Types Of Irritable Bowel Syndrome (IBS)
What are the three sub-types of irritable bowel syndrome?
The three sub-types of IBS, which is based on bowel habit, is IBS with diarrhea, IBS with constipation, IBS with mixed pattern-- meaning that the patients have both diarrhea and constipation within hours or days. So I can have IBS with diarrhea and go to the bathroom three times a week, but if every time I go I have loose watery stools, I'm going to be a diarrhea patient. Patients with constipation, they typically don't go very often, but if they go to the patient three times a day, or five times a day, because they never fully evacuate, but they have hard stools, they have constipation. They don't have diarrhea sub-type. The mixed pattern means that you change from loose watery stools to hard lumpy stools, or vice versa, within hours to days. The term IBS with alternating bowel habits, which is a term we used more before, we use that term when you transition between subgroups, so you transition over months to years from IBS with diarrhea to IBS mixed pattern or to IBS with constipation. Studies have shown that the mixed pattern group tends to go to the diarrhea side or the constipation side. It's pretty unusual to be pure diarrhea with IBS and transition to an IBS with constipation. It can happen, but it's much less common.
What are the symptoms of IBS with diarrhea?
The symptoms of IBS with diarrhea mean that the patient has abdominal pain or discomfort. It has to be chronic or recurrent but it has to be associated with diarrhea symptoms, and that means it has to be associated with loose or watery stools or going to the bathroom more often than normal which would be more than three times per day. But typically, it is associated with loose watery stools. Other symptoms that the IBS with diarrhea patients can have is urgency. That's a very predominant symptom and one that I think is linked to impacting quality of life because that's when they feel like they need to go the bathroom. If you have really severe IBS diarrhea, you can have incontinence.
How is IBS with diarrhea treated?
For Irritable Bowel Syndrome (IBS) with diarrhoea, in general, we start with ant diarrheal agents, such as lope amide which you can get over the counter. It comes in tablet or liquid form. And typically, you give it to patients if they have diarrhoea. The way patients take it is by reading the instructions on the label and that's fine. But what it tells you to do is to take the medicine once you have diarrhoea and in Irritable Bowel Syndrome (IBS) patients, that's too late. So what you try to teach the patients is to take it proactively. So, if patients have chronic diarrhoea, like daily diarrhoea, and it's pretty predictable, they can actually take Imodium, or lope amide, on a daily basis at the start of the day. Now, I know a lot of patients, what they'd like to do is they want to have a bowel movement - it makes them feel better. But then afterwards, so you don't want to go multiple times during the day, you can actually take some lope amide or an ant diarrheal agent. They're short acting, sometimes you have to take it later. I usually start at a low dose with my patients, because I don't want them to swing to the constipation side. They're very uncomfortable with that. So I start with a low dose, and then just titrate it up to what they need. Typically, if a patient is going on a long trip or have a long meeting, or they're going out to dinner; it's always much more anxiety provoking when you're outside of your house, because you not close to your bathroom and you're out of your comfort zone. So a lot of times patients will take a proactive ant diarrheal agent ahead of time, because it at least causes them not to have diarrhoea when they go out of their house. The trick is not to give them too much that they become constipated. If someone has more chronic symptoms, you can try a medication like a low dose tricyclic agent i.e. desipramine, amitriptlyne. Those are used because they have what is called an ant cholinergic effect - they slow down the motility of the bowel. So they're constipating, in a sense. For a diarrhoea patient, you're just trying to normalize the bowel movements. So that's often used at low doses. It's only at bedtime dose you can give the patients. Some health care providers use fiber, but it's really not shown that fiber supplementation helps diarrhoea. There is a drug that's FDA approved, only in severe patients with IBS with diarrhoea, particularly women, and that's called alosetron. But it has some side effects, so it's under restricted use, meaning that you have to go to a doctor that's part of the prescribing program and the patient and physician have to sign an attestation form stating that they understand the risks and benefits of the medication. It can be a great medication in patients with severe Irritable Bowel Syndrome (IBS) with diarrhoea, but it's under restricted use by the FDA.
What are the symptoms of IBS with constipation?
