Irritable Bowel Syndrome – A Homeopathic Perspective

Definition
Irritable bowel syndrome (IBS) also called spastic colon, is an idiopathic and functional bowel disorder char- acterized by chronic abdominal pain, discomfort, bloating relieved by defe- cation or a change in bowel habit with features of disordered defecation and distension in absence of any detect- able structural or biochemical abnor- malities.
Epidemiology
Approximately, twenty per cent of the general population suffers from irrita- ble bowel syndrome, but only ten per cent of these seek medical advice. It is a disorder of young people with most cases presenting before the age of forty five. However, some reports suggest that the elderly are troubled by irrita- ble bowel syndrome up to ninety two per cent as compared to middle aged persons. Women are affected 2-3 times more than men and make up eighty per cent of the population with severe irritable bowel syndrome. High preva- lence has been found in countries like Mexico, Brazil, Pakistan, US, UK, Ja- pan and Canada.
Classification

1. IBS-D (Diarrhea predominant)
2. IBS-C (Constipation predominant)
3. IBS-A (Alternating stool patt ern)
4. IBS-P (Pain predominant)
5. IBS-PI (Post-infectious)

Etiology
Though inconclusive, few causes are enlisted below :
1. Psychosocial abnormalities
Panic attacks, chronic stress, anxiety, depression, somatization, neurosis, overt psychiatric diseases, etc. may alter intestinal motility or modulate pathways affecting CNS processing of visceral afferent sensations.
2. Altered gastrointestinal motility
Irritable bowel syndrome patients ex- hibit increased recto-sigmoid motor activity for up to three hours after eat- ing. Provocative stimuli also induce exaggerated colonic sensory and mo- tor responses to visceral stimulation. IBS-D patients exhibit rapid jejunal contraction waves, rapid intestinal transit and increased number of fast and propagated colonic contractions. As a result, the colonic epithelium loses its ability to absorb fluids, result- ing in diarrhea. IBS-C patients exhibit decreased oro-caecal transit and de- creased number of colonic contraction waves. As a result, extra fluid is ab- sorbed resulting in constipation.
3. Visceral hypersensitivity
Balloon distension studies of the rectosigmoid has revealed lower visceral
pain threshold induced by lower volumes of colonic gas, rectal urgency
despite small rectal volume of stool, etc. These exaggerated responses may
be due to spinal hyperexcitability or neuroplasticity. Positron Emission Tomography (PET) has revealed alterations in regional cerebral blood fl ow
in irritable bowel patients, causing cingulated cortex, resulting in cerebral dysfunction and increased perception of visceral pain.
4. Luminal factors
Bacterial gastroenteritis, intolerance of specific dietary components, for example, lactose, broccoli, wheat, etc. may contribute in irritable bowel syn- drome. Up to thirty per cent patients, especially women and patients with increased life-stressors develop IBS- PI. Increased number of inflammatory cells have been found in the mucosa, submucosa and muscularis, suggest- ing chronic inflammation. Though not confirmed, some researchers held Blastocystis and Dientamoeba fragilis responsible for irritable bowel syn- drome. Many also suspect overgrowth of small intestinal bacterial flora, which responds quickly to antibiotic Rifamixin.
5. Sexual abuse
Verbal aggression, exhibitionism, sexual harassment, touching or rape results in visceral hypersensitivity.
6. Others
Drug abuse (especially sedative- hypnotics, antidepressants, antihy- pertensives and anticholinergics), undetermined immune reaction, neu- rotransmitter imbalance (especially high level of serotonin), reproductive hormones, etc. also may play an im- portant role in the pathogenesis of ir- ritable bowel syndrome.
Clinical Features
Symptoms should be present for at least three months before the diagno- sis can be considered. The diagnosis is established in the presence of compat- ible symptoms and after the exclusion of organic disease.
Symptoms

