GASTROENTEROLOGY

A natural approach to IBS, backed by science

Motility disorders, which can affect any part of the gastrointestinal (GI) tract, are characterised by abnormal movements, causing the abnormal transit of contents - either too fast or too slow - in the absence of mucosal disease or obstruction. Motility is a huge problem in irritable bowel syndrome (IBS), one of the most common disorders of gut–brain interaction worldwide. 1,3

IBS is defined according to patterns of GI symptoms. Rome IV defines IBS as a functional bowel disorder in which recurrent abdominal pain is associated with defecation or a change in bowel habits. 1,2

Disordered bowel habits are typically present (eg constipation, diarrhoea or a mix of constipation and diarrhoea), as are symptoms of abdominal bloating/distension. Symptom onset should occur at least six months prior to diagnosis and symptoms should be present during the last three months. 2

IBS subtypes

Patients with IBS are classified into specific subtypes, which is based on the predominant bowel habit. Classifying patients according to these subtypes can aid clinicians in decisionmaking regarding management.

The four subtypes are: 1 IBS with predominant constipation (IBS-C) 2

IBS with predominant diarrhoea (IBS-D)

3

With mixed bowel habits (IBS-M)

4

IBS, unsubtyped.

More than 50% of patients with IBS have either IBS-D or IBS-M. Bristol stool types 1 and 2 or types 6 and 7 are considered abnormal. 2,5 number of reasons: 2 » Symptoms may change over time, and these fluctuations may make the clinician feel as if the disorder is more complicated than it truly is » Symptoms of IBS may mimic other disorders (eg lactose or fructose intolerance) and thus may fail to respond to empiric treatment » Clinicians may not be aware of current guidelines or definitions on how to properly make the diagnosis of IBS » A precise biomarker for IBS does not exist — patients may have persistent or recurrent symptoms but clinicians cannot order a test to confidently diagnose the condition » Patients may want testing to identify the cause of their symptoms, although routine tests generally result as normal, which is frustrating to the patient, since symptoms persist.

What causes IBS?

Although it is still unclear what causes IBS, numerous studies have postulated that enteric infections, immunomodulation, visceral hypersensitivity, and an imbalance in neurotransmitters may all play a role in the development of IBS. 14

Importantly, alterations in the gut microbiota can induce changes in gut motility, permeability, food processing and visceral perception which eventually leads to the occurrence of IBS-related symptoms. 14

Studies have also shown that IBS patients experience bacterial overgrowth in the small intestine or altered GI microbes. A meta-analysis observed that patients with IBS (particularly IBS-D) have significantly reduced GI colonies of Bifidobacterium, Lactobacillus and Faecalibacterium prausnitzii bacteria compared to healthy individuals. 14

Furthermore, the link between GI microbial disruption and IBS is corroborated by the fact that 10%–53% of patients are diagnosed with IBS following a GI infection. 14

How is IBS treated?

Management of IBS is complicated due to the lack of consensus regarding the causes of IBS, states the World Gastroenterology Organisation (WGO). As a result, no single treatment is currently regarded as being universally applicable to the management of IBS patients. 4

Treatment goals are aimed at resolving symptoms such as pain, bloating, cramping, and diarrhoea or constipation. Pharmacotherapy includes: 4,7 » Antispasmodics for pain » Laxatives, fibre, and bulking agents for constipation » Fibre, bulking agents, and anti-diarrheals for diarrhea » Charcoal resins, antiflatulents, and other agents are widely used, although without supporting evidence, for bloating, distension, and flatulence » Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) are effective for symptom relief in IBS. Adverse effects are common, with

86%

4

4

Figure 1: Abnormal bowel movements are classified using the Bristol stool form scale

Type 1

Separate hard lumps, like nuts (hard to pass)

Type 2

Sausage-shaped but lumpy

Type 5

Soft blobs with clear-cut edges (passed easily)

