An overview of irritable bowel syndrome and its homoeopathic management

Dr Sushmitha

ABSTRACT
Irritable Bowel Syndrome (IBS) is a functional bowel disorder characterized by abdominal pain or discomfort and altered bowel habits in the absence of detectable structural abnormalities.¹ It has also been referred to as nervous colon, irritable colon, mucous colitis, spastic colon, functional bowel condition, nervous diarrhea, chronic catarrhal colitis, and vegetative neurosis.²   Functional gastrointestinal disorders (FGIDs) account for at least 40% of all referrals to gastroenterologists. The prevalence in India is said to be around 4.2%, and approximately 10–20% seek medical care.³ The prevalence of IBS in a North Indian community is 4%. IBS poses a significant burden on the rural adults.⁴

Currently, there is no agreement on the best form of treatment for IBS. Homoeopathy can be explored as a valid treatment option for IBS. Homoeopathic system of medicine is based on holistic approach in which mental and physical both symptoms considered in each individual case, so we able to find out the efficacy of Homoeopathy in the management of Irritable Bowel Syndrome.

KEYWORDS: ; Irritable Bowel Syndrome Severity Scoring System, IBS with diarrhoea (IBS-D), IBS with constipation (IBS-C) and IBS with mixed diarrhoea and constipation (IBS-M)

INTRODUCTION:
Irritable Bowel Syndrome (IBS) is a functional bowel disorder characterized by abdominal pain or discomfort and altered bowel habits in the absence of detectable structural abnormalities.¹

According to the predominant bowel habit, defined by stool consistency and form, IBS patients are divided into subgroups which include IBS with diarrhoea (IBS-D), IBS with constipation (IBS-C) and IBS with mixed diarrhoea and constipation (IBS-M). The World Gastroenterology Organization has reported that up to one-third of cases are IBS-C, one third are IBS-D and a third to a half of cases are IBS-M. The treatment of the condition largely depends on the subtyping of the condition such as constipation or diarrhoea– predominant syndrome and the underlying pathophysiology³

The prevalence in India is said to be around 4.2%, and approximately 10–20% seek medical care.⁴ The prevalence of IBS in a North Indian community is 4%. IBS poses a significant burden on the rural adults.⁵

In today’s fast and modern life psychological stress is continuously increasing in human economy, which is one of the main contributing factor for IBS, due to which the prevalence of IBS is continuously progressing (>20%), not only in India but also in other countries. Irritable bowel syndrome (IBS) is important because of its high prevalence, substantial morbidity and enormous costs. Irritable Bowel Syndrome (IBS) can have significant impact on individual’s social, personal, and professional life. As psychological disturbances are one of the proposed mechanisms behind the pathophysiology of Irritable Bowel Syndrome, up to 80% of IBS patients are recorded with psychological factors which influence pain thresholds in Irritable Bowel Syndrome.¹

At this point, opinions regarding the most effective way to treat IBS diverge. As a legitimate therapeutic option for IBS, homoeopathy can be investigated. Irritable Bowel Syndrome can be effectively managed with homoeopathy since it is based on a comprehensive approach that takes into account both physical and mental symptoms in each individual instance.

DEFINITION:
Irritable Bowel Syndrome (IBS) is a functional bowel disorder characterized by abdominal pain or discomfort and altered bowel habits in the absence of detectable structural abnormalities.¹

RISK FACTORS:
Over the past few decades, several risk factors have been identified for IBS through case–control- and community-based studies the relative importance of each factor is evolving, and currently we may view IBS as a disease in which several factors can interact along the whole life of the subject, from the genetic background to daily life experiences. gastroenteritis in the adulthood, a well recognized risk factor for IBS. ⁷

A.FAMILIAL AGGREGATION

In population-based investigations, familial aggregation of IBS has been demonstrated. IBS has lately been linked to families, according to research where relatives’ IBS status was directly obtained from them. The risk of IBS among relatives of patients with IBS was three times greater than among relatives of controls. According to twin studies, the hereditary component of IBS may account for up to 20% of cases. ⁷

The twin study also reveals that genetic and environmental variables play a significant role in the development of IBS. The challenge for the following ten years will be the search for a “IBS gene.” Although a number of possible genes have been suggested, no conclusive connections have been proven. ⁷

1. EARLY LIFE EVENTS

Early life experiences have come to light as potential important elements. According to various research, having functional gastro intestinal disease in the past doubles the risk of developing IBS as an adult. In a population-based study, chronic stomach discomfort in childhood—more precisely, between 7 and 9 years old—was linked to adulthood, regardless of maternal emotional distress or psychiatric co-morbidity. External experiences during childhood and adolescence can potentially cause IBS in adulthood. Several very early stressful life events have been linked to IBS. In a twin research, infants with low birth weight (less than 1.5 kg) had a twofold increased chance of developing irritable bowel syndrome, and infants who had nasogastric suction had a threefold increased risk of developing a functional gastrointestinal disorder in adulthood. ⁷

1. DIET

Food is said to trigger or exacerbate symptoms in many patients, and IBS in the general population has also been linked to this. Only one population-based study looked at nutrition and IBS; the findings indicated that food sensitivity rather than a varied diet’s composition may be connected to IBS. ⁷

