IBS Irritable Bowel Syndrome

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IBS Irritable Bowel Syndrome
Exclusive version for patients of
the Ohio Gastroenterology Group
(low resolution; not for print)
IBS Irritable Bowel Syndrome
A Gastroenterologist Answers Your Questions
Author: William B. Salt II, M.D.
Cover design: Susan Edison, Edison Design
Illustrations: William B. Salt II, M.D
Photography: Susan S. Salt
Copyright © 2014 William B. Salt II, M.D.
PDF version offered exclusively for patients of
the Ohio Gastroenterology Group, Columbus, Ohio
and available as an ebook in online bookstores and as
an Aerbook (link on author’s website):
ISBN: 978-0-9657038-0-2 (Amazon)
ISBN: 978-0-9657038-1-9 (epub for Apple and Kobo)
ISBN: 978-0-9657038-2-6 (Aerbook)
Parkview Publishing, Columbus, Ohio
http://www.IBSAnswersForYou.com
Version 1.02. All rights reserved. Without limiting the rights under copyright
reserved above, no part of this publication may be reproduced, stored in or
introduced into a retrieval system, or transmitted, in any form, or by any
means (electronic, mechanical, photocopying, recording, or otherwise)
without the prior written permission of both the copyright holder and the
publisher of this book. Purchase only authorized editions. This PDF is
provided exclusively for patients of the Ohio Gastroenterology Group.
Sanibel, Florida
This book is not intended as a medical manual. The
information provided is designed to assist you in
making informed decisions regarding your health. It
cannot serve as a substitute for consultation with a
medical doctor. The author and publisher recommend
that you be aware of your condition and seek
competent medical help before you begin any health
program, including making dietary changes and
undertaking an exercise plan.
Contents
Going
deeper
Contents
IBS Irritable Bowel Syndrome
A Gastroenterologist Answers Your Questions
Dedication
Foreword
Introduction
Case Presentations
1) What Is It?
2) What Causes It?
3) How Can I Get Well?
4) IBS-D (Diarrhea)
5) IBS-C (Constipation)
6) Belching and “Gas”
Afterword
About the Author
Updates
Resources
Biopsychosocial Models
“IBS”
Dedicated to You,
the Patient
Nerita Beach
Sanibel, Florida
Finding
your way
DEDICATION
IF YOU HAVE IBS, you'll find the answers to three
questions on a short journey through this book, which
includes 90 photographs and illustrations to help you
see and understand clearly:
What is it?
What causes it?
How can I get well?
AND, IBS is one of over 30 Functional GI Disorders
(FGIDs), including heartburn and upper midabdominal pain that may or may not be related to
eating, which do not improve with powerful acid
reducing medications. Another common FGID is
abdominal bloating (with or without abdominal
enlargement, called distention). Medical tests are usually normal, but these are real
diseases and not “all in the head.” IBS and FGIDs are
all interrelated and commonly occur together. They
share common causes.
SO this book will help if you suffer with any FGID.
AND, most patients with IBS and other FGIDs also
have one or more chronic symptom syndromes, such as
fibromyalgia, fatigue, headaches, back pain, and
interstitial cystitis (painful bladder). As with IBS and
FGIDs, medical tests are usually normal. Nevertheless,
these diseases are real. They are not imagined, and they
are not mental illnesses. They are all interrelated and
share common causes.
SO this book can help.
This book was written for patients of the Ohio
Gastroenterology Group in Columbus, Ohio. but it is
now available in online bookstores. The ebook will be
continually updated.”
Life is difficult.
Foreword
M. Scott Peck, M.D. opens The Road Less Traveled with
this great truth. While beautiful and mysterious, life is
also complicated. We have pain and symptoms,
negative thoughts and memories of old hurts, stress,
and emotional distress. As many as 1 in 5 of us has IBS,
and life has a lot to do with causing it. By contrast, the
disease of IBS makes life even more difficult. It’s a
vicious circle.
Life
IBS
I’m a M.D. gastroenterologist in a group of 36 (Ohio
Gastroenterology Group in Columbus, Ohio) with 35
years of experience caring for patients with IBS while
teaching both medical students and doctors in training.
I’m going to answer your IBS questions in this book.
You’ll become an “IBS expert,” so you can work
effectively with your doctor and other caregivers to get
better. Join me on a short journey through the pages of
this book so you can change your life.
It’s go time!
Introduction
Larry & Buck Salt
Let’s go!
On your IBS journey, you’ll want to keep in mind:
• IBS involves your entire body: GUT (gastrointestinal
tract or GI tract), HEAD (mind/brain), and their
CONNECT (intercommunications).
• You have two brains: one in your HEAD and one in
your GUT.
• Your two brains are in 24/7 communication with one
another through the CONNECT; they are both
independent and interdependent.
• IBS is a disease — it’s a disturbance of how your
body and brains function and work together.
• Medical tests usually do not detect this disturbance,
or “dysfunction.”
• IBS often occurs with other diseases.
• You can get better by changing both brains with your
mind AND by applying the latest medical treatment.
Case Presentations
Nerita Beach
Sanibel, Florida
Beautiful
Mysterious
Complicated
Anne (name changed to protect confidentiality) is a 26
year old woman referred with a diagnosis of IBS. She
began having cramping pain in her lower abdomen
associated with diarrhea in high school. Sometimes she
calls it discomfort rather than pain. The diarrhea is
often loose and even watery brown. She usually feels
better following defecation. Stool urgency can be very
distressing, and she prefers to know the location of the
bathroom wherever she may go. She also suffers from
abdominal bloating and even distention (abdominal
enlargement) that worsens throughout the day.
Symptoms often occur after eating. She has not lost any
weight or noticed blood in the stool. Blood tests and a
colonoscopy by another gastroenterologist showed no
cause for her distressing symptoms, which very much
interfere with the quality of her life. Her physical
examination is normal.
Author comment: Anne describes the typical symptoms of
IBS-D (diarrhea), the first of two main IBS subtypes. Some
patients describe abdominal discomfort rather than pain,
which may or may not be the same symptom, but there is an
association of pain and/or discomfort with bowel
dysfunction. While not part of the current definition of IBS,
abdominal bloating and distention are commonly present,
and symptoms often occur after eating.
John (name changed to protect confidentiality) is a 35
year old man referred with constipation.
He has been suffering with constipation much of his
adult life, but the problem has worsened over the past
several years. He has cramping abdominal pain in the
middle and lower abdomen that become more
troublesome each day he has not had a bowel
movement, and he can sometimes go as long as 14 days
without one. He feels better following defecation. The
stools are hard and often difficult to pass, so it is often
necessary for him to strain hard. He describes
abdominal bloating and distention. He has not lost any
weight or noted rectal bleeding. Blood tests and a
colonoscopy by another gastroenterologist showed no
cause for the distressing symptoms, which very much
interfere with the quality of his life. His physical
examination is normal.
Author comment: John describes the typical symptoms of
IBS-C (constipation), which is the second of two main IBS
subtypes. As with IBS-D, abdominal bloating and distention
are also commonly present. Abdominal pain, discomfort,
bloating, and distention usually progressively worsen each
day without a bowel movement.
Sandy (name changed to protect confidentiality) is a 47
year old woman referred with abdominal pain,
bloating, distention, diarrhea, and heartburn.
She has symptoms consistent with IBS-D (diarrhea),
but she also has heartburn and upper mid-abdominal
pain that may or may not be related to eating, which do
not improve with powerful acid reducing medications.
Her symptoms developed suddenly following an acute
food-related gastroenteritis one year ago. She had not
recalled this until she was asked specifically about how
the symptoms began. She has had blood tests and even
endoscopy and colonoscopy by another
gastroenterologist showing no cause for her distressing
symptoms, which very much interfere with the quality
of her life. Her physical examination is normal.
Author comment: Sandy describes the typical symptoms of
IBS-D along with those of two other related Functional GI
Disorders (FGIDs), functional heartburn and central upper
abdominal (epigastric) pain/dyspepsia, that began suddenly
following foodborne GI infection and have persisted. About
25% of patients with IBS have IBS-PI (post-infectious).
Other FGIDs commonly co-occur with IBS, regardless of
onset. The most common are functional heartburn and
functional epigastric pain/dyspepsia.
Jennie (name changed to protect confidentiality) is a 55
year old woman referred with lower abdominal pain,
diarrhea, and both heartburn and upper abdominal
pain often worsened after meals unresponsive to
treatment with strong acid reducers. Her symptoms are
similar to those that Sandy describes, but she also has
fatigue, widespread pain, headaches, and a painful
bladder. She has seen several specialists and been
diagnosed with fibromyalgia, tension headaches, and
interstitial cystitis. She has had blood tests and both
endoscopy and colonoscopy by another
gastroenterologist showing no cause for her distressing
symptoms. All of her symptoms very much interfere
with the quality of her life. Her physical examination is
normal.
Author comment: Jennie describes the typical symptoms of
IBS-D (diarrhea), which are also associated with other
FGIDs (functional heartburn and epigastric pain/dyspepsia).
She has several other troublesome non-gastrointestinal
symptoms and diagnoses. She did not realize that all of her
symptoms and syndromes may be interrelated and share a
common cause.
Chapter 1
What Is It?
Sanibel, Florida
Text
Text
Collecting
information
Welcome!
You’re going to learn that IBS is a real disease that
involves the whole of you. You’ll understand how
doctors define IBS, know what the symptoms are, learn
about other related diseases, and appreciate how the
diagnosis of IBS is made.
Sections in Chapter 1
What is IBS?
IBS Involves Your Whole Body
The Biopsychosocial Model of IBS
Definition of IBS
GUT Anatomy
Functional GI Disorders (FGIDs)
Functional Symptom Syndromes
Normal Bowel Movement Frequency and Amount
Abdominal Pain and/or Discomfort
Bowel Movement Form (Consistency)
Other Common Symptoms
Abdominal Wall Pain
Diary
Diagnosis
IBS Involves Your Whole Body
See yourself in Figure 1.1.
Figure 1.1
The target is your GUT (GI tract).
The red circle is your HEAD (mind/brain).
The arrows are your CONNECT
(their communication systems).
A good part of your problem resides in your GUT. This
is the basis for GUT therapy, which can reduce spasm
and heightened sensation of the GI tract with dietary
changes, enzyme supplements, and medications.
Triggers within the GUT can be managed, such as bile
salts and bacteria that live there.
But your HEAD plays an equally important role in
causing the pain and symptoms of IBS. This is the basis
for HEAD therapy, which can reduce heightened pain
and symptom sensitivity in the brain, negative
thoughts and effects of old hurts, harmful stress, and
emotional distress.
CONNECT therapy is directed to the communication
systems between your HEAD and GUT.
The Biopsychosocial Model of IBS
Now see that YOU are a complex system (Figure 1.2).
THOUGHT
HEAD
Conscious
Subconscious
Memory
SENSITIVITY
Pain & Symptoms
STRESS
CONNECT
EMOTION
Depression
Anxiety
GUT
YOU
Gender
Nature/Nurture
Figure 1.2
Biopsychosocial Model of IBS in Response to Environment
Doctors explain the disease of IBS (and all diseases)
with a model that integrates the body (bio), the mind/
brain (psycho), and their relationship with the world,
including other people (social). (The spiritual dimension
will not be discussed in this book.) Even though YOU
are complicated, you can and you will understand this
model by the time you’ve finished your journey here.
IBS cannot be understood any other way.
Definition of IBS
The medical diagnosis of IBS is based upon symptoms
of abdominal pain and/or discomfort associated with
bothersome bowel symptoms: diarrhea, constipation,
or both. IBS symptoms are recurrent at least 3 days per
month in the last 3 months. Furthermore, symptoms
must have an onset at least 6 months prior to the
diagnosis of IBS.
The pain and symptoms of IBS are not imagined or “all
in the head.” IBS is not a psychiatric or psychological
diagnosis, even though emotional distress can be
associated and require treatment.
IBS is a functional symptom syndrome. “Functional”
refers to how the body works. When doctors say a
symptom or collection of symptoms (a “syndrome”) is
functional, they mean “dysfunction” or disturbance of
how the body works.
Disease is dysfunction.
Pain and symptoms are the expression.
IBS is a real disease.
Medical tests are usually normal with functional
diseases, such as IBS. Blood tests, x-rays, endoscopies,
and scans usually don’t show the dysfunction.
GUT Anatomy
The GI tract (GUT) extends from the throat to the anus
and is about 30 feet in length (Figure 1.3).
Figure 1.3
The GUT
IBS affects the small intestine (blue arrow) and the colon,
which is shaped like a horseshoe (gray arrow).
Digestion and absorption of nutrients occur in the
small bowel, which is at least 15 feet long. The contents
passed down to the colon are liquid. The colon is about
3 feet long and absorbs fluid, making the waste solid
and storing it as stool. The sigmoid colon is the most
common location of IBS pain, because it is the most
muscular portion.
Functional GI Disorders (FGIDs)
IBS is the most common functional symptom syndrome
of the GUT. Gastroenterologists call these symptom
syndromes, “Functional GI Disorders” (FGIDs). You
can learn more about the FGIDs at the Rome
Foundation website: www.RomeCriteria.org (Figure
1.4). Or click “Rome III Diagnostic Criteria” circled in
red on the left menu, which describes all of the FGIDs.
Figure 1.4
www.RomeCriteria.org
Rome Foundation Website
Functional GI Disorders (FGIDs)
The symptoms of FGIDs can involve any location of the
GUT from the top to the bottom (Figure 1.5).
Figure 1.5
FGIDs can affect the GUT anywhere from the throat (top red
arrow) to the rectum and anus (bottom red arrow).
Gastroenterologists describe over 30 FGIDs, the most
common of which are listed below:
• Globus (lump in the throat)
• Chest pain (like heart angina)
• Heartburn (not responsive to treatment with strong
acid reducing drugs)
• Belching
• Rumination (regurgitation not caused by acid reflux)
• Dyspepsia or epigastric pain
(pain or discomfort in the middle of the upper
abdomen often related to eating not caused by acid
or ulcer that does not respond to strong acid
reducing drugs)
• Abdominal bloating/distention (distention is
abdominal enlargement)
• Biliary (attacks of severe upper abdominal pain
without gallstones)
• Nausea
• Vomiting
• IBS
• Constipation (without pain)
• Abdominal pain (without bowel dysfunction)
• Rectal pain
The FGIDs are all interrelated and commonly co-occur.
Most IBS patients have more than one FGID. One of the
most common combinations of FGIDs is heartburn (not
responsive to treatment with strong acid reducing
drugs), dyspepsia/epigastric pain not caused by acid
or ulcer, and IBS (Figure 1.6).
FGIDs
Heartburn
Dyspepsia
IBS
Figure 1.6
Functional GI Disorders (FGIDs) often co-occur,
with the three most common in combination shown here.
Functional Symptom Syndromes
Any part of the body can express the pain and
symptoms of a functional symptom syndrome. They
are often called “somatic” syndromes, with the term
referring to the body.
Specialists in almost every area of medicine define at
least one of these dysfunctional syndromes, the most
common of which are listed below:
• FGIDs (IBS is the most common FGID)
• Fibromyalgia (widespread pain and fatigue)
• Fatigue
• Headaches
• TMJ (temporomandibular joint disorder)
• Myofascial pain (pain that can occur anywhere in
muscles and soft tissues)
• Irritable larynx syndrome (chronic cough, lump in
the throat, muscle spasm in the throat, hoarseness,
throat clearing, voice dysfunction)
• Chronic low back pain
• Interstitial cystitis (painful bladder syndrome)
• Chronic pelvic pain
• Dysmenorrhea
• Multiple chemical sensitivity
• Multiple medication sensitivity
• Somatic symptom disorder, or SSD (This term
replaces "somatoform disorder" in the fifth edition of
the Diagnostic and Statistical Manual of Mental
Disorders, or DSM-5. SSD is characterized by somatic
or bodily symptoms that are either very distressing
or result in significant disruption of functioning, as
well as disproportionate thoughts, feelings, and
behaviors regarding those symptoms.)
The FGIDs are functional symptom syndromes, which
are similarly interrelated (Figure 1.7).
Functional
Symptom
Syndromes
FGIDs
HA
IC
IBS
CF
LBP
FM
Figure 1.7
IBS and other FGIDs are functional symptom syndromes.
The most common symptom syndromes are represented here:
HA = headaches; CF = chronic fatigue; FM = fibromyalgia;
LBP = low back pain; IC = interstitial cystitis.
Functional symptom syndromes often occur together
(Figure 1.8).
Functional
Symptom
Syndromes
FGIDs
IBS
FM
Figure 1.8
Functional symptom syndromes often occur together
because they all share common causes, which will be
explained in Chapter 2. As many as one half of IBS patients
also have fibromyalgia (FM).
Normal Bowel Movement Frequency and Amount
The normal bowel movement frequency in developed
countries is from 3 stools each day to 3 per week
(Figure 1.9).
Range
3/day
Normal # stools/day
3/week
Figure 1.9
Normal bowel movement frequency
In developed countries, the normal amount of stool per
bowel movement is about 7 ounces (Figure 1.10).
Figure 1.10
The normal amount of stool in a bowel movement
would not quite fill an 8 ounce glass.
