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TALK WITH YOUR DOCTOR Table of Contents Here are some questions to ask your doctor. WHAT IS IRRITABLE BOWEL SYNDROME? 4 SYMPTOMS 5 MANAGING IBS WITH DIET 8 MEDICATIONS 10 STRESS REDUCTION 12 YOUR MICROBIOME 14 Irritable bowel syndrome. It can cause diarrhea so unpredictable that you always know where to find the nearest bathroom. Or it can lead to constipation so uncomfortable that you wish for relief. Abdominal cramps, gas, and bloating are often part of the mix too. Irritable bowel syndrome has no clear cause and, often, no straightforward treatment. But with patience, persistence, and trial and error, chances are good that you will find relief. 2 irritable bowel syndrome Are there any foods that I should avoid? Would lifestyle changes help relieve my symptoms? What is the role of stress in irritable bowel syndrome? Would I benefit from stress-reduction therapy or techniques? Will medication help? Is there anything other than irritable bowel syndrome that could be causing my symptoms? Tell your doctor: How often you have bowel movements If you are bothered by diarrhea, constipation, or both Whether your symptoms improve after a bowel movement If specific foods seem to trigger your symptoms What medications you are taking, if any To what extent your symptoms interfere with your day-to-day activities If you plan to try alternative or complementary therapies irritable bowel syndrome 3
WHAT IS IRRITABLE BOWEL SYNDROME? SYMPTOMS OF IBS IBS may cause a variety of symptoms. Irritable bowel syndrome (IBS) is a very common condition that causes a variety of unpleasant symptoms. IBS has no clear cause at least, not one that has been identified yet. Two factors that may play a role include too much activity of the colon (large intestine) and heightened sensitivity to pain. Abnormal intestinal activity abdominal pain gas These include: diarrhea and/or constipation cramping bloating Normally, the intestines have smooth, rhythmic contractions. Not so for people with IBS. They often experience irregular contractions with spasms. Sometimes, the spasms lead to diarrhea; other times, to constipation. Heightened pain sensitivity In addition, people with IBS have a heightened sensitivity to pain in their gut. Experiments have shown that people with IBS generally have a much lower threshold for experiencing pain in the colon, rectum, and small intestine than healthy people do. The symptoms of IBS usually start in your late teens, 20s, or 30s. You re relatively healthy; then you begin to suffer abdominal discomfort. You may have to move your bowels more often than usual. And when you have to go, you have to go right away. Or you may notice you are moving your bowels less than usual and need to strain. You often feel bloated and full of gas. Some people with IBS have only some of these symptoms. Others have all of them. Over time, your main problem might be frequent loose stools, known as diarrhea-predominant IBS, or IBS-D. Or it may be the opposite: difficulty having bowel movements. This is known as constipation-predominant IBS, or IBS-C. People with IBS generally feel better after a bowel movement or passing gas. But they may not feel that they have fully emptied their rectum, even after a movement. Some people with IBS have continuous symptoms. Others experience long symptom-free periods. 4 irritable bowel syndrome irritable bowel syndrome 5
DIAGNOSIS There is no specific test to diagnose IBS. IT S PROBABLY NOT IBS IF... Certain symptoms are not associated with IBS. If you experience any of the following, it s not caused by IBS: abdominal pain accompanied by fever (fever can signal inflammation or infection) rectal bleeding bright red blood in the stool black, tarry stool excess fat in the stool persistent pain in just one part of your belly unintended weight loss Some symptoms, such as abdominal pain with fever, rectal bleeding, or black stools, require immediate medical attention. Food intolerance For some people, gas, stomach upset, diarrhea, cramps, and flatulence (all common symptoms of IBS) may be caused by food intolerance the body s inability to digest a particular substance. Dairy products and grain products containing gluten are two common types of food that cause intolerance. IBS is a clinical diagnosis, which means your doctor diagnoses IBS based primarily on your symptoms. Usually, you will be diagnosed with IBS if you experience abdominal pain or discomfort