What are Irritable Bowel Treatments?
Just a quick overview of what is Irritable Bowel Syndrome:
It is a functional gastrointestinal disorder meaning there are no biochemical or structural abnormalities on investigation such as those found in IBD (inflammatory Bowel Disease). It is fairly common in Australia.
The syndrome is characterised by:
- Recurrent abdominal pain, related to defecation or passing of wind.
- Associated with a change in stool frequency or form.
It is sub-typed by the predominant stool form as follows:
- diarrhoea predominant (IBS-D)
- constipation-predominant (IBS-C)
- mixed subtype (IBS-M – for alternating bowel habit)
The diagnostic criteria, referred to as the Rome criteria, are based on an expert consensus governed by the Rome Foundation.
The Rome IV diagnostic criteria for diagnosing Irritable Bowel Syndrome.
Recurrent abdominal pain, on average, at least one day per week in the last three months associated with two or more of the following criteria:
- Related to defecation or passing of a bowel motion.
- Associated with a change in the frequency of stool.
- Associated with a change in the form (appearance) of stool.
Criteria fulfilled for the last three months with symptom onset at least 6 months before diagnosis.
Screening for serious conditions that are medically known as “red flags” is vital so as not to miss an underlying serious health issue that needs a specialist to manage.
- Age: >50 years of age, with no previous colon cancer screening and presence of symptoms. I.e. such as a recent change in bowel habit.
- Rectal bleeding – is called maleana and is an intestinal bleed until proven otherwise
- Vomiting dark blood – is due to bleeding oesophageal varices (varicose veins at the base of the oesophagus) or in the stomach from an ulcer. This is called haematochezia.
- Unexplained weight loss.
- Abdominal pain, especially if it’s not completely relieved by passing a bowel movement, or occurs at night.
- Family history of colorectal cancer or inflammatory bowel disease.
- Iron deficiency – unexplained.
- Positive faecal occult blood test.
- Persistent or night time diarrhoea – important to exclude coeliac disease.
Insight: There is no one test to diagnose Irritable bowel syndrome.
The main focus of treatment to date has been on symptom relief to enable anyone with IBS to live as normally as possible.
Treatment options vary according to the type of IBS pattern present and the severity of symptoms.
In mild cases, simple changes to lifestyle and diet may be of benefit such as:
- Diet: avoid eating foods that trigger symptoms, eat high fibre food and drink plenty of water.
- Trigger foods: try eliminating foods that cause gas and bloating, avoid gluten, or trial eating a low FODMAP diet.
- Stress management: with regular exercise and getting enough sleep.
- Medications: a review of these to avoid medications that may aggravate IBS.
More moderate or severe symptoms may need further strategies.
This needs to be tailored to each individual. What works for one person – may not work for another. E.g. Fibre – having soluble and increasing water intake can help with IBS – C (Constipation type IBS), and may aggravate with IBS – D (Diarrhoea type IBS).
Trigger foods: are best avoided.
- Caffeine – increases gastric motility and may aggravate IBS – D.
- Alcohol – can irritate the stomach lining and has the potential to cause stomach ulcers long term.
- Spicy food.
- Fibre – for IBS – D. May cause gas and bloating.
- Fats and oils – may aggravate IBS – D.
This information comes from Australian research and looks at the “sugar chains” attached to foods or specific carbohydrate chains that aren’t absorbed readily causing gas, bloating and sometimes diarrhoea. These are found in foods that are commonly eaten.
- F = Fermentable – foods that cause fermentation and gas.
- O = Oligosaccharides – Fructans and GOS (Galacto-Oligo-Saccharides) – found in wheat, rye, garlic, onions and legumes / beans.
- D = Disaccharides – Lactose
- M = Monosaccharides – Fructose
- A = And
- P = Polyols – Artificial sweeteners such as Sorbitol, Mannitol or Xylitol.
This requires an in-depth assessment of one’s diet and the use of a food diary may help to find foods that trigger IBS.
A low FODMAP diet may help to alleviate painful symptoms such as bloating, cramps and diarrhoea.
It involves a 2-6 weeks period of trialling a low FODMAP diet. This involves removing foods that contain high FODMAP content. i.e. foods full of short-chain carbohydrates.
