Download Gastrointestinal Dysbiosis: What it is and How to Recognize it g

Gastrointestinal Dysbiosis:
What it is and How to
Recognize
g
it
Gerard E. Mullin, MD
Advanced Practice Module: Restoring Gastrointestinal Equilibrium
Austin, TX
February 2010
©2010, The Institute for Functional Medicine
Learning Objectives
•
•
•
Be able to recognize the signs and
symptoms
y p
associated with dysbiosis
y
to help in the proper diagnosis of this
condition
E l
Evaluate
dysbiosis
d bi i using
i conventional
i
l
and unconventional laboratory testing
so as to be able to treat appropriately
Evaluate patients for suspected
parasitic infections so as to
appropriately diagnose these
conditions
©2010, The Institute for Functional Medicine
Dysbiosis
Dysbiosis (also called
dysbacteriosis) is the condition of
having microbial imbalances on or
within the body. Dysbiosis is most
prominent in the digestive tract or on
the skin but can also occur on any
exposed surface or mucous
membrane
b
such
h as th
the vagina,
i
lungs, nose, sinuses, ears, nails, or
eyes.
©2010, The Institute for Functional Medicine
Dysbiosis: History
©2010, The Institute for Functional Medicine
Dysbiosis: History
•
•
•
•
Concept consolidated by Metchnikoff in 1908
119 Medline articles indexed by “dysbiosis” as of
November 2008
Other related terms:
• Dysbacteriosis
• Autointoxication
• Dermatitis-arthritis syndrome
• Short bowel syndrome
• Small
S ll intestinal
i t ti l bacterial
b t i l overgrowth
th (SIBO):
(SIBO) IBS
IBS,
fibromyalgia
• Mucosal colonization
• Subclinical infection
Some controversy still exists in the medical literature
©2010, The Institute for Functional Medicine
Dysbiosis is not so much
about the microbe as it is
about
b t the
th effect
ff t off that
th t
microbe on a susceptible
host; i.e., it is about the
relationship between host
and microbe.
©2010, The Institute for Functional Medicine
Dysbiosis
We are not looking for classic “infection”
•
•
•
Determine if imbalances in the gut
microbiota may be exacerbating
inflammation and the patient’s symptoms
Dysbiosis in one patient may present with
d
dermatitis;
titi the
th same microbial
i
bi l imbalance
i b l
in
i
another patient can present as peripheral
neuropathy or inflammatory arthritis.
Often what we find when working with
autoimmune/inflammatory patients is that
they
y are having
gap
pathogenic
g
inflammatory
y
response to a nonpathogenic microbe
©2010, The Institute for Functional Medicine
Subtypes of Dysbiosis
• Insufficiency
ff
dysbiosis: Lack off beneficial
f
microbes
• Bacterial overgrowth: Colonic microbes in the small
•
•
•
•
bowel
Immunosuppressive dysbiosis: Microbes produce
toxins that suppress immune function [e.g., the
pp
mycotoxin
y
produced
p
by
y
immunosuppressive
Candida albicans is called gliotoxin]
Hypersensitivity/allergic dysbiosis: Some people
have an exaggerated immune response to otherwise
“normal” yeast and bacteria
Inflammatory dysbiosis: Causes reactive arthritis
P
Parasites:
it
A
Amoebas,
b
cysts,
t protozoa,
t
and
d other
th
parasites
©2010, The Institute for Functional Medicine
The Many Faces of
Dysbiosis
©2010, The Institute for Functional Medicine
The Many faces of Dysbiosis
Toxins
