How to treat Irritable Bowel Syndrome

How to treat Irritable Bowel Syndrome

The most important thing is to understand what pattern of Irritable Bowel Syndrome is present and causing symptoms. Excluding those conditions that are known as “red flags” or serious health conditions – such as IBD (Inflammatory Bowel Disease) – is vital.

Treatment guidelines based on Irritable Bowel Syndrome patterns are readily available online and from reputable sources based here in Australia.

The following is a summary of treatments already covered in my last article – see What are Irritable Bowel Syndrome Treatments?.

General advice is given to address general lifestyle and diet factors such as:

  • Diet – increase dietary fibre, for those for whom it is relevant. Avoid trigger foods that cause gas production. Include caffeine in this category as it accelerates bowel activity that can aggravate IBS – type D. 
  • Low FODMAP Diet 
  • Lifestyle advice – regular sleep and exercise has been found to be helpful with Irritable Bowel Syndrome. 
  • Stress Management and Relaxation Techniques – techniques to help manage stress where this has a clear impact on gut health. Mindfulness therapies to assist with relaxation and gut-related hypnotherapy may be of benefit and as effective as a low FODMAP Diet. (1) 
  • Medicines – anti-diarrhoeal, antispasmodic medicines, pain killers, antidepressants, and antibiotics are all discussed in “What are Irritable Bowel Syndrome Treatments”. 
  • Probiotics – this is a contentious area and needs further studies to clarify the efficacy of specific strains of probiotics or a combination of probiotics that are proven to be helpful. This area is full of ongoing studies and there is tentatively some relief for IBS sufferers with some Lactobacillus strains.  
  • New approaches – enzyme therapy and the impact of herbal extracts – both are novel and require further studies. 
stress management techniques
  1. Diet changes: a FODMAP approach may help to identify trigger foods. Avoiding caffeine can alleviate as it increases bowel motility. 
  2. Symptom control using anti-diarrhoeal medications +/ anti-spasm medications or peppermint may also assist with this.

Slightly *alternate view:  

  1. Probiotics: single probiotic therapy – Bacillus Coagulans MCT 5856 has been found in animal studies to relieve diarrhoea (2.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. (2.b.)

Overall relief from bloating, gas, and incomplete evacuation with Bifidobacterium infantis 35625. (2.c)

Combination therapy with a variety of probiotic strains (Lactobacillus acidophilusL. rhamnosusBifidobacterium breveB. actisB. longum, and Streptococcus thermophilus) was shown in one particular study was found to provide effective relief for IBS – Type D sufferers. (2.d.)

  1. Antibiotics: Rifaximin was approved by the FDA in 2015 to treat IBS – Type D. It is given over 10-14 days. (3)  
  2. Faecal Microbial Transplant (FMT): or “poo transplant” has been shown to give symptom relief for IBS – Type D and Type D + C for up to 3 months, but not effective at 12 months. (4) 
  1. Dietary fibre: in the form of soluble fibres such as taking psyllium husks, guar gum or inulin to assist with softening the consistency of the stool. 
  2. Hydration: increase water intake to improve stool consistency. 
  3. Laxatives: can create problems long term with disturbed bowel wall activity. It can lead to a “lazy” bowel thereby worsening the situation. 
  4. Antispasmodics: to relieve cramping pain. Such as Peppermint oil by decreasing the sensitivity of pain fibres in IBS. It is a calcium channel blocker and acts in the smooth muscle of the bowel, thus leading to a decrease in muscular contraction = anti-spasm.

Slightly *alternate view: 

  1. Probiotics: a study showed that a combination probiotic (L. acidophilus, L. reuteri, L. plantarum, L. rhamnosus, and B. animalis subsp. lactis) to help improve bowels movements and stool consistency in a group of IBS – Type C sufferers. (2.e.) 

Sboulardii CNCM I-745  was found to decrease substance P (pain fibres and proinflammatory cytokines in an animal study that mimicked the conditions found in IBS – Type C. (2.f.)

Another strain (S.Boulardii I-3856 at a dose of 1,000 mg per day) was found to decrease pain, discomfort and bloating cf to placebo. (2.g.)  

  1. Antibiotics: the use of Rifamxin + Neomycin was found to improve constipation, straining and bloating in a small group of IBS – Type C patients. (5)
  2. Faecal Microbial Transplant: it appears that IBS C patients have an altered gut flora and may benefit from FMT. (6) 

Mainstream focus is on: 

  1. Diet: is focussed on avoiding triggers that exacerbate symptoms. In this case fibre may aggravate symptoms and is best avoided. 

Avoid trigger foods!!! An elimination diet to figure out trigger foods. Dairy and caffeine also need to be considered carefully. 

  1. Lifestyle: sleep, regular exercise and stress management are vital. Even consider mindfulness therapies as previously mentioned – see above. 
  2. Medications: the use of antidepressants such as SSRI’s are used to alter the pain signalling associated with IBS. 
  3. Symptom relief: see above.

