Irritable Bowel Syndrome
Description
Irritable bowel syndrome (mucous colitis) is not a disease but a collection of symptoms. It is marked by chronic or periodic diarrhea, alternating with constipation, and is accompanied by straining and abdominal cramps. Onset of irritable bowel syndrome is usually during late adolescence or early adulthood and is at least twice as common in women as in men. It is the most common gastrointestinal complaint told to doctors. IBS is caused by a functional, rather than structural, defect of the following symptoms.
1. Abdominal pain
2. Altered bowel functions, constipation, or diarrhea
3. Hypersecretion of colonic mucus
4. Dyspeptic symptoms (flatulence, nausea, anorexia)
5. Varying degrees of anxiety or depression.
IBS is alternately called nervous indigestion, spastic colitis, mucous colitis and intestinal neurosis. Splenic flexure syndrome is a variant of the irritable bowel syndrome in which gas in the bowel leads to pain in the lower chest or the left shoulder. IBS is the most common gastrointestinal disorder seen in general practice and accounts for 30 to 50% of all referrals to gastroenterologists.
Although many sufferers never seek medical attention, it has been estimated that approximately 15% of the population complains of IBS. Although twice as many women as men are reported to have IBS, it seems more likely that an equal number of males as females have this syndrome but that males just do not report their symptoms as often.
In making a diagnosis, the physician will rule out conditions which mimic IBS by taking a detailed medical history and physical examination. In most cases, a comprehensive stool and digestive analysis, sigmoidoscopy, complete blood count, erythrocyte sedimentation rate and serum protein concentration will be performed to determine the diagnosis.
Abdominal distension, relief of pain with bowel movements and the onset of loose or more frequent bowel movements with pain seem to correlate best with the diagnosis of IBS. While IBS is often a diagnosis of exclusion, clinical judgment is used to determine the extent of the diagnostic process.
Conditions which may mimic IBS include the following.
1. Miscellaneous dietary factors (such as excessive tea, coffee, carbonated beverages and simple sugars)
2. Infectious enteritis (such as amebiasis and giardiasis)
3. Inflammatory bowel disease
4. Lactose intolerance
5. Laxative abuse
6. Intestinal candidiasis
7. Disturbed bacterial microflora (as a result of antibiotic or antacid usage)
8. Malabsorption diseases (such as pancreatic insufficiency and celiac disease)
9. Metabolic disorders (such as adrenal insufficiency, diabetes mellitus, and hyperthyroidism)
10. Mechanical causes such as fecal impaction
11. Diverticular disease
12. Cancer
After ruling out other conditions there are four major considerations in formulating a treatment plan:
1. Increasing dietary fiber
2. Eliminating certain foods in the case of food allergy or food intolerance
3. Controlling psychological components
4. Using herbal therapy when appropriate
Causes
Primary factors
The primary cause of irritable bowel syndrome is excessive spasms of the large intestine.
Some causative factors in the irritable bowel syndrome (IBS) are a low fiber diet, food sensitivities, intestinal candidiasis, and psychological stress. The first three causes are discussed in the Dietary Considerations section of this topic; the latter will be discussed here.
Psychological Factors
Contibuting psychological factors include:
Stress
Nervousness
Anxiety
Guilt
Depression
Mental or emotional problems such as anxiety, fatigue, hostile feelings, depression and sleep disturbances are reported by almost all patients with irritable bowel syndrome (IBS).
There are several theories that link psychological factors to the symptoms of IBS. According to the learning model, gastrointestinal symptoms are a learned response to repeated exposure to stressful situations. Another theory holds that the IBS is a manifestation of depression or chronic anxiety, or both.
Personality assessments of IBS sufferers have shown them to have higher anxiety levels and a greater feeling of depression. However, these studies were based on personality assessments after the individual developed IBS. It has since been determined by pre-illness personality assessment that IBS sufferers have normal personality profiles. Therefore, many of the psychological symptoms may be either secondary to the bowel disturbances (particularly malabsorption) or the result of a common causative factor, e.g., stress, food allergy, environmental illness, or candidiasis.
