Scientific Basis for Ayurvedic Therapies -24

Scientific Basis for

Ayurvedic Therapies 

edited by

Brahmasree Lakshmi Chandra Mishra

Irritable Colon (Grahani)

Shankar K. Mitra and Paramesh R. Rangesh

20.1 Introduction

Irritable colon is also known as Irritable Bowel Syndrome (IBS). It is a gastrointestinal (GI)

motility disorder for which there is no organic or structural cause. Because the symptoms

of IBS can mimic other disorders, such as hypothyroidism, it is diagnosed when all other

local and systemic conditions have been ruled out.

In Ayurvedic literature, the symptom of a disease called

grahani

resembles most of IBS

symptoms. According to Ayurveda, grahani can be due to a number of factors such as

improper diet, heavy foods, overeating, constipation, hemorrhoids, drinking too much

fluid (especially cold water when hungry), exercising too soon after eating, forcing or

straining natural urges, and taking chemical drugs.

20.2 Definition

The disease condition is called

grahani

, which indicates the pathological state of function

and integrity of the intestinal tract (mostly small intestine), a particular part of the GI

system known as

grahani

in

Sanskrit.

1

Grahani

is the seat of enzymes (agni). Normally, it

holds up the food (until it is digested) and releases it from the side after it is digested.

But when it is deranged due to weak digestive enzymes, it releases the ingested material

even in undigested conditions.

1

A disorder characterized by abnormally increased motility of the small and large intestines,

producing abdominal pain, constipation, or diarrhea, is also known as irritable colon,

spastic colon, or mucous colitis.

20.3 Clinical Description

Ayurvedic literature characterizes the disease by the passage of stools alternated with

constipation or diarrhea and with undigested food particles. This disease is also associated

with thirst, distaste, blackouts, pedal edema, pain in the bone, fever, and vomiting.

2

It is

a motility disorder involving the entire GI tract, causing recurring upper and lower GI

symptoms, including variable degrees of abdominal pain, constipation and diarrhea, and

abdominal bloating.

20.4 History and Epidemiology

IBS has been a problem for people for thousands of years, as it is mentioned in the earlier

literatures of Ayurveda. IBS, also known as spastic colon, is a common disorder affecting

as many as 20% of the population, more so among women than men. Because it is a clinical

diagnosis, the prevalence figures vary depending upon the definition of IBS used.

Although only about 10% of IBS patients actually seek medical attention, it accounts for

about 3 million physician visits and over 2 million prescriptions in the U.S. annually. It is

the seventh leading diagnosis among all physicians, and these patients utilize an additional

$300 per year of health-care costs than do their non-IBS counterparts.

3

20.5 Etiology

Although no specific causes are mentioned in Ayurvedic literatures, most of them focus

on the dietary injudiciousness as the foremost cause of IBS. Examples include the quality

of food, such as extremely dry, astringent, spicy, and heavy to digest (protein rich) foods;

the quantity of intake (e.g., overeating); and the improper frequency of intake (e.g.,

untimely eating habits). Certain lifestyles including excessive traveling and controlling

various natural urges (e.g., defecation and urination) are described to be the foremost

causes that affect the function and integrity of digestive system.

4

In conventional medicine, the cause of IBS is unknown. No anatomical cause can be

found. Emotional factors, diet, drugs, or hormones may precipitate or aggravate heightened

GI motility. Some patients have anxiety disorders (particularly panic disorders),

major depressive disorders, and somatization disorders. Stress and emotional conflict do

not always coincide with symptom onset and recurrence. Some patients with IBS appear

to have a learned aberrant illness behavior (i.e., they tend to express emotional conflict as

a GI complaint, usually abdominal pain). The physician evaluating patients with IBS,

particularly those with refractory symptoms, should investigate for unresolved psychological

issues, including the possibility of sexual or physical abuse.

3

20.5.1 Food Intolerance

True food allergy is mediated by the immune system and is associated with hives, asthma,

eczema, nasal discharge, and positive skin-prick radioallergosorbent test (RAST) scores

or other allergy tests.

5

However, food intolerance, rather than true food allergy, is believed

to be more significant in IBS.

6

Between 33 and 66% of IBS patients report having one or

more food intolerances.

5

The most common culprits are dairy (40 to 44%) and grains (40

to 60%); the resulting GI bloating, flatulence, and pain caused by this reaction appears to

be mediated by inflammatory prostaglandin synthesis.

