Irritable bowel syndrome (IBS) is a common chronic gastrointestinal disorder, characterized by chronic or recurrent abdominal pain and bloating. Complementary and alternative medicine (CAM) is a diverse group of medical treatments that are not commonly considered to be a part of conventional medicine yet frequently used together with conventional medicine. CAM is widely used, particularly for chronic medical conditions that are difficult to treat. Because only a limited number of treatments are available for IBS, many patients choose CAM. This article reviews current evidence supporting the use of CAM in IBS, with a focus on prebiotics, acupuncture, and herbal medicines.
Irritable bowel syndrome (IBS) is a common chronic gastrointestinal disorder, characterized by bloating and chronic or recurrent abdominal pain associated with alterations in bowel habits. IBS can be categorized based on the predominant bowel habit: constipation, diarrhea, or both (ie, alternating pattern of diarrhea and constipation). IBS affects between 10% and 15% of the North American population. Because only a limited number of treatments are available for IBS, many patients choose complementary and alternative medicines (CAMs).
CAM is a diverse group of medical treatments that are not commonly considered to be a part of conventional medicine yet frequently used together with conventional medicine. CAM is widely used particularly among patients who have chronic medical conditions that are difficult to treat. In 2002, it was estimated that approximately 35% of the population used CAM in the previous year. A population-based study from Australia showed that approximately 21% of patients with IBS sought care from a CAM provider, and a study from the United Kingdom found that approximately 50% of patients with IBS attending an outpatient gastrointestinal clinic had used CAM. In the United States, a prospective 6-month study conducted in a large health maintenance organization setting found CAM use in 35% of patients with functional bowel disorders, including IBS, with an annual cost of $200. In this study, CAM use was highest in women and in those with higher education and anxiety.
This article reviews current evidence supporting the use of CAM in IBS, with a focus on prebiotics, acupuncture, and herbal medicines.
Prebiotics
A prebiotic is considered to be a “non-digestible food ingredient that beneficially affects the host by selectively stimulating the growth and/or activity of one of a limited number of potentially health-promoting bacteria in the colon,” most notably lactobacilli and bifidobacteria. Stimulating the growth of probiotics such as Lactobacillus or Bifidobacterium results in an increase in the absorption of vitamin and minerals, improves digestion, and increases protection against harmful bacteria, fungi, and viruses. Other mechanisms by which prebiotics modulate the immune system include increasing the number of lactic acid–producing bacteria, increasing the amount of short-chain fatty acids, and activating carbohydrate receptor immune cells.
Prebiotics are most commonly carbohydrates. Fructo-oligosaccharides such as oligofructose and inulin are the best studied and meet the strict definition of a prebiotic put forth by Roberfroid. Other commonly used prebiotics include galacto-oligosaccharides (GOS), trans-GOS, soya oligosaccharides, xylo-oligosaccharides, pyrodextrins, isomalto-oligosaccharides, and lactulose. Prebiotics can be further classified into short-chain, long-chain, and full-spectrum prebiotics. Short-chain prebiotics, such as oligofructose, ferment more quickly in the colon, whereas long-chain prebiotics, such as inulin, ferment more slowly and therefore work predominantly in the. Full-spectrum prebiotics, such as oligofructose-enriched inulin, target the entire colon. Prebiotics can also be found in a variety of food sources such as bananas, garlic, wheat, rye, and asparagus.
