Due to its moderate effectiveness additional intake

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tion, however, decreased abdominal pain in IBS patients. Due to its moderate effectiveness, additional intake of soluble fiber may be recommended for IBS-C patients. Studies also revealed that pain relief was not associated with increased fiber intake and that the addition of in- soluble fiber such as nuts or whole grains to the diet had either no effect or exacerbated IBS symptoms [79] . LACTOSE INTOLERANCE Patients with IBS were found to have significantly more subjective lactose intolerance complaints (bloating, dis- tention, and diarrhea) than those without IBS and to have increased likelihood of lactose malabsorption than the general population [81] . Thus, decreased intake of lactose can benefit some IBS patients [82] . It is hypothesized that, following ingestion of lactose, hydrogen gas is produced and gut distention is promoted due to bacterial fermenta- tion of the unabsorbed lactose. Interestingly, the majority of IBS sufferers, however, failed to test positive for hy- drogen breath tests that indicate lactose intolerance [82] . PHARMACOTHERAPY In the past patients with IBS were treated by giving medi- cines targeting individual symptoms of IBS such as bloat- ing, abdominal pain, diarrhea, and constipation. However, newer medications are beginning to focus on the molecu- lar level like serotonin receptor agonists and antagonists and drugs that act locally on chloride channels (Lubipro- stone) and guanylate cyclase receptors (linaclotide) in the gastrointestinal tract [83] . The problem is that no one drug fits all, meaning that the IBS population is very diverse with each individual presenting with different prevailing complaints. The heterogeneity of the IBS population exists because of the wide range of complaints and the varying degree of symptom severity. Because of poorly designed studies and ill-defined outcomes, the medical literature regarding IBS therapy is generally inconsis- tent [84,85] . The placebo response in IBS patients is quite significant with short-term trials reporting a 30%-80% response [86] . One can imagine the difficulty of treating a syndrome that is heterogeneous in its presentation, lacks in significant supporting medical literature, and has a remarkably high placebo response rate. Even though patients’ symptoms overlap, addressing them individually allows the physician to simplify and organize the appro- priate medical therapy. ABDOMINAL PAIN The major contributing factor in abdominal pain expe- rienced by IBS patients is visceral hypersensitivity. The management of abdominal pain in IBS has changed very little over the past few decades: antispasmodics remain a cornerstone of therapy. Antispasmodic agents work by anticholinergic properties like dicyclomine and hyoscya- 6765 June 14, 2014 | Volume 20 | Issue 22 | WJG | Saha L. Evidence based review on IBS
mine. The evidence of the effectiveness of these agents is not compelling, as even the meta-analyses for smooth muscle relaxants are conflicting. One meta-analysis dem - onstrated an advantage over placebo for antispasmodics in terms of abdominal pain and distention [87] . Brandt et al [43]

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