IRRITABLE BOWEL SYNDROME
by Konstantin Monastyrsky
This guide debunks the universally accepted view that the causes of irritable bowel syndrome are unknown, describes them one by one, and explains how to eliminate each one safely and permanently. This information is particularly important for persons in the high-risk group for ulcerative colitis, Crohn's disease, and colon cancer because the conventional diagnostic and treatment of IBS raises these risks considerably.
According to the 2007
edition of the world's leading medical reference — The Merck Manual of
Diagnosis and Therapy— the causes of irritable bowel syndrome are still
unknown, as you can clearly see from this illustration (modified to fit this page,
click picture to view actual page):
Though it's hard to
accept that in the era of routine heart transplantation the causes of
IBS are still a mystery(1),
it's even harder to stomach
that the recommended treatment makes IBS worse. “Patients
with IBS may subsequently develop
additional GI disorders,” — says the Merck Manual.
By additional they mean inflammatory bowel disease (IBD) — the progenitor of ulcerative colitis and Crohn's
disease. In these cases, close to half of all patients end up needing
a colectomy — the surgical removal of the large intestine. This is the only
way to stop these patients from bleeding to death.
Even when patients do get spared these
uncontrollable bleedings with aggressive medical therapies(2) , such as immunodepressants, antibiotics,
these nasty IBDs increase the risk of colon cancer up to thirty two
To prevent an almost inevitable cancer, patients are commonly recommended
a prophylactic colectomy “just in case.” When choosing between an almost
certain death from cancer and an undergarment colostomy bag, most choose the bag.
Live by the book, die by the book,
The Merck Manual represents
what's known as “standards of care.” These standards, in turn, are
followed by doctors who wish to deliver “the best possible care” to
their patients. The problem is — when a standard is wrong, as is
the case with IBS, the best possible care invariably turns into the
worst possible nightmare.
If you happens to have IBS, and are uninsured or
have limited access to medical care, you are safer and better
off untreated than those well insured and, presumably, more fortunate,
who will be on the receiving end of the Merck-recommended treatment:
I realize, you may find this information disturbing,
but, so far, unsubstantiated. So lets begin by deconstructing this
doctor-speak with surprisingly bad grammar into plain English (3):
Q. What has “support and understanding” to do with bowel disease?
According to the Merck Manual, IBS is a partially
“psychosocial” condition. Essentially, this means
that patients with IBS are psychotic individuals, whose own mental attitudes
contribute to intermittent constipation, diarrhea, and abdominal pain.
This is junk science at it's
worse — irritable bowel syndrome is a 100% physiological condition, not
psychosocial. If anything, the constant pain, suffering, and bad
treatment may turn IBS victims into psychotic wrecks, but not the other
It's true that stress plays a
role in IBS unfolding (as well as in practically all other human ills),
but not in ways that can be effectively treated by psychological
(hypnosis, counseling) or psychiatric (prescription drugs) intervention.
You can learn more about the role of stress in IBS, and how to
counteract its impact on digestive disorders here.
Q. What does “normal diet, avoiding gas-producing and
diarrhea-producing foods” mean?
The primary “gas-producing” foods are indigestible
carbohydrates, that get fermented in the large intestine by innate,
beneficial, and essential gut
bacteria (microflora). Two of the most prominent indigestible carbohydrates are
dietary fiber and lactose (milk sugar) [link].
The primary “diarrhea-producing” foods are sugar
alcohols, such as sorbitol, found in bananas and prunes; soluble fiber, such as pectin found in
apples and oranges; beta-D-glucan found in oats, numerous unnamed polysaccharides
found in most plants and psyllium laxatives; and fiber
fillers and stabilizers found in practically all processed food, such as guar gum, carrageen, cellulose
gum, inulin, and numerous others [link].
In essence, this advice means to avoid the following: dairy because of lactose and fiber stabilizers
(yogurt, ice cream, sour cream, cream cheese); fruits rich
in pectin (oranges, apples); fruits rich in sugar alcohols (bananas,
prunes, prune juice), and food rich in fiber (oatmeal, morning cereals, bran,
whole wheat bread, pasta), fiber laxatives; and all processed food with
This is good and easy advice to follow until you
consider their next recommendation...
Q. How come they recommend “Increased fiber intake for
constipation,” if fiber is a well-known gas- and diarrhea-producing
To me, that‘s either the biggest “medical mystery”,
or the biggest “medical idiocy,” or simply outrageous negligence, or,
perhaps, all of the above. In fact, to unravel this mind-boggling
incongruity for myself and others, I wrote a book entitled “Fiber
Menace: The Truth About the Leading Role of Fiber in Diet Failure,
Constipation, Hemorrhoids, Irritable Bowel Syndrome, Ulcerative Colitis,
Crohn's Disease, and Colon Cancer”, and you are welcome to read it.
If you are a skeptical medical professional reading
this, and, all things considered,
I don‘t blame you a bit for being skeptical, consider the following two quotes from
the American College
of Gastroenterology Functional Gastrointestinal Disorders Task Force [link]:
“Fiber doesn't relieve chronic constipation
and all legitimate clinical trials demonstrated no improvement in stool
frequency or consistency when compared with placebo.”
“In the management of IBS, psyllium is similar to
placebo. In fact, the bloating
associated with psyllium use will likely worsen symptoms in an IBS
Psyllium is a source of soluble and insoluble fibers found in Metamucil-type laxatives, and
digestive properties are identical to all other types of fiber.
Q. Will Loperamide (Imodium) enable IBS recovery?
No, it will not. It may temporarily stop diarrhea by
literally paralyzing your intestines, but only to cause severe constipation,
because, along with “dizziness, drowsiness, [and] tiredness”,
constipation is the most immediate and prominent side effect of Imodium.
Of course, for me — a former pharmacist — there is no
surprise here. Imodium is a synthetic opioid (opium-like drug). Just
like all opioids, it “kills” the contraction of circular and
longitudinal smooth muscles, which line up the stomach, esophagus,
intestines, bowel, and major blood vessels. This effectively stops the propulsion of
food and feces throughout the entire digestive tract, and, in turn,
causes more constipation, more indigestion, more bloating, more
flatulence, and stronger cramps.
Just like all opioids, Imodium diminishes blood
circulation and oxygen delivery to the brain. This causes dizziness,
drowsiness, and tiredness — depression-like symptoms.
Q. Would “tricyclic antidepressants” help my depression
Well, since your doctor may think that you are
affected by IBS because you are psychotic, and you are miserable from
incessant abdominal pain caused by more fiber, and you are depressed
from Imodium, these potent antidepressant drugs may indeed keep you away
from the psychiatric ward.
Funnily enough, constipation is one of tricyclics‘ most
common side effects along with more drowsiness, dizziness, fatigue, and
muscle and joint aches. So you quickly return to your doctor for even
more support and understanding, more fiber to relieve constipation, more
painkillers, more Imodium, and even more antidepressants.
Q. Why does the conventional diagnosis of IBS increase
the risk of colon cancer?
Not just the colon, but any cancer! A visual
examination of the large intestine (i.e. colonoscopy) requires a bowel
prep — a thorough cleansing with synthetic laxatives. This procedure
damages intestinal flora, disrupts stools, makes resuming normal bowel
movements difficult, and may cause intestinal inflammation — the
precursor of colorectal polyps and cancers.
In addition to all of the side effects from a bowel
prep for conventional colonoscopy, a single virtual colonoscopy (CT
scan) exposes patients to radiation 2,000 to 3,000 times more potent
than a single dental X-ray. This dose of radiation, according to the
Federal Drugs Administration [link],
increases a person's lifetime risk of any cancer to 20%, or one chance
With minor variations, these ineffective and risky
diagnostic and treatment guidelines are repeated in
textbooks, references, how-to books, and health-related web sites. Not
surprisingly, according to the International Foundation for
Functional Gastrointestinal Disorders,
”irritable bowel syndrome (IBS) affects approximately 10-20% [30 to 60
million ? ed.] of the general population.” Lets hope you aren't
one of them, and if you are — lets get you out of this tangle before
it's too late.
At this juncture, you have three choices: (1) Do
nothing, and get by with this or that irritating your gut for the rest
of your life; (2) Continue with the conventional treatment I just
described above, and face the music; or (3) Study this page, follow its
recommendations, and recover from IBS.
“Recover” doesn‘t mean that you‘ll be able to eat and
drink with reckless abandon just like your happy-go-lucky buddies.
Unfortunately, you won‘t and you can‘t because an extended history
of IBS and, particularly, its conventional treatment causes damage that
completely reversible. So if eating and drinking with reckless abandon
are your objectives, don‘t bother reading this any further — alas, I am
not a magician.
But if you are a realist, then to “recover” means that by following my recommendations:
(1) you‘ll be free from abdominal pain and discomfort associated with
IBS; (2) you‘ll be able to attain normal stools without laxatives in
case of constipation, or fiber and medication in case of diarrhea; (3)
you‘ll boost your immune system, energy, stamina, and overall health,
and (4) you‘ll significantly reduce your chances of getting colorectal
Depending on your age and overall health, you may also
enjoy several unexpected benefits:
Improved quality of life. Your energy levels and stamina may
increase substantially, particularly from the elimination of
pain-relievers, antibiotics, antidepressants, laxatives, and
anti-diarrheal drugs. Most of these medicines are systemic, which means
they affect your body and mind just as strongly as your bowels.