Only a few studies have been conducted on the role of prebiotics in patients with IBS. A clinical trial published in 2009 evaluated the effect of the prebiotic trans-GOS in changing the colonic microbiota and IBS symptoms. A total of 44 patients with Rome II IBS-C (IBS with constipation), IBS-D (IBS with diarrhea), or IBS alternate criteria were enrolled in this 12-week trial. The patients were randomized to receive 3.5 g/d or 7.0 g/d of the prebiotic trans-GOS or 7.0 g/d placebo. IBS symptoms were assessed using the Bristol Stool Form Scale and an IBS-specific questionnaire developed and validated by Drossman and colleagues on a weekly basis over the course of 12 weeks. In this study, the prebiotic trans-GOS significantly increased fecal bifidobacteria counts (3.5 g/d, P <.005; 7.0 g/d, P <.001) compared with placebo. The bacteriologic data suggested that the 7.0-g dose rather than 3.5-g dose had the best effect on increasing fecal bifidobacteria counts. The prebiotic trans-GOS also improved IBS symptoms, particularly at the 3.5-g/d dose, which resulted in significant improvement in stool consistency, flatulence, and bloating. This study suggests that prebiotics may serve as a therapeutic treatment of IBS. There were no adverse events in this study.
Other studies have analyzed the optimal dose of prebiotics. A study examined the dose-response effects of short-chain fructo-oligosaccharides (scFOS). In this study, 40 healthy volunteers following their usual diets were randomized to 2.5, 5.0, 7.5, or 10 g/d of scFOS or placebo. The investigators concluded that 7 days of ingestion of scFOS at a dosage of 10 g/d resulted in an increase in fecal bifidobacteria counts and minimized side effects.
For a discussion on the role of probiotics in the treatment of IBS, see the articles by Mark Pimentel and Eamonn Quigley elsewhere in this issue.
Acupuncture
Acupuncture, an ancient traditional Chinese medical practice, is becoming more widely accepted and used in the Western society. Acupuncture has been practiced in China for several thousand years, although this traditional healing art has become common in the United States only since the early 1970s. Traditional Chinese medicine is based on a theory of energy or life force (qi) that runs through the body in channels called meridians. Qi is essential to health, and disruptions of this energy flow, which are thought to contribute to symptoms and diseases, can be corrected at identifiable anatomic locations (acupoints) with acupuncture. The acupuncture technique involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electric stimulation. It has been used to treat gastrointestinal symptoms in functional and organ diseases and has been shown to influence visceral reflex activity, gastric emptying, and acid reflux. In IBS, acupuncture is thought to alter visceral sensation and motility by stimulating the somatic nervous system and the vagus nerve. Therefore, the brain-gut disturbances implicated in IBS make it reasonable to hypothesize that acupuncture might provide an effective treatment modality.
In 2006, a Cochrane database systematic review analyzed 6 randomized trials using acupuncture in IBS. The studies were generally of poor quality, included relatively small numbers of patients, and differed significantly in the acupuncture method used. This systematic review found inconclusive evidence as to whether acupuncture is superior to sham acupuncture in treating IBS. Subsequently, several large well-conducted randomized studies have been published ( Table 1 ). Schneider and colleagues published the results of a study that included 43 patients with IBS who were randomized to acupuncture or sham acupuncture. Although patients in both groups improved significantly compared with baseline, there was no significant difference between the response rates in patients receiving acupuncture and sham acupuncture based on quality-of-life measurements.
