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Programme 5. - Irritable Bowel Syndrome
RADIO 4
THURSDAY 30/08/07 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
ANTON EMMANUEL
PRODUCER:
BETH EASTWOOD
NOT CHECKED AS BROADCAST
MYERS
Hello. Irritable is a word that only hints at the experience - Irritable Bowel Syndrome can be so severe as to make normal life all but impossible. Abdominal cramps and bloating are the least of it, what's really distressing is the often desperate need to empty the bowels at very short notice or conversely the seeming impossibility of producing anything at all in the loo. But the symptoms can come and go, so could it be what you eat, is it something you're doing or is it a question of how you're feeling? Everyone knows what nerves can do to the gut - is stress the cause of IBS? And what if any treatments work for you? Do share your experience and put your questions today to our medical expert, he's Dr Anton Emmanuel, he's a consultant gastroenterologist at University College Hospital in London.
The phones are very busy and the first to get through is Miss Snow and she's ringing from Ringwood wondering whether you've got IBS, what symptoms have you got Miss Snow?
SNOW
Well it's not the symptoms that a couple of friends I've got are familiar with - I don't have any constipation, I don't have any diarrhoea. It always seems to happen after I've laid down at night time about two o'clock in the morning. I don't eat ready made meals, I'm a vegetarian, I'm very good about my diet. I have colpamine, buscapane and colafac and as far as I'm concerned they just don't work.
MYERS
So what is the symptom you're getting in the early hours of the morning - are you talking about cramps?
SNOW
I get terrible cramps, I don't get a bloated feeling, I get terrible cramps, terrible abdominal pain - that's the worse thing - and the pain is so terrible it makes me violently sick. I don't have it regularly, I might only have it once every three months or once every six months. Last time I was so ill the doctor came out and gave me an injection.
MYERS
What do you say then - is this in any way classic IBS or are we talking about something altogether different here Anton?
EMMANUEL
This sounds very different. I'm sorry to hear about your troubles Miss Snow. I mean I think the hallmark symptom that you describe is getting pain at night and that's really highly unusual for IBS and would really take that diagnosis out of the book in some way. So I would say that with the frequency of it your symptoms being sort of every few weeks to every few months the best thing to do is to be investigated when you're having a bout of symptoms and really to be looked - having somebody see you in that kind of acute urgent sense when you get them.
MYERS
I'll go to our second caller because Elizabeth, who's in Hampshire, I think may have what could be called more classic IBS symptoms and perhaps you can say what they are and what your particular concerns are Elizabeth, I know you're fed up with the whole business.
ELIZABETH
That's right. Trying to think - sorry - sounds as - I feel rather mental now. I get this awful constipated business - get up in the morning and I always drink - I drink sort of Aspro Clear because it seems to help a little bit and then I, with luck, I might be able to go to the lavatory then but sometimes I can't and I go and eat things like grape nuts and I don't like taking - what's the stuff called - Senna tablets because I feel it's rather bad to start doing that - I mean I do occasionally - desperate. And then - as I say - I get the usual thing, either I'm very, very constipated and I can't do anything hardly or one gets this ghastly diarrhoea and it can be quite painful.
MYERS
Well Anton is nodding at this point because I think that, as you say, the paradox - sometimes you're absolutely bunged up and sometimes you can't get to the loo fast enough - that is classic isn't it?
EMMANUEL
Absolutely.
MYERS
So what should our caller Elizabeth be doing about this and indeed perhaps all the other people out there who recognise this set of symptoms?
EMMANUEL
I mean the hallmark symptoms are that fluctuation of bowel pattern but also an association with abdominal pain, you really need both sets of things - the pain and the alteration of bowel habit. The first thing to do is to be sure that this isn't something else going on causing you to have these symptoms. Gut illnesses are very common in our society and the range of symptoms that gut illnesses produce is fairly narrow actually, it's the same sort of thing - pain, variation in bowel function - and really it's important therefore that if you have new symptoms that they are checked out and if you have any of the things that we need to worry about excluded - so stool tests, blood tests or sometimes even tests of your gut itself.
