There is no doubt about it, Irritable Bowel Syndrome is a huge problem, particularly for those who suffer from it as well as in economic terms. Irritable Bowel Syndrome (IBS) affects 10 - 25% (figures vary from report to report) of the general population and is more frequently diagnosed in women compared with men, in young people compared with old and in western countries compared with the developing world. It is often associated with emotional stress and is frequently triggered by life changes. According to consultant neurologist Dr. Jane Collins, Irritable Bowel Syndrome is becoming increasingly common among children, as for that matter is diabetes mellitus and is childhood obesity.

Irritable Bowel Syndrome is also known as spastic colon, mucous colitis, spastic colitis, nervous stomach or irritable colon. It is a functional gastrointestinal disorder (FGID) which means that the bowel doesn't work properly without there being an identifiable structural or biochemical cause for this. According to Professor Robin Spiller (Professor in Gastroenterology and Honorary Consultant Physician, Division. Gastroenterology University of Nottingham) and Professor Nicholas Talley (University of Sydney, Napean Hospital) there is growing evidence that Irritable Bowel Syndrome can no longer be purely regarded as a functional disorder and they prefer to judge the disorder to be a discrete collection of organic bowel diseases, with characteristic morphological, psychological, and physiological changes only now being fully appreciated. Key point remains that the gut becomes abnormally sensitive to its content (visceral hypersensitivity), causing changes in contractions and changes in bowel function. Fortunately enough you can do things to make life with IBS a lot easier. I hope this long page gives you some interesting and useful natural medicine advice on IBS. If you have Inflammatory Bowel Disease (Crohn's Disease, Ulcerative Colitis) then please visit www.bioterrain.co.uk/IBD.html

IBS SYMPTOMS
There is diarrhoea-predominant IBS , constipation-predominant IBS but in practice, this division between constipation-predominant and diarrhoea-predominant IBS is not clear-cut with a category of patients alternating between diarrhoea and constipation. From feedback it is clear that no one pattern is better than another, each has its own uncomfortable problems. Broadly the symptoms of IBS are:

• crampy abdominal pain, often relieved by defaecation/defecation
• an alteration in bowel habit (diarrhoea/diarrhea, constipation or alternating)
• bloating and (painful) swelling of the abdomen
• rumbling noises (borborygmi) and excessive passage of wind
• increased gastro-colic reflex, this is an awakening of the childhood reflex where food in the stomach stimulates colonic activity, resulting in the need to open the bowels.
• urgency - a need to rush to the toilet and incontinence (if a toilet isn't nearby)
• a sharp pain felt low down inside the rectum (proctalgia fugax)
• right-sided abdominal pain, either low or under the right lower ribs which does not always get better on opening the bowels; or pain under the left ribs (splenic flexure syndrome) and when the pain is bad it may ascend to the left armpit.
• sensation of incomplete bowel movement
• possible associated symptoms are: indigestion, belching, nausea, headaches, dizziness, ringing in the ears, fibromyalgia, backache, passing urine frequently, tiredness or even chronic fatigue, shortness of breath, anxiety and depression

IBS DIAGNOSIS
The diagnostic criteria of Irritable Bowel Syndrome always presume the absence of a structural or biochemical explanation for the symptoms and is made only by a physician after gathering a careful medical history and giving a thorough physical examination. Irritable Bowel Syndrome can be diagnosed based on at least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has two out of three features:

1. Relieved with defaecation; and/or
2. Onset associated with a change in frequency of stool; and/or
3. Onset associated with a change in form (appearance) of stool.

Symptoms that Cumulatively Support the Diagnosis of IBS:

Abnormal stool frequency (may be defined as greater than 3 bowel movements per day and less than 3 bowel movements per week); Abnormal stool form (lumpy/hard or loose/watery stool); Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation); Passage of mucus; Bloating or feeling of abdominal distension.

(Courtesy of Rome II Criteria, Degnon Assoc. 2000 © All rights reserved.) You need specific tests (gastroscopy, colonoscopy, ultrasound, barium studies or other) when there is unexplained weight loss, blood in the stools, fever or an abrupt and continuing change in bowel habit. These are red flags for other bowel conditions.

IBS CAUSES
There is no single cause for Irritable Bowel Syndrome (IBS) but there are three factors that certainly contribute to increased gut sensitivity namely food allergy / sensitivity , inflammation which may be related to this, and anxiety/stress .

Food Allergy and Food Sensitivity

Because symptoms of IBS can be triggered by foods or fluids, it is sensible to examine this. Allergen specific IgE tests (Total IgE, Skin and RAST testing) do not highlight sensitivity well, so we use a very sensitive ELISA assay instead. Because RAST and standard blood tests so often come back being normal, many gastroenterologists believe that it is not so much the food that it causing the problem, but the sensitive gut that is simply overreacting to its contents. But because sensitive guts have a greater wall permeability, the detection of serum antibodies to common food substances may help in dietary management. Sensitivity and food clearly are a chicken and egg scenario and a recent research paper is of interest here: Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial ; W Atkinson, T A Sheldon, N Shaath and P J Whorwell; Department of Medicine, University Hospital of South Manchester, Manchester, UK; Department of Health Sciences, University of York, York, UK.