| Study | Design | Patients | Control | Outcome Measures | Main Results |
|---|---|---|---|---|---|
| Forbes et al, 2005 | DB, parallel group 10 sessions over 10 wk | 59 patients with Rome I IBS | Sham | Primary: decrease in symptom score at week 13 Others: weekly assessments of 8 symptoms by Likert scales, HAD, EuroQoL | No difference between acupuncture and sham (40.7% vs 31.2%, P >.05) Both groups improved compared with baseline |
| Schneider et al, 2006 | DB, parallel group 10 sessions over 5 wk | 43 patients with Rome II IBS. Study stopped early because of poor enrollment | Sham | Primary: improvement in QoL by FDDQL Others: BDQ, PHQ-D, SF-36 at baseline, at the end of therapy, and at 3 mo | No difference between acupuncture and sham (11% and 10% increase in global FDDQL score) Both groups improved compared with baseline No significant AEs |
| Lembo et al, 2009 | DB, parallel group 6 session over 3 wk | 230 patients with Rome II IBS | Sham | Primary: IBS-GIS Others: IBS-AR, IBS-SSS, IBS-QoL | No difference between acupuncture and sham (41% vs 32%, P = .25) Both groups improved compared with waiting-list group (37% vs 4%, P <.001) No significant AEs |
More recently, a large clinical trial was published by Lembo and colleagues from the Beth Israel Deaconess Medical Center in Boston, Massachusetts. This study tested the effect of acupuncture and sham acupuncture in relieving IBS symptoms compared with waiting-list control or no treatment. Following a run-in phase in which all patients except those in the no-treatment arm received sham acupuncture, a total of 230 adult patients with IBS were randomly assigned to 3 weeks of true or sham acupuncture (6 sessions) or continued no treatment. In addition, patients receiving true or sham acupuncture were also randomly assigned to either an augmented or limited patient-practitioner interaction. The primary end point of the study was the Global Improvement Scale, in which participants were asked about changes in their IBS symptoms during the course of the treatment. Secondary global end points included IBS Adequate Relief, IBS Symptom Severity Scale, and IBS Quality of Life Questionnaire. There was no significant difference in both primary and secondary outcomes between the groups that received acupuncture and sham. However, patients receiving acupuncture or sham acupuncture were more likely to be responders on the Global Improvement Scale than patients in the waiting-list control group (37% vs 4%, P <.001) ( Fig. 1 ). Likewise, patients receiving acupuncture or sham acupuncture versus those on the waiting-list control were significantly more likely to be responders in regard to secondary outcomes. Three adverse events were reported during the acupuncture versus sham acupuncture phase of the study: (1) painful foot cramp following treatment (sham acupuncture), (2) nausea/hip pain (true acupuncture), and (3) rib pain after a fall (sham acupuncture). All these events were considered to be unrelated to the study procedure. The results demonstrated that, although there was a trend toward improvement with acupuncture, there was no statistically significant difference between acupuncture and sham acupuncture in improving the symptoms of IBS. Similar to the Schneider and colleagues study, this study estimated that more than 600 patients would be needed to properly power a study to show the superiority of acupuncture over sham acupuncture. This study showed that acupuncture and sham acupuncture were significantly better than no treatment, suggesting that either sham acupuncture is effective at relieving symptoms associated with IBS or the ritual of acupuncture (ie, nonspecific placebo effects) is effective.
Acupuncture
Acupuncture, an ancient traditional Chinese medical practice, is becoming more widely accepted and used in the Western society. Acupuncture has been practiced in China for several thousand years, although this traditional healing art has become common in the United States only since the early 1970s. Traditional Chinese medicine is based on a theory of energy or life force (qi) that runs through the body in channels called meridians. Qi is essential to health, and disruptions of this energy flow, which are thought to contribute to symptoms and diseases, can be corrected at identifiable anatomic locations (acupoints) with acupuncture. The acupuncture technique involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electric stimulation. It has been used to treat gastrointestinal symptoms in functional and organ diseases and has been shown to influence visceral reflex activity, gastric emptying, and acid reflux. In IBS, acupuncture is thought to alter visceral sensation and motility by stimulating the somatic nervous system and the vagus nerve. Therefore, the brain-gut disturbances implicated in IBS make it reasonable to hypothesize that acupuncture might provide an effective treatment modality.
In 2006, a Cochrane database systematic review analyzed 6 randomized trials using acupuncture in IBS. The studies were generally of poor quality, included relatively small numbers of patients, and differed significantly in the acupuncture method used. This systematic review found inconclusive evidence as to whether acupuncture is superior to sham acupuncture in treating IBS. Subsequently, several large well-conducted randomized studies have been published ( Table 1 ). Schneider and colleagues published the results of a study that included 43 patients with IBS who were randomized to acupuncture or sham acupuncture. Although patients in both groups improved significantly compared with baseline, there was no significant difference between the response rates in patients receiving acupuncture and sham acupuncture based on quality-of-life measurements.
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Centrally Acting Therapies for Irritable Bowel Syndrome
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Emerging Pharmacological Therapies for the Irritable Bowel Syndrome
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