• Alternative Rx for IBS
• Probiotic
• Candida treatment
• Herbal
• Allergy tests

Alternative treatment is a term that can cover a wide range of options.

Prebiotics and functional foods.

1. This is the concept that dietary changes can alter the type of bacteria in the colon or that certain by products of bacterial metabolism may be helpful.
2. Resistant starch is metabolized to produce butyrate which is a "fuel" for intestinal cells.
3. There is no evidence that this is helpful. One problem is the production of "wind" by bacterial fermentation which is likely to aggravate irritable bowel.

Digestive Enzyme Supplements

1. These products usually contain pancreatic enzymes as the main active ingredients.
2.  A deficiency of pancreatic enzymes is a very rare problem - the body makes enzymes much in excess of requirements.
3. There is no suggestion of any problem with the digestion and absorption of nutrients with irritable syndrome. Therefore there is rationale for the use of these supplements but a few people with IBS do seem to have some benefit.

Fish Oil and Omega-3 Supplements

Peppermint Oil

1. Peppermint may have an anti-spasmodic effect on the colon - reducing lower abdominal cramping pain in irritable bowel syndrome. Peppermint also relaxes the valve at the lower end of the oesophagus and can aggravate reflux (heartburn). This is why peppermint is given out at the end of a meal in restaurants - to encourage belching and ease any pressure in the stomach - but potentially will also allow reflux of the meal (and acid).
2. To reduce this effect on the oesophagus, peppermint oil is given as an enteric-coated capsules that releases the peppermint in the small bowel and colon. This is available as Colpermin. It is available directly from chemists and is not funded.
   
3. There have been a few small clinical trials showing a benefit in IBS but there have also been some trials showing no effect. If it is effective the only symptom that may improve is pain from colonic spasm.
4. I suspect that most pain from IBS is not spasm but distension of an over-sensitive colon with wind therefore this approach will have only limited success. Overall the effects are disappointing in my experience.  It is worth trying peppermint tea (certainly as a substitute for coffee)

Chinese Herbal Remedies

1. This is beginning to be some formal evaluation of several traditional herbal approaches to IBS. To date the trials have been negative or disappointing but further work is being done.
2. Combination Chinese herbal treatments include ingredients such as barley, cardomen, licorice, rhubarb. Ginger may be given alone - minimal studies done - may decrease nausea.

Naturopathy

1. These therapists have a good record in treating bowel symptoms from IBS and have a variety of approaches to the symptoms.  A wheat-free and diary-free diet is commonly recommended.
2.  These dietary exclusions are often effective as discussed in the IBS and diet section.  Other natural treatments as discussed above are given in combination sometimes with success.

Hypnotherapy

1. Some of the best studies in irritable bowel have shown that hypnotherapy is effective. This is not widely available and I have no direct experience of any beneficial results. These studies do emphasize the complex connections between mind and gut.
2. Published data suggests an 80% improvement rate (well above any other treatment - conventional or alternative) - and this effect lasts for 6 months or more after treatment completed. Does require weekly therapy over several months (high cost).
3. Dependant on the therapist - not many have experience in treatment of IBS.

Acupuncture

1. This has been studied in a randomised trial and a benefit was shown. This treatment may have most value if pain is the predominant symptom.
2.  Also used to treat bloating, nausea - difficult to see how this should work. Small clinical studies show contradictory results.

Inner Health Plus contains 25 billion bacteria - a mixture of Lactobacillus and Bifidobacterium. One capsule gives the equivalent of 22 servings of natural yoghurt.


