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Treatment of the “Irritable Stomach” and the “Irritable Colon”*
TREATMENT OF THE "IRRITABLE STOMACH" AND THE "I RRIT ABLE COLON" '10 FRANZ J. INGELFINGER, M.D.t
Olt' any group of patients with gastro-intestinal complaints, a large number suffer from functional disorders of the digestive tract. 1 These patients, when subjected to a careful history and physical examination, as well as appropriate laboratory procedures, are found to be free from organic disease. Even a laparotomy would fail to reveal any morbidity of the ahdominal viscera. Yet these patients are not helpless psychopaths or in4 veterate neurotics; their distress is real enough, and they derive little solace from being told that they should forget their symptoms. Such an attitude of therapeutic nihilism is often adopted by the physician because the lack of an organic lesion which is remediable by specific therapy makes treatment difficult and unrewarded by dramatic results. Nevenheless, the patient with functional gastro-intestinal abnormalities-be they abnonnalities of motility, secretion, or absorption-deserves as carefully planned a regimen as the patient with organic disease. In thIS clinic, plans for treating two common functional disorders of gastro-intestinal motility will be presented. For want of better names, these disorders can be called "irritable stomach" and "irritable colon." Definitions of Syndromes
The patient with "irritable stomach" complains of (I) postcibal fullness and pressure in the epigastrium, (2) belching, bloating and eructations, (3) more or less intolerance to certain foods, usually fatty, and (4) varying degrees of nausea. ------------------_._--------- -
--
* From the Evans Memorial, Massachusetts Memorial Hospitals and the
Dl:partment of Medicine, Boston University School of Medicine. t Assistant Professor of Medicine, Boston University Medical School; Associate, Evans Memorial, Massachusetts Memorial Hospitals; Chief, Gastrointestinal Clinic, Outpatient Depanment and Assistant Visiting Physician, Massachusetts Memorial Hospitals. 1385
1386
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INGELFINGER
The patient with "irritable colon" complains of (1) intermittent dull pains usually located over the cecum or the sigmoid, (2) constipation and small, hard bowel movements covered by strands of mucus, and (3) borborygmic flatulence. Frequently the two syndromes are concomitant; often they are associated with the habitual use of laxatives. Frequently, too, they are less prominent during periods of physical activity. Abnormal Physiology
Gastro-intestinal motility in anyone area depends on: (1) the nature and the amount of intestinal contents; (2) the local motor reaction stimulated by the presence of the contents; (3) the resistance to the outflow of the contents, which is determined by the motor activity of adjoining intestinal areas, particularly of those lying distally; and (4) nervous and humoral influences of intestinal or extra-intestinal origin. Normally these factors are so balanced that the movement of chyme and gas in the intestinal tract does not occasion any unpleasant sensations. Should an acute intestinal obstruction occur, the balance would obviously be destroyed, and the disorganized intestinal motility would give rise to violent symptoms of colic, distention, nausea and vomiting. In functional disorders, the process is not so acute, but qualitatively the same thing happens: the balance and integration between various parts of the gastrointestinal tract are upset, and the abnormal motor function makes itself known in the guise of "gas pains," borborygmi, fullness, or nausea. Abnormal motor function in the absence of organic disease of the intestinal tract and of other organs can in a large number of cases be ascribed to (1) emotional and neurogenic influences and (2) poor habits of e.ating and elimination. It is on these causes that our therapeutic attention must be focused. TREATMENT OF THE INDIVIDUAL
Whether we are treating the "irritable stomach" or the "irritable colon," our treatment of any abnormal emotional and psychogenic conditions affecting gastro-intestinal motility will be the same. Observance of the following procedures is recommended. 1. Relieve the patient of any fear or worr), that his symptoms
"IRRITABLE STOMACH" AND "IRRITABLE COLON"
1387
may occasion. The first prerequisite in attaining this end is a careful and thorough examination in which all necessary clinical and laboratory tests should be utilized. The patient must be convinced that the physician is speaking on the basis of factual knowledge rather than on the basis of superficial impressions. Explain to the patient the nature of his symptoms. This is not done by telling him that nothing is the matter. His symptoms are more persuasive than such brief reassurance, and he will seek relief elsewhere. Nor is it a good plan in most instances to tell him that he is nervous or that he has a "nervous stomach." Many patients resent having their symptoms ascribed to nervousness, even though it may be the truth, and some will even misinterpret the physician's statement and believe themselves to be accused of harboring imaginary ills. Instead, the patient is simply told that his stomach, or his bowel, is not performing its work properly. This statement is elucidated by making an analogy. One of the best is to compare the patient's intestinal tract to a motor whose component parts are in perfect shape but which runs poorly because the timing mechanism is improperly adjusted. The delicate timing mechanism of his intestinal activity, the patient is told in further explanation, is subject to change by mental tension, strong emotion, and poor dietary habits. To emphasize this point, the patient can be reminded that violent anger kills the best appetite, that diarrhea may be caused by tense anticipation. Once a patient understands the nature of his symptoms, his fear of them, his dread of cancer, is in good part alleviated; and the physician has eliminated one of the psychogenic influences which often helps to perpetuate a functional disorder. 2. Warn the patient that a dramatic cure cannot be expected. Since functional disorders are often of long standing, of obscure origin, and not subject to specific therapy, it is understandable that their correction cannot be a matter of days. It may, for instance, take a year to cure a well-established laxative habit. The patient should be apprised of this fact, for otherwise he may be disappointed at the slow progress and drop the presc"ribed regimen. 3. Try to ascertain the specific background for mental tension. Should the patient's functional disorders represent the expression of deep-seated emotional or mental tension, the phys-
1388
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INGELFINGER
ician is confronted by a true problem in psychosomatic medicine. In some instances, the assistance of a psychiatrist must be sought. In many cases, however, the causes for the state of tension are obvious enough and can be traced to social, economic, marital, or sexual difficulties. Obviously the physician must try to help the patient either in removing the offending cause or in making an adjustment to an unalterable situation. 4. Use sedatives lightly. General sedation may be practiced in moderation and always with the understanding that it represents a temporary measure. Well-known drugs can be used: Phenobarbital. . . . . . . . . . . . . . . .. 30 mg. (grain ¥.l) b.i.d. or d.d. Sodium or Triple Bromide .. ,. 0.5 to 1.0 gm. (grains 7¥.! to 15) b.i.d. or t.i.d.