Microbial Antigens
D-Lactic
Acidosis
Mitochondrial
Inhibitors
Proinflammatory
Cytokines
Neuroendocrine
Dysregulation
Autoantibodies
False NTs
©2010, The Institute for Functional Medicine
Immune Complex
Deposition
Dysbiosis: Assessment
Clinical assessments:
• Swab and culture / DNA pprobe / PCR
• Antigen tests (e.g., stool H. pylori
antigen)
• Breath hydrogen/methane for SIBO
• Jejunal aspiration – fungus and SIBO
• Stool
St l tests
t t – speciality
i lit labs
l b
• Response to treatment: objective
markers (e.g., ESR, CRP, disease
activity indexes)
©2010, The Institute for Functional Medicine
Flora Balance
Dysbiosis:
• Broad-spectrum antibiotics
• Chronic
Ch
i maldigestion
ldi
ti
(including
(i l di
PPIs)
PPI )
• Chronic constipation
• Stress suppresses lactobacilli
lactobacilli,
bifidobacteria, and sIgA
Catecholamines stimulate growth of gram-negative
organisms (yersinia,
(yersinia pseudomonas)
45–50% of total body production of NE occurs in
mesenteric organs
Anger
A
or ffear iincreases Bacteroides
B t
id fragilis
f
ili
©2010, The Institute for Functional Medicine
Flora Balance
Beneficial Bacteria:
• Digestion
• Synthesis of vitamins
• Enterohepatic recirculation of
hormones
• Acidification
• Prevention of colonization by
pathogens
• Oral tolerance
• SCFA production
©2010, The Institute for Functional Medicine
Action of BetaBeta-glucuronidase
Gl
Glucuronidation
id ti off
estrogen in liver
Conjugated estrogen
excreted in bile
Re-absorption leads to
increased estrogen
circulation
Cleaves glucuronide
Release of free estrogen
+++ Beta-Glucuronidase
Excreted in Stool
©2010, The Institute for Functional Medicine
Beta--glucuronidase
Beta
•
•
Bacterial enzyme that acts to deconjugate
glucuronides of toxic molecules, rendering
th
them
active
ti again
i – recirculation
i
l ti
off
carcinogens, hormones, etc.
Inducible enzyme,
y , upregulated
p g
by:
y
•
•
•
•
Diet high in meat fat
Alkaline pH of the gut
Lower activity
L
ti it with
ith increased
i
d fiber,
fib
lactobacilli, oranges
Calcium-d-glucarate
g
inhibits enzyme
y
activity
©2010, The Institute for Functional Medicine
Stool Microbiology
©2010, The Institute for Functional Medicine
Candida albicans
and Normal Flora
•
•
•
•
Candida is commensal at low levels
A lower gut pH (lactic acid and
SCFAs) inhibits Candida growth
Candida overgrowth lowers mucosal
immunity by splitting sIgA molecules
C did mannans (polysaccharides)
Candida
( l
h id )
impair host immune response
©2010, The Institute for Functional Medicine
Yeast Overgrowth
•
•
Microscopy and culture
Organic acids
• Arabinose
• Citramalic acid
• Tartaric acid
• BetaKetoGlutaric acid
Fonseca C, et al. FEBS J. 2007 Jul;274(14):3589-600,
and Based on Clinical Experience
©2010, The Institute for Functional Medicine
Common Symptoms
of Yeast Overgrowth
•
•
•
•
•
•
•
•
Fatigue
Poor Memory, “Spacey”
Insomnia or Hypersomnia
Anxiety
Mood Swings
Muscle and Joint Aches and Pains
Alcohol Intolerance
Pruritus
©2010, The Institute for Functional Medicine
XXX
“Pillsbury Doughboy”
©2010, The Institute for Functional Medicine
Infectious Diarrhea
©2010, The Institute for Functional Medicine
Which Condition is
the Most Common Cause of
Bacterial Diarrhea?
