The Problem With Irritable Bowel Syndrome (IBS)

The Problem with Irritable Bowel Syndrome (IBS) is that it ranges from being diarrhoea-predominant (IBS-D) to constipation-predominant (IBS-C) and it can mix i.e. alternate (IBS-A) which is possibly the worst because you don’t know whether you’re coming or going. No one approach fits all because what helps IBS-C, say a high fibre diet, is likely to aggravate IBS-D. So far for the obvious. Still, there are things you yourself can do that aren’t prescribed or over-the-counter medication and that will help. The below is our approach tweaked for IBS and we hope that you will find this useful (if you do then please share this page).

One thing that you will have noticed with your IBS is that it isn’t the same all the time. For an IBS-D the diarrhoea doesn’t have the same severity from one day to another. For an IBS-C the constipation fluctuates. So, even for constant patterns, the symptoms fluctuate. Meaning that, whatever triggers your symptoms must fluctuate too… If you look at three things that are known to be associated with IBS symptoms (Food, Stress, Inflammation) then the greatest likelihood of being quick-variables are food and stress. Inflammation changes also, just not as quickly. We would love to help you, so lets talk through these three points…

Most if not all IBS sufferers benefit from improving their gut microbiome, not just because this improves abdominal comfort but because a healthier microbiome improves digestive capacity (membrane related enzymes), so the response to foods becomes more normal, as well as your ability to cope with stress. Teaming up kefir + aloeride + mind work is formidable.

IBS – Food Sensitivity

IBS symptoms often are triggered by foods, so it’s sensible to examine this, but how do you do it? Allergen specific IgE tests (Total IgE, Skin and RAST testing) and standard blood tests often come back being normal, which is why many gastroenterologists believe that it isn’t so much the food that is causing the problem, but a sensitive gut that is simply overreacting to its contents. And they have a point somewhere along the line… for, say, if you don’t have the resources to make enough enzymes, undigested food stuff may irritate, we know this from changes in sensitivity to dairy products. A fair observation would seem that you can make your bowels more robust and this you too can achieve.

Because sensitive (irritable, irritated) guts have a more permeable wall (see leaky gut below), the detection of serum antibodies to common food substances may help in dietary management. Sensitivity and food are a chicken and egg scenario and this research paper is of interest here: Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial; W Atkinson, T A Sheldon, N Shaath and P J Whorwell; Department of Medicine, University Hospital of South Manchester, Manchester, UK; Department of Health Sciences, University of York, York, UK. In as much that, if peanuts give you anaphylactic shock (IgE!), the easiest way to avoid anaphylactic shock is not to go anywhere near peanuts, it also is true that if, say, wheat causes slow onset (IgG!) uncomfortably bloating, then don’t go near wheat for now. Temporary food exclusion. Whilst you’re off your wheat, you put effort into make your bowels more robust (i.e. digestively capable, tolerant) and chances are that, in moderation and with rotation, you’re going to be fine with wheat in future.

The FoodScan113 has been a great help over the years. The above example of such an Elisa assay shows you that a patient had a reaction (3) to egg white and egg yolk. This definitely means strict exclusion for now and possibly some transgressions being tolerated in the future. Brazil nuts and cows milk scored (2) which often can be managed, without doing anything further, with rotation (i.e. eat one day, do not eat for next two days). Certainly sensitivity to cows milk will respond very favourably to you improving your microbiome (double fermented milk (yes!) kefir, just introduce it gradually + aloeride). All the measurements that scored (1) are manageable with rotation but, nine out of ten, making your gut more robust sorts it completely. As a FoodScan113 used to costs approximately £250.00, some of you may wish to defer this and try out the trio approach first (aloeride+well made milk kefir+mind work).

IBS – Leaky Gut

   
Leaky gut is the common name for hyperpermeability syndrome. Instead of the wall of your gut keeping what must stay inside the gut inside the gut, little gaps in between the cells of the wall work like a sieve. Body-foreign molecules thus bypass selective uptake and gatecrash where they shouldn’t go, and this can trigger the immune system. Intestinal permeability can be tested with low-molecular weight polyethylene glycols (PEG 400). These gaps (loss of tight junctions, see below diagram) appear because something crossed the protective (when robust) lining of the wall, irritated the wall, caused swelling, caused the closed-packed positions to become lose-packed positions… So, the obvious thing to do, is to stop ingesting what is irritating the gut wall (hopefully temporarily), to ingest the herb that’s well known to help the gut and restore your microbiome. Selective uptake through the enterocytes is healthy, non-selective uptake in between the enterocytes is the unhealthy leaky gut (hyperpermeability syndrome) situation. Not having effective borders means that macromolecules can venture where they have no business to be and where the immune system will recognise them as foreign particles. It causes a conflict that is thought to be one of the drivers of auto-immune disorders. Swipe the image below and spot how a healthy gut is discriminate and how molecules can indiscriminately invade when tight junctions are open.

