Irritable Bowel Syndrome, Colitis, Crohn's disease
Paul Reller, L.Ac.
Irritable Bowel Syndrome (IBS) affects more than 15 percent of the U.S. population, and is a complex and poorly defined functional disease. Classification as a functional disease is what differentiates it from Inflammatory Bowel Disorders such as Colitis and Crohn's Disease. Other diseases related to dysfunction are Gastroesophageal Reflux Disease (GERD) and functional dyspepsia. Research has found that a variety of causes and contributors to this GI dysfunctional disease are important, each to a percentage of patients, and so the treatment strategy must be broad and tailored to the individual. No medication has been found to significantly affect the disease, and symptom control is the goal of standard medicine. Zelnorm (tegaserod) was routinely prescribed, but the FDA issued stern warnings of cardiovascular risk in 2007, and found that benefits were meager. The FDA approved restricted use only for patients who exhausted other treatment options.
One of the options increasingly popular with patients suffering from IBS is Complementary Medicine, especially the combination of acupuncture, herbal medicine, nutrient prescription, and medical advice with diet and lifestyle. This approach provides the time intensive and comprehensive care and guidance needed to correct the dysfunctions, inflammatory problems, and associated symptoms tied to the this complex syndrome. Since IBS affects both the upper and lower intestinal tract, and is affected by dysfunction of the nervous and immune systems, there is no single therapy that is effective. A step-by-step approach with a knowledgable physician practicing Complementary Medicine is the practical course for the patient.
Irritable Bowel Syndrome, or IBS, is a complex disease of broad dysfunction in the body, including not only the large intestine, but the upper gastrointestinal tract, autonomic nervous system, and immune reaction. While no specific therapy produces significant cure or control of the syndrome, a comprehensive array of therapies has shown dramatic results. Complementary Medicine is highly suited to this approach, and should be pursued after an Integrative M.D. has thoroughly evaluated your condition.
Irritable Bowel Syndrome (IBS) is defined on the basis of recently modified Rome III criteria as recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months, and that cannot be explained by a structural or biochemical abnormality. Two of three factors are determined necessary for diagnosis, either (1) improvement of symptoms after a bowel movement, (2) onset of the disease associated with a change in frequency of bowel movements, or (3) onset associated with a change in appearance of the stool. Patients with IBS experience a wide variety of symptoms associated with the entire gastrointestinal tract as well as extra-intestinal symptoms. Chronic abdominal pain, usually described as a cramp, may vary in intensity and periodic exacerbation, and is usually located in the lower abdomen. Often, emotional stress aggravates the pain, and often, but not always, the pain or discomfort is relieved by a bowel movement. Periods of frequent bowel movement, and/or constipation, may occur, often alternating and with periods of normal bowel movement. Upper GI symptoms of heartburn, difficulty swallowing, dyspepsia, fullness, nausea, and chest pain are not uncommon. Increased belch and flatulence are also common. Many patients also complain of chronic joint and muscular pain, headache, urinary frequency or urgency, insomnia, periodic sexual dysfunction, and pain with intercourse, although none of the symptoms except for abdominal discomfort and changes in bowel habits need to be apparent to confirm diagnosis. If you have few of the symptoms, the syndrome is probably in an early stage.
Symptoms presentation may vary widely with IBS, and patients without the classic symptom presentation are common. The prevalence of alternating periods of constipation and diarrhea imply that the disease mechanisms are also varied. Patients may present with just chronic diarrhea and no constipation. Differential diagnosis is important, and sometimes this is a prolonged process. Standard medicine will often first test for more threatening underlying diseases, and usually, and hopefully, these tests will be negative. This does not mean that the patient should give up on testing or further diagnosis. A diligent pursuit of sound objective diagnostic data is recommended, although often this is a difficult and prolonged process. With symptoms of chronic diarrhea, Giardia or other protozoal, or even low-grade viral infection, may be present, and testing and evaluation with an experienced physician is needed. Current research is confirming the efficacy of various Chinese herbs, such as Curcuma, to treat Giardia, other protozoal infections, and persistent viral pathologies (see links below in additional information). Concurrent problems may also exist, making the actual diagnosis in chronic cases more difficult and complex. Standard medicine wants to narrow the diagnosis to one specific problem, but often a variety of concurrent problems exist. Knowing more of the underlying conditions helps the Complementary Medicine physician design a more thorough and comprehensive treatment plan. The failure to design such comprehensive individualized treatment plans is the main reason that so many IBS patients are frustrated with the results of care.
There are no completely definitive tests for IBS, and so the diagnosis is one of exclusion, meaning that if you meet the above criteria, and no other disease is proven to account for your symptoms, we assume that IBS is the diagnosis. Tests are useful to both rule out other potential causes and to help guide the therapeutic protocol. Once a diagnosis of IBS is made, further testing is needed to complete the diagnostic assessment. Initial testing by your M.D. specialist should include a complete blood count, chemistry panel including tests for antigliadin and antiendomysial IgA, thyroid function studies where appropriate, and stool analysis. Copies of the test results should be obtained, and brought to the Licensed Acupuncturist, so that treatment strategy reflects proof of problems, especially where celiac disease and chronic intestinal infections are concerned. Older patients, or any patient with apparent blood in the stool, feces that are becoming thin in shape, or with significant weight loss or diarrhea, may want to have a colonscopy to rule out cancer or other structural colon pathology. Sigmoidoscopy is generally not recommended as useful in diagnosis, but development of video capsule endoscope has revolutionized imaging of the small bowel mucosa and facilitated evaluation, helping to differentiate IBS from Crohn's disease, other inflammatory disorders, cancer and various tissue growth and bleeding pathologies.
As studies of IBS pathology increase, testing procedures are also being refined, although standard medicine often does not keep pace. Pathogenic protozoal parasites are increasingly found to be associated with chronic IBS-D, or diarrhea-dominant IBS. In 2010, the University of Technology Sydney, in Australia, found that a newer test, mutiplex tandem PCR (MT-PCR) was much more accurate for detection of the 4 common pathogenic protozoan parasites found in urban populations, Giardia intestinalis, Cryptosproridium spp., Entamoeba histolytica, and Dientamoeba fragilis. The study of MT-PCR demonstrated that this test was able to provide “rapid, sensitive and specific simultaneous detection and identification of the four most important diarrhoea causing protozoan parasites that infect humans”, and pointed out the lack of sensitivity demonstrated in standard microscopic evaluation of stool samples. Often, this type of evaluation is dismissed in current testing and assessment of IBS. With more specific information, the holistic therapy may target the most important aspects of the disease and increase efficiency.
The need to integrate Complementary Medicine in the treatment of Irritable Bowel Syndrome and Functional Gastrointestinal Disorders
Most medical organizations point to the current failure of standard therapy with pharmaceuticals in the treatment of IBS. Drugs that treat diarrhea often worsen the symptoms when the disorder turns to a predominance of constipation, and likewise, drugs that treat constipation often worsen symptoms when the syndrome turns to a diarrhea-predominant phase. Patients are often frustrated and go off of these medications. Eventually, many patients are prescribed anti-depressants and anti-anxiety medications to cope with the disease. Medication to treat acid reflux may worsen the functional intestinal disorders with chronic use. Some of the newer medications prescribed, such as Zelnorm, Lotronex, or Amitiza come with considerable health risks, warnings, and side effects. Zelnorm (tegaserod) is a 5HT4 receptor agonist, meaning that it increases the actions of the neurotransmitter 5HT (hydroxytrytophan). It was approved by the FDA in 2002, and clinical trials showed that IBS patients improved 5-10% better with symptoms than placebo, but that benefits were most dramatic in the first month, and effects waned after 3 months. The European Union refused to approve Zelnorm in 2005 and 2006. The consumer advocacy group Public Citizen has challenged the approval of Zelnorm, with Drs. Elizabeth Barbehenn and Sidney Wolfe stating that it is a drug that is minimally effective and comes with considerable risk with long-term use. In 2007, the FDA requested that the drug maker discontinue marketing voluntarily based on findings of increased risk of serious cardiovascular (heart) events associated with use. Zelnorm was allowed to be prescribed to a restricted subset of patients only, and is approved only for women with a constipation dominant IBS who are under age 55 and have had no satisfactory response to other medications.
In 2008, the FDA gave limited approval for Amitiza (lubiprostone) as the only drug available to treat a constipation-dominant IBS (IBS-C). Approval was limited to women with IBS-C who were 18 and over, and stated that the efficacy in men was not demonstrated in clinical trials. Amitiza is a fatty acid derivative (prostaglandin E1) that increases chloride-rich secretions. Significant side effects in clinical trials were nausea (31%), diarrhea (13%), headache (13%), abdominal distention and pain (7%), increased flatulence (6%), and increased sinusitis (5%). Natural herbs that stimulate chloride channels and treat bowel dysfunction include Aloe vera, and Curcumin (Yu jin, E zhu). A number of essential fatty acids found in herbs work by converting to prostaglandin E1, including the omega-6 fatty acid gammalinolenic acid (GLA). Evening primrose oil has long been used to supplement this fatty acid, and currently, GLA is available as a supplement to treat chronic inflammation, derived from black currant seed oil.
Due to the lack of FDA approved drugs to treat IBS, and the problems with standard therapy, many MDs are currently tentatively suggesting that various Complementary Medicine therapies could be integrated into treatment protocol. While many medical websites and organizations now suggest that cognitive and behavioral psychotherapy, hypnotherapy, meditation, and biofeedback training are recommended, there is still a reluctance to recommend TCM therapies with acupuncture, herbal medicine and nutrient medicine. A review of current clinical trials for herbs to treat gastrointestinal dysfunction in 2006, reviewing the Cochrane medical database, by Beijing University of Chinese Medicine, found that there is strong evidence in clinical trials that 22 herbal medications were proven to have significant benefit in treating symptoms of Irritable Bowel Syndrome, 29 herbal medicines performed as well as standard therapy, and 6 herbal preparations showed significant benefits when added to conventional therapy. No serious adverse events were found in these numerous clinical studies. To see this review, click here: http://www.ncbi.nlm.nih.gov/pubmed/16437473
Because of the substantial numbers of strong clinical trials found in this review, standard medicine is now recommending herbal medicine in the treatment protocol for IBS. Since MDs do not receive training in herbal medicine, this means that a referral should be made to a professional herbalist. The profession of Acupuncture (TCM) is the only licensed medical profession that includes substantial education in herbal medicine, besides the Naturopathic doctor. The Licensed Acupuncturist that is trained in herbal medicine can design an integrated course of treatment that combines acupuncture, herbal medicine, and nutrient medicine to increase the efficacy. For patients that do not want acupuncture, the Licensed Acupuncturist is still an excellent choice to receive professional consultation and individually designed courses of herbal and nutrient medicines. The one drawback in the United States is that the government is still dragging its feet in approving professional herbal prescription as a medicine, due to pharmaceutical lobbying, and thus this therapy is not paid for by standard insurance coverage. Considering the wealth of scientific information, the public needs to urge their legislators to act on this type of public health legislation now. A significant number of patients are utilizing health spending accounts, though, to pay for such professional herbalism. Health Savings Accounts, a tax deductible health expense, also cover herbal and nutrient medicines, but only if they are recommended by a medical practitioner for a specific medical condition diagnosed by a physician. Some of these expenses are now being challenged, and may require professional documentation, which the Licensed Acupuncturist can provide.
