Episode two of the IBS and Functional Bowel chapter covers the diarrhea-predominant subtype, the neuromodulators and behavioral therapies that work across subtypes, and the mechanistic workup of bloating. Drug selection is mechanism-matched to the dominant symptom and driver, not subtype-matched in the abstract. Carry mechanism, subtype indication, and contraindication together to pick the right answer. Topics covered IBS-D pharmacology Loperamide, rifaximin, eluxadoline Bile acid sequestrants and alosetron Neuromodulators by side-effect match Antispasmodics and peppermint oil Behavioral and mind-body therapy Bloating versus distension Low-FODMAP diet and fiber Key decisions Loperamide controls stool frequency and urgency but never abdominal pain; for crampy IBS-D add a low-dose tricyclic or rifaximin, not more loperamide. Rifaximin responders who relapse can be retreated with the same 14-day course, up to two retreatments for three courses total; never lock the patient out. Eluxadoline is absolutely contraindicated after cholecystectomy (sphincter of Oddi spasm causing pancreatitis), and with biliary obstruction, heavy alcohol use, pancreatitis history, or severe constipation. Alosetron is restricted to women with severe refractory IBS-D, carries ischemic colitis and severe constipation boxed warnings, and is contraindicated in the mixed subtype; obstipation means stop and evaluate, not titrate. For IBS-D neuromodulation, low-dose tricyclics are favored because the anticholinergic transit slowing is therapeutic; switch amitriptyline to nortriptyline or desipramine for side effects, and SSRIs do not help IBS-D pain. Abdomino-phrenic dyssynergia is the answer for visible distension out of proportion to luminal content, with daytime progression, overnight resolution, and no excess gas on CT, treated with diaphragmatic breathing retraining. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - Introduction: IBS-D, cross-subtype therapy, bloating (00:46) - Loperamide: frequency, not pain (01:28) - Rifaximin and the retreatment rule (02:27) - Eluxadoline: the contraindication list (07:35) - Neuromodulators by side-effect match (09:17) - Behavioral and mind-body therapies (10:19) - Bloating versus distension and its workup (12:33) - Low-FODMAP diet and fiber

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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