6

20.5.2 Neurochemical Imbalance

Interaction between the brain and the gut occurs via nerves that send neurotransmitter

signals. An imbalance between two of these neurotransmitters, serotonin and norepinephrine,

are implicated in IBS. Constipation may result when levels of norepinephrine

increase, causing a reduction in serotonin levels and inhibition of another neurotransmitter

called acetylcholine. Conversely, diarrhea can occur when increased serotonin inhibits

norepinephrine and causes levels of acetylcholine to increase. For IBS patients, such an

imbalance in the nervous system can lead to the fluctuating bowel symptoms of constipation

and diarrhea.

7

20.5.3 History of Analgesic Use

The use of acetaminophen, a common pain-relieving medication, is associated with diarrhea-

predominant IBS. Its action may be due to an imbalance in the neurotransmitter

serotonin. Because acetaminophen can cause elevated levels of the serotonin by-product

5-hydroxy-indole-acetic acid (HIAA) in the urine, it is possible that acetaminophen somehow

interferes with serotonin metabolism. Plasma serotonin levels have indeed been

shown to be elevated after eating by patients with diarrhea-predominant IBS. Clinically,

a drug that blocks the 5- HT3 serotonin receptor (5-HT3 receptor antagonist) is effective

for women with diarrhea-predominant IBS. It is interesting to note that asthma, another

condition associated with disordered smooth muscle function, was recently found to be

associated with acetaminophen.

8

20.5.4 Reproductive Hormones

IBS occurs more than twice as frequently in women than in men and tends to follow a

cyclic pattern, with aggravation during the postovulatory (progesterone predominant)

and premenstrual phases of the menstrual cycle.

9

Progesterone is known to delay gastric

emptying and cause constipation; constipation with straining and the frequent passage

of hard stools is a more prevalent IBS manifestation in women, especially during the

postovulatory phase.

10

At the end of the postovulatory phase, the sudden withdrawal of

progesterone that occurs with the start of the premenstrual phase may trigger increased

bowel activity. Women frequently report loose stools and diarrhea before or with the

onset of menstruation. In contrast to progesterone, estrogen has not been associated with

exacerbations of IBS symptoms.

11

Along with progesterone levels in women, prostaglandins E2 and F2 alpha also increase

in the premenstrual phase. Because they are powerful stimulants of bowel contractions,

it is possible that women with IBS may have an exaggerated response to these prostaglandins.

9

20.5.5 Mood

Anxiety, hostile feelings, sadness, depression, and sleep disturbance are associated with

IBS. Adverse life events such as family death, marital stress, financial difficulties, and

especially physical and sexual abuse have also been reported more frequently in IBS

patients than in the general population. However, it is possible that IBS patients with this

social or psychological background may be more likely to seek medical treatment or

participate in research studies.

5

The impact of stress on bowel motility and pain were explored in one study

5

by administering

corticotrophin-releasing factor (CRF), a hormone released in the body during

stress. CRF increases motility of the descending colon and can induce abdominal pain.

The researchers found that IBS patients had greater colonic motility and more abdominal

pain after receiving CRF.

20.5.6 Small Intestine Bacterial Overgrowth

Excess bacteria in the small intestine, an area that is normally relatively bacteria free, is

being recognized as important in the development of IBS. When these bacteria are present

in the small intestine, excessive gas, bloating, abdominal distension and pain, and altered

gut motility can result.

5

20.6 Pathogenesis and Pathology

According to Ayurveda, there is a certain pathogenesis of this disorder. Due to the above

causative factors, the enzyme secretion gets disturbed by the dominant

dosa

, which results

in the production of enterotoxin. This toxin causes the food to undergo acidification, which

damages the mucous membrane of the intestines; the result is a decrease of intestinal

transit time, causing early evacuation of bowel contents or alternated with a state of

constipation, which is influenced by

apana vata

.

2

In IBS, the circular and longitudinal muscles of the small bowel and sigmoid are particularly

susceptible to motor abnormalities. The proximal small bowel appears to be

hyperreactive to food or parasympathomimetic drugs. Small-bowel transit is variable in

patients with IBS, and changes in bowel transit time often do not correlate with symptoms.

Intraluminal pressure studies of the sigmoid show that functional constipation can occur

when austral segmentation becomes hyperreactive (i.e., increased frequency and amplitude

of contractions); in contrast, diarrhea is associated with diminished motor function.

Excess mucus production, which often occurs in IBS, is not related to mucosal injury.

