Imagine waking up every day with a sense of dread, uncertain if today will be the day when your digestive system decides to rebel once again. For millions of individuals worldwide, this is the daily reality of living with Irritable Bowel Syndrome (IBS). As a naturopathic doctor whose battled with her own IBS journey, I made it my mission to help those grappling with this condition. I understand the profound impact IBS can have on your life to the point that social connections, nourishing your body, and achieving your dreams become far out of reach. In this blog, we will delve into the troubling symptoms of IBS and explore a holistic approach to help you find relief and regain control of your life.
The Unpredictable World of IBS
IBS is a complex and often mystifying gastrointestinal disorder. It doesn't discriminate, affecting people of all ages and backgrounds. The symptoms are as diverse as the individuals they afflict, making it challenging to diagnose and manage effectively.
1. Abdominal Pain and Cramping: The hallmark of IBS, abdominal pain and cramping can range from mild discomfort to debilitating agony. These unpredictable episodes can strike at any moment, leaving you anxious about when the next one will occur.
2. Bloating and Gas: Persistent bloating and excessive gas can lead to social discomfort and embarrassment, preventing you from fully enjoying your social life and affecting your self-esteem.
3. Diarrhea or Constipation: IBS is often categorized into subtypes, one of which includes diarrhea-predominant IBS (IBS-D) and constipation-predominant IBS (IBS-C). Sufferers of IBS-D experience frequent, urgent bowel movements, while IBS-C can lead to infrequent and painful constipation.
4. Alternating Symptoms: For some, IBS presents as a bewildering combination of both diarrhea and constipation, causing even more uncertainty and distress.
5. Fatigue and Anxiety: The physical symptoms of IBS often lead to emotional distress, including anxiety and depression. Living with the constant uncertainty of when symptoms will strike can be mentally exhausting.
The Impact on Daily Life
Living with IBS can feel like an endless rollercoaster ride, with symptoms dictating your daily activities and social engagements. You may find yourself avoiding certain foods, canceling plans, or even missing work or school due to the unpredictable nature of your condition. Relationships can suffer as you struggle to explain the invisible battles raging within your body to friends and family.
Diagnosing IBS
Irritable Bowel Syndrome (IBS) is a gastrointestinal disorder diagnosed through a combination of clinical evaluation, medical history assessment, and specific criteria, including the Rome Criteria. Here, we'll explore how IBS is diagnosed conventionally and how the Rome Criteria are used in the diagnostic process.
Conventional Diagnosis of IBS
Medical History and Symptoms Assessment: The diagnostic process typically begins with a thorough medical history and symptom assessment. Your healthcare provider will ask about your symptoms, their duration, and any associated factors such as changes in bowel habits, abdominal pain or discomfort, bloating, and the presence of mucus in stools.
Physical Examination: A physical examination may be performed to rule out other potential causes of your symptoms. This can include checking for signs of inflammation, masses, or abdominal tenderness.
Exclusion of Other Conditions: To diagnose IBS, other gastrointestinal conditions with similar symptoms, such as inflammatory bowel disease (IBD), celiac disease, or colorectal cancer, must be ruled out. This often involves additional tests and investigations, including blood tests, stool tests, imaging studies (like colonoscopy or endoscopy), and sometimes biopsies.
Rome Criteria: The Rome Criteria are a set of standardized diagnostic criteria that have been developed to aid in the diagnosis of functional gastrointestinal disorders, including IBS.
Blood Tests: Although there are no specific blood tests to diagnose IBS, blood work may be ordered to rule out other potential causes of gastrointestinal symptoms. These tests may include a complete blood count (CBC), liver function tests, and tests for markers of inflammation.
Stool Tests: Stool samples may be analyzed to rule out infections, malabsorption disorders, or other gastrointestinal conditions that could mimic IBS symptoms.
Imaging Studies: In some cases, imaging studies like X-rays, ultrasounds, or CT scans may be conducted to evaluate the gastrointestinal tract and rule out structural abnormalities or other conditions.