Is acupuncture alone scientifically proven to work in the treatment of Irritable Bowel Disorder and functional GI syndromes? Yes, depending on the criteria for proof. In clinical experience, when combined with research-based herbal and nutrient medicines? Yes.
An article from Duke University Medical Center, published in the Journal of Gastroenterology, May, 2006, stated that acupuncture has been shown to alter acid secretion, GI motility and visceral pain, and that it is expected that acupuncture will be used in the standard treatment of patients with functional GI disorders in the future. Research at Duke found that electroacupuncture at a single point, ST36, stimulated colon motility via a sacral parasympathetic nervous system pathway, revealing how acupuncture stimulation works. (Am J Phsyiol Gastrointest Liver Physiol. 2006 Feb;290(2):G285-92). A study headed by Dr. Richard Holloway of the University of Adelaide, South Australia, found that one of the known causes of GERD, transient lower esophageal sphincter relaxations, were inhibited 40% by electrical stimulation at the P6 point on the wrist. The study was published in the August, 2005 issue of the American Journal of Physiology-Gastrointestinal and liver Physiology. A review of studies of acupuncture to treat gastrointestinal motility disorders by the University of Texas in 2010 concluded that “acupuncture or electroacupuncture is able to treat gastrointestinal motility functions and improve gastrointestinal motility disorders. However, more studies are needed to establish the therapeutic roles of electroacupuncture in treating functional gastrointestinal diseases.” (Autonomic Neuroscience.2010 Oct.28;157(1-2):31-37) Further study by the NIH is underway to confirm these studies and provide well-funded research evidence to duplicate evidence from Chinese studies. Of course, none of these studies will incorporate the entire protocol routinely used by the competent Licensed Acupuncturist and Herbalist. Providing proof of efficacy with uniform acupuncture treatments for specific aspects of these difficult to treat diseases is no easy task, though, when you look at how these studies are designed.
As patients seek treatment strategies for these difficult and complex functional GI disorders, standard medical groups still often discourage the patients seeking relief with acupuncture and herbal medicine, citing lack of proof that these treatments are effective. Research with these therapies in the treatment of IBS has been problematic due to study design, and many medical journals therefore state that there is insufficient proof that specific treatments in Complementary Medicine perform better than placebo in human trials. This does not mean that there is no proof. The fact that these human trials continue to be performed reflects the fact that much scientific study has revealed the promise of acupuncture and the chemicals in nutrient and herbal medicines in the restoration of a healthy gastrointestinal function. Despite the problems with human clinical trials of specific therapies, clinical effectiveness with Complementary Medicine is widely acknowledged today, by both patients and physicians. The major hurdle to overcome in human clinical trials is designing these trials so that they accurately respresent the individualized and thorough approaches to treatment used in the clinic. The most informative scientific studies provide information on how the various therapies work, and this is what guides treatment in Complementary Medicine today. Most patients utilizing Complementary Medicine in the treatment of IBS do so because other patients have recommended this treatment, or their physicians have suggested that they try it based on these studies.
Since there is such a variety of presentations in IBS, and since the symptom presentation varies for most patients within the course of the disease, research studies with standardized treatments, investigating just parts of the holistic treatment protocol, produce excellent results with only the appropriate subset of patients. In the clinic, physicians overcome this problem by utilizing an individualized step-by-step approach, combining a variety of therapeutic measures in succession to achieve the goals of therapy. Since the disease is affected greatly by emotional factors and stress, the improvements shown in human clinical trials, which usually reflect a 40% improvement over a short course, utilizing just one type of standardized therapy, are still often attributed to a placebo effect. The researchers are still skeptical. Researchers also base results on comparison to placebo, and designing a placebo for acupuncture is an obvious problem. The placebo is often just other acupuncture points, which provide effective stimulation themselves. Study effectiveness is measured by the difference between the so-called placebo acupuncture and the points chosen as the so-called real acupuncture points. Study design is thus a key determining factor of outcome. None of the acupuncture prescriptions used in studies are individualized to the patient presentation, as they are in real clinical practice. Funding for studies of acupuncture is problematic, with most sources of medical research funding tied to pharmaceuticals, and there is absolutely no monetary incentive to support acupuncture and herbal medicine in this realm. Most of the few small completed studies have therefore discounted acupuncture, despite consistent benefits shown, usually due to skepticism based on the small size of the study.
Study design utilizing individually tailored treatments that are adjusted to the patient condition, combined with herbal medicine, nutrient therapy, and appropriate changes in diet and routines of daily living, is not possible within the framework of modern double-blinded placebo controlled clinical trials on humans. All of this has served to discourage the use of Complementary Medicine in the treatment of IBS so far, but more and more patients are discovering that a safe comprehensive approach with gradual restoration of function, utilizing an array of herbal and nutrient medicines, acupuncture, dietary changes, and decrease in the effects of stress, makes a lot of sense. A wealth of clinical data, as well as continuing scientific study of these treatments, guides the experienced Licensed Acupuncturist in choosing best treatments for each individual.
To make this course of treatment effective for patients with IBS, the patient must understand the disease and the treatment strategy. There is no quick and magic cure, and the patient must be persistent with the choice of sensible and effective therapies, and the right individualized changes in dietary and lifestyle habits. To this end, this website article seeks to educate the patient to improve the proactive role in therapy that must be assumed. Since the patient is dealing with the problem every day of the year, he or she must be the person that is ultimately responsible for success. The various physicians utilized are there to help and guide the patient, but without a knowledgeable proactive approach, overcoming functional GI disorders such as IBS is problematic.
The causes, or etiology, of Irritable Bowel Syndrome
No specific patterns of cause have been found for IBS. Instead, we see a variety of causative factors in scientific studies, including chronic intestinal infection, immune hyperreactivity to glutens or incompletely broken down protein fragments, dysfunction of stomach emptying and acidity, stress of the nervous system, poor bile flow or quality of bile acids, serotonin imbalance, deficiency of the innate immune system, autonomic disorder in chronic myofascial pain syndromes or other diseases, and intestinal permeability, or Leaky Gut Syndrome. Hormonal imbalances may also play part in the cause or aggravation of the disorder. To achieve success both with symptom relief, and to effect a cure, the holistic physician should assess all of these causative factors and address them appropriately.
Since the usual course of the disease presents with periods of relative normal function, as well as dysfunctional states of frequent stools and constipation, the physician treats the present symptoms with different treatments, and when symptoms are relieved, uses this time to correct the underlying dysfunctions of the immune system, the autonomic nervous system, and any contributing factors. Treatment should continue during the asymptomatic periods to achieve the best results. The patient should be prepared for a prolonged course of therapy, although the constraints of time and money may call for the treating physician to utilize a continuing course of herbs and nutrient medicine, punctuated with short courses of acupuncture.
An example of a step-by-step approach to treatment would be to first address the possibility of chronic infection or fungal infections, such as candidiasis, followed by relief of constipation or frequent stools, and then treatment for celiac problems, such as hyperreaction to glutens. The World Health Organization now confirms that a significant portion of the world population is affected by celiac disease from immune hyperreactivity (see the article entitled Malabsorption Syndromes on this website). Various herbal formulas and acupuncture choices would be utilized to restore intestinal function in this way, and would include relief of chronic inflammation as well as dryness of intestinal membranes and restoration of enzymatic function. Research has shown that there are frequent patterns of specific enzyme deficiency in many of these cases, especially with celiac disease, or allergic reaction to food or metabolic accumulations in the linings of the small intestine. Products are emerging that address these new research findings, such as N-acetyl cysteine and dipetidyl peptidase-4, found to be deficient in the small intestine membranes in a high percentage of patients with celiac disease. After this, stomach function can be normalized with a comprehensive approach, and quality probiotics utilized to restore the lower intestinal balance of flora and fauna. Health problems that add stress to the nervous system can also be addressed, especially if there is autonomic stress frome chronic pain and inflammation, or if hormonal balances are present.
Herbal formulas typically include from four to twelve herbs and address a broad and balanced set of therapeutic objectives. In addition, each herb has a set of chemicals in it that have been studied as to physiological effects. Specific herbs and herbal preparations can address specific needs in therapy due to this extensive herbal research. Bowel motility, duodenal spasm, stomach emptying, immune enhancement as well as suppression of specific immune responses, antifungal, antiviral, and antibacterial activity, inflammatory regulation, modulation of the nervous system, and hormonal balance may all be addressed with specific herbal extracts. Acupuncture itself is well documented concerning specific effects, both with thousands of years of empirical proof, as well as modern studies with acupuncture and mapping of brain response with functional MRI, and with studies of chemical responses.
“Since Irritable Bowel Disease is a problem that expands and worsens over time, and affects young and old, male and female alike, treatment should be started at an early stage of the disease, and if there is a family history, preventative treatment started as soon as a problem is suspected.”
Physiology and understanding of Irritable Bowel Syndrome
To feel fully comfortable with a prolonged course of therapy, the patient should always be educated to the disease and put in charge of the course of therapy. The person to depend on with monitoring and control of a complex course of therapy is yourself. Your various integrated physicians are there to provide specific expertise and oversee the treatment, but no one can insure continuity and attention to detail in the course of therapy like yourself. Here are a few facts to help you understand what needs to be accomplished and why. While the scientific explanation of your disease or disorder can be complex and seem overwhelming at first, a little understanding goes a long way to insure that you are on the right path to restoring health and stopping irritable bowel syndrome once and for all.
A wealth of scientific study has elucidated the complex nature of the irritable bowel syndrome. Links to these studies can be accessed below in additional information. A study of 202 patients with IBS found that 78 percent had small intestine bacterial overgrowth. Immune cells such as lymphocytes and leukocytes were increased in almost all patients. The increased immune response in local cells produced increased 5HT and inflammatory cytokines, which in turn led to enhanced motility, increased intestinal permeability, and lowered sensation thresholds. While there is a normal healthy bacterial colony in your small intestine that helps with digestion, abnormal growth of specific bacteria creates an imbalance of flora and fauna, as well as poor function. This leads to overgrowth of fungi, protozoa, helminths, and viral infection, as well as other pathogens that are difficult to detect with testing. While research has shown that this abnormal flora and fauna may not directly effect your symptoms in IBS, it certainly is thought to be a probable cause of dysfunction, and hence an indirect cause of symtpoms. Herbal medicines exert a broad effect on modulation and regulation of all of these pathogens. The herbal plant itself was affected by such infections, and evolved complex and balanced chemical means of protecting itself, both from the pathogens and from chemicals the cells produced to destroy the pathogens. This is why herbal medicine is both effective and safe.