Increased colonic motility during exposure to stressful situations has been shown to occur in both normal subjects and those suffering IBS. This apparently accounts for the increased abdominal pain and irregular bowel functions seen in patients with IBS and normal subjects during periods of emotional stress.
Some researchers believe that IBS sufferers have difficulty adapting to life events, although this has not been fully demonstrated in clinical studies. Psychotherapy, in the form of biofeedback or dynamically oriented short-term individual (brief) psychotherapy, has been shown to enhance the results of standard medical treatment of IBS.
There is no evidence for the efficacy of anxiolytic drugs, a combination of tranquilizers and antispasmodics, and antidepressants in IBS. Therefore, these drugs should not be used in the treatment of IBS.
An increase in physical exercise seems to be beneficial for IBS patients. Many find daily leisurely walks markedly reduce symptoms, probably due to the known stress reduction effects of exercise.
Physical Factors
Heavy smoking
Poor diet
Food allergies; intolerance of lactose, coffee,or raw fruits and vegetables are especially common
Food poisoning
Drugs, especially improper use of laxatives
Diverticular disease
Colon cancer
Signs & Symptoms
The irritable bowel syndrome is characterized by some combination of the following symptoms:
1. Abdominal pain
2. Altered bowel function, constipation, or diarrhea
3. Hypersecretion of colonic mucus
4. Dyspeptic symptoms (flatulence, nausea, anorexia)
5. Varying degrees of anxiety or depression.
Nutritional Supplements
Structure & Function: Intestinal Health
---------------------------------
General Supplements
---------------------------------
| Adult | ||
| Acidophilus ** | 2 - 3 tsp daily | |
| Aloe vera* | ||
| Betaine HCl | 5 - 15 grains | |
| DHEA* | ||
| Fiber* | ||
| Fish oils* | ||
| Lactase* | ||
| L-acidophilus* | ||
| N-A Glucosamine | ||
| Peppermint* | ||
| Vitamin A | 10,000 - 20,000 IU | |
| Vitamin B-5 | 100 - 200 mg | |
| Vitamin E | 100 - 200 IU | |
| Zinc | 20 - 30 mg |
** with meals
* Please refer to the respective topic for specific nutrient amounts.
Discussion:-
The bowel may also benefit from the removal of fat from the colon wall, which is accomplished with glucomannan (a form of fiber). Fiber is also recommended following surgery, specifically: guar gum. The simplest everyday source of fiber is probably bran (oat or other: 1 tablespoon).
It is usually recommended to restore proper bowel function through the supplementation of beneficial microflora e.g. L-acidophilus.
As a precaution, one form of antioxidant, pycnogenol™, may irritate the bowel.
Note: All amounts are in addition to those supplements having a Recommended Dietary Allowance (RDA). Due to individual needs, one must always be aware of a possible undetermined effect when taking nutritional supplements. If any disturbances from the use of a particular supplement should occur, stop its use immediately and seek the care of a qualified health care professional.
Dietary Considerations
High Fiber Diet and Elimination Diet are the two primary dietary plans recommended for IBS.
Dietary fiber
Dietary fiber has a long and irregular history as a therapy for irritable bowel syndrome. One problem not addressed in studies on the therapeutic use of dietary fiber is the role of food allergy. Wheat bran is often used in both research and clinical practice. Since food allergy is a significant causitive factor in this condition and wheat is commonly implicated in malabsorptive and allergic conditions, the use of wheat bran for IBS should be contraindicated.
While IBS patients with constipation may respond favorably to wheat bran, those with diarrhea may actually experience a worsening of their symptoms. Patients with diarrhea would respond better to water-soluble dietary fibers and mucilages.
Dietary fiber from fruit and vegetable sources, rather than cereal sources, may be of greater benefit in many individuals. In one uncontrolled clinical study, there was no significant difference in improvement when a diet composed of 30 grams of fruit and vegetable fiber and 10 grams of cereal fiber was compared with one having the opposite ratio.
