National Institutes of Health • National Center for Complementary and Integrative Health
Complementary Health Approaches for Irritable Bowel Syndrome
What the Science Says
There is some preliminary evidence that suggests some probiotics may improve symptoms of IBS; however, benefits have not been conclusively demonstrated, and not all probiotics have the same effects. The American College of Gastroenterology issued a monograph in 2014 on the management of IBS and chronic idiopathic constipation, stating that “taken as a whole, probiotics improve global symptoms, bloating, and flatulence in IBS,” but recommendations cannot be made at this time regarding species, preparations, or strains due to insufficient and conflicting data.
The Evidence Base
- The evidence base on the efficacy of probiotics for IBS consists of several systematic reviews and meta-analyses, and a 2014 monograph on the management of IBS and chronic idiopathic constipation issued by the American College of Gastroenterology.
- In 2014, the American College of Gastroenterology issued a monograph on the management of IBS and chronic idiopathic constipation, assigning the recommendation as “weak” and quality of evidence as “low.” They noted that although probiotics appear to improve some IBS symptoms, recommendations regarding specific strains, species, or preparations cannot be made due to insufficient of conflicting data.
- A 2014 systematic review and meta-analysis of 43 randomized controlled trials found that probiotics had beneficial effects on global IBS symptoms, abdominal pain, bloating, and flatulence scores; however, the species and strains that provide the most beneficial effects are unclear.
- A 2010 systematic review of 19 randomized controlled trials involving a total of 1,650 participants with IBS found that probiotics were statistically significantly better than placebo, but the level of benefit and the most effective species and strain remain uncertain.
- In healthy people, probiotics usually have only minor side effects, if any. However, in people with underlying health problems (for example, weakened immune systems), serious complications, such as infections, have occasionally been reported.
- Most research about safety of probiotics comes from studies of Lactobacillus and Bifidobacterium; less is known about other probiotic strains.
Some studies have suggested benefit of hypnotherapy for IBS symptoms, including gastrointestinal symptoms, anxiety, depression, disability, and health-related quality of life. However, the American College of Gastroenterology issued a monograph in 2014 on the management of IBS and chronic idiopathic constipation, concluding that a variety of psychological interventions, including hypnotherapy, are effective in improving IBS symptoms. The 2014 monograph assigned the recommendation as “weak” and the quality of evidence supporting hypnotherapy for IBS symptoms as “very low.”
The Evidence Base
- The evidence base on the efficacy of hypnotherapy for IBS symptoms consists of several systematic reviews, including a Cochrane review, meta-analyses of randomized controlled trials, and a 2014 monograph on the management of IBS and chronic idiopathic constipation issued by the American College of Gastroenterology.
- A 2015 systematic review of 24 randomized controlled trials involving a total of 1,390 children with pain-related functional gastrointestinal pain disorders found that significant improvement in abdominal pain was reported after hypnotherapy compared with standard care or wait-list approaches.
- A 2014 meta-analysis and systematic review of 48 randomized controlled trials analyzed data on the effect of antidepressants and psychological therapies, including hypnotherapy, on IBS symptoms and found that hypnotherapy was a beneficial treatment.
- Another 2014 systematic review and meta-analysis of eight randomized controlled trials involving a total of 464 patients demonstrated that hypnosis (over a median of 12 weeks) provided symptom relief in more than half of patients with IBS.
- A 2013 randomized controlled trial of 90 adults with IBS found that more than half of participants who had 10 gut-directed hypnotherapy sessions over 12 weeks had improved IBS-related quality of life, compared with those who received standard medical treatment (with supportive talks). The duration of benefit was at least 15 months.
- Gut-directed hypnosis is generally considered safe and tolerable among children and adults when led by licensed hypnotherapists with special training in this technique.
There is some evidence that enteric-coated peppermint oil capsules may be modestly efficacious, in the short-term, in reducing several common symptoms of IBS, in particular abdominal pain, bloating, and gas. Long-term efficacy has not been established. A 2011 Cochrane review found statistically significant benefits for peppermint oil. The American College of Gastroenterology issued a monograph in 2014 on the management of IBS and chronic idiopathic constipation, concluding that “peppermint oil is superior to placebo in improving IBS symptoms,” and “the risk of adverse events is no greater with peppermint oil than with placebo.” However, based on the evidence, they assigned the recommendation as “weak” and the quality of evidence as “moderate.”
