Irritable Bowel Syndrome (IBS) is a common gastrointestinal disorder. It is characterized by recurrent episodes of stomach cramps, bloating, diarrhea, constipation, and indigestion.

IBS affects 1 in 7 people in the United States, that is about 10-15% of the population. Most people who suffer from IBS are under 50 years of age and women, although it can affect both men and women of all ages, even children.

Although IBS does not pose a serious threat to life, it tends to be a life-long ailment. IBS symptoms can last few days a month or occur daily over several years.

IBS can substantially impact a person’s quality of life. It can be an economic burden, as you need frequent medication and therapies to deal with the illness.

Unlike Inflammatory bowel disease (IBD), IBS is not shown to increase risk for colorectal cancer. But newer studies are showing some overlap between IBS and IBD especially when it comes to inflammation.  Inflammation in the gastrointestinal mucosa in the microscopic and molecular level in IBS patients.

Types of IBS

There are multiple forms of IBS. Identifying the type of IBS you have can lead to better treatment approach.

1.IBS with Constipation (IBS-C):

In this type of IBS, you may have fewer bowel movements, or you may strain to have a bowel movement. The stool is often hard and lumpy. Abdominal discomfort and bloating are often accompanying symptoms.

2. IBS with Diarrhea (IBS-D):

In this type of IBS, you may have increased frequency of bowel movements and the stool may be loose and watery. The diarrhea is often accompanied by abdominal pain and frequent urges to pass stools.

3. IBS with Mixed Bowel Habits (IBS-M):

As the name implies, in this type of IBS, there is alternating constipation and diarrhea.  The stool can be hard and lumpy at one time and loose and watery other times, even happening on the same day. There is higher occurrence of abdominal pain or discomfort, in this type of IBS.

Most Common IBS symptoms

These symptoms commonly occur, irrespective of the type of IBS

• Feeling of incomplete defecation – need to pass stools even after a bowel movement
• Abdominal cramps or discomfort in the lower half of the abdomen
• Excess bloating
• Irregular bowel movements
• Stool consistency-loose or hard
• Excess passing of gas
• Urgency to pass stools
• Abdominal pain relieved after bowel movement

Less common symptoms include

• Lethargy
• Heartburn
• Insomnia
• Loss of Appetite

Symptoms which need immediate medical attention

If you are primarily diagnosed with IBS, but your symptoms are not getting better with medication and therapies, it is time to consult with a healthcare professional. If the existing symptoms keep worsening or some new symptoms arise, it indicates that a serious underlying condition could be the cause.

Some of the symptoms to look for, to evaluate a serious underlying condition are;

• Sudden weight loss

• Blood in vomit

• Nausea or recurrent vomiting

• Diarrhea keeping you up at night

• Anemia

• Rectal Bleeding

• Excruciating pain that doesn’t go away after passing gas

• Abdominal pain affects your quality of life

Risk Factors or Triggers of IBS

Family history of IBS:

Researchers from Mayo clinic found out in their earlier work that people with family members diagnosed with IBS were twice as likely to develop IBS. However, later they denounced this research saying IBS has little to do with genes. But more advanced studies have shown that certain genetic factors and immunological conditions may trigger onset of IBS.

Stress and Anxiety

Stress and Anxiety do not directly cause IBS but prolonged stress and untreated anxiety may result in worsening of IBS symptoms.  These mental health conditions share genetic pathways with IBS.

Emotional trauma

A history of sexual, emotional or physical abuse may be a risk factor for developing IBS.

Age below 50

IBS commonly occurs in people younger than 50 years of age. Typically onset of IBS is seen between 20 and 30 years of age

Food Intolerance

It is rare to see a true food allergy with IBS but ingestion of certain foods or beverages may trigger a flareup in symptoms. The type of foods that triggers IBS varies from person to person. These are the most common foods which are considered potential triggers:

• Eggs
• Fried and fatty foods
• Cow’s milk and other dairy containing foods
• Peanuts
• Soy
• Citrus fruits
• Beans
• Wheat
• Chocolate containing drinks and food
• Carbonated drinks

Major Causes of IBS

The exact cause of IBS is unknown, but it is important to understand that IBS is not a problem that arises in the GI tract alone. It is mainly thought to be caused by improper interaction between the gut and the brain.

