This is the general term used to embrace two syndromes:
1 Non-ulcer dyspepsia
2 The irritable bowel syndrome
These conditions are extremely common worldwide, making up to 60-80% of patients seen in a gastroenterology clinic. The two conditions overlap, with some symptoms being common to both. gives some gastrointestinal symptoms that are suggestive of psychosomatic disorders.
This consists of a heterogeneous group of patients whose symptoms are mainly stress-related. Patients complain of indigestion, wind, nausea, early satiety, heartburn, i.e. dyspepsia, when no ulcer is found. It can be difficult on the history to differentiate it from the symptoms of peptic ulceration, but typically patients with ulcers have nocturnal pain and also respond to antacids. Barium studies or endoscopy are often performed to exclude ulceration, but are best avoided in patients under 35 years, as no abnormality is found in the majority (80%). Chronic active gastritis due to H. pylori is found more frequently than in asymptomatic controls, but the relationship of this finding with symptoms is unclear.
Treatment is by reassurance. Antacids and Hz-receptor antagonists are probably of little benefit apart from the placebo effect. Cisapride 10 mg three times daily and metoclopramide 10 mg three times daily sometimes help particularly in the patients with fullness and early satiety, some of whom have been shown to have slow gastric emptying. The irritable bowel syndrome.
The pain is classically situated in the left iliac fossa and is usually relieved by defecation or the passage of wind. The patient may complain of constipation or diarrhoea with the passage of frequent small-volume stools and a feeling of incomplete emptying of the rectum. Stools may be ribbon-like or rabbity in appearance. True watery diarrhoea suggests organic disease. The pain, however, can be very variable and occur in any part of the abdomen and the bowel habit may be normal.
Abdominal distension and bloating are extremely common and if present strongly suggest the diagnosis of the irritable bowel. Women are more frequently affected than men, and often the symptoms occur at the time of the period. The length of history is usually long with frequent recurrent episodes and long symptom-free intervals. The patient may give a history of recurrent episodes of abdominal pain as a child and there is an increase of childhood or sexual abuse in some series. Mild episodes of pain occur frequently (approximately 40%) in the normal population and are often disregarded. The reason why some patients attend doctors is unclear, but it is sometimes related to other social factors. The patient with the irritable bowel syndrome looks well despite frequent episodes of pain, some of which can be very a cute and require hospital admission to rule out an acute abdominal condition.
Motility abnormalities have been found in the irritable bowel syndrome, but these abnormal findings have not been consistent and do not always correlate with episodes of pain.
Psychological factors are important and most patients find the symptoms are exacerbated by stress. Some patients are depressed, and this fact may be missed unless carefully looked for.
Examination reveals no abnormality. Rectal examination and sigmoidoscopy should be performed. Although sigmoidoscopy shows a normal mucosa, air insufflation may reproduce the pain. If diarrhoea is a feature, a rectal biopsy should be performed, even if the mucosa looks normal, to help rule out inflammatory bowel disease.
The amount of investigation varies in individual patients. A young girl with pain in the left iliac fossa exacerbated by stress will require no investigation. Conversely, an elderly person who has developed pain or diarrhoea for the first time must be investigated, with a full radiological assessment, before the diagnosis of functional bowel disease is made.
In many patients symptoms are not severe and are clearly stress-related. These patients often require nothing but a discussion of their life-style and reassurance. Over-investigation (Information box 4.6) and drug therapy should be avoided.
• Patients must be reassured of the benign nature of the condition. Cancer phobia must be dispelled. Patients are encouraged to learn to cope with their symptoms, as they tend to be recurrent.
• A high-fibre diet or even a change in diet help some patients.
• Antispasmodics, e.g. mebeverine, are given.
• A small group of patients who are often hospital attenders have severe symptoms and treatment here is difficult. Many are depressed and improve with antidepressant therapy. Other therapies, i.e. biofeedback and hypnotherapy, have been tried.