Chapter 8. Irritable Bowel Syndrome

“One in five Americans has IBS, making it one of the most common disorders diagnosed by doctors. It occurs more often in women than in men, and it usually begins around age 20.”
Irritable Bowel Syndrome; National Institutes of Health[1]

Irritable bowel syndrome (spastic colon) is a chronic condition characterized by bloating, cramping, persistent abdominal pain or discomfort, frequent bowel movements, and bouts of diarrhea alternating with constipation. Inferring from the opening quote, it afflicts over 60 million Americans.

Left unchecked, irritable bowel syndrome gradually progresses to inflammatory bowel disease (IBD), which is one step away from ulcerative colitis (UC) and Crohn’s disease. The fine line that separates IBS from IBD is in the eye of the beholder—if you were to start poking around the bowel of an affected person, you’re bound to find some inflammation of the intestinal mucosa. In general, the causes, treatment, and prevention strategies of IBS and IBD are identical, except that in the case of IBD you suffer more, the treatment and healing takes longer, and the urgency is much higher.

Constipation is one of the most common afflictions associated with IBS. When the constipation is latent, the underlining conditions are hidden from view by the perception of regularity. That’s why ten times as many people complain of having IBS, rather than constipation.

There is an interesting paradox about IBS-related constipation: doctors may not recognize or diagnose IBS because patients may not have constipation at all, or have stools in the prescribed interval of time (at least three times weekly). By “prescribed,” I mean the diagnostic criteria set forth in The Merck Manual of Diagnosis and Therapy[2] (for general doctors), or the more authoritative source, such as Rome II Diagnostic Criteria For Functional Gastrointestinal Disorders[3] (used mainly by the specialists).

The pathologies that cause constipation-related IBS result from an abnormal amount of formed, hardened feces that may accumulate from the rectum all the way back to the cecum. This is a condition typical of latent constipation. The stools correspond to type 1 to 3 on the Bristol Stool Form Scale. The extended contact of the formed fecal mass with the intestinal wall causes irritation and mechanical abrasion of the bowel’s mucosa, especially during the periodic peristaltic contraction of muscles, and the propulsion of stools toward the rectum. In turn, perennial irritation and abrasion of mucosa cause inflammation and low-level discomfort, while peristalsis causes a more acute pain sensation, ranging from mild to sharp, which is referred to as cramps, or cramping.

Defecation is usually distressing, difficult, and requires intense straining. After defecation, some time passes before the residual abdominal pain subsides. This happens because of the transition of the hardened fecal mass from the upper regions of the large intestine into the lower part, which was just voided by defecation.

The initial accumulation of the hardened fecal mass (that causes IBS) inside the large intestine is the hallmark of functional constipation. Fiber by itself doesn’t cause IBS. But it does bulk up and harden fecal mass. Fiber creates even more discomfort and pain from the gases and acidity that result from bacterial fermentation. In time, fiber transforms functional constipation into latent, and, eventually into organic because of the colorectal damage incurred from large stools and straining.

Anorectal disorders that result from constipation, such as hemorrhoids and diverticular disease, are the most challenging aspect of IBS to deal with, because they’re irreversible. Fortunately, the pain, discomfort, and delayed or incomplete emptying of stools can be overcome, but these problems require a proactive approach, described elsewhere in this book.
Besides constipation, other prominent causes of IBS are:

