Irritable Bowel Syndrome Message Boards | 11 year old daughter been in pain every night for a year!

Its extremely unlikely its SIBO, she doesn't match the symptoms for one. Of course you could get a test for it, but I think its unlikely the problem.

IBS and SIBO are also two different conditions. Despite some of the controversy lately about it, although its possible for them to overlap. I could explain if you wish.

She does match IBS if anything and her age is also more the likelyhood its IBS.

Gas can cause pain because of sensitive nerves linig the gi tract in IBS.

The chemical the gut releases to signal to the brain sensations in the gut is serotonin and they know there is a problem with that in IBSers.

All pain is processed in the brain. There is an impairment in IBS in a particular part of the brain called the Anteior Cinculate Cortex, so the signals coming from the gut can be not working right.

I might have missed something, but what testys has she had done.

Bloodwork
stool tests (three)
colonoscopy?

You might also want to read this.

http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm?pg=disease1&organ=6&disease=43&lang_id=1

and this

with permission

Frequent stomachaches in
children: a reason for concern?
By Miranda Van Tilburg, PhD
Assistant Professor of Medicine
Division of Gastroenterology and
Hepatology
School of Medicine
The University of North Carolina at
Chapel Hill
Most children will complain of
a stomachache once in a while,
because it is one of the most common
childhood pain experiences.
Complaints can range from a vague
queasy feeling in the stomach to
doubling over in pain accompanied
by vomiting, diarrhea or constipation.
Fortunately, in a majority of cases,
the reasons for a stomachache are minor and
relatively benign. Most often, the complaint
settles without a specific diagnosis, even when
a doctor is consulted.
However, some children are more prone to
developing abdominal pain than others. These
children experience frequent stomachaches
over a period of several months to several years,
which can be very disrupting in the child's life.
Due to (a fear of developing) stomachaches,
these children often miss out on family events,
social outings with friends, and attending school.
Stepping out of normal life in this way makes
these children vulnerable to loneliness, anxiety,
depression and low self-esteem.
In the late 1950's, the English pediatrician John
Apley was one of the first to systematically study
and describe this phenomenon of childhood
stomachaches, which he named Recurrent
Abdominal Pain (RAP). In his first monologue on
RAP, Apley describes the typical situation of a
child who complains of frequent stomachaches.
This child has been sent home from school
and may even have vomited however, by the
time he arrives at the doctor's office, the pain
is usually gone and upon examination nothing
but indefinite tenderness in the abdomen is
found. The doctor usually does not find anything
definitive on which to base a diagnosis. Most
likely, the child has had the stomach pain before
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as well as somebody in his immediate family. The
pediatrician feels he or she can wait for further
developments with the child but has doubts
about having missed something. Was (s)he right
to express only reassurances or should further
investigations have been carried out? This
description of the pain-prone family
and doubtful physician is still true
today.
What is RAP?
Apley defined RAP as at least three
episodes of pain occurring within
three months that are severe enough
to affect the child's activities. This
diagnosis is still widely used in
clinical practice and research.
Sometimes, Rome classification
is used, with the most common
diagnoses being Functional
Dyspepsia (FD) or Irritable Bowel
Syndrome (IBS). FD is diagnosed when there
has been at least 12 weeks of persistent or
recurrent pain in the upper abdomen, without
evidence of organic disease and no relief with
defecation or change in stool form or frequency.
IBS is diagnosed when there has been at least 12
weeks of abdominal pain, without structural or
metabolic abnormalities and at least two of the
following three features -- relief with defecation,
change in stool frequency, or change in stool
consistency. Upon careful review of RAP patients,
it is found that pediatric IBS is very common � 45
to 70% of RAP patients meet Rome criteria for
IBS and about 16% are ascertained to suffer from
functional dyspepsia.
Nobody is in as much pain as my child
RAP patients and their parents often believe their
symptoms are unlike "normal" stomachaches
reported by other children. Pediatricians and
gastroenterologists, on the other hand, perceive
RAP as a problem that is overflowing their
practices. The truth lies somewhere in between
these two perspectives. RAP is one of the most
common chronic pain complaints in childhood,
but only 10 to 25% of children are affected.
Symptoms often wane with time and spontaneous
remission of RAP is likely. Yet, more than half
of RAP children will continue to suffer from
frequent somatic or psychological symptoms
into adulthood. For example, Christensen and
Mortensen reported that 11 out of the 18 RAP
patients in their study suffered from abdominal
pain 29 years later.
