Irritable Bowel

Syndrome
National Digestive Diseases Information Clearinghouse

What is irritable bowel IBS is often classified into four subtypes

based on a person’s usual stool consistency.
syndrome (IBS)? These subtypes are important because they
Irritable bowel syndrome is a functional affect the types of treatment that are most
gastrointestinal (GI) disorder, meaning likely to improve the person’s symptoms.
symptoms are caused by changes in how the The four subtypes of IBS are
GI tract works. People with a functional GI
disorder have frequent symptoms; however, • IBS with constipation (IBS-C)
the GI tract does not become damaged. IBS –– hard or lumpy stools at least
is a group of symptoms that occur together, 25 percent of the time
not a disease. In the past, IBS was called –– loose or watery stools less than
colitis, mucous colitis, spastic colon, nervous 25 percent of the time
colon, and spastic bowel. The name was
changed to reflect the understanding that • IBS with diarrhea (IBS-D)
the disorder has both physical and mental –– loose or watery stools at least
causes and is not a product of a person’s 25 percent of the time
imagination.
–– hard or lumpy stools less than
IBS is diagnosed when a person has had 25 percent of the time
abdominal pain or discomfort at least three
• Mixed IBS (IBS-M)
times a month for the last 3 months without
other disease or injury that could explain –– hard or lumpy stools at least
the pain. The pain or discomfort of IBS 25 percent of the time
may occur with a change in stool frequency –– loose or watery stools at least
or consistency or be relieved by a bowel 25 percent of the time
movement.
• Unsubtyped IBS (IBS-U)
–– hard or lumpy stools less than
25 percent of the time
–– loose or watery stools less than
25 percent of the time
What is the GI tract?
The GI tract is a series of hollow organs
joined in a long, twisting tube from the
mouth to the anus—the opening through Mouth
Esophagus
which stool leaves the body. Food is digested
by the movement of muscles in the GI tract,
along with the release of hormones and Stomach
enzymes. Organs that make up the GI tract
are the mouth, esophagus, stomach, small
intestine, large intestine—which includes the
appendix, cecum, colon, and rectum—and
anus. The intestines are sometimes called
the bowel. The last part of the GI tract—
called the lower GI tract—consists of the
Small
large intestine and anus. intestine
The large intestine absorbs water and any Large
remaining nutrients from partially digested intestine
food passed from the small intestine. The Appendix
large intestine then changes waste from
Rectum Anus
liquid to a solid matter called stool. Stool
passes from the colon to the rectum. The
rectum is located between the last part of The organs of the GI tract
the colon—called the sigmoid colon—and
the anus. The rectum stores stool prior
to a bowel movement. During a bowel
movement, stool moves from the rectum to
the anus.

