Articles

Irritable Bowel Syndrome (IBS)

Introduction

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders that physicians treat. Patients with this non life-threatening condition may present with a broad range of symptoms which typically include abdominal pain associated with altered bowel habits, including constipation, diarrhea, or alternating constipation and diarrhea, and a less common presentation of painless diarrhea. Although the symptoms are typically intermittent, they may be continuous and should be present for at least three months before the diagnosis of irritable bowel syndrome is considered.

In the late 1970's, Manning and colleagues identified several characteristic symptoms of IBS. These symptoms include; abdominal distention, abdominal pain relief following a bowel movement, increased frequency of stools, changes in the consistency of the stools, passage of mucus, and the sensation of incomplete evacuation. (1) Evaluative and diagnostic criteria that include the "Manning Criteria" have been developed and used in clinical practice. (2) Patients with irritable bowel syndrome are also more likely to have other symptoms such as gastro esophageal reflux with heartburn, dysphagia, noncardiac chest pain, urologic dysfunction, fatigue, and gynecologic problems. (3) In general a patient’s likelihood of having IBS increases as they present with more symptoms included within the "Manning Criteria" and other possible causes of the symptoms can be eliminated. Other conditions that may present with symptoms similar to IBS include; lactose intolerance, giardiasis, Crohn’s disease, ulcerative colitis, neoplasms, obstructions, ischemic conditions, certain psychiatric disorders and endometriosis.

Irritable bowel syndrome is considered a "functional" disorder because the problems persist without an identifiable etiology in what appears to be a normal intestinal tract. IBS is likely the culmination of several coexisting disorders with no consistent findings among any subgroup of patients. Irritable bowel syndrome is often assumed to be caused by altered colonic motility or sensation. Periods of acute stress, such as eating or anger, may lead to IBS exacerbations for some patients, but there is no proof that chronic emotional stress is the cause of IBS. (4) Evidence suggests that gut innervation may mediate the pathophysiology of IBS. (5)

Psychosocial factors are an important part of fully understanding of irritable bowel syndrome, playing a vital role in the development, precipitation and perpetuation of IBS. Though less than half of IBS patients seek medical attention, there is an increased frequency of psychiatric diagnoses among those who do. Improvement in the clinical outcome does occur when psychosocial factors are addressed in the assessment and management of IBS patients. (6) Psychosocial factors do not cause IBS symptoms, they do influence the patients response to IBS. The presence of psychosocial disorder is an indicator for the likelihood that the patient will seek medical attention for IBS as well as other medical conditions. (7)

The diagnosis of IBS is made more upon the basis of exclusion than that of pertinent medical findings. The findings from the physical exam are generally unremarkable. Routine laboratory test results are typically normal in IBS. Yet both are essential diagnostic tools in an effort to eliminate other potential problems. Flexible sigmoidoscopy is performed in certain patient populations to exclude neoplasms and inflammatory bowel disease. An extensive history is an excellent way to assess IBS. The history should involve an assessment abdominal pain, bowel habits, the "Manning Criteria," medication usage and an extensive diet history. The diet history should focus on foods sweetened with fructose or sorbitol, and the exclusion of lactose intolerance. It is also important to consider addressing any psychosocial dysfunction if present.

Statistic

International Foundation for Functional Gastrointestinal Disorders, 2002.

  • IBS affects 5 to 25 % of people in countries around the world.

Universiti Putra Malaysia, 2003.

  • Malaysians suffering from IBS with a prevalence rate of 15.8%.

The American Gastroenterological Association, 2002.

    An estimated 10 to 20 percent of people in the general population experience symptoms of IBS, but only about 15 percent of affected people actually seek medical help.

Mayo Foundation for Medical Education and Research, 2000.

    An estimated 35 million Americans have irritable bowel syndrome. IBS accounts for about 3 million physician visits in the United States every year.

