Irritable Bowel Syndrome -part 2- with Constipation and Methane Dominance

Gut Health
Written By Varsha Rathod

Irritable Bowel Syndrome with Constipation (IBS-C) is a functional gastrointestinal disorder characterized by chronic constipation and abdominal discomfort. In the Western world, IBS-C is so common that it is considered normal and therefore is often asymptomatic till some other health crisis arises such as a sinus infection that needs antibiotics before symptoms begin to be felt.

A subset of patients with IBS-C exhibit elevated levels of methane gas in their gut, often referred to as "methane-positive" IBS-C or IMO- Intestinal Methanogen Overgrowth. This condition involves a complex interplay of gut motility, microbiota composition, and gas production, which may exacerbate constipation symptoms. It is the topic of this article. There are other causes of constipation and IBS that were discussed in the general blog article on IBS and will not be discussed here.

This slide is from a webinar given by Dr. Mark Pimentel, M.D. Note the red part of the slide that is pertinent to this article.

Pathophysiology of Methane-Positive IBS-C

Methane gas in the gut is primarily produced by methanogenic archaea, such as Methanobrevibacter smithii. (This is neither a bacterium nor a virus, but an ancient species known as Archaea.) Normally, a clean-up wave in the small intestine called the Migrating Motor Complex (MMC) sweeps bacteria into the colon, maintaining optimally low levels of bacteria in the small bowel. However, methane slows transit time, leading to constipation and incomplete cleaning of the small intestine, creating a vicious cycle. Methane-positive IBS-C is often familial and can be resistant to treatment compared to other forms of IBS. It is helpful to rule out infection and autoimmunity as a cause for methane production as it is treated a little differently.

Symptoms and Diagnosis

Patients with methane-positive IBS-C often report:

  • Severe and persistent constipation

  • Bloating and abdominal distension

  • Flatulence

  • Abdominal pain

  • Hard, pellet-like stools

  • A sensation of incomplete evacuation

  • Abnormal weight gain

  • Rosacea- though this is associated with all forms of IBS micro types.

This slide is from a webinar given by Dr. Mark Pimentel, M.D. showing how the production of H2 by E. coli species in the small bowel, allows it to be used by M. Smithii to produce Methane. Why M Smithii and other archae colonizes the gut is a mystery to be solved. This is not a bacterium but an ancient species known as Archaea.

Diagnosis involves:

  1. Clinical History and Physical Examination: To rule out other causes of constipation.

  2. Breath Testing: Mark Pimentel, M.D. from UCLA has pioneered and studied the best triple breath test using lactulose called TRIO Smart. It checks what type of gas production is causing your issue i.e. if you manufacture hydrogen, hydrogen sulfide or methane.

  3. IBS.Smart tests your blood for infectious causes for IBS by testing for antibodies to cytodistending peptide B (cdpB) and Vinculin. The latter antibody leads to constipation. This would be treated differently than if you are naturally a methane producer.

  4. I also use Vibrant labs leaky gut testing (wheat zoomer and gut-zoomer ) to personalize treatment for digestion, addressing other pathogens, inflammation and probiotics usage. The stool test often shows a preponderance of Methanobrevibacter smithii and a pattern of SIBO although that pattern is only suggestive of SIBO and cannot be used diagnostically.

  5. Colonoscopy or Imaging: Performed in select cases to exclude structural abnormalities.

Management Strategies

1. Dietary Modifications

  • Fermentable Fiber: While low-fiber diets are often used to treat SIBO, long-term fiber intake is essential for methane-positive SIBO to promote peristalsis and stool movement. Recommended sources include flax, chia, psyllium, acacia, quinoa, millet, brown rice, and small doses of legumes. I also prescribe Fiber-mend by Thorne* and other supplements.

  • Polyphenols: Green tea, Pendulum Polyphenol*, and Atrantil can help prevent excess bacterial fiber fermentation by creating an optimal environment for them. The more colorful the foods consumed, the higher the polyphenol content in your gut.