Consider the gut, brain and nervous system as three legs of a stool. If even one of these legs does not work properly, it will weaken and destabilize the whole system.

Here are five of the most common causes of IBS:

Damaged digestive muscles (Dysmotility)

Dysmotility is defined as the impairment of muscles in the gastrointestinal tract that results in change in the speed, strength, and coordination.

When the muscle in the GI tract or the nerves that coordinate and control their action, do not function properly, it disrupts the onward “wave” movement of the liquefied food and digestive enzymes.

Imbalance in the gut microbiome (Dysbiosis)

The combination of millions of bacteria, fungus and other microorganisms that reside in the gut is collectively called the gut microbiome. When there is imbalance in the microbiome, it is called dysbiosis.

When there is loss of good micro-organisms, it consequently results in the overgrowth of pathogenic (harmful and illness-causing) microbes.

Gut Dysbiosis is brought on by several causes including

• Poor diet – high in sugar, carbohydrates, and food additives

• Taking certain medication especially antibiotics

• Excess consumption of alcohol

• Stress

• Environmental toxins

Visceral hypersensitivity

Visceral hypersensitivity is defined as a person’s lower than normal threshold for pain in the visceral organs (soft internal organs located in your chest, abdomen, and pelvic cavity).

Dysfunction in the gut-brain interaction

You must have used phrases like “My gut says no” while making a decision or “I feel butterflies in my stomach” while being nervous. It is because you have probably received messages from your little “gut” brain.

This second “brain in your gut” controls digestion and communicates with the big brain, thus indirectly affecting your thoughts and mood.

Thus a healthy mind free from worry is the token to a healthy gut, and vice versa.

Post-infectious IBS

In some cases, IBS develops following an episode of acute infectious  gastroenteritis. It is estimated that 10% of people who suffer acute gastroenteritis develop IBS.  If symptoms from the initial infection is severe or lasts longer, then the risk to develop IBS is higher.

Gender-specific symptoms of IBS (Women vs Men)

An interesting lesser-known fact related to IBS is that

• Women are twice as likely as men to develop IBS.
• IBS with constipation is more common in women whereas IBS-D is more common in men.

IBS in Women

One reason of the high prevalence of IBS in women is thought to be due to the effect of estrogen and progesterone hormones on GI function. 

Among women, IBS symptoms are more common during menstruating years.  There are life stages and phases in the menstrual cycle when symptoms are often worse.

IBS and menstruation

IBS symptoms are worse between ovulation and menstruation, with increased uterine cramps during menstruation. The other common symptoms which tend to get worse during menstruation are:

• Abdominal pain
• Fatigue
• Backache
• Bloating
• Constipation
• Diarrhea

IBS and Pregnancy

Elevated levels of estrogen and progesterone and the pressure of a growing fetus on the bowel walls are the key factors that are responsible for worsening of IBS symptoms.

Studies show that

• Many women suffering from IBS, reported heartburn and increased insomnia in the first trimester.
• One-third of pregnant women suffering from IBS complained about increased constipation or diarrhea during the third trimester.

IBS and sexual intercourse

A high number of patients with IBS reported sexual dysfunction. Sexual dysfunction can either be decreased sexual drive or painful intercourse. Visceral hypersensitivity plays a major role in IBS with respect to sexual functioning.

IBS in Men

Although there are no anatomical differences observed between the gastro-intestinal tract of males and females, there are differences in the symptoms. Men may experience more severe abdominal pain and bowel movements brought on by diarrhea. They may also have difficulty with sexual intimacy.

Diagnosis of IBS

In the past IBS was considered a diagnosis of exclusion, where the diagnosis was provided only after extensive testing was done to rule out other GI disorders that could cause similar symptoms.

But these days, a Gastroenterologistwill be able to provide a diagnosis based on obtaining a thorough health history and physical examination, in the absence of any alarming symptoms. 

In the case of mild to moderate symptoms, evaluation for diagnosis may include;

• Blood tests to rule out celiac disease

• Stool samples and blood tests to check for signs of infection and Inflammatory bowel disease (IBD)

In the case of severe symptoms especially rectal bleeding or unexplained  weight loss, in addition to above tests, diagnostic imaging may be ordered.