Friendly bacteria - probiotics

Probiotics

• There is some evidence to suggest that irritable bowel syndrome is an imbalance of bacteria in the colon (large bowel).
  • In particular there may be an over abundance of bacteria that produce gases by fermentation.
  • This imbalance can be aggravated by;
    • frequent antibiotic treatment.
    • by a gastroenteritis infection.
    • prolonged exposure to less hygienic foods - living in an underdeveloped country for months or years.
  • One approach to try to selectively change the bacterial flora by taking a "selective antibiotic".
    • Such a drug does not exist but a course of metronidazole (Flagyl) or ornidazole (Tiberal) for 1 week can be helpful.
    • In a USA an antibiotic drug called Rifaxin is promoted for IBS.
    • This is not available in NZ and the results are debated.
  • Taking probiotics ("nice" or helpful bacteria) is a concept that has been tried and studied for at least 30 years.
    • The problem has been knowing what strain or strains of bacteria to test and knowing how much is required to be taken to have an effect.
    • Another problem is developing a strain of bacteria that has a reasonable shelf life and one that is able to resist digestion by gastric acid (one of the main roles of acid is to sterilize food coming into the stomach).
• A range of products are available.
  • Only some of these are supported by any scientific data. The product availability is increasing all the time.
  • Natural yoghurts do contain lactobacillus and acidophilus and this may be helpful. However the amounts of bacteria may be too small to have any effect (10-100 million per serve).
  • It may be that these "bacteria" have to be taken as capsules or powders to get a sufficient dose.  I recommend Inner Health Plus which has 25 billion bacteria ( a combination of Lactobacillus acidophilus and Bifidobacterium)
  • Even this amount of bacteria is small compared with the 14 trillion bacteria in the colon (14,000 billion)
  • There is no evidence that these bacteria colonize in the colon (that is set up home).
    • They seem to pass on through.
    • This means that the effect will only be demonstrated while taking the "bacteria".
    • Once the probiotic is stopped - theoretically the benefit will cease.
• Uses of probiotics;
  • The most convincing scientific data is for the prevention of antibiotic-associated diarrhoea.
    • The probiotic has to be started before taking the antibiotics but can shorten the duration of diarrhoea if continued for 2 weeks.
  • Trials in irritable bowel are less convincing but there is enough evidence to suggest there may be an effect.
  • There are some studies in colitis and Crohn's disease.
    • There are some positive studies and it is worth trying in combination with medical treatment

Anti-Candida Treatment (and treatment of other possible infections)

• The idea of an overgrowth of candida in the bowel has been proposed for many years (initial proposal in 1978 by Dr Orian Truss) but is not supported by much evidence.
  
• The original concept was that many symptoms such as IBS, tiredness, pre-menstrual syndrome, headache etc could be explained by a diffuse hypersensitivity to Candida.
  • The treatment trials with nystatin (an anti-fungal) are conflicting and in my view unimpressive.
    • Small doses of nystatin are used in some homeopathy treatments and are very unlikely to have any benefit.
  • Diets that are low in pure or refined sugars may be helpful.
    • This is not because of a reduction in yeast / candida in the bowel but may be because bacterial fermentation and gas production is decreased (see diet and IBS section).
• There has been some interest in the role of protozoa infections that may persist after exposure to unhygienic food - usually during overseas travel.
  • The organisms of most interest have been Entomoeba coli, Blastocystis hominis, and Dientamoeba fragilis.
    • It is generally considered that all these organisms are non-pathogenic - that is they do not have any adverse effect.
    • Certainly is has been my experience that irritable bowel symptoms do NOT improve after antibiotic treatment for these organisms.
  • Giardia lambda is a protozoan infection that is a common cause of acute diarrhoea.
    • Symptoms may persist for several months (less common).
    • More long-term symptoms (over several years) are very unlikely to be due to Giardia infection in the past.
  • There is no doubt that irritable bowel can follow a gastroenteritis illness but this is not due to persisting infection - see IBS section .

Aloe vera juice may have anti-spasm properties and is a mild laxative

Herbal treatments

Aloe Vera Juice

1. Parts of the aloe vera succulent have been used for medicinal purposes for centuries. There is a gel that has been used to encourage wound healing. An extract from the leaf can be taken orally ( as a juice).
2. There is has some supporting evidence for aloe vera juice in irritable and constipation. It is a mild laxative and also has some anti-spasmodic effects.
3. Aloe vera can be combined with kiwifruit if constipation is a major problem . This is available as a juice by Nekta - a NZ fruit juice company and available in supermarkets

Slippery Elm

• This is mainly a laxative and therefore only beneficial in constipation or irritable bowel with predominant constipation. It is available through health food outlets.

Allergy Tests

• Food allergy probably has a limited role (perhaps no role) in causing IBS symptoms.
  • Skin prick tests with various food substances is commonly suggested and may reveal some positive results.
  • The problem is that dietary exclusion based on these results usually does not result in improvement in irritable bowel.
    • It can lead to unnecessary exclusions and a very restricted diet.
    • It is better to base dietary exclusion on foods that have been commonly reported to cause problems.
  • At this stage there is no shortcut - it is a matter of trial and error (see section on diet and IBS).
  • It is thought that allergy plays little part in IBS.
    • Allergy tests with food substances placed directly on the bowel could be revealing but this is not practical!!