# Webmd Chat transcipt IBS Diagnostic and Treatment Issues



## eric (Jul 8, 1999)

FYI http://my.webmd.com/content/article/1700.50850 ------------------ http://www.ibshealth.com/


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## eric (Jul 8, 1999)

------------------ http://www.ibshealth.com/


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## JeanG (Oct 20, 1999)

Another great article, Eric. Thanks for posting it.







JeanG


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## eric (Jul 8, 1999)

Irritable Bowel Syndrome: Diagnostic and Treatment Issues Special Program By Eugene Burbige, MD Event Date: 08/29/2000. This event is sponsored by Glaxo Wellcome. Glaxo Wellcome has had no influence on the selection of the guest or the content presented in this event. Moderator: Welcome to WebMD Live Events. Our guest today is Eugene Burbige, MD, chairman of the gastroenterology division of Mount Diablo Medical Center in Concord, CA. We will be discussing diagnostic and treatment options for irritable bowel syndrome. Welcome Dr. Burbige. How are you today? Dr. Burbige: I'm fine. How is everybody out there? Moderator: Before we begin taking questions, can you please tell everyone a little bit about your background and area of expertise? Dr. Burbige: I can start at I went to University State medical school, did my residency and gastroenterology fellowship at John Hopkins Hospital in Baltimore, then I moved to California in 1975, where I was chief of gastroenterology, at the hospital of University of California at Davis, for 12 years. I've been in private practice in Concord, CA for 12 years, where I'm chief of gastroenterology at Mount Diablo Medical Center. And also am chief of liver research and gastroenterology at East Bay, Concord, CA. I've done research in peptic ulcer, IBS, and reflux disease. mommyme1_webmd: How can I tell if what I have is IBS (irritable bowel syndrome)? What are the symptoms? I get diarrhea frequently and suddenly. Dr. Burbige: The definition of IBS is that it's a chronic condition that affects people from years to decades, with symptoms of abdominal pain, altered bowel habits, and bloating distension, which results in changes in quality of life. The diagnostic criteria for IBS is 12 weeks within the preceding 12 months of abdominal pain, associated with altered bowel habits. In order to make diagnosis, some preliminary diagnostic tests must be done by your doctor to rule out other serious illnesses. morris71_lycos: What is the difference between IBS and IBD (inflammatory bowel disease)? Dr. Burbige: IBS is abdominal pain associated with altered bowel habits in the absence of structural change in the bowel. IBD is associated with inflammation of the bowel wall. In other words, if a biopsy of the bowel is taken from a patient with IBS it will look normal, whereas with IBD, there will be inflammation of the lining of the bowel. This is important, because both abnormalities are treated by different means. mommyme1_webmd: What kind of tests do I have to have done? You said the doctor had to do some preliminary diagnostic tests. Dr. Burbige: The full definition for IBS is as I mentioned, 12 weeks in the preceding 12 months of abdominal pain, with pain relieved with bowel movement, or associated change with passage of stool, or appearance of stool. The doctor, depending upon the age of patient, will do blood tests to make sure there's no anemia, no elevated sed rate (sedimentation rate) which is an indirect test for inflammation, and the stool will be tested for hidden blood. And a history will be done, depending upon age of the patient, there may be necessity to do a sigmoidoscopy. A sigmoidoscopy is a test where the physician looks in the lower part of the colon with a flexible tube to make sure there is no premalignant, or malignant changes, or inflammation in the bowel wall. This is done after a preparation with a laxative, and an enema. morris71_lycos: Can IBS cause colon cancer if left untreated? Dr. Burbige: First of all, IBS does not lead to more serious illnesses, such as colon cancer. There is no documented causation of colon cancer by IBS. However, IBS can lead to marked changes in people's quality of life. Worrying about colon cancer is important, and often makes people with IBS seek medical attention. One out of five American women suffer from IBS. But only about 15 to 20% of those people seek medical care. There's lots of reasons why people do not seek medical care for IBS. One is embarrassment over talking about bodily functions. Another reason is fear over diagnosis such as cancer. Another reason is that women have seen physicians in the past for these symptoms and have come away wanting for adequate diagnosis and treatment. The reason that prompts people to seek medical care is diagnosis of cancer in a friend, or death of a relative. People come to myself and other physicians, worrying about cancer, peptic ulcer disease, and other serious illness. I'll say again, that IBS does not lead to colon cancer. Although IBS is not life threatening, patients frequently report restricted lifestyle that has been adapted to cope with their condition. These coping mechanisms have cost the patients in terms of time lost from work, job opportunities, psychological consequences, and social interactions with family and friends. That's a long winded answer to "Does IBS cause colon cancer?" It doesn't, but can affect people's lives in serious ways. Moderator: Please describe what normal bowel habits are? Dr. Burbige: As human beings, we feel that everyone is the same as we are. So what is our bowel habits become normal to us. However, if we go by strict definitions of normal bowel habits, in order to qualify for diarrhea as a diagnosis, it has to be more than three bowel movements per day. To qualify for constipation, it has to be less than three bowel movements a week. However, for an individual, what becomes abnormal is a change in bowel habits. If an individual has two bowel movements a day, for the last ten years, then suddenly begins having three or four a day, that is abnormal. At this point they should seek medical help to make sure there is no organic issues causing the problem.


