Irritable bowel syndrome (IBS) is a problem that affects the large intestine. It can cause abdominal cramping, bloating, and a change in bowel habits. Some people with the disorder have constipation. Some have diarrhea.
Others go back and forth between the two. Although IBS can cause a great deal of discomfort, it does not harm the intestines.
IBS is common. It affects about twice as many women as men and is most often found in people younger than 45 years. No one knows the exact cause of IBS. There is no specific test for it. Your doctor may run tests to be sure you don't have other diseases.
These tests may include stool sampling tests, blood tests, and x-rays. Your doctor may also do a test called a sigmoidoscopy or colonoscopy.
Most people diagnosed with IBS can control their symptoms with
The signs and symptoms of irritable bowel syndrome vary depending on its type.
Doctors often classify IBS into one of four types based on your usual stool consistency. These types are important because they affect the types of treatment that are most likely to improve your symptoms.
The four types of IBS are
IBS with constipation, or IBS-C
hard or lumpy stools at least 25 percent of the time
loose or watery stools less than 25 percent of the time
IBS with diarrhea, or IBS-D
loose or watery stools at least 25 percent of the time
hard or lumpy stools less than 25 percent of the time
Mixed IBS, or IBS-M
hard or lumpy stools at least 25 percent of the time
loose or watery stools at least 25 percent of the time
Unsubtyped IBS, or IBS-U
hard or lumpy stools less than 25 percent of the time
loose or watery stools less than 25 percent of the time
the feeling that you haven’t finished a bowel movement
whitish mucus in your stool
Women with IBS often have more symptoms during their menstrual periods.
Irritable bowel syndrome can be caused by various factors.
Brain-Gut Signal Problems
Signals between your brain and the nerves of your gut, or small and large intestines, control how your gut works. Problems with brain-gut signals may cause IBS symptoms.
GI Motility Problems
If you have IBS, you may not have normal motility in your colon. Slow motility can lead to constipation and fast motility can lead to diarrhea. Spasms can cause abdominal pain. If you have IBS, you may also experience hyper reactivity—dramatic increases in bowel contractions when you feel stress or after you eat.
If you have IBS, the nerves in your gut may be extra sensitive, causing you to feel more pain or discomfort than normal when gas or stool is in your gut. Your brain may process pain signals from your bowel differently if you have IBS.
A bacterial infection in the GI tract may cause some people to develop IBS. Researchers don’t know why infections in the GI tract lead to IBS in some people and not others, although abnormalities of the GI tract lining and mental health problems may play a role.
Small Intestinal Bacterial Overgrowth
Normally, few bacteria live in your small intestine. Small intestinal bacterial overgrowth is an increase in the number or a change in the type of bacteria in your small intestine. These bacteria can produce extra gas and may also cause diarrhea and weight loss. Some experts think small intestinal bacterial overgrowth may lead to IBS. Research continues to explore a possible link between the two conditions.
Neurotransmitters (Body Chemicals)
People with IBS have altered levels of neurotransmitters—chemicals in the body that transmit nerve signals—and GI hormones. The role these chemicals play in IBS is unclear. Younger women with IBS often have more symptoms during their menstrual periods. Post-menopausal women have fewer symptoms compared with women who are still menstruating. These findings suggest that reproductive hormones can worsen IBS problems.
Whether IBS has a genetic cause, meaning it runs in families, is unclear. Studies have shown IBS is more common in people with family members who have a history of GI problems.
Many people with IBS report that foods rich in carbohydrates, spicy or fatty foods, coffee, and alcohol trigger their symptoms. However, people with food sensitivity typically don’t have signs of a food allergy. Researchers think that poor absorption of sugars or bile acids may cause symptoms.
listens to sounds within your abdomen using a stethoscope
taps on your abdomen checking for tenderness or pain
What tests do doctors use to diagnose IBS?
In most cases, doctors don’t need to perform tests to diagnose IBS. Your doctor may perform a blood test to check for other conditions or problems. Your doctor may perform more tests based on the results of the blood test and if you have
Doctors use blood tests to check for conditions or problems other than IBS. A health care professional sends your blood sample to a lab.
A stool test is the analysis of a sample of stool. Your doctor will give you a container for catching and holding a stool sample. You will receive instructions on where to send or take the kit for analysis, to check for blood or parasites. Your doctor may also check for blood in your stool by examining your rectum during your physical exam.
