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Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a chronic (long-term) disorder that affects the digestive system. It causes abdominal pain, diarrhoea and constipation.
Brought to you by NHS Choices

Overview

Introduction

There are different types of IBS, depending on your main symptom. It’s known by a variety of other names, including spastic colon, spastic colitis, mucous colitis, nervous diarrhoea, nervous colon and nervous or functional bowel. However, some of these names misrepresent the condition. Colitis, for example, is an inflammation of the colon and this symptom isn’t found in people with IBS.

The symptoms of IBS can fluctuate. There may be times when your symptoms are particularly troublesome and times when you experience no symptoms at all.

Although IBS poses no serious threat to health, it can have an adverse effect on a person’s quality of life. The exact causes of IBS are unknown.

How common is IBS?

IBS is one of the most common gastrointestinal conditions. It is estimated that 10-20% of the UK’s population is affected by IBS at any one time, although this figure may be higher because many people with the condition do not report their symptoms to their GP.

IBS is twice as common in women as it is in men. The condition normally develops in people who are between 20 and 30 years of age, but it can affect people of any age.

While there is no cure for IBS, the symptoms can be controlled with lifestyle changes and medicine.

Symptoms

Symptoms of IBS

The most common symptoms of irritable bowel syndrome (IBS) are:

  • abdominal pain and cramping which is often relieved by emptying your bowel,
  • a change in your bowel habits, such as diarrhoea, constipation or, sometimes, both,
  • bloating and swelling of your abdomen,
  • excessive wind,
  • experiencing an urgent need to go to the toilet, which can result in incontinence if a toilet is not nearby,
  • a feeling that you have not fully emptied your bowel, and
  • the passing of mucus from your rectum (back passage).


The symptoms of IBS are usually worse after eating. Most people will experience a ‘flare-up’ of symptoms, lasting between 2-4 days, after which the symptoms improve, or disappear altogether.

For reasons that are not completely understood, IBS can also cause symptoms in other parts of your body, as well as in your bowel. These symptoms include:

  • lower back pain,
  • muscle and joint pain,
  • constant tiredness,
  • nausea,
  • headache,
  • burping,
  • bad breath, and
  • a frequent and urgent need to urinate.


Due to the pain, discomfort and embarrassment that are sometimes associated with IBS, some people also experience feelings of anxiety and depression.

Causes

Causes of IBS

The exact cause of irritable bowel syndrome (IBS) is unknown. However, most experts believe that it may be caused by a number of interrelated factors. Possible factors include:

  • an abnormality with how the muscles move food through the digestive tract,
  • having digestive organs that are particularly sensitive to pain,
  • a malfunctioning immune system,
  • a problem with how the central nervous system controls the digestive system,
  • an unusual response to infection, and
  • environmental, dietary, and genetic factors that are as yet unknown.

Diagnosis

Diagnosing IBS

If you have the symptoms of irritable bowel syndrome (IBS), your GP will usually recommend that you undergo a blood test in order that other conditions that cause similar symptoms, such as infection, or Coeliac disease (a stomach condition caused by gluten intolerance) can be ruled out.

GPs can usually confidently diagnose IBS by asking you about your symptoms.

Your GP will ask you whether you have had any of the following symptoms that have lasted for at least six months:

  • changes in your bowel habits, such as constipation, or diarrhoea,
  • pain and discomfort in your abdomen, and
  • a bloated feeling.


Your GP will be looking for some specific symptoms that are needed for a positive diagnosis of IBS. These are either:

  • abdominal pain, or discomfort, that goes away after you empty your bowel, or
  • abdominal pain, or discomfort, with a change in your bowel habits - for example, you may go to toilet more often than you did before, or you may produce stools that look different from usual.


For IBS to be diagnosed, you will also need to have at least two of the following symptoms:

  • a change in how you pass stools, such as needing to strain, feeling a sense of urgency, or feeling that you have not emptied your bowels properly,
  • bloating, hardness or tension in your abdomen,
  • symptoms that are worse after eating, or
  • the passing of mucus from your rectum (back passage).


When further tests are required

Further testing is usually only required when you have specific symptoms, or signs, that suggest that you may have a more serious condition than IBS. These symptoms include:

  • unexplained weight loss,
  • abdominal and rectal mass (localised swelling in the abdomen and/or rectum),
  • bleeding from your rectum (back passage), and
  • anaemia (a condition that occurs when there is a reduced number of red blood cells, or haemoglobin concentration in the blood).


