How to treat abnormal bowel movements, loose stools, and chronic stomach pain in a person who has Agoraphobia?

Question

Hi doctor,

I suffer from agoraphobia, and getting out is difficult for me, but my stomach problems have worsened this condition. It has now got to the point that I am scared to eat anything hours before I go out as I am so concerned about losing control of my bowels with diarrhea (which has happened before). After that, I am frightened to eat anything at all. I have diarrhea often, and it comes on suddenly without warning. I usually run to the toilet, so I do not want to be in any place where there is no toilet. I have tried cutting everything out of my diet and making different changes, but nothing works.

My stomach hurts very often. This problem started around 20 years ago. My GP sent me to a gastroenterologist at the hospital. The doctor there asked me a few questions and recommended fiber supplements and an SSRI as he diagnosed IBS. Unfortunately, the supplement went straight through me, and the SSRI caused panic attacks leading to the development of the panic disorder. So it often happens that after having a meal, and within five minutes to one hour, I will have to run to the toilet. It is almost always very loose bowel movements or diarrhea, but the stools are often very yellow. But the urge to go to the toilet is sudden and immediate. I have mistaken this sensation for gas and bloating in the past and tried to pass gas, resulting in me soiling myself, but I do not know if this is psychological as I am so concerned about diarrhea.

I have been asking my GP about this for 20 years, and they tell me it is happening because I am anxious or that it could be due to the other medications I take. So I reported all the events to my GP two months ago again. He said to try the IBS drug Mebeverine. But this has not helped too. So I went to another GP, and they did some blood tests (which I shall attach). After looking at the results, they increased my Atorvastatin from 20 mg to 80 mg.

My cholesterol and triglycerides have always been high, so are my mother's and my grandfather's. So the plan at the moment is to tackle this problem with the increased 80 mg of Atorvastatin. For around 20 years, I mostly had loose bowels, sudden urgency to go toilet, fecal incontinence, and episodes of stomach pain. However, I am trying to lose weight. I am often exercising and concentrating on cardio workouts. It is hard to go out to exercise when you have constant loose bowels and you are frightened to be away from a toilet. The doctors want me to improve my diet, but if I eat fruits, vegetables, legumes, oats, or wheat, I run to the toilet.

I have asked my GP if this could be bile acid malabsorption, and they have told me that this is all due to my weight and medication. But that cannot be true as this has been happening for 20 years. It happened to me when I was 80 kg and at 130 kg. It happened before I was on these current medications that I take,

1. Tablet Pregabalin 300 mg twice daily.

2. Tablet Atorvastatin was 20 mg daily, raised to 80 mg.

3. Tablet Escitalopram 10 mg once daily.

4. Tablet Mebeverine 135 mg thrice daily.

5. Tablet Mirtazapine 30 mg once daily.

6. Tablet Propranolol 40 mg once daily.

7. Tablet Quetiapine 25 mg once daily.

I have also taken SSRIs and Benzodiazepines in the past.

So is there anything you can suggest? Is there anything obvious that appears to you? I cannot even go to the local hospital to visit a specialist anymore, as my agoraphobia is so bad now. Leaving my street sometimes is impossible, and all consultations with my GPs are now over the phone.

Is there anything you can suggest for me?

Please help.

Answer 1

Hello,

Welcome to icliniq.com.

I went through your query and understood your concern.

I have seen your reports (attachment removed to protect the patient's identity). So I think a few issues are related to your case. First, I agree with the diagnosis of IBS (irritable bowel syndrome) because you have a change in the bowel movement (BM)- number and consistency, and the pain, which is a spasm type of pain, leads you to rush to the toilet and no severe findings such as weight loss. In fact, you have been gaining weight.

Secondly, stomach pain is constant, which is secondary to another condition called epigastric pain syndrome or functional dyspepsia. The latter is commonly associated with irritable bowel syndrome. I have reviewed your medication, and I think we need to make a few modifications. First, I suggest you to stop taking the tablet Escitalopram (antidepressant) and replace it with the tablet Tryptinol (Amitriptyline) 25 mg at night daily. Take this medication for at least two to four weeks to see a response in your bowel movements and stomach pain.

Other problems, like cholesterol, borderline sugar, obesity, and fatty liver, can aggravate the symptoms of IBS. The best approach would be to exercise and reduce your weight. Since you have all the important investigations, I suggest you do a stool test to diagnose pancreatic insufficiency (pancreatic elastase in stool), which can be associated with IBS and your raised triglycerides level. In addition, I suggest you to undergo an endoscopy and colonoscopy to see inside your gut.

The dose of Tryptinol can be increased if the modifications mentioned above are not effective in four weeks.

Kindly consult a specialist, talk with them and take the medications with their consent.

I hope this has helped you.

Take care.

Answer 2

Hi,

Welcome back to icliniq.com.

Here are my answers to your questions,

1. No, I do not think it is bile acid malabsorption diarrhea. Bile acid malabsorption occurs in certain conditions, like someone with a history of small bowel resection or someone with extensive small bowel diseases such as Crohn's disease, celiac disease, drug-induced malabsorption syndrome, sprue, and autoimmune enteropathy. Since, at the moment, you do not have such a history, nor do we have evidence to say it is bile acid malabsorption syndrome. The one reason for asking you to undergo endoscopy and colonoscopy is to take a biopsy from your large and small bowel and rule out if you have any malabsorption conditions, as mentioned above. Bile acid malabsorption is an isolated occurrence that is very unusual.

2. Yes, you can take tablet Loperamide (anti-diarrhea medication), but taking tablet Tryptinol (Amitriptyline) will also solve this problem. In addition, you can take tablet Rifaximin (antibiotic) 200 mg thrice daily for two weeks and see if there are any improvements. Also, you will not need Loperamide if there are improvements.

3. Yes, the medication can cause such side effects, particularly Escitalopram (Selective serotonin reuptake inhibitors - SSRIs) and Quetiapine (an antipsychotic medication), but since the other physician has started, I could not stop it. You might have some rebound symptoms if we stop them at once.

Kindly consult a specialist, talk with them and take the medications with their consent.

I hope I have answered your question.

Take care.

How to treat abnormal bowel movements, loose stools, and chronic stomach pain in a person who has Agoraphobia?

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