Irritable bowel syndrome (IBS)

treatment

Diet: It is unclear from studies if diet has a great effect on the symptoms of IBS. Nevertheless, patients often associate their symptoms with specific foods (such as salads, fats, and spicy foods), and patient's symptoms improve when dietary changes are made. Dietary fiber is often recommended for patients with IBS. Fiber probably is of benefit to IBS patients with constipation, but it does not reduce abdominal pain and may even cause it. Eating foods high in pectin (such as apples) may help decrease diarrhea. A diet of bananas, rice, apple sauce, and dry toast may be helpful.
Lactose (milk sugar) intolerance often is blamed for diarrhea-predominant IBS, but it does not cause IBS. Because they are both common, lactose intolerance and IBS may coexist. In this situation, restricting lactose will improve, but not eliminate the symptoms. Lactose intolerance is easily determined by testing the effect of lactose (hydrogen breath testing) or following a strict lactose free elimination diet. Intolerance to sugars other than lactose, specifically, fructose, sucrose, and sorbitol, may cause symptoms that are similar to IBS or make IBS worse. However, it has not been proven that these sugars cause IBS.
Constipation treatments: Constipation is due to the slow transport of intestinal contents through the intestines, primarily the colon. This slow transit may be due to either abnormal function of the muscles of the entire colon or just the muscles of the anus and rectum. There are a number of prescription and over-the-counter treatments for constipation available.
Enemas: Saline enemas cause water to be drawn into the colon. Phosphate enemas (Fleet Phospho-soda®) stimulate the muscles of the colon. Mineral oil enemas lubricate and soften hard stool. Emollient enemas (Colace Microenema®) contain agents that soften the stool.
Enemas are particularly useful when there is impaction (hardening of stool in the rectum). Defecation (bowel movement) usually occurs between a few minutes and one hour after the enema is inserted. Enemas are meant for occasional rather than regular use. The frequent use of enemas may cause disturbances of the fluids and electrolytes in the body.
Suppositories: Different types of suppositories have different mechanisms of action. Bisacodyl (Dulcolax®) is an example of a stimulant laxative suppository. Glycerin suppositories are believed to have their effect by irritating the rectum. They are commonly used in infants and children with constipation. The insertion of the finger into the rectum where the suppository is placed may itself stimulate a bowel movement.
Laxatives: If an individual with IBS needs a laxative, osmotic agents such as polyethylene glycol (Miralax®), sorbitol, and lactulose (Cephulac®) are good choices. Side effects may include diarrhea and abdominal discomfort (cramping, bloating).
Diarrhea treatments: The most widely studied drug for the treatment of diarrhea in IBS is loperamide (Imodium®). Loperamide appears to work by slowing down the contractions of the muscles of the small intestine and colon. Loperamide is approximately 30% more effective than a placebo in improving symptoms among patients who have diarrhea as the main symptom of their IBS. It is not clear if loperamide reduces abdominal pain. Dosages of loperamide include an initial dose of 4mg (two capsules) followed by 2mg (one capsule) after each unformed stool. The dose must be carefully adjusted and individualized for each patient. Another commonly used anti-diarrheal drug is diphenoxylate/atropine (Lomotil®). Lomotil® is a controlled substance and may cause drug dependence. Other side effects may include dry mouth, headache, constipation, blurred vision, and drowsiness.
Diarrhea may cause dehydration (loss of water and electrolytes such as sodium and potassium). The fluid and electrolytes lost during diarrhea need to be replaced quickly, as the body cannot function properly without them. Dehydration is particularly dangerous for infants and children, who may die from it within a matter of days. Although water is extremely important in preventing dehydration, it does not contain electrolytes. To maintain electrolyte levels, sports drinks (Gatorade® or Powerade®), broth or soups (which contain sodium), or fruit juices may be consumed. Consuming large amounts of water unbalanced by dietary electrolytes may result in a dangerous electrolytic imbalance which in rare cases may prove fatal (water poisoning or water intoxication).
For children, doctors often recommend a special rehydration solution that contains the electrolytes and nutrients (vitamins and minerals) needed. Examples include Pedialyte®, Ceralyte®, and Infalyte®. A rehydration fluid sanctioned by the World Health Organization (WHO) consists of sodium chloride, potassium chloride, glucose and sodium bicarbonate.
