BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 2. - IBS
RADIO 4
TUESDAY 04/08/07 2100-2130
PRESENTER:
MARK PORTER
REPORTER:
ANGELA ROBSON
CONTRIBUTORS:
ROBIN SPILLER
NAYLA ARIBI
STEPHEN MIDDLETON
JENNY LEE
PAMELA CRUICKSHANKS
PETER WHORWELL
PRODUCER:
HELENA SELBY
NOT CHECKED AS BROADCAST
PORTER
Hello. As many as 1 in 10 adults in Britain has some degree of irritable bowel syndrome - or IBS. It's so common, and so troublesome, that the average GP can expect to see a couple of cases every day. And it's a familiar problem in hospital clinics too.
CLIP
When I eat anything spicy it's been bad, so it gives me diarrhoea.
Do you get any pain at all?
Yes, yes.
Can you tell me something about the pain?
Well it's very uncomfortable, it's sort of all down in the lower part of your tummy and your tummy does bloat and then you feel sort of full up and it makes you feel very lethargic.
Does the pain get better after you open your bowels?
Yes.
And do you get any mucus in your stools?
Mmm.
And a sensation of not having completely emptied your bowels?
That's right, then you have to go back again. And then of course the more times you go back again the sorer you get, so it gets very uncomfortable and then that's when you bleed and you seem to go through gallons of toilet paper and wipes.
PORTER
Pamela Ellis telling Dr Nayla Aribi what it's like living with IBS and we'll be hearing more from Dr Aribi about the latest research into new treatments to ease those symptoms later in the programme.
I will also be looking at how attitudes to fibre have changed in recent years. Back in the '80s a high fibre diet - or roughage as it was called then - was the mainstay of therapy for IBS. Today it's used far more selectively. I'll be finding out why.
And, last but by no means least, I'll be discovering how hypnotherapy has emerged as one of the more effective treatments for IBS.
CLIP
Just imagine that it's flowing, really helping that part of your mind that's responsible for your gut.
My guest today is Robin Spiller, he's Professor of Gastroenterology at the Queen's Medical Centre in Nottingham.
Robin - let's start with who gets IBS and why? But first what exactly do we mean by the term IBS?
SPILLER
Well the patient with irritable bowel syndrome will typically have a diffuse abdominal pain and some disturbance in bowel habits. They'll often also describe an unpleasant sensation or discomfort and they may describe it as bloating.
PORTER
And that disturbance in bowel habit can be, in my experience tends to be, loose or diarrhoea but they can be constipated as well can't they.
SPILLER
Yes, so about a third with diarrhoea, about a third with constipation and a third with a mixed habit with both features.
PORTER
But the symptoms are not limited purely to the bowel.
SPILLER
No, one of the characteristic features of irritable bowel syndrome are what we call the non-colonic features, so this would include lethargy, sleep disturbance, semantic aches and pains as well which are very common.
PORTER
Backache and things like that.
SPILLER
Yes and headaches yes.
PORTER
And what's causing the IBS, this is often a problem with seeing people in their 20s and 30s and 40s, what triggers it, what's gone wrong?
SPILLER
Well this is an area of great interest. My own interest has been in a small group who develop IBS after an infection and we've learned quite a lot about IBS from studying this. In other cases it's been shown clearly to relate to stressful events in life - bereavement, separation, job loss - so certainly stress can play a part. When we've looked at infection you can see that there is - and I think this is a theme which is common in IBS - there's both a peripheral component and a central component. So, for example, people who are depressed or have had adverse life events in that period preceding the infection are much more likely to get IBS and equally if we look at the gut end certain bacteria will be much more likely to cause it and in general they're the ones that cause more damage to the gut.
PORTER
How do we make the diagnosis because there is no one diagnostic test to confirm that somebody has IBS?
SPILLER
No. I mean the abdominal pain and disordered bowel habit is a feature of many diseases. However, just on probability grounds the diagnosis of IBS must be quite high. However, what the doctor's really looking for is features which warn him that he should do further tests.
PORTER
Features like?
