Irritable bowel syndrome: strategies for managing a complex condition

by Richard Glickman-Simon, MD

Irritable bowel syndrome (IBS) doesnt easily fit into the traditional medical model. Researchers have not yet come up with a coherent scientific explanation, let alone a cause, for its debilitating symptoms. This means that there is no cure or even a comprehensive treatment. The best that doctors can offer is management of symptoms, one at a time. It is no wonder IBS is a prime target for alternative therapies.

Doctors diagnose IBS in women three times more often than in men, and gastroenterologists report that it is the number one diagnosis they make.

Fifteen percent of Americans report symptoms consistent with IBS. The main symptoms are abdominal pain, usually associated with bloating and gas, and a change in bowel movements (diarrhea, constipation, or alternating bouts of each). Mucus may be present with diarrhea, but there is no blood or pus.

Because tests show no abnormalities, physicians usually diagnose IBS only after ruling out similar diseases. Doctors suspect IBS when a person experiences at least 12 weeks of abdominal pain in the past 12 months, with at least two of the following features:

• Pain is relieved after a bowel movement
• The onset of pain is associated with diarrhea or constipation
• The onset of pain is associated with a change in the form of the stool (loose, watery, or pellet-like)

While its exact cause remains a mystery, IBS is almost certainly due to a combination of genetic, environmental, and emotional factors, including:

• Disjointed muscular contractions of the intestines, possibly related to stress or certain foods
• Lower pain threshold due to excessive sensitivity of the intestine to being stretched
• Increased levels of chemicals that transmit nerve signals to and from the intestine
• Excessive focus on minor bodily symptoms and the fear that they mean something serious

Many people who see their doctors for IBS are found to have a psychiatric diagnosis (depression or anxiety, for example). There is no evidence, however, that psychiatric illness is the cause of IBS. It is clear, though, that changing emotional states influence the course of IBS.

Dietary restrictions

Since IBS primarily affects the GI tract, diet is a good place to start. Many people benefit from avoiding certain foods and ingredients, such as:

• Caffeine
• Alcohol
• Fatty foods
• Gas-producing vegetables
• Products containing sorbitol (e.g., sugarless gum)

For those who find a connection between their symptoms and what they eat, avoiding those foods can be effective.

A controversial theory is that IBS may be associated with food allergies. If this is true, eliminating allergenic foods—dairy, wheat, corn, peanuts, citrus, soy, eggs, fish, and tomatoes—could theoretically help. One approach is to remove all these foods from your diet for two weeks. Then reintroduce foods one at a time every three to four days, and carefully monitor symptoms.
Fiber

Fiber may improve the colons function and reduce symptoms, especially in people who tend to be constipated. Scientific research suggests that 20-30 grams of fiber per day is optimal. Good sources of fiber include:

• Whole grains, fruits, vegetables, and legumes (dried beans)
• Raw bran (1 teaspoon at each meal)
• Psyllium seeds (4-5 g of powdered husk mixed in at least 150 ml of water 1-4 times daily)
• Flaxseeds (1 tablespoon of whole seeds with at least 150 ml of water 2 -3 times daily)

Peppermint

Of the many herbs and supplements that have been recommended for IBS, peppermint oil (Mentha x piperita) is one of the few backed by some scientific evidence. The recommended dose is one or two 0.2 ml capsules three times daily after meals. Be sure to take the enteric-coated form, so that the capsule will not be broken down in the stomach before it reaches the intestines. Do not use this herb if you have unresolved gallbladder disease.

Stress management

Stress management and exercise have the potential to significantly ease IBS symptoms. A connection between psychological stress and IBS is certainly plausible, but the nature of this association is complex and poorly understood. There is some evidence to suggest that various mind-body interventions can reduce symptoms and change the course of IBS. The most promising of these are:

• The relaxation response – the use of meditation and similar techniques to soothe the response to stress
• Biofeedback – the use of computers and probes to dampen the physiologic manifestations of stress
• Cognitive-behavioral therapy – teaching people to reframe the way they perceive pain and to modify their maladaptive responses

Regular aerobic exercise tends not only to mitigate stress, but to also help normalize the muscular activity of the intestines. This may be particularly helpful for people with constipation.

In addition to lifestyle changes, there are a number of medications available to treat the individual symptoms of IBS.

For abdominal pain:

• Antispasmodic agents (hyoscyamine, dicyclomine)
• Low-dose tricyclic antidepressants (amitriptyline, nortriptyline)
• Non-steroidal anti-inflammatory drugs (ibuprofen, naproxyn)

For diarrhea:

• Loperamide
• Diphenoxylate

For constipation:

• Osmotic laxatives (lactulose, polyethylene glycol, milk of magnesia)

These medications, while often helpful, are no substitute for a comprehensive lifestyle approach. By finding effective ways to manage stress, exercise regularly, and modify your diet you can attempt to address the complex underlying causes of IBS.