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DR AILEEN SEAH,
CONSULTANT COLORECTAL SURGEON
COLORECTAL CLINIC@ NATIONAL UNIVERSITY HOSPITAL
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A diary of food intake and symptoms can be useful in identifying foods that may trigger off symptoms. Some patients benefit from avoiding or limiting their intake of foodstuff like caffeine, alcohol, fatty-foods, gas-producing vegetables, milk etc. Being aware of this can give the patient a sense of control of their symptoms. Be careful of over-zealous elimination such that nutrition is inadequate.
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Fibre and bulking agents have been traditionally used for IBS patients with constipation. However, a sudden increase in fibre can give rise to symptoms like bloating.
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The opiate and opioid analogues diphenoxylate-atropine and loperamide stimulate receptors in the enteric nervous system that inhibit peristalsis and fluid secretion. Loperamide is effective against diarrhea but not pain, in patients with IBS. A bile-acid binder can be added empirically to control refractory diarrhea, and is effective for post-cholecystectomy, diarrhea-predominant IBS.
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Anticholinergics
Several studies have shown that symptoms of IBS do not respond significantly to anticholinergics alone. Side effects are common.
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Smooth muscle relaxants
Mebeverine is a phenylethlamine derivative of reserpine that has a direct spasmolytic effect on smooth muscles, with few atropine-like effects. It is useful in patients with abdominal pain. When used together with a bulking agent and an anxiolytic agent this combination has been found to improve symptoms up to 90% of patients,
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Peppermint Oil
Peppermint oil appears to have direct relaxing effects on gastrointestinal smooth muscle, so it might act as an antispasmodic agent. However, it relaxes the lower oesophageal sphincter and can cause heartburn.
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Osmotic laxatives such as magnesium salts, phosphate salts, and polyethylene glycol-based laxatives have been used. Nonabsorbed carbohydrates laxatives such as lactulose and sorbitol are effective but can promote the formation of gas, which many patients find uncomfortable and difficult to expel. Stimulant cathartics like bisacodyl and senna can cause cramping and are associated with tachyphylaxis and dependency and should be avoided long-term.
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Tricyclic antidepressants in low doses appear effective for irritable bowel syndrome. Tricyclic antidepressants are recommended for moderate-to-severe irritable bowel syndrome in which pain is prominent or when other therapies have failed. Because of a delayed onset of action, treatment should be continued for 3 to 4 weeks and continued for 3 to 6 months before tapering.
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Tegaserod (Zelmac), a drug similar to the prokinetic agent cisapride, is a partial agonist of the 5-HT4 receptor. It accelerates gastric emptying and small-bowel transit. Tegaserod has been approved by the FDA for use for up to 12 weeks in women with constipation-predominant IBS. It should be reserved for female patients whit constipation-predominant IBS who have no response or fibre or laxatives and antispasmodic agents. A recent study on tegaserod on Asian patients suggest that majority of Asian men and women with non-D-IBS or IBS-C will benefit from it.
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Psychosocial stressors are important triggers for symptoms of IBS and patients who seek treatment for IBS have a greater prevalence of psychological diagnoses. Various techniques such as cognitive behavioral therapy (directed at maladaptive perceptions of illness and behavior), dynamic psychotherapy (directed at interpersonal problems), relaxation and stress management therapy, and hypnotherapy, alone or in combination are reportedly effective for symptoms.
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Probiotics are beneficial strains of bacteria and yeast found in the human gut. However, there is currently no clinical evidence to recommend this as a standard form of treatment.
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Many patients with IBS seek relief using acupuncture, a component of Traditional Chinese Medicine (TCM). The Cochrane Collaboration meta-analysis was unable to make any conclusions as to whether acupuncture is more effective and sham acupuncture or other interventions for treating IBS as most of the trials included in the review were heterogeneous in terms of interventions, controls and outcomes measured. TCM does not have a clinical diagnosis of IBS. Instead the TCM approach is different compared to western medicine. From a TCM perspective, management is not based on anatomical pathology, but rather, diagnostics, treatment and choice of acupuncture points are based on syndrome differentiation. For example, a possible reason for constipation is insufficiency of qi and blood and treatment would be geared towards replenishing qi and blood by stimulating points like pishu, weishu, zusanli etc. A different conglomeration of symptoms associated with constipation may be due to excess heat in the stomach and intestines and a different set of acupoints like quchi, hegu will be used.
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