Endoscopic Procedures (If Needed): In certain situations, if your symptoms are atypical or if there are concerns about other gastrointestinal conditions, your healthcare provider may recommend an upper endoscopy or colonoscopy. During these procedures, a flexible tube with a camera is used to visualize the upper or lower gastrointestinal tract, and biopsies may be taken if necessary to rule out other conditions.
Using the Rome Criteria for IBS Diagnosis
The Rome Criteria help healthcare providers make a diagnosis of IBS based primarily on the pattern and characteristics of your symptoms. The Rome Criteria have evolved over time, with different versions (e.g., Rome I, Rome II, Rome III, Rome IV) offering updated guidelines for diagnosis.
The Rome IV criteria, which were the most recent at my knowledge cutoff date in September 2021, are divided into four subtypes based on the predominant bowel habit:
IBS with Constipation (IBS-C): Criteria include abdominal pain or discomfort at least once per week in the last three months, associated with two or more of the following: straining during bowel movements, lumpy or hard stools, and a sensation of incomplete evacuation.
IBS with Diarrhea (IBS-D): Criteria include abdominal pain or discomfort at least once per week in the last three months, associated with loose or watery stools, urgency, and frequency of bowel movements.
Mixed IBS (IBS-M): Criteria include abdominal pain or discomfort at least once per week in the last three months, with a combination of symptoms from both IBS-C and IBS-D subtypes.
Unsubtyped IBS (IBS-U): Criteria include abdominal pain or discomfort at least once per week in the last three months, but the specific subtype cannot be determined based on the symptoms.
It's important to note that the Rome Criteria help guide the diagnosis but do not replace the need for a comprehensive evaluation that includes ruling out other medical conditions. Additionally, diagnosis and classification may evolve as new iterations of the Rome Criteria are developed.
Along with the new Rome IV diagnostic criteria, the Rome Foundation will be publishing a number of complementary tools to assist medical professionals in using the new system. These include 5 books: The Rome IV Diagnostic Algorithms, The Rome IV Multidimensional Clinical Profile (MDCP), Rome IV for Primary Care and Non GI Clinicians, Rome IV Pediatric Functional GI Disorders, and a book on validated adult and pediatric questionnaires. Together, these materials are meant to provide better background information to physicians and patients working to establish precise diagnoses and find targeted, personalized treatment that works.
Other diagnoses to consider in patients with IBS symptoms:
Celiac's Disease an autoimmune disorder characterized by a heightened immune response to the consumption of gluten, a protein found in wheat, barley, rye, and their derivatives. This immune reaction triggers inflammation and damage to the small intestine's lining, specifically the villi, which are tiny finger-like projections responsible for nutrient absorption.
Inflammatory Bowel Disease (IBD), which includes Ulcerative Colitis (UC) and Crohn's Disease (CD). These conditions involve chronic inflammation of the gastrointestinal tract and can cause symptoms similar to IBS, such as abdominal pain, diarrhea, and bloating. Distinguishing between IBD and IBS is crucial, as their management and treatment differ significantly.
Diverticulitis is a medical condition that occurs when small pouches called diverticula, which can form in the walls of the colon (large intestine), become inflamed or infected. These pouches are known as diverticula, and the condition where they become inflamed is referred to as diverticulitis. Diverticulitis is a common gastrointestinal problem, especially in older adults.
Gastrointestinal infections such as bacterial or parasitic infections, can cause symptoms similar to IBS, including diarrhea, abdominal pain, and bloating. In some cases, a stool test may be necessary to identify the presence of an infection.
Gastrointestinal motility disorders Conditions like gastroparesis (delayed stomach emptying) and chronic intestinal pseudo-obstruction can lead to symptoms resembling IBS. Diagnostic tests such as gastric emptying studies may be needed to evaluate motility disorders.
