How to meet the challenges of managing patients with IBS
Establish a strong relationship with your patient. Rule out “red-flag” diagnoses. Then choose from one of the therapies detailed here to target the subtype of disease.
PRACTICE RECOMMENDATIONS
› Make the diagnosis of irritable bowel syndrome (IBS) based on clinical findings, after excluding red flags in the presentation. C
› Screen patients with diarrhea-predominant IBS with fecal and serologic studies to rule out inflammatory bowel disease and celiac disease. B
› Counsel all IBS patients to increase their intake of soluble fiber, follow a low-FODMAP (fermentable oligo-, di-, and monosaccharide, and polyol) diet, and increase physical activity. B
› Prescribe an antispasmodic to treat mild IBS of all subtypes. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
The 2 main diets studied for the treatment of IBS are a diet low in fermentable oligo-, di- and monosaccharides and polyols—the so-called low-FODMAP diet (TABLE 330)—and a gluten-free diet. Evidence behind the benefits of both diets conflicts; trials of the low-FODMAP diet are more favorable.
A small study with 20 patients with IBS-D and IBS-M who followed a low-FODMAP diet found improvement in IBS symptoms and a reduction in serum levels of proinflammatory cytokines, fecal bacteria, and total fecal short-chain fatty acid levels.29 Several meta-analyses have shown improvement in overall IBS symptoms for patients who follow a low-FODMAP diet. Because of the heterogeneity of the studies, however, the quality of the data is low.31-34
Data supporting the use of a gluten-free diet for IBS patients are insufficient.31
The American College of Gastroenterology (ACG) gave a weak recommendation for the low-FODMAP diet and recommended against the gluten-free diet in IBS patients.3 More data are needed regarding the safety profile of using a low-FODMAP diet for an extended period: There is concern about the risk of nutritional deficiencies associated with long-term use of this diet.3
Supplementation with poorly fermentable soluble fiber has been shown to alleviate global IBS symptoms; insoluble fiber does not yield improvement of symptoms. Psyllium fiber is recommended over wheat bran.3,35
Continue to: Consider a low-FODMAP diet...
