Irritable bowel syndrome: constipation-predominant (C-IBS)

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Chapter 3 Irritable bowel syndrome

constipation-predominant (C-IBS)

Jason Hawrelak, ND, B Nat (Hons), phD

AETIOLOGY

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterised by altered bowel habit and abdominal pain.1 It is a chronic disorder of unclear aetiology.2 Recent research, however, has brought to light a number of possible aetiological factors:

• enhanced visceral perception. Patients with IBS have been found to have increased visceral sensation and visceral hyperalgesia compared to healthy controls.3,4
• low-grade inflammation. Irritable bowel syndrome patients show no identifiable inflammation on routine colonic biopsies. However, some do show increased expression of inflammatory markers (increased enterochromaffin and mast cell numbers, increased intraepithelial T-lymphocytes and increased mucosal interleukin-1β messenger RNA), suggesting low-grade inflammation is present. This mild mucosal inflammation is theorised to cause local disruptions to neuromuscular function.4,5
• altered gastrointestinal tract (GIT) motility. Subjects suffering from C-IBS have been found to have significant delays in overall colonic transit time and decreased numbers of fast and propagated colonic contractions compared to healthy controls.6 There also appears to be impaired transit of intestinal gas.7
• altered GIT microflora (dysbiosis). Colonic fermentation studies have found patients with IBS produce significantly more colonic hydrogen than healthy controls,8 as well as having altered faecal short-chain fatty acid profiles.9 Additional studies have found the GIT microflora of IBS patients to differ from that of healthy controls, most notably lower faecal concentrations of bifidobacteria and lactobacilli and higher concentrations of Enterobacteriaceae.10–12

RISK FACTORS

Several factors that appear to play a role in initiating and maintaining IBS have been identified. These factors include a genetic predisposition, a history of enteric infections, antibiotic use, a history of stressful life events, and concurrent anxiety and/or depressive disorders:

• It is believed that a genetic disposition may contribute to the development of IBS in some patients.13,14 This predisposition may not be disease-specific, but more related to alterations in the responsiveness of the central nervous system to stimuli.
• Several studies have shown a relationship between acute gastrointestinal infections and the onset of IBS symptoms.15–17 It has been postulated that long-lasting alterations in mucosal function and structure may be responsible for postinfective IBS. These alterations include increased intestinal permeability, increased expression of inflammatory markers (such as interleukin-1β), and neuromuscular dysfunction.17,18
• Two studies have found an association between antibiotic use and increased frequency of IBS symptoms.19,20 This association is thought to be mediated via antibiotic-induced alterations in the GIT microflora and/or enhanced visceral sensitivity.
• Stressful and traumatic life events are frequently reported to precede the initial onset of IBS symptoms and symptom flare-ups in patients already suffering from IBS.21,22 Additionally, IBS has consistently been found to have a high degree of psychiatric comorbidities, such as dysthymia, depression, panic disorder and generalised anxiety disorder.23,24

CONVENTIONAL TREATMENT

Many agents are currently used for the treatment of IBS and no one agent has proven particularly effective and/or free from side effects.25–27 Key classes of medications used to treat C-IBS include antispasmodics, antidepressants, laxatives and 5-hydroxytryptamine type 4 receptor agonists (such as tegaserod). Therapeutic gains (the difference in treatment response between placebo and active therapy) have often been minimal with these agents28 and adverse events severe.29

NATUROPATHIC TREATMENT AIMS

• Optimise GIT microflora.
• Promote daily, easy-to-pass bowel movements.
• Manage GIT symptoms.
• Support the nervous system.
• Decrease gut inflammation and diminish visceral hypersensitivity.
• Improve liver function.

KEY TREATMENT PROTOCOLS

GIT microflora: overview

The microflora of the GIT represents an ecosystem of the highest complexity.30 The microflora is believed to be composed of over 50 genera of bacteria,31 accounting for over 500 different species.32 The adult human GIT is estimated to contain 1014 viable microorganisms, which is 10 times the number of eukaryotic cells found within the entire human body.33 Some researchers have called this microbial population the ‘microbe’ organ – an organ that is similar in size to the liver (1–1.5 kg in weight).34 Indeed, this ‘microbe’ organ is now recognised as rivalling the liver in the number of biochemical transformations and reactions in which it participates.35

The microflora plays many critical roles in the body; thus, there are many areas of host health that can be compromised when the microflora is altered. The GIT microflora is involved in the stimulation of the immune system, synthesis of vitamins (B group and K), enhancement of GIT motility and function, digestion and nutrient absorption, inhibition of pathogens (colonisation resistance), metabolism of plant compounds (for example, phytoestrogens and glycosides), and production of short-chain fatty acids and polyamines.30,36,37

