Is Irritable Bowel Syndrome (IBS) curable?

Irritable Bowel Syndrome (IBS) Is Not Curable But Can Be Effectively Managed

IBS is not curable, but symptoms can be substantially improved through appropriate management strategies focused on improving quality of life. 1

Understanding IBS

IBS is characterized by:

• A chronic disorder with recurrent, fluctuating symptoms 1
• A benign prognosis with a relapsing/remitting course 1
• A disorder of gut-brain interaction involving a sensitive or hyperactive gut 1
• Symptoms that can be triggered by stress, intercurrent illnesses, medications, and often the act of eating 1

Prognosis

• Once diagnosed, the chance of developing serious organic disease is extremely low 1
• Long-term studies show very few initial misdiagnoses or development of new significant diagnoses over 5-year follow-up periods 1
• However, the prognosis for complete symptom resolution is less favorable:
  • Approximately 30% of patients remain symptomatic at 5 years 1
  • Only about 5% become completely symptom-free according to Danish follow-up studies 1
  • Symptoms often vary in both severity and quality over time 1

Management Approach

Patient Education and Expectations

• Clear explanation of IBS as a disorder of gut-brain interaction is essential 1
• Patients should understand that cure is unlikely, but substantial improvement in symptoms, social functioning, and quality of life is achievable 1
• Explaining the brain-gut axis and how it is impacted by diet, stress, and emotional responses helps improve patient understanding and acceptance 1

Dietary Management

• Balanced diet with adequate fiber intake is recommended 1
• Dietary modifications based on predominant symptoms:
  • Increase or decrease fiber for constipation or diarrhea, respectively 1
  • Identify and reduce excessive intake of lactose, fructose, sorbitol, caffeine, or alcohol in those with diarrhea 1
  • Consider low FODMAP diet for global gastrointestinal symptoms, particularly bloating and abdominal pain 1

Pharmacological Treatment

Treatment is directed toward predominant symptoms:

• For abdominal pain:

  • First-line: Antispasmodics (including peppermint oil) 1
  • Second-line: Neuromodulators such as tricyclic antidepressants (e.g., amitriptyline) 1

• For diarrhea:

  • First-line: Anti-diarrheals such as loperamide 1
  • Second-line: Alosetron, ramosetron, rifaximin, or eluxadoline where available 1

• For constipation:

  • First-line: Osmotic laxatives (polyethylene glycol) and stimulant laxatives 1
  • Second-line: Secretagogues such as linaclotide or plecanatide 1

Psychological Approaches

• Psychological therapies are effective and should be considered early in treatment 1
• Options include:
  • Cognitive behavioral therapy (CBT) for psychological stress, negative emotions, and maladaptive cognitive processes 1
  • Gut-directed hypnotherapy for psychological stress and somatization 1
  • Mindfulness-based stress reduction for psychological stress and negative emotions 1

Lifestyle Modifications

• Regular exercise has shown benefits, particularly for constipation, with effects lasting up to 5 years 1
• Stress reduction techniques and regular time for defecation 1

Managing Expectations

• Complete symptom resolution is often not achievable, which must be made clear to patients 1
• The efficacy of all treatments for IBS is modest 1
• Drug treatment is not a panacea but one component of a multimodal approach 1

For Severe or Refractory IBS

• Review the diagnosis and consider further targeted investigation 1
• Manage with an integrated multidisciplinary approach 1
• Consider combination gut-brain neuromodulators (with vigilance for risks of serotonin syndrome) 1
• Avoid iatrogenic harms from opioid prescribing or unnecessary surgery 1

Common Pitfalls to Avoid

• Repeated, unnecessary investigations after establishing the diagnosis 1
• Expecting complete cure rather than symptom management 1
• Focusing solely on pharmacological treatment without addressing dietary, psychological, and lifestyle factors 1
• Prescribing opioids for pain management, which can lead to narcotic bowel syndrome 1