The Evidence Base
- The evidence base on the efficacy of peppermint oil for symptoms of IBS consists of a small number of randomized controlled trials, a few systematic reviews and meta-analyses, and a 2014 monograph on the management of IBS and chronic idiopathic constipation issued by the American College of Gastroenterology.
- A 2014 systematic review and meta-analysis of nine studies involving a total of 726 participants found peppermint oil to be superior to placebo for global improvement of IBS symptoms and improvement in abdominal pain. A 2008 systematic review and meta-analysis of four studies involving a total of 392 participants had similar results.
- A 2011 Cochrane review of 29 studies in a total of 2,333 participants evaluated the efficacy of antispasmodics for the treatment of IBS and found statistically significant benefits for peppermint oil.
- Non-enteric coated forms of peppermint oil may cause or worsen heartburn symptoms, but otherwise appears to be generally safe over the short-term.
The evidence that herbal remedies might improve IBS symptoms is very limited.
The Evidence Base
- The evidence base on the efficacy of herbal remedies for IBS consists of a Cochrane systematic review and many randomized controlled trials on various herbal preparations; however, the methodological quality of most of these studies is poor.
- A 2011 Cochrane review of 75 randomized controlled trials involving a total of 7,957 participants with IBS concluded that while some herbal remedies may improve IBS symptoms, positive findings from less rigorous trials should be interpreted with caution due to inadequate methodology, small sample sizes, and lack of confirming data.
- Herbal supplements may contain dozens of compounds and all of its ingredients may not be known.
- Some herbs can interact with medications. For example, St. John’s wort is a potent inducer of both cytochrome P-450 enzymes and intestinal P-glycoprotein. Clinically significant interactions have been documented with St. John’s wort and cyclosporine, the antiretroviral agent indinavir, oral contraceptives, coumadin, digoxin, and benzodiazepines, among others.
- Some herbs can cause serious side effects. For example, comfrey and kava can cause liver toxicity.
In sham-controlled, randomized trials, acupuncture was found to be no better than placebo for IBS symptom severity or health-related quality of life. In Chinese studies, acupuncture appeared to provide greater benefits than two antispasmodic drugs, although these benefits may have been due to patient preferences or expectations of improvement.
The Evidence Base
- The evidence base on the efficacy of acupuncture for IBS consists of many randomized controlled trials, many of which compare acupuncture with sham acupuncture, other active treatments, or no (specific) treatment, and a meta-analysis and Cochrane systematic review.
- A 2014 meta-analysis of six randomized, placebo-controlled trials found some benefit of acupuncture for IBS symptoms; however, only one of the six studies showed a positive effect. The authors concluded that data are insufficient to establish long-term results or to recommend acupuncture as first-line treatment.
- A 2012 Cochrane review of 17 randomized controlled trials involving a total of 1,806 participants found no evidence of an improvement with acupuncture compared to a sham acupuncture control for symptom severity or quality of life. The review also included four Chinese comparative effectiveness trials and found acupuncture to provide greater benefits than two antispasmodic drugs (pinaverium bromide and trimebutine maleate), which have been known to provide modest benefits for IBS symptoms. However, it is unclear if the benefits of acupuncture in these studies were due to patient preferences or expectation of improvement.
- Relatively few complications from using acupuncture have been reported. Still, complications have resulted from use of non-sterile needles and improper delivery of treatments.
- When not delivered properly, acupuncture can cause serious adverse effects, including infections, bleeding, pneumothorax and injury to the central nervous system.
There is insufficient evidence to support homeopathy as an effective treatment for IBS or any other specific condition.
The Evidence Base
- The evidence base on the efficacy of homeopathy remedies for IBS consists of a Cochrane review of three randomized controlled trials; however, these studies were conducted decades ago—two in the 1970s, and the third in 1990.
- A 2013 Cochrane review of three randomized controlled trials involving a total of 213 participants suggests a possible benefit for clinical homeopathy (using asafoetida) compared with placebo for constipation-predominant IBS; however, the reviewers noted that because of low quality of reporting, high risk of bias, short-term follow-up, and scant data, these findings should be interpreted with caution. In addition, the reviewers found no statistically significant difference between homeopathy and usual care (defined as high doses of dicyclomine hydrochloride, fecal bulking agents, and diet sheets advising a high fiber diet), but because of the small number of participants and high risk of bias, no conclusions could be drawn.
