IBS-D
(Irritable Bowel Syndrome with Diarrhea)

  • Medical Author:
    John P. Cunha, DO, FACOEP

    John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.

  • Medical Editor: Bhupinder S. Anand, MBBS, MD, DPHIL (OXON)
    Bhupinder S. Anand, MBBS, MD, DPHIL (OXON)

    Bhupinder S. Anand, MBBS, MD, DPHIL (OXON)

    Dr. Anand received MBBS degree from Medical College Amritsar, University of Punjab. He completed his Internal Medicine residency at the Postgraduate Institute of medical Education and Research, Chandigarh, India. He was trained in the field of Gastroenterology and obtained the DPhil degree. Dr. Anand is board-certified in Internal Medicine and Gastroenterology.

  • Medical Reviewer: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

Irritable Bowel Syndrome (IBS) Facts

Facts and definition of IBS-D

  • Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder.
  • Symptoms of IBS include:
  • 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.
  • The most common symptoms of the disorder includes:
  • 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.
    • Home remedies for include avoiding certain foods that "trigger" or worsen diarrhea, bloating and gas, such as foods high in FODMAPs, such as:
    • Cruciferous vegetables (for example, cauliflower, wasabi, kale, and broccoli)
    • Legumes (for example, black beans, edamame, soy nuts, and fava beans)
    • Dairy products
    • Wheats and grains
  • Other home remedies to relieve symptoms the condition include adding fiber to the diet, drinking plenty of water, avoiding soda, eating smaller meals, and eating more low fat and high carbohydrate foods.
  • There is currently no known cure for IBS. Medical treatment for irritable bowel syndrome includes antispasmodic medicines, antidiarrheal medicines, antidepressants, laxatives, and other drugs.
  • It is a chronic (long-term) disease, and symptoms usually recur.
  • It also has been called spastic colon, functional bowel disease, and mucous colitis, although IBS is not a true "colitis." The term colitis refers to a different group of diseases such as ulcerative colitis, Crohn's disease, microscopic colitis, and ischemic colitis.

What are the risk factors for IBS-D?

Risk factors for IBS include:

Anxiety or depression may accompany the syndrome, though these have not been found to be a direct cause of it.

What causes IBS-D?

  • IBS 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 occurs in 5% to 20% of children.
  • IBS 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, but so far a hereditary link has not been found.
  • Symptoms of the syndrome may worsen during periods of stress or during menstruation, but these factors are unlikely to be the cause that leads to the development of IBS.

Quick GuideIBS - Irritable Bowel Syndrome: Symptoms, Diet, Treatment

IBS - Irritable Bowel Syndrome: Symptoms, Diet, Treatment

IBS-D (Irritable Bowel Syndrome with Diarrhea) Triggers

IBS-D or irritable bowel syndrome with diarrhea triggers may include:

  • Fatty foods, for example, fatty meats and fatty dairy products
  • Foods that contain high levels of fructose or sorbitol (often found in chewing gum)
  • Fried foods
  • Broccoli, onions, cabbage and large helpings of beans

What are the symptoms of irritable bowel syndrome including IBS-D?

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 are 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 completely 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 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):

When should you seek medical care if you think you have IBS-D?

If a person has any of the symptoms of IBS as discussed previously, or if a person with known IBS 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.

Is there a test to diagnose IBS-D?

IBS can be difficult to diagnosis. 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

There are two relatively new blood tests that may help diagnose irritable bowel syndrome with diarrhea (IBS-D) and irritable bowel syndrome with diarrhea and constipation (irritable bowel syndrome mixed 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 bacterium. The overgrowth of these bacteria in the gut may trigger an immune attack on an individual’s own intestinal tissues (autoimmunity) with the ensuing inflammation and damage to the tissues, which cause signs and symptoms of IBS.

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 the 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, it is highly likely that the patient 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 test, costing around $500 to over $1,000.

What medications treat IBS-D?

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

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

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

Is there a specific diet for IBS-D?

Diet and lifestyle changes are important in decreasing the frequency and severity of the symptoms of the syndrome.