Since bacterial overgrowths and loss of the natural protection supplied by a balanced microbial flora and fauna in the intestine are a key aspect of the pathology, may patient take some form of probiotic. This step alone, though, will usually not correct the problem. Introduction of probiotic bacteria does not guarantee sufficient colonization by these microbes. Restoration of microbial balance should include both reduction of overgrowths of a variety of microbes, and introduction of healthy probiotic species. As stated, loss of the normal protection that symbiotic bacteria creates for us allows for an increased chance that common overgrowths of fungi, such as candida species, and infection by protozoa, such as Giardia, will occur. Candida, in a pathological setting, turns from a yeast to a fungi, and imbeds into the intestinal lining, and then may disseminate systemically via the blood or lymph. Restoring bacterial balance may not result in a quick ridding of candidiasis. The patient and physician may need to be persistent if symptoms persist. Many patients wander how they could have been infected with a parasite, such as Giardia. Recent studies in Japan and Europe showed that in the general urban populations, some areas had a 1.5% incidence of Giardia casts in stool samples. Research has shown that the Giardia may spread from pets, or from poorly treated waste water from commercial meat growers. Studies have shown that 10-20% of puppies, in certain subsets, in Japan, which has strict standards, have been tested positive for Giardia. Studies of commercial beef production has found a much higher percentage of cattle infected in many locations. Broad studies have determined that a frequency of infection of 2.5% was found overall in domestic animals, and rate of infection of 1.5% in humans. Genetic analysis determined that the genotypes of Giardia found in wild animals was rarely seen in humans, but that the Giardia species found in domestic animals was compatible with the species of Giardia found in humans. A person is not exempted from a Giardia infection when they have not been exposed to untreated water while camping or hiking. Recent passage of increased FDA regulation of the food production industry will encourage better protections against fecal contamination from large cattle producers and farms that utilize their manures. With improved guidelines in handling manure, concentrations of Giardia and Cryptosporidium were drastically reduced in farm and ranch runoff into water systems.
Celiac disease, commonly called gluten intolerance, is found in a high percentage of IBS patients. Often, the symptoms of celiac disease are not apparent, yet the condition of latent or potential celiac disease still causes dysfunction. The disease is characterized as an exaggerated immune response to glutens and gliadins, found primarily in wheat, oats, and barley as well as other grains, but especially with hyperreaction to high gluten flours, universally used in commercial baked goods and other prepared foods. The Ig antibodies primarily react to protect us from harmful toxins in our foods. IgA deficiencies are found in a significant percentage of youth around the world, implying a deficiency in innate or acquired immune function. When such exaggerated immune responses occur, chronic inflammatory states result in the intestinal tract. Tests for celiac disease are not completely reliable, and are thought to underdiagnose this problem, but a study of 102 patients with diarrhea-predominant IBS found that 35% tested positive for human leukocyte antigen (HLA-DQ2), 23% had increased intraepithelial leukocyte counts, and 30% had increased celiac disease associated antibodies in duodenal aspirates. This implies that a large percentage of IBS patients are affected by active or latent celiac disease. Use of key protease enzymes, formulas to enhance stomach function and immune responses, and specific acupuncture protocols will correct this problem.
Visceral hypersensitivity and brain-gut interaction are integral factors in the pathology of Irritable Bowel Syndrome. The exact mechanisms have not been found, and it is believed that the whole nervous system, and a feedback system from the gut to the brain is involved. Abdominal pain in IBS is not explained by a hyerreaction to pain at the peripheral pain receptors. The discomfort is not an exagerrated reaction to common pain stimuli, but rather a real pain caused by mechanical dysfunction and chemical imbalance. Some of the reasons for this are listed below. Gut motility, or the frequency that your intestinal muscles react to push food through, varies in IBS. Increased motility causes frequent stools, and decreased motility causes constipation and worsens the balance of flora and fauna in the lower intestine. This motility is regulated by the autonomic nervous system, but responds both to stomach and pancreatic function, as well as psychosocial stress. Treatment protocol must address all the potential problems to insure that the autonomic regulation of gut motility is normalized. Recent studies cited in Psychology Today have found that more than half of patients with IBS also meet the criteria for a diagnosis of mood disorders, and treatment with specific probiotics have produced positive neurochemical changes in animal studies related to mood disorder and brain chemistry. The probiotic Bifidobacterium infantis was linked to higher bioavailability of the serotonin precursor tryptophan in the frontal lobe of the brain and the amygdala, which plays a part in mood regulation. Chronic infection has been linked to reduced growth factor proteins in the brain, and treatment with the probiotic Bifidobacterium longum has normalized the brain growth factor BDNF in the hippocampus of the brain in animal studies. Restoration of the complex microbial health of the intestines could have a very positive effect on mood disorders. Since there are more than 40,000 species of symbiotic microbes in the gut, future research may turn up even more links between flora and fauna imbalance in IBS and the physiology of mood disorders. To restore this balance, the patient often needs a step-by-step approach to first clear microbial excess, then restore a homeostatic balance and clear the underlying functional and immune problems that perpetuate this imbalance. The Complementary Medicine physician may be an ideal person to oversee this step-by-step therapeutic approach.
The Autonomic Nervous System (ANS): autonomic deregulation, has been found in virtually all patients with the neuroimmune disorder that we call Irritable Bowel Syndrome, according to recent research at Harvard University. The autonomic nervous system is the peripheral visceral, or organ, nervous system, made up of the sympathetic and parasympathetic systems. The ANS controls all organ functions unconsciously, although it also may be affected by conscious will. The ANS has both sensory and motor nerve aspects. Parasympathetic tone of the organs is maintained via the brain stem, cranial nerves, vagal nerve, and the sacral nerves, while the sympathetic tone is maintained via the thoracic and upper lumbar nerves, but joins into a sympathetic ganglion chain under the spinal cord, where all of the sympathetic nerves connect. Nerve fibers from this chain ganglion not only connect to other ganglions that branch to the organs, but also have smaller fibers that connect back to the spinal cord and go to the muscles, sweat glands and blood vessels. A balance between the sympathetic and parasympathetic peripheral nervous systems is essential to healthy function in the body. Neuroendocrine stress in the brain may easily affect parasympathetic regulation, while adrenal stress, myofascial pain, and various organ stresses may affect sympathetic regulation. These various stresses, as well as excess sensory stress, may cause imbalance between the sympathetic and parasympathetic systems, and deregulation of organ function. This autonomic deregulation directly affects intestinal peristalsis and tone, as well as digestive blood flow, and metabolism. The location of the pathways of the parasympathetic and sympathetic nervous systems may explain why acupuncture trigger point stimulation is so effective in regulation of visceral systems. Visceral trigger points along the spine and on the abdomen are well documented and mapped as key visceral systems regulators in TCM, and many scientific studies now demonstrate how stimulation of key points directly affects the brain stem, hypothalamus, and vagal nerve. A balanced array of point stimulation may restore the balanced function of the parasympathetic and sympathetic portion of the autonomic nervous system, and is referred to in TCM as a balance of yin and yang.
Most experts agree that an altered brain-gut communication in the ANS is at the root of the manifestation of IBS. Research shows that IBS patients display altered central nervous system responsiveness to normal stimuli that controls intestinal function, and intestinal hyperresponsiveness to environmental chemicals and intestinal lumen events. The trouble is that there are so many chemicals in the body that mediate gut motility and intestinal visceral hypersensitivity, and targeting just one chemical in allopathic pharmacological therapy probably won't correct problems with the enteric nervous system and the brain-gut communication dysfunctions. Motility, or intestinal muscle activity, is mediated by serotonin, acetylcholine, adenosine triphosphate, motilin, nitric oxide, somatostatin, substance P (a pain mediator), and vasoactive intestinal polypeptide (VIP). Intestinal hypersensitivity is mediated by serotonin, bradykinin (a key inflammatory mediator), tachykinins, calcitonin gene-related peptide (CGRP), and neurotropins. Nerve receptors to 5-HT (Serotonin) and Enterochromaffin (EC) cell populations in the intestinal lining are also a part of the problem. EC cells produce and contain about 90% of the serotonin, or 5-HT precursor, in the intestinal lining. In IBS, increased EC cells are seen with diarrhea, and decreased EC cells are seen in constipation. EC cells respond to autonomic nerve stimulation and release histamine. Common antacid medication (e.g. Tagamet/Cimetadine), and many other medications today work by inhibiting histamine, including allergy medications, dermatologic medications, and may play a part in the dysfunction in IBS. EC cells are endocrine cells, and thus may also be implicated in a variety of hormonal imbalances, especially adrenal insufficiency syndromes and subclinical hyperparathyroid disorders. Subclinical hormonal disorders related to hypothalamic function may also be implicated. Research has proven that a wide array of health factors, and both mental and physical stress, may play a part in the IBS pathology.
Many medications may slow stomach function and emptying and thus contribute to problems of functional gastrointenstinal disease, including antacids containing aluminum hydroxide, antidepressants, Lithium, narcotic pain meds and calcium channel blockers and proton pump inhibitors prescribed to relieve reflux and other problems. Stomach emptying may also be inhibited by poor response of the pancreas in excreting digestive enzymes into the upper small intestine, or duodenum. Poor excretion of cholecystokinin, which stimulates bile release and pancreatic enzymes has long been linked to IBS. Somatostatin, a hormone released by the neuroendocrine system, especially by neurons in the hypothalamus of the brain, inhibits release of cholecystokinin and other gastrointestinal protein hormones. The hypothalamus is responsible for many autonomic nervous system functions, and is highly affected by emotional stress as well as hormonal imbalances. Use of corticosteroids, in control of asthma, skin rash, or pain, for example, or other steroid hormones, in body-building, could alter hypothalamic function. Adrenal stress syndrome is a subclinical disorder that is common, and could affect hypothalamic function and autonomic regulation. Hormonal imbalances can be found in both men and women, although symptoms of menstrual problems and menopausal symptoms make them much more apparent in women. Men too, commonly have hormonal imbalances, and both sexes may benefit from an inexpensive test of active hormone metabolites in the saliva and bloodstick. Ask about this type of testing. By accumulating objective information on neurohormonal imbalances, the Complementary Medicine physician is better able to solve the often complex puzzle of underlying causes and contributors to IBS, and thus better able to devise the right individualized treatment protocol to restore autonomic and hormonal balance, as well as gastrointestinal function.
The medications Prilosec and Nexium, similar proton pump inhibitors, are also linked to a variety of problems with chronic use that could cause or contribute to a number of dysfunctions related to IBS symptoms, or perhaps to the IBS itself. Prilosec, or omeprazole, is now available over the counter and may be taken by many people when it is not appropriate. Hypochloridia, or slow deficient stomach acid production, is now found to be more prevalent than hyperchlorydia, or excess production of stomach acid, and has many of the same symptoms. While inhibition of stomach acid production may give some periods of relief in these patients, because the hypofunction of the stomach may result in an eventual excess acidic reaction well after eating, the use of a gastric inhibiting drugs in these cases will only perpetuate the problem. Restoration of gastric function in these cases is necessary. Also, Prilosec has now, after many years of use and study, been associated with chronic malabsorptions causing osteoporosis and increasing risk of hip fractures, anemias and nervous dysfunctions related to poor Vitamin B12 absorption due to loss of intrinsic factor in the gastric lining, diarrhea related to the chronic parasitic microbe Clostridium difficile, increased risk of pneumonia in weakened states, and even chronic kidney inflammation, or tubulointerstitial nephritis, which may also be related to overgrowths of microbes such as Clostridium difficile. These are all problems related to chronic use, and sometimes in variance of metabolism and genetic expression in individual patients, which accounts for differences in the effectiveness of the drug, and perhaps chronic excess dosage. Side effects of these medications seen in more than 1 percent acutely in clinical trials included diarrhea, abdominal pain, nausea, dizziness, headaches, sleep deprivation, and trouble waking from sleep in a normal manner, and these may be also related to chronic use of Prilosec, confusing the symptom assessment in IBS. Nexium is a drug that is almost the same as Prilosec, but introduced only when the patent protection on Prilosec was expiring. Patients may try to control the symptoms treated with Prilosec and Nexium with less potentially problematic treatments and avoid chronic use of the drugs if these problems are suspected. Complementary Medicine has much to offer in this regard. Sometimes it is better to be safe than sorry. Gastric hypofunction may cause a chain of events of gastrointestinal dysfunction that lies at the heart of the irritable bowel syndrome.
