Irritable Bowel Syndrome- more than a gut feeling.
You may have heard the term ‘IBS’ thrown around, and it is often associated with certain diets such as ‘gluten-free’, ‘dairy-free’ and ‘low-FODMAP’. But what is IBS, and how do you know if you have it?
Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder, that may manifest in pain and alteration of bowel habits. For some patients they may be prone to constipation, others may experience diarrhoea or un-formed stools, and a third group experience a flux between the two.
These days there is a greater awareness and acceptance of IBS amongst doctors and specialists. Back in 2004 I went to a gastroenterologist for symptoms of IBS and my condition was completely dismissed. I was told that my symptoms of bloating were merely abdominal fat and that I needed to do more stomach crunches. I developed IBS following a parasite infection from living overseas and eating contaminated food. Long after the parasite infection had left, my symptoms remained. Fortunately a lot has changed since then, and IBS is now more accepted by doctors and specialists as a functional disorder.
What is Irritable Bowel Syndrome?
Irritable Bowel Syndrome is a disease which usually manifests in symptoms of recurrent abdominal discomfort or pain as well as an alteration in consistency and frequency of bowel movements (1). The cause of IBS is unknown and the pathophysiology isn’t completely understood. In the past, IBS was thought to be purely psychosomatic as no anatomic cause can be found on laboratory tests, x-rays or biopsies. Nowadays there is more acceptance that IBS is a combination of psychosocial and physiologic factors.
How is Irritable Bowel Syndrome diagnosed?
As there is no test to confirm the presence of IBS, diagnosis is based on the exclusionof other diseases with similar symptoms (differential diagnoses) such as:
- Lactose intolerance
- Drug-induced diarrhoea
- Postcholecystectomy syndrome
- Laxative abuse
- Parasitic diseases (e.g. giardiasis)
- Eosnophilic gastritis or enteritis
- Microscopic colitis
- Small-bowel bacterial overgrowth
- Coeliac disease
- Early inflammatory bowel disease
In order to exclude the differential diagnoses listed above a patient may undergo routine blood tests, stool tests, physical examination, a colonoscopy, a sigmoidoscopy, and sometimes an ultrasound (2). If all other gastrointestinal diseases are eliminated, then IBS is then made according to the patient’s symptoms: primarily a change in the patient’s bowel patterns and the existence of abdominal pain.
Once all other potential diseases have been excluded, the treating physician may use a standardised symptom-based questionnaire to diagnosis IBS: also known as the “Rome criteria”. The Rome criteria require the presence of abdominal pain for at least 1 day/week in the last 3 months along with two or more of the following:
- Pain that is related to bowel movement.
- Pain that is associated with a change in frequency of bowel movement.
- Pain that is associated with a change in consistency of stool.
What are the causes of Irritable Bowel Syndrome?
The causes of IBS are unknown as no anatomic cause can be discovered on x-rays, biopsies or laboratory tests. However, there are certain factors that may trigger IBS and these are:
- Emotional factors such as stress
From a functional perspective, the causes of the symptoms may be due to:
- Abnormal muscle contractions in the intestine. The intestines contain layers of muscle that contract to move food through which eventually forms a stool. If the contractions are stronger or longer than normal this can cause gas, bloating or diarrhoea. Weak intestinal contractions may cause slow food transit and and lead to hard, dry stools.
- Nervous system.
What are the symptoms of IBS?
- Abdominal pain, cramping or bloating that is relieved (either partly or completely) by passing a bowel movement (3).
- Excess gas.
- Diarrhoea and/or constipation (some patients are more prone to constipation or diarrhoea whilst other patients have alternating bouts of both).
- Mucous in the stool.
Most people with IBS experience times when the symptoms are worse and other times when the symptoms improve or disappear.
How is IBS normally treated?
- Support and understanding.
- Avoidance of gas-producing and diarrhoea-producing foods.
- Increased fibre consumption for constipation.
- Drug therapy directed at the dominant symptoms. Anticholinergic drugs (e.g. hyoscyamine) may be used for their antispasmodic effects. Tricyclic antidepressants (TCAs) may help to relieve symptoms of diarrhoea, abdominal pain and bloating. Polyethylene glycol laxatives are often used for chronic constipation, whereas loperamide is more often used to relieve diarrhoea.
The brain-gut connection
Nowadays it is better understood and accepted that the gastrointestinal tract is sensitive to emotions such as anger, anxiety, sadness and happiness (4). The brain-gut axis serves as the communication channel in which the brain and intestines continually send chemical and nerve signals that can greatly affect how an individual feels.
A recent article published in Gastroenterology & Hepatology(5) details the various behavioural therapies that are used to manage IBS. The most common brain-gut therapies are Cognitive behavioural therapy (CBT) and gut-directed hypnosis. Cognitive Behavioural Therapy provides patients with strategies for reducing the stress response in their body, including diaphragmatic breathing, muscle relaxation and mindfulness techniques in order to modify their arousal or relaxation strategies. Relaxation stimulates the parasympathetic nervous system which aids with the down-regulation of pain thresholds and regulates gut motility. Similarly, gut-directed hypnosis provides patients with a tool fo coping with abdominal and bowel discomfort with gut-focused strategies whilst the body is in a relaxed state.
