Constipation can be a very disabling symptom. Often all that is needed is an increase in fibre but sometimes this is not effective and different approaches are required...

Alternative Rx for IBS

Glutamine is an abundant naturally occuring amino acid. It is found in many foods (from the breakdown of proteins) and is synthesized by the body. Intestinal cells use glutamine as a fuel source.
Peppermint oil has a long history of use for abdominal pain
Peppermint oil

Alternative treatment is a term that can cover a wide range of options.

  • Complementary medicine is perhaps a better term.
  • There is no doubt that alternative treatments are popular for gastrointestinal complaints - partly because of dissatisfaction with "traditional" or scientific medicine.
  • Most comments in this section refer to treatment of irritable bowel syndrome.

Gut health / cleanse / repair

  • Products labelled as treatments for gut health, gut cleanse, gut repair and leaky gut usually have multiple combinations of ingredients, such as magnesium, aloe vera and fibre (slippery elm). Some other ingredients are laxatives, such as liquorice and cascara.  
  • Other ingredients include antioxidants, such as milk thistle, which contains silymarin. This is an interesting compound that is a powerful antioxidant. It has been investigated in several studies of various liver diseases, but there is no evidence of clinical activity.
  • Some herbs have been suggested to have a special ability to help heal gut-lining damage, including slippery elm, marshmallow root and deglycyrrhizinated liquorice. There is no scientific support for these claims. 

Fuel for the gut - glutamine and butyrate

  • Glutamine is the main energy source for small bowel enterocytes, and butyrate is the energy source for the colonic epithelium. 
  • Glutamine is a common ingredient in many natural products. A small trial of glutamine supplements in post-infectious, diarrhoea-predominant irritable bowel syndrome showed a reduced IBS score, reduced daily bowel movement frequency and reduced intestinal permeability. This observed benefit may only be in this subgroup of IBS that follow an episode of gastro-enteritis or food poisoning. 
  • Butyrate, a short-chain fatty acid, is produced through microbial fermentation of dietary fibre in the colon. Butyrate has many possible beneficial effects: it helps maintain gut barrier function by stimulating mucin production, upregulating antimicrobial peptide expression, enhancing tight junction assembly and reducing colonic oxidative stress.
  • Butyrate enemas have been trialled for inflammatory bowel disease (modest benefit from rectal administration) but butyrate is not used in supplements, primarily due to an offensive odour.  

Prebiotics and alternative fibre.

  • This is the concept that dietary changes can alter the type of bacteria in the colon and that certain by-products of bacterial metabolism may be helpful.
  • The type and number of bacteria in the gut can be influenced by diet but there are still no clear recommendations in this area.
  • Ideally, a prebiotic should increase beneficial bacteria, such as Bifidobacteria, and increase butyrate-producing bacteria. Studies do not consistently show that both effects can be achieved. 
  • Resistant starch is metabolized to produce butyrate which is a "fuel" for colonic cells.
  • One formulation is wheat dextran (marketed as Benefibre)
  • There is no evidence that this approach is helpful. One problem is the production of "wind" by bacterial fermentation which is likely to aggravate irritable bowel. This is a problem common to most prebiotics.
  • Inulin is promoted as a useful prebiotic  -  the value of this additive is still unclear.
  • Inulin is a poorly absorbed carbohydrate. It is found naturally in some foods but is also added to commercial products. The ingredient list may describe inulin, oligofructose, oligofructose-enriched inulin, chicory root fibre or fructo-oligosaccharides. 
  • Extravagant claims are made for many natural products. Fermented foods, such as kimchi, sauerkraut, kefir and kombucha, are stated to help replenish beneficial bacterial species. The bacterial count in fermented foods is generally low, and any health benefits are unlikely to be due to a probiotic effect. Gastric acid will effectively sterilise any bacteria in food.

Digestive Enzyme Supplements

  • These products usually contain pancreatic enzymes as the main active ingredients.
  • Pancreatic enzymes from animal sources and other plant-based enzymes are sold as natural products. The doses of lipase and proteases in commercial supplements are very low, while plant-based enzymes have very low potency.  
  • A deficiency of pancreatic enzymes is a very rare problem - the body makes enzymes much in excess of requirement.  Pancreatic enzymes are the key to breakdown of food for absorption – gastric acid contributes very little and bile is only important for the emulsification of fats. These enzymes are produced in excess of requirements, and clinical malabsorption is observed only when more than 90 per cent of the pancreas has been severely damaged. 
  • Pancreatic enzymes are so potent they are activated once in the duodenum (first part of ther small bowel). Otherwise, auto-ingestion of pancreatic tissue would occur – this does happen in patients with acute pancreatitis.  
  • There is no suggestion of any problem with the digestion and absorption of nutrients with irritable syndrome. Therefore there is NO rationale for the use of these supplements but a few people with IBS do seem to have some benefit (this could just be a placebo response)