Frequent stomachaches in children: a reason for concern?
Miranda Van Tilburg
3
out as early as possible. Depending on the symptoms, a
physician can order blood, urine and stool tests to rule
out some common conditions. But, the use of X-rays, CTscans
and endoscopies are usually restricted to cases in
which the history or physical exam raises questions as to
the diagnosis. Even with extensive testing, the odds are
against finding an organic cause for a child who meets
symptom criteria for RAP. In only one out of 10 cases,
an organic cause can be identified and misdiagnosis
is extremely rare. Even up to 20 years after an initial
diagnosis of RAP, the chance of identifying an initially
undiagnosed organic disorder is very low.
Is it all in your head?
Apley believed that if there is no organic cause for the
pain, then the stomachaches are psychogenic. In other
words, RAP patients suffer from an emotional disorder.
He came to this conclusion because stress seemed to
exaggerate or precede pain attacks and psychotherapy
was usually effective in relieving attacks. In trying to
explain the absence of abnormal physiological findings,
many have followed Apley's lead and suggested these
children suffer from psychological problems. RAP
patients have been described as fussy, perfectionistic,
high strung and anxious, and several studies have
shown they suffer from more psychological problems
than healthy children.
However, the landmark work of Walker & Greene
has shown that anxiousness is a consequence of the
presence of abdominal pain rather than a cause. RAP
patients are not necessarily more anxious or depressed
than patients suffering from peptic ulcer or IBD, in which
the abdominal pain is caused by inflammation of the GI
tract. These findings suggest that chronic abdominal pain
affects patients in similar ways regardless of etiology,
and the notion that RAP is a psychogenic disorder has
now fallen largely out of favor. Psychosocial factors are
assumed to influence GI functioning and can exaggerate
symptoms, but they play only a limited causal role.
Suffering from abdominal pain does, however, generate
psychological distress. It can produce not only anxiety
but also increased depressive symptoms, somatization
and lower self-esteem. Now it is understood that the
cause of RAP is neither organic nor psychogenic,
but there is close interplay between physiology and
psychology.
What is causing RAP?
Although no structural abnormalities or diseases
may be found, RAP patients do show some abnormal
physiological characteristics. There is growing evidence
that a disruption in the functioning of the GI tract is one
of the major causes of RAP. This basically means that the
Frequent stomachaches in children: a reason for concern?
In other words, RAP patients suffer
from an emotional disorder. He came
to this conclusion because stress
seemed to exaggerate or precede
pain attacks and psychotherapy was
usually effective in relieving attacks.
Are RAP stomachaches real, imagined or faked?
Since stomachaches are notoriously used as an excuse
for skipping school, they have gotten a bad reputation.
A child with RAP is often thought of as a whiner who
uses his bellyaches to get attention or get out of things,
especially when a physiological cause for the pain
cannot be identified. RAP children and their families
face this type of prejudice almost daily, even among
many health care professionals. However, it is important
to understand that the pain of RAP is real and not faked
or imagined. Even abdominal pain caused by stress
or worry about going to school is usually real. Most
children never think about faking it. Acknowledging the
validity of RAP stomachaches is the right thing to do,
but keeping a child who suffers from RAP out of school
every time he or she complains is not necessary. If no
other symptom, such as vomiting or fever is present, it
is usually safe for the child to go to school.
Has a serious disease been overlooked?
Both parents and physicians are often doubtful about
the diagnosis of RAP. There is no marker or test to
identify RAP; the diagnosis is made purely on the basis
of symptom characteristics. Common organic causes of
abdominal pain are usually ruled out before giving a
diagnosis of RAP. The list of disorders that can cause
abdominal pain is lengthy and, generally, it is neither
ethically nor financially possible to test every child for
all possibilities. Serious illnesses can sometimes explain
recurrent stomachaches and it is important to rule these
When RAP persists into adulthood, these patients
are most likely to develop IBS. There are striking
similarities between adulthood IBS and childhood RAP
in terms of prevalence, course, medical and psychiatric
co-morbidity, family medical and psychiatric history,
and stressful life events. There is data to suggest that
the prognosis is worse for children who have a parent
who suffers from recurrent pain and for children who
experience more negative life events. Therefore,
although it is true that some children will eventually
grow out of their stomachaches, there is a good chance
that abdominal or other somatic symptoms will reoccur
later in life.
4
bodies of children with RAP work somewhat differently.
This etiological model has been adapted largely from
research findings on adulthood IBS. As discussed earlier,
