IBS An Integrative Approach

IBS An Integrative ApproachDr. Shandis PriceApril 21, 2012Annual Scientific AssemblyObjectivesTo review diagnosis and pathophysiology of IBSTo review diet and IBSTo become aware of botanicals that may be useful in the management of IBSTo review probiotics, acupuncture and mind-body treatments for IBSIBS - definitionA syndrome characterized by chronic abdominal pain and altered bowel habits without an organic causeMost common GI disorderMore common in women and younger patientsAbdominal pain usually crampy Often worse after eating and with emotional stressOften better with defecationDiagnosisRome III criteria (revised 2005)Recurrent abdominal pain or discomfortat least 3 days per month in the past 3 monthsonset at least 6 months prior to diagnosisassociated with 2 or more of the following:improvement of pain with defecationOnset of pain associated with a change in frequency of stoolOnset of pain associated with a change in the form (appearance) of stool

Diagnosis (contd)Supportive Sx (not part of Rome criteria)Abnormal stool frequency 3 BMs per dayAbnormal stool formlumpy/hard, loose/wateryDefecation strainingUrgencyFeeling of incomplete emptyingPassing mucusup to 50% pts with IBS describe passing mucusBloatingDiagnosis (contd)Subtypes of IBSDiarrhea predominant IBSHard/lumpy stools < 25%Loose/watery stools >25%Constipation predominant IBSLoose/watery stools 5%Mixed IBSHard/lumpy stools >25%Loose/watery stools >25%Diagnosis (contd)Alarm symptomsRectal bleedingNocturnal or progressive abdominal painWeight lossAbnormal labsAge >50FHx colon CA / IBD

Should get further investigations / colonoscopyInvestigationsLabs CBC, lytes should all be normalCeliac screenMeta-analysis (Ford, Archive Int Med, 2009)Celiac disease 4x more common in patients with IBS than in controlsShould check celiac screen on all patients with IBSStool cultures if diarrhea predominant IBSr/o GiardiaPathophysiologyVisceral hypersensitivitymore sensitive to visceral stimuliAbnormal gut motilityIncreased/decreased gut transit timeIncreased motility to various stimuli compared to controlsPsychosocial factorsBrain-Gut interaction / neuroendocrine dysfunctionLatent or potential Celiac diseaseInfection and inflammationPost-infectious IBS, altered gut floraPharmacologic treatmentsAntidepressantsTCAs and SSRIsAntispasmodic agentsEg. Pinaverium DicetelLoperamide (Immodium)Selective serotonin (5-HT4, 5-HT3)reuptake inhibitorsEg. alosetron, tegaserodIschemic colitis, CV eventsNon-absorbable antibiotics (rifaximin)Overall low patient satisfaction with pharmacologic treatments 50% of patients with IBS turn to CAM therapies

Diet and IBSLactose (dairy)Lactose intolerance is commonCan aggravate IBS or cause Sx that are similar to IBSTrial of 3 weeks dairy-free diet for all patients with IBS

Diet and IBSGluten sensitivity (without overt celiac disease)Latent or potential celiac diseasenon-celiac gluten intoleranceBiesiekierski et al., Am J Gastroenterol. 2011Double-blind randomized placebo-controlled trial of 34 patients with IBS controlled on gluten-free dietRe-introduction of gluten for 6 weeks significantly worsened SxConsider trial of gluten-free diet

Diet and IBSExclusion of gas-producing foodsUnderlying visceral hyperalgesiaExclusion of foods that increase gas production:beans, cruciferous vegetables (broccoli, cauliflower, cabbage), celery, carrots, raisins, bananas, prunesDiet and IBSCarbohydrate malabsorption FODMAPs

FermentableOligosaccharidesDisaccharidesMonosaccharidesAndPolyols

May lead to Sx of IBS, increased intestinal permeability and possibly inflammationOligosaccharidesFructans (wheat, onions, artichokes)Galactans (legumes, cabbage, and brussel sprouts)DisaccharidesLactose (dairy)MonosaccharidesFructose (honey, watermelon, high fructose corn syrup)Polyols (sugar alcohols)Sorbitol (chewing gum)XylitolMannitol

Some studies restricting FODMAPs have suggested benefitConsider trial of low FODMAPs diet

Diet and IBSFood allergiesRole is unclearNo reliable method of testing for food allergiesDiet and IBS (contd)Elimination dietsEmpiric trial to systematically remove certain food allergens/sensitivitiesSinister 7Cows milk, wheat, soy, corn, yeast, refined sugar, eggsCan remove all 7 from diet x 14 days then systematically re-introduce every 72 hrsOr remove one at a time and then reintroduce

Botanicals and IBSSeveral botanicals have been studiedResults limited by often small sample sizes and substantial placebo responsePeppermint OilAnti-spasmodic helps with crampingSlows gut motility / transit timeMechanism of action smooth muscle relaxation via Ca-channel blockadeUseful for diarrhea-predominent IBS

