Here’s Our Agenda, and We Begin with Irritable Bowel Syndrome (IBS)

Irritable Bowel Syndrome

If you suffer with an “enteropathy,” this is the third article or lesson of our series. I will educate, enlighten, and empower you. You’ll want to return here often to remain updated.

If you haven’t already done so, I recommend you begin by reviewing our two introductory articles:

Welcome and Empowerment
Gut Health = Your Health!

The Enteropathy Triad

In review, enteropathy refers to a triad of the most common gastrointestinal or “gut” symptoms:

  • Abdominal pain and/or discomfort
  • Gas (abdominal bloating, distention, flatulence, and/or gurgling, rumbling)
  • Bowel dysfunction (diarrhea, constipation, or both)

About two of three people with enteropathy report that eating triggers these symptoms.

We’ll begin our series by taking a close look at irritable bowel syndrome (IBS) because it’s the most commonly diagnosed enteropathy.

Definition of IBS

IBS occupies the left side of the enteropathy map introduced in Article 1, because it’s the most-common enteropathy diagnosis. For now, disregard the complex interconnections, which I’ll address in Article 4 of this series.

The formal definition of IBS is described in Figure 3.1.


formal definition of IBS

The figure describes the symptom-based approach to IBS developed and recommended by The Rome Foundation, an international group of gastroenterologists and experts. IBS is one many “functional gastrointestinal disorders,” now called disorders of gut-brain interaction. (Remember you have two brains, shown in Figure 2.1 and Figure 2.2 of Article 2.) Most non-gastroenterologists aren’t familiar with the Rome Foundation and their diagnostic and therapeutic recommendations.

You can “see red” in the figure, since I don’t agree with the exclusion of “discomfort” in the definition because I find many patients don’t call it “pain.” Furthermore, most report that symptoms are related to eating.

The diagnosis of IBS also requires absence of “red flags” or concerning features, which may require further testing, including colonoscopy and scans, when the concerning features are present,:

  • New symptoms, particularly if onset is 50 years or older
  • Significant change in symptoms
  • Severe or progressively worsening symptoms
  • Unintended weight loss
  • Blood in the stool/rectal bleeding
  • Diarrhea interfering with sleep
  • Flushing
  • Family history of colon cancer, celiac disease, or inflammatory bowel disease
  • Abnormal physical examination or laboratory testing
  • Iron deficiency anemia

Don’t Forget My Enteropathy Map

Sadly, most healthcare professionals make a diagnosis of IBS in the absence of red flags and don’t consider the many other diagnoses and conditions included in my map (Figure 1.2). As a result, I say, “Opportunities for treatment and healing are missed.” For example, Sucrose Intolerance caused by Congenital Sucrase-Isomaltase Deficiency (CSID) in adults usually isn’t associated with red flags.

Yes, IBS is an enteropathy, but there are many other diagnoses and disorders to consider. Furthermore, it’s very common for more than one to be present, providing more than one treatment target. One of the most common combinations I see is post-infectious IBS-D/M (which I’ll explain later), Sucrose Intolerance caused by CSID, and bile acid malabsorption — three opportunities for treatment.

So, you should be able to appreciate how we’re trying to help here with our Enteropathy Series!

The Bristol Stool Form Scale (BSFS)

The BSFS is a useful diagnostic tool to evaluate stool form (Figure 3.2). Types are assigned a number from 1 through 7 corresponding to descriptions on the scale.


Bristol Stool Form Scale

Accurate classification of IBS and enteropathy subtype based upon bowel habit abnormalities using the BSFS should be made without taking treatment medications, including laxatives and antidiarrheal agents. Subtyping is most accurate when bowel habits are abnormal at least 4 days per month.

Stools that are well-formed and easy to pass (Types 3 and 4) are considered “normal.”

Classification of IBS

IBS diagnosis includes identifying four subtypes based upon predominant bowel function:

  • IBS-C (constipation)
  • IBS-D (diarrhea)
  • IBS-M (mixed, or both constipation and diarrhea)
  • IBS-U (unclassified)

I recommend combining IBS-D and IBS-M and recognizing two types, if possible.

  • IBS-D/M
  • IBS-C

Here’s why. Most individuals with IBS-D and IBS-M have an “irregularly” irregular bowel pattern: irregular form and irregular frequency. Furthermore, many with IBS-D have some constipation. Finally, research by gastroenterologist Mark Pimentel and colleagues at Cedars-Sinai Medical Center in Los Angeles shows that most with IBS have associated gut microbiome dysbiosis, which refers to disturbances of the resident gut microbiome (Figure 2.1 and Figure 2.2). IBS-D and IBS-M are most commonly associated with small intestinal bacterial overgrowth, or SIBO. IBS-C is most commonly associated with growth or BLOOM of a microbe residing in the colon. Are you curious? It’s called Methanobrevibacter smithii! I’ll shorten this long, scientific name to M. smithii from this point on.

Post-Infectious IBS-D/M

Dr. Pimentel has confirmed the most common cause of IBS-D/M is an autoimmune enteropathy resulting in SIBO triggered either by bacterial food poisoning (Campylobacter, Salmonella, Shigella, and E. coli) or colitis caused by Clostridium difficile infection. He has developed a diagnostic blood test called IBSSmart. You can learn more about the test at


To be clear, IBS-C with associated M. smithii isn’t associated with bacterial food poisoning or Clostridium difficile infection. However, the microbe produces methane gas, which interferes with gut motility and causes or contributes to symptoms, particularly constipation.

Associated Disorders: Mind/Body-BrainS/Gut Dysfunction

Note that “BrainS” is plural because in the introductory article of our series, you discovered that you have a second brain in your gut. Most with IBS also suffer with other bodily symptoms, such as fatigue, headaches, brain fog, anxiety, depression, skin disorders, and unexplained pain, which can be widespread. Commonly associated medical diagnoses include fibromyalgia, chronic sinusitis, interstitial cystitis, and thyroid disease.


Gut Health = Your Health!
Unhappy Unhealthy Gut = Unhappy Unhealthy You

Here’s how bodily symptoms and diagnoses occur (see Figures 2.1 and 2.2 in Article 2):

  • “All disease begins in the gut.”
  • Gut microbiome dysbiosis results in gut dysfunction.
  • “Leaky gut” allows certain substances to be absorbed, resulting in bodily chronic inflammation, autoimmunity, and allergy.
  • Impaired absorption results in nutrient deficiencies.
  • Heightened sensation of pain and symptoms by both brains is like turning the volume control all the way up on two radios.
  • Mast cells, part of the body’s immune system – most of which is located in the gut, release histamine, which can both irritate nerves and cause or contribute to symptoms involving any organ system.

Future Agenda

Now that I’ve thoroughly covered IBS, here are the lessons you can look forward to:

  • Diagnosis of the causes of and conditions associated with enteropathy
  • Diagnosis of food intolerance and sensitivities. Eating triggers symptoms in most individuals with enteropathies.
  • Diagnosis of Sucrose Intolerance (table sugar)
  • Diagnosis of carbohydrate maldigestion
  • Preparing for consultation with a gastroenterologist
  • Treating IBS
  • Recognizing conditions and disorders commonly associated with celiac disease and non-celiac gluten or wheat sensitivity
  • Deciding whether to take a probiotic, including suggestions on how to select and take the product
  • Knowing the most common causes of diarrhea and when to consult with a doctor
  • Understanding abdominal bloating and distention, along with management suggestions

In the next lesson, I’ll show you how I approach diagnosis of enteropathy, including IBS.

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