Dr. Shandis Price
April 21, 2012
Annual Scientific Assembly
Objectives
 To review diagnosis and pathophysiology of IBS
 To review diet and IBS
 To become aware of botanicals that may be useful in
the management of IBS
 To review probiotics, acupuncture and mind-body
treatments for IBS
IBS - definition
 A syndrome characterized by chronic abdominal pain
and altered bowel habits without an organic cause
 Most common GI disorder
 More common in women and younger patients
 Abdominal pain usually crampy
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Often worse after eating and with emotional stress
Often better with defecation
Diagnosis
 Rome III criteria (revised 2005)
 Recurrent abdominal pain or discomfort
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at least 3 days per month in the past 3 months
onset at least 6 months prior to diagnosis
associated with 2 or more of the following:
 improvement of pain with defecation
 Onset of pain associated with a change in frequency of stool
 Onset of pain associated with a change in the form
(appearance) of stool
Diagnosis (cont’d)
 Supportive Sx (not part of Rome criteria)
 Abnormal stool frequency
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</= 3 BM’s per week or >3 BM’s per day
 Abnormal stool form
 lumpy/hard, loose/watery
 Defecation straining
 Urgency
 Feeling of incomplete emptying
 Passing mucus
 up to 50% pts with IBS describe passing mucus
 Bloating
Diagnosis (cont’d)
 Subtypes of IBS
 Diarrhea predominant IBS
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Hard/lumpy stools < 25%
Loose/watery stools >25%
 Constipation predominant IBS
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Loose/watery stools <25%
Hard/lumpy stools >5%
 Mixed IBS
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Hard/lumpy stools >25%
Loose/watery stools >25%
Diagnosis (cont’d)
 Alarm symptoms
 Rectal bleeding
 Nocturnal or progressive abdominal pain
 Weight loss
 Abnormal labs
 Age >50
 FHx colon CA / IBD
 Should get further investigations / colonoscopy
Investigations
 Labs – CBC, lytes – should all be normal
 Celiac screen
 Meta-analysis (Ford, Archive Int Med, 2009)
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Celiac disease 4x more common in patients with IBS than in
controls
 Should check celiac screen on all patients with IBS
 Stool cultures if diarrhea predominant IBS
 r/o Giardia
Pathophysiology
 Visceral hypersensitivity
 more sensitive to visceral stimuli
 Abnormal gut motility
 Increased/decreased gut transit time
 Increased motility to various stimuli compared to controls
 Psychosocial factors
 Brain-Gut interaction / neuroendocrine dysfunction
 Latent or potential Celiac disease
 Infection and inflammation
 Post-infectious IBS, altered gut flora
Pharmacologic treatments
 Antidepressants
 TCA’s and SSRI’s
 Antispasmodic agents
 Eg. Pinaverium – Dicetel
 Loperamide – (Immodium)
 Selective serotonin (5-HT4, 5-HT3)reuptake inhibitors
 Eg. alosetron, tegaserod
 Ischemic colitis, CV events
 Non-absorbable antibiotics (rifaximin)
 Overall low patient satisfaction with pharmacologic
treatments
 50% of patients with IBS turn to CAM therapies
Diet and IBS
 Lactose (dairy)
 Lactose intolerance is common
 Can aggravate IBS or cause Sx that are similar to IBS
 Trial of 3 weeks dairy-free diet for all patients with IBS
Diet and IBS
 Gluten sensitivity (without overt celiac disease)
 Latent or potential celiac disease
 “non-celiac gluten intolerance”
 Biesiekierski et al., Am J Gastroenterol. 2011
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Double-blind randomized placebo-controlled trial of 34
patients with IBS controlled on gluten-free diet
Re-introduction of gluten for 6 weeks significantly worsened
Sx
 Consider trial of gluten-free diet
Diet and IBS
 Exclusion of gas-producing foods
 Underlying visceral hyperalgesia
 Exclusion of foods that increase gas production:
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beans, cruciferous vegetables (broccoli, cauliflower, cabbage),
celery, carrots, raisins, bananas, prunes
Diet and IBS
 Carbohydrate malabsorption – “FODMAP’s”
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Fermentable
Oligosaccharides
Disaccharides
Monosaccharides
And
Polyols
 May lead to Sx of IBS, increased intestinal
permeability and possibly inflammation
 Oligosaccharides
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Fructans (wheat, onions, artichokes)
Galactans (legumes, cabbage, and brussel sprouts)
 Disaccharides
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Lactose (dairy)
 Monosaccharides