Healthier children. If you have young children, you own positive
experience will teach you and them the habits of colorectal health (gut
sense), and they will grow up healthier, stronger, and well prepared for
today‘s demanding and competitive world.
Higher income. Your work performance and career will enjoy a
considerable boost because it‘s next to impossible to be productive,
efficient, and sociable while suffering from insomnia, or experiencing
day-long abdominal discomfort and flatus, or being affected by
Reproductive health. If you are a woman, you may find relief from PMS — an
oftentimes IBS-related condition. If you can‘t conceive a child without
any organic cause, or have been experiencing spontaneous miscarriages,
you may be able to overcome these two devastating problems as well.
Better sex life. If you are sexually active, your sex life will
improve dramatically, because you‘ll be free of bloating, flatulence,
and abdominal pain, which are particularly bothersome during
intercourse. You‘ll also experience stronger orgasms because you‘ll be
sufficiently relaxed to enjoy them without fearing embarrassing flatus
Significant savings. You‘ll be able to save a bundle of money related to
treatment of IBS-related symptoms and side effects, such as
constipation, diarrhea, hemorrhoids, diverticular disease, and numerous
Reduced cancer risk.
Finally, you are less likely to succumb to colorectal cancer — the
second leading cause of cancer-related deaths in the United States. This
is particularly important for high-risk individuals for colorectal
cancers. And with less x-rays and drugs — the same applies to all
With all these prudent goals in mind, here are the detailed
stage-by-stage descriptions of IBS causes, followed by step-by-step recovery
guidelines. It will take you less time to study this page than a single
visit to a GI specialist. Besides, this information is free to read, safe
to use, and tons more effective.
Reader's Testimonial "I've suffered for 10-12 years with IBS, and I've followed all the advice given to no avail. You know the advice. Fiber, fiber, fiber and little or no fat. I've written a novel, and in order to market it, I will have to hold book signings. This was a terrifying thought, considering I would go from constipation to "sudden" severe diarrhea. Never knowing when it might strike. In desperation, I searched the web — again — for an answer, and stumbled upon your website. I'm not doing the victory dance quite yet. But for about three months, I've been eating a normal diet. Moderate fiber, moderate fat, two meals a day. (I'm eating like I did before this happened - which by the way, I think was brought on by a weight loss diet that pushed high fiber, low fat. I ate fiber 5-6 times a day). And from week one I've improved to the point where my system is operating in a nearly normal way. Long story short (too late) I can't thank you enough!"" L.W.W., USA (via e-mail)
The Causes of
Irritable Bowel Syndrome
The following stage-by-stage narrative deconstructs the
etiology and unfolding of irritable bowel syndrome. Once IBS is no
longer a mystery, you'll have more confidence and motivation to proceed
toward your complete recovery, and avoid the relapse.
You may not
experience some of the symptoms and/or stages described below, but, with
minor variations, this is the most common scenario:
The loss of indigenous (innate) intestinal flora
(bacteria) precedes IBS, and is, in general terms, its initial and
primary cause. All the other problems (and causes) get layered in the
stages that follow.
Intestinal bacteria are an essential component of
normal colon ecology. They form stools, protect the intestinal membrane
from bacterial and viral pathogens, govern the primary immune response
(phagocytosis), and produce a range of micronutrients, essential for
health and longevity.
The two best known byproducts of intestinal flora
biosynthesis are vitamin K (responsible for blood coagulation) and
biotin (vitamin B-7). Vitamin K deficiency is behind internal bleedings,
pernicious anemia, inoperable ulcers, and strokes. Biotin deficiency is
behind hair loss, connective tissue disorders (i.e. dermatitis,
osteoarthritis, weak nails), and diabetes.
The common “killers” and causes of intestinal bacteria
are all well known. These are ubiquitous antibacterial medicines and
compounds (antibiotics and synthetic agents, such as isoniazid,
sulfonamide, methenamine, rifampin, hexachlorophene, etc.); antibiotic-laced meat and
dental amalgams (black fillings); mercury in fish and seafood; chlorine, arsenic and lead in drinking
water; lead in paint and environment; silverware, common laxatives, food
colorings, artificial sweeteners, infectious
diseases, intestinal inflammations, colonoscopies, x-rays, radiation,
chemo treatments, and numerous others.
Any one of the above factors may lead to partial or
complete evisceration of intestinal bacteria, a pathology known
as disbacteriosis (dysbiosis). In turn,
disbacteriosis results in hard stools, either small or large. These two
conditions — disbacteriosis and hard stools precipitates irritable bowel
syndrome. Enters Stage 2.
Bacteria are single-cell microorganisms. Just like all
cells in nature, they hold water, and hold it tight. Intestinal mucus
binds these “wet” bacteria with dry inorganic food remnants into moist,
soft, and pliable stools. But without bacteria, stools become small,
dry, and hard. The transformation of succulent grapes into weathered
raisins is a telling analogy:
The raisin-like small stools are a problem because the
large intestine wasn't designed to move around small objects, so they
get stuck — as in constipation. Unlike raisins though, small stools dry
up even more and become as hard as pebbles.
The pebble-like stools are an even bigger problem
because your anus isn't made of steel, but of a delicate and sensitive
tissue — similar to the inside lining of your nose. Thus the human anus
wasn't meant for passing “pebbles” through any more than your teeth were
meant for opening beer bottles (even though some of you probably can...)
If you are affected by disbacteriosis, and your diet is
low in fiber, then the hardened stools remain small and dry. If fiber is
present, then the hard stools are larger, because fiber adds bulk.
You may experience hard stools and still remain
regular, because you are an “expert” strainer, or can tolerate pain
better than others, or the degree of hardness is still tolerable, or all
of the above.
Constipation means irregular stools. A person is
considered “officially” constipated when bowel movements are absent over
three days. Diagnosing constipation is like reporting a missing
person—don't bother calling the police until 24 hours have passed.
Ditto, don't bother calling your doctor until 3 days have passed. If
it's only 2.5 days—sorry, you are still fine...
For this reason I prefer using the terms impacted
stools, hard stools, or costivity—slow in moving hard stools — instead
of constipation, which refers to not having stools over three days. This
way it's easier to convince people who pass hard stools in “under three
days,” (i.e., who are still technically regular) to seek treatment.
Hard stools, costivity, and constipation are commonly
reported by people trying out low-fiber diets, such as Atkins‘.
Obviously, it isn't the diet‘s fault that people run into these
problems. The cause is rather having disbacteriosis before commencing
If you consume plentiful fiber or fiber laxatives,
stool hardness may be less apparent. That's, incidentally, why fiber is
recommended in the first place. As in the next stage, of course.
Stage 4. Treatment of constipation with fiber
Medical professionals and Dr. Moms alike recommend
dietary fiber and fiber laxatives to “naturally” alleviate hardness,
particularly when stools are small and dry. Fiber bulks up (enlarges)
and moisturizes stools by either retaining water, blocking water
absorption, or both.
The most apparent damage from fiber in enlarged stools
are mechanical, related to its sheer physical bulk. Fiber is the only
commonly consumed nutrient that reaches the large intestine undigested
and expanded up to five times (500%) its original weight. On the other
hand, proteins, carbohydrates, and fats leave behind less than 5% of
Here is the same math in weight units: once in the
colon, 100 g of fiber turns into 500 g of undigested residue, while 100
g of proteins, fats, and carbohydrates digest down to less than 5 g of
solids. Thus, per unit of weight, undigested fiber is 100 times more
dense than all other nutrients (500 g / 5 g = 100 ). That's why doctors
refer to fiber-free diet as low density, and a high-fiber—as a high bulk
diet or roughage.
Historically, indigenous diets, even plant-based, were
low-density. That‘s because prehistoric people didn't have the means and
skills to grow, process, and prepare high-fiber food. For these
evolutionary reasons, human digestive organs haven‘t adapted to
high-bulk diets, and remain as vulnerable today as they did millennia
Unfortunately, enlarged stools require straining,
particularly as you get older. Welcome to Stage 5.
Stage 5. The hallmark of IBS: Straining
Younger people can expel large stools without apparent
difficulties because they still have much better control of pelvic and
abdominal muscles, stronger intestinal peristalsis, and less resistance
from internal hemorrhoids.
Normal defecation requires just as much effort as
urination—zero. If straining is necessary, however moderate, it means
that the size of stools exceeds the optimal spread of the anal canal.
The anal canal aperture maxes out at 35 mm or 1.4". For
normal, notice-free passing, soft and moist stools shouldn‘t be much
wider than one‘s index finger or a nickel (21 mm, U.S. currency 5 ?
coin), and correspondingly smaller in children.
If you need convincing that your anal canal is that
narrow, you can perform a digital rectal self-exam. No, you don't need a
computer. Just lubricate your pointing finger with petroleum jelly, and
slowly insert it into the anus. You will immediately realize just how
tight and narrow it is. (This test is called a digital test, because
“finger” in Latin is “digit.”)
Straining applies strong force by abdominal and pelvic
muscles on the colon and rectum to squeeze out stools — just like you
would squeeze out the last bit of toothpaste from a spent tube below:
Yes, that's pretty much what happens to the colon and
rectum when you strain extra hard. The damage isn't far behind: internal
and external hemorrhoidal disease, loss of urge sensation because of
anal nerve damage, stubborn anal fissures (skin tears inside anal canal)
that won‘t heal, loss of muscle tone and ensuing “lazy gut” syndrome,
rectal prolapse, rectocele (rectal wall prolapse into vagina),
diverticular disease, usually lethal colon perforation, and others.
