Common Digestive Concerns

Dr. Ellen Wong, BSc (Hons), NDAcademic and Clinic Faculty – CCNM

Today We Will… Evaluate the role of various factors

contributing to development of digestive conditions

Evaluate and manage a case of IBS, IBD, GERD and/or Celiac disease given restrictions of a typical naturopathic practice

Adapt evaluation and management based on updated guidelines and available evidence

47yoa female, Diarrhea of 1 week HPI: Worsening diffuse “crampy” LLQ abdominal pain (6/10,

10=worst) Pain relieved by bowel movement

Worsening urge for diarrhea of 10-20 BM/day Diarrhea: watery, brown, minimal mucous, streaks of bright red

blood Fever, loss of appetite (lost 5lbs), nausea Denies trauma Relevant ROS: Maine trip (consumed stream water 1 mos

ago) PMHx: birth of 2 children, UTI 3 wks ago(Rx amoxicillin for 7

days) SHx: divorced with 2 children + puppy, grade 2 teacher PE: appears unwell and in discomfort, LLQ pain with guarding,

no rebound tenderness, increased bowel sounds, otherwise unremarkable

Case

Background InformationEpidemiology, Pathophysiology, Risk Factors

5 million Canadians 1x/week Will likely sharply increase with aging

pop’n 10-20% of Western world 34-41% of px experience sxs for >10yrs

before Dx

Direct cost: $52,235,910/yr Indirect cost: 6.7h/week lost work

GERD

IBS

http://www.aboutibs.org/site/about-ibs/facts-about-ibs/statistics

2.4-3.5 million annual physician visits/yr

m/c disorder diagnosed by gastroenterologists

12% of primary care visits

Cost: $21 billion+/yr

IBD

IBD

Celiac

1 in 133 persons in Canada Be mindful of malabsorption

Anemia Chronic diarrhea Weight loss Fatigue Cramps and bloating Irritability Rash

Clinical EvaluationDiagnostic guidelines, Signs and Symptoms, Assessment Tools

Canadian Digestive Health Foundation Public Impact Series: Gastroesophageal reflux disease in Canada:Incidence, prevalence, and direct and indirect economic impact. Can J Gastroenterol Vol 24 No 7 July 2010

GERD

GERD

Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2013; 108:308 – 328; doi: 10.1038/ajg.2012.444; published online 19 February 2013Moayyedi P , Talley NJ , Fennerty MB et al. Can the clinical history distinguish between organic and functional dyspepsia? JAMA 2006 ; 295 : 1566 – 76 .Numans ME , Lau J , de Wit NJ et al. Short-term treatment with proton pump inhibitors as a test for gastroesophageal reflux disease: a meta-analysis of diagnostic test characteristics . Ann Intern Med 2004 ; 140 : 518 – 27 .

GERD

Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2013; 108:308 – 328; doi: 10.1038/ajg.2012.444; published online 19 February 2013

GERD

IBS

World Gastroenterology Organization, 2009

IBS

IBS

IBS

IBD

Celiac

Anti-tissue Transglutaminase (anti-tTG) Antibodies, IgA

Anti-tissue Transglutaminase (anti-tTG) Antibodies, IgG

Anti-Gliadin Antibodies (AGA), IgG and IgA Anti-Endomysial Antibodies (EMA), IgA

Deamidated Gliadin Peptide (DGP), IgA

Biopsy

Management StrategiesBehavioural, Natural, Pharmaceutical Tools and Interventions

Therapeutic Order Establish conditions for health

Stimulate healing power of nature

Address weakened of damaged systems or organs

Correct structural integrity

Address pathology

Suppress or surgically remove pathology

CUT THE

CYCLE!

