By Dr. Stephanie Karozos
4/25/2019
IBS Pathophysiology:
● Visceral hypersensitivity
● Abnormal gut motility
● Psychosocial factors
○ Brain-gut interaction
● Dysbiosis
● Leaky gut
● Following infection
● Latent or potential celiac disease
Diagnosing IBS
● Medical, surgical, family history
● HPI
● Physical
● Rule out celiac disease
● Rule out inflammatory bowel disease
● Clinical diagnosis
Treatment Step 1: Identify triggers
Dietary interventions
● Gluten free diet
● Elimination diet
● FODMAP diet
Elimination Diet
● Type 1
○ Eliminate the most potentially allergenic foods for 7-14 days (21
days)
○ Cow’s milk, corn, wheat, soy, yeast, eggs, refined sugars
■ Caffeine, alcohol
■ Food coloring
■ Citrus fruits
■ Any foods that patients crave or eat >4x/week
○ Add back one food group at a time
● Type 2
○ Eliminate one trigger at a time for 7-14 days
○ Longer process but less stressful/easier to adhere
FODMAP
● Low FODMAP diet
● High FODMAP foods eliminated x 2-6 weeks
● Reintroduce one high FODMAP food at a time
● Identify high FODMAP triggers
● Starts out restrictive, eventually hope to liberalize
diet
● MONASH FODMAP website & app
Treatment Step 2: Symptom Management
● Conventional pharmacologic treatments
● Herbal supplements
○ Supplements
○ Medicinal teas
● Non-med interventions
○ Mindfulness
○ Gentle movement
○ Behavioral health
○ Acupuncture
● Dietary
○ AI diet
○ Mediterranean diet
Herbal Supplements
IBS-C
○ Ginger
○ Triphola
○ Psyillium
○ Flax
IBS-D
● Peppermint oil (EC capsules, with meals)
● Chamomile +
● Pectin (applesauce)
● Tannins (Green or black tea)
IBS-mixed
● Turmeric 500mg TID
● Lemon balm tea
● Licorice
Additional Supplement Considerations
● Prebiotics
○ Non-digestible fibers
● Probiotics
○ Actual bacteria
● Magnesium
● Melatonin
● Fish oil
Non-med Interventions
● Mindfulness*
○ MBSR
○ Meditative practices
● Gentle movement
○ Yoga
○ Tai Chi
○ Qi Gong
● Acupuncture
● Behavioral Health*
Dietary Interventions
● Anti-inflammatory diet
○ Pro-inflammatory cytokines were higher than healthy controls
○ Post-infectious IBS ⅓ of all cases – a/w immune activation
○ Microbiota contributes by causing abnormal motility, low grade
inflammation, visceral hypersensitivity, disrupted gut-brain axis
communication
● Mediterranean diet
○ Same rationale as AI diet
Treatment Step 3: Treat SIBO
● When to think SIBO
○ Bloating predominant
○ PPI use
○ Bentyl use
○ Frequent antibiotic use
○ Taking meds that slow transit (i.e. opioids)
○ Gastroparesis or medical conditions linked to dysmotility
■ SLE
■ Diabetes
■ Scleroderma
● Testing options are suboptimal & expensive
○ Breath testing is most commonly used
○ Glucose and lactulose breath tests have sensitivities of 60–70%, with
specificities of 40–80%
○ Studies have found that the specificity of the 10-g lactulose breath
test and the 14C-labeled 1-g xylose test were 100% when radionuclide
scintigraphy was done during the test to assess gastric emptying..
○ Elevated fasting breath hydrogen (>19 ppm or methane >10 ppm) are
excellent predictors of overgrowth, being highly specific (>90%) but
not sensitive (<30%)
Dukowics, et. al.
● Treatment study: Abx vs Herbs (Chedid)
● Antibiotics
○ Rifaximin 1200mg daily (400mg TID) x 4 weeks
○ Non-responders: triple antibiotic therapy or herbal tx
■ clindamycin 300 mg TID, metronidazole 250 mg TID, neomycin 500 mg
TID
● Herbal
○ Dysbiocide + FC Cidal (2 capsules BID)
○ Candibactin-AR + Candibactin-BR (2 capsules BID)
● Similar response rates and safety profiles
● Rifaximin 1600mg/d better outcomes than 1200mg/d for 1
week treatment in another study (Scarpellini)
● Another study found 1200mg/d x 14 days had a 87-91%
success rate at normalizing GBT and improved symptoms
(Lombard)
● What I’ve done
○ Dysbiocide + ADP (emulsified oil of oregano) – Diaz treatment
■ 2 capsules BID until bottle runs out
○ Rifaximin 1200mg/d x 14 days
References
Arizona Center for Integrative Medicine “Integrative Medicine in Residency” curriculum, notes from lecture by Tieraona Low Dog, MD
Chedid V, Dhalla S, Clarke JO, et al. Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Glob Adv
Health Med. 2014;3(3):16–24. doi:10.7453/gahmj.2014.019
Dukowicz AC, Lacy BE, Levine GM. Small intestinal bacterial overgrowth: a comprehensive review. Gastroenterol Hepatol (N Y). 2007;3(2):112–122.
Hopkins Medicine SIBO page
Lombardo, Lucio et al. Increased Incidence of Small Intestinal Bacterial Overgrowth During Proton Pump Inhibitor Therapy. Clinical Gastroenterology
and Hepatology. Volume 8 , Issue 6 , 504 – 508
SCARPELLINI, E. , GABRIELLI, M. , LAURITANO, C. E., LUPASCU, A. , MERRA, G. , CAMMAROTA, G. , CAZZATO, I. A., GASBARRINI, G. and
GASBARRINI, A. (2007), High dosage rifaximin for the treatment of small intestinal bacterial overgrowth. Alimentary Pharmacology & Therapeutics,
25: 781-786.