The colon is the most heavily colonised area of the GIT and this microbial ecosystem is believed to play the greatest role in human health. The colonic microflora is composed almost entirely of anaerobic bacteria, with the largest two genera being Bacteroides (accounting for up to 30% of all organisms) and Bifidobacterium (which can constitute up to 25% of total faecal counts). Other numerically important anaerobes include eubacteria, lactobacilli, clostridia and gram-positive cocci. Existing in smaller proportions are coliforms, methanogens, enterococci and dissimilatory sulfate-reducing bacteria. These important groups of bacteria have been divided into species that exert either beneficial or harmful effects on the host, as outlined in Figure 3.1.37 When the beneficial species are present in insufficient numbers or when concentrations of potentially harmful bacteria are relatively high, then dysbiosis is said to result. Dysbiosis is a state in which the microflora produces harmful effects through one or more of the following factors: (1) qualitative and quantitative changes in the intestinal flora itself; (2) changes in their metabolic activities; and (3) changes in their local distribution.38

image

Figure 3.1 The predominant microbiota of the colon categorised into health-promoting and potentially harmful groups.31

Optimise the GIT microflora

In the naturopathic treatment of C-IBS, dysbiosis is viewed as one of the most important aetiological factors. Hence, treatments aimed at addressing this imbalance are seen as crucial to the management of this condition. Treatments aimed at improving the GIT ecosystem can be divided into three categories: probiotics, prebiotics and synbiotics.

Probiotics

The term ‘probiotic’ is derived from the Greek and literally means ‘for life’. It was first coined in 1965 by Lilley and Stillwell to describe substances secreted by one microorganism that stimulate the growth of another.39 In 1974, Parker modified this definition to ‘organisms and substances which contribute to intestinal microbial balance’.40 The current World Health Organization definition of probiotics is ‘live microorganisms which when administered in adequate amounts confer a health benefit on the host’.41 Probiotic organisms can be found in fermented foods (such as yoghurt, sauerkraut and kefir), as well as supplements. The microorganisms found in these products are typically lactobacilli and bifidobacteria.42

Probiotics have a long history of successful use in the treatment of IBS. In fact the first case series detailing the efficacy of a Lactobacillus acidophilus supplement in IBS was published in 1955.43 A recent systematic review and meta-analysis of randomised, controlled trials found probiotic use to be associated with improvements in global IBS symptoms compared to placebo and reductions in abdominal pain.44 It is well-known, however, that efficacy in this condition, as it is in all conditions, is strain dependent. Commercially available probiotic strains that have shown efficacy in the treatment of IBS include L. fermentum PCC45,46 and L. plantarum 299V.47,48 Commercially-available strains found to be ineffective in the management of IBS include L. acidophilus NCFM49 and L. rhamnosus GG.50,51

To achieve the desired therapeutic results, it is imperative to prescribe the precise probiotic strains that have demonstrated therapeutic and clinical efficacy in the condition in question. Strains that work in one condition will not necessarily be effective in other conditions. For example, Lactobacillus rhamnosus GG appears to be effective in the prevention of antibiotic-associated side effects,65 but not of any demonstrable benefit in urinary tract infections.66 Tables 3.2 and 3.3 outline the most appropriate probiotic strains and prebiotic to use for specific disease conditions, as determined by human trials.

Table 3.1 Mechanisms of delivery of probiotics, and their advantages and disadvantages

DELIVERY SYSTEM ADVANTAGES DISADVANTAGES
Fermented foods
• Affordable and accessible
• Easily incorporated into daily lifestyle
• Additional nutritional benefits
• Enhanced bacterial survival through upper GIT (100 × less can be given per dose if given in a dairy base)52
• Effective in upper GIT

• May contain dairy proteins or lactose
• Unsuitable when travelling
• Unsuitable for vegans (if dairy-based)

Capsules
• Ease of administration
• No binders

• Not therapeutic for upper GIT unless opened or chewed
• May contain allergenic excipients
• Higher cost
Tablets
• Ease of administration
• Effective in upper GIT (if chewed)
• May contain allergenic binders and excipients such as gluten
• Higher cost
Powders
• Effective in upper GIT
• Dosage easily adjusted
• May be incorporated into food and drinks
• No binders
• May contain allergenic excipients
• Higher cost

Table 3.2 Most appropriate probiotic strains for specific disease conditions

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Delivery of probiotics

Probiotic organisms can be delivered through a variety of mechanisms: fermented foods (such as yoghurt, kim chi and sauerkraut), capsules, tablets and powders. Each method has its advantages and disadvantages, which are listed in Table 3.1.

