Try, Try Again When It Comes to Managing Symptoms of IBS

Overview and Pathophysiology

IBS is a common functional syndrome effectively hindering a patient’s quality of life of varying degrees.1  Characterized by irregular bowel movements, abdominal discomfort, and bloating or rectal urgency,2 it has an ebb and flow pattern that varies significantly in which drug therapies have thus far been insufficient in developing due to its multifactorial variability.

There are many influences over the disease including genetics, family history, stress, the gut biome, inflammation and immune system activation, nerve sensitivity and environmental factors like stress, and sleep.2   However, four major features seem to dominate:

Gut Permeability - Studies have shown that up to 40% of  IBS-D patients have increased colonic permeability.  This supports the leaky gut theory with altering microbiome, infections, food allergies and autoimmune disease being a common presentation.2 

Gut Microbiome - Gut microflora seems to have a dynamic influence over IBS, with a 3.5x  increase in developing IBS after a colon infection,3 and after antibiotic usage.  Multiple studies have shown a decreased diversity of the species that make up the gut microbiotic community, and overgrowth in areas of the colon in areas where there shouldn’t be, as is the case in SIBO.2

Immune System - Abnormal activation of the immune system also seems to be a paramount characteristic as the role of gut microflora largely influences the activation of the immune system.4

ENS - Here again, it seems our tiny friends, the gut microflora, modify the symptoms of IBS due to the signaling of this “gut-brain” connection.2  It is recognized that stress and affections affect the function of the GI tract and change the gut microbiome, thus changing hormones, neurotransmitters, and ultimately symptoms.5

Due to these many influences, treatment ends up being more symptom based, and is diagnosed at the exclusion of other illnesses.2

Food and Diet’s Influence

Interestingly, 65-95% of patients diagnosed with IBS will indicate that their symptoms are triggered by specific foods.6  In fact, up to 50% of patients will describe worsening symptoms after meals.[hayes[

Food allergies add an interesting component as food allergy rates have stayed stable, while food sensitivity rates have steadily increased.2  Reports of triggering foods include MSG, dairy, lactose containing foods, fructose containing foods, gluten, fatty foods, and fiber.2

Removing grains and refined sugars, thus reducing the feeding of harmful microbiota, the SCD has been positioned as an effective diet for IBS.2  The SCD avoids all polysaccharides including grains, refined sugars, processed foods and dairy aside from yogurt, and many starches like potatoes.7 The diet instead relies on nuts, meats, fruits, and vegetables.7  It has the effect of starving off the unwanted bacteria in the gut biome, and heavily focuses on specially cultured yogurt as a source for nourishing and re-populating a healthy microbiome.  This yogurt is considered a key component of the diet as it restores the right levels, species, and diversity of colonic beneficial bacteria when eaten twice daily for 8 weeks.8

While more study is needed, the SCD has largely been studied for Crohn’s and celiac diseases. Some studies lump GI disturbances together, and there are few directed towards SCD and IBS specifically, however, one 12 week study shows that those families following homemade SCD foods had a greater percentage in macro and micronutrients across the board7, suggesting better nutrient intake of those necessary for colon health, without the inflammatory influence of the foods avoided.

Supplements to Consider

Probiotics are a key nutritive in IBS9, but you must pay particular attention to the species.  The recommendations is currently a half and half blend of lactobacillus plantarum and B. breve at 25 billion units, twice daily for 6-8 weeks.2  As we have noted the importance of the role of the microbiome, we pay homage to proper nourishment and replenishment of a diverse species.  Probiotics have the ability to repopulate the gut with the right kinds of colonies that support the critical role in development and functioning of the digestive tract.2  They decrease fermentation (the major feature of the popular low FODMAPs diet), improve balance of pathogenic flora to beneficial flora and stimulate balanced immune functioning.2  They also balance the inflammatory cytokines commonly present in bowel inflammatory illnesses.10 Probiotic supplementation, however, should be avoided in severely immunocompromised patients, or those with severe pancreatic disease.2

Peppermint oil is a carminative anti spasmodic that can be soothing to the GI tract and reduce many symptoms of IBS9 by reducing spasmodic muscle contractions of smooth muscle tissue. Peppermint also has natural pain-relieving compounds activated through a person’s opioid receptors.  70% of IBS patients had reported a reduction in stomach pain, and showed beneficial effects after only 2 weeks of daily use.11  The dose is 200-400mg of enteric coated capsules three times a day in between meals, for adults.2  This supplement is contraindicated for those experiencing heartburn.9

Conclusion

In conclusion, while IBS can be, well, quite “irritating”, the varying modalities and treatments are vast and selective depending on each individual.  As the right treatment pattern is highly individualized and must include a number of components including diet and lifestyle, stress reduction, and systemic supports, the old adage, “Try, try again” seems to be a fitting piece of wisdom.

References:

1. Matricon J, Meleine M, Gelot A, et al. Review article: Associations between immune activation, intestinal permeability and the irritable bowel syndrome. Aliment Pharmacol Ther. 2012;36(11-12):1009-1031. doi:10.1111/APT.12080

2. Rakel D. Integrative Medicine. In: Integrative Medicine. 4th ed. Elsevier; 2018:320-333.

3. Rajilić-Stojanović M, Jonkers DM, Salonen A, et al. Intestinal microbiota and diet in IBS: causes, consequences, or epiphenomena? Am J Gastroenterol. 2015;110(2):278-287. doi:10.1038/AJG.2014.427

4. Simreń M, Barbara G, Flint HJ, et al. Intestinal microbiota in functional bowel disorders: a Rome foundation report. Gut. 2013;62(1):159-176. doi:10.1136/GUTJNL-2012-302167

5. Mayer EA. Gut feelings: the emerging biology of gut–brain communication. Nat Rev Neurosci. 2011;12(8):453-466. doi:10.1038/NRN3071

6. Hayes PA, Fraher MH, Quigley EMM. Irritable Bowel Syndrome: The Role of Food in Pathogenesis and Management. Gastroenterol Hepatol (N Y). 2014;10(3):164. Accessed November 15, 2021. /pmc/articles/PMC4014048/

7. Morrison A, Braly K, Singh N, Suskind DL, Lee D. Differences in Nutrient Intake with Homemade versus Chef-Prepared Specific Carbohydrate Diet Therapy in Inflammatory Bowel Disease: Insights into Dietary Research. Pediatr Gastroenterol Hepatol Nutr. 2021;24(5):432. doi:10.5223/PGHN.2021.24.5.432

8. Min YW, Park SU, Jang YS, et al. Effect of composite yogurt enriched with acacia fiber and Bifidobacterium lactis. World J Gastroenterol. 2012;18(33):4563. doi:10.3748/WJG.V18.I33.4563

9. Ross K. Lower GI. 2012;(c):1-28. http://www.ouhsc.edu/histology/text sections/lower gi.html

10. O’Mahony L, Mccarthy J, Kelly P, et al. Lactobacillus and bifidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles. Gastroenterology. 2005;128(3):541-551. doi:10.1053/J.GASTRO.2004.11.050

11. Khanna R, Macdonald JK, Levesque BG. Peppermint oil for the treatment of irritable bowel syndrome: a systematic review and meta-analysis. J Clin Gastroenterol. 2014;48(6):505-512. doi:10.1097/MCG.0B013E3182A88357