Frequently Asked Questions: Irritable bowel syndrome
Doctors, particularly in the United States, are trained to look for physical manifestations, such as inflammation, obstruction, or bleeding. But, for a while, IBS displays none, particularly in younger patients.
Despite this common knowledge, the diagnosing of IBS allows for a ton of billable services to seek out “the clues:”
“CBC [complete blood count], biochemical profile (including liver tests), ESR [erythrocyte sedimentation rate], stool examination for ova and parasites (in those with diarrhea predominance), thyroid-stimulating hormone and Ca for those with constipation, and flexible sigmoidoscopy or colonoscopy should be done” — advises Merck, and piles up even more tests to “test the tests:”
“Additional studies (such as ultrasound, CT [computer tomography], barium enema x-ray, upper GI esophagogastroduodenoscopy, and small-bowel x-rays) should be undertaken only when there are other objective abnormalities”.
All in all, that's several thousand dollars worth of mostly irrelevant testing, which in the case of “true” IBS will reveal little or nothing, and in all cases will cause even more colorectal damage from x-ray radiation, laxatives used to lavage the intestines before colonoscopy or CT, and anesthesia administered during colonoscopy.
Merck even says this much: “Many patients with IBS are overtested”. But the only true and relevant diagnostic criteria of IBS — dysbacteriosis, stool size, stool density, and internal hemorrhoids and straining (both may be absent in younger patients)— aren't considered.
In general terms, diarrhea-predominant IBS is a greater problem than constipation-predominant, because diarrhea suggests the presence of inflammatory disease in the large intestine. Whenever the mucosal membrane is affected by inflammation, it fails to remove fluids from feces and form stools. The ensuing accumulation of fluids causes diarrhea.
In terms of actual recovery, patients with diarrhea-predominant IBS require a guarded diet to eliminate food allergens and inflammation triggers, such as soluble fiber, pectin, sorbitol, and others.
Also, these patients must be screened for fecal impaction (a cause of paradoxical diarrhea), Clostridium difficile (a bacterial cause of colitis), parasites, viral infections, biliary and pancreatic disorders, and undergo the required medical treatment. That's where the value of a skilled and attentive physician is paramount.
Some individuals, particularly children and young women, may experience stress-related diarrhea for reasons explained here. Obviously, it's impossible to eliminate stress, but it's possible to learn how to redirect and reduce your response to it. More about it here.
Constipation and diarrhea are late stage complications of IBS. When IBS develops in younger people, they rarely experience constipation or diarrhea, because they still have taught, supple, and functional colons and rectums, sensitive anorectal plexes, undamaged anal canals, and so they move their bowels like clockwork.
IBS itself begins with the gradual enlargement of stools either from fiber, or from a mild inflammation of the intestinal mucosa caused by the by-products of fiber fermentation, or from evolving food allergies, or from the loss of intestinal flora, or from all of the above.
At one point or another enlarged stools require moderate straining. This, in turn, enlarges internal hemorrhoids (unbeknown to most until late or at all) and constricts an already narrow anal canal even more. This leads to incomplete emptying, further hardening of stools, further enlarging of hemorrhoids, and more straining. Then, one day, a person can't strain hard enough to move bowels at all for more than three days. That's — no stools for more than three days — what The Merck Manual calls constipation, and that's the definition that most doctors and patients are saddled with.
It may take you 5, 10, 20, 30 or more years to reach that day, depending on your doctor's directions, age, gender, diet, toilet habits, degree of luck, and multitude of other factors discussed throughout this site.
If prior to that moment you had uncomfortable stools every other day or so, technically you were not constipated. Medically speaking, you are “healthy” until day four! Before that — don't bother the doctors, and take more fiber.
All of this would be really funny if it wasn't so tragic. You can learn more about this charade doctors “play” with constipation here. The role of fiber in the pathogenesis of colorectal disorders, including IBS, is explained here.
The "syndrome" in IBS stands for a collection of symptoms that make up this condition. Its‘ interpretation varies from textbook to textbook, from reference to reference, and from doctor to doctor. In other words, diagnosing IBS is a "free-for-all" enterprise, because there are no actual physical attributes (i.e. inflammation, bleeding, high-temperature, blood tests, etc.) to cling too.