Although both diets resulted in similar significant reduction of abdominal pain, bowel habits and state of well-being, the presence of large quantities of potentially allergic wheat fiber in both diets would probably have obscured any differences.
In general, consuming a diet rich in complex carbohydrates and dietary fiber will benefit a great number of individuals with symptoms of the irritable bowel syndrome, particularly if the source of dietary fiber is derived primarily from water-soluble fiber like that found in oat bran, vegetables, guar, psyllium, fruits and legumes. Elimination Diet and Food Sensitivities. The importance of food sensitivities as a cause of IBS has been recognized since the early 1900s. Recent studies have further documented the association between food and the irritable bowel. Food sensitivity in IBS is not believed to be mediated by the immune system. Therefore, "food intolerance" is a more appropriate term than "food allergy". According to double-blind challenge methods, approximately two thirds of the patients with IBS have at least one food intolerance, and some have multiple intolerances.
Since current food allergy tests are designed to determine only immune system mediated food sensitivities, many food allergy tests are not appropriate.
Additionally, since the majority of food allergies are mediated by IgG rather than the classic allergic antibody IgE, traditional allergy tests like the skin scratch test and the IgE-rast are usually poor indicators of food intolerance, although widely used for this purpose. The IgE/IgG-rast may be a better indicator, although many sensitivities may still be undetectable by currently available laboratory procedures.
The elimination diet is the least expensive method for detecting food sensitivity, yet appears to yield the best results in patients with IBS.
In an elimination diet, the individual is placed on a limited diet. Common foods are eliminated and replaced with either hypoallergenic foods, foods rarely eaten or special hypoallergenic formulas. Typically, the elimination diet consists of lamb*, chicken, potatoes, rice, banana, apple and a vegetable from the brassica family. The individual stays on this limited diet for at least one week and up to one month.
A large number of individuals will feel a marked improvement while on the elimination diet. If the symptoms are related to food sensitivity, they typically disappear by the fifth or sixth day of the diet. If the symptoms do not disappear by then, it is possible the reaction is to a food remaining in the elimination diet and an even more restricted diet must be followed.
After one week, individual foods are reintroduced according to a plan where a particular food is reintroduced every two days. Usually after the one week "cleansing" period, the patient will develop an increased sensitivity to offending foods. Reintroduction of the offending food(s) will typically produce a more severe or recognizable symptom than before. The food should be reintroduced alone as the entire meal.
A careful, detailed record must be maintained, describing when foods were reintroduced and any accompanying symptoms. The wrist pulse should be monitored during reintroduction, as pulse changes may occur when an offending food is consumed.
In one interesting study, a small group of patients who did not respond to an allergy elimination diet and the administration of the anti-yeast drug Nystatin (600,000 U/day, for ten days) were found at the 6-month follow-up visit to be still hosting the yeast Candida albicans in the their stools. As the presence of Candida albicans in the intestinal tract favors the development of allergic and pseudo-allergic reactions, it is often a complicating factor.
Homeopathic Remedy
Colitis - Chrohns Disease
1.* Nitricum acidum - 6C long term use
2. Carbo vegetabilis - 30C
3.* Nux vomica - 30C
Treatment Schedule
Doses cited are to be administered on a 3X daily schedule, unless otherwise indicated. Dose usually continued for 2 weeks. Liquid preparations usually use 8-10 drops per dose. Solid preps are usually 3 pellets per dose. Children use 1/2 dose.
Legend
X = 1 to 10 dilution - weak (triturition)
C = 1 to 100 dilution - weak (potency)
M = 1 to 1 million dilution (very strong)
X or C underlined means it is most useful potency
Asterisk (*) = Primary remedy. Means most necessary remedy. There may be more than one remedy - if so, use all of them.
References
Boericke, D.E., 1988. Homeopathic Materia Medica.
Coulter, C.R., 1986. Portraits of Homeopathic Medicines.
