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Logan Japikse

Prof. Waggoner

ENG 1201

21 March 2021

A New Approach to the Treatment of IBS

At one point or another everyone has been there. After a greasy or spicy meal, a night of

stomach aches leads to camping out in the bathroom. It seems that no amount of pepto bismol or

antacids can solve the problem and the only solution is to wait it out. Luckily, this experience

happens only on rare occasions and lasts not much longer than the night. However, for a number

of people all around the world, this is a common occurrence and leads to significantly decreased

quality of life. These individuals are afflicted with the condition known as Irritable Bowel

Syndrome (IBS). IBS is one of the most common gastrointestinal disorders. Its prevalence may

even be understated because of the difficulty in diagnosing the condition. Treatment for the

condition is also difficult, as symptoms differ from patient to patient and response to treatment

differs equally. One of the most common long term treatments for IBS is the prescription of a

class of medication known as anticholinergics. Anticholinergics can have beneficial effects on

patients with IBS; however, due to their short and long term side effects the most beneficial

treatment for IBS consists of a well rounded approach to each patient's needs.

Knowing how the condition affects the body can assist in an accurate assessment for

treatment. The body reacts to IBS in a similar way that it responds to injury, however no damage

in being afflicted. Under the condition, the gut sends signals to the brain that are interpreted as

pain. The cause of this pain could be anything from certain foods to stress in everyday life. IBS

manifests in two distinct ways. Patients can either have IBS-C or IBS-D. IBS-C consists of
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constipation oriented symptoms while IBS-D consists of diarrhea oriented symptoms. The two

different forms have separate treatments. However, both share the commonality that treatment is

based on symptoms and not stopping the issue as a whole. As Emanon Quigley, a leading

gastroenterologist, put it, “It’s not a definitive disease. It’s a collection of symptoms… IBS

probably encompasses a number of entities.” (qtd. in Adams). It’s this lack of knowledge on the

subject that makes treatment for IBS difficult. While a patient suffering from IBS-C might be

recommended stool softeners, IBS-D prominent patients would need medication to do the

opposite. Most patients with IBS report bloating, cramping, pain in the stomach, and a feeling of

fullness, but other symptoms can vary widely from patient to patient. Each patient’s affliction is

unique and as such needs to be treated with personalized care.

Because there are no formal tests or ways to identify the disorder, other methods are

needed to accurately identify and treat individuals with IBS. The most widely accepted

assessment is known as the Rome criteria. The criteria is updated along with advancements in the

field. The Rome IV criteria is the version currently employed by doctors. The Rome IV criteria is

used to identify a number of gastrointestinal disorders that do not have specific tests. Pulling

from data and experts from around the world, Rome IV outlines a general test for IBS. The most

prominent question for possible IBS patients is recurring pain in the stomach or lower gut area.

In order for an IBS diagnosis to be considered, a patient must have two main factors; 1) weekly

pain for the past three months and 2) issues with gut motility coinciding with this pain. Even

with the Rome Criteria, patients usually go through a number of misdiagnosis before being

treated with IBS.

A new advancement in treatment for IBS follows the connection between the gut and the

brain. New evidence suggests that the gut has a more complex arrangement of neurons than
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previously thought. This allows it to function as its own small operating system. A lot more than

just food can have an effect on how the gut operates; “thoughts, emotions, and behaviours are

proposed to be bi-directionally related to gut physiology and symptom manifestations in IBS”

(Hamarashid, 44). The connection between IBS and the brain can be seen through its connection

to neurological disorders. Patients with IBS commonly have other conditions such as anxiety or

depression. When the brain struggles with one of these issues, signals can get mixed up in the

brain and reduce the functionality of the gut. The gut brain connection does not only occur in one

way. Adversely, if the gut is struggling to function properly, the signals sent to the brain can lead

to the aforementioned neurological disorders (Harvard Health Publishing). Knowing which way

this path was taken, or if there is a chance the path has yet to be taken could be imperative to

treating the condition. Treating one half of the gut brain connection without addressing the other

side of things could make any treatment a futile endeavor. The holistic approach of treating

possible ailments to the mind could lead to a considerable impact on the gut.

