W. Grant Thompson

Negative affect and the seeking of medical care in university students with irritable bowel syndrome: A preliminary study

In a preliminary study using only self-report measures, university students completed questionnaires about their bowel symptoms and trait anxiety. Results showed that students with irritable bowel syndrome (IBS) reported higher trait anxiety than asymptomatic controls. Among the students with IBS, there were no significant differences in trait anxiety between those who had sought medical care for IBS mostly from a primary care physician, and those who had not sought care for IBS. Students who had sought medical care for IBS reported being more bothered by the symptoms and were more concerned about their meaning than those students who had not sought care. The results are compared to other research with IBS patients referred to specialist clinics, and a distinction is made between initial vs. continued care seeking for IBS.

Laxatives: Clinical Pharmacology and Rational Use

SummaryProprietary laxatives represent a multimillion dollar industry and are widely used by the apparently well population. They are traditionally classified into bulk laxatives, lubricants, stimulants, stool softeners, and osmotic laxatives. The latter 3 probably act mainly by favouring accumulation of fluids and electrolytes in the lumen of the gut. Magnesium-containing saline laxatives are believed to act by releasing cholecystokinin which, in turn, favours intraluminal fluid accumulation. Bran is not a proprietary laxative. It is a bulking agent with capacity to hold water in the stool, thereby improving bowel function. The lubricant, mineral oil (liquid paraffin), is obsolete.In constipation associated with the spastic colon, bran will transform the difficult-to-pass scybala into softer, bulkier and more easily passed stools. Atonic constipation, in which defaecation fails to be triggered by a full rectum, is less satisfactorily treated with bran. In these individuals, chronic laxative use often compounds the problem. Bowel retraining with occasional (and decreasing) use of laxatives such as bisacodyl or ‘Senokot’ (standardised senna) are often effective. Occasionally, a glycerin suppository will trigger the defaecation reflex.Patients with an acute illness, undergoing surgery or suffering from perianal disease benefit from the early institution of bran to encourage the easy passage of soft stool. Bisacodyl or ‘Senokot’ should be kept in reserve. In patients who become impacted, particularly following a barium enema, an oil retention enema followed by a tap water enema may be successful, but manual disimpaction should not be unduly delayed. Laxatives may alter the appearance of the colon mucosa and so should be avoided before sigmoidoscopy. Preparation for an air contrast barium enema or colonoscopy necessitates a 2 day program of taxation including a fluid diet.Laxatives are probably more important to modern medicine for the harm they do than for their benefit. Use of the stimulant cathartics can lead to an atonic colon in which the neuromuscular apparatus is permanently damaged. Vigorous purgation may produce a paradoxical diarrhoea complicated by electrolyte derangement, malabsorption, and protein-losing enteropathy. Other than bran, most clinicians will have little need for laxatives and their use by patients should also be discouraged.

Irritable Bowel Syndrome

Excerpt To the editor: In his editorial note in the March 1979 issue, Drossman (1) draws attention to our study (2) in which certain symptoms were found to be more characteristic of the irritable b...

Does uncomplicated diverticular disease produce symptoms

A questionnaire dealing with bowel symptoms was administered to 97 outpatients referred for air-contrast barium enema. Subsequenlly, the barium enema was interpreted by a radiologist who did not know the results of the questionnaire. Forty-nine had normal x-rays, and 27 had uncomplicated diverticular disease. Weight loss, rectal bleeding, abdominal pain, and pain at night were as common in those with a normal examination as in those with diverticula. Symptoms of colon dysfunction included abdominal pain relieved by defecation, altered stool frequency and consistency with pain onset, abdominal distension, feeling of incomplete evacuation after defecation, and mucus in the stool. These were equally prevalent in both groups. Therefore, no symptoms could be ascribed to the presence of diverticula

The Irritable Gut

There is a tendency to deprecate functional complaints. Physicians are trained to get to the organic core of a problem and to understand disease in terms of its pathology. When there is no structural or biochemical abnormality, symptoms are difficult to understand. It is easiest to ignore or dismiss that which is not understood. Thus the aim in diagnosis is to identify or exclude pathology. The irritable gut is what is left when no organic explanation for gut symptoms can be found. This negative approach to the diagnosis of functional disease leads to tests and therapy that may be inappropriate and often trivialize patients’ complaints (Figure 10). After all, no one has ever died from an irritable gut.