Prebiotics

A prebiotic is defined as ‘a nondigestible food ingredient that beneficially affects the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon.’53 For food ingredients to be classified as prebiotics, they must:

• be neither digested nor absorbed in the stomach or small intestine42
• act as a selective food source for one or a limited number of potentially beneficial commensal bacteria in the large intestine42
• change the colonic microflora ecosystem towards a healthier composition,42 and
• induce luminal or systemic changes that improve the health of the host.37

Most emphasis to date has been on finding and trialling food sources that are used by lactic acid-producing bacteria. This is due to the health-promoting properties of these organisms.42 The best known lactic acid-producing bacteria belong to the genera Lactobacillus and Bifidobacterium. Commonly used prebiotics include lactulose, fructo-oligosaccharides (FOS), and galacto-oligosaccharides (GOS). The most appropriate prebiotics to use for specific health conditions are highlighted in Table 3.3.

Table 3.3 Prebiotics for disease conditions

DISEASE CONDITIONS PREBIOTIC
Prevention of UTIs Lactulose (25 g/day)
Lowered immunity: decreased rates of infection FOS (2 g/day in infants)
Poor calcium absorption FOS (8 g/day)
Atopic eczema: prevention in infants GOS and FOS (0.8 g/100 mL formula)
Constipation
• Lactulose (10–40 g/day)
• GOS (9 g/day)
• FOS (10 g/day)

One trial has been performed investigating the efficacy of FOS in IBS with disappointing results.54 However, the dose of FOS used in the study (20 g/day in a single dose) is known to cause significant gastrointestinal side effects (such as bloating, distension, borborygmi and increased flatulence).55 Thus it is not surprising that FOS failed

PREBIOTICS VERSUS COLONIC FOODS

There are a number of other substances that are frequently referred to as prebiotics. Many of these, however, fail to meet the criteria outlined above. Slippery elm, psyllium husks, guar gum and pectin would more accurately be described as colonic foods rather than prebiotics as they appear to lack the selectivity of fermentation that is required of prebiotics.56–58 Other substances, such as polydextrose and larch arabinogalactans, have been shown to increase the growth of beneficial bacteria in human trials.59–60 However, they have thus far been the subject of inadequate research to determine if they meet all of the prebiotic requirements.

to reduce these same GIT symptoms in trial participants. It is possible that administration of lower doses of FOS (for example, 3 g/day) or other prebiotic agents (lactulose or GOS) will result in better clinical outcomes.

Synbiotics

Synbiotics are products that contain both probiotic and prebiotic agents.61 The combination is theorised to enhance the survival of the probiotic bacteria through the upper GIT, improve implantation of the probiotic in the colon, and have a stimulating effect on the growth and/or activities of both the exogenously provided probiotic strains and the endogenous inhabitants of the bowel.62 Synbiotics are a promising treatment avenue in C-IBS with two recently published, open-label trials finding a synbiotic preparation (containing a daily dose of 5 × 109 CFU Bifidobacterium longum strain W11 and 2.5 g fructo-oligosaccharides) to significantly decrease abdominal pain and bloating in patients with C-IBS, as well as increasing stool frequency.63,64

Promote daily, easy-to-pass bowel movements

C-IBS is associated with infrequent bowel movements and hard lumpy stools. Interventions aimed at increasing stool frequency and softening the stools are thus well-indicated. The three main tools used to address this issue are fibre, fluid and exercise.

Epidemiological studies have consistently found correlations between dietary fibre intake and improved bowel function.107,108 As the amount of dietary fibre in the diet is increased, mean gastrointestinal transit time decreases, stool frequency increases and stools become softer and easier to pass.107 Clinical trials of fibre supplementation have also consistently found increased bowel movement frequency and improved stool consistency.109

HOW DOES DIETARY FIBRE WORK?

There appear to be at least five ways by which dietary fibre consumption improves laxation. First, plant cell walls that resist microfloral degradation are able to exert a physical bulking effect by retaining water within their cellular structure. This increased bulk stimulates colonic movement. Secondly, the vast majority of consumed dietary fibre is extensively broken down and metabolised by the colonic microflora. This stimulates microbial growth, leading to an increase in microbial products and microbes themselves in faeces – again leading to an increase in faecal bulk. Thirdly, the increase in faecal bulk speeds up the faeces’ rate of passage through the bowel. As transit time decreases, the efficiency with which the bacteria grow improves – further bulking the stools. Shortened transit time also leads to reduced water absorption by the colon and, hence, moister stools. Fourthly, fermentation of dietary fibre by the colonic microflora results in the production of hydrogen, methane and carbon dioxide gas. When trapped within the gut contents they further add to stool bulk.116 Lastly, other end-products of fermentation (short-chain fatty acids, particularly acetate) enhance muscular contraction in the colon.117,118

