The American College of Gastroenterology’s new position paper on Irritable Bowel Syndrome (IBS) includes a cautious endorsement of probiotics and psychosocial interventions. The paper represents the first time this organization has formally supported probiotics to treat this common but difficult condition.

That’s good news, as the need for safe, effective, minimally-invasive IBS therapies has never been greater. Up to 20% of US adults have IBS. The disorder predominantly affects reproductive-aged women, and often occurs in association with gynecologic disorders. In 50% of those diagnosed, the age of onset is less than 35 years (Camilleri M, Choi M. Aliment Pharmacol Ther. 1997; 11: 3. Everhart J, Renault P. Gastroenterol. 1991; 100: 998).

ACG’s new guidelines, titled An Evidence-Based Position Statement on the Management of Irritable Bowel Syndrome, and published with the January 2009 American Journal of Gastroenterology, state that, “Probiotics possess a number of properties that may prove of benefit to patients with IBS.” They cite favorable data for probiotics containing Bifidobacteria alone or in combination with other organisms like Lactobacilli.

With the caveat that “Interpretation … is hampered by difficulties in comparing studies using probiotics that varied widely in terms of species, strains, preparations, and doses,” ACG’s Task Force on IBS notes that, “the dichotomous data suggest that all probiotic therapies have a trend for being efficacious,” and that probiotics are, “well tolerated and free from serious adverse side effects.”

The Task Force also smiled on psychosocial interventions, noting that “cognitive therapy, dynamic psychotherapy, and hypnotherapy, but not relaxation therapy, are more effective than usual care.”

The authors were less sanguine on dietary interventions. Though roughly 60% of IBS patients, “believe that food exacerbates their symptoms, and research has suggested that allergy to certain foods could trigger IBS symptoms,” ACG’s review of 8 exclusion diet studies does not arrive at a clear conclusion. These studies did not include control groups, so it is difficult to know if response rates (ranging from 12% to 67%) reflect true therapeutic effects or placebo responses.

The role of food allergies or intolerances in IBS is controversial, but most integrative practitioners at least consider the possibilities. Several studies show associations between allergies and IBS (Jones V, et al. Lancet. 1982; 2: 1115–1117. Petitpierre M, et al. Ann Allergy. 1985; 54: 538–540. Nanda R, et al. Gut. 1989; 30: 1099–1104. Gertner D, Powell-Tuck J. Practitioner. 1994; 238: 499–504).

The following is a review of natural therapeutics I’ve found useful in treating women with IBS.

Probiotics

Like many holistic/naturopathic practitioners, I’m a fan of probiotics, and I’m glad to see the ACG acknowledging their value.

Dysregulation in gut flora is very common in IBS (Riordan S, Kim R. Curr Opin Gastroenterol. 2006; 22: 669–673). Two recent trials underscore the efficacy of probiotics. In one 5-month study, 86 patients were randomized to either a multispecies probiotic daily or placebo. The IBS score decreased 14 points from baseline with the probiotics versus only 3 points with placebo. In particular, probiotic-treated patients reported less abdominal distension and pain (Kajander K, et al. Aliment Pharmacol Ther. 2008; 27: 48–57).

In the second trial, 40 IBS patients were randomized to placebo or a Lactobacillus acidophilus probiotic. After 4 weeks, there was a 20% greater reduction in abdominal pain or discomfort in the probiotic group versus the placebo (Sinn DH, et al. Dig Dis Sci. 2008; 53: 2714–2718).

Fiber & Other Dietary Factors

Fiber from grain, fruits and vegetables should be a cornerstone of IBS treatment.

Constipation-dominant IBS patients may benefit more from fiber/bulking agents than those who have more diarrhea. Clinically, we see improvement by increasing fruit and vegetable intake. Cereal-based fiber is important as well.

For those with diarrhea-dominant IBS, cooked vegetables may be the best choice to help reduce symptoms.

In considering supplemental fiber, keep in mind there are two forms: Insoluble fiber increases stool bulk, softens stools, and shortens bowel transit time. Soluble fiber dissolves in water, forming a soft gel that eases elimination.

