The treatment of disease is constantly changing and evolving as a result of new information and new technologies, and irritable bowel syndrome (IBS) is no exception.
Rome III criteria
There is no specific reliable test for IBS, and the diagnosis is made based on the history of the patient (symptoms) and by excluding possible causes. Instead of speaking of a cure, in the case of IBS the emphasis is on measures to relieve the symptoms.
Currently, the Rome III criteria are used to diagnose IBS. The criteria are recurrent abdominal pain or discomfort, at least three days per month for the last three months, with symptoms having started six months prior to diagnosis.
The symptoms are associated with two or more of the following:
- Improvement with defecation, and/or
- Onset associated with a change in frequency of stool, and/or
- Associated with a change in form (appearance) of stool
Although IBS can at times be excruciatingly painful, it is not a dangerous or fatal condition. Symptoms of IBS vary and some people are affected more severely than others. About twice as many women are affected as men.
Dr Wilken weighs in
Dr Estelle Wilken, Health24’s Digestive Health Expert, has her finger on the pulse of current and new developments in the treatment of IBS:
Firstly doctors need to follow the Rome III criteria to make sure that the patient is actually suffering from IBS, as the condition is frequently misdiagnosed. Doctors sometimes label patients as IBS sufferers when they actually have functional abdominal pain (with a different set of symptoms).
If it has been conclusively established that the patient suffers from IBS, there are several new treatment avenues that can be explored:
- A new antibiotic, Rifaximin, gives long lasting symptom relief, emphasising the huge role of the gut mycrobiota as a cause of IBS. This antibiotic is not absorbed systemically, and is mostly used in conditions such as liver failure and Clostridium difficile infections. IBS has a huge placebo problem, meaning that about 45% of patients will respond to medicine, but will relapse within 6 months because the placebo effect is lost. Rifaximin works for much longer – at this time we cannot say how long, because this is work in progress, but test subjects are still doing fine after a year on the medication.
- In a recent study, IBS patients were screened for coeliac disease. Around 7–9 percent tested positive, which gives credence to the practice of excluding gluten from IBS sufferers’ diet.
- It is now a well-known fact that there is a non-coeliac gluten entity. This would explain why some IBS patients get much better on a coeliac diet, although all their tests are normal.
- There is also now the FODMAP diet (fermentable oligo-, di-, monosaccharides and polyols). It is a very difficult diet to follow and there are only a few dietitians in South Africa who can provide information about this diet. Most of the patients who respond well to the diet (and most do well when they have access to it), appear to have a problem with wheat and fructose intolerance. This is probably also the reason why they respond to a gluten free diet.
Causes of IBS
With IBS there aren’t any obvious physical abnormalities and it has not been established what exactly causes the problem. (There is some consensus that the pain is caused by spasm in the bowel, although there may be several factors that play a part.)
The following are generally accepted theories:
- Problems with serotonin. Serotonin is involved in bowel movements and serotonergic drugs have had a positive effect on IBS.
- Genetic causes. IBS does seem to run in families.
- Inflammation. Numerous mast cells are found in patients with IBS, indicating inflammation.
- Bacterial overgrowth and changed bowel flora. Many IBS patients have overgrowth of bacteria in the small bowel, which is the origin of symptoms like bloating, abdominal pain and diarrhoea.
- Psychological causes. There is some controversy about whether psychological conditions can cause IBS, but a 2007 study found that non-drug psychologic or mind/body treatment for IBS have proven efficacious in clinical trials.
Because there are no known pathogens or physical damage involved in IBS, there is also no specific cure for the condition. However, when symptoms are no longer present IBS can be considered to be in remission. Symptoms may return or the patient may remain symptom free for the rest of their life.
The following are examples of “standard” IBS treatments:
- Serotonergic drugs
- Traditional therapies like bulking agents and antispasmodics
- Drugs that increase fluid secretion in the gut to improve the ease of stool passage
- Natural or alternative treatments like probiotics, herbal remedies (e.g. slippery elm) and acupuncture
- Changes in lifestyle or eating habits. Exercise may improve constipation and the removal of e.g. gluten and “gas-forming” foods may ease discomfort.