What is Irritable bowel syndrome (IBS)?

Irritable bowel syndrome (IBS) is a disorder affecting the intestine. IBS involves problems with motility (movement of digested food through the intestines) and sensitivity (how the brain interprets signals from the intestinal nerves), leading to abdominal pain, changes in bowel patterns and other symptoms. Although often disruptive, debilitating and embarrassing, it may be some comfort to know that IBS is not life-threatening, nor does it lead to cancer or other more serious illnesses. Canada has one of the highest rates of IBS in the world. It is estimated that at least 5 million Canadians suffer from IBS, with an additional 120,000 people developing the condition every year. About 40% of people with IBS seek medical attention, while those with milder symptoms typically self-treat their condition with lifestyle changes, food avoidance and the purchase of non-prescription remedies. IBS is more common in women than men. In Canada, the economic and health-care related costs of IBS exceed $6.5 billion annually. Causing frequent work and school absenteeism, IBS can significantly erode an individual’s productivity and quality of life. Canadians suffering from IBS symptoms are absent from work an average of 13 days each year, representing an additional $8 billion of lost productivity.

What is IBS-C?

Irritable Bowel Syndrome with constipation, also referred to as IBS-C, is a distressing condition that can significantly affect the quality of life of those affected. Constipation occurs when digested food moves slowly through the digestive tract. As a result, stool remain in the large intestines for prolonged periods of time where the intestines remove excess water causing stool to become hard, dry, lumpy and difficult to pass.

What is IBS-D?

Irritable Bowel Syndrome with diarrhea is IBS with diarrhea as the primary symptom, also referred to as IBS-D People with IBS-D experience frequent abdominal pain and watery bowel movements, and, on occasion, loss of bowel control. In fact, approximately 1 out of every 3 people with IBS-D have loss of bowel control or soiling. This has a strong, negative impact on day-to-day life, however these and other symptoms of IBS-D can be managed.

Can I prevent Irritable bowel syndrome (IBS)?

The exact cause of IBS is unknown, however, the following lifestyle changes may help to prevent or ease your IBS symptoms:

• Exercise regularly to promote movement of the colon and reduce stress. Exercise can take many forms, but 20 to 30 minutes of activity at least three times per week can be helpful.
• Get enough rest. A lack of sleep and fatigue can worsen the symptoms of IBS.
• Minimize stress and tension. The brain and colon are linked through many complex pathways and emotional stress can disrupt intestinal function and cause pain. Yoga, meditation, and slow, relaxed breathing techniques can help people with IBS manage stress.
• Limit intake of caffeine, alcohol, carbonated drinks and fatty foods.
• Follow through on an urge to have a bowel movement, if at all possible.

Living Positively

Lifestyle changes for IBS

The following lifestyle changes may help to prevent or ease your IBS symptoms:

• Exercise regularly to promote movement of the colon and reduce stress. Exercise can take many forms, but 20 to 30 minutes of activity at least three times per week can be helpful.
• Get enough rest. A lack of sleep and fatigue can worsen the symptoms of IBS.
• Minimize stress and tension. The brain and colon are linked through many complex pathways and emotional stress can disrupt intestinal function and cause pain.
• Yoga, meditation, and slow, relaxed breathing techniques can help people with IBS manage stress.
• Limit intake of caffeine, alcohol, carbonated drinks and fatty foods.
• Follow through on an urge to have a bowel movement, if at all possible.

Dietary changes for IBS

Food intolerances have been linked to IBS symptoms for many years, however conflicting information often creates confusion and frustration as to what foods IBS patients should include, or avoid, in their diet. Recent research has identified six key strategies for the successful dietary management of IBS.