Its cause is unclear, but it may be related to cholinergic hyperactivity. Hypersensitivity to

normal amounts of intraluminal distention exists, as does a heightened perception of pain

in the presence of normal quantity and quality of intestinal gas. The pain of IBS seems to

be caused by an abnormally strong contraction of the intestinal smooth muscle or by an

increased sensitivity of the intestine to distention. Hypersensitivity to the hormones gastrin

and cholecystokinin may also be present. However, hormonal fluctuations do not

correlate with clinical symptoms. The caloric density of food intake may increase the

magnitude and frequency of myoelectrical activity and gastric motility. Fat ingestion may

cause a delayed peak of motor activity, which can be exaggerated in IBS. The first few

days of menstruation can lead to transiently elevated prostaglandin E2, resulting in

increased pain and diarrhea. This is not caused by estrogen or progesterone but by the

release of prostaglandins.

3

20.7 Diagnosis

Ayurvedic literature indicates that there are four different types of IBS. They are constipation-

predominant IBS (

vata grahani

), diarrhea-predominant IBS (

pitta grahani

), dysentery-

predominant IBS (

kapha grahani

), and complex IBS (

tridosha grahani

). All three

dosas

are involved (

vata

,

pitta

, and

kapha

). Other literature also describes two chronic types of

IBS: accrual IBS (

samgraha grahani

) and an incurable type called tympanitis predominant

IBS (

ghatiyanthra grahani

).

2

The clinical

features of all types of IBS are described below.

1. Constipation-predominant IBS — This type of IBS presents the clinical features of

dryness in skin, mouth, or throat; more constipation or alternating constipation

and diarrhea; thirst; bloating; flatulence; and a cold feeling. It is also associated

with back or groin pain, weight loss, debility, anal fissures, insomnia, and anxiety.

2. Diarrhea-predominant IBS — This type of IBS clinically shows the presence of

heartburn, thirst, feeling hot, irritable or angry, inflammation, sweating and fever,

fluid, and foul smelling stools and eructation.

3. Dysentery-predominant IBS — This type of IBS exhibits the presence of nausea,

indigestion, and excess sputum in the pharyngeal region, heaviness in the chest

and abdomen, bad-smelling eructation, lethargy, sluggish bowels, and mucus in

the stools.

4. Complex IBS — This type reveals the combined signs and symptoms of all the

above types.

5. Accrual IBS — This type of IBS presents the combined features of all the

tridosas

and is more chronic. It is specially diagnosed with clinical features of

borborygmi

,

diurnal changes that the bowel movements are increased in the daytime and stop

at night. The nature of the stool will be pastier and slimy, have undigested food

particles, and be eliminated with pain. The pattern of the bowel movement will

be accumulation of stools for some days followed by passage of loose stools for

several days.

6. Tympanites-predominant IBS — In this type of IBS, the clinical symptoms are

rumbling sounds heard in abdomen and increased bowel movements with lots of

undigested food particles.

2

Conventional medicine states that IBS tends to begin in the second and third decades

of life, causing bouts of symptoms that recur at irregular periods. Onset in late adult life

is rare. Symptoms usually occur in the awake patient and rarely rouse the sleeping patient.

Symptoms can be triggered by stress or the ingestion of food.

The features of IBS are pain relieved by defecation, an alternating pattern of bowel

habits, abdominal distention, mucus in the stool, and sensation of incomplete evacuation

after defecation. The more symptoms that are present, the likelier it is that the patient has

IBS. In general, the character and location of pain, precipitating factors, and defecatory

pattern are distinct for each patient. Variations or deviations from the usual symptoms

may suggest intercurrent organic disease and should be thoroughly investigated. Patients

with IBS may also have extra intestinal symptoms (e.g., fibromyalgia, headaches, dyspareunia,

temporomandibular joint [TMJ] syndrome).

Two major clinical types of IBS have been described. In

constipation-predominant IBS

,

constipation is common, but bowel habits vary. Most patients have pain over at least one

area of the colon, associated with periodic constipation alternating with a more normal

stool frequency. Stool often contains clear or white mucus. The pain is either colicky, comes

in bouts, or has a continuous dull ache; it may be relieved by a bowel movement. Eating

commonly triggers symptoms. Bloating, flatulence, nausea, dyspepsia, and pyrosis can

also occur.

Diarrhea-predominant IBS

is characterized by precipitous diarrhea that occurs immediately

on rising or during or immediately after eating. Nocturnal diarrhea is unusual. Pain,

bloating, and rectal urgency are common, and incontinence may occur. Painless diarrhea

is not typical and should lead the physician to consider other diagnostic possibilities (e.g.,

malabsorption, osmotic diarrhea).

