Doctor's Review: Medicine on the Move

September 20, 2017

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Getting comfortable with bowel health

Talking to patients about IBS with constipation

Diagnosis and management of irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) can be challenging in busy primary care settings. IBS-C and CIC are among the most common functional gastrointestinal disorders worldwide. The prevalence of all types of IBS is 11%, with roughly one-third being constipation-predominant, while CIC occurs in about 14% of the population. There’s some overlap between IBS-C and CIC in symptoms, but the hallmark of IBS-C is abdominal pain or discomfort that improves upon defecation.

Although IBS-C and CIC are not life-threatening conditions, don’t underestimate their impact on patients’ lives. From mildly annoying to debilitating, symptoms can interfere with work, daily activities and socializing, and lead to lower health-related quality of life. The lack of biologic markers and curative treatments can lead to a vicious cycle of ineffective management: repeated visits, tests, referrals and drugs feed negative perceptions on both sides and, ultimately, prolong suffering by the patient. Breaking this cycle requires a strong, positive therapeutic alliance.

Ask and ye shall receive

Some patients actively seek health care for bowel symptoms and aren’t shy about discussing them, while others only mention problems as an afterthought. But many people—perhaps most—never report symptoms to their doctor, no matter how distressing. Asking patients about their bowel movements may be a tough sell for overworked family physicians, but it’s worthwhile because effective treatments are indeed available for IBS-C and CIC, and it’s a real opportunity to improve someone’s quality of life.

The first step is to ensure patients feel comfortable discussing their symptoms. For patients who are embarrassed to describe their bowel movements, a little humour can really help. My go-to icebreaker is: “It may be poop to you, but it’s bread and butter to me!”

Questions about bowel symptoms not only demonstrate your concern, but also are crucial to establish the diagnosis and help rule out organic causes. The classic medical definition of constipation is fewer than three bowel movements a week, but there are many different definitions among patients, including straining, pain, bloating, a sensation of retained stool, or not having as many bowel movements as they think they should. The type, intensity and frequency of pain and discomfort also vary. “How are your bowel movements?” and “What exactly is unsatisfactory about your bowel movements?” are good questions to get them to be more specific.

But it’s not just about bowel movements. Anxiety and depression are frequent comorbidities with IBS, and stress can exacerbate symptoms, so it’s important to find out how patients are feeling generally. Sometimes such emotional issues require tact to elicit. Simply listening to patients may be our most important intervention; it can be both diagnostic and therapeutic.

Knowledge is power

The cornerstones of IBS-C and CIC management are reassurance, explanation and support. This is a situation where you have to be a “talk-doc” rather than a “do-doc.” If you’re short on time, it may be more practical to schedule followup visits. Patients need to feel that you’re not in a rush and that their concerns are tantamount.

The key to reassuring patients lies in how confident you are in the diagnosis. Do as many tests as you need to be sure—if you’re still worried about organic disease, your concerns will be sensed by the patient. For some patients, just hearing that they don’t have something serious like cancer is all the relief they need.

You may also need to explain to patients that constipation itself is not harmful, despite what their mothers and the internet told them. Many people think that if their stools are retained, poisons that the body is trying to get rid of will leach out into the blood and make them sick. This notion dates as far back as the ancient Egyptians and peaked in the early 20th century with the “autointoxication” theory that blamed constipation for a host of diseases from skin disorders to cancer. Although the autointoxication theory was thoroughly debunked decades ago, colonic cleansing and “detoxification” remain popular among laypeople and are a lucrative industry.

Another element of reassurance for patients is to validate that their pain is real. Explaining the mechanisms of IBS-C and CIC will help them understand what’s causing their symptoms and shows that you take their suffering seriously.

I explain colonic dysmotility as bowel muscle contractions that aren’t well-coordinated, and emphasize that “It’s the bowel’s fault, not yours.” I compare it to a toothpaste tube: the upper part of bowel should contract to squeeze the stool downward, while the lower part should relax to release the stool from the body. Using a tube of lubricant, I show them what happens in IBS, squeezing it at top and bottom to cause a bulge in the middle. On seeing this, many patients exclaim that their abdomen is visibly distended during an episode, and they can understand why that might cause discomfort.

To understand why IBS-C is painful, and how certain drugs and psychologic interventions can help, a simple explanation of the gut-brain connection is in order. When the bowel is stretched, gut nerves send signals to the brain, where they may be interpreted as pain. In people with IBS, the gut may be oversensitive and send more signals than in healthy people. The brain, in turn, may misinterpret normal gut messages as pain, or may even trigger gut dysmotility or hypersensitivity in response to stress, certain hormones, and brain chemicals.

Keeping it real

There’s no one-size-fits-all treatment for IBS-C and CIC. Work with patients to establish realistic treatment expectations. Be clear that there’s no cure—these are chronic, often lifelong conditions, and coping is key. It’s a good idea to ask which symptoms are the most troublesome. Actively involve patients in management. For example, instead of saying “I think you should try this drug,” you could say: “Changing diet is hard and tends to be of only minimal benefit, whereas drugs are more potent but less ‘natural.’ Which would you prefer?” Most patients have tried various dietary changes and over-the-counter products remedies before coming to you. Find out what they’ve used, to make sure their trials were appropriate and to avoid duplication.

The goal in the treatment of constipation is to make the patient feel comfortable. Explain that there’s no magic number of bowel movements, so people shouldn’t panic if they don’t go once a day —if a patient has one bowel movement a month and feels well, that’s okay. For pain and bloating, the aim is to reduce severity and/or frequency of episodes.

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