Irritable Bowel Syndrome Frequently Asked Questions
IBS Foundation
What this FAQ covers:
This FAQ deals primarily with questions, problems, and concerns
associated with Irritable Bowel Syndrome (IBS).
What this FAQ does NOT cover:
This FAQ is about IBS and IBS only. It does not answer questions
related to other diseases of the colon (IBDs such as Crohns and
Ulcerative Colitis). It does not answer any questions related to food
allergies, including lactose intolerance and wheat/gluten intolerance
(Celiac disease).
Questions Covered in This FAQ
PART 1: Background
1a: What is Irritable Bowel Syndrome?
1b: What is the prevalence of IBS?
1c: What factors contribute to the onset of IBS?
1d: How long does IBS last?
1e: What effect does IBS have on one's lifestyle?
1f: Are my symptoms just "all in my head" or psychosomatic?
1g: What factors contribute to health care utilization?
PART 2: Symptoms
2a: What are the symptoms of IBS?
2b: How severe are these symptoms?
2c: Does everybody get the same symptoms?
PART 3: Medical Facts
3a: What causes IBS?
3b: What is the role of psychological and/or social factors in IBS?
3c: Is IBS life-threatening?
3d: Will IBS lead to colon or rectal cancer?
3e: Will IBS lead to IBD (Crohn's, ulcerative colitis)?
3f: Will my IBS eventually go away, or will I have it for the rest of
my life?
PART 4: Diagnosis
4a: How do I know for sure if I have IBS?
4b: Is IBS a legitimate diagnosis? Should I seek a second opinion?
PART 5: Treatment
5a: What are the treatments for IBS?
5b: What is the role of fiber therapy in IBS?
5c: Is it necessary to make drastic dietary changes?
5d: What conventional prescription medications are used to treat IBS?
5e: Are there any natural or herbal remedies for treating IBS?
5f: What are some of the psychologic treatments available?
5g: How can keeping a record of my symptoms and triggers be helpful?
5h: With all these different treatments, how do I know which will work
for me?
PART 6: Related Maladies
6a: How does IBS differ from Crohn's disease or ulcerative colitis?
6b: How does IBS differ from gluten enteropathy/celiac disease?
6c: How does IBS relate to other broad-spectrum symdromes, such as
Fibromylagia, Chronic Fatigue Syndrome (CFS), Myofascial Pain Syndrome
(MPS), Multiple Chemical Sensitivity Syndrome (MCSS), and others?
--------------------------------------------------------------------------------
Part 1: BackGround
1a: What is Irritable Bowel Syndrome?
Irritable Bowel Syndrome (IBS) is part of a spectrum of diseases known
as Functional Gastrointestinal Disorders which include diseases such as
noncardiac chest pain, nonulcer dyspepsia, and chronic constipation or
diarrhea. These diseases are all characterized by chronic or recurrent
gastrointestinal symptoms for which no structural or biochemical cause
can be found.
1b: What is the prevalence of IBS?
IBS affects between 25 and 55 million people in the United States and
results in 2.5 to 3.5 million yearly visits to physicians.
Approximately 20 to 40 percent of all visits to gastroenterologists are
due to IBS symptoms.
IBS symptoms affects men and women of all ages and of all races. The
prevalence of IBS in the general population of Western countries varies
from 6 to 22%. IBS affects 14-24% of women and 5-19% of men. The
prevalence is similar in Caucasians and African Americans, but appears
to be lower in Hispanics. Although several studies have reported a
lower prevalence of IBS among older people, the present studies do not
allow to definitely conclude whether or not an age disparity exists in
IBS. In non-Western countries such as Japan, China, India, and Africa,
IBS also appears to be very common.
1c: What factors contribute to the onset of IBS?
