When I was battling c diff infection, I joined a support group online. Since I have healed I follow the group and offer such support as I can. One thing I have noticed is the very common experience of abdominal symptoms that occur after infection has been treated. To be clear, these symptoms feel like the c diff infection did, but individuals test negative for c diff. What is going on? We believe, it is post-infectious irritable bowel syndrome (PIIBS) after c diff.
What is PIIBS?
PIIBS is defined as the new onset of irritable bowel syndrome occurring after a gastrointestinal infection, either bacterial (like c diff), viral (like norovirus) or parasitic (like Giardia). It is considered a functional problem; your gut just doesn’t work right. The American College of Gastroenterologists (ACG) calls IBS a “disorder of the gut-brain interaction”. One document describes PIIBS as a “post-traumatic stress” of the colon. Your brain becomes hypersensitive to everything going on down there. You feel everything, every little ripple.
PIIBS is associated with alterations in gut motility, increased permeability of the colon (things leak into the bloodstream through the colon wall more easily), persistent inflammation and increased cytokine production (cytokines are the immune system product that causes fever, they make you feel crappy).
What is the incidence of PIIBS after c diff infection?
Multiple studies have been done, demonstrating a range from 5-40% of persons with c diff developing PIIBS. We know the risk of getting IBS in general increases by 6 times after having a viral or bacterial infection of the colon. Some studies suggest that the incidence of PIIBS is about 25% in people that have had c diff.
What are the risk factors for getting PIIBS after having c diff?
More studies need to be done to clarify risk factors. So far, we see in increased risk of developing PIIBS when people experience:
- Symptoms of c diff lasting 7 or more days
- Nausea, vomiting or abdominal pain occurring with c diff
- Current anxiety (as PIIBS feels like c diff recurrence this is really common)
- Increased BMI (in one study thought to be >27 BMI)
- Decreased microbiome diversity
- Possibly bacterial vs. viral preceding infection- bacterial infections are more likely to trigger PIIBS
Interestingly, the following are not associated with PIIBS risk:
- Age
- Gender
- Having blood in the stool
- Environment
- Ethnic differences
PIIBS is a global phenomenon, occurring worldwide.
What are the symptoms of PIIBS?
Symptoms of PIIBS are the same as those of IBS in general, including changes in stool consistency and frequency, abdominal pain, cramping, bloating, excessive gas, and mucus in stool. Please note that these greatly overlap symptoms of c difficile infection, which is quite alarming when you are trying to heal from c diff.
There are three types of IBS: diarrhea predominant (IBS-D), constipation predominant (IBS-C), and mixed with both diarrhea and constipation (IBS-M). In contrast, PIIBS is more often diarrhea predominant. As c diff is a diarrheal illness, having recurrence of diarrhea is scary, because it mimics infection. Once you’ve had c diff, you NEVER want to get that again. And for many of us, it has taken months, sometimes years to finally resolve an infection. PIIBS following c diff infection may constant worry about c diff recurrence.
What triggers PIIBS?
In addition to having had a recent bacterial, viral or parasitic GI infection, stress and food can trigger PIIBS. Fighting c diff is very stressful, and many of those dealing with c diff are experiencing anxiety. Fear of c diff recurrence is real. Early evidence suggests that an alteration in the gut microbiome can be associated with PIIBS, and an altered microbiome may be associated with alterations in serotonin. Your gut is considered your “second brain” so the association with anxiety as a trigger is not surprising.
How does c diff cause PIIBS?
C diff makes two toxins, A and B. These toxins damage the cells that line the colon. Apparently toxin B is 1,000 times as potent as toxin A. (Toxin B is the target for Zinplava, a monoclonal antibody infusion that reduces recurrence of c diff). When these cells – enterocytes, colonocytes and enteric glial cells (ECGs) are damaged, that sets up a cascade of inflammation, causing the enterocolitis associated with c diff.
ECG cells that are damaged in this way cannot recover. They can be replaced but it takes time. Their role is to promote normal GI function, including motility, immune responses, blood flow and nutrient absorption. This dysfunction of the colon causes delays in healing and persistence of symptoms.
How long does PIIBS last?
Most studies suggest PIIBS can last for months or even years; one study suggested that it can last over 10 years. Yikes! Most of those with PIIBS will improve over several months. Studies suggest that prompt and early treatment of c diff infection can prevent many cases of PIIBS.
How is PIIBS treated?
PIIBS is not mentioned in the c diff guidelines of either the Infectious Disease Society of America (IDSA) or the ACG. The ACG does have IBS guidelines that mention PIIBS but do not mention c diff as a cause. Treatment is the same: dietary measures, and possibly some medications. Medications such as cholestyramine help to slow down diarrhea (and it also binds c diff toxins, added bonus) and antispasmodics are not recommended by guidelines but are sometimes used. Recommended mediations include secretagogues to reduce constipation for IBS-C and agents that slow diarrhea for IBS-D. Sometimes tricyclic antidepressants are used; these boost serotonin and reduce pain signaling.
As with everything c diff, restoring a healthy microbiome is essential in treating PIIBS after c diff. Guidelines do not recommend probiotics, however, citing the need for more studies to affirm a benefit.
What are the dietary measures used to treat PIIBS?
IBS is treated with the FODMAP diet. FODMAPs are a type of carbohydrate found in certain foods. Carbohydrates give us energy, along with fat and protein. FODMAPS are not easily absorbed by the bowel and are fermented by bacteria in the gut, causing bloating, gas and distention.
The FODMAP diet reduces certain carbohydrates to improve symptoms and function. It is an elimination diet. You begin by reducing high FODMAP foods for a while, then gradually add them back, on at a time over several days. If symptoms recur, you stop consuming the offending item. People who benefit from reducing FODMAPs will usually show a benefit in 4-6 weeks. I’ve included a couple of helpful links, below, including a printable PDF to put on your fridge.
PIIBS is common after gastrointestinal infections, including c diff. The severity and duration of PIIBS is variable, but the vast majority of people that develop PIIBS recover within months.
Please join me next time for a talk about something a little different: sourdough. Yeah, I started making sourdough during the pandemic, but I have made my own starter off and on for years. I am looking a little more into the science of sourdough and the benefits.
Irritable bowel syndrome – Symptoms and causes – Mayo Clinic
Low_FODMAP_Diet_12.16.pdf (virginia.edu)
Wow! Great information. Thank you.