Living with a dysfunctional gut-brain axis?

A functional bowel disorder is not life-threatening and does not damage the intestine, nor cause cancer but it can lead to low quality of life, anxiety and depression, writes Dr Naresh Bhat

Functional gastrointestinal disorders (FGIDs) are common disorders characterised by persistent and recurring GI symptoms. Many of them suffer because they do not get relief with standard prescriptions. It is estimated that more than 40% of patients coming to GI OPD are diagnosed to have FGID.

Why does FGID occur?

The symptoms originate in the GI tract, but no structural or biochemical abnormalities are seen. Hence, all medical tests such as x-rays, CT scans, blood tests and endoscopic exams are normal. They are seen in many age groups — in children, toddlers and young adults and affect both men and women. The keyword used to describe them is visceral hypersensitivity and Gut-Brain Axis disorders. This is because though symptoms originate in the gut they are greatly modulated by signals sent from the brain to the nerves in the gut. There is an interplay of the gut motility, gut microbiome, nerve transmitters in the GI tract and perception in the brain. Therefore the problem can start due to dietary factors or changes in the microbiome or even stressful events. There are more than 20 functional GI disorders that can affect any part of the GI tract like the esophagus, stomach, bile duct or intestines. Two of the most common types of FGIDs are Irritable Bowel Syndrome (IBS) and Functional Dyspepsia (FD).

Irritable Bowel Syndrome (IBS): It is a group of symptoms that can affect the digestive system. It can cause pain in the abdomen, changes in bowel habits and bloating. Symptoms may be recurring or persistent and easily suspected if long-standing. The challenge is, however, to exclude sinister diseases like cancer, TB and Crohn’s disease. Hence, it is not readily diagnosed in older adults and those with anaemia, weight loss, fever and recent onset of symptoms.

Functional Dyspepsia (FD): People with this disorder generally have upper abdomen bloating, burning and belching. It is one of the most common functional disorders. A diagnosis is often made after ensuring that a gastroscopy has excluded ulcer disease and stomach cancer. People having trouble swallowing food, vomiting, those losing weight, or having anaemia, and the elderly are not likely to have Functional Dyspepsia.

How are FGIDs diagnosed?

Since routine tests generally show negative for people with FGIDs, these disorders cannot be based on test results. Rome Criteria are a set of criteria used to help make a diagnosis of a patient with an FGID (a disorder of gut-brain interaction) and also classify the kind of disorder. Hence, the diagnosis is made when a patient’s combination of symptoms and other factors meet the Rome Criteria for a specific functional disorder. An experienced doctor usually diagnoses the disorders based on the symptoms experienced by the patient for more than six months.

Also, the role of investigations which are done selectively after understanding the patient’s history is critical to diagnosing FGIDs. This will help the doctor evaluate and exclude other conditions. These patients may frequently be also affected by migraine, fibromyalgia, pelvic pain and urinary disorders.

The greatest challenge is to avoid too many investigations and also to avoid missing serious disorders. It is important to understand that FGIDs are not psychiatric disorders and hence largely managed by gastroenterologists.

However, psychological stress can exacerbate symptoms of FGID. Various researches have been conducted to understand the psychological aspect of FGIDs. There is a bi-directional pathway between the brain and the GI tract, known as ‘the brain-gut axis’. It is found that external stressors and emotions or thoughts can affect GI sensation, motility and secretion. In other words, the brain affects the gut. Also, psychosocial disturbances can amplify the illness and can impair the quality of one’s life. Hence, patients with FGIDs have a low quality of life and are often anxious and depressed.

Treatments for FGID

The modalities of treatment vary and depend on the particular symptoms a person is experiencing. A sympathetic and patient listening and understanding of his suffering is the first step. Reassuring the patients that they are suffering and need help plays a vital role. Symptomatic therapy for pain, constipation, bloating, nausea and diarrhoea are used.

Various neuro modulators which modify the signals from the gut and brain are often the mainstay of therapy. Breathing techniques, biofeedback therapy, yoga and meditation are extremely beneficial too. Rarely do we need to use relaxation therapy, hypnosis or cognitive behavioural therapy to help patients learn to better manage symptoms.

Some dietary restrictions are suggested to minimise symptoms as and when indicated.

(The author is chief of medical gastroenterology & liver disease at a leading chain of hospitals in Bengaluru.)