Finding Freedom for Your Patients From Exasperating Irritable Bowel Syndrome
Consider medication, dietary modifications, and OMT for treatment
By Jeffrey D. Rettig, DO, FACOFP
Irritable bowel syndrome (IBS) is a condition defined as abdominal pain and discomfort with altered bowel habits in the absence of any other mechanical, inflammatory, or biochemical explanation for the symptoms.4 It involves gastrointestinal dysmotility and visceral hypersensitivity.6
Not a new or infrequent ailment, this common functional gastrointestinal disorder was described in 1820 by Powell.14 Symptoms include constipation, diarrhea, or alternating bowel habits. In addition, abdominal pain, bloating, dyspepsia, belching, and flatulence may occur. Other descriptive names of IBS are nervous colon, spastic colon, spastic colitis, and mucus colitis.15
A diagnosis of exclusion, there are a variety of criteria for IBS. IBS affects three to fifteen percent of the general population at any given time. It primarily affects young to middle aged adults and is more likely to affect women than men. Studies also show a familial component, as genetics can play a part in the development of IBS.4,9
This condition can be frustrating to both patients and physicians. Often, IBS is chronic and recurrent in nature, and difficult to treat. Frequently, patients experience the burden of multiple healthcare visits that often include expensive testing and over-the-counter and prescription medications.11 This accounts for not only a great cost, but also lost workdays associated with IBS.
Irritable bowel syndrome is the reason for up to 50 percent of gastroenterologist visits.15 It is also a common cause of medical tests and occasional unnecessary surgery.
Evidence confirms this is truly a worldwide disease associated with symptoms and impairments in personal and social function.2
IBS Diagnosis
IBS is a multifactorial disease process. Once diagnosed, individuals can usually be further separated into diarrhea predominant-irritable bowel syndrome (IBS-D) or constipation predominant-irritable bowel syndrome (IBS-C.)17 These diagnoses are not only descriptive of the individual’s disease process, but are helping in tailoring the medical treatment of their IBS.
More formal diagnosis of IBS can be made by researchers and gastroenterologists using the Manning, ROME I, or ROME II criteria. However, practitioners most often use the diagnosis of exclusion/inclusion method.18,19
They first determine the patient’s complaints, which involve a functional gastrointestinal motility disorder. Next, they exclude other disease processes, and then look for the normally accepted inclusion symptoms that point to IBS.18,19
Organic Vs. Functional Disorder
The new evolving information on irritable bowel syndrome diagnosis and treatment points now to IBS being an organic disorder. Research shows it is characterized by “identifiable pathophysiologic changes, including alterations in interleukin Il-10/IL-12 rations consistent with a pro-inflammatory state, defects in serotonin receptors, and abnormalities in visceral hypersensitivity.” In other words, current research shows IBS is not a “functional disorder” that can only be diagnosed after other organic disorders are ruled out with diagnostic tests.17
Treatment
Armed with the information developed since the 1800’s regarding IBS as a functional disorder and the current research showing IBS as an organic disorder there are three forms of treatment. Singularly or in combination, these three forms of treatment can be used to suppress or cure the patient’s IBS:
• Medication
• Dietary changes
• Osteopathic manipulative treatment
Medical treatment varies from older generation antidepressants to new generation anxiolytics and antidepressants, medication for constipation, antidiarrheals, bulking agents and antispasmodics. Recent research has improved our understanding of IBS pathophysiology, especially as it relates to neurotransmitters and hormones in gastrointestinal motility. This has led to some newer treatments such as Prucalopride and Tegeserod for IBS-C and Alosetron for women with IBS-D.8 (Tegeserod was removed from the market 3/07)
Other success in IBS-D has involved Loperamide or a somatostatin analogue Octreotide, involved in targeting end organ receptors influencing motor function or secretion.
nterestingly, antidepressants found to be clinically beneficial also affect serotonin metabolism.5 Probiotics may have the benefit of altering bacterial flora and acting as an anti-inflammatory agent, but further study is needed.7
Herbs may also be beneficial. Specifically, peppermint oil led to improvement in some patients. Fish oil, primarily used for vascular health and treatment of certain lipid abnormalities, helps some patients with other IBS symptoms.
Food Factors
Dietary considerations and treatment of IBS may show significant decrease in symptoms. Hypersensitivity of food antigens has been demonstrated. Food sensitivities are frequently present in IBS.10
This fact along with identified pathophysiologic changes previously mentioned is changing the way IBS is diagnosed and treated. Going from the time-honored idea of a functional GI motility disorder to an organic disorder, there is a commercially available test that checks certain food and chemical sensitivities.3 Based on the results, a dietary management program may be offered. Not only does this have the benefit of disease treatment, but it may also be a disease management tool.
Other IBS treatment studies found food elimination based on serum immunoglobulin G antibodies in IBS resulted in significant symptom decrease. According to Gastroenterology Clinics of North America, June 2005, “Dietary manipulation may result in substantial improvement in IBS symptomatology provided it is individualized to the particular patient.” 9
By further understanding the mechanisms involved in dietary intolerance, it should be possible to optimize the benefits of this treatment approach. With current disease management protocols for asthma, pneumonia, congestive heart failure, etc, IBS may be another disease where significant strides can be made by disease management.
OMT for IBS
Osteopathic manipulative treatment offers another treatment form for short-term and long-term relief of IBS symptoms. One study showed significant improvement in IBS symptoms after two treatments, and these results increased continuously over a 10-week period of a custom tailored osteopathic treatment approach.13 Typically the somatic dysfunction would be thoracic or lumbosacral in origin. However, a thorough osteopathic musculoskeletal examination may reveal lesions elsewhere which if left untreated may impede treatment success. The type of manipulation did not seem to matter and unless proven, should be left to the care of the treating Osteopathic Physician.
Osteopathy professes the body has the inherent ability to heal itself. If there is a dysfunction in structure, the body’s function is impaired. Manipulation is used to treat dysfunction. Treatment benefits patients by optimizing structure, function, relaxation, normalizing autonomic control mechanisms inherent in our body and relieving congestion.14
Since these tenets of osteopathy have stood the test of time, it is readily apparent why osteopathic manipulative treatment can be so effective. Studies have also shown osteopathic treatment can be more effective than allopathic treatment.20
IBS Treatment
Irritable bowel syndrome is an elusive disease, at times, and successful treatment may be just as elusive. Though labeled as functional gastrointestinal motility disorder, studies that are more recent indicate it may well be an organic gastrointestinal disorder. As such, it becomes diagnosable by medical testing. Though easily identifiable and economically reasonable testing does not yet exist for IBS in the general medical community, progress is being made in this direction.
However, testing is available for one component of treatment. Non-IgE mediated immunologic food reaction testing is available and based on results, dietary treatment can be recommended.18 Currently, medications, dietary changes, and osteopathic manipulations are the most common treatments available. Other treatments have involved psychotherapy, relaxation therapy, and hypnotherapy. All have shown positive results.7
The diagnosis and treatment of IBS can be very difficult and frustrating for both the patient and the practitioner. The concerns and expectations of the patient must be met, along with any psychosocial issues. Any form of IBS without addressing all the issues may be unsuccessful.
In irritable bowel syndrome, as in other disease processes, the art of medicine as well as the science of medicine is fully integrated for successful diagnosis and treatment of this disease.
Dr. Jeff Rettig is a 1987 graduate of the Kirksville College of Osteopathic Medicine, Kirksville, Missouri. He received his certification in family medicine in 1995 and is in private practice at Rettig Family Health Care in Groesbeck, Texas.
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