Po

ta

to

es

0

Figure 3-2. Food intolerance: common food items incriminated by patients with irritable bowel syndrome (N = 189). Adapted and printed with permission from Nanda R, James R, Smith H, et al. Food intolerance and the irritable bowel syndrome. Gut 1989;30:1099-1104.

On the sham diet, people continued to eat the foods that they had an immune response to, although other foods were removed, so that no one knew whether or not they had received an active intervention. The results were fascinating. Those in the modified-diet group had a significant improvement in their symptoms, more so than the sham-diet group. The foods that were most commonly implicated were milk, cheese, and wheat-containing products. These results remain to be confirmed by other studies, but they  do suggest that some people with IBS, whose symptoms do not respond to the usual dietary recommendations discussed above, might still respond to eliminating certain foods from their diet. Another way to test for food intolerance is by introducing a very bland diet and then slowly adding a number of different foods to see whether these induce symptoms. Even though the process is very laborious and expensive, if you are particularly troubled with IBS and standard treatments have failed, this would be worth considering with the help of your physician and an expert dietician.

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Chapter 3 - Diet and Exercise—Key Helpers in the Battle!   59

FODMAPS: A MOUTHFUL TO GUIDE YOU I gave the elimination diet my best try…. To my immense relief, the pain due to bloating ceased, and I began to feel a lot better. It has taken me five years to work out my own regimen for comfort. —An IBS sufferer

In previous sections, we covered several foods that commonly cause IBS-related symptoms. For example, foods containing excess lactose can make IBS worse. OK—now I have something new in the diet world to share with you that is very exciting, although at first, you might be overwhelmed by its name.This new diet knocks out most of the known bad IBS foods, much like a food-intolerance diet, and it helps many with IBS based on all the evidence to date.9,10 To give you a sense of why this diet might work, I will share a little more about our relationship to the bacteria that live inside us. It turns out that we all eat a lot of foods that are poorly digested and absorbed. These foods enter our lower intestines where bacteria break them down. We are all full of bacteria—they own our bowels and possibly affect our minds.11 We have more bacteria in our gut than human cells in our body. It has been mused we exist only because our bugs need a home—a disturbing thought. If the gut bacteria are primed to produce excess gas from foods (a process called fermentation), then we will produce excess gas. The gas will cause the gut to swell, resulting in bloating and pain. In those who are likely to develop IBS and therefore are highly sensitive to gas and swelling of the bowel, this process can lead to symptoms. This diet works in part by starving those bad bacteria in the bowel. By avoiding a combination of the likely culprit foods, you may feel a lot better. Sue Shepherd, a dietician from Melbourne, Australia, invented this diet. I now recommend it as a first treatment for my patients, especially if you are troubled by bloating or diarrhea. It is known as a FODMAP diet. This refers to: Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols. What a mouthful! But there is evidence this diet works. Perhaps around 70% of people get some relief, although the diet is not a

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Apple, cherry, mango, pear, watermelon

Asparagus, artichokes, sugar snap peas

Fruits

Vegetables

Grains and cereals Nuts and seeds

Free fructose

Food type

Lactose

Artichokes, beetroot, Brussels sprouts, chicory, fennel, garlic, leek, onion, peas Wheat, rye, barley Pistachios

Peach, persimmon, watermelon

Fructans

Apple, apricot, pear, avocado. Blackberries, cherry, nectarine, plum, prune Cauliflower, Mushroom. Snow peas

GalactoPolyols oligosaccharides

Some common food sources of FODMAPs - a low FODMAP diet can be prescribed for IBS

Table 3-6.

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Honey, highfructose corn syrup

Milk, yogurt, ice-cream, custard, soft cheeses

*From Ref. 10; used with permission from American Journal of Gastroenterology.

Inulin, FOS

Legumes, lentils, chickpeas Chicory drinks

Legumes, chickpeas, lentils

Sorbitol, mannitol, maltitol, xylitol, isomalt FODMAPs, fermentable oligo-, di-, and mono-saccharides and polyois; FOS, fructo-oligosaccharides

Food additives

Other

Legumes

Milk and milk products

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62   Conquering Irritable Bowel Disease

cure.9 If your symptoms are related to fermentable foods, then following this diet could stop the abnormal process in its track, but relaxing the diet would result in a return of your symptoms. The diet may also help other IBS symptoms related to an overactive immune system. The FODMAP diet is a type of food-intolerance diet that knocks out the main culprits simultaneously. The FODMAP diet is complex, requiring the help of a dietician or nutritionist to eliminate all the bad (high FODMAP) and choose only the good (low FODMAP) foods. Although a low FODMAP diet is harder to follow than some of the other dietary advice given in this chapter, it seems to have the best chance of a good result. I recommend trying the FODMAP diet if simple approaches like avoiding lactose are not enough. Books describing FODMAP recipes are now available and may help you (Figure 3-3).12 If your symptoms improve on the diet, your dietician will guide you on reintroduction of certain foods after a few months (Figure 3-4).

BOWEL REGULARITY: NOT A NEW SUBJECT We are reminded by Dr.Whorton, Professor of History of Medicine at the University of  Washington that obsession with the bowels is not a recent phenomenon.13 He notes that an Egyptian papyrus from the sixteenth century BC discusses the poisoning of the body by waste in the colon. Indeed, this thought gained more credibility when bacteria were discovered throughout the bowel. Could these bacteria poison the body? People in the early twentieth century believed so; they feared constipation could reduce the life span and linked it to many of the unexplained diseases of the day, including what we now recognize as IBS. To combat this fear of supposed poisoning from the contents of the colon, or colonic intoxication, all sorts of laxative treatments and devices were developed. All-Bran was introduced in the 1920s and 1930s to actually fight this problem. Another cereal of the time was marketed as DinaMite! There were electrical stimulators and obscene dilators, massage machines and colonic irrigations, all developed with the purpose of combating what some were ­calling

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Figure 3-3. FODMAP picture chart. Used with permission from http://www .ibsgroup.org/brochures/fodmap-intolerances.pdf.

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3

Yes

Alarm features?

Medical and psychosocial history, physical examination

No

Investigations as indicated: eg colonoscopy, blood and stool tests, duodenal biopsy

7

Consider limited No screening tests

8

6

No

5

Yes

No Any abnormality identified?

Irritable bowel syndrome (IBS)

Evaluation of stool consistency (using Bristol Stool Form Scale)

10

Celiac disease, giardiasis, inflammatory bowel disease, microscopic colitis, small intestinal bacterial overgrowth, colorectal neoplasia

Yes

Any abnormality identified?

9

13

12

11

Diagnosis of IBS. From theromefoundation.org; Used with permission (© The Rome Foundation).

Figure 3-4.

4

2

Patient with recurrent abdominal pain/discomfort associated with disordered bowel habit

IBS with diarrhea (IBS-D)

Mixed IBS (IBS-M)

IBS with constipation (IBS-C)

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Chapter 3 - Diet and Exercise—Key Helpers in the Battle!   65

civilization’s curse: the constipated bowel. Colonic irrigation survives to this day, and is of no proven help! We now know the idea that the colon could be poisoned by constipation is absolute nonsense, and certainly there is no evidence that being constipated shortens your life. However, this still hasn’t stopped some people even today from going to extreme lengths to fix their bowel regularity if they perceive it as not normal. We all tend to feel so much better if we can have a good regular bowel movement. Indeed, we are often taught this is important by our parents, and we have this instilled from childhood. The trouble is, bowel regularity is pretty variable. While ninety-five percent of the general population has a bowel movement anywhere from three times a day to three times a week, there are some who naturally fall outside this range, having bowel movements more or less frequently. If you happen to be one of these few people, and you experience no other symptoms, you are unlikely to have any type of disease. Indeed, if you have absolutely no other symptoms and have always had the same bowel frequency, don’t worry! You don’t need anything special done. However, people with IBS will often experience widely varying bowel patterns, which come and go and can be terribly distressing. Indeed, a lack of predictability about one’s bowel habit is an issue that worries people frequently. In reality, there is no such thing as a normal number of bowel movements per week; normal is in the eye of the beholder.

FOOD CHEMICALS If you don’t improve on a diet, this does not mean food isn’t important in curing symptoms.We showed that foods high in salicylates, a natural chemical, may cause symptoms in IBS (e.g., in milk, wheat, eggs).7 So cutting out food chemicals, especially salicylates, may be worth a try, although we need more evidence that this really helps.10

ME—GLUTEN FREE? Some people develop an allergy to a protein called gluten. This is called celiac disease. Gluten is a common ingredient in many foods. It helps dough to rise and is found in wheat, barley, and rye products.

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Celiac disease can cause symptoms just like IBS, so many doctors routinely test for celiac disease with a blood test (and current guidelines for doctors suggest this testing should be done routinely). If the blood test is positive, you need a special test done (taking tissue through the endoscope from the upper small intestine) to confirm the diagnosis. But even if you don’t have celiac disease, eating gluten might cause some IBS symptoms. If the dietary advice given earlier in this chapter isn’t working for you, it may be worth trying a gluten-free diet for a few months to see if your symptoms go away. I recommend you see your doctor (to rule out celiac disease with a blood test) and then a dietician. You need to avoid all gluten for a period of several weeks, then reintroduce it to see if the diet will work for you. Only if your symptoms go away on the diet and return when you eat gluten again should you continue to go gluten free. The randomized trial evidence indicates pain, bloating, gas, and tiredness in IBS may improve on a gluten-free diet, if you are affected.14 A gluten-free diet is tough to do because you have to restrict lots of foods. It is also more expensive than a normal diet. But if it truly works to relieve your symptoms, that’s a great outcome! Seek expert advice and don’t try this all alone.

CANDIDA Overgrowth of Candida, or yeast, in the bowel has been blamed for all sorts of health problems, including IBS. But all the scientific evidence confirms that this is another piece of utter nonsense. I admit if you search the internet you will find lots of believers. (But many people also used to believe in witches centuries ago and nothing could dissuade them of the belief—humans haven’t changed.) Candida is common in the stools of most healthy people (and of course in people with IBS, too). Although there is a Candida diet for IBS, it looks awfully like a diet low in fructose, which does help IBS. So, any benefit that a Candida diet might provide, I would suggest, has nothing to do with Candida. Don’t waste your time or money here, in my opinion.

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TIPS AND TRICKS FOR REGULARITY Part of your bowel behavior is under voluntary control and can be changed. For example, if you suppress the urge to have a bowel movement repeatedly, you can train yourself to become constipated. A published experiment has confirmed this; healthy people were asked to suppress going to the bathroom to pass stools for four days, which did lead to temporary constipation.15 It was also reported that their stomachs emptied more slowly. This illustrates that you can change your body function with bad habits! However, this can be reversed with a special form of training called biofeedback, discussed later in this book. If you are attempting to improve your bowel regularity, here are my suggestions: 1.  Try not to delay going to the bathroom when you feel the urge. 2. Relax and allow sufficient time. Do not hurry to have a bowel movement. 3. Avoid straining excessively or trying to force your bowels, which could damage muscles and nerves that control bowel function. Train, don’t strain! 4. Every day laxatives aren’t necessarily good just because you want to have a bowel movement. It may make your bowel problems worse temporarily. Laxatives will be discussed in a later chapter.

EXERCISE IS BENEFICIAL I have never taken any exercise except sleeping and resting. —Mark Twain

Mark Twain (Samuel Clemens) was a great wit, but this comment—unlike many of his witticisms—hasn’t aged well. We now know exercise has wide-ranging health benefits—we are built to be constantly active. For a healthy mind and spirit, exercise is essential. It helps the immune system (which is overactive for some with IBS).

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It is healing. It helps regulate body functions. Exercise reduces stress and can be truly fun and relaxing. Exercise is also good for helping to maintain a healthy weight. It may give you a rhythm to your day and can be a great boredom reliever. While lack of exercise does not seem to cause IBS, adding exercise to a normal routine often helps my patients manage their symptoms. This is particularly true for patients feeling low in energy or those struggling with stress-related bowel symptoms. Clinical trial evidence indicates that people with IBS who choose to exercise report a better quality of life and improvement of symptoms.16,17 Almost any type of exercise can be helpful in my experience. This includes yoga, exercises to stretch and strengthen, and aerobic activities. A key issue is to find something that you like to do and do it regularly. Try different types of activity to maintain your interest. Joining a gym can help. However, if you have other health problems such as heart or lung disease don’t start exercising vigorously until you speak with your doctor. Group exercise activities may be the most helpful because they provide a level of support and friendship that can only be beneficial. If you possibly can, try exercising, and plan to do it for life!

DO YOUR KEGELS! Several different problems can lead to weakness of the pelvic muscles that help in controlling bladder and bowel function. A number of exercises have been developed particularly for women who have weak pelvic floor muscles and leak urine when they cough, laugh, or exercise, called stress urinary incontinence. A set of exercises commonly called Kegel exercises, or Kegels, are done by contracting or squeezing the pelvic floor muscles to make them stronger, reducing urine leakage. In addition people with other pelvic floor muscle problems, such as leakage of stool, may also find strengthening these muscles to be helpful. Stool leakage affects about one in twenty people with IBS. These exercises may also help people who strain the muscles around the anus while trying to have a bowel movement, hindering defecation. Pelvic muscle exercises combined with other treatments can improve all aspects of the muscle function down at the bottom end.

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Many people need help identifying which muscles Kegel exercises are designed for. To identify the key muscles, imagine you are tightening the muscles around the anus area to block passing gas, for example. When you squeeze these muscles around the anus and bladder area, try to lift or draw in the muscles down there without moving your abdomen or legs. Remember to relax completely after tightening the muscles. So, let’s practice. First, empty your bladder.Then, go somewhere quiet where you can concentrate on doing these exercises properly. You can try them while sitting, standing or lying down, whichever is most comfortable for you. Breathe regularly. Then, tighten the muscles for a count of five and then relax them for a count of five. Repeat for ten times.Then, tighten the muscles for a count of three and relax them for a count of three, and do this ten times. Repeat the same exercise set three times over the course of a day.You might feel some soreness around the area at the beginning but this usually settles down. You may also find it difficult to contract the muscles for more than a second or two at the beginning, but practicing will improve your strength, which is the whole idea of the exercise program. Once you get the hang of it, you can do your Kegels in the car or while standing in line at the post office and no one will even notice. It takes six to twelve weeks to improve the muscles. And like any muscle training program, you must be patient if you want to see success. The great benefit will be after this initial period. Assuming you have done the exercises correctly and consistently, you should see some improvement in your symptoms. Consider maintaining your Kegel exercises at least three times a week to continue the benefit. Try Kegel exercises if you think the muscles down there might be weak; you may be amazed by the results.

COMBINATIONS WIN—DIET AND EXERCISE CAN REALLY HELP! In my experience, diet really can help, but it is in your hands to make this happen. In addition to considering simple changes such as adding fiber, I recommend trying a low FODMAP diet first—if it works, that is marvelous. Of course some people do not find that

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70   Conquering Irritable Bowel Disease

this diet provides sufficient relief of their symptoms, so further steps are needed. An expert dietician who knows about IBS can be very helpful. I also recommend regular exercise along with diet change. If you are constipated, more fiber may help; but build up the amount very slowly. Otherwise you may get more gas. Remember to eat regular meals while avoiding large meals in a stressful environment. Sometimes reducing or eliminating caffeine, alcohol, or tobacco will improve your symptoms naturally. Remember that if you do have the urge to move your bowels, respond to this rather than suppressing it, but try not to strain excessively whatever the situation. Your bowels may only want to move naturally a few times per week or less and this may be quite normal. It will certainly not cause you any harm. It is your body and you can take charge.You can learn to help control some of the body’s key functions, ultimately reducing or even eliminating many symptoms of IBS.

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s ABC

LEARN YOUR ABCs TO GAIN CONTROL AND RELIEF

Just adjusting your diet may be all you need for symptom relief. But remember to increase fiber slowly: increase your fiber by no more than three grams of fiber daily each week. A low FODMAP diet may help. Remember your Kegel exercises to strengthen pelvic muscles. Lose weight and feel great by exercising! Diet and exercise are winners in IBS.

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Chapter

4 THE MIND-BODY ­CONNECTION: HOW WE CAN HEAL OURSELVES In a moment we’ll turn to the importance of the mind–body connection in healing (or how we can heal ourselves). But how will you know what really works and what just doesn’t? There is a barrage of information out there on different treatment approaches for IBS and related conditions. Just try an internet search on the topic. You might be amazed at the number of web sites that seem to cover the area after just a few clicks. For example, one web site found with a Google search is entitled “Beating IBS.” The author is purportedly a patient who has developed a self-help program, and for a small sum you can purchase it. According to the author, the program is guaranteed to cure the problem in most people. A number of testimonials that support his claims are provided. So the question is: Could this program be THE answer? Another web site talks about irritable bowel relief with 100% guaranteed results for an all-natural colon-cleaning product. The 73

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trouble is, a large number of other sites make similar claims, although they all seem to recommend very different sorts of approaches to treatment. They too have good testimonials. Do all these treatments work? If so, why does it often seem so hard to get better? So, how will you know that something could work? How do you know what you are being told is the truth? Should you believe “the experts” on the TV or the radio? This is where science can help. You need to be able to take control here. There are enormous amounts of information out there, some of it absolute nonsense and some truly useful! The fact that someone is marketing a product does not mean what they say is true (or false). Furthermore, testimonials alone are not of much value. If one person got better on some kind of treatment for IBS does that mean the treatment really works? Any benefit of treatment could be due to all sorts of reasons, including the possibility of just naturally getting better for a while. This does happen in up to one-third of people with IBS in the community without any treatment. Or perhaps the benefit is due to what’s called the placebo effect.

