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Gastrointestinal - Phytotherapeutic approaches to lower bowel disease Part I

Part I: Chronic Inflammatory Bowel Disease

Chanchal Cabrera MNIMH, AHG

Medical Herbalism 11(2):1,3-9

The lower bowel, large intestine or colon, measuring about 6 ½ feet in an adult, is specially adapted for absorption of fluids from the stool and the forward movement of food wastes. The mucosal lining both absorbs fluids and some food particles, but also secretes lubricating mucus and is a mechanism for the excretion of substances from the blood stream into the gut.

The digestive function of the colon is carried out largely by bacteria. There may be over 3 lbs. of bacteria in a healthy colon and these ferment remaining carbohydrates, producing lactic acid, hydrogen, carbon dioxide and methane. The bacteria also convert remaining amino acids into simpler substances: indole, skatole, hydrogen sulfide, and fatty acids. The indole and skatole are carried off in the feces and give them their characteristic odor, and the rest are absorbed into the blood stream for transport to the liver. The bacteria also decompose bilirubin breakdown products into stercobilin which gives the feces their color and they produce vitamins K and B12. Healthy bowel flora is critical and can be promoted with the use of psyllium, garlic, and probiotics. Fructo-oligosaccahrides (complex fruit sugars) are the preferred food of many beneficial bacteria and a daily teaspoon of Slippery Elm powder stirred into water can be very helpful.

There are many different strains of bacteria naturally present in the colon and when supplementing them it is important to take a broad spectrum product. Ideally the supplement should include some or all of the following strains: Lactobacillus acidophilus, L. rhamnosus, L. casei, L. bulgaricus, Streptococcus thermophilus, Bifidobacterium bifidum, B. longum and Enterococcus faecium.

Bowel disease comes for many reasons and in many forms. Generally full blown disease is preceded by years of dietary abuses and poor lifestyle habits with low grade symptoms of digestive disturbance including episodes of constipation or diarrhoea, flatulence, belching, bloating and cramping. Attention to the fundamental dietary and lifestyle issues forms the foundation of the treatment plan.

Diseases of the colon may be inflammatory (Crohn’s Disease, ulcerative colitis, diverticulitis) or may be functional (constipation, diarrhoea, diverticulosis). Inflammation of the colon commonly leads to leaky gut syndrome triggering food allergies which may in turn aggravate the inflammation.

Chronic inflammatory bowel disease

In chronic inflammatory bowel disease there is a strong correlation with genetic markers in the blood and with auto-immune inflammatory disease elsewhere in the body. There are greatly increased levels of prostaglandins in the serum, stools and enteric mucosa. In particular there is an increase in the levels of leukotrines that are formed from arachidonic acid and which promote inflammation. The bowel flora is usually very disturbed. This will impair nutrient absorption and promote diarrhoea, fermentation and flatulence. In active ulcerative colitis there is a significant decrease in the amount of mucus produced in the colon as well as a reduction of the sulphur content of the mucus. Thus there is a deficiency of soothing, anti-inflammatory mucus and of antibacterial, vulnerary sulphur.

Crohn’s Disease

This is also called regional enteritis and refers to a chronic patchy inflammation of the digestive tract from anywhere oesophagus to anus, but most usually affecting the terminal ileum. Most cases of Crohn’s disease occur between the ages of 20 and 40 years. It occurs about equally in men and women. Crohn’s disease occurs mostly in white persons of Northern European and Anglo Saxon ethnic derivation. Caucasians are 5 times more likely to develop Crohn’s disease than are blacks or orientals.

In the early stages of Crohn’s disease there are tiny “aphthoid” ulcers of the mucosa with underlying nodules of lymphoid tissue. The inflammation progresses to involve all layers of the intestinal wall, especially the submucosal area. There is widespread lymphatic congestion around the gut and eventually the intestinal wall will become fibrotic. In advanced cases the transmural inflammation, deep ulceration, local oedema and fibrosis may cause bowel obstruction. There are often sinuses and fistulas, the latter of which may lead to many complications as infected material spreads to other hollow organs or to the peritoneal cavity.

The primary presenting symptoms are chronic diarrhoea (rarely with blood in the stool), flatulence, low grade fever, loss of appetite and weight, malaise and a feeling of fullness or sometimes crampy pain in the left iliac fossa. The symptoms frequently remit and recur over many months or years, but each relapse tends to be longer and more severe than the preceding one. Occasionally the patient will present with an acute onset of disease manifesting as intestinal obstruction, peritonitis or other forms of the ‘acute abdomen’.

Ulcerative Colitis

This refers to an episodic inflammation of the mucosal lining of the colon or rectum. Like Crohn’s disease, the commonest age of presentation is between 15 and 30 years although with ulcerative colitis there is another small peak in incidence between 50 and 70 years. The aetiology of ulcerative colitis is unclear but it may be associated with infection, allergy, auto-immune disorders and psychogenic factors. It often co-exists with Crohn’s Disease and the aetiology may overlap.