Absorbents: Absorbents are compounds that absorb water. Absorbents that are taken orally bind water in the small intestine and colon and make loose stools less watery. They also may bind toxic chemicals produced by bacteria that cause the small intestine to secrete fluid. The over-the-counter (OTC) absorbents include attapulgite (clay) and calcium polycarbophil. Attapulgite (Kaopectate®, Donnagel®, Diasorb® and Rheaban Maximum Strength®) are considered by the FDA as Category 1 agents (safe and effective) for the treatment of acute diarrhea. Attapulgite is not absorbed systemically (into the body); therefore, side effects are minimal. Attapulgite may decrease the absorption of nutrients and other drugs. Because of this effect, individuals should not to take any other medications within two to three hours of taking attapulgite. Most experts agree not to use attapulgite preparations for more than two days unless doctor recommended, if blood or mucus is present in the stool or in infants or children less than three years of age. Calcium polycarbophil (Mitrolan®, Equalactin®, FiberCon®, Fiberall®) is a bulk-forming laxative, but can be used for diarrhea when the intestines are incapable of absorbing water at normal rates. Polycarbophil absorbs fecal water, forming a gel to aid in the production of formed stools. Like attapulgite, polycarbophil is not absorbed systemically. It can absorb up to sixty times its weight in water. Studies have demonstrated that polycarbophil decreases the frequency of bowel movements and improves stool consistency in patients with acute as well as chronic diarrhea.Side effects include epigastric (abdominal) pain and bloating.
Anti-motility drugs: Anti-motility medications are drugs that relax the muscles of the small intestine and/or the colon. Relaxation results in slower flow of intestinal contents. Slower flow allows more time for water to be absorbed from the intestine and colon and reduces the water content of stool. Cramps, due to spasm of the intestinal muscles, also are relieved by the muscular relaxation. The two main anti-motility medications are loperamide (Imodium®), which is available without a prescription, and diphenoxylate/atropine (Lomotil®), which requires a prescription. Loperamide, though related to opiates, does not cause addiction. Diphenoxylate is a man-made medication that at high doses can be addictive because of its opiate-like, euphoric (mood-elevating) effects. Diphenoxylate can cause drowsiness or dizziness, and caution should be used if driving or performing tasks that require alertness and coordination. Anti-motility medications should not be used to treat diarrhea caused by inflammatory bowel diseases such as ulcerative colitis or Crohn's, C. difficile colitis (inflammation of the colon caused by the bacterium C. difficile), and intestinal infections by bacteria that invade the intestine (E. coli, Salmonella, Shigella). Their use can lead to more serious inflammation and prolong the infections. Anti-motility medications are not to be used in children younger than two years of age.
Antispasmodics: The most widely studied drugs for the treatment of abdominal pain are a group of drugs called antispasmodics, which cause muscle relaxation. Muscle relaxation in the abdominal area helps decrease spasms and cramping. Commonly used smooth muscle relaxants are hyoscyamine (Levsin® and Levsinex®), dicyclomine (Bentyl®), and methscopolamine (Pamine®). Antispasmodic drugs are also available in combination with sedating or tranquilizing drugs, such as chlordiazepoxide and clidinium (Librax®) and mixed salts of belladonna alkaloids and phenobarbital (Donnatal®). Antispasmodics are generally taken 30 - 45 minutes before meals to relieve cramping that follows eating. Side effects may include drowsiness, dry mouth, blurred vision, and inability to urinate.
For severe diarrhea, opiates (narcotics, normally used for pain control) may be used, including morphine or codeine. Opiates are habit forming and should be used with care. They may cause drowsiness.