3

Diagnosis of IBS is based on characteristic bowel patterns, time and character of pain,

and exclusion of other disease processes through physical examination and routine diagnostic

tests. Standardized criteria have been developed for IBS. The Rome criteria for IBS

include abdominal pain relieved with defecation and a varying pattern of altered stool

frequency or form, bloating, or mucus. The key to diagnosis is effective history taking.

This requires attention to directed (but not controlled), elaboration of the presenting

symptoms, history of present illness, past medical history, family history, familial interrelationships,

and drug and dietary histories. The patient's interpretation of personal

problems and overall emotional state are equally important. The quality of patient–physician

interaction is key to diagnostic and therapeutic efficacy.

On

physical examination

, patients with IBS generally appear to be healthy. Palpation of

the abdomen may reveal tenderness, particularly in the left lower quadrant, at times

associated with a palpable, tender sigmoid. A routine digital rectal examination should

be performed on all patients, and a pelvic examination should be performed on women.

Stool examination for occult blood (preferably a 3-day series) should be performed. Routine

testing for ova and parasites or a stool culture is rarely indicated without a supporting

travel history or supporting symptoms (e.g., fever, bloody diarrhea, acute onset of severe

diarrhea).

Proctosigmoidoscopy with a flexible fiber-optic instrument should be performed. Introduction

of the sigmoidoscope and air insufflation frequently trigger bowel spasm and

pain. The mucosal and vascular pattern in IBS usually appears normal. In patients with

chronic diarrhea, particularly older women, mucosal biopsy can rule out possible microscopic

colitis, which has two variants: collagenous colitis, seen on trichrome stain as

increased submucosal collagen deposition, and lymphocytic colitis, characterized by

increased numbers of mucosal lymphocytes. The mean age of presentation for these

disorders is 60 to 65 years old, with a female predominance. Similar to IBS, presentation

involves nonbloody, watery diarrhea. Diagnosis can be made via rectal mucosal biopsy.

Laboratory examination should include a complete blood count (CBC); erythrocyte

sedimentation rate; 6- and 12-channel biochemical profile (sequential multiple analyses 6

and 12), including serum amylase; urinalysis; and thyroid-stimulating hormone. An

abdominal sonogram, barium enema x-ray, and upper GI esophagogastroduodenoscopy

or colonoscopy may be selectively used, based on the patient’s history, physical examination,

age, and follow-up evaluations. These studies should be undertaken only when less

invasive and less expensive studies reveal objective abnormalities.

Diagnosis of IBS should never preclude suspicion of intercurrent disease. Changes in

symptoms may signal another disease process. For example, a change in the location, type,

or intensity of pain; a change in bowel habits; constipation and diarrhea; and new symptoms

or complaints (e.g., nocturnal diarrhea) may be clinically significant. Other symptoms

that require investigation include fresh blood in the stool, weight loss, very severe abdominal

pain or unusual abdominal distention, steatorrhea or noticeably foul-smelling stools,

fever or chills, persistent vomiting, hematemesis, symptoms that wake the patient from

sleep (e.g., pain, the urge to defecate), or a steady progressive worsening of symptoms.

Patients more than 40 years old are more likely than younger patients to have an intercurrent

organic illness.

3

Characteristic symptoms of IBS include recurrent abdominal pain; abdominal pain

relieved by defecation; disordered bowel habit, including constipation, diarrhea, or an

alternation between the two; and abdominal distension and bloating.

12

IBS is also associated with nongastrointestinal conditions such as headache, low back

pain, arthritis, noncardiac chest pain, difficult urination, and fibromyalgia.

13

20.8 Clinical Course and Prognosis

According to Ayurvedic literature, IBS is curable in children, difficult to treat in middle

age, and incurable in older patients. The chronic accrual IBS is difficult to cure whereas

tympanites-predominant IBS is incurable.

20.9 Therapy

The Ayurvedic principle of the involvement of

dosas

is very helpful because it provides

an understanding of the symptoms and how they vary from one type to another. It also

provides a system of treatment specific to that particular

dosa

imbalance. Ayurveda utilizes

not only diet and herbs, but also lifestyle advice so that treatment of IBS can be more

specific and more successful.