Please note that I am not referring to acute allergic reactions here, this is not the dangerous IgE province with anaphylaxis and life saving treatment with a shot of epinephrine (Epi-Pen). This is the province of the delayed type allergies. Nothing you'll die of, but nonetheless able to disrupt your health and your life. ELISA tests aren't cheap but if they can help to reduce your misery, then I think they are worth every penny. We use a London medical laboratory and can send out a prepaid sample kit so your doctor/nurse can take 2 Vacutainer® blood samples and you send it to the lab (as long as the sample does not arrive there on a Fri/Sat/Sun). The tests measures the release of chemical mediators from white blood cells once they have been stimulated and incubated with 233 food allergens. These IgG/IgE and cytotoxic reaction tests score from 0 (no response) to 4 (biggest response), the 1s and perhaps also the 2s may get away with simple rotation of foods/drinks. The 3s and 4s definitely need to be eliminated from your present diet. Is a person's sensitivity a constant? Unfortunately no it isn't, it can vary for instance with emotional upsets. These variations are a common and infuriating (read frustrating) pattern also seen in Multiple Chemical Sensitivity whereby enzyme availability dictates what biophysical pathways of detoxification will run or not. If you then realise that complex enzymes are in part apoprotein and in part mineral or vitamin, you'll realise that this takes you full circle to nutrients passed on to you from your mother and what you have taken in and especially taken up since. Nonetheless, to a great many people this ELISA assay has been of help. To order a 233 foods prepaid test kit ring the Integrated Medicine Practice on +44 (0)1858 465005 [supplements and anti-inflammatory medication should be avoided prior to this test, cost i.r.o. £245.00] The worst foods for IBS are wheat, dairy, coffee, tea, citrus fruits and lactose, for some potatoes are a problem too (they are part of the Nightshade family of plants, the green part of which contains alkaloid which is an irritant - others in this family are tomatoes, peppers and eggplant). For many IBS sufferers getting their diet right is difficult, you share this plight with CD/UC sufferers and coeliacs. It will come as no surprise that everybody welcomes a buffer for this acrobatic walking the wire. Because Aloeride® placates the epithelium [optimum quantity & superiority of polysaccharide chains binds to the gut polysaccharide receptors and Peyer's patches] we get feedback from people using Aloeride® that it provides an effective buffer because keeping to a diet is difficult, unintentional slip-ups are commonplace.

Inflammation

A small proportion of people develop IBS for the first time after a bout of gastroenteritis, raising speculation that, although the infection clears up, this experience might make the gut more sensitive. In support of this, recent research has shown that the small proportion of people with post-infectious IBS also tends to have a mild, ongoing inflammation of the gut which begs the question, why do some people have persistent bowel symptoms after an attack of gastroenteritis while most others get better? Research has shown that post-infectious IBS is much more likely if the person was anxious, depressed and was experiencing difficult life situations at the time of the original illness. Psycho-neuro-immunology established that such scenarios lower ones immune response. Perhaps ongoing emotional upset creates the nervous tension that maintains a low-grade bowel inflammation. Alternatively, the memory of the bowel upset was recruited by brain-gut connections to express an unresolved life situation. Similar observations have been made for IBS occurring for the first time after hysterectomy. An attack of gastroenteritis or the antibiotics given to treat it can alter the balance of bacteria in the colon, reducing populations of beneficial anaerobic bacteria and encouraging the overgrowth of pathogenic species. Although it is not established whether this mechanism can result in chronic symptoms of IBS, restoring beneficial populations of colonic bacteria with good probiotics or live culture containing yoghurts has become a popular treatment of IBS. [much text in this paragraph is from Professor Nick Read, MA, MD, FRCP, consultant gastroenterologist and analytical psychotherapist and trustee to the IBS Network]

For any inflammation to subside you need anti-inflammatory agents plus cessation of any aggravation (i.e. colonic rest). Inflammation often is accompanied by reactive spasms and for this antispasmodics can be used but peppermint oil can be useful too. At the Integrated Medicine Practice we advise patients to take 2 capsules of Aloeride® first thing in the morning and 1 capsules (2 only if very severe ) last thing at night, both with a good glass of water. As soon as the inflammation settles, patients reduce Aloeride® down to their maintenance dosage. The cessation of aggravation comes by way of avoiding foods & fluids that irritate the gut wall (see ELISA assay as mentioned before). Non-steroid-anti-inflammatory drugs (NSAIDs) have the known disadvantage of causing hyperpermeability (leaking) of the gut, so they are not ideal because in IBS the gut is already leaky and increasing that is undesirable. Well researched proteolytic enzymes preparations such as Wobenzym® are an excellent NSAIDs alternative. They may not be tolerated by all IBS patients so, if you want to try them, please do so with caution.

In respect of the (reactive) spasms, Magnesium is known to relax smooth muscles so checking red blood cell magnesium level, or less invasively via hair mineral analysis, may be a good idea. Note however that Magnesium salts (for instance Epsom salts = magnesium sulphate) are known to induce diarrhoea, willy-nilly ingestion of Magnesium may cause havoc in diarrhoea-predominant IBS. Patients with chronic diarrhoea actually do have a progressive depletion of Magnesium (ditto Potassium - Mg/K are half of the mineral quartet that keeps the autonomic nervous system in balance) but there is a tendency to regain the magnesium status during the convalescent period. [ J Trop Pediatr. 1990 Jun;36(3):121-5.] Surreptitious magnesium laxative abuse is a cause of unexplained chronic diarrhoea, so here is a warning for the constipation-predominant IBS sufferer. Magnesium is abundantly available in fresh chlorophyll containing (dark green) vegetable matter. Vegetable & fruit juicing is a useful way to replenish any depletion and maintain normal levels. The advantage of juicing is that you can combine it with IBS-useful fresh garden plants such as mint (Mentha piperita or pulegium ), ginger (Zingiber officinale ) - in gallbladder disease one should use this herb with some caution, chamomile (Matricaria chamomilla ), rhubarb (Rheum x cultorum ) is a liver stimulant and a laxative - best not use in diarrhoea-predominant IBS, yarrow (Achillea millefolicium ), fennel (Foeniculum vulgare ) and silverweed (Potentilla anseriva ). The amount of fresh herbal juices is 20 - 60mL per serving within any glass of fresh vegetable & fruit juice. I have written a Top Tips newsletter about juicing should you want to know more.

