From the Guidelines
The most effective approach to managing mixed-type Irritable Bowel Syndrome (IBS) with both diarrhea and constipation involves a comprehensive strategy that includes dietary modifications, lifestyle changes, and medications, with a strong emphasis on soluble fiber and a low-FODMAP diet as first-line treatments, as recommended by the British Society of Gastroenterology guidelines 1 and supported by the AGA clinical practice update on the role of diet in IBS 1.
Key Components of Management
- Dietary modifications:
- Start with a low-FODMAP diet for 4-6 weeks, eliminating fermentable carbohydrates like certain fruits, dairy, wheat, and artificial sweeteners, followed by systematic reintroduction to identify personal triggers, as outlined in the AGA clinical practice update 1.
- Incorporate soluble fiber, such as ispaghula, at a low dose (3–4 g/day) and gradually increase to avoid bloating, as recommended by the British Society of Gastroenterology guidelines 1.
- Lifestyle changes:
- Regular physical activity (30 minutes daily) to help regulate bowel movements and reduce symptoms.
- Stress management techniques such as meditation or yoga to address the gut-brain connection.
- Adequate hydration to prevent constipation and reduce symptom severity.
Medication Options
- For overall symptoms: peppermint oil capsules (0.2-0.4 ml three times daily) can help alleviate symptoms.
- For constipation phases: osmotic laxatives like polyethylene glycol (17 grams daily) may help regulate bowel movements.
- For acute diarrhea episodes: loperamide (2-4 mg as needed, maximum 16 mg daily) can provide relief, as suggested by the Rome Foundation working team report on post-infection IBS 1.
- For persistent symptoms: consider low-dose tricyclic antidepressants like amitriptyline (10-25 mg at bedtime) or the gut-specific antibiotic rifaximin (550 mg three times daily for 14 days), as recommended by the Rome Foundation working team report on post-infection IBS 1.
Implementation and Monitoring
- Patients should be motivated to make dietary changes and have insight into their meal-related gastrointestinal symptoms, as emphasized by the AGA clinical practice update 1.
- Referral to a registered dietitian nutritionist (RDN) is recommended for personalized dietary advice and implementation, as suggested by the AGA clinical practice update 1.
- Regular follow-up and monitoring of symptoms are crucial to adjust the treatment plan as needed and ensure the best possible outcomes for patients with mixed-type IBS.
From the Research
Management of Mixed-Type Irritable Bowel Syndrome (IBS)
- Mixed-type IBS is characterized by both diarrhea and constipation, making it challenging to manage 2.
- A comprehensive approach to managing mixed-type IBS includes dietary interventions, probiotics, and fibers, which have shown efficacy in treating IBS symptoms 3, 4, 5, 6.
Dietary Interventions
- A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols is commonly recommended for IBS patients and has the most evidence for efficacy 4.
- This diet consists of three phases: restriction, reintroduction, and personalization, and patients should be aware of these phases when following this diet 4.
Fiber Supplementation
- Soluble fiber, such as psyllium, has been shown to be effective in improving IBS symptoms, particularly in patients with mixed-type IBS 5, 6.
- Fiber supplementation can help increase fecal mass, reduce symptoms of abdominal pain and bloating, and improve overall symptoms in patients with IBS 5, 6.
Behavioral Therapies
- Behavioral interventions, such as gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy, can be effective in modifying interactions between the gut and the brain and reducing IBS symptoms 4.
- These therapies can help patients manage stress and cognitive factors that trigger IBS symptoms 4.
Integrated Care Model
- An integrated care model that includes dietary modifications, behavioral interventions, and medications can offer the greatest likelihood of success in managing patients with mixed-type IBS 4.
- This approach recognizes the complexity of IBS and the need for a comprehensive treatment plan that addresses the physical, emotional, and psychological aspects of the condition 4.