childhood RAP has many similarities with adulthood
IBS and many young RAP patients will have or develop
abdominal pain in their adult life. RAP is therefore often
seen as a precursor to adulthood IBS and identical
etiological mechanisms have been suggested. It is
important to realize, however, that few studies to date
have focused on etiological mechanisms of childhood
RAP compared to the extensive literature on adult IBS,
and findings have not always been identical.
It has been suggested that the Autonomic Nervous
System (ANS) is disrupted in RAP. The ANS consists of
neurons that run between the central nervous system
(e.g., the brain) and various internal organs, such as
the bowels and stomach. The ANS is responsible for
monitoring conditions in the internal environment
and bringing about appropriate changes in them.
For example, after eating, the ANS acts to ensure the
stomach and bowel contract to move the food through
the digestive tract. This happens largely involuntary,
although we do have some control over our bowels as
is shown by people practicing yoga or under hypnosis.
It has been suggested that the ANS in RAP is weak -- it
does not adapt to changes as effectively as in healthy
children. For example, after stimulation of the rectum,
RAP patients show slower recovery than children who
do not suffer from RAP.
A second mechanism that could explain RAP is
disruptions in motility (the speed with which food
moves through the digestive system). In many cases,
RAP is associated with either diarrhea or constipation.
This seems to suggest that food is either moving too
quickly or too slowly through the bowels and that this
motility problem could account for the pain. Some
studies have observed increased transit time in RAP
patients, but these findings have not been found in all
studies. Furthermore, adding fiber to the diet to slow
transit time has been found to benefit only a subgroup
of RAP patients.
Lately, visceral hypersensitivity has received
considerable attention as one of the major pathways that
causes RAP symptoms. Visceral hypersensitivity means
that nerves in the gut are very sensitive: RAP patients
feel pain in areas of the GI tract much more easily.
Because of this heightened sensitivity, RAP children
perceive 'normal' gastrointestinal events -- such as
small increases in motility or gas -- as painful.
There is convincing evidence of visceral hypersensitivity
in many adult IBS patients and it has been reported in
children with RAP, as well. This abnormal perception of
pain (low pain threshold) can be due to changes in both
the central (brain) and enteric (gut) nervous system.
Nerves in the gut can become overly sensitive and start
reacting to events that would otherwise be ignored. The
brain, on the other hand, can overreact by not inhibiting
as much information coming from the gut as usual,
thereby enabling more pain stimuli to pass through
into our awareness. Psychological distress can augment
these processes.
It should be emphasized that there might be different
etiologies explaining RAP. In some children abdominal
pain might be caused by disruptions in the ANS, while
for others the pain is due to an increase in motility or
visceral hypersensitivity, and for a third group the pain
may be largely psychogenic. It is very likely that in most
RAP patients multiple mechanisms can be identified
that influence each other. For example, frequent severe
pain due to increased motility may eventually lead to
hypersensitivity for motility which, in turn, generates
more pain due to heightened sensitivity to changes in
motility.
What about stress?
Many parents, children and physicians understand that
stress can exacerbate the pain. However, most studies
so far have failed to find a clear relationship between
major stressors (such as death or illness in the family, a
divorce, or a move) and the occurrence of RAP. It might
be possible that minor chronic stresses or daily hassles
-- such as having to wait in line at the store, quarrels
with siblings, constantly stopping for bathroom visits,
or vigilantly monitoring what one's eating -- may be
far more significant than the stress of major life events.
Unfortunately, there is still little research on the effects
of minor chronic stress.
Effectiveness in coping may be even more important in
explaining RAP than exposure to stress. When a child is
an effective coper, even high levels of stress might not
affect him or her very much. By contrast, an ineffective
coper is likely to become distressed when faced with
only minor setbacks in life. Coping with abdominal
pain and other stresses is often difficult for children
who suffer from RAP. Many RAP children use avoidance
strategies such as denial, avoiding thinking about it and
wishful thinking which, in turn, can result in elevated
levels of pain, somatic symptoms and distress. By
contrast, effectively adapting to (coping with) the pain
by regulating attention and cognitions (e.g., distraction,
acceptance of the pain or positive thinking) are
associated with less pain, fewer somatic symptoms and
Frequent stomachaches in children: a reason for concern? 5
less distress. Acting directly on the pain in an attempt to
change the environment or one's emotions (e.g., taking
medications, visiting a physician, reducing stress in
one's life) can be somewhat helpful, but these actions
