Irritable bowel syndrome: What helps – and what doesn’t

Photo of a man writing in a diary (PantherMedia / Lev Dolgachov) There are a lot of treatments for the relief of irritable bowel syndrome (IBS) – but there's a lack of good-quality research on them. Because it's not clear what causes IBS, it's difficult to find suitable treatments. But research has suggested that at least some medications and treatments may help.

The main symptoms of irritable bowel syndrome are abdominal pain, constipation and diarrhea. Most people only have mild symptoms that they can cope with fairly well without having treatment. Over time they learn to understand their body's signals. But some people have more severe symptoms that greatly affect their everyday lives, so they look for a treatment to reduce the symptoms.

Some things help, others don't

Although there are all sorts of tips and recommendations out there when it comes to IBS treatment, there's a lack of good research in this area. Generally speaking, it's fair to say that there's no treatment that is guaranteed to relieve the symptoms. But research has shown that some treatments can at least help in some people or in the short term. These include the following:

  • Dietary supplements containing peppermint oil or probiotics
  • Certain anti-cramping medications, antidepressants and drugs to relieve constipation
  • Psychological treatments such as cognitive behavioral therapy and hypnosis

But research has also shown that these treatments – particularly the medications – can cause side effects.

Studies on the effects of acupuncture have found that it doesn't help in IBS.

Many other recommended treatments haven't been studied properly so it isn't clear how well they work. These include reflexology massage, enemas and changing what you eat – for instance, more fiber or certain diets.

What can help?

Studies have suggested that the following substances and medications can help. But the groups of people who took part in the studies aren't suitable for comparison. So it's not possible to say which treatment approach is most likely to work. Overall, 10 to 30 percent of the participants noticed an at least short-term improvement in symptoms. The different treatments have different side effects, though.

Peppermint oil

Peppermint oil is supposed to have a calming effect on the intestine by relaxing the muscles of the intestine. Several studies have indeed shown that some people benefit from peppermint oil, at least temporarily.

In these studies, peppermint oil was taken in capsules that are resistant to stomach acid. The dose used was between 500 and 800 mg per day. It's not clear whether peppermint solutions or drops help too. 9 out of 100 study participants had mild side effects from the peppermint oil capsules, such as heartburn or acid reflux.

Probiotics

The intestine contains different types of bacteria (gut flora) that play an important role in how well it works. These include lactic acid bacteria and bifidobacteria. Some people with IBS have abnormal gut flora, so it is thought that probiotics containing these bacteria (for instance, in yogurts and drinks) might be able to help.

A number of studies found that probiotics relieved IBS symptoms in some people. But more research is needed to be able to find out which type of bacteria helps the most and what dose is most effective. Probiotics are generally well tolerated. They only rarely lead to mild side effects such as flatulence (gas).

Anti-cramping medications

People whose main IBS symptom is cramping often use anti-cramping medications. These medications are meant to relieve the pain by relaxing the muscles of the intestine. Research suggests that four anti-cramping medications may help: butylscopolamine, cimetropium, pinaverium and otilonium. Butylscopolamine is the only one of these that is available in Germany. You can buy it at pharmacies, without a prescription. One study found that this drug relieved IBS symptoms in some people.

Another anti-cramping drug, known as mebeverine, is often prescribed in Germany. But there isn't enough research to be able to say whether it helps.

The possible side effects of anti-cramping medications include a dry mouth, dizziness and blurred vision. About 5 out of 100 people in studies had these types of side effects.

Medications for constipation or diarrhea

Medications for constipation or diarrhea can also be used, depending on which of these problems a person mainly has. But there's hardly any research on their effectiveness in IBS. Many laxatives and anti-diarrhea medications are available in pharmacies without a prescription.

If they don't work, a doctor can prescribe constipation medications containing the drugs prucalopride (Resolor) or linaclotide (Constella). Studies have shown that linaclotide can relieve the symptoms of IBS with constipation. These medications may cause side effects such as headaches, abdominal pain, nausea, dizziness and blood in the stool.

All medications for diarrhea or constipation have the disadvantage that they may just replace one problem with another: Medication for diarrhea may cause constipation if its effect is too strong. Similarly, medication for relieving constipation can lead to diarrhea. In people who have alternating diarrhea and constipation, it's important to make sure that the medications don't make the symptoms even worse.

Antibiotics

Antibiotics are sometimes considered as a treatment option for people whose IBS causes diarrhea or flatulence. The best-studied antibiotic is called rifaximin. In Germany, this drug is only approved for treating traveler's diarrhea. Yet doctors can still prescribe it “off-label” after providing full information about that type of use. It is considered to be "off-label use" if the medication is used in a way that hasn't been officially approved by a country's health authorities. When a drug is prescribed off label, insurers will only cover the costs in specific cases.

