A number of treatments have been found to be effective, including fiber, talk therapy, antispasmodic and antidepressant medication, and peppermint oil. Diet FODMAP FODMAPS are short chain carbohydrates that are poorly absorbed in the small intestine. A 2018 systematic review found that although there is evidence of improved IBS symptoms with a low FODMAP diet, the evidence is of very low quality. Symptoms most likely to improve include urgency, flatulence, bloating, abdominal pain, and altered stool output. One national guideline advises a low FODMAP diet for managing IBS when other dietary and lifestyle measures have been unsuccessful. The diet restricts various carbohydrates which are poorly absorbed in the small intestine, as well as fructose and lactose, which are similarly poorly absorbed in those with intolerances to them. Reduction of fructose and fructan has been shown to reduce IBS symptoms in a dose-dependent manner in people with fructose malabsorption and IBS. FODMAPs are fermentable oligo-, di-, monosaccharides and polyols, which are poorly absorbed in the small intestine and subsequently fermented by the bacteria in the distal small and proximal large intestine. This is a normal phenomenon, common to everyone. The resultant production of gas potentially results in bloating and flatulence. Although FODMAPs can produce certain digestive discomfort in some people, not only do they not cause intestinal inflammation, but they help avoid it, because they produce beneficial alterations in the intestinal flora that contribute to maintaining the good health of the colon. FODMAPs are not the cause of irritable bowel syndrome nor other functional gastrointestinal disorders, but rather a person develops symptoms when the underlying bowel response is exaggerated or abnormal. A low-FODMAP diet consists of restricting them from the diet. They are globally trimmed, rather than individually, which is more successful than for example restricting only fructose and fructans, which are also FODMAPs, as is recommended for those with fructose malabsorption. A low-FODMAP diet might help to improve short-term digestive symptoms in adults with irritable bowel syndrome, but its long-term follow-up can have negative effects because it causes a detrimental impact on the gut microbiota and metabolome. It should only be used for short periods of time and under the advice of a specialist. A low-FODMAP diet is highly restrictive in various groups of nutrients and can be impractical to follow in the long-term. More studies are needed to assess the true impact of this diet on health. In addition, the use of a low-FODMAP diet without verifying the diagnosis of IBS may result in misdiagnosis of other conditions such as celiac disease. Since the consumption of gluten is suppressed or reduced with a low-FODMAP diet, the improvement of the digestive symptoms with this diet may not be related to the withdrawal of the FODMAPs, but of gluten, indicating the presence of unrecognized celiac disease, avoiding its diagnosis and correct treatment, with the consequent risk of several serious health<unk> , including various types of cancer. Fiber Some evidence suggests soluble fiber supplementation (e.g., psyllium/ispagula husk) is effective. It acts as a bulking agent, and for many people with IBS-D, allows for a more consistent stool. For people with IBS-C, it seems to allow for a softer, moister, more easily passable stool. However, insoluble fiber (e.g., bran) has not been found to be effective for IBS. In some people, insoluble fiber supplementation may aggravate symptoms. Fiber might be beneficial in those who have a predominance of constipation. In people who have IBS-C, soluble fiber can reduce overall symptoms but will not reduce pain. The research supporting dietary fiber contains conflicting small studies complicated by the heterogeneity of types of fiber and doses used. One meta-analysis found only soluble fiber improved global symptoms of irritable bowel, but neither type of fiber reduced pain. An updated meta-analysis by the same authors also found soluble fiber reduced symptoms, while insoluble fiber worsened symptoms in some cases. Positive studies have used 10–30 grams per day of ispaghula (psyllium). One study specifically examined the effect of dose, and found 20 g of ispaghula (psyllium) were better than 10 g and equivalent to 30 g per day. Medication Medications that may be useful include antispasmodics such as dicyclomine and antidepressants. Both H1-antihistamines and mast cell stabilizers have shown efficacy in reducing pain associated with visceral hypersensitivity in IBS. Laxatives For people who do not adequately respond to dietary fiber, osmotic laxatives such as polyethylene glycol, sorbitol, and lactulose can help avoid "cathartic colon" which has been associated with stimulant laxatives. Lubiprostone is a gastrointestinal agent used for the treatment of constipation-predominant IBS. Antispasmodics The use of antispasmodic drugs (e.g., anticholinergics such as hyoscyamine or dicyclomine) may help people who have cramps or