Gastrotintestinal - Phytotherapeutic approaches to lower bowel disease Part II

Part II: Constipation, diarrhea, IBS, Diverticular Diseases

Chanchal Cabrera, MNIMH, AHG

Medical Herbalism 11(2):1,3-7

This article is continued from our last issue.


This is a condition in which bowel movements occur infrequently, or in which the feces are hard and small, or where the passage of feces causes difficulty or pain. Constipation is a symptom, not a disease, and should be treated as such. Attempts must be made to find out the underlying cause, otherwise treatment will not be effective in the long term, or may cause injury. Ideally the number of bowel movements in a day should be equal to the number of meals eaten the previous day. This is often not the case, but there should be at least one good elimination each day. The stool should be soft but not loose or runny and should break apart a little in the toilet pan. The color will vary somewhat according to the diet but generally should be a uniform light brown.

While occasional constipation (a missed day or two) will not be seriously detrimental to the health, chronic constipation can have significant implications in the body. The bowels are a major channel of elimination and if they are not working adequately then the other channels (kidney, skin and lungs) will have a greater work load. Many metabolites cannot be eliminated by other channels, so if the bowels are incompetent then toxins rapidly accumulate in the body. This may manifest as bad breath, body odor, skin eruptions, visual impairment, headaches, muscle & joint pains and mental confusion. Prolonged constipation may result in absorption of toxins and bacteria from the bowel and has been associated with diabetes mellitus, meningitis, myasthenia gravis, thyroid disease, auto-immunity, cancer and ulcerative colitis.

There are many possible causes and aggravating factors in constipation. These include:

Dietary factors such as low fiber, inadequate fluids and excess refined foods.

Physical inactivity e.g.. prolonged bed rest or general lack of exercise.


Endocrine imbalance such as hypothyroidism, hypopituitarism or phaeochromocytoma.

Bowel diseases such as diverticulitis, irritable bowel syndrome, or tumors.

Acute abdominal disease such as peritonitis and appendicitis.

Nerve disorders e.g.. acute injuries to the head or spinal cord; or chronic degenerative conditions such as multiple sclerosis, tumors of the spine or splanchnic nerves that supply the abdominal organs, or cerebral disorders such as stroke, Parkinsonism, or tumors.

Various drugs such as anesthetics, antacids, anticholinergics, anticonvulsants, antihypertensives antipsychotics, beta-blockers, diuretics, iron, bismuth, muscle relaxants, antispasmodics, opiates, and certain heavy metals like arsenic, lead & mercury.

Metabolic abnormalities such as hypokalemia, hyperglycemia, or uraemia.

Psychogenic factors such as stress and nervous tension or emotional disturbances.

Repeated ignoring of the urge to defecate will result in lack of sensitivity to the need for elimination.

Repeated use of retention enemas will dilate the colon and make it insensitive to the nerve impulses that occur with dilation and that begin the defecation process.

Laxative abuse.

Holistic treatment of constipation

Before commencing treatment for the constipation itself the causative factors must be identified and treated. Often this is sufficient and the constipation will spontaneously resolve. If treatment is required for the constipation then there are several factors to consider.


Dietary fiber holds water in the colon which makes the stools softer and bulkier. This stimulates the defecation reflex and makes the stools easier to pass. Fiber also tends to hold toxins in the stool and minimize their reabsorption as well as making the transit time faster. Fiber is exclusively found in plant foods (fruits, vegetables, pulses and grains. It does not occur in animal foods. Thus the diet should emphasize vegetable foods and minimize animal foods. Oat bran appears to be the gentlest and most effective form of added fibre to use. 1/4 to ½ cup per day should be added to soups, stews, baking and cooked cereals. Psyllium may also be taken. Raw foods tend to be more stimulating to the colon so should be increased to form at least ½ of the daily intake of food. Plenty of fluids should be taken, 6 - 8 glasses of water per day being ideal. Herb teas would also work but coffee and black tea are constipating and should be avoided.


Adequate exercise is very important to ensure good circulation and muscle tone in the pelvic cavity. Any exercise that gets the legs and pelvis moving will be good: yoga, walking, running, dancing. The exercise should be reasonably vigorous and should last at least 20 minutes 3 or 4 times per week.