Many patients with IBS report that their symptoms began during periods
of major life stressors such as a divorce, death of a loved one, or
school exams. Many patients also report the onset of symptoms during or
shortly after recovering from a gastrointestinal infection or abdominal
surgeries. Symptoms of IBS have also been known to appear upon the
ingestion of a certain food to which the individual is sensitive. The
type of food which causes symptoms varies with the individual. (There
is no one definite universal food trigger for IBS.) Similarly, a flare
of symptoms in a patient with long-standing IBS may be triggered by all
of the symptoms listed above, or for no apparent reason.
1d: How long does IBS last?
Almost everything about IBS is totally dependent on the individual
patient. For some, IBS may arise during times of stress or crisis, and
then subside once the stressful event has passed. For others, IBS
strikes seemingly randomly and without warning and never completely
goes away. Still others will get IBS for a while, then it will go away
for a long period of time, then come back. The duration of IBS is
different for everybody.
1e: What effect does IBS have on one's lifestyle?
IBS can be nothing more than a mild annoyance, completely debilitating,
or anywhere in between. Again, it depends on the person and how he or
she reacts to it and treats it.
1f: Are my symptoms just "all in my head" or psychosomatic?
Several studies have shown that psychological disturbances are more
common in IBS patients than patients with other gastrointestinal
diagnoses and healthy controls. However, people with IBS who do not
seek medical care have a similar psychological profile as the general
population. Therefore, IBS is not caused by psychological problems, but
a person's outcome and illness behavior is affected by their
psychological make-up. Different people respond differently to their
IBS and IBS symptoms, depending on a number of psychosocial factors.
1g: What factors contribute to health care utilization?
Although IBS is very common in the general population, only a minority
of people ever seek medical care for their symptoms. Cultural factors
may affect health care utilization. For example, as opposed to the U.S.
and Europe, in India male patients are more likely to seek medical care
than women. The presence and severity of abdominal pain, and the number
of "Manning Criteria" correlate with health care consultation. Finally,
psychological disturbance (e.g. anxiety or depression) also appears to
influence health care utilization.
Part 2: Symptoms
2a: What are the symptoms of IBS?
The most common symptoms that IBS patients complain of are: frequent
diarrhea, abdominal pain (usually in the lower abdomen area), gas,
bloating, diarrhea alternating with constipation, mucus in the stool,
bowel urgency or incontinence, and a feeling of incomplete evacuation
after a bowel movement. Since IBS is considered mainly to be a disorder
of the lower gastrointestinal tract, the symptoms tend to remain
located below the navel. However, several symptoms of the upper
gastrointestinal tract have also been shown to be common in those with
IBS, including: difficultly swallowing, a sensation of a lump in the
throat or a closing of the throat, heartburn or acid indigestion,
nausea (with or without vomiting), and chest pain.
A number of expert investigators during a meeting in Rome, Italy,
developed a consensus definition and criteria for IBS, known as the
"Rome" criteria.
At least 3 months of continuous or recurrent symptoms of:
1. Abdominal pain or discomfort, e.g.:
a. Relieved with defecation and/or
b. Associated with a change in frequency of stool; and/or
c. Associated with a change in consistency of stool; and
2. Two or more of the following, at least on one-fourth of occasions or
days:
a. Altered stool frequency
b. Altered stool form (e.g. watery/loose stools or hard stools)
c. Altered stool passage (e.g. sensations of incomplete evacuation
after bowel movements, straining, or urgency)
d. Passage of mucus and/or
e. Bloating or feeling of abdominal distention.
In addition, a number of other non-colonic symptoms may be present in
patients with IBS. These include: nausea, feeling full after eating
only a small meal, sensation of urinary urgency, incomplete emptying
after urinating, fatigue, and pain during sexual intercourse.
2b: How severe are these symptoms?
As with just about everything associated with IBS, the severity of
symptoms vary greatly from person to person, ranging from barely
noticeable to completely debilitating, and can vary for the same person
over periods of time.
2c: Does everybody get the same symptoms?
No. Although the symptoms listed in 2a are the most common, each
person's experience and presentation will be slightly different. The
severity and frequency of abdominal pain or discomfort will also vary
from an intermittent abdominal discomfort during stress life events to
severe continuous abdominal pain. Likewise, bowel habits can vary.
