Treatment Approaches

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 is 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.

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:

1. 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.
2. 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.
3. 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.
4. Pelvic floor physical therapists evaluate and treat pelvic floor dysfunction, which can contribute to IBS symptoms, particularly constipation.
5. 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.

1. 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.

2. Is it necessary 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.

3. Is a referral needed to see 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.

4. Who benefits 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

We discuss dietary therapy and ways working with a GI dietitian can help in more detail in lesson 6 and the In The Office segment with GI dietitian Nancee Jaffe. We also provide dietary resources including how to find a GI dietitian in our IBS Resources.

5. Who benefits from brain-gut behavioral therapy?

Brain-gut behavioral therapy can be especially helpful for patients who have any of the following:

• Symptoms associated with stress, mood or emotional factors
• Symptom-related anxiety and/or ineffective coping related to gastrointestinal symptoms, such as avoidance behaviors
• Moderate-to-severe symptoms with insufficient relief with medical therapy
• Interest in brain-gut behavioral therapies and willingness to engage in developing these skills

We discuss brain-gut behavioral therapy in more detail in lesson 5 and the In The Office segment with GI Psychologist Dr. Meredith Craven. We also provide more details on how to seek GI Psychology care in our resources section.

6. Who benefits 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.