Irritable Bowel Syndrome - Term Paper Example

Irritable Bowel Syndrome (IBS) is a chronic multifactorial disease effecting 7-20% of individual worldwide and predominant in female. The symptoms include altered bowel movements accompanied by abdominal pain, constipation, flatulence and diarrhea. The disease pathophysiology is incompletely understood and therapeutic regimens available include both pharmacological and complementary & alternative medicine (CAM). Unlike most other diseases, CAM is the popular treatment method for IBS. In recent years however a patient centered holistic approach of Integrative medicine is being developed that combines treatment protocols of both conventional and CAM methods. The current paper attempts to explore the integrative approach for treatment of IBS and assess the risk benefit ratio of the approach on the basis of available evidence. Abstract 2 Introduction 3 Symptoms and Diagnostic Criteria 3 Pathophysiology 5 Conventional treatment 5 Pharmacological Management 5 Complementary & Alternative treatment (CAM) 7 Dietary Management 8 Integrative Treatment 11 Risks or Benefits of Integrative Approach 12 Conclusion 13 References 14 Abstract 2 Introduction 3 Symptoms and Diagnostic Criteria 3 Pathophysiology 4 Conventional treatment 5 Pharmacological Management 5 Complementary & Alternative treatment (CAM) 6 Dietary Management 6 Integrative Treatment 8 Risks or Benefits of Integrative Approach 9 Conclusion 10 IRRITABLE BOWEL SYNDROME CONVENTIONAL AND ALTERNATIVE MEDICINES Introduction The Irritable Bowel Syndrome (IBS) is a prevalent functional gastrointestinal (GI), symptom based disorder affecting 7 to 20% of adults worldwide (Grundmann & Yoon, 4691; Rey & Tally, 772). It is defined by abdominal pain and altered bowel habits (Pimentel & Chang, 69). The socioeconomic burden of IBS involves impaired health related quality of life (HRQOL), lower work productivity and high costs (Agarwal & Spiegel, 11). It adversely affects sleep, diet, and sexual performance leading to emotional distress and overall quality of life. The disease affects families and is found in multiple generations though not a Mendelian character (Saito, 45). IBS has a multifactorial pathogenesis that differs from individual to individual (Hasler, 21). Symptoms and Diagnostic Criteria The disease is characterized by multiple chronic or recurrent intestinal symptoms such as abdominal pain, constipation, diarrhea, disturbed bowel movements and abdominal bloating; along with other symptoms such as depression, anxiety, insomnia, fatigue and palpitations. Manning et al in 1978 had given a set of identifying criteria for IBS that has been continuously updated (Abraham). Table 1: Manning Criteria for Diagnosis of IBS (Abraham) Looser stool at onset of pain More frequent bowel movements at onset of pain Pain eased after bowel movements Visible distension Feeling of distension Mucus per rectum The Rome III diagnostic criteria are the latest set of criteria prepared by 100 international experts that are members of Rome Foundation Board. The criteria involves at least three months, with preceding onset of at least 6 months of recurrent abdominal pain along with at least one of the following symptoms presented in table (badgut). Improvement with defecation Onset associated with a change in frequency of stool Onset associated with change in form or appearance of stool The latest diagnosis criteria for IBS, Rome III subtype IBS on the basis of stool consistency exclusively (badgut):  IBS with constipation (IBS-C),  IBS with diarrhea (IBS-D),  IBS mixed type (IBS-M), and  IBS unsubtyped (IBS-U). Pathophysiology Evidence is available for an association between brain and gut involved in development of IBS along with anxiety further affecting the disease development. IBS involves motor function disruption in regions of small intestine and colon along with impaired functioning of smooth muscle in large intestine and other regions of the digestive region. Visceral and somatic regions also exhibit disruption of sensory function that could be due to altered processing of afferent stimulus by Central Nervous System (Hasler, 21). The disease is more common in female patients and those of ages 30 to 50 years (Hadley & Gaarder, 2501). A major factor contributing to the pathophysiology of the disease is diet, which has been shown to aggravate the condition. (Eswaran et al., 141). However, the disease etiology is incompletely understood and is perhaps associated with multiple biological and psychosocial causes (Tanaka et al., 131). Thus therapeutic regimens explored for IBS involve both conventional medicine that target relief from common symptoms; as well as alternative medicines that focus on