Diarrhea, constipation, or alternating between the two may be the
predominant bowel pattern.
Part 3: Medical Facts
3a: What causes IBS?
Recent physiological and psychosocial data have emerged to improve our
understanding of IBS. A biopsychosocial model of IBS involving
physiological, emotional, cognitive, and behavioral factors is now felt
to be involved in symptom generation. Physiological factors implicated
in the etiology of IBS symptoms include: visceral hypersensitivity to
spontaneous contractions and to balloon distention of the bowel,
autonomic dysfunction including exaggerated colonic motility response
to stress and alterations in fluid and electrolyte handling by the
bowel, and an alteration in the gastrocolonic response. However,
alterations in these physiological parameters are generally found in
only a subset of patients and frequently do not correlate with bowel
symptoms. Behavioral factors such as stressful life events are reported
by up to 60% of IBS patients to be associated with the first onset of
the disease or with its exacerbation. Laboratory stressors have also
been shown to affect gastrointestinal motility and visceral perception.
Cognitive factors such as inappropriate coping styles and illness
behavior are common in IBS patients and influence healthcare
utilization and clinical outcomes. Emotional and psychiatric factors,
such as anxiety and depression, are present in 40 to 60% of IBS
patients seeking healthcare with increased prevalence in those patients
presenting to tertiary referral centers. IBS patients who have sought
medical care are more likely to have abnormal psychological profiles,
abnormal illness behaviors, and psychiatric diagnoses than patients
with other medical illnesses.
3b: What is the role of psychological and/or social factors in IBS?
Psychiatric diagnoses are present in 42-62% of IBS patients who have
sought medical consultation. In comparison, psychiatric diagnoses are
present in around 20% of patients with other gastrointestinal
diagnoses. The majority of these psychiatric diagnoses are cases of
anxiety and depression. Other common diagnoses include somatization
disorder and hypochondriasis.
Stress can affect the functioning of the gastrointestinal tract of all
people, and particularly those with IBS. Several studies have shown
that IBS patients are more likely to report that stress changes their
stool pattern and leads to abdominal pain than people without bowel
problems. In one study 65% of IBS patients reported a severe stressful
life event prior to developing IBS. The kinds of psychological
stressors often reported by patients with IBS vary considerably, but
include: loss of a parent or spouse through death, divorce, or
separation, and sometimes is accompanied by feelings of unresolved
grief, and also significant life changes which demand many social and
personal adjustments such as moving to a new job or a new city.
3c: Is IBS life-threatening?
No, however, IBS is serious. Patients with IBS have a higher rate of
hospitalizations, work absenteeism, feelings of poor quality of life,
and abdominal surgeries than healthy controls and patients with other
gastrointestinal illnesses. In the general population, people with IBS
symptoms missed more than 3 times as many work days than did people
without bowel symptoms.
3d: Will IBS lead to colon or rectal cancer?
No. IBS has not been linked to any type of cancer. In fact, those with
IBS are more likely to be better aware of bowel health and cancer
prevention.
3e: Does IBS lead to IBD (Crohn's, ulcerative colitis)?
No. IBS symptoms are often present in patients with IBD, however, there
is no evidence to suggest that IBS leads to IBD.
3f: Will my IBS eventually go away, or will I have it for the rest of
my life?
IBS symptoms may fluctuate over time. In one study, more than 50% of
IBS patient remained symptomatic 5 years after their initial diagnosis.
Part 4: Diagnosis
4a: How do I know for sure if I have IBS?
Since there is no diagnostic marker associated with IBS, the diagnosis
is based on symptoms and by excluding other diseases which may have a
similar presentation. The extent of the medical evaluation which is
necessary prior to making a diagnosis of IBS will vary depending on the
duration of symptoms, the patient's age and clinical presentation. For
example, recent onset of symptoms in an older patient will require more
extensive testing than a younger person with unchanged symptoms for
many years. Most patients, however, will be given a thorough physical
exam which is performed mainly to rule out other medical illnesses. If
further testing is necessary it will usually be directed toward the
predominant symptom. For example, patients with significant diarrhea
will often undergo stool tests for ova and parasite, and malabsorption
if clinically indicated. On the other hand, patients with constipation
will often undergo tests such as radiopaque marker studies (Sitzmarker)
for colonic functioning and anorectal manometry for pelvic floor
functioning. Most patients over the age of 50 years should have a
flexible sigmoidoscopy. In addition, if occult blood is found by either
rectal exam or on hem-occult testing a colonoscopy may be necessary.
