Pelvic, Urinary & Lower GI
“Everything Came Back Normal, So It Is Probably IBS”
That sentence has been delivered to an enormous number of people as though it were a shrug. It is not a shrug. IBS is a positive diagnosis with published criteria, recognised mechanisms, and treatments that work.
The Short Version
IBS is not what is left over when the tests are normal. It is a disorder of gut–brain interaction with defined diagnostic criteria and identifiable subtypes.
The subtype matters enormously, because the treatment for constipation-predominant IBS and the treatment for diarrhoea-predominant IBS point in opposite directions. Being handed a generic fibre recommendation without a subtype is how people end up worse.
The delivery is usually apologetic. The tests were normal, the scope was clear, and so the diagnosis arrives sounding like an absence of one. Many people leave that appointment believing they have been told nothing is wrong — which is not what was said, but is what was heard.
What was actually being described is a genuine, mechanistically understood condition affecting a very large number of people, with a treatment literature considerably better than its reputation suggests.
The Reintroduction Phase Almost Nobody Completes — And Why It Is The Part That Matters.
Why staying in low-FODMAP restriction indefinitely is the most common self-inflicted mistake in IBS, and how the protocol is meant to run.
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It Is Diagnosed Positively, Using Criteria
The Rome criteria define IBS by recurrent abdominal pain associated with defecation, or with a change in stool frequency, or with a change in stool form, over a defined period. That is a positive rule, not an exclusion.
Subtype is then set by stool form on the days symptoms occur: constipation-predominant, diarrhoea-predominant, or mixed. This is the step most often skipped, and skipping it makes coherent treatment nearly impossible.
Limited testing is still appropriate to exclude coeliac disease, inflammatory bowel disease, and a few other conditions that mimic the presentation. But the point of that testing is to exclude specific named conditions, not to hunt indefinitely.
The Mechanism Is Not Mysterious
Two features come up repeatedly. The first is visceral hypersensitivity: the gut reports ordinary distension as pain. The volume control on the signal is turned up, not the volume of gas.
The second is altered motility and gut–brain signalling. The traffic between gut and brain runs in both directions continuously, which is why symptoms track stress reliably without being caused by it. Real pain with a functional mechanism is still real pain.
This is also why treatments aimed at the signalling — rather than at the bowel wall — perform as well as they do.
Take these to your appointment
- Stool form on symptom days, using the Bristol scale
- Whether pain reliably eases or worsens after passing stool
- Whether coeliac disease has ever actually been tested for
- Foods you already suspect, and how confident you are
- Whether symptoms ever wake you from sleep
- Any family history of inflammatory bowel disease or bowel cancer
You Do Not Have More Gas Than Other People. Your Gut Is Reporting The Same Volume As Pain.
Visceral hypersensitivity explained plainly — and why it makes gut-directed therapies effective rather than dismissive.
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✓ HIPAA-Compliant Intake|✓ Registered Dietitian On Staff|✓ Most Insurance Accepted
What Actually Has Evidence Behind It
Dietary work, specifically a properly structured low-FODMAP protocol run with a dietitian, has a solid evidence base. It is three phases — restriction, systematic reintroduction, personalisation — and the reintroduction phase is not optional. People who stay in restriction indefinitely narrow their diet without ever learning what their actual triggers are.
Gut-directed hypnotherapy and cognitive behavioural therapy have some of the strongest data in the field. These are not offered because the condition is psychological. They are offered because they act on gut–brain signalling, which is where the mechanism lives.
Targeted medication is prescribed by subtype: antispasmodics, agents for constipation or diarrhoea specifically, and low-dose neuromodulators that alter pain signalling at doses well below antidepressant range. Peppermint oil has reasonable supporting evidence and is often underused.
When to seek urgent careRectal bleeding, unintentional weight loss, symptoms starting after age 50, iron deficiency anaemia, a family history of bowel cancer or inflammatory bowel disease, or symptoms that wake you from sleep are not typical IBS features and require investigation.
IBS Has Published Diagnostic Criteria. Ask Whether Yours Were Ever Applied.
The Rome criteria in plain language, the subtype table, and the specific tests that should precede the label.
We send the dossier and nothing else unless you ask. No sharing, no selling, no third-party lists. Unsubscribe in one click.
✓ HIPAA-Compliant Intake|✓ Registered Dietitian On Staff|✓ Most Insurance Accepted