Treatment

The cornerstone of treatment is patient education so that they understand their illness and the wide range of symptoms it can cause. It is also important to understand that it is NOT a psychological problem. Stress will make it worse but it does not cause IBS in the first place. We do not know the cause but the theories on this are discussed here.

Most patients with IBS notice that eating makes their symptoms worse and often conclude that they have some form of dietary allergy and nearly always ask for a diet sheet. We have written about this in detail elsewhere and this can be found amongst our publications (161). Probably the most useful dietary manipulation is to reduce the amount of cereal fibre in the diet. This means removing brown bread, wholemeal bread etc as well as breakfast cereals except rice crispies. We find our diet sheet helps about 50% of patients. By this we mean it reduces symptoms rather than curing them. The only problem with our diet is that it can make constipation slightly worse in those IBS patients who are already constipated. This can usually be sorted out with a small dose of a laxative.

Fructose is a sugar that is becoming increasingly used by the food industry as a sugar substitute because it is poorly absorbed from the gut and, therefore, does not cause weight gain.  It is also found in a lot of fruits and some patients with IBS seem to be quite intolerant of fructose.  It is sometimes worthwhile trying to reduce the amount of fructose in the diet by checking if a food contains a lot of fructose and this information is usually available on the label of many foods and drinks.  A list of the fruits and the amount of fructose they contain can be found in a paper published by Barrett and Gibson.



Antispasmodics
The pain of IBS is caused by spasm and that is why "antispasmodics" are used. Examples of these drugs are mebeverine (Colofac), hyoscine (Buscopan), dicycloverine (Spasmonal) and peppermint capsules (Colpermin). It is worth trying each one to find out which one suits a particular person the best. They are probably best taken on an "as necessary" basis rather like paracetamol (Panadol, Tylenol) is taken for a headache. They may not abolish pain altogether but they are worth continuing with as long as they provide some relief. They are all completely safe.
Antidiarrhoeals
If diarrhoea is a feature of a particular individuals IBS then it is perfectly reasonable to take an antidiarrhoea medicine. The ones most often used are loperamide (Imodium) and diphenoxylate (Lomotil). Loperamide (Imodium) is the most commonly used one for this purpose and is extremely effective. It is absolutely safe and up to 8 capsules a day can be taken. In some patients even one capsule may be too much in which case the capsule can be opened and the contents divided into perhaps a half or a quarter until an effective dose is arrived at by trial and error. With regard to side effects the worst that can happen is that it may lead to constipation and bloating but this soon wears off once it is stopped. It is perfectly reasonable to take Loperamide (Imodium) before an event where you don't want your bowels to let you down or where it might prove to be embarrassing to have to go to the toilet.
Laxatives
If a patient with IBS has constipation it is best treated with laxatives and it is completely untrue that laxatives damage the bowel or are habit forming in any way. The most commonly used laxatives are lactulose, senna or movicol. Lactulose (Duphalac) should be avoided in IBS as it tends to make bloating worse and can cause excessive wind. The best way to use laxatives is on a regular, daily basis in order to try and mimic a normal bowel habit as much as possible. Each patient will require a different dose, so it is up to the individual to find the dose that, when taken on a regular basis, produces the desired effect.  It is best to take the optimum dose of one laxative rather than combining different products. It is sensible to take a reasonable amount of fluid with laxatives but it does not need to be excessive.
Antidepressants
Patients with IBS are often told that the condition is all due to stress or depression but nothing could be further from the truth. Of course the state of a persons nerves can make IBS worse but it does not cause the problem in the first place. Antidepressants can be used to treat IBS and they are often very effective.  It is thought that they work by calming the gut down rather than having an effect on the brain. This is because they usually are effective at much lower doses than would be expected to improve depression. The old fashioned so called tricyclic antidepressants appear to be more effective than the modern serotonin re-uptake inhibitors such as prozac and are very safe. Unlike antispasmodics the antidepressants have to be taken on a continuous, often long term basis.
Hypnotherapy
We have found that hypnotherapy seems to be very effective for treating IBS that has not responded to any other form of treatment. We use a special form of hypnotherapy which is focussed on the gut and there is no 'probing' of the mind or other psychological component. In fact the patient is not asked to say anything, they just sit comfortably in a chair and listen to the therapist telling them how to get better.
Conclusion
Most patients with IBS can manage to achieve some improvement in their symptoms with a combination of the treatments outlined here. It is unrealistic to expect cure but the aim of our Unit is to put the patient back in control of their IBS so they control it rather than it controlling them.