1. PSYCHOSOCIAL FACTORS AND ABUSE

IBS has long been known to be influenced by psychological variables, and numerous population-based studies have demonstrated this connection without the need for medical intervention. Higher levels of neuroticism have consistently been documented, meaning that people with IBS are more likely to experience anxiety and higher levels of stress when confronted with dangerous situations. Daily stress has in fact been linked to IBS symptoms on a regular basis. IBS patients have been discovered to have higher serum levels of numerous pro-inflammatory cytokines, and il-6 levels were found to be correlated with anxiety in these individuals. Proinflammatory cytokines may activate the hypothalamus pituitary axis, which would modulate psychological symptoms, however the direction of this link is currently unknown. Abuse is one traumatic event that has been linked to IBS for a long time. Although it wasn’t consistently observed in all community research, childhood maltreatment, particularly sexual abuse, has been connected to IBS in both the general population and patient populations. In population-based research, maltreatment in adulthood has been linked to IBS, and ongoing abuse also seems to be significant. However, neuroticism might act as a mediating factor in any association between maltreatment and IBS.⁷

AETIOPATHOGENESIS:
IBS pathogenesis is thought to be multifaceted, resulting from the interaction of genetic, psychological, and environmental variables. These lead to anomalies in the central nervous sytem producing aberrant motility and perhaps abnormal secretory activity in the peripheral nervous system as well as during nervous system processing. It is doubtful that there is a single unifying explanation because no consistent anatomical, physiological, or microbiological anomaly has been shown.⁸                                               

The main causes of symptom development are believed to be changes in gastrointestinal motor function, enhanced perception of stimuli coming from the gut wall, and psychosocial variables. A number of new elements have been discovered and speculated to interact with these classical mechanisms in recent years. Abdominal pain, bloating, and reduced capacity to release intestinal gas may be caused by bowel distension and gas entrapment. Following painful stimulation of the rectum, abnormal activity of specific brain areas suggests impaired afferent signal processing.In a subset of IBS patients (i.e., post-infectious IBS), who are most likely unable to treat their symptoms, An acute gastrointestinal infection is now recognized as an aetiological cause for the development of symptoms. These people are likely unable to effectively down-regulate the original inflammatory stimulation. Additionally, in post-infectious and non-specific IBS, low-grade inflammatory infiltration and mast cell activation in close proximity to neurons in the colonic mucosa may also contribute to the frequency and intensity of felt abdominal discomfort. Initial research points to alterations in gut flora, serotonin metabolism, and a genetic component in the pathogenesis of IBS.⁸

1.ALTERED MOTOR FUNCTION:

IBS has been always considered a gut motor disorder. IBS patients colons and small bowels have been shown to have a variety of motor abnormalities. It has been demonstrated that eating, stress, mechanical stimulation, colecystokinin infusion, and CRF infusion all cause exaggerated gut motor responses.^8,9 Colonic myoelectrical and motor studies conducted in the absence of stimulation have not consistently revealed abnormalities in IBS. Colonic motor anomalies, on the other hand, are more obvious in IBS enhanced circumstances. IBS sufferers may exhibit more active rectosigmoid muscles for up to three hours after eating. Similar to how inflating rectal balloons causes pronounced and protracted distention-evoked contractile activity in IBS-D and IBS-C patients. When compared to healthy subjects, recordings from the transverse, descending, and sigmoid colon revealed that diarrhea-prone IBS patients had significantly higher motility index and peak amplitude of high-amplitude propagating contractions (HAPCs), which were linked to rapid colonic transit and accompanied by abdominal pain.^1,8,9,10

2.VISCERAL HYPERSENSITIVITY:

IBS patients frequently display excessive sensory reactions to visceral stimuli, similar to studies of motor activity. Food intolerance perceptions occur at least occasionally more frequent than in the overall population by two times. In 74% of patients, postprandial pain was temporally associated to food bolus penetration into the cecum. On the other hand, extended fasting is frequently linked to a large reduction in symptoms in IBS patients. In IBS patients, compared to healthy controls, rectal balloon inflation causes non-painful and unpleasant feelings at lower volumes without changing rectal tension, suggesting visceral afferent dysfunction in IBS. In IBS patients, lipid lowers the thresholds for the initial experience of gas, discomfort, and pain. As a result, an enhanced sensory component of the gastrocolonic response that is nutrient-dependent may help to partially explain postprandial symptoms in IBS patients. IBS patients do not show increased sensitivity elsewhere in the body, in contrast to increased gut sensitivity. As a result, it appears that IBS-related afferent pathway abnormalities favor visceral innervation while sparing somatic pathways. Investigations are still ongoing to determine the mechanisms underlying visceral hypersensitivity^1,8,9

3.CENTRAL NEURAL DYSREGULATION:

The role of central nervous system (CNS) factors in the pathogenesis of IBS is strongly suggested by the clinical association of emotional disorders and stress with symptomation and the therapeutic response to therapies that act on cerebral cortical sites. Functional brain imaging studies such as magnetic resonance imaging (MRI) have shown that in response to distal colonic stimulation, the mid-cingulate cortex—a brain region concerned with attention processes and response selection—shows greater activation in IBS patients. Modulation of this region is associated with changes in the subjective unpleasantness of pain. In addition, IBS patients also show preferential activation of the prefrontal lobe, which contains a vigilance network within the brain that increases alertness. These may represent a form of cerebral dysfunction leading to the increased perception of visceral pain^{1,8, 9}