WHAT IS THE PLACEBO EFFECT? The art of medicine consists of amusing the patient while nature cures the disease. —Voltaire

The word placebo means “I shall be pleasing” in Latin. In essence, a placebo is something like a treatment, such as a pill or another type of therapy, only one consisting of ingredients considered to be inactive. It is sometimes referred to as a sugar pill.You would think that if anyone was given only inactive ingredients, no one’s symptoms would improve. Many times, over many years, however, different researchers have found that when a patient receives a placebo, there’s a chance that something desirable will happen. Sometimes, their symptoms actually improve. The effect of a placebo varies depending on the trial, but the placebo is effective enough that doctors generally assume that about one-third of patients with IBS will get better for a while just by taking a placebo. Much of what I will summarize here comes from a wonderful review of placebos by Professor Grant Thompson that appeared in

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The American Journal of Gastroenterology, where you should go for more details.1 In the early part of the twentieth century, deliberately prescribing pills that had no action (sugar or dummy pills) was considered a standard part of medicine. However, in more recent years, using a placebo as medical therapy is now considered to be deceptive. Indeed, even Thomas Jefferson referred to placebos as “a pious fraud.” Dr. Howard Brody called placebo “the lie that heals.” As we’ve discussed in this book, the brain plays an important role in IBS. The signals from the body to the brain and back again can be changed by what we think and do. Dysfunction of certain neural pathways is one of the main underlying problems in some people with IBS. One way to potentially and naturally correct these pathways seems to be a true belief that a treatment really works. Experts still do not understand why placebos seem to work.The brain remains a mysterious organ despite all our probing. Some part of the placebo response is explained by natural fluctuations in IBS symptoms. This occurs in many chronic yet intermittent diseases, where the symptoms seem to come and go without an obvious reason. If a treatment is given at the same time that a natural remission happens, then someone might mistakenly give credit to the treatment, a type of placebo effect. Peptic ulcers seemed to heal by taking a placebo for this reason (because stomach ulcers naturally heal then break open again). The benefit of a placebo may also be related to its ability to reduce your feeling of stress when symptoms start. Reducing stress can help allow the brain to turn down pain signals being sent up from the body. (If you don’t process the pain signal in the brain, you feel no pain). The effects are not always diminished by telling people they are getting a placebo, which is amazing! So the placebo effect is not explained by any lack of knowledge or understanding. Even more amazing is evidence that the placebo response can be increased by some simple actions of the healthcare practitioner. A published experiment showed that up to sixty percent of the patients in the study improved with a placebo when it included a strong physician-to-patient interaction. This is compared to the expected forty percent of patients with IBS getting better using a placebo alone.2 These interactions included simple physician behaviors such as offering reassurance and thoughtful reflection during the visit. No wonder shoddy alternative medicine

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practices that aren’t really effective—but are delivered by engaging ­practitioners—can get rave reviews and fantastic, albeit somewhat misleading, testimonials. The doctor–patient interaction can increase the placebo response; and good doctors use this every day, consciously or subconsciously, to help their patients. With all due respect to the rich diversity of cultures throughout the world, I will share with you that the placebo response may further be influenced by one’s cultural background. All cultures have widespread popular beliefs that are held independently of the evidence of the effectiveness of certain treatments. It seems these culturally based beliefs can lead to measurable effects on the human condition. For example, in indigenous Australian aborigines, there has been a deeprooted cultural belief that a hex from the medicine man can be lethal. I remember as a young doctor in Australia caring for an aboriginal man who suffered from unexplained high-grade fevers. He reported that he had been hexed by the pointing of the bone. Despite all of the marvels of modern medical technology, no cause was ever found for his symptoms, and he deeply believed that his illness was a result of the hex put on him. A negative placebo response is called a nocebo effect. Another example of the mysteries of the placebo may be illustrated by the faith healers that claim healings on television with remarkable apparent benefit. Religious belief can be healing.We will address spirituality later in this chapter.This positive force may somehow be linked to the mysterious placebo response found in medicine.

THE PLACEBO RESPONSE IN ACTION— UNNECESSARY SURGERY One of the disadvantages of going to doctors is actually the flip side of the benefit of going to doctors, and that is: they will look hard for a possible cause for your symptoms. Although this can lead to relief, sometimes it leads to uncovering medical problems that in fact have absolutely nothing to do with the pain or bowel dysfunction that bothered you in the first place. A good example is suspecting the gallbladder as a source of abdominal pain and examining it for gallstones. The gallbladder is often suspected of being a cause of pain. Many people have “silent” gallstones in their gallbladder that will never, ever, cause them any trouble. They are better left alone.

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Doctors recognize that sometimes gallstones or a dysfunctional gallbladder can cause abdominal pain, which leads them to consider removing it. We now know that people with IBS are three times more likely to have surgery to remove their gallbladder compared with the normal population in the United States.3,4 This means that there are a very large number of operations performed in people with IBS that are almost certainly quite unnecessary.The same goes for other surgeries, such as appendectomies, hysterectomies, and back surgeries in people with IBS.4 The trouble is, even after your surgery, your risk for complications can add to the struggle. This does not mean that having an operation is always unnecessary in the setting of IBS. Quite the contrary: if, for example, you have very severe pain in the upper abdomen that is quite different from your other IBS symptoms, then this could be due to a problem like gallstones. Before having an operation, however, you need to weigh the issues very carefully with your physician. Even consider seeking further opinions before having the procedure done, to be sure it is in your best interest. There is no such thing as a quick fix for irritable bowel; you need to take control of your own health here. To link this back to our discussion of mind–body connections, I would like to emphasize that sometimes people with IBS do get better for a while after surgery, which indeed encourages the surgeon and the patient. But for patients with IBS, this is often because the surgery acts as the placebo, and the symptoms typically come back. Remember another old adage, if it ain’t broke don’t fix it. And even if it is broke a little, it don’t necessarily need fixing anyway. Silent gallstones (the ones not causing pain) just don’t need to be taken out. One of the great principles for doctors in medicine is: first, do no harm (in Latin, primum non-nocere). It is terribly easy even for the best doctors to initially misdiagnose and mislabel IBS.

HOW CAN I KNOW WHETHER A TREATMENT WILL WORK? You need to take control of your body and the treatments that you receive for your symptoms. To do this, you need to be informed, but the overload of information can be a real problem. Indeed, how do you obtain accurate information that will guide

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you? Even if you are an expert in the field of IBS, the amount of literature to read in this area remains enormous and grows every single day. Later in this chapter, we will discuss particular therapies for which there may or may not be evidence that they are more effective than a placebo. You need tools to sift through the masses of information like this that is out there, so you can read what is really most useful and, with the assistance of your doctor and other relevant healthcare professionals, gain control of and relief from the problem. This is where evidence-based medicine can help you. Guidelines are available that I will share with you for deciding what to read and how to judge the benefits objectively, regardless of the opinion of the author.

WHAT IS A GOOD SCIENTIFIC STUDY? EVIDENCE-BASED MEDICINE An expert is a person who has made all the mistakes that can be made in a very narrow field. —Niels Bohr

Scientists, including medical scientists, need to be skeptical. No matter what everyone else may believe! Remember when AIDS first burst on the scene and no cause was known? Many people proclaimed all sorts of wild views (which miraculously disappeared when the HIV virus was identified and anti-viral treatments started to work). But good scientists were swayed only by evidence. Even today, however, a small minority of people deny AIDS is caused by the HIV virus. This is simply amazing when there is so much convincing data. The scientific process is simple when considering a new ­treatment—start out being skeptical, thinking, “this won’t work.” This is the null (or, “it won’t work”) hypothesis. Test it; measure it. Is the therapy working? If it is, and the experiment was done correctly, then you can reject the first assumption that the treatment won’t work. But sometimes as more evidence comes in, you will change your mind again based on all the facts at hand—the truth can be evasive, especially early on.

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So in science, studies are actually done in an attempt to prove that a new therapy is worthless! Many things that we think of as treatments for a disease, even if used for thousands of years, won’t work when we properly test them. Only after multiple studies or experiments all point the same way can anyone be confident that the initial skepticism was wrong. Only then can you be confident the treatment does probably work (or not). Note, I said probably, not definitely. Science is not about being definite, just reasonably certain. Scientists refer to this philosophical approach as “the method of deduction” and it remains a key tenet of the scientific method in medicine. This is the experimental method that has led us to all the marvels of today, including miracle drugs (like anti-cancer drugs or anti-virals) and safe organ transplantations that transform people’s lives! And even reaching the moon would not have been possible without the method of deduction. You should only have confidence in therapies that have successfully withstood standard attempts to demonstrate they are no better than placebo.This is the only way to identify what really works and what doesn’t.While a placebo can sometimes help more than doing nothing, its effects are generally short lived. Any drug or treatment needs to beat the placebo response. As a medical scientist, my top priority is finding what really works. (I also like to know how it works so we can design even better treatments to follow, but that is something to ask later.) Anyone arguing that you can know what treatment really works in health without doing a proper experiment is either deluded or selling something. The idea of using evidence to guide medical treatment is actually somewhat new. There have been many examples where this approach has not been taken and the best medical experts of the day were completely misled. In the early 1960s, gastric freezing was used as a treatment for peptic ulcer disease. The surgeons were so impressed with this approach that thousands of gastric freezing machines were purchased in the United States. However, when a proper study was done, it was found that gastric freezing gave almost the same results as no treatment. Indeed, the evidence showed that those who received the gastric freeze procedure seemed to have even worse results. Gastric freezing died a natural death following this trial. Now we know peptic ulcers are most often caused by a specific bacterial infection. No wonder freezing was bound to fail!

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It is a pity that so many of the treatments touted for IBS (with no evidence to support them) have not also died such a natural death themselves. When you read a scientific paper or a newspaper report, trying to determine whether the treatment really might work, you should ask yourself some simple but key questions.5,6 The first is this: was a process called peer review performed? In other words, has the research been evaluated by other experts in the field? One strength of serious scientific journals is that all articles undergo a process in which other expert researchers carefully read the paper and comment on its accuracy and importance. They ask, “Has this study been performed well enough to merit publication?” However, being published doesn’t mean it’s correct. Many studies report initial or preliminary results that could be exciting but certainly are not definitive (and often will turn out to be just plain wrong!). The second question you should ask is: Does the study compare the possible treatment with a placebo (or dummy treatment)? In IBS, most good trials include a placebo group or a “sham” treatment group. If there is no placebo, be really suspicious. The study can’t be definitive! I wouldn’t usually believe a study is true unless there is a placebo group. Third: Are the groups of patients in the study randomized, or randomly assigned to a treatment? This would be like the experimenter flipping a coin (or more likely using a computer program) to determine who will receive the active treatment and who will receive the placebo treatment. Obviously rigging any trial is not acceptable (e.g., assigning the sicker patients to the placebo group while the healthier ones receive the active treatment), but if it’s not randomized it might be very misleading. So randomization is a critical issue. If the trial examines a new therapy but is not randomized, ignore it and read something else. The fourth question to ask when evaluating information about a possible treatment is about blinding. Have the investigators set up the experiment so that neither they nor the patients in the trial know who is receiving a placebo therapy and who is receiving an active therapy? You must remember that investigators desperately want to find treatments that work to help their patients and to advance the field (even though they should be skeptical).The companies that ­sponsor

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clinical trials also desperately want their drugs to work. Hence, if they actually knew who was on active therapy, they may alter subtly (again consciously or unconsciously) how they rate the benefit of the treatment. It can be difficult or impossible to blind some treatments, however, like hypnotherapy or acupuncture. Finally, ask what happened to everyone who was treated. Testimonials alone aren’t worth the screen or paper they are written on for lots of reasons. For example, the person sponsoring the treatment, for all you know, may only publish the good testimonials, and leave out all the bad press. (How often do you see bad testimonials of treatments on the internet?) Good trials always include information on what happened to everyone, those on treatment and those on placebo. One trial is not sufficient. This is why the Food and Drug Administration (FDA) in the United States requires two large randomized, double-blind, placebo-controlled trials of active drugs before a new drug can be approved. This is to show that the new medication really is of benefit in IBS. Even though we can never be absolutely sure, the probability that the therapy is effective is much higher if two trials find the same results. Therapies that have not been subjected to randomized, double-blind, placebo-­controlled trials may work, but without the evidence for success, be very ­suspicious!

WHAT IF THERE IS NO EVIDENCE? I have one last bit of insight to share with you about evaluating therapies for IBS before we discuss the ones related to the mind– body connection. When testing different treatments in IBS that depend on a mind–body connection, the experimenter often finds it virtually impossible to blind either the patient or the therapist to the treatment. For example, in hypnotherapy the therapist must know they are hypnotizing a patient and the patient will usually know whether or not they are being hypnotized. There is no fake (sham) treatment that can be given to hide the therapy. This means that the studies undertaken can be misleading because, without realizing it, patients or therapists may influence the outcomes. So, finding good evidence for these therapies is difficult.

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Many unproven approaches to treating IBS are available. Some of these treatments may well provide additional benefit. In deciding what therapy to try, you need to carefully weigh not only whether the treatment will work, but also, and even more importantly, whether it has any adverse reactions that you really want to avoid. There are lots of charlatans out there who would be happy to take your money to treat you with an unproven therapy. So in this situation, it really must be “patient beware” when you seek alternative treatments.

COMPLEMENTARY AND ALTERNATIVE THERAPIES: A GROWING TREND There is no alternative medicine. There is only medicine that works and medicine that doesn’t work. —Richard Dawkins

In addition to the placebo and its mysteries, there are other treatments that make use of the connection between the brain and the body. The National Institutes of Health in the United States has created The National Center for Complementary and Alternative Medicine that defines complementary and alternative medicine as: “a group of diverse medical and health care systems, practices and products that are not generally considered to be part of conventional medicine.”7 Among the many approaches to alternative medicine are yoga, Tai Chi, meditation, herbal treatments, mega doses of vitamins, chiropractic, homeopathy, ayurvedic medicine, and image therapy, including magnetic therapy or Reiki. Psychotherapy can be considered a complementary therapy to traditional Western medicine, as can relaxation techniques and spirituality.The alternative therapies that involve taking something into the body will be discussed in Chapter 5. About a third of US adults regularly use complementary and alternative medicine, and their use is increasing. Indeed, two-thirds have used some type of complementary or alternative medicine therapy at some time in the past. However, the majority of people never tell their physician they are using these therapies, which is a pity not only because physicians need to be educated but also

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because sometimes these therapies have toxicities. Unless the physician knows the patient is on the treatment, signs of a possible ­toxicity possibly won’t be picked up until too late. I have seen cases of liver failure (and death) from use of herbal medicines in multiple family members. Alternative medical product sales are at a level of approximately $3 billion dollars in the United States, and this is increasing annually at about ten percent, which is extraordinary. More is being spent (over $21 billion) for various complementary and alternative medicine professional services; half of this is paid out of pocket by the patient, making traditional medicine look almost inexpensive, which we know it is not.

REFLEXOLOGY, ACUPUNCTURE, AND CHIROPRACTIC Reflexology has been tested in IBS. In this treatment, pressure is applied to specific body zones in the feet, hands, or ears. The approach makes no sense in terms of known anatomy. In a single small trial, reflexology applied to the foot was of no benefit in IBS.8 I advise you to forget this approach right now. Acupuncture applied to the colonic meridian (L1-4) was shown to be better than “sham” (fake) acupuncture.9 In another trial of twenty-five patients, no benefit of acupuncture could be demonstrated. Perhaps this was because the number of patients studied was too small to detect any benefit.10 My research team has also looked at the effects of acupuncture on colon function but has been unimpressed. Currently, this approach looks rather unpromising.2 In other studies, however, acupuncture seems useful for back pain. This could have a benefit for patients with IBS if their pain is poorly controlled. Further studies will determine whether this is true or not. There is no good evidence acupuncture works in IBS, but at least this has been tested.11 Chiropractic is totally unproven in IBS. I am deeply skeptical it really helps here. The onus is on the practitioners of these arts to establish these are better than a placebo or sham therapy for IBS— and I’m betting on sham! OK, I am now going to discuss some safe mind–body therapies I think may be of more help. Not all have been rigorously tested in

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IBS. The evidence for benefit may be indirect or limited, so please take what I say with a grain of salt until we have more data!

PROGRESSIVE MUSCLE RELAXATION There is good evidence that formal psychological therapies can help IBS (and these are discussed later in this chapter). One simple approach is a progressive muscle relaxation program. In my experience this can really help you feel calm and quiet. The mind in IBS is often overactive, in part because of all of the abnormal signals flooding the brain from the bowel. This seems to be a part of the disease. Relaxation can provide you with a sense of freedom from some of these signals and symptoms, and help you to cope. It may take some time to learn the techniques and become comfortable with them, but relaxation can be very useful as a regular part of your life. The evidence that relaxation works in IBS is limited, but in controlled trials, relaxation leads to symptom improvement, suggesting this is not a technique to casually dismiss.12 Progressive muscle relaxation is a systematic way of relaxing all the muscles of the body. Usually starting with the hands and arms, the body is divided into a series of large muscle groups. Each group is first tensed and then relaxed, moving throughout the body and ending with the legs and feet.You can try progressive muscle relaxation on your own. But before you can experience the full benefits of this technique, you will need to practice tensing and relaxing all the muscle groups of your body. The following instructions will help you to identify all your major muscle groups. Remember to maintain tension for about five seconds followed by relaxation lasting about ten to fifteen seconds.

Instructions for Tensing and Relaxing Muscle Groups OO

OO

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Clench the right/left fist, feeling the tension in the fist and forearm and then relax. Repeat with the opposite hand. Bend the elbow and tense the biceps muscle of the upper arm, keeping the hands relaxed and then relax. Repeat with the opposite arm.

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OO

OO

Straighten the arm and tense the triceps leaving the lower arm supported with the hands relaxed, and then relax. Repeat with the opposite arm. Wrinkle the forehead by raising the eyebrows and then relax. Bring the eyebrows close together (as in a frown) and then relax.

OO

Scrunch up the muscles around the eyes and then relax.

OO

Tense the jaw by biting the teeth together and then relax.

OO

OO OO

OO OO

OO OO

OO

OO

OO

Press the tongue hard and flat against the roof top of the mouth with lips closed, notice the tension in the throat and then relax. Press the lips tightly together (as in a pout) and then relax. Stretch your neck back as far as it will go looking at the ceiling and then relax. Press the chin down onto the chest and then relax. Hunch the shoulders towards the ears and circle the shoulders and then relax. Breathe in and pull in the stomach and then relax. Stick out your chest and arch the lower back away and then relax. Tense the buttocks and calves by pressing the feet and toes downwards and then relax. Tense the shins by flexing the feet and toes upwards and then relax. Curl your toes in then stretch them out and then relax.

Now that you have practiced tensing and relaxing the muscle groups, you can experience a deeper level of relaxation by following these steps: 1.  Find a quiet room and a comfortable chair or bed with good support for the head and shoulder. 2. Close your eyes.

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3. Notice your breathing. Breathe calmly and regularly during the relaxation exercises. 4. Go through the tension–relaxation muscle groups mentioned above. 5. At the conclusion, get up slowly, trying to preserve the state of relaxation for as long as possible. Ideally, progressive muscle relaxation should be practiced daily. To start achieving the long-lasting effects of relaxation, you should commit yourself to at least eight weeks of daily practice. Scripts are available either free or for purchase to help you do these exercises. You may download or purchase an audio script with soothing music as an added help. Hopefully, these exercises will shift your focus away from the pain or discomfort, give you the sense of control over these systems, and refresh you as they help you heal.