The urge to defecate should never be suppressed. To train the bowel to function optimally, it is recommended to develop the habit of going to the bathroom every morning at a regular time regardless of whether the defecation urge occurs. Over time the body will learn that this is the time for elimination. Evacuation is easiest in a squatting position which relaxes the pelvic floor muscles. Some countries have toilets designed for this. Where squatting is not possible then it will be helpful to raise the feet on a small stool.


Sometimes dietary and lifestyle changes are insufficient to reverse old patterns of constipation and then a laxative may be useful. Care should be taken that the person doesn’t become dependent on the laxative.

Laxatives derive their effects in several ways.

Hydrophillic and osmotic laxatives draw water to themselves and hold it in the colon. This serves to soften the stool and give it bulk. Osmotic laxatives may also be called bulking agents or stool softeners. Examples: Plantago ovata (Psyllium), Linum usitasissimum (Flax)

Contact stimulants irritate the colon wall and cause it to attempt to evacuate the offending substance. Mineral oil and castor oil are the most common of this type of laxative.

Bowel wall tonics and stimulants promote regular and strong contractions of the colonic musculature. Herbal remedies in this category commonly contain anthraquinone glycosides. Examples: Rhamnus spp. (Cascara / Buckthorn), Cassia spp. (Senna), and Bryonia dioica (White bryony).

Hepatics, cholagogues and choleretics improve bowel function by activating the liver and gall bladder. This creates a reflex activation of the bowel and also tends to improve the tone of the colon musculature.

There are 4 classes of herbal laxative, each stronger than the last. Only the first 2 are normally used.


Taraxacum off. radix (Dandelion)

Arctium lappa (Burdock)

Rumex crispus (Yellow Dock)

Rheum off./palmatum (Turkey Rhubarb)


Gentle bulking type

Linum usitasissimum (Flax/Linseed)

Plantago psyllium (Psyllium seeds)

Stronger irritating type

Rhamnus frangula (Alder Buckthorn)

Rhamnus purshiana (Cascara sagrada)

Bryonia dioica (White Bryony)


Prunus verticillastus (Black Alder)

Cassia angustifolia (Senna)

Ulmus glutinosa (Alder)


Aloe africana (Cape Aloes)

Phytolacca decandra (Pokeroot)

Herbal laxatives of all classes are usually prescribed with a carminative to minimize griping.

Before prescribing a laxative you should attempt to determine whether there is hypertonicity or hypotonicity in the colon. Either situation may lead to constipation but will require different treatment approaches. Lack of exercise, prolonged bed rest or habitual use of laxatives generally leads to a loss of bowel tone (hypotonicity) while stress and nervous tension generally leads to excessive bowel tone (hypertonicity). Hypertonic constipation is more common in younger people while hypotonic constipation is more common is the elderly.

In the hypotonic state, stimulating laxatives and liver and gall bladder remedies may be the most appropriate while in the hypertonic situation you should avoid stimulating the bowel and use, instead, the osmotic bulking agents as well as nervines and muscle relaxants.

Aloe vera gel is a bulk laxative that is very soothing and healing to the entire digestive tract. The aloe plant contains glucomannan a polysaccharide which is the bulking agent. It also contains aloin, aloe-emodin & barbaloin, anthraquinone-glycosides that are cathartic if used in excess.

Colonic irrigation can be very helpful in retraining the bowel whether it is hypotonic or hypertonic. This procedure can also be useful in assisting the reduction of laxative abuse.

Procedure for reducing laxative use

This is a protocol that can be used to assist people who are habitually using commercial laxative as well as those who wish to wean themselves off herbal laxative agents. People who have been taking commercial laxatives should switch to an herbal formula for 1 week, the dose depending on their individual requirement to ensure 1 bowel movement a day. After this first week the dosage should be reduced by half for 1 week. Each week thereafter reduce the dosage by half until the amount is so small that you can stop altogether. If constipation recurs at any point then go back to the previous weeks dose for a further week then reduce again.


