Journal of Medicinal Plants Research Vol. 5(32), pp. 6934-6938, 30 December, 2011 Available online at http://www.academicjournals.

org/JMPR ISSN 1996-0875 2011 Academic Journals DOI: 10.5897/JMPR11.1224

Review

Herbal treatment of irritable bowel syndrome: A review

M. Akram1*, Muhammad Irfanullah Siddiqui2, Naveed Akhter3, Muhammad Khurram Waqas4, Zafar Iqbal 3, Muhammad Akram5, Aubid Allah Khan3, Asadullah Madni3, H.M. Asif3
2

Shifa ul Mulk Memorial Hospital, Hamdard University, Karachi, Pakistan. Department of Community Medicine, Faculty of Medicine, Umm Al-Qura University, Saudi Arabia. 3 Department of Pharmacy, The Islamia University of Bahawalpur, Pakistan. 4 Department 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 the world. 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 functional gastrointestinal (GI) disorders. Herbal medicines have been used in Unani system of medicine for a long time. Most of the patients are beginning to receive herbal medicines. The aim of this study is to review 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 or recurrent abdominal pain, altered bowel habits, and bloating, with the absence of structural or biochemical abnormalities to explain these symptoms. Irritable bowel syndrome is part of a broader group of disorders known as functional gastrointestinal (GI) disorders. The colon (large intestine) is responsible for packaging and eliminating stool. As food moves through the colon it absorbs water while forming stool. Muscle contractions (squeezing motions) in the colon push the stool toward the rectum (the lower five inches of the large intestine) (Francis et al., 1997). These contractions are controlled by nerves, hormones and by electrical activity in the colon musculature and result in defecation or bowel movement (Mertz, 2003). Normal bowel function varies widely from person to person, normal bowel function ranges from three stools a day to three each week. A normal movement is one that is formed but not hard, contains no blood, and is passed without cramps or pain (Thompson et al., 1999). However, when colonic nerves become irritated the muscle contractions may become too hard (causing abdominal pain), may stop (causing constipation and bloating), or may accelerate (causing diarrhea and an urgency to have a bowel movement). Irritated colonic nerves also make the colon very sensitive to distention which may also cause pain. Emotional factors such as stress, anxiety or depression are not necessary to cause disease but still may play a role 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 can almost always be managed and does not lead to any other serious diseases. With attention to proper diet, stress management, and sometimes prescription medications, most people with IBS can keep their symptoms under control (Mayer, 2008). PATHOPHYSIOLOGY
*Corresponding author. E-mail: makram_0451@hotmail.com. Tel: 92-021-6440083. Fax: 92-021-6440079.

The pathophysiology of irritable bowel syndrome is not

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well understood, but likely factors include: altered gastrointestinal motility, increased gut sensitivity, and increased intestinal contractions. Proposed mechanisms include: stress as an aggravating factor because of corticosporin releasing factor, gastric emptying delay, and accelerated colonic transit; visceral hypersensitivity, with a decreased threshold after exposure; abnormal brain activation; altered colonic motility and disturbed motor function; response to eating as a stimulus to colonic activity; abnormal gas propulsion and expulsion; dietary intolerance, most commonly to wheat and dairy products; and inflammation, with production of prostaglandins, bradykinins, nerve growth factors, adenosine, and 5hydroxytryptamine (Maxwell et al., 1997). Symptoms of irritable bowel syndrome Abdominal pain, bloating, and discomfort are the major symptoms of irritable bowel syndrome. However, symptoms can vary from person to person (Okhuysen et al., 2004; Marshall et al., 2006). Some people have constipation, which means hard, difficult-to-pass, or infrequent bowel movements (Mitchell et al., 1987). Often these people report straining and cramping when trying to have a bowel movement but cannot eliminate any stool, or they are able to eliminate only a small amount. If they are able to have a bowel movement, there may be mucus in it, which is a fluid that moistens and protect passages in the digestive system. Some people with IBS experience diarrhea, which is frequent, loose, watery, stools. People with diarrhea frequently feel an urgent and uncontrollable need to have a bowel movement. Other people with IBS alternate between constipation and diarrhea. Sometimes people find that their symptoms subside for a few months and then return, while others report a constant worsening of symptoms over time (AGA, 2002). Diagnosis In the past it was thought that the diagnosis of irritable bowel syndrome (IBS) relied on a diagnosis of exclusion (Olden, 2003). That is, if one cannot find a cause then IBS is the diagnosis. Currently the diagnosis of irritable bowel syndrome relies on meeting Rome II inclusion criteria (updated by Rome III criteria) and excluding other illnesses based on history, physical examination, and laboratory testing. Although, the Rome II and Rome III criteria 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 still only useful as a tool to rule out more serious problems unless further investigation is employed to discern an addressable condition (Spiller, 2007; Manning et al., 1978)

