How to treat irritable bowel syndrome

IBS treatment aims to control symptoms and reduce the impact on life and wellbeing. IBS is a long lasting (chronic), often lifelong condition - but you may have periods of time where there are no symptoms and then it flares up again. There's no cure but treatments can achieve a big improvement in symptoms and quality of life.

IBS treatments include:

• Lifestyle changes - such as exercise and diet.

• Probiotics.

• Medicines to treat symptoms.

• Psychotherapy.

If you think you may have IBS find out what to do here. This will tell you if you need to see a doctor and how it is treated.

In this series of articles centred around IBS, you can read about the symptoms of IBS, IBS treatment, and IBS causes- all written by one of our expert GPs.

The rest of this feature will take an in-depth look at the treatment of IBS as, at Patient, we know our readers sometimes want to have a deep dive into certain topics.

How to treat IBS

There are lots of different IBS treatments. IBS is a very diverse condition, and everyone experiences it differently. Which treatments are correct depends on the symptoms, their severity, and what's been tried before.

There are several different dietary ways to treat IBS, including:

Diet changes

• Eating three regular meals a day and avoiding snacks.

• Avoid skipping meals or eating late at night.

• Limiting alcohol - drinking no more than two units a day, and having at least two alcohol-free days each week.

• Reducing caffeine intake - no more than two mugs of tea/coffee a day.

• Keeping well hydrated - drinking 6-8 cups or glasses of water a day.

• Avoiding, or reducing, fizzy drinks.

• Cutting down on fatty foods, fried foods, and sugary or fatty snacks.

• Limiting fresh fruit to three portions a day - one portion is 80 g, such as an apple, a banana or two satsumas. Fresh fruit contains the sugar fructose, which can make some people's IBS symptoms worse.

Keeping a food diary

This can help pinpoint which foods you eat are a particular trigger for IBS symptoms, allowing you to work out which things to reduce or avoid to manage IBS.

The low FODMAP diet

This is usually a second-line option if the general dietary changes above aren't working well enough:

FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) - are a set of carbohydrates that aren't properly absorbed in the gut. Instead, gut bacteria use them for fermentation, producing gas. This gas stretches the gut walls, leading to pain and bloating in people with IBS.

High FODMAP¹ foods include some fresh fruits, some vegetables, grains and cereals, pulses and legumes, and some types of dairy foods.

The low FODMAP diet is best used as a three-stage process:

• • • Step 1 - eat a low FODMAP diet only, for 2-6 weeks. It's difficult to follow this diet long-term, hence the next two steps.

    • Step 2 - gradually re-introduce different types of FODMAPs, one at a time, to see which ones trigger symptoms, and which ones you can tolerate without problems. This takes about 8-12 weeks in total.

    • Step 3 - follow a personalised diet long-term, avoiding only the FODMAPs you found triggered your symptoms in step 2. This is much easier to stick to in the long run than an entirely low FODMAP diet.

Gluten-free diet

Some people with IBS report that a gluten-free diet helps their symptoms. We don't really have enough evidence to tell if this really works or not, so it's not recommended routinely.

However, if you've found that it helps, it's worth continuing - this is different to coeliac disease, where people are allergic to gluten and really do need to have a strict gluten-free diet.

Exercise

There is scientific evidence that regular exercise helps IBS symptoms, particularly constipation. Exercise is good for physical and mental health generally.

Probiotics

One theory is that the gut microbiome - the bacteria, viruses, and fungi that live in the gut and help it work - is disrupted in IBS, and that people with IBS have too few good bacteria in their gut.

Probiotics aim to restore good bacteria in the gut. They come in various different forms, such as capsules, powders, fermented milks, and yoghurts. There is evidence that probiotics containing the bacterial species Lactobacillus, Bifidobacterium and/or Escherica can improve IBS symptoms. Most research has looked individually at one type of probiotic for IBS treatment - there isn't much that compares them, and so it's difficult to say which probiotic is best.

If you wish to try probiotics, it's best to take them for up to 12 weeks. If there's no benefit by 12 weeks, it's unlikely to help, and you can stop them.

IBS treatments for cramping, bloating and wind (flatulence)

Specific ways to ease bloating and excessive farting (flatulence) include:

• Eating fewer gas-producing foods - such as beans and pulses, cauliflower, or sugar-free mints and chewing gum.

• Eating oats - such as oat-containing porridge or breakfast cereals, though this can make it worse in some people.