MASSAGE Massage can be a form of relaxation therapy as well as a form of communication. Massage by a partner, for example, will not only reduce some of the muscle tension that may be aggravating the stomach pain you have but also may provide greater intimacy and support. Massage can also help you to feel more refreshed, revitalized, and relaxed.There is no research on the benefits of massage in IBS, but I think it’s worth a try. If you do not have a partner who can help you with this, a regular massage therapist may also provide very helpful support. The abdominal wall muscles can be quite tense in some people with IBS, perhaps secondary to the underlying bowel dysfunction. Although the abdominal muscles are not massaged themselves, even muscles away from the abdomen can be involved and help with release of tension throughout the body. Many people with IBS also experience the symptoms of fibromyalgia. Massage may be able to help desensitize some of these hypersensitive muscle areas.

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IBS AND SLEEP Studies show that IBS and sleep disturbances are related.13 Although sleep studies measuring brain electrical activity and sleep phases in people with IBS are normal, they commonly report not getting a good night’s sleep. It appears their quality of sleep is abnormal rather than their patterns of sleep.14 Some people who sleep poorly will suffer from the problem of a specific sleep disorder (like sleep apnea, where the airway becomes blocked during sleep). However, most people who have insomnia don’t have a specific sleep disorder but have learned bad habits that can be unlearned. Trials testing whether better sleep improves IBS symptoms aren’t available, but in my experience this helps. So what can you do to get a good night’s sleep? Here are some tips that can be helpful to promote good sleep habits: 1.  Avoid taking regular sleeping tablets. Unfortunately, while these can occasionally be helpful, using them every day can cause a problem.You may become dependent on them. 2. Prepare yourself to sleep well. Reserve the hour before bedtime for only quiet activities. Bedtime rituals help your body learn that indeed it is time to sleep and get set up to do so. Perhaps you can learn to do the progressive muscle relaxation exercises found in this chapter as a part of your bedtime ritual. 3. Prepare your environment. Keep the bedroom lighting appropriate and keep the room adequately cool, but be sure it is warm in the bed. Make sure that the clock is out of site during the night; sometimes this can be distracting.Try to keep the bedroom quiet and use a fan or other sound-producing device if you are troubled by outside noises. Make sure that you have a comfortable bed with clean linen that you like. 4. Avoid bad habits at night. Watching television in bed can be a problem as well as eating or drinking in bed if you are having insomnia. Don’t drink any caffeine or other beverages that may stimulate you before you go to bed. Indeed, decaffeinated coffee can sometimes be stimulating, so try to avoid this too. Alcohol can also induce poor sleep.

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It may make you sleepy initially, but then you may wake up very early because of the alcohol’s effect on the brain. If this is a problem for you, don’t drink alcohol after seven o’clock at night. If you need to go to the bathroom during the night, try not to drink any liquids after seven. 5. Focus on pleasant images when you go to bed. Perhaps you can use the ideas in this book about imagery as inspiration to promote healing and induce sleep. 6. Napping regularly during the day may seriously interfere with your ability to sleep at night. 7. Stress can make sleeping difficult. Indeed, stress can be one of the major factors causing insomnia. So I recommend addressing this issue with relaxation exercises, plus a visit to your doctor. 8. Regular exercise will make your body tired and help you to sleep. Exercise may also help IBS symptoms! 9. Try getting up at the same time every morning, even if you went to bed at a slightly different hour. It is so important to establish your daytime as well as nighttime routines. These are controlled by the brain’s central clock and are under genetic control. The brain’s clock is quite accurate, which is why many people don’t need an alarm clock to wake up. 10. If you don’t feel sleepy and haven’t been able to sleep for half an hour after going to bed, get up and do something quiet but avoid stimulating activities and then go back to bed when you feel more sleepy. As we age, we often need to go to bed earlier to feel refreshed; listen to your body clock. Teenagers go to bed late and wake up later—a different but normal “sleep phase shift.” Remember some people need much less sleep than others. A few people only need a few hours’ sleep, although most adults need seven to eight hours (but this declines as we age). If you are able to function well with little sleep, this doesn’t mean that there is anything wrong. Indeed, I seriously envy such people who can get away with only a few hours of sleep at night and function effectively during the day; it would help me in my job.

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We’ll talk about taking melatonin as a possible sleep aid in Chapter 5.

IMAGERY The nice thing about meditation is that it makes doing nothing quite respectable. —Paul Dean

According to people with serious illnesses, focusing on positive images may enable you to help your body heal. In my view, it is a form of hypnotherapy. The benefits of imagery in IBS are unknown, but certainly imagery is likely only to help rather than hinder. Moreover, it provides an active way to participate in the healing process. So I can see nothing wrong with trying it out and seeing what happens. Here are some suggested images to introduce the idea. Try and imagine that the food you are eating or the medications that you are taking are assisting your intestine to function properly. Imagine the peristaltic waves in your bowels moving in a coordinated way, reducing gas and smoothing discomfort away. Imagine the connections from your brain to your bowels transmitting signals to dampen the pain. Imagine that your brain will override the signals received when the bowel is disturbed, so that your symptoms will naturally dissipate. See the pictures of these suggestions in your mind and concentrate on them while conscientiously undertaking relaxation techniques found elsewhere in this chapter. Put aside any negative images while you are doing this, and focus on feeling calm and totally empowered. Try this daily. You may think of other healing images that you can use. It could become part of your ritual either in the evening or first thing in the morning. Find a time that suits you. Practice. Relax.

YOGA Yoga is a very old treatment intervention. It has been practiced for at least 2,000 years. The ancient texts describe yoga as a union of body with mind, mind with spirit, and spirit with consciousness.

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A comprehensive description of yoga was written by Pantanjali around 200 years before Christ. In his description, there were eight integrated steps in the practice of yoga, with physical and breathing exercises constituting two central components. Small clinical trials have reported yoga and other meditation techniques to be of benefit in a number of different diseases, including high blood pressure, asthma, diabetes, osteoarthritis, depression, and stress.15 There are few studies of yoga’s effectiveness in IBS, but some positive results have been reported.16 It would seem reasonable to suppose yoga could be useful and worth trying.Yoga could be helpful because it reduces stress and anxiety, as well as improves abdominal muscle tone. Yoga exercises should be relaxing.17 They aim to train and tone different parts of the body, including the abdominal wall muscles. Indeed, there is a group of basic yoga exercises believed to massage and tone not only the abdominal muscles but also the organs inside the abdomen including the colon. These exercises are done lying down using different combinations of movement of the legs and abdominal muscles.A key component of these exercises is mental visualization of the muscles and organs that are being exercised or massaged. Slow regular deep breathing in combination with physical exercises practiced regularly is believed to help regulate bowel function and may improve symptoms of IBS. As I have said, there is limited evidence right now that this is the case. Further research in this area is ongoing. If you decide to practice yoga, find a qualified instructor and let them know that you particularly want to focus on the abdominal muscles and abdominal organs in your yoga program. I hope this is helpful for you.

SPIRITUALITY The role of spirituality in healing and health has always been consid­ ered important. Some may find expression of their spirituality through seeking a church, journaling, meditation, or art or relaxation therapy. Others may find spirituality in friendship, reading, or experiencing the magnificent natural wonders that surround us. When managing chronic pain, discomfort, and disabling illness, spirituality offers benefits.18 Presumably, this is also helpful for people

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managing the symptoms of IBS. Specific and controlled studies, however, remain unavailable. Spirituality may also help reduce feelings of anxiety or depression affecting people with IBS.This is a very personal search. Specific advice cannot be given, but don’t discount the importance of healing the mind when trying to heal the body.

JOURNALING If you are having troubling symptoms, I would encourage you to try writing about them. Write about your feelings, your experiences, and your thoughts. Try this on a regular basis. Perhaps writing poems or stories will be therapeutic for you if you like to write. I find writing cathartic, even if no one else reads a word of it! Many people find that writing leads to new and helpful insights. Try expressing yourself through writing so that your feelings, reflections, and thoughts might become clear.You may identify physical or emotional needs that you didn’t realize you had. Maybe through writing you’ll find ways of addressing these needs, which could lead to some symptom relief. Journaling can also help you remember the questions you have about the condition, so you can ask your doctor or other experts for answers. Also, if you are having trouble sleeping, this may help you to calm down and be less fearful and anxious. This is not for everyone. It can be therapeutic to write it all down. It may help you to share these journals with close family or friends. I know this hasn’t been tested in scientific studies in IBS, but it seems to help. So start today if you think this might be a positive step for you.

ART THERAPY Like journaling, art therapy is a means of self-expression that can be cathartic in IBS. I think being creative allows feelings that are hidden to be expressed, especially with the sharing of creative work. It also helps family and friends to better understand the impact of the illness. Whether it has any therapeutic benefit in IBS is unknown, but it is another natural way to potentially promote healing. The International Foundation for Functional Gastrointestinal Disorders

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(IFFGD) has an impressive collection of artwork by people with IBS who have creatively expressed their feeling, fears, and anger related to the illness. All of the paintings in this book come from patients with IBS who have contributed to the IFFGD library of art. It is a great privilege to be able to present a small portion of this work here. Consider trying art therapy for yourself.

HUMOR THERAPY Happiness is good health and a bad memory. —Ingrid Bergman

It is funny, but humor seems to be therapeutic. Laughing alters our brain temporarily. When we laugh we reduce or even temporarily abolish stress. Laughing stimulates the heart, lungs, and muscles. It seems to improve our physical well-being. Even though there is no evidence that laughing improves IBS, it increases the release of endorphins in the brain and reduces anxiety; this seems likely it would be helpful. We need proper randomized trials, but how could we blind them, I wonder? How can one seek out humor? Obviously this is something that each individual needs to cultivate. Going to comedy clubs or movies or—even better—spending lots of time with people who make you laugh is something I believe people with IBS should actively seek. We all need to remember not to take ourselves too seriously. Sometimes discussing life events with friends or a counselor can help you laugh at yourself and increase your receptiveness to amusing events that happen in life. Don’t forget add humor into every day of your life.

PET THERAPY Animal-assisted therapy is believed to provide a form of psychological support. It may distract you from your pain or discomfort within the stomach (assuming you like pets, of course). The sense of being needed and loved is a natural human desire; if you feel this is missing in your life, consider buying a kind of pet that you would like to care for.

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If you need encouragement to do more exercise, buying a dog could be the ideal approach to make exercise really happen in your life. We have already discussed how useful adding exercise may be for the control of IBS, so don’t dismiss this option. Having a pet may also entertain and stimulate you, as well as increase your confidence and self-esteem. I suspect a pet can help you if you have IBS (but again we have no randomized trials). We all need love and a sense of purpose; think about pet therapy in your life.

PSYCHOTHERAPY As far as working with your doctor: That’s a laugh…. Like the one that told me “Tell your brain, you’re not in pain.” He should have been a poet! —An IBS sufferer

Telling your brain to dull the pain is actually feasible; this is a goal of psychological therapy. There are good studies in this area that indicate this approach is better than standard care in the treatment of IBS.19 Cognitive behavioral therapy (CBT) is one example of a type of talk therapy (or psychotherapy). The therapist empowers the patient to train the mind to think in healthier ways. This may include developing abilities to identify and challenge (or stop) irrational thoughts, to calm down using self-talk, and to use imagination to face difficult fears. It also focuses on behavioral techniques, teaching ways for the mind to handle tough times and experiences. These might include deep breathing exercises, progressive muscle relaxation (discussed previously), assertiveness training, and desensitization (or ways to become less sensitive or fearful, such as gradual exposure to something that produces fear, like eating or going to the toilet). This treatment usually occurs face to face with a trained therapist, but can sometimes be done over the internet with ­success.20,21 While the benefits of cognitive behavioral therapy have been controversial with both positive and negative trials in the literature, overall this does help.22,23 These approaches tend to improve wellbeing and may empower you to cope, but they are not a cure for IBS. My conclusion is CBT can help and is worth a try. Ask your

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health professional to help you find a good therapist (usually a psychologist). Unfortunately, finding a good therapist can be challenging. Many therapists haven’t had specific training or experience in managing IBS.

HYPNOTHERAPY Hypnotherapy for bowel symptoms has been consistently shown to provide a benefit in IBS, based on a number of randomized, controlled trials.24-26 Dr. Peter Whorwell from England is an expert in this area and has written the most about it. Peter has a hypnotic voice when you listen to him, and I am not surprised he can hypnotize his patients so effectively (he does this to me in lectures). Peter and his team have been able to show that hypnotherapy can alter some normal functions in the bowel, including sensation and contraction. This implies that hypnotherapy works through altering the brain, although the mechanisms are unknown. Peter has shown astounding results, training patients through hypnosis to either speed up or slow down their bowel function, depending on whether they have constipation or diarrhea. Hypnosis can also reduce abnormal sensation patterns in those who have a lot of abdominal pain. Patient acceptance of the technique is reasonably high, and it is extremely safe.The major problem with hypnosis is finding a practitioner who has sufficient expertise with bowel-related hypnosis. I have been impressed by these results and feel that, for people who have failed other approaches, hypnosis is an excellent alternative. More research in hypnosis is now needed to try to understand the best technique and how it may work. We are working on it!

BIOFEEDBACK If you have bad constipation, the muscles around the anus may be the problem. Here the muscles squeeze up rather than relaxing when you strain to pass a bowel motion, blocking you up. Maybe one-third of people with IBS and constipation have this problem. The neat thing is it can be corrected! If someone is ­having ­difficulty passing stools due to a problem with contracting the ­voluntary

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muscles around the anus, biofeedback provides a solution through retraining these muscles. How might you know you have a pelvic muscle problem blocking defecation? Symptoms, such as straining a lot, feeling a blockage in the anus when attempting to move your bowels, feeling incompletely emptied of stool, or feeling the need to press around the anus, point in this direction.You can be tested by a gastroenterologist or colorectal surgeon using either a simple balloon placed in the rectum to measure the pressure of these muscles (during what is called anorectal manometry studies) or a special X-ray or MRI study (called a defecating proctogram). A number of different techniques are used to teach biofeedback.27 One method involves lying on your right side facing the person who will be conducting the retraining program. A balloon is then inserted into the rectum and is filled with some air so it feels like the rectum is full. Small surface electrodes are then placed on the skin near the anus. Tracings on a TV screen (EMG or electromyogram display) that track muscle activity as you squeeze or relax the muscles around the back passage are monitored.You will then be asked to try and push out the balloon from the anus while watching the tracings. If your muscle activity increases (rather than decreases as it should) when trying to pass the balloon out, you will be asked to concentrate on that area and strain without squeezing the anal muscles closed. This may take a number of different attempts before you get used to relaxing rather than squeezing down there.You will also be taught to relax the muscles around the anal area while squeezing your abdominal muscles to pass stool, as some people do not strain adequately. Each treatment session lasts about half an hour. The length of training programs vary, but my experience is that the best results are obtained with five to ten sessions over one to two weeks. The benefits of biofeedback for people with IBS who tend toward constipation have not been very well studied, but it seems to help.28 There is no doubt, however, for people with severe constipation that does not respond to laxatives and who have excess muscle contractions that biofeedback can be very helpful. This has been tested in excellent randomized trials.29 About three-quarters of people receive help from this technique if their constipation is caused by problems with their pelvic

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muscles, but some will find this method useless. The quality of the therapist conducting the treatment is very important for the best success rate. It is worth seeking an experienced center to attempt to learn biofeedback. Home training is available once initial sessions are conducted, which seems as good as having all of the training sessions at a specialty center. For some people, biofeedback can lead to long-term improvement without the need for laxatives or other treatments. I recommend, if constipation is your main symptom, that you discuss biofeedback with your doctor. You may need a specialist for this approach, because many family doctors have limited experience with biofeedback.

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s ABC

LEARN YOUR ABCs TO GAIN CONTROL AND RELIEF

Mind-Body Connections can be beneficial (but we need more ­evidence): Art Therapy—creativity as a path to healing Biofeedback—re-learning muscle control to relieve constipation Humor Therapy—laughter is sometimes still the best medicine Hypnotherapy—good evidence, but find a good therapist Imagery—use your imagination Journaling—writing for insight Massage—a possible way to relax the pain away Pet Therapy—finding companionship and exercise Progressive Muscle Relaxation—it’s important to relax daily Psychotherapy—changing thoughts and behaviors for ­symptom relief Sleep Habits—improve your routine to improve your sleep Spirituality—find your center and find hope Yoga—an ancient practice to relieve current symptoms

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CHAPTER

5 CAN I JUST TAKE A PILL? OVER-THECOUNTER DRUGS AND HERBS The desire to take medicine is perhaps the greatest feature which distinguishes man from animals. —Sir William Osler

If you walk into any pharmacy, you can see the shelves loaded with medicines for you to try. The question is: How do you choose? There are compounds for diarrhea, others for constipation, some for gas, others for indigestion, and still more that claim to aid digestion. Let’s look at what is out there now and the evidence for any benefit in irritable bowel. There are indeed a number of useful medicines, available over the counter, that may really be helpful for short-term control of IBS symptoms, particularly during times of exacerbation. As I shared in the previous chapter, the use of over-the-counter as well as complementary and alternative medicine is increasing. I will stress again that it is important to share with your doctor if you 99

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are one of many patients who are using therapies that are not currently considered part of traditional medicine. If you choose these therapies (or any medicine), you must weigh not only whether the treatment might work, but as stated earlier, also whether it might have any adverse reactions that you really want to avoid.

DEVELOPING EFFECTIVE DRUG TREATMENTS FOR IBS As discussed in the previous chapter, all therapies, including new compounds, must be shown to have a benefit on symptoms greater than the important placebo response. The cost to the drug company to successfully bring a new drug onto the market is perhaps a billion dollars or more (the exact number is controversial and does vary but is at least 100 million dollars).The process of drug discovery, commonly known as research and development, is highly regulated by the FDA in the United States as well as other regulatory bodies worldwide. The point of all this regulation is to try and ensure that drugs found to be safe and effective are the only ones made available for purchase. Even though the process is meticulous, lengthy, and expensive, unexpected dangers can arise after a new drug is in widespread use. Out of every five thousand new compounds identified during the discovery process, only about five are considered safe for human testing. After three to six years of further clinical evaluation, only one of these compounds is likely to be approved as a marketed drug. The research-based pharmaceutical industry investment has been doubling every five years, but success in finding blockbuster drugs (new chemical compounds that are dramatically better than what is available now) has significantly slowed. Instead, “copy-cat” drugs have proliferated, adding little over what is already available. Money alone doesn’t lead to better medicines; the combination of a better understanding of disease pathways, innovative drug design, and adequate funding are all needed for success. Despite all of these innovations, studies, and dollars, problems may still occur after a new drug reaches the market. Uncommon or rare side effects may not be detected until a drug is marketed and used by many thousands of people. So sometimes new treatments cause more harm than good. A wise physician once taught me,

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when I was in training, to avoid using new drugs if alternatives are available until there is considerable experience with them. There is no such thing as a completely safe drug, unfortunately. But the same goes for drugs used by alternative therapists. It is important to understand that herbs are also drugs! You might have noticed that the same drug can be called by different names.This can be confusing.To simplify things a little, let’s just consider two types of drug names, the generic name and the trade (or brand) name.While the generic name refers to what the drug is called by the regulatory agencies (e.g., the FDA), the trade name is what name the drug company uses to market a drug. An example is omeprazole, the acid-pump blocker for heartburn. Omeprazole is marketed as Prilosec™ in the US and Losec™ elsewhere in the world (also Axorid™, Boots Avid Reflux™, Mepradec™, Zanprol™). The medical literature typically uses the generic name, not the trade name; so if you are trying to read medical papers, keep this in mind.