Fig. 1 Graph showing the most common illnesses that coincide with IBS (“One in 10 IBS with

diarrhoea patients wish they were dead when their condition is bad”).

For most chronic IBS patients, prescription medications are used to help treat symptoms.

The most common of these are antispasmodics and antidepressants. Antispasmodics help to
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decrease the tension caused by contractions in the intestines. This helps alleviate pain and

bloating as reported by Hadley and Gaarder in their research on the subject (2503). However,

there is some contention over the use of antispasmodics. When gastroenterologist William D.

Chey was asked his thoughts on the use of antispasmodics, also called anticholinergics in this

setting because of their application, he stated that, “it doesn't make sense, any sense to me to use

anticholinergics for chronic abdominal pain. I can't envision a reason why that would work” (qtd.

in HCPLive). While there is usefulness in certain scenarios, the effect that the antispasmodics

have is not practical for most patients suffering only from abdominal pain. Antidepressants,

referred to as neuromodulators in this setting, have a similar anticholinergic effect on the body.

Although not specifically prescribed for this reason, the antidepressants could benefit those who

are afflicted by a neurological disorder existing with IBS. Both of these types of medication are

much more effective in treating IBS-D patients. The data is not in strong support of helping IBS-

C patients (HCPLive 02:43-04:03). Because of this exclusivity in those able to be treated by the

medication, the benefits they may have are not game changing when it comes to treating IBS;

however the effects of the medications should not be fully discredited.

While anticholinergics can benefit patients with IBS, they are not without their own

drawbacks. Similar to any other prescription medication, anticholinergics have a number of side

effects. Joseph Lieberman reported in his study of the drug that anticholinergics result in a

myriad of side effects affecting vision, the mouth, as well as the digestive tract (20). These are

mostly physical in nature and are not serious although they can lead to worse conditions. The

effect these medications have on sweating and breathing can increase the risk of overheating in

hot weather or exercise. The more pressing side of anticholinergics are the effect they can have

on a patient's mental function. Patients on these medications experience effects such as memory
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loss and confusion (21). This along with psychosis and delirium, especially in older patients,

questions anticholinergics benefits to detriments. When comparing the quality of life gained

from reduced pain and bloating to the quality of life lost to mental and physical side effects of

the drugs, the best option depends on the severity of the IBS or the reaction the patient has to the

medication. Luckily, all of these side effects are short term and are resolved when use of the

medication is discontinued.

The greatest danger presented with the use of anticholinergics is their association with

dementia. In a comparison done by Shelley Gray and Joseph Hanlon, it was found that the results

of several studies point to a relationship between use of anticholinergics and dementia or

Alzheimer’s (223). Given the chronic nature of IBS and its personalized nature, these

medications would be taken indefinitely and at varying doses. The increase in chance is not

insignificant. In a study done by Coupland et al it was reported that, “There was nearly a 50%

increased odds of dementia associated with total anticholinergic exposure” (1089). Patients are

placed in a troubling position. Do they continue use in the drug to lead a less painful life even if

it places them at risk? Answering yes could put them at risk of serious cognitive problems later

in life. If they decide not to take the medication, they are left without relief. The side effects of

both long and short term use are troubling. Anticholinergics are not practical when trying to find

a solution to IBS. Not only so they only benefit a certain category of those afflicted, the dangers

of their application greatly outweigh the benefits.