A recent systematic review and meta-analysis found fibre to significantly improve global IBS symptoms (see Table 3.4, the review of evidence table) and IBS-related constipation. However, fibre supplementation was found to significantly worsen abdominal pain. When soluble fibre was examined in isolation, it was found to induce a greater reduction in global IBS symptoms and to improve constipation in C-IBS subjects. Conversely, insoluble fibre supplementation was found to have no significant effect upon global IBS symptoms, although it did improve constipation. The authors concluded that fibre supplementation appears to be of benefit in improving global IBS symptoms and particularly constipation; it does not, however, improve IBS-related abdominal pain.110

Table 3.4 Review of the major evidence

image

The findings from this systematic review suggest that sources of soluble fibre would be more appropriate therapeutic tools than sources of insoluble fibre in the treatment of C-IBS. Good sources of supplemental soluble fibre include ground flaxseeds,111 slippery elm powder,112 psyllium husks,113 oat bran114 and pectin.115

Fluid intake

Ensuring the intake of adequate fluid is also a vital, although under-researched, therapeutic tool. Positive associations have been observed between bowel movement frequency and fluid intake in epidemiological research.108 Stool frequency and stool weight have also been found to be significantly decreased during enforced periods of low fluid intake in prospective, human research.119 Adequate fluid intake is usually described as 2100–2600 mL daily, although this would need to be increased in warmer climates.120

Exercise

Epidemiological research has found an association between level of physical activity and frequency of bowel habit, with lower levels of physical activity being linked with impaired bowel habit.121 This link between physical activity levels and bowel health is widely known amongst the general populace, with even Roald Dahl remarking in his Revolting Rhymes:122

An early morning stroll is good for people on the whole.

It makes your appetite improve,

It also helps your bowels to move.

In support of this connection, prospective human research has found that daily moderate exercise is capable of significantly accelerating gastrointestinal transit time, which should equate to softer, easier-to-pass stools.123 Additionally, a recently published, randomised, controlled trial found daily exercise to significantly improve constipation-related symptoms in IBS subjects.124

Manage GIT symptoms

Although it is a benign disorder, IBS is associated with significant impairments in quality of life.134 Recent research has found that three gastrointestinal symptoms (straining at stool, abdominal pain and abdominal bloating) have the greatest negative impact upon quality of life in IBS sufferers.135 Providing relief from these symptoms should thus be at the forefront of naturopathic management of this condition.

Straining at stool is usually addressed with the agents and interventions discussed in the ‘Promote daily, easy-to-pass bowel movements’ section above. Occasionally, however, laxative herbs are needed at the onset of treatment. Sometimes gentle laxatives like Glycyrrhiza glabra are adequate. In more severe cases of constipation, the anthraquinone-containing laxatives can be used: Senna spp., Rhamnus purshiana,

WHAT IS A ‘NORMAL’ BOWEL PATTERN?

This question should really be broken up into two questions: what is a ‘normal’ bowel habit and what is a ‘healthy’ or ‘optimal’ bowel habit? A ‘normal’ bowel habit has been defined by conventional medicine as between three bowel movements per day to three bowel movements per week. These frequencies are based on epidemiological studies conducted on Western populations which have found the vast majority of individuals to have a bowel frequency within this range, with the most common frequency being once daily.125,126 Constipation is thus defined as less than three bowel movements per week.127

Naturopaths would generally not consider patients who experience three bowel movements per week to have a ‘normal’ bowel habit. Naturopath Henry Lindlahr stated in his 1919 classic Natural Therapeutics that ‘normally a person should have a copious movement of the bowels once in twenty-four hours – twice is better’.128 Studies looking at non-Western populations eating traditional fibre-rich diets found defecation frequencies to average two or three times daily.129 Other studies looking at vegans eating high-fibre diets (about 47 g fibre daily) have found a mean bowel movement frequency of ≥ 1.5 per day.107,108 From these data we can gather that individuals consuming a high-fibre, plant-based diet pass stools more frequently than individuals consuming the typical low-fibre, Western diet (about 11–16 g fibre daily).130 Optimal bowel frequency should be considered to be one, two or three movements daily. Naturopaths generally consider patients as being constipated if they experience less than one bowel movement daily.

Bowel habit: men versus women

Studies have consistently found men to have an increased frequency of daily bowel movements, to produce a greater quantity of faeces daily, to have shorter gastrointestinal transit times and to have softer, less-formed faeces than women.107,108,125 Stool form and bowel movement frequency also appears to vary in women according to the menstrual cycle. During the luteal phase of the cycle, gastrointestinal transit time significantly slows, resulting in more formed, harder stools.107

What is the ‘perfect’ bowel movement?

