Irritable Bowel Syndrome (IBS) Lecture Notes PDF

IRRITABLE BOWEL SYNDROME (IBS) YEAR 1 - HERBAL MEDICINE Dr. Matt Gowan, ND email: [email protected] LEARNING OBJECTIVES Define the main herbal actions used to treat IBS Identify commonly used herbs for IBS Remember both common names and latin binomials for the herbs discussed Explain the main...

IRRITABLE BOWEL SYNDROME (IBS) YEAR 1 - HERBAL MEDICINE Dr. Matt Gowan, ND email: [email protected] LEARNING OBJECTIVES Define the main herbal actions used to treat IBS Identify commonly used herbs for IBS Remember both common names and latin binomials for the herbs discussed Explain the main indications and actions for the herbs Understand what class of phytochemicals is responsible for the medicinal effects Evaluate the safety issues and contraindications of the herbs Provide a summary of the leading research on the herbs used to treat IBS  DIFFERENT TYPES OF IBS IBS-D (mostly diarrhea) IBS-C (mostly constipation) IBS-A (alternating constipation & diarrhea)  POSSIBLE CAUSES OF IBS Food sensitivities Dysbiosis - changes in gut microbes Low fiber diet Stress  A NATUROPATHIC APPROACH TO IBS Remove food sensitivities (IgG testing, Elimination diet) Increase fiber (Bulk laxative) Relieve bloating and gas (Carminatives) Eliminate cramping (Antispasmodics) Eradicate infection (Antimicrobials) Increase good bacteria (Probiotics & plant-based diet) Stress management HERBAL ACTIONS IRRITABLE BOWEL SYNDROM (IBS) HERBAL ACTIONS Bulk laxative - promotes bowel movements by increasing the volume of the stool Stimulating laxative - Promotes bowel movements by causing influx of water into the lumen and directly stimulating peristalsis. Carminative - increases circulation to the intestinal tract and relaxes smooth muscles & normalized peristalsis to relieve gas and bloating. Antispasmodic - relaxes smooth muscles & relieves spasms and cramping Antimicrobial - Destroys or inhibits the growth of microorganisms (e.g. antibacterial, antifungal, antiviral, anti-parasitic) MATERIA MEDICA PEPPERMINT Peppermint Latin: Mentha piperita Family: Lamiaceae Part: Leaf Drug: Menthae piperitae folium Optional: Click here to read a monograph online PEPPERMINT MAIN INDICATIONS Bloating and gas Indigestion Nausea Intestinal cramping Irritable bowel syndrome ACTIONS Carminative Antispasmodic Antiemetic Cholagogue/Choleretic Antiinflammatory Antitussive Photo courtesy of Matt Gowan PEPPERMINT German Commission E (Approved) The Commission E approved the internal use of peppermint leaf for spastic complaints of the gastrointestinal tract, the gallbladder, and bile ducts. King's American Dispensatory, 1898 Used in the treatment of gastrodynia, flatulent colic, hysteria, spasms or cramps of the stomach, to allay the griping of cathartics, to check nausea and vomiting, and to disguise the unpleasant taste of other medicines. The British Herbal Compendium The British Herbal Compendium indicates peppermint leaf for dyspepsia, flatulence, intestinal colic, and biliary disorders PEPPERMINT PHYTOCHEMICALS Essential oils - Monoterpenes (menthol) Flavonoids (luteolin, hesperidin, and Menthol rutin) Phenolics (caffeic, chlorogenic, and rosmarinic acids) SAFETY GRAS (Generally Recognized As Safe) Reflux - may aggravate Pregnancy: SAFE! :) RESEARCH Meta-Analysis: Peppermint oil improved IBS symptoms and pain. RESEARCH Clinical trial (2019): Small intestine release of peppermint oil reduced pain, severity and IBS severity. LEMON BALM Latin: Melissa officinalis Family: Lamiaceae Part: Leaf Drug: Melissa folium Optional: Click here to read a monograph online LEMONBALM MAIN INDICATIONS Nervous stomach Indigestion Colic Irritable bowel syndrome (IBS) Anxiety Insomnia ACTIONS Carminative Antispasmodic Sedative Antidepressant Antiinflammatory Photo courtesy of Matt Gowan LEMONBALM German Commission E (Approved) The Commission E approved the internal use of lemon balm for nervous sleeping