By Chris Cunningham

BOWEL TROUBLE, IBS and FMNot even the subject of sexuality is as taboo as constipation, diarrhea, and flatulence. While such topics as Bowel Trouble constitute “bathroom humor” among young people, they are more likely to elicit embarrassed silence or quiet apologies in adult social situations.

But those who suffer from Irritable Bowel Syndrome (IBS)- a disorder characterized by frequent bouts of abdominal cramping and bloating, compounded by diarrhea, or constipation, or episodes of each, know that bowel irregularity is no laughing matter.

As 55-year-old Marilyn puts it, “If you look at any movies, IBS is made fun of-bathroom situations are laughed at. And even though I have laughed and made fun of myself to cover my embarrassment, there really was nothing funny about being in horrible pain due to the severe diarrhea, and missing out on much of my life, and my children’s events.”

The mother of two, Marilyn has experienced IBS symptoms since 1983. A self-motivated woman, she has learned coping strategies that work. Yet many others suffer in embarrassed silence rather than seeking help, perhaps unaware that IBS is a functional disorder in which the bowel does not work properly.

“The social stigma attached to talking about bowel symptoms contributes to ignorance about (IBS) and isolation for sufferers in a way that is generally not seen with other physical ailments,” says Jeff Roberts, president and founder of the IBS Self Help and Support Group and the Irritable Bowel Syndrome Association.

The 45-year-old Roberts, who was diagnosed with IBS in 1976, adds that this social stigma likely prevents sufferers from talking to their families and doctors-and seeking treatment.

The National Women’s Health Information Center reports that IBS afflicts one in five Americans. About two-thirds of these are females. It is not yet known whether females are more likely than males to seek medical attention, or whether hormonal differences account for the variation in prevalence.

IBS symptoms frequently surface before the age of 35, and are a major cause of work and school absenteeism. People with IBS often report having a family member with IBS,so the condition may have a genetic basis.

IBS Overlaps with FM

Fibromyalgia occurs in up to 60 percent of those with IBS, and up to 70 percent of those with a diagnosis of FM have symptoms of IBS.

Those with IBS and FM share a number of different symptoms: stress exacerbates physical discomfort; disturbed sleep and fatigue are commonplace; and medications and behavioral therapies are effective in reducing pain.

Medical experts say that, like FM, the underlying causes of IBS are not clearly understood. Even a decade ago, physicians commonly identified IBS as a psychosomatic condition. Today, the medical community understands that stress aggravates, but does not cause, IBS symptoms.

Compelling- but not conclusive- data indicate that an excess of bacteria in the small intestine prevents the body from absorbing fat and carbohydrates, causing IBS symptoms. Sweets and starchy foods apparently cause the worst symptoms.

Some researchers say the fermenting bacteria in the intestines create gas, bloating, pain, mucus in stools, and diarrhea. Other speculate that excess bacteria can cross the lining of the gut and enter the body, an invasion that triggers the immune system to produce chemicals that interfere with the nerves and cause IBS symptoms.

Furthermore, some researchers suggest this bacterial overgrowth may explain the altered brain-gut interaction, since inflammation of the small bowel activates multiple brain changes.

The social stigma attached to talking about bowel symptoms contributes to ignorance and isolation

IBS researchers are actively investigating the “circuitry” between the brain and the gut, which can affect pain perception and a person’s appraisal of IBS symptoms. Called the “brain-gut axis” in medicine, the International Foundation for Functional Gastrointestinal Disorders defines this circuitous relationship as the “continuous back-and-forth interactions of information and feedback that take place between the gastrointestinal tract and the brain and spinal cord, which together comprise the central nervous system.”

According to Lin Chang, M.D., of the Center for Neurovisceral Sciences & Women’s Health, Greater Los Angeles Health Care System, “No one knows exactly what causes Irritable Bowel Syndrome. The lack of a biologic marker makes it difficult to have consensus on the underlying etiology.
“However, it is generally accepted that IBS is a disorder in which a key mechanism is altered in brain-gut interactions,” she adds. “This can lead to many different physiologic alterations: visceral hypersensitivity, abnormal gut motility (in which the gut does not operate freely or spontaneously), or autonomic responses and neuro immune change.”

She suggests that , like other chronic medical conditions, IBS be viewed in the context of genetics, physiology, and emotional, cognitive, and behavioral factors. While these factors are interrelated, their degree of importance varies from person to person. “Previously, IBS was considered a disorder of altered gut motility,” Chang says. “Now, both increased bowel sensitivity (visceral sensitivity) and altered brain-gut interactions are believed to play important roles.”

For example, Chang says, people with IBS have altered intestinal motility­ particularly exaggerated contractions in the lower colon-during stressful situations or following food intake. These alterations may explain why many IBS patients experience abdominal cramping, bloating, and gas following a meal, or an exacerbation of symptoms when they are under stress.

Chang points out that published studies measuring visceral sensitivity suggest that a variety of abnormal sensations or perceptions in relation to bowel stimuli may be more frequent in IBS patients. “There has been compelling evidence that IBS patients have enhanced perception of bowel (visceral) stimuli, such as food, stool, and gas, or distensions of the gut wall.”