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Fructose (honey, watermelon, high fructose corn syrup)
 Polyols (sugar alcohols)
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Sorbitol (chewing gum)
Xylitol
Mannitol
 Some studies restricting FODMAP’s have suggested benefit
 Consider trial of low FODMAP’s diet
Diet and IBS
 Food allergies
 Role is unclear
 No reliable method of testing for food allergies
Diet and IBS (cont’d)
 Elimination diets
 Empiric trial to systematically remove certain food
allergens/sensitivities
 “Sinister 7”
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Cow’s milk, wheat, soy, corn, yeast, refined sugar, eggs
 Can remove all 7 from diet x 14 days then systematically
re-introduce every 72 hrs
 Or remove one at a time and then reintroduce
Botanicals and IBS
 Several botanicals have been studied
 Results limited by often small sample sizes and
substantial placebo response
Peppermint Oil
 Anti-spasmodic – helps
with cramping
 Slows gut motility /
transit time
 Mechanism of action –
smooth muscle
relaxation via Cachannel blockade
 Useful for diarrheapredominent IBS
Peppermint Oil
 Meta-analysis (Ford, BMJ, 2008)
 Peppermint oil effective in symptom relief in patients
with IBS
 NNT=2.5 for benefit with peppermint oil
 2009 American College of Gastroenterology
recommendations for the treatment of IBS
 Peppermint oil recommended for short-term relief of
abdominal pain/discomfort in IBS
Peppermint Oil (cont’d)
 Dose: enteric coated peppermint oil capsules
 0.2mL tid
 S/E’s:
 anal burning and heartburn
 Take peppermint oil capsules with food
 Worthwhile to try first in diarrhea predominant IBS
Botanicals – Carminatives
 Spices and herbs traditionally used for bloating and
gas
 64% of patients with IBS complain of bloating
 Also have other properties / secondary benefits
 eg. antimicrobial properties, anxiolytic properties
Carminatives – secondary benefits
 Basil – anti-inflammatory
 Caraway - slows GI transit time
 Peppermint - slows GI transit time
 Ginger – pro-kinetic, anti-emetic
 Cinnamon – insulin resistance
 Thyme - coughs, colds
 Dill – lactagogue
 Sage - hot flashes/sweating
Ginger
 Prokinetic and anti-
emetic
 Useful in IBS –
constipation dominant
 Useful for gas and
bloating (carminative)
 Also used as an antiinflammatory (being
studied for arthritis)
Ginger (cont’d)
 Dose:
 dried powdered ginger
 500mg dried ginger root – 1 tab tid before meals
 safe in pregnancy
 NOT concentrated extracts of ginger
 Extracts used as anti-inflammatory
 Can cause heartburn and GI distress at high doses and
safety not confirmed in pregnancy
Iberogast (STW 5)
 Blend of 9 herbs / plant extracts
 Candytuft
 Chamomile
 Peppermint
 Caraway
 Licorice root
 Lemon balm
 Celandine
 Milk thistle
 Angelica
 Study (Madisch, 2004) –
double-blind placebo RC T
 Showed effective in relieving
IBS symptoms
Fiber
 Commonly recommended
 May exacerbate symptoms in some patients
 Fiber supplements (eg. psyllium) may be beneficial for
constipation predominant IBS
 Main side effect is bloating and gas
 Take with lots of water, titrate slowly
Probiotics
 Living organisms that, upon digestion in certain
numbers, exert health benefits beyond those of basic
nutrition
 Some commonly studied probiotics
 Lactobacillus
 Bifidobacterium
 Saccharomyces boulardii
Probiotics (cont’d)
 May be a role of altered gut flora in the pathogenesis of
IBS
 Probiotics help balance the gut flora
 McFarland, 2008
 Meta-analysis of 23 studies showed improvement of
global IBS symptoms and abdominal pain
 warrents further study
 TuZen
 Lactobacillus plantarum 299v
Acupuncture and IBS
 Manheimer et al., April 2012, (Am J of
Gastroenterology)
 Systematic review and meta-analysis of Acupuncture
and IBS
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17 RCT’s (N=1806)
Acupuncture vs. sham acupuncture (5 trials) – no difference
Acupuncture more effective than pharmacologic therapy (5
trials)
Acupuncture equal effectiveness to bifidobacterium (2 trials)
or psycotherapy (1 trial)
Addition of acupuncture to standard medical care more
effective than standard medical care alone (2 trials)
Acupuncture (cont’d)
Mind-body and IBS
 Dysregulation of the brain-gut axis
 Visceral hypersensitivity
 Stress plays a role in onset and ongoing IBS symptoms
 Mind-body approaches have been investigated in
management of IBS Sx
 Meditation, relaxation, hypnotherapy, CBT
Mind-body (cont’d)
 Yoga and relaxation
 Useful to recommend in patients with IBS, especially if
they are “stressed”
 2 studies show benefit of yoga on IBS Sx

(Kuttner 2006, Taneja 2006)
 CBT
 Shown to be effective in IBS (Drossman, 2003)