Generally, Ayurveda suggests drinking warm water at first, when morbidity and enterotoxin

is located in IBS and is flared up with the improperly digested food. Appetizers, a

light diet (e.g., liquid gruel) followed by ghee mixed with appetizers,

vata

-alleviating

drugs, and an enema are then advised as a line of treatment. Ayurvedic treatment is based

on the nature of the stool with (

sama

) or without (

nirama

) enterotoxin stool. The therapy

process is highlighted as follows:

1. According to Ayurveda, dyspepsia and enterotoxin in IBS are important pathological

processes that have to be treated effectively along with consideration

of bowel movements with respect of stools with or without mucus discharge.

When enterotoxin dominates this stage, it is treated with fasting and administration

of digestives and carminatives. Use of warm water is highly recommended.

2. In constipation-predominant IBS, the first line of treatment is administration of

digestives like

chitrakadi vati

and

shankha vati

to eliminate enterotoxin. It is recommended

to follow the digestive with an administration of medicinal ghee preparations

such as

dashmuladi ghrita

and

thryushanadi ghrita

.

3. Emesis (

vamana

) is the first line of treatment in diarrhea-predominant IBS, followed

by the herbal bitters.

4. The first line of treatment for dysentery-predominant IBS is laxatives (

virechana

)

followed by the administration of herbs with spicy and sour tastes.

5. Complex IBS is treated with the

panchakarma

line of treatment and supported by

digestives and carminative preparations.

6. Generally, in the treatment of IBS, the use of buttermilk (

takra

) is emphasized. The

patient has to be kept on the diet of buttermilk, which is the treatment and

nutrition in IBS. Buttermilk is digestive, astringent, and light to digest and helps

in improving the consistency of the stool. Buttermilk is given along with asafetida,

cumin, and rock-salt powder to control the bowel movements. It contains a good

amount of lactobacillus bacteria, which helps restore the normal flora of the

intestines.

14

When treating IBS, a light diet is advised. Indigestible foods such as bread; cheese; red

meat; and cold, hard, and raw foods should be avoided. A light fast can be helpful taking

only vegetable soups and a little basmati rice and green gram beans. Herbs like ginger,

fennel, and cumin that stimulate enzyme secretions will improve digestion, absorption,

and clear

ama

from the digestive tract.

20.9.1 Common Herbs Used in IBS

20.9.1.1 Constipation-Predominant IBS

The following herbs are used in this type of IBS for their respective benefits:

1. Ginger, clove, fennel, cumin, cardamom, and a little cinnamon will all stimulate

digestive enzymes.

2. Chebulic myrobalan (

Terminalia chebula

) clears excess

vata

from the bowel.

Triphala

,

a mixture of chebulic myrobalan, Indian gooseberry (

Emblica Officinalis

), and belliric

myrobalan (

Terminalia belerica

), is a gentle bowel tonic excellent for chronic

constipation and IBS and for clearing toxins from the bowel. It can be taken in

powder or capsule form at bedtime.

3. Asparagus (

Asparagus racemosus

),

ashwagandha

(

Withania somnifera

), and sesame

oil all calm

vata

. This is often given as an enema but can also be massaged over

the body, particularly over the abdomen 5 min before soaking in a warm bath.

Sweet, sour, and salty foods are best.

20.9.1.2 Diarrhea-Predominant IBS

The following herbs are used in this type of IBS for their respective benefits:

1. Indian gooseberry (

Emblica officinalis

) is a rejuvenative tonic and renowned remedy

for

pita

problems, which balances

dosas

.

2. Coriander water cools

pita

, as does sandalwood powder prepared in ghee, which

is often mixed with fennel, long pepper, black pepper, and cloves.

3. Nutgrass (

Cyperus rotundus

) improves intestinal absorption and stops diarrhea.

4.

Aloe vera juice, turmeric, Indian madder (

Rubia cordifolia

), guduchi (

Tinospora

cordifolia

) and Indian asparagus (

Asparagus racemosus

) are all excellent for balancing

pitta

. Sweet, bitter, and astringent foods are best.

20.9.1.3 Dysentery-Predominant IBS

The following herbs are used in this type of IBS for their respective benefits:

1. Ginger, lime juice, and honey are excellent to control

kapha

.

2.

Trikatu

, a compound containing black pepper, long pepper, and ginger, is specific

for low enzyme and high enterotoxin.

3. Turmeric, cardamom, cinnamon, cloves, sandalwood, cumin, nutmeg, rock salt,

and long pepper raise digestive enzyme and clear

kapha

.

