Habba Syndrome or Irritable Bowl?

Forty-five million Americans struggle with Irritable Bowel Syndrome and the discomfort it often brings—stomach pain, constipation, or diarrhea.  But, those patients who have been unable to find relief from traditional treatment may not actually have IBS. Instead, it could be a newly- diagnosed digestive condition.

There was a time when Deborah Wilson hated to eat in public.

"I was so afraid of the consequences of eating," Wilson told Ivanhoe.

Wilson would eat—and run—to the nearest restroom. As a result, she started to waste away. At one point, she hit ninety-eight pounds. Doctors told her it was Irritable Bowel Syndrome. But IBS treatments didn't work.

"I started getting different tests done, but nobody could figure out what was wrong," Wilson said.

"We are stuck with a patient that had chronic diarrhea, diagnosed with IBS, that didn't get any better," Saad Habba, MD, Gastroenterologist, Mount Sinai School of Medicine, told Ivanhoe.

Dr. Habba, ordered a nuclear test of Wilson's gallbladder and discovered the organ wasn't working.

Dr. Habba then prescribed Wilson the same medication taken by patients who have had their gallbladders surgically removed. Wilson takes a pill now before every meal to end sudden diarrhea.

"I'm encouraging all the patients to go back to their physicians and say this… do more… there is something wrong here. Believe in what I'm telling you… it's not IBS," Dr. Habba said.

"I knew I had to find out why so I could get my life back," Wilson said.

Dr. Habba says if you are not getting better using traditional IBS methods, insist the doctor check your gallbladder.Dr. Habba wrote about his research in medical journals and now the condition of a malfunctioning gallbladder is known as—Habba Syndrome.

BACKGROUND: Habba Syndrome can cause chronic diarrhea or three or more bowel movements per day for at least three months. The diarrhea is mostly after meals. Because of this, patients are usually looking for a bathroom wherever they go also known as "bathroom mapping". The symptoms can cause social embarrassment and interference with daily activities. Some patients stay home because they are afraid of social embarrassment. Some even lose weight.

SIGNS/SYMPTOMS: The Habba Syndrome is a dysfunction of the gall bladder. There is inappropriate bile in the gastrointestinal tract. It can cause painful stools which are watery and without blood. Most of the patients have normal gallbladder ultrasounds. Even the presence of gallstones on an ultrasound does not rule out the diagnosis of the syndrome.

NEW TREATMENT: Therapy is aimed at changing the constitution of bile acids to decrease the diarrheal effect of the bile acids. Agents that bind the bile acids have been proven to be safe, effective and inexpensive. They should be used one half hour before meals to bind the bile acids so they are effective. Cholestyramine, Colestipol and Colesevelam are some of the medicines that can be used to treat the symptoms. Some patients are diagnosed with IBS. This can be a "catch all" or "wastebasket" diagnosis. When patients are tagged with an IBS diagnosis, they can be dissatisfied and continue to change physicians in hopes of getting relief. Physicians should continue tests on the patients to get an exact diagnosis so it can be treated accordingly. (Source: http://habbasyndrome.com/conclusions.html)


Saad Habba, MD


Mount Sinai School of Medicine

Office: (908) 273-3434


"Habba Syndrome or Irritable Bowel?" Saad Habba, MD Tell us why you felt the need to look further when patients came to you with symptoms of  IBS and then you found out later it was not.

Dr. Habba: This all started because I had difficulty dealing and helping patients that had chronic diarrhea that had been previously diagnosed with IBS diarrhea type. I felt that these patients have tried different medications, they've undergone many tests and could not improve. Their lifestyle was really messed up, it was destructive. Their social lives were disrupted and we felt we couldn't help them. It came to a point where I thought there was something more to it, I believed in the patient, I believed that I was being ineffective in helping the patient. So I really wanted to go a little further and see if I'm missing anything, that's really when it all started.

And you discovered that you were indeed missing something.

Dr Habba: We've always grown up with the diagnosis of IBS.  We went to medical school with IBS. We knew all of that and it was easy for us to tag somebody with IBS particularly after doing certain tests and didn't get better they were diagnosed with IBS. Then we try different medications. We try antispasmodic's with poor response, antidiarrheal agents and antidepressants which sometimes work. Now they've talked about possibly using antibiotics which again don't work. We knew all the time that IBS was a catch all term. It was a kind of a wastebasket diagnosis but we had no other alternative. Basically we just were stuck with the patient that had chronic diarrhea diagnosed with IBS who didn't get any better.

What did you do?

Dr Habba:  I listened to the patient and their presentation which was very similar to the presentation when we take out the gallbladder. They would have postprandial diarrhea. That means every time you eat you go to the bathroom. A lot of these patients actually protect themselves and their symptoms by not eating when they go out so that they don't embarrass themselves. Their symptom is very definitive. They also present with what I call bathroom mapping. When they walk into a place they would want to know where the bathroom is. That tells you how much this symptom is really interfering with their lives to a point that they have to feel secure that a bathroom close by. This type of presentation, post eating diarrhea if you will, protecting yourself when you don't eat and sometimes with incontinence when you have the diarrhea, occurs in 10% of patients that have their gallbladders out. So my thought was what if the gallbladder is intact but it is not working. It is presenting in the same fashion as if you don't have a gallbladder. We've always known that we can treat the post cholecystectomy diarrhea so why don't I study the gallbladder and see if the gallbladder is working because if that is the case maybe I can try the same medication. And indeed I started studying the patients gallbladders. I did gallbladder ultrasounds, which most of the times were normal. But there's a further study to understand the function of the gallbladder and see if the gallbladder contracting. This is done by a nuclear medicine test which is a standard test that measures the ejection fraction and it's done with a test called HIDA or DISIDA scan. By doing that we measure the activity, the function of the gallbladder, the emptying the gallbladder and low and behold I found that the gallbladders are not working. So I said, well, they have an intact gallbladder but it's not working. This is very similar to the presentation of no gallbladder. So why don't I give them the same medication that we've used in the past to bind the bile acids since the bile acid is the problem here. So we gave them the medication which is a generic medication, it's cheap and safe. We've used it for many years; we know that it has minimal side effects and the response as we expected in post cholecystectomy patients was incredible. In fact the response rate according to 303 patients in my study was 98%. This is entirely different from the response that we get from patients with irritable bowel syndrome diarrhea type which at best is 25 to 30% with different trials of medications. So I knew there was a connection between the gallbladder function and diarrhea. So we described this as a new syndrome and obviously was followed up with other studies and many publications and we continue to work on that.