Further testing may also be recommended if you have a family history of bowel, or ovarian, cancer, or if you are over 60 years of age and you have experienced a change in your bowel habits that has lasted more than six weeks.

Is IBS serious?

Although the symptoms of IBS can be similar to those seen in more serious conditions, once it has been diagnosed there’s no reason to think that it will develop into anything more sinister. In particular, people with IBS are no more likely than anyone else to develop bowel cancer.

Treatment

Treating IBS

Diet

Making changes to your diet can help to control the symptoms of irritable bowel syndrome (IBS). However, there is no ‘one size fits all’ diet for people with IBS. Different individuals will respond better to individually tailored diets.

Keeping a food diary and making a note of whether certain foods make the condition better, or worse, may be helpful. Once you have identified any ‘trigger foods’ you can avoid them.

People with IBS are often advised to modify the amount of fibre in their diet. For some people, this will be a case of reducing the amount of insoluble fibre (the type that make stools bulkier and soft) in their diet. This may mean reducing your consumption of wholemeal bread, cereals, and whole grains, such as brown rice.

Other people with IBS may need additional fibre in their diet, usually soluble fibre. This may mean taking a fibre supplement, or eating more foods that are high in soluble fibre, such as oats.

Your GP will be able to advise you about what your recommended fibre intake should be. The dietary advice listed below may also help you to control your symptoms of IBS.

  • Have regular meals, and take your time when eating.
  • Avoid missing meals, or leaving long gaps between eating.
  • Drink at least eight cups of fluid a day, particularly water, or other non-caffeinated drinks, such as herbal teas.
  • Restrict tea and coffee to three cups a day.
  • Reduce your intake of alcohol and fizzy drinks.
  • Reduce your intake of ‘resistant starch’ (starch that resists digestion in the small intestine and reaches the colon intact). It is often found in processed, or re-cooked, foods.
  • Limit fresh fruit to three portions (80 g each) a day; a suitable portion would be half a grapefruit, or one apple.
  • If you have diarrhoea, avoid sorbitol, which is an artificial sweetener that is found in sugar-free sweets (including chewing gum) and drinks, and in some diabetic and slimming products.
  • If you have wind and bloating, consider increasing your intake of oats, for example, oat-based breakfast cereal, or porridge, and linseeds (up to one tablespoon a day).


Do not undertake a single food avoidance and exclusion diet (a diet where you avoid a class of food, such as dairy products, or red meat) unless you are under the supervision of a dietician.

Exercise

Exercise can help to relieve the symptoms of most (but not all) people with IBS. However, regular exercise has many associated health benefits and should form part of your daily and weekly routine regardless of whether you have IBS or not. Your GP will be able to advise you about whether exercise is suitable for you.

If exercise is suitable for you, you should aim to exercise for a minimum of 30 minutes of vigorous exercise a day, at least five times a week. The exercise should be strenuous enough to increase both your heart rate and breathing rate. Walking briskly and walking up a hill are both examples of vigorous exercise.

Probiotics

Some people find that taking probiotics help to relieve the symptoms of IBS. Probiotics are dietary supplements that are available at most supermarkets, which contain so-called ‘friendly bacteria’.

You will need to take probiotics for at least four weeks to see if they have a beneficial effect. When taking it, make sure that you follow the manufacturer’s instructions and recommendations.

The use of prebiotics - dietary supplements that encourage the growth of certain types of bacteria in the intestine - is not recommended as a treatment for IBS.

Stress

Taking steps to reduce the levels of stress in your life may hep to reduce the frequency and severity of your IBS symptoms.

Some ways to help relieve stress include:

  • relaxation techniques, such as meditation, or breathing exercises,
  • physical activities, such as yoga, or Tai Chi (a Chinese martial art), and
  • regular exercise.


If you are finding that stress is a problem in your life, you may benefit from a talking therapy, such as stress counselling, or cognitive behaviour therapy (CBT). See below for more information about CBT.

Medication

A number of different medications are used to help treat IBS. These are.