Abdominal Pain and/or Discomfort
Abdominal pain and discomfort may or may not mean
the same thing to you (some patients don’t consider the
abdominal symptom to be pain). If possible, try to
determine whether abdominal pain and discomfort are
the same or different symptoms.
Remember, the pain or discomfort of IBS is associated
with bowel dysfunction. So abdominal pain or
discomfort is associated with two or more of the
following:
• Improvement after a bowel movement
• Change in stool frequency (either more or less often
than normal, which is 3 a day to 3 per week)
• Change in stool form (appearance) or consistency
(either loose or hard)
Abdominal pain or discomfort without bowel dysfunction is
not IBS. A diagnosis of IBS cannot be considered in a patient
with chronic and recurrent abdominal pain unless bowel
dysfunction is associated.
The pain of IBS is usually located in the left lower
quadrant (LLQ) of the abdomen. Recall that this is the
location of the sigmoid colon (Figure 1.11).
RUQ
LUQ
RLQ
LLQ
Figure 1.11
The most common location of IBS pain is the LLQ.
But IBS pain can be located anywhere in the belly or
involve the entire abdomen. Pain can be referred into
the pelvis and back. The pain can even be referred into
the chest and upper thighs.
The abdominal pain of IBS is usually colicky, coming
and going in a cramping fashion. It can last for a few
minutes or for hours.
But the abdominal pain can be constant. Its character
can be dull, aching, sharp, or burning.
Pain often occurs after eating. Diarrhea or loose stools
are often associated with pain triggered by meals.
When associated with constipation, the pain commonly
becomes increasingly severe each day without having a
bowel movement and is relieved following defecation.
When associated with diarrhea, the pain often worsens
around the time of bowel movement but is usually
relieved following defecation.
Abdominal pain can occur in sudden “attacks.” These
episodes can be so severe that the patient decides to
visit a doctor immediately or go to the emergency
room.
Research shows that pain is a symptom experienced
with more significant intensity or severity than is
discomfort. When describing abdominal pain to the
doctor, it’s more helpful to rate the intensity (severity)
of the pain than to describe the frequency (how often it
occurs).
It helps the doctor to better understand your IBS if pain
is based upon new government guidance on IBS for
industry and researchers. Rate your “worst abdominal
pain over the past 24-hours” on a 10 point scale, with
0 = no pain and 10 = very severe pain (Figure 1.12).
1 2 3 4 5 6 7 8 9
NONE
0
Range of your worst abdominal
pain over the past 24-hours
SEVERE
10
Figure 1.12
Record the number daily for at least one week.
Then compute the weekly average.
Note that if you had pain all day rated about a 3 but
that if the intensity of the pain reached a 6 for a short
period of time, then your worst abdominal pain over
the past 24-hours would be 6.
For example, your daily worst abdominal pain over the
past 24-hours was 4+6+8+5+7+6+6 = total of 42. Divide
42 by 7 days in the week = 6. So the weekly average of
your worst abdominal pain over the past 24-hours is
6.
Bowel Movement Form (Consistency)
The Bristol Stool Form Scale can help both you and
your doctor understand what your bowel dysfunction
is like (Figure 1.13).
Type 1
Separate hard lumps, like nuts (hard to pass)
Type 2
Sausage-shaped but lumpy
Type 3
Like a sausage but with cracks on the surface
Type 4
Like a sausage or snake, smooth and soft
Type 5
Soft blobs with clear-cut edges
Type 6
Fluffy pieces with ragged edges, a mushy stool
Type 7
Watery, no solid pieces; entirely liquid
Figure 1.13
The Bristol Stool Form Scale
Other Common Symptoms
Most patients with IBS report symptoms that are not
part of the formal definition.
Belching and “gas” include air expelled from the
mouth and abdominal bloating, abdominal distention
(enlargement), loud abdominal noises, and excessive
flatulence or farting (Chapter 6).
Meal triggered symptoms, including abdominal pain,
“gas,” and diarrhea are commonly described by
patients suffering with IBS (Figure 1.14).
Treat?
or
Trigger?
Treat?
Or trigger?
Figure 1.14
At least one half of IBS patients experience
symptoms that occur during or after meals.
Mucus is a white stringy substance similar to thick
saliva normally made by the colon lining. IBS patients
often misinterpret mucus in or on the stool as pus or
infection.
Menstruation often triggers IBS pain and diarrhea. IBS
is often associated with painful menstruation
syndrome (dysmenorrhea). Both are functional
symptom syndromes.
Fatigue is the most common non-GUT symptom that
patients with IBS report.
Autonomic nervous system symptoms include
shortness of breath, fast heart rate (tachycardia),
dizziness (low blood pressure), feeling sweaty
(diaphoresis), and nausea.
The autonomic nervous system is involved with GUT
function, as you will come to understand in Chapter 2.
Abdominal cramping, bowel changes, nausea, and
vomiting are related to autonomic nervous system
dysfunction in the GUT.
Abdominal Wall Pain (AWP)
Many patients with IBS also have abdominal pain
originating in the abdominal wall. Some patients with
this problem are incorrectly diagnosed with IBS, even
though they do not have associated bowel dysfunction.
AWP commonly involves the right upper quadrant
(RUQ) of the abdomen (Figure 1.15).
RUQ
LUQ
RLQ
LLQ
Figure 1.15
Abdominal wall pain (AWP) often occurs in the
right upper quadrant (RUQ) of the abdomen.
The liver and gallbladder are located under the ribs just
above the RUQ, so AWP frequently leads to imaging
with ultrasound, CT scan, or MRI.
AWP may or may not be close to an old surgical scar. It
also may be located at the outer edge of the abdominal
muscle (rectus abdominis). The pain is usually sharp
and there is often extreme tenderness upon gentle
stroking or pinching of the skin over the area of pain.
The tenderness on abdominal examination is typically
sharply localized to a very small area (the size of a
quarter or fifty cent piece), but it can be more broadly
distributed. AWP can be aggravated by wearing tight
clothing and gaining weight. Triggers include changing
body position, standing, lifting, stretching, or
coughing. Relief may be found by sitting, lying, or
pressing on the affected area.
A diagnostic clue to AWP on physical examination of
the abdomen is called the Carnette test, where the
tenderness continues or increases with tensing of the
abdominal wall by elevating the head and shoulders or
raising the legs. Click here to see a video of the
Carnette test.
AWP can be caused by localized myofascial pain
(muscle tension), nerve entrapment, or hernia. It can be
treated with properly placed anesthetic/steroid
injection, physical therapy, and sometimes with
surgery. Diabetics can develop severe AWP called,
“thoracolumbar radiculopathy.”
Diary
Patients and doctors don’t have much time to spend
together. This limitation commonly interferes with the
diagnostic and therapeutic process.
Now you know how to accurately describe your pain
and bowel symptoms. Keeping a symptom diary will
also help your doctor comprehend and understand
what you are experiencing. As you will soon discover,
you and your doctor are going to try to subtype your
IBS based upon the predominant bowel dysfunction,
because successful and appropriate IBS treatment
depends upon it.
Here’s how to keep a daily symptom diary for at least
one week, where you record abdominal pain, stool
frequency, stool consistency, and then your overall IBS
symptom assessment at the end of each week.
• Record your worst abdominal pain over the past
24-hours each day. Compute the weekly average.
• Record your stool frequency daily.
• Record your stool consistency for each stool daily
(refer to the Bristol Stool Form Scale).
• Determine your overall (global) IBS symptom
assessment at the end of each week:
‣ Very severe
‣ Severe
‣ Moderate
‣ Mild
‣ None
SAMPLE IBS DIARY FOR LAST DAY OF 7 DAYS
DATE:
Worst abdominal pain over the past 24 hours: 6
Stool frequency: 3 stools
Stool consistency (for each stool):
Bristol 1
Bristol 2
Bristol 4
End of week average pain score: 5
End of week overall symptom assessment: Severe
Diagnosis
The foundation of IBS diagnosis is recognition of the
characteristic pain and symptoms that meet the Rome
III Diagnostic Criteria (C1, page 889 of the PDF on the
Rome Criteria website).
Doctors are encouraged to use these symptom criteria
in diagnosis of IBS as long as symptoms and findings
that raise concern about presence of a disease
masquerading as IBS are absent. (You will learn about
these “red flags” shortly.) However, the reality in
clinical practice is that most primary care specialists are
not familiar with Rome criteria, and few
gastroenterologists use them. Furthermore, there are
problems associated with their use. It may be difficult
to determine the IBS subtype, even with use of a
patient diary, because bowel function is variable in
most patients with IBS, regardless of subtype. The
criteria may not distinguish IBS from several diseases
and conditions that mimic or trigger IBS, and they may
not identify coexisting diseases.
The author may use a comprehensive and customized
“state of the art” method to establish the diagnosis of
IBS. This method includes consideration of the
following:
• Confirmation that Rome III symptom-based criteria
are met
• Recognition of sudden onset
• Effect of antibiotics
• Classification by subtype
• Recognition of associated FGIDs
• Recognition of heightened sensitivity to pain and
symptoms
• Acknowledgement of stress
• Screen for emotional distress and negative thoughts
• Identification of “red flags”
• Consideration of
“differential diagnoses”
• “IBS Plus” other diseases
Confirmation that Rome III symptom-based criteria
are met
Recall that the pain/discomfort of IBS must be
associated with bowel dysfunction and have been
present for 6 months.
Recognition of sudden onset
Research confirms that many patients with IBS-D or
IBS-C and other FGIDs, such as heartburn and
dyspepsia/epigastric pain report the sudden onset of
their symptoms following the GI “flu,” gastroenteritis,
or suspected food poisoning. Patients may not recall
this unless the doctor asks about it. While a specific
infectious cause may be found on stool culture, the
culprit is commonly not identified. A clue is that one or
more other people also became sick around the same
time. Continuing symptoms following sudden onset
can be associated with small intestinal bacterial
overgrowth (SIBO), which may be treatable.
Effect of antibiotics
Some IBS patients benefit by antibiotics, while others
find that their symptoms are worsened by them. If
symptoms are strongly affected by antibiotics, small
intestinal bacterial overgrowth (SIBO) may be present,
which many be treatable. (SIBO is discussed in
Chapters 4, 5, and 6.)
Classification by subtype
Two main IBS subtypes are determined based upon the
predominant bowel dysfunction: IBS-D (diarrhea) and
IBS-C (constipation). Treatment is based upon this
classification. Three other subtypes may also be
recognized.
IBS-D (diarrhea)
• Diarrhea is the troublesome symptom.
• Constipation is not a troublesome symptom.
• Abdominal pain intensity (severity) is 3 or greater.
• Stool form (consistency) is either a Bristol Stool Form
6 or 7 (which is loose or watery) at least twice a week.
• Bowel function is irregularly irregular in frequency
and form. Bowel frequency commonly varies from
day to day. Bowel form commonly varies in the
average week with 3 or more different stool forms
based upon The Bristol Stool Form Scale.
IBS-C (constipation)
• Constipation is the troublesome symptom.
• Diarrhea is not a troublesome symptom.
• Abdominal pain intensity (severity) is 3 or greater.
• There are fewer than 3 complete spontaneous bowel
movements per week (without laxatives).
• Stool form is usually but not invariably hard (Bristol
Stool Form 1 or 2).
IBS-M (mixed)
Stool form varies from loose to hard over hours to
days. Treatment guidelines for IBS-M are not clear, but
stress, emotional distress, and diet are often symptom
triggers.
IBS-A (alternating)
Stool form changes over weeks to months, most
commonly from IBS-D to IBS-C.
IBS-PI (post-infectious)
Approximately 25% of patients diagnosed with IBS
report the sudden onset of the disease following an
acute GI infection.
Recognition of associated FGIDs
As you have learned, most patients diagnosed with IBS
also suffer from one or more FGID. The most common
FGIDs that occur with IBS are functional heartburn that
does not respond to strong acid reducing drugs and
dyspepsia/epigastric pain not caused by acid or ulcer,
which also does not respond to strong acid reducing
drugs.
Recognition of heightened sensitivity to pain and
symptoms
Most patients suffering with IBS also have nervous
system dysfunction, which amplifies sensations and
feelings originating in the body and GUT in response to
the environment (including what we eat). This
dysfunction results in heightened sensitivity to pain
and symptoms represented by Figure 1.16.
Figure 1.16
The speaker with a high volume control setting
represents dysfunction in the nervous system
that amplifies pain and symptoms.
Dysfunction in the central nervous system (CNS)
(central sensitivity) can result in heightened sensitivity to
pain and symptoms throughout the body and GUT.
Dysfunction in a second brain in the GUT
(visceral sensitivity) can result in heightened sensitivity
to pain and symptoms throughout the GUT.
Visceral sensitivity affecting the GUT occurs in most
patients with IBS and related functional GI disorders
(FGIDs). There are no tests for central sensitivity
outside of research centers. However, central sensitivity
with heightened sensitivity to pain and symptoms
throughout the body and GUT commonly resulting in
functional somatic symptom syndrome diagnoses can be
easily recognized by the following (the more present, the
greater the likelihood that central sensitivity is present):
• Chronic pain anywhere or widespread
• Functional GI disorder (FGID) diagnosed
• Functional symptom syndrome diagnosed
• Fatigue
• Memory and concentration problems (“brain fog”)
• Insomnia
• Sensitivity to foods, medications, chemicals, light,
sound, odors
• Family history of chronic pain, FGIDs, or functional
symptom syndromes
• Abuse history (physical, emotional, sexual)
Acknowledgement of stress
Life is difficult. Life is stressful. These are universal life
truths for everyone. Science confirms the body and
brain are constantly damaged by stress and that much
of it occurs without our conscious awareness. Stress
triggers and exacerbates IBS pain and symptoms. While
there are many “stress tests” available, what’s most
important is that you accept the fact that life is stressful
and hurts you (Figure 1.17).
Figure 1.17
“The Stress Ball”
While in college years ago, my daughter
Shelley once confided, “Dad, I’m such a ‘stress ball!’”
She created this illustration.
Screen for emotional distress and negative thoughts
A screening tool is available to help identify
psychosocial problems commonly faced by patients
suffering with FGIDs. The questionnaire screens for
anxiety, depression, suicidal ideas, pain severity,
impairment, impaired coping, and abuse.
Click here to review the Rome III Psychosocial Alarm
Questionnaire for the Functional GI Disorders (FGIDs).
Identification of “red flags”
The diagnosis of IBS is based upon absence of certain
history, symptoms, or findings called, “red
flags” (Figure 1.18).
Figure 1.18
“Red flags” raise concern a disease is present that either
mimics, co-occurs with, or aggravates symptoms of IBS.
Red flag history
• Onset over age 50
• Symptoms progressively worsening
• Vomiting
• Weight loss
• Fever
• Blood in the stool
• Diarrhea that is constant, watery, occurs even
without eating, and/or occurs during the night
• Flushing that is dry
• Family history of colorectal cancer
• Family history of inflammatory bowel disease
• Family history of celiac disease
Red flag test results
• Complete blood count: anemia, inflammation, and
cancer
• C-reactive protein (CRP) and erythrocyte
sedimentation rate (ESR): inflammation
• Stool calprotectin: inflammation
• Comprehensive metabolic panel (CMP) with many
tests, including:
‣ Albumin: low with inflammation, malabsorption,
cancer
‣ Total protein: high with inflammation
‣ AST and ALT: most common elevation caused by
fatty liver
‣ Alkaline phosphatase: elevation comes from either
bone or liver disease
‣ Bilirubin: most common cause of elevation is a
harmless condition (Gilbert’s syndrome)
Note: certain alternative evaluations have not been
validated or shown to be helpful, such as stool testing to
detect dysbiosis and small intestinal bacterial overgrowth.
Consideration of “differential diagnoses”
Testing for several diseases and disorders may be
necessary before a diagnosis of IBS can be established,
because they can be mistaken for IBS. Furthermore,
new research shows that several conditions commonly
trigger or aggravate IBS symptoms. The most common
of these are malabsorption of bile acids and
carbohydrates, non-celiac gluten sensitivity, and small
intestinal bacterial overgrowth (SIBO).
IBS-D (diarrhea)
Recall the symptoms are commonly triggered by eating
and that actual diarrhea must be present (Figure 1.19).
Type 6
Fluffy pieces with ragged edges, a mushy stool
Type 7
Watery, no solid pieces; entirely liquid
Figure 1.19
Stool form (consistency) in IBS-D is either a
Bristol Stool Form 6 or 7 at least twice a week.
• Inflammatory bowel disease or IBD (Crohn’s
disease and ulcerative colitis) is usually diagnosed
with colonoscopy, but scans, x-rays, and/or small
intestinal capsule endoscopy (a tiny swallowed
camera) may be needed.
• Celiac disease is an intestinal injury caused by gluten
in wheat, barley, and rye resulting in impaired
absorption of nutrients and fat (malabsorption). The
diagnosis is based upon blood tests and duodenal
biopsies at endoscopy.
• Microscopic colitis is different than IBD. Diagnosis is
made with colonoscopy and biopsies, because there
are no visible changes in the colon lining.
