Irritable Bowel Syndrome:
A Gut Reaction

Irritable bowel syndrome (IBS)—also called spastic colon—is considered by most allopathic physicians a "functional" bowel disorder. By this, diagnosticians mean that while the gastrointestinal tract is not operating well, no anatomic or pathologic cause can be found. Common tests used to examine the stool of patients with IBS usually result in no significant findings: no blood, no excess white cells, no parasites, no bacteria. Sigmoidoscopy to explore the colon and common laboratory exams usually reach the same conclusion: no organic disease. In some cases, though, a stool exam may reveal such things as improper digestion, imbalance of beneficial bacteria or the presence of certain types of intestinal parasites that are not considered pathogenic but may present symptoms, suggesting an underlying cause of IBS. Food choices may also play a role in the cause of IBS.

A person with IBS usually has vague abdominal symptoms. However, it is not safe to assume that such complaints are "only" IBS. Anyone experiencing the cardinal symptoms of irritable bowel syndrome—abdominal pain, diarrhea and/or constipation, and uncomfortable distention after eating—should get a thorough physical exam and laboratory testing. Riskier diseases such as diverticulitis, regional enteritis, colitis, ulcers and cancer can begin with symptoms similar to those of IBS.

Beyond the primary symptoms, the unremarkable laboratory tests and the exclusion of other diseases, physicians also diagnose irritable bowel syndrome by certain distinctive features: Pain is generally relieved by defecation, stools become more frequent and looser as abdominal pain increases, and the rectal area is tender to palpation and exam. In many IBS patients, headache, nausea, heartburn, belching, gas, mucous stools, frequent urination and fatigue accompany the condition. Women with IBS often also suffer painful menstrual periods, prompting researchers to consider a hormonal connection. [1]

In fact, women are three times more likely than men to contract IBS. Other daunting statistics indicate that 20 percent of Americans have suffered from IBS. It accounts for about half of all gastrointestinal complaints at medical facilities and 50 percent of referrals to gastrointestinal specialists. [2]

The precise etiology of IBS has yet to be established. However, two theories predominate. The first postulates that IBS patients have motor abnormalities in the smooth muscles of the bowel, resulting in either hypercontractility and subsequent spastic colon and diarrhea, or slowed contractility that leads to constipation and distention. The second theory is that the disorder is actually an IBS patient's inappropriate response to healthy bowel activity. It is the basis for treating patients as neurotic, depressed or anxious, and then medicating them accordingly.

Part of what lulls physicians into seeing IBS as a psychological problem is that IBS is notably individual in its expression. Not every IBS patient has the same set of symptoms, and onset of the condition and pain triggers vary from patient to patient. However, what seems to be consistent about IBS is that, left untreated, each individual's symptom pattern stays consistent from month-to-month and year-to-year. Significant changes in this pattern indicate a need for physician evaluation.

For example, let us presume that for the past three years IBS patient A has had pain in the lower left side of the abdomen, along with loose, mucous stools and frequent gas. IBS patient B, meanwhile, has had pain in the lower right side, constipation and frequent belching. Both patients have been thoroughly examined by their physicians and have been told they have IBS. If patient A were to begin to complain of constipation and pain on the lower right side, however, he should see his physician because appendicitis or another organic bowel disease may be responsible for these symptoms.

IBS is a fairly common condition, yet a tough one for medical doctors to treat. Conventional medicine offers little beyond assurances that the condition is not life-threatening and medicating with fibrous bulking agents, antispasmodics and antidepressants. For some IBS patients, the latter remedy carries with it a stigma that the pain is all of their own making, that they are overly sensitive or even psychopathic. [3]

These factors make IBS sufferers more likely than most to seek help with alternative medicine. [4] And while certain forms of natural medicine make sense for IBS patients, understanding the disease makes it easier to find what works best.

Dietary Influences

There are effective ways to determine the cause of IBS and to then treat the problem. Unfortunately, conventional practitioners regard it as a "functional" problem that requires treating symptoms or the mind of the person with symptoms. Most conventional doctors are not trained to evaluate things such as a peculiar physiological imbalance or a unique sensitivity that can cause IBS.

