IBS - Triggers and treatments to ease your symptoms

Everyone with IBS has a different experience, so symptoms and their solutions need to be tailored to you. But most people follow the same pattern each time it flares up, so it’s best to think about which symptom predominates your experience. As a rough guide, bowel habit will be altered more than a quarter of the time to meet the criteria for diagnosis.

Diarrhoea-predominant IBS

Some experience loose or runny stool, an increased frequency and an urgency to go. Occasionally leakage may be a problem. There’s a typical “morning rush” sensation, where people have an urge to pass stool several times, once they’ve woken or around breakfast time. They may feel like the bowels aren’t completely emptied.

Abdominal pain-predominant IBS

People often experience stomach cramps and constant or gnawing pain, and they often say this improves after a bowel movement.

Bloating and gas

Many complain of lots of gas in the tummy, causing bloating and flatulence, and typically this is relieved after they've opened their bowels. It’s more common in women, and some experience a tummy that feels hard, tense or distended.

Constipation-predominant IBS

Some IBS sufferers experience constipation, which results in difficulty passing hard stool or opening their bowels much less frequently. Some feel like they haven’t completely emptied the bowels.

Mixed stool pattern IBS

Mixed stool pattern IBS isn't common, but some find they switch between diarrhoea and constipation, which makes treatment a bit more tricky.

Other symptoms

Nausea, reflux symptoms and feeling full early in a meal all fit with the syndrome. Eating may worsen symptoms, and some pass mucus, a clear or white gel-like substance, with a bowel motion.

Non-gastric symptoms include headaches, backache, fatigue and lack of energy, urinary symptoms and pain having sex (dyspareunia).

When should I see my doctor?

IBS can mimic other conditions, so we need to make sure you have no red flags that alert us as doctors that something more serious could be causing your symptoms. Red flags include:

• unexplained weight loss
• bleeding from the back passage
• a change in bowel habit (looser or more frequent stools) over the age of 60, for more than 6 weeks
• persistent or frequent bloating in females, especially if aged over 50
• an abdominal or rectal mass
• a family history of bowel cancer, ovarian cancer, coeliac disease or inflammatory bowel diseases like ulcerative colitis or Crohn’s disease

If you have any red flag symptoms, book an urgent appointment with your doctor. If they think that cancer is a possibility – notably bowel or ovarian cancer – they will refer you urgently to a specialist team for investigations like blood tests, a colonoscopy (a small camera tube passed via your back passage) or a scan.

IBS used to be considered a diagnosis of exclusion – doctors could diagnose it if tests for other gut conditions were negative – but this is now considered outdated, and your doctor will ask in detail about symptoms and duration and diagnose if these fit the criteria. So, if your bowel symptoms have persisted for several months, and diet and lifestyle changes have not resolved them, do book an appointment with your doctor.

They will ask about your symptoms, what you’ve tried so far, and your family history. They will examine your abdomen, and they may suggest an examination of the back passage. They may order blood tests, stool tests and possibly a colonoscopy to rule out other causes of your symptoms.

If history, examination or tests show abnormalities that point to gut conditions like Crohn’s disease, ulcerative colitis or coeliac disease, they will likely refer you to the gastrointestinal team for specialist input.

If your doctor determines that IBS is the most likely diagnosis, they may prescribe relevant medications according to your symptoms, and they may refer you to a dietician for a specialist diet.

IBS can present with a range of symptoms, so treatments are tailored to provide relief for specific symptoms, and a multi-faceted approach is sometimes needed to deal with multiple causes for the same symptoms.

Diarrhoea in IBS is believed to be related to disrupted nerve connections between the gut and the brain, causing uncoordinated bowel contractions. When these contractions speed up, they cause diarrhoea, and when they slow down, you get constipation. This may be one reason why stress plays a significant role in diarrhoea-predominant IBS.

Some treatments aim to slow down overactive contractions in the bowel. Anti-diarrhoeal agents such as Imodium (contains loperamide 2mg work to reduce gastric motility and reduce the frequency of passing motions.

Other agents may also be useful to bind and thicken up the consistency of stool to make them less watery, such as products containing kaolin mixture or bismuth subsalicylate, like Pepto-Bismol.

Diarrhoea reduces the absorption of electrolytes and minerals, and this can cause fluid loss, leading to dehydration, both of which can be countered using a hydration electrolyte salt drink mixture such as O.R.S or Dioralyte.

Abdominal cramps can be very painful for IBS sufferers, and they often get diarrhoea alongside an urgency to open the bowels. There are anti-spasmodic medicines such as those containing alverine or mebeverine, such as Colofac IBS.

Peppermint oil is a traditional remedy for relaxing the smooth muscle in the bowel and the cramping it can cause, and is available as capsules.

Bloating, trapped wind and flatulence: Peppermint oil’s ability to relax smooth muscles can also help to reduce trapped wind. Other products such as Wind-Eze (contains simeticone) can help to relieve flatulence (excess gas), trapped wind and bloating.

