Irritable bowel syndrome (IBS) is a functional bowel disorder that is characterized by a change in bowel habits with features of disordered defecation and bowel distention in the absence of any demonstrable causes. Chronic or recurrent gastrointestinal (GI) symptoms associated with this disorder include stool urgency, abdominal fullness, bloating, diarrhea alternating with constipation, and abdominal cramps that are relieved with defecation.
IBS is the most common intestinal disorder seen in physicians' offices today, affecting at least 22 million people in the United States and approximately 10- 20% of all adults worldwide with a female predominance (Talley et al. 2002). According to the National Institute for Diabetes, Digestive and Kidney Disease (NIDDK)
, IBS causes 34,000 hospitalizations each year, 3.5 million physician office visits, and 2.2 million prescriptions; and results in 400,000 people becoming disabled. Reportedly, IBS patients have twice as many healthcare visits per year as age-matched controls (Levy et al. 2000). In the United States, IBS accounts for up to a 75% excess in healthcare visits that are for non-GI somatic (of the body) complaints (Levy et al. 2000). This is because the syndrome is associated with other somatic disorders. As a result, this syndrome alone poses a significant impact on heathcare costs. Individuals with IBS are absent from work three times more than other persons in the work force and they experience an overall impaired quality of life (Sperber et al. 1999; Markowitz et al. 2001). A familial predisposition of the syndrome has also been established (Talley et al. 2002; Gonsalkorale et al. 2003).
Psychiatric disorders such as major depression, anxiety, and somatoform (psychic in origin) disorders also occur in the majority of IBS patients. Whitehead et al. (2002) reported that these disorders occur in up to 94% of patients. Additionally, approximately 49% of patients with fibromyalgia were found to have IBS, as well as 51% of chronic fatigue syndrome patients; 50% of patients with chronic pelvic pain; and 64% of patients with temporomandibular joint (TMJ) dysfunction, according to special reports assembled by Whitehead et al. (2002). Clinical observation of these patients has found that worsening of IBS symptoms is correlated with an exacerbation of the psychiatric disorder. Other less frequently occurring conditions that have been associated with this disorder are numerous and include back pain, various gynecological disorders, and interstitial cystitis. The incidence of headache also occurs more frequently in patients who have IBS than in the general population. Additionally, patients with IBS often experience urinary dysfunction, sexual dysfunction, and altered sleep patterns (Whitehead et al. 2002).Symptoms and Diagnosis
As noted in the introductory comments, symptoms of IBS include abdominal cramps, abdominal bloating, flatulence, belching, diarrhea or constipation, or diarrhea alternating with constipation. A diagnosis of IBS used to be made by ruling out all other causes of the patient's symptoms (a diagnosis of exclusion). Clinically, this still holds true. However, because the disorder is so common, three different criteria to assist in making the diagnosis have been developed: the Manning, Rome I, and Rome II criteria. Rome II, the most recent, has more stringent parameters regarding the frequency of symptoms. Critics of this newer set of standards argue that many cases of true IBS are left undiagnosed when only the Rome II criterion is used. Therefore, the criteria are most useful for research purposes and are used clinically as an aid to diagnosis rather than as an absolute. Essentially, the Rome criteria divide IBS into two major variants:
1. Diarrhea-predominant IBS: three to seven bowel movements per day; loose, watery stools; and fecal urgency. One or more of these symptoms must be present.
2. Constipation-predominant IBS: fewer than three bowel movements per week; hard or lumpy stools; and straining during bowel movements. One or more of these symptoms must be present.
All patients with this syndrome have pain and urgency of defecation with relief after a bowel movement. Organic diseases that may cause the symptoms should be considered before making the diagnosis. This is accomplished with a thorough medical history and physical examination by a well-trained physician. Based on the findings of the medical history and physical examination, the physician might consider ruling out infectious causes of the symptoms; malabsorption disorders such as lactose intolerance or lipid intolerance; other irritable bowel diseases such as ulcerative colitis or Crohn's disease, diverticulitis, and Clostridium dificile colitis; and endocrinopathies such as diabetes and thyroid disorders. Dietary influences should also be investigated. For example, a diet high in nonabsorbable artificial sweeteners can cause diarrhea. A diet low in fiber and fluids can cause constipation. In some instances, a physician may want to rule out colon cancer as well.