Signs and Symptoms

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Symptoms include; abdominal distention, abdominal pain relief following a bowel movement, increased frequency of stools, changes in the consistency of the stools, passage of mucus, and the sensation of incomplete evacuation.

Symptoms compatible with the irritable bowel syndrome are reported by 10 to 22 percent of adults, with predominance among women greater than 2:1. Patients who have experienced bacterial gastroenteritis may actually be at an increased risk for IBS. (8) It has been reported that less than half of the symptomatic adults actually seek medical attention. Typically, symptoms begin in young adulthood, but the prevalence of IBS is similar among all adult age groups. IBS has similar prevalence rates throughout the world. (9)

General

    Abdominal distention and pain Abdominal pain relief following stool Increase in frequency of stools Changes in stool consistency Passage of mucus Sensation of incomplete evacuation

Treatment Options

Conventional

The most important aspect of treatment is to establish a therapeutic physician-patient relationship. This will provide an environment of understanding and concern as well as the opportunity to educate the patient about treatment and prognosis of IBS. The chronic nature of IBS requires a long-term physician-patient relationship where realistic expectations can be established and the patient may be involved in treatment decisions.

Dietary modifications are generally the initial recommendations and may lessen the symptoms of IBS. Eliminating certain foods, such as dairy products and legumes. Other foods problematic for the patient like those causing gas buildup should also be avoided. Though the true efficacy is questioned, fiber supplementation is generally benign, and thus reasonable in IBS patients.

Numerous medications are used for a variety of symptoms present in the irritable bowel syndrome, but none have been determined to be effective. (10) Addressing and treating the symptoms present is one approach used in practice. For patients with diarrhea, an antidiarrheal agent would be recommended such as loperamide. Cholestyramine may also benefit patients with diarrhea due to its ability to bind bile salts. Patients with pain, gas, and bloating, antispasmodic, anticholinergic agents such as belladonna or dicyclomine may be tried. Tricyclic antidepressants are used effectively in chronic pain. This in conjunction with their antidepressant activity may have added benefit, yet unproved.

Nutritional Supplementation


Zinc

Low zinc levels have been reported in patients with irritable bowel disease. Two subgroups were identified. One of the groups is characterized by low blood zinc levels and the other exhibits increased fecal excretion of zinc. (11) Another study reported that individuals with irritable bowel problems are less capable of absorbing zinc from the intestinal tract compared to healthy controls. (12) Thus, it seems prudent to evaluate zinc status in patients with irritable bowel conditions and provide appropriate supplementation in patients who are found deficient.


Lactobacillus acidophilus

It has been suggested that some of the symptoms in patients with IBS are due to imbalances in the intestinal microflora. A group of 60 patients with irritable bowel problems were administered a drink containing 5 x 107 cfu/ml of Lactobacillus plantarum or a placebo for 4 weeks. Flatulence was rapidly and significantly reduced in the test group compared with the placebo group. The patients completed a symptom questionnaire at the beginning of the study and then again one year later. At the 12-month follow-up, it became apparent that the patients that had consumed the Lactobacillus-containing product had maintained a better overall level of gastrointestinal function than the patients that served as controls. (13)

Herbal Supplementation


Psyllium Seed

An estimated 4 million Americans use psyllium products daily. (14) Psyllium is rich in dietary fiber, which is the most satisfactory prophylactic and treatment for functional constipation. (15) Dietary fiber increases the mass of stools, their water content, and the rate of colonic transit. Psyllium has traditionally been used as a bulk-forming laxative; however, recent research points to other uses including hypercholesterolemia, irritable bowel syndrome, and ulcerative colitis. (16) , (17) In February, 1998, the FDA gave permission to allow food manufactures to make a health claim on the packaging of food products regarding psyllium. The claim reads: "Eating soluble fiber from foods such as psyllium as part of a diet low in saturated fat and cholesterol may reduce the risk of heart disease." These findings make psyllium a potential agent for reducing the risks of cardiovascular diseases. Psyllium has been reported effective in supporting the management of irritable bowel syndrome (IBS) and ulcerative colitis. (18) , (19) , (20) One report, an open label, parallel-group, multicenter, randomized clinical trial, was conducted on patients with ulcerative colitis who were in remission. (21) The patients received oral treatment with psyllium seeds (10 gm twice a day), mesalamine (500mg three times a day), and psyllium seeds plus mesalamine at the same doses. The primary efficacy outcome was maintenance of remission for 12 months. The authors concluded that psyllium seeds may be as effective as mesalamine in maintaining remission in ulcerative colitis. In IBS, psyllium has been reported to increase bowel movements, appearing to be a major reason for the therapeutic success.


