Linda is a 26-year-old single mother of two children. She came to see me in some distress, complaining of quite severe abdominal cramps, tummy swelling and constipation, writes Dr Muiris Houston.
When I examined her tummy it was swollen and felt quite hard - almost like the surface of a drum. Her bowel sounds were present and there were no other signs of intestinal obstruction.
In the past, Linda had been investigated for similiar complaints, including an examination of her large bowel using a flexible tube (colonoscope) and had been told that nothing could be found. Although I was fairly sure she had irritable bowel syndrome, (IBS) I was concerned at the severity of her symptoms.
Resisting the temptation to refer her into hospital again, I arranged to see her the following day and prescribed some medication overnight. Linda was slightly better when she returned and we chatted at length about what might be going on.
She described how difficult life could be managing two children on her own. Although her Mum lived nearby, she was herself in poor health. Linda said she always tended towards being anxious, and that she had been feeling particularly stressed for the previous two weeks.
I saw her again the following day - to ensure that I was not missing a more serious diagnosis and to continue to reassure Linda. By now her tummy had softened, her bowels were begining to move and, although the cramps were still present, they were less severe. Linda has also visibly relaxed.
Linda's story has a number of features which are typical of IBS. The marked distension of her tummy, crampy pain and the hard and less frequent bowel motions. The role of stress in the condition and how it had dominated her life for a week or so.Admittedly, the sheer intensity of her symptoms and signs was unusual.
Irritable bowel syndrome affects 10 per cent of adults, with a female to male ratio of 2.5:1. Patients complain of either looser and more frequent stools or harder and less frequent ones. There is usually pain relief following a bowel motion. Some patients pass mucus in the stool. And the pain and tummy swelling described by Linda are also typical.
In the past, the diagnosis was made by exclusion. That is, you had to go through a whole range of hospital tests to rule out other causes before a specialist could tell you that you had IBS.
This is no longer the case, and your family doctor can now usually make the diagnosis using symptomatic criteria. While IBS was traditionally relegated to the realm of psychosomatic illness, research is now begining to define the mechanisms of what is undoubtedly a complex disorder.
Most patients with irritable bowel syndrome agree that stress aggravates the condition. Research suggests that chronic sustained stress, such as separation and bereavement, is more important in developing IBS, with acute stress responsible for flare-ups.
The actual scientific mechanisms which cause particular symptoms are not at all clear. But at least researchers are now begining to examine genetics, infection, inflammation of the bowel and the possibility of abnormal nerve signals to the brain as reasons why some people suffer from IBS when stressed and others don't.
Abdominal bloating and constipation have been linked to an abnormally slow transit of material through the bowel. The urgent need to defaecate with resulting diarrhoea represents a colon which suddenly bursts into overactivity. As the bowel normally contracts and relaxes at a steady pace, it is clear that, whatever the specific symptoms, IBS is affecting the ability of the intestine to maintain a nice steady rate of working.
MORE than 50 per cent of patients with IBS report a worsening of symptoms after eating. This could be due to the failure of the stomach and small bowel to empty properly after a meal. It may also suggest an intolerance to specific foods.
Treatment for IBS is aimed at the predominant symptoms. For those with diarrhoea, loperamide is helpful. Intermittent laxative use will help constipation. Anti-spasmodic drugs will help the painful spasms. And recently, the low-dose tricyclic antidepressants have been shown to be effective in treatment.
Cognitive behavioural therapy and relaxation techniques undoubtedly help a considerable number of patients and are a good long term treatment option.
But probably one of the most valuable "treatments" is a good relationship with a doctor who understands you and the condition: someone who provides appropriate reassurance, reliable information, helps you set realistic treatment goals and who provides a ready "ear" is vital.
I was pleased to read recently in a seminar on IBS in the Lancet medical journal that irritable bowel can no longer be purely regarded as a psychosomatic disorder. "We prefer to judge the disorder to be a discrete collection of organic bowel diseases, and we believe that such a view will benefit research in the area, and eventually our patients", was the authors' reassuring conclusion.
Dr Muiris Houston, Medical Correspondent, mhouston@irish-times.ie