Surveillance with a colonoscopy or a rectosigmoid-oscopy with a barium enema may be required to exclude other causes of the symptoms before making a diagnosis of IBS. Blood, stool, and imaging tests may also be indicated. However, a physician must use discretion in each patient to avoid unnecessary testing. Data reported by researchers in November 2002 support this discretion. Patients in the study who met the symptom-based criteria for IBS were rarely identified as having organic GI diseases. However, there was an increased incidence of celiac disease among IBS patients in that study (Cash et al. 2002).Etiology and Pathophysiology
To date, three of the most important mechanisms that contribute to the development of IBS include an altered visceral perception (pain) in the gut, disturbed GI motility (resulting in cramps, diarrhea, and/or constipation), and psychosocial factors (such as chronic stress, anxiety, and depression). Other significant factors implicated in the etiology of IBS include recent GI infection, inflammation of the GI mucosa, and alteration in the intestinal ecosystem (De Schryver et al. 2000; Talley et al. 2002).
Great strides have been made regarding the pathophysiology of IBS during the past several years. Numerous studies have demonstrated that IBS is characterized by visceral hypersensitivity, suggesting that patients with IBS may have more sensitive pain receptors in the GI tract than age-matched controls. These studies strongly suggest that alteration in communication between the nervous system and the immune system in the GI tract may trigger a series of events that give rise to chronic changes in visceral sensitivity, causing the affected individual to have highly sensitive pain receptors in the GI tract. Animal studies have demonstrated that gas in the bowel stretching the bowel wall causes psychological stress and can also cause an increase in the sensitization of visceral receptors, which results in a lower threshold for pain (Delvaux 1999).
Researchers exploring the causes of IBS, fibromyalgia, and the chronic fatigue syndrome have proposed that the cause may be due to a neuroendocrine-immune system dysfunction that is characterized by a complex integration of pathways that connect the nervous, endocrine, and immune systems to the GI tract (Mayer et al. 2001a, 2001b; Ringel et al. 2001; Chang et al. 2002). This connection is, in part, mediated by the neurotransmitter serotonin (Goldberg et al. 1996). The relationship is particularly interesting because these disorders often coexist, and the likelihood of a common etiology cannot be overlooked (Whitehead et al. 2002).
Monga et al. (1997) discovered that women with IBS have lower bladder and esophageal sensory thresholds, suggesting that there may be an underlying smooth muscle hyperreactivity disorder that is related to the autonomic nervous system. This explains the increased incidence of coexisting IBS with an irritable bladder condition and gastroesophageal reflux disease (GERD). The hypothesis deserves further investigation.
Regardless of whether it is diarrhea predominant or constipation predominant, IBS is frequently associated with depression and anxiety, and the symptoms of IBS may be exacerbated by stress (Chang et al. 1997). Studies have been inconclusive regarding which comes first, IBS or the psychological stressors. To date, it is believed that either can come first; however, IBS can be exacerbated by psychological stressors in either instance (Yehuda et al. 2002).
A focus of attention among researchers has also been on the pathways that connect the nervous system and the GI tract. It has been established that activities in the GI tract such as inflammation, infection, hypermotility, or changes in visceral sensitivity affect the nervous system. Conversely, psychosocial stressors such as stress, anxiety, and depression that manifest in the central nervous system (CNS) are transmitted to the bowel by various pathways. This gut-brain connection has provided a basis for new therapeutic approaches to IBS (Monnikes et al. 2001).
Several studies have suggested that infection and inflammation in the GI tract cause changes in the intestinal physiology that can persist after the infection and inflammation have resolved. The altered intestinal lining that is left after the inflammation has resolved is believed to trigger a neuroimmune interaction that may be implemented in the pathogenesis of some IBS patients (Yehuda et al. 2002).
Researchers have found that cells that mediate inflammation have been found very close to nerve endings in the intestinal lining of animals (Tornblom et al. 2002). Inflammation in the GI mucosa has been found to coexist with a degeneration of intestinal nerves of IBS patients (Tornblom et al. 2002).These findings have been implemented in the pathogenesis of this syndrome and provide a basis for further investigation.
Another discovery still under investigation is that symptoms are possibly mediated through partial degranulation of mast cells (mediators of inflammation) in the bowel mucosa (Bodemar et al. 2001).Yang et al. (1997) found an increase in mast cells in the bowel mucosa (specifically in the cecum and ileojejunal junction) of animals with IBS. These mast cells were often located very close to unmyelinated nerves, suggesting that mast cell stabilizers or the antagonism of mast cell products may have potential therapeutic applications in IBS (Yang et al. 1997).