Slightly *alternate view: 

  1. Probiotics: there is no one probiotic that resolves all symptoms in IBS and there is a lack of consistent data. This link shows a table with probiotic strains and their efficacy. (2.h.)

Strain specificity for symptom relief, single or multiple strains, and dosage are needing further studies to give clear guidelines. (2.i.)

  1. Antibiotics: see above. 
  2. Faecal Microbial Transplant: so far the general consensus that FMT as a general treatment for IBS is that it has no advantage over a placebo. (7) IBS is a complex condition and it’s management needs to be more specific or targeted. 

Summary of How to treat Irritable Bowel Syndrome.

This overview is to give a guide as to what is accepted as evidence-based treatment options for Irritable Bowel Syndrome. Some areas definitely fall into the “grey zone” where the answer is as clear cut. E.g. the concept of a specific probiotic to alleviate specific symptoms.

What I often see in practice are patients are wanting clarity with what is wrong with them and what they need to do next to get better.

They may not be aware they even have Irritable Bowel Syndrome and are relieved to have a diagnosis!

This isn’t a ONE SIZE FITS ALL situation.

What do you do when the above doesn’t work???

Well, this is a controversial area and each case needs to be considered very carefully. An integrative or holistic approach is an individualistic approach in that the focus is looking at that one individual as a whole and trying to find what is unique to that person and what may be of help for them.

The digestive tract is like a factory line, it takes one step in that process to muck up to create dysfunction.

My recommendation is: 

  1. Diagnosis: seek professional advice and guidance to exclude important “red flags” or medical conditions that are serious. This may include seeing a gastroenterologist (or gut doctor).
  2. Investigations: may include testing to determine exactly what’s going in your gut. This may involve blood testing, stool tests, and possibly breath testing to determine if there is an imbalance in the gut flora (or “gut bugs”). 
  1. Food Diary: where you write down what you’re eating every day and then noting any bowels symptoms. This can help to identify trigger foods for Irritable Bowel Syndrome. 
  1. Elimination diet: involves finding what foods trigger the IBS symptoms and removing them from the diet. A low FODMAP diet is helpful with this. 
  1. Referral: to a dietician or nutritionist familiar in dealing with introducing a low FODMAP diet, to see if this helps. Alternatively, check out what work is being done at https://www.monashfodmap.com/. This has a wonderful guide into the world of FODMAP’s with up to date information and aides. 

When nothing else works? Dysbiosis (or bacterial overgrowth) may be the culprit and further investigations – such as breath testing for Hydrogen or Methane production. 

Stay tuned for more re: SIBO – or Small Intestinal Bacterial Overgrowth. 

References:

1. Hypnotherapy for irritable bowel syndrome: an audit of one thousand adult patients.

Miller V, et al.

Aliment Pharmacol Ther. 2015 May; 41(9):844-55.

2.a. Evaluation of anti-diarrhoeal activity of Bacillus coagulansMTCC 5856 and its effect on gastrointestinal motility in Wistar rats. Int J Pharma Bio Sci 2016; 7: 311–16.

Majeed M, Natarajan S, Sivakumar A, Ali F, Pande A, Majeed S, et al.

2.b. Bacillus coagulans MTCC 5856 supplementation in the management of diarrhea predominant Irritable Bowel Syndrome: a double blind randomized placebo controlled pilot clinical study.

Majeed M, et al.

https://www.ncbi.nlm.nih.gov/pubmed/26922379

2.c. Efficacy of an encapsulated probiotic Bifidobacterium infantis 35624 in women with irritable bowel syndrome.

Whorwell PJ, et al.

https://www.ncbi.nlm.nih.gov/pubmed/16863564

2.d. Effect of administering a multi-species probiotic mixture on the changes in fecal microbiota and symptoms of irritable bowel syndrome: a randomized, double-blind, placebo-controlled trial

Hyuk Yoon, et al.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4566021/

2.e. A Randomized, Double-Blind, Placebo-Controlled Trial: The Efficacy of Multispecies Probiotic Supplementation in Alleviating Symptoms of Irritable Bowel Syndrome Associated with Constipation

Valerio Mezzasalma et al.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4993960/

2.f. Saccharomyces boulardii CNCM I-745 supplementation reduces gastrointestinal dysfunction in an animal model of IBS

Paola Brun, et al.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0181863

2.g. Randomized double blind placebo-controlled trial of Saccharomyces cerevisiae CNCM I-3856 in irritable bowel syndrome: improvement in abdominal pain and bloating in those with predominant constipation

Robin Spiller, et al

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924426/

2.h. https://badgut.org/information-centre/a-z-digestive-topics/probiotics-for-irritable-bowel-syndrome/

2.1. The Role of Bacteria, Probiotics and Diet in Irritable Bowel Syndrome

Ashton Harper, et al.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5848117/

3. Rifaximin for Irritable Bowel Syndrome

A Meta-Analysis of Randomized Placebo-Controlled Trials

Jun Li, et al.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5291563/

4. Faecal microbiota transplantation versus placebo for moderate-to-severe irritable bowel syndrome: a double-blind, randomised, placebo-controlled, parallel-group, single-centre trial.

