Irritable Bowel Syndrome (IBS)

Irritable Bowel Syndrome (IBS) icon

IBS is characterised by a mixture of symptoms including recurrent chronic bloating, abdominal discomfort/cramping or pain, which can be associated with a variable bowel habit. The bowels can be constipated, loose or a mixture of both. Symptoms can range from being mild to severe, greatly interfering with quality of life. IBS is not related or a risk for inflammatory bowel disease and cannot cause colorectal cancer.

In essence the bowel looks normal but does not behave normally, with the usually smooth contractions and pressure moving the bowel contents along the gastrointestinal tract being disturbed or uncoordinated. The cause is unclear. One theory suggests the pathways connecting the brain and Gastrointestinal tract may interact abnormally in some way. Patients often feel worse around times of stress, but food intolerances and allergies, or even infection can impact symptoms.

Diagnosis

IBS is a diagnosis of exclusion as unfortunately there is not a specific test to diagnose IBS. Your general practitioner can test for causes other than IBS after assessing your history and examining you. Generally basic blood tests will assess for anaemia (blood loss); inflammation; malabsorption; thyroid dysfunction; or the presence of coeliac antibodies. A stool analysis can assess for infection, blood and even inflammation markers. An abdominal X-ray is a simple way to assess for unrealised constipation. In some cases more invasive testing is recommended. Alarm signs include symptoms occurring over the age of 40; anaemia; rectal bleeding; weight loss; fever; and a family history of inflammatory bowel disease or bowel cancer. In these situations review with a colonoscopy is advised.

Management of IBS

The approach should ideally be individualised and multifactorial. Despite medical limits in a definitive diagnostic test for IBS, there are successful options for relief of distressing and impactful symptoms.

Diet

It is important to eat breakfast - avoid skipping meals and long periods without eating. Restricting fast foods and processed foods can help. Maximising fluid intake to 2 litres daily and adjusting fibre intake to your predominant bowel habit is helpful. If you have constipation, have at least 30 grams of fibre daily but if diarrhoea is the predominant issue, fibre intake should be restricted.

A food diary can help identify dietary triggers and guide dietary decisions.

Food intolerances and allergies are becoming better understood. Allergies to fruit and vegetables are more common in adulthood and can result from cross-sensitisation to certain inhaled allergens or even tick bites.

Salicylates, amines, histamines and glutamate can sometimes be identified as triggers of IBS-like symptoms. Even moderate restriction of these foods can significantly help IBS symptoms. A Dietitian can assist in guiding these restrictions.

Bloating is a significant problem for some IBS patients. Avoiding constipation is important to avoid bloating, but certain foods can create more gas than others. Foods and drinks with a high sorbitol content such as diet soft drinks, sugar free gum and lollies particularly, should be avoided. Restriction of raffinose containing foods like pulses, cabbage, brussel sprouts and brassica vegetables like broccoli may help.

In recent years restricting foods high in certain sugars e.g. fructans (found in apples, pears, watermelon, fig, mango, pawpaw, onions, leeks, green beans, artichokes, honey, and large amounts of wheat) alleviates bloating.

A comprehensive restricted carbohydrate diet known as the low FODMAP diet has been proven to be very effective in some patients with IBS. If you find dietary restrictions help, over time try to gradually reintroduce small amounts back into your diet to establish your tolerance levels. A dietitian is advised if simple restrictions are unhelpful.

Lifestyle/Psychological

Sleep is important and often IBS patients report waking unrefreshed with fatigue a common issue. Sleep hygiene is important so make sure you sleep in a cool dark room and develop a night time routine. Take the time to unwind and relax at the end of the day. Your general practitioner can advise strategies to help improve sleep if needed.

Work life balance, regular exercise, and regular engagement with effective stress management strategies (e.g. yoga, meditation) are important in gut health and maintaining brain-gut balance. If necessary, underlying psychological issues such as anxiety and depression can be managed with your general practitioner.

If needed a referral for more formal psychological assistance, or in some cases medication may be required.

Medications/Supplements

Peppermint is a carminative herb which can be taken in a tablet or preparation like tea to help dispel gas and prevent bloating.

Psyllium based fibre supplements are effective in some patients but should be introduced slowly. This bulking agent can help constipation and diarrhoea. Short term and long term safe laxatives/aperients information can be sourced from your GP. It is recommended to avoid senna containing laxative products long term.

Anti spasmodics like Buscopan (hyoscine butylbromide) and simple pain relievers like Panadol (paracetamol) in recommended dosages can help abdominal discomfort.

For more information on Irritable Bowel Syndrome, download the GESA patient information PDF

Reflux

Reflux icon

Despite being a common gastrointestinal issue, the cause of heartburn/reflux is not well understood. Usually the direction of our ingested food via the gastrointestinal tract is from north to south–from the mouth downwards through to the back passage. Food is chewed in the mouth, passes down the oesophagus (food tube/gullet) and enters the stomach with the junction of the food tube and stomach contracting closed. This closure prevents the food moving back up into the food tube as well as acid refluxing from the stomach back into the oesophagus, and even into the mouth. The failure of this junction to contract properly can cause reflux. Acid contact with the lower oesophagus can cause inflammation known as Gastro-Oesophageal Reflux Disease (GORD).

