The most common way is to manage one’s diet. It is helpful to keep track of food intake and any associated symptoms or flareups for a timeframe (4-6 weeks). At the start, it may make the most sense to start with a limited set of food items and slowly expand the list as time goes on. For example, steamed vegetables, rice and a fruit in week 1.
Common food and drinks that can cause discomfort are listed below:
– Gas-producing vegetables
– High fat foods
– Carbonated beverages
– Artificial sweeteners
– Caffeine
– Alcohol
People with lactose intolerance and fructose malabsorption need to pay additional care to rule out causative foods. Elimination diets to remove dairy or high FODMAPs (fermentable oligo-, di-, monosaccharides, and polyols) are other options to explore. Each person’s journey tends to be unique with IBS and a combination of remedies may work best.
Fiber
Dietary fiber has long been used in the treatment of several gastrointestinal conditions. It is widely believed that IBS is caused primarily by a deficient intake of dietary fiber. Increasing the dietary fiber intake has been the standard recommendation for patients with IBS.
Dietary fiber can be divided into soluble types (i.e., dissolving in water) and insoluble types based on their physical and chemical properties. Soluble Dietary fiber can be divided further into short-chain and long-chain carbohydrates, and fermentable or non-fermentable types. Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) are to be considered to be the short-chain carbohydrate, soluble, and highly fermentable type of dietary fiber.
Short-chain, soluble and highly fermentable dietary fiber (e.g., oligosaccharides) results in rapid gas production that can outpace the capacity of the gastrointestinal tract to absorb gas into the bloodstream for final elimination through the lungs. This imbalance can cause abdominal pain/discomfort, abdominal bloating/distension and flatulence. On the other hand, long-chain, soluble and moderately fermentable dietary fiber (e.g., psyllium) results in a low gas production and the absence of the symptoms related to excessive gas production.
Physicians usually recommend patients with IBS to increase their intake of dietary fiber to 20–35 g daily in order to regulate the stools and reduce abdominal pain. Supplementation with long-chain, soluble and moderately fermentable dietary fiber such as psyllium can improve the global symptoms of IBS. To further ease the stress on your digestive system, smaller, more frequent meals instead of the traditional breakfast, lunch, dinner may help.
A number of other treatments have also been found to be effective, including fiber, talk therapy, antispasmodic and antidepressant medication, and peppermint oil.
FODMAPs
FODMAPs are short-chain carbohydrates that are poorly absorbed in the small intestine. Symptoms most likely to improve on this type of diet include urgency, flatulence, bloating, abdominal pain, and altered stool output. One national guideline advises a low FODMAP diet for managing IBS when other dietary and lifestyle measures have been unsuccessful. The diet restricts various carbohydrates which are poorly absorbed in the small intestine, as well as fructose and lactose, which are similarly poorly absorbed in those with intolerances to them. Reduction of fructose and fructan has been shown to reduce IBS symptoms in a dose-dependent manner in people with fructose malabsorption and IBS.
FODMAPs are fermentable oligo-, di-, monosaccharides and polyols, which are poorly absorbed in the small intestine and subsequently fermented by the bacteria in the distal small and proximal large intestine. This is a normal phenomenon, common to everyone. The resultant production of gas potentially results in bloating and flatulence. Although FODMAPs can produce certain digestive discomfort in some people, not only do they not cause intestinal inflammation, but they help avoid it, because they produce beneficial alterations in the intestinal flora that contribute to maintaining the good health of the colon. FODMAPs are not the cause of irritable bowel syndrome nor other functional gastrointestinal disorders, but rather a person develops symptoms when the underlying bowel response is exaggerated or abnormal.
A low-FODMAP diet consists of restricting them from the diet. They are globally trimmed, rather than individually, which is more successful than for example restricting only fructose and fructans, which are also FODMAPs, as is recommended for those with fructose malabsorption.
A low-FODMAP diet might help to improve short-term digestive symptoms in adults with irritable bowel syndrome, but its long-term follow-up can have negative effects because it causes a detrimental impact on the gut microbiota and metabolome. It should only be used for short periods of time and under the advice of a specialist. A low-FODMAP diet is highly restrictive in various groups of nutrients and can be impractical to follow in the long-term. More studies are needed to assess the true impact of this diet on health.
