Overview: Irritable Bowel Syndrome

• Irritable bowel syndrome (IBS), one of the most common symptom complexes seen by the primary care physician, affects 30 to 50 million people in the United States. Based on the Rome Foundation's Rome III criteria (Fable 40-1), the prevalence of IBS has been estimated to range from 10% to 18% in Western countries.

• IBS has a major impact on modern industrialized societies in terms of economic costs from lost days of employ ment and health care expenditures, as well as impaired quality of life because of symptoms and impaired psychosocial functioning.

• In the United States, $10.5 billion is spent each year on direct medical costs and an additional $20 billion on indirect medical costs associated with IBS and related conditions, with an additional $20 billion in indirect costs and absenteeism.

• Several studies have highlighted that patients with IBS cost insurers 50% more annually than do patients without IBS. Patients with IBS visit their physicians three times more often for symptoms not related to the gastrointestinal (GI) tract than do patients without IBS.

• Symptoms are reported by 12% to 15% of the US. population and are the reason for 30% to 50% of referrals to gastroenterology clinics.

• IBS is often not seen as a serious medical condition, but patients with the disorder experience a poorer quality of life than described by US. norms and than experienced by patients with asthma, diabetes, or migraine headaches.

Important Points to Consider

• Ninety-five percent of the body's serotoninis in the gut and not the brain.

• Etiologic factors-infection, parasites, pancreatic insufficiency, celiac disease, food sensitivities, and Clostridium difficile infection-should be considered in the differential diagnosis of irritable bowel syndrome before treatment is begun.

• Sorbitol-containing chewing gum can be a common trigger of initable bowel syndrome, and the clinician should screen for its use when taking the patient's history.

• Soluble fiber (psyllium, ispaghula, calcium polycarbophill improves symptoms, whereas insoluble fiber (com, wheat bran) can worsen symptoms in some cases.

• Altered gastrointestinal flora (also known as dysbiosis) is considered a critical factor in immune dysregulation and altered function. Correction of dysbiosis is necessary in the treatment of irritable bowel syndrome.

• Testing the stool for pancreatic elastase is a relatively inexpensive way to check for pancreatic insufficiency.

• Persons with irritable bowel syndrome symptoms often have a combination of mental and emotional stressors and alterations in the psychoneuroimmunologic axis. Ensuring a proper gut milieu, along with stre stress management strategies, is necessary for optimal gut function.

Prevention Prescription

• Primary prevention in the first 2 years of life: Limit or avoid antibiotics and antimicrobial herbs to maximize opportunity for bowel microflora to develop

• Practice breast-feeding on demand for the first 12 months of life, avoid formala feeding, if possible.

• Introduction of solid foods: Delay introduction of grains until after age 6 months, preferably after age 12 months. Carbohydrates Avoid or delay introduction of simple sugars because they provide the substrate for abnormal bacteria to perpetuate in the Gl tract, Stress the importance of taking time to eat. preparing food, and eating it with others.

• Promote learning to reduce stress or the internalization of emotion Encourage the use of a Paleolithic diet, with fewer processed foods and fewer grains.

• Treat enteric infections and watch for sequelae, particularly in patients with life stress during infection or a history of trauma.

Integrative therapeutics review

An initial diagnostic evaluation is necessary to target effective therapies for irritable bowel syndrome (IBS). For the patient with mild to moderate symptoms of no clear cause, this ladder approach is appropriate.

Mind-Body Therapy

• Cognitive-behavioral therapy

• Hypnotherapy

Nutrition

• Elimination/challenge diet (see Chapter 84, Food Intolerance and Elimination Diet)

• For some patients, additional motivation through diagnostic testing (IgG food allergy testing)

Probiotic Supplements

• 50 billion CFUs/day as 25 billion CFUs/day of Bifidobacterium and 25 billion CFUs/day of Lactobacillus, or Bifidobacterium infantis 36524 at 5 billion CFUs/day

• Soluble fiber (psyllium, guar gum): 15g/day with meals

Botanicals

• Peppermint oil: one to two enteric-coated capsules 3 times/day between meals.

• Traditional Chinese medicine herbs: Tong Xie Yao Fang

• Tibetan herbs/Padma Lax for IBS with constipation: two capsules/day for 3 months

• STW 5: 20 drops three times/day for 4 weeks

Pharmaceuticals

• Oral cromolyn: 200 mg (two capsules) four times/day before meals and before bedtime

• Antibiotic: rifaximin, 550 mg three times/day for 14 days, if evidence of small intestine bacterial overgrowth86

• Tricyclic antidepressants: lower doses to start, such as amitriptyline at 10 to 25 mg/day

Key Web Sources

• www.iffgd.org.

• www.fxmed.com.

• www.holistic-board.org.