Peppermint

Peppermint is a widely used herb for both medicinal and culinary purposes. Peppermint tea has long been used in treating children’s digestive problems such as colic, flatulence and upset stomach. The oil of peppermint is used routinely in Europe as a spasmolytic, carminative and cholagogue, with its most prevalent use in Irritable Bowel Syndrome (IBS).

Peppermint oil has an antispasmodic action on the isolated ileum of laboratory animals, characterized by a decline in the number and amplitude of spontaneous contractions. It relaxes the ileal longitudinal muscle, but less potent than papaverine. (22) Peppermint oil acts competitively with nifedipine and blocks calcium exciting stimuli, with the antispasmodic properties being characteristic of calcium channel blockers. (23)

Eight randomized, controlled trials have reported positive benefits in IBS when using enteric coated peppermint oil, confirming the antispasmodic, pain-relieving action of peppermint oil when administered as enteric coated tablets. (24) , (25) , (26) There has been one study that showed no effect in relieving symptoms of IBS. (27)


Cat's Claw

Cat’s claw is one of the most promising herbs to come out of the rain forest to date. It has been used as a traditional medicine, possibly dating back as far as the Incan civilization. Cat’s claw reportedly affects the immune system and acts as a potent free radical scavenger. (28) Cat’s claw has glycosides which reportedly reduce inflammation and edema. (29) The anti-inflammatory effects of cat’s claw are considered to be due to the sum total of the plant’s constituents, but the sterols have demonstrated anti-inflammatory activity in animal studies. The glycosides are also reported to enhance and stimulate phagocytosis, which if true would be a key part of cat’s claw’s immune function activity. (30) Isopteridine, an alkaloid which has been isolated, is claimed to have immuno-stimulatory properties. Triterpenoid alkaloids and quinovic acid glycosides have been isolated and studied for antiviral activity, possibly inhibiting replications of some DNA viruses. (31) , (32)

Colon toxicity has been somewhat ignored in Western medicine. It is now becoming apparent that bowel hygiene and proper flora are essential to good health. If the colon flora is out of balance (dysbiosis) or if food is not being properly digested and assimilated, toxic metabolites and mutagens may be produced. Cat’s claw is reported to have the ability to soothe irritated and inflamed tissues and help eliminate pathogens from the GI tract. (33)

Clinicians agree that the use of pentacyclic alkaloids (POA's) from cat’s claw root bark are the health promoting constituents. Tetracyclic alkaloids (TOA's) do occur in the root bark, but should be kept to a minimum in the final product as to maximize the health benefits of cat’s claw as a dietary supplement.


Olive Leaf

Olive leaf extract has been reported to be an effective antimicrobial agent against a wide variety of pathogens, including Salmonella typhi, Vibrio parahaemolyticus and Staphylococcus aureus (including penicillin-resistant strains), Klebsiella pneumonia and Eschericha coli, causal agents of intestinal or respiratory tract infections in man. (34) The component usually associated with olive leaf’s antimicrobial properties is oleuropein. (35) , (36) Oleuropein also has been reported to directly stimulate macrophage activation in laboratory studies. (37)

Olive leaf extract has reported antiviral activity, caused by the constituent calcium elenolate, a derivative of elenolic acid. (38) , (39) Recent laboratory studies in laboratory animals reported hypoglycemic and hypolipidemic activity. (40) , (41) The constituent with the activity was reported to be oleuropein, with a proposed mechanism of action being: (1) potentiation of glucose-induced insulin release, and (2) an increase in peripheral blood glucose uptake.


