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FEATURE ARTICLE Irritable Bowel Syndrome: Common Integrative Medicine Perspectives Richard Nahas ABSTRACT Previous reviews have highlighted complementary and alternative medicine therapies that are used to treat irritable bowel syndrome (IBS) based on published clinical trial data. Here the author describes and comments on a number of potentially relevant factors that have been commonly emphasized by practitioners who treat IBS and patients who have the disease. They include gluten and other food allergies, the candida syndrome and bioſlm, interference ſelds and post-infectious IBS, as well as mind-body factors. KEYWORDS integrative medicine, complementary medicine, irritable bowel syndrome, allergy, candida, bioſlm, post-infectious irritable bowel syndrome
Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by symptoms of abdominal discomfort that are associated with disturbed defecation. This condition, which is the most common functional gastrointestinal disorder, affects about 12% of the population worldwide(1). The diagnosis and treatment of many functional disorders using conventional medical approaches can be challenging, and IBS is no exception. Patients are increasingly using complementary and alternative medicine (CAM) therapies to treat their IBS symptoms, and recent reviews suggest that there is good evidence supporting the use of several CAM therapies to treat IBS symptoms(2-4). The integration of CAM therapies into the therapeutic toolkit is definitely a step forward. The most evidence-based approaches include peppermint oil, probiotics, Tongxie Yaofang ( )(5) and other herbal formulae, soluble fiber, cognitive-behavioural therapy and other mind-body therapies. In addition to these modalities, it has become increasingly apparent to integrative practitioners that it may be appropriate to address the underlying factors that may be contributing to the IBS rather than focusing only on symptom management. Clearly, this syndrome is more accurately considered a state of dysfunction that can have a number of potential causes. When evidence-based approaches fail, or when patients and practitioners seek to achieve long-term eradication of symptoms, it
may be appropriate to consider other strategies. This short review cites the relevant medical literature when appropriate, but the main purpose is to share some of the most relevant "clinical pearls" that are commonly used by experienced practitioners. It should serve as a resource for judicious use with patients when appropriate.
Gluten Gluten is the storage protein of several grains, including wheat, rye, barley, spelt and kamut. Celiac disease is an autoimmune disorder in which CD 4+ lymphocytes become sensitized to gliadin, a protein present in the alcohol-soluble fraction of gluten. These CD 4+ lymphocytes attack gliadin peptides on the surface of antigen-presenting cells, an autoimmune state. They also release inammatory mediators that lead to villous atrophy and crypt hyperplasia of the small intestine. The diagnosis of celiac disease is typically conſrmed by the presence of tissue transglutaminase or anti-gliadin antibodies in the serum, or by small bowel endoscopic biopsy. A potentially paradigmshifting observation that has been made by many integrative practitioners is that there is a significant
© The Chinese Journal of Integrated Traditional and Western Medicine Press and Springer-Verlag Berlin Heidelberg 2011 Seekers Centre for Integrative Medicine, 942 Merivale Road, Ottawa, Ontario, K1Z 5Z9, Canada, Tel: 001-613-7277246, Fax: 001-613-7277247, E-mail: richard@seekerscentre.com DOI: 10.1007/s11655-011-0759-2
Chin J Integr Med 2011 Jun;17(6):410-413
and growing number of people with IBS and other functional disorders whose celiac testing is negative but who appear to beneſt from a gluten-free diet. These individuals will experience a major improvement in their symptoms while they are glutenfree, and their symptoms recur almost immediately after ingesting gluten-containing foods. While it is tempting to ascribe this phenomenon to the placebo effect or a psychosomatic phenomenon, it occurs even after accidental ingestion of gluten. Patients will typically experience uncomfortable symptoms, leading them to "retrace their steps" to ſnd out why. The author is unaware of any documented evidence of this phenomenon in the peer-reviewed medical literature. Nonetheless, any practitioner with real-world clinical experience treating IBS can attest to the overwhelming benefit of a gluten-free diet for many IBS patients. This will likely be evaluated in a clinical trial quite soon, as there are growing numbers of patients seeking gluten-free foods. Until then, these patients do not yet merit the label of "celiac disease", and are instead called "gluten-sensitive". Based on the known long-term complications of celiac disease, including increased risk of several malignancies, these patients are commonly advised to maintain a gluten-free diet, but the benefit of this approach is uncertain.
Other Food Allergies Other commonly-recognized food allergens include dairy, eggs, corn, soy and nuts. These and other food allergies are typically diagnosed using percutaneous skin tests. These identify mast cellbound IgE responses to specific allergens, but integrative practitioners commonly rely on other diagnostic tools. One approach is to measure serum IgG antibody levels; this is based on the notion that the immune response to airborne antigens is typically mediated by IgE antibodies, whereas orally ingested antigens may only trigger an IgG response. This IgG serum antibody testing is typically performed by third-party laboratories that measure IgG responses to a panel of common food antigens. Food elimination based on serum IgG antibody panels was validated in a small double-blind study of 150 outpatients with IBS, with
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the control group undergoing food elimination based on sham test results(6). After 12 weeks, those who adhered to the true elimination diet noted 26% greater symptoms improvement than those on the sham diet (P <0.001). These panels are commonly used but are still considered controversial. Other commonly used allergy testing methods include serial dilution endpoint titration (SDET), electroacupuncture according to Voll (EAV) and applied kinesiology techniques. These approaches are quite controversial and beyond the scope of this article, but the practitioner will commonly encounter patients who have undergone such testing. In some cases, the results correlate surprising well with clinical ſndings or other testing methods. Dealing with food allergies can be challenging for the integrative clinician seeking to practice evidence-based medicine. In dealing with this issue, it is important to keep in mind that the allergic response is still incompletely understood, that allergies appear to be increasing in prevalence and importance, and that they may be greatly influenced by other factors as discussed below. When in doubt, a 1-2 month elimination of specific foods that are suspected allergens as a therapeutic trial is a reasonable approach in motivated patients.
