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IBS

IBS / Irritable Bowel Syndrome / Spastisch colon / Prikkelbaar darmsyndroom

Functionele dysfunctie van dikke darm zonder duidelijke, structurele veranderingen.

Andere namen: Spastisch colon, Colon irritable. 

Symptomen
  • Regelmatige chronische buikpijn, krampen
  • Afwisselend diarree en verstopping
  • Slijm in ontlasting
  • Soms psychische symptomen: angst, depressie
Mogelijke oorzaken
  • Psychische problemen (ontregeling vegetatieve zenuwstelsel?)
  • Voeding: gebrek aan vezels (volkoren, zemelen, fruit met schil)
  • Allergisch voor sommige voedingsmiddelen (lactose in melk)
  • Andere kwalen uitsluiten: kanker, IBD, Ziekte van Crohn
Algemene behandeling
Voeding veranderen, vooral meer vezels (vooral water oplosbare), dus volkoren, fruit met schil, zaden (slijmstoffen: lijnzaad, haver)
Allergenen in voeding opsporen (lactose vermijden)
Darmflora verbeteren: probiotica (Lactobacillus acidophilus, joghurt)
Fytotherapie: slijmstofplanten, carminativa, leverplanten, kruiden zenuwstelsel en e.o. munt
Ontspanning, stressreductie (massage, beweging..)

Fyto basiskruiden
Mentha piperita, vooral e.o. in capsulevorm
+ carminativa: Foeniculum, Anisum, Carum carvi, Matricaria
+ leverplant, bitterstofplanten: Cynara scolymus, Taraxacum
+ slijmstofplanten: vooral Linum (Lijnzaad)
+ kruiden voor zenuwstelsel: Hypericum, Melissa en eventueel adaptogenen?
+ FOS in voeding: aardperen, cichorei (darmflora verbeteren)

Andere kruidenmengsels
  • Ayurveda: Although prescriptions are specifically tailored to each case, some herbs are more frequently found in formulas applicable to cases defined as IBS by Western medicine. For example, a set of three herbs (Terminalia chebula, Terminalia belerica, and Emblica officinalis) are often given together as a mixture or included as ingredients of a complex formula
  • Chinees kruidenmengsel: peony, atractylodes, citrus, siler soms aangevuld met anderen zoals, saussurea, polyporus, hoelen, chih-ko, rose fruit, and licorice. (Li Yujun and Zhou Xitin, Observation on comparative treatment of 45 cases of functional diarrhea by traditional Chinese and western medical therapies, Journal of Traditional Chinese Medicine 1985; 26(5): 27-28.)
  • Anguraté: Mentzelia cordifolia (Wirksamkeit und Vertraglichkeit eines Magentees (Anguraté) bei funktionellen Magen und Darmbeschwerden. Ztschr. Fur Phytoth. 12, 192-194 (1991). Doc. Maurice Godefridi)
  • Iberogast (Steigerwald) samenstelling: Iberis amara (basis), Chelidonium, Silybum, Melissa, Carum carvi, Glycyrrhiza, Angelica, Matricaria en Mentha
Voeding
  • Meer: vezelrijke voeding, volkoren granen (haver) en fruit
  • Minder: suiker (negatieve invloed op darmflora), cafeïne
  • Intolerantie voor lactose, fructose en sorbitol controleren
  • Andere voedingsstoffen met mogelijke invloed: magnesium (ontkrampend)
Referenties / onderzoek
  • Walker AF, Middleton RW, Petrowicz O. Artichoke Leaf Extract Reduces Symptoms of Irritable Bowel Syndrome in a Post-marketing Surveillance Study. Phytotherapy Research 2001;15:58-61.
  • A Tibetan Medical Perspective On Irritable Bowel Syndrome. Eliot Tokar, Ariana Vora. Originally published in Alternative & Complementary Therapies Volume 4, No. 5; October 1998 (Doc. Maurice Godefridi)
  • Darmflora, gastro-intestinaal immuunsysteem en hun interacties. Solgar 2001
  • Bohmer CJ, Tuynman HA. The clinical relevance of lactose malabsorption in irritable bowel syndrome. Eur J Gastroenterol Hepatol 1996;8:1013–6.
  • Klein-Galinski C, Sassin I. Anwendungsbeobachtung zur Wirksamkeit und Vertraglichkeit von Iberogast in der Therapie des Colon Irritabile Abstract. 10. Jahrestagung der Gesellschaft fur Phytotherapie. Phytotherapie an der Schwelle zum neuen Jahrtausend 1999;11-13;125.

Peppermint
Peppermint oil is widely used for IBS. However, the research evidence is a bit contradictory. In the most recent trial, 42 children with IBS were given either peppermint oil or placebo. The results showed significant improvement in pain levels in the treated group as compared to the placebo group.
Kline RM, Kline JJ, Di Palma J, et al. Enteric-coated, pH-dependent peppermint oil caps for the treatment of irritable bowel syndrome in children. J Pediatr. 2001;138:125–128)

Probiotics 
"friendly" bacteria may be helpful for IBS, although some types may work better than others.
In a 4-week double-blind placebo-controlled trial of 60 individuals with IBS, probiotic treatment with Lactobacillus plantarum reduced intestinal gas significantly. The benefits persisted for an additional year after treatment was stopped.
In another 4-week, double-blind trial, individuals with IBS again received either L.plantarum or placebo.25 The results showed improvements in abdominal pain and symptoms in the treated group as compared to the placebo group. A small 6 week trial using L. acidophilus also found indications of benefit.
However, in a double-blind, placebo-controlled crossover study of 24 individuals with irritable bowel syndrome, use of Lactobacillus GG failed to produce any benefit.
Nobaek S, Johansson ML, Molin G, et al. Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome. Am J Gastroenterol. 2000;95:1231–1238.
Halpern GM, Prindiville T, Blankenburg M, et al. Treatment of irritable bowel syndrome with lacteol fort: a randomized, double-blind, cross-over trial. Am J Gastroenterol. 1996;91:1579–1585.

