Irritable bowel syndrome

IBS symptoms and their intensity can vary from person to person. Symptoms often occur after eating a large meal or when you are under stress, and they are often temporarily relieved by having a bowel movement.

• Chronic and recurring abdominal pain
• Constipation followed by diarrhea
• Gassiness or bloating
• Abdominal bloating, or the sensation of being full
• Distention, or swelling of the abdomen
• Nausea
• Indigestion
• Heartburn
• Vomiting
• Worsening of pain with food intake and relief with defecation
• Mucus in the stool
• The urge to move your bowels without being able to have a bowel movement

Other Symptoms:

• Patients with IBS often complain of anxiety, depression, and tension headaches
• Some women with IBS notice a link between pain episodes and their menstrual cycle

The exact cause of IBS is not known; however, it is frequently associated with other comorbidities such as:

• Muscle Contractions in the Intestine: As food passes through the digestive tract, the muscles lining the intestinal walls contract. Weak intestinal contractions can cause slow food passage and hard, dry stools, whereas stronger and longer-lasting contractions result in gas, bloating, and diarrhea.
• Problems in Nerve Signaling: Poorly coordinated brain-intestine signals can cause the body to overreact to changes in the digestive process, resulting in pain, diarrhea, or constipation. Note: Reduced plasma serotonin levels, a hormone and neurotransmitter that aids in the regulation of GI motility, sensation, and secretion, may be linked to constipation-predominant IBS, whereas increased serotonin release may be linked to diarrhea-predominant IBS.
• Severe Infection: IBS can develop following a severe bout of diarrhea (gastroenteritis) caused by a bacterial or viral infection.
• Changes in Gut Microbes: Changes in the bacteria, fungi, or viruses that inhabit the small intestine are also important in the development of IBS.

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• Genetics: Genes may play a role in the development of IBS. Many individuals with IBS have a first-degree relative (parent, child, or sibling) who also has the condition.
• Age: IBS is more common in people under the age of 50 and is rarely diagnosed after that age. Over the age of 50, symptoms are more likely to be caused by an organic condition rather than IBS.
• Gender: Females are more likely than males to be diagnosed with IBS. Estrogen therapy, either before or after menopause, is another risk factor for IBS.
• Stress: Individuals who have experienced stressful life events, particularly during childhood, are more prone to developing IBS.
• Mental Health Problems: If you have anxiety or depression, you may be more susceptible to developing IBS. Conversely, having IBS may increase the likelihood of experiencing anxiety or depression. These mental health issues can exacerbate symptoms in IBD and IBS patients. Consultation with a psychologist or psychiatrist familiar with IBD and IBS can be beneficial in managing these conditions.
• History of Childhood Abuse: Individuals with a history of childhood physical or sexual abuse have a higher risk of developing IBS.
• Other Factors: Smoking, frequent alcohol consumption, physical or psychological stress, underlying depression, exposure to antibiotics, food poisoning, obesity, sleep problems, low levels of physical activity, and a family history of mental illness can all contribute to the risk of IBS.

Your doctor may be able to diagnose IBS based on your symptoms. They may also take one or more of the following steps to rule out other possible causes of your symptoms:

• Adopt a specific diet or eliminate certain food groups temporarily to rule out food allergies.
• Conduct a stool test to rule out infection or the presence of Inflammatory Bowel Disease (IBD).
• Perform complete blood tests to check for anemia and rule out celiac disease, which is a serious immune reaction to gluten.
• Conduct a colonoscopy if there is suspicion of any type of Inflammatory Bowel Disease.
• Measure erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) to check for inflammation in the body, which does not occur with IBS.

The diagnosis of IBS is made by performing a careful review of the patient's symptoms, determining the presence or absence of red flags, conducting a thorough physical examination, and utilizing the Rome IV criteria.

Rome IV Diagnostic Criteria for Irritable Bowel Syndrome

Abdominal pain that occurs, on average, at least 1 day per week over the last 3 months, associated with two or more of the following criteria:

• Related to defecation
• Associated with a change in the frequency of stool
• Associated with a change in the form (appearance) of stool

Evaluation of IBS should include a thorough history and identification of any red flags, such as:

• IBS should not cause rectal bleeding, fever, weight loss, or anemia.
• Diarrhea that prevents sleep.
• Red flags may indicate the need for a colonoscopy.

IBS symptoms vary from person to person. Some individuals experience constipation, while others may have diarrhea. Symptoms can worsen at times and improve or even disappear completely at other times.

Here are a few tips that may help you better manage IBS symptoms:

• Avoid foods and drinks that trigger IBS.

