Version 3.1.1 
30 October 1996
Authors: Laura Zurawski (juniper@uiuc.edu)
  Dr. Anthony Lembo (alembo@UCLA.edu)

INTRODUCTION

This FAQ deals primarily with questions and problems associated with
Irritable Bowel Syndrome (IBS).

COPYRIGHT AND DISCLAIMER

See end of FAQ for complete use and distribution information, and all
applicable disclaimers.  This FAQ is by no means meant to be a
replacement for proper medical treatment from a qualified caregiver.
You should always check with your doctor if you have any concerns about 
your condition, or before attempting any new treatment program.

OTHER RESOURCES OF INFORMATION

- alt.support.crohns-colitis Information Resources FAQ, posted monthly
  on alt.support.crohns-colitis

World Wide Web (WWW) resources: 

- WWW page for bowel disorders: http://qurlyjoe.bu.edu/cduchome.html
- The IBS Page: http://www.panix.com/~ibs
- IBS Self Help Group: http://www.ibsgroup.org/

---------------------------------------------------------------------
QUESTIONS COVERED IN THIS FAQ

PART 1: Background
1.1: What is Irritable Bowel Syndrome?
1.2: What is the prevalence of IBS?
1.2.1: What factors contribute to the onset of IBS?
1.2.2: How long does it last?
1.3: What effect does IBS have on one's lifestyle?
1.4: Is it all in my head?
1.5: What factors contribute to health care utilization?

PART 2: Symptoms
2.1: What are the symptoms of IBS?
2.1.1: How severe are these symptoms?

PART 3: Medical Facts
3.1: What causes IBS?
3.2: What is the role of psychosocial factors in IBS?
3.2.1: Is IBS life-threatening?
3.2.2: Will IBS lead to cancer?
3.2.3: Will IBS lead to IBD (Crohn's, ulcerative colitis)?
3.3: Will my IBS eventually go away, or is it for the rest of my life?

PART 4: Diagnosis
4.1: How do I know for sure if I have IBS?
4.1.2: Is IBS really a "cop-out" diagnosis?  Should I just accept it?

PART 5: Treatment
5.1: What are the treatments for IBS?
5.1.1: What is the role of fiber therapy in IBS?
5.1.2: What sort of dietary modifications are required?
5.1.3: What conventional prescription medications are used to treat
        IBS?  
5.1.4: Are there any natural or herbal remedies for treating IBS?
5.1.5: What are some of the psychologic treatments available?
5.2: How can keeping a record of my symptoms and triggers be helpful?
5.3: With all these different treatments, how do I know which will
         work for me?

PART 6: Related and/or Often-confused Maladies
6.1: How does IBS differ from Crohn's disease or ulcerative colitis?
6.2: How does IBS differ from gluten enteropathy/celiac disease?
---------------------------------------------------------------------

PART 1: BACKGROUND

1.1: What is Irritable Bowel Syndrome?

Irritable Bowel Syndrome (IBS) is part of a spectrum of diseases known as
Functional Gastrointestinal Disorders which include diseases such as
noncardiac chest pain, nonulcer dyspepsia, and chronic constipation or
diarrhea.  These diseases are all characterized by chronic or recurrent
gastrointestinal symptoms for which no structural or biochemical cause can
be found.   IBS affects between 25 and 55 million people in the United
States and results in 2.5 to 3.5 million yearly visits to physicians.
Approximately 20 to 40 percent of all visits to gastroenterologists are due
to IBS symptoms.  

Because there is no diagnostic marker associated with IBS, the diagnosis is
one of exclusion and is based on symptoms.  Manning and his colleagues were
the first to report six symptoms which differentiated IBS from other
gastrointestinal diseases.  The six 'Manning Criteria' are as follows:  1)
relief of abdominal pain with defecation, 2) looser stools with the onset 
of
pain, 3) more frequent bowel movements at onset of pain, 4) abdominal
bloating or distention, 5) feelings of incomplete evacuation, and 6) 
passage
of mucus per rectum.  In general the more 'Manning Criteria' present the
more likely it is that a patient has IBS. While the 'Manning Criteria' are
helpful in diagnosing IBS a consensus meeting in Rome, Italy recently
further refined these criteria (see 2.1).  In addition, since many other
gastrointestinal diseases can present with similar symptoms, a diagnosis of
IBS should only be made in the right clinical setting.  