The pathological presentation is of a continuous area of inflammation in the colon, causing the mucosa to be swollen and red. Ulceration may be deep or superficial, but is widespread, causing sloughing off of mucosa and exposure of unprotected cells. Inflammation usually begins in the rectosigmoid area and spreads upwards into the descending, transverse and ascending colon.

The presenting symptom is usually chronic diarrhoea with varying degrees of blood and mucus in the stool. There is commonly, also, some mild lower abdominal pain. Such attacks will come and go but, like Crohn’s disease, each one tends to worse than the one before. If the ulceration is confined to only the rectum or sigmoid colon then the stools may be normal but there will also be rectal loss of mucus with or between bowel movements.

There may be occasional acute onset of ulcerative colitis. The person will present with sudden violent diarrhoea, high fever, signs of peritonitis and profound toxaemia. This is a medical emergency and the person should be taken to hospital immediately.

Comparison of:             Ulcerative Colitis    Crohn’s Disease

Age                usually 20-40        0-50 but more common 20-40

Bleeding                very common        unusual

Abdominal pain            rare            common

Abdominal tenderness        rare            occasional

Abdominal masses        no            occasional

Anal lesions            no            common

Rectal involvement        95%            50%

Small intestine involvement    no            usual

Possible complications of chronic inflammatory bowel disease include:

Chronic low grade fever.

Malabsorption syndrome.

Perianal skin tags an anal fistulae.

Finger clubbing.

Arthritis.

Iritis and uveitis.

Rashes

 Aphthous Ulcers

Colon cancer

Erythema nodosum.

Ankylosing spondylitis.

Kidney stones.

Dehydration.

Malabsorption.

Loss of appetite and weight loss.

Local lymphadenopathy.

Leucocytosis and raised ESR.

Holistic treatment of chronic inflammatory bowel disease

Malnutrition is very common in inflammatory bowel disease. The severity will depend on the severity and duration of attacks. There are a number of possible reasons for this malnutrition which include:

Loss of appetite and hence reduced intake of food.

Diarrhoea allowing insufficient time for absorption.

Decreased absorptive surfaces due to the disease process.

Bacterial overgrowth and imbalance.

Increased secretions in to the gut lumen leading to electrolyte and mineral loss in the stool.

Increased intestinal cell turnover thus requiring more protein.

Increased requirements of certain nutrients such as the essential fatty acids.

Certain drugs such as corticosteroids and cholestyramine.

Insufficiency of bile salts following surgical intervention.

Malabsorption syndrome.

The nutritional approach to the treatment of inflammatory bowel disease is initially to use a modified cleansing program. Often symptoms of pain and abdominal discomfort are minimized by avoiding foods so, as long as the person is not too debilitated, then 2 or 3 days of mono food fasting would be ideal. Apples are excellent because the pectin content will soothe and protect the mucosal lining at the same time as acting as a gently bulking agent to give form and substance to the stool. Vegetable juices or brown rice are other useful fasting foods in this situation.

Garlic should be taken in high doses during the fast. At least 3 cloves per day and more if the person can tolerate them. Fresh raw garlic should be used. This will promote healing, reduce inflammation and balance the bowel flora. Slippery elm gruel can also be taken to soothe the inflamed tissues and promote healing.

Following the fast it is a good time to do allergy testing. The foods that are reintroduced into the diet will depend upon the individual tolerances. If it does not irritate the intestines then the person can go on to several days of raw foods then part raw and part cooked. If the digestive system is very sensitive then potassium broth is the best food to break the fast with, several bowls per day for 2 days before eating any solid foods.

Every 2 weeks the person should do a one day water fast to allow the mucus membranes to cleanse and regenerate. On the night before the fast and in the morning and evening of the fast the person should take 2 to 3 chopped cloves of garlic with 2 teaspoons of Slippery Elm powder in water.

It is important to emphasize the role of food allergies in the treatment of chronic inflammatory bowel disease. Lactose intolerance and frank allergy to milk protein is common and all dairy products should be strictly avoided for at least one month to assess the impact of this. Many patients achieve significant improvement from complete avoidance of all grains and cereals. This may be due to impaired digestive ability leading to passage of partially digested carbohydrate into the bowel where it causes disturbance in the bowel flora, or may be due to a more classical allergy. A book by Elaine Gottschall called ‘Breaking the Vicious Cycle’ can be helpful in guiding the patient through this process of grain and carbohydrate elimination.

