Hypnotherapy In Adelaide

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Classification

IBS can be classified as either diarrhea -predominant (IBS-D), constipation -predominant (IBS-C), or with alternating stool pattern (IBS-A or pain-predominant). In some individuals, IBS may have an acute onset and develop after an infectious illness characterized by two or more of the following: fever, vomiting, diarrhea, or positive stool culture,  This post-infective syndrome has consequently been termed "post-infectious IBS" (IBS-PI).

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Signs and symptoms

The primary symptoms of IBS are abdominal pain or discomfort in association with frequent diarrhea or constipation and a change in bowel habits. There may also be urgency for bowel movements, a feeling of incomplete evacuation (tenesmus), bloating, or abdominal distension. In some cases, the symptoms are relieved by bowel movements. People with IBS, more commonly than others, have gastroesophageal reflux, symptoms relating to the genitourinary system, chronic fatgue syndrome, fibromyalgia, headache, backache and psychiatric symptoms such as depression and anxiety. Some studies indicate that up to 60% of persons with IBS also have a psychological disorder, typically anxiety or depression.

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Causes

The cause of IBS is unknown; several hypotheses have been proposed. The risk of developing IBS increases sixfold after acute gastrointestinal infection. Postinfection, further risk factors are young age, prolonged fever, anxiety, and depression. Publications suggesting the role of brain-gut "axis" appeared in the 1990s, such as the study "Brain-gut response to stress and cholinergic stimulation in IBS" published in the Journal of Clinical Gastroenterology in 1993. A 1997 study published in Gut magazine suggested that IBS was associated with a "derailing of the brain-gut axis." Psychological factors may be important in the etiology of IBS.

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Active infections

Other researchers have focused on an unrecognized protozoal infection as a cause of IBS as certain protozoal infections occur more frequently in IBS patients. Two of the protozoa investigated have a high prevalence in industrialized countries and infect the bowel, but little is known about them as they are recently emerged pathogens.

blastocysis is a single-cell organism that has been reported to produce symptoms of abdominal pain, constipation and diarrhea in patients though these reports are contested by some physicians. Studies from research hospitals have identified high blastocystis infection rates in IBS patients, with 38% being reported from London School of Hygiene & Tropical Medicine, 47% reported from the Department of Gastroenterology at Aga Khan University in Pakistan and 18.1% reported from the Institute of Diseases and Public Health at University of Ancona in Italy. Reports from all three groups indicate a blastocystis prevalence of approximately 7% in non-IBS patients. Researchers have noted that clinical diagnostics fail to identify infection, and Blastocystis may not respond to treatment with common antiprotozoals.

Dientamoeba Fragilis is a single-cell organism that produces abdominal pain and diarrhea. Studies have reported a high incidence of infection in developed countries, and symptoms of patients resolve following antibiotic treatment. A 2002 study reported on a large group of patients with IBS-like symptoms who were found to be infected with Dientamoeba fragilis and experienced resolution of symptoms following treatment. Researchers have noted that methods used clinically may fail to detect some Dientamoeba fragilis infections. It is also found in people without IBS

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Diagnosis

There is no specific laboratory or imaging test that can be performed to diagnose irritable bowel syndrome. Diagnosis of IBS involves excluding conditions that produce IBS-like symptoms and then following a procedure to categorize the patient's symptoms. Ruling out parasitic infections, lactose intolerance, small intestinal bacterial overgrowth, and celiac disease is recommended for all patients before a diagnosis of irritable bowel syndrome is made. In patients over 50 years old, it is recommended that they undergo a screening colonoscopy.

Differential diagnosis

Colon cancer, inflammatory bowel disease, thyroid disorders, and giardiasis can all feature abnormal defecation and abdominal pain. Less common causes of this symptom profile are carcinoid syndrome, microscopic colitis, bacterial overgrowth, and eosinophilic gastroenteritis: IBS is, however, such a common presentation, and testing for these conditions would yield such low numbers of positive results, that it is considered difficult to justify the expense. Because there are many causes of diarrhea that give IBS-like symptoms, the American Gastroenterological Association published a set of guidelines for tests to be performed to rule out other causes for these symptoms. These include gastrointestinal infections, lactose intolerance, and coeliac disease. Research has suggested that these guidelines are not always followed. Once other causes have been excluded, the diagnosis of IBS is performed using a diagnostic algorithm. Well-known algorithms include the Manning Criteria,  the obsolete Rome l and ll criteria, and the Kruis Criteria, and studies have compared their reliability. The more recent Rome lll Process was published in 2006. Physicians may choose to use one of these guidelines or may simply choose to rely on their own anecdotal experience with past patients. The algorithm may include additional tests to guard against misdiagnosis of other diseases as IBS. Such "red flag" symptoms may include weight loss, gastrointestinal bleeding, anemia, or nocturnal symptoms. However, researchers have noted that red flag conditions may not always contribute to accuracy in diagnosis; for instance, as many as 31% of IBS patients have blood in their stool, many possibly from hemorrhoidal bleeding.