Improper levels of bile salts may also lead to a slow response of stomach emptying. Cholesterol lowering statin drugs work by inhibiting genetic expression of enzymes controlling cholesterol production. Since most of the cholesterol produced in the liver goes to creation of bile, these drugs also inhibit bile production. Bile stones or other obstructions related to ductal inflammatory scarring, or poor function of the liver and bile formation may contribute to this problem, as well as problems with cholecystokinin and the neurohormonal system. If the gallbladder has been removed, bile salt deficiency may be significant and the patient may consider supplementation with oral bile salts. Studies have shown that patients with deficient bile excretion and poor intestinal function have a higher incidence of tissue irritations in the body from poor breakdown of toxins, malabsorption of fatty acids etc. This often leads to increased psoriasis, muscle inflammation and arthritis, as well as gastroesopohageal reflux and IBS. Problems with insufficient bile excretion can also cause excess cholecystokinin release, which is shown to stimulate increased bowel motility, often seen in IBS patients with frequent stools. Bile salt supplementation, when prescribed properly, has been shown to help with these problems. When deficiencies or dysfunction occurs in the excretion of bile salts and digestive enzymes, proteins in our diet can be inadequately broken down, and large protein fragments accumulate in the intestinal lining, leading to chronic inflammatory reaction and celiac disease. IBS patients are frequently advised to decrease protein consumption because of this. A proper assessment helps you to understand these problems, and why various therapies may need to be used.
Excess bile salts may also cause problems with stomach function and GERD. Excess bile salts, caused by a high fat consumption, poor stomach and small intestine function, or poor colon health, along with aspirin, alcohol and other irritants, are directly injurious to the mucosal linings and may alter the permeability. This allows back diffusion of stomach acids, or hydrochloric acid, injuring tissues, especially blood vessels, and liberating excess histamine, which is a stimulant of increased acid and pepsin secretions. This vicious cycle needs to be corrected, not just subdued. Health of biliary system and restoration of healthy mucosa needs to be achieved with a holistic approach. The Complementary Care Physician may help you to properly assess your problem and take the right approach to treatment.
Overuse or chronic use of aspirin and other NSAIDS (non-steroidal anti-inflammatories) may also damage gastroesophageal linings and cause reflux. This problem is very serious, and each year thousands of people die of GI bleeding when taking these common pain relievers. Why does this happen? Study shows that these drugs, which work by blocking inflammatory regulating chemicals called prostaglandins, inhibit the protective role of these prostaglandins in the mucosal linings of your stomach, esophagus and the sphincter between your stomach and esophagus. Prostaglandins are abundant in this mucosa and play an important role in gastric mucosal defense. When this defense is compromised, normal stomach acids, or pepsin, is allowed to autodigest these mucosal linings. This mucosal lining also prevents backflow of hydrogen ions from the lumen to the blood even with periods of high acidity. When the mucosa is compromised, blood acidity may increase, causing total body acidity that disrupts normal metabolism, and threatening cardiovascular irritation that eventually may lead to areas of atherosclerotic plaque accumulation. Compromise of mucosal integrity may also lead to unwanted toxins and larger molecules getting through your body's defenses into the blood stream. This is called ‘Leaky Gut Syndrome’ and may cause muscle inflammation and pain as well as increased stress for the liver detoxification process.
This mucosal breakdown also allows permeability of large proteins, both into the blood, and out of damaged blood vessels, sometimes causing significant loss of plasma proteins which carry many essential chemicals in to body, including steroid hormones. This permeability may also allow antigen proteins to enter the blood, stimulating allergic hyperreactions. When the issue of mucosal health is not addressed, health problems arise that the patient did not realized were connected to poor stomach and intestinal health. When symptoms were controlled by anti-secretory drugs, the patient felt that all was well, but this may be a serious mistake.
A common problem related to IBS and functional disorders of the gastrointestinal tract is diverticula. A large percentage of the population, sometimes estimated at nearly 40 percent, acquire diverticula in the small or large intestine due to mucosal breakdown, as they age. A diverticulum is an enlarged pocket associated with a blood vessel in the mucosal lining of the intestine. These most often occur near the junction of the small intestine and the large intestine, called the cecum. The problem relates to mucosal herniations, and may involve inflammation, in which case the problem is diagnosed as diverticulitis. Most of these diverticula go unnoticed and produce few symptoms. The causes of diverticulosis and diverticulitis remain unclear, but we do know that poor health of the mucosal lining and increased pressure within the intestine combine to cause the herniations. Generally, low fiber diets, chronic imbalance of the intestinal flora and fauna, degeneration of the arterial valves, slow digestion with collection of undigested food particles within the diverticula, obesity, decreased physical activity, use of synthetic corticosteroid drugs, non-steroidal anti-inflammatory drugs, or excess consumption of alcohol, caffeine or cigarette smoke, are linked to diverticulosis. By the time that this problem becomes severe with symptoms, simple remedies, such as adding dietary fiber and probiotics, may not correct the problem on their own. A comprehensive package of treatment that deals with the individual condition, correcting constipation, slow digestion, overgrowth of harmful flora and fauna, healing of necrotic tissues, and restoration of healthy intestinal mucosa should be instigated. There is understandably a high correlation between IBS and Diverticulitis.
Acupuncture is just one of the effective treatments in the TCM protocol to treat IBS, and should be combined with a step-by-step approach with herbal and nutrient medicine, dietary changes, and stress reduction. An article from Duke University Medical Center, published in the Journal of Gastroenterology, May, 2006, stated that acupuncture has been shown to alter acid secretion, GI motility and visceral pain, and that it is expected that acupuncture will be used in the standard treatment of patients with functional GI disorders in the future. A study headed by Dr. Richard Holloway of the University of Adelaide, South Australia, found that one of the known causes of GERD (gastroesophageal reflux disorder), transient lower esophageal sphincter relaxations, were inhibited 40 percent by electrical stimulation at the acupuncture P6 point on the wrist. The study was published in the August, 2005 issue of the American Journal of Physiology-Gastrointestinal and liver Physiology. Further study by the NIH is underway to confirm these studies and provide well-funded research evidence to duplicate evidence from Chinese studies. Of course, none of these studies will incorporate the entire protocol routinely used by the competent Licensed Acupuncturist and Herbalist. Links to these and many other scientific studies is found below in additional information.
While Irritable Bowel Syndrome is a complex problem, I hope that the information in this article helps elucidate your pathology somewhat and helps you in your treatment decisions. More information will be added in time, as well as up-to-date resources below.
For more information on IBS and other intestinal disease click on the links below:
- The National Digestive Diseases Information Clearinghouse, a service of the NIH, gives reliable basic information. http://digestive.niddk.nih.gov/ddiseases/pubs/ibs/
Ulcerative Colitis and Crohn's Disease
The subject of chronic inflammatory disease of the gastrointestinal tract is complex. The wide spectrum of contributing disorders that may lead to these chronic inflammatory states, and the large variance in patient presentations, as well as the often inexplicable episodic nature, has led to a confusion in allopathic medicine. Our standard allopathic approach has been to monitor the disease and try to control symptoms until a more drastic allopathic treatment is necessary, such as colon resection, or harsh medications. Patients, as well as medical doctors open to Complementary Medicine, have been increasingly utilizing a more conservative and holistic approach, which is proving successful for a large number of patients. Ulcerative colitis affects nearly 2 million patients in the U.S. and the exact cause remains undetermined. Medical experts agree that the condition appears to be related to a combination of genetic propensity and environmental factors, which is standard medical jargon for “we don't know.” Recent studies have determined that NSAIDS (non-steroidal anti-inflammatory drugs) may be a causative factor. Studies on animals found that ibuprofen selectively inhibited oxidation of butyrate, leading to increased permeability of the colon membrane, and various studies have linked a number of NSAIDS to acute episodes of colitis. If you routinely take prescription medications you might want to discuss possible gastrointestinal side effect with the prescribing medical doctor, and reduce use when possible.
Diagnosis of inflammatory bowel disease involves analysis of symptom history (frequent or episodic diarrhea, abdominal cramping or tenderness, blood in the stool, weight loss or loss of appetite, low-grade fever, fatique or malaise), as well as stool cultures, fecal blood tests, complete blood labs, sigmoidoscopy or colonoscopy. Since hormonal imbalances have been linked to the pathological mechanisms, an active hormone metabolite panel may also be helpful in a full analysis to guide treatment. Allergy testing has become popular, but often the lab results are somewhat misleading. We all have antibodies to all foods, and so various problems could trigger the higher than normal antibody responses to common foods seen in allergy tests. A practical way to determine if food allergies are effecting your condition is to keep a food journal and systematically analyze worsening symptom episodes in relation to food intake, then eliminate these foods from the diet and see if improvement occurs.
To understand how the gastrointestinal mucosa could acquire an inflammatory problem that the body is not able to control, we need to take a look at the pathophysiology of inflammatory ulcers and the various known causes. The stomach lining, or mucosa, is a very protected type of tissue, since it is subjected to hydrochloric acid and other digestive chemicals that are able to break down and dissolve almost anything that we ingest. Gastritis, or inflammation of the stomach lining, can be caused by any of, or combination of, factors, including flora and fauna imbalance (primarily bacterial), medication (anti-inflammatory medication causes the most cases, but a wide variety of medications may lead to uncontrolled mucosal inflammation), excessive alcohol intake, autoimmune reactions, food allergies, and functional disorders of the GI tract. The bottom line, in pathophysiological terms, is a problem of excess gastric acids not countered by appropriate alkiline secretions, and insufficient or excess immune responses. The causes of these physiological dysfunctions is the chief concern in the holistic treatment, and these gastric dysfunctions and problems could elucidate the pathology of the inflammatory bowel disease.