Small Intestinal Bacterial Overgrowth (SIBO) and or Small Intestinal Fungal Overgrowth (SIFO) characterized by an excessive growth of bacteria and or yeast in the small intestine. Normally, the small intestine contains relatively few bacteria compared to the large intestine (colon). However, in SIBO, there is an overgrowth of bacteria in the small intestine, which can lead to various gastrointestinal symptoms and other health issues. Typically bloating is worse after eating or at night and best in the morning before eating.
Causes of SIBO/ SIFO:
Impaired Motility: Conditions that affect the normal movement of the small intestine, such as gastrointestinal surgery, certain medications, or neurological disorders, can lead to SIBO.
Structural Abnormalities: Anatomical abnormalities in the small intestine, like strictures or diverticula, can create stagnant areas where bacteria can accumulate.
Dysfunction of the Ileocecal Valve: The ileocecal valve normally acts as a barrier to prevent the backflow of colonic contents into the small intestine. Dysfunction of this valve can contribute to SIBO.
Low Stomach Acid: Reduced stomach acid production can allow bacteria to survive passage through the stomach and enter the small intestine.
Impaired Immune Function: Conditions that weaken the immune system can make the body less effective at controlling bacterial overgrowth.
Diet which does not support healthy bacteria such as one high in processed foods, sugars and inadequate fruits, vegetables, insoluble and soluble fibres. This can also contribute to fungal overgrowth.
Dysbiosis: Any of the above cause an imbalance in type and amount of bacteria in the small intestine. When good bacteria is limited, it allows yeast to overgrow.
Microscopic colitis an inflammatory condition of the colon that can cause chronic diarrhea, similar to IBS-D. Diagnosis typically involves colonoscopy with biopsies to identify characteristic changes.
Bile acid malabsorption can lead to diarrhea and abdominal discomfort, similar to IBS-D
Food Intolerances such as lactose intolerance or fructose malabsorption, can cause gastrointestinal symptoms like bloating, diarrhea, and abdominal pain. Elimination diets and breath tests can help diagnose these conditions.
Functional Gastrointestinal Disorders such as functional dyspepsia or functional constipation, may coexist with IBS or have similar symptoms.
Endometriosis: In some cases, endometriosis can lead to symptoms that mimic IBS, such as abdominal pain and changes in bowel habits. A gynecological evaluation may be necessary to rule out endometriosis.
Psychological Conditions: Psychological factors, such as anxiety and depression, can exacerbate or mimic IBS symptoms. It's essential to consider the impact of mental health on gastrointestinal symptoms.
Diagnosing IBS involves a process of exclusion, where other potential causes of symptoms are ruled out through medical history, physical examination, laboratory tests, and, in some cases, endoscopic procedures. If results are negative but the patient is suffering, the diagnosis is often deduced via symptoms by going through the ROME III criteria.
Causes of IBS
IBS is a complex and heterogeneous condition, meaning that the factors contributing to it can vary from person to person. Additionally, the exact cause of IBS is still under investigation, and new insights continue to emerge. Several potential contributing factors have been identified:
Gastrointestinal Motility Issues: One of the leading theories is that IBS may be related to abnormal gastrointestinal motility, which can lead to changes in the frequency and intensity of bowel movements. Some individuals with IBS experience spasms or abnormal contractions of the intestinal muscles.
Visceral Hypersensitivity: People with IBS may have a heightened sensitivity to pain in the gastrointestinal tract. Even normal contractions and movements of the intestines can be perceived as painful or uncomfortable.
Altered Gut Microbiota: Research suggests that changes in the composition of the gut microbiota (the community of microorganisms in the intestines) may play a role in IBS. An imbalance in the gut microbiome could lead to gastrointestinal symptoms and inflammation.
Dietary Factors: Certain dietary factors can trigger or exacerbate IBS symptoms. Common triggers include high-fat foods, certain types of carbohydrates (FODMAPs), caffeine, alcohol, and spicy foods. However, dietary triggers can vary widely among individuals.