Antidepressant drugs: Patients with IBS are frequently found to be suffering from depression, but it is unclear if the depression is the cause of IBS, the result of IBS, or unrelated to IBS. Several trials have shown that antidepressants are effective in IBS in relieving abdominal pain and, perhaps, diarrhea. These drugs have been shown to alter the activity of nerves and to have analgesic (pain-relieving) effects as well, which may be why they work in some individuals with IBS. The most commonly used antidepressant drugs in IBS are the tricyclic antidepressants (TCA), amitriptyline (Elavil®) and desipramine (Norpramine®). Side effects include constipation, dry mouth, blurred vision, dizziness, inability to urinate, and sedation. Although studies are encouraging, it is not yet clear whether the newer class of antidepressants, the serotonin-reuptake inhibitors, such as fluoxetine (Prozac®), sertraline (Zoloft®), and paroxetine (Paxil®) are effective.
Alosetron (Lotronex®) is used to treat diarrhea and abdominal discomfort that occurs in women with severe IBS that does not respond to other simpler treatments. Alosetron is a serotonin antagonist (blocks the effects of serotonin). It was approved by the U.S. Food and Drug Administration (FDA) in February 2000, but was withdrawn from the market in November, 2000, because of serious, life-threatening, gastrointestinal side effects including severe intestinal inflammation (in 10% of patients). In June 2002, it was approved again by the FDA for marketing but in a restricted manner as part of a drug company-sponsored program for managing the risks associated with treatment. Use of alosetron is allowed only among women with severe, diarrhea-predominant IBS who have failed to respond to conventional treatment.
Cilansetron (Calmactin®) is another serotonin antagonist for IBS diarrhea in clinical trials.
Recent studies have suggested that rifaximin (Xifaxan®) a non-absorbable antibiotic, may be used as an effective treatment for abdominal bloating and flatulence, giving more credibility to the potential role of bacterial overgrowth in some patients with IBS.
Psychotherapy: Psychotherapy includes cognitive-behavioral therapy (based on modifying everyday thoughts and behaviors, with the aim of positively influencing emotions), and psychodynamic or interpersonal psychotherapy (working with an individual and their relationships with others), and relaxation/stress management. Psychotherapy has been used in patients with IBS who are psychologically distressed to the point that their quality of life is being impaired. A few studies have shown that psychological treatments may reduce anxiety and other psychological symptoms in addition to reducing IBS symptoms, particularly pain and diarrhea.
Other treatments: Using a bench to elevate the feet increases the abdominal pressure on the colon and may help evacuate the chair in constipation. Toilet paper may irritate the anus, so using baby wipes may be better.
Over-the-counter (OTC) creams or ointments containing hydrocortisone (Cortaid®, Preparation H®), applied sparingly to the affected area may reduce inflammation and itching. A protective ointment that contains zinc oxide (Desitin®, Balmex®) also may help. If the symptoms are worse at night, an antihistamine (such as diphenhydramine or Benadryl®) may be prescribed to reduce itching until topical treatments take effect. With proper treatment, most individuals experience complete relief from anal itching in less than a month.

integrative therapies

Good scientific evidence :
Hypnotherapy: Hypnotherapy involves the power of suggestion during a deep state of relaxation. Early research suggests hypnotherapy may lower the sensory and motor component of the gastro-colonic (intestinal) responses in patients with irritable bowel syndrome (IBS). Better studies are necessary to make a conclusion.
Peppermint: Peppermint (Mentha piperita) oil may improve irritable bowel syndrome (IBS) symptoms such as spasms (cramping) and bloating. Several clinical trials have used enteric-coated peppermint oil in irritable bowel syndrome (IBS) or recurrent abdominal pain in children. Significant improvements in symptoms of IBS were reported. Antispasmodics and serotonin agonists, both commonly used drugs for IBS, did not offer superior improvement rates over peppermint oil. However, more research is needed before a firm conclusion can be made. Caution is advised when taking peppermint supplements, as adverse effects including heartburn, anal burning, and drug interactions are possible. Peppermint oil by mouth may increase blood levels of the drugs felodipine (Plendil®) and simvastatin (Zocor®). Peppermint oil increases levels of cyclosporine in the blood. Peppermint oil used on the skin with 5-fluorouracil (5-FU) may increase the rate of absorption of 5-FU. Peppermint supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor. Do not use peppermint oil in individuals with gallbladder problems.