Over the counter remedies can be less intrusive than full prescriptions and help to

increase a patient’s quality of life. One such remedy is probiotics. As Bahra Hamarashid

explained, “Probiotics are live strains of strictly selected microorganisms that confer a health

benefit on the host when administered in adequate amounts” (44). These can be used to
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reestablish a healthy microbiome in the intestines. The microbiome is the composition of

symbiotic bacteria living in a person's digestive tract. In research done by Chong et al, it was

discovered that a key organism is not found as prevalent in patients with IBS. These organisms

convert hydrogen in the body to methane. Without these important organisms, hydrogen builds

up and adds to the bloating and increased gas experienced by patients with IBS. However,

probiotics can be hit or miss for some patients. Guidelines on quality are not strictly set and that

leads to widely different effectiveness and quality across brands (Adams). Other research has

pointed to the possibility that gut microbiomes can affect the gut brain connection. Marilla

Crabotti et al concluded that,“It interacts with CNS by regulating brain chemistry and

influencing neuro-endocrine systems associated with stress response, anxiety and memory

function” (28). These tiny organisms in the human stomach and colon can have a huge impact on

the functionality of the gastrointestinal system. An imbalance can cause such a variety of adverse

effects like bloating and causing the gut brain connection to react in unpleasant ways. Probiotics

are a treatment option that should be considered for all patients. With little to no drawbacks or

unpleasant side effects, finding a brand that benefits a patient the most has the potential to

greatly improve their condition.

Probiotics are not the only way to reestablish a healthy microbiome. One of the

procedures on the forefront of IBS treatment is Fecal Microbiota Transplant (FMT). FMT

consists of taking a stool sample from a healthy individual and transplanting it into a patient

suffering from IBS. The hopes of this procedure is to have the microbiome of the healthy donor

be replicated into the afflicted patient. An experiment carried out by El-Salhy et al showed that

IBS patients who received FMT had significant decrease in abdominal symptoms including

bloating, pain, and other complications of the condition (864). The most notable finding of FMT
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success is its ability to be used for any subtype of IBS. Although, the procedure is still relatively

new and its efficacy is in debate. Some researchers at the University of Michigan compiled and

reviewed research on FMT procedures to determine if there was convincing evidence that it was

beneficial. The researchers concluded that there was no significant increase in condition for

FMT; however, they also recognized the limitations of their research. The results varied widely

across the research they studied and the sample sizes were relatively small (Xu et al, 6-7). Their

findings do not eliminate hope for FMT. The newness of the procedure means that there is no

standard for carrying out an FMT and with more research and investigation in the procedure,

FMT might become an invaluable option for patients with IBS.

Other over the counter medications can have benefits, however no one of these is enough

to fully encompass all the symptoms. Certain medications, like immodium, are effective in

reducing the speed at which the bowel moves, but patients are still left with the pain, bloating,

and other adverse effects of the disorder (HCPLive 01:06-01:44). Similarly, for patients with

IBS-C, laxatives can operate in the opposite fashion, helping patients have more frequent and

consistent bowel motility. For short term symptom relief, patients may turn to using over the

counter medications, but their effectiveness for long term and all around relief is questionable.

Another downside to relying on over the counter medication is cost. Prescription medications can

be granted financial help through insurance but over the counter medication cannot. Given the

fact that multiple medications are needed to fully address the range of symptoms and its chronic

nature, patients would be spending a lot more money if they chose to only consider over the

counter medications.

Because of the drastic change in functionality for a patient’s digestive processes,

changing the way they live their life can have a definite impact on the condition. The most
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noticeable difference is through an altered diet. Patients affected with IBS can be sensitive to

certain foods. It’s no secret that spicy foods among other things can cause an upset stomach. An

approach to countering the effects of these triggering foods is the low-FODMAP diet. The goal

of the low-FODMAP diet is to decrease the amount of indigestible foods. Similar to other

treatments, each patient has a different set of foods that can cause a flare up. Getting positive

results from a FODMAP diet can be a long and arduous process. A patient has to start with

removing all FODMAP foods and adding them back into their diet one by one (Adams). This

long and arduous process can be disheartening for patients. Taking every FODMAP food out of

their diet makes it difficult to find meals and replacements can be much more expensive than the

standard products. A simpler diet that has shown benefits is removing gluten. Although IBS

patients don’t react to gluten like a patient with celiac would, it's still recommended that patients

try out the diet as well. If this option

works, its application and benefits would

be present much more quickly than in the

low FODMAP diet. Aside from cost,

attempting diet modification has little

possibility of making a patient's

condition worse and should be

considered along with other treatment

options.