Food Intolerances: Food intolerances, such as lactose intolerance or fructose malabsorption, can lead to gastrointestinal symptoms that mimic IBS. Some individuals with IBS may have underlying food intolerances that contribute to their symptoms.
Stress and Anxiety: Stress and anxiety can exacerbate IBS symptoms in some individuals. The gut-brain connection plays a significant role, and emotional stress can trigger or worsen gastrointestinal symptoms.
Infections: Gastrointestinal infections, such as food poisoning, can lead to IBS-like symptoms in some cases. This is known as post-infectious IBS (PI-IBS), where symptoms persist long after the infection has resolved.
Hormonal Factors: Hormonal changes, particularly in women, can influence IBS symptoms. Some women experience worsening symptoms during their menstrual cycle.
Genetics: There may be a genetic component to IBS, as it tends to run in families. However, specific genetic factors have not been definitively identified.
Abnormal Immune Response: Some research suggests that an abnormal immune response in the gut may contribute to IBS, particularly in individuals with post-infectious IBS.
Holistic Approach to IBS
Now that we've explored the symptoms and the profound impact of IBS, it's essential to emphasize that you're not alone in this journey. I understand that treating IBS is not just about alleviating physical symptoms but also addressing the emotional toll it takes on your well-being. Management of IBS often involves identifying triggers and implementing a personalized treatment plan that may include dietary modifications, stress management, medications, and lifestyle changes to alleviate symptoms and improve quality of life.
The best diet for irritable bowel syndrome (IBS) can vary from person to person, as IBS symptoms and triggers can differ widely. However, dietary modifications can be an essential part of managing IBS symptoms. It's often helpful to work with a healthcare provider or registered dietitian to develop a personalized dietary plan based on your specific symptoms and needs. Here are some dietary approaches that can be beneficial for managing IBS:
Low-FODMAP Diet: FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyol) are certain types of carbohydrates found in various foods that can trigger IBS symptoms in some individuals. A low-FODMAP diet involves limiting or avoiding high-FODMAP foods for a period and then gradually reintroducing them to identify specific triggers. FODMAPs include foods like certain fruits (e.g., apples, pears), vegetables (e.g., onions, garlic), dairy products, and grains. No patient should stay on a low FODMAP diet longer than 6 months as it can be extremely limiting in nutrients and calories. It is also a very difficult diet to adhere to. An antimicrobial protocol has been devised to help treat SIBO.
Soluble Fiber: Soluble fiber can help regulate bowel movements and ease symptoms of IBS, particularly for those with constipation-predominant IBS (IBS-C). Foods high in soluble fiber include oats, psyllium husk, beans, and certain fruits (e.g., bananas, berries).
Probiotics: Probiotics are beneficial bacteria that may help improve gut health and IBS symptoms in some individuals. Consult with a healthcare provider to determine if a specific probiotic strain may be suitable for you.
Small, Frequent Meals: Eating smaller, more frequent meals rather than large meals can help prevent overloading the digestive system and reduce the likelihood of symptoms.
Hydration: Staying well-hydrated is essential for managing IBS symptoms. Proper hydration helps maintain regular bowel movements and prevent constipation.
Limiting Trigger Foods: Keep a food diary to identify specific trigger foods that exacerbate your IBS symptoms. Common trigger foods include high-fat foods, caffeine, alcohol, spicy foods, carbonated beverages, and artificial sweeteners.
Gluten-Free Diet (For Those with Non-Celiac Gluten Sensitivity): Some individuals with IBS may benefit from a gluten-free diet, even if they do not have celiac disease. This approach should be discussed with a healthcare provider and a registered dietitian to ensure proper nutritional balance.
Mindful Eating: Practicing mindful eating techniques, such as eating slowly, chewing thoroughly, and paying attention to hunger and fullness cues, can help reduce symptoms triggered by eating.