The pathways that connect the brain and the gut are mediated by intrinsic neuroreceptors called 5-hydroxytryptamine-3(5-HT3) and 5-hydroxytryptamine-4 (5-HT4). These serotonin receptors are involved in both the modulation of visceral pain and regulation of GI motility that cause diarrhea and constipation and urgency. Because patients with IBS have both hypermotility of the smooth muscle of the bowel and hypersensitivity to visceral pain, a new class of therapeutic agents targets the modulation of these serotonin receptors in the bowel (Goldberg et al. 1996; Sanger et al. 1998; Houghton et al. 1999). This new class of serotonin receptor medications will be discussed later.
Over the past 30 years, numerous studies have looked at the overlap between IBS and psychiatric disorders. These studies found that 54-94% of IBS patients meet the diagnostic criteria for at least one psychiatric disorder. Major depression followed by generalized anxiety disorder rank among the most commonly associated psychiatric conditions associated with IBS. Consequently, serotonin reuptake inhibitors that are used to treat depression have been used to treat IBS because serotonin is involved peripherally in the regulation of motility and sensation in the gut and centrally in mood disorders (Whitehead et al. 2002).
Interestingly, a history of sexual abuse and to a lesser degree physical abuse is more common in patients with IBS than in patients with other GI conditions; however, this does not mean that a patient with IBS has been sexually abused. The only explanation found so far is that there is an overall increase in somatic complaints among abused persons (Walker et al. 1993; Talley et al. 1995; Blanchard et al. 2002).Treatment Options
* Conventional Drugs
* Natural TherapiesConventional Drug Treatment
* On the Horizon
Traditionally, IBS has been treated symptomatically with agents that relax the intestinal smooth muscle to relieve abdominal cramps that are associated with muscle spasms (Bentyl, Levsin, or Levsinex), antidepressants to target associated depression and anxiety (SSRIs such as Prozac or Paxil) in patients who exhibit those co-morbid conditions, antidiarrheal agents in patients who have diarrhea (Lomotil or Immodium), and bulk-forming laxatives and fiber (Metamucil or guar gum) in patients who have constipation. Unfortunately, no panacea has been found to date that consistently relieves the symptoms, and many patients continue to suffer the consequences of poor quality of life. As more information becomes available about the exact etiology of the symptoms, researchers can delve into a potential cure. However, as described earlier in this protocol, the etiology and pathophysiology appear to be a complicated integration of several systems. On a more positive note, breakthroughs regarding how the systems integrate have been enormous in the past decade and it appears that investigators are on the brink of putting together the entire picture in the next decade. More recently, newer classes of agents that modulate the serotonin receptors 5-HT3 and 5-HT4 have been used.
Tegaserod maleate (Zelnorm) was approved for the treatment of IBS in July 2002. Tegaserod is a 5-HT4 receptor partial agonist that increases GI motility. This medication is used for short-term treatment of women with constipation predominant IBS. Although the drug is probably just as effective in men as in women, the drug was approved specifically for women because the clinical trials that were used to obtain FDA approval consisted of 2470 women and no men.
This prescriptive medication should only be given to adults who are over the age of 18. It should be taken before meals in a dose of 6 mg twice daily for 4-6 weeks. If the patient responds to this drug therapy, a physician may consider an additional 4- to 6-week course of drug therapy. Contraindications to the use of tegaserod maleate include severe liver impairment, severe kidney impairment, history of bowel obstruction, symptomatic gallbladder disease, suspected sphincter of Oddi dysfunction, and abdominal adhesions. Tegaserod maleate should not be initiated in patients who are currently experiencing or frequently experiencing diarrhea. Common adverse reactions include abdominal pain, diarrhea, nausea, flatulence, and headache and back pain (PDR 2002). (Note: Tegaserod meleate will be under close observation by the FDA because medications that affect the serotonin system have historically been associated with side effects.)
Alosetron HCL (Lotrinex), a 5-HT3 antagonist, is indicated for women with severe diarrhea-predominant IBS who have had chronic IBS symptoms for more than 6 months, have been refractory to conventional therapy, have been excluded from anatomic or biochemical abnormalities of the GI tract, and who have frequent and severe abdominal pain/discomfort, frequent bowel urgency/fecal incontinence, and severely impaired quality of life and restriction of activities of daily living due the symptoms of IBS.
