Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome

Irritable bowel syndrome (IBS) is a complex, functional gastrointestinal condition characterized by abdominal pain and alteration in bowel habits without an organic cause. One of the subcategories of this disorder is IBS with diarrhea (IBS-D). Clinically, patients who present with more than 3 months of abdominal pain or discomfort associated with an increase in stool frequency and/or loose stool form are defined as having IBS-D. This review addresses IBS-D, detailing the epidemiology, etiology and genetics, pathophysiology and pathogenesis, diagnosis, clinical manifestations and physical examination findings, differential diagnosis, treatment, emerging therapies, complications, and prognosis. Figures show potential mechanisms and pathophysiology of IBS, IBS-D suspected by clinical assessment and Rome III criteria, pharmacologic and nonpharmacologic treatment options, potential mechanisms of action of probiotics, and potential treatment modalities. Tables list the Rome criteria for IBS, alarm signs and symptoms suggestive of alternative diagnoses, IBS criteria, differential diagnosis of IBS-D, dietary advice options for IBS-D, and alternative and emerging therapies in IBS-D. This review contains 5 figures, 6 tables and 42 references KEYWORDS: IBS-D, eluxadoline, rifaximin, probiotics, bloating, antidepressants, bile acid malabsorption, microscopic colitis, celiac

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Irritable bowel syndrome

Oxford Textbook of Medicine ◽

10.1093/med/9780198746690.003.0308 ◽

2020 ◽

pp. 2951-2959

Author(s):

Adam D. Farmer ◽

Qasim Aziz

Keyword(s):

Irritable Bowel Syndrome ◽

Abdominal Pain ◽

Recurrent Abdominal Pain ◽

Bowel Habit ◽

Western World ◽

Older Individuals ◽

Butyl Bromide ◽

Rome Iii ◽

Fermentable Carbohydrates ◽

Irritable Bowel

Symptoms suggestive of disturbed lower gastrointestinal function without adequate explanation are very common in adults in the Western world, up to 15% of whom experience such symptoms at any one time, although most do not seek medical advice. The currently used terms are best viewed as an attempt to provide some clinically useful, rather than pathophysiologically accurate, categorization of patients and their symptoms based on disordered gut–brain interactions. Irritable bowel syndrome is defined according to the Rome III criteria as recurrent abdominal pain or discomfort associated with a change in bowel habit for at least 6 months, with symptoms experienced on at least 3 days of at least 3 months. Many subtypes are recognized. Routine haematological and biochemical screening is usually performed on the assumption that it will be normal. Features that raise the suspicion of organic disease and indicate a need for further investigation include the onset of symptoms in middle-aged or older individuals, weight loss, or blood in the stool. Management remains empirical: no single pharmacological agent or group of agents has ever been found to be consistently effective. The principal task of the physician is to provide explanation and reassurance (sometimes supplemented by psychological treatments), but particular symptoms are often treated as follows: (1) constipation—defecation may be eased by supplementary dietary fibre and poorly absorbed fermentable carbohydrates which increase faecal bulk and soften the stool; osmotic laxatives and enemas are used for the severely constipated patient, as well as more novel agents; (2) diarrhoea—attention to diet is often helpful, as are simple antidiarrhoeal agents; and (3) abdominal pain—antispasmodics (e.g. hyoscine butyl bromide) are frequently used, as are antidepressants.

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Some antispasmodic drugs for the irritable bowel syndrome

Drug and Therapeutics Bulletin ◽

10.1136/dtb.24.24.93 ◽

1986 ◽

Vol 24 (24) ◽

pp. 93-95

Keyword(s):

Irritable Bowel Syndrome ◽

Abdominal Pain ◽

Intestinal Disease ◽

Bowel Habit ◽

Dietary Advice ◽

Irritable Bowel

Irritable bowel syndrome (IBS) is commonly diagnosed when the typical symptoms of irregular bowel habit, abdominal pain and distension, and a feeling of incomplete defaecation are not associated with other gastro-intestinal disease. The management of the patient with IBS has been covered previously1 but if dietary advice, reassurance and simple psychotherapy have proved unhelpful the doctor may be under pressure to prescribe as symptoms are usually recurrent. We now review the evidence to support the use of some antispasmodic drugs.

