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Can IBS Become IBD?

In this blog, I want to distinguish the conditions IBS and IBD and talk about a concept that I know other practitioners, especially conventionally trained ones, will likely disagree with. And the concept is this: IBS and IBD are on the same spectrum of disease.

I'll explain this from more of a functional perspective throughout this post. Let me start by saying when I had my first colonoscopy many years ago, I was initially given a diagnosis of IBSD, sent home, and told to try a probiotic, which is not surprising or uncommon in the conventional space. But years after that, when I started to slide back downhill again and struggle, I went back in to seek the help of GI doctors and a lot of them told me “Oh, it's probably just IBS and we don't really need to do a second colonoscopy. You know, try this or try that.” They basically ran through their gamut of elementary offerings with me. Of course, nothing worked. If you’ve struggled with IBS you’ll know this is not surprising, right? This frustration played a large role in the reason why I got on the path to become a functional practitioner. 

At any rate, several years later, I did finally elect to have a second colonoscopy done. The practitioner I was working with at the time thought that enough time had passed that it made sense. And interestingly, after that second colonoscopy, I found out I did have an IBD diagnosis of microscopic colitis. So I can at least say in my experience of n= 1 that it is possible for IBS to eventually turn into IBD.

I don't know statistically what percentage of people out there that captures, but I think having come full circle with my training as a functional practitioner and understanding the body from more of a holistic lens, the possibility for IBS to become IBD is always there, especially if the genetics lay the groundwork for that potential gene expression. And that's always the wild card that we never know when we're on this this path of life; when we’re considering what may or may not happen with our health, we can look at any hundred of different ways disease might play out for a given individual. It just depends on the triggering events and exposures and factors that set off particular disease states or help those symptoms to express.

In the conventional medicine world, I feel like it's very easy and clean to deal with one label at a time and consider things through just the lens of IBS or just the lens of IBD. But one big difference that we aim for in the functional space, is to look at things more holistically.

And yes, we want to know the label if there is one, but we also want to take a step back from that and ask, “Okay, what are things going on outside of just this system of the body? And what are some clues we might be able to look for that could explain why this particular system is expressing a disease state or why this person has, you know, three different systems expressing symptoms, for example.” We don't just limit it to one clean lens through which we're viewing the body. That’s because we operate from the understanding that when health breaks down, it's doing so because of a multitude of different factors impacting it.

And we want to try to unravel that tangle and help clients figure out which different areas of their life, health, and nutrition are driving this entire mess so that we can help them get their health back on track. And the more factors we identify, the better the chances of a client restoring his or her health. 

So let's talk a bit about just IBS and IBD as different conditions. So IBS is considered a diagnosis of exclusion because typically, these are people who go in to see a GI doc, and are given a full workup, which often will include an endoscopy, a colonoscopy, sometimes a bunch of other tests as well. And basically, at the end of all that, nothing abnormal is found. And then normally, the doctor will say, "Look, like we did all this testing, but we can't find anything that actually shows on the scale of diagnosable here. So you have IBS or irritable bowel syndrome. And there are some things we can try to help you with your symptoms." And that's basically as far as it goes.

Just to reinforce the point: this is the way that the conventional medical system is set up to work. It's set up to diagnose and prescribe and treat a disease, not necessarily help troubleshoot the symptoms on the path to having a diagnosable disease. That's a very different thing, in my opinion.

Now, IBD or inflammatory bowel disease is usually characterized by some degree of tissue damage. It often comes after an endoscopy or colonoscopy or both have been performed and visual damage is observed by the performing doctor, or it's seen under the microscope or after a biopsy was taken of the tissue, and then they see the damage.

That is the main difference between IBS and IBD. However, both conditions, as well as most chronic health conditions, share a common characteristic of ongoing inflammation. And a principle that we work from in the functional medicine space, is that we're always concerned about this idea of “inflammation” and minimizing inflammation. In fact, I would say it's actually a buzzword. Now, what exactly is inflammation? Most of us have a general idea of what inflammation is. But to get a little bit more specific, according to the American Heritage Dictionary, inflammation is 1) the act of inflaming or the state of being inflamed and 2) a localized protective reaction of tissue to irritation, injury, or infection characterized by pain, redness, swelling, and sometimes loss of function. 

This second definition gets at the idea that there's some degree of activation of the immune system, irritation, or injury happening, and also visible, observable changes to the tissue. And then along with that, disruption in function, or sometimes even the loss of function, which I think is a good way of kind of looking at any number of chronic health conditions. This could apply to anything on the autoimmune spectrum, but even things like chronic joint pain could also be characterized that way. 

The third definition of inflammation is: the act of inflaming, kindling or setting on fire, also the state of being inflamed. This third definition kind of provokes this image of a fire, which also can be quite helpful because, one of the things I think that can be especially challenging when it comes to dealing with inflammatory states is getting things to calm down and balance out. With a really big fire, you're not going to put that out with a couple drops of water.It's going to take a big bucket of water to put that fire out. 