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## eric (Jul 8, 1999)

enbee_lycos: What are the most common food irritants for IBS sufferers? I've read that fructose is one of them and I am amazed at the number of food products containing it. Dr. Burbige: We can talk a little about treatment. first of all, there is no cure for IBS, but there are treatments. The treatment of IBS for all cases requires education. People need to become educated about their disease, the causes and exacerbations of it. When diagnosis is made, their questions need to be answered. Then lifestyle modification. A large component of that would revolve around diet. Generally, we recommend a low-fat, high-fiber diet. In addition, we recommend to decrease the caffeinated beverages, alcohol, which increases intestinal secretions, chocolate, gassy foods, and certain carbohydrates. In terms of diet, there is no causal relationship between food elements and IBS. However, certain substances can worsen symptoms. Included in there are particularly the carbohydrate intolerance, such as lactose, and rarely sucrose or fructose intolerance. Again, I stress they don't cause IBS, but can worsen symptoms. These carbos or sugars, if not absorbed in the small intestine, pass to the large intestine, where bacteria digests them. This produces gas and diarrhea. Lactose intolerance, or the inability to digest lactose sugars, is fairly common. Sucrose intolerance is rare, and so is fructose intolerance. However, if anyone ingests large amounts of these substances, they may overwhelm the body's ability to digest them. These should be taken in moderation. If lactose intolerance is present, either avoidance of dairy, or the taking of over-the-counter supplements can help in the digestion of these products. Moderator: Can you please give us examples of the carbohydrates that should be avoided? What gassy foods should be avoided? Dr. Burbige: Going into diet in a little more depth, we need to consider an individual's intolerances. As I've said, there is no causal relationship between diet and IBS, but only worsening of symptoms in people with IBS. Not all people with IBS need to avoid carbos. Generally, I recommend to my patients, that if they can eat a particular food without problem, then to go ahead and eat that food, except for caffeinated beverages, chocolate and alcohol. If certain foods do cause symptoms, then for that patient, the avoidance of that product is recommended. In general, people who are lactose intolerant have to avoid dairy such as milk, cheeses and ice cream. But if a person can eat these with no symptoms, then they don't need to avoid them. In terms of gassy foods, they're the ones we all know about such as beans, apples, broccoli, cabbage -- but again, if you can eat these without any symptoms, there's no reason to avoid them. They may contain good fiber, which may help in the underlying bowel problem. On several occasions, I've mentioned high fiber, and the value of fiber in products such as apples and other veggies. Physicians recommend fiber routinely for IBS, but to be honest, it's role is controversial. There is no doubt that fiber helps patients with constipation predominant IBS, it decreases transit time in the bowel, relieves abdominal distention, and relieves abdominal pain. It may also help some patients with diarrhea by changing pressure characteristics of the bowel and relieving spasms. However, in some individuals, it may actually worsen symptoms because the fiber is fermented in the bowel and produces more gas and distention. Therefore, the use of fiber remains controversial, but should be given as a trial. kelseygram_webmd: Isn't it associated with stress, the individual's reaction to stress? Dr. Burbige: For years IBS has been thought of as a psychosomatic disorder. People have been told it's in there heads. However, we now realize it is a real disorder, with pathophysiologic abnormalities. It's no longer rational for us to decide whether IBS is psychological or physiologic. We've come to realize it's a combination of the two, and it's important for doctors to realize this and determine the degree to which each of these is fixable. We now recognize that IBS is associated with the hypersensitivity of the nerves within the bowel. This sensory input is influenced by psychological factors. The thinking now is almost a big brain/little brain type of situation, with the little brain being the nervous system in the bowel, which can act independently than our brain in our cranium. This connection between the big brain and little brain is referred to as the brain/gut axis. We have to remember that there's a bi-directional communication between the brain and gut. Things