Treatment of irritable bowel syndrome.

bowel syndrome. This raises the question as to what induces these normal people to become irritable bowel syndrome patients. Patients with irritable bowel syndrome take up a considerable proportion of a gastrointestinal clinic's attention (250' in one study2) but this is still substantially less than the potential number. It has been proposed that irritable bowel syndrome is a result of a deficiency of dietary fibre. The paper by Drs Ritchie and Truelove suggests that this is not the case. The complex therapeutic regimen that they have found necessary suggests a less obvious aetiology. This is further suggested by a survey that we made of 60 patients who had received bran as the sole treatment for irritable bowel syndrome. These patients were characterised as having lower abdominal pain (78%), diarrhoea (51%), flatulence (18%), urgency of defecation (22%), and passage of mucus (12%). An important feature of the diagnosis was relief of symptoms after defecation and normal findings from sigmoidoscopic examination, rectal biopsy, and barium enema. The patients were instructed to take 20-40 g of wheat bran each day according to their weight. Two to four years later they were contacted and 85% replied to a questionnaire. Of these, 78%, were still taking bran; 65% felt better and 35% showed no improvement. Bowel habit was regarded as normal in 61 %. However, 88% of the subjects still experienced lower abdominal pain after two years of treatment and 64/o after four years. The frequency of diarrhoea had fallen to 27% after two years and 12% after four years. Flatulence had increased so that 40% now had this complaint. The frequency of urgency, distension, and passage of mucus was unchanged. Bran may treat symptomatically a disease state characterised by colon spasm but not remove the cause. While a primary muscle or emotional factor is attractive, we are attracted to the possibility that a spasmogen is present in the contents of the lumen. The spasmogen may be dietary, bacterial, or endogenous in origin. Bran could alleviate symptoms by expanding the faecal bulk by virtue of water binding3 and hence diluting the concentration of the spasmogen. HENRY NYHLIN MARTIN EASTWOOD