6.0 Pain and Discomfort with Bloating and IBS

The focus with IBS is often on bowel habit, rather than pain or discomfort. In some ways this is for a good reason - if we can improve the bowel habit, the pain (and any gassy problems) may go. But not always, which is why we have included this section.

6.0.1 Overview

Many of us with pain may have quite a normal bowel habit. This is thought to be due to what is called “intestinal hyper-sensitivity” (sometimes called "visceral hypersensitivity"- viscera is another medical name for the "guts").

6.0.2 We all know what a pain is, but there can be different types

6.0.2.1 Episodic or “colicky” pain: Pain that comes in waves and is like a cramp. Imagine the natural “peristaltic” waves moving along the gut that are trying to push something out, whether it is a hard stool or diarrhoea

6.0.2.2 Constant pain: There are many causes of constant pain (in the tummy or pelvis) that are not due to IBS- so, important to highlight this constant character to your doctor.

6.0.2.3 Dyspareunia: Another type of pain to mention is that which women can get during sexual intercourse, called "dyspareunia". This can be confused with being a gynaecological problem but can be treated with the other symptoms of IBS (once gynaecological causes have been excluded).

6.1 Why the vagueness of the pain?
Many of us though don’t get pain as such but rather a “discomfort” which can move about and can be difficult to describe. The vague nature of this discomfort is explained by how the nerve endings in the gut are wired up (if you have read the Bloating and Flatus section you will have seen this explanation before- it again shows how IBS is a series of problems, all linked together).

We all know that the nerves to our skin are very sensitive and send a very precise message to the brain. If you prick your finger with a pin, you know exactly which part of which finger of which hand. But, if there were a way of opening up your tummy and sticking a pin into just your bowel, you wouldn’t feel it, not even one little bit! This is because the nerves are of a different type- a good thing because otherwise we would feel every mouthful of food going down the gut.

When the nerve endings in the bowel wall are irritated, they send a very vague message to the brain. This message doesn’t give much information about what is happening or even exactly where it is happening, so it is no surprise that we find it difficult to put such sensations into words.

Treating this pain/discomfort is often through getting the associated bowel upset or "gassiness" right and diet can be key to this.

If the pain does not disappear as the other symptoms of IBS improve, it can still be due to the IBS but, it is best to talk things through again with your doctor or nurse, as other tests might be needed to make sure that nothing else is going on (e.g.performing a "tube" test to confirm the colon (lower bowel) is all ok; checking the ovaries in women, the testes in men or kidneys etc. in either).

The pain of IBS should never wake you up in the middle of the night. If this is a feature of your problem, do highlight it to your doctor or nurse.

6.2 Tests for Pain of Bloating and IBS
The role of tests for IBS with pain/discomfort is really to make sure that nothing else has been missed. They are particularly important if IBS treatment helps all the other symptoms that we might have, but the pain does not ease.

Tests can include Ultrasound of the Abdomen (tummy) and Pelvis (these are different tests, but can be done together); a camera tube test of the lower bowel (Colonoscopy or Flexible Sigmoidoscopy) and a blood test for the ovaries, CA125.

6.3 Treating Pain and Discomfort in Bloating and IBS
Diet change will help many of us with IBS-related pain but, mainly those with altered bowel habit or gas. If it doesn’t work there are other answers. These can include medications ranging from simple over-the-counter ones to prescription drugs; psychological therapy such as Cognitive Behavioural Therapy (CBT); Complementary medicine or management by a dedicated Pain Specialist (most hospitals have "Pain Teams").

It can be happen quite often that if we have IBS with Constipation, the pain (more often than not in the left lower part of the tummy) stays with us even after the Constipation has been sorted out. So, often two over-lapping treatments are required to treat each symptom.

As an aside, many of us with IBS use a hot-water bottle over the sore area to ease things. It is not a good idea, as with time, it can “tattoo” the skin on the tummy giving it a permanent red/brown coloured net-like pattern that will never fade (so common a problem that there is an old medical name for this "erythema ab igne", literally translates as "redness from fire").

6.3.1 Medications for Pain with Bloating and IBS
There is a broad range of medications available ranging from over the counter to prescription only. They can be extremely effective.

6.3.1.1 Simple medications: those that have been shown to work include peppermint (tea, capsules of oil), mebeverine, alverine and Hyoscine (“Buscopan”) - they all seem to work by relaxing the muscle in the bowel wall.

