Alternative Rx for IBS Alternative Rx for IBSProbioticsCandida treatmentHerbalAllergy testsLeaky gut Peppermint oil has a long history of use for abdominal painPeppermint oilAlternative 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 refer to treatment of irritable bowel syndrome. Prebiotics and functional foods.This is the concept that dietary changes can alter the type of bacteria in the colon or 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.Resistant starch is metabolized to produce butyrate which is a "fuel" for intestinal 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.Inulin is promoted as a useful prebiotic - the value of this additive is still unclearDigestive Enzyme SupplementsThese products usually contain pancreatic enzymes as the main active ingredients. A deficiency of pancreatic enzymes is a very rare problem - the body makes enzymes much in excess of requirements.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)Fish Oil and Omega-3 SupplementsThere 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 placeboPeppermint OilPeppermint 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).I suspect that 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 suggest that reducing wind and therefore distension of the bowel is the main way to relieve pain Chinese Herbal RemediesThere 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. NaturopathyThese 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. Hypnotherapy and counsellingSeveral 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 counselling (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. AcupunctureThis 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. Inner Health Plus contains 25 billion bacteria - a mixture of Lactobacillus and Bifidobacterium. One capsule gives the equivalent of 22 servings of natural yoghurt.Friendly bacteria - probioticsProbioticsThere is some evidence to suggest that irritable bowel syndrome is an imbalance of bacteria in the colon (large bowel). In particular there may be an over abundance of bacteria that produce gases by fermentation. This imbalance can be aggravated by frequent antibiotic treatment, a gastroenteritis infection or prolonged exposure to less hygienic foods - living in an underdeveloped country for months or years. One approach is to try to selectively change the bacterial flora by taking a "selective antibiotic". In the USA an antibiotic drug called Rifaxin (rifaxamin) is promoted for IBS. This is not yet available in NZ and the results are debated; also very expensive. Taking probiotics ("nice" or helpful bacteria) is a concept that has been tried and studied for at least 30 years. The problem has been knowing what strain or strains of bacteria to test and knowing how much is required to be taken to have an effect.Another problem is developing a strain of bacteria that has a reasonable shelf life and one that is able to resist digestion by gastric acid (one of the main roles of acid is to sterilize food coming into the stomach).Probiotics probably have a wide range of effects - there may be a direct effect on the gut that enhances healing, reduces inflammation and reduces permeabilty (leaky gut). Much of this work is preliminary but is often translated into unsupported claims by manufacturers A range of probiotics are available. Only some of these are supported by any scientific data. The product availability is increasing all the time. Natural yoghurts do contain Lactobacillus acidophilus and Bifidobacterium - this may be helpful. However the amounts of bacteria are probably be too small to have any effect (10-100 million per serve). It may be that these "bacteria" have to be taken as capsules or powders to get a sufficient dose. I recommend Inner Health Plus which has 25 billion bacteria ( a combination of Lactobacillus acidophilus and Bifidobacterium). Even this amount of bacteria is small compared with the 14 trillion bacteria in the colon (14,000 billion) It is possible that different strains of probiotic will be needed for different problems. There are a number trials of Lactobacillus plantarum showing some benefit. Available in NZ as "IBS Support" by Ethical NutrientsThere is no evidence that these bacteria colonize in the colon (that is set up home!). They seem to pass on through. This means that the effect will only be demonstrated while taking the "bacteria". Once the probiotic is stopped - theoretically the benefit will cease. Uses of probiotics The most convincing scientific data is for the prevention of antibiotic-associated diarrhoea. The probiotic has to be started before taking the antibiotics but can shorten the duration of diarrhoea if continued for 2 weeks. Trials in irritable bowel are less convincing but there is enough evidence to suggest there may be an effect. There are some studies in colitis and Crohn's disease. There are some positive studies and it is worth trying probiotics in combination with medical treatmentThere is a formulation called VSL#3 which has been studied in colitis and also in a particular problem called pouchitis. The study for pouchitis showed a clear benefit and this was a major boost for the idea of benefit from probiotcs. It is clear from this study that the probiotic needed to be taken long-term and was only effective for preventing episodes of pouchitis. This formulation is expensive (about $5 per sachet). It is available through some pharmacies and also online. Search online for nearest supplier. More information can be obtained from the website. This is a combination of 8 different strains of bacteria - total bacterial count is over 400 Billion - much more than other products. There is no risk of infection or any side-effect with this type of treatment. The success of this product has lead to the suggestion that combinations are the best option. It is likely that different strains have activity through different mechanismsClaims about diet and CandidaCandida albicans under a microscopeCandida albicans growing in a diskCandida and other possible infections The idea of an overgrowth of candida in the bowel has been proposed for many years (initial proposal in 1978 by Dr Orian Truss) but is not supported by much evidence. The original concept was that many symptoms such as IBS, tiredness, pre-menstrual syndrome, headache etc could be explained by a diffuse hypersensitivity to Candida. The treatment trials with nystatin (an anti-fungal) are conflicting and in my view unimpressive. Small doses of nystatin are used in some homeopathy treatments and are very unlikely to have any benefit. Diets that are low in pure or refined sugars may be helpful. This is not because of a reduction in yeast / candida in the bowel but may be because bacterial fermentation and gas production is decreased (see diet and IBS section). There has been some interest in the role of protozoa infections that may persist after exposure to unhygienic food - usually during overseas