Symptoms and Syndromes

Thus far, we have discussed the anatomy and physiology of the gut and the concept of normal bowel habit. As we turn our attention to disturbed bowel function, that is, the irritable gut, some definitions are necessary. In this chapter, we shall discuss the definition of the irritable gut and introduce its symptoms and syndromes.

Effect of cholestyramine on absorption of3H digoxin in rats

To determine the effect of cholestyramine on the absorption of digoxin, intragastric3H digoxin was given to 12 rats, 6 of whom were on an 8% cholestyramine diet. The cholestyramine-fed animals showed a significant decrease in stool radioactivity and an increase in urine radioactivity. In another experiment 16 rats had a laparotomy and 8 of these had common bile duct ligation. Half of each group received cholestyramine. In the sham-operated animals there was again decreased stool and increased urine recovery of radioactivity in those receiving cholestyramine. In the bile duct-tied animals, there was decreased stool radioactivity and increased urine radioactivity, and the addition of cholestyramine did not alter the result. The apparent enhancement of digoxin absorption in intact animals by cholestyramine can best be explained by reduction in bile flow due to interruption of the enterohepatic circulation of bile salts by the resin. This may decrease biliary excretion of digoxin.To determine the effect of cholestyramine on the absorption of digoxin, intragastric3H digoxin was given to 12 rats, 6 of whom were on an 8% cholestyramine diet. The cholestyramine-fed animals showed a significant decrease in stool radioactivity and an increase in urine radioactivity. In another experiment 16 rats had a laparotomy and 8 of these had common bile duct ligation. Half of each group received cholestyramine. In the sham-operated animals there was again decreased stool and increased urine recovery of radioactivity in those receiving cholestyramine. In the bile duct-tied animals, there was decreased stool radioactivity and increased urine radioactivity, and the addition of cholestyramine did not alter the result. The apparent enhancement of digoxin absorption in intact animals by cholestyramine can best be explained by reduction in bile flow due to interruption of the enterohepatic circulation of bile salts by the resin. This may decrease biliary excretion of digoxin.

The Fiber Story

The search for a comprehensive explanation for the ills of humanity has led seekers of health down many garden paths. The snake oil peddlers of the nineteenth century touted remedies for everything from constipation to cancer, and faith healers, spiritual and pharmaceutical, continue to profit from the gullible. The credibility of important medical discoveries has been endangered by a tendency to generalize. Thus, with the discovery of cyanocobalamin, vitamin B12 injections became a nostrum for complaints ranging from tired blood to bad nerves. Following Sir McFarlane Burnett’s exposition of the clonal selection theory, all sorts of conditions were attributed, without evidence, to autoimmunity. The concept of total environmental allergy is an absurd example of this tendency.

Management of the Irritable Bowel

The irritable bowel syndrome affects 15-20% of people.1,2 Fortunately, most sufferers do not seek medical attention. Those who do constitute an important health problem and make up 30-50% of referrals to Western gastroen-terologists.3 Most patients are female, and there is an association with personality or psychiatric disturbance, but amongst noncomplainers the sexes are equally represented and psychosocial backgrounds are similar among nonsufferers.4,5 Threatening life events often precede the patient’s visit to a doctor.6,7 The IBS is a benign condition with no organic consequences other than those resulting from injudicious tests or treatments. It usually begins in youth and continues or recurs throughout life.8-10 Thus, any management strategy must take into account the patient’s psychosocial history, the benign but lifelong nature of the symptoms, and the lack of any generally accepted pathophysiologic conception of how the symptoms are generated.

The Chronic Abdomen

Chronic, undiagnosed abdominal pain may pose difficult and frustrating problems in diagnosis and management. Imprecise diagnosis is disappointing to both patient and physician. Terms like “abdominal pain not yet diagnosed,” “functional,” or “psychogenic abdominal pain” may sustain the physician’s mystique but may do little to clarify the cause or indicate useful treatment. Patients seeking help for chronic pain risk two harmful extremes of management. In one extreme, the physician, unable to understand the nature of the complaint, may minimize its importance and force the patient to seek advice elsewhere. Regrettably, there are charlatans who prey on such patients. At the other extreme, repeated complaints of abdominal pain may generate costly consultations, hazardous investigations, and futile treatments (even surgery), which serve only to exaggerate the importance of the pain and the patient’s concern. The chronic abdomen is the most difficult gut reaction to understand or treat.