Frequently Asked Questions about
Irritable Bowel Syndrome.
The following are the questions I am most frequently asked by my
patients with IBS. The questions stem from their personal concerns
and experiences. Based on my discussions with IBS patients around
the nation, these concerns and questions are shared by most people
with IBS. It is my hope that my answers will be helpful to the many
people with IBS who have not been able to find the answers to their
problem. In addition, my answers will give validation to patients
who often had their concerns and symptoms dismissed as psychological
and stress-based. The questions and answers below are adapted from
a chapter of the book.
When I am stressed, my IBS is worse, but even when I am
relaxed it’s still there. What can I do about this?
Many people—physicians and patients alike—are convinced
that stress exacerbates the symptoms of IBS. One statement from
IBS patients triggers the “all in your head” button
with the physician: the declaration that “my IBS is worse
when I am stressed”. The physician then needs to ask the more
important question; “But, do you still have symptoms even
when you are not stressed?” I cannot deny that stress—any
kind of stress—can affect bowel habits.
For example, a very serious exam, a problem at work, difficult times
in your home life, and even a happy event, such as getting married
or receiving a promotion can make anyone’s bowels behave differently,
perhaps making underlying IBS symptoms worse.
This is not unusual, since we also know that stress can affect
normal GI function, for example causing diarrhea due to so-called
“butterflies” in the stomach. Those effects on the gut
are mentioned in Chapter 3 of the book in relationship to cortisol-releasing
factor (CRF), a hormone that is produced in the brain in response
to stress. Elevated CRF levels cause the colon to contract excessively.
In addition, the stomach will empty more slowly, but most importantly
CRF also inhibits the cleaning waves of the gut. So under stressful
circumstances, the colon will be more active and the cleaning waves
will slow down or stop.
Therefore, it is possible that, number one, stress can exaggerate
bacterial overgrowth, and number two, it can worsen the diarrhea
symptoms that many IBS patients already have. But, again, I must
emphasize that stress is not believed to cause IBS, so when the
stressful situation resolves, the patient’s symptoms may improve
but do not go away. The patient still suffers every day. I have
many patients who tell me that they’ll go to the most relaxing
place they know for a couple of weeks on a vacation and yet they
still suffer from their IBS symptoms.
So, though alleviating stress will not all by itself resolve IBS
problems—as this book makes clear—it still makes good
sense to learn how to deal with stress more successfully so that
your symptoms can become more manageable. There are many ways to
cope with stress, but to describe them in detail is well beyond
the scope of this book. Here are some suggestions that can help
you get started.
• Practice Relaxation Exercises.
• Meditate or Pray.
• Examine your beliefs and attitudes.
• Develop your sense of humor.
• Make time for yourself and your hobbies.
None of these methods address the bacterial overgrowth that is
at the heart of most cases of IBS. Nonetheless, by making them a
regular part of your life, you will find yourself becoming much
better able to deal with stress, helping to prevent stress from
exacerbating your IBS symptoms. In addition, you will also improve
your overall health.
My doctor doesn’t believe that bacterial overgrowth
causes IBS and he’s pretty smart.
I am now asked this question much less frequently than before,
since numerous investigators are publishing studies that confirm
our findings. Thus gastroenterologists are now recognizing the role
that bacterial overgrowth plays in IBS. Nevertheless, there are
still many physicians who are unfamiliar with this emerging research
link between bacterial overgrowth and IBS. In some cases, they dismiss
the thought altogether without taking the time to study the evidence.
Having read this book and examined the evidence for yourself, I
hope you will realize that there is help that truly addresses your
IBS problems. Moreover, it is also important to understand that
physicians are inundated with medical information and have a hard
time sifting through so many areas of research to draw their own
conclusions. This makes them susceptible to the influence of IBS
I am not trying to “push” a theory, but rather to accelerate
people’s knowledge of a concept with scientific evidence.
New concepts take years to be adopted by internists and gastroenterologists.
As such, some physicians continue to say things like, “Well,
I don’t know anything about bacterial overgrowth being a factor
in IBS, so therefore it must not be true.”
We should not be so quick to blame the physician for this lack
of knowledge but perhaps assist them by giving them opportunities
to take interest in the latest information in this area. There are
many theories for many conditions, not only IBS, and sorting through
all of these theories can be confusing for physicians, as well as
their patients. Many physicians simply do not have time to synthesize
the evidence, given their busy schedules.
Though my colleagues and I initially developed the Cedars-Sinai
Protocol for IBS based on the findings of just a few scientific
papers we had published recounting our initial studies, our ultimate
goal was to prove that bacterial overgrowth causes the vast majority
of IBS cases in double-blind studies, and to confirm our findings
to justify the initial study conclusions. More importantly, other
physicians and researchers are now reproducing our findings with
their own studies and clinical trials. You can mention such studies
to your physician (see the Research Bibliography in the Appendix).
