How Can You Manage IBS-D? What Are The Foods To Avoid?

IBS-D is irritable bowel syndrome with diarrhea.

Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder. The cause of IBS currently is unknown. It is thought to result from a combination of abnormal gastrointestinal (GI) tract movements, increased awareness of bodily functions, and a disruption in the communication between the brain and the GI tract.

IBS-D is irritable bowel syndrome with diarrhea.

IBS is diagnosed by exclusion, which means a doctor considers other alternatives first, performing tests to rule out other medical problems. There are new blood tests that may help diagnose some forms of IBS.

IBS-D is not contagious, inherited, or cancerous. It occurs more often in women than in men, and the onset occurs before the age of 35 in about half of the cases. IBS-D occurs in 5% to 20% of children.

• IBS-D also has developed after episodes of gastroenteritis ("stomach flu").
• It has been suggested that the condition is caused by dietary allergies or food sensitivities, but this has not been proven.
• Genetics also is suggested as a potential cause of IBS-D, but so far, a hereditary link has not been found.

IBS-D symptoms may worsen during periods of stress or menstruation, but these factors are unlikely to be the cause that leads to the development of IBS-D.

Risk factors for IBS-D include:

• Abnormal (too fast or slow, or too strong) movements of the colon and small intestines
• Hypersensitivity to pain caused by gas or full bowels
• A viral or bacterial infection of the stomach and intestines (gastroenteritis)
• Small intestinal bacterial overgrowth (SIBO)
• Reproductive hormones or neurotransmitters may be off-balance in people with IBS.

Anxiety or depression may accompany the syndrome, though these are not a direct cause of it.

IBS-D is the presence of abdominal pain that is associated with constipation and diarrhea.

IBS affects each person differently. Some people have severe symptoms while others may be able to manage symptoms with only diet and lifestyle modification. The hallmark of IBS in adults and children is abdominal discomfort or pain.

The following signs and symptoms also are common:

• Abdominal cramping and pain that is relieved with bowel movements
• Alternating periods of diarrhea and constipation
  • Those who mostly have diarrhea as a symptom are considered to have IBS with diarrhea (IBS-D), characterized by sudden urges to have bowel movements, along with loose stools, frequent stools, abdominal pain and discomfort, gas, and the feeling of being unable to empty the bowels. In severe cases of IBS-D, patients may lose control of their bowels.
  • Those who mostly have constipation as a symptom are considered to have IBS with constipation (IBS-C), characterized by the passage of hard, lumpy stools, straining during bowel movements, and infrequent stools
• Change in the stool frequency or consistency
• Gassiness (flatulence)
• Passing mucus from the rectum
• Bloating
• Abdominal distension
• Loss of appetite

Though not a symptom of the condition, indigestion affects up to 70% of people with IBS.

The following are NOT signs and symptoms or characteristics of IBS (but should still be brought to the attention of a health care professional since they may be signs and symptoms of other conditions):

• Blood in stools or urine
• Black or tarry stools
• Vomiting (rare, though may occasionally accompany nausea)
• Pain or diarrhea that interrupts sleep
• Fever
• Weight loss

Irritable bowel syndrome may initially be diagnosed by your primary care providers, such as your family doctor, internist, or family medicine specialist. A gastroenterologist (a doctor who specializes in disorders of the digestive system) usually will provide further treatment. An emergency medicine specialist may be seen if you have an acute flare-up of symptoms of the condition.

If a person has any of the symptoms of IBS-D as discussed previously, or if a person with known IBS-D has unusual symptoms, a health care professional should be consulted. Go to a hospital emergency department if problems are severe and/or come on suddenly.

IBS-D can be difficult to diagnose. It is called a diagnosis of exclusion, which means a doctor considers many other alternatives first, performing tests to rule out other medical problems. Some of these tests may include laboratory studies, imaging studies (such as a CT scan or small intestinal X-rays), and endoscopy and/or colonoscopy. An endoscopy is a procedure in which a flexible tube with a tiny camera at one end is passed into the GI tract while the patient is under conscious sedation. A combination of history, physical examination, and selected tests are used to help diagnose irritable bowel syndrome.

