If you have had months or years of stomach pain and unpredictable bowels, and more than one provider has told you the tests are normal and it is probably stress, you have not been given an answer. There is a real diagnosis that likely fits, and it responds to treatment.
What IBS is
Irritable bowel syndrome is a disorder of how the gut and the brain communicate. That is not a softer way of saying “it’s in your head.” The nerves in your digestive tract and the nerves in your brain are in constant two-way conversation, and in IBS that signaling becomes oversensitive — normal gut activity gets registered as pain, and normal stress gets translated into cramping, urgency, or constipation.
Estimates of how common it is vary widely depending on which diagnostic criteria a study uses — a 2020 systematic review in The Lancet Gastroenterology & Hepatology put global prevalence at about 3.8% under the strictest current definition, while more recent reviews using broader criteria have landed considerably higher. Every version of the data agrees on two things: it is common, and it affects women roughly twice as often as men.
Here is what makes IBS different from most conditions we manage: there is nothing to find on a scan. That is a feature of the diagnosis, not a failure of the workup. Nothing is damaged. The signaling is turned up too high.
What people actually notice
- Abdominal pain that comes and goes, often eased or triggered by a bowel movement
- Diarrhea, constipation, or an alternating pattern between the two
- Bloating and visible abdominal swelling that worsens through the day
- Urgency, or the feeling that you never quite finished
- Symptoms that flare with stress, poor sleep, travel, or certain meals
- Planning your day around bathroom access — which is often the part that quietly shrinks a life
A picture of what this can look like
Consider a man in his forties who drives a delivery route. He has had cramping and unpredictable diarrhea for three years. He has stopped drinking coffee, stopped eating breakfast, and mapped every restroom on his route. His labs and colonoscopy were normal, which he found more discouraging than reassuring. He has never mentioned that he has stopped going to family gatherings, because nobody asked. (This is a fictitious composite, not a real patient.)
The bowel symptoms are why he came in. The withdrawal is the bigger problem, and it is treatable too.
How it is diagnosed — without endless testing
The 2021 American College of Gastroenterology clinical guideline made a point that changed how good primary care approaches this: IBS should be diagnosed with a positive strategy, meaning we actively confirm it, rather than by running test after test to exclude everything else. Endless testing does not make the diagnosis more certain. It delays treatment and teaches people that something dangerous is being missed.
A positive diagnosis uses the Rome IV criteria, published by the Rome Foundation in 2016 and considered the standard: recurrent abdominal pain at least one day a week over the previous three months, associated with at least two of the following — related to bowel movements, a change in stool frequency, or a change in stool consistency.
Alongside that, the ACG guideline recommends a short and specific workup rather than a broad one:
- Blood testing for celiac disease in people with IBS and diarrhea.
- Fecal calprotectin (or lactoferrin) and C-reactive protein in people with suspected IBS and diarrhea and no alarm features, to rule out inflammatory bowel disease.
- Against routine stool testing for infections in everyone, and against routine colonoscopy in people under 45 with IBS symptoms and no warning signs.
Alarm features change all of this: bleeding, unintentional weight loss, anemia, a family history of colon cancer or inflammatory bowel disease, or symptoms that begin later in life. Those get investigated properly, and we will tell you plainly if you have one.
Naʻau — why the gut-mood link is not a Western idea
In ʻōlelo Hawaiʻi, naʻau means the intestines and bowels — and in the same breath it means mind, heart, feelings, and temper. Traditional Hawaiian understanding placed thought, intuition, and deep knowing in the gut rather than in the head. When someone says a decision came from their naʻau, they mean it came from the part of them that knows before it can explain.
I point this out because patients with IBS are routinely made to feel that the gut-brain connection is a polite dismissal. It is the opposite. It is a physiological reality that Hawaiian knowledge described long before gastroenterology had a name for it, and it is the reason the most effective treatments work on both ends of the conversation at once.
This also fits lōkahi — balance across the connected parts of a life. Papa Ola Lōkahi, the Native Hawaiian health organization established under the Native Hawaiian Health Care Act, frames healing through the ahupuaʻa model: health as reciprocal relationships among kānaka (people), ʻohana (family), kaiāulu (community), and the land, where the work is strengthening protective factors rather than chasing surface symptoms. A condition that responds to sleep, stress, food, and connection is exactly the kind that model was built for.