ELIZABETH
Yes so I feel rather a fraud because I've had lots of blood tests and things for this and that and the other and it always seem to come up kind of okay but I still get the symptoms. The other thing that's so ghastly is that I sometimes want to pee and I get there and I simply can't, it's as though the one business is preventing the other.
EMMANUEL
That's not being a fraud at all, I mean the key point is that those blood tests have been normal is a positive diagnostic step that tells us with your symptoms that it is likely to be IBS. So don't feel a fraud, number one. In terms of what you do then - it's having established what the diagnosis is we would then try and treat - or one should try and treat your symptoms as they arrive. We aren't in the position yet to be able to cure the condition, we're not talking about getting rid of these symptoms forever, we have to manage them as they occur and for you they fluctuate.
ELIZABETH
What about food, I mean - you see - I heard somebody the other day tell me that you shouldn't eat lettuce and salad and things, it made it all worse, but I don't think I've noticed that particularly and I thought the whole idea was to eat as much salad and fruit and things as you can do, I don't know, I mean I'm too fat that's for sure but I am rather old, I've got the most ghastly stomach and I'm trying to do something about it but it's so difficult when you're old.
EMMANUEL
I empathise. The situation is that - you've hit the nail on the head in terms of diet - it's highly variable and terribly individual. - you can point to somebody who says to you that lettuce and so and so is the be all and end all and you find that you don't make any difference to your symptoms with taking that. The way to do this really, I'm sure we'll come back to this, is to really to pick your own way through the maze and say look every time I've eaten eggs it's caused me to have trouble and every time I've eaten Y I've been a bit better and it's common sense that part of it.
ELIZABETH
It's interesting, I used to have migraines every single day and I was put on a drug called Migral, I think, and then somebody was horrified at the amount I was having, I was having one every night you see and it did seem to help with my headaches but at the same time they came back all the time. In the end I was taken off it - I saw a specialist, I've forgotten what he was exactly - and he sent me to a sort of food woman who went through - showed you pictures of all the bowels ...
MYERS
Elizabeth I'm going to stop you there only because - I know we have a great string of people also wanting to come in on this. Stay listening though because I think some of the advice that comes forward will be helpful all round. But I wanted just to go to Alison Cooper who's in London and is picking up a little bit what we were saying about how in this case the symptoms can be a sign that something else is wrong and - well tell us your story Alison because these symptoms can be a little bit hard sometimes to tease out can't they?
COOPER
Yes, hello there. I think one of the problems first to say is that the symptoms of Irritable Bowel are quite embarrassing for a lot of people, which makes it difficult for you to actually approach a GP in the first place. I was misdiagnosed with IBS about 20 years ago, kept going back to my GP because the symptoms persisted, tried absolutely everything and eventually saw a gastroenterologist and was diagnosed with something called bile salt malabsorption which occurs in about - I understand about 10% of people with persistent diarrhoea and bloating.
EMMANUEL
That's right.
COOPER
I now receive treatment and it's like a miracle - it's absolutely changed my life.
MYERS
So in a way ...
COOPER
I'd encourage anyone to go forward really and speak to someone a bit more - a bit more experienced in these matters than just the GP.
MYERS
So that does affirm the point you were making, I think Anton, that it's very important to get these symptoms really diagnosed properly and it's only when the tests have been done that you can then say we've got a diagnosis of exclusion, it's Irritable Bowel Syndrome, it's not something worse.
EMMANUEL
Absolutely because the fear of the unknown as well, if you have symptoms and you've been reassured maybe forcefully, that itself will keep the symptoms going. So you need to get the symptoms excluded and that means sometimes having the gut looked at but also think about how the gut works and what the caller has been mentioning is this thing about bile salts, which is a test which looks at how the guts work rather than how they look so in her case she got the right diagnosis.
MYERS
What other conditions can sort of mimic the symptoms - are we talking about celiac disease for example?
EMMANUEL
Celiac disease is a very prevalent condition in the Western world. We're also talking about the very common things that occur like bowel cancers and bowel tumours - these are unfortunately prevalent conditions as well with very similar symptoms and that's really the key thing to exclude. People with inflammatory bowel diseases - Crohns Disease or ulcerative colitis - will present often very similarly with diarrhoea and rushing to the toilet and pain. And those three are the sort of hallmark conditions first excluded. But Celiac Disease is one that people always assume you have to have a family history but there's often no family history and you can still get the diagnosis.
