Irritable Bowel Syndrome (IBS)

The exact cause of irritable bowel syndrome is unknown and may be due to multiple factors.

Irritable bowel syndrome is a gastrointestinal disorder characterized by the presence of a cluster of symptoms and signs in adults or children that include cramping, abdominal pain, increased gas, altered bowel habits, food intolerance, and bloating (distention).

Irritable bowel syndrome is a "functional" disorder. This term refers to the changes in the functioning of the digestive system that result in the collection of symptoms referred to as IBS, meaning that it is a problem with movement (motility) rather than any damage to the tissues of the digestive system.

In the past, irritable bowel syndrome was also called spastic colon or bowel, functional bowel disease, mucous colitis, or nervous colon.

Based on different patterns of changes in the bowel movements or the presence of abnormal bowel movements, IBS is of three types. Certain diets or medications may work for one type of IBS but not for the other or may make other types worse. People with IBS often have normal bowel movements on some days and abnormal bowel movements on other days.

The three types of IBS are:

• IBS with constipation (IBS-C): It is also called constipation-predominant IBS. It presents with the following symptoms on days when the person has at least one abnormal bowel movement:
  • More than a quarter of the stools are hard or lumpy
  • Less than a quarter of the stools are loose or watery
• IBS with diarrhea (IBS-D): It is also known as diarrhea-predominant IBS. In IBS-D, on days when the person has at least one abnormal bowel movement:
  • More than a quarter of the stools are loose or watery
  • Less than a quarter of the stools are hard or lumpy
• IBS with mixed bowel habits (IBS-M): It is also called alternating type IBS or IBS-A. In this type of IBS, on days when there is at least one abnormal bowel movement:
  • More than a quarter of the stools are hard or lumpy
  • More than a quarter of the stools are loose or watery

While both irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) can have similar symptoms including abdominal pain, diarrhea, and urgent bowel movements, IBS is not the same as IBD.

• IBD is a group of separate diseases that includes ulcerative colitis and Crohn's disease and is a more severe condition.
• IBS or Irritable bowel syndrome is considered a functional gastrointestinal disorder because there is abnormal bowel function. IBS is a group of symptoms and not a disease in itself, which is why it's called a "syndrome" and it is considered less serious than IBD.
• IBS does not cause inflammation like inflammatory bowel disease, and it does not result in permanent damage to the intestines, intestinal bleeding, rectal bleeding, ulcers, or harmful complications that are often seen with IBD.

Small intestinal bacterial overgrowth (SIBO) is considered one of the factors that may produce signs and symptoms of irritable bowel syndrome (IBS). The medical data from studies done on SIBO are conflicting.

Some studies show an increase in gas production by intestinal bacteria as a cause of the pain and bloating associated with IBS. However, other studies done to determine if SIBO is the cause of IBS and if antibiotic treatment of SIBO helps reduce or eliminate IBS symptoms have not been conclusive.

The exact cause of irritable bowel syndrome is unknown. It is believed to be due to several factors, including alteration in the gastrointestinal (GI) tract motility, abnormal nervous system signals, increased sensitivity to pain, and food intolerances.

The following are risk factors thought to cause IBS:

• Abnormal movements of the colon and small intestines (too fast, slow, or too strong)
• Hypersensitivity to pain from a full bowel or gas
• Food sensitivities, possibly caused by poor absorption of sugars or acids in food
• Gastroenteritis ("stomach flu" or "stomach bug"), a viral or bacterial infection of the stomach and intestines, may trigger IBS symptoms
• Psychological conditions such as anxiety or depression are observed in many people with IBS, though these conditions are not a direct cause of IBS.
• Reproductive hormones or neurotransmitters may be off-balance in people with IBS.
• Small intestinal bacterial overgrowth (SIBO)
• Genetics is thought to be a possible cause of IBS, but so far, this hereditary link has not been proven.

What you eat and how you eat can affect the symptoms of this condition. While it may not be possible to completely prevent IBS symptoms, you may find that certain foods trigger IBS symptoms. To help figure out which foods cause your symptoms, a doctor may suggest keeping a food diary.

Some foods can help in the prevention of symptoms.

