Get to the root cause of abdominal pain

Originally published in The Ottawa Citizen August 17, 2004
Original Title:”Mommy, my stomach hurts”

There are numerous causes for abdominal pain and cramps, warranting a thorough evaluation; diagnoses include peptic ulcer disease, acid reflux, colitis and bowel cancer, among others.

Evaluation of abdominal pain is a complex process because many diseases share common symptoms. When a thorough history, physical examination and appropriate diagnostic testing eliminate most causes, thoughts turn to irritable bowel syndrome.

Studies indicate that the worldwide incidence of IBS varies from three to 22 per cent. Approximately 50 per cent of people experience symptoms before the age of 35, and 40 per cent between 35 and 50 years of age. They account for about half of all consults to gastroenterologists.

Women have a greater prevalence accounting for 70 per cent of all IBS patients. Many women with IBS suffer from chronic pelvic pain, menstrual period pain (dysmenorrhea) or painful intercourse (dyspareunia). They may have a history of several abdominal surgeries.

Physicians use a set of specific guidelines like the Rome II Diagnostic Criteria to assist in the diagnosis (www.helpforibs.com/footer/rome_guidelines.asp). For most people there are distinct symptoms: constipation or diarrhea in concert with bloating and abdominal cramps and distention. Indeed, the symptoms and signs of the disease will determine what kind of IBS the patient has.

There are three overlapping types of IBS: constipation-, diarrhea- and pain-predominant.

Some patients will have changes in their bowel movement frequency. Others may have mucousy stools, a sensation of an ongoing need to defecate or a feeling of not being able to fully empty the bowel. In IBS, bowel movements usually provide immense relief from the abdominal spasms, bloating and pain.

There is a risk of using the post hoc ergo propter hoc (“it happened after so it was caused by”) approach with respect to IBS triggers, because there is no unifying cause for this disorder. Most people do not share a common set of factors that trigger their IBS.

Indeed, myriad seemingly unrelated factors are implicated in the expression of IBS: dietary factors, impaired ability of the small and large intestine to move contents forward, sexual and physical abuse, drug and alcohol abuse, fibromyalgia and chronic fatigue syndrome, among many others.

The important point is that this disorder is not imagined. It is real and is debilitating. What does the evidence to date indicate?

The relationship between IBS and food intolerance and allergy is not clear-cut because only a small percentage of patients have these conditions. Low-fibre diets seem to contribute to IBS. Indeed, the addition of a fibre-rich foods or supplements has helped a minority of patients. Populations that follow high-fibre diets seem to have a low incidence of IBS.

IBS patients experience over-reactive and intense intestinal spasm in response to certain emotional and physical triggers. This response can be triggered following a meal, by a low pain threshold or rectal pressure. Endoscopic procedures like colonoscopy can reproduce this intense response.

Blaming IBS on psychiatric factors is not in keeping with the available evidence because chronic disease can lead to depression and anxiety related reactions. Indeed, more than 50 per cent of people with IBS have a psychiatric illness. People who abuse drugs and alcohol or who have experienced severe emotional trauma (e.g. divorce, death of a family member or sexual abuse) seem to have a greater risk of developing IBS.

Treatment of IBS depends on the patient’s understanding of their triggers and symptoms. Treatment includes changing dietary habits, increasing fibre content of foods (note that high fibre diets may worsen diarrhea-predominant IBS), re-training the bowel, increased physical activity, stress-reduction counselling and medications.

Dietitians provide an invaluable service in the preparation of a dietary plan to minimize food triggers and maximize proper nutrition. They will help you achieve a balance between soluble and insoluble fibre.

Avoiding intestinal stimulants such as caffeine, nuts, corns, seeds, alcohol and nicotine may help alleviate the symptoms.

There are many medications available to control the intestinal spasm. Tegaserod (Zelnorm), trimebutine (Modulon) and pinaverium bromide (Dicetel) help restore the bowel’s normal contraction process Tegaserod is indicated for women with constipation-predominant IBS whereas the others treats all types.

There is no standard approach to treatment because of the nature of this disease. Your doctor and dietitian can help you develop a comprehensive treatment program that may include other therapies and medications not mentioned in this column; it is by no means complete.

For more information, visit the Canadian Society of Intestinal

Research website at www.badgut.com/index.php?contentFile=ibs&title=Irritable%20Bowel %20Syndrome .

For an IBS symptom checklist and questionnaire, go to www.ibsvillage.com/info/c/c10.jsp .


© Dr. Barry Dworkin 2004

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