Understanding and Managing Pain in Irritable Bowel Syndrome (IBS)

Introduction

Pain, by definition, is the dominant symptom experienced by patients with irritable bowel syndrome (IBS). Three out of 4 people with IBS report continuous or frequent abdominal pain, with pain the primary factor that makes their IBS severe. Importantly, and unlike chronic pain in general, IBS pain is often associated with alterations in bowel movements (diarrhea, constipation, or both).

The standard general definition for pain is an unpleasant sensory and emotional experience that’s associated with actual or perceived damage to the body. Pain that is short-lived is termed acute, while pain that lasts 6 months or longer is termed chronic. Chronic pain may be constant or recurring frequently for extended periods of time.

The chronic pain in IBS can be felt anywhere in the abdomen (belly), though is most often reported in the lower abdomen. It may be worsened soon after eating, and relieved or at times worsened after a bowel movement. It is not always predictable and may change over time. People with IBS use different descriptors to explain how the pain feels; some examples include cramping, stabbing, aching, sharp, or throbbing.

IBS is a long-term condition that is challenging both to patients and healthcare providers. It affects 10–15% of adults. Less than half of those see a healthcare provider for their symptoms. Yet patients with IBS consume more overall health care than those without IBS. The primary reason people with IBS see a clinician is for relief of abdominal pain.

Understanding pain in IBS

Chronic abdominal pain in irritable bowel syndrome (IBS) is not associated with structural damage, like ulcers, but the pain is just as real. The sensation starts in the gut and then travels to the brain, which interprets the sensation as pain. The pain is not related to obvious damage in the body, like a broken bone.

Brain imaging shows that people with IBS feel more pain for a certain level of stress than other people. Those with IBS are hypersensitive; they have an increased response that makes a stimulus feel more painful. They may experience pain from sensations that other people don’t think are painful (called allodynia) or have more severe pain than others (called hyperalgesia).

How is the pain experienced?

In IBS, some signals in the gut are experienced in some brain regions as pain. After the brain receives pain signals, it can modify the signals to increase or reduce the feeling of pain.

The brain’s ability to modify sensations is called the gate control theory of pain. Signals that travel from the body to the brain pass through the spinal cord, which can serve as a kind of “gate”. The brain can open and close this gate, like a volume switch on a stereo. Opening the gate increases the signals that reach the brain and increases the feeling of pain. Closing the gate decreases signals and blocks pain.

This explains how a person can sprain an ankle while running a race and not feel pain until the race is over. Or, how during a bad day at work, a minor discomfort can feel really painful – all because the spinal cord acts as a gate to modify how much pain in the brain feels. 

Managing the Pain

All treatment for IBS begins with education to understand the nature of the condition, including why and how symptoms arise. IBS is a brain-gut disorder. For people with IBS that is mild, the treatment is at the level of the gut. But, when more severe chronic pain is present, the treatment also needs to be at the level of the brain. 

Learn more about Cognitive Behavioral Therapy to help with the brain-gut interaction

Can the chronic pain state be reversed?

With proper treatment, chronic pain can be reduced or stopped. Different approaches include medication, psychological approaches, and self-management. Using more than one therapy may work better than using just one method alone. For example, combining psychological approaches with medication is often effective. When treating chronic pain, it is important to be patient. Treatments often take time before they start wo

Treatment approaches for IBS

When pain is chronic it takes time for it to go away. Because pain is an emotional experience, taking steps to improve emotions can lead to reduction of the harmful effects of the pain even when it is still present.

Maintaining an active role in life, engaging in physical activity, and addressing emotional and social health are important to help promote a sense of well-being, which counters negative expectations.

  • Medications
    • Anticholinergic agents taken before a meal can provide short-term relief. These gut-targeted medications work on several IBS symptoms, including pain, diarrhea, and constipation.
    • Central acting agents, or central neuromodulators, can block signals from the brain. This type of drug can help decrease intestinal and central hypersensitivity, help the brain control the pain, and improve gut motility. Central acting agents use two approaches to help reduce pain. In the first approach, the medication helps the brain to limit nerve signals by closing the gate to pain. In four to six weeks, the pain is generally 30%–50% better. The second approach involves helping to regrow the damaged nerves. Regrowth takes a long time; anywhere from six months to a year or more. Creating new functioning nerves is vital to prevent the pain from returning.
    • There is no evidence that opioids can help IBS. In fact, taking opioids can slow the gut, causing constipation, nausea, and vomiting. Learn more about opioid-Induced constipation

  • Psychological approaches
    The power of the mind can be harnessed to affect pain by sending signals or thoughts to close the pain gate. Techniques such as hypnosis, meditation, and cognitive behavioral therapy (CBT) can help ease symptoms and improve control over the disorder.