In terms of consistency, the most common stool passed by typical Western populations is well-formed (sausage or snake-like) with either cracks on its surface or a smooth and soft surface (types 3 and 4 in Figure 3.2).125 Populations consuming a predominantly plant-based, high-fibre diet, on the other hand, have softer, bulkier stools that tend to be less formed and more ‘mushy’ (type 5). These stools are associated with shorter gastrointestinal transit times, whereas harder stools are associated with longer transit times.107 So, what is the perfect bowel movement? Optimal stool form should vary between well-formed, sausage-like stools with cracks on its surface (type 3) through to softer blobs with clear-cut edges (type 5). In addition, there should be little-to-no straining at stool, little urgency and a feeling of complete evacuation after the event.131

image

Figure 3.2 The Bristol Stool Form Scale132

What stimulates the bowels to move?

Colonic motility is the key factor determining the whens and whys of bowel movements. The greatest stimulant of colonic contractile activity is morning awakening. Colonic motility is greatly reduced and sometimes even completely abolished during sleep. Upon awakening contractile activity increases briskly.133 Not surprisingly, population studies have found that the vast majority of bowel movements occur between 6 and 9 a.m.125 The other main stimulus of colonic motility is eating – referred to as the colonic motor response to eating or the gastrocolonic reflex. Within minutes of consuming the first mouthful of food, colonic contractile activity begins, and lasts for at least 3 hours.133 In Western populations, a second peak of defecation frequency has been observed at 6–7 p.m., the time at which the largest meal of the day is typically consumed.125

Rumex crispus or Juglans cinerea. The use of these agents can result in griping abdominal pain; concurrent administration of carminatives and antispasmodics is thus highly recommended. If anthraquinone-containing laxatives are used, the aim should be to use them for a short-term period only.

Abdominal pain and bloating can be addressed using a combination of carminatives and antispasmodics. Useful carminatives include Mentha piperita, Mentha spicata, Carum carvi, Foeniculum vulgare, Citrus reticulata, Coriandrum sativum, Elettaria cardamomum, Origanum vulgare and Anethum graveolens. Commonly prescribed GIT antispasmodics include Matricaria recutita, Viburnum opulus, Dioscorea villosa, Melissa officinalis and Zingiber officinale.

Support the nervous system

Given that C-IBS is often associated with depression23,24 and given the link between perceived stress levels and IBS-symptom severity,21,22 support for the nervous system is also an important component of naturopathic management. Mood has also been shown to affect bowel habit, with depression significantly slowing gastrointestinal transit time and anxiety significantly speeding it.136

Both nervines and adaptogens have a role to play in the treatment of C-IBS. Depending upon patient presentation, thymoleptics (Hypericum perforatum, Albizzia julibrissin, Crocus sativus, Sceletium tortuosum or Leonurus cardiaca) or anxiolytics (Passiflora incarnata, Valeriana officinalis or Lavandula angustifolia) can be used alongside trophorestoratives (for example, Verbena officinalis or green seed Avena sativa). If patients are currently experiencing conditions of high stress, adaptogens will also play an important role in management. If fatigue is part of the patient presentation, stimulating adaptogens such as Rhodiola rosea, Panax ginseng and Eleutherococcus senticosus may be the best choices. If anxiety or overstimulation is present, relaxing adaptogens may be more appropriate (for example, Withania somnifera, Schisandra chinensis or Ganoderma lucidum).

Decrease gut inflammation and diminish visceral hypersensitivity

Patients with IBS have been shown to have increased visceral sensation and may suffer from mild colonic mucosal inflammation.3,4 Ingestion of gastrointestinal anti-inflammatories such as Curcuma longa, Glycyrrhiza glabra and Matricaria recutita may help decrease this inflammation. Recent research has found a combination of peppermint (Mentha piperita) and caraway (Carum carvi) essential oils effective in decreasing visceral hypersensitivity in an animal model of IBS.137 A proprietary herbal preparation (Iberogast) has also been found to decrease visceral hypersensitivity in an animal model.138 Iberogast is an ethanolic extract containing Iberis amara, Angelica archangelica, Silybum marianum, Carum carvi, Glycyrrhiza glabra, Chelidonium majus, Matricaria recutita, Melissa officinalis and Mentha piperita.

Improve liver function

Poor liver function is viewed by some practitioners as an important contributing factor in IBS.139 Liver congestion has also long been seen by naturopaths as a common cause of constipation128 and bile salts are well-known laxative agents.140 Accordingly, patients with C-IBS can sometimes receive benefit from the ingestion of cholagogues (Cynara scolymus, Curcuma longa, Taraxacum officinale radix, Chelidonium majus, Berberis vulgaris or Juglans cinerea). See Chapter 19 for information on liver function and detoxification.