GERD

Stanciu C , Bennett JR . Effects of posture on gastro-oesophageal reflux. Digestion 1977 ; 15 : 104 – 9 .Hamilton JW , Boisen RJ , Yamamoto DT et al. Sleeping on a wedge diminishes exposure of the esophagus to refluxed acid . Dig Dis Sci 1988 ; 33 : 518 – 22 .Pollmann H , Zillessen E , Pohl J et al. Effect of elevated head position in bed in therapy of gastroesophageal reflux . Z Gastroenterol 1996 ; 34 (Suppl 2) : 93 – 9 .Schindlbeck NE , Heinrich C , Dendorfer A e t al. Influence of smoking and esophageal intubation on esophageal pH-metry . Gastroenterology 1987 ; 92 : 1994 – 7. Waring JP , Eastwood TF , Austin JM et al. The immediate effects of cessation of cigarette smoking on gastroesophageal reflux . Am J Gastroenterol 1989 ; 84 : 1076 – 8 .Kadakia SC , Kikendall JW , Maydonovitch C et al. Effect of cigarette smoking on gastroesophageal reflux measured by 24-h ambulatory esophageal pH monitoring . Am J Gastroenterol 1995 ; 90:1785 – 90

GERD - Lifestyle

EtOH: lower LES pressure, increases gastrin, impairs gastric emptying

Smoking: lower LES pressure and prolongs acid clearance

GERD - Lifestyle

GERD - Lifestyle

Jacobson BC , Somers SC , Fuchs CS et al. Body-mass index and symptoms of gastroesophageal reflux in women . N Engl J Med 2006 ; 354 : 2340 – 8 .Fraser-Moodie CA , Norton B , Gornall C et al. Weight loss has an independent beneficial effect on symptoms of gastro-oesophageal reflux in patients who are overweight . Scand J Gastroenterol 1999;34:337 – 40 .Mathus-Vliegen LM , Tytgat GN . Twenty-four-hour pH measurements in morbid obesity: effects of massive overweight, weight loss and gastric distension . Eur J Gastroenterol Hepatol 1996 ; 8 : 635 – 40 .

GERD - Lifestyle

GERD - Pharm

GERD - Pharm

Chronic PPI therapy:C. difficile diarrhea: OR 2.1-2.6Commuinty acquired pneumonia: OR 1.5-1.9Bone fracture: OR 1.4-1.6Vitamin B12 def: OF 1-4.46

Recent FDA warning:Monitor Mg levels

Valuck RJ, Ruscin JM. A case-control study on adverse effects: H2 blocker or proton pump inhibitor use and risk of vitamin B12 deficiency in olderadults. J Clin Epidemiol 2004;57:422–428.Salom IL, Silvis SE, Doscherholmen A. Effect of cimetidine on the absorption of vitamin B12. Scand J Gastroenterol 1982;17:129–131.Russell RM, Golner BB, Krasinski SD, et al. Effect of antacid and H2 receptor antagonists on the intestinal absorption of folic acid. J Lab Clin Med 1988;112:458–463.Sturniolo GC, Montino MC, Rossetto L, et al. Inhibition of gastric acid secretion reduces zinc absorption in man. J Am Coll Nutr 1991;10:372–375.Aymard JP, Aymard B, Netter P, et al. Haematological adverse effects of histamine H2-receptor antagonists. Med Toxicol Adverse Drug Exp1988;3:430–448.Ghishan FK, Walker F, Meneely R, et al. Intestinal calcium transport: Effect of cimetidine. J Nutr 1981;111:2157–2161.Odes HS, Fraser GM, Krugliak P, et al. Effect of cimetidine on hepatic vitamin D metabolism in humans. Digestion 1990;46:61–64.Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA 2006;296:2947–2953.

GERD - Pharm

CCB Theophylline Nitrates PDE-5 inhibitors Anticholinergics Narcotics Benzodiazepines Anti-depressants Inhales bronchodilators

NSAIDs Ferrous sulfate Bisphosphonate

GERD - Pharm

Lower LES Pressure

Irritate Esophagus

Mohammed I, Nightingale P, Trudgill NJ. Risk factors for gastrooesophageal reflux disease symptoms: A community study. Aliment Pharmacol Ther 2005;21:821–827.

GERD - Melatonin

P: n=351 adults with heartburn sxs I: melatonin, vitamin and aminoacid blend C: omeprazole 20mg O: time for patients to achieve first 24h

interval w/o sxs

GERD - Melatonin

Potent reactive oxygen metabolite scavenger and AO

Secretion, motility, digestion and absorption

GI mucosal integrity Ulcer healing Enhancement of mucosal generation of

PGE2 and gastrin levels Inhibits metalloproteinases -3 and -9

GERD - Melatonin

GERD - Herbs

Larkworthy W, Holgate PF. Deglycyrrhizinized liquorice in the treatment of chronic duodenal ulcer: A retrospective endoscopic survey of 32 patients. Practitioner 1975;215:787–792.