Kent, J.T., 1989. Repertory of the Homeopathic Materia Medica.
Koehler, G., 1989. Handbook of Homeopathy.
Shingale, J.N., 1992. Bedside Prescriber.
Smith, Trevor, 1989. Homeopathic Medicine.
Ullman, Dana, 1991. The One Minute (or so) Healer.
Tissue Salts
| Calc. Phos. | children: emaciated, flabby; |
| Kali Phos. | children: wasting, putrid stools; |
Herbal Approaches
----------
Herbs
-----------
Aloe vera
Chamomile
Ginger Root (Zingiber officinale)
Marshmallow root
Peppermint Leaves (Mentha piperita)
Slippery elm bark (Ulmus fulva)
Turmeric
Valerian root
Note: The misdirected use of an herb can produce severely adverse effects, especially in combination with prescription drugs. This Herbal information is for educational purposes and is not intended as a replacement for medical advice.
Discussion:
Aloe Vera juice has gained popularity in recent years to cleanse the system and suppress symptoms. Some constituents may even have antiseptic, antibacterial and antiviral properties, including AIDS.
A number of manufacturers are vying for the market, so their literature is confusing, regarding the efficacy of different concentrations of aloe, the role of flavors or additional ingredients etc.
Chamomile reduces inflammation, counteracts flatulence and pain in gastroenterological conditions e.g. celiac disease, nontropical sprue, or gluten sensitivity. (1,500 mg t.i.d. between meals.)
Common ginger plant (Zingiber officinale) has a very long history of use in the treatment of a wide variety of intestinal ailments.
A clue to ginger's efficacy in alleviating gastrointestinal distress was offered in a recent double-blind study which showed that ginger is very effective in preventing the symptoms of motion sickness. In fact, ginger was shown to be far superior to Dramamine, a commonly used over-the-counter and prescription drug for motion sickness. Although ginger's mechanism of action in alleviating gastrointestinal distress has yet to be elucidated, it has been regarded as a carminative for thousands of years.
Turmeric belongs in this same category (with ginger) as it is also an excellent carminative (promoting the elimination of intestinal gas) and spasmolytic (relaxing and soothing the intestinal tract).
Herbal antispasmodics
Many plants possess direct antispasmodic action on the gastrointestinal tract. Perhaps the most commonly used herbs with this activity are chamomile (Matricaria chamomilla), valerian (Valeriana officinale), rosemary (Rosmarinus officinalis), peppermint (Mentha piperita) and lemon balm (Melissa officinalis). The antispasmodic activities of these herbs has been demonstrated in experimental studies. The use of these herbs may be of great benefit in mild intestinal colic.
Marshmallow root is a mucilaginous product which soothes inflamed tissue and speeds healing. (1,500 mg t.i.d. between meals.)
Peppermint oil inhibits gastrointestinal smooth muscle contraction and relieves gas. It has been used to reduce colonic spasm during a diagnostic procedure known as an endoscopy. An enteric-coated peppermint oil capsule has been used in treating the irritable bowel syndrome in Europe. In order for peppermint oil to be of benefit in treating IBS, it must reach the colon. Enteric coating prevents the peppermint oil from being released in the stomach. Instead of being rapidly absorbed in the stomach and upper intestine, peppermint oil in enteric-coated capsules is thus allowed to move on to the colon where it relaxes the spastic intestinal muscles.
The effects of ingesting peppermint oil without enteric coating are predominantly upper gastrointestinal, with common side effects such as esophageal reflux and heartburn.
In one study, enteric-coated peppermint oil was shown to significantly reduce the abdominal symptoms of the irritable bowel syndrome. The study concluded "Peppermint oil in enteric-coated capsules appears to be an effective and safe preparation for symptomatic treatment of the irritable bowel syndrome." This is quite significant since many sufferers of the irritable bowel syndrome are told it is a condition they will just have to live with.
The capsules should be consumed between meals. Some patients have noted a transient, hot, burning sensation in the rectum during defecation due to unabsorbed menthol. If this occurs do not be alarmed, simply reduce the dose.
