Irritable Bowel syndrome - a
challenge in medical practice
Prof G R Mohan
(NHJ, Vol 8, no 2,
March/April-2006
full length article in Wonders of Homoeopathy an evidence based study
Irritable bowel syndrome a motility disorder involving the entire GI tract, it is a challenge to
treat Irritable Bowel Syndrome in clinical practice with high prevalence of one
in four. The
cause of irritable bowel syndrome is unknown. No anatomic cause is seen.
Emotional factors, diet, drugs, or hormones may precipitate or aggravate GI
motility. Some patients of IBS have anxiety disorders, particularly panic
disorder; major depressive disorder; and somatization disorder. However, stress
and emotional conflict do not always coincide with symptom onset and
recurrence. This clinical condition, which has long been misunderstood and misdiagnosed,
may represent a complex interaction of altered neurochemical mediators in the
enteric nervous system with psychosocial and environmental influences. (2).
The pathogenesis of IBS is poorly
understood although roles for abnormal gut motor and sensory activity, central
neural dysfunction, psychological disturbances, stress and other factors have
been proposed.
Abnormal
psychiatric features are recorded in upto 80% of IBS patients, however no
single psychiatric diagnosis predominates. An association between prior sexual
or physical abuse and development of IBS has been reported. Forms of sexual abuse associated with IBS
include verbal aggression, exhibitionism, sexual harassment, sexual touching
and rape. The pathophysiologic relationship between IBS and sexual and physical
abuse is unknown. However physical and sexual abuse may result in hyper
vigilance to body sensations at CNS level and visceral hypersensitivity at the
gut level.
Gender, race, and age all play a role in the
prevalence of IBS. Recent studies suggest that in the United States
There are two
major clinical types of IBS, constipation predominate IBS, and Diarrhea
predominate IBS.
In constipation-predominant
IBS, constipation is common, but bowel habits vary. Most
patients have pain over at least one area of the colon, associated with
periodic constipation alternating with a more normal stool frequency. Stool
often contains clear or white mucus. The pain is either colicky, coming in
bouts, or a continuous dull ache; it may be relieved by a bowel movement. Eating
commonly triggers symptoms. Bloating, flatulence, nausea, dyspepsia, and
pyrosis can also occur.
Diarrhea-predominant
IBS is characterized by
precipitous diarrhea that occurs immediately on rising or during or immediately
after eating. Nocturnal diarrhea is unusual. Pain, bloating, and rectal urgency
are common, and incontinence may occur. Painless diarrhea is not typical and
should lead to consider other diagnostic possibilities e.g., malabsorption,
osmotic diarrhea, and etc.
The key to diagnosis of IBS is effective
history taking, which requires attention to directed, but not controlled,
elaboration of the presenting symptoms, history of present illness, past
medical history, family history, familial interrelationships, and drug and
dietary histories. Equally important are the patient's interpretation of
personal problems and overall emotional state. The quality of patient-physician
interaction is key to diagnostic and therapeutic efficacy. Patients with IBS
generally appear to be healthy. Palpation of the abdomen may reveal tenderness,
particularly in the left lower quadrant, (4)
• Relief with defecation
• Onset associated with change in stool frequency.
• Onset associated with change in stool formation.
Supportive Symptoms-
1. Fewer than three bowel movements per week.
2. More than three bowel movements per day.
3. Hard or lumpy stools.
4. Loose or watery stools.
5. Straining during bowel movements.
6. Fecal urgency.
7. Feelings of incomplete evacuation.
8. Passage of mucus during bowel movement.
9. Sensation of abdominal fullness or bloating
Diarrhea-predominant irritable bowel syndrome = one or more of 2, 4, and
6 and none of 1, 3, and 5
Constipation-predominant irritable bowel syndrome = one or more of 1, 3,
and 5 and none of 2, 4, and 6 (4)
Symptoms can
be triggered by stress or the ingestion of food is 50% higher than for patients
who do not fit the diagnostic criteria. These patients undergo more surgical
procedures (such as hysterectomy, appendectomy, and cholecystectomy) and have a
higher rate of work absenteeism and an increased number of physician visits per
year. Moreover, these patients have significantly impaired quality of life even
when compared with chronic disease such as diabetes. Upto 40% of referrals to
gastroenterologists are IBS. (2,3).
Lactase intolerance is another common
condition that can mimic diarrhea-predominant IBS, antecedent event such as a
viral gastroenteritis or food-borne illness is important because there is
evidence that up to 30% of patients will develop IBS-like symptoms after experiencing
Salmonella enteritis,
Laboratory examination:
- Physical exam.
- Blood tests.
- X ray of the bowel: This x-ray test is
called a barium enema or lower GI (gastrointestinal) series. Barium is a
thick liquid that makes the bowel show up better on the x-ray. Before
taking the x ray, the doctor will put barium into your bowel through the
anus.
- Endoscopy: The doctor inserts a thin
tube into your bowel. The tube has a camera in it, so the doctor can look
at the inside of the bowel to check for problems.
