Digestive health: Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD) – different conditions along the same spectrum
Irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) are two different diseases affecting the digestive tract. Through my specialization of treating digestive system disorders and through the observation of patients with IBS and IBD, I have noticed clear differences (which is expected), but also certain similarities in both symptoms and their causes.
For example, someone with a clear diagnosis of IBD as either ulcerative colitis (UC) and Crohn’s disease (CD), can also exhibit IBS symptoms (such as gas, bloating or constipation). Patients with IBD are often left with unresolved symptoms despite being in remission of their primary disease (i.e. IBD). At times, finding solutions to IBD symptoms can be found within the context of our IBS understanding. Dr. Gary Weiner, ND who practices in Portland, Oregon (USA) recently wrote an excellent article entitled “The IBS within the IBD” describing such findings (NDNR, January 2016). My goal is to provide a summary of this article and include clinical findings that I have observed in my naturopathic medical practice.
Here’s a list of findings that are either unique to IBS or IBD, or have SHARED characteristics:
- A functional disease with no detectable structural abnormalities or pathology (e.g. scar tissue formation such as strictures found in CD, or destruction for the lining of the gut). However, functional doesn’t mean that there are no problems or causes. – IBS
- Severe intestinal inflammation of the mucosal lining (superficial lining of the digestive tract) and/or transmural lining (deeper layers of digestive tract). – IBD
- Mild mucosal intestinal inflammation. – frequent in IBS
- Etiology (causes) are many and therefore a careful assessment of the patients is paramount – SHARED
- Pathophysiologic mechanisms (i.e. where things can go wrong): – SHARED
- interaction between microbiotia (gut bacteria or other gut microbes) and immune cells located in the mucosal layers of the digestive system;
- heightened mucosal immune system activity causing varying degrees of inflammation;
- altered mucosal permeability (aka “leaky” gut);
- disrupted microbiota (i.e. lack of good bacteria or presence of bad microbes, aka dysbiosis);
- a dysregulated enteric nervous system (i.e. nerve cells/tissues found within the gut lining fail to send appropriate directions that normally coordinates gut function);
- dysregulated gut-brain communication (info between the gut and the brain becomes dysfunctional);
- alterations in gut motility (the way that stool moves down the tract is disruption); and
- the role of stress as a trigger of symptoms.
- Digestive symptoms may be present for years prior to diagnosis. – SHARED
- IBD patients often have a history of IBS symptoms, at times occurring for years prior to diagnosis of IBD. This suggests that certain IBD cases may actually start out as IBS.
- When IBD patients are in complete remission (as noted by endoscopy/colonoscopy, and by lab values which monitors inflammation), such patients may still present with IBS-like symptoms such as constipation and bloating.
- Small intestinal bowel overgrowth (SIBO) is an important cause of IBS in some patients, and has now been shown to occur in IBD patients as well. Research studies so far show that SIBO does not cause CD or UC, but rather that SIBO represents a frequently ignored yet clinically relevant complication of IBD. – SHARED
- IBS and IBD patients diagnosed with SIBO and who follow treatments to eradicate SIBO often show improvements in symptoms. – SHARED
- SIBO when found in IBD, can even affect the progression of the IBD itself.
- Pain and discomfort can present as abdominal cramping, aching, or bloating. – SHARED
- Severe abdominal distention (bloating) is more associated with IBS and is a hallmark symptom of SIBO.
- Although more commonly seen in IBS, constipation can also occur in IBD. If constipation is seen in IBD, it may be connected to SIBO (especially methane producing bacteria) and therefore should be verified via laboratory assessment. Diagnostic testing for SIBO (via breath test) is available at the Moncton Naturopathic Medical Clinic.
- Bowel urgency, increased bowel movement frequency or constipation, ineffectual stools (urgency, but no stool comes out), or mucus. – SHARED
- Mucus is usually more abundant in IBD.