SPILLER
Well certainly age is very important, the likelihood of having some other disease if you're younger than 50 is much, much lower, particularly serious diseases like colon cancer. The other key feature we look for are rectal bleeding - certainly would be an indication for further investigations - a family history of colorectal cancer; weight loss is not a feature of IBS and that's obviously worrying and should be investigated and the other thing is when you go to sleep IBS symptoms should remit. And people who are woken from sleep with symptoms that again is what we call an alarm feature or a red flag, we definitely want to investigate patients like that.
PORTER
Well, once a diagnosis has been made, dietary manipulation seems a logical first step. Historically that would have centred around increasing the amount of fibre in a person's diet, but that can make symptoms worse in those prone to diarrhoea. Stephen Middleton is Consultant Gastroenterologist at Addenbrookes Hospital in Cambridge, and a leading proponent of dietary intervention in IBS.
MIDDLETON
Patients who have predominantly constipation they often are taking too little fibre and we then increase the fibre and often they get better. They tend to be filtered out in the primary healthcare setting, the GPs will pick this up, increase the fibre and they do quite well. Some patients, if you increase the fibre, their symptoms get worse. They're the ones that confuse people in primary care very often and they send them along to us at the hospital. And we would then reduce the fibre a bit, in particular fibres that tend to be fermented - like wheat bran for instance - and they often get better.
PORTER
So you actually differentiate between the different types of fibre that someone's taking in and you mentioned there that the type of fibre that's likely to be fermented - we're talking about bran based cereals for instance are we?
MIDDLETON
Yes, yes, certainly some patients will be more prone to get symptoms with wheat, others with vegetables or dried fruit. So there's a difference actually, it's not just any fibre.
PORTER
Where do the medical type fibres come in then in terms of prescribing the fibre drinks that we use, is that the sort of fibre that's likely to be fermented?
MIDDLETON
Some of them are, like Fibre Gel for instance is a very highly fermented fibre and people with IBS, if they take Fibre Gel, very often their symptoms are worse. Whereas a poorly fermented fibre like Methyl Cellulose will often make them better without causing wind, it'll get rid of the constipation.
PORTER
And what about the role of other foodstuffs in IBS, some people they describe themselves as being intolerant to different types of foods do you think that's playing a role in IBS as well?
MIDDLETON
Yes we think that quite a large group of people just need fibre modulation and I would say about probably 70-80% of the food intolerant type of patient but there are a group of patients, maybe about a quarter of patients, who seem to be specifically intolerant to certain foods and they go on to a more rigorous exclusion diet.
PORTER
And likely culprits would be?
MIDDLETON
Well you're talking about dairy products, eggs, nuts very often although there's fibre there as well in nuts and then it is very variable after that.
PORTER
And in a properly monitored environment like yours if you had a hundred patients come and see you with IBS what sort of response rate would you imagine that you'd see through dietary measures alone, what sort of proportion might see some improvement?
MIDDLETON
Well we've recently done an audit of 500 consecutive patients who fulfilled the classical criteria for diagnosing irritable bowel and of those about 75% of them were suitable we felt - suitable for dietary treatment, some of them needed other types of treatment. So the ones we gave the dietary treatment to we had a 64%-65% had a very good response, so that's all the treatment they needed with the diet.
PORTER
That's a good response.
MIDDLETON
It is yeah. What that means to the patient is they don't need any drugs because irritable bowel is a chronic condition, so you're going to have it long term probably in many cases, so that means taking tablets everyday. But if you can modify your diet slightly then you haven't got that problem.
LEE
My name is Jenny Lee and I'm the gastroenterology dietician at Addenbrookes Hospital.
PORTER
Jenny, once you're confident that the patients have IBS, let's assume that their fibre intake is optimum you think for them and they have suspicions that certain foods may be worsening the symptoms or even triggering them, how do you approach that?
LEE
If they do have that suspicion then there is something called an exclusion diet which we could look at, we could test to see if they would be intolerant to certain foods. The main food groups that it would exclude would be wheat, rye, barley, corn and oats - so it's really a rice based diet and they can have all different forms of rice like rice noodles, rice pasta, rice cakes and rice ...
PORTER
And how long - and how long would you want them on that for?