4.ABNORMAL PSYCHOLOGICAL FEATURES: Abnormal psychiatric features are recorded in up to 80% of IBS patients, especially in referral centers; however, no single psychiatric diagnosis predominates. Most of these patients demonstrated exaggerated symptoms in response to visceral distention, and this abnormality persists even after exclusion of psychological factors. Psychological factors influence pain thresholds in IBS patients, as stress alters sensory thresholds.^30,31,32 An association between prior sexual or physical abuse and development of IBS has been reported. Clinical studies suggest that IBS has a strong developmental component which involves interactions of genetic and epigenetic factors early in life. These may modulate brain networks related to emotional arousal and/ or central autonomic control, salience and somatosensory integration. Abuse is associated with greater pain reporting, psychological distress, and poor health outcome. Brain functional MRI studies show greater activation of the posterior and middle dorsal cingulate cortex, which is implicated in affect processing in IBS patients with a past history of sexual abuse. Thus, patients with IBS frequently demonstrate increased motor reactivity of the colon and small bowel to a variety of stimuli and altered visceral sensation associated with lowered sensation thresholds. These may result from CNS–enteric nervous system dysregulation^{1,8, 9}

5. POSTINFECTIOUS IBS: A GI infection may cause IBS. One-fourth of 544 patients with confirmed bacterial gastroenteritis in the study went on to develop IBS. In contrast, around a third of people with IBS first developed chronic IBS symptoms after suffering from an acute “gastroenteritis-like” sickness. Females are more likely to experience this type of “postinfective” IBS, and younger patients are more likely to be affected than older ones. In order of relevance, the following risk factors for developing postinfectious IBS include prolonged initial disease duration, bacterial strain toxicity, smoking, mucosal markers of inflammation, female sex, depression, hypochondriasis, and negative life experiences in the previous three months. While taking antibiotics has been linked to an increased risk, age more than 60 may protect against postinfectious IBS. Shigella, Campylobacter, and Salmonella are the microorganisms that are responsible for the initial infection. Toxin-positive patients with Campylobacter infection are more prone to experience postinfective IBS. Increased T lymphocytes, increased gut permeability, and increased rectal mucosal enteroendocrine cells are acute alterations following Campylobacter enteritis that may last for more than a year and contribute to postinfective IBS.^1,8,9

6.IMMUNE ACTIVATION AND MUCOSAL INFLAMMATIONS: IBS patients exhibit lingering symptoms of low-grade mucosal inflammation, including activated mast cells, lymphocytes, and increased proinflammatory cytokine production. Peripheral blood mononuclear cells (PBMCs) from IBS patients exhibit aberrant release of proinflammatory cytokines such IL6, IL1, and TNF, according to other studies. Visceral hypersensitivity and aberrant epithelial secretion may be impacted by these disorders. There is mounting evidence that some TRP cation channel superfamily members, including as TRPV1 (vanilloid) channels, are essential for the onset and maintenance of visceral hypersensitivity. Increased expression of TRPV1 in the enteric nervous system can result from mucosal inflammation. IBS has been associated with an increased expression of TRPV1 channels in the sensory neurons of the gut, and this expression appears to correlate with visceral hypersensitivity and abdominal pain. Interesting, clinical research has also revealed increased intestinal permeability in IBS-D patients. Pro-inflammatory cytokines are released more frequently under conditions of psychological stress and worry, which in turn may change the permeability of the intestine. According to a clinical investigation, the lactulose/mannitol ratio revealed increased intestinal permeability in 39% of IBS-D patients. Additionally, these IBS patients showed greater Functional Bowel Disorder Severity Index (FBDSI) scores and increased sensitivity to stimuli that cause visceral nociceptive pain. This establishes a functional connection between psychological stress, immunological activation, and the development of symptoms in IBS patients.^1,8,9

7. ALTERED GUT FLORA: Based on a positive lactulose hydrogen breath test, it has been discovered that IBS patients have a high prevalence of small intestinal bacterial overgrowth. Several additional research that used jejunal aspirate culture to get their conclusions reported no greater incidence of bacterial overgrowth, which cast doubt on this conclusion. Small-bowel quick transit can induce abnormal H₂ breath tests, which could result in a misinterpretation. Therefore, it is unclear what purpose testing for small intestine bacterial overgrowth serves in IBS patients.^1,8,9
8. BRAIN-GUT INTERACTION: New to the understanding of IBS pathogenesis are changes in the brain-gut axis. Sensation in the gut can be influenced by environmental, cognitive, and emotional factors. The brain-gut axis is affected by stress responses, which have an impact on both the brain and the gut. Corticotropin-releasing hormone (CRH) is a key mediator of these responses. Colonic motility was made worse by the intravenous infusion of CRH, and was prevented from increasing due to stress by peripheral administration of a CRH antagonist.

The increased release of serotonin may be a factor in these patients’ postprandial symptoms because serotonin is crucial for the regulation of GI motility and visceral perception. This justifies the use of serotonin antagonists in the treatment of this illness.^1.8,9

9. ABNORMAL SEROTONIN PATHWAYS: Compared to healthy people or patients with ulcerative colitis, a subpopulation of IBS-D patients had more serotonin (5-HT)-containing enterochromaffin cells in the colon. Furthermore, compared to healthy controls, this group of patients had significantly greater postprandial plasma 5-HT levels. The rate-limiting enzyme in the production of 5-HT in enterochromaffin cells, tryptophan hydroxylase 1 (TPH1), has been linked to specific kinds of IBS habits. ^1,8,9

CLINICAL FEATURES:
Although IBS can affect people of any age, the majority of individuals experience their first symptoms before the age of 45. People who are older report less frequently. IBS affects women two to three times more frequently than men and  account for 80% of those with severe IBS. Pain is an important symptom for the diagnosis of IBS. This symptom need to be connected to defecation and/or have its onset connected to a change in the frequency or consistency of stools. Rome IV’s standards are stricter than Rome III’s, requiring abdominal pain to occur at least once per week and eliminating “discomfort” as a need. Constipation or diarrhea without pain does not meet the diagnostic criteria to be categorized as IBS. Defecation straining, urgency or the sensation of an incomplete bowel movement, passing mucus, and bloating are examples of supportive symptoms that do not meet the diagnostic criteria.^1,9