IgG is the province of delayed type allergies, nothing you’ll die of, but nonetheless able to make life miserable. Broadly speaking the worst foods for IBS are wheat, dairy, coffee, tea, citrus fruits and lactose, for some potatoes are a problem too (they are part of the Nightshade family of plants, the green part of which contains alkaloid which is an irritant – others in this family are tomatoes, peppers and eggplant). For many IBS sufferers getting the diet right is difficult, you share this plight with people with Crohn’s Disease, Ulcerative Colitis or Coeliac disease. A simple trick that works for most people, is to put a buffer in place that supports the diversity of your microbiome. That’s where for many the Aloeride comes into it.

This may make you smile. A randomised, cross-over, placebo-controlled study of aloe vera on patients with Irritable Bowel Syndrome (IBS) was unable to show that the aloe vera was superior to placebo in improving any aspect of patient quality of life using generic or disease specific tools following the treatment of symptoms associated with IBS. Unfortunately this study was done with aloe vera gel (independently measured it had a PHA* = 48.2ppm which, according to Consultant Gastroenterologist Dr. Danhof MD PhD, would have laxative effect if dosed at manufacturer’s recommendations). Small wonder those with IBS-D or IBS-A experienced no improvement in quality of life. The problem is not just ND² (name disease name drug) thinking, but using one brand of aloe and then generically stating that aloe vera is useless for IBS. All it would take to do much better is to avoid obvious manufacturing pitfalls, dose aloe properly and use well-made aloe vera in wider context is the approach we recommend. *polyhydroxy-anthraquinones

IBS – Inflammation

A small proportion of people develop IBS for the first time after a bout of gastroenteritis, raising speculation that, although the infection clears up, this experience might make the gut more sensitive. In support of this, recent research has shown that the small proportion of people with post-infectious IBS also tends to have a mild, ongoing inflammation of the gut which begs the question, why do some people have persistent bowel symptoms after an attack of gastroenteritis while most others get better?

Research has shown that post-infectious IBS is much more likely if the person was anxious, depressed and was experiencing difficult life situations at the time of the original illness. From Psycho-Neuro(endocrine)-Immunology we know for certain that stressors like that lower the immune response. So, perhaps ongoing emotional upset creates the nervous tension that maintains a low-grade bowel inflammation. Alternatively, the memory of the bowel upset was recruited by gut-brain connections to express an unresolved life situation. Similar observations have been made for IBS occurring for the first time after hysterectomy. An attack of gastroenteritis or the antibiotics given to treat it, can alter the balance of bacteria in the colon (microbiome), reducing populations of beneficial anaerobic bacteria and encouraging the overgrowth of pathogenic species. Although it is not established whether this mechanism can result in chronic symptoms of IBS, restoring beneficial populations of colonic bacteria with good probiotics or live culture containing kefir/yoghurt has become a popular treatment of IBS [Source: Professor Nick Read, MA, MD, FRCP, Consultant Gastroenterologist and Analytical Psychotherapist and trustee to the IBS Network].

For any inflammation to subside, you need anti-inflammatory agents plus stopping the aggravation (i.e. colonic rest). Inflammation often is accompanied by reactive spasms (hence old diagnosis of spastic colon, now non-PC) and for this antispasmodics can be used but peppermint oil may be useful too. Non-latex aloe vera in vegetarian capsules first thing in the morning and last thing at night helps as do clever smoothies which should contain tart cherries (stoned), sweet cherry powder, goji berry powder and curcumin powder, as these are known to reduce levels of c-reactive protein. Stopping aggravation happens by way of avoiding foods & fluids that irritate the gut wall (see ELISA assay as mentioned before). Non-steroid-anti-inflammatory drugs (NSAIDs) have the known disadvantage of causing hyperpermeability (leaking) of the gut, so they are not ideal because in IBS the gut is already leaky and increasing that is undesirable.