• Rule out lactose intolerance. The symptoms of lactose intolerance (an inability to digest the sugar in milk) and the symptoms of IBS often overlap.
• Limit insoluble fibre. The type of fibre in the diet is important for people with IBS. Insoluble fibre (cannot dissolve in water) which is found primarily in wheat bran, brown rice, seeds, nuts, dried fruit and whole grain breads, adds bulk to the stool and can aggravate IBS symptoms in some people. Peeling fruits and vegetables to remove the high insoluble fibre skin or peel can be beneficial.
• Supplement with linseeds for constipation: Linseeds (also known as flaxseed) may help to relieve constipation, abdominal discomfort and bloating. For IBS patients with constipation, adding ground linseeds to the diet for a 3-month trial may help bowel function.
• Reduce fermentable carbohydrates (FODMAPs): Fermentable carbohydrates (also known as FODMAPs), are small carbohydrate (sugar) molecules found in everyday foods that may be poorly absorbed in the small intestine of some people. FODMAPs are fermented (digested) by intestinal bacteria, which can lead to symptoms of abdominal pain, excess gas, constipation and/or diarrhea. Following a low-FODMAP diet may help to reduce gastrointestinal symptoms in 75% of IBS patients.
• Try a probiotic. Probiotics are live microorganisms that, when taken in adequate amounts over sufficient time, may provide a health benefit. They are natural, ‘healthy’ bacteria that may help with digestion and offer protection from harmful bacteria in the intestines. Studies have found that, in some cases, probiotics may help to improve symptoms of IBS. If other dietary strategies have not been successful, a 4-week trial of a probiotic (in the dose recommended by the manufacturer) may be helpful. Probiotics are not medicine. They are available to purchase as capsules, tablets or powders, and can also be found in some fortified yogurts and fermented milk products. However, not all probiotics are the same. It is important to choose a product that is reliable, proven to be safe and offers benefits for the specific symptoms you want to relieve. Speak to your doctor or pharmacist about which probiotic may be right for you. It is important to take the probiotic in the dose and duration recommended by the manufacturer to achieve the best results.
• Eliminate a suspected trigger food for 2-4 weeks: If a particular food seems to trigger IBS symptoms, eliminate the food from your diet for a period of 2 to 4 weeks. If symptoms do not improve during that time, the food is unlikely the cause of IBS symptoms.

Lifestyle Changes for IBS-C

Sometimes making simple changes to your lifestyle can be helpful for managing mild IBS-C symptoms such as:

• Regular exercise not only increases your strength, it can also boost bowel activity.
• Get enough rest. This allows your body to maintain basic function, repair and manage stress.
• As already mentioned, stress can affect bowel function. Try to find ways to manage your stress at home, work or school through good time management practices and prioritizing your health.
• Limit alcohol consumption
• Don’t smoke

Dietary Changes for IBS-C

Some foods support good bowel health while others can increase constipation. It is important to recognize the impact certain foods have on your digestive and overall health. Below are a few suggestions that may be helpful:

• Reduce gassy foods: If bloating is bothersome or you are passing more than usual amounts of gas, your doctor may suggest eliminating trigger foods such as: carbonated beverages, greasy, fried foods, and refined sugar.
• Increase fluids: Try to consume adequate amounts of non-caffeinated, low sugar liquids each day. Healthy fluids include water, juices, milk and low sodium soups. Avoid liquids high in refined sugar or artificial sweeteners.
• Increase Soluble fibres: Soluble fibres are derived from plants and cannot be broken down or absorbed. This fibre attracts water and turns into gel during digestion, slowing digestion and making stools soft and easy to pass.
• Increase Insoluble fibres: Insoluble fibres are not broken down or absorbed by the digestive system. These fibres add bulk to stool, which helps move stool through the digestive tract.
• Explore a Low-FODMAP Diet: Some individuals are sensitive to types of carbohydrates such as fructose, fructans, lactose and others. These are called FODMAPs (fermentable oligo-, di-, and monosaccharides and polyols). FODMAPs are found in certain grains, vegetables, fruits and dairy products.

Lifestyle and Diet Changes for IBS-D:

