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Abstract

Irritable bowel syndrome (IBS) is one of the most common conditions seen in primary care settings. Despite this, there is no consensus as to the pathogenesis of this disorder or a consistently effective therapeutic regimen for many patients. This has encouraged the use of various alternative therapies from behavioral or complementary medicine. This review will address the evidence for alternative therapies, including the following: cognitive behavior therapy, hypnosis, elimination diets based on food antibody testing, nutrition supplements (such as fiber, probiotics, and prebiotics), and, finally, peppermint, l-glutamine, zinc, and cromolyn sodium. The review also explores the evidence for and the therapeutic ramifications of the hypothesis that increased intestinal permeability underlies the symptoms of IBS in many patients, and how a therapeutic plan that addresses nutrition, elimination diets, and nutrition supplements may be useful in restoring the integrity of the gut immune barrier.

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References

Hungin AP, Whorwell PJ, Tack J, Mearin F. The prevalence, patterns and impact of irritable bowel syndrome: an international study of 40,000 subjects. Aliment Pharmacol Ther.2003 ;17(5):643 -650.

Spanier JS, Howden CW, Jones MP. A systematic review of alternative therapies in the irritable bowel syndrome. Arch Intern Med.2003 ;163(3):265 -274.

Pasricha PJ. Desperately seeking serotonin: a commentary on the withdrawal of tegaserod and the state of development for functional and motility disorders. Gastroenterology.2007 ;132(7):2287 -2290.

Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology.2002 ;123(6):2108 -2131.

Drossman DA, Toner BB, Whitehead WE, et al. Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders. Gastroenterology.2003 ;125(1):19 -31.

Lackner JM, Jaccard J, Krasner SS, Katz LA, Gudleski GD, Blanchard EB. How does cognitive behavior therapy for irritable bowel syndrome work? A mediational analysis of a randomized clinical trial. Gastroenterology.2007 ;133(2):433 -444.

Kennedy TM, Chalder T, McCrone P, et al. Cognitive behavioural therapy in addition to antispasmodic therapy for irritable bowel syndrome in primary care: randomised controlled trial. Health Technol Assess.2006 ;10(19):iii -iv, ix-x, 1-67.

Labus JS. In search of mechanisms of change in treatment outcome research: mediators and moderators of psychological and pharmacological treatments for irritable bowel syndrome. Gastroenterology.2007 ;133(2):702 -705.

Lackner JM, Mesmer C, Morley S, Dowzer C, Hamilton S. Psychological treatments for irritable bowel syndrome: a systematic review analysis. J Consult Clin Psychol.2004 ;72(6):1100 -1113.

10.

Cremonini F, Delgado-Aros S, Camilleri M. Efficacy of alosetron in irritable bowel syndrome: a meta-analysis of randomized controlled trials. Neurogastroenterol Motil.2003 ;15(1):79 -86.

11.

Evans BW, Clark WK, Moore DJ, Whorwell P. Tegaserod for the treatment of IBS and chronic constipation. Cochrane Database Syst Rev. 2007;(4):CD003960 .

12.

Jackson JL, O'Malley PG, Tomkins G, Balden E, Santoro J, Kroenke K. Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis. Am J Med.2000 ;108(1):65 -72.

13.

Holroyd KA, Penzien DB. Pharmacological versus non-pharmacological prophylaxis of recurrent migraine headaches: a meta-analytic review of clinical trials. Pain.1990 ;42(1):1 -13.

14.

Whorwell PJ, Prior A, Faragher EB. Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. Lancet.1984 ;2(8414):1232 -1234.

15.

Whitehead WE. Hypnosis for irritable bowel syndrome: the empirical evidence of therapeutic effects. Int J Clin Exp Hypn.2006 ;54:7 -20.

16.

Wilson S, Maddison T, Roberts L, et al. Systematic review: the effectiveness of hypnotherapy in the management of IBS. Aliment Pharmacol Ther. 2006;24:769 -780.

17.

Tan G, Hammond DC, Joseph G. Hypnosis and irritable bowel syndrome: a review of efficacy and mechanism of action. Am J Clin Hypn.2005 ;47(3):161 -178.