we see, hear, and smell, are modified by memory and affect, they are then taken with the input from the gut, and sensation is then felt. These influences then have physiologic affects on bowel motility and secretions, and can affect our conscious perception of symptoms. This again is a complicated long answer to the question about stress. Stress is important in causing worsening of symptoms, but there is an underlying abnormality of the bowel itself. In the majority of people with IBS, they do not have significant psychological abnormalities. In a smaller number of people, 20 to 25% of people with IBS, they may have more severe psychological disturbances. They will benefit from some type of psychological counseling. There are a number of psychological interventions which have been looked at in IBS, but there have not been a lot of clinical studies. There are studies looking at various types of psychological intervention including relaxation therapy, hypnosis, interpersonal psychotherapy, and cognitive or behavioral psychotherapy. There are only about 11 well-controlled studies done using a combination of these types of therapies, and about 60 to 70% showed significant improvement with psychological treatment over conventional treatment. kelseygram_webmd: So other than diet restrictions such as corn, should there be medications prescribed? Dr. Burbige: As when we talked about treatment earlier, we talked about reassurance, education, and lifestyle modification. These should be instituted in every case. But if we look at IBS overall, doctors tend to break them down to mild, moderate and severe cases. If we move on from the mild to moderate cases, they require the three elements we talked about, but at this point it is usually necessary to move to medical treatments. Additionally, counseling can be helpful for those who can associate trigger factors that set off symptoms, such as stress. If we look at medications for treatment, unfortunately for a long time, most treatment has been aimed at individual symptoms. In other words, one medication for diarrhea, one for bloating, one of pain, resulting in a number of medications to control all of the symptoms. Medications that have been used for diarrhea include Lomotil (diphenoxylate/atropine), or Imodium (loperamide), or tincture of Opium. Medications for spasm and pain have included anticholinergics, although there is no control study to prove that anticholinergics work for pain associated with IBS. The use of some of these medications may also be associated with adverse effects, such as constipation, more bloating, dry mouth, and blurry vision. Recently, one new medication has been approved for treatment of diarrhea-predominant IBS. That product is alosetron (Lotronex), and is approved for female patients with diarrhea-predominant. Another medication is soon to be approved for constipation-predominant IBS, and is named tegaserod (Zelmac). In patients with severe IBS, this group comprises five percent of the patient group. In these individuals, the pain is more constant, and is associated with marked psychological abnormalities. In these patients, besides medications for bowel symptoms, the use of psychotherapeutic medications, such as antidepressants, are often necessary. daisy_63_webmd: After four weeks of diarrhea with no medications working, my gastroenterologist put me on tincture of opium. This past week I am having bloating and abdominal pain. Could it be the medication? Dr. Burbige: With tincture of opium, it affects the motility of the bowels, and tends to slow things down. This may easily lead to more distention of the bowel and a feeling of bloating. In the case of any adverse reaction, or possible adverse reaction to medication, it's wise to inform your physician of these changes. I would recommend that you notify him/her, but your symptoms may be due to that. He/she may want to consider the use of the newer agent I mentioned earlier, Alosetron (also known as Lotronex) which is recommended for people with diarrhea-predominant. It's been shown to decrease frequency of bowel movements, and improves the consistency. If diarrhea is predominant, with no constipation, this agent may be helpful for you. But you should check with your physician. With the particular agent, you'd not have the adverse affects you've described. cnettles_webmd: Are the side effects we've heard about these drugs temporary? Dr. Burbige: If we look at the side effects of drugs used to treat IBS, the ones that happen most commonly are the ones with the anticholinergics. The newer agent, Alosetron, has a side effect profile similar to placebo or sugar pill in clinical trials. Except for constipation. In the clinical