These drugs can be used in combination with those advocated in subsequent paragraphs. 5. Physical and mental activity. Exhausting physical exercise or intense mental activity may temporarily relieve the patient, but subsequently the symptoms return, often with increased severity. Enforced idleness and long periods of rest are likewise of questionable value since they give the patient time to ponder his symptoms. It appears, therefore, that the patient should avoid extremes of physical and mental activity. Depending on the patient's habits and occupation, the physician should, however, recommend such changes as he believes would benefit the patient's general health and fitness. TREATMENT OF THE "IRRITABLE STOMACH"
The Diet 1. The diet 'lnUst be nutritionally adequate. Whatever diet
is used, it must be adequate in respect to calories, proteins, minerals and vitamins. The tables published in a previous number of these clinics by Dr. Ruth Guy2 or the Food Charts prepared under the auspices of the American Medical Association3 offer concise information concerning the food requirements of adults. Unless these requirements are met, more harm than good will be derived from the dietary regimen. This is particularly true of functional gastro-intestinal disorders which may find their origin in poor dietary habits and malnutrition. Only in the case of obese persons can an exception be made. In these patients, it is often of advantage to reduce the caloric intake
"IRRITABLE STOMACH" AND "IRRITABLE COLON"
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(i.e., fats and carbohydrates) while treating the gastric complaints. 2. Food should be taken regularly and at least three times daily. The gastro-intestinal tract becomes conditioned to regular habits of food intake, and the motility of the esophagus, stomach. and small intestine tends to be better coordinated if these regular habits are observed. This does not mean that the patient may not have a bedtime or midafternoon snack, but it does mean that irregular nibbling of food, particularly of candy, should be interdicted. Gum chewing is likewise taboo as it stimulates gastric functions at irregular intervals and promotes aerophagia. The patient should be encouraged to eat some breakfast. Many persons who suffer from an "irritable stomach" complain of anorexia and nausea in the morning. As a result, they either take no breakfast or, at the most, a cup of coffee. All the factors involved in the symptom of nausea are not clear, but it is probable that the motor activity of the upper intestinal tract is abnormal during nausea.4 Hence, the regular ingestion of breakfast, even though the patient may experience difficulties at first, helps condition the re-establishment of normal motility and gradients. 3. "Better is a dry morsel and quietness therewith than a house full of feasting 'With strife." This often-used quotation from Proverbs, 17, 1, paraphrases another rule which the patient with functional disorders must obey. He must take enough time for meals. Also, while eating, he must avoid as much as possible any disquieting influences, be they physical or mental. 4. Ice-cold food or drink should not he poured into the stomacb, especially if this organ is empty. For example, a glass of icecold juice taken the first thing in the morning is inadvisable, bur lIttle harm will come of taking ice cream slowly at the end of a full meal. S. Smoking in ordinary amounts (less than 10 cigarettes a day) apparently does not disrupt favorable gastro-intestinal motility when food has been taken recently. Smoking on the empty stomach should, however, be prohibited. 6. Alcobol in small amounts stimulates gastric secretion and motility and, temporarily at least, allays nervous tension. Hence a pre-meal cocktail, a glass of wine, or a liqueur is not neccs-
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sarily detrimental to the "irritable stomach." Individual response to alcoholic drinks varies considerably, however, and the pros and cons of allowing alcohol must be weighed on the patient's specific reactions to alcoholic intake. In any case, anything more than light drinking should not be countenanced. 7. Food. The accompanying table lists the foods which should and which should not be given. Fats are given in small amounts because their normal action of reducing the gastro-duodenal DIET LIST FOR PATIENTS WITH "IRRITABLE STOMACH" AND "IRRITABLE COLON"
Choice of:
Breakfast
Fruit .............. . ...... Juices, grapefruit or orange flesh (avoid membranes), peaches (peeled), ripe strawberries, ripe bananas, cooked fruits (no seeds or skins) Cereal with milk ........... Any cooked cereal not containing bran, or a dry cereal such as corn flakes, puffed rice, dry oatmeal products Eggs ....................... Boiled, poached, or baked Bread ................. . ... Enriched white, finely milled rye. May be toasted. Sugar, honey ............... As desired . .. As desired Milk .......... Coffee ........ 1 cup . ....... Not more than 1 pat Butter ....... Cream .. ' ...... Not more than 1 tablespoonful Clear jelly ....... As desired
Noon and Evening Meals Choice of: Soups ..................... Pureed vegetable soups, clear bouillon, clear broths containing no fat Meat ....... All varieties allowable except spiced meats, sausages, frankfurters, fat, gristle. Avoid fried meats. Fish ............... . ..... Haddock, halibut, cod, filet of sole, and other fish with white flesh. Avoid fried, spiced, kippered and oily fish. . ..... Lobster Shellfish .... Fowl ...................... Chicken, turkey. Avoid fat and skin. Do not fry. Eggs ......... . ..... Boiled, poached or baked Cheese ......... . .........• Cottage, cream, muenster Milk ...................... As desired . ... Enriched white bread, potatoes (not fried), Starch products ... spaghetti, macaroni, noodles, rice. Use unspiced and pureed tomato sauces.