Most of the IBS symptoms are also present in IBD (i.e. inflammatory bowel disease). The primary distinguishing characteristics of early stage IBD (i.e. before endoscopy shows inflammation) are: stools close to diarrhea; excess mucus in stools; sustained, round-the-clock bloating, but with less flatulence, typical for IBS because by this time most of the bacteria are dead, and fermentable matter (i.e. fiber, the source of gases) is rapidly disposed off during diarrhea.
The absence of flatulence (i.e. gases) points out to dysbacteriosis. When flatus is present, the bloating results primarily from gases. The bloating without gases (or with very little) indicates inflammation of the mucosal membrane of the small and large intestine.
This inflammatory condition traps gases and fluids (i.e. prevents their absorption into blood), and increases the diameter of intestines, particularly the small intestine. Because this organ is so large (around 14 to 22 feet in adults) and so tightly packed inside the abdominal cavity, even a small increase in its diameter distends (pushes out) the abdominal wall, hence the "bloating."
The gases in the small intestine are always naturally formed when the acidic content of the stomach moves in, and gets neutralized by pancreatic juices (bicarbonate).
The putrefaction (rotting) of undigested proteins may form gases too. The gases in the large intestine are formed when undigested carbohydrates (fibers, lactose, polysaccharides, sugar alcohols) get fermented by bacteria.
Bacteria are often present in the lower small intestine (ileum), and may form profuse gases there from fermentation too. These are usually the most bothersome, because they have no place to escape.
The gases from the large intestine may also escape into the small intestine whenever the ileocecal valve opens up to let the content of the small intestine pass into the large intestine.
Antibiotics kill bacteria in the small and large intestine, and terminate fermentation of undigested carbohydrates. This stops fermentation and production of gases, alcohols, and fatty acids, and helps subdue an inflammatory condition. In turn, the intestines shrink and reduce internal pressure on internal organs.
Unfortunately, antibiotics also ruin normal colon ecology, and cause problems, ranging from severe diarrhea to an equally severe constipation. They also strip the intestinal membrane from it's natural protectors (i.e. bacteria), reduce primary immunity (phagocytosis), blood clotting, vitamin synthesis, and so on. So, logically, you are better off excluding fiber and other sources of undigested carbs to stop fermentation, rather than use an "atomic bomb" approach to wipe out bacteria.
Besides, there are always some antibiotic-resistant mutant bacteria (such as methicillin-resistant Staphylococcus aureus, MSRA) left behind, and they are the ones which may eventually kill you, particularly in the hospital setting. At this point, you have nobody to thank, but the profit-driven “Big Pharma” and careless doctoring.
Insoluble fiber (bulking agent) makes stools large. Large stools induce straining, straining causes the enlargement of internal hemorrhoids, enlarged hemorrhoids cause incomplete emptying, incomplete emptying causes impacted stools, impacted stools cause abdominal cramps.
Soluble fiber (hydrophilic mucilloid) blocks the absorption of digestive fluids. Blocked fluids, including astringent bile and omnivorous enzymes, slip down into the large intestine, and wreak havoc there. To cleanse itself of irritants and impacted stools, the large intestine responds with profuse diarrhea. When the diarrhea is over, the colon's examination shows no visible damage. Back on fiber, and the cycle starts again.
Both fibers are fermentable. If the bacteria level is normal, soluble fiber ferments 100%, insoluble — about 50% with normal motility, almost 100% with slow motility (common in IBS).
In the overall scheme of things, soluble fiber is by far more damaging then insoluble, except in the cases of (a) inflammatory bowel disease (caused primarily by soluble fiber), and (b) obstruction in young children and older adults. In the case of IBD — because inflammation prevents water absorption and narrows the passageway; in young children — because their internal organs as so tiny and so easy to obstruct; and in older adults — because of slow and inefficient peristalsis, often made worse by the indiscriminate use of systemic drugs, which may affect peristalsis even more.
Along with advice to use fiber, this is one of the most damaging recommendations in all of IBS-related dietary dogma. In fact, the absence of fats makes IBS and its‘ side-effects much worse, and turns it into IBDs. You can read more about the role of fats in digestion and colorectal disorders here.
If anything, the absence of fats will cause more damage to your entire digestive tract, health, and cause severe constipation (i.e. a primary symptom of IBS), because dietary fats are essential for regularity. You can read more about the role of fats in constipation here.
It's true that dietary fats precipitate the gastrocolic reflex and peristaltic mass movement — two conditions essential for normal propulsion of food through the GI tract, normal stool formation, and normal defecation. Indeed, this normal physiological effect of fat precedes pain and cramping in impaired individuals, and results from normal peristalsis encountering large stools and gases — an effect similar to giving a shiatsu massage to your abdomen in the midst of IBS relapse.
In the long-term, the “killing” or reducing of peristalsis by restricting fats makes all IBS-related constipation even worse — more constipation, more fecal impaction, larger stools, more gases, more pain, more sensitivity to pain, stiffer, smooth muscles, and impaired muscle contraction from severe calcium deficiency, because calcium doesn't get assimilated without fat in the diet.
Q. Does stress contribute to IBS? Is there indeed a psychosocial aspect to IBS?
Stress contributes to practically all disorders, not just IBS, because the chemistry behind the stress response isn't merely mental or perceptual, but endocrine — meaning any stress or even the anticipation of stress elicits an unconscious secretion or over-secretion of multiple stress hormones, which govern physical aspects of the stress response. These are adrenalin, noradrenalin, cortisol, and some others.
In the case of IBS, stress hormones inhibit gastric digestion and intestinal propulsion (peristalsis). These two conditions predispose people to a broad range of functional GI disorders. The most typical ones are: nausea, vomiting, indigestion, heartburn, GERD, peptic ulcers, bloating, abdominal cramps, and constipation or diarrhea, depending on stress intensity and duration.
There are two core reasons behind all these happenings:'
- Elevated blood pressure compensation. Rapidly elevated blood pressure in response to a sudden, strong stress event causes a near instant release of excess blood plasma into the stomach and large intestine lumen to normalize it. This is the body's “safety release valve”, essential to prevent blood vessels and capillaries from rupture. Unfortunately, rapid stretching of the stomach with fluids stimulates the vomiting center which causes nausea and vomiting. Similarly, excess fluids in the colon flow downwards, stimulate the anal plexus and provoke profuse diarrhea.
- Impact on digestion and motility. Moderate or even low-level sustained stress inhibits digestion and motility (peristaltic propulsion of food and stools) in order to mobilize energy for a flight-or-fight type of response. Sustained, long-term stress leads to indigestion “on the top,” and constipation “on the bottom” because nothing, literally, moves. Both conditions — indigestion and constipation — contribute mightily to IBS and related digestive disorders.
Can you do anything about it? Yes, you can. In cases of major stress events, it's a matter of training and conditioning. Professional soldiers don't soil their pants or vomit when they get fired at — they duck, evade, and respond. If they can be trained to ignore bullets, so can you to evade mother-in-law, ignore an obnoxious co-worker, and duck away from rude drivers, and there is plenty of specialized literature, dedicated to this subject.
Moderate and/or extended stress must be managed with proper nutritional “hygiene.” When exposed to stress of any modality or duration, use the following rules:
Restrict proteins. While under severe or even moderate stress, protein may not digest fully because stress hormones inhibit gastric secretion and peristalsis. Restricting proteins allows you to prevent indigestion, dyspepsia, food poisoning, and related complications.
This particular advice often elicits scorn and disdain from low-carb zealots, particularly young turks with no formal training in medicine or nutrition. One such turk wrote on his blog about my similar advice to people with gastritis: “Smart and intelligent people can be very stupid.” Well, kid, I'd rather be stupid and healthy, than smart and dead. And so are my readers. This page (or my books) aren't about low-carbing, but chronic digestive disorders.
- Always hydrate (drink water) yourself on an empty stomach. If your stomach is full with food, don't flood it with more water because (a) it will inhibit digestion even more; (b) it may cause nausea and vomiting; and (c) it will not satisfy your thirst because water can't get down into the intestines to get assimilated. Instead, place something sweet into your mouth, sweetness stimulates saliva secretion and this will make the thirst less apparent.
- Normalize blood sugar. After an initial spike of stress hormones, blood sugar dives down considerably, and you may experience strong cravings for sweets. If your stomach is already full, don't stuff it with more food to get your sugar fix — they won't give you any more “blood sugar” until carbs get down into the intestines. Instead, use near instant sublingual glucose tablets, or dissolve a sugar cube, or piece of chocolate under the tongue. You only need 2-3 grams of glucose to stabilize low blood sugar, and, in this case, the sublingual path is the fastest available (other than an I.V. drip).
- Eat only if hungry. Don't eat your regular meals if you aren't hungry — most people under stress aren't, except to satisfy their sugar cravings. If you do eat, you aren't likely to digest these foods anyway. So if you crave sugar, then get some sugar, not a turkey sandwich.
- Don't skip regular bowel movements. You aren't likely to experience the defecation urge because stress inhibits intestinal peristalsis. But missing even one bowel movement dries out and enlarges stools already in the colon — a prescription for constipation. To stimulate stools without straining, use the “helpers” described here.
As you can see, it isn't the stress per se, that causes IBS, but the lack of knowledge and readiness to deal with it and its aftermath. Well, now you know!
Q. So what's the role of psychotherapy in all this? Is it a fluke or has it some role?
Yes, in a very limited way, but absoluty “no” in all substantive ways. Here is the drill:
— No, because psychotherapy can't eliminate the underlying, physical causes of irritable bowel syndrome by pep talk and/or hypnosis alone.
— No, because psychotherapy can't completely rewire the innate, evolutionary, fight-or-flight type of stress response even in the most sophisticated, dedicated, and motivated individuals.
— No, because a shrink isn't a substitute for a normal poop.
— No, because wishful thinking is the worst treatment for internal disorders with clear-cut physiological causes.
— Yes, because many cases of stress response are self-perpetuating — i.e. fear breeds more fear. Assuming you can find and afford a skilled enough psychologist to break that endless loop, yes, it helps a great deal.
— Yes, because you can learn (or be taught) to respond to stress in a less self-destructive and agonizing way.
— Yes, because psychotherapy and related approaches (yoga, meditation, prayer, controlled breathing, chants, etc.) do offer a palliative, temporary release from acute pain. This effect results from the general relaxation and temporary reduction of stress hormones.
But, as I have already said, you can't chase away excess gases and large stools, or plant back missing bacteria by using palliative psychology any more than you can fill a cavity with hypnosis or reverse breast cancer with motivational therapy.
Yes, it is, because smoking stimulates saliva secretion. In turn, smoke-laced saliva gets swallowed, and stimulates the secretion of gastric juices, the gastrocolic reflex, and peristaltic mass movement — the precursors to abdominal cramps and/or diarrhea. That's, incidentally, why people are told not to smoke on an empty stomach.
Interestingly, my own bout with severe IBS started soon after I quit smoking in 1984, but for exactly the opposite reason — I no longer had sufficient stimulation of intestinal peristalsis to initiate regular bowel movements, skipped a few, became chronically constipated, and started to rely on fiber laxatives, such as Metamucil, to move my bowels.
In general, yes, it's bad for IBS, particularly during acute stages. Lets review the reasons:
- First, alcoholic beverages in themselves are fluids which inhibit gastric digestion when consumed in excess with or after food. The side effects of indigestion and related complications inevitably boomerang into IBS.
- Second, excessive alcohol (whenever you feel the buzz) inhibits digestive tract peristalsis. For this reason you may actually feel a temporary relief from abdominal pain and cramping. But, just like in the case with Imodium, poor contraction contributes to constipation.
- Third, alcohol in excess causes dehydration and sodium loss because the large intestine is very effective at recovering every bit of moisture and sodium from stools. This particular aspect of alcohol-related dehydration dries out stools, causes constipation, and may contribute to IBS.