Flexible sigmoidoscopy is a procedure that uses a flexible, narrow tube with a light and tiny camera (called a sigmoidoscope) on one end to look inside your rectum and lower colon.This procedure can show signs of conditions or problems in the lower GI tract . During the procedure, the doctor can take a biopsy.
Colonoscopy is a procedure that uses a long, flexible, narrow tube with a light and tiny camera (called a colonoscope) on one end to look inside your rectum and colon.
Colonoscopy can show irritated or swollen tissue, ulcers, polyps, and cancer.
Lower GI series
A lower GI series, also called a Barium Enema, uses x-rays to look at your large intestine. During a lower GI series, you’ll be asked to lie on a table while the doctor inserts a flexible tube into your anus. The doctor will fill your large intestine with barium. You may be asked to change positions several times during the test.
There are many different treatments that may be tried for irritable bowel syndrome (IBS). All will have an effect on some people, but none will help in every person with IBS.
No treatment is likely to take away symptoms completely, but treatment can often ease symptoms and improve your quality of life.
If symptoms are more troublesome or frequent, one or more of the following treatment options may be advised:
PLAN 1: Lifestyle changes
Regular periods of exercise help to ease the symptoms.
Stress and other forms of emotional upset are believed to aggravate the symptoms of disease. So all tactics aimed to reduce stress tackle the disease in itself.
Keeping a symptom diary
It may help to keep a food and lifestyle diary for 2-4 weeks to monitor symptoms and activities. Note everything that you eat and drink, times that you were stressed, and when you took any formal exercise. This may identify triggers, such as a food, alcohol, or emotional stresses, and may show if exercise helps to ease or to prevent symptoms.
If you are advised to try a particular treatment, it may be sensible to keep a symptom diary before and after the start of the treatment. For example, before changing the amount of fiber that you eat, or taking a probiotic, or starting medication. You may wish to jot down in the diary the type and severity of symptoms that you have each day for a week or so.
Keep the diaries going after you start treatment. You can then assess whether a treatment has improved your symptoms or not.
PLAN 2: Dietary changes
Have regular meals and take time to eat at a leisurely place.
Avoid missing meals or gaps in between your meals.
Drink at least 1.5 l of fluid per day including water and other non-caffeinated beverages. This helps to keep the stools soft and facilitates easy passage through the gut.
Restrict tea and coffee to 3 cups/day.
Avoid too much alcohol.
Eat limited amount of high-fiber diet.
Limit fresh fruits to three portions per day.
People with diarrhea, should avoid intake of sorbitol found in artificial sweeteners, beverages and other products.
In people with bloating and winds, consider increase in the intake of oats and linseed.
Intake of fiber us related to the type of symptom you have. In people with predominant constipation, they are advised to take plenty of fiber. In patients with diarrhea, they need to limit fiber intake from diet.
There are two main types of fibre - soluble fibre (which dissolves in water) and insoluble fibre. It is soluble fibre rather than insoluble fibre that seems to help ease symptoms in some cases. So, if you increase fibre, have more soluble fibre and try to minimise the insoluble fibre.
Dietary sources of soluble fibre include oats, ispaghula (psyllium), nuts and seeds, some fruit and vegetables and pectins. A fibre supplement called ispaghula powder is also available from pharmacies and health food shops. This seems to be the most beneficial type of supplement.
Insoluble fibre is chiefly found in corn (maize) bran, wheat bran and some fruit and vegetables. In particular, avoid bran as a fibre supplement.
The low-FODMAP diet
Recently, it has been discovered that a low-FODMAP diet may help some people with IBS.
These are a group of carbohydrates found within foods, which may make IBS symptoms worse.
Examples of foods to avoid in a low-FODMAP diet include:
Certain fruits, such as apples, cherries, peaches and nectarines.
Some green vegetables, such as peas, cabbage, broccoli and Brussels sprouts.
Foods high in lactose, such as milk, ice cream, cream cheeses, chocolate and sour cream.
If you wish to try a low-FODMAP diet, you should discuss this with a dietician. It is difficult to cut down on so many foods, and keep eating a healthy diet without specialist advice. Your GP can arrange a referral to a dietician, and they can help you eat the right things.