1.2: What is the prevalence of IBS?

IBS symptoms affects men and women of all ages and of all races.  The
prevalence of IBS in the general population of Western countries varies 
from
6 to 22%.  IBS affects 14-24% of women and 5-19% of men.  The prevalence is
similar in Caucasians and African Americans, but appears to be lower in
Hispanics.  Although several studies have reported a lower prevalence of 
IBS
among older people, the present studies do not allow to definitely conclude
whether or not an age disparity exists in IBS.  In non-Western countries
such as Japan, China, India, and Africa, IBS also appears to be very 
common.  

1.3: What triggers IBS?

Many patients with IBS report that their symptoms began during periods of
major life stressors such as a divorce, death of a loved one, or school
exams.  Many patients also report the onset of symptoms during or shortly
after recovering from a gastrointestinal infection or abdominal surgeries.
Symptoms of IBS have also been known to appear upon the ingestion of a 
certain food to which the individual is sensitive.  The type of food 
which causes symptoms varies with the individual. (There is no one 
definite universal food trigger for IBS.)
Similarly, a flare of symptoms in a patient with long-standing IBS may be
triggered by all of the symptoms listed above, or for no apparent reason.

1.4: Is it all in my head?

Several studies have shown that psychological disturbances are more common
in IBS patients than patients with other gastrointestinal diagnoses and
healthy controls.  However, people with IBS who do not seek medical care
have a similar psychological profile as the general population.  Therefore, 
IBS is not caused by psychological problems, but a person's outcome and 
illness behavior is affected by their psychological make-up.  Different 
people respond differently to their IBS and IBS symptoms, depending on a 
number of psychosocial factors.

1.5:  What factors contribute to health care utilization?

Although IBS is very common in the general population, only a minority of
people ever seek medical care for their symptoms.  Cultural factors may
affect health care utilization.  For example, as opposed to the U.S. and
Europe, in India male patients are more likely to seek medical care than
women.  The presence and severity of abdominal pain, and the number of
"Manning Criteria" correlate with health care consultation.  Finally,
psychological disturbance (e.g. anxiety or depression) also appears to
influence health care utilization.
 
-----
PART 2: SYMPTOMS

2.1: What are the symptoms of IBS?

A number of expert investigators during a meeting in Rome, Italy, developed
a consensus definition and criteria for IBS, known as the "Rome" criteria.  

At least 3 months of continuous or recurrent symptoms of:
   1. Abdominal pain or discomfort that is:
 a. Relieved with defecation and/or
 b. Associated with a change in frequency of stool; and/or
 c. Associated with a change in consistency of stool; and
   2.  Two or more of the following, at least on one-fourth of occasions             
or days:
 a. Altered stool frequency
 b. Altered stool form (e.g. watery/loose stools or hard stools)
 c. Altered stool passage (e.g. sensations of incomplete 
    evacuation after bowel movements, straining, or urgency)
 d. Passage of mucus and/or
 e. Bloating or feeling of abdominal distention.

In addition, a number of other non-colonic symptoms may be present in
patients with IBS.  These include: nausea, feeling full after eating only a
small meal, sensation of urinary urgency, incomplete emptying after
urinating, fatigue, and pain during intercourse.

2.1.1: Does everybody get the same symptoms?

No.  Although the symptoms listed in 2.1 are the most common, each person's
experience and presentation will be slightly different.  The severity and
frequency of abdominal pain or discomfort will also vary from an 
intermittent
abdominal discomfort during stress life events to severe continuous
abdominal pain.  Likewise, bowel habits can vary.  Diarrhea, constipation, 
or alternating between the two may be the predominant bowel pattern.

