Is this woman's lower abdominal pain really IBS?
Dr Melanie Wynne-Jones discusses
Dr Melanie Wynne-Jones discusses
Lisa is 32 and has come to see you about her lower abdominal pain. She has already seen two other doctors in the practice who both diagnosed irritable bowel syndrome. Antispasmodics and peppermint oil capsules have not helped, and she mentions several times that her symptoms are making life very difficult.
What is really bothering Lisa?
Understandably Lisa wishes to be rid of the symptoms of IBS. The Manning criteria for diagnosis are any three of the following: abdominal pain, relief on defaecation, increased stool frequency with pain, looser stools with pain, mucus in stools or feeling of incomplete evacuation.
As well as being unpleasant, noisy peristalsis, excessive wind or the need to rush to the toilet can be embarrassing and interfere with travel, work or social activities.
But she may be worried that the diagnosis or treatment are wrong, or she has some sinister underlying disease, such as cancer. You also need to consider whether it is in fact her difficult life that is making her symptoms worse, rather than the other way round.
What symptoms does Lisa have?
Constipation, diarrhoea, urgency, nausea, flatulence, bloating, toothpaste- or pellet-like stools and sometimes mucus are typical IBS symptoms; IBS can also produce non-specific symptoms such as lethargy, back pains and urinary disturbance.
Take the history again from scratch, checking that she has no symptoms of inflammatory bowel disease such as bleeding, fever or weight loss, and no joint, skin or eye symptoms. Asking Lisa how her symptoms impact on daily life may tell you about her various relationships, workload, coping mechanisms and mental state. The words she uses and her general manner may suggest she is anxious or depressed.
Explaining that research has shown a strong link between our emotions and bowel activity, and that 'some people find that their tummies get upset when they are upset themselves' allows you to ask explicitly about her mood. However, Lisa may be keen to externalise her problems, and it may be difficult to work out whether her distress is the cause or result of her symptoms.
Now is a good time to ask what she thinks or fears may be wrong, and what she hopes you can do.
What investigations should you perform?
IBS can often be safely diagnosed from the history if it is classical and the patient is young. But to rule certain diagnoses in or out, or to reassure Lisa, you may consider:
- FBC, ESR, C-reactive protein, liver and thyroid function tests
- stool analysis for infection or blood
- MSU and vaginal/cervical swabs
- endomyseal and antigliadin antibodies, serum iron and/or jejunal biopsy
- ultrasound scan
- referral for bowel, gynaecological or urological investigations
If it's 'just' IBS, what can you suggest?
There is no single magic cure for IBS, and sufferers often end up finding their own solutions. Success has been reported for:
- increasing/decreasing the amount of wheat, bran or roughage in the diet, or using a bulking laxative such as ispaghula husk or methylcellulose; improvement may take several weeks
- simple painkillers such as paracetamol
- codeine or loperamide for diarrhoea
- laxatives to relieve constipation (lactulose may increase wind; stimulant laxatives may gripe)
- antispasmodics such as mebeverine, or dicyclomine
- peppermint oil – relaxes smooth muscle
- charcoal biscuits for offensive wind
- eliminating suspect foods
- reducing yeast-containing foods such as bread and alcohol
- 'probiotic' yoghurts containing 'friendly bacteria' such as lactobacilli
- alternative therapies such as homoeopathy, acupuncture or reflexology
- medical hypnotherapy
- relaxation techniques or CBT
- medication for anxiety or depression
Melanie Wynne Jones is a GP in Marple, Cheshire