do not appear to influence the pain very much.
Are non-GI symptoms related to RAP?
Children with RAP can present with a multitude of
other unexplained symptoms (co-morbidity), and
the physician may wonder if these are related to the
stomachaches. Co-morbid symptoms are important
since they may be indicative of: (1) psychological
problems that could either drive the GI symptoms or
be a consequence of coping with multiple pains, or
(2) more severe or longer duration of pain which can
trigger pain in other areas. Relatively little is known
about co-morbid somatic symptoms in RAP. About
half the children who report stomach pain indicate
more than one pain location. Multiple pain sites are
more commonly reported by girls than boys, and they
increase with age. The most common combination is
headache and abdominal pain and is reported in 25%
of cases with two sites of chronic pain.
In a study of RAP patients consulting a physician, the
number of co-morbid symptoms was found to increase
with the duration of RAP. In other words, one pain might
initiate other pain. But, it could also be possible that
only those patients who have multiple symptoms are
seen by a doctor over a longer period of time. Another
study did not find a relationship between the duration
of stomachaches and the occurrence of other symptoms
during a three-month follow-up of patients. However,
three months might have been too short a period of
time to see an effect. More research into associated
symptoms, who is at increased risk, and what is causing
the co-morbidity is needed.
Do more severe symptoms result in more
disability?
RAP has a large impact on suffering, health care costs
and functional disability. School absences are one of
the most common and obvious effects of RAP, and often
one of the first goals in therapy is to resume school
attendance. The RAP child who misses school also tends
to use more health care services. Health care resource
use is particularly high among RAP patients, but not all
children who suffer from RAP consult a doctor or miss
school. Currently, there is little research-based insight
into the characteristics of the child who is most likely to
miss school and consult a physician for stomachaches.
In a study by Hyams and colleagues, only 9% to10% of
middle and high school students with RAP reported they
had seen a doctor for abdominal pain within the last
year. But, students who did visit a doctor for abdominal
pain reported increased pain severity, frequency and
duration and more disruption of their lives. In a study
by Venepalli and colleagues, health care consulting and
school attendance of middle school children could not
be predicted by pain intensity or psychosocial distress
of either the mother or the child. Identification of children
who show high levels of functional disability is important,
because this would allow for targeting (preventive)
interventions, determining cost-effectiveness of care,
and preventing poor academic performance due to
school absences.
Are the parents to blame?
Physicians confronted with an anxious parent of a child
with RAP often feel these parents play a major role in
the maintenance and exacerbation of the symptoms.
Parents for RAP children, on the other hand, feel they
have no control over the situation and do not appreciate
being 'blamed' for their child's symptoms. It is important
to understand that a disorder seldom affects only the
patient. People around the person in pain are affected,
as well -- they can be stressed about the pain and its
meaning. In fact, many parents of children who suffer
from abdominal pain show increased levels of anxiety
and somatization themselves. This is a normal reaction
and does not imply that parents cause RAP.
However, parental beliefs, stress, and coping strategies
are of great influence on the child's pain perception
of pain. Children are still developing their coping
repertoires and look to adults for guidance about
when to get anxious or worried and how to deal with
symptoms. When a child is sick, in pain or discomfort,
parents have the difficult task of interpreting the
seriousness of the symptoms and deciding how to take
action. Any parental action or reaction will influence
how their children approach future illness and health.
How can a doctor help a child who suffers from
RAP?
Standard medical care for RAP consists of (1) limited
medical tests to rule out organic diseases, (2)
acknowledgment that the pain is real, (3) reassurance
that there is no illness causing the pain, and (4) advice
on how to cope with the symptoms. Parents and children
need to be partners with their physician in their health
and health care. Since most patients visit a physician in
search of a 'cure,' it is important for physicians to explain
that RAP is a chronic condition and that returning to
normal life as much as possible is the goal, rather than
complete pain relief. Medications can be given to treat
accompanying symptoms, such as constipation.
6 Frequent stomachaches in children: a reason for concern?
Many RAP patients may come to the doctor's office with
questions about diet. In fact, most of them will have
changed their eating behavior before seeing a doctor.
They may propose that food sensitivities, unhealthy
diets or dysfunctional eating patterns are possible