In respect of the reactive spasm that follows inflammation near muscles, Magnesium is known to relax smooth muscles so checking red blood cell magnesium level, or less invasively via hair mineral or sweat analysis, may be a good idea. Note however that Magnesium salts (for instance Epsom salts = magnesium sulphate) are known to induce diarrhoea, willy-nilly ingestion of Magnesium may cause havoc in diarrhoea-predominant IBS. Patients with chronic diarrhoea have a progressive depletion of Magnesium (also of Potassium, these are half of the mineral quartet that dictates the predominance in your autonomic nervous system) but there is a tendency to regain the magnesium status during the convalescent period [J Trop Pediatr. 1990 Jun;36(3):121-5]. Surreptitious magnesium laxative abuse is a cause of unexplained chronic diarrhoea, so here is a warning for the constipation-predominant IBS sufferer! Magnesium is abundantly available in fresh chlorophyll containing (dark green) vegetable matter, so smoothies are a useful way to replenish any depletion and maintain normal levels. In smoothies consider adding IBS-useful fresh garden plants such as mint (Mentha piperita or pulegium ), ginger (Zingiber officinale – in gallbladder disease you should use this herb with some caution), chamomile (Matricaria chamomilla ), rhubarb (Rheum x cultorum – is a liver stimulant and a laxative, best not use in diarrhoea-predominant IBS), yarrow (Achillea millefolicium ), fennel (Foeniculum vulgare ) and silverweed (Potentilla anseriva ).

IBS – Stress

The gut is an important route by which emotion is expressed in the body. If ever you have felt your stomach knot up before a speech, you too know that the brain and digestive tract are holding hands. This constant bidirectional dialogue is known as the gut-brain axis. Even perfectly healthy people can worry their way to stomach pain, nausea or diarrhoea. A physician won’t find anything wrong but the misery is real enough. It has been suggested that patients with IBS feel more emotional upsets than ‘healthy people’ or patients with other gastrointestinal diseases and have experienced more traumatic life events and difficult life situations both in adulthood and childhood. Hmmm.

What does stress actually do to you/your gut? It’s the fight or flight reaction as you know: flight response may root in a fear of failure (common a muck) and fight response may root in ‘anger’ to yet another thing on the plate when life is already too busy (common as muck). So your brain, adrenal-, pituitary- and thymus-gland produce more adrenaline, noradrenaline and corticosteroids… In the gut, stress increases the intestinal permeability to large antigenic molecules i.e. molecules venture where they shouldn’t and thus may evoke an allergic response (leaky gut). It can lead to mast cell activation & degranulation (i.e. histamine reactions) and colonic mucin depletion (loss of protective barrier). A reversal of small bowel water and electrolyte absorption occurs in response to stress and is mediated cholinergically (gallbladder). Stress itself also leads to increased susceptibility to colonic inflammation. [Stress and the gastrointestinal tract, Bhatia V., Tandon R.K., J Gastroenterol Hepatol. 2005 Mar;20(3):332-9.]

About the gut-brain axis: the digestive tract is supplied by extrinsic and intrinsic sensory neurons which, together with endocrine and immune cells, form a surveillance network that is essential to gut function. The three players for this are gastrointestinal tract (GIT), central nervous system (CNS) and enteric nervous system (ENS) and they communicate with one another via parasympathetic and sympathetic pathways, each comprising efferent fibres such as cholinergic and noradrenergic, respectively, and afferent sensory fibres required for gut-brain signalling. The gut-brain axis is relevant not only to normal digestive function but also to abdominal pain and heightened sensitivity to pain.

A growing body of data shows that microbes in the gut influence behaviour and can alter brain physiology and neurochemistry. Microbial metabolites influence the basic physiology of the blood–brain barrier: gut microbes break down complex carbohydrates into short-chain fatty acids with an array of effects: the fatty acid butyrate for example, fortifies the blood–brain barrier by tightening connections between cells. Research by John Cryan, a neuroscientist at University College Cork in Ireland, shows that myelination (formation of fatty sheathing that insulates nerve fibres) can be influenced by gut microbes, at least in a specific part of the brain. Increasingly it looks reasonable to portray the microbiome as our ‘puppet master’. In order to thrive and advance its own evolutionary success, the microbiome’s nutritional and environmental requirements need to be met. It rather looks that they have the means, motives and opportunity to manipulate us.

The neural network of the brain, which generates the stress response, is called the Central Stress Circuitry (CSC). It receives input from tissue & organ (somatic and visceral) feedback pathways and also from the organ (visceral) motor cortex. The output of this CSC is called the emotional motor system and includes automatic efferents, the hypothalamus-pituitary-adrenal axis and pain modulatory systems. Severe or long-term stress can induce long-term changes in the stress response (plasticity). Corticotropin Releasing Factor (CRF = the fight or flight hormone) is a key mediator of the central stress response.