Stress

The gut is an important route by which emotion is expressed in the body. If ever you have felt your stomach knot up before a speech, you too know that the brain and digestive tract are holding hands. This constant dialogue is known as the brain-gut axis. Even perfectly healthy people can worry their way to stomach pain, nausea or diarrhoea. A physician won't find anything wrong but the misery is real enough. It is suggested that patients with IBS have more emotional upset than healthy people or patients with other gastrointestinal diseases and have experienced more traumatic life events and difficult life situations both in adulthood and childhood.

About the brain-gut axis: the digestive tract is supplied by extrinsic and intrinsic sensory neurons which, together with endocrine and immune cells, form a surveillance network that is essential to gut function. The three players for this are gastrointestinal tract (GIT), central nervous system (CNS) and enteric nervous system (ENS) and they communicate with one another via parasympathetic and sympathetic pathways, each comprising efferent fibres such as cholinergic and noradrenergic, respectively, and afferent sensory fibres required for gut-brain signalling. The brain-gut axis is relevant not only to normal digestive function but also to abdominal pain and heightened sensitivity to pain.

The neural network of the brain, which generates the stress response, is called the Central Stress Circuitry (CSC). It receives input from tissue & organ (somatic and visceral) feedback pathways and also from the organ (visceral) motor cortex. The output of this CSC is called the emotional motor system and includes automatic efferents, the hypothalamus-pituitary-adrenal axis and pain modulatory systems. Severe or long-term stress can induce long-term changes in the stress response (plasticity). Corticotropin Releasing Factor (CRF = the fight or flight hormone) is a key mediator of the central stress response. So what does stress actually do to you? Other than the brain, adrenal-, pituitary- and thymus-gland producing more adrenaline, noradrenaline and corticosteroids… which initially is part of you coping until in time your resources are outstripped. In the gut stress increases the intestinal permeability to large antigenic molecules i.e. molecules venture where they shouldn't and thus may evoke an allergic response. It can lead to mast cell activation & degranulation (i.e. histamine reactions) and colonic mucin depletion (loss of protective barrier). A reversal of small bowel water and electrolyte absorption occurs in response to stress and is mediated cholinergically. Stress itself also leads to increased susceptibility to colonic inflammation. [Stress and the gastrointestinal tract, Bhatia V., Tandon R.K., J Gastroenterol Hepatol. 2005 Mar;20(3):332-9.]

A growing number of reports have demonstrated a disordered autonomic function (i.e. nervous sytem controlling rest - activity) in FGIDs, they point to a generally decreased parasympathetic outflow (PSNS) or increased orthosympathetic activity (OSNS) in conditions usually associated with slow or decreased gastrointestinal motility, while other studies found either an increased cholinergic activity or a decreased sympathetic activity in patients with symptoms compatible with an increased motor activity. [The autonomic nervous system in functional bowel disorders, Tougas, G., Can J Gastroenterol. 1999 Mar;13 Suppl A:15A-17A.] At the Integrated Medicine Practice we use a protocol orthostatic test (Heart Rate Variability) to measure such balance shifts as this objectively demonstrates if your body/mind ‘considers' itself to be in stress. HRV also helps us to teach patients effective (i.e. measurable) relaxation techniques.

IBS TREATMENT
There is no known cure for IBS but it can be helped. Dietary and drug therapy falls into two categories: end organ treatment (mostly antispasmodic drugs), disturbed bowel habits (antidiarrhoeal and bulking agents) and central treatment (antidepressants, hypnotherapy, psychotherapy). At a gastroenterology conference held in 1999 at the Royal College of Physicians there was a rather disheartening review of the 50 or so trials of pharmacotherapies revealed overall benefit for none. (in similar read makes Quartero AO, Meineche-Schmidt V, Muris J, Rubin G, de Wit N.. Bulking agents, antispasmodic and antidepressant medication for the treatment of irritable bowel syndrome. The Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003460.pub2. DOI: 10.1002/14651858.CD003460.pub2.) Reportedly current research is liberating itself from hunting for single explanations, while moving towards closer collaboration with colleagues in a broad range of other disciplines. In different websites by medical consultants you can now see active referrals to medical hypnosis, meditation, acupuncture or Aloeride®. What is clear from research to date is that what may work for one IBS sufferer can fail in another IBS sufferer. Successful management does have some common ground.

At the Integrated Medicine Practice we ask patients to making a life event timeline + a symptoms timeline which then may highlight any possible trigger. It may help identifying what may be associated with remissions. On the Internet I saw IBS paraded as a misdiagnosed dientamoebe fragilis infection which is exactly what that is, a misdiagnosis, naught to do with IBS. Also a systemic candida albicans overgrowth should be regarded as a consequence - that has undisputed further implications - rather than a primary issue in IBS proper. Following on from the above listing of three factors contributing to visceral hypersensitivity in IBS, I shall discuss natural treatment in the same order: food, inflammation, stress.

F O O D

Aloeride®
From feedback we know that many Irritable Bowel Syndrome sufferers have tried an aloe vera before and found their IBS reacting poorly to this. When a product is not very high in potency, does not have the required-for-efficacy polysaccharides, contains laxative anthraquinones and/or unwanted additions, then predictably IBS will react poorly to it. Aloeride® is a 100% pure herbal yet manufactured uniquely to pharmaceutical GMP (classified as grade D (EU grade) / class 100,000 (US class Federal Standard 209E) / ISO 8) which explains why in Aloeride® researched phytochemical effects manifest themselves without disappointment. Aloeride® works on the epithelium (which is the barrier between air and body cells i.e. skin and invaginations: lung, urogenital and digestive tract lining) and also modulates the immune response. Adults work your way DOWN in dosage, if your IBS is very bad then you start at 3cap a day i.e. 2 upon waking and 1 just before going to be, always away from food and with a good glass of water. As symptoms abate you reduce the dosage to your individual maintenance level;special offers are available to make it financially. The dedicated site www.aloeride.co.uk includes testimonials from IBS sufferers and there is also a form should you wish to ask a confidential question. (order online)