"IRIUTABLE STOMACH" AND "IRRITABLE COLON"
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Vegetables ...
. ....... String beans, carrots, fall squash, peas, beets, asparagus, strained tomatoes. Broccoli, spinach and lima beans may be allowed if patient does well. Butter ................... Not more than 1 pat per meal Dessert .... . ...... Junket, jello, custard, fruit whips made with egg-white, cooked fruits (no seeds or skins), ice cream, starch or rice puddings (no raisins)
Avoid the Following Foods: Spices, relishes, pickles, mustard, hot sauces Fried foods All vegetableS! not listed above All raw vegetables Any food containing seeds or skins Bran products Notes: I. The patient with the "irritable colon" does not have to restrict his butter and cream consumption. He may also eat some fried foods, if care is taken to remove excess grease. H. From nutritional viewpoint, following minimum daily intakes are advisable: 1. Fresh fruit or juice daily 2. Two green or yellow vegetables daily 3. Choice of: (a) 4 glasses milk, meat or fish (b) Dark cereal, meat or fish, cheese, 1 egg (c) 2 glasses milk, 2 eggs, meat or fish (d) Dark cereal, 3 glasses milk, 1 egg, cheese
gradient apparently is deranged in patients with the "irritable stomach" syndrome. As a rule, those foods and drinks are excluded which appear to affect gastro-intestinal motility adversely. Drugs
Drugs should be considered merely as temporary adjuvants in the attempt to re-establish normal gastro-intestinal functions. The antispasmodic drugs typified by atropine can be used in the following dosages: Tincture of Belladonna Sig.: 12 drops in one-half glass of water t.Ld. a.c. Trasentin .................. 75 mg. (grains 1*) (Ciba) Sig.: 1-2 tablets t.i.d. a.c. Syntropan ................. 50 mg. (grain %) (Hoffman-LaRochc) Sig.: 1 tablet t.i.d. a.c. Novatropine ............... 2.5 mg. (grain :V24) (Campbcll products) Sig.: 1-2 tablets t.i.d. a.c.
Our own preference lies with belladonna and trasentin.
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It may occasion surprise that atropine-like drugs which depress gastro-intestinal motility should be used in correcting a disorder which may be characterized by abnormal gradients of intestinal pressures. The rationale for the treatment lies in the fact that atropine affects all portions of the gastro-intestinal tract. Hence an integrated motility under the influence of atropine will replace a functional motor disorder, even though the motility of the digestive tract as a whole will be depressed. On empirical grounds, an inert powder such as bismuth subnitrate may be used in doses of 2 to 4 gm. (Y2 to 1 dram) before meals. Supposedly it exerts a demulcent action on mucous membranes and Jhus prevents spasm, but its effectiveness varies considerably from patient to patient. Preparations containing sodium bicarbonate are not recommended. True, they often afford relief by facilitating a good belch; but in so doing they do not correct the basic functional disorder. Vitamins
Clear cut vitamin deficiencies, particularly of the vitamin 13 complex, are known to affect gastro-intestinal function markedly. On the other hand, no conclusive evidence has been presented that any vitamin or group of vitamins specifically controis. gastro-intestinal motility. deciding whether a functional intestinal disturbance should be treated with vitamin supplements, the physician must evaluate the adequacy of a patient's vitamin intake in view of the patient's size and physical activity. If the intake has been inadequate, then those vitamins are indicated in which the diet has been deficient, whether or not such vitamins are said to be concerned with gastro-intestinal function. For instance, the man who hates fruits should receive additional cevitamic acid. Usually, however, the vitamin B complex is needed. Some of the requirements will be supplied by the meat, milk and cereals of the diet listed previously. This diet can be fortified by giving 2 to 4 tablets (1 to 2 gm., 15 to 30 grains) of dried brewers' yeast or one teaspoonful (2 gm., 30 grains) or brewers' yeast powder with each meal. According to the Council on Foods and Nutrition of the American Medical Association,5 such yeast preparations should contain at least
In
"IRRITABLE STOMACH" AND "IRRITABLE COLON"
1393
0.12 mg. of thiamine hydrochloride, 0.04 mg. of riboflavin, and 0.25 mg. of nicotinic acid per gram.
If the patient's diet has been quite inadequate, onc of the concentrated preparations of the vitamin B complex or combin~ tions of such of its isolated fractions as are available may be urescribed. According to our present knowledge, these fractions should be used in the following proportions;5 Thiamine Hydrochloride .... ,.,"',." .. , .,', ....... ,
Riboflavin , .. , .. " .. ,.,., ... ,"',.,"",.,.,', .... ,.,'
I
part
2 parts Nicotinic Acid ........ , ........... , ....... , ....... ,. 10 parrs
TREATMENT OF THE "IRRITABLE COLON"
General Rules 1. Establish regular bowel habits. Every morning, about 10 to 20 minutes after breakfast, the patient should go to the bathroom and try to have a bowel movement. He should spend at least ten minutes in the attempt, but he should not strain. Obviously, he will not be successful at first, but in time a gastrocolic reflex will be established and spontaneous bowel movements will occur. In order to carry the regimen through to success, the patient must exercise will power and take the necessary time. Many a normal bowel function is disrupted in persons who are too hurried to move their bowels when they feel the need to do so. 2. The following rules apply to the patient with "irritable colon" as well as to the patient with "irritable stomach":
(a) The diet must be nutritionally adequate.