In the small intestine, the mucosa is also protected by the alkilinity of pancreatic secretion, the bile, and the secretions of the Brunner's glands, all of which normally contain large quantities of sodium bicarbonate that neutralizes the gastric acids that enter the intestine. The small intestine also has feedback mechanisms that are meant to inhibit excess gastric acid from both being secreted inappropriately, and emptied into the intestine in excess. The hormone secretin is normally secreted to regulate these protective reflexes. When any of these mechanisms are dysfunctional, or inhibited by improper diet, hormonal imbalance, or medications, there is increased risk of stimulating the intestinal inflammatory disease. Malabsorption syndromes, such as celiac sprue, or malabsorption of glutens and gliadins, may also stimulate an allergic or autoimmune response. These inflammatory problems may be well controlled during periods of less stress on the body's immune system, but when a number of physiological stressors occur or increase, the immune capability is not up to the task of controlling the inflammatory disease, and episodes of intestinal inflammation will occur. Medical experts associate oxidative stress, imbalance of normal flora and fauna, abnormal glycosaminoglycen content of the mucosa, increased intestinal permeability, increased sulfide production, decreased oxidation of short chain fatty acids, and decreased methylation as common pathological finding with ulcerative colitis. While these appear highly technical to the patient, they do point Complementary Medicine in the right direction to discover effective treatment protocols.
Large studies have shown that there is a high incidence of inflammatory diseases outside of the intestines, as well as malabsorption syndromes, autoimmune disorders, gallstones and kidney stones, associated with ulcerative colitis and Crohn's disease. In 1976, a review of the records of 700 such patients in Baltimore hospitals found that 42% fo patients with colon disease also has extra-intestinal inflammatory complications with their health, and the 23% of patients with upper intestinal disease had such complications. Some more recent studies reveal that even larger percentage of patients have these more systemic inflammatory, functional disorders, or immune health problems. Certain hormonal disorders, such as Vitamin D hormone deficiency, have been strongly linked, as well as specific nutritional deficiencies and problems with protein metabolism. All of this information points to the need for a holistic approach to care. As with all difficult diseases, the complexity of the pathological process is frustrating, but persistence and knowledge are the key to eventual success with treatment.
Both Crohn's disease and ulcerative colitis have been linked to immune dysfunction. Crohn's disease appears to be a T-cell autoimmune disease associated with T-helper 1 (Th1), while ulcerative colitis appears to be associated with Th2 dominance. These findings reflect evidence of high levels of IgG antibodies and autoantibodies. Crohn's disease usually shows high levels of inflammatory mediators associated with autoimmune reaction in the blood as well as in the intestinal mucosa, whereas ulcerative colitis usually shows these inflammatory mediators are high in the mucosa only. For this reason, Crohn's disease was called an autoimmune disease in the past while ulcerative colitis was not. The inflammatory mediators that are involved in both types of inflammatory bowel disease are the interleukins 1,2 6, 8, and TNFalpha (tumor necrosis factor). Interferon gamma is also usually high in the mucosa of Crohn's disease patients.
The lower intestine, or colon, may be reactive to these common problems of the upper GI, or may have problems of chronic inflammation that are unique to the colon itself. Research has found that the colon mucosa resected from patients had altered glycosaminoglycans (GAGs), which is related to inflammatory conditions, and these GAGs had a high amount of hyaluronic acid content. This could signify that the body is producing more of this protective acid in response to bowel inflammation, or it could signify an excess that could come from an overgrowth of certain bacteria that have capsules made of hyaluronic acid, such as streptococcus A. Since hyaluronic acid can inhibit our immune responses to inflammatory mediators, or cytokines, and stimulate excess of the various interleukins and lymphocytes involved in the autoimmune responses, this could be a key part of the disease process. An herbal course of treatment that utilizes formulas to counter excess bacterial growth, then restores normal flora and fauna could be a key strategy in treatment.
Studies of the fecal microflora in inflammatory bowel disease have produced no consistent culprit, with the execption of Clostridium difficile, which was specific to patients that had colitis induced by antibiotic use. Overuse of antibiotics leads to imbalances of normal flora and fauna, and some of these drugs have high rates of side effects and allergic reactions. Antibiotic resistant strains of Clostridium difficile and Streptococcus are becoming epidemic in recent years in the United States, and an herbal course may be a smart part of the overall therapy. Quality probiotics have also been proven effective to counter the various overgrowths associated with ulcerative colitis, such as Clostridium difficile. While no specific culprits have been implicated, a number of pathogens with potential association have been found in the mucosal microflora of these patients. These include E. coli, diplostreptococcus, Clostridium difficile, Fusobacterium necrophorum, Shigella, Heliobacter hepaticus, RNA virus, Bacteroides vulgatus and Yersinia, and various strains of mycobacterium. Unlike antibiotics, herbal antibacterial and antiviral agents have a broad spectrum of application, since they protect the plant from a wide variety of these pathogens.
High sulfate levels in the diet and produced by the metabolism also play a potential role in unhealthy colon mucosal cells. High sulfates result in high amounts of sulfate-reducing bacteria, which produces hydrogen sulfides, which inhibit the metabolism of butyric acid and other metabolites, which starves cells in the colonic mucosa. High sulfate results from excessive meat eating, eating of preservative chemicals, eating of aged cheeses and meats, as well as wines, and possibly even use of shampoos that contain sodium laurel sulphate. Sulphites are highly related to allergic diseases, and many people suffer from intolerances. Migraines, hives, gastritis, water retention, lethargy, depression and rapid heart beat episodes have all been linked to sulfites. These should be avoided.
Increased cancer risk is associated with Ulcerative Colitis and Crohn's disease
Persons with ulcerative colitis (UC) have an increased risk for colon cancer. Standard therapy with resection and harsh medications, may not decrease this risk, and this is another important reason why the patient should engage in a more thorough, but complicated, holistic treatment regimen. Studies have shown that common medications used to treat inflammatory bowel disease actually increase the cancer risk, such as mitronidazole, sulfasalazine and low dose aspirin. Sulfasalazine also results in inhibition of folic acid absorption, a key aspect of inflammatory dysfunction explained below. A 2001 population-based study at the University of Manitoba, Winnipeg, Canada found that there was an increased incidence of colon cancer for both Crohn's disease and UC patients compared to a randomly selected portion of the general population without inflammatory bowel disease. UC patients had an increased risk of rectal carcinoma, and Crohn's disease patients had an increased risk of small intestinal cancer and lymphoma. Both Crohn's and UC patients had an increased risk of liver cancer. This is despite the therapy with steroidal anti-inflammatory and immunomodulating drugs. The study authors stated that these findings corroborated previous findings regarding increased cancer risk in the broad North American population.
Numerous studies have linked oxidant free radical stress in inflammatory bowel disease to the mechanisms of these cancers. Many experts now believe that decreasing oxidant stress will both aid in the treatment of inflammatory bowel disease and reduce cancer risks. A variety of oxidant free radicals and oxidant dysfunctions have been identified that contribute to both cancers and inflammatory bowel disease, and for this reason a number of key antioxidants are being heavily researched. In animal studies, treatment with N-acetyl cysteine reduced both the intestinal inflammation and tumor incidence (see study link below). The glutathione antioxidant and detoxification mechanism is perhaps the most important inherent intercellular defense. Studies with animals have shown that when this system is disrupted, incidence of inflammatory bowel disease and colon cancer increase dramatically. You may read my article on the glutathione mechanism on this website to gain a better understanding of maintenance of this system with herbal and nutrient medicine. Melatonin, resveratrol, methylselenocysteine, zinc monomethionine, B12, 5MTHF (active folate), and various Chinese herbs, as well as electroacupuncture stimulation at key points, have all been proven to boost the function of the glutathione metabolism. Incorporating these therapeutic regimens into an individualized holistic protocol will not only help to treat inflammatory bowel disease, but will help prevent cancers, and unlike harsh pharmaceutical steroid and immunomodulating drugs, will actually benefit the overall health and will have no side effects.
For more information on ulcerative colitis, Crohn's disease, and other intestinal disease click on the links below:
- A 1997 clinical study of the probiotic non-pathogenic Escherichia coli showed proof of probiotic benefit as part of a package of maintenance therapy for ulcerative colitis: http://pt.wkhealth.com/
- A 2004 German meta-analysis of clinical studies of extraintestinal health problems associated with inflammatory bowel disease found that more than 50% suffered with a more systemic inflammatory, hormonal or metabolic problem: http://www.ncbi.nlm.nih.gov/pubmed/15024484
- A 2005 meta-analysis by the University of Alberta Division of Gastroenterology concluded that probiotics and nutriceuticals have been proven and explained sufficiently in treatment of gastrointestinal disorders to warrant clinical usage, but that different strains of probiotics have different levels of efficacy: http://www.sciencedirect.com/science
- A 2001 study published in the Oxford Journals Carcinogenesis found that N-acetyl cysteine, a key antioxidant in treatment of inflammatory bowel disease, inhibited ulcerative colitis-associated colorectal cancer in animal studies: http://carcin.oxfordjournals.org/
Common symptoms and the physiology that explains them
Chronic symptoms are often the signs of an underlying health problem, and when this is the case, this health problem needs to be addressed, not just the symptom.
Flatus, or increased gas expelled from the intestines, is usually caused by activity of gas-forming normal bacteria in the intestine. Certain foods contain fermentable carbohydrates that may be poorly digested, such as beans, cabbage, onions, cauliflower and corn, and so stimulate an overgrowth of gas-forming bacteria that may continue to produce excess gas until the normal balance of flora and fauna is restored. Refraining from eating these foods may not solve the problem, and a course of corrective herbs, acupuncture and probiotics is recommended. Often, in gastrointestinal disorders, it is the excessive motility, or muscle action, resulting from bowel irritation, that causes excess gas to be moved through the bowels instead of being absorbed through the intestinal mucosa and utilized by the body. Normally, 7-10 liters of gas is produced daily, but only 0.6 liters is expelled. Various physiological problems can also upset the balance of gases, which include carbon dioxide, hydrogen gas, methane and oxygen. These problems need to be addressed with chronic excess flatus release. Lactose intolerance frequently causes excess flatus, or gas. This occurs because the lactose is not easily broken down into glucose and galactose, but instead continues on in the digestive tract to the bacteria in the small intestine, where excess fermentation occurs, producing excess gases, acids, and other osmotically active molecules that irritate and increase small intestine motility, often resulting in loose stools.
Diarrhea may be caused by a) poor absorption in the intestinal membrane with excess osmotic load in the small intestine, resulting in increased fluid drawn into the small intestine and retained, rather than absorbed; b) obstruction of the veinous return or lymphatic circulation, which results in increased fluid pressure, altered permeability in the intestinal mucosa, and passive secretion of fluid and electrolytes into the small intestine, rather than into the veins or lymphatic channels; c) excess stimulation of the mucosal enzymes by bacterial toxins or other factors, causing active transport of electrolytes and fluids into the small intestine; d) small intestine mucosal dysfunction, creating excess fluid in the small intestine; e) side effects of drugs (antibiotics, antacids, laxatives, gout medication, diuretic (ethacryinic), hypertension drug (guanethidine), metyrosine, methotrexate, etc.); f) various medical treatments, such as radiation therapy, gastroenterostomy, gastrectomy, pyloroplasty. A common theme here is poor health of the small intestine membrane, which should be addressed in therapy to clear the underlying cause of chronic diarrhea. Malabsorption syndromes, lactose intolerance, fungal and parasitic infection, IBS, Crohn's, Ulcerative colitis, TB, thyrotoxicosis (thryroid toxicity), and cancer are all common diseases that should be assessed and diagnosed to direct therapy expertly. IBS patients with chronic diarrhea are more likely to have Celiac disease.
