Pain in the gut

Published in InterAction 45, Summer 2003

We regret that our medical adviser cannot respond to individual enquiries.

Dear Doctor: Pain in the gut

Two years ago I was diagnosed with M.E. One of the main problems I have are gut symptoms such as cramping pain in my lower abdomen , alternating constipation and diarrhoea, and bloating – particularly after eating. My GP says I have Irritable Bowel Syndrome but is not sure whether this is connected to the M.E.

However, I have noticed that my gut symptoms get worse when my other M.E. symptoms increase and when I’m extra tired or stressed. I’ve also had lots of antibiotics for infections in the last year.

I’m not sure what I should do about my current diet and whether I should have any tests or request a referral to a gastro-enterologist or dietitian. I am also considering paying to see a nutritionist privately.

AfME principal medical adviser Prof. Tony Pinching responded:

There are two broad approaches to managing IBS symptoms: namely medication and dietary changes, although many patients find that reducing stress can help too.

Medications are generally used to reduce gut spasms; this may reduce bloating and the alternative diarrhoea and constipation. Mebeverine (Colofac) or alverine are the most commonly used, but buscopan seems to be better for some. If you are not using them for other reasons, low dose tricyclic drugs, such as amitriptyline or nortriptyline can help too.

Your GP should be able to guide you on treatment, but if the problems are bad or not responding to intervention, a gastro-enterologist can assess and advise further, as well as ruling out other gut conditions.

If you have a lot of gut symptoms from IBS, it may be because you have become intolerant of certain foods. The commonest problems are not tolerating high fibre diets (cereals, brown bread, etc), wheat specifically, or sometimes dairy products. A dietitian is often the best person to assess your diet and advise on changes.

If this doesn’t work, then you could avoid specific foods you suspect may be upsetting you (one at a time, each for a few weeks) to see if that makes a difference. If it doesn’t, there is no need to keep restricting the diet. However, if you do plan to cut something out of your diet long-term, get advice from a dietitian, so that you can ensure you are replacing essential nutrients, if necessary with supplements (e.g. calcium, if you are cutting out diary produce).

Rhona Wilson, state registered dietitian at Barts’ hospital in London added:

Irritable Bowel Syndrome seems to be a common problem in CFS/M.E.

A study by the Royal College of Physicians found 63% of individuals with this illness also had IBS symptoms, compared to 22% of the general population. Since the underlying cause of IBS is not fully understood, there is no standard approach to treatment. Gradually increasing dietary fibre is most likely to help if constipation is your predominant problem, but it doesn’t work for everyone. If diarrhoea and flatulence are the main problem, then increasing fibre may make your symptoms worse!

A change in the composition of bacteria in the digestive tract has been suggested as a contributory factor in IBS. Antibiotics can also change the balance of this. The use of foods containing beneficial live bacteria is currently being researched. Although their role in IBS has yet to be defined, you may find including foods like live yoghurt or fermented drinks such as Yakult and Actimel helpful. If you cannot tolerate dairy products, you can by capsules of lactobacillus from chemists and health food stores. Peppermint (tea or capsules) may also alleviate bloating and cramped pain.

There has been a lot of speculation about the role food tolerance may play in both IBS and CFS/M.E. This remains a very controversial area in need of further investigation. Food intolerance occurs when the body finds it difficult to tolerate certain foods leading to a wide variety of symptoms such as bloating, rashes, headache and diarrhoea> The variation in symptoms can often make intolerance difficult to diagnose but keeping a food diary can help you identify if there is a pattern to your symptoms.

A dietitian can assess your diet and look at strategies to help minimise your symptoms. For individual advice you can be referred to a state registered dietition via you local hospital or by your GP.

GP Dr Andy Wright worked for eight years in a gastro-enterology clinic. He responded:

Over 80% of my CFS/M.E. patients reported symptoms typical of IBS.

Treatment is based on symptom relief using anti-spasmodics such as those outlined by Tony Pinching. While laxatives and constipating agents can be bought at chemists, this can become expensive and I would advise anyone to see their GP for regular prescriptions.

Also employed in more severe, intractable cases are antidepressants with pain-relieving properties such as amitriptyline, and stress-reduction therapies such as hypnosis, counselling and bio-feedback techniques. Stress doesn’t cause irritable bowel but certainly exacerbates it, as it does with CFS/M.E!

Certain foods do seem to exacerbate symptoms but there is no one food group affecting everybody. Common offenders are wheat, dairy products, peppers and onions. Alcohol and caffeine drinks can also be a problem. Reduction or withdrawal of suspect foods should be tried in rotation of around four weeks at a time, to test each food group.

I find probiotics, or ‘friendly ‘bacteria supplements helpful, especially if the IBS follows antibiotic therapies. Other therapies include herbs such as mint, ginger and camomile and I have also seen some people’s gut symptoms respond to massage, acupuncture and homeopathy.

Conditions that may be worth excluding where symptoms indicate exclude:

• Coeliac disease, caused by allergy to gluten (present in wheat, rye, oats and barley). This is usually – but not always – associated with pale stools, weight loss and iron deficiency and is easy to test for on the NHS. I see about three people a year with CFS/M.E. and IBS symptoms who in fact have coeliac disease and recover on a gluten-free diet.
• Crohns’ disease or ulcerative colitis, both of which are associated with bloody stools and sometimes weight loss as well as gut pain
• Parasites such as Blastocystis hominis, as in my experience, these are commoner in CFS/M.E. patients than in the normal population.
• Cancer of the bowel, which can sometimes present as IBS-type symptoms. This needs to be considered if there is a change in bowel habits associated with bleeding and weight loss, especially in the over 45 age group and in anyone with family history of bowel cancer.

I feel it is important for everybody with persistent bowel symptoms (i.e. for longer than two weeks) to seek the advice of their GP who may decide to order further blood or stool tests, X-rays or endoscopic examinations of the bowel to rule out the above.

InterAction commentator Dr Kelly Morris concluded:

Symptoms like constipation, diarrhoea, pain, and bloating usually arise from the large bowel (colon). Essential to normal colon function are the billions of bacteria that inhabit the large bowel. Activity of these friendly bugs is disrupted in people with irritable bowel syndrome. However nothing seems to disrupt the number and type of the normal gut flora like antibiotic courses, leading to what is popularly known as gut dysbiosis.

The right amount of water and fibre, plus avoidance of alcohol, caffeine, extra sugars and refined carbohydrates seem important to maintain healthy functioning of the fermentation tank formed by colon and bugs. Bowel movement (motility) also affects and is affected by bowel-bug function so I would advise caution with drugs like anti-spasmodics that alter motility, since rebound effects are common. I have personally found acunpuncture a useful alternative for such symptoms.

Although probiotics seem a theoretically attractive solution to reintroduce healthy bugs, studies so far in people with IBS have produced conflicting results perhaps due to differences among probiotics used, which need to survive stomach acid and bile secretions before they reach the colon. Probiotics seem most useful for the prevention and treatment of antibiotic-associated gut symptoms, and thus might be appropriately taken as courses before and during antibiotic treatment.