The GP Collective, part of The Prince’s Foundation for Integrated Health’s Integrated Health Associates (IHA), held its fourth meeting at the King’s Fund on 27 September 2007.
This document summarises the key issues and discussions that emerged from the meeting. It is not necessarily an expression of the views of The Prince's Foundation for Integrated Health.
Introduction:
There was a general consensus that IBS diagnosis is a ‘dumping ground’ for complex, chronic, multi-system disorders - defined by the effects, not the causes. Patients presenting with IBS will frequently suffer from a number of other functional disorders such as chronic fatigue syndrome and irritable bladder.
Generally GPs find it difficult to do anything for these patients, due to time and budget restraints. We need to look at it from every angle – and the holistic approach has a fairly good success rate.
IBS as a multi-causal condition:
The bowel is a complex organ with numerous functions. IBS is therefore a mixed bag, and can be triggered and worsened by a combination of functional, emotional and parasite disorders.
1. Parasites:
o There are two common parasites that contribute to IBS, but are rarely found in stool tests administered in the UK – one of the doctors said that they send samples to America, as this tends to yield better results; and others sent to The Tropical Medicine Hospital to test for these.
o Paramomycin - used aggressively over 10 days can have 75% success in getting rid of parasites.
o However, you can get rid of the parasites and not see an improvement. Treating for parasites generally gives a 50% remission – adding treatments for other bacteria and yeast will bring this up to a 90% remission.
o The Parascope laboratory (UK based) is good for picking up Blastocytes in stool tests.
o It’s important to remember that any anti-microbial will kill essential gut flora too, and should therefore be used with caution.
2. Diet:
o You cannot treat IBS without a change to diet.
o However, determining the correct dietary changes can be very difficult and the mainstream response of implementing a high-fibre diet is not a fix all solution.
o From the nutritionist’s perspective, IBS is seen as being a sensitivity to certain foods, most commonly wheat and dairy.
Why do other cultures not get IBS when, like us, they have their staple foods that they eat all the time?
o Lots of countries with a wheat staple do not seem to suffer.
o IBS is a westernised condition. Reasons:
Additives
Cocktail of toxins in everyday life
Antibiotics – change the ecology of the bowel
Importing food from abroad – should eat local and seasonal food. Nature is smart, and we should therefore eat what is available to us.
Triggered by emotional stresses
3. Emotions:
o You cannot untangle emotions and physicality, they are intrinsically linked. IBS does not have one cause, and needs approaching from many different angles; it is heavily linked to the emotions.
o It is not just diagnostic criteria that are important, but also the degree to which the condition affects people's lives. If people were surveyed in a busy street random, you would typically find that 25% have some symptoms of IBS and most will not have sought medical help.
o People only come to medics when it has become a problem for them in their everyday life.
o In any case, there will always be a psychological impact, even if it starts as a functional problem such as gastroenteritis; and the condition itself can create a state of stress due to the effect upon the patient’s quality of life.
4. Environmental factors
In providing these interventions aren't we just helping people to maintain dysfunctional lives in London? If they are living for example in Cornwall, would they be responding so dramatically to their body’s ills?
o The urban lifestyle contributes to this chronic condition. There is a huge difference between the health of people who live in inner cities and those in the country and suburbs. Multiple psychosomatic complaints often arise from urban lifestyles, and functional bowel disorders are therefore very common in inner city areas.
o A case is given: Patient with diabetes, anxiety, claustrophobia. Gut improved 60% after treatment and his quality of life dramatically. He previously had anxiety scores of 19/21 - which were reduced down to 10 with hypnotherapy. Reviewed recently, and he'd maintained this improvement. He was a poet from Cornwall, who'd lived on a farm and was now in a London bedsit. It was clear that for further improvement he would need to go back to the countryside.
5. Other triggers
o Post Traumatic Stress Disorder (PTSD)
o Lack of confidence
o Over-responsibility for others
o Stress
o Colonoscopy
o Antibiotics
o Hysterectomy
Approaches to the treatment/ management of IBS:
General Practice:
o The group thought that IBS is generally not considered to be a multi-factorial condition in orthodox medicine.
o One GP said that if results aren’t gleaned from a stool test, then most will not believe that there is a problem.
o Therefore, IBS is still not recognised as being a "real problem" - it doesn't shorten lives; and the patient’s quality of life is not an issue.
o GPs tend not to refer on to gastroenterologists, as this can be an invasive and unpleasant experience for patients, and often does not help really them.
o IBS cases take time - "fat file syndrome" – as patients keep coming back and rarely just one issue involved. It is difficult to strike a balance between helping them and over-investigating them.
Private Practice:
o One private doctor in the group commented that there is an increasing trend for people, especially those with long-term chronic conditions such as IBS, who would not normally go private to consult a private doctor in an effort to improve their health.
o The doctor discussed the approach to IBS taken in their practice, which sees an 80% success rate in the reduction of symptoms. The interventions taken included:
o Nutritional advice – all patients see a nutritionist
o Stool testing
o Intolerance testing
o Probiotics
o Hypnotherapy
o Each patient has their own care pathway which is worked out with them; work against them, and you won't get anywhere.
Homeopathy:
o 67% of IBS patients at the London Homeopathic get better with homeopathy alone.
o What's important is the counselling that goes along with homeopathy - it's an integral part of the process.
Probiotics:
o Probiotics have moved from fringe to mainstream in research terms - even if that hasn't yet spilled over into clinical practice.
Hypnotherapy:
o Hypnotherapy can be effective in the management of IBS; women tend to respond better to this intervention than men.
o Even people with low anxiety/depression scores can respond well to hypnosis as a treatment for IBS
Diet and nutrition:
o The group felt that nutritionists are gold dust in the treatment of IBS. The advice needs to be individualised and tailored to each patient and their specific symptoms. However, the quality of nutritionists differs greatly as the profession is not yet regulated.
o From a nutritionist’s perspective, IBS is seen as being a sensitivity to certain foods.
o Possible dietary interventions include:
o Rotational diet, where the patient does not eat any of the same foods for 4 days in a row. This isn't a cure, but a useful tool for management of symptoms.
o Exclusion diets, where trigger foods are completely avoided.
o Intolerance testing, to identify problem foods.
o Stool testing
o Probiotics
o Dietary supplements
o Improvement to general diet and nutritional intake
o Herbal remedies
o Eating local foods within the season