For decades naturopathic physicians have successfully treated IBS by using an individualized, cause-oriented approach. In many cases the cause can be found and then corrected, making symptom treatment unnecessary. Dana Keaton, N.D., adjunct professor of nutrition and oncology at Southwest College of Naturopathic Medicine and Health Sciences in Tempe, Ariz., says IBS patients should work with a physician who is willing to look beyond the IBS diagnosis. "Gastroenterologists," she says, "do a good job of diagnosing IBS and ruling out bowel pathology. But from there, patients need to go further. They need to understand what is causing the functional problem and take care of it."

One way she and other naturopathic physicians address the problem is through diet. Diets low in fiber, high in sugar and fats, and including known bowel irritants such as coffee and alcohol, are certain antagonists for IBS. In simple poor-diet-induced IBS, a change to whole, fresh foods may lead to a complete cure. But a healthy, high-fiber diet clearly does not resolve all cases of IBS. That's because other digestive factors may play a significant role.

Food sensitivities have long been understood to contribute to IBS. Common well-known offenders are wheat and dairy. Anyone treating IBS patients should also consider the possible irritant effects of citrus, coffee, corn, eggs, garlic, soy, tea, and a variety of grains and fruits. [2 ]

Once a food sensitivity has been determined, eliminating the offending food can significantly improve IBS. [5] Knowing their food sensitivities can help people with IBS select useful fiber sources. Given the high incidence of wheat sensitivity, they may find that psyllium seed is a more readily tolerated bulking agent than wheat bran. Ispaghula (Plantago ovata), also called Indian flea seed, has even greater bulking properties. It stimulates intestinal motility and water retention. In a study of 80 patients with IBS, 82 percent generally improved following ispaghula treatment compared to 53 percent on placebo. Constipation significantly improved in the ispaghula group and was unchanged in the placebo group. [6] Many IBS patients with grain sensitivities also do well with pectin-based fiber found in citrus fruits, apples, and many other fruits and vegetables. Animal studies on pectin indicate that it is a good bulking agent, and it also improves colon structure and function. [7]

The digestive process also plays a role in IBS. People with IBS can have abnormal bowel flora, inadequate digestive enzyme production, or a deficiency in short chain fatty acids (SCFAs), which are formed by fiber breakdown within the intestines. Certain specialty laboratories analyze stool for these markers, which can help doctors better understand a patient's intestinal function and craft an individualized treatment program.

Among the therapeutic agents used for IBS patients are probiotics such as Lactobaccilus acidophilus and Bifidobacterium bifidum, digestive enzymes and fiber. Fibers such as apple and citrus pectins, guar gum and legumes are usually recommended for patients with SCFA deficiency, because they produce more SCFAs than insoluble grain-based fibers. Conventional research on these specific treatments of IBS is limited, but interest is increasing and will undoubtedly lead to further study. [8-10]

Botanical Therapies

Although the cause of IBS remains elusive, a number of botanical remedies have recently received attention as promising IBS treatments. A blinded, randomized, controlled trial using two Chinese herbal formulations to treat IBS concluded that the formulations improved symptoms and perhaps relieved the actual causes. [11 ]

The study, published in the November 1998 Journal of the American Medical Association, was interesting for two reasons. First, it validated an alternative form of medicine in the treatment of a common ailment. Second, the trial showed the superiority of individualized therapy to treat IBS. The study compared placebo with two forms of Chinese herbal medicine: 43 subjects took a standard Chinese herbal formulation used for IBS, 38 were given individualized treatment, and 43 took placebo.

Patients for this study were recruited from two teaching hospitals in Sydney, Australia, and from the private practices of five gastroenterologists there. The 116 participants, aged 18 to 75, were screened by a gastroenterologist and diagnosed with IBS. Scientists measured pain/discomfort, bloating, constipation, diarrhea, and overall severity of symptoms. Patients were asked to self-assess the degree of life interference caused by IBS symptoms.

The herbs used in the trial were available over-the-counter in Australia. The individualized formulas could contain up to 81 individual dried powdered herbs. The standard herbal formulation included 20 herbs (See chart, page 130). The placebo was designed to look, smell and taste like a Chinese herbal formula. Patients took five capsules three times daily for 16 weeks.