18.

Gonsalkorale WM, Miller V, Afzal A, Whorwell PJ. Long term benefits of hypnotherapy for irritable bowel syndrome. Gut.2003 ;52(1):1623 -1629.

19.

Forbes A, MacAuley S, Chiotakakov-Faliakov E. Hypnotherapy and therapeutic audiotape: effective in previously unsuccessfully treated IBS. Int J Colorectal Dis.2000 ;15(5-6):328 -334.

20.

Houghton LA, Heyman DJ, Whorwell PJ. Symptomatology, quality of life and economic features of IBS: the effect of hypnotherapy. Aliment Pharmacol Ther.1996 ;10(1):91 -95.

21.

Palsson OS, Turner MJ, Whitehead WE. Hypnosis home treatment for IBS: a pilot study. Int J Clin Exp Hypn.2006 ;54(1):85 -99.

22.

Roberts L, Wilson S, Singh S, Roalfe A, Greenfield S. Gut-directed hypnotherapy for IBS: piloting a primary care–based randomized controlled trial. Br J Gen Pract.2006 ;56(523):115 -121.

23.

DeMeo MT, Mutlu EA, Keshavarzian A, Tobin MC. Intestinal permeation and gastrointestinal disease. J Clin Gastroenterol.2002 ;34(4):385 -396.

24.

Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. J Gastroenterol Hepatol.2003 ;18(5):479 -497.

25.

Hulsewe KW, van Acker BA, Hameeteman W, et al. Does glutamine-enriched parenteral nutrition really affect intestinal morphology and gut permeability? Clin Nutr.2004 ;23(5):1217 -1225.

26.

Marshall JK, Thabane M, Garg AX, et al. Intestinal permeability in patients with irritable bowel syndrome after a waterborne outbreak of acute gastroenteritis in Walkerton, Ontario. Aliment Pharmacol Ther.2004 ;20(11-12):1317 -1322.

27.

Spiller RC, Jenkins D, Thornley JP, et al. Increased rectal mucosal enteroendocrine cells, T lymphocytes, and increased gut permeability following acute Campylobacter enteritis and in post-dysenteric irritable bowel syndrome. Gut.2000 ;47(6):804 -811.

28.

Barbara G. Mucosal barrier defects in irritable bowel syndrome: who left the door open? Am J Gastroenterol.2006 ;101(6):1295 -1298.

29.

Soderholm JD, Perdue MH. Stress and gastrointestinal tract, II: stress and intestinal barrier function. Am J Physiol Gastrointest Liver Physiol.2001 ;280(1):G7 -G13.

30.

Forchielli ML, Walker WA. The role of gut-associated lymphoid tissues and mucosal defence. Br J Nutr.2005 ;93(suppl 1):S41 -S48.

31.

Barbara G, Stanghellini V, De Giorgio R, Corinaldesi R. Functional gastrointestinal disorders and mast cells: implications for therapy. Neurogastroenterol Motil.2006 ;18(1):6 -17.

32.

Gwee KA, Collins SM, Read NW, et al. Increased rectal mucosal expression of interleukin 1β in recently acquired post-infectious irritable bowel syndrome. Gut.2003 ;52(4):523 -526.

33.

Taché Y. Corticotropin releasing factor receptor antagonists: potential future therapy in gastroenterology? Gut.2004 ;53(7):919 -921.

34.

Dunlop SP, Hebden J, Campbell E, et al. Abnormal intestinal permeability in subgroups of diarrhea-predominant irritable bowel syndromes. Am J Gastroenterol.2006 ;101(6):1288 -1294.

35.

Barbara G, De Giorgio R, Stanghellini V, Cremon C, Corinaldesi R. A role for inflammation in irritable bowel syndrome? Gut.2002 ;51(suppl 1):i41 -i44.

36.

Collins SM. A case for an immunological basis for irritable bowel syndrome. Gastroenterology.2002 ;122(7):2078 -2080.

37.

