What is IBS?

IBS is a functional gastrointestinal disorder where the exact cause remains unclear. It is a diagnosis of exclusion, meaning that other gastrointestinal diseases such as inflammatory bowel disease (IBD), colorectal cancer, or infections should be ruled out first. The lack of any identifiable structural abnormalities on imaging or endoscopy is what sets IBS apart from other serious gastrointestinal conditions.  

It is important to recognize that IBS can significantly affect a patient’s quality of life, as it often leads to chronic discomfort, altered bowel habits, and persistent abdominal pain.   

About 10-15 percent of the population are affected at some time but only 10 percent of these consult their doctor because of symptoms. The chronic, intermittent nature of the symptoms can sometimes cause patients to feel that their condition is not severe enough to require medical consultation.  

Young women are affected more often than men. This gender disparity may be linked to hormonal factors, as IBS often worsens during menstrual cycles.  

About 10-15 percent of the population are affected at some time but only 10 percent of these consult their doctor because of symptoms.

Young women are affected more often than men.

What are the causes of IBS?

The exact cause of IBS is incompletely understood but biopsychosocial factors along with luminal factors, such as diet and the gut microbiota play an essential role. 

Several other factors can cause IBS: 

•  Serotonin and gastrin maintain the coordination between the brain and GIT through nerve signals. Abnormal coordination of serotonin production can lead to dysregulation of motility in the gastrointestinal tract. In IBS-D (diarrhoea-predominant IBS), the overproduction of serotonin can cause an increase in gut motility and secretion, leading to diarrhoea. On the other hand, IBS-C (constipation-predominant IBS) may occur due to a deficiency in serotonin, which causes reduced motility and slower transit times.  
• Most patients seen in general practice do not have psychological problems but 50 percent of the patients with IBS have a psychiatric illness, such as anxiety, depression, somatization, and neurosis. Stress and emotional disturbances are thought to exacerbate IBS symptoms. 
• Luminal factors like both quantitative and qualitative alteration in intestine contents have been noticed. Overgrowth of bacteria in the small intestine (Small Intestinal Bacterial Overgrowth – SIBO) can be present in some patients. It is increasingly recognized that imbalance in the gut microbiota plays a central role in the pathophysiology of IBS. Patients with IBS often show an altered microbiome compared to healthy individuals, and dysbiosis (an imbalance between beneficial and harmful bacteria) may exacerbate symptoms.  

• Dietary factors are also important. Some patients are susceptible to chemical food (not allergy) and have difficulty absorbing, some short-chain carbohydrates like lactose, and fructose, among others, which can cause fermentation in the colon. It is well documented that IBS patients often have sensitivities to high FODMAP foods, and these can worsen symptoms such as bloating and diarrhoea. Food intolerances (such as to gluten or dairy) can trigger or exacerbate IBS symptoms.  

• Genetic factors also play a crucial role in this. IBS can run in families, suggesting a potential genetic predisposition. However, no specific genetic markers have been consistently identified. Environmental factors, along with genetics, likely interact in a complex manner to influence the onset of IBS. 
• Hormonal factors play a significant role in IBS, particularly in women. Many women report symptom exacerbation during menstrual cycles due to hormonal fluctuations. Progesterone is thought to slow down gut motility, leading to constipation, while oestrogen may increase gut motility, leading to diarrhoea.

What are the clinical features of IBS?

What triggers IBS?

A trigger doesn’t cause the disease, but it can worsen or flare up the symptoms. Common triggers include: 

1. Periods (Menstrual Cycle):

   Females may notice symptoms worsen predictability according to their menstrual cycle. Female hormones, particularly progesterone, can exacerbate IBS symptoms. 

2. Foods:

   Symptoms my flare up due to some foods like dairy, foods that contain gluten(wheat), carbonated drinks. FODMAPs: Certain short-chain carbohydrates like fructose, lactose, onions, and garlic may cause fermentation in the colon.

3. Stress:

   Some researches suggest that IBS may be triggered by stress. Emotional stress can trigger or worsen IBS symptoms, which is why IBS is sometimes referred to as a “nervous stomach” or “anxious stomach.”   The gut-brain axis plays a role, where stress can affect gut motility.

4. Infections (Post-Infectious IBS): 

   Some individuals develop IBS after a gastrointestinal infection like food poisoning or gastroenteritis, which can disrupt normal gut function and lead to chronic IBS symptoms. 