MYERS
So is the message to people who may be listening to this and thinking yes I can recognise a lot of these symptoms in myself am I actually suffering from something quite serious, is the message if you're concerned and there's an abnormal pattern going on you should get it checked out, even if it turns out only - if you like - only to be IBS?
EMMANUEL
Sure, I mean if there are new symptoms obviously with any sort of worrisome types in terms of weight loss or losing blood then obviously you must get that checked out immediately and that's absolutely critical. But any change of pattern - if you've had an unusual bowel pattern for a long time and it's changed to normality or become more abnormal that's again a reason to discuss it with a professional because sometimes it doesn't need testing, you can be reassured with simply an examination and blood test and that's the end of it but it's important not to sit on your symptoms and that's really a key message of the ongoing screening programme, which is another separate issue altogether for another programme.
MYERS
Let's go to another caller then. Karl in Camden in London has got problems in the morning, bit of a rush to the loo for you is it Karl?
KARL
Hello.
MYERS
Hello.
KARL
Yes I'm 72 years old, almost a vegan, and it was over - well I think 12 years ago that I noticed a certain pattern in the movement of my bowels, I would be doing a visit to the toilet almost the first thing when I got up, it was not just for urinating but the movement of the bowels. And then it seemed that there was no problem, within minutes it was over, but then it seemed that the bowels didn't empty themselves entirely and so say after a couple of hours or so I would again have the urge to do that. Now I've no pains, no problems of constipation and it seems that the bowel movements are quite normal. Now I don't know why I have to do it like this, it is a well established pattern now. I wonder if - I mean I in '91, that's 16 years back, I was first diagnosed as having a little problem with my prostate.
MYERS
Ah well now look ...
KARL
I wonder if there's any connection.
MYERS
Well we're dealing with the prostate next week so you're a week early on that.
KARL
No, no but I wonder if there is any connection that in the morning I want to urinate and I just have to empty my bowels also. And then secondly it's not - the movement is not completed, I have to do that again.
MYERS
That feeling that you haven't quite finished, that I think is quite common isn't it and is a sign of IBS.
EMMANUEL
It can be a feature of IBS and it does tie up to some of the things we were talking about I'm sure about nerves because the nerves which help your bowel and your bladder empty are the same pairs of nerves which tell you when you need to go, when you've finished going, actually help you move to go as well. So I suspect some of your symptoms may well be related to your prostate.
MYERS
Is there anything you can suggest that Karl actually does?
EMMANUEL
In the - I mean in the mornings in response to that is to recognise that it's not an abnormal problem to have to go to the loo on waking up, the question then is how one evacuates one's bowel and to try and make it in one go rather than several trips to the toilet and there are ways we can sort of help people, train people, or retrain them should I say, so that you can evacuate the bowel more completely in one go and then be able to ignore the urge if they get one later on and that's often the way we'd treat someone like - with Karl's symptoms.
MYERS
Jonathan is on the line next and is interested in drug treatments, maybe we have the opportunity to talk about sort of the recommended drugs for these different symptoms. But what are you taking Jonathan and is it helping you?
JONATHAN
Hello. Yes. I've been taking codeine phosphate for some time. I tried Loperamide, which can be I know a very good short term drug for diarrhoea but the irritable bowel when I went on to the Loperamide it caused me awful nausea and other side effects. Also I found that with codeine I could estimate in my body - I knew what was going to happen, I knew if I was going to have bowel urgency or not, so I found that Loperamide as well as its side effects, although it can be a very good short term drug, I wouldn't recommend it personally.
MYERS
Okay, well let's see what the doctor has to say about this. So we're talking about Loperamide, this is to help slow the bowel down if you're someone who's finding urgency is the problem, but obviously the concern there that if you're taking any drug there might be side effects and not necessarily something you'd want to take for life but the IBS may be a lifelong condition.
