Irritable Bowel Syndrome: Frequently Asked Questions
By Laura Zurawski & Dr. Anthony Lembo
What this FAQ covers:
This FAQ deals primarily with questions, problems, and concerns associated with Irritable Bowel Syndrome (IBS).
What this FAQ does NOT cover:
This FAQ is about IBS and IBS only. It does not answer questions related to other diseases of the colon (IBDs such as Crohns and Ulcerative Colitis). It does not answer any questions related to food allergies, including lactose intolerance and wheat/gluten intolerance (Celiac disease).
Part 1: Background
1a: What is Irritable Bowel Syndrome?
Irritable Bowel Syndrome (IBS) is part of a spectrum of diseases known as Functional Gastrointestinal Disorders which include diseases such as noncardiac chest pain, nonulcer dyspepsia, and chronic constipation or diarrhea. These diseases are all characterized by chronic or recurrent gastrointestinal symptoms for which no structural or biochemical cause can be found.
1b: What is the prevalence of IBS?
IBS affects between 25 and 55 million people in the United States and results in 2.5 to 3.5 million yearly visits to physicians. Approximately 20 to 40 percent of all visits to gastroenterologists are due to IBS symptoms.
IBS symptoms affects men and women of all ages and of all races. The prevalence of IBS in the general population of Western countries varies from 6 to 22%. IBS affects 14-24% of women and 5-19% of men. The prevalence is similar in Caucasians and African Americans, but appears to be lower in Hispanics. Although several studies have reported a lower prevalence of IBS among older people, the present studies do not allow to definitely conclude whether or not an age disparity exists in IBS. In non-Western countries such as Japan, China, India, and Africa, IBS also appears to be very common.
1c: What factors contribute to the onset of IBS?
Many patients with IBS report that their symptoms began during periods of major life stressors such as a divorce, death of a loved one, or school exams. Many patients also report the onset of symptoms during or shortly after recovering from a gastrointestinal infection or abdominal surgeries. Symptoms of IBS have also been known to appear upon the ingestion of a certain food to which the individual is sensitive. The type of food which causes symptoms varies with the individual. (There is no one definite universal food trigger for IBS.) Similarly, a flare of symptoms in a patient with long-standing IBS may be triggered by all of the symptoms listed above, or for no apparent reason.
1d: How long does IBS last?
Almost everything about IBS is totally dependent on the individual patient. For some, IBS may arise during times of stress or crisis, and then subside once the stressful event has passed. For others, IBS strikes seemingly randomly and without warning and never completely goes away. Still others will get IBS for a while, then it will go away for a long period of time, then come back. The duration of IBS is different for everybody.
1e: What effect does IBS have on one's lifestyle?
IBS can be nothing more than a mild annoyance, completely debilitating, or anywhere in between. Again, it depends on the person and how he or she reacts to it and treats it.
1f: Are my symptoms just "all in my head" or psychosomatic?
Several studies have shown that psychological disturbances are more common in IBS patients than patients with other gastrointestinal diagnoses and healthy controls. However, people with IBS who do not seek medical care have a similar psychological profile as the general population. Therefore, IBS is not caused by psychological problems, but a person's outcome and illness behavior is affected by their psychological make-up. Different people respond differently to their IBS and IBS symptoms, depending on a number of psychosocial factors.
1g: What factors contribute to health care utilization?
Although IBS is very common in the general population, only a minority of people ever seek medical care for their symptoms. Cultural factors may affect health care utilization. For example, as opposed to the U.S. and Europe, in India male patients are more likely to seek medical care than women. The presence and severity of abdominal pain, and the number of "Manning Criteria" correlate with health care consultation. Finally, psychological disturbance (e.g. anxiety or depression) also appears to influence health care utilization.
Part 2: Symptoms
2a: What are the symptoms of IBS?
The most common symptoms that IBS patients complain of are: frequent diarrhea, abdominal pain (usually in the lower abdomen area), gas, bloating, diarrhea alternating with constipation, mucus in the stool, bowel urgency or incontinence, and a feeling of incomplete evacuation after a bowel movement. Since IBS is considered mainly to be a disorder of the lower gastrointestinal tract, the symptoms tend to remain located below the navel. However, several symptoms of the upper gastrointestinal tract have also been shown to be common in those with IBS, including: difficultly swallowing, a sensation of a lump in the throat or a closing of the throat, heartburn or acid indigestion, nausea (with or without vomiting), and chest pain.