Supervision with an experienced practitioner is useful and is the best way to guide one through this journey.
If access is an issue there are resources found at www.monashfodmap.com.
In cases where stress and or anxiety have an impact on IBS, seeing a psychologist or trained professional to work on stress management techniques may also be of value.
Gut focused hypnotherapy may be of assistance to some IBS sufferers.
May be of benefit for those individuals that have episodic flares of their symptoms.
- Anti-diarrhoea medicines: readily available medications over the counter to acutely relieve diarrhoea.
- Antispasmodic medicines: to relieve cramping. Such as Peppermint oil by decreasing the sensitivity of pain fibres in IBS. And are calcium channel blockers in the smooth muscle of the bowel, thus leading to a decrease in muscular contraction = anti-spasm.
- Painkillers: to relieve acute pain and some times may slow down bowel transit time – which is increase with IBS-D. Best avoided due to long term complications such as addiction, tolerance and narcotic bowel syndrome. The latter is best described as chronic or frequently recurring abdominal pain that worsens with continued or escalating doses of narcotics.
- Antidepressants: may alleviate symptoms for those that are sensitive to stress and present with IBS – M (Mixed). Where the excess stress response form the brain has a direct effect on gut function known as central sensitization or by altering visceral hypersensitivity. The latter occurs in IBS sufferers, they have a lower threshold for pain in their abdomen. SSRI’s and Tricyclic Antidepressants have been found to be useful for modulating neuropathic pain in IBS.
- Antibiotics: Rifaxamin is a non-absorbable antibiotic used in the treatment of SIBO (Small Intestinal Bacterial Overgrowth). It has been found to relieve IBS symptoms of gas and bloating in the short term. However, it’s role in long term management of IBS is uncertain.
Probiotics are live bacteria or yeast found in food (yoghurt or fermented foods) or supplements and have become a part of gut focussed treatments.
Our gut flora is full of bacteria and yeast.
Probiotics are thought to have a role in enabling balance within our gut flora as these bacteria or yeast interact with our gut lining and immune system.
- Protective role – prevent harmful bacteria from entering our system.
- Immune boost – help modulate the immune system in the gut and overall to improve resistance to infection.
- Antimicrobial – are able to produce substances that act like antibiotics and inhibit the growth of other species.
- Aid digestion.
There is some research identifying certain strains with assisting with IBS control.
E.g. Bacillus Coagulans MCT 5856 has been found in animal studies to relieve diarrhoea (1.a.) A small trial on humans showed a significant decrease in bloating, diarrhoea, abdominal pain and stool frequency in the group receiving Bacillus Coagulans MCT 5856 compared to the placebo group in IBS – Type D sufferers. (1.b.)
Overall relief from bloating, gas, and incomplete evacuation with Bifidobacterium infantis 35625. (1.c.)
And combination therapy with a variety of probiotic strains (Lactobacillus acidophilus, L. rhamnosus, Bifidobacterium breve, B. actis, B. longum, and Streptococcus thermophilus) was shown in one particular study was found to provide effective relief for IBS – Type D sufferers. (1.d.)
Another study showed a combination probiotic (L. acidophilus, L. reuteri, L. plantarum, L. rhamnosus, and B. animalis subsp. lactis) to helped improve bowel movements and stool consistency in a group of IBS – Type C sufferers. (1.e.)
Here is a very good reference looking at single or double probiotic studies with various strains with treating IBS. The conclusion is that the results are mixed. IBS is multi-factorial and specific probiotics have a “drug-like” effect suggesting that further clinical trials are required. (1.f.)
Strain specificity and ability to target certain symptoms are where probiotic research may give further treatment options. (1.g.)
Note: this topic is an article all on its own. The area is full of ongoing research using looking at a number of probiotic strains for a specific treatment/response with the management of IBS.
NEW APPROACHES TO IBS TREATMENTS: Digestive enzymes
Digestive enzymes in the management of IBS is a new direction.
Only recently has there been a study at Monash University that used a specific enzyme for GOS – Galacto-Oligo-Saccharide – called alpha-galactosidase with a group of IBS sufferers.
They had 31 individuals on a low FODMAP diet that had a high GOS content and were tested over a period of 3 days.