A. C. difficile infection
B. Salmonella
C. Shigella
D. Campylobacter
py
©2010, The Institute for Functional Medicine
C. difficile
©2010, The Institute for Functional Medicine
Infectious Diarrhea: C. difficile
Anaerobic, spore-forming, gram +
bacteria associated with diarrhea and
colitis
liti after
ft antibiotic
tibi ti use
• More common than previously
thought
• Presentation not always “sick”
patient
• Chronic and recurrent infections
common
• Need to test for toxins A and B
©2010, The Institute for Functional Medicine
Clinical Pearl
•
•
•
Some of those infected with C. difficile
may
y have recurrent mild to moderate
diarrhea that may resemble IBS
C. difficile may also present as a
condition
di i indistinguishable
i di i
i h bl from
f
IBD
with cramps, diarrhea, urgency,
mucus, and blood
So unless it is diagnosed, C. difficile
may be misdiagnosed as IBS or IBD
©2010, The Institute for Functional Medicine
Common Symptoms
of Parasites
•
•
•
•
•
•
•
Diarrhea or constipation
Abdominal pain
Belching, flatulence, distention
Anorexia nausea
Anorexia,
nausea, chills
chills, fever,
fever
headache, rash, pruritus
Blood or mucous in stools
Intractable fatigue
Weight loss
©2010, The Institute for Functional Medicine
Parasite Detection
Detection
D
t ti rates
t are a ffunction
ti of:
f
• Specimen collection and handling
• Number and kind of specimens examined
• Concentration procedures
• Staining procedures
• Macroscopic and microscopic
examination techniques
• Quality of training, frequency of practice,
and dedication of laboratory personnel
©2010, The Institute for Functional Medicine
Common Parasites
•
•
•
•
•
A recentt study
t d b
by a commercial
i l
laboratory revealed 23.5% of clinical
samples tested positive for at least one
parasite
it (3,223/13,857)
(3 223/13 857)
Blastocystis hominis (12.5%)
Di
Dientamoeba
b ffragilis
ili (3.8%)
(3 8%)
Entamoeba spp. (3.4%)
Endolimax nana (2.2%)
Giardia lamblia (0.7%)
Courtesy of P. Hanaway
©2010, The Institute for Functional Medicine
Parasitology
R
Report
t
©2010, The Institute for Functional Medicine
Secondary Investigations
Microbiology, Parasitology, Immunology
•
•
•
•
•
Culture
Mi
Microscopy
EIA testing
DNA testing
Ab’s
©2010, The Institute for Functional Medicine
Small Intestinal
Bacterial Overgrowth
A frequently overlooked contributor in
common disorders:
• IBS
78% of patients tested positive
48% of successfully treated patients no
longer met Rome criteria for IBS
• Fibromyalgia and CFS
78% and 77% of subjects, respectively,
have SIBO
Both disorders overlap with IBS
©2010, The Institute for Functional Medicine
Small Intestinal
Bacterial Overgrowth
• Dysmotility syndromes
• Systemic disease
disease, e
e.g.,
g DM
DM, scleroderma
• Prior intestinal surgery
• Strictures of the small intestine
•
•
•
•
Jejunal diverticulosis
Crohn’s disease
Symptoms in celiac disease,
disease despite no gluten
Aging
• 64%
% of individuals > 75 y
years with chronic diarrhea
• SIBO is most common cause of malabsorption in the
elderly
©2010, The Institute for Functional Medicine
Natural Defense Factors that Prevent
SIBO are Shown Within the Circles
Stomach
Absorption
Acid
Enzyme
&
Pancreas
Bile
Duodenum
Motility
Immunity
y
Jejunum
Ileocecal
valve
©2010, The Institute for Functional Medicine
Ileum
Causes of SIBO
•
•
•
•
•
•
•
Achlorhydria
Motor abnormalities
Scleroderma
Intestinal pseudoobstruction
Diabetic
enteropathy
Vagotomy
Abnormal
communication
between colon and
small bowel
©2010, The Institute for Functional Medicine
•
•
•
•
•
•
Fistulas between colon
and small bowel
Resection of ileocecal
valve
Structural abnormalities
Surgical loops (Billroth II,
II
entero-entero
anastomosis)
Duodenal or jejunal
diverticula
Partial obstruction of
small bowel (stricture,
adhesions, tumors)
Flora in SIBO
•
Composition varies:
•
•
Coliforms and strict anaerobes
Concentrations always higher than
normal (>105/mL)
Bacteria that are normal in the colon
may produce deleterious effects
within the delicate environment of
the small intestine …
©2010, The Institute for Functional Medicine
Clinical Consequences
off Bacterial
B t i l Overgrowth
O
th
Gas and bloating
bloating, abdominal discomfort
• Bacterial fermentation of
intraluminal sugars
g
Classic SIBO syndrome:
• Megaloblastic
g
anemia (B
( 12
deficiency)
• Weight loss and diarrhea secondary
to fat
f malabsorption
l b
i
©2010, The Institute for Functional Medicine
Distribution of Intestinal Bacterial
Flora in Normal Gut and in SIBO
Origin of gas/bloating of IBS patients with SIBO
Lin, H. C. JAMA 2004;292:852-858.