probable etiological factors (Harris & Heitkemper, 12). . Conventional treatment Conventional treatment methods for IBS include symptomatic first line pharmacological treatments that are usually prescribed along with certain lifestyle changes. The current guidelines for the treatment are based on recommendations of American College of Gastroenterology (ACG) and British Society of Gastroenterology (Brandt et al., 1). Pharmacological Management Pharmacological treatments address the symptoms of IBS rather than its cause since the pathophysiology of IBS is not fully understood. Some of the common pharmacological agents used include: Antidiarrheal Agent Antidiarrheal agents such as loperamide and Diphenoxylate have been recommended for treatment of IBS-D by British Society of Gastroenterology and Prodigy. Loperamide is a synthetic opioid that reduces food transit duration and increases water and ion absorption in the intestine. However no improvements in symptoms of IBS have been reported in studies (Abraham, 58). Further they involve the risk of development of dependence (Grundmann & Yoon, 348). Antipasmodics Drugs that reduce abdominal pain by lowering visceral smooth muscle contractions are known as antispasmodics. Even though studies are inconclusive, the British Society of Gastroenterology recommends its use for IBS (Abraham, 58). Prokinetics Most commonly used drugs along with antispasmodics (Grundmann & Yoon, 348). Prokinetics enhance motility in gut; e.g. cispride and domperidone. Evidences for these indicate them to ineffective (Abraham, 59). Laxatives Efficacy of laxatives has not been studied for IBS and no controlled trials are reported for the same. Polyethylene glycol has been reported to be effective for constipation (Abraham, 59). Serotonergic Drugs Pathophysiology of IBS has been linked to the neurotransmitter serotonin. 5HT3, 5HT4, 5HT1b are the subtypes of serotonin receptors involved in GI function such peristalsis and secretory reflexes; and visceral sensations.. The serotonin reuptake transporter and its inactivation have been proposed to cause IBS. 5HT4 agonists such as tegaserod are used in constipation related symptoms of IBS since 5HT4 are involved in peristalsis initiated by 5HT1 receptor stimulation. 5HT3 antagonists such as alosetron and cilasentron are useful for management of visceral pain and also for treatment of diarrhea since they reduce transit time in gut and colon. Though randomized control trials have reported positive results for tegaserod and alosteron, yet both limited due to due to negative side effects such as ischemic colitis and severe constipation, alosteron showing the best risk to benefit ratio (Fayyaz & Lackner, 41, Grundmann & Yoon, 348). Antidepressants Besides Selective serotonin uptake inhibitors (SSRI), other antidepressants such as tricyclic (TCA) alleviate IBS symptoms (Grundmann & Yoon, 348). Antibiotics Certain IBS patients have been reported to develop low grade inflammation due to post infection IBS and SIBO (small intestinal bacterial growth. Antibiotics such as rifaximin have been effective, while antieffectives such as nystatin and tetracyclines exhibited low reponse as well as negative and systemic side effects. Also salicylate derivative mesalazine have been reported to be effective in such cases. Glucocorticoids have also been shown to be effective but the research is confined to animal models as yet (Grundmann & Yoon, 349). During the recent years studies have revealed the involvement of substances such as substance P, cholecystokinin (CCK), CGRP, Neutrophins and cytokines in nociception. Thus new drugs that can affect these substances and help in treatment of IBS are being developed. Some of these drugs are cilansteron, clonidine, somatostatin analogues, tachykinin receptor antagonists and prucalopride. However safety and efficacy of these drugs remains to be determined conclusively (Abraham, 62). Complementary & Alternative treatment (CAM) CAM are by far the most common treatment protocols followed for IBS. Approximately 50% patients are known to self prescribe herbs and dietary supplements along with lifestyle modifications. It has also been often used along with pharmacological treatments (Grundmann & Yoon, 349). Dietary Management Although not considered a part of CAM, dietary management is the first method used, later complemented with CAM (Brandt et al., 1). Popular belief still remains that IBS is most closely associated to improper diet and can be managed by following a restrictive diet. Certain patients have been reported to have intolerance to specific food items or components such as lactose, fat-rich food, spices, dairy products etc. A trial and error method of eliminating food has been