(b) Food should be taken regularly and at least three times daily.
(c) Rapid ingestion of ice-cold foods and gum chewing are for-
bidden.
(d) Smoking and alcohol are allowed in moderation.
3. Water drinking. The consumption of large quantities of water increases the water content of the urine, not of the feces. The drinking of hot water on arising does, at times, promote bowel evacuation, but usually does so by initiating a gastrocolic reflex, not by softening the feces. Although no harm comes from taking water for this purpose, no particular advantage is derived from such a practice. The large bowel can be
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conditioned to empty itself after a good breakfast as well as after a glass or two of steaming hot water. Diet
The diet recommended for the patient with an "irritable colon" is similar to that given to the patient with an "irritable stomach" (q.v.) except that the patient with the dysfunction of the colon may eat fatty foods. Its main purpose is to avoid rough and sharp, undigestible residues which might induce more spasm. The bulk of the feces should be of average size; the abnormally functioning bowel is not helped by forcing it to transport and expel a huge fecal mass. Laxatives and Enemas
All irritant enemas and laxatives promote immediate expulsion of the colonic contents, but they leave behind a residual spasm which tends to aggravate any functional disorder which may be present. Hence all laxatives and enemas are excluded with the following exceptions: 1. Mineral oil. If the patient has scybalous movements which cause pain in passing the anus, or which are covered with streaks of blood-tinged mucus, mineral oil is prescribed. The dose should be sufficient to soften the feces. If leakage occurs, too much oil is being given. Usually Y2 to 1 ounce daily is sufficient. The dose should be given at bedtime, since mineral oil interferes with the absorption of carotene and possibly also with the absorption of vitamins D and K. The absorption of vitamin A itself is not impaired by liquid petrolatum. 2. Saline enemas (1 teaspoonful of table salt per pint of water) are allowed if no movement occurs for three days. Once the patient is having spontaneous movements, the mineral oil should be gradually withdrawn. If its administration is stopped too abruptly, some of the patient's symptoms may recur. Heat
Symptomatic relief is often obtained by applying heat over that abdominal area where the patient experiences the most distress.
"IRRITABLE STOMACH" AND "IRRITABLE COLON"
1395
Drugs
As in the case of "irritable stomach," drugs are given as adjuvants in helping the bowel re-establish a normal motor function. Atropine and its derivatives may be given in the same dosages as outlined above. According to Atkinson et al.,6 atropine and trasentin are more effective than syntropan. In constantly worried or depressed individuals, benzedrine sulfate, which also is a mild antispasmodic, can be advantageously combined with belladonna or trasentin: Trasentin Benzedrine Sulfate 00000
000000
00
75 mgo (grains gi) toi.d. 5 mg. (grain ~2) b.i.d. morning and noon
000000
••••
00.
In more excitable patients, atropine-like drugs and sedatives can be combined: Atropine Sulfate . 30.0 cc. (~ 1) Elixir Phenobarbital ............................ oqs. ad 180.0 (~ 6) Sig.: 4 cc. (3i) t.i.d. a.c. 0
•
0
0
0
0
•
0
0
0
0
0
0
0
0
0
0
0
•••
0
••••
0
••••
0
0
•••
0
Any of the drugs listed here should not be used continually for more than a month. Offhand, it would appear that drugs which stimulate colonic motility would not be of use in treating the "irritable colon." One must distinguish, however, between propulsive and nonpropulsive motility, which includes local spasm. Hence, it is at times rational to treat the "irritable colon" with drugs which stimulate propulsive motility. The drug of choice here is prostigmine bromide, one tablet (15 mg. or grain) of which is given by mouth at breakfast time. If results are still unsatisfactory, prostigmine and ergotamine tartrate, which act synergistically1, can be given together:
*
Prostigmine Bromide o. 7.5 mg. or 15 mg. (gr. Ergotamine Tartrate ............ 1.0 mg. (gr. 1;60) p.o. .0.
0
0
0
0
•
0
0
% or lA) p.o.
These drugs are very effective in promoting a good evacuation and may be used in aiding the patient establish normal bowel habits. Ergotamine, of course, must be used with caution; the daily dose of 1 mg. should not be given for a period of more than fifteen days. In patients whose functional disorder gives rise to considerable pain, prostigmine and ergotamine should be used with care since the pains may be aggravated. In general,
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INGELFINGER
the use of these drugs should be reserved for those patients whose colonic disorders have not responded to other measures. SUMMARY
Many functional disorders of the gastro-intestinal tract are produced by an abnormal and uncoordinated motor behavior of the stomach and bowels. These disorders can best be treated by relieving the patient of undue emotional and mental tension and by establishing orderly habits of eating and elimination. BIBLIOGRAPHY
1. Miller, T. G.: The Causes of Indigestion and Their Recognition. New England J. Med., 224:537, 1941. 2. Guy, R.: Vitamins and the General Practitioner. MED. CLlN. N. AM., 26;
1347 (Sept.) 1942. 3. Food charts prepared by a Joint Committee of the Council on Foods and Nutrition of the American Medical Association and of the Food and Nutrition Board of the National Research Council. Distributed by Mead Johnson & Company. 4. Ingelfinger, F. J. and Moss, R. E.: The Activity of the Descending Duodenum During Nausea. Am. J. Phys., 136:561, 1942. 5. The Proper Use of Vitamins in Mixtures. Report of Council on Foods and Nutrition. J.A.M.A., 119:948, 1942. 6. Atkinson, A. ]., Adler, H. F. and Ivy, A. c.: Motility of the Human Colon: The Normal Pattern, Dyskinesia and the Effect of Drugs. J.A.M.A., 121:646, 1943.