ABDOMINAL PAIN:Abdominal pain is a required clinical characteristic of IBS, under the current diagnostic criteria. In IBS, both the location and the intensity of abdominal pain are quite varied. It is commonly crampy and episodic, but it could also be accompanied by a persistent aching. Pain can be insignificant or it can get in the way of regular activities. Despite this, malnutrition brought on by insufficient calorie intake is incredibly uncommon in people with IBS. Absence of sleep is particularly rare because abdominal pain usually always occurs only when awake. However, individuals with severe IBS frequently experience nighttime awakenings, making nocturnal pain a poor indicator of either organic or functional bowel disease. Eating or experiencing emotional stress can often make pain worse and improved by the passage of stools or flatus. Additionally, female IBS patients frequently claim that their symptoms get worse before and during their premenstrual and menstrual periods.^1,9

ALTERED BOWEL HABITS: Constipation alternating with diarrhea is the most common pattern, usually with one of these symptoms predominating. Initially episodic, constipation eventually becomes continuous and becomes increasingly resistant to laxative treatment. Stools are typically hard and narrowed in caliber, possibly reflecting excessive dehydration brought on by prolonged colonic retension and spasm. Most patients also feel as though their evacuation isn’t complete, which prompts them to defecate multiple times quickly. Patients with constipation as their main complaint may experience transient bursts of diarrhea every few weeks or months. Diarrhea may be the main symptom in other patients. IBS-related diarrhea typically consists of tiny amounts of loose feces. Stool quantities in patients range from 200 mL to less. IBS patients do not experience nocturnal diarrhea. Either eating or experiencing mental stress might make diarrhea worse. Large volumes of mucous may pass through the stool along with it. IBS does not cause malabsorption or weight loss, and bleeding only occurs when hemorrhoids are present. ^1,9

GAS AND FLATULENCE: Patients with IBS frequently express feelings of abdominal fullness, excessive belching, or flatulence, all of which they attribute to an accumulation of gas. Quantitative measurements show that the majority of patients who complain of increased gas emit no more than a normal quantity of intestinal gas, notwithstanding the possibility that some individuals with similar symptoms may genuinely have more gas than others. Most IBS sufferers have impaired intestinal gas load tolerance and transit. Belching may be explained by the fact that people with IBS frequently experience gas reflux from the distal to the more proximal gut. Some patients with bloating may also notice a noticeable distention along with an increase in belly fat. Both symptoms are more prevalent in female patients and those with higher total somatic symptom checklist scores.^1,9

UPPER GI SYMPTOMS: About 25 to 50 percent of IBS patients have dyspepsia, heartburn, nausea, and vomiting. This implies that the colon may not be the only portion of the gut involved. Long-term ambulant recordings of small-bowel motility in IBS patients reveal a significant incidence of anomalies during the diurnal (waking) phase; nocturnal motor patterns are similar to those in healthy controls. IBS and dyspepsia share a lot of symptoms. Patients who reported having dyspepsia were more likely to have IBS (31.7%) than patients who did not have any dyspepsia symptoms (7.9%). On the other hand, dyspepsia symptoms were reported by 55.6% of IBS patients. Additionally, the symptoms of functional abdominal pain can alter over time. People who have IBS or dyspepsia can alternate between the two.^1,9

SUBTYPES OF IRRITABLE BOWEL SYNDROME: ^2,3,17,19
Subtypes of bowel patterns are quite unstable. 75% of patients change subtypes and 29% transition between IBS-C and IBS-D over the course of a year in a patient population where the prevalence rates of IBS-diarrhea predominant (IBS-D), IBS-constipation predominant (IBS-C), and IBS-mixed (IBS-M) forms are each 33%.

Based on bowel patterns ^2,3,9,11:

1. IBS-D [Diarrhea predominant ]
2. IBS-C [Constipation predominant]
3. IBS-M [Mixed type]

BRISTOL STOOL FORM SCALE[BSFS]:

The BSFS is widely used throughout the world in both clinical and research settings. The Rome Foundation recommends use of the BSFS for sub-typing irritable bowel syndrome (IBS) according to the new Rome IV criteria. The Bristol Stool Form Scale (BSFS) is one of the most commonly used stool form measures, despite the fact that several have been created and validated for use in adults. ¹²

The BSFS is an ordinal scale of stool kinds, with Type 1 being the hardest and Type 7 being the softest. Types 1 and 2 are thought to be excessively hard feces (together with other constipation-related symptoms), whereas Types 6 and 7 are thought to be abnormally loose/liquid stools (along with other diarrhoeal symptoms). Therefore, type 3, type 4, and type 5 are widely regarded as the most “normal” stool forms, and these types of stools are the modal stool patterns in cross-sectional surveys of healthy persons.^2,8,12                    

DIAGNOSIS:
No clear diagnostic markers exist for IBS; thus, the diagnosis of the disorder is based on clinical presentation. In 2016, the Rome III criteria for the diagnosis of IBS were updated to Rome IV criteria.¹ Since there is no test to confirm the diagnosis of IBS, it might be difficult to make the diagnosis. Since 1978, criteria have been developed, with the most recent revision being in 2016. These revisions aimed to clarify and assist practitioners in making the diagnosis. For patients to receive the most affordable diagnosis of IBS and to comply with the Rome IV diagnostic criteria should only require the minimal testing described above in the presence of a normal physical examination and the absence of any warning indications. Instead of encouraging them to take additional tests, you should reassure and educate them. The Bristol stool chart should also be used to accurately identify bowel patterns and categorise patients so that treatment can be tailored to the prevailing symptom. Hence the diagnosis is based on clinical presentation using Rome 1V criteria , ruling out red flag symptoms⁹

ROME IV CRITERIA^1,2: Recurrent abdominal pain on average at least 1 day/week in the last 3 months, associated with two or more of the following criteria:

1. Related to defecation
2. Associated with a change in the frequency of stool
3. Associated with a change in the form (appearance) of stool

(These criteria should be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.)