©2010, The Institute for Functional Medicine
SIBO Diagnosis: Breath Testing
70
•
•
Indirect test
Measures
fermentation: H2
and CH4
Transit too fast
Transit:
gives false positive
Substrate:
•
•
Glucose spec >
sens
Lactulose sens >
spec
©2010, The Institute for Functional Medicine
Hyddrogen (ppm)
•
•
60
50
40
30
20
10
0
15
30
45
60
75
90
105 120 135 150 165 180
Time (in minutes)
Normal
SIBO
A Breakthrough:
Diagnosing SIBO
•
•
Clues: Bloating
g after
carbohydrate meals
Conventional testing
g
(breath hydrogen)
HYDROGEN BREATH TEST
200
157
150
ppmH2
•
116 116 112
133
79
100
50
2
2
18
30
45
0
Specialized
p
testing:
g
urinary organic acids
(indican, D-lactate)
©2010, The Institute for Functional Medicine
Breath Samples
137
156
Mechanisms of Fat
Malabsorption in SIBO
1) Bacteria deconjugate bile salts to free
bil acids
bile
id
 Mucosal damage  malabsorption
(also disaccharidase and peptidase
deficiencies)
 Low bile salts leads to impaired
micelle formation  fat
malabsorption and steatorrhea
2) Pseudomembrane  mechanical
interference with absorption
©2010, The Institute for Functional Medicine
Malnutrition in SIBO
• Unabsorbed
U b
b d fatty
f tt acids
id may form
f
insoluble
i
l bl
soaps with minerals such as Ca and Mg 
• Osteomalacia, night blindness, hypocalcemic
tetany metabolic bone disease possible
tetany,
• Vitamin B12 deficiency
• Bacteria utilize B12 and detach B12 from intrinsic
•
factor
Serum folate usually normal or elevated
• Hypoproteinemia
yp p
• Protein-losing enteropathy or protein malabsorption
• Bacterial metabolism of proteins to ammonia and
fatty acids
• Iron deficiency anemia (rare)
©2010, The Institute for Functional Medicine
Causes of Digestive Disease: SIBO
Etiologies:
• Achlorhydria
• Hypochlorhydria
H
hl h d i
• PPIs
• Stasis – dysmotility
• Malnutrition
• Collagen vascular
disease
• Immune deficiency
©2010, The Institute for Functional Medicine
Consequences:
• Carbohydrate/fiber
intolerance
• Bloating after meals
• Iron, vitamin D, and B12
deficiency
• Fat malabsorption
• Enteropathy
• Food
F d allergies
ll
i
• Systemic inflammation
• Autonomic dysfunction
Case Study:
Digestive Insufficiences
Insufficiences,
IBS, Malnutrition,
Dysbiosis
Gerard E. Mullin, MD
Faculty, The Institute for Functional Medicine
Advanced Practice Module: Restoring Gastrointestinal Equilibrium
Austin, TX
February 2010
©2010, The Institute for Functional Medicine
Learning Objectives
•
•
•
•
•
Apply the Functional Medicine Matrix
Model™ to complex clinical issues
Decipher an integrative 5R action plan
for patients with IBS
Evaluate problems and implement
practical solutions in a logical manner
Apply
pp y nutritional and lifestyle
y
interventions to improve patient
outcomes
Systematically assess response to the
treatment plan
©2010, The Institute for Functional Medicine
Case Presentation
•
42-year-old female with longstanding IBS
and Scleroderma presents with weight loss,
failure to thrive, and diarrhea



•
•
•
IBS since traveling to Mexico 10 years ago
Works as a literary manager-travels
internationally
Scleroderma for 12 years
2000 – Went through a divorce, IBS
worsened, improved after psychotherapy
2005 – moved locations, IBS flared
2008 – Diarrhea 5
5–6x/d,
6x/d loose stool,
stool bloating,
bloating
malodorous stools after fatty meals
©2010, The Institute for Functional Medicine
Case Presentation
•
•
•
•
•
•
•
ROS: Heartburn on occasions
occasions, “low
energy”, listlessness, mental lethargy
PMHx: depression
p
FHx: Mother depression, 80; father; 82,
Alzheimer’s disease, no siblings
Meds: None
Supplements: None
Di t Wh
Diet:
Whole
l foods
f d as much
h as possible
ibl
Soc.: Divorced-remarried, 2 children –
10,12 years old, high
high-stress
stress job as
literary manager, nonsmoker, good
relationships
©2010, The Institute for Functional Medicine
Case Presentation
•
•
•
•
•
•
Self-care, beliefs: Spiritual – religious, holistic
minded, cannot exercise-fatigue
Objective data: BP is 83/61
83/61, pulse 115
115, weight
95, BMI of 15.3
She has temporal wasting; She has
scleroderma-like features
Her lungs are clear; she does have wasting in
the subscapular area and sternocleidomastoid
area
On cardiac exam, S1 and S2 are heard
throughout without murmurs, gallops or rubs
Abdomen is thin, scaphoid; exam is benign
©2010, The Institute for Functional Medicine
Case Presentation
•
•
Extremities are wasted
She is able to ambulate up and down
f
freely
l
•
Questions:
•
•
•
•
What are the underlying etiologies/
pathophysiologies?
