Mary has had constipation-predominant IBS for most of her adult life. She also has severe intolerance to fats and more recently a lot of other foods, which give her symptoms of bloating and pain. She tries to control her symptoms by taking a restricted diet, but any lapse makes her panic and brings on the symptoms she most dreads.
Constipation is often associated with gallstones. Stagnation of the colon may be accompanied by stagnation in the gallbladder, facilitating an overgrowth of bacteria which may form a nidus for supersaturated cholesterol in bile to come out of solution form stones and cause inflammation of the gall bladder wall. Cholecystitis is a major cause of fat intolerance, but removal of her gall bladder only made the problem worse. Any ingestion of fat could leave her in agonies of pain and cause her severe bloating. She also developed bloating with fruit and vegetables, perhaps because the constant leakage of bile acid irritated her intestine or because stagnation of the small intestine led to bacterial overgrowth. It was only when her doctors found that the severe pain she experienced with fat was associated with raised liver enzymes that they confirmed the diagnosis of Sphincter of Oddi Dysfunction.
The Sphincter of Oddi is a ring of muscle that lies at the end of the common bile duct that normally relaxes to allow bile and pancreatic secretions to enter the duodenum during digestion of a meal. Between meals, it is normally under a state of tonic contraction but release of the hormone cholecystokinin by fat and protein in a meal relaxes the sphincter, induces peristaltic contractions in the common bile duct and also contracts and gall bladder and stimulates pancreatic secretion.
Sphincter of Oddi dysfunction can occur because of scarring or inflammation but most often results from a functional spasm of Oddi’s sphincter and dysmotility of the terminal few centimetres of the common bile duct. It would seem to bear an uncanny resemblance to the anal spasm and distal colonic dyskinesia recorded in patients with constipation predominant IBS. That would seem to suggest that her SOD may be a component of IBS in some people. SOD is often instigated by cholecystectomy, which impairs the response of the sphincter to cholecystokinin. Nowadays many surgeons treat SOD by dividing the sphincter to aid drainage of bile, but that has yet been tried for Mary.
The cause of SOD is as uncertain as the cause of IBS. There may be some constitutional or genetic susceptibility, but there is also evidence that SOD is associated with high levels of stress and particularly the use of work, humour, sublimation, denial or passive aggression to suppress emotion associated with life trauma. It is more common in middle aged women, whose symptoms initially respond to cholecystectomy but then return often with a vengeance. It may be relevant that constipation is also associated with repression with conscientiousness, denial and depression.
Mary’s symptoms of bloating and extreme fatigue started with a bout of epidemic labyrinthitis, following a prolonged period of multiple stresses. Always conscientious and capable, she never liked to let people down. So she was trying to support her elderly widowed father and also her mother-in-law with dementia, she helping her dyslexic son with his business and she was organising her daughter’s wedding. It had all been a bit too much.
Although Mary denies any trauma in her life, when she was 21, she fled the country to join her boy friend upon discovering she was pregnant. The child was stillborn. Nevertheless, she returned to England, married, had two children and tried to settle down, but the marriage didn’t survive. She was left alone with two small children and a mortgage to support. Never one to give up, Mary put what happened behind her and got on with life with a combination of hard work and humour. She trained to become a teacher.
Mary says her life has always been stressful, though her second husband has been a tower of strength through all her recent woes. They are able to enjoy their retirement with no money worries. Mary describes herself as ‘a happy introvert despite the restrictions imposed by my health problems. I knit and sew when I have the energy and she plans to take up drawing and painting and do more in the garden. As long as I know where I stand and am not flying by the seat of my pants, I can manage.’
Mary has demonstrated a considerable degree of resilience despite the instability of her first marriage. Life could be a lot worse. Her attitude is that ‘we have to play the hand that life deals us as best we can’. Nevertheless, none of us can escape being affected by what has happened to us. This fits with the somewhat stoical psychological profile, described in the study quoted above, and may cause her to react to situations in ways that are no longer relevant, holding onto tension in her gut and repressing the secretion of bile. Excessive biliary secretion leading to bilious vomiting has often had connotations of anger. Bile is a metaphor for anger, and choleric an adjective for angry. I have even read that the Mexican word coraje is used to describe the fury of women who had been so wronged that they vomited bile.
The body always remembers. Such symptoms only make sense when seen from the perspective of what happened. They may be calmed by drugs or procedures that alter the physiology, or by restricting life to avoid the triggers or by denying what happened and toughing it out. But the evidence suggests that long term resolution of persistent post traumatic bodily symptoms is only likely to occur if people can make sense of them and reprocess them with understanding and forgiveness in the context of psychodynamic therapies.