Irritable Bowel Syndrome (IBS)

Irritable bowel syndrome (IBS) is a disorder of the digestive tract that causes recurring abdominal pain and constipation or diarrhea.

• • Symptoms vary but often include lower abdominal pain, bloating, gas, and constipation or diarrhea.
  • A variety of substances and emotional factors can trigger symptoms of IBS.
  • A doctor usually diagnoses IBS based on the symptoms but does tests to rule out other problems.
  • Diet modification and drugs can usually relieve specific symptoms.

IBS affects about 10 to 15% of the general population. Some but not all studies suggest women with IBS are more likely to consult a doctor. IBS is the most common disorder diagnosed by gastroenterologists (doctors who specialize in disorders of the digestive tract) and is a common reason why many people visit their primary care physician.

IBS is generally classified as a functional disorder because it impairs the functioning of the body's normal activities, such as the movement of the intestines, the sensitivity of the nerves of the intestines, or the way in which the brain controls some of these functions. However, although the normal functioning is impaired, there are no structural abnormalities that can be found with an endoscope (a flexible viewing tube), x-rays, biopsies, or blood tests. Thus, IBS is identified by the characteristics of the symptoms and, when done, normal results of tests.

Causes of IBS

The cause of irritable bowel syndrome is not clear. In many people with IBS, the digestive tract is especially sensitive to many stimuli. People may experience discomfort caused by intestinal gas or contractions that other people do not find distressing. Although the changes in bowel movements that occur with IBS might seem to be related to abnormal intestinal contractions, not all people with IBS have abnormal contractions, and in many of those who do, the abnormal contractions do not always coincide with symptoms. In some people, symptoms of IBS begin after an episode of gastroenteritis.

Emotional factors (for example, stress, anxiety, depression, and fear), diet, drugs (including laxatives), hormones, or minor irritants may trigger or worsen a flare-up (a bout or attack) of IBS.

For some people, high-calorie meals or a high-fat diet may be a trigger.

For other people, wheat, dairy products, beans, chocolate, coffee, tea, some artificial sweeteners, certain vegetables (such as asparagus or broccoli), or stone fruits (such as apricots) seem to aggravate the symptoms. These foods contain carbohydrates that are poorly absorbed by the small intestine. The carbohydrates become fermented by bacteria in the intestine, which causes gas, bloating, and cramping. Because many food products contain several ingredients, it may be difficult to identify the specific trigger.

Other people find that eating too quickly or eating after too long a period without food stimulates a flare-up. However, the relationship is inconsistent.

People do not always get symptoms after a usual trigger, and symptoms often appear without any obvious trigger. It is not clear how all the triggers relate to the cause of IBS.

Symptoms of IBS

IBS tends to begin in the teens and 20s, causing bouts of symptoms come and go at irregular periods. The start of IBS symptoms in late adult life is less common but not rare. Flare-ups almost always occur when a person is awake, and they rarely wake a person from sleep.

Symptoms of irritable bowel syndrome include abdominal pain related to or relieved by having a bowel movement (defecation), change in stool frequency (such as constipation or diarrhea) or consistency (loose or lumpy and hard), abdominal expansion (distention), mucus in the stool, and the sensation of incomplete emptying after defecation. The pain may come in bouts of continuous dull aching or cramps, usually over the lower abdomen.

Bloating, gas, nausea, headaches, fatigue, depression, anxiety, muscle aches, and difficulty concentrating are other possible symptoms.

In general, the character and location of pain, triggers, and the pattern of bowel movements are relatively consistent over time. However, symptoms may increase or decrease in severity and also change over time.

Diagnosis of IBS

• • A doctor's evaluation based on the Rome criteria
  • Laboratory and imaging tests to look for other disorders

Most people with IBS appear healthy. Doctors base the diagnosis of irritable bowel syndrome on the characteristics of the person's symptoms. Doctors also use standardized symptom-based criteria for diagnosing IBS called the Rome criteria. They may also do tests to diagnose common illnesses that can cause similar symptoms, particularly when people are over 40 or have warning signs such as fever, weight loss, rectal bleeding, or vomiting.

Doctors use the Rome criteria to diagnose IBS in people who have had abdominal pain for at least 1 day a week in the last 3 months along with 2 or more of the following:

• • Pain that is related to defecation.
  • Pain is associated with a change in stool frequency (constipation or diarrhea).
  • Pain is associated with a change in the consistency of stool.

A physical examination generally does not reveal anything unusual except sometimes tenderness over the large intestine. Doctors do a digital rectal examination, in which a gloved finger is inserted in the person's rectum. Women undergo a pelvic examination.

