Elsevier

Mayo Clinic Proceedings

Volume 93, Issue 12, December 2018, Pages 1858-1872
Mayo Clinic Proceedings

Thematic Review Series on Gastroenterological Diseases
Management Options for Irritable Bowel Syndrome

https://doi.org/10.1016/j.mayocp.2018.04.032Get rights and content

Abstract

Irritable bowel syndrome (IBS) is associated with diverse pathophysiologic mechanisms. These mechanisms include increased abnormal colonic motility or transit, intestinal or colorectal sensation, increased colonic bile acid concentration, and superficial colonic mucosal inflammation, as well as epithelial barrier dysfunction, neurohormonal up-regulation, and activation of secretory processes in the epithelial layer. Novel approaches to treatment include lifestyle modification, changes in diet, probiotics, and pharmacotherapy directed to the motility, sensation, and intraluminal milieu of patients with IBS. Despite recent advances, there is a need for development of new treatments to relieve pain in IBS without deleterious central or other adverse effects.

Section snippets

Dietary Modifications

Many patients believe that their IBS symptoms are due to food sensitivity.12

Prebiotics and Probiotics

Prebiotics include food ingredients such as fructo-oligosaccharides or inulin that remain undigested in the human gastrointestinal system and can promote the growth or activity of gut bacteria. In contrast, probiotics are live or attenuated microorganisms that can affect the composition of the intestinal microorganisms. Probiotics may have anti-inflammatory and antinociceptive properties.49, 50, 51, 52

Two trials of prebiotics in IBS were reported in the past 3 years. An RCT of 12 weeks'

Medications for Pain

Numerous pharmacological agents for treatment of IBS are currently available, with varying modes of action, efficacy, quality of data, and adverse events (Table).

Medications for Diarrhea

Opioid agents and antidepressants (TCAs and SNRIs) may relieve diarrhea in addition to their effects on pain (Table).

Intestinal Secretagogues

Lubiprostone is a prostaglandin derivative that acts on chloride channels on the apical membrane of the intestinal enterocyte to induce chloride secretion, which is then followed by the passive movement of sodium ions and water into the lumen. As a result, stools become looser and gastrointestinal transit is accelerated.129 The drug is approved at a dose of 8 μg twice daily for women with IBS-C130 and 24 μg twice daily for men and women with chronic constipation.131, 132 There are general

Conclusion

Currently, the treatment of IBS remains focused on treating the patient's most troublesome symptom. These treatments are quite efficacious for bowel dysfunction, although the treatment of pain without use of opioids or centrally acting agents is suboptimal. Hence, lifestyle interventions including diet, cognitive behavioral therapy and hypnotherapy (the lattermost not discussed here) should be considered to relieve symptoms in a holistic approach to the patient's symptoms. Pharmacotherapies

Acknowledgments

The funding organization had no role in the design and execution of the study, in the collection, analyses, and interpretation of the data, or in the preparation, review, or approval of the submitted manuscript.

References (144)

  • M.I. Vazquez Roque et al.

    A controlled trial of gluten-free diet in patients with irritable bowel syndrome-diarrhea: effects on bowel frequency and intestinal function

    Gastroenterology

    (2013)
  • U. Wahnschaffe et al.

    Predictors of clinical response to gluten-free diet in patients diagnosed with diarrhea-predominant irritable bowel syndrome

    Clin Gastroenterol Hepatol

    (2007)
  • I. Aziz et al.

    Efficacy of a gluten-free diet in subjects with irritable bowel syndrome-diarrhea unaware of their HLA-DQ2/8 genotype

    Clin Gastroenterol Hepatol

    (2016)
  • L. O'Mahony et al.

    Lactobacillus and bifidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles

    Gastroenterology

    (2005)
  • E.F. Verdú et al.

    Lactobacillus paracasei normalizes muscle hypercontractility in a murine model of postinfective gut dysfunction

    Gastroenterology

    (2004)
  • Y. Zhang et al.

    Effects of probiotic type, dose and treatment duration on irritable bowel syndrome diagnosed by Rome III criteria: a meta-analysis

    BMC Gastroenterol

    (2016)
  • H.P. Ammon et al.

    Spasmolytic and tonic effect of Iberogast (STW 5) in intestinal smooth muscle

    Phytomedicine

    (2006)
  • U. Simmen et al.

    Binding of STW 5 (Iberogast) and its components to intestinal 5-HT, muscarinic M3, and opioid receptors

    Phytomedicine

    (2006)
  • A. Bensoussan et al.

    Efficacy of a Chinese herbal medicine in providing adequate relief of constipation-predominant irritable bowel syndrome: a randomized controlled trial

    Clin Gastroenterol Hepatol

    (2015)
  • A. Amato et al.

    Effects of menthol on circular smooth muscle of human colon: analysis of the mechanism of action

    Eur J Pharmacol

    (2014)
  • B. Liu et al.

    TRPM8 is the principal mediator of menthol-induced analgesia of acute and inflammatory pain

    Pain

    (2013)
  • H.J. McQuay et al.