IBS-D test

Two relatively new blood tests may help diagnose irritable bowel syndrome with diarrhea (IBS-D) and irritable bowel syndrome with diarrhea and constipation (irritable bowel syndrome mixed with IBS-M). These tests are for anti-CdtB and anti-vinculin antibodies that are thought to develop in some patients after an acute bout of stomach flu (gastroenteritis) caused by several different, common types of bacteria. The overgrowth of these bacteria in the gut may trigger an immune attack on an individual’s intestinal tissues (autoimmunity) with the ensuing inflammation and damage to the tissues, which cause signs and symptoms of IBS-D.

The IBS tests may help distinguish between irritable bowel syndrome and a different type of bowel inflammatory disease, which includes ulcerative colitis and Crohn’s disease, called inflammatory bowel disease or IBD. Irritable bowel syndrome and inflammatory bowel disease are two very different types of problems with the bowel and are not the same disease.

Both tests appear to be useful in diagnosing patients with irritable bowel syndrome with diarrhea IBS-D, but not IBS with constipation (IBS-C). The tests also appear to be specific, and if the antibodies are present, the patient likely has IBS-D or IBS-M. But the tests are insensitive, meaning if the antibodies are not present, the patient still may have IBS. Thus, the tests may be identifying only a subset of patients with IBS, those with post-infectious IBS. The tests have not undergone rigorous testing and have not yet been approved by the FDA. Both tests are expected to be expensive, costing around $500 to over $1,000.

Antispasmodic drugs

Antispasmodic medicines, such as dicyclomine (Bemote, Bentyl, Di-Spaz) and hyoscyamine (Levsin, Levbid, NuLev), are sometimes used to treat symptoms of irritable bowel syndrome. Antispasmodic medicines help slow the movements of the digestive tract and reduce the chance of spasms.

Antispasmodic drug side effects may include:

• Palpitations
• Constipation
• Difficulty urinating
• Dry mouth
• Blurred vision

Other treatment plans are available, depending on the symptoms and condition.

Antidiarrheal drugs

Antidiarrheal medicines, such as loperamide (Imodium), a kaolin/pectin preparation (Kaopectate), and diphenoxylate/atropine (Lomotil), are sometimes used when diarrhea is a major symptom of the syndrome. Do not take these on a long-term basis without first consulting a health care professional.

Antidiarrheal drug side effects may include:

• Dizziness
• Dry mouth
• Nausea
• Vomiting
• Abdominal pain

Antidepressants

Antidepressants may be very effective in smaller doses than those typically used to treat depression. Imipramine (Tofranil), amitriptyline (Endep), nortriptyline (Pamelor), and desipramine (Norpramin) are some commonly used medicines that may alleviate irritable bowel syndrome symptoms. Some other antidepressants are more commonly prescribed when depression and IBS coexist.

Antidepressant side effects may include:

• Insomnia
• Anxiety
• Nausea
• Vomiting
• Palpitations
• Dry mouth
• Constipation
• Rash
• Weight gain or loss

Peppermint Oil

A meta-analysis of multiple studies showed that peppermint oil can be an effective way to manage symptoms of IBS in some people. Peppermint oil (Mentha Piperita) is a naturally-occurring substance that contains contains L-menthol, a substance that blocks calcium channels in smooth muscle, leading to reduced spasms of the muscles in the gastrointestinal tract.  Peppermint oil is available in capsule form without a prescription.

Diet and lifestyle changes are important in decreasing the frequency and severity of the symptoms of IBS-D.

The first thing your doctor may suggest is to keep a food diary. This will help you figure out foods that trigger your symptoms.

• Limit foods that contain ingredients that can stimulate the intestines and cause diarrhea, such as:
  • Caffeine
  • Alcohol
  • Dairy products
  • Fatty foods
  • Foods high in sugar
  • Artificial sweeteners (sorbitol and xylitol)
• Some vegetables (cauliflower, broccoli, cabbage, Brussels sprouts) and legumes (beans) may worsen bloating and gassiness and should be avoided.
• A diet for IBS includes high fiber, which may lessen symptoms of constipation.
• Drink plenty of water, and avoid carbonated drinks such as soda, which may cause gas and discomfort.
• Eat smaller meals and eat slowly to help reduce cramping and diarrhea.
• Low-fat, high-carbohydrate meals such as pasta, rice, and whole-grain bread may help (unless you have celiac disease).
• Probiotic supplements such as lactobacillus acidophilus or prebiotics may help alleviate IBS-D or IBS-C symptoms including abdominal pain, bloating, and bowel movement irregularity.
• A diet low in FODMAPs (fermentable oligo-saccharides, di-saccharides, mono-saccharides, and polyols), a group of short-chain carbohydrates, may help relieve symptoms. Consult your health care professional for more information.

