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My Approach to IBD & IBS

Mechanisms and Processes

An examination of the similarities and differences

By Andrew Kornfeld, BA, BS

Why I’m Writing This Post

As many of you know, I’ve been working diligently on the next iteration of IBDCoach, a transformative company set to address a multitude of chronic health conditions. Our mission is to fundamentally change healthcare systems, and we are set to launch next year. While our flagship program will continue to focus on the Inflammatory Bowel Diseases (IBD – Crohn’s disease, ulcerative colitis, indeterminate colitis, and microscopic colitis), we plan to expand to other gut-related conditions such as Irritable Bowel Syndrome (IBS), Small Intestinal Bacterial Overgrowth (SIBO), and diverticulitis shortly thereafter.

In the interim, I’ve been extremely fortunate since opening my personal coaching practice to be working with incredible new individuals with both IBD and IBS and I wanted to write a post to help demystify some of the differences between the conditions and illuminate the similarities – especially in the mechanism of action. This post will provide you a unique insight and may help you see your condition differently regardless of your diagnosis: IBD, IBS, or another lifestyle based condition.

Let’s dive in 👇

IBD Mechanism

In IBD, a combination of genetic, microbial (dysbiosis)[1–3], psychosocial, and other environmental factors contribute to the breakdown of the mucosal membrane. [4] This results in increased gut permeability [5,6] due to dysfunctional tight junction proteins, which are essential for holding the cells of the GI tract together. When microbes from the microbiota seep into the lamina propria (an area just beneath the first layer of cells), the body initiates an immune response (inflammation) [5] against these organisms. This isn’t an attack on the tissue itself; however, there’s collateral damage to the digestive tract in the process. In Crohn’s disease, this inflammation can manifest anywhere and is transmural, often appearing in the terminal ileum and colon. In contrast, ulcerative colitis affects only the most superficial layers, with inflammation exclusively located in the colon.

IBS Mechanism

Similar to IBD, factors such as genetics, microbes, psychosocial influences, and other environmental elements play a role in IBS. Additionally, there’s a believed increase in membrane permeability, possibly involving tight junction proteins, akin to IBD. There’s also an immune response, but the narrative shifts at this juncture. Instead of the immune activity leading to visible, physical lesions, this inflammation activates the Enteric Nervous System (ENS, which governs the gut). This, in turn, stimulates the Central Nervous System (CNS, comprising the brain and spinal cord), causing alterations in gut motility, changes in bowel movements, and visceral hypersensitivity (intense pain perception in the bowels). [7–9] These disturbances culminate in the signature symptoms of IBS: abdominal pain and variations in bowel movements. This can manifest as diarrhea (IBS-D), constipation (IBS-C), a combination of both (IBS-Mixed or IBS-M), or as undefined symptoms (IBS-U). [10]

Figure Sources: Molecular Mechanisms of Microbiota-Mediated Pathology in Irritable Bowel Syndrome (open source article)

Approaching IBD and IBS

While both the ENS and CNS play significant roles in IBD, especially contributing to changes in bowel movements such as diarrhea, they play an even central role in IBS.

To simplify, I’ve delineated my processes for addressing IBD and IBS with this difference in mind:

3 Step Process to IBD

(For a detailed approach, see our poster presented at the Crohn’s and Colitis Congress in 2022.)

4 Step Process to IBS

(I’ll soon release a microcourse on IBS that dives deeper into this, but for now, read more below.)

Inflammation

In IBD, it’s possible to halt inflammation using a multidimensional approach. In acute cases, corticosteroids often offer the quickest relief and can be the spark for lifestyle interventions (like diet, exercise, and mindfulness) to be a primary or secondary maintenance strategy. However, in the long run, in some cases other immunomodulatory, small-molecule medications and biologics can play an essential role. [11] It’s worth noting that I don’t see medications as “life-sentences,” but rather as strategic tools to control inflammation for specific periods. Countless foods and supplements, including vitamin D, [12] omega-3 fatty acids, [13] quercetin, [14] curcumin, [15] and other flavonoids and polyphenols found in tea, pomegranate juice, blueberries, [16,17] etc., can help modulate the immune system in IBD. It’s possible many of these agents can be beneficial in IBS (especially curcumin [18]), albeit in a more indirect manner and over extended durations, and additionally for prevention of flare ups. Modulating inflammation in IBS is an emerging concept and more research is needed in how to best address it. While there is less evidence in controlling inflammation directly in IBS with anti-inflammatory herbs and medicines, the role of inflammation is quite established and cannot be ignored. While the inflammation in IBD could be more related to the body’s over reactions to microbial translocations (leakage), the inflammation in IBS appears more strongly tied to the gut-brain axis and the enteric and central nervous systems.[19]

Figure Source: The Role of Inflammation in IBS (open source article)

