Q&A: Breaking down IBS from an integrative perspective

Photo Cred: Andrea Piacquadio/Pexels

By Avery St. Onge

Contrary to conventional medicine’s characterization of irritable bowel syndrome, IBS is not a psychosomatic condition, according to Robert Rountree, MD, founder of Boulder Wellcare, a private practiced focused on personalized healthcare in Boulder, Colorado.

We spoke to Rountree, who presented on systems biology and IBS at the 2022 Integrative Healthcare Symposium in New York, about what IBS is, it’s root causes, and some integrative treatment options for the condition.

Integrative Practitioner: How does conventional medicine view IBS?

Robert Rountree: Conventional medicine has long looked at IBS as being a ‘functional disorder.’ In mainstream medicine when you say something is functional you mean that you can’t ‘find anything wrong.’ IBS is often characterized as a collection of symptoms. Conventional medicine says there are no identifiable immune problems, structural problems, or any other problems that can be found across IBS patients. In the absence of those problems, all that’s left is a list of symptoms.

There has long been an agreement that the symptoms of IBS are consistent from person to person. IBS patients have a disorder in motility that can either be constipation or diarrhea or both. There’s consensus that IBS is a bowel sensitivity problem that’s thought to be a disorder of nerve signaling from the gut and most often it makes the person uncomfortable. We call that visceral hypersensitivity.

Integrative Practitioner: How do you define IBS?

Robert Rountree: IBS is a constellation of symptoms in the gut that are tied together by abnormalities in systems biology. There are abnormalities in the biological system that governs normal digestion and motility in response to that digestion.

Integrative Practitioner: How do doctors usually go about diagnosing IBS?

Robert Rountree: A typical patient would come in with recurring abdominal pain, frequent diarrhea, a tendency to constipation, and the doctor would do tests to make sure they don’t have inflammatory bowel disease, or anything else. They might do a colonoscopy, they might do a blood test to look for inflammation, and if all that’s negative, they would diagnose the patient with IBS. They look for other things and if they can’t find them, then IBS is the default. The symptoms of IBS are consistent and well established but what’s unclear is what causes it.

Integrative Practitioner: What does cause IBS?

Robert Rountree: That’s where it really gets interesting. The mainstream journals have plenty of research showing that there’s all kinds of things happening on a microscopic or physiologic level. When you see a review article of IBS that says it’s a group of symptoms in the absence of identifiable abnormalities, that’s simply ignoring what’s right there in front of them in the research.

There are several potential things that could tie together all these symptoms like abnormal nerve firing, abnormal production or absorption of bile acids, abnormal immune responses to gut bacteria, or abnormal production of neurotransmitters. It’s important to note that most of the neurotransmitters in the body are made in the gut. When we talk about serotonin in the body, most of the serotonin is produced in the gut and that influences the vagus nerve, which directly connects the brain to the gut. If you’ve got a person with IBS and a mood disorder, you have to ask, did the mood disorder precede the IBS or do they have a mood disorder because they have IBS?

When you start looking at gene variants alone, that could predispose someone to IBS, there’s a lot of them. They’re involved in all different kinds of things from nerve firing to production of digestive enzymes, to production of bile acids. Genes alone could set somebody up to have all these symptoms that we describe as IBS.

Integrative Practitioner: How do you go about treating someone with IBS?

Robert Rountree: Because you’re dealing with a system, you approach it in many ways. You approach it with diet. You can also use medications, although I don’t tend to go to medications as my first choice. I’d rather treated with diet and then supplements and herbs.

We used to just put people on a drastic elimination diet and reintroduce foods one by one. I’m not knocking elimination diets, but they can be overwhelming to people because you don’t know where to start. Today, the notion of elimination diet has been narrowed down by the discovery of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs). FODMAPs are certain carbohydrates that can be fermented by gut bacteria to produce gas. They can also produce chemicals that pull water into the gut and increase motility. When FODMAP foods are cut out of a diet for three weeks, a huge percentage of people with IBS will get better. The problem is that most FODMAPs are really good foods that you want to be eating to feed the healthy bacteria in your microbiome. That’s the FODMAP paradox.

