How Should I Treat a Patient Who Is Experiencing Irritable Bowel Syndrome Symptoms After Rectal Surgery?

Wendy L. Wright, MS, RN, ARNP, FNP, FAANP

Disclosures

April 06, 2004

Question

How can I best help someone who has had rectal surgery for cancer and is now having related irritable bowel syndrome (IBS) symptoms?

Patricia Jenner, RN, BS, MS

Response From the Expert  

Wendy L. Wright, MS, RN, ARNP, FNP
Adult and Family Practice, Merrimack Village Family Practice, Merrimack, New Hampshire

Approximately 10% to 20% of all Americans suffer from IBS[1,2] Approximately 75% of these individuals are women. It is clearly a significant problem for those who are affected, resulting in 3 million visits to healthcare providers yearly.[1] The total cost to the healthcare system from IBS is $30 billion per year.[3] Therefore, it is imperative that we, as nurse practitioners (NPs), treat this condition accurately and aggressively.

The first step in the treatment of this individual is accurate diagnosis. The diagnosis of IBS is made with the following established criteria. Abdominal discomfort must be present for 12 weeks or more of the preceding 12 months and must be accompanied by 2 or more of the following: relief of abdominal discomfort with defecation, onset associated with a change in stool frequency, or onset associated with a change in stool form. This diagnostic criterion is often referred to as the ROME II criteria.[4]

Approximately 90% of those with IBS develop symptoms before the age of 50 years.[4] Therefore, if symptoms occur after the age of 50 years or are accompanied by weight loss, fever, nocturnal awakening, or black/bloody stools, the clinician must consider such differentials as cancer and inflammatory bowel disease.[4]

The question posed above is a complicated one. First and foremost, it is imperative that the symptoms presented by the patient be evaluated completely and that the potential for additional cancer be considered. A gastroenterology consultation is certainly recommended. Although it is likely that the symptoms are related to the surgery, hyper/hypothyroidism, inflammatory bowel disease, or infectious diarrhea must also be considered.

Once it has been determined that the symptoms are IBS, the first line of treatment is dietary modification. If the individual is constipated, increasing fiber to 20 to 30 g per day may be helpful. This can be as simple as adding a small bowl of high-fiber cereal and a green apple into the diet. Although this can also be recommended for individuals with diarrhea-predominant IBS, it has not been shown to be successful in a number of trials.

A reduction of stress and anxiety may also be helpful. Anyone having been diagnosed with cancer may certainly be suffering from significant stress, anxiety, or even depression. If this is the case, a selective serotonin reuptake inhibitor may be a useful adjunct. These have been shown in a few small trials to be helpful with the symptomatology of IBS. Over-the-counter medications, such as loperamide (Imodium A-D), may provide benefit for those with diarrhea-predominant IBS. Other medications such as hyoscyamine (Levsin) and dicyclomine (Bentyl) reduce sigmoid motility and decrease postprandial pain and distension by inhibiting postprandial colonic contractions. Many individuals find significant benefit from these products.

Alosetron (Lotronex) is indicated for the woman with diarrhea-predominant IBS. It provides a significant reduction in the number of bowel movements and pain associated with IBS, but is currently only available from a gastroenterologist. Tegaserod (Zelnorm) is indicated for women with constipation-predominant IBS. It is dosed at 6 mg twice daily before meals and has been shown to increase the frequency of bowel movements as well as decrease the abdominal discomfort associated with this condition.

Given this patient's history, additional differentials must also be considered. A consultation with a gastroenterologist or an NP specializing in this field is also recommended. Once it has been determined that IBS is the diagnosis, a number of lifestyle modifications and medications may be recommended.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....