In support of the use of cholagogues in C-IBS, two clinical trials have been conducted on herbal cholagogues with both trials finding evidence of therapeutic effectiveness. In a post-marketing surveillance study Cynara scolymus extract was found to significantly decrease abdominal pain, bloating, flatulence and constipation in subjects with IBS over a 6-week period.141 In an open-label trial, two different doses of turmeric extract (Curcuma longa) were examined to assess their effects on IBS symptoms.142 Both extracts were found over an 8-week period to significantly reduce abdominal pain/discomfort scores from baseline. Additionally, bowel pattern was found to normalise. There were, however, no significant differences between the high and low dose groups.

image

Figure 3.3 Naturopathic treatment decision tree—C-IBS

INTEGRATIVE MEDICAL CONSIDERATIONS

Referral

In many ways, IBS is a clinical diagnosis – a diagnosis is based on the presence of typical signs and symptoms (see the box on the Rome III criteria for current diagnostic criteria). Specificity of using the Rome criteria for the diagnosis of IBS has been found to be about 98% in the absence of ‘alarm features’. Hence further investigations are typically not required to confirm the diagnosis and exclude organic disease. If ‘alarm features’ are present, however, referral for further investigation is recommended. ‘Alarm features’ include the presence of blood in the stools, weight loss, fever and family history of colon cancer.4 Any change in bowel pattern in individuals over 45 years of age is also an ‘alarm feature’ requiring further investigation.165

DIARRHOEA-PREDOMINANT IBS

Diarrhoea-predominant IBS (D-IBS) is defined as IBS with loose (mushy) or watery stools ≥ 25% of bowel movements (type 6 or 7 on the Bristol Stool Form Scale) and hard or lumpy stools < 25% of movements (Bristol Stool Form Scale types 1 and 2).127 Management of D-IBS shares a number of treatment goals with C-IBS, such as optimising the GIT microflora, supporting the nervous system, decreasing gut inflammation, and managing acute symptoms such as abdominal pain and bloating. However, there is a focus on decreasing bowel movement frequency and solidifying the stools. If anxiety plays a pivotal role in bowel symptoms and particularly in increased stool frequency, then supporting the nervous system with anxiolytics, nervous system trophorestoratives, adaptogens and thymoleptics (as discussed above) is well-indicated. Herbal antidiarrhoeal agents will have a more direct effect in the bowel. Herbal antidiarrhoeal agents can be divided into those that are tannin-based and those that are not. Tannin-based agents include Quercus robor, Polygonum bistorta, Geranium maculatum, Croton lechlerii and Agrimonia eupatoria. In Western herbal medicine, two of the few non-tannin based antidiarrhoeal agents currently in use are nutmeg (Myristica fragrans) and black pepper (Piper nigrum) – although black pepper can be too ‘spicy’ for some patients with D-IBS. The benefit of utilising non-tannin antidiarrhoeals is that they can be mixed together with alkaloid-containing herbs without causing precipitation.

REDISCOVERING OUR HERBAL ROOTS

Western herbalists have always been eclectic, using herbs from many different locations and herbal traditions. Western herbalists have also, until recently, been intimately involved with making the medicines they use. In Australia today, industry supplies herbal medicines to the bulk of practitioners, meaning that very few herbalists have a close connection to the plant medicines they currently use in practice. This situation has also indirectly limited the materia medica most practitioners can practise with. Only those herbs that are commercially profitable become available to use; the others become ‘lost’. There is, however, a renaissance of sorts occurring in Australia today, with practitioners reconnecting with the herbs they use as medicines, with a growing number of herbalists returning to making their own medicines.

A number of herbs with specific actions very helpful to GIT disorders have been ‘lost’ to modern Australian practitioners. Some of these and their actions are discussed below:

