Neuromodulation
IBS and Spinal Cord Stimulation
By: Elliot Krames, MD
Irritable bowel syndrome (IBS) is a gastrointestinal (GI) disorder that interferes with the normal function of the large intestine. People with IBS may experience abdominal pain, cramping, diarrhea, constipation and bloating. IBS is the most common GI disorder seen in primary care and gastroenterology practices in the United States and is one of the most common disorders diagnosed by doctors. Researchers estimate that 10-20% of Americans have the disorder and as many as 1-2% of Americans are diagnosed with IBS each year. About 10-20% of people with IBS seek medical care.1
People with IBS miss work more frequently than people who do not have the disorder.2 Americans and Europeans demonstrate similar frequency of IBS. Researchers and health care professionals are unclear what role different cultural influences and varying health care seeking behaviors play in the disorder. Women in western countries are two to three times more likely to have IBS than men. Patients often report that they first began experiencing abdominal pain and altered bowel habits during childhood and about 50% of patients with IBS report their symptoms began before they reached their 30s. Fibromyalgia is a common co-morbid disease.3,4,5
IBS can be a life-altering disorder – it causes pain and distress and can be disabling. Some people with IBS are unable to work, engage in social activities or travel even short distances. IBS does not, however, permanently damage the intestines.
Physicians using conservative therapies to treat IBS include treating pain and correcting altered GI movement, teaching patients to acknowledge their personal stressors and use stress avoidance techniques, psychiatric treatment if indicated, fiber supplements, increased fluid intake, and avoiding certain substances, such as caffeine and green beans. Medications for IBS are targeted to the treat the most troubling symptom the patient is experiencing. For example, if the patient has abdominal pain, the most frequent medications used are antispasmodics, which decrease the motility of the bowels. Antispasmodics are especially helpful in people whose pain comes on after meals. When constipation is the predominant symptom, fiber or psyllium products and some other medications such as sorbitol or lactulose can be helpful. If diarrhea is the predominant symptom, opioids (narcotics) can be useful in decreasing the diarrheal episodes.6,7,8
Doctors may use psychological treatment when the patient's symptoms of pain and diarrhea are associated with psychological distress. Psychologic care reduces anxiety, encourages health-promoting behavior, gives the patient some control in their treatment and improves pain tolerance.9
A relatively small number of patients with IBS report constant pain and have severe symptoms that persist in spite of good medical care. These patients often are unable to perform activities of daily living (e.g., work, travel), see their doctors more often than others and have psychosocial difficulties such as anxiety, depression, personality disturbance, and an increased focus on their bodies.10 These patients may not believe that their emotions may have something to do with their increase in pain and distress. They may not want to participate in psychological treatments, but such treatments are effective in decreasing both emotional distress and pain.
In the past, medical professionals believed IBS was a disorder of bowel motion or motility only; however, most doctors now view IBS as an abnormality in the interaction between bowel function and central nervous system functions. In other words, IBS symptoms may arise from complex interactions between the brain, the spinal cord and the bowels themselves. In effect, IBS, like many chronic pain problems, is a neuropathic process – an abnormal interpretation of the signals of the nervous system – that might respond to spinal cord stimulation (SCS). Spinal cord stimulation is a therapy where electrical signals produced by an implanted device confuse the abnormal signals in the spinal cord. The system converts the abnormal signals to normal signals, reducing pain and other symptoms related to IBS.
Based on a single literature report on the use of spinal cord stimulation in a rat model of IBS where the rats treated with SCS had complete restitution of their diarrheal episodes11, this author placed a SCS system into a patient who had intractable IBS with severe, narcotic insensitive pain and diarrheal episodes that was pushing her to the brink of suicide. Immediately after implanting an SCS system, this patient's diarrhea stopped and her pain significantly decreased. After three months, she continued to be diarrhea free; however her pain increased to the point she required the placement of an intrathecal opioids delivery system (i.e., a pump to deliver medication directly to the affected site). Today, this patient is no longer suicidal. As she has expressed in her own story, she "has her life back!" We have published our experience and scientific explanation for the use of SCS in IBS in the journal Neuromodulation.12
Patients should be cautious when considering any surgical treatment and physicians should not rush to place spinal cord stimulators in their patients with intractable IBS. This is only one case report and not science. A well-designed, multi-centered randomized controlled study is necessary to establish SCS as an appropriate therapy for severe IBS. Readers also should realize that this patient only underwent SCS after a long and frustrating course of interdisciplinary pain care that involved the individual expertise of psychologists, gastroenterologists, and pain physicians. This author, expert in interdisciplinary care and interventional pain management, only used SCS in the above patient as last resort therapy after all conventional therapies including pharmacologic management, psychologic care, and other interventions had failed and her quality of life was severely compromised. As with any surgical procedure, there are risks associated with SCS. Patients should find expert and experienced surgeons and discuss all their treatment options with their physicians.
People with IBS miss work more frequently than people who do not have the disorder.2 Americans and Europeans demonstrate similar frequency of IBS. Researchers and health care professionals are unclear what role different cultural influences and varying health care seeking behaviors play in the disorder. Women in western countries are two to three times more likely to have IBS than men. Patients often report that they first began experiencing abdominal pain and altered bowel habits during childhood and about 50% of patients with IBS report their symptoms began before they reached their 30s. Fibromyalgia is a common co-morbid disease.3,4,5
IBS can be a life-altering disorder – it causes pain and distress and can be disabling. Some people with IBS are unable to work, engage in social activities or travel even short distances. IBS does not, however, permanently damage the intestines.
