Bloating and IBS: understanding long-lasting digestive symptoms

Feeling bloated after a large meal is normal. Feeling bloated, crampy and unsettled week after week, with bowel habits that swing between loose and hard, is a different matter. Long-lasting digestive symptoms like these are very often caused by irritable bowel syndrome (IBS), a common condition that can be managed well once it is recognised. This guide explains what IBS is, how bloating fits in, which signs should be checked promptly and the range of approaches that can help.

What IBS is

IBS is a common condition of the digestive system. It is usually long term, often lasting years, with symptoms that come and go and periods of flare-ups in between calmer spells. IBS can be painful and disruptive, but it does not damage the digestive tract or lead to other health problems.

The exact cause is not known, and different factors may matter for different people. Experts believe the following can play a part:

• Gut-brain interaction. Changes in how the brain and gut communicate can affect how quickly food moves through the bowel and how sensitive the gut is. Some people feel pain from normal amounts of gas or stool.
• Infections and gut bacteria. A previous bacterial infection of the digestive tract, or an overgrowth of bacteria in the small intestine, may contribute.
• Food sensitivities. Some foods may provoke symptoms in some people.
• Genes and life experiences. Genes may make some people more likely to develop IBS, and difficult life events, anxiety and depression are more common in people with IBS.

Common symptoms

The main symptoms of IBS are:

• abdominal pain or cramps, often worse after eating and eased by a bowel movement
• bloating and a feeling of fullness
• diarrhoea, sometimes with a sudden urge to go
• constipation, with straining and a feeling that the bowel has not fully emptied

Other symptoms can include wind, mucus in the stool, tiredness, nausea, backache, bladder symptoms and pelvic pain. Women may notice that symptoms are worse around their period. Doctors often describe IBS by its main bowel pattern: mostly diarrhoea, mostly constipation, or a mixture of both. This helps guide treatment.

Common triggers

Flare-ups can happen without any clear reason, but many people notice that certain things make symptoms worse, including:

• alcohol and caffeine
• fatty or spicy foods
• stress and anxiety
• courses of antibiotics

Keeping a simple diary of what you eat, how you feel and your bowel habits for a few weeks can help you and your doctor spot your personal triggers.

Bloating: not always IBS

Bloating is one of the most common reasons people seek advice about their digestion, and it has many possible causes. The most frequent is gas in the gut, which can come from certain foods and fizzy drinks or from swallowing air while eating. Other causes include constipation, food intolerance, coeliac disease and IBS, and some people feel bloated around their period.

Simple measures often help: eating smaller meals, eating with your mouth closed, limiting fizzy drinks, alcohol and caffeine, avoiding foods that you know cause gas, regular exercise and drinking enough water. Rarely, persistent bloating can be a sign of a more serious condition, which is why bloating that is regular or does not improve with diet changes should be checked by a doctor.

Signs that need prompt medical attention

Some symptoms are not typical of IBS and should be assessed quickly. Seek an urgent medical appointment if you have:

• unexplained weight loss
• bleeding from the bottom, bloody diarrhoea or black, tarry stools
• a hard lump or swelling in your abdomen
• signs of anaemia, such as shortness of breath, a racing heartbeat or unusually pale skin
• bloating together with a high temperature, vomiting or abdominal pain
• an inability to pass stool or wind

Seek emergency care if bloating comes with a swollen abdomen and sudden severe pain, vomiting blood or severe difficulty breathing.

How IBS is diagnosed

There is no single test for IBS. Instead, doctors look for a typical pattern of symptoms and make sure nothing else is responsible.

The symptom pattern

IBS is likely when abdominal pain occurs regularly, on average at least once a week over the past three months, together with at least two of the following: the pain is related to bowel movements, it comes with a change in how often you open your bowels, or it comes with a change in how your stool looks. Typically, symptoms began at least six months earlier, although a diagnosis can sometimes be made sooner.

History and examination

Your doctor will ask about your symptoms, diet, medicines, recent infections and stressful events, and whether anyone in your family has had coeliac disease, inflammatory bowel disease or bowel cancer. A physical examination checks the abdomen for swelling and tenderness.

Tests to rule out other conditions

Tests are often not needed. When they are, they help exclude other causes:

• blood tests for anaemia, infection and other digestive diseases
• stool tests for blood, infection or signs of other disease
• further tests chosen according to your symptoms and history, such as a hydrogen breath test, an upper endoscopy with biopsy to check for coeliac disease, or a colonoscopy to look for inflammatory bowel disease or bowel cancer

See a doctor if you think you have IBS and your symptoms have lasted more than about four weeks.

Managing IBS: what can help

There is no single diet or medicine that works for everyone, so management is usually a process of finding the combination that suits you.

Diet

• Eat regular, balanced meals; do not skip or delay meals, and try not to eat too quickly.
• Limit fatty, spicy and highly processed foods.
• If constipation is the main problem, increase soluble fibre, for example from oats, pulses, carrots and linseeds.
• If diarrhoea is the main problem, cutting back on high-fibre foods such as wholegrains, nuts and seeds may help.
• For bloating and wind, regular oats can help, and some people benefit from avoiding hard-to-digest foods such as cabbage, beans and onions, or sweeteners such as sorbitol.
• A low FODMAP eating plan is another option. Because it involves removing and then reintroducing groups of foods, it is ideally followed with support from a dietitian.

Lifestyle

Regular physical activity, enough sleep, plenty of fluids, and cutting back on caffeine, alcohol and fizzy drinks are all worth trying. Finding ways to relax matters too, as stress is a common trigger.

Medicines and probiotics

Depending on your main symptoms, your doctor or pharmacist may suggest antispasmodic medicines for cramps, medicines to slow diarrhoea, or fibre supplements and laxatives for constipation. For ongoing pain, some people are prescribed certain antidepressant medicines, used in this case to ease gut pain rather than to treat mood. Probiotics can be tried for a limited period; research on how well they work for IBS is still ongoing, so discuss them with your doctor.

Psychological therapies

Because the gut and brain are closely linked, therapies such as cognitive behavioural therapy, gut-directed hypnotherapy and relaxation training can reduce symptoms for some people. These are recognised treatments for IBS, not a suggestion that symptoms are imagined.

It may take time and a few attempts to find what works. If diet changes and pharmacy remedies are not enough, your doctor can refer you to a dietitian or a specialist.

Next steps

If bloating, diarrhoea, constipation or abdominal pain have become a regular part of your life, a specialist can confirm the cause, rule out other conditions and help you build a plan that fits your symptoms.

• Learn more about our gastroenterology services.
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