The diagnostic algorithm identifies a name that can be applied to the patient's condition based on the combination of the patient's symptoms of diarrhea, abdominal pain, and constipation. For example, the statement "50% of returning travelers had developed functional diarrhea while 25% had developed IBS" would mean that half the travelers had diarrhea while a quarter had diarrhea with abdominal pain. While some researchers believe this categorization system will help physicians understand IBS, others have questioned the value of the system and suggested that all IBS patients have the same underlying disease but with different symptoms.

Investigations

Investigations are performed to exclude other conditions:

Stool microscopy and culture (to exclude infectious conditions)

Blood tests: Full blood examination, liver function tests, erythrocyte sedimentation rate, serological testing for coeliac disease

Abdominal ultrasound (to exclude gallstones and other biliary tract diseases)

endosopy and biopsies (to exclude peptic ulcer disease, coeliac disease, inflammatory bowel disease, malignancies)

Hydrogen breath testing (to exclude fructose and lactose malabsorption)

Misdiagnosis

Published research has demonstrated that some poor patient outcomes are due to treatable causes of diarrhea being misdiagnosed as IBS. Common examples include infectious diseases, coeliac disease, Helicobacter pylori, parasites. 

Coeliac disease in particular is often misdiagnosed as IBS. The American College of Gastroenterology recommends that all patients with symptoms of IBS be tested for coeliac disease.

Bile acid malabsorpton  is also often missed in patients with diarrhea-predominant IBS. SEHCAT tests suggest that around 30% of D-IBS have this condition, and most respond to bile acid sequestrants.

Chronic use of certain sedative hypnotic drugs, especially the benzodiazepines, may cause irritable bowel-like symptoms that can lead to a misdiagnosis of irritable bowel syndrome.

Comorbidities

Researchers have identified several medical conditions, or comorbidities, which appear with greater frequency in patients diagnosed with IBS.

Headache, fibromyalgia, chronic fatigue syndrome and depression:  A study of 97,593 individuals with IBS identified comorbidities such as headache, fibromyalgia, and depression. A systematic review found that IBS occurs in 51% of chronic fatigue syndrome patients and 49% of fibromyalgia patients, and psychiatric disorders were found to occur in 94% of IBS patients.

inflammatory bowel disease IBD: Some researchers have suggested that IBS is a type of low-grade inflammatory bowel disease. Researchers have suggested that IBS and IBD are interrelated diseases, noting that patients with IBD experience IBS-like symptoms when their IBD is in remission. A three-year study found that patients diagnosed with IBS were 16.3 times more likely to be diagnosed with IBD during the study period. Serum markers associated with inflammation have also been found in patients with IBS (see Causes).

Abdominal surgery: A 2008 study found that IBS patients were at increased risk of having unnecessary cholecystectomy (gall bladder removal surgery) not due to an increased risk of gallstones, but rather to abdominal pain, awareness of having gallstones, and inappropriate surgical indications. A 2005 study reported that IBS patients are 87% more likely to undergo abdominal and pelvic surgery and three times more likely to undergo gallbladder surgery. A study published in Gastroenterology  came to similar conclusions, and also noted IBS patients were twice as likely to undergo hysterectomy.

endometriosis: One study reported a statistically significant link between migraine headaches, IBS, and endometriosis.

Other chronic disorders: interstitial cystitus may be associated with other chronic pain syndromes, such as irritable bowel syndrome and fibromyalgia. The connection between these syndromes is unknown.

Management

A number of treatments have been found to be better than placebo, including fiber, antispasmodics, and peppermint oil.

Diet

Some people with IBS may have food intolerances.

A low FODMAP diet has been shown to reduce symptoms in functional GI disorders such as IBS by 60-80%. This diet restricts various carbohydrates which are poorly absorbed in the small intestine as well as fructose and lactose, which are similarly poorly absorbed in those with intolerances to them. Reduction of fructose and frutan have been shown to reduce IBS symptoms in a dose-dependent manner in patients with fructose malabsorption and IBS. Many individuals with IBS are lactose intolerant and a trial of a lactose-free diet is often recommended. Alternatively, an over-the-counter remedy containing lactase enzyme can be taken before consuming milk products. Allergy to milk products also causes diarrhea and other symptoms, and this will not be improved by a lactase enzyme supplement. Many who benefit from a low FODMAP diet need not restrict fructose or lactose.

Some IBS patients believe they have some form of dietary intolerance; however, tests attempting to predict food sensitivity in IBS have been disappointing. A small study reported that an IgG antibody test was somewhat effective in determining food sensitivity in IBS patients, with patients on the elimination diet experiencing 10% greater symptom reduction than those on a sham diet. However, more research is necessary before IgG testing can be recommended.

There is no evidence that digestion of food or absorption of nutrients is problematic for those with IBS at rates different from those without IBS. However, the very act of eating or drinking can provoke an overreaction of the gastrocolic response in some patients with IBS owing to their heightened visceral sensitivity, and this may lead to abdominal pain, diarrhea, and/or constipation.

