Introduction (General and Western Approach)
Irritable Bowel Syndrome (IBS), known as an irritable colon, is a very common reason for visits to primary care physicians or gastro-intestinal specialists. IBS causes great distress to patients. It is an idiopathic, functional, gastrointestinal disorder characterized by abdominal pain and altered bowel habits, including diarrhea, constipation, alternating diarrhea and constipation, distension, bloating, nausea, and sensation of incomplete evacuation. There also may be symptoms of the upper gastrointestinal tract (GI) such as heartburn, chest pain and dysphagia. Also, there is broad range ofnon-GI tract symptoms. These may include somatic and psychological symptoms such as fatigue, irritability, headache, anxiety, depression, and even urologic dysfunction and gynecologic symptoms. Because of such a wide range of symptoms, clinicians should use the MANNING CRITERIA to increase correctness of the diagnosis of IBS, which is defined as "abdominal pain or discomfort that is relieved by defecation or associated with change in stool frequency or consistency, abdominal distension, the sensation of incomplete evacuation and the passage of mucus". [l]
Prevalence of IBS varies between 10 to 22% of the US population. It is believed that as much as 30% of the population might have had it during some period of their lives. About 60-80% of IBS sufferers are women. Researchers aren't sure why this is so, but they suspect that changing hormones in the female menstrual cycle may have something to do with it. IBS can affect people of all ages, but it is more likely to occur in people in their teens through their forties. Many adults have IBS. However, fewer than half of adults with symptoms seek medical attention. IBS is a worldwide disorder with a similar prevalence rate in both developed and developing countries.
Etiology and Pathogenesis
''JBS is called a functional disorder because no structural, biochemical or infectious etiology has been found."  There is definitely a disorder of motor and sensory functions of the GI tract. Some other functional disorders of the GI are non-cardiac chest pain and non-ulcer dyspepsia. They both share underlying pathogenesis mechanisms with IBS:
- a) Stress is often considered an important factor but there is no proof that it is the direct cause of IBS. Most likely, stress can lead to exacerbation of !BS. More than half of IBS sufferers who seek medical help have underlying anxiety or somatiz.ation. Those who do not seek medical help are similar psychologically to normal individuals.
- b) Abnormal myoelectrical activities have formed in the colon and small intestines. Differences are reported between patients with constipation predominant and diarrhea predominant symptoms.
- c) One study describes that "IBS patients often have lower visceral pain threshold, reporting abdominal pain at lower volumes of colonic gas insufilation or colonic balloon inflation than control group. Although many patients complain of bloating and distention, their absolute gas volume is normal. Many patients report rectal urgencies despite small rectal volume of stool." 
- d) Women and patients with increased life stressors at the onset of bacterial gastroenteritis have increased risk of developing post-infection IBS. It is possible to find inflammatory cells in mucosa, sub-mucosa and muscular layer of intestines.
Symptoms and Signs
Abdominal pain is cramp-like and intermittent in the whole abdominal area or specifically the lower abdominal area Onset of pain is common with change of stool frequency and usually relieved by defecation. Itdoes not occur during sleep. Patients can have:
- I. Constipation predominant type (infrequent bowel movement less than three times per week, a bard lump stool with straining)
- 2. Severe diarrhea predominant type (frequent and loose stool more than three times per day and mucous is frequently seen)
- 3. Constipation-diarrhea alternation type.
The diagnosis of IBS is based on detailed history evaluation, physical examination, laboratory tests, and further testing that is needed to exclude other diseases. Symptoms must be present at least three months before the diagnosis can be made. It is important to exclude other diseases, especially those which can threaten the life of patients, but it is also important not to over-test.
First, dietary history should be evaluated:
- • caffuinated beverages or food and beverages sweetened by fructose or sorbitol may cause cramps, bloating and diarrhea
- • a three week trial of a lactose free diet should be done in order to exclude lactose intolerance
- • emotional and social life should be examined for symptoms like stress, panic disorders and/or depression, which are often present with GI symptoms
Physical examination is unremarkable, mild tenderness may be present Any lumps in abdomen, an enlarged liver or spleen, or positive observable blood tests, require further evaluation. Inwomen, endometriosis should be excluded. Patients should be asked about red flags for disorders other than IBS, especially patients older than 40 years of age. Symptoms such as severe constipation or diarrhea, nocturnal diarrhea, weight loss, history of cancer and inflammatory bowel disease must be considered and included in further examination. Laboratory tests usually test for the complete blood count, serum albumin ESR, and thyroid function. Jn patients with diarrhea, serological test for celiac disease and stool examination for ova and parasites should be done. Jn patients under the age of 45, flexible sygmoidoscopy should be considered to exclude ulcerative colitis. Jn patients over the age of 45 who have not had a previous evaluation, a barium enema or a colonoscopy should be performed in order to exclude malignancy. Jn a differential diagnosis, colonic neoplasia, inflammatory bowel disease, hypo or hyperthyroidism, chronic endometriosis or other causes of chronic diarrhea must be excluded. Jn women, prior sexual or physical abuse should be taken into consideration.