The approach by conventional system in the treatment of IBS
is without consideration of person as a whole but in Homoeopathic system the
successes rate is more due to holistic approach, in considering the mental and
physical aspects of the individual. Giving importance to mind in treatment is
the need of the hour in IBS; so homoeopathic treatment has edge over other
systems
A high-fiber
diet should be advised to reduce digestive system irritation. Alcohol,
caffeine, and fatty, gassy, or spicy foods should be avoided. Recommended
stress management techniques include yoga, meditation, hypnosis, biofeedback,
and reflexology. Reflexology is a technique of foot massage that is thought to
relieve diarrhea, constipation, and other IBS symptoms.
The following
two interesting cases of IBS treated in OPD
C A S E S:
NAME- Mr.G, 35years.
Male-Sex,
Religion-
Hindu. Married.
Occupation – Works in
a Private Bank.
Date of first
visit-13.03.03 (OPD)
Presenting
complaints-
·
Burning
in throat since 3 years.
·
Irregular bowel habits since 10 months.
History of presenting complaints-
Patient was well before 3-4
years; to start with he developed symptoms of pain in the right hypochondrium,
burning pain in throat, sour eructations, regurgitation of food after eating.
he was diagnosed as having cholelithiasis and he was operated for it. He was
very well up to 5/6 months of operation, but gradually he developed following
symptoms.
Burning in throat since 3 years < Afternoon 2-3 p.m. , taking spicy food, excess quantity of
food and after any anxiety or tension.
Regurgitation of food
and water
Irregular bowel
habit-morning at least gets 3 times urgency before 9 a.m. (before going to office, in holidays also he gets
for 3 times.)
First –just after
raising from bed.
2nd-
mostly after breakfast.
3rd-
commonly before starting for office.
Itching in scalp
since 4-5years.
Past history-
Chickenpox in childhood.
Treatment history.
1.Allopathic
2.Homoeopathic-a) Ars.alb200.b) Arg.Nit 200.
Personal history-
Appetite-good, now taking food in small quanties.
Thirst- normal.
Desires –cold drinks.
Aversions-Sweets.
Bowels-3/4 times
daily. (3times before 9 a.m. ).
Sweat- on exertion,
offensive odour.
Sleep –sound.
Dreams –not specific.
Thermal reactions-
Likes open air. Likes winter.
Life space
investigation- He hails from one
middle class family. Now works in a private bank. Happy with his work. Married
and having a son of two year. Relationship with family members and others is
good. Can’t concentrate in one thing for a long time, low in confidence.
Physical examination- Well nourished, moderate
built.
No signs of pallor, icterus, cyanosis, clubbing and edema.
B.P-120/80 mm of Hg.
Pulse rate-75/min, regular, full, and no spl. character.
Heart rate –75/min regular, full, no spl. character
Systemic examination-
GIT- No relevant sign found.
Investigations- Within the normal range.
Clinical diagnosis- Irritable bowel syndrome.
Disease classification: Dynamic chronic
fully developed miasmatic disease.
Miasmatic Diagnosis: Mixed miasmatic disease
(Predominantly Psoric)
Repertorial totality.
Complete Repertory Selected
Mind- Anxiety.
Ailments from anxiety.
Confidence want of self.
Concentration difficult.
Male genital- Sexual; Desire
increased
Generalities- Food and drinks
sweets aversion.
Food and
drinks, cold drinks water desires.
Perspiration- Odor- offensive.
Stool- Frequent.
Morning.
Throat- Pain – Burning.
Stomach-Eructations-food of, regurgitation.
Result of repertorisation.
1. Lyco-26/11. 6.Ars.alb-20/10.
2. Phosp-25/10. 7.Caust-20/10.
3. Merc-22/10. 8.Puls-20/10.
4. Sil-22/10. 9.Sulph-20/10.
Remedy selected.
Lyco 200/ 1 dose on 20/03/2003
Follow up-
|
|
No change in
symptoms.
|
Placebo- 1 dose
|
|
|
No change in
symptoms.
Along with previous
mental symptoms patient now have a marked aversion to do the official work.
As before he has a
strong desire for cold drinks,
Basing upon these
symptoms and as before also Phos. was in the 2nd position in
repertorization , Phos 200 planned to be prescribed.
|
Phosphorus 200C / 1
dose.
|
|
|
Feels better.
Bowel habit reduced
to 2 times in morning.
|
Placebo/1 dose.
|
|
|
Feels better.
Bowel habit once in
the morning.
Burning pain and
regurgitation reduced.
|
Placebo /1 dose
|
Case Summary: In this case due importance was given to the mental
symptoms of the patient and the case was marked improved after Phos 200 may be
due to its highest similarity to the case and as it covering more prominent
mental symptoms.