4. 1/2 tsp of Hingvastaka, a mixture of asafetida, ginger, black pepper, rock salt, etc.

taken in a little warm water 1 to 2 h before lunch and supper, increases enzymes

and clears enterotoxin. Pungent, bitter, and astringent tasting foods are best.14

20.9.2 Lifestyle Changes

The following changes in lifestyle help to control IBS:

1. Identify and remove food intolerances — A trained practitioner can supervise

an elimination diet. Many foods are removed from the diet for a brief period

and then reintroduced sequentially to isolate the body’s reaction to the offending

foods. Because grains are a common culprit, it is important to remember

that carbohydrate digestion begins in the mouth and that chewing grains thoroughly

allows amylase, the digestive enzyme present in saliva, to digest the

grains.

2. Improve gut motility — Soluble fiber increases bowel transit, stools, and relieves

constipation. Wheat bran has been used in some research studies, but it is not

recommended for people who may have intolerances to wheat. Psyllium is a good

source of soluble fiber and is readily available. Sufficient water should be taken

or fiber can have the opposite effect and result in greater constipation. Flaxseed

(Linum usitatissimum) also acts as a gentle laxative. It is useful for chronic constipation,

damage to the colon wall from laxative abuse, irritable colon, and soothing

GI inflammation.

3. Restore a healthy balance of bacteria in the gut — Lactobacillus acidophilus and

Bifidobacterium bifidum can help restore a healthy balance of bacteria in the gut.

They can decrease the amount of bacteria with gas-producing abilities and relieve

IBS symptoms such as abdominal distension and flatulence. Bifidobacterium acts

as a barrier against colonization of the gastrointestinal tract by pathogenic bacteria,

and lactobacillus inhibits the attachment of pathogens onto the intestinal mucous

lining.5

Low fiber intake is associated with an overgrowth of toxin-producing bacteria

and a lower percentage of lactobacillus bacteria. A diet high in dietary fiber

increases the formation of short-chain fatty acids, such as butyrate, which is the

preferred energy source of the cells that line the colon.15

4. Pancreatic enzymes — These enzymes help inhibit the growth of bacteria in the

small intestine. They help improve protein digestion. Goldenseal (Hydrastis

canadensis) also inhibits bacteria and prevents the conversion of proteins to vasoactive

amines.6

5. Mind–body therapy — Brief psychotherapy was found to be helpful in improving

IBS symptoms of pain and diarrhea. Relaxation training to induce whole-body

relaxation and stress management, hypnosis, and biofeedback have all been helpful

in treating IBS.16 Antidepressants have been shown to be very effective for

treating bowel motility and visceral nerve responses, in addition to addressing

the emotional component of IBS.

Therapy is supportive and palliative. A physician’s sympathetic understanding and

guidance are of overriding importance. The physician must explain the nature of the

underlying condition and convincingly demonstrate to the patient that no organic disease

is present. This requires time for listening and explaining normal bowel physiology and

the bowel’s hypersensitivity to stress, food, or drugs. These explanations form the foundation

for attempting to reestablish a regular bowel routine and individualize therapy.

The prevalence, chronicity, and need for continuing care of IBS should be emphasized.

Psychological stress and anxiety or mood disorders should be sought, evaluated, and

treated. Regular physical activity helps relieve stress and assists in bowel function, particularly

in patients who present with constipation.

In general, a normal diet should be followed. Patients with abdominal distention and

increased flatulence may benefit from dietary reduction or elimination of beans, cabbage,

and other foods containing fermentable carbohydrates. Reduced intake of apple and grape

juice, bananas, nuts, and raisins may also lessen the incidence of flatulence. Patients with

evidence of lactose intolerance should reduce their intake of milk and dairy products.

Bowel function may also be disturbed by the ingestion of sorbitol, mannitol, fructose, or

combinations of sorbitol and fructose. Sorbitol and mannitol are artificial sweeteners used

in dietetic foods and as drug vehicles, whereas fructose is a common constituent of fruits,

berries, and plants. Patients with postprandial abdominal pain may try a low-fat diet

supplemented with increased protein.

Increasing dietary fiber can help many patients with IBS, particularly those with constipation.

A bland bulk-producing agent may be used (e.g., raw bran, starting with 15 ml

[1 Tbsp] with each meal, supplemented with increased fluid intake). Alternatively, psyllium

hydrophilic mucilloid with two glasses of water tends to stabilize the water content

of the bowel and provide bulk. These agents help retain water in the bowel and prevent

constipation. They also can reduce colonic transit time and act as a shock absorber to

prevent spasm of the bowel walls against each other. Fiber added in small amounts may

also help reduce IBS-induced diarrhea by absorbing water and solidifying stool. Excessive

use of fiber can lead to bloating and diarrhea. Fiber doses must therefore be adjusted to

individual patient needs.