Flaxseeds (Vlas en andere slijmstofplanten)
In a double-blind study, 55 people with chronic constipation caused by irritable bowel syndrome received either ground flaxseed or psyllium seed (a well-known treatment for constipation) daily for 3 months. Those taking flaxseed had significantly fewer problems with constipation, abdominal pain, and bloating than those taking psyllium. The flaxseed group had even further improvements in constipation and bloating while continuing their treatment in the 3 months after the double-blind study ended. The researcher concluded that flaxseed relieved constipation more effectively than psyllium.
Tarpila S, Kivinen A. Ground flaxseed is an effective hypolipidemic bulk laxative [abstract]. Gastroenterology. 1997;112:A836.
Ligny. Dubbelblind gecontroleerde studie om doeltreffendheid van een preparaat op basis van hemicellulosen uit te testen bij patiënten met IBS. Doc. M. Godefridi


Onderzoek Australië met Chinese kruiden
The standard formula used in the trial, consisting of 20 Chinese herbs, was not identified by name in the paper, nor were the individualized formulas described. The herbs included in the highest proportions in the standard formula were yin chen at 13 percent (Artemisia capillaris Thunb., Asteraceae), bai zhu at 9 percent (Atractylodes macrocephala Koidz., Asteraceae), dang shen at 7 percent (Codonopsis pilosula [Franch.] Nannfeldt., Campanulaceae), yi yi ren (Job's tears) at 7 percent (Coix lacryma-jobi L., Poaceae), and wu wei zi (schizandra) at 7 percent (Schisandra chinensis [Turcz.] Baill., Schisandraceae).

Doc. Maurice Godefridi

  • Irritable Bowel Syndrome and Food.
  • Phytotherapeutic Approaches to Lower Bowel Disease Part II Constipation, diarrhea, IBS, Diverticular Diseases
  • Chanchal Cabrera, MNIMH, AHG. Medical HerbalismVolume 11, Number 2 February 2000 A Journal for the Clinical Practitioner
  • Treatment of IBS with Chines herbs. S. Dharmananda.
  • IBS HN fytoschema.
  • IBS possible causes


Les plantes à la rescousse du côlon
Le psyllium veille au transit intestinal
Déjà connues par les Égyptiens il y a plus de 3000 ans, les graines de psyllium (ou ispaghul) contiennent des fibres solubles qui ralentissent le transit des aliments et ramollissent les selles. Elles sont donc appropriées pour soulager autant la diarrhée que la constipation. Les doses conseillées sont de 5 à 30 g par jour (en 3 fois). À ingérer avec un grand verre d’eau. Ne pas utiliser en cas d’obstruction gastro-intestinale
et de sténose intestinale ou œsophagienne. Mieux digérer avec la menthe

La menthe poivrée est connue pour faciliter la digestion et pour ses effets antispasmodiques. Plusieurs études ont déterminé que la consommation de 180 mg d’huile essentielle de menthe sous forme de capsules gastroré- sistantes 3 fois par jour pendant plusieurs semaines était bénéfique contre le syndrome de l’intestin irritable17. Cependant, elle est contre-indiquée chez les enfants de moins de 7 ans, les femmes enceintes et les épileptiques. L’infusion à la menthe est également recommandée contre les troubles intestinaux.

La mélisse, alliée de poids
La mélisse est un précieux allié pour combattre les maux intestinaux. D’une part, elle stimule la digestion, d’autre part
elle calme les spasmes abdominaux. Et si cela ne vous suffit pas, sachez qu’elle est même efficace contre le stress et l’anxiété.
Vous pouvez l’utiliser en infusion : 1,5 g à 4,5 g de mélisse (parties aériennes séchées) dans 150 ml d’eau 1 à 3 fois par jour. En
cas de stress ou de nervosité, il est aussi possible de masser les tempes avec quelques gouttes de son huile essentielle.

Une tisane pour apaiser le ventre
La tisane carminative, en plus de stimuler les sécrétions digestives, rééquilibre la flore intestinale et calme les douleurs et les spasmes abdominaux. Pour la préparer, il faut mélanger à parts égales : aneth, carvi, cumin, coriandre, anis vert et fenouil et ajouter une demi-dose d’angélique. Mettez ensuite le mélange dans de l’eau froide et faites fré- mir le tout. Laissez infuser 10 à 15 minutes et filtrez. À
consommer chaud ou froid pendant les repas en cas de troubles chroniques. 



Abstracts
: Peppermint oil for irritable bowel syndrome: A critical review and meta-analysis
Pittler MH., Ernst E.,Dept. of Complementary Medicine, Postgraduate Medical School,University of Exeter, UK. ESCOP 1998

Background
Peppermint oil is the major constituent of several over-the-counter remedies for symptoms of Irritable Bowel Syndrome (IBS). As the etiology of IBS is not known and treatment is symptomatic there is a ready market for such products. However, evidence to support their use is sparse. The aim of this study was to review the clinical trials of extracts of peppermint (Mentha X piperita L.) as a symptomatic treatment for IBS.

Methods
Computerised literature searches were performed to identify all randomised controlled trials of peppermint oil for IBS. Databases included Medline, Embase, Biosis, CISCOM and the Cochrane Library. There were no restrictions on the language of publication. Data were extracted in a standardised,
predefined fashion, independently by both authors. Five double-blind, randomised controlled trials were entered into a meta-analysis.