A number of expert investigators during a meeting in Rome, Italy, developed a consensus definition and criteria for IBS, known as the "Rome" criteria.
At least 3 months of continuous or recurrent symptoms of:
1. Abdominal pain or discomfort, e.g.:
- a. Relieved with defecation and/or
- b. Associated with a change in frequency of stool; and/or
- c. Associated with a change in consistency of stool; and
2. Two or more of the following, at least on one-fourth of occasions or days:
- a. Altered stool frequency
- b. Altered stool form (e.g. watery/loose stools or hard stools)
- c. Altered stool passage (e.g. sensations of incomplete evacuation after bowel movements, straining, or urgency)
- d. Passage of mucus and/or
- e. Bloating or feeling of abdominal distention.
In addition, a number of other non-colonic symptoms may be present in patients with IBS. These include: nausea, feeling full after eating only a small meal, sensation of urinary urgency, incomplete emptying after urinating, fatigue, and pain during sexual intercourse.
2b: How severe are these symptoms?
As with just about everything associated with IBS, the severity of symptoms vary greatly from person to person, ranging from barely noticeable to completely debilitating, and can vary for the same person over periods of time.
2c: Does everybody get the same symptoms?
No. Although the symptoms listed in 2a are the most common, each person's experience and presentation will be slightly different. The severity and frequency of abdominal pain or discomfort will also vary from an intermittent abdominal discomfort during stress life events to severe continuous abdominal pain. Likewise, bowel habits can vary. Diarrhea, constipation, or alternating between the two may be the predominant bowel pattern.
Part 3: Medical Facts
3a: What causes IBS?
Recent physiological and psychosocial data have emerged to improve our understanding of IBS. A biopsychosocial model of IBS involving physiological, emotional, cognitive, and behavioral factors is now felt to be involved in symptom generation. Physiological factors implicated in the etiology of IBS symptoms include: visceral hypersensitivity to spontaneous contractions and to balloon distention of the bowel, autonomic dysfunction including exaggerated colonic motility response to stress and alterations in fluid and electrolyte handling by the bowel, and an alteration in the gastrocolonic response. However, alterations in these physiological parameters are generally found in only a subset of patients and frequently do not correlate with bowel symptoms. Behavioral factors such as stressful life events are reported by up to 60% of IBS patients to be associated with the first onset of the disease or with its exacerbation. Laboratory stressors have also been shown to affect gastrointestinal motility and visceral perception. Cognitive factors such as inappropriate coping styles and illness behavior are common in IBS patients and influence healthcare utilization and clinical outcomes. Emotional and psychiatric factors, such as anxiety and depression, are present in 40 to 60% of IBS patients seeking healthcare with increased prevalence in those patients presenting to tertiary referral centers. IBS patients who have sought medical care are more likely to have abnormal psychological profiles, abnormal illness behaviors, and psychiatric diagnoses than patients with other medical illnesses.
3b: What is the role of psychological and/or social factors in IBS?
Psychiatric diagnoses are present in 42-62% of IBS patients who have sought medical consultation. In comparison, psychiatric diagnoses are present in around 20% of patients with other gastrointestinal diagnoses. The majority of these psychiatric diagnoses are cases of anxiety and depression. Other common diagnoses include somatization disorder and hypochondriasis.
Stress can affect the functioning of the gastrointestinal tract of all people, and particularly those with IBS. Several studies have shown that IBS patients are more likely to report that stress changes their stool pattern and leads to abdominal pain than people without bowel problems. In one study 65% of IBS patients reported a severe stressful life event prior to developing IBS. The kinds of psychological stressors often reported by patients with IBS vary considerably, but include: loss of a parent or spouse through death, divorce, or separation, and sometimes is accompanied by feelings of unresolved grief, and also significant life changes which demand many social and personal adjustments such as moving to a new job or a new city.
3c: Is IBS life-threatening?
No, however, IBS is serious. Patients with IBS have a higher rate of hospitalizations, work absenteeism, feelings of poor quality of life, and abdominal surgeries than healthy controls and patients with other gastrointestinal illnesses. In the general population, people with IBS symptoms missed more than 3 times as many work days than did people without bowel symptoms.
3d: Will IBS lead to colon or rectal cancer?
No. IBS has not been linked to any type of cancer. In fact, those with IBS are more likely to be better aware of bowel health and cancer prevention.
3e: Does IBS lead to IBD (Crohn's, ulcerative colitis)?