2   Irritable Bowel Syndrome

How common is IBS and • constipation—having fewer than three
bowel movements a week. During a
who is affected? bowel movement, stools can be hard,
Studies estimate IBS affects 3 to 20 percent dry, and small, making them difficult to
of the adult population, with most studies pass. Some people find it painful and
ranging from 10 to 15 percent.1 However, often have to strain to have a bowel
only 5 to 7 percent of the adult population movement.
has been diagnosed with the condition.2 IBS
affects about twice as many women as men • feeling that a bowel movement is
and is most often found in people younger incomplete.
than age 45.1 • passing mucus—a clear liquid made by
the intestines that coats and protects
What are the symptoms tissues in the GI tract.
of IBS? • abdominal bloating.
The most common symptoms of IBS are Symptoms may often occur after eating
abdominal pain or discomfort, often reported a meal. To meet the definition of IBS,
as cramping, along with changes in bowel symptoms must occur at least three times a
habits. To meet the definition of IBS, the month.
pain or discomfort will be associated with at
least two of the following three symptoms: What causes IBS?
• bowel movements that occur more or The causes of IBS are not well understood.
less often than usual Researchers believe a combination of
• stool that appears less solid and more physical and mental health problems can
watery, or harder and more lumpy, than lead to IBS.
usual
Brain-Gut Signal Problems
• bowel movements that improve the Signals between the brain and nerves of the
discomfort small and large intestines, also called the gut,
Other symptoms of IBS may include control how the intestines work. Problems
with brain-gut signals may cause IBS
• diarrhea—having loose, watery stools symptoms, such as changes in bowel habits
three or more times a day and feeling and pain or discomfort.
urgency to have a bowel movement.
GI Motor Problems
Normal motility, or movement, may not be
present in the colon of a person who has IBS.
Slow motility can lead to constipation and
fast motility can lead to diarrhea. Spasms,
or sudden, strong muscle contractions that
1Grundmann O, Yoon SL. Irritable bowel syndrome: come and go, can cause abdominal pain.
epidemiology, diagnosis, and treatment: an update for Some people with IBS also experience
health-care practitioners. Journal of Gastroenterology
and Hepatology. 2010;25:691–699. hyperreactivity—a dramatic increase in
bowel contractions in response to stress or
2Irritable bowel syndrome. American College of
eating.
Gastroenterology website. www.patients.gi.org/topics/
irritable-bowel-syndrome. Accessed May 27, 2014.

3 Irritable Bowel Syndrome

Hypersensitivity IBS, and some studies have shown antibiotics
People with IBS have a lower pain threshold to be effective in treating IBS. However,
for bowel stretching caused by gas or stool more research is needed to show a link
compared with people who do not have IBS. between small intestinal bacterial overgrowth
The brain may process pain signals from the and IBS.
bowel differently in people with IBS. Body Chemicals
Mental Health Problems People with IBS have altered levels of
Mental health, or psychological, problems neurotransmitters—chemicals in the
such as panic disorder, anxiety, depression, body that transmit nerve signals—and GI
and post-traumatic stress disorder are hormones, though the role these chemicals
common in people with IBS. The link play in developing IBS is unclear. Younger
between these disorders and development of women with IBS often have more symptoms
IBS is unclear. GI disorders, including IBS, during their menstrual periods. Post-
are often found in people who have reported menopausal women have fewer symptoms
past physical or sexual abuse. Researchers compared with women who are still
believe people who have been abused tend to menstruating. These findings suggest that
express psychological stress through physical reproductive hormones can worsen IBS
symptoms. problems.

Bacterial Gastroenteritis Genetics

Some people who have bacterial Whether IBS has a genetic cause, meaning
gastroenteritis—an infection or irritation it runs in families, is unclear. Studies have
of the stomach and intestines caused by shown IBS is more common in people with
bacteria—develop IBS. Researchers do family members who have a history of GI
not know why gastroenteritis leads to IBS problems. However, the cause could be
in some people and not others, though environmental or the result of heightened
abnormalities of the GI tract lining and awareness of GI symptoms.
psychological problems may be factors. Food Sensitivity
Small Intestinal Bacterial Many people with IBS report that symptoms
Overgrowth are triggered by foods rich in carbohydrates,
spicy or fatty foods, coffee, and alcohol.
Normally, few bacteria live in the small However, people with food sensitivity
intestine. Small intestinal bacterial typically do not have clinical signs of food
overgrowth is an increase in the number or allergy. Researchers have proposed that
a change in the type of bacteria in the small symptoms may result from poor absorption
intestine. These bacteria can produce extra of sugars or bile acids, which help break
gas and may also cause diarrhea and weight down fats and get rid of wastes in the body.
loss. Some researchers believe that small
intestinal bacterial overgrowth may lead to