Results
Eight randomised controlled trials were located. Collectively they indicate that peppermint oil could be efficacious for symptom relief in IBS. A metaanalysis of five placebo-controlled, double-blind trials seems to support this notion. In view of the methodological flaws associated with most studies, no definitive judgement about efficacy can be given.

Conclusion
The role of peppermint oil in the symptomatic treatment of IBS has so far not been established beyond reasonable doubt. Well-designed and carefully executed studies are needed to clarify the issue.



Artichoke Leaf Extract Treats Irritable Bowel Syndrome

Walker AF, Middleton RW, Petrowicz O. Artichoke Leaf Extract Reduces Symptoms of Irritable Bowel Syndrome in a Post-marketing Surveillance Study. Phytotherapy Research 2001;15:58-61.

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder with symptoms including abdominal pain, dyspepsia (indigestion), nausea, cramps, constipation, and/or diarrhea, and flatulence. The prevalence of IBS was found to be about 22 percent in many countries, including the U.S. and China. Its cause unknown, possible etiologic factors include hypersensitivity or hyperactivity of the gut, abnormal response of smooth muscle to central nervous system signals, inflammation, and food sensitivity. Because the cause and pathophysiology of IBS are not understood, it is difficult to treat the disorder effectively. Many drugs and dietary therapies have been tried for IBS, generally targeting either the intestine or the central nervous system.

Artichoke leaf (Cynara scolymus L., Asteraceae) has been used since ancient times for its medicinal properties, including antiemetic, spasmolytic, and carminative (including gas expulsion) effects. Artichoke, also called globe artichoke, is not to be confused with Jerusalem artichoke (Helianthus tuberosus l., Asteraceae). Currently, artichoke leaf extract (ALE) is used in Germany, Finland, and Switzerland to treat dyspepsia as it stimulates bile production, which increases digestive activity. Symptoms of the two disorders overlap considerably, therefore, ALE might be useful in treating IBS.

This article reports on a post-marketing surveillance study of ALE therapy. The study, conducted in Germany, included 553 patients with dyspeptic syndrome or non-specific gastrointestinal complaints. The authors focus on a subgroup of 279 patients who reported having at least three of five IBS symptoms (abdominal pain, bloating, flatulence, right-sided abdominal cramps, and constipation).

Data were collected prospectively for six weeks while the patients took Hepar-SL forte (now produced by Lichtwer Pharma of Berlin, Germany, and Eatontown, NJ), a standardized, high-dose, aqueous-alcohol extract of artichoke leaf. Each 400-mg capsule contained 320 mg ALE (320 mg dry extract of artichoke leaf 3.8–5.5:1, corresponding to about 1,490 mg of dried artichoke leaves, water extract). Patients took the recommended dosage of two capsules three times per day with meals. Symptoms were rated by the patients and their physicians at baseline and following three weeks and six weeks of ALE treatment, respectively.

The results showed that mean scores for all five IBS symptoms were significantly (p=<0.05) reduced after six weeks of treatment, with reductions in severity ranging from 65 percent to 77 percent. Patients noted improvement in their symptoms after an average of 10.4 days of treatment with ALE. On a scale of 1 (excellent) to 5 (insufficient), the overall efficacy of ALE was rated as 1.95 by physicians and as 1.99 by patients. Eighty-four percent of both patients and physicians rated the overall effectiveness of ALE as “good” or “excellent.”

Eighty-six percent of patients rated ALE as substantially or slightly more effective than previous treatments used. ALE appeared to be responsible for three mild adverse events (hunger in one patient and temporarily increased flatulence in two patients).

Study limitations include the lack of a control group and the possible influence of patient expectations. Also, the subset of patients with IBS was defined on the basis of only five IBS symptoms, which were also symptoms of dyspepsia; other IBS symptoms were not considered in defining the subset.

Surveillance studies such as this mainly assess tolerability of the treatment; ALE was well tolerated, confirming two previous studies. These results could provide the basis for performing a controlled clinical trial of ALE for IBS, the authors add.



Pepermuntolie effectiever dan reguliere PDS medicijnen

Recente studies wijzen uit dat pepermuntolie in de vorm van geregistreerd geneesmiddel een eerste optie is bij de medische behandeling van PDS (prikkelbare darm syndroom). Het blijkt effectiever bij buikpijn, lichte darmkrampen en winderigheid dan de reguliere krampstillende middelen.

In een artikel in Modern Medicine [1] geeft prof. Brouwers aan dat studies die de laatste 17 jaar zijn uitgevoerd, uitwijzen dat “pepermuntolie ten opzichte van spasmolytica of vezels een betere effectiviteitsratio heeft”.
De werking van pepermuntolie bij het prikkelbare darm syndroom (PDS) is zowel spierontspannend als pijnstillend, aldus Brouwers. Met het milde bijwerkingenprofiel behaalt de behandeling bovendien een betere tolerantiegraad bij ouderen.

Menthol en dikke darm receptoren
Menthol, de werkzame stof van pepermuntolie, zou de druk tussen de holtes in de dikke darm aanzienlijk verminderen, omdat de pepermuntoliecapsules werking hebben op de blokkade van zogeheten calciumkanaaltjes waardoor spasmen verminderen. Dat is wezenlijk anders dan bij de reguliere krampstillende middelen (spasmolytica), die ook bij PDS worden toegepast. Bovendien zou het effect ervan lang aanhouden.
Nieuw is het inzicht dat menthol ingrijpt door zich in de dikke darm te binden aan receptoren (‘ontvangers’, delen van een cel waaraan een stof zich bindt) die verantwoordelijk zijn voor pijnprikkels. Pijn die bij PDS-patiënten dus kan optreden.

