What Is Causing My Chronic Diarrhea, Gas, and Bloating?

A dear friend of mine has been suffering with abdominal discomfort for over a decade. She has undergone every study and procedure known to gastroenterology - including tests for infectious disease, autoimmune disorders, and allergies. She has had unremarkable colonoscopies, followed restrictive diets, and felt perpetual embarrassment regarding her ill-behaved intestines.

Although she still has no definitive diagnosis, the answer may be irritable bowel syndrome (IBS). An estimated 25-45 million people in the United States have IBS though many cases go undiagnosed. For those who are diagnosed it may take up to 6 or 7 years for a clinician to figure it out. The reason why it's hard to diagnose is that its course is so unpredictable (it comes and goes in severity, with no obvious pattern), and because embarrassment may cause people not to seek help.

But wait, it gets worse.

The truth is that doctors don't yet know what causes IBS for certain, and there is no reliable cure for it either. In fact, IBS is a general term for what might be several different underlying diseases, yet to be clarified by science and research.

What causes IBS?
We do have some theories, though. First of all, the intestines are stimulated to contract by a complex plexus of nerves. In some people, these nerves may be overactive or triggered by stress. It's not unheard of for people to lose control of their bowels when they are terrified. Imagine that a much smaller stimulus - say, stress at home or at work - could trigger a similar response in more delicate guts. IBS is known to be more common in people with anxiety, depression, or a history of sexual, physical, or emotional abuse.

Secondly, a lot has been learned over the last few years about the importance of gut bacteria. You've probably heard about "good bacteria" and "probiotics" and how important it is to consume foods like yogurt, kefir, or kambucha, especially after a course of antibiotics. Well, it's possible that people with IBS don't have the best bacterial micro-environment, resulting in excessive fermentation of food with gas production and bloating sensations.

Thirdly, some foods may trigger excessive bloating, constipation, diarrhea, and abdominal pain. This is not due to an allergic reaction, but simply an intolerance. Foods known to predispose to IBS symptoms include sugar, wheat, dairy, beans, cabbage, high fiber, artificial sweeteners, and fried foods. These foods are enthusiastically fermented by normal gut bacteria, but for patients with IBS, the action can be overwhelming.

So what can people do about IBS?
The first steps are to address the most common triggers: mental health and diet. If you have symptoms of IBS and know that there is a lot of stress in your life, or perhaps a history of anxiety or depression, start by treating the psychological condition(s). Some people are helped significantly by stress-reduction techniques such as meditation, progressive relaxation, or talk therapy. Others may benefit from medications.

The next step is to avoid foods that are known to make IBS worse. These foods include "high gas" foods such as: carbonated and alcoholic beverages, caffeine, raw fruit, and certain vegetables, like cabbage, broccoli and cauliflower. Some people are sensitive to gluten (without being allergic to it) which is found in wheat, barley, and rye. And others are sensitive to easily fermented carbohydrates. This is sometimes referred to as a low FODMAP (fermentable oligo-, di-, and monosaccharides and polyols) diet. FODMAPs are found in certain grains, vegetables, fruits and dairy products.

Finally, encouraging healthy bacterial colonies to develop may be as simple as taking probiotic tablets or drinking live culture fermented beverages (such as Kambucha). Yogurt may be a good idea, though the fact that dairy is forbidden on the IBS diet may give you pause. For some people, avoiding dairy may be more helpful than getting probiotics through yogurt.

The next level…
There are medications on the market that can help to speed up or slow down the transit time of food through the colon, depending on whether you have diarrhea-predominant or constipation-predominant IBS. Alosetron (Lotronex), and Eluxadoline (Viberzi) are approved for diarrhea-predominant IBS, and Lubiprostone (Amitiza) and Linaclotide (Linzess) are used in constipation-predominant IBS.

When all else fails…
Some studies suggest that slow release peppermint oil pills may help with IBS, and other studies support repopulating the gut flora with someone else's bacteria. This may sound off-putting (fecal transplantation?) but it makes some sense that good bacteria from a healthy gut could make a new happy home elsewhere.
In one small study, 70% of people with IBS symptoms that failed to respond to diet, medication, and mental health treatments, found relief or resolution after a fecal microbiota transplantation (FMT). More research would be helpful in clarifying exactly when this measure (harvesting and cleaning someone's stool sample and transplanting it through an enema to the IBS sufferer) is indicated.

And so, in the final analysis, it may be that the cure for years of intestinal misery (for my friend, or someone you know) is to simply receive a dose of someone else's crap.

I'm sure there's some deeper wisdom in there somewhere. I'd rather take the peppermint oil, though.

References
https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/symptoms-causes/syc-20360016
https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/diagnosis-treatment/drc-20360064
https://gi.org/media/press-releases-for-acg-annual-scientific-meeting/fmt-ibd-ibs/

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