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:
  • Some vegetables (cauliflower, broccoli, cabbage, Brussels sprouts) and legumes (beans) may worsen bloating and gassiness and should be avoided.
  • A high fiber diet 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 breads may help (unless you have celiac disease).
  • Probiotic supplements such as lactobacillus acidophilus or prebiotics may help alleviate IBS 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.

What foods should you avoid if you have IBS-D or IBS-C?

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 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.

What home remedies and diet changes treat or soothe IBS-D symptoms?

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:

  • 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 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 breads may help IBS symptoms (unless you have celiac disease).

What other lifestyle changes help soothe IBS-D symptoms?

In addition to dietary changes, there are some healthy habits that may also help reduce IBS 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 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

What new medications are being developed or are in clinical trials to treat IBS-D?

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

Quick GuideIBS - Irritable Bowel Syndrome: Symptoms, Diet, Treatment

IBS - Irritable Bowel Syndrome: Symptoms, Diet, Treatment

What are the complications of IBS-D?

IBS has 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 the pain, and can impact a person's daily life.

What medications are reserved for people that do not improve with standard IBS-D drugs?

The following medications are typically reserved for patients with symptoms that do not improve with the previously mentioned 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 in order 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 has not been sufficiently studied in men; therefore, the FDA has not approved the drug for 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 produce softer and more frequent bowel movements in people who have chronic idiopathic constipation.
  • Tegaserod (Zelnorm) was a medication used to treat IBS but was removed from the market in 2007 due to increased risk of heart attack, stroke, and ischemic colitis.

What is the outlook for a person with IBS-D?

Because irritable bowel syndrome 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. 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.

Can IBS-D be prevented?

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.

Which specialties of doctors treats IBS-D?

Irritable bowel syndrome may initially be diagnosed by your primary care provider 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.

REFERENCES:

Camilleri, M. "Current and future pharmacological treatments for diarrhea-predominant irritable bowel syndrome." Expert Opinion on Pharmacotherapy; (2013);14 (9), 1151-1160.

International Foundation for Functional Gastrointestinal Disorders. "IBS Diet: Cramping and Diarrhea." Updated: Jun 14, 2016.
<http://www.aboutibs.org/ibs-diet/cramping-and-diarrhea.html>

International Foundation for Functional Gastrointestinal Disorders. "Newer IBS Medications." Updated May 09, 2016.
<http://www.aboutibs.org/medications/newer-ibs-medications.html>

Novak, K. A Serologic Test for Irritable Bowel Syndrome and Other News from ACG. Gastroenterology. Oct 21, 2013.

Pimentel, M., et al. Development and Validation of a Biomarker for Diarrhea-Predominant Irritable Bowel Syndrome in Human Subjects. Published: May 13, 2015.

Rezaie, A., et al. Assessment of Anti-vinculin and Anti-cytolethal Distending Toxin B Antibodies in Subtypes of Irritable Bowel Syndrome. Dig Dis Sci. 2017 Jun;62(6):1480-1485.

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Reviewed on 9/22/2017
References
REFERENCES:

Camilleri, M. "Current and future pharmacological treatments for diarrhea-predominant irritable bowel syndrome." Expert Opinion on Pharmacotherapy; (2013);14 (9), 1151-1160.

International Foundation for Functional Gastrointestinal Disorders. "IBS Diet: Cramping and Diarrhea." Updated: Jun 14, 2016.
<http://www.aboutibs.org/ibs-diet/cramping-and-diarrhea.html>

International Foundation for Functional Gastrointestinal Disorders. "Newer IBS Medications." Updated May 09, 2016.
<http://www.aboutibs.org/medications/newer-ibs-medications.html>

Novak, K. A Serologic Test for Irritable Bowel Syndrome and Other News from ACG. Gastroenterology. Oct 21, 2013.

Pimentel, M., et al. Development and Validation of a Biomarker for Diarrhea-Predominant Irritable Bowel Syndrome in Human Subjects. Published: May 13, 2015.

Rezaie, A., et al. Assessment of Anti-vinculin and Anti-cytolethal Distending Toxin B Antibodies in Subtypes of Irritable Bowel Syndrome. Dig Dis Sci. 2017 Jun;62(6):1480-1485.

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