Whether you have IBS-D or IBS-C, there are foods to avoid that may trigger symptoms.

Certain foods may worsen bloating and gassiness. Foods to avoid with IBS include cruciferous vegetables and legumes, such as:

• Cabbage
• Cauliflower
• Radishes
• Horseradish
• Watercress
• Wasabi
• Brussels sprouts
• Bok choy
• Arugula
• Kale
• Broccoli
• Chinese cabbage
• Collard greens

Legumes also may worsen gassiness and bloating, for example:

• Black beans
• Black-eyed peas
• Chickpeas (garbanzo beans)
• Edamame
• Fava beans
• Lentils
• Lima beans
• Red kidney beans
• Soy nuts

Some foods may trigger symptoms of abdominal cramps and diarrhea, including:

• Fatty foods
• Fried foods
• Coffee
• Caffeine
• Alcohol
• Sorbitol (a sweetener found in many diet foods, candies, and gums)
• Fructose (found naturally in honey and some fruits, and also used as a sweetener)

Eating large meals also may trigger abdominal cramping and diarrhea.

Most people with the syndrome have symptoms only occasionally, and the following measures may treat or soothe symptoms during a flare.

Add fiber to the diet

Fiber theoretically expands the inside of the digestive tract, reducing the chance it will spasm as it transmits and digests food. Fiber also promotes regular bowel movements, which helps reduce constipation. Fiber should be added gradually, because it initially may worsen bloating and gassiness. If you have IBS-D, look for foods with more soluble fiber, the type that takes longer to digest (such as that found in oats, beans, barley, peas, apples, carrots, and citrus fruits).

Reduce stress and anxiety

Stress and anxiety may cause "flares." Health care professionals may offer specific advice on reducing stress. These tips may help reduce stress and problems associated with IBS-D:

• Eat regular balanced meals
• Reduce caffeine intake
• Exercise may help reduce stress
• Smoking may worsen symptoms of the syndrome, which is another good reason to quit

Other home remedies to soothe and lessen IBS-D symptoms include:

• Increase fiber in the diet
• Drink plenty of water
• Avoid soda, which may cause gas and abdominal discomfort
• Eat smaller meals to help lessen the incidence of cramping and diarrhea
• Low-fat and high-carbohydrate meals such as pasta, rice, and whole-grain bread may help IBS-D symptoms (unless you have celiac disease)

In addition to dietary changes, some healthy habits may also help reduce IBS-D symptoms.

• Maintain good physical fitness to improve bowel function and help reduce stress.
• Exercise regularly.
• Stop smoking for overall good health.
• Avoid coffee/caffeine and chewing gum.
• Reducing or eliminating alcohol consumption may help.
• Stress management can help prevent or ease IBS-D symptoms.
  • Use relaxation techniques: deep breathing, visualization, Yoga
  • Do things you find enjoyable: talk to friends, read, listen to music
  • Gut-directed hypnosis can reduce stress and anxiety
  • Biofeedback teaches you to recognize your body's responses to stress and you can learn to slow your heart rate and relax.
• Pain management techniques can improve tolerance to pain
• Cognitive-behavioral therapy or psychotherapy with trained counselors

New medications for IBS-D are also being developed or are in clinical trials. Those that are most promising include:

• Serotonin synthesis inhibitors may help reduce pain and improve stool consistency
• Ramosetron is similar to alosetron (Lotronex); this is reported to relieve symptoms with less constipation
• Spherical carbon adsorbent offers short-term relief from pain and bloating, but no improvement in stool consistency
• Benzodiazepine receptor modulator (dextofisopam): this has the potential to reduce colonic motility and gut sensitivity reactions in response to stress
• Peripheral k-agonist (asimadoline, a kappa-opioid agonist) is in clinical trials, and it shows reduced pain, urgency, and stool frequency