Also, straining wreacks havoc “above and beyond” the
colon and rectum—strong abdominal pressure affects all organs situated
in the lower abdominal and pelvic cavity: the rest of the colon, small
intestine, uterus, bladder, and others.
This damage may manifest itself as obstruction of the
small intestine, reflux of fecal matter back into the small intestine,
abdominal and inguinal (men‘s) hernias, pelvic cramps, spontaneous
abortion (miscarriage), vaginal bleeding, symptoms of PMS, the blockage
of fallopian tubes, and other mechanical damage of internal organs.
Straining may also temporarily constrict major blood
vessels and cause blood clotting. Stray clots may cause pulmonary
embolism, heart attack, or stroke. Elevated blood pressure related to
straining may cause cardiac arrest, aortic rupture, internal
hemorrhages, strokes, heart attacks, and other major cardiovascular
calamities. Even the eyes aren't spared from vessel rupture and related
retinal and macular damage.
The vascular problems are made worse by poor blood
coagulation—disbacteriosis results in an acute deficiency of vitamin K—a
clotting factor. Normally, vitamin K is synthesized by intestinal
Women are expert strainers, because they have a far
greater voluntary control of pelvic muscles than do men. In some
respects, straining is similar to what's happening during natural
childbirth. Not surprisingly, women are affected by major colorectal
disorders — particularly hemorrhoidal and diverticular diseases — more
often than men.
On the other hand, men have stronger abdominal muscles,
and are more likely to develop abdominal wall or inguinal (groin)
hernias. If you look at weightlifters pumping heavy iron, their facial
expressions and grunts aren't that different from those of guys having a
hard time in the loo. But unlike an average Joe in the john,
weightlifters wear abdominal binders and groin trusses to prevent
herniation. (This may be a good gift idea for the ?constipated man‘ in
Even children aren't spared from the aftermath of
straining—nowadays, hemorrhoids are becoming commonplace even among preschoolers.
Just ask any pediatric gastroenterologist.
As you can see, there are plenty of reasons not to
strain, and even more reasons not to encourage children to strain.
Otherwise it's a straight path to hemorrhoidal disease.
Stage 6. The inevitable side effect of IBS: Internal hemorrhoids
Hard stools and straining, even moderate, cause the gradual
enlargement of internal hemorrhoids. That‘s due to the pressure applied
by passing stools on the inner walls of the anal canal inside, and
abdominal and pelvic muscles from the outside.
Internal hemorrhoids aren‘t a “disease,” but a part of
the anal canal anatomy—small collagenous pads that cushion passing
stools. Their enlargement is akin to calluses on your palms from
shovelling snow. According to the experts, by age 50, most adults have
asymptomatic enlarged internal hemorrhoids without realizing it.
External hemorrhoids are dilated, varicose veins of the
hemorrhoidal plexus. The thrombosis of external hemorrhoids causes
swelling and severe pain, but rarely bleeding. They do not affect
defecation per se, but may cause stool withholding and incomplete
emptying because of fear of pain and bleeding.
Anal intercourse damages the anal canal in a way
similar to hard stools and straining, only in reverse. Lubrication may
help to protect the anal canal from laceration, but not from the
enlargement of internal hemorrhoids, nerve damage, and the loss of
muscle tone in anal sphincters. Because of the latter, anal intercourse
is more likely to lead to fecal incontinence than constipation. This
fact is well known to gastroenterologists, who specialize in anorectal
restorative surgeries for men and women who engage in anal intercourse.
(Yes, I realize that some penile implements are wider
than 1.4” (35 ml), and have a hard time explaining how it's possible to
insert them into the anus. But, then, I tell myself—if some people can
swallow swords and others can swallow fists, then, with practice,
patience, and disregard for common sense, everything is possible.)
The very first symptoms of anal canal damage are pain
and bleeding. “Welcome” to the next stage!
Stage 7. Hemorrhoid-related pain and bleeding
The enlargement of internal hemorrhoids from straining
causes further constriction of an already narrow anal canal. While
passing through a constrained anal canal, hard stools lacerate its
delicate skin. Laceration causes bleeding or “streaking” of stools with
bright red blood.
Anal pain may differ in intensity, depending on the
degree of nerve damage. Older adults and diabetics may no longer feel
any pain because the nerve damage is complete. But when it isn't, the
anal plexus region is quite sensitive, and the pain, even from slight
pressure, may be quite sharp.
Seeing blood and experiencing pain brings about the
next problem—the sometimes conscious, sometimes unconscious decision to
withhold stools in order to avoid or prevent an unpleasant experience.
This causes an incomplete emptying of the bowels, and is particularly common
among toddlers, who can tolerate pain the least.
The large intestine of an average adult is 4.5 feet
(1.5 m) long, and can easily accumulate significant amounts of feces.
Because of incomplete emptying, many people routinely retain 5-10 or
more lbs of impacted stools without realizing it.
If a person isn't overweight, an experienced physician
may detect retained stools during a manual exam of the lower abdomen.
Because minerals aren't 100% transparent to the imaging source, retained
stools can be seen with various degrees of clarity on imaging scans,
such as x-ray, ultrasound, computed tomography, and MRI.
A person affected by disbacteriosis and on a fiber-free
diet can go without a single bowel movement for a month or more, and not
experience any noticeable side effects. With just 100 to 200 grams of stool
generated daily under these conditions, the large intestine has enough
holding capacity to store many weeks worth — particularly after these
stools dry up.
When the colon is filled to capacity, retained stools
are pushed down and out into the rectum, where they may stimulate
painful defecation. This way, more room is freed on top for the newer
feces to pile up, and repeat this cycle again and again.
When defecation is no longer attainable, the situation
is called fecal impaction. In this case, there are four possible
outcomes, and none of them are very good: (1) elective manual
disimpaction or surgery; (2) colon perforation; (3) fecal reflux (feces
flow back into the small intestine; (4) intestinal obstruction and ensuing
Okay, enough scarecrows... Normally, the large
intestine should contain well under 2 lb (1 kg) of retained feces, or
two to three days worth. A healthy stool shouldn‘t exceed 100-120 grams
per bowel movement*, usually twice daily.
People on high-fiber diets expel on average 300 to 500
g per bowel movement*, usually once daily. Longer intervals between
bowel movements increase total stool weight, but not linearly, because
of stools' drying out. (*Source: R.F. Schmidt, G. Thews; Human
Physiology, 2nd edition. 29.7.)
As incomplete emptying progresses, retained stools
compress, enlarge, harden up, dry out, and let newer feces pile up on
top to do the same. Incomplete emptying results in impacted stools,
described in the next stage of irritable bowel syndrome evolution.
This process of stool impaction is similar to sausage
manufacturing—a butcher uses a stuffing machine to fill in the casings,
ties the ends, and hangs them out to dry. That‘s why impacted stools and
certain brands of dry sausages look very much alike:
This is a “stage nine” cured dry chorizo sausage. Only
the “sausage” inside one's gut can get even larger and longer—around 3 to
5 feet, and
correspondingly heavier. And that braided shape of the sausage mirrors
the haustra pattern (small pouches) along the colon's walls. (Type 2 on Bristol Stool Scale].
Looking at this picture, it's easy to understand why
so many people suffer from the ravages of PMS, prostatitis,
constipation, hemorrhoids, irritable bowel syndrome, diverticular
disease, and, eventually, polyposis and colon cancer. Try imagining this kind of “sausage” inhabiting your
large intestine years on end, and not getting your colon irritated, or
your genitourinary organs not trampled upon. Yuck...
Impacted stools often bypass anal sinuses (the folds
between the colon and rectum) and enter the rectum (normally, the rectum
chamber is empty). This condition can be determined via rectal
self-exam. The presence of stools in the rectum may cause pain,
discomfort, and the feeling of incomplete emptying—the condition is known
as levator syndrome (from levator ani muscle).
When the colon and rectum can't accumulate any more
stools, the incoming digestive fluids may seep over, and cause a
diarrhea-like condition, which is called “paradoxical diarrhea.” But the
real paradox in this, pardon the pun, “shitty” situation is that very
few primary care physicians are familiar with it.
Thus, instead of disimpacting a sufferer (removing
impacted stools by hand, a specialized procedure usually performed in
hospitals), doctors may recommend even more fiber to “restore stools.”
When the additional fiber has no place to go, it causes obstruction,
perforation, or necrosis of the small intestine. These conditions are
rarely survivable, and always require massive abdominal surgery in order
to excise the affected sections.
Here is even more bad news: unlike small, soft, and
moist normal stools, impacted stools cause mechanical abrasions of
the mucous membranes. In turn, these abrasions open a pathway to various
pathogens into the inner reaches of the intestinal membranes, and seed
precancerous polyps. Along with the lack of protective bacteria, this, I
believe, is the PRIMARY cause of colorectal cancers. One more reason to
restore proper colon ecology! Only then can you avoid impacted stools,
prevent disbacteriosis, and restore intestinal flora.
