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Moderate Evidence

Promising research with growing clinical support from multiple studies

Irritable Bowel Syndrome (IBS)

Irritable bowel syndrome (IBS) is a chronic, relapsing disorder of gut–brain interaction characterized by abdominal pain associated with altered bowel habits, without structural disease that explains the symptoms. Western medicine classifies IBS using the Rome IV criteria: recurrent abdominal pain, on average, at least 1 day per week in the last 3 months, associated with two or more of the following—related to defecation, associated with a change in frequency of stool, and associated with a change in form (appearance) of stool—with symptom onset at least 6 months before diagnosis. Subtypes are defined by predominant stool pattern: diarrhea-predominant (IBS-D), constipation-predominant (IBS-C), mixed (IBS-M), and unclassified. Pathophysiology is multifactorial: visceral hypersensitivity, altered motility, immune activation and barrier dysfunction, dysbiosis, bile acid malabsorption in a subset, and central modulation via the gut–brain axis. Psychosocial stressors and early life adversity can amplify symptoms through bidirectional brain–gut signaling. Evidence-based Western management is multimodal and personalized. First-line lifestyle strategies include regular physical activity, sleep optimization, and diet. The low-FODMAP diet—temporary restriction of fermentable oligo-, di-, monosaccharides and polyols—has strong evidence for reducing global IBS symptoms when delivered in a structured elimination and reintroduction program (best studied by Monash University). Soluble fiber (psyllium) is recommended in IBS-C and some mixed phenotypes, while insoluble fiber may worsen symptoms. Pharmacologic options are matched to subtype and dominant symptoms: antispasmodics (e.g., dicyclomine, hyoscyamine) for cramping; loperamide for urgency/diarrhea control (not for global symptom relief); bile acid sequestrants in suspected bile acid diarrhea; non-absorbed antibiotic rifaximin for IBS-D; secretagogues such as linaclotide and plecanatide for IBS-C; lubiprostone (women with IBS

Gastroenterology Updated February 19, 2026

This content is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider before starting, stopping, or changing any supplement or medication regimen.

Western Medicine

Diagnosis

Rome IV criteria: recurrent abdominal pain at least 1 day/week in the last 3 months, associated with ≥2 of the following—related to defecation, change in stool frequency, change in stool form—with symptom onset ≥6 months before diagnosis; evaluate alarm features (GI bleeding, weight loss, anemia, nocturnal symptoms, family history of colorectal cancer/IBD/celiac) and perform limited testing (e.g., celiac serology in IBS-D/M, fecal calprotectin to exclude IBD when appropriate). Classify subtype by Bristol Stool Form Scale: IBS-D, IBS-C, IBS-M, IBS-U.

Treatments

  • Dietary therapy: low-FODMAP diet (structured elimination + reintroduction), individualized trigger minimization, adequate soluble fiber (psyllium)
  • Lifestyle: regular physical activity, sleep hygiene, stress reduction
  • Antispasmodics for cramping (short-term, as needed)
  • Antidiarrheals (loperamide) for urgency/diarrhea control
  • Bile acid sequestrants for suspected bile acid malabsorption (subset of IBS-D)
  • Non-absorbed antibiotic rifaximin for IBS-D (short courses; retreatment for recurrence)
  • Secretagogues for IBS-C: linaclotide, plecanatide; chloride channel activators: lubiprostone (women)
  • 5-HT4 agonist: tegaserod for select women <65 years with low cardiovascular risk and IBS-C
  • Mixed opioid receptor modulator eluxadoline for IBS-D (with safety screening)
  • Gut–brain axis modulators: low-dose tricyclic antidepressants (TCAs) for pain/IBS-D; SSRIs for mood and sometimes IBS-C
  • Gut-directed psychotherapies: cognitive behavioral therapy (CBT), gut-directed hypnotherapy; mindfulness-based stress reduction as adjunct
  • Peppermint oil (enteric-coated) for global symptoms and pain
  • Emerging microbiome-directed therapies: targeted probiotics (heterogeneous evidence), postbiotics, and FMT in trials

Medications

  • Rifaximin (IBS-D)
  • Eluxadoline (IBS-D; contraindications apply)
  • Loperamide (symptom control)
  • Bile acid sequestrants: cholestyramine, colesevelam (for bile acid diarrhea)
  • Antispasmodics: dicyclomine, hyoscyamine (mebeverine/otilonium where available)
  • Peppermint oil (enteric-coated)
  • Linaclotide (IBS-C)
  • Plecanatide (IBS-C)
  • Lubiprostone (women with IBS-C)
  • Tegaserod (select women with IBS-C)
  • TCAs: amitriptyline, nortriptyline (low dose)
  • SSRIs/SNRIs: sertraline, citalopram, duloxetine (selected cases)