A rising heat, mid chest discomfort or even a persistent cough or recurrent hoarse voice can be due to acid refluxing into the food tube. If you have symptoms which are new or persist for a few weeks, a gastroscopy may be advised to assess the cause and see if any physical changes are present within the oesophagus or stomach.

Caffeine, alcohol, high fat & large volume meals, and some medications can be causes or associated with worsening heartburn.

Keeping your weight down, especially around the belly, can prevent mechanical pressure on the stomach and reflux may be less likely to occur.

For night time symptoms, avoid eating and drinking at least 2 hours before going to bed. It also may help to elevate the chest and head using either a European pillow, boomerang style pillow or even a foam wedge under the head of the mattress/base. Don’t just elevate your head as this is not elevating the level at the junction of the food tube and stomach.

Acid lowering medications are available which have varying strengths. If you require them for longer than 3 months, a gastroscopy is advised to assess your oesophagus. If you need to increase their use and/or still have symptoms despite taking them, it is important you report these breakthrough symptoms to your GP to consider a review gastroscopy. Rarely if medication relief is unsuccessful, anti-reflux keyhole surgery can be considered for refractory cases.

Read more information on gastroscopy

For more information on reflux and heartburn, download the GESA patient information PDF

Barrett’s Oesophagus

Barrett’s oesophagus icon

When acid reflux has occurred untreated over a period of time, or in some cases silently at night for instance, Barrett’s oesophagus can occur. It is the finding of cell changes at the junction of the lower oesophagus where it meets the stomach. Patches of different cells not usually present at the lower end of the oesophagus (above the junction of the food tube/stomach) are noted. It seems to be a defence response where the stomach-like cells replace the previous food tube cells as the acid keeps coming into contact with that area. This transition means the altered areas are vulnerable to further changes called dysplasia and eventually some dysplasia can progress to cancer. This potentially precancerous condition can be identified and monitored with gastroscopy.

Once Barrett’s is identified, the affected oesophageal area is monitored for any changes by review gastroscopies and taking tissue samples. It is a bit like sun-damaged skin being checked by your GP or dermatologist regularly. Early changes can be picked up with interval gastroscopies. Early changes can be treated locally, and only in very significant cases of advanced change is surgery required. Oesophageal cancer only occurs in a minority of cases.

Long term acid lowering medication prescribed by your GP or Gastroenterologist is advised to decrease the risk of further Barrett’s development and reduce the risk of complications. However, there is no way to reverse the existing Barrett’s oesophageal changes. It is also important to keep your weight in the healthy range for your height, avoid excess belly fat, reduce alcohol to recommended levels for your gender, and cease smoking. Newer research is suggesting very hot drinks should also be avoided as the thermal injury may induce a reaction in the food tube/oesophagus.

Read more information on gastroscopy

Coeliac Disease

Coeliac disease icon

Coeliac disease occurs when you develop antibodies to the proteins in gluten found in wheat and wheat based products. This is an allergy to the protein gluten found in wheat. As a result, when the lining of the small bowel is in contact with gluten containing foods, it reacts with inflammation. This is like a rash on the inside. The subsequent inflammation in the small bowel interferes with absorption. You are not born with coeliac disease but with the genetic potential to develop it anytime between the ages of 2 and 90. Only some of the people born with the coeliac gene develop the disease. It can produce a variety of symptoms or none at all. However, some patients have itchy skin lesions, oral ulcers, nausea, constipation, diarrhoea, unexplained weight loss, abdominal bloating and/or discomfort. It is the second commonest cause of iron deficiency anaemia in Australia.

It can only be diagnosed if small bowel tissue samples are taken during a gastroscopy, sent for assessment under a microscope, and classic coeliac-like changes are noted. The large surface folds are shrunken and lots of inflammation is noted. You have to be eating wheat prior to the biopsies being taken otherwise the tissue samples can potentially look falsely normal.

Just like a rash, when the causative irritant is removed, the skin returns to normal, so does the small intestine lining with total restriction of gluten in those diagnosed with coeliac disease. After 12 months of a gluten free diet, the small bowel tissue samples should be repeated to confirm the small bowel has returned to a normal lining. Rarely the small bowel does not return to normal and is called refractory coeliac disease, requiring trials of special medications. As it is a genetic disease, once a family member is diagnosed, close relatives should also be checked. Initially this should be a blood test to measure coeliac antibodies.

Read more information on gastroscopy

For more information on coeliac disease, download the GESA patient information PDF

Diverticulosis

Diverticulosis icon

Diverticulosis or diverticular disease is a common finding in patients older than 60, but, increasingly is being identified in younger patients. It is thought exposure within the colon to high pressure over a long period of time leads to the development of diverticula or pockets within the wall of the large bowel, most likely due to insufficient dietary fibre. Although common, only a minority of people experience complications.