The enlarged stools fill up the large intestine, and
produce considerable pressure on internal organs, particularly the
bladder, uterus and fallopian tubes among women, and prostate gland
among men. Since all of these organs have strong innervation and are quite
sensitive, you may feel in considerable pain, specific to premenstrual
syndrome (PMS) before and during periods. Men may experience heightened
sexual tension from the pressure on the prostate gland. Both genders may
be affected by frequent urination but without any significant volume of
At this point many people turn to
“nutritionally-orientated” doctors and “natural” web sites, which
enthusiastically recommend restoring bacterial flora with all sorts of
preparations. Great and well-worn advice by now, except for one little
detail: mixing fiber with bacteria in one's gut is like making compost
in one's backyard.
Household compost pile. Look familiar?
The incessant, round-the-clock fermentation of the
“compost pile” produces copious gases, sharp acids, and toxic alcohols.
Gases expand the large intestine. The expansion causes bloating. The
bloated intestines squeeze neighboring organs and may cause
obstructions, gastritis, heartburn, genital cramps, and so on. Acids
irritate the mucosal membranes and may cause inflammation. Methanol—one of
the alcohols—seeps into the blood and causes hangover-like side effects.
Alas, not enough ethanol is produced to at least enjoy the experience.
The degree of suffering from abdominal cramps and
intoxication varies greatly depending on one's age, gender, health,
occupation, character, genetics, amounts of fiber, types of fiber,
sources of fiber, and a whole load of other factors itemized in minutiae
throughout this site and in Fiber Menace.
For as long as all of the above is tolerable, it's
broadly accepted as a part of living. Between 10% and 15% of all
Americans endure diagnosed or undiagnosed irritable bowel syndrome as
just described. When the going gets tough, the tough... go to see their
A conservative treatment for severe abdominal distress
relies on antibiotics — along with more fiber and/or fiber laxatives.
First, antibiotics kill any remaining intestinal bacteria, terminate
“composting,” and alleviate intestinal inflammation. This stops bloating
and flatulence caused by gases and acidity produced by the fermentation
of fiber. Antibiotics don't reduce stool size or relieve constipation.
They may help to arrest diarrhea by removing and/or reducing its causes.
Next comes fiber: “Dietary fiber can help many patients
by absorbing water and solidifying stool. It may benefit patients with
either constipation or diarrhea.” So advises The Merck Manual of
Diagnosis and Therapy, an unquestionable “gold standard” reference for
most American doctors.
And so we go:
cramps—antibiotics—fiber—cramps—antibiotics—fiber? In other words you
become dependent on fiber and/or laxatives.
The absence of bacteria requires more fiber or
laxatives to deal with impacted stools. Newly consumed insoluble fiber
acts as a plunger by pushing them out. That's essentially what fiber is
— a plumber's plunger. And the straining is its handle.
To make the passage possible, soluble fiber or
laxatives lubricate and break down hardened stools, just like Drano?
would hair clog. They soften them up somewhat, and, when consumed in
excess, stimulate diarrhea.
Too bad your “plumbing” isn't made from cast iron. Even
then, this stage may last and last — until one unfortunate day your gut
“can't take it anymore,” and hits you “on the head” with a leak...
At one point impacted stools, or inflammatory disease,
or both, may cause profuse diarrhea—an innate physiological reaction to
“self-cleanse” the affected large intestine, similar to vomiting.
After a while the colon becomes “as clean as a
whistle,” but the diarrhea disrupts the colon's ecology. Fiber is
recommended to “restore formed stools.” Formed stools usher back
constipation and impacted stools, and this cycle repeats itself over and
Of course, these well known outcomes describe the
classical symptoms of irritable bowel syndrome—round-the-clock abdominal
distress accompanied by alternating patterns of constipation and
diarrhea, while, according to the doctors, “there is nothing wrong
Back to “square one,” unless... unless you follow my
suggestions and break out from this trap, otherwise it's down to Stage
#13. Oh, how appropriate...
The vicious cycles of intermittent constipation and
diarrhea repeat over and over again until more serious complications
arise. It may be hard-to-treat ulcerative colitis, or a devastating
Crohn‘s disease, or excruciatingly painful hemorrhoids, or dreadful
appendicitis, or gut-piercing diverticulitis, or a rarely survivable
perforated colon, or a deadly colon cancer, and God only knows what
When a person recovers from the initial treatment, more
fiber is prescribed again to prevent all these conditions. Not
surprisingly, up to 40% of ulcerative colitis victims undergo
proctocolectomy—a surgical removal of colon and rectum. Otherwise they
may bleed to death or die from colon cancer.
It's the exact same pattern for Crohn's disease, for
hemorrhoidal disease, for diverticular disease, for cancer survivors,
and pretty much for everything else. Fiber, more fiber, more darn fiber,
until one day, no patient—no problem. And it all started with the
accidental death of some “dirty little bugs” in Stage 1.
The next section explains how to reverse the causes of
IBS naturally, and to roll-back your state of health to pre-stage 1
status — proper colon ecology, normal stools, and no symptoms of IBS.
This approach may not make you again “as good as new” —
some of the above damage, unfortunately, is irreversible, but it
certainly beats becoming “as good as dead,” if you follow the
conventional IBS treatment.
IBS Recovery Guidelines
As I have already remarked in the introduction, the IBS treatment guidelines in
The Merck Manual represent what's known as the standard of care, or
“a diagnostic and treatment process that a clinician should follow for a
certain type of patient, illness, or clinical circumstance,”
according to Webster's Medical Dictionary.
— Okay, okay, I'll have more fiber tomorrow!
This “standard of care” approach is taught in medical
schools and residencies, and followed closely by
the majority of the U.S. medical doctors, who (a) may not know another (or better)
approach, and/or (b) use it to insulate themselves from malpractice
lawsuits by deferring to their own training, peer-reviewed protocols,
and the said standard of care.
It's important to note that the “standard of care” doesn't mean “best care,”
“effective care,” or even “good care.” At best, it reflects the current
consensus and prevailing groupthink of individuals and
institutions, which profit from the treatment (or mistreatment in the
case of IBS) of GI
Unlike The Merck Manual and similar references, this page enumerates in plain
language the exact physiological causes of irritable bowel syndrome and
offers effective, inexpensive, and self-administered treatment guidelines
which provide full and rapid recovery, assuming your condition hasn't
progressed far beyond IBS.
Even then, you still will find excellent (if
not full) relief from bloating, flatulence, constipation, diarrhea,
cramps, and pain, except it may take you longer, and you'll need to
manage intercurrent conditions, such
hemorrhoids, anal fissures, or diverticulosis, more attentively.
I encourage you to share the information on this site
and in Fiber Menace with
your physicians. They won't find anything contradictory in these texts to the
tenets of human anatomy, physiology, biology, biochemistry, and
pathology. To help them (and you), this site as
well as my books, are all thoroughly referenced and, with few
exceptions, accessible over the Internet.
Throughout the years, scores of medical
professionals have read my books, heard my radio talk shows, attended my
seminars, and scrutinized my web publications, and not
one, I repeat, not a single one has ever sent me a note pointing out an
error in my analysis or recommendations.
If anything, I am hearing back
praise and encouragement — doctors and nurses are people
too, and they suffer from digestive disorders just as much or more
(because they are more likely to follow Merck-type advice) as the general
There are no risks or side-effects associated with any
recommendations because I do not propose drugs, lopsided diets, or
invasive procedures. Your only risk is to ignore them, and progress to
inflammatory bowel diseases such as ulcerative colitis or Crohn's
disease, or degenerative diseases of the GI tract, such
as enlarged hemorrhoids, diverticulosis, or colorectal cancers.
Some readers, particularly medical professionals
trained in the so called evidence-based medicine, may
respond to these claims with a well-expected challenge: Mr. Monastyrsky,
Actually, it would be against the laws of medical
ethics (as well as civil and criminal statutes) to conduct a randomized
controlled medical trial with a known negative outcome (for patients in
the control group who would follow the Merck's guidelines).
IBS is classified by Merck as constipation-predominant
or diarrhea-predominant. Some people are diagnosed with IBS without
experiencing either constipation or diarrhea. Your steps to recovery
will depend on your particular type:
Step 1. Wean yourself off fiber. If you
have been consuming dietary fiber or taking fiber laxatives, you'll have
to break the dependence on these substances first because it's
impossible to overcome IBS while consuming fiber. Skip this step if it
isn't applicable in your case. Follow the recommendations in the Overcoming Fiber Dependence guide.
Step 2-A. Normalize stools for
constipation-predominant IBS. Follow the recommendations in the Constipation guide. As soon as you complete this step, you'll
find substantial relief from flatulence, bloating, abdominal pain, and
Step 2-B. Normalize stools for diarrhea-predominant IBS. If you can't abate diarrhea on your own by reducing or eliminating fiber, and using over-the-counter medications such as Imodium, ask your
doctor to test your stool for C.difficile infection.
Do this quickly, otherwise this condition may
cause significant anorectal damage (i.e. hemorrhoids, anal fissures,
nerve damage), and eventually turn into IBD, or inflammatory bowel
disease — an euphemism for ulcerative colitis and Crohn's disease.
If you are already affected by IBD (such as ulcerative colitis), you may not be able to
reverse it completely on your own because they have a significant
autoimmune component. Still, all of the strategies described on this
site and in Fiber Menace may help you a great deal.
Step 2-C: Normalize stools for IBS without
either constipation or diarrhea. This condition is common in
younger people, and explained here. In this case, proceed with the Colorectal Recovery Program.
Step 3. Restore intestinal flora and heal
bowel inflammation (if any). This step restores proper colon
ecology and stool morphology, and protects you from IBD, polyps, and
colorectal cancer. Follow the recommendations in the Restoring Intestinal Flora guide.