Slippery elm bark is another mucilaginous product, which is soothing and healing. (1,500 mg t.i.d. between meals.)
Valerian root extract is a carminative. (2 tablets t.i.d.)
Robert's Formula
Although no research has been done to document its efficacy in IBS, an old naturopathic remedy, Robert's Formula, has a long history of use in this condition. Although different variations of the formula exist, typically Robert's formula contains:
Geranium (Pelargonium sp.)
Cabbage(Brassica oleracea)
Marshmallow (Althaea officinalis)
Slippery elm bark (Ulmus fulva)
Okra (Hibiscus esculentis)
Echinacea (Echinacea angustifolia)
Goldenseal (Hydrastis canadensis)
Pancreatin
Duodenal substance
Niacinamide
Other herbs, containing irritants, may exacerbate GI symptoms. (After Newall)
| Herb | Effects |
| Alfalfa | Irritant, canavanine in seeds |
| Arnica | Irritant to mucous membranes |
| Asafetida | Irritant gum, |
| Blue Cohosh, | Irritant to mucous membranes; |
| spasmogenic in vitro | |
| Blue Flag | Irritant gum and oil |
| Bogbean (Buck Bean) | Irritant to GI tract |
| Boldo | Irritant oil |
| Buchu | Irritant oil |
| Capsicum | Capsaicinoids, mucosal irritants |
| Cassia (see Cinnamon) | |
| Cinnamon | Irritant to mucous membranes, oil |
| Cowslip | Irritant saponins |
| Drosera (Sundew) | Plumbagin. irritant |
| Eucalyptus | Irritant Oil |
| False Unicorn Root | Large doses may cause vomiting |
| Figwort | Purgative effect |
| Garlic Plant | Raw clove |
| Ground Ivy | Irritant oil |
| Guaiacum | Avoid if inflammatory condition |
| Horse chestnut | Saponins, contra-indicated in renal disease |
| Horse radish | Irritant oil |
| Hydrangea | Hydrangin, possible gastro-enteritis |
| Jamaican Dogwood | Irritant to humans |
| Juniper | Irritant oil |
| Lemon Verbena | Irritant oil |
| Lime Flower | Irritant to kidney |
| Nettle | Tea irritant to stomach |
| Parlsey Plant | Irritant oil |
| Pennyroyal | Toxic & irritant oil |
| Pilewort | Irritant sap |
| Pleurisy Root | GI irritant |
| Pokeroot | Saponins |
| Pulsatilla | Irritant to mucous membranes |
| Queen's Delight | Diterpenes |
| Sarsaparilla | Saponins |
| Senega | Saponins |
| Skunk Cabbage | Inflammatory & blistering to skin |
| Squill | Saponins |
References:
Jones, V et al., Food intolerance: a major factor in the pathogenesis of irritable bowel syndrome. Lancet, 1982(ii):115-118.
Lech, U et al., Treatment of irritable bowel syndrome with peppermint oil. A double-blind study with a placebo. Ugeskr. Laeger. 1988, 150:2,388-2,389.
Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-care Professionals. London: The Pharmaceutical Press, 1996.
Petitpierre, M et al., Irritable bowel syndrome and hypersensitivity to food. Ann. All. 1985, 84:538-540.
Aromatherapy - Essential Oils
It may be difficult to distinguish between an inflammatory condition (which colitis strictly speaking is) and an infection.
Chamomile is noted for its gentle, soothing effect.
Intestinal infections:
| Basil Essence, | Bergamot Essence, |
| Cinnamon Essence | (Red) Thyme Essence. |
Two folk favorites, which have been applied to every gastro-intestinal condition through the ages, include:
| Ginger Essence, | Peppermint Essence. |
Related Health Conditions
| Anxiety | Bleeding |
| Constipation | Cramp |
| Diarrhea | Inflammation |
| Pain | Spasm |
| Stress | Ulcers |
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