RED FLAG SYMPTOMS: Symptoms that are against the diagnosis of irritable bowel syndrome. These Red Flag Symptoms that make the Diagnosis of Irritable Bowel Syndrome Unlikely.¹³

• Fever
• Weight loss
• Nocturnal diarrhoea
• Blood in stools
• ↓ Haemoglobin
• ↓ albumin
• ↑ ESR
• Recent symptoms in middle age/elderly

Features against the diagnosis of Irritable Bowel syndrome ¹³

• [Late age (>40 years) at onset of symptoms]
• Large-volume diarrhoea or steatorrhea
• dehydration
• Significant weight loss
• Progression of symptoms or development of new symptoms
• Physical examination Abdominal mass Signs of malabsorption, bowel obstruction, thyroid dysfunction Extraintestinal manifestations (arthritis, skin lesions)
• Laboratory findings Occult blood in stools
• Validity and reliability of the Bristol Stool Form Scale in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome

INVESTIGATIONS
The National Institute for Health and Care Excellence (NICE) guidelines for the management of irritable bowel syndrome (IBS) state that invasive tests, such as colonoscopy, are not required to make a diagnosis of IBS. Without alarm features,  Patients with IBS-compatible symptoms rarely have organic pathology. The gold standard for diagnosing IBS, symptom-based diagnostic criteria, perform just moderately, and current biomarkers don’t do any better. It is preferable to combine symptoms with a constrained panel of blood tests and indicators of psychological mood. Therefore, General Physicians should think about using this strategy, which is supported by NICE, to help with IBS diagnosis. ¹⁴

Tests that NICE considers as unnecessary for diagnosing IBS¹⁴

• Colonoscopy or barium enema;
• Rigid or flexible sigmoidoscopy;
• Hydrogen breath test for small intestinal bacterial overgrowth and lactose intolerance
• Thyroid function test
• Fecal ova and parasite test and
• Fecal occult blood test.

Hence the required minimal tests to rule out the alarming features or red flag symptoms are^12.21

1. Complete blood count
2. Erythrocyte sedimentation Rate
3. C- Reactive protein

DIFFERENTIAL DIAGNOSIS^11,12

                                        Table 1: Differential Diagnosis OF IBS

CONDITION	FEATURES
Colorectal cancer	·       Older patients, Unintended weight loss ·       Rectal Bleeding and obstruction ·       Mucus discharge, anaemia ·       Feeling of incomplete evacuation ·       Colicky lower abdominal pain
Coeliac disease	·       Intolerance of wheat or gluten ·       Tiredness, weight loss ·       Iron or folate deficiency ·       Oral ulceration ·       Dyspepsia, bloating
Inflammatory bowel disease	·        Persistent diarrhea ·        Abdominal pain ·        Rectal bleeding, bloody stools ·        Weight loss ·        Fatigue
Amoebic dysentery	·       Loose stools, abdominal cramps ·       Frequent watery or bloody stools ·       Flatulence ·       Appetite loss ·       Fatigue ·       Recurrent fever
Bacillary dysentery	·       Fever, nausea, vomiting ·       Abdominal cramps ·       Diarrhoea ·       Blood and mucus in stools

TREATMENT:

GENERAL MANAGEMENT:
Patient Counselling and Dietary Alterations: Reassurance and careful explanation of the functional nature of the disorder and of how to avoid obvious food precipitants are important first steps in patient counselling and dietary change. Occasionally, a meticulous dietary history may reveal substances (such as coffee, disaccharides, legumes, and cabbage) that aggravate symptoms. Excessive fructose and artificial sweeteners, such as sorbitol or mannitol, may cause diarrhea, bloating, cramping, or flatulence. As a therapeutic trial, patients should be encouraged to eliminate any foodstuffs that appear to produce symptoms. However patients should avoid diets that are nutritionally lacking, nevertheless. Patients with IBS have been proven to benefit from a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs).^1,11

                        Table 2 : Some common food sources of FODMAP’s ¹

Fruits	Apple, cherry, mango, pear, watermelon Peach, persimmon, watermelon, apricot, pear, avocado, blackberries, cherry, nectarine, plum, prune
Vegetables	Asparagus, artichokes, sugar ,snap peas, Artichokes, beetroot, Brussels sprout, chicory, fennel, garlic, leek, onion, peas Cauliflower, mushroom, snow peas
Grains and Cereals	Wheat, rye, barley Nuts and seeds Pistachios
Milk and milk products	Milk, yogurt, ice cream, custard, soft cheeses
Others	Honey, high-fructose corn syrup Chicory drinks
Food additives	Inulin, FOS Sorbitol, mannitol, maltitol, xylitol, Isomalt

Low FODMAP Diet: IBS can be well managed with a low-FODMAP diet. Dietitians that specialize in the management of gastrointestinal illnesses must be assessed and educated in order for the diet to be successful. They must also use the most recent patient resources. It is critical that patients are informed during the first educational session that if patients have experienced symptomatic improvement, subsequent dietitian guidance will concentrate on food reintroductions and long-term management. That the low-FODMAP diet is not a diet for life. Finding a balance between clinical improvements and possible adverse effects on the dietary restriction is the long-term objective.^15.16,17