Verder onderzoek met ‘Reduce PDS’
Momenteel loopt er een zorgtraject voor PDS-patiënten (Reduce PDS) in 14 ziekenhuizen in Nederland, waarbij 10 mogelijke behandelopties (o.a. antibiotica, spasmolytica en pepermuntolie) met de patiënt worden besproken.
Pepermuntolie lijkt in veel gevallen “voor heel wat PDS-patiënten een belangrijke en vooral veilige keuze te zijn als starttherapie”.

Uitzondering: PDS met brandend maagzuur
Pepermuntolie bij behandeling van PDS wordt weliswaar afgeraden bij mensen met brandend maagzuur (reflux), omdat dat theoretisch zou kunnen toenemen. Echter is het bijwerkingenprofiel in het algemeen mild. Desondanks wordt aanbevolen om enkel “producten te gebruiken die een farmaceutische kwaliteit pepermuntolie bevatten en waarvan de capsules een maagresistent laagje hebben.”

Een medicijn dat voldoet aan die voorwaarden is Tempocol, dat klinisch bewezen en gecontroleerd is.
[1] Modern Medicine, 2015, nr.3, p. 106, Gastro-enterologie, prof.dr. J.R.B.J. Brouwers, Pepermuntolie bij het prikkelbare darm syndroom
Bron: Modern Medicine, via Nieuwsbank



FODMAP dieet
Buikpijn, een opgeblazen gevoel, diarree of juist verstopping? Misschien behoor je tot een van de vele mensen die last heeft van een prikkelbare darm of PDS. Met alle klachten die daar helaas bij horen. Goed nieuws: er is een nieuw dieet ontwikkeld waar veel mensen baat bij hebben.

Het FODMAP–dieet draait om bepaalde groepen koolhydraten in de voeding (FODMAP is een afkorting van Fermentation of Oligosaccaharides, Disaccharides, Monosaccharides And Polyols). Bij mensen met het prikkelbare darmsyndroom komen deze koolhydraten (deels) onverteerd in de dikke darm terecht. Daar worden deze koolhydraten afgebroken door de darmbacteriën. Daarbij ontstaan stoffen en gassen die de darm kunnen prikkelen als je daar gevoelig voor bent. Ook kunnen deze koolhydraten vocht aantrekken in de darm, waardoor de darm opzwelt. Door de druk krijg je een opgeblazen buik en pijn. Voorbeelden van deze koolhydraten zijn lactose (melksuiker), fructose (vruchtensuiker) en koolhydraten uit tarwe, kool en peulvruchten. Ze komen dus wijdverspreid in de voeding voor.

Weglaten en toevoegen
In het dieet start je met de strenge eliminatiefase, een fase waarbij je heel veel producten weg streept uit je voeding. Je laat vier tot zes weken lang alle producten die rijk zijn aan FODMAP’s weg uit je voeding. Dat is een behoorlijk streng dieet en ook een flink gepuzzel! Een diëtist inschakelen voor advies en begeleiding is daarom zeer aan te raden. Veel mensen merken in deze fase dat hun klachten sterk afnemen of zelfs helemaal verdwijnen.

Daarna worden stap voor stap de FODMAP’s weer toegevoegd, bijvoorbeeld fructose (appels en peren) of lactose (melk). Als de klachten dan wegblijven, kunnen die producten blijven. Maar als de klachten terugkomen, is het duidelijk wat de boosdoeners zijn. Uiteindelijk ontstaat een dieet op maat, zonder de koolhydraten die bij jou klachten geven. Dat dieet kun je blijvend volgen om klachten te voorkomen.

Nederlands onderzoek
Het FODMAP dieet is ontwikkeld door onderzoekers in Australië en is inmiddels wereldwijd bekend. In het Martini Ziekenhuis in Groningen is onlangs een onderzoek uitgevoerd met dertig patiënten met PDS, die door hun arts waren geselecteerd. Van de dertig patiënten had maar liefst 73 procent minder klachten door het volgen van het FODMAP-dieet. Ook in andere landen wordt het dieet onderzocht en steeds blijken weer goede resultaten. Er zijn zelfs al voorzichtige aanwijzingen dat dit dieet ook heilzaam kan zijn voor mensen met darmziekten als de ziekte van Crohn en colitis ulcerosa.

Wil je het FODMAP-dieet ook uitproberen? Kijk eens op www.fodmap-dieet.nl. Daar vind je een online cursus, kun je een boek bestellen en vind je adressen van gespecialiseerde diëtisten.
Opgelet: het FODMAP-dieet is niet geschikt voor mensen zonder darmklachten. Waarschijnlijk zijn FODMAPrijke producten juist gezond voor mensen zonder darmklachten, omdat ze de darmflora gunstig beïnvloeden. Niet iets om mee te experimenteren dus!

Voorbeelden van FODMAP-rijke producten:
Appel, pruimen, kersen, peer, gedroogd fruit, artisjokken, champignons, peulvruchten, prei, uien, alle producten gemaakt van tarwe en rogge, amandelmelk, koemelk, honing, zoetmiddelen zoals sorbitol en xylitol, vruchtensap en venkelthee.

Voorbeelden van FODMAP-arme producten:
Aardbeien, banaan, mandarijn, glutenvrij brood, havermout (max 25 gram per dag), rijst, rijstwafels (max 2 stuks per dag), quinoa (max 155 gram gekookt per dag), sojadrink, harde kaas, lactosevrije yoghurt, suiker (niet te veel), popcorn, eieren, kip, vlees, vis, noten en pitten (in kleine hoeveelheden).