FIBER PRODUCTS (BULKING AGENTS) FOR CONSTIPATION There is no doubt that fiber and the fiber products available over the counter can aid constipation in IBS. Commercial fiber compounds are generally safe but are not all the same (see Table 5-1). Researchers have looked at the results of several studies that tested fiber products in IBS.1 The value of these products is controversial, although they do help constipation.1,2 I suggest trying fibercontaining products; those that are most useful are the ones that list psyllium, ispaghula, or calcium polycarbophil as their active ingredient. Psyllium is a very common fiber product. Ispaghula is the husk of psyllium and is coarser than other products. The studies give us important insights about fiber supplements in IBS. First, fiber is better than placebo for helping relieve constipation in IBS.2 Second, abdominal pain or discomfort or bloating present in people with IBS may not improve with fiber supplements. Third, soluble fiber supplements (mainly psyllium) provided the greatest benefit, while insoluble fiber (corn or wheat bran) didn’t help at all.2 Guar gum has not been tested in IBS. So, if you are choosing a fiber product, I would recommend following the evidence.

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Table 5-1. Examples of commonly used, commercially available fiber products

Product Fybogel Psyllium Celevac Methylcellulose Metamucil Psyllium Psyllium FiberCon Polycarbophil Fiberall Polycarbophil Psyllium Psyllium Citrucel Methylcellulose

Form

Fiber Content

Sachets

3.5 g/dose

Tablets

500 mg/tablet

Powder Wafers

3.4 g/dose* 3.4 g/wafer

Tablets

0.5 g/tablet

Tablets Wafers Powder

1.0 g/tablet 3.4 g/wafer 3.4 g/tsp

Powder

2.0 g/tbsp

Regular and sugar-free—one teaspoon; orange and strawberry flavor—one tablespoon.

*

From Zighelboim J, Talley NJ: Irritable bowel syndrome. Gastroenterology 1993;104:1196-201, with permission.

The benefit of fiber supplements is modest but very safe, so try a fiber supplement, especially if you are constipated. It is very important to start off with a soluble fiber supplement like psyllium and begin at a low dose (lower than it says on the pack), increasing the amount you take very slowly (every few weeks) to try to reduce any bloating or gas problems from the medication. Unfortunately, fiber can increase bloating and gas even if started in a low dose. But I encourage my patients to persist with the fiber supplement for at least four to eight weeks before giving up on the idea (the bloating often settles by then). I no longer recommend

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corn or wheat bran because these are more likely to cause gas and bloating and do not improve other symptoms. If you find fiber products helpful, then it is reasonable to continue them for life. Many patients who stop taking fiber once the benefit occurs find their symptoms do return. My clinical experience shows that reinstitution of fiber in this situation doesn’t always work as well again, although I don’t really understand why. Psyllium may cause rare side effects such as severe allergic reactions, including asthma and collapse, as well as blockage of the esophagus or intestine. The safety of using psyllium during pregnancy is unclear, and like all medications, unless advised otherwise by your doctor, it should be stopped during pregnancy, preferably before conception.

LAXATIVES TO TREAT CONSTIPATION “You have a cough? Go home tonight, eat a whole box of Ex-Lax— tomorrow you’ll be afraid to cough.” —Pearl Williams

If your major problem with IBS is constipation, then you may be confused by how many different laxatives there are. Let’s discuss the different types of laxatives, in order to understand what may be helpful. I will add, however, that evidence to justify the amount of money spent on laxatives is lacking. 1.  Stool softeners, such as Colace™, Dioctyl™, Dulcoease™, and Norgalax™ seem to help reduce hard stools by decreasing the surface tension and increasing the amount of fluid in the stool itself. Colace™ is one of the most common brands available in the United States. This compound is also used for softening wax in eardrops. Another is Surfak™. Some side effects of stool softeners are diarrhea, abdominal cramping, nausea, and skin rash. Stool softeners usually do little to help the constipation of IBS! 2. Mineral oil lubricates the stool to make it softer but usually fails to improve bowel function in IBS. It is generally safe but should not be taken routinely. There are no clinical trials of this drug class in IBS. The biggest problem with

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mineral oil is that it seems to cause leakage of small amounts of liquid stool. It can cause pneumonia and block absorption of important fat-soluble vitamins, like vitamin D, which is needed for healthy bones, and vitamin A, which is needed for vision. Even over-the-counter medicines can sometimes cause harm. 3. Osmotic laxatives draw fluid out from the lining of the bowel and increase the water volume inside the bowel. Examples include magnesium-containing laxatives like milk of magnesia. It is important for people who have any history of kidney disease or renal failure to avoid these products. Magnesium is a heavy metal that accumulates in the body if the kidneys don’t work properly. The signs of a build-up of magnesium salts are nausea, vomiting, flushing of the skin, excessive thirst, low blood pressure, drowsiness, confusion, slurred speech, double vision, weakness in the muscles, slow heart rate, and, rarely, even death. The elderly are more at risk for these toxic reactions. Magnesium must be avoided in pregnancy unless given under strict medical supervision. 4. Polyethylene glycol (PEG) is a potent osmotic laxative that has worked well in clinical trials in people with severe constipation, although few studies have been done in IBS. One brand on the market in the US is Miralax™. European brands of PEG include Movicol™, Forlax™, and Laxido™. Most trials have been short, but there is one study that tested the drug over a twenty-week period.3 PEG certainly increases bowel movements in patients with difficult to treat constipation, and I prescribe it. I find it valuable for treating IBS with constipation. 5. Sorbitol and lactulose are two other types of osmotic laxatives. Sorbitol is a sugar alcohol present in many fruits and vegetables that is prepared commercially as an artificial sweetener. It worsens feelings of gas and induces diarrhea. Lactulose is sold under the trade names Duphalac™, Chronulac™, and Kristalose™ in the US and as Duphalac™, Lactugal™, and Laevolac™ in Europe. The taste is somewhat unpleasant to many, and it occasionally induces nausea and vomiting.

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6. Stimulant laxatives work by directly stimulating the nerve endings in the colon, causing contractions and fluid release in the bowel. There are many different stimulant laxatives on the market. Some contain bisacodyl (like Gentlax™, Carter’s pills™, Dulcolax™ and Correctol™). Others have senna (like Senokot™, Perdiem Overnight™, Ex-Lax™, and Fletcher’s Castoria™). Combination laxatives are also available, such as Senokot-S™ or Peri-Colace™ (containing senna and a stool softener) and Manevac™ (senna plus psyllium). All of these stimulant laxatives can induce cramping, which is a problem. Senna products can cause occasional allergic and asthma reactions. Heavy use of senna has been linked with hepatitis. It is my opinion that most stimulant laxatives do not control constipation very well in IBS. They often wear off and can aggravate abdominal discomfort or pain. I do not generally recommend them, and they should not be taken daily for long periods. The one exception is bisacodyl (e.g., Dulcolax™): a clinical trial indicates this is helpful for constipation at a dose of 10 mg daily for a month.4 Note, however, that the trial participants were not IBS patients, and the treatment was pretty short. I suggest only taking this medicine for short periods and include treatment holidays (that is, scheduling weeks off of therapy). 7. Castor oil is another example of a stimulant laxative, which was once widely used by mothers to “regulate” their children’s bowels (what a disaster—some children may have developed bowel problems they otherwise would never have had). 8. Phenolphthalein and the anthraquinones are two more stimulant laxatives. Phenolphthalein has been removed from the US market because of concerns of long-term bowel damage and studies in rats and mice that link it to cancer, but it is still available in some countries as a laxative. Anthraquinones can actually make the colon look blackish, as seen in a colonoscopy, but this is not thought to be a problem. Stimulant laxatives have not been properly studied in IBS.

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How can you choose the right laxative? First, consider that they have only very modest benefits, and any help is temporary.They are not addictive, but any benefit in IBS is usually small. The second thing to think about is the lack of evidence that they really work in IBS. However, for constipation problems they can be of help and many people do try them. It is generally recommended to start with an osmotic laxative. If this fails, you could then try a stimulant laxative like bisacodyl alone (check the medicine name on the bottle or packet to see if your laxative has this drug in it and not other drugs too). These laxative drugs generally appear to be safe if not used all the time, but you need to discuss the type of laxative to use with your physician before embarking on the life-long use of this or any other type of treatment. Alternative treatments exist for constipation, such as biofeedback. These therapies might help you (see Chapter 4), so do see your doctor.

ENEMAS AND SUPPOSITORIES FOR CONSTIPATION Many patients (particularly men, it seems) do not like the idea of inserting anything into the anus to help with defecation. If there is a problem, however, particularly with feelings of a blockage in this area and excessive straining, sometimes the use of enemas or suppositories can be beneficial for short-term relief. Keep in mind there are often better alternatives. For example, if there is a problem with the muscles around the anal area blocking defecation, they can be retrained with biofeedback. This is an important idea to consider with your doctor and is described in the previous chapter of this book.

WHAT WILL STOP DIARRHEA? Over the counter, there are a number of different drugs sold to help diarrhea. Here, we have good evidence of what truly works. Loperamide, sold as Imodium AD™, Imodium Advanced™, or Imodium Plus™, is a type of opiate compound, but since it does not cross into the brain it has none of the euphoric effects seen with ­opiates used on the street. It is not addictive. Well-done,

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r­ andomized, placebo-controlled trials have tested this agent in IBS. They have reported good results for the diarrhea, but the abdominal pain and bloating of IBS do not improve on the drug. Loperamide slows the speed of material moving through the intestine and reduces the movement of water and salt in the bowel. So in a sense it plugs you up temporarily. You can also consider this drug if you suffer from urgency or occasional leakage of stool, because it tightens up the anal muscles. Its main problem is that it tends to cause constipation. This can be a real issue in IBS, because constipation can be as troubling as diarrhea for the person who develops it. Rarely, allergic reaction to loperamide can occur, but generally this is a very safe drug. So how should you use it? If you follow the package instructions on the use of this drug, it actually won’t work terribly well for IBS diarrhea. You should not wait to take the medication until after you have had your first episode of diarrhea. It is much better, particularly if your diarrhea is reasonably predictable, to use it as a preventative measure. For example, if your diarrhea usually happens after breakfast or after a meal, or when you are likely to become particularly stressed, then take a dose of Imodium™ before the event. This can be really helpful! Alternatively, I often tell patients to take this first thing in the morning upon waking, to prevent the morning-rush diarrhea.You can also take it at night before bed if you are disturbed during the night with diarrhea. It takes a little bit of trial and error in terms of learning how best to use it. Some people need quite a high dose of the drug for it to work well. Guidance by your doctor is critical. Loperamide is a very good drug for diarrhea in IBS. If you have this problem, consider trying it. Another drug that is often tried for diarrhea in IBS is diphenoxylate or Lomotil ™ or Co-phenotrope™.This is actually a combination of two different drugs, namely diphenoxylate and atropine. The atropine is to deter people from taking too much of the diphenoxylate which can cause a “high.”   The FDA-labeled indication for this drug is diarrhea, not IBS. No studies of this drug in IBS have been reported, although in my experience it does seem to help some people. Side effects include dizziness, drowsiness, tiredness, nausea, vomiting, and abdominal pain. Rare but serious allergic reactions have been reported, including dilation of the colon and inflammation of the pancreas.

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Despite the lack of strong evidence, another drug that could be useful in IBS is bismuth subsalicylate (e.g. Pepto-Bismol™). This drug is often used for the prevention of traveler’s diarrhea, nonspecific diarrhea, and indigestion. Some people experience major improvement when they take this for IBS and diarrhea. Bismuth’s antibacterial and anti-inflammatory properties may in theory improve the inflammation of IBS, although this is not proven. Bismuth makes your stools go black which is harmless, but doctors may be concerned since black stools also occur if you bleed into your stomach (so tell your doctor if you are taking bismuth). The main problem with this therapy is that since bismuth is a heavy metal, it can potentially cause brain damage if used in high doses for a long time. There have been links between encephalopathy, a brain disease, and heavy usage of bismuth. So, it must be taken as a short-term medication only. However, if you have IBS symptoms only for a few weeks and then are symptom free for long periods, a trial of bismuth might be worthwhile. Before you take it for any length of time, definitely consult your doctor.

DRUGS FOR GAS AND BLOATING Although gas is a major challenge in the management of IBS and there is no shortage of over-the-counter, anti-gas products available, there are few truly useful agents for this particular problem. The two over-the-counter products I will mention here are: simethicone and activated charcoal. Simethicone doesn’t reduce gas at all but acts as an anti-bubbling agent. By reducing gas-­bubble surface tension, simethicone allows bigger bubbles to form. The hope is gas will then pass easily (unfortunately hope and science often don’t mix well). Usually available in capsules of simethicone or as a chewable tablet in combination with an antacid, some of these products include: Gas-X™, Mylanta Gas™, and Phazyme™. In the UK, simethicone is available as Infacol™ and WIND EZE™, and in the Nordic countries as Miniform™. Take two to four tablets or doses half an hour before meals. Simethicone is not absorbed so is generally very safe, but there are

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reports that simethicone-­containing products may cause diarrhea, nausea, vomiting, headaches, and, rarely, a rash. I’m afraid I am not impressed with how it works for gas in IBS. The other gas-reducing drug I will mention is activated charcoal (e.g., Charco Caps™, Charcoal Plus™, and in the UK Carbomix™ and Actidose-Aqua Advance™). It is used as an anti-gas agent, but the evidence that this is beneficial is even often less than simethicone in IBS. Because charcoal can occasionally cause a blockage in the bowel, which is serious, I don’t generally recommend it to help with anti-gas problems. What else can you do? A probiotic can help (see later in this chapter). And a prescription medicine discussed in Chapter 6 (a non-absorbed antibiotic) is also promising. Also, if constipation is a problem, treating it can help with the bloating feelings.

ANTACIDS Many antacids are available, and may sometimes help with gas and indigestion in IBS. On the one hand, magnesium-containing antacids can also help with constipation, since they tend to cause diarrhea. Aluminum-containing antacids, on the other hand, are constipating, so try these if your problem is diarrhea. Remember, most antacids mix magnesium and aluminum products to try and prevent diarrhea or constipation! Short-term use of antacids is generally safe, but regular, heavy use should be discussed with your doctor.

ACID-REDUCING DRUGS Antacids neutralize acid but don’t stop acid production by the stomach. Acid-reducing drugs stop the stomach from making acid for part of the day and are more effective than antacids. Two different classes of acid-reducing drugs are available over the counter: (1) the histamine receptor antagonists and (2) the proton pump inhibitors. Although the names sound technical, I wanted to share them with you because these drugs are very popular and seem to be marketed everywhere you go.

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First, the histamine receptor agonists include many different drugs, such as ranitidine (Zantac™) or cimetidine (Tagamet™) or famotidine (Pepcid™). They help reduce acid secretion and relieve indigestion symptoms associated with IBS, particularly heartburn.They work pretty promptly and are most useful for occasional heartburn.The doses sold over the counter are relatively low. If this type of drug is helpful, you might discuss with your doctor trying a higher prescription dose. Some people who take acid-suppressing drugs report that their bowel symptoms also improve.Whether this is just a placebo response or not is unknown; there are no proper trials of these agents in IBS. Side effects with the histamine antagonists are infrequent, but diarrhea, dizziness, tiredness, headache, and rashes can occur. Very rare adverse events include liver damage, blood disorders, inflammation in the pancreas, heart disorders, as well as the development of a small amount of breast tissue in men. Long-term follow-up of patients taking this type of drug shows they are remarkably safe and can generally be used with real confidence. The second type of acid-suppressing drug seems much more potent. These are the proton pump inhibitors (PPIs for short). Some are available only by prescription, but omeprazole (Prilosec™ in the United States or Losec™ elsewhere, as well as under the brand names Axorid™, Boots Avid Reflux™, Mepradec™, and Zanprol™) is now available over the counter in the United States. Omeprazole blocks the release of acid into the stomach. This class of agents is excellent for control of heartburn, although not everyone will experience relief. Take it on an empty stomach thirty minutes before a meal for maximum effect. Zegrid™ combines omeprazole with an antacid for faster heartburn relief. Another example of a PPI available over the counter is lansoprazole (Prevacid™ and Zoton Fast Tab™ or as lansoprazole generics in the UK). Again, the over-the-counter dose is lower than the prescription dose, so it is less effective. As observed with the histamine receptor blockers, some people with IBS report that their bowel symptoms improve with omeprazole and other similar drugs. Again, whether this is a placebo response is unknown.The drug class is generally very safe; however, a few people get abdominal pain with PPIs, which is obviously a disadvantage. Headaches can occur. Although it is rare, serious skin rashes or blood count problems have also been reported.

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LICORICE FOR PAIN AND CONSTIPATION Licorice is available in sweets, soft drinks, and chewing tobacco. It is also used in cough mixtures. It comes in different types and is made from dried plants, including Spanish, Russian, and Persian varieties. Licorice reduces inflammation and works as an antispasmodic and laxative. Although there are no randomized trials using it in IBS, licorice sometimes seems to help. Interestingly, licorice has a history of healing of peptic ulcer disease, although now peptic ulcer disease is treated most effectively with antibiotics (because ulcers are commonly caused by a type of bacteria in the stomach). There are some significant side effects to be aware of, if licorice is taken in large doses. Licorice can increase fluid retention, which affects some people with heart conditions. It can also cause muscle weakness, headaches, as well as missed menstrual periods.Again talk to your doctor if you have any concerns.

PEPPERMINT OIL FOR ABDOMINAL PAIN Obtained from a flower (Mentha X Piperita L.), the active ingredient in peppermint oil is menthol. A review of the studies testing peppermint oil in IBS showed mixed results.5 Overall, there was a benefit of peppermint oil over placebo, although the studies were not rigorous enough to provide strong support for this conclusion. A study looking at a larger number of patients would help us know if peppermint oil benefits people with IBS. Peppermint oil is worth a try for the abdominal pain and cramps of IBS. The usual dose is 0.2 milliliters three times a day taken onehalf to one hour before eating and swallowed whole, not chewed. Do not take peppermint oil with alcohol as this can increase side effects. A number of uncommon reactions have been reported with peppermint oil including red skin rashes, headaches, a slow heart rate, tremors in the muscle, and a feeling of severe unsteadiness. Increased symptoms of heartburn, worsened asthma, and an irregular heartbeat due to atrial fibrillation have also been reported with peppermint ingestion. It is not a treatment without any risk. Peppermint oil is available in the UK under the brands Colpermin™ and Mintec™.