Fiber

There is some evidence that soluble fiber supplementation (e.g., psyllium/ispagula husk) is effective in the general IBS population. It acts as a bulking agent, and for many IBS-D patients, it allows for a more consistent stool. For IBS-C patients, it seems to allow for a softer, moister, more easily passable stool.

On the contrary, insoluble fiber (e.g., bran) has not been found to be effective for IBS. In some people, insoluble fiber supplementation may aggravate symptoms.

Fiber might be beneficial in those who have a predominance of constipation. In patients who have IBS-C, soluble fiber at doses of 20 grams per day can reduce overall symptoms but will not reduce pain. The research supporting dietary fiber contains conflicting, small studies that are complicated by the heterogeneity of types of fiber and doses used.

One meta analysis found that only soluble fiber improved global symptoms of irritable bowel, but neither type of fiber reduced pain. An updated meta-analysis by the same authors also found that soluble fiber reduced symptoms, while insoluble fiber worsened symptoms in some cases. Positive studies have used 10–30 grams per day of psyllium. One study specifically examined the effect of dose and found that 20 grams of ispaghula husk was better than 10 grams and equivalent to 30 grams per day. An uncontrolled study noted increased symptoms with insoluble fibers. It is unclear if these symptoms are truly increased compared with a control group. If the symptoms are increased, it is unclear if these patients were diarrhea predominant (which can be exacerbated by insoluble fiber), or if the increase is temporary before benefit occurs.

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Psychotherapy

The mind-body or brain-gut interactions has been proposed for irritable bowel syndrome and is gaining increasing research attention. For some patients, psychological therapies may help with symptoms. Cognitive behavioural therapy and Hypnosis have been found to be the most beneficial. Hypnosis can improve mental well-being, and cognitive behavioural therapy can provide psychological coping strategies for dealing with distressing symptoms as well as help suppress thoughts and behaviours that increase the symptoms of irritable bowel syndrome. Cognitive behavioural therapy has been found to improve symptoms in a number of studies. Relaxation therapy has also been found to be helpful.

A questionnaire in 2006 designed to identify patients’ perceptions about IBS, their preferences on the type of information they need, and educational media and expectations from health care providers revealed misperceptions about IBS developing into other conditions, including colitis, malnutrition, and cancer.

The survey found IBS patients were most interested in learning about foods to avoid (60%), causes of IBS (55%), medications (58%), coping strategies (56%), and psychological factors related to IBS (55%). The respondents indicated that they wanted their physicians to be available via phone or e-mail following a visit (80%), have the ability to listen (80%), and provide hope (73%) and support (63%).

Stress relief

Reducing stress may reduce the frequency and severity of IBS symptoms. Techniques that may be helpful include:

Relaxation techniques such as meditation

Physical activities such as yoga or tai chi 

Regular exercise such as swimming, walking or running

Exercise

Many patients find that exercise helps with IBS. At least 30 minutes of strenuous exercise 5 times a week is recommended.

Alternative medicine

Because of often unsatisfactory results from medical treatments for IBS, up to 50 percent of people turn to complementary alternative medicine.

Probiotics

Probiotics can be beneficial in the treatment of IBS; taking 10 billion to 100 billion beneficial bacteria per day is recommended for beneficial results. However, further research is needed on individual strains of beneficial bacteria for more refined recommendations. A number of probiotics have been found to be effective including: Lactobacillus plantorum and bifidobacteria infantis;

however, one review found that only bifidobacteria infantis showed efficacy. Some yogurt is made using probiotics that may help ease symptoms of irritable bowel syndrome.

Herbal remedies

Peppermint oil: Enteric coated peppermint oil capsules have been suggested for IBS symptoms in adults and children.There is evidence of a beneficial effect of these capsules and it is recommended that peppermint be trialed in all irritable bowel syndrome patients. Safety during pregnancy has not been established, however, and caution is required not to chew or break the enteric coating ; otherwise gastroesophageal reflux may occur as a result of lower esophageal sphincter relaxation. Occasionally nausea and perianal burning occur as side effects.

Iberogast: The multi-herbal extract lberogast was found to be significantly superior to placebo via both an abdominal pain scale and an IBS symptom score after four weeks of treatment.

Cannabis

Kiwifruit IBS/C

Commiphora mukul

Plantago ovate

There is only limited evidence for the effectiveness of other herbal remedies for irritable bowel syndrome. As with all herbs, it is wise to be aware of possible drug interactions and adverse effects.

Yoga

Yoga may be effective for some with irritable bowel syndrome, especially poses which exercise the lower abdomen.

Acupuncture

Acupuncture may be worth a trial in select patients, but the evidence base for effectiveness is weak. A meta analysis by the Cochrane Collaboration found no benefits of acupuncture relative to placebo for IBS symptom severity or IBS-related quality of life.