Some commonly performed tests are:
Lower G.I. x-ray (a.k.a. the barium enema)
Small bowel series x-ray
Stool parasite culture
Flexible sigmoidoscopy and/or colonoscopy
It is important to note that the ONLY way to be absolutely certain you
have IBS is through a doctor's diagnosis.
Because there is no diagnostic marker associated with IBS, the
diagnosis is one of exclusion and is based on symptoms. Manning and his
colleagues were the first to report six symptoms which differentiated
IBS from other gastrointestinal diseases. The six 'Manning Criteria'
are as follows: 1) relief of abdominal pain with defecation, 2) looser
stools with the onset of pain, 3) more frequent bowel movements at
onset of pain, 4) abdominal bloating or distention, 5) feelings of
incomplete evacuation, and 6) passage of mucus per rectum. In general
the more 'Manning Criteria' present the more likely it is that a
patient has IBS. While the 'Manning Criteria' are helpful in diagnosing
IBS a consensus meeting in Rome, Italy recently further refined these
criteria (see 2a). In addition, since many other gastrointestinal
diseases can present with similar symptoms, a diagnosis of IBS should
only be made in the right clinical setting.
4b: Is IBS a legitimate diagnosis? Should I seek a second opinion?
Many times a person may think that he or she is being "slighted" by
being given a diagnosis of IBS. Unfortunately, to some doctors, IBS is
not considered a "true" disease, but rather an unimportant minor
condition (when in reality it is hardly all that "minor" to those who
have to deal with it), and therefore may not be given the medical
attention it deserves. Don't despair; there ARE competent doctors out
there who are very good at dealing with IBS cases. A good doctor won't
just tell you that you have IBS and give up on you. He or she should be
willing to go over your questions and concerns, and outline and monitor
a program of treatment for your individual case of IBS. If you suspect
that you have not had a thorough enough examination for other diseases
before the doctor tells you that you have IBS, you should seek a second
opinion.
Part 5: Treatment
5a: What are the treatments for IBS?
The treatment of IBS is based on the severity and the nature of each
person's symptoms and the effect psychosocial factors are having on
their illness behavior. Therefore, each person's therapy is tailored to
their symptoms and may include one or more of the following: lifestyle
changes, pharmacological treatment, and psychological treatment.
Therefore, there really is no one good general treatment for IBS.
Different things work for different people, and really the only way to
know exactly what works for you is by trial-and-error.
5b: What is the role of fiber therapy in IBS?
Fiber is the non-digested part of plant food and adds bulk to the
stools by absorbing water. There are two types of fiber: soluble and
insoluble. Soluble fiber dissolves in water and is found in oat bran,
barley, peas, beans, and citrus fruits. Insoluble fiber are found in
wheat bran and some vegetables. Fiber increases the transit time of the
colon and decrease the pressures within the colon. However, the role of
fiber in the treatment of IBS has not been well established. One study
showed that the response to bran in terms of daily stool weight, bowel
frequency and symptoms was determined more by pre-existing psychometric
variables such as anxiety and depression that the amount or nature of
the bulking agent administered. From our experience, however, patients
with mild constipation predominant IBS may derive some benefit.
Fiber can be added to the diet through the eating of more fiber-rich
foods, or by taking fiber supplements (common brands are Metamucil,
Citrucel, and FiberCon).
5c: Is it necessary to make drastic dietary changes?
