As a naturopathic doctor who specializes in the treatment of complex gastrointestinal disorders, I see many patients who carry the diagnosis of IBS (irritable bowel syndrome). In fact, before I was diagnosed with Celiac disease, I myself was given the diagnosis of IBS by a gastroenterologist. What this diagnosis unfortunately means to many doctors is “we don’t really know what’s wrong with you and why you have abdominal pain/constipation/diarrhea, etc.” In my case, I never had IBS. I had Celiac disease. But no one tested me for that until much later. This is why I feel that labeling patients with the term IBS has the potential to cause harm. If I had taken my diagnosis at face value, I would have gone home and stopped bothering doctors about my symptoms anymore. And my Celiac disease would have continued to get worse and cause me additional harm (spoiler alert- it did).
Often if we spend additional time with patients and use appropriate lab testing, we can get to the root cause of why patients have IBS. While there are many different conditions that cause IBS-like symptoms, here are the top five conditions that I see in my practice:
SIBO: Research suggests that up to 78% of IBS patients have underlying SIBO infections (1). SIBO (small intestinal bacterial overgrowth) is a disorder caused by an over-abundance of bacteria in upper intestinal tract. It is also possible to develop SIFO (small intestinal fungal overgrowth). Common symptoms of SIBO are excessive upper abdominal gas and bloating, early satiety, abdominal pain, and either constipation or diarrhea depending on what microbe or microbes are present. SIBO can be tested for using a home breath test kit that measures the amount of gas released from the small intestine after consuming sugar.
Large Intestinal Dysbiosis: The small intestine is not the only area of the body that can host pathogenic bacteria. I very frequently find that my IBS patients have abnormal levels of “bad” or “commensal” bacteria in their colon, a term we call dysbiosis. Commensal bacteria are bugs that should be present in small or moderate amounts in a healthy colon, but become pathogenic if their numbers rise above a certain level. Candida albicans also fits into the category of commensal yeast. Dysbiosis symptoms are typically lower intestinal gas, bloating, and pain, along with either constipation or diarrhea. Advanced stool testing can show us if there is an imbalance in bacterial or fungal levels in the large intestine. The test I use most often for this is Genova’s GI Effects Comprehensive Panel.
Multiple Food Intolerances: Food intolerances can cause very similar symptoms to SIBO and large intestinal dysbiosis: abdominal discomfort, gas, bloating, constipation, diarrhea, etc. They can also cause additional symptoms like skin rashes, fatigue, mood changes, and even increased environmental allergy symptoms. Patients often mistakenly think they would be able to tell if they had food intolerances by just paying attention to how they feel after each meal. But food intolerance reactions actually occur between 2-24 hours after the food has been ingested, and most people are eating foods that they are intolerant to multiple times per day. This makes it impossible to diagnose a food intolerance reaction with something like a diet diary or just general recall. I use US Biotek’s 96 Food Panel to identify food intolerance reactions in my patients and find their results to be accurate and reliable even with repeat testing.
Digestive Enzyme Insufficiency: When we eat food, our stomach, pancreas, and gallbladder increase their production of different types of digestive enzymes. The function of these enzymes is to break down food into small particles that can then be absorbed in the small intestine. If we don’t put out enough enzymes when we eat, food will move into the small intestine while it is still in large pieces. These large particles are too big to be properly absorbed. This can lead to uncomfortable symptoms like gas, bloating, reflux, and even malnutrition if the problem is bad enough. We can test for pancreatic enzyme insufficiency with a test called stool pancreatic elastase, and this test is often covered by insurance. Acid testing can be done by referring patients for an exam called a Heidelberg test. In both cases, we can also just test for deficiency by giving supplemental enzymes and seeing if symptoms improve. With acid supplementation, I do recommend working with a physician as patients with undiagnosed gastritis can suffer additional damage with acid experimentation.
Celiac Disease: While I myself have Celiac disease, I see it much less frequently than all the above conditions. But due to the long term-complications of undiagnosed Celiac disease, all IBS patients should have a simple blood test to rule out Celiac as an underlying cause of their symptoms. Celiac disease is an autoimmune reaction against the gluten protein in wheat products, and patients with this disease can display a wide variety of symptoms. The most common presentation of Celiac disease is unintentional weight loss, gas, bloating, abdominal pain, and diarrhea. But the disease may also present with constipation, mood changes, skin rashes, sleep difficulties, and even weight gain. I’m especially concerned about the possibility of Celiac disease if the patient exhibits symptoms of malabsorption: anemia, low growth rate in children, undigested food in the stool, and/or weight loss.
I want to encourage any patient with a diagnosis of IBS that they may not have to suffer with their uncomfortable and embarrassing symptoms for the rest of their life. In many cases, once we are able to identify and treat the REAL underlying cause of their symptoms, many patients are able to live much healthier and happier lives.
Dr. Katie Nuckolls is a naturopathic physician and owner of Thrive GI: Natural Digestive Medicine in Vancouver, Washington. She currently sees patients that live in Washington and Oregon using telemedicine. For more information, visit our contact page or schedule a free 15-minute consultation online.