EMMANUEL
Sure. Well I mean IBS we have to think about as being potentially a lifelong problem but the worry we have with codeine is that it is a drug of dependents and we'd worry that somebody would need escalating doses over time and it also works on the brain as well as the gut, so we're not desperately keen on people using that long term. Loperamide can cause the kind of side effects that Jonathan mentions and in that situation the first thing we'd do is to say that sometimes the capsules that one buys over the counter are often too big a dose for an individual and very, very often we get great success in patients who get side effects of the sort Jonathan is describing by reducing the dose and using the liquid suspension of Loperamide where we can be much more subtle about the dose we give and really [indistinct word] and juggle the dose much more accurately to control bowel function without giving side effects. So the first thing we'd do is to think about that. In terms of where we go ...
JONATHAN
That's interesting. Could you tell me the liquid form now - Loperamide is usually gastroenteric coated to prevent irritation - gastric irritation - so how does the liquid actually cope with that?
EMMANUEL
It isn't actually coated to prevent irritation but it comes in a capsule form, as you say, and the liquid works actually slightly more effectively, it gives you a very good rapid absorption and it works very effectively. So it's not something we see as being destroyed by the stomach or being irritating to the stomach, so there shouldn't be a problem with that. But there are other agents if we want to move on to other things that we can sometimes use. Certainly an evolving area for us to consider is the use of probiotics, these so-called beneficial or good bacteria, and we can sort of regulate a little bit how the balance between good and bad bacteria in your bowels goes by giving you probiotics and that can be very helpful for some patients with diarrhoea in particular. We can use ...
MYERS
Is that, by the way, sort of medicinal probiotics because I think people may now have heard about probiotics in food, I think you get in yoghurt and certain other foods, do you need a medicinal quantity or does the dietary supplement help?
EMMANUEL
Sure. We all vary, some people are very sensitive to the small food stuff type additives you see in the food cabinets. But usually what I'm talking about is the research that has been done looking at the formal drug type manipulations and there are some licensed products in this country now - you can buy lots of them over-the-counter anyway, in health food shops as well. But certainly probiotics are a huge evolving area for us for treatment of IBS. And then there's the old club classic remedies that we've had and we're beginning to understand a bit more about how they work now - drugs like antidepressants - which we use in very low doses, not to treat depression but to treat the gut nerves. And there are even a newer family of antidepressants which again we can use in low doses to treat gut nerves very specifically. So there are quite a number of treatments beyond just slowing the bowel down.
MYERS
Well we've got the question from Julian Hobden now, he's in Lincolnshire, and I think he's got the concern, which is the opposite of Jonathan, he's got constipation, rather than diarrhoea and is wondering about treatments, so perhaps we can help him with that. Are you trying anything at the moment Julian?
HOBDEN
No, I have tried various things, I've had Mebeverine, which I've taken with a meal but I've now had sort of nausea and stomach pain constantly day in, day out for about three, four, maybe five months now. I've had a camera down the top end and I'm awaiting a colonoscopy. But in the past I've actually had the running to the toilet but that was years and years ago and this has just reoccurred recently and gone the opposite way.
EMMANUEL
Right. And to date apart from waiting for investigations you've tried altering your diet or you've tried ...?
HOBDEN
Yes, yes I've theoretically a good diet, I basically eat no red meat, fish, turkey, chicken and four or five vegetables with a meal. I've managed to increase going to the loo slightly better, whereas I was going four or five days without going. I've taken dried figs and also prunes, which seem to have actually made me go every two or three days.
EMMANUEL
Right. I mean the first thing to do is obviously to complete the investigation cycle and then hopefully we can be reassured that that's what we're dealing with and that's great. And then beyond that we would then say the way to treat most people's constipation is to try and - what I was alluding to earlier on - try and get them to retrain how to evacuate their bowel more completely and we know that if we can get their rectum - the lower part of the bowel - emptied that'll make the whole upper part of the gut often improve in terms of bloating and pain and emptying function in its own right can improve with that. So we often would just go along that first line, that would help two-thirds of patients and then we retrain and that process is through something called biofeedback and that'll be a very helpful first step to try and avoid laxatives because obviously if we come to that stage and biofeedback fails then the only thing that's left beyond there is - or the next step, should I say, is to consider suppositories or laxatives on a regular basis and that obviously is less attractive.
