IBS: Managing Your Gut Reaction -- Steven Peikin, MD -- 06/03/03

Last Editorial Review: 10/19/2004

By Steven Peikin
WebMD Live Events Transcript

Irritable bowel syndrome can turn the digestive process into a painful trial. If the constipation, diarrhea, and cramps of IBS interfere with your life, read our treatment and management Q and A with gastroenterologist Steven Peikin, MD.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD Live, Dr. Peikin. We have several questions from our members, so let's get right to those.

Member: I have had constipation since I was very young. Emotional disturbances cause indigestion for me. Can this be classified as IBS?

Peikin: It is possible that you have constipation-predominant IBS. The fact that you have chronic constipation and it seems to be worse when you are under stress is suggestive; however, any diagnosis of IBS must include abdominal pain as a symptom. Do you have abdominal pain?

Member: Yes, all the time. I have gas pains.

Peikin: There are several things you can do.

  • Initially, we try to manage the problem with diet. A high-fiber diet may be beneficial in some patients with constipation-predominant IBS. On the other hand, some patients develop increased bloating and discomfort when they ingest fiber. If this is the case, then something like Milk of Magnesia, one ounce at bedtime, may be helpful.
  • For those people who benefit from dietary fiber but have difficulty eating enough fiber in their diet, a fiber supplement, like Metamucil or Konsyl, may be helpful.
  • The cramps at times can be treated with prescription medications. However, most of the drugs that treat cramps can make constipation worse, such as hyoscyamine, otherwise known as Levsin, or dicyclomine, also known as Bentyl. A relatively new prescription drug called Zelnorm has been recently released for women with constipation-predominant irritable bowel syndrome. The drug is taken twice a day one-half hour before breakfast and one-half hour before dinner and tends to improve bowel motions and may decrease bloating and abdominal pain.

Member: I do eat a lot of fiber, but the gas has not lessened in any degree.

Peikin: Fiber will increase gas. The purpose of fiber is to improve bowel motions, but one of the negative potential side effects of fiber is gas formation, since fiber is an indigestible carbohydrate. When it reaches the colon, bacteria ferment the fiber and produce hydrogen gas.

Member: I suffer from both lactose intolerance and constipation-type IBS. Consequently, I have to severely limit or entirely avoid many foods that I highly enjoy. Recently, I followed through on a recommendation to try taking enzyme supplements with certain problem meals. I have tried GNC's "Agree with Meals," which contains a small, varied arsenal of enzymes specific to commonly difficult-to-digest foods (i.e. fungal protease, cellulase, etc.). I have tried this supplement several times with sporadic success. I was wondering if you could offer some opinions about enzyme supplements such as this one. Do they generally work? Will they help people with IBS? Is the frequency of effectiveness directly linked with proper dosage? Could there be other factors involved that may alter the supplement's effectiveness (i.e. eating a meal that is too hot and may inactivate the enzyme)?

Peikin: I'm unfamiliar with the GNC's Agree product so cannot comment on it, but certainly gas-forming foods may aggravate patients with irritable bowel syndrome. If you are lactose intolerant (and most of the world's population is) you are unable to digest the milk sugar lactose. Lactose, instead of being absorbed by your body would then reach the colon and bacteria in the colon would ferment the sugar, producing gas. Thus, if you are lactose intolerant and would like to consume products containing lactose, you need to use an enzyme supplement containing lactase. Brand names that contain lactase include Lactaid and Dairy Ease.

Legumes can also be a problem. Beans contain non-digestible carbohydrates, and no human being can digest all the carbohydrates in beans. Taking an enzyme supplement like Beano may help. Otherwise, you may need to restrict legumes and cruciferous vegetables like broccoli and cauliflower.

Member: Any thoughts on probiotics as a treatment for IBS?

Peikin: Probiotics are usually what we generally refer to as healthy bacteria or good bacteria. For instance, if you are lactose intolerant, you could take lactobacillus tablets or drink acidophilus milk. These products contain the good bacteria lactobacillus, which produce the enzyme lactase, which is necessary to digest the milk sugar lactose. In the absence of lactose intolerance, results using other probiotics in patients with irritable bowel syndrome have been conflicting. I personally have some patients who swear by probiotics. Others have no benefit. Since probiotics are relatively safe to take, it may be worth a try.