In some cases, certain foods can aggravate IBS symptoms and should be
avoided. In particular, lactose in lactose deficient individuals, gas
producing vegetables such as beans and broccoli, fatty foods, and
alcohol. It is should be noted however that while these foods can
exacerbate IBS symptoms, they are not the sole cause of typical IBS
symptoms. To determine which foods trigger which symptoms, one often
needs to start with very basic bland diet and gradually add one new
food each day and record any symptoms associated with that particular
food.
5d: What conventional prescription medications are used to treat IBS?
Conventional medications used in the treatment of IBS include (but are
not limited to):
Anti-spasmodic drugs like Bentyl and Levsin are considered to part of
the class of anti-cholinergic drugs. Anti-cholinergic drugs act by
decreasing the abnormal sensitivity of choninergic (muscarinic M2)
receptors in gut smooth muscle. Significant improvement in abdominal
pain and rectal urgency have been reported in some studies compared to
placebo in short-term trials. However, there is no evidence that
anticholinergic are more efficacious than placebo in the longer term.
Antacids/anti-gas medications (e.g. Simethicone or BEANO). There is no
current data which supports their use in the treatment of IBS symptoms,
though many people report that they aid in the reduction of
embarrassing flatulence and the accompanying lower abdominal pain.
Anti-diarrhea medications/Opioid-receptor agonist (e.g. loperamide or
"immodium"). Loperamide is an mu opioid receptor agonist which does not
cross the blood-brain barrier. It delays small and large bowel transit,
increases the frequency of small bowel phase 3 of the migrating motor
complexes, decreases intestinal secretory activity, and increases
rectal sphincteric muscle tone. Some studies have shown improvement in
diarrhea, rectal urgency, and abdominal pain in IBS.
Prokinetic Agents (e.g. Cisapride or "Propulsid"). A prokinetic drug
which is a 5HT4 agonist and a 5HT3 antagonist. Cisapride has been
reported to help in gastroesophageal reflux disease and dyspepsia
related to delayed gastric emptying. Its efficacy in constipation
predominant IBS, however, has not been well established.
Antidepressants. Tricyclic antidepressants (e.g. amitriptyline,
imipramine, and despramine) or serotonin reuptake inhibitors (e.g.
fluoxetine, sertraline, and paroxetine) are commonly used to treat IBS.
Although commonly used in IBS patients their efficacy is still being
debated. Even though antidepressants are often used in patients with
associated depression, antidepressants appear to improve symptoms
independent of their antidepressive effects. One study using despramine
found this drug to be superior to both atropine (an anticholinergic-
which is a common side-effect of the tricyclic antidepressants) and
placebo in relieving both gastrointestinal symptoms and depression.
Therapeutic effect can take as long as 4-6 weeks and therefore
therapeutic trial should continue at least this long.
Smooth muscle relaxants (e.g. mebeverine (not yet available in the
U.S.) and peppermint oil) have direct relaxant properties on gut smooth
muscle. Placebo controlled trials, however, have not produced any
consensus on their efficacy in IBS.
5e: Are there any natural or herbal remedies for treating IBS?
For many reasons, a large percentage of IBS patients find some relief
in treatments not considered to be part of "conventional" medicine.
Some herbs, such as mint, ginger, chamomile, etc. have been touted as
ways to alleviate gastrointestinal distress. Some patients have also
benefitted from meditation and relaxation therapy, hypnosis,
acupuncture, massage therapy, biofeedback therapy, and the like.
Probably the best natural remedy for IBS is through dietary
modifications and an increase in exercise level. Some people find that
a combination of conventional medication and natural therapies are
ideal for controlling their symptoms.
5f: What are some of the psychological treatments available?
Psychological treatments should be considered symptoms are severe and
are associated with psychological distress. Some of the treatments
which have been used successfully include but are not limited to
cognitive-behavioral therapy, biofeedback therapy, relaxation therapy,
and hypnotherapy.