The Microbiome and Dysbiosis

Distinct patterns of dysbiosis are evident in both IBS and IBD, with the latter displaying more pronounced deviations. [3] Fortifying the microbiome with prebiotics and probiotics is paramount for both conditions. [20–22] When opting for a microbiome supplement, especially a probiotic, it’s crucial to select one with proven efficacy for your specific condition and its subtypes. For instance, the dysbiosis patterns in IBS-D (diarrhea dominant) differ from IBS-C (constipation dominant), implying that the most beneficial probiotic may vary based on the subtype. Similarly, for IBD, the probiotic Visbiome (formerly VSL#3) offers no benefit for Crohn’s disease but proves effective for ulcerative colitis and proctitis for some individuals. [23] Personally, I prefer sourcing my probiotics from foods like kimchi, sauerkraut, yogurt (be it dairy or non-dairy), miso, and occasionally kombucha. It’s also vital to ensure adequate fiber and prebiotic intake from vegetables and fruits. Remember, these fibers undergo fermentation by intestinal bacteria, producing short-chain fatty acids (SCFAs) such as butyrate, which nourish colonocytes and assist in barrier repair. [24] Another point worth noting is that flavonoids and polyphenols, especially those found in dark berries, are among the few non-carbohydrate compounds that feed the microbiome. [17, 25] In IBD, dietary strategies like the specific carbohydrate diet (SCD), which reduces starchy complex carbohydrates, and in IBS, strategies that lower specific saccharides known as FODMAPs, may modulate the microbiome resulting in lower symptoms, inflammation, and visceral hypersensitivity. [26, 27] Based on my experience, these strict dietary interventions, akin to medications, aren’t permanent solutions. They’re more effective when used for specific periods before transitioning to long-term, sustainable strategies. In regards to microbiome testing one of my advisors, Dr. Lucy Mailing Ph.D. is currently one of the most pioneering and innovative voices in the microbiome and testing space. While most testing is generally more interesting than it is actionable, we have both found the Thorne microbiome test to be of potential benefit given that it provides the user with raw data down to the individual species of microbe in both IBD and IBS.

The Intestinal Barrier and Soothing the Gut

Both IBD and IBS show a leakage of bacterial and food particles, primarily due to dysfunctional tight junction proteins. While IBD showcases more damage to the intestinal lining, sealing this barrier and mending the lining remains essential. As mentioned, nourishing the microbiome, especially with gelatinous fermentable fibers (like blueberries, avocado, bananas) that lead to SCFA production, [24] is critical for sealing the barrier, considering their nutritional benefit to colonocytes. Supplements, including glutamine, [28] butyrate, [29] phosphatidylcholine, [30] Serum-derived bovine immunoglobulins (SBIs), [31] and herbs like marshmallow and slippery elm, [32–34] can be beneficial in both conditions, particularly in IBD. Lastly ginger and peppermint oil may show some gut soothing qualities in IBS. [35,36]

The Nervous Systems and Gut-Brain Axis

(also referred to as the Gut-Brain-Microbiome Axis)

My approach to IBD, grounded in systems thinking and neuroscience (particularly in activating neuroplasticity), places significant importance on the brain’s role. Activating plasticity allows individuals to reduce stress and stress hormones (like cortisol, which can disrupt the immune system) and, crucially, enables them to navigate the world, making lifestyle and food choices conducive to healing. In IBS, the CNS takes a more prominent role (as discussed earlier), making strategies like meditation, hypnotherapy, [37] and biofeedback [38] potentially scientifically valid for IBS treatment. The visceral pain and hypersensitivity in IBS stem directly from the interactions between the CNS and ENS. For meditation (in both IBD and IBS) the app Insight Timer (a non-profit company) is incredible, allowing for a lot of customization around silent practices or guided practices. I’ve also found the app Nerva which provides a hypnotherapy framework for IBS, to be useful; however I’m working on enhanced and more efficient protocols. Notably, vagal nerve stimulation shows promise in IBD treatment, interfacing directly with the gut-brain axis and thus may also play a role in IBS. [39,40]

Figure Source: Uncovering the pathophysiology of irritable bowel syndrome by exploring the gut-brain axis: a narrative review (open source article)

Concluding Thoughts

You likely will not find a single silver bullet, but rather a multifaceted approach

This post is just scratching the surface of exploring the gut through understanding the similarities and differences between IBS and IBD. The fact remains that both conditions can be extremely debilitating. While IBD is objectively (in most cases) a more severe diagnosis, the diagnosis itself is more defined, while by contrast IBS is increasingly more broad and even more enigmatic. I’ve always believed what many gastroenterologists and researchers write in the literature: that IBD may encompass several dozen, even over a hundred subtypes. It’s likely IBS has even more.

I did not cover frontline medications for either condition in depth. However, there are several promising options for IBS-C, IBS-D and the IBDs. Most of these in IBS focus on addressing symptoms and some downstream functional problems while in IBD all medications work almost exclusively on inflammation. As you now know, the story is quite a bit more complex.

I’ve expanded my work to IBS and other chronic conditions (outside of just IBD) because IBS is more prevalent than IBD (about 10 times), there are significant overlap between the two conditions, and because by understanding both we can develop better overall theories of the gut, inflammation, microbiology, and the interaction with the nervous systems (primarily the CNS and ENS).

Regardless if you have IBD, IBS, or another gut-related or autoinflammatory/autoimmune condition, I’d love to work with you in applying my proven framework to your situation. Specific tools I utilize the like the Remission Master Plan (RMP) and the Adaptive Dietary Framework (ADF) are used nowhere else in the coaching industry or healthcare system. Working on a systems-based level addressing lifestyle, diet, supplements and herbs, medications, healthcare navigation, and mindset are vital to healing chronic health conditions of all types. Remember, it’s rarely one approach that will be your magic bullet. Rather, your key to success are multidimensional and coordinated interventions aimed at addressing you as a human being and building conducive environments.

When you’re in the depths of chronic illness, nothing matters but healing. Often an hour out of the day doesn’t go by without anxiety about your future. Learning to take control of these conditions is like learning a new language – this is the language of your body, of your health, and most importantly of your mind. Turning you into the human that perseveres is my number ONE job.

Let’s do it together. 🚀

Let's talk about your health

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