Due to the impaired digestive ability and rapid transit time, many nutrients may be poorly absorbed and sub-clinical malnutrition is common. The fat soluble vitamins are particularly at risk of poor absorption. A comprehensive supplement program is helpful to ensure adequate supply of essential nutrients. For improved absorption it is ideal to take supplements in liquid form. If these are not readily available try crushing tablets and opening capsules. A basic protective program will include:

Zinc            30 - 50 mg daily

Folic acid            800 mcg daily

B 12            800 mcg daily

Beta carotene        20,000 iu daily

Glutamine        up to 4 grams daily

Vitamin C            2 grams daily (buffered form)

Vitamin E            800 iu daily

Calcium citrate        500 mg daily

Magnesium citrate    500 mg daily

Evening Primrose oil    3 grams daily

Digestive enzymes    1 - 2 capsules after each meal (broad spectrum)

Gamma oryzanol        500 mg daily

N-acetyl-glucosamine        1500 mg daily

Herbal remedies

Mucilaginous herbs

Astringent herbs

Anti-inflammatory herbs

Mucosal tonics

Immune enhancers

Anti-inflammatories

These are herbs which reduce the inflammatory processes by a variety of mechanisms. The may soothe the irritated mucus membranes by coating them with mucilage, regulate the fatty acid - prostaglandin cascade, improve circulation to the affected area and regulate the functions of cortisol and the actions of the immune system.

Chamomilla recutita (Chamomile)

Calendula officinalis (Marigold)

Salix nigra/alba (Black/White Willow)

Filipendula ulmaris (Meadowsweet)

Dioscorea villosa (Wild Yam)

Glycyrrhiza glabra (Licorice)

Harpagophytum procumbens (Devil’s Claw)

Althea officinalis (Marshmallow)

Ulmus fulvus (Slippery elm)

Curcuma longa (Turmeric)

Astringents

Herbs that tone and tighten the lining of the gut and prevent bleeding or fluid loss. They all contain tannins which are antibacterial, anti-viral and anti-inflammatory. Astringents with a tissue specificity for the bowel include

Agrimonia eupatoria (Agrimony)

Quercus alba / rubra (White / Red Oak)

Geranium maculatum (Cranesbill)

Geranium robertianum (Herb robert)

Potentilla spp. (Tormentil)

Capsella bursa-pastoris (Shepherd’s Purse)

Rubus ideaus (Red raspberry)

Geum urbanum (Avens)

Demulcents

These are herbs especially rich in mucilage that can soothe and protect irritated or inflamed tissues. They are a type of anti-inflammatory and are somewhat vulnerary (healing) as well.

Symphytum off. (Comfrey)

Althea off. (Marshmallow)

Ulmus fulvus (Slippery Elm)

Mucosal tonics and regeneratives

These are herbs which nourish and strengthen the mucosal lining and improve its integrity. They combine very well with the use of N-acetyl-glucosamine which improves the quality and regulates the quantity of mucus being produced.

Gotu kola (Centella asiatica)

Plantain (Plantago lanceolata / major)

Goldenseal (Hydrastis canadensis)

When treating ulcerative colitis and Crohn’s disease it is important to remember that they can be significantly affected by stress factors. Most patients will tell you that the symptoms are much worse when they are under stress so you should encourage the person to practice stress reduction techniques and possibly to take nervine herbs.

Psyllium may be used freely (1 - 2 teaspoon stirred into cold water once or twice a day on an empty stomach). This will give form and bulk to the stool. The high fibre content may bind some minerals and make them unavailable for absorption so it is best taken on an empty stomach.

Exercise is useful to reduce stress and maintain general levels of wellness. Exercise such as walking, cycling or dancing that encourages blood flow in the pelvis may be beneficial.

Sample formulas

For ulcerative colitis

2 parts     Calendula off. (Marigold) anti-inflammatory, immune stimulant, bitter alterative,                 lymphatic stimulant, vulnerary

1part    Geum urbanum (Avens) astringent

1 part    Glycyrrhiza glabra (Licorice) anti-inflammatory, immune supporting,         adaptogenic

1 part    Centella asiatica (Gotu kola) mucosal tonic

1 part    Dioscorea villosa (Wild yam) anti-inflammatory

1 part    Althea off. (Marshmallow) soothing demulcent

1part    Hydrastis canadensis (Goldenseal) mucus membrane tonic, bitter, antibacterial

For Crohn’s disease

2 parts    Chamomilla recutita (Chamomile) bitter, anti-inflammatory, anti-allergenic,                 relaxing nervine

1 part    Ceonothus (Red root) lymphatic and tissue decongestant, immune support

1part    Achillea millefolium (Yarrow) pelvic decongestant, astringent, bitter

1 part    Glycyrrhiza glabra (Licorice) anti-inflammatory, immune supporting,         adaptogenic

1 part    Centella asiatica (Gotu kola) mucosal tonic