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Irritable Bowel Syndrome: Update From ACP 2015

Irritable Bowel Syndrome: Update From ACP 2015

  • US prevalence of IBS is ~12%; female to male ratio, 1.5:1. Prevalence was higher in women than in men; prevalence higher in unmarried than in married individuals and unemployed individuals than in employed individuals. 51% had seen physician for IBS symptoms in the past year; most had used Rx, >90% had used OTC medications. Based on SF-36, patients with IBS report reduced overall quality of life based on US norms.
  • Survey: 1242 patients; mean age was 39.3 +/- 12.5 years, educational attainment 15 +/- 2.6 years, 85% female, IBS duration 6.9 +/- 4.2 years, 79% have seen an MD for IBS in the past 6 months, and 92.6% have used the Web for health information. Most prevalent misconceptions: IBS is caused by lack of digestive enzymes (52%); is a form of colitis (42.8%); will worsen with age (47.9%); and can develop into colitis (43%), malnutrition (37.7%), or cancer (21.4%). Patients wanted to know more about foods to avoid (63.3%), causes of IBS (62%), coping strategies (59.4%), medications (55.2%), will they have to live with IBS for life (51.6%), and research studies (48.6%).
  • 60% of IBS patients reported worsened symptoms after meals and found relief by eating smaller meals (69%), avoiding fat (64%), increasing fiber (58%), and/or avoiding dairy (54%).
  • Food intolerances in IBS patients may range from 20%-67%.(2) Food could trigger IBS symptoms by stimulating mechanoreceptors or chemoreceptors, releasing hormones/peptides, altering secretions, or changing osmolarity, causing luminal distention via fermentation.
  • Lactose intolerance affects 30%-35% of US adults, with slightly higher prevalence in IBS. Maintaining calcium and vitamin D stores while avoiding dairy is important. Many dairy-free options: Lactaid©; milk made from rice, almond, coconut, hemp, soy, quinoa, oat, hazelnut, cashew.
  • Up to 40% of IBS patients may have fructose intolerance. Fruits, honey, table sugar are very poorly absorbed on their own, but efficiently absorbed when eaten with glucose; avoid high-fructose corn syrup. One study found that following a fructose-free diet led to a 50% reduction in bloating in about 75% of participants with IBS.(3) Non-absorbable sugars: artificial sweeteners (eg, sorbitol, mannitol). Also found in small amounts in some fruits.
  • Fiber: Both high- and low-fiber diets are widely recommended for treating IBS, but studies suggest no improvement in symptoms with either a high- or low-fiber diet, vs placebo. Low-fiber diet may be more helpful in diarrhea-predominant or mixed IBS. A high-fiber diet can increase bloating and flatulence, and may harden stools. Wheat: Considered a fructan, may be hard to digest and fermentable in large amounts, contributing to IBS symptoms. Other fermentable foods: fructans, galactans, polyols (aka FODMAPs)
  • Fermentable Oligo-, Di-, Monosaccharides, And Polyols. FODMAPs to avoid are fructans: onions, peppers, artichokes, wheat (large amounts), rye (large amounts); fructose: fruits, honey, juices, soda; galacto-oligosaccharides: legumes (beans, peas), lentils, cabbage, brussel sprouts, asparagus, green beans; polyols: artificial sweeteners, apples, watermelon, mushrooms; count total FODMAPs in a meal, not individual ones.
  • Lean proteins; gluten-free breads, rolls, pasta; rice; corn; oats; quinoa; buckwheat (kasha); millet; amaranth; sorghum; taro; teff; potatoes; safe fruits and vegetables: mandarin oranges, snow peas, bok choy, carrots.
  • Lubiprostone: FDA-approved, 2006(4) activates chloride channels and promotes water secretion into the colon. Linaclotide: FDA-approved, 2012(4) agonizes guanylate cyclase 2C, decreasing activation of colonic sensory neurons and activating colonic motor neurons, leading to increased smooth muscle contraction and increased bowel movements. Phase 3 trial showed linaclotide significantly decreased abdominal pain and IBS symptoms compared with placebo over 26 weeks.(5)
  • Prucalopride: Approved in EU, 2009, not in US.(6) Selective 5-HT4 receptor agonist, targets impaired colonic motility in chronic constipation. Phase 3 trial showed prucalopride significantly improved complete spontaneous bowel movements and quality-of-life measures, vs placebo.
  • Common food culprits in IBS include lactose, fructose, non-absorbable sugars, fiber, wheat, and FODMAPs. FODMAPS are Fermentable Oligo-, Di-, Monosaccharides, And Polyols that may be difficult for IBS patients to digest, contributing to symptoms. Wheat is considered a FODMAP; some IBS patients may need to avoid wheat in large amounts. Newer medications for constipation-predominant IBS include lubiprostone, linaclotide, and prucalopride.

Patients have wide misconceptions about the causes of IBS and fears about what it means for longevity. They are also eager for education on what they can eat, drugs that might help, and methods to cope.

Based on information presented at the 2015 annual American College of Physicians Internal Medicine meeting, the short slide show above highlights:

Demographics of patients with IBS

Foods recommended and not recommended, and why

Current prescription medications that may help



1. Andrews EB, Eaton SC, Hollis KA, et al. Prevalence and demographics of irritable bowel syndrome: results from a large web-based survey. Aliment Pharmacol Ther. 2005;22:935-942. doi:10.1111/j.1365-2036.2005.02671.x
2. Halpert A, Dalton CB, Palsson O, et al. What patients know about irritable bowel syndrome (IBS) and what they would like to know. National Survey on Patient Educational Needs in IBS and development and validation of the Patient Educational Needs Questionnaire (PEQ). Am J Gastroenterol. 2007;102:1972-1982. Epub 2007 May 3.
3. Choi YK1, Kraft N, Zimmerman B, et al. Fructose intolerance in IBS and utility of fructose-restricted diet. J Clin Gastroenterol. 2008;42:233-238. doi:10.1097/MCG.0b013e31802cbc2f.
4. Lacy BE. Let’s get moving: a rational approach to diarrhea and constipation. Presented at: the American College of Physcians Internal Medicine Meeting; April 30-May 2, 2015; Boston.
5. Chey WD, Lembo AJ, Lavins BJ, et al. Linaclotide for irritable bowel syndrome with constipation: a 26-week, randomized, double-blind, placebo-controlled trial to evaluate efficacy and safety. Am J Gastroenterol. 2012;107:1702-1712.
6. Quigley EM, Vandeplassche L, Kerstens R, et al. Clinical trial: the efficacy, impact on quality of life, and safety and tolerability of prucalopride in severe chronic constipation—a 12-week, randomized, double-blind, placebo-controlled study. Aliment Pharmacol Ther. 2009;29:315-328. doi:10.1111/j.1365-2036.2008.03884.x. Epub 2008 Nov 8.

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