In studies, rifaximin was shown to relieve IBS symptoms in some people. But it's not clear whether it also has a positive effect in the long term. According to current recommendations, antibiotics shouldn't be used too often because they can have various side effects, including allergic reactions, nausea and fungal infections. Also, improper use or overuse of antibiotics can contribute to bacteria becoming resistant to antibiotics, and then they won't be as effective in the future. Antibiotics affect the gut flora too, which can sometimes make IBS symptoms worse.

Antidepressants

Sometimes IBS is treated with drugs that are normally used to treat depression. These include tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), which you can only get if you have a prescription from a doctor. In Germany, they haven't been approved for the treatment of IBS, so they can only be used off-label.

It is thought that certain antidepressants can relieve pain in IBS. Some may affect the muscles in the digestive tract.

Research has shown that tricyclic antidepressants and SSRIs can help relieve IBS. But they are generally only considered if other treatments haven’t worked.

Antidepressants can have various side effects: In the above-mentioned studies, 15 out of 100 people had side effects like loss of appetite, nausea and decreased sex drive. Some antidepressants can themselves lead to constipation or diarrhea.

Psychological treatments

Because it is thought that psychological stress may contribute to IBS, relaxation and stress management techniques are sometimes used. There's a lack of research on the effectiveness of these approaches. But some studies have suggested that a combination of relaxation techniques, stress management and biofeedback could help.

Other treatment options include psychological approaches like cognitive behavioral therapy. This treatment is mainly considered in people who have very severe symptoms. It aims to help you learn to cope better with the symptoms. There is some evidence that cognitive behavioral therapy can indeed help in IBS.

Some people who have IBS try hypnosis-based treatment (hypnotherapy). During a hypnotherapy session, you focus so intensely on a certain idea that you become unaware of the things around you and are more receptive to what your therapist tells you (“suggestions”). In the treatment of IBS, one example of such a suggestion is imagining that you have a healthy, well-functioning bowel. There is also evidence to suggest that hypnotherapy can reduce IBS symptoms for several months in some people.

What doesn't help?

Many people say that they feel better after having acupuncture. But a number of studies have shown that this is not due to the specific effects of acupuncture: It was no better than a "fake" treatment (placebo).

What has not been studied?

There's no research on the following treatments and approaches, so it's not known whether they work. They may also have disadvantages and be associated with risks.

Changing your diet

Most people who have IBS find that certain foods improve their symptoms, or make them worse. Unfortunately, there's very little good research on how diet may affect the symptoms – but that's not to say that it plays no role. Different people react very differently to certain types of foods, though.

It usually takes a while to find out what your bowel can and can't handle. It might help to keep a food diary for a few weeks. You can write down what you eat over the course of the day, whether you have any symptoms and, if so, what kind. You can also mention any other factors that might explain the symptoms (such as stress at work). You may gradually start recognizing patterns that help you identify which foods you don't tolerate. You can show your doctor the diary to talk about whether it would be a good idea to stop eating certain foods.

Avoiding fermentable carbohydrates (the FODMAP diet)

In recent years, IBS has increasingly been associated with foods containing fermentable carbohydrates. These are known as FODMAPs, which stands for "fermentable, oligo-, di-, mono-saccharides and polyols". They are found in many foods, including fructose (a monosaccharide), lactose and starch (oligosaccharides) and sweeteners (sugar alcohols). It is believed that the absorption of FODMAPs in the body can result in more liquid in the intestine, which increases the risk of diarrhea. As these carbohydrates ferment, more gas is produced in the intestine too, causing bloating and wind. The composition of the intestinal bacteria is also influenced by diet.

In the low-FODMAP diet, you avoid all foods containing these sugars. But this increases your risk of malnutrition because it is then difficult to get enough vitamins and minerals in your diet. It is also hard to keep up such a strict diet in day-to-day life.

There is currently no good-quality research proving that the low-FODMAP diet can relieve IBS symptoms.

Soluble fibers

People who eat a balanced diet already get enough fiber in their diet. There's no proof that taking fiber supplements helps. There are two different types of fiber supplements:

  • Soluble fiber, which absorbs water in the bowel (e.g. psyllium, also called isphagula)
  • Insoluble fiber, which hardly absorbs any water (e.g. bran)

If you would like to try out fiber: People who have IBS are advised to try eating soluble fiber rather than insoluble fiber, and then see if it helps.

Reflexology massage and enemas

Reflexology massage and enemas (a colon cleanse) are also used in the treatment of IBS.

But there's a lack of scientific research on these approaches, so it's not clear whether they're effective. Enemas are associated with risks such as an electrolyte imbalance, infections and injury to the wall of the bowel.