Step 4. Restore anorectal sensitivity. This step is essential for late stage IBS, particularly constipation or
diarrhea-predominant, because both conditions damage anorectal
sensitivity, so you don't experience the defecation urge sensation. This
sensation is important to maintain regularity and enjoy a complete
emptying of the bowels. Follow the recommendations in the Restoring Anorectal Sensitivity guide.
Step 5. Stabilize and maintain your recovery.
This isn't, really, a step, but a final and ongoing process. Use all of
the available information on this site and in Fiber Menace to prevent an
You should see and feel improvements soon
after you start. Depending on your age and degree of acquired, organic
(irreversible) damage, it takes from three to six months to become
completely free from IBS and its most bothersome and offensive symptoms.
It takes considerably more time to desynthesize
hypersensitive nerves (visceral hyperalgesia) inside your abdomen; to
reverse unconditional, endocrine reflexes (excessive secretion of
certain substances in the anticipation of food and stress); to reduce
autoimmune reactions to common food allergens; and to readjust to a new
style of nutrition. Just as with IBS itself, the actual length of time
will depend on your age, health, and a degree of commitment and
compliance with proper diet and supplements.
If you are relatively young and healthy, you won't have
to think much about IBS after full recovery. For older people with a
long history of IBS, staying free from IBS will require a life-long
commitment and vigilance. Whatever it takes, it's better to be healthy
and a bit preoccupied with your diet and colon, than to be in pain,
unhealthy, miserable, on a diet, and preoccupied with your colon even
more. That is, if you still have one!
The optimal nutrition for IBS
depends on your age, health, and extent of your condition. “Optimal
nutrition” means not just “best” or “permitted” nutrients, but also the
frequency of eating, food preparation techniques, meal composition, and
your ability to properly digest consumed food.
These considerations are commonly
ignored or overlooked in the routine treatment of IBS. Consequentially,
most people consume presumably a “healthy” diet, but only to dig
themselves into even more problems.
Here are the principal recommendations:
frequency of eating to two, maximum three times daily. Do not snack or
drink fluids between meals. Do not chew gum. Make middle-day meals as
low in fat as possible. Why? Any time you open your mouth, and begin chewing and swallowing,
particularly food rich in fat, the body goes though the
motions of the gastrocolic reflex and mass peristalsis, or a contraction
of the entire digestive tract.
These contractions are the primary cause
of cramping, abdominal pains, and/or excessive bowel movements that may
be confused with diarrhea-dominant IBS when they are semi-liquid.
dietary advice for people with IBS is the complete opposite — eat
smaller portions more often, snack between meals, drink plenty of
fluids, etc. This commonplace ignorance has little to do with either IBS
or the physiology of digestion.
absence of pain and cramping, frequent stools are the norm, not a
symptom of IBS, regardless of what your doctor may have been telling you
all along. These stools remain unformed simply because your colon isn't
getting enough time to remove moisture and form them.
If you are
consuming excess fiber, particularly soluble, it may also complicate
things by blocking the absorption of fluids and causing mild irritation
of the intestinal, mucosal membrane. All these factors may stimulate
peristalsis and excessive bowel movements, particularly in young and
healthy people, who aren't yet affected by nerve damage and/or bad
habits such as withholding stools.
proteins. These are casein — a protein found in dairy (milk, ice cream,
cream cheese) and gluten — a protein found in wheat, oats, bran, barley,
malt, ice creams, processed meats (chicken nuggets), gravies, brewer's
yeast, and derivative products (bread, pasta, morning cereals, beer, soy
sauce, cakes, pastries, etc.)
Why? Because humans lack the enzymes to digest
these proteins, and they are highly allergenic, particularly for people
with digestive disorders. When undigested proteins pass into the intestines,
they petrify (rot), cause gases, bloating, and low-level poisoning
expressed as severe fatigue, foul mood, muscle pain, nausea, and so on.
Adapt your diet content
and volume to your age.
Most adults past 45-50 years old, particularly in the United States,
suffer from age onset gastric deficiency (AOGD, a term I coined), or a
low level of digestive enzymes and gastric acid in the stomach.
condition causes indigestion, heartburn, delayed stomach emptying,
hiatus- hernia, gastritis, duodenitis, peptic ulcers, stomach and
esophageal cancers, and so on. AOGD is exacerbated by antacid
medication, alcohol, mixed meals, overeating, frequent eating,
inadequate chewing (habitual bad teeth, poor fitting dentures), and
overhydration. AOGD starts a chain of events which lead to a condition
known as gastroenterocolitis, or an inflammatory disease of the entire
There is only one way to adapt to AOGD: reduce the number of
daily meals to two, maximum three; do not eat mixed meals (i.e. proteins
and carbohydrates); eat protein-containing meals once daily (the last
meal is best), and follow other rules described on this site and in my
books. This approach is described in detail in Fiber Menace, chapter
Always consume fluids 30 to
60 minutes before meals. This allows water to pass the stomach chamber
into the small intestine and get assimilated there almost immediately.
Any fluids consumed after meals remain “locked” in the stomach until
digestion is complete, hence you can't easily satisfy thirst even if you
drink plenty of fluids. Excess fluids dilute already deficient gastric
juices and cause indigestion or delayed digestion. Healthy children and
young adults can consume plentiful fluids with meals or after with
apparent impunity because they have smaller (less stretched out)
stomachs, so the excess fluids are "pushed" out into the small
intestine; they enjoy better teeth, and have a much higher level of acid
and enzymes in the digestive juices.
professional-grade supplements and, if necessary digestive enzymes. They
are essential to augment nutrients and enzymes missing from any
restricted diet; to recover from long-term malnutrition caused by IBS
and IBD; and to compensate for age- and disease-related problems with
the assimilation of micronutrients. There is a great deal of talk going
on about supplements causing harm. If you consider the sub-par quality
of consumer-grade supplements that most people are taking, this talk is
fully justified. [link]
Maintaining proper nutrition
is one of the most difficult tasks for any person affected by digestive
disorders. It isn't because there is anything specific or particular
about it, but because eating (and overeating) became social phenomena;
because it's so hard to keep a separate diet from a healthy partner;
because restaurants don't cater to people with digestive disorders;
because most presumably healthy foods are atrocious, industrial junk;
because the art and habit of simple and nutritious home cooking has been
lost by most Americans born and raised in the fast-food era; because
there are so many enticements to overconsume; and because so many people
refuse to acknowledge their aging bodies, and fail to adjust to new
In any event, when confronted with the choice of
“keeping up with the Joneses” vis-?vis living without IBS, drugs, and
fear of colon cancer, I hope you'll choose the latter. And if you are
still relatively young, and your experience with IBS is brief and
fleeting, most likely you'll be able to continue eating with blissful
(or reckless) abandon for a good chunk of time. Assuming, of course,
that you fix the IBS first, stay off fiber, and guard your gut from
The FAQ section below expands the nutritional guidelines
considerably. I also recommend to review the rest of this site, and the
discussion of transition away from a fiber-dependent diet in Chapter
11, Avoiding the Perils of Transition in Fiber Menace.
Q. Why doctors can't find anything wrong with IBS
Doctors, particularly in the United States, are
trained to look for physical manifestations, such as inflammation,
obstruction, or bleeding. But, for a while, IBS displays none,
particularly in younger patients.
Despite this common knowledge, the diagnosing of IBS
allows for a ton of billable services to seek out “the clues:”
“CBC [complete blood count], biochemical profile
(including liver tests), ESR [erythrocyte sedimentation rate], stool
examination for ova and parasites (in those with diarrhea predominance),
thyroid-stimulating hormone and Ca for those with constipation, and
flexible sigmoidoscopy or colonoscopy should be done” — advises Merck, and piles up even more
tests to “test the tests:”
“Additional studies (such as ultrasound, CT [computer
tomography], barium enema x-ray, upper GI esophagogastroduodenoscopy,
and small-bowel x-rays) should be undertaken only when there are other
All in all, that's several thousand dollars worth of
mostly irrelevant testing, which in the case of “true” IBS will reveal
little or nothing, and in all cases will cause even more colorectal damage from x-ray
radiation, laxatives used to lavage the intestines before colonoscopy or
CT, and anesthesia administered during colonoscopy.
Merck even says this much: “Many patients with IBS
are overtested”. But the only true and relevant diagnostic
criteria of IBS — disbacteriosis, stool size, stool density, and
internal hemorrhoids and straining (both may be absent in younger
patients)— aren't considered.
Q. What is the difference in
treatment between diarrhea- and constipation-predominant IBS.
In general terms,
diarrhea-predominant IBS is a greater problem than
constipation-predominant, because diarrhea suggests the
presence of inflammatory disease in the large intestine. Whenever the
mucosal membrane is affected by inflammation, it fails to remove fluids from feces
and form stools. The ensuing accumulation of fluids causes diarrhea.
In terms of actual recovery,
patients with diarrhea-predominant IBS require a guarded diet to
eliminate food allergens and inflammation triggers, such as soluble fiber,
pectin, sorbitol, and others.
these patients must be screened for fecal impaction (a cause of
paradoxical diarrhea), Clostridium difficile (a bacterial cause
of colitis), parasites,
viral infections, biliary and pancreatic disorders, and undergo
the required medical treatment.
That's where the value of a skilled and attentive physician is paramount.