Foods to eat that may provide symptom relief

• Water
• Low-fat foods
• High-carbohydrate foods (such as whole wheat pasta, brown rice, and whole grain pieces of bread)
• Probiotics (containing Lactobacillus acidophilus a and Bifidobacterium) and prebiotics
• Some people report kefir or Aloe Vera juice helps with symptoms. Talk to a doctor about these home remedies.
• A high-fiber diet or fiber supplements may help relieve constipation in some cases of IBS, but it may also worsen some symptoms such as bloating and gas. The current recommended daily fiber intake is 20-35 grams daily. Most people fall short of this daily fiber intake and can benefit from a small increase in fiber, but it is best to increase the amount in your diet slowly to reduce gas.

Foods to avoid or limit if you have IBS

• Dairy products, including milk and cheese (Lactose intolerance symptoms can be similar to IBS symptoms.)
• Certain vegetables that increase gas (such as cauliflower, broccoli, cabbage, Brussels sprouts) and legumes (such as beans)
• Fatty or fried foods
• Alcohol, caffeine, or soda
• Foods high in sugars
• Artificial sweeteners
• Chewing gum
• Nuts

Irritable bowel syndrome is characterized mostly by abdominal pain and cramping.

Other symptoms and signs include:

• Diarrhea (IBS with diarrhea (IBS-D) can come with sudden urges to have bowel movements and loose stools)
• Constipation (IBS with constipation (IBS-C) can be accompanied by straining during bowel movements and infrequent stools)
• Increased gas
• Abdominal swelling or bloating
• Abdominal pain or discomfort
• Cramping pain after eating certain foods
• Nausea
• The appearance of mucous or foam in the stool
• Unexplained weight loss
• Loss of appetite

While not technically a symptom, nearly 70% of people with IBS also experience indigestion.

Symptoms are often relieved by bowel movements. Women with IBS may have more symptoms during their menstrual periods.

A primary care provider, family medicine specialist, or a child's pediatrician may first diagnose irritable bowel syndrome. You will likely be referred to a gastroenterologist (a specialist in disorders of the digestive system) for further treatment.

Irritable bowel syndrome is diagnosed by excluding other GI disorders that can cause similar symptoms. A complete history and physical are taken to determine the duration and frequency of symptoms. To be diagnosed with the condition, the duration of symptoms should be at least 6 months and should occur at least 3 times a month.

A doctor may order tests, including blood tests, stool tests, X-rays, or CT scans. There is no specific finding on these tests that can confirm the diagnosis of IBS, however, other problems can be ruled out by performing them.

Irritable bowel syndrome test

Two relatively new blood tests may help diagnose irritable bowel syndrome. One test is for irritable bowel syndrome with diarrhea (IBS-D), and the other is for irritable bowel syndrome with both diarrhea and constipation (irritable bowel syndrome mixed with IBS-M). Neither test can diagnose irritable bowel syndrome with constipation (IBS-C).

Both blood tests are for anti-CdtB and anti-vinculin antibodies. It is thought that these antibodies develop in some patients after an acute bout of gastroenteritis that is caused by several different, common types of bacteria. The overgrowth of these bacteria in the gut may trigger an immune attack on the patient's intestinal tissues (autoimmunity) with the ensuing inflammation and damage to the tissues causing the symptoms of IBS.

The tests may help distinguish between irritable bowel syndrome and inflammatory bowel disease or IBD, a different type of intestinal inflammatory disease that includes Crohn's disease and ulcerative colitis.

The antibody tests seem to be useful in the diagnosis of irritable bowel syndrome with diarrhea IBS-D, but not IBS with constipation (IBS-C). The tests also appear to be specific, and if the antibodies are present, IBS is likely present. However, the tests are insensitive, meaning if the antibodies are not present, the patient still may have IBS. Thus, these irritable bowel syndrome tests may be identifying only a subset of patients with IBS, those with post-infectious IBS. Both IBS blood tests have not undergone rigorous testing, and have not yet been approved by the FDA. It is expected to be an expensive test costing $500 to over $1,000.

Other diagnostic tests

A doctor also may send the patient to a gastroenterologist (a specialist in the digestive system). Depending on the symptoms, an upper endoscopy and/or colonoscopy may be performed.

Dietary modifications are the first treatments that should be tried to treat IBS. There are several types of foods in particular that often trigger characteristic symptoms and signs.

If dietary modifications and lifestyle changes do not adequately treat the symptoms and signs, a doctor may recommend medical therapies.

