Irritable bowel syndrome (IBS) can be more disruptive than Crohn’s disease or ulcerative colitis, with some data suggesting it can lead to a similar reduction in quality of life as bowel cancer, says gastroenterologist Associate Professor Rebecca Burgell, head of the Functional Gut Disorder Clinic at Alfred Health and researcher at Monash University’s Central Clinical School.
It is also eminently treatable, she stresses, and effective management can improve outcomes in more than three-quarters of patients.
Both Associate Professor Burgell and Dr Helena Popovic, a general practitioner and ambassador for The Gut Foundation, agree that managing IBS effectively takes time.
“If the patient doesn’t feel they have had their concerns taken seriously upfront, it can set them down a pathway of constantly doubting any advice that they’re given,” Associate Professor Burgell says.
IBS is a disorder of gut-brain interaction. Dr Popovic suggests dedicating the first consult—ideally a long one—to information gathering, particularly about any underlying issues that may be contributing.
She asks patients whether symptoms:
“I don’t want patients to think I’m suggesting it’s all in their mind, because it’s definitely not. It is playing out in their body,” Dr Popovic says. “However, that doesn’t mean it doesn’t have a psychological cause they may be completely unaware of. And unless you address this, even the most perfect diet in the world will not help.”
It’s also important to ask about medications since some can cause, trigger or exacerbate IBS, especially if administered over a long period. These include:
“Basically any medication could be an exacerbating factor in an individual person with a particular sensitivity,” Dr Popovic says. “Good history-taking should elicit this. Or simply see what happens when the medication is slowly reduced and replaced with something else.”
She also takes a dietary history and asks patients to keep a diary documenting the pattern of symptoms, including any days or times they are not present.
Patients with suspected IBS should have a full blood count, iron studies and coeliac serology testing, Associate Professor Burgell says. For those with diarrhoea-predominant disease, she recommends a faecal calprotectin test to discriminate between Inflammatory bowel disease and IBS. Those who are constipated may need thyroid function and/or calcium tests.
“If they’re all normal and abdominal examination is normal and the features are consistent with diagnostic criteria for a functional bowel disorder, usually no further investigations are warranted and it would be absolutely fine to crack on, start treating, and see if you can improve symptoms,” she says.
There is good data to support use of dietary therapy in IBS, Associate Professor Burgell says, and it’s important to assess someone’s diet before applying any restrictions.
“If you have a patient that’s got a very poor-quality diet—it’s all junk food, there’s no fibre—of course it’s going to impact their gut and you may well be able to fix it by just optimising that to start with,” she says.
“That being said, we know the low FODMAP diet is a really effective therapy in patients with IBS.”
This should involve a “short-term restriction of FODMAPs followed by re-challenges to get the patient on the least restrictive diet possible,” she says, noting some patients will have already over-restricted their diet while attempting to manage their symptoms.
Dr Popovic starts by getting patients to eliminate ultra-processed foods, she says, citing a recent review of epidemiological meta-analyses which found an association between greater consumption of ultra-processed foods and various adverse health outcomes. Emerging evidence suggests these may be mediated through changes to the gut microbiome and increased inflammation.
Patients with IBS can have varying levels of heightened sensitivity to food additives such as flavourings, colourings and preservatives, she explains. Some people will also need to avoid spicy foods.
Following this approach can be difficult, but it isn’t forever, she adds. “It just means we have to eliminate everything to start with. And then we’ll slowly start adding things back because for you, it might only be emulsifiers or MSG or artificial sweeteners that are the problem, and you can eat the other stuff.”
Patients may also benefit from eating more slowly and mindfully, she adds.
Medications can be helpful for managing symptoms, Associate Professor Burgell says.
“It really depends on the severity and how much it’s impacting on the patient’s quality of life and day-to-day function.”
You can start by targeting the predominant symptom.
“If diarrhoea is the main concern, using something as simple as loperamide may be enough to improve quality of life,” Associate Professor Burgell says. “If a patient is constipated, you can try a fibre supplement or laxatives. If it’s pain or spasm, using an antispasmodic or peppermint oil have all got very good evidence.”
For patients with global symptoms, a tricyclic antidepressant could be worth considering, she adds. A recent randomised, double-blind, placebo-controlled, phase 3 trial found that low-dose amitriptyline as a second-line treatment for IBS in primary care led to superior outcomes than placebo, and was safe and well tolerated.
There is also evidence that rifaximin can improve global IBS symptoms, she says, but it is not PBS approved for this indication and is expensive.
Dr Popovic says that while probiotics are popular, the evidence for their effectiveness in IBS is low.
These are another evidence-based mainstay of IBS management, with a 2019 meta-analysis of 35 RCTs comparing psychological therapies with controls finding that relaxation therapy, cognitive behavioural therapy, multi-component psychological therapy, hypnotherapy, and dynamic psychotherapy all showed benefits when data from two or more trials were pooled.
Clinical guidelines from the UK recommend considering referral for psychological therapy if people have not responded to pharmacological interventions after 12 months.
In this case, Associate Professor Burgell recommends finding a professional with expertise in managing patients with disorders of brain-gut interaction.
Dr Popovic says it’s essential to address stressors that are contributing to symptoms.
Patients often deny they are under stress if asked directly, she says, so ask specific questions instead. She suggests first asking whether there are any issues at work, such as excessive pressure or conflict.
Bullying is particularly problematic and must be addressed, she says.
“We’ve actually found that bullying increases the permeability of your gut and punches holes in the blood brain barrier.”
It’s also important to ask about personal and relational issues such as a betrayal or juggling care for elderly parents with raising a family, which can be a “massive stress”, Dr Popovic says.
She recommends people change what they can (by accepting help, for example) and practise stress reduction techniques such as cyclic sighing, which a recent randomised, controlled study found was more effective than mindfulness meditation and two other breathwork techniques for improving mood and reducing respiratory rate.
“By controlling something that’s usually under autonomic control, it increases our sense of efficacy. And that awareness, combined with the vagal activation, dramatically reduces anxiety. And vagal activation improves IBS,” she says.
Don’t underestimate the value of regular physical activity, Dr Popovic adds, with some research suggesting it can increase diversity of the gut microbiome independent of other factors.
“I will physically write down on a prescription pad 30 minutes of physical exercise a day or more. Whatever you enjoy. Both cardio and resistance training are important. If they’re doing nothing, then just a short walk will do.”
Learning to ride out the symptoms can also be helpful, she says, suggesting patients maintain a non-judgmental awareness of what is happening in their bodies rather than focusing excessively on the symptoms.
Helpful resources
Gastroenterological Society of Australia | IBS4GPs – developed by functional gut disorder experts (in consultation with GPs), this online tool assists you to assess symptoms, make a diagnosis and treat IBS patients effectively.
NICE Guidelines | Irritable bowel syndrome in adults: diagnosis and management
British Society of Gastroenterology guidelines on the management of irritable bowel syndrome
American College of Gastroenterology | Monograph on Management of Irritable Bowel Syndrome
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