-----
PART 3: MEDICAL FACTS

3.1: What causes IBS?

Recent physiological and psychosocial data have emerged to improve our
understanding of IBS.  A biopsychosocial model of IBS involving
physiological, emotional, cognitive, and behavioral factors is now felt to 
be
involved in symptom generation.  Physiological factors implicated in the
etiology of IBS symptoms include visceral hypersensitivity to spontaneous
contractions and to balloon distention of the bowel, autonomic dysfunction
including exaggerated colonic motility response to stress and alterations 
in
fluid and electrolyte handling by the bowel, and an alteration in the
gastrocolonic response.  However, alterations in these physiological
parameters are generally found in only a subset of patients and frequently
do not correlate with bowel symptoms.  Behavioral factors such as stressful
life events are reported by up to 60% of IBS patients to be associated with
the first onset of the disease or with its  exacerbation.  Laboratory
stressors have also been shown to affect gastrointestinal motility and
visceral perception.  Cognitive factors such as inappropriate coping styles
and illness behavior are common in IBS patients and influence healthcare
utilization and clinical outcomes.  Emotional and psychiatric factors, such
as anxiety and depression, are present in 40 to 60% of IBS patients seeking
healthcare with increased prevalence in those patients presenting to
tertiary referral centers. IBS patients who have sought medical care are
more likely to have abnormal psychological profiles, abnormal illness
behaviors, and psychiatric diagnoses than patients with other medical 
illnesses.

3.2: What is the role of psychosocial factors in IBS?

Psychiatric diagnoses are present in 42-62% of IBS patients who have sought
medical consultation.  In comparison, psychiatric diagnoses are present in
around 20% of patients with other gastrointestinal diagnoses.  The majority
of these psychiatric diagnoses are cases of anxiety and depression.  Other
common diagnoses include somatization disorder and hypochondriasis.
   
Stress can affect the functioning of the gastrointestinal tract of all
people, and particularly those with IBS.  Several studies have shown that
IBS patients are more likely to report that stress changes their stool
pattern and leads to abdominal pain than people without bowel problems.  In
one study 65% of IBS patients reported a severe stressful life event prior
to developing IBS.  The kinds of psychological stressors often reported by
patients with IBS vary considerably, but include: loss of a parent or 
spouse
through death, divorce, or separation, and sometimes is accompanied by
feelings of unresolved grief, and also significant life changes which 
demand 
many social and personal adjustments such as moving to a new job or a new 
city.  A history of physical or sexual abuse in childhood has also been 
found to be associated with chronic abdominal pain and IBS in some 
patients.

3.2.1:  Is IBS life-threatening?
  
No, however, IBS is serious.  Patients with IBS have a higher rate of
hospitalizations, work absenteeism, feelings of poor quality of life, and
abdominal surgeries than healthy controls and patients with other
gastrointestinal illnesses.  In the general population, people with IBS
symptoms missed more than 3 times as many work days than did people without 
bowel symptoms. 


3.2.2: Will IBS lead to cancer?

No.

3.2.3: Does IBS lead to IBD (Crohn's, ulcerative colitis)?

No.  IBS symptoms are often present in patients with IBD however there is 
no
evidence to suggest that IBS leads to IBD.

3.3: Will my IBS eventually go away, or is it here for the rest of my life?

IBS symptoms may fluctuate over time.  In one study, more than 50% of IBS
patient remained symptomatic 5 years after their initial diagnosis.  

-----
PART 4: DIAGNOSIS

4.1: How do I know for sure if I have IBS?