As a patient, the criteria you should use in evaluating whether
or not your physician is helping you with your health problems is
to ask yourself if the treatment protocols he or she recommends
are providing you with the relief you are looking for. If, after
a reasonable period of time, they are not, then you may need to
seek other help or options.
Is there a genetic predisposition for IBS?
Currently, the Mayo Clinic is conducting research on genetics as
it relates to IBS. The problem with answering this question with
any certainty has to do with answering such questions as to whether
family members have IBS because of a genetic predisposition or because
they all grew up together and were exposed to the same factors,
for example got food poisoning with the same pathogens. This is
a big issue that’s going to be difficult to resolve. I believe
it will be very difficult to prove that IBS is genetic because you
can’t eliminate other factors shared by families, such as
Does IBS leave me with an increased risk for colon cancer?
This is an especially important question when people talk about
bacterial overgrowth in relationship to IBS. People often ask me,
“What will happen if I don’t treat my IBS or the bacterial
overgrowth? What if I don’t want to take an antibiotic? Is
something going to happen to me?”
As far as we currently understand IBS, it is a benign condition
in terms of progressing to any kind of cancer. In the 1970s, there
was some data suggesting that when methane was present during breath
testing in humans, or in the colon of humans, there was an increased
risk for colon cancer. No researchers said for certain that this
was due to the methane gas, however, or to the methane-producing
organisms. But then subsequent studies refuted that possibility
and, as far as I know, the issue has never been looked at again.
What I tell my patients is that we don’t really know if there
is a link between the two diseases, nor do we know if leaving IBS
untreated can cause any other type of damage over time. It’s
really an issue of morbidity rather than mortality. People suffer
from IBS but it does not kill them, but young, productive people
are suffering and have a compromised quality of life, both socially
and at work. So choosing to be treated or not really depends on
what sort of quality of life patients want.
My doctor wants to scope me. Do I really need this?
Even prior to our understanding of the bacterial theory of IBS,
there were guidelines on the type of workup physicians should conduct
for an IBS patient. The first step was blood tests, to check for
anemia, get a sedimentation rate test, (to check for any evidence
of elevated immune system activity), or in other words, inflammation
in the body, and then basic chemistry panels to be sure that there
isn’t kidney failure or sodium or potassium imbalances in
the body. Abnormal blood tests, blood in the stool or weight loss
are often referred to in the IBS investigative workup as “red
flags”. These are circumstances in which the physician needs
to consider further testing.
The other test that is often recommended is that patients be checked
with at least a flexible sigmoidoscopy, which uses the short scope
that is inserted up into the colon and doesn’t require sedation.
This test ensures that there isn’t any inflammation in the
colon, or other signs of ulcerative colitis. The decision to conduct
a flexible sigmoidoscopy is really a very arbitrary one, and in
most cases is not really necessary.
Contrary to some patients’ understanding, for example, physicians
very often miss detecting Crohn’s disease with a flexible
sigmoidoscopy since, in order to do so, it is necessary to look
all the way through the colon into the small bowel, where the sigmoidoscope
does not reach. It addition, sigmodoscopies often miss colon cancer
that develops on the right side of the colon. In fact, it misses
so many different colon disorders that the role of flexible sigmoidoscopy
in general is now being questioned.
Therefore, the primary question to consider is when should physicians
scope a patient? One of the things that I look for is whether or
not a patient’s IBS symptoms fluctuate. It doesn’t matter
if their IBS symptoms are constipation predominant or diarrhea predominant,
or in between; I am looking for changes in their symptom patterns
that might indicate the development of some other type of health
problem. This is a grey area, because no IBS patient has identical
symptoms from day to day. One thing that is absolutely characteristic
of IBS is the number of bowel movements that IBS patients have from
day to day. One day, they may have two bowel movements; the next
day they might only have one; the day after that, they might not
have any; and on day four, they might have three or four. Such fluctuations
aren’t really abnormal when it comes to IBS. But if a patient
comes to me and says, “I’m having ten bowel movements
a day, every single day,” then that’s a worrisome symptom
to me and merits a colonoscopy, because IBS, generally speaking,
doesn’t behave that way. In IBS there is always some degree
of fluctuation in the number of the patient’s daily bowel
Just as importantly, if a patient suddenly starts to experience
constipation to the point where he or she is having only one very
hard bowel movement a week and this never changes, then that’s
of concern to me, too, and I’m more apt to investigate further.
I’m apt to consider looking for the possibility of celiac
disease when I treat the patient’s bacterial overgrowth and
it comes back immediately. Or when I do the breath test and the
patient doesn’t have bacterial overgrowth at all, and therefore
bacterial overgrowth is not the explanation for his or her symptoms.