Individual food intolerance
Some people with IBS find that one or more individual foods can trigger symptoms, or make symptoms worse (food intolerance or sensitivity). If you are not sure if a food is causing symptoms, it may be worth discussing this with a doctor who may refer you to a dietician. A dietician may be able to advice on an exclusion diet.
Then, advise on adding in different foods gradually to your diet to see if any cause the symptoms. It may be possible to identify one or more foods that cause symptoms. This can be a tedious process, and often no problem food is found. However, some people say that they have identified one or more foods that cause symptoms, and then can control symptoms by not eating them.
The foods that are most commonly reported to cause IBS symptoms in the UK are:
Wheat (in bread and cereals).
Coffee (and other caffeine-rich drinks such as tea and cola).
Probiotics are nutritional supplements that contain good germs (bacteria). That is, bacteria that normally live in the gut and seem to be beneficial. Taking probiotics may increase the good bacteria in the gut which may help to ward off bad bacteria that may have some effect on causing IBS symptoms.
The dose is on the product label. Some foods that contain pro-biotic bacteria include certain milk drinks, yoghurts, cheeses, frozen yoghurts, and ice creams. They may be labelled as 'probiotic', 'containing bacterial cultures' or 'containing live bacteria'.
There is some evidence that taking probiotics may help to ease symptoms in some people with IBS. At present, there are various bacteria that are used in probiotic products.
PLAN 3: Medications
These medicines relax the abdominal musculature. These include mebeverine, hyoscine, and peppermint oil. If one does not work well, it is worth trying a different one. If one is found to help then you can take it as required when pain symptoms flare up.
Many people take an antispasmodic medicine for a week or so at a time to control pain when bouts of pain flare up. Some people take a dose before meals if pains tend to develop after eating. Pains may ease with medication but may not go away completely.
Laxatives are advised to people with constipation predominant IBS. Lactulose is better avoided in such patients. A new medicine called linaclotide has been approved for people who have constipation as a main symptom of IBS.
It works in a completely different way to other medicines for treating constipation by acting on chloride receptor channels and altering the influx of ions. It is taken once a day and has been shown to reduce pain, bloating and constipation symptoms.
Loperamide is the preferred drug. The dose of loperamide needed to control diarrhoea varies considerably. Many people use loperamide as required but some take it regularly.
Many people learn to take a dose of loperamide in advance when they feel diarrhoea is likely to be a problem.
For example, before going out to places where they know it may be difficult to find a toilet.
Peppermint oil is suggested for such patients.
A tricyclic antidepressant is sometimes used to treat IBS. In particular, it tends to work best if pain and diarrhoea are the main symptoms. An example is amitriptyline. (Tricyclic antidepressants have other actions separate to their action on depression. They are used in a variety of painful conditions, including IBS.
Other types of antidepressants, called selective serotonin reuptake inhibitors (SSRIs) are also occasionally used for IBS. For example, a tablet called fluoxetine. They may work by affecting the way you feel pain.
Unlike antispasmodics, you need to take an antidepressant regularly rather than as required. Therefore, an antidepressant is usually only advised if you have persistent symptoms, or frequent bad flare-ups that have not been helped by other treatments.
Possible new treatments
Various other treatments show promise. For example: Rifaximin is an antibiotic but mainly stays in the gut and very little is absorbed into the body. The theory is that it may kill some germs (bacteria) in the gut that may have some role in IBS. It is taken for two weeks. Further research is needed to clarify its role in IBS.
A medicine called tegaserod seems to be useful for people with constipation.
Studies have shown that certain Chinese herbal medicines may help to ease symptoms in some cases. However, results vary. So more research is needed to clarify their safety and usefulness.
Newer medicines that affect certain functions of the gut are also being developed and may become useful treatments in the future.
PLAN 4: Psychological treatment
Situations such as family problems, work stress, examinations, recurring thoughts of previous abuse, etc, may trigger symptoms of irritable bowel syndrome (IBS) in some people. People with anxious personalities may find symptoms difficult to control. The relationship between the mind, brain, nervous impulses, and over activity of internal organs such as the gut is complex. Psychological treatments are mainly considered in people with moderate-to-severe IBS:
When other treatments have failed; or
When it seems that stress or psychological factors are contributing to causing symptoms.
Cognitive behavioral therapy, hypnotherapy or psychological therapy should be considered when your symptoms have not improved with medication after one year.