disorders and functional gastrointestinal complaints. Paracelsus (1493-1541) Prescribed lemon balm for nervous system disorders PHYTOCHEMICALS Essential oils (citronellal) Flavonoids (apigenin, quercitin) Polyphenol (Rosmarinic acid) Triterpenoids (Ursolic acid, oleanolic acid ) Citronellal SAFETY O GRAS (Generally Recognized As Safe) HO OH Side-Effects: May aggravate GERD. OH Pregnancy: Caution. May be harmful. O HO OH O Rosmarinic acid RESEARCH In vivo: Experimental models with rats showed Lemon balm improved defecation patterns. FENNEL Latin: Foeniculum vulgare Family: Apiaceae Part: Seed Drug: Foeniculi fructus Optional: Click here to read a monograph online Note: Anise (Pimpinella anisum) seeds are very similar to fennel seeds and could be used interchangeably. FENNEL MAIN INDICATIONS Indigestion Bloating and gas Infantile colic Poor lactation Menstrual issues ACTIONS Carminative Antispasmodic Antiinflammatory Expectorant Phytoestrogen Galactagogue Photo courtesy of Matt Gowan FENNEL German Commission E (Approved) The Commission E approved the internal use of fennel seed preparations for dyspepsias such as mild, spastic gastrointestinal afflictions, fullness, and flatulence. It is also approved for catarrh of the upper respiratory tract. Fennel syrup and fennel honey are used for catarrh of the upper respiratory tract in children. King's American Dispensatory, 1898 Used in flatulent colic, and as a corrigent of unpleasant medicines. May be used in amenorrhoea and in suppressed lactation. PHYTOCHEMICALS Essential oils Phenylpropenes (anethole) SAFETY Generally recognized as safe (GRAS) Anethole Side-Effects: May aggravate GERD. Pregnancy: Caution. It may be harmful. RESEARCH Review: Combo with fennel and curcumin reduced IBS pain. RESEARCH Review: Anise oil (very similar to fennel) is more effective than placebo or Colpermin™ (peppermint oil) for relieving IBS symptoms. PSYLLIUM Latin: Plantago ovata Synonyms: Plantago psyllium Family: Plantaginaceae Part: Seed husk Drug: Psyllii semen Optional: Click here to read a monograph online PSYLLIUM MAIN INDICATIONS Constipation Diarrhea Blood sugar Cholesterol ACTIONS Bulk laxative Antisecretory Demulcent Photo courtesy of Matt Gowan PSYLLIUM German Commission E (None) The Commission E approved the use of blonde psyllium seed for chronic constipation and disorders in which easy bowel movements with a loose stool are desirable, e.g., for patients with anal fissures, hemorrhoids, following anal/rectal surgery, or during pregnancy. It was also approved as a secondary medication in the treatment of varying kinds of diarrhea and in the treatment of irritable bowel syndrome. King's American Dispensatory, 1898 Psyllium - They yield a mucilage, used in southern Europe as that of flaxseed, slippery elm, etc., is used in this country. The seeds, in tablespoonful doses, in a glass of water, before dinner, have been successfully employed to relieve chronic constipation. Ispaghula seeds are very mucilaginous and form a thick jelly with water. They are employed, either in substance or in decoction, in India, for the treatment of diarrhea and dysentery. In chronic diarrhea, they are often given whole PSYLLIUM PHYTOCHEMICALS Fiber: Mucilage SAFETY Side-Effects: Bloating and gas. It must be consumed with lots of water! Esophageal blockage & bowel obstruction- has occurred when taken with insufficient water. Acute constipation - may aggravate Pregnancy: No restrictions known. Drugs: May delay absorption. RESEARCH Clinical Trials: Psyllium reduced IBS severity in children in two studies. FLAX SEED Latin: Linum usitatissimum Family: Linaceae Part: Seed Drug: Lini semen Optional: Click here to read a monograph online FLAX SEEDS MAIN INDICATIONS Chronic constipation Irritable bowel syndrome Blood sugar Cholesterol ACTIONS Bulk laxative Demulcent Phytoestrogen Antioxidant Anti-inflammatory Photo courtesy of Matt Gowan FLAX SEEDS German