Irritable Bowel Syndrome: A Constitutional Approach
NATIONAL JOURNAL OF HOMOEOPATHY 2000 July / Aug VOL II NO 4.
Dr Anita Lobo
'Fer-met

Irritable bowel syndrome is one of the commonest GI problems in clinical practice. Although not life- threatening, it is distressful to patients and frustrating to physicians.

Definition: IBS is characterized by gripping associated with defecation, or altered bowel habits together with abdominal distension.

Epidemiology: 50% patients with GI symptoms are thought to have IBS. It is two or three times more common in women and increasingly seen in developed countries with a relation to stress, life-style and dietary factors. Symptoms typically begin in early adulthood and the prevalence of IBS is similar in elderly and younger adults.

Etiology And Pathogenesis
IBS is considered a functional disorder because no definitive structural, biochemical or infectious etiology has been established. The fundamental disturbance is thought to relate to disordered motor or sensory function of the GIT. Despite extensive investigation, no proof has established that emotional stress causes IBS, but for most patients stress leads to exacerbations.

IBS is probably a heterogeneous group of disorders. Numerous studies though not universally, have reported GIT motility abnormalities, probably caused by altered colonic motility, because the characteristic symptoms are consistent with colonic dysfunction with pains referable to colonic area. The most reproducible finding in IBS patients is altered visceral sensation. Balloon distention of the rectum, sigmoid colon or small intestine causes abdominal pain in IBS patients, at values much lower than normal subjects. Lower pain thresholds have been found at multiple locations in the gut, suggesting that IBS involves a generalized disorder of visceral pain sensation.

Psychosocial Factors: play an important role in IBS. These patients have an increased frequency of psychiatric diagnosis- personality disorders, anxiety, depression, hysteria and somatization. While psychosocial factors do not cause the symptoms, they may influence the way patients respond.

Diagnostic Evaluation
There being no confirmatory test, a diagnosis of IBS is mainly clinical: a careful history to elicit characteristic symptoms (ie Manning criteria) physical examination, selected laboratory tests and others to exclude other disorders.

1. Manning Criteria -Diagnostic criteria for IBS
   At least 3 months of continuous or recurrent symptoms of -
   1. Abdominal pain or discomfort that is
      1. Relieved with defecation
      2. Change in frequency of stool or
      3. Change in consistency of stool and
   Two or more of the following, at least 25% times:
   1. Altered stool frequency (> 3 bowel movements daily or < 3 bowel movements weekly)
   2. Altered stool consistency (thin, fragmented, pellet-like/lumpy/ hard or loose/ watery stools)
   3. Altered stool passage (straining, urgency or feeling of incomplete evacuation)
   4. Passage of mucus
   5. Bloating or feeling of abdominal distension.
   
   
2. Essential history to exclude other causes:
   1. Exclude symptoms not compatible with IBS alone:
      1. Visible or occult blood in the stool
      2. Weight loss
      3. Fever
      4. Pain or diarrhoea awakening the patient from sleep.
   2. Obtain dietary history to exclude lactose intolerance or excessive use of sorbitol, fructose or caffeine known to cause diarrhoea /bloating / cramps.
   3. Review medications with possible GI side effects/ aggravation
   4. Consider depression or panic disorders.
   
   
3. Physical examination:
   It is generally unremarkable. Abdominal tenderness, often in the left lower quadrant, may be elicited but is typically mild. A mass, an enlarged liver or spleen, or a positive fecal occult-blood test are not compatible with IBS alone and require further evaluation. In women a pelvic examination should be performed to rule out endometriosis.
   
   
4. Laboratory examination:
   1. Complete blood count; erythrocyte sedimentary rate, chemistry panel.
   2. Flexible sigmoidoscopy (all patients with diarrhoea > 40 years) is generally included, to exclude colonic neoplasms; in younger patients to exclude inflammatory bowel disease. This may also be coupled with sigmoidoscopic biopsy.
   3. If diarrhoea is a predominant symptom:
      1. Examine stool for ova and parasites, leukocytes, excessive fat.
      2. Thyroid function tests

Treatment

1. Most important: establish rapport between physician-patient.
2. No single universally accepted therapeutic agent for IBS. Treatment aimed at reducing the frequency and intensity of triggering factors and ameliorating symptoms.
3. Reassure patient -not organic disease. Explain: with simple description of intestinal motility and its disorder, spasm, which can cause pain. Those with reflux oesophageal symptoms should eliminate foods such as chocolate, peppermint, alcohol and coffee. Direct oesophageal mucosal irritants such as tomatoes, citrus juices, alcohol etc to be limited. Gaseous syndromes may be reduced by avoidance of smoking and an excessive liquid intake to be maintained.

Case 1: 8/8/96
Mr S P, 32 years, Hindu Male
Works as a waiter in a Restaurant
Spouse:28 y - House-wife
Father: 65 y Mother:58 y

Location	Sensation	Modalities	Concomitants
GITract Abdomen Rectum Since 10 years <3 - 2 years Rx - Allopathic and Ayurvedic with not much relief	Pain- Pricking Loose motion 6-7/d Watery, Mucus++ OffensiveNo blood in stool Abdo distended Loose stools < constipation. Pain- stool during	< Morning3 < Fatty food3 < Travelling 3 < Eggs3 > Defecation > Hot food > Eruptions > Passing flatus	Weakness Vomiting Salivation Nausea

He has had recurrent respiratory tract infections on and off.
F/ H: Fa: hypertension. Mo: bronchial asthma.

Patient As A Person:
Diet: Mixed. Appetite - Reduced.
Cravings: Hot food2, sour things2, meat
Aversion: Milk
Thirst: Increased- cold water.2 L/ day
Perspiration: General­ offenisve2, debilitating, stains the linen yellow.
Stool: Watery, yellowish, offensive
Hard. Satisfaction - temporary
Urine - D/N - 6-7/ 1-2

Life Space Investigations:
The patient was born and brought up in a poor family; unhappy childhood. Due to financial difficulties, he had to stop his studies at an early age and go to work. He left home once and lived and worked on his own but could not meet even his own expenses, so came back very soon. Then, he started to work in a hotel. The girl he was to marry was mentally ill, which he came to know only on the previous day of the wedding. He, however, married her at the word of her father, who agreed to take all responsibility if anything happens later. Soon after the marriage, she was sick again. Any type of mental exertion, stress or tension would worsen her condition. He doesn't express his anger for fear of aggravating her condition. He is very much worried about wife's and his own physical illness too. He dislikes sharing problems or consolation.

Mental State: Intellectual:
Memory, weak (recent)
Work, efficiency++
Thoughts3 - Uncontrolled, attempts suppression
Emotional state:
Irritable2
Despair
Suppresses
Anxious (about complaints and future)
Disturbed sleep

Reactions; A/ F -
Anger < Contradiction < Company <³
Reaction Physical Factors:
Meteriological - C₂H₃
< Sun: Weakness+ Giddiness, Dimness vision
Thermal Relations Fan - Prefers ,Bath - Likes cold
Covering - Thin bed sheet
O/E: Moderately built and nourished.
Wt- 64 kg; Ht 5'3 Pulse: 80/min.Resp R 16/min.T 98.6°F. BP: 130/80
P/A, RS, C.V.S---NAD
Investigations
Liver Function Tests - NAD Radiological - Barium meal - NAD
Endoscopy- NAD
Clinical Diagnosis Irritable Bowel syndrome.

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