causes of the symptoms. At this time, there is only
limited data on the effects of diet on RAP symptoms.
The most extensively studied are the influence of
lactose malabsorption and lack of sufficient fiber in the
diet. Many parents will have placed their children on
a lactose-free diet, but the majority of patients do not
report benefits from this dietary restriction. Even lactoseintolerant
children do not necessarily see a significant
improvement in their RAP symptoms, suggesting that
lactose intolerance might be an additional dysfunction
the child is dealing with but it is not a major cause for
the stomachaches. As mentioned above, fiber therapy
can be helpful in some cases, but the currently limited
research data is conflicting with regard to its benefit.
Nevertheless, some suggest that because of its low cost
and low risk, it might be worthwhile to try high fiber
therapy in children presenting with RAP.
Although standard medical care can result in significant
improvements, many RAP patients need additional
therapy. Psychological therapies such as Cognitive
Behavioral Therapy (CBT) have been found to be
effective in treating RAP. CBT teaches children and/or
their parents to change unhelpful thoughts about the
disorder and learn effective coping skills, and it is often
combined with relaxation exercises. CBT has been shown
to produce significant improvements in pain, health care
utilization and school attendance. Unfortunately, these
therapies are not available to a majority of the RAP
patients. They require multiple meetings with a highly
trained therapist, insurance often does not necessarily
cover these costs, and most physician offices lack the
time and resources to implement such a program. There
is a need for effective psychological treatments for RAP
that are more accessible.
There is no quick fix for RAP and the road to recovery can
be bumpy and challenging for all parties. Patients and
their families may feel misunderstood and discouraged
by relapses. Physicians might feel they are not able to
convey their message to the family or lack the time to
give adequate coping advice. Although RAP is a very
challenging disorder, there are many ways in which
children, their parents and physicians can help to ease
the pain. No one approach will work in every child, but
the right combination of understanding the disorder
and its causes, medications, reduction of stress, changes
in eating and bowel movement patterns, coping advice,
and encouragement to fully participate in school and
social life can be of great benefit in managing, reducing
and controlling the pain. For many children, the care and
encouragement of a good physician will be sufficient to
take control over the symptoms.
However, for children needing additional care, it can
be challenging to find the right therapist or therapies.
This gap is recognized and more research is being
done in developing behavioral interventions. For
example, the UNC Center for Functional GI & Motility
Disorders is currently partnering with Dr. Rona Levy at
the University of Washington to test a short Cognitive
Behavioral Therapy for RAP in which both the children
and parents are involved. At UNC, we are also in the
process of developing a hypnosis program for RAP that
can be used by any health care professionals without
extensive training, making it more widely available to
many patients. Some pediatric gastroenterologists are
already teaming up with therapists who have specialized
in pediatric GI disorders.
In sum, the most important intervention for children
who suffer from recurrent abdominal pain is to reassure
them that we understand their pain is real but also that it
can be managed with appropriate medical care and/or
psychological therapy.
Selected reading (a complete reference list can be obtained from the
author)
Apley J, Naish N. Recurrent abdominal pain: A field study of 1000
school children with recurrent abdominal pain. Archives of Diseases
of Childhood 1958;46:337-340.
Scharff L. Recurrent abdominal pain in children: a review of
psychological factors and treatment. Clin Psychol Rev 1997;17:145-
166.
Christensen MF, Mortensen O. Long-term prognosis in children with
recurrent abdominal pain. Arch Dis Child 1975;50:110-114.
Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis PA. Abdominal
pain and irritable bowel syndrome in adolescents: a communitybased
study. J Pediatr 1996;129:220-226.
Venepalli N, Van Tilburg MAL, Whitehead WE. Recurrent Abdominal
Pain (RAP): The relationship between illness behaviors and health
services consulting? American Journal of Gastroenterology
2004;126:A372.
Walker LS, Greene JW. Children with recurrent abdominal pain and
their parents: More somatic complaints, anxiety, and depression than
other families? Journal of Pediatric Psychology 1989;14:231-243.
Walker LS, Garber J, Greeene JW. Psychosocial correlates of recurrent
childhood pain: A comparison of pediatric patients with Recurrent
Abdominal Pain, organic illness and psychiatric disorders. Journal
of Abnormal Psychology 1993;102:248-258.
Walker LS, Claar RL, Garber J. Social consequences of children's
pain: when do they encourage symptom maintenance? J Pediatr
Psychol 2002;27:689-698.
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7 Frequent stomachaches in children: a reason for concern?

