Irritable Bowel Syndrome (IBS)

WHAT IS IRRITABLE BOWEL SYNDROME (IBS)?

In Canada, irritable bowel syndrome (IBS) is the most common disorder of gut-brain interaction (DGBI). It is thought that IBS is due to a change in how the gut and brain communicate with each other. This miscommunication causes the nerves lining the gut to become sensitive. This can affect how the brain interprets pain signals from the gut and cause pain in your stomach area (abdominal area), which is usually the main symptom of IBS.

People with IBS have frequent episodes of abdominal pain related to bowel movements (poop). There are also changes in the frequency of their bowel movements and stool (poop) form. There are different types of IBS and it is based on your stool form using the Bristol Stool Form Scale.

SYMPTOMS

You may have some or all of these symptoms listed below. It is important to review your symptoms with your healthcare provider to determine if they are due to IBS or another health problem.

IBS-C

Constipation

Abdominal pain
Infrequent bowel movements
Excessive straining during bowel movements
Incomplete emptying after a bowel movement
Bloating
Excess gas
Hard stool: more than 25% of stools are Bristol type 1 or type 2

IBS-D

Diarrhea

Abdominal pain
Unpredictable bowel patterns
Increased sense of needing to have a bowel movement
Bloating
Excess gas
Loose stool: more than 25% of stools are Bristol type 6 or type 7

IBS-M

Mixed

Abdominal pain
Bloating
Excess gas
More than 25% of stools are Bristol type 1 or 2, and more than 25% are Bristol type 6 or 7

IBS-U

Undefined

Abdominal pain
Change in frequency of bowel movements, either more or less
Bloating
Excess gas
Stool forms that do not fit any of the previous categories

CAUSES

The causes of IBS are complex and can be different for everyone. Some possible factors may be linked to IBS:

Prior severe gastrointestinal infection
Food poisoning
Use of antibiotics or new medications
A change in dietary patterns
Childhood trauma or stressors

Chronic stress exposure

A history of certain mental health conditions
Other chronic pain conditions such as fibromyalgia, chronic pelvic pain, etc.
Poor sleep
Family history of IBS

DIAGNOSIS

Your healthcare provider will start by asking you questions about your health history and family health history, and complete a physical assessment. A few tests may be ordered to rule out other health problems. If you have any concerning features, you likely do not have IBS.

There is no specific test to diagnose IBS. If your healthcare provider suspects you have IBS, the Rome IV criteria may be used to diagnose IBS. The criteria is abdominal pain that occurs at least once a week in the last 3 months and is related to bowel movements, a change in the frequency of bowel movements, or a change in stool form.

TREATMENT

Treatment for IBS starts with understanding your symptoms and their impact on your daily life. The goal of treatment is to manage your symptoms instead of seeking a cure.

The symptoms of IBS can be different for everyone, and treatment is personalized. It is important to have a good relationship with your healthcare provider. Regular follow-up with your healthcare provider is important to review how you respond to treatment and discuss if other treatment options should be considered. Your healthcare provider may first recommend lifestyle and dietary changes. These changes can impact symptom management and can be combined as a part of your treatment regimen.

Always speak with your healthcare provider before trying any treatment to see if they are right for you and to review potential harmful effects.

The following recommendations are general guidelines for IBS treatment and may not be suitable for everyone.

Low FODMAP Diet

A low diet in FODMAPs has been studied and may improve IBS symptoms. This diet may not be right for everyone. It is important to speak with your healthcare provider to see if it is right for you.

FODMAP stands for fermentable oligo-, di, mono-saccharides, and polyols. Foods that are high in FODMAPs cause symptoms of bloating, gas, and

abdominal pain. It is important to work with a Registered Dietician (RD) when starting a low FODMAP diet. The RD can help you identify foods low in FODMAPs, figure out what foods are causing your symptoms, and help you bring back foods you stopped eating. This diet is recommended to help figure out which foods cause your IBS symptoms. It is not a long-term diet, and it is recommended that patients try this diet for 2 to 4 weeks. Once you know which foods trigger your IBS symptoms, you limit those food triggers and resume eating other high FODMAPs that do not cause your IBS symptoms.