travel. The organisms of most interest have been Entomoeba coli, Blastocystis hominis, and Dientamoeba fragilis. It is generally considered that all these organisms are non-pathogenic - that is they do not have any adverse effect. Certainly is has been my experience that irritable bowel symptoms do NOT improve after antibiotic treatment for these organisms. Giardia lambda is a protozoan infection that is a common cause of acute diarrhoea. Symptoms may persist for several months (less common). More long-term symptoms (over several years) are very unlikely to be due to Giardia infection in the past. There is no doubt that irritable bowel can follow a gastroenteritis illness but this is not due to persisting infection - see IBS section .Aloe vera juice may have anti-spasm properties and is a mild laxativeSlippery elm powderSlippery elmHerbal treatmentsAloe Vera JuiceParts of the aloe vera succulent have been used for medicinal purposes for centuries. There is a gel that has been used to encourage wound healing. An extract from the leaf can be taken orally (as a juice).There is has some supporting evidence for aloe vera juice in irritable and constipation. It is a mild laxative and also has some anti-spasmodic effects.Aloe vera can be combined with kiwifruit if constipation is a major problem . This is available as a juice by Nekta - a NZ fruit juice company and available in supermarkets Herbal teaThe benefit of herbal tea is the resulting reduction in coffee intake. There is no data for green tea. Camomille tea has an anti-spasm effect Slippery ElmThis is mainly a laxative and therefore only beneficial in constipation or irritable bowel with predominant constipation. It is available through health food outlets.Other herbsBoswellia has some anti-inflammatory properties and has been advocated for inflammatory bowel diseaseSkin prick allergy tests - the results don't seem to correlate with foods that causes IBSFood allergy has a limited role in IBS Skin prick tests with various food substances is commonly suggested and may reveal some positive results. The problem is that dietary exclusion based on these results usually does not result in improvement in irritable bowel. It can lead to unnecessary exclusions and a very restricted diet.It is better to base dietary exclusion on foods that have been commonly reported to cause problems. At this stage there is no shortcut - it is a matter of trial and error (see section on diet and IBS). It is thought that allergy plays little part in IBS. Allergy tests with food substances placed directly on the bowel could be revealing but this is not practical!!Leaky gutThis is concept that has some scientific evidence but this limited data is often extrapolated or extended way beyond our current knowledgeThe lining of the bowel - but small and large bowel mucosa - has a remarkable ability to absorb nutrients but to also maintain a barrier to gut bacteria.This barrier function is known to break down with severe illness leading to migration of gut bacteria into the circulation with severe consequences - this leaky gut in a medical, scientific sense.The concept promoted by more alternative therapists is somewhat differentThat is the food intolerances or allergies that is left "unmanaged" leads to a breakdown of the gut barrier in an otherwise healthy person. This then leads to migration of bacteria or other toxins (unspecified) into the rest of the body leading to general illhealth - tiredness, headaches, bloating etc. There is no evidence for this concept - however it is clear that dietary exclusions can help IBS symptoms and therefore some foods are triggers for this condition. The question is what is the mechanism for this "triggering" by certain foods. There are probably several mechanisms involved. Leaky gut could be one mechanism but there is no supported evidence in IBS - what evidence there is comes from people with severe illness. We know that excess fermentation of poorly absorbed carbohydrates causes symptoms - this is why the FODMAP diet works.There are other foods outside of the FODMAP diet that are triggers for some people.Red meat is often more of the problem that chicken and fish - ? why. Breakdown products are different for red meats.Coffee and spicey foods are direct irritants - perhaps through stimulation directly of some gut sensors or receptorsSmall bowel bacterial overgrowthThis is an associated concept promoted by some gastroenterologists as well as alternative therapistsThe small bowel usually has low numbers of bacteria compared to very high bacterial load in the colon (10 trillion bacteria). This low number is maintained by active peristalsis, a valve between the small and large bowel preventing backward movement of faecal contents and anti-bacterial substances secreted by the small bowel Increased bacteria in the small bowel could disrupt the barrier function leading to "leaky gut". In addition there will be increased fermentation in the small bowel as the bacteria has access to a rich nutrient supply.Increased fermentation will lead to bloating and abdominal painThis is an attractive concept to explain some of the symptoms with IBS. The difficulty is proving is this really exists as a problem in IBS. It certainly can be a problem when gut peristalsis (active forward movement) is impaired by various diseases.Tests for this condition have major problems with interpretation. The commonest test used in practice is the lactulose hydrogen breath test. An increased and early peak of H2 (hydrogen) may represent bacteria metabolizing lactulose in the small bowel. However if the lactulose passes rapidly through the small bowel then there will be an identical result.This is a simple test (although requires 3 hours of breath sampling and analysis) and is offered in some gastroenterology practices. At this stage I am unconvinced of the accuracy of this testThe next question is what to do with a positive result (if you believe it is meaningful and reliable). In general frequent antibiotics aggravate IBS by altering the normal balance of gut bacteria. The ideal antibiotic would be confined to the gut (i.e not absorbed) and reducing small bowel bacteria without disrupting bacterial balance in the colon. The closest agent we have is rifaxamin. This is available in NZ but not funded for IBS because it is very expensive. The data is support of this treatment is liited to a few centres in the world that are enthusiats and as yet this treatment has not gains widespread support. Two weeks of treatment may give relief for several months but it is not clear how to manage symptoms in the longer term - how often to give antibiotics and does the treatment continue to work after multiple courses. What is the impact of bacterial resistance to antibiotics.So watch this space. A few people with IBS do report some benefit after antibiotics given for other reasons. This is not the norm but can happen. Occasionally metronidazole can be helpful.