An irritable bowel syndrome is a group of GI symptoms that occur without explanation. This article deals with all you have to know about it.
Irritable bowel syndrome is a gastrointestinal tract disorder that causes several symptoms without any specific injury or pathology in the gastrointestinal tract. The absence of a specific organic cause labels it as a functional gastrointestinal disorder.
The exact mechanisms and explanations behind irritable bowel symptoms remain a heated topic of discussion for the medical community. Back in the day, it used to be an exclusion diagnosis. This meant that irritable bowel syndrome was the diagnosis of choice when all other possible explanations for the patient’s symptoms were ruled out. Although it is no longer strictly an exclusion diagnosis, physicians must rule out several conditions before making the diagnosis.
Moreover, studies suggest that irritable bowel syndrome affects around 10% to 20% of the general population. However, it is hard to get accurate numbers about this disease because diagnosis depends on how the patient describes its symptoms and the criteria used to diagnose it.
Not all IBS patients seek medical attention; only 10% to 20% of patients have symptoms severe enough actually to seek care. Commonly affected groups vary from region to region. For example, while in the western hemisphere, women are two to three times more likely to develop irritable bowel syndrome, in the Indian subcontinent, men represent 80% of cases.
Sadly, the reasons for these geographical differences remain unknown. Irritable bowel syndrome is more common below the age of 35. Being older than 40 does not exclude the diagnosis but should prompt the search for an organic cause (a severe underlying disease).
What causes bowel symptoms in irritable bowel syndrome?
The exact cause of irritable bowel symptoms remains unknown; possibly, the disease does not have a single specific reason and is instead the consequence of several factors.
Some popular theories that explain IBS symptoms include:
- Altered GI motility: Some studies have shown that IBS patients have either delayed or accelerated meal transit.
- Visceral hypersensitivity: An enhanced perception of visceral pain (pain to bowel distention, for example)
- Psychopathology: Irritable bowel syndrome is more frequent among sufferers from psychiatric conditions, such as major depressive disorder, anxiety disorder, and frequent panic attacks. However, the way these disorders lead to irritable bowel syndrome is still unexplained.
- Microscopic inflammation: This groundbreaking discovery is the only demonstrable pathologic alteration in irritable bowel syndrome. It is more frequent in patients in which onset occurs after a digestive tract infection.
- Alterations in the intestinal microbiome: A bacterial overgrowth in the small intestine is a common finding among IBS patients.
What are the symptoms of irritable bowel syndrome?
Because there is no way of diagnosing irritable bowel syndrome through any specific test or laboratory finding, symptoms are of particular importance in this condition. The problem is (and this is one reason diagnosis is so complicated) that symptoms vary significantly among affected individuals.
Four main symptom categories vary between patients.
- Altered bowel habit: The term bowel habit refers to the frequency of depositions. IBS patients can have an accelerated bowel habit or a decreased bowel habit; many times, both conditions coexist in the same patient. Patients can go through phases of diarrhea alternated with long periods of constipation. However, in most patients, one of the two features is the predominant symptom.
- Abdominal pain: Pain in irritable bowel syndrome varies from patient to patient; some describe a constant dull pain, others an episodic sharp pain, some describe it as a simple abdominal discomfort, and others as abdominal cramping. The most common location is the left lower abdominal quadrant.
- Abdominal bloating or abdominal distension: Patients with irritable bowel syndrome often report abdominal distension and bloating; however, this perception is not always objectively measurable.
Additional symptoms (other symptoms that may or may not be present)
- Sexual dysfunction
- Increased urinary symptoms
What symptoms make irritable syndrome unlikely?
Some alarm symptoms make physicians discard IBS as a diagnosis and think of organic pathologies. Some of these alarm symptoms include:
- Blood in the stool
- Painless diarrhea
- Loss of appetite
- Weight loss
- Gluten intolerance
- Symptoms that get progressively worse
What are the complications of irritable bowel syndrome?
Irritable bowel syndrome does not increase the risk of mortality or decrease life expectancy in any way. That is to say, it does not increase the likelihood of dying in comparison to healthy people without this disease. However, IBS patients have a higher risk of pregnancy problems, such as miscarriage and ectopic pregnancy.
Keep in mind; irritable bowel syndrome patients often suffer from anxiety disorders and depression. Yet, it is still not clear if psychological disorders are a consequence or a cause of IBS. For example, in some patients, irritable bowel syndrome causes several lost days of work and lower wages.
How is IBS diagnosed?
IBS diagnosis is a clinical one; after other conditions are ruled out, your doctor will study if you fit the Roma III diagnostic criteria for IBS.
The criteria go as follows:
Recurrent abdominal pain for at least one day of the week for three months or more (with at least two of the following criteria)
- Worsening or improvement with defecation
- Associated with a change in frequency of stool (diarrhea or constipation)
- Change in the form or appearance of the stool
These criteria must be filled at least three months before making a definitive diagnosis.
What can IBS be mistaken for?
Many different diseases can cause somewhat similar symptoms as IBS. Therefore, These diseases must be ruled out before making a diagnosis. Some diseases that might resemble IBS include:
- Inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
- Celiac disease
- Colorectal cancer
- Chronic pancreatitis
- Colon cancer
- Lactose Intolerance
- Bacterial gastroenteritis
- Bacterial overgrowth syndrome
- Abdominal angina
- Food allergies
- Pancreatic cancer
What workup does IBS require?
The workup in each case depends on the patient in question. Age, comorbid conditions (other diseases the patient may have) and the patients’ symptoms will be key factors in deciding the appropriate tests.