Anticholinergic (antispasmodic) drugs (e.g., hyoscyamine [0.125 mg 30 to 60 min before

meals]) may be used in combination with fiber agents. The use of narcotics, sedative

hypnotics, and other drugs that produce dependency is discouraged. In patients with

diarrhea, 2.5 to 5 mg of diphenoxylate (1 to 2 tablets) or 2 to 4 mg of loperamide (1 to 2

capsules) may be given before meals. Chronic use of antidiarrheals is discouraged because

tolerance to the antidiarrheal effect may occur. Antidepressants (e.g., desipramine, imipramine,

and amitriptyline [50 to 150 mg/day]) help many patients with both constipation-

and diarrhea-predominant IBS. In addition to constipation and diarrhea, abdominal

pain and bloating are relieved by antidepressants. These drugs can also reduce pain by

down regulating the activity of spinal cord and cortical afferent pathways arriving from

the intestine. Finally, certain aromatic oils (carminatives) can relax smooth muscles and

relieve pain caused by cramps in some patients. Peppermint oil is the most commonly

used agent in this class.3

Available information and indications on some of the treatments are given below.

1. Peppermint oil (Mentha piperita) — Abdominal pain, the most frequent and disabling

symptom of IBS, improves when the intestinal smooth muscles are relaxed.

Peppermint oil can reduce abdominal pain and distension of IBS, possibly by

blocking the influx of calcium into muscle cells and inhibiting the excess contraction

of intestinal smooth muscles.19 It is a carminative, which means it helps

eliminate intestinal gas. Peppermint oil should be used only in enteric-coated

capsules to ensure that it reaches the intestines intact; otherwise, the oil can relax

the lower esophageal sphincter and cause heartburn.

In a randomized, double-blind controlled trial,20 in children with irritable bowel

syndrome (IBS), enteric-coated peppermint oil capsules proved to be effective by

reducing the severity of pain associated with IBS.

2. Fennel seed (Foeniculum vulgare) — Fennel is another herb that is used to relieve

spasm of the gastrointestinal tract, feelings of fullness, and flatulence.21

3. Psyllium (Plantago ovata) — An herbal product derived from seeds of the plantago

plant, psyllium is a source of dietary fiber that may aid constipation and diarrhea

by absorbing water and adding bulk to the stool. (Be sure to drink one to two

glasses of water when you take psyllium, and drink plenty of extra water throughout

the day.) If psyllium aggravates symptoms instead of relieving them, discontinue

using it.

4. Acidophilus — This form of beneficial bacteria normally inhabits the digestive

tract, helps digest food, and also fortifies the body against digestive disorders

by stopping the harmful bacteria that cause disease from growing uncurbed.

It is especially important to take after a round of antibiotics. (Obtain pills

containing 1 to 2 billion "live" organisms per pill.) You can enhance the effect

of the acidophilus by taking it in combination with fructo-oligosaccharides

(FOS), a supplement containing indigestible carbohydrates that feed the

friendly bacteria.

5. Gammaoryzanol — This is a natural substance isolated from rice-bran oil. Studies

have shown that it protects the mucous lining of the GI tract by regulating nervous

system control and exerting antioxidant activity. Clinically, gammaoryzanol has

been found to be effective in a broad range of GI complaints, including IBS. Earlier

studies suggested that gammaoryzanol may act on the hypothalamus and pituitary

glands of the brain, resulting in an inhibition of leutinizing hormone; further

research has not supported this finding.15

Compound formulations commonly used for the treatment of IBS are given in Table 20.1.

TABLE 20.1

Ayurvedic Formulas Commonly Used in the Treatment of IBS

Name of Formulation Activity Dose Adjuvant Ref.