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MELATONIN FOR PAIN AND MAYBE BETTER SLEEP Melatonin is a hormone produced in the brain but is also produced in the bowel. Our body uses melatonin to regulate sleep (so travelers take it to try and avoid jet lag with variable benefits). It also reduces pain and inflammation. Clinical trials of melatonin in IBS suggest that at a dose of 3 milligrams per day, it can reduce symptoms without disturbing sleep.6 These are fascinating observations, but the exact benefits in IBS have yet to be fully documented. Melatonin is generally considered safe but I recommend taking it for no more than a few weeks to reset your internal sleep clock. It can make you sleepy, dizzy or depressed. I do prescribe melatonin for my patients’ pain or poor sleep, and it can be helpful.

HOMEOPATHY There are some ideas so wrong that only a very intelligent person could believe in them. —George Orwell

Do tiny doses of herbs or chemicals help cure disease? Homeopaths give highly diluted mixtures of such products to their patients (so tiny they don’t change function in the body, it is assumed). The theory is: substances capable of producing a disease in a healthy individual can remove the problem if given to a sick person, so, the more you dilute, the theory goes, the better the result. Most homeopathic solutions are so diluted there is no herb or chemical left in it. What nonsense therapy! The studies say this approach just doesn’t work (and why should it—if you don’t alter function nothing happens). In 2010, the British House of Commons science and technology committee concluded that homeopathy was no better than a placebo. The American magician and sceptic James Randi was so incensed that he offered $1 million to whoever could prove that homeopathy works. This was put to the test on a TV show in the UK in 2002, overseen by scientists from the Royal Society—Randi got to keep his money! Homeopathy is a great example of placebo therapy hoodwinking people (even those who practice it).

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The great bulk of evidence available indicates it is useless. In my opinion, don’t waste your money on it.

PROBIOTICS FOR BLOATING AND DIARRHEA We all have bacteria living in our bowels—and loads of them. Changing those bacteria might help IBS. It has been theorized that by changing the gas-producing bacteria, symptoms of diarrhea and bloating would be relieved. By removing or replacing the bacteria—presto!—the gas is gone. To actually achieve this, though, is difficult. Probiotics are live or dead bacteria taken in the hope of changing the bacteria in the bowel for the better.There is a lot of interest and research in this area to understand the role of these products. You can buy lots of different probiotics at the health food store or pharmacy, but what really works in IBS is much less certain. There are many factors that could affect the benefits of this treatment, such as whether the bacteria in probiotics are alive or dead, the number of bacteria, the mix of bacteria and how the bacteria are delivered. Due to some promising early results, probiotics have become popular for IBS.7 One product with a good profile, called Align™, contains good bacteria called Bifido (Bifidobacterium infantis to be specific). Remember, not everyone responds to it (many don’t!). So I suggest giving it at trial for a month. If you feel no better, don’t waste your money. There are many probiotics on the pharmacy shelf. Using the principles of evidence-based medicine discussed in this book can help you know how to examine the evidence very carefully regarding the possible benefits of probiotics in IBS.

HERBAL PRODUCTS AND SUPPLEMENTS No herb ever cured anything, it is only said to cure something. This is always based on the testimony of somebody called Cuthbert who died in 1678. No one ever says what he died of. —Miles Kington

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Many different herbal products are recommended by various ­practitioners of alternative medicine for people with IBS-type symptoms, but for the most part evidence about whether these products work remains extremely limited. Another thing to consider is that among the many preparations labeled as one kind of herb, there may be differences among manufacturers in purity and strength. This makes for an inconsistent dose and leads to difficulties with comparisons and studies. However, there is some evidence that at least some of these treatments do help. Digestive enzymes include papaya extract, lactase, ox bile extract, and by prescription, pancreatic enzymes. These are often taken by people with IBS. There are testimonials that some of these types of treatments work, but there is no decent evidence that, in fact, they are better than placebo. It can be worth trying pancreatic enzymes if you have a lot of diarrhea. One small trial shows a digestive enzyme called pancrealipase can work but more evidence is needed.8 A few people with IBS and diarrhea can respond to pancreatic enzymes like Creon.9 These are taken with meals. But if they work, this might mean you have a problem with the pancreas itself. You should then see a physician for an evaluation. Better treatments are available to treat a pancreas problem. At this stage, digestive enzymes are of unproven benefit. An Ayurvedic preparation (containing Aegle marmelos correa plus Bacopa monniera Linn) was tested in one study. Here, the preparation seemed to be better than placebo in IBS even though no other studies are available.10 This work was done in India and has yet to be repeated elsewhere to confirm the results. Ayurvedic medicine is of uncertain help with very little research to back up claims of a benefit (I remain very skeptical). Ginger and Aloe vera are actually marketed to treat IBS in some places, but there is absolutely no controlled-trial evidence that they work for IBS symptoms. Similar compounds that have been investigated by small, uncontrolled studies include: artichoke leaf extract, changjitai, bitter candytuft (Iberis amara), and Padma Lax.11 These studies have suggested some possible benefit for IBS. However, I am concerned that there is a lack of convincing evidence, while the potential toxicity of many of these preparations remains unclear.

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There also is really no evidence that vitamins help IBS. In fact, vitamins seem to be helpful only for vitamin deficiency due to a very poor diet; I don’t like to take vitamins in large doses because of possible toxicity.

CHINESE HERBAL MEDICINE A more promising treatment for IBS has come from traditional Chinese herbal medicine. Along with Dr. Allan Bensoussan in ­Sydney, an expert in Chinese herbal medicine, I conducted a proper double-blind, randomized, placebo-controlled trial in patients with IBS in Sydney, Australia, to test the effectiveness of different Chinese herbs.12 As a part of good study design, we encapsulated the herbs in pills so that neither the herbalist nor the patient knew who was assigned to the different groups. One group received placebo herbs. Another group got standard doses of the herb combination we chose. A third group got individualized doses of the herbs (based on the herbalists recommendations), in identical capsules (Figure 5-1). All capsules were prepared by a third party who had not met the patient (so we could keep everyone blinded until the end of the study). We used twenty different herbs, all of which were considered by the experts in Chinese herbal medicine to add value in the treatment of the IBS-symptom complex. These herbs included all sorts of different substances. The list of the different herbs included in our formulation is provided in Table 5-2. I was a skeptic (good scientists are taught to be open-minded skeptics); I believed that such a combination would not work in IBS, but I was wrong.12 While patients rated the placebo as effective only about a third of the time, both the standard and individualized herbal therapies provided improvement for two-thirds to three-quarters of patients, significantly better than the placebo. Even fourteen weeks after the completion of the study, two-thirds or more of those who received Chinese herbal medicine still felt improved compared with only one-third who took the placebo. We published the results of our study in the Journal of the American Medical Association. Of course, one positive trial does not prove anything. However, this is possibly the best Chinese herbal medicine trial that has been done to date. The challenge remains to identify the key

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Chinese herbal medicine and IBS

Randomized double-blind

116 Patients with IBS

5 capsules 3 times a day for 16 weeks

Individualized Chinese herbs (N = 38)

Standard Chinese herbs (N = 43)

Placebo (N = 35)

64% improved ∗

76% improved ∗

33% improved (patient rating)

75% better ∗

63% better ∗

32% better 14 weeks post trial

Figure 5-1. Chinese herbal medicine and irritable bowel syndrome (IBS). Asterisk (*) denotes a statistically significant result. Reproduced with permission from Bensoussan et al.

.

c­ omponents of this complex herbal formula that really may be benefiting patients. Future studies are needed to understand any possible toxicities, although no serious side effects occurred during this trial. It is too soon to widely recommend Chinese herbal medicine for IBS, but it is something to consider. If you do seek such care, discuss it with a qualified herbalist. Finding such a person who

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Table 5-2. Chinese herbal medicine standard formula (capsule ­ingredients)

Chinese Name

Pharmaceutical Name

Dang Shen Huo Xiang

Codonopsis pilosulae, radix Agastaches seu pogostemi, herba Ledebouriellae sesloidis, radix Coicis lachryma-jobi Bupleurum chinense Artemesiae capillaris, herba Atactylodis macrocephalae, rhizoma Magnoliae officinalis, cortex Citri reticulatae, pericarpium Zingiberis offinicinalis, rhizoma Fraxini, cortex Poriae cocos, sclerotium (Hoelen) Angelicae dahuricae, radix Plantaginis Phellodendri, cortex Glycyrrhizae uralensis, radix Paeoniae lactiflorae, radix Saussureae seu vladimirae, radix Coptidis, rhizoma Schisandrae, fructus

Fang Feng Yi Yi Ren Chai Hu Yin Chen Bai Zhu Hou Po Chen Pi Pao Jiang Qin Pi Fu Ling Bai Zhi Che Qian Zi Huang Bai Zhi Gan Cao Bai Shao Mu Xiang Huang Lian Wu Wei Zi

Powdered Herb (%) 7 4.5 3 7 4.5 13 9 4.5 3 4.5 4.5 4.5 2 4.5 4.5 4.5 3 3 3 7

From Bensoussan A, Talley NJ et al. “Treatment of irritable bowel syndrome with Chinese herbalmedicine” JAMA 280:1586. Copyright © 1998, American Medical Association. All rights reserved. Used with permission.

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has the training and expertise to possibly help you safely might be difficult. I personally don’t recommend Chinese herbal medicine for my patients with IBS yet, although I will discuss the results of this study with them and consider the option if they are strongly interested. I always emphasize that there may be serious side effects from Chinese herbs (like any drug). I also tell my patients that any benefits shown in this trial may not apply to them individually.

SIDE EFFECTS VERSUS ALLERGIES: HOW CAN I TELL? Even over-the-counter medicines have side effects, including rare but serious side effects. Any drug can cause a reaction.This may not necessarily be due to an allergy to the drug. Many side effects occur because of the way the drug works in the body. For example, a drug that stimulates the bowel to move material through it more quickly (namely, a stimulant laxative) will obviously cause diarrhea in some people as well as excessive cramps (from the increased abdominal contractions). To conclude that such side effects are allergic reactions to the stimulant laxative would be wrong; in this case the side effects are just to be expected! If you experience side effects like this, you may consider reducing the dose or changing to a different drug of the same type. Of course, any drug can also cause rare allergic reactions. Rashes, breathing problems, collapse, or swelling of the body may be evidence of a true drug allergy. In this situation, you should never be exposed to the compound again.

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s ABC

LEARN YOUR ABCs TO GAIN CONTROL AND RELIEF

iNcrease fiber—but slowly using a fiber supplement with psyllium. Over the counter (OTC) medications for IBS: Treat constipation with: osmotic laxatives first; if this fails then a stimulant laxative (e.g. bisacodyl) or licorice. Treat diarrhea with: Loperamide (before it happens if needed every day); or Lomotil™ or Co-phenotrope™; or try PeptoBismol™ (but not every day). Treat gas and bloating with: Simethicone or a probiotic (charcoal probably doesn’t help much). Treat heartburn with: antacids; acid reducers; such as ranitidine (Zantac™); or omeprazole (Prilosec™, Losec™, Axorid™, Boots Avid Reflux™, Mepradec™, Zanprol™) or similar medicines OTC. Treat IBS-related abdominal pain with: peppermint oil or try melatonin. Probiotics—a highly promising therapy for IBS including bloating but many brands won’t help. Qin Pi and other Chinese herbs—another up-and-coming therapy for IBS, but more evidence is needed.

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Chapter

6 PRESCRIPTION DRUG TREATMENTS FOR IBS—EVIDENCE FOR WHAT WORKS! I do not think that my GI doctor understands the severity of my condition… He has referred to my condition as “uncomfortable” and “annoying,” understatements to say the least. —An IBS sufferer

In a chapter devoted to prescription medications, remember that we are comparing the drug’s effectiveness to a placebo treatment. We have previously mentioned that the placebo (or “sugar pill”) can provide relief of IBS symptoms for one or even two in five people. Some clinical trials show up to seven in ten people with IBS receive some benefit when given a dummy (or placebo) treatment.1 (See Image 6-1, an artist’s rendering of IBS discomfort.) The evidence about prescription drugs for IBS might surprise you. Many of the treatments commonly prescribed by

121

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Image 6-1. Hour by Hour from the International Foundation for Functional Gastronintestinal Disorders (IFFGD) Art of IBS Collection. Used with permission from the IFFGD (© 2012 IFFGD).

doctors have limited or no evidence that they actually work better than a placebo. There are, however, newer drugs released for IBS with stronger evidence from clinical studies for their effectiveness. When you consider using a prescription drug, you also need to know that most drugs have side effects that can be worrying. For most people, side effects are mild if they occur at all, but any drug acting in one area of the body will also affect other systems in the body. Occasionally this leads to serious problems, including, although certainly rare, death. This is where doctors and patients need to weigh the potential benefits of a treatment versus the risks. It is clear that if a drug has no benefit and yet possesses a potentially serious risk, then it shouldn’t be used. However, if the drug is particularly effective but there are still serious side effects that occasionally occur, the decision to use it is much more difficult. This is always a personal decision.Your physician can guide you through the problem. If the drug will improve your quality of life substantially, then it may be worth taking the risk of a serious side effect.

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PRESCRIPTION TREATMENTS FOR CONSTIPATION In the previous chapter, we discussed several laxatives available without a prescription. Here are some options to treat constipation when over-the-counter treatments are not enough. 1.  Linaclotide is an interesting new drug that has only very recently been approved by the US FDA for treatment of IBS.. It works inside the bowel without being absorbed into the body. This is a very safe way to deliver a medicine. The drug increases fluid in the bowel, lubricating the waste products and allowing them to wash through cleanly. It also improves pain and bloating by reducing nerve signals. The drug appears very safe so far, and it definitely helps patients with constipation, whether or not they have IBS. For example, clinical trials have been published in the New England Journal of Medicine showing a clear benefit over dummy pills.2,3 Some people do not respond to the drug, however. We are all individuals in terms of how a certain drug may be of benefit or not. So, if you have constipation and find that laxatives are not working, this is a reasonable next choice. The drug has now been approved in the United States for treatment of IBS and chronic constipation. 2. Another option for constipation is lubiprostone. It also stimulates the release of fluid into the bowel, although it works differently than linaclotide. Although the drug beats placebo in clinical trials, it can cause nausea (so take it with a meal to try and avoid the problem).4 This drug does not work for the majority of people, but it is worth a try if other treatments for constipation have not been successful. 3. Prucalopride (Resolor™) is a really strong drug that increases muscle movements (peristalsis) in the bowel (Figure 6-1). The drug also acts on a serotonin receptor, so this drug works if you have bad constipation. It is available for constipation in Europe, Australasia, and Mexico but not yet in the United States. Although it has not been tested in IBS,

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124   Conquering Irritable Bowel Disease Control of peristalsis (bowel contractions) Top

Bottom Increased movement of content Neurons in the myenteric plexus

Motor neurons (cause contraction by releasing acetylcholine)

Motor neurons (cause relaxation by releasing nitric oxide)

5-HT (serotonin)

Food stroking the bowel causes enterochromaffin cells to release 5-HT to the nerves

5-HT4 receptor (stimulated by tegaserod) 5-HT1p receptor

Figure 6-1. Tegaserod stimulates bowel peristalsis by stimulating serotonin receptor type 4 (5-HT4). Note the intricate circuits in the nerves that control the bowel. From Grider JR, et al. 5-Hydroxytryptamine 4 receptor agonists initiate the peristaltic reflex in human, rat, and guinea pig intestine. Gastroenterology 1998;115:370-80; MedReviews, LLC; and Gershon MD. Serotonin and its implications for the management of irritable bowel syndrome. Reviews in Gastroenterology Disorders 2003; 3(Suppl 2):S25-34, a copyrighted publication of MedReviews, LLC. Adapted with permission from the American Gastroenterological Association (Grider et al.) and MedReviews, LLC.

some doctors are prescribing it for IBS with constipation. It seems to help and does not appear to have heart or other major side effects. It can cause diarrhea, pain, headaches, or nausea.

AN ANTIBIOTIC FOR IBS As we discussed with probiotics, one way to treat IBS may involve changing the bacteria present inside the bowel. Antibiotics change bacteria in the bowel, at least for a short time. But normal antibiotics, which are designed to enter the bloodstream through the bowel, usually don’t help IBS and often cause diarrhea themselves. A special class of antibiotic designed to stay in the bowel has been developed, but at this time it is not FDA approved. In the near future, it will likely have a role in the treatment of IBS.

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Randomized trials have shown that people with IBS and looser stools can respond to the antibiotic called rifaximin (Xifaxin™, Xifaxanta™ [UK]).5 The neat part is almost all of this antibiotic stays in the intestine and is not absorbed, so it seems pretty safe. But, remember, no drug or chemical is ever totally safe. A study published in the prestigious New England Journal of Medicine reported that rifaximin was better than placebo for IBS with diarrhea. The antibiotic definitely beat placebo, but not everyone got better. On placebo, one in three people got better while on the antibiotic two in five got better (so more on the antibiotic had a good result, but not everyone).5 The benefit can last for months, but for most people, symptoms will eventually return. It seems a repeat course of the drug might help, too.6 We don’t know if the treatment eventually stops working. Some people with constipation and IBS might also benefit from Xifaxin™, but this needs to be studied. If a gas called methane, produced by the bacteria living in the large bowel, causes their constipation by slowing the muscle movements of the bowel, then this antibiotic could reduce the methane-producing bacteria and relieve their symptoms. This is an emerging area, and gut bacteria are complex, so it may take more than one medicine to make a difference.7 This is an area to watch. While Xifaxin™ seems safe short term, taking antibiotics long term is not practical in most situations. Right now, using Xifaxin™ to treat IBS is considered “off label.” In other words, a doctor can prescribe it, but there is no official indication for its use in IBS, by the FDA or other regulatory agencies. But if you have bad diarrhea or bloating from IBS, it might help.

