# IBS Management



## eric (Jul 8, 1999)

FYIubmedIrritable Bowel Syndrome. Wald A University of Pittsburgh Medical Center, Pittsburgh University Hospital, Mezzanine Level, C-Wing, 200 Lothrop Street, Pittsburgh, PA 15213-2582. [Record supplied by publisher] I believe there are four essential elements in the management of patients with irritable bowel syndrome (IBS): to establish a good physician-patient relationship; to educate patients about their condition; to emphasize the excellent prognosis and benign nature of the illness; and to employ therapeutic interventions centering on dietary modifications, pharmacotherapy, and behavioral strategies tailored to the individual. Initially, I establish the diagnosis, exclude organic causes, educate patients about the disease, establish realistic expectations and consistent limits, and involve patients in disease management. I find it critical to determine why the patient is seeking assistance (eg, cancer phobia, disability, interpersonal distress, or exacerbation of symptoms). Most patients can be treated by their primary care physician. However, specialty consultations may be needed to reinforce management strategies, perform additional diagnostic tests, or institute specialized treatment. Psychological co-morbidities do not cause symptoms but do affect how patients respond to them and influence health care-seeking behavior. I find that these issues are best explored over a series of visits when the physician-patient relationship has been established. It can be helpful to have patients fill out a self-administered test to identify psychological co-morbidities. I often use these tests as a basis for extended inquiries into this area, resulting in the initiation of appropriate therapies. I encourage patients to keep a 2-week diary of food intake and gastrointestinal symptoms. In this way, patients become actively involved in management of their disease, and I may be able to obtain information from the diary that will be valuable in making treatment decisions. I do  not believe that diagnostic studies for food intolerances are cost-effective or particularly helpful; however, exclusion diets may be beneficial. I introduce fiber supplements gradually and monitor them for tolerance and palatability. Synthetic fiber is often better-tolerated than natural fiber, but must be individualized. In my experience, excessive fiber supplementation often is counterproductive, as abdominal cramps and bloating may worsen. Antidiarrheal agents are very effective when used correctly, preferably in divided doses. I use them in patients in anticipation of diarrhea and especially in those who fear symptoms when engaged in activities outside the home. I encourage patients to make decisions as to when and how much to use. However, almost always, a morning dose before breakfast is used (loperamide, 2 to 6 mg) and, perhaps again later in the day when symptoms of diarrhea are prominent. I prefer antispasmodics to be used intermittently in response to periods of increased abdominal pain, cramps, and urgency. For patients with daily symptoms, especially after meals, agents such as dicyclomine before meals are useful. For patients with infrequent but severe episodes of unpredictable pain, sublingual hyoscyamine often produces rapid relief and instills confidence. In general, I recommend that oral antispasmodics be used for a limited period of time rather than indefinitely, and generally for periods of time when symptoms are prominent. For chronic visceral pain syndromes, I recommend small doses of tricyclic antidepressants. These agents are especially effective in diarrhea-predominant patients with disturbed sleep patterns but may be unacceptable to patients with constipation. I educate patients that side effects occur early and benefits may not be apparent for 3 to 4 weeks. I consider using SSRIs in low doses in patients with constipation-predominant IBS; cisapride, 10 to 20 mg three times per day, also may be beneficial. When taken with drugs that inhibit cytochrome P450, cisapride has been associated with serious cardiac arrhythmias caused by QT prolongation, including ventricular arrhythmias and torsades de pointes. These drugs include the azole fungicides; erythromycin, clarithromycin, and troleandomycin; some antidepressants; HIV protease inhibitors; and others. In patients with IBS with mild to moderate co-morbid depression, I have found that the use of SSRIs such as paroxetine, fluoxetine, or sertraline may be beneficial. It is important to tell patients that anxiety and disturbed sleep may occur during the first 10 days and benefits may not occur for 3 to 4 weeks. I prescribe a small amount of a short-acting benzodiazepine such as alprazolam, 0.5 mg two times per day, to control these symptoms. For generalized anxiety without depression, buspirone or clonazepam may be useful. I have found that patients who also have associated panic disorder may benefit from a benzodiazepine, tricyclic antidepressant, or an SSRI. However, these patients are best managed in conjunction with a psychiatrist or psychologist. I consider the use of alternative therapies in patients who fail to respond to conventional measures and who are receptive to alternative strategies. These include general relaxation techniques such as biofeedback and hypnosis therapies. PMID: 11096567 ------------------ http://www.ibshealth.com/ www.ibsaudioprogram.com


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## JeanG (Oct 20, 1999)

Thank you for posting this, Eric. It explains IBS management quite well.JeanG


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## Mike NoLomotil (Jun 6, 2000)

Comment:First reaction was that the author was doing well until he got to here: _______________________________________"I do not believe that diagnostic studies for food intolerances are cost-effectiveor particularly helpful; however, exclusion diets may be beneficial." ______________________________________since the statement is of personal belief not currebt fact, BUT I forget where the author is coming from. As may the casual reader.I stepped back and considered that, based upon the technology and methods of in vitro testing that have been available prior to this year, the limitations of which led our immunologist-led research group to develop the Mediator Release Test and the dietary protocols to go with it (perfecting the LEAP method), the author is correct, and we would be in 100% agreement absent the newly patented MRT technology. One becomes accustomed to having a tool during research, development, and early clinical application and forgets the tool has not been distributed yet, so others are not aware of it.And since it is new, and thus its distribution and availability is in its infancy, most people are not aware that an effective short cut is now available. So this will change with time.The fact remains that PROPER elimination-challenge dietary approaches can provide patients most of the information needed on their most-reactive foods or additives to bring substantial symptomatic relief through elimination dieting based on the results. The key word is "PROPER", to ensure that the method is effective, and doing so takes time and committment. This is the main element that in vitro testing brings to the table...it requires no particular discipline on the part of the patient and results are swift. Integrated dietary, psychological-behavioral support of various kinds, and interventional pharmacotherapy until diet and behavior modification (affective and cognitive) attenuate symptoms remains the regimen of choice with the highest overall long term success rates, compared to single-mode therapy.MNL__________________ www.leapallergy.com [This message has been edited by Mike NoLomotil (edited 12-04-2000).][This message has been edited by Mike NoLomotil (edited 12-04-2000).]


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