Irritable Bowel Syndrome (IBS) Symptoms and Approaches to Care

It is not unusual for a patient to mention to me, while being seen for another illness, "I think I have IBS.” So, I am including a brief discussion of IBS here for those who have developed chronic bowel problems and may want to look into it more. Explore Irritable Bowel Syndrome (IBS) Symptoms and Approaches to Care

IBS is a chronic disorder of the gut manifested by either chronic diarrhea (IBS-D), chronic constipation (IBS-C), both, or alternating IBS-M (mixed) or IBS-U (unsubtyped). These symptoms are episodic and can last for hours to days, weeks, or even months, depending on the trigger and effectiveness of treatment. There is no cure as it is a lifelong condition, but long-term remission can often be attained.

Although it has been recognized for decades (and has likely been around for much, much longer!). It has only recently come to the forefront of practitioners' diagnoses of gastric diseases. An estimated 10-25% of people in the United States are afflicted with this problem.

What Causes IBS?

As noted on other pages here, chronic constipation and/or diarrhea may have a lot of different causes. However, a provider must look beyond the more common diagnoses and consider other possible underlying problems that may point to IBSheredity. For example, organic changes in a person's gut microbiome, thyroid problems, diabetes, cancer, inflammation, or heightened sensitivity of the gut lining, motility changes, and changes in the nervous system (Parkinson's, MS), and changes in neurotransmitters, like serotonin. While underlying chronic diseases may be responsible for symptoms of IBS, lifestyle and heredity also tend to play a significant role.

When examining a patient for "gut problems," a healthcare provider (or a gastroenterologist) will do a thorough history and exam to rule out the usual problems underlying "diarrhea" and "constipation" (above). A screening for IBS is in order when a patient has an ongoing/chronic case of gastrointestinal symptoms (abdominal pain and/or stool changes).

IBS Can Cause Abdominal Pain

Irritable Bowel Syndrome (IBS) Symptoms and Approaches to Care

Symptoms of IBS

IBS symptoms, while an annoyance to its sufferer, is not usually severe.

An excellent standard screening tool used to diagnose IBS, is the ROME IV. It is often used for people who develop chronic stomach problems. MDCALC has a succinct questionnaire based on the Rome IV criteria. These questions are asked when a person develops chronic stomach problems. Of course, it is important to speak to a healthcare provider about problems you may be having.

Diagnostic criteria*              

According to the ROME IV, IBS is recognized by recurrent abdominal pain, on average, at least one day/week in the last three months, associated with two or more of the following criteria:

1. Related to defecation (discomfort comes on when "pooping")

2. Associated with a change in the frequency of stool (how often you "poop."

3. Associated with a change in form (appearance) of stool (is it a hard stool? diarrhea? etc.)

     * Criteria includes symptoms for the last three months with symptom onset at least six months before (Depending on other history, exam, and symptoms, the healthcare provider might also test for diseases such as Celiac disease, diverticulitis, and inflammatory bowel disease [ulcerative colitis, and Crohn's] by using labs, scans, endoscopies, colonoscopies, lactose intolerance tests, breath tests [for bacterial overgrowth] and others).

In addition to changes in your stool consistency, IBS may be accompanied by the following:

• Cramping

• Abdominal pain

• Diarrhea and fecal incontinence

• Bloating

• Gas

• Nausea and, possibly, vomiting

• Weakness

• Fatigue

• Mood changes – This is an interesting connection because there are many more serotonin (neurotransmitter) receptors in your gut than in your brain. Present in both the brain and gut, serotonin affects digestive functions (i.e., transit times, fluid absorption, nausea, vomiting), mood changes (anxiety and depression), sexual desire, sleep, and others. So, presumably, increases and decreases in serotonin could affect your mind and gut. See "Mental Health" for a discussion on serotonin's important function in the brain.

Support and Treatment of IBS

Treatment for IBS is varied depending on the cause and severity of symptoms

General Approaches to IBS

General approaches and lifestyle changes are the recommended first-line measures to take with IBS-

• Hydration

• Dietary Changes: Exclusion- Avoid dietary "triggers" and irritants. These include wheat, dairy products, citrus fruits, beans, cabbage, milk, and carbonated drinks, sugar-free gum and candies, gluten-free (may help)

• Food diary

• Low FODMAPS diet. (Fodmaps-Poorly absorbed carbs)

• Avoid stress,

• Add to your diet easy-to-digest foods: Eggs, chicken, turkey, fish, extra-firm tofu, and plain lactose-free Greek yogurt.

• Exercise

• Sleep (7-9 hours)

• Relieve Stress through deep breathing, yoga, and guided imagery

• Heating Pad

• Abdominal massage

• Meditation: Especially mindfulness, may help. Immerse yourself in the present moment, focus on your breathing and body processes without using judgment

• Biofeedback

• Probiotics - Certain strains of probiotics may help diarrhea.