Some individuals, particularly
children and young women, may
experience stress-related diarrhea for reasons explained here. Obviously, it's
impossible to eliminate stress, but it's possible to learn how to redirect
and reduce your response to it. More about it here.
Q. How come I was diagnosed with IBS while I have
never been constipated or had diarrhea?
Constipation and diarrhea are late stage complications
of IBS. When IBS develops in younger people, they rarely experience
constipation or diarrhea, because they still have taught, supple, and
functional colons and rectums, sensitive anorectal plexes, undamaged anal
canals, and so they move their bowels like clockwork.
IBS itself begins with the gradual enlargement of
stools either from fiber, or from a mild inflammation of the intestinal
mucosa caused by the by-products of fiber fermentation, or from evolving
food allergies, or from the loss of intestinal flora, or from all of the
At one point or another enlarged stools require
moderate straining. This, in turn, enlarges internal hemorrhoids
(unbeknown to most until late or at all) and constricts
an already narrow anal canal even more. This leads to incomplete
emptying, further hardening of stools, further enlarging of hemorrhoids,
and more straining. Then, one day, a person can't strain hard enough to move
bowels at all for more than three days. That's — no stools for more
than three days — what The Merck Manual calls constipation, and
that's the definition that most doctors and patients are saddled with.
It may take you 5, 10, 20, 30 or more years to reach
that day, depending on your doctor's directions, age, gender, diet, toilet habits,
degree of luck, and multitude of other factors discussed throughout this
If prior to that moment you had uncomfortable stools
every other day or so, technically you were not constipated. Medically
speaking, you are
“healthy” until day four! Before that — don't bother the doctors, and take more fiber.
All of this would be really funny if it wasn't so
tragic. You can learn more about this charade doctors “play” with
The role of fiber in the pathogenesis of colorectal disorders, including
IBS, is explained here.
Q. How can I distinguish IBS from IBD?
The "syndrome" in IBS stands for a collection of symptoms
that make up this condition. Its‘ interpretation varies from textbook to
textbook, from reference to reference, and from doctor to doctor. In
other words, diagnosing IBS is a "free-for-all" enterprise, because
there are no actual physical attributes (i.e. inflammation, bleeding,
high-temperature, blood tests, etc.) to cling too.
Most of the IBS symptoms are also present in IBD (i.e.
inflammatory bowel disease). The primary distinguishing characteristics
of early stage IBD (i.e. before endoscopy shows inflammation) are:
stools close to diarrhea; excess mucus in stools;
sustained, round-the-clock bloating, but with less flatulence,
typical for IBS because by this time most of the bacteria are dead, and
fermentable matter (i.e. fiber, the source of gases) is rapidly disposed
off during diarrhea.
Q. What's the difference between just "bloating"
vis-?vis "bloating and flatulence?"
The absence of flatulence (i.e. gases) points out to
disbacteriosis. When flatus is present, the bloating results primarily
from gases. The bloating without gases (or with very little) indicates
inflammation of the mucosal membrane of the small and large intestine.
This inflammatory condition traps gases and fluids
(i.e. prevents their absorption into blood), and increases the diameter
of intestines, particularly the small intestine. Because this organ is
so large (around 14 to 22 feet in adults) and so tightly packed inside the abdominal
cavity, even a small increase in its diameter distends (pushes out) the
abdominal wall, hence the "bloating."
The gases in the small intestine are always naturally formed when
the acidic content of the stomach moves in, and gets neutralized by
pancreatic juices (bicarbonate).
The petrifaction (rotting) of
undigested proteins may form gases too. The gases in the large intestine
are formed when undigested carbohydrates (fibers, lactose,
polysaccharides, sugar alcohols) get fermented by bacteria.
Bacteria are often present in the lower small intestine
(ileum), and may form profuse gases there from fermentation too. These
are usually the most bothersome, because they have no place to escape.
The gases from the large intestine may also escape into
the small intestine whenever the ileocecal valve opens up to let the content of the
small intestine pass into the large intestine.
Q. Why do antibiotics reduce cramping and bloating
related to IBS and IBD?
Antibiotics kill bacteria in the small and
large intestine, and terminate fermentation of undigested carbohydrates.
This stops fermentation and production of gases, alcohols, and fatty
acids, and helps subdue an inflammatory condition. In turn, the
intestines shrink and reduce internal pressure on internal organs.
Unfortunately, antibiotics also ruin normal colon
ecology, and cause problems, ranging from severe diarrhea to an equally
severe constipation. They also strip the intestinal membrane from it's
natural protectors (i.e. bacteria), reduce primary immunity (phagocytosis), blood
clotting, vitamin synthesis, and so on. So, logically, you are better
off excluding fiber and other sources of undigested carbs to stop
fermentation, rather than use an "atomic bomb" approach to wipe out
Besides, there are always some antibiotic-resistant
mutant bacteria (such as methicillin-resistant Staphylococcus aureus,
MSRA) left behind, and they are the ones which
may eventually kill you, particularly in the hospital setting. At this
point, you have nobody to thank, but the profit-driven “Big Pharma” and
Q. What's a difference between the role of soluble and
insoluble fiber in the pathogenesis of IBS?
Insoluble fiber (bulking agent) makes stools large.
Large stools induce straining, straining causes the enlargement of
internal hemorrhoids, enlarged hemorrhoids cause incomplete emptying,
incomplete emptying causes impacted stools, impacted stools cause
Soluble fiber (hydrophilic mucilloid) blocks the
absorption of digestive fluids. Blocked fluids, including astringent
bile and omnivorous enzymes, slip down into the large intestine, and
wreak havoc there. To cleanse itself of irritants and impacted stools,
the large intestine responds with profuse diarrhea. When the diarrhea is
over, the colon's examination shows no visible damage. Back on fiber,
and the cycle starts again.
Both fibers are fermentable. If the bacteria level is
normal, soluble fiber ferments 100%, insoluble — about 50% with normal
motility, almost 100% with slow motility (common in IBS).
In the overall scheme of things, soluble fiber is by
far more damaging then insoluble, except in the cases of (a)
inflammatory bowel disease (caused primarily by soluble fiber), and (b)
obstruction in young children and older adults. In the case of IBD —
because inflammation prevents water absorption and narrows the
passageway; in young children — because their internal organs as so tiny
and so easy to obstruct; and in older adults — because of slow and
inefficient peristalsis, often made worse by the indiscriminate use of
systemic drugs, which may affect peristalsis even more.
Q. Why people with IBS are advised to avoid fats?
Along with advice to use fiber, this is one of the most
damaging recommendations in all of IBS-related dietary dogma. In fact,
the absence of fats makes IBS and its‘ side-effects much worse, and
turns it into IBDs. You can read more about the role of fats in digestion
and colorectal disorders here.
If anything, the absence of fats will cause more damage to your entire
digestive tract, health, and cause severe constipation (i.e. a primary
symptom of IBS), because dietary fats are essential for regularity. You
can read more about the role of fats in constipation here.
It's true that dietary fats precipitate the
gastrocolic reflex and peristaltic mass movement — two conditions
essential for normal propulsion of food through the GI tract, normal
stool formation, and normal defecation. Indeed, this normal
physiological effect of fat precedes pain and cramping in impaired
individuals, and results from normal peristalsis encountering large
stools and gases — an effect similar to giving a shiatsu massage to your
abdomen in the midst of IBS relapse.
In the long-term, the “killing” or reducing of
peristalsis by restricting fats makes all IBS-related constipation even
worse — more constipation, more fecal impaction, larger stools, more
pain, more sensitivity to pain, stiffer, smooth muscles, and impaired
muscle contraction from severe calcium deficiency, because calcium
doesn't get assimilated without fat in the diet.
Q. Does stress contribute to IBS? Is there indeed a
psychosocial aspect to IBS?
Stress contributes to practically all disorders, not
just IBS, because the chemistry behind the stress response isn't merely
mental or perceptual, but endocrine — meaning any stress or even the
anticipation of stress elicits an unconscious secretion or
over-secretion of multiple stress hormones, which govern physical
aspects of the stress response. These are adrenalin, noradrenalin,
cortisol, and some others.
In the case of IBS, stress hormones inhibit gastric
digestion and intestinal propulsion (peristalsis). These two conditions
predispose people to a broad range of functional GI disorders. The most
typical ones are: nausea, vomiting, indigestion, heartburn, GERD, peptic
ulcers, bloating, abdominal cramps, and constipation or diarrhea,
depending on stress intensity and duration.
There are two core reasons behind all these happenings:
Elevated blood pressure
compensation. Rapidly elevated blood pressure in response to a
sudden, strong stress event causes a near instant release of excess
blood plasma into the stomach and large intestine lumen to normalize it.
This is the body's “safety release valve”, essential to prevent blood
vessels and capillaries from rupture. Unfortunately, rapid stretching of
the stomach with fluids stimulates the vomiting center which causes
nausea and vomiting. Similarly, excess fluids in the colon flow
downwards, stimulate the anal plexus and provoke profuse diarrhea.
Impact on digestion and
motility. Moderate or even low-level sustained stress inhibits
digestion and motility (peristaltic propulsion of food and stools) in
order to mobilize energy for a flight-or-fight type of response.
Sustained, long-term stress leads to indigestion “on the top,” and
constipation “on the bottom” because nothing, literally, moves. Both
conditions — indigestion and constipation — contribute mightily to IBS
and related digestive disorders.