I advise using probiotics that have high cell counts, preferably greater than one billion cells per dose. Lactobacillus GG, which is made by Danon, may be helpful in patients with antibiotic-related diarrhea, and those with traveler's diarrhea. Probiotica is another quality product. Some probiotics can be consumed as yogurt rather than pills. If you are using yogurt rather than pills, make sure the yogurt contains a high quantity of the bacteria.

Member: A recent study published in the Archives of Internal Medicine states that celiac disease occurs in at least 1 in 133 people. But celiac disease is still so rarely mentioned or covered in the media. Is it possible that many of the people who think they have IBS actually suffer from celiac disease and their doctor just didn't know enough about celiac to suggest checking for it?

Peikin: The answer is yes. This is a good question. We gastroenterologists now recognize that there are many people who have the wheat allergy known as celiac disease, otherwise known as gluten sensitive enteropathy, or sprue. Although in its most florid form, patients with celiac disease have diarrhea, greasy stools, and profound weight, many celiac patients have milder forms of the disease, and their symptoms may be indistinguishable from patients with diarrhea-predominant irritable bowel syndrome.

I recommend that my patients with diarrhea-predominant IBS -- and you could make a case for any patient with IBS -- get blood tests to exclude celiac disease. The blood tests include anti-gliadan antibodies, anti-endomysial antibodies, and tissue transglutaminase.

Member: What is your suggestion for people who experience both constipation and diarrhea at times?

Peikin: Patients with irritable bowel syndrome often swing back forth between constipation and diarrhea. We call them alternators. The first step, again, is diet. A high-fiber diet may improve constipation and by virtue of fiber's ability to absorb fluid, may also make the stool less watery. Thus, fiber can help lessen the swings from constipation to diarrhea.

For abdominal pain associated with this condition, I usually will try hyoscyamine or dicyclomine. And if there is no response, I may use my magic bullet, which is amitriptyline at a low dose (10 to 25 mg) at bedtime. Amitriptyline is an excellent drug for IBS pain. It may produce drowsiness initially, and that's why we usually give it at night.

Member: I heard there is a new drug out for IBS called Zelnorm. My doctor is hesitant to prescribe the drug because of lack of history. Is the drug worthwhile and is it safe?

Member: I was recently diagnosed with IBS and have been given a prescription for Zelnorm, which has worked wonderfully. My question is, is the medicine safe for long-term use or should I attempt to just treat with change in diet?

Peikin: Although Zelnorm is relatively new it has been a well studied drug and has been known to be very safe in many clinical trials. The two main side effects are diarrhea and headache, but most people do not experience these symptoms. Most people should be taking it twice a day.

It works best if you do not take it with food. It may take a few days to work, so I usually advise my patients to stay on their fiber product or stool softener until the Zelnorm begins to work.

Although Zelnorm is a good drug, it does not work for everyone. If there's no improvement at the 6 mg dose given twice a day for a month, it probably is not going to work.

The drug seems to be safe to take for several months. There is not much experience with Zelnorm beyond one year of use, but there is no indication at present that long-term use of Zelnorm causes any problems. As soon as you stop Zelnorm, it is likely that your original symptoms will recur within a few days. Zelnorm is only indicated for people with constipation-predominant irritable bowel syndrome. I would hesitate using it in alternators unless it was being used in their constipation phase, and I would never use it in patients with diarrhea-predominant IBS.

Member: Is there medical research to suggest that efforts to combat stress and anxiety with activities like yoga, deep breathing, and other relaxation techniques are effective for controlling IBS symptoms? I have found my symptoms have a direct link to my feelings of anxiety, and these techniques seem to help me. Sometimes, however, the link between gut and brain works faster than I can and the pains come on regardless of what I do.

Peikin: There is certainly something known as the brain-gut axis. Your mind really does have a lot of control over your digestive tract. As I have outlined in my book, Gastrointestinal Health, stress reduction techniques, such as yoga and other forms of meditation can be very helpful in selected individuals.

Member: The only thing that keeps my IBS under control is taking over-the-counter loperamide. Is there any harm in taking this on a regular basis?