The FDA initially approved Alosetron in February 2000. Within 8 months of being on the market, numerous reports of ischemic colitis (a potentially lethal condition characterized by a blockage of blood supply to the intestines) were associated with this drug. Alosetron HCL was also responsible for causing severe constipation in many persons who used the drug. Four deaths have been linked to Alosetron HCL. The severity and frequency of these side effects resulted in the drug being withdrawn from the market by its sponsor. On June 7, 2002, the FDA issued a supplemental new drug application that allows Alosetron to be marketed through a prescribing program that specifies the restrictions for its use listed above. This prescribing program requires an attestation and qualification form signed by the prescribing physician and an informed consent form signed by the patient.
An editorial report in the September 2002 issue of the British Medical Journal
estimates that under this present program, approximately 2 million people in the United States will be approved to take Alosetron. According to previously reported statistics, this would result in 2,000 cases of severe constipation, 5,714 cases of ischemic colitis, 11,090 surgical interventions, and 324 deaths. The decision by the FDA to allow this medication back on the market was made in spite of strong opposition that is still ongoing. Opponents argue that this is a serious and significant public health concern and the risks of using Alosetron may outweigh potential therapeutic benefits. However, Alosetron has proven to be a miracle drug for many who could not obtain relief from other traditional therapies and who did not experience side effects from taking this medication. The FDA will closely monitor reports of adverse events of Alosetron in the future (Lievre 2002).Drugs on the Horizon
Additional drugs that affect the serotonin receptors similarly to Tegaserod and Alosetron are currently under investigation by competing pharmaceutical companies and may become available in the future.
Other medications that may soon become available to treat diarrhea predomnant IBS are the more selective antispasmotics--M3-receptor antagonists such as Zamifenacin--and darifenacin in constipation-predominant IBS. Clinical trials are also ongoing to test these drugs.
In addition, the role of inflammatory cytokines such as tumor necrosis factor alpha, interleukin-6, interleukin 1(b), and leukotriene B(4) in the inflammation of the intestinal tract of IBS patients should be investigated.
Psychosocial factors such as stress reduction and the effect of anxiety and depression should be addressed in every patient with IBS. Additionally, studies have shown that the physician/patient relationship is especially important for IBS patients. Physician/patient support is an essential part of treatment and cannot be overlooked (De Schryver et al. 2000).Natural Therapies
Peppermint and Caraway Oil in Combination
- Peppermint and Caraway Oil in Combination
- Enzymes and Laxatives
- Dietary Intervention
- Nondietary Interventions
An enteric-coated peppermint/caraway oil combination (sold under the name Regiment) has been used successfully to treat cramps and abdominal pain associated with IBS. This combination acts locally to relax the smooth muscle of the intestines. The enteric coating allows the oil to bypass digestion in the stomach where the acid environment would otherwise destroy the active ingredient so that it can be delivered to the site where pain and cramping are located. (Note: Uncoated peppermint oil ingested orally has an undesirable side effect of relaxing the gastroeso-phageal sphincter that allows food to enter from the esophagus to the stomach during digestion. Relaxation of this sphinchter causes backflow of food and acid from the stomach into the esophagus, a condition called gastroesophageal reflux disorder or GERD. The enteric coating on the fixed combination of peppermint/caraway oil prevents this side effect.)
This fixed peppermint/caraway herbal combination has offered significant relief for many persons who experience the debilitating effects of IBS and cannot get results from traditional medications. The product, when taken as directed, is also considered to be safe and well tolerated. The combination was initially used in Germany where it was approved by a government authority (the German Kommission E) equivalent to the United States FDA.
A fixed combination is defined as a formula containing multiple herbal ingredients, prepared consistently in exactly the same proportions. To be approved by the German Kommission E, the combination must show the following: each active component must make a positive contribution to the evaluation of the whole preparation, proof of effectiveness should be established by clinical documentation for each component or for the whole preparation, the components of the fixed combination must have an established dosage for appropriate effectiveness, and the safety of all fixed combinations is to be tested by suitable methods. Approved fixed combinations can be advantageous over single herbs if the therapeutic effectiveness is increased or if the side effects of a single component are lessened or negated. Currently, the largest category of use for approved fixed combinations is for digestive complaints (35 combinations).
