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Health Matters: Intestinal condition is widespread and unexplained

Conway McLean, DPM, Journal columnist

Some afflictions get all the attention. The media latches onto some condition and soon the celebrities are doing tv spots and the telethons appear. Not to say those maladies so attended are unworthy; that is not the implication. More so, many others simply don’t get the publicity. There are many reasons and a multitude of factors. Let’s face it, some subjects are not very appealing. For example, infected wounds! Not particularly subtle, tending toward the particularly disgusting.

Another easy example would be matters of the lower intestine….and that end of things. I think the implication is clear to those of you paying attention. But, for example, how common is rectal cancer? I am happy to report it is not high on the list of most common diseases of the gastro-intestinal system. In contrast is a disease of the lower intestine, termed Irritable Bowel Syndrome. This common condition affects an unbelievable 15 to 20 percent of the world’s population. That works out to about a fifth of humanity. It affects some more directly than others. A family member with IBS (a more palatable way to name it), will almost certainly change your life in some way, be it significant or not.

IBS is a condition altering the functions of the lower intestine. Two of its most prominent characteristics are abdominal pain and altered bowel habits. Another important hallmark is the absence of any specific or unique organic pathology. This means we can’t find anything chemically or physically wrong with people who have IBS. To physicians and scientists, this is tremendously frustrating.

It is an odd disease in many ways. There is no increased risk of mortality, yet can haunt those affected nearly every day. It has an identified association with depression and suicidal ideation but the connection is unknown. It is as common elsewhere in the world as it is here, so there can’t be a connection with a particular diet. Strangely, most of the people with IBS are under the age of 50 because IBS is diagnosed 25% less often in those over 50 years. Despite this, many older adults suffer as well. Nearly two-thirds of those with IBS are female.

Many live their lives with IBS without ever getting a diagnosis or a treatment prescribed. Only 30% of those with the condition will consult their doctor. Strangely, those who do report it don’t have significantly different symptoms but do have higher levels of anxiety, as well as a reported lower quality of life. No discernible association with socioeconomic status has yet to be revealed. Most difficult is the absence of any blood test, chemical or histologic marker or identifier.

The diagnosis is primarily one of exclusion, although the experts will tout their latest improvements in their ability to make this diagnosis. Despite their protestations and the guidelines developed, it is generally the lack of identifying labs and tests, as well as the symptoms of the disease, that give it away. It is well recognized the symptoms fluctuate and change. Some symptoms may suddenly disappear while others develop just as quickly. Two basic types of IBS are recognized, with each characterized by completely different types of bowel movements. One is defined by diarrhea, aka IBS-D, while the other by constipation (IBS-C).

Half of those with irritable bowel syndrome will develop certain coexisting, “functional” conditions. Some examples include fibromyalgia, chronic fatigue syndrome, chronic back pain and chronic headaches, although none of the individuals interviewed for this report suffered any such problem. Still, their quality of life does seem to be significantly affected. Most experience abdominal pain, which tends to be vague and ill-defined. Those with IBS-D, the type who have diarrhea, generally have bowel movements that are small in volume and preceded by urgency, especially after eating. Some other symptoms occasionally reported include heartburn, nausea, even vomiting. These latter symptoms are less common and not a hallmark of IBS-D. Another characteristic is the result of said urgency, leading to an inability to “maintain”, despite the sufferers best efforts.

Diagnosis is frustratingly challenging in the absence of specific tests that might enable us to identify IBS with certainty. Studies to rule out other disorders are usually performed and can include a blood cell count to screen for anemia or inflammation. Testing for a blood-borne infection is also frequently performed. An evaluation of the patient’s metabolism is recommended, to evaluate for metabolic disorders and to rule out dehydration or an electrolyte disturbance. A stool sample should be evaluated for a parasite or a C. diff infection (Clostridium difficile).

How does IBS develop, and why? Seems like an appropriate question but definitive answers are lacking. Some have demonstrated higher levels of inflammation of the intestinal lining. Small bowel bacterial overgrowth has been proposed as a mechanism for some of the symptoms, especially bloating and distention. Often mentioned is some alteration of the gut-brain axis, a critically important facet of health about which we know too little.

Naturally at this juncture the talk turns to treatment. Unfortunately, once again, few specifics have been established. There is no definitive or standardized therapy, with many of the preparations available over the counter and some patients not requiring any medication. Management of irritable bowel syndrome consists primarily of providing psychological support and recommending dietary measures. Pharmacologic treatment, at this point in time, is adjunctive and is directed at symptoms.

Dietary changes may consist of supplementation with increased fiber intake. One example would be the product Citrucel, a polycarbophil compound, which causes less gas produced than psyllium compounds (eg, Metamucil). Some sufferers benefit from the avoidance of caffeine products, which can exacerbate symptoms. Probiotics are recommended, although experts are uncertain of their benefits in decreasing IBS symptoms. Psychological interventions, like cognitive-behavioral therapy and hypnotherapy, are more effective than placebo, and speak to the existence of some type of organic gut-brain connection.

How does one measure the consequences of a disease, the suffering, the pain? Is there some meter or technology that can determine such a thing? Where does the money go that is directed toward medical research? Is it for studying a one-in-a-million disease, that causes a horrific death? Or a common problem that occurs in many, but doesn’t cause any life-threatening illness? Also at issue, funding varies greatly from one country to another.

Many have voiced concerns about the direction our research funding has taken us. Much of ours is funded by pharmaceutical companies who want, understandably, to promote their product. Certainly, many beneficial advances have been made in the field of pharmacology and we are better off for it. But is sufficient weight given to the study of non-pharmacologic and non-surgical options for these many difficult and resistant problems?

Many of your friends and neighbors are living with irritable bowel syndrome, but probably haven’t made a grand announcement. Who would? Where is the excitement in having a disease of one’s bowels, dominated by diarrhea, pain and urgency? There should be no question it causes great suffering, if only because of the number of people who have it. Perhaps a better question concerns the development of a better understanding of IBS. Is there sufficient funding for research, elaborating on the mechanisms at play. Do we know what are the most effective, safe therapies? Many would resoundingly say “No!”. Probably about 15 percent of us.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.

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