- It is important to note that several key concepts of homeopathy are inconsistent with fundamental concepts of chemistry and physics. There are significant challenges in carrying out rigorous clinical research on homeopathic remedies.
- While many homeopathic remedies are highly diluted, some products sold or labeled as homeopathic may contain substantial amounts of active ingredients and can cause adverse events or drug interactions. Negative health effects from homeopathic products of this type have been reported.
- A 2007 systematic review found that highly diluted homeopathic remedies, taken under the supervision of trained professionals, are generally safe and unlikely to cause severe adverse reactions. However, these products could pose risks if improperly manufactured.
- A 2012 systematic review of case reports and case series concluded that using certain homeopathic treatments (such as those containing heavy metals like mercury or iron that are not highly diluted) or replacing an effective conventional treatment with an ineffective homeopathic one can cause adverse effects, some of which may be serious.
- Chao GQ, Zhang S. Effectiveness of acupuncture to treat irritable bowel syndrome: a meta-analysis. World J Gastroenterol. 2014;20(7):1870–1877.
- Ford AC, Moayyedi P, Lacy BE, et al. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. American Journal of Gastroenterology. 2014;109:S2-S26.
- Ford AC, Talley NJ, Spiegel BM, et al. Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis. BMJ. 2008;337:a2313.
- Ford AC, Quigley EM, Lacy BE, et al. Effect of antidepressants and psychological therapies, including hypnotherapy, in irritable bowel syndrome: systematic review and meta-analysis. Am J Gastroenterol. 2014;109(9):1350–1365.
- Ford AC, Quigley EM, Lacy BE, et al. Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis. Am J Gastroenterol. 2014;109(10):1547–1561.
- Hempel S, Newberry S, Ruelaz A, et al. Safety of Probiotics to Reduce Risk and Prevent or Treat Disease. Evidence Report/Technology Assessment no. 200. Rockville, MD: Agency for Healthcare Research and Quality; 2011. AHRQ publication no. 11-E007.
- Hibberd PL, Kleimola L, Fiorino AM, et al. No evidence of harms of probiotic Lactobacillus rhamnosus GG ATCC 53103 in healthy elderly—a phase I open label study to assess safety, tolerability and cytokine responses. PloS One. 2014;9(12):e113456.
- Hungin AP, Mulligan C, Pot B, et al. Systematic review: probiotics in the management of lower gastrointestinal symptoms in clinical practice—an evidence-based international guide. Alimentary Pharmacology and Therapeutics. 2013;38(8):864–886.
- Khanna R, MacDonald JK, Levesque BG. Peppermint oil for the treatment of irritable bowel syndrome: a systematic review and meta-analysis. J Clin Gastroenterol. 2014;48(6):505–512.
- Liu JP, Yang M, Liu Y, et al. Herbal medicines for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews. 2006;1:CD004116.
- Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews. 2012;5:CD005111.
- Moayyedi P, Ford AC, Talley NJ, et al. The efficacy of probiotics in the treatment of irritable bowel syndrome: a systematic review. Gut. 2010;59(3):325–332.
- Moser G, Trägner S, Gajowniczek EE, et al. Long-term success of GUT-directed group hypnosis for patients with refractory irritable bowel syndrome: a randomized controlled trial. Am J Gastroenterol. 2013;108(4):602–609.
- Peckham EJ, Nelson E, Greenhalgh J, et al. Homeopathy for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews. 2013;11:CD009710.
- Ruepert L, Quartero AO, de Wit NJ, et al. Bulking agents, antispasmodics and antidepressants for the treatmet of irritable bowel syndrome. 2011. Cochrane Database Syst Rev. 2011;8:CD003460.
- Rutten JM, Korterink JJ, Venmans LM, et al. Nonpharmacologic treatment of functional abdominal pain disorders: a systematic review. Pediatrics. 2015;135(3):522–535.
- Sanders ME, Akkermans LMA, Haller D, et al. Safety assessment of probiotics for human use. Gut Microbes. 2010;1(3):164–185.
- Sanders ME, Guarner F, Guerrant R, et al. An update on the use and investigation of probiotics in health and disease. Gut. 2013;62(5):787–796.
- Schaefert R, Klose P, Moser G, et al. Efficacy, tolerability, and safety of hypnosis in adult irritable bowel syndrome: systematic review and meta-analysis. Psychosom Med. 2014;76(5):389–398.
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