Greally P, Hampton FJ, MacFadyen UM, Simpson H. Gaviscon and Carobel compared with cisapride in gastro-oesophageal reflux. Arch Dis Child 1992;67:618–62

GERD - Herbs

Digestive Enzymes

GERD – Misc.

Narain PK, DeMaria EJ, Heuman DM. Lecithin protects against plasma membrane disruption by bile salts. J Surg Res. 1998 Aug;78(2):131-6Eial EJ, et al. Oral phosphatidylcholine preserves the gastrointestinal mucosal barrier during LPS-induced inflammation. Shock. 2008 Dec;30(6):729-33Eros G, Kaszaki J, Czbel M, Boros M Magy Seb.Effects of phosphatidylcholine pretreatment during acute experimental biliary reflux 2005 Dec ; 58(6): 406-14

GERD – Other Mod

McDonald-Haile J, Bradley LA, Bailey MA, et al. Relaxation training reduces symptom reports and acid exposure in patients with gastroesophageal reflux disease. Gastroenterology 1994;1:61–69. Hein T. Some effects of chiropractic manipulation on reflux oesophagitis: A case report. Br J Chiropractic 1999;3:59–61.Parkinson WL, Kumbhare DA, Annis RS. Functional dyspepsia: Can chiropractic help? J Am Chiro Assoc 2001;38:34–36.

GERD – Other Mod

P: n=30 with minimum 3 mos GERD sxs at least 2 days/wk and taking PPI (omeprazole 20mg qd)

I: omeprazole 20mg qd + acupuncture

C: omeprazole 20mg bid

O: GERD symptom checklist and SF-36

Acupuncture + PPISignificant decrease in day and night time heartburn

Improvement in SF-36

GERD – Other Mod

10 sessions over 4 weeks

1st 2 weeks: q2days

Next 2 weeks: 2x/wk

IBS

National Institute for Health and Clinical Excellence (NICE)

Recommends discussion of:

Healthy diets

Psychological interventions CBT Hypnotherapy Psychological therapy

Biofeedback

IBS - Pharm

Paterson W G et al. CMAJ 1999;161:154-160 ©1999 by Canadian Medical Association

IBS - Pharm

Paterson W G et al. CMAJ 1999;161:154-160 ©1999 by Canadian Medical Association

AGA Technical Review on Irritable Bowel Syndrome. GASTROENTEROLOGY 2002;123:2108–2131

IBS - Pharm

IBS - Stress

AGA Technical Review on Irritable Bowel Syndrome. GASTROENTEROLOGY 2002;123:2108–2131

Predictors of positive response to psychological treatment:

1) Awareness of stress exacerbation 2) At least mild anxiety or depression 3) Predominant sxs is pain or diarrhea 4) Abdominal pain waxes and wanes 5) Sxs are of relatively short duration 6) Catastrophizing behaviour

IBS - Stress

Guthrie E, Creed F, Dawson D, Tomenson B. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology1991;100:450–457.Toner BB, Segal ZV, Emmott SD, Myran D. Cognitive-behavioral treatment of irritable bowel syndrome: The brain-gut connection. New York: Guilford Press, 2000:188

IBS

Worst Combinations:Acetaminophen + aspirin

Aspirin + NSAID

IBS – Food Sensitivity

IBS – Food Sensitivity

Induce IBS Sxs:Milk, caffeine, alcohol, fruits, seasonings, “diet” foods , fast foods, fatty fods, multigrain, red meats, sauces, popcorn, baked goods

IgG4 Ab: milk, eggs, wheat, beef, pork, lambAt 3 mos: pain severity (p<0.001), pain frequency (p 0.034),

bloating severity (p 0.001), BM (p 0.004), QOL (p 0.008)At 6 mos: sxs improvement continued, rectal compliance (p

0.011), anxiety and depression

IBS – Food Sensitivity

Significant improvements were seen in stool frequency (p < 0.05), pain (p < 0.05), and IBS-QOL scores (p < 0.0001)

IBS – Food Sensitivity

IBS – Oils and Fibre

Ford AC, Talley NJ, Spiegel BM, et al. Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: Systematic review and meta-analysis. Br Med J 2008;337:a2313.