• Identify food triggers – Tracking foods you eat and logging the times you experienced symptoms/distress may help reveal connections between food and IBS-D. You should take detailed notes that should include the types and amounts of foods eaten and the time of consumption. It’s important to also record the time and description of distressing bowel events or related pain and discomfort. Below are some dietary considerations which you may want to discuss with your doctor and/or registered dietitian.
• High-fat foods may worsen symptoms of IBS-D
• Dairy products – lactose free products may be better tolerated
• Avoid alcohol
• A reduction of caffeine may be beneficial. This includes caffeinated drinks, such as coffee, tea, colas and energy drinks
• Sorbitol sweeteners (found in some chewing gum) may be problematic
• Drink plenty of water
• Probiotic supplements such as lactobacillus acidophilus may help alleviate IBS symptoms including abdominal pain, bloating, and bowel movement irregularity. Ask your health care professional for more information.
• A diet low in FODMAPs (fermentable oligo-saccharides, di-saccharides, mono-saccharides, and polyols), a group of short-chain carbohydrates, may help relieve symptoms. The diet is used in the short-term followed by re-introduction to assess tolerance to individual foods. Consult your health-care professional for more information.
• Eating large meals also may trigger abdominal cramping and diarrhea. It’s best to eat smaller meals.
• Fibre may be helpful in reducing symptoms of IBS-D. If a trial of a fiber supplement such as psyllium is used, fiber should be added gradually, because it initially may worsen bloating and gassiness. If you have IBS-D, look for foods with more soluble fiber, the type that takes longer to digest (such as that found in oats).
• Stress is considered one of the triggers of IBS symptoms. Here are some healthy habits that may also help reduce IBS symptoms.
• Exercise may improve and could reduce stress.
• Get enough rest. This allows your body to maintain basic function, repair and manage stress.
• Use relaxation techniques: deep breathing, visualization, Yoga.
• Consult a professional trained in Cognitive Behavioral Therapy or Gut Directed Hypnotherapy.

How do I prepare to talk to my doctor about IBS?

Good communication with your doctor is an important part of effective management of a functional GI disorder like IBS. Before your appointment, take the time to keep a symptom journal that can help you and your doctor see patterns in your activities and identify specific triggers for your symptoms.

Include the following information in your IBS journal:

• Write down the symptoms that are bothering you and how long you have had them. • Write down key personal and medical information, including any recent changes or stressful events in your life. • Make a list of the triggers (food, stress, activity, menstrual cycle) that seem to make your symptoms worse. • Make a list of medications are you taking, including the conditions you take them for. Also note if any of your medications seem to affect your symptoms. • Talk to your family members and note if any relatives have been diagnosed with IBS, inflammatory bowel disease (IBD), celiac disease or colon cancer. • Questions to ask your doctor during your appointment. You may want to ask: • What do you think is causing my symptoms? • Are there other possible causes for my condition? • What diagnostic tests do I need? • Do these tests require any special preparation? • What treatment approach do you recommend trying first? • If the first treatment doesn’t work, what will we try next? • Are there any side effects associated with these treatments?

Statistics

• Canada has one of the highest prevalence of irritable bowel syndrome (IBS) in the world – estimated 18% vs. 11% globally. (Lovell et al. 2012)
• More than 70% indicate that their symptoms interfere with everyday life and 46% report missing work or school due to IBS. (Gastrointestinal Society 2016)
• 54% of those with IBS experience symptoms of fatigue. (Gastrointestinal Society 2018; Han et al. 2016)
• 40 to 60% of those with IBS experience psychological symptoms, including anxiety disorders and depression. (Gastrointestinal Society 2018)
• On average, IBS patients reported they would give up 25% of their remaining life (15 years) to live a symptom-free life. (Gastrointestinal Society 2018)
• Data from the US suggest that on average, costs are US$2,026 more per year per patient among those with IBS as compared to those without IBS. (Buono et al. 2017)
• On average, it takes 4 years for an individual to receive a definitive diagnosis of IBS. (Gastrointestinal Society 2018)
• In Canada, 45% of the direct costs for IBS treatment are attributed to diagnostic tests. (Fedorak et al. 2012)

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Citations:

_{Buono JL et al. Economic burden of irritable bowel syndrome with diarrhea: Retrospective analysis of a U.S. commercially insured population. J Manag Care Spec Pharm. 2017 Apr;23(4):453-60.}

_{Fedorak RN et al. Canadian Digestive Health Foundation Public Impact Series 3: Irritable bowel syndrome in Canada. Incidence, prevalence, and direct and indirect economic impact. Can J Gastroenterol. 2012 May;26(5):252-6.}

_{Gastrointestinal Society. 2018. IBS Global Impact Report 2018. https://badgut-5q10xayth7t3zjokbv.netdna-ssl.com/wp-content/uploads/IBS-Global-Impact-Report.pdf [accessed 3 September 2018]}

_{Gastrointestinal Society. 2016. 2016 Survey Report: Irritable bowel syndrome. https://badgut-5q10xayth7t3zjokbv.netdna-ssl.com/wp-content/uploads/IBS-Survey-Results-2016.pdf [accessed 3 September 2018]}

