Irritable bowel syndrome (IBS)

What is IBS

IBS is irritable bowel syndrome. This is a condition characterised by increased abdominal pain, bloating and discomfort associated with a change in bowel habits (constipation or diarrhoea or both).

These symptoms occur without any visible change or damage to the digestive system.

Prevalence

• This condition affects the large intestine.
• About 10-20% of the population globally are affected by IBS
• This disorder is more common in women than men and develops between the age of 20-30 years.
• This disease is lifelong but can be managed with proper diet and lifestyle changes
• IBS is also known by the names spastic colon, mucous colitis, nervous colon and spastic bowel

For some people, the symptoms are generally bad immediately after eating. For others, symptoms flare up and stay for a few days before subsiding.

Many of the symptoms of IBS generally overlaps with the symptoms of other diseases. Hence IBS is generally not diagnosed at the right time.

Symptoms of IBS include,

• Change in the appearance and/or structure of the stools
• Abdominal pain or bloating
• Diarrhoea/constipation or incomplete bowel movements
• Flatulence
• Passing of mucus in the stools
• Discomfort in the stomach which is relieved after passing the stool

Consequence of IBS in the long term

Although IBS is not life threatening, it can greatly lower the quality of life. The symptoms can vary both with respect to type and degree. It can be severe enough to require hospitalisation.

Hence certain steps should be taken to keep the disease in control and avoid flare ups.

IBS if left untreated can lead to the following -

• Dehydration - if diarrhoea is present and for a long period of time it may lead to dehydration if proper fluids and electrolytes are not provided on time.
• Nutritional deficiency - since intestine is the place where the nutrients are absorbed, diarrhoea could lead to malabsorption of nutrients causing deficiency disorders.
• IBS can cause undue stress to manage the disease leading to anxiety and depression.

IBS is classified into four types based on the stool consistency. It is important to know the type of IBS to decide the course of treatment that needs to be taken to manage the disease.

BS - C (IBS with constipation)

In this case, more than 25% of the stools are hard and painful to pass especially during IBS flare ups. In certain cases less than 25% of the time people experience watery stools and diarrhoea.

There is bloating followed by abdominal pain during constipation. Increasing fibre and fluid intake helps to get rid of constipation and manage IBS.

IBS - D (IBS with diarrhoea)

It is the complete opposite of IBS- C. In this condition, more than 25% of the stools are watery while less than 25% of the stool is hard and lumpy. Bloating and abdominal pain are other symptoms. There is no bowel control

Psychological stress and certain foods are triggers for this type of IBS. Proper counseling/therapy coupled with antidiarrheal medication and food restriction is required to bring the condition under control

IBS - M (Mixed IBS)

Those with IBS will suffer alternating bouts of constipation and diarrhoea. This means diarrhoea and constipation are experienced during the same flare-up. In this case, triggers will need to be identified in order to balance treatments

IBS - U (Unsubtyped IBS)

People with this type of IBS do not experience any irregularities with respect to their stools. The symptoms experienced by patients with IBS-U includes -

• Gas
• Cramping
• Bloating
• Mucus in the stool
• Abdominal pain and discomfort

The exact cause of IBS is not known. It is believed that IBS can be caused due to digestion related issues or can be a result of any emotional stress.

Causes include -

• Digestion issues/motility changes

Food either passes too quickly through the intestines causing diarrhoea or it passes too slowly causing constipation. The reason can be a disruption in the signal between the brain and the gut.

• Psychological factors

Research shows the association between the gut and the brain. The nerves in the stomach is sensitive to the psychological changes.

Any type of emotional stress/tragic incidence/stressful situations/abuse can cause changes in the digestive function triggering IBS.

Also people suffering from IBS have been known to show traits like anxiety, depression and so on making this a vicious cycle of IBS-mental disorder-IBS¹.

Getting a professional help to deal with the emotional stress and including yoga/meditation can help in managing this condition.

• Infections

Any bacterial/viral infection causing inflammation in the stomach lining can trigger off IBS. One of the symptoms include itching in the rectum area. Taking proper medications (antifungal or antibiotics) plus supplementing the diet with probiotics, the disease can be controlled and managed.

• Excessive bacteria in the small intestine -

Small intestinal bacterial overgrowth (SIBO) is a condition in which excessive levels of bacteria are present in the small intestine. Recent data suggest that SIBO may contribute to the pathophysiology of Irritable bowel syndrome².

SIBO can be diagnosed with a breath test (that measures gas produced by bacteria) and a urine test (analyses the byproducts produced by bacteria)

Treatment with antibiotics and dietary changes help to reduce the bacterial overgrowth.

• Genetic susceptibility -

Studies published to date suggest that there is evidence of genetic susceptibility to IBS. One study showed that patients with IBS were more likely to present a family history of IBS than controls (33.9% and 12.6%, respectively)³.

