Understanding Irritable Bowel Syndrome

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There is no known specific cause, but some experts suggest people who suffer from IBS have a colon that is more sensitive and reactive to certain foods and stress. The disorder is also known as spastic colon.

Although IBS can be painful and uncomfortable, it is not permanently damaging to the intestines, nor does it cause other gastrointestinal diseases. People with IBS frequently suffer from anxiety and depression, which can worsen symptoms. Evidence also suggests that the immune system, also responding to stress, plays a role.

IBS can also make you feel more anxious and depressed. While there is no cure for IBS, treatments can manage the symptoms and discomfort. Of those who do seek treatment, research has found that 50 to 90 percent have a psychiatric disorder such as an anxiety disorder or depression. ADAA is not a direct service organization. ADAA does not provide psychiatric, psychological, or medical advice, diagnosis, or treatment.

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Breadcrumb Understand the Facts. People feel the effects of stress and anxiety in many ways.

1. Pain and cramps

Irritable bowel syndrome Also called IBS, this disorder is characterized by abdominal pain, cramping, bloating, gas, constipation, and diarrhea. All patients with IBS are likely to benefit from dietary and lifestyle changes such as increasing exercise and reducing stress and for some, this approach may provide sufficient control over their symptoms. The majority of patients with IBS find that certain foods will trigger their symptoms, e. Often, patients will have already altered their diet to minimise or exclude foods that trigger their symptoms and some will report benefit from these changes.

In the past, however, most guidelines for the management of IBS have not included consistent dietary advice as there has been a lack of evidence that excluding or restricting foods resulted in a significant improvement for patients. The British Dietetic Association has recently released evidence-based guidelines for the dietary management of IBS in adults. Once a diagnosis of IBS has been established, first-line dietary advice for all patients should be to encourage a diet that is healthy and nutritionally adequate.

Establish if the patient has any known or suspected allergies or intolerances to foods, e. A food and symptoms diary can be a useful tool to establish the frequency and timing of symptoms and whether any patterns are present, e. Common foods that can aggravate symptoms in people with IBS include caffeine, alcohol, fatty food, spicy food, wheat, cheese, milk, pure fruit juices, artificial sweeteners and vegetables that increase flatus, such as cabbage, Brussels sprouts, corn, onion and legumes e.


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Many patients will have been advised in the past to increase their intake of fibre, particularly insoluble fibre such as wheat bran, however, there is now good evidence that this is unlikely to be beneficial for the majority of patients with IBS, particularly those with IBS-D, and may worsen symptoms. If the patient has not had an improvement in symptoms with first-line interventions the next steps are recommended. If constipation is the predominant symptom , an increase in a form of soluble fibre may be beneficial. The patient should be advised this can be achieved by increasing their intake of foods that are high in soluble fibre such as oats, 1 or with a prescription product containing psyllium husk or sterculia.

A four week trial of probiotics in the form of yogurts or other fermented milk products can be considered, however, some of these products also contain ingredients that may worsen IBS symptoms, such as fructans, fructose or lactose. A recent systematic review has concluded that there is some evidence that probiotics, e.

Understanding Irritable Bowel Syndrome with Constipation (IBS-C)

Lactobacillus, may improve the overall symptoms, abdominal pain, bloating and distension in patients with IBS but little or no evidence that they will improve other symptoms such as diarrhoea, constipation and flatus. If there has been no improvement in symptoms after second-line approaches have been trialled, consider an exclusion diet where one or two foods that appear to aggravate symptoms are excluded for two to four weeks and then re-introduced as a challenge.

Their work began with observations of the role of fructose in producing symptoms in patients with IBS. Although there is evidence that individual components of the FODMAP group contribute to IBS symptoms, the new concept was to consider the collective role of these poorly absorbed short-chain carbohydrates and to show the benefits for patients of a diet low in FODMAPs. There is increasing evidence that a low FODMAP diet can be of benefit for many patients with IBS, however, it is not a cure-all and as yet, there is little evidence regarding its use in the longer term.

