IBS - triggers and treatments to ease your symptoms

Everyone with IBS has a different experience, so symptoms will vary, and their treatment needs to be tailored to them. Most people follow the same pattern each time it flares up, so it’s best to think about which symptoms predominate.

Diarrhea-predominant IBS

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

Abdominal pain-predominant IBS

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

Bloating and gas

People may complain of gas in the tummy, causing bloating and flatulence. This is typically relieved after they've passed stool. 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 being able to defecate 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 diarrhea and constipation, which makes treatment a bit trickier.

Other symptoms

Nausea, reflux symptoms and feeling full early in a meal are also symptoms of IBS. Eating may worsen symptoms, and some pass mucus, a clear or white gel-like substance, with a bowel movement.

Non-gastric symptoms include headaches, backache, fatigue and lack of energy, urinary symptoms, and pain with 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 doctors that something more serious could be causing your symptoms. Red flags include:

• unexplained weight loss
• bleeding from the rectum
• a change in bowel habits (looser or more frequent stools) over the age of 60 years, for more than 6 weeks
• persistent or frequent bloating in females, especially if aged over 50 years
• an abdominal or rectal mass
• a family history of bowel cancer, ovarian cancer, celiac 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 blood tests, a colonoscopy (a small camera tube passed via your rectum), or a scan.

IBS if often considered a diagnosis of exclusion – doctors diagnose it if tests for other gastrointestinal conditions are negative. Your doctor will ask for details about symptoms and duration and will be able to diagnose IBS 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.

Your doctor will ask what you’ve tried so far for your symptoms and your family history. They will examine your abdomen and they may suggest an examination of your rectum. 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 other gastrointestinal conditions such as Crohn’s disease, ulcerative colitis, or celiac disease, they will likely refer you for specialist input.

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

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

Some treatments aim to slow down overactive contractions in the bowel. Anti-diarrheal agents such as loperamide (Imodium) work to reduce gastric motility and reduce the frequency of bowel movements.

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

Diarrhea 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 diarrhea along with it.

Peppermint oil is a traditional remedy for relaxing the smooth muscle in the bowel and the cramping it can cause. It is available in capsule form.

Bloating, trapped gas, and flatulence: Peppermint oil’s ability to relax smooth muscle can also help to reduce trapped gas. Other products such as simethicone (Gas-X) can help to relieve flatulence, trapped gas, and bloating.

Constipation: There’s a variety of laxatives available and these work in different ways. The most suitable laxatives are osmotic laxatives or stool softeners. Osmotic laxatives such as polyethylene glycol (Miralax) work by drawing more water into the large bowel, thereby making stools softer, more hydrated, and easier to pass. They work within 12 to 48 hours.

Stool softeners like docusate sodium (Colace) 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 senna (Senokot) or bisacodyl (Dulcolax). These work by stimulating movement of the stool through the intestines, by speeding up a process called peristalsis. But 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 diarrhea, as stool is harder to pass when it gets hard and compacted. Those containing soluble fiber are a good option, like psyllium husk or ispaghula 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 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, diarrhea, cramping, or bloating.

The cause of IBS is still unknown and it’s likely that multiple factors are at play. Research suggests that there is a disruption in 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 than a food allergy, which is not thought to be a factor in IBS. Your gut may not be upset by all the following foods, but some common culprits are:

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

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

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

Stress plays a significant role in IBS, and many people 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 overload, pressure, or conflict, in both the home and workplace.

Post-bacterial gastroenteritis can initiate 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 method to improve symptoms and no cure. It requires a multi-pronged approach, addressing lifestyle and dietary factors, exploring psychological triggers and therapies, and then, if needed, using medications to ease symptoms.

Finding the right diet for IBS

Aim to keep a food and symptom diary so that you can see a pattern of which foods upset you and then avoid them. Some foods may make abdominal pain, bloating, and diarrhea worse, but some of them – plums, prunes, and fiber – can improve constipation, if that’s a problem. It’s likely that you’re not sensitive to all common trigger foods, so it’s worth investing time in finding what works for you. You should make one change in your diet at a time to see if it helps and give your bowels time to adjust to any changes.

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

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, peas, sprouts, and cauliflower, and sugar-free mints and chewing gum.

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

Insoluble fiber 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, peas, 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, prepared 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 drawing 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 causing a significant burden to daily functioning. The good news is that scientific research backs this approach, with symptoms improving 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 studies suggests that a combination of probiotics can help for abdominal pain or a combination of IBS symptoms, but not particularly for bloating. You can try a probiotic drink or fermented dairy products (live yogurt cultures, kefir) for at least 4 weeks before determining if it has 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 IBS symptoms and assess whether things have improved. It may be the little things that add up to a big difference.

Reducing alcohol and keeping hydrated

Limit alcohol to no more than 2 drinks 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 per day, especially with diarrhea. Make sure you stay hydrated with about 8 glasses of water (64 ounces) a day. This will help soften stools in constipation and replace lost fluids in diarrhea.

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, suppressing harmful bacteria, decreasing inflammation and reducing diarrhea. Others advocate for peppermint and chamomile as “gut-settlers”. St. John’s wort, flaxseed oil, and fish oil have also been marketed to 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 reduce nervous system activity, relax muscles, and rest the mind.

Cognitive behavioral therapy (CBT) is a more formal process 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 prepare for events that will be stressful, giving yourself a chance to set in place coping strategies, or ways to minimize impact, or even avoiding certain events or situations altogether.

Addressing anxiety and depression

Many people consult with their doctor for anxiety and depression about their gut symptoms, and it’s important to seek help if you recognize that you are suffering. Your doctor can discuss avenues to help, such as antidepressants, therapy, or it may help just to have your feelings validated. 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 decrease stress hormones and boost feel-good endorphins that have a positive effect on your mood. 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 and increase your heart rate. 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 been adopted by western medicine to relieve pain and psychological imbalance. With IBS, there is not enough evidence 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 for control of 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.