Question: I am a 55 yr old male, resident of Calcutta, in generally good health, without history of major illness or surgical procedure, 162cm, 75kg, with a high-stress work & family environment. Family history of IBS & amoebiasis, no cancer. Normal medication includes Cardivas 25mg od, Aztor 10mg .I have not been taking Aspirin for the last 1 year. I have had several episodes of ?amoebic colitis, not severe enough to prevent functioning office, about once 1-2 years, responding to Metronidazole etc. Over the years, my bowel movements have naturally increased to about 3-4 times every morning, very naturally, soft solid stool but not always well-formed. I have started taking Isabgul 2tsf at bedtime for the last 1 year and have found relief from a feeling of incomplete defecation that was quite common. I have 3 sub-5mm polyps in the gallbladder detected during routine health check-up 17 years ago, and monitored every year through annual health-checkups -- no change of size. Recent USG shows mildly fatty liver, with negligible elevation of liver enzymes

One recent episode -- 5 months ago -- of digestion discomfort/stool-with-mucous/indigestion/tenderness abdomen was untreated for about a month, after which there were intermittent twinges of pain at the edge of the ribs. Condition treated with Metronidazole, and Ciprofloxacine, with significant relief of symptoms. However, thereafter, I have been experiencing episodes of dyspepsia occuring every 3-4 weeks, random and unrelated to extreme food/outside food etc. Symptoms include indigestion, burping/flatulence, a feeling of tightness in the area around the navel reduced after passing stool/wind, and constipation with incomplete defecation. Symptoms last about 3-4 days, and return to normal with supportive enzymes & Nutrolin B-Plus bd for about 5-7 days. However ever since the episode referred above, I get mild discomfort at the edge of the ribs along the disaphragm -- so much on the bone that suspected to costochondritis, but location can be a point anywhere from left to right or under the sternum. This happens 6-7 times a day, so mild as to be almost unnoticeable, and lasts about a minute each time -- typically, the involuntary reaction is to put a finger on the spot to locate the mild discomfort, feel some tenderness on the bone when finger-pressure applied, and then disappearance of sysmptoms after a minute. However, there is some increase of intensity or frequency of this intermittent discomfort during the recurring dyspeptic episodes. My general-medicine physician has been prescribing enzymes/lactobacillus etc and advising me that these symptoms unlikely to be significant. Since the last one week, he suspects IBS and has put me on IBSCIM (1 bd) and Dompan (1bd) in addition to enzymes.

As you can realise, the discomfort is not significant enough affect my functioning in any way, but I would like to be sure that I am not missing something, particularly because I am a somewhat intense personality with an inadequate erratic familarity with some aspects of healthcare!

Thanks for your reply.

1. No no disturbance to sleep at all
2. No loss of weight.
3. CBC done: Hb 13.3, RBC 4.24 mil/micro-l, PCV 38.7%, MCV 91.3, MCH 31.4, MCHC 34.4 lac/micro-L, Platelets 7800 cells/micr-L, WBC 7800. DC -- Neutro (66), Lympho (29), Mono (3), eosino (2), Baso (0). ESR 13
Stool R/E -- XXXXXXX Brown, Soft, Mucous PRESENT, Visible Blood ABSENT, Acidic, Occult Blood NEGATIVE, Reducng substance ABSENT, Pus Cells 0-1/HPF, Veg Cells PRESENT (+), RBC/Ova/Parasite/Cyst ABSENT

Endoscopy not done -- not advised. Also, somewhat apprehensive of such investigative procedures and want to avoid them.

Would add 1 week of IBSCIM & Dompan appear to help -- shifting intermittent mild discomfort below ribs significantly less frequent. However, require more time to defecate -- slight constipation? -- because of IBSCIM?

Thank you for your response.

I would be grateful if you could answer the following follow-up queries for my general understanding and for me to deal with situations in future:

1. Is the intermittent shifting discomfort below the ribs an indication of dyspepsia? What precisely causes this (eg, bloating due to gas affecting weakened abdominal muscles)? This is the only new experience -- all other symptoms are well-known.

2. Assuming that it is IBS & Functional Dyspepsia, what is the treatment duration -- I have been prescribed IBSCIM 1bd x 15 days, and Dompan 1bd x 10 days. Should I repeat this treatment regime if symptoms recur, as they usually do every 3-4 weeks?

3. I appreciate that my age is a factor. However, symptoms were never so strong to make me non-functioning, they have improved, and symptoms are "explained" by your (and my GP's) expectation of the disease process. In that case, it seems unlikely that I should now immediately pursue endoscopy/colonoscopy. At what point, or with additional indications, should I treat the problem with more seriousness and alarm?

4. Since IBSCIM has slight constipative side-effects, is there any other drug that I can discuss with my GP, that may be better?

Thanks for your clarity of response and patience.