• Gastroenteritis. The large intestine is at the very end of the “food” chain. All of the conditions that adversely affect the stomach (gastro-) and small intestine (-enteritis) inevitably ricochet in the gut (-colitis). Diarrhea, not constipation, is the most likely outcome. Bouts of diarrhea alternate with periods of constipation in the classical IBS pattern, because severe diarrhea washes out the intestinal flora essential for the formation of normal stools. Indigestion, food allergies, dietary irritants, food poisoning, malnutrition, viral and bacterial infections, smoking, chewing tobacco, and other assorted pathologies are the primary causes of gastroenteritis.
• Anorectal disorders. Anything that causes anal pain during defecation (stimulated by mechanical friction from passing stools or straining) is likely to cause delayed or incomplete emptying of stools. The pain may emanate from hemorrhoids, anal fissures, diverticular disease, and similar conditions that had previously been caused by chronic constipation or diarrhea. Incomplete emptying of stools leads to fecal impaction, which in turn causes severe IBS-related symptoms.
• Antibacterial agentsdecimate intestinal flora, and cause constipation and related complications, the harbingers of IBS. Among those agents, medicinal antibiotics and dental amalgams (mercury-based fillings) are particularly harmful and omnipresent, especially in the United States, where there are such a huge number of IBS sufferers.
• Adverse effects of medication. Numerous prescription and OTC medicines cause IBS-like side effects. This is especially true for “life-style” drugs taken regularly to mitigate the side effects of diets and aging, such as those used to treat heartburn (GERD), hypertension, migraine, diabetes, elevated cholesterol, constipation, bone disease, depression, even IBS itself, and others.
• Susceptibility to stress. I avoid saying “personality causes IBS,” because individual response to stress is determined, to a large extent, by a person’s diet. Actually, this is good news, because it means that you can mitigate the impact of stress by just changing your diet. This aspect of IBS (individual response to stress) is also the reason behind stress-induced sudden cramping and diarrhea.
• Bad luck. For many people, an “introduction” to IBS stems from a misfortune—food poisoning, viral or bacterial infection, an allergic reaction to a food, adverse effects of antibiotics intended to treat unrelated conditions, or a trauma that leaves one bed-ridden for a while.

You can’t insure against stress, infections, bad luck, or aging. You can, however, study this book to “insure” against improper nutrition and treatments, that makes an already bad situation even worse.

Regardless of the cause of IBS, dietary fiber is a common denominator in the majority of cases. The fiber causes bulk, flatulence, and acidity, which deliver a one-two-three punch that only the very lucky can resist or deflect.
According to the International Foundation for Functional Gastrointestinal Disorders, we are in the midst of an IBS epidemic:

The mayhem really starts from getting first-line-of-defense IBS remedies—more fiber, more water, and more exercise. By the time you’re stuffed with fiber up to your nose, water is pouring out of your ears, and you’re straining to the point of tears with your reinvigorated abdominal muscles, you’ve created more problems for yourself than you began with because:

• Constipation-related IBS. For persons with latent and organic constipation, fiber causes stools to become larger, heavier, and harder, which in turn increase the severity of IBS.
• Stress-related IBS. Carbohydrates containing fiber elevate blood sugar and insulin levels, and make a person even more prone to stress.
• Food allergy-related IBS. The protein gluten is a potent food allergen. It is abundant in cereals, breads, and pasta made from wheat flour, which are broadly recommended as a major source of dietary fiber.
• Medicine-related IBS. Gastrointestinal disorders ranging from indigestion to constipation, from bleeding ulcers to diarrhea, are common side effects of many prescription drugs. If you take fiber to alleviate these side effects, you are adding fiber’s own side effects to the mix, and making the whole situation even worse.
• Colorectal disorder-related IBS. Conditions such as hemorrhoidal or diverticular disease are caused by large stools and the straining required to expel them. There is only one food component that makes stools larger and heavier—dietary fiber.

Am I blowing everything out of proportion? Well, let’s again take another look at the prevailing medical view regarding the best treatment for IBS. According to the National Institutes of Health:

But the same document also explains the nature of pain related to irritable bowel syndrome:

Doesn’t this depiction of IBS’s action describe exactly what we already know about the damaging properties of fiber and its effect on the large intestine? Yes, it does! The document points out:

• That dietary fiber in the colon stimulates colon contraction (affects muscle activity) in order to evacuate feces in an abnormally short 24 hours instead of the required 72 hours.
• That impacted and expanded dietary fiber contacts the intestinal mucosa, stretches out the bowels, and that fiber’s mechanical and volumetric properties are strong irritants (affect nerve sensiti­vity).
• That the by-products of dietary fiber’s bacterial fermentation are highly acidic irritants (again affecting nerve sensitivity), and that the fermentation causes the formation of gases leading to a “stre­tching of the bowel.”
• That all of the above leads to inflammation of the intestinal mucosa, which in turn prevents the absorption of electrolytes and water, leading to diarrhea.
• That “during or shortly after” a meal, the natural gastrocolic reflexstimulates a vigorous contraction of the large intestine, and that this natural action is interpreted as painful “cramping” by victims of IBS.