Diarrhea may occur due to problems with intestinal lumen, mucosa, or with vascular or lymphatic problems. Impaired fat absorption in the intestinal lumen, usually due to reduced bile salts with chronic low-grade liver dysfunction or chronic gallbladder problems of inflammation, or sludge and stone formation, are the most common causes. Bacterial overgrowths may also be suspected, though. Problems with bile and fat digestion usually result in stool that floats, appears greasy or shiny, and often has a pale appearance. Fat malabsorption typically results in increased symptoms after eating fatty foods, and could also be related to deficiencies of Vitamins E, K, A and D (vitamin D is actually a prohormone, and not a vitamin, although metabolites of Vitamin D cholecalciferol are vitamins). Problems with pancreatic insufficiency (typically called Spleen dificiency in Traditional Chinese Medcicine) are also suspect, and deficient enzyme excretion may be a problem. Problems in the mucosal phase typically are linked to Celiac disease, or sprue. Inhibition of absorption of B12 and folates may also be involved. Diarrhea caused by stool transport problems typically are related to lower bowel health problems, with vascular and lymphatic ill health in the intestinal border, sometimes related to diverticulosis or Crohn's disease, but also may be seen in Celiac disease, or sprue, involving the small intestine. Imbalance of intestinal flora and fauna, or microbial imbalance, may lead to congestion or inflammation of small blood vessels or lymphatics as well.
Chronic diarrhea is defined as diarrhea that last more than 4 weeks during an episode. It is characterized not just by frequency of bowel movements, but by loose stools with excesses of water, electrolytes, fat, or other substances. More than 200 grams (about 1 cup) of loose stool per day is passed with diarrhea. Patients with frequents or urgent bowel movements, but passing less than 200 grams of loose stool per day may have health problems other than IBS, Chrohn's, UC, malabsorption, or lactose intolerance. A very large amount of fluid passes through the intestines each day, with 10 liters considered normal, and 90% should be absorbed in the small intestine, while 90% of the remaining fluid should be absorbed in the colon. This implies that the small intestine is the most likely area of dyfunction, although up to 1000ml of fluid is normally absorbed in the colon, and loose stool implies that an increase of only 50-60ml is occurring. Colorectal health should be assessed with testing and exam to rule out health problems here, as more threatening problems may be found, such as cancer, but negative testing merely implies that the small intestine is the most likely cause of the diarrhea. Problems with mucosal resistance are most likely in the upper small intestine, or jejunum. With chronic problems a combination of malabsorption, inflammatory problems, altered motility, and mucosal resistance with osmotic and secretory dysfunction are all likely involved. These must all be addressed in therapy over time.
A problem that may occur with either chronic diarrhea or acute episodes of diarrhea with increased fluid loss, is a deficiency of the electrolyte potassium ion. This problem may account for chronic fatique and asthenia in cases of chronic diarrhea. In severe cases of acute diarrhea, loss of potassium ion can be very threatening, and frequently, patients are given potassium salts, or potassium chloride, as a means of preventing dysfunction of the organ muscles of the heart. In chronic diarrhea, supplementation with a low dosage of natural potassium salt may improve symptoms of sluggish asthenia and fatique. In case studies of chronic potassium ion depletion with diarrhea, routine laboratory studies of the blood, stool, and urine are usually unremarkable. Sometimes, mild abnormalities of the electrocardiogram (ECG, or EKG) are noted, suggesting hypokalemia (potassium deficiency), and repeated blood tests often reveal fluctuating and mildly deficient serum potassium levels and chloride concentrations. Usually, in these cases, other electrolyte values are normal, such as serum sodium, calcium, and phosphorus. In these cases, standard medicine usually does not prescribe potassium chloride, as there are risks of accumulating too much potassium chloride and creating problems with cardiac function. Chronic potassium depletion is not uncommon, though. Patients prescribed diuretics for hypertension often must switch to a potassium sparing diuretic due to chronic potassium depletion. In the clinical setting, up to 20% of patients complaining of chronic diarrhea practice laxative abuse, often as part of an acquired eating disorder, such as anorexia nervosa or bulimia, and seek medical care related to symptoms of potassium depletion. Chronic potassium deficiency is also seen at times with fasting, alcoholism, hyperaldosteronism, and other adrenal excess syndromes, and in hereditary problems such as Liddle's syndrome. Potassium deficiency is almost never caused by a poor diet, as most fresh foods contain potassium. If a mild chronic potassium deficiency is part of a chronic diarrhea syndrome, supplementation with a low dose of natural potassium salts, such as India Black Salt, may clear fatique and asthenia with a short course of 1/2 teaspoon per day.
Constipation is usually due to a decrease in bowel motility, or to a decrease in fluids in the intestine, producing either infrequent bowel movements or dry hard feces, with some overlap. For most patients, constipation is defined by the need to strain in order to have a bowel movement, or the discomfort of bowel pressure, or fullness. Other patients may be bothered by incomplete bowel movements, and the sensation that the feces is not completely eliminated, often resulting in the patient trying to evacuate the bowel a few times each day. The usual underlying causes include motility dysfunction, anatomic defects, poor diet and lack of exercise, or psychological factors affecting the autonomic nervous system. Chronic use of opioid pain relievers is also a well known cause, and this is mainly because opioid receptors are located on the smooth muscle of the intestine and pain medications reduce motility, although opioids are also found to inhibit fluid and electrolyte secretion. Tissue studies in patients with chronic constipation find tissue changes that result in fewer nerver receptors, such as 5HT and serotonin receptors, making it difficult to react to normal stimuli of bowel movment, or motility. Restoration of the health of the intestinal lining as well as healthy autonomic function is often necessary to fully restore healthy function.
Studies at the Mayo Clinic in 2000 found that found that constipation, irritable bowel syndrome, and diverticulosis are much more prevalent in the aging population. For women, this appeared to be often related to disturbances in pelvic floor function, and for men, the study indicated that disorders of inhibitory control of neuromuscular function were predominantly responsible, with excessive collagen deposition and neurodegeneration in the myenteric nerve plexus. The key findings related to neural injury or neurodegenerative problems in men, and pelvic floor myofascial problems in women. Health of the nerve plexus may relate to oxidant stress, hormonal deficiencies and growth factors, as well as pelvic floor dysfunction. Drs. Rodney Anderson and David Wise of the Stanford University department of neurology have researched and written on an understanding and treatment of the problems of pelvic floor myofascial dysfunction, and developed the Wise-Anderson Protocol (refer to their book: A Headache in the Pelvis). This research takes a holistic approach to a variety of related common problems, notably urinary urgency, low back and pelvic pain, discomfort with bowel movements and urination, sexual dysfunction, and constipation. Treatment focuses on active release techniques, contract and release, paradoxical relaxation, and myofascial trigger point release. Dr. Wise believes that the common diagnostic and treatment protocol that utilizes X-ray, CT, MRI, extensive blood tests, and a variety of pharmacological treatments is a waste of the health dollar. Tests administered in the Stanford Protocol involve active hormone metabolites of cortisol, androgens, etc. evaluated in saliva tests. Patients suspecting pelvic floor dysfunction should purchase this book to gain an understanding, and the book also presents many therapeutic protocols that the patient self-administers at home, which is very important.
Feeling very tired or low energy after eating, termed postprandial asthenia, may be explained by a variety of mechanisms. Common manifestations of chronic Giardia and viral infection often produces fullness feeling, increased bowel sounds, diarrhea soon after eating, increased flatus, chronic diarrhea, fatty food intolerance, foul smelling gas or stool, frothy appearance to loose stool, lethargy after eating, and malaise (depression). The patients with these chronic problems usually have a low-grade infection, and typically have a thin appearance. Lactose intolerance is usually acquired. The onset of disease typically occurs after traveling or hiking. In some cases sexual practices involving oral/anal sex may precede the Giardia or viral problem. A series of microlab testing of stool samples and duodenal fluid is recommended if this is suspect, although a full set of tests may be prohibitively expensive for patients without insurance coverage, and in this case, simpler tests can be used. A large number of testing companies have sprouted in the last decade, with some question as to testing standards, presenting a confusing situation for the patient. Great Smokies Lab was among the first labs that performed quality inexpensive testing, and is highly rated. Genova Diagnostics is perhaps the largest testing company utilized in the U.S. and Europe for these types of tests. Test kits must include specimen sample containers with fomalin or zinc sulfate preservatives and 3 samples must be taken on nonconsecutive days. Giardia antigen tests are the most cost-effective.
The typical signs and symptoms of chronic Giardia or viral intestinal infection include easy fatique, depression with a mood disorder that involves a discouraged sense, chronic anxiety, tiredness or asthenia, and diffuse inexplicable body aches and pains. The differential diagnosis is often not pursued adequately in these cases, and often the patient may go for years with a nonspecific diagnosis of Irritable Bowel Syndrome. Concurrent Celiac Disease is also common, and a patient with this diagnosis may be unaware in cases with chronic diarrhea that they have a Giardia, protozoal, or low-grade viral infection. Treatment with herbal formulas contains may chemicals, typically, addressing a wide variety of chronic infections, and this type of course is recommended. Short courses of various herbal formulas devised for these problems is typically used, punctuated between therapeutic protocols to restore the intestinal membrane health, autonomic function, and balance of flora and fauna in the intestine. There is no substitute for such a comprehensive package of care, which may be administered after trying a standard course of pharmaceuticals as well, if diagnosis is specific. After ridding the body of Giardia, protozoa or low-grade viral infection, an immediate course of restoration of intestinal health with Complementary Medicine is recommended to avoid reinfection and to treat the systemic chronic symptoms.
Treatment strategies that are well documented for ulcerative colitis and inflammatory bowel disease are explained below.