- Acute episodes that include intense pain, severe urgency and increased frequency of bowel movements (patients may have as many as 10-20 bowel movements in a day). – IBD
- Bowel movements occurring at night usually associated with pain and urgency. – IBD
- Blood mixed with stool or free-flowing bleeding. – IBD
- Typically bleeding should not occur in IBS unless there are active hemorrhoids. There are certain exceptions however. Infants with severe casein (milk protein) allergies can have intestinal bleeding (once casein is eliminated, the bleeding stops). Beyond infancy, I have observed a few exceptions to this ‘rule’: for example, bleeding in the stool of one IBS patient was attributed to the significant amounts of daily milk consumption. Using a specialized blood test conducted at the Moncton Naturopathic Medical Clinic, a severe IgG food sensitivity to casein was diagnosed. The bleeding was rectified by removing all dairy products and by healing the lining of the gut. This patient was also referred to a gastroenterologist who confirmed via colonoscopy that it was indeed IBS (and not IBD or colorectal cancer).
- Symptoms manifesting outside the intestinal tract (but related to the inflammation within the digestive system itself): joint paint or arthritis, mouth ulcers, skin rashes, rectal lesions, liver/gallbladder disease. These are often exacerbated during flare-ups. – IBD
- Symptoms manifesting outside the intestinal tract (but often related to the inflammation within the digestive system itself): joint paint or arthritis, dermatitis (e.g. eczema), urinary dysfunction (e.g. interstitial cystitis), environmental allergies, chronic respiratory infections (e.g. repeated ear, sinus, throat or lung infections). – IBS
- Linked with a higher incidence of other health conditions (i.e. comorbidities), such as chronic headaches, fibromyalgia, chronic fatigue syndrome, chronic back pain, chronic pelvic pain, temporomandibular joint (TMJ) dysfunction, and insomnia. – IBS
- Growth delays in children. – IBD (CD)
- Nutritional deficiencies due to gut malabsorption. – SHARED. Especially common and more severe in IBD were multiple vitamin (e.g. vitamin D, B12, folate, etc…) and mineral deficiencies (e.g. iron, magnesium, zinc, etc.) are seen. Note: I have seen many IBS patients with iron and/or B12 deficiencies that cannot be explained from causes outside the intestinal tract (e.g. little or no meat intake, etc.); therefore, gut malabsorption appears to be also common in IBS.
- Fever, weight loss and failure to thrive – IBD (during acute episodes)
- Weight loss occurring over a longer time span can occur in IBS if an overly restricted diet is required to reduce symptoms.
- Bowel strictures (scar tissue causing a narrowing of the intestinal opening), fistulas, abscesses, bowel obstructions and bowel perforations. – IBD
So what can we learn from these observations?
- There is significant overlap between IBS and IBD, despite being two separate diseases. IBS and IBD are two conditions affecting the intestines along the same spectrum. IBS being a more functional problem, but also incorporating some of the immune dysfunction and inflammation that is seen in a much more aggressive way in IBD.
- For anyone with digestive symptoms, a complete review is important to obtain a proper diagnosis. It is important that your family Medical Doctor or Naturopathic Doctor (ND) spend sufficient time with you in order to conduct appropriate physical examinations, review of symptoms and determine if advanced diagnostic testing is required. Referral to a gastroenterologist may be recommended as well.
- A patient with either IBS and IBD can have debilitating symptoms that affect their quality of life.
- IBS is not just a diagnostic made out of the exclusion of other diseases. Patients diagnosed with IBS have often told me that they were recommended to “eat more fiber” and to “learn to live with your symptoms”. Rather, I would recommend a more comprehensive approach. As a ND, I specialize in treating IBS and therefore have excellent success in healing patients.
- Because IBS is related to other health implications or can manifest into a more serious condition, IBS should be taken seriously and treated more promptly and effectively.
- When treating someone with IBD (either Crohn’s or ulcerative colitis) it is important to determine whether symptoms are related to the disease itself or whether IBS symptoms are occurring at the same time. This is especially important for IBD patient’s who are in remission (as confirmed by their gastroenterologist), but continue to have symptoms (that are better described by IBS).
- Because of the severity of IBD and to its heightened inflammatory episodes (often resulting by the underlying autoimmune process), a combined approach using both conventional medicine (as recommended by your gastroenterologist) and naturopathic medicine (as recommended by your ND) is required.
- Bottom line: if you have unresolved digestive symptoms, seek help, because treatment options exist.
Published by Dr. Gleixner on March 13th 2016.
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