• Colon and rectal cancer (CRC) affects at least 150,000
Americans each year. The red flag symptom of rectal
bleeding or hidden (occult) blood in the stool may or
may not be present. Diagnosis is usually made with
colonoscopy.
• Fat malabsorption caused by bile acid malabsorption
or disease of the intestine or pancreas is detected
with a stool test for increased fecal fat.
• Diverticular disease of the colon
Diverticulosis of the colon (small outpouches)
becomes increasingly common with aging.
Inflammation is a complication of diverticulosis
called, “diverticulitis.” Subsequently, symptoms of
IBS-D can develop or persist even if the inflammation
has healed. Diagnosis is made with colonoscopy and
CT scan.
• Bile acid malabsorption (BAM) occurs in at least one
of every three patients otherwise diagnosed with IBSD and is a common cause of symptoms triggered by
eating. Since there’s no test for BAM available to
doctors outside of research centers, diagnosis
requires a treatment trial with a bile acid binding
drug for diagnosis.
• Carbohydrate malabsorption
Certain carbohydrates in the diet can be fermented
by the GUT bacteria, resulting in gas symptoms.
Diagnosis is based upon hydrogen breath testing and
assessing response to dietary treatment.
• Non-celiac gluten sensitivity (NCGS)
This recently recognized disorder is considerably
more common than is celiac disease. Diagnosis
requires testing to exclude celiac disease and a
dietary treatment trial, since a medical test for NCGS
is not available.
• Small intestinal bacterial overgrowth (SIBO) can
contribute to IBS symptoms. Diagnosis of SIBO
depends upon either a hydrogen breath test,
treatment trial, or both.
IBS-C (constipation)
Recall that there are fewer than 3 complete
spontaneous bowel movements per week (without
laxatives) in IBS-C and that the stool form is usually
hard (Figure 1.20).
Type 1
Separate hard lumps, like nuts (hard to pass)
Type 2
Sausage-shaped but lumpy
Figure 1.20
The stool form in IBS-C is usually but not invariably hard
(Bristol Stool Form 1 or 2).
• Diverticulosis of the colon (small outpouches)
becomes increasingly common with aging.
Inflammation is a complication called,
“diverticulitis.” Subsequently, symptoms of IBS-C
can develop or persist even if the inflammation has
healed. If inflammation persists or inflammation
from scar tissue develops, blockage can occur.
Diagnosis is made with colonoscopy, CT scan, and
barium enemia.
• Colon and rectal cancer (CRC) affects at least 150,000
Americans each year. The red flag symptom of rectal
bleeding or hidden (occult) blood in the stool may or
may not be present. Diagnosis is usually made with
colonoscopy.
• Inflammatory bowel disease or IBD (Crohn’s
disease and ulcerative colitis) is usually associated
with diarrhea, but some patients are constipated. IBD
is usually diagnosed with colonoscopy, but scans, xrays, and/or small intestinal capsule endoscopy (a
tiny swallowed camera) may be needed.
• Functional constipation is an (FGID) that can co-occur
with IBS-C. There are three main types:
1. Normal transit (stool movement through the colon
is normal)
2. Slow transit (stool movement through the colon is
slow)
3. Obstructed defecation (stool evacuation from the
rectum and anus is difficult). Decreased stool
frequency and/or difficulty evacuating stool from
the rectum are the bothersome symptoms, rather
than abdominal pain and discomfort. As with IBSC, the stool is not necessarily hard. Obstructed
defecation is the most important type of functional
constipation to recognize, since it can be treated.
The most common type of functional constipation that
occurs along with IBS-C is obstructed defecation, with the
following symptom clues:
‣ Straining to defecate
‣ Incomplete rectal emptying
‣ Sense of anorectal blockage
‣ Need for applying pressure between or within the
vagina and rectum
‣ Actual direct evacuation of the stool from the
rectum with the fingers
These symptoms may or may not be present, and
special testing is necessary to diagnose functional
obstructed defecation:
‣ Digital rectal examination (DRE)
‣ Rectal balloon expulsion
A good screening test for obstructed defecation is
inability to defecate a rectal balloon inflated in the
rectum within a short period of time (Figure 1.21).
Figure 1.21
The rectal balloon expulsion catheter is used to screen
for functional obstructed defecation.
‣ Anorectal manometry
This test involves inserting a special soft balloon
into the rectum to evaluate the function and
coordination of anal sphincters and pelvic floor
muscles. Anorectal manometry requires very
sophisticated equipment to record and analyze
the results.
‣ Sitzmarks Colonic Transit Diagnostic Test
This test involves swallowing a small capsule
that contains 24 tiny soft rings that can be seen
on a plain x-ray of the abdomen (Figure 1.22).
Figure 1.22
The Sitzmarks capsule
The plain abdominal x-ray is taken 5 days later
to determine the location and extent of
elimination of the rings.
Interpretation of the Sitzmarks test is based
upon the extent of elimination of the rings
and their location if retained (Figures 1.23 1.25).
Figure 1.23
If 5 or less markers remain,
colonic transit is probably normal.
Figure 1.24
If most rings are scattered about the colon,
slow colon transit is likely.
Figure 1.25
If most rings are gathered in the rectum and sigmoid colon,
functional obstructed defecation is likely.
“IBS Plus” other diseases
As you have learned, IBS commonly co-occurs with
other functional GI disorders (FGIDs), such as
heartburn unresponsive to treatment and functional
symptom syndromes, such as fibromyalgia.
Most patients and many doctors don’t know that IBS
commonly co-occurs with other GI (GUT) diseases. The
author calls this co-occurrence, “IBS Plus” (Figure 1.26).
+
Other
Diseases
IBS
Figure 1.26
“IBS Plus”
IBS commonly co-occurs with several diseases,
such as diverticular disease of the colon,
inflammatory bowel disease, and celiac disease.
It’s important to recognize “IBS Plus,” so the IBS can be
treated and the other disease isn’t over-treated or mistreated. A common example is shown in Figure 1.27.
IBS
+
IBD
Figure 1.27
An example of “IBS Plus”
is IBS + IBD.
IBD is Inflammatory Bowel Disease
(Crohn’s disease and colitis).
In the example of IBS+IBD, the disease activity and
inflammation of IBD may not explain symptoms of
diarrhea and abdominal pain, which are more related
to the co-occurring IBS. Medical testing may be
required to evaluate for disease activity and
inflammation in order to avoid unneeded IBD
treatment.
Now you’re ready to learn what “causes” IBS and why
it’s commonly associated with functional GI disorders
(FGIDs) and functional somatic symptom syndromes
involving other locations of the body.
Chapter 2
What Causes It?
Nerita Beach
Sanibel, Florida
Examining
What causes IBS?
You’re ready to discover answers to this second
question. Here’s a hint: Note the “s” in the word,
“causes.” There’s more than one cause of IBS, other
functional GI disorders (FGIDs), and functional
symptom syndromes. It’s complicated, but you can and
you will understand!
Sections in Chapter 2
What Causes It?
IBS Involves Your Whole Body
You Have Two Brains
It’s More Than a Feeling
Anatomy and Physiology
Dysfunction is Responsible
Symptom Syndromes Revisited: Central Sensitivity
Syndromes
Functional GI Disorders (FGIDs) Revisited
“IBS Plus” Other Diseases
The Causes of IBS
The Biopsychosocial Model Revisited
IBS Involves Your Whole Body
You were introduced to this key concept in the first
chapter with Figure 1.1. YOU are “all in” with IBS
(Figure 2.1).
Figure 2.1
The target is your GUT (colon of your GI tract).
The red circle is your HEAD (mind/brain).
The arrows are your CONNECT
(their communication systems).
You Have Two Brains
As you discovered in Figure 1.16, there’s a brain in
your HEAD and an equally important second brain
in your GUT (Figure 2.2).
Brain
CONNECT
Second
Brain
Figure 2.2
Both brains are independent but interdependent
and in constant communication with one another.
This “second brain” is located within the GUT lining
from top to bottom. Both brains developed from the
same origin when you were growing within your
mother’s womb until they separated into your two
brains. So the brains in your HEAD and GUT contain
the same nerve cells and chemical messenger
molecules, such as serotonin and norepinephrine.
Your brains are bother independent. The central brain
in the HEAD is responsible for generating and
expressing thought/memory, emotion, the stress
response, pain, and symptoms. The second brain in the
GUT is managing GI tract function, including
digestion.
However, your brains are also interdependent in a 24/7
dialogue with one another via the CONNECT, which
includes both the nervous system and the chemical
messengers. Your central brain processes the sensory
information sent from the body in response to the
environment (including food and ingested substances).
Your second brain enables you to “feel” the inner world
of your GUT and it’s contents, including food, ingested
substances, and resident bacteria. This sensory input
from the GUT influences central brain function as
much as the central brain affects the GI tract.
It’s More Than a Feeling
You know your HEAD brain affects your GUT second
brain. For example, most of us experience “butterflies”
in the stomach when excited or stressed. But we may
not know what stressor causes a sudden attack of
abdominal cramping and diarrhea accompanied by
anxiety in a panic attack. The HEAD can perceive stress
and express bodily and GUT symptoms without
conscious awareness of the stressor.
You may not be aware that your GUT brain does a
whole lot more than handle breakdown of food,
digestion, absorption, and both storage and elimination
of stool. The 2 main “vagus” nerves connecting your
two brains transmit 90% of information from the GUT
to the brain, rather than the other way around. Your
second brain affects your state of mind (both thoughts
and emotions) and plays a key role in IBS, FGIDs, and
other functional symptom syndromes, such as
fibromyalgia.
Much of your mental state is influenced by GUT
feelings. These inner feelings actually affect both your
thoughts and emotions, with or without your conscious
awareness of them. This is the basis for sayings, such
as, “My gut instinct tells me... .”
Medical science has confirmed that mental illness
involves both the physical brain as well as the mind
within the HEAD. For example, antidepressants, such
as selective serotonin reuptake inhibitors (SSRIs)
increase serotonin levels in the brain, where 5% of the
body’s serotonin is located. But 95% of serotonin is
located in the GUT brain. In part, IBS-D arises because
of excess serotonin in the GUT. So IBS is in part like
“mental illness” of the second brain.
Your GUT feelings, the food you eat, the substances
you ingest, and the bacteria residing in your GUT affect
your entire body. Again, most of what’s happening
occurs without your conscious awareness.
Anatomy and Physiology
To answer the important second question of this
chapter, you need to know a little bit about how your
two brains communicate with one another and what’s
going on within and between them. They talk through
the CONNECT, which is shown in Figure 2.3.
Figure 2.3
The CONNECT between the two brains
is represented by the red arrows:
central nervous system (CNS),
autonomic nervous system (ANS),
and chemical messenger system (CMS).
Your central nervous system (CNS) is the first of three
CONNECT systems (Figure 2.4).
Brain
Vagus
Nerves
Spinal
Cord
Figure 2.4
The central nervous system (CNS) of the CONNECT
includes the brain, spinal cord,
and two large vagus nerves.
Information exchange between your two brains is a
two-way and 24/7 ongoing process. Most of the time,
you’re not aware of the discussion that’s going on. For
example, you’re not usually aware of your gut feelings,
even though there’s a lot going on within your GI tract
all of the time.
Your autonomic nervous system (ANS) is the second of
three CONNECT systems (Figure 2.5).
Brain
Vagus
Nerves
Spinal
Cord
Figure 2.5
The autonomic nervous system (ANS) of the CONNECT
is located within the brain and spinal cord
and includes two vagus nerves.
The ANS is also located within the GUT brain,
which lines the GI tract.
The ANS functions automatically, controlling
breathing, heart rate, sweating, blood pressure, and
digestive function. Symptoms of ANS dysfunction are
very commonly associated with IBS.
The autonomic nervous system (ANS) includes two
branches that balance one another, much like a teeter
totter (Figure 2.6).
Brain
Vagus
Nerves
Sympathetic
Spinal
Cord
Parasympathetic
Figure 2.6
The autonomic nervous system (ANS) of the CONNECT
includes two main branches. The sympathetic nervous
system functions as the “accelerator,” which is the
“fight, flight, freeze” reaction in response to stress.
The parasympathetic nervous system
is the “brake” and “relaxer.”
Your chemical messenger system (CMS) is the third of
three CONNECT systems (Figure 2.7).
Receptor
(Lock)
Cell
Figure 2.7
The chemical messenger system (CMS) of the CONNECT
includes chemical messengers, which are like tiny keys that
float throughout the body in the bloodstream and fluids.
All cells in the body have thousands of tiny receptors like
locks on the surface. When the correct lock and key
combination occurs, the function of the cell is changed, for
better or worse. Examples of these chemical messengers are
serotonin, norepinephrine, and histamine.
Dysfunction is Responsible
Recall that the term, “dysfunction” refers to abnormal
function of how the body works. This dysfunction
involves interactions of your body and two brains. It
usually cannot be detected by medical testing outside
of research centers. But the pain and symptoms are
real.
Your HEAD, CONNECT, and GUT are all in on this.
See yourself with two brains in Figure 2.8 and focus
upon your HEAD first.
Your World
(Environment)
Physical
Social
Manmade
Cell
Figure 2.8
The brain in the HEAD responds to the world through
the five senses: sight, hearing, smell, taste, and touch.
Now look at your second brain in the GUT in Figure
2.9. It’s your sixth sense!
Your World
(Environment)
Physical
Social
Manmade
Figure 2.9
The second brain in the GUT is a sixth sense responding to
the world: food, ingested substances, and gut contents.
The little brain in your GUT responds to chunks of the
external environment (your world), which is the food
and substances that you ingest. Your second brain
independently controls the functions of your GUT
while interdependently communicating with your
brain. Other GUT contents, including bile acids,
enzymes, digestive juices, and resident bacteria also
participate in the responses made by your second
brain.
To help you understand the causes of IBS, FGIDs, and
functional symptom syndromes, picture a transmission
tower sending signals to a radio shown in Figure 2.10.
Figure 2.10
The transmission tower silently sends information through
airwaves 24/7 to a radio located within the red oval.
A speaker with a high volume control setting
broadcasts loudly with distortion in Figure 2.11.
Figure 2.11
The radio broadcasts sound through a
speaker. The volume control setting is turned high,
resulting in sound that is loud and even distorted.
You were introduced to the speaker earlier in Figure
1.16. It represents nervous system dysfunction resulting
in heightened sensitivity to pain and symptoms.
By analogy, YOU are like this radio tower, radio, and
speaker (Figure 2.12).
Pain
Symptoms
Bodily Feelings
Figure 2.12
Responding to the environment, all parts of the body
and GUT transmit feelings to the mind/brain. After these
feelings are processed, they are broadcasted
and only then may be experienced.
The dysfunction of nervous system sensitivity amplifies
and distorts the bodily and GUT feelings
so they are felt as pain and symptoms.
Now picture your small intestine and colon containing
the second brain as a radio tower transmitting their
feelings to a radio in your head shown in Figure 2.13.
Figure 2.13
In response to the environment (including food and
ingested substances), the brain in the GUT
silently transmits feelings and sensation
from the small intestine and colon 24/7
to the SENSITIVITY system (red oval)
of the brain in the HEAD.
This communication through the CONNECT occurs
24/7 without your conscious awareness. You don’t yet
experience these feelings.
With help from other systems in your mind/brain you
will soon study, the SENSITIVITY system in your
HEAD “broadcasts” GUT feelings from the small
intestine and colon as pain and symptoms through a
speaker. The speaker dial has a high volume control
setting representing dysfunction, called “central
sensitivity” (Figure 2.14).
IBS
Central
Sensitivity
Cell
Figure 2.14
The dysfunction of “central sensitivity”
results in heightened sensation to IBS pain and symptoms
originating in the colon. Furthermore, there is increasing
evidence that dysfunction of the small intestine occurs in
IBS, particularly when symptoms include “gas,” with
abdominal bloating, distention, and flatulence.
Remember that your second GI brain lines the entire
GUT. So it’s not only your small intestine and colon
sending hidden signals to your brain. All locations of
your GUT transmit their feelings, which is why the pain
and symptoms of the dys-functional GI disorders
(FGIDs) can originate from any location in your GI
tract, from the top (throat) to the bottom (rectum and
anus). Central sensitivity also explains why patients
with IBS commonly have one or more additional FGIDs
(Figure 2.15).
FGIDs
Central
Sensitivity
Cell
Figure 2.15
Note the elongated target representing pain and symptoms
involving any location in the GUT.
The dysfunction of heightened sensitivity can also
occur in the second brain in the GUT. This is “visceral
sensitivity.” Appropriately, the definition of “visceral”
includes “felt in or as if in the internal organs of the
body” and “coming from strong emotions and not from
logic or reason” (Figure 2.16).
FGIDs
Visceral
Sensitivity
Figure 2.16
Note the speaker in the GUT representing dysfunction
resulting in increased sensitivity. This GUT
“visceral sensitivity” contributes to the pain
and symptoms of IBS and all of the
functional GI disorders (FGIDs).
All of the tissues and organs of your body are sending hidden
signals to your brain. Your whole body can be seen as a
radio tower silently transmitting bodily and GUT
feelings to the brain in your HEAD. Central sensitivity
helps explain how you can have unexplained pain and
symptoms anywhere in your body and GUT. The new
name for dysfunctional symptom syndromes,
including FGIDs and IBS is central sensitivity
syndromes (CSS), shown in Figure 2.17.