LEE
The typical time would be for two weeks where you would expect to see an improvement. The other foods that it would exclude would mainly be dairy foods.
PORTER
And then at the end of the two weeks assuming that their symptoms get better, if they don't get better it suggests that they probably haven't got an intolerance.
LEE
That's right, that's right.
PORTER
But if they do get better we then have to find out exactly what's causing the trouble.
LEE
If they do get better we would then go through a reintroduction process, they would come back to clinic to see me after the two week period and then we would talk through how to reintroduce the foods and how they would do that would be to reintroduce one food at a time and one food every two days and they would eat that food in a good portion twice a day at least. If the symptoms get worse again, assuming they have improved on the initial basic diet, then that is obviously showing that they have some sort of intolerance to that food. If they don't get worse then they're okay with that food and they can continue to eat that with everything else.
PORTER
And if you find them to be intolerant of a particular food they're obviously going to need to exclude that long term and then you can give specific advice on any implications that may have for their diet, for instance, if they were to miss out dairy products?
LEE
Yeah it's very important that we're looking to replace those foods with suitable alternatives that include the nutrients that those foods give, so for example putting soya products into the diet instead of dairy.
BARKER
My name is Susan Barker.
PORTER
Do you follow a special diet at the moment?
BARKER
I do, I have an exclusion for several items - chicken, yeast and high fibre.
PORTER
High fibre, so you're on a sort of moderate to low fibre diet?
BARKER
Yes, yeah.
PORTER
And no chicken at all.
BARKER
No it upsets me even with the slightest.
PORTER
And when you say yeast what sort of foods does that mean?
BARKER
So that means I can't have bread, wines and beers.
PORTER
What sort of effect has your new diet had on the way that you feel?
BARKER
I feel a 100% better. Before I had bouts of very bad pain where even with painkillers I would spend the day in bed and would have very bad sort of diarrhoea but it was the pain more than anything which is now non-existent. But I find the slightest food - like with chicken, the other week I had a Chinese from a takeaway and they must have used chicken stock and it triggered my stomach straightaway.
PORTER
You're that sensitive?
BARKER
Yes, to the chicken yeah.
PORTER
So how difficult is it to stick to that diet?
BARKER
Not too bad, it's just changing the way you eat really. I think it was the snacking more than anything - where you could have a sandwich because of the yeast it cut out the bread. I found that the hardest. And also I can't drink tea, that's another thing. I miss that first cup of tea in the morning.
PORTER
Susan Barker at the Dietetic Clinic at Addenbrookes.
You are listening to Case Notes, I'm Dr Mark Porter and I am discussing IBS with my guest Professor Robin Spiller.
Robin, Not all specialists I speak to are as keen on dietary intervention as Stephen is - do your experiences mirror his?
SPILLER
Yes I think we need to make it clear that different doctors see different patients and they are quite variable. Although I certainly am very interested in what the patients eat and I do look out for dairy intolerance and wheat intolerance many patients who've come to me are already aware, for example, if they're lactose intolerant and so producing it further is usually fairly disappointing. I would say my figures would be more like a quarter of patients might benefit from this sort of approach.
PORTER
Let's move on to drug treatments. What's currently available, what can we prescribe?
SPILLER
Well quite limited actually. We have anti-spasmodics which have been around for 25 years, they are certainly very cheap and safe, they're effectiveness is perhaps 1 in 10 of the patients.
PORTER
That's not very much is it - 1 in 10? And they're working presumably just by relaxing the bowel, preventing the bowel moving.
SPILLER
Yes, so those colicky pains which are relieved by defecation they almost certainly are due to pressure in the bowel associated with strong contractions which are part of the emptying of the bowel reflex. The other drugs we've got to use, which are quite useful, is loperamide, I think most people will be familiar with this when they use it for their tourist diarrhoea, it's very good for urgency and it gives patients a sense of control, so they don't worry about finding a toilet and such like.
PORTER
This symptom of urgency - this is the need - when you need to go, you need to go in a hurry?
SPILLER
Yes, which is very disabling, socially it's very limiting and if people experience this they often won't eat out for example or they'll be worried about travelling. So it's a disabling symptom if you can control it it's good.