Herbal medicines for the management of irritable bowel syndrome: A comprehensive review
Roja Rahimi and Mohammad Abdollahi

Abstract
Irritable bowel syndrome (IBS) is a functional gut disorder with high prevalence. Because of various factors involved in its pathophysiology and disappointing results from conventional IBS medications, the treatment of IBS is challenging and use of complementary and alternative medicines especially herbal therapies is increasing. In this paper, electronic databases including PubMed, Scopus, and Cochrane library were searched to obtain any in vitro, in vivo or human studies evaluating single or compound herbal preparations in the management of IBS. One in vitro, 3 in vivo and 23 human studies were included and systematically reviewed. The majority of studies are about essential oil of Menta piperita as a single preparation and STW 5 as a compound preparation. Some evaluated herbs such as Curcuma xanthorriza and Fumaria officinalis did not demonstrate any benefits in IBS. However, it seems there are many other herbal preparations such as those proposed in traditional medicine of different countries that could be studied and investigated for their efficacy in management of IBS.

INTRODUCTION
Irritable bowel syndrome (IBS) is a functional gut disorder characterized by abdominal pain or discomfort, bloating, and bowel disturbances[1] with a higher prevalence ratio of women to men (ratio of 2:1)[2]. Studies from Asia suggest higher prevalence of IBS in more developed countries such as Singapore (8.6%) and Japan (9.8%) compared with India with the lowest prevalence (4.2%)[3]. The pathophysiology of IBS is most likely multifactorial involving visceral hypersensitivity, abnormal gut motility, intestinal microbiota, inflammation and immune disturbance, genetic factors, abnormal gas handling, psychosocial factors, intestinal infections, central nervous system, and serotonin[1,4,5]. Pharmacological treatment of IBS varies from antidepressants including tricyclic antidepressants[6] and selective serotonin reuptake inhibitors[7], to antispasmodics[8,9], 5-hydroxytryptamine-3 receptor (5-HT3) antagonists[10], 5-HT4 agonists[11], antibiotics[12], probiotics[13], and melatonin[14]. But involvement of numerous factors in pathophysiology and a very significant placebo effect[15] cause therapy of this disease to be more complex. Due to disappointing results with conventional IBS treatments, complementary and alternative medicines are becoming attractive options for many patients[16].

In the present paper, management of IBS by herbal medicines and their modes of action have been evaluated in detail. For this purpose, electronic databases including PubMed, Scopus, and Cochrane library were searched to obtain studies giving any in vitro, in vivo, or human evidence of the efficacy of herbs in the treatment of IBS. Data were collected for the years 1966 to 2011 (up to February). The search terms were: “complementary and alternative medicine”, “plant”, or “herb” and “irritable bowel syndrome”. Reference lists of the retrieved articles were also reviewed for additional applicable studies. The title and abstract of each article were examined to eliminate duplicates, reviews, studies examining functional bowel diseases other than IBS, and studies assessing complementary and alternative medicines other than herbs. Figure ​Figure11 shows a flow diagram of the study selection process.

INVESTIGATED HERBAL PREPARATIONS IN IBS
Single herbs used for treatment of irritable bowel syndrome

Aloe vera

Fifty-eight patients with IBS were randomized to receive Aloe vera or matching placebo for a month but no significant difference was found between Aloe and placebo groups[17].

Curcuma species

Eight-week treatment of IBS patients with Curcuma longa extract tablet decreased IBS prevalence and abdominal pain/discomfort score significantly between baseline and after treatment. There were significant improvements in the IBS quality of life (QOL) scales. Approximately two thirds of all subjects reported an improvement in symptoms after treatment, and there was a favorable shift in self-reported bowel pattern[18]. In a randomized, double-blind, placebo-controlled trial, IBS patients were randomly assigned to receive Curcuma xanthorriza or placebo. IBS-related pain increased in the Curcuma group and decreased in the placebo group. IBS-related distension showed a greater reduction in the placebo group compared to the curcuma group. Additionally, the global assessment of changes in IBS symptoms and psychological stress due to IBS did not differ significantly among the two treatment groups. Thus, Curcuma xanthorriza did not show any therapeutic benefit over placebo in patients with IBS[19]. Thus, the species of Curcuma used is an important factor in determining its efficacy in IBS. The efficacy of Curcuma in IBS may be due to bactericidal[20], anti-inflammatory[21], and spasmolytic[22] activities.

Cynara scolymus

Cynara scolymus was demonstrated to have both preventive and curative roles in IBS. The leaf extract of Cynara scolymus was evaluated in healthy volunteers suffering concomitant dyspepsia and showed a 26.4% fall in IBS incidence after treatment. A significant shift in self-reported usual bowel pattern away from “alternating constipation/diarrhea” toward “normal” was observed. The nepean dyspepsia index (NDI) total symptom score significantly decreased by 41% after treatment. Similarly, there was 20% improvement in the NDI total QOL score in the subset after treatment[23]. When the leaf extract of Cynara scolymus was administered to patients with IBS for 6 wk, a significant reduction in the severity of symptoms was observed. Ninety-six percent of patients rated this extract better than or at least equal to previous therapies administered for their symptoms. Furthermore, the tolerability of Cynara scolymus extract was very good[24]. It was reported that Cynara scolymus affects intestinal microbiota[25] and has antispasmodic activity[26].

Fumaria officinalis

The efficacy of Fumaria officinalis, because of its antispasmodic activity, has been investigated in IBS patients. In the randomized, double-blind, placebo-controlled trial, IBS-related pain decreased more in the fumitory group compared to the placebo group. IBS-related distension decreased in the placebo group and increased in the fumitory group. Additionally, the global assessment of changes in IBS symptoms and psychological stress due to IBS did not differ significantly among the two treatment groups[19].

