7: Irritable bowel syndrome

Case 7 Irritable bowel syndrome

Description of irritable bowel syndrome

Definition

Irritable bowel syndrome (IBS) is a chronic, functional bowel disorder characterised by abnormal defecation, visceral hypersensitivity and altered bowel motility. Depending on the prevailing stool pattern of the condition, IBS may be classified as IBS with constipation (IBS-C), IBS with diarrhoea (IBS-D), mixed IBS (IBS-M) or unclassified IBS (IBS-U).¹

Epidemiology

Between four and thirty-five per cent of the world’s population is affected by IBS. Much of this variation can be explained by geographical variability, with higher prevalence rates observed in China and Western countries, and lower rates noted in South Africa and Thailand.¹ Onset of IBS typically occurs in the teens or second decade of life; incidence peaks in the third and fourth decades of life and falls in the sixth and seventh decades.¹ Race does not appear to be a factor in the incidence of IBS, though the condition does more commonly affect women than men, at a ratio of 3:1.²

Aetiology and pathophysiology

IBS appears to be a disease of multifactorial aetiology. While the primary cause is still not known, a number of factors have been shown to precipitate or aggravate the condition. These triggers include psychosocial stress (e.g. parental rejection, history of abuse, increased life stressors), anxiety, infectious gastroenteritis, diet (e.g. food intolerance), medication (e.g. antibiotics, hormone replacement therapy) and the act of eating.¹^–³

Even though the cause of IBS is not yet known, many theories have attempted to explain the pathophysiological basis of the disease. It is postulated that exposure to the triggers mentioned above, together with genetic predisposition, contributes to the development of chronic enteric inflammation and/or small intestinal bacterial overgrowth. These pathological changes may be responsible for local neuronal degeneration and immune dysfunction, and the subsequent development of visceral hypersensitivity (which may cause abdominal and/or rectal discomfort) and altered bowel motility (a possible cause of constipation, diarrhoea and nausea).^1,³

Clinical manifestations

People with IBS often present with an array of gastrointestinal, psychological and/or systemic symptoms of varying intensity and frequency. Non-specific symptoms such as fatigue, chronic headache and sleep disturbances may be accompanied by psychological manifestations that include poor concentration, anxiety and depression. An individual may also complain of dyspepsia, flatulence, mucorrhoea, rectal sensitivity, nausea, abdominal bloating, left lower quadrant tenderness and periodic constipation and/or diarrhoea.² According to the Rome III criteria for the diagnosis of IBS, the defining feature is the presence of colicky pain or continuous dull ache to the lower abdomen or left lower abdominal quadrant for at least 3 days a month in the past 3 months (with the onset of symptoms occurring at least 6 months prior), which is associated with at least two of the following: a change in stool consistency, a change in the frequency of defecation and/or improvement post defecation.¹

Clinical case

32-year-old woman with irritable bowel syndrome

Rapport

Adopt the practitioner strategies and behaviours highlighted in Table 2.1 (chapter 2) to improve client trust, communication and rapport, as well as the accuracy and comprehensiveness of the clinical assessment.

Assessment

Once measures have been put into place to build client–practitioner rapport, the clinician can begin the clinical assessment.

Health history

History of presenting condition

A 32-year-old woman presents to the integrative healthcare clinic complaining of a 6-month history of lower abdominal discomfort and loose bowel actions. The client is initially referred to the clinic’s general practitioner, who diagnoses irritable bowel syndrome with diarrhoea (IBS-D). The client is commenced on loperamide as a short-term measure, and is then referred onto the clinic’s CAM practitioner for further care. Her pain, located in the left lower quadrant of the abdomen, is described as dull and colicky, non-radiating, moderately intense (pain score = 5/10) and of 3–4 hours duration. The pain began 6 months ago after completion of a second course of oral antibiotics for severe infectious gastroenteritis. Since then, the pain has occurred at least once every 2 weeks and is often accompanied by loose bowel actions (stools are described as brown in colour and mushy in texture), flatulence, mucorrhoea and abdominal bloating. These symptoms are embarrassing and inconvenient for the client when at work. The symptoms are aggravated by emotional stress and ameliorated after defecation. Interstate or international travel, use of aperients and the consumption of sugar-free or artificially sweetened foods have been excluded as potential causes of the IBS symptoms.

Medical history

Lifestyle history

Tobacco use

Alcohol consumption

Social drinker. 2–3 standard-size rum and colas every 2–3 weeks.

Illicit drug use

Diet and fluid intake
Breakfast	Coffee, wheat biscuits (breakfast cereal) with full-cream milk.
Morning tea	Coffee, 2–3 sweet biscuits, muesli bar.
Lunch	Vegetarian pasty, white bread roll with lettuce, tomato and cheese, sandwich with white bread, ham, cheese and tomato, cola.
Afternoon tea	Coffee.
Dinner	White pasta with Neapolitan or carbonara sauce, chicken Kiev or cordon bleu with cauliflower, broccoli and green beans, omelette with ham and cheese.
Fluid intake	3–4 cups of instant coffee a day, 2–3 cups of water a day, 375 mL cola 1–2 days a week.
Food frequency
Fruit	0–1 serve daily
Vegetables	2–3 serves daily
Dairy	2–3 serves daily
Cereals	5–6 serves daily
Red meat	3–4 serves a week
Chicken	2 serves a week
Fish	0–1 serve a week
Takeaway/fast food	once a week

Quality and duration of sleep

Difficulty falling asleep (sleep latency is less than 1 hour), continuous sleep; average duration is 6–7 hours.