Fiber

A diet high in fibre can help improve constipation and diarrhea IBS symptoms. It has been shown to bulk stool form, change the gas production from foods, and change the gut microbiome. There are two types of fibre:

soluble (melts in water) and insoluble (does not melt in water).

Soluble fiber can be found in supplements such as psyllium husk (Metamucil®) and guar gum (Fiber 4®). Foods high in soluble fibre include oats, dried beans, rice bran, barley, citrus fruits, flaxseeds, and carrots.

Insoluble fiber include the skins of fruits and vegetables, legumes (for example, lentils), nuts, seeds, and whole-grain products like cereals, whole-grain bread, and brown rice.

Soluble fiber can be used to manage either constipation or diarrhea. When using soluble fiber for constipation, drink plenty of water to help soften stool. Soluble fiber can help soak up water for diarrhea and make the stool more solid. If you drink a lot of water, you may need to increase the amount of soluble fiber or decrease your water intake until your stools are firmer.

Insoluble fiber is best used for constipation. These fibers help move stool in your colon to treat constipation but it does not soften stools like soluble fibers.

Peppermint Oil

Peppermint oil has been shown to help control IBS symptoms of abdominal pain and bloating.

It is important to note that peppermint oil can increase acid reflux/heartburn symptoms. Different forms are available that release peppermint oil in the intestine to alleviate your symptoms. Speak with your healthcare provider to see what is available and if it is the right option for you.

Probiotics

Some research shows that probiotics can help reduce IBS symptoms like abdominal pain, bloating, and gas. The two commonly researched strains for IBS are lactobacillus and bifidobacterium. The evidence for probiotics is still growing, and a trial of probiotics for one month may be helpful. If there is no effect on IBS symptoms, treatment should be stopped.

It is important to speak with your healthcare provider before using probiotics. Probiotics may not be recommended for certain medical conditions.

Medications

There are over-the-counter and prescription medications available to treat IBS symptoms. It is important to work closely with your healthcare provider to:

1) Determine what treatment options are available
2) Decide if treatment options are practical in your everyday life
3) Establish treatment goals
4) Review which treatments are short-term and long-term options

If your symptoms do not improve after some time on treatment, speak with your healthcare provider to review other options. Always speak with your healthcare provider before starting any new medications or treatments to see if it is right for you.

Before starting any new medications, you should consult your Pharmacist to review your current medications (prescribed, over-the-counter medications or natural/herbal products) to check for drug interactions.

IBS Diarrhea

Antibiotics that work specifically in the intestines may improve some IBS symptoms. These medications require a prescription and is not covered by the provincial drug plan.

Example: rifaximin (Zaxine550)

IBS Constipation

Prescription medication for IBS constipation and abdominal pain are available but not not covered by the provincial plan.

Examples:

linaclotide (Constella)
tenapenor (Ibsrela)
plecanatide (Trulance)

Anti-spasmodics

Anti-spasmodics can help manage abdominal pain by relaxing the abdominal wall muscles.

These medications can be purchased over-the-counter

Example: hyoscine butylbromide (Buscopan)

Neuromodulators

Neuromodulators help decrease gut hypersensitivity to manage abdominal pain.

Always review the side effects with your healthcare provider.

Many of these medications are covered by the provincial drug plan.

Example: amitriptyline (Elavil)

Psychological Therapy

There are various psychological that have been shown to be effective in managing IBS symptoms. These therapies emphasize strategies to cope with IBS symptoms. These include:

Mindfulness-based stress reduction
Cognitive Behavioural Therapy
Gut-directed hypnotherapy
Yoga

Consult with a trained professional that can determine which form of therapy would be best for you.