Symptom triggers

Many patients with IBS report that symptoms occur or worsen in response to specific triggers

IBS is a heterogeneous condition in which symptoms in individuals may be triggered and worsened by various emotional or physical factors, including1-5:

  • Diet
  • Stress
  • Sleep
  • Menstruation and pregnancy

In people with IBS, the interplay of some or all of these factors may lead to the hallmark symptoms of IBS, including abdominal pain, diarrhea, and constipation, and affect disease severity6,7

Diet

Certain foods are known to trigger or exacerbate IBS symptoms, such as abdominal pain, bloating, and changes in bowel habits8

Two out of three people with IBS consider their symptoms to be meal-related9

Percentage of IBS patients with GI symptoms upon ingestion of trigger foods5

Although several studies agree that symptoms can worsen in patients with IBS following food ingestion,10 diagnosis of food allergy in these patients is very low (1-3%)11

What foods should my patients with IBS avoid?9,12,13

Foods are capable of simultaneously triggering multiple symptoms and may have different mechanisms in which they elicit GI symptoms9

IBS symptoms are often reported upon ingestion of high-fat and high-sugar foods and dairy9

Fatty and fried foods have been shown to exacerbate bloating and abdominal distention, since lipids promote gas retention9

What about FODMAPs (fermentable oligo-, di-, and monosaccharides, and polyols)?

FODMAPs are known as IBS symptom triggers, although exact mechanisms are poorly understood8

These unabsorbed carbohydrates act as a substrate for bacterial fermentation and gas production in the distal small bowel and colon, triggering GI symptoms6,14

Poorly digested high FODMAP foods pass through the gut quickly in individuals with IBS, causing diarrhea when excess water is not reabsorbed in the large intestine15

Although there are conflicting reports regarding low FODMAP diets, short-term use may help determine food triggers through reintroduction of foods, with the help of an experienced healthcare professional15,16

Low FODMAP foods17
Fruits
Banana
Blueberries
Grapefruit
Grapes
Honeydew melon
Kiwifruit
Lemon
Lime
Orange
Raspberries
Strawberries
Vegetables
Carrot
Celery
Corn
Eggplant
Green beans
Lettuce
Pumpkin
Tomato
High FODMAP foods17
Fruits
Apple
Pear
Peach
Mango
Snap peas
Watermelon
Apricot
Cherries
Plum
Avocado

Others
Sweeteners
Honey
Cereal
Legumes
(beans of any kind)
Vegetables
Artichoke
Asparagus
Beets
Brussels sprouts
Broccoli
Cabbage
Garlic
Leeks
Onions
Cauliflower
Mushrooms

Dairy
Milk
Ice cream
Yogurt
Cheese

What about gluten?

Studies regarding the effect of gluten on GI symptoms in patients with IBS with non-celiac gluten sensitivity are controversial18,19

Effects attributed to gluten may be triggered by non-absorbable carbohydrates such as fructans and galactans present in wheat, rather than by gluten itself20

However, gluten-free diets have shown to be effective in some patients with IBS, suggesting that at least a subset of patients with IBS might benefit from a gluten-free or reduced-gluten diet15,21,22

Providing patients with a diary may help to identify potential symptom triggers

DOWNLOAD THE PATIENT DIARY
Stress

Up to 60% of patients with IBS indicate that stress is the factor that triggered first onset or exacerbation of symptoms23

Anxiety and stress in early life are linked to the development of IBS symptoms and play an ongoing role in sustaining fluctuating IBS symptoms via immune system regulation7

Stress has been linked to increased sympathetic nervous system responses, resulting in hypersensitivity, enhanced perception, and exaggeration of GI symptoms7,24

Patients with IBS experience exaggerated neuroendocrine responses and visceral perception during stress24,25

Enhanced perception may be due to altered central pain modulation circuits in various networks of the brain7,26

Therefore, efforts to reduce stress should be encouraged in patients with IBS2,3

Sleep

Disturbances in sleep can lead to exacerbated symptoms5

Quality of sleep has been shown to affect morning IBS symptoms5

People who have IBS may have altered sleep perception even when sleep is normal and experience additional symptoms27:

  • Diminished sleep quality
  • Increased daytime dysfunction
  • Exaggerated responses to physiological stimuli

Since sleep difficulties are common in patients with IBS, maintaining good sleep hygiene is important3,5

Menstrual cycle and pregnancy

Hormones including estrogen and progesterone, which may fluctuate during menstrual cycle phases and pregnancy, may affect IBS symptoms4,28

Women with IBS often report worsening of diarrhea, abdominal pain, and constipation during menstruation28,29

Constipation is one of the most common complaints of pregnant women generally, hence in women with IBS, especially close monitoring is recommended4,30

Learn more about IBS

References

  1. American Gastroenterological Association. IBS: A patient’s guide to living with irritable bowel syndrome. Available at: https://www.gastro.org/patient-center/IBS_Brochure_Online.pdf. Accessed March 2016.
  2. Qin HY et al. World J Gastroenterol 2014; 20: 14126-14131.
  3. International Foundation for Functional Gastrointestinal Disorders. Sleep and Irritable Bowel Syndrome. Available at: http://www.aboutibs.org/signs-and-symptoms-main/sleep-and-irritable-bowel-syndrome-2.html. Accessed July 2016.
  4. Mulak A, Tache Y. Gastroenterol Pol 2010; 17: 89-97.
  5. Goldsmith G, Levin JS. Dig Dis Sci 1993; 38: 1809-1814.
  6. El-Salhy M. World J Gastroenterol 2015; 21: 7621-7636.
  7. Mayer EA et al. Nat Rev Gastroenterol Hepatol 2015; 12: 592-605.
  8. De Giorgio R et al. Gut 2016; 65: 169-178.
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  10. Hayes PA et al. Gastroenterol Hepatol (N Y) 2014; 10: 164-174.
  11. Mansueto P et al. World J Gastroenterol 2015; 21: 7089-7109.
  12. Halland M, Saito YA. BMJ 2015; 350: h1622.
  13. Simrén M et al. Digestion 2001; 63: 108-115.
  14. Gibson PR, Shepherd SJ. Aliment Pharmacol Ther 2005; 21: 1399-1409.
  15. DeWeerdt S. Nature 2016; 533: S108-S109.
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  17. Gibson PR, Shepherd SJ. J Gastroenterol Hepatol 2010; 25: 252-258.
  18. Biesiekierski JR et al. Am J Gastroenterol 2011; 106: 508-514.
  19. Biesiekierski JR et al. Gastroenterology 2013; 145: 320-328.
  20. Gibson PR, Muir JG. Gastroenterology 2013; 145: 693.
  21. Rodrigo L et al. Arthritis Res Ther 2014; 16: 421.
  22. Vazquez-Roque MI et al. Gastroenterology 2013; 144: 903-911.
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  24. Dickhaus B et al. Am J Gastroenterol 2003; 98: 135-143.
  25. Posserud I et al. Gut 2004; 53: 1102-1108.
  26. Tillisch K, Mayer EA. CNS Spectr 2005; 10: 877-882.
  27. Elsenbruch S et al. Am J Gastroenterol 1999; 94: 2447-2452.
  28. Heitkemper MM, Chang L. Gend Med 2009; 6 Suppl 2: 152-167.
  29. Kane SV et al. Am J Gastroenterol 1998; 93: 1867-1872.
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