Central Sensitivity
Syndromes
(CSS)
Central
Sensitivity
Cell
Figure 2.17
The dysfunction of “central sensitivity” results in
heightened sensation to all bodily pain and symptoms,
represented by the red box around the figure.
Symptom Syndromes Revisited: Central Sensitivity
Syndromes
This term, central sensitivity syndromes (CSS) is
relatively new. Most doctors will not be familiar with it
as the name for functional somatic symptom
syndromes, which you learned about in the first
chapter and are again listed below:
• FGIDs (IBS is the most common)
• Fibromyalgia (widespread pain and fatigue)
• Fatigue
• Headaches
• TMJ (temporomandibular joint disorder)
• Myofascial pain (pain that can occur anywhere in
muscles and soft tissues)
• Irritable larynx syndrome (hoarseness, throat
clearing, voice dysfunction, chronic cough)
• Chronic low back pain
• Interstitial cystitis (painful bladder syndrome)
• Chronic pelvic pain
• Dysmenorrhea
• Multiple chemical sensitivity
• Multiple medication sensitivity
• Somatic symptom disorder or SSD (formerly called
“somatoform disorder”)
Functional GI Disorders (FGIDs) Revisited
Most of the causes of IBS are also causes of the other
FGIDs (Figure 2.18).
Figure 2.18
The functional GI disorders (FGIDs)
share similar causes, which is why
they so commonly co-occur.
This is represented by the elongated target.
Recall that the more than 30 FGIDs can affect the GUT
anywhere from the top (throat) to the bottom (rectum
and anus). Furthermore, most patients with IBS have
more than one FGID. For example, IBS commonly cooccurs with other FGIDS, such as functional heartburn
and dyspepsia/epigastric pain that do not respond to
strong acid reducing drugs.
“IBS Plus” Other Diseases
You were introduced earlier to the concept of the
common co-occurrence of IBS with other GUT diseases,
such as diverticular disease of the colon, inflammatory
bowel disease, or IBD (Crohn’s disease and ulcerative
colitis), and celiac disease. This is called “IBS Plus.”
It’s important to recognize “IBS Plus,” so the IBS can be
treated and the co-occurring disease isn’t over-treated
or mis-treated.
The Causes of IBS
The dysfunction that causes IBS involves complex
systems of your body (bio), your mind/brain (psycho),
and your relationship with the world, including other
people (social). This can only be understood with the
biopsychosocial model (Figure 2.19).
THOUGHT
HEAD
Conscious
Subconscious
Memory
SENSITIVITY
Pain & Symptoms
STRESS
CONNECT
EMOTION
Depression
Anxiety
GUT
YOU
Gender
Nature/Nurture
Figure 2.19
Biopsychosocial Model of IBS in Response to Environment
See yourself (YOU) in Figure 2.19 as the causes of IBS
are described. As you learn about each cause, you can
click on YOU to review and study your
biopsychosocial model above as needed:
• Complex adaptive systems
• Gender
• Nature/Nurture
• Central sensitivity
• Cellular inflammation
• HEAD
• CONNECT
• GUT
YOU
Complex adapative systems
A complex adaptive system has a large number of
components that interact and adapt or learn
collectively in response to the changing environment.
From their interaction emerges something that is not a
property of any part or component of the system. For
example, your central brain is a complex adaptive
system (Figure 2.20).
Interaction
BRAIN
CELLS
THOUGHT
Interaction
Figure 2.20
Brain cells (neurons) cannot think, but the central brain is
a complex adaptive system composed of billions of neurons
whose interactions result in the emergence of thought.
As Aristotle taught, “The whole is greater than the sum
of its parts.” You are a big complex adaptive system
composed of many such systems, which are smaller
and interactive. Your two brains interact. Pain and
symptoms emerge from their dysfunction.
YOU
Gender
Gender refers to differences in dysfunction and disease
in women and men. In general, women are more pain
sensitive than are men, but the reasons for this are not
understood. More women than men consult with
doctors about central sensitivity syndromes (CSS), IBS,
and FGIDs.
YOU
Nature/Nurture
Nature/nurture refers to the effects of both heredity
(genetics) and early life experience. Both equally
influence pain and symptom expression by their effects
on the volume control involving central sensitivity
(figure 2.21).
Nature
(heredity/genetics)
Nurture
(early life experience)
Figure 2.21
Nature and nurture equally affect central sensitivity.
Studies clearly show that IBS, FGIDs, and CSSs can run
in families. Heredity is one factor, likely influencing
genes and function of HEAD, GUT, and their
CONNECT.
The influence of nurture in the household is equally
important, such as serious illness of self or other family
member, relationship difficulties, divorce, and financial
difficulties. A history of abuse (physical, emotional,
and/or sexual) can strongly influences the later
expression of pain and symptoms with greater severity,
stress reactivity, emotional distress, and poorer daily
function and coping ability.
YOU
Central sensitivity
Your sensitivity to pain and symptoms depends upon
your central volume control setting (Figure 2.22).
Sensitivity to Pain
Low
High
Figure 2.22
An individual’s sensitivity to pain and symptoms
depends upon where he or she is located
on a bell-shaped curve of the population.
Gender, nature, and nurture affect your pain sensitivity.
Some people have a low setting. Many people have a
high volume control setting. This is why IBS, FGIDs,
and dysfunctional symptom syndromes (central
sensitivity syndromes) are so common.
YOU
Cellular inflammation
You can’t feel the damage being done to the cells of
your body, GUT, and brains by inflammation, because
it’s happening at the subconscious level. This cellular
dysfunction underlies chronic diseases, including
obesity, heart, diabetes, hypertension, cancer, IBS,
FGIDs, and central sensitivity syndromes (Figure 2.23).
Cell
Figure 2.23
Chronic inflammation damages the cells
of the body, GUT, and both brains.
It is a cause of all diseases.
The damage caused by chronic inflammation can kill you
(such as by diabetes, heart attack, and stroke).
YOU
HEAD
The causes of IBS, FGIDs, and central sensitivity
syndromes aren’t all in your HEAD. But your HEAD
matters. Four mind/brain systems are involved (Figure
2.24).
THOUGHT
HEAD
Conscious
Subconscious
Memory
SENSITIVITY
STRESS
CONNECT
EMOTION
Depression
Anxiety
GUT
Figure 2.24
Four mind/brain systems in the HEAD are involved
with the causes of IBS, FGIDs, and central sensitivity
syndromes. The ovals overlap, which emphasizes
the systems communicate with and affect one another.
Nature/nurture can increase pain and symptom
sensitivity, negative cognition, stress reactivity, and
susceptibility to emotional distress.
SENSITIVITY
Your volume control setting and SENSITIVITY to the
pain and symptoms of IBS, FGIDs, and central
sensitivity syndromes are affected by the other three
mind/brain systems. Much of what’s happening occurs
without your conscious awareness.
THOUGHT
This mind/brain system includes both conscious and
subconscious thought and memory. Negative thoughts
and memories of old hurts (conscious and
subconscious) can increase pain and symptom
sensitivity. For example, catastrophic thinking (“I’ll
never get well!”) and/or memory of emotional,
physical, or sexual abuse can increase pain and
symptom experience, stress responsiveness, emotional
distress, and ability to cope.
STRESS
The damage done by chronic stress is called, “allostatic
load,” which causes dysfunction and physical injury to
both brains. Many patients with IBS, FGIDs, and
central sensitivity syndromes have increased sensitivity
and reactivity to stressors. The pain and symptoms are
commonly exacerbated by stressors, which come in
many forms:
• Psychosocial stress and distress
• Early life stressors
‣ Injury
‣ Institutionalization
‣ Abuse (physical, emotional, sexual)
• Painful bodily disorder, (such as IBS and arthritis)
• Physical trauma (such as auto accident or injury)
• Combat
• Infections
EMOTION
In many patients with IBS, FGIDs, and central
sensitivity syndromes, psychological disorders coexist.
This co-occurrence is called, “comorbidity.”
Psychological distress increases pain and symptom
sensitivity and reduces ability to cope. Some patients
cannot recognize psychosocial difficulties, and this
impairment can develop early in life.
The most common psychiatric comorbidities include:
• Depression (including dysthymia)
• Anxiety disorders (panic and generalized anxiety
disorders)
• Somatic symptom disorder (formerly called
“somatoform disorder”)
• Phobic disorders
YOU
CONNECT
Recall the CONNECT includes the central nervous
system (CNS), autonomic nervous system (ANS), and
the chemical messenger system CMS (Figure 2.25).
ANS
Sympathetic
Parasympathetic
Figure 2.25
CONNECT dysfunction commonly involves
imbalance in the autonomic nervous system (ANS).
ANS dysfunction can result in symptoms of abdominal
cramps, diarrhea, nausea, rapid heart rate, dizziness,
faintness, and feeling sweaty.
Chemical messengers may not function correctly. For
example, dysfunction involving histamine can cause
abdominal cramping, nausea, diarrhea, and flushing
(face and chest turning red).
YOU
GUT
It’s important to understand a little normal GUT
anatomy and physiology before learning about GUT
dysfunction as another cause of IBS and FGIDs (Figure
2.26).
HEAD
CONNECT
GUT
Figure 2.26
The GUT includes a second brain and is a sixth sense.
Your GUT responds to chunks of the environment in
the food and substances that you eat. GUT contents of
bile acids, enzymes, and resident bacteria are also
involved.
Your GI tract (GUT) is 30 feet long. Amazingly, the total
surface area of the GUT is about the size of a football
field! Figure 2.27 explains how this is possible.
The inside lining (mucosa) has
many folds visible to the eye
The gut is a long tube
(about 30 feet)
Very tiny villi on vill require an
electron microscope to see
Tiny villi of the lining require a
microscope to see
Gut cells
Figure 2.27
The GUT has a surface area
about the size of a football field.
Research shows that many patients suffering with IBS
have abnormalities in their GUT itself, which can
require special research techniques to detect. These
findings usually cannot be shown with regular tests,
such as lab tests, x-rays, scans, and scopes. The role
these findings play in causation of pain and symptoms
is not yet clear and is the subject of considerable
research.
• Increased GUT leakiness (“permeability”)
The GUT is normally permeable to permit absorption
of nutrients and to allow secretion of digestive juices.
There is no single diagnosis of “leaky gut syndrome.”
However, alterations in permeability can be found in
some diseases, including IBS and IBD.
• Microscopic inflammation in GUT lining
• Activation or alteration of certain chemical
messengers
• Changes in immune cells and their chemical
messengers
Remember to picture your colon and small intestine as
a transmission tower silently sending your GUT
feelings 24/7 to the radio in the SENSITIVITY system
of your mind/brain. However, your GUT also directly
causes dysfunction (Figure 2.28).
SENSITIVITY
MOTILITY
BACTERIA
Figure 2.28
There are three main types of small intestinal and colon
dysfunction that contribute to the causes of IBS.
All three fundamental types of GUT dysfunction are
treatment targets:
• Sensitivity
Heightened sensitivity to pain and symptoms
involving the GUT is related to dysfunction
involving both central sensitivity and visceral
sensitivity. Recall the analogy of the speaker with a
high volume control setting.
•
Motility affects GUT and colon contraction and
movement of content forward. Dysfunction of
motility includes spasm (pain), which can result in
gas trapping and altered movement (too fast—
diarrhea; too slow—constipation).
•
GUT bacteria (the “microbiome”)
Hundreds of different bacteria live in the GUT. This
“microbiome” plays an important role in both
digestive as well as overall health. Dysfunction of the
microbiome, called “small intestinal bacterial
overgrowth” (SIBO) can cause or contribute to the
symptoms of IBS.
As there are stressors that trigger dysfunction in the
mind/brain of the HEAD, stressors trigger dysfunction
in the second brain of the GUT (Figure 2.29).
Figure 2.29
GUT Stressors
• Diet
• Ingested substances
• Infections
• Medications and antibiotics
• Inflammation
• Bile acids
• Gut bacteria (microbiome)
• Menstruation
GUT pain and symptoms are themselves stressors that
affect your HEAD, which in turn can worsen them. It’s
another vicious circle (Figure 2.30).
HEAD
GUT
IBS
Figure 2.30
GUT pain and symptoms stress the HEAD.
The HEAD worsens all pain and symptoms.
It’s vicious circle.
At both the conscious and subconscious level, IBS pain
and symptoms stress the four mind/brain systems.
They “mess with your HEAD,” increasing pain and
symptom sensitivity, negative thoughts, stress
reactivity, and depression/anxiety. In turn, your HEAD
then worsens pain and symptoms not only in your GUT, but
also in your whole body.
The Biopsychosocial Model Revisited
Now you see the complex systems dysfunction that
causes IBS also causes other FGIDs and central
sensitivity syndromes, as it affects the whole YOU
(Figure 2.31).
THOUGHT
HEAD
Conscious
Subconscious
Memory
SENSITIVITY
Pain & Symptoms
STRESS
CONNECT
EMOTION
Depression
Anxiety
YOU
GUT
Gender
Nature/Nurture
Figure 2.31
The Biopsychosocial Model of Functional GI Disorders
(FGIDs) and Central Sensitivity Syndromes
Disease is dysfunction. Pain and symptoms are the
expression anywhere in the GUT and body. The target
now includes the entire GI tract, and the whole body is
enclosed in a red rectangle.
Chapter 3
How Can I Get Well?
Key West, Florida
Finding
balance
You will know how to get well with IBS.
It’s likely that you decided to embark on the journey of
reading this book because you’ve been overwhelmed
by information (and misinformation) regarding IBS and
chronic pain. But you’ve studied the important and
relevant information here, placed it in context, and now
you understand. This is knowledge, and knowing the
answers to the first two questions here is therapeutic. It
validates your symptom experience and empowers you
to take charge of your health.
You’re ready to know your treatment opportunities.
The answers to the third question, How can I get well?
are provided for you in the next 4 chapters.
Wisdom is application of knowledge. There’s usually no
one way to get better. You’re going to need to explore
“HEAD,” “CONNECT,” and “GUT” therapeutic
options with your doctor and caregivers.
My colleague, Rick Edgin, says you’re going to need to
“tinker” to find what works best for you. He’s right.
Everyone is unique. A lot of trial and error may be
necessary.
Sections in Chapter 3
How Can I Get Better?
IBS Involves Your Whole Body
HEAD
Change your brains
Self-care
Diary
Start here, right now
Medication
Antidepressants
Anticonvulsants
Miscellaneous drugs
Sleep
Opioids (narcotics) and non-steroidal antiinflammatory drugs (NSAIDs)
CONNECT
GUT
IBS Involves Your Whole Body
To get well, you have to see the biopsychosocial “big
picture” of the whole YOU (Figure 3.1).
THOUGHT
HEAD
Conscious
Subconscious
Memory
SENSITIVITY
Pain & Symptoms
STRESS
CONNECT
EMOTION
Depression
Anxiety
YOU
GUT
Gender
Nature/Nurture
Figure 3.1
Getting well with IBS requires a biopsychosocial
therapeutic approach to your environmental responses
involving HEAD, CONNECT, and GUT.
HEAD
HEAD therapy targets heightened pain and symptom
sensitivity in the brain, negative thoughts and effects of
old hurts, emotional distress, and harmful stress by
using mind-body management, which may also
include medication (Figure 3.2).
Figure 3.2
HEAD Therapy for IBS
Change your brains
Stress, emotional distress, and the mind can make life
and living with IBS more or less difficult. Science
confirms stress management and therapeutic mind/
body approaches can improve dysfunction of all 4
mind/brain systems by reducing sensation of pain
(SENSITIVITY), fostering positive cognitions and
dealing with old hurts (THOUGHT), decreasing stress
reactivity (STRESS), and improving mood (EMOTION).
Look at Figure 3.3.
THOUGHT
HEAD
SENSITIVITY
Conscious
Subconscious
Memory
STRESS
CONNECT
EMOTION
Depression
Anxiety
GUT
Figure 3.3
There are two brains to change (blue arrows).
Medical science has confirmed that the function and
actual structure of the brains can be changed for the
better at any age with the mind. Keep the following in
your mind:
• State of mind affects your whole body well-being
through your brains.
• Thoughts and emotions change the activity of genes
in nerve cells, which alters pathways in the brain.
• Your brain can be nurtured and trained to transform
your life through self-awareness and conscious
intention.
• There are many ways to manage stress, including
conscious breathing, exercise, and mind/body
techniques.
Here’s a simple mind/body technique. Do you feel the
shoe on your left foot? You probably didn’t until you read
the question. If you were hurting, it’s likely that your
shift in bodily attention resulted in reduction of the
intensity and distress of the pain. You can learn mind/
body techniques like this one on your own. You can
work with a health care professional to learn others,
such as:
• Relaxation training reduces autonomic sympathetic
nervous system arousal and stress reactivity.
Examples include mindful breathing and meditation,
(which can also be done during exercise) and yoga.
• Cognitive behavioral therapy (CBT) changes
maladaptive thoughts contributing to depression and
anxiety, which in turn can aggravate IBS symptoms.