The core of cognitive-behavioral therapy is the way a person thinks
about their bowel symptoms. For example, thoughts or cognitions such as
"there must be more stool in my rectum to evacuate" can lead to anxiety
or attention which, in turn, can lead to increased IBS symptoms such as
sensations of incomplete evacuation. During cognitive-behavioral
therapy patients learn exercises and strategies to control their
symptoms. Therefore, cognitive-behavioral therapy retrains patients'
cognitions about their illness beliefs as it pertains to their
gastrointestinal symptoms. Several studies have found
cognitive-behavioral therapy to be superior to control treatment.
Biofeedback and relaxation training for IBS is designed to increase the
awareness and control of physical and emotional responses, and is
particularly useful in helping patients control the physiological
consequences of stress. The gastrointestinal system is particularly
sensitive to stress and for many patients stress leads to an
exacerbation of their IBS symptoms. Typical techniques used in
biofeedback and relaxation therapy include breathing and muscle
relaxation, hypnosis or imagery techniques, or a combination of these.
Hypnotherapy uses techniques aimed at increasing suggestibility in
patients. Whorwell and colleagues were the first to report it to be an
effective treatment in IBS. In particular they found that patients who
received hypnotherapy to have more improvement in gastrointestinal
symptoms including abdominal pain and diarrhea in comparison to
placebo.
5g: How can keeping a record of my symptoms and triggers be helpful?
This will help you to identify foods, activities, or stressors that
were previously not considered as triggering factors. By identifying
inciting factors lifestyle modifications can be made to reduce symptom
exacerbation.
5h: With all these different treatments, how do I know which will work
for me?
The only way to know for sure which treatment will work best for you is
to consult your doctor and discuss which method of treatment would be
best for you. Sometimes, one has to try several different treatments
before finding the one that will work the best. The important thing is
not to get discouraged -- there is something that is right for you.
Part 6: Related Maladies
6a: How does IBS differ from Crohn's disease or ulcerative colitis?
The symptoms of IBS differ from the symptoms of Inflammatory Bowel
Disease (IBD) in that there is NO trace of blood in the stool, or
history of fevers or chills. IBS is a functional disporder, meaning
that there is no demonstrable pathology in the colon or small bowel.
6b: How does IBS differ from celiac disease?
People with celiac disease experience marked intestinal symptoms such
as diarrhea and gas upon the consumption of foods that contain gluten,
such as products made from wheat, oats, rye, and barley. Upon the
elimination of gluten-containing foods, the symptoms disappear. Some
people with IBS may experience an aggravation of symptoms with the
consumption of similar wheat-related products and eliminating these
products can help alleviate symptoms.
6c: How does IBS relate to other broad-spectrum symdromes, such as
Fibromylagia, Chronic Fatigue Syndrome (CFS), Myofascial Pain Syndrome
(MPS), Multiple Chemical Sensitivity Syndrome (MCSS), and others?
An interesting point to note here is that many IBS patients also
experience symptoms in non-gastrointestinal systems. Research has been
done on the frequent "overlap" of nonspecific broad-spectrum syndromes
in a large number of patients. Muhammad Yunus, M.D., of the University
of Illinois College of Medicine has studied a group of syndromes as
being part of a larger spectrum of conditions, which he calls
Dysregulation Spectrum Syndrome or DSS.
The following syndromes are considered to be part of DSS, according to
Dr. Yunus:
Fibromylagia Syndrome (FMS)
Chronic Fatigue Syndrome (CFS)
Myofascial Pain Syndrome (MPS)
Irritable Bowel Syndrome (IBS)
Temporomandibular Joint Disorder (TMJ)
Restless Leg Syndrome (RLS)
Periodic Limb Movement (PLMS)
Multiple Chemical Sensitivity Syndrome (MCSS)
Tension Headaches
Irritable Bladder
Primary Dysmenorrhea
Migraine Headaches
Other studies are being conducted on the occurrence of overlapping
syndromes in patients. The exact cause of such a wide range of
syndromes and symptoms in a patient is not yet clear, but it does seem
to be the case that a patient with one particular syndrome on the above
list is much more likely to have symptoms from one or more other
syndromes on the same list.
For more information visit: http://www.ibsfoundation.org