First of all, physicians should reassure patients that JBS is not a life threatening disease. They should provide support, educate patients about JBS, and explain all stress foods and lifestyle choices which can cause exacerbation of problems. They should discuss the importaoce of mind-gut interaction; explain the circu/ous vitiosus phenomena, that the more you worry about functional symptoms, the more anxiety and distress you will feel.
Patient must learn that fatty foods, caffeine, fructose, sorbitol, legumes, crucifers, raw onions, grapes, plums, garlic, red vine, and beer exacerbate symptoms. Jn patients with constipation, high fiber foods may help.
Pharmacological measures are predominantly symptomatic. More than two-thirds of JBS patients have mild symptoms. Drug therapy is for the one third with severe symptoms. Here are some drugs which may help patients with severe symptoms:
- a) Anti-spasmodic agent: and anti-cholinergic agent which is used for treatment of acute episodes of pain and bloating. (belladonna, hyoscyamine). Anti-cholinergic side effects are common; some side effects are urinary retention, tachycardia, dry mouth and constipation
- b) Anti-diarrheal (loperamid) - usually used prophylactically in stressful situations
- c) Anti-constipation agent's trial of fibers supplementation with psyllium, methylcellulosis, polycarbophil, bran can be helpful for treatment of constipation but may exacerbate intestinal gas or bloating. Milk of magnesia may increase stool frequency and reduce straining.
- d) Psychotropic agents are beneficial for patients with pain and bloating. Low doses of tricyclic depressants and anxiolytics should be used only in acute anxiety episode because of their habituation potential.
- e) Serotonin receptor agonist and antagonists, tegaserod and alosetron. Tegaserod increases stool frequency, improves stool consistency, and reduces abdominal pain and bloating. Alosetron is used for treatment of women with severe IBS with predominant diarrhea It alters visceral sensation through blocking of 5-HT3 receptors, increases the pain threshold and slows colonic transit time.
- a) Behavioral modification with relaxation techniques, biofeedback and hypnotherapy may be helpful to some patients. Sometimes, evaluation by a psychiatrist or psychologist should be done.
- b) Alternative medicine therapies. According to James Braly, MD (medical director of lmmuno Lab, INC in Fort Lauderdale, FL), nuts, seeds, fruits with small seeds, alcohol, caffeine, and spices should be avoided. He also recommends supplements, including zinc, vitamin A, primrose oil, enteric-coated peppermint oil and ginger, all of which have a good reputation of helping. Chamomile, valerian, rosemary, balm have antispasmodic effects.
- c) David Hoffinan recommends mixtures of tincture of bayberry, gentian, peppers and wild yam in equal parts.
The Ayurvedic Approach to IBS
Introduction and definition
In Ayurvedic literature, the symptoms, called grahani, resemble most of the IBS symptoms, which can occur due to a number of factors: improper eating, drinking, exercising too soon after eating, forcing or restraining natural urges, taking chemical drugs, etc. Grahani is a pathological condition of the function and integrity of the GI tract, especially of the small intestine tract, which is the site of enzymes (digestion), of absorption of nutrition from food and the release of undigested food to the large intestines. IBS is a disorder characterized by abnormally increased motility of the small and large intestines. Stodies show that ''the circular and longitudinal muscles of the small bowels and sigmoid colon are highly susceptible to motor abnormalities. As a result, many factors could influence their contraction rate and lead to excess activity of their function, which is the basis of IBS. So, Ayurveda evaluation of IBS is made by search of various root causes of excessive GI motility through determination of the imbalances in the functioning mode."
The Ayurvedic history of IBS
IBS has been a problem for people for thousand of years and has been mentioned in the earlier literatures of Ayurveda.
Basic causes of IBS (Etiology or Nidana] 
- 1. Toxins accumulating in tissue blocking the circulation.
- 2. Poor nutrition, like consumplion of heavy food, overeating, consumption of improper food, consumption of too many fluids or fluids that are too cold.
