Chapter 8. Irritable Bowel Syndrome

“One in five Americans has IBS, making it one of the most common disorders diagnosed by doctors. It occurs more often in women than in men, and it usually begins around age 20.”
Irritable Bowel Syndrome; National Institutes of Health[1]

Irritable bowel syndrome (spastic colon) is a chronic condition characterized by bloating, cramping, persistent abdominal pain or discomfort, frequent bowel movements, and bouts of diarrhea alternating with constipation. Inferring from the opening quote, it afflicts over 60 million Americans.

Left unchecked, irritable bowel syndrome gradually progresses to inflammatory bowel disease (IBD), which is one step away from ulcerative colitis (UC) and Crohn’s disease. The fine line that separates IBS from IBD is in the eye of the beholder—if you were to start poking around the bowel of an affected person, you’re bound to find some inflammation of the intestinal mucosa. In general, the causes, treatment, and prevention strategies of IBS and IBD are identical, except that in the case of IBD you suffer more, the treatment and healing takes longer, and the urgency is much higher.

Constipation is one of the most common afflictions associated with IBS. When the constipation is latent, the underlining conditions are hidden from view by the perception of regularity. That’s why ten times as many people complain of having IBS, rather than constipation.

There is an interesting paradox about IBS-related constipation: doctors may not recognize or diagnose IBS because patients may not have constipation at all, or have stools in the prescribed interval of time (at least three times weekly). By “prescribed,” I mean the diagnostic criteria set forth in The Merck Manual of Diagnosis and Therapy[2] (for general doctors), or the more authoritative source, such as Rome II Diagnostic Criteria For Functional Gastrointestinal Disorders[3] (used mainly by the specialists).

The pathologies that cause constipation-related IBS result from an abnormal amount of formed, hardened feces that may accumulate from the rectum all the way back to the cecum. This is a condition typical of latent constipation. The stools correspond to type 1 to 3 on the Bristol Stool Form Scale. The extended contact of the formed fecal mass with the intestinal wall causes irritation and mechanical abrasion of the bowel’s mucosa, especially during the periodic peristaltic contraction of muscles, and the propulsion of stools toward the rectum. In turn, perennial irritation and abrasion of mucosa cause inflammation and low-level discomfort, while peristalsis causes a more acute pain sensation, ranging from mild to sharp, which is referred to as cramps, or cramping.

Defecation is usually distressing, difficult, and requires intense straining. After defecation, some time passes before the residual abdominal pain subsides. This happens because of the transition of the hardened fecal mass from the upper regions of the large intestine into the lower part, which was just voided by defecation.

The initial accumulation of the hardened fecal mass (that causes IBS) inside the large intestine is the hallmark of functional constipation. Fiber by itself doesn’t cause IBS. But it does bulk up and harden fecal mass. Fiber creates even more discomfort and pain from the gases and acidity that result from bacterial fermentation. In time, fiber transforms functional constipation into latent, and, eventually into organic because of the colorectal damage incurred from large stools and straining.

Anorectal disorders that result from constipation, such as hemorrhoids and diverticular disease, are the most challenging aspect of IBS to deal with, because they’re irreversible. Fortunately, the pain, discomfort, and delayed or incomplete emptying of stools can be overcome, but these problems require a proactive approach, described elsewhere in this book.
Besides constipation, other prominent causes of IBS are:

• Gastroenteritis. The large intestine is at the very end of the “food” chain. All of the conditions that adversely affect the stomach (gastro-) and small intestine (-enteritis) inevitably ricochet in the gut (-colitis). Diarrhea, not constipation, is the most likely outcome. Bouts of diarrhea alternate with periods of constipation in the classical IBS pattern, because severe diarrhea washes out the intestinal flora essential for the formation of normal stools. Indigestion, food allergies, dietary irritants, food poisoning, malnutrition, viral and bacterial infections, smoking, chewing tobacco, and other assorted pathologies are the primary causes of gastroenteritis.
• Anorectal disorders. Anything that causes anal pain during defecation (stimulated by mechanical friction from passing stools or straining) is likely to cause delayed or incomplete emptying of stools. The pain may emanate from hemorrhoids, anal fissures, diverticular disease, and similar conditions that had previously been caused by chronic constipation or diarrhea. Incomplete emptying of stools leads to fecal impaction, which in turn causes severe IBS-related symptoms.
• Antibacterial agentsdecimate intestinal flora, and cause constipation and related complications, the harbingers of IBS. Among those agents, medicinal antibiotics and dental amalgams (mercury-based fillings) are particularly harmful and omnipresent, especially in the United States, where there are such a huge number of IBS sufferers.
• Adverse effects of medication. Numerous prescription and OTC medicines cause IBS-like side effects. This is especially true for “life-style” drugs taken regularly to mitigate the side effects of diets and aging, such as those used to treat heartburn (GERD), hypertension, migraine, diabetes, elevated cholesterol, constipation, bone disease, depression, even IBS itself, and others.
• Susceptibility to stress. I avoid saying “personality causes IBS,” because individual response to stress is determined, to a large extent, by a person’s diet. Actually, this is good news, because it means that you can mitigate the impact of stress by just changing your diet. This aspect of IBS (individual response to stress) is also the reason behind stress-induced sudden cramping and diarrhea.
• Bad luck. For many people, an “introduction” to IBS stems from a misfortune—food poisoning, viral or bacterial infection, an allergic reaction to a food, adverse effects of antibiotics intended to treat unrelated conditions, or a trauma that leaves one bed-ridden for a while.

You can’t insure against stress, infections, bad luck, or aging. You can, however, study this book to “insure” against improper nutrition and treatments, that makes an already bad situation even worse.

Hell of a treatment, or the treatment from hell?

Regardless of the cause of IBS, dietary fiber is a common denominator in the majority of cases. The fiber causes bulk, flatulence, and acidity, which deliver a one-two-three punch that only the very lucky can resist or deflect.

According to the International Foundation for Functional Gastrointestinal Disorders, we are in the midst of an IBS epidemic: