It has to be that way, as irritable bowel syndrome has no specific diagnostic test - and some of the other possibilities are rather serious.
Your tests so far have hopefully included tTG blood test and an upper abdominal ultrasound. These are for coeliac diseaseˢᵉᵉ ⁿᵒᵗᵉˢ ᵇᵉˡᵒʷ and pancreatic cancer.
If however, you've had your complaint for, say 3 years or more, then your story may allow a pretty definite diagnosis of irritable bowel syndrome. Serious complaints will have been largely ruled out by passage of time.
Symptoms present for only a few months, definitely need looking into.
If you find it hard to remember back, think specifically of special occasions, birthdays, holidays etc. and whether you had the trouble then.
The story in irritable bowel syndrome is likely to be of pain in your lower tummy, associated with irregular bowel habit and sometimes relieved by passing a bowel action.
Bloated feeling, incomplete emptying, urgent bowel actions and even accidents are typical. Anxiety can lead to attacks (and vice versa.)
Certain foods may aggravate your symptoms. For instance, chilli may increase pain.
Keep a diary for a week or two at the start, for later comparison of symptoms. It is really difficult later on to remember exactly what one was feeling, months earlier.
We tend to whitewash our memories, particularly regarding unpleasant things like irritable bowel syndrome symptoms.
If you've just been given this label, be thankful. Dorothy Owens et al¹ followed up 112 people with your diagnosis, for a median time of 29 years, and found no excess adverse health nor longevity outcomes.
This condition can follow gastroenteritis or travellers diarrhoea.
Campylobactor and Salmonella infections can be followed by this.
Follow up studies after local epidemics have shown 1 in 4 people had "IBS" for up to four years subsequently. Fewer (about 15%) of the general population have it.
Chlostridium difficile infection can persist for up to a year. This is a very resistant germ which can cause diarrhoea after antibiotics knock out its competition.
Blastocystis¹<span style='font-size: 50%'> is commonly misdiagnosed as IBS and at least in Pakistan was found in a lot of people diagnosed with IBS⁹.
Although people often talk about food allergies, intolerance or sensitivity are probably better terms to use.
Food allergy is usually reserved for immediate reactions such as sneezing from pollen or anaphylaxis from peanut or shellfish.
This is an area of medicine where opinions are severely polarized, and very few allergy specialists would agree with my attitude. I was fortunate to come in contact with people such as William Rae, in the 1980's, and to have very good specialists in this area available in Victoria.
One example of research on IBS was by Jones et al². 14 of 21 patients were able to find foods which aggravated their IBS by elimination and re-challenge tests.
Some of the 14 were hospitalized and tested by feeding through a stomach tube, and in nearly all cases they were able to tell when fed a food bad for them.
Sue Shepherd's FODMAP reduction diet, helps about 3/4 of IBS.
At any rate, my advice is to check this out.
You may be happy you did.
Atkinson et al³ found that using IgG4 blood tests then excluding foods based on the tests, was very effective. People who did exactly what was advised had two chances in 5 of improving their irritable bowel syndrome.
A combination of IgE plus IgG4 blood tests is reputed to give 80% concordance with the result of careful elimination and re-introduction of foods.
This all costs money, and you can test yourself for free.
You can combine Dr. Marshall Mandell's 5-day elimination diet⁴, for example, with Dr. Arthur Coca's pulse test.
When a food is totally removed from your diet for between 5 and 14 days, intolerance symptoms are likely to improve. Re-introduction during this time window is likely to bring on more immediate and more definite symptoms.
If your symptoms don't tell you, the pulse test may.
Do not do this if you have asthma or other serious allergic symptoms. Do not re-introduce foods if you are home alone, or unable to be taken quickly to an emergency room.
The author of one of my allergy books always got his patients to come to his surgery waiting room to have the first dose of each food.
There are a number of other ways you can test for food sensitivity, including electrodermal tests, dowsing, kinesiology or just going on your gut feelings (intuition.)
Now I may be in danger of losing you at this point.
Please stick around.
One way to see if this area is important for you, is to live briefly on an elemenal diet - Vivonex or Emsogen are examples, consisting of food broken down into its components which we can't be allergic to.
Good studies have been done in people with this condition, seeing how much pressure is needed to produce pain, on blowing up a balloon in their rectum!
Yup, I no kid.
Guess what - it takes less pressure than in people without IBS.
This is called "visceral hypersensitivity" (of the rectum here.)
The part of our autonomic nervous system which runs our bowels, may not be functioning as per "normal" in irritable bowel syndrome.
We have more nerve cells (neurones) in our gut than in our spinal cord. In animal experiments, this part of our nervous system can operate when completely cut off from the brain. Most of our body's serotonin neurotransmitter, is here - more than in our brain.
Our gut nerve system can be repaired. There are stem cells there, capable of turning into new neurones, under the influence of neurotrophic factors such as BDNF, NT-3 and GDNF.
The production and activity of these neurotrophic factors may be supported by nutrient supplements such as tryptophan, acetyl-l-carnitine, vitamin A and possibly D.
There is no doubt that the brain in our head is involved as well as the mini-brain in our gut.
Placebo reactor rates range from 25 to 70% in different studies of IBS. If nearly half can improve with a dummy treatment, it shows how much our mind is able to control it.
Anti depressant drug trials have given 40 to 83% (average 70%) response in IBS.
This involvement of our brain is seen in the high levels of corticotrophin releasing factor found in a majority of studies on IBS patients.
CRF is the chemical messenger from our brain to our pituitary gland, governing our adrenal gland.
The function of our emotional motor systemⁿᵒᵗᵉ ᵃ can be supported.
This may involve restoring balance between the sympathetic and parasympathetic arms of our autonomic nervous systemᵇ.
It may be by helping our hypothalamic pituitary adrenal axisᶜ, or our endogenous analgesic systemᵈ.
Naturopaths have protocols for such help, such as those from Henry Osiecki at Bioconcepts / Orthoplex in Australia.
Hypnosis, meditation and hatha yoga are paths to these ends.
If you are on any prescribed medication, it makes sense to check about drug-herb interactions before you try herbs.
Iberogast is a good one, to all accounts¹¹. It has stood the test of time and even the "double-blind, randomised, placebo-controlled trial."
This last is when no one knows who got the active and who the dummy treatment, until after the trial.
Peppermint oil enteric coated capsules are probably worth a try. It apparently can burn your bum, though.
One trial⁵ of Lactobacillus plantarum plus Bifidobacterium breve, compared to dummy treatment, reduced the abdominal pain to half in 50 IBS patients after a month. The dummy treatment helped by 11%.
In another trial⁸ a yeast strain (Saccharomyces cerevisiae) also improved abdominal pain and discomfort more than a placebo, by the 4th week.
"specific carbohydrate diet" emphasizes the effect of different dietary carbohydrates on the germs in the bowel.
GTN as a tablet or spray under your tongue, rapidly relaxes smooth muscle.
Our skeletal muscles are made of "striated muscle fibers," so called because of the microscopic appearance.
The muscle of our lower gullet, stomach and gut is called "smooth muscle" as it doesn't have that appearance. This is also the muscle of our gallbladder and our blood vessels.
As smooth muscle spasm may be responsible for colicy pain from our innards, GTN may be a useful treatment here.
a. Our "emotional motor system" runs the reactions we experience in our guts, via the two arms...
b. The "sympathetic nerves come from our spine between the base of our neck and the small of our back.
Our "parasympathetic nerves come from our neck and the base of our spine.
They make up the "autonomic nervous system," which along with our gut hormones, control the muscles and glands in our abdomen.
There is a current concept that dysfunction here can involve one being dominant (over the other.)
Parasympathetic dominance shows as increased appetite, loose bowel movements, slow pulse and possibly low blood pressure.
Sympathetic dominance includes reduced appetite, constipation, bloating and burping, higher pulse rate and blood pressure
Other sympathetic dominance indicators are anxiety and depression, sweaty palms and soles, dry mouth and eyes and intolerance to fatty foods.
c. The hypothalamic pituitary adrenal (HPA) axis consists of those three links in the chain of command between our brain and our cortisol and adrenaline stress hormones.
The hypothalamus is part of our brain.
The pituitary is a gland behind our eyes.
Our adrenal glands are on top of our kidneys.
CRF is the hormone messenger between the first two parts of this chain.ACTH is the messenger between the second and third parts.
d. Our endogenous analgesic system involves central nervous system production of opium - like substances, and diffuse noxious inhibitory controls, whereby pain is disregarded, reduced or blocked completely.
e. Tests for coeliac disease depend on whether one is still consuming gluten.
If so the tTG picks up a fair proportion, but only if the total IgA is normal. Duodenal biopsy remains the gold standard (most accurate) test.
If you have already gone on a gluten free diet, these tests will be inaccurate until you've consumed 4 slices of bread (or equivalent) per day for 6 weeks.
f. Bowel cancer and inflammatory bowel disease have to be checked for, most commonly by endoscopy these days.
g. Breath tests are available for lactulose, fructose and lactose. These measure hydrogen from fermentation by the germs in our bowel, of carbs we can't digest (producing gas and symptoms.)
The equipment to measure methane is expensive, so this is not often measured, even though also important in some people.
Fructose malabsorption is present in 30% of both healthy and irritable bowel syndrome sufferers. In the latter, a positive test for fructose can direct dietary advice, to avoid fructose and fructan containing foods.
Such avoidance may not have to be strict.
One of my earlier embarrassments in my medical career, was because of an excess of grapes. I called a senior doctor down to the emergency department, to see a woman I believed to have gallstone colic. She didn't have, and I hadn't obtained the history of eating lots of grapes.
Grapes are actually one of the better fruits, relatively low in wind forming fructose and fructan oligosaccharides.
In a study⁷ of 245 young people aged 2 and 18 years with unexplained
chronic abdominal pain, researchers in Tacoma, Washington found hydrogen
&/or methane breath tests positive after fructose load in 132.
Two thirds of the 132 were improved by avoiding fructose.
Problem fruits include...
Apple, apricot, avocado, blackberies, cherries, lychee, mango, nashi, nectarine, peach, pear, persimmon, plum, prune and watermelon.
Better fruits include...
Banana, blueberry, boysenberry, canteloupe, cauliflower, cranberry, grape, grapefruit, honeydew melon, kiwi fruit, lemon, lime, mandarin, mushroom, orange, passionfruit, paw paw, pineapple, raspberry, rhubarb, and strawberry.
Problem vegetables include...
Asparagus, beans (the seeds,) beetroot, brussel sprouts, cabbage, fennel, garlic, globe artichoke, jerusalem artichoke, leek, okra, onion, peas, shallot, snow peas and spring onion (the white part.)
Better vegetables include...
Alfalfa, bamboo and bean shoots, bok choy, broccoli, capsicum, carrot, celery, chives, corn, cucumber, eggplant, ginger, lettuce, marrow, olives, parsnip, potatoe, pumpkin, silverbeet, spinach, swede, sweet potatoe, taro, tomatoe, turnip and zucchini.
Lists such as these are what is generally so, but "one man's meat is another man's poison." The proof of the pudding has to be in the irritable bowel syndrome individual's eating.
One study⁶ of this individual idiosyncrasy, using IgG4 blood tests, found antibodies to milk, eggs, wheat, beef, pork and lamb commonly elevated.
Their IBS symptoms were improved by avoiding the foods to which they had elevated antibody titres.
Rice is generally OK. Artificial sweeteners are fermentable, and can cause excessive gas.
1. Annals of Internal Medicine 122(2) pp107-112 15th Jan 1995
2. Jones V. A. et al Lancet. 1982 Nov 20;2 pp:1115–1117.
3. Atkinson W, Sheldon TA, Shaath N, Whorwell PJ.
Gut. 2004 Oct;53(10):1459-64.
4. The Complete Guide to Sensible Eating p 92 By Gary Null
google "dr mandell 5 day elimination diet" to view this book
5. Saggioro, Alfredo MD
Journal of Clinical Gastroenterology 2004;38(suppl 2):104-106
6. Zar S Food-specific IgG4 antibody-guided exclusion diet improves symptoms and rectal compliance in irritable bowel syndrome Scand J Gastroenterol. 2005 Jul;40(7):800-7 http://www.ncbi.nlm.nih.gov/pubmed/16109655
7. American College of Gastroenterology 2010 Annual Scientific Meeting: Poster abstract 400. Presented October 17, 2010.
8. Prof. Pierre Desreumaux, University of Lille, France. Saccharomyces cerevisiae CNCM I-3856 Reduced Digestive Discomfort and Abdominal Pain in Subjects With Irritable Bowel Syndrome: A Randomized Double-Blinded Placebo-Controlled Clinical Trial. Presented at the 18th United European Gastroenterology Week, Barcelona, October 28, 2010
This is Lynside® Pro GI+, produced by Lesaffre Human Care.
9. JAVED YAKOOB et al IRRITABLE BOWEL SYNDROME: IN SEARCH OF AN ETIOLOGY: ROLE OF BLASTOCYSTIS HOMINIS Am J Trop Med Hyg April 2004 vol. 70 no.4 pp.383-385 http://www.ajtmh.org/content/70/4/383.long
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Don't you just love acronyms. This little lot are brain derived neurotrophic factor, neurotrophin-3 and glial derived neurotrophic factor.
Further down the page you'll find CRF which stands for corticotrophin releasing factor, followed by ACTH for adrenal cortical trophic hormone (another name for corticotrophin.)
Fructans are chemical compounds made of chains of fructose molocules, also called oligosaccharides (which can contain other sugars.)