Irritable Bowel Syndrome

Abdominal pain is typically crampy and varies in intensity, ranges from mild to severe, and periodically has exacerbations.Defecation can improve or worsen pain. Emotional stress and meals may exacerbate the pain.

This can include diarrhea, constipation, alternating diarrhea and constipation, or normal bowel habits alternating with either diarrhea and/or constipation. Large volumes of diarrhea, bloody stools, waking in the middle of the night to have a BM, and greasy stools are not common with IBS.

Diarrhea

Characterized by frequent loose stools, small to moderate volume,that usually occur during the daytime, most often in the morning or after meals. Diarrhea is often preceded by lower abdominal cramping, urgency, and followed by a feeling of incomplete emptying. About one-half of people with IBS also notice mucous discharge with stools.

Constipation

Stools that are hard and pellet-shaped. You may not feel completely empty after a bowel movement even when the rectum is empty.

Other symptoms of IBS include bloating, gas, and belching.

The first step in treating IBS is usually to monitor symptoms by tracking diet, bowel habits, and any other factors that may affect your bowels. This can help to identify factors that worsen symptoms in some people with IBS, such as lactose or other food intolerances, and stress.

Patients with IBS may benefit from exclusion of gas-producing foods, a diet low in fermentable/poorly absorbed carbohydrates (FODMAPs), and in select cases, lactose,and/or gluten avoidance.Fiber can also be recommended in the appropriate situation.

Foods that cause gas

Eliminating these foods are reasonable if gas or bloating is bothersome.

• The most common gas-producing foods are legumes (such as beans) and cruciferous vegetables (such as cabbage, Brussels sprouts, cauliflower, and broccoli).
• In addition, some people have trouble with onions, celery, carrots, raisins, bananas, apricots, prunes, sprouts, and wheatgerm, pretzels, and bagels.
• Alcohol and caffeine should be avoided.

FODMAPs Diet

Shortened named for“fermentable oligosaccharides, disaccharides, monosaccharides and polyols” diet. This diet is aimed at reducing/avoiding certain foods that contain carbohydrates that are hard to digest. It includes 3 phases: elimination, reintroduction, and personalization. FODMAPs diet takes several weeks to implement and should be guided by a dietician.

Lactose 

A lactose-restricted diet should be considered for those who experience persistent abdominal bloating despite exclusion of gas-producing products. Although the incidence of lactose malabsorption is not higher in patients with IBS, patient with IBS and lactose intolerance can have an exaggerated symptom response to lactose ingestion.

• The greatest concentration of lactose is found in milk and ice cream, although it is present in smaller quantities in yogurt, cottage and other cheeses, and any prepared foods that contain these ingredients. 
• All lactose containing products should be eliminated for two weeks. If IBS symptoms improve, it is reasonable to continue avoiding lactose. If symptoms do not improve, you may resume eating lactose-containing foods.

Gluten 

Gluten has been demonstrated to alter bowel barrier functions with patients with IBS-D. Evidence to support gluten avoidance in patients with IBS has been conflicting though.

Increasing dietary fiber 

The role of fiber is controversial but given lack of serious side effects and potential benefit, it may be used in patients whose predominant complaint is constipation.

• A bulk-forming fiber supplement (such as psyllium or methylcellulose)may be recommended to increase fiber intake if it is difficult to consume enough fiber in your diet.
• Fiber supplements should be started at a low dose and increased slowly over several weeks to reduce the side effects of excessive intestinal gas and bloating, which can occur in some people during the beginning of fiber therapy. A starting dose of ½ to 1 tablespoon daily is recommended, then titrated up based on response.

Stress and anxiety can worsen IBS symptoms in some people. The best approach for reducing stress and anxiety depends upon your situation and the severity of your symptoms. Have an open discussion with your clinician about the possible role that stress, and anxiety could be having on your symptoms, and together decide upon the best course of action.

• Some people benefit from formal counseling, with or without antidepressant or antianxiety medications. Cognitive behavioral therapy helps you to focus on a particular problem in a limited time period. You learn how your thoughts contribute to anxiety or stress and learn how to change these thoughts.
• Participation in a support group can also be valuable.
• Many patients find daily exercise to be helpful in maintaining a sense of well-being. Exercise can also have favorable effects on the bowels, therefore, 20 –60 minutes, 3 –5 times per week of moderate to vigorous intensity exercise is recommended.

Anticholinergic drugs block the nervous system's stimulation of the gastrointestinal tract, helping to reduce severe cramping and irregular contractions of the colon.

Tricyclic antidepressants (TCAs) have a pain-relieving effect in people with IBS. The dose of TCAs is typically much lower than that used for treating depression. It is believed that these drugs reduce pain perception when used in low doses, although the exact mechanism of their benefit is unknown.TCAs also slow movement of contents through the gastrointestinal tract and may be most helpful in people with diarrhea-predominant irritable bowel syndrome.Should be used cautiously in patients with constipation.

Selective Serotonin Reuptake Inhibitors, another class of antidepressants, may be recommended if you have both IBS and depression.

Suggested for patients with constipation who fail a trial of soluble fiber. Polyethylene Glycol (PEG)is inexpensive, widely available, and has few side effects compared to other medications such as Milk of Magnesia. Side effects can include bloating and abdominal discomfort. These medications often help with constipation but not abdominal pain.

The drugs loperamide(Imodium®) or diphenoxy late with atropine(Lomotil®) can help slow the movement of stool through the digestive tract by inhibiting movement, prolonging transit time, and reducing fecal volume.Clinicians usually recommend these drugs be used on an as needed basis rather than continuously.

Second line therapy for IBS-D, after anti-diarrheal drugs.Such rational is based on the suggestion that 50% of patients with a diagnosis of functional diarrhea and IBS-D have bile acid malabsorption. Bile acids cause diarrhea by stimulating colonic secretion and motility. Medications in this category can be limited by side effects including bloating, flatulence, abdominal discomfort, and constipation.

Provide short term relief of abdominal pain in patients with IBS, but their long-term efficacy has not been established. They are used on an as-needed basis and/or in anticipation of stressors with known exacerbating effects.

Sometimes there are specific drugs prescribed by a Gastroenterologist that may be used if your symptoms are not responsive to the previously mentioned treatments. The role of antibiotics remains unclear. Probiotics are not routinely recommended in patients with IBS, although they have been associated with an improvement in symptoms. The most effective species/strains and extent of benefit remain unclear.

Several herbal and natural therapies have been advertised for the treatment of IBS. Unfortunately, there is no significant evidence supporting their benefit.