NNT for Sxs reduction:

Fiber 11Antispasmodics 5Peppermint oil 2.5

Grigoleit HG, Grigoleit P. Gastrointestinal clinical pharmacology of peppermint oil. Phytomedicine 2005;12:607–611.Grigoleit HG, Grigoleit P. Peppermint oil in irritable bowel syndrome. Phytomedicine 2005;12:601–606.Cappello G, Spezzaferro M, Grossi L, et al. Peppermint oil (Mintoil) in the treatment of irritable bowel syndrome: A prospective double blind placebocontrolled randomized trial. Dig Liver Dis 2007;39:530–536.Kligler B, Chaudhary S. Peppermint oil. Am Fam Physician 2007;75: 1027–1030.van Zanten SV. Review: Fibre, antispasmodics, and peppermint oil are all effective for irritable bowel syndrome. Evid-Based Med 2009;14:84.Merat S, Khalili S, Mostajabi P, et al. The effect of enteric-coated, delayed-release peppermint oil on irritable bowel syndrome. Dig Dis Sci 2010;55:1385–1390.

IBS – Oils and Fibre

RR: 0.43 (CI 0.32-0.59)

IBS - Probiotics

IBS - Probiotics

Product or Strain Dose (CFU) Effects

VSL#33xBifidobacterium4xLactobacillus1xStrep salivarius

450 billion Decrease bloating and flatulenceNo changes in urgency or pain8 weeks

Prescript Assist29 strainsPrebiotic

65 MillionAcid, bile, heat resistant

Decrease nausea, indigestion, flatulence, pain

Closest to paleo?

SCM IIIL. acidophilus , L. helveticus , and B. spp

Decrease bloating and painRegulated bowel habits

FlorastorSaccharomyces boulardii

5 billionHas lactose200 billion

May improve QOL

No changes in IBS-D or IBS-C sxs

IBS - Probiotics

Product or Strain Dose (CFU) Effects

L. rhamnosus GG and LC705, B. breve Bb99, and Propionibacterium freudenreichii spp. shermanii JS

8 billion Decrease urgency, incomplete evacuation, flatulence, pain, bloating4-6months

L. ReuteriL. casei

100 million No difference

L. plantarum 299v With oat flour

50 million bid400mL with 50 million CFU

Decrease flatulence, almost complete resolution of pain, improvement in global IBS sxs4 weeks

L. Rhamnosus GG 3 billion bid Significant decrease in painDecreased # of loose stools

IBS - Probiotics

Product or Strain Dose (CFU) Effects

B. infantis 35624 100 million Decrease pain, bloating, BM difficulty, sensation of incomplete evacuation, passage of gas

B. animalis DN-173010 + Activia and Danone (S. thermophilus and L. Bulgaricus)

Improvement in stool frequency (if <3BM/week)Slight decrease in bloating and discomfort

