Dr Hilary Jones


This article written by the popular Doctor Hilary Jones explores Irritable Bowel Syndrome and the role of fibre.

The article covers:

  • What is Irritable Bowel Syndrome?
  • How common is it and who suffers most?
  • What are the main symptoms?
  • Effect on lifestyle
  • What causes Irritable Bowel Syndrome?
  • How is it diagnosed?
  • How is Irritable Bowel Syndrome treated?
  • Top 10 tips for regular bowel

Irritable Bowel Syndrome and the role of fibre

Dr Hilary Jones GP

What is Irritable Bowel Syndrome?

Irritable Bowel Syndrome is a very common digestive disorder causing inconvenient, tiresome and sometimes painful symptoms such as abdominal cramps, bloating and constipation alternating with diarrhoea. It is not usually present all of the time, but tends to come and go as the muscles which influence intestinal movement react to changing conditions such as diet and stress.

How common is it and who suffers most?

Irritable Bowel Syndrome affects at least 1/5 of the adult population of the UK, but if you include everyone who experiences just one symptom in any year, probably 70% of the population has been aware of it. Around 8 million Britons therefore have Irritable Bowel Syndrome, with men and women affected equally. It usually begins in the late 20s to 30s and only tends to ease up again naturally after the age of 60 or so. Not only does it curtail a sufferer’s personal and social life, but it also leads on average to people taking between 2-3 weeks off work each year, and costs the country about 500 million pounds as a result.

What are the main symptoms?

No two people with Irritable Bowel Syndrome will experience exactly the same symptoms as one another, and the triggers which bring their symptoms on and the frequency with which they notice them will vary considerably. However, the main symptoms are usually painful constipation or unpredictable diarrhoea, or a tiresome and alternating combination of both. There is often also distension of the abdomen with bloating and wind, tummy cramps and indigestion. For some people, having to rush to the loo to empty the bowel, feeling that bowel emptying is incomplete, and knowing that eating out or at any social function in company is likely to promote symptoms is typical. Gynaecological symptoms such as pre-menstrual tension and painful periods may be associated with Irritable Bowel Syndrome in some women, as may urinary symptoms and problems such as headache, insomnia, anxiety and depression in both sexes.

Effect on lifestyle

Although not life-threatening or associated with any malignant or progressive condition, Irritable Bowel Syndrome can seriously restrict a person’s social activities, work commitments and relationships. Sufferers often avoid social engagements, travelling, domestic and leisure activities and resort to planning their daily life around access to toilets. Furthermore, because the diagnosis of Irritable Bowel Syndrome is so hard to reach with certainty, and because so many of its symptoms are similar to more inflammatory and sinister conditions such as colitis and bowel cancer, it is little wonder that anxiety and sleeplessness are common constant companions of the Irritable Bowel Syndrome victim as frequent trips to the GP or hospital outpatient clinic to rule out the latter are hardly conducive to a peaceful life.

What causes Irritable Bowel Syndrome?

The usual smooth process of digestion continues day in, day out without any voluntary control or consciousness on our behalf. Each part of the digestive system has its own important function, but all of them are controlled by the nervous system which can turn off or stimulate the digestive process at any time. When we are tense and stressed, blood flow is diverted away from the gut and rhythmic muscular contractions in the wall of the intestine which propel food forward slow down. Conversely, when we are calm and relaxed, the nervous system powerfully stimulates the bowel enabling it to perform its various functions. Severe anxiety such as that manifested before an exam, a running race or even a first date is also mediated through the nervous system, but along different pathways, resulting in the diarrhoea experience in these particular circumstances. This explains how worry and stress from all kinds of sources can bring on symptoms of Irritable Bowel Syndrome. Problems with interpersonal relationships, work concerns, bereavement for example, can all trigger symptoms. This is also why people who are born worriers or who have depression are more prone to Irritable Bowel Syndrome. In addition to these psychological factors, some Irritable Bowel Syndrome sufferers also seem to have increased physical sensitivity in the gut generally while others may be intolerant to certain elements in their diet or have been slow to get better following a bout of food poisoning or gastroenteritis. There is almost certainly a hereditary component to Irritable Bowel Syndrome also.

How is it diagnosed? 

