Diagnosing Irritable Bowel Syndrome

By Dr. Ralph Golan


Q: My lower, left abdomen started hurting in January. Twice, I was told an enlarged prostate was causing it. But the pain has spread to other areas of my abdomen, especially my right side. I had a polyp removed from my colon a month ago and was told that this should relieve the symptoms. They actually got worse. My doctor put me on Levbid because he suspected irritable bowel syndrome (IBS). I have never had regular bowel movements and have always been a worrier and high strung. Could this be the culprit? Could I have something else? I have seen six doctors and nobody can seem to help me.

A: Irritable bowel syndrome is an extremely common diagnosis given to people who complain of abdominal pain or cramps, gas and bloating, constipation or diarrhea. A doctor will often make this diagnosis from the presence of one or more of these symptoms, if no other conditions responsible for those symptoms are suspected or diagnosed.

      A major difficulty with the IBS diagnosis is that it simply describes the problem but doesn't suggest any specific, underlying cause. If the patient responds poorly to standard IBS treatment, the doctor often feels ill-equipped to offer anything else, and the patient often feels discouraged.
      If you have been diagnosed with IBS and are not responding well to treatment, or, if you have intestinal symptoms that have defied diagnosis and successful treatment, you may do yourself a service in finding a doctor who can evaluate you for digestive function, intestinal infections and food sensitivity. You do not need severe symptoms nor do you need to feel, or look, unusually ill to qualify for these tests and trials. The persistence of chronic symptoms and the gradual erosion of your well-being are all the indications needed. From such an evaluation, you may discover some surprising straightforward answers.
      In your case, it sounds as though you have at least had colonoscopy, so it is likely your doctor has ruled out inflammatory bowel disease, diverticulitis and colorectal cancer. If the other five doctors have determined that your stomach, pancreas, gall bladder, liver, kidney, bladder and prostate are not causing your pain, or if they felt your condition did not merit such a full internal workup, then it may very well be that IBS is what ails you.
      Your chronic constipation, long-standing anxiety and now abdominal pain certainly suggest IBS. If it eases your symptoms some to take the Levbid (an anti-spasm medication) or to take a fiber supplement and drink plenty of water, this would also support the diagnosis.
      It may be very possible, however, that constipation is your primary diagnosis, and that it has grown so severe that you now have pain as a result of bowel distention, pressure and spasm. Correcting your constipation may simply be all you need.

      Whether it is just severe constipation, or IBS, a protocol of tests can often distinguish why one has these gastrointestinal symptoms and can show how to reverse them. These tests are indispensable to me for helping individuals who have constipation, diarrhea, abdominal pain, or nearly any gastrointestinal symptom that standard tests and exams have failed to diagnose and common-sense IBS treatments have failed to ameliorate.

The tests fall into three categories: digestive function; intestinal infections or overgrowth of normal intestinal organisms; and food allergy or sensitivity.
      Digestive function: Finding deficiencies or imbalances may lead to treatments. For example, some people's stomachs do not make enough hydrochloric acid. Doctors and the public are mostly concerned with excessive stomach acidity. But in fact, insufficient stomach acid may be as common as hyperacidity while rarely recognized. A few symptoms of insufficient hydrochloric acid include gas, bloating, constipation, heartburn and acid indigestion. Taking acid blockers and antacids would help quiet heartburn and reflux problems but would only worsen the other consequences of the problem. With insufficient hydrochloric acid, excessive alkaline concentrations develop in the intestine promoting the overgrowth of unfavorable bacteria and fungi.
      So testing for this could be critical. To assess stomach-acid production I often recommend the Heidelberg telemetry test. When that's not feasible, I recommend a carefully supervised trial of supplemental hydrochloric acid. I have had patients whose chronic constipation wouldn't budge until they got a diagnosis of hypochlorhydria and took a prescribed dosage of a hydrochloric-acid supplement.

      Then there is the pancreas, which produces digestive enzymes to break down protein, carbohydrates and fats. Insufficient digestive enzymes result in gas, bloating and loose stool. The fecal chymotrypsin test will show if digestive enzyme levels are adequate. I will often prescribe a digestive enzyme supplement when these levels are low and will often see significant improvement.
      Infections and overgrowth: For patients with typical IBS symptoms, I will frequently recommend a microscopic exam for parasites in stool specimens, but also more sensitive antigen tests for giardia and cryptosporidia. I don't do this just for hikers, swimmers and people who have traveled in underdeveloped countries. Intestinal parasitic infections are quite common in adults as well as children, and I often order this parasite screen on anyone who has chronic symptoms not traceable to other causes. It is common for the treatment of chronic intestinal parasites to put your bowel and the rest of you back on the road to health.

      While intestinal parasites are usually considered foreign invaders, yeast (Candida albicans) is a normal resident of the bowel. But with too many courses of antibiotics or too much sugar in the diet, yeast can overgrow in the bowel (and elsewhere) and cause a variety of digestive and bowel symptoms. Prolonged antacid therapy; prolonged nonsteroidal, anti-inflammatory drug therapy; multiple pregnancies; diabetes; chemotherapy; intestinal parasitic infections; and many other factors can tip the balance in favor of yeast. It's not recognized by the majority of conventional physicians - due largely, I believe, to a published study that was poorly designed and ended up, unfortunately, faulting this diagnosis. There is, however, a growing minority of physicians now recognizing the importance of diagnosing and treating this condition, not only for irritable-bowel patients but also for those with chronic fatigue, depression and other conditions. I often recommend a stool candida culture and a serum candida antigen titer test. Serum candida antibody tests are also available. Treatment includes a candida-control diet that minimizes sweets and yeast- and mold-containing foods; acidophilus and bifidus supplements; and anti-fungal medication. It is not uncommon for this treatment to put a halt to years of symptoms and doctor-hopping.
      Foods: Food allergy or food intolerance is another important area in determining underlying causes of IBS symptoms. Sometimes the reaction to the foods are immediate and quite clear, but more often they are delayed hours or days. Standard scratch tests are often inaccurate for food sensitivity as they are designed only for immediate sensitivity reactions. Several blood tests are available with variable consistency and accuracy in determining food sensitivity. I try to steer my patients, however, toward a much cheaper self test: An elimination diet where they avoid completely, for one to three weeks, the most repetitive and frequently used items in their diet - the ones they eat at least three to four days per week.
      On this elimination list I will frequently see cow's milk products, wheat products, oranges, peanuts, chocolate, corn, soy, tomatoes. During this elimination trial, I will have them substitute other foods of nutritional equivalence. After seeing a clearing of symptoms, they will reintroduce the foods, one at a time, to observe for both immediate and delayed reaction. In this manner, my patients are often able to clearly distinguish which foods they tolerate well and which they do not, and they are able to exercise a great degree of influence over their intestinal symptoms.
      Not every IBS patient I see has underlying food sensitivity, parasitic infections, yeast overgrowth or digestive deficiencies. But those who do will often respond significantly to appropriate treatment.
      There's one last important aspect of IBS: stress. A very common thread among IBS sufferers is the clear relationship between stress and anxiety and their gastrointestinal symptoms. Learning a skilled relaxation technique, whether meditation, self-hypnosis, progressive muscular relaxation, biofeedback, neurofeedback or other practice that balances the mind/body link, may prove as valuable as any other measure.


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