How do you spell relief for irritable bowel syndrome?
Many treatment options lack strong evidence for their efficacy. Others have proven efficacy, but restricted use.
Exercise or dietary therapies have no proven benefit in otherwise healthy IBS patients (SOR: C).1
Set realistic goals, address patient fears
When caring for a patient with IBS, it’s important to set and discuss realistic goals. Be sure to address patient concerns, as well. IBS patients are frequently frustrated by a lack of diagnostic findings and may worry about being labeled as having a psychological disorder rather than having a true GI abnormality. This concern, especially if the patient feels that the physician is not adequately addressing her (or his) symptoms, may exacerbate the already troublesome IBS symptoms.
Assure your patient that comorbid psychological conditions do not cause symptoms, but can contribute to pain and bowel dysfunction. Consider the possibility of behavioral therapy, if indicated by patient history.
Advise the patient that the initial approach you are taking to alleviate her (or his) symptoms may provide significant improvement. Manage expectations appropriately and be open to discussion about what the patient may need to alleviate both physiologic and psychologic stressors that perpetuate symptoms. Family practitioners, not specialists, are ideally suited to address the patients’ needs and expectations as they are the ones who know the patients’ histories, personalities, and families best.1 Tell the patient that rather than hoping for a cure, the goal for the both the physician and patient should be to achieve symptom relief.
Mary Jane finally gets some relief
After speaking with Mary Jane and doing a thorough exam, you reassure her that her symptoms meet the criteria for the diagnosis of IBS, and that research indicates that she can safely be treated for the disorder.
You tell your patient that you’d like to begin treatment by putting her on loperamide—2 capsules at onset of diarrhea and 1 capsule after each diarrheal episode to a maximum of 8 capsules a day and a low-dose amitriptyline (25 mg at bed-time). You explain that the tricyclic should provide her with some relief by modifying the way the nervous system of the intestine communicates with the brain.
Two months later, during a follow-up visit, Mary Jane tells you that the medications are providing her with relief, but when she feels particularly stressed at home, she notices that her symptoms flare up. You and she discuss the benefits of cognitive behavioral therapy, and you provide her with the names of some therapists in the area. You suggest that she consult her health plan and make some phone calls to identify a provider that she feels comfortable with.
You advise her to schedule another follow-up visit in 3 months so that you can see how the therapy is working. You also tell her to call any time she experiences significant pain or any symptoms that are persistent or worrisome to her.
Correspondence
Neil T. Moynihan, MD, Johnson Memorial Hospital, 201 Chestnut Hill Road, Stafford Springs, CT 06076; nmoynihan@earthlink.net