Candida Many IBS patients eventually consider the possibility that they may be suffering from symptoms related to overgrowth of Candida albicans or other fungi. This so-called Candida syndrome is widely reported on self-help internet sites and has been commonly included in anecdotal treatment protocols used by integrative practitioners worldwide. There is little to no published data to support the hypothesis that Candida contributes to IBS symptoms in outpatient populations(7). Candida albicans can be cultured from stool in over 70% of healthy adults. Diagnosis is sometimes based on the presence of serum anti-Candida IgG and IgM antibodies. Urine organic acid tesing is also commonly used; this test identifies the presence of acids that are produced exclusively by fungal metabolism, and are elevated in cases of Candida overgrowth. Some clinicians also make the diagnosis on clinical grounds.
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The Candida diet remains one of the most popular approaches to self-management. This typically involves the elimination of all grains and simple sugars, including the fructose that is naturally present in fruits and fruit juice. These strict diets are often combined with antifungal drugs and natural medicines, including caprylic acid, bentonite clay, grapeseed extract and psyllium husks, among others. Unfortunately, long-term eradication of Candida is nearly impossible, and many patients eventually ſnd this approach to be frustrating and difſcult. It may be more prudent to consider Candida overgrowth, when it is suspected, as an opportunistic infection, and focus treatment on the normalization of immune function.
Biolm An emerging understanding of the complex physiologic alterations seen in many pathogenic bacterial and fungal infections includes their ability to make biofilms. These are collections of microorganisms which adhere to the intestinal epithelial surface and are enclosed by extracellular polymeric substances. The bioſlm surrounds microbes like a protective cocoon and largely keeps out attacks from the environment, including the immune system. Current treatment protocols are based on anecdotal reports from individual practitioners, and incorporate therapies such as psyllium husks, proteolytic enzymes, metal chelators and adsorbents such as activated charcoal.
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are also known as interference ſelds, and have been commonly reported by practitioners in patients with post-infectious IBS. Other common causes of such disturbed neurologic function include abdominal surgery, antibiotic use or any other major insult to the abdomen. These can be treated using a variety of techniques, including body or auricular acupuncture, or subcutaneous injections of procaine according to the principles of neural therapy(9).
Mind-Body Medicine The commonly reported comorbid psychiatric symptoms that are seen in IBS patients should come as no surprise to the integrative physician. The gutbrain axis is an integral component of integrative physiology, and even conventional approaches to treatment include serotonin-3 and serotonin-4 agonists and tricyclic antidepressants. Clinical hypnosis is a powerful yet poorly-studied mind-body therapy, but gut-directed hypnotherapy is a hypnosis protocol with demonstrated efficacy in the treatment of IBS symptoms(10). A number of other modalities have been evaluated with positive results, including cognitivebehavioural therapy(11), meditation, mindfulness-based stress reduction, functional relaxation(12), autogenic training, Tai Chi, and Qigong. They should be more strongly considered in patients who report that situational stress is an important symptom trigger, or in patients with a past history of emotional trauma.
Intestinal Repair Post-Infectious IBS It is widely recognized that IBS symptoms can arise de novo following an exposure to acute gastroenteritis. This phenomenon, known as postinfectious IBS, has been reported to occur in up to 32% of cases of gastroenteritis (8) . The exact mechanism is unknown, but it has been attributed to persistent intestinal inflammation, altered motility and increased intestinal permeability. There is no evidence-based treatment for post-infectious IBS, but clinicians should rule out persistent infection with stool culture and microscopy, and support the normalization of intestinal microora with probiotic therapy.
Interference Fields Experienced practitioners can sometimes identify focal areas of disturbed neurologic function using pulse diagnosis, applied kinesiology, neural therapy or other integrative diagnostic techniques. Such foci
Regardless of the cause, it is prudent to consider a regimen of natural medicines to promote the restoration of intestinal barrier function, establish normal intestinal microora and promote the long-term reduction of inammation. Increased intestinal permeability is typically confirmed by an elevated lactulose:mannitol (L: M) ratio. This requires the patient to ingest 5 g of lactulose and 10 g of mannitol, followed by a urine collection 2-6 h later. The larger lactulose molecule will only appear in the urine in the presence of an abnormally permeable intestinal barrier. While a positive test is an indication for treatment, some patients with a normal L:M ratio will also beneſt from a short course of treatment. There are literally dozens of herbal medicines and supplements that are commonly used for this
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purpose. They include L-glutamine, Saccharomyces boulardii , various strains of probiotic bacteria (13), essential fatty acids and herbal formulas based on a traditional Chinese medicine diagnosis(14).
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6. Atkinson W, Sheldon TA, Shaath N, Whorwell PJ. Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial. Gut 2004;53:1459-1464. 7. Schulze J, Sonnenborn U. Yeasts in the gut: from
Summary
commensals to infectious agents. Dtsch Arztebl Int
The practicing clinician should keep in mind that many of these therapeutic strategies are considered controversial and unproven. Nonetheless, they represent the current "state of the art" for the management of the difficult-to-treat IBS patient. The rapidly evolving understanding of the complex set of physiologic abnormalities will hopefully soon shed more light on the heterogeneous group of causative factors that can lead to this common syndrome.
2009;106:837-842.
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(Received Match 25, 2011) Edited by WANG Wei-xia