Irritable Bowel Syndrome Treatment & Management

Management of irritable bowel syndrome consists primarily of providing psychological support and recommending dietary measures. Pharmacologic treatment is adjunctive and should be directed at symptoms.

The 2009 ACG position statement recommends addressing nongastrointestinal symptoms and comorbidities to improve health-related quality of life as well as to reduce symptom severity. Evidence considered in the position statement was insufficient to recommend exclusion diets or food allergy testing.^[13]

Successful management relies on a strong patient-provider relationship. Reassure the patient that the absence of an organic pathology indicates a normal life expectancy. Emphasize the expected chronicity of symptoms with periodic exacerbations. Teach the patient to acknowledge stressors and to use avoidance techniques.

Fiber supplementation may improve symptoms of constipation and diarrhea. Individualize the treatment because a few patients experience exacerbated bloating and distention with high-fiber diets. Polycarbophil compounds (eg, Citrucel, FiberCon) may produce less flatulence than psyllium compounds (eg, Metamucil).

The data regarding the effectiveness of fiber are controversial because 40-70% of patients improve with placebo. A Cochrane systematic review found no benefit from fiber/bulking agents on irritable bowl syndrome symptoms or global assessment.^[14]

Judicious water intake is recommended in patients who predominantly experience constipation.

Caffeine avoidance may limit anxiety and symptom exacerbation. Legume avoidance may decrease abdominal bloating. Lactose and/or fructose should be limited or avoided in patients with these contributing disorders. Take care to supplement calcium in patients limiting lactose intake.

Gluten intolerance has been further associated with irritable bowel syndrome. In a small but important study, patients with irritable bowel syndrome who were well-controlled on a gluten-free diet were rechallenged in a double-blind fashion.^[15] Approximately two thirds of these patients had poor symptom control with rechallenge. As with many irritable bowel syndrome studies, the placebo response was high (40%). Notably, neither intestinal inflammation nor permeability was different among the groups, and no difference in positivity for celiac disease–related HLA haplotypes or antibody markers was noted.

Consider psychiatric referral. Previous evidence has supported improvement in GI symptoms with successful treatment of psychiatric comorbidities, but studies by Zijdenbos et al and Ford et al indicate caution should be used when interpreting such data.^{[16, 17]}

In a meta-analysis by Zijdenbos et al of 25 randomized trials consisting of single psychological interventions with usual care or mock intervention in patients older than 16 years, the authors found that although cognitive-behavioral therapy and interpersonal psychotherapy were effective immediately after treatment completion, there was no convincing evidence for sustained treatment effects for any treatment modality. Thus, Zijdenbos et al recommended that future research should focus on current irritable bowel syndrome treatment guidelines and their long-term effects.^[16]

Ford et al reached similar conclusions regarding the use of psychological interventions in irritable bowel syndrome. The authors concluded that antidepressants are effective for treatment of irritable bowel syndrome, but although the available data suggest that psychological therapies may be of comparable efficacy, there is less high-quality evidence for the routine use of psychological therapies in patients with IBS. They performed a systematic review and meta-analysis of randomized controlled trials in adults with IBS; however, their selection criteria included trials comparing antidepressants with placebo as well as those comparing psychological therapies with control therapy or usual care. The investigators noted that the quality of studies were generally good for those involving antidepressants but poor for those involving psychological therapy.^[17]

A Cochrane systematic review determined that antidepressants improved both IBS symptoms and global assessment scores compared with placebo. Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants were each shown to be effective in subgroup analyses.^[14]

The 2009 ACG position statement concluded that psychological interventions, cognitive behavioral therapy, dynamic psychotherapy, and hypnotherapy, are more effective than placebo. Relaxation therapy was no more effective than usual care. In agreement with the above analysis, study quality was described as low.^[13]

Frequent visits with the clinician enhance the patient-provider relationship, especially in patients who were recently diagnosed with irritable bowel syndrome. Visits can become less frequent as patients are educated and reassured.