This refers to unusually frequent bowel movements, or the passage of abnormally soft or liquid stools. It is often associated with nausea or vomiting and colicky pain. There are many possible types and causes of diarrhea:

Osmotic diarrhea occurs when there is an excess of non-absorbable water-soluble substances present in the bowel leading to retention of water in the stool. Possible causes include lactose intolerance, ingestion of large amounts of sugars, excessive intake of vitamin C, over use of laxatives containing magnesium, phosphate, or sulphate, general nutrient malabsorption and the use of certain antacids containing magnesium. In this type of diarrhoea the extent and severity is proportional to the amount of the offending substance ingested and the situation is alleviated by cessation of the intake of the substance.

Secretory diarrhea occurs when the large intestine secretes rather than absorbs electrolytes and water. Possible causes include the presence of bacterial toxins (e.g.. from food poisoning or drinking polluted water) where water is required to wash them away; unabsorbed bile acids after ileal resection; certain entero-pathogenic viruses; unabsorbed dietary fats in liver or gall bladder disease; excessive use of anthraquinone cathartics or other irritating laxatives; imbalances of certain hormones such as secretin or calcitonin; or prostaglandin imbalances.

Note that malabsorption syndrome can cause diarrhoea by either of the above mechanisms.

Exudative diarrhea occurs when there is acute or chronic inflammation in the gastro-intestinal tract leading to copious production of inflammatory exudate.

Short transit time will cause diarrhea because there is insufficient time for fluid absorption to occur. The most common causes of this are intestinal resection, which reduces the surface area of the intestines, and stress which speeds up peristalsis.

Diarrhea may also result from anti-biotic use causing the death of commensal bowel flora.

The holistic treatment of diarrhoea

Diarrhea, like constipation, is a symptom not a disease in itself. You must always look for the underlying pathology before attempting to treat the diarrhoea itself.

If the diarrhoea is due to food poisoning or a virus or bacteria then it should be regarded as a cleansing process and should not be suppressed unless very severe or prolonged.

Food allergies, specially lactose or gluten intolerances, are very common causes of chronic low grade diarrhoea. A short fast followed by challenge testing may be employed to determine the type and extent of allergic involvement.

Most cases of diarrhea are simple and self limiting. Minimal interference is the best policy, with simple dietary and herbal remedies usually being adequate. Only if the problem does not resolve within 1 week would you begin to consider other more detailed treatment.

During an acute attack of diarrhoea no solid foods should be taken. There should be a high fluid intake, diluted vegetable juices and broth being the best along with certain herbal teas. If dehydration is feared then the World Health organization recommends the following rehydration formula:

3.5 g. sodium chloride

2.5 g. sodium bicarbonate

1.5 g. potassium chloride

20 g. glucose

This is dissolved in 1 liter of water. 1 liter to be taken hourly for dehydration in adults, proportionately less for children. The liquid part of this formula could be made of herbal teas such as Fennel, Peppermint, Chamomile, Lemon Balm, or any other carminative.

When food is reintroduced, it should be low-allergen and easily digested. Vegetable soup, yogurt, cooked fruits, or grated apple are preferred foods. It will be useful to take probiotics and garlic to re-colonize the bowel flora, which may become depleted during diarrhoea.

If it becomes necessary to stop the diarrhoea itself, then astringent herbs may be employed in the form of teas or enemas. Psyllium seeds may also be used to absorb excess water in the colon and thus give solidity to overly loose stools. In bacterial infections, Hydrastis canadensis and Berberis vulgaris may be useful because of their strong anti-bacterial properties. They both also have a tonic effect on the bowel. A quick and effective remedy to stop acute diarrhoea is to take 1 tablespoon of unsweetened carob powder and stir it into a cup of water. This can be taken hourly as needed.

Irritable Bowel Syndrome

This is the most common gastro-intestinal disorder reported to general practitioners and up to 50% of referrals to gastro-intestinal specialists are for this complaint. It presents as recurrent abdominal pain and distention with diarrhoea and/or constipation, in the absence of any demonstrable organic pathology. It is more common in women, especially between ages 20-40 years. There is commonly a mufti-factorial etiology including psychogenic factors (stress) , food intolerance, antibiotic therapy, or food poisoning. Lactose intolerance is common among people with IBS.

Symptoms include:

Pain in the right and / or left iliac fossae and/or in the hypogastrium.