diarrhea. A meta-analysis by the Cochrane Collaboration concludes if seven people are treated with antispasmodics, one of them will benefit. Antispasmodics can be divided into two groups: neurotropics and musculotropics. Musculotropics, such as mebeverine, act directly at the smooth muscle of the gastrointestinal tract, relieving spasm without affecting normal gut motility. Since this action is not mediated by the autonomic nervous system, the usual anticholinergic side effects are absent. The antispasmodic otilonium may also be useful. Discontinuation of proton pump inhibitors Proton pump inhibitors (PPIs) used to suppress stomach acid production may cause small intestinal bacterial overgrowth (SIBO) leading to IBS symptoms. Discontinuation of PPIs in selected individuals has been recommended as it may lead to an improvement or resolution of IBS symptoms. Antidepressants Evidence is conflicting about the benefit of antidepressants in IBS. Some meta-analyses have found a benefit, while others have not. There is good evidence that low doses of tricyclic antidepressants (TCAs) can be effective for IBS. With TCAs, about one in three people improve. However, the evidence is less robust for the effectiveness of other antidepressant classes such as selective serotonin reuptake inhibitor antidepressants (SSRIs). Because of their serotonergic effect, SSRIs have been studied in IBS, especially for people who are constipation predominant. As of 2015, the evidence indicates that SSRIs do not help. Antidepressants are not effective for IBS in people with depression, possibly because lower doses of antidepressants than the doses used to treat depression are required for relief of IBS. Other agents Magnesium aluminum silicates and alverine citrate drugs can be effective for IBS. Rifaximin may be useful as a treatment for IBS symptoms, including abdominal bloating and flatulence, although relief of abdominal distension is delayed. It is especially useful where small intestinal bacterial overgrowth is involved. In individuals with IBS and low levels of vitamin D supplementation is recommended. Some evidence suggests that vitamin D supplementation may improve symptoms of IBS, but further research is needed before it can be recommended as a specific treatment for IBS. Psychological therapies There is low quality evidence from studies with poor methodological quality that psychological therapies can be effective in the treatment of IBS; however there are no significant adverse effects from psychological therapies for IBS. The mind-body or brain-gut interactions has been proposed for IBS, and is gaining increasing research attention. Hypnosis can improve mental well-being, and cognitive behavioural therapy can provide psychological coping strategies for dealing with distressing symptoms, as well as help suppress thoughts and behaviours that increase the symptoms of IBS. Although the evidence base for effectiveness of psychotherapy and hypnosis is weak and such therapies are in general not recommended, in treatment-resistant cases where pharmacological therapies over a period of at least 12 months have failed to give relief, NICE clinical guidelines recommend that consideration should be given to psychological treatment strategies such as cognitive behavioural therapy CBT, hypnotherapy and/or psychological therapy. Reducing stress may reduce the frequency and severity of IBS symptoms. Techniques that may be helpful include: * Relaxation techniques such as meditation * Physical activities such as yoga or tai chi * Regular exercise such as swimming, walking, or running Vagus nerve stimulation Vagus nerve stimulation has anti-inflammatory effects and its potential for the treatment of IBS is actively researched. Alternative medicine A meta-analysis found no benefits of acupuncture relative to placebo for IBS symptom severity or IBS-related quality of life. Probiotics Probiotics can be beneficial in the treatment of IBS; taking 10 billion to 100 billion beneficial bacteria per day is recommended for beneficial results. However, further research is needed on individual strains of beneficial bacteria for more refined recommendations. Probiotics have positive effects such as enhancing the intestinal mucosal barrier, providing a physical barrier, bacteriocin production (resulting in reduced numbers of pathogenic and gas-producing bacteria), reducing intestinal permeability and bacterial translocation, and regulating the immune system both locally and systemically among other beneficial effects. Probiotics may also have positive effects on the gut-brain axis by their positive effects countering the effects of stress on gut immunity and gut function. A number of probiotics have been found to be effective, including Lactobacillus plantarum, and Bifidobacteria infantis; but one review found only Bifidobacteria infantis showed efficacy. B. infantis may have effects beyond the gut via it causing a reduction of proinflammatory cytokine activity and elevation of blood tryptophan levels, which may cause
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