practiced though the impact of this method has neither been studied exhaustively nor its benefit clear. Studies have been conducted to explore the impact of individualized diet but have provided inconclusive evidence (Abraham, 57). Further completely skipping meals can aggravate IBS (Grundmann & Yoon, 349). Besides elimination certain supplements such as bulking agent and fibers are provided for IBS treatment, and have been reported to have some efficacy in management of constipation by increasing food transit time in the digestive tract. They are not able to control pain. Also insoluble fibres such as nuts and whole grains are reported to aggravate IBS symptoms (Grundmann & Yoon, 349). Yet these studies too remain inconclusive. Probiotics used to increase the endogenous bacterial population of gut; have also been studied for IBS management, but again the evidences are insufficient (Abraham, 57). Exercise A significant lifestyle change for IBS patients is exercise of the mild form or physical activity that definitely helps in management of bloating and gas production. Specific postures of Yoga that involves low levels of stress on joints such as Pranayam have been found effective for IBS-D patients. It has been reported to increase the sympathetic activity similar to daily loperamide intake. Herbal Medicines Herbal medicines and supplements either alone or in combination have been found effective in controlled trials. Single Herbal Medicine Peppermint extracts help in management of abdominal pain, however the effect did not last once the medication was stopped. It has been recommended by both American Academy of Paediatricians as well as ACG. Peppermint oil has mono- and sesquiterpenes that are known anti-spasmolytics (Grundmann & Yoon, 350). Artichoke extracts are also used and studied for IBS. They have been known for long to help in digestion, reduce abdominal pain, bloating, diarrhea and constipation by effecting GI motility. Besides peppermint and artichoke, a number of other herbal medicines such as curcuma, fumitory extracts etc are recommended and have long been used for IBS, studies exploring them are insufficient as well as marred by traditional bias. Combination Herbal Medicine The first combination herbal medicine to receive attention was Iberogast, which is a mixture of 9 herbal extracts and has been in use since past 30 years. The components are derived from chamomile flowers, angelica root, milk thistle, greater celandine, peppermint, licorice root, lemon balm leaves, caraway fruits and bitter candytuft. The medicine has been reported to be effective in IBS treatment and effects serotoinin, opioid and acetylcholine receptors. ACG recommends it as complementary medicine (Brandt et al., 1). A Tibetan medicine Padma lax, containing rhubarb root (laxative), cascara bark, nux vomica seeds has been found effective in RCT, though the dose was adjusted to suit certain patients who developed loose stools. Many traditional Chinese medicinal combinations (individualized preparations) are in use as part of CAM. But studies on these are difficult due to lack of standardization, hence leading to inability to conduct clinic trials for determining their effectiveness (Grundmann & Yoon, 352). Mind Body Therapies Mind Body therapies are supported by the pathophysiology of IBS involving brain gut interactions. These involve such techniques as Yoga, acupuncture, relaxation techniques, Tai-chi, deep breathing exercises, hypnotherapy, and meditation. While the former three involve a combination of physical and psychological component aiming at mechanical methods to alter body physiology; the rest depend on psychological methods entirely. These have been individually studied and reported to improve IBS symptoms (Mehling et al.). Mechanical Interventions Mechanical Interventions include yoga, massage, acupuncture and physical exercises. Physical activities such as aerobics, bike riding etc have shown improvement in flatulence and other IBS symptoms, though strenuous exercise has been reported to aggravate it. Little information is available on massage. Yoga involves both relaxation techniques and mild physical activity concentration on muscle contraction and relaxation. It targets alleviation of symptoms through improving GI motility and pain perception. Limited numbers of trials conducted suggest beneficial effects of yoga. Gut directed Acupuncture attempts to alleviate IBS symptoms through regulation of neurotransmitter systems, focusing on serotonergic, glutametergic, and cholinergic pathways. No conclusive evidence is available for the technique due to lack of sufficient studies. The major limitations of physical methods are inability of certain patients to get involved in