Of this group 1/3 tolerated the diet and 2/3’s did not. They reacted to the high GOS content.
The GOS sensitive IBS patients where given the digestive enzyme in:
- full dose – half dose was given prior to the meal and the other half with the meal.
- half dose.
In this group the full dose of enzyme was found to relieve their symptoms.
High GOS foods: type of sugar commonly found in beans.
- Legumes – e.g. hummus dip
- Cashews and pistachios
- Soy milk
- Oat milk
- Thawed peas, butternut pumpkin, and beetroot.
- Custard apple
The use of pancreatic enzymes (Amylase, Lipase and Protease) maybe of help in a smaller number of IBS-D sufferers, this is approximately 6% IBS sufferers. This is thought to be due to a degree of exocrine pancreatic insufficiency (EPI). Exocrine refers to the dual role the pancreas has of making digestive enzymes that are secreted from the pancreas and released into the duodenum at the very beginning of the intestines.
EXO = external or outside. Vs ENDO = refers to internal or inside.
The endocrine role of the pancreas is to produce and release insulin INTO the bloodstream to help regulate blood sugar levels.
There is a decline in the production of digestive enzymes from the pancreas that can lead to a secondary diarrhoea type of bowel habit and presenting as an IBS-D pattern. Loose stools that may be difficult to flush suggesting impaired fat absorption as we rely on lipase from the pancreas to initiate fat digestion.
Lactase is the enzyme used to break down lactose and this has commonly been used in individuals that are lactose intolerant. Without it lactose can work it’s way down the digestive tract causing bloating, gas and cramps.
Now these enzymes are highly specific and are exact in how they work.
Over the counter digestive enzymes may have additives in them that can cause digestive issues and may have no evidence to support that they work. As found in the study at Monash Uni, the specificity of the enzyme and dose is important – the full dose was found to be efficacious.
This may pave the way for specific or targeted approaches to Irritable Bowel Syndrome treatments in the future.
Further potential treatments or adjuncts for IBS:
Is derived from turmeric which is used widely as a spice in cooking.
Curcumin has a number of actions in that is an antioxidant, anti-inflammatory, antimicrobial, antidepressant, immune-modulating and may give pain relief.
Animal studies have shown a number of mechanisms by which curcumin alleviated anxiety and depressive-like behaviours in rats with IBS. (2)
Also with altering VH (visceral hypersensitivity) in rats with IBS via two different pain receptors.
Also extracted from several plants. Has anti-inflammatory, antioxidant, and antiulcer activity.
A recent study found this to reduce IBS – D symptoms and improve QOL (Quality Of Life) in IBS patients. (3)
The extracts from Ginsengs known as Ginosides inhibit the 5HT3A receptor (a serotonin receptor). (4)
Stimulation by serotonin on it’s receptors in the gut cause bloating, nausea and vomiting.
A trial using Panax Ginseng In IBS sufferers (n 24) was found to help control abdominal pain. (5)
FAECAL MICROBIAL TRANSPLANTS: otherwise known as FMT.
This involves transplanting a faecal sample from a healthy donor to another also known as “poo transplants”. The thought behind this is that Irritable Bowel Syndrome is due to dysbiosis or imbalanced gut flora leading to bacterial overgrowth.
It is a treatment for Clostridial Difficle colitis and trials as to its efficacy in IBD (Inflammatory Bowel Disease) show it cost-effective to treat the former and may have some therapeutic benefit for treating Ulcerative Colitis but not Crohns. (6)
One trial has shown some benefit for relieving symptoms of IBS – Type D or Type D and C at 3 months, but not at 12 months. (7).
The scope for approved treatment options for Irritable Bowel Syndrome has mainly focused on symptom control to date.
A controversial view point that considers the underlying mechanism for Irritable Bowel Syndrome is that is may be due to a disruption in the gut microflora also known as a “baterial overgrowth”. Whereby a colony of bacteria establishes itself in the gut causing disruption and symptoms due to substances it makes.
Evidence from studies targeting gut flora with antibiotics and probiotics that show a degree of efficacy in symptom relief seem to support this concept.
An area for further research and “food for thought”.
1. a. Bacillus coagulans MTCC 5856 for the management of major
This is an excellent overview of probiotics.