SINGAPORE – A weekly Tuesday clinic at the Singapore General Hospital (SGH) offering an integrated approach to tackling hard-to-treat cases of irritable bowel syndrome (IBS) has witnessed a steady uptick in the number of cases since it started in 2019.

IBS is the most common gastrointestinal condition, and its symptoms include abdominal pain, diarrhoea and constipation. At the clinic, more time is devoted to finding out why the patients are experiencing these issues, and there is a psychologist to help address psychological issues such as poor coping mechanisms and personality traits that can worsen the issue.

In 2021 and 2022, the clinic saw around 300 patients each year, up from 200 in 2020.

From January to March in 2023, there were nearly 100 patients, which puts the projected number for the year at 400.

Dr Andrew Ong, a consultant gastroenterologist at SGH who started the clinic in April 2019 and is the only specialist running it, said he now gets referrals from other hospitals, including the private ones.

Dr Ong said the holistic treatment approach with the psychologist addresses the close two-way interaction between the gut and the gastrointestinal system or what is called the gut-brain axis, which is often ignored in the treatment of IBS. This pathway is why some people may experience abdominal pain or diarrhoea before an important event.

Stress and anxiety can trigger or worsen IBS, because the changes that occur in the brain when one is very stressed do impact the way one perceives the pain signals coming from the gut.

Conversely, gut issues can also bring on psychological conditions like anxiety or depression.

IBS, which affects about one in 10 people around the world, is the result of abnormal gut-brain interactions, though the psychological and social factors would usually only be significant in the complex cases, said Dr Ong.

He added that while the numbers for the IBS clinic have increased steadily, they do not truly reflect the patient load, as the general gastroenterologist still sees the bulk of the patients. He started the clinic to treat the complex cases. “The symptoms are perpetuating because of many things biologically, psychologically, socially. If you don’t address all of it, the patient will not get better.”

Other institutions may provide a multi-disciplinary approach where doctors and psychologists see the patient independently, unlike the weekly clinic where the patient can see both in the same sitting, he said. There is also a smaller number of gastroenterologists here who have learnt it in detail as a sub-speciality, he added.

The patients that he sees at the weekly clinic have often been told by their doctors that IBS is stress-related, as the scans and scopes they have done were all negative, he said.

He also has some foreign patients from the region. “We will spend a lot of time educating them about what exactly is going on. So we tell them: ‘This is a gut issue. This is not an issue of their mind’.”

A female patient who struggled with constipation had visited the weekly clinic, after seeing several doctors in the public and private sectors. They had given her laxatives, but her condition did not improve.

Dr Ong noticed she was an athlete in school, had a stressful job and a Type A personality, and discovered, after talking to her, that the whole act of sitting on a toilet bowl to poop was a performance to her.

“And if she couldn’t do it, she became anxious because she added the pressure on herself to perform,” he said. “Eventually, she got better because she herself understood that this wasn’t a performance. This was just a normal thing that people do.”

The clinic could expand in 2024, if SGH can hire another gastroenterologist who is keen and willing to do this speciality, he said.

Meanwhile, the research on gut microbiome, the complex ecosystem of trillions of bacteria, viruses, fungi and other microbes in the gut, is advancing. “At this point, we’re not sure in terms of causality, whether it’s the irritable bowel syndrome causing a change in the way that bacteria population is or if it is the bacterial population that causes irritable bowel syndrome, and maybe it’s even a... two-way relationship,” said Dr Ong.

But, changing the bacterial composition could potentially be a treatment option for IBS, he said.

At local precision gut microbiome company Amili, which houses South-east Asia’s first and only gut microbiome transplant bank, co-founder Jonathan Lee has published a paper on colorectal cancer in Cell Host and Microbe, which showed that different types of precancerous polyps have unique microbiome signatures.

“Identifying these specific microbes holds potential for developing population-scale screening tests for colon cancer based on an individual’s gut profile,” said Amili’s CEO, Dr Jeremy Lim.

“Then, we can look at giving those who are at high risk (of colon cancer) certain foods, certain supplements to change their microbiome and mediate their risk.”

He said the National University of Singapore and Amili are now exploring a partnership to conduct further research and commercialise a diagnostic kit based on these and further research.