- Antioxidants: studies have shown particular antioxidant deficiencies in patients with ulcerative colitis. These include retinols, alpha tocopherol, lycopenes, and beta carotene. This helps to direct the choice of antioxidant supplements, but more importantly, points to the various health problems associated with these deficencies. In addition, there are a number of antioxidants that have very strong antioxidant effects, and could be effective with short term use. Antioxidants are naturally manufactured by the body to counter cellular wastes, called free oxygen radicals, that damage the immune response if they are accumlated in excess. These free radicals are manufactured by our cells in excess when there is chronic inflammatory disease, damage from environmental toxins or radiation, or if there is a metabolic problem, such as metabolic syndrome and insulin resistance in our fat cells. Retinols are Vitamins A1 alcohol and various metabolites, and nutritional defiencies are rare. The problems with retinol deficiencies appear to be associated with estrogen deficiency and hormonal imbalance in a large number of cases. Studies in Japan showed that injection of estrogens stimulated an increase in circulating retinols. Taking Vitamin A may not be helpful in and of itself, and prolonged taking of a high dosage Vitamin A has a risk of toxicity. The second antioxidant type on the list is alpha tocopherol. Alpha tocopherol is a type of Vitamin E that is synthesized by the body or derived from wheat germ oil, and is used by our bodies to slow oxidation of fats and thus protect our lipid membranes. To maintain our natural alpha tocopherol levels, our bodies need zinc, and to insure dietary uptake, selenium. Taking copper/zinc SOD and selenium may be advisable with ulcerative colitis to insure proper alpha tocopherol metabolism. A topical cream may also work well to deliver alpha tocopherol. SOD, or super oxide dismutase, is a particularly potent antioxidant enzyme the protects our cells from the most damaging type of free radical, super oxide. Taking copper/zinc SOD may supply zinc, benefit alpha-tocopherol metabolism, and clear intestinal tissues of super oxides. Dried barley grass is also an excellent source of SOD and many other types of antioxidants, and is highly recommended for a number of reasons, explained below. Third on the list of deficient antioxidants in inflammatory bowel disese is lycopene. Lycopene is a type of carotene found in red vegetables and fruits, such as tomato skins and watermelon, and both lycopene and beta-carotene are found in orange vegetables, such as carrots. Beta-carotene is also a precursor for Vitamin A, included in the retinol category. Vitamin A is an especially effective antioxidant in mucous membranes, such as the intestinal lining. RECOMMENDED: dried barley grass powder, carrot juice, copper/zinc SOD or zinc methionine (OptiZinc), and selenium as methylselenocysteine; as well as attention to hormonal balance. Melatonin is also a powerful antioxidant in the body, and has been found in the GI tract at 10-100 times the levels found in the blood, and 400 times the level found in the pineal gland of the brain. Melatonin has also been found to relieve intestinal spasm and inhibit TNFalpha to curb allergic, inflammatory, or autoimmune reactions. High dosage is recommended in short courses, with at least 15 mg take daily. Certain herbs may stimulate increased melatonin also, such as kava kava, and the psoralen containing herbs, such as bai xian pi (antifungal), and psoralea corylifolia (Bu gu zhi). 5HTP is a supplement that also provides increased bioavailability of melatonin as a precursor, and improves the neurological health of the intestines, where most of our HTP (hydroxytrytophan) receptors are located. A combination of melatonin, 5HTP, St. Johns Wort, and P5P (active vitamin B6) is a recommended combination, and available from Vitamin Research, called Positrol. N-acetyl cysteine is also a potent antioxidant and aid to the glutathione cellular detoxification metabolism. N-acetyl cysteine is also a mucolytic, helping to dissolve overly thick mucus in mucuous membranes. This nutritional chemical is now often combined with cellulose and other aids to intestinal function (N-Accelle), and is marketed by pharmaceutical companies under dozens of brand names around the world due to the strength of the research supporting its medical use.
- Deficient folates and Vitamin B12 with high homocysteine levels: this condition has been found to occur more commonly in patients with inflammatory bowel disease (27% compared to 3% in the normal population). High homocysteine levels indicate a problem with normal metabolism or increased need for homocysteine, and deficient folates and B12 are associated with this disorder in studies. Taking of folic acid and sublingual B12 couldn't hurt, and to improve the homocysteine metabolism, taking Zinc methionine (OptiZinc) is recommended. High homocysteine levels are now the chief marker indicating cardiovascular disease as well, and indicates that a problem is occurring with this metabolite normally converts to methionine with flolate/B12 interaction. Folate deficiency has been found in 45% of the population and may lead to poor tissue repair and capillary fragility, as well as deficient glutathione metabolism. A metabolite of folate, 5MeTHF, can increase nitric oxide production and directly scavenge superoxide radicals. Proper metabolism will perhaps aid tissue repair in ulcerative colitis in a number of ways. To fully insure restoration of this metabolic cycle, take folic acid, sublingual B12, Vitamins B6 and B2, spirulina, krill oil, and SAMe. A course of these supplements should restore the metabolism, and continuous use is unnecessary. This course will help to restore the glutathione metabolism as well, which is a key antioxidant metabolism, and important for healthy liver function. Understanding of all of the exact metabolic pathways is complicated, but this is why we have naturopathic medical colleges and vast numbers of researchers, and we should rely on these experts.
- Dietary changes: Dietary studies around the world conclude that there are certain foods posing increased risks in ulcerative colitis. These include refined sugar, simple carbohydrates and starches, excess protein, polyunsaturated fats (trans-fats), sucrose, animal fat, and fast food. A change of diet has been considered key to the overall treatment strategy for many patients, and incorporation of whole grains, fresh vegetables, and legumes is very important, as well as consumption of healthy fats and oils.
- Hormonal balance: DHEA levels have been found to be consistently low with chronic inflammatory conditions, and relative estrogen deficiency, as well as adrenal insufficiency with poor diurnal cortisol control, have all been linked in study to patients with inflammatory bowel disease. Bio-identical hormones and herbal formulas can be very helpful if this is a problem, and topical creams with pregnenelone, the hormonal precursor to DHEA, may be effective, especially when applied to the abdomen. Active metabolite saliva tests are inexpensive and will reveal these problems to the physician. Professional guidance is a must with use of bioidentical hormones.
- Vitamin K, cholecalciferol, and coral calcium: studies have linked these deficiencies to inflammatory bowel disease. Vitamin K is a necessary component to control bleeding, Vitamin D3 is useful in tissue repair and maintenance, coral calcium is easily absorped and is useful in tissue problems related to calcium deficiency. All three of these deficiencies are also related to hormonal balance, and this must be addressed.
- Vitamin C: An Australian study examined colon biopsies from inflammatory bowel disease patients and determined that mucosal concentrations of this vitamin, essential for tissue repair, were very low. An herbal supplement with quality Vitamin C is recommended when there are episodes of bowel inflammation.
- Dried barleygrass powder: barley grass contains many nutrients that are valuable to correcting chronic inflammatory conditions. Barleygrass contains 3 key anti-inflammatory biologics; chlorophyll, PD41 and mucopolysaccharides, is rich in Vitamin A and healthy protein, and will absorb mineral accumulation from tissues efficiently. Mineral accumulations, such as calcium accumulation and environmental heavy metals, are large irritants and stimulate excess inflammatory and autoimmune reactions. PD41 stimulates RNA/DNA renewal, and has been tested and proven to be an anti-inflammatory that outperforms cortisone. Barleygrass also contains many enzymes, as well as SOD, a premier antioxidant. This makes dried barleygrass powder a supersupplement for patients with inflammatory bowel disease. Barleygrass powder tends to clump when dissolved in water, and so you should slowly add the powder to hot water or juice in a blender to make a smooth drink that sits well in the stomach. For patients with a sensitive stomach digestion, introducing the dried barleygrass powder slowly and increasing dosage, and making sure that the powder is blended well in warm water or nonacidic juice is important.
- Flavonoids: flavonoids are a large class of chemicals produced in the body and abundant in foods and herbs. Quercetin, a key bioflavonoid in a number of Chinese herbs, has been well studies in relation to ulcerative colitis, and was found to reduce colonic adhesions and membrane surface damage by 30-45%. By itself, this flavonoid did not improve the overall disease severity, but as a part of the holistic treatment plan could be a key ingredient to success. Quercetin counteracts glutathione deficiency and improves antioxidant metabolism, as well as improving capillary health and microcirculation. Taking a quercetin supplement may help, but taking herbs rich in quercetin may offer a more complete therpeutic package. Ji mu (Loropetalum chinense) has been used to treat duodenal ulcers and intestinal bleeding for centuries and is rich in quercetin. Luo bu ma (Apocynum venetum) is a remarkable herb with quercetin used to treat a variety of visceral deficiencies and check intestinal hyperactivity. Sang ji sheng (Loranthus paraciticus) is used in many formulas and aids microcirculation in the tissues, as well as inhibiting the immune cytokines TNFalpha and IL-1, which studies link to the allergic and autoimmune reactions in inflamatory bowel disease. Fan shi liu (Psidium guajava) contains quercetin and has been traditionally used to treat diarrhea and intestinal bacterial overgrowths and inflammation. Ce bai ye (Biota orientalis) is used traditionally to treat duodenal bleeding and hematochezia. Yu xing cao (Houttuynia cordata) also contains quercetin and treats intestinal inflammation, dysentery, and has a broad antibacterial and antiviral activity. We see from this list how Chinese herbs traditionally used to treat symptoms of inflammatory bowel disease contain this key flavonoid. Gingko biloba is also a well studied herb rich and flavonoids and is addressed below. Professional prescription and use of these herbs in individualized protocol is important, and the Licensed Acupuncturist and herbalist that is knowledgeable is best able to deliver this herbal protocol in the correct manner.
- Proteolytic enzymes: bromelain and a number of proteolytic enzymes have been studied in clinical trials in relation to inflammatory bowel disease. These enzymes help clear accumulations of irritating protein fragments in the tissues, and thus exert a potent anti-inflammatory potential. The field of enzyme therapy for tissue inflammation continues to expand, and recent advances in research continue to produce promising supplements. These enzymes are now key parts of formulas used to treat inflammatory bowel disease and functional disorders, and a professional herbalist can supply the most effective and professional grade products in formula. A specific proteolytic enzyme, dipeptidyl peptidase 4, is found is to be deficient in a large percentage of patients with Celiac disease and gluten malabsorption syndromes, and a patented blend of enzymes to enhance DDP4 has been created in Japanese research (re: Health Concerns Enteromend). Other potent proteolytic enzymes include serratiopeptidase, nattokinase, and seaprose.
- Phytosterols: plant sterols, or bioidentical hormones, are the subject of much research. Beta-sitosterol and beta-sitosterolin were studied in animal studies and proven to normalize T-cell function and dampen overactive antibody responses. Since the T-cell responses have been proven overactive in inflammatory bowel disease, herbs, topical bioidentical hormones, key supplements, and direct supplements with these phytochemicals may be beneficial in therapy. Typical treatment may also include the lowest effective dose possible of topical creams to encourage production of pregnenelone, progesterone, estriol and testosterone. The aim of this type of therapy should be to restore, and not supplant, natural hormonal prodcution and balance, and homeostatic mechanisms. These creams usually contain a variety of seed oils that are high in beta-sitosterol and beta-sitosterolin as well as key phytohormonal herbs. A number of zinc supplements also contain beta-sitosterol and may be useful.
- Plant lignans and the production of Enterolactone and Enterodiol: lignans in plants account for some of the most potent and beneficial nutrients that we consume, and are a big reason that increased fiber, whole grain and more vegetarian diets, and consumption of legumes, nuts and seeds are shown to benefit patients with inflammatory bowel diseases, as well as treat and prevent various cancers, cardiovascular disease, and osteoporosis. These chemicals are called phytoestrogens, along with bioflavonoids and coumestans, but while they produce hormonal effects, some of which are estrogen-like, they are not estrogens. Plant lignans are able to be turned into intestinal hormones, enterolactone and enterodiol, via the activity of normal intestinal symbiotic bacteria. They have potent immunomodulatory effects, inhibiting cell proliferation and cytokine production, and TNF-alpha production, all of which drive inflammatory bowel disease. These hormonal chemicals also are proven to pass the intestinal barrier and modulate cytokine (inflammatory mediators) production in the intestinal wall. More potent delivery of these dose-dependant lignans is available in a product called NuLignan, derived from the Norway spruce. A number of Chinese herbs also deliver a potent dosage of lignans, the most famous of which is Schisandra berry. To utilize lignans, though, improving the health of the intestinal bacterial colony is important. Taking short courses of clearing formulas and following with effective probiotic formulas is recommended to insure that NuLignan, improved dietary lignan, and lignans in Chinese herbs produce sufficient enterolactone and enterodiol. The Chinese have also developed an economical way to produce these intestinal hormones outside of the body naturally, utilizing human bacterial activity, and these products may soon be on the market. This type of therapy could be very effective in the protocol to correct immune dysfunction driving intestinal inflammation.