MYERS
Can you say just a bit more about this biofeedback and retraining of the gut, is that actually possible to do, are you very successful with that to make sure that you fully empty the bowel and have some control whether you're going with urgency or whether you're not able to go at all, does it work in both ways?
EMMANUEL
Absolutely, it's two ends of a sort of a see saw almost and what retraining's about is not necessarily to make one go more often or less often it's to get the balance of the two systems, so that sometimes people will get a problem of not being able to go, as you've just heard, sometimes, as you heard earlier on, people going too often or too frequently and not emptying properly. And so what we try and do is to re-educate that link between the brain, the spinal cord nerves and the gut - because they're all linked, it's all - it's not a separate system. And we try and get patients to understand how their bowels work, understand what eating does to the bowel, what emptying your bowel does in its own right and then once patients understand what they're doing then we can manipulate it. The analogy I often use - it's a bit like trying to learn to play the piano, if you can't hear the notes as you're playing you will keep making mistakes but the biofeedback part is feeding back information, it's exactly hearing the notes so you can see or see or hear what's going on. And once you do that then you can say oh I've done that wrong, I'll correct that and then repeating it endlessly and endlessly and you become ...
MYERS
If someone listening to this wants to take this up with their own GP would they get a sympathetic hearing or would they need to seek specialist referral to a centre such as yours?
EMMANUEL
I mean often times biofeedback's only available in sort of small specialist centres but there are practices out there which have a particular interest in dealing with these so-called functional disorders, whether they're gut or back or headache related.
MYERS
And if you wanted to try and do something on your own account could you - there was the idea of toilet training that you should actually, for example, try and use the loo at the same time each day, for example, give yourself plenty of time. Something as simple as that, would that work?
EMMANUEL
Absolutely, absolutely and lots of centres like ours will send information out by post which providing somebody's been through the tests are just simple things to learn to either to control when not to go and to control how to go when you have the time to. So a lot of it is common sense and women who've been through pelvic floor exercises are often very good at picking up on these things because it's not the same as but it's analogous to those exercises that one has done.
MYERS
Let's go to another caller in Bradford this time, Theresa Smith is waiting to speak to us, wants to talk about stress in relation to IBS, what's your story Theresa?
SMITH
Hello yes. I just phoned the programme because I heard the trailer and saying that you don't really know what necessarily causes Irritable Bowel Syndrome and that stress is a possibility. And six years ago I gave up full time teaching and as everybody knows teaching is a very stressful job. I'd had a lot of difficulty with - I'd been diagnosed with Irritable Bowel Syndrome - the symptoms that have been discussed previously on the programme had those. And I suppose within about - oh I don't know - six months of giving up full time teaching so all the symptoms disappeared.
MYERS
Can we all give up our jobs? Is that possible?
SMITH
That would nice wouldn't it.
EMMANUEL
It would be ideal wouldn't it. No I mean that's a really, really important observation that we've as doctors and scientists have come to rather late I'm afraid to say but we have finally come to and it's really led to a whole burgeoning new understanding of how IBS and similar disorders may be caused and therefore in turn may be treated. And you've done the sort of one solution which is to take the stress out of your life, a lot of us can't do that.
SMITH
Yes well I was just fortunate enough, I mean I didn't do - I didn't give up full time teaching because of my difficulties with the IBS but I gave it up because I was fortunate enough to be able to have to do that. But it was really noticeable very quickly - the symptoms just faded away.
EMMANUEL
No, we recognise that patients with IBS have a very particular way in which their gut can respond to stress and that is very different to healthy people and more importantly we've recognised we ought to test for that and through testing that we are about to I think have drugs that we can use to target the stress response in your gut specifically, so this is a big area and thank you very much for pointing it out.
MYERS
Another watch this space, thank you very much indeed. Thanks to our expert today - Dr Anton Emmanuel. Thanks to everyone who's phoned, has e-mailed and has listened to the programme, I hope that you found some of the answers you were seeking. If you do want more information there are further resources, they're listed on our website bbc.co.uk/radio4, you can also listen to this programme again there. Or if you prefer to get in touch by phone ring 0800 044 044. And join us at the same time next week when we will indeed be inviting your questions on the subject of the prostate.
ENDS
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