PRESCRIPTION DRUGS FOR DIARRHEA IN IBS We considered over-the-counter treatments for diarrhea in the previous chapter. Let’s take a look at therapies available by ­prescription. 1.  Cholestyramine (Questran™) or colestipol (Colestid™) is used to lower cholesterol, but may also help with diarrhea. Evidence shows that some people with IBS do not absorb bile salts, causing diarrhea.8 Cholestyramine or colestipol can clean up these bile salts and help relieve diarrhea. For people with troublesome IBS and diarrhea who have not

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benefited from over-the-counter medicines like loperamide this might be helpful. I usually prescribe colestipol as this is well tolerated. 2. In the United States, alosetron (or Lotronex™) is available for women with severe diarrhea-type IBS (Figure 6-2). However, if your bowel pattern switches between diarrhea and constipation or if you are constipated, then you should absolutely never take this drug. It has excellent benefits for IBS and diarrhea, improving wellbeing,1,9 but it can have serious side effects. Constipation is common. But in about one out of a thousand patients, serious complications can occur. These include difficulties due to constipation as well as a problem with the colon’s blood supply, called ischemic colitis, causing diarrhea and bleeding. Here, the risk-to-benefit ratio has to be carefully weighed by you

Alosetron (5HT3 antagonist) in diarrhea-IBS (all females) Percentage with relief

70 60 *

50 40

*

Alosetron * * *

*

*

7

8

*

*

*

*

*p < .05

* Placebo

30 20 10 0

1

2

3

4

5

6

9 10 11 12 +1 +2 +3 +4

12 weeks treatment

4 weeks follow-up

Figure 6-2. Results of a randomized, double-blind, placebo-controlled trial of alosetron beat placebo in this study. (P < 0.05 means a statistically significant result.) From Camilleri M, Northcutt AR, Kong S, et al. Efficacy and safety of alosetron in women with irritable bowel syndrome: a randomized, placebo-controlled trial. Lancet 2000;355:1035-40. Used with permission from Lancet.

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and your physician. Other reports suggest that people with IBS develop ischemic colitis more often anyway than people not suffering with IBS (the risk is two to four times higher but it is still rare).10 However, Lotronex™ clearly increases the risk of this problem. People on this drug need to be monitored by their doctor regularly. Lotronex™ is definitely useful for women with very severe IBS and diarrhea; but for now the drug is limited to them by the FDA, although evidence supports a benefit in men too.11

AVOID NARCOTICS FOR IBS—THEY CAN MAKE YOU WORSE Powerful pain killers (narcotics) like morphine or fentanyl can make you worse over time as well as block up your bowel. Another drug to avoid is codeine phosphate, on prescription only. The problem with codeine is that while it works clinically, it unfortunately can lead to dependence and can even end up worsening IBS symptoms.Therefore, it cannot generally be ­recommended.

PRESCRIPTION TREATMENT FOR ABDOMINAL PAIN IN IBS: ANTISPASMODICS Despite limited evidence, many doctors prescribe medicines called anti-spasmodics in the hope of reducing muscle spasms of the bowel that might occur in some people with IBS. In the United States, only a few of these drugs are available, all containing hyoscyamine or dicyclomine. Their trade names are listed in Table 6-1. In Europe and other parts of the world, other antispasmodic agents are available. Only a few trials of these medications have been published.1 A couple of studies showed no significant benefit of the drug over placebo, but one study showed IBS symptoms improved with a high dose of an anti-spasmodic compared with the placebo. Overall though, it seems anti-spasm drugs do provide a small improvement in both overall symptoms and abdominal pain in IBS.12

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Table 6-1. Some Antispasmodics for IBS

Medication Trade Name Alverine Spasmonal™ ­citrate Hyoscine Buscopan™ Hyoscyamine Levsin™ Levsinex™ Mebeverine Otilonium bromide Tincture of Belladonna drops Dicyclomine

Colofac Spasmoctyl™

Form Capsules

1.1 mL = 2 drops Bentyl™

Mintec, ­Colpermin

60 mg and 120 mg 10 mg 0.125–2.5 mg*

Tablet Tablet, elixir, drop Timed-release 1–2 tablets capsule twice daily Tablet 135 mg Tablet 40 mg

Tablet, capsule, and syrup Pro-Banthine Propantheline™ Tablet Peppermint oil

Dose

Capsules

0.2–0.75 mL*

20–40 mg*

7.5 and 15 mg, 1 per day* 0.2 mL

*Before meals and at bedtime. From Zighelboim J, Talley NJ: Irritable bowel syndrome. Gastroenterology 1993;104:1196–201. Used with permission.

Older drugs such as mebeverine and trimebutine are not available in the United States but are in Europe and Australasia.You might ask why these drugs are not available. Well, it seems that marketing forces are at work.The road to drug approval by the FDA is long and expensive. Since these drugs can be made in generic form, pharmaceutical companies do not see them as potential moneymakers. It seems a shame not to have access to medication that is relatively safe, available elsewhere, and is at least somewhat beneficial in IBS. Only political action in the US could change this situation, although the lobbying forces against such action would likely be considerable.

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PRESCRIPTION TREATMENT OF ABDOMINAL PAIN IN IBS: ANTIDEPRESSANTS Many patients become very frightened or upset when their physician suggests they should try an antidepressant medication for their IBS symptoms. However, you should not feel this way! Regardless of whether or not you are depressed, these drugs appear useful to treat IBS, but not because they work for depression. Instead, antidepressants do work in the brain and the intestine, reducing pain signals from the bowel.13 Different types of antidepressants are available. The tricyclic antidepressants, which are older agents, seem to provide the most of benefit for IBS. They are listed in Table 6-2. For example, sixty percent of people taking the tricyclic antidepressant desipramine (Norpramin™) obtained a benefit compared with forty-seven percent on placebo.

Table 6-2. Antidepressants that may be prescribed for IBS*

Generic Name

Trade Name

Usual Daily Dose (mg)

Amitriptyline Desipramine Doxepin Imipramine Nortriptyline Trazodone

Elavil™, generics Norpramin™ Sinequan™, Sinepin™ Tofranil™ Aventyl™, Pamelor™ Desyrel™, generics

Fluoxetine Citalopram Escitalopram

Prozac™ Celexa™, Cipramil Lexapro™, Cipralex

25–75 25–75 25–75 25–75 25–75 100–150 (in divided doses) 20–40 (once daily) 20 (once daily) 10 (once daily)

*Adapted from Zighelboim J, Talley NJ: Irritable bowel syndrome. Gastroenterology 1993;104:1196–201. Used with permission.

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Treatment of IBS symptoms requires a much lower dose than what is usually needed to treat depression. The drug might work by a different pathway in IBS.These drugs take time to work. Consider at least one month for the treatment before it is stopped. Taking the medication for just a few days is not adequate. It takes time for the agent to have its effects on the body’s chemicals. The problem with the tricyclic antidepressants is the potentially serious side effects associated with all of them. Most physicians use this type of drug for someone with moderate or severe IBS after attempting other treatments. The benefits may then outweigh the risks of therapy. Many of my patients who have taken antidepressants for IBS have done very well, although not all of them. You must discuss taking an antidepressant carefully with your doctor. But if your symptoms severely affect your quality of life, then it is worth considering. Some newer antidepressants are also of benefit in IBS, and they can also have fewer side effects. These are the selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac™).14 Several different SSRIs are currently available. If one type of antidepressant doesn’t work, another type may help. Here again, a physician with expertise in these medications can be helpful for people with troublesome IBS. The individual response to different agents varies enormously (probably in part for genetic reasons), so you might find there is some trial and error required to determine the best one for you. The antidepressants do not lead to addiction or dependence. A number of herbs have been tested in depression, such as St. John’s wort.15 St. John’s Wort turned out to be just a placebo in IBS—in other words, it doesn’t work!16

ANTI-ANXIETY DRUGS HELP ANXIETY, BUT NOT IBS Some people try to reduce anxiety associated with their IBS by trying anti-anxiety medications (like diazepam—Valium™ [US], Diazemuls™ [UK]). This can be useful for very short-term treatment of the anxiety, but they probably don’t help IBS. They can also cause significant side effects including problems with sleep, as well as dependency and, therefore, are not recommended. Kava15 is

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from a plant and is used in a traditional drink in the South Pacific. It can help anxiety in the short term but again there are no studies in IBS. Non-drug methods are helpful in reducing anxiety. These are worth trying.

THE FUTURE I never think of the future. It comes soon enough. —Albert Einstein

Research is ongoing in IBS, but more is needed. The National Institutes of Health in the United States now recognizes IBS as an important problem, although more funding is essential. Just as you can walk more than one path to reach the top of a mountain, we need to find all the paths that lead to IBS to cure it (and a single path is unlikely). For example, if we find that inflammation and excess bacteria are major causes of IBS symptoms, then attacking these problems together will probably lead to long-term benefits. We also may find it possible to prevent the development of IBS following a gastrointestinal infection in the very near future. Many compounds come and go without ever reaching clinical practice, either because of toxicity or a lack of benefit, or both. Only a very small number of drugs ever get through the drug approval process. When they are approved, however, hopefully you will be empowered to judge whether or not the new drugs are right for you using your knowledge of evidence-based medicine gained in this book. So, what might be around the corner? Here are several of the latest ideas: 1.  Food-related therapies are emerging as an exciting option. This type of therapy would focus on changing the foods a patient consumes in order to provide relief of symptoms. Another aspect of food-related therapy is changing harmful food products (like gluten) so people who have an intolerance to a particular food type can just eat a modified version of it. This field is rapidly coming of age, and I predict it will help IBS sufferers avoid difficult diets. 2. New anti-inflammatory drugs that block chemical and cell pathways from further inflammation look promising.

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Low-grade inflammation seems to play a role in causing IBS in some people. For example, a drug like one used in Crohn’s disease (a nasty chronic inflammatory disease of the bowel) called 5-ASA (5-amino-salicylic acid) might be helpful in reducing the inflammation of IBS. However, studies in IBS for this particular drug are not yet convincing.17 Perhaps there will be other options soon. Drugs that block a certain cell type called mast cells might be particularly useful. Watch this area—it seems possible that good and safe anti-inflammatory agents will be developed for IBS. 3. New pain-blocking drugs are currently either in development or in testing for IBS. These may help pain or discomfort in particular.18 There are several types. One type is called kappa opioid agonists. These block pain receptors and are not addictive. Some are being tested now for IBS. Another group of pain-blocking receptors are the tackykinin receptor antagonists. These drugs can be constipating and may be best for people with diarrhea-type IBS. The corticotropin-releasing factor antagonists (CRF antagonists) were discussed in other parts of the book because of their potential importance in stopping the stress response. Only a few of these compounds are currently available, but more may be developed and reach testing in people. So far, this approach has not worked (biology is complex!), but work continues. 4. Serotonin agents, beyond Lotronex™ (alosetron) mentioned earlier, may one day find a place in treating IBS. One serotonin type-3 receptor antagonist called cilansetron had been tested for treating diarrhea and pain, but work was stopped because it had side effects similar to those of Lotronex™. 5. Drugs that affect the nervous system may hold some promise. One drug, named clonidine (marketed as Catapres™), is available for the treatment of high blood pressure. This drug has been shown to reduce pain sensation from the bowel when given to people with IBS.19 It also helps

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diarrhea and urgency. It also causes a drop in blood pressure, however, and can therefore have some significant side effects. A number of similar agents are in development that may have some future role in IBS. Scientists are working on the development of new drugs that directly or indirectly relax smooth muscle, possibly bringing relief to the pain associated with IBS. Many people are familiar with Valium™ (diazepam), commonly used for anxiety (Diazemuls in the UK). There are drugs similar to Valium™ that are more specific in targeting brain receptors and are currently being tested for the treatment of IBS. Right now, I recommend that IBS sufferers generally avoid Valium™ and similar drugs for IBS because they can be habitforming and are of little help. 6. There is a family of compounds that may help nerve cells regrow and reconnect in the bowel. These may hold great hope not only for people with IBS but also those with other serious nerve diseases of the bowel.20 One such factor is called recombinant human-brain derived neurotrophic factor (BDNF), and another is called recombinant human neurotrophic factor-3 (NT-3). 7. In the future, the study of genetics seems likely to produce tools we will use to help guide how best to personalize treatments in IBS (and many other medical areas).21 I am convinced this field (called pharmacogenomics) will grow greatly in the twenty-first century. 8. Electrical stimulation of the bowel may be of help in the near future. This method holds real promise for constipation in particular.22 Even if the colon moved slowly, electric stimulation over the lower back (sacrum) helped.23 9. Fecal transplant is one of the rather unusual approaches proposed as a potential treatment of IBS. The idea is that if the bacteria in the patient’s bowel is abnormal, then perhaps a transplant of bacteria from other people might help. Some remedies are worse than the disease. —Publius Syrius

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Some claim that this treatment does help the symptoms of IBS, but this has not been shown in proper randomized placebo ­controlled studies.24 Furthermore, it is likely any transplanted bacteria are quickly eliminated, and the potential dangers of this approach remain somewhat unclear. I certainly do not suggest this approach yet, although the concept of altering the bacterial flora in the bowel is still an attractive consideration. Fecal transplants do help people with a very bad bowel infection (called Clostridium difficile) when antibiotics have failed.

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LEARN YOUR ABCs

s ABC TO GAIN CONTROL AND RELIEF

Rx drugs useful in IBS For Constipation—linaclotide, lubiprostone, prucalopride For Diarrhea—cholestyramine, alosetron For Abdominal Pain—anti-spasmodics (e.g. hyoscyamine) Some other prescription drugs that may help IBS: Xifaxin™ (US), Xifaxanta (UK)—an antibiotic that might help some people with IBS (generic name: rifaximin) Anti-depressants—tricyclics, SSRIs Many potential therapies—anti-inflammatories, pain-blocking drugs, and others

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Chapter

7 DEFEAT IBS: A SUMMARY Let’s summarize some of what we now know about IBS. To make it easy, I’ve listed below 10 myths about IBS. These are adopted from Jeffrey Roberts, the founder of the IBS Self Help and Support Group (www.ibsgroup.org): 10 Myths: 1.  I can diagnose IBS myself. The truth is, you might be able to, but I don’t recommend it. See your doctor, as other conditions can sometimes cause very similar symptoms. 2. IBS symptoms are the same in everyone. No they are not. Some people have diarrhea, others constipation, and some both. Bloating may be present (or not). But everyone has abdominal pain or discomfort if they have IBS. 3. IBS makes everyone miserable. It can, but some people are not badly affected. A good quality of life doesn’t have to disappear if you have IBS. 137

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4. Only women get IBS. No! Men suffer too, but men are less likely to see a doctor about it in America and Europe. 5. IBS can lead to cancer or worse. No! IBS does not result in cancer, ever. You may even have a better chance of not getting colon cancer. 6. IBS is caused by stress. Stress is an important factor and can make you worse, but it doesn’t seem to be the cause. Infection, inflammation, and bad bacteria seem more important! 7. IBS is all in your head. Well, you need a brain to feel IBS symptoms, but it’s not all about your head—the gut is deranged, and that’s real. 8. Eating fiber will cure IBS. Unfortunately, not true—fiber can help constipation sometimes but not the other symptoms. 9. There is no treatment—learn to live with it. Absolutely untrue—Good treatments exist, and a combination approach (including diet and exercise) can be of real benefit. 10. IBS shortens your life. No! In fact, we showed in a study you live just a little bit longer if you had IBS (just a few days).

So how can we defeat IBS? Let’s go through the options below: D. Diet is the first type of therapy to try—consider the low FODMAP diet.You will need a dietician or nutritionist to guide you. E. Exercise every day—start with walking daily and build to sixty minutes a day. F. Fiber is important for constipation-type IBS—start low and build slow. Adding a fiber supplement may work best.

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E. Engage and enjoy—you are not alone! Joining a group could provide the support you need. Taking regular breaks and vacations can be rejuvenating. A. Anxiety and stress reduction is vital—use simple meditation or relaxation techniques daily. T. Therapy, as guided by your doctor—there are benefits and limitations to old and new therapeutic approaches, such as linaclotide for constipation-type IBS or rifaximin for diarrhea-type IBS. I. Inform yourself about ongoing research about IBS— remain up to date. B. Bust bad bacteria in your gut—consider a probiotic, such as Align™. S. Sleep hygiene will improve the quality and quantity of sleep—it promotes healing and revival of your body. Melatonin may be a useful aid too. Let’s examine each of these more closely.

DIET As described in Chapter 3, the simple change of adding fiber can improve some IBS symptoms. But you must consider a gradual approach. Adding too much fiber too quickly will cause your symptoms to get worse! Remember, dietary change and fiber supplements take time, perhaps several weeks, to work. Since this is generally safe and simple, I recommend it first. If you are looking for a comprehensive way of improving your diet with the goal of improving your symptoms, the FODMAP diet, also described in Chapter 3, appears to be a powerful tool to do it. It gives you a list of foods that commonly cause IBS symptoms. Eliminating most of them may be your path to relief. The FODMAP diet is complex. Perhaps you feel you need help with this, and your doctor can recommend a nutritionist to help you.You can start on your own, however, by deciding to keep track of everything you eat for a while. As difficult as this might be for you, keeping a food diary is a good way to discover what

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sort of changes you need to make. You need to take control here. You just might discover that your food diary is consistent with the FODMAP diet. That is, when you eat high FODMAP foods, you find you have more trouble. And perhaps you will see that when you choose low FODMAP foods, some of your symptoms improve. If you can successfully change your diet and improve your symptoms, then you can avoid medications. Taking pills is harder than it might appear. As discussed, there are side effects and other disadvantages to consider. It is reasonable to think that by changing your diet, you can be relieved of most, if not all, of your symptoms. But wait, there are other simple and healthy things you can do to DEFEAT IBS.

EXERCISE Even though doctors talk about it so often that you may get tired of hearing it, there is no way to overstate the value of exercise. Taking daily exercise, after speaking to your doctor, is essential to good health and improvement of symptoms. If exercise is new for you, start a safe, low-impact program, such as walking daily. Build up by ten minutes a week to a goal of exercising for a total of sixty minutes a day. Or buy a step counter and build up to 10,000 steps a day, slowly. Other exercise, beyond walking, might include yoga, or perhaps a group exercise class. Joining a gym or fitness center will give you many options. Again, this will appeal differently to each individual. But find something you like, and do it regularly.

FIBER SUPPLEMENTS FOR CONSTIPATION-TYPE IBS I always recommend dietary management first, including the judicious use of fiber supplements. Start with a low dose and build up slowly. I don’t recommend wheat bran—it might make you worse! Adding fiber is important because it is safe and can make a difference for life. Psyllium products in particular can be a good place to start.You need to allow sufficient amounts of time for your

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changes to work before you can expect to see the benefits. This is not a quick-fix approach. Fiber products can help constipation. Sometimes they may help diarrhea, too. Nothing is completely safe. Rare side effects and allergies happen even with fiber supplements. But most people will not have trouble unless they increase their dose too quickly.