When dehydration and sodium loss become extreme, you may actually experience diarrhea because of a sodium-potassium blood imbalance. To compensate, the body dumps excess potassium (along with gobs of plasma, of course) into the colon's lumen. This, in turn, causes profuse diarrhea, which dehydrates you even more.
A similar chain of events (sans alcohol) causes runner's diarrhea. Western athletes listen to that stupid advice and load themselves up with Gatorade — a potassium- and sugar-rich drink — before and while running. No wonder, the diminutive Kenyans win all those darn marathons — they don't have sports medicine doctors or Gatorade in Kenya yet to compromise their health and performance. To be fair, Gatorade contains sodium, but not enough to compensate its losses with sweat during actual races.
To my amazement, the cause of runner's diarrhea is still (2008) considered unknown. Well, not anymore. To prevent dehydration and diarrhea, load up on salt before the race because sodium is essential for water retention. That's why the hospital I.V. drip contains 0.9% of sodium chloride, not potassium. For the same reason, pickles and brine are so “therapeutic” after a sauna or for a hangover. Who, but the Russians, would know all that...
- Fourth, alcohol affects the liver function. This, in turn, may cause a profuse release of bile — the body‘s way of removing offensive metabolites. This action causes an almost immediate diarrhea, which may lead to constipation, and contribute to IBS.
- Fifth, some alcoholic beverages are highly allergenic to sensitive individuals. The biggest offenders are: beer for gluten-sensitive individuals (most people with IBS are); tonic mixed with gin from allergies to quinine; sulfites in wines, cognacs, and aged scotch, which may cause diarrhea; loads of fiber in V-8 added to ‘Bloody Mary,’ and probably many others.
- Six, alcohol lowers blood sugar (this, actually, causes drunkenness). In turn, low blood sugar raises the levels of insulin and that's what makes some drunk people so angry and aggressive, as it raises their levels of stress hormone. These two simultaneous actions stimulate appetite on the one hand, and inhibit digestion on the other, and that's what is causing nausea, vomiting, and hangovers. One bad binge may easily precipitate IBS, particularly in middle-aged persons who aren‘t adept at hard drinking. Younger people are less vulnerable, because, for a while, they enjoy “guts of steel.”
Will you get harmed by a glass of wine along with dinner? Probably not, as long as you are drinking French or Italian table wines, vin de table and vino da tavola, respectively.
Vintage (or quality by the European Union definition) wines are aged in oak casks. New wine casks are treated with sulfites to prevent expensive oak wood from rotting. Aging infuses wines with these sulfites. Unlike vintage, table wines are made and kept in stainless steel vats, and they never get exposed to oak impregnated with sulfites.
The less scrupulous producers of inexpensive table wines (and often vintage wines too), add extra sulfites to prevent spoilage, so these wines can be shipped, sold, and stored without regard to temperature almost indefinitely.
This practice is widespread outside of the European Union, but particularly in the United States and Latin America. For this reason I never touch American wines, unless the label says “Organic.” This way I am assured of having good night sleep and clear head the “morning after.”
Sulfites are very strong allergens. Just like MSG, they produce a very unpleasant “histamine flush,” which is what causes its‘ nasty after-effects, such as migraine, insomnia, nausea, dizziness, sweating, tachycardia, wheezing, hives, pale skin, and even anaphylaxis in hypersensitive individuals. Unfortunately, histamine intensifies inflammatory conditions, which are prevalent in people with IBS.
It‘s not such a big deal in the United States where the culture of daily wine drinking was all but non-existent until very recently and the drinking age is 21. But it is (a big deal) for French or Italians who drink table wines with practically every meal and literally from birth (though highly diluted).
No wonder they can‘t afford experiencing daily hangovers or anaphylactic shock, particularly among children. For these reasons adding sulfites to table wine intentionally may get one into prison in France, while in the United States it‘s taught in winery courses as “good business.”
You‘ll still see the “Contains Sulfites” statement on practically all wine labels, table or not, because, apparently, they occur in wines naturally. I say “apparently,” because I don‘t believe this is true. But it‘s cheaper for the E.U.-based winemakers and distributors to comply with the U.S. labeling regulations, than to certify their wines as “organic” or “sulfites-free.” After all, table (a.k.a. jug) wines are bought mainly on price, not the quality or purity of content.
