What is IBS And How Does IBS Affect The Quality of Life?
Irritable bowel syndrome (IBS) is a gastrointestinal (GI) disorder that can cause patients to experience chronic and/or recurrent abdominal pain that can either be relieved, or further aggravated, by a bowel movement (defecation). IBS patients are typically classified according to whether they predominantly experience constipation (IBS-C), diarrhea (IBS-D) or a mix of both stool patterns.
It is estimated that almost 20% of the global adult population is affected by some form of IBS, thereby making this disorder the most common complaint to gastroenterologists around the world. There are various underlying causes that have been associated with IBS, of which include:
- Genetic factors
- Disturbances in Intestinal Microbiome
- Activation of the Immune System
- Disordered Bile Salt Metabolism
- Changed Brain Function
- Changes in Serotonin Metabolism
IBS and the Gut Microbiome
In a healthy individual, the intestine will contain a healthy microbiota that is comprised of more than a thousand microbial species. The microbiome is in a mutualistic relationship with each human being – that is, the microbes of the gastrointestinal (GI) tract harvest energy and nutrients obtained from the foods we eat to survive, and, in return, the microbiome protects our bodies against invasion from potentially harmful pathogens2. Changes in how these microbial organisms function, as well as their diversity within our intestines, has been associated with IBS.
How are IBS and SIBO Connected?
The overlap between small intestinal bacterial overgrowth (SIBO) and IBS has been extensively studied. SIBO, which is defined as an increase in the number of bacteria, which may or may not be accompanied by a change in the type of bacteria, within the proximal part of the small intestine. Quantitatively, SIBO is diagnosed in patients who have 105 or more colonies of bacteria present within each milliliter of small intestinal fluid (aspirate). It has been reported that up to 78% of IBS patients also suffer from SIBO3; therefore, the connection between these two conditions is extremely relevant.
The three main hypotheses connecting IBS and SIBO include:
- SIBO develops first, which is then followed by the development of IBS.
- IBS develops first and causes various motor and visceral disturbances to occur within the small intestine. This dysfunction promotes the overgrowth of bacteria to follow.
- SIBO and IBS are two entirely different disorders that do not have any similar physiological characteristics3.
|Frequency of SIBO in IBS Patients||Reference|
|34/76 (44.7%)||Park et al. (2010)|
|28/43 (65%)||Scarpellini et al. (2009)|
|55/127 (43%)||Carrara et al. (2008)|
|89/258 (34.5%)||Mann et al. (2009)|
|64/98 (65%)||Nucera et al. (2005)|
|157/202 (78%)||Pimentel et al. (2000)|
|14/59 (23.7%)||Sachdeva et al. (2011)|
|35/98 (36%)||Reddymasu et al. (2010)|
|49/200 (24.5%)||Lombardo et al. (2010)|
Table 1: Clinical studies that examine the prevalence of SIBO in IBS patients.
In the medical community, IBS is often referred to as a heterogeneous condition, which refers to the fact that a wide range of factors can contribute to IBS. These factors can include changes in the gut microbiome as previously mentioned, as well as changes in the permeability of the intestines (the ability of nutrients to easily pass through the GI tract), the ability of the immune system to function properly, changes in the movement of the intestines and much more.
The heterogeneity of IBS, which includes the ability of this disorder to cause patients to exhibit one type of stool pattern more often than another, can be used to support the connection that exists between IBS and SIBO. For example, SIBO patients will typically exhibit an excess amount of gas present within their GI tract as a result of the increased presence of gas-producing bacteria. An increased amount of gas often causes patients to experience more frequent bloating, which is often a complain of IBS patients.
What It’s Like to Live with IBS
While everyone experiences stomach aches at some point in their life, people with IBS often experience chronic pain and discomfort that can prevent them from performing normal daily tasks. In addition to these symptoms, additional digestive complains associated with IBS may include:
- Alternating bouts of constipation and diarrhea
- Bowel movements are difficult to pass
- May feel incomplete
- May be uncontrollably urgent
- Clear or white mucus within the stool5
One of the most troubling aspects of having IBS is being told that your symptoms are “all in your head.” The doubts that your friends, family and even health professionals may have on the reality of your symptoms can lead to vague diagnoses that may end up doing more harm than good.