_{Han CJ and Yang GS. Fatigue in irritable bowel syndrome: A systematic review and meta-analysis of pooled frequency and severity of fatigue. Asian Nurs Res (Korean Soc Nurs Sci). 2016 Mar;10(1):1-10.}

_{Lovell RM and Ford AC. Global prevalence of and risk factors for irritable bowel syndrome: A meta-analysis. Clin Gastroenterol Hepatol. 2012 Jul;10(7):712-21.e4.}

Signs and Symptoms

Signs & symptoms of IBS

• Abdominal pain (cramping):IBS pain can be felt anywhere throughout the abdomen. Each bout of pain can vary in length and severity, and pain may increase and decrease over time. IBS pain is often relieved following a bowel movement.
• Constipation: Symptoms of constipation can include passing three or fewer stools in one week, passing hard, dry stools, the passage of only small amounts of stool, and frequent straining during a bowel movement.
• Diarrhea: Symptoms of diarrhea can include passing stools three or more times per day, passing loose, watery stools or feeling an urgent need to have a bowel movement.
• A feeling of incomplete emptying of the bowels
• Whitish mucus (a fluid made in the intestines) within or around the stools.
• Gas
• Heartburn
• Bloating
• Nausea

While most people experience digestive troubles once in a while, what sets IBS apart is abdominal pain and diarrhea or constipation that comes back again and again. At times, the pain and discomfort of IBS symptoms may be severe and debilitating, and at other times, they may improve or even disappear completely.

Signs & symptoms of IBS with constipation (IBS-C)

When living with IBS-C, symptoms may suddenly worsen (flare) and then improve for no apparent reason. When symptoms flare, they may be severe, debilitating and last for days or months. Possible signs and symptoms of IBS-C are:

• abdominal pain or discomfort
• gas, bloating and abdominal distention
• straining when having a bowel movement
• a sense that something is blocking your rectum
• infrequent bowel movements (less than three per week)
• feeling like you have not completed your bowel movement other illnesses so that those can be ruled out.
• diarrhea or loose, watery stools, especially in the morning or after meals
• passing stools three or more times per day
• sudden urgency before bowel movements
• feeling of incomplete emptying after bowel movements
• abdominal pain or cramping
• loss of bowel control or soiling yourself

What causes irritable bowel syndrome (IBS)?

The exact cause of IBS is unknown, however, it is believed that IBS may be caused by one of several factors. In some patients, it may be linked to a prior infection or event which disrupts the normal functioning of the intestines. It is common for people to develop IBS following a gastrointestinal infection, food poisoning, traveller’s diarrhea, surgery, a change in diet or the use of antibiotics or new medications. In others, an imbalance of intestinal bacteria or a change in the body’s level of hormones, immune signaling in the bowel wall or neurotransmitters (brain chemicals) may also lead to the development of IBS. Currently, there is a great deal of interest in possible alterations in the number or type of bacteria within the intestine, but the exact role this may play in IBS is not yet known. In people with IBS, bowel function can be altered in several ways:

• Motility (movement of contents through the intestines): Normally, waves of coordinated intestinal muscle contractions (peristalsis) transport digested food through the intestines. In people with IBS, the rhythm and coordination of these contractions may be altered. This altered motor function can result in the bowel moving too quickly (causing diarrhea) or too slowly (causing constipation) and can lead to spasm and pain.
• Sensitivity (how the brain interprets signals from the intestinal nerves): The network of nerves surrounding the digestive organs may become unusually sensitive. For some people with IBS, even a small change in intestinal activity can trigger the nerves to send messages to the brain causing abdominal pain.
• Brain-gut dysfunction:In IBS, there may be problems in how the brain receives and processes sensations coming from the intestines. A malfunction may occur along the many different pathways that connect the brain and gut, interfering with the normal function of the intestines. Many aspects of everyday living can trigger or aggravate IBS symptoms. Triggers vary from person to person, but the most common ones include certain foods, medications, emotional stress and hormone fluctuations. In particular, foods such as caffeine, alcohol, carbonated drinks, fatty foods, certain fruits and vegetables, as well as lactose, fructose and gluten (wheat protein) can cause problems for people with IBS.