• Sigmoidoscopy (examination of the lower half of the colon)

• Colonoscopy (examination of the entire colon)

Complications with IBS

Typically, physical complications are more common with IBS- constipation

Anal fissures:

The straining to pass stools can result in small tears in the anus, causing pain, itching or bleeding.

Fecal impaction:

Severe constipation can result in formation of large amount of stools that gets stuck in the rectum or backed up into colon, that cannot be pushed out. Medical intervention is needed to manage and avoid further complications.

Hemorrhoids:

Hemorrhoids are swollen veins in the anus or lower part of the rectum, causing symptoms of pain and bleeding. It can be caused by prolonged constipation or diarrhea.

Nutrient deficiency:

Whether it is following a very restrictive diet to manage flareups or as a result of frequent diarrhea, nutrient deficiency can arise.

The complications of IBS go beyond physical health complaints and can affect quality of life and mental health.

Missing school or work:

Research indicates that people with IBS frequently miss work, three times more compared to someone who does not have IBS.

Impact on social life:

Frequent bathroom trips in case of a flare up, discomfort from IBS symptoms and concern over accidentally eating possible trigger foods are some of the reasons, people with IBS have challenges with their social life.

Sleep issues:

People with IBS often have difficulty falling asleep or wake up frequently through the night, typically from the gastrointestinal symptoms. In turn, sleep disruption can make the IBS symptoms worse, continuing the vicious cycle.

Mood issues:

Low mood, anxiety, excess irritability, mood swings or inability to focus are often commonly seen in people with IBS, especially in people with severe symptoms. Although, there is no direct cause relationship between IBS and mood issues, the two often occur together. This association is possibly due to the gut-brain interaction.

Treatment Options

Conventional Treatment:

Conventional medicine treatments focus on improvement of IBS symptoms. They range from laxatives to relieve constipation to antispasmodics to help with reducing abdominal cramps.

Naturopathic Medicine Approach to IBS:

IBS symptoms go beyond the gut; often accompanied by stress, restrictive diet, lifestyle challenges, anxiety or low mood to name a few. So a multi-faceted holistic approach has great success in helping people with IBS.

Diet: Fundamental to Naturopathic Medicine Approach to IBS

When it comes to IBS, diet is a huge factor in helping to manage symptoms. This is not a surprise as IBS flareups are often tied to eating certain foods.

Low FODMAP diet is one of the most studied diet when it comes to IBS. FODMAP stands for “fermentable, oligosaccharides, disaccharides and polyols”. This diet involves eliminating high fermentable carbohydrate foods, to make digestion less challenging.

But this diet does not work for everyone or even if it works, the list of foods  are too restrictive to follow long term.

Identifying sensitivities to certain foods with testing helps narrow down the list of foods to avoid.

To learn about food sensitivities read my blog on what is food sensitivity

When following an elimination diet long term, make sure to work with an experienced, nutrition focused health provider to reduce the risk of developing nutritional deficiencies.

Balance the Microbiome:

Microbiome is a combination of all the bacteria, yeast and other microorganisms that reside in your gut.

Studies show that the number and distribution of micro-organisms is altered with IBS. Several factors such as stress, diet, lifestyle and genetics influence the alteration in the microbiome.

Taking a probiotic may help some but for others, it may make all their IBS symptoms worse. A thorough history and testing can help determine the best way to balance the altered microbiome.

Address Inflammation:

Studies have shown, that constant low grade inflammation in the gut mucosa lining occurs with IBS.

In addition to mucosal inflammation, neuroinflammation is thought to play a role as well, acting via the gut-brain axis.

So a comprehensive approach to IBS should involve addressing inflammation, by avoiding triggers of inflammation and including anti-inflammatory support.

Normalize HPA Axis dysfunction

Hypothalamus-pituitary-Adrenal axis is responsible in helping your body adapt to stress, via the neuro-endocrine mechanism. And when HPA axis becomes dysfunctional due to prolonged, it can negatively influence the parasympathetic nervous system.

The parasympathetic nervous system controls many important functions within your body including “rest and digest” response. Thus HPA axis dysfunction can result in poor digestion, altered colon motility and intestinal permeability, which are all important factors in IBS.

Optimizing your HPA with nutrients, herbs and lifestyle can help reduce IBS symptoms.

Digestive Support

Digestive enzymes helps breakdown macronutrients such as carbohydrates, protein and fat from your diet.