The following medications are typically reserved for patients with symptoms that do not improve with the previously mentioned IBS-D treatments:

• Alosetron (Lotronex) is a restricted drug approved only for short-term treatment of women with severe, chronic, diarrhea-predominant IBS (IBS-D) who have failed to respond to conventional IBS therapy. Fewer than 5% of people with irritable bowel syndrome have the severe form, and only a fraction of people with severe IBS have the diarrhea-predominant type. Alosetron was removed from the United States market but was reintroduced with new restrictions approved by the FDA in 2002. Physicians must be registered with the pharmaceutical manufacturer to prescribe the medication. Serious and unpredictable gastrointestinal side effects (including some that resulted in death) were reported in association with its use following its original approval. The safety and efficacy of alosetron have not been sufficiently studied in men; therefore, the FDA has not approved the drug for the treatment of IBS in men.
• Rifaximin (Xifaxan) is an antibiotic medication for IBS-D that works by reducing or altering gut bacteria, and it can improve symptoms of bloating and diarrhea after a 10- to 14-day course of treatment. Some patients require retreatment at higher doses for symptom relief.
• Eluxadoline (Viberzi) is another newer medication for IBS-D that helps reduce abdominal pain and improves stool consistency in adults.
• Linaclotide (Linzess) is a kind of drug that relieves constipation and pain for some adults with the syndrome. In drug trials, people with IBS-C had more frequent and better bowel movements and less abdominal pain after taking daily doses of Linzess. The drug often began working within the first few days of treatment.
• Lubiprostone (Amitiza) is a type of laxative used to treat severe IBS-C in women who are at least 18 years of age. It is a capsule taken orally, twice a day with food. It is used to relieve stomach pain, bloating, and straining; and to produce softer and more frequent bowel movements in people who have chronic idiopathic constipation.
• Tegaserod (Zelnorm) was removed from the market in 2007 due to cardiovascular risks. However, it was reintroduced in 2019 under specific restrictions (without significant cardiac risk factors) for women under 65 with IBS-C.

Because IBS-D is a chronic (long-term) disease, symptoms usually return from time to time. This may be influenced by factors such as stress, diet, or other environmental causes. No known treatment cures IBS-D. Multiple factors may play a role in aggravating the syndrome, so it is difficult to predict what triggers may make it worse in a particular person. Establishing a good relationship with a health care professional may help alleviate concerns over symptoms and allow rapid recognition of changing or worsening symptoms.

IBS-D has a few associated complications. It does not lead to rectal bleeding, colon cancer, or inflammatory bowel diseases including ulcerative colitis. Diarrhea and constipation may aggravate hemorrhoids in people who already have them. If a person eliminates too many foods from their diet, and the diet is too limited in nutrients that could cause health problems.

The effect on a person's quality of life is the biggest complication of IBS. Stress and anxiety can result from pain and can impact a person's daily life.

Follow the diet and lifestyle recommendations as outlined in this article, and as discussed with your health care professional. Avoiding triggers is the best way to prevent symptoms of IBS-D.

• How can I live with IBS-D? Living with IBS-D can be overwhelming at times, but some simple changes to your lifestyle and eating habits can help alleviate symptoms and reduce flare-ups. Consider planning and preparing for your day in advance, following a low-FODMAP diet to avoid triggers, and identifying known triggers that may aggravate your symptoms. It can also be helpful to schedule important events well ahead of your eating times and to build a strong support system to keep you motivated.
• What is an IBS-D flare-up like? An IBS-D flare-up is characterized by a worsening of existing symptoms and may include frequent bowel movements, loose or watery stools, abdominal pain or cramps that worsen after eating and relieve after a bowel movement, bloating, mucus in the stool, and the feeling of incomplete bowel evacuation.
• Are eggs OK for IBS-D? Eggs are low in FODMAPs and are considered one of the best foods to consume for individuals with IBS-D. They are rich in protein and various nutrients, with very few fermentable carbohydrates, which may help slow down bowel movements. However, it’s important to monitor whether eggs trigger your symptoms, as individual responses can vary.
• What is the root cause of IBS-D? The exact root cause of IBS-D is unknown. However, doctors believe that issues with brain-gut interaction may disrupt the body's normal mechanisms and cause IBS-D.