Studies conducted over the past 20 years support the use of enteric-coated peppermint oil alone for the treatment of IBS symptoms. As early as 1979, a multicentered, double-blind, crossover trial conducted by Rees et al. demonstrated that peppermint oil was superior to placebo for relieving symptoms of the irritable bowel syndrome. The active ingredient in peppermint oil (menthol) relaxes the intestinal smooth muscle, relieving spasms of the bowel (Dew et al. 1984). Although multiple well-designed studies support the use of enteric-coated peppermint oil for the treatment of IBS, one compelling study using the herbal combination of enteric-coated peppermint oil and caraway oil strongly favored the use of this combination over the use of peppermint oil alone. This is based on a review of the literature, which suggests that it was the most effective treatment, producing the best relief in the shortest duration of time.
In a clinical trial using a fixed combination of peppermint/caraway oil, 45 patients with nonulcer dyspepsia (the majority with IBS) were studied in a double-blind placebo-controlled trial. The test group took 1 capsule, 3 times daily, for a period of 4 weeks. Each capsule contained 90 mg of peppermint oil and 50 mg of caraway oil. While all patients complained of moderate to severe pain before the commencement of therapy, almost one half of the patients (42.1%) in the test group were pain-free in just 2 weeks after taking the combination therapy. Only one patient (5%) in the placebo group reported freedom from pain. After 4 weeks of treatment, 63% of the patients were pain-free; and 89% showed improvement in the test group vs. 25% in the placebo group. With regard to clinical global impression, 95% of the test group showed overall improvement in their condition (May et al. 1996). Similarly, physicians and naturopaths who have used the enteric preparation of peppermint oil and caraway oil for the treatment of IBS symptoms have reported improved clinical outcomes for their patients.Probiotics
Probiotics are a dietary supplement consisting of beneficial bacterial flora that normally inhabit the small and large intestines. These beneficial bacteria compete with pathological bacteria to maintain a balanced ecosystem in the intestines. This balanced ecosystem is responsible for the production of digestive enzymes such as lactase to digest dairy products and is considered a significant part of the immune system that is present in the GI tract. When we consume medications such as antibiotics or steroids, this ecosystem is disrupted. Antibiotics, which are often over-prescribed, destroy not only pathological microorganisms, but also the beneficial ones. This causes an overgrowth of yeast in the intestines, resulting in inflammation of the GI mucosa on the walls of the intestines. This condition adversely affects the absorption of nutrients (such as dairy products) during digestion, causing gas and bloating and sometimes abdominal pain after meals.
In time, the disruption of normal intestinal flora adversely affects the immune system. Steroids, which have potent anti-inflammatory properties, exert negative effects on the immune system in the intestines as well as contributing to the overgrowth of yeast microorganisms. This condition is called leaky gut syndrome. Dysbiosis lactose intolerance can be created by this syndrome due to a lack of the digestive enzyme lactase that is naturally produced by beneficial gut flora. When flora is diminished, symptoms of lactose (milk sugar) intolerance can develop. Consequently, IBS symptoms can be improved by the ingestion of digestive enzymes that include lactase.
Leaky gut syndrome is believed to be the cause of many of the symptoms in IBS patients. Unfortunately, the evidence-based literature does not support this concept because little research has been done to examine this cause/effect relationship. However, studies have shown that probiotics administered to patients with irritable bowel disease (colitis or Crohn's disease) resulted in improvement in symptoms. If inflammation is part of the pathoetiology of IBS, this process would likely be the culprit in many instances of IBS (Shanahan 2001). Note: Research on the subject of irritable bowel disease and prebiotics-probiotics shows that prebiotics increase the numbers of lactobacilli acidophilus and bifidobacterium. Bifido-bacteria are more likely to reside in the large intestine, with lactobacilli acidophilus residing primarily in the small intestine. The digestive tract primarily contains Bifido bacteria until the age of 5; after age 5, Lacto-bacillus acidophilus becomes more prominent in the small intestines and bifidobacterium remains more prevalent in the large intestines. (Prebiotics are most often fiber- or sugar-based nutrients that pass through the stomach and small intestine undigested. In the large intestine, they nurture and promote the growth of beneficial probiotic species by positively affecting the pH balance of the gut.)
