A Case for Columbo
I receive many letters on The IBS Network website (Ask Prof Nick) from people tormented daily and often for years by their abdominal pain, bloating and bowel upset. Although Susie’s letter was not at all unusual, I felt it deserved a more thoughtful response and one that might helpfully be shared in this blog.
Susie (not her real name) wrote: ‘I’m looking for some advice’, I have suffered for 6 years with IBS and I am currently undergoing tests with my doctors for the 3rd time. The York Test revealed many food intolerances. I have avoided all the foods identified and I am still suffering. IBS came along suddenly at the age of 20 after years of being fine; now I can’t remember the last time I had normal day. I have to go to the toilet around 6-10 times a day and always have diahorrea (apologies for the spelling, but it fits better). I was told by a nutritionist to take acidophilus which I do daily as she thought it could be a build up of bad bacteria. However I can detect no change. Can you suggest anything else I can try to calm the symptoms?
My heart sank. Where do I start? A colleague once described me as the Columbo of Gastroenterology. I decided to take it as a compliment though I’m not entirely sure he meant it to be. Do you remember Lieutenant Columbo, played by Peter Falk in the nineties television series of the same name? He was that shambling, self deprecating detective who most people ignored, but who nevertheless had a skill at teasing out the contradictions and paradoxes in the statements of his suspects and identifying the truth behind them. So, faced with questions like Susie’s, I try to imagine what Columbo would do.
Despite what NICE would have us believe, medicine is not an exact science, especially at the ‘unexplained’ end of the spectrum occupied by what is called IBS. So we have to apply a large dose of informed common sense and evaluate probabilities. Susie’s key statement is that her diarrhoea started suddenly at the age of 20. Now food intolerance or dysbiosis would not occur suddenly ‘out of the blue’. So what might have happened?
There is a distinct possibility that her diarrhoea started with an attack of gastroenteritis or perhaps a course of broad spectrum antibiotics for something else, but if so, why didn’t she mention it? In most cases, gastroenteritis tends to clear up within a few days, although symptoms may persist if the infection is particularly severe and upsetting or if the ‘attack’ is associated with a distressing situation or event that could not come to terms with.
Late teens and early twenties is the time in most of our lives when there are a lot of changes; leaving home, going to Uni, starting a job, forming intimate relationships. It’s also a time of turmoil and turbulence when somewhat overprotected young people are more likely to encounter distressing events and situations that are quite alien to their previous experience and too shameful or frightening to admit or deal with. Under such circumstances, the mind protects the mental integrity of the person by suppressing the memory of what happened, but the record of what happens never disappears. If it can’t be acknowledged and dealt with, the continued emotional tension is played out in the body as symptoms which convey in some way the memory and meaning of what happened. All too often, it’s ‘the sensitive gut that tells the tale’.
So is Susie’s distressing diarrhoea the visceral expression of something that she finds too frightening or shameful to think or talk about? I don’t know and unlike Columbo I am not employed by the Los Angeles Police Department to offer any suggestions. Only Susie’s turbulent gut can reveal the secret, though she may need some help to decode it.
Her colonoscopy which is scheduled for this month, might reveal she has a serious colonic disease, but this seems unlikely as she does not say she has lost weight or been passing blood. So another negative investigation may plunge her deeper into the stigma of having an embarrassing illness with more than a hint of mental disturbance.
But Susie is not constitutionally neurotic or weird in any way. I looked on her Facebook page. Her images show an attractive, happy young woman with a handsome boyfriend and a lively and much loved terrier dog. Her mum looks warm and caring though dad does not feature. And apart from one disturbing Rocky Horror image for Halloween, all seems well. But Facebook can be like that. Something has clearly happened. Was this gastroenteritis, antibiotics, trauma or just the vicissitutudes and realities of adult life; who can tell. Susie can’t, and her colon is not giving up its secret easily.
She asks if there is anything else she can do to calm the symptoms. I sense a desperation that could be making things worse.
Getting better is a two stage process. First of all, she needs to calm herself and her symptoms. Diet, medicines and probiotics do not seem to be working, although I note she doesn’t mention a low FODMAP diet. Body based methods to calm the emotional response centres in the basal brain might offer more respite and with that an opportunity to engage the cognitive centres in the frontal cortex. These involve techniques that assist what has become known as mindfulness and include body movement, dance therapy, gentle exercise as well as more creative activity such as art and craft, writing, music, cooking, whatever she can identify with to get her into ‘the zone’ where she can gain respite from the obsessive focus on symptoms. Complementary therapies such as acupuncture, hypnotherapy, reflexology, therapeutic massage, tapping on acupressure points (EFT) and eye movement desensitization and reprogramming (EMDR) can also be very useful to ‘engage brain’.
Only when the emotional brain is calmed, will Susie be able to contemplate exploring with a counsellor or psychotherapist the situations that may have instigated or led to the persistence of her symptoms. Then, bringing what has happened from the body into the mind allows it to be thought about and ‘worked through’ and slowly integrated into a healthy and intact sense of self.
So were Columbo a gastroenterologist, he would not accuse the obvious suspects, diet, dysbiosis or inflammation, he would want to explore the context and meaning. That is the art of detection.
But …. he would not always be right. Only the patient can know for sure.
The Sensitive Gut 
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