An Integrative Approach to Irritable Bowel Syndrome May-Lynn Chu, - PowerPoint PPT Presentation

An Integrative Approach to Irritable Bowel Syndrome May-Lynn Chu, DO Family Medicine, Adventist Health

Where to start…  First appointment to focus on detailed history – Past medical history (autoimmune conditions, psychiatry conditions, previous surgeries) – Dietary habits – Childhood illness or traumas – Family history of gut syndromes – Recent medication changes/antibiotic use – Work history/personal stressors

Diet  General rule – decrease inflammation  Remove, replace, repair  Eliminate inflammatory ingredients one at a time for 2-3 week period trials.  Avoid hard to digest foods like raw vegetables  Try fruit without skin  Avoid heavy spices or saucy foods  Reduce high fat dairy foods.  For constipation – Increase soluble fiber in small amounts per day 2-3 grams/day – Beans, fruit, oat products  Try eating smaller meals, more often, spread throughout your day. Instead of 3 meals, try 5 or 6 regularly scheduled small meals.  Slow down; don't rush through meals

Diet  Foods that may cause cramping and diarrhea (what to tell patients to avoid) – Large meals – Foods high in fat content – Fried foods – Caffeine, alcohol – Sorbital containing foods (sweeteners, candies) – Fructose containing foods (some fruits, honey)

Diet  Foods that may cause gas bloating (what to tell patient’s to avoid) – Beans – Cabbage – Legumes – Cauliflower – Broccoli – Lentils – Brussel sprouts – Raisins – Onions

Supplements  Probiotics – balance the microbiome – Bifidobacterium, lactobacillus and streptococcus  L-glutamine (2-5 grams daily, powder form)  Peppermint – Enteric coated capsules recommended, dissolves lower in GI tract, reduces risk of reflux  Omega 3 fatty acids – Cod liver oil  Digestive enzymes (with meals)  Magnesium (good if constipation noted)  Aloe Vera  Cannabidiol oil (anti-inflammatory)

Lifestyle changes  Cognitive behavioral therapy – Best evidence  Hypnotherapy – gut base  Regular exercise – stay in motion as often as possible  Yoga  Mindfulness exercises  Breathing exercises  Adequate sleep routine

SIBO (small intestinal bacterial overgrowth)  What is it? – Bacterial colonization of the small intestines – Small intestines should have low bacterial count – Large intestines is the place for large bacterial count  What causes it? – Any thing that damages the gut  What are the symptoms? – Abdominal pain – Bloating – Flatulence – Altered bowel patterns – diarrhea/constipation

SIBO – How to test for this  Lactulose breath testing  Helps to measure hydrogen and methane gases through fermentation of non- absorbed carbohydrates  Test is sensitive but not specific – no gold standard test for SIBO  If symptoms are suggestive of SIBO, not responsive to other therapies, treat empirically.

SIBO - Treatment  Antibiotics – Rifaximin and Neomycin – Rifaximin for diarrhea predominance (dosed at 550 mg PO 3 times a day for 2 weeks, can extend to 4 weeks if needed) – Neomycin plus rifaxmin for constipation and diarrhea. (Neomycin dosed at 500 mg PO twice daily)  Guar gum = prebiotic agent – Favors growth of bifidobacteria and lactobacillus – Rifaximin combined with hydrolyzed guar gum in one study showed a breath test normalization of 85%

SIBO - Treatment  Herbal remedies (shown to be as effective as Rifaximin for SIBO symptoms) – Peppermint oil (standard dose 0.2 ml, 3 times a day) – Neem – Allicin – Berberine (goldenseal or Oregon grape) – Oregano – Wormwood (Artemisia)  www.siboinfo.com  Elemental diet – seeks to starve the bacteria, but feed the person, by replacing meals for 2 weeks – Elemental formulas are powdered nutrients in pre-digested, easily absorbed form – Many brands are available over the counter such as Vivonex Plus, Neocate Jr. & Physicians Elemental Diet.

Resources  Reynolds, Kristen H. "Small Intestinal Bacterial Overgrowth: A Case- Based Review." Journal of Patient-Centered Research and Reviews 2.4 (2015): 165-173.  Quigley EM. Small intestinal bacterial overgrowth: what it is and what it is not. Curr Opin Gastroenterol. 2014;30:141-6.  Scarpellini E, Gabrielli M, Lauritano CE, et al. High dosage rifaximin for the treatment of small intestinal bacterial overgrowth. Aliment Pharmacol Ther. 2007;25:781-6.  Logan AC, Beaulne TM. The treatment of small intestinal bacterial overgrowth with enteric-coated peppermint oil: a case report. Altern Med Rev. 2002;7:410-7.  de Roest RH, Dobbs BR, Chapman BA, et al. The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. Int J Clin Pract.

Resources  http://www.ncbi.nlm.nih.gov/pubmed/14992438  Gibson PR. Food intolerance in functional bowel disorders. J Gastroenterol Hepatol. 2011;26 Suppl 3:128–131  Ostgaard H, Hausken T, Gundersen D, El-Salhy M. Diet and effects of diet management on quality of life and symptoms in patients with irritable bowel syndrome. Mol Med Rep. 2012;5:1382–1390  Dai C, Zheng CQ, Jiang M, Ma XY , Jiang LJ. Probiotics and irritable bowel syndrome. World J Gastroenterol. 2013;19:5973–598  . Halmos EP , Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2014;146:67-75.e5