A prospective study by the University of Otago, Christchurch, New Zealand to determine whether a low FODMAP diet improves symptoms in IBS patients. A symptom questionnaire was used to prospectively assess the impact of a reduced FODMAP diet. In addition, assessments of adherence and satisfaction with symptom improvement, dietary recommendations, and diet were made. 90 patients were taken and the average follow-up and the study lasted for 15.7 months. The majority of symptoms, including bloating, flatulence, diarrhoea, and abdominal discomfort, considerably decreased. Most patients (72.1%) were satisfied with their symptoms. Hence the study was concluded that for people with IBS, a low-FODMAP diet is effective.¹⁸

High fibre rich diet: IBS is typically treated with high-fiber diets and bulking substances like bran or hydrophilic colloids. Because fiber can enhance fecal production of bacteria, it may help to increase stool volume through its propensity to hold water. Fiber also expedites colonic transit in the majority of people. Whole-colonic transit occurs more quickly in patients who are prone to diarrhea; dietary fiber, however, can slow transit. Furthermore, stool-bulking drugs prevent both excessive and dehydration of stool by binding water due to their hydrophilic characteristics. The latter finding may explain the clinical finding that some IBS patients’ diarrhea is relieved by a high-fiber diet. Psyllium, a fiber supplement, has been proven to lessen the sensation of rectal distention, suggesting that fiber may have a beneficial effect ¹⁸

Outcome assessment by Irritable Bowel Syndrome Severity Scoring System (IBS-SSS)¹⁹
The IBS-SSS is a 5-question survey that asks the severity of abdominal pain, frequency of abdominal pain, severity of abdominal distention, dissatisfaction with bowel habits, and interference with quality of life in general. Subjects respond to each question on a 100-point scale. Scores on the IBS-SSS can range from 0 to 500 with higher scores indicating more severe symptoms. Subjects can be categorized as having mild (75-175), moderate (175-300), or severe (>300) IBS. IBS Severity Score is assessed during first visit and during each follow up. Final outcome is analyzed by comparing the IBS severity score between first visit and final follow up. A decrease of 50 points is associated with improvement.

HOMOEOPATHY AND IRRITABLE BOWEL SYNDROME:
Hahnemann established the Homoeopathic medical system in 1796. The foundation of homoeopathy is the “Similia Similibus Curentur” or “Like cures like” natural rule of healing. Medicines that can treat symptoms can also produce those symptoms in healthy people. Instead than focusing on the sickness, homoeopaths treat the whole person. In Aphorism 226, Hahnemann explains the connection between mind and physical ailments. Dr. Hahnemann also describes the chronic diseases caused by the miasms, including psora, sycosis, and syphilis. The word “Constitution” is first used by Dr Samuel Hahnemann in aphorism 5 of his Organon of Medicine. The Latin verb “CONSTITUERE,” which means “to establish,” is the root of the term “CONSTITUTION.” The constitution of a person is a representation of both their general makeup and their genetically based organizational structure.²⁰

According to John H Clarke: Human body is made up of water i.e. oxygen, hydrogen, carbon & nitrogen. Any difference in these elements in the blood & tissues makes the basic difference in the constitution of the individual. Once the constitution known & cured, all the rest of the symptoms clear up²¹

According to Dr M L Dhawale: the constitution of a person represents to us what he has made of the hereditary plan of organization as determined by the genes. In other words, it represents the end result of the influence of the environment on hereditary characteristics. The sum total of the individual characteristics, in the three planes- emotional, intellectual & physical- depicts the constitution. Thus, a study of the past (longitudinal section) & of the present (cross section) is essential for a complete study of personality, without which much of the illness remains as engine²²

According to GH G Jahr: In chronic diseases the constitutional additional symptoms provide the characteristics indications for the choice of remedy. The origin of disease in an acquired or inherited diathesis, they are often so intimately amalgamated with the individual constitution of the patient that he does not even think of communicating the constitutional anomalies, which the patient does not even consider as pathologic²³

IBS is a psychosomatic illness that affects both the body and the mind. IBS is brought on by psychological issues such emotional stress, rage, fear, etc. as well as unusual sensitivity to particular foods. Homoeopathy emphasizes a holistic approach and addresses a patient’s interaction with their mind and body. Currently, there is no agreement on the best form of treatment for IBS. Homoeopathic system of medicine is based on holistic approach in which mental and physical both symptoms considered in each individual case, so we able to find out the efficacy of Homoeopathy in the management of Irritable Bowel Syndrome.^24,25,26,27

Dr Hahnemann describes specific remedy in (§147) in Organon of Medicine.²⁰

The specific remedy in homeopathy is the one which has greater similarity to the totality of symptoms of the patient. Specific remedy is selected based on the symptoms exhibited by the patient at present condition. Medicine which is similar to the striking, uncommon, peculiar and rare symptoms of the patient will be the specific remedy.²⁰

Kent’s Views on Specific Remedy: Lecture no. XXX-Characteristics²⁸

Only characteristic symptom in each individual totality of the patient will lead to “specific remedy” in homeopathy. Homeopathic specific remedy is the one – which has demonstrated its curative relation to the patient, after having been prescribed in accordance with his symptoms, the recovery takes place in the proper direction, from above downward, from within out, and in the reverse order of appearance of symptoms. As a matter of fact, the homeopathic physician prescribes for the patient on that which characterizes the sickness, even though this is what is called  self-limiting disease.²⁸