Irritable bowel syndrome is not really a diagnosis at all. It is more a description of the reactivity of your bowel to certain factors after all other more serious disorders of the intestinal system have been excluded. Mostly the diagnosis is made on the symptoms alone, as only about half of all people with Irritable Bowel Syndrome ever consult their GP and of the ones who do, only 20% are referred on to a hospital clinic. If someone is under the age of 45 with typical symptoms and in whom nothing is found on physical examination, the diagnosis is often made clinically. If however there is any weight loss, any rectal bleeding or severe symptoms sufficient to wake people up at night for example, or if symptoms have come on very suddenly and in older people, particularly, further tests may be required. These may include examination of the bowel with a narrow viewing instrument and in women, exclusion of gynaecological disorders such as pelvic inflammatory disease or endometriosis. Hospital investigations will occasionally be necessary in severe or difficult cases but there can be disadvantages as ongoing tests can be time-consuming, can increase underlying anxiety unnecessarily and may find minor abnormalities which are not in fact responsible for the symptoms. A logical, step-wise approach with the individual patient in mind is therefore essential.

How is Irritable Bowel Syndrome treated?

In my experience as a GP, the reassurance of a diagnosis of Irritable Bowel Syndrome and the exclusion of other more serious conditions is helpful in itself. Many sufferers are happy to live with the condition by adjusting their lifestyles once they realise what it is. As well as these, a combination of complementary as well as conventional approaches can produce positive results and of these, the most important include dietary change, psychological therapies, and medication.

Lifestyle changes

Dehydration is a major factor in Irritable Bowel Syndrome and increasing one’s intake to at least two litres of fluid a day is useful. Exercise helps regulate the influence of the nervous system on the digestive system as does addressing any emotional problems which may promote anxiety or depression. Certain medications may cause constipation or diarrhoea as a side-effect and clearly these are worth avoiding.

Dietary adjustment

A few people may have food intolerances which may promote Irritable Bowel Syndrome. Some 1/100 people are sensitive to gluten, a protein in certain cereals, whereas others may be lacking in an enzyme which helps to digest sugar in milk or in fruit. For them, some degree of food elimination may be helpful in avoiding the trigger which causes their symptoms. Probiotics the so- called ‘friendly bacteria’ which normally inhabit the large intestine, have an important role in digestion and taking these in the form of supplements are beneficial in many people especially those who have recently had any form of gastroenteritis or bowel upset caused by medicines such as antibiotics. Undoubtedly however, for any individual, altering the amount of fibre which is enjoyed in their diet is vital. Fibre is found in the tough fibrous part of fruit and vegetables and on the outer part of grains, seeds and fruits. It is also in the flesh of the softer parts of fruit and vegetables, although indigestible in the small intestine. In the large intestine, the colon, this insoluble fibre maintains the water content of the motions and promotes the multiplication of probiotics. This makes the stools larger and softer and easier to pass. Consequently, sufficient fibre in a diet is essential to control symptoms such as constipation, but it’s important only to increase intake slowly, otherwise symptoms may initially get worse until the body has adjusted. Good sources of fibre include wholemeal and wholegrain bread, wholegrain and high fibre breakfast cereals, wholemeal flour, brown rice, wholemeal pasta, pulses such as peas, lentils and beans, nuts, seeds, fruit and vegetables. Some forms of high fibre foods will cause some people to experience increased symptoms such as excess wind or discomfort in which case alternative sources of fibre such as bulk forming laxatives or extra bran may be appropriate.

Keeping regular

My top 10 tips for regular bowel action are as follows: 

  1. Always go to the loo when you feel the urge.
  2. Make this a routine if you can, such as after breakfast ?or on rising.
  3. Eat more natural fibre.
  4. Drink at least 2 litres of fluid daily.
  5. Keep as active as possible.
  6. Avoid laxatives.
  7. Ensure you have access to good toilet facilities at work ?and at home.
  8. Eat regular meals.
  9. Take regular exercise.
  10. Consider a healthy fibre supplement.(e.g. Psyllium husk.)

Talking therapies

A healthy influence of the nervous system over the digestive process may be maximised by cutting out emotional factors linked to anxiety, stress and depression. Relaxation techniques may be learned to cope with the triggers known to cause psychological distress and much success has been had with hypnotherapy where somebody learns to control symptoms on their own through a better understanding of the negative influences of stress and better ways of dealing with it. Similarly, cognitive behavioural therapy and biofeedback can help with the majority of patients reporting an improvement of 60-70% in their symptoms as a result.

Conventional therapy

Irritable Bowel Syndrome remains one of those problems in both the general practice and hospital setting which do not respond well to conventional medication. Many medicines are limited in their efficacy and can cause side-effects in their own right. Laxatives and stopper medication (anti-diarrhoeals) for example merely treat the immediate symptoms and do little to normalise the healthy equilibrium of a bowel struggling to find balance. Where appropriate, anti-anxiety and anti- depressant medication may help and anti-spasmodics may for a short time at least reduce the painful spasms of the muscles in the intestinal walls which result in abdominal pain. As millions of Irritable Bowel Syndrome sufferers will testify however, the results of such conventional medications are usually disappointing.

