Saturday, August 21, 2004

Irritable Bowel, Chronic Fatigue, and Fibromyalgia

A clinical review in JAMA discusses a new theory into the misunderstood diseases of Irritable Bowel, Chronic Fatigue, and Fibromyalgia. It also suggests how these three disorders may be connected. Irritable bowel disease can present with many different symptoms. However, bloating after eating a meal is the most common symptom. Researchers discovered that the increased gas had less to do with an intolerance to any particular kind of food and more to do with bacterial overgrown in the small intestine. Bacteria do serve a critical role in the colon or large intestine. However, the small intestine between the stomach and the colon in healthy people is a mostly sterile environment. This is achieved by the acidity of the stomach which kills most bacteria which enters in the upper GI tract. On the other end a special valve at the insertion of the small intestine to the large intestine called the iliocecal valve prevents bacteria in the colon from ascending up and overgrown in the small intestine. Well, in the case of irritable bowel that is just what happens. The symptoms of bloating come from certain disaccharide like sorbitol, lactose, lactulose, and fructose found in certain foods which are not absorbed entirely in the upper small intestine, reach the bacteria in the lower small intestine and cause the bacteria to grow and produce gas. The small bowel gets distended due to the gas causing pain and bloating. The iliocecal valve keeps the gas bottled up in small intestine from being released into the colon and then expelled as flatus. Glucose and sucrose are easily absorbed in the upper small bowel and do not cause bacterial overgrown, gas production, bloating, and abdominal pain.

So, what about the constipation, diarrhea, or a combination of the two which are common symptoms in irritable bowel. Well, these symptoms are due to what kinds of bacteria are growing in the small intestine and what gases they produce. Methane gas causes decreased paristalsis and constipation. Other gases include hydrogen, and hydrogen sulfide. Diarrhea is related to toxins released by certain bacterias which stimulate the small intestine to secrete water. In the colon, a variety of bacteria are found that all compete with one another so no one kind overgrows the others. In the small intestine it is common for one or two specific bacterial species to overgrow and cause the symptoms of irritable bowel.

So, what about fibromyalgia and chronic fatigue syndrome. It's no revelation that these mysterious disorders seem to run together. Well, researchers have discovered that fibromyalgia and chronic fatigue may be caused by the same small intestine bacterial overgrown as irritable bowel. Turns out there is a great new test to diagnose irritable bowel. Symptomatic patients can be given a dose of oral lactulose and then a breathalizer test can be taken measuring for increased methane, hydrogen, and hydrogen sulfide production. Well, it turns out that patients with irritable bowel symptoms have higher gas production than healthy individual. What was even a greater surprise was that almost 100% of individuals suffering from fibromyalgia and chronic fatigue symptoms also had positive lactulose challenge, breathalizer tests. This means that having fibromyalgia and chronic fatigue could be linked to bacterial overgrown and irritable bowel (chronic fatigue can be associated with post mononucleosis as well as other potential chronic infectious, genetic, and environmental diseases and exposures).

However, not all individuals with irritable bowel have fibromyalgia. This is due to the kind of bacteria that is overgrown in the small bowel and the individual's immune reponse to the specific bacterial strain. According to the article, bacteria as well as signs of inflammation where found in neighboring lymph nodes adjacent to the small intestine in suffers of fibromyalgia and chronic fatigue. The subsequent inflammatory reaction to the bacteria results in the characteristic body aches, pains, malaise, and fatigue.

So, what to do about it. Well no official studies have been perfomed. But the review article suggests several ideas. While symptoms persist, an irritable bowel sufferer should temporarily avoid foods that contain complex disaccharide such as lactose (dairy products), sorbitol (apple juice), and even fructose (fruit) in some cases. Suffers will need to learn which foods cause bloating, constipation, and diarrhea. Temporarily eliminating these from the diet will stop feeding the bacteria in the lower small intestine and prevent the bacterial overgrown and gas production.

Another idea it to replace bad bacteria with good bacteria. Since, bacterial overgrown is believed to be due to one or two offending stains of bacteria, adding good bacteria to the mix could help control bacterial overgrown by increasing the competition for food between good and bad bacteria. Yogurt and Cranberry juice have not been shown effective in helping to alleviate symptoms of irritable bowel due to active yogurt culture and antibiotic properties in the later. This is probably because these also contain lactose and fructose which exacerbate the condition. Several prescription and nonprescription products which contain milk bacteria (Lactobacillis acidophilis) or other mixed strains of bacteria (probiotics) may be helpful (Culturel, Bifidobacterium bifidus, fecal probiotics). Probiotic therapies have proven successful in the treatment of inflammatory bowel (Crohns disease, Ulcerative colitis, Clostridium difficile colitis, recurrent diarrhea, rota virus?).

Finally, 14 day treatment with the antibiotic Flagyl (metronitazole) is also effective at treating irritable bowel. However, doctors feel uneasy about relying on antibiotic treatment due to possible emergence of resistant basteria strains.