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 23 October 2017

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Classical Case Studies

GastroenterologyFunctional bowel disorders

Irritable bowel syndrome

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Stephen DH Malnick, Ehud Melzer and Alon Basevitz Kassam colon: a case of irritable bowel syndrome triggered by exposure to Kassam rocket attacks
Stephen DH Malnick, Ehud Melzer and Alon Basevitz, 20 August 2008
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Abstract

Irritable bowel syndrome (IBS) is a common condition and clearly related to stress. We report a 35-year-old man working in Shderot, Israel, who experienced recurrent rectal pain and abdominal distension with diarrhea following exposure to either Kassam missile attacks or the alarm of the early warning system. Physical examination, laboratory testing and sigmoidoscopy were all normal. To the best of our knowledge, this is the first case of IBS related to missile attacks or an early warning system.

Case report

Introduction
Irritable bowel syndrome (IBS) is a gastrointestinal syndrome manifested by chronic abdominal pain and altered bowel habits in the absence of any organic cause. It is the most commonly diagnosed gastrointestinal condition, with a prevalence of 10-15% in North America [1-6] and 11.5% in Europe [7].

Patients with IBS who present to tertiary referral centers have been found to have increased anxiety, depression, phobias, and somatization. A recent American Gastroenterological Association technical Review of IBS has concluded that psychological stress increases GI symptoms, psychological and psychiatric morbidity is common in IBS patients, that this morbidity affects both health status and clinical outcome and that psychosocial factors determine which patients present to physicians [8].

The residents of the town of Shderot and the surrounding settlements have been subjected to a barrage of thousands of Kassam missiles over the past few years [9]. There have been some fatalities but little is known regarding psychological effects on the residents of the area. In addition an early warning system has been developed which triggers an alarm several seconds before a missile lands. The residents of the area are exposed to many more early warning alarms than actual missile strikes.

We wish to report a previously healthy 35-year-old man who developed rectal pain and classic IBS symptoms following exposure to Kassam missile strikes in Shderot.

History
A previously healthy 35-year-old man complained of both rectal and abdominal pain. The episodes of pain had started after he was transferred to work in Shderot for his employer, a high-tech corporation.

He reported that his complaints started 7 months previously shortly after a Kassam missile fell near his office. There was no structural damage and he was not injured but he reported the event as stressful.

Following this whenever he heard the Red Alarm early warning alert (with or without a possible explosion from a nearby missile) he suffered from acute rectal pain. Over the course of the next few months he also suffered from pain of a colicky nature in the abdomen, accompanied by abdominal distension and occasional diarrhea which appeared following missile alerts or explosions. He had not experienced similar episodes when at home in the center of the country, which is outside of the range of the missiles and where there are no early warning alarms to be heard.

He was of good health and had grown up in Kiryat Shmoneh, in the North of Israel until the age of 18 where he was subjected to frequent Katyusha rocket attacks but had not experienced similar episodes of pain.

Examination and investigation
Physical examination was unremarkable - specifically there was no clubbing, no signs of malnutrition and the abdomen was soft, non-tender and there was no organomegaly.

Laboratory investigations including ESR, CRP, CBC renal, liver and electrolyte determinations as well as TSH and vitamin B12were all within normal limits. Stool analysis was normal and flexible sigmoidoscopy to a depth of 50 cm was normal.

Outcome
The patient remained well while there was a normal situation in Shderot but has experienced many repeat episodes due to the frequent sounding of the red alert and shooting of Kassam missiles from Gaza.

Discussion
We report here a previously healthy 35-year-old man who developed complaints typical of IBS following exposure to Kassam missiles. Both physical examination and routine laboratory and endoscopic investigations were normal. The complaints were compatible with the revised Rome criteria for IBS [10].

The clear temporal link between symptoms and the Kassam missiles strongly implicates the anxiety and tension provoked by these attacks as the initiating factor for the episodes of abdominal and rectal pain. This is further supported by the absence of symptoms while out of the range of the missiles.

Previous Scud missile attacks on the Israeli civilian population during the first Gulf War resulted in psychological damage [11]. Interestingly in those populations with previous trauma such as Holocaust survivors, there was reactivation or exacerbation of the survivor system and post-traumatic stress disorder [12].

In this war there were a total of 18 missile attacks with a total of 39 surface-to-surface Scud missiles. A total of 773 casualties were evacuated to hospitals and 43% of these were classified as psychological casualties [13]. Interestingly, as in our patient, the majority of those who experienced psychological stress maintained intact levels of functioning [11]. In immigrant populations exposed to missile attacks, the degree of psychological stress during the attacks was related to the pre-war level of distress [14]. We suspect that there was some residual psychological effect of the previous chronic exposure to missile attacks during the first 18 years of his life which explain some of the extreme reaction to repeat missile attacks in Shderot. A report detailing the symptoms of children 5 years after the Gulf War found that 8% of the children still had severe post-traumatic symptoms [15]. Our patient was exposed to repeat Katyusha attacks for many years during his childhood and adolescence which is a far longer period of time than the Gulf war.