at least three days a month, for at least three months, with two or more of the following: improvement in symptoms after a bowel movement increase or decrease in frequency of bowel movements The following features (if they occur more than about one-quarter of the time) further support a diagnosis of IBS: abnormally hard or loose stool straining, urgency, or the feeling of incomplete emptying passage of mucus in bowel movements a change in the form (appearance) of stools bloating or the sensation of having a distended abdomen more than three bowel movements per day or fewer than three per week Your doctor will want to be sure that your symptoms or exam findings are not caused by a condition other than IBS. If needed, your doctor may perform certain tests to rule out other conditions. 6 irritable bowel syndrome irritable bowel syndrome 7
MANAGING IBS WITH DIET Making strategic changes to your diet and the way you eat may help reduce symptoms. For diarrhea, loose stools, and cramps Most important, you will need to discover what dietary changes help you the most. Make notes in a food diary to help you keep track of how each change affects your symptoms. Start by considering meal size. Perhaps eating large meals causes cramping, bloating, and loose stools. Eating smaller meals or snacks multiple times per day may help improve these symptoms. Eating quickly can cause you to swallow air, which can cause belching or gas. Try eating slowly and more mindfully. It s important to try different strategies to find what works best for you. To help you get started, here are some general guidelines based on whether you tend to be bothered more by constipation or diarrhea. For constipation Fiber and water are most important. Fiber is the nondigestible component of plant food that helps soften stool and move it forward through the intestines. Drink plenty of water to make sure the stool stays soft and bulky. You can increase the fiber in your diet by eating plenty of fresh fruits and vegetables. Fiber supplements containing psyllium or methylcellulose can also help. When introducing fiber to your diet, do so gradually to avoid bloating and excess gas. 8 irritable bowel syndrome Try a low-fodmap diet. FODMAPs is the nickname for a group of dietary sugars that are poorly absorbed by the small intestine. Gut bacteria feed on these sugars, creating gas, bloating, abdominal discomfort, and increased trips to the bathroom. To follow a low-fodmap diet, first eliminate all FODMAPs from your diet. Then add them back one at a time and monitor your symptoms. You may tolerate some foods better than others. High-FODMAP foods (to avoid or eat less of) include: Dairy: cow s milk, yogurt, pudding, custard, ice cream, cottage cheese, ricotta cheese, and mascarpone Fruits: apples, apricots, blackberries, cherries, pears, peaches, mangoes, nectarines, plums, and watermelon Vegetables: artichokes, asparagus, Brussels sprouts, broccoli, beets, cauliflower, mushrooms, snow peas, garlic, and onions Grains: wheat and rye Beans and legumes: chickpeas, lentils, kidney beans Sweeteners: high-fructose corn syrup, honey, and agave nectar; sorbitol, mannitol, xylitol, maltitol, and isomalt found in sugar-free gum and mints, and cough medicines and drops irritable bowel syndrome 9
MEDICATIONS TO TREAT IBS Medications can t cure IBS. But they can ease symptoms. The medication your doctor prescribes will depend on whether you have diarrhea- or constipationpredominant IBS. For people who have diarrhea-predominant IBS (IBS-D), medication options include: u Antidiarrheals. These medicines reduce fluid secretion by the intestine and slow down intestinal contractions. Although they are available overthe-counter (OTC) and by prescription, always follow your doctor s advice. u Antispasmodics. These medications, available by prescription, may provide temporary relief of mild abdominal pain by reducing bowel spasms. People who regularly experience cramps after eating may experience reduced symptoms if they take one of these medications before meals. u Antidepressants. Tricyclic antidepressants are sometimes prescribed to treat IBS pain. Selective serotonin reuptake inhibitors (SSRIs) do not control pain as effectively as the tricyclics, but they tend to cause fewer side effects. u Antibiotics. Research suggests that there is a connection between IBS and the mix of bacteria in the intestines (see Your microbiome, page 14). Treatment with certain antibiotics may help