7. Adlcr, H. F., Atkinson, A. ]. and Ivy, A. C.: Supplementary and Synergistic Action of Stimulating Drugs on the MotIlity of the Human Colon Surg., Gynec. and Ohst., 74:809, 1942.
Olt' any group of patients with gastro-intestinal complaints, a large number suffer from functional disorders of the digestive tract. 1 These patients, when subjected to a careful history and physical examination, as well as appropriate laboratory procedures, are found to be free from organic disease. Even a laparotomy would fail to reveal any morbidity of the ahdominal viscera. Yet these patients are not helpless psychopaths or in4 veterate neurotics; their distress is real enough, and they derive little solace from being told that they should forget their symptoms. Such an attitude of therapeutic nihilism is often adopted by the physician because the lack of an organic lesion which is remediable by specific therapy makes treatment difficult and unrewarded by dramatic results. Nevenheless, the patient with functional gastro-intestinal abnormalities-be they abnonnalities of motility, secretion, or absorption-deserves as carefully planned a regimen as the patient with organic disease. In thIS clinic, plans for treating two common functional disorders of gastro-intestinal motility will be presented. For want of better names, these disorders can be called "irritable stomach" and "irritable colon." Definitions of Syndromes
The patient with "irritable stomach" complains of (I) postcibal fullness and pressure in the epigastrium, (2) belching, bloating and eructations, (3) more or less intolerance to certain foods, usually fatty, and (4) varying degrees of nausea. ------------------_._--------- -
--
* From the Evans Memorial, Massachusetts Memorial Hospitals and the
Dl:partment of Medicine, Boston University School of Medicine. t Assistant Professor of Medicine, Boston University Medical School; Associate, Evans Memorial, Massachusetts Memorial Hospitals; Chief, Gastrointestinal Clinic, Outpatient Depanment and Assistant Visiting Physician, Massachusetts Memorial Hospitals. 1385
1386
FRANZ
J.
INGELFINGER
The patient with "irritable colon" complains of (1) intermittent dull pains usually located over the cecum or the sigmoid, (2) constipation and small, hard bowel movements covered by strands of mucus, and (3) borborygmic flatulence. Frequently the two syndromes are concomitant; often they are associated with the habitual use of laxatives. Frequently, too, they are less prominent during periods of physical activity. Abnormal Physiology
Gastro-intestinal motility in anyone area depends on: (1) the nature and the amount of intestinal contents; (2) the local motor reaction stimulated by the presence of the contents; (3) the resistance to the outflow of the contents, which is determined by the motor activity of adjoining intestinal areas, particularly of those lying distally; and (4) nervous and humoral influences of intestinal or extra-intestinal origin. Normally these factors are so balanced that the movement of chyme and gas in the intestinal tract does not occasion any unpleasant sensations. Should an acute intestinal obstruction occur, the balance would obviously be destroyed, and the disorganized intestinal motility would give rise to violent symptoms of colic, distention, nausea and vomiting. In functional disorders, the process is not so acute, but qualitatively the same thing happens: the balance and integration between various parts of the gastrointestinal tract are upset, and the abnormal motor function makes itself known in the guise of "gas pains," borborygmi, fullness, or nausea. Abnormal motor function in the absence of organic disease of the intestinal tract and of other organs can in a large number of cases be ascribed to (1) emotional and neurogenic influences and (2) poor habits of e.ating and elimination. It is on these causes that our therapeutic attention must be focused. TREATMENT OF THE INDIVIDUAL
Whether we are treating the "irritable stomach" or the "irritable colon," our treatment of any abnormal emotional and psychogenic conditions affecting gastro-intestinal motility will be the same. Observance of the following procedures is recommended. 1. Relieve the patient of any fear or worr), that his symptoms
"IRRITABLE STOMACH" AND "IRRITABLE COLON"
1387
may occasion. The first prerequisite in attaining this end is a careful and thorough examination in which all necessary clinical and laboratory tests should be utilized. The patient must be convinced that the physician is speaking on the basis of factual knowledge rather than on the basis of superficial impressions. Explain to the patient the nature of his symptoms. This is not done by telling him that nothing is the matter. His symptoms are more persuasive than such brief reassurance, and he will seek relief elsewhere. Nor is it a good plan in most instances to tell him that he is nervous or that he has a "nervous stomach." Many patients resent having their symptoms ascribed to nervousness, even though it may be the truth, and some will even misinterpret the physician's statement and believe themselves to be accused of harboring imaginary ills. Instead, the patient is simply told that his stomach, or his bowel, is not performing its work properly. This statement is elucidated by making an analogy. One of the best is to compare the patient's intestinal tract to a motor whose component parts are in perfect shape but which runs poorly because the timing mechanism is improperly adjusted. The delicate timing mechanism of his intestinal activity, the patient is told in further explanation, is subject to change by mental tension, strong emotion, and poor dietary habits. To emphasize this point, the patient can be reminded that violent anger kills the best appetite, that diarrhea may be caused by tense anticipation. Once a patient understands the nature of his symptoms, his fear of them, his dread of cancer, is in good part alleviated; and the physician has eliminated one of the psychogenic influences which often helps to perpetuate a functional disorder. 2. Warn the patient that a dramatic cure cannot be expected. Since functional disorders are often of long standing, of obscure origin, and not subject to specific therapy, it is understandable that their correction cannot be a matter of days. It may, for instance, take a year to cure a well-established laxative habit. The patient should be apprised of this fact, for otherwise he may be disappointed at the slow progress and drop the presc"ribed regimen. 3. Try to ascertain the specific background for mental tension. Should the patient's functional disorders represent the expression of deep-seated emotional or mental tension, the phys-
1388
FRANZ
J.
