An in-depth guide to irritable bowel syndrome (IBS)

In his latest online article, renowned IBS specialist Dr Syed Shariq Hasan offers his expert insight into the condition. He explains in-depth the symptoms, causes, diagnosis and treatment of this condition.

What is Irritable Bowel Syndrome (IBS)?

Irritable bowel syndrome (IBS) is the most common illness among the ‘Disorders of Gut Brain Interaction (DGBI)’ formerly called ‘Functional gastrointestinal disorders’ [1]. It may be defined as;

‘A condition comprising a group of functional bowel disorders in which abdominal discomfort or pain is associated with defecation or a change in bowel habit with features of disordered defecation’ [2].

Although IBS does not pose serious health risks, it can significantly impact a person's quality of life and productivity.

What are some common symptoms of IBS?

The symptoms of IBS can vary from person to person, and individuals may experience them differently in terms of severity and frequency[3]. It is essential to note that the symptoms may come and go, and they can be triggered or worsened by various factors such as stress, dietary triggers, medical or surgical intervention and hormonal fluctuations.

The most common symptoms include:

• Abdominal pain or discomfort (any site): Often relieved after a bowel movement.
• Bloating: A feeling of fullness or tightness.
• Distension: Increase in the abdominal girth.
• Changes in bowel habits: This can include diarrhoea (IBS-D), constipation (IBS-C), alternating (IBS-A) or unclassified (IBS-U).
• Changes in the form of stool:  Change in the appearance or consistency of stool.
• Flatulence: Excessive wind may accompany other symptoms.
• Mucus in stools: Sometimes, mucus may be present in the stool.
• Incomplete evacuation: Feeling of not emptying properly.

However, there are some red flag symptoms as shown below that should not be ignored and warrant further investigations:

• Nocturnal pain: Pain that awakens or interferes with sleep.
• Diarrhoea: Clinical suspicion of organic disease (stool wt. >250g/day).
• Rectal bleeding: Blood in the stools (visible or occult).
• Weight loss: Sudden unintentional.
• Fever: Without any cause.
• Abnormal physical examination: Any abnormal finding during physical examination.

In addition there may be certain non-colonic symptoms [4] such as:

• Nausea/vomiting
• Difficulty in swallowing
• Early satiety

Some patients may also present with any of the following extra-intestinal symptoms alongside their gut problems:

• Back pain
• Head ache
• Thigh pain
• Poor sleep
• Fatigue/ lethargy
• Bad breath
• Urinary symptoms
• Gynaecological symptoms

What are the Principal Causes of IBS?

The exact cause of IBS remains unclear, but several factors can contribute to its development. Some potential causes and triggers include:

• Motility: It is a disorder of motility and the abnormal contractions can involve any part of the gut which may contract intensely or slowly than usual, leading to changes in bowel movements.
• Visceral sensitivity: The increase sensitivity of the nervous system in the gut leads to increase in the severity abdominal symptoms.
• Inflammation: Previous inflammatory changes or the existence of current low-grade inflammation can lead to the abnormality of bowel function.
• Infections: Gastrointestinal infection may either cause an exacerbation of existing IBS symptoms or could be a trigger for post-infective IBS.
• Antibiotics: Some patients develop IBS symptoms usually after long-term or repeated use of antibiotics.
• Dysbiosis: Dysbiosis is the imbalance between the host and intestinal microbiota caused as a result of gastrointestinal infections, bowel surgeries, dietary irregularity and excessive use of antibiotics.
• Pelvis surgery: IBS may develop as a consequence of abdomino-pelvic or gall bladder surgery.
• Genetic predisposition: IBS has been shown to run in some families thus indicating a genetic predisposition.
• Dietary factors: Food sensitivities and eating disorders result in exacerbation of symptoms and also difficulties in managing the condition.
• Psychological factors: Emotional stress, mental health problems, psychological trauma and a history of any form of abuse can exacerbate the symptoms of IBS.  

How is IBS diagnosed?

Diagnosing IBS involves a process of elimination, as there is no specific test for the condition. Doctors rely on the patient's medical history, symptoms, and physical examination to rule out other gastrointestinal disorders. Diagnostic tests, such as stool samples, blood tests, and imaging studies, may be performed to rule out other conditions [5].

What is the treatment of IBS?

The treatment of IBS involves pharmacological and non-pharmacological approaches.

Pharmacologic:

The pharmacological treatment depends on the IBS type and severity.

• Antidiarrheal- For patients with diarrhoea predominant IBS
• Laxatives- For patients with constipation predominant IBS
• Antispasmodics- Smooth muscle relaxants for pain.
• Antidepressants- Help manage bowel symptoms including pain

Non-pharmacologic:

Lifestyle changes:

Certain lifestyle changes can effectively manage IBS symptoms and improve overall well-being. Some helpful strategies include:

• Dietary modifications: Identifying and avoiding trigger foods, eating smaller meals, and maintaining a balanced diet helps to manage the symptoms.
• Stress management: Techniques like meditation, mindfulness, deep breathing exercises, and help reduce stress and its impact on IBS.
• Regular exercise: Engaging in moderate physical activity can promote healthy bowel function and relieve symptoms.
• Adequate hydration: Drinking plenty of water helps keep the digestive system functioning smoothly.
• Probiotics: Some individuals find relief from IBS symptoms by taking probiotics to support gut health.