    A systematic review of antidepressants in neuropathic pain

    Pain

    (1996)
  • D.A. Drossman et al.

    Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders

    Gastroenterology

    (2003)
  • M. Camilleri et al.

    Opioids in gastroenterology: treating adverse effects and creating therapeutic benefits

    Clin Gastroenterol Hepatol

    (2017)
  • L.S. Dove et al.

    Eluxadoline benefits patients with irritable bowel syndrome with diarrhea in a phase 2 study

    Gastroenterology

    (2013)
  • A.C. Ford et al.

    Irritable bowel syndrome: a 10-yr natural history of symptoms and factors that influence consultation behavior

    Am J Gastroenterol

    (2008)
  • M. Camilleri et al.

    Validating biomarkers of treatable mechanisms in irritable bowel syndrome

    Neurogastroenterol Motil

    (2014)
  • M. Camilleri

    Review article: biomarkers and personalised therapy in functional lower gastrointestinal disorders

    Aliment Pharmacol Ther

    (2015)
  • S.M. Brierley et al.

    Neuroplasticity and dysfunction after gastrointestinal inflammation

    Nat Rev Gastroenterol Hepatol

    (2014)
  • D. Julius

    TRP channels and pain

    Annu Rev Cell Dev Biol

    (2013)
  • M. Camilleri et al.

    Invited Review: Pharmacotherapy for irritable bowel syndrome

    J Clin Med

    (2017)
  • An evidence-based position statement on the management of irritable bowel syndrome

    Am J Gastroenterol

    (2009)
  • A.C. Ford et al.

    American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation

    Am J Gastroenterol

    (2014)
  • R. Spiller et al.

    Guidelines on the irritable bowel syndrome: mechanisms and practical management

    Gut

    (2007)
  • M. Camilleri

    American College of Gastroenterology monograph on the management of irritable bowel syndrome

    Expert Opin Pharmacother

    (2015)
  • L. Böhn et al.

    Self-reported food-related gastrointestinal symptoms in IBS are common and associated with more severe symptoms and reduced quality of life

    Am J Gastroenterol

    (2013)
  • G. Ragnarsson et al.

    Pain is temporally related to eating but not to defaecation in the irritable bowel syndrome (IBS): patients' description of diarrhea, constipation and symptom variation during a prospective 6-week study

    Eur J Gastroenterol Hepatol

    (1998)
  • M.A. Sullivan et al.

    Colonic myoelectrical activity in irritable-bowel syndrome: effect of eating and anticholinergics

    N Engl J Med

    (1978)
  • M. Simrén et al.

    An exaggerated sensory component of the gastrocolonic response in patients with irritable bowel syndrome

    Gut

    (2001)
  • L.A. David et al.

    Diet rapidly and reproducibly alters the human gut microbiome

    Nature

    (2014)
  • P. Moayyedi et al.

    The effect of dietary intervention on irritable bowel syndrome: a systematic review

    Clin Transl Gastroenterol

    (2015)
  • W. Atkinson et al.

    Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial

    Gut

    (2004)
  • C.J. Bijkerk et al.

    Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial

    BMJ

    (2009)
  • P. Moayyedi et al.

    The effect of fiber supplementation on irritable bowel syndrome: a systematic review and meta-analysis

    Am J Gastroenterol

    (2014)
  • A. Erdogan et al.

    Randomised clinical trial: mixed soluble/insoluble fibre vs. psyllium for chronic constipation

    Aliment Pharmacol Ther

    (2016)
  • J. Tomlin et al.

    Laxative properties of indigestible plastic particles

    BMJ

    (1988)
  • M.A. Zimmerman et al.

    Butyrate suppresses colonic inflammation through HDAC1-dependent Fas upregulation and Fas-mediated apoptosis of T cells

    Am J Physiol Gastrointest Liver Physiol

    (2012)
  • S.M. Lee et al.

    Beneficial effects of soy milk and fiber on high cholesterol diet-induced alteration of gut microbiota and inflammatory gene expression in rats

    Food Funct

    (2015)
  • R. Undseth et al.

    Abnormal accumulation of intestinal fluid following ingestion of an unabsorbable carbohydrate in patients with irritable bowel syndrome: an MRI study

    Neurogastroenterol Motil

    (2014)
  • E.P. Halmos et al.

    Diets that differ in their FODMAP content alter the colonic luminal microenvironment

    Gut

    (2015)
  • Cited by (0)

    Grant Support: This work was supported by grant R01-DK92179 and R01-DK115950 from the National Institutes of Health.

    Potential Competing Interests: Dr Camilleri has received research funding regarding this topic from Novartis AG, Allergan, and Entera Health, Inc. He has done consulting regarding this topic (with the fee going to his employer, Mayo Clinic) for Elobix AB, Shire, and Takeda Pharmaceutical Company Limited.

    The Thematic Reviews on Gastroenterological Diseases will continue in an upcoming issue.

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