INGELFINGER
ician is confronted by a true problem in psychosomatic medicine. In some instances, the assistance of a psychiatrist must be sought. In many cases, however, the causes for the state of tension are obvious enough and can be traced to social, economic, marital, or sexual difficulties. Obviously the physician must try to help the patient either in removing the offending cause or in making an adjustment to an unalterable situation. 4. Use sedatives lightly. General sedation may be practiced in moderation and always with the understanding that it represents a temporary measure. Well-known drugs can be used: Phenobarbital. . . . . . . . . . . . . . . .. 30 mg. (grain ¥.l) b.i.d. or d.d. Sodium or Triple Bromide .. ,. 0.5 to 1.0 gm. (grains 7¥.! to 15) b.i.d. or t.i.d.
These drugs can be used in combination with those advocated in subsequent paragraphs. 5. Physical and mental activity. Exhausting physical exercise or intense mental activity may temporarily relieve the patient, but subsequently the symptoms return, often with increased severity. Enforced idleness and long periods of rest are likewise of questionable value since they give the patient time to ponder his symptoms. It appears, therefore, that the patient should avoid extremes of physical and mental activity. Depending on the patient's habits and occupation, the physician should, however, recommend such changes as he believes would benefit the patient's general health and fitness. TREATMENT OF THE "IRRITABLE STOMACH"
The Diet 1. The diet 'lnUst be nutritionally adequate. Whatever diet
is used, it must be adequate in respect to calories, proteins, minerals and vitamins. The tables published in a previous number of these clinics by Dr. Ruth Guy2 or the Food Charts prepared under the auspices of the American Medical Association3 offer concise information concerning the food requirements of adults. Unless these requirements are met, more harm than good will be derived from the dietary regimen. This is particularly true of functional gastro-intestinal disorders which may find their origin in poor dietary habits and malnutrition. Only in the case of obese persons can an exception be made. In these patients, it is often of advantage to reduce the caloric intake
"IRRITABLE STOMACH" AND "IRRITABLE COLON"
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(i.e., fats and carbohydrates) while treating the gastric complaints. 2. Food should be taken regularly and at least three times daily. The gastro-intestinal tract becomes conditioned to regular habits of food intake, and the motility of the esophagus, stomach. and small intestine tends to be better coordinated if these regular habits are observed. This does not mean that the patient may not have a bedtime or midafternoon snack, but it does mean that irregular nibbling of food, particularly of candy, should be interdicted. Gum chewing is likewise taboo as it stimulates gastric functions at irregular intervals and promotes aerophagia. The patient should be encouraged to eat some breakfast. Many persons who suffer from an "irritable stomach" complain of anorexia and nausea in the morning. As a result, they either take no breakfast or, at the most, a cup of coffee. All the factors involved in the symptom of nausea are not clear, but it is probable that the motor activity of the upper intestinal tract is abnormal during nausea.4 Hence, the regular ingestion of breakfast, even though the patient may experience difficulties at first, helps condition the re-establishment of normal motility and gradients. 3. "Better is a dry morsel and quietness therewith than a house full of feasting 'With strife." This often-used quotation from Proverbs, 17, 1, paraphrases another rule which the patient with functional disorders must obey. He must take enough time for meals. Also, while eating, he must avoid as much as possible any disquieting influences, be they physical or mental. 4. Ice-cold food or drink should not he poured into the stomacb, especially if this organ is empty. For example, a glass of icecold juice taken the first thing in the morning is inadvisable, bur lIttle harm will come of taking ice cream slowly at the end of a full meal. S. Smoking in ordinary amounts (less than 10 cigarettes a day) apparently does not disrupt favorable gastro-intestinal motility when food has been taken recently. Smoking on the empty stomach should, however, be prohibited. 6. Alcobol in small amounts stimulates gastric secretion and motility and, temporarily at least, allays nervous tension. Hence a pre-meal cocktail, a glass of wine, or a liqueur is not neccs-
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sarily detrimental to the "irritable stomach." Individual response to alcoholic drinks varies considerably, however, and the pros and cons of allowing alcohol must be weighed on the patient's specific reactions to alcoholic intake. In any case, anything more than light drinking should not be countenanced. 7. Food. The accompanying table lists the foods which should and which should not be given. Fats are given in small amounts because their normal action of reducing the gastro-duodenal DIET LIST FOR PATIENTS WITH "IRRITABLE STOMACH" AND "IRRITABLE COLON"
Choice of:
Breakfast
Fruit .............. . ...... Juices, grapefruit or orange flesh (avoid membranes), peaches (peeled), ripe strawberries, ripe bananas, cooked fruits (no seeds or skins) Cereal with milk ........... Any cooked cereal not containing bran, or a dry cereal such as corn flakes, puffed rice, dry oatmeal products Eggs ....................... Boiled, poached, or baked Bread ................. . ... Enriched white, finely milled rye. May be toasted. Sugar, honey ............... As desired . .. As desired Milk .......... Coffee ........ 1 cup . ....... Not more than 1 pat Butter ....... Cream .. ' ...... Not more than 1 tablespoonful Clear jelly ....... As desired
Noon and Evening Meals Choice of: Soups ..................... Pureed vegetable soups, clear bouillon, clear broths containing no fat Meat ....... All varieties allowable except spiced meats, sausages, frankfurters, fat, gristle. Avoid fried meats. Fish ............... . ..... Haddock, halibut, cod, filet of sole, and other fish with white flesh. Avoid fried, spiced, kippered and oily fish. . ..... Lobster Shellfish .... Fowl ...................... Chicken, turkey. Avoid fat and skin. Do not fry. Eggs ......... . ..... Boiled, poached or baked Cheese ......... . .........• Cottage, cream, muenster Milk ...................... As desired . ... Enriched white bread, potatoes (not fried), Starch products ... spaghetti, macaroni, noodles, rice. Use unspiced and pureed tomato sauces.