Probiotics
Everybody knows that the intestines contain health promoting bacteria as well as harmful, pathogenic bacteria. It is obvious that the balance of these cultures should favour the health promoting species. In 2003 gastrointestinal motility specialist Henry C. Lin, associate professor of medicine in the Keck School of Medicine of University Of Southern California together with his research partner Mark Pimentel of Cedars-Sinai Medical Center, found that 84% of IBS patients were found to have abnormal breath test results suggesting small intestinal bacterial overgrowth. In this double-blind, placebo-controlled study, patients received either antibiotic therapy or a sugar pill. Patients whose small intestinal bacterial overgrowth was eradicated by antibiotics reported a 75 percent improvement in symptoms. Overprescribing of antibiotics is nowadays recognised by everybody so to correct an imbalance you should look at shifting the balance by introduction of viable health-promoting strains. If you want to know more about this then I suggest you read “The Digestive Contract” by Prof.Dr.med. Micheal Kirkman and Dr. Lennart Cedgard MD (ISBN 0-9543405-0-7) which is a pleasantly thin yet comprehensive booklet. It is well established that probiotic bacteria are helpful for various digestive problems, it is not often appreciated what their knock-on effects are. One last thing on probiotics, not all are good, we only use WasaMedicals who developed a new tableting method which improves the quality and viability of lactic acid cultures more than 5-fold (prebiotics and probiotics) as compared to standard methods. Pre- and pro-biotic (the latter contain fructooligosaccharidescultures and proponents say that it stimulates growth of only beneficial bacteria which is untrue as FOS do stimulate the growth of Klebsiella pneumoniae one of the big three gram-negative pathogenic bacteria) help to create and maintain a healthy microflora in the gastrointestinal tract. In the preparations we use, these cultures are first partly inactivated and stabilized in a dried form and become activated when deposed in the stomach. In the gut they will reduce the production of toxic metabolites and, because of their role in enzyme production, they improve the absorption of minerals, vitamins and trace elements. Research by Dr. Jeffrey Bland showed that the use of a product like Aloeride® in conjunction with probiotics (also live culture containing yoghurt or home made 24hr fermented yoghurt) is very beneficial.

Hepatobiliary and hepatoprotective remedies (liver-gallbladder)
A 2001 study published in Phytother Res. 2001 Feb;15(1):58-61 reviewed results for Artichoke extract with people with non-ulcer dyspepsia and it was found that in a sub-group of patients who also suffered from IBS, 96% reported better results using the Artichoke extract. The phytochemicals in artichoke have been well documented, Caffeoylquinic acid is responsible for increased bile production whilst cynarin increases bile production and is choleretic i.e. improves flow of bile as well as the contractive power of the bile duct. Cynarin has been listed in the The Merck Index (a pharmaceutical guide) for relief of flatulence. It is interesting to note that people with IBS are significantly more likely to have had their gall bladder removed (cholecystectomy) than controls and a clear, inverse relationship exists between cerebrospinal fluid (CSF) and plasma cholecystokinin (CCK) levels. As changes in liver-gallbladder function through a natural cholerectic can affect IBS, it is wise to review what affects your hepatobiliary (liver-gallbladder) workload: stress, (wrong) fat ingestion, alcohol, some prescribed medication, nutrition/herbs that affect liver function.

One of such herbs is Milk Thistle (Silybum marianum ) which is one of the most effective herbs for detoxifying and regenerating the liver. Clinical studies in more than 2,000 patients showed benefits in alcohol and chemical induced fatty liver, cirrhosis, chronic hepatitis, bile duct inflammation and non-specific changes in liver tissue. Elevated liver enzymes (blood tests for liver function) also improve with milk thistle. Finally there are the curcumoids - curcumin, demethoxycurcumin, bisdemethoxy-curcumin - within the herb Turmeric (Curcuma longa) that are powerful antioxidants also beneficial to IBS.

Of interest is a finding published in the American Journal of Gastroenterology (August, 2000;95:2140) that a dysfunctional gallbladder may be the cause of unexplained chronic diarhoea/diarrhea unresponsive to treatment.Often these patients are diagnosed as having IBS. Nineteen patients were given the cholesterol-lowering drug cholestyramine which binds bile acids normally stored in the gallbladder and all of them improved within 24 hours. In this respect the conditionally-essential amino acid Taurine is of interest because it conjugates (binds) bile acids, increases sulphonation pathway detoxification, helps membrane stabilisation, osmoregulation and regulates cellular calcium levels. In a double-blind, randomized study, acute hepatitis patients with significantly elevated bilirubin levels were given oral taurine - four grams three times daily after meals. Taurine-supplemented patients exhibited notable decreases in bilirubin, total bile acids, and biliary glycine:taurine ratios within one week when compared to control subjects. The icteric period was also decreased. [ Matsuyama Y, Morita T, Higuchi M, Tsujii T. The effect of taurine administration on patients with acute hepatitis. ProgClin Biol Res 1983;125:461-468. ] With few exceptions, animal and human studies have shown taurine administration to be safe, even at higher doses so this is an avenue to explore for diarrhoea-predominant IBS sufferers. Taurine is usually administered orally, with the adult dosage being 500 mg to 3 gram daily in divided doses. Pediatric dosages vary according to the size and age of the child, but range from 250 mg to 1 gram daily in divided doses.

