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Making Sense of IBS
A Physician Answers Your Questions about
Irritable Bowel Syndrome
SECOND EDITION
Brian E. Lacy, Ph.D., M.D.
Note to the reader: This book is not meant to substitute for medical care,
and treatment should not be based solely on its contents. Instead, treatment
must be developed in a dialogue between you and your doctor. It is
especially important to discuss the use of any medications with your doctor.
© 2006, 2013 Johns Hopkins University Press
All rights reserved. Published 2013
Printed in the United States of America on acid-free paper
98765432
Johns Hopkins University Press
2715 North Charles Street
Baltimore, Maryland 21218-4363
www.press.jhu.edu
Library of Congress Cataloging-in-Publication Data
Lacy, Brian E.
Making sense of IBS : a physician answers your questions about irritable
bowel syndrome / Brian E. Lacy, Ph.D., M.D. — Second edition.
pages cm. — (A Johns Hopkins Press health book)
Includes bibliographical references and index.
ISBN-13: 978-1-4214-1115-6 (pbk. : alk. paper)
ISBN-10: 1-4214-1115-6 (pbk. : alk. paper)
ISBN-13: 978-1-4214-1116-3 (electronic)
ISBN-10: 1-4214-1116-4 (electronic)
1. Irritable colon. I. Title. II. Title: Making sense of irritable bowel
syndrome.
RC862.I77L33 2013
616.3'42—dc23 2013006074
A catalog record for this book is available from the British Library.
All illustrations except Figure 11.1 are by Jacqueline Schaffer.
Special discounts are available for bulk purchases of this book. For more
information, please contact Special Sales at 410-516-6936 or
[email protected].
Johns Hopkins University Press uses environmentally friendly book
materials, including recycled text paper that is composed of at least 30
percent post-consumer waste, whenever possible.
Contents
Preface
Acknowledgments
List of Abbreviations
PART I
Irritable Bowel Syndrome: The Basics
1. Overview of IBS
2. What Is IBS?
3. Why Do I Have IBS?
4. How Common Is IBS?
5. What Is My Prognosis?
6. The Anatomy of Digestion
PART II
Diagnosing Irritable Bowel Syndrome
7. How Is IBS Diagnosed?
8. Diagnostic Tests and What They Mean
9. IBS and Other Medical Disorders
10. IBS and Diet
11. IBS and Small Intestine Bacterial Overgrowth (SIBO)
12. IBS versus IBD
PART III
Treating Irritable Bowel Syndrome
13. Treatment Basics
14. Lifestyle Modifications
15. Diet Modifications
16. Treatment Options for IBS with Constipation
17. Treatment Options for IBS with Diarrhea
18. Medications for Abdominal Pain Associated with IBS
19. Treatments for Gas and Bloating
20. Probiotics and Antibiotics: Frequently Asked Questions
21. Complementary and Alternative Medicine
22. Psychological, Hypnotherapeutic, and Psychiatric Therapies
23. The Ingredients of an Effective Doctor’s Appointment
PART IV
Other Issues
24. IBS and Children
25. What Does the Future Hold?
Appendix: About Clinical Trials and Scientific Research
Patient Resources
Glossary
References
Index
Preface
If you’ve picked up this book, then it is quite likely that you or a friend, a
coworker, or someone in your family has irritable bowel syndrome (IBS). I
can safely make that statement because 1 in 6 to 1 in 7 adult Americans
suffers from this problem. Although the condition is quite common, people
who have IBS have often found it difficult to get help for their symptoms
or answers to their questions. Fortunately, over the past 10 years,
significant advances have been made in our understanding of IBS. We now
have a much clearer picture of why IBS develops, and we also better
understand the very complex interactions that occur between the brain and
the gut in patients who have IBS. In addition, researchers, scientists, and
physicians have made significant contributions to our ability to manage the
multiple symptoms of this often frustrating disorder.
Because education of patients and health care providers about IBS has
been limited, I wanted to write this book to share this wealth of new
information with more people. The book has several goals:
• to convey what we currently understand about IBS
• to clear up the many misconceptions and misperceptions that
surround IBS
• to help you recognize the symptoms of IBS
• to describe tests that may be used during the evaluation of IBS
symptoms
• to discuss the many treatment options available for the diverse
symptoms of IBS
• to provide information that will allow people who have IBS to better
understand their symptoms, institute changes, and improve their
quality of life.
To accomplish these goals, I have divided this book into four parts. Part
1 provides a general introduction to the disorder. Part 2 focuses on the
evaluation and diagnosis of a patient who has symptoms of IBS. Part 3
focuses on the treatment of IBS, and Part 4 discusses children who have
IBS and the future for IBS treatments and education. Terms used in the
book are defined in a glossary at the back, and at the front of the book is a
list of abbreviations. There is also a short appendix about the design and
importance of clinical studies.