The Brain and IBS
While it is clear that IBS is not just “all in your head,” there has been a significant amount of research connecting this GI disorder to structural changes that occur within the brain. For example, a recent study that has compared with brain anatomy of patients with IBS with healthy patients has found that patients with IBS consistently shown a thinning of the gray matter within their brain, which is an area of the brain that is particularly rich in neurons, which are the cells of the brain and spinal cord6. Thinning of this area of the brain can lead to a cascade of psychological problems, some of which include an oversensitivity to bowel sensations, inability to control emotions when faced with chronic pain, as well as the ability of IBS patients to control their pain. Additional brain-related symptoms associated with IBS can include lower back pain, anxiety, depression and headaches.
Living with IBS goes far beyond just taking your medications. Since there is ultimately no cure for this disorder, it is important for patients to recognize what types of foods and/or situations may trigger their symptoms to occur. As a result, it is often recommended that IBS patients keep track of their symptoms throughout the day. In a symptoms journal, patients are urged to write down when they experience stomach pain, any type of discomfort, bloating, diarrhea or constipation, as well as what what they were doing when these symptoms came on.
- What symptoms are you feeling?
- How did that symptom make up feel?
- What did you eat right before you began to feel this way?
- What medication did you take before you began to feel this way?
- Did eating some type of food make your symptom(s) go away?
- Did taking a certain medication help your symptom(s) improve?
By taking detailed notes on their symptoms and any factors that may have contributed to them, patients can use this information to determine any lifestyle factors that may trigger their IBS symptoms to flare. Furthermore, patients can work with their doctors to better recognize these triggers to ultimately devise a treatment plan, such as modifying their current diet or treatment regimen(s) in some way, to prevent these problems and/or symptoms from controlling the patient’s life.
The Challenges of Treating SIBO
Since SIBO and IBS patients often experience similar symptoms, it is extremely common for SIBO to be misdiagnosed by physicians as IBS. Furthermore, since SIBO patients can experience a wide range of symptoms, it is also not uncommon for this disorder to be undiagnosed altogether. As a result, the symptomatic treatment of patients may provide temporary relief to their symptoms, but ultimately does little to address the root of the problem.
Current Treatment Options for IBS
The incorporation of various diets has been shown to dramatically alleviate IBS-related symptoms to ultimately improve quality of life. Some of the most common diets that have been used by IBS patients include:
Low FODMAP Diet
FODMAP is an acronym that describes the five different sugars commonly found in foods, of which include fermentable, oligosaccharides, disaccharides, monosaccharides and polyols. Each FODMAP sugar is associated with poor absorption within the small intestine, as well as the ability to rapidly ferment, both of which can lead to increased GI symptoms such as bloating, gas, abdominal pain, nausea, diarrhea and/or constipation. Numerous clinical studies have found evidence supporting the success of a low FODMAP diet for both IBS and SIBO patients.
To find out more about exactly what a low FODMAP diet entails, click here.
Increasing your fiber intake will increase the bulk of your stools to ultimately push stools through your intestines at a fast rate. As a result, some IBS patients have found that increasing their fiber consumption through foods such as fruits, vegetables and whole grains can help to alleviate their constipation. While this may be true for some patients with IBS, it is crucial to recognizes that high fiber diets may actually make IBS symptoms worse, especially when SIBO is being considered. Therefore, it is highly recommended that you speak with your doctor before incorporating high-fiber foods into your diet.
As previously mentioned, high-fiber foods can actually worsen IBS symptoms. If you have experienced worsening symptoms after consuming high-fiber foods and are considering completely eliminating fiber from your diet, it is instead recommended that patients focus on ingesting food products that contain more soluble fiber. Since soluble fiber dissolves better in water, patients can better digest these food products and benefit from the good properties of fiber without experiencing any unwanted symptoms. Some foods that contain soluble fibers include:
It is not uncommon for people who are gluten-intolerant to also experience IBS. In this type of situation, the elimination of grain products such as barley, rye and wheat from your diet may improve IBS symptoms.