  
  

Irritable Bowel Syndrome - Diarrhea type (IBS-D )

Over-the-Counter

• Imodium AD (Multi-symptom Imodium has additional ingredients for gas and bloating)    ​

• Bulking Agents – Oddly enough, bulking agents, which are used for constipation, it is also used for diarrhea because they expand in the GI tract and sometimes can help diarrhea turn into a more formed stool: Metamucil

• Bismuth subsalicylate (common: Pepto Bismol or Kaopectate). (read the contraindications on the label). It may cause your stool to become black. Avoid if fever or if you have blood in stool.

Natural Approaches and Remedies

See page on gastroenteritis for approaches to diarrhea

• Probiotics - Some of those with diarrhea-predominant IBS found probiotics Saccharomyces boulardii and Bifidobacterium, sometimes effective. Note that not all people can take probiotic - i.e. Those with immunity problems; those on chemo. Speak to your healthcare provider if in doubt.

• Peppermint oil (antispasmodic)

• Berry leaf teas - Teas made from blueberry, blackberry, or raspberry leaves contain tannins that may reduce inflammation and intestinal fluid secretion. 

• Peppermint -This herb has soothing and antispasmodic properties. You can take peppermint as a tea or as a peppermint oil capsule. 

• Apple cider vinegar - This fermented product may help ease digestive issues. 

• Magnesium - This mineral may help calm the bowel and act as a laxative. 

• Turmeric - A 2022 study found that 600 mg of curcumin daily improved bloating and abdominal pain in people with IBS. May help with regularity. Decreases gut inflammation.

• Slippery elm

• Acupuncture

Prescriptive Treatment:

• Antispasmodics like hyoscyamine

• Lomotil (narcotic - scheduled medication) inhibits peristalsis

• Bile acid binders

• Antibiotics (common: Rafimixin-taken for two weeks)

• Pain/bloating relievers (dicyclomine, hyoscyamine)

• Cholestyramine (common: Questran)

• Opioid agonists/antagonists (i.e. Eluxadoline-controlled substance))

• Neuromodulators: Antidepressants-Tricyclics (amitriptyline, nortriptyline, others).

well as SSRIs and SNRIs may help (common: paroxetine, citalopram).

Irritable Bowel Syndrome - Constipation type (IBS-C)

General Approaches to IBS - Constipation

• Gluten-free or low FODMAP diet

• Hydration – Drink plenty of fluids.

• Fiber- Natural sources – fruits, vegetables, legumes, and whole grains, of course, prunes.

• Exercise stimulates muscles and builds tone in the digestive tract to help move food along the gastrointestinal tract.

• Dietary change - Avoid constipating foods and increase fiber

Consider medication changes – Discuss medication changes with a healthcare provider.

Treatment and Remedies for IBS-C

​Over-the-Counter

Laxatives:

•  Osmotic laxatives (common: MiraLAX) draw water into the bowel and 

      decrease the density of stool making it softer

•   Peristaltic stimulants (common: Bisacodyl/Dulcolax) stimulate muscles in the colon which help move stool along

•   Bulk-forming laxatives: Psyllium (common: Metamucil, Citrucel)

•   Enemas: These can help introduce fluid into the colon which softens the stool. Some actually stimulate the colon muscles to help move the stool on. Note: It is important to understand that overuse of laxatives can cause harm. Too much, too often, can lead to harm to muscle and nerves of the colon. In addition, these can lead to electrolyte and mineral disturbances as well as dehydration(some draw fluid into the colon from the body). You don't want to use these too often.​

Natural and Considered Approaches to Constipation​

• Senna

• Warm Epsom salt bath

• Fish oil

• Magnesium

• Lemon in warm water

• Dried fruits, fresh kiwi or cherries which have lots of fiber

• Probiotics may help. ConsumerLab (can get a trial for this site) cites some evidence regarding the benefit of using Lactobacillus casei - strain Shirota for chronic constipation.

  (in some fermented foods and yogurts, Kefir - Read Labels!). Others include Bifidobacterium infantis, B. animalis. Note that not all people can take probiotic - i.e. Those with immunity problems; those on chemo. Speak to your healthcare provider if in doubt.

• Ginger

• Slippery Elm

• Rhubarb

Prescriptions for Constipation

Most of the time, constipation is just...well...just constipation. However, you should speak to a healthcare provider if you have any of the following: Frequent bouts of constipation (recurring episodes for beyond three weeks), presence of blood in your stool, significant pain, unexplained weight loss, change in the color of your stools, vomiting, inability to pass gas, fever and low back pain.

Prescriptive Treatment

• Linaclotide (Linzess)$$$: Helps stools pass more efficiently by increasing fluid secretion in the intestines, Lubiprostone (common: Amitiza), and others

• Plecanatide (common:Trulance)$$$ (not for patients under 18 years) – increases intestinal fluid and motility.

• Neuromodulators: Antidepressants-Tricyclics (amitriptyline, nortriptyline, others).

  as well as SSRIs and SNRIs may help (common: paroxetine, citalopram).