Do you have any advice for patients who have been told that you have IBS and nothings working, do you have advice for what they should mention to their doctor?

Dr. Habba: I'm encouraging all the patients to go back to their physicians and say listen, do more, there is something wrong here. Look into some other conditions. They need to be investigated because there are many other reasons why the patient can present in a similar fashion. We should detach ourselves from a IBS diagnosis. It's a catchall term. So if we detach ourselves a little bit and investigate the patient more you may end up with an entity that you can actually treat. And then I think your problem is solved or the patient's problem is solved.

It's interesting, so you're saying that we shouldn't even use IBS as a diagnosis, just don't even say it.

Dr. Habba:  If you detach yourself from that term then you are open to other possibilities. But if you get secure as a physician and getting yourself under this umbrella then you are going to stop and try different therapeutic measures. But if you say, okay, I can't help you but let's find out more, it can't be just IBS, let's investigate a little bit more, let's look into other conditions. Let's look into gallbladder dysfunction, see if you have the syndrome, let's look into microscopic colitis, colitis or other things. You know, you have to spend more time investigating particularly when you have poor response from the therapeutic agents that you've used to the patient.

What's going to be the response from your colleagues? I know IBS is a term that we've been using for years, you study it in medical schools and now you're going to say let's kind of start thinking?

Dr. Habba: It's difficult, it's very difficult. As I said we grew up with IBS, everybody knows IBS. It's like telling you all of a sudden there is no diabetes. The term is different. This is a big problem, about 10% to 15% of the population in the United States are diagnosed with IBS. This is a huge entity. Physicians should detach from the diagnosis IBS and say investigate some more. Results are phenomenal if you do that because it's very rewarding to the patient. Remember these patient's lives are completely disrupted. They can't go out, they had lost control of their bowels in cars and interviews and meetings. Relationships have been broken because of that. I hear them all. I think we are obliged to go a little further and investigate and find out what it is so that we can help them out because there is a way out. That's the most important thing. There is a way for the patient to get better and IBS should be challenged, that's the whole idea.

You mentioned that the medication is there and is not that expensive.

Dr. Habba: Yes, it's bile acid binding agent. It changes the characteristic of the bile acids that causes diarrhea and with that you actually get better. Because, remember, the gallbladder is basically a storage and a controlling organ for bile. If that is not working, it's like a thermostat that's not working in a room. You'll get irregularity in the heat and the cold. Here you get irregularity in bile control. So this medication will bind the bile and change the constitution so it takes away the diarrhea effect of bile. And this has been known for a long time and we've used it and it's safe, it's cheap, it's generic, it doesn't have to be an expensive issue but the response is phenomenal.

What are the concerns of doctors who are not going with the Habba syndrome, and I would think that they don't know that's their biggest concern.

Dr. Habba: That is the issue...they just don't know.

Who funded your study?

Dr. Habba: Nobody, it was an independent study done. I received no funding from anybody either institutional, pharmaceutical or otherwise.

Are you directly or indirectly compensated by the manufacturer for your involvement?

Dr. Habba: Absolutely not.

Will your hospital or organization benefit financially from this?

Dr. Habba: No.

It was clear enough for people to get it and to go and ask their doctors because so many people are affected.

Dr. Habba: That's really what we're trying to achieve is that we need to send the patients back to their doctors and say, let's challenge this and go a little bit further. That's all I'm asking of them. I'm not asking them to do anything crazy because we have taken refuge with this diagnosis as physicians and I think we are the problem not the patient. Because we have been sitting back and found a safe haven in this diagnosis. Generally, physicians give the patient a little tag on their lapel that you've got IBS, good luck. But then you're stuck with it and the patient moves on from one doctor to the other.

And of course you're getting all these secondary illnesses like you mentioned depression, what about eating disorders?

Dr. Habba: As I said, if they go out on any social event or any activity they subconsciously don't eat because they don't want to be in a position to go out and have diarrhea or seek a bathroom or indeed sometimes even lose control of their bowels.

How soon after one eats is there a particular half hour, 15 minutes?

Dr. Habba: Usually within the hour, but it depends on how fatty the meal is. That's the usual response.

At this point there is no cure because that medication is something that will be with the patient probably for the rest of his or her life.

Dr. Habba: Correct. I mean it would be best if we can come up one day with a solution for the function of the gallbladder then we are treating the actual cause of the problem.

When a person has to have their gallbladder removed what is the reason for that?

Dr. Habba: Usually either pain, inflammation, stones these are the issues. We don't recommend taking out the gallbladder for the Habba syndrome because it really makes no difference. The gallbladder is not working whether it's there or whether it's not there, is the same thing.

So it's just an extra operation?

Dr. Habba: It's an extra operation that's not necessary. But if you start having pain or inflammation of the gallbladder, that's a different story then you have to take that gallbladder out anyway.