5. Medications: 

• Antibiotics: These can alter the gut microbiota and lead to an imbalance, exacerbating IBS symptoms like diarrhoea. 
• Painkillers: Some medications, like NSAIDs, can worsen IBS symptoms by irritating the gut lining. 

• Antidepressants or antipsychotic medications can also affect gut motility and contribute to symptoms. 

  6. Sleep Disruptions: 

         Poor sleep quality or irregular sleep patterns can worsen IBS symptoms. Lack of sleep affects the        gut-brain axis, making the gut more sensitive and leading to heightened discomfort. 

  7. Travel:

Changes in routine (e.g., travel) can impact eating habits, sleep cycles, and stress levels, all of which can trigger IBS flare-ups. 

Jet lag and new environments can also disrupt normal digestion. 

  8. Overuse of Caffeine or Alcohol: 

• Caffeine can increase gut motility, causing diarrhoea in some individuals. 

• Alcohol can irritate the intestines and disrupt the gut microbiota, leading to abdominal discomfort. 

What are the types of IBS?

According to the Rome III criteria, IBS is classified into four main types, based on the predominant stool pattern and symptoms.  

1. IBS with Diarrhoea (IBS-D): 

In this type, most of the stools are loose, watery, and may occur frequently. 

Symptoms: 

• Frequent bowel movements with urgency, often within an hour of eating. 
• Stools may appear liquid, and patients often experience a feeling of incomplete evacuation. 
• Abdominal cramping and bloating are common. 

   2. IBS with Constipation (IBS-C): 

Predominantly hard, lumpy stools that are difficult to pass. Bowel movements are infrequent, typically less than three times a week. 

Symptoms: 

• Abdominal pain and discomfort are often relieved by passing stool. 
• The stool may be dry, pellet-like, and difficult to pass. 
• Patients may experience straining during defecation and may feel bloated. 

   3. Mixed IBS (IBS-M): 

This type involves a combination of diarrhoea and constipation. Patients may experience alternating episodes of loose stools and hard, lumpy stools. 

Symptoms: 

• Intermittent diarrhoea followed by constipation, or vice versa, which can be unpredictable. 
• The alternating patterns can cause bloating, cramping, and discomfort that fluctuate depending on the phase. 

   4. IBS Unspecified (IBS-U): 

• This category is used when symptoms do not fit neatly into the other categories of IBS. Patients may experience a mixture of symptoms that are not strictly related to either diarrhoea, constipation, or alternating bowel habits. 

Symptoms: 

• Variable stool consistency that does not conform to one pattern of diarrhoea or constipation. 
• Unpredictable abdominal discomfort, bloating, and changes in bowel habits that do not align with any of the other IBS types. 
• Predominant Type: The classification into IBS-D, IBS-C, IBS-M, or IBS-U may change over time for some patients, as the predominant symptoms may vary. For instance, a patient with IBS-C may start experiencing IBS-D symptoms later, and vice versa. 

What are the diagnostic criteria for IBS?

Rome III Criteria for Diagnosis of IBS: 

The diagnosis of Irritable Bowel Syndrome (IBS) is primarily based on the Rome III criteria, which focus on symptoms and patient history. It’s important to remember that IBS is a functional disorder, so no specific structural abnormality is identified on imaging or laboratory tests. Diagnosis is made when symptoms are consistent with the following criteria: 

Rome III Criteria for Diagnosis of IBS: 

1. Recurrent Abdominal Pain or Discomfort: 

• Pain or discomfort must occur at least once per week for the last 3 months. 
• The discomfort should be relieved by passing stool or associated with a change in bowel movement patterns. 

   2. Change in Frequency of Stool: 

• Symptoms must start with a change in the frequency of bowel movements. This could be increased or decreased frequency, typically occurring with abdominal discomfort. 

   3. Change in the Form of Stool: 

• There should be noticeable changes in the appearance of stool, including diarrhoea (loose stools), constipation (hard, lumpy stools), or a combination of both. 
• Absence of Rectal Bleeding: A key feature for distinguishing IBS from other gastrointestinal disorders is the absence of rectal bleeding. 

Features Supporting a Diagnosis of IBS: 

1. Symptoms Persist for More Than 6 Months: 

• The symptoms should be chronic and have been ongoing for at least 6 months or more. 
• Sudden or recent-onset symptoms may warrant further investigation to exclude other conditions. 

   2. Stress Aggravates Symptoms: 

• Many IBS patients report that stress significantly worsens their gastrointestinal symptoms. 
• This psychological link further strengthens the diagnosis of IBS. 