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My website on IBS is www.ibshealth.com

Print Remind Me Notify Moderator

Carbohydrates break down in the gut into tryptofan and then to serotonin and serotonin is a real problem in IBS.

You can also have a problem with wheat and not have full blown celiac.

also did you see this by any chance?

IBS

Bette Bischoff
Background
Prior to medical school when I was a practicing dietician, I had the privilege of
working with many patients who had irritable bowel syndrome (IBS). I found
the subject of nutritional intervention related to IBS to be very rewarding and
often challenging because there is no "perfect" diet for this syndrome. In light
of the different etiologies potentially at work in each patient with IBS, nutrition
therapy should be carefully and thoughtfully tailored to each person. This can
be likened to times past when a cobbler hand-made each person's shoes. Since
each IBS patient can differ dramatically, careful documentation of exacerbating
factors listed in the IBS diary maintained by patients may yield important clues
to an effective approach to diet and nutrition.
One of the issues is that patients with IBS may have a lower threshold to stressors
compared to people without IBS. An example of this is patients with carbohydrate
intolerances as well as a diagnosis of IBS, who experience an even greater
response to problematic carbohydrates such as lactose or fructose as compared
to someone who does not have IBS. Another important issue is being alert to
unnecessary food aversions. Individuals may experience abdominal discomfort
and associate this with eating a certain food, so they decide to avoid eating that
particular item, even for life. This may lead to excessive food restriction and the
potential for a full-blown eating disorder. What must be kept in mind is that IBS
is characterized by increased gut and central nervous system (CNS) reactivity
to stressors, and that these stressors can include any dietary excesses as well as chain fatty acids. Good sources of soluble fiber
include oats, psyllium seed, pectin, and guar gum.
Insoluble fibers consist of the outer husk of the
grain and generally tend to decrease transit time.
The national nutrition guidelines recommend an
intake of 20-30 grams of fiber per day, yet the
typical American consumes less than 10 grams of
fiber per day. Fiber intake should be increased
gradually in IBS patients with constipation,
with an emphasis on including adequate water
consumption (5).
The overall fiber picture can become a bit more
confusing than a simple recommendation to
increase fiber intake. Insoluble fiber may have a
high content of cereal bran, which is the outer husk
of the grain. A recent paper investigated the effects
of adding or omitting bran and found conflicting
results. It appears the primary care provider may
see a greater benefit from patients adding fiber
to their diet than the gastroenterologist, possibly
because primary care physicians see mostly
milder forms of IBS and gastroenterologists see
patients with more severe IBS. Whorwell studied
100 patients in a primary care setting that were
encouraged to increase cereal bran. The results
in the primary care provider scenario produced
a "mixed" picture -- 22% reported worsening
of IBS symptoms while 27% who showed
improvement. This may be the result of visceral
hypersensitivity triggered by bran consumption.
Whorwell recommends that patients identified
with IBS and visceral hypersensitivity should be
counseled to exclude cereal (insoluble) fibers
for a brief period to see if symptoms improve,
especially if this is within the care of a specialty
clinic. Another study found that cereal fibers were
associated with a 55% worsening of symptoms (6,
7). Thus, if the goal is to increase transit rate and
increase the frequency of bowel movements (for
IBS-C), one could add insoluble fiber to the diet;
however, since IBS is also associated with visceral
hypersensitivity, if discomfort/pain or bloating
occurs, the patient may need to switch solely to
soluble fiber.
Caffeine is a gastrointestinal stimulant. For IBS
patients with diarrhea, a period of caffeine
sensitivities to particular foods that are unique to
the individual rather than to the IBS condition.
This article reviews some of the literature in this
area and then presents some treatment options
to be considered in the nutritional management
of IBS. It should be noted that the research and
peer-reviewed published literature regarding IBS
and diet is still very limited and, therefore, some
of the resources cited in this article will date back
several years.
Nutritional Factors Influencing Motility:
Fiber, Fat and Caffeine
IBS is the most common of the functional GI
disorder, affecting approximately 10-15% of the
US population (1). IBS is a multifactorial illness with
several different emerging pathophysiologies,
including disorders of motility, visceral
hypersensitivity, central processing dysfunctions,
psychological factors, and post-infectious
inflammation.
Fiber: A recent survey reported that close to
95% of general practitioners believe that fiber
deficiency is the main cause of IBS. In fact, the
most common dietary advice offered to patients
with IBS is for them to increase their intake of
fiber, primarily to address the constipation that
may be associated with IBS. However, since IBS
is also associated with visceral hypersensitivity,
luminal distension -- as might be caused by the
bacterial fermentation of insoluble fiber -- can
also produce discomfort (2).
Dietary fiber is a non- starch polysaccharide
derived from plant foods that are poorly digested
by human enzymes. A fiber-enriched diet can
relieve constipation, accelerate intestinal transit
time, and may reduce intracolonic pressure.
Furthermore, the intake of fiber is associated
with a reduction in the intraluminal concentration
of bile acids, which may reduce the contractile
activity of the colon (3, 4).
There are two types of fiber -- soluble and
insoluble. Soluble fiber is derived from fruits and
grains, and is fermented in the colon to form short