Pain may be ‘flitting’ and is typically increased with food and reduced by defecation

 Bowel habits are variable and frequently alternating: diarrhoea especially in the morning, pellet-like (‘rabbit dropping’) stools, constipation


Excessive flatus

Loud bowel sounds


Weight loss


Lack of energy

Conditions which may mimic IBS include:

Inflammatory bowel diseases such as Ulcerative colitis or Crohn’s disease.

Laxative abuse.

Diverticular disease.

Metabolic disorders such as diabetes mellitus, hyper or hypothyroidism and adrenal insufficiency.

Disturbance of bowel flora from antibiotic or antacid use.

Intestinal candidiasis.

Infectious enteritis (e.g. amoebiasis or giardiasis).

Lactose intolerance.

Holistic treatment of irritable bowel syndrome

The diet should consist of small regular meals with no binging or fasting. A high fibre diet will be helpful to increase stool bulk and act as a stool softener. As wheat is so often implicated in food allergies, it is probably best to avoid adding wheat bran to the diet but to increase fibre by the use of fruits, vegetables, legumes, oat bran and psyllium.

Because food intolerances are so often implicated in the aetiology of IBS it is important to determine what these may be and avoid aggravating foods. Conventional blood tests of suspected allergens will be unlikely to give positive results because many food allergies are mediated by IgG and not IgE which is what most of the blood tests measure. Also some food intolerances are not mediated by the immune system at all. Thus the best way of testing for IBS food intolerances is by elimination diets and systematic reintroduction of foods. See related article Constitutional Food Intolerance by Paul Bergner in Volume 11, Number 1 Spring 1999 issue.

Many people diagnosed with IBS will find that their symptoms clear up when they undergo a treatment for systemic candidiasis and it is often useful to follow the anti - candida program.

Psychogenic factors are very significant in the causation and the aggravation of IBS and it may be useful for the sufferer to undergo a course of counseling, hypnotherapy or psychotherapy in order to learn to deal with these factors. Relaxing nervines will also be of benefit.

Herbal remedies


Intestinal tonics

Anodynes/analgesics as required.

Tonic nervines and relaxants

If the psychogenic factors are very predominant then the person may be helped by Valeriana off. (Valerian) and other relaxing nervines and hypnotics

Chamomilla recutita (Chamomile), Melissa off. (Lemon balm) and Humulus lupulus (Hops) are particularly useful herbs in IBS because they have relaxing and calming effect on both the digestive system and the nervous system.

Bulk laxative herbs (Psyllium, Ulmus fulva) may be taken for both diarrhea and constipation, softening and bulking a small hard stool and absorbing water and giving form to a very loose stool. In cases of constipation more water should be taken with the fibre.

Sample formula for irritable bowel syndrome

Where constipation is the predominant bowel pattern

Chamomilla recutita (Chamomile) carminative, relaxing nervine, bitter, anti-inflammatory    1 part

Melissa officinalis (Lemon balm) relaxing nervine, carminative, anti-spasmodic                1 part

Rumex crispus (Yellow dock) mildly laxative for occasional use                        1 part

Viburnum opulus (Cramp bark) muscle relaxant, anti-spasmodic    1 part

Althea off. (Marshmallow) soothing demulcent, anti-inflammatory    1 part

Lobelia inflata (Lobelia) muscle relaxant, anti-spasmodic        ½ part

Where diarrhoea and looseness are the predominant bowel pattern

Chamomilla recutita (Chamomile) carminative, relaxing nervine, bitter, anti-inflammatory    1 part

Humulus lupulus (Hops) astringent, bitter, carminative, relaxing nervine    1 part

Potentilla tormentilla (Tormentil) gentle astringent                1 part

Mentha piperita (peppermint) carminative, tonic nervine            1 part

Hydrastis canadensis (Goldenseal) astringent, bitter, mucosal tonic        1 part

Cinnamomum zeylanica (Cinnamon) warming, astringent, circulatory tonic    1 part

Diverticular Disease

Diverticulae are pouches or small herniations of the colonic mucosa through the muscular gut wall. They may occur anywhere in the colon but are most frequent in the sigmoid colon. The size varies from 3mm. to over 3cm. in diameter. They are present in up to 40% of persons over the age of 50 years and the incidence rises with increasing age. Their presence is labeled diverticulosis. If they become inflamed or infected then the resulting condition is referred to as diverticulitis.