What are the
antecedents/triggers/mediators?
Use the Matrix to organize the case history
Once we give you more data,
data you will be
asked to formulate your treatment plan
©2010, The Institute for Functional Medicine
FUNCTIONAL MEDICINE MATRIX MODEL™
Immune Surveillance
and Inflammatory Process
Oxidative/Reductive
Homeodynamics
IBS
OXIDATIVE STRESS
FATIGUE BRAIN FOG
FATIGUE,
Digestion
and Absorption
Detoxification and
Biotransformatio
CAFFEINE
ANTIDEPRESSANTS
The Patient’s Story Retold
IBS
Antecedents
HYPOCHLORHYDRIA
? FAT MALABSORPTION
Hormone and
Neurotransmitter Regulation
((Predisposing)
ed spos g)
FAMILY HISTORY
Structural
and Membrane
I
Integrity
i
LEAKY GUT
FOOD ALLERGIES??
Nutrition Status
Triggering
gg
g Events
HPA AXIS
FATIGUE
(Activation)
INFECTION
FOOD
POISIONING
STRESS!!
TRAVEL
JOB
Exercise
Sleep
Beliefs & Self-Care
NONE
7-8
HRS
RELIGIOUS
Psychological
and Spiritual Equilibrium
DEPRESSION
Relationships
BMI 15.1 LOW!
Albumin 3
3.9
9 g/dL
Date: ____ Name: ___________________ Age _____ Sex______ Diagnoses:
____________________________________________
©2010, The Institute for Functional Medicine
SATISFACTORY
©2008 The Institute for Functional Medicine
What tests would you order
to assess her case?
©2010, The Institute for Functional Medicine
Where Would You Begin?
•
•
•
•
•
Digestion/Absorption
I t ti l Permeability
Intestinal
P
bilit
Gut Microbiota/Dysbiosis
y
Inflammation/Immune
Nervous System
©2010, The Institute for Functional Medicine
Digestion/Absorption
Lab assessment:
• C
CBC/diff
C/d
•
•
•
•
•
•
•
WBC 7.1
H/H 9.7/28.8 (MCV
89)
RDW 20.1 (HIGH)
CMP-lipids nl chol
124
25-OH D 28 ng/mL
Thyroid hormone
TSH 0.2 Abnl
©2010, The Institute for Functional Medicine
•
•
•
•
Food allergy panel:
multiple allergies –
Stool O&P (-)
Celiac panel (-)
Yeast Ab panel (+)
Digestion/Absorption
D Xylose Test
D-Xylose
COMPONENT TEXT ***
TIME POST DOSE (BLOOD)
DOSE
XYLOSE BLOOD
XYLOSE,
BLOOD, 1 HRPOST
*** COMPONENT REMARK ***
©2010, The Institute for Functional Medicine
1 HOUR 11
11:47
47
25 g
47.0
47
0 mg/dL
Reference Range:
25 GM DOSE: 29-72
5 GM DOSE: 8-28
Digestion/Absorption
•
•
•
•
•
•
Organic Acids - indican, arabinitol elevated
Low WBC zinc
Serum B12 212 pg
pg/mL
Methylmalonic acid, serum 445 nmol/L
(87-318)
RBC folate WNL
RBC magnesium low
©2010, The Institute for Functional Medicine
Digestion/Absorption
pH = 5
SURG PATH REPORT
COLLECTION DATE/TIME: 09/23/2008 00:00
1st Specimen collected on 09/23/2008 Accessioned on 09/24/2008 at
09:51 a
FINAL DIAGNOSIS ----------- Pathologist: Elizabeth Montgomery,
Montgomery M.D.
MD
1.
2.
3.
