Irritable Bowel Syndrome: A Real Condition with Real Treatment
Irritable bowel syndrome affects a large proportion of adults and is routinely dismissed as nerves or gas. It is a genuine disorder of gut-brain interaction with identifiable mechanisms and treatments that work, and it is also a diagnosis that should never be made without excluding the conditions that mimic it.
What is actually happening
Three mechanisms interact:
Visceral hypersensitivity. The gut’s nerves are over-sensitive, so normal volumes of gas and normal contractions are perceived as pain.
Altered motility. Contractions are too fast, too slow or uncoordinated, producing diarrhoea, constipation or alternation.
Gut-brain axis dysfunction. The two-way communication between gut and brain is disturbed. This is why stress worsens symptoms and why drugs acting on nerve signalling help, and it is not the same as saying the symptoms are imaginary.
Contributing factors include a previous episode of gastroenteritis, which causes post-infectious IBS, altered gut bacteria, small intestinal bacterial overgrowth in some patients, low-grade inflammation, and food sensitivity.
Diagnosis
The Rome IV criteria require recurrent abdominal pain on average at least one day a week in the last three months, associated with two or more of: related to defecation, associated with a change in stool frequency, associated with a change in stool form.
Subtypes: IBS-D diarrhoea predominant, IBS-C constipation predominant, IBS-M mixed, IBS-U unclassified.
Reasonable tests before settling on the diagnosis: complete blood count, CRP, coeliac serology, thyroid function, faecal calprotectin to distinguish inflammatory bowel disease, and stool tests for parasites, which matters a great deal in India where giardiasis and amoebiasis commonly masquerade as IBS.
Red flags that are NOT IBS
Any of these needs investigation rather than an IBS label:
- Onset after age 50
- Blood in the stool, or black tarry stools
- Unintentional weight loss
- Anaemia or iron deficiency
- Fever
- Nocturnal symptoms that wake you from sleep
- Progressive worsening
- Family history of colorectal cancer, coeliac disease or inflammatory bowel disease
- A mass felt in the abdomen or rectum
- Persistent vomiting
- Difficulty swallowing
Treatment by symptom
For pain and cramping: antispasmodics such as mebeverine, hyoscine or drotaverine; peppermint oil capsules, which have reasonable evidence; and heat.
Unlock More Content
Watch a short ad to continue reading the rest of this article for free.
Preparing your free unlock…
For constipation: soluble fibre, specifically psyllium rather than wheat bran, which commonly worsens IBS; adequate fluids; polyethylene glycol; and prescription agents such as linaclotide or lubiprostone in resistant cases.
For diarrhoea: loperamide used before predictable triggers rather than continuously; bile acid sequestrants where bile acid malabsorption is suspected, which is an under-diagnosed cause; and rifaximin, a non-absorbed antibiotic, for selected patients.
For bloating: the dietary approach below, simethicone, and treating constipation, since much bloating is retained stool.
Neuromodulators: low-dose tricyclics such as amitriptyline, particularly useful in IBS-D, and SSRIs in IBS-C. These are prescribed at doses far below antidepressant doses and act on gut nerve signalling. Being offered one is not a statement that the problem is psychiatric.
Psychological therapies, which have strong evidence: cognitive behavioural therapy adapted for IBS, and gut-directed hypnotherapy, which has among the best long-term results of any IBS treatment.
Probiotics: evidence is mixed and strain-specific. A trial of a single product for four weeks, judged honestly and stopped if useless, is reasonable.
The low FODMAP diet
FODMAPs are fermentable carbohydrates that draw water into the bowel and are rapidly fermented by gut bacteria, producing gas and distension. Roughly 50 to 70 percent of IBS patients improve substantially on a low FODMAP diet.
High FODMAP foods common in Indian diets include wheat, onion, garlic, rajma, chana, dals in larger quantities, cauliflower, milk, mango, apple, watermelon and jaggery.
It is a three-phase process, and the third phase is the one people skip:
- Restriction, for 4 to 6 weeks only
- Reintroduction, testing each FODMAP group systematically to find personal triggers
- Personalisation, a long-term diet as varied as possible
Staying in phase one indefinitely is harmful: it is nutritionally restrictive, socially isolating in a food culture built on wheat, onion and garlic, and it damages the gut microbiome. It should be done with a dietitian where possible.
Garlic and onion flavour can be retained using infused oil, since FODMAPs are water-soluble and not oil-soluble.
Other practical measures
- Regular meal times, not skipping meals
- Eating slowly, chewing properly, smaller portions
- Limiting caffeine, alcohol, carbonated drinks, very spicy and very fatty food
- Regular physical activity, which improves symptoms measurably
- Sleep, which strongly influences symptom severity
- Stress management, not because the condition is imaginary but because the gut-brain axis is real
- A symptom and food diary for a few weeks to identify personal patterns
Expectations
IBS is a long-term condition managed rather than cured, with periods of remission and flare. Most people achieve good control with a combination of dietary adjustment, targeted medication for their dominant symptom, and attention to sleep and stress. Being told it is IBS should be the beginning of treatment, not the end of the conversation.
This is general information. Any red flag symptom needs investigation, and restrictive diets are best undertaken with a dietitian rather than from an internet list.