- 3. Poor digestion as a result the intake of improper food at improper times, or skipping meals
- 4. Imbalance of the nervous system
- 5. Accumulation of physical and mental stress
- 6. Diminished natoral resistance and immunity (low ojas)
- 7. Disruption of natural biological rhythm
Rupa (Signs and Symptoms)
Besides all the symptoms mentioned in the general introduction like diarrhea, constipation, alteration of diarrhea and constipation, gas, distension and abdominal pain (severe in Vata-type), there may be evidence of malabsmption on the tongue. Malabsmption is a state of weakness of the small intestine and can be created by any dietary extremes: food that is too hot or too cold, too much sweet food, a diet that is too complex or too irregular, overeating or too much fasting, and junk food. Extreme eating can bring imbalance of the digestive fire.
According to Ayurvedic literature, the most important causes of IBS is Vata vitiation and low ojas, caused by stress and different diet and lifestyle imbalances: quality of food (extreme tastes and qualities), overeating, certain lifestyle (stress, too much traveling, ignoring bodily urges and irregular sleeping patterns). Pitta vitiation can be combined with Vata, but Vata is predominant. Also, food intolerance (dairy or grains), rather than food allergy could be present in 33-66%of IBS patients. An imbalance between two neurotransmitters, serotonin and norepinephrine, may cause problems. Therefore, interaction between the brain and gut is disturbed. A history ofuse of acetaminophen is associated with diarrhea-predominant IBS (imbalance of action of the neurotransmitter serotonin). Reproductive hormones in women, specifically progesterone, which is high in the postovulatory phase, can cause constipation. Also, before or during the onset of menstruation, women may report loose stool or dianhea As mentioned before, stress, because of a variety ofreasons, can cause IBS: financial or marital problems, death in family, and especially emotional, sexual and physical abuse are all possible causes of stress. We should mention anxiety, depression, and hostile feelings as well.
Samprapti ( Pathology)
In the Vata type IBS, ''Vala accumulates and becomes aggravated in the purishavaha srota (colon) and overflows to the rasa and rakta dhatus. Itthan relocates to the small intestine where it vitiates samana vayu and disturbs agni.". The symptoms are gas, distention, malabsorption, and diarrhea/constipation alternation. IfVata relocates into mamsa dhatu of mahavaha srota, cramping is present. Ifirregular habits vitiate samana vayu in the manovaha srota, the mind becomes unstable and the patient may experience "anxiety due to prana vayu vitiation and worry due to vyana vayu vitiation" Inthe Vata/Pitta type, "pachaka pitta accumulates and becomes aggravated in the small intestine where it causes burning indigestion and loose stool. It overflows to the rakta dhatu where it vitiates ranjaka pitta causing increased systemic heat. Pitta then relocates into the mind, disturbing sadhaka pitta and causing anger. This is combined with the pathology described under vata." The enzyme secretion due to all the causative factors is disturbed by the dominant dosha, and the result is secretion of enterotoxins. They cause acidification of fuod, which damages the mucous membrane of the intestines. The result is disturbance in apana vayu, or the evacuation of bowel contents. Excess mucous in the stool is a very frequent symptom and it isnot related to mucous injury, but may be related to cholinergic hyperactivities. Abdominal pain in IBS patients is probably "caused by abnormally strong contractions of the intestinal smooth muscles or by an increased sensitivity of the intestine to distention."
Some Ayurvedic literature states that there are two different types ofIBS (Vata and Ptta/Vata); others state that there are four types or even six.
- 1. Vata or the constipation type of JBS with all vata symptoms: dryness of skin and mucous, constipation or alternation of constipation and diarrhea, a cold feeling thirst, bloating, insomnia, anxiety, fissures, weight loss.
- 2. Pitta or the diarrhea type of JBS with presence of hotness, thirst, heartburn, diarrhea, irritability, anger, sweating, inflammation, fever, and foul smelling stool.
- 3. Kapha or dysentery type ofIBS, with presence of nausea, indigestion, heaviness in the chest and abdomen, foul smelling belching, mucus in the stools, sluggish bowels and lethargy.
- 4. Tridoshic or complex type of!BS with combined symptoms of all the above types.
- 5. Accrual type of !BS has combined symptoms of all three doshas with a lot of borborygmi, undigested food and alternation of several days of accumulation of stools followed by several days of passage ofloose stools. It is a chronic type of !BS.
- 6. Tympanites type of !BS is chronic as well and its symptoms are rumbling sounds in abdomen and increased bowel movements with undigested food particles. "
Western medicine diagnostic methods are explained in a general approach. They are very useful in Ayurveda diagnostics, but the most important thing is determination of which doshas are involved after taking a detailed patient's history of symptoms, lifestyle and habits.