Hypericum perforatum

Hypericum perforatum is a popular herbal medicine for the treatment of depression and it may be beneficial in the management of IBS by modulating psychological stress and serotonin[27]. The efficacy of Hypericum perforatum (St John’s wort) was evaluated in IBS patients during a 12-wk randomized, double-blind, placebo-controlled trial. The overall bowel symptom score (BSS) from baseline was decreased both in Hypericum and placebo groups whereas the placebo arm showed significantly lower scores at the end of treatment. Individual BSS for diarrhea (D-BSS), constipation (C-BSS), pain or discomfort, and bloating, adequate relief (AR) of IBS of at least 50% during the last 4 wk of therapy and IBS quality-of-life score showed greater improvement in the placebo group when compared with the Hypericum group. Thus Hypericum perforatum showed lower efficacy for treatment of IBS than placebo[28]. Another study showed that Hypericum perforatum can improve the psychologic symptoms and the ANS reactivity to stress and relieve intestinal symptoms in women with IBS. In patients with IBS, intestinal symptoms of IBS were also relieved significantly[29].

Maranta arundinacea / Arrowroot

The efficacy of powdered root of Maranta arundinacea (Arrowroot) was assessed in patients with diarrhea predominant-IBS. It reduced diarrhea with a long-term effect on constipation. It also reduced abdominal pain[30].

Mentha × piperita

The evidence for the efficacy of essential oil of Mentha × piperita (peppermint oil) in IBS seems to be more than other herbal preparations[9,31]. In a prospective, randomized, double-blind, placebo-controlled clinical study, the efficacy of an enteric-coated peppermint oil formulation was evaluated in outpatients with IBS. Seventy-nine percent of patients on Mentha capsule experienced an alleviation of the severity of abdominal pain, 83% had less abdominal distension, 83% showed a reduced stool frequency, 73% had fewer borborygmi, and 79% less flatulence. Corresponding figures for the placebo group were: 43% with reduced pain, 29% with reduced distension, 32% with reduced stool frequency, 31% with fewer borborygmi, and 22% with less flatulence. Symptom improvements after Mentha capsule were significantly better than after placebo. No significant side effect was seen in the Mentha group and peppermint oil was well tolerated[32]. In another randomized, double-blind, placebo-controlled study conducted on outpatients with IBS, the number of subjects free from abdominal pain or discomfort changed from 0 at week 0 to 14 at week 8 in the peppermint oil group and from 0 to 6 in the placebo group. The severity of abdominal pain was reduced significantly in the peppermint group as compared to the placebo group. Furthermore, peppermint oil capsule significantly improved the QOL. No significant adverse reaction was reported from peppermint oil capsule[33]. In another study, the effectiveness of an enteric-coated peppermint oil capsule was evaluated in patients with IBS in whom small intestinal bacterial overgrowth, lactose intolerance and celiac disease were excluded. The symptoms evaluated were: abdominal bloating, abdominal pain or discomfort, diarrhea, constipation, feeling of incomplete evacuation, pain at defecation, passage of gas or mucus and urgency at defecation. The number of patients who showed reduction of the basal total IBS symptoms score in the peppermint oil group was greater than that in the placebo group[34]. In a randomized, double-blind controlled trial of children with IBS, 75% of those receiving peppermint oil showed a reduced severity of pain associated with IBS. At the end of the trial, the peppermint oil group reported a more significant improvement in the change of symptom scale than the placebo group. Symptoms such as changes in abdominal rumbling, abdominal distention, belching, gas, and heartburn exhibited no changes when peppermint oil was compared with placebo. The most predominant effect of peppermint oil was reduction in the severity of abdominal pain. No side effects were reported by either the investigator or patients during the 2-week study period[35]. Mentha was shown to have antimicrobial[36] and antispasmodic[37] activity and cause reduction in gastric motility[38].

Paeonia lactiflora

The root of Paeonia lactiflora is used in many herbal preparations for IBS. Paeoniflorin (PF) is one of the principle active ingredients of the root of Paeonia lactiflora. A dose-dependent analgesic effect was produced by both intraperitoneal and central administration of PF on visceral pain in rats with neonatal maternal separation. Further investigation showed that this effect may be mediated by kappa-opioid receptors and α (2)-adrenoceptors in the central nervous system[39].

Plantago psyllium

The efficacy of seed from Plantago psyllium in IBS was determined during a randomized controlled trial. The proportion of responders was significantly greater in the Plantago group than in the placebo group during the first month and the second month of treatment. After three months of treatment, symptom severity in the Plantago group was reduced by 90 points, compared with 49 points in the placebo group. No differences were found with respect to QOL[40].


Combination herbal therapies used for irritable bowel syndrome

Carmint

Carmint is an Iranian herbal medicine containing total extracts of Melissa officinalis, Mentha spicata, and Coriandrum sativum. Thirty-two IBS patients randomly received either carmint or placebo, plus loperamide or psyllium (based on their predominant bowel function), for 8 wk. The severity and frequency of abdominal pain/discomfort were significantly lower in the carmint group than the placebo group at the end of the treatment according to severity and frequency of bloating[41].

A Chinese herbal medicine

A randomized, double-blind, placebo-controlled trial was conducted to determine whether a Chinese herbal medicine (CHM) is of any benefit in the treatment of IBS. This formulation composed of 20 different herbs (Table ​(Table2).2). Compared with patients in the placebo group, patients in the CHM groups showed a significant improvement in bowel symptom and global improvement scores as rated by patients and by gastroenterologists. Patients reported that treatment significantly reduced the degree of interference with life caused by IBS symptoms[42].

Padma Lax

Padma Lax, a complex Tibetan herbal formula (Table ​(Table2),2), was evaluated for safety and effectiveness in treating constipation-predominant IBS in a 3-mo double-blind randomized pilot study. Significant improvement was demonstrated after 3 mo in the Padma Lax group compared to placebo in constipation, severity of abdominal pain, daily activities, incomplete evacuation, abdominal distension and flatus/flatulence. Significantly more Padma Lax patients than placebo patients rated the current treatment superior to previous therapies tried for IBS. Laboratory parameters displayed no clinically significant changes. The primary side effect of Padma Lax was loose stools which improved by lowering dose[43].

