IBS Awareness Month

April is IBS awareness month (1). Irritable Bowel Syndrome (IBS) is a chronic, relapsing, and often debilitating disorder of gut-brain interaction affecting between 5 - 20% of the global population (2). Symptoms of IBS include on-going stomach cramps, gas, bloating, diarrhoea and constipation. Some people can control their symptoms by managing diet, lifestyle and stress. More-severe symptoms may need to be treated with medication and counselling.

The pathophysiology of IBS is not fully understood, but likely to be multifactorial involving biological, psychological, and social factors. Factors that may play a role include:

Gut Motility – contractions in the walls of the digestive tract that are stronger and last longer than usual can cause gas, bloating and diarrhoea. Weak contractions can slow food passage and lead to hard, dry stools.

Gut-Brain Axis - the nervous system and digestive system are linked by the vagus nerve and various chemical messengers that travel between the gut and the brain. If the signals between the brain and the intestines get out of sync this can cause spasms in the intestines resulting in pain, diarrhoea or constipation.

Gut Hormones - abnormalities in gut hormones may be present in IBS patients. As gut hormones control and regulate gastrointestinal motility and sensation, this may explain the abnormal gastrointestinal motility and hypersensitivity in patients with IBS. 

Infection - IBS can develop after a severe bout of diarrhoea caused by bacteria or a virus.  This is called gastroenteritis and may be caused by food poisoning or a stomach bug.

Dysbiosis – this is a general term that means any imbalance in the gut microbiota. Different gut organisms have different effects on gut motility. 

SIBO, SIFO and LIBO – are types of dysbiosis. SIBO = small intestinal bacterial overgrowth, SIFO = small intestinal fungal overgrowth and LIBO = large intestinal bacterial overgrowth. They all indicate that there are too many of the wrong kinds of organisms in the named part of the digestive system leading to digestive problems.

Lack of stomach acid or digestive enzymes – these help to break down food into its component parts. 

Stress – people who experienced stress in childhood tend to be more likely to get IBS, but stress can strike anyone at any time of life.

Risk factors

Many people have occasional digestive symptoms but it’s only diagnosed as IBS if they persist. You are more likely to have IBS if you fall into any of the following categories:

• Young - IBS occurs more frequently in people under age 50.
• Female - IBS is more common among women. HRT and the contraceptive pill may both increase the risk of developing IBS.
• Have a family history of IBS – Genes and lifestyle factors may both play a role.
• Have anxiety, depression or other mental health issues

Types of IBS

For the purpose of treatment, IBS can be divided into four types: constipation-predominant (IBS-C), diarrhea-predominant (IBS-D), mixed or unclassified.

There's no test to definitively diagnose IBS but your doctor may use any of the following diagnostic procedures and tests:

Rome criteria - These criteria include belly pain and discomfort averaging at least one day a week in the last three months, alongside at least two of the following: Pain and discomfort related to defecation, a change in the frequency of defecation, or a change in stool consistency.

Colonoscopy - a small, flexible tube is used to examine the entire length of the colon.

CT scan - this produces images of your abdomen and pelvis that might rule out other causes of your symptoms, especially if you have belly pain.

Upper endoscopy - a tube with a camera on the end is inserted down your throat and into the oesophagus so your doctor can view your upper digestive tract. During an endoscopy, a tissue sample (biopsy) may be collected. A fluid sample may be collected to look for bacterial overgrowth.

Lactose intolerance tests – this test will ascertain whether your symptoms are caused by an intolerance to lactose, the sugar found in dairy products.

Breath tests – may be used to determine if you have bacterial overgrowth in your small intestine.

Stool tests – these are used to look for bacteria, parasites or the presence of bile acid.

Treatment

Any treatment programme should aim to address the root cause as well as ameliorating the symptoms.

You may be recommended to avoid foods that trigger your symptoms. These might include:

• Gas forming foods - If you experience bloating or gas, you might avoid items such as carbonated and alcoholic beverages and certain foods that may lead to increased gas. 

• Gluten - some people with IBS report improvement in diarrhoea symptoms if they stop eating gluten (wheat, barley and rye) even if they don't have coeliac disease.