Risk factors of IBS

• Age: IBS can affect people of all ages, but it often begins in the teen years or early adulthood.
• Gender: IBS affects more women than men.
• Family history of IBS: People with a first-degree relative (parent or sibling) with IBS are at greater risk of developing the condition.

What causes IBS with constipation (IBS-C)?

The cause of IBS-C is not yet known; however, there are a variety of factors that may contribute to the disorder. These include:

• Intestinal motility: The walls of the intestines are lined with layers of muscles that contract and relax in a coordinated rhythm as they move food from your stomach to your intestines through a process called peristalsis. For those with IBS-C, contractions within the intestine may be reduced or delayed causing gas, bloating and stool to move slower than normal.
• Nerve Hyper-Sensitivity:Poorly coordinated signals between the brain and the gut can make your body overreact to the activities taking place during digestion causing increased sensitivity. This may explain why those with IBS-C experience abdominal pain and discomfort. Excess fluid absorption: Constipation results when the intestine absorbs too much fluid from the stool, which can occur because of reduced or delayed contractions. Brain-bowel connection: There is a strong connection between our brain and bowel. This is sometimes called the brain-gut connection. In individuals with IBS-C, a possible disconnect or miscommunication between the mind and gut, may impact motility, pain sensitivity and fluid absorption. This disconnect may result in abdominal pain, discomfort and constipation.

Risks associated with IBS-C

If left untreated, IBS-C can potentially lead to additional health complications. These include:

• Hemorrhoids: enlarged veins (blood vessels) in the rectum that may bleed or descend through the anus
• Anal fissure: a crack in the lining of the anus caused when large or hard stools stretch the anal sphincter
• Fecal impaction: a mass of hard stool that cannot be excreted by a normal bowel movement and may need to be removed manually
• Rectal prolapse: rectal tissue pushes out through the anus
• Lazy bowel syndrome: caused from frequent use of laxatives to have bowel function properly

What causes irritable bowel syndrome with diarrhea (IBS-D)

Although the exact cause of IBS-D is unknown, it is believed that IBS-D may be caused by one of several factors:

• Brain-gut dysfunction: There is a dynamic bidirectional communication between the gut and the brain. A malfunction may occur along the many different pathways that connect the brain and gut and changes in one pathway ultimately cannot affect others.
• Bacterial Infection: Food poisoning, traveler’s diarrhea. These infectious agents are cleared from the body typically within days but lead to chronic alterations in motility (gut too fast or too slow) and abnormal sensory signalling to the brain.
• Bile acids: These are normally absorbed in the small bowel but some patients spill too many into the large bowel (colon) and this can trigger diarrhea and cramps.
• Food Sensitivity: Many patients have meal-induced symptoms. Some patients have a hypersensitive gut and meals induce gut motility (e.g. distention) that can cause symptoms. There is also growing evidence that some food may also have specific actions on gut motility and this could involve alterations in the microbiome or that an individual’s microbiome might also make them more susceptible to specific foods. However much more research is needed in this area.
• Use of antibiotics or new medications: Antibiotics can cause an imbalance of intestinal bacteria and other medications a change in the motility in the gut.
• Stress and anxiety: These are not the cause of lBS-D but are recognized as a common trigger of symptoms in some individuals.
• Heredity:IBS-D can run in families but it is unclear how much of this association is related to some common environment or genetics. Recent research has identified one or more genetic defects that could be involved in a sub-set of IBS but further studies are needed to determine whether these defects are important. Consequently, genetic testing is not indicated.

Risks associated with IBS-D

If left untreated, IBS-D can potentially lead to additional health complications. These include:

• Diarrhea may aggravate hemorrhoids in people who already have them.
• Eliminating many foods from the diet may result in a diet that is too limited in nutrients that could cause health problems.
• Stress and anxiety can result from the pain, and can impact a person’s quality of life.

Tests and Treatment

Testing for irritable bowel syndrome (IBS)

Often, symptoms alone can provide doctors with the information they need to diagnose IBS. Your doctor will perform a physical examination and take a complete medical history that includes a careful review of your symptoms. For this reason, it is important to be candid and specific with your doctor about the problems you are having. A set of specific symptom criteria (referred to by physicians as the Rome IV Criteria) has been developed to help physicians diagnose IBS.

Rome IV Criteria

In May 2016, the Rome Foundation released the new Rome IV criteria for diagnosing IBS. All around the world, physicians follow this organization’s lead when diagnosing IBS.