MIASMATIC INTERPRETATION
As the disease is only in the functional level and there is no structural pathological changes, IBS comes under psoro-sycotic miasm, predominantly sycosis. ²⁹

PSORIC SYMPTOMS³⁶

• Feeling of abdominal distention due to accumulation of gas
• Constipation primarily psoric (slow peristalsis)
• Ineffectual urge for stool

SYCOSIS SYMPTOMS²⁹

• Crampy, spasmodic abdominal pain
• Discomfort after eating
• Colicky symptoms even from simplest food
• Diarrhea ( exaggerated peristalsis)
• Diarrheas or any stool where colic predominates

RESEARCH ON IBS IN HOMOEOPATRHY
Tushita Thakur, Consultant Homoeopathy, AYUSH Wellness Clinic, President’s Estate, New Delhi, India, did a clinical study on the homoeopathic management of irritable bowel syndrome in 2018. The study included 15 patients who visited the homoeopathy OPD. Following case taking, individualizing each patient, and consulting the Material Medica/Repertory, a single effective homeopathic remedy was provided. The dosages of the remedies utilized were 30, 200, and 1 M, depending on the needs of each specific instance. six-month follow-up on cases. In order to gauge the severity, a symptom score was developed. P>0.05, P 0.01, and P 0.001 levels were used for the paired “t” test. Insignificant P>0.05, Significant P0.05, and Highly Significant P0.01; P0.001 were the interpretations of the results. The findings of this study demonstrate that homoeopathy is effective in treating this illness and call for additional research with a bigger sample size, longer follow-up, and stricter evaluation criteria³⁰

At RKDF Homoeopathic Medical College Hospital & Research Centre, Bhopal, India, a study was undertaken on the effectiveness of Argentum nitricum and Lycopodium Clavatum in the therapy of Irritable Bowel Disease. The study has 30 participants. As a prospective before-and-after comparative study, this one was created. Each of the two groups of 15 instances for Lycopodium clavatum and Argentum nitricum was created from all the cases. As a result, at the conclusion of the study, results were divided after statistical analysis. The findings imply that men were more likely than women to have IBS. The age range between 25 and 35 years saw the highest occurrence (14 cases), followed by the range between 35 and 45 years (8 cases), 15 to 25 years (6 cases), and 45 to 55 years (2 cases). Out of 30 cases, 24 cases (80%) have a fundamental miasm associated with psora, five cases (16.67%) have sycosis, and one case (3.33%) is syphilitic. Homoeopathic treatment appeared to lessen the symptoms of irritable bowel syndrome, with the Lycopodium clavatum group showing slightly better results than the Argentum nitricum group.³¹

At Bharati Vidyapeeth Homoeopathic Hospital in Pune, India, a clinical trial was done on patients who complained of IBS. 30 participants signed up for the trial. The subjects received constitutional medicine treatment. Depending on each patient’s susceptibility, homoeopathic medications were recommended in 30CH, 200CH, and 1M potencies. In accordance with the intensity of the patient’s symptoms, placebos were also administered in between treatments. The severity of the IBS symptoms experienced by the patients was assessed using the IBS-SSS assessment score. The constitutional remedies were prescribed, including phosphorus, arsenic album, nux vomica, sulphur, and many others. According to this study, people between the ages of 21 and 30 are more likely to have IBS. The study’s conclusion that the IBS-SSS evaluation instrument³²

A therapeutic article published in International journal of homoeopathic sciences by Dr. Anshul Chahar and Dr. Samridhi Sharma (Swasthya Kalyan Homoeopathic Medical College & Research Centre, Sitapura, Jaipur, Rajasthan, India) on Irritable bowel syndrome and it’s homoeopathic therapeutics, in which Nux vomica indications in Irritable Bowel Syndrome has been described.³³

A Case report on Irritable Bowel Syndrome Treated by Haresh Kumar Maharaj Associate Professor, Department of Practice of Medicine, R.B.T.S Govt. Homoeopathic Medical College & Hospital, Muzaffarpur. In this case presentation, we see that how Homoeopathic individualised medicine helps to manage a case of IBS. Homoeopathy have potential scope to manage any kind of gastro-intestinal disease. Here, with the help of Nux vomica complete cure occurs without having any side effects³⁴

In 2017, a case series study was carried out in a hospital associated with a postgraduate homoeopathic medical college in Maharashtra. Thirty patients To evaluate the effectiveness of Nux Vomica in the treatment of irritable bowel syndrome, a study was carried out. For the study, a simple randomized sampling approach was used. Thirty patients diagnosed with Manning’s criteria and were given Nux vomica as medicine. According to the study, out of 30 cases, 25 patients recovered after taking Nux Vomica, or 83%. Three patients scored 10% of participants in the trial and several patients showed partial improvement. Two patients, or 7% of the entire trial population, did not improve after taking Nux Vomica. Hence Nux vomica can  therefore be used to treat IBS.³⁵

OTHER HOEMOEOPTHIC THERAPEUTICS OF IRRITABLE BOWEL SYNDROME:
SULPHUR :This remedy is often indicated when a sudden urge toward diarrhea wakes the person early in the morning (typically five a.m.) and makes them hurry to the bathroom. Diarrhea can come on several times a day. The person may, at other times, be constipated and have gas with an offensive and pervasive smell. Oozing around the rectum, as well as itching, burning, and red irritation may also be experienced. A person who needs this remedy may tend to have poor posture and back pain, and feel worse from standing up too long.^9,30

