Please read this Overview first, as it sets the seen for what Bloating and IBS more generally is all about

1.0 First, some key-points about Irritable Bowel Syndrome (IBS)…

1.0.1 Normal for the gut is not one thing- it is a range. A normal bowel habit is hugely variable and passing some gas, also is normal

1.0.2 IBS is a real diagnosis, not just a good guess - tests are needed.

1.0.3 There is no link between IBS and bowel cancer.

1.0.4 Constipation with excessive straining when passing a bowel motion can be a sign of a pelvic floor muscle problem.

1.0.5 Different IBS symptoms respond to different diets: the diet for say Gas and Constipation is different to that for Diarrhoea.

1.0.6 Food Allergy in adults is rare but Intolerances are common.

1.0.7 Diets for IBS have nothing to do with weight loss, or foods that are Natural, Healthy or Clean.

1.0.8 Changing diet AND lifestyle helps IBS greatly.

1.0.9 IBS diets are not always easy to follow

1.0.10 Diet may not be the complete answer - several different approaches together may be the solution.

1.0.11 There is always a solution

1.1 IBS in general

We are not here just to give you a Diet Treatment Plan targeted to your particular tummy problems, we also want to make sure you know how to get diagnosed and managed properly.

The big questions to be answered in trying to sort out your tummy are: What do the symptoms mean? Could I have: a food intolerance, allergy, Irritable Bowel Syndrome (IBS), or could it be something else? Do I need tests? What diet? What else can be done?

A quick-ish answer (in two parts):

1.1.1 Answer part 1:

If you have had your tummy problems for over 6 months, and you are younger than 45 years old, then it could well be "Irritable Bowel" or a food intolerance. But, tests are needed still to be certain.

Symptoms can't tell us what is causing them because anything that goes wrong in our tummies shares the same symptoms. "Irritable Bowel", food intolerance, gluten allergy, bowel inflammation, you name it... all can cause the same symptoms.

This brings us quickly to the second part of the answer- you MUST get tests done and that goes for everyone, irrespective of age. Let's repeat that! You MUST get tests done!

1.1.2 Answer part 2:

It is important to see your GP about getting simple tests done to make sure that it is not something else like a gluten allergy (coeliac disease), bowel inflammation ("colitis") or other things.

It is particularly important to see your GP if you have passed blood with a bowel motion (even if you think it might be piles/haemorrhoids), have constant lower tummy bloating or pain, have lost weight for no obvious reason or have a family history of bowel / ovarian cancer.

You may find it surprising when we say that there is a very good chance that the tests will be normal even though these symptoms are having such an impact on your life. This is because gut symptoms are nearly always completely out of proportion to what is causing them

1.2 So what is IBS?

1.2.1 The ABC of IBS symptoms are:

• Abdominal pain / discomfort

• Bloating

• Change of bowel habit (to Diarrhoea or Constipation or both [Mixed / Alternating type])

1.2.2 The different types of IBS

IBS is a general name-tag, but doesn't say what needs to be done to get it better. We need to know what type of IBS we have: is it more Diarrhoea than Constipation? Is it sometimes Diarrhoea/sometimes Constipation? Is gas or bloating a problem? The changes that we need to make in what we eat is very much decided by the most troublesome symptom.

An international committee of experts (called the Rome Group) meet every few years to agree and fine-tune what symptoms best diagnose IBS. Surprisingly, it is not that easy a job and we are now onto out fourth set of Rome classifications (Rome IV), which divides IBS into different types, dependent on whether diarrhoea, constipation, or a mixture of these two is the main problem.

The Rome classification is very important because it guides us to what the best treatment for each type of IBS will be. IBS is not "just IBS" to be treated in exactly the same way regardless of the exact symptoms and type. Unfortunately, that's what usually happens, but, not with us!

The key types of IBS are:

- Diarrhoea predominant

- Constipation predominant

- Mixed or Alternating type (both diarrhoea and constipation)

- (and for us: Bloating)

1.2.3 But what is a Normal bowel habit?

To understand what is "not normal", we need to know what "normal" is.

Normal is not one thing, it is a range: it can be passing a bowel motion once or twice a day and it can be going only once every three days. We don't have to go every day to be normal!

Bowel habit and motions (stools) can change a lot naturally (but this needs to be checked by a doctor if it happens suddenly and we are over the age of 45-50 years):

- It is normal to pass some mucus (this is white / clear and jelly-like)

- It is normal to pass gas every day- but, it shouldn't be a key feature of life

- Going to the loo should be neither urgent nor require straining every time (occasionally, these things happen to any of us "normally")

- Opening the bowels should not be painful (apart from very occasionally if we are constipated, which again can happen to all of us, particularly if we change diet as when we go on holiday)

- It is NEVER normal to pass blood (that must always be investigated by a doctor, even if we suspect it is due to haemorrhoids or 'piles'). On this point, just because the doctor finds some piles, at the least a “qFIT” stool sample is needed to make sure that there is nothing else further up in the bowel. If there is blood, not doing a test is just taking chances.

A normal stool should be soft, firm, sausage-shaped and passed easily, but most of us will at times experience bowel motions that range from hard “pebbles” to gushing liquid. The lower bowel is not a perfect machine to turn out an identical “product” every time! This can vary hugely with diet and changes to lifestyle, such as stress at work or going on holidays.