PORTER
And loperamide would give them four, five hours window where they know that they're probably going to be alright?
SPILLER
Yes, but I think that you do have a problem with loperamide as you tend to oscillate between diarrhoea and constipation, which is unpleasant.
PORTER
Robin, we had someone call the 91Èȱ¬ about the use of the antidepressant Amitriptyline in low dose, she has IBS had been put on amitriptyline and it's worked very well but she's wondering whether it can be used in the long term. How's this drug working?
SPILLER
Okay so this is a drug that's been around a long time, it's safe and cheap in low dose, it's not actually used that much now as an antidepressant, the SSRIs have taken over - the newer drugs. It's a complicated action but one of its actions is to block histamine and I think most people will be familiar with antihistamines, they do relax you as well, and that may be part of the benefit if particularly taken at night in a low dose.
PORTER
So although it might be acting on the nerves and all sorts of different things you think the effects are probably that of a mild tranquilliser?
SPILLER
Yes and it makes people relaxed, it makes them sleep better and they feel better for the day the next day.
PORTER
What about long term use?
SPILLER
They're perfectly safe and in low doses, as I say, there's very little toxicity. In higher doses it's a different story.
PORTER
Drugs and diet, of course, aren't the only ways of helping people with IBS. Psychological approaches like hypnotherapy, cognitive behavioural therapy and relaxation techniques can help too.
Although not universally available on the NHS, hypnotherapy is now a well established treatment for the condition. But what does it actually involve? We sent Angela Robson to Wythenshawe hospital in Manchester to watch hypnotherapist Pamela Cruickshanks working her magic.
HYPNOTHERAPY SESSION
Just imagine the calmness getting stronger and stronger, imagine it's flowing into your lungs so that as you breathe you can breathe calmly and comfortably.
CRUICKSHANKS
What we do in hypnosis is we give the patient ideas and suggestions of how they can modify the way that the gut works. So, for example, if a patient likes imagery we'll suggest to patients look imagine your gut is like a river flowing along through beautiful countryside, sort of very peacefully. But when you've got IBS if you've got diarrhoea it's more like a waterfall and when you've got constipation it's more like the walls of the river have fallen in. So what we need to do is to try and imagine this good picture, you modifying it and imagine that it just flows beautifully along.
ROBSON
Now I'm now with Cass who's here with Pamela, this is her ninth session of hypnotherapy. Cass how is your life affected by irritable bowel syndrome?
CASS
Previously before starting the sessions absolutely in agony, depressed, stressed and there was a point when I actually said I'm a woman on the edge and I really just want to die, it was that bad. What has happened is there is a change in how my body started to approach the problem of eating, first of all, and then the actual pains that were coming as the IBS was the problem. But since then and working with Pam no problems, no problems.
HYPNOTHERAPY SESSION
Good comfortable messages flowing into your tummy so that it can work more and more comfortably.
WHORWELL
I'm Peter Whorwell, I'm a professor of medicine and gastroenterology, I run the hypnotherapy and irritable bowel unit at Wythenshawe Hospital. When thinking about irritable bowel you have to remember that there's a person round that bowel and if that person's distressed that bowel's going to reflect that stress. So there's no doubt that hypnosis does help stress. But we're pretty certain now that hypnosis does more than that and we feel that we are actually teaching the patient to control gut function. And we've shown that the lining of the gut becomes much less sensitive after hypnosis because one of the problems in IBS is the gut is over-sensitive. We've also shown that the contractions in the gut when the muscles in the gut contract that gives you the pain we've shown that those contractions or spasms of the gut can also be decreased by hypnosis. And there's evidence now that the way the brain processes pain coming up to it from various parts of the body can be modified by hypnosis. So there's a mounting body of evidence now that hypnosis can actually change the physiology of the body in a positive way. There seems to be a definite trend for women to do a bit better with this technique and it's difficult to work that out, is it because IBS is more common in women or is it because the IBS that men get is a little more complicated? So I don't think it's a case of men are not responsive to hypnotherapy, I think it may be something to do with the illness that we're dealing with. We still get 50-60% of men better but it's not as good as women, which is 70%.