  • Antispasmodic medicines, which help to reduce abdominal pain and cramping,
  • Laxatives, which help to treat the symptoms of constipation,
  • Antimotility medicines, which help to treat the symptoms of diarrhoea, and
  • Tricyclic antidepressants (TCAs), which were originally designed to treat depression, but also help to reduce the feeling of abdominal pain and cramping.

See below for more information on these medications.

There is also a medicine called Kolanticon, which contains an antispasmodic drug and three other ingredients. The other ingredients are simeticone, which relieves trapped wind, and two different antacids, which reduce stomach acid and treat heartburn. Kolanticon is available from your pharmacy without prescription.

Antispasmodic medicines

Antispasmodic medicines work by helping to relax the muscles in your digestive system. Examples of antispasmodic medicines include mebeverine and therapeutic peppermint oil.

Side effects of antispasmodic medicines are uncommon. However, people taking peppermint oil can sometimes experience occasional heartburn and irritation on the area of skin around their anus (back passage).

Antispasmodic medicines are not recommended for use by pregnant women.

Laxatives

The type of laxative known as a bulk-forming laxative is usually recommended for people who are experiencing IBS-related constipation. Bulk-forming laxatives work by making your stools denser and softer, which means that they should be easier to pass.

It is important to drink plenty of fluids when using a bulk-forming laxative because this will prevent the laxative causing an obstruction in your digestive system.

You should start on a low dose, and if necessary increase it every few days until one or two soft, formed stools are produced every one or two days. You should not take a bulk-forming laxative immediately before going to bed.

Side effects of taking laxatives can include bloating and flatulence (wind). However, side effects can usually be avoided or reduced by gradually increasing the dose.

Antimotility medicines

The antimotility medicine known as loperamide is usually recommended for the treatment of IBS-related diarrhoea. Loperamide works by slowing the contractions of the muscles in the intestines which, in turn, slows how fast food passes through your digestive system. This allows more time for your stools (faeces) to harden and solidify.

Side effects of loperamide include:

  • abdominal cramps,
  • dizziness,
  • drowsiness,
  • skin rashes,
  • bowel obstruction, and
  • abdominal bloating.


Loperamide is not recommended for use by pregnant women.

Tricyclic antidepressants (TCAs)

Tricyclic antidepressants (TCAs) are usually recommended if antispasmodic medicines have failed to control your symptoms of abdominal pain and cramping. TCAs work by relaxing the muscles in your digestive system.

Side effects of TCAs include:

  • constipation,
  • dry mouth,
  • drowsiness, and
  • fatigue.


Due to their potential to cause drowsiness and fatigue, you may be advised to take TCAs before going to bed. You should not drive, or operate heavy machinery, if you are experiencing drowsiness.

If you fail to respond to TCAs, an alternative antidepressant, known as a selective serotonin reuptake inhibitor (SSRI) may be recommended for you.

Complementary therapies

A number of complementary therapies for IBS have been suggested including:

  • acupuncture,
  • reflexology (a type of massage therapy), and
  • the herbal remedy aloe vera (a plant that is native to north Africa).


However, there is no evidence that these complementary therapies are effective at treating IBS. You should also be aware that aloe vera has been linked to a number of possible adverse effects, such as dehydration, and a reduction in blood sugar levels.

Psychological interventions

If your symptoms of IBS are still causing you problems after 12 months of treatment, you may be referred for a type of therapy known as a psychological intervention.

There are several types of interventions available, but they all work by teaching you psychological techniques that can help you to control your condition more effectively.

Psychodynamic interpersonal therapy (PIT)

Psychodynamic interpersonal therapy (PIT) is a type of psychotherapy that has had some success in helping people with IBS. PIT is based on the principle that your unconscious thoughts, beliefs, and attitudes can have an important influence on the way that you think, act, and feel.

During PIT, your therapist will help you to explore your past in order to determine how it might have affected you unconsciously, and they will help you to confront unwelcome, or unhelpful beliefs, attitudes, and behaviour in an attempt to change them.

Hypnotherapy

Psychological interventions for IBS include hypnotherapy. In this type of therapy, hypnosis is used to change your unconscious mind’s attitude towards any symptoms that you may have. You may also be taught self-hypnosis techniques.

Hypnotherapy has been shown to be effective in helping some people reduce their symptoms of pain and discomfort.