Stress Management: Stress and anxiety can exacerbate IBS symptoms. Incorporating stress management techniques like relaxation exercises, yoga, meditation, or counseling may be beneficial.
Individualized Approach: IBS is highly individual, and what works for one person may not work for another. Working with a healthcare provider and a registered dietitian to develop a customized dietary plan based on your specific symptoms and triggers is essential.
It's important to note that IBS management may require a combination of dietary, lifestyle, and, in some cases, medication-based approaches. Additionally, self-diagnosis and self-initiated dietary changes are not recommended. Consulting with healthcare professionals can ensure that your dietary modifications are appropriate and safe for your specific condition.
Functional Medicine & Naturopathic Medicine Approach to the Treatment of IBS
Herbal and Nutraceutical Treatment Approaches
Anti-Microbial Treatments:
Garlic (Allium sativum): Garlic is well-known for its antimicrobial properties. It contains allicin, a compound with antibacterial, antiviral, and antifungal properties. Garlic is often used to support immune health and combat infections. In SIBO, as garlic is a high FODMAP food, it is not well-tolerated. Allicin, its constituent is often used to bypass it's undesirable symptoms.
Goldenseal (Hydrastis canadensis): Goldenseal contains berberine, a compound with strong antimicrobial properties. It has been used traditionally to treat various infections, including respiratory and digestive infections.
Berberine-containing Herbs: Besides goldenseal, other herbs like barberry (Berberis spp.) and Oregon grape (Mahonia spp.) also contain berberine and exhibit antimicrobial properties.
Grapefruit Seed Extract: Believed to have antimicrobial properties, particularly against bacteria and fungi. It's sometimes used as a natural preservative and in skin care products.
Thyme (Thymus vulgaris) possesses antimicrobial properties attributed to compounds like thymol and carvacrol. These active components are known for their potent antibacterial, antifungal, and antiviral effects, making thyme a historically used remedy for infections. Thymol and carvacrol can disrupt the cell membranes of microorganisms, leading to cell damage and death. Thyme has demonstrated efficacy against a range of bacteria, fungi, and, to some extent, viruses in laboratory studies
Oregano (Origanum vulgare): Oregano oil is rich in compounds like carvacrol and thymol, which have potent antimicrobial properties. It's used to address various infections, including bacterial, fungal, and parasitic.
Neem (Azadirachta indica): Neem has a long history of use in traditional medicine for its antimicrobial, antifungal, and antibacterial properties. It is used for various skin conditions and oral hygiene.
Ginger (Zingiber officinale): Ginger has antimicrobial and anti-inflammatory properties. It is commonly used to alleviate symptoms of respiratory infections and digestive issues.
Turmeric (Curcuma longa): Curcumin, the active compound in turmeric, has demonstrated antimicrobial activity against various pathogens. Turmeric is also known for its anti-inflammatory and antioxidant properties.
Anti-Yeast / Anti-Fungal Treatments:
Caprylic acid, a saturated fatty acid found in foods like coconut oil, is believed to possess antifungal properties. It is thought to disrupt fungal cell membranes, inhibit fungal growth, and interfere with fungal fatty acid metabolism. This makes it potentially effective against fungal infections, particularly Candida overgrowth.
Oregano Oil (Origanum vulgare): Oregano oil is rich in compounds like carvacrol and thymol, which have potent antifungal properties. It can be used topically or taken internally under the guidance of a healthcare provider.
Garlic (Allium sativum): Garlic contains allicin, which has antifungal properties. It can be consumed in various forms, including raw garlic, garlic supplements, or topical garlic preparations.
Grapefruit Seed Extract: Grapefruit seed extract is believed to have antifungal properties and is sometimes used for fungal infections. It can be diluted and applied topically or taken internally.
Tea Tree Oil (Melaleuca alternifolia): Tea tree oil is known for its antimicrobial and antifungal properties. It's commonly used topically for skin and nail fungal infections.
