Irritable bowel syndrome - understanding clinical features

Irritable bowel syndrome (IBS) is one of the common bowel problems. Other names are spastic colon, nervous bowel, mucous colitis, functional bowel disorder, intestinal hurry. Many persons suffering from this won’t disclose it to others and their doctors because of fear. Even though the symptoms are distressing many of them can be relieved with proper medication. About 20% of general population may be suffering from the disease but only 10% seek medical attention. This can occur at any age majority experience the first attack before 45 yrs. IBS is mainly a disease of young women. Understanding and treating the condition is important because it will affect the quality of life and frequent work absenteeism .This is a functional disorder of bowel without any structural abnormality.

Clinical features of Irritable bowel syndrome

IBS is characterized by recurrent abdominal pain associated with defecation and altered bowel habits. Symptoms vary from person to person . Predominants symptoms are abdominal pain, altered bowel habits, gas and flatulence, upper gastrointestinal symptoms. Even healthy people may  have occasional stomach upset and diarrhea , IBS  patients experience it more frequently.

1. Abdominal pain

It is the most common and key symptom of IBS. It can be colicky or cramp like mainly felt in the lower abdomen and is relieved by medication. Some patients experience a constant ache in the abdomen. Severity of pain varies from patient to patient. Usually pain is present only during wakeful hours and won’t disturb the sleep. Factors that aggravate pain include eating or emotional stress and it is  improved by passage of flatus or stools. In females during premenstrual and menstrual period worsening of symptoms can occur. 

2. Alteration in bowel habits 

One of the most consistent clinical features in IBS is alteration in bowel habit. Patient may experience diarrhea (IBS-D), or constipation (IBS-C) or a mixture of these (IBS-M ).The usual  pattern is constipation alternating with diarrhea,eithr of these symptom can predominate. In constipated patients stools may be hard with narrow caliber described as marble like or pencil thin. Patients also explain incomplete evacuation this will lead to repeated defecation .In some people diarrhea predominates. This is small volume loose stool. Usually there is no diarrhea at night. Emotional stress and eating will worsen the diarrhea. Passage of mucus per rectum can occur. Usualy there is no weight loss or malabsorption. Rectal bleeding is not seen. 

3. Gas and flatulence

Patients also complain of abdominal distension and flatulence, many patients complain of increasing gas, but that need not be present, there is alteration in bowel transit of intestinal gas and intolerance to gas. Those patients with bloating and abdominal distension experience less abdominal pain.

4. Upper gastrointestinal symptoms

About 25-50% of patients with IBS also experience dyspepsia, heartburn, nausea, and vomiting. The prevalence of IBS is more among patients with dyspepsia. 

Other coexisting conditions are fibromyalgia, non ulcer dyspepsia, chronic fatigue syndrome, headache, backache and dysmenorrhea in females. 

Stress  and IBS

Emotional factors are linked to IBS. Anger, anxiety may increase the bowel movements and produce diarrhea. Upto 50% of people may experience anxiety, depression, obsessive-compulsive disorder .Some patients also gives history of prior physical or sexual abuse.

Rome III criteria for diagnosis of irritable bowel syndrome

Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months, associated with two or more of the following:

• Improvement with defecation.

• Onset associated with a change in frequency of stool.

• Onset associated with a change in form (appearance) of stool.

Features supporting IBS

• Symptoms for more than 6 months.

• Frequent medical visits for non-gastrointestinal problems.

• Prior symptoms which are medically unexplained.

• Worsening of symptoms by stress.

Alarming features of IBS, if present immediately consult physician 

• Age more than 50 yrs.

• Male gender

• Weight loss

• Nocturnal symptoms ( Symptoms at night ) 

• Family history of colon cancer

• Anaemia – Decreased heamoglobin

• Rectal bleeding

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Causes of hypoglycemia in diabetic patients

Hypoglycemia is common problem seen in diabetic patients on insulin. It is due to imbalance between insulin requirement and administration. Highest risk is just before meals and during night. All patients on insulin and oral hypoglycemic agents should be aware of the causes  of hypoglycemia and try to avoid them.

Causes of hypoglycemia in diabetes 

Relative or absolute insulin excess.

Increased dose of insulin or insulin secretagogue (agents that help to increase insulin secretion) such as sulfonylureas and meglitinides which stimulate insulin secretion.

Intake of glucose is reduced.

• Missed or delayed meals.
• Insufficient carbohydrate in meals.

Increased glucose utilization.

• Vigorous exercises.

Increased sensitivity to insulin.              

• With improved glycemic control, late after exercise, in the middle of the night, weight loss. All this situation causes increased sensitivity to insulin.

Deceased glucose production.

• Alcohol intake.

Reduced clearance of insulin.

Renal failure.

Poorly decoded insulin regimen.