SMALL BOWEL (BIOPSY): DUODENAL MUCOSANONDIAGNOSTIC
STOMACH (BIOPSY OF ANTRUM): ANTRAL MUCOSA WITH
MILDCHRONIC INFLAMMATION. NO HELICOBACTER PYLORI
ORGANISMS
3. GASTRIC BODY (BIOPSY): OXYNTIC MUCOSA WITH MILD
CHRONIC INFLAMMATION. NO HELICOBACTER PYLORI
ORGANISMS
©2010, The Institute for Functional Medicine
Digestion/Absorption
pH = 5
4.
GE JUNCTION (BIOPSY): CARDIAC MUCOSA WITH
CHRONIC INFLAMMATION
INFLAMMATION. NO GOBLET CELLS
CHARACTERISTIC OF BARRETT MUCOSA OF THE
DISTINCTIVE TYPE ARE SEEN. NO HELICOBACTER
PYLORI ORGANISMS ARE IDENTIFIED ON DIFF-QUIK
STAIN..
Note: PAS/AB stains were reviewed for each part.
Reported by:
The Johns Hopkins Hospital, Surgical Pathology
401 N. Broadway, Baltimore, MD 21231
Tel: 410-955-3580
Final Report Signed on 09/26/2008 at 04:39 pm
©2010, The Institute for Functional Medicine
Digestion/Absorption
Gastrin 325 pg/mL (<101) *
Intrinsic
t s c Factor
acto b
blocking
oc g AB NEGATIVE
G
Gastric parietal cell AB, ELISA 12.1 U*
Reference
Range
NEGATIVE
EQUIVOCAL
POSITIVE
©2010, The Institute for Functional Medicine
<= 20.0
20.1–24.9
>= 25.0
25 0
Intestinal Permeability
©2010, The Institute for Functional Medicine
Food
Allergy
Profile
©2010, The Institute for Functional Medicine
Gut Microbes
Gastric Aspirate
FLUID, MISC
SPECIMEN: 49
49-4L0231
4L0231
COLLECTION DATE/TIME: 09/23/2008 00:00
Specimen descriptor: FLUID MISC:(SMALL BOWEL)
TEST: FUNGAL CULT,MICROSCO
COMPONENT: FUNGAL MICRO EXAM
NO FUNGUS SEEN BY POTASSIUM HYDROXIDE;
Result finalized: 09/24/2008 09:53:05
©2010, The Institute for Functional Medicine
Gut Microbes
Gastric Aspirate
TEST: FUNGAL CULT, MICROSCO
COMPONENT: FUNGAL CULTURE
POSITIVE AT 2 DAYS
ORG 1:
1
CANDIDA ALBICANS
Result finalized: 09/25/2008 12:47:45
Test performed by:
Johns Hopkins Medical Labs
Meyer B1-100
600 North Wolfe Street
Baltimore, MD. 21287
©2010, The Institute for Functional Medicine
SIBO
©2010, The Institute for Functional Medicine
Immune/Inflammatory
Adrenal Stress Index
Salivary Cortisol
Morning
Noon
Evening
Midnight
4.23
8.12
10.89
7.24
S li
Salivary
DHEA
1.32
©2010, The Institute for Functional Medicine
5–23 nmol/L
1.8–11.0 nmol/L
1.0–6.5 nmol/L
0.75–4.7 nmol/L
0.75–2.5 nmol/L
Nervous System
•
•
•
•
Depression
Brain Fog
Low B12 status
Low RBC Magnesium
©2010, The Institute for Functional Medicine
What is your assessment?
©2010, The Institute for Functional Medicine
Assessment
•
•
•
•
Dysbiosis
D
bi i
• Small Intestinal Bacterial Overgrowth
• Yeast Overgrowth
• IgG Food Sensitivities
Hormonal Imbalances
• HPA Axis Dsyfunction
• Adrenal Fatigue
Nutritional Imbalances
• Zinc, Vitamin D Insufficiency
Hypochlorhydria
©2010, The Institute for Functional Medicine
What is your treatment
plan?
5 R’s
Rs
• Remove
• Replace
• Reinoculate
• Repair
• Re-Balance
©2010, The Institute for Functional Medicine
What is your treatment
plan?
