The first step is to take a good history. In my practice all new patients fill out an extensive questionnaire that covers many aspects of health, but an important part of it is a section on gastrointestinal symptoms, travel and exposure history, family history 3 generations back, toxic exposures, and a dietary log. Based on this, I can usually get a good idea of what might be the problem's cause and how I should then use diagnostic testing.
In every case, I first clean up the diet. Many cases of IBS are really low-grade (or not so low-grade) food allergies/sensitivities. I always first remove the typical offending foods. The major changes I make are completely eliminating grain and grain-based products-especially gluten, high-glycemic carbohydrates such as sugar and fruit juice, and dairy products. I encourage the eating of lean proteins, healthy fats, and many varieties of non-starchy vegetables. To this I may add a smoothie containing berries, ground flax seed, almond milk and hydrolyzed whey protein. Hydrolyzed whey is fairly non-allergenic, even if a person is sensitive to dairy. I place all patients on this antiinflammatory and low allergenicity diet for 8 weeks and add vitamins D3, Vitamin A, a pharmaceutical-grade multivitamin, magnesium glycinate (for constipation), and balance their hormones. Progesterone deficiency and even mild hypothyroidism are particularly associated with constipation. I may add a probiotic, but usually I wait to see how they do at the followup visit. No alcohol. As in many situations, I want to remove as many possible causes of a problem at first, and then reevaluate the situation. My corresponding action is to restore missing components and nutrients needed for a healthy diet and healthy bowel function.
At the 8 week visit, most of my patients tell me that their bowel symptoms are greatly improved if not eliminated. Usually the GERD is gone, they are off of their "purple pill",they are moving their bowels normally, without bloating or cramps or constipation. For those people, clearly the cause was dietary (eating something bad or not eating something needed), hormonal, or a nutritional deficiency. If they are happy, I leave things alone and recommend they continue with this new way of eating. The full program is part of our new patient dietary recommendations and much of it can be found in the Paleo Diet, a book by Loren Cordain.
Some patients require more effort or wish to get a clear diagnosis. They may not have complete improvement or they may not have any improvement(rare). I first establish what they have really been eating; I am always amazed at how what people really eat is so different than what they tell you they ate. I may give them yet another diet survey(a 7 day version). This may give me some clues. I also move on to diagnostic testing. Some patients have a deficiency of stomach acid and cannot digest their food, resulting in food allergies when raw undigested proteins are dumped into the gut from the stomach. I reviewed this situation in my previous posts. I diagnose this condition with the Heidelberg testing system and treatment is fairly straightforward. I will usually test for food allergy/sensitivities using blood tests that measure levels of IgG, IgE and IgA antibodies to a variety of foods, spices, inhalants, and also do some specialized tests for celiac disease or gluten sensitivity. These tests will often reveal the culprit food, low grade celiac disease/gluten sensitivity, or will indicate a widespread sensitivity to virtually all foods. The latter situation is suggestive of increased gut permeability, a situation where an inflammatory or infectious process has so damaged the gut surface that anything they eat leaks through and triggers an immune reaction.
The next essential test I use is the CDSA or "complete diagnostic stool analysis." This test first analyzes a stool specimen for levels and types of bacteria both good ones and disease-causing ones using PCR and technology that actually isolates and identifies the DNA of the organism. Alternatively, we can use a test that uses "proteomics" to identify proteins made by various bacteria and thus identify the bacteria present. This is a nearly 100% accurate way of catching the bad bugs in the act. Regular hospital lab stool tests miss about 90% of the disease-causing germs since they don't use this technology. Colonoscopy or endoscopy misses subtle cases of infection and inflammation. I identify and determine levels of beneficial bacteria as well as disease-causing bacteria and can then treat with appropriate antibiotics or probiotics. The same test can identify yeast overgrowth, parasites, worms, inflammatory bowel disease, gluten sensitivity, food allergies, a lack of digestive enzymes, and malabsorption of fats or protein. These conditions can all be treated successfully.
Other testing that is sometimes used measures the permeability of the gut and tests for lactose intolerance. I have not found these tests to be as necessary as the others mentioned above, but they are sometimes helpful.
We can use a methane/hydrogen breath test to diagnose small intestine bacterial overgrowth (SIBO).
I have yet to meet the patient with IBS that did not have a potentially causative factor identified on one of these tests. The most common causes of IBS symptoms that I have found are these:
Lack of adequate stomach acid leading to food allergies, maldigestion, bloating, diarrhea,gas
Dairy Allergy to milk proteins
Pathological Bacteria or Bacterial Overgrowth
Inflammatory Bowel Disease
Lack of adequate pancreatic enzymes
Parasites and Worms
After making a diagnosis, the harder task is to actually treat the patient successfully. This often requires a permanent change in diet-to a more healthful one, tailored to avoid food allergies they may not have been aware of. It involves treating chronic intestinal infections and it involves optimizing digestive function through the use of various nutritional supplements. It may involve balancing of hormones. The good news is that IBS symptoms, when the cause is identified and treated, will generally get better.
If you have IBS symptoms, there is help available. You just have to find a doctor who is skilled at applying the principles of functional medicine to your situation and who knows how to use the advanced testing options available and can then treat you with both pharmaceutical or natural products. I encourage you to explore my website, listed below, to learn more about the testing options available to you and to read some encouraging testimonials from patients.
Dr. Joseph Kaye