Dear Dr. Roach: My 18-year-old daughter has had digestive problems on and off for a few years now. Her appendix was removed in March 2015. She had brutal abdominal pain, but the ultrasound scan didn’t show anything wrong with her appendix. Summer 2018, she started having bad digestion problems. She could hardly hold anything in. The food came back out, either by diarrhea or vomiting.
Our family doctor sent her to a pediatric gastroenterologist. She had a complete workup, including stool cultures, the entire thing. They found nothing wrong with her. Now she has noticed that eating anything warm makes her feel “wobbly.” She often eats a popsicle when that happens, and the “wobbliness” magically disappears.
Do you think it could be a problem with her vagus nerve? Our family doctor is not taking this possibility seriously at all and will not investigate it. She now has diarrhea only once or twice a month, which starts with pain or discomfort. She occasionally still has vomiting. The abdominal discomfort gets somewhat better after a bowel movement, but it’s really the popsicle that makes it get better. — J.M.
Answer: Abdominal pain and changes in the bowel, especially in a young woman, should make the doctor consider irritable bowel syndrome. IBS is a disorder with how the bowel functions. It is extremely common, but many patients do not seek medical attention. People with irritable bowel syndrome may have diarrhea, constipation or both, in addition to the abdominal pain. Relief of abdominal discomfort with a bowel movement supports the diagnosis of IBS.
The vagus nerve is the major nerve going to the abdominal organs, sending information to them and receiving information back. A major theory about the underlying cause of IBS is that there’s an increased sensitivity to intestinal distension — bloating — although there are many other possibilities. So, in a sense, IBS is at least partially brought on by the vagus nerve — even though the actual abnormality may be either in the gut or perhaps in the signal processing area of the brain.
People with IBS generally find that certain foods trigger symptoms; however, I was able to find reports of people in whom meal temperature was a major catalyst. Both too-cold meals and too-hot meals can bring on IBS. If a too-hot meal was a problem, it makes sense something cold may help, although some people can be triggered by both.
IBS is a diagnosis that should be made only after evaluation of other causes. Some of these are serious, such as inflammatory bowel disease. Evaluation usually includes a colonoscopy and/or an upper endoscopy. A new test, the fecal calprotectin level, is helpful at excluding IBD, especially in people with low inflammatory markers, such as C-reactive protein, in the blood. Celiac disease should also be considered. Vomiting, however, is not a common finding in IBS (even though it does happen in some people) and that should bring up the possibility of gallbladder disease.
Treatment for IBS needs to be individualized and starts with avoiding triggers.
In your daughter’s case, that clearly includes hot foods, but gas-producing foods — beans, broccoli, onions, dried fruits and many others — are commonly on that list as well. Lactose, a sugar found in milk, is another. For people in whom simple dietary advice is not helpful, I recommend a visit with a dietitian nutritionist to consider a low FODMAP diet (fermentable oligo-, di-, and monosaccharides and polyols; these are difficult-to-absorb carbohydrates found in many foods).
I can only scratch the surface of this complex disease. There are many good places to find out more, including https://gi.org/topics/irritable-bowel-syndrome/.