The Bristol stool chart

This cartoon chart (invented, as the name suggests, by doctors in Bristol, UK) is used to make it easier for us to describe our stools. This is actually very important because what one person means by “constipation” or “diarrhoea” can be hugely different to what someone else means.

A type 4 stool on the Bristol Stool Chart is accepted as being "normal", or certainly what we aim towards at most visits to the toilet (Type 1 is small pebbles and type 7 is like water).

As you will see, we use this chart to help guide you to the best diet for your particular symptoms.

Whilst we're on the subject:

• the colour or smell of stools is rarely of any medical importance

• long thin ribbon-like stools are almost never a sign of bowel narrowing

1.3 How the gut/bowel works

Let's talk about the various part of the gut and what they do. It can be a bit confusing because words are used interchangeably (“gut” = “intestine” = “bowel”) and the same area has different names (e.g. the lower bowel = the large bowel = the colon). Also, all of us use the word "stomach" to loosely refer to our tummy. In fact, the stomach is a very specific organ, in a specific area.

The main parts of our gut

You don’t have to know how the gut works, but it does help with explaining how diet can help with Bloating/gas and IBS. It’s worthwhile knowing and there is no exam at the end!

The gut is made up of three parts - each doing a different job. What the parts have in common is that they are made up of a long hollow tube of muscle, which, like rings on a pond, sends ripples of movement every few seconds along its length, from the mouth to the far end.

To co-ordinate these waves, the gut has its own "pacemaker". This is a bundle of nerves that generates an electrical impulse with a regular timing. This stimulates the muscle of the bowel wall to contract and push things along. It seems that for many of us with IBS, there is some problem with how this system works, causing areas of spasm rather than the more normal gentle "ripples".

These “ripples” are called peristaltic waves and carry food and waste along with them. Think of a boa-constrictor swallowing something. It is because of these waves, that bowel pains can often be like repeated cramps ("colicky" pain) and why medications such as mebeverine, alverine, mint oil and hyoscine (Buscopan) can help relieve tummy discomfort.

1.3.1 The gullet (oesophagus) and stomach: transport and preparation

The gullet is about 40cm long and its job is to pass food from the mouth to the stomach. The stomach is a muscular bag "preparation" area, where food is slowly churned with acid and broken down into a 'paste'. This is to allow the small bowel a better chance of digesting food completely.

The end part of the stomach is shaped like a funnel whose 'spout' can become wider or narrower depending on the type of food- fatty foods, caffeine, alcohol and chocolate all make the 'spout' narrower and so slow down emptying of the stomach. That is why we feel very full after "rich" foods- we are full! The food is literally sitting there waiting for the spout to allow it to pass.

1.3.2 The small intestine: digestion and absorbing nutrients

Immediately after the stomach comes the small intestine, which is about six metres long. It is called "small" because it is narrow in width (about the width of your thumb) when compared with the large intestine (about three fingers wide).

The small intestine is where all the digestion and absorption of nutrients into the body take place. It is lined with millions of microscopic "fingers" (the villi), which are themselves covered in enzymes that work like chemical "scissors" to chop-up and absorb nutrients.

To help this digestion, bile juice is released from the liver and pancreatic juice from the pancreas. The liver is a pretty big solid organ found below the right-side ribs. It is like a factory for the body. The pancreas is shaped like a tadpole and lies deep behind the stomach, just below the breast-bone in the upper abdomen. Both organs are joined to the small bowel by narrow tubes ("ducts").

The job of the bile from the liver is to break fat into smaller droplets, which makes it easier in turn for the other enzymes in pancreatic juice to break it down. Bile looks like washing-up liquid (clear and green-yellow in colour) and does exactly the same thing (breaks up fats). The pancreatic juice (which is colourless) also digests proteins and carbohydrates.

The bile and pancreatic juices do part of the digestion but other key players are the "scissor" like enzymes that cover the small bowel lining. These enzymes are very important for breaking down the sugars that occur naturally in food (lactose in milk and fructose in fruit / vegetables). You'll hear a lot more about these in other sections- especially in relation to Gas.

Nutrients from the digested food paste are then slowly absorbed (over several hours) as it makes its way along the small intestine.

At the end of the small bowel, just before it enters the large bowel (colon), the bile gets absorbed so that it can be re-cycled and used again for your next meal. But, in some people, the bile just carries on down into the colon, which really does not like it one bit- this can cause very bad, profuse, watery diarrhoea. This type of diarrhoea is called "bile acid diarrhoea" (“BAD”) and can be mis-diagnosed as IBS (it's discussed in another section).

There is normally only a relatively small number of bacteria in the small intestine, but in some people, the number of bacteria can increase greatly. This is termed Small Intestinal Bacterial Overgrowth (SIBO), which can cause bloating and diarrhoea.

1.3.3 The large (lower) intestine (colon): absorbing water and making waste

The large intestine (colon) is about one metre long. It is the widest part of the bowel (about 2-3 finger breadths; hence its called "large"). The job of the colon is to absorb excess water left after food has been digested - if we didn’t have a colon, we would all have very watery stools and have to drink huge amounts of fluid every day to keep hydrated.

The small intestine joins up with the colon in the lower right side of the tummy, just above the right hip bone. The colon runs like a "picture frame" around the tummy - up the right side, across the top (below the ribs) and then down the left side to the bottom (rectum). This is why we can get discomfort in different areas of the tummy, particularly if we have bloating or gas, as it shifts around the bowel.