• Altered bowel habit
• Constipation/Diarrhea/Alternating stool pattern
• Constipation: Infrequent (less than three motions per week), hard, lumpy, pellet or ribbon-like stools with straining, abdominal pain or proctalgia; due to excessive dehy- dration caused by prolonged co- lonic retention and spasm
• Diarrhea: Frequent (more than three motions a day), low volume, loose stools, rarely nocturnal, ur- gency or fecal incontinence, ‘morn- ing rush’ after getting up or often during and after breakfast
• Alternating diarrhea and consti- pation: Firm stool in the morning, followed by progressively looser movements towards the evening, not usually nocturnal
• Abdominal pain: Colicky, cramp- ing, recurrent lower abdominal pain; often exacerbated by eating or emotional stress; relieved by defecation
• Distension : Abdominal distension or bloating that worsens through- out the day; not due to an abnormal quantity of intraluminal gas; rather reduced tolerance of distension
• Belching : Belching due to reflux of gas from distal to proximal intes- tines
• Rectal mucus : Rectal mucus, but no bleeding
• Sensation : Feeling of incomplete defecation
• Weight : No weight loss
• Functional symptoms : Dyspepsia, gastro-esophageal reflux, heart- burn, quick satiety while eating, headache, backache, fibromyalgia, depression, poor sleep, urinary frequency from ‘irritable bladder ’, dysparunia, chronic fatigue syn- drome, etc.

Differential Diagnosis and Laboratory Findings
The diagnosis is based on clinical find- ings and exclusion of other disorders. The following diagnostic tests are usu- ally performed:

• Complete blood count, ESR, CRP, LFT, sigmoidoscopy and stool for OPC; increased CRP, elevated ESR, evidence of anemia, presence of WBC or blood in stool argue against irritable bowel syndrome
• Barium enema or colonoscopy in older patients (>40 years) to exclude colorectal carcinoma or inflamma- tory bowel disease (IBD)
• In IBS-D patients, investigations should be done to exclude ulcer- ative colitis, lactose intolerance, bile acid malabsorption, celiac sprue, hyperthyroidism, laxative abuse, inflammatory bowel disease or in- fection
• In IBS-C patients, investigations should be done to rule out hypo- thyroidism, hypoparathyroidism or drug abuse (anticholinergics, antihypertensives, antidepressants, etc.)
• Ultrasound of gall bladder in pa- tients complaining about postpran- dial right upper quadrant pain
• Lactose-free diet for three weeks to exclude lactose intolerance
• Upper gastrointestinal radiographs or esophago-gastroduodenoscopy in patients with concurrent symp- toms of dyspepsia
• Pain in epigastric or periumbili- cal region – biliary tract disease, pelvi-urethral stricture, intestinal ischemia, carcinoma stomach and carcinoma pancreas
• Pain in lower abdomen – diverticu- lar disease of colon, inflammatory bowel disease, carcinoma colon
• Postprandial pain with bloating, nausea, vomiting – gastroparesis, partial intestinal obstruction, intes- tinal infestation with Giardia lam- blia or other parasites
• Painful constipation – lead poison- ing, acute intermittent porphyria

Treatment
Irritable bowel syndrome, though it does not lead to serious conditions in most patients, is however a source of chronic pain, fatigue and it increases the medical expenses besides contrib- uting to work absenteeism. Research- ers have reported that high preva- lence of irritable bowel syndrome, in conjunction with increased costs, produces a disease with high societal cost. It is regarded as a chronic illness that can dramatically affect the quality of a sufferer ’s life. Recent studies have found that irritable bowel syndrome patients are at an increased risk of ‘un- necessary’ abdominal and pelvic sur- gery (for example, cholecystectomy, hysterectomy, etc.).
1.General measures
Reassurance, education, support, good doctor-patient relationship
regular exercise, meditation, adequate
sleep, colonic massage for IBS-C pa- tients, etc.
Dietary modifications

• Avoidance of fatty and fried foods, caffeine (coffee, tea, colas), brown beans, brussel sprouts, rye, barley, cabbage, cauliflower, raw onion, garlic, soya bean, egg, beef, lamb, hot spices, high purine foods (meat, herring, mackerel, sardines, yeast, mussels,   roe,   etc.),   high   boron fruits (apple, pear, tomato, grapes, plums, red peeper, etc.), raisins, red wine, beer and smoking
• Avoidance of lactose in IBS-D pa- tients; cultured dairy products (yo- ghurt, curd, cheese, etc.) are better choices because these contain bac- teria that supply lactase to digest lactose
• Avoidance  of  dietary  fructose (fruits) and sorbitol (artificially sweetened foods, for example chewing gum, dietetic candy, etc.). Refined sugar shortens oro-anal transit  time,  increases  fecal  bile acid concentration and bacterial fermentation in the colon.
• Soluble dietary fiber supplemen- tation (oats, isapghula/psyllium, nuts, seeds, green vegetables, etc.) and  avoidance  of  insoluble fibers (corn, wheat, high bran cereals, etc.). Isapghula/psyllium husk 20-30 grams, dissolved in juice or water is advised daily.
• Dietary   supplementation   of   fish oils (rich in Ω-3 and Ω-6 fatty ac- ids), magnesium (chicken, green vegetables, etc.), vitamin C (amla, guava, lemon, orange, amaranth, spinach, etc.), vitamin E (vegetable oils, sunflower oil, butter, etc.) and vitamin B complex (dairy products,liver, fish, whole grain cereals, etc.)
• Probiotic supplements (for exam- ple, Lactobacillus plantarum, Bifi- dobacteria infantis, etc.), digestive enzymes,  ginger,  GABA in  warm water, glutamine powder in water or fruit juice
• Removal of foods causing IgG im- mune response (varies in individu- als)
• Avoidance of large or infrequent meals; eating three meals a day – a good breakfast, a moderate lunch and a light dinner
• Intake of enough water, at least 7-8 glasses a day