Some patients may enquire about investigation of fructose malabsorption. This can be measured using a breath hydrogen test after a challenge with fructose, however, this test is not widely available in New Zealand. Despite this, the use of multiple medicines for the control of symptoms is often reported as being of insufficient benefit and there is the potential for dissatisfaction with the treatments and for an increase in adverse effects.

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Medicines that have the potential to target more than one symptom of IBS, such as tricyclic antidepressants, are increasingly recommended. Dietary advice should be given following the three-tiered plan outlined above. Increasing dietary fibre is not recommended because this is likely to worsen symptoms in patients with diarrhoea as their main symptom. A Cochrane review found that the use of bulking agents a fibre supplement was not effective in the treatment of patients with IBS, particularly those with diarrhoea-predominant IBS. The combination of a regular daily dose of loperamide and an antispasmodic, such as mebeverine, can help to increase stool firmness, decrease stool frequency and reduce urgency.

Loperamide can be used as a regular daily medicine at a fixed daily dose e. Mebeverine one mg tablet can be taken three times daily as required, 20 minutes prior to meals which may help postprandial symptoms. An approach that has been suggested for patients who are fearful of the sudden and urgent need to defaecate that can occur with IBS, is for them to take 2 — 4 mg of loperamide approximately 45 minutes before leaving their house, particularly if access to a toilet is limited such as when shopping or exercising.

There is some evidence that serotonin antagonists 5HT3-receptor antagonists such as ondansetron may modulate the effect of stressors on gut function and reduce diarrhoea. Some patients in whom constipation is the predominant symptom may find that an increase in either soluble dietary fibre, from foods such as oats or soluble fibre in the form of a bulk-forming laxative such as psyllium husk, and avoiding foods with insoluble fibre, e.

People with IBS-C should avoid eating foods with carbohydrates that are poorly digested in the small intestine regarded now as FODMAPs and therefore reach the colon relatively intact to aggravate symptoms. Laxatives may be required; the dose is usually adjusted by the patient depending on the consistency of the stool. Lactulose should be avoided as it may aggravate bloating. The recommended dose is one sachet, once daily, dissolved in half a glass approximately mL of water, although this can be increased to 2 — 3 sachets daily if required.

Antispasmodic medicines are likely to be effective for the relief of abdominal pain or discomfort. Mebeverine is the recommended first-line antispasmodic medicine dosed the same as for patients with IBS-D. Bloating may be relieved or reduced by the use of peppermint oil or tea. Peppermint oil capsules 0. The recommended dose is one to two capsules taken 30 — 60 minutes before meals, three times daily, for up to three months if necessary. Opioid analgesics should be avoided as they are likely to worsen constipation which may in turn aggravate abdominal pain, however, low dose codeine, used cautiously, can be effective in firming the stool in patients with diarrhoea.

It is characterised by chronic or frequently recurrent abdominal pain that worsens with escalating or ongoing doses of opioids. If patients experience nausea as part of their IBS symptoms, domperidone may be effective. Domperidone 10 — 20 mg can be taken up to four times daily if required, 15 — 20 minutes before meals.

There is good evidence that tricyclic antidepressants TCA are effective in reducing abdominal pain in patients with IBS and that they can also have a global effect on a variety of other symptoms. The majority of the research has focused on the use of amitriptyline and imipramine, however, nortriptyline is also thought to be effective and is generally better tolerated by patients.

There is less evidence that SSRIs are effective in patients with IBS, however, they appear to provide similar benefits to TCAs and can be considered in people who are unable to tolerate these. Although self-management of IBS should be encouraged, patients should continue to be reviewed medically to assess how they are coping with the condition and to check for the emergence of any red flags or alarm symptoms.