Alarming Features (Indicating Need for Further Investigation): 

While IBS is a functional disorder, certain alarm features should prompt further investigations to rule out serious conditions such as colorectal cancer, inflammatory bowel disease (IBD), or other gastrointestinal pathologies. 

• Age Over 50 Years:  Colorectal cancer risk increases with age. 
• Family History of Cancer:  A family history of colon cancer or other gastrointestinal cancers significantly raises the risk, warranting further evaluation. 
• Unexplained Weight Loss: Unintentional weight loss is a red flag for underlying malabsorption, cancer, or other serious gastrointestinal disorders. 
• Anemia: Low hemoglobin levels may indicate bleeding, which is not typical of IBS.  
• Rectal Bleeding: The presence of rectal hemorrhage is not a feature of IBS. It may indicate  Crohn’s disease or ulcerative colitis and should prompt a thorough workup. 

Laboratory and Diagnostic Testing: 

While IBS is a clinical diagnosis, certain laboratory tests and imaging may be performed to exclude other conditions. 

• CBC and Fecal Calprotectin: Complete Blood Count (CBC) is done to check for anemia, which could indicate bleeding or malabsorption. 

Fecal Calprotectin is an inflammatory marker that is typically normal in IBS but elevated in conditions like IBD. 

• Colonoscopy: Colonoscopy is recommended for patients older than 40 years, especially those with alarm symptoms (e.g., weight loss, rectal bleeding). 

• Endoscopy: Endoscopy is essential if the patient presents with rectal hemorrhage or other symptoms suggestive of ulcerative colitis or gastritis. 

Other Investigations for Diarrhoea: 

If the patient presents with diarrhoea or chronic loose stools, the following tests may be performed: 

• HLA-DQ2 and HLA-DQ8 testing to rule out Celiac disease. 

• Thyroid Profile: To exclude thyrotoxicosis (hyperthyroidism), which can cause diarrhoea. 
• Lactose Intolerance Test: To check for lactose malabsorption, which may cause bloating, diarrhoea, and abdominal pain in some IBS patients. 
• SeHCAT Test: To rule out bile acid malabsorption, which can mimic IBS symptoms like diarrhoea and abdominal discomfort. 

What is the management of the IBS?

• The most important thing is to make a positive diagnosis. 

• Due to recurrent episodes, some patients may develop anxiety or fear of cancer or any other serious health condition, in that case, reassure the patient that these symptoms are not due to serious underlying disease but instead, are the results of behavioral, psychosocial, physiological or luminal factors. 

• Symptoms of IBS can be relieved by changes in diet and lifestyle. 

• Up to 20 percent may benefit from the wheat-free diet, and some may respond to lactose exclusion, excess intake of caffeine or artificial sweeteners, such as sorbitol should be addressed. 

• A Low FODMAP diet (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) may help some patients with abdominal cramps, diarrhoea, constipation, etc. 

• Probiotics in capsule forms are very effective if taken for several months. 

• In anxiety-prone patients, psychological intervention, such as cognitive behavioral therapy should be done for the most difficult cases. 

• Complementary and alternative therapies should be introduced in regular lifestyles like meditation, hypnosis, cognitive therapy, etc. 

How Does IBS Impact Nutrition and Vitamin Absorption? 

Impact of IBS on Nutrition: 

• Malabsorption: IBS typically does not cause significant malabsorption of nutrients like IBD or other gastrointestinal disorders. However, some IBS patients may experience suboptimal nutrient absorption, particularly when they have diarrhoea-predominant IBS (IBS-D).  

• Dietary Restrictions: Many IBS patients find that certain foods trigger or worsen their symptoms (e.g., dairy, gluten, high-fat foods, and foods high in FODMAPs). As a result, patients may adopt restrictive diets, which can lead to potential nutritional gaps over time. 

Vitamin Deficiencies in IBS: 

• Vitamin D: Some IBS patients, particularly those with diarrhoea-predominant IBS (IBS-D), may be at higher risk of vitamin D deficiency due to malabsorption. Vitamin D is essential for bone health and immune function. 

• Vitamin B12: Though not common, patients with IBS may experience low levels of vitamin B12 if they have a history of significant gastrointestinal distress.  

• Iron: In IBS patients who have frequent diarrhoea, the absorption of iron can be impaired, potentially leading to iron-deficiency anemia. 

How can IBS be prevented?

While IBS cannot always be fully prevented, certain strategies can help reduce the risk of developing symptoms or minimize flare-ups: 

• Dietary Modifications: Avoid known triggers like dairy, gluten, high-FODMAP foods, and processed foods. A balanced, Fiber-rich diet can help manage constipation and regulate bowel movements. 