With irritable bowel syndrome (IBS), there are some steps that can be taken to help avoid triggers and prevent symptom flare-ups.
Talk to your GP about IBS prevention steps.
Diet triggers for IBS constipation
Some foods can worsen IBS-related constipation. These include:
Refined breads and cereals
Refined foods such as crisps and biscuits
Drinks such as coffee, fizzy drinks, and alcohol
Gradually increase daily fibre. Good sources of fibre include whole grain bread and cereals, beans, fruits, and vegetables. Be aware that some people with IBS find that increasing fibre symptoms worsens their symptoms.
Drink eight glasses of plain water a day
Try ground flaxseed. It can be sprinkled on salads and cooked vegetables.
Diet triggers for IBS diarrhoea
Some foods can worsen IBS-related diarrhoea. These include:
Too much fibre, especially insoluble fibre found in the skin of fruits and vegetables
Food and drinks with chocolate, alcohol, caffeine, fructose, or the sugar substitute sorbitol
Fried and fatty foods
Food and drinks with dairy
Foods with wheat, some people may be intolerant or allergic or have a negative reaction to gluten.
Eat a moderate amount of soluble fibre. It adds bulk to the bowel motions and can help prevent spasms. Good sources are
whole wheat breads,
the flesh of fruit (as opposed to the skin),
and dried fruits
Try not to consume foods with extreme temperatures, such as ice- cold water and steaming hot soup, in the same meal
Reduce or avoid foods like
and cabbage if you find these make diarrhoea or bloating worse
Eat smaller portions
Drink six to eight glasses of plain water a day, but drink the water an hour before or after meals, not with meals
Consult with your doctor or a dietitian if you suspect you may have a wheat intolerance or allergy.
Some people with IBS have symptoms similar to lactose intolerance with excess wind. A trial of a lactose-free diet and avoidance of foods that produce excess wind such as beans, Brussels sprouts, wheat germ, raisins, and celery may help reduce symptoms.
Stress and anxiety triggers for IBS
Stress and anxiety can exacerbate IBS symptoms such as
Different things cause stress for different people. Stress can include:
Problems at work
Problems at home
A sense that things are beyond your control.
Practice healthy living. Eat a well-balanced diet that is appropriate for your IBS. Get regular exercise and enough sleep
Do something fun. Listen to music, read, shop, or take a walk
Try behavioural therapy. Learn how to calm yourself down with the help of techniques such as relaxation therapy, hypnotherapy, cognitive behavioural therapy (CBT) and psychotherapy
Talk to people. If you feel comfortable doing so, tell your family members, close friends, boss, and colleagues about your IBS. They may provide vital support. Plus, the conversation may prevent any misunderstandings when your symptoms flare up and you are not able to meet expectations
Plan ahead. Ease worries about going out if your symptoms flare up. Get up earlier if you know IBS makes you late for work. If you are driving, map your route so that you know the locations of toilets. At social events, choose aisle seats close to the toilets. Know what's on the menu so you can eat beforehand if the food will not be agreeable to you.
Medicines that can trigger IBS
Some medicines can trigger spasms of the colon and symptoms of IBS. These spasms can lead to constipation or diarrhoea.
Antibiotics, especially after prolonged use
Medicine containing sorbitol, such as cough syrup.
Talk with your GP about changing to a medicine that won't worsen your IBS symptoms. Don't stop taking a medicine without consulting with your doctor.
If an antidepressant is worsening your diarrhoea or constipation, talk with your doctor about switching medicine. Older antidepressants (called tricyclic antidepressants) can cause constipation. One type of newer antidepressant (called selective serotonin reuptake inhibitors, including fluoxetine, citalopram, paroxetine and sertraline) can cause diarrhoea. Your GP can help you find an antidepressant that will not worsen your IBS symptoms.
Menstrual triggers for IBS
Studies show that women with IBS tend to have worse symptoms during their periods. Your GP may recommend certain strategies to ease pain and discomfort during your period. Prevention strategies:
Oral contraceptives. These drugs can regulate periods. Side effects may include upset stomach, vomiting, stomach cramps or bloating, diarrhea, and constipation. Work with your GP to find a pill that works for you without causing side effects
Premenstrual dysphoric disorder (PMDD) medicines. These include medicines also used to treat depression, such as fluoxetine, citalopram, sertraline and paroxetine. PMDD is a severe form of PMS. These drugs adjust levels of serotonin, a brain chemical thought to be out of balance during certain phases of a woman's cycle.
