What’s wrong with my poop?
Many people experience a change in stool from time-to-time – what one has eaten, medications and supplements, a shift in the normal morning schedule, and emotional events all may contribute to irregular “pooping” patterns. However, if symptoms such as constipation, diarrhea, bloating, abdominal pain, or gas occur frequently, there may be underlying undiagnosed issues contributing to these changes. When shifts or disruptions in digestive health happen far too frequently, we must question if there is an underlying flora imbalance, food sensitivities or intolerances, or many other factors that lead to the symptoms of what is often diagnosed as irritable bowel syndrome (IBS).
What is IBS?
IBS is one of the most common chronic gastrointestinal conditions, affecting approximately 13 to 17% of adults globally and is one of the most common reasons people seek care for chronic digestive symptoms. Symptoms include chronic gastrointestinal (GI) patterns of diarrhea and/or constipation, feelings of incomplete bowel evacuation, bloating, flatulence, abdominal pain and cramps, and mucus in the stool. Some individuals additionally may experience anxiety, fatigue, and diminished quality of life if symptoms are severe. If IBS symptoms are accompanied by unexplained sudden weight loss, difficulty swallowing or blood in the stools, further medical investigations must be sought.
IBS is diagnosed as a syndrome – a set of characteristic signs and symptoms, as opposed to a disease, which has an identifiable underlying pathophysiological basis. Diagnosis of IBS may involve ruling out other possible problems such as celiac disease, inflammatory bowel disease (Crohn’s, ulcerative colitis), or other conditions that present with similar symptoms. Unfortunately, conditions such as celiac disease are often underdiagnosed, as they are not assessed for if someone has general gastrointestinal symptoms and lacks a family history significant for celiac or autoimmunity.
Common Underlying Causes of IBS
Food sensitivities, lactose intolerance, fructose malabsorption, and small intestinal bacterial overgrowth (SIBO) are possible underlying issues which may be misdiagnosed as IBS and should be assessed for, as one may have resolution of their symptoms if these conditions are appropriately treated. Because IBS is a diagnosis based on symptoms, identifying and addressing underlying contributors can often lead to meaningful improvement in digestive health and quality of life.
An imbalance in flora or an infection in the large intestine (as opposed to SIBO, which reflects the small intestine) also may contribute to gastrointestinal and systemic symptoms. The gut microbiome plays an important role not only in digestion, but also immune function, metabolism, inflammation, and communication with the brain. Large intestinal health, microbial balance, and digestive function are best assessed with a comprehensive digestive stool analysis, often including assessments for parasites as well. Correction of large and small intestinal flora imbalances can improve systemic symptoms such as low mood, chronic pain, and skin conditions in addition to digestive symptoms.
With IBS symptoms, there may be systemic inflammation as well. Foods which trigger an immune response, infectious or dysbiotic microbes, stress, and even intense exercise may lead to altered health of the gut lining and increased intestinal permeability (sometimes referred to as “leaky gut”). Along with this, there often are problems at the brush border of the intestines where many of the enzymes for digestion exist and are activated. For example, lactase, which digests lactose sugars in milk, is a brush border enzyme and may be present at lower levels after an enteric infection. Collectively this creates an inflammatory state and digestion problems with a variety of foods such as individuals with IBS often experience.
Dietary Approaches for IBS: Food Triggers, Elimination Diets, and FODMAPs
Common foods which may cause problems (in addition to food sensitivities) include disaccharides (a common type of sugar, found in table sugar and other forms), fructose (the kind of sugar found in fruit, agave syrup, and high fructose corn syrup), lactose (the kind of sugar found in dairy products), cellulose (found in vegetables), and gluten (the protein found in wheat and several other grains). Foods that are high in histamine or histamine-releasing foods can also lead to problems in some individuals. Many of these foods fall within categories commonly referred to as FODMAPs, which are fermentable carbohydrates that can trigger symptoms in susceptible individuals. Food sensitivity testing may help isolate if proteins in certain foods are contributing to problems, however it will not give indication of if many of these (disaccharides, fructose, lactose, cellulose, or histamine) are problems, hence the use of an elimination diet.
Elimination diets focus on the removal of potential problematic foods for a period of time (which can range from a couple weeks to months), with the gradual introduction of foods one at a time after this period to determine which foods (or substances in them) were contributing to symptoms. An elimination diet can be one of the most effective ways to identify food triggers contributing to IBS symptoms, but it’s not for everyone due to the restriction of dietary intake for a period of time. For that reason, an elimination diet may be guided by food sensitivity and/or allergy testing to evaluate if there is an immune response to particular foods, especially in children where highly restrictive diets are often difficult and may lead to deficiencies of essential nutrients.
With SIBO there often are digestive problems with a wide range of foods. Symptoms tend to improve with a dietary focus on proteins and fats and utilizing guidelines of a Paleolithic (aka “Paleo”) diet, a low Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols (FODMAPs) diet or the Specific Carbohydrate Diet (SCD).
Natural Supplements and Digestive Support for IBS
In addition to a diet with adequate water and fiber, there are natural substances that can help the body to eliminate with improved regularity. Supporting the body with digestive support such as hydrochloric acid (which your stomach naturally makes), digestive enzymes, pancreatic glandular substances, or supplemental bile acids may improve IBS symptoms for many people. Stress negatively impacts the body’s secretion of many compounds like these which are necessary for digestion. Inadequate biliary secretions are not uncommon and can contribute to constipation and dysbiosis, and because of this, supplemental bile acids may support digestion and bowel regularity in individuals with inadequate bile flow. Magnesium and vitamin C are two natural substances which can have an osmotic laxative effect after a certain dosage threshold (which varies individually) is reached.
Intestinal secretory IgA (sIgA) is a critical and synergistic part of the gut’s immune system; essential for establishing and maintaining a healthy balance of gut bacteria and protecting the body from things like food proteins as well. Levels of sIgA can be affected by acute and chronic stress states as well as infections and routine consumption of food sensitivities. Saccharomyces boulardii is one probiotic that has been extensively studied and has been shown to improve mucosal function and sIgA levels.
Stress, IBS, and the Gut-Brain Axis
Finally, altered bowel habits commonly coexist in individuals with anxiety and depression. The gut and brain are connected through a complex communication network known as the gut-brain axis, which involves the nervous system, immune system, hormones, and gut microbiome. In a recent study, acute anxiety was shown to coexist in 84.1% of individuals with gastrointestinal disorders. These relationships do not directly imply causation but do shed light on a mental/emotional relationship with bowel issues that also should be addressed.
Autoimmune diseases such as celiac and ulcerative colitis also have increased symptoms when under stress or with anxiety. Muscle contraction abnormalities and visceral hypersensitivity of the digestive tract also exist in some patients with IBS. These disturbances are often provoked by stress, shedding light on the importance of addressing the body's stress response as well. Abdominal massage is one tool that may not only improve digestive symptoms like constipation or diarrhea directly but also can promote relaxation and reduce the body’s hormonal response to stress.
Looking for a Holistic Approach to IBS in Hood River and Beyond?
IBS can be frustrating and often requires looking beyond symptom management alone. At Gorge Naturopathic and Massage, digestive health evaluations may include assessment of food sensitivities, SIBO, gut microbiome health, stress, and other contributing factors. Therapeutic massage, including visceral abdominal tissue work, is often included as a holistic approach to wellness. Identifying underlying causes can help create a personalized plan to support long-term digestive wellness.
Written by Dr. Carrie Decker, ND