Medicine for diarrhea

• Antidiarrheal medications such as loperamide (Imodium), attapulgite (Kaopectate), and diphenoxylate and atropine (Lomotil) can be helpful if loose stools are one of the main signs. Eluxadoline (Viberzi) is a prescription for the treatment of irritable bowel syndrome with diarrhea (IBS-D).
• For females with IBS who experience severe diarrhea, alosetron (Lotronex) has been used.
• Rifaximin (Xifaxan) is an antibiotic for the treatment of irritable bowel syndrome with diarrhea (IBS-D) and IBS-related bloating.
• Bile acid binders including cholestyramine ( (Prevalite), colestipol (Colestid), or colesevelam (Welchol) can help some patients with IBS-D, but can also cause bloating.

Medicine for constipation medication

• Over-the-counter laxatives such as polyethylene glycol 3350 ( (MiraLax), bisacodyl (Dulcolax), and psyllium seed husks (Metamucil) can help relieve constipation and keep bowel movements regular. Senna laxatives (Senokot, Ex-Lax Gentle Nature) may be taken short-term. Prescription laxatives such as lactulose (Constulose) may also be prescribed.
• Two drugs specifically used to treat IBS are lubiprostone (Amitiza), a laxative, and linaclotide (Linzess), a constipation medication.
• SSRI antidepressants fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), paroxetine (Paxil), and escitalopram (Lexapro) may be helpful for those with constipation (IBS-C), but they can trigger IBS attacks in patients with diarrhea (IBS-D).

• Antidepressants in low doses, such as tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), may help relieve symptoms associated with IBS.
• Bismuth subsalicylate (Pepto-Bismol) and magnesium hydroxide (Milk of Magnesia).
• Antibiotics may be used when small intestinal bacterial overgrowth (SIBO) is suspected.
• Antianxiety medications such as diazepam (Valium), lorazepam (Ativan), and clonazepam (Klonopin) are occasionally prescribed short-term for people whose anxiety worsens their irritable bowel syndrome symptoms.

• Antispasmodics, such as metoclopramide (Reglan), dicyclomine (Bentyl), and hyoscyamine (Levsin), decrease symptoms of pain and cramping.
• Antidepressants such as amitriptyline (Elavil, Paregoric), doxepin (Silenor), desipramine (Norpramin), nortriptyline (Pamelor), and imipramine (Tofranil) may help with abdominal pain but due to side effects are usually reserved for severe cases.

Some lifestyle changes that can also help relieve symptoms are as follows:

• Eat smaller, more frequent meals
• Quit smoking
• Exercise regularly
• Take probiotics
• Avoid caffeine
• Use stress management and relaxation techniques
• Mindfulness training
• Gut-directed hypnosis
• Biofeedback
• Pain-management techniques
• Cognitive behavioral therapy or psychotherapy
• Regular exercise such as walking or yoga
• Get an adequate amount of sleep
• Try ginger or peppermint, which may help with digestion
• Avoid laxatives unless prescribed by your healthcare professional

A low FODMAP diet may also help relieve symptoms of IBS. FODMAP refers to a group of short-chain carbohydrates (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) that are not well absorbed in the small intestine and are rapidly fermented by bacteria in the gut. These bacteria produce gas, which can contribute to IBS symptoms.

The lists of foods both high and low in FODMAPs are extensive. The International Foundation for Functional Gastrointestinal Disorders, Inc. (IFFGD) has suggestions for foods to eat and foods to avoid if you follow the FODMAP diet for IBS. Talk to your doctor for more information.

There is no known cure for IBS, but there are many treatment options to reduce or eliminate symptoms. Good communication with a doctor is important to help manage this condition.

Irritable bowel syndrome is a chronic disease with symptoms that tend to come and go. The overall prognosis for patients with IBS depends on the severity and frequency of symptoms, and the patient's ability to control these symptoms, whether by diet, lifestyle changes, or medications.

In general, there are few complications associated with this functional disease other than the symptoms of the disease itself. If someone has hemorrhoids, the diarrhea and constipation associated with IBS may irritate them. Moreover, a diet that is too strict limits nutrients that could cause problems related to lack of proper nutrition.

The biggest complication of IBS may be the quality of life. The stress and anxiety as well as the impact on daily activities the condition can cause may be troublesome for patients.

Irritable bowel syndrome does not lead to the following:

• Colon cancer
• Rectal bleeding
• Inflammatory bowel diseases (Crohn's disease and ulcerative colitis or UC

It may not be possible to prevent developing IBS, but you can take steps to prevent symptoms from occurring or worsening. As discussed earlier, dietary and lifestyle changes can help you manage symptoms. To identify food triggers, your doctor may suggest that you keep a food diary and avoid foods that cause symptoms. Manage stress and anxiety, and try cognitive therapy or psychotherapy if needed.