Constipation: There’s a choice of laxatives available and these work in different ways. The most suitable laxatives are osmotic laxatives or stool softeners. Osmotic laxatives such as macrogol-based sachets like Movicol, work by drawing more water into the large bowel, thereby making stools softer, more hydrated and easier to pass. They get to work within 12 to 48 hours.

Stool softeners like Dulco-Ease (contains docusate sodium) work by making stools more permeable to water and fats by affecting the surface tension of any hard, dry stools, making them softer and easier to pass. They have a mild stimulant activity, too, working on the nerves in the colon and rectum to contract, thereby helping to move stools out of the large bowel.

Widely used for other causes but less helpful for IBS are stimulant laxatives like Senokot (contains senna) or Dulcolax (containing bisacodyl). These work by stimulating movement of the stool down the intestines, by speeding up a process called peristalsis. Buy this action can cause abdominal cramps, which many with IBS find intolerable.

A laxative that adds bulk to stool can be helpful for both constipation or diarrhoea, as stool is harder to pass when it gets hard and compacted. Those containing soluble fibre are a good place to start, like psyllium husk or isphagula husk, found in Fybogel sachets.

Finally, if constipation has been persistent for a few days, a rectal product may help like glycerol or glycerin suppositories, or an enema.

Dietary supplements can help to support a good bacterial balance in the gut. Prebiotics and probiotics may improve some IBS symptoms, although possibly not bloating. Supplements containing lactase enzymes, like Lactaid or Milkaid, also help to improve digestion, and they may reduce bloating. Products containing organic mineral polymethylsiloxane polyhydrate (PMSPH), such as Enterosgel, can help bind toxins and allergens in the gut, and help eliminate them from the body, reducing symptoms of constipation, diarrhoea, cramping or bloating.

The cause of IBS is still largely unknown and it’s likely to be multiple factors at play. Research suggests that something disrupts the normal functioning of the bowel, and it becomes over-sensitive to very mild stimulation, causing a variety of reactions.

Food intolerance best describes the sensitivity of many IBS sufferers to certain foods, resulting in abdominal spasms and a gassy gut. This is different to a food allergy, which is not thought to be a factor in IBS. Your gut may not be upset by all of these foods, but The IBS Network, a national UK charity, lists common culprits as:

• wheat
• milk, butter and cream
• fruits like plums, apricots, peaches, mangos, apples and pears
• onions, leeks and garlic
• beetroot
• brassicae like cauliflower, cabbage and sprouts
• pulses like peas, beans and lentils
• coffee
• chocolate
• hot spices like chilli
• red meat
• fatty ready meals and sauces
• fried food

For women IBS is twice as common, and it’s more common in child-bearing age than in the post-menopausal phase of life. Many report symptoms are worse around menstruation.

Anxiety and depression are more common in those with IBS, and in turn, the chronic and disabling symptoms and social isolation of IBS seem to push people into anxiety and depression.

Stress plays a significant factor in IBS, and many regard their gut as the barometer of their emotional well-being. If people haven’t been taking time to relax and recuperate, eat and sleep well, IBS can flare up. It also comes at times of deadlines, pressure or conflict, in both the home and workplace.

Post-bacterial gastroenteritis kicks off IBS symptoms in up to 1 in 3 people. However, bacterial gut infections are much less common than viruses in causing gastroenteritis or food poisoning.

IBS is a complex condition in which there is no single solution to improve symptoms and no cure. It needs a multi-pronged approach, and addressing lifestyle and dietary factors is key, alongside psychological triggers and therapies, and then, if needed, medications to ease symptoms.

Finding the right diet for IBS

Aim to keep a food and symptom diary, so you can see patterns of which foods upset you, and then avoid them. Some foods may make abdominal pain, bloating and diarrhoea worse, but some of them – plums, prunes and fibre – can improve constipation, if that’s a problem. It’s likely that you’re not sensitive to all on the list, so it’s worth investing time in finding what works for you. According to the British Dietetic Association, you should make one change at a time to see if it helps and give your bowel time to adjust to any changes.

For those with diarrhoea-predominant IBS, sorbitol should be avoided – this is a sugar carbohydrate found naturally in plums, apricots, peaches, apples and berries, and also in processed sugar-free foods and drinks. Mannitol and xylitol are sweeteners found in similar sugar-free products, and these may also worsen diarrhoea.

If flatulence and bloating are an issue, boost your diet with a tablespoon a day of linseeds and oats, and avoid gas-forming foods like beans, pulses, the brassicae like sprouts and cauliflower, and sugar-free mints and chewing gum.

Soluble fibre is a good option to soften stools for those with constipation-predominant IBS (and by the same token, should be avoided in those with diarrhoea). This is found in fruits without their skins on and vegetables. Start adding this gradually, as a sudden increase could worsen symptoms.

