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September 4, 2015

Irritable Bowel Syndrome (IBS)

The healthy gastrointestinal tract produces anywhere between 3 bowel movements a day to 3 per week. While majority of people experience constipation, diarrhea, bloating and gas at one point or another, about 20 % of the general population experiences these symptoms frequently and over a prolonged period of time. Irritable Bowel Syndrome (IBS) is a disorder characterized by changes in bowel movements such as constipation, diarrhea, and abdominal pain without detectable structural abnormalities.

There are different types of IBS:

  • IBS-D: IBS With Diarrhea is characterized by frequent loose stools and abdominal pain and the urgent need to move bowels.
  • IBS-C: IBS With Constipation is characterized by difficulty having bowel movements and the frequent urge to defecate but inability to do so.
  • IBS-M: IBS Mixed have symptoms of both IBS-D and IBS-C.

IBS is a worldwide problem and can affect all genders, ethnic groups, and ages. Most new patients present with this disorder before the age of 45. IBS is considered to be the most common cause of referrals to GI physicians and can lead to frequent and excessive absences from school or work. Although IBS may impair quality of life, there are various effective ways to manage symptoms, whether it be through diet, stress management, or medications prescribed by a doctor.

Causes

IBS comes from a mix of hypersensitive nerve endings in the intestine, abnormal contraction patterns, and brain center feedback on how the gut works. There are factors related to past infections, such as, very subtle ongoing inflammation, possible altered “barrier function” (the “leaky gut” idea, whereby certain substances normally not absorbed in health can be absorbed and trigger subtle immune or inflammatory or other nerve-mediated function changes), and other aspects clearly related to stress. The result is a variety of chronic symptoms, food sensitivities and bowel function changes. The role of abnormal amounts of bacteria in the small intestine is sometimes major. (See IBS and SIBO)

Signs & Symptoms

Symptoms of Irritable Bowel Syndrome include the following.

  • Changes in bowel movement patterns—diarrhea or constipation, sometimes both, often feelings of incomplete evacuation.
  • Bloating and excess gas, often the most annoying symptom.
  • Pain, mostly in the lower abdomen but sometimes other locations including back.
  • Mucus in stools, without bleeding – unless bleeding is due to hemorrhoids or other causes

Irritable Bowel Syndrome can cause a lot of distress, discomfort, and interference with daily activities, however, it does not cause any internal harm, no matter how often or how long symptoms act up.

Screenings & Diagnostic Tests

Since there are no detectable structural abnormalities in the bowel, most IBS diagnosis can be done through careful review of medical history and physical examination and may not require additional tests other than what was ordered for primary care check-ups. Depending on the situation, your gastroenterologist may order tests to help confirm that no other disorders or serious medical conditions are present. These tests may include blood and/or stool sample tests to check for hidden bleeding and infections. Imaging tests, such as ultrasound or CAT scans, may be ordered if your doctor strongly believes there may be alternative causes for abdominal pain. A colonoscopy may be ordered to evaluate for other possible diseases, particularly when chronic diarrhea is the main problem.

The important thing to realize is that NEW symptoms related to IBS shouldn't be ignored or assumed to be IBS without discussing it with a doctor. If bleeding, fever or new types of abdominal pain occurs, please consult your doctor about it. Unexplained steady or worsening changes in bowel habits may be cause for concern and require urgent attention.

Treatment

Several aspects of IBS treatment:

Stress Management: Stress is one of the major triggers for IBS attacks. Adequate sleep, exercise, recreational and enjoyable activities are the main keys to remember – not just for the offset of IBS, but for an overall healthy lifestyle. Meditation, massage, tai chi etc. are just some suggested activities people can choose to participate in to manage emotional or chronic stress. If you do not respond to other natural treatments, medicine used to treat anxiety and depression can also be helpful in managing IBS triggers. A form of therapy called “Cognitive Behavioral Therapy” done under the care of a psychologist or therapist can be very helpful for individuals who have a difficult time managing symptoms. “Mindfulness Meditation” is a psychological technique centered on the idea of being fully present in the moment and maximizing awareness of all senses. It has been proven to be very effective in helping individuals manage symptoms and stress.

