Q&A: Long-Term Integrative Treatment Protocols for IBS

Long thought to originate in the brain, historically, irritable bowel syndrome (IBS) has been disregarded by conventional medicine and treated as a symptom of neurosis. However, according to Robert Rountree, MD, while the brain plays a role in the condition, IBS is more likely a result of abnormalities in the gut. 

“If the emphasis is on the brain, then the emphasis in treatment is going to be towards teaching the person to calm down, doing mindfulness meditation, and maybe certain kinds of exercises,” explained Dr. Rountree. “All that's fine, but the implication is, if you just meditate enough, then maybe your gut is going to get better. But if the problem really originates in the gut, then all the meditation in the world isn't going to help.”

Dr. Rountree, who practices integrative family medicine in Boulder Colorado, defines IBS as a constellation of symptoms in the gut tied together by abnormalities in systems biology, making it not only hard to treat, but hard to diagnose. In a podcast interview, we spoke with Dr. Rountree about the specifics of IBS and the patterns to look for in testing, as well as realistic interventions for long-term symptom relief.

Integrative Practitioner: How does one develop IBS? Are patients born with IBS, or is the condition usually triggered by something?

Robert Rountree, MD: Well, I think there are two major categories of people. There is certainly one group that says, yes, I've always had gut problems as long as I can remember; I hear that all the time. Now, that doesn't mean something new hasn't occurred, that there hasn't been some kind of change. They may say I reached a certain age, and my symptoms got worse, or I changed my diet, and my symptoms got worse, but that's on a background of remembering that I had problems when I was a baby. I ask people regularly, “Do you have a history of colic?" which might seem like a weird question to ask a person in their fifties, but it can certainly tell you that maybe there was dysbiosis or something else going on in the beginning. 

Then, there's another group of people that say, “My gut has always been fine, and then I went on a trip to a less developed country and got an acute illness, and my intestines have not been right since.” I can't tell you how many times I've heard that. The interesting thing is, when you test those people, you typically find dysbiosis, which is an imbalance of the microbes in the gut. But it can be a different kind of dysbiosis for different people. In other words, it's not always the same problem. The way the literature describes it is that post-infectious IBS is “agnostic to the type of infection the person got.” So, if they get acute gastroenteritis from a virus or a bacterium, it doesn't matter; they end up with the same kind of persistent problem. So, I really see these two major categories.

Integrative Practitioner: How do you test for IBS? It doesn’t seem like there’s a singular test that can conclusively diagnose IBS. 

Dr. Rountree: There are a number of research papers in the medical literature that claimed to have discovered the “the microbial signature for IBS,” and the irony is that those papers all have different opinions about the signature. So, it makes it really confusing to a practitioner who was hoping to find that, you know, this particular bug is high and this one's low. 

There is a tendency towards seeing more pro-inflammatory bacteria and less beneficial bacteria. So, there's this general trend, but that's a little bit different than a signature. Now, if somebody has, say, gone on a trip to an undeveloped country, let's say they're out in the jungle, they come back, they've got diarrhea, cramping, etc., then I'm going to do a more classical kind of stool test, to make sure they don't have something that needs to be treated, whereas a person who has chronic symptoms that have gone on for years, I'm not going to do that kind of tests, which is called a multiplex test. 

Instead, I'm going to do what's called shotgun metagenomics, where I look at the ecology of the gut. The fact that we can’t identify a specific signature doesn't mean that we don't see certain patterns. Again, the patterns would be an increase in inflammatory bacteria and a decrease in what we call the gatekeepers. 

Integrative Practitioner: In your practice, what are the most common symptoms you're seeing patients complain of? Also, at what age are patients generally seeking treatment? Or is that just a huge range?

Dr. Rountree: It’s a huge range. I wouldn't say that I see a lot of adolescents or young kids seeking treatment. By the time a person's got to be 30, or 40, if they're still having symptoms, that’s when they’re more likely to seek medical care. 

The kind of symptoms that usually bring people in are things like chronic discomfort. Almost everybody with IBS doesn't feel good about their gut; there’s often a vague sense of bloating, distension, or cramping. So that discomfort is probably the number one symptom and that is part of what's called the Rome criteria for diagnosing abdominal discomfort. 

Patients with IBS also have abnormal motility, which is either a tendency towards diarrhea, constipation, or alternating between the two. So, almost everybody with IBS has something off about their motility. It's either too slow, too fast, or erratic; it's not stable. I would say those are the things that really stand out: the discomfort, the bloating, the distension, and the erratic patterns in motility. 

Integrative Practitioner: I know a lot of patients with IBS have been told by conventional doctors that their symptoms are all in their heads, and that's not helpful. But I'm wondering, to what extent does their mental health impact IBS symptoms?

Dr. Rountree: The way I think about it is as a loop; it doesn't start in one place and end in the other. You typically see people with IBS having emotional distress about their symptoms. So, which is the cause? And what is the effect? And I think you're right; conventionally, we thought, “This is something that happens to a neurotic person. This person is more obsessed with their bowel function. They think about sensations in their body more than a normal person. And so maybe the symptoms are not that big a deal; they're just overly obsessed with the symptoms.” So, that creates a neurosis, that creates anxiety, that creates irritability. The thinking was that IBS starts in the brain, which sends signals to the gut that enhance problems with motility. 