Insoluble fibres like wheat bran or the outer shell of seeds, grains, fruit and vegetables, should be avoided in all patients with IBS. Foods high in resistant starch, like unripe bananas, pulses and wholegrains, are best limited to three portions a day, as they’re difficult for the gut to digest.

Rich fatty or fried foods are also tough on the gut, so avoid temptations like chips, crisps, ready meals, fast foods like burgers and sausages, chocolate, cakes and biscuits.

Following a low FODMAP diet

Foods high in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs), ferment easily and are thought to increase IBS symptoms by encouraging water out of the gut in a process called osmosis. They are found in apples, artificial sweeteners and lactose-containing foods.

This is a strict diet to follow, and commitment and consistency is key. It’s recommended to only be undertaken with the guidance of a dietician and only if your own modifications to your diet haven’t worked and symptoms are adding a significant burden to daily functioning. The good news is that scientific research backs this approach, with symptoms improved by up to 86%.

Adding probiotics

Prebiotics and probiotics may have a role to play, as research has found the balance of bacteria – the gut microbiome – differs in IBS sufferers compared to that of healthy volunteers. A comprehensive review of published papers suggests that a combination of probiotics can help for abdominal pain or a combination of IBS symptoms, but they didn’t particularly help bloating. You could try a probiotic drink or fermented dairy products like live yoghurt and kefir for at least 4 weeks before determining if it’s helped or not.

Keeping a routine

Studies have found that those with IBS tend to have erratic sleep, erratic eating habits and erratic moods. It’s difficult to decipher which is causing which, but it’s worth thinking about how you can break the negative cycle to bring your body, mind and gut back into balance. Start with a routine, regular bedtime and waking up time that you stick to on weekdays and weekends. Add in three regular meals and avoid long gaps in eating or meals late at night. Keep a diary of symptoms and assess whether things have improved for your IBS. It’s going to be the little things that add up to a big difference.

Reducing alcohol and keeping hydrated

Limit alcohol to no more than 2 units per day, and have at least 2 alcohol-free days per week. Reduce fizzy drinks that increase stomach gas, and restrict your tea and coffee to no more than 3 cups (2 mugfuls) per day, especially with diarrhoea. Make sure you keep hydrated for a healthy gut, with about 8 glasses of water (1.5 litres) a day. This will help soften stool in constipation and replace lost fluids in diarrhoea.

Taking herbal remedies

Some find ginger can be effective at relieving all sorts of gut symptoms, from pain to nausea. Some say it goes further, mopping up harmful bacteria, dampening down inflammation and reducing diarrhoea. Others advocate peppermint and chamomile as “gut-settlers”. St John’s wort, flaxseed oil and fish oil have also been marketed at IBS sufferers, but only peppermint has scientific evidence to back it, with peppermint oil capsules relieving IBS-related cramps and bloating.

Reducing stress

Finding ways to unwind and rest are individual to each person, but the important thing is making the time to relax each day, with whatever works for you. Mindfulness, meditation and yoga are enjoyed by many, and other relaxing activities include reading, listening to music or chatting with friends or family. These techniques help quieten nervous system activity, relax muscles and rest the mind.

CBT (cognitive behavioural therapy) is a more formal structure to break negative thought patterns and formulate more positive and productive thought patterns and coping strategies. Evidence shows improvement in patients with moderate to severe IBS over a course of CBT treatment, above any positive effects with medication.

It can be useful to pre-empt events that will be stressful, giving yourself a chance to set in place coping strategies, or ways to minimise impact, or even avoiding certain events or situations altogether.

Addressing anxiety and depression

Many people consult their doctor for anxiety and depression above gut symptoms, and it’s important to seek help if you recognise that you are suffering. Your doctor can discuss avenues to help, such as antidepressants, and talking therapies or it may help just to recognise and validate your feelings, and feel supported. Hopefully this will encourage your gut to respond positively too.

Taking exercise

Physical activity has been shown in studies to improve IBS symptoms. It can also burn off stress hormones and boost feel-good endorphins that have a positive effect on your mood and any anxiety. Current guidance is to aim for 150 minutes of physical activity per week, which is 5 sessions of half an hour, where you get out of breath. Swimming, yoga and walking are good places to start, building up gradually from a couple of sessions a week.

Applying heat pads

A hot compress such as a hot water bottle wrapped in a towel may help ease abdominal cramps and pain. A warm cup of non-caffeinated tea, like chamomile, may provide a similar relief from the inside.

Using acupuncture and other complementary therapies

Acupuncture, the ancient art of applying tiny needles to certain body points, has long been adopted by western medicine to relieve pain and it can help with psychological imbalance, too. With IBS, an extensive review of scientific papers showed evidence was not robust enough to support its widescale use, but some may have a positive experience.

A biofeedback machine has been used by some as a mind-body technique to learn to control certain symptoms, such as response to painful stimuli. It may have a role if control of the bowels is a problem, but more data is needed.