Irritable Bowel Syndrome: What is it & is there a cure?

Updated: May 22

I suffered for years with the symptoms of irritable bowel syndrome (IBS).


Abdominal pains kept me awake at night.

I was bloated to the point I looked pregnant.

Passing stools was a major challenge, and I could be blocked up for days.

Then there was the fatigue, brain fog, nausea, depression and acne.


What was the specialist's response?

You have irritable bowel syndrome. Eat more fibre, take Metamucil and drink more water.


But, none of those things helped.


Until one day, with the help of a knowledgeable holistic health practitioner I discovered the root causes of my IBS symptoms. With a clear plan, dietary changes and some natural supplements I was able to address those causes and now I consider myself an ex-IBS sufferer!


You see, irritable bowel syndrome (also known as IBS) is a BS diagnosis!


It is a term used for a collection of symptoms (like abdominal pain, constipation, diarrhea and gas) with numerous underlying triggers and causes.


It is a "waste basket" diagnosis used when other conditions such as colitis, inflammatory bowel disease (IBD), colorectal cancer and coeliac disease have been excluded (hopefully). (1,2,3)


Unlike, those with inflammatory bowel disease (IBD), for example, IBS shows no visible signs of structural damage to the bowel.

IBS is therefore considered a functional gastrointestinal disorder, characterized by chronic, often disabling, abdominal pain and changes in bowel habits. (2,4,5)

Abdominal pain with IBS

What are the symptoms of IBS?

Common symptoms of IBS include:

  • Generalized abdominal pain or cramping

  • Constipation (difficulty emptying bowels, or infrequent bowel movements)

and/or

  • Diarrhea (loose stools, with or without a sense of urgency - having to rush to the toilet)

Some can alternate between constipation and diarrhea. (2)


Many with IBS or poor gut health also complain of:

  • Bloating (3,6)

  • Feeling of incomplete evacuation (7,9)

  • Mucus with bowel movements (8,9)

  • Worsening of symptoms after eating (8,9)

  • Excessive or smelly flatulence (gas) (9,10)

  • Gastro-oesophageal reflux or heart burn (10,11)

  • Indigestion (dyspepsia) (12)

  • Frequent burping or belching (9,10)

  • Nausea (10,13)

  • Chronic fatigue or low energy (14,15)

  • Depression and/or anxiety (16,17,18)

  • Muscle and joint pain or Fibromyalgia (19,20)

  • Brain fog or poor memory (21,22,23,24)

  • Skin issues such as acne, hives, psoriasis or eczema (25,26,27,28,29,30,31)

  • Allergies, sensitivities or intolerances - food or environmental (29,30,32)

  • Migraines or headaches (33,34,35)

  • Weight changes (36,37,38) - weight gain is more common with IBS, but weight loss can occur with dietary restrictions or unresolved diarrhea.


What are "red flag" or "alarm" symptoms?

Alarm symptoms, such as unintended weight loss, frequent watery diarrhea, anemia, and appearance of blood in stool, should trigger a clinician to consider an alternative diagnosis and investigate further. (2,3)


Symptoms that interfere with sleep, that develop after age 50 years, that occur in those with a family history of inflammatory bowel disease, colorectal cancer and/or coeliac disease should also make the clinician more wary. (3)


IBS can be debilitating & severely impact a person's quality of life

IBS digestive symptoms can vary widely, but abdominal pain is a hallmark of the condition and bloating has been found to affect more than 80% of people with IBS (5,6).


People with IBS often report a reduced quality of life, with abdominal pain being the most common disruptive symptom. (39,40 ).


One US study found IBS sufferers had more days off work (6.4 vs. 3.0) and days in bed, and reduced activities to a greater extent than non-sufferers. (41)


Sadly, another large study reported that people with IBS said they would give up an average of 25% of their remaining lives in order to be symptom-free! (42).


What are the types of IBS?

Subtyping of IBS is controversial, but is based on stool form, which can be aided by use of the Bristol Stool Form Scale. (4)

Bristol Stool Chart

There are 4 types or sub-types of IBS: (3)

IBS-C = IBS with predominant Constipation (>25% hard stools, <25% loose stools)

IBS-D = IBS with predominant Diarrhea (>25% loose stools, <25% hard stools)

IBS-M = IBS with Mixed bowel habits (>25% loose stools, >25% hard stools)

IBS-U = Unclassified IBS.


How is Irritable Bowel Syndrome medically defined?