No. IBS symptoms are often present in patients with IBD, however, there is no evidence to suggest that IBS leads to IBD.
3f: Will my IBS eventually go away, or will I have it for the rest of my life?
IBS symptoms may fluctuate over time. In one study, more than 50% of IBS patient remained symptomatic 5 years after their initial diagnosis.
Part 4: Diagnosis
4a: How do I know for sure if I have IBS?
Since there is no diagnostic marker associated with IBS, the diagnosis is based on symptoms and by excluding other diseases which may have a similar presentation. The extent of the medical evaluation which is necessary prior to making a diagnosis of IBS will vary depending on the duration of symptoms, the patient's age and clinical presentation. For example, recent onset of symptoms in an older patient will require more extensive testing than a younger person with unchanged symptoms for many years. Most patients, however, will be given a thorough physical exam which is performed mainly to rule out other medical illnesses. If further testing is necessary it will usually be directed toward the predominant symptom. For example, patients with significant diarrhea will often undergo stool tests for ova and parasite, and malabsorption if clinically indicated. On the other hand, patients with constipation will often undergo tests such as radiopaque marker studies (Sitzmarker) for colonic functioning and anorectal manometry for pelvic floor functioning. Most patients over the age of 50 years should have a flexible sigmoidoscopy. In addition, if occult blood is found by either rectal exam or on hem-occult testing a colonoscopy may be necessary.
Some commonly performed tests are:
- Lower G.I. x-ray (a.k.a. the barium enema)
- Small bowel series x-ray
- Stool parasite culture
- Flexible sigmoidoscopy and/or colonoscopy
It is important to note that the ONLY way to be absolutely certain you have IBS is through a doctor's diagnosis.
Because there is no diagnostic marker associated with IBS, the diagnosis is one of exclusion and is based on symptoms. Manning and his colleagues were the first to report six symptoms which differentiated IBS from other gastrointestinal diseases. The six 'Manning Criteria' are as follows: 1) relief of abdominal pain with defecation, 2) looser stools with the onset of pain, 3) more frequent bowel movements at onset of pain, 4) abdominal bloating or distention, 5) feelings of incomplete evacuation, and 6) passage of mucus per rectum. In general the more 'Manning Criteria' present the more likely it is that a patient has IBS. While the 'Manning Criteria' are helpful in diagnosing IBS a consensus meeting in Rome, Italy recently further refined these criteria (see 2a). In addition, since many other gastrointestinal diseases can present with similar symptoms, a diagnosis of IBS should only be made in the right clinical setting.
4b: Is IBS a legitimate diagnosis? Should I seek a second opinion?
Many times a person may think that he or she is being "slighted" by being given a diagnosis of IBS. Unfortunately, to some doctors, IBS is not considered a "true" disease, but rather an unimportant minor condition (when in reality it is hardly all that "minor" to those who have to deal with it), and therefore may not be given the medical attention it deserves. Don't despair; there ARE competent doctors out there who are very good at dealing with IBS cases. A good doctor won't just tell you that you have IBS and give up on you. He or she should be willing to go over your questions and concerns, and outline and monitor a program of treatment for your individual case of IBS. If you suspect that you have not had a thorough enough examination for other diseases before the doctor tells you that you have IBS, you should seek a second opinion.
Part 5: Treatment
5a: What are the treatments for IBS?
The treatment of IBS is based on the severity and the nature of each person's symptoms and the effect psychosocial factors are having on their illness behavior. Therefore, each person's therapy is tailored to their symptoms and may include one or more of the following: lifestyle changes, pharmacological treatment, and psychological treatment. Therefore, there really is no one good general treatment for IBS. Different things work for different people, and really the only way to know exactly what works for you is by trial-and-error.
5b: What is the role of fiber therapy in IBS?
Fiber is the non-digested part of plant food and adds bulk to the stools by absorbing water. There are two types of fiber: soluble and insoluble. Soluble fiber dissolves in water and is found in oat bran, barley, peas, beans, and citrus fruits. Insoluble fiber are found in wheat bran and some vegetables. Fiber increases the transit time of the colon and decrease the pressures within the colon. However, the role of fiber in the treatment of IBS has not been well established. One study showed that the response to bran in terms of daily stool weight, bowel frequency and symptoms was determined more by pre-existing psychometric variables such as anxiety and depression that the amount or nature of the bulking agent administered. From our experience, however, patients with mild constipation predominant IBS may derive some benefit.
