Irritable bowel syndrome: what’s stressing your belly and how to treat it

It’s one of the most common and yet relatively unexplained gastrointestinal diagnoses worldwide: irritable bowel syndrome (IBS). It’s estimated that between five and ten per cent of people worldwide (link in German) suffer from non-specific flatulence, diarrhoea, constipation and abdominal cramps. If no trigger for the symptoms is found, the issues are often as labelled irritable bowel syndrome.

«There are many chronic gastrointestinal conditions. And often, things are called irritable bowel syndrome, even if they’re not,» says Prof. Dr. Daniel Pohl, Senior Attending Physician at the Department of Gastroenterology and Hepatology at Zurich’s university hospital. He explains what a reliable IBS assessment entails, which symptoms are indicators and how the condition can be treated with relaxation exercises, the right diet or hypnosis.

Complex appearance: how IBS manifests itself

Due to the non-specific nature of the symptoms, patients often feel like their condition isn’t being taken seriously. Furthermore, the road to diagnosis can be long. What’s important to know is that IBS isn’t a fabrication of people’s minds, but a functional bowel disease. There are many different ways IBS makes itself known.

The specialised intestinal centre «Darmnzentrum Bern» describes four symptomatic types of IBS in a German publication. While type 1 is characterised by diarrhoea, type two is the subject of constipation. Type 3 involves alternate bouts of diarrhoea and constipation and, finally, there’s type 4, which mainly causes flatulence and pain.

Irritable bowel syndrome is defined as chronic abdominal pain for which no other explanation can be found. The diagnosis hinges on the duration of the abdominal pain and any change in the stool. «If a patient has chronic, non-acute abdominal pain – in other words, if they have a belly ache at least once a week for more than three months – they may have IBS», says Dr. Pohl. «There must also be a change in stool frequency or consistency for IBS to be diagnosed.»

Irritable bowel syndrome isn’t life-threatening, but it can be a gruelling condition, even though there are no alarming symptoms such as blood in the stool, night sweats or fever. However, the causes aren’t fully understood yet and affected people need to be patient when it comes to diagnosis and treatment.

Causes: what we know about IBS so far

Many factors seem to come into play with IBS. Triggers can be your genetic predisposition, severe gastrointestinal infections, psychological trauma or «learned factors» such as your diet or influences from family members and partners. «If your dad always had a belly ache after eating, you’ll internalise that as a child and be more at risk later on. That's one of the learning components,» says Dr. Pohl. Factors including sugar, smoking, stress, alcohol or lack of sleep are additional drivers of the condition.

What appears to be decisive, however, is a change in the intestinal flora as well as disrupted communication between the central nervous system in the brain and the intestinal nervous system.Basically, your head and belly.

The intestine is equipped with a nervous system structurally very similar to the nervous system in the brain. In other words, your gut isn’t just a crude digestive organ, but also influences your emotional health, such as feelings and decisions (it’s not called a «gut feeling» for no reason). Dr. Pohl says: «A simple example of this communication is if you have an important exam coming up and suddenly get diarrhoea.»

Various triggers are suspected to be responsible for the miscommunication between your brain and your gut. Severe gastrointestinal infections, for example, Dr. Pohl explains: «The local immune system is mobilised and allergens that are naturally part of the diet can penetrate the intestinal mucosa. The antibodies formed in the process often remain in the body – even if the infection has already passed.» For people with irritable bowel syndrome, the body always reacts by activating antibodies and releasing histamine as soon as it’s confronted with the same allergens and foods.

Severe psychological trauma can also cause a disruption of the gut-brain axis. «There’s data that reveals the number of IBS patients who were subjected to psychological or physical trauma. Sadly, a closer inspection of people’s medical histories often reveals this.»

Diagnosis: how the condition’s diagnosed

A proper diagnosis is crucial for successful treatment. And given the number of possible triggers, this isn’t quite so easy to give.

The ROM-IV criteria or the S3 guideline (link in German) commonly used in German-speaking countries are often used for diagnosis. «The S3 guideline identifies three factors,» says Dr. Pohl. «Have the complaints lasted for more than three months? Are they accompanied by changes in stool? And is the patient restricted in their everyday life?» In addition, other conditions, such as coeliac disease, need to be ruled out.

This involves a blood test to check the inflammation status, liver values, kidney values, coeliac disease antibodies and thyroid values. Furthermore, the stool is examined and patients with diarrhoea-like conditions usually undergo a colonoscopy. Dr. Pohl adds: «Women should also always have an endovaginal ultrasound. This can rule out ovarian cancer, which is often initially misdiagnosed as irritable bowel syndrome.» As the carcinoma can’t be detected in a colonoscopy, women with suspected irritable bowel syndrome should always undergo a gynaecological examination as well.

Treating irritable bowel syndrome: the FODMAP diet ...

The treatment of IBS requires cross-disciplinary approaches from the fields of gastroenterology, psychology, relaxation theory and nutritional counselling.

Initially, symptoms such as constipation, diarrhoea or abdominal pain can be treated with medication. In addition to this, however, the main focus should be on food. «As many as 86 per cent of patients have symptoms that can be influenced by what they eat,» says the expert. Dietary recommendations are as individual as IBS itself. Having said that, one tried and tested approach is the FODMAP diet.

FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols – i.e. highly gas-producing foods. «Basically, FODMAPS are fermentable sugars,» Dr. Pohl says. «Fructose or lactose, for example. Frequently, they can’t be fully absorbed in the small intestine and then enter the large intestine where they cause gas and pain.» Complaints are assessed in a FODMAP load test and the corresponding foods are then cut out from the diet.

... and medical hypnosis

«I’d always consult a dietitian for this diet,» says Dr. Pohl. «After all, the FODMAP diet is lower in calories and can lead to nutrient deficiencies or even eating disorders.» With professional consulting, FODMAPS can be gradually reintroduced into the diet after a maximum of three to six weeks.

And as psychological strain such as trauma or stress also plays a role in IBS, accompanying psychotherapy and relaxation exercises are recommended for treatment.

Abdominal hypnosis is another medical relaxation technique that has also proven effective in scientific studies. It involves sounds and images that are used to reduce negative thoughts associated with the symptoms and to practise stress reduction and relaxation. The treatment isn’t standard, but it’s an effective, complementary therapy that usually isn’t covered by health insurance.

«Some patients aren’t suitable for medical hypnosis. These include patients who don’t understand the diagnosis, don’t understand the concept of communication between the psyche and the gut, don’t have or don’t want to spend time dealing with their illness or who actively use drugs.» However, patients who are open-minded, are willing to invest some time and are actively looking for coping strategies for stress and the symptoms of their irritable bowel syndrome are.