What goes wrong in people with irritable bowels and what can be done about it? Gastrointestinal specialist Heiko De Schepper is happy to dispel misunderstandings and fake news about IBS.
She has long forgotten what it feels like to simply enjoy a meal. Her insides feel black and blue, as if someone had taken them out of her stomach, tied them in a few knots, and put them back in place backwards. She suffers from terrible stomach aches almost daily. During these attacks she has to rush to the toilet one moment and is terribly constipated the next. The constant up and down waves of these complaints are extremely exhausting. Normal social functioning has been absent for some time now. Performing her work is becoming increasingly difficult due to lack of energy. In addition, any form of emotional turmoil leads to an increase in abdominal cramps and toilet visits. Her friends and family, so understanding when the misery started, are gradually dropping out and do not understand why the cause of her complaints has not yet been found.
The story of Annick from the clear, accessible book Irritable bowels by UZA gastrointestinal specialist Heiko De Schepper gives people with irritable bowel syndrome (IBS) a face. That is not an insignificant group, because about one in ten people and twice as many women as men suffer from it. After a blood, stool and, if necessary, intestinal test, they are told that all tests are ‘negative’, so normal. They have no food allergies and there is nothing wrong with their intestines from an organic point of view. There are no ulcers, strictures, polyps or tumors to explain their intestinal complaints.
Too many incentives
“And yet their complaints are not imagined”, emphasizes Professor De Schepper. “Compare it with a computer: there is nothing wrong with the hardware, but with the software. And by software we mean the gut-brain communication. Too many stimuli are sent from the intestines to the brain, the stimuli are overestimated by the brain, the brain or nerves misdirect the intestinal function. Many software errors are possible that can make the intestines highly sensitive. As a result, people with IBS are constantly aware of what is happening in their intestines and they also feel the urge to go to the toilet more often. They experience intestinal stimuli that are painful for everyone, such as with an intestinal infection, twice as intensely. And intestinal stimuli that are not normally felt, such as when digesting food, can already cause them discomfort to downright pain.”
Many software errors are possible that can make the intestines highly sensitive.
Especially with food for which we as humans are not optimally equipped to digest it in large quantities, people with IBS have a more difficult time. Spicy or very fatty food, for example, but also large amounts of caffeine, alcohol and fizzy drinks cause many a gut to go red. But also for the lactose in dairy products and other carbohydrates in grain products, vegetables, fruit and sweeteners, some of us have a somewhat more limited digestive capacity. Undigested carbohydrates retain moisture and are fermented upon arrival in the large intestine by the bacteria that thrive there. This releases gases that, together with the moisture, put pressure on the intestinal wall.
“You don’t feel that, unless you have highly sensitive intestines,” says De Schepper. “Because then that pressure is more easily translated into abdominal cramps, diarrhea and a swollen abdomen. Contrary to popular belief, people with IBS are not allergic for fermentable carbohydrates, they just tolerate them less well. Food allergies do exist, of course, but they are less common and mainly cause the typical allergic complaints such as itching, watery eyes, difficult breathing and red spots. Intestinal complaints are often secondary to a real food allergy.”
First a diet
But one irritable bowel is not the other. Finding out exactly which foods give you the most complaints can be done by determining your IgG food antibodies, some laboratories claim on their websites for the general public. “But that type of antibody simply reflects your diet,” warns De Schepper. “For example, if you often eat a lot of apples, you will have a high level of IgG antibodies against apples in your blood, without any evidence that apples are also responsible for your complaints! Rather opt for the sound, scientifically substantiated low-FODMAP diet under the guidance of a specialized dietician.”
Veerle Huysmans, dietitian and lecturer in nutrition and dietetics at Thomas More University of Applied Sciences, explains how this works: “Fermentable carbohydrates, or FODMAPs in technical jargon, are present in foods based on wheat, rye and barley, in some types of fruit. , vegetables and nuts, in legumes, dairy products and some sweeteners. For the first six weeks, all FODMAPs are eliminated from your diet. If your complaints then decrease, the different FODMAPs are gradually reintroduced. This way you can find out exactly which FODMAPs you react to and what amount you can still tolerate. There are also apps that you can use yourself, such as the Fodmapp. Dieticians at UZ Leuven also developed an app with a simplified version of the low-FODMAP diet. The app was tested in the ‘Domino study’ and turned out to score slightly better than medication in people with a not too serious form.”
Regular walking or a mild fitness regimen can make a big difference.
An accessible tool such as an app has the advantage that you can reach more people, Huys believes, but on the other hand it can lead to unnecessary restrictions in eating patterns. “It is not that easy to find out for yourself which foods you are sensitive to. For many people, a personal approach by a specialized dietitian offers the best guarantee of a varied and healthy diet with as few complaints as possible.”