  • Protein and Fat Intake: Reducing high-fat and processed meats, replacing them with lean protein like steamed or baked chicken and fish, and opting for 0% fat yogurt if dairy is tolerated are good options. Nuts and seeds should be consumed in moderation. Legumes and grains that are tolerated should be gradually increased as they not only provide protein but also fermentable fiber and allow a diverse array of microbial species to thrive and create an optimal community of gut commensals or microbial residents. Interestingly, patients with this form of IBS do not tolerate grains and legumes, yet it is what they need to get better. This is why the transition to a plant forward diet high in fiber must be undertaken cautiously by including a lot more steamed soft squashy vegetables and root vegetables initially and then gradually beginning to add and subsequently increase the grains, legumes and the high sulfur containing vegetables.

2. Antimicrobial Therapy

  • Antibiotics: Rifaximin alone helps only 41% of patients who are methane producers but, combining it with Neomycin increases success rates to over 85%. Neomycin should not be used for more than 7-14 days.

  • Botanical Antibiotics: Atrantil* and Atrantil Pro* have been studied as effective alternatives. A small 2016 study found that 21 out of 24 patients responded positively. Some practitioners also use Allimed* (450 mg), Oregano (Biotics ADP*), and Neem (Ayush*) or Blood Cleanse by Banyan Botanicals*) along with biofilm disruptors. I use these after a course of antibiotics. Please note that these antibiotics do not have systemic effects in the body but remain largely localized to the gut. ( to use the Las Vegas adage, what stays in the gut remains in the gut!)

3. Breaking Biofilms

Most gut bacteria reside in mucus colonies known as biofilms, which protect them from antibiotics. Breaking down biofilms enhances treatment efficacy. Effective agents include:

  • Enzymes: Kirkman Biofilm Defense*, Klaire Labs Interphase Plus* (with EDTA), and Biodisrupt** (which includes enzymes, herbs, and NAC).

  • These should be taken twice daily, one hour before eating or two hours’ post-meal.

4. Probiotics

Different bacterial strains have varying effects on motility, so personalized probiotic use is recommended based on gut testing. Prebiotics and postbiotics, such as fiber and butyric acid as (tributyrin supreme) by Designs for health or (tributyrin 350 Active) by apex labs*) supplements, can also support gut health in patients with constipation. Butyrate is the fuel that is utilized by colonic cells to repair its lining and regenerate. It also reduces inflammation and creates a healthy environment for the right kind of microbial colonies to populate the colon thereby reducing the overabundance of some species that lead to an imbalance.

5. Digestive Support must be personalized.

  • Betaine, digestive enzymes, and bile salts can improve digestion and motility. I use Digest or Carbo G by Transformation Enzymes* as well as Liver Support-Transformation Enzymes*, if constipation is leading to elevated liver enzymes. If the liver enzymes are more likely from fatty liver than treating inflammation and insulin sensitization will help.

  • Bitters and liver support may help, especially for patients with elevated liver enzymes. I usually use liver support by Transformation Enzymes* when the liver enzymes are elevated due to constipation rather than to insulin resistance. Vitanica makes Bitters extra*- 1 capsule with a meal helps digestion. It is usually taken with a digestive enzyme.

Emerging Therapies and Research

Research into methane-positive IBS-C is ongoing, with areas of interest including:

  • Microbiome Modulation: Exploring targeted therapies to alter gut microbial composition.

  • Fecal Microbiota Transplantation (FMT): Investigating its potential to restore a healthy gut microbiota balance.

  • Novel Antibiotics and Enzyme Inhibitors: Development of treatments that specifically target methane-producing archaea.

Conclusion

Methane-positive IBS-C presents unique challenges due to the interplay between methane production and slowed intestinal transit. A personalized approach, integrating dietary adjustments, pharmacological interventions, and lifestyle changes, offers the best prospects for symptom relief. As research advances, a deeper understanding of gut microbiota and methane’s role in gastrointestinal health may pave the way for more effective therapies. While this article outlines a plan to treat yourself, I highly recommend working with a functional medicine professional who is actively treating and testing for the various IBS micro types rather than directly ordering supplements.



 

Varsha Rathod
Next

Irritable Bowel Syndrome-the underlying cause- part 1