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Abdominal Pain

What is the nature of abdominal pain in IBS?

Abdominal pain in IBS can present in different ways and the quality and frequency of the pain can change from time to time. Typically, abdominal pain in IBS is a dull pain that occurs around the belly button (periumbilical area) and is usually trigged by eating. It also may be experienced as burning, hunger pain in the upper abdomen. In addition, the pain may be crampy and occur in the lower left part of the abdomen. This crampy abdominal pain usually improves with a bowel movement. The site of the pain may change from time to time. It also can be experienced as a fleeting, tense, stabbing pain that occurs in the lower abdomen or rectum.

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Diarrhea

How do you define Diarrhea?

The exact definition of diarrhea has always been a topic for discussion. Many parameters, such as ethnicity, culture and diet play an important role in the actual frequency and our expectation of the number and consistency of our bowel movements. In fact, the frequency of bowel movements varies widely from individual to individual. For example, some individuals may have three bowel movements a week, while others have three bowel movements a day and both situations could be normal, depending on the person’s usual bowel function. So, while it might sound strange, one man’s diarrhea may be another man’s constipation. For example, in many South American countries, normal bowel habits consist of two to three bowel movements per day; and individuals in these countries would think they were constipated if they had one bowel movement per day. There is also another classification for diarrhea that is based mainly on stool consistency and called Bristol Stool Form Scale or Bristol Stool Chart. In this classification, the appearance of the stool in a toilet has been categorized into seven groups. This classification was developed by Dr. K. W. Heaton at the University of Bristol and was first published in 1990. Based on this scale the diarrhea stool starts from soft bleb with clear edges (Type 5) to fluffy pieces with ragged edges or mushy stool (Type 6) to extreme form of watery stool with no solid pieces (Type 7).

To return to your question. My definition is based on both parameters and I think diarrhea is any significant increases in stool frequency or changes in stool consistency compared to the person’s baseline bowel habits. You also should bear in mind that there are numerous reasons for diarrhea and IBS is only one of them. Other causes include lactose intolerance, parasitic infection and food-related problems. Among patients with IBS, diarrhea usually occurs in the morning; it is associated with increased mucus or whitish phlegm, with or without a significant amount of gas. Usually, people with this type of diarrhea describe their stool as initially soft or normal, followed by mushy or liquid stool. They usually go to the bathroom two to three times within a very brief period, due to a sense of incomplete evacuation. The frequency of the bowel movement is often no more than three to four times a day and sometimes it is interspersed with episodes of constipation. Nocturnal diarrhea that awakens the individual is not a symptom of IBS. However, if the patient suffers from insomnia and wakes up in the middle of the night for other reasons, it is not uncommon to have nocturnal bowel movements. Blood in the stool, bulky or greasy stool or weight loss are not associated with IBS either. These are red flags for organic GI disorders and should be investigated immediately.

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Constipation

I move my bowel twice a week. Is this bad?

The definition of constipation is even more controversial than that of diarrhea. As I mentioned, the frequency of a bowel movement may vary from three times a week to three times a day in healthy individuals. Many physicians would consider less than three bowel movements per week to be constipation. Some physicians use Bristol Stool Form Scale or Bristol Stool Chart for definition of constipation. Based on this scale the normal stool is either a soft sausage (Type 4) or a sausage with crack on it (Type 3). Harder stools that form sausage with lumps (Type 2) or separate hard lumps like nuts (Type 1) are considered constipation. In my opinion definition of constipation should be based on the specific individual’s routine bowel habit. Any significant changes in bowel habits, including change in consistency or decreased frequency of stool or increased effort in bowel movements, should be considered constipation. Similar to diarrhea, there are numerous reasons for constipation and IBS is only one of them. Constipation in IBS is usually associated with episodes of abdominal pain, cramps, colic, bloating and flatulence. Furthermore, many IBS patients complain of a sense of incomplete evacuation (incomplete bowel movements, or the need to use the bathroom several times within a very short period of time), and pencil or palette- like stools. Some individuals have intermittent diarrhea and constipation.

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Gas and Bloating

I feel I am filled with gas but nothing comes out.

Interestingly, feelings of bloating and fullness among patients with IBS are not essentially due to an increase in the gas content of the bowel!!! You may ask, “How could this be possible?” The bowels are in a state of mild but continuous contraction which is called "tone". When the tone is increased, even the presence of small amounts of gas in the lumen of the bowel increases the pressure inside the bowel. This could be experienced as discomfort and misinterpreted as a significant amount of gas. The intestine of people with IBS is similar to a thick balloon, in which a minimal increase in air creates a lot of pressure. In contrast, large amounts of air in the normal bowel (similar to a thin balloon) create a minimal increase in pressure. Unfortunately, the release of some of the gas results in only minimal and transient relief. Several studies have indicated that the majority of IBS patients do not have significantly more luminal gas compared to healthy individuals. I should mention that in a minority of patients with IBS, the feeling of abdominal distension is associated with a visible distention or increase in abdominal size. Among these individuals, abnormal motility results in retention of luminal gas. A recent study of IBS subjects found that the passage of gas could be hampered in the GI tract due to poor motility. This results in the accumulation of gas in the bowel lumen due to a series of ineffective, back and forth movements of the bowel. This ineffective handling of gas by the GI tract results in a buildup of gas in the bowel and a sense of bloating. Other possible causes for distention and gas are lactose intolerance, bacterial overgrowth and aerophagia. Aerophagia is the swallowing of air and usually happens during stressful situations or rushed eating. I will discuss bacterial overgrowth and lactose intolerance later in this chapter. I also should mention that there are a variety of foods that inherently produce a large amount of gas such as beans, legumes and certain vegetables such as turnips and beets.

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Red Flags

I Lost 15 Pound Recently. Is This Part of the IBS Package?

Red Flag symptoms are almost always signs of an organic disorder. One characteristic of IBS is maintaining a steady weight over time. In fact, any indication of weight loss, loss of appetite, fever, anemia or blood in the stool is not part of the IBS presentation and should be seriously investigated.

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