Psyllium husks and flax seeds are insoluble bulk-forming agents that absorb water, soften stool, increase stool weight and the number of bowel movements per day. In diarrhea-dominant IBS, psyllium makes the stools less watery. However, sometimes it can increase flatulence and bloating (Marlett J, et al. Am J Clin Nutr. 2000; 72: 784–789).

Citrus pectin is a soluble fiber that also helps stabilize intestinal flora. It can ease both constipation and diarrhea-associated IBS (Monograph. Modified Citrus Pectin Altern Med Rev. 2000; 5: 573–575). Guar gum is a soluble fiber from the seed of the guar plant; it can be used for treating diarrhea, constipation, and IBS (Biaccari S, et al. Clin Ter. 2001; 152: 21–25).

The choice of fiber supplements needs to be individualized, so work with each patient to find what works best. When starting a patient on any type of fiber, begin with small doses and increase slowly over days to weeks. Make sure patients know to take fiber with at least 8 oz. of water.

If a particular form of fiber aggravates rather than ameliorates a patient’s symptoms, encourage her to try something else. If several types of fiber prove ineffective in someone with constipation-dominant IBS, consider osmotic laxatives such as magnesium. Magnesium citrate, sulfate and hydroxide are the most common forms; sulfate salt is the most potent.

Botanicals for IBS

Artichoke leaf extract (Cynara scolymus L.) can reduce severity of IBS in a subset of patients with dyspepsia (Walker A, et al. Phytother Res. 2001; 15: 58–61). In Dyspepsia/IBS patients randomly assigned to either 320 or 640 mg capsules of a standardized (1:5) aqueous extract of artichoke leaves taken daily for 2 months, the herb produced a 41% mean reduction in total symptom scores; quality of life scores showed a 20% improvement (Bundy R, et al. J Altern Comp Med. 2004; 10(4): 667–669).

Peppermint oil, specifically enteric-coated peppermint oil (ECPO), inhibits gastrointestinal smooth muscle spasms and improves rhythmic intestinal contractions. Peppermint oil has been studied in children and adults with IBS, but the results have been conflicting (Kline R, et al. J Pediatr. 2001; 138: 125–128. Liu J, et al. J Gastroenterol. 1997; 32: 765–768).
A 1999 meta-analysis of 5 studies was inconclusive (Pittler M, Ernst E. Am J Gastroenterol. 1998; 93: 1131–1135). But in one of those studies, 110 IBS patients took either ECPO, 0.2 ml per dose, or placebo, 3 or 4 times daily for a month. For all symptom categories (abdominal pain/distension, stool frequency, gas and borborygmi (GI “growling”), the ECPO group showed 2 to 3-fold improvement compared to those on placebo (Liu H, et al. J Gastroenterol. 1997; 32: 765–768). One problem with ECPO is that it can be irritating for some patients who also have gastroesophageal reflux.

Turmeric (Curcuma longa) was shown to reduce IBS symptoms in a pilot study of 207 patients taking either one or two 72 mg tablets of a standardized extract for 8 weeks. IBS symptom prevalence decreased 53% in the once-daily group, and 60% in the twice-daily group. Two-thirds of all patients reported improvement (Bundy R, et al. J Altern Comp Med. 2004; 10(6): 1015–1018).

Marshmallow root (Althaea officinalis) has a rich history of use to treat constipation, diarrhea, gastric inflammation and peptic ulcers. The leaves and roots contain mucilaginous polysaccharides that soothe and protect intestinal mucous membranes, and help stool move more easily through the bowel, thereby increasing comfort and elimination (Fleming T, ed. Marshmallow. In: PDR for Herbal Medicines, 3rd ed., pp. 556–557, 2004, Montvale, NJ: Medical Economics Co.).

Wild yam (Dioscorea villosa), in tincture form, is one of my favorite herbs for abdominal cramping related to IBS. It has antispasmodic effects on smooth muscle. I’ve found that one teaspoon of tincture, twice daily, has helped many of my IBS patients.