Uncommon complications can include inflammation, narrowing of the bowel and rectal bleeding. Sometimes inflammation starts in the diverticulum, can move along the wall of diverticular and even spread along the wall of the colon. Inflammation can range from mild to severe, leading to lower abdominal pain, fever and sometimes nausea. Antibiotics usually settle the episodes but rarely, further complications of infection including abscess or bowel perforation can occur, requiring surgery. The changes in the bowel wall from extensive diverticulosis can also lead to thickening of the bowel wall with subsequent narrowing of the colon. This can cause delay of bowel contents, constipation, bloating and subsequent abdominal discomfort. Less commonly, bright rectal bleeding can occur and sometimes be significant requiring hospital care. Fortunately it usually settles with time but can require surgery in those cases where it does not.

It is important to avoid constipation to help prevent further diverticular development. Dietary choices and at times stool softeners are used to try to establish a large volume soft stool daily. If tolerated, a high fibre diet is recommended and there are no dietary foods to exclude. In the past it was wrongly thought seeds and nuts should be avoided, but in fact a high fibre diet can be key to avoiding more diverticular developing.

For more information on diverticular disease, download the GESA patient information PDF

Inflammatory Bowel Disease

Inflammatory Bowel Disease icon

The spectrum of inflammatory bowel disease includes Crohn’s disease, ulcerative colitis and indeterminate colitis. These are autoimmune diseases and theories suggest in the genetically predisposed individuals, an environmental trigger e.g. infection, can lead to an immune reaction against parts of the gastrointestinal tract. Although the ages of 15 to 30 years are the most likely time these diseases first occur, the onset can occur anytime in adulthood.

The bowel wall is inflamed, and at times ulcerated to the point of bleeding, or past inflammation has led to narrowing and fibrosis. The level of inflammation can vary as can the extent of the gastrointestinal tract involved. Symptoms can be predominantly recurrent abdominal pain alone, a change in bowel habit (constipation or diarrhoea intermittently), or rectal bleeding (bright on the outside of formed stool or bloody diarrhoea ). If severe, weight loss, nausea, fatigue and significant anaemia (blood loss) can occur.

Inflammatory bowel disease is a remitting and relapsing condition where symptoms can come and go sometimes months and years apart. On average there is a delayed diagnosis of up to 2 years. In Crohn’s disease, inflammation affects the small bowel just before it joins the large bowel in the majority of cases. In those cases, abdominal pain is the most common symptom. Colitis means the large bowel is inflamed and this can range from a small segment to involving the whole colon. In ulcerative colitis, the rectum or left side of the bowel is the most commonly affected area. When the whole colon is affected, this is known as pancolitis.

Although called inflammatory bowel diseases, rarely some patients have other areas of their bodies involved including joints (arthritis); skin (ulcers and inflamed nodules); liver (hepatitis); and bile ducts (cholangitis).

To establish the diagnosis of inflammatory bowel disease, blood tests measure for inflammation, certain antibodies, vitamin deficiencies and anaemia; colonoscopy views the large bowel internally and sometimes special X-rays establish areas of bowel involved above the colon.

Management is decided on the basis of where the bowel is inflamed and the extent of the inflammation. A range of anti-inflammatory medications alter the level of inflammation while some medications alter the body’s immune reactions. The aim of the medications is to establish a remission and try to prevent relapses. Usually medication is needed for some time. A well balanced diet and healthy lifestyle will help achieve a good quality of life.

For more information on Inflammatory Bowel Disease, download the GESA patient information PDF

Fatty Liver (Steatosis)

Fatty liver (Steatosis) icon

When fat cells accumulate inside the liver, an inflammatory response can occur called steatosis; and if associated with raised liver blood tests as well, it is called steatohepatitis. It is not a benign condition but can occur with no symptoms. It is common in patients with diabetes regardless of weight; in people drinking excess alcohol; and it can be associated with taking certain medications. Unfortunately it is occurring in increasing numbers as more people carry excess weight, especially around the belly. Women are at risk if their girth is over 80 cm, and men if their girth is over 94 cm. The girth is measured around the level of the umbilicus (belly button).

Associated medical conditions can also include elevated cholesterol, raised blood pressure, insulin resistance and abnormal blood sugar levels. The ongoing liver irritation can be like any chronic hepatitis and progress to cirrhosis, and even liver cancer rarely.

The liver changes can be noted with repeated mildly elevated liver blood tests and in some cases there are changes noted on an abdominal ultrasound.

The key to management is to focus on reversible factors associated with fatty liver. It is important to lose weight and increase exercise. Your GP can help manage high blood pressure; diabetes if present; and reduce cholesterol. Ideally once fatty liver is identified, alcohol should be restricted or in some cases avoided altogether. To avoid any further potential liver injury, vaccinations for Hepatitis A and B viruses are encouraged. To monitor fatty liver, your GP can measure your blood tests, blood pressure, weight, girth, and if needed, check the structure of the liver with abdominal ultrasounds from time to time.

For more information on fatty liver disease, download the GESA patient information PDF

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