Through microbiome testing we’ve found that when people are on a low FODMAP diet, their gut microbiome becomes less diverse and less healthy. So clearly, you don’t want to keep people on that diet for very long. Eventually you want to start reintroducing FODMAP foods to identify certain FODMAP foods that patients can tolerate. The last thing I want to do is get someone on a diet so restrictive that they feel that they can’t enjoy life.

Integrative Practitioner:  What are some supplements that you recommend for treating IBS?

Robert Rountree: My first supplement is some kind of digestive enzyme. The kind of supplement depends on a patients’ problems. For instance, if you determine that the problem is with lactose then maybe lactase will do the trick for that person.

I also use a lot of prebiotics. That’s again a little bit of a paradox because many of the prebiotics can also be FODMAPs. However, there are probiotics that people seem to be able to tolerate better. One is called partially hydrolyzed guar gum, better known as PHGG. Guar gum is notorious for causing gas and bloating, diarrhea, and cramping, but when it’s hydrolyzed it breaks down and becomes more digestible. There are studies showing that it normalizes bowel movements. Even if a person’s got diarrhea, they can take PHGG, it will slow down the number of stools, and if they’ve got constipation, then it improves the number of stools.

I also use probiotics that are also a little controversial. Many mainstream medical journals say probiotics are not effective for people with IBS but that’s simply not true. The best thing you can say is that some probiotics work for some people some of the time. 

There’s three probiotics that I use a lot. One is called Saccharomyces boulardii which is closely related to the yeast that’s used to make bread and beer. I like to use it to create a healthier bowel wall. Saccharomyces boulardii are beneficial especially for somebody that has taken multiple courses of antibiotics or have gone to a foreign country and gotten infectious diarrhea and never quite got better.

I like Bacillus coagulans, which is a spore-forming bacteria. [There’s] some really good research on it for IBS and it’s cheap, it’s safe, [and] you can get it from a number of different sources. Both B coagulans and Saccharomyces boulardii are readily available. The third probiotic that has good data is a form of lactobacillus known as Lactobacillus plantarum that is over the counter and can help patients with IBS.

Besides enzymes, prebiotics, and probiotics, I like to use curcumin which is one of the active ingredients in the herb, turmeric. Curcumin is anti-inflammatory. I also sometimes use dried aloe powder and boswellia as anti-inflammatories. The other herbs that I use a lot that’s evidence based is enteric-coated peppermint oil. Peppermint oil is an antispasmodic. If a patient is getting a lot of cramping, even bloating, then the enteric-coated peppermint oil, which is coded so that it’s released in the intestines, not in the stomach, can be helpful.

Then it gets a lot more specific. I usually don’t use antibiotics if I can avoid it. I would prefer to use something natural. I often use an herbal extract called berberine which is a useful and safe compound. I often resort to berberine if I’ve got evidence that the person has overgrowth of an unhealthy bacteria and I want to bring that back into balance.

Integrative Practitioner: Besides supplements, do you suggest any lifestyle changes?

Robert Rountree: There was an interesting article that was in the New England Journal of Medicine Journal a few years ago that basically said people who suffered from IBS would give up several years of their life for a cure. I thought that was really profound and telling about how much people can suffer from IBS. If somebody has had IBS for years and years, it often it can create all kinds of emotional distress. Mindfulness meditation can be very helpful so that people can learn to love their guts again.

When you first started hearing about all these different pieces – there’s the digestive enzyme piece, the bacterial imbalance piece, the nerve firing abnormality piece, right? At first, it seems overwhelming, but it’s consistent. It’s not an infinite number of things that can cause IBS. It’s a finite number of things. This is not imaginary. It’s not psychosomatic. It’s a real issue. And you just need to roll up your sleeves if you’re a practitioner and figure out how to get to the bottom of it.

Editor’s note: This interview has been edited and condensed.