VOL: 101, ISSUE: 10, PAGE NO: 36
Nicola Bristow, RN, is surgical sister, East Surrey Hospital
Irritable bowel syndrome (IBS) is a problem that affects the large intestine. Langman (1982) states that it is one of the most common causes of lower bowel symptoms in western populations, but the causes and mechanisms are poorly understood.
This functional bowel disorder is medically defined as ‘the association of abdominal discomfort with an alteration in bowel habit for which no cause can be found on routine investigation’ (Zinser, 2003).
There are many symptoms that are associated with IBS and it has taken time to encourage GPs to make a clear diagnosis of the disorder.
The large bowel is approximately 1.5m long, its functions are to absorb water and sodium and secrete mucus to give colonic contents an alkaline nature (pH=8). Live bacteria from the colon enable production of vitamin K, thiamine and riboflavin, and finally the bowel stores faeces until defecation (Elcoat al, 1986).
Dunlop (2002) states that a normal bowel habit may range from the passage of one motion every three days to three per day. The colon (large bowel) links the small bowel to the rectum and anus (back passage), and is the source of most common symptoms of IBS.
The intestine has three main components: the lining or mucosa, the muscles and the digestive glands. The lining, or mucosa, lines the intestine from end to end, it has a layer of cells with glands that produce mucus, the lining stops undigested food from entering the bloodstream but allows digested sugars, fats, proteins, vitamins and minerals to pass through. A person with IBS will usually have a healthy lining.
The two muscles of the intestine are used to propel food through while it is being broken down, digested and absorbed into the body and, while waste residues are formed. This process usually takes between one and two days in men and up to three days in women. In IBS, the muscles are either overactive, underactive or they contract inefficiently. To ensure food and digestive products pass along smoothly, the muscles must work together and be coordinated. In IBS this does not happen and pressure and pain can build up within the bowel.
Finally the digestive juices produced by the stomach, pancreas, liver and the small glands in the wall of the small bowel can occasionally have difficulty in digesting certain foods resulting in symptoms so similar to those of IBS that they are difficult to distinguish (Stewart and Stewart, 1994).
There are a number of clinical disorders that can affect the large bowel, such as inflammatory bowel disease and cancer. These can be detected through various investigations. IBS often has similar symptoms to these disorders but is not always diagnosed as easily.
Dunlop (2002) states that IBS is a functional bowel disease that is relevant to surgical practice because it presents with symptoms that are often distinguishable from structural bowel disease. Because of the lack of discriminatory clinical features, the diagnosis is largely one of exclusion once appropriate investigation has ruled out other disorders.
The physiology of the bowel and IBS
Although the colon takes the brunt of the disorder, motility problems of the small intestine or upper gastrointestinal tract may also be a problem. Since IBS is a smooth muscle disorder, symptoms related to the oesophagus, stomach, small bowel, biliary and urinary tract or uterus are often present upon close questioning.
The cause of IBS is not fully understood. As medical science has not been able to find an organic cause for IBS, research has suggested that the cause is due to emotional conflict and stress. While a certain amount of stress may be good for us as it tends to keep us mentally alert, too much can be overwhelming. When we are under a considerable emotional and psychological stress we are more likely to develop food intolerances. Often when the stress persists, the symptoms of IBS become chronic or the individual may be passed off as neurotic or hypochondriac. Women with IBS have more symptoms during certain times during their menstrual cycle, suggesting that reproductive hormones can increase IBS.
Anxiety, depression and stress-related pressures of life are commonly associated with IBS. Feeling low may occur as a result of having distressing bowel symptoms, but in some people it occurs spontaneously and seems to aggravate the problem. Symptoms of IBS may increase stress because of the fear that there is some serious disease present.
Ordinary events such as eating and distention from gas or other material in the colon can cause an overreaction in the person with IBS. Certain medicines and foods may trigger spasms in some people. Sometimes spasm delays the passage of stool leading to constipation (Fig 1). Chocolate, milk or large amounts of alcohol are frequent causes of spasm. Caffeine causes loose stools in many people but it is more likely to affect people with IBS.
Clinical features and diagnosis
Doctors often refer to IBS as a ‘functional’ bowel disorder. By functional they mean that it affects the way the bowel functions - although no anatomical disease can be identified when the colon is examined (Zinser, 2003).
Reaching a universal definition of IBS has proved to be elusive. Often comparisons cannot be made between different studies as different definitions of the condition are used.
The National Digestive Diseases Clearinghouse (2005) has listed the symptoms of IBS as including cramp-like pains in the abdominal area (Box 1). Pain in IBS may be focal at the splenic flexure or the hepatic flexure, it may or may not be associated with disturbed bowel habit and there is usually localised tenderness in this area.
Stewart and Stewart (1994) have described pain in IBS as usually somewhere in the abdomen and being a common sign but not a universal symptom. They add that IBS pain can be anything from a mild ache to a severe cramp-like pain. This pain can be felt almost anywhere in the abdomen from underneath the ribs to low down just above the pubic bone and on either side of the abdomen. Low back pain can also be present.