Lipohypertrohy at injection sites - Erratic insulin absorption from areas of fat

Gastroparesis

Malabsorption diseases

Risk  factors of hypoglycemia in diabetic patients

1. Impaired awareness of hypoglycemia-Patient fail to recognize the clinical features of hypoglycemia.
2. Strict glycemic control.
3. Extremes of age group.
4. Long duration of dm.
5. Type 2 DM treated with sulfonylureas, insulin.
6. Somogyi phenomenon.

Early morning hypoglycemia (at 3 am) followed by hyperglycemia resulting in elevated fasting blood glucose. This phenomenon is due to increased night dose of insulin.

Management of hypoglycemia

1. Primary prevention
2. Patient education
3. Frequent self monitoring
4. Use flexible drug regimens
5. Professional guidance

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Clinical feature of gout

Gout is a disease in which body uric acid pool is increased. This will lead to deposition of urate crystals in the joints. Most people with hyperuricemia are asymptomatic. Gout is typically seen in middle aged men. Attacks may be precipitated by excessive food, alcohol, dehydration and diuretic therapy.

Clinical syndrome caused by hyperuricemia

1. Acute urate synovitis –acute gout.
2. Chronic urate polyarticular gout.
3. Chronic tophaceous gout. 
4. Urate renal stone formation.

Commonest clinical presentation is sudden onset pain in a single joint. Common sites affected are the following. In 50% of cases it involves big toe (metatarsophalangeal joint) as shown in figure.

Podagra. Acute gout with  swelling and erythema

Other sites affected are 

1. Ankle
2. Midfoot
3. Knee
4. Small joints of hands
5. Wrist
6. Elbow

Large joints of limbs and axial skeleton (spinal joints) are rarely affected.

Acute gout

Characteristic features of pain in acute gout are given below

1. Sudden onset of pain, which reach maximum severity in 2 to 6 hours, it may wake up the patient in early morning.
2. Patients describe the pain as very severe and ‘worst pain ever’.
3. On touching the area severe tenderness occur, patient cannot even wear a sock or let bedding rest on the joint.
4. There can be marked swelling with overlying skin become red and shiny.
5. The disease is self-limiting, pain resolves over 5 to 14 days, with complete resolution.
6. Once the attack subsides, pruritus (itching) and desquamation of skin is seen.
7. Along with the above features there can be fever, malaise and confusion particularly if large joints are affected.
8. Some patients experience only milder attack. More than one joint may be affected. Cluster attack can occur ,in such case other joint is affected after a few days. But polyarticular involvement is unusual.

Chronic gout

Chronic pain and damage to joints occur which may lead to severe disability and functional impairment. If the hyperuricemia is uncontrolled repeated attack can occur  and progress to chronic gout. 

Tophus with white monosodium urate monohydrate

Chronic poly articular gout is rare, it is seen in elderly on long duration of diuretic therapy and chronic renal failure. 

Chronic tophaceous gout - Urate crystal may be deposited in joints and soft tissues to produce tophi, which appear as irregular firm nodule white in colour. Common sites affected are extensor surfaces of fingers, hands, forearm, elbows, Achilles tendons (back of the ankle joint) and the helix of the ear. Tophi may undergo ulceration and infection.

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Fibromyalgia clinical features

Fibromyalgia, common clinical condition in which there is widespread musculoskeletal pain and tenderness. It is also called as CWP  (chronic widespread pain). Although it is primarily a pain syndrome it may be associated with neuropsychiatric manifestations. This is more commonly seen in women with a female to male sex ratio 9:1. It can occur at any age  but incidence increase with increase in age. Fibromyalgia produces negative impact on social and psychological functioning.

Risk factors of fibromyalgia 

1. Psychosocial stress such as marital disharmony.
2. Alcoholism in the family.
3. Injury or assault.
4. Law income.
5. Self reported childhood abuse. 

Clinical features

Clinical features include wide spread pain and neuropsychiatric manifestation. Patient usually complain of pain in one region of body initially, later pain becomes widespread.

Characteristics of pain

1. Poorly localized.
2. Can’t ignore.
3. Severe in intensity.
4. Reduce the functional capacity.
5. Worsened by physiotherapy.
6. Unresponsive to NSAIDS (Analgesic).

Duration of pain

Pain is present almost through out the day on most days for at least 3 months.

Site of pain

1. Pain is present above and below the waist.
2. Pain is present on both side of body.
3. It involve the axial skeleton (neck, chest, back). 

Patients also complain about headache. Facial and jaw pain, abdominal and pelvic pain.

Neuropsychiatric manifestations are the following

Fatigue - It is very common, more  severe in the morning. There will be severe disability, so the patient experience difficulty in doing house work, shopping etc although they can dress, feed and groom themselves.

Stiffness 

Sleep disturbances 

Anxiety

Depression

Cognitive dysfunction - Difficulty in concentration, short term memory loss.

