I have irritable bowel syndrome with diarrhea. Can probiotics help?

Question

Hello doctor,

I have had IBS-D (irritable bowel syndrome with diarrhoea) for a while now, and I often experience loose stools, urgency, and a constant bloated feeling. It is really unpredictable and makes it difficult to go out or eat with friends.

I have tried avoiding gluten. I am tired of having to plan my day around bathrooms. and dairy; however, I am still not sure what triggers it. Stress definitely makes it worse.

I was prescribed Rifaximin once, and it seemed to work for a few weeks, but the symptoms returned.

Are there any newer medications that work in the long term?
What do you think about probiotics?
Are they really useful, or are they just hype?

Please help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Since you have IBS-D (irritable bowel syndrome with diarrhoea) and your symptoms returned after Rifaximin, you need a comprehensive management plan. It is also important to rule out common conditions that can mimic IBS-D, such as bile acid diarrhoea (which may respond to a trial of Cholestyramine or Colesevelam), lactose intolerance, thyroid disease, and microscopic colitis (which requires colon biopsies even if the colonoscopy appears normal).

There are several long-term treatment options that work well for many people with IBS-D:

Loperamide: Can be used strategically before outings or meetings at the lowest effective dose.
Low-dose Ondansetron: Often helps firm stools and reduce urgency, although it is not FDA-approved for IBS-D.
Eluxadoline: May help with diarrhoea and abdominal pain. Do not take it if you do not have a gallbladder or if you are at risk of pancreatitis.
Low-dose tricyclic antidepressants (TCAs) such as Amitriptyline or Nortriptyline: Among the most effective medications for cramping, urgency, and the anxiety associated with IBS.
Repeat Rifaximin: May be considered if it was beneficial previously, but it should be combined with identifying and controlling symptom triggers.

Instead of avoiding many foods indefinitely, follow a structured low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet for 2 to 6 weeks, then gradually reintroduce foods to identify your specific triggers. Adding psyllium slowly may also help improve stool consistency.

There is no consistent evidence that probiotics provide lasting benefit for IBS-D. If you decide to try one, use a single product for 4 to 8 weeks. If you do not notice a clear improvement or your bloating worsens, it is best to stop.

Most importantly, stress does not cause IBS, but it can significantly worsen flare-ups. Cognitive behavioural therapy (CBT) or gut-directed hypnotherapy can help reduce symptom severity and ease anxiety related to bowel urgency.

For more queries, feel free to reach out to me anytime.

Thank you.