UAB Medicine News
Irritable Bowel Syndrome: When to See Your Doctor, and Why
There are many causes of mild, occasional stomach distress, bowel discomfort, and similar gastrointestinal problems, most of them rarely being serious or chronic. But when an upset stomach becomes a common occurrence instead of an occasional one, and if symptoms always include severe abdominal pain, constipation and diarrhea, it may be time to talk to a doctor about irritable bowel syndrome (IBS).
Although IBS is broadly defined as a condition of the intestines that causes abdominal pain or discomfort, it is important to note that IBS is a group of symptoms that occur together. Pain may occur with constipation or diarrhea. Other symptoms are bloating, mucus in the stool, or a sensation that the bowel has not completely emptied. For this reason, causes of IBS are not always detectable or easily distinguished from other gastrointestinal conditions. Nipun Reddy, MD, who directs the Gastroenterology and Hepatology clinic at the Kirklin Clinic of UAB Hospital, describes IBS as “a constellation of factors.”
“There is not a simple, singular aspect of this array of factors associated with intestinal distress that we can point to or label as IBS,” Reddy says. “A third of my patients have overlapping symptoms of IBS. We know that there’s not an isolated thing a patient does that triggers the symptoms, or one symptom or event that determines diagnosis.”
Criteria for Diagnosis
Reddy says that the experts in gastroenterology have settled on guidelines that indicate when the associated symptoms may be diagnosed as IBS. Known as the Rome Criteria, (after the 13th International Congress of Gastroenterology in Rome, Italy in 1988), these guidelines have been revised and updated three times. The current version, Rome IV, lists the following criteria:
"Recurrent abdominal pain, on average, at least one day per week in the last three months, associated with two 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.”
Duration and onset are also critical elements in Rome IV. Not only must the signs and symptoms be present for the past three months, but IBS can't be diagnosed any earlier than six months after symptoms began.
Rome IV is far more nuanced and detailed than earlier criteria used in evaluating signs and symptoms, so much so that IBS is now categorized as a complex spectrum of symptoms that people experience in different forms, as opposed to a homogeneous condition. It even notes differences in how men and women describe or react to IBS. However, a patient’s decision to see a doctor to begin the process of diagnosis doesn’t need to be as complex.
“I tell patients that if these GI symptoms bother you every day for a month, enough to make everyday life difficult, then you should definitely see your doctor,” Reddy says. “It would not be practical to ask patients to follow precise guidelines. That happens after they see their physician.”
IBS diagnosis is also an exclusionary process. That means, in most cases, that doctors don’t use one test to diagnose IBS, but will first order blood tests, stool tests, and other tests to determine which GI conditions a patient does not have.
“We are actually eliminating worst case scenarios for our patients before we settle on IBS,” Reddy says. “That means we rule out serious symptoms such as weight loss, vomiting, or blood in the stool. Those are red flags that may alert us to a bowel obstruction, or perhaps some cancer somewhere in their system. Then we make sure their gallbladder is okay, and that we aren’t dealing with acid reflux. We eliminate Crohn's disease or ulcerative colitis. If all the possible causes of their GI problems are negative, then we can consider settling on a diagnosis of some form of IBS.”
Strategies for Successful Treatment
For many people who already struggle with the often severe stress and inconvenience of IBS, the trial-and-error process of diagnosis and treatment can be a source of frustration or may cause a sense of hopelessness. It can also be discouraging to learn that medical research still has not settled on a specific condition for IBS or its causes. However, even in the absence of a known precise cause there are successful remedies for relief.
Doctors may treat IBS by recommending diet and lifestyle changes, medicines, probiotics, and mental health therapies. A number of strategies may include increasing physical activity, reducing stressful work/life situations as much as possible, and adjusting sleep patterns to ensure that you are getting enough rest.
A FODMAP diet may be one solution. FODMAP stands for fermentable oligo-, di, mono-saccharides and polyols. The acronym consists of types of carbohydrates known to create digestive symptoms such as bloating, gas, and stomach pain. FODMAPs are found in varying amounts in numerous foods, so avoiding those through a specific diet may reduce or eliminate causes of IBS. Your doctor may also recommend probiotics. Probiotics are live microorganisms, most often bacteria, similar to microorganisms you normally have in your digestive tract.
Many patients are having success in reducing the severity of IBS symptoms through mental health approaches such as cognitive behavioral therapy, which focuses on positive thought and behavior patterns. A similar method is relaxation training, a system of muscular stress reduction. In relation to stress reduction, certain antidepressants have been found to reduce IBS symptoms.
Reddy emphasizes that a key component in forming a treatment plan is to categorize the IBS as it relates to constipation, diarrhea, or a mixed pattern of those two. With that information, a doctor can then explore what the patient is eating, when, and how much.
“One of the first areas of treatment for our patients will deal with their diet,” Reddy says. “We can start with a food journal, for which a patient writes down symptoms and what they ate that day. Over a week’s time we can look for a pattern. The IBS trigger may be spicy food for a late evening meal, or the coffee you drank all day. A food journal will show habits or patterns you otherwise might not be aware of, such as how much caffeine or how many diet drinks you consume. If your lifestyle makes keeping a food journal impractical, then we can go ahead and assign a diet. For six to eight weeks you can try a FODMAP diet.”
Recent research has revealed that a high percentage of people suffering from symptoms associated with IBS use over the counter medications to relieve symptoms, or sometimes attempt diet changes and other treatments on their own, without consulting a doctor. To be safe, anyone with persistent and/or severe symptoms should consider that the most important element of IBS diagnosis is the elimination of serious causes and chronic GI conditions.
Click here to learn more about irritable bowel syndrome, UAB’s diverse team of digestive health experts, advances in diagnostics, and the UAB Medicine Digestive Health Center.
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