ENGAGE AND ENJOY You are a unique individual and deserve to enjoy and benefit from family, friends, and the community—you are not alone! Join a support group and enjoy your life. Take short breaks and regular vacations with family and friends. Help is out there, and you should seek it. Being proactive and looking for ways to connect can help you. In many countries, patient support groups and organizations are available. One prominent example is The International Foundation for Gastrointestinal Disorders, founded by Nancy Norton. This is the best known US national organization. It provides memberships, an excellent magazine, and the opportunity to meet people living with similar symptoms. The organization includes experts in the field of functional gastrointestinal disorders, including your author. The founder has been particularly successful in increasing research funding for studies of IBS and related disorders. This a worthy organization offering support for all affected by IBS: International Foundation for Functional Gastrointestinal Disorders P. O. Box 170864 Milwaukee, WI 53217 Toll-free number: 888-964-2001 www.iffgd.org

ANXIETY AND STRESS REDUCTION Whether it is progressive muscle relaxation or cognitive behavioral therapy sessions with a psychologist, learning how to manage stress and anxiety is important in finding control and relief.

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You  may begin with simple meditation or relaxation techniques. Apply them daily. Massage, yoga, imagery, journaling, and more can all contribute to an overall improved sense of well-being. I encourage you to explore—try something new—and know that your state of mind affects your body. Formal psychological treatments can help you too.Your doctor may recommend a psychologist to give you deeper insights about your own personal mind–body connections. Hypnotherapy may be helpful to you as well.

THERAPY If simple measures are failing, see your doctor to consider a prescription medication. Discuss the pros and cons of new therapeutic approaches (such as linaclotide for constipation IBS, or rifaximin for diarrhea IBS). As we have discussed, a number of different medicines are available, but individual response to them is variable. Only certain people will respond to certain types of medications. Many doctors divide IBS into two major categories: those with mainly diarrhea and those with mainly constipation. Of course, many people change from diarrhea to constipation and back again, and some people only have minor bowel symptoms, which makes this distinction somewhat artificial. Still, it is a useful framework for thinking about the kinds of treatments to try. All medications you are currently taking should be reviewed by your doctor. Many medications cause constipation and diarrhea. While following the advice of your doctor, discontinuing medications, if possible, might help. Sometimes medicines aren’t needed long term, but for some reason they have not been stopped (especially if prescribed by a doctor elsewhere, or if you do not have a regular doctor). I’ve seen this quite often, especially in older folks. Medicines need to be reviewed regularly and stopped whenever possible.

Constipation Constipation can be very troubling. Discuss the possibility with your physician that constipation might be due to a pelvic muscle problem, blocking the normal passage of stools. Biofeedback can

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be very effective for treating this type of constipation, with about three-quarters of patients getting better, so this is important to consider. If constipation remains a problem despite diet and fiber supplements, then adding a safe, over-the-counter, gentle laxative such as one of the osmotic laxatives (e.g. containing polyethylene glycol or milk of magnesia) is a reasonable next step. If that is not enough, then it is reasonable to consider the prescription drug linaclotide, which works for approximately two-thirds of patients who try it. The disadvantage of these drugs is that when you stop treatment, the symptoms will most likely return, leading you to continue taking the medications to control your symptoms. Clearly, if your symptoms improve with just diet, then this is preferable to long-term medication. Alternative drugs for constipation and IBS symptoms that have not responded to the other therapies mentioned include lubiprostone (in the USA) or (but based on less evidence for IBS) prucalopride (in Europe, Mexico, or Australasia).

Diarrhea If diarrhea is the major problem and diet is not helping, then I suggest taking Imodium (loperamide) to prevent the diarrhea, as described in Chapter 5. This is a better option than taking it after the diarrhea occurs. Sometimes high doses are needed, which should be discussed with your doctor. This medicine can be very helpful for many people. If you have tried the other recommendations and your diarrhea is still terrible, then you might consider Lotronex (­alosetron), if you live in the United States. It can be of great benefit. But remember, it has serious side effects and must never be taken if you become constipated. It is currently FDA-approved only for women.

Pain Meltanonin may help (3 mg at night) but usually I suggest taking it for no more than 2 months. Meltanonin can cause you to feel sleepy, dizzy, or depressed and can interfere with some medicines, so speak to your doctor before taking it.

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Antidepressant medications are very useful for pain and also can influence the bowel disturbance in a positive way if used properly. Antidepressants called the tricyclics are particularly helpful if diarrhea is a problem, because they have a constipating effect. The SSRIs mentioned in Chapter 6, like Prozac™, tend to be more helpful if constipation is the problem, as they tend to induce diarrhea. Of course, some people even with diarrhea will do very well on Prozac™, and some people with constipation will do very well on the tricyclics. The particular drug and dose chosen—and there are many—can determine whether this approach will work well, or not at all. See an expert medical practitioner if you think you might benefit from this type of drug. If your pain is severe and more constant and fails to respond to the previously suggested therapies, ask your doctor about a referral to a specialty pain clinic.They can provide stress reduction therapies and medications in combination. Sometimes injecting the muscles of the abdomen with local anesthetic and a steroid can help muscle pains that can be confused with IBS.

Overall Management Plan You need to work with your doctor when it comes to creating a management plan for IBS. I now recommend what I call quadruple (4-part) therapy— diet (low FODMAPs if tolerated), exercise (a structured, regular program), probiotic (e.g., Align™, once daily), and melatonin (3 mg at night for the first 2 months). This advice is based on clinical experience and has not been tested in a clinical trial yet. In reality, much of it will be up to you to find out, often through trial and error, what works for you. Adjusting your diet, managing your stress, and choosing which medication to take are all part of finding what will work best for you individually. Since there is a wide variation in the response to treatment, it can be difficult for your doctor to find the best combination. Providing accurate feedback about your experiences of the treatment is invaluable. With your help, your physician can make logical changes in your therapy. I know from personal experience that by working with their doctors and receiving proper medical management, the vast majority of people with IBS will experience substantial improvement. Some will actually lose all of their symptoms.

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INFORM YOURSELF ABOUT IBS AND STAY UP TO DATE You can learn how to search the internet for medical information and discern what sources of information to use. Look to the reputable organizations listed in this section for reliable information.

The Internet Be cautious! Much misinformation is out there, so always apply the principles of evidence-based medicine discussed in this book. Testimonials are not the same as evidence that a treatment works! Indeed, you will rarely find negative testimonials. But as I have emphasized, no treatment will work for everyone, so where is the full truth? Make sure, before you decide to try a new treatment, that it is at least safe. If there is any doubt, seek the opinion of your physician.

Medical Journals Many scientific medical journals publish articles on IBS. Peerreviewed journals are publications that require articles to pass critical examination by experts in the field. However, do not blindly believe the study conclusion; it could still be wrong! There are many, but here are the top journals to consult.

General Medical Journals Annals of Internal Medicine

www.annals.org

British Medical Journal

www.bmj.com

(Free on the Web, an excellent source!) Lancet New England Journal of Medicine

www.thelancet.com www.content.nejm.org

Gastroenterology Specialty Journals American Journal of Gastroenterology Gastroenterology Gut

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Look particularly for articles labeled as a review article or metaanalysis on IBS treatment to help guide your understanding. Discuss any articles with your doctor.

Books The Rome Foundation’s book is an excellent and authoritative resource for doctors that patients may also find interesting. It is written by the world’s authorities in the field, and your author is an editor of the book. A new Rome book will be published in 2016. Here is the complete reference to the 3rd edition: Drossman DA, et al., eds. Rome III:The Functional Gastrointestinal Disorders. 3rd ed. McLean,VA: Degnon Associates; 2006. There are other books that give advice, but remember to discern whether the content is based on current scientific evidence, or not. Chances are that much of the opinion will be wrong!

Search Pub Med Online Searches for journal articles can be conducted online using PubMed, a free and excellent resource. The address is: www.ncbi. nlm.nih.gov/pubmed/. If you enter the term “IBS” or “irritable bowel syndrome” in Pub Med, many articles in peer-reviewed and non-peer-reviewed journals will be listed, with short summaries (abstracts) available for most. Some complete articles are available free over the internet, while others can be purchased for a small fee. Even though you can retrieve many articles using this great tool, it alone does not identify all relevant medical articles. This requires multiple search engines, careful consideration of search terms, and, in the end, searching the reference lists of the major articles one by one. Ask your doctor to show you how to search PubMed!

BUST BAD BACTERIA IN YOUR GUT I am now recommending a probiotic (e.g. Align™ which ­contains Bifidobacteria infantis) for most of my patients. ­Particularly for bloating, probiotics can help as a part of a multipronged approach, including diet, exercise, and stress management (­relaxation ­therapies).

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SLEEP HYGIENE The feeling of sleep deprivation is remarkably common in IBS. Getting enough good-quality sleep is essential to heal and revive the body. Review the steps from Chapter 4 to improve your bedtime routines and increase the quality of your sleep. Consider melatonin if these simple measures are not enough.

DO YOU WANT TO VOLUNTEER FOR A RESEARCH TRIAL? You may want to volunteer for new treatment studies in IBS. Many large centers, such as Mayo Clinic, University of California in Los Angeles (UCLA), and University of North Carolina conduct such trials regularly.  The pharmaceutical industry often conducts country-wide studies. Contacting local and national medical organizations can put you in touch with the latest trials. Visit the U.S. National Institutes of Health Web site, ClinicalTrials.gov, for current studies in the United States. In the UK, you can visit http://guidance.nice.org.uk/CG61/ Guidance/pdf/English to access Clinical ­Practice ­Guideline. Irritable bowel syndrome in adults: Diagnosis and ­management of irritable bowel syndrome in primary care. February 2008. The ­following site is available free for patients: http://www.nhs.uk/Conditions/ Irritable-bowel-syndrome/Pages/Introduction.aspx, Irritable Bowel Syndrome: NHS Choices.The IBS Network can be found at http:// www.theibsnetwork.org/.

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s ABC

LEARN YOUR ABCs TO GAIN CONTROL AND RELIEF

Treatments—There are many to try. Always discuss them with your doctor. Support GroUps—A great source of information and, well, support! Veggies and Fruit—One way to add more fiber. Always start with your diet. Watch out—Emerging therapies might become available. eXercise—I hope you get the point. Yoga—And other relaxation techniques are vital. Zzzzz—Good sleep is essential.

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GLOSSARY OF TERMS Abdomen  An area of the body below the chest; may be referred to as the tummy; contains the gut (intestinal) organs. Abdominal distention  The feeling that the abdomen is swollen or bloated. The swelling may be visible to yourself; you may look pregnant and someone else may be able to see the swelling, such as a family member. Abuse  Threats or actions of a sexual, physical, or emotional type. Usually there is a difference in power between the person doing the abuse and the victim. Aerophagia  Swallowing of air. Repeated belching is usually associated because this makes you swallow more air without knowing it. Afferent nerve  These are nerve fibers that carry sensations from an organ such as the stomach or large bowel to the brain. Alarm symptoms  These are worrying symptoms such as unexplained weight loss, repeated vomit-ing, blood in the stools, trouble swallowing or fever. These symptoms are not explained by IBS but must have another explanation, which is why people with these symptoms should see their physician promptly. Also called “red flags” in the medical literature. Anal fissure  A crack in the skin near the anus which causes itching or pain, particularly when opening the bowels. It can occur with constipation. Anorexia  Loss of appetite or lack of desire for food. Antidepressant  A group of drugs that change neurotransmitters in the brain. These drugs are used to treat depression but also are useful in the management of IBS, not because they work as antidepressants but because they reduce pain processing both in the brain and in the gut.

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Anxiety  A sense of feeling nervous or worried which often occurs with other symptoms such as excessive fear, churning in the abdomen, shortness of breath, the heart racing fast and sweating. Belch  The bringing up (burping) of air from the ­stomach through the mouth. It is usually from air that has been first ­swallowed. Biofeedback  The use of an electronic or other device that gives information either by sound or vision so that an individual can be taught to control a process. In constipation, biofeedback can be used to un-learn tensing of the muscles that block passing stools normally. Blind  This applies in a clinical trial where you are unaware of the treatment and the person giving the treatment is also unaware of what is being given (called double-blinding). Bloating  A feeling of fullness or distention that either may be just felt or it may actually be able to be seen (visible abdominal ­distension). Bristol stool form scale  This is a seven point scale that rates the stool from either watery to hard or lumpy. It was developed in Bristol, England. The numbers on this scale correspond reasonably well to the measurement of movement of material through the gut using objective tests. Bulking agents  These are drugs that increase the amount of stool and help soften the stool because increased water is bound to it. Bulking agents of plant origin include bran. Bulking agents cannot be split by the usual enzymes in the human gut but in the colon may be partially digested producing excessive gas. Cholecystokinin (CCK)  A hormone that is released from the small bowel in response to a meal. This is also a neurotransmitter substance in the nerves in the gut. Cognitive behavioral therapy  In IBS, this therapy explores how certain thoughts and behaviors may negatively upset the gut so these can be modified to help coping with symptoms. It is a useful treatment for learning how to cope with IBS. Colic  Pain or cramps that come and go usually over periods of minutes. 150    Glossary of  Terms

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Colon  The large bowel, connecting the anus to the small bowel. Control  In a trial, this is someone who does not receive the active treatment. Usually a placebo (dummy) control is used. Corticotrophin releasing factor (CRF)  A stress hormone released from the brain. Depression  A feeling of sadness, tearfulness, and pessimism that can vary from mild to severe. Appetite is usually suppressed and sleep pattern is upset. There is often fatigue and loss of energy. There may be feelings of guilt and worthlessness. In severe types there are suicidal feelings. Dietary fiber  Naturally occurring materials from plants which cannot be normally digested in the small bowel and therefore increase stool weight and soften stool. Discomfort  This refers to a feeling that is not painful but is unpleasant. Distention of the ­abdomen  A swelling of the stomach or abdomen that can be seen by either oneself or another observer. Double-blind  Neither the people in the experiment nor those conducting the experiment know what type of therapy is actually being given. Dyspepsia  A feeling of pain or discomfort in the upper stomach area. Early satiety  Inability to finish eating a normal meal because of discomfort; this can be due to stomach dysfunction. Efferent nerve  Nerve fibers that carry impulses from the brain or spinal cord, which lead to a muscle to contract. Enteric nervous system  A system of nerves that works automatically within the walls of the gut and does not require the brain to function ­effectively. Esophagus  Swallowing tube connecting the back of the mouth (pharynx) to the stomach. Fart  The passage of gas (wind) through the anus, or the act, sound, or odor of gas passing through this area. Glossary of  Terms    151

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Flatulence  This may mean passing gas through the anus or any type of feeling of bloating or gaseousness. It is a vague word! Flatus  Passage of gas through the anus. Functional bowel ­disorder  A disorder of the gut which can occur in the upper or lower abdominal area but which does not have a clear cut cause when the bowel is examined by x-rays or endoscopy. Gas  This refers to gas escaping from the mouth or the anus. It is called wind in England and Australia. Gastrin  A hormone released from the stomach that stimulates acid secretion. Gastroenterologist  A physician specialist with a major interest and expertise in the gastrointestinal (gut) system. Gastroesophageal reflux  The passage of upper gut contents into the swallowing tube (esophagus), typically causing heartburn (from stomach acid in the wrong place). Gut hypersensitivity  This means the gut is more sensitive to normal or abnormal stimuli such as blowing up a balloon. Heartburn  Burning sensation or discomfort in the chest that usually rises up towards the throat, and is typically made better by taking an antacid at least temporarily. Helicobacter pylori  An infection in the stomach that always causes inflammation. It is usually acquired in childhood and then persists for life. The infection causes chronic peptic ulcers and gastric cancer but most people with the infection do not become ill from it. It does not cause IBS. 5 Hydroxytryptamine (5HT)  One of the key gut neurotransmitters; it is also an important neurotransmitter in the brain. Hypnotherapy  The application of hypnosis (a state of heightened suggestibility and deep relaxation) to treat symptoms. Incontinence of feces  The leakage of stool (liquid or solid) into the underwear. This may occur with or without a sense of needing to defecate. 152    Glossary of  Terms

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Indigestion  This is a vague term that can mean pain or discomfort in the stomach area, heartburn, passage of excessive gas through the mouth or many other symptoms. Irritable bowel ­syndrome (IBS)  An important disease that causes abdominal discomfort or pain associated with abnormal bowel movements (either constipation or diarrhea), and often bloating or visible abdominal swelling. Laxative  Drug that increases stool frequency or induces looser or more watery stools by a number of different mechanisms. Manning Criteria  Described by Dr. Manning and other colleagues in an important medical paper which showed that certain symptoms could identify irritable bowel syndrome patients from those with other gut diseases. Meta-analysis  A method for accurately combining rando-mized controlled trials so that the overall effect of the treatment can be estimated. Meta-analysis of randomized trials represents a good way to assess the evidence of the benefit of a treatment. Nausea  A feeling of the need to vomit, or a queasiness or sick feeling. Neurotransmitter  A substance that is released from nerve cells and allows the nerve cells to talk to each other and transmit signals accurately. Pain  An unpleasant sensation that may feel as if there is tissue damage occurring. It may not be possible to accurately distinguish pain from discomfort, although in some cultures this is clearer than others. Parasympathetic nervous system  Part of the autonomic nervous system that controls the gut and other bodily functions. Placebo  A dummy or inactive treatment. Placebo response  The response to a dummy or inert treatment in a randomized controlled trial. Primary care  The first contact medical care where patients can see a physician without referral by another doctor. Glossary of  Terms    153

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Probiotic  A type of medicine that changes the gut bacteria to make the composition healthier; this is done by giving live or dead organisms that alter the gut bacteria. Proctalgia fugax  Sharp, often severe, but short lived pain in the anal area due to muscle spasm. Prokinetic  A drug that enhances the speed of material being moved through the gut by acting at the nervous system level, usually in the gut, leading to a release of neurotransmitters. Psychiatric diagnosis  The diagnosis of a disease classified by a psychiatrist which includes depression and anxiety. However, one may have feelings of depression or anxiety and not have a psychiatric diagnosis of anxiety or depression. Psychiatrist  A medical doctor specializing in mental health problems. Psychological  A branch of science that deals with the mind and mental processes. Psychologist  A non-medical specialist with usually a masters or doctoral (Ph.D.) degree who treats problems of the mind and mental processes. Psychosomatic  An old term that describes diseases that were thought to be do to psychological characteristics. Peptic ulcer used to be called a psychosomatic disease until it was realized that most peptic ulcer was caused by an infection (Helicobacter pylori). Quality of life  A feeling of well-being, both physical and psychological, that can be affected by disease or illness. Randomization  Subjects in a clinical trial are selected not by the investigator but usually by a computer in random order, so that people being treated and people not being treated are similar and therefore would be more likely to provide a true result. Rome Criteria  The international diagnostic criteria for IBS and other functional gut disorders, created by a consensus of experts. The criteria comprise of a list of symptoms. Small bowel  The gut connecting the stomach to the colon. It is about 30 feet in length, and is key in absorbing food. 154    Glossary of  Terms

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Stools  Waste products from the colon that are stored and passed by the colon. Stress  Any external or internal factor that interferes with a person’s life including health. Transit time (gut)  Time it takes for food or other material to move through a specified region of the gut. Visceral hypersensitivity  This refers to an increased gut sensitivity to various stimuli such as blowing up a balloon in the gut. Vomit  The violent expelling of stomach contents through the mouth.