The NICE guideline suggests an annual review, although, how often the patient will be seen is likely to be determined by their need for medicines and their response to any interventions. Patients who develop any of the red flag or alarm symptoms should be referred for further investigation. New understanding of the underlying mechanisms that cause the symptoms of IBS has led to increased interest in treatments that target the gastrointestinal flora and the immune system.

However, currently there is limited evidence and a lack of consistent guidance on the use of these treatments. Antibiotics — Due to the increasing evidence that intestinal bacterial may have a role in the pathophysiology of IBS, there has been research into the use of antibiotics e. Anti-inflammatory medicines — there is currently no evidence to support the use of anti-inflammatory medicines in patients with IBS.

Linaclotide — a synthetic amino acid peptide, has recently been approved for use in Europe and the USA for patients with IBS-C and a clinical trial commenced in New Zealand at the end of It acts in the gastrointestinal tract to increase colonic transit, to stimulate the secretion of fluid and to reduce abdominal pain. Lupiprostone — a locally acting chloride channel activator, has approval for use in the USA for treatment of females aged 18 years and over with IBS-C, however, research is ongoing with regards to its effectiveness and safety.

Alosetron — a serotonin antagonist 5-HT3 receptor antagonist , is also available in the USA for the treatment of severe diarrhoea-predominant IBS in female patients only who have not responded to other conventional treatments. Follow us on facebook. Forgot your login? Login to my bpac. Remember me. Gastroenterology Nutrition. Irritable bowel syndrome in adults: Not just a gut feeling Irritable bowel syndrome IBS is a chronic gastrointestinal disorder characterised by recurrent bouts of abdominal discomfort and pain, bloating and a changeable bowel habit.

In this article What is irritable bowel syndrome? What is irritable bowel syndrome? Pathophysiology of IBS The pathophysiology of IBS remains unclear, however, what is known is that it is a complex biopsychosocial illness. Three key factors are responsible for the majority of symptoms of IBS The three key factors that appear to most influence the symptoms of patients with IBS are: Altered gastrointestinal motility Altered sensation within the gastrointestinal tract Psychosocial factors, e. Emerging evidence on the role of gastrointestinal bacteria and the immune system in IBS Gastrointestinal bacteria have an important role in the normal physiological and immunological function of the gastrointestinal tract.

Check for red flags The presence of red flag symptoms should raise the possibility of an alternative diagnosis and referral to secondary care is recommended. Red flags from the history include: 1, 2, 12 Unintentional or unexplained weight loss Rectal bleeding that is not due to haemorrhoids Nocturnal symptoms, e. These include: Abdominal mass Rectal mass Iron deficiency anaemia Raised inflammatory markers.

The Manning criteria, which date from , includes six symptoms that were significantly more common amongst patients and felt to be characteristic of IBS: 17, 19 Looser stools at onset of pain More frequent bowel movements at onset of pain Pain eased after bowel movement often Visible distension Feeling of incomplete emptying Mucus per rectum The Manning criteria have been criticised for a lack of specificity which led to the development of the Rome criteria. Unfortunately, many doctors seek quick and generalised solutions, and patients often end up stuck living with the symptoms.

Treating IBS always needs a multi-faceted and customised approach. It is not enough just to know that a patient has IBS. It is important also to define and find as many factors contributing to the disturbed functions as possible. The combination of factors that are present in any given IBS patient varies from individual to individual.

Therefore, treating IBS needs a vastly different and personalised plan for every individual.


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The doctor also needs to help the patient develop a clear understanding of the condition, paying particular attention to lifestyle and psychological factors. Some patients will also benefit from medications, but these have to be carefully selected. Unnecessary surgery should be avoided. The short answer is no, there is no single right diet for IBS patients. The diet that helps one person may actually make another feel worse. For example, a widespread idea is to eat a high-fibre diet.

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However, this is unhelpful for many people as a diet high in fibre can further disturb the digestive system. Other popular health trends promote the idea of clearing toxins from the body. However, mainstream science does not support the concept of detoxification except in very few circumstances like liver cirrhosis or liver failure.