Foods that may worsen IBS constipation include:

• Dairy products, especially cheese
• High-protein diets
• Carbonated drinks
• Caffeine and alcohol
• Processed foods, such as cookies or chips
• Refined grains (e.g., white flour) in bread and cereals

Foods that may worsen IBS diarrhea include:

• Dairy foods, especially if lactose intolerant
• Foods with wheat if gluten-sensitive
• Chocolate
• Carbonated drinks
• Caffeine
• Alcohol
• Excess insoluble fiber, such as from the skin of fruits and vegetables
• Fried foods

• If you’re unsure about your triggers, try the elimination approach. List the foods you believe may be contributing to your symptoms. For 12 weeks, cut out one food at a time to see if it affects how you feel.
• Avoid or limit processed foods. Processed foods often contain unexpected or hidden ingredients that can cause IBS flare-ups.
• Avoid large meal portions. Aim for multiple small meals throughout the day instead of three large meals.
• Avoid eating too quickly. Eating quickly, chewing gum, or eating with your mouth open can increase the amount of air you swallow.
• Avoid foods high in FODMAPs. Foods containing high FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) are not well digested in the intestine and can cause excess gas production, leading to pain and diarrhea. Include low FODMAP foods like lettuce, carrots, crab, lobster, oils, pumpkin seeds, butter, peanuts, quinoa, and brown rice in your diet to help reduce gastrointestinal symptoms. Consult a dietitian or nutritionist to help reduce high FODMAPs in your diet.
• Avoid gas-producing foods. Limiting carbonated drinks, caffeine, raw fruits, and cruciferous vegetables like cabbage, broccoli, and cauliflower may help if bloating and gas are concerns.
• Don’t smoke. Smoking can irritate the digestive system and worsen IBS symptoms, so it's important to avoid smoking or quit if you are a smoker.

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Drug therapy may be initiated when IBS symptoms start to diminish the patient’s quality of life.

1. Drug Treatments for IBS with Diarrhea

• Antidiarrheal Medications:
  • Losetron
  • Atropine
  • Eluxadoline
  • Loperamide
  • Diphenoxylate
• Antibiotics, such as Rifaximin, are prescribed to treat bacterial infections.

2. Drug Treatments for IBS with Constipation

• Lubiprostone
• Linaclotide
• Plecanatide
• Fiber supplements with psyllium, in case dietary fiber intake is insufficient.

3. Medication to Treat Abdominal Pain in People with IBS

• Antispasmodics, which relax the smooth muscle in the small and large intestines, thereby reducing abdominal spasms and cramps. Examples include:
  • Hyoscyamine
  • Dicyclomine
  • Pinaverium
  • Peppermint oil
  • Trimebutine
• Low-dose tricyclic antidepressants: Diazepam, Lorazepam, Clonazepam
• Low-dose selective serotonin reuptake inhibitors (SSRIs): Tegaserod
• Coated peppermint oil capsules

4. Bloating/Gas

It requires probiotics, dietary changes, and medications such as fluoxetine. Probiotics contain good bacteria such as bifidobacteria and lactobacilli, which help maintain the health of the digestive tract and aid in proper digestion.

1. Be careful with fiber: Adding fiber to your diet can help manage constipation. Increase the amount of fiber in your diet gradually over a few weeks. Whole grains, fruits, and vegetables are high in fiber. Avoid excessive fiber intake if you have diarrhea.

2. Avoid trigger foods: If certain foods aggravate your signs and symptoms, avoid them. Beans, cabbage, milk, cauliflower, and broccoli may cause gas.

3. Eat at regular times: To help regulate bowel function, do not skip meals and try to eat at the same time every day.

4. Be mindful of dairy products: If you are lactose intolerant, consider replacing milk with curd. Consuming dairy products in small amounts or combining them with other foods can be beneficial.

5. Drink plenty of liquids: Include plenty of fluids in your diet. Aim for 8-10 glasses of water daily.

6. Have gluten-free food: A gluten-free diet can be very helpful for individuals with IBS. Gluten, a group of proteins found in grains such as rye, wheat, and barley, may cause issues for some people with IBS.

7. Probiotics: Probiotics are live microorganisms similar to the beneficial bacteria in the digestive tract. Consuming them through food or supplements can help relieve gas and bloating. In a 2022 study, IBS patients who took a probiotic called Bifidobacterium longum for one month observed a significant decrease in symptom severity compared to baseline measurements. Want to know more benefits of probiotics? Tap here.

8. Keep a food and symptom diary: Record the foods you eat and the symptoms you experience to identify which foods help or worsen your symptoms.

9. Exercise regularly: Exercise can relieve depression and stress, stimulate normal bowel contractions, and improve your overall well-being.

10. Manage stress: Your mood and stress levels can affect your gut and bowel habits. Spend some time each day doing something that helps you relax or de-stress, such as meditating, going for a walk, or reading a book. Watch this video to learn more about stress and anxiety and how to cope in such situations. Tap here.