5 R’s
Rs
• Remove the bugs! (parasites,
SIBO allergens)
SIBO,
• Replace (HCl, enzymes)
• Reinoculate
R i
l t (Flora)
(Fl
)
• Repair (glutamine, Zn-carnosine)
• Re-Balance (mind-body: Yoga)
©2010, The Institute for Functional Medicine
Remove/Replace
•
•
•
•
•
Elimination diet
Botanicals for SIBO w/garlic,
oregano oil
oil, berberine
Antifungal therapy
HCl
Enzymes
©2010, The Institute for Functional Medicine
Causes of Digestive Disease
Small
S
a Intestinal
es a Bacterial
ac e a O
Overgrowth
ego
Etiologies
Consequences
•
•
•
•
•
•
•
•
•
CHO/fiber intolerance
•
•
•
•
•
Fat malabsorption
•
Achlorhydria
Hypochlorhydria
PPI’s
PPI
s
Stasis-dysmotility
Malnutrition
Collagen Vascular
Disease
Immune deficiency
©2010, The Institute for Functional Medicine
Bloating after meals
Iron, vitamin D and B12
deficiency
Enteropathy
Food Allergies
Systemic inflammation
Autonomic dysfunction
Food Elimination Based on IgG Antibodies in
Irritable Bowel Syndrome: A Randomized
Controlled Trial
P < 0.001
0 001
Atkinson W, et al. Gut. 2004;53:1459-1464.
©2010, The Institute for Functional Medicine
Reinolculate/Repair
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•
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•
•
Anti-inflammatory medical food
Pre-/probiotics
Calcium/magnesium
Vitamin D3 (DRI 1000 IU/d)
CoQ10 200 mg/d
•
•
•
•
•
Betaine HCl w/meals
Zinc citrate
MVI, SL B12 dots
Aloe-glutamine supplement
Full-spectrum
Full
spectrum light
©2010, The Institute for Functional Medicine
Comparative Effects of a Bifidobacterium, a
Lactobacillus, and Placebo on Composite Score (Pain,
Bl ti
Bloating,
etc.)
t ) in
i IBS over an 8-week
8
kT
Treatment
t
t Period
P i d
O’Mahony L, et al. Gastroenterology. 2005;128(3):541-551.
©2010, The Institute for Functional Medicine
Rebalance
IBS Pathophysiology
Current Opinion in Gastroenterology. 2006;22(2):128-135.
©2010, The Institute for Functional Medicine
Rebalance
IBS Pathophysiology
•
•
•
•
•
•
Yoga
Light therapy
Less international traveling
g
Psychological counseling
CBT
Ashwagandha, 5-HTP, light exercise
Current Opinion in Gastroenterology. 2006;22(2):128-135.
©2010, The Institute for Functional Medicine
Diet
Then Advance Diet to include prebiotics
• FOS-containingg foods: Asparagus,
p
g
Jerusalem artichokes, onions, leeks
• Cruciferous vegetables vs. indole-3-carbinol
• Mediterranean
M dit
diet:
di t
• Rich in green, leafy vegetables
• Whole grains
• High in fish, poultry
• Olive oil as essential fattyy acid base
©2010, The Institute for Functional Medicine
Follow-up
•
•
•
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6 weeks: Less diarrhea, less depressed,
more energy
energy, sleeping better,
better BMI 17
17.2
2
8 weeks: 70% better, more energy
12 weeks: BMI 18
18.3,
3 no fatigue
fatigue, walking
26 weeks: 90% better, minimal diarrhea,
more energy
energy, no fatigue
©2010, The Institute for Functional Medicine
Current Thought Process
Future Outlook
Individual Conditions
SIBO Overlap
Fibromyalgia
IC
RLS
SIBO
Pi-IBS
Pi
IBS
FM, IC, RLS…
CFS
IBS
©2010, The Institute for Functional Medicine
IBS
SIBO
Pi-IBS
Take Home Sticky Points
•
•
•
•
•
Dysbiosis is an imbalance in the
commensal p
population
p
of flora
Dysbiosis has deleterious
consequences both in the gut and
systemically
i ll if left
l f untreated
d
Suspect SIBO in patients w/ IBS
Treat Candida overgrowth
Reinnoculate w/ Probiotics
©2010, The Institute for Functional Medicine
•
The practice
Th
ti off medicine
di i is
i an art,
t nott a
trade; a calling, not a business; a calling in
which your heart will be exercised equally
with
i h your head.
h d Often
Of
the
h best
b
part off your
work will have nothing to do with potions
and powders, but with the exercise of an
influence of the strong upon the weak, of
the righteous upon the wicked, of the wise
upon the foolish.
~ Sir William Osler, The Three Great Lessons of Life
©2010, The Institute for Functional Medicine