Doctors usually do some tests—for example, blood tests, a stool examination—to differentiate IBS from Crohn disease, ulcerative colitis, cancer (mainly in people over age 40), collagenous colitis, lymphocytic colitis, celiac disease, and the many other diseases and infections that can cause abdominal pain and changes in bowel habits. These test results are usually normal in people with IBS.

Doctors usually do more tests, such as ultrasonography of the abdomen, x-rays of the intestines, or a colonoscopy, in older people and in people who have symptoms that are unusual for IBS, such as fever, bloody stools, weight loss, and vomiting. Doctors may do a test to rule out lactose intolerance or bacterial overgrowth and also ask questions to rule out laxative abuse.

Other digestive tract disorders (such as appendicitis, gallbladder disease, ulcers, and cancer) may develop in a person with IBS, particularly after age 40. Thus, if a person's symptoms change significantly, if new symptoms develop, or if symptoms are unusual for IBS, further testing may be needed.

Because IBS symptoms can be triggered by stress and emotional conflicts, doctors ask questions to help identify stress, anxiety, or mood disorders.

Treatment of IBS

• • Eating a normal diet and avoiding gas-producing and diarrhea-producing foods
  • Increasing fiber for constipation
  • Sometimes drugs

Treatment of irritable bowel syndrome differs from person to person. If particular foods or types of stress appear to bring on the problem, they should be avoided if possible. For most people, especially those who tend to be constipated, regular physical activity helps keep the digestive tract functioning normally.

Diet

Many people do better eating frequent, smaller meals rather than less frequent, larger meals (for example, 5 or 6 small meals rather than 3 large meals a day). People should try to slow their pace while eating. People with bloating and increased gas (flatulence) should avoid beans, cabbage, and other foods that are difficult to digest.

Some people find relief from IBS symptoms by restricting their intake of foods that are high in certain carbohydrates called fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. These foods are collectively called FODMAPs. FODMAPs are carbohydrates that are poorly absorbed and rapidly fermented by bacteria in the small intestine, leading to increased gas and discomfort.

Sorbitol, an artificial sweetener used in some foods, drugs, and chewing gums, should not be consumed in large amounts. Fructose, a sugar found in fruits, berries, and some plants, should be eaten only in small amounts. A low-fat diet helps some people, particularly those whose stomach empties too slowly or too quickly. People who have IBS and who cannot digest the sugar lactose (called lactose intolerance), which is found in milk and other dairy products, should consume dairy products in moderation.

Constipation can often be relieved by eating more fiber. People with constipation can take a tablespoon of raw bran with plenty of water and other fluids at each meal, or they can take psyllium mucilloid supplements with two glasses of water. Increasing the dietary fiber may aggravate flatulence and bloating. Occasionally, such flatulence may be reduced by switching to a synthetic fiber preparation (such as methylcellulose).

Drugs

Certain laxatives are reasonably safe and often effective for people with constipation. Such laxatives include those containing sorbitol, lactulose, or polyethylene glycol, and stimulant laxatives such as those containing bisacodyl or glycerin. The prescription laxative drugs lubiprostone and linaclotide may also relieve constipation.

Anticholinergic drugs, such as hyoscyamine, can relieve abdominal pain by blocking spasms of the intestinal muscles. However, these drugs often cause anticholinergic side effects (see Anticholinergic: What Does It Mean?), such as dry mouth, blurred vision, or difficulty urinating.

Antidiarrheal drugs, such as diphenoxylate or loperamide, help people with diarrhea. Alosetron, which decreases the effects of serotonin (a chemical messenger in the body), may be given to some women whose diarrhea caused by IBS cannot be managed with other drugs. However, because it has been associated with increasing the risk of ischemic colitis, its use is restricted. Eluxadoline is another drug that may be given to people who have severe diarrhea caused by IBS.

Rifaximin, an antibiotic, may be prescribed to relieve symptoms of diarrhea, bloating, and abdominal pain.

Antidepressants help relieve symptoms of abdominal pain as well as diarrhea and bloating in many people. Long-term use of certain antidepressants such as nortriptyline or desipramine is often helpful. Antidepressants may not only relieve pain and other symptoms but also may help relieve sleep problems and depression or anxiety.

Probiotics, which are bacteria naturally found in the body that promote the growth of good bacteria, may alleviate IBS symptoms, particularly bloating. Aromatic oils, such as oil of peppermint, often help relieve pain caused by cramps in some people.

Other treatments

Behavior modification techniques (such as cognitive-behavioral therapy), psychotherapy, and hypnotherapy (hypnosis) are often effective for managing symptoms of IBS.