Youakim A, Ahdieh M. Interferon-γ decreases barrier function in T84 cells by reducing ZO-1 levels and disrupting apical actin. Am J Physiol.1999 ;276(5)(pt 1):G1279 -G1288.

38.

Sugi K, Musch MW, Field M, Chang EB. Inhibition of Na⁺, K⁺–ATPase by interferon γ down-regulates intestinal epithelial transport and barrier function. Gastroenterology.2001 ;120(6):1393 -1403.

39.

Chadwick VS, Chen W, Shu D, et al. Activation of the mucosal immune system in irritable bowel syndrome. Gastroenterology.2002 ;122(7):1778 -1783.

40.

D'Inca R, Di Leo V, Corrao G, et al. Intestinal permeability test as a predictor of clinical course in Crohn's disease. Am J Gastroenterol.1999 ;94(10):2956 -2960.

41.

Niec AM, Frankum B, Talley NJ. Are adverse food reactions linked to irritable bowel syndrome? Am J Gastroenterol.1998 ;93(11):2184 -2190.

42.

Zar S, Benson MJ, Kumar D. Food-specific serum IgG4 and IgE titers to common food antigens in irritable bowel syndrome. Am J Gastroenterol.2005 ;100(7):1550 -1557.

43.

Gremse DA, Nguyenduc GH, Sacks AI, DiPalma JA. Irritable bowel syndrome and lactose maldigestion in recurrent abdominal pain in childhood. South Med J.1999 ;92(8):778 -781.

44.

Nanda R, James R, Smith H, Dudley CR, Jewell DP. Food intolerance and the irritable bowel syndrome. Gut.1989 ;30(8):1099 -1104.

45.

Barnes RM. IgG and IgA antibodies to dietary antigens in food allergy and intolerance. Clin Exp Allergy.1995 ;25(suppl 1):7 -9.

46.

Hunter JO. Food elimination in IBS: the case for IgG testing remains doubtful. Gut.2005 ;54(8):1203 .

47.

Zuo XL, Li YQ, Li WJ, et al. Alterations of food antigen–specific serum immunoglobulins G and E antibodies in patients with irritable bowel syndrome and functional dyspepsia. Clin Exp Allergy.2007 ;37(6):823 -830.

48.

Atkinson W, Sheldon TA, Shaath N, Whorwell PJ. Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial. Gut.2004 ;53(10):1459 -1464.

49.

Zar S, Mincher L, Benson MJ, Kumar D. Food-specific IgG4 antibody–guided exclusion diet improves symptoms and rectal compliance in irritable bowel syndrome. Scand J Gastroenterol.2005 ;40(7):800 -807.

50.

Fernandez-Banares F, Esteve-Pardo M, de Leon R, et al. Sugar malabsorption in functional bowel disease: clinical implications. Am J Gastroenterol.1993 ;88(12):2044 -2050.

51.

Fasano A, Shea-Donohue T. Mechanisms of disease: the role of intestinal barrier function in the pathogenesis of gastrointestinal autoimmune diseases. Nat Clin Pract Gastroenterol Hepatol.2005 ;2(9):416 -422.

52.

Bashir ME, Louie S, Shi HN, Nagler-Anderson C. Toll-like receptor 4 signaling by intestinal microbes influences susceptibility to food allergy. J Immunol.2004 ;172(11):6978 -6987.

53.

Montalto M, Maggiano N, Ricci R, et al. Lactobacillus acidophilus protects tight junctions from aspirin damage in HT-29 cells. Digestion.2004 ;69(4):225 -228.

54.

Rosenfeldt V, Benfeldt E, Valerius NH, Paerregaard A, Michaelsen KF. Effect of probiotics on gastrointestinal symptoms and small intestinal permeability in children with atopic dermatitis. J Pediatr.2004 ;145(5):612 -616.

55.

Seehofer D, Rayes N, Schiller R, et al. Probiotics partly reverse increased bacterial translocation after simultaneous liver resection and colonic anastomosis in rats. J Surg Res.2004 ;117(2):262 -271.

56.

Kalliomaki M, Salminen S, Arvilommi H, Kero P, Koskinen P, Isolauri E. Probiotics in primary prevention of atopic disease: a randomised placebo-controlled trial. Lancet.2001 ;357(9262):1076 -1079.