So what can you do to prevent, treat, and get rid of IBS? Exactly the opposite of what most medical authorities are telling (or not telling) you to do—cut the fiber to reduce the stools’ volume, consume water in moderation to prevent gastroenteritis, and exclude drugs that may cause gastrointestinal distress. Here are the details:

• Eliminate the primary causes of general digestive disorders. Follow the recommendations throughout this book to gradually rid yourself of conditions affecting the health of the entire alimentary canal.
• Exclude dietary fiber. Remove all sources of indigestible and soluble fiber from your diet to reduce stool volume, formation of gases, and the mechanical and chemical irritation that it causes inside the bowel.

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• Reduce water consumption and frequency of meals. Stop the endless drinking, snacking, and consumption of four or five meals a day to reduce the frequency and severity of the gastrocolic reflex and ensuing perception of “cramping.”
• Restore intestinal microflora. Maintain proper balance of intestinal microflora to alleviate dysbacteriosis, constipation and inflammation.
• Provide essential nutrients. Consume adequate quantities of essential protein and fats to restore intestinal mucosa, and eliminate other symptoms and causes of the chronic inflammation of entire alimentary canal (systemic gastroenterocolitis).
• Eliminate medication side effects. Phase out all types of medication that affect the large intestine’s functionality and/or irritate its mucosal membrane, especially laxatives. Just read the labels!
• Seek out a competent, caring physician to guide you. This book, an anatomy primer from a local library, and your unambiguous determination to recover is all that you need to convince a reasonable doctor to help you get rid of IBS. Believe me, the last thing doctors want to deal with are irate patients with irritable bowels.

Ironically, many well-meaning doctors and their families are also victimized by IBS, perhaps even more so than the general population, because they aggressively treat themselves and their families in the way they’d been taught. The scariest claim about IBS, however, is that it’s completely risk and damage-free:

Well, if you disregard diverticulosis, hemorrhoids, anal fissures, ulcerative colitis, precancerous polyps, and colorectal cancer, then I guess there isn’t any risk. To keep this from happening to you, consider the following key points:

Summary:

• Latent constipation is one of the most common and least recognized causes of IBS.
• IBS-related diarrhea results in functional constipation because diarrhea decimates stool-forming bacteria.
• The treatment of dysbacteriosis is essential for effective treatment of IBS and prevention of IBS-related constipation.
• IBS has many more primary causes than just constipation. Regardless of the causes, functional constipation that results from IBS sets the stage for more severe forms of latent and organic constipation.
• If you have IBS-related constipation, it isn’t enough to treat just constipation. You must also treat the causes of IBS to prevent constipation relapse.
• There is no effective medical treatment of IBS. Ironically, leaving IBS untreated may be in some instances safer than undergoing aggressive medical therapy with fiber, antibiotics, and other prescription drugs.
• Conventional treatment of IBS-related constipation with dietary fiber and medication is a principal reason for transforming IBS into Inflammatory Bowel Disease, Crohn’s disease, and ulcerative colitis.
• Though the term IBS implies that this is just a bowel-related condition, in fact it commences in the stomach and small intestine, and the treatment must begin there.
• A Western-style diet, especially a diet patterned after the Food Guide Pyramid, predisposes one to the development of IBS, because the core foods in the Pyramid contain hyperallergenic components and known GI irritants, and lack essential, primary amino and fatty acids.
• Diet-related malnutrition is as culpable in the development of IBS as overconsumption in the Western countries.
• Certain lifestyle choices, such as smoking, chewing gum, and consuming alcohol, coffee, carbonated beverages, and artificial sweeteners, may contribute to or directly cause IBS and IBS-related constipation.
• If left untreated, IBS may progress into life-threatening conditions, such as ulcerative colitis and Crohn’s disease. Undoubted­ly, just as with those conditions, chronic IBS predisposes a person to colorectal cancers.
• Finally, IBS is an eminently avoidable and treatable condition, but not by conventional allopathic means. The information presented in this book is sufficient for overcoming the most stubborn cases of IBS.
• Always consult your doctor and/or pharmacist regarding possible IBS-related side effects of the medicines you are taking. Do not abandon prescribed medications without consulting a physician.

Footnotes