Johnsen PH, et al.

https://www.ncbi.nlm.nih.gov/pubmed/29100842

5. Antibiotic treatment of constipation-predominant irritable bowel syndrome.

Pimentel M, et al.

https://www.ncbi.nlm.nih.gov/pubmed/24788320

6. Gut Microbiota and Chronic Constipation: A Review and Update.

Ohkusa T, et al.

https://www.ncbi.nlm.nih.gov/pubmed/30809523

7. Systematic review with meta‐analysis: efficacy of faecal microbiota transplantation for the treatment of irritable bowel syndrome

Gianluca Ianiro, et al.

https://onlinelibrary.wiley.com/doi/10.1111/apt.15330

Disclaimer:

This article is written to give an overview of IBS Treatments only. It is meant to be a therapeutic guide that is best used in supervision with an appropriate health professional.

Where treatments are written as an “*alternate view” is to show an area that is not considered a mainstream medical approach to treating this condition. It is an emerging treatment that is under research and not accepted as a generally “accepted” or approved medical therapy.  

Irritable Bowel Syndrome (IBS) and Symptoms

Irritable Bowel Syndrome (IBS) and Symptoms

Irritable Bowel Syndrome (IBS) is a relatively modern phenomenon that came about from an increasing number of individuals developing a functional disorder of their bowels. 

What does that mean??? 

If you go back into the history of medicine – there was no Irritable Bowel Syndrome 50 years ago. 

If there was – we, mainstream medicos – had no idea that this was around and if so hadn’t yet understood what it means or described it. 

The criteria for diagnosing Irritable Bowel Syndrome was underway when I was a medical student! 

So if we look at Irritable Bowel Syndrome it can best be described as an issue with “how” the bowel works (or functions). 

The structure of the bowel or intestine doesn’t change. I.e. if an Irritable Bowel Syndrome sufferer was to have a colonoscopy (or camera on the inside) of their bowel it would look normal. 

It doesn’t lead to a serious condition such as bowel cancer. 

Unlike INFLAMMATORY BOWEL DISEASE (IBD), such as Crohn’s Disease or Ulcerative Colitis where there is inflammation of the bowel or intestinal wall. This inflammation causes a pathological change in the intestinal wall, thereby affecting the structural integrity of the intestinal wall, leading to the development of symptoms and signs. Such as pain (symptoms) associated with passing blood in stools with mucous (sign). 

With Irritable Bowel Syndrome, there is dysfunction leading to a number of symptoms that create discomfort/inconvenience for those that suffer from this. For some, the symptoms can be highly debilitating and distressing. 

It is thought to affect the large bowel or intestine mainly and as many as 1 in 5 Australians now suffer from Irritable Bowel Syndrome. 

Up to 50% of those that suffer from Irritable Bowel Syndrome can have symptoms that affect them physically and mentally with associated anxiety and depression. 

It tends to occur more in women than in men. 

It has a spectrum or variety in its presentation in that it can range from: 

  1. Bowel habit that ALTERNATES from diarrhoea to constipation (mixed type). 
  2. Bowel habit that is mainly CONSTIPATED (IBS Type C). 
  3. Bowel habit that is mainly DIARRHOEA (IBS Type D). 

Diagnosis of Irritable Bowel Syndrome relies on a patient’s symptoms. 

The cause of Irritable Bowel Syndrome is unknown. Although several mechanisms have been implicated in its pathophysiology or development and can be considered as multifactorial. It is thought to result from: 

a. Abnormal gastrointestinal tract movements – see Transit Time below. 

b. Gut – Brain miscommunication is thought to play a role in Irritable Bowel Syndrome. There are issues leading to a disruption in communication or signalling between these two areas and these signalling issues go both ways. 

  1. Central sensitisation: refers to altered pain perception in IBS sufferers. 

2.  Visceral sensitisation: IBS sufferers have a lower threshold for pain in their abdomen

c. Heightened awareness of or sensitivity to how one’s body functions. 

d.The inflammatory reaction occurring in the intestinal mucosa (gut lining).

e. Changes in gut microflora (or gut bugs). 

