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Irritable Bowel Syndrome
In Pregnancy and Beyond
Janice Joneja, Ph.D., RD
The Alimentary Journey
1
Definition of Irritable Bowel Syndrome
• Irritable bowel syndrome (IBS) tends to be an
umbrella term for a variety of bowel
disturbances of unknown origin
• Sometimes called:
– “irritable colon”
– “spastic colon”
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Symptoms of IBS
• Symptoms include:
– Change in bowel habit
• often alternating constipation and diarrhea
– Abdominal bloating and distension
– Sometimes abdominal pain, frequently relieved
by defecation
– Feeling of incomplete defecation
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IBS Characteristics
• There is usually no sign of structural damage to
the wall of the intestine (frequently indicated by
blood in the stool)
• Weight loss or nighttime fever are not experienced
• A diagnosis of irritable bowel syndrome is made
when all organic disease has been ruled out by
appropriate medical tests
• The Manning Criteria or the Rome (I, II or III)
classification system are often used for diagnosis
_____________
Drossman 2006
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Rome II Criteria for Diagnosis of IBS
• Abdominal pain or discomfort for 12 weeks
or longer over the past 12 months
• Plus two of the following:
– Relief of discomfort with defecation
– Association of discomfort with altered stool
frequency (diarrhea, or constipation, or
alternating)
– Associated discomfort with stool form (hard,
soft, loose, liquid etc)
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Diagnosis of IBS in Pregnancy
• Many women already have IBS before entering
pregnancy
• When symptoms of IBS arise during pregnancy
same criteria for diagnosis applies
– However, accuracy of Rome criteria not tested during
pregnancy
– Rule out alarm symptoms of organic disease:
•
•
•
•
Blood in the stool
Weight loss
Fever (especially night-time)
Abdominal masses
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Tests for IBS in Pregnancy
• Used to rule out other causes of symptoms:
– Blood count
– Inflammatory mediators (sedimentation rate)
– Stool analysis for infections in diarrheaassociated symptoms
• Ova and parasites
• Bacterial pathogens
_______________
Sanders et al 2001
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Tests for IBS in Pregnancy:
Differential Diagnosis
– Rule out celiac disease:
• Anti-endomysial antibodies
• Anti-tissue transglutaminase (tTGA) antibody
– Lactase deficiency:
• Hydrogen breath test
• Blood glucose or galactose
– Thyroid function
8
Classification of IBS
• IBS can be classified according to the
predominant bowel symptoms:
– IBS with constipation predominant features
(IBS-C)
– IBS with diarrhea predominant features (IBSD)
– IBS with alternating symptoms of diarrhea and
constipation (IBS-A)
________________________
Hammerle and Surawicz 2008
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Etiology of IBS
• While the exact pathophysiology of IBS is
unclear, suggested causes include:
–
–
–
–
–
–
–
Genetics
Post-inflammatory changes
Hormone level fluctuations
Psychosocial factors
Side-effects of medications
Use of oral antibiotics
Food allergy and food intolerances
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Gastrointestinal Pathology:
Inflammation
• Infection (post-infective (PI)-IBS)
• Pathology in the digestive tract, resulting in
inflammation, cell damage and
hyperpermeability
– Inflammatory bowel disease
– Crohn’s disease
– Celiac disease
• Surgical procedures in the digestive tract
resulting in persistent inflammation, change
in microbial flora or other disturbances
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Hormones Associated with GI Tract Function
Hormonal fluctuations
– Menstrual cycle
– Pregnancy
– Thyroid function
• Hormonal changes during pregnancy may modify
gastrointestinal function
• Estrogen and progesterone increase
•
– Affect GI functions eg gastric slow wave rhythm
– May delay colonic transit, especially during the third
trimester
– May affect nociception (perception of pain)
__________
Hasler 2003
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Pain Perception and Hormones
• Women exhibited reduced thresholds for
pain during certain phases of menstrual
cycle: assumed hormonal involvement2
• Hormone changes in pregnancy may alter
the perception of pain and increase the
distress associated with IBS
_______________
2Mayer et al 1999
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Neurological Factors
• Psycho-social factors causing
dysregulation within the brain-gut axis:
–
–
Psychiatric disorders
Stress
• Motor dysfunction
• Intestinal motility disorders
• Sensory dysfunction
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Alteration in the Microbial Flora of the
Digestive Tract
• Change in types of micro-organisms in the large
intestine due to:
– Oral antibiotics
– Other oral medications
– Change in substrate (ie type of food passing into the
bowel)
• Alteration in microbial flora results in:
– Different products resulting from the action of microorganisms on undigested food material:
• Gases
• Organic acids
• Others
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Composition of the Diet
• Suggested dietary causes include:
Food allergy (immune-mediated responses)
– Food intolerance (non-immunologicallymediated reactions)
- Food composition:
–
•
•
•
•
•
Inadequate fiber
Inappropriate fibre
High fat levels
Gas-producing foods
Carbonated beverages
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Mechanisms Responsible for Symptoms
• Key factors in functional gastrointestinal disease
(FGID) resulting in symptoms include:
– Inflammation
• Resulting from release of inflammatory mediators
– Increased sensitivity to pain
• Neuropeptides (tachykinins) generated by the
central nervous system interact with neurokinin
receptors on the spinal cord
• May also result from a response to inflammatory
mediators (e.g. histamine)
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Mechanisms Responsible for Symptoms
(continued)
– Motility dysfunction
• Resulting from changes in autonomic
nervous system signals
• Resulting from products of microbial
fermentation
– Fermentation
• Of undigested food in the large bowel
• As a consequence of abnormal motility
• As a consequence of altered microbial flora
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Altered Motility in the G.I. Tract
• Altered speed of food passing through the G.I.