I hope that this book will answer your many questions about IBS and
allow you to make sense of this common disorder.
Acknowledgments
The process of writing, editing, and publishing a book is a significant
undertaking that represents the collective efforts of many people.
Unfortunately, and unfairly, the cover of a book lists only the author’s
name and does not credit the many others so intimately involved in this
lengthy process. Although it is not possible to properly thank everyone who
contributed to this project, I would like to acknowledge some of them.
First, I want to thank all of the patients who have IBS whom I have seen
over the past fifteen years. I appreciate their willingness to describe their
symptoms and share how IBS affects their lives. I hope that this book will
provide them with new ideas and information that will enable them to
better understand this complex disorder and ameliorate their symptoms.
Thanks also go to Executive Editor Jacqueline Wehmueller and to Sara
Cleary, both of the Johns Hopkins University Press, for their cogent
thoughts, continued encouragement, and tireless efforts in editing and
revising the manuscript. In addition, I owe great thanks to all of my friends
and colleagues at Dartmouth for their wonderful suggestions, advice, and
support.
Finally, I dedicate this book to the memory of my father, who taught me
to be patient and understanding, and to Elaine, for her unwavering patience,
support, and selflessness.
Abbreviations
Abbreviations will usually be defined where they first appear in the text.
This list is provided for convenient reference.
ANS autonomic nervous system
CBC complete blood count
CBT cognitive behavioral therapy
CFS chronic fatigue syndrome
CMV cytomegalovirus
CNS central nervous system
CPP chronic pelvic pain
CRF corticotropin releasing factor
CRP C-reactive protein
CT computed tomography
DNA deoxyribonucleic acid
EGD esophagogastroduodenoscopy
ENS enteric nervous system
ESR erythrocyte sedimentation rate
FDA Food and Drug Administration
5-HT 5-hydroxytryptamine, also called serotonin
GERD gastroesophageal reflux disease
GI gastrointestinal
gm gram(s)
Hct hematocrit
Hgb hemoglobin
HIV human immunodeficiency virus
IBD inflammatory bowel disease
IC interstitial cystitis
LES lower esophageal sphincter
LFTs liver function tests
mg milligram(s)
ml milliliter(s)
MRI magnetic resonance imaging
MSG monosodium glutamate
OAB overactive bladder
O&P ova and parasites
OTC over-the-counter
PEG polyethylene glycol
PET positron emission tomography
PMR polymyalgia rheumatica
p.r.n. pro re nata (as needed)
RAP recurrent abdominal pain
SLE systemic lupus erythematosus
SSRI selective serotonin reuptake inhibitor
TCA tricyclic antidepressant
TIA transient ischemic attack
TMJ temporomandibular joint
TSH thyroid stimulating hormone
US ultrasound
UTI urinary tract infection
WBC white blood cell
PART I
Irritable Bowel Syndrome: The Basics
CHAPTER 1
Overview of IBS
Irritable bowel syndrome is one of the most common disorders seen in
medical practice today. During a typical week, the average family
practitioner or internist will see more patients who have irritable bowel
syndrome (IBS) than patients who have asthma, diabetes, hypertension, or
cardiovascular disease. To help put this into perspective, consider that
approximately 15 percent of adult Americans have symptoms of IBS,
which translates to approximately 45 million adult Americans having
recurring symptoms of abdominal pain, discomfort, bloating, distention,
and either constipation or diarrhea (or both). This helps to explain why the
aisles in your local pharmacy or drugstore are packed with over-the-counter
medications designed to treat digestive problems.
Although IBS is common, the condition remains poorly understood.
Lack of understanding of this prevalent, complex disorder is pervasive
among family members and coworkers of people who have IBS as well as
insurers, health care plans, the public at large, and even some physicians.
People misunderstand IBS on many different levels. For example, some
people believe that IBS is an uncommon disorder and that the attention
paid to it occurs only because of the actions of a very small but vocal group
of people who have IBS. On the contrary, multiple large population-based
research studies have shown that up to 15 percent of adult Americans have
IBS.
Another common misconception is that IBS affects only young women.
In fact, nothing could be further from the truth. Irritable bowel syndrome is
an equal opportunity disorder. It does not discriminate based on age, sex,
race, or nationality. Some insurance companies and health care providers
believe that IBS is nothing more than an annoyance and that it should not
even be considered a medical problem. It is well documented, however,
that from a patient’s perspective, this common disorder significantly affects
patients’ quality of life on a daily basis.
Finally, some people mistakenly argue that IBS is a new problem that
has appeared in response to the stresses of an industrialized society or that
it is a problem manufactured by pharmaceutical companies solely to
improve their revenue. But multiple studies have clearly shown that IBS is
found throughout the world and is not just limited to Western societies.
