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Irritable bowel syndrome

MagazineDecember 2010 (Vol. 21 Issue 9)Irritable bowel syndrome

Although it's not life-threatening, the symptoms-which include abdominal pain, bloating, wind, constipation and diarrhoea-can severely affect the IBS sufferer's quality of life

Although it's not life-threatening, the symptoms-which include abdominal pain, bloating, wind, constipation and diarrhoea-can severely affect the IBS sufferer's quality of life. Those with IBS frequently report experiencing loss of freedom, spontaneity and social con-tacts, as well as feelings of fearfulness, shame and embarrassment (Dig Dis Sci, 2009; 54: 1532-41).

Adding to the problem, conventional therapy is highly inadequate. Many treatments (such as antispasmodics, antidiarrhoeals, bulking agents, tran-quillizers and sedatives) can harm more than help, and none of them has proved to be globally effective at treating
IBS symptoms (J Chin Med Assoc, 2009; 72: 294-300).

It's no surprise, therefore, that a growing number of IBS patients are turning to complementary and alternative medicine (Gastroenterol Clin Biol, 2009; 33 Suppl 1: S79-83).

The role of sugar

Part of the problem of treating IBS is that no one knows what causes it. The latest research, however, suggests that certain foods might play a role, an idea that alternative practitioners have been expounding upon for years. In par-ticular, the more recent studies have revealed that around a third of IBS patients may have problems with processing fructose, the type of sugar that is found in fruits, some vegetables, honey and high-fructose corn syrup. 'Fructose malabsorption', as it's officially known-which refers to the body's failure to completely absorb fructose as it passes through the small intestine-can lead to many of the symptoms that are typically seen in IBS (J Am Diet Assoc, 2006; 106: 1631-9).

In one American study, researchers at the Immanuel St Joseph's Hospital, part of the Mayo Health System in Minnesota, looked at 80 patients with IBS and found that 31 (38 per cent) also had fructose malabsorption. Of these patients, 26 were then put on a fructose-restricted diet, and those who managed to stick with the diet (only around half of them) enjoyed signifi-cant improvements in their symptoms, including abdominal pain, belching, bloating, feelings of fullness, indigestion and diarrhoea. The patients who didn't stick with the dietary restrictions, on the other hand, generally saw no change in their symptoms (J Clin Gastroenterol, 2008; 42: 233-8).

Similarly, in a study of 32 children with persistent unexplained abdominal pain, 11 of them were found to have fructose malabsorption and, so, were subsequently put on a low-fructose diet. After two months, all but two of these children showed rapid improve-ment of their symptoms, and all continued to report positive changes thereafter. The researchers, from the New York Medical College in the US, concluded that "fructose malabsorp-tion may be a significant problem in children and that management of dietary intake can be effective in reducing gastrointestinal symptoms" (J Pediatr Gastroenterol Nutr, 2008; 47: 303-8).

Although the researches into the precise role and mechanism(s) behind fructose malabsorption in IBS are still
in their early stages, in cases where symptoms of gas, bloating and diarrhoea appear to be related to eating fruit, a fructose elimination
diet might be something worth considering.

Other problem foods

Besides fruit sugars, other ferment-able, poorly absorbed carbohydrates-such as lactose (found in milk), fructans (found in wheat and onions) and sorbitol (a common sweetener)-are also able to cause or exacerbate the usual symptoms of IBS (J Am Diet Assoc, 2009; 109: 1204-14; Curr Gastroenterol Rep, 2009; 11: 368-74).

What's more, some of the foods that are commonly recommended to ease IBS may actually be making the condition worse. Wheat bran, for instance, often prescribed for constipation due to its high fibre content, only helped 10 per cent of sufferers in one study. On the other hand, more than half of the IBS sufferers followed-up by researchers at the University Hospital of South Manchester, in the UK, reported that bran made their symptoms-including bowel disturbances, and abdominal distention and pain-worse, leading the researchers to conclude that "excessive consumption of bran in the community may actually be creating patients with irritable bowel syndrome" (Lancet, 1994; 344: 39-40).

Considering that wheat (along with milk and eggs) is one of the most common triggers of symptoms in those with IBS, such results are hardly surprising (Am J Gastroenterol, 1998; 93: 2184-90).

If any fibre is to be recommended, then Plantago seeds-a source of soluble fibre that is sold commercially as 'psyllium' or 'ispaghula' fibre-appears to be a better option, but it can still aggravate symptoms in some IBS sufferers (Townsend Letter Docs, 2004; 252: 159).