• Nutrient deficiency -

Deficiency of zinc has been known to cause infectious and persistent diarrhoea. It can be one of the causes for IBS-D. The reason being, low levels of zinc inturn lowers the immune system making the body susceptible to infections.

Who are at risk for developing IBS

It is not possible to pinpoint at a particular risk factor but a few conditions make people more susceptible to IBS than others. They include -

• Gender - women are twice more prone to IBS than men. Changing hormonal levels can be one of the triggers for IBS.
• Age - IBS is more common in the young age group of 20-40 years than in people over 50 years.
• Food - certain food act like IBS triggers. These triggers vary from person to person but common ones include - dairy, wheat, high caffeine drinks, fried foods, processed foods like cookies or chips, chocolates, alcohol
• Personality traits -  Personality traits and emotional patterns play key roles in affecting autonomic, immune, inflammatory, and endocrine functions, thus contributing to disease physiopathology.
• Medicines - some antibiotics can affect the gut microbes and can trigger IBS.

There are no specific tests for detecting IBS. Doctors generally rely on the

• patient’s medical history,
• signs and symptoms and the duration of time that the symptoms were present.
• stool test in case of infection
• certain blood tests to rule out other conditions like celiac disease that have similar symptoms.
• Further testing like colonoscopy (procedure to see inside of the large intestine) may be recommended if there is a family history of stomach or colon cancer.

Since the cause of IBS is not due to a single factor, the treatment approach also is multifactorial. The major role of any intervention is to address the root cause and improve the quality of life.

It is better to find the cause that is triggering IBS and treat the same than treating the symptoms alone.

The treatment options are based on addressing the cause of IBS and they include -

1. Medicines
2. Dietary changes
3. Lifestyle changes
4. Stress management
5. Alternate therapies

Medication⁴

A number of different medications can be used to help treat IBS, including:

• antispasmodics – which help reduce abdominal (stomach) pain and cramping by relaxing the muscles of the digestive tract. Commonly used is peppermint oil capsule
• laxatives – which can help relieve constipation by softening the stools and allowing smooth passage.
• antimotility medicines – which can help relieve diarrhoea. This works by slowing down the passage of stools through the digestive tract thereby hardening the stools.
• Low-dose antidepressants – which were originally designed to treat depression, but can also help reduce stomach pain and cramping independent of any antidepressant effect. They work by preventing signals being sent to and from the nerves in your digestive system.

Lifestyle modification to manage IBS

Here are a few lifestyle modifications that can help in dealing with IBS.

Exercise regularly

Studies were done to examine the relationship between the physical activity and bowel movements. It was found that there exist a positive association between increasing physical activity and mean bowel movements.

Physical activity could improve gastric motility and prevent stomach cancer. Not only IBS, there is also consistent improvement in general health on including at least 30 min of moderate to high intensity exercise 5 days a week.

Stress Management

Although it has not been proven that stress leads to IBS, it is seen that inability to manage stress exacerbates the IBS condition.

• Practice yoga and meditation to relieve stress
• Involving in a hobby or any activity that helps you to de-stress
• Certain relaxation techniques under the guidance of a psychologist can help to manage stress.

Adequate sleep

Disturbed sleep i.e.waking up couple of times after the sleep onset can lead to aggravation of IBS^11.  Research suggests that sleep disturbances lead to greater abdominal and somatic pain reporting in IBS patients¹².

Sleeping and waking up at the same time everyday helps to set our body clock giving good quality sleep.

Food intolerances or allergies are strong contributors to the exacerbation of IBS symptoms. Individuals with IBS often discover that certain foods aggravate symptoms while others have found relief from IBS symptoms by modifying their daily diet.

Foods to be included in the diet

The standard procedure is to increase the amount of dietary fibre to manage the symptoms of IBS since a diet low in fibre is believed to be one of the reasons for the onset of IBS⁵.

Including the food in the given list that are rich in fibre helps with IBS-C.

• Oats and oatmeal
• Barley
• Legumes like peas, beans etc
• Fruits like apple, citrus fruits, bananas, avocados, figs, guava, pear
• Vegetables like carrots, sweet potatoes, broccoli,
• Nuts like flax seeds, sunflower seeds, hazel nuts
• Sufficient fluid intake to support the fibre intake

Foods to be restricted

Insoluble fibre (which does not get digested in the stomach) present in certain food can lead to bloating and gas.

Apart from the fibre, lactose, gluten and some forms of carbs present in the food can aggravate IBS. Given below are the food items that can trigger IBS and need to be restricted -  

• Wheat and wheat products, rye, garlic, onion, legumes like kidney beans, dry peas and whole gram, leek
• Dairy and products like curd, yoghurt, cream, cheese, milk powder, condensed milk and desserts made with milk/milk products
• Fruits like mango, watermelon, pears, cherries, plums can lead to bloating in susceptible people
• Artificial sweeteners especially those containing mannitols or xylitols.
• Ready to eat and commercially processed items containing refined flour and additives.