• Hypnosis is an intervention that uses a special
mental state of enhanced receptivity to suggestion to
facilitate therapeutic psychological and physiological
changes.
• Biofeedback is a form of behavior training. It uses
continuous visual or auditory feedback of physical
activity to enable patients to learn how to voluntarily
control those bodily functions.
• Psychotherapy in all forms can help.
One example is existential psychotherapy, which
explores life, pain, and symptoms relative to four
basic conflicts that drive human behavior - both
adaptive and maladaptive. These four ultimate
concerns are death, freedom, existential isolation, and
meaninglessness.
Self-care
Answering the third question of this book involves
committing your whole being to getting better and
healthy.
Write your self-care plan down and modify it as
needed (Figure 3.4).
Mind/Brain
Spirit
Body
Figure 3.4
A self-care plan can be simple,
but it is most effective when written.
This sample can be replicated and used.
Diary
Scientific research clearly shows that writing your
observations, plans, and progress down can be very
beneficial in management and treatment of IBS, FGIDs,
and central sensitivity syndromes.
Keeping a diary will help you:
• Accept responsibility and take control for your own
health.
• Clarify your vision so you can begin to picture
yourself getting better and healthier.
• Transform intention into action.
• Partner with your doctor in a shared decisionmaking relationship.
• Document what does and doesn’t work, since
successful management often requires trial and error
and more than one treatment.
Start here, right now
You’ve learned that you are stressed and inflamed,
right down to your cells (Figure 3.5). The damage is
occurring without your awareness.
Cell
Figure 3.5
Stress and inflammation damage the body and brains
subconsciously, which contributes to the pain
and symptoms of IBS, FGIDs, and
central sensitivity symptom syndromes.
This silent injury hurts you by contributing to nervous
system sensitivity (recall the speaker with the high
volume control setting), which amplifies your pain and
symptoms.
It can even kill you (like with heart disease).
Here’s what every one of us must do to reduce stress
and inflammation:
• Eat an anti-inflammatory diet, beginning with
breakfast. One example of an anti-inflammatory diet
is the Mediterranean diet. The main goal is to keep
blood sugar low and stable, which reduces the
inflammatory effects of insulin spikes.
‣ Eat complex carbohydrates, mainly vegetables
and fruits (you’ll learn to avoid triggering foods
later).
‣ Limit saturated fats and eat omega-3 fats (consider
taking omega-3 supplements).
‣ Try to eat 25 - 30 grams of protein with meals.
Most people aren’t eating enough protein while
placing too much emphasis on carbohydrates.
• Exercise regularly.
There is clear, scientific evidence of benefit for IBS
and overall health. Walk 10,000 steps/day and/or
take a brisk 30 + minute walk on most days. Consider
including strength training.
• Achieve and maintain a healthy weight.
• Get adequate rest and sleep.
Medication
Several types of drugs, including certain
antidepressants can favorably affect all four mind/
brain systems by turning the central (mind/brain)
volume control for pain and symptoms down
(SENSITIVITY), reducing the stress response (STRESS),
and improving depression and anxiety (EMOTION).
This can clear the way for positive thoughts, intentions,
and constructive action (THOUGHT).
Definitions
Two terms are important to understand HEAD Down
drug therapy.
• “Off-label” therapy refers to the common practice of
prescribing an FDA (Food and Drug Administration)
approved drug for an unapproved disease (such as
IBS) or unapproved age group, dose, or form of
administration.
• “Augmentation” therapy refers to the use of a
combination of drugs from different classes in low
doses rather than one drug at a maximal dose.
Augmentation “combo” therapy is intended to
optimize synergistic and beneficial effects while
minimizing the potential for dose-dependent side
effects.
Treatment strategy
Keep the following in mind if you elect to try
medication:
• Start low, go slow, consider combo.
This means starting treatment with a low dosage and
gradually increasing dosage if needed. An alternative
to using high doses of a single drug is to combine
medications in lower doses to increase the benefits
and decrease side effect potential (augmentation
therapy).
• Be patient
Studies show that many patients give up on a
medication within the first week. It may take several
weeks for the drug or drugs to work. If side effects
do occur, they often diminish or disappear over time.
A given drug is not effective or tolerated by
everyone. Treatment often includes trial and error.
Antidepressants
The common association of emotional distress
(depression and anxiety) with chronic pain and
symptoms, including IBS confuses and frustrates both
patients and doctors. Remember that the four mind/
brain systems of SENSITIVITY, THOUGHT, STRESS,
and EMOTION overlap and talk, sharing chemical
messengers and nerve pathways (Figure 3.6).
Antidepressant
Figure 3.6
Antidepressants can relieve pain in doses lower than
necessary to treat depression. In full therapeutic dosage,
antidepressants can clear the way for positive thoughts,
lift mood, relieve anxiety, and reduce stress reactivity.
Sensitivity to pain and symptoms is more “sensitive” to
these antidepressants than is emotional distress. Therefore,
antidepressant drug doses lower than are necessary to
treat depression and anxiety are commonly prescribed
off-label to relieve pain and symptoms of IBS, other
functional GI disorders (FGIDs), and other central
sensitivity syndromes. Full dosing may be necessary if
significant depression and anxiety co-occur.
Note that antidepressants have an FDA Black Box
Warning of increased risk of suicidality in children,
adolescents, and young adults less than 24 years of age
suffering with major depressive or other psychiatric
disorders. Physiologic dependency (not addiction) can
occur with antidepressants, which requires gradual
tapering of dosage to reduce the possibility of
withdrawal symptoms.
Serotonin norepinephrine reuptake inhibitor
antidepressants (SNRIs)
These antidepressants increase brain levels of two
chemical messengers: serotonin and norepinephrine.
Affecting the “n” chemical messenger, norepinephrine
is particularly important in reducing central sensitivity
and heightened pain and symptom sensation.
SNRI tricyclic antidepressants (TCAs)
TCAs were the first antidepressants, which are rarely
used for this purpose now because of the emergence of
better antidepressants. Furthermore, high doses of TCAs
were necessary to treat depression, which were
associated with adverse side effects. Doctors have used
TCAs off-label in low dosage for many years to reduce
the pain and symptoms of dysfunction.
Examples of these TCAs are nortriptyline (brand name
is Pamelor); desipramine (brand name is Norpramin);
amitriptyline (brand name is Elavil); and doxepin (also
available as Silenor for treating insomnia).
Cyclobenzaprine (brand name is Flexeril) is approved
as a muscle relaxant, even though it is essentially an
SNRI TCA. It also has sedating properties that can help
with sleep.
The risk of side effects with TCAs is greatly reduced by
using very low doses. Furthermore, second generation
TCAs (nortriptyline or desipramine) are associated
with lower likelihood of side effects.
Potential TCA side effects include sedation,
constipation, rapid heart rate, urinary retention, dry
mouth, insomnia or nightmares, agitation, and weight
gain.
Cardiac arrhythmias that could be life-threatening are
very rare in low dose TCA therapy. An EKG or
cardiology consult may be recommended in the elderly
or for patients with a history of heart disease or a
family history of arrhythmias or sudden death.
SNRI antidepressants for fibromyalgia and also IBS
As you now know, IBS and fibromyalgia commonly
occur together. Both are functional symptom syndrome
central sensitivity syndromes, with similar brain
amplification of pain and symptoms.
Two SNRI drugs are approved for fibromyalgia and can
be used off-label for treatment of IBS and other central
sensitivity syndromes. Both drugs are currently being
tested in research trials for IBS treatment.
Cymbalta
Cymbalta is an antidepressant also used to treat
anxiety. In addition to fibromyalgia, the drug is
approved for treatment of chronic low back pain,
which is also a central sensitivity syndrome.
The most common side effects of Cymbalta are nausea,
headache, dry mouth, and constipation.
Savella
Savella is an SNRI antidepressant approved for
treatment of fibromyalgia but not studied for
antidepressant use. Savella has relatively more
norepinephrine than serotonin effects. The most
common side effect is nausea.
Other SNRI antidepressants
Two other SNRI antidepressants are venlafaxine
(generic name; original brand name was Effexor) and
Pristiq (no generics available).
Selective serotonin reuptake inhibitor antidepressants
(SSRIs)
SSRIs increase brain levels of the chemical messsenger,
serotonin. Unlike SNRIs, SSRIs do not affect brain
levels of norepinephrine. While SSRIs can be effective
for off-label treatment of IBS pain and symptoms, the
evidence for benefit is stronger for SNRIs that affect
norepinephrine levels in the brain and for anticonvulsant drugs. Regardless, SSRIs can have a
beneficial effect on overall well-being and any anxiety
or depressive symptoms associated with IBS. They can
be effective components of augmentation therapy in
IBS pain and symptom reduction.
Potential side effects of SSRIs are usually mild and
include nausea, diarrhea, sexual dysfunction
(decreased libido and delayed orgasm), anxiety,
nervousness, tremor, insomnia, and nightmares.
Available SSRI antidepressants include fluoxetine
(brand names are Prozac and Sarafem), paroxetine
(brand name is Paxil), sertraline (brand name is Zoloft),
citalopram (brand name is Celexa), and escitalopram
(brand name is Lexapro).
SSRIs may also have beneficial GUT therapy direct GI
effects. Since diarrhea can be a side effect of SSRIs, they
can be helpful in the treatment of IBS-C (constipation).
Paroxetine may be the best choice for IBS-D (diarrhea),
because it is the least likely SSRI associated with the
side effect of diarrhea.
Anticonvulsants
Anticonvulsants can be as effective as SNRIs in the
relief of chronic pain, including the pain of
fibromyalgia and as off-label treatment of IBS.
Lyrica
Lyrica is approved for treatment of fibromyalgia. The
drug is currently being studied as a treatment for IBS
and can be used off-label.
The two most common side effects of Lyrica are
dizziness and sleepiness, which may lessen or resolve
with time. A less common side effect is swelling of
hands, legs, and feet.
Gabapentin
Gabapentin is the generic name of Neurontin.
Gabapentin is similar to Lyrica, but it is not FDAapproved for fibromyalgia.
Miscellaneous Drugs
Three other drugs can be considered.
Mirtazepine
The original brand name of this drug was Remeron.
Mirtazepine is a tetracyclic antidepressant. It can also
be effective off-label as a hypnotic for sleep, antiemetic, and appetite stimulant.
When used off-label in treatment of IBS, the main
benefit of mirtazepine may be in augmenting the
benefit of the antidepressant and anti-anxiety effects of
other drugs, such as TCAs or SNRIs or when
symptoms of nausea or vomiting or low body weight
are present (such as with a co-existing eating disorder).
Buspirone
The original brand name of this drug was BuSpar.
Buspirone is a non-benzodiazepine anti-anxiety agent
that can augment the effect of antidepressants.
Buspirone may be helpful off-label in treatment of IBS
when functional GI disorders dyspepsia and/or
epigastric pain are associated.
Atypical antipsychotic drugs
These drugs were initially approved for the treatment
of schizophrenia, bipolar disorder, and as
augmentation to treat depression. One example is
quetiapine (Seroquel). Atypical antipsychotics can be
considered in off-label treatment of IBS and FGIDs with
or without associated emotional distress (depression
and/or anxiety) when symptoms are severe,
significantly interfere with quality of life and function
(missing work), and fail to respond to other GUT Up
and HEAD Down treatment and management,
including combination therapy with an SNRI or SSRI
together with a TCA.
The atypical antipsychotic drug can be added to an
SNRI or TCA in augmentation therapy. Collaboration
with a psychiatrist is usually advisable.
Sleep
Poor sleep can amplify the pain and symptoms of IBS,
FGIDs, and central sensitivity syndromes by adversely
affecting all four mind/brain systems.
Treatment considerations for insomnia include
anticonvulsants (Lyrica or gabapentin), giving the
higher amount at night; doxepin as the SNRI drug,
which is FDA-approved as a hypnotic: Silenor);
cyclobenzaprine; the atypical antidepressant trazadone;
the hypnotic zolpidem (brand name is Ambien); and
the hypnotic zalepion (brand name is Sonata).
Opioids (narcotics) and non-steroidal antiinflammatory drugs (NSAIDs)
Opioids and NSAIDs are usually not effective in
treatment of IBS, FGIDs, and related central sensitivity
syndromes. Both opioids and NSAIDs can have serious
side effects.
Opioid (narcotic) risks
Opioids can eventually worsen pain and cause GI
symptoms of nausea, vomiting, abdominal bloating,
distention, and constipation. They can even simulate
bowel obstruction (called the “narcotic bowel
syndrome”). Narcotics can lead to dependency and
addiction. Tramadol is an analgesic that can be
considered in treatment, because it also has SNRI
effects. However, tramadol does have opioid effects.
Patients and doctors may not be aware that tramadol
can result in dependency and addiction.
NSAID risks
NSAIDs can cause pain, ulceration, and bleeding
anywhere in the GUT, most commonly the stomach
and duodenum. NSAIDs can even cause strictures (scar
tissue) to form in the small intestine, which can result
in blockage.
CONNECT
Now you understand the role of dysfunction involving
your central nervous system, autonomic nervous
system, and chemical messenger system (Figure 3.7).
Figure 3.7
Connect Therapy for IBS
Your state of mind affects your entire body, including
your brains through the CONNECT. This is why you
can get better with self-awareness, conscious intention,
a self-care plan, and with drugs if needed.
GUT
You’ve come a long way on your journey and have part
of the answers to the third question,
How can I get well?
You’re ready to learn about GUT therapy options
(Figure 3.8).
Figure 3.8
GUT Therapy for IBS
GUT therapy helps the whole you by breaking the
vicious cycle of GUT pain and symptoms “messing
with your HEAD,” which in turn worsens pain and
symptoms in your GUT and whole body. So successful
treatment of GUT pain and symptoms can reduce
central sensitivity, which reduces pain and symptoms
of associated central sensitivity syndromes. It can also
reduce stress sensitivity, negative thinking and memory
recall, and depression/anxiety.
GUT therapy is discussed in following chapters:
Chapter 4: IBS-D (diarrhea)
Chapter 5: IBS-C (constipation)
Chapter 6: Belching and “Gas”
Chapter 4
IBS-D (Diarrhea)
Break
free
GUT Therapy: IBS-D (Diarrhea)
Getting well with IBS-D includes determining goals,
bowel retraining, considering psyllium fiber
supplements, dietary changes, enzyme therapy,
treatment directed to dysfunction of the GUT bacteria
(microbiome), and medication.
Sections in Chapter 4
IBS-D (Diarrhea)
Goals
Bowel Retraining
Psyllium
Diet
FODMAPS
Wheat and Gluten
Uncommon Dietary Approaches
Enzymes Supplements
Small Intestinal Bacterial Overgrowth (SIBO)
Medication
Goals
Reasonable goals in treating IBS-D include:
• No more than 3 complete bowel movements on
most days
• Minimal urgency to defecate
• The weekly average of your “worst abdominal pain
over the past 24-hours” rated 2 or less
If bowel function improves and abdominal pain and
discomfort continue despite GUT therapy described in
this chapter, HEAD therapy can help.
Bowel Retraining
Either initially or after completing this chapter and
getting better with treatment, you may be able to
retrain your bowel to regularly empty more completely
and predictably. Sit on the toilet for about 15 minutes
daily and try to completely empty the rectum. Many
people with IBS-D don’t spend enough time on the
toilet and must return soon several times.
Since eating stimulates colonic activity, the best time to
do this is 10 to 20 minutes after a meal and preferably
after breakfast. Realize that coffee is a bowel stimulant.
Don’t strain to have a bowel movement. If you are not
successful, go on about your life.
Be patient. Bowel retraining can take several weeks.
Psyllium
Psyllium is a unique, natural, non-gluten, nonfermentable fiber that is not absorbed. It promotes a
soft but solid stool form. While psyllium is most
commonly helpful in management of IBS-C, some
patients with IBS-D can benefit by taking a psyllium
fiber supplement. If psyllium triggers or aggravates
symptoms, it can always be discontinued.
There are additional benefits to taking psyllium daily.
Clinical studies have shown that 7 grams of soluble
fiber from psyllium taken daily as part of a heart
healthy diet low in saturated fat and cholesterol may
reduce the risk of heart disease by lowering LDL “bad”
cholesterol. Psyllium helps maintain low blood sugar
levels, which is anti-inflammatory. Because it is filling,
psyllium can also reduce appetite, which helps with
weight control.
Two main psyllium fiber supplements
In the United States, two main psyllium fiber
supplements are available by brand and in generic
equivalents.
• Konsyl (6.0 grams of psyllium per teaspoonful)
• Metamucil (3.4 grams of psyllium per teaspoonful)
How to take psyllium fiber supplements
• Begin with 3.4 to 7 grams of a psyllium fiber
supplement taken every day with meals (taking it
intermittently won’t help).
• As dosage is increased, it is best to take psyllium
more than once each day.
• Increase the dosage gradually over several weeks to
achieve the goals.
• Most people need 15 to 20 grams/day, but 30 to 40
grams/day and even more may be necessary.
• Be patient, because it can take several weeks to respond to
psyllium fiber supplements.
Remember, If psyllium triggers or aggravates
symptoms, it can always be discontinued.
Diet
Over one half of IBS-D patients suspect that eating
triggers symptoms immediately or up to 2 hours later.