I think there’s been a sea change in how we've considered this loop. More and more, there's a realization that the problem is actually starting in the gut, and that influences the brain. So clearly, there's a mind-body effect going on here. But where should the emphasis be? If the emphasis is on the brain, then the emphasis in treatment is going to be on teaching the person to calm down, doing mindfulness meditation, and maybe certain kinds of exercises. All that's fine, but the implication is if you just meditate enough, then maybe your gut is going to get better. But if the problem really originates in the gut, then all the meditation in the world isn't going to help. 

If there's a food reaction or sensitivity, for instance, if the person can't tolerate a certain fermentable carbohydrate, that’s because they don't have the enzyme to break that food down, or they have an excess of bacteria that ferment the food and produce a lot of gas. You can meditate on that a lot; it's not going to change the symptoms. Maybe they'll be less distressed by the symptom, but it’s still there.

Integrative Practitioner: How personalized are your treatments for each patient? Are there some baseline treatments you use that have seemed to work?

Dr. Rountree: I would say the menu is similar for most people, but the things I pick from the menu of interventions are going to have different emphases. That’s where the personalized part comes in. So, I'm typically going to use similar antispasmodics. For example, something like enteric-coated peppermint oil is a good thing to try. If a person has bloating right after meals, and I suspect that they've got bacterial overgrowth or fungal overgrowth in their small intestine, then I might use anti-microbial agents like Berberine or a combination of herbal anti-microbials to try to bring that down. 

Typically, we’ll have a person try a low FODMAP diet, regardless of whether they’re constipation-predominant or diarrhea-predominant. I still think it's worth it for them to identify any foods that might be a problem. The low FODMAP diet is kind of an update of the old elimination diet. With the old elimination diet, we had people take out most of the common foods that they're eating, maybe do a fast for three or four days on a rice protein or something, and then introduce different groups one at a time. The FODMAP diet is a significant improvement over that because we're really looking at a broad category of foods that a lot of people, especially those with IBS, just don't digest well. And that’s either because they don't have the enzymes to digest it or because they have an overgrowth of certain bacteria that will do the digesting for them, causing gas and bloating. So, I love low FODMAP diets, and I think they are a mainstay of the intervention. That's not to say that low FODMAP diets are the treatment there. That's simply an elimination diet. I don't think low FODMAP diets are a good thing in the long run because if you avoid those foods, which are typically prebiotic foods, those are beneficial for the gut. But I do want people to know if there's a certain food that they just can't eat. I hear this all the time: a person goes on the diet and says, “I've realized that if I don't eat garlic, then my gut symptoms are dramatically better. If I don't eat beans, then my sentiments are dramatically better.: Well, that's great if it's that easy. 

Integrative Practitioner: Do you use probiotics at all?

Dr. Rountree: I do use probiotics; I haven't found them to be dramatic in the short term. It does help to do a gut microbiome analysis to try to get a sense of which ones might be good. But I see the probiotics more as something to bring in for the long-term. It's really rare for an individual to start taking a simple probiotic like lactobacillus acidophilus, Bacillus coagulans, or lactobacillus plantarum and see immediate results. If they're going to see improvements from that, it's usually weeks or months out. So, it’s not a short-term intervention. Probiotics are designed to restore the healthy mix of flora in the gut. I'm more inclined to use prebiotics. The paradox is that prebiotics are often FODMAPs. So, it's a tricky thing; you've got to play it very carefully. Because if you have somebody that's complaining of gas and bloating, etc., and you say, I want you to take all these fibers, and it makes the gas and bloating worse, then you've lost that patient very quickly. So, you've got to help them understand the whole purpose of using prebiotics, which is to reach a point where they have a more balanced gut flora.

Integrative Practitioner: Are there any lifestyle interventions you suggest to patients with IBS? 

Dr. Rountree: Yes. I certainly recommend meditation. As I mentioned, I think that if you're doing meditation and you're sending signals to your gut that everything is fine and calm, then it's going to make it less irritable. But again, if the problem is caused by food, you can only go so far with that, but I still find it helpful. And there are a couple of apps for smartphones that incorporate meditation specifically for IBS. So, I recommend that, especially for people who are constipated. Exercise is important too. The more they can get up and move around, the more that's going to enhance motility. 

The other major lifestyle intervention is to have people eat consciously. Mark Davis has written a number of books on this, eating slowly, chewing food carefully, and trying to swallow a lot of air when eating. And that's often a surprising problem for people who have a lot of gas and bloating. They realize I'm wolfing down my food, I don't have much time for lunch, or I go to a fast-food joint, and I get a hamburger and eat it in my car. They’re inhaling the food but also inhaling air. So, just slowing down the process of eating and enjoying meals can make a big difference.

Editor's Note: This interview has been edited and condensed. To listen to the original podcast interview, click here.