Clinical experience in physicians' practices has supported the cause and effect relationship between IBS and inflammation because patients with IBS symptoms frequently improve when they take probiotics (Niedzielin et al. 2001; Marteau 2002; Sach et al. 2002) with digestive enzymes. Some experts in this field claim that probiotics should be taken with prebiotics called fructo-oligosaccharides (FOS). FOS serve as food for the beneficial bacteria to feed on, allowing them to proliferate and adhere to the bowel wall (Sghir et al. 1998).
Other authorities argue that FOS that feed the good bacteria also feed yeast, but there appears to be no support for this argument. A stool digestive analysis for bacterial flora and yeast, performed by the Great Smokies Diagnostics Laboratory (GSDL) can aid in the treatment plan. This is not a standard test and most traditional physicians are not familiar with it. Controversy also exists regarding the type of bacterial flora that one should consume. Most probiotics consist of Lactobacillus acidophilus and Bifidobacterium species as well as a host of other beneficial bacteria. Some authorities maintain that one type of bacterial species such as Lactobacillus acidophillis is preferred so that the organisms do not compete with each other. Others claim that it is best to use a combination of several beneficial strains.
In either case, the supplement should contain at least 3 billion microorganisms of bacteria because the shelf life is limited. The expiration date of the bottle should also be checked. The product often requires refrigeration to preserve the bacteria, but some do not. If yeast is present, a Candida diet can be helpful. This diet may be found in the Candida protocol in this book. It can take up to 9 months of daily treatment for leaky gut syndrome for gut flora to be completely restored. In refractory cases where overgrowth of yeast is severe, an antifungal prescription medication such as Nystatin or Diflucan may be necessary to eradicate the yeast.
An example of a remarkable clinical case history demonstrates the benefits of restoring the gut flora in a patient with severe abdominal pain resembling a clinical picture of IBS. For this patient, every test had been performed to rule out the cause of the patient's excruciating, debilitating pain, which came in waves of exacerbations and remissions. All tests were negative. Medications had failed to consistently relieve the symptoms. The patient finally had a surgical procedure (an exploratory laparoscopy) of the abdomen and pelvis to look for a cause. Some adhesions (scars) from a previous surgery were removed and were thought to be the cause. However, a few months later, the symptoms of severe abdominal pain returned. In a desperate attempt to try anything, the physician gave the patient probiotics and digestive enzymes. The symptoms never returned. This clinical case history is one of many seen in physicians' offices.
Without a doubt, more documented research needs to be done to support the use of probiotics in clinical practice. When this research is done, perhaps more physicians will use this functional medicine concept in their clinical approach to IBS and fewer patients will have to suffer as a result.Enzymes and Laxatives
Digestive enzymes and nutrients that enhance bile flow from the liver may aid in digestion and enhance the transit time of food through the GI tract. Digestive enzyme capsules and artichoke-black radish tablets should be taken five minutes before meals to enhance digestion and improve bowel function.
Bulk-forming laxatives such as psyllium as well as the soluble fiber guar gum have been shown to be effective in some patients with constipation-predominant IBS. In one bulk laxative study, soluble fiber (guar gum) and insoluble fiber (bran) were compared to determine which one was more effective in relieving symptoms with the fewest side effects. Patients preferred guar gum, although bran was also effective. Guar gum was found to be more tolerable and less irritating to the bowel. At least three other studies have shown that bran supplementation either exacerbated symptoms or did nothing other than relieving constipation (Cann et al. 1984; Francis et al. 1994; Snook et al. 1994).
Those suffering from constipation-predominant IBS may not benefit from bulk forming laxatives. They may, instead, need to judiciously use natural therapies that can induce rapid peristalsis in order to completely evacuate their bowels. One such therapy is to mix in an eight-once glass of water a powdered vitamin C supplement that is buffered with potassium or magnesium and drink this on an empty stomach.Curcumin May Be Effective Treatment for Inflammatory Bowel Disease (IBD)
Ulcerative colitis and Crohn' disease
are inflammatory bowel diseases characterized by abdominal pain, digestive difficulty, diarrhea or constipation and recurrent bowel ulceration. The July 2003 issue of the American Physiological Society journal, Gastrointestinal and Liver Physiology, published the findings of Canadian researchers that curcumin, a derivative of the common spice turmeric, may be a well-tolerated and effective therapy for these diseases.
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