Evening Primrose

Evening primrose oil (EPO) is rich in gamma-linolenic acid which is an omega-6 fatty acid. (42) , (43) Omega-6 fatty acids reportedly reduce the arachidonic acid cascade and decrease inflammation through inhibiting the formation of inflammatory mediators in this process. Supplementation with essential fatty acids such as EPO has been shown to prevent zinc deficiency, thereby potentially improving immunity. (44) Fatty acids are an important part of normal homeostasis. The human body can produce all but two fatty acids - omega-3 and omega-6 fatty acids. Both must be obtained through the diet or by the use of supplements. Obtaining a balance of these two fatty acids is essential. Essential fatty acids are needed for building cell membranes and are precursors for production of hormones and prostaglandins. Modern diets tend to be lacking in quality sources of fatty acids.


Grapefruit Seed

Grapefruit seed extract has been reported to be a broad-spectrum antimicrobial both in vitro and in vivo. Studies indicate that the antimicrobial activity of grapefruit seed extract exists in the cytoplasmic membrane of the invading bacteria, where the uptake of amino acids is prevented, there is disorganization of the cytoplasmic membrane and leakage of low molecular weight cellular contents ultimately resulting in inhibition of cellular respiration and death. (45)

Grapefruit seed extract also inhibits the growth of H. pylori and C. jejuni, both causative agents in gastrointestinal ulcers. (46) By inhibiting causative agents of bowel dysbiosis (the imbalance of normal bacterial flora in the GIT) including Candida sp. In vivo, grapefruit seed extract is a useful agent in maintaining bowel integrity. (47) In this human study, an improvement in constipation, flatulence, abdominal distress and night rest were noticed after 4 weeks of therapy. Most clinicians now agree on the importance of maintaining homeostasis of the microflora in health and disease. (48)


Artichoke

Artichoke leaf extract (ALE) may have potential for treating irritable bowel syndrome (IBS). In a study evaluating the use of ALE in dyspeptic patients, a small subset was identified as having IBS. This subset had the severity of their symptoms reduced and provided an overall favorable evaluation of the extract. As many as 96% of the subset claimed that the artichoke leaf extract was well tolerated and that it worked at least as well as other therapies used for their symptoms. (49)

Homeopathic

Argentum nitricum

Typical Dosage: 6X or 6C, 30X or 30CInflammation and ulceration of the stomach and intestines; Diarrhea; Anticipation anxiety; Desire for sugar and sweets even though these are difficult to digest

Colchicum autumnale

Typical Dosage: 6X or 6C, 30X or 30CHypersensitivity to odors; Smell of food brings nausea; Copious diarrhea and flatulence

Colocynthis

Typical Dosage: 6X or 6C, 30X or 30CIntense, spasmodic pain in the digestive tract; Better from doubling up; Painful diarrhea

Acupuncture & Acupressure

Acupuncture Treatment
Cao treated 58 cases of IBS by pricking the acupoint Shenque (Ren 8) with red-hot needles. The procedure: Three-edged pricking needles were heated on an alcohol burner; when the needles were red-hot, they were used to prick the acupoint Shenque. Each session called for pricking the acupoint twice, and the treatment was repeated every other day. Seven sessions constituted one unit of treatment, and a three-day break was instituted between units of treatment. The results: 46 cases (79.31%) were recovered, 6 (10.34%) significantly improved, 4 (6.90%) improved, and 2 (3.45%) did not respond to the treatment, with a total effective rate of 96.55%. (50)

