notes by dr Claudio Italiano
Irritable bowel syndrome (SCI) is characterized by pain, alvee disorders (diarrhea or flatulence constipation, but no lesions, at least obvious of the colonic mucosa, have been demonstrated, although in recent times the inflammatory theory of the mucosa of the bowel. In particular, we refer to a recent study: "mucosal immune activation in Irritable Bowel Syndrome. This study has been shown that at the base of irritable bowel syndrome is an activation of the immune system, with an increase in the mucosa of immunocompetent cells that infiltrate the organ wall of the colon and which are represented by mast cells.
So there an extreme confusion about the treatment of the syndrome.
It's therefore necessary to
immediately clarify the purpose of clarifying if :
• Other pathologies exist at the base of the symptoms
• Establish a score that allows to evaluate the syndrome
The diagnosis is still by exclusion, ie it is based on the exclusion of pathologies and sometimes requires the execution of a colonoscopy or a double-contrast opaque enema, unless the doctor is certain of the pathology, otherwise it will resort precisely to the investigations.
The 3 most striking symptoms to talk about SCI are:
• Meteorism Diarrhea or constipation Pain in the lower limbs
In general, care is directed towards the treatment of the factors that determine
it:
Constitutional Psychological Inflammatory Dietetics
a) Abstention from milk and derivatives because it is known that a lactase
deficiency causes flatulence, which is the enzyme responsible for the degradation of lactose,
the milk sugar.
In Italy a pathological lactose breath test is present in 80% of cases. This is
explained on constitutional and genetic grounds or because such deficiency of
lactase would be secondary to chronic inflammatory damage of the colonic mucosa
within the syndrome itself.
b) Exclusion diets. There is debate and many authors disagree about the
therapeutic use of exclusion diets. It is true, however, that there are some
subjects with strange food allergies. For my professional experience I met some
patients who just fed the substances for which he was allergic, suffered from
nausea, vomiting, diarrhea until dehydration, with high total IgE and specific
for food allergens. The foods that can generally give allergies are:
- milk and derivatives, eggs and derivatives, fruit (nuts, strawberries,
raspberries, citrus fruit), coffee and chocolate, tea, pork and derivatives,
fish, molluscs, crustaceans, onions, garlic, pumpkin, cucumber and mushrooms,
spices.
The patient must refrain from consuming them. For example, if you suspect an
allergy and intolerance to foods of this type, for a few days you will have to
eat rice, beef and light tea. Sex hormones are also important in the
characteristics of sex-dependent IBS and it seems that sex hormones play a role
in influencing the immunological system as well as the function of mast cells.
In particular, mast cells express receptors for progesterone and estrogen.
Moreover, in males with IBS, CD3 + CD8 + T cells are higher, while females have
more mast cells. Mast cells can still play a role and stimulate sensory-motor
nerve endings, as well as having a classically their role in allergic facts and
in digestive allergopathies. Mesalazine also plays a role, so in the treatment
of borderline forms with chronic inflammatory bowel disease.
The indication of this choice lies in the fact that it is believed that at the
base of the SCI there is the belief that in the case of a slag-free diet,
considerable pressure is determined in the colon, due to its segmenting,
concomitant and propulsive motor activity. The fibers would increase the
diameter of the organ, according to the Laplace law, thus determining the
endoluminal pressure. Against this theory the fact that in SCI there is a
variety with constipation, but also a variety with constipation and diarrhea or
only with diarrhea or only with pain (!). In any case, it is quite justified to
use diets high in fiber and slag, albeit with particular gradualness, in
patients with forms of SCI characterized by constipation.
We have antispasmodics, those, that is, that control the motility of the
organ:
trimebutin, domperidone, cimetropio bromuro, iodine methyl bromide, tyropramide,
propanteline, dicyclomine, haloperidol, pinaverio bromide, heterioium bromide,
floroglucinol, trichiclasmodo, octilonium bromide, alverine citrate, fenoverin,
loperamide.
With these preparations, positive results are reported, especially with
mebeverin dicyclomine, porphymium bromide, trimebutin, octylonium bromide,
cimetropium bromide; there are Anglo-Saxon studies where peppermint oil and
other plants have been used.
Recently, the use of 3-acetyl-11 keto-beta-boswellic acid or AKBA, pentacyclic
terpenoid derivative, which in a dose-dependent manner blocks the formation of
leukotrienes responsible for stimulation of nociceptors with a pain-relieving
effect, has been successfully proposed. Incensole acetate that counteracts the
factors of mucosal inflammation (TNFalfa and inhibits the expression of the
Nuclear Factor kB.
Desipramine, fluphenazine-nortriptyline, amitriptyline chlordiazepoxide,
trimipramine, meprobamate, mepiprazole, lorazepam, phenobarbital, amobarbital,
diazepam, bromide bromide. These drugs do not find great indication except in
limited cases where the depressive syndrome and the fluctuating anxiety find
somatization to the colon, so their role is only in the psychic component of the
SCI. They exist for the purpose of the preparations containing both specialties:
anxiolytic + anticholinergic, but their use is questionable. The loperamide,
which is a synthetic drug similar to those derived from morphine, so far the
undersigned has used it only in a patient over thirty years of career as a
gastroenterologist, since it was a patient poorly controlled by anticholinergics,
which for working reasons, required a period free from symptoms (diarrhea). Food
supplements follow: senna, isphagula, psyllium, glucomannan which create a
gelatinous mass and facilitate evacuation.
Other drugs: pancreatic enzymes, diphenylhydantoin, pentaerythrol, peppermint,
nifedipine, diltiazem, lidamidine, timolol.