"The diagnosis of IBS is usually made by performing a careful review of the patient's symptoms, taking a thorough health history, evaluating the patient for the presence of warning signs, performing a guided physical examination, and using the Rome IV criteria". (5)


According to the Rome IV criteria the patient must have:


Recurrent abdominal pain, on average, at least 1 day per week in the last 3 months, associated with 2 or more of the following criteria: – Related to defecation – Associated with a change in frequency of stool – Associated with a change in form (appearance) of stool

The criteria needs to be fulfilled for the last 3 months with symptom onset at least 6 months. (3,5,43)


So, usually, once other conditions such as coeliac disease, colon cancer and inflammatory bowel disease have been ruled out, everyone else who meets the following criteria are lumped under one umbrella term, IBS. (1,2,3)


Ultimately, IBS is a diagnosis of exclusion.


Yet it is a serious issue of epidemic proportions.


Prevalence and risk factors for IBS

IBS affects between one in 11 and one in 26 people globally, at any point in time. (44)
Some studies suggest it could be as high as 45% of the general population! (45).

It is reported to be one of the top reasons for visiting an general practitioner (GP) and the most common reason for visiting a gastroenterologist. (46, 47)


Although it is thought that up to 50% of people with symptoms of IBS do not even consult their General Practitioner. (48)

toilet paper

It is the second most common reason, after common flu, to be absent from work (1).


Women are more likely to experience IBS than men, in a ratio of 2:1. (1)


The peak of the disease often starts in early adulthood. (1)


IBS with diarrhea (IBS-D) was the most common subtype reported with the Rome IV criteria (1).


Women more commonly suffer from IBS-C and men from IBS-D (1).


Why are we told there is no cure for IBS and why use the term IBS, at all?


This is because there is not just one single cause or treatment, and determining the cause or causes in an individual can be tricky when relying on standard medical testing.


Furthermore, we like our labels. It reduces fear and uncertainty. We'd rather be told we have IBS, than be told "sorry, we don't know what's wrong with you".


Although a label provides comfort in the short term and makes it easier to talk about, it does little to empower an individual to find a long-term solution to their symptoms.


We may leave with a diagnosis, but no effective guidance on the next steps to take, and little desire to search out the root cause of the symptoms.


The IBS label implies that the problem has been identified, which is far from the truth.


IBS is NOT a cause, it is only a description of the symptoms (3,5).


Man on toilet

What are the causes of IBS?

Fortunately over the past decade, there has been an explosion of research on gut health and the identification of specific diseases and disorders that can cause IBS symptoms.


Some of the conditions listed, such as endometriosis, or a parasitic infection, would ordinarily not be considered an IBS root cause, as they are stand alone conditions. However, they have similar symptoms to IBS and are frequently missed or not thoroughly investigated.


Also, there appears to be frequent overlap between IBS and other functional gastrointestinal disorders, urogenital pelvic disorders, and even possibly inflammatory bowel disease (when in remission). (2).


There are several mechanisms that are thought to contribute to IBS symptoms: (2,49,50).

  1. disruption of the gut-brain axis

  2. gut dysmotility (poor gut movement or motions)

  3. increased pain sensitivity (visceral hypersensitivity and poor pain modulation)

  4. low-grade mucosal gut inflammation

  5. increased intestinal permeability (aka a "leaky" gut)

  6. and an imbalanced gut microbiome (altered microbiota)


Some of the common underlying causes include: (Click the coloured links for more information on each).


Intestinal dysbiosis (i.e. a disrupted gut microbiome or imbalanced gut bacteria). There are various different manifestations of dysbiosis. This can be due to antibiotic or medication use, previous infection, poor diet and more. Common ones include:

SIBO is thought to be one of the most common causes of IBS, with some indications it could be as high as a 78% incidence rate! (56)

  • Large intestinal bacterial overgrowth (LIBO) (55)

  • Candida or fungal overgrowth (Small Intestinal or large intestinal Fungal Overgrowth - SIFO or LIFO) (56,58,59)

"There is emerging literature that an overgrowth of fungus in the small intestine of non-immunocompromised subjects may cause unexplained GI symptoms." (59)

In one small study, 26% of people with unexplained GI symptoms had an overgrowth of fungus in the small intestines (SIFO). Another study found 25.3% had SIFO. (59)


Infectious or post-infectious IBS - due to pathogenic or disease-causing microorganisms (also a form of dysbiosis):

Post-infectious IBS begins after an episode of acute gastroenteritis, also referred to as a "tummy bug", and is due to a bacterial or viral infection. (65, 66)


Clostridium difficile is a species of bacteria that is frequently hospital acquired and can cause severe diarrhea, and even psychological symptoms. (67)


Medication use

Certain medications can directly disrupt gut function or increase susceptibility to infection and bacterial or fungal overgrowth.