Commission E The Commission E approved the internal use of flaxseed for chronic constipation, for colons damaged by abuse of laxatives, irritable colon, diverticulitis, and as mucilage for gastritis and enteritis. External use is approved as a cataplasm for local inflammation. King's American Dispensatory, 1898 An infusion of the entire seeds, an ounce to a quart of water at 100° C. (212° F.), forms a mucilaginous draught which is much employed in ardor urinae and urinary diseases, nephritic pains, coughs, colds, colo-rectitis, pulmonary, gastro-enteric, and urinary inflammations. When not contraindicated, the addition of lemon juice improves the flavor, or it may be sweetened with loaf sugar or honey. An infusion of flaxseed, or of flaxseed meal, forms an excellent laxative injection; and the meal added to boiling water, and made of the proper consistence, makes an excellent cataplasm FLAX SEEDS PHYTOCHEMICALS Fiber: Mucilage Polyphenols: Lignans Fixed oils: Omega-3s SAFETY Side-Effects: None known. Drugs: May delay absorption. Pregnancy: Caution. It may be harmful (contains phytoestrogens). RESEARCH Clinical Trial: Flaxseed may be helpful (but the small sample size did not provide statistical significance) SENNA Latin: Senna alexandrina Synonym: Cassia senna Synonym: Cassia angustifolia Family: Fabaceae Drug: Sennae folium; Sennae fructus Optional: Click here to read a monograph online Note: Alder buckthorn and the resin (not gel) from Aloe vera contain similar phytochemicals. They can be used interchangeably.. SENNA MAIN INDICATIONS Acute constipation ACTIONS Stimulating laxative Photo courtesy of Matt Gowan SENNA German Commission E The Commission E approved the internal use of senna leaf for constipation. King's American Dispensatory, 1898 Wind or bilious colics; a laxative for non- inflammatory conditions of the intestinal tract. SENNA PHYTOCHEMICALS Anthraquinone glycosides SIDE-EFFECTS: Cramping Diarrhea Discoloration of urine (red/brown) Hypokalemia (↓ potassium) Melanosis (bowel staining) Dependency (limit use 7-10 days) CAUTION: Inflammatory bowel disease (IBD) Children under 12 y.o. Kidney disease Heart medications Nursing - might cause loose stools in breastfed infants. RESEARCH Clinical trial: Chronic constipation improvement in 69% in the senna group vs response rate 12% in the placebo group. BARBERRY Latin: Berberis vulgaris Family: Berberidaceae Part: Root Drug: Berberis Radix Optional: Click here to read a monograph online Note: Goldenseal and Oregon Grape are closely related to barberry and have similar phytochemicals (berberine). They can be used interchangeably. BARBERRY MAIN INDICATIONS Infections Infectious diarrhea Indigestion Liver congestion and gallstones Constipation Skin conditions (eczema, psoriasis) Parasites ACTIONS Antimicrobial (antibacterial, antiparasitic, antifungal) Digestive Bitter Antidiarrheal Laxative Photo courtesy of Matt Gowan BARBERRY King's American Dispensatory, 1898 In all cases where tonics are indicated, also in jaundice, and chronic diarrhea and dysentery. The berries form an agreeable acidulous draught, useful as a refrigerant in fevers, also beneficial in dysentery, cholera infantum, diarrhoea, etc. The bark is bitter and astringent, and has been used with advantage as a tonic. The bark of the root is the most active; a teaspoonful of the powder will act as a purgative. A decoction of the bark or berries, has been found of service as a wash in aphthous sore mouth, and in chronic ophthalmia. German Commission E (None) Not included. BARBERRY PHYTOCHEMICALS Isoquinoline alkaloids (berberine) Flavonolignans SAFETY Contra-Indications: Gastritis & stomach ulcers, obstructed gallbladder Side-Effects: May cause GI irritation leading to nausea, vomiting and diarrhea. Pregnancy & lactation - unsafe RESEARCH RCT: Berberine reduced symptoms diarrhea pre-dominant IBS after 8 weeks. RESEARCH SUMMARY RESEARCH SUMMARY HERB RESEARCH