IBS/Irritable Bowel Syndrome can be triggered by: 

  • Infection: bowel symptoms can occur after having had gastroenteritis. They cause is unknown and may involve changes in how the nerves work in the bowels or possibly changes in gut flora/bacteria
  • Stress: some individuals have a heightened stress response when anxious or under duress.
  • Poor sleep
  • Food intolerance: symptoms may be exacerbated or worsened by impaired absorption of Lactose (the sugar found in dairy), fructose (the sugar found in fruit) or another sugar called sorbitol which is used as an artificial sweetener. A diet low in fibre may aggravate constipation.  
  • Hormonal factors such as menstruation  
  • Medications: certain medications can contribute to aggravating Irritable Bowel Syndrome symptoms such as antibiotics – may cause diarrhoea, painkillers – may cause constipation, and antacids. 

The triggers for IBS can vary according to an individual. What may trigger one person may not necessarily trigger another. 

triggers for irritable bowel syndrome

Understandably recurring pain over time is distressing with gut bloating, pain and cramps being some of the leading symptoms of Irritable Bowel
Syndrome. 

Normal Gut-Brain function relies on a coordinated signalling system between both systems for normal digestion to occur. The signals between the two systems use a combination of input from the autonomic nervous system, hormones and to some degree gut flora (gut bacteria) to communicate so that healthy digestion can occur. 

Irritable Bowel Syndrome sufferers appear to have their own specific signalling patterns or circuits involving these systems that impact on their Gut-Brain axis that is unique to them. See Central Sensitisation – above.

This describes that time it takes food to go from the mouth and to come out at the bottom as a “poo” (stool). 

Normally this process takes 8-12 hours. 

You can time this by eating corn and seeing how long it takes for this to come out of the rectum (bottom). 

The symptoms of Irritable Bowel Syndrome occur due to an alteration in the transit time of the sufferers’ bowels. 

The longer the stool takes to pass through the bowel leads to increased extraction of water. Making the stool dry and hard to pass. Hence making constipation worse. 

Leaves less time for water to be extracted and the stool tends to be looser. Hence diarrhoea. 

What are Irritable Bowel Syndrome Symptoms?

Symptoms of Irritable Bowel Syndrome may vary in their presentation in one person and be completely different in another person. There is no “one size fits all”. They can last for several days or weeks. Flaring up at times and then settling down. 

Irritable Bowel Syndrome is characterised by the following symptoms: 

  • Abdominal PAIN; often relieved by passing wind or bowel motion. 
  • Abdominal BLOATING; can occur straight after eating – this tends to suggest gastric bloating, or delayed bloating (1-2 hours after eating) – suggests intestinal origin. 
  • Chronic or recurrent DIARRHOEA. (IBS Type D)
  • Chronic or recurrent CONSTIPATION. (IBS Type C)
  • ALTERNATING bowel habit. (IBS – Mixed)
  • Mucous in the stool.

Associated symptoms: 

  • Fatigue.
  • Sleep difficulties.
  • Anxiety and Depression.

The 3 Types of Irritable Bowel Syndrome are: 

  1. IBS Type C – constipated IBS
  2. IBS Type D – diarrhoea type IBS
  3. IBS Mixed – where the bowel motion can alternate from constipation to diarrhoea. 

Take a look at our other blog about How to treat Irritable Bowel Syndrome.

What are Irritable Bowel Treatments

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: 

  1. Related to defecation or passing of a bowel motion. 
  2. Associated with a change in the frequency of stool. 
  3. 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 focussed 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. 

Probiotic actions: 

  • 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 acidophilusL. rhamnosusBifidobacterium breveB. actisB. 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. 

What are IBS Treatments

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: 

  1. full dose – half dose was given prior to the meal and the other half with the meal.
  2. half dose.
  3. Placebo. 

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
  • Freekah
  • 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 will 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: 

CURCUMIN: 

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.  

BERBERINE: 

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)  

GINSENG: 

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). 

OVERVIEW: 

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”. 

References:

1. a.

Bacillus coagulans MTCC 5856 for the management of major 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6034030/

1.b. 

https://www.ncbi.nlm.nih.gov/pubmed/26922379

1.c. 

https://www.ncbi.nlm.nih.gov/pubmed/16863564

1.d. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4566021/

1.e. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4993960/

1.f. 

https://badgut.org/information-centre/a-z-digestive-topics/probiotics-for-irritable-bowel-syndrome/

1.g.

https://www.racgp.org.au/afp/2009/december/ibs/

This is an excellent overview of probiotics. 

https://www.mja.com.au/journal/2008/188/5/probiotics-sorting-evidence-myths#0_i1092172

2. https://www.ncbi.nlm.nih.gov/pubmed/24807589

3.  https://www.ncbi.nlm.nih.gov/pubmed/26400188

4. https://www.ncbi.nlm.nih.gov/pubmed/14644011

5. https://www.sciencedirect.com/science/article/pii/S0102695X17303885

6. https://onlinelibrary.wiley.com/doi/full/10.1111/imj.14212

7. https://www.ncbi.nlm.nih.gov/pubmed/29100842