4   Irritable Bowel Syndrome

How is IBS diagnosed? Additional diagnostic tests may include
a stool test, lower GI series, and flexible
To diagnose IBS, a health care provider will
sigmoidoscopy or colonoscopy. Colonoscopy
conduct a physical exam and take a complete
may also be recommended for people who
medical history. The medical history will
are older than age 50 to screen for colon
include questions about symptoms, family
cancer.
history of GI disorders, recent infections,
medications, and stressful events related to A stool test is the analysis of a sample of
the onset of symptoms. An IBS diagnosis stool. The health care provider will give the
requires that symptoms started at least person a container for catching and storing
6 months prior and occurred at least three the stool. The sample is returned to the
times a month for the previous 3 months. health care provider or a commercial facility
Further testing is not usually needed, though and sent to a lab for analysis. The health
the health care provider may perform a care provider may also do a rectal exam,
blood test to screen for other problems. sometimes during the physical exam, to
Additional diagnostic tests may be needed check for blood in the stool. Stool tests can
based on the results of the screening blood show the presence of parasites or blood.
test and for people who also have signs such
as A lower GI series is an x ray that is used
to look at the large intestine. The test is
• fever performed at a hospital or an outpatient
• rectal bleeding center by an x-ray technician, and the
images are interpreted by a radiologist—a
• weight loss doctor who specializes in medical imaging.
• anemia—too few red blood cells in the Anesthesia is not needed. The health
body, which prevents the body from care provider may give written bowel prep
getting enough oxygen instructions to follow at home before the
test. The person may be asked to follow a
• family history of colon cancer clear liquid diet for 1 to 3 days before the
• family history of inflammatory bowel procedure. A laxative or an enema may be
disease—long-lasting disorders that used before the test. A laxative is medication
cause irritation and ulcers, or sores, in that loosens stool and increases bowel
the GI tract movements. An enema involves flushing
water or laxative into the anus using a special
• family history of celiac disease—an squirt bottle.
abnormal immune reaction to gluten, a
protein found in wheat, rye, and barley,
that damages the lining of the small
intestine and prevents absorption of
nutrients

5   Irritable Bowel Syndrome

For the test, the person will lie on a table In most cases, light anesthesia and possibly
while the radiologist inserts a flexible tube pain medication help people relax during
into the person’s anus. The large intestine colonoscopy. For either test, the person will
is filled with barium, making signs of lie on a table while the gastroenterologist
underlying problems show up more clearly inserts a flexible tube into the anus. A small
on x rays. camera on the tube sends a video image of
the intestinal lining to a computer screen.
For several days, traces of barium in the
The tests can show signs of problems in the
large intestine cause stools to be white or
lower GI tract.
light colored. Enemas and frequent bowel
movements may cause anal soreness. A The gastroenterologist may also perform
health care provider will provide specific a biopsy, a procedure that involves taking
instructions about eating and drinking after a piece of intestinal lining for examination
the test. with a microscope. The person will not feel
the biopsy. A pathologist—a doctor who
Flexible sigmoidoscopy and colonoscopy
specializes in diagnosing diseases—examines
are similar, although colonoscopy is used
the tissue in a lab.
to view the rectum and entire colon, while
flexible sigmoidoscopy is used to view just Cramping or bloating may occur during the
the rectum and lower colon. These tests first hour after either test. Driving is not
are performed at a hospital or an outpatient permitted for 24 hours after a colonoscopy to
center by a gastroenterologist—a doctor allow the sedative time to wear off. Before
who specializes in digestive diseases. Before the appointment, a person should make
either test, a health care provider will give plans for a ride home. Full recovery is
written bowel prep instructions to follow at expected by the next day.
home. The person may be asked to follow a
clear liquid diet for 1 to 3 days before either How is IBS treated?
test. The night before either test, the person
may need to take a laxative or one or more Though IBS does not have a cure,
enemas. One or more enemas may also the symptoms can be treated with a
be required about 2 hours before a flexible combination of
sigmoidoscopy. • changes in eating, diet, and nutrition
• medications
• probiotics
• therapies for mental health problems