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Vegetables ...
. ....... String beans, carrots, fall squash, peas, beets, asparagus, strained tomatoes. Broccoli, spinach and lima beans may be allowed if patient does well. Butter ................... Not more than 1 pat per meal Dessert .... . ...... Junket, jello, custard, fruit whips made with egg-white, cooked fruits (no seeds or skins), ice cream, starch or rice puddings (no raisins)
Avoid the Following Foods: Spices, relishes, pickles, mustard, hot sauces Fried foods All vegetableS! not listed above All raw vegetables Any food containing seeds or skins Bran products Notes: I. The patient with the "irritable colon" does not have to restrict his butter and cream consumption. He may also eat some fried foods, if care is taken to remove excess grease. H. From nutritional viewpoint, following minimum daily intakes are advisable: 1. Fresh fruit or juice daily 2. Two green or yellow vegetables daily 3. Choice of: (a) 4 glasses milk, meat or fish (b) Dark cereal, meat or fish, cheese, 1 egg (c) 2 glasses milk, 2 eggs, meat or fish (d) Dark cereal, 3 glasses milk, 1 egg, cheese
gradient apparently is deranged in patients with the "irritable stomach" syndrome. As a rule, those foods and drinks are excluded which appear to affect gastro-intestinal motility adversely. Drugs
Drugs should be considered merely as temporary adjuvants in the attempt to re-establish normal gastro-intestinal functions. The antispasmodic drugs typified by atropine can be used in the following dosages: Tincture of Belladonna Sig.: 12 drops in one-half glass of water t.Ld. a.c. Trasentin .................. 75 mg. (grains 1*) (Ciba) Sig.: 1-2 tablets t.i.d. a.c. Syntropan ................. 50 mg. (grain %) (Hoffman-LaRochc) Sig.: 1 tablet t.i.d. a.c. Novatropine ............... 2.5 mg. (grain :V24) (Campbcll products) Sig.: 1-2 tablets t.i.d. a.c.
Our own preference lies with belladonna and trasentin.
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It may occasion surprise that atropine-like drugs which depress gastro-intestinal motility should be used in correcting a disorder which may be characterized by abnormal gradients of intestinal pressures. The rationale for the treatment lies in the fact that atropine affects all portions of the gastro-intestinal tract. Hence an integrated motility under the influence of atropine will replace a functional motor disorder, even though the motility of the digestive tract as a whole will be depressed. On empirical grounds, an inert powder such as bismuth subnitrate may be used in doses of 2 to 4 gm. (Y2 to 1 dram) before meals. Supposedly it exerts a demulcent action on mucous membranes and Jhus prevents spasm, but its effectiveness varies considerably from patient to patient. Preparations containing sodium bicarbonate are not recommended. True, they often afford relief by facilitating a good belch; but in so doing they do not correct the basic functional disorder. Vitamins
Clear cut vitamin deficiencies, particularly of the vitamin 13 complex, are known to affect gastro-intestinal function markedly. On the other hand, no conclusive evidence has been presented that any vitamin or group of vitamins specifically controis. gastro-intestinal motility. deciding whether a functional intestinal disturbance should be treated with vitamin supplements, the physician must evaluate the adequacy of a patient's vitamin intake in view of the patient's size and physical activity. If the intake has been inadequate, then those vitamins are indicated in which the diet has been deficient, whether or not such vitamins are said to be concerned with gastro-intestinal function. For instance, the man who hates fruits should receive additional cevitamic acid. Usually, however, the vitamin B complex is needed. Some of the requirements will be supplied by the meat, milk and cereals of the diet listed previously. This diet can be fortified by giving 2 to 4 tablets (1 to 2 gm., 15 to 30 grains) of dried brewers' yeast or one teaspoonful (2 gm., 30 grains) or brewers' yeast powder with each meal. According to the Council on Foods and Nutrition of the American Medical Association,5 such yeast preparations should contain at least
In
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0.12 mg. of thiamine hydrochloride, 0.04 mg. of riboflavin, and 0.25 mg. of nicotinic acid per gram.
If the patient's diet has been quite inadequate, onc of the concentrated preparations of the vitamin B complex or combin~ tions of such of its isolated fractions as are available may be urescribed. According to our present knowledge, these fractions should be used in the following proportions;5 Thiamine Hydrochloride .... ,.,"',." .. , .,', ....... ,
Riboflavin , .. , .. " .. ,.,., ... ,"',.,"",.,.,', .... ,.,'
I
part
2 parts Nicotinic Acid ........ , ........... , ....... , ....... ,. 10 parrs
TREATMENT OF THE "IRRITABLE COLON"
General Rules 1. Establish regular bowel habits. Every morning, about 10 to 20 minutes after breakfast, the patient should go to the bathroom and try to have a bowel movement. He should spend at least ten minutes in the attempt, but he should not strain. Obviously, he will not be successful at first, but in time a gastrocolic reflex will be established and spontaneous bowel movements will occur. In order to carry the regimen through to success, the patient must exercise will power and take the necessary time. Many a normal bowel function is disrupted in persons who are too hurried to move their bowels when they feel the need to do so. 2. The following rules apply to the patient with "irritable colon" as well as to the patient with "irritable stomach":
(a) The diet must be nutritionally adequate.
(b) Food should be taken regularly and at least three times daily.
(c) Rapid ingestion of ice-cold foods and gum chewing are for-
bidden.
