IBS often goes undiagnosed, largely because it is difficult for people to discuss their symptoms. As a result, the first step in successful treatment is a good doctor-patient relationship, in which patients feel comfortable discussing the details of their symptoms and the impact on the quality of life. Once the diagnosis has been established, IBS can be managed with a range of therapies, ranging from fiber to drugs that act on digestive system receptors for the chemical serotonin. Below, Dr. John Johanson, a clinical associate professor at the University of Illinois College of Medicine in Urbana, discusses treatment options and how people with IBS can help make sure they get the best treatment possible.
What is IBS?
IBS stands for irritable bowel syndrome, and it is a condition that is actually manifested mainly by symptoms. Patients predominantly have pain associated with a change in their bowel habits. The bowel function change could either be diarrhea or constipation or, in some cases, both. We're starting to realize, with the discovery of serotonin receptors in the gastrointestinal tract, that serotonin probably plays an important role in IBS symptoms.
Could you describe some obstacles in receiving treatment for IBS?
In the United States, people are often uncomfortable talking about diarrhea or constipation. I think this reluctance most often affects IBS diagnosis and management in the primary care doctor's office. Primary care doctors usually don't have a lot of time, so if the patient is reluctant or unable to complain about their symptoms, they are not going to be addressed. Gastroenterologists tend to look closely at abdominal symptoms, so we'll take a more extensive history, focusing on symptoms of constipation, diarrhea and pain.
What are the main goals in managing IBS?
The main goals are to eliminate the symptoms as completely as possible. But even more important, the goal is to eliminate the anxiety that's surrounding the symptoms. Most patients are fairly anxious about their symptoms, so assuring them that this is not a life-threatening disorder will sometimes ease symptoms that may be magnified by their anxiety.
There are a number of factors that influence the success of therapy. I think one of the biggest obstacles to effective treatment is patients' expectations. Motility, or motor function, of the intestine in patients with IBS is not normal, so these patients may never have normal bowel habits.
Once the patient has been reassured, what is the next step in the control of IBS symptoms?
Lifestyle changes are variably effective. People will often relate flares of their symptoms to stressful events. By increasing their exercise or by getting stress management, people can reduce stress and therefore reduce the stimulus for their symptoms.
As far as dietary changes go, there's not a universal list of foods that cause symptoms. I will always recommend that patients avoid foods that they know affect their gut and set off their symptoms.
Soluble fiber, which can be dissolved, actually works well in patients with diarrhea because it tends to absorb some of the excess fluid and make the stool more formed or bulked. In patients with constipation, it tends to draw more water into the stool so they have softer stool.
I would say probably 20 percent to 30 percent of patients respond to fiber. Now, that may be an underestimation on my part because as a gastroenterologist I tend to see the more severe cases, so it might even be more effective than that in the primary care physician's office—maybe up to 50 percent or more.
What are some strategies if lifestyle changes are not enough?
We start by looking at their specific predominant symptom complex. For a patient with IBS and constipation who doesn't respond to fiber, laxatives may be of use. We try to avoid the stimulant laxatives because there are some concerns about long-term safety, so we use osmotic laxatives, which work by drawing water into the colon. Medications are also available that bind to receptors for serotonin, a chemical in the gut that stimulates the bowel to work better.
How is IBS with diarrhea treated differently?
If a patient's diarrhea does not respond to fiber, then we may try anti-spasmotic medications to slow the gut down by relaxing the smooth muscle of the colon. To some extent, by reducing the contractility of the colon, they also reduce the discomfort.
In patients who have diarrhea, but primarily complain about pain, we might use antidepressant medications that have some pain modulating effects. There are also serotonergic drugs available for the treatment of diarrhea, but they tend to be reserved for younger patients with very severe diarrhea who have tried many medications and don't get better.
What is there a role for mental health counseling for IBS?
Mental health counseling in the average IBS patient is probably not necessary, although it still may be beneficial because it may deal with some of the underlying psychosocial triggers for the IBS symptoms. But I don't that it is something that we should think about except in the minority of patients that have really severe symptoms. Some of these patients may also have a psychiatric disorder.
What new developments in the management of IBS can patients and their doctors look forward to?
I think this is a wonderful time in the course of IBS, particularly IBS therapy. There are drugs that work and there are education initiatives, so patients will start learning about these newer therapies. I'm excited about how patients are going to get better and am anxiously awaiting the newer therapies.