tract can result in disturbance of the normal
process of digestion and absorption of nutrients:
– Increased speed results in :
• Incomplete breakdown of food components in the
small intestine
• Increase in fluid retention in the colon leading to
diarrhea
– Decreased speed leads to increase in:
• Fermentation of undigested food remaining in the
colon
• Decrease in fluid in the colon and constipation
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Gender-related Differences in GI Tract
Function
• Colonic transit generally slower in women
than men
– May be affected by phase of menstrual cycle1
• GI tract symptoms increase in the late luteal
and menses phases of the cycle
• Gastric emptying tends to be slower in
women
_______________
1Turnbull et al 1989
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GI Tract Motility Changes During
Pregnancy
• Normal hormonal changes that occur during
pregnancy cause changes in GI tract
function1
– One third of pregnant women report an
increase in stool frequency
– 38% report constipation
• Prolonged oro-cecal transit in third trimester
of pregnancy2 contributes to constipation
__________
1Hasler 2003
_____________
2Wald et al 1982
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Fermentation
• All food materials not absorbed through the lining
of the small intestine pass into the large bowel
• Millions of bacteria colonise the organ
• Perform “end-stage digestion”
• Products of microbial activity can be important
nutrients:
– some B vitamins (pantothenic acid; biotin)
– vitamin K
22
Causes of Intestinal Symptoms:
Carbohydrates
• Non-digested carbohydrates pass into the large
intestine causing:
– Osmotic imbalance: causes excess fluid in the
lumen of the large bowel resulting in loose stool
– Increased bacterial fermentation resulting in
production of:
• organic acids (acetic, lactic, butyric, propionic)
– increase osmotic imbalance
• gases such as carbon dioxide and hydrogen
– cause bloating and flatulence
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Symptoms of Excessive Fermentation of
Carbohydrate
• Patients complain of abdominal fullness,
bloating, and cramping pain, sometimes
within 5-30 minutes, sometimes several
hours after ingesting carbohydrate
• Watery diarrhea occurs from 5 minutes to 5
hours after ingestion
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Examples of Fermentation of Undigested Sugars:
Lactose Intolerance
•
•
Milk sugar, lactose, is digested by lactase enzyme
produced in the cells lining the digestive tract
Lactose is a disaccharide (double sugar) which
cannot be absorbed through the lining of the
digestive tract until it is broken down into its two
single sugars (monosaccharides):
–
–
•
Glucose
Galactose
Lack of lactase reserves makes lactose
particularly vulnerable to maldigestion
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Therapeutic Management of IBS
Clinical Approach to IBS
• Optimal treatment of IBS remains to be defined
• Based on treatment of the prevalent symptoms:
does not address the cause (which in most cases is
either unknown or not amenable to treatment)
• When pain predominates:
– Antispasmodic medications
• Diarrhea predominant:
– Loperamide to reduce bowel frequency
• Constipation predominant:
– Soluble fibre
• Antidepressants (e.g. SSRI) to control pain and
relieve associated depressive symptoms
_____________
Drossman 2006
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Drugs in Pregnancy
• Contraindicated: if at all possible drugs
should be avoided:
– Balance risk vs benefit
• Recommended:
– Education (reassurance and attitude to distress)
– Stress reduction
– Dietary modification
___________
Hasler 2003
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Probiotics in Management of IBS
• IBS involves dysfunction in a variety of
complex interactive mechanisms
• Many of these involve microorganisms:
– Interaction between different micro-organisms
within the microflora
– Interaction of microorganisms with the host
– Interactions between microorganisms and the
immune tissues within the gut resulting in
inflammatory processes that lead to:
– Hyperpermeability of the intestinal lining
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Probiotics and IBS
• Probiotic management of IBS is in its
infancy
• Studies demonstrate the possible value of
probiotics in short-term management of
specific symptoms of IBS, namely:
– Diarrhea
– Constipation
– Abdominal bloating
• Specific strains, dose, and viability remain
to be determined
________________________
Quigley and Flourie 2007
______________
Parkes et al 2010
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Examples of Preliminary Studies
• Bifidobacterium infantis shows some
evidence of:
– Reducing flatulence
– Retarding colonic transit
• Dosage, duration, and extent of clinical
benefits in IBS remain to be determined
____________
Kim et al 2005
____________
Reid et al 2008
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Synbiotic and Constipation
• 2008 study: women between the ages of 18 and 55
with and without functional constipation
• Activia yogurt containing 10(8) UFC/g of
Bifidobacterium animalis and fructoligosaccharide
– 2 units/day of Activia or a lacteous dessert without
probiotics (control) for a period of 14 days
• Results:
– Improvement in the quality of the stools
– Reduced perception of straining effort
– Reduced perception of pain associated with defecation
________________
De Paula et al 2008
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Probiotics in Management of IBS:
Lactose intolerance
Lactobacilli, bifidobacteria and Streptococcus
thermophilus, assist in reducing the symptoms of
lactose intolerance
• Produce the enzyme beta-galactosidase (lactase) in
yogurt
• Microbial lactase breaks down lactose
• The fermented milk itself delays gastrointestinal
transit, thus allowing a longer period of time in
which both the human and microbial lactase
enzyme can act on the milk lactose.
