Letting patients help

Anne came in for her annual health maintenance visit with great news. Her irritable bowel syndrome was no longer a problem. “I hope you aren’t upset with me, but I’m cured.”

 

She was a patient with long-standing irritable bowel syndrome (IBS). She had had a thorough evaluation, first by me and then by a gastroenterologist. She had had blood and stool studies and upper and lower endoscopies. Because her symptoms had seemed to develop in association with a job change (promotion) we had discussed the possible role of stress and she had seen a counsellor and followed through with relaxation training. She was on a combination of imodium, fiber, exercise and bed time amitriptyline. We had tried cholestyramine, empiric treatment for Giardia, and diphenoylate/atropine (Lomotil). Yes, she had improved on this regimen, but had remained unhappy with her symptoms. 

She was still taking the amitriptyline, but largely for sleep and to prevent her intermittent migraine. She used imodium for travel, but said it was for psychological reasons - she had forgotten it several times and had had no problems. What was the solution, I wanted to know.

She had had some spare time in an air port, and spent her time googling IBS and chronic diarrhea. Her Google searches led her to a reference to a case report in The Lancet from 1995 of a flight attendant with sorbitol induced diarrhea. She described pulling her breath mints out of her purse and reading the label: sorbitol was the sweetener. She threw them out and experienced a dramatic resolution of her symptoms. In retrospect, she said, it was obvious. Her episodes of bloating, cramps and diarrhea  occurred most often in association with travel for meetings, big work surges and important presentations, all times when she used lots of them. (We had interpreted this data as a stress response.

That was a very enjoyable visit.  We had both been frustrated with our regular conversations about her irregularity (pardon the humor) and our inability to fix it, and we were happy to enjoy her triumph.

But it was especially nice for me, because I remembered a patient from several months earlier, also struggling with bloating and diarrhea in the setting of known IBS (and a negative evaluation) His flares seemed to be associated with intermittent periods of alcohol excess, and he had not been thrilled with my speculation that the alcohol was causing his flares. Yes, he did agree that his flares rarely happened in the absence of alcohol excess, but he often drank with no flare.  What struck me that day was that he was a salesperson and therefore very sensitive about alcohol on his breath. I knew that the heavy mint to his breath was a signal that he had already started drinking that day. After work I called and asked him to look at his mints to see if they contained sorbitol. Yup, He stopped and was much better.

Listening to patients is good. Learning from them is better.  Letting them help is best

 


 

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