Interestingly enough, both the standard formula and the individualized treatment were similarly effective in reducing IBS symptoms during the course of treatment. However, 14 weeks after treatment ceased, the patients who received individualized therapy maintained improvement, while the benefits of the standard herbal treatment seemed to wane. Because patients in the individualized group benefited beyond the course of treatment, this suggests more of a causative cure. On the other hand, the standardized treatment seemed effective only while taking it, suggesting symptomatic relief only.

The single most prominent botanical used for IBS is peppermint (Mentha piperita) oil, the effectiveness of which has been known since the early 1900s. Its primary ingredient is menthol, which relaxes the muscles in the small intestine by reducing calcium influx. [12] The July 1998 American Journal of Gastroenterology contained a critical review of eight randomized, controlled trials of peppermint oil for IBS. Most studies use 0.2 mL (1 capsule) three times daily between meals. These studies collectively indicated that peppermint oil could provide symptomatic relief of IBS. Nonetheless, the study authors concluded that due to "methodological flaws" in each of the studies, the usefulness of peppermint oil has not been established "beyond a reasonable doubt," and more studies are needed.

For IBS patients wanting to try peppermint oil before all reasonable doubt has been eliminated, enteric-coated capsules seem to be the most useful. The enteric coating prohibits the absorption of antispasmodic menthol into the stomach, allowing it instead to be delivered directly to the large intestine. [13] Excess intake can cause nausea, appetite loss and other nervous system problems.

Two other spasmolytic herbs, chamomile (Matricaria chamomilla) and cramp bark (Viburnum opulus), are used to reduce the cramping pain associated with IBS. Sedative herbs such as valerian (Valeriana officinalis) and scullcap (Scutellaria lateriflora) have both relaxing and antispasmodic properties, and therefore are indicated for IBS patients who also suffer with insomnia and/or anxiety. [14 ]

Perhaps more than most physical illnesses, IBS is an idiosyncratic medical condition. The symptoms vary from person to person, and what works for one person may not be at all useful for another. It is a condition that can teach all of us what holistic medicine truly means.

Sidebars:

Don't Stress Over IBS

Chinese Secret to IBS Revealed

Jamison Starbuck, N.D., practices natural and holistic medicine in Missoula, Mont. She is a past president of the American Association of Naturopathic Physicians.

References:

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2. Berkow R, et al. The merck manual. Rahway (NJ): Merck Research Laboratories; 1992. P 841-2.

3. Kellow J, et al. Advances in the understanding and management of the irritable bowel. Med J Australia 1989 July;151:92-9.

4. Smart HL. Alternative medicine consultations and remedies in patients with the irritable bowel syndrome. Gut 1986 July;27(7):826-8.

5. Gaby A. The role of hidden food allergy/intolerance in chronic disease. Alt Med Rev 1998 April;3(2):90-100.

6. Prior A, Whorwell PJ. Double blind study of ispaghula in irritable bowel syndrome. Gut 1987;28(11):1510-3.

7. Roth J. Pectin improves colonic function in rat short bowel syndrome. J Surg Residence 1995 Feb;58(2):240-6.

8. Spiller GA. Dietary fiber in health and nutrition. Boca Raton (FL): CRC Press, 1994.

9. Suarez F, et al. Pancreatic supplements reduce symptomatic response of healthy subjects to a high fat meal. Dig Dis Sci 1999 Jul;44(7):1317-21.

10. Duffy LC, et al. Perspectives on bifidobacteria and biotherapeutic agents in gastrointestinal health. Digestive Diseases and Sciences 1999 Aug;44(8):1499-1505.

11. Bensoussan A, et al. Treatment of irritable bowel syndrome with Chinese herbal medicine. JAMA 1998 Nov;280 (18):1585-9.

12. Hills JM, Aaronson PI. The mechanism of action of peppermint oil in gastrointestinal smooth muscle. Gastroenterology 1991;101:55-65.

13. Pittler M, et al. Peppermint oil for irritable bowel syndrome: a critical review and meta-analysis. Am J Gastroenterol 1998 Jul;93(7):1131-5.

14. Bone, K. Phytotherapy and irritable bowel syndrome. Br J Phytother 1998;4(4);190-8.

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