DETAILS Peppermint oil Meta-Analysis Reduced symptoms of IBS Lemon balm In vivo Improved defecation patterns Fennel Clinical Trials Anise (similiar to Fennel) and fennel/curcumin combo reduced IBS symptoms Psylium Clinical Trials Improved IBS symptoms Flax Clinical trial May improve symptoms. Senna Clinical Trial Helps in chronic constipation / Barberry Clinical trials Berberine, which is the main active ingredient in barberry, improves diarrhea-predominant IBS. REFERENCES REFERENCES - BOOKS Barnes J, Anderson LA, Phillipson JD. Herbal Medicines, 3rd ed. London: Pharmaceutical Press, 2007. Bundesinstitut für Arzneimittel und Medizinprodukte , The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines Editors Mark Blumenthal, Werner R. Busse, J Klein, American Botanical Council, R. Rister, T. Hall, C. Riggins, Joerg Gruenwald, Ph.D., Alicia Goldberg. Institute for Drugs and Medical Devices, Bundesinstitut f ur Arzneimittel und Medizinprodukte (Germany). Publisher: American Botanical Council, 1998 Bone K. Principles and Practice of Phytotherapy. Edinburgh: Churchill Livingstone, 2000. Felter HW, Lloyd JU. King's American Dispensatory. 1898. http://www.ibiblio.org/ herbmed/eclectic/kings/main.html. Accessed: Nov 19, 2022. Hoffman D. Medical Herbalism. Rochester, Vermont: Healing Arts Press, 2003. REFERENCES - RESEARCH 1: Khanna R, MacDonald JK, Levesque BG. Peppermint oil for the treatment of irritable bowel syndrome: a systematic review and meta-analysis. J Clin Gastroenterol. 2014 Jul;48(6):505-12. doi: 10.1097/MCG.0b013e3182a88357. PMID: 24100754. 2: Weerts ZZRM, Masclee AAM, Witteman BJM, Clemens CHM, Winkens B, Brouwers JRBJ, Frijlink HW, Muris JWM, De Wit NJ, Essers BAB, Tack J, Snijkers JTW, Bours AMH, de Ruiter-van der Ploeg AS, Jonkers DMAE, Keszthelyi D. Efficacy and Safety of Peppermint Oil in a Randomized, Double-Blind Trial of Patients With Irritable Bowel Syndrome. Gastroenterology. 2020 Jan;158(1):123-136. doi: 10.1053/j.gastro.2019.08.026. Epub 2019 Aug 27. PMID: 31470006. 3: Morishita D, Tomita T, Mori S, Kimura T, Oshima T, Fukui H, Miwa H. Senna Versus Magnesium Oxide for the Treatment of Chronic Constipation: A Randomized, Placebo-Controlled Trial. Am J Gastroenterol. 2021 Jan 1;116(1):152-161. doi: 10.14309/ajg.0000000000000942. PMID: 32969946. 4: Alammar N, Wang L, Saberi B, Nanavati J, Holtmann G, Shinohara RT, Mullin GE. The impact of peppermint oil on the irritable bowel syndrome: a meta-analysis of the pooled clinical data. BMC Complement Altern Med. 2019 Jan 17;19(1):21. doi: 10.1186/s12906-018-2409-0. PMID: 30654773; PMCID: PMC6337770. 5: Dolatabadi F, Abdolghaffari AH, Farzaei MH, Baeeri M, Ziarani FS, Eslami M, Abdollahi M, Rahimi R. The Protective Effect of Melissa officinalis L. in Visceral Hypersensitivity in Rat Using 2 Models of Acid-induced Colitis and Stress-induced Irritable Bowel Syndrome: A Possible Role of Nitric Oxide Pathway. J Neurogastroenterol Motil. 2018 Jul 30;24(3):490-501. doi: 10.5056/jnm17035. PMID: 29879761; PMCID: PMC6034661. 6: Mosaffa-Jahromi M, Lankarani KB, Pasalar M, Afsharypuor S, Tamaddon AM. Efficacy and safety of enteric coated capsules of anise oil to treat irritable bowel syndrome. J Ethnopharmacol. 2016 Dec 24;194:937-946. doi: 10.1016/j.jep.2016.10.083. Epub 2016 Nov 1. PMID: 27815079. 7: Chen C, Tao C, Liu Z, Lu M, Pan Q, Zheng L, Li Q, Song Z, Fichna J. A Randomized Clinical Trial of Berberine Hydrochloride in Patients with Diarrhea- Predominant Irritable Bowel Syndrome. Phytother Res. 2015 Nov;29(11):1822-7. doi: 10.1002/ptr.5475. Epub 2015 Sep 24. PMID: 26400188. 8: Cockerell KM, Watkins AS, Reeves LB, Goddard L, Lomer MC. Effects of linseeds on the symptoms of irritable bowel syndrome: a pilot randomised controlled trial. J Hum Nutr Diet. 2012 Oct;25(5):435-43. doi: 10.1111/j.1365-277X.2012.01263.x. Epub 2012 Jun 13. PMID: 22690855. THANK YOU M AT T G O W A N , N D M G O W A N @ N D A S S I S T. C O M