Limitations

IBS is heterogeneous; no single therapy works for all patients. Placebo response rates are high. Low-FODMAP requires skilled guidance to avoid over-restriction and potential microbiome changes; long-term strict restriction is not advised. Pharmacotherapies can have adverse effects (e.g., diarrhea with linaclotide, constipation with eluxadoline, anticholinergic effects with antispasmodics). Rifaximin benefits may wane, requiring retreatment. Access to trained dietitians and gut-focused psychotherapists can be limited. Evidence for probiotics and FMT is inconsistent; guidelines are cautious.

Evidence: Strong Evidence

Sources

  • American College of Gastroenterology Clinical Guideline: Management of Irritable Bowel Syndrome (Lacy BE et al., 2021)
  • Rome IV Diagnostic Criteria for Functional GI Disorders (Drossman DA et al., 2016)
  • Monash University low-FODMAP program and RCTs (e.g., Halmos EP et al., Gastroenterology 2014; Staudacher HM et al., Gastroenterology 2012)
  • Pimentel M et al., Rifaximin for IBS-D, N Engl J Med 2011 (TARGET 1 & 2) and follow-up studies
  • Chey WD et al., Linaclotide for IBS-C, N Engl J Med 2012; Plecanatide Phase 3 trials (Miner PB et al., Am J Gastroenterol 2017)
  • Ford AC et al., Antidepressants and psychological therapies in IBS, Am J Gastroenterol 2019 meta-analyses
  • Everitt HA et al., ACTIB trial—CBT for IBS, Lancet Gastroenterol Hepatol 2019
  • ACG 2021 guideline statements on probiotics and FMT (cautious/against routine use)
  • El-Salhy M et al., FMT in IBS, Gut 2020 (mixed results across trials)

Eastern & Traditional Medicine

Traditional Chinese Medicine (TCM)

IBS is viewed as disharmony among Liver, Spleen, and Stomach. Common patterns include Liver qi stagnation invading the Spleen (stress-triggered pain/urgency, bloating, alternating bowel habits) and Spleen qi deficiency with dampness (fatigue, loose stools, postprandial bloating). Treatment principles aim to soothe Liver, strengthen Spleen, move qi, transform dampness, and harmonize the middle jiao. Pattern differentiation guides individualized herbal formulas and dietary therapy.

Techniques

  • Pattern-based herbal formulas: Tong Xie Yao Fang (painful diarrhea), Xiao Yao San or Si Ni San (Liver qi constraint), Shen Ling Bai Zhu San (Spleen qi deficiency), modifications per patient
  • Dietary therapy aligned with TCM: warm, cooked, easily digestible foods; avoidance of dampness-producing foods; stress modulation
  • Acupoints commonly used alongside herbs: ST25, ST36, SP6, LR3, PC6
Licensed TCM physician Licensed acupuncturist Integrative medicine physician
Evidence: Emerging Research

Acupuncture (within TCM)

Regulates qi flow, modulates visceral sensitivity and motility, and influences central pain processing. Often combined with pattern-based herbs or used as monotherapy for pain, bloating, and bowel habit irregularity.

Techniques

  • Body acupuncture with points such as ST25, ST36, SP6, LR3, LI4; electroacupuncture in some protocols
  • Course: typically 1–2 sessions weekly for 4–8 weeks
Licensed acupuncturist Physician acupuncturist
Evidence: Moderate Evidence

Phytotherapy: Peppermint oil (bridging traditional and modern)

Traditional carminative validated by modern trials. Enteric-coated peppermint oil exerts antispasmodic effects on intestinal smooth muscle (calcium channel blockade), reduces visceral pain, and decreases bloating.

Techniques

  • Standardized enteric-coated capsules (e.g., 180–225 mg per dose) 2–3 times daily before meals; specialized microsphere formulations used in some RCTs
Gastroenterologist Primary care/integrative physician Herbalist/Naturopath
Evidence: Strong Evidence

German/TCM-influenced multi-herb formulas (e.g., STW 5/Iberogast)

Multi-targeted herbal combinations to modulate motility, secretion, and visceral sensitivity; traditionally used for functional dyspepsia and IBS-like symptoms.