________________
Montalto et al 2006
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Diet in the Management of Irritable
Bowel Syndrome
Role of Food in IBS
• Food does not cause IBS
• Food passing through “damaged organ”
continues or exacerbates the condition
• Food interacts with gastrointestinal tissues
in several ways:
– Immunologically
– Physiologically
– Biochemically
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Contributory Factors
in IBS
• It is likely that a variety of factors are
contributing to the symptoms in an individual
sufferer
• A practical approach to the dietary management
of IBS takes into account as many of these
factors as possible
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2007 Study, Canada
• Diet is the primary factor manipulated by
women with IBS to manage their condition
• Few participants received assistance from
primary health care professionals
• All participants indentified food/beverages
that caused exacerbation of their symptoms
• All participants had individual triggers
• “One size does not fit all!”
________________
Jamieson et al 2007
_______________
Fletcher et al 2008
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Dietary Fibre and IBS
• Increased dietary fibre has been a mainstay
of therapy for patients with IBS following
an article in 1984
• The basis for this was thought to be:
– Decrease in colonic pressure
– Acceleration of oro-anal transit
_____________
Cann et al 1984
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Fibre and IBS:
Current Recommendations
• Investigations indicate that increased fibre is of
little value in treatment of IBS: there was little
difference between treatment group and placebo,
and no relief of abdominal pain
• Insoluble fibre (corn, wheat bran) may worsen the
symptoms1
• Abnormal bacterial fermentation of the undigested
fibre in the colon can cause excessive gas
production, bloating and abdominal pain and
worsen the clinical outcome in IBS2
______________________
_____________________________
1Bijkerk
2Haderstorfer
et al 2004
et al 1989
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Fibre and IBS: Current Recommendations
• The American College of Gastroenterology
Functional Gastrointestinal Disorders Task
Force recommends use of fibre in patients
with constipation, but not for the treatment
of IBS
Brandt 2002
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General Guidelines for Dietary Management of
IBS
1. Reduce inflammation in all parts of
the digestive tract
– Avoid inflammatory triggers
2. Reduce the amount of fermentable
substrate passing into the colon
– Increase digestion and absorption in
the small intestine
Joneja 2004
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Dietary Management of IBS (continued)
Triggers and exacerbators of inflammation
include:
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Allergens
Chemicals that enhance release of
inflammatory mediators (e.g. tartrazine;
benzoates)
Raw foods
Alcohol
Caffeine and other methylxanthines
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General Instructions
• It is important to eat a balanced diet complete in
all essential nutrients
• Eat three meals a day, with two or three snacks as
desired
• For each food avoided, substitute one of equal
nutritional value
• Supplemental micronutrients (vitamins and
minerals) should be considered especially during
pregnancy and lactation
• Choose ones without additives (colour, sugar,
preservatives)
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Dietary Guidelines: Milk
AVOID: All milk and milk products
• Eliminate:
– Milk
- Yogurt
– Cheese of all types
- Butter
– Any food containing milk solids or derivatives
• Consume protein to level usually consumed as
milk products
• Add calcium and Vitamin D supplements to
age-appropriate level during pregnancy and
lactation:
– Vitamin D: 5 mgm/day
– Calcium: Age 14-18: 1,300 mg/day
Age 19-50: 1,000 mg/day
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Dietary Guidelines:
Grains
• AVOID: Specific cereal grains and flours: wheat,
rye, oats, barley, and corn
• Use alternative grains to provide equivalent
nutrients:
–
–
–
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Millet
Tapioca
Arrowroot
Sago
– Quinoa
– Amaranth
– Rice
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Dietary Guidelines:
Fruit and Vegetables
COOK All:
–
–
•
Vegetables (including salad vegetables)
Fruits
Fruit and vegetable juices
Raw vegetables, raw salads, raw fruit, raw juices, are not