How does Chinese Medicine view IBS?
In Chinese Medicine, IBS can have a variety of causes, with the most common being ‘rebellious liver qi invading the spleen’ (6). This pattern has a large emotional component, with symptoms flaring when a person feels emotions such as anger, frustration and resentment. The liver qi (energy) is easily affected by these emotions, and then it stagnates and interferes with the function of digestion (which is said to be controlled by the spleen). Dysfunction in the stomach and intestines is also common in an IBS diagnosis.
Poor diet, irregular eating and eating when in a hurry or when feeling emotional or angry can cause the liver qi to rebel towards the spleen and affect digestion. These days there is an emphasis on ‘mindful eating’: savouring each bite slowly, focusing only on the food on your plate without any distractions such as a looking at a book or mobile phone.
What does the research say on Chinese medicine and IBS?
The World Journal of Gastroenterology published a meta-analysis of 6 randomised controlled trials in 2014 (6). The review found that acupuncture clearly leads to control of IBS symptoms which is both statistically characteristic and statistically significant.
A separate review investigated more broadly, the mechanisms by which acupuncture regulates the gastrointestinal (GI) function (7). The review found that acupuncture has the potential to treat gastrointestinal disorders by regulating: GI motility, the GI barrier, visceral sensitivity, and the brain-gut axis.
Moxibustion is a type of heat therapy often used in Chinese Medicine that involves burning compressed mugwort on or near a person’s skin to help alleviate various conditions involving pain and discomfort, including IBS. A review of 20 randomised-controlled trials on treating IBS with moxibustion showed moxibustion may also provide a benefit to IBS patients, and that further research is needed to confirm this (8).
A randomised-controlled trial undertaken in Australia in 2015 showed that Chinese herbal medicine may be an effective treatment in relieving IBS (9). The double-blinded trial included 125 patients with constipation-type IBS, and it found that Chinese herbal medicine increased bowel satisfaction, stool consistency and decreased straining compared with placebo.
How does Chinese medicine work with IBS?
In Chinese medicine we use acupuncture to regulate the stress response. Acupuncture is known to reduce stress which has an effect on the gastrointestinal system. Acupuncture also directly affects the gastrointestinal system by helping to relieve pain and regulate the bowel movements.
Chinese herbal medicine works on treating the symptoms and cause of IBS. Whether the predominant symptom is diarrhoea or constipation, Chinese herbs will be chosen appropriately for the individual’s pattern.
We also recommend a daily meditation practice as a way of reducing stress.
Last but not least, we work with patient to create a dietary plan, reducing foods that are potentially irritating or inflammatory. For some patients this may mean that they need to eliminate wheat and/or dairy for a period of time.
- Merck Manual (2018). “Irritable Bowel Syndrome”. Available at: https://www.msdmanuals.com/en-au/professional/gastrointestinal-disorders/irritable-bowel-syndrome-ibs/irritable-bowel-syndrome-ibs
- Mayo Clinic (2018). “Irritable Bowel Syndrome”. Available at: https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/symptoms-causes/syc-20360016
- Harvard Health Publishing (2018). ‘The gut-brain connection.’ Available at: https://www.health.harvard.edu/diseases-and-conditions/the-gut-brain-connection
- Riehl, M. (2018). ‘The Emerging Role of Brain-Gut Therapies for Irritable Bowel Syndrome.’ Gastroenterology & Hepatology14(7), 436-438.
- Maciocia, G. (2015). The Foundations of Chinese Medicine. UK: Elsevier.
- Chao, C. & Zhang, S. (2014). ‘Effectiveness of acupuncture to treat irritable bowel syndrome: a meta-analysis.’ World Journal of Gastroenterology, 20(7), Available at: https://doi.org/10.3748/wjg.v20.i7.1871
- Li, H., He, T., Xu, Q., Li, Z., Liu, Y., Li, F., Yang, B. & Liu, C. (2015). ‘Acupuncture and regulation of gastrointestinal function’. World Journal of Gastroenterology, 21(27), 8304-8313.
- Park, J., Lee, B. & Lee, H. (2013). ‘Moxibustion in the management of irritable bowel syndrome: systematic review and meta-analysis’. BMC Complementary and Alternative Medicine, 13. Available at: https://bmccomplementalternmed.biomedcentral.com/articles/10.1186/1472-6882-13-247
- Bensoussan, A., Kellow, J., Bourchier, S., Fahey, P., Shim, L., Malcolm, A. & Boyce (2015). ‘Efficacy of a Chinese Herbal Medicine in Providing Adequate Relief of Constipation-predominant Irritable Bowel Syndrome: A Randomized Controlled Trial’. Clinical Gastroenterology and Hepatology, 13(11), Pages 1946-1954.