According to the Rome IV diagnostic criteria, IBS is characterised by recurrent abdominal pain for, on average, at least one day per week in the last three months, associated with two or more of the following:

• Symptoms related to defecation
• Symptoms associated with a change in stool frequency
• Symptoms associated with a change in form (appearance) of stool

There is no laboratory test, X-ray or scope to diagnose IBS, however, your doctor may order tests, particularly if there are red flags. To rule out other infections or underlying medical problems, these tests may include some of those listed below:

• Blood tests: Blood tests can help to rule out anemia, diabetes, abnormal thyroid function, changes in the calcium level that can affect the gastrointestinal tract, and celiac disease.
• Stool sample tests:A stool analysis can detect blood in the stool and rule out bacterial infection, malabsorption, parasites and other digestive problems.

Imaging tests:

Your doctor may order tests to see inside your lower digestive organs. This is done to rule out potential, more serious health problems.

These safe tests can help to identify problems such as ulcers, polyps (growths on the lining of the intestines), colon cancer or inflammatory bowel disease (IBD) and include:

• Colonoscopy: A slim flexible tube equipped with a light and a tiny camera is guided through the rectum into the large intestine (colon). The colonoscope allows your doctor to examine the lining of both the upper and lower sections of the colon.
• Flexible sigmoidoscopy: In a procedure similar to a colonoscopy, a flexible scope allows your doctor to view the lining of lower part of the colon only.
• CT (computed tomography) colonography: In most centres, barium enemas have been replaced by CT colonography. This scan takes cross-sectional pictures of the abdomen and uses special computer software to create a 3D image of the entire colon. It is very accurate at detecting larger polyps and cancers.

Dietary tests:

• Lactose intolerance: Lactose intolerance (an inability to digest the sugar in milk) can cause gastrointestinal symptoms similar to IBS. Your doctor can rule out lactose intolerance by performing a hydrogen breath test or by asking you to eliminate lactose from your diet for 2 weeks, and then reintroducing lactose and recording your symptoms.
• Celiac Disease: Celiac disease (a condition where the immune system reacts against gluten, a protein found in wheat) causes damage to the lining of the small intestine and may also cause symptoms similar to IBS. Celiac disease can be ruled out with a simple blood test performed at the doctor’s office or with a home kit that you can purchase at the pharmacy. You must be eating gluten at the time of the test in order for the results to be accurate. If the blood test is positive, a biopsy is needed to confirm a diagnosis of celiac disease.

Treating irritable bowel syndrome (IBS)

Take comfort in knowing that IBS is an extremely common problem, and in many cases, simple changes in your lifestyle and diet can provide symptom relief. However, no one treatment works for everyone and treatment will depend on the types of symptoms you have, their severity and how they affect your daily life.

Your doctor may recommend prescription or over the counter products if your IBS symptoms are severe and if lifestyle and dietary strategies have not helped. Typically, medications are targeted at the dominant symptom – diarrhea, constipation or pain.

• Antispasmodic medications may help reduce muscle spasms, abdominal pain and cramping.
• Antidepressant medications, in low doses, act on the chemical messengers in the digestive tract and can help relieve diarrhea, pain and cramping. In higher doses, these medications help to relieve depression and anxiety that may accompany IBS.
• Antidiarrheal medications, such as Loperamide, can help control diarrhea by reducing stool frequency and slowing the movement of the intestines.
• Laxatives speed up the motion of stool through the intestines and may be prescribed for people who have IBS with constipation. Laxatives are available in prescription or over-the-counter formulations. Speak to your doctor about which one is best for you.
• Prosecretory and analgesic agents, which increase the amount of fluid in the digestive tract as well as reduce the sensitivity of pain nerves in the intestines. They have been shown to soften bowel movements and make them occur more often, reduce the amount of bloating and to decrease abdominal pain in patients with IBS.

Treating irritable bowel syndrome with constipation (IBS-C)

It is important to find a solution that works best for you so you can find relief and enjoy the best quality of life possible despite IBS-C. Your healthcare provider will try to help you manage your symptoms. Recommendations generally begin with changes to lifestyle and diet. If those changes do not bring relief, over-the-counter (OTC) products or prescription medications may be prescribed.