allowed
Corn is avoided
Substitute with:
–
–
Tinned fruit
Pasteurized juices
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Dietary Guidelines:
Spices and Herbs
AVOID: Spices (root, seed, bark of plant); examples:
– Cinnamon
– Coriander seed
– Curry spices
– Mustard seed
– Chilli seasoning spices
– Pepper
– Others
Substitute with:
• Herbs (leaves and flowers); examples:
–
–
–
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Thyme
Sage
Rosemary
Oregano
– Mint
– Parsley
– Basil
– Coriander leaves
– Others
• Cooked garlic and ginger are allowed, if tolerated
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Dietary Guidelines:
Disaccharides
Avoid:
•
Sucrose (Table sugar)
–
–
–
–
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Granulated
Castor
Demarara
Brown
Syrup of any type
Substitute with:
Honey
– Fructose (“fruit sugar”; laevulose)
Unless there is evidence of fructose
malabsorption
– Glucose (dextrose) is allowed but is not very
sweet
–
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Dietary Guidelines:
Legumes
AVOID: Legumes with indigestible, hard, outer skins; examples:
– Dried peas and beans
– Green peas, sugar peas, lima beans, broad beans
Substitute with:
Runner beans, French beans, yellow wax beans, green
beans
– Dried legumes without outer skins (lentils, split peas)
– Legumes ground into flours (chick pea flour, soy flour,
black or red bean flour)
–
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Dietary Guidelines:
Nuts and Seeds
AVOID: Whole nuts and seeds
• Eat as “butters” (paste) only; examples
–
–
–
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–
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Peanut butter (without any added sweeteners)
Almond butter
Cashew butter
Sesame butter and tahini
Sunflower seed butter
Pumpkin seed butter
50
Dietary Guidelines:
Meat and Fish
AVOID: “Deli meats” such as:
– Fermented sausages (salami, bologna, pepperoni,
hot dog wieners)
– Smoked meat or fish
Cook all meats and fish from fresh or frozen sources
– No breaded, battered, sweet cured meats
– No smoked fish or meat
– Do not add cream sauces
Avoid excess fat in meats, especially in diarrhea
51
Dietary Guidelines:
Fermented Foods and Beverages
AVOID: Alcoholic beverages of all types
AVOID: Vinegar and foods containing vinegar:
–
–
–
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Pickles
Relish
Prepared mustard
Ketchup
AVOID: Fermented foods such as:
–
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Sauerkraut
Soy sauce
52
Dietary Guidelines:
“Irritating” Foods and Beverages
AVOID: Caffeine and benzoates
Avoid coffees and regular tea
– Herbal tea (without spices) are allowed. Some
decaffeinated coffees contain chemicals to which
sensitive individuals react
– Note: If several cups of coffee or black tea are
consumed per day, reduce intake gradually;
sudden total withdrawal can produce unpleasant
side effects
53
Dietary Guidelines:
Vitamin and Mineral Supplements
To ensure adequate intake of micronutrients, a
multivitamin/mineral supplement is recommended
Supplement should be free from:
• Wheat
• Yeast
• Lactose
• Corn
• Additives such as artificial colours, flavours, and
preservatives.
54
Dietary Guidelines (continued)
–
–
–
People differ in their degree of reactivity to some
of the restricted foods
Many individuals do not react adversely to vinegar
and fermented foods
Some people can drink coffee and eat chocolate
but react adversely to tea (probably indicating
benzoate sensitivity rather than a reaction to
caffeine)
55
General Guidelines
• The diet is initially followed for four weeks
• If no improvement, keep a careful record of foods
consumed and symptoms experienced for a further
seven days
• Based on the food/symptom record, increase
restrictions for a further two weeks
• If still no improvement, proceed to reintroduction
of foods
56
Dietary Management of IBS:
The Next Stage
If significant improvement is achieved open food
challenge may be initiated
• Use sequential incremental dose challenge
(SIDC) to determine sensitivity and limit of
tolerance to each eliminated food in its purest
form
• Symptom-free status may be maintained by
avoiding the culprit foods and obtaining
complete balanced nutrition from alternative
sources
57
Invitation to Further Information
www.allergynutrition.com
Joneja, J.M.Vickerstaff. Digestion, Diet and Disease:
Irritable Bowel Syndrome and Gastrointestinal Function.
Rutgers University Press, Piscataway, New Jersey 2004
58