Brhat gangadhara curna Astringent 1–3 g three times/

day before meals

Warm water 14

Dadimastaka curna Carminative,

hemetinic

1–3 g three times/

day before meals

Warm water 17

Jatiphaladi curna Antacid 1–3 g three times/

day before meals

Warm water 17

Bilvadi lehyam Antacid,

antispasmodic

3–6 g 1/2 h

before meals

3–6 g butter three

times/day

17

Chitrakadi vati Relieves enterotoxin,

carminative

250–500 mg

two times/day

Warm water 18

Shankha vati Digestive,

antispasmodic

250–500 mg

two times/day

Warm water 14

Dashmuladi ghrita Carminative, nutritive 1–2 tsp two

times/day

Warm water 1

Pancamrta parpati Antacid,

antispasmodic

120–360 mg

three times/day

Honey and water 17

Rasa-parpati Antacid, antiflatulent 120–360 mg

three times/day

Honey 17

20.10 Scientific Basis

20.10.1 Review of Clinical Trials

20.10.1.1 Holarrhena antidysenterica, Beans of Acacia arabica, Fruit Pulp of Aegle

marmelos, and Seeds of Cuminum cyminum

In a study on 60 cases of IBS diagnosed according to Ayurvedic guidelines, patients were

separated into two equal groups. The first group received a herbal combination of equal

quantities of the powders of the stem bark of Holarrhena antidysenterica, beans of Acacia

arabica, fruit pulp of Aegle marmelos, and seeds of Cuminum cyminum in the dose of 1 g

three times/day with water and showed better response in the character of the stools

within a week of treatment. The second group received kutaja ghanavati (dry extract of the

bark of Holarrhena antidysenterica) in the dose of 1 g three times/day with two drops

shankha drava (dissolved in 1/2 oz of water). This group showed marked relief with more

than 75% of the signs and symptoms of the disease being controlled along with significant

improvement in body weight, hemoglobin and fat, and undigested food particles in the

stool. The duration of the treatment was 3 weeks.22

20.10.1.2 Zingiber officinale

Powder of the rhizome of Zingiber officinale at the dose of 3 g three times/day with warm

water was given to 30 patients with grahani for 4 weeks. The results showed a definite

effect on the bowel movement by way of controlling the number of motions and changes

in the consistency of the stool within 7 days of the treatment. It also has shown improvement

in hemoglobin and body weight. Observation of clearance of giardia and entamebic

cyst in the stool was also made.23 Further, it was reconfirmed on 111 cases of grahani that

the administration of powder of the rhizome of Zingiber officinale is effective in controlling

frequency of bowel movements, consistency, improvement in general health and anemia,

and the relief of associated symptoms in most of the patients. The effect of this powder

on the elimination of amoebiasis and giardiasis is also significantly observed, though it

does not have any effect on ascaris.24

20.10.1.3 Acorus calamus Rhizome, Aegle marmelos Fruit, Withania somnifera Roots,

Sesame Oil, and Common Salt Powder

A randomized, placebo-controlled trial25 studied the effect of vasti (medicated enema

comprising of extracts of Acorus calamus rhizome, Aegle marmelos fruit, Withania somnifera

roots, sesame oil, common salt powder) on 53 patients with IBS. Results showed a significant

reduction in abdominal distention and pain and increased retention time and Dxylose

excretion when compared with a control group. It is concluded that vasti alters the

visceral pain perception, acting via the regulation of the enteric nervous system, and brings

about anxiolytic and antidepressant effects.

20.10.1.4 Aegle marmelos and Bacopa monniere

Among 169 patients with IBS, standard therapy (with clidinium bromide, chlordiazepoxide,

and isaphaghulla) and a compound Ayurvedic preparation (with Aegle marmelos

correa and Bacopa monniere Linn.), along with a matching placebo were given in a doubleblind,

randomized trial for 6 weeks. The Ayurvedic preparation in 57 patients was found

effective in 64.9%, whereas standard therapy (60 patients) was useful in 78.3%. Patients

on placebo (52 patients) showed improvement in only 32.7%. Ayurvedic therapy was

particularly beneficial in the diarrhea-predominant form as compared with the placebo.

The standard therapy was more useful in the painful form of IBS as compared with the

placebo and Ayurvedic preparation. In the gas-predominant form, the effects of standard

and Ayurvedic therapy were similar to the placebo. Long-term follow-up (greater than

6 months) showed that both forms of therapy were no better than the placebo in limiting

the relapse.26

Acknowledgments

The authors acknowledge the data input provided by M.V. Venkataranganna S. Gopumadhavan,

Pre-Clinical Pharmacology Laboratory, R&D Center, The Himalaya Drug Company,

Makali, Bangalore, India.

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Om Tat Sat

                                                        

(Continued...) 

(My humble salutations to H H Maharshi ji,  Brahmasri Sreeman Lakshmi Chandra Mishra ji and other eminent medical scholars and doctors   for the collection)