MYSTERY STOMACH PAIN RESOLVED
Up to one fifth of Canadians may suffer from irritable bowel syndrome. Are you among them?
DIGESTIVE ISSUES, BLOATING, stomach pain, constipation and diarrhea—Sandra David’s childhood and adolescence were dominated by gastrointestinal distress. Finally, at the age of 23, she saw a doctor. But it would take three more years and a succession of different specialists before the administrative assistant from Montreal, now 43, found out what was ailing her.
David’s affliction? Irritable bowel syndrome (IBS). The 2013–2014 Canadian Community Health Survey, released by Statistics Canada, revealed that mucous colitis—the other name for IBS—affects 2.7 per cent of Canadians over the age of 12. But according to the GI Society (the Canadian Society of Intestinal Research), the actual number of sufferers is closer to 13 to 20 per cent. The reason for the disparity could be that just one quarter to one half of people who suffer from IBS symptoms seek medical attention and, on average, wait a decade before doing so.
PAIN, CONSTIPATION AND diarrhea are the most common recurring symptoms of IBS, a chronic disorder of the gastrointestinal tract, the exact cause of which is unknown. It can also lead to heartburn, nausea, sweating, chills, bloating, flatulence and other changes in bowel function.
“It’s quite easy to diagnose,” says Dr. Mickael Bouin, a gastroenterologist at Hôpital Saint-Luc du CHUM and an associate clinical professor at the Université de Montréal. “While the symptoms are common to other illnesses, their emergence and recurrence are rather specific to IBS. In the vast majority of cases, a family physician will make the diagnosis after examining the patients and asking them to complete a questionnaire.”
Long overlooked, IBS research is growing rapidly, but Bouin acknowledges that science has yet to fully comprehend why patients suffer from these symptoms. “There’s a lot of drug development research, but we still know very little about the mechanisms of the disease,” he explains.
Fortunately, most patients can manage or improve their symptoms. Here are eight insights to help sufferers better understand their digestive health.
1. Rule out other disorders
Some illnesses, from celiac disease— a reaction to gluten—to certain types of cancer, can feel a lot like IBS. While much less common, they must be eliminated as potential culprits in order to make a final diagnosis.
“Approximately six per cent of patients who suffer from IBS develop symptoms that may be mistaken for the signs of celiac disease, which can be detected with a simple blood test,” says Bouin.
Gastroenterologists now have a new test to identify intestinal inflammation
markers and exclude Crohn’s disease and ulcerative colitis, both major categories of inflammatory bowel disease (IBD): fecal calprotectin dosage, a stool test that can help evaluate the severity of the inflammation through the presence of a particular protein. But according to Bouin, it is used only in cases in which the doctor is determining between a diagnosis of IBS or an inflammatory bowel disease.
Colon, stomach and ovarian cancer screening may also be necessary: “If the patient’s IBS is somewhat atypical or when the patient is a certain age, they have to be ruled out,” he says.
2. There’s more than one type of IBS
Patients generally suffer from one of three types: IBS with diarrhea, IBS with constipation or IBS with alternating constipation and diarrhea, which have varying causes.
“Each patient may have a different problem. The gut, however, has only so many ways to complain,” explains gastroenterologist Dr. John Marshall, a leading IBS researcher at McMaster University in Hamilton, Ont.
“Research is pointing to a variety of subtle changes that may each underlie the development of IBS, such as an altered immune system, the presence of low-grade inflammation, the proliferation of nerve fibres in the intestinal wall or pre-existing genetic susceptibility,” notes Dr. Giovanni Barbara, researcher and clinical gastroenterologist at the University of Bologna, Italy.
3. Post-infectious IBS is common
Almost one third of IBS cases occur following a gastrointestinal infection or food poisoning caused by a virus or bacteria. Some of the world’s most extensively documented cases happened 17 years ago in Walkerton, Ont., when 2,500 people fell ill from water contamination caused by an outbreak of E. coli and Campylobacter. A team of researchers, including Marshall, monitored the victims for eight years. Among those affected, 36 per cent developed IBS. While the symptoms disappeared in most cases, some people, including Kevin Doyle, a farmer in his late 40s at the time of the incident, still suffer today. “I have to be very careful. If I experience any stress, it will flare up,” says Doyle.