Type 6

Fluffy pieces with ragged edges, a mushy stool

Type 3

Like a sausage but with cracks on its surface

Type 4

Like a sausage or snake, smooth and soft

Type 7

Watery, no solid pieces, entirely liquid

drowsiness and dizziness the most common, and may limit patient tolerance. TCAs are associated with significant adverse effects in treating IBS-D and should be avoided in

IBS-C. Clinicians should expect one adverse effect for every three patients who benefit from therapy » SSRIs may be considered in resistant IBS-C, although it is not currently recommended that SSRIs should be routinely prescribed for

IBS in patients without comorbid psychiatric conditions, because of conflicting and limited data regarding efficacy, safety, and long-term outcomes. Apart from pharmacotherapy, the WGO also recommends the incorporation of nonpharmacological treatment into the management strategy, which the body says are often ignored.

These include for example dietary changes and psychological intervention such as behavioural therapies. A meta-analysis has demonstrated significant benefit of the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols or FODSMAP diet in improving functional GI symptoms in IBS patients. Overall these studies suggest the low FODMAP diet is effective in reducing IBS symptoms in 50%-80% of people. Furthermore, the WGO supports herbal therapies, which it says appear to show a benefit. 4

Steps the clinician can take to positively influence treatment outcome: 4 » Acknowledging the disease » Educating the patient about IBS » Reassuring the patient.

How effective is pharmacotherapy?

Because IBS is a symptom-based disorder, no therapy has been shown to alter the long-term natural course of the condition and no goldstandard for treatment exists. 7

Although some studies have shown that targeted pharmacotherapy do alleviate some symptoms, others report that these therapies are ‘largely unfruitful’ due to a lack of clarity regarding local GI nervous system and central modulation mechanisms involved in visceral hyperalgesia, as well as the multiple neurotransmitters involved in this hypersensitive state. As a result, many patients prefer to avoid medications and desire alternative approaches. 8

What natural alternatives are available and how effective are they?

According to Bokic et al, one way of meeting the challenge of IBS treatment is the use of herbal medicine. A study by Chedid et al showed that herbal therapy was as effective as rifaximin, an antibiotic used to treat IBS, traveller’s diarrhoea, and hepatic encephalopathy. 6,9

Rome IV defines IBS as a functional bowel disorder in which recurrent abdominal pain is associated with defecation or a change in bowel habits.

Ginger (Zingiber officinalis) has been used as far back as the fourth century BC for stomach aches, nausea, and diarrhoea. Bundy et al investigated whether artichoke (Cynara cardunculus) leaf extract can ameliorate symptoms in IBS patients (n=208) with concomitant dyspepsia. A subset analysis of a previous dose-ranging, open, postal study, in adults suffering dyspepsia. Incidence, selfreported usual bowel pattern, and the Nepean Dyspepsia Index (NDI) were compared before and after a two-month intervention period. There was a significant fall in IBS incidence of 26.4% after treatment. A significant shift in self-reported usual bowel pattern away from alternating constipation/diarrhoea toward normal was observed. NDI total symptom score significantly decreased by 41% after treatment. Similarly, there was a significant 20% improvement in the NDI total QOL score in the subset after treatment. 10,11

A 2015 study by Giacosa et al looked at the effect of a combination of ginger and artichoke supplementation on patients (n=126) with functional dyspepsia. The supplement and placebo over a period of four weeks was performed. Two capsules/day were supplied (before lunch and dinner) to patients (supplementation/placebo). After 14 days of treatment, only the supplementation group showed a significant amelioration. At the end of the study, the advantage of supplementation versus placebo persists without variation. The researchers reported significant improvements in nausea, epigastric fullness, epigastric pain, and bloating in the supplementation group. They concluded that the combination of ginger and artichoke appears safe and efficacious in the treatment of functional dyspepsia and represents a promising treatment. 12