Cognitive behaviour therapy (CBT)

Another psychological intervention for IBS is cognitive behaviour therapy (CBT). CBT is based on the principle that the way that we feel is partly dependent on the way that we think about things.

Studies into the effectiveness of CBT have shown that people who train themselves to react differently to their condition by using relaxation techniques, and maintaining a positive attitude, report a decrease in pain levels.

CBT may also help you to cope better with stress, anxiety, and depression.

Colonic irrigation

Colonic irrigation is a procedure for removing waste and toxins from the bowel. It’s known as an alternative therapy and there is no real medical evidence to prove that it’s effective. However, some people believe it can help with bloating, flatulence (wind), diarrhoea, IBS, fatigue, allergies, indigestion, constipation, multiple sclerosis and back pain. It’s not available on the NHS.

Complications

Complications of IBS

Access to toilet facilities

Finding access to toilets can be an important issue if you are experiencing symptoms of sudden and urgent diarrhoea. In the most severe cases of irritable bowel syndrome (IBS), some people are afraid to visit public places in case they experience an episode of incontinence.

There are a number of steps that you can take to help you deal with the problem. For example, the IBS charity, ‘The Gut Trust’ operates a ‘Can’t Wait’ card scheme. This is a small card, confirming that you have a medical condition which indicates that you may require immediate access to toilet facilities. Should you need to, you can use the card to gain access to the toilet facilities of businesses, supermarkets, or other organisations.

Another alternative is to join the National Key Scheme. The National Key Scheme (NKS) offers independent access to people with certain health conditions, such as IBS, to around 7,000 locked public toilets around the country.

Psychological impact

As IBS is not a life-threatening condition, it is sometimes trivialised it as being nothing more that a form of indigestion. However, the pain, discomfort, and inconvenience caused by IBS can have a profound psychological affect on the individual.

It is estimated that the majority of people with moderate to severe IBS will experience feelings of depression and anxiety at some point in their life.

If you find that you have been feeling particularly down over the past month, and you no longer take pleasure in the things that you used to enjoy, you may be depressed. You should see your GP for advice and treatment.

Cognitive behavioural therapy (CBT) may also help you cope better with your condition and any feelings of depression and anxiety that you have.

You may also want to consider joining an IBS support group because talking to people who share your condition can reduce feelings of loneliness, isolation, and stress. Your GP may be able to provide details of support groups in your local area.

Expert view

Family doctor Dawn Harper on the questions to ask

Irritable bowel syndrome (IBS) is a common gut disorder that will affect up to one in five people in the UK at some stage in their life. Symptoms can vary, from abdominal pain and bloating to bouts of diarrhoea and/or constipation. There is no cure for IBS, but symptoms can often be eased with treatment.

We asked GP Dr Dawn Harper what she would want to know if she was diagnosed with IBS.

 

Is my diet causing my IBS?
Keep a food diary. Writing down everything you eat and when symptoms flare up can be enlightening. Dairy products and wheat are common triggers of IBS, but beware of excluding these foods permanently. Cut them out in the short term and continue your symptom diary. If your symptoms disappear, these foods may have been responsible.

Remember, stress and routine can play a significant role in IBS, so re-challenge your system a few weeks later to see if the symptoms recur. If you’re considering eliminating a food group from your diet long term, speak to a dietitian about how to replace the lost nutrients.

What other factors can affect my condition?
Eat regularly. Missing meals then binging will make your symptoms worse. Try to sit down to eat. Eating on the move isn’t good for your digestive system.

How can I manage my stress levels?
This may be easier said than done, but try making a note of stressful situations that trigger your IBS. You won’t be able to avoid some stresses, but putting them down on paper may help you to identify the ones you can do something about.

Are there any natural remedies or supplements that may help?
Consider a daily probiotic. These are dietary supplements containing potentially beneficial bacteria or yeast. They’re available as tablets, cereals or drinks, and many IBS sufferers find them helpful in easing their symptoms. If you’re experiencing painful bowel spasms, talk to your GP about medication to help ease the pain.

Lifestyle

Living with IBS

Leading dietician Dr Sarah Schenker offers her top tips to help you manage your IBS

Water
Drinking plenty of water is important if you’re suffering from either diarrhoea or constipation. Regular bouts of diarrhoea can lead to dehydration as you lose too much body water, whereas constipation can become worse if you don’t drink enough. Water helps to loosen stools and allow them to pass through the gut.