Medications

While lifestyle and dietary changes can play a role in helping manage mild IBS-C symptoms, if your symptoms do not improve or even worsen, you may require further intervention. Over the Counter (OTC) and prescription therapies are available for treating IBS-C. OTC medications are recommended for short term/occasional use. If you symptoms are still unresolved, you should consult with your health care provider. With the right medication, you should find relief and prevent IBS-C from inhibiting your everyday activities and quality of life.

OTC therapies for IBS-C:

• Osmotic laxatives: are non-stimulant laxatives that draw water into the colon, increase bowel movements and allow stool to pass through the colon more easily.
• Bulk-forming laxatives are non-stimulants containing fibre. Fibre brings water into the colon, softens and increases the bulk of stool, and softens stool. Psyllium or methylcellulose are the most common bulking laxatives used.
• Stool softeners are non-stimulants, which soften the stool by reducing surface tension and allowing intestinal fluids to penetrate the stool to make it softer and easier to pass. Stimulant laxatives stimulate the nerves and muscles of the intestine to trigger a bowel movement by increasing contractions of muscles in the intestine. This helps stool pass through the colon more quickly.

Prescription Medications for IBS-C

Some IBS-C patients do not find relief with lifestyle and diet changes nor over the counter medications. These individuals need safe and effective long-term therapies. There are currently two classes of prescription medications that may help. These are:

• Prokinetic agents which stimulate movement and contractions of the bowel. This increases the speed with which stool travel through the digestive system, increases frequency of bowel movements, and reduces IBS-C symptoms.
• Prosecretory and analgesic agents increase the amount of fluid in the digestive tract as well as reduce the sensitivity of pain nerves in the intestines. They have been shown to soften bowel movements and make them occur more often, reduce the amount of bloating and to decrease abdominal pain in patients with IBS-C.
• Identify food triggers – Tracking foods you eat and logging the times you experienced symptoms/distress may help reveal connections between food and IBS-D. You should take detailed notes that should include the types and amounts of foods eaten and the time of consumption. It’s important to also record the time and description of distressing bowel events or related pain and discomfort. Below are some dietary considerations which you may want to discuss with your doctor and/or registered dietitian.
• High-fat foods may worsen symptoms of IBS-D
• Dairy products – lactose free products may be better tolerated
• Avoid alcohol
• A reduction of caffeine may be beneficial. This includes caffeinated drinks, such as coffee, tea, colas and energy drinks
• Sorbitol sweeteners (found in some chewing gum) may be problematic
• Drink plenty of water
• Probiotic supplements such as lactobacillus acidophilus may help alleviate IBS symptoms including abdominal pain, bloating, and bowel movement irregularity. Ask your health care professional for more information.
• A diet low in FODMAPs (fermentable oligo-saccharides, di-saccharides, mono-saccharides, and polyols), a group of short-chain carbohydrates, may help relieve symptoms. The diet is used in the short-term followed by re-introduction to assess tolerance to individual foods. Consult your health-care professional for more information.
• Eating large meals also may trigger abdominal cramping and diarrhea. It’s best to eat smaller meals.
• Fibre may be helpful in reducing symptoms of IBS-D. If a trial of a fiber supplement such as psyllium is used, fiber should be added gradually, because it initially may worsen bloating and gassiness. If you have IBS-D, look for foods with more soluble fiber, the type that takes longer to digest (such as that found in oats).
• Stress is considered one of the triggers of IBS symptoms. Here are some healthy habits that may also help reduce IBS symptoms.
• Exercise may improve and could reduce stress.
• Get enough rest. This allows your body to maintain basic function, repair and manage stress.
• Use relaxation techniques: deep breathing, visualization, Yoga.
• Consult a professional trained in Cognitive Behavioral Therapy or Gut Directed Hypnotherapy.

Medications for IBS-D

While lifestyle and dietary changes can play a role in helping manage mild IBS-D symptoms, if your symptoms do not improve, you may require further intervention. Over the Counter (OTC) and prescription therapies are available for treating IBS-D.

OTC medications are recommended for short term/occasional use. If your symptoms are still unresolved, you should consult with your health care provider. With the right medication, you may find relief and prevent IBS-D from inhibiting your everyday activities and quality of life.

OTC therapies for IBS-D

• Peppermint oil
• probiotics
• fiber
• alpha galactosidase enzymes (e.g. Beano), simethicone, although efficacy with many products is not proven.