Eating while working or driving
Eating too quickly
Lack of exercise.
Performing different activities while eating may cause you to swallow more air, eat more quickly, and feel bloated. Take time out from other activities while you enjoy your food
Not enough exercise can also cause constipation. Try to get at least 30 minutes of exercise each day. Take a long walk to help your bowels and ease tension.
7 Alternative and Homeopathic Remedies
Several homeopathic remedies exist for irritable bowel syndrome (IBS).
Some of the homeopathic medicines prescribed for IBS patients are:
However, these medicines are to be taken with the prescription of registered homoeopathic physician.
With all these options before you, and with patience on your part, you are sure to get the better of your IBS.
8 Lifestyle and Coping
Lifestyle modifications are necessary in order to cope with irritable bowel syndrome (IBS).
Many sufferers are unaware that the basic cause is just an imbalance in the bacterial flora present in the digestive tract.
Those who suffer for a long time automatically develop a stress response to the stimulus of acute gastric discomfort and believe stress to be the main culprit. They are told ‘it’s all in your head’ whereas it may actually be ‘all in your gut’!
It may have occurred due to excessive use of antibiotics and other allopathic medicines over the years. For those severely affected for many years, the best way to resolve this issue is a simple, practical, three-step method.
To ensure that you really do have IBS, first get yourself thoroughly checked by a competent gastroenterologist.
The three steps are:
First of all, rule out any bacterial or fungal infection of the gut by doing a simple stool test or stool culture analysis. (Sometimes in severe cases, an endoscopy, colonoscopy, and blood tests for detecting pancreatic enzymes and liver enzymes levels are advised. In case of infection, get treated with required antibiotics and or anti fungal medication or, in case of enzymes deficiency, get the required enzyme supplements prescribed by a gastroenterologist). If the reports are normal, go to step b.
Start with the strongest probiotic in the market. Each of these capsules contains eight different kinds of good digestive bacteria that help to increase the good bacterial count in the gut. Take one or two capsules per day, after meals, for at least two or three months, or as prescribed by the doctor. Initially the gas formed would be the gut’s way of adjusting to the good bacteria and that can be ignored. Gradually, the stomach settles down, stools are well formed and symptoms recede until one feels normal and can digest a variety of foods. Stop the medicine if there is any resultant constipation. Have a high fibre diet and plenty of fluids, to prevent haemorrhoids formation.
After the capsules are stopped, continue with a milder probiotic like Vizylac or Rinifol capsules (especially for the dairy intolerant who cannot take yoghurt). Take one capsule per day after meals only if required and follow the doctor’s advice. Continue taking yoghurt or Yakult on a daily basis, to maintain the good gut bacteria count. Certain prescribed digestive enzymes like fish oil capsules can be taken along with meals.
Genetic causes have to be borne as we can neither choose our genes nor do away with them. However appropriate precautions ensure a good quality of life.
Yoga, meditation and counseling help to control the anxious response to stressful situations. Relaxing the mind requires a lot of time and patience but the benefits are many as sudden panic situations can be handled without disturbing the gut. A constitutional treatment from a good trained homeopath helps too, if one wants to avoid allopathic medications for the mind which may be habit forming in the long run.
Food intolerance can be determined by a food allergy test or by simply ruling out certain probable problem foods, turn by turn and figuring out for oneself, what is actually causing the problem. The most common are dairy intolerance and gluten intolerance (Celiac Disease).
Other allergens include
An allergic reaction causes hives and inflammation. Intolerance, on the other hand, causes gas formation, bloating, and indigestion, thus precipitating an IBS attack. Complete dairy intolerance would require one to rule out any product containing any
milk or milk product ingredients,
Read contents on food packets to rule out the above. Soy milk and peanut butter are good alternatives.
In case of gluten intolerance (Celiac Disease), avoid
desserts made with gluten flours.
Gluten free products include
Legumes, nuts and seeds can be taken.
Regularise eating habits. Eat small nutritious wholesome meals over the day, to maintain energy levels. Eat on time, chew slowly, and avoid gulping down food. Food should not be too hot.
Drink water half an hour after meals, for proper digestion. Avoid eating if you are tense or not hungry. Sometimes, eating tasty food that one craves for intensely, helps in salivation and digestion and wards off an IBS attack Walk around for 15 minutes after any heavy meal.