Of particular note are:

Proton pump inhibitors (PPIs) - used for reflux and heart burn (68,69)

medication

Opioids

These include pain-relieving prescription drugs like codeine, morphine, oxycodone and vicodin. Plus, the recreational drug heroin. Constipation is a common symptom of opiate use. (70, 71,72)


Anti-biotics

Prolonged or broad-spectrum antibiotics have been shown to induce changes in the gut and increase susceptibility to certain infections. (73, 74, 75)


Non-steroidal anti-inflammatories (NSAIDs)

These include: aspirin (such as Disprin), ibuprofen (such as Nurofen), naproxen (such as Naprosyn), diclofenac (such as Voltaren), celecoxib (such as Celebrex).

As well as an increased risk of gastric ulcers, gastrointestinal bleeding, heart attack, and stroke, they may promote a "leaky gut" (increased intestinal permeability). (76, 77)


Food allergies, sensitivities and intolerances

"60% to 70% of IBS patients report a worsening of symptoms after meals, 50% to 70% report intolerance to various foods, and more than 70% believe that foods cause their symptoms." (78)

Distension of the gut, food hypersensitivity, and direct action of the food chemicals on the gut have been proposed as mechanisms by which food items might induce symptoms. (79, 80,81)


Foods commonly reported as symptom triggers include: fruits (citrus, banana), grains (wheat, barley, rye, oats, corn), vegetables (onions, peas, potatoes), dairy products (yogurt, milk, cheese, eggs, butter), legumes (beans, lentils), wine, chocolate, coffee, tea, and fried foods. (81, 82)


Double-blind oral food challenges have confirmed banana, coffee, corn, eggs, milk, peas, potatoes, and wheat as common triggers. (83)

gluten free

Gluten, a component of wheat, barley and rye has also been shown to impact those with Irritable Bowel Syndrome. Studies have shown a gluten-free diet can have a significant effect on the reduction of symptoms. (84,85).


The term Non Coeliac Gluten Sensitivty (NCGS) refers to people who do not suffer from Coeliac disease (CD), but their symptoms improve by removing gluten from their diet. Clinically, they present with IBS-like symptoms, but even systemic manifestations (tiredness, headache, fibromyalgia-like joint or muscle pain, leg or arm numbness, brain fog, dermatitis or skin rash, depression, anxiety, and anaemia) can occur (86).


Nutrient deficiencies

These can perpetuate a vicious cycle of poor gut health. For example, Vitamin D and zinc deficiencies are known to interfere with gut function (87, 88).


Emotional stress

Stress is a known trigger as it impacts greatly on gut motility (motion) and "leakiness"; enzyme, bile and stomach acid secretions; and the diversity of the microbiome. But it's typically not the only cause (89).


Increased intestinal barrier permeability (leaky gut) - usually due to any of those mentioned above.


Malabsorption issues

Such as Bile Acid Malabsorption (BAM) which can cause diarrhea. (130)


Thyroid disease

Hypothyroid patients typically experience constipation. For those with hyperthyroidism, diarrhea is more likely. The cause is due the thyroid hormones impact on gut transit time. (131).

Nutrient deficiencies due to poor gut absorption can also lead to thyroid dysfunction.


Endometriosis

Women with endometriosis, can also experience IBS-like symptoms. (132, 133)


Often, more than one condition is involved, interacting in a way to produce a perfect storm of debilitating symptoms.


What tests are available to identify the root causes of IBS?

It is only in the past decade that we have gained access to more accurate and reliable testing.

stool testing

Stool testing can now use DNA technology (PCR analysis) to identify previously undetected harmful bacteria, viruses and parasites. PCR (polymerase chain reaction) tests look for the genetic fingerprint of a wide range of pathogens and is far more sensitive test than the old fashioned technique of looking through a microscope.


The hydrogen and methane breath test used to diagnose a small intestinal bacterial overgrowth (SIBO) is now more fully understood and reliable (90).


There are even more accurate blood tests available for assessing food allergies and sensitivities, that include IgE, all subclasses of IgG and complement markers C3D or C1q (91).