Bloating is one of the most common symptoms with any type of IBS. Taking a digestive enzyme, makes it easy for your body to digest food and reduce the occurrence of bloating.

In similar manner, taking carminative (a.k.a an agent that relieves gas)  herbs and spices can provide relief from bloating. My top 5 carminative foods that can help with IBS are

1. Peppermint

Peppermint Oil is the essential oil taken from flowers and leaves of peppermint plants.

Peppermint oil is muscle-relaxant. The menthol in peppermint has a decompressing effect on the intestinal soft muscles. It can alleviate inflammation and ward off bacteria.

A small amount of peppermint oil in enteric-coated capsules may help improve IBS in adults.

2. Chamomile

Chamomile can help with many symptoms associated with IBS, such as indigestion, loss of appetite, diarrhea and abdominal pain.

The herb acts as a nervine relaxing and toning the nervous system, thereby reducing anxiety and stress which is common in people with IBS.

It can be used fresh or dried in infusion or in tincture form made from the herb.

To make an infusion, steep 2 teaspoons of the herb in 1 cup of boiling water and leave it covered. This infusion can be drunk 3-4 times in a day as needed.

3. Ginger

Ginger root helps reduce nausea, decrease inflammation and provides pain relief.

A study found that taking 1200mg of ginger accelerated gastric emptying.

So if you have constipation symptoms, including ginger in your diet could be helpful. It can be taken as a tea or used in cooking or available in supplement form.

4. Fennel

Fennel seed relieves gas and abdominal pain by supporting digestion.

It also reduces inflammation in the GI tract and relaxes the muscles lining the intestinal walls.

Infusion can be made with 1 teaspoon of coarsely crushed fennel seeds. It is also available as liquid extract supplements, tincture, syrup or dried ginger root capsules.

5. Caraway

The oil from the caraway seeds have shown to relieve spasms in the intestine, stop growth of bad bacteria and reduce gas and bloating.

Topical application of few drops of caraway oil mixed with olive oil base, on the abdomen area, have shown to reduce colic and relieve gas.

Your takeaway

IBS symptoms even if it improves at first, has a high relapse rate.

So if your symptoms are mild, you can try diet and digestive support interventions after discussing with your health care provider.

But if you have been suffering with IBS long term and none of the treatments you have tried have been helpful, Naturopathic Medicine can be of help.

As a Naturopathic Doctor, I help people with IBS by providing an individualized plan based on functional tests that evaluates gut function and HPA axis and a through health history.  

The information and other content provided in this blog are for information purpose only, and not intended and should not be considered as medical advice. If you have a medical concern, you should consult with your health care provider before you make any changes to your diet or lifestyle.

Resources

Anbardan SJ, Daryani NE, Fereshtehnejad SM, Taba Taba Vakili S, Keramati MR, Ajdarkosh H. Gender Role in Irritable Bowel Syndrome: A Comparison of Irritable Bowel Syndrome Module (ROME III) Between Male and Female Patients. J Neurogastroenterol Motil. 2012;18(1):70-77. doi:10.5056/jnm.2012.18.1.70

Khanna R, MacDonald JK, Levesque BG. Peppermint oil for the treatment of irritable bowel syndrome: a systematic review and meta-analysis. J Clin Gastroenterol. 2014;48(6):505-512. doi:10.1097/MCG.0b013e3182a88357

Ng QX, Soh AYS, Loke W, Lim DY, Yeo WS. The role of inflammation in irritable bowel syndrome (IBS). J Inflamm Res. 2018;11:345-349. Published 2018 Sep 21. doi:10.2147/JIR.S174982

Hoffman, David. Medical Herbalism: The Science Principles and Practices of Herbal Medicine . Healing Arts Press. August 30, 2003.

Cleveland Clinic “Irritable Bowel Syndrome” Cleveland Clinic last updated on 9/4/2020, https://my.clevelandclinic.org/health/diseases/4342-irritable-bowel-syndrome-ibs

Mayo Clinic Staff “Irritable Bowel Syndrome” . Cleveland Clinic, May 8/2022, https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/symptoms-causes/syc-20360016

Greg Sayuk MD, MPH, What is IBS, updated 2022, https://aboutibs.org/what-is-ibs/