IBS can lead to both physical and mental health complications such as:

• Diarrhea or Constipation: Diarrhea occurs when you have three or more liquid bowel movements per day. Constipation occurs when stools are frequently hard and pellet-shaped. Even when the rectum is completely empty, patients may experience a sense of incomplete evacuation.
• Anal Fissures/Tears: These can occur as a result of pushing too hard during a bowel movement. During constipation, these small tears can be difficult to heal.
• Hemorrhoids: Hemorrhoids can cause rectal bleeding and may develop from constipation-related straining.
• Fecal Impaction: This occurs when stool gets stuck in the rectum, requiring healthcare workers to manually remove the impacted stool.
• Rectal Prolapse: This occurs when the rectum exits the anus, causing mucus to leak out. Chronic constipation can contribute to this condition.
• Cramping: Cramping is usually caused by overeating. Both cramping and diarrhea may be alleviated by reducing food intake or consuming smaller meals.
• Malnourishment: This can develop from avoiding certain nutritious foods that aggravate IBS symptoms.
• Bladder Issues: Pressure on the bladder can lead to irregular urination and irritation.
• Problems in Sex Life: Individuals with IBS may experience difficulties enjoying their sex life due to increased urgency to use the restroom or other symptoms.
• Agoraphobia: This is a fear of going out in public. Anxiety about finding a restroom in unfamiliar places can lead to symptoms of agoraphobia.
• Anxiety and Depression: These may arise as a result of coping with IBS symptoms. IBS symptoms can cause anxiety, which in turn can exacerbate the symptoms, creating a vicious cycle.
• Sleeping Disturbances: Sleep problems are common with IBS, as abdominal pain and other cramps can disrupt sleep at night.

• Herbal therapies: Herbal remedies have been shown to significantly affect the management of IBS symptoms. Examples include turmeric extract, peppermint oil extract, and artichoke leaf extract. Learn more about herbs that help in managing IBS here.
• Mind-body therapies: Stressful situations (e.g., family problems, work stress, or examinations) may trigger symptoms of IBS in some individuals.
• Hypnotherapy: Hypnotherapy for IBS can help you learn relaxation techniques and new ways to manage stress.
• Cognitive behavioral therapy (CBT): CBT can help patients develop coping strategies to control symptoms triggered by anxiety. The aim is to help patients identify stressors and formulate healthier responses to reduce their impact. Learn more here.
• Relaxation techniques: Specific exercises focused on promoting relaxation, such as breathing exercises, are particularly helpful in combating anxiety. This boosts confidence in managing negative thoughts and improves behavioral responses.
• Gut-directed hypnotherapy: This is one of the most effective treatment approaches for chronic IBS. In addition to decreasing pain perception at the brain level, hypnosis may enhance immune function in IBD and IBS, increase relaxation, reduce stress, and alleviate feelings of anxiety.
• Acupuncture: Acupuncture can help IBS by stimulating the nervous system, releasing chemicals and hormones that relieve pain, stress, and other symptoms.
• Moxibustion: This traditional Chinese medicine therapy is typically administered alongside acupuncture, as the two approaches complement each other. Moxibustion involves burning dry herbs close to the skin, often near acupuncture points, and may help alleviate IBS symptoms when combined with acupuncture.

1. Sociological impact - IBS has a significant negative impact on patients' personal and professional lives, including a decreased tendency to travel, reduced socializing, and a loss of earnings. IBS makes it difficult to carry out daily tasks outside of the home, where access to a bathroom is a concern. This can eventually lead to social isolation. There are several ways to manage the sociological impact of IBS:

• Join a support group for individuals with IBS or seek professional counseling to address the emotional impact of IBS on your life.
• Communicate with others about your condition, needs, and limitations. This can help reduce anxiety and make social interactions more comfortable.

2. Psychological impact - According to some studies, having IBS might increase your risk of depression, anxiety, sleep disorders, or bipolar disorder. Depression and anxiety can also exacerbate IBS. Here are some tips to help manage the psychological impact of IBS:

• Practice stress-reducing activities such as meditation, yoga, and deep breathing.
• Talk to loved ones.
• Consider consulting with a mental health professional who can help you develop coping strategies for managing anxiety, depression, and stress.
• Stay physically active, as it helps reduce stress.
• Track your symptoms. This can help you avoid foods that trigger your symptoms, which can reduce stress and anxiety.

3. Financial burden - IBS can be financially draining due to hospitalizations, physician services, prescription drugs, over-the-counter drugs, and skilled nursing care. This can be managed through:

• Understanding the cost of therapy well in advance.
• Communicating any financial issues with the doctor's team. This will help doctors look for affordable alternatives.
• Finding financial support resources through doctors or online.
• Seeking assistance from your health insurance partners.

4. Role of caregivers - Caregivers play a crucial role in the overall disease outcome of patients diagnosed with IBS. The important roles of caregivers include:

• Making decisions about disease management options.
• Participating in doctor appointments.
• Administering medications to the patient on time.
• Assisting with meal preparation.