Hypothyroidism

It is one of the most common diseases of the gastrointestinal tract and appears to affect 9-23% of the world’s population. It is defined as the presence of abdominal pain or discomfort with abnormal function of the gastrointestinal tract. The abnormalities that comprise this syndrome and relate to its pathophysiology have to do with GI motility, visceral sensation, brain-gut interaction and psychosocial discomfort. Usually not all of the above coexist in the majority of IBS patients but one of them. Recent studies have shown increased activation of gut immune function in people with the syndrome and gut microflora also seems to be associated. Environmental contributors to the syndrome include stress, food intolerance, antibiotics and intestinal infections.

Symptoms include abdominal pain or discomfort, unusual gastrointestinal tract function with diarrhoea or constipation or both. Other symptoms include bloating, distension, symptoms caused by eating and change in the location of pain. Other features are that it usually occurs after the age of 50, there is unexplained weight loss, diarrhoea at night, bleeding from the rectum, iron deficiency and there is likely to be a family history of gastroenterological disease such as IBS, bowel cancer and inflammatory bowel disease,

Criteria IV are used to diagnose the syndrome, which include recurrent abdominal pain, on average, at least 1 day/week, associated with 2 or more of the following criteria: associated with defecation, associated with a change in stool frequency, and associated with a change in the form (appearance) of stool. Criteria must be met for the last 3 months with active symptoms for at least 6 months prior to diagnosis. 

Subcategories of IBS:

  IBS-D: IBS with diarrhoea

  IBS-C: IBS with constipation

  IBS-M: IBS with both

As far as laboratory tests are concerned, if there are no worrying findings such as: weight loss, hematochezia, iron deficiency and symptoms typical of IBS, regular diagnostic testing is not recommended. However, if there are worrisome symptoms, specific tests, complete blood cell count, complete metabolic profile, inflammatory markers such as erythrocyte sedimentation rate or C-reactive protein(CRP), and thyroid stimulating hormone (TSH) level should be done. If diarrhoea (rather than constipation) predominates, stool leukocytes and stool samples should be taken to test for Clostridium difficile bacteria when needed (such as patients who have used antibiotics in the last 3 months or have recently had chemotherapy). Patients’ medical history should also be taken, and if they have had a recent trip another test for Giardia and Cryptosporidium parasite antigens should be done. All patients suspected of having IBS should have a tissue transglutaminase (TTG) or TTG-IgA (gliadin immunoglobulins) test, it should be performed as part of the examination for all patients suspected of having IBS associated with diarrhoea or mixed IBS (diarrhoea – constipation, IBS-M). Colonoscopy is acceptable in patients with a family history of inflammatory bowel disease (IBD), colorectal cancer, worrisome symptoms such as hematochezia, nocturnal or progressive abdominal pain, weight loss, anaemia, elevated inflammatory markers or electrolyte imbalances or in patients over 50. When colonoscopy is performed in patients with IBS-D (predominantly diarrhoea), random biopsies should be performed to exclude the possibility of colitis.

There seems to be no specific cause for IBS, however there are some associations, such as too fast or slow passage of food through the gut, hypersensitivity to the gut nerves, stress and family history of IBS.

Nutritional management must be individualised. It is advisable for the patient to restrict suspect foods and reintroduce them and record the recurrence of symptoms. To achieve this, it would be advisable for the patient to record the foods reintroduced, and the occurrence or non-occurrence of symptoms in a food diary. This allows patients to have an active role in trying to better manage themselves. 

 It is also used, the low FODMAP dietary pattern, which essentially reduces the intake of foods rich in fermentable oligosaccharides, disaccharides, monosaccharides and polyols. 

  Fermentable oligosaccharides, disaccharides, monosaccharides and polyols.

These sugars have low to minimal absorption in the small intestine. They have a small molecular size and this leads to an osmotic reaction of the carbohydrates by pumping water into the large intestine

FODMAPs are then fermented by the flora of the large intestine where hydrogen (H₂) and methane (CH₄) are produced and the increase in hydrogen and methane (liquid and gas) can cause diarrhoea, flatulence, bloating , abdominal pain etc. .

Foods high in FODMAP and their alternatives

Usually the plan is quite restrictive for 4-6 weeks, so as to reduce the symptoms. However, thereafter, food will be slowly reintroduced. There is also a specific, specific breath test in which the breath hydrogen is measured after eating sorbitol, lactose or fructose. An increase in levels after consumption of one of the three sugars indicates poor absorption with subsequent fermentation by the intestinal microflora, otherwise it means that the sugar consumed does not cause symptoms. However, there are sugars for which the test cannot be performed, such as fructans and galactooligosaccharides, and mannitol is rarely offered as a test. These 3 sugars should be considered as a “spark” for the onset of symptoms, and foods containing them should be avoided. 

Exclusion diet

The way this diet plan is used is to exclude certain common allergens such as eggs, fish, seafood, nuts, peas and beans, specific chemicals in foods (natural or added, salicylates, benzoic acid, penicillin, yeast and tartrazine) including restrictions on the use of hygiene products and medicines containing these chemicals. For a minimum 2 of the above and then reclassify them 1 for 1. This diet is too restrictive, as it excludes too many foods and food groups that have some of the banned substances and for this reason it has not been used in studies involving people with IBS. 

If one of the 2 dietary plans is followed, especially in the exclusion diet, it is very likely that vitamin and trace mineral supplementation will also be needed and certainly proper information and education of patients on how to apply these diets is essential. 

As far as vitamins are concerned, usually in low FODMAPS diets, there is a low intake of calcium since lactose is included in FODMAPS. Alternative sources of calcium to avoid calcium deficiency are fish, plant-based milk such as almond milk fortified with calcium, lactose-free cheese (cottage), arugula and broccoli are sources of calcium, chia seeds, tofu (hard) , sesame seeds etc.. 

It also appears that people with IBS often have gluten intolerance as well, however more research is needed to confirm the findings and if needed some further recommendation as to how to reduce symptomatology. 

Also other studies have shown that perhaps caffeine and fats cause IBS symptoms, but more research is needed. It can be removed from the diet and reintroduced to see if it causes symptoms. 

As for the dietary management of patients, a low FODMAP plan seems safe and effective against IBS symptoms, always with personalisation and nutritional education by the dietician while the patient can also have an active role by keeping a diary. 

There is also scarce data on the ketogenic diet that it improves IBS symptoms, however more studies are needed to confirm the data. 

In cases with IBS-D it is good to be well hydrated. It would also be good to avoid very fatty foods, as they can make diarrhoea more difficult, as large amounts of simple carbohydrates can cause diarrhoea symptoms. Also if there is lactose intolerance, it is advisable to prefer lactose-free milk. Finally, spicy foods as well as sweeteners (sorbitol and mannitol) found in chewing gum and soft drinks and sweets, are best avoided due to the risk of diarrhoea distress. Also reduce whole grain products in the diet, rich in fibre until diarrhoea symptoms improve. Prebiotics and soluble fibre can also be used since they seem to reduce symptomatology, especially B. Coagulans. 

In IBS-C patients would be well advised to increase fibre in the diet with whole grain products, nuts, fruits and vegetables, but which do not cause symptoms, with an individualised plan after discussion of the patient with the dietitian to record and isolate these foods. The mobility of the intestines should also be increased with exercise.