There is a balance here, however. We need to have the ability to inflame under the right conditions. One easy example of that would be strength training. Strength training involves breaking down muscle tissue, which causes some degree of inflammation. When that inflammation resolves, the muscle should be stronger and bigger muscle. But in the case of chronic health issues, the problem becomes that the inflammation switch gets turned on and it becomes especially difficult to get it to turn back off. We want to be able to have inflammation happen when it's appropriate, but we also want the body to be able to manage inflammation and turn it off so it doesn't become damaging in the long term. If we look at the third definition of inflammation, we're really seeing this picture of the immune system mounting a response to some sort of provoking agent, which could be a lot of different things, especially from a functional perspective.

When the body is in a chronic state of creating inflammation, the majority of the time, there's going to be some degree of immune dysregulation at play because of a provoking agent. And sooner or later, if that switch doesn't get turned off, it will start to lead to tissue damage and destruction. Believe it of not, most autoimmune conditions can take decades to fully reach a diagnosable level. So in other words, the actions that are leading to the tissue destruction could already be in place at a very small level and over time, slowly building and moving in a more severe direction. It’s common that a person might finally go into their doctor after months or years of struggling with symptoms, and one day finally, there's enough of a damage seen by the doctor that the person struggling can finally be diagnosed with something on the autoimmune spectrum.  If you've been struggling with your health for a long time, it can be validating to actually go in, have the tests done and feel like your symptoms aren’t all in your head.

Now, in the case of IBS, that often doesn't happen. A lot of times, at least the IBS clients I've worked (and in my own case as well), were made to feel like they were crazy at times. When I was struggling with my own IBS, I was made to feel I wasn't doing enough with the things the doctor was trying to tell me to do to keep the IBS under control, all the while thinking, "No, this feels more serious than IBS. I am doing everything I can and this is still happening.” So IBS can be very frustrating because if it doesn't rise to the level of a diagnosable problem, it can very much feel like you're just beating your head against a wall and being told that this is because of stress or because of depression or because of nerves or genetics, or any number of other things. And what's really often happening is there is the same mechanism at play as IBD, just at a much more minor level that really can't rise to the level of detectable, at least as far as that diagnostic criteria goes. In the case of IBD, it can be very affirming to finally get that diagnosis and not be left feeling like the body isn’t having all of the symptoms for no reason.

So there is a time and a place to have that evaluation and that diagnosis. But at the end of the day, the conventional medicine process is not really set up to help patients get clear on the factors driving their symptoms. And even if you have the label, or you have the diagnosis, you're still often left with the prospect of taking a med or possibly some simpler things like a probiotic, that often are not going to be enough to make the symptoms disappear. The most important question that should be asked is: what do we do to try to troubleshoot these symptoms and understand what's driving body dysfunction before that person gets a diagnosis? And that's not really a question that conventional medicine is set up to answer. It can be very frustrating when they're struggling with symptoms for a long time, cycling through different practitioners and being told that “nothing's wrong” or if something is wrong, the best solution is to just take a drug. This frustration is warranted, and I know that I personally experienced it when I was a patient in the system. 

Conditions like IBS and even conditions that go beyond the gut, like fibromyalgia and chronic fatigue, are thought of in conventional medicine as idiopathic conditions because their root causes not well understood. These diagnoses often given as these diagnoses of exclusion because the symptoms are meeting a specific diagnostic criteria that can pinpoint what’s specifically wrong. These labels are often given based on the presentation of symptoms and ruling out more serious conditions. There is often some crossover with these three conditions. There's always an element of fatigue, but there can often be body pain or stomach pain or, you know, different types of pain going on as well with all of these different conditions.

I would still say that if we're looking at all chronic disease as being on this spectrum of chronic inflammation, we could put IBS, chronic fatigue and fibromyalgia on the milder end of the spectrum compared to more serious things like IBD or other autoimmune conditions. I've actually heard other functional practitioners even talk about disorders like type 2 diabetes and even cancer through the lens of immune dysfunction, and even having autoimmune characteristics, because often with all of these immuno-regulatory disorders, you're often seeing some aspect of under-activation of a part of the immune system, alongside over-activation of part of the immune system.

Thinking of all disease states as being on a spectrum of inflammation is helpful because the reality is, the body always breaks down as the whole, not just as a part. And again, to try to troubleshoot this backwards, we really want to take stock of where are we along the spectrum of inflammation, and identify as many different factors feeding into this disease state as possible, so we can work on those things and help the body regain health on its own. Before closing, it’s worth noting that once a person is given one autoimmune diagnosis, it's much more likely that they will have a second or a third diagnosis in their lifetime. If that disease state continue without interruption, it's very common to see other systems and tissues start to get impacted as well. This just reaffirms that there is a collective process of breakdown happening in the body.

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