Fiber can be added to the diet through the eating of more fiber-rich foods, or by taking fiber supplements (common brands are Metamucil, Citrucel, and FiberCon).
5c: Is it necessary to make drastic dietary changes?
In some cases, certain foods can aggravate IBS symptoms and should be avoided. In particular, lactose in lactose deficient individuals, gas producing vegetables such as beans and broccoli, fatty foods, and alcohol. It is should be noted however that while these foods can exacerbate IBS symptoms, they are not the sole cause of typical IBS symptoms. To determine which foods trigger which symptoms, one often needs to start with very basic bland diet and gradually add one new food each day and record any symptoms associated with that particular food.
5d: What conventional prescription medications are used to treat IBS?
Conventional medications used in the treatment of IBS include (but are not limited to):
- Anti-spasmodic drugs like Bentyl and Levsin are considered to part of the class of anti-cholinergic drugs. Anti-cholinergic drugs act by decreasing the abnormal sensitivity of choninergic (muscarinic M2) receptors in gut smooth muscle. Significant improvement in abdominal pain and rectal urgency have been reported in some studies compared to placebo in short-term trials. However, there is no evidence that anticholinergic are more efficacious than placebo in the longer term.
- Antacids/anti-gas medications (e.g. Simethicone or BEANO). There is no current data which supports their use in the treatment of IBS symptoms, though many people report that they aid in the reduction of embarrassing flatulence and the accompanying lower abdominal pain.
- Anti-diarrhea medications/Opioid-receptor agonist (e.g. loperamide or "immodium"). Loperamide is an mu opioid receptor agonist which does not cross the blood-brain barrier. It delays small and large bowel transit, increases the frequency of small bowel phase 3 of the migrating motor complexes, decreases intestinal secretory activity, and increases rectal sphincteric muscle tone. Some studies have shown improvement in diarrhea, rectal urgency, and abdominal pain in IBS.
- Prokinetic Agents (e.g. Cisapride or "Propulsid"). A prokinetic drug which is a 5HT4 agonist and a 5HT3 antagonist. Cisapride has been reported to help in gastroesophageal reflux disease and dyspepsia related to delayed gastric emptying. Its efficacy in constipation predominant IBS, however, has not been well established.
- Antidepressants. Tricyclic antidepressants (e.g. amitriptyline, imipramine, and despramine) or serotonin reuptake inhibitors (e.g. fluoxetine, sertraline, and paroxetine) are commonly used to treat IBS. Although commonly used in IBS patients their efficacy is still being debated. Even though antidepressants are often used in patients with associated depression, antidepressants appear to improve symptoms independent of their antidepressive effects. One study using despramine found this drug to be superior to both atropine (an anticholinergic- which is a common side-effect of the tricyclic antidepressants) and placebo in relieving both gastrointestinal symptoms and depression. Therapeutic effect can take as long as 4-6 weeks and therefore therapeutic trial should continue at least this long.
- Smooth muscle relaxants (e.g. mebeverine (not yet available in the U.S.) and peppermint oil) have direct relaxant properties on gut smooth muscle. Placebo controlled trials, however, have not produced any consensus on their efficacy in IBS.
5e: Are there any natural or herbal remedies for treating IBS?
For many reasons, a large percentage of IBS patients find some relief in treatments not considered to be part of "conventional" medicine. Some herbs, such as mint, ginger, chamomile, etc. have been touted as ways to alleviate gastrointestinal distress. Some patients have also benefitted from meditation and relaxation therapy, hypnosis, acupuncture, massage therapy, biofeedback therapy, and the like. Probably the best natural remedy for IBS is through dietary modifications and an increase in exercise level. Some people find that a combination of conventional medication and natural therapies are ideal for controlling their symptoms.
5f: What are some of the psychological treatments available?
Psychological treatments should be considered symptoms are severe and are associated with psychological distress. Some of the treatments which have been used successfully include but are not limited to cognitive-behavioral therapy, biofeedback therapy, relaxation therapy, and hypnotherapy.
The core of cognitive-behavioral therapy is the way a person thinks about their bowel symptoms. For example, thoughts or cognitions such as "there must be more stool in my rectum to evacuate" can lead to anxiety or attention which, in turn, can lead to increased IBS symptoms such as sensations of incomplete evacuation. During cognitive-behavioral therapy patients learn exercises and strategies to control their symptoms. Therefore, cognitive-behavioral therapy retrains patients' cognitions about their illness beliefs as it pertains to their gastrointestinal symptoms. Several studies have found cognitive-behavioral therapy to be superior to control treatment.