Peikin: Loperamide, otherwise known as Imodium, is an excellent drug to control diarrhea in patients with diarrhea-predominant IBS. Although the package says not to be used for more than three days without consulting your doctor, you can, in fact, use it on a long-term basis. The reason they say to contact your doctor is to make sure that you have the proper diagnosis before using it on a more long-term basis. I often will tell my patients who expedience rectal urgency and diarrhea to take loperamide prophylactically [preventively] before going out in the morning if they are not going to be able to be near a bathroom or they experience anxiety about leaving the house with those symptoms.

Member: Can IBS lead to diverticulitis or anything else?

Peikin: The good news about irritable bowel syndrome is that you do not go on to develop serious medical problems such as diverticulitis or colon cancer. Because symptoms of IBS can at times mimic symptoms of those other disorders, patients with IBS may be asked to undergo diagnostic tests, such as CAT scan, barium enema, and colonoscopy.

Diverticulosis is a common disorder in the United States, where we tend to eat a low-fiber diet. Many people with constipation-predominant IBS may have diverticulosis as well; however, there is not necessarily a direct link between IBS and diverticulosis, two common problems.

Member: I am 60 years old, have had IBS for years. Two years ago, my gall bladder was removed. Since that time, diarrhea has been uncontrollable to the extent I have had two accidents in public places and now stay home mostly. Why?

Peikin: It is not unusual for people to experience loosening of their stools after a cholecystectomy or gall bladder removal. While most people do not experience loose stools, some do. The exact reason is not known, but I believe that it is due to improper handling of bile salts by the small intestine. When you have a gall bladder, bile gets deposited in the small intestines all at once immediately following a meal when the gall bladder contracts, thus there is extensive mixing of the bile salts with food. This may make the subsequent absorption of bile salts by the small intestines more efficient.

After your gall bladder is removed, bile flows continuously from the liver to the small intestines, thus the bile may be present even where there is no food in the gut, and it may not be absorbed as well by some people in this situation. If bile salts are not fully reabsorbed in the lower part of the small intestines, they enter the large intestines and cause diarrhea. Patients who experience postcholosystecomy diarrhea, may be benefited from taking a bile-binding resin, such as cholestyramine (brand name Questran).

Member: Does IBS seem to have some heredity in families?

Peikin: I do not believe a heredity cause of IBS has been described. That being said, I do see quite a few patients who have a strong family history of IBS. It is hard to know whether this is due to environment or genetics. I suspect both, as it is in many diseases.

Member: My daughter has IBS. She is going to be a senior in college and plans on going to medical school. Stress seems to be a factor in control of the IBS. What else other than her Asacol can relieve some of her symptoms? She strives to be best at all she tries and I know that pressure in itself contributes to her symptoms but doubt that will go away as she is a driven personality. She will make a great doctor someday if we can keep her healthy. Any help? I have read there are some new drugs but we are concerned about side effects. Thank you.

Peikin: Asacol is a drug used to treat inflammatory bowel disease, not IBS. There are some people, however, usually those patients with diarrhea-predominant IBS, who, on colonoscopy are found to have a normal-appearing colon but on biopsy there is evidence of inflammation.

This so-called microscopic colitis, or lymphocytic colitis, may be misdiagnosed as IBS.

The diarrhea seen in patients with microscopic colitis will usually respond to treatment with Asacol. However, patients with diarrhea-predominant IBS without inflammation in their colon usually do not respond. I tend to perform a colonoscopy in patients with diarrhea-predominant IBS and take random biopsies of the colon to rule out microscopic colitis.

Moderator: Dr. Peikin, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Peikin: My final comments would be that irritable bowel syndrome, while difficult to treat is usually immensely treatable in most patients. The predominant symptom, whether it is abdominal pain, constipation, or diarrhea, can usually be controlled with diet and medication. Untreated, IBS can have a serious adverse effect on quality of life. It should therefore be aggressively treated in all patients. New remedies, such as amitriptyline, some of the SSRI drugs, Zelnorm, and in patients with severe diarrhea predominant IBS, Lotronex, may be extremely beneficial. Stress reduction, and at times psychotherapy, may also help.

Member: We are out of time. Our thanks to Steven Peikin, MD. And thank you members for joining us today. For more information, please read Gastrointestinal Health, by Steven Peikin, MD. And explore all of the information here at WebMD, including our message boards: Digestive Disorders: Scott Ketover, MD and Digestive Disorders: Support Group. Goodbye and good health!

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