Irritable
bowel syndrome (IBS) is a complex gastrointestinal disorder related to over
activity of nerves supplying the gut.1
It has been matter of enormous concern for both the patients and treating
physicians’. The clinical course is diverse and takes different twist and
turns. Sometimes it does present with typical symptoms like bloating,
flatulence and altered bowel habits. At times there is mental illness like
severe depression that comes in the way which is real challenge for the physicians
to treat as mere reassurance doesn’t suffice. The longer the history of
symptoms, more complicated it gets. There are multiple obstacles before making
in rows in treatment.2
The
most frustrating point is when the patient fails to show any improvement after
months of treatment. They have symptoms in relapsing and remitting manner. Post
infectious IBS is more agonizing as the patient need antibiotics in an era of
increasing resistance.3
Failure of one antibiotic to resolve symptoms leads to usage of multiple ones
at the same time. The cramping abdominal pain and the sleepless nights leading
to daytime fatigue do have an enormous and disastrous impact on the activities
of daily living. After the decades of research, optimization of treatment for
irritable bowel syndrome is still a daunting task even for experienced
gastroenterologists.4
The
emergence of alarm symptoms like bleeding per rectum, unintentional weight loss
and feeling of abdominal mass in individuals who have altered bowel for years
do ring the bell for physicians to act vigilantly who were otherwise
complacent.4
They were relying on traditional treatment regimens like giving laxatives,
anti-spasmodic and medications for depression. Some of them do consider
expeditious referral to psychiatrist without getting to the bottom of the
situation. Colonoscopy is advised at the end when much damaged have been caused
already. It will be excellent practice to advised stool routine examination,
culture, ESR, CRP and calprotectin levels.5
They will give an idea of level of inflammation in the gut as invasive
investigations are always dangerous in setting of acute flare of disease such
as inflammatory bowel disease leading to perforations. Many clinicians do mix
up irritable bowel syndrome with inflammatory bowel diseases such as Crohn's disease
and Ulcerative Colitis. Remember the bitter reality that IBS is a diagnosis of
exclusion that needs sound clinical judgement.
In
the 21st century, medicine has revolutionized. There has been great
advancement in treatment of IBS. There is concept of more multidisciplinary
approach involving gastroenterologist, dietician and psychologists.6 The high co-morbidity of psychological
disorders in gastrointestinal disorders suggests a close and complex connection
between the brain and the gut. It will be advisable to have a coordinated
approach for its treatment as failure to respond is a misery for the patient
and practicing physician both. There is no harm in considering cognitive
behavioural therapy (CBT), interpersonal therapy and FODMAP (Fermentable Oligosaccharides, Disaccharides,
Monosaccharides and Polyols) diet if traditional long used regimens have failed.7 The drawback of CBT is that it is time- and
effort-consuming for therapists, and there is limited availability of competent
therapists as well.
The road to IBS treatment has been and will
always be complex. It’s so easy to be driven away by simple symptoms and
missing sinister signs. It so inevitable to keep a threshold for dangerous
disease such as colorectal cancer and do refer a patient to gastroenterologist
when the clinical suspicion is high. The prompt diagnosis of patient is an art
which comes with experience and timely referral of patient is wisdom which we
need to have for safe and better clinical practice.8
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CONFLICT OF INTEREST
Authors
declared no conflict of interest
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 This
is an Open Access article distributed under the terms of the Creative Commons
Attribution-Non-Commercial 2.0 Generic License.
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https://doi.org/10.35845/kmuj.2023.23285 LETTER
TO THE EDITOR
, Ayesha
Qaisar 2, Azhar Zahir Shah 3