Traditional Therapies for IBS
Physicians using conservative therapies to treat IBS include treating pain and correcting altered GI movement, teaching patients to acknowledge their personal stressors and use stress avoidance techniques, psychiatric treatment if indicated, fiber supplements, increased fluid intake, and avoiding certain substances, such as caffeine and green beans. Medications for IBS are targeted to the treat the most troubling symptom the patient is experiencing. For example, if the patient has abdominal pain, the most frequent medications used are antispasmodics, which decrease the motility of the bowels. Antispasmodics are especially helpful in people whose pain comes on after meals. When constipation is the predominant symptom, fiber or psyllium products and some other medications such as sorbitol or lactulose can be helpful. If diarrhea is the predominant symptom, opioids (narcotics) can be useful in decreasing the diarrheal episodes.6,7,8
Doctors may use psychological treatment when the patient's symptoms of pain and diarrhea are associated with psychological distress. Psychologic care reduces anxiety, encourages health-promoting behavior, gives the patient some control in their treatment and improves pain tolerance.9
A relatively small number of patients with IBS report constant pain and have severe symptoms that persist in spite of good medical care. These patients often are unable to perform activities of daily living (e.g., work, travel), see their doctors more often than others and have psychosocial difficulties such as anxiety, depression, personality disturbance, and an increased focus on their bodies.10 These patients may not believe that their emotions may have something to do with their increase in pain and distress. They may not want to participate in psychological treatments, but such treatments are effective in decreasing both emotional distress and pain.
Why IBS Might Respond to Spinal Cord Stimulation
In the past, medical professionals believed IBS was a disorder of bowel motion or motility only; however, most doctors now view IBS as an abnormality in the interaction between bowel function and central nervous system functions. In other words, IBS symptoms may arise from complex interactions between the brain, the spinal cord and the bowels themselves. In effect, IBS, like many chronic pain problems, is a neuropathic process – an abnormal interpretation of the signals of the nervous system – that might respond to spinal cord stimulation (SCS). Spinal cord stimulation is a therapy where electrical signals produced by an implanted device confuse the abnormal signals in the spinal cord. The system converts the abnormal signals to normal signals, reducing pain and other symptoms related to IBS.
Based on a single literature report on the use of spinal cord stimulation in a rat model of IBS where the rats treated with SCS had complete restitution of their diarrheal episodes11, this author placed a SCS system into a patient who had intractable IBS with severe, narcotic insensitive pain and diarrheal episodes that was pushing her to the brink of suicide. Immediately after implanting an SCS system, this patient's diarrhea stopped and her pain significantly decreased. After three months, she continued to be diarrhea free; however her pain increased to the point she required the placement of an intrathecal opioids delivery system (i.e., a pump to deliver medication directly to the affected site). Today, this patient is no longer suicidal. As she has expressed in her own story, she "has her life back!" We have published our experience and scientific explanation for the use of SCS in IBS in the journal Neuromodulation.12
Patients should be cautious when considering any surgical treatment and physicians should not rush to place spinal cord stimulators in their patients with intractable IBS. This is only one case report and not science. A well-designed, multi-centered randomized controlled study is necessary to establish SCS as an appropriate therapy for severe IBS. Readers also should realize that this patient only underwent SCS after a long and frustrating course of interdisciplinary pain care that involved the individual expertise of psychologists, gastroenterologists, and pain physicians. This author, expert in interdisciplinary care and interventional pain management, only used SCS in the above patient as last resort therapy after all conventional therapies including pharmacologic management, psychologic care, and other interventions had failed and her quality of life was severely compromised. As with any surgical procedure, there are risks associated with SCS. Patients should find expert and experienced surgeons and discuss all their treatment options with their physicians.
- Longstreth GF, Wolde-Tsadik G: Irritable bowel-type stimulation in HMO examinees. Prevalence, demographics, and clinical correlates. Dig Dis Sci 1993 Sep; 38(9):1581-9.
- Drossman DA, Liz, Anduzzi E, et al. US Householder Survey of Functional GI disorders: Prevalence, Sociodemography and health impact. Dig Dis Sci 1993; 38:1569-80.
- Zukerman MJ, Guerra LG, Drossman DA: Comparison of bowel patterns in Hispanic and non-Hispanic white. Dig Dis Sci 1995 Aug; 40(8):1763-9.
- Sanderler, RS, 1990. Epidemiology of IBS in United States. Gastroenterology 99, 409-415.
- Mendeloff, A.L., 1983. Epidemiology of functional GI disorders. In: Chey, W.Y.(Ed.), Functional Disorders of the Digestive Tract. Raven Press, NY, pp 9-13.
- Evans PR, Bak YT, Kellow JE, Effect of oral cisapride on small bowel motility in IBS. Aliment Phamacol Ther 1997 Oct; 11 (5):837-44.
- Prior A, Read NW. Reduction of rectal sensitivity and post prandial motility by grainsetron, a 5-HT3-receptor antagonist, in patients with IBS. Aliment Pharmacol Ther 1993; 7: 175-180.
- Von der Ohe MR, Hanson RB, Camilleri M., Serotonergic mediation of postprandial colonic tonic and phasic response in humans. Gut 1994; 35:541.
- Drossman DA, Creed FH, Fava GA, et al. Psychosocial aspects of the functional GI disorders. Gastroenterol Int 1995; 8:47-90.
- Guthrie E, Creed F, Dawson D, Tomenson B. A controlled trial of psychological treatment for IBS. Gastroentrol 1991: 100:450-7.
- Greenwood-Van Meerverd Johnson AC, Forman RD, Linderoth B. Attenuation by spinal cord stimulation of a nociceptive reflex generated by colorectal distension in a rat model. Autonomic Neuroscience: Basic and Clinical 2003; 104: 17-24.
- Krames ES, Mousad DG. Spinal cord stimulation reverses pain and diarrheal episodes of irritable bowel syndrome: a case report. Neuromodulation 2004;7(2):82-88.