Clinical features

Usual symptoms

1. Multiple regional pain
2. Marked fatigability
3. Marked disability
4. Broken,non-restorative steep
5. Low affect, irritability,weepiness
6. Poor concentration,forgetfulness

Variable locomotor symptoms

1. Early morning stiffness      
2. Numbness, tingling of all fingers 
3. Swelling of hands, fingers

Additional, variable, non-locomotor symptom

1. Non-throbbing bifrontal headache (tension headache)
2. Colicky abdominal pain, bloating, variable bowel habit (irritable bowel syndrome)
3. Bladder fullness, nocturnal frequency (irritable bladder)
4. Hyperacusis,dyspareunia, dtecomfort when touched (allodynia)
5. Frequent side-effects with drugs (chemical sensitivity) 

Comorbid conditions associated with fibromyalgia include other musculoskeletal pain, infectious disease, metabolic and psychiatric disorders. Twenty percentages (20%) of patients have associated degenerative or inflammatory rheumatoid disease.

On examining the patient there wont be any evidence of synovitis or joint damage, neurologic deficit or wasting. Some time evidence of osteoarthritis may be present. On touching certain body part people complain of increased pain.

Why people develop fibromyalgia?

Possible causative mechanisms in fibromyalgia.

The exact mechanism is not known. There is alteration in pain processing in brain and patients have increased sensitivity to pain. There is decreased threshold to pain perception and tolerance at certain sites throughout the body. Certain peripheral pain generators act as trigger such as arthritis, bursitis, neuropathy and other degenerative and inflammatory conditions.

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How to diagnose depression and what are the criteria for major depression

Five or more of the following symptoms can happen during two week.

Period representing a change from normal functioning. 
At least one of the symptoms is either depressed mood or decreased interest or pleasure. Do not include symptoms due to medical conditions, delusion or hallucination. 

1. Depressed mood*.
2. Substantial weight loss or weight Gain.
3. Insomnia/lack of sleep or hypersomnia.
4. Feelings of worthlessness or inappropriate guilt.
5. Recurrent thoughts of death or suicide or suicide attempt.
6. Decreased interest or pleasure*.
7. Psychomotor retardation or agitation.
8. Fatigue or loss of energy
9. Diminished ability to think or concentrate

*From Diagnostic and Statistical Manual of Mental Disorders, fourth edition

*One of these symptoms must be present 

• Symptom should not meet the criteria for mixed episode.
• There  is  clinically significant distress in social, occupational, or other important areas of functioning.
• These symptoms are not due to the direct physiologic effects of a substance (e.g. drug of abuse, medication) or a general medical condition (e.g. hypothyroidism)
• The symptoms are not better accounted for by bereavement (i.e. after the loss of a loved one).

The episodes are diagnosed as mild, moderate and severe depending on the number of symptoms and intensity. Minimum duration of the whole episode is expected to be about two weeks.

Screening questions for depression

1. How have you been feeling recently?
2. Have you been low in spirits?
3. Have you been able to enjoy the things you usually enjoy?
4. Have you had your usual level of energy, or have you been feeling tired?
5. How has your sleep been?
6. Have you been able to concentrate on newspaper articles or your favourite television or radio programmers? 

Following are the difficulties for a non psychiatrist in diagnosing depression

1. Making sense of the emotional experience of the patient.
2. Pinning down the predominant mood state.
3. Assumptions /attributions to a physical or external factor.
4. Difficult questions to explore deeply.
5. Either normalising or interpreting any sadness as depression.

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Obesity a rising problem

Obesity is a chronic metabolic disorder with excessive fat deposition in the body .WHO defines obesity as body mass index more than  30 kg/m². Incidence of obesity is increasing worldwide, also in developing countries. As the people get older they accumulate more fat. Obesity indicate an excess fat storage, and looking at the undressed patient it can be easily identified. The term  overweight (rather than obese) indicate individuals with BMI between 25 and 30. It is medically significant and worthy of therapeutic intervention, especially in persons with  risk factors such as hypertension and glucose intolerance.

The distribution of adipose tissue in the body is important and has implications for morbidity. Intra-abdominal and abdominal subcutaneous fat have more significance compared to subcutaneous fat in the buttocks and lower extremities. This is clinically  detected  by the waist-to-hip ratio, with a ratio > 0.9 in women and >1.0 in men being abnormal. This may be because intra-abdominal adipocytes are more lipolytically active than those from other sites. 

Incidence of obesity is increasing  because of the following 

1. Increased availability of energy rich drinks and foods.
2. Increase in labour-saving devices (e.g. lifts and remote controls).
3. Increase in passive transport(cars as opposed to walking)

Obesity can be simple obesity or it can be associated with other conditions. Most  patients have simple obesity, Even when it is associated with other conditions, excess calories consumed in the diet  than expenditure through exercise and body functions, is the main cause of obesity.

Energy balance

1. 1 kg body weight gained has energy of approx 7000 kcal.
2. 10 kg weight gain over 5 years -70000/5*365=_ _38 kcal/day.
3. This is a daily error of energy balance of _1.5%.
4. OR 10 minutes’ walk.
5. OR one square (1/8) of a 2oz milk chocolate bar.
6. OR half a digestive biscuit.

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