Diet: Regular, well-balanced, low fat meals with good fluid intake (over a quart of liquids a day) are frequently recommended for patients with IBS.

Studies on the effectiveness of high-fiber diets in IBS patients have produced mixed results. Some patients do better with smaller amounts of gluten (wheat protein) products or a lactose free diet. What diet approach works for each patient varies. Your clinician will help you decide based on your individual experience with foods, symptom patterns and many times treatment trials of one or another dietary approach.

A more recent helpful diet has emerged from work at Monash University in New Zealand, called low FODMAPs diet—we have separate brochures about this. The idea is to eliminate a variety of foods that result in slow digestion, too much gas fermenting and thus tendency to bloat, gas and altered bowel function. Up to 70% of people with IBS get substantial relief with restriction of FODMAPs. It isn’t simple to implement and your physician should give you guidance, sometimes referrals to a dietitian or nutrition expert.

Medications:

Stool-bulking Agents such as Bran or hydrophilic colloid are often used for treating IBS. Fiber supplements, such as psyllium (like Metamucil, Konsyl, PerDiem), methylcellulose (Citrocel) or pectin fiber (Benefiber), add more fiber for the colon to work with. The water holding action of fiber, increases stool bulk. This relaxes the colon and makes the contractions calmer and more effective. However, some people tolerate the fiber supplements poorly, and other approaches to constipation are used. Acacia powder may be better tolerated if other forms are not, and is a supplement we stock through our group since it is gentle to IBS patients. IBS patients with diarrhea often experience more unpleasant symptoms when they use fiber supplements. Relaxant herbal teas such as mint and chamomile are helpful for soothing pain, as is heat applied to the abdomen.

Antispasmodics and Antidiarrheal Drugs:Antispasmodics relax intestinal contractions or spasm and can be useful in the treatment of IBS. These include prescription medications including dicyclomine (Bentyl), hyoscyamine (Levsin, Levsinex,), belladonna (Donnatal), clindex (Librax) and glycopyrrolate (Robinul).

Although a temporary solution, antidiarrheal medications such as Diphenoxylate (Lomotil) and over-the-counter Loperamide are great in helping patients manage IBS with diarrhea. Pepto-Bismol also has a good anti-spasm and antidiarrhea effect, as does enteric coated peppermint extract. Again, our offices carry the best form of peppermint oil extract we could locate, often helpful and inexpensive. An over-the-counter lower strength higher cost option is IB Gard.

Antiflatulence/Anti-gas Medicines:Antiflatulence/Anti-gas Medicines can help gas disperse or break up easier. Simethicone (GasX, Mylicon) are examples of Anti-gas medication. Not many people find these very helpful.

Antidepressants, Selective Serotonin Reuptake Inhibitors and Norepinephrine-Selective Reuptake Inhibitors:Low doses of drugs originally used to treat depression have proven helpful in treating patients with IBS. These include particularly tricyclics (nortriptyline for example); or for some people SSRI’s or NSRI’s (generics for Prozac; Lexapro; Effexor; and similar) are helpful.

Other Drugs Drugs that are focused on improving the abnormal gut motility are under development; some have come and gone (Cisapride, Zelnorm), because of side effects observed after they were in broad use. Alosetron (Lotronex) or newer medication eluxadaline (Viberzi) is sometimes used for stubborn IBS diarrhea, but requires supervision for careful and safe use. Drugs for stubborn IBS constipation such as Amitiza (luboprostone) and Linzess (linaclotide) can help by increasing the fluid within the intestine, improving motility, and reducing gut sensitivity. Plecanatide (Trulance) was FDA approved for stubborn chronic constipation and is being tested in IBS constipation.

PROBIOTICS - Many individuals find higher dose probiotics of certain types to be useful for gassy bloat and/or constipation, though ordinarily not very helpful for IBS diarrhea. These like other supplements aren’t reviewed by FDA for effectiveness but do have benefits and little downside for most people. Our group stocks a range of good quality adequately potent probiotics, commonly in strengths of 20B (billion) to 50B for this purpose.

We encourage patients with Irritable Bowel Syndrome to discuss approaches they would like to try so we can review them for safety, medical evidence, and give precautions where appropriate.

Additional Resources

IBS 101