ROBSON
Pamela, you spend an hour a week with each patient and then how do they then put this into practise?
CRUICKSHANKS
What the patient does is they have a CD, so that they can take it away, part of the treatment is that they practise with it at least once a day.
HYPNOTHERAPY SESSION
Hello. [Indistinct words] Lucy, how are you today?
I'm well thank you.
Oh good. Would you like a seat?
ROBSON
Lucy, this is your 10th session of hypnotherapy, how have you found the treatment so far?
LUCY
To be honest I didn't really know what to expect at first because I've never - apart from seeing hypnotists on the television, never seen anything else to do with it and I just thought you know I'm not quite sure how it's going to work. And I don't really understand how it does work but it does work.
ROBSON
You had pretty severe symptoms before you came.
LUCY
Yeah I did and I think that's part of the reason why I thought this isn't going to - it's not that I didn't, you now, wasn't positive about it but I didn't expect it to be as successful as it was, as quickly as it was, because it was literally within the first few sessions I saw a really massive improvement. Basically the kind of IBS that I had was that I could go days without having a bowel movement. On an average it was about three or four days and it was like that all the time. In a worse case scenario it was about 10 days. So it wasn't ideal. And literally within about three or four weeks of coming to the hypnotherapy my stomach got itself in a rhythm where I was actually having a bowel movement everyday. I can't ever remember having my stomach work normally ever, so it was just brilliant.
PORTER
A satisfied customer talking to Angela Robson at Wythenshawe hospital.
Well, Robin, it certainly worked for that patient. What about the long term effectiveness, does that effect carry on?
SPILLER
Yes I think that's one of the really attractive features of the psychological therapies, particularly hypnosis, where they often - well it's part of the process, is they teach the patient to do it themselves and this empowers the patients and it certainly does have long term effects. The cognitive behavioural therapy, which is another psychological treatment, the evidence for long lasting effect is not as good I'm afraid and that maybe because they're not so empowered.
PORTER
What about accessing these types of therapies? I mean certainly as a GP I can't access them, I can't refer patients directly into them in my area.
SPILLER
No, I'm afraid I can't either. The problem is that this is an intensive treatment by a very skilled person and it costs quite a lot of money so my patients have to go privately and they pay about £70, £75 an hour and I don't think that's an unreasonable fee actually.
PORTER
And they'd need to be seen for six or seven sessions presumably?
SPILLER
Yeah, yeah.
PORTER
Robin, I want to move on to newer therapies now. Dr Nayla Arabi is Consultant Gastroenterologist at St Mark's Hospital in London and currently working on two studies involving patients with IBS.
ARIBI
At present we don't know the cause for irritable bowel syndrome and we're undertaking a number of studies trying to identify what could be contributing to the symptoms of irritable bowel syndrome. Now so far we know that there is an element of what we call visceral hypersensitivity. In other words the nerves in the gut, which are the visceral, respond more to any stimulus which is in the gut, so this could be food, this could be the enzymes in the gut or even actually in some cases the gut bacteria.
The other thing we know is that the brain is also involved in deciding how much of this hypersensitivity we decide to perceive or to express. In terms of furthering our research in the gut we know that there are certain things that change the sensation of gut nerves. Many people with irritable bowel syndrome develop their condition or symptoms after an acute bout of gastroenteritis and this suggests that either inflammation or the gut bacteria may alter the way the nerves respond.
So we've taken this further by trying to change the gut bacteria by giving patients probiotics, which is a concentration of bacteria which they drink once or twice a day. And it's been shown in animals that doing this can change the way the gut nerves respond. And we're trying to reproduce this in humans. So we're testing the way that the gut responds before giving the probiotics and after and measuring the changes and response.