The elimination of certain foods for a given period of time may help patients figure out if a specific food is causing their symptoms to worsen. Some of the main food items that patients tend to eliminate first include coffee, chocolate, insoluble fiber and nuts. It is recommended that patients eliminate a single food item for about 12 weeks and note down any differences that may occur in their symptoms in their symptoms journal before moving on to the next food item to be eliminated.
When bacterial overgrowth is expected, it is common for physicians to turn to antibiotic treatment. Antibiotics are often used to specifically target the bacterial strains that are growing uncontrollably within the small intestine of SIBO patients. Rather than completely remove all bacteria from the GI tract, since a healthy amount of bacteria does play an important role in our bodies, antibiotic treatment for SIBO patients is focused on improving the symptoms that may be caused by an increase in the number and/or diversity of these bacteria.
Unfortunately, it is very difficult for physicians to specifically target bacteria for each patient through antibiotic treatment. As a result, the scientific community does not have a standard choice of what type, dose and/or duration of antibiotics should be used for SIBO treatment. Physicians will therefore prescribe antibiotics that affect a wide range of bacteria to treat SIBO, of which include:
Regardless of which type of antibiotic is used to treat SIBO, it is not uncommon for patients to require multiple courses, or even long-term use of antibiotics. To prevent potential antibiotic resistance from occurring, it is recommended that physicians repeat breath testing on SIBO patients when symptoms such as abdominal pain, diarrhea, bloating and/or flatulence recur.
Probiotics are live bacteria that are the same, or similar to, the bacteria that is naturally found within our digestive tract. For example, Lactobacillus, which can be found in most yogurts and other fermented foods, as well as Bifidobacterium, which is found in most dairy products, are two of the most common bacterial species that are found within our bodies, as well as in many probiotic supplements. By introducing healthy bacteria colonies into our digestive system, probiotics have been shown to ease some of the symptoms of IBS, such as constipation and improved functioning of the immune system.
For patients that predominantly suffer from constipation, the use of prokinetic agents is common. As implied in its name, “pro,” meaning for, and “kinetics,” meaning movement, are used to promote the movement of stool through the GI tract. Some of the most common prokinetic agents used in the United States include metoclopramide and erythromycin.
Unfortunately, conventional treatment approaches do not always work with helping relieve the often-debilitating symptoms of IBS. As a result, patients often look to herbal medications as a way to improve their symptoms without risking any significant adverse effects. Some of the most common herbal medications used for IBS include:
- Peppermint oil
- Artichoke leaf extract
- Aloe vera
- Blond psyllium (plantago)
- Turmeric (curcumin)
- Iberoglast ®
- Padma lax ®
To learn more about the numerous herbal medications that have been shown to help IBS patients combat their symptoms, click here.
- Holftmann, G. J., Ford, A. C., & Talley, N. J. (2016). Pathophysiology of irritable bowel syndrome. Gastroenterology & Hepatology 1(2); 133-146. DOI: 10.1016/S2468-1253(16)30023-1.
- Salem, A., Singh, R., Ayoub, Y. K., Khairy, A. M., & Mullin, G. E. (2018). The gut microbiome and irritable bowel syndrome: State of art review. Arab Journal of Gastroenterology 19(3); 136-141. DOI: 10.1016/j.ajg.2018.02.008.
- Salem, A., & Ronald, B. C. (2014). Small Intestinal Bacterial Overgrowth. Gastrointestinal & Digestive System 4(5). DOI: 10.4172/2161-069X.1000225.
- Sachdev, A. H. & Pimentel, M. (2013). Gastrointestinal bacterial overgrowth: pathogenesis and clinical significance. Therapeutic Advances in Chronic Disease 4(5); 223-231. DOI: 10.1177/2040622313496126.
- “Irritable Bowel Syndrome (IBS) Symptoms” – WebMD
- Seminowicz, D. A., Labus, J. S., Bueller, J. A., Tillisch, K., Naliboff, B. D., et al. (2010). Regional Gray Matter Density Changes in Brains of Patients with Irritable Bowel Syndrome. Gastroenterology 139(1); 48-57. DOI: 10.1053/j.gastro.2010.03.049.