A diet which is highly refined, high in meats and consistently low in fibre causes the colon to contract harder to move matter along. Eventually this increased intra-luminal pressure may cause herniation of the mucosa through weak spots in the colon wall (usually where colonic blood vessels pierce the muscle to supply the underlying mucosa). The diverticulae are easily filled with feces, and because they are only mucosal and have no musculature they cannot contract to expel it. Thus a local inflammation occurs which may progress to actual infection. This process may be single or multiple, and may spontaneously resolve or may cause frank diverticular disease. As the intraluminal pressure builds up in the colon, the thin-walled diverticulae can rupture and this will permit leakage of bowel contents and bacteria into the pelvic cavity with consequent peritonitis. The inflamed bowel segment often adheres to other pelvic organs (e.g. uterus or ovaries) and a fistula may develop from bowel to another hollow organ. With repeated inflammations the colon wall thickens and the lumen narrows. This may lead to bowel obstruction. Occasionally rupture of the diverticula may also rupture a branch of the colonic artery and this can lead to acute bowel hemorrhage.

Simple diverticulae are frequently asymptomatic, the signs and symptoms occurring usually once the sacs become infected or inflamed. Possible symptoms and signs include:

Varying degrees of left iliac fossa pain of a colicky nature.

Constipation with bouts of (sometimes bloody) diarrhoea.

Rectal bleeding.

Loss of appetite.


Pain and tenderness may also be present in other parts of the colon, depending on where the diverticulae occur. A tender mass may be palpable in the colon, most commonly in the left iliac fossa. There may also be hard, tender, multiple, small masses that do not move on palpation. Pain aggravated by urination indicates adhesions of the bowel onto the bladder. Pain that is worst before or during the menses indicates adhesions of the bowel onto the uterus. Irregular menses suggests the possibility of adhesions of the bowel onto the ovaries.

Holistic treatment of diverticular disease

Regular exercise is important to ensure that there is adequate blood flow in the pelvic cavity which will help inflammation and relieve pelvic congestion. Yoga, walking, cycling, swimming, dancing and running are all effective.

Constipation should be addressed with the use of softening bulk laxatives. Never use harsh irritating laxatives such as Senna or Cascara. If something stronger than Psyllium is required use Yellow dock and Dandelion root. Water should be taken at a rate of one 8 oz glass per 20 pounds weight. A high fibre diet will also help.

The maintenance diet should emphasize fruits and vegetables and meat and dairy products should be minimized. All seeds and nuts should be ground or soaked and all grains should be well cooked to avoid irritating the colon mucosa and to prevent them from getting stuck in the diverticulae. Sugar, fried foods, coffee, black tea and spices should be avoided. Flax seeds are useful to provide both fibre and essential fatty acids. The seeds should be freshly ground just before using, 2 - 4 tablespoons per day in cooked cereals, soups, salads etc.

The same supplement regime as described in the section on chronic inflammatory bowel disease (See Volume 11, Number 1, Spring 1999) may be usefully employed in diverticlar disease.

Herbal remedies



Soft bulk laxative

Alteratives & blood cleansers

Pelvic decongestants

Other useful treatments include clay or castor oil packs over the abdomen to improve local circulation, alleviate inflammation and remove congestion. Colonic irrigation with chlorophyll implants are very beneficial in breaking down the impacted feces and removing it from the system. High doses of garlic and probiotics are useful in helping to regulate the bowel flora. Warm sitz baths with Chamomilla recutita (Chamomile) and Lavandula spp. (Lavender) may be beneficial in relaxing the colonic musculature and reducing inflammation.

Sample formula for diverticular disease

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

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

                                        1 part

Dioscorea villosa (Wild yam) anti-inflammatory            1 part

Althea off. (Marshmallow) soothing demulcent                1 part

Chamomilla recutita (Chamomile) bitter, anti-inflammatory, anti-allergenic, relaxing nervine                                     1 part

Viburnum opulus (Cramp bark) muscle relaxant, anti-spasmodic    1 part
  Copyright 2001 Paul Bergner

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