trials, constipation occurred in high percentages of patients. This may well be an expected side effect in a drug meant to treat diarrhea. The dosage of the drug needs to be titrated in individuals who develop constipation. This should be done in conjunction with your physician. It's recommended that if constipation develops while taking this medication, that it be stopped and your physician be notified. In most cases, after treatment of constipation, the drug can be restarted. There have been a small number of cases of rectal bleeding in patients using this medication. And if this develops, the physician again needs to be notified. These side effects have occurred in a very small number of patients, and overall, the drug has a good safety profile. enbee_lycos: Why is it that a person can live for many years with no problems, and then suddenly develop IBS symptoms? Dr. Burbige: Generally, in most individuals with gastrointestinal symptoms, it may date back to adolescence. It may be they are low-grade symptoms, but then a sudden life event may exacerbate the symptoms. This can be something like retirement, which can bring on changes in bowel habits. It may not be that the person was asymptomatic, but may have had low grade symptoms, which become exacerbated. It's important that if a patient has a sudden change in bowel habits, it may be something more serious than IBS, and you should see your physician for further investigation. rosie2000_webmd: Can exercise help? Dr. Burbige: There are many alternative strategies to use with symptoms, and exercise is one. The bowel is thought of as a muscle, and will improve with exercise. Exercise does a number of things, such as increasing endorphin levels, and can decrease psychological stress, which can worsen IBS. In a general healthy lifestyle, exercise is an important component. topgun99_webmd: Is there a way to know which doctors in my area are particularly knowledgeable about IBS? Dr. Burbige: It's difficult to give direct information on your area, I generally recommend that you first see your primary care physician, discuss the problem, and it will be necessary to get a feel for how well the physician seems to listen to you, and to be knowledgeable of IBS. This is a widespread problem. In a recent survey, women reported seeing an average of three physicians before a diagnosis was made, and that took on an average of three years before a diagnosis was made. In that same series, 3% of the patients had to see eight or more physicians before diagnosis was made. Therefore, I recommend seeing your personal care physician, and see how he reacts and how knowledgeable he seems. In most cases your physician can handle the problem. If there is uneasiness, or a lack of knowledge, then you should see a gastroenterologist. I suggest that patients check with friends or relatives for referral information. This is not an easy problem, because the same survey I alluded to also showed a wide variance in their knowledge of IBS. Generally, questions to the physician to determine his knowledge of pathophysiology should be helpful. If the physician understands hypersensitivity in association with the psychological effects, that's a good sign. If the doctor feels it's totally psychosomatic, then it may be wise to seek other help. Moderator: We are almost out of time, Dr. Burbige. Do you have any final comments for our members today? Dr. Burbige: I want to thank everyone for their questions, all of which were very good. I hope I've enlightened people about this condition, and hopefully people who have not sought help, will seek help. My aim is to increase awareness of IBS, that it is a serious disorder in some people in that it can affect people's sleep, employment, sexual functioning, leisure and travel, and can vary from trivial complaints to incapacitating complaints, with the latter having a major impact on social and functional areas. The disorder is real, it can be diagnosed, and there is treatment that is effective. I would end by encouraging individuals who think they may have this disorder to seek help. Moderator: We are out of time. Our thanks to our guest, Dr. Eugene Burbige of the Mount Diablo Medical Center. daisy_63_webmd: Thank You. Moderator: To register for IBS updates from Glaxo Wellcome, go to www.webmd.com/2000/Glaxo/. And please visit our WebMD message board devoted to irritable bowel syndrome. This is a message board for members to discuss experiences of being diagnosed with irritable bowel syndrome (IBS). Scott Ketover, MD, answers member questions several times each week. Thank you for joining us. Be well and goodbye.------------------ http://www.ibshealth.com/


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