From a homeopathic point of view the following liver/gallbladder remedy may be of interest: HEPEEL® which is a complex remedy of Lycopodium clavatum D3, Chelidonium majus D4, China D3, Nux moschata D4, Carduus marianus D2, Phosphorus D6, Veratrum album D6 and Citrullus colocynthis D6. A contrainidication is hypersensitivity to quinine, in general allow 1 tablet to be dissolved underneath the tongue 3x/day in a 'clean mouth' i.e. away from foods, fluids, toothpaste, chewing gum etc.

5-HTP
Tryptophan is an essential amino acid that is metabolized by the body into 5-HTP (5-hydroxy-tryptophan) which is the direct metabolic precursor to the neurotransmitter serotonin. As a supplement 5-HTP is preferable to its amino acid because you then do not have to rely on the tryptophane - 5HTP conversion taking place. Vitamin B6 and Magnesium is necessary for the 5-HTP-serotonin conversion so IBS patients with low vitamin B/Mg levels must address that for 5-HTP to be effective.

Colonic and rectal balloon distension studies have shown that IBS patients become aware of distension and perceive pain at lower pressures and volumes than healthy volunteers and subsequent findings indicate that IBS is also associated with increased sensitivity to normal intestinal conmtractions. Serotonin (5-HT) has emerged as a key chemical messenger in the pathogenesis of IBS [MD Gershon, “ Review article: roles played by 5-hydroxytryptamine in the physiology of the bowel”, Aliment Pharmacol Ther (1999), 13: pp. 15-30.] The gastrointestinal tract contains approximately 95% of the body's serotonin and colic mucosal serotonin metabolism has been reported to be altered in IBS patients. Serotonin mediates reflexes that control gut motility and secretion, as well as pain perception, predominantly through interactions with 5-HT1p , 5-HT3 and 5-HT4 receptors in the gastrointestinal tract.

Conventional pharmacological management of IBS is often suboptimal, addressing only the most predominant symptom at any one time. According to a 2004 paper by Novartis, newer serotonergic agents that target the multiple symptoms of IBS represent a significant advance in the treatment of this disorder, and together with other measures, such as patient education, promise to improve IBS management. Here at the Integrated Medicine Practice we use the metabolic precursor 5-HTP to restore serotonin levels because this helps with pain reduction, mood enhancing including anxiety reduction. Furthermore 5-HTP helps you to go into a deeper sleep. We use 5-HTP from Nutri Ltd., a plant source precursor of seratonin which is an important neurotransmittor for brain and nerve function and is necessary to control mood, it also regulates sleep patterns. Adults may take up to a maximum of 2tbl 3x/day (600mg) - children 20mg/10kg body weight. (order from NUTRI 0800 212 742 / Ref: 187410)

Pharmaceutical serotonergic agents do not come problem free. One systematic review of 5HT4 Receptor Agonists found that in women with constipation-predominant IBS, tegaserod maleate improved symptoms compared with placebo. It found insufficient evidence about the effects of tegaserod in men. Tegaserod was more likely to cause diarrhoea than placebo. One systematic review found that alosetron hydrochloride (a 5HT3 Receptor Antagonist) improved symptoms in women with diarrhoea-predominant IBS compared with placebo or mebeverine. As of November 2000, the FDA had received 70 reports of serious adverse effects of Lotronex (alosetron hydrochloride), including 49 cases of ischemic colitis and 21 cases of severe constipation resulting in severely obstructed or ruptured bowels. Of these 70 cases, 34 required hospitalization, 10 required surgery and 5 died. [JAMA, Editor's correspondence, Vol. 162 No.1, January14, 2002] Consequently Lotronex was ‘voluntarily' withdrawn from the market, Dr. Richard S. Kent, Glaxo's chief medical officer and vice president estimated that ischemic colitis occurred in one of every 1,000 Lotronex patients and that "about half are managed as outpatients and half are hospitalized." Although pharmacological serotonergic agents do not come without issues, serotonin is undoubtedly a key player in the management of IBS.

Using the direct precursor to serotonin allows the body to convert this precursor on an as-needed basis. Please note that interactions between 5-HTP and prescribed medication may/does occur with: sedating antihistamines, Selective Serotonin Re-uptake Inhibitors (SSRI's e.g. Prozac), codeine/morphine, L-dopa, Monoamine oxidase inhibitors, tricyclic antidepressants, barbiturates and other tranquilisers, botanical and non-botanical ephedrine or pseudoephedrine medication (Ephedra sinica is a sympathomimetic that acts directly and indirectly on the sympathetic nerves ) and ingested alcohol . If you are in any doubt at all about you using 5-HTP you should consult a well-informed, non-prejudiced physician.

Juicing
We use vegetable & fruit juicing within our own household as an extra, concentrated source of fresh vitamins (especially yeast-free vitamin Bs that, as said, are necessary for 5HTP conversion, B vitamins are present in greater abundance in the darker green vegetables), alkaline minerals and enzymes. In this way you take out the fibrous content so on the whole it is friendly for both constipation- and diarrhoea-predominant IBS. The constipation-predominant can mix a little of the pulp in the juice to raise their natural fibre intake or mix it in their (24hr fermented) live culture containing yoghurt. Lots of possibilities! Juicing remains tolerable even when there is significant inflammation of the gut wall i.e. when solid matter may cause aggravation. B vitamins, like vitamin C are water soluble and therefore are not stored in the body, they need to be ingested daily so you need to juice daily. In the paragraph about reactive spasm I mentioned some herbs that are appropriate to use for IBS.

We use a simple Braun MP80 which is every bit as cumbersome to clean as any other juicer, it may extract about 10% less than fancy juicers BUT it costs only 10% of those expensive ones. It is decidedly unlikely that a centrifugal juicer heats water containing vegetables & fruit above normal body temperature (37°C), enzymes will not become denatured. There is a dedicated Top Tips page on juicing should you wish to learn more about it.


