Patients with irritable bowel syndrome are frequently told there is nothing wrong with them, which is both unhelpful and inaccurate. IBS is a genuine disorder of gut function with measurable abnormalities in how the gut moves and how it signals pain.
It is not dangerous, it does not lead to cancer, and it can be managed considerably better than most patients experience.
What IBS Is
IBS is a disorder of gut brain interaction. The structure of the bowel is normal, but its function is not.
Three mechanisms are involved. The gut is hypersensitive, so normal amounts of gas or stool produce pain. Motility is abnormal, moving too fast or too slow. And communication between the gut and brain is altered, which is why stress genuinely worsens symptoms and why this is not a psychological diagnosis.
Many patients report onset after a bout of gastroenteritis, which is a recognised pattern called post infectious IBS.
The Symptom Pattern
The defining feature is abdominal pain related to defecation, with a change in stool frequency or form.
- Abdominal pain or cramping, often relieved after passing stool
- Bloating that worsens through the day
- Diarrhoea, constipation or alternating between them
- Urgency, or a feeling of incomplete evacuation
- Mucus in the stool
- Symptoms fluctuating over months and years
Subtypes are described by predominant stool pattern: diarrhoea predominant, constipation predominant, or mixed. This matters because treatment differs considerably between them.
What Must Be Excluded First
IBS is diagnosed on symptom criteria alongside the absence of alarm features, not by extensive testing. But certain conditions mimic it and must be excluded.
- Coeliac disease: blood tested for in everyone with IBS type symptoms, since it is underdiagnosed in India
- Inflammatory bowel disease: suggested by blood in stool, weight loss, night symptoms, and raised faecal calprotectin
- Thyroid dysfunction
- Lactose intolerance, very common in Indian adults
- Parasitic infection, particularly giardia
- Bile acid diarrhoea, often after gallbladder removal
- Colorectal cancer, in older patients or where alarm features exist
Basic testing usually includes blood counts, coeliac serology, thyroid function, inflammatory markers and stool tests. Extensive imaging is not needed in a young patient with typical symptoms and no alarm features.
Alarm Features That Rule Out IBS
These are not compatible with a diagnosis of IBS and require investigation.
- Blood in the stool
- Unintentional weight loss
- Symptoms waking you from sleep
- Fever
- Anaemia
- A family history of bowel cancer or inflammatory bowel disease
- New symptoms starting after age fifty
- A palpable abdominal mass
Night symptoms are particularly significant. IBS characteristically does not wake people, so pain or diarrhoea disturbing sleep points elsewhere and usually warrants colonoscopy.
The Low FODMAP Approach
This is the dietary intervention with the strongest evidence, improving symptoms in a majority of patients.
FODMAPs are fermentable carbohydrates that are poorly absorbed, draw water into the bowel and are fermented by gut bacteria, producing gas and distension.
High FODMAP foods common in Indian diets include wheat, onion, garlic, rajma and chana, cauliflower, milk, mango, apple and honey.
The approach has three phases and all three matter. Strict restriction for four to six weeks, then systematic reintroduction of each group to identify personal triggers, then a personalised long term diet. Staying on the restriction phase indefinitely is a mistake, since it narrows the diet unnecessarily and harms the gut microbiome.
Onion and garlic are the most common triggers in Indian patients, and eliminating them from cooking is difficult without guidance. Our dietetics team supervises this process.
Other Measures That Help
Beyond diet, several approaches have reasonable evidence.
- Soluble fibre such as psyllium helps constipation predominant IBS. Insoluble bran often worsens symptoms
- Peppermint oil capsules reduce cramping, with decent evidence
- Antispasmodics for pain episodes
- Regular meal timing rather than skipping and then eating large amounts
- Regular exercise, which improves gut motility and symptoms
- Adequate sleep, since poor sleep worsens gut sensitivity
- Reducing caffeine and alcohol
Probiotics have mixed evidence, with some strains helping some patients. A trial of four weeks is reasonable, discontinuing if there is no benefit.
The Gut Brain Connection Is Real
Stress does not cause IBS but it genuinely worsens it, through direct nerve and hormonal pathways between brain and gut. This is physiology, not imagination.
Approaches targeting this connection have good evidence. Gut directed cognitive behavioural therapy and gut directed hypnotherapy both produce meaningful symptom improvement in trials.
Low dose tricyclic antidepressants are also used, not for depression but because they modify gut pain signalling and slow transit. The dose is far lower than that used for mood, and explaining this prevents patients feeling their symptoms are being dismissed as psychological.
Living With It
IBS is a long term condition that fluctuates, and management is about reducing its impact rather than curing it.
- Keep a symptom and food diary for a few weeks to identify patterns
- Plan for flares rather than being surprised by them
- Know where toilets are when travelling, which reduces the anxiety that itself worsens symptoms
- Avoid restricting your diet progressively without guidance, which is common and harmful
- Return for review if the pattern changes, since a new symptom in an established IBS patient still needs assessment
That last point matters. Having IBS does not protect you from developing something else, and a genuine change in pattern deserves fresh attention.
IBS is real, common and manageable. Get coeliac disease excluded, use the low FODMAP approach properly with all three phases, address sleep and stress, and be alert to alarm features that mean the diagnosis needs revisiting.
Our gastroenterology department at T. Nagar assesses IBS and excludes the conditions that mimic it.
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