Irritable Bowel Syndrome (IBS) is a complex medical problem and most doctors shy away from getting too involved in its management. This is because the causes are unknown and conventional treatments are hit and miss.
Various causes have been postulated in the past including somatisation, muscular spasms, dysmotility, over-sensitive intestinal nerves, stress and anxiety. The popularity of explanations has come in waves. The management approach has evolved accordingly but has been medically-focused with questionable efficacy. During my training in the eighties, I often heard my mentor diagnose IBS and immediately send the patient home with no treatment, as he was so unconvinced it would be of use.
I was equally sceptical and the patients I saw were largely discharged with the same problems as they presented with. I was intrigued by a landmark paper by Brian Cooper that described wheat sensitivity in IBS.(1) It went largely unnoticed (citations to this publication in the literature started in 2012) and it took me a few years before I tried a wheat-free diet in patients with IBS, with considerable success for certain symptoms. It was not until about 2012 that the medical literature suggested a benefit, resulting in implementation of the low FODMAP diet which has become one of the main treatments for IBS.
There was a lot of excitement when the gut microbiome became a focus in IBS. The term gut-brain axis was coined, whereby IBS was proposed to be due to an impairment in the messages received between the two and induced by a subtle change in the gut microbiome (i.e. intestinal dysbiosis). Commercial companies had a field day and there has been a proliferation of available probiotics with no shortage of claims of efficacy. Like most gastroenterologists, I was dismissive about all the unfounded claims on the efficacy of probiotics.
However, in 2008, I agreed to launch a properly designed study (randomised, double-blind, placebo-controlled) on the possible efficacy of Symprove in IBS. I was exceptionally sceptical and in fact my main goal was to prove that probiotics were not effective in managing IBS. The trial took 3 years to complete and I failed in my goal – the study completely changed my view on probiotics and evolved my management approach.
Based on the results, I decided to take an integrated approach to supporting my IBS patients rather than to rely on single medically-focused treatment modalities. Most of my patients now receive dietary and lifestyle intervention and Symprove as first line. I involve a dietitian where possible, particularly if advising a low FODMAP diet (usually as second line). The patients I see often have significant anxiety/low mood/stress issues which exacerbate the perceived severity. I estimate that I refer about 50% to my liaison psychiatrist, who uses one of the many cognitive behavioural therapy interventions.
The results are that rather than simply reassuring the patient that nothing serious is going on (which is still practiced by many doctors), I estimate that about 70% of IBS patients benefit significantly from this integrated approach. I rarely need to see these patients ongoing. Of course there are failures, especially in those with the chronic fatigue syndrome and hyper-mobility syndromes and others with relentless long-standing symptoms.
I’ve been delighted to see my local GP network implement similar diet and lifestyle changes, including trialling Symprove. From my own personal perspective, this appears to have reduced referral rates.
I’m often asked which strains of bacteria are appropriate for which conditions or symptoms. There is a range of studies discussing benefits of different strains but the evidence is often mixed. What I’ve come to learn from my research with Symprove is that being water-based is critical to success, as it ensures the bacteria remain viable and metabolically active from consumption.
In summary, it is simplistic to the extreme to expect a single bullet for IBS with its diverse and largely unexplained pathogenesis and pathophysiology. An integrated approach of dietary and lifestyle intervention, including a water-based probiotic, can support the management of IBS in my clinical experience.
References
1. Cooper BT, Holmes GK, Ferguson R, Thompson RA, Allan RN, Cooke WT. Gluten-sensitive diarrhoea without evidence of celiac disease. Gastroenterology. 1980;79:801-6.