Irritable bowel syndrome exists in rural areas, underpopulated areas, and
nonindustrialized societies. Irritable bowel syndrome is not new; it likely
has been present for thousands of years, if not longer. In this book, I
address these common misconceptions and provide answers to common
questions about IBS using the most recent data from scientific studies
performed around the world.
Although irritable bowel syndrome is now a relatively familiar term, the
disease was given a number of different names in the past. Some of these
are colorful (spastic colitis), while others are somewhat pejorative (nervous
colitis), and still others are simply misnomers (mucus colitis, unstable
colitis, and inflammatory colitis). These terms are misleading, confusing,
and often distressing to people who have IBS. People who receive a
diagnosis using one of these old-fashioned terms may be worried that they
are receiving a different diagnosis of a more severe disorder rather than
IBS. For example, the term “mucus colitis” may lead someone to think that
they have ulcerative colitis or Crohn’s disease, both of which are
inflammatory bowel diseases (see Chapters 7, 8, and 12). For these reasons,
such older labels should not be used, and anyone who is diagnosed with
one of these labels should ask his or her doctor for a different diagnosis.
Despite the variety of names and labels for IBS, the disease has
remained the same over the years. Noted English physician W. Cumming
published a description of IBS more than 150 years ago that seems
remarkably similar to our current description. In an 1849 passage taken
from the London Gazette, he described IBS in the following manner: “The
bowels are at one time constipated, at another time lax, in the same person.
How the disease has two such different symptoms I do not profess to
explain.”
There is significant confusion over this common medical problem, and a
host of unanswered questions remain. What, then, is IBS? Irritable bowel
syndrome is a common, chronic (meaning that it continues for a long time
or recurs frequently) disorder of the gastrointestinal tract. Characteristic
symptoms include abdominal pain or discomfort, in association with
disordered bowel habits consisting of either constipation or diarrhea (or
alternating symptoms of both, in many cases). Other common symptoms
include bloating, gassiness, abdominal distention, passage of mucus with a
bowel movement, significant straining during a bowel movement, or the
very urgent need to have a bowel movement. Although these symptoms are
well recognized, they are not specific to IBS; other medical conditions can
cause these or similar symptoms, too. The following story of a young
woman referred for the evaluation of chronic gastrointestinal symptoms
illustrates the misconceptions and misperceptions that surround this
common medical problem.
Meredith is a 29-year-old woman referred by her family practitioner for a second opinion. She
explained that her problems first began in college. Every several months she would have several
days of lower abdominal cramps and diarrhea. The diarrhea was loose and watery but never bloody.
It seemed to be associated with significant bloating and distention of her abdomen. Her friends often
joked that during these episodes she looked six months pregnant. She attributed these episodes to a
viral illness on one occasion, food poisoning on another, and overly rich food on a third occasion.
After college she worked for a consulting firm. This was a stressful job and she had little free
time for exercise or relaxing social activities. Several times a month, she would have three to four
days of lower abdominal cramps and pain. The pain would generally start shortly before an episode
of diarrhea, and she noted that she would often have to run to the bathroom because the urge to have
a bowel movement was so strong and forceful. The cramps and lower abdominal discomfort would
eventually subside, but each episode left her feeling exhausted. Her friends suggested that she might
be lactose intolerant (unable to break down and digest the major sugar in milk products; see Chapter
10). However, even after she eliminated milk and cottage cheese from her diet, her symptoms
continued. Meredith mentioned her symptoms to her gynecologist at her next routine office visit.
After examining her, he told her he could find nothing wrong and that it was probably “just stress.”
During the next year, her symptoms did not change significantly but did occur more frequently. It
was now common for her to have three to four days in a row of lower abdominal pain and
discomfort associated with significant bloating and distention. Although she had always been
slender, Meredith had to buy new clothes with elastic waistbands, because many of her clothes felt
tight on the days when she was bloated. She began to plan her errands and social events more
carefully, because sometimes the urge to go to the bathroom came on so suddenly that she was afraid
she would have an accident. Meredith tried a variety of over-the-counter medications without any
relief. One friend told her that she probably was not digesting her food properly and that enzyme
supplements would help her. She tried these for a month, but they did not seem to help. Another
friend told her that she wasn’t getting enough fiber in her diet. Meredith became a strict vegetarian
and eliminated all animal products from her diet. This only seemed to make the bloating worse.
Another friend told her that her symptoms sounded just like her aunt, who had celiac disease (an
allergy to wheat products; see Chapter 10).
After researching the topic online, Meredith thought that her symptoms could be the result of a
wheat allergy, so she eliminated all wheat products from her diet, which was very hard to do. After
two months without any improvement in her symptoms, she abandoned this strict wheat-free diet.
Meredith next tried acetaminophen and a variety of over-the-counter anti-inflammatory medications
in an attempt to help with the lower abdominal pain, but none of them alleviated her symptoms, and