• FODMAPs - Some people are sensitive to certain sugars such as fructose, fructans, lactose and others, known as FODMAPs — fermentable oligosaccharides, disaccharides, monosaccharides and polyols. FODMAPs are found in some grains, vegetables, fruits and dairy products.

Other recommendations: 

• Experiment with fibre – some types of fibre may reduce constipation but may worsen gas and cramping in some people. Try slowly increasing the amount of fibre in your diet with foods such as whole grains, fruits, vegetables and beans. A fibre supplement might cause less gas and bloating than fibre-rich foods.

• Cook from scratch and avoid ultra-processed low nutrient foods.

• Keep a food and symptom diary – include what and when you eat and any symptoms.

• Eat mindfully and chew well.

• Avoid alcohol, carbonated drinks and coffee - as these can be irritating.

• Drink plenty of fluids between meals, but not too much with meals 

• Eat at regular times – this can help regulate bowel function.

• Exercise regularly - exercise helps relieve depression and stress and stimulates contractions of your intestines.

• Get enough good quality sleep.

• Hypnosis - A trained professional teaches you how to enter a relaxed state and then guides you in relaxing your abdominal muscles. Hypnosis may reduce abdominal pain and bloating.

• Peppermint - Studies show that in people who have IBS with diarrhoea enteric-coated peppermint oil capsules can ease bloating, urgency and abdominal pain.

• Stress management – yoga, breathing exercises and meditation can help manage stress. 

You may be prescribed:

• Laxatives for constipation.
• Loperamide for diarrhoea.
• An antispasmodic drug for abdominal pain or spasm.
• A low-dose tricyclic antidepressant (TCA) for refractory abdominal pain.
• A selective serotonin reuptake inhibitor (SSRI) for refractory abdominal pain, if a TCA is ineffective, contraindicated, or not tolerated.

If your problems are moderate or severe, your doctor might suggest counselling — especially if you have depression or if stress tends to make your symptoms worse. 

Tom Oliver’s Supplements for Digestive Health

• Women’s or Men’s Multivitamin/Mineral – people with digestive problems are often at risk of poor absorption. This can lead to further health problems. A multi vitamin/mineral is a good way to reduce the likelihood of nutrient deficiencies.

• Curcumin complete – curcumin has anti-inflammatory and antioxidant properties and an ability to modulate gut microbiota making it useful in the treatment of IBS (3). Research has found it to reduce digestive symptoms and anxiety levels in adults with digestive complaints (4). It is safe and well-tolerated, with no adverse events reported.

• Probiotics – these are beneficial bacteria that live in your intestines and are found in certain foods, such as yogurt, sauerkraut, kefir and in supplements. Recent studies suggest that some probiotics may relieve IBS symptoms, such as abdominal pain, bloating and diarrhoea.

• Vitamin D3/K2 - vitamin D treats IBS by improving gut microbiota, immune regulation, and anti-inflammatory effects (5). 

• Zinc – needed for the central nervous system, mental health, gut homeostasis and the immune system. Research finds that zinc deficiency may be associated with IBS-D (6).

 

References

1. https://gutscharity.org.uk/awareness/ibs-awareness-month/
2. https://cks.nice.org.uk/topics/irritable-bowel-syndrome/
3. Clin Med. 2018 Sep 22;7(10):298. A Meta-Analysis of the Clinical Use of Curcumin for Irritable Bowel Syndrome (IBS). Qin Xiang Ng et al.
4. BMC Complement Med Ther. 2021 Jan 21;21(1):40. Efficacy of a curcumin extract (Curcugen™) on gastrointestinal symptoms and intestinal microbiota in adults with self-reported digestive complaints: a randomised, double-blind, placebo-controlled study. Lopresti AL et al.
5. World J Clin Cases. 2023 Apr 26;11(12):2677-2683. Role of in vitamin D in irritable bowel syndrome. Xiao-Lan Yu et al.
6. Sci Rep. 2022 Jun 29;12(1):11002. Zinc nutritional status, mood states and quality of life in diarrhea-predominant irritable bowel syndrome: a case-control study. Mahsa Rezazadegan et al.