How it is treated
Gut-directed behavioral therapy is not a last resort. The ACG guideline recommends gut-directed psychotherapy — including cognitive behavioral approaches and gut-directed hypnotherapy — to treat overall IBS symptoms. This is the piece most often skipped, and it is the piece we can offer in the same practice as your primary care, which is the whole point of keeping behavioral health under the same roof as primary care. You are not being sent away to talk about your feelings. You are being treated for a nerve-signaling problem using the tool that works on nerve signaling.
Diet, done carefully. The guideline supports a limited trial of a low-FODMAP diet — a short, structured reduction of certain fermentable carbohydrates, followed by systematic reintroduction. The word that matters is limited. This is not a permanent restriction, it should be time-bound and guided, and it works best with dietitian support. Long-term self-imposed food restriction narrows nutrition and, for some people, feeds an unhealthy relationship with eating. If you have a history of disordered eating, tell us before we go down this road.
Medication targeted to your pattern. The guideline supports different agents depending on whether constipation or diarrhea predominates — chloride channel activators and guanylate cyclase activators for constipation-predominant IBS, and rifaximin for diarrhea-predominant IBS. Which of these fits, if any, is a clinical conversation.
Sleep and mood, treated in their own right. Depression and anxiety travel with IBS often enough that ignoring them means treating half the problem.
Keiki get this too. Recurrent stomach pain is common in children and is evaluated differently than in adults — with attention to school avoidance and anxiety alongside the physical symptoms. If your child has frequent stomachaches, bring it to a pediatric visit rather than waiting it out.
Getting care by telehealth
About 85% of our care happens by secure video, and IBS fits that well. The diagnosis rests on your history and a short, targeted set of labs — not on a hands-on exam. Follow-ups while we adjust an approach are brief and frequent, which is far easier from your kitchen than from a waiting room in another town. Behavioral treatment works well remotely.
Some parts need to happen in person: an abdominal exam when the picture is unclear, blood draws, and any procedure. If you have alarm features, we will arrange in-person evaluation and referral rather than manage it remotely. Interpretation and language assistance are available at no cost. Care is provided to patients located in Hawaiʻi, where our providers are licensed. We accept Med-QUEST, Medicare, and most major plans.
When to seek help now
Get seen promptly, not eventually, for rectal bleeding, black stools, unintentional weight loss, fever with abdominal pain, or pain severe enough to stop you in your tracks. Those are not IBS symptoms and need evaluation.
Living with a chronic condition that other people minimize wears on mental health. If you are having thoughts of harming yourself:
- Call or text 988 — Hawaiʻi CARES 988, available 24/7, or call 1-800-753-6879 or 808-832-3100
- Medical emergency: call 911
If this describes your last few years, you can request an appointment and we will start with a positive diagnosis instead of another round of tests.
Written by George Mackel, MSN, APRN, NP-C, PMHNP-BC, CARN-AP
President & Owner, OhanaPsych / Ohana Care Clinic
Date published: August 10, 2026
Last reviewed: August 10, 2026
Citations verified: August 10, 2026
This article is general health education from Ohana Care Clinic. It is not a substitute for a personal evaluation by a qualified clinician who knows your situation, and reading it does not create a provider–patient relationship. If you think you may have a medical condition, reach out to us or another licensed provider. In an emergency, call 911.
References
American College of Gastroenterology. (2021). ACG clinical guideline: Management of irritable bowel syndrome. American Journal of Gastroenterology, 116(1), 17–44. https://journals.lww.com/ajg/fulltext/2021/01000/acg_clinical_guideline__management_of_irritable.11.aspx
Hawaiʻi CARES 988. (n.d.). Crisis & suicide. State of Hawaiʻi Department of Health, Behavioral Health Administration. https://hicares.hawaii.gov/how-we-help/crisis-and-suicide/
Nā Puke Wehewehe ʻŌlelo Hawaiʻi. (n.d.). Naʻau. Retrieved August 10, 2026, from https://wehewehe.org
Oka, P., Parr, H., Barberio, B., Black, C. J., Savarino, E. V., & Ford, A. C. (2020). Global prevalence of irritable bowel syndrome according to Rome III or IV criteria: A systematic review and meta-analysis. The Lancet Gastroenterology & Hepatology, 5(10), 908–917. https://www.thelancet.com/journals/langas/article/PIIS2468-1253(20)30217-X/abstract
Papa Ola Lōkahi. (n.d.). Ahupuaʻa – Cultural healing model. https://www.papaolalokahi.org/program/ahupuaa-model
Rome Foundation. (n.d.). Rome IV criteria. https://theromefoundation.org/rome-iv/rome-iv-criteria/
