Has this ever happened to you? After months, no years, of suffering, you finally open up to your doctor, pouring out the most intimate details of your bowel movements, the gas and bloating, the pain and cramping. You finish your embarrassing confession and wait for a response. God, I know it’s cancer. Or maybe Crohn’s disease. “You most likely have irritable bowel syndrome”, he proclaims. “We’ll run some tests to rule out more serious problems”, blah, blah, blah. There is talk of celiac disease and dietary changes, but all you hear is ‘it’s all in your head’. He thinks I’m a wuss. Then why does it hurt so bad? How does he know?
(Author’s note: I chose this doctor to be male for no particular reason; the number of women gastroenterologists is rapidly approaching that of men.)
So how does your doctor know you have irritable bowel syndrome (IBS)? It has been said that 90% of making a GI diagnosis comes from the history alone (physical exam and testing- labs, xrays, endoscopy- make up the rest). The devil is in the details. Any symptom- take abdominal pain- can be caused by diseases as different as cancer, inflammatory bowel disease (IBD), peptic ulcer, food sensitivities, pancreatitis, and yes, stress. Again, details. What kind of pain are you having? What makes your pain better? What makes it worse?
Then you need to take into account other symptoms, pain does not usually occur all by its lonesome. Diarrhea, constipation, nausea, vomiting, anorexia (loss of appetite), weight loss, bloody stools. It’s often the combination of symptoms that holds the key. That and things like your age, gender, ethnicity and lifestyle. The challenge for your doctor, thus, is to sift through your specific symptoms and construct a list of the most likely causes. He (or she) then has a pretty good idea of what the problem is and can order the necessary tests (“the workup”) to figure it all out. Some docs will share this with you on the first visit, others, not so much.
There is another saying, “common things are common”. During your office visit, your doctor is thinking ‘what is the most likely cause of this person’s problem?’. Makes sense, right? Well, IBS is common, in fact, the most common GI disorder that people seek medical attention for. But IBS won’t kill you. Cancer can. I know I just said we make decisions based on probabilities, but there is also a bit of a “worst case scenario” mindset. Now, not every patient needs every test to exclude every terrible diagnosis. However, if it is reasonable to think someone could have cancer, then it is reasonable to make sure they do not. So how many tests (how big a workup) are needed? For one thing, it makes a difference if you are 20 years old or 65. Or if you’ve had symptoms for many years or they just started last month. This is where the art of medicine comes into play. Good medicine will never be a simple algorithm, where a symptom or group of symptoms leads to a test, which leads to a diagnosis and treatment. Doctors’ experiences, instincts and sometimes biases all play a significant role in what is, after all, the bottom line- making you better.
I spent some time today going over the thought process doctors go through in evaluating a patient with GI symptoms. I’m not sure if this is too much information, or not enough or if you really don’t care. Maybe your attitude is ‘just do whatever it takes, Doc’. And that’s OK. I don’t always ask my electrician why he’s doing what he’s doing. But doctors generally prefer patients who are involved in their care, who are partners in deciding the course of action. This partnership often does lead to a better outcome.
My goal in this blog is to explain common digestive disorders, starting with symptoms, then pathophysiology (“what’s actually happening in there”), next testing and finally, treatment. We’ll begin with IBS and other “functional GI disorders”. Functional diseases are those in which everything may look normal on “usual tests” such as endoscopy or xray, but the contraction, or function, of the gut is abnormal. Or sometimes the signals from the gut to the brain (sometimes referred to as the brain-gut axis) are screwed up. Or oftentimes both, resulting in pain or screwed up bowel movements. Exactly how that happens is complicated, but don’t worry, I won’t get bogged down in the nitty nitty gritty. This is going to be GI-made easier.
That’s enough for today. Hope to see you next time for IBS 101!