Probiotics: Probiotics are beneficial bacteria (sometimes referred to as "friendly germs") that help to maintain the health of the intestinal tract and aid in digestion. They also help keep potentially harmful organisms in the gut (harmful bacteria and yeasts) under control. Most probiotics come from food sources, especially cultured milk products. Many varieties and combinations of probiotics have been studied in clinical trials for IBS. Findings frequently report reductions of symptoms including pain, flatulence, bloating and stool frequency. There is some evidence of reduced inflammation. The magnitude of benefit seen in most studies is modest. Not all studies, however, show beneficial effects. More studies are needed to determine the best protocols and the level of benefit that can be expected. Commonly used probiotics for IBS include Lacobacillus acidophilus and Saccharomyces boulardii. Probiotics are generally regarded as safe for human consumption. Probiotics may cause diarrhea in large doses.
Unclear or conflicting scientific evidence :
Acupressure, Shiatsu: The practice of applying finger pressure to specific acupoints throughout the body has been used in China for thousands of years, prior to the use of acupuncture. It is proposed that acupressure may reduce muscle pain and tension, improve blood circulation, release endorphins, and release/eliminate toxins. A small study suggests that acupressure may improve gastrointestinal motility. Additional research is necessary before a firm conclusion can be drawn.
Acupuncture: The practice of acupuncture originated in China 5,000 years ago. Acupuncture involves the use of needles to stimulate body function and bring the body into balance. Although limited evidence suggests benefit of acupuncture in IBS may be possible, more studies are needed.
Acustimulation: Acustimulation involves electrical stimulation at various points on the body (as an alternative to needles in acupuncture) and may be applied to reduce certain symptoms. One small study suggests that acustimulation to points on the wrist and below the knee may help patients with irritable bowel syndrome to reduce symptoms and pain. However, the design was weak, and more studies are needed to determine benefits in IBS.
Agrimony: Anecdotally, agrimony (Agrimonia eupatoria) has been used for many gastrointestinal conditions such as appendicitis, mild diarrhea, stimulation of appetite and ulcers. Human data is lacking for these uses. Caution is advised when taking agrimony supplements, as adverse effects including increased bleeding, lowered blood pressure, and drug interactions are possible. Agrimony supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor.
Bacopa: Bacopa (Bacopa monnieri) is a commonly used herb in the Ayurvedic (Hindu Indian) system of medicine. In one study, a combination of bacopa leaf and bael fruit (Aegle marmelos correa) was used to treat irritable bowel syndrome. The effect of bacopa cannot be isolated in this study, and more high-quality studies using bacopa alone are needed. Caution is advised when taking bacopa supplements, as adverse effects including drug interactions are possible. Bacopa supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor.
Chiropractic: Chiropractic is a health care discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. Although chiropractic is used anecdotally in colic therapy, there is not enough reliable scientific evidence on the effects of chiropractic techniques in the management of infantile colic.
Clay: There is not enough scientific evidence to recommend the medicinal use of clay by mouth in patients with gastrointestinal disorders. Some clay preparations have been found to be similar to Kaolin® and Kaopectate®, which are used to treat gastrointestinal disturbances including diarrhea. However, overall, there are significant potential risks that accompany the use of clay, including intestinal blockage and injury as well as lead poisoning.
Globe artichoke: Globe artichoke (Cynara scolymus) is a species of thistle that has been used for centuries for various gastrointestinal disorders. Several studies have found that globe artichoke supplements may decrease the symptoms associated with IBS, such as gas, bloating, and cramping. However, there is insufficient evidence from these controlled clinical trials to recommend for or against the use of artichoke in relieving the symptoms of irritable bowel syndrome. Caution is advised when taking globe artichoke supplements, as adverse effects including an increase in bleeding and drug interactions are possible. Globe artichoke supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor.
Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. Preliminary study of reflexology in humans with irritable bowel syndrome has not yielded definitive results. Better research is needed in this area.
Relaxation therapy: There are many types of relaxation therapies, all with the goal of decreasing stress and relaxing the body and mind. Early research in humans suggests that relaxation may aid in the prevention and relief of irritable bowel disease symptoms. Large, well-designed trials are needed to confirm these results.
Rhubarb: Rhubarb (Rheum palmatum) has been used by Chinese herbalists for thousands of years for various health conditions, and has been used as a stimulant laxative.