STW 5

STW 5 (Iberogast), a formula composed of hydroethanolic extracts of nine herbs, has been prepared for functional gastrointestinal disorders like IBS and its efficacy and mechanisms of action were investigated in several studies. It was significantly better than placebo in reducing the total abdominal pain and the IBS symptom scores. In a double-blind, placebo-controlled, multicentre trial, STW 5-II, another formula composed of 6 of 9 herbal extracts used in STW 5, and a preparation containing only one of 9 herbal extracts (extract of Iberis amara) were compared with placebo. STW 5-II like STW 5 showed more significant reduction in the total abdominal pain and the IBS symptom scores compared with placebo. There were no statistically significant differences between the mono-extract group and the placebo group[44]. Different mechanisms have been proposed for the efficacy of STW 5 in IBS. A study evaluating STW 5 effects on mucosal secretion in human intestinal mucosa/submucosa preparations and in the human epithelial cell line T84 suggested that this herbal preparation is a secretogogue in the human intestine by direct epithelial actions and through activation of enteric neurons. The prosecretory effect is due to increased epithelial chloride fluxes via cystic fibrosis transmembrane conductance regulator and calcium dependent chloride channels[45]. STW 5 was studied in vitro for binding affinities to serotonin (5-HT3 and 5-HT4) and muscarinic (M3) receptors of the intestine that play central roles in the etiology of IBS. STW 5 showed binding affinity to 5-HT4, M3 and to a lesser degree 5-HT3[46]. STW 5 has also controlled visceral hypersensitivity by reducing intestinal afferent sensitivity to mechanical and chemical stimuli in the upper gastrointestinal tract in male Wistar rats. Following the different doses of serotonin and bradykinin, the peak in afferent nerve discharge was always reduced after pretreatment with STW 5 compared to controls. The ramp distension of the intestinal loop stimulated a rise in intestinal afferent nerve discharge that was lower in the STW 5 pretreated group compared to controls[47]. STW 5 decreased acetylcholine- and histamine-induced contraction of guinea pig ileum. This was also true for extracts of some constituents of this compound formula including Mentha piperita leaf, Matricaria recutita flower and Glycyrrhiza uralensis root. Extract from Iberis amara, however, showed no spasmolytic action; on the contrary, it increased the basal resting tone and contraction of atonic ileal segments. These data may explain, at least in part, the clinically observed therapeutic efficacy of STW 5 in both hypotonic and spastic dysmotility symptoms of IBS[48]. Another study on STW 5 and its components showed that STW 5 evoked a relaxation of the proximal stomach but increased antral motility whereas both effects are myogenic. The extracts of Angelica sinensis root, Matricaria recutita flower and Glycyrrhiza uralensis root mimicked the inhibitory effects in the proximal stomach whereas the extracts of Chelidonium majus, Melissa officinalis leaf, Carum carvi fruit and Iberis amara increased motility of the proximal stomach. All extracts increased motility in the antrum comparable to the effects of STW 5[49]. These data justify the differential effect of STW 5 which is a result of the combined actions of its individual components explaining the clinically observed therapeutic efficacy of STW 5 in both hypotonic and spastic dysmotility symptoms of IBS. Moreover, STW 5 reduced inflammation-induced alterations in ileum/jejunum segments. The effects were associated with a restoration of the disturbed acetylcholine-induced contraction, pathohistological protection and inhibition of tumor necrosis factor (TNF)-α[50].

A traditional Chinese medicine

Therapeutic efficacy of a traditional Chinese medicine (TCM) (Table ​(Table2)2) was investigated in patients with diarrhea-predominant IBS. There was no significant difference in the proportion of patients with global symptom improvement between the TCM and placebo groups. Moreover, there was no difference in individual symptom scores and the quality-of-life assessment between the two groups[51].

Tong-xie-ning

Tong-xie-ning (TXNG) is a traditional Chinese medicine composed of four different herbs. The efficacy of this preparation was evaluated in diarrhea predominant-IBS patients by a prospective, randomized, double-blind, placebo-controlled trial. IBS-related pain measured by the numeric pain intensity scale in the TXNG group, significantly decreased as compared with the placebo group. A total of 82.7% of the patients reported a reduction in IBS-related pain in the TXNG group compared with 39.3% in the placebo group. Furthermore, there was a significant reduction in the frequency and the duration of abdominal pain between the TXNG group and the placebo group. In addition, IBS-related stools improved in form or appearance in the TXNG group in comparison to the placebo group. The stool frequency was significantly decreased in the TXNG group compared with the placebo group. Moreover, stool passage (urgency or feeling of incomplete rectal emptying) in the TXNG group was significantly improved when compared with the placebo group. There was a 20.7% and 42.9% loss of appetite in the TXNG and placebo groups, respectively. An observable improvement in IBS-related diarrhea was seen in 86.2% of subjects in the TXNG group and 42.9% of subjects in the placebo group. There was no statistical difference in either the effective time of IBS-related pain or the effective time of IBS-related diarrhea between the two groups. However, the IBS-related pain alleviation time and the IBS-related diarrhea alleviation time in the TXNG group were markedly shorter than those in the placebo group[52].

Tong-Xie-Yao-Fang

Tong-Xie-Yao-Fang (TXYF) is a prescription in TCM, prepared from four herbs (Table ​(Table2).2). A study was done to compare the efficacy of this formulation with Myarisan, a probiotic formulation, in treating diarrhea-predominant IBS. No significant difference between the two groups in terms of the total efficacy or the scores of symptoms before and after treatment was found. In this study, the number of activated mast cells was decreased in the TXYF group after treatment, showing a significant difference as compared with that before treatment as well as with that in the Myarisan group after treatment. This result suggested that the mechanism of action of TXYF might be through adjustment of mast cells activation to decrease visceral hypersensitivity[53]. This product has been investigated in experimental visceral hypersensitivity models that showed a dose-dependent analgesic effect. It significantly decreased serotonin levels in serum and CRF concentrations in the brain. Moreover, it was found that visceral hypersensitivity alleviation by TXYF was dependent on substance P (SP) expression in the colon mucosa[54].