• Nutmeg (Myristica fragrans): In the Banda Islands of Indonesia where nutmeg is native, nutmeg is used to treat abdominal cramping, excessive flatulence, nausea and vomiting, restlessness and insomnia.143 Nutmeg was used by the eclectics to alleviate nausea, vomiting, abdominal pain, flatulence and diarrhoea.144 It is used in traditional Chinese medicine for the treatment of abdominal pain and distension, vomiting and chronic diarrhoea.145 Similarly in Ayurveda, nutmeg is used for diarrhoea, excessive intestinal gas, nervous disorders and insomnia.146 Animal studies have found nutmeg to possess antisecretory activity and to slow gastrointestinal transit time.147 It has also been found to exhibit antidepressant-like activity148 and anxiolytic activity.149
• Black pepper (Piper nigrum): The eclectic physicians considered black pepper to be a digestive stimulant, carminative, antiemetic, and circulatory stimulant.150 In Ayurvedic medicine, it is used for indigestion, colic, diarrhoea and cold extremities, as well as for its adjuvant action.146 In traditional Chinese medicine, it is used for vomiting, diarrhoea and abdominal pain.145 Animal research has supported its role as a digestive stimulant, where it has been found to stimulate gastric acid secretion,151,152 enhance bile flow153 and improve functioning of digestive enzymes.154 Black pepper has also been found to slow gastrointestinal transit155 and to exhibit antisecretory action156 – both of which support its traditional application in diarrhoea.
• Caraway (Carum carvi): While still a commonly used cooking spice, caraway seeds have lost their place in the materia medica of most Australian herbalists. Weiss describes caraway, traditionally viewed as a carminative and gastrointestinal antispasmodic, as ‘one of our most reliable and powerful carminatives’.157 Human trials have found a combination of caraway and peppermint essential oils effective in alleviating the symptoms of functional dyspepsia, such as abdominal pain and the sensation of fullness and heaviness post-meals.158–160
• Saffron (Crocus sativus): The stigma of saffron has long been revered as both medicine and spice. In the Middle East, where it was originally cultivated, saffron is considered an antispasmodic, thymoleptic, carminative, cognition enhancer, aphrodisiac and emmenagogue.161 It is used in traditional Chinese medicine primarily for its ability to invigorate the blood, dispel stasis and unblock the menses, and a text from the Mongol dynasty states that ‘long-term ingestion causes a person’s heart to be happy’.145 In 1862, an English herbalist Christopher Catton was quoted as remarking that ‘saffron hath power to quicken the spirits, and the virtue thereof pierceth by and by to the heart, provoking laughter and merrines’.162 Recent human research has confirmed this thymoleptic activity, with randomised, controlled trials finding saffron stigma as effective as pharmaceutical antidepressants in the treatment of mild-to-moderate depression.163,164

ROME III DIAGNOSTIC CRITERIA FOR C-IBS

1. Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months, associated with 2 or more of the following:

• improvement with defecation
• onset associated with change in stool frequency
• onset associated with change in stool form.

2. Hard and lumpy stools (Bristol Stool Form Scale types 1 and 2) occur at least 25% of the time and loose (mushy) or watery stools occur less than 25% of the time (Bristol Stool Form Scale types 6 and 7).127

Traditional Chinese medicine

Initial research suggested that acupuncture may have a role to play in the management of IBS.166 Follow-up research using more rigorous designs has not backed this up, however167,168 and a recent systematic review of randomised, controlled trials failed to find acupuncture more effective than sham acupuncture in the management of IBS symptoms.169 The results of a recent systematic review of herbal medicines in IBS found Chinese herbal medicine formulas effective in relieving IBS symptoms, while being very well tolerated. Unfortunately many of the trials were of poor quality, preventing firm conclusions about efficacy from being drawn.170

STRAIN SELECTIVITY OF ACTION

Within each species of bacteria there is a multitude of strains. Some probiotic strains are resilient and strong, with a demonstrated capacity to survive passage through the upper GIT and inhibit pathogenic bacteria, whereas others are weak and cannot even survive transit through the stomach. It is vital to note that just because one strain of bacteria in a given species has a proven action or characteristic, it does not mean that another strain will too, even if they are closely related. Strains of bacteria within the same species can have significantly different actions, properties and characteristics, as these are all essentially strain-specific qualities.171

Herbal formula

Schisandra chinensis 1:2 30 mL
Albizzia julibrissin 1:2 40 mL
Eleutherococcus senticosus 1:2 30 mL
100 mL 7.5 mL b.d.  
Iberogast 20 drops t.d.s.  

Nutritional prescription

Lactobacillus fermentum PCC 1 billion CFU daily with meals
Ground flaxseeds (Linum usitatissimum) 2 tab/day
Ulmus fulva powder 1 tsp t.d.s.
Curcuma longa extract 1 tablet daily

Continued prescription

B-vitamin complex
Coversyl

Example treatment

The patient was encouraged to seek counselling to help her through the recent marital upheavals. It was also suggested that she take a brisk walk first thing each morning for 30 minutes along the beach. She was prescribed the liquid herbal formula displayed in the table at a dose of 7.5 mL twice daily. Albizzia julibrissin is a Chinese herb used to treat depression, anxiety and insomnia. It is particularly indicated in times of grief and ‘heartache’ caused by substantial loss. Schisandra chinensis and Eleutherococcus senticosus were both used for their adaptogenic qualities.

