A twenty-eight year old man complains of daily bloating of his stomach with abdominal cramps for ten years. He often has multiple diarrhoea especially in the mornings, and his symptoms go away he visits the toilet.

The patient never experiences these symptoms at night while asleep, and there is no weight loss. In fact he is slightly obese and otherwise feels completely fine. He says the symptoms get worse when he is under stress. He was planning to go to Dubai for work, but is nervous that his condition may cause problems. His physical examination and basic blood tests were all normal.

Irritable bowel syndrome (IBS) which this patient has is one of the most common problem a doctor (specially a gastroenterologist, a bowel doctor) comes across in his clinic in Nepal. This is known as clinical diagnosis where the doctor makes a prognosis after taking a careful history of the patient's problems and doing a simple physical exam. Special blood tests, scoping procedures of the bowel, or radiological tests are not required.

Additional evaluation is not only unnecessary and expensive but also potentially harmful when invasive procedures are ordered. Of course if the patient is older, has fever, chills and weight loss, other more serious diagnosis may need to be considered.

The most important part of the treatment is to assure the patient that although this problem is annoying and inconvenient, it is not life-threatening.

Sometimes patients with IBS have concomitant difficulties digesting milk and other dairy products, which is called lactase deficiency. Lactase is the enzyme in the small intestine necessary for digesting dairy products.

Amazingly about 90 per cent of people in South Asia are lactase-deficient which leads to the classic gurgling noise ("paet gadyang gudung") from the belly followed by loose motion after drinking a glass or two of milk. Because this is such a common problem here, lactase deficiency may overlap with IBS.

Patients with IBS should try staying away from milk and dairy products and see if that helps them. There is also evidence that IBS is linked to mental problems like depression and anxiety and seeking help in this regard may also be helpful in the treatment of IBS.

This patient in question did see a competent Nepali gastroenterologist who made the correct diagnosis without resorting to unnecessary, expensive laboratory or radiological testing. He is now working in Dubai.