Lazzini et al (2016) looked at the effect of a ginger and artichoke extract supplement on gastric motility. This was a randomised, crossover study comparing supplementation with a ginger and artichoke combination therapy and placebo. Each participant underwent two evaluations, at a seven-day interval. Ten minutes before the main meal, the baseline area of gastric volume was determined by ultrasonography. The subject was then given one supplement or placebo capsule, and then consumed a standardised meal. One hour after the meal, the gastric volume was measured again. Two weeks after the second evaluation, three subjects repeated the abovementioned procedures taking two capsules of the supplement. The researchers reported that at baseline, the mean gastric area was 3.2 ± 0.5 cm2 after the meal. Patients taking the supplementation had an after-meal gastric area that was significantly smaller (-24%) compared to the placebo group. They concluded that the combination of ginger and artichoke significantly promotes gastric emptying without being associated with notable adverse effects. 13

Conclusion

IBS affects around one in 10 people globally. The causes of IBS are not clear. IBS is characterised by symptoms such as constipation, diarrhoea, as well as abdominal bloating, distension, and pain. IBS treatment is directed at the alleviation of symptoms and pharmacological treatment has been shown to have some limitations, prompting an increasing number of patients to seek alternative therapies. These therapies have been shown to improve nausea, bloating, gastric emptying as well as epigastric fullness and pain, which resulted in significant improvements in QoL.

References:

1. Black CJ and Ford AC. Global burden of irritable bowel syndrome: trends, predictions, and risk factors. Nature Reviews Gastroenterology & Hepatology, 2020. 2. Lacy BE and Patel NK. Rome Criteria and a

Diagnostic Approach to Irritable Bowel Syndrome.

Journal of Clinical Medicine, 2017. 3. Bolen B. Motility Dysfunction in Irritable Bowel

Syndrome (IBS). https://www.verywellhealth.com/ motility-dysfunction-in-ibs-1945280 4. World Gastroenterology Organisation

Global Guidelines. Irritable Bowel Syndrome: a Global Perspective. https://www. worldgastroenterology.org/guidelines/globalguidelines/irritable-bowel-syndrome-ibs/ irritable-bowel-syndrome-ibs-english 5. Black CJ, Burr NE, Camilleri M et al. Efficacy of

Pharmacological Therapies in Patients With IBS

With Diarrhoea or Mixed Stool Pattern: Systematic

Review and Network Meta-Analysis. Gut, 2020. 6. Bokic T, Storr M and Schicho R. Potential causes and present pharmacotherapy of irritable bowel syndrome (IBS): an overview. Pharmacology, 2015. 7. Patel N and Shackelford K. Irritable Bowel Syndrome. [Updated 2020 Jan 3]. In: StatPearls [Internet].

Treasure Island (FL): StatPearls Publishing, 2020. 8. Werlang ME, Palmer WC and Lacy BE. Irritable

Bowel Syndrome and Dietary Interventions.

Gastroenterol Hepatol, 2019. 9. Chedid V, Dhalla S, Clarke JO et al. Rifaximin for the

Treatment of Small Intestinal Bacterial Overgrowth.

Glob Adv Health Med, 2014. 10. Weydert JA. Recurring Abdominal Pain in Pediatrics.

Integrative Medicine (Fourth Edition), 2018. 11. Bundy R, Walker A, Middleton R et al. Artichoke

Leaf Extract Reduces Symptoms of Irritable

Bowel Syndrome and Improves Quality of Life in Otherwise Healthy Volunteers Suffering from

Concomitant Dyspepsia: A Subset Analysis. Journal of

Alternative and Complementary Medicine, 2004. 12. Giacosa A, Guido D, Grassi M et al. The effect of ginger (Zingiber officinalis) and artichoke (Cynara cardunculus) extract supplementation on functional dyspepsia: a randomised, double-blind, and placebocontrolled clinical trial. Evid Based. Complement

Alternat Med, 2015 13. Lazzini S, Polinelli W, Riva A et al. The effect of ginger (Zingiber officinalis) and artichoke (Cynara cardunculus) extract supplementation on gastric motility: a pilot randomized study in healthy volunteers. European Review for Medical and

Pharmacological Sciences, 2016. 14. Asha MZ and Khalil SFH. Efficacy and Safety of Probiotics, Prebiotics and Synbiotics in the

Treatment of Irritable Bowel Syndrome. Sultan

Qaboos University Medical Journal, 2020. SF

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