Treatment of irritable bowel syndrome Irritable bowel syndrome is an intestinal disorder which may occur at any age. The common symptoms are bloating 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 bowel syndrome or IBS. The major causes are irregular food habits, unhealthy diet and lack of physical exercise (Camilleri et al., 1992). There are different natural remedies for irritable bowel syndrome. These natural remedies for irritable bowel syndrome can be used effectively to cure the symptoms without many side effects (Vincent, 1990; Smart et al., 1986). The following are some natural remedies for irritable bowel syndrome: 1. Ginger: It reduces inflammation. But it should be avoided by pregnant women. 2. Peppermint: Peppermint oil is a good natural remedy for irritable bowel syndrome. 3. Flax seed: This is an effective natural remedy for irritable bowel syndrome. It cleans the stomach. 4. Pomegranate: Another natural remedy for irritable bowel syndrome is to take pomegranate seeds with black salt. Chamomile Chamomile tea is also a good natural remedy. Traditionally considered a cure all, chamomile tea has been recommended for a host of afflictions involving the central nervous system, respiratory system, the digestive system, the urogenital system, the musculoskeletal system, and topical preparations for various skin conditions (Hadley et al., 1999). It is currently used for nausea, irritable bowel syndrome, peptic ulcer and colic, as well as disorders of the nervous system and dysmenorrhea. Cinnamon It can be used to prevent diarrhea and other symptoms of irritable bowel syndrome. Generally, people who live a sedentary lifestyle suffer from irritable bowel syndrome. So another natural remedy is to perform regular exercise. Peppermint Peppermint is obtained from dried leaves and flowering branch tips of Mentha x pipertia. The oil contains more than 100 components, including menthol (29 to 48%), methyl acetate (3 to 10%), menthone (20 to 31%),

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caffeic acid, azulene, and flavonoids. It exerts antibacterial and antiviral actions, as well as spasmolytic effects on smooth muscles. When taken as entericcoated capsules, peppermint oil may have antispasmodic effects on smooth muscle of the intestines, its antispasmodic activity results from the calcium antagonist effect of menthol. Flavonoids may cause its bilestimulating effect. Azulene may have anti- inflammatory and antiulcer action. Peppermint is available as an essential oil, ointment liniment extract, tincture, leaves dried herb, and capsules (Kligler et al., 2007; Cappello et al., 2007). Reported uses Peppermint is used to treat nausea, irritable bowel syndrome (IBS), colitis, colic, ileitis, Crohns disease and other spasmodic conditions of the bowel. Its also used in liver and gallbladder complaints, cramps of the upper GI tract and bile ducts, menstrual cramps, colds and flu, inflammation of the oral and pharyngeal mucosa, loss of appetite, dyspepsia, flatulence, and gastritis (Mearin et al., 2005). Peppermint is used to treat the nausea and vomiting related to pregnancy and motion sickness. Its used externally formyalgia, itching, and skin irritation, and the oil is applied to the forehead to relive tension and migraine headaches (Nash et al., 1986) PHARMACOLOGY The active ingredients are volatile oils such as menthol, menthone and methyl acetate. Its current use is mainly for colic and irritable bowel syndrome. Enteric, coated capsules of a standardized oil have been shown to be effective against irritable bowel syndrome in placebo controlled 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 for postherpetic neuralgia was found to be beneficial in one report (Davies, 2002).