The American College of Gastroenterologists does not recommend extensive laboratory testing or imaging studies in patients below the age of fifty years with typical IBS symptoms. Nevertheless, the presence of alarm features such as weight loss, anemia, or a family history of organic GI tract disease call for more extensive testing.
Furthermore, over the age of fifty, patients also require more extensive testing because they have a higher risk of suffering from organic disease.
Some useful tests to discard other conditions in cases of suspected IBS include:
- Complete blood count: Helps ruling out anemia and an elevated blood count that points towards ischemia.
- Stool examination: Examining the stool helps rule out parasitic and bacterial infections and the presence of toxins.
- Imaging studies: Patients older than fifty or with alarm symptoms might benefit from imaging studies such as CT scanning, lower and upper abdominal endoscopy
- Dietary testing: Improvement after a lactose-free diet during a week combined with lactase supplements points towards lactose intolerance.
Also, other dietary intolerances that may explain gastrointestinal symptoms include FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), gluten, and fructose.
How is irritable bowel syndrome treated?
Treating IBS consists of three main cornerstones:
- Dietary and lifestyle changes
- Psychological support
- Pharmacologic treatment
This article will describe each one of these pillars step by step.
What should you eat if you have irritable bowel syndrome?
Currently, there is no ideal diet for every IBS patient. Different patients benefit from different dietary modifications according to their symptoms. For example, individuals with constipation-predominant IBS respond differently than patients with high motility predominant IBS.
Patients with a constipation-predominant diet tend to benefit more from a high-fiber diet. Fiber-rich foods such as vegetables, fruit, and whole grains improve constipation. However, it also tends to generate gas that can worsen bloating symptoms. Accordingly, fiber intake should not be massive right from the start; it should be adjusted according to its effect and decreased if necessary.
A high-fiber diet must be accompanied by high fluid intake, no less than 8 cups of non-caffeinated drinks a day. Fiber supplement has not proven to have any significant benefits compared with placebo (doing nothing).
Importantly, patients with diarrhea symptoms benefit from high fluid intake to replace the losses produced by diarrhea. Live probiotic yogurts can also be very helpful, but for them to work, you have to take them in a disciplined manner: every day in the dose recommended by the manufacturer for at least a month. Fresh and dried fruit should be limited to three servings a week in patients in which diarrhea is predominant.
What should I not eat with irritable bowel syndrome?
Patients with IBS avoid the following foods and drinks:
- Alcohol: Particularly in patients with predominant diarrhea, alcohol should not exceed two units a day.
- Caffeinated drinks: Not only coffee, but it also includes green and black tee as well as energy drinks; caffeine avoidance decreases abdominal bloating and also decreases anxiety.
- Sugar-free sweets such as mints and gums and also any products containing sorbitol
- Fizzy drinks
- Insoluble fibers
- High-fat foods: High-fat foods are normally poor in fiber, which can worsen constipation symptoms. A low-fat diet also helps in preventing diabetes and heart disease.
- Gluten: Some patients have shown to benefit from a gluten-free diet; however, the evidence is not conclusive.
Remember that before you start any new diet, you should consult with your attending physician. Everyone is different, and the best diet for you may take a while to discover.
Is psychological help necessary?
Importantly, several studies have proven that treating psychological comorbidities through psychotherapy leads to decreased gastrointestinal symptoms. Although cognitive-behavioral therapy and interpersonal psychotherapy are effective immediately after treatment, benefits have not proven to be sustained over time. Tricyclic antidepressant therapy has also shown effectiveness in the management of IBS symptoms.
What medication is useful in IBS?
Medications in IBS treat symptoms but not the disease itself. As with diet, different individuals respond to different medications differently. Hence, finding the right medication is a process of trial and error in which your doctor will guide you.
The FDA has approved several drugs specifically for the IBS treatment; these include:
- Lotronex (Alosetron hydrochloride): It is a serotonin receptor blocker that helps improve diarrhea symptoms
- Eluxdaloline: Helps with the small bowel and large bowel contractions that cause diarrhea
- Lubiprostone: Activates chloride channels in the small intestines improving constipated symptoms.
- Rifaximin: This one is a bit different from the others. Rifaximin is an antibiotic that must be taken three times a day for fourteen weeks. In some patients, it has proven to improve symptoms of diarrhea. It is thought to affect bacterial overgrowth.
All these IBS drugs, except rifaximin, are intended for long term use (6 months or longer). Other drugs are not specific for IBS but can be consumed for short periods to control specific symptoms such as diarrhea, bloating, and constipation. Some examples include:
- Anti-diarrheal drugs: Such as loperamide and diphenoxylate.
- Antispasmodics: The drugs decrease visceral contraction, thus reducing abdominal cramping, some are regular pharmacy drugs, and others are herbal medicines. Examples include belladonna alkaloids, hyoscyamine, and peppermint oil.
- Laxatives: These drugs are helpful to treat isolated constipation, some by softening the stools (bulking agents) and others by stimulating bowel movements. Some examples include: lactulose, milk of magnesia, and polyethylene glycol 3350
- Probiotics: These medications do not directly decrease symptoms but indirectly improve the quality of your intestinal bacterial flora.
Do you have symptoms of irritable bowel syndrome?
This tool is an Irritable Bowel Syndrome Symptoms Checker. It gathers the most important symptoms and risk factors of this condition. Therefore, the tool will tell anybody who uses it the likelihood that their symptoms are because of IBS. Using the tool is free and would only take a few minutes.