Know your fiber
People with IBS therefore face the challenge of finding out which fermentable carbohydrates give them the most complaints, so that they can limit their intake somewhat. But at the same time it is important that they continue to eat enough fiber, even though dietary fiber also consists of carbohydrates that cause gas formation during fermentation.
“Dietary fibers can thicken stools that are too soft and soften stools that are too hard, if you drink enough with it,” explains De Schepper. “Above all, try to take in a lot of the most efficient fibers. That are the soluble fibers, such as in linseed, oats, barley, legumes and citrus fruits, apples and cooked vegetables. They are also available as a supplement. And if the fiber therapy does not help enough, there are antidiarrheal and laxatives that can help with derailed bowel movements. Another lifestyle measure to achieve a more regular bowel movement is to move a lot. You don’t have to run a marathon for that. Regular walking or a mild fitness regimen can make a big difference. A lot of exercise also helps to reduce feelings of stress.”
Antidepressants, why?!
Stress can not only exacerbate the symptoms of IBS, but is also an important risk factor for the onset of the disease. “And by stress we don’t just mean stress at work or in your relationship, for example, but also the psychological disorders that are placed in the stress group, such as depression and anxiety problems,” says De Schepper. “Chronic stress leads to a number of biological changes with a possible impact on the function of the gastrointestinal system. Which is not to say that you can get IBS from chronic stress alone. IBS is not a pure stress disorder. You can also get IBS while you go through life very relaxed. What is certain is that stress can contribute significantly to the onset of the disease and – once you have the disease – to the aggravation of the complaints. So don’t hesitate to take the step to psychotherapy if you find it difficult to control your stress or if your IBS complaints dominate your daily life.”
IBS is not a pure stress disorder. You can also get IBS while you go through life very relaxed.
Especially the almost daily abdominal cramps can be very disabling. “To relieve the pain, people with IBS are often prescribed long-term classic painkillers, and unfortunately even morphine derivatives,” notes De Schepper. “But they do no good to intestines that are already struggling. In addition, intestinal pain is a different kind of pain than the pain we know when we stub a toe, for example. It’s visceral pain, which calls for other kinds of painkillers. Irritable bowels are not spastic bowels, as the old disease name ‘spastic colon’ suggests, but spasmolytics can help relieve the pain. And with insufficient lighting, we also prescribe antidepressants.
‘So the pain with IBS is still between the ears’, people sometimes respond. But the pain of IBS patients is indeed physical pain. And although antidepressants are drugs that have been developed primarily for depression – hence the name antidepressants – they also have a specific analgesic effect. They can reduce the hypersensitivity of the nerve pathways that transmit pain signals to the brain.”
Mass murder
The exact cause of IBS is still being researched. For the time being, only a few factors are known that make it easier to develop the disease, such as chronic stress, but also intestinal infections and antibiotics. Research shows that you are four times more likely to develop IBS after an intestinal infection. Whether an infection with the coronavirus can also increase that risk is still being investigated. “We suspect so, because we know that the coronavirus can also bind to cells in the intestines and thus cause intestinal complaints,” says De Schepper.
We know that the coronavirus can also bind to cells in the intestines and thus cause intestinal complaints.
But not only germs, also medicines that fight germs can trigger IBS. “When passing through our intestines, antibiotics cause a veritable mass murder among the bacteria and other micro-organisms that flourish there,” explains De Schepper. “If the gut microbiome doesn’t fully recover from that, it can no longer fully support gut-brain communication. You then get IBS more easily or more serious complaints if you already have the disease.”
No burden of proof
In recent years, many ‘probiotics’ have appeared on the market as food supplements or yogurt drinks that are said to have a beneficial effect on the gut microbiome, especially for people with IBS. “But the burden of proof is not very strong,” says De Schepper. “You can try them out safely, but if they don’t reduce your IBS symptoms, you might as well stop. Some laboratories even promote to the general public a ‘complete analysis of your personal gut microbiome’ in order to sell you the ‘appropriate’ supplements ‘against further harm’. While science to this day cannot yet say which composition of the intestinal microbiome is exactly normal! This is still being researched, among other things with a view to possible stool transplants for people with very serious IBS complaints.”
“Finally, don’t be fooled by pseudomedical companies that claim that IBS complaints can be attributed to a so-called leaky gut, a ‘leaky gut’. Or to an occupation of the small intestine by bacteria from the large intestine, referred to as SIBO, the abbreviation for Small Intestinal Bacterial Overgrowth. These two phenomena do exist, but an association with IBS could not be demonstrated in proper scientific studies. The supplements that leaky gut– and promote SIBO believers have no predictable beneficial effect for irritable bowels. So unfortunately there is a lot of fake news circulating about IBS and its treatment.”
Irritable bowels. Everything you need to know about irritable bowel syndrome, Heiko De Schepper, Pelckmans, 2021.
ibsbelgium.org