  • Aim to drink about 1.5 to two litres of water per day. Other drinks count towards your fluid intake. Try milk, fruit juices, smoothies, yoghurt drinks and even tea and coffee.
  • Sip water and other healthy drinks throughout the day and carry a bottle of water with you wherever you go. Don’t wait until you feel thirsty before you drink, by then you’re already becoming dehydrated.
  • Avoid fizzy soft drinks, not only are they bad for your teeth and bones, but the gas can upset your digestion.
  • Caffeine can have a mildly dehydrating effect if consumed in large amounts over a short space of time. Caffeine is also a stimulant that some people might find aggravates their gut. Remember, caffeine is not just found in coffee, it’s also in tea, cola, energy drinks and chocolate.

Fibre
A good intake of fibre is recommended for people with IBS, most of which should be in the form of soluble fibre, found in apples, pears, dates and most other fruit and vegetables, as well as oats, barley and rye.

  • Aim to have at least five portions of fruit and vegetables every day.
  • Peel or remove the skin of fruit and vegetables if you know they irritate your gut. The flesh will still provide plenty of soluble fibre.
  • Incorporate oats, barley and rye into your diet. Porridge or instant oats make a filling breakfast, providing long-lasting energy all morning. Rye or pumpernickel bread makes an interesting alternative for a sandwich and barley is delicious added to soups, salads and stews.
  • Cut down on foods that are known to produce wind, such as pulses, beans and lentils, especially when you’re experiencing any symptoms.
  • Don’t sprinkle bran on foods or take bran tablets. Bran was once recommended for IBS but is now known to make the condition worse.
  • Avoid wheat-based, high-fibre breakfast cereals or breads. Try mixing wheat-based cereals with rice- or corn-based cereals and alternating pasta with rice or potatoes for main meals.

Friendly bacteria
Try foods or supplements containing probiotic bacteria. These bacteria are known as friendly bacteria because they help to maintain the balance of bacteria in the gut, alleviate symptoms of IBS and promote general health and well-being.

  • Choose your product carefully. Look for the term ‘probiotic’ on the label. The bacteria in these products is specially selected and treated to survive the journey through the gut to the large bowel, where they can be most effective.
  • Take probiotic foods or supplements after a course of antibiotics. Antibiotics can destroy the beneficial bacteria in our guts, which can cause IBS symptoms to flare up.
  • Don’t confuse the terms ‘live’ or ‘bio’ to mean probiotic bacteria. These products may contain beneficial bacteria but the majority of them can be destroyed by stomach acids once they’re eaten.

Stress
IBS is linked to stress, and periods of stress at work or home can bring on IBS symptoms.

  • Learn to recognise stressful situations or identify potential periods of stress, such as planning a wedding or moving house, and think carefully about what you eat during this time. Try to plan small regular meals and snacks for yourself in advance and eat them slowly and calmly, allowing food to digest for a while after you’ve finished.
  • Don’t allow times of stress to interfere with good eating habits. Don’t skip meals, rush your food or eat food on the go. Try to avoid eating too many high in fat and salt fast foods or takeaways because you’re pushed for time.

I get terribly embarrassed at work because I can’t stop burping and farting. How can I make it stop?

Excess belching can be the result of eating too quickly, drinking too quickly or drinking too many fizzy drinks. It can also be caused by nervousness, which makes people swallow a lot. The bicarbonate in saliva reacts with stomach acid to make CO2, which is then belched.

Excess farting may be due to eating too much fibre (which is broken down by bacteria in the large bowel), or certain vegetables whose carbohydrate can’t be digested by the human gut (baked beans are notorious for this, as are artichokes, onions and leeks).

Extra-smelly farts are sometimes due to having too much fat in the diet. Fats may be broken down in the large bowel by bacteria, which produce volatile, unpleasant fatty acids.

Real stories

Ansar’s story

‘I’ve found the wheat-free ranges at the supermarket very helpful’

Suffering from IBS for more than 20 years, Ansar Ahmed Ullah is finally learning to live with his condition

“I think my IBS came from too many curries!” says Ansar Ahmed Ullah. He first came to London in the early 1980s. Living in shared accommodation, he relied on spicy takeaways for his main meal in the evening. “We’d also go to the community centre at lunchtime where they served curry and rice,” he remembers.