The Walkerton research, which is still underway, has helped highlight certain risk factors of post-infectious IBS, including being female, suffering from a serious illness, taking antibiotics or experiencing an anxiety disorder at the time of infection and having a genetic predisposition.
4. Pinpoint food triggers
Many patients maintain that certain foods aggravate their symptoms. “If I eat garlic, my stomach will bloat as
if I were six months pregnant,” says Sandra David, who, for the past two years, has been careful about her eating habits. On top of garlic, she no longer consumes onions, dairy products, gluten, tomatoes or apples.
In the past few years, the lowFODMAP diet developed in Australia has made headlines, as certain studies have revealed that 75 per cent of people who received an IBS diagnosis had fewer symptoms while following these dietary guidelines. FODMAP is an acronym for fermentable oligo-, di-, monosaccharides and polyols—a collection of short-chain carbohydrates found in a number of fruits, vegetables, grains and dairy products that tend to ferment and transform into sugars in the intestine. Because the diet is very limited—the complete list includes over 100 high-FODMAP foods to restrict or avoid—IBS sufferers are told to follow it for six to eight weeks and gradually reintroduce different items to figure out what their body can handle.
Cinzia Cuneo, the co-founder of Montreal’s Sukha Technologies Inc. and the company’s meal-planning website SOS Cuisine, is very well acquainted with the low-FODMAP diet. In conjunction with a team of nutritionists, she recently published The Low-FODMAP Solution. “It’s not a diet that is designed to be followed for life for several reasons,” says Cuneo. “Firstly, because people aren’t usually sensitive to every FODMAP. Most only react to one, two or three fermentable carbohydrates, so there’s no use eliminating them all. Also, the foods have important nutritional properties, so they shouldn’t be eliminated permanently.” The nutrition team provides meal plans as well as advice, especially during the food elimination and reintroduction phases. The goal is for each individual to determine a level of tolerance to the foods that are problematic for them.
According to Bouin, there is a general consensus in favour of the FODMAP diet, but that doesn’t make it a cure-all. “It helps certain patients, but a person who stops eating [trigger foods] will obviously suffer less stomach pain. The objective is to halt as many symptoms as possible by eliminating a minimum number of foods. That’s the challenge.”
5. Focus on the right fibre
Doctors have recommended fibre for decades, but we now know not all kinds of fibre have the same effects. A 2009 Dutch study co-authored by Dr. Niek de Wit at the University Medical Centre in Utrecht, Netherlands, found that insoluble fibre—present in wheat bran, whole grains and peas, for example—is to be avoided.
But soluble fibre, which can be found in oat bran, black beans, soy
and oranges, among other foods, can sometimes help lessen symptoms. In patients with diarrhea, the fibre absorbs excess water and turns to gel, slowing digestion. For people who suffer from constipation, it helps soften stool. “A daily supplement of soluble fibre [psyllium husk is a good bet] is one of the most effective places to start for IBS,” says de Wit.
6. Delve into the braingut connection
While the theory that the disease is rooted in a single psychological source has been debunked, research reveals that there is a brain-gut connection. According to Dr. James Whorwell, director of the South Manchester Functional Bowel Service in the U.K., stress and anxiety exacerbate symptoms in most IBS sufferers.
“Stress will often have an impact on the colon, which is extremely sensitive. If the person also suffers from IBS, the symptoms will be even more severe and last longer,” says Bouin.
Treatment options in those cases can include cognitive behavioural therapy, relaxation techniques and hypnosis.
7. Try a probiotic
Increasingly—and especially in cases of post-infectious IBS—physicians suspect patients may have a disruption in the bacterial flora that normally inhabit the gut and help with digestion. Certain probiotics have proved relatively effective, and IBS researchers expect designer probiotics will one day be able to target specific bacterial deficits. “My hope is that manipulating the microbiome and replacing missing good bacteria may lead to a significant improvement of symptoms,” says Marshall.
8. Seek support
People who suffer from IBS can feel isolated—intestinal problems aren’t often a popular topic of conversation. However, communities of IBS patients have cropped up across the Internet. In Canada, for example, the GI Society has a bilingual website, badgut.org, which provides information on the most common digestive disorders, including IBS.
“I always put education at the top of my list,” says Whorwell. “Patients have to understand their condition if they’re going to be able to manage it.”