IBS - Probiotics

IBS - ProbioticsMimura T , Rizzello F , Helwig U et al. Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis . Gut 2004 ; 53 : 108 .Gionchetti P , Rizzello F , Helwig U et al. Prophylaxis of pouchitis onset with probiotic therapy: A double-blind placebo controlled trial . Gastroenterol 2003 ; 124 : 1202 .Surawicz CM , McFarland LV , Elmer G et al. Treatment of recurrentClostridium difficile colitis with Vancomycin and Saccharomyces boulardii . Am J Gastroenterol 1989 ; 84 : 1285 – . 7Johansson ML , Molin G , Jeppsson B et al. Administration of different Lactobacillus strains in fermented oatmeal soup: in vivo colonization of human intestinal mucosa and effect on the indigenous flora . Appl Environ Microbiol 1993 ; 59 : 15 – 0 2 .Alander M , Korpela R , Saxelin M et al. Recovery of Lactobacillus rhamnosus GG from human colonic biopsies . Lett Appl Microbiol 1997 ; 24 : 361 – . 4Silva M , Jacobus NV , Deneke C et al. Antimicrobial substance from a human Lactobacillus strain . Antimicrob Agents Chemother 1987 ; 31 : 131 1– 2 33 .Pathmakanthan S , Li C , Cowie J et al. Lactobacillus plantarum 299: Beneficial in vitro immunomodulation in cells extracted from inflamed human colon . J Gastroenterol Hepatol 2004 ; 19 : 166 – 3O ’ Mahony L , McCarthy J , Kelly P et al. Lactobacillus and Bifidobacterium in irritable bowel syndrome: Symptom responses and relationship to cytokine pro les . Gastroenterol 2005 ; 128 : 41 5– 551.Floch MH . Use of diet and probiotic therapy in the irritable bowel syndrome . J Clin Gastroenterol 2005 ; 39 : S243 – 6Tsuchiya J , Barreto R , Okura R et al. Single blind follow-up study on the effectiveness of a symbiotic preparation in irritable bowel syndrome . Chin J Dig Dis 2004 ; 5 : 169 – 74Saggioro A . Probiotics in the treatment of irritable bowel syndrome . J Clin Gastroenterol 2004 ; 38 : S104 – 6Kajander K , Hatakka K , Poussa T et al. A probiotic mixture alleviates symptoms in irritable bowel syndrome patients: A controlled 6-month intervention . Aliment Pharmacol B er 2005 ; 2 : 387 – 4 9.D'Souza AL, Rajkumar C, Cooke J, Bulpitt CJ: Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis. BMJ 2002, 324:1361.Macfarlane GT, Cummings JH: Probiotics and prebiotics: can regulating the activities of intestinal bacteria benefit health? BMJ 1999, 318(7189):999-1003.

Yamazaki S, Kamimura H, Momose H, Kawashima T, Ueda k: Protective effect of bifidobacterium monoassociation against lethal activity of E coli. Bifidobacteria and Microflora 1982, 1:55-60Bittner AC, Croffut RM, Stranahan MC: Prescript-Assist probiotic-prebiotic treatment for irritable bowel syndrome: a methodologically oriented, 2-week, randomized, placebocontrolled, double-blind clinical study. Clin Ther 2005, 27(6):755-61.Bausserman M, Michail S: The use of Lactobacillus GG in irritable bowel syndrome in children: a double-blind randomized control trial. J Pediatr 2005, 147(2):197-201.Gawronska A, Dziechciarz P, Horvath A, Szajewska H: A randomized double-blind placebo-controlled trial of Lactobacillus GG for abdominal pain disorders in children. Aliment Pharmacol Ther 2007, 25(2):177-84.Kajander K, Hatakka K, Poussa T, Farkkila M, Korpela R: A probiotic mixture alleviates symptoms in irritable bowel syndrome patients: a controlled 6-month intervention. Aliment Pharmacol Ther 2005, 22(5):387-94.Kim HJ, Camilleri M, McKinzie S, Lempke MB, Burton DD, Thomforde GM, et al.: A randomized controlled trial of a probiotic, VSL#3, on gut transit and symptoms in diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther 2003, 17(7):895-904.Kim HJ, Vazquez Roque MI, Camilleri M, Stephens D, Burton DD, Baxter K, et al.: A randomized controlled trial of a probiotic combination VSL# 3 and placebo in irritable bowel syndrome with bloating. Neurogastroenterol Motil 2005, 17(5):687-96.Niedzielin K, Kordecki H, Birkenfeld B: A controlled, doubleblind, randomized study on the efficacy of Lactobacillus plantarum 299V in patients with irritable bowel syndrome.Eur J Gastroenterol Hepatol 2001, 13(10):1143-7.Niv E, Naftali T, Hallak R, Vaisman N: The efficacy of Lactobacillusreuteri ATCC 55730 in the treatment of patients with irritable bowel syndrome – a double blind, placebo-controlled, randomized study. Clin Nutr 2005, 24(6):925-31.

IBS - Probiotics

IBS – Acupuncture

Acupuncture vs Measure Effect

Sham Sxs severity

Slight favour for acupuncture

Sham QOL Small favour for sham

Pharmacology Sxs severity

Favours acupuncture

Bifidobacterium Sxs severity

No difference

Psychotherapy Sxs severity

No difference

Other TCM tx Sxs severity

Slight favour for acupuncture

No treatment Sxs severity

Slight favour for acupunctureLim B, Manheimer E, Lao L, et al. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database Syst Rev 2006;4:CD005111.Reynolds JA, Bland JM, MacPherson H. Acupuncture for irritable bowel syndrome—an exploratory randomised controlled trial. Acupunct Med2008;26:8–16.

