A common question asked by patients is if their IBS can be "cured." In reality, for most people, IBS is a relapsing and remitting chronic condition with symptoms that fluctuate over time. Patients with IBS may experience periods where they are symptom free, but also other times when symptoms are intense, frequently and occur daily.
The goal of IBS treatment is to minimize symptoms and overall impact on quality of life. It is important to understand that IBS is a condition similar to diabetes or high blood pressure, where treatment may control symptoms, but once treatment is stopped symptoms are likely to recur.
Treatment for IBS is highly individualized based on an individual's specific symptoms, triggers, preferences, and lifestyle. Therapeutic options for IBS include lifestyle therapies, pharmacologic options, supplements, diet, physical therapy, and brain-gut behavioral therapy. Patient preference is essential for determining a treatment approach as preferences influence how likely an individual is able to incorporate treatment long term. While there are many different treatment options, it is important to highlight some key takeaways about IBS treatments:
Response to IBS treatment is highly individualized. Therapies that work well for some patients may not be effective for other patients.
Treatments are not mutually exclusive and most patients will achieve the best outcomes with a combination of 2 or more different therapeutic options.
Treatment strategies may change over time as external lifestyle factors and other medical conditions change.
Recognizing individual triggers for IBS symptoms such as poor sleep, certain foods in the diet or high stress situations are an important aspect of managing IBS. While minimizing exposure to triggers is the goal, sometimes triggers are unavoidable or unpredictable and may lead to a flare in symptoms. During these times a patient may need additional treatment strategies to control symptoms during a flare prior to return to baseline.
The Integrative Care Model
While IBS is usually diagnosed by a medical provider such as a primary care provider or gastroenterology provider, experts recommend a multidisciplinary approach to managing IBS by a team of health care professionals, known as the integrative care model. The integrative care model takes into account the multifactorial influences on IBS physiology and symptoms including gut-brain physiology, alongside psychological, behavioral, and social factors. A purely symptom-based approach often overlooks these important contributors.
In practice this usually involves:
Gastroenterologists or gastroenterology advance practice providers (physician assistants or nurse practitioners) provide medical expertise to make the diagnosis including: order and interpret any diagnostic testing, educate patients on the diagnosis and the role of the gut-brain connection, guide overall treatment strategy, coordinate and refer to other members of the healthcare team and prescribe any pharmacologic therapies.
GI dietitians review symptom relationship to diet and eating patterns, help patients identify trigger foods, create an individualized diet plan and provide evidence-based knowledge regarding nutrition.
GI psychologists identify and address the emotional, behavioral, and cognitive factors that contribute to IBS symptoms, provide education about the brain-gut connection, teach coping strategies and develop behavioral strategies to improve symptom management including therapies such as cognitive behavioral therapy or gut-directed hypnotherapy.
Pelvic floor physical therapists evaluate and treat pelvic floor dysfunction which can contribute to IBS symptoms particularly constipation.
Primary care providers play an important role in the management of IBS including performing the initial diagnostic evaluation and management, referral to specialty gastroenterological care if necessary, and managing other medical issues which may impact IBS symptoms.
Choosing the right IBS care team: FAQs
Can a primary care provider manage IBS?
Many primary care providers manage IBS in their practice. Depending on the nature and severity of symptoms, the experience of the individual provider and preferences of the patient some may elect to refer to or seek care from a gastroenterology specialist for further evaluation and treatment.
Do patients need to see a gastroenterology provider who specializes in IBS?
Most gastroenterology providers care for a wide variety of gastrointestinal conditions including IBS, inflammatory bowel disease, liver disease and perform colon cancer screening. Some gastroenterology providers, such as the experts in our course, specialize in treating IBS and other disorders of gut brain interaction. The decision to refer or seek care from a provider who specializes in IBS depends on the severity of symptoms, provider experience and patient preferences. Access to a gastroenterology provider who specializes in IBS can be challenging and may require long wait times and potential travel.
Alternatively patients can consider seeing another gastroenterology provider as experience and interest in managing IBS vary among general gastroenterology providers. Finding the right provider to manage your symptoms is a crucial aspect of IBS care management. Patients are encouraged to find a provider that makes them feel heard and empowered to seek care for their symptoms.
Do patients need their primary care or gastroenterology provider to initiate referral to a GI dietitian, GI Psychologist or other member of the GI care team?
It is not a universal requirement to get a referral to see another member of your IBS care team. The requirements depend on individual providers and insurance coverage. Some patients may need to or choose to pay for these specialty services out of pocket and this provides additional flexibility to seek care without a referral. Some GI dietitians, GI psychologists or pelvic floor physical therapists may require referral from another healthcare professional.
While referral may not be required patients are encouraged to discuss referral with their primary care or gastroenterology provider as this can help facilitate communication between the members of the care team and improve overall care.
Which patients would benefit from seeing a GI dietitian?
A GI dietitian can be especially helpful for patients who have any of the following:
Symptoms associated with food
Limited diet due to symptoms
Experience fear and anxiety around eating
Confused or have questions about the impact of diet on IBS symptoms
Currently on or are interested in trying the low FODMAP diet
Looking for guidance on dietary therapy for management of IBS symptoms
Which patients would benefit from pelvic floor physical therapy?
Patients where pelvic floor dysfunction is contributing to their IBS symptoms would benefit from referral to a pelvic floor physical therapist. Most commonly this is a patient with IBS-C or IBS-M diagnosed with pelvic floor dysfunction by their medical team. More advanced testing with a balloon expulsion test, anorectal manometry and/or defecography can evaluate for the presence of pelvic floor dysfunction including dyssynergic defecation. Dyssynergic defecation is a condition where the muscles of the pelvic floor fail to coordinate to have a successful bowel movement.
More information about diagnosing dyssynergic defecation can be found in Lesson 3. Many patients with dyssynergic defecation are referred to biofeedback therapy which is a specialized type of pelvic floor therapy. Biofeedback therapy is considered safe, with minimal risks, and studies show symptomatic benefit in 70 to 80% of patients with dyssynergic defecation.