“Bitters”: Western and Asian herbal traditions have included “bitters” in formulas for GI problems. These are alkaloid-rich herbs usually taken in liquid form 10–30 minutes before a meal. They stimulate GI motility and increase gastric secretions. Common bitters include Ginger (Zingiber officinale), Dandelion (Taraxacum officinalis), Fumitory (Fumaria officianlis), Wormwood (Artemisia spp.), Gentian (Gentiana spp.), Candytuft (Iberis amara) and Artichoke (Cynara scolymus).
In Western botanical traditions, bitters are often combined with cholagogues (stimulate bile flow), carminatives (reduce flatulence), antispasmodics, anti-microbials, anti-inflammatories, astringents, and nervines (mild sedatives).
One such combination that has been studied in IBS contains the bitter Candytuft (Iberis amara); along with Celandine (Chelidonium majus) as a cholagogue; Caraway (Carum carvi), Peppermint (Mentha piperita), and Chamomile (Matricaria recutita) as carminatives; Licorice (Glycyrrhiza spp.) as an anti-inflammatory; Lemon Balm (Melissa officinalis), Angelica (Angelica archangelica), and Milk Thistle (Silybum marianum) as nervines.
In a 4-arm study, 208 IBS patients were randomized to receive: an alcohol extraction of the complete herbal combination; the same formula excluding the cholagogue and the nervines; a Candytuft extract only; or placebo. Patients took 20 drops of the assigned remedy thrice daily for 4 weeks. The full combination formula and the modified preparation yielded measurable reductions in IBS symptoms; The single-herb Candytuft extract and the placebo did not (Madisch A, et al. Alimentary Pharmacol Ther. 2004; 19: 271–279).

Serotonin & Melatonin

L-tryptophan and 5-hydroxytryptophan (5-HTP) are both produced in the gut, not just the brain. In fact, roughly 95% of the body’s serotonin is found in the gut. Specific serotonin receptors regulate GI motor and secretory function as well as visceral sensation (Gerson M, Tack J. Gastroenterology. 2007; 132: 397–414).

Alosetron (Lotronex), a 5-HT₃ receptor antagonist, was the first FDA-approved drug for severe IBS in women whose predominant symptom is diarrhea. It was introduced in 2000, but withdrawn within months, owing to serious, life-threatening GI side effects. It was re-introduced in June 2002, but the re-approval limited use only to women with severe diarrhea-dominant IBS, who did not respond to other therapies.

Modulation of serotonin pathways with L-tryptophan and 5-HTP certainly makes sense as a treatment approach, and is probably safer than pharmaceuticals like Alosetron. Common dosing for L-tryptophan is 500 mg up to 6,000 mg per day, before bed. For 5-HTP, it’s in the range of 50 mg–100 mg/day, also to be taken before bed. Be aware that tryptophan can sometimes cause heartburn, belching, flatulence, nausea, and other GI adverse effects.

Melatonin can really help some IBS patients. In an 8-week, placebo-controlled trial, those taking melatonin experienced a 3.5-fold improvement in IBS symptom scores. In addition, quality of life was nearly 3-fold better in the melatonin group (Saha L, et al. J Clin Gastroenterol. 2007; 41(11): 29–32). Another placebo-controlled trial of 40 individuals showed that melatonin reduced abdominal pain and rectal pain (Song G, et al. Gut. 2005; 54(10): 1402–1407).

Lastly, in a study of young women with IBS, those taking melatonin for 8 weeks had less abdominal pain, diarrhea and constipation than those on placebo. Interestingly, IBS symptoms improved without any measurable melatonin effect on sleep (Lu W, et al. Aliment Pharmacol Ther. 2005; 22(10): 927–934). Typical melatonin dosing is in the range of 0.3 mg–5 mg nightly, before bed, although higher doses can be used.

Over the years, I’ve found that patients with IBS respond well to a holistic approach that includes avoiding food triggers, increasing dietary fiber, introducing probiotics, tailored use of herbal options, melatonin/tryptophan, and psychological/behavioral therapies addressing the complex but intimate relationship between the gut and the brain.