In addition, the use of a low-FODMAP diet without verifying the diagnosis of IBS may result in misdiagnosis of other conditions such as celiac disease. Since the consumption of gluten is suppressed or reduced with a low-FODMAP diet, the improvement of the digestive symptoms with this diet may not be related to the withdrawal of the FODMAPs, but of gluten, indicating the presence of unrecognized celiac disease, avoiding its diagnosis and correct treatment, with the consequent risk of several serious health complications, including various types of cancer.
Fiber
Some evidence suggests soluble fiber supplementation (e.g., psyllium/ispagula husk) is effective. It acts as a bulking agent, and for many people with IBS-D, allows for a more consistent stool. For people with IBS-C, it seems to allow for a softer, moister, more easily passable stool.
However, insoluble fiber (e.g., bran) has not been found to be effective for IBS. In some people, insoluble fiber supplementation may aggravate symptoms.
Fiber might be beneficial in those who have a predominance of constipation. In people who have IBS-C, soluble fiber can reduce overall symptoms but will not reduce pain. The research supporting dietary fiber contains conflicting small studies complicated by the heterogeneity of types of fiber and doses used.
One meta-analysis found only soluble fiber improved global symptoms of irritable bowel, but neither type of fiber reduced pain. An updated meta-analysis by the same authors also found soluble fiber reduced symptoms, while insoluble fiber worsened symptoms in some cases. Positive studies have used 10–30 grams per day of ispaghula (psyllium). One study specifically examined the effect of dose, and found 20 g of ispaghula (psyllium) were better than 10 g and equivalent to 30 g per day.
Physical Activity
Recent studies have demonstrated the potential beneficial effects of Physical activity on irritable bowel syndrome. Some randomised controlled trials (RCTs) have demonstrated a beneficial effect of physical activity on IBS symptoms. Three RCTs showed a significant improvement in Irritable Bowel Syndrome – Severity Scoring System, while 1 RCT showed a significant improvement only in symptoms of constipation. In light of this, the latest British Society of Gastroenterology guidelines on the management of IBS have stated that all patients with IBS should be advised to take regular exercise (strong recommendation, weak certainty evidence), whereas the American College of Gastroenterology guidelines have suggested with a lower certainty of evidence. Exercise is Medicine recently provided simple practical indications based on world health organization guidelines, which should be followed when physicians prescribing exercise training. As shown by the previous studies, a good Physical activity prescription during the visit could significantly improve patients’ adherence and, consequently, lead to a significant clinical benefit for symptoms of irritable bowel syndrome.
Medication
Medications that may be useful include antispasmodics such as dicyclomine and antidepressants. Both H1-antihistamines and mast cell stabilizers have shown efficacy in reducing pain associated with visceral hypersensitivity in IBS.
Laxatives
For people who do not adequately respond to dietary fiber, osmotic laxatives such as polyethylene glycol, sorbitol, and lactulose can help avoid “cathartic colon” which has been associated with stimulant laxatives. Lubiprostone is a gastrointestinal agent used for the treatment of constipation-predominant IBS.
Antispasmodics
The use of antispasmodic drugs (e.g., anticholinergics such as hyoscyamine or dicyclomine) may help people who have cramps or diarrhea. A meta-analysis by the Cochrane Collaboration concludes if seven people are treated with antispasmodics, one of them will benefit. Antispasmodics can be divided into two groups: neurotropics and musculotropics. Musculotropics, such as mebeverine, act directly at the smooth muscle of the gastrointestinal tract, relieving spasm without affecting normal gut motility. Since this action is not mediated by the autonomic nervous system, the usual anticholinergic side effects are absent. The antispasmodic otilonium may also be useful.
Other treatments/medications
Magnesium aluminum silicates and alverine citrate drugs can be effective for IBS.
Rifaximin may be useful as a treatment for IBS symptoms, including abdominal bloating and flatulence, although relief of abdominal distension is delayed. It is especially useful where small intestinal bacterial overgrowth is involved.
In individuals with IBS and low levels of vitamin D supplementation is recommended. Some evidence suggests that vitamin D supplementation may improve symptoms of IBS, but further research is needed before it can be recommended as a specific treatment for IBS.
Psychological therapies
There is low quality evidence from studies with poor methodological quality that psychological therapies can be effective in the treatment of IBS. Reducing stress may reduce the frequency and severity of IBS symptoms. Techniques that may be helpful include regular exercise, such as swimming, walking, or running.