Overall, however, I think performing the breath test first to check
for bacterial overgrowth actually increases your likelihood of detecting
other possible conditions.
Summing up, if you notice a change in your IBS symptoms, getting
scoped might be advisable, but rather than suggesting a uniform
rule of thumb, I prefer to make that decision on a case by case
basis, depending on each patient’s current symptoms status.
Why do I feel worse with milk products, yet even when I’m
off dairy products entirely, I still have IBS?
There has been some research from Europe suggesting that part of
IBS development may be due to lactose intolerance. Among my own
patients, if I were to quantitate lactose intolerance symptoms,
approximately 80 percent of them either avoid milk and dairy products
altogether or recognize that milk and dairy foods are an issue in
terms of creating more bloating for them. Yet, even when they eliminate
milk and dairy products from their diets, they still have IBS. The
only difference is that, when they drink milk, their bloating symptoms
become worse. One part of the reason is that most bacteria rely
on sugar as their main nourishment. If bacteria could only have
one food, sugar would be the one thing they would want.
When a normal, healthy person drinks one cup of milk, the amount
of lactose sugar it contains requires almost the entire length of
small intestine to absorb it. Humans are all relatively deficient
in the lactase enzyme necessary to assimilate lactose, and as we
age, our lactose intolerance becomes even more pronounced because
our stores of lactase enzyme are reduced over time. Any sugar that’s
reaching the farthest parts of the small bowel will feed any bacterial
overgrowth in the small intestine. As the bacteria feed on this
sugar, they ferment it most readily, creating gas. My colleagues
and I have shown this in a study in which, when we conducted breath
tests with the lactose sugar, the breath test profile looked identical
to the same patient getting a lactulose breath test to look for
bacterial overgrowth, meaning that what you’re seeing on the
lactose breath test using milk sugar is really bacterial overgrowth.
We then compared this to the actual lactose tolerance test, which
is the gold standard for determining whether or not a person cannot
assimilate lactose. Only three out of 20 IBS patients had true lactose
intolerance based on this test. This points out the fact that using
the lactose breath test to screen for lactose intolerance isn’t
accurate because the test may be demonstrating bacterial overgrowth
in most cases.
To return to the question at hand, eliminating milk and other dairy
products will not, in and of itself, resolve the problem of IBS.
In many instances, however, it can help to reduce the symptoms of
bloating associated with IBS, because doing so will reduce the amount
of sugar the bacteria have to feed on. A better solution, of course,
would be to address the bacterial overgrowth directly. See Chapter
6 in the book for dietary suggestions that may help.
What about the gluten-free diet? Will this help my symptoms?
A gluten-free diet is used to treat a condition called celiac disease,
which has symptoms similar to IBS. To a somewhat lesser degree,
this diet is similar to the popular Atkins Diet in the sense that,
in both diets, the person is reducing carbohydrates (sugars). In
the case of a gluten-free diet, you are switching your carbohydrates
more to potato starches and to rice, and therefore to more simple
carbohydrates. The complex carbohydrates are the ones that come
from grain cereals, and that’s where gluten, which is believed
to be the protein that causes celiac disease, comes from.
Some people often feel that they might have celiac disease, even
though all their tests for it came back negative, because they do
feel somewhat better on a gluten-free diet. This makes sense because,
when you eliminate gluten-containing foods, you are also eliminating
complex carbohydrates, and carbohydrates, like sugar, are what bacteria
thrive upon. If you starve bacteria of carbohydrates, they cannot
sustain their large numbers, so the degree of bacterial overgrowth
actually drops. We believe that explains why IBS symptoms are less
pronounced, including bloating. Again, though, while a gluten-free
diet may provide benefit for IBS patients, it rarely is enough for
eliminating the bacterial overgrowth, which should be the primary
aim of any IBS treatment program.
To some extent we have confirmed this concept. In a study we published
recently, we were able to completely eradicate bacterial overgrowth
and facilitate a dramatic improvement in IBS using a nutritional
product from Novartis, called Vivonex™ (see Chapter 6 of the
book for full details). Vivonex is an elemental diet, which means
the food that it contains is already completely predigested.
Therefore, when a person consumes this product, the food is absorbed
so readily into the blood that the food does not travel much beyond
the first 2 feet of small intestine (the absorbing area of the gut;
the full length of the gut is 15 feet). In the case of bacterial
overgrowth where, in most cases, the bacteria are further into the
small intestine than 2 feet, the patient’s eating this type
of food starves them. The ability to get rid of bacterial overgrowth
with this type of diet for two weeks is nearly 90%. The problem
is that this diet is very difficult to tolerate even for brief periods