Once the restriction has brought about symptomatic relief, the next step would be to reintroduce the foods listed under restricted section, one by one. This will give an idea of the foods that exacerbate the IBS symptoms.

After the triggers have been identified, it is better to maintain a food diary to keep an account of the foods that trigger IBS and avoid them in the future while returning to the normal diet.

Dietary tips

Since IBS cannot be completely cured, certain modifications in our day to day life can help to improve the quality of life  and manage IBS.

• Have regular meals and take time to eat.
• Avoid missing meals or leaving long gaps between eating.
• Drink at least eight cups of fluid per day, especially water or other non-caffeinated drinks, for example herbal teas.
• Restrict tea and coffee to three cups per day.
• Reduce intake of alcohol and fizzy drinks.
• It may be helpful to limit intake of high-fibre food (such as wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice).
• Reduce intake of ‘resistant starch’ (starch that resists digestion in the small intestine and reaches the colon intact), which is often found in processed or re-cooked foods.
• People with wind and bloating may find it helpful to eat oats (such as oat-based breakfast cereal or porridge)

Use of probiotics for IBS

There is some evidence that certain probiotics may help improve irritable bowel syndrome (IBS) symptoms. Probiotics are the good bacteria that regulate the gut microbiome.

Changing the gut microflora using probiotics have been helpful in giving symptomatic relief from gas and bloating in people with IBS⁹. Probiotics can regulate bowel function including motility, sensation, and immune function.

The type and duration of the probiotic course would depend on the severity of IBS and hence must be taken after consultation with a professional healthcare practitioner.

According to ayurveda, IBS is a disease which manifests mainly due to imbalance in agni and doshas, specifically Vata dosha. Ayurveda involves a three tier treatment for IBS -

Medicines

• Rasayan treatment helps in treating inflammation and improving peristalsis.
• Medicines like praval panchamruta, kamdudha, shankhavati are extremely beneficial in helping treat inflammation but one has to take it under medical guidance.

Lifestyle management

• Avoiding oily, spicy food, non veg, heavy to digest food like chole, rajma or legumes etc especially in evening meals.
• Sleeping in time and having early dinners helps a long way in treating the disease.
• Junk food, processed food, stale food, refrigerated food, cold drinks, food with refined flour ( maida ) etc should be completely avoided.
• The meals should be in regulated amounts , overeating has to be avoided. Sleeping immediately after meals or sitting for long hours needs to be avoided to improve digestion.

Exercise & yoga

• Daily pranayama , meditation helps in relieving stress and mild to moderate exercise is helpful in reducing the symptoms to a great extent.

Complementary and alternative medicine (CAM)

Mind-body therapies have been evaluated for their potential application as CAM in IBS. Clinical evidence supporting the use of yoga, relaxation, acupuncture, hypnotherapy, and cognitive behavior therapy is indicating that these CAM interventions show improvement in IBS symptoms and overall quality of life¹³.

Acupuncture - has been one of the CAM that has been researched and found to be effective in reducing the symptoms of IBS.

It has been shown that application of acupuncture in IBS patients reduces cortisol levels (stress hormone)¹³

Hypnotherapy - A total of 14 published studies were reviewed on the efficacy of hypnosis in treating IBS (eight with no control group and six with a control group).

They concluded that hypnosis consistently produces significant results and improves the cardinal symptoms of IBS in the majority of patients.

However it is best to consult a medical professional before starting on any of the alternative therapies.

In the nutshell, Irritable bowel syndrome has no cure. However with many medications, ayurvedic applications, yoga and alternative therapies, it is possible to manage the disease and improve the quality of life.

No matter what course of treatment one opts for, it is better to keep your doctor into the loop who would be the best judge to decide the type of treatment required to manage the disease.

References

1. https://www.sciencedirect.com/science/article/pii/002239999290025W
2. https://bmcgastroenterol.biomedcentral.com/articles/10.1186/1471-230X-10-23
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468846/
4. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/irritable-bowel-syndrome-ibs#treating-ibs
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468846/
6. https://www.jillcarnahan.com/2011/09/18/fodmaps-the-diet-that-may-eliminate-your-ibs-symptoms/
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4918736/
8. https://www.ncbi.nlm.nih.gov/books/NBK51960/
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886445/
10. https://onlinelibrary.wiley.com/doi/full/10.1111/apt.13677
11. https://link.springer.com/article/10.1007/BF01296103
12. https://onlinelibrary.wiley.com/doi/full/10.1111/apt.13677
13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3923011/
14. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2006.02776.x