them as well as non compliance (Grundmann & Yoon, 353). Psychological Interventions The two most studied methods include hypnotherapy and cognitive behavior therapies (CBT). While hypnosis involves leading the patient in to a subconscious state with enhanced senses and control over body functions; CBT focuses on the conscious awareness of the individual. Both techniques attempt to replace negativity in the patient with a positive attitude, thereby attempting to treat the psychological aspects of disease such as anxiety, depression etc. This in turn is believed to effect physiological functioning and hence cure psychosomatic symptoms. While insufficient evidences are available for hypnosis, CBT has been shown to improve quality of life by alleviating pain perception, anxiety and depression (Grundmann & Yoon, 355). The major drawback of CAM treatments is lack of evidence based study therefore despite popular use the knowledge about CAM is extremely limited. ACG Task Force on IBS has reported the lack of consistent effectiveness of CAM treatments. Recent research, however have found them to be reasonably effective. Iberogast and peppermint oil are the two CAM treatments that are strongly supported by clinical trials (Brandt et al., 1). Integrative Treatment Most studies have focused on the comparison of conventional versus CAM; therefore leaving the patient in a dilemma, making him chose one over other. A new approach has been recommended in recent years of combining the two methods of treatment; that is an integrative approach. It would also be appropriate to say that even though scientifically discussed recently, this approach has always been practiced by patients who receive consultations for pharmacological treatments and simultaneously self prescribe alternative medicines or therapies choosing one or more based on their cultural or traditional beliefs. Multiple clinical trials in recent years have found that this integrative approach benefits patients more than any of the individual approaches. The last decade has experienced a leap in the integrative approach with the growth of Consortium of Academic Health Centers for Integrative medicine with such prestigious members as Yale, Stanford, and Johns Hopkins Universities. The approach has gained popularity due to its patient centered healthcare that focuses on improvement of life irrespective of the treatment approach(s), making it a holistic therapeutic protocol. The approach is yet incompletely defined and is not without controversy (Grundmann & Yoon, 356). Risks or Benefits of Integrative Approach CAM medicines are favored for IBS therapy due to multiple factors including functional diagnosis and demographics of disease (in favor of female population), patient beliefs and perception of pain as well as treatment, and psychosocial factors such as anxiety, medical history etc (Usher et al., 5). The popular belief in CAM becomes a negative factor in conducting standardized and unbiased trials to establish the efficacy of this mode of treatment. In absence of clinical trials for CAM medicines, the integrative approaches cannot be standardized; neither can risk assessment be done. Figure 1: Evolution of Fields of Medicne (Rakel & Weil, 6) On the basis of current level of research CAM and by extrapolation integrative medicine can only be considered dangerous, solely due to lack of research. The integrative medicine is based on least invasive and least dangerous treatment approaches. This is based more on discretion of the physician rather than evidence (Rakel & Weil, 6). The only point of caution that can be stressed here is that CAM should not interfere with the conventional medicine prescribed and vice versa (Grundmann & Yoon, 355). Conclusion The multifactorial disease IBS is with is numerous and varied symptoms; along with incompletely understood physiology is a management challenge for therapists as well as researchers. Further lack of alarming features in primary care leads to a complicated situation. Therapeutic approaches have been improved in recent years with sub-classification of disease and better understanding has been developed of brain gut relation in disease etiology. Still drugs are mainly symptomatic while CAM therapies are not supported by evidences mainly due to lack of sufficient studies. On the brighter side, CAM has been identified and accepted as an effective therapeutic procedure and being developed as a part of the integrative approach. The integrative approach is still in its infancy and extensive researches are required to establish this approach and risk benefit ratio for the same needs to thoroughly assessed. References 1. Abraham, P. 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