(d) Smoking and alcohol are allowed in moderation.
3. Water drinking. The consumption of large quantities of water increases the water content of the urine, not of the feces. The drinking of hot water on arising does, at times, promote bowel evacuation, but usually does so by initiating a gastrocolic reflex, not by softening the feces. Although no harm comes from taking water for this purpose, no particular advantage is derived from such a practice. The large bowel can be
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conditioned to empty itself after a good breakfast as well as after a glass or two of steaming hot water. Diet
The diet recommended for the patient with an "irritable colon" is similar to that given to the patient with an "irritable stomach" (q.v.) except that the patient with the dysfunction of the colon may eat fatty foods. Its main purpose is to avoid rough and sharp, undigestible residues which might induce more spasm. The bulk of the feces should be of average size; the abnormally functioning bowel is not helped by forcing it to transport and expel a huge fecal mass. Laxatives and Enemas
All irritant enemas and laxatives promote immediate expulsion of the colonic contents, but they leave behind a residual spasm which tends to aggravate any functional disorder which may be present. Hence all laxatives and enemas are excluded with the following exceptions: 1. Mineral oil. If the patient has scybalous movements which cause pain in passing the anus, or which are covered with streaks of blood-tinged mucus, mineral oil is prescribed. The dose should be sufficient to soften the feces. If leakage occurs, too much oil is being given. Usually Y2 to 1 ounce daily is sufficient. The dose should be given at bedtime, since mineral oil interferes with the absorption of carotene and possibly also with the absorption of vitamins D and K. The absorption of vitamin A itself is not impaired by liquid petrolatum. 2. Saline enemas (1 teaspoonful of table salt per pint of water) are allowed if no movement occurs for three days. Once the patient is having spontaneous movements, the mineral oil should be gradually withdrawn. If its administration is stopped too abruptly, some of the patient's symptoms may recur. Heat
Symptomatic relief is often obtained by applying heat over that abdominal area where the patient experiences the most distress.
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Drugs
As in the case of "irritable stomach," drugs are given as adjuvants in helping the bowel re-establish a normal motor function. Atropine and its derivatives may be given in the same dosages as outlined above. According to Atkinson et al.,6 atropine and trasentin are more effective than syntropan. In constantly worried or depressed individuals, benzedrine sulfate, which also is a mild antispasmodic, can be advantageously combined with belladonna or trasentin: Trasentin Benzedrine Sulfate 00000
000000
00
75 mgo (grains gi) toi.d. 5 mg. (grain ~2) b.i.d. morning and noon
000000
••••
00.
In more excitable patients, atropine-like drugs and sedatives can be combined: Atropine Sulfate . 30.0 cc. (~ 1) Elixir Phenobarbital ............................ oqs. ad 180.0 (~ 6) Sig.: 4 cc. (3i) t.i.d. a.c. 0
•
0
0
0
0
•
0
0
0
0
0
0
0
0
0
0
0
•••
0
••••
0
••••
0
0
•••
0
Any of the drugs listed here should not be used continually for more than a month. Offhand, it would appear that drugs which stimulate colonic motility would not be of use in treating the "irritable colon." One must distinguish, however, between propulsive and nonpropulsive motility, which includes local spasm. Hence, it is at times rational to treat the "irritable colon" with drugs which stimulate propulsive motility. The drug of choice here is prostigmine bromide, one tablet (15 mg. or grain) of which is given by mouth at breakfast time. If results are still unsatisfactory, prostigmine and ergotamine tartrate, which act synergistically1, can be given together:
*
Prostigmine Bromide o. 7.5 mg. or 15 mg. (gr. Ergotamine Tartrate ............ 1.0 mg. (gr. 1;60) p.o. .0.
0
0
0
0
•
0
0
% or lA) p.o.
These drugs are very effective in promoting a good evacuation and may be used in aiding the patient establish normal bowel habits. Ergotamine, of course, must be used with caution; the daily dose of 1 mg. should not be given for a period of more than fifteen days. In patients whose functional disorder gives rise to considerable pain, prostigmine and ergotamine should be used with care since the pains may be aggravated. In general,
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the use of these drugs should be reserved for those patients whose colonic disorders have not responded to other measures. SUMMARY
Many functional disorders of the gastro-intestinal tract are produced by an abnormal and uncoordinated motor behavior of the stomach and bowels. These disorders can best be treated by relieving the patient of undue emotional and mental tension and by establishing orderly habits of eating and elimination. BIBLIOGRAPHY
1. Miller, T. G.: The Causes of Indigestion and Their Recognition. New England J. Med., 224:537, 1941. 2. Guy, R.: Vitamins and the General Practitioner. MED. CLlN. N. AM., 26;
1347 (Sept.) 1942. 3. Food charts prepared by a Joint Committee of the Council on Foods and Nutrition of the American Medical Association and of the Food and Nutrition Board of the National Research Council. Distributed by Mead Johnson & Company. 4. Ingelfinger, F. J. and Moss, R. E.: The Activity of the Descending Duodenum During Nausea. Am. J. Phys., 136:561, 1942. 5. The Proper Use of Vitamins in Mixtures. Report of Council on Foods and Nutrition. J.A.M.A., 119:948, 1942. 6. Atkinson, A. ]., Adler, H. F. and Ivy, A. c.: Motility of the Human Colon: The Normal Pattern, Dyskinesia and the Effect of Drugs. J.A.M.A., 121:646, 1943.
7. Adlcr, H. F., Atkinson, A. ]. and Ivy, A. C.: Supplementary and Synergistic Action of Stimulating Drugs on the MotIlity of the Human Colon Surg., Gynec. and Ohst., 74:809, 1942.