The other thing we're trying to do actually is to try and dissect out how much of the symptoms are due to what's happening in the gut and how much of it is because of what's happening in the brain. So this is quite a novel approach and what we're doing is we're testing or stimulating the gut of patients with irritable bowel syndrome and looking at the electrical activity in the brain which can be used to dissociate these two mechanisms - the early part of the wave indicates that perhaps the nerves are very sensitive and the later part of the wave indicates that maybe the brain is more involved. And this will open up a novel approach to treating patients with irritable bowel syndrome because if you know that somebody has more gut hypersensitivity then you'll treat them with a particular drug which works on the gut nerves. If you know that somebody has more of a brain hypersensitivity which means that they're perceiving things in the brain more, rather than the gut responding more, then you would treat them with drugs predominantly on the brain, something like an antidepressant at low dose.
PORTER
Gastroenterologist Nayla Aribi
Robin Spiller, there are new drugs that target that bowel side of that pathway, we've got them already, they're just not available in the UK?
SPILLER
That's right. So the ones we're talking about are drugs which block the action of serotonin, this is a chemical which I think most people will be familiar with as being important in the brain in controlling mood but what they may not be aware of is there's a lot more in the gut and it's very important for gut function. So blocking -people with diarrhoea for example may have an excess of serotonin - and if you block it you can control certainly urgency and pain.
PORTER
Now drugs were launched to do just that and they were very effective but there's been some problems with them and they're no longer available, what's happened there?
SPILLER
Yes. So the drug that was launched in the States was very successful - about 15% of the patients who took it experienced a good benefit - but a very small number - 1 in about 700 - developed some bleeding from the bowel and this was unexpected and unexplained and the manufacturers decided to withdraw the drug because of that. Which is a shame because a lot of people got considerable benefit from it.
PORTER
These are the 5HT antogonists, as a group, there are other products out there, are there any in the pipeline that might be safer do we think?
SPILLER
Certainly there are other drugs blocking serotonin that are in development and there's an older one that has been more or less ignored which is available and really I think we need to do some trials to establish its efficacy.
PORTER
So that's not currently licensed for use in IBS?
SPILLER
It's not currently licensed no.
PORTER
Nayla mentioned probiotics there, what are your views on them?
SPILLER
Probiotics are a way of altering the gut flora. We know the gut flora's very important for bowel function, anybody who's taken antibiotics will realise that if you kill the good bacteria you get problems, you get diarrhoea and pain. So there's very good evidence that probiotics, for example, will reduce the chances of bowel dysfunction when you're taking antibiotics or if you have a bacterial diarrhoea they will shorten the duration of that diarrhoea. The evidence of benefit in IBS is quite specific, some bacteria do benefit and some do not and so I think people have to be careful that if they buy a probiotic they buy one there is good trial evidence for benefit.
PORTER
So what bacteria should they be looking for, what do we know works?
SPILLER
There are several trials using certain lactobaccili, there's a wide range of different lactobaccili - lactobaccili plantarum has been shown to have a benefit. And there's another bacteria - bifidobacteria infantis - which was found in the stool of a baby and this has been shown in a large controlled trial to have a beneficial effect.
PORTER
So if they're taking products, properly produced products, would they need to take them on a daily basis presumably containing those bacteria?
SPILLER
Yes, they don't actually survive very long in the gut so you have to take them everyday.
PORTER
And does it matter how people are actually taking those probiotics, whether they come in a drink or whether they come in - all the different products that are there - are some better than others or is it all much of a muchness?
SPILLER
The bacteria can be killed in the stomach so the ones that are taken in a drink, which neutralises some of the acid in the stomach, seem to do better. There can be a problem - some - certain formulations don't work at all, they get destroyed.
PORTER
And how long does it take before you'd expect to see a result, in other words how long should you try these things for before giving up?
SPILLER
There is a lag between what you eat and what happens in the bowel, so in general a week, one to two weeks.
PORTER
Professor Robin Spiller we must leave it there, thank you very much.
If you want to listen to any part of the programme again then you can use the Listen Again facility, that's on our website at bbc.co.uk/radio4 - where you will also be able to find some useful links and contacts for all the issues we've discussed today.
If you don't have access to the internet then you can call our Action Line on 0800 044 044.
Next week I'll be getting up close and personal with a look at sexual dysfunction - a medical umbrella term for problems ranging from premature ejaculation to difficulty achieving orgasm. And from losing interest in sex, to loving it but being unable to rise to the occasion.
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