Irritable bowel syndrome

DESPITE THE FACT THAT IRRITABLE BOWEL SYNDROME, which causes pain and rumbling in the abdomen, has been studied for decades, its causes are still unknown. How to live with IBS and whether it is possible to defeat it once and for all, we found out from specialists: candidate of medical sciences, gastroenterologist, director of the evidence-based medicine clinic “Rassvet”, author of the book “Intestine with comfort” Alexei Paramonov and psychiatrist GBUZ “Psychiatric hospital No. 14 ”by Sophia Shemyakina.

What it is

Irritable bowel syndrome (IBS) is a condition in which a person experiences abdominal discomfort for at least three months a year, but tests show they have no health problems. Each of the symptoms of IBS – pain, bloating, diarrhea, or constipation – can manifest on its own or alternate with others. It is customary to isolate irritable bowel syndrome with a predominance of diarrhea or with a predominance of constipation, although the opposite symptoms can be replaced by each other in both variants. It is wrong to believe that IBS is a separate disease that always proceeds in a typical way: it is rather a whole group of similar disorders.

How is it diagnosed

According to doctor Alexei Paramonov, IBS and related disorders are several times more common than all other bowel diseases combined. This fact served as the reason for revising the diagnostic approach that dominated in medicine before: it was believed that irritable bowel syndrome is a “disease of exclusion,” that is, the diagnosis was made on a leftover basis, when all other options were excluded. To rule out diseases such as bowel cancer, Crohn’s disease, ulcerative colitis, patients underwent colonoscopy. But over time, it became clear that the likelihood of finding a malignant tumor in a twenty-year-old patient with abdominal pain for five years is close to zero.

As a result, the approach to diagnostics has become more individualized. For example, a colonoscopy for a young patient will be prescribed only if he has alarming symptoms: blood in the stool, a sharp decrease in weight, an increase in temperature, changes in blood test parameters. Good and non-invasive methods have emerged, such as the fecal occult blood immunochemical test and the stool test for calprotectin (a marker of intestinal inflammation). If during such examinations deviations from the norm are found, then a colonoscopy will be necessary at any age.

Is it possible to make the diagnosis even easier

In theory, irritable bowel syndrome can be diagnosed with just one blood test for a couple of additional parameters. Under the leadership of Dr. Mark Pimentel, a group of gastroenterologists and laboratory diagnostics specialists have developed a new method. It is based on the idea that IBS is a post-infectious autoimmune disease. According to this hypothesis, an organism that has suffered a bacterial intestinal infection continues to experience the negative effects of the bacterial cytoletal loosening toxin (CLTD). There has been a large study in thousands of patients and healthy people, and they really could be distinguished from each other by detecting antibodies to CLTD and to the intestinal protein vinculin.

This immunological test has passed all the necessary checks and is registered with the FDA for medical use in the United States. It would seem that the origin of irritable bowel syndrome has been established, it can be diagnosed in one fell swoop, and should be treated with anti-inflammatory drugs. But the test has several serious drawbacks. For example, it is only effective for diarrhea-predominant IBS but not constipation-predominant IBS, and it also works better in women. Therefore, the test is recommended for post-infectious IBS with a predominance of diarrhea, that is, only the form of the syndrome.

What treatment is effective

Alexey Paramonov notes that although some progress has been made recently in the diagnosis of irritable bowel syndrome, there have been no large-scale changes in treatment for a very long time. Long-acting antispasmodics are still used, symptomatic drugs – laxatives for constipation, “Loperamide” for diarrhea – but this approach is ineffective and helps only with short exacerbations. A new drug, Linaclotide, has now been registered in the United States. It is a laxative effective in treating IBS with constipation, which helps relieve pain and is not addictive. In Russia, this medicine is not yet available and older versions are used. Good results are obtained by a combination of “gastroenterological” drugs with drugs that affect the psyche. Of course, one cannot equate IBS and mental abnormalities, but the connection between the syndrome and depression, anxiety, and obsessive compulsions has been scientifically proven . At the same time, some drugs used in psychiatry proved to be effective in IBS, regardless of the presence or absence of psychological problems in the patient.

According to Paramonov, there is a good evidence base for tricyclic antidepressants and drugs of the SSRI group – serotonin and norepinephrine reuptake inhibitors (the latter are usually better tolerated). Nevertheless, doctors do not yet have an answer to the question of how to treat any form of IBS so as to obtain good results. Psychiatrist Sophia Shemyakina notes that irritable bowel syndrome can be a psychosomatic disorder. At the same time, there are two categories of patients: some themselves report the onset of an illness or its progression after stress and respond positively to psychotherapy and antidepressant treatment, others do not see any connection between the ailment and their own experiences, and the effect of taking psychotropic drugs and psychocorrection is lower for them.

It is important that the intestinal disturbances themselves only increase stress – a person is forced to quit communicating with other people more often, change their diet or lifestyle. At the same time, stress hormones provoke contraction of the intestinal walls, increasing pain, which is perceived by the brain as a deterioration in the condition – and stress hormones are released again. This is a “vicious circle” from which it is not easy to get out, so patients with IBS need psychotherapeutic and psychopharmacological support. According to Shemyakina, tricyclic antidepressants and SSRIs antidepressants not only improve mood and reduce anxiety, but also relieve pain and reduce or increase appetite. Of the psychotherapeutic methods, the best effect is given by cognitive-behavioral therapy and psychodynamic therapy based on psychoanalysis. Autogenic training combined with progressive muscle relaxation and antidepressant medication can also be beneficial.

What treatment does not work

There have been attempts to use the anti-inflammatory drug “Mesalazine” – the “classic” for many bowel diseases in IBS, but they were unsuccessful. For most patients, this remedy does not help, and those who managed to get better probably did not initially suffer from IBS, but microscopic colitis, an inflammatory disease that can only be detected on biopsy. The lack of universal remedies in the fight against IBS provokes attempts to solve the problem with unscientific methods. As an example, Alexey Paramonov cites the worldwide FUDMAP diet (its essence is the exclusion of easily digestible carbohydrates from the diet). It is effective in the small intestine bacterial overgrowth syndrome (SIBO), similar in symptoms to IBS, but in the case of IBS, it can give only a slight symptomatic effect, while significantly reducing the quality of life. The doctor adds that the GAPS diet is equally popular, but unlike FUDMAP, it is completely useless for IBS. The situation is similar with probiotics . These medications may speed recovery from antibiotic-treated diarrhea or infectious diarrhea, but their effectiveness in irritable bowel syndrome remains unconfirmed.

According to doctors, a real breakthrough will be the movement towards personalized medicine, when it becomes possible to predict the success of therapy based on the patient’s genotype, and it will be possible to treat irritable bowel syndrome individually. All this is in the future, but for now, an antispasmodic with an antidepressant with the support of psychotherapy and symptom control is a real and affordable way to improve well-being for most patients with IBS.

local_offerevent_note July 16, 2021

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