The symptoms of IBS with constipation are mainly hard or lumpy stools. Dry, pellet-like stools and decreased bowel movement frequencies, going less than three times per week and also straining. Some of the patients will also have bloating and sensation of incomplete evacuation. It's not seen in all patients with IBS with constipation, but it's fairly common.
How is IBS with constipation treated?
The treatment of IBS with constipation is pretty typical for how you would treat another patient with chronic constipation that may not necessarily be due to IBS. But, there was one medication that was FDA-approved for IBS with constipation that was tegaserod, but that has been recently suspended by the FDA for a low prevalence, but a prevalence of cardiovascular events. So that the information is being rediscussed and re-evaluated, but currently tegaserod is suspended. That was the only FDA-approved medication for IBS with constipation. So in general, to treat patients with constipation, you usually give them a laxative agent or an agent to stimulate motility and movement of stool through the bowel. And, laxatives are divided into osmotic laxatives and stimulant laxatives. Now none of these have been FDA-approved or studied in high-quality studies in IBS, but, they are generally used for constipation whether it is due to IBS or not. Osmotic laxatives are saline laxatives or magnesium-based laxatives like Milk of Magnesia, which you can get over-the-counter. It's probably better for more mild symptoms. And then we have stimulant laxatives which are also over the counter and they include senna-based products. Two other osmotic laxatives that have been shown in high quality studies to effectively treat chronic constipation, not specifically IBS with constipation, that's lactulose and polyethylene glycol, which is now actually sold over-the-counter.
How is the IBS pain treated?
Sometimes giving a diarrhoea patient, anti-diarrheal will help their pain. And giving a patient a laxative or constipation medication may help their pain. But it doesn't necessarily do that, because patients have this hyper sensitivity of their gut. So often you want to treat the patient specifically for the pain. One of the more common medications to use is a group of medications called the tricyclic agents. Now previously they were used at high doses for anxiety and depression, but there are newer medications to treat that. And they are associated with a high degree of side effects. We currently use tricyclic agents as analgesic agents or to decrease pain. And it's not only for the bowel. You can use it for patients who have nerve pain. Like herpes is ostrorelated nerve pain or diabetic neuropathy. It's used for fibromyalgia. So it's really a general analgesic agent at a low dose. Where it doesn't actually treat mood. So these medications include Desipramine, which has actually been studied well in irritable bowel syndrome. Amitriptyline and Nortriptyline are commonly used. They do have side effects. So for example Amitriptyline is commonly used for sleep disorder. So if you have an IBS patient that doesn't sleep well and you want to restore their sleep, Amitriptyline might be a good choice, because not only does it restore sleep, it can treat their pain that's associated with their IBS. Now another class of agents to use is the SSRI's. Which are Selective Serotonin Reuptake Inhibitors. And those are FDA approved for the treatment of depression and anxiety. You're not necessarily always treating mood, although if you treat mood that's good because it can also help the management of their symptoms. But there is evidence, recent evidence that's shown that treatment with SSRI's actually improve bowel symptoms and pain irrespective of their effects on mood.
What are the symptoms of IBS with mixed pattern?
Symptoms of Irritable Bowel Syndrome (IBS) with mixed pattern means that they have loose watery stools that are characteristic of a diarrhoea pattern, and also hard lumpy stools are a characteristic of a constipation pattern. What you can commonly see in patients with Irritable Bowel Syndrome (IBS) with mixed pattern is that they'll even, on the same day, have a change from hard stools to loose stools. So, very characteristically they'll say when they first get up and have a bowel movement, it's hard and may be difficult to pass and when they have a bowel movement later in the day it will become progressively more loose and watery. They don't necessarily have it. Other patients characteristically will have the pattern where they will be constipated for four or five days, or even a week, and then they'll have a lot of pain and dramatic loose stools. Almost like the bowel is trying to empty itself. They're a very difficult group to treat. It's almost like they're on a high wire, a tight wire and they can go either one way or the other. So, it can be so difficult sometimes. If a patient gives me the history that they have a period of time when they're more constipated, and then they develop diarrhoea, I generally try to treat the constipation so that they don't go many days without having a bowel movement. And it seems to decrease their diarrhoea episodes which can be very painful. That's not really proven in a study, although there is a study that has shown that to gas rod, which was used to treat Irritable Bowel Syndrome (IBS) with constipation actually helps patients with the alternating or mixed pattern. For the diarrhoea phase in the Irritable Bowel Syndrome (IBS) with mixed pattern, they're typically treated with an anti diarrheal agent. So these patients really have to get treated for constipation and diarrhoea.