"Anti-inflammatory"  - diet and natural products 

  • There is no inflammatory change in the gut in the absence of disease; conditions with intestinal inflammation include inflammatory bowel disease, postinfectious IBS (subtle changes) and an uncommon condition called microscopic colitis. There is also immune-mediated inflammation of the upper small bowel in coeliac disease, which causes disruption of villi and hyperplasia of crypts.  
  • There is no definite condition of gluten sensitivity in the absence of coeliac disease, but various attempts have been made to define non-coeliac gluten sensitivity. If this condition is a real entity, there does not seem to be any inflammatory component.  
  • There are several natural products that appear to have anti-inflammatory activity in the gut. Turmeric (active ingredient is curcumin) may have some activity in IBD. 
  • There is renewed interest in anti-inflammtory and pro-inflammtory foods.  This has been dismissed as "fringe" by gastroenterologists.
  • Mediterranean diet (olive oil, fish, high fat fish like salmon), highly coloured vegetables (dark leefy green, yellow, red) may be "anti-inflammatory and "junk" food, red meat, high energy drinks may be pro-inflammatory.  A lot more work is required in this area. 

Fish Oil and Omega-3 Supplements

  • There is some evidence for an anti-inflammatory effect of these supplements.
  • Irritable bowel is not an inflammatory disorder therefore no benefit would be expected but there could be an effect for colitis.  Controlled studies have been equivocal  - some showing a positive effect; others showing no effect compared to placebo
  • Fish oil, krill oil or flax oil are high in omega-3 fatty acids.  High doses may be effective, but a benefit for functional gut problems seems unlikely. 

Peppermint Oil

  • Peppermint may have an anti-spasmodic effect on the colon - reducing lower abdominal cramping pain in irritable bowel syndrome. 
  • Peppermint also relaxes the valve at the lower end of the oesophagus and can aggravate reflux (heartburn). This is why peppermint is given out at the end of a meal in restaurants - to encourage belching and ease any pressure in the stomach - but potentially will also allow reflux of the meal (and acid).
  • To reduce this effect on the oesophagus, peppermint oil is given as an enteric-coated capsules that releases the peppermint in the small bowel and colon. This is available as Colpermin (also Mintec). It is available directly from chemists and is not funded.
  • There have been a several clinical trials showing a benefit in IBS particularly for relief of pain (presumably as the result of colonic spasm).
  • Most pain from IBS is not spasm but distension of an over-sensitive colon with wind therefore this approach will have only limited success. Overall the effects of peppermint are disappointing in my experience.  It is worth trying peppermint tea (certainly as a good substitute for coffee).
  • The success of the FODMAP diet in reducing pain from IBS suggests that reducing wind and therefore distension of the bowel is the main way to relieve pain

Chinese Herbal Remedies

  • There is beginning to be some formal evaluation of several traditional herbal approaches to IBS. To date the trials have been negative or disappointing but further work is being done.
  • Combination Chinese herbal treatments include ingredients such as barley, cardomen, licorice, rhubarb. Ginger may be given alone - minimal studies done - may decrease nausea.


  • These therapists have a good record in treating bowel symptoms from IBS and have a variety of approaches to the symptoms.  A wheat-free and diary-free diet is commonly recommended.
  • These dietary exclusions are often effective as discussed in the IBS and diet section.  Other natural treatments as discussed above are given in combination sometimes with success.
  • A more elaborate approach is a complex and detailed analysis of faecal microflora leading to a long list of potential exculsions - many overseas labs offer this service but the interpretation of results is difficult and generally not helpful in my experience.

Hypnotherapy and counseling

  • Several good studies in irritable bowel have shown that hypnotherapy is effective. This is not widely available and I have no direct experience of any beneficial results. These studies do emphasize the complex connections between mind and gut.
  • Published data suggests an 80% improvement rate (well above any other treatment - conventional or alternative) - and this effect lasts for 6 months or more after treatment completed. It does require weekly therapy over several months (high cost) and is dependent on the therapist - not many have experience in treatment of IBS.
  • There is evidence that cognitive behavioural therapy can work. This is a form of counseling (actually the most widely practiced) that concentrated on coping mechanisms.  There is even a web-based program being developed.  Would certainly be a lot cheaper. 
  • This illustrates the need to consider treatment at all levels  (from the lining of the gut to the brain).  The way we process signals from the gut is affected by stress and by our learned coping mechanisms.  We learn by our life experience some unhelpful strategies such as internalising stress as a bodily symptom  - approaches that need to be unlearnt or adjusted. 
  • There are some app-based programs for gut-directed hypnosis. Nerva is one option.
  • A helpful reference. J Psychosom Res. 2014 Jul;77(1):1-12.  Cognitive-behavioral therapy for irritable bowel syndrome: a meta-analysis. Li L, Xiong L, Zhang S, Yu Q, Chen M.


  • This has been studied in a randomised trial and a benefit was shown. This treatment may have most value if pain is the predominant symptom.
  •  Also used to treat bloating, nausea - difficult to see how this should work. Small clinical studies show contradictory results.
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