Since there is no diagnostic marker associated with IBS, the diagnosis is
based on symptoms and by excluding other diseases which may have a similar
presentation.  The extent of the medical evaluation which is necessary 
prior
to making a diagnosis of IBS will vary depending on the duration of
symptoms, the patient's age and clinical presentation.  For example, recent
onset of symptoms in an older patient will require more extensive testing
than a younger person with unchanged symptoms for many years.  Most
patients, however, will be given a thorough physical exam which is 
performed
mainly to rule out other medical illnesses.  If further testing is 
necessary
it will usually be directed toward the predominant symptom.  For example,
patients with significant diarrhea will often undergo stool tests for ova
and parasite, and malabsorption if clinically indicated.  On the other 
hand,
patients with constipation will often undergo tests such as radiopaque
marker studies (Sitzmarker) for colonic functioning and anorectal manometry
for pelvic floor functioning.  Most patients over the age of  50 years
should have a flexible sigmoidoscopy.  In addition, if occult blood is 
found
by either rectal exam or on hem-occult testing a colonoscopy may be
necessary.    

Some commonly performed tests are listed below:
 - Lower G.I. x-ray (a.k.a. the barium enema)
 - Small bowel series x-ray
 - Stool parasite culture
 - Flexible sigmoidoscopy and/or colonoscopy

It is important to note that the ONLY way to be absolutely certain you have
IBS is through a doctor's diagnosis. 

4.1.2: Is IBS really a "cop-out" diagnosis?  Should I just accept it?

Many times a person may think that he or she is being "slighted" by being
given a diagnosis of IBS.  Unfortunately, to some doctors, IBS is not
considered a "true" disease, but rather an unimportant minor condition 
(when
in reality it is hardly all that "minor" to those who have to deal with 
it),
and therefore may not be given the medical attention it deserves.  Don't
despair; there ARE competent doctors out there who are very good at dealing
with IBS cases.  A good doctor won't just tell you that you have IBS and
give up on you.  He or she should be willing to go over your questions and
concerns, and outline and monitor a program of treatment for your 
individual
case of IBS.  If you suspect that you have not had a thorough enough
examination for other diseases before the doctor tells you that you have
IBS, you should seek a second opinion.

-----
PART 5: TREATMENT

5.1: What are the treatments for IBS?

The treatment of IBS is based on the severity and the nature of each
person's symptoms and the effect psychosocial factors are having on their
illness behavior.  Therefore, each person's therapy is tailored to their
symptoms and may include one or more of the following:  lifestyle changes,
pharmacological treatment, and psychological treatment.  Therefore, there
really is no "one" good general treatment for IBS.  Different things work
for different people, and unfortunately the only way to know exactly what
works for you is by trial-and-error.

5.1.1: What is the role of fiber therapy in IBS?

Fiber is the non-digested part of plant food and adds bulk to the stools by
absorbing water.  There are two types of fiber: soluble and insoluble.
Soluble fiber dissolves in water and is found in oat bran, barley, peas,
beans, and citrus fruits.  Insoluble fiber are found in wheat bran and some
vegetables.  Fiber increases the transit time of the colon and decrease the
pressures within the colon.
However, the role of fiber in the treatment of IBS has not been well
established.  One study showed that the response to bran in terms of daily
stool weight, bowel frequency and symptoms was determined more by
pre-existing psychometric variables such as anxiety and depression that the
amount or nature of the bulking agent administered.  From our experience,
however, patients with mild constipation predominant IBS may derive some
benefit.

Fiber can be added to the diet through the eating of more fiber-rich foods,
or by taking fiber supplements (common brands are Metamucil, Citrucel, and
FiberCon).

5.1.2: What sort of dietary modifications are required?

In some cases, certain foods can aggravate IBS symptoms and should be
avoided.  In particular, lactose in lactose deficient individuals, gas
producing vegetables such as beans and broccoli, fatty foods, and alcohol.
It is should be noted however that while these foods can exacerbate IBS
symptoms, they are not the sole cause of typical IBS symptoms.  To 
determine
which foods trigger which symptoms, one often needs to start with very 
basic
bland diet and gradually add one new food each day and record any symptoms
associated with that particular food.  

5.1.3: What conventional prescription medications are used to treat IBS?