C-IBS and DA-IBS formulations

The efficacy and tolerability of C-IBS, a formula designed to treat constipation-predominant IBS, and DA-IBS, a formula designed to treat diarrhea-predominant and alternating bowel habit IBS, were evaluated in an uncontrolled study. Ingestion of the DA-IBS formula was associated with a small, but significant, increase in bowel movement frequency. Reductions in straining, abdominal pain, bloating, flatulence, and global IBS symptoms were also demonstrated in patients using this formula. Subjects in the C-IBS group experienced a 20% increase in bowel movement frequency and significant reductions in straining, abdominal pain, bloating, and global IBS symptom severity, as well as improvements in stool consistency. Both formulas were well-tolerated[55].

CONCLUSION
In this paper, different herbal preparations investigated for the management of IBS and their possible mechanisms of action were reviewed. Among the single preparations, the most evidence for efficacy in IBS patients was found for essential oil of Mentha piperita. Some single preparations including Aloe vera, Curcuma xanthorriza, Fumaria officinalis showed no benefit in IBS. There are conflicting results for the efficacy of Hypericum perforatum in IBS. Among compound preparations, most studies had been performed with STW 5, a formula containing hydroethanolic extract of 9 herbs. Hopeful results come from the efficacy of this herbal preparation in the management of IBS with different mechanisms of action such as anti-inflammatory, prosecretory activity, and affecting gastrointestinal motility. Because of multifactorial nature of the pathophysiology of IBS, it seems that compound preparations can be more efficacious than single ones. Despite the wide prevalence of IBS, there are few studies on the use of herbal medicine in IBS and most studies in this area have focused on the use of peppermint oil and STW 5; while it seems that more effective herbal preparations can be found. For example, in traditional Iranian medicine (TIM) many single and compound herbal preparations have been introduced for the management of various gut disorders such as IBS[56]. Among the herbal contents of this preparations, oleogumresin from Boswellia carterii, fruit of Trachyspermum amum, flower of Eugenia caryophyllata, gall of Quercus infectoria, seed of Nigella sativa, fruit of Cuminum cyminum, tabasheer (a hard, whitish, translucent substance extracted from the joints of different Bambusa species), and fruit of Cucurbita pepo can be stated[57-59]. There is evidence in modern phytotherapy for the beneficial effects of these plants in IBS. Boswellia carterii has shown anti-inflammatory[60,61] and immunomodulatory activity[62]. An in vitro study demonstrated that Trachyspermum copticum has a beneficial effect on intestinal microbiota by inhibiting the growth of potential pathogens[63]. Eugenia caryophyllata has anti-inflammatory[64], immunomodulatory[65], and antimicrobial[66] properties. Gall of Quercus infectoria possesses anti-inflammatory[67] and antibacterial[68] activity. Nigella sativa showed anti-inflammatory, antimicrobial, and immunomodulatory activity[69]. Antimicrobial properties were reported for Cuminum cyminum[70] and Cucurbita pepo[71]. However, more studies are required to get more conclusive results about the efficacy of these herbs in IBS.

S- Editor Tian L L- Editor O’Neill M E- Editor Zhang DN

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Irritable Bowel Syndrome 

Symptoms, Epidemiology, and Approaches to Treatment 

Irritable bowel syndrome (irritable colon) is a common, chronic functional disorder defined as a variable combination of chronic and recurring gas- 
trointestinal symptoms with no identifiable structural abnormalities or biochemical pathology. The cardinal symptoms are abdominal pain, constipation, diarrhea, altered defecation, and bloating. Functional disturbances of gastrointestinal motility, generalized hypersensitivity of the visceral smooth muscle, and visceral hyperalgesia have been postulated as pathophysiologic factors. Psychopathologic factors, especially anxiety disorders, also play a  role and suggest that irritable bowel syndrome is related to the somatoform  disorders (F45 in ICD 10 classification). The diagnosis is made by excluding organic disease according to the Manning criteria (Manning et ah, 1978) or  the Rome diagnostic criteria for functional bowel disorders and functional abdominal pain (Thompson et al., 1992). 

Irritable bowel syndrome is very common. Its prevalence in European  countries, the U.S., China, and Japan is estimated at between 10% and 25% of the adult population (Camilleri and Choi, 1997). From 30% to 50% of patients seen by gastroenterologists have irritable bowel syndrome. Symptoms start before age 35 in about 50% of cases, and another 40% have their onset between age 35 and 50. Women are affected more frequendy than men. The etiology is unknown (Maxwell et al, 1997). 

Treatment is symptomatic and depends on individual manifestations. Constipation can be treated with a fiber supplement such as wheat bran, 
linseed, or psyllium, while diarrhea is managed by reducing dietary fat intake and, if necessary, by taking an antidiarrheal agent that reduces 
bowel motility. Abdominal pain and spasms can be treated with mebeverine-type antispasmodics, but peppermint oil is equally or more effective . Antidepressants are recommended for the treatment of somatoform disorders, especially when significant anxiety is present. In  the field of phytotherapy, St. John’s wort preparations may be considered for this purpose. Regardless of the type of pharmacotherapy used, the physician has a responsibility to manage and counsel the patient. It has been estimated that 40-70% of the success in irritable bowel therapy is based on psychodynamic effects (Friedmann, 1991; Maxwell et al., 1997). 

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