Symptom Management Is Possible

Diet, fiber supplements, medications, and stress reduction techniques, such as hypnotherapy management and cognitive behavioral therapy, have made a positive difference for many IBS sufferers. Sophie, like many others with IBS, finds that certain foods intensify her IBS symptoms. These include fatty foods, milk products, chocolate, alcohol, caffeine, and carbonated drinks.

“Diet does seem to be a major factor in my IBS, especially eating wheat or gluten-containing products,” says the 29- year-old woman, who created IBS Tales (, a website that offers IBS sufferers an opportunity to exchange ideas and information.

“The main thing I have done is to cut out all gluten from my diet, which is not easy,” she says. “Gluten is found in things like bread and pasta, but the food manufacturers also put it into all kinds of processed foods.” These days food products have labels indicating they are gluten-free, which makes grocery shopping a little easier for Sophie. “I also find that I tend to feel better when I’m taking a maximum dose of a fiber supplement, like methylcellulose [Citrucel], and also leaving out obvious triggers like caffeine and alcohol.”

Forty-nine-year-old Cindy’s internist suggested that the sugar substitute Sorbitol could be contributing to her abdominal pain and constipation. The body is not able to absorb Sorbitol, which manufacturers use in many sugar-free or dietetic candies, cake mixes, syrups, and other foods. When he suggested Cindy keep a diary of her eating habits, she became aware of the products in her diet that contain Sorbitol, such as chewing gum. A well-balanced, high fiber diet, and a daily glass of fiber supplement have helped Cindy keep her IBS “under pretty good control.”

Christine Gerbstadt, M.D., a registered dietitian and spokeswoman for the American Dietetic Association, says the “judicious use f medications,” as well as daily physical activity and a healthy diet with adequate fiber from fruits, vegetables, and whole grains, “can relieve symptoms of chronic constipation, diarrhea, bloating and gas.” She says these recommendations benefit those with FM too.

Gerbstadt advises people with IBS to test their blood for food allergies before initiating a gluten-free diet. ”A wheat gluten-free diet is only indicated when food allergy testing shows gluten sensitivity . … There is no known benefit to following this diet without documentation of a condition from blood testing.”
She says probiotics-microorganisms such as Lactobacillus species and Bifidobacterium species and yeasts-may improve the balance of microflora (bacteria colonies that aid digestion) in the small intestine.

But people with IBS should be prudent with supplements, Gerbstadt says. “Stimulating laxatives can become ‘habit forming,’ in that a bowel movement may be made only with their continued long-term use in some persons. Chronic use may alter fluid and electrolyte balance, but this can be corrected by regular monitoring with blood work.”

Up to 70 percent of those with a diagnosis of FM have symptoms of IBS

Jeannie Moloo, R.D., Ph.D., another ADA spokeswoman, says that “taking fiber supplements to manage IBS should not be harmful long-term as long as no one food group, such as vegetables, is excluded from the diet in lieu of taking the supplement.” She notes that many of her clients’ symptoms have improved on high-fiber diets.

Moloo adds that, because some serious conditions can mimic IBS, anyone who experiences IBS symptoms should first request a complete evaluation by a gastroenterologist and then work closely with a registered dietitian for individualized nutrition counseling.

Marilyn has found relief with behavioral therapy. She says physicians prescribed numerous IBS medications over a 12-year period, from antispasmodics and antidiarrheals to anti-depressants, and over-the-counter agents too. “My gastroenterologist told me in 2000 that there was nothing left [to try] and to investigate and research newer treatments,” Marilyn says. “What finally worked for me was clinical hypnotherapy.”

She began listening to the IBS Audio Program 100, developed in England by Michael Mahoney, which teaches people how to focus their attention, and through techniques such as arm levitation and relaxation, how to use imagery to relax the GI tract.

“The techniques that Michael uses are directed to that part of our brain that goes into an ‘automatic’ response,” Marilyn says. “The suggestions given in the sessions address the brain-gut connection.”

While the results were not immediate for Marilyn, she eventually learned how to “alleviate symptoms more and more often, and over time, they became less severe and less frequent,” as she replaced the dread of impending symptoms with thoughts of “I don’t need this, I don’t want this.”

“I wish I could say there was [a specific] visualization or technique I did that helped with the symptoms,” she says, “but it truly was the listening to the program over the course of the 100 days” that helped relieve Marilyn’s symptoms.

Research has confirmed that others with IBS benefit from cognitive behavioral therapy, which is based on the premise that irrational and self-defeating thoughts cause psychological distress and can exacerbate the symptoms of functional bowel disorders. With CBT, patients learn to identify self-defeating thoughts and substitute them with more positive ones.

Roberts offers other recommendations: “Learn what may be a trigger for you by keeping a personal symptom journal. Learn as much as you can about the illness, and share your feelings, fears and successes with your partner, family, or friends. Find a health care professional you trust and have confidence in. Don’t be afraid to ask for help. Learn to roll with the bad days. And keep in mind that good days will return.”