IBS – Acupuncture

P: n=233 adults with IBS (IBS SSS >100) I: 10 weekly individualized AcQ + usual care C: usual care alone O: IBS SSS @ 3 mos

IBS – Acupuncture

@ 3 mos: IBS SSS -27.43 (95% CI -48.66 to -6.21, p=0.012) more than control group

NNT for “successful” treatment (>50pt reduction IBS SSS): 6

Results persisted to 12 mos

IBS - Herbs

75 RCT with 7957 participants 71 different herbal medicines vs placebo or conventional

pharmacology Vs. Conventional therapy: 22 herbal medicines showed

statistically significant benefit for sxs improvement Vs. Conventional therapy: 29 herbal medicines showed no

difference for sxs improvement + conventional therapy: 6 herbal preparations showed added

benefit

Best results: STW5 and STW5-II Padma Lax (Tibetan) Tongxie Yaofang Marmelos correa + Monniere Linn (Ayurvedic)

Liu JP, Yang M, Liu YX, et al. Herbal medicines for treatment of irritable bowel syndrome. Cochrane Database Syst Rev 2006;1:CD004116.Bian Z, Wu T, Liu L, et al. Effectiveness of the Chinese herbal formula TongXieYaoFang for irritable bowel syndrome: A

systematic review. J Altern Complement Med 2006;12:401–407.

Herbal medicine vs Measure Best Results

Placebo improvement of sxs ppr

Padma Lax

Placebo improvement of sxs as per specialist

Ayurvedic preparationSTW5, STW5-IITongxie Yaofang

Placebo Passing stool (6-7days/wk)

Padma Lax

Placebo Constipation relief Ayurvedic preparation

Placebo Pain relief in IBS-C Padma LaxSTW5

Placebo Diarrhea relief Ayurvedic preparationTong xie ning

Placebo Pain relief Padma LaxAyurvedic preparationSTW5, Tong xie ning

IBS - Herbs

Herbal medicine vs Measure Best Results

Placebo IBS score ppr Standard and Individualized Chinese herbs

Placebo IBS score as per specialist

Standard and Individualized Chinese herbsSTW5, STW5-II

Conventional (pharmacotherapy or proB)

Global improvement of sxs

16 TCM patents

Conventional (pharmacotherapy or proB)

Diarrhea relief Ayurvedic preparation

Conventional (pharmacotherapy or proB)

Pain Jianpi Shugan Tang

Conventional (pharmacotherapy or proB)

Recurrent episodes

Shenling Baishu San Baile Ercha

IBS - Herbs

STW5 Commonly available as Iberogast Each 100 mL bottle contains:

German Chamomile flower (matricaria recutita) 20 mL Clown’s Mustard Plant (iberis amara) 15 mL Angelica root and rhizome (angelica archangelica) 10

mL Caraway fruit (carum carvi) 10 mL Milk Thistle fruit (silybum marianum) 10 mL Lemon Balm leaf (melissa officinalis) 10 mL Celandine aerial part (chelidonium majus) 10 mL Licorice root (glycyrrhiza glabra) 10 mL Peppermint leaf (mentha x piperita) 5 mL.

IBS - Herbs

STW5 II same as STW5 but without celandine, angelica, milk thistle

Tong Xie Yao Fang (痛瀉要方 ) 防風 (Fang Feng) saposhnikovia root,

ledebouriella root 3-6g

陳皮 (Chen Pi) aged tangerine peel, citrus 4.5-9g

白术 (Bai Zhu) (white) atratylodes rhizome, ovate atractylodes, angelica root 9-12g

白芍 (Bai Shao) white peony root, peony 6-24g

IBS - Herbs

IBS – 5HTP

IBS patientsLower mucosal and higher systemic concentrations of

5HTP

IBS - Melatonin

Melatonin 3 mg at bedtime for 8 wksDecreased severity and frequency of pain, bloating

Improved bowel habitsDecreased h/a, nausea, GERD

Improved QOL

IBD

National Institute for Health and Clinical Excellence (NICE)

Recommends discussion of: Smoking cessation Patient experience Medication Adherence and ASE Fertility and sexual relationships Possible delay of growth Diet and nutrition Prognosis Cancer risk Surgery Support groups

IBD-UC - Pharm

http://www.cfp.ca/content/57/5/568.full.pdf+html

IBD-UC - Pharm

http://www.cfp.ca/content/57/5/568.full.pdf+html

IBD - Bromelain

Kane S, Goldberg MJ. Use of bromelain for mild ulcerative colitis. Ann Intern Med 2000;132:680.