Vitamin & mineral supplementation
Why might you supplement? Because a compromised function of the small intestine results in poorer uptake of nutrients. Well spotted, if the uptake is poor, aren't you wasting a lot of money that is not going to be uptaken? Correct. So ensure a better uptake, start with cessation of any aggravation and the gut wall will breathe a sigh of relief. Take Aloeride® daily. And when your gut feels better, it stands to reason that your nutrient uptake will be better too. What to supplement with? If you are an avid juicer of dark green vegetables - with some fruit to soften the bitter taste - then you probably do not need vitamin B complex. Overconsumption or sensitivity to Iron for instance can cause constipation so for constipation-predominant IBS you would do better to take a (multi) supplement without Fe. Overconsumption of Zinc, especially zinc sulphate (> 20mg/day, or > 50mg if taken in conjunction with 5mg Copper), may cause diarrhoea so diarrhoea-predominant patients may need to ingest zinc with some caution (Zn is absorbed via the gut membrane bound to picolinic acid which is produced from tryptophan in the pancreas but it needs B6 for that; it is interesting that conversion of B6 into its biologically active form pyridoxine-5-phosphate [P5P] happens via Zinc-dependent pyridoxine kinase (i.e. uptake and use have a two-way connection). No body can work without zinc, I am proposing that diarrhoea-predominant IBS sufferers introduce a single zinc supplement slowly or better still, use a multi mineral supplement that is well balanced). A really good supplement could be MULTIGENICS WITHOUT IRON = a comprehensive vitamin/mineral formula that includes dedicated nutrients to support liver and adrenal function. Take 1-2 tbl 3x/day with meals. (in the UK order from NUTRI 0800 212 742 / Ref: 187410)

Essential Fatty Acids
Introducing the right type of fats in our diet affects pain and inflammation in a positive way. Omega-3 oils found in cold water oily fish, walnuts, flax and pumpkin seeds reduce inflammation. It may be beneficial to supplement the omega 3 oils with flax oil or fish oil capsules. Olive oil is another type of oil that won't promote inflammation. Oil is very useful for constipation-predominant IBS because it is a lubricant but introduce it carefully if you are diarrhea-predominant or you have difficulty in digesting lipids. Faecal impaction which as you may know occurs most commonly in children and the elderly, is often remedied by taking mineral oil by mouth and enemas. Note that laxatives containing mineral oil deplete fat-soluble nutrients including vitamins A,D,E,K, beta-carotene, Calcium and Phophorus. Anyway, we use only the purest: ESKIMO 3 = mixture of omega 3 oils and EPA and DHA and natural vitamin E (as a preserving antioxidant). Not recommended for haemophiliacs or patients on anticoagulants. Take 3 capsules 1-3x/day or, if you buy the liquid, take one 5mL teaspoon with every meal. Store bottle in fridge after opening and use within 2 months. (order from NUTRI 0800 212 742 / Ref 187410). Just to make you aware: a recent survey by the Food Safety by the Food Safety Authority of Ireland examined a range of popular European fish oil capsules for the presence of dioxins. Alarmingly, one of the products tested showed the dioxin level to be five times the maximum limit. Eskimo-3 stable fish oil was found to have the lowest levels of contaminants, which included dioxins and dioxin-like PCB's. Concentration of heavy metal contaminants such as cadmium and mercury was below detection levels in Eskimo-3. Not al that is made available to the consumer is good, same problem happens in aloe vera or anything else nutraceutical produced without rigorous quality control. If you want a balanced omega 3 - omega 6 oil then we advise Dr. Udo Erasmus OPTIMAL OIL BLEND 500ml - this is less likely to disturb the balance between omegas 3/6 in long term use. It is important that you keep Udo's oil in the fridge. Mix 1 tablespoon in fruit juice at breakfast time; same at lunch or dinner. (in the UK order from SAVANT 08450 606070 / Ref: vand02)

Diet
Our species, Homo sapiens dates back to some 1.8 million years ago and we, like every other species on the planet, adapt to circumstances as best we can. A species that doesn't becomes extinct (in the UK you see this happening with the red squirrel being unable to compete with the grey squirrel that came to the UK in 1876). Problem is the genetic process of adaptation takes place VERY slowly and the human genome is known to have changed little in the past 50,000 years. For our diet this means that our digestive abilities and our nutritional requirements remain pretty identical to that of stone age people. Yet our diet has changed beyond recognition. In 1888 the erudite British physician Dr. Samuel Gee gave a classic description of “The Coeliac Affection” (I know I'm writing an IBS page!) and stated “what the patient takes beyond his ability to digest does harm". This is a lucid example of how some people (coeliacs) fail to adapt to the introduction of grains (gluten/wheat) by (industrialised) agriculture. There is a message in it for the IBS sufferer as well as anybody else struggling with their digestion.

The biggest bone of contention are grains. Did you know that grains, that is any grains that are unsprouted, contain phytic acid like nuts and seeds do (soak for 12 hrs and that problem is solved). Phytates inhibit the absorption of bivalent minerals (e.g. Ca, Mg, Fe, Cu, Zn) and block enzyme activity. Unsprouted grains also contain aflatoxins. Just think that diets high in carbohydrates from cereal grains were not part of the human evolutionary process until recently in evolutionary terms. The high phytate content of whole grain cereals can impair mineral metabolism i.e. iron, calcium, and other anti-nutrients have the potential to interact with the gastrointestinal tract and perhaps the immune system as well. The high lectin content of whole grain cereals can bind enterocytes in the small intestine and cause villous atrophy in addition to changing tight junction characteristics thereby allowing intestinal antigens (both dietary and pathogenic) access to the peripheral circulation (i.e. leaky gut). The staple diet for more than 2 million years has been lean game meat, seafood, fish, lean poultry & domestic meat (all need the effort & luck of the chase) plus fresh fruits and vegetables (these do not require chasing) and this at the expense of cereal grains. A 35% plant to 65% animal substance ratio is a good starting point for improving nutrition, sorry I know I am upsetting vegetarians with this. Just to step on another set of toes, lactose intolerance has not been discussed yet. William was brought to my practice when he was 8 months old, he had horrific digestive problems and could not tolerate any formula he had been given. He was feeding through a stoma line, his growth was stinted and he was losing weight. What do you think the common factor is in all those formulas dissolved in cow's milk? If he was given more than 10cc at any time, projectile vomiting resulted. His parents do not dare take him off milk because the consultant paediatrician reportedly forbade this, William needs all the calcium he can get. Even though Aloeride® has provided an almost surprisingly effective buffer, this is an example to remember for those who think lactose is alright for sensitive digestive tracts.