During the mid-1980s, Ansar started to suffer from frequent constipation, bloating, occasional bouts of diarrhoea and stomach pain. On one occasion, the pain was so bad that he was rushed to hospital. “I was there for a week,” he remembers. “The doctors gave me all kinds of tests. They thought I might have a stomach ulcer, but they didn’t find anything.”

Eventually, Ansar mentioned his troubles to his GP, who diagnosed IBS. He was prescribed painkillers and a muscle relaxant drug to ease his constipation. Unfortunately, neither drug was effective. Ansar decided to try and treat himself.

He joined the IBS Network to educate himself about his condition, and underwent several food allergy tests, discovering that he was sensitive to wheat, spicy food and dairy products.

“Luckily, I’m still able to eat chicken and fish,” he says. “Avoiding dairy and wheat is very difficult. I love milk in my tea. I’ve never been able to stand the taste of soya and I love bread and biscuits. I’ve found the wheat-free ranges at the supermarkets very helpful, though.”

Ansar says he’s tried every IBS remedy on the market. “I’ve more or less resigned myself to the fact that I’m not going to be cured of IBS,” he says. “It can be very difficult, though.

“The mornings are the worst. I’m no longer working, but when I was employed, I was constantly late because I had to spend so long in the toilet with constipation. There’s not a lot of awareness of IBS, particularly among young people, and it’s hard for people to understand what you’re going through.”

Ansar says IBS also affects his relationship with his partner. “She does sometimes get annoyed when she needs to go somewhere in a hurry and I’m still in the toilet. It’s also very awkward when you’re out and about and you need to use a loo suddenly or for a long period of time. The IBS is in the back of my mind all the time. I have to consider it when I go anywhere or do anything.”

However, Ansar tries not to let his IBS get him down. “I do my best to stick to my wheat-free diet and I make sure I eat plenty of fruit. I’ve found that really helps the constipation. I’m also planning to take more exercise. I already go to Pilates classes and I’ve got a bike, which I should really use more! I think I’m learning to live with my IBS.”

Geoff’s story

‘A non-dairy diet seems to help’

Geoff Lyon, 57, has had severe IBS since early childhood. He tells us his story.

“It all started when I was about eight years old. I was getting a lot of unexplained diarrhoea and feeling sick. I couldn’t go anywhere without wanting to go to the toilet and my parents didn’t understand what was wrong with me.

“As I grew up, it didn’t get any better. I was still suffering diarrhoea and nausea, as well as constipation, headaches and feeling tired all the time. Sometimes it would wake me up at night and I’d sit for a couple of hours on the toilet sweating, with a severe cramping pain in my gut. I wouldn’t be able to go, then suddenly, I’d have a gush of diarrhoea. I would be exhausted the next day.

“It wasn’t until 1980, when I was 29, that I was referred to hospital to have a barium enema (when the colon is filled with a liquid that shows up on X-ray) and a blood test. They couldn’t find anything seriously wrong and eventually diagnosed irritable bowel syndrome (IBS). I was relieved to finally have a diagnosis.

“I was given an antispasmodic drug to take two to three times a day, which slows the contractions in your gut. I now control my IBS with codeine phosphate, an antidiarrhoeal drug.

“Not only has the treatment helped, but also cutting out dairy products from my diet. About nine years ago my doctor suggested I try a non-dairy diet and it seems to help. I’ve always loved milk and cream so it was difficult switching from them to soya products, but it’s worth it. One Christmas I gave in and had some cream trifle, and within half an hour I was on the toilet, which proves it isn’t good for me.

“At the moment I do still get attacks, quite frequently, but they’re not as bad and I’m more in control of them. I know when I’m going to have an attack as I become really lethargic and my stomach distends the night before, like I’m six months pregnant.

“I’ve noticed that if I’m stressed, my IBS kicks in a couple of days later, so I try to relax and remove any stress from my life.

“I run a self-help group for The Gut Trust charity, which I’d recommend joining. You get lots of factsheets and a ‘Can’t Wait’ card that you can show to hotels or shops if you desperately need to use their toilet facilities.”

Useful links

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External links

 

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