Bromelain: divided doses up to 3200mgSmall case study

3-4 bloody BM/qd and on salfasalazine, mesalamine, topical steroids (proctits)

Decreased to 1 formed BM qd

IBD – Aloe Vera

P: n=40, adults mild to mod active IC I: oral aloe vera 100mL bid C: placebo O: Clinical, sigmoidoscopic and histological

remission Reduction in sxs scores

IBD – Aloe Vera

Significant reduction in SCCAI and

sigmoidoscopic scores

IBD – Fish Oil

Inconsistent evidence2.7g qd for 12 months may reduce relapse rate of Crohn’s

In remission: FO 59%; placebo 26%OR compared to placebo: 4.2 (95% CI 1.6-10.7)

IBD – FO + Fiber

FO + fiberMay reduce prednisone requirements

Does not seem to reduce disease activity or improve histology

IBD - Boswellia

Boswellia 350mg tid vs salfasalazine82% (Boswellia) in remission compared to 75% (sulfasalazine)

Boswellia 300mg tid vs salfasalazine 1g tid70% (Boswellia) in remission compared to 40% (sulfasalazine)

Similar results when compared to mesalamine

IBD – Wheat Grass

Wheat grass juice (100cc qd) vs placeboFor 1 month

Reduction in disease activity (P=0.031)Improvement in rectal bleeding severity (P=0.025)

Gionchetti P, Rizzello F, Venturi A, et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology 2000;119:305-9.

Mimura T, Rizzello F, Helwig U, et al. Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis. Gut 2004;53:108-14.

Venturi A, Gionchetti P, Rizzello F, et al. Impact on the composition of the faecal flora by a new probiotic preparation: preliminary data on maintenance treatment of patients with ulcerative colitis. Aliment Pharmacol Ther 1999;13:1103-8.

Bibiloni R, Fedorak RN, Tannock GW, et al. VSL#3 probiotic-mixture induces remission in patients with active ulcerative colitis. Am J Gastroenterol 2005;100:1539-46.

Tursi A, Brandimarte G, Giorgetti GM, et al. Low-dose balsalazide plus a high-potency probiotic preparation is more effective than balsalazide alone or mesalazine in the treatment of acute mild-to-moderate ulcerative colitis. Med Sci Monit 2004;10:PI126-31.

IBD - Probiotics

VSL #3 For 1 year

Maintain remission in 85% of patientsMay need daily consumption

VSL#3 +balsalazide significantly increases remission rates compared to treatment with balsalazide alone or 5-ASA alone in

patients with active mild-to-moderate ulcerative colitis

IBD - Curcumin

IBD - Curcumin

P: n=89, adults with stable UC for 4 weeks I: curcumin 1g bid + salfasalazine (2g qd) or

mesalamine (2.25g qd) C: placebo + salfasalazine (2g qd) or

mesalamine (2.25g qd) O: Clinical activity index (CAI) and endoscopic

index (EI)

Significant reduction in

recurrence rates at 6 mos

IBD - Glutamine

Glutamine (7g tid) vs Placebo (7g tid)Placebo = glycine?

No differences in groups

IBD - Psyllium

IBD - Psyllium

P: n=105 adults, UC in remission >3 months

I1: 10g psyllium bid I2: mesalamine 1.5g qd I3: 10g psyllium bid + mesalamine 1.5g qd

O: Relapse + evidence on sigmoidoscopy

Relapse rates @ 1 yrI1: 37.1%I2: 35.1%I3: 23.3%

Clin Rev Allergy Immunol. 2013 Jun;44(3):274-83. doi: 10.1007/s12016-012-8328-9. Considerations of traditional chinese medicine as adjunct therapy in the management of ulcerative colitis. Zhang C, Jiang M, Lu A.

