By Dr. Brian Bressler, MD, MS, FRCPC (biography and disclosures)
What I Did Before
The approach to patients with irritable bowel syndrome has changed significantly as we continue to understand the cause behind patients’ symptoms. Traditionally, the approach to symptoms related to irritable bowel syndrome has focused on altering the stool consistency to allow easier handling of it through the colon. The traditional example of such intervention would be supplementing a patient’s diet with fibre, often with Metamucil or a similar product. Clinical studies have not supported this approach. Another focus in therapy has been altering the enteric nervous system, as it has been known now for a long time that a large component to the pathophysiology of irritable bowel syndrome is centred around the dysfunction of the nerves controlling the bowel. Typical medical approaches to this have included Dicetel and Zelnorm (this medication has been removed from the market due to cardiovascular concerns).
What Changed My Practice
We are beginning to understand the complex nature and interaction the bacterial flora has in our body, specifically our GI tract. On average, 100-200 grams of feces is excreted by a person each day. Approximately 50% of this mass is bacteria. Ninety percent of the total cells in the human body are bacteria. For every gram of stool, it is estimated that there are one trillion bacteria. We are far from understanding the role each bacteria have in our bowels, and we are unable to permanently manipulate our bacterial flora. The definition of a probiotic is live micro-organisms which, when administered in adequate amounts, confers a health benefit on the host. A good probiotic must have certain critical characteristics. First and foremost, it must be safe for the consumer, it must be delivered alive to the gut in the correct concentration. This last point is critical when evaluating a probiotic because the design of it must allow the bacteria to stay alive despite the gastric acids and bile salts that it is exposed to, as well as it must be able to resist other microbes in the intestines. Finally, a good probiotic must have proven efficacy. Recently there has been clinical evidence for using probiotic therapy for various medical conditions, including treatment of acute gastroenteritis, prevention of antibiotic-associated diarrhea and irritable bowel syndrome. Recent studies using probiotic therapy have proven that altering intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome. A controlled double-blinded randomized study on the efficacy of Lactobacillus plantarum 299v (a probiotic available in Canada) in patients with irritable bowel syndrome revealed significant improvement in the active group compared to the control group in treating symptoms associated with irritable bowel syndrome.
What I Do Now
For the most part, patients are interested in exploring non-pharmacological approaches to treating irritable bowel syndrome. With the clinical evidence that is now available for certain probiotics, I have begun to use probiotics in treating patients’ irritable bowel syndrome.
A probiotic is like an antibiotic and one cannot use any probiotic for any medical condition.
I emphasize to patients that the appropriate probiotic which has been studied for the medical condition that one wants to treat should be tried and many others which are commonly used, such as Lactobacillus acidophilus has no proven clinical efficacy in GI conditions such as irritable bowel syndrome. Tuzen and Activa yogurt are two examples of probiotics I use for treating IBS. VSL3 I use for treatment of pouchitis and to a lesser extent ulcerative colitis. Florastor I use in patients with recurrent C diff, or in some circumstances to treat antibiotic induced diarrhea.
The major drawback to probiotic therapy is the expense and to date I am not aware of third-party coverage of these supplements. I have had many patients use probiotic therapy to treat their irritable bowel syndrome to minimize the impact this syndrome has on the quality of their life. As we go forward, my hope is that we learn further the role that microflora has on our health and, with that knowledge, we can isolate and use specific bacteria to treat more effectively irritable bowel syndrome as well as many other conditions relating to our gastrointestinal tract.
References for the data regarding Lactobacillus Plantarum: (Note: Direct article downloads and article requests require a login ID with the BC College of Physicians website)
[1.] Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome. Nobaek S, Johansson ML, Molin G, Ahrné S, Jeppsson B. Am J Gastroenterol. 2000 May;95(5):1231-8.PMID: 10811333 [View PubMed – indexed for MEDLINE]
[2.] A controlled, double-blind, randomized study on the efficacy of Lactobacillus plantarum 299V in patients with irritable bowel syndrome. Niedzielin K, Kordecki H, Birkenfeld B. Eur J Gastroenterol Hepatol. 2001 Oct;13(10):1143-7.PMID: 11711768 [View PubMed – indexed for MEDLINE] [View Article]