Conventional medications used in the treatment of IBS include (but are
not limited to):

        - Anti-spasmodic drugs like Bentyl and Levsin are considered to 
part
of the class of anti-cholinergic drugs.  Anti-cholinergic drugs act by
decreasing the abnormal sensitivity of choninergic (muscarinic M2) 
receptors
in gut smooth muscle.  Significant improvement in abdominal pain and rectal
urgency have been reported in some studies compared to placebo in 
short-term
trials.  However, there is no evidence that anticholinergic are more
efficacious than placebo in the longer term.

        - Antacids/anti-gas medications (e.g. Simethicone or BEANO).  There
is no current data which supports their use in the treatment of IBS 
symptoms, though many people report that they aid in the reduction of 
embarrassing flatulence and the accompanying lower abdominal pain.

        - Anti-diarrhea medications/Opioid-receptor agonist (e.g.
loperamide or "immodium")
Loperamide is an mu opioid receptor agonist which does not cross the
blood-brain barrier.  It delays small and large bowel transit, increases 
the
frequency of small bowel phase 3 of the migrating motor complexes, 
decreases
intestinal secretory activity, and increases rectal sphincteric muscle 
tone.
Some studies have shown improvement in diarrhea, rectal urgency, and
abdominal pain in IBS. 

        - Prokinetic Agents (e.g. Cisapride or "Propulsid").  A prokinetic
drug which is a 5HT4 agonist and a 5HT3 antagonist.  Cisapride has been
reported to help in gastroesophageal reflux disease and dyspepsia related 
to
delayed gastric emptying.  Its efficacy in constipation predominant IBS,
however, has not been well established. 

  - Antidepressants.  Tricyclic antidepressants  (e.g. amitriptyline,
imipramine, and despramine) or serotonin reuptake inhibitors (e.g.
fluoxetine, sertraline, and paroxetine) are commonly used to treat IBS.
Although commonly used in IBS patients their efficacy is still being
debated.  Even though antidepressants are often used in patients with
associated depression, antidepressants appear to improve symptoms
independent of their antidepressive effects.  One study using despramine
found this drug to be superior to both atropine (an anticholinergic- which
is a common side-effect of the tricyclic antidepressants) and placebo in
relieving both gastrointestinal symptoms and depression.  Therapeutic 
effect
can take as long as 4-6 weeks and therefore therapeutic trial should
continue at least this long.

      -  Smooth muscle relaxants (e.g. mebeverine (not yet available in the
U.S.) and peppermint oil) have direct relaxant properties on gut smooth
muscle.  Placebo controlled trials, however, have not produced any 
consensus
on their efficacy in IBS.  

5.1.5: What are some of the psychological treatments available?

Psychological treatments should be considered symptoms are severe and are
associated with psychological distress.  Some of the treatments which have
been used successfully include but are not limited to cognitive-behavioral
therapy, biofeedback therapy, relaxation therapy, and hypnotherapy.  

The core of cognitive-behavioral therapy is the way a person thinks about
their bowel symptoms.  For example, thoughts or cognitions such as "there
must be more stool in my rectum to evacuate" can lead to anxiety or
attention which, in turn, can lead to increased IBS symptoms such as
sensations of incomplete evacuation.   During cognitive-behavioral therapy
patients learn exercises and strategies to control their symptoms.
Therefore, cognitive-behavioral therapy retrains patients' cognitions about
their illness beliefs as it pertains to their gastrointestinal symptoms.
Several studies have found cognitive-behavioral therapy to be superior to
control treatment.

Biofeedback and relaxation training for IBS is designed to increase the
awareness and control of physical and emotional responses, and is
particularly useful in helping patients control the physiological
consequences of stress.  The gastrointestinal system is particularly
sensitive to stress and for many patients stress leads to an exacerbation 
of
their IBS symptoms.  Typical techniques used in biofeedback and relaxation
therapy include breathing and muscle relaxation, hypnosis or imagery
techniques, or a combination

Hypnotherapy uses techniques aimed at increasing suggestibility in 
patients.
Whorwell and colleagues were the first to report it to be an effective
treatment in IBS.  In particular they found that patients who received
hypnotherapy to have more improvement in gastrointestinal symptoms 
including
abdominal pain and diarrhea in comparison to placebo.  

