Irritable Bowel syndrome & Homoeopathy

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 the incidence of IBS is 10% and its prevalence 20%. These numbers are dependent on the diagnostic criteria used as well as on the population studied. Approximately 70% of patients who meet the diagnostic criteria for IBS do not seek medical care; the remaining patients account for 12% of primary care visits. Community-based estimates suggest that up to 30% of patients with a gastrointestinal complaint will have IBS but only a minority of patients diagnosed by a gastroenterologist.

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)

Rome II Criteria for diagnosis of Irritable Bowel Syndrome

Abdominal discomfort or pain with two of the following three features for at least 12 weeks, not necessarily consecutive, during the previous 12 months:

 • 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.

2^nd- mostly after breakfast.

3^rd- 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-

27/03/2003	No change in symptoms.	Placebo- 1 dose
8/05/2004	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.
22/05/2004	Feels better. Bowel habit reduced to 2 times in morning.	Placebo/1 dose.
29/05/2004	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/1^st hr, 9/2^nd 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
26/06/2004	First prescription (Based on acute emotional causative modality)	Ign 200C/1D
01/07/2004	Complaints slightly reduced.  General’s normal.	S.L / 2 weeks
07/07/2004	Complaints completely reduced. Generals’ normal.  Patient was discharged and advised to attend OP every Thursday.	S.L/ 1 month
15/07/2004	Recurrence of complaints since 3 days. App-reduced, thirst- more, H/o of grief	Nat.m 1M/1D S.L / 2 weeks
19/08/2004	No recurrence of complaints.  Burning pain in the soles reduced completely.	S.L/2 weeks
23/09/2004	No recurrence of complaints.	S.L / 2 weeks
28/10/2004	No recurrence of complaints.  Patient feels better	S.L / 2 weeks
20/01/2005	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: McGraw-Hill, 1998

2) By Rebecca C. Dunphy, MD, and G. Nicholas Verne, MD, Malcom Randall Veterans Affairs Medical Center and the University of Florida College of Medicine in 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 textbook of medicine.  Oxford medical publishers, Oxford, 3^rd edition – 1996.

“  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.