Clinical Course and Prognosis
IBS is generally difficult to cure and it takes time. According to Ayurveda scholars and practitioners, it is curable in children, difficult to treat in middle age patients and incurable in older patients. The chronic types of IBS are very difficult to cure or even incurable.
Vata type IBS:
The most important thing in Ayurveda therapy is reducing stress. All stress-reducing measures are helpful: meditation, pranayama,, doing asanas, aromatherapy, gem therapy, color therapy and massage. Routine in everyday life is important, like regular sleeping and eating, and avoiding stressful situations. Generally, sattvic life is important. The Ayurveda practitioner should give lifestyle advice. Understanding of dosha involvement is important and unique and it is an essential tool in Ayurvedic healing of IBS. Besides stress management and diet, herbs are part of therapy as well. Digestive tonics like chitrakadi vati and shankha vati are beneficial for the elimination of enterotoxins. That could be followed with the administration of medicinal ghee preparation like dashmuladi ghrita. Triphala is beneficial as a long term formula in the form of shita kshaya. In 8oz of room temperature water, !tbs of triphala should stand overnight or for one day and should be consumed without the powder on the bottom. Nutmeg is beneficial for malabsorption, cramping and vata-type diarrhea. Carminatives, like asofoetida and ginger are good in case of distention and gas. Ashwaganda is beneficial as a nerving tonic and generally calm vata. Sesame oil can be used with food or as massage oil or enema The abdomen should be massaged 5 min. before soaking in warm water. Ginger.fennel, clove, cardamom will stimulate digestion, absorption and clear ama from the digestive system. Hingvashtaka chuma, in a dose of Itsp, mixed with I tsp of ghee twice per day, followed by hot water, is a good remedy for flatulence. Shanka pushpi andjatamamsi are used in case of anxiety as a nervine sedative. Light food is advised in treatment of Vata IBS. Food like bread, cheese, red meat, and foods that are cold, hard, dry and raw should be avoided. A light fast, like consuming only vegetable soups, takra, a little basmati rice, or kitcharee, is beneficial. Takra, which is half buttermilk, half water, churned with asofoetida, rock salt and cumin is an excellent digestive astringent and improves the consistency of stool. It contains Lactobacillus bacteria, which helps to restore the normal flora of the intestines.
Vata-Pitta type of IBS
The important thing is to manage the mind and digestive system. Because pitta and vata are involved, it is important to manage both. It is important to use bitters to cool the annavaha srota and the rakta dhatu. "A good choice is aloe vera, because it is moist and a not too strong bitter alterative and it will not vitiate vata. Caution must be present because oflaxative effecta of aloe vera, and long term of use can lead to dryness."  Red raspberries are an example of astringent herbs which are a good choice for pitta diarrhea. Fennel, coriander, cardamon are excellent dipanas for this type of IBS. Pitta emotions like anger, intensity, can be alleviated by cool nervines like shankhapushpi and gotu kola. Sandalwood powder in ghee is good for cooling pitta. Turmeric, guducci, shatavari are all excellent for balancing pitta. Demulcents like licorice, marshmallow, besides aloe vera and shatavari, are good for burning diarrhea and smelly gas.
Sweet, bitter and astringent foods are the right choices for this type of IBS. General principles of eating light, easily digestive foods (like vegetable soups, kitcharee, takra with a good choice of spices) are applicable to diet for this type of IBS. Avoiding greasy and fried food is important. Patients with chronic IBS need tonification, so bala and shatavari may be used.
- 1. Increase dietary fibers.
- 2. Restore healthy balance of bacteria in GI tract.
- 3. Identify and remove food intolerances.
- 4. Mind-body therapy.
- 5. Bring daily routine into life.
- 6. Be aware that IBS is not life threatening health problem.
- 7. Learn not only what the right food is, but also how to prepare and combine food properly.
MS is an intriguing disorder and a challenge for any health practitioner. Fortunately, this disorder is not life-threatening but it can make life very difficult for IBS sufferers. It is important that practitioners and patients are aware that a cure may take time. Patients need to learn how to cope with and minimize the symptoms of their disorder in the case that it isnot curable.
  Harrison's Principles of Internal Medicine, pg 1646  Current Medical Diagnosis and Trea1ment, pg.593
 MHalpern, Principles of Ayurveda Medicine, Digestive System, 1-38  M. Halpern, Principles of Ayurveda Medicine, Digestive System, 1-40  Mishra, L. Scientific Basis for Ayurvedic Therapies, pg 359
 MHalpern, Principles of Ayurveda Medicine. Digestive System, 1-41
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