LYCOPODIUM: This remedy is often indicated for people with chronic digestive discomforts and bowel problems. Bloating and a feeling of fullness come on early in a meal or shortly after, and a large amount of gas is usually produced. Heartburn and stomach pain are common, and the person may feel better from rubbing the abdomen. Things are typically worse between four and eight p.m. Despite so many digestive troubles, the person can have a ravenous appetite, and may even get up in the middle of the night to eat. Problems with self-confidence, a worried facial expression, a craving for sweets, and a preference for warm drinks are other indications for Lycopodium.^9,30

NATRUM CARBONICUM :This remedy is often indicated for mild people who have trouble digesting and assimilating many foods and have to stay on restricted diets. Indigestion, heartburn, and even ulcers may occur if offending foods are eaten. The person often is intolerant of milk, and drinking it or eating dairy products can lead to gas and sputtery diarrhea with an empty feeling in the stomach. The person may have cravings for potatoes and for sweets (and sometimes also milk, but has learned to avoid it). A person who needs this remedy usually makes an effort to be cheerful and considerate, but, when feeling weak and sensitive wants to be alone to rest.^9,30

BRYONIA ALBA: All complaints < on motion. Dryness of mucous membranes generally (lips, mouth, stomach, wants drink in large quantities, at long intervals; intestines, dry hard stools as if burnt). Effusions in serous membranes (meninges, pleura, peritoneum, etc.). Constipation (no desire) or diarrhoea, < mornings on beginning to move. Stitching pains, especially in serous membranes and joints. Sitting up causes nausea and faintness. Modalities: < from motions, warm weather after cold. > from quiet, lying on painful side. Suitable to dry, spare, nervous, slender persons, of irritable disposition; rheumatic tendency. Complaints in hot weather, or exposure to dry, cold air, in wet weather. ^9,30

COLOCYNTH: Disinclined to talk, to see friends, impatient, easily offended, danger within indignation; colic or other complaints as a consequence. Colic, terrible; they seek relief by bending double or pressing something hard against the abdomen. Dysentery-like diarrhoea; renewed after least food or drink, often with the characteristic colic pains. Tendency to painful cramps, with all pains. Modalities: < evening, anger; after eating; > from coffee, bending double and hard pressure. ^9,30

ARGENTUM NITRICUM: Impulsive: time goes too slow; must walk fast. Apprehension, on getting ready for church, opera, etc., has an attack of diarrhea. Vertigo, with buzzing in the ears and weakness and trembling. Canthi, as red as blood; swollen, standing out like a lump of red flesh. Irresistible desire for sugar; gastric ailments, with violent loud belching. Stool; green, mucous, like chopped spinach in flakes; turns green on remaining on diaper; expelled with much spluttering. Profuse, sometimes purulent, discharges from mucous membranes, generally. Dried-up, withered patients, made so by disease. Craves fresh^9,30

GRATIOLA: Acts especially on gastro-intestinal tract. Obstinate ulcers. Useful in mental troubles from overweening pride. Especially useful in females. Nux symptoms in females often met by Gratiola. Diarrhoea; green, frothy water, followed by anal burning, forcibly evacuated without pain. Constipation, with gouty acidity. Haemorrhoids, with hypochondriasis. Rectum constricted. Vertigo during and after meals; hunger and feeling of emptiness after meals. Dyspepsia, with much distention of the stomach. Cramps and colic after supper and during night, with swelling of abdomen and constipation. Dysphagia for liquids. ^9,30

DIOSCOREA: As a remedy for many kinds of pain, especially colic, and in severe, painful affections of abdominal and pelvic viscera Persons of feeble digestive powers; tea- drinkers, with much flatulence Pains suddenly shift to different parts; appear in remote localities, as fingers and toes. Rumbling, with emission of much flatus. Griping, cutting in hypogastric region, with intermittent cutting in stomach and small intestines. Colic; better walking about; pains radiate from abdomen, to back, chest, arms; worse, bending forwards and while lying. Sharp pains from liver, shooting upward to right nipple. Pain from gall-bladder to chest, back, and arms. Renal colic, with pain in extremities. Hurried desire for stool. ^9,30

CHINA : Debility from exhausting discharges, from loss of vital fluids, together with a nervous erethism, calls for this remedy. Periodicity is most marked. Sensitive to draughts. Seldom indicated in the earlier stages of acute disease. Tender, cold. Vomiting of undigested food. Slow digestion. Weight after eating. Ill effects of tea. Hungry without appetite. Flat taste. Darting pain crosswise in hypogastric region. Milk disagrees. Hungry longing for food, which lies undigested. Flatulence; belching of bitter fluid or regurgitation of food gives no relief; worse eating fruit. Hiccough. Bloatedness better by movement. Abdomen.- Much flatulent colic; better bending double. Tympanitic abdomen. Pain in right hypochondrium. Gall-stone colic. Liver and spleen swollen and enlarged. Jaundice. Internal coldness of stomach and abdomen. Gastro-duodenal catarrh. Stool is Undigested, frothy, yellow; painless; worse at night, after meals, during hot weather, from fruit, milk, beer. Very weakening, with much flatulence. Difficult even when soft^9,30

PODOPHYLLUM : Is especially adapted to persons of bilious temperament. It affects chiefly the duodenum, small intestines, liver, and rectum The Podophyllum disease is a gastro-enteritis with colicky pain and bilious vomiting. Stool is watery with jelly-like mucus, painless, profuse. Gushing and offensive. Many troubles during pregnancy; pendulous abdomen after confinement; prolapsus uteri; painless cholera morbus. Torpidity of the liver; portal engorgement with a tendency to haemorrhoids, hypogastric pain^9,30

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SUSHMITHA
PG Scholar,
Government Homoeopathic Medical College and Hospital, Bengaluru
drsushmithanair@gmailcom