A growing number of reports have demonstrated a disordered autonomic function (i.e. nervous sytem controlling rest vs. activity) in FGIDs, they point to a generally decreased parasympathetic outflow (PSNS) or increased orthosympathetic activity (OSNS) in conditions usually associated with slow or decreased gastrointestinal motility, while other studies found either an increased cholinergic activity or a decreased sympathetic activity in patients with symptoms compatible with an increased motor activity. [The autonomic nervous system in functional bowel disorders, Tougas, G., Can J Gastroenterol. 1999 Mar;13 Suppl A:15A-17A.] Orthostatic testing (Heart Rate Variability) can objectively measure if your body/mind and thus bowels ‘consider’ it to be in stress. Every aspect of Brain Gain helps you to reduce stress, from the (electronically helped) meditation to simple DIY exercises like mapping you and your journey. Easy to do, yet this can yield big positive changes.

Here are several paragraphs of things you are unlikely not to know already.

IBS affects 10-25% (figures vary from report to report) of the general population and is more frequently diagnosed in women compared with men (approximately 80% of the most severe cases involve women), in young people compared with old and in Western countries compared with the developing world. It is often associated with emotional stress and is frequently triggered by life changes. According to Consultant Neurologist Dr. Jane Collins, Irritable Bowel Syndrome is becoming increasingly common among children,… as for that matter is diabetes mellitus and childhood obesity whilst the number of children seeking counselling for exam stress has risen by 200% (source ChildLine charity).

In days gone by Irritable Bowel Syndrome was known as spastic colon, mucous colitis, spastic colitis, nervous stomach or irritable colon. According to Professor Robin Spiller (Professor in Gastroenterology and Honorary Consultant Physician, Division Gastroenterology University of Nottingham) and Professor Nicholas Talley (University of Sydney, Napean Hospital) there is growing evidence that Irritable Bowel Syndrome can no longer be purely regarded as a functional gastrointestinal disorder (FGID) and they prefer to judge the disorder to be a discrete collection of organic bowel diseases, with characteristic morphological, psychological, and physiological changes only now being fully appreciated.

So it’s not just a FGID… Key issue in IBS remains that the gut becomes abnormally sensitive to its content (visceral hypersensitivity), causing changes in contractions and changes in bowel function. Fortunately you can influence IBS.

IBS Symptoms

• crampy abdominal pain, often relieved by defaecation/defecation
• an alteration in bowel habit (diarrhoea/diarrhea, constipation or alternating)
• bloating and (painful) swelling of the abdomen
• rumbling noises (borborygmi) and excessive passage of wind
• increased gastro-colic reflex, this is an awakening of the childhood reflex where food in the stomach stimulates colonic activity, resulting in the need to open the bowels
• urgency – a need to rush to the toilet (incontinence if a toilet isn’t nearby)
• a sharp pain felt low down inside the rectum (proctalgia fugax)
• right-sided abdominal pain, either low or under the right lower ribs which does not always get better on opening the bowels; or pain under the left ribs (splenic flexure syndrome) and when the pain is bad it may ascend to the left armpit
• sensation of incomplete bowel movement
• possible associated symptoms are: indigestion, belching, nausea, headaches, dizziness, ringing in the ears, fibromyalgia, backache, passing urine frequently, tiredness or even chronic fatigue, shortness of breath, anxiety and depression

IBS Diagnosis

The diagnostic criteria of Irritable Bowel Syndrome always presume the absence of a structural or biochemical explanation for the symptoms and is made only by a physician after gathering a careful medical history and giving a thorough physical examination. IBS can be diagnosed based on at least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has two out of three features: 1. Relieved with defaecation; and/or 2. Onset associated with a change in frequency of stool; and/or 3. Onset associated with a change in form (appearance) of stool.

Symptoms that cumulatively support the diagnosis of IBS are: Abnormal stool frequency (may be defined as greater than 3 bowel movements per day and less than 3 bowel movements per week); Abnormal stool form (lumpy/hard or loose/watery stool); Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation); Passage of mucus; Bloating or feeling of abdominal distension. (Courtesy of Rome II Criteria, Degnon Assoc.) You need specific tests (gastroscopy, colonoscopy, ultrasound, barium studies or other) when there is unexplained weight loss, blood in the stools, fever or an abrupt and continuing change in bowel habit. These are red flags for other bowel conditions.