Xue treated 14 cases of IBS with a combination of acupuncture and massage. The procedure was as follows: Acupuncture treatment was applied daily at the acupoints Zusanli (St 36) and Sanyinjiao (Sp 6) by the lifting-thrusting-twisting-twirling method, with the needles retained for 20 minutes after insertion. Six sessions constituted one unit of treatment. In addition, with the patient lying on their back and the knees bent, massage was applied at the acupoints Zhongwan (Ren 12), Qihai (Ren 6), and Guanyuan (Ren 4) by pushing and kneading maneuvers, at the bilateral acupoint Tianshu (St 25) by progressively more forceful thumbing, and around the navel by palm-rubbing; then, with the patient sitting upright, massage was applied at the acupoints Pishu (B 20), Dachangshu (B 25), Shenshu (B 23), and Mingmen (Du 4) by pushing and pressing. Each daily massage session lasted 20 minutes. The results: after 1-3 units of treatment, all 14 cases were recovered. A follow-up on 10 patients conducted 2-5 years after the treatment found no relapses in six patients. (51)

Massage
Xu treated 68 cases of IBS with a combination of massage and herbal therapy. The acupoints Hegu (LI 4) and Guanyuan (Ren 4) received massage treatment three times a day, one hour before a meal: the acupoint Hegu was first pressed with a thumb for about half a minute to initiate the treatment, and then kneaded 100 times clockwise; the acupoint Guanyuan was first pressed with a thumb to initiate the treatment, and then gently palm-kneaded 50 times clockwise, and 50 times counter-clockwise. The herbal therapy used a formula called Bu Pi Fang (spleen-invigorating decoction), which consisted of Dang Shen, Fu Ling, Bai Zhu, Rou Dou Kou, Bai Shao, Shan Yao, Wu Zhu Yu, and Zhi Gan Cao. One dose of the formula in water decoction was administered daily at three takings just before the massage sessions. One unit of treatment lasted ten days. A comparison group of 84 cases was treated with various Western medications (e.g., vitamin B, diazepam, etc.) The results: of the treatment group, 36 cases were recovered, 27 improved, and 5 did not respond to the treatment, with a total effective rate of 92.6%; in comparison, the corresponding numbers for the comparison group were 11, 32, 41, and 51.2%, respectively. (52)

Other Treatments
Lu treated 48 cases of IBS with auricular pressure and millimeter wave therapies. The procedure of the auricular pressure therapy: three times a day, each time for a duration of five minutes, a vicaria seed was pressed against the acupoint Shenmen and points related to the liver, spleen, and kidney, to gain a feeling of warmth, swelling, and slight pain; the bilateral points were alternated in receiving the treatment, and 10 sessions constituted one unit of treatment. The procedure of the millimeter wave therapy: once a day, each of the acupoints Daheng and Qihai were treated with millimeter wave for 10 minutes; ten sessions constituted one unit of treatment. The results: 34 cases were recovered, 7 significantly improved, 5 improved, and 2 did not respond to the treatment, with a total effective rate of 95.8%. (53)

Traditional Chinese Medicine

Irritable Bowel Syndrome (IBS)

Extensive information regarding the treatment of this health condition using Traditional Chinese Medicine is available through the link above.

Diet & Lifestyle

Identify and eliminate food allergies. Eliminate consumption of sugar, refined carbohydrate and caffeine.

Avoid milk and dairy: Lactose maldigestion may be a contributory factor in children and adults with IBS, and lactose avoidance in these patients can cause symptomatic improvement and reduce medication use. (54) , (55)

Diet: Numerous studies report that dietary food allergies are frequently responsible for many of the symptoms experienced by patients with irritable bowel syndrome. One physician reported that it took from 3 to 6 weeks of detective work to correctly identify a patient’s offending foods. 113 patients were followed for one year. Careful avoidance of the offending foods resulted in the following symptomatic improvements: distention was relieved in 88%, colic in 90%, diarrhea in 85% and constipation in 65%. Seventy-nine percent of the patients also reported improvements other conditions such as hay fever, sinusitis, asthma, eczema and urticaria. Food triggers were twice as frequent as inhalants, which included danders, grasses and perfumes. (56)