Biofeedback and relaxation training for IBS is designed to increase the awareness and control of physical and emotional responses, and is particularly useful in helping patients control the physiological consequences of stress. The gastrointestinal system is particularly sensitive to stress and for many patients stress leads to an exacerbation of their IBS symptoms. Typical techniques used in biofeedback and relaxation therapy include breathing and muscle relaxation, hypnosis or imagery techniques, or a combination of these.
Hypnotherapy uses techniques aimed at increasing suggestibility in patients. Whorwell and colleagues were the first to report it to be an effective treatment in IBS. In particular they found that patients who received hypnotherapy to have more improvement in gastrointestinal symptoms including abdominal pain and diarrhea in comparison to placebo.
5g: How can keeping a record of my symptoms and triggers be helpful?
This will help you to identify foods, activities, or stressors that were previously not considered as triggering factors. By identifying inciting factors lifestyle modifications can be made to reduce symptom exacerbation.
5h: With all these different treatments, how do I know which will work for me?
The only way to know for sure which treatment will work best for you is to consult your doctor and discuss which method of treatment would be best for you. Sometimes, one has to try several different treatments before finding the one that will work the best. The important thing is not to get discouraged -- there is something that is right for you.
Part 6: Related Maladies
6a: How does IBS differ from Crohn's disease or ulcerative colitis?
The symptoms of IBS differ from the symptoms of Inflammatory Bowel Disease (IBD) in that there is NO trace of blood in the stool, or history of fevers or chills. IBS is a functional disporder, meaning that there is no demonstrable pathology in the colon or small bowel.
6b: How does IBS differ from celiac disease?
People with celiac disease experience marked intestinal symptoms such as diarrhea and gas upon the consumption of foods that contain gluten, such as products made from wheat, oats, rye, and barley. Upon the elimination of gluten-containing foods, the symptoms disappear. Some people with IBS may experience an aggravation of symptoms with the consumption of similar wheat-related products and eliminating these products can help alleviate symptoms.
6c: How does IBS relate to other broad-spectrum symdromes, such as Fibromylagia, Chronic Fatigue Syndrome (CFS), Myofascial Pain Syndrome (MPS), Multiple Chemical Sensitivity Syndrome (MCSS), and others?
An interesting point to note here is that many IBS patients also experience symptoms in non-gastrointestinal systems. Research has been done on the frequent "overlap" of nonspecific broad-spectrum syndromes in a large number of patients. Muhammad Yunus, M.D., of the University of Illinois College of Medicine has studied a group of syndromes as being part of a larger spectrum of conditions, which he calls Dysregulation Spectrum Syndrome or DSS.
The following syndromes are considered to be part of DSS, according to Dr. Yunus:
- Fibromylagia Syndrome (FMS)
- Chronic Fatigue Syndrome (CFS)
- Myofascial Pain Syndrome (MPS)
- Irritable Bowel Syndrome (IBS)
- Temporomandibular Joint Disorder (TMJ)
- Restless Leg Syndrome (RLS)
- Periodic Limb Movement (PLMS)
- Multiple Chemical Sensitivity Syndrome (MCSS)
- Tension Headaches
- Irritable Bladder
- Primary Dysmenorrhea
- Migraine Headaches
Other studies are being conducted on the occurrence of overlapping syndromes in patients. The exact cause of such a wide range of syndromes and symptoms in a patient is not yet clear, but it does seem to be the case that a patient with one particular syndrome on the above list is much more likely to have symptoms from one or more other syndromes on the same list.
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Disclaimer: This FAQ is provided by the author as a supplement to the usenet newsgroups alt.support.crohns-colitis and alt.support.ibs and other various internet IBS services, including IBS-related websites, and is meant as supplemental material only. In no way is this document meant to be a substitute for professional medical care or attention by a qualified practitioner, nor should it be implied as such. ALWAYS check with your doctor if you have any questions or concerns about your condition, or before starting a new program of treatment. Information for this FAQ come from personal experience with the disease and from research and clinical experience in the field by Dr. Anthony Lembo at UCLA Medical Center. The authors are not responsible or liable, directly or indirectly, for ANY form of damages whatsoever resulting from the use (or misuse) of information contained in or implied by this document.