Some patients report certain specific food triggers.
Historically, caffeine, alcohol, fat, and fiber have been
considered to be dietary triggers with little scientific
evidence to support the observation. Meals are
complex mixtures of many dietary components, and
the timing of symptom onset following ingestion can
vary, which makes identification of the dietary culprit
difficult.
Food and ingested substances don’t cause IBS. Instead,
certain food intolerances increase the likelihood and
intensity of food responses, which trigger symptoms. In
many patients with IBS, the gut is so responsive and
sensitive that eating anything triggers symptoms.
Keep four things in mind regarding diet and IBS. First,
research confirms that eating an anti-inflammatory
diet, such as the Mediterranean type diet, dramatically
reduces cellular inflammation and is important for
overall health. Eating an anti-inflammatory diet may
also reduce sensitivity in both the GUT and HEAD
brains.
Second, certain carbohydrates aren’t digested normally
in many patients with IBS, which results in
fermentation, gas formation, and dysfunction that can
trigger IBS pain and symptoms. Reduction or
elimination of these carbohydrates can help to relieve
IBS symptoms.
Third, wheat and gluten can trigger IBS symptoms.
You’ll soon see how and why.
Fourth, certain food chemicals and substances can be
IBS triggers. However, very little is understood about
this.
FODMAPS
Certain sugars, carbohydrates, and fiber in foods are
fermentable by the GUT bacteria. FODMAPS is an
acronym for Fermentable Oligosaccharides,
Disaccharides, Monosaccharides, And PolyolS.
Developed by Dr. Sue Shepherd, a low FODMAPS diet
avoiding the most common FODMAPS carbohydrates
has been scientifically shown to help around 75% of
patients with IBS-D and “gas.”
Dietary therapy should be tried for at least one month.
Consider working with a dietitian and/or consulting
Resources. The most important FODMAPS to restrict
and avoid are:
• Fructo-oligosaccharides (fructans)
Wheat and rye (in large amounts), onions, garlic (in
large amounts), artichokes, asparagus, inulin
(note that wheat contains both gluten and fructans)
• Galacto-oligosaccharides (GOS)
Legume beans, lentils, chickpeas
• Lactose
Milk, ice cream, soft unripened cheeses
• Fructose
Honey, apple, mango, pear, watermelon, high
fructose corn syrup (HFCS)
• Polyols
Apples, pears, stone fruits, mushrooms, prunes,
sugar-free mints/gums with sweeteners ending in
“ol”
Certain foods can inhibit carbohydrate digestive
enzymes (glucosidases): spicy foods, onions, garlic,
corn, and peppers.
Wheat and Gluten
Wheat contains poorly absorbed carbohydrates that
can trigger IBS symptoms, which is why wheat
restriction is a component of the low FODMAPS diet.
Celiac disease (celiac sprue)
Gluten is the protein in wheat, barley, and rye
responsible for celiac disease (CD) or celiac sprue.
Gluten damages the GUT lining through an immune
response in genetically susceptible individuals. CD
affects 1 in 100 people in the US and is considered in
the differential diagnosis of most patients with IBS-D
and/or “gas.” CD can rarely be associated with
constipation. CD is associated with impaired
absorption, but some patients are overweight or obese.
Many people with CD are undiagnosed, because it
does not necessarily cause GUT symptoms.
Non-celiac gluten sensitivity
Even more common than celiac disease is non-celiac
gluten sensitivity (NCGS), which is driving the multibillion dollar gluten-free food industry. NCGS may
influence GI symptoms through another type of
immune activation or alterations in intestinal leakiness
or permeability.
Gluten can trigger GUT symptoms in some IBS patients
who do not have celiac sprue, including loose stool and
diarrhea (often after eating), and/or “gas” (abdominal
bloating, distention, and flatulence). Eating a gluten
free diet can result in significant benefit of IBS
symptoms.
Some patients with NCGS have non-GI symptoms
regardless of whether they have IBS. These symptoms
include fatigue (the most common), headache,
attention deficit/hyperactivity disorder, depression,
and dizziness.
Distinguishing CD from NCGS can be difficult
The symptoms of both can be similar, and some
patients seeking diagnosis have been eating a gluten
free diet, which can cause falsely normal testing for
celiac sprue. Only patients with celiac sprue have
abnormal duodenal biopsies, which are obtained with
endoscopy. Celiac antibody blood tests can be positive
in patients with either celiac sprue or NCGS.
Celiac genetic blood testing (HLA-DQ2/DQ8) is
positive in virtually all patients with celiac disease.
Negative results exclude celiac disease. But 1 of every 3
people in the United States has positive celiac genetics
and most don’t have CD. They can have CD without
symptoms (+ duodenal biopsy), potential CD
(negative biopsy), or NCGS (negative biopsy). New
research shows that most patients with NCGS have
positive celiac genetic blood testing.
Diagnosis and treatment of NCGS
After testing for CD in IBS-D patients, a
2 - 4 week trial of a gluten free diet is necessary to
diagnose NCGS, since no diagnostic blood testing is
available and duodenal biopsies are normal. It is not
necessary to be as careful avoiding gluten in NCGS as
it is in CD, since GUT injury and malabsorption do not
occur.
If IBS and gas symptoms are relieved or improved and
a gluten free diet is continued, consultation with a
dietitian is advisable. Eating a gluten free diet can be
difficult and result in certain nutritional deficiencies.
Uncommon Dietary Approaches
Dietary triggering or exacerbation of symptoms may
persist despite the low FODMAPS diet, trial of glutenfree eating, and restriction of coffee, caffeine, alcohol,
and fiber. In this case, it is likely that the GUT is
hypersensitive to even normal amounts of digestive
tract content. Additional dietary approaches to
consider include a trial of a very low fat diet, very low
carbohydrate diet, and an elimination diet.
Very low fat diet (VLFD)
While some IBS patients find that fat triggers
symptoms, a VLFD has not been studied as dietary
treatment, as has eating a low FODMAPS diet.
Very low carbohydrate diet (VLCD)
A VLCD for IBS-D was shown to be beneficial in one
study. It is rarely used and difficult, requiring doctor
supervision and collaboration with a dietitian.
Elimination diet (ED)
There is no research using an ED to treat IBS-D,
restricting common food allergens (wheat, cow’s milk,
soy, eggs, fish, shellfish, peanuts, and nuts), specific
chemical substances in foods (naturally occurring or
added; salicylates, benzoates, penicillin, yeast, and
tartrazine), and restrictions on the use of personal
hygiene products and medications that contain these
chemicals. If an ED is considered, both an allergist and
dietitian should be be involved.
Enzyme Supplements
Four enzyme supplements may help digest certain
triggering carbohydrates, which can reduce IBS-D
symptoms and “gas.”
Lactase (beta-galactosidase)
Lactase is the enzyme that digests lactose (milk sugar).
Lactase treated milk can be purchased. Lactase enzyme
supplements are available without prescription.
Alpha amylase
Alpha amylase is contained in pancreatic enzyme
medications used to treat certain pancreatic diseases.
These drugs require a prescription and can be used offlabel as a treatment alternative. Two such drugs are
Zenpep and Creon.
Alpha amylase containing products can be purchased
without a prescription and identified on the web by
searching the National Institutes of Health Dietary
Supplement Label Database.
Beano (alpha-galactosidase)
Beano is a dietary supplement that breaks down
polysaccharide and oligosaccharide carbohydrates in
foods, especially raffinose. Beano can help prevent gas
and abdominal discomfort from beans, vegetables, and
whole grains.
It is necessary to take Beano before eating as a
preventative.
Xylose isomerase
Fructose is broken down by xylose isomerase. One
brand name of a product containing xylose isomerase is
Fructosin.
Small Intestinal Bacterial Overgrowth (SIBO)
(refer to Resources for details of SIBO)
SIBO refers to alterations in the types, numbers, and/or
location of GUT bacteria. Hundreds of different
bacteria live in the GUT. This “microbiome”) plays an
important role in both digestive as well as overall
health, even though it is not yet understood. SIBO can
be associated with several GUT diseases, including
IBS-D, IBS-C, and “gas” (abdominal bloating,
distention, noisy bowel sounds, and flatulence). SIBO
can be treated.
Diagnosis of IBS-D/SIBO
Hydrogen breath testing following ingestion of a nonabsorbed carbohydrate called lactulose supports
diagnosis of SIBO (Figure 4.1).
Lactulose
(Carbohydrate)
Hydrogen Gases are measured
in the breath
Methane
Figure 4.1
Small intestinal bacteria break lactulose down into one or
both of two colorless gases, depending upon the types and
numbers of bacteria. Elevated levels of hydrogen are
evidence of SIBO. Detection of methane is found in 1/3
of people and can be associated with constipation,
which will be discussed in the next chapter.
Hydrogen breath testing is not perfect. It may not
always detect SIBO. Furthermore, a positive test for
SIBO does not assure that treatment will be effective. A
caveat: SIBO cannot be diagnosed with stool tests. Some
laboratories make misleading claims that “dysbiosis”
can be detected by stool testing.
Sudden onset of symptoms with food poisoning can
result in IBS, which becomes complicated by SIBO.
Treatment of IBS-D/SIBO without medication
It is usually first necessary to treat SIBO with a
unique antibiotic regimen, which will be discussed in
the next section.
PPI acid reducers
Stomach acid kills most ingested bacteria, and there is
evidence that reduction of stomach acid secretion by
strong acid reducing drugs called, proton pump
inhibitors PPIs) can promote SIBO. Examples of PPIs
include Prilosec (generic name is omeprazole),
Nexium, and Prevacid (generic name is lansoprazole).
Many patients with chronic heartburn can reduce
dosage or frequency of PPIs or switch to much less
potent acid reducing drugs called H2RAs (histamine-2
receptor antagonists). Examples include cimetidine
(brand name is Tagamet), ranitidine (brand name is
Zantac), and famotidine (brand name is Pepcid).
Motility dysfunction
Altered intestinal function promotes SIBO (Figure 4.2).
MMC
Figure 4.2
The migrating motor complex (MMC) of the small
intestine is like a broom and “housekeeper of the gut,”
cleaning the small intestine every 90 to 120 minutes
during fasting by sweeping contents (including bacteria)
into the colon. Dysfunction of the MMC occurs in most
patients with IBS, which can result in small intestinal
bacterial overgrowth (SIBO). The MMC is deactivated by
eating and stress. So avoidance of snacking, stress
management, and exercise can help reduce SIBO.
Antibiotics
While some IBS-D patients benefit by antibiotics, others
find that their symptoms are worsened by them.
Antibiotics are generally overused and should only be
taken when necessary.
Probiotics
These are microorganisms that may confer a health
benefit on the host. Lactic acid bacteria and
bifidobacteria are the most common types of microbes
used in probiotics. Very little is known about using
probiotics to manipulate GUT bacteria for health. Over
500 different bugs live in the GUT, and it is unlikely
that any one probiotic will prove to be of benefit in
treating and preventing SIBO.
“Probiotics: A Consumer Guide for Making Smart
Choices” is available by the International Scientific
Association for Probiotics and Prebiotics, or ISAPP
(www.ISAPP.net). The guide advises that there are five
criteria consumers should consider when selecting a
probiotic: probiotic strain, proof, packaging, quality,
and quantity.
Use of probiotics to treat IBS/SIBO is trial and error, and
they should be taken for at least one month before a
judgement is made about response to treatment.
Based upon research, 4 probiotics may help improve
IBS symptoms:
• Activia yogurt (constipation) www.Activia.com
• Align www.AlignGI.com
• Florastor www.Florastor.com
• VSL#3 www.VSL3.com
Opioids or narcotics
These drugs can cause or contribute to SIBO by causing
dysfunction of motility and peristalsis. If they are
continued, it can be difficult or impossible to
successfully treat SIBO and/or prevent relapse.
Treatment of IBS-D/SIBO with Xifaxan
Xifaxan is a unique antibiotic that has been found to be
the most effective antibiotic treatment for IBS-D/SIBO,
and it will likely be approved by the FDA in the near
future. Xifaxan is not absorbed, so the risk of side
effects is minimal.
Meanwhile, many gastroenterologists prescribe Xifaxan
off-label for IBS-D/SIBO. The drug is taken for 10 to 14
days. (Treatment was 14 days in research, but 10 days is
usually effective and reduces cost.) It does not matter if
Xifaxan is taken on an empty stomach or with food.
Restricting carbohydrates during treatment can reduce
likelihood of response, because the bacteria protect
themselves. A regular diet should be eaten during treatment.
Prevention of Relapse of IBS-D/SIBO
If IBS-D/SIBO responds to treatment, symptoms can
return up to 9 months later. Relapse soon after
discontinuation of treatment can be a clue that the
differential diagnoses of IBS-D may need to be reconsidered.
In addition to following treatment of IBS-D/SIBO
without medication, the likelihood of relapse can be
reduced by medication taken at bedtime to promote
normal function of the MMC and by dietary therapy to
prevent bacteria return and regrowth.
Medication
Three medications can be used to promote the MMC.
• Erythromycin is an antibiotic used here off-label for
its effects on the MMC. Erythromycin is taken in very
low dosage daily at bedtime. Side effects of
erythromycin with this regimen are uncommon and
include nausea, abdominal pain, and diarrhea.
Potential serious and unpredictable allergic reactions
can occur with erythromycin, as they can with any
antibiotic that is absorbed.
• Resolor (generic name is prucalopride) is approved
for treatment of constipation and IBS-C in many
other countries and will likely soon become FDA
approved in the United States. Until then, health
insurance will not pay for Resolor. It can be obtained
through Canadian pharmacies.
A low dose of Resolor is taken at bedtime. Potential
side effects include headache, nausea, diarrhea, and
abdominal pain.
• Naltrexone is FDA approved for treatment of opioid
addiction and alcohol dependence. A very low
dosage is taken at bedtime, which is much lower than
used to treat opioid and alcohol dependence and
addiction. Potential side effects of low dose
naltrexone include insomnia, nausea, headache,
abdominal pain, muscle aches, rash, dizziness,
fatigue, and dizziness.
Dietary Therapy
In addition to medication, it is also necessary to change the
diet. Carbohydrates are the main food source for the
small intestinal bacteria. So carbohydrates feed the
bacteria and worsen SIBO, and the bacteria ferment the
carbohydrates, releasing gas.
While the low FODMAPS diet can be effective, the
easiest SIBO preventative diet to follow is the Low
Fermentation Diet developed by Mark Pimentel, M.D.
with Cedars Sinai Hospital in Los Angeles (see
Resources). The diet is not low carbohydrate and
allows grains refined as wheat (gluten), rice, and also
starchy vegetables. It avoids dairy and beans.
Sweeteners: avoid corn syrup (including non-diet
soda), mannitol, sorbitol (often found in gum),
sucralose (Spenda), lactose, and lactulose. Acceptable
sweeteners are glucose, sucrose (table sugar), and
aspartame (Equal or NutraSweet).
Dairy: these products are best avoided initially because
of lactose content. Lactase containing enzymes and/or
lactose-free milk can be used.
Soy: some people find that soy products are not
tolerated.
Fruit juice: limit food and food products sweetened
with fruit juice, which contains fructose.
“High residue” foods: limit or eliminate beans (kidney
beans, garbanzo beans, pinto beans, etc.), lentils, and
peas (including split pea soup).
Fruits: can be eaten in moderation (no more than 2
servings a day). Fruits contain fructose, which is
fermentable. Dried fruits concentrate the fructose and
should be limited.
Vegetables: fresh, non-starchy vegetables are healthy
foods. Consider eating 3 - 5 cups of cooked vegetables
daily. Cooked or lightly steamed vegetables are
preferable to raw vegetables, because they are easier to
digest and absorb. Avoid large salads with raw
vegetables.
Potatoes, pasta, rice, bread, and cereals: these are
acceptable, although some people need to limit glutencontaining foods (wheat, pasta, bread, cereals). This is
trial and error. Some people have non-celiac gluten
sensitivity. While they do not have celiac disease, they
feel better in their GUT and overall when they restrict
or avoid gluten containing foods.
More Dietary Advice
Remember, a regular diet is eaten during the treatment
period. Then dietary changes are essential to reduce the
risk of SIBO relapse. There is no test to determine each
person’s best diet. Trial and error is involved.
It is important to space meals 4 - 5 hours apart and not
eat after going to bed. The MMC is only active during
fasting and is inactivated by eating.
Retreatment with Xifaxan
If IBS-D/SIBO responds to treatment with Xifaxan, it
can be used again effectively. Research shows that
retreatment with Xifaxan is effective up to 8 times. In
some situations, it may be necessary to continue a low
dose of Xifaxan indefinitely to prevent relapse.
Treatment of IBS-D/SIBO with alternative antibiotics
Other antibiotics have been reported to be effective, but
they have not been formally studied as has Xifaxan.
Furthermore, there is no research that favors one over
another. Unlike Xifaxan, most other antibiotics are
absorbed. One exception is neomycin, with less than
3% absorption. Antibiotics include risk of side effects
and allergy and may result in Clostridium difficile
infection. Antibiotics can also contribute to the
development of bacterial resistance, which has not been
a problem associated with Xifaxan to date.