Another lifestyle modification that can benefit patients is exercise. Exercise is known to

have many benefits such as better sleep and reduced stress. Seeing as IBS symptoms can be set

on by stress, this benefit could help decrease the severity and frequency of flare ups. However
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the actual effectiveness of these changes are debated. As Eamonn Quigley stated, “Exercise and

diet therapies received weak recommendations due to the lack of high-quality evidence,”

however he did not discredit the ideas all together (666). Exercise has been known to benefit the

gut and digestive system for everyone, IBS or healthy. While data might not entirely back up this

option for treatment, there is still support for its benefit. Because of the chronic nature of IBS,

treatment is mainly focused on increasing quality of life for patients. While exercise may not

necessarily cure the symptoms of IBS, its improvements to overall quality of life are worth

exploring. Exercise is not going to cause any harm to a patient and therefore is a worthwhile

supplement to consider alongside other forms of treatment.

Because of the connection between the brain and the gut, psychotherapy has been shown

to improve a patient's conditions. If a patient’s anxiety or depression begins to worsen, the

occurrence and severity of IBS flare ups are likely to follow. To counter this cycle,

psychotherapies like cognitive behavioral therapy can be employed. On the topic of CBT, the

International Foundation of Gastrointestinal Disorders reported that, “we can help train our

bodies to switch over to this relaxing state by engaging in activities such as diaphragmatic

breathing, progressive muscle relaxation, and guided imagery” (“Psychological Treatments”).

The goal of CBT in general is to change behaviors and promote healthy coping strategies.

Through changing behavior, thoughts and emotions can follow. The most prevalent mental

trigger for IBS is stress. Stress can be caused by any number of activities or events. Hypnosis can

be a powerful counter to this stress. At its best, hypnosis can lead to up to 5 years of life without

medication needed. However, a significant proportion of patients see no benefit from it

(“Psychological Treatments”). When evaluating the usefulness of psychotherapy two factors

have to be considered; cost and effectiveness. Finding a psychotherapist is difficult, especially

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finding one that is effective and connects with the patients. On top of this, this treatment option

is considerably more expensive than other options. Given the chance that it might not show

benefits, even though there are no adverse effects of psychotherapy, this treatment option is not

the most viable for general IBS treatment.

When considering treatment options, patients with IBS have a lot of factors to consider.

For a patient who might not have disposable income, a few different options can be pursued.

Since long term over the counter medication is not a viable option, a prescription might be

considered. Granted that the anticholinergics can be detrimental to their health, their options may

be limited to dietary modifications and exercise. Further down the road, receiving FMT

transplants at intervals might be a more economical option, especially if the FMT process

continues to be researched and improved. Patients with a larger amount of disposable income

have a few more options. Psychotherapy shows promise of improving the quality of life in

patients with the least amount of intrusion or side effects. However, seeing as not all patients

respond to psychotherapy well, other treatment may be necessary. Being able to afford

replacements for FODMAP foods would make that route of treatment worth exploring. Exercise

and probiotics are recommended no matter what the economic status. Overall, treatment is

unique to each individual. The IBS subtype each patient is subject to dominates their treatment.

Finding the best treatment is about how the patient reacts and all comes down to what

combination contributes to the greatest increase in quality of life.

The research around IBS is ongoing, and as such, so is the treatment. It is important to

consider all aspects of a patient’s health when addressing such a complex and interconnected

condition. While it has been common practice to prescribe anticholinergics, it may be time to

consider other options. The microbiome throughout the gastrointestinal system shows the most
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promise of changing the playing field from IBS treatment. Not only can an imbalance of bacteria

be the cause of the physical manifestations of IBS symptoms, it can also cause problems with the

CNS, leading to more pressing neurological disorders. The treatment of IBS has been focused on

addressing issues symptom by symptom, but newer research shows that promising new

procedures could lead to all around improvement for patients. Given the consistent evolution of

treatment options, the next big break for IBS could be right around the corner. Until that comes,

listening to how the patient reacts to treatment options and considering a wide variety of causes

is the most effective way to help these individuals return to normal life.
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