exclusion may prove beneficial. The total intake
of caffeine-containing beverages by many adults
and children often reaches levels that can induce
pharmacological effects. Evidence associating
caffeine with GI symptoms suffered by patients
with IBS is limited in the current literature, but one
study revealed that caffeinated coffee stimulated
colonic motor activity in a magnitude similar to
that of an entire meal and had a 60% stronger
effect than ingesting water (.
Dietary fat is also a potent modulator of gut
motor function. This macronutrient delays gastric
emptying time and accelerates small bowel
transit rates. Symptoms of bloating are commonly
reported after consuming a high-fat meal. Serra
et al. found that after an infusion of enteral fat,
the volume of retained gas increased from 298
to 505 ml (9, 10). For patients who need to limit
their fat intake, counting actual fat grams in the
diet can be an excellent way to identify high-fat
food sources. In general, IBS patients should aim
for only 40-50 grams of fat per day. If weight loss
becomes an issue with fat restriction, medium
chain triglycerides (MCT) are an excellent source
of calories. Unfortunately, MCT oils are expensive
and, due to taste issues, are generally not wellreceived
by patients.
Food Allergy, Hypersensitivity and
Intolerance
Although up to 45% of the population reports
adverse reactions to food, the actual prevalence
of immune-mediated food allergy is unknown.
Symptoms are more common in atopic individuals
who often have allergies to non-food antigens
as well, such as pollens, and in young children
who tend to outgrow an allergy. The role of food
allergy in IBS has not been studied well. Surveys
indicate that 40-70% of food-allergic patients
report GI symptoms including nausea, vomiting,
abdominal pain, bloating, and diarrhea. Stefanini
et al. conducted a 4-week multi-center study
comparing the efficacy of the mast cell stabilizing
agent sodium cromoglycate at 1500 mg per day
with an elimination diet, and 67% of the patients
reported improvement in their symptoms (11).
Attempts to "test" for food hypersensitivity in
IBS have largely focused on the classic food
allergy, which is based on the presence of IgE --
immunoglobulins of the "immediate type". These
antibodies attach to certain cells in the body
that release chemicals that cause anaphylaxis.
Present speculation in the literature suggests
that adverse reactions to food in patients with
IBS might be due to forms of immunological
mechanisms other than a dietary allergy, namely
IgG antibodies. These tend to have a delayed
response following exposure to a particular
antigen and have been implicated in some cases
of food hypersensitivity. IgG studies surfacing in
the IBS literature are promising, but the issue of
the validation of serum IgG testing is often raised.
Atkinson et al. observed significant improvement
in IBS symptoms in elimination diets using Elisa
IgG antibody testing. Their results suggest
that IgG antibodies may have a role in helping
patients identify candidate foods for elimination
(12). Collins et al. also found significant change
in patients receiving the IgG exclusion diet. The
foods that were most frequently associated with
elevated IgG levels were yeast, milk, eggs, wheat,
cashew nuts, peas, almonds, and barley. The
mechanism by which the IgG antibodies have a
detrimental effect is unclear, but most likely is
associated with low-grade inflammation (12,13).
For the most part, most patients with IBS do not
have immune-mediated allergies to food and,
more likely, have increased sensitivity to the direct
effects of food on digestive function including
increased food volume ingestion and the addition
of fats, caffeine, carbohydrates, alcohol, etc.
Food Intolerance and Exclusion Diets
Niec recently summarized the literature on clinical
trials using food elimination diets followed by
rechallenge. Of the seven studies included in their
review, positive response rates varied from 15 to 75
percent. A higher rate of response was correlated
with diarrhea-predominant IBS. Milk, wheat and
eggs were the most frequently implicated foods
(14). Although the principle of food elimination
or exclusion appears straightforward, it can be
very demanding for the patient. If the patient
appears hesitant or confused about food choices,
physician referral to a registered dietitian may be
helpful. With the exclusion of entire food groups,
such as dairy products, the risk of developing a
nutritional deficiency must be considered.
Carbohydrate Malabsorption
Carbohydrate intolerance can be seen in many