Can you do anything about it? Yes, you can. In cases of
major stress events, it's a matter of training and conditioning.
Professional soldiers don't soil their pants or vomit when they get
fired at — they duck, evade, and respond. If they can be trained to
ignore bullets, so can
you to evade mother-in-law, ignore an obnoxious co-worker, and duck away
from rude drivers, and there is plenty of specialized literature, dedicated to this
Moderate and/or extended stress must be managed with
proper nutritional “hygiene.” When exposed to stress of any modality or
duration, use the following rules:
While under severe or even moderate stress, protein may not digest fully
because stress hormones inhibit gastric secretion and peristalsis.
Restricting proteins allows you to prevent indigestion, dyspepsia, food
poisoning, and related complications.
This particular advice often
elicits scorn and disdain from low-carb zealots, particularly young
turks with no formal training in medicine or nutrition. One such turk wrote on his blog
about my similar advice to people with gastritis: “Smart and
intelligent people can be very stupid.” Well, kid, I'd rather be
stupid and healthy, than smart and dead. And so are my readers. This
page (or my books) aren't about low-carbing, but chronic digestive
Always hydrate (drink
water) yourself on an empty stomach. If your stomach is
full with food, don't flood it with more water because (a) it will
inhibit digestion even more; (b) it may cause nausea and vomiting; and
(c) it will not satisfy your thirst because water can't get down into
the intestines to get assimilated. Instead, place something sweet into
your mouth, sweetness stimulates saliva secretion and this will make the
thirst less apparent.
Normalize blood sugar.
After an initial spike of stress hormones, blood sugar dives down
considerably, and you may experience strong cravings for sweets. If your stomach is
already full, don't stuff it with more food to get your sugar fix — they
won't give you any more “blood sugar” until carbs get down into the
intestines. Instead, use near instant sublingual glucose tablets, or
dissolve a sugar cube, or piece of chocolate under the tongue. You only
need 2-3 grams of glucose to stabilize low blood sugar, and, in this
case, the sublingual path is the fastest available (other than an I.V.
Eat only if hungry. Don't eat your regular meals if you aren't hungry — most people under
stress aren't, except to satisfy their sugar cravings. If you do eat, you aren't
likely to digest these foods anyway. So if you crave sugar, then get
some sugar, not a turkey sandwich.
Don't skip regular bowel
movements. You aren't likely to experience the defecation urge
because stress inhibits intestinal peristalsis. But missing even one
bowel movement dries out and enlarges stools already in the colon — a
prescription for constipation. To stimulate stools without straining,
use the “helpers” described here.
As you can see, it isn't the stress per se, that causes
IBS, but the lack of knowledge and readiness to deal with it and its
aftermath. Well, now you know!
Q. So what's the role of psychotherapy in all this? Is
it a fluke or has it some role?
Yes, in a very limited way, but absoluty “no” in all
substantive ways. Here is the drill:
— No, because psychotherapy can't eliminate the
underlying, physical causes of irritable bowel syndrome by pep talk
and/or hypnosis alone.
— No, because psychotherapy can't completely rewire the
innate, evolutionary, fight-or-flight type of stress response even in
the most sophisticated, dedicated, and motivated individuals.
— No, because a shrink isn't a substitute for a normal
— No, because wishful thinking is the worst treatment
for internal disorders with clear-cut physiological causes.
— Yes, because many cases of stress response are
self-perpetuating — i.e. fear breeds more fear. Assuming you can find
and afford a skilled enough psychologist to break that endless loop,
yes, it helps a great deal.
— Yes, because you can learn (or be taught) to respond
to stress in a less self-destructive and agonizing way.
— Yes, because psychotherapy and related approaches
(yoga, meditation, prayer, controlled breathing, chants, etc.) do offer
a palliative, temporary release from acute pain. This effect results
from the general
relaxation and temporary reduction of stress hormones.
But, as I have already said, you can't chase away
excess gases and large stools, or plant back missing bacteria by using
palliative psychology any more than you can fill a cavity with hypnosis
or reverse breast cancer with motivational therapy.
Q. Is smoking bad for IBS?
Yes, it is, because smoking stimulates saliva secretion.
In turn, smoke-laced saliva gets swallowed, and stimulates the secretion
of gastric juices,
the gastrocolic reflex, and peristaltic mass movement — the precursors
to abdominal cramps and/or diarrhea. That's, incidentally, why people
are told not to smoke on an empty stomach.
Interestingly, my own bout with severe IBS started soon
after I quit smoking in 1984, but for exactly the opposite reason — I
no longer had sufficient stimulation of intestinal peristalsis to
initiate regular bowel movements, skipped a few, became chronically constipated, and
started to rely on fiber laxatives, such as Metamucil, to move my
Q. What about alcohol? Is it bad for IBS?
In general, yes, it's bad for IBS, particularly during
acute stages. Lets review the reasons:
First, alcoholic beverages in
themselves are fluids which inhibit gastric digestion when consumed in
excess with or after food. The side effects of indigestion and related
complications inevitably boomerang into IBS.
Second, excessive alcohol
(whenever you feel the buzz) inhibits digestive tract peristalsis. For
this reason you may actually feel a temporary relief from abdominal pain
and cramping. But, just like in the case with Imodium, poor
contraction contributes to constipation.
Third, alcohol in excess
causes dehydration and sodium loss because the large intestine is very
effective at recovering every bit of moisture and sodium from stools.
This particular aspect of alcohol-related dehydration dries out stools,
causes constipation, and may contribute to IBS.
When dehydration and sodium
loss become extreme, you may actually experience diarrhea because of
a sodium-potassium blood imbalance. To compensate, the body dumps excess
potassium (along with gobs of plasma, of course) into the colon's lumen.
This, in turn, causes profuse diarrhea, which dehydrates you even more.
A similar chain of events
(sans alcohol) causes runner's diarrhea. Western athletes
listen to that stupid advice and load themselves up with Gatorade — a
potassium- and sugar-rich drink — before and while running. No wonder,
the diminutive Kenyans win all those darn marathons — they don't have
sports medicine doctors or Gatorade in Kenya yet to compromise their
health and performance. To be fair, Gatorade contains sodium, but not
enough to compensate its losses with sweat during actual races.
To my amazement, the cause of
runner's diarrhea is still (2008) considered unknown. Well, not anymore. To prevent dehydration and diarrhea, load up on salt before the
race because sodium is essential for water retention. That's why the
I.V. drip contains 0.9% of sodium chloride, not potassium. For the same
reason, pickles and brine are so “therapeutic” after a sauna or for a
hangover. Who, but the Russians, would know all that...
Fourth, alcohol affects the
liver function. This, in turn, may cause a profuse release of bile — the
body‘s way of removing offensive metabolites. This action causes an almost
immediate diarrhea, which may lead to constipation, and contribute to
Fifth, some alcoholic
beverages are highly allergenic to sensitive individuals. The biggest
offenders are: beer for gluten-sensitive individuals (most people with
IBS are); tonic mixed with gin from allergies to quinine; sulfites in
wines, cognacs, and aged scotch, which may cause diarrhea; loads of
fiber in V-8 added to ?Bloody Mary,‘ and probably many others.
Six, alcohol lowers blood
sugar (this, actually, causes drunkenness). In turn, low blood sugar
raises the levels of insulin and that's what makes some drunk people so
angry and aggressive, as it raises their levels of stress hormone. These
two simultaneous actions stimulate appetite on the one hand, and inhibit
digestion on the other, and that's what is causing nausea, vomiting, and
hangovers. One bad binge may easily precipitate IBS, particularly in
middle-aged persons who aren‘t adept at hard drinking. Younger people
are less vulnerable, because, for a while, they enjoy “guts of steel.”
Will you get harmed by a glass of wine along with dinner? Probably
not, as long as you are drinking French or Italian table wines, vin de
table and vino da tavola, respectively.
Q. What‘s so special about table wines, and what
it has to do with IBS?
Vintage (or quality by the European Union
definition) wines are aged in oak casks. New wine casks are treated with
sulfites to prevent expensive oak wood from rotting. Aging infuses wines
with these sulfites. Unlike vintage,
table wines are made and kept in stainless steel vats, and they never
get exposed to oak impregnated with sulfites.
The less scrupulous producers of inexpensive table
wines (and often vintage wines too), add extra sulfites to prevent spoilage, so these wines can be
shipped, sold, and stored without regard to
temperature almost indefinitely.
This practice is widespread outside of the European
Union, but particularly in the United States and Latin America.
For this reason I never
touch American wines, unless the label says “Organic.” This way I am
assured of having good night sleep and clear head the “morning after.”
Sulfites are very strong allergens. Just like MSG,
they produce a very unpleasant “histamine flush,” which is what causes
its‘ nasty after-effects, such as migraine, insomnia, nausea, dizziness,
sweating, tachycardia, wheezing, hives, pale skin, and even anaphylaxis
in hypersensitive individuals. Unfortunately,
histamine intensifies inflammatory conditions, which are prevalent in
people with IBS.
It‘s not such a big deal in the United States where the
culture of daily wine drinking was all but non-existent until very
recently and the drinking age is 21. But it is (a big deal) for French or
Italians who drink table wines with practically every meal and literally
from birth (though highly diluted).
No wonder they can‘t afford experiencing daily
hangovers or anaphylactic shock, particularly among children. For these
reasons adding sulfites to table wine intentionally may get one into
prison in France, while in the United States it‘s taught in winery
courses as “good business.”