Peppermint OilMeta-analysis (Ford, BMJ, 2008)Peppermint oil effective in symptom relief in patients with IBSNNT=2.5 for benefit with peppermint oil

2009 American College of Gastroenterology recommendations for the treatment of IBSPeppermint oil recommended for short-term relief of abdominal pain/discomfort in IBS

Peppermint Oil (contd)Dose: enteric coated peppermint oil capsules 0.2mL tidS/Es: anal burning and heartburnTake peppermint oil capsules with food

Worthwhile to try first in diarrhea predominant IBS

Botanicals CarminativesSpices and herbs traditionally used for bloating and gas64% of patients with IBS complain of bloatingAlso have other properties / secondary benefitseg. antimicrobial properties, anxiolytic properties

Carminatives secondary benefitsBasil anti-inflammatoryCaraway - slows GI transit timePeppermint - slows GI transit timeGinger pro-kinetic, anti-emeticCinnamon insulin resistanceThyme - coughs, coldsDill lactagogueSage - hot flashes/sweating

GingerProkinetic and anti-emeticUseful in IBS constipation dominantUseful for gas and bloating (carminative)Also used as an anti-inflammatory (being studied for arthritis)

Ginger (contd)Dose:dried powdered ginger500mg dried ginger root 1 tab tid before mealssafe in pregnancy

NOT concentrated extracts of gingerExtracts used as anti-inflammatoryCan cause heartburn and GI distress at high doses and safety not confirmed in pregnancy

Iberogast (STW 5)

Blend of 9 herbs / plant extractsCandytuftChamomilePeppermintCarawayLicorice rootLemon balmCelandineMilk thistleAngelica

Study (Madisch, 2004) double-blind placebo RC TShowed effective in relieving IBS symptoms

FiberCommonly recommendedMay exacerbate symptoms in some patientsFiber supplements (eg. psyllium) may be beneficial for constipation predominant IBSMain side effect is bloating and gasTake with lots of water, titrate slowlyProbioticsLiving organisms that, upon digestion in certain numbers, exert health benefits beyond those of basic nutritionSome commonly studied probioticsLactobacillusBifidobacteriumSaccharomyces boulardii29Probiotics (contd)May be a role of altered gut flora in the pathogenesis of IBSProbiotics help balance the gut floraMcFarland, 2008Meta-analysis of 23 studies showed improvement of global IBS symptoms and abdominal painwarrents further study

TuZenLactobacillus plantarum 299v

Acupuncture and IBSManheimer et al., April 2012, (Am J of Gastroenterology)Systematic review and meta-analysis of Acupuncture and IBS 17 RCTs (N=1806)Acupuncture vs. sham acupuncture (5 trials) no differenceAcupuncture 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 (contd)

Mind-body and IBSDysregulation of the brain-gut axisVisceral hypersensitivityStress plays a role in onset and ongoing IBS symptomsMind-body approaches have been investigated in management of IBS SxMeditation, relaxation, hypnotherapy, CBT33Mind-body (contd)Yoga and relaxationUseful to recommend in patients with IBS, especially if they are stressed2 studies show benefit of yoga on IBS Sx(Kuttner 2006, Taneja 2006)CBTShown to be effective in IBS (Drossman, 2003)Mind-Body (contd)HypnotherapyMultiple studies have shown benefit in IBSan intentional induction of the hypnotic state that is achieved by various methods including deep relaxation, mental imagery or more subtle indirect techniquesGood 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 IBSPsychological therapies, including cognitive therapy, dynamic psycotherapy and hypnotherapy more effective than usual care in relieving global symptoms of IBSMind-body (contd)Placebo effect and IBSKaptchuk et al 2010Placebos without deception: A Randomized Controlled Trial in Irritable Bowel Syndrome- 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. no-treatment controls with the same quality of interaction with providersStatistically significant improvement in global improvement scores, reduced symptom severity and adequate relief scoresPlacebos administered without deception may be an effective treatment for IBSExerciseIncreased physical activity may help with symptoms of IBSRCT (Johannesson, 2011)showed improved GI symptoms in patients with IBS20-60min moderate to vigorous activity 3-5x/weekShould be recommended to all patients with IBSgood for general health as wellSummaryRule out celiac diseaseTrial no dairy x 3 weeksTrial gluten-free diet x 3 weeksCan try elimination diet or low FODMAPs diet if motivatedTrial of peppermint oil if diarrhea-dominant or mixedTrial of probioticsTrial of acupunctureRecommend exercise to all patientsRecommend trial of yoga, CBT, hypnotherapyReferencesBorrelli 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):217-23Manheimer et al., Acupuncture for Irritable Bowel Syndrome: Systematic Review and Meta-Analysis. Am J of Gastroenterology, 10 April 2012Masdisch 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):2650-61.Ford et al., Effect of Fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis. BMJ. 2008 Nov 13; 337:a2313Ford 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 2012Ryan 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.Up To DateComments/Questions?