• Stress Management: Since stress is a common trigger for IBS symptoms, incorporating stress-reduction techniques like yoga, meditation, deep breathing, and regular exercise can be beneficial. 

• Regular Physical Activity: Exercise helps improve digestion and reduces stress. It can also help manage constipation, a common IBS symptom. 

• Adequate Sleep: Ensuring good sleep hygiene can help manage stress and improve overall gut function, potentially reducing IBS symptoms. 

• Probiotics: Some studies suggest that probiotics may improve gut health and help balance the microbiota, potentially reducing IBS symptoms. 

What are the complications of IBS?

Physical Health Complications: 

• Mineral and Vitamin Deficiencies 
• Hemorrhoids 
• Weight Loss 

Mental Health Complications: 

• Depression and Anxiety 
• Social and Emotional Isolation 

Gastrointestinal Complications:

• Anemia 
• Rectal Bleeding 

Additional Complications:

• Disruption of Daily Life 
• Poor Quality of Life 

What is prognosis of IBS 

• Chronic but manageable: IBS is a long-term condition but does not cause serious complications or damage to the intestines. Most patients can manage symptoms effectively with the right treatment. 

• Symptom fluctuation: Symptoms can flare up during stress, dietary changes, or hormonal shifts but often subside during remission periods.  

• Impact on quality of life: While IBS doesn’t cause life-threatening issues, it can affect daily activities, leading to discomfort, social isolation, and mental health issues like anxiety and depression. 

• Factors influencing prognosis: Patients with milder symptoms or those who respond well to treatments (diet, medications, psychological support) generally have a better outlook. Co-existing conditions like anxiety can worsen the prognosis. 

What are the homeopathic medicines for IBS?

The most prominent homeopathic medicines used symptomatically for IBS treatment include Nux Vomica, Lycopodium, Bryonia Alba, Kali Phos and Argentum Nitricum. 

1. Lycopodium: Patients who need Lycopodium often experience a sensation of fullness in the stomach, with troublesome constipation being a key symptom. The stool is hard, difficult, small, and incomplete, with ineffectual urging to pass it. There is a fullness in the rectum without the desire to pass stool. The first part of the stool is hard, but the last part is loose. Patients may also experience faintness and weakness after passing stool. A great accumulation of flatulence in the lower abdomen is a characteristic feature of Lycopodium. 
2. Nux Vomica: Nux Vomica is indicated for a sensation of tightness in the hypochondriac region and flatulent colic, particularly in the morning. The stool is frequent but ineffectual, with a sensation as if the anus is closed. Despite the state of the stool, there is a persistent feeling of constipation. Constipation and diarrhoea alternate, and patients may experience cutting abdominal pain while passing stool. There is also a constant feeling of uneasiness in the rectum and a painful, spasmodically closed anus. 
3. Argentum Nitricum: Argentum Nitricum is particularly useful in cases where diarrhoea is triggered by anticipatory anxiety (such as anxiety before public appearances). The stool is typically green, slimy, and spinach-like, often accompanied by excessive flatulence. A notable feature is diarrhoea after consuming sugar. The patient may experience gripping, cutting abdominal pain. Diarrhoea is often associated with copious amounts of gas, and there may be significant distension of the stomach due to excessive flatulence. 
4. Bryonia: Bryonia is indicated for a sensation as if the stomach would burst, often accompanied by hard, dry, and burnt-like stool. There is tenderness of the abdominal walls, and patients feel a complete lack of desire to pass stool. The stool is composed of small, dry components that appear burnt. After passing stool, there is a profuse sweat and a feeling of fatigue. It often feels as though the stool remains in the rectum, making the passage incomplete. 
5. Kali Phosphoricum: Anxiety: Anxiety, especially in bed, after eating, or about the future, tends to aggravate gastrointestinal symptoms. There is a sensation of fullness in the abdomen after eating, along with burning, cramping, and soreness in the abdominal area. Diarrhoea can occur due to fear or excitement, particularly in the morning. The stool may be offensive and putrid, with burning in the anus during and after passing stool. It is often dark, copious, and frequent, sometimes resembling rice-water diarrhoea. 

Disclaimer: The information provided is for educational purposes only and should not be construed as medical advice. Always consult a qualified healthcare professional or physician before starting any treatment or using any medication. Self-medication without professional guidance can be harmful to your health. The content provided here is not intended to replace professional medical advice, diagnosis, or treatment.