Irritable Bowel Syndrome: Treatment

There is no specific curative treatment. The therapeutic regimen should focus on relief of symptoms and reassuring the patient that a serious illness is not present. The following nutritional interventions and several medications have been used with varying success:

• Avoid possible food triggers, including lactose and artificial sweeteners (eg, sorbitol, saccharin, sucralose).
• Diarrheal symptoms can be treated with loperamide, cholestyramine, or other antidiarrheal medications.
• Constipation can be treated with fiber supplementation, osmotic laxatives, or prokinetic agents such as tegaserod.
• Abdominal pain may respond to antispasmodic agents (eg, mebeverine, dicyclomine, hyoscyamine) or tricyclic antidepressants (eg, amitriptyline).
• Recent studies suggest that antibiotic therapy (eg, rifaximin) can be useful in certain cases, especially in patients with bacterial overgrowth and diarrhea.

Psychological interventions should also be considered and are often necessary. Individuals with irritable bowel syndrome may have enhanced autonomic, neuroendocrine, attentional, and pain–modulatory responses to stimuli.¹ Brain imaging studies have demonstrated increased activation of the anterior mid–cingulate cortex that is linked to fear and psychological distress, and repression of descending opiate–mediated inhibitory pathways originating in the anterior cingulated gyrus of the limbic system.² Sympathetic activity is increased at rest.³

Affected individuals also have higher prevalence of psychological distress, major depression, anxiety, panic disorder and agoraphobia, somatization, and hypochondriasis, compared with other patients.^4,5 A recent review of randomized, controlled trials of psychological treatments found that 8 out of 12 treatments showed positive responses, mainly reductions in pain and diarrhea, with no effect on constipation.⁶ Treatment guidelines published by the American Gastroenterology Association suggest that cognitive–behavioral treatment, dynamic (interpersonal) psychotherapy, hypnosis, and stress management/relaxation are effective in reducing abdominal pain and diarrhea.⁷ Hypnotherapy has also been critically evaluated and found to be effective.^8,9