57.

Oien T, Storro O, Johnsen R. Intestinal microbiota and its effect on the immune system: a nested case-cohort study on prevention of atopy among small children in Trondheim: the IMPACT study. Contemp Clin Trials.2006 ;27(4):389 -395.

58.

Gionchetti P, Rizzello F, Helwig U, et al. Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. Gastroenterology.2003 ;124(5):1202 -1209.

59.

Quigley EM. The use of probiotics in functional bowel disease. Gastroenterol Clin North Am.2005 ;34(3):533 -545, x.

60.

Quigley EM. Bacteria: a new player in gastrointestinal motility disorders: infections, bacterial overgrowth, and probiotics. Gastroenterol Clin North Am.2007 ;36(3):735 -748.

61.

Kajander K, Krogius-Kurikka L, Rinttila T, Karjalainen H, Palva A, Korpela R. Effects of multispecies probiotic supplementation on intestinal microbiota in irritable bowel syndrome. Aliment Pharmacol Ther.2007 ;26(3):463 -473.

62.

Kajander K, Myllyluoma E, Rajilic-Stojanovic M, et al. Clinical trial: Multispecies probiotic supplementation alleviates the symptoms of IBS and stabilizes intestinal microbiota. Aliment Pharmacol Ther.2008 ;27(1):48 -57.

63.

Balsari A, Ceccarelli A, Dubini F, Fesce E, Poli G. The fecal microbial population in the irritable bowel syndrome. Microbiologica.1982 ;5(3):185 -194.

64.

O'Mahony L, McCarthy J, Kelly P, et al. Lactobacillus and Bifidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles. Gastroenterology.2005 ;128(3):541 -551.

65.

Camilleri M. Probiotics and irritable bowel syndrome: rationale, putative mechanisms, and evidence of clinical efficacy. J Clin Gastroenterol.2006 ;40(3):264 -269.

66.

Whorwell PJ, Altringer L, Morel J, et al. Efficacy of an encapsulated probiotic Bifidobacterium infantis 35624 in women with irritable bowel syndrome. Am J Gastroenterol.2006 ;101(7):1581 -1590.

67.

Ringel-Kulka T, Ringel Y. Probiotics in irritable bowel syndrome: has the time arrived? Gastroenterology.2007 ;132(2):813 -816.

68.

Gibson GR, Roberfroid MB. Dietary modulation of the human colonic microbiota: introducing the concept of prebiotics. J Nutr.1995 ;125(6):1401 -1412.

69.

Hunter JO, Tuffnell Q, Lee AJ. Controlled trial of oligofructose in the management of irritable bowel syndrome. J Nutr.1999 ;129(7)(suppl):1451S -1453S.

70.

Quartero AO, Meineche-Schmidt V, Muris J, Rubin G, de Wit N. Bulking agents, antispasmodic and antidepressant medication for the treatment of irritable bowel syndrome. Cochrane Database Syst Rev. 2005;(2):CD003460 .

71.

Jenkins DJ, Kendall CW, Marchie A, et al. Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants. Am J Clin Nutr.2005 ;81(2):380 -387.

72.

Mosenthal AC, Xu D, Deitch EA. Elemental and intravenous total parenteral nutrition diet–induced gut barrier failure is intestinal site specific and can be prevented by feeding nonfermentable fiber. Crit Care Med.2002 ;30(2):396 -402.

73.

Deng G, Jiang Z, Liu Y, He G, Xu Y. Dietary fiber protects intestinal structure and barrier function. Zhonghua Wai Ke Za Zhi.1998 ;36(12):759 -762.

74.

Giannini EG, Mansi C, Dulbecco P, Savarino V. Role of partially hydrolyzed guar gum in the treatment of irritable bowel syndrome. Nutrition.2006 ;22(3):334 -342.

75.

Parisi G, Bottona E, Carrara M, et al. Treatment effects of partially hydrolyzed guar gum on symptoms and quality of life of patients with irritable bowel syndrome: a multicenter randomized open trial. Dig Dis Sci.2005 ;50(6):1107 -1112.