Histamine receptors (H2) play an important role in the secretion of gastric juices, and, correspondingly, in digestion. For these reasons sulfites and alcohol may cause dyspepsia — a general term for unspecific stomach distress. This condition is particularly harmful to people already affected by irritable bowel syndrome or inflammatory bowel diseases.
In general, if you have already developed an allergic reaction to sulfites in wines, you may react adversely even to “clean” wines — the immune system commonly produces antibodies to other wine components, and retains this “body memory” for a considerable length of time. In this case, you are better off skipping alcoholic beverages aged in casks, such as wines, ports, champagnes, vermouths, sakes, cognacs, whiskeys (scotches), and others.
— What‘s left? Any good triple-distilled vodka, such as Smirnoff. And don‘t waste your money on all those “gourmet” vodkas in artisan bottles. Many of those have that discerning taste precisely because they are inadequately distilled and are more likely to cause hangovers. Only this time around, it isn‘t from added sulfites, but from toxic alcohols other than ethanol (i.e. pure alcohol).
So, show me some wine (scotch, cognac, etc.) ‘cognoscenti’ — those snobbish and oftentimes arrogant guys, and nowadays, gals too — who swoon over aged bottles of expensive grape juice or malted barley, and discuss “notes” the way mere mortals deconstruct Angelina Jolie of early vintage, and I‘ll show you a fool in the high-risk group for IBS, IBD, peptic ulcers, and digestive cancers.
How come the French get away with it? Well, actually, they don‘t. The rate of digestive cancers in France is quite high as well, but it has to do more with smoking than wine. Besides, even when the French drink vintage wines on special occasions or after dinner, they do so by the sip, not by the goblet, the way the ‘nouveau riche’ drink nowadays.
— What do I drink? Lately, I don‘t, because alcohol interferes with my writing, energy, mood, and sleep. The only exception — when we are going out for sashimi. In this case, I‘ll have a glass of sake in order to sterilize raw fish with alcohol. I also always take with me MSG and gluten-free soy sauce. Just like sulfites, both of these substances are an absolute no-no for people with IBS, IBD, or a past history of both.
I don't know any more about “all this” than most doctors, particularly board certified gastroenterologists, gastric oncologists, or endoscopists, except that I am better trained to research and analyze broadly available information and research, investigate inconsistencies, connect the dots, and describe my findings in accessible language.
All of the background information I rely upon is described in exceptional depth in primary medical texts as well as medical references, including The Merck Manual, which I quote so often. I learned most of these basic facts back in the seventies in medical schools from textbooks authored decades earlier, and from professors trained before World War II.
If a medical doctor doesn't know “all this” basic information about human digestion, he/she wouldn't be able to pass a licensing board exam. So this question should really ask: “Why doctors don't use all this information to treat patients?”
Well, some do, particularly outside of the United States. Since most of the healthcare delivery in the United States is orchestrated by pharmaceutical companies, which publish the majority of textbooks and references, administer continuous medical education (CME) courses, design and administer licensing exams, and own or sponsor most of the medical publications and web sites, doctors are trained to rely more on tests and drugs, than on inexpensive and truly effective solutions.
Besides, it's faster and easier to write prescriptions; drugs offer quick relief to patients and create an aura of competence; and the drugs' side effects bring a ton more repeat business soon thereafter. So why kill the bonanza writing web pages (such as this), or waste valuable “face” time teaching patients the fine points of stools?
In the doctors' defense, I have to say this: the majority of their patients don't give a damn about the causes of their diseases; don't care to learn how to eliminate these causes, don't want to change anything in their lives and diets, and prefer an instant fix with this or that pill, ideally for free.
Naturally, doctors, insurers, and pharmaceutical companies respond to “market pressures” just like any other business worth its salt would — they give their customers what they want! It's good business, and, besides, it's great for business.
If you have read this page this far, you are a welcome exception. So don't be a dupe, do the right thing, don't dwell far too long over things outside of your circles of control and influence, and show others the way simply by getting well. It sure beats popping pills, wearing a colectomy bag, or bleeding to death.