Pharmacologic measures
Antispasmodics, antidiarrheal, laxa- tives, psychotropics, serotonin recep- tor agonists and antagonists, etc.
Psychological therapies
Counselling, cognitive – behavioral therapies, relaxation therapies, hyp- notherapy, biofeedback, etc.
Alternative treatments
Iberogast (multi-herbal extract), en- teric-coated peppermint oil capsules, Chinese herbal medicine, acupunc- ture, etc.
Homeopathic Approach
When the conventional (allopathic) system of medicine declares irritable bowel syndrome as incurable, ho- meopathic medicines, chosen strictly according to individual symptom totality and constitutional back- ground, offers the longest duration of alleviation of symptoms.
Commonly chosen homeopathic medicines with their indications are given below:
Aloe socotrina

• Insufficient, incomplete, unsatisfac- tory stools with jelly-like lumps of mucus
• Lack of confidence in the anal sphincters; driving out of bed early in the morning; has to hurry imme- diately after eating or drinking
• Excruciating pain and rumbling flatulence before stool; the pain ceases after defecation, followed by profuse sweating and weakness

Anacardium orientale

• Ineffectual  urging  and  straining;great desire, but no evacuation
• Dyspepsia; sensation of a plug lodged in the throat and rectum
• Intolerance of hunger, which causes headache; better from eating
• Weak memory and loss of confi- dence

Argentum nitricum

• Digestive upset from nervousness, apprehension and anxiety; worse from cold foods and drinks
• Bloating, rumbling flatulence, nausea, greenish diarrhea – sudden and intense, immediately after drinking water
• Craving but intolerance of sweets and salty foods
• Expressive, impulsive, claustro- phobic
• Chilly when uncovered, yet feels suffocated if wrapped up; longs for fresh air
• Lean, thin, withered, dried-up, may be diabetic

Asafoetida

• Feeling of constriction all through the gastrointestinal tract; sensation of a bubble stuck in the throat or a lump moving up from the stomach z Abdomen inflated, but hard to pass gas in any direction to get relief; loud and difficult eructation
• Explosive diarrhea with regurgita- tion of food; constipation with grip- ping pain
• Hysterical patients with strong emotions
• Worse during rest and at night; bet- ter from slow motion and in open air stomach pain; all worse between 4-8 pm and better from gentle rubbing
• Ravenous appetite; gets up in the middle of the night to eat; fond of sweets and salty foods; prefers warm food and drink
• Greedy and misery; lack of self- confidence; dread of both men and solitude
• Young people with complaints of impotence and old people having a strong desire with erectile dysfunction
• Complaints worse from disturbed sleep and mental exertion, in the morning after waking

Paraffinum

• Frequent but unsuccessful desire for stool; gradually develops into obstinate constipation with hemorrhoids
• Bloating and rumbling in the abdomen, loud belching
• Pain extends from lower abdomen to rectum and various parts
• Excessive hunger, profuse salivation, bitter taste in the mouth

Colocynthis

• Cutting, cramping colic compels the patient to bend double or lie down to press the abdomen
• Pain worse before and after stool, after eating fruits and drinking water
• The complaints arise from unex- pressed emotions, indignation and anger
• Patient is irritable, impatient, short- tempered; becomes angry on being questioned.