5.2: How can keeping a record of my symptoms and triggers be helpful?

This will help you to identify foods, activities, or stressors that were
previously not considered as triggering factors.  By identifying inciting
factors lifestyle modifications can be made to reduce symptom exacerbation.

5.3: With all these different treatments, how do I know which will work for 
me?

The only way to know for sure which treatment will work best for you is
to consult your doctor and discuss which method of treatment would be
best for you.  Sometimes, one has to try several different treatments
before finding the one that will work the best.  The important thing is
not to get discouraged -- there is something that is right for you.

-----
PART 6: RELATED AND/OR OFTEN-CONFUSED MALADIES

6.1: How does IBS differ from Crohn's disease or ulcerative colitis?

The symptoms of IBS differ from the symptoms of Inflammatory Bowel Disease
(IBD) in that there is NO trace of blood in the stool, or history of fevers
or chills.  IBS is a functional disporder, meaning that there is no 
demonstrable pathology in the colon or small bowel.
colon or small bowel.


6.2: How does IBS differ from celiac disease?

People with celiac disease experience marked intestinal symptoms such as
diarrhea and gas upon the consumption of foods that contain gluten, such
as products made from wheat, oats, rye, and barley.  Upon the
elimination of gluten-containing foods, the symptoms disappear.
Some people with IBS may experience an aggravation of symptoms with the
consumption of similar wheat-related products, but it is not these foods
that actually cause the symptoms.

------------------------------------------------------------------------
NOTICE: This document is the sole work and property of the authors.  It
may not be redistributed or sold for profit in ANY WAY without consent
of the author. Permission is granted for the copying of this document
ONLY for one's own personal use or redistribution to others on a
strictly informational and NON-profit basis, provided that: A.)the
document is not edited or modified in any way, B.)the authors are not held
responsible or liable for its content (see disclaimer below), and
C.)this notice and the disclaimer below remain attached in their
entirety.

DISCLAIMER: this FAQ is provided by the author as a supplement to the
newsgroup alt.support.crohns-colitis, and is meant as supplemental
material only.  In no way is this document meant to be a substitute for
professional medical care or attention by a qualified practitioner, nor
should it be implied as such.  ALWAYS check with your doctor if you have
any questions or concerns about your condition, or before starting a new
program of treatment.  Information for this FAQ come from personal
experience with the disease and from research and clinical experience in 
the
field by Dr. Anthony Lembo at UCLA Medical Center.  The
authors are not responsible or liable, directly or indirectly, for ANY
form of damages whatsoever resulting from the use (or misuse) of 
information
contained in or implied by this document.

-----
ACKNOWLEDGMENTS: The original version of this FAQ was written using the
information that Ms. Zurawski has acquired from a great many sources during
the many years which she has lived with IBS.  These sources are mainly
licensed gastroenterologists, especially Eric J. Yegelwel, Arlington 
Heights,
Illinois.  Ms. Zurawski wishes to thank Dr. Yegelwel for his help and
support over the years.

** In 1996, the IBS FAQ was significantly edited and revised by Dr. Anthony
Lembo, an IBS specialist doing research at UCLA, and subsequently
reviewed by Ms. Zurawski for posting.  Dr. Lembo's efforts are greatly
appreciated, as are those of his colleague, Dr. Kevin Horgan, who helped
to get the revisions started.

Ms. Zurawski would like to acknowledge the following people for their
suggestions, contributions, and references for this version and previous
versions of this FAQ:

Dr. Anthony Lembo, UCLA
Dr. Kevin Horgan, UCLA
Susan Blanc
Jeanne Zurawski
Elliott B. Hammett
Christopher Holmes
Michael Bloom
Bill Robertson
the readers of alt.support.crohns-colitis
the readers of alt.support.ibs

------------------------------------------------------------------------
Please send all comments, suggestions, corrections, or ideas for
improvement of this FAQ to: alembo@UCLA.edu or juniper@uiuc.edu