The condition of Irritable Bowel Syndrome (IBS) is one of the most challenging conditions to treat and manage for clinician and patient alike.
However, in many cases of IBS, symptoms persist even after the aforementioned treatment protocols are implemented. One of the most important areas to consider when dealing with recalcitrant cases of IBS is small intestine bacterial overgrowth (SIBO), a condition in which abnormally large amounts of commensal bacteria are present in the small intestine. This bacterial overgrowth results in the impairment of digestion and absorption in the small intestine and the production of large amounts of hydrogen and methane gas resulting from the fermentation of carbohydrates by the intestinal bacteria. This article will discuss the various symptoms which result from SIBO and either cause or contribute to the condition of IB, present the most common TCM patterns which present in these complex cases and discuss treatment protocols using TCM herbal / acupuncture protocols.
In the presentation of SIBO, the production of hydrogen and methane gas in the small intestine leads to symptoms such as bloating, gas, pain/cramps, diarrhea, constipation, heartburn, nausea, and malabsorption (with concomitant anemia and steatorrhea). It is important to note that the symptoms of SIBO need not be limited to the gastric environment and often have a systemic expression with symptoms such as joint pain, malaise/fatigue, low grade fever, headache and rosacea. In my clinical experience there are several key indicators which would suggest that SIBO is a major contributing factor in IBS cases. These include the following: when the patient experiences significant improvement in IBS symptoms after administration of antibiotics, when a patient experiences constipation and worsening of IBS symptoms upon increasing the amount of fiber in the diet, when a patient experiences worsening of symptoms upon taking a probiotics, and patients with a history of using proton pump inhibitor medications for heartburn. While not a definitive diagnosis by any means, these scenarios strongly suggest that SIBO may be a contributing factor in chronic recalcitrant IBS.
Two of the most important factors for the treatment and prevention of SIBO are adequate production of pancreatic enzymes / gastric acid and proper small intestine motility. These factors can be correlated with the functions of the Spleen, Stomach and Liver in TCM; if the Spleen/Stomach Qi are weak or damaged and if the Liver coursing mechanism is stagnant, an environment is created which is highly conducive to SIBO. The clinician can have the patient take hydrochloric acid/ digestive enzymes / enteric-coated peppermint and magnesium citrate to target these factors from a naturopathic perspective however this often does not correct the underlying functional problem. In these cases the use of pattern appropriate TCM formulas and acupuncture protocols can shift the underlying functional weakness in the gastric environment and even allow the administration of HCL / enzymes / motility stimulants to more effectively ameliorate the chronic symptoms.
The most important basic TCM patterns which occur in SIBO are as follows: Spleen Qi Vacuity, Stomach Heat, Liver Depression Qi Stagnation, and Liver/Spleen disharmony with Depressive Heat. In chronic cases of IBS where bleeding was a common symptom and PPI medications were used long term, it is not uncommon to see patterns such as Blood Vacuity and Stomach Yin Vacuity. The following are the most common formulas to target the aforementioned TCM patterns:
- Spleen Qi Vacuity: Si Jun Zi Tang, Shen Ling Bai Zhu San, Bu Zhong Yi Qi Tang
- Stomach Heat: Qing Wei San, Xie Huang San
- Liver Depression: Chai Hu Shu Gan San, Yue Ju Wan, Xiao Yao Wan
- Liver/Spleen disharmony with Depressive Heat: modified Yue Ju wan, Jia Wei Xiao Yao Wan, modified Xiao Chai Hu Tang, modified Bu Zhong Yi Qi Tang.
- Blood Vacuity: Dang Gui Bu Xue Tang, modified Si Wu Tang, Dang Gui Shao Yao San
- Stomach Yin Vacuity: Liu Wei Di Huang Wan, Er Zhi Wan ( in this case gentle Yin tonics are used as the Spleen is often vacuous in IBS / SIBO and heavy cloying Yin tonics will likely cause loose stools.)
These TCM formulas should ideally be individually modified according to the patient's unique disease expression.
In IBS / SIBO, patterns are complex and it is not uncommon to use rotate 2-3 formulas as symptoms improve and change over course of treatment. However if the patient is not compliant with teas or powdered extracts, the clinician can still intelligently combine appropriate patent medications and still see significant symptomatic improvement if dosed correctly. It is not uncommon to see a patient with long standing IBS and concomitant SIBO to have a TCM pattern diagnosis of Liver/Spleen disharmony with Depressive/Damp Heat and Blood Vacuity.
So it is crucial that the clinician establish a comprehensive and accurate differential diagnosis which adequately addresses all factors in the pattern of disharmony; the clinician not target just one facet of a complex pattern expression and expect to see any significant clinical outcomes. In part II of this article we will expand upon the use of TCM formulas and discuss important acupuncture protocols which can be used in harmony with both prescribed medicinals and prescribed medications. We will also discuss crucial dietary factors which must be addressed in order to completely and effectively eliminate the condition of SIBO.
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