Pau d'Arco (Tabebuia spp.): Pau d'arco is a tree bark with antifungal properties. It is sometimes brewed as a tea and consumed for its potential health benefits.
Black Walnut (Juglans nigra): Black walnut contains juglone, a compound with antifungal properties. It is sometimes used as a dietary supplement.
Goldenseal (Hydrastis canadensis): Goldenseal contains berberine, which has been shown to have antifungal activity. It is available in various forms, including capsules and tinctures.
Neem (Azadirachta indica): Neem has antifungal properties and is used in traditional medicine for various skin conditions and fungal infections.
Turmeric (Curcuma longa): Curcumin, the active compound in turmeric, has demonstrated antifungal activity. Turmeric is often consumed as part of the diet or taken as a supplement.
Echinacea (Echinacea spp.): Echinacea is known for its immune-boosting properties and may help the body combat fungal infections.
Clove (Syzygium aromaticum): Clove oil contains eugenol, a compound with antifungal properties. It can be used topically for fungal infections.
Pau d'arco contains compounds like lapachol and beta-lapachone found in Pau d'arco may inhibit fungal growth, disrupt fungal cell membranes, and have immunomodulatory and anti-inflammatory effects. These properties make it traditionally used as a natural remedy for fungal infections, including candidiasis.
Biofilm Disrupters:
Biofilms are communities of microorganisms, including bacteria and fungi, encased in a protective matrix, often associated with chronic infections.
Clove oil is believed to function as a biofilm disrupter due to its active compound, eugenol. Eugenol in clove oil is thought to disrupt biofilms by affecting the integrity of the matrix and interfering with the adhesion and communication among the microorganisms within the biofilm. This disruption weakens the biofilm structure, making it more susceptible to antimicrobial treatments and potentially aiding in the management of chronic infections where biofilms are a concern.
Black Cumin (Nigella sativa) Seed oil: Research suggests that compounds found in black cumin seed oil, such as thymoquinone, may have antimicrobial and biofilm-disrupting properties. Thymoquinone is believed to interfere with the formation and stability of biofilms, making it harder for microorganisms to adhere to surfaces and communicate within the biofilm. This disruption can potentially increase the susceptibility of biofilm-associated infections to treatment.
Commonly used, natural motility aids:
Motility agents stimulate the migrating motor complex (MMC) and push pathogens into the colon from the small intestine between meals and during fasting at night. It may be beneficial for patients to intermittent fast, or not eat after dinner for 12 hours. Prokinetic agents may not be effective if there are known physiologic strictures in the GI tract or in people with complete loss of gut motility due to conditions/ injuries.
Ginger
Bitters
Magnesium citrate
Motility aids are a complex topic and will be discussed in another blog post.
Probiotics:
Saccharomyces boulardii
Bacillus coagulans
Lactobacillus species
Bifidobacterium species
The dosing, frequency and duration need to be determined by an experienced practitioner.
Die-off Reactions aka Herxheimer Reaction
When bacteria and fungi or yeast are killed-off, they release toxic byproducts that can overwhelm our detox pathways. Our liver, which filters the toxins released by our GI tract, typically gets overwhelmed in the peak of this purge. Keeping the livers detox pathways active during this time, can reduce symptoms.
Liver support, and the support of detox pathways is key to quench by-products from the die- off reactions. Diet, supplements, herbs and lifestyle factors can be utilized.
Staying hydrated
Fibre
Dry sauna
Red light therapy
N-Acetyl-L-cysteine
Diindolylmethane (DIM)
Indole-3-Carbinol
Calcium D-Glucarate
Sulfuraphane
Glycine
Milk thistle seeds
Dandelion root
Artichoke
Beets
Cruciferous vegetables
The dosing, frequency and duration need to be determined by an experienced practitioner.
References:
Gastrointestinal Society. (n.d.). Rome IV. BadGut.org. https://badgut.org/information-centre/a-z-digestive-topics/rome-iv/