Case Study

Maddie, 38, had been juggling the intense pressures of regular work as a secretary with the challenges of family life looking after a partner and three children aged between 4 and 12. She had always had a tendency to be constipated having just 2 or 3 bowel actions every week since she was a teenager and sometimes she would also suffer from bloating, a very noisy tummy, the build-up of gas resulting in inevitable episodes of explosive diarrhoea. She had also noticed that her symptoms were worse when her workload increased or whenever she ate out in restaurants or at dinner parties with other people. When her partner was made redundant and financial pressures increased, her symptoms became markedly worse and she visited her doctor. He asked her detailed questions about her symptoms and because of their severity, referred her to a gastroenterologist at the local hospital with a special interest in Irritable Bowel Syndrome. After some simple blood tests and a colonoscopy, a diagnosis of Irritable Bowel Syndrome was eventually reached. She had 10 sessions of hypnotherapy and the help of a dietician to enable her to adjust her dietary intake which meant including a greater quantity of water and a higher amount of insoluble fibre on a daily basis. Three months later, Maddie was much happier in general with fewer symptoms, a new found ability to control them, and a greater understanding of the type of high fibre foods that would give her a daily comfortable bowel action and better control of her Irritable Bowel Syndrome generally.

Useful Addresses

The Irritable Bowel Syndrome Network Unit 5?, Mowbray Street, Sheffield ?S3 8EN www.Irritable Bowel Syndromenetwork.org.uk

NHS Direct Tel: 0845 4647 www.nhsdirect.nhs.uk

NHS Scotland 0800 224488

The UK Register of Irritable Bowel Syndrome Hypnotherapists? PO Box 57 Warrington WA5 1FG? Tel: 0800 085 3970 www.Irritable Bowel Syndrome-register.co.uk

References

  1. Irritable bowel syndrome. Clinical Knowledge Summaries. www.cks.nhs.uk, accessed 24 August 2009?
  2. Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care. National Institute for Health and Clinical Excellence (NICE), 2008. www.nice.org.uk 
  3. NICE: CG61 Irritable bowel syndrome: quick reference guide: www.nice.org.uk?
  4. Agrawal A, Whorwell PJ. 2006. Irritable bowel syndrome: diagnosis and management. BMJ 2006; 332:280 
  5. Joint Formulary Committee, British National Formulary. 55th ed, London: British Medical Association and Royal Pharmaceutical Society of Great Britain, 2009:53?
  6. Irritable bowel syndrome – management. When should I refer? NHS Clinical Knowledge Summaries: www.cks.nhs.uk 25 August 2009 
  7. Probiotics. The British Dietetic Association, 2007. www.bda.uk.com?
  8. American Journal of Gastroenterology 2003; 98 (9): 1970-75?
  9. Mertz HR. Drug therapy: Irritable bowel syndrome. N Engl J Med 2003; 349: 2136
  10. British Medical Association. Family Doctor Series. Irritable Bowel Syndrome 2006 

Further Reading 

  1. The British Dietetic Association, www.bda.uk.com
  2. Food Standards Agency, www.eatwell.gov.uk 

About the author 
Dr. Hilary Jones 

Dr Hilary Jones qualified in 1976 at the Royal Free Hospital in London having studied Arts subjects to A level and then converting to a 6 year medical degree. 
In 1979 he worked for a year as the single-handed medical officer on Tristan da Cunha, the most isolated inhabited island in the world. In 1981 he worked as a troubleshooting GP and emergency doctor for the oil industry at Sullom Voe in Shetland for Offshore Medical Support. 
He became a Principal in General practice and a GP Trainer in the early 1980’s. He also worked as a Senior House Officer in Ophthalmology before entering general practice, assisting in Glaucoma and Cataract extraction procedures and learning the science of refraction. 
He then began presenting educational medical TV programmes for British Medical TV in 1986. Sky TV then adopted these programmes for their news bulletins soon after. In 1989 Dr Hilary joined the most successful TV breakfast station ever, TVAM. He and Lorraine Kelly were the first presenters to be signed up by GMTV when it won the breakfast franchise in 1993. He is now the Health Editor for breakfast television. 
He has written several books including ‘Before You Call The Doctor, ‘What’s The Alternative?’, ‘Your Child’s Health’, ‘I’m Too Busy To Be Stressed’, ‘Total Well Being’ and ‘Natures Remedies’. His first novel, ‘What’s Up Doc?’ was published in August 2009. 
He is a regular contributor to the Steve Wright Show on Radio 2, Radio 5 Live Gabby Logan programme and also writes for Fabulous magazine and Rosemary Conley magazine. 
He practices as a part time GP in the NHS and also has a private practice in London.

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