Iris versicolor

• Burning of the whole gastrointestinal tract; sour taste, sour vomiting and sour eructation
• Profuse salivation, loss of appetite, flatulent colic, diarrhea and burning at the anus
  Complaints are accompanied by sick frontal headache
• All complaints are worse during rest, evening and night

Lycopodium clavatum

• Bloating and feeling of fullness early in a meal or shortly after; better from loosening garments
• Dyspeptic ailments, heartburn,

Natrium carbonicum

• Mild people with weak digestive and assimilative powers
• Indigestion, heartburn, pelviurethral stricture
• Milk intolerance; however, craves milk, sweets and potatoes
• Sudden call for stool; escapes with haste and noise; spluttering diarrhea
• Aversion to open air and any exercise – mental or physical
• Intolerance to heat of summer

Nux vomica

• Abdominal pain and irregular bowel movement with a constricting sensation, chilliness and irritability
• Constipation with a frequent urge to move the bowels, but passes small amount and is unsatisfactory; constant uneasiness
• Diarrhea alternates with constipation; pain ceases after passing stool
• Craving for strong spicy foods, alcohol, tobacco, coffee and other stimulants; but feels worse from having these
• Menses too late, black, profuse

Podophyllum peltatum

• Cramping pain in abdomen with gurgling, sinking, empty feeling; followed by watery, offensive diarrhea
• Stool pasty, yellow, often with mucus
• Diarrhea while taking a bath; alternates with constipation; followed by headache
• Complaints are worse early in the morning; better from rubbing the liver region
• Young girls with suppressed menses; aged persons with stiffness of joints

Pulsatilla nigricans

• Abdominal pain with constant chilliness and thirstlessness; stool of varying and alternating color and consistency
• Restless sleep on account of inter- nal heat and panic attacks; very tired and sleepy in the morning
• Persistent nausea with nearly all symptoms at night and during menses
• Desire for company and open air;cannot stay alone
• Especially adapted to women hav- ing a mild, weeping disposition; suffer from anticipation anxiety and recurrent styes; history of delayed menarche or suppressed menses

Sulphur

• Morning diarrhea – sudden urges make the person awake early in the morning and they hurry to the bathroom
• May be constipated; offensive flatus, oozing around the anus with irritation, itching and burning
• Poor posture and back pain; feels worse from standing up too long
• Hot patients, but aversion to being washed
• Complaints of climacteric women and of chronic alcoholics

Conclusion
Often it becomes necessary, in course of treatment, to diagnose the mias- matic trait of the patients, particularly when the best selected remedies fail to produce a favorable impact or the improvement ceases after a certain extent. Then a suitable anti-miasmatic can remove the miasmatic blockage and accelerate cure to an incredible degree. Besides, while selecting medi- cines, miasmatic manifestations of the patient should be kept in mind and the selected medicine should be com- patible with the miasmatic domain of the patient for long term alleviation of sufferings. Otherwise improvement becomes short lasting.
References:
• Current Medical Diagnosis and Treat- ment, 2007; 46th edition; L.M.Tierny S.J.McPhee, M.A.Papadakis.

• Davidson’s Principle & Practice of Medicine; 21st edition; C.Haslett, E.R.Chilvers,N.A.Boon,N.R.Colledge, J.A.A.Hunter.
• Harrison’s Principles of Internal Med- icine; 16th edition; Braunwald, Fauci, Kasper, Hauser, Longo, Jameson.
• Pocket Manual of Homoeopathic Ma- teria Medica with Repertory; 3rd Indian edition; Dr William Boericke
• Keynotes and Characteristics of the Materia Medica; Dr H.C.Allen.
• ‘Irritable Bowel Syndrome – Current Concepts’ – JK Practitioner/ Vol.10/ No.4/Oct-Dec 2003/Snoaber J Mir, Showkat Bashir.

• Homoeopathic Remedies for Irritable  Bowel Syndrome’ – Truestar Vitamin and Supplement Plans.
  • ‘Homoeopathy Eases Irritable Bowel Syndrome and Frees Teen to Follow Her Dreams’ – Nancy Gahles.
  • ‘Nutritional Influences on Illness: Irri- table Bowel Syndrome’– Billie J. Sah- ley.
  • ‘Food and Irritable Bowel Syndrome’– Melvyn R. Werbach.
  • http://www.nih.gov
• http://www.iffgd.org
• http://www.digestive.niddk.nih.gov
• http://www.theguttrust.org

Author: Dr Krishnendu
Source: The Homoeopathic Heritage, January 2017