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Journal of Medicinal Plants Research Vol. 5(32), pp. 6934-6938, 30 December, 2011 Available online at http://www.academicjournals.org/JMPRISSN 1996-0875 2011 Academic Journals DOI: 10.5897/JMPR11.1224

Review

Herbal treatment of irritable bowel syndrome:A review

M. Akram 1*, Muhammad Irfanullah Siddiqui 2, Naveed Akhter 3, Muhammad Khurram Waqas 4,Zafar Iqbal 3, Muhammad Akram 5, Aubid Allah Khan 3, Asadullah Madni 3, H.M. Asif 3

1Shifa ul Mulk Memorial Hospital, Hamdard University, Karachi, Pakistan.2Department of Community Medicine, Faculty of Medicine, Umm Al-Qura University, Saudi Arabia.

3Department of Pharmacy, The Islamia University of Bahawalpur, Pakistan.4Department of Pharmacy, The University of Faisalabad, Pakistan.

5

Department of Pharmacy, University of Sargodha, Pakistan. Accepted 14 November, 2011

Irritable bowel syndrome (IBS) is a disabling disorder that affects most of the population in all over theworld. Symptoms of irritable bowel syndrome include recurrent abdominal pain, altered bowel habits,and bloating. Irritable bowel syndrome is part of a broader group of disorders known as functionalgastrointestinal (GI) disorders. Herbal medicines have been used in Unani system of medicine for along time. Most of the patients are beginning to receive herbal medicines. The aim of this study is toreview the usage of herbal medicine in irritable bowel syndrome.

Key words: Irritable bowel syndrome, herbal medicine, treatment of irritable bowel syndrome.

INTRODUCTION

Irritable bowel syndrome (IBS) is defined as chronic orrecurrent abdominal pain, altered bowel habits, andbloating, with the absence of structural or biochemicalabnormalities to explain these symptoms. Irritable bowelsyndrome is part of a broader group of disorders knownas functional gastrointestinal (GI) disorders. The colon(large intestine) is responsible for packaging andeliminating stool. As food moves through the colon itabsorbs water while forming stool. Muscle contractions(squeezing motions) in the colon push the stool towardthe rectum (the lower five inches of the large intestine)

(Francis et al., 1997). These contractions are controlledby nerves, hormones and by electrical activity in thecolon musculature and result in defecation or bowelmovement (Mertz, 2003). Normal bowel function varieswidely from person to person, normal bowel functionranges from three stools a day to three each week. Anormal movement is one that is formed but not hard,

*Corresponding author. E-mail: makram_0451@hotmail.com.Tel: 92-021-6440083. Fax: 92-021-6440079.

contains no blood, and is passed without cramps or pain(Thompson et al., 1999). However, when colonic nervesbecome irritated the muscle contractions may becometoo hard (causing abdominal pain), may stop (causingconstipation and bloating), or may accelerate (causingdiarrhea and an urgency to have a bowel movement).Irritated colonic nerves also make the colon verysensitive to distention which may also cause pain.Emotional factors such as stress, anxiety or depressionare not necessary to cause disease but still may play arole in IBS by worsening symptoms and interfering with

the ability to cope with symptoms (Talley et al., 1996).Though IBS can cause a great deal of discomfort, it canalmost always be managed and does not lead to anyother serious diseases. With attention to proper diet,stress management, and sometimes prescriptionmedications, most people with IBS can keep theirsymptoms under control (Mayer, 2008).

PATHOPHYSIOLOGY

The pathophysiology of irritable bowel syndrome is not

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well understood, but likely factors include: alteredgastrointestinal motility, increased gut sensitivity, andincreased intestinal contractions. Proposed mechanismsinclude: stress as an aggravating factor because ofcorticosporin releasing factor, gastric emptying delay, andaccelerated colonic transit; visceral hypersensitivity, with

a decreased threshold after exposure; abnormal brainactivation; altered colonic motility and disturbed motorfunction; response to eating as a stimulus to colonicactivity; abnormal gas propulsion and expulsion; dietaryintolerance, most commonly to wheat and dairy products;and inflammation, with production of prostaglandins,bradykinins, nerve growth factors, adenosine, and 5-hydroxytryptamine (Maxwell et al., 1997).

Symptoms of irritable bowel syndrome

Abdominal pain, bloating, and discomfort are the majorsymptoms of irritable bowel syndrome. However,symptoms can vary from person to person (Okhuysen etal., 2004; Marshall et al., 2006). Some people haveconstipation, which means hard, difficult-to-pass, orinfrequent bowel movements (Mitchell et al., 1987). Oftenthese people report straining and cramping when trying tohave a bowel movement but cannot eliminate any stool,or they are able to eliminate only a small amount. If theyare able to have a bowel movement, there may be mucusin it, which is a fluid that moistens and protect passagesin the digestive system. Some people with IBSexperience diarrhea, which is frequent, loose, watery,stools. People with diarrhea frequently feel an urgent anduncontrollable need to have a bowel movement. Otherpeople with IBS alternate between constipation anddiarrhea. Sometimes people find that their symptomssubside for a few months and then return, while othersreport a constant worsening of symptoms over time(AGA, 2002).

