New IBS Thinking
Irritable Bowel Syndrome (IBS)
IBS is a functional bowel disorder characterized by symptoms of abdominal pain or discomfort associated with disturbed defecation. In addition, IBS is often associated with bloating, gas and excess mucus.
The Latest Thinking in IBS
However, the healthcare community had the understanding that the site of disturbance in IBS was primarily in the colon. This understanding was based on the colon’s association with disrupted bowel movements and visceral sensitivity.
The latest scientific investigations reveal the part of the GI tract that is disrupted in IBS is the small intestine, while the visceral sensitivity is throughout the GI tract 1. In addition, it is now known that the dysmobility 2 and abnormal permeability 3 observed in IBS is localized in the small intestine.
In patients reporting bloating, it has been found that the small intestine is the region responsible for ineffective gas propulsion 4. Finally, the disruption of the microbiome in IBS patients is also known to be in the small intestine 5.
The Impact of IBS on Nutrients
The small intestine is the primary site for digestion and absorption of nutrients. Up to 90% of nutrients are absorbed in this region ref. 1. The symptoms of IBS often occur within 90 minutes of eating 6. This 90 minutes reflects the time it takes for food to reach the small intestine. In IBS, the ability to absorb nutrients is disrupted due to bacterial overgrowth 7 and its related injuries to the GI tract 8 plus formation of excess mucus. This manifests in patients not being able to absorb fructose, bile acid and other nutrients ref. 2. More specifically, carbohydrate malabsorption and the inability to absorb essential amino acids is impaired and can only be partially corrected by antibiotic therapy 9. The low serum level of essential amino acids results in a depressed rate of synthesis of proteins 10. Along with a depressed rate of protein synthesis, there is protein-losing enteropathy in subjects with bacterial overgrowth 11.
The combination of protein loss and the depressed rate of protein synthesis is probably the cause of sub-clinical protein malnutrition observed in IBS patients 12. Dietary modification alone, as a management strategy, has had mixed success, because diet alone does not address the complex disruptions of the small intestine ref. 3.
To effectively manage IBS, it is important to help normalize small intestine transit time, inhibit bacterial overgrowth, enhance permeability of nutrients and remove the gas that disrupts absorption.
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1 Trimble, K.C. et. al. Heightened Visceral Sensation in Functional Gastrointestinal Disease is Not Site-Specific, Digestive Disease and Sciences; 40:8 (1607-1613) 1995
2 Kellow, John E. et. al. Altered Small Bowel Motility in Irritable Bowel Syndrome is Correlated with Symptoms, Gastroenterology; 92:6 (1885-1893) 1987
3 Dunlop, Simon P. et. al. Abnormal Intestinal Permeability in Subgroups of Diarrhea-Predominant Irritable Bowel Syndromes, Am J Gastroenterology; 101 (1288-1294) 2006
4 Salvioli, Beatrice et.al. Origin of Gas Retention and Symptoms in Patients with Bloating, Gastroenterology; 128:3 (574-579) 2005,
Reference 1: Your Digestive System and How it Works, IFFGD publication #190 (1-5) 2004
5 Pimentel, Mark, et. al. Large-Scale Deep Sequencing Reveals Altered Microbial Composition in IBS, Gastroenterology and Hepatology, Fall 2013 Reference 1 Your Digestive System and How it Works, IFFGD publication #190 (1-5) 2004
6 Ragnarsson, Gudmundur et.al. Pain is temporally related to eating but not to defecation in the irritable bowel syndrome (IBS). Patients’ description of diarrhea, constipation and symptom variation during a prospective 6-week study, European Journal of Gastroenterology & Hepatology, 10:5 (415-421) 1998
7 Saltzman, John R. et. al Nutritional Consequences of Intestinal Bacterial Overgrowth, Comprehensive Therapy; 20:9 (523-530) 1994
8 Singh, Virmeet V. et. al. Small Bowel Bacterial Overgrowth: Presentation, Diagnosis, and Treatment, Current Gastroenterology Reports; 5:(365-372) 2003 Reference 2 Niaz, S. K. et.al. Postinfective diarrhea and bile acid malabsorption, Journal of the Royal College of Physicians; 31:1 (53-56) 1997 & Helms, Sherri et. al. Fructose Malabsorption: A Possible Factor in Functional Bowel Disorders, US Pharm; 36:12 (41-44) 2011
Reference 2: Niaz, S. K. et.al. Postinfective diarrhea and bile acid malabsorption, Journal of the Royal College of Physicians; 31:1 (53-56) 1997 & Helms, Sherri et. al. Fructose Malabsorption: A Possible Factor in Functional Bowel Disorders, US Pharm; 36:12 (41-44) 2011
9 Giannella, R.A. et. al. Jejunal Brush Border Injury and Impaired Sugar and Amino Acid Uptake in the Blind Loop Syndrome, Gastroenterology; 67:5 (965-974) 1974
10 Yap, S. H. et. al Rate of Synthesis of Albumin in Relation to Serum Levels of Essential Amino Acids in Patients with Bacterial Overgrowth in the Small Bowel, Europ J. clin. Invest; 4: (279-284) 1974
11 King, Charles E. et. al. Protein-Losing Enteropathy in the Human and Experimental Rat Blind-Loop Syndrome, Gastroenterology; 80: (504-509) 1981
12 Maudgal, D.P., et. al. Subclinical Protein Malnutrition in IBS-Assessment by Retinal Binding Protein (RBP) and Thyroxine-Binding Pre-Albumin (TBPA), Human Nutrition, 1983 37c, 37-41 Reference 3: Shepherd, Susan J. et. al. Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for Effective Dietary Management, Jrnl ADA; 106 (1631-1639) 2006
Reference 3: Shepherd, Susan J. et. al. Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for Effective Dietary Management, Jrnl ADA; 106 (1631-1639) 2006