Friday, April 5, 2013

Irritable Bowel Syndrome by David Musnick MD

Irritable Bowel Syndrome by David Musnick MD 


Irritable Bowel Syndrome(IBS) is a functional gastrointestinal condition. It is the most common gastrointestinal condition that is diagnosed in the US and Canada. The US prevalence is estimated at 10-15% of the population. There is a higher incidence in women than men and the incidence appears to increase with age. The diagnostic criteria are:

1.      Recurrent and intermittent abdominal pain for at least 3 days per month in the last 3 months. The pain is periumbilical and can be fairly widespread. The pain is usually mild to moderate but not severe. The abdominal pain can be set off by foods, stress etc. For the diagnosis the abdominal pain must have been a consistent but not necessarily constant symptom.
 
And at least 2 of the following symptoms:

1.      Gas and bloating.

2.      Irregular frequency of stools. The patient may have constipation or diarrhea. Often these patients have multiple unformed stools per day. (Note: of concern is more than 4 watery stools per day.  Also cause for concern would be any blood in the stools as this is not associated with IBS).

3.      Mucous in the stools. This is a minor criterion.

4.      Straining and urgency with bowel movements or incomplete emptying.

Causes of IBS

One known cause is post-GI infection IBS in which the GI infection precedes the onset of IBS or makes it a lot worse.

There appears to be a dysregulation of the enteric nervous system in all forms of IBS and thus there is sensitization of the GI nervous system. This leads to abdominal pain with less provocation and less gas and distention.

Patients with fibromyalgia are at more risk for developing IBS and there appears to be some inflammatory cytokines involved in the pathophysiology.

Contributing and Aggravating Factors

1.      Food allergies can trigger worsening of IBS and need to be tested for and treated.

2.      Gluten sensitivity and celiac disease need to be checked with antibody panels or specialized arrays from Cyrex Labs.

3.      GI inflammation.

4.      Deficiencies of stomach acid and pancreatic enzymes can make IBS worse

5.      Dysbiosis in the small and large intestine can make IBS significantly worse. Small intestinal bacterial overgrowth can make IBS worse.

6.      Leaky gut

7.      NSAIDS

8.      Stress

9.      Dysfunction of the enteric nervous system. There appears to be sensitization of this system. The implications of this is that it takes less to trigger and set off abdominal pain. A little gas may trigger pain in a patient with IBS compared to a patient without IBS. The degree of this sensitization can vary patient to patient.

10.   Gastroenteritis can greatly flare up IBS.

11.  Menstruation can aggravate IBS.

Approach to Treatment

1.      Determine if the patient has a constipation-dominant IBS or a loose stool, diarrhea-dominant IBS. For constipation-dominant recommend magnesium-rich foods. Add magnesium in supplement form in either a powder or capsule. The oxide form is more likely to lead to bowel movement output. Consider also powdered vitamin C 3-5 grams to achieve bowel movements without an actual laxative. Also use aerobic exercise 20-40 minutes per day to improve GI motility.  Consider adding some non-absorbable sugars like xylitol-containing gum unless that provokes pain. For diarrhea and loose stool IBS limit all of the non-absorbable sugars. For this type consider all of the below recommendations including a low FODMAPS diet (fermentable oligo-, di- and mono-saccharides, and polyols) if the other recommendations are not enough.

2.      When taking any mineral or bone products make sure there is a balance of magnesium with it or take extra supplemental magnesium. Evolving Nutrition offers Tri-Magnesium (BioGenesis).

3.      Use and introduce fiber in small amounts. Try to use food-based fiber sources first and if unsuccessful introduce small amounts of fiber in a supplement form. Monitor carefully to make sure the fiber does not increase symptoms. Limit wheat bran fiber. If you use a fiber supplement do not use it in the morning and use more soluble than insoluble fiber. Do not introduce very much supplemental fiber especially in diarrhea-dominant IBS. Always have a lot of water with the fiber.

4.      Consider the addition of lubricant type foods such as: chia, flaxseed, toasted sesame oil, olive oil, okra, leeks, etc.

5.      Limit caffeine in diarrhea-prone IBS. Use caffeine in constipation-dominant IBS.

6.      Limit or eliminate irritant-prone foods such as: alcohol, sugar, non-absorbable sweeteners, sugar alcohols, etc.

7.      Use an anti-inflammatory diet.

8.      Avoid long periods of time with the patient going without food. Ask them to eat protein regularly.

9.      Avoid eating sweets, chips and other non-nutritive foods.

10.  Test for food allergies with at least an IgG panel as well as test for gluten sensitivity.

11.  Eliminate all allergic foods. If the patient is gluten sensitive they must eliminate all gluten completely and consistently.

12.  Eliminate NSAIDS and spicy foods.

13.  Start treating the leaky gut syndrome with supplements to heal the GI lining. Consider Intestinal Repair Complex powder mixed in water in between meals for at least one month. Consider adding extraL-glutamine powder with BioGenesis GlutaminePowder.

14.  Use a good probiotic that resists stomach acid or is protected from the stomach acid and use at least 5 billion organisms per day. The strains that have been tested and show efficacy in IBS are: Lactobacillus rhamnosus GG and LC705, Bifidobacterium breve, VSL#3, Bifidobacterium animalis as well as Bifidobacterium infantis, Streptoccocus thermophilus and Lactobacillus bulgaricus. Consider BioGenesis Pro Flora Colonizer.

15.  Run a test for stool parasites and dysbiotic bacteria and yeast. If you find them, treat them. Consider BioGenesis Para Biotic Plus to treat parasites and dysbiotic bacteria.

16.  Support digestion with BioGenesis PanZyme or VegiZyme.

17.  If necessary, support stomach acid with Betaine HCL.

18.  Consider zinc carnosine to also aid in healing the gut lining.

19.  Consider curcumin to treat the inflammatory component if the prior steps do not work well enough. Use highly bioavailable forms.

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