As mentioned previously, a large number of patients with IBS symptoms do not report them to their physicians. And some symptomatic patients do not request specific treatment even when they go to the clinic, preferring to extrapolate numerous benefits from explanations about their diagnosis and factors that exacerbate IBS symptoms (including stress and possible dietary factors). As a step-by-step process, it is necessary to establish a trusting doctor-patient relationship at the beginning of effective treatment for IBS. This process is summarized in Table 3. The healthcare provider should reassure the IBS patient that the condition will not progress to other life-threatening diseases, that at most it may manifest as physiologic abnormalities including intestinal dynamics and sensory systems, and that IBS is associated with psychosocial disorders that require treatment at the onset of symptoms. In this regard, determining the severity of the condition may help in planning a life regime that will be therapeutic. As an example, most patients with severe abdominal pain and other symptoms that affect overall quality of life require investigation for a history of physical or sexual abuse and/or the previously mentioned psychiatric disorders. (4) Early psychological or psychiatric intervention is beneficial for these patients. If a patient with a GI disorder is predominantly a physiologic disorder, it is reasonable and potentially beneficial to engage in pharmacotherapy. After an IBS diagnosis has been made, dietary modifications may improve symptoms. In one study, 48% of IBS patients benefited after excluding dietary modifications and gradually adding foods that did not cause additional symptoms. more than 60% of Americans are lactose intolerant and have symptoms similar to IBS, so removing lactose from the diet is recommended. In normal volunteers, both caffeine and decaffeinated coffee beverages have been shown to stimulate rectosigmoid activity. Sorbitol, a sugar alcohol used as a major ingredient in sugar-free candy, medications, and acid suppressants, may produce flatulence, diarrhea, and gas-like symptoms of IBS. Establishing a routine that includes exercise and treatment for stressful conditions is also recommended. One way to clarify whether life stress, the composition of the diet, and other psychosocial factors exacerbate the symptoms of IBS is to use a symptom log over a 2-6 week period. This method can be used to identify dietary factors and stressful events associated with exacerbation of IBS symptoms. These logs can be used as recommendations for dietary contraindications, treatment of stressful conditions and psychological counseling. Additional treatment for IBS is necessary when the patient and their physician believe that the current condition has affected the patient’s quality of life. Initial treatment of patients with constipation-predominant IBS often involves increased dietary fiber intake and the addition of commercial fillers. Fiber decreases the overall GI circulation time and reduces the contractility of the colon. Several studies have demonstrated the benefit of increased fiber intake in patients with constipation-predominant IBS. A variety of fiber supplements are commercially available in finished form, including synthetic fibers containing calcium polycarboxylate (Fiberconò, Equalactin). Soluble fiber occurs naturally in a number of fruits and grains, including apples, oranges, apricots, prunes, and oat bran. Plantago ovata, the active ingredient of Metamucilò and Konsylò, is also a soluble fiber. Methylcellulose, the active ingredient of Citrucelò, is an insoluble fiber. In comparison with soluble fibers methylcellulose may theoretically lead to a reduction in gas and flatulence in some patients. Over-the-counter laxatives can be helpful for some patients with IBS where constipation is predominant. Osmotic laxatives including milk of magnesia, paraffin oil, and sodium docusate capsules (e.g., sodium docusate) can be used safely and effectively in some patients. Polyethylene glycol in electrolyte balancing solution (MiralaxÔ) is a prescription medication that is similar to the solution used during colonoscopy prep. It is administered as 16 grams dissolved in 8 ounces of fluid 1-2 times/day. This medication has been shown to be effective in patients with intractable constipation. In addition, treatment with antispasmodic medications including anticholinergics can also help relieve pain. The use of antispasmodic drugs in constipation-dominant IBS is also limited based on their ability to cause constipation. Antidepressants have been used in the treatment of IBS and other bowel dysfunctions, and its effectiveness initially occurred in the activity of the central nervous system. Tricyclic antidepressants, a drug with anticholinergic effects, have been shown to relieve symptoms of abdominal pain and diarrhea in patients with IBS. These drugs often cause constipation, so they should be used with caution in patients with constipation-predominant IBS. Selective 5-hydroxytryptamine reuptake inhibitors (SSRIs), which may cause diarrhea or constipation, have been used in the clinical management of IBS and other bowel disorders. Evidence-based medical studies suggest that the effectiveness of most IBS treatments is still lacking in terms of long-term efficacy. Recently, the 5-HT4 agonist tegaserod (Zelnormò) has been approved by the FDA for the treatment of constipation-based IBS. This drug can bind 5-HT4 receptors with high efficiency. In laboratory studies it has been shown to stimulate bowel movements and intestinal secretion as well as to reduce visceral sensitivity. tegaserod also stimulates the release of other neurotransmitters, including calcitonin gene-related peptides (which may have an effect on gastrointestinal function). Physiological studies have demonstrated that tegaserod enhances basal bowel motility activity and corrects bowel motility in patients with constipation-predominant IBS. Prior to approval of this drug, three randomized, placebo-controlled, 12-week, double-blind clinical trials were completed in which a total of 2471 female patients with constipation-predominant IBS received tegaserod (6 mg, bid) or placebo. These studies showed that tegaserod relieved discomfort as well as other symptoms in female patients with constipation-predominant IBS (Figure 2). In addition, patients taking tegaserod had more frequent stools, relief of abdominal pain, and increased stool viscosity. The most common side effect that limits the use of tegaserod is diarrhea. Future treatments for constipation-predominant IBS include additional agonists of 5-HT4, such as prucalopride and renzapride. other treatments for IBS targeting the GI tract are being investigated, including 5-HT1 receptor agonists, kappa opioid receptor agonists, growth inhibitor analogs, and antagonists of neurokinin and tachykinin.