76.

Parisi GC, Zilli M, Miani MP, et al. High-fiber diet supplementation in patients with irritable bowel syndrome (IBS): a multicenter, randomized, open trial comparison between wheat bran diet and partially hydrolyzed guar gum (PHGG). Dig Dis Sci.2002 ;47(8):1697 -1704.

77.

Nair B. Final report on the safety assessment of Mentha piperita (peppermint) oil, Mentha piperita (peppermint) leaf extract, Mentha piperita (peppermint) leaf, and Mentha piperita (peppermint) leaf water. Int J Toxicol.2001 ;20(suppl 3):61 -73.

78.

Pittler MH, Ernst E. Peppermint oil for irritable bowel syndrome: a critical review and metaanalysis. Am J Gastroenterol.1998 ;93(7):1131 -1135.

79.

Grigoleit HG, Grigoleit P. Peppermint oil in irritable bowel syndrome. Phytomedicine.2005 ;12(8):601 -606.

80.

Kline RM, Kline JJ, Di Palma J, Barbero GJ. Enteric-coated, pH-dependent peppermint oil capsules for the treatment of irritable bowel syndrome in children. J Pediatr.2001 ;138(1):125 -128.

81.

Wischmeyer PE. Can glutamine turn off the motor that drives systemic inflammation? Crit Care Med.2005 ;33(5):1175 -1178.

82.

Hulsewe KW, van der Hulst RW, van Acker BA, von Meyenfeldt MF, Soeters PB. Inflammation rather than nutritional depletion determines glutamine concentrations and intestinal permeability. Clin Nutr.2004 ;23(5):1209 -1216.

83.

De-Souza DA, Greene LJ. Intestinal permeability and systemic infections in critically ill patients: effect of glutamine. Crit Care Med.2005 ;33(5):1125 -1135.

84.

Cordain L, Eaton SB, Sebastian A, et al. Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr.2005 ;81(2):341 -354.

85.

Cavallo G, De Magistris R, Miluccio V, Iannuzzi R. Changes in the blood zinc in the irritable bowel syndrome: a preliminary study [in Italian]. Minerva Dietol Gastroenterol.1990 ;36(2):77 -81.

86.

Aggarwal R, Sentz J, Miller MA. Role of zinc administration in prevention of childhood diarrhea and respiratory illnesses: a metaanalysis. Pediatrics.2007 ;119(6):1120 -1130.

87.

Mahmood A, Fitzgerald AJ, Marchbank T, et al. Zinc carnosine, a health food supplement that stabilises small bowel integrity and stimulates gut repair processes. Gut.2007 ;56(2):168 -175.

88.

Bolin TD. Use of oral sodium cromoglycate in persistent diarrhoea. Gut.1980 ;21(10):848 -850.

89.

Lunardi C, Bambara LM, Biasi D, et al. Double-blind cross-over trial of oral sodium cromoglycate in patients with irritable bowel syndrome due to food intolerance. Clin Exp Allergy.1991 ;21(5):569 -572.

90.

Stefanini GF, Saggioro A, Alvisi V, et al. Oral cromolyn sodium in comparison with elimination diet in the irritable bowel syndrome, diarrheic type: multicenter study of 428 patients. Scand J Gastroenterol.1995 ;30(6):535 -541.

91.

Stefanini GF, Prati E, Albini MC, et al. Oral disodium cromoglycate treatment on irritable bowel syndrome: an open study on 101 subjects with diarrheic type. Am J Gastroenterol.1992 ;87(1):55 -57.

92.

Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. J Am Board Fam Pract.2004 ;17(1):59 -67.

93.

Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary heart disease? The lifestyle heart trial. Lancet.1990 ;336(8708):129 -133.

94.

Gould KL, Ornish D, Scherwitz L, et al. Changes in myocardial perfusion abnormalities by positron emission tomography after long-term, intense risk factor modification. JAMA.1995 ;274(11):894 -901.

Behavioral and Complementary Approaches for the Treatment of Irritable Bowel Syndrome

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