I am a psychotherapist and just recently received a referral for a 68 woman diagnosed with Irritable Bowel Syndrome. In the initial assessment, it was clear that she does not have a mood or anxiety disorder per se, but this disorder has crippled her life. She apparently has had this for many years, but states it has gotten much worse since her gallbladder was removed in 1989. Her father had the exact same symptoms throughout the course of his life.....so there is clearly the genetic component.
Her symptoms are not typical in some ways.....her primary symptom is extreme urgency, and this always follows eating anything. If she does not eat, she tends not to have the problem. She describes the urgency as so severe however, that she is now apprehensive about going anywhere outside her home or home of a family member. Generally, if she delays leaving until an hour or two after eating, she is fine. She does control her diet and avoids spicy foods.
Given that the problem tends to occur primarily after eating, does this suggest some type of spasm? And is this consistent with IBS? She is being followed by a gastroenterologist and is currently on Quarzan and Valium (up to 5 mg per day), but I wondered if there are any other options available. She has not had weight loss, and apparently examination of the colon reveals nothing. In addition, she is on Allopurinal for gout as well as a hyptertensive medication, as well as Premarin. Obviously I wondered if any of these medications can exacerbate the problem.....
Any insight or suggestions you can provide are much appreciated!
REPLY:--------
The diagnosis of Irritable Bowel Syndrome in individuals over age 40 is worrisome unless the individual has had symptoms for many years (as appears to be the case with your patient). This is because so many other (more serious) possibilities can produce similar symptoms. Even in persons with what is felt to be an established diagnosis of IBS investigations looking for other conditions may be appropriate as the patient ages so as not to pin a diagnosis to someone and overlook the possibility that another condition may have newly developed. In this regard your report that a colonoscopy is recently negative is reassuring.
Many individuals have an active gastro-colic reflex with the urge to defecate stimulated by ingesting a meal. Some people report this and similar symptoms worse after gallbladder surgery. Your patient is already taking both a sedative and an antispas- modic drug. This type of treatment is often of benefit with such symptoms.
In older individuals we always worry about an unusual presentation of a hidden malignancy. This would seem to be unlikely if indeed your patient has been fully evaluated, has a stable weight, non- progressive symptoms, etc. None of the medications you mention is an obvious source for these symptoms and this is especially true is these drugs have been taken without change for many years.
I think you might do well to contact your patient's gastroenter- ologist (with her consent, of course) and discuss the degree to which these symptoms are interfering with this person's life activities. Perhaps this will prompt further evaluation, changes in treatment, suggestions for dietary changes, etc.
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Bruce Sckolnick, M.D.
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