• Eating up to one tablespoon a day of linseeds.

• Reducing the amount of insoluble fibre,which doesn't dissolve in water, you eat instead, it stays intact inside the digestive system. Foods that are high in insoluble fibre include wholemeal or high-fibre flour, bran cereals, and whole grains like brown rice.

• Taking peppermint oil capsules, which are available without prescription, or drinking peppermint tea.

• Taking Buscopan (hyoscine butylbromide), which is available without prescription, or mebeverine (such as Colofac, also available without prescription) - these can help with pain, cramps, and gut spasms.

Treatments for IBS with diarrhoea

• Reducing the amount of fibre you eat.

• Reducing caffeine-containing drinks.

• Avoid food and drink that contains sorbitol, a type of sweetener.

• Taking medicines like loperamide, such as Imodium which is available without prescription. This can cause constipation, bloating and stomach pain, but sometimes starting at a low dose and increasing slowly can help to find the right amount to use. Loperamide is particularly useful for short-term use if needing to prevent diarrhoea occurring during an important occasion, or when you won't be near a toilet - such as a long journey.

Treatments for IBS with constipation

• Increasing the amount of fibre you eat, ideally soluble fibre that dissolves. Foods high in soluble fibre include oats and linseeds.

• Keeping well hydrated and drinking plenty of water.

• Taking laxatives, most of which are available without prescription. Most laxatives are suitable for IBS, except lactulose, which can cause extra gas production in the digestive system and therefore make symptoms worse. Fybogel, Normacol, and Movicol are good options, amongst others, and can help make each bowel movement softer and more regular.

Prescription-only medicines

As well as the treatments mentioned there are further prescription-only medicines that can be prescribed in certain situations - usually if the treatments above haven't worked - these include

• Antidepressants - such as tricyclic antidepressants like amitriptyline, or SSRIs like sertraline. These are thought to work in IBS by affecting the way the nerves in the gut interact with the nerves in the brain. They can be useful for IBS even if people don't have symptoms of depression.

• Prescription-only drugs for diarrhoea, such as eluxadoline, rifaximin, or ondansetron. These are usually only prescribed by gastroenterology specialist doctors, if other treatments haven't worked.

• Prescription-only drugs for constipation. Some laxatives available over the counter might be prescribed if people need to use them regularly. Gastroenterology specialists might also use other medicines, such as linaclotide, if other treatments haven't worked.

Psychotherapy

IBS is thought to be due to a complex set of interactions between the gut and the brain. Symptoms of IBS often cause mental and psychological distress. This, in turn, can make IBS symptoms worse.

Psychological treatments can help to get control of the way the gut and brain are talking to each other, improving IBS symptoms as well as helping to relieve feelings of stress, anxiety, and depression, if they are present.

Currently, psychological therapies are generally used if drugs have been tried for at least 12 months, and haven't worked. However, there is research ongoing about using them earlier in the course of treatment. Some people might benefit from having psychotherapy at an earlier stage.

Examples of these type of treatments include:

• Cognitive behavioural therapy (CBT). Some CBT programmes are specifically designed for IBS.

• Gut-directed hypnotherapy.

Both IBS-specific CBT and gut-directed hypnotherapy have some research evidence from trials to show that they can help with IBS symptoms.

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What happens if you leave IBS untreated?

It's a good idea to speak to a doctor if you think you have IBS. It's important to make sure the symptoms aren't caused by anything else. Doctors can diagnose IBS but also look for other, potentially more serious conditions.

IBS itself isn't a life-threatening condition. IBS treatment aims to control symptoms. People whose IBS symptoms are mild or well controlled may not need any treatment at all.

If IBS symptoms are distressing, treatment can help. People who are suffering from uncontrolled IBS symptoms often find that their lives are negatively affected, and that their mental health is affected, leading to symptoms of depression and anxiety.

Further reading

1. FODMAPs and Irritable Bowel Syndrome; Monash University Low FODMAP Diet.

2. Irritable bowel syndrome; NICE CKS, September 2022 (UK access only).

3. Vasant DH, Paine PA, Black CJ, et al; British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. Gut. 2021 Jul;70(7):1214-1240. doi: 10.1136/gutjnl-2021-324598. Epub 2021 Apr 26.

4. Irritable bowel syndrome (IBS) and diet : Food Fact Sheet; The Association of UK Dietitians.