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January 2003

Irritable bowel syndrome 

by Dr. Howard Loomis

The symptoms of diarrhea, constipation, abdominal cramps and even rectal bleeding are fairly common in today's society. Many patients treat these symptoms themselves, never realizing their potential for devastating consequences. It is guess‑timated that 15% of the population is affected by irritable bowel syndrome (IBS).

Unfortunately, medical diagnosis of this syndrome is not well‑defined since definitive tests are expensive and difficult to perform and, more often than not, inconclusive. Therefore, most symptoms of bowel irritability are routinely treated with anti‑inflammatory drugs until more serious symptoms arise, such as fever, weight loss, anorexia, nocturnal symptoms, anemia (gastrointestinal bleeding), and pain. These "alarm symptoms" differentiate chronic inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis, from IBS.

Early recognition of this problem is a perfect way for you to ethically increase your patient load and at the same time make clinical practice more rewarding professionally as well as financially. Like many other conditions, such as back pain, medicine has long considered IBS to be a psychosomatic disorder and is only now beginning to recognize it as a complex pathophysiologic condition.

Normal function

Homeostasis is maintained constantly by the hypothalamus through the endocrine and autonomic nervous systems in response to any visceral irritation. Any organ or tissue unable to perform its functions adequately to maintain normal conditions within the extracellular fluid will be symptom‑productive. Therefore, we are best served by classifying bowel dysfunction by the patient's predominant symptom and then identifying the cause.

While the cause may theoretically be somato‑visceral, in the majority of cases the culprit is the patient's diet or prescription drug use.

For example, it is not common knowledge that 20% of patients who receive antibiotic therapy in hospitals develop colitis associated with Clostridium difficile. This anaerobic bacteria feeds on protein material in the bowel and produces gases, acids, and exotoxins that irritate the mucous lining of the bowel. This is a particularly difficult and frustrating problem for medicine. Increasingly stronger antibiotics such as Flagyl are used, but complete remission of the symptoms cannot always be obtained.

The waste material produced by microorganisms (exotoxins) can be absorbed across the gut wall and produce the inflammatory symptoms associated with such conditions as irritable bowel syndrome, fibromyalgia, and arthritis. Left undiagnosed and untreated, more advanced problems (diseases) result.

IBS medical criteria

Given the lack of a biologic marker, no definitive lab tests exist for IBS. Nevertheless, routine lab tests such as complete blood count, chemistry panel, thyroid function tests, and a test for occult blood are ordered. However, diagnosis is still based on symptoms that are positive for this syndrome and which exclude other conditions.

Primary among the criteria for identifying IBS is abdominal pain or discomfort for at least 12 weeks within the last 12 months. The 12 weeks need not be consecutive, but pain must be accompanied by one of the following:

***  Abdominal pain or discomfort relieved by defecation.

***  Onset is associated with a change in stool frequency.

***  Onset is associated with a change in the form or appearance of the stool.

For those that do not practice medicine, it is not necessary to wait from 12 to 52 weeks to be certain of the diagnosis. In the absence of the alarm symptoms, a more immediately productive procedure would be a review of symptoms, dietary analysis, and palpation of the abdomen and paraspinal musculature.

Physical examination

Physical examination will reveal muscle contraction in the area of L1 to L3, but abdominal palpation must be used to differentiate symptoms that may be arising from other visceral organs such as the kidneys, urinary bladder, and female organs.

There is poor localization of pain from the intestines, but the associated muscle contraction is quite exact. Generally, pain from the duodenum is periumbilical. Problems of the jejunum are felt in the upper left quadrant. The jejunum is where the simple sugars‑sucrose, lactose, and maltose‑are digested. Inadequate sucrose digestion produces constipation, while incomplete lactose and maltose digestion produces diarrhea. Correlation of symptoms and dietary intake with paraspinal and abdominal palpation will quickly delineate the cause of the patient's problem.

It is important to remember that the muscle contractions or trigger points are only present while the visceral organ is distressed. Once the stress is removed, the only remaining indications will be the symptoms and the paraspinal muscle contraction since the offending dietary problem is undoubtedly repeated at most meals. In other words, the subluxation pattern becomes chronic.

Problems in the ileum can be palpated over the right lower quadrant or around the McBurney point on the right side. Problems in the transverse and descending colon will be associated with muscle contraction in the lower left quadrant. Problems in the sigmoid colon produce pain and muscle contraction in the suprapubic area and posteriorly around the sacrum.