Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change.  (Search our archives for her posts, calling on the expertise of medical specialists, on topics from angiography to vulvar melanoma.)

This week she calls on a gastroenterologist to counsel a woman diagnosed with irritable bowel syndrome who finds that her GP’s treatment suggestions aren’t working.

irritable-bowel-syndromeImage via

Dear Dr. Pat:

I am 40 years old and have been told that I have IBS. Basically, I function with two bowel movements a week, feeling bloated most of the time unless I travel; then I have NO bowel movements without taking Dulcolax, which causes terrible cramping, then prolonged time in the bathroom, making travel less and less appealing.

Then I get the opposite problem when I am stressed: I have severe cramps and then diarrhea.

Other than travel and stress, I can’t pinpoint when I am going to have these disabling problems.

I have seen my GP and he basically told me to have more fiber, drink more water, and take more time in the bathroom . . . and this is not working.

Maybe I don’t have IBS?  What recommendations do you have for either diagnosis or treatment for me to discuss with my doctor?

Ellen

 

Dr. Pat Responds:

Dear Ellen:

Bowel dysfunction causes great discomfort to many people, inhibiting their food choices and often preventing them from leading full lives when the fear of diarrhea or the memory of days of constipation affect travel choices or attending events that might cause anxiety.  It is time for you seek consultation from a gastroenterologist to rule out any underlying bowel disorder.  If “only IBS” is left as the diagnosis, then there are medications and dietary modifications that are often helpful, along with developing skills for management of stress, which worsens the underlying problem.  Dr. Brian R. Landzberg, Clinical Assistant Professor of Medicine in the Division of Gastroenterology and Hepatology at the Weill Medical College of Cornell University, is a gastroenterologist in private practice in New York City and a member of our Medical Advisory Board. He will discuss your symptoms and questions.

Dr. Pat

 

Dr. Landzberg Responds:

Dear Ellen:

Thanks for your questions.  I am sure there are many fellow sufferers out there with the same ones. Your symptoms certainly seem consistent with IBS, and an initial approach of reassurance, dietary fiber, and fluids, as your GP suggested, is certainly reasonable. 

So what should be done when that doesn’t work?  See a gastroenterologist, whose first duty will be to rule out structural diseases that may present with symptoms similar to IBS, such as celiac disease, inflammatory bowel disease, bacterial overgrowth, malignancy (unlikely), or thyroid dysfunction. This begins with a THOROUGH history and physical examination, looking at timing and quality of symptoms, precipitating and relieving factors, or psychosocial stresses. This should be followed by blood work, evaluation of small and large bowel with colonoscopy and possibly upper endoscopy, as well as potential radiographic or sonographic evaluations. 

If this workup is negative, and a diagnosis of IBS is made, how do we treat then? For the symptoms you described, with swings between constipation and diarrhea, fiber can be “the great equalizer,” but can be a two-edged sword. Fermentable fiber such as what is found in natural products like psyllium (Metamucil) and bran, can lead to significant gas/bloat symptoms.  Synthetic fiber, such as methylcellulose (Citrucel), taken twice daily, may even out bowel movements without producing “the bloat.”  Other chronic medications (prescription and over-the-counter) and supplements, such as calcium blockers and calcium supplements, may contribute to symptoms, and alternatives may need to be considered.  Probiotics, including Align and Culturelle, are potentially helpful and easy to recommend, given the extremely low risk of side effects.  Meeting with a dietitian to review FODMAPs  may often help.

Other treatments include antispasmodics (hyoscyamine) for cramping pain, osmotic laxatives (Miralax) to effect bowel movements, Linzess to both treat pain and effect BMs, luminal antibiotics given empirically for bacterial overgrowth, abdominopelvic physical therapy, and even hypnosis! 

There are many options for treating IBS; they should be discussed with a gastroenterologist who has the experience and is willing to take the time to review the treatment options with you, then follow up if the initial treatment plan is not effective.

Hope that helps!

Dr. Brian Landzberg

 

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  • Frederick Doner April 28, 2014 at 5:51 pm

    Following a proscribed diet has lead to 95% of the success I have experienced managing my colitis, a form of IBS. The book I used to establish this diet was: “Eating Right for a Bad Gut” by James Scala, Ph.D.

    Following the clearly laid out “Do’s, Don’t and Caution” lists of foods in this book works well. If I veer from the diet, then taking a generic version of Azulfadine called Sulfasalazine has helped correct the problem. Admittedly my colitis at its worst was milder than the most difficult to manage IBS illnesses. But for me, diet, far more than medication, was key.

    Reply
  • Sandra April 28, 2014 at 1:54 pm

    My IBS responded to a lower-fat diet high in vegetables and whole, real foods, lots of walking, and initially, Citrucel. I don’t need the Citrucel anymore, and use milk of magnesia when I travel, as I have constipation when I travel, like Ellen. I don’t need to take anything for the IBS except when I travel.

    Reply