    Learn more about psychological approached in managing IBS 

  • Self-management
    Pain is an emotional experience, so taking steps to improve emotions can reduce the harmful effects of the pain even when it is still present. Tackling emotional and social health is essential to promote a sense of well-being, which counters negative expectations.

    Here are 10 things you can do to help reach treatment goals:

    1. Acceptance: Accept that the pain is there, and learn about the condition and its management
    2. Get involved: Take an active role in care by developing a partnership with healthcare providers
    3. Set priorities: Look beyond symptoms to establish what is important. Eliminate the rest
    4. Set realistic goals: Break larger goals into smaller, manageable steps. Celebrate when you reach goals, even small ones!
    5. Know your rights: You have the right to be treated with respect, to ask questions, voice your opinions, and to say no without guilt
    6. Recognize and accept emotions: Your mind and body are connected, and strong emotion affects pain. Acknowledge your emotions to reduce stress and manage pain.
    7. Relax: Exercises like hypnosis, meditation, yoga, or deep breathing can help reclaim control of the body and reduce pain.
    8. Exercise: Staying active can help increase your sense of control and divert attention from symptoms.
    9. Refocus: Focus on abilities instead of disabilities to help realize that you can live a normal life.
    10. Reach out: Share thoughts and feelings with healthcare providers, family, and friends. Seek support and healthy interaction.

How quickly does a central agent have effect on the pain?

There are two levels to taking one of these agents. At the first level the medication increases the brain’s ability to down-regulate nerve signals through the gate control mechanism, closing the gate to reduce pain. Within four to six weeks the pain is generally 30–50% better.

The second level is the neurogenesis, and that can take six months to a year or more. This is important to help prevent the pain from coming back, or relapsing.

The two effects are the physiologic effect of the pain control through the gating mechanism, and the neuroplastic effect through the brain to regrow those nerves that have been damaged by the chronic pain.

What kind of healthcare provider best treats IBS pain?

A gastroenterologist who works in neurogastroenterology addressing the brain-gut axis, or a primary care doctor who knows how to work with chronic pain is usually best to treat IBS pain. They may work with a multi-disciplinary team of therapists. Finding and working with a patient-centered healthcare provider familiar with the concepts presented here will help ensure the best care for chronic pain and other symptoms of IBS.

Be on the alert for pain management clinics that use opioids as treatment, which are not a treatment for IBS and may worsen symptoms. Pain is the dominant symptom of IBS. Like all functional gastrointestinal disorders, IBS is a disorder of brain–gut interactions. The pain in IBS is related to a change in the part of the brain that receives signals from the gut, which “turns up the volume” on sensations. This understanding of the brain–gut connection is essential, not only to the cause of the chronic pain, but also to its treatment. There is no cure for pain in IBS. However, there are a few options that can reduce and control the pain. These include self management, psychological approaches, and medications. Opioids are not a treatment for IBS pain; there is no evidence of long-term benefit. Finding and working with a patient-centered healthcare provider familiar with these concepts will help ensure the best available care for the chronic pain and other symptoms of IBS.

Putting it all Together

  • Brain imaging shows that people with IBS feel more pain than other people
  • Sensations travel from the gut through the spinal column to the brain where they are felt as pain.
  • The brain can modify the sensation of pain, either increasing or decreasing it
  • Therapy and medications can help reduce or prevent the pain from IBS
  • Strong painkillers like opioids should not be used for pain in IBS; in fact, they might increase pain.
  • Neurogastroenterologists or primary care doctors who know how to work with chronic pain are the best to help treat IBS pain 


Adapted from IFFGD Publication #274 “Understanding and Managing Pain in IBS” by Douglas A. Drossman, M.D., Center for Education and Practice of Biopsychosocial Care, Center for Functional GI and Motility Disorders at UNC, and Drossman Gastroenterology, Chapel Hill, NC. Adapted by Abigale Miller

For healthcare providers
Here is a video of a presentation by Douglas A. Drossman delivered at the UCLA GI Week 2016 on the topic, “State of the Art Lecture: Understanding and Management of Patients with Chronic Abdominal Pain and Narcotic Bowel Syndrome.”

Acknowledgment
We are grateful to The Allergan Foundation for a health and human services educational grant in support of this publication.

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