Diagnosis

In the past it was thought that the diagnosis of irritablebowel syndrome (IBS) relied on a diagnosis of exclusion(Olden, 2003). That is, if one cannot find a cause thenIBS is the diagnosis. Currently the diagnosis of irritable

bowel syndrome relies on meeting Rome II inclusioncriteria (updated by Rome III criteria) and excluding otherillnesses based on history, physical examination, andlaboratory testing. Although, the Rome II and Rome IIIcriteria were not designed to be a management guideline,it is currently a gold standard for the diagnosis of IBS.Unfortunately an IBS diagnosis in an adult patient is stillonly useful as a tool to rule out more serious problemsunless further investigation is employed to discern anaddressable condition (Spiller, 2007; Manning et al.,1978)

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Treatment of irritable bowel syndrome

Irritable bowel syndrome is an intestinal disorder whichmay occur at any age. The common symptoms arebloating and abdominal pain, constipation or diarrhea,changes in bowel habits, fatigue, headache, decreased

appetite and increased thirst (Ringel et al., 2001).There are a number of causes for irritable bowelsyndrome or IBS. The major causes are irregular foodhabits, unhealthy diet and lack of physical exercise(Camilleri et al., 1992). There are different naturalremedies for irritable bowel syndrome. These naturalremedies for irritable bowel syndrome can be usedeffectively to cure the symptoms without many sideeffects (Vincent, 1990; Smart et al., 1986). The followingare some natural remedies for irritable bowel syndrome:

1. Ginger: It reduces inflammation. But it should beavoided by pregnant women.2. Peppermint: Peppermint oil is a good natural remedyfor irritable bowel syndrome.3. Flax seed: This is an effective natural remedy forirritable bowel syndrome. It cleans the stomach.4. Pomegranate: Another natural remedy for irritablebowel syndrome is to take pomegranate seeds with blacksalt.

Chamomile

Chamomile tea is also a good natural remedy.Tr aditionally considered a cure all, chamomile tea hasbeen recommended for a host of afflictions involving thecentral nervous system, respiratory system, the digestivesystem, the urogenital system, the musculoskeletalsystem, and topical preparations for various skinconditions (Hadley et al., 1999). It is currently used fornausea, irritable bowel syndrome, peptic ulcer and colic,as well as disorders of the nervous system anddysmenorrhea.

Cinnamon

It can be used to prevent diarrhea and other symptoms ofirritable bowel syndrome.

Generally, people who live a sedentary lifestyle sufferfrom irritable bowel syndrome. So another natural remedyis to perform regular exercise.

Peppermint

Peppermint is obtained from dried leaves and floweringbranch tips of Mentha x pipertia. The oil contains morethan 100 components, including menthol (29 to 48%),methyl acetate (3 to 10%), menthone (20 to 31%),

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6936 J. Med. Plants Res.

caffeic acid, azulene, and flavonoids. It exertsantibacterial and antiviral actions, as well as spasmolyticeffects on smooth muscles. When taken as enteric-coated capsules, peppermint oil may have antispasmodiceffects on smooth muscle of the intestines, itsantispasmodic activity results from the calcium antagonist

effect of menthol. Flavonoids may cause its bile-stimulating effect. Azulene may have anti- inflammatoryand antiulcer action. Peppermint is available as anessential oil, ointment liniment extract, tincture, leavesdried herb, and capsules (Kligler et al., 2007; Cappello etal., 2007).

Reported uses

Peppermint is used to treat nausea, irritable bowelsyndrome ( IBS), colitis, colic, ileitis, Crohns disease andother spasmodic conditions of the bowel. Its also used inliver and gallbladder complaints, cramps of the upper GItract and bile ducts, menstrual cramps, colds and flu,inflammation of the oral and pharyngeal mucosa, loss ofappetite, dyspepsia, flatulence, and gastritis (Mearin etal., 2005). Peppermint is used to treat the nausea andvomiting related to pregnancy a nd motion sickness. Itsused externally formyalgia, itching, and skin irritation, andthe oil is applied to the forehead to relive tension andmigraine headaches (Nash et al., 1986)

PHARMACOLOGY

The active ingredients are volatile oils such as menthol,menthone and methyl acetate. Its current use is mainlyfor colic and irritable bowel syndrome. Enteric, coatedcapsules of a standardized oil have been shown to beeffective against irritable bowel syndrome in placebocontrolled trials (Hdley et al., 1998; Thomson et al.,2002), relieving or improving all symptoms of the disorder(Hdley et al., 1998). The topical use of peppermint oil forpostherpetic neuralgia was found to be beneficial in onereport (Davies, 2002).