Painful diarrhoea and/or constipation has been studied by Langman (1982) who states that symptoms may vary from profuse watery diarrhoea with or without abdominal discomfort or colic through morning bowel frequency to occasionally a complete reversal with small, constipated stools.
Stewart and Stewart (1994) state that mucus in stools may be present but this is simply catarrh produced by glands in the lining of the bowel that have become irritated. They state that while these symptoms do not always occur, they are not uncommon.
Swollen or bloated stomach may also be present. Jones (1993) states that discomfort and bloating confined to the upper abdomen may be due to distension of the transverse colon. The feeling that the person is unable to empty their bowels is present. Other symptoms may include flatulence, nausea and loss of appetite.
Patients with gastroenterological symptoms for which no pathophysiological cause can be found are at least as common in clinical practice as those for whom a cause has been established.
Jones et al (2004) have written guidelines on the management of IBS for The British Society of Gastroenterology. They state that diagnosis can be made safely in general practice on the basis of typical symptoms, a normal physical examination and absence of sinister features. The diagnosis should be confirmed in general practice by observation over time. If symptoms are atypical then it is usually appropriate for the patient to be referred for further tests, often via hospital referral.
Management of patients diagnosed with IBS should include reassurance, listening to patients’ concerns, lifestyle advice, dietary advice, psychological therapies, relaxation therapies and psychiatric referral. The latter is of importance if a careful history reveals significant psychiatric disease. This should be treated on its own merits.
Cooper et al (1987) have listed the key factors in the management of IBS (Box 2). Strohmeyer and Caplan (2004) describe the importance of nursing care in the management of IBS. In relation to giving patients reassurance about their condition, they state that people suffering with IBS believed that they may have coped better if had they been given more information about the condition. These patients felt they needed to have their illness taken more seriously by health care professionals and felt they needed reassurance that their condition was not life-threatening and would not lead to cancer or shorten their life expectancy. This reassurance and guidance can be provided by nursing staff.
Strohmeyer and Caplan (2004) add that a strong nurse-patient relationship can help the nurse to share information with the patient, assist them in setting goals and evaluate patient adherence.
A high-fibre diet is required to reduce symptoms of IBS, and the nurse should develop a working relationship with a dietitian to discuss the best diet for the patient.
Dancy and Backhouse (1997) state that doctors will often advise someone with IBS to increase their fibre intake whatever the symptoms. However, if the patient suffers with diarrhoea, flatulence or abdominal bloating, a high-fibre diet can make things worse.
Zinser (2003) states that patients suffering with diarrhoea should reduce their fibre intake, adding that too much fibre can cause diarrhoea, although if the person suffers with constipation, high-fibre foods included in the everyday diet should alleviate chronic constipation. She adds that for some people fibre can aggravate their symptoms.
Zinser (2003) also advises that if it is necessary to increase fibre intake then it should be done slowly as a rapid change could cause an increase in wind and abdominal discomfort.
Cooper et al (1987) have stated that drugs may be necessary, including:
- Benzodiazepines to control anxiety;
- Lactulose for constipation;
- Antidiarrhoeal medicines.
Strohmeyer and Caplan (2004) state that people with intense intestinal pain may benefit from antidepressant medication that can improve symptoms by altering abnormal pain thresholds.
Strohmeyer and Caplan (2004) state that an important role for nurses is evaluating the need for patients to have counselling and directing them to appropriate resources for stress reduction and support.
Self-help groups are formed for the purpose of sharing personal experiences of a particular problem and for giving mutual support and information (Dancey and Blackhouse, 1997).
Self-help groups can help people with IBS indirectly in relieving symptoms because they assist them in relieving their symptoms of stress and anxiety, which are a known cause of IBS.
Despite considerable research, the cause of IBS remains incompletely understood and there is, as yet, no cure. It is an extremely common disorder and surveys show about half those attending hospital outpatient departments with digestive disorders have IBS (Langman, 1982).
It has been suggested that continuing research into the syndrome is necessary to understand the reasons behind the symptoms and help patients who have IBS to realise that it is a non-life threatening condition.
The main nursing management is to provide advice on diet and lifestyle. Nurses also need to reassure patients that their condition can be controlled.
Each week Nursing Times publishes a guided learning article with reflection points to help you with your CPD. After reading the article you should be able to:
- Understand the symptoms of irritable bowel syndrome;
- Know the causes of irritable bowel syndrome;
- Be familiar with the physical and psychological effects of irritable bowel syndrome;
- Understand the treatment options for irritable bowel syndrome.
Use the following points to write a reflection for your PREP portfolio:- Outline why you read this article and how it is relevant to your practice;
- Summarise the main points this article makes about IBS;
- Identify something new that this article has taught you about IBS;
- Consider how you will use what you have learnt about IBS in your future practice;
- Explain how you intend to follow up what you have learnt.