Fibre
Soluble fibre are carbohydrates (starch) which chemical bonds cannot be cleaved by digestive enzymes. They present no caloric value nor can they feed any bad bacteria in opportunisctic yeast overgrowth. It is totally inert and merely stimulates the intestinal wall in passing (if you are being tickled you move, same with gut, it contracts when its wall is being tickled). It is prescribed as an antispasmodic and bulking agent. Although it promotes bowel motility it is not a laxative. An interesting pure soluble fibre product is Heather van Vorous' organic Acacia Tummy Fiber™. Fybogel Mebeverine is psyllium husk based and FiberChoice contains inulin [a non-digestible fructooligosaccharides] , both may increase bloating and flatulence. You may wish to know that aspartame - a Fybogel sachet ingredient - consumption may constitute a hazard because of its contribution to the formation of formaldehyde adducts [Life Sci., Vol. 63, No. 5, pp. 337+, 1998] and it only takes a low presence of the enzyme aldehydehydrogenase for you to react badly to aspartame. Linseed could be a good alternative. Please note that any bulking agent taken with too little fluid can cause a bowel obstruction.

Activated Carbon has been purified for pharmaceutical use and its enormous adsorptive power makes it the ideal agent for binding toxins from gastro-intestinal tract (in poisoning and diarrhoea/diarrhea) and from the blood (dialysis) and eliminating them from the body. The dosage depends on what patients present with, it is both a safe and a failsafe method to arrest those dreaded moments. It arrests diarrhoea/diarrhea. Do note that you must take activated carbon away from foods because it binds anything and everything, so if you take it at meal times few of the nutrients will benefit you but instead end up in the toilet, still firmly bound to the AC. Also note that activated carbon should not be used in active ulcerative colitis because its fine carbon particles would mechanically irritate the ulcers; in any other situation of (acute) diarrhoea it is a fantastically quick and dirt cheap remedy. (order online)

Water
Drinking 1.5 - 2.0 L water a day is a normal physiological water intake for an average adult and is one prerequisite for normal faecal transit. If you don't drink enough, your body will get its water via resorption in the large intestine. And you're wondering why that little package cannot exit comfortably... Whilst on the topic of fluids, in an IBS magazine I read with considerable surprise about their group coffee mornings. For coffee is an irritant to the gut wall (why not try Dr. A. Vogel's Bambo as an alternative or 'see-through tea' as opposed to the traditional English brew) and caffeine, albeit not a carbohydrate stimulates the pancreas to secrete a small amount of insulin particularly if you are prone to hyperinsulism. If you want coffee, drink an occasional small cup of real Italian espresso coffee, the high pressure of steam causes the ground coffee to release its flavour in concentrated form without releasing too much caffeine at the same time. Organic green tea (Clipper) can and possibly should form part of this 1.5 - 2.0 L (for average activity adults, if you're physically active you need more) and because of its very high anti-oxidant potential, it is an excellent defence against any onslaught of free radicals. Boil water but leave it to cool a little, pour onto the green tea in the tea egg and leave to brew, stonger green tea has the higher antioxidant value but is an acquired taste.

I N F L A M M A T I O N

Two aspects as discussed before 1) reduction of irritation which may be achieved by a judicious choice foods & drinks based upon an ELISA test. 2) anti-inflammatory action for which we use Aloeride® successfully. Omega3 oils also possess anti-inflammatory properties but if your fat digestion is poor then these may not be tolerated well. It is right and proper to point out that most people with IBS rely on pharmacological therapies i.e. prescribed drugs of one kind or another, yet a great many people search for workable alternatives and I hope that this webpage is helping them in this.


S T R E S S

The most commonly accepted definition of stress is that stress is a condition or feeling experienced when a person perceives that “demands exceed the personal and social resources the individual is able to mobilise.” In the book Conversations With God it is proposed that all human activity is either based on fear or based on love - hate and anger are deemed subversions of fear. Stress clearly is fear based, early work on stress conducted by Walter Cannon in 1932 established the flight-or-flight response. If possible, it is wise to find the ‘well' from where your stress bubbles up and to do this, it may be helpful to make a life events ~ IBS start/flareup timeline:

• memory and feelings of past bad life experience(s) continue to pollute the present day - forgiveness of trespassers and realise you are worthy to move into Love and Light.
• bad life experience in the here and now - make a sensible plan and take action, get help and/or support.
• akin to what happens in torture, the anticipation of bad things to come stresses you out; this may be based upon your perception of reality but frankly when it comes to diarrhoea-predominant IBS, you only need a few mishaps to be very understandably stressed about going out of the house.

Looking at the above it is obvious that pharmacological therapy is useful but never addresses underlying issues. It is a coping strategy but a welcome one because it can be very difficult to come to terms with serious life events. If you are born seeing a half-empty glass, how do you change your heart to see that it is half-full. A elderly woman in my practice turned out to have been sexually abused by her uncle as a child, she had spent her whole life coming to terms with that. Life can be cruel and pharmacological therapy can be a blessed help. However, not all antidepressants suit all forms of IBS, tricyclic antidepressants tend to slow gut transit while the specific serotonin reuptake inhibitors (SSRI) tend to produce more rapid transit, particularly in the small intestine. Therefore, SSRIs may be more appropriate in constipation predominant IBS but effectiveness of SSRIs in the management of IBS is yet to be established. Tricyclic antidepressants need to be used cautiously in constipation-predominant patients as they can cause or aggravate constipation.