IBD - TCM

IBD - Acupuncture

4 trials on IBS (3 UC, 1 CD)Methodological concerns

Real acupuncture significantly superior to Sham in UC and CD

Real acupuncture superior to salfasalazine for UC

HOM - Diarrhea

“Individualized homeopathic treatment decreases duration of acute childhood diarrhea”

HOM - Psychiatry

“…the incremental cost associated with the purchase of gluten-free products, as compared to the cost of comparable non-gluten-free products.”

Certified in writing

http://www.cra-arc.gc.ca/tx/ndvdls/tpcs/ncm-tx/rtrn/cmpltng/ddctns/lns300-350/330/clc-eng.html

Celiac

Breast Feeding Ivarsson, A. et al. Epidemic of coeliac disease in

Swedish children. ACTA Paediatr 2000:89:165-71. Ivarsson, A. et al. Breast-feeding protects against

celiac disease. Am J Clin Nutr 2002:75:914-21. Nash, S. Does exclusive breast-feeding reduce the

risk of celiac disease in children? Br J Community Nurs. 2003:8:127-32.

Troncone, R. et al. The controversial epidemiology of coeliac disease. ACTA Paediatr 2000:89:140-141

Celiac

AmaranthArrowroot flourBaking sodaBean flourBuckwheatCassava (Manioc flour)Chick pea flourCorn flourCornmealCornstarch (Masa farina)Cream of tartarDal or DahlFlaxGelatinGreen pea flourGums:

Acacia (Gum Arabic)Carob bean gumCarrageenanCelluloseGuaicaGuar, KarayaLocust beanTragacanthXanthan

Invert SugarKudzuLecithinLegumes:

ChannaChick peasGramLentilsPeanutsPeasSoya

Malto dextrin, MaltolMaltoseMannitolMilletMolassesMustard flour (ground mustard)Oats*PoiPotato flour, Potato starchQuinoaRice bran, Rice flourRice polishings, Rice starch

SorghumSoya flourSoya starchSpicesSweet potatoTapioca flourTapioca starchTeffTofuVanillaWhite vinegar **Xanthan gumYamYeast

Celiac Friendly

Not-Celiac Friendly

Atta (chapatti flour)Barley (flakes, flour, pearl)Beer, ale, lagerBreading and bread stuffingBrewers yeastBulgurCommunion wafersCouscousCroutonsDinkel (also known as spelt) *Durum *Einkorn *Emmer *FarinaFarro or Faro (also known as spelt) *Graham flourHydrolyzed wheat proteinKamut *Malt, malt extract, malt syrup and malt flavouringMalt vinegarMalted milk

Malted milkMatzoh, matzoh mealModified wheat starchOatmeal, oat bran, oat flour and whole oats ***PastasRye bread and flourSeitan ****SemolinaSpelt (also known as farro or faro, dinkel) TriticaleWheat branWheat flourWheat germWheat starch

Maybe?

Milk and Alternatives

Cheese spreads or sauces (e.g. nacho), seasoned (flavoured) shredded cheese

May be thickened/stabilized with wheat flour or wheat starch.Seasonings may contain hydrolyzed wheat protein, wheat flour or wheat starch.

  Flavoured or frozen yogurt

May contain granola, cookie crumbs or wheat bran.

Vegetables and Fruits Dates May be dusted with commercial oat flour, dextrose or rice flour.

  French fried potatoes

Often cooked in the same oil as gluten-containing products resulting in cross-contamination.

Away From Home Practices

Bulk bins Deli counter Buffet lunches French fries Grilled meat Gluten-free

pasta Cereals and

candy bars

Celiac

Butter dish and cooking board

Toaster / toaster bag Counter space Gluten-free cooking

first Utensils Double Dipping Washing grains

Medications!

Home Practices

Digestive Concerns: Wrap UpTake Home Messages

Individualize

Food sensitivities / aggravating factors

Cut the cycle!

Address stress and co-morbidities

Probiotics, melatonin, boswellia, curcumin Iberogast, 5HTP, herbal medicine, wheatgrass Acupuncture Homeopathy