Happy New Year! Hope everyone had a fun and safe holiday season. Last time we talked about what irritable bowel syndrome (IBS) is and maybe what causes it.
A quick review. The technical definition of IBS is abdominal pain (which can be bloating, cramping or generalized discomfort) that is directly related to your bowel movements in at least 2 of these 3 ways:
- gets better or worse with BMs,
- your stools are now more or less frequent,
- there is a change in the appearance of your BMs (harder or looser).
2 & 3 are kind of linked because if you are going more often, they are usually looser. For most people, the pain is relieved, or at least improved, with going to the bathroom.
So, you and your doctor are pretty sure you have IBS. What are your options? Well, for openers, there is no magic bullet. OK? No matter what your neighbor or your chiropractor tells you, or what you may read online. IBS is a chronic condition that may wax or wane (gets better or worse) for no good reason, but has a way of hanging around. But fear not, there are LOTS of things you can do. Your symptoms may not disappear (darn!), but they can be more manageable and livable.
The first thing people ask is “what can I eat, Doc?” This is a very active area of research right now, the effect of diet on IBS. It is important to understand the difference between food allergies and sensitivities. Food allergies, relatively uncommon in adults, are driven by the immune system (IgE antibodies, mast cells, etc). Antibodies and immune cells react to specific proteins to cause inflammation and then symptoms. IBS is not related to classic food allergy. Food sensitivities, on the other hand, are quite common. You just don’t feel good after eating something, but it’s not an allergic thing (hives, lip swelling, skin rash). Identifying food sensitivities by an elimination diet can improve symptoms of IBS in many people.
Another term you may hear is food intolerance. This refers to the inability to digest a specific food, often carbs. Lactose intolerance is the classic example, caused by the body’s inability to break down and absorb the sugar lactose.
What about gluten, you ask? That’s a little complicated. Gluten free diet (GFD) is often said to be good for what ails you. If you have been diagnosed with celiac sprue (by endoscopic biopsy and/or blood tests), yes, the diet should help. But GFD has not been shown to have a significant benefit in IBS in clinical trials and is not recommended routinely. Having said that, there are certainly many people without celiac sprue who feel better on the diet and swear by it. We might call this gluten sensitivity. Keep in mind that it is not an easy diet to correctly follow, as many of you know.
It’s easy to get bogged down on this topic. Most people with IBS have a pretty good idea of what sets them off. Avoidance, easier said than done, is the key. There is one diet that has been shown to work objectively in IBS- the low FODMAP diet. The low FOD-what? FODMAPS (fermentable oligo, di, monosaccharides and polyols) are basically carbohydrates that many people have trouble digesting and absorbing. Sort of a nonspecific food intolerance thing. As a consequence, these short chain carbs pass through the small intestine and get into the colon, where the normal bacteria there gobble them up and spit out hydrogen and other molecules that cause stuff like gas and bloating.
Low FODMAP diet has been carefully studied and proven to work pretty well. It’s not that difficult, just takes some teaching and discipline. Ah yes, discipline. Why does this word keep coming up when we talk about diets? Keep in mind, it’s basically a trial and error approach right now; you should know in 3-4 weeks if it’s right for you.
Remember how last time, we went over the 3 (sub)types of IBS- IBS-C (constipation), IBS-D (diarrhea) and IBS-M (mixed)? If you fit into one of these categories, it probably makes sense to you that the treatment (medication) options are different for each.
Let’s start with IBS-C. What can actually help you move your bowels more often, and help with the bloating and belly ache? Fiber works, yes it does, but soluble (psyllium, oat bran) is better than insoluble (wheat bran, whole grains). PEG (polyethylene glycol, trade name MIRALAX) will help you go more often and more easily, but may not decrease your bloating discomfort. There are a number of very safe prescription drugs, some of which you have seen advertised on TV, that have been shown to definitely help both BM frequency and abdominal pain. In my experience, when these drugs work, they work great, and with basically no side effects. They don’t always work, but usually worth a try.
Next, IBS-D. Take a close look at your diet. Fat content, garlic, onion, wheat maybe. There are various drugs to slow down your BMs, ranging from OTC loperamide (Imodium) to bile salt binders to opiod and serotonin blockers. You need to work with your doctor to see if any of these would be a good fit for you. One very good idea is an antibiotic called rifaximin taken for 2 weeks to alter your microbiome. This nonabsorbable med has been shown to be both safe and effective in a good percentage of patients.
If you are mixed, or an alternator (the name makes sense if you’ve got it), unfortunately your options are more limited. The drugs that speed up your gut, or the drugs that slow it down, well, you’re more complicated than that. Try to eat well- lower fat, higher fiber. For pain, sometimes we use medicines that were originally used to treat depression (for example, amitriptyline, or Elavil) to trick the brain-gut axis. Be open to this suggestion if your doctor brings it up. The meds are used at low dose and it doesn’t mean he thinks you’re depressed or crazy.
Lastly, hypnotherapy and what’s called gut-directed behavioral therapies have been shown to help. Things like meditation, mindfulness and yoga. I don’t have a lot of experience with this, but look into medical centers with specialized IBS centers for more info.
Cannabis? The endocannabinoid system plays a role in regulating the enteric nervous system (remember, the gut brain?) It makes sense that CBD and maybe THC could decrease the abdominal pain in IBS and there are many proponents out there. Unfortunately, there are no good studies that can prove a benefit at this time and medical marijuana is not approved for IBS. It is a fact that cannabis is legal in many states in the US and some folks choose to self-medicate. What’s the old saying, smoke ‘em if you got ‘em?
So there you go. Lots of options to make your IBS better. Awareness and understanding go a long way. Get a good doctor. Adopt a positive attitude. Peace out.