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Inflammatory Bowel Disease and Cancer by Simple and Inexpensive Tests
In the absence of red flag symptoms or positive screening tests, patients with putative IBS do not need to be referred to a hospital; recent guidelines suggest they are better diagnosed and managed in primary care. But this does not mean that they need to occupy the already restricted time of the busy GP. There is no reason why IBS cannot be diagnosed and managed by specially trained nurses, dietitians, counsellors, or complementary therapists, while being monitored by the doctor with telephone/email access to specialists in secondary care if required.
Informed self-care is the new soundbite for most long-term medical conditions. Patients need to be informed, advised, and supported in how to manage their own illness in what is best for them. This can be done within the practice, but the charitable sector can provide many of the resources necessary to support practice nurses. The IBS Network is the national charity for people with IBS. This month, it has published its own comprehensive and holistic IBS Self Care Plan that provides information and advice for patients, self-help groups, or health care professionals. The IBS Network also publishes a monthly newsletter (Relief), a quarterly magazine (Gut Reaction), and ‘can’t wait cards’. Personal advice can be obtained via a telephone helpline, staffed by IBS-trained nurses, and by email responses from medical specialists.
The management of IBS changes with fashion, and people need to be kept up to date with recent trends. Thirty years ago, specialists were advocating coarse wheat bran for everything, particularly IBS. Now it seems, the wheels have fallen off the bran wagon. Dietary fiber needs to be taken advisedly. The NICE guidelines (2007) suggest that soluble fiber such as oats and linseeds would be more soothing to the gut than wheat bran, which may make symptoms worse. Other studies have suggested that many fruits and some vegetables contain complex sugars and starches that escape absorption and are fermented in the colon, worsening symptoms of pain and bloating, though such foods may require more fruit ‘n fiber. Prune juice, for example, is a great laxative. Those with diarrhea may be better on a low residue diet, but it depends on the individual patient. In IBS, as with many other ‘unexplained’ conditions, it is better to understand the patient than the illness.
Two factors tend to instigate symptoms of IBS: food and mood, and they often operate together. Despite popular belief, there is no good evidence that food allergy is responsible for more than 1% of cases of IBS, and specific food intolerance is also uncommon. Lactose, fructose, and wheat intolerance are probably more related to changes in bowel transit and sensitivity to gaseous distension than any specific effect of the food. So, it’s not so much the fault of the food, but more an intolerant gut. This might be due to mild inflammation caused by previous infection but is most commonly related to emotional tension. Even when IBS has been instigated by an attack of gastroenteritis, anxiety, depression, and life events predict the persistence of symptoms. Food intolerance is not a life sentence; many patients report that it comes and goes according to how they are feeling. It is often more useful to direct therapy to calming the gut than avoiding specific foods.
My clinical work with people who suffer from IBS has revealed that not only the symptoms of IBS but the foods that cause them may re-enact the dominant themes in a person’s life. To help people, it may not be so much a matter of selecting the right medicine or diet, but getting at the meaning (and the memory). One of my patients could never eat a meal of fish since the time her fiancé dumped her over a fancy meal in a fish restaurant. Foods may carry strong connotations that may be established by experience, often early in life, and are often enhanced by fashion and the media. How many of our convictions about food are established in childhood? What are the feelings around meat, shellfish, smelly cheese, milk, and chocolate? “I like it, but it doesn’t like me.” If certain foods create emotional tension (fear or guilt), that tension will often preferentially go to the gut, which will consolidate the belief about that food.
IBS, like many illnesses, does not have a single cause but is the interaction of several factors: a previous infection, diet, lifestyle (too busy, rushed), stress, memory, and meaning. Symptomatic treatment with drugs that reduce intestinal spasm and regulate bowel action may help but rarely cure. What patients often need is the confidence, belief, and control that may be brought about by insight and understanding.
Contact Dr. Read via his website www.nickread.co.uk or email info@nickread.co.uk.
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