General Approach to Treatment

© The principal goal of IBS treatment is to reduce or control symptoms. The treatment strategy is based on: (a) the prevailing symptoms and their severity, (b) the degree of functional impairment, and (c) the presence of psychological components. A standard treatment regimen is not possible because of the heterogeneous nature of the IBS patient population. Patients suffering from IBS can benefit from clinician support and reassurance, because specific pathology is unlikely to be found.

Nonpharmacologic Therapy

Diet and Other General Modifications

Dietary modification is a standard therapeutic modality. Food hypersensitivities and adverse effects are thought to occur widely in IBS patients, especially those with IBS with diarrhea subtype. Elimination diets are the most commonly used strategy, usually focusing on milk and dairy products, fructose and sorbitol, wheat, and beef. Flatulence may be controlled by reducing gas-causing foods such as beans, celery, onions, prunes, bananas, carrots, and raisins. Response to elimination diets varies widely, but they may be useful in individual patients. Care must be taken to avoid creating nutritional deficits while attempting to eliminate an offending food.

Probiotics may also be an option for some patients with IBS. Bifidobacterium in-fantis is one product used for its effect in constipation, diarrhea, gaseousness, bloating, and abdominal discomfort. Reportedly, it is not associated with significant unto-

ward effects. The usual dose is one 4-mg capsule daily. Psychological Treatments

Psychotherapy focused on reducing the influence of the CNS on the gut has been studied. Cognitive behavioral therapy (CBT), dynamic psychotherapy, relaxation therapy, and hypnotherapy have been reported to be effective in some patients. However, CBT

and relaxation therapy do not appear to be better than standard approaches. Biofeedback may provide relief in cases of severe constipation, but definitive evidence is lacking.21,22 Psychotherapy interventions provide relief from pain and diarrhea but not

from constipation.

Pharmacologic Therapy


Peppermint oil is widely advocated; it acts as an antispasmodic agent due to its ability to relax GI smooth muscle. However, it also relaxes the lower esophageal sphincter, which could allow reflux of gastric contents into the esophagus. The usual dose is 1 to 2 enteric-coated capsules containing 0.2 mL of peppermint oil two to three times daily.

Matricaria recutita, known as German chamomile, is also purported to have antispasmodic properties. It is taken most often as a tea up to four times a day. Benzodiazepine, alcohol, and warfarin users should be cautioned against taking this product because it can cause drowsiness, and it contains coumarin derivatives.2


Antispasmodic agents such as dicyclomine or hyoscyamine have been among the most frequently used medications for treating abdominal pain in patients with IBS (Table 21-5). Side effects include blurred vision, constipation, urinary retention, and (rarely) psychosis. Although their effectiveness remains unconfirmed, these drugs may deserve a trial in patients with intermittent postprandial pain.18


Tricyclic antidepressants (TCAs) such as amitriptyline and doxepin have been used with some success in the treatment of IBS-related pain (Table 21-5). They modulate pain principally through their effect on neurotransmitter reuptake, especially nore-pinephrine and serotonin. Their helpfulness in functional GI disorders seems independent of mood-altering effects normally associated with these agents. Low-dose TCAs (e.g., amitriptyline, desipramine, or doxepin 10-25 mg daily) may help patients with IBS who predominantly experience diarrhea or pain.

The selective serotonin-reuptake inhibitors (SSRIs) paroxetine, fluoxetine, and sertraline are potentially useful due to the significant effect of serotonin in the gut. SSRIs principally act on 5-HT1 or 5-HT2 receptors, but they can also have some effect on gut-predominant 5-HT3 and 5-HT4 receptors, perhaps reducing visceral hypersensitivity. They maybe beneficial for patients with IBS-C or when the patient presents with

IBS complicated by a mood disorder. SSRIs should be reserved for use when TCAs are not effective because evidence supporting their use solely in IBS is lacking.

Table 21-5 Common Pharmacologic Treatments for IBS

Generic (Brand) Name



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