Techniques

  • Commercial standardized liquid formula (STW 5/Iberogast) dosing as per label; other region-specific patent formulas based on TCM patterns
Integrative medicine physician Gastroenterologist familiar with phytotherapy TCM practitioner
Evidence: Moderate Evidence

Sources

  • Maciocia G. The Foundations of Chinese Medicine (pattern frameworks)
  • Systematic reviews of Chinese herbal medicine for IBS (e.g., Liu JP et al., Cochrane Database Syst Rev 2006/updated reviews)
  • Meta-analyses on Tong Xie Yao Fang and related formulas for IBS-D (e.g., Zhang S et al., Medicine (Baltimore) 2017)
  • Manheimer E et al., Acupuncture for IBS, Cochrane Database Syst Rev 2012 (low–moderate certainty; benefits vs no treatment; equivocal vs sham)
  • Recent meta-analyses suggesting symptom improvement vs pharmacotherapy, with limitations in blinding/heterogeneity
  • Khanna R et al., Peppermint oil for IBS, J Clin Gastroenterol 2014 meta-analysis
  • Cash BD et al., Randomized trial of targeted peppermint oil (IBGard), Dig Dis Sci 2016
  • ACG 2021 guideline endorses peppermint oil for global IBS symptoms
  • Melzer J et al., Iberogast—systematic review, Phytomedicine 2013
  • Randomized and observational studies showing symptom reduction in functional dyspepsia and some IBS cohorts (Madisch A et al., various)

Integrative Perspective

A practical integrative plan starts with a positive diagnosis using Rome IV criteria, limited exclusion testing, and IBS subtype classification. Combine high-quality Western evidence with individualized traditional modalities: (1) Diet: Implement a dietitian-led low-FODMAP program for 2–6 weeks, then reintroduce to personal tolerance. A TCM-informed dietary lens can guide food preparation (warm, cooked, simple) and meal regularity, complementing FODMAP choices while avoiding long-term over-restriction that may impact the microbiome. (2) Rapid symptom relief: Enteric-coated peppermint oil is a well-validated, low-risk option bridging East–West paradigms for global symptoms and pain. (3) Subtype-targeted pharmacotherapy: rifaximin or eluxadoline in IBS-D; linaclotide/plecanatide or lubiprostone in IBS-C; antispasmodics as needed. (4) Gut–brain axis: Combine CBT or gut-directed hypnotherapy with mindfulness-based practices (MBSR) to address stress reactivity; acupuncture may be added for pain and bloating in patients who prefer this modality. (5) Herbal support: In centers with appropriate expertise and quality sourcing, consider pattern-based TCM formulas (e.g., Tong Xie Yao Fang for IBS-D features) and multi-herb combinations like STW 5, monitoring for interactions and tolerability. (6) Microbiome care: Replete soluble fiber (psyllium), diversify diet after low-FODMAP reintroduction, and use probiotics selectively; routine FMT remains investigational. Coordinate care among gastroenterology, dietetics, and qualified traditional practitioners. Highlight: Peppermint oil exemplifies a traditional remedy now strongly supported by modern RCTs and endorsed in guidelines.

Sources

  1. American College of Gastroenterology Clinical Guideline: Management of IBS (Lacy BE et al., Am J Gastroenterol 2021)
  2. Rome IV Diagnostic Criteria (Drossman DA et al., Gastroenterology 2016)
  3. Halmos EP et al., A diet low in FODMAPs reduces IBS symptoms, Gastroenterology 2014
  4. Staudacher HM et al., Mechanisms and efficacy of low-FODMAP diet, Gastroenterology 2012
  5. Pimentel M et al., Rifaximin therapy for IBS-D, N Engl J Med 2011
  6. Chey WD et al., Linaclotide for IBS-C, N Engl J Med 2012; Miner PB et al., Plecanatide trials, Am J Gastroenterol 2017
  7. Everitt HA et al., ACTIB trial—CBT for IBS, Lancet Gastroenterol Hepatol 2019
  8. Khanna R et al., Efficacy of peppermint oil in IBS, J Clin Gastroenterol 2014
  9. Cash BD et al., Targeted-release peppermint oil in IBS, Dig Dis Sci 2016
  10. Manheimer E et al., Acupuncture for IBS, Cochrane Database Syst Rev 2012
  11. Liu JP et al., Cochrane reviews on Chinese herbal medicine for IBS (various updates)
  12. El-Salhy M et al., FMT in IBS, Gut 2020

Health Disclaimer

This content is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider before starting, stopping, or changing any supplement or medication regimen.