Frequency and duration of exercise

Client states she has limited time available for physical exercise. Walks 20–30 minutes, 1–2 times a week. Drives to work. Engages in incidental exercise (e.g. work-related walking, cleaning) less than 3 hours a day. Engages in sedentary activities (e.g. desk-bound activities) more than 6 hours a day.

Socioeconomic background

The client is English-born with a German-born father and Dutch-born mother. The client is a non-practising Christian with no firm cultural affiliations. Since completing her teaching degree 11 years ago she has been employed as a full-time secondary school teacher, which she enjoys but often finds very stressful. The client has no children and is living with her partner in a de facto relationship in a small unit in the outer suburbs. Her partner and family are all supportive; she has a group of very close friends.

Physical examination

Inspection

The oral cavity is unremarkable. There is no evidence of goitre or proptosis. Abdomen is flat with no visible masses, herniation, discolouration or lesions. A 3-cm scar is evident over the right lower quadrant. The client denies the presence of haemorrhoids, anal bleeding, pruritis ani and anal or perineum discomfort. Client reports her stools to be generally brown in colour, mushy in texture (with a Bristol stool chart rating of 6) and often coated in small amounts of clear to pale white mucus.

Olfaction

There is no evidence of halitosis or other abnormal body odours. According to the client, flatus can be foul-smelling, whereas stools generally are not.

Palpation

Abdomen is soft with no palpable masses. Mild left lower quadrant tenderness is evident (pain score = 4/10). Rebound tenderness, Murphy’s sign, Rovsing’s sign and voluntary guarding are absent.

Percussion

Percussive tones over the abdomen are unremarkable.

Auscultation

Bowel sounds are normoactive in all four quadrants.

Additional signs

Client is afebrile (36.3°C, per oral) and of normal weight (weight is 70.5 kg, BMI is 22.2 kg/m², waist circumference is 69 cm). Weight has remained stable over the past 6 months, ranging between 69 and 72 kg. Blood pressure is 128/74.

Clinical assessment tools

The score for all 34 items on the irritable bowel syndrome quality of life (IBS-QoL) measure was 47/100, which indicates the client has moderate quality of life. A higher score would indicate better quality of life, while a lower score would indicate poorer quality of life.

Diagnostics

CAM practitioners may request, perform and/or interpret findings from a range of diagnostic tests in order to add valuable data to the pool of clinical information. While several investigations are pertinent to this case (as described below), the decision to use these tests should be considered alongside factors such as cost, convenience, comfort, turnaround time, access, practitioner competence and scope of practice, and history of previous investigations.

Pathology tests

Carbohydrate breath test

This test examines carbohydrate malabsorption (specifically, lactose and/or fructose malabsorption), orocecal transit time and small intestinal bacterial overgrowth.⁴ This test may be indicated if carbohydrate malabsorption is a suspected cause of IBS symptoms.

Faecal analysis

This test assesses a number of stool characteristics, including appearance, colour, occult blood, epithelial cells, leucocytes, carbohydrates, fat, meat fibres and trypsin.⁵ It may also help to exclude colorectal carcinoma, malabsorption, inflammatory bowel disease or intestinal infection as potential causes of IBS symptoms.

Radioallergosorbent test (RAST) and enzyme linked immunosorbent assay (ELISA)

RAST and ELISA quantify the presence of IgE in client serum.⁵ These tests may be required if food allergy is a suspected cause of IBS.

Radiology tests

The diagnosis of IBS is generally based on clinical examination alone. Where other conditions are suspected of masquerading as IBS, such as diverticulosis or colorectal carcinoma, a CT, MRI or lower GI series may be indicated.

Functional tests

A comprehensive digestive stool analysis (CDSA) obtains data on enzymatic digestion, fatty acid absorption, microbiological balance and metabolic markers of disease. This test may be warranted if intestinal dysbiosis, intestinal candidiasis, malabsorption and/or indigestion cannot be excluded as potential causes of IBS symptoms.⁶

Invasive tests

Invasive tests are not usually required for a diagnosis of IBS. When serious underlying pathology is a suspected cause of the IBS symptoms, certain tests may be indicated, for example, small bowel biopsies can be performed to rule out coeliac disease and a colonoscopy and/or sigmoidoscopy may be indicated if colorectal carcinoma, inflammatory bowel disease or diverticulosis are suspected.

Miscellaneous tests

Not applicable.

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Tags: Clinical Decision Making in Complementary & Alternative Medicine

Jul 22, 2016 | Posted by admin in MANUAL THERAPIST | Comments Off

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