Soak a teaspoonful of fennel seeds (saunf), in a glass of water overnight. Chew the soaked fennel seeds and drink the water, first thing in the morning. This helps to digest meals well throughout the day.
In ayurveda, Irritable Bowel Syndrome (IBS) has been included under a specific disease condition called grahani. According to ayurveda, IBS is of four types based on the dosha system. Constipation-predominant IBS (vata grahani), Diarrhoea-predominant IBS (pitta grahani), Dysentery-predominant IBS (kapha grahani) and Complex IBS (tridosha grahani).
IBS can be somewhat controlled by making certain dietary changes. Include old rice, jowar, lentils, green gram, gourd and coriander leaves in the diet. Black pepper, dried ginger, wood apple, pomegranate, nutmeg, skimmed milk and buttermilk are also helpful. Drink plenty of hot water to aid digestion.
spiked dolichos (legume),
Try to keep calm, and avoid sleeping in the day.
Identifying and removing food intolerances is a must. This can be achieved by eliminating certain food items from the diet for a week each and seeing which elimination gives the maximum relief.
Improving gut motility is also necessary. Psyllium (Isabgol) is a good source of soluble fibre that helps in bowel transit and gives relief from constipation.
Restoration of good bacteria in the gut and maintaining their balance is also important. Ayurveda emphasises the use of buttermilk.
Increasing the amount of pancreatic enzymes is another important for IBS patients. These enzymes help inhibit the growth of bacteria in the small intestine and also improve protein digestion.
Intake of ashwagandha churna, brahmi churna, aswagandharishta is helpful in balancing and relaxing the mind. A relaxed mind indirectly helps combat IBS
Drink at least 2-4 glasses of buttermilk tempered with cumin (jeera) powder and black salt.
Include a good amount of curd in diet.
Use of turmeric (haldi) powder 3 gms twice a day reduces the inflammation of intestinal inner lining mucosa, which helps to relieve symptoms like abdominal pain, bloating, altered bowel habits and increased stool frequency.
Drink mint tea to reduce abdominal pain, bloating and gas. Soak one teaspoonful of dried peppermint leaves in one cup of boiling water for ten minutes. Strain and cool. Drink four to five times a day in-between meals.
Triphala powder (3-6 gms) once or twice a day is useful in IBS with diarrhea.
Coriander water helps to ease the gut.
Trikatu powder is beneficial. It is a combination of three herbs – shunthi (sonth/dried ginger), maricha (black pepper) and pippali mixed in equal quantity. It helps regulate digestion and metabolism.
A specific medication procedure – parpati kalp may be taken under strict supervision of an ayurvedic expert. It offers a wonderful cure for IBS.
Avoid consuming excess tea, coffee, alcohol, or carbonated beverages. Drink lukewarm water for relief.
Ensure you get plenty of rest and sleep, which in combination with ayurvedic medicines, works well for IBS patients.
Apart from these cures, taking anti IBS capsules is also helpful. These capsules harmonise the doshas associated with IBS and calms the psychological component of the digestive system and brain.
9 Risks and Complications
There are several complications associated with irritable bowel syndrome (IBS).
The complications of functional diseases of the gastrointestinal tract are relatively limited.
Since the symptoms are often provoked by eating, patients who alter their diets and reduce their intake of calories may lose weight. Fortunately, loss of weight is unusual in functional diseases, and it should suggest the presence of a non-functional disease. Symptoms that awaken patients from sleep also are more likely to be due to non-functional than functional diseases.
Most commonly, functional diseases interfere with the patients' comfort and daily activities.
For example, patients who suffer from morning diarrhea may not leave their home until the diarrhea stops. If the diarrhea is constant, they may go only to places where they know that a toilet is readily available.
Patients who develop pain after eating may skip lunch. Very commonly, patients associate symptoms with specific foods, such as milk, fat, vegetables, etc. Whether or not such associations are real, these patients will restrict their diets accordingly.
Milk is the food that is most commonly eliminated, often unnecessarily and to the detriment of adequate calcium intake.
The interference with daily activities also can lead to problems with interpersonal relationships, especially with spouses.
However, most patients with functional disease tend to just live with their symptoms and only infrequently visit physicians for diagnosis and treatment.
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