Medication
Several medications are available for the treatment of
IBS-D.
Imodium
This is the brand name of loperamide, which is
available in generic form and can be purchased without
prescription. Treatment of IBS-D can result in
improvements in stool consistency, stool form, and
urgency. Loperamide is not sedating, non-addictive,
and safe to use during pregnancy and lactation.
Loperamide can be taken as needed or regularly. Side
effects are uncommon unless constipation occurs.
Loperamide has the added advantage of tightening the
anal sphincter muscle, which can be helpful if fecal
incontinence is also present.
Diphenoxylate-atropine
This antidiarrheal is available by prescription as the
generic of the original brand name, Lomotil. It is an
opiate that has never been formally studied as
treatment for IBS-D. However, gastroenterologists
know that it can be effective.
Because diphenoxylate is an opioid, it can be habitforming and associated with side effects, including
constipation, sedation, dizziness, and dry mouth.
Atropine is an anticholinergic drug added to
diphenoxylate to reduce potential for abuse, which is
consequently very uncommon.
Lotronex
This is the only FDA-approved drug available for the
treatment of IBS-D. Lotronex can improve global
symptoms (quality of life), abdominal pain, bloating,
and diarrhea (both stool frequency and urgency).
Lotronex can be considered as off-label treatment in
men. It was effective during research trials, but not
enough men were included for the studies to achieve
statistical significance.
Risks of Lotronex include severe constipation, which is
why the drug should be used for more severe cases of
IBS-D without associated troublesome constipation that
have not responded to treatment. While a form of
colitis (ischemic colitis) has rarely been reported in
patients taking Lotronex, the disease of IBS is itself a
predisposing factor to this form of colitis.
Bile acid sequestrants (BAS)
At least one third of patients diagnosed with IBS-D
have bile acid diarrhea (BAM), which can be very
effectively treated. Since a test for BAM is not available
outside of research centers, the diagnosis is based upon
response to treatment.
BAM symptoms are commonly triggered by eating.
They are related to GUT mishandling of livermanufactured bile acids which are necessary to absorb
fat. Normally, these bile acids are reabsorbed in the
lower small intestine (ileum) and reused by the liver. In
BAM, the bile acids are not reabsorbed properly and
enter the colon where they cause dysfunction. This
commonly occurs after cholecystectomy and Crohn’s
disease.
BAS used to lower cholesterol bind bile acids and can
be prescribed off-label to relieve IBS-D symptoms
related to BAM. These drugs include cholestyramine
(powder), colestipol (tablets and powder), and Welchol
(tablets). They are not absorbed and have very little
potential to cause systemic side effects. Cholestyramine
and colestipol (less likely Welchol) interfere with
absorption of some drugs and vitamins, which should
be taken at least one hour beforehand. Potential GUT
side effects of bile acid sequestrants include
constipation, nausea, and “gas” symptoms.
When effective, BAS work within the first 1 - 2 weeks
and then must be continued indefinitely. The optimal
time of treatment is at bedtime, and most patients with
BAM require dosing twice daily. Some patients with
BAM are very sensitive to BAS. For example, only one
pill of colestipol or Welchol taken daily may be
adequate. If constipation occurs after treatment is
initiated, dosage can be lowered to achieve satisfactory
symptom relief.
Welchol may have three advantages in treating IBS-D
associated with BAM, because it is less likely to
interfere with absorption of other medications, research
has shown benefit, and it may be effective when the
other two drugs are not.
EnteraGam
EnteraGam is a prescription medical food product for
the management of IBS-D that is not absorbed and
works in the GUT to improve diarrhea, absorption,
immune function, and permeability ("leakiness"). The
main ingredient of EnteraGam is a protein that works
with the body's defenses in the GUT. This protein is
serum-derived bovine immunoglobulin/protein isolate
(SBI), which is composed of beef proteins. EnteraGam
does not contain any milk products, such as lactose,
casein, or whey. It is gluten free, dye free, and soy free.
Enteragam contains a form of sugar, called "dextrose"
to help with mixing in liquids and with taste and also a
sunflower-derived ingredient called, "lecithin" to help
the powder dissolve easily. EnteraGam is a powder that
easily dissolves in liquids and can be mixed with foods.
There are no restrictions on the length of therapy of
EnteraGam, and no serious side effects have been
reported. Side effects are no more likely to occur than
with placebo and are seen in less than 5%: mild nausea,
constipation, stomach cramps, headache, and increased
urination. EnteraGam should not be taken by patients
allergic to beef protein. Pregnant and nursing patients
should not take EnteraGam even though it is not
absorbed, because it has not been studied in these
populations.
Antispasmodics
Antispasmodics can improve intermittent abdominal
pain and discomfort, particularly if triggered following
meals. They are unlikely to relieve diarrhea. Examples
of generic antispasmodics requiring prescription
include dicyclomine and hyoscyamine.
Potential side effects of antispasmodic drugs can
include sedation, dizziness, dry mouth, and
constipation. Side effects are more likely to occur in the
elderly.
Peppermint has been used for digestive symptom relief
for centuries. It has been shown to have antispasmodic
effects, which can relieve IBS pain. Most products have
an enteric coating that prevents the peppermint from
dissolving in the stomach where it can cause heartburn.
Peppermint containing antispasmodics do not require a
doctor’s prescription. One such product is called,
CompleteRelief®.
Antispasmodics with anti-anxiety drug
Two antispasmodics also include an anti-anxiety drug.
They have the same potential side effects of
antispasmodics and greater likelihood of causing
drowsiness.
Donnatal
Donnatal is the brand name for a drug that includes
antispasmodics (belladonna alkaloids) and
phenobarbital. Phenobarbital is a barbiturate that has
sedative and anti-anxiety effects. It is rarely used for
these purposes now.
Librax
Librax is the brand name of a drug now discontinued
but available in generic form. It includes an
antispasmodic (clidinium) and a benzodiazepine antianxiety drug (chlordiazepoxide). The original brand
name of chlordiazepoxide was Librium, which is
related to diazepam (original brand name was Valium).
Antidepressants
If needed to treat depression/anxiety or reduce pain
sensitivity, SNRIs may be helpful in off-label treatment
of IBS-D as direct GUT therapy because of the common
side effect of constipation. If SSRIs are used, paroxetine
is less likely than others to cause diarrhea.
Chapter 5
IBS-C (Constipation)
St. John
New Brunswick
Canada
Stones
and
rocks
GUT Therapy: IBS-C (Constipation)
Getting well with IBS-C involves determining goals
and prioritizes improving bowel function by following
new constipation management guidelines. Associated
obstructed defecation requires treatment. Two drugs
are available to treat IBS-C, which may also be
amenable to treatment if SIBO is associated.
Sections in Chapter 5
IBS-C (Constipation)
Goals
Remove the Hard Stool Plug
Bowel Retraining Program
AGA Guidelines
Psyllium fiber supplements
Osmotic agents
Laxatives
Prunes
Obstructed Defecation
Medication
Small Intestinal Bacterial Overgrowth (SIBO)
Goals
Reasonable goals in treating IBS-C include:
• At least 3 complete bowel movements each week,
which are comfortable and do not require hard
straining
• The weekly average of your “worst abdominal pain
over the past 24-hours” rated 2 or less
• Initial emphasis is directed to improving bowel
function
The abdominal pain and discomfort of IBS-C usually
become increasingly severe on each consecutive day
without a bowel movement as the colon fills up with
stool.
So the abdominal pain and discomfort can be expected
to be relieved as bowel function improves. But if bowel
function improves and abdominal pain and discomfort
continue despite GUT therapy described in this
chapter, HEAD therapy can help.
Remove the Hard Stool Plug
Think of your colon as being “blocked” by a hard glob
of stool. If you add psyllium fiber to your diet and
begin other treatments, which will be discussed in the
next sections, your success may be jeopardized, as stool
“piles up” behind the blockage.
Begin by removing the “plug” with laxatives, enemas,
or even a colonoscopy prep. You can use whatever
works for you. This way you begin your program with
a “clean” colon.
Bowel Retraining Program
Think of this as behavioral modification for you and
your colon. Either initially or after completing this
chapter and getting better with treatment, you may
well be able to retrain your bowel to empty regularly
more completely and predictably. You’re going to
improve bowel function, with the expectation that your
abdominal pain and discomfort will then respond.
Current medications can be continued as prescribed.
The bowel retraining method includes:
• Sit on the toilet for about 15 minutes daily and try to
completely empty the rectum.
• The best time to do this is 10 to 20 minutes after a
meal with coffee.
• Don’t strain to have a bowel movement.
• If you are not successful, go on about your life.
• If you don’t have a bowel movement in 2 to 3 days,
insert a suppository into the rectum 30 minutes after
eating. It may eventually be possible to discontinue
the use of the suppositories.
• Be patient. Bowel retraining can take several weeks.
AGA Guidelines
New guidelines for the management of chronic
constipation, including IBS-C were published by the
American Gastroenterological Association in 2013.
Treatment of constipation is initially focused upon
improving bowel function with psyllium fiber
supplements, osmotic agents, and laxatives.
While dietary guidelines call for most people to eat 25
to 35 grams or more of fiber/day, most eat only about
15 grams/day. Some with IBS-C don’t benefit from
fiber or find that it makes them worse.
However, the potential benefit of using psyllium fiber
is commonly underestimated by both patients and
doctors. The keys are to understand what psyllium
fiber supplements are and know how to use them.
Psyllium fiber supplements
Psyllium (ispaghula) is a unique, natural, non-gluten,
soluble fiber that is not absorbed. There is scientific
evidence that psyllium fiber supplements (but not
insoluble dietary fiber, such as wheat bran) improve
bowel symptoms in IBS-C and chronic constipation.
There are additional benefits to taking psyllium daily.
Clinical studies have shown that 7 grams of soluble
fiber from psyllium taken daily as part of a heart
healthy diet low in saturated fat and cholesterol may
reduce the risk of heart disease by lowering LDL “bad”
cholesterol. Psyllium helps maintain low blood sugar
levels, which is anti-inflammatory. Because it is filling,
psyllium can also reduce appetite, which helps with
weight control.
Two main psyllium fiber supplements
In the United States, two main psyllium fiber
supplements are available by brand and in generic
equivalents.
• Konsyl (6.0 grams of psyllium per teaspoonful)
• Metamucil (3.4 grams of psyllium per teaspoonful)
How to take psyllium fiber supplements
• Begin with 3.4 to 7 grams of a psyllium fiber
supplement taken every day with meals (taking it
intermittently won’t help).
• As dosage is increased, it is best to take psyllium
more than once each day.
• Increase the dosage gradually over several weeks to
achieve the goals.
• Most people need 15 to 20 grams/day, but 30 to 40
grams/day and even more may be necessary.
• Be patient, because it can take several weeks to respond to
psyllium fiber supplements.
Psyllium and “gas”
If “gas” (abdominal bloating, distention, and/or
flatulence) seems to increase with psyllium therapy, it
commonly diminishes with regular daily use over time.
Psyllium fiber supplements are usually not directly
responsible for “gas,” because psyllium is not a
fermentable fiber. Chapter 6 provides more information
on management of “gas.”
Sometimes “gas” can be reduced by switching to an
alternative fiber supplement. Examples include
methylcellulose (brand name: Citrucel; generics
available,) calcium polycarbophil (brand name:
Fibercon; generics available), and Benefiber.
Osmotic agents
These products soften hard stool and can be taken as
often as daily. Osmotic agents are not absorbed.
Polyethylene glycol (PEG) is available as Miralax
without prescription (generics are available). It is a
powder, which is dissolved in water.
An alternative to PEG is a magnesium osmotic, such as
Phillips Milk of Magnesia, with generics available.
Laxatives
The new AGA constipation guidelines confirm the safety of
using stimulant laxatives and that they can be taken either
intermittently or even regularly and daily if needed.
•
Bisacodyl (a brand name is Dulcolax) is available
without prescription an can be used as often as daily,
either in oral form or as a suppository.
• Senna (a brand name is Senokot) can be taken in oral
form as often as daily.
• A suppository (brand names include Dulcolax or
Fleet) can be used 30 minutes after eating to
potentiate meal stimulated colonic contraction.
Prunes
Prunes contain a natural laxative in the peeling. Each
medium sized prune contains 1/2 gram of soluble fiber.
Prunes also contain sorbitol, which can be beneficial as
an osmotic agent. However, sorbitol is a FODMAP, so
there is a risk of aggravating IBS symptoms of
abdominal pain, discomfort, and “gas” with prunes.
Obstructed Defecation
Based upon the AGA constipation guidelines, if you fail
to respond to psyllium, osmotic agents, and laxatives,
then you and your doctor will consider further
evaluation to determine if you have both IBS-C and
functional obstructed defecation.
If a defecatory disorder (obstructed defecation) is
identified, then you can consider pelvic floor
retraining. The concept is similar to the bowel
retraining program described here for IBS-C. However,
pelvic floor retraining is more sophisticated and you’ll
need professional help. It involves biofeedback and
pelvic floor relaxation training therapy.
Research confirms that symptoms improve in more
than 70% of patients with defecatory disorders using
pelvic floor retraining. The method can be used to train
patients to relax pelvic floor muscles during straining
and to correlate relaxation and pushing to achieve
defecation. Then the non-relaxing pelvic floor is
gradually suppressed and normal coordination is
restored. Emphasis is placed upon appropriate
coordination of abdominal and pelvic floor motion
during evacuation. Several sessions may be necessary
(for example, 6 sessions lasting 30 - 60 minutes at 2
weekly intervals).
Medication
Several drugs can be helpful in treatment of IBS-C.
SSRIs
If IBS-C is present and an antidepressant is advisable,
SSRIs may be preferable. They can potentiate direct
GUT therapy because of their common side effect of
diarrhea.
Amitiza
Amitiza is approved for treatment of IBS-C in women
and chronic functional constipation in adults. The most
common side effects of Amitiza are nausea, diarrhea,
and headache. Nausea is less likely to occur if Amitiza
is taken with food. Occasional patients experience a
sensation of chest tightness and shortness of breath
within one hour of taking Amitiza. These symptoms
usually go away within three hours but may recur with
repeated use. The safety of Amitiza in pregnancy is not
established.
It is necessary to be patient taking Amitiza. Side effects
can resolve over time. Furthermore, relief from
abdominal pain, discomfort, and bloating may take
several weeks.
Linzess
Linzess is approved for treatment of IBS-C and chronic
functional constipation in adults. Linzess works
directly upon the GUT by increasing fluid secretion
and movement (motility and peristalsis) and by
reducing the activity of pain sensitive nerves.
The risk of systemic side effects with Linzess are
minimal, because the drug is not absorbed and works
directly on the GUT. The main side effect risk is
diarrhea. It is not known if Linzess will harm unborn
babies. It is also not known if Linzess passes into breast
milk.
The effect of Linzess on bowel function occurs within
the first week or so after initiation of treatment, which
can result in reduction of pain and discomfort.
However, the direct effect of Linzess on decreasing pain
and symptom sensitivity on the GUT can take several
weeks.
It is necessary to be patient taking Linzess for two
reasons. First, if diarrhea occurs, the drug is working.
Diarrhea is likely to resolve with time as the GUT
becomes accustomed to the drug. Second, the
abdominal pain, discomfort, and bloating relief may
not be fully realized for several weeks.
Small Intestinal Bacterial Overgrowth
IBS-C can be associated with SIBO (IBS-C/SIBO),
which may respond to off-label treatment with a
unique antibiotic called, Xifaxan, COMBINED with
another non-absorbed antibiotic called, neomycin. For
details on diagnosis and treatment of SIBO, refer to
Chapter 4 and Resources. About 1/3 of people have
GUT bacteria that produce methane, which can be
detected on hydrogen breath testing. This gas interferes
with GI motility and can either cause or contribute to
constipation.
Neomycin is a poorly absorbed antibiotic, so side
effects are rare (nausea, vomiting, and diarrhea).
Serious reactions are extremely rare and include injury
to the kidneys and ears (impaired hearing and/or
impaired balance) that can be permanent (primarily
associated with chronic kidney disease and/or long
term use over months).
A less studied off-label alternative to neomycin sulfate
is metronidazole, an absorbable antibiotic which is
taken by mouth for 10 to 14 days COMBINED with
Xifaxan. Possible side effect risks include nausea,
vomiting, diarrhea, indigestion, metallic taste, and
furry tongue. Other side effects are possible, but they
are rare.
Chapter 6
Belching and “Gas”
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Orlando, Florida
Fill ‘er up
Stones
and
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GUT Therapy: Belching and “Gas”
Most patients with IBS report troublesome symptoms
with belching and/or “gas,” even though these
symptoms are not a formal component of the disease
definition of IBS.
It’s first necessary to distinguish belching (the audible
— you and others can hear it— escape of air from the
esophagus into the mouth) from “gas” (abdominal
bloating, abdominal distention, noisy bowel sounds,
and/or flatulence and farting), because treatments are
quite different.
If belching and “gas” persist despite GUT therapy
directed to the predominant IBS subtype and the
advice offered in this chapter, HEAD therapy can help,
as discussed in Chapter 3 (How Can I Get Well?).