Hazards

Adverse effects associated with peppermint include:headache, flushing spasm of tongue, eye irritation,gastroesophageal reflux, respiratory arrest, contactdermatitis, irritation, and allergic reactions. Calciumchannel blockers, such as amlodipine, bepridil, diltiazem,felodipine, isradipine nicardipine, nimodipine,nitrendipine, and verapamil, may have decreased effectsif used with peppermint and if patients are monitoredclosely. Patients with gallstones, obstructed bile ducts,gallbladder inflammation and severe liver damage shouldnot use peppermint. The oil should not be applied to theface or nasal of infants or children because of the risk of

tongue spasms or respiratory arrest (Huang, 1990; Liu etal., 1997).

Peppermint oil and irritable bowel syndrome

An oil extract of the peppermint plant ( Mentha piperitaLinnaeus) has been used to treat stomach upset forthousands of years. It appears to relax intestinal smoothmuscle cells by interfering with calcium channels. Short-term trials suggest that daily use of 3 to 6 enteric-coatedcapsules containing 0.2 to 0.4 ml of peppermint oil eachimproves IBS symptoms. These observations aresupported by 2 meta-analyses. The first was based on 5trials that suggested efficacy, but heterogeneousdiagnostic criteria and symptom scores weakened thefindings. Another review of 4 small trials found overallsymptom improvement with peppermint oil (odds ratio2.7, 95% CI 1.6 to 4.8).

These results are strengthened by a recent trial of 110patients who were screened for celiac disease, lactoseintolerance. After patients took 4 capsules daily for 4weeks, symptoms improved in 75% of those takingpeppermint oil compared with 38% of those takingplacebo ( P < 0.01). The strict inclusion criteria limit thegeneralizability of the results, but peppermint oil could beconsidered for all patients with IBS symptoms.Peppermint oil appears to alleviate IBS symptoms,including abdominal pain. Patients should be remindednot to chew the capsules, which are enteric coated toprevent gastroesophageal reflux from lower esophagealsphincter relaxation. Perianal burning and nausea areoccasionally reported side effects. The safety of

peppermint oil during pregnancy has not beendemonstrated (Rees et al., 1979).

Probiotics

Probiotics are nutritional supplements that contain goodbacteria (Drossman, 1999). That is, bacteria that normallylive in the gastrointestinal tract and seem to be beneficial.Taking probiotics may increase the good bacteria in theGIT which may help to ward off bad bacteria that mayhave some effect on causing irritable bowel syndromesymptoms.

There is some evidence that taking probiotics may helpease symptoms in some people with IBS. At present,there are various bacteria that are used in probioticproducts. Further research is needed to clarify the role ofprobiotics and which one or ones are most helpful (Dewet al., 1984). Prebiotics are the substances, which reachto colon in intact form, that is, without getting depleted bythe gastric pH and digestive acids. These prebiotics alsoselectively promote the growth of colonic probioticbacteria, hence they act as fertilizers for these symbioticbacteria. For example, insulin which is a polyfructoseobtained from raw chicory (roots of Cichorium intybus) or

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Jeruslem artichoke. Chicory is rich in fibrouspolysaccharide inulin, which is soluble dietary fibre andresistant to digestive enzymes, thus reaches to largeintestine or colon essentially intact, where it is fermentedby resident bacteria, Lactobacilli and Bifidobacteria digestinulin and feed themselves on it. The dairy products like

sour milk and A/B culture yoghurt contain theseprebiotics.

Antispasmodic medicines

Antispasmodic medicines are usually used for relaxationof muscle in the gastrointestinal tract. Mebeverine andpeppermint oil are prescribed as antispasmodicmedicines. Antispasmodic drugs have few or no sideeffects. Antispasmodic drugs are not given to pregnantwomen (Dew et al., 1984).

Modification of diet

A diet history might reveal patterns of symptoms relatedto dairy or gas-producing foods. Exclusion of foods thatincrease flatulence (for example, beans, onions, celery,carrots, raisins, apricots, prunes, brussels sprouts, wheatgerm, pretzels, bagels) should be considered in patientswith symptoms of bloating or gas (Spiller et al., 2007).Underlying visceral hyperalgesia in irritable bowelsyndrome may explain the exaggerated discomfortexperienced with the consumption of gas-producingfoods. An increase in the intake of fiber is generallyrecommended, through diet or the use of commercialbulking supplements. Although, the efficacy of fibersupplements has not been proved, some improvementhas been demonstrated in patients with IBS whoseprimary complaints are abdominal pain and constipation.Many types of fiber supplements are available; some aresynthetic, such as polycarbophil or methylcellulose, andothers are from natural sources, such as bran or psylliumcompounds. All types of fiber can cause increasedbloating and gaseousness because of the colonicmetabolism of nondigestible fiber. Because of its safety, atrial of fiber supplementation is advised for patients withIBS, especially those with constipation-predominantsymptoms. The amount should be titrated to symptoms(Lawson et al., 1988).

CONCLUSION

Herbal medicines are affective in the treatment of irritablebowel syndrome. The efficacy and safety of herbalmedicine have been proved. People all over the world areusing herbal medicine in the treatment of irritable bowelsyndrome. It is concluded that herbal medicine havetherapeutic efficacy.

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