improve symptoms, though the exact reason why they help is not known. u Serotonin antagonist. This drug is approved only for women with severe diarrhea-predominant IBS who have not responded to other treatments. To receive this drug, you must sign a form stating that you are aware of life-threatening complications, such as a blocked, ruptured, or damaged bowel. For people with constipation-predominant IBS (IBS-C), if medication is needed, your doctor may prescribe: u Laxatives. Laxatives that promote the secretion of water into the colon are generally considered to be safe and effective for IBS. Stimulant laxatives may cause cramping. u Prescription drugs for IBS-C. Drugs currently approved by the FDA to treat constipationpredominant IBS act on the cells that line the inside of the intestines. They promote increased fluid secretion into the intestine, making it easier for stool to pass through, and help relieve discomfort. Try heat A home heating pad can be a simple and inexpensive way of soothing abdominal pain. Heat can help relax cramping muscles. Similarly, drinking warm, non-caffeinated tea such as chamomile may help reduce discomfort. 10 irritable bowel syndrome irritable bowel syndrome 11
STRESS REDUCTION FOR SYMPTOM RELIEF Stress can trigger chemical and physical responses in the body that worsen symptoms and lead to more discomfort. For example, stress stimulates colon spasms in people with IBS. It can also influence how the body regulates pain signals from the gut, making existing pain seem even worse. Treating stress, through behavioral therapy or relaxation techniques, can help relieve IBS symptoms. Cognitive behavioral therapy (CBT). CBT involves reframing negative thoughts and actions into more positive and productive ways of thinking and behaving. CBT can reduce the stress of dealing with IBS. As stress decreases, symptoms often improve. Relaxation response training and meditation. Simple and easy to learn, these techniques help reduce nervous system activity and relax muscles. A mind-body program, relaxation response CD, or meditation class can help you to learn these techniques. Yoga. This ancient Indian discipline seeks to bring body and mind into balance. It has proved valuable to some IBS sufferers. Yoga, like meditation, can serve as a form of self-relaxation. 12 irritable bowel syndrome ALTERNATIVE AND COMPLEMENTARY THERAPIES People with IBS frequently turn to alternative or complementary therapies to ease symptoms. Biofeedback. Biofeedback is a mind-body technique. Participants use a machine to see and learn to control their body s responses to stimuli such as pain. Acupuncture. This is a system of applying small needles to specific points along the body. It has been used to treat IBS symptoms, but evidence to support its effectiveness is weak. Herbal remedies. Peppermint oil may improve abdominal pain and overall symptoms in people with IBS. It appears to work by relaxing the smooth muscles in the walls of the intestine. The evidence in support of other herbal remedies for IBS is limited. Let your doctor know before you start taking an herb or supplement. These preparations are not regulated by the FDA. irritable bowel syndrome 13
YOUR MICROBIOME IBS may result, in part, from the mix of bacteria in the intestines. NOTES The bacteria in our intestines make up our microbiome. We all have trillions of bacteria in our gut. Researchers have found that some people with IBS have a different mix of intestinal bacteria. This may contribute to the bloating, diarrhea, constipation, and heightened sensitivity to pain that are common in IBS. Antibiotics may help improve symptoms by changing some of this bacterial mix (see Medications to treat IBS, page 10). Probiotics and prebiotics Probiotics and prebiotics may also help by nurturing our microbiome. Probiotics are live bacteria used to benefit health. Prebiotics are nonliving substances that promote the growth of beneficial bacteria. Fermented or cultured dairy products, such as yogurt and buttermilk, are good sources of probiotics. Other sources include miso, tempeh, and soy beverages. Prebiotics are found in asparagus, bananas, oatmeal, and legumes. Probiotics and prebiotics are both also available as dietary supplements. Probiotics are generally considered safe. But there s not yet enough evidence to declare which ones are truly effective. 14 irritable bowel syndrome irritable bowel syndrome 15
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