- Essential fatty acids: double-blind placebo-controlled clinical trials have been conducted and prove both that need of these omega 3 and 6 EFAs are increased in inflammatory bowel diseases, and that remission of episodic exacerbations of symptoms in ulcerative colitis subsided more quickly with the use of EPA (eicosapentanoic acid). Although the results of the trial were not dramatic, and some measures of cure were not quite clinically significant, patients receiving these omega-3 fatty acids used less steroid medication to treat symptoms and a measured 50% decrease in immune response of leukotriene B4 synthesis was noted. It should be noted that a fairly high dose of omega-3 EPA was needed to significantly benefit the flaring of symptoms in episodes of inflammatory bowel disease. These studies point to the advantage of inclusion of these supplements into the treatment protocol, though, rather than a dependence on them as a single treatment protocol. Krill oil is the most concentrated source of EPA and DHA, and will not go rancid easily, like most fish oils. A high dose of krill oil involves just a few small capsules, whereas a high dose of fish oil would amount to a handful of large capsules of oil, which often upset the stomach. A balance of essential fatty acids is key to use of fatty acid supplements in general. Patients that eat a predominantly meat and starch based diet probably need to supplement with Omega-3 EPA and DHA. Patients that are predominantly vegetarian may have an omega-6 deficiency, supplementation with such omega-6 fatty acids as gammalinolenic acid, from black currant seed, is recommended and mentioned in this article in relation to the last approved drug to treat IBS, which is a synthetic fatty acid related to omega-6.
- Phosphatidylcholine: phosphatidylcholines are a class of phospholipids (main components of cell membranes) that contain choline. Lecithin, the first phosphatidlycholine identified, has been much utilized since its discovery in egg yolk in 1847, both as an emulsifier and lubricant, but also for its significant effects on improving lipid metabolism, lowering total cholesterols and triglycerides and improving HDL levels, especially when used with niacin, or Vitamin B3. Choline deficiency has been linked to liver and muscle damage in postmenopausal women and andropausal men, infertility, growth impairment, bone abnormalities and hypertension. A 2010 study (cited below) at the University of Heidelberg, Germany, found that phophatidylcholine is a potent addition to the treatment protocol in IBS, both as an anti-inflammatory and as a compound that improves surface hydrophobicity, acting both to improve intestinal immune health and potentially decrease chronic diarrhea. The anti-inflammatory activities of phosphatidylcholine include inhibition of TNF-alpha, and activation of NF-kB, to modulate inflammatory mechanisms. The concurrent use of phosphatidylcholine with plant lignans may increase these enterocyte effects, and stimulate production of the valuable hormomes enterolactone and enterodiol by intestinal bacteria. A further combination of these nutrient medicines with bovine colustrum and probiotics could act to restore intestinal membrane health and immune function considerably.
Herbs included in clinical studies to date for inflammatory bowel diseases in the United States and Europe
Gingko biloba, Boswellia serrata, St. John's Wort, Taraxacum officinale (pu gong ying), Melissa officinalis, Calendula officianalis, fennel, Peumus boldus, Peppermint oil, and others have been studied and found successful in small clinical trials. Other herbs and formulas have been studied in China, Japan and Korea, but the results have still not been published in the United States. Various formulas will contain these herbs. Professional guidance is recommended always, and this practitioner is able to obtain and utilize any of these clinically studies herbs. Below are just a few of the studied herbs for your research. As stated above in this article, recent mega-analysis of clinical studies has found proof of efficacy in over 50 Chinese herbal medicines, although there is a reluctance to publish these numerous studies in standard medical journals in the United States or Europe, and thus we are still waiting for them to appear on PubMed. To see this review, click here: http://www.ncbi.nlm.nih.gov/pubmed/16437473
- Gingko biloba: small studies of this herb, which promotes improved circulation and contains key flavonoids, have proven effectiveness for 30% of patients. As with all herbs, they are an effective part of the overall holisitic regimen. The question is not which herb, but what herbs and supplements should I take in combination, or with a step-by-step protocol.
- Yarrow (Shi cao): this herb contains several alkaloids, flavonoids and essential oils, and has been traditionally used to treat abdominal fullness. It has antibacterial actions against a number of intestinal bacteria overgrowths, including E. coli, bacillus dysenteria, staphylococcus aureus, and streptococcus. To obtain the oils, an alcohol tincture may be needed.
- Boswellia serata: this herb, used for allergic reactions and tissue healing traditionally, was studied in relation to inflammatory bowel disease and proven effective. The common name is Frankincense, and is available in many of the Chinese formulas used to promote tissue healing. Since it is a tree resin, a liquid resin formula that includes other beneficial resins, such as Dragon's blood, is also available. Dragon's blood resin was proven very effective to inhibit heliobacter pylori in clinical studies, and could aid tissue healing and heliobacter overgrowths in the colon as well as the stomach. The active ingredient studied, catalposide, is also found in the Chinese herb Sheng di huang (treated rehmannia), which is used to clear blood heat and inflammation and nourish the blood. Studies have also confirmed that concurrent use of Piper nigrum (Hu jiao pepper), or the chemical constituent piperine, aid the absorption and bioavailability of boswellia resin to increase effectiveness. Piper nigrum is traditionally prescribed for chronic diarrhea and poor stomach and intestinal function. Since it is a pepper, it is taken after a meal and never with alcohol. Ground Piper nigrum may also be added to liquid Boswellia resin formula.
- Artemesia absinthia: studies at Yale University School of Medicine in 2007 examined the use of this herb in herbal formula in a double-blinded placebo study of Crohn's Disease. Patients already receiving a steroid, prednisone, were given the herbal formula and the steroid therapy was tapered off. 90% of the patients receiving the herbal formula showed a steady improvement in symptoms as they tapered off of steroid use, and after 8 weeks of therapy, there was almost complete remission of symptoms in 65% of patients, while the placebo group showed no decrease in symptoms. Restarting of steroid therapy was necessary in only 10% of patients. The study also found that emotional mood and other quality of life factors were improved by the herbal formula. PMID: 17240130; Phytomedicine. 2007 Feb;14(2-3):87-95. The studies at the University of Freiburg, Germany, also found that Artemisia absinthium suppresses key inflammatory mediators thought responsible for the autoimmune symptoms of Crohn's, such as tumor necrosis factor alpha (TNFalpha). Other strains of artemisia, such as Artemesia qinghao, have also been studied and found effective to decrease Crohn's symptoms, as well as the symptoms in ulcerative colitis.
Herbal chemicals may be extracted into water, alcohol or glycerine. different mediums will extract different chemicals. The choice of herbal supplement should be guided not by what is most convenient, but by what will work the best. Often, a combination of water extract pills or capsules, and alchohol/glycerite tinctures, is most effective. Some of the researched herbs can be combined in tinctures. A tincture of Gingko biloba standardized extract, Yarrow, Boswellia serrata, and Artemisia absinthia can be prepared by a professional herbalist.
Additional information and research
- A 2009 study at the Nerve-Gut Research Laboratory of Royal Adelaide Hospital in Adelaide, Australia, found that chronic dysregulation of the immune system, with a Th1 dominance (T-helper cell 1 response over Th2), induces intestinal hypersensitivity, and may be the central mechanism underlying IBS: http://www.ncbi.nlm.nih.gov/pubmed/19566823
- A 2011 study at the Institute of Medical Psychology and Behavioral Immunology at the University of Duisburg-Essen, in Germany, found that dysfunctional immune responses in IBS contributed to a hypersensitive neural response to pain involving both the peripheral and central nervous system (brain-gut axis), which altered emotional and cognitive pain modulation, eventually created functional and structural brain changes involving the prefrontal and cingulate areas, and pointed to a need for a holistic treatment protocol in IBS: http://www.ncbi.nlm.nih.gov/pubmed/21094682
- A 2010 study and research megareview at the University of Toulouse, France, is investigating the promising research of the past the confirms the effectiveness of various Chinese herbs of the Curcuma family (E Zhu, Yu Jin, and Jiang Huang/Turmeric) against parsites such as Giardia, Candida, Coccidia, Babesia, Sarcoptes, which are increasingly seen in urban populations: http://www.ncbi.nlm.nih.gov/pubmed/21104602
- A 2003 study at the Fourth Military Medical University in Xian, China, found that electroacupuncture at a single point, ST36, produced significant downregulation of the inflammatory mediator TNF-alpha in cases of ulcerative colitis. TNF-alpha is a key cytokine overexpressed in this disease that stimulates many of the symptoms, and perpetuates the inflammatory bowel disease: http://www.ncbi.nlm.nih.gov/pubmed/12717850
- A 2010 study at the University degli Studi di Milano, in Italy, found that lignan induced enterolactone and enterodiol were able to cross the intestinal barrier and modulate inflammatory mediators (cytokines) that drive inflammatory bowel disease. http://www.ncbi.nlm.nih.gov/pubmed/20446732
- A 2009 study at the Shanghai Institute of Acupuncture found that electroacupuncture at the points ST25 and ST37 can decrease the number of mucosal mast cells in the intestine that are associated with chronic inflammation, and also down-regulate the expression of corticotropin-releasing hormone in the hypothalamus, effectively decreasing two of the most significant markers of the irritable bowel syndrome: http://www.ncbi.nlm.nih.gov/pubmed/19891022
- A 2008 study at Fudan University in Shanghai, China, found that electroacupuncture at the points ST36 and ST37 may significantly decrease hypersensitivity of the colon in irritable bowel syndrome and attenuate the related neural receptors (glutamate receptors) at the spinal cord: http://www.ncbi.nlm.nih.gov/pubmed/18694764
- A 2010 study at the University of Heidelberg, Germany, found that phosphatidylcholine exerted significant effects to aid in therapy of IBS (ulcerative colitis) by exerting both potent anti-inflammatory effects and improving membrane health and immune response, increasing hydrophobicity to potentially decrease diarrhea, and aiding the neurological signaling potential of the gut: http://www.ncbi.nlm.nih.gov/pubmed/21152327
- A 2010 article from the University of Heidelberg, Germany, proposed that phosphatidylcholine depletion could lie at the heart of the pathology in ulcerative colitis, as the deficiency impairs the mucosal barrier and allows the initial attacks of commensal bacteria to induce the complex cascade of pathological events leading to IBS and ulcerative colitis. This research demonstrates the potential of phosphatidylcholine as part of a preventive treatment in early stages of IBS: http://www.ncbi.nlm.nih.gov/pubmed/21105858
The information on this website is not intended to be used as a specific medical advice or cure. Please consult with the practitioner or an appropriate physician, such as a licensed acupuncturist, naturopath, or medical doctor, to discuss the proper application of the information contained on this website.