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CHAPTER 5 1.  Ruepert L, Quartero AO, de Wit NJ, van der Heijden GJ, Rubin G, Muris WM. Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome. Cochrane Database System Review 2011; CDO03460. 2.  Ford AC, Talley NJ, Spiegel BMR, Foxx-Orenstein AE, Schiller L, Quigley EMM, Moayyedi P. Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: Systematic review and metaanalysis. British Medical Journal. 2008;337;a2313. 3.  Corazziari E, Badiali D, Habib FI, et al. Small volume isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in treatment of chronic nonorganic constipation. Digestive Diseases and Sciences. 1996;41:1636–42. 4.  Kamm MA, Mueller-Lissner S, Wald A, et al. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clinical Gastroenterology and Hepatology. 2011;9(7):577–83. 164   References

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CHAPTER 6 1.  Brandt LJ, Bjorkman D, Fennerty MB, et al. Systematic review on the management of irritable bowel syndrome in North America. American Journal of Gastroenterology. 2002;97(11 Suppl):S7–26. References   165

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20. Yu YB, Zuo XL Zhao QJ, et al. Brain-derived neurotrophic factor contributes to abdominal pain in irritable bowel syndrome. Gut. 2012;61:685–94. 21. Saito YA, Talley NJ. AJG Series: Molecular Biology for Clinicians [Review]. American Journal of Gastroenterology. 2009;104:2583–87. 22. Leong LC,Yik YI, Catto AG, et al. Long-term effects of transabdominal electrical stimulation in treating children with slow-transit constipation. Journal of Pediatric Surgery. 2011;46:2309–12. 23. Kamm MA, Dudding TC, Melenhorst J, et al. Sacral nerve stimulation for intractable constipation. Gut. 2010;59:333–40. 24. Borody TJ, Khoruts A. Fecal microbiota transplantation and emerging applications. Nature Reviews: Gastroenterology and Hepatology. 2011;9(2):88–96.

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INDEX

A

B

 Abdominal discomfort.   See Abdominal pain    Abdominal pain, 6   peppermint oil for, 111   prescription treatments for, 127–130    Abdominal swelling, 2    Abdominal wall muscles, 86    Abnormal bowel responses, 23    Acid-reducing drugs, 109–110    Acid-suppressing drugs, 110    Actidose-Aqua Advance™, 109    Acupuncture, 83    Alcohol, 87–88    Align™, 113    Allergies  vs.  side effects, medicines, 118    Aloe vera in treating IBS, 114    Alosetron, 126, 132, 143    Alternative therapies, 82–83    Aluminum-containing antacids, 109    5-Amino-salicylic acid (5-ASA), 132    Amygdala, 22    Anal sphincter, 42    Anemia, 27    Animal-assisted therapy, 92–93    Antacids, 109    Anthraquinones, 105    Anti-anxiety drugs, 130–131, 133    Antibiotics for IBS, 124–125    Antidepressants, 129–130   medication, 144    Anti-infl ammatory drugs, 131    Antispasmodics, 127–128    Anxiety, 139, 141–142   drugs for, 130–131, 133    Artifi cial sweeteners, excess gas, 51    Art therapy, 91–92    5-ASA.  S   ee 5-Amino-salicylic acid (5-ASA)    Aspartame, 51    Atropine, 107    Autonomic nervous system, 17    Axorid™, 101, 110  

 Bacteria in IBS, 21    Baked beans, 50    Barium, 28    BDNF.  S   ee Recombinant human-brain  derived neurotrophic factor (BDNF)    Beano™, 51    Belching, reducing, 52–54    Belly   breathing, 53   measuring, 30–31    Bifi do, 113    Bile, 40–41    Bile salts, 41    Biofeedback, 94–96    Bisacodyl, 105, 106    Bismuth subsalicylate, 108    Bloating, 6, 30   drugs for, 108–109   probiotics for, 113    Bloatometer, 30    Blood test for diagnosis of IBS, 27    Bomix™, 109    Boots Avid Refl ux™, 101, 110    Bowel   dysfunction, 3   electrical stimulation of, 133   habits, change in, 26   infection, 134   movements, types of, 7   muscle movements in, 123, 124   short-term changes in, 24–25    Bowel regularity, 62–65   improving, 67    Bowel spasms, 23    Brain, 17, 21–23   role in IBS, 75    Bran cereal.   See Unprocessed wheat bran    Breathing, diaphragmatic, 53    Bristol stool form scale, 31    Burping.  S   ee Belching    Bust bad bacteria in gut, 139, 146  

169

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C Caffeine, 87 Cancer, 25, 26, 29, 138 Candida, 66 Carbohydrates, 16, 39, 40, 43 Carter’s pills™, 105 Castor oil, stimulant laxative, 105 Catapres™, 132 Causes of IBS, 13 bacteria, 21 genes, 17–18, 19 infection, 18–19 inflammation, 19–20 CBT. See Cognitive behavioral therapy (CBT) Celiac disease, 27, 65–66 Charcoal Plus™, 109 Charco Caps™, 109 Chinese herbal medicine, 115–118 Chiropractic treatments, 83 Chlorophyll, 52 Cholesterol, 41, 43, 125 Cholestyramine, 125 Chronulac™, 104 Cilansetron, 132 Cimetidine, 110 Clonidine, 132 Clostridium difficile, 134 Codeine phosphate, 127 Cognitive behavioral therapy (CBT),  93–94 Colace™, 103 Colestid™, 125 Colestipol, 125 Colitis, ischemic, 126, 127 Colon. See Large intestine Colon cancer screening test, 26–27 Colonoscopy, 28–29 Colpermin™, 111 Complementary therapies, 82–83 Constipation, 7, 44, 53, 142–143 enemas for, 106 fiber products for, 101–103 laxatives to treat, 103–106 licorice for, 111 prescription treatments for, 123–124 suppositories for, 106 Co-phenotrope™, 107 “Copy-cat” drugs, 100 Correctol™, 105

Corticotropin-releasing factor antagonists (CRF antagonists), 132 Cost of IBS, 8–10 CRF antagonists. See Corticotropinreleasing factor antagonists (CRF antagonists) Crohn’s disease, 132

D Dairy products, 51 Defeat IBS, 138–139, 141 Defecation, 42, 95, 106 Desipramine, 129 Diagnosis of IBS, 25, 64, 137 blood test for, 27 Manning criteria, 32 Rome criteria, 32–33 Diaphragmatic breathing, 53 Diarrhea, 2, 106–108, 143 IBS, 5, 7, 41 prescription drugs for, 125–127 probiotics for, 113 Diazemuls™, 130, 133 Diazepam, 130, 133 Diet, 138, 139–140, 144 and exercise, 69–70 fiber. See Fiber FODMAP. See FODMAP diet gas excess, 48–52 gluten-free, 65–66 Digestion, 39–42 Digestive enzymes, 114 Dioctyl™, 103 Diphenoxylate, 107 Doctor’s visit, preparation for, 34 Dried fruit, 44 Drugs acid-reducing, 109–110 acid-suppressing, 110 affect nervous system, 132–133 anti-anxiety, 130–131, 133 anti-inflammatory, 131 for bloating, 108–109 for constipation and IBS symptoms, 143 “copy-cat,” 100 gas-reducing, 108–109 pain-blocking, 132 prescription, for diarrhea,  125–127 treatments for IBS, 100–101

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Early satiety, 16 Electrical stimulation of bowel, 133 Electrolyte solutions, 41 Endoscope, 13 Enemas for constipation, 106 Enteric nervous system, 17 Enzymes, 39 digestive, 114 pancrealipase, 114 Esophagus, 15 Evidence-based medicine, 78–81 Excess bacteria, 19, 131 Exercise, 138, 140 diet and, 69–70 health benefits, 67–68 Kegel, 68–69 Ex-Lax™, 105 External sphincter, 42 Extra-bowel symptoms, 7

Fletcher’s Castoria™, 105 Fluoxetine, 130 FODMAP diet, 59–62, 63, 138, 139–140 Food allergy, 57 Food and Drug Administration (FDA),  81, 100 Food intolerance, 57–58 Food-related therapies, 131 Foods chemicals, 65 fiber content of, 45–47 gas-forming, 49, 51–52 high-lactose, 56 intolerance, 57–58 lactose-free and low-lactose, 55 less gassy fiber-containing, 50 sources of FODMAPs, 60–61 Forlax™, 104 Freezing, gastric, 79 Fruits 4-6 grams of fiber per serving,  46–47 gas-forming, 49, 50 less gassy fiber-containing, 50 2-3 grams of fiber per serving,  45–46 Fundus, 16

F

G

Famotidine, 110 Farting, 48 Fats, 40 Fecal transplant, 133, 134 Fentanyl, 127 Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols diet. See FODMAP diet Fermentation, 59 Fiber, 43–44 content of foods, 45–47 increasing, 44 supplements, 48 Fiber products benefit of, 102 for constipation, 101–103 Fiber supplements for constipation-type IBS, 138, 140–141 Fibromyalgia, 86 Flatus, 48

Galactosemia, 51 Gallbladder, 41 Gas excess, diet, 48–52 Gas-forming foods, 49, 51–52 Gas-reducing drugs, 108–109 Gastric freezing, 79 Gastrocolic response, 42 Gastroenteritis, 18 Gastrointestinal tract, 15, 39 Gas-X™, 108 Genes, development of IBS, 17–18, 19 Gentlax™, 105 Ginger in treating IBS, 114 Gluten, 65–66 Gluten-free diet, 65–66 Grain product 4-6 grams of fiber per serving, 46 less gassy fiber-containing, 50 2-3 grams of fiber per serving, 45 Guar gum, fiber product, 101 Gut, bust bad bacteria in, 139, 146

Dulcoease™, 103 Dulcolax™, 105 Dumping syndrome, 16 Duphalac™, 104 Dysfunction of neural pathways, 75

E

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H

K

Habits of sleep, 87–89 Healing, spirituality in, 90–91 Healthcare practitioner, 75 Herbal medicine, Chinese, 115–118 Herbal products, 113–115 High-amplitude propagated contractions (HPACs), 42 High-fiber diets, 43 High-flatus foods, 51 High-lactose foods, 56 Histamine antagonists, 110 Histamine receptor agonists, 110 Histamine receptor blockers, 110 Homeopathy, 112–113 Hormone, 17, 112 Humor therapy, 92 5-Hydroxytryptamine 4 receptor  (5-HT4), 124 Hygiene, sleep, 139, 147 Hypnotherapy, 81, 89, 94, 142 Hysterectomy, 24

Kappa opioid agonists, 132 Kegel exercises, 68–69 Kristalose™, 104

I IFFGD. See International Foundation for Functional Gastrointestinal Disorders (IFFGD) Imodium, 143 Imodium™, 107 Imodium AD™, 106 Imodium Advanced™, 106 Imodium Plus™, 106 Infacol™, 108 Infection, 4 causes of IBS, 18–19 Inflammation, 4 causes of IBS, 19–20 Insoluble fiber, 43–44 Insomnia, 87 Internal anal sphincter, 42 International Foundation for Functional Gastrointestinal Disorders (IFFGD), 6, 8–9, 91–92, 141 Internet, IBS information from, 145 Ischemic colitis, 126, 127 Ispaghula, fiber product, 101

J Journaling in IBS, 91

L Laboratory investigations for suspected IBS, 28 Lactase deficiency, 40,  54–56 Lactose, 40 Lactose-free foods, 55 Lactose intolerance. See Lactase deficiency Lactugal™, 104 Lactulose, 104 Laevolac™, 104 Large intestine, 16, 40 Laxatives, 41, 67 magnesium-containing, 104 osmotic, 104 stimulant, 105 to treat constipation, 103–106 Laxido™, 104 Legumes, 49 Licorice for pain and constipation, 111 Linaclotide drug, 123, 143 Lomotil™, 107 Loperamide, 106, 107, 143 Losec™, 101, 110 Lotronex, 143 Lotronex™, 126, 127, 132 Low-fiber diet, 43 Low-flatus diet, 51 Low hemoglobin. See Anemia Low-lactose food, 55 Lubiprostone, 123

M Magnesium-containing antacids, 109 Magnesium-containing laxatives, 104 Management plan for IBS, 144 Manevac™, 105 Manning criteria for IBS, 32 Mannitol, 51 Massage, 86 Mast cells, 20 Medical journals, IBS information from, 145–146

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Medication, 89, 91, 128, 143 anti-anxiety, 130 antidepressants, 144 over the counter (OTC), 119 types of, 142 Medicine evidence-based, 78–81 herbal, Chinese, 115–118 side effects vs. allergies, 118 Melatonin for pain and sleep, 112 Meltanonin, 143 Mepradec™, 101, 110 Methane gas in causing IBS symptoms, 125 Milk of magnesia, 104 Mineral oil, bowel function in IBS, 103–104 Miniform™, 108 Mintec™, 111 Miralax™, 104 Modified-diet group, 57, 58 Morphine, 127 Movicol™, 104 Muscle contractions, 42 Muscle interactions, complicated nerve and, 17 Muscle movements in bowel,  123, 124 Muscle relaxation, progressive, 84–86 Mylanta Gas™, 108

N Narcotics, 127 Natural fluctuations in IBS symptoms, 75 Negative placebo response, 76 Nervous system, drugs affect in, 132–133 Neural pathways, dysfunction of, 75 Nocebo effect, 76 Norgalax™, 103 Norpramin™, 129 NT-3. See Recombinant human neurotrophic factor-3 (NT-3)

O Oil, bowel function in IBS castor, 105 mineral, 103–104 peppermint, for abdominal pain, 111 Omeprazole, 101, 110 Osmotic laxatives, 104 Over the counter (OTC) medications, 119

P Pain, 143–144 abdominal, peppermint oil for, 111 licorice for, 111 melatonin for, 112 Pain-blocking drugs, 132 receptors, 132 Pancrealipase enzyme, 114 Parasympathetic nervous system, 17 Passing gas, 48 Peer review process, 80 PEG. See Polyethylene glycol (PEG) Pelvic muscle exercises, 68 People with gas trouble, 50 People with IBS, 7, 8 Pepcid™, 110 Peppermint oil for abdominal pain, 111 Pepsins, 40 Peptic ulcers, 75, 111 Pepto-Bismol™, 108 Perdiem Overnight™, 105 Peri-Colace™, 105 Peristalsis, 17, 123, 124 Pet therapy, 92–93 Pharmacogenomics, 133 Phazyme™, 108 Phenolphthalein, 105 Physical abuse, risk of developing IBS, 24 Physician behaviors, 75 Placebo effect, 74–76 Placebo response in action, 76–77 Polyethylene glycol (PEG), 104 PPIs. See Proton pump inhibitors (PPIs) Prescription drugs for diarrhea, 125–127 Prescription treatments for abdominal pain, 127–130 for constipation, 123–124 Prevacid™, 110 Prilosec™, 101, 110 Probiotics for bloating and diarrhea, 113 Progressive muscle relaxation, 84–86 Protein, digestion of, 40 Proton pump inhibitors (PPIs), 110 Prozac™, 130, 144 Prucalopride, 123 Pseudo pregnancy, 2 Psychotherapy, 82, 93–94 Psyllium, fiber product, 101–103 Pub Med Online, IBS information from, 146

Index    173

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Q Quadruple therapy, 144 Questran™, 125

R Ranitidine, 110 Receptors 5-hydroxytryptamine 4, 124 pain-blocking, 132 serotonin, 123, 124, 132 tackykinin, 132 Recombinant human-brain derived neurotrophic factor (BDNF), 133 Recombinant human neurotrophic factor-3 (NT-3), 133 Reflexology, 83–84 Regular exercise, 53 Resolor™, 123 Rifaximin, 125 Rome criteria for IBS, 32–33

S Saccharin, 51 Salt treatment, 41 Screening test for colon cancer, 26–27 Selective serotonin reuptake inhibitors (SSRIs), 130 Senna products, allergic and asthma reactions in, 105 Senokot™, 105 Senokot-S™, 105 Serotonin agents, 132 receptor, 123, 124 type-3 receptor antagonist, 132 Sexual abuse, risk of developing IBS, 24 Sham diet group, 57–58 Short-term bowel changes, 24–25 Side effects vs. allergies, medicines, 118 Sleep hygiene, 139, 147 IBS and, 87–89 melatonin for, 112 Small bowel. See Small intestine Small intestine, 16, 40 Smooth muscle, 8 Soluble fiber, 43–44 supplements, 101, 102 Sophisticated scanning techniques, 22

Sorbitol, 51, 104 Spirituality in healing and health, 90–91 SSRIs. See Selective serotonin reuptake inhibitors (SSRIs) Steatorrhea, 41 Stimulant laxatives, 105 Stomach, 15 Stool, 16, 31–32 softeners, 103 Straining, 42 Stress, 7, 88, 138, 139, 141–142, 144 and bowel problems, 23 reducing, 53, 75 urinary incontinence, 68 Sugars, 40 Suppositories for constipation, 106 Surfak™, 103 Swallowing air, reducing, 52–54 Sweetener, excess gas in, 51 Sympathetic nervous system, 17 Symptom diary for IBS, 35 Symptoms of IBS, 26, 32, 33, 137 celiac disease, 27, 66 diarrhea and abdominal pain, 14 fibromyalgia, 86 gas, 40 heartburn, 111 lining of bowel, 14 Manning criteria, 32 natural fluctuations in, 75 short-term bowel changes, 24–25 short-term control of, 99

T Tackykinin receptor antagonists, 132 Tagamet™, 110 Tensing, instructions for, 84–86 Tests for IBS, 25–30 Therapy, 139, 142–144 Treatments, 81–82, 137. See also Prescription treatments drug, for IBS, 100–101 Tricyclic antidepressants, 129,  130, 144

U Ulcers, peptic, 75, 111 Unprocessed wheat bran, 47 Urine symptoms in IBS, 8

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V Valium™, 130, 133 Vegetables 4-6 grams of fiber per serving, 46–47 less gassy fiber-containing, 50 2-3 grams of fiber per serving, 45–46 Virtual colonoscopy, 26, 29 Vomiting, 8

W Water treatment, 41 WIND EZE™, 108

Xifaxin™, 125 X-ray techniques, colon cancer, 28

Y Yeast, 66 Yoga, 89–90

Z Zanprol™, 101, 110 Zantac™, 110 Zegrid™, 110 Zoton Fast Tab™, 110

X Xenical™, 41 Xifaxanta™, 125

Index    175

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Index.indd 176

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