tongue spasms or respiratory arrest (Huang, 1990; Liu et al., 1997). Peppermint oil and irritable bowel syndrome An oil extract of the peppermint plant (Mentha piperita Linnaeus) has been used to treat stomach upset for thousands of years. It appears to relax intestinal smooth muscle cells by interfering with calcium channels. Shortterm trials suggest that daily use of 3 to 6 enteric-coated capsules containing 0.2 to 0.4 ml of peppermint oil each improves IBS symptoms. These observations are supported by 2 meta-analyses. The first was based on 5 trials that suggested efficacy, but heterogeneous diagnostic criteria and symptom scores weakened the findings. Another review of 4 small trials found overall symptom improvement with peppermint oil (odds ratio 2.7, 95% CI 1.6 to 4.8). These results are strengthened by a recent trial of 110 patients who were screened for celiac disease, lactose intolerance. After patients took 4 capsules daily for 4 weeks, symptoms improved in 75% of those taking peppermint oil compared with 38% of those taking placebo (P < 0.01). The strict inclusion criteria limit the generalizability of the results, but peppermint oil could be considered for all patients with IBS symptoms. Peppermint oil appears to alleviate IBS symptoms, including abdominal pain. Patients should be reminded not to chew the capsules, which are enteric coated to prevent gastroesophageal reflux from lower esophageal sphincter relaxation. Perianal burning and nausea are occasionally reported side effects. The safety of peppermint oil during pregnancy has not been demonstrated (Rees et al., 1979). Probiotics Probiotics are nutritional supplements that contain good bacteria (Drossman, 1999). That is, bacteria that normally live in the gastrointestinal tract and seem to be beneficial. Taking probiotics may increase the good bacteria in the GIT which may help to ward off bad bacteria that may have some effect on causing irritable bowel syndrome symptoms. There is some evidence that taking probiotics may help ease symptoms in some people with IBS. At present, there are various bacteria that are used in probiotic products. Further research is needed to clarify the role of probiotics and which one or ones are most helpful (Dew et al., 1984). Prebiotics are the substances, which reach to colon in intact form, that is, without getting depleted by the gastric pH and digestive acids. These prebiotics also selectively promote the growth of colonic probiotic bacteria, hence they act as fertilizers for these symbiotic bacteria. For example, insulin which is a polyfructose obtained from raw chicory (roots of Cichorium intybus) or

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

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Jeruslem artichoke. Chicory is rich in fibrous polysaccharide inulin, which is soluble dietary fibre and resistant to digestive enzymes, thus reaches to large intestine or colon essentially intact, where it is fermented by resident bacteria, Lactobacilli and Bifidobacteria digest inulin and feed themselves on it. The dairy products like sour milk and A/B culture yoghurt contain these prebiotics. Antispasmodic medicines Antispasmodic medicines are usually used for relaxation of muscle in the gastrointestinal tract. Mebeverine and peppermint oil are prescribed as antispasmodic medicines. Antispasmodic drugs have few or no side effects. Antispasmodic drugs are not given to pregnant women (Dew et al., 1984). Modification of diet A diet history might reveal patterns of symptoms related to dairy or gas-producing foods. Exclusion of foods that increase flatulence (for example, beans, onions, celery, carrots, raisins, apricots, prunes, brussels sprouts, wheat germ, pretzels, bagels) should be considered in patients with symptoms of bloating or gas (Spiller et al., 2007). Underlying visceral hyperalgesia in irritable bowel syndrome may explain the exaggerated discomfort experienced with the consumption of gas-producing foods. An increase in the intake of fiber is generally recommended, through diet or the use of commercial bulking supplements. Although, the efficacy of fiber supplements has not been proved, some improvement has been demonstrated in patients with IBS whose primary complaints are abdominal pain and constipation. Many types of fiber supplements are available; some are synthetic, such as polycarbophil or methylcellulose, and others are from natural sources, such as bran or psyllium compounds. All types of fiber can cause increased bloating and gaseousness because of the colonic metabolism of nondigestible fiber. Because of its safety, a trial of fiber supplementation is advised for patients with IBS, especially those with constipation-predominant symptoms. The amount should be titrated to symptoms (Lawson et al., 1988).

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CONCLUSION Herbal medicines are affective in the treatment of irritable bowel syndrome. The efficacy and safety of herbal medicine have been proved. People all over the world are using herbal medicine in the treatment of irritable bowel syndrome. It is concluded that herbal medicine have therapeutic efficacy.

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