Mind-Body (cont’d)
 Hypnotherapy
 Multiple studies have shown benefit in IBS
 an intentional induction of the hypnotic state that is
achieved by various methods including deep relaxation,
mental imagery or more subtle indirect techniques
 Good evidence to show that hypnotherapy is effective for
treatment of IBS and has long term benefits
(Gonsalkorale 2002, 2003)
 2009 American College of Gastroenterology
recommendations for the treatment of IBS
 Psychological therapies, including cognitive therapy,
dynamic psycotherapy and hypnotherapy more effective
than usual care in relieving global symptoms of IBS
Mind-body (cont’d)
 Placebo effect and IBS
 Kaptchuk et al 2010
 Placebos without deception: A Randomized Controlled Trial
in Irritable Bowel Syndrome
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- 70 patients with IBS, 3 wk RCT
"placebo pills made of an inert substance, like sugar pills, that have
been shown in clinical studies to produce significant improvement
in IBS symptoms through mind-body self-healing processes“ vs. notreatment controls with the same quality of interaction with
providers
Statistically significant improvement in global improvement scores,
reduced symptom severity and adequate relief scores
“Placebos administered without deception may be an effective
treatment for IBS”
Exercise
 Increased physical activity may help with symptoms of
IBS
 RCT (Johannesson, 2011)showed improved GI
symptoms in patients with IBS
 20-60min moderate to vigorous activity 3-5x/week
 Should be recommended to all patients with IBS
 good for general health as well
Summary
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Rule out celiac disease
Trial no dairy x 3 weeks
Trial gluten-free diet x 3 weeks
Can try elimination diet or low FODMAP’s diet if
motivated
Trial of peppermint oil if diarrhea-dominant or mixed
Trial of probiotics
Trial of acupuncture
Recommend exercise to all patients
Recommend trial of yoga, CBT, hypnotherapy
References
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Borrelli et al., Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomitting. Obstet Gynecol. 2005 Apr;
105(4): 849-56.
Drossman et al., Cognitive-behavioral therapy versus education and desipramine vs. placebo for moderate to severe functional bowel
disorder. Gastroenterology. 2003 Jul;125(1):19-31.
Johannesson et al., Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial. Am J Gastroenterol. 2011
May; 106(5):915-22.
Kaptchuk et al., Placebos without deception: A Randomized controlled trial in Irritable Bowel Syndrome., PLoS One 2010 Dec 22;5(12)
Kuttner et al., A randomized trial of yoga for adolescents with irritable bowel syndrome. Pain Res Manag. 2006 Winter;11(4):217-23
Manheimer et al., Acupuncture for Irritable Bowel Syndrome: Systematic Review and Meta-Analysis. Am J of Gastroenterology, 10 April 2012
Masdisch et al,. Treatment of Irritable bowel syndrome with herbal preparations: results of a double-blind, randomized, placebo-controlled,
multi-centre trial. Ailment Pharmacol Ther., 2004 Feb 1; 19(3):271-9.
McFarland LV, Dublin S. Meta-analysis of probiotics for the treatment of irritable bowel syndrome. World J Gastroenterol 2008; 14(17):265061.
Ford et al., Effect of Fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and metaanalysis. BMJ. 2008 Nov 13; 337:a2313
Ford et al., Yield of diagnostic tests for celiac disease in individuals with symptoms suggestive of irritable bowel syndrome: systematic review
and meta-analysis. Arch Intern Med. 2009;169(7):651.
Gonsalkorale et al. Hypnotherapy in irritable bowel syndrome: a large-scale audit of a clinical service with examination of factors influencing
responsiveness. Am J Gastroenterol. 2002 Apr;97(4):954-61.
Gonsalkorale et al. Long term benefits of hypnotherapy for irritable bowel syndrome. Gut. 2003 Nov;52(11): 1623-9.
Manheimer et al., Acupuncture for Irritable Bowel Syndrome: Systematic Review and Meta-Analysis. American Journal of Gastroenterology,
10 April 2012
Ryan et al., Ginger (Zingiber officinale) reduces acute chemotherapy-induced nausea: a URCC CCOP study of 576 patients. Support Care
Cancer. 2011 Aug 5.
aneja et al., Yogic versus conventional treatment in diarrhea-predominant irritable bowel syndrome: a randomized control study. Appl
Psychophysiol Biofeedback. 2004 Mar;29(1):19-33.
Wu et al., Effects of ginger on gastric emptying and motility in healthy humans. Eur J Gastroenterol Hepatol. 2008 May; 20(5):436-40.
University of Arizona Integrative Medicine Fellowship – Integrative Gastroenterology - Irritable Bowel Syndrome.
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