Brain Gut Behavioural Therapies:

Brain gut behavioural therapies such as, ‘Gut Directed Hypnotherapy’ has been shown through extensive research to be very effective in the management and treatment of IBS [6-15]. The benefits have been shown to last long-term [16].

In addition to this cognitive behavioural therapy, psychotherapy psychodynamic interpersonal psychotherapy, expressive writing etc. are also used to manage symptoms of IBS [17].

Is there a connection between IBS and other gastrointestinal disorders?

IBS may have overlapping symptoms with other gastrointestinal disorders, making the diagnosis more challenging. Conditions such as inflammatory bowel disease (IBD), celiac disease, and gastroesophageal reflux disease (GERD) share some symptoms with IBS. Proper medical evaluation and testing are crucial to differentiate between these disorders and develop an appropriate treatment plan.

If you would like to book a consultation with Dr Syed Shariq Hasan, you can do so today via his Top Doctors profile. 

References:

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2.            Thompson WG, L.G., Drossman DA, Heaton KW, Irvine EJ, Müller-Lissner SA, Functional bowel disorders and functional abdominal pain. Gut, 1999.

3.            Maxton DG, M.J., Whorwell PJ. , Ranking of symptoms by patients with the irritable bowel syndrome. . BMJ. , 1989 Nov 299(6708): p. 1138.  .

4.            Whorwell PJ, M.M., Creed FH, Roberts CT.   , Non-colonic features of irritable bowel syndrome. Gut., 1986 27(1): p. 37-40.

5.            NICE, Irritable bowel syndrome in adults: diagnosis and management National Institute for healthcare and excellence guidelines; , in CG61. 2008.

6.            Miller V, C.H., Morris J, Hasan SS, Archbold S, Whorwell PJ. , Hypnotherapy for irritable bowel syndrome: an audit of one thousand adult patients. . Aliment Pharmacol Ther. , 2015 41(9): p. 844-55.

7.            Vasant D, H.S., Cruickshanks P, Whorwell P. , Gut-focused hypnotherapy for children and adolescents with Irritable Bowel Syndrome. . Frontline Gastroenterology, 2020.

8.            Hasan SS, W.P., Miller V, Morris J, Vasant DH. , Six vs 12 Sessions of Gut-focused Hypnotherapy for Irritable Bowel Syndrome: A Randomized Trial. . Gastroenterology, 2021. 160(7): p. 2605-2607.e3. .

9.            Hasan SS, V.D., The Emerging New Reality of Hypnosis Teletherapy:A Major New Mode of Delivery of Hypnotherapy and Clinical Hypnosis Training. International Journal of Clinical and Experimental Hypnosis (In Press), 2023.

10.          Hasan SS, P.J., Morris J, Whorwell PJ. , Skype hypnotherapy for irritable bowel syndrome: effectiveness and comparison with face to face treatment International Journal of Clinical and Experimental Hypnosis 2019.

11.          Donnet AS, H.S., Whorwell PJ.   , Hypnotherapy for irritable bowel syndrome: patient expectations and perceptions. . Therap Adv Gastroenterol., 2022 p. 15;15:17562848221074208. .

12.          Noble H, H.S., Whorwell PJ, Vasant DH.  , The symptom burden of Irritable Bowel Syndrome in tertiary care during the COVID-19 pandemic. Neurogastroenterology & Motility, 2022: p. 34:e14347.

13.          Noble H, H.S., Simpson V, et al  Patient satisfaction after remotely delivered gut-directed hypnotherapy for irritable bowel syndrome during the COVID-19 era: implications for future practice. BMJ Open Gastroenterology, 2022;: p. 9:e001039. .

14.          Sasegbon, A., Hasan, S.S., Whorwell, P.J. and Vasant, D.H. , Experience and clinical efficacy of gut-directed hypnotherapy in an Asian population with refractory irritable bowel syndrome. JGH Open, 2022. 6: p. 447-453. .

15.          Gonsalkorale WM, W.P., Hypnotherapy in the treatment of irritable bowel syndrome. Eur J Gastroenterol Hepatol., 2005. 17(1): p. 15-20. .

16.          Calvert EL, H.L., Cooper P, Morris J, Whorwell PJ. , Long-term improvement in functional dyspepsia using hypnotherapy. . Gastroenterology. , 2002 123(6): p. 1778-85. .

17.          Guthrie E, W.P., Psychotherapy and hypnotherapy in IBS. , in Irritable Bowel Syndrome: Diagnosis and Treatment, S.R. In: Camilleri M, eds., Editor. 2002, WB Saunders: London. p. 151–9.