However with newer, more advanced tests, comes a cost. A cost, governments are unwilling to pay at this point in time. So, many of these tests are not readily available through GPs, hospitals or even specialists.


For example, standard stool tests used by regular medical practitioners have been known to miss infections and certainly do not assess any microbial imbalance. The reference library used also determines if less common or emerging pathogenic species are detected (92).


Examination of multiple stools (with validated PCR probes and microscopy) is imperative if wanting to rule out parasitic infection, because intestinal parasites are intermittently shedded (93).


A comprehensive stool analysis is exactly that, comprehensive, and will use three samples, (not just one) to assess:

  • A large number of microbes (bacteria, viruses, yeasts, and parasites).

  • Certain digestive markers to indicate how well the food is being digested.

  • Inflammation levels by looking at markers such as lysozyme, lactoferrin, white blood cells and mucus.

  • Red blood cells and signs of bleeding in the gut.

  • Secretory IgA immune marker, which can indicate how well the gut mucus lining is acting as an immune defense barrier.

  • Short chain fatty acid (SFCA) levels, as good levels are essential for a healthy gut.

  • Levels of beneficial and commensal bacteria and an assessment of microbial balance.

GI 360 by Doctors Data is my preferred stool test.

Why doesn't the medical profession delve deeper into investigating and addressing the underlying causes?


Unfortunately only a small percentage of medical training involves exploring how nutrition, gut health, and our microbiome impacts our overall health and well-being.


Those interested in a more holistic approach need to undergo post graduate study in these areas, and then find a way to implement these discoveries into their very busy practices.


So time and knowledge is a factor, along with cost and access to more thorough testing.


Plus, the focus for the medical system is to typically uncover the more serious causes of the symptoms, such as bowel cancer, coeliac disease or inflammatory bowel disease.


Although invasive, gastroscopies and colonoscopies performed by gastroenterologist specialists are incredibly useful for ruling out these causes.


However, once an IBS diagnosis is given, the investigations usually stop there, and medications are frequently given to manage the symptoms. The sufferer may also be referred to a dietician to start a low FODMAP diet.

Can a low FODMAP diet help IBS sufferers?

A diet low in fermentable carbohydrates known as FODMAPs is frequently recommended for the management of irritable bowel syndrome (IBS) (94,95).


Several studies have suggested that avoiding high FODMAP foods can help manage bloating, stomach pains, flatulence, diarrhea and constipation (96, 97, 98).


Bacteria in the gut help break down food through a process called fermentation. When this occurs gas is released.


For some IBS sufferers, certain high FODMAP foods are thought to increase gas production in the gut, leading to distension and discomfort, because they are rapidly fermented and can be poorly absorbed.


This is likely to be exacerbated in the presence of a small intestinal bacterial overgrowth (SIBO), as there is more bacteria available for fermentation.


With SIBO, the type of bacteria in excess can also impact stool consistency. Those with predominantly methane gas-producing bacteria tend towards constipation. Those with mainly hydrogen gas-producing bacteria are more likely to have loose stools or diarrhea (99).


What does FODMAP stand for and what foods are high FODMAP?

FODMAP stands for fermentable oligo-, di-, mono-saccharides and polyols (100).

The four groups of FODMAPs and their main dietary sources include:

  • Oligosaccharides: fructans (FOS) and galacto- oligosaccarides (GOS) are subsets. Wheat, rye, legumes, lentils and various fruits and vegetables, such as garlic and onions.

Oligosaccharides are poorly absorbed in everyone, because humans lack the enzymes to break these carbohydrates down. Those with IBS tend to be more sensitive to their consumption and the gas produced.

  • Disaccharides: Lactose is the main carb and is found in milk and milk products, like yoghurt and cheese. People who lack the enzyme lactase will malabsorb lactose.

  • Monosaccharides: Fructose is the main carb. Found in various fruits including pear and mangoes, sweeteners such as honey and agave nectar, and products containing high fructose corn syrup.

  • Polyols: Certain fruits and vegetables including blackberries and lychee, as well as some artificial sweeteners like those in sugar-free gum and low calorie processed foods and drinks. Sorbitol and mannitol are the most common polyols in the diet.

A large range of foods contain these fermentable carbs, making a low FODMAP diet complicated and often very restrictive (101).


Confusion on what to eat

How to know which high FODMAP foods trigger symptoms

Determining which of the four groups is the most triggering requires a 3 step process over many months. This is usually done with the help of a dietician and the