Probiotics
Probiotics can be beneficial in the treatment of IBS; taking 10 billion to 100 billion beneficial bacteria per day is recommended for beneficial results. However, further research is needed on individual strains of beneficial bacteria for more refined recommendations. Probiotics have positive effects such as enhancing the intestinal mucosal barrier, providing a physical barrier, bacteriocin production (resulting in reduced numbers of pathogenic and gas-producing bacteria), reducing intestinal permeability and bacterial translocation, and regulating the immune system both locally and systemically among other beneficial effects. Probiotics may also have positive effects on the gut–brain axis by their positive effects countering the effects of stress on gut immunity and gut function.
A number of probiotics have been found to be effective, including Lactobacillus plantarum, and Bifidobacteria infantis; but one review found only Bifidobacteria infantis showed efficacy. B. infantis may have effects beyond the gut via it causing a reduction of proinflammatory cytokine activity and elevation of blood tryptophan levels, which may cause an improvement in symptoms of depression. Some yogurt is made using probiotics that may help ease symptoms of IBS. A probiotic yeast called Saccharomyces boulardii has some evidence of effectiveness in the treatment of irritable bowel syndrome.
Certain probiotics have different effects on certain symptoms of IBS. For example, Bifidobacterium breve, B. longum, and Lactobacillus acidophilus have been found to alleviate abdominal pain. B. breve, B. infantis, L. casei, or L. plantarum species alleviated distension symptoms. B. breve, B. infantis, L. casei, L. plantarum, B. longum, L. acidophilus, L. bulgaricus, and Streptococcus salivarius ssp. thermophilus have all been found to affect flatulence levels. Most clinical studies show probiotics do not improve straining, sense of incomplete evacuation, stool consistency, fecal urgency, or stool frequency, although a few clinical studies did find some benefit of probiotic therapy. The evidence is conflicting for whether probiotics improve overall quality of life scores.
Probiotics may exert their beneficial effects on IBS symptoms via preserving the gut microbiota, normalisation of cytokine blood levels, improving the intestinal transit time, decreasing small intestine permeability, and by treating small intestinal bacterial overgrowth of fermenting bacteria.
Herbal remedies
Peppermint oil appears useful. In a meta-analysis it was found to be superior to placebo for improvement of IBS symptoms, at least in the short term. An earlier meta-analysis suggested the results of peppermint oil were tentative as the number of people studied was small and blinding of those receiving treatment was unclear. Safety during pregnancy has not been established, however, and caution is required not to chew or break the enteric coating; otherwise, gastroesophageal reflux may occur as a result of lower esophageal sphincter relaxation. Occasionally, nausea and perianal burning occur as side effects. Iberogast, a multi-herbal extract, was found to be superior in efficacy to placebo. A comprehensive meta-analysis using twelve random trials resulted that the use of peppermint oil is an effective therapy for adults with irritable bowel syndrome.
Research into cannabinoids as treatment for IBS is limited. GI propulsion, secretion, and inflammation in the gut are all modulated by the ECS (Endocannabinoid system), providing a rationale for cannabinoids as treatment candidates for IBS.
Only limited evidence exists for the effectiveness of other herbal remedies for IBS. As with all herbs, it is wise to be aware of possible drug interactions and adverse effects.
References:
- Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM (January 2009). “An evidence-based position statement on the management of irritable bowel syndrome” (PDF). The American Journal of Gastroenterology.
- Dionne J, Ford AC, Yuan Y, Chey WD, Lacy BE, Saito YA, Quigley EM, Moayyedi P (September 2018). “A Systematic Review and Meta-Analysis Evaluating the Efficacy of a Gluten-Free Diet and a Low FODMAPs Diet in Treating Symptoms of Irritable Bowel Syndrome”. The American Journal of Gastroenterology.
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Ford AC, Quigley EM, Lacy BE, Lembo AJ, Saito YA, Schiller LR, Soffer EE, Spiegel BM, Moayyedi P (September 2014). “Effect of antidepressants and psychological therapies, including hypnotherapy, in irritable bowel syndrome: systematic review and meta-analysis”. The American Journal of Gastroenterology.
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Gibson PR, Shepherd SJ (February 2010). “Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach”. Journal of Gastroenterology and Hepatology.