patients with IBS. Fructose, lactose and sorbitol
malabsorption are common among patients who
have IBS, and dietary restriction of these sugars
may improve symptoms (15,16). One study found
that 42% of IBS patients developed symptoms
from sorbitol-fructose mixtures compared to 3.5
% in the control group (1. This could be an
important factor when patients are consuming
large amounts of weight-loss products or have
diarrhea-predominant IBS.
Lactose malabsorption occurs when lactose, the
primary sugar in dairy products, is not completely
digested and absorbed in the small bowel. Lactase,
the enzyme required to hydrolyze lactose for
intestinal absorption, is found primarily in the tips
of the jejunum. When unabsorbed lactose reaches
the colon, colonic bacteria uses this substrate
for fermentation, producing gas and short chain
fatty acids. The unabsorbed lactose also affects
osmolality, causing water to be drawn into the
bowel and accelerating the intestinal transit
time. If lactose intolerance is suspected, it can be
confirmed with a hydrogen breath test. Lactose
intolerance appears to be dose dependant. This
means that many patients can tolerate small
amounts of dairy products throughout the day,
such as � cup of milk, but not larger amounts.
Although it may seem obvious which foods
contain lactose, some sources may be difficult to
discern. Patients should look for hidden sources
in baked goods, salad dressings, and powdered
mixes. Labels with the following words contain
lactose: nonfat dry milk, milk powder, dry milk
solids, whey curds, and caseinate milk sugar.
Contrary to popular belief, acidophilus milk
does not have the lactose sugar digested and
is, therefore, a poor substitute for regular milk.
Soymilk and rice milk do not contain lactose and
are, therefore, good dairy substitutes. However,
these products are often low in calcium and
vitamin D. Hard cheeses and cultured yogurt
are usually acceptable alternatives. For patients
who do not tolerate lactose but want to consume
dairy products, supplemental lactase enzymes
are available. Several studies have shown that
patients with lactose intolerance have significantly
less calcium intake than those who tolerate
lactose. In one study, patients who were lactose
intolerant had a calcium intake of approximately
300 mg per day (1, which is only 20-40% of the
recommended calcium intake for adults. Patients
with lactose intolerance have also exhibited
decreased bone mass density (19). In light of the
potential for compromised calcium and vitamin D
intake, it would be prudent to evaluate all patients
with lactose intolerance for a calcium supplement
if needed.
Fructose is a hexose sugar that is highly utilized
in the western diet. In the past 20 years, there
has been a 10-fold increase due to its use in
highly processed food products. It is often used
as high fructose corn syrup in soda, fruit juices,
cookies, baked goods, jellies, and candy. Unlike
glucose, which is completely absorbed, fructose
absorption capacity is limited. Therefore, when
ingested in small quantities, dietary fructose
will probably not be an issue. However, when
consumed in larger amounts, fructose may serve
to osmotically draw fluid into the intestinal lumen.
This may cause distension of the small intestine
and produce symptoms such as abdominal pain,
bloating and discomfort. Furthermore, after
reaching the colon, unabsorbed fructose may
be fermented by colonic bacteria, producing
excessive gas (20).
Probiotics
Several studies now exist defining the potential
role of probiotics in IBS. These papers have
exhibited a great degree of variability, possibly
due to the use of different probiotic strains, their
ability to adhere and colonize in the GI tract,
and the number of colony-forming units actually
ingested by the individual. The probiotics most
often studied are lactobacillus, bidifobacterium,
and some non-pathogenic forms of e-coli. In a
recent study, bifidobacterium 35624 significantly
alleviated symptoms of abdominal pain and
discomfort, bloating, and distension. There was
also a normalization of IL-10/IL-12 ratios (this
skewed cytokine ratio may be indicative of a
proinflammatory Th-1 state). The bifidobacterium
used in this study is currently unavailable in the
US marketplace in the concentrations used in this
study (21,22).
Food products that are high in probiotics include
fermented milk, pourable yogurt, and yogurt with
live active cultures. Currently, there is no federal
agency in the US that routinely tests or "polices"
the market to ensure standardization and quality
of probiotic products. Independent tests have

revealed that up to 30% of probiotics on the
market are "laced" with reasonably adequate
live bacteria. One study used DNA extraction to
test five probiotic products at a local health food
store. The PCR analysis revealed that 2 of the 5
products did not contain the bifidobacterium
claimed on the label (23). I called a well-known
dairy in the Midwest several years ago. The
technician responsible for mixing the probiotic in
the yogurt explained that the bacteria are added
to a very large vat of product. The yogurt is then
packaged in individual cartons and there is no
final definitive measurement to ensure that the
amount of probiotic stated on the label is actually
in each individual container.
Putting It All Together
Due to the complex underlying pathophysiologies
in patients with IBS, nutritional intervention will
vary with each patient. The following general IBS
categories attempt to help "map" an approach
for dietary manipulation in the patient with IBS.
For individuals with diarrhea predominant IBS,
consider limiting nutrients that exacerbate GI
motility or intestinal secretion -- caffeine, fat
and some carbohydrates (fructose, lactose and
alcohol sugars). Probiotics can also be of benefit,
especially if post-infectious IBS or bacterial
overgrowth is suspected, or the patient has had
numerous antibiotic therapies in the past. If
constipation is the main issue, make sure the
patient has had an adequate trial of increased
insoluble fiber. This usually means that the
patient needs to count fiber grams and seek to
attain 20 grams of fiber per day. When visceral
hypersensitivity is suspected, ask the patient
to limit the amount of food eaten in one session
and instead to eat three small meals per day with
snacks. A low-fat diet and avoidance of insoluble
fiber may also be helpful for these patients.
Targeting nutritional intervention in the patient
with IBS can be challenging due to the many
different etiologies of this syndrome and the fact
that some patients have heightened responses to
different foods. A food diary kept by IBS patients
can be a particularly helpful way to ascertain which
foods may be problematic. It is recommended that
the clinician look for food "trends" in the journal,
with the goal of steering the patient away from
excessive food restriction behaviors.
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My website on IBS is www.ibshealth.com

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