Sections in Chapter 6
Belching and “Gas”
Belching or “Eructation”
Treatment of Belching
“Gas”
Abdominal bloating
Abdominal distention
Noisy intestinal sounds or “audible borborygmi”
Flatulence or farting
Malodorous flatulence (smelly gas)
Treatment of “Gas”
Treatment of abdominal distention
Belching or “Eructation”
This is the audible (you and others can hear it) escape
of air from the esophagus into the mouth. There are
two types of belch: the gastric belch and supragastric
belch.
Gastric belch
This belch is the escape of swallowed air from the
stomach back into the esophagus and mouth. This is
the result of normal function (reflexes) and occurs 25 to
30 times a day. A gastric belch may or may not be
audible.
Supragastric belch
“Supra” means above, so this belch involves the
esophagus, which is above the stomach. The swallowed
air in the esophagus immediately escapes into the
mouth. Supragastric belches are not the result of a
reflex. Instead, they are the consequence of learned
behavior. The diaphragm is the breathing muscle that
separates the chest from the abdomen. When the
diaphragm contracts, it creates a negative pressure in
the chest and the esophagus, which “suctions” air into
the esophagus, where it is belched into the mouth by
straining. A few patients ingest air into the esophagus
by contracting the muscles at the base of the tongue
and throat.
Supragastric belching is most commonly associated
with stress and anxiety. Remember, much of what’s
happening occurs without conscious awareness.
Supragastric belching usually stops during speaking
and does not occur during sleep. It cannot occur if the
mouth is completely open, because swallowing is
difficult.
Supragastric belching can be associated with GERD
(gastroesophageal reflux). GERD symptoms of
heartburn and regurgitation are usually present, and
the associated symptom of belching usually responds
to GERD treatment. Rarely, supragastric belching can
be associated with heart disease, ulcer, gallstones, or
pancreatic disease.
Supragastric belching is a learned behavior. It is the
symptom of an FGID (“functional excessive belching”).
Treatment of Belching
The easiest way to “unlearn” supragastric belching is to
become aware of and then understand what is
happening and accept that abnormal gas production in
the stomach or upper intestine is not the cause.
Then supragastric belching can be controlled or
stopped by opening the mouth widely and breathing
through the mouth rather than nose, which reduces
swallowing (of air). A pencil or pen placed laterally in
the back of the mouth helps with this, because opening
the mouth virtually prevents swallowing.
Controlled abdominal breathing through the mouth is a
mind/body relaxation technique that diverts attention
and elicits relaxation and calming. Placing a hand or
both hands over the upper abdomen can help you learn
abdominal breathing. If belching does not eventually
stop, then consultation with a speech therapist or
cognitive behavioral specialist is the next step.
“Gas”
Symptoms include abdominal bloating, abdominal
distention, noisy abdominal and intestinal sounds, and
flatulence (farting).
Abdominal bloating
Bloating is a sense of pressure or fullness in the
abdomen. Abdominal bloating usually involves the
entire abdomen, but some patients can localize the
symptom to one or more areas of the belly. Bloating is
the symptom of an FGID (“functional bloating”).
Abdominal distention
Distention is actual enlargement of the abdominal
girth. About half of patients who describe bloating also
have abdominal distention. Both abdominal bloating
and distention are commonly triggered by eating and
can fluctuate through the day. Bloating and distention
are usually minimally present upon awakening and
become worse as the day progresses.
Abdominal distention is caused by an abnormal
accommodation reflex following meals or a bloating
stimulus. Normally, relaxation of the diaphragm and
some contraction of the upper abdominal muscles
occurs. Abdominal distention is caused by a reversal of
this reflex, called “abdomino-phrenic dyssynergia.”
The underlying cause of this abnormal reflex (Figure
6.1) causing abdominal distention is not understood,
but dysfunction of small intestinal motility (peristalsis),
gas movement and handling, and sensitivity are
involved.
Normal
Distention
Figure 6.1
Abdominal Distention
The diaphragm is shown in red.
Normally following a bloating stimulus or meal, the
diaphragm relaxes, becoming dome-shaped and ascending,
while the upper abdominal muscles tighten.
With abdomino-phrenic dyssynergia (dysfunction),
the diaphragm contracts, both flattening and descending
(down arrow) while the upper abdominal muscles relax,
causing the abdomen to enlarge forward (right arrow).
Noisy intestinal sounds or “audible borborygmi”
Loud gurgling, rumbling, and growling sounds coming
from the belly can be very embarrassing. Waves of
contractions, called peristalsis cause movement of
fluids and gas through the small intestines, which is
what causes the sounds.
Flatulence or farting
The average number of farts passed from the colon
daily is around 14, but many patients with IBS consider
farting to be bothersome and/or embarrassing,
regardless of number (Figure 6.2).
Range
7
Average # farts/day = 14
21
Figure 6.2
Normal daily flatulence
The amount of gas expelled each day normally ranges
from 1 to 4 pints. Part of it comes from swallowed air.
The major source of gas is fermentation of ingested
carbohydrates by the GUT bacteria: hydrogen, oxygen,
nitrogen, carbon dioxide, and, in about one-third of
people, methane, which is colorless and odorless).
Malodorous Flatulence
When farts have a bad smell, they contain hydrogen
sulfide, which is produced by fermentation of certain
sulfur-containing foods by GUT bacteria. Treatment of
“gas,” including excessive, bothersome, and or smelly
flatulence is discussed in the next section.
Treatment of “Gas”
Gas symptoms can respond to improvement of bowel
function. The initial treatment for “gas” associated with
IBS is directed to management of the bowel
dysfunction, which is based upon the predominant IBS
subtype: IBS-D and IBS-C.
Emphasis is then placed upon reducing and correcting
carbohydrate maldigestion and malabsorption.
Treatment includes diet, enzymes, and consideration of
small intestinal bacterial overgrowth (SIBO).
• Diet: Low FODMAPS
• Diet: Wheat and Gluten Restriction
• Diet: Malodorous Flatulence
Avoid sulfur-containing foods, including red meat
(the prime offender), cruciferous vegetables (broccoli,
cabbage, brussels sprouts, and cauliflower), garlic,
dried and sulfured fruit (e.g., apricots), certain
aromatic spices, and beer (for unexplained reasons).
• Enzyme Supplements (lactase, alpha amylase, and
Beano)
Lactase (beta galactosidase) Lactase is the enzyme
that digests lactose (milk sugar). Lactase treated milk
can be purchased. Lactase enzyme supplements are
available without prescription.
Alpha amylase is contained in pancreatic enzyme
medications used to treat certain pancreatic diseases.
These drugs require a prescription and can be used
off-label as an IBS-D treatment alternative. Two such
drugs are Zenpep and Creon. These drugs also
contain a fat digesting enzyme, called "lipase" that
can be helpful if fat malabsorption is also present.
Alpha amylase containing products can be purchased
without a prescription and identified on the web by
searching the National Institutes of Health Dietary
Supplement Label Database.
Beano (alpha-galactosidase) is a dietary supplement
that breaks down polysaccharide and oligosaccharide
carbohydrates in foods, especially raffinose. Beano
can help prevent gas and abdominal discomfort from
beans, vegetables, and whole grains. It is necessary to
take Beano before eating as a preventative.
• Small Intestinal Bacterial Overgrowth (SIBO)
IBS-D and IBS-C
Treatment of Abdominal Distention
Management requires trial and error, and the following
may help:
• Seeing a photograph of a patient with abdominal
distention and understanding the abnormal reflex of
abdomino-phrenic dyssynergia is validating and
provides reassurance that the problem is not
imagined or related to mental illness. This can be
therapeutic.
• Having a full colon and/or bladder can trigger
abdominal distention. Manage constipation and
empty the bladder regularly.
• Treating “gas” reduces the most important bloating
stimulus.
• Taking an antispasmodic or an antispasmodic
containing an anti-anxiety drug just before or with
meals can reduce the bloating stimulus.
• Visceral sensitivity in the GUT may be reduced with
medication to treat IBS-C (Amitiza and Linzess) or
IBS-D (Lotronex).
• Central sensitivity may be reduced, as discussed in
Chapter 3 (How Can I Get Well?), with HEAD
therapy
• Finally, apply self biofeedback and exercise to relax
the diaphragm and tighten the belly muscles.
Expire
Exercise
Distention
Normal
Figure 6.3
Treatment of Abdominal Distention with
Self-Biofeedback and Exercise
Figure 6.2 described the abnormal abdomino-phrenic reflex
responsible for abdominal distention. Here the illustrations
are reversed, with distention shown on the left.
The diaphragm is contracted, flat, and descended.
The upper abdominal muscles are relaxed.
Both responses result in forward enlargement of the abdomen.
Practice relaxing the diaphragm by deep expiration, which causes
the diaphragm to relax, assume a dome shape, and ascend.
Then practice tightening the upper abdominal muscles.
This can be considered a form of self-biofeedback.
Strengthen and tone the muscles abdominal muscles.
Consider physical therapy.
Afterword
Captiva, Florida
It’s
go time!
You’ve come full circle in your journey to find IBS
answers. You see the whole picture:
IBS is disease that involves the whole you.
You know what IBS is, what causes it, and your
treatment opportunities. If you apply HEAD,
CONNECT, and GUT therapy,” you can get well.
To take charge of your health, “be your own doctor,”
and work effectively with your doctors and caregivers,
you’ll want to study portions of this book carefully. It
will continue to be your IBS resource. The ebook
version will be updated periodically.
Check the website regularly for IBS news:
www.IBSAnswersForYOU.com.
You can find additional IBS help that I recommend in
Resources.
Being healthy is an active process. It takes work.
It really is “go” time.
It’s time to take care of yourself.
About the Author
It’sYou
never
goare
time!
alone
I received my M.D. degree from The Ohio State
University in 1972 and completed training in internal
medicine and gastroenterology at Vanderbilt
University Hospitals in 1977, where I also served as a
Chief Resident in Medicine. In 2012, following a three
year retirement, I returned to practice with the Ohio
Gastroenterology Group, where I had been a founding
partner.
Life is beautiful and mysterious, but it’s also difficult
and complicated for everyone. Life and IBS are truly a
vicious circle, and it’s increasingly difficult to find the
knowledge lost in information and misinformation
overload, particularly in the hurried patient - doctor
relationship.
I wrote this book for our patients at the Ohio
Gastroenterology Group and for you. I’m confident
you’ll find the help you need to see the whole picture
of you, get better, and become healthier than you’ve
ever been.
Updates
This PDF of the ebook is version 1.02. It will be
updated periodically. Check here first to learn what has
changed.
Check the website regularly for news, updates, and
errata: www.IBSAnswersForYOU.com
Eager
to
learn
Resources
Umbrella Girl
German Village
Columbus, Ohio
Don’t
forget your
shoes
Resources
Click here to see a list of the most common functional
GI disorders (FGIDs).
IBS Support Groups
International Foundation for Functional
Gastrointestinal Disorders (IFFGD)
IFFGD was founded by Nancy and Bill Norton in 1991
to help people suffering with functional GI disorders.
Rome Foundation
The mission is “To improve the lives of people with
functional GI disorders.”
Irritable Bowel Syndrome Self Help and Support
Group was founded by Jeffrey D. Roberts in 1987 and is
the first and largest on-line community for sufferers of
irritable bowel syndrome.
Resources
Patient-Physician Relationship
Douglas Drossman, M.D., is a gastroenterologist and
authority on IBS, FGIDs, and the biopsychosocial
model (The author has been profoundly influenced by
Dr. Drossman’s work.)
Clifton K Meador, M.D., writes books about the effects
of mind on body. (The author was Dr. Meador’s
student while training at Vanderbilt University
Hospitals. He considers Dr. Meador to be his most
important medical role model and the inspiration for
his personal and professional interest in the
mind/brain — body relationship.)
Resources
Low FODMAPS Diet
Sue Shepherd, Ph.D., dietitian, (developed the low
FODMAPS diet): Sue Shepherd, Ph.D. and Peter
Gibson, M.D. The Complete Low-FODMAPS Diet
(book). thelowfodmapdiet.com.
Patsy Catsos, M.S., R.D., (website and book, IBS -- Free
at Last). She provides a directory of Registered
Dietitians who have identified themselves as capable of
assisting clients with low FODMAPS diets.
Irritable Bowel Syndrome Self Help and Support
Group founded by Jeffrey D. Roberts has a simple,
printable low FODMAPS diet page that lists suitable
and unsuitable foods.
John Pandolfino, M.D., is a world renowned
gastroenterologist and esophageal expert at
Northwestern University who studies and treats
patients suffering with functional heartburn. (The
author and his esophageal expert colleague at the Ohio
Gastroenterology Group, John Castor, M.D., appreciate
the recent opportunity to spend time in the
Northwestern GI laboratory and study with Dr.
Pandolfino.)
Resources
Small Intestinal Bacterial Overgrowth (SIBO)
Mark Pimentel, M.D., is a gastroenterologist doing
pioneering research regarding the role of SIBO in IBS
and other FGIDs. He is the author of A New IBS
Solution. (The author appreciates his personal
conversation with Dr. Pimentel intended to provide the
latest recommendations for treatment of IBS/SIBO in
this book.)
Dr. Pimentel and the Ohio Gastroenterology Group
utilize hydrogen breath testing to diagnose SIBO
provided by Commonwealth Laboratories, Inc.
Click here to see a short video about how SIBO breath
testing is done. (The author appreciates the support of
Brian and Craig Strasnick of Commonwealth Labs.)
Click here to see Dr. Pimentel’s treatment algorithm for
IBS/SIBO.
K. Scarlata, dietician, “Small Intestinal Bacterial
Overgrowth - What to Do When Unwelcome Microbes
Invade.” Today’s Dietitian. April, 2011 (Vol 13) No. 4 P
46.
www.SIBOinfo.com is a very helpful resource on SIBO.
Resources
Psychology and Psychiatry
Barbara Bolen, Ph.D., is a clinical psychologist in New
York with special interest and expertise in IBS. She
serves as the Guide to Irritable Bowel Syndrome for
About.com.
Peter Zafirides, M.D., is a psychiatrist in Columbus,
Ohio with special expertise in chronic pain and
existential psychotherapy. He provides helpful
information on his website (Dr. Zafirides was one of
this author’s “star” students.)
David D Clarke, M.D., is a gastroenterologist with a
helpful website and book about “Stress Illness” (central
sensitivity syndromes).
Howard Schubiner, M.D. has a website, book, and
program for Mind Body Syndrome (central sensitivity
syndromes) based upon the work of John Sarno M.D.
M. Scott Peck, M.D., (book) The Road Less Traveled: A
New Psychology of Love, Traditional Values, and Spiritual
Growth. (This author considers this book to be one of
the best self-help books ever written.)
Resources
Central Sensitivity
Muhammad B Yunus, M.D., is a rheumatologist at the
University of Illinois at Peoria, IL who pioneered the
concept of central sensitivity and central sensitivity
symptom syndromes.
D. J. Clauw, M.D., is a University of Michigan
rheumatologist who researches and advances the
concept of central sensitivity and “chronic
multisymptom illnesses,” which are central sensitivity
symptom syndromes.
Manuel Martinez-Lavin, M.D., is a rheumatologist and
fibromyalgia expert in Mexico who researches and
writes about fibromyalgia, stress, central sensitivity,
and chronic pain.
Stress
Bruce S. McEwen, Ph.D., is a neuroscientist at The
Rockefeller University in New York and one of the
world’s leading experts on the damaging effects of
stress on the brain and body. He advances the concept
of allostasis and allostatic load and emphasizes the
resiliency and adaptability of the brain to change.
Resources
Change Your Brains
Superbrain (2012), is a new book by best-selling author
and physician, Deepak Chopra, M.D., and Harvard
neuroscientist, Rudolph E. Tanzi, Ph.D., explaining
how the brain and body can be changed for the better
by the mind with increased self-awareness and
conscious intention.
THOUGHT
HEAD
Conscious
Subconscious
Memory
SENSITIVITY
Pain & Symptoms
STRESS
CONNECT
EMOTION
Depression
Anxiety
GUT
YOU
Gender
Nature/Nurture
Figure 1.2 and 2.18
Biopsychosocial Model of IBS in Response to Environment
© William B. Salt II, M.D.
THOUGHT
HEAD
Conscious
Subconscious
Memory
SENSITIVITY
Pain & Symptoms
STRESS
CONNECT
EMOTION
Depression
Anxiety
YOU
GUT
Gender
Nature/Nurture
Figure 2.30
The Biopsychosocial Model of Functional GI Disorders
(FGIDs) and Central Sensitivity Syndromes
in Response to the Environment.
© William B. Salt II, M.D.
“IBS”
by Reese Knickle
(the author’s granddaughter)
IBS
Irritable Bowel Syndrome
A Gastroenterologist Answers Your Questions
William B. Salt II, M.D.
This book was written for patients of the Ohio
Gastroenterology Group, but it is available in all online
bookstores.
ISBN: 978-0-9657038-0-2 (Amazon)
ISBN: 978-0-9657038-1-9 (epub for Apple and Kobo)
ISBN: 978-0-9657038-2-6 (Aerbook)
Consult the author’s website for more details:
www.IBSAnswersForYou.com
(including the Aerbooks version)

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