6   Irritable Bowel Syndrome

Eating, Diet, and Nutrition Medications
Large meals can cause cramping and A health care provider will select
diarrhea, so eating smaller meals more often, medications based on a person’s symptoms.
or eating smaller portions, may help IBS
• Fiber supplements may be
symptoms. Eating meals that are low in fat
recommended to relieve constipation
and high in carbohydrates, such as pasta,
when increasing dietary fiber is
rice, whole-grain breads and cereals, fruits,
ineffective.
and vegetables, may help.
• Laxatives may help constipation.
Certain foods and drinks may cause IBS
Laxatives work in different ways, and
symptoms in some people, such as
a health care provider can provide
• foods high in fat information about which type is best for
each person. Read more in Constipation
• some milk products
at www.digestive.niddk.nih.gov.
• drinks with alcohol or caffeine
• Loperamide is an antidiarrheal that has
• drinks with large amounts of artificial been found to reduce diarrhea in people
sweeteners, which are used in place of with IBS, though it does not reduce
sugar pain, bloating, or other symptoms.
Loperamide reduces stool frequency
• beans, cabbage, and other foods that
and improves stool consistency by
may cause gas
slowing the movement of stool through
People with IBS may want to limit or avoid the colon.
these foods. Keeping a food diary is a good
• Antispasmodics, such as hyoscine,
way to track which foods cause symptoms so
cimetropium, and pinaverium, help to
they can be excluded from or reduced in the
control colon muscle spasms and reduce
diet.
abdominal pain.
Dietary fiber may improve constipation
• Antidepressants, such as low doses of
symptoms in people with IBS, although it
tricyclic antidepressants (TCAs) and
may not help with reducing pain. Fiber
selective serotonin reuptake inhibitors
softens stool so it moves smoothly through
(SSRIs), can help relieve IBS symptoms,
the colon. Adults are advised to consume
including abdominal pain. In theory,
21 to 38 grams of fiber a day.3 Fiber may
TCAs should be better for people with
cause gas and trigger symptoms in some
IBS-D and SSRIs should be better for
people with IBS. Increasing fiber intake
people with IBS-C due to the effect
slowly, by 2 to 3 grams a day, may help
on colon transit, although this theory
reduce the risk of increased gas and bloating.
has not been confirmed in clinical
studies. TCAs work in people with
IBS by reducing sensitivity to pain in
the GI tract as well as normalizing GI
motility and secretion.
3Dietary reference intakes: recommended dietary

allowances and adequate intakes, total water and

macronutrients. In: Ross AC, Taylor CL, Yaktine
AL, Del Valle HB, eds. Dietary Reference Intakes
for Calcium and Vitamin D. Washington, D.C.: The
National Academies Press; 2011: 1110.

7   Irritable Bowel Syndrome

 • Lubiprostone (Amitiza) is prescribed and safe care, people should discuss their
for people who have IBS-C. The use of complementary and alternative
medication has been found to improve medical practices, including their use of
abdominal pain or discomfort, stool dietary supplements and probiotics, with
consistency, straining, and constipation their health care provider. Read more at
severity. www.nccam.nih.gov/health/probiotics.
• Linaclotide (Linzess) is also prescribed Therapies for Mental Health
for people who have IBS-C. Linzess has
been found to relieve abdominal pain
Problems
and increase the frequency of bowel The following therapies can help improve
movements. IBS symptoms due to mental health
problems:
The antibiotic rifaximin can reduce
abdominal bloating by treating small • Talk therapy may reduce stress and
intestinal bacterial overgrowth; however, improve IBS symptoms. Two types
scientists are still debating the use of of talk therapy used to treat IBS are
antibiotics to treat IBS and more research is cognitive behavioral therapy and
needed. psychodynamic, or interpersonal,
therapy. Cognitive behavioral therapy
Probiotics focuses on a person’s thoughts and
Probiotics are live microorganisms, actions. Psychodynamic therapy focuses
usually bacteria, that are similar to on how emotions affect IBS symptoms.
microorganisms normally found in This type of therapy often involves
the GI tract. Studies have found that relaxation and stress management
when taken in large enough amounts, techniques.
probiotics, specifically Bifidobacteria and • Hypnotherapy may help a person relax
certain probiotic combinations, improve the muscles in the colon.
symptoms of IBS. However, more research
is needed. Probiotics can be found in • Mindfulness training teaches people
dietary supplements, such as capsules, to focus their attention on sensations
tablets, and powders, and in some foods, occurring at the moment and avoid
such as yogurt. A health care provider can catastrophizing, or worrying about the
give information about the right kind and meaning of those sensations.
amount of probiotics to take to improve
IBS symptoms. To help ensure coordinated