Probiotic yoghurt is another popular recommendation for people with IBS, but this, too, can make symptoms worse. While probiotics may be beneficial for the condition in some, dairy products have also been found to trigger symptoms in a significant proportion of IBS sufferers. According to Dr Stephen O. Wangen, Chief Medical Officer of the IBS Treatment Center in Seattle, WA, "A large number of our patients who experience IBS are actually suffering from a dairy allergy but don't realize it. Yogurt, although it is fermented, is still a dairy product and can be a potent trigger of their digestive problems. For these people, the consumption of yogurt, even brands with high probiotic bacteria content, is inadvisable" (Townsend Letter, 2008; June: 35).

Clearly, diet is a crucial factor in IBS, but there is no one-size-fits-all approach when it comes to successful treatment. Experimenting with limiting or completely eliminating certain foods from your usual diet and/or working with an experienced nutritional practitioner may be the best way to get the condition under control.

Other treatment approaches

Along with a change of diet, there are a number of other natural ways to tackle IBS.

o Hypnotherapy. Emotional and psychological factors appear to be involved in IBS, which may explain why hypnosis has proved helpful for patients with the condition. According to an extensive review of the medical/scientific literature carried out by the prestigious Cochrane Collaboration, which resulted in a pooled meta-analysis of four studies involving 147 patients altogether, hypnotherapy was superior to both the standard medical care and no treatment in relieving abdominal pain and other IBS symptoms-at least for the short term (Cochrane Database Syst Rev, 2007; 4: CD005110). Clearly, however, more high-quality studies are needed before any definitive conclusions can be drawn.

o Relaxation. As numerous trials have already identified the role of psychological and emotional factors as triggers in patients with IBS, relaxation techniques are often recommended. In Germany, the technique called 'functional relaxa-tion'-a term coined decades ago to describe a form of relaxation that is also known as 'self-hypnosis'-aims to maintain equilibrium within the nervous system and appears to be beneficial for IBS. In a randomized controlled trial of 80 patients, who received either functional relaxation or enhanced medical care (standard treatment plus two counselling sessions) for five weeks, the results showed that functional relaxation was significantly more effective than the control treatment. Indeed, the positive effects-both physical and mental-were still present three months later (J Altern Complement Med, 2010; 16: 47-52).

A small-scale (21 IBS patients), randomized controlled trial, carried out at Tohoku University Graduate School of Medicine in Japan, involved the use of 'autogenic training' (AT), a relaxation tech-nique that teaches your body how to respond to your verbal com-mands through six standard exercises. The technique appears to combine elements of both self-hypnosis and biofeedback. The results of this study suggest that AT can benefit IBS by "enhancing self-control", as reflected by the patients' responses to a number of IBS-related questionnaires (Appl Psychophysiol Biofeedback, Dec 8 2009; Epub ahead of print).

o Exercise. There is also evidence to suggest that exercise may be an effective intervention for IBS. When pitted against conventional care in
a 12-week trial, the patients in the exercise group reported significant improvement in symptoms of constipation (Int J Sports Med, 2008; 29: 778-82). Another trial concluded that even mild physical activity can reduce gas and abdominal bloating (Am J Gastroenterol, 2006; 101: 2552-7).

o Peppermint oil. According to a review of the literature, eight out of 12 placebo-controlled studies showed statistically significant positive effects with peppermint oil for the treatment of IBS. The average response rates, as a reflection of 'overall success', were 58 per cent for peppermint oil and 29 per cent for placebo. However, even though peppermint oil usually comes in specially coated capsules designed to protect the stomach, these capsules may still lead to side-effects such as heartburn or rectal irritation (Phytomedicine, 2005; 12: 601-6).

o Chinese herbal medicine (CHM). In a trial involving more than 100 IBS patients, those treated with CHM, using formulas that were either individualized or standard-ized, saw significant improvements in terms of bowel symptoms as well as overall quality of life. However, only the CHM group taking herbals tailored to the patient were able to maintain the improvements 14 weeks later. Furthermore, only two patients taking CHM reported any adverse effects: one complained of gastrointestinal discomfort while the other experienced headaches (JAMA, 1998; 280: 1585-9).

o Acupuncture. The results of one trial in the US found that acupunc-ture combined with moxibustion may be promising for IBS manage-ment (Gastroenterol Nurs, 2009; 32: 243-55). However, a major review of the studies up to 2006 found only six randomized controlled trials, which were, in fact, inconclusive due to poor quality or not comparable because of too many differences in the variables studied. Also, orthodox researchers have concluded that it is still not clear whether traditional acupuncture is any better than sham acupuncture at reducing IBS symptoms (Cochrane Database Syst Rev, 2006; 4: CD005111).

Joanna Evans

WDDTY VOL 21 NO 1


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