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The role of diet in irritable bowel syndrome: implications for dietary advice

Journal of Internal Medicine ◽

10.1111/joim.12966 ◽

2019 ◽

Vol 286 (5) ◽

pp. 490-502 ◽

Cited By ~ 8

Author(s):

A. Rej ◽

I. Aziz ◽

H. Tornblom ◽

D. S. Sanders ◽

M. Simrén

Keyword(s):

Irritable Bowel Syndrome ◽

Dietary Advice ◽

Irritable Bowel

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Low fermentable oligo-di-mono-saccharides and polyols dietversusgeneral dietary advice in patients with diarrhea-predominant irritable bowel syndrome: A randomized controlled trial

Journal of Gastroenterology and Hepatology ◽

10.1111/jgh.14051 ◽

2018 ◽

Vol 33 (6) ◽

pp. 1192-1199 ◽

Cited By ~ 15

Author(s):

Mohammad Javad Zahedi ◽

Vahideh Behrouz ◽

Maryam Azimi

Keyword(s):

Randomized Controlled Trial ◽

Irritable Bowel Syndrome ◽

Controlled Trial ◽

Dietary Advice ◽

Randomized Controlled ◽

Irritable Bowel

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Efficacy of a low FODMAP diet in irritable bowel syndrome: systematic review and network meta-analysis

Gut ◽

10.1136/gutjnl-2021-325214 ◽

2021 ◽

pp. gutjnl-2021-325214

Author(s):

Christopher J. Black ◽

Heidi M. Staudacher ◽

Alexander C. Ford

Keyword(s):

Irritable Bowel Syndrome ◽

Abdominal Pain ◽

Meta Analysis ◽

Tertiary Care ◽

Bowel Habit ◽

Dietary Advice ◽

Abdominal Bloating ◽

Irritable Bowel ◽

Fodmap Diet ◽

The Impact

ObjectiveA diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) is recommended for irritable bowel syndrome (IBS), if general lifestyle and dietary advice fails. However, although the impact of a low FODMAP diet on individual IBS symptoms has been examined in some randomised controlled trials (RCTs), there has been no recent systematic assessment, and individual trials have studied numerous alternative or control interventions, meaning the best comparator is unclear. We performed a network meta-analysis addressing these uncertainties.DesignWe searched the medical literature through to 2 April 2021 to identify RCTs of a low FODMAP diet in IBS. Efficacy was judged using dichotomous assessment of improvement in global IBS symptoms or improvement in individual IBS symptoms, including abdominal pain, abdominal bloating or distension, and bowel habit. Data were pooled using a random effects model, with efficacy reported as pooled relative risks (RRs) with 95% CIs, and interventions ranked according to their P-score.ResultsWe identified 13 eligible RCTs (944 patients). Based on failure to achieve an improvement in global IBS symptoms, a low FODMAP diet ranked first vs habitual diet (RR of symptoms not improving=0.67; 95% CI 0.48 to 0.91, P-score=0.99), and was superior to all other interventions. Low FODMAP diet ranked first for abdominal pain severity, abdominal bloating or distension severity and bowel habit, although for the latter it was not superior to any other intervention. A low FODMAP diet was superior to British Dietetic Association (BDA)/National Institute for Health and Care Excellence (NICE) dietary advice for abdominal bloating or distension (RR=0.72; 95% CI 0.55 to 0.94). BDA/NICE dietary advice was not superior to any other intervention in any analysis.ConclusionIn a network analysis, low FODMAP diet ranked first for all endpoints studied. However, most trials were based in secondary or tertiary care and did not study effects of FODMAP reintroduction and personalisation on symptoms.

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