There is little data in the literature regarding IBS in other areas of conflict in the Middle East. Post-traumatic stress syndrome has been found in adolescents and children in the Gaza strip [16, 17] but no information regarding IBS was available. An increased prevalence of IBS has been found in Gulf-war era veterans [18] and also in Romania following the uprising in December 1989 [19].

The majority of IBS patients do not refer themselves to physicians [20] and thus there is a need for rigorous population studies in order to determine the true prevalence of IBS in areas of chronic violence.

In summary, we present a case of IBS in which the symptoms are clearly triggered by either missile attacks or the auditory stimulus of an early-warning system.

This article first appeared on GastroHep.com on 20 August 2008.

Authors

Stephen DH Malnick
Ehud Melzer
Alon Basevitz

Department of Internal Medicine C
1 - Gastroenterology Institute
Kaplan Medical Center, Rehovot 76100, Israel
(Affiliated to Hebrew University, Jerusalem)

Contact

Stephen DH Malnick
Department of Internal Medicine C
1 - Gastroenterology Institute
Kaplan Medical Center, Rehovot 76100, Israel
Fax +972-8944-1852
Email: stevash@trendline.co.il

References

  1. Talley NJ, Zinsmeister AR, Van Dyke C, et al. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterol 1991; 101: 927-34.
  2. Drossman DA, Li Z, Andruzzi E, et al. US householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci 1993; 38: 1569-80.
  3. Brandt LJ, Bjorkman D, Fennerty MB, et al. Systematic review on the management of irritable bowel syndrome in North America. Am J Gastroenterol 2002; 97(Suppl): S7-26.
  4. Hahn BA, Saunders WB, Maier WC. Differences between individuals with self-reported irritable bowel syndrome (IBS) and IBS-like symptoms. Dig Dis Sci 1997; 42: 2585-90.
  5. Saito YA, Locke GR, Talley NJ, et al. A comparison of the Rome and Manning criteria for case identification in epidemiological investigations of irritable bowel syndrome. Am J Gastroenterol 2000; 95: 2816-24.
  6. Thompson WG, Irvine EJ, Pare P, et al. Functional gastrointestinal disorders in Canada: first population-based survey using Rome II criteria with suggestions for improving the questionnaire. Dig Dis Sci 2002; 47: 225-35.
  7. Hungin AP, Whorwell PJ, Tack J, et al. The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects. Aliment Pharmacol Ther 2003; 17: 643-50.
  8. Drossman DA, Camilleri M, Mayer EA, et al. AGA technical review on irritable bowel syndrome. Gastroenterology 2002; 123: 2108-31.
  9. Israel Ministry of Foreign Affairs website. 26 October 2007. www.mfa.gov.il.
  10. Longstreth GF, Thompson G, Chey WD, et al. Functional bowel disorders Gastroenterology 2006; 130: 1480-91.
  11. Bleich A, Kron S, Margalit C, et al. Israeli psychological casualties of the Persian Gulf war: characteristics, therapy, and selected issues. Isr J Med Sci 1991; 27: 673-6.
  12. Robinson S, Hemmendinger J, Netanel R, et al. Retraumatization of Holocaust survivors during the Gulf War and SCUD missile attacks on Israel. Br J Med Psychol 1994; 67: 353-62.
  13. Bleich A, Dycian A, Koslowsky M, et al. Psychiatric implications of missile attacks on a civilian population. Israeli lessons from the Persian Gulf War. JAMA 1992; 268: 613-5.
  14. Lerner Y and Zilber N. Psychological distress among recent immigrants from the former Soviet Union to Israel, II. The effects of the Gulf War. Psychol Med 1996; 26: 503-10.
  15. Laor N, Wolmer L, Cohen DJ. Mothers' functioning and children's symptoms 5 years after a SCUD missile attack. Am J Psychiatry 2001; 158(7): 1020-6.
  16. Elbedour S, Onwuegbuzie AJ, Ghannam J, et al. Post-traumatic stress disorder, depression, and anxiety among Gaza Strip adolescents in the wake of the second Uprising (Intifada). Child Abuse Negl 2007; 31: 719-29.
  17. Qouta S, Punamäki RL, Montgomery E, et al. Predictors of psychological distress and positive resources among Palestinian adolescents: trauma, child, and mothering characteristics. Child Abuse Negl 2007; 31: 699-717.
  18. Gray GC, Reed RJ, Kaiser KS, et al. Self-reported symptoms and medical conditions among 11,868 Gulf War-era veterans: the Seabee Health Study. Am J Epidemiol 2002; 155: 1033-44.
  19. Dumitrascu DL and Baban A. Irritable bowel syndrome complaints following the uprising of December 1989 in Romania. Med War 1991; 7: 100-4.
  20. Thompson WG and Heaton KW. Functional bowel disorders in apparently healthy people. Gastroenterology 1980; 79: 283-8.

 
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