8   Irritable Bowel Syndrome

What other conditions are • depression
associated with IBS? • anxiety
People with IBS often suffer from other • somatoform disorders—chronic pain
GI and non-GI conditions. GI conditions or other symptoms with no physical
such as gastroesophageal reflux disease cause that are thought to be due to
(GERD) and dyspepsia are more common psychological problems
in people with IBS than the general
population. GERD is a condition in How does stress affect IBS?
which stomach contents flow back up into
the esophagus—the organ that connects Stress can stimulate colon spasms in people
the mouth to the stomach—because the with IBS. The colon has many nerves that
muscle between the esophagus and the connect it to the brain. These nerves control
stomach is weak or relaxes when it should the normal contractions of the colon and
not. Dyspepsia, or indigestion, is upper cause abdominal discomfort at stressful
abdominal discomfort that often occurs times. In people with IBS, the colon can be
after eating. Dyspepsia may be accompanied overly responsive to even slight conflict or
by fullness, bloating, nausea, or other GI stress. Stress makes the mind more aware
symptoms. Read more in Gastroesophageal of the sensations that arise in the colon. IBS
Reflux (GER) and Gastroesophageal Reflux symptoms can also increase a person’s stress
Disease (GERD) in Adults and Indigestion at level. Some options for managing stress
www.digestive.niddk.nih.gov. include

Non-GI conditions often found in people • participating in stress reduction and

with IBS include relaxation therapies such as meditation
• getting counseling and support
• chronic fatigue syndrome—a disorder
that causes extreme fatigue, which is • taking part in regular exercise such as
tiredness that lasts a long time and walking or yoga
limits a person’s ability to do ordinary
• minimizing stressful life situations as
daily activities
much as possible
• chronic pelvic pain
• getting enough sleep
• temporomandibular joint disorders—
problems or symptoms of the chewing
muscles and joints that connect the
lower jaw to the skull

9 Irritable Bowel Syndrome

 Points to Remember –– passing mucus
• Irritable bowel syndrome (IBS) is –– abdominal bloating
a functional gastrointestinal (GI) • The causes of IBS are not well
disorder, meaning symptoms are understood. Researchers believe a
caused by changes in how the GI tract combination of physical and mental
works. People with a functional GI health problems can lead to IBS.
disorder have frequent symptoms;
• To diagnose IBS, a health care
however, the GI tract does not
provider will conduct a physical
become damaged.
exam and take a complete medical
• IBS is a group of symptoms that occur history. The medical history will
together, not a disease. include questions about symptoms,
• Studies estimate IBS affects 3 to family history of GI disorders,
20 percent of the adult population, recent infections, medications, and
with most studies ranging from stressful events related to the onset of
10 to 15 percent. However, only 5 to symptoms.
7 percent of the adult population has • Though IBS does not have a cure,
been diagnosed with the condition. the symptoms can be treated with a
• The most common symptoms of IBS combination of
are abdominal pain or discomfort, –– changes in eating, diet, and
often reported as cramping, along nutrition
with changes in bowel habits. Other –– medications
symptoms of IBS may include
–– probiotics
–– diarrhea –– therapies for mental health
–– constipation problems
–– feeling that a bowel movement is
incomplete

10   Irritable Bowel Syndrome

Hope through Research Acknowledgments
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research into many digestive disorders. Whitehead, Ph.D., University of North
Carolina Center for Functional GI and
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11   Irritable Bowel Syndrome

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