O P Kapoor Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008 Sharad Shah Hon Gastroenterologist, Sir HN Hospital, Mumbai 400 004.
When properly diagnosed, irritable bowel syndrome affects 15 to 20% of our population. It will therefore be worth studying the life history of this very common illness. Being a functional illness, it is not fatal. But this is not a consolation to the patients who may suffer for a lifetime from the illness.
Group I : Patients complaining of "abdominal pain" as a predominant symptom with or without altered bowel habit have a bad prognosis. When they present with a hepatic flexure syndrome, splenic flexure syndrome, severe spasm of the caecum, they can be easily mistaken to be suffering from cholecystitis, perforated ulcer or appendicitis. So, the patient can land up with the surgeon and a laparotomy may be performed. In that case, morbidity and mortality of laparotomy will be applicable to them. Surprisingly this above presentation is much less common in Indians.
Group II : The main symptom is bloating and abdominal distension especially after fatty meals. In the absence of any bowel complaints, (in our country and in many other parts of the world) these patients are investigated for gall bladder disease and a wrong diagnosis of non-calculus chronic cholecystitis is made and the gall bladder is removed. Thus they are subjected to morbidity and mortality of this major surgery.
Group III : These patients suffer so much that normal life activities are interfered with. Examples are:
a) There are patients who have five to six bowel movements early morning before and after breakfast. Such patients are often handicapped by this early morning diarrhoea and cannot reach their office in time. Also the fear of post-lunch-gastrocolic reflex leads to inability to concentrate on their work.
b) Other patients have the main problem of "time" spent in evacuation. Such people spend as much as half to one hour in the toilet. Not only are they a nuisance to other family members, but often they cannot keep their schedule.. After sitting in the toilet for so long, they get exhausted physically and mentally (specially if they use an Indian toilet).
c) Some patients develop symptoms of irritability of the other organs. Thus, they can develop irritable oesophagus, irritable rectum and irritable heart syndrome (theoretically even irritability of small bowel has been described).
Irritable e oesophagus leads to chest pain, burning and other symptoms of upper abdominal dyspepsia. The irritable rectum can lead to severe urgency of stool or unproductive call to the toilet which becomes a nuisance. Irritable heart patients develop symptoms of palpitations, dyspnoea and cardiac neurosis and often land up with a cardiologist.
Group IV : In a few patients, rectal evacuation becomes a "fixation". These patients start using "finger" evacuation. This can lead to chronic proctitis. Such patients can then pass blood in the stools, which causes confusion in diagnosis and leads to re-investigations.
Group V: Some patients develop a 'stool fixation'. They keep on looking at the contents of the stools passed and worry about the appearance of undigested food-particles, skin of the tomatoes and shape and consistency of the stools and brood over them.
Group VI: There is a group of patients who are convinced that their digestion is defective. Thus they start avoiding high caloric fatty and fried foods (often at the advice of family physicians). They then start losing weight and when they visit a second physician, they are again extensively investigated to rule out organic disease of the intestines.
There are others who lose weight because they avoid food for fear of gastrocolic reflex.
It is worth remembering that majority of the patients of irritable bowel syndrome who have learnt to live with the disease have a very good appetite and often are overweight.
Group VII : Lactose intolerance is so common in certain patients of irritable bowel syndrome that omission of milk in such patients has given them nearly a new life! This is because, they are relieved of symptoms of borborygmi, excessive flatus and explosive diarrhoea which are often embarrassing.
Group V111 : Patients who develop irritable bowel syndrome after an attack of amoebiasis have a relatively good prognosis because they respond very well to antiamoebic drugs. But often they relapse as soon as these drugs are discontinued.
Group IX: There are others who develop "neurosis" over the diagnosis of amoebiasis made by their family doctors. They go on carrying stool reports in the file which have shown occasional cyst of E. histolytica and yet these patients do not respond to antiamoebic drugs.
Group X : In a large number of patients the main complaint is incomplete evacuation. Often they learn to go to the toilet for the second time after breakfast or in the evening.
Group XI: Although anxiety and depression are connected to the aetiology of irritable bowel syndrome, only those who have obvious clinical picture of anxiety or depression respond very well to anxiolytic drugs, others do not.
Group XII : Many patients of irritable bowel syndrome are silent sufferers and non-reporters. They do not visit the doctors because they consider these symptoms as part of normal life or related to stress.
Group XIII : Many patients of irritable bowel syndrome learn to live with the disease. Of course, there are remissions, relapses and exacerbations related to the stresses in life. Many of them limit their social activities due to frequency of stools and the gastrointestinal upset caused by hotel or the party food, the alcoholic drinks and the snacks which usually are more oily and spicy.
It is worth remembering that patients of irritable bowel syndrome form nearly 50% of the cases seen in gastrointestinal clinics all over the world