Are there alternative treatments for IBS?
There are other treatments that have been shown to be effective for IBS that are not medications. And these are typically psychological and behavioural treatments and they include Cognitive Behavioural Therapy, Interpersonal Psychotherapy, Hypnosis, and Relaxation training. They can help patients with IBS regardless of the bowel habits subtypes. There is good data to show that they are effective treatments. You would suggest Cognitive Behavioural Therapy if the patient has some mal-adaptive management skills, meaning that the way they manage or cope with their symptoms are not necessarily to their benefit. One of the types of poor scoping skills is a term known as “catastrophizing”. So for example, you have the symptoms and you are thinking, “Gee, this is terrible pain. I am never going to be able to do anything. When is this ever going to end?” That would be considered mal-adaptive or not good. And so, you train the patient to think of more positive thoughts or to focus on the present tense and not to focus on what is the end result or the subsequent factors or events that are going to occur. Interpersonal Psychotherapy would be suggested in an individual where they feel that their symptoms or their condition is impacted negatively by a stressor, whether it is a personal relationship stressor or work-related stress. Psychotherapy can often help patients with those relationships or stressors that may be negatively impacting their symptoms and then could improve their symptoms of IBS. Hypnosis is another very interesting treatment intervention. It has been studied the most in the United Kingdom by a group of investigators led by Peter Wurl. And they have done some really nice studies that have shown that hypnosis can be very beneficial in treating or relieving the symptoms of IBS but also changing the physiology of the gut making the gut less sensitive. But it is really gut-directed hypnotherapy. I think the issue is more of finding a good hypnotherapist that you get along with that would be good in treating and managing the symptoms of IBS.
Are antibiotics or probiotics helpful treatments for IBS?
In some patients with IBS, if you treat the patients with antibiotics, particularly those who have bacterial overgrowth, which you can detect by a breath test or by other modalities, that those patients will have improvement of their IBS symptoms. We need alot more information, there needs to be other centers to conduct those studies, and we don't know enough about, once you finish that antibiotic treatment, then what? If the symptoms recur then how do you treat them, how long is the efficacy lasting, and who are the patients that do respond to this treatment? Because it doesn't appear that all subjects will improve with that type of treatment. The other related treatment, would be, probiotics, and probiotics are live bacteria. One thought is that there is good and bad bacteria in the gut, and you want to balance it so you have more good bacteria than bad bacteria and probiotics are good bacteria. Now there are thousands of probiotics and they can have all different types of functions. But, the reason why it's being studied in IBS is that some of of these probiotics have actually been used with inflammatory bowel disease with the thought that these probiotics decrease the inflammation in inflammatory bowel disease. Now in IBS, one thought is that some of the patients have microscopic immune activation, or maybe inflammation, but that is a term I am using loosely for that. And that a probiotic will decrease the inflammation or immune reactivity and promote an anti-inflammatory state.
What complimentary alternative medicines help treat IBS?
There's a whole host of complimentary alternative medicines treatment interventions and sometimes patients will ask about other modalities that are under the umbrella of complimentary alternative medicine but there really isn't good data or studies to determine or provide information of whether these treatment modalities are effective. But I will say that I know there are ongoing studies and a lot of interest in conducting proper trials to assess the efficacy of these different treatment modalities, so hopefully we'll have more information in the future. The two that come to mind most commonly would be acupuncture and herbal therapy. Acupuncture has been studied only in small studies and it's hard to do a controlled trial of acupuncture - to really define or determine if it's efficacious. There have been limited studies, and in general, they haven't been positive to show an outright benefit of IBS. There have been Chinese herbal medication trials in IBS that have shown, compared to a placebo, and it's not easy to make a Chinese herbal medicine placebo, but there have been studies in controlled trials where they've shown that Chinese herbal therapy can be efficacious in treating IBS.