An interesting non-drug approach is the Emotional Freedom Technique (EFT) pioneered by Gary Craig. It is a seemingly weird technique of facial & chest pattern tapping, eye movements, affirmations and visualization. And the no less weird thing is that it helps. It is being used to overcome allergies, trauma & abuse or panic & anxiety by ‘erasing' memory data. Reportedly its effect lasts too unlike what a placebo effect would achieve in a long-term issue. IBS sufferers have a higher percentage of emotional trauma in their life - in comparison with the general population there is a two to threefold increase in a history of physical/sexual abuse - with presumably their IBS rooted in distant bad memory/memories, EFT may be able to wipe this off your memory. Thus might change how your brain-gut axis works, this should be with less orthosympathic dominance (i.e. less stress).

The herb St. John's Wort ( Hypericum perforatum ) is known to help with stress and anxiety, in vivo its extract leads to a downregulation of beta-adrenergic receptors and an upregulation of serotonin 5-HT2 receptors in the frontal cortex and causes changes in neurotransmitter concentrations in brain areas that are implicated in depression. Another herb of interest is Valerian Root ( Radixx Valerianae ). Clinical research to identify the mechanism of action in Valerian suggests that its sedative and anti-anxiety effects occur as a result of direct action on the GABA neurotransmitter in the central nervous system. It is believed that valepotriates and the GABA phytochemical extracts from the root are responsible for this action. In respect of IBS you should note that a small percentage of (non IBS) users experienced transient mild headaches and gastrointestinal disturbances. Significant drug interaction, that is loss of therapeutic effect, between St. John's Wort and Indinavir, a protease inhibitor used to treat HIV infection, has been established (February 12, 2000 Lancet publication (Piscitelli, et al) and it is expected that drugs that are similarly metabolized, including the nonnucleoside reverse transcriptase inhibitors (NNRTIs), are also affected by SJW's cytochrome P450 metabolic pathway induction. This is one of the liver's clean up pathways and because SJW makes that pathway run faster, it lowers the plasma concentrations of pharmaceutical drugs. Not so much true interaction perhaps as making costly drugs less effective.

On the note of psychotherapeutic intervention, most prescribed drugs deplete nutrients. Monoamine Oxidase Inhibitors (MAOIs) for instance deplete B6 which is an essential cofactor for 5-hydroxytryptophan decarboxylase which is an enzyme that catalyses one of the steps in the conversion of tryptophan to serotonin. A vitamin B6 deficiency can limit the brain's ability to synthesise serotonin and low serotonin levels are associated with depression. Biochemically you are now full circle and in need of more antidepressants. How do MAOIs work? The brain's three neurotransmitters - the monoamines serotonin, norepinephrine and dopamine - look after the messaging in the brain. After they've done that, they get burned up by a protein in the brain called monoamine oxidase, a liver and brain enzyme. MAOIs work by blocking that cleanup activity. By halting the destruction of these neurotransmitters they accumulate in the brain and depressive symptoms get less. But also getting less is B6 necessary for serotonin which you need to be happy in the first place. [Drug-Induced Nutrient Depletion Handbook ISBN 0-916589-79-X]

Another excellent way to de-stress is via proper sleep. Sleep is the time when your body repairs itself, it therefore stands to reason that, if you improve the quality and if necessary length of that time, body repair happens better. Which of you wondered how - since IBS is a functional disease with therefore nothing to repair - sleep can possibly help? Sleep may not directly do anything for Irritable Bowel Syndrome but, given that stress and anxiety have a clear relationship to IBS, it seems a good opportunity to explore.

Firstly with the parasympathetic nervous system predominantly active when you sleep well, all of your body repairs and rejuvenates better. Secondly when you start the day more rested and with more energy, the challenges of life seem smaller and any anxiety or stress will fade or at least become less. The huge advantage of making sure that your sleep quality is better, is that you do not have to allocate extra time to this. I am pleased to have read this book on sleep by Dr. William Dement MD who makes an excellent, well documented case for looking into smarter sleeping. [ISBN 0-330-35460-4]

One aspect of sleeping is the role of the neurotransmittor melatonin. Melatonin is produced in the pineal gland from serotonin which, as explained above, is produced from 5-HTP. You are right to recognise two cascades: 5-HTP - serotonin - better gut, and 5-HTP - serotonin - melatonin - better sleep - relaxed autonomic nervous system - better gut. However, for these biochemical cascades to run properly (or at all) you need ample nutrients such as Mg/B6. Even obliquely these cascades can be torpedoed, a B3 deficiency for instance will force conversion of tryptophan into niacin (B3), leaving little tryptophan available for conversion into 5-HTP and subsequent cascade. Without optimum nutrition you should never expect good health, in failing health it is something you overlook at your peril and also is something that no pharmacological drug - however clever - can replace.

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Disclaimer: the above information is for general, educational purposes only and should not be regarded as a substitute for the diagnosis, treatment and medical advice from your own doctor or other licensed healthcare provider. Throughout this website, statements are made pertaining to the properties and/or functions of nutritional products, these statements have not been evaluated by the Food and Drug Administration and products are not intended to diagnose, treat, cure or prevent any disease. This webpage was written by Han van de Braak BSc LicAc MCSP MBAcC AACP - Chartered Physiotherapist, Registered Acupuncturist and Naturopath - for the Integrated Medicine Practice, England. This webpage was last updated on 15/09/2005.