Prescription Drugs for IBS-D

IBS-D patients suffer from a multitude of symptoms including abdominal pain, bloating, and diarrhea. The commonly used prescription drugs only address a single symptom rather than the constellation of symptoms observed in IBS-D patients. Recent advancements in the treatment of IBS have produced newer medications that not only treat the multiple symptoms but have been specifically studied and approved for use by Health Canada in IBS-D patients.

Physicians may now prescribe one or a combination of drugs that:

• reduce abdominal pain by blocking the pain signals to the brain
• relax the muscles in the gut to reduce diarrhea and the urgent, uncontrollable need to use the washroom (urgency)
• reduce both abdominal and bowel symptoms including pain, bloating, urgency and diarrhea Your doctor can determine if a combination or a single treatment is right for you.

FAQs

How is IBD different than IBS?

Although both illnesses can be seriously debilitating, there are several primary differences between Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS). IBD is an autoimmune disorder that causes swelling and ulcerations (sores) in the bowel. IBS involves problems with motility (how the bowel moves contents through our intestines) and sensitivity (how the brain interprets sensations in the bowel). Symptoms of IBS may wax and wane and possibly disappear altogether whereas IBD is a chronic condition.

What is the cause of excessive flatulence and burping?

This is a common problem! We all pass gas and or experience burping but for some people, these symptoms can be really bothersome. It is important to recognize that everyone has gas in the digestive tract. When there is some gas and fluid in the intestines, movements (contractions) of the intestines to propel the contents onwards may cause rumblings.

There two major causes of excessive gas:

First, subconscious swallowing of air can result in excessive burping. Eating slowly, avoiding gum chewing and smoking, rectifying problems that lead to phlegm accumulation in the back of the throat (such as postnasal drip), and correcting a habit of clearing the throat and swallowing can help minimize air swallowing. Belching often induces instinctive reflex swallowing with further gas accumulation so you need to make a conscious effort not to swallow after each belch.

And second, gas can form as a result of the breakdown of certain dietary items, especially carbohydrates, by bacteria normally present in the large intestine. Foods that cause gas include beans, broccoli, cabbage, fruit drinks, carbonated drinks, and dairy products. Beano (obtainable over-the-counter) may help to reduce gas formation when you have a lot of vegetables and fruits at any meal.

There is no one answer or diagnosis that applies to all people. I suggest that you contact your family doctor and discuss your symptoms and the tests he or she might want to do.

Do you recommend colon hydrotherapy or enemas in support of colon health?

There is no scientific basis that colonic hydrotherapy or enemas benefit a person's health. On the contrary, if a person has undiagnosed colonic symptoms and tries this approach, it can be associated with significant adverse consequences in the presence of underlying disease.

Understanding the FODMAP Diet

In this handy printable resource, CDHF covers the basics of the FODMAP diet.

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What does FODMAP mean?

FODMAPs are a group of small carbohydrate (sugar) molecules found in everyday foods. Carbohydrates are made up of carbon, hydrogen, and oxygen and provide an important source of energy for the body. FODMAP carbohydrates that may be poorly absorbed in the small intestine of some people.

FODMAPs move through the digestive tract to the large intestine (colon), where they can draw water into the colon and are rapidly fermented (digested) by naturally-occurring gut bacteria. The fermentation of FODMAPs produces gas and other by-products. It is estimated that 50% of people with IBS may benefit from a low FODMAPs diet, however, the quality of scientific evidence is very low. Of these people, there is a possible benefit for overall symptoms such as abdominal pain, cramping, bloating, excess gas, constipation and/or diarrhea.

Download and print this resource to help you understand the FODMAP diet. Complete with easy to reference cheat sheets of common low FODMAP food options, as well as a list of foods to avoid, this resource is a great opportunity for those who are new to the diet to learn the basics.

This guide is meant to explain the basics only, and CDHF encourages any IBS patients who are thinking about attempting this elimination diet for themselves to do so under the guidance of a registered dietitian.

Understanding IBS-D Webinar

https://www.youtube.com/watch?v=Xioy3qi5G7U

Living Positively with IBS Animation

https://www.youtube.com/watch?v=T1dmbtesTjo

IBS, IBD & Mental Health Webinar

https://www.youtube.com/watch?v=RbeytaBjqi0