Another group of researchers suggested irritable bowel syndrome is sometimes caused by disturbances in bacterial fermentation and colonic gas production. To test this theory, the team placed six healthy adult women and six patients with irritable bowel syndrome on an "exclusion" diet based on one often used to reduce symptoms in patients, which eliminates beef, dairy products, and cereals other than rice. The study diet also restricted the consumption of other suspect foodstuffs, such as yeast, citrus fruits, caffeinated drinks, and tap water. This regimen was supplemented with other foods so that its nutrient value was equal to that of a normal Western diet.

Switching to the exclusion diet "significantly improved symptoms" in patients with irritable bowel syndrome. After 2 weeks on the diet, flatulence levels had also fallen dramatically among the patients studied whereas no such changes occurred in the healthy controls. This reduction may be associated with alterations in the activity of hydrogen-consuming bacteria. The investigators felt that these results support the notion that diet-linked bacterial fermentation may be an important factor in the development of irritable bowel syndrome. (57)

Fiber: The issue of dietary or supplemental fiber in patients with irritable bowel syndrome remains controversial. Additional fiber improves symptomology in some patients while worsening symptoms in others. In general, researchers suggest that it is probably best to recommend that patients with IBS be left to judge for themselves whether increased fiber helps or exacerbates their symptoms. (58) , (59) However, one group of physicians studying the relationship of fiber to various diseases suggested that the most suitable fiber for patients with irritable bowel syndrome is methylcellulose or polycarbophil. (60)

Abuse: sexual, emotional and physical. Some studies report finding a high prevalence of sexual abuse among IBS patients. It has been suggested that many of these patients could benefit from psychotherapy counseling. (61)

The results from other studies demonstrate an association between IBS and emotional abuse, as well as a possible connection with psychosocial variables that may mediate the connection between emotional abuse and functional bowel symptoms. (62)

Clinical Lab Assessment

Some of the following laboratory testing can provide information necessary for diagnosis and treatment. In addition, the tests listed may also give insight to functional metabolism and functional nutrient status in the body.

Allergy and Food Sensitivity Response Assessment

Immune response is suggested as a possible cause for IBS. (63) Hyper-reaction of the local cellular immune system to numerous microbial and nutritional antigens normally present in the intestine may have considerable impact on the inflammatory process. Improvements may be seen on food elimination diets. Alternative methods of addressing allergic sensitivities begin with thorough assessment of sensitivity responses. The aspects of mineral uptake and utilization compel thorough evaluation of influences on digestive function, including food sensitivity response.

Fatty Acids

Dietary polyunsaturated fatty acids (PUFA) are primarily composed of omega 3 and omega 6 fatty acids. PUFA are vital in the production of eicosanoids – components involved in regulating inflammatory response, blood vessel leakage, lipid accumulation and immune cell response.

Ova Parasites

Gastrointestinal pathogens play a role in efficient digestion and absorption of nutrients as well as the production on toxic metabolic products. A stool evaluation for these microbial agents can provide useful information regarding causes for nutrient deficiencies contributing to various disease processes.

Clinical Notes

Glutamine
The protein synthesis for healing from surgery, trauma, and other types of injury creates increased requirements for glutamine. In one study, administration of glutamine enemas reduced the severity of experimentally induced colonic inflammation in laboratory animals. (64) Research indicates that glutamine is therapeutically useful for maintaining the integrity of intestinal mucous membranes and their permeability to luminal toxins in animal models for inflammatory bowel disease. (65) There is some concern regarding the use of glutamine in Crohn's disease. In several double-blind, placebo-controlled trials, patients with Crohn’s disease who took 7 grams of glutamine three times daily did not perform any better than the placebo controls. (66) , (67) , (68) Thus, glutamine’s use in inflammatory bowel disease and Crohn’s disease requires more study.

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