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Treatment of IBS



General Principles4

Irritable bowel syndrome (IBS) is a chronic condition with no known cure and a multifactorial underlying pathophysiology with differences between individual patients.10 As a result, the focus of treatment should be on relief of symptoms and addressing the patient's concerns. However, it is unrealistic to expect that a single treatment could control all IBS symptoms in every patient.10 The most important component of treatment lies in the establishment of a therapeutic physician-patient relationship. Education on the proposed mechanisms of IBS helps to validate the patient's illness experience and sets the basis for therapeutic interventions. Patients should be informed of the chronic and benign nature of IBS, and also informed that the diagnosis (if well-established) is not likely to be changed, and that he or she should have a normal life span.4

Modifications of Lifestyle, Diet and Microbiota
Increased physical activity may help with the symptoms of IBS.4 Furthermore, diet modifications may be helpful as up to 60% of patients report postprandial worsening of their symptoms.11 Most of these adverse reactions are based on non-immunological food intolerance or sensitivity, and IgE-mediated food allergies are uncommon.11 Individual patients may profit from soluble fibre supplementation (e.g. ispaghula) or a low FODMAP (Fermentable Oligo-, Di- and Monosaccharides and Polyols) diet.12 FODMAPs are short-chain carbohydrates poorly absorbed in the small intestine and fermented in the colon, occurring in a wide range of foods, including wheat, onion, pear, apple, legumes and lactose. Some patients presenting with IBS symptoms are sensitive to wheat. After adequate exclusion of coeliac disease and wheat allergies, gastrointestinal symptoms in these  NCGS (Non-Coeliac Gluten Sensitivity) patients can be improved by a gluten-free diet.12
The importance of the gut microbiota in IBS has drawn increasing attention. Recent evidence suggests that at least subgroups of IBS patients have an altered gut microbiota composition or dysbiosis. The composition of microbiota is responsive and adaptable to diet and in some IBS patients, non-absorbable antibiotics, probiotics and prebiotics may have beneficial effects.

Last update: October 2015

Behavioral Treatments4
Behavioral treatments may be considered for motivated patients who associate symptoms with stressors, although their benefits remain controversial. Hypnosis, biofeedback, and psychotherapy help to reduce anxiety levels, encourage health promoting behavior, increase patient responsibility and involvement in the treatment, and improve pain tolerance.

Last update: October 2015

Medications4
Pharmacologic agents are only viewed as supportive therapy in IBS patients. Antispasmodic agents are the most frequently used pharmacologic agents in the treatment of pain symptoms of IBS.6
Antidepressants have analgesic properties independent of their mood improving effects and may therefore be beneficial in patients with neuropathic pain. Multiple alternative forms of therapy for IBS have been suggested, such as herbs, probiotics, acupuncture, and enzyme supplementation.Peppermint oil has also been studied in randomized trials with positive effects, e.g. an improvement in IBS symptoms and in abdominal pain.14-16

Last update: October 2015
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