Iberogast was prescribed to address the visceral hypersensitivity seen in IBS and to reduce the main gastrointestinal symptoms of pain, bloating, distension and excessive flatulence. She was advised to cease taking Lactobacillus acidophilus NCFM, as this strain has been found to be ineffective in IBS.49 Instead L. fermentum PCC was prescribed – a probiotic strain clinically proven to reduce abdominal pain and bloating, and to decrease flatulence in IBS sufferers (see the box on strain specificity of action).46 Freshly ground flaxseeds were used as a source of soluble fibre to promote laxation. Slippery elm powder was prescribed to decrease the gastric irritation caused by the Celebrex. Additionally, she was put on a turmeric extract primarily to reduce the bursitis-related pain and inflammation, but also for

Case Study

A 43-year-old married woman presented with cramping abdominal pain, distension, excessive flatulence and constipation. Further questioning reveals that bowel movements occur once every 2 days and that she can go several days between movements at times. Symptoms have been present over the previous 13-year period. For the past 2 years she has also been suffering from upper GIT pain. This pain started soon after she began taking NSAIDs (Celebrex) for bursitis in her left shoulder. Her GP then prescribed her Nexium in an attempt to help with the upper GIT complaint. Concurrent complaints include raised blood pressure and migraine headaches (about two episodes per month). She is currently going through a highly stressful period and is feeling very flat with little vital energy; there has also been a flare-up in her IBS symptoms. Previous investigations included FBC, TFT and abdominal ultrasound, which were all NAD. Current medications and supplements were Celebrex, Nexium, Coversyl, B vitamins and a probiotic (Lactobacillus acidophilus NCFM strain).

SUGGESTIVE SYMPTOMS

• Abdominal pain or discomfort

– typically relieved by defecation
– often associated with changes in stool frequency and/or appearance

• Abdominal bloating and distension
• Infrequent bowel movements (strictly speaking < 3 movements/week)
• Hard, lumpy stools
• Straining at stool passage
• Passage of mucus per rectum

its GI anti-inflammatory and cholagogue actions. After 7 days of taking the turmeric extract and slippery elm she was advised to start weaning off the Celebrex and Nexium. She was advised to continue taking the B-complex and the Coversyl.

She was also given dietary advice, as her diet was low in fruit, vegetables and whole grains. She was advised to consume at least two serves of fruit daily, to increase her vegetable intake and to choose wholegrain options over their processed counterparts whenever possible. Her fluid intake was already good (about 2 litres daily) and needed no modification.

Expected outcomes and follow-up protocols

If treated with carminatives and GI antispasmodics (or, in this case, Iberogast), gastrointestinal symptoms such as cramping pain and bloating should improve rapidly over the next few days. In the author’s experience, the key to keeping C-IBS symptoms under control is to ensure daily, easy-to-pass bowel movements. If the bowels are kept moving regularly, this tends to prevent the other GI symptoms (for example, bloating and cramping) from occurring – the pain and bloating is actually secondary to the constipation. If patients are able to implement dietary changes that successfully increase their fibre intake, exercise regularly and ingest adequate amounts of fluid, then this is usually adequate to maintain daily bowel movements for most individuals suffering from C-IBS. The addition of a soluble-fibre source, such as ground flaxseeds, is usually needed in the short-term and is obviously healthy to take long-term if need be – the consumption of freshly milled flaxseeds has a number of ancillary health benefits. Initially, the carminative, anti-inflammatory and antispasmodic herbs should be taken throughout the day every day, but after a few weeks their use can be reserved as prophylaxis for situations that are known to cause symptom flare-ups and to treat flare-ups. Nervines and adaptogens provide restoration over the long term, so their use should be continued until both the practitioner and the patient are confident that they are no longer needed. Pro-, pre- and synbiotics can (in IBS) be considered disease-modifying agents that need to be taken long-term for their benefits to be truly felt.

KEY POINTS

• IBS is a commonly encountered condition in naturopathic practice, typically diagnosed on clinical findings (the presence of typical signs and symptoms). Be aware of alarm features, which indicate the need for referral and/or further investigation.
• Dysbiosis appears to be a key aetiological factor in IBS and treatments aimed at addressing this imbalance (probiotics, prebiotics and synbiotics) have shown great promise in its treatment.
• In C-IBS, one of the main treatment aims should be to promote daily, easy-to-pass bowel movements.
• In some patients, stress will be the key contributing factor to their IBS symptoms. Avoid the temptation to focus solely on the gastrointestinal tract to the neglect of the nervous system.
• Remember that, although addressing aetiological factors is important in the long-term, providing relief of gastrointestinal symptoms (such as abdominal pain and bloating) needs to be done in the short-term to ensure the patient will come back.

Further reading

Azpiroz F., et al. Mechanisms of hypersensitivity in IBS and functional disorders. Neurogastroenterol Motil. 2007;19(Suppl. 1):62-88.

Hawrelak J.A., Myers S.P. The causes of intestinal dysbiosis: a review. Altern Med Rev. 2004;9(2):180-197.

Spiller R. Review article: probiotics and prebiotics in irritable bowel syndrome. Aliment Pharmacol Ther. 2008;28:385-396.

Ohman L., Simren M. New insights into the pathogenesis and pathophysiology of irritable bowel syndrome. Dig Liver Dis. 2007;39(3):201-215.

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