CASE NO.2
Mr. K, 51yrs/M, Hindu, Married, illiterate, Agricultural laborer,
admitted in our IPD, Bed no.31 with the complaints of sensation of fullness of
abdomen < after eating, stool >flatus; aching pain in the abdomen on and
off with urging to stool < during urging to stool >flatus; constipation,
frequent, ineffectual, urging and burning sensation in both soles
Past History
No significant past history. Took allopathic treatment for the presenting
complaints for the last 6 months with only temporary relief
Personal History:
Appetite: reduced Thirst: 5-6 glasses/day.
Desires: Sweets Aversions: sour things
Urine: (D/N): 6-7/0-1 Perspiration:
only on exertion
Bowels: Constipated, frequent, ineffectual,
urging.
Sleep: refreshed
Thermal state: Ambithermal
Mental generals: Ailments from
silent grief, cannot bear contradiction.
Investigations: On 24/06/2004,
CBP: Hb%- 13.5gm%, T.RBC-4.8 milli/cu mm, T.WBC-8,000cells, ESR-5mm/1st
hr, 9/2nd hr; DC-L.60%, L.33%, E.5%, M.2%: Stool analysis-No cyst,
No ova, No occult blood, No parasite. FBS, LPT – with in normal limits
Diagnosis: Irritable Bowel
Syndrome.
Disease classification: Dynamic chronic
fully developed miasmatic disease
Miasmatic Diagnosis: Predominant
Psora - Syphilis
Repertorial Totality:
[KT] [Stomach] Desire:
Sweets:
[KT] [Stomach] Desire: Sour:
[KT][Abdomen] Fullness,
sensation of: Eating: after:
[KT][Abdomen] Fullness,
sensation of: Flatus, passing: amel:
[KT][Abdomen] Pain: Aching:
Flatus, passing: amel:
[KT][Abdomen] Pain: Aching: Stool: Urging,
during.
[KT][Abdomen] Pain: Aching:
Stool: Before:
[KT][Rectum] Constipation: Ineffectual
urging and straining
[KT][Extremities Pain] Pain:
Burning: Hand: Palm: Night:
[KT][Extremities Pain] Pain:
Burning: Foot: Sole: Night:
Repertorial Result: Sulph 20/9,
Lyc 17/7, Carb.veg 16/8, Sep 15/8, Calc.carb 12/6
Previous Homoeopathic Treatment: Initially Nux
vom 200C and Lyco 1M prescribed based upon the prominent physical generals and
gastric symptoms but there has been no relief for 15 days, but after careful
interrogoration about his life space investigation, he revealed the death of
his son 6 months back, after that he was constantly brooding over that matter
without expressing outwards and from then onwards started his complaints
gradually and cannot bear contradiction
Follow Ups:
|
Date
|
Observation and progress
|
Treatment
|
|
|
First prescription (Based on acute emotional causative modality)
|
Ign 200C/1D
|
|
|
Complaints slightly reduced.
General’s normal.
|
S.L / 2 weeks
|
|
|
Complaints completely reduced. Generals’ normal. Patient was discharged and advised to
attend OP every Thursday.
|
S.L/ 1 month
|
|
|
Recurrence of complaints since 3 days. App-reduced, thirst- more, H/o
of grief
|
Nat.m 1M/1D
S.L / 2 weeks
|
|
|
No recurrence of complaints.
Burning pain in the soles reduced completely.
|
S.L/2 weeks
|
|
|
No recurrence of complaints.
|
S.L / 2 weeks
|
|
|
No recurrence of complaints.
Patient feels better
|
S.L / 2 weeks
|
|
|
No recurrence of complaints.
|
S.L/2 weeks
|
Case Summary: Mr. K, aged 51 years, developed
fullness and aching pain in the abdomen after stool and burning sensation in
the soles following his son’s death. He was treated initially with Ign 200C/1D
and later Natr.mur 1M/1D as per the case required. This led to marked improvement as there was
no recurrence of complaints and the patient is still under observation and
further results awaited.
Bibilography
1) Lynn, Richard B.,
and Lawrence S. Friedman. Irritable bowel Syndrome In Harrison's Principles of Internal Medicine,
edited by Anthony S. Fauci, et al. New
York
2) By
Rebecca C. Dunphy, MD, and G. Nicholas Verne, MD, Malcom Randall Veterans
Affairs Medical
Center University of Florida College of Medicine Gainesville
3) Manning AP, et al: Towards a positive
diagnosis of the irritable bowel syndrome. BMJ 2:653, 1978.
4) Thompson WG, et
al.Functional bowel disorders and Functional abdominal pain. Gut
45(suppl II):1143, 1999.
5) Phlip M Bailey,
Homoeopathic psychology,B.Jain publications
6) Weatherall D.J,
Ledingham G.G and Wavell D.A : Oxford Oxford Oxford
“ Doctors are men who
prescribe medicines of which they know little, to cure diseases of which they
know less, in human beings of which they know nothing” - VOLTAIRE, 1694-1778
Prof. G. R. Mohan, H.O.D, P.G.
Dept. of Organon and Phil.
Dr. Ch.v.Kishore kumar, P.G. Final year. Dr
Amulya Ratna Sahoo, P.G. Final year.