Transcutaneous electrical nerve stimulation (TENS): TENS is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Wires may be connected to acupuncture needles and also inserted into the skin. There is conflicting evidence from clinical trials on the effectiveness of TENS in post-operative ileus (impairment of bowel movement). Well-designed, large studies are needed before a recommendation can be made.
White horehound: White horehound (Marrubium vulgare) has been found to have antispasmodic properties and has been used traditionally to treat intestinal disorders. However, there are few well-designed studies in this area, and little information is available about the effectiveness of white horehound for this use. Caution is advised when taking white horehound supplements, as adverse effects including drug interactions are possible. White horehound supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor.
Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Early evidence suggests that yoga may be beneficial in the management of IBS by helping to regulate colon function through exercise. Further research is needed in this area.
Fair negative scientific evidence :
Traditional Chinese medicine (TCM): TCM has been studied for diarrhea predominant irritable bowel syndrome but herbal formulations used in available studies have not led to global symptom improvement. Further studies may be necessary to characterize the role of TCM in the management of IBS.
Turmeric: Preliminary clinical study investigated the effects of Curcuma xanthorriza on IBS and found that treatment did not show any therapeutic benefit over placebo. More studies are needed to verify these findings.
Strong negative scientific evidence :
Trigger point therapy: Clinical study demonstrated that trigger point therapy might be effective for treatment of abdominal pain. The results of this study warrant future investigations with more stringent study guidelines.
Traditional or theoretical uses lacking sufficient evidence :
Chamomile: Chamomile (Matricaria recutita) has been used medicinally for thousands of years, and is widely used in Europe. Chamomile is used traditionally for numerous gastrointestinal conditions, including irritable bowel syndrome, diverticulitis, intestinal cramps, stomach cramps, and intestinal spasms. However, reliable human research is currently unavailable in any of these areas. Additional study is needed. Caution is advised when taking chamomile supplements, as adverse effects including drowsiness and drug interactions are possible. Chamomile supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor.
Fennel: For centuries, fennel (Foeniculum vulgare) has been used as traditional herbal medicine in Europe and China. An emulsion (oil and water mixture) of fennel seed oil and an herbal tea containing fennel has reduced colic in two randomized, double-blind, placebo-controlled trials. Additional studies are warranted in order to more conclusively confirm its benefits. Caution is advised when taking fennel supplements, as adverse effects, including an increase in bleeding and drug interactions, are possible. Fennel supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor.
Slippery elm: Slippery elm (Ulmus fulva) is traditionally used to treat inflammatory conditions of the digestive tract such as gastritis, peptic ulcer disease, or enteritis. It may be taken alone or in combination with other herbs. While anecdotally reported to be effective for irritable bowel syndrome, supporting evidence is largely based upon traditional evidence and the fact that the mucilages (mucous-like components) contained in the herb appear to possess soothing properties. Scientific evidence is necessary in this area before a clear conclusion can be drawn. Caution is advised when taking slippery elm supplements, as adverse effects including drug interactions are possible. Slippery elm supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor.

prevention

Nutritional and lifestyle choices may help prevent or relieve symptoms of IBS.
Diet: Cutting out alcohol, caffeine, dairy products, refined sugars, and fatty foods may significantly reduce symptoms. Many individuals may have food sensitivities (allergies) that aggravate IBS or trigger episodes. Some common food triggers include dairy products, corn, peanuts, citrus, soy, eggs, fish, rye, barley, tomatoes, and wheat products (including gluten). Food allergy testing may be suggested by a doctor. A low-fat diet may also help relieve abdominal pain following meals.
Fiber: Eating sufficient amounts of fiber may alleviate constipation, improve diarrhea, and prevent muscle spasms. Soluble and insoluble fiber can be found in foods such as whole-grain cereals and breads, fruits, vegetables, and legumes (dried peas and beans). Fiber should be introduced gradually into the diet.
Exercise: Regular exercise (especially abdominal muscle exercises) and brisk walking are recommended according to the age and physical condition of the individual. Regular exercise may help reduce stress, decrease constipation, and improve physical performance.
Stress reduction: Stress may be decreased through relaxation and meditation methods.