You‘ll still see the “Contains Sulfites” statement on
practically all wine labels, table or not, because, apparently, they
occur in wines naturally. I say “apparently,” because I don‘t believe
this is true. But it‘s cheaper for the E.U.-based winemakers and
distributors to comply with the U.S. labeling regulations, than
to certify their wines as “organic” or “sulfites-free.” After all, table
(a.k.a. jug) wines are bought mainly on price, not the quality or purity
Histamine receptors (H2) play an important role in the
secretion of gastric juices, and, correspondingly, in digestion. For
these reasons sulfites and alcohol may cause dyspepsia — a general term
for unspecific stomach distress. This condition is particularly harmful
to people already affected by irritable bowel syndrome or inflammatory
In general, if you have already developed an allergic
reaction to sulfites in wines, you may react adversely even to “clean”
wines — the immune system commonly produces antibodies to other wine components, and
retains this “body memory” for a considerable length of time. In this
case, you are better off skipping alcoholic beverages aged in casks,
such as wines, ports, champagnes, vermouths, sakes, cognacs, whiskeys
(scotches), and others.
— What‘s left? Any good triple-distilled vodka, such as
Smirnoff. And don‘t waste your money on all those “gourmet” vodkas in
artisan bottles. Many of those have that discerning taste precisely
because they are inadequately distilled and are more likely to cause
hangovers. Only this time around, it isn‘t from added sulfites, but from toxic
alcohols other than ethanol (i.e. pure alcohol).
So, show me some wine (scotch, cognac, etc.)
?cognoscenti‘ — those snobbish and oftentimes arrogant guys, and
nowadays, gals too — who swoon over aged bottles of expensive grape
juice or malted barley, and discuss “notes” the way mere mortals
Angelina Jolie of early vintage, and I‘ll show you a fool in the high-risk group for IBS, IBD,
peptic ulcers, and digestive cancers.
How come the French get away with it? Well, actually,
they don‘t. The rate of digestive cancers in France is quite high as
well, but it has to do more with smoking than wine. Besides,
even when the French drink vintage wines on special occasions or after
dinner, they do so by the sip, not by the goblet, the way the ?nouveau
riche‘ drink nowadays.
— What do I drink? Lately, I don‘t, because alcohol
interferes with my writing, energy, mood, and sleep. The only
exception — when we are going out for sashimi. In this case, I‘ll have a
glass of sake in order to sterilize raw fish with alcohol. I also always
take with me MSG and gluten-free soy sauce. Just like sulfites,
both of these substances are an absolute no-no for people with IBS, IBD, or a
past history of both.
Q. Why do you know all this and doctors don't?
I don't know any more about “all this” than
particularly board certified gastroenterologists, gastric oncologists, or
endoscopists, except that I am better trained to research
and analyze broadly available information and research, investigate inconsistencies,
connect the dots, and describe my findings in accessible language.
All of the background information I rely upon is
described in exceptional depth in primary medical texts as well as
medical references, including The Merck Manual, which I quote so often.
I learned most of these basic facts back in the seventies in medical
schools from textbooks authored decades earlier, and from professors trained
before World War II.
If a medical doctor doesn't know “all this” basic
information about human digestion, he/she wouldn't be able to pass a
licensing board exam. So this question should really ask: “Why doctors
don't use all this information to treat patients?”
Well, some do, particularly outside of the United
States. Since most of the healthcare delivery in the United States is
orchestrated by pharmaceutical companies, which publish the majority of
textbooks and references, administer continuous medical education (CME)
courses, design and administer licensing exams, and own or sponsor most
of the medical publications and web sites, doctors are trained to rely
more on tests and drugs, than on inexpensive and truly
Besides, it's faster and easier to write prescriptions;
drugs offer quick relief to patients and create an aura of competence;
and the drugs' side effects bring a ton more repeat business soon
thereafter. So why kill the bonanza writing web pages (such as this), or waste valuable
“face” time teaching patients the fine points of stools?
In the doctors' defense, I have to say this: the majority
patients don't give a damn about the causes of their diseases; don't care to learn
how to eliminate these causes, don't want to change anything in their lives
and diets, and
prefer an instant fix with this or that pill, ideally for free.
Naturally, doctors, insurers, and pharmaceutical companies respond to
“market pressures” just like any other business worth its salt would —
they give their customers what they want! It's good business, and,
it's great for business.
If you have read this page this far, you are a welcome
exception. So don't be a dupe, do the right thing, don't dwell far too
long over things outside of your circles of control and influence, and
show others the way simply by getting well. It sure beats popping pills,
wearing a colectomy bag, or bleeding to death.
I suffered from IBS most of my adult life. I can easily
trace its origins to my mother's insistence that I never use public restrooms, to indiscriminate use of antibiotics before I
became aware of their perils, to dental
amalgams that I briefly had, to fiber laxatives that I took for chronic
constipation, and, finally, to years
of a high-fiber, vegetarian diet.
I am IBS-free for almost a decade now. Unfortunately, by the time I had learned all this,
enlarged internal hemorrhoids and reduced anorectal sensitivity had already been “set in stone,”
although I “don't know” about them for as long as I follow all of the
same recommendations described above.
So my interest in and the knowledge of this subject is far from abstract — I am not exactly a nun
teaching sex education
from textbooks written by a celibate monk.
Still, one man's journey through hell isn't enough to plot a
path to heaven for another... That's why my work is so
explicitly thorough, referenced, and detailed, and why it took me almost ten years
after my own complete recovery from IBS to contemplate, research, and
write this page.
Good luck and be well,
 Re: “the
causes of IBS are still a mystery”
There is nothing mysterious about IBS. Its causes
are well-known and well-studied functional conditions, such
as disbacteriosis, suppression of stools, hard stools, excess dietary
fiber, common food allergens, laxatives, the side effects of medications,
and some others. All of them can be reversed reasonably well, with
minimal effort, and without a doctor.
Merck Manual, on the other hand, recommends screening patients for
inflammations, ulcers, polyps, and other pathologies with IBS-like
approach is similar to using radiology (x-rays) and endoscopy to diagnose
indigestion, while ignoring to check for inadequate acidity, low
enzymes, bad diet, and poor-fitting dentures — the four principal causes
of bad digestion. No wonder then, when gastritis or ulcers aren't found,
indigestion too becomes a mystery.
it is surprising. In the general paradigm of allopathic medicine (which
forms Merck's diagnostic and treatment framework), the disease isn't a
disease, unless it has a diagnostic procedure or drug treatment attached
Unfortunately for patients with IBS — a functional condition completely
outside of Merck‘s framework — this reality introduces harmful
diagnostic procedures, the side effects of unnecessary drugs, and more
health problems down the road.
 Re: Aggressive medical treatment of
inflammatory bowel disease
A nutritional approach to GI disorders described on this site
and in Fiber Menace may be
effective for the early stages of ulcerative colitis, and should always be
tried before starting “shock and awe” treatment with antibiotics,
steroids, and immunodepressants.
also enhance the treatment and improve the outlook of Crohn's disease,
but not really “fix it,” because this condition has a significant
autoimmune component that can‘t be controlled by diet alone.
approach works well because a great deal of U.C.-related intestinal
inflammation may result from gastroenteritis, so a gradual recovery must
begin at the very top of the digestive tract.
Later stages of U.C.
require a more thorough and intensive therapy, determined by your
physician. But the nutritional approach is the same.
Originally, I described nutritional intervention for ulcerative colitis
in my earlier Russian-language books. According to limited accounts
from readers who followed it, they have recovered and remained in
remission for as long as they maintained vigilance — ulcerative colitis
may be easily set off again by preexisting trigger factors.
 Re: “Criticism” of The Merck Manual of
Diagnosis and Therapy
Some people may get mad at me
for suggesting that their revered Merck Manual may be wrong, and who am
I to criticize it?
Most of the Merck Manual's
shortcomings and biases are heavily influenced by the drugs-driven ways
of it's publisher and a charter member of the Big Pharma — Merck & Co.
Inc. The borderline
between influence and profit is a very narrow one, and it
forms an approach that may initially have good intentions, but not
necessarily good outcomes.
Besides, if Merck & Co. could err so
“deadly” with Vioxx or Fosamax, they can err just as much with The
because its editorial and professional scrutiny is nowhere
near the hoops reserved for prescription drugs prior to their review by
To be truly credible,
trustworthy, and useful to doctors and patients alike, The Merck Manual
should be fully divested from its ignominious parent, and obliged to follow rules of disclosure and transparency
similar to the rest of the academic medical press.
You and I aren't alone consuming fiber in the name of our health only to suffer unknowingly from the scourge of IBS and its countless complications. And the more you suffer from this criminal racket, the more fiber you are told to consume, so that the Big Agra, Big Pharma, and Big Medicine can keep minting blood money from selling you more drugs, more toxic laxatives, more colonoscopies, and more surgeries.
According to the National Digestive Diseases Information Clearinghouse, as many as 20% of the adult population — that's close to 50 million Americans — are affected by IBS [link]. One of these people may be your close friend, colleague, or relative. Or a child... But you may not even know about it because most people we know don't usually discuss the goings on inside their guts.
So, just like I shared with you all that I know about the devastating role of fiber in the pathogenesis of IBS, please click one or more of the buttons below to share this critical information with the people you love!