When using peppermint oil capsules or mebeverine, they work much better if taken regularly (usually three times a day before meals) rather than waiting for the pain to come on- think along the lines of “prevention is the best cure”. Buscopan is a good drug to use for “breakthrough” pain (not available in USA).

6.3.1.2 Low dose Anti-depressants: certain kinds of anti-depressants can work very well for pain. If you are prescribed them, it doesn’t mean that everyone thinks that you have depression (unless this is specifically diagnosed) or are “imagining” the pain, it’s just because, they can work very well for some people! The reason that they work is that the nerve endings of the gut are almost a direct extension of the brain.

A few points about using such medications: The brain is a collection of nerve-endings so it is not too surprising that a medication that works on the brain (“centrally” in medical-speak) could have an effect on nerve endings elsewhere in the body (“peripherally”); The same drug can have different effects on the body when used in different amounts (doses). For example: non-steroidal pain killers (e.g. aspirin or ibuprofen can cause gout at normal doses but are used to treat gout at high dose; high dose aspirin is a pain killer, low dose aspirin 'thins' the blood and prevents strokes etc.); The medications amitriptyline and nortriptyline are often used at low dose (10mg to 50mg once a day in the evening) for pain in scars after operations or for nerve pain with severe rashes (e.g. shingles). At high dose (hundreds of milligrammes) they work as anti-depressants. Interestingly, their helpfulness for many with IBS has been shown to have nothing to do with changing our mood.

6.3.1.3 Amitriptyline: is often used for IBS when both diarrhoea/urgency and pain are a problem. It is best taken once a day in the evening. Initially, it can cause slight drowsiness and / or a dry mouth. Often these side effects disappear after a couple of weeks but some people are very sensitive and the medication needs to be stopped. It is best to take this medicine in the evening, not later on when going to bed, as then any drowsiness should have gone by morning.

6.3.1.4 Nortriptyline: is a sister drug to amitriptyline (used in same dose, again in the evening time) but has a less constipating effect and causes less drowsiness or dry mouth. It is used if pain with constipation is the main bowel symptom or if amitriptyline is not agreeing with the person. It is less effective than amitriptyline for controlling diarrhoea.

6.3.1.5 Other types of similar medicines: Citalopram, fluoxetine and paroxetine (all “SSRI” type drugs- they work by affecting how the chemical serotonin is controlled in the body) are also commonly used for IBS. The “SNRI” drugs (e.g. venlafaxine and duloxetine- not to be confused with "Dulcolax" which is a laxative!) are similar but can be better for pain prevention.

6.3.2 Talking therapies for Pain with Bloating and IBS
Cognitive Behavioural Therapy (CBT) or psychotherapy can be effective for managing IBS symptoms, but like any other therapy, they are not for everyone. You may wish to discuss CBT with your doctor or nurse.

Some of us with IBS are can be both anxious and have a degree of depression. Using an anti-depressant, maybe with CBT or psychotherapy, can be a very effective treatment.

6.3.3 Alternative and complementary medicine for Pain with Bloating and IBS
Some of us find alternative therapy to be helpful; up to 50% of us with IBS do try something different. It is difficult to know what works but certainly, as with most treatments, some things work for some people and not for others.

In using an alternative approach, it is important to think about the balance between the costs (which you will have to pay), any potential side-effects and likely benefits.

It is important to be especially cautious in using some alternative medications, in particular traditional Chinese herbs and Ayurvedic medicine: Chinese herbs can be contaminated with heavy metals (e.g. lead) and up to a quarter of Ayurvedic medicines available can be spiked with other drugs. Also, do not use non-prescription drugs (even as creams) during pregnancy and avoid them if you are on other medicines as there might be interactions.

Green Tea Extract (a concentrate, not the tea we buy in ordinary shops) can be toxic for the liver. Herbal remedies should be avoided in anyone with liver disease.

Honest and un-biased information about alternative medication is available from the American website: www.ConsumerLab.com

In the UK, NICE (a government advisory committee for healthcare) says that treatments such as Aloe vera, Reflexology and Acupuncture are to be avoided. That having been said though, there is some evidence (but not conclusive, hence the NICE guideline) that Aloe vera works for IBS (at the risk of Diarrhoea) and it is possible that acupuncture could help with IBS-related pain though not helping other problems like Diarrhoea/Constipation, Bloating etc.