What Gastroenterologists Should Know About Managing IBS
Brian E. Lacy, MD, PhD
Mayo Clinic, Jacksonville, Florida
Lacy BE. What Gastroenterologists Should Know About Managing IBS [published online August 22, 2019]. Gastroenterology Consultant.
Diagnosing irritable bowel syndrome (IBS) entails multiple factors. One is that the patient’s symptoms should be chronic; they cannot have experienced just 1 week of symptoms but rather 6 months of symptoms, which must be active in the last 3 months. The cornerstone of the diagnosis of IBS is abdominal pain with disordered bowel habits, such as a change in stool form, a change in bowel movement frequency, or a relationship of the abdominal pain with the disordered bowel habits. Some patients can have pain and constipation-type symptoms, and while others can have abdominal pain with diarrhea-type symptoms. Some patients can also experience pain by exhibiting alternating symptoms of constipation and diarrhea.
Oftentimes, patients can have overlapping symptoms of a variety of disorders. For example, if a patient presents with IBS with diarrhea, is it just IBS, or could it be IBS along with lactose intolerance? Or can it be IBS with—though rare—celiac disease? The mistake a provider or patient can make is focusing on only one of the disorders or not checking for celiac disease. To avoid this mistake, I like to think about prevalence, or the epidemiology of the disorder. With 14% of the US population having it, IBS is fairly common, presenting in 14% of the US population. Lactose intolerance is pretty common as well, with a 35% prevalence rate among US adults. Celiac disease, however, is not common. Only 1 in 250 people have celiac disease—that is 0.4% of the population. Of course, the overlap is possible so physicians should think about that and analyze symptoms logically.
Current guidelines are vague on how to approach the possibility of a patient with IBS having celiac disease. Some recommendations indicate that everyone with suspected diarrhea-predominant IBS (IBS-D) have laboratory values checked for celiac disease. Some believe this approach is not cost-effective, suggesting that a patient be checked for celiac disease only if they fail standard therapy and symptoms are persistent.
Something else to keep in mind is that IBS is a heterogenous disorder. IBS-D is often discussed as one disorder, but it is probably at least 9 or 10 separate disorders under that one large umbrella. I can see 50 patients in a row with IBS-D and have the underlying pathophysiology be different for many, if not all of them. So, while a diagnostic treatment algorithm would make life easier, developing one will be difficult.
Treating With A Holistic Approach
When I discuss treatment of IBS with patients, I present a holistic approach. I explain to the patient that we will discuss diet, stress, sleep, abdominal pain, bowel habits, and—if it is present—psychological distress. Therefore, I might have a patient see a dietician to help with IBS symptoms. I might discuss ways to improve sleep. If stress seems to be playing a role in symptom generation, I will discuss ways to decrease stress which may include exercise, yoga, or meditation. For some patients I will discuss psychological therapy to help improve gastrointestinal (GI) symptoms.
The benefits of psychological therapy come in different forms. There first is a greater awareness of the brain-gut connection and how thoughts and emotions, of which patients may not have been aware of, can influence the GI tract and conversely, how GI symptoms can influence the brain. It is really a bi-directional pathway. Psychological therapy also frequently teaches patients useful stress reduction techniques. It can guide them on how to deal with anxiety, depression, somatization, or catastrophizing. Cognitive behavioral therapy (CBT) in particular can offer very helpful self-awareness and coping strategies. The idea behind CBT is to not only fully understand and accept the chronic disorder, but to also learn coping strategies to help patients move ahead with their lives.
Barriers to psychological therapies
Although an effective approach, there are barriers to implementation of psychological therapy. Gastroenterologists may not be aware that psychological therapies are a good management option. There is also a lack of large, placebo-controlled trials to assess efficacy and safety. CBT is the one psychological therapy that has been the best studied to date.
Another barrier to implementation occurs in the office. Gastroenterologists may be unsure or unclear on how to address the use of psychological therapies with their patients. If you were to advise a patient to see a psychologist, the patient might get offended, believing you think they are “crazy” or that the IBS pain is “in their head.” To prevent this unfortunate and unpleasant possibility of miscommunication, clinicians should be sure to explain and emphasize the brain-gut connection. They can say something like, “We are going to work on the GI tract with diet and medications, but we also need to address the whole body, which includes the brain because we know there is a connection between the brain and the GI tract.” If approached the wrong way with a patient, an opportunity for a good therapeutic relationship could be lost.
Ford AC, Lacy BE, Talley NJ. Irritable bowel syndrome. New Eng J Med. 2017; 376:2566-2578. https://www.nejm.org/doi/10.1056/NEJMra1607547.
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