Beyond Basics - Clinical Case Studies & Protocols For Difficult GI Cases

Beyond
Basics
Clinical Case Studies & Protocols for Difficult GI Cases
Jill C. Carnahan, MD, ABFM, ABIHM, IFMCP
Fla$ron Func$onal Medicine
Boulder, CO
ChrisAne Stubbe, ND
Medical EducaAon Specialist -‐ Asheville
Website: www.jillcarnahan.com LinkedIn Group: www.linkedin.com/groups/FlaAron-‐FuncAonal-‐
Medicine-‐3760769
Facebook: www.facebook.com/flaAronfuncAonalmedicine
Email: DrJCarnahan@comcast.net
Twi3er: @DocCarnahan

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Beyond Basics
Boulder, CO
The 5 R Program
1. REMOVE
2. REPLACE
3. REINOCULATE
4. REPAIR
5. REBALANCE
Remove
• Stress
• Abnormal microbes
– Bacteria
– Yeast
– Parasites
• Food SensiAviAes: EliminaAon Diet
• Drugs or herbs to eradicate a parAcular pathogen
• Eliminate GMO foods and xenobioAcs
Replace
• DigesAve enzymes
– Plant or fungal based enzymes
– PancreaAn (lipase, amylase, protease)
– PrescripAon enzymes (Creon, Zenpep)
• Hydrochloric acid – Betaine HCl 500-‐3500mg with protein
containing meal
• Bile acids
• Botanicals
– Bromelain 1200-‐2400 MCU; 250-‐500 mg taken with meals
– Papain 50,000 usp units/mg; 100-‐200 mg taken with meals
– Ginger (Zingiber officinale), 500 mg-‐2 grams before meals
– GenAan (GenAana lutea), 1-‐2 ml; 1:5 Ancture before meals
– Swedish bipers, 1-‐2 ml before meals
Reinoculate
• ProbioAcs, such as bifidobacteria and lactobacillus species

• PrebioAcs – inulin, FOS, arabinogalactans
• Fiber – Chia seed, ground flax seed, psyllium
• Saccromyces Boulardii
Repair
• Vitamins and minerals
• Immune support: Whey protein or colostrum
• AnAoxidants
– Vitamins C, E, D & A
– Alpha lipoic acid
– Coenzyme Q10
• AnA-‐inflammatories
– Curcumin
– Fish oil
• Mucosal healing agents
– Glutamine and Aloe
– Deglycyrrhizinated licorice extract
Rebalance
• Lifestyle change – restore balance

• Adequate sleep
• Mindful eaAng
• Balanced brain and nervous system
– Heart rate variability -‐ heart math
– Acupuncture
– Yoga, tai chi
– Prayer and meditaAon
Mindfulness…being aware of
what is happening right now
without wishing it were
different; enjoying the
pleasant without holding on
when it changes; being with
the unpleasant without fearing
it will always be this way
~James Baraz
Case Studies
Case #1
Dyspepsia & Belching
• 62 y/o male consulAng for dyspepsia, foul
gas and bloaAng, and frequent belching
aqer meals
• Avid runner but gut symptoms affect ability
to run
– Occasionally has acute urgency during run and
has to stop for bowel movement
• PMHx: Congenital abnormal kidney, IBS,
sinusiAs, gout, Raynaud's syndrome
• Meds: Bentyl, Librax, FluoxeAne
• Allergies: sulfa
Case #1
H. Pylori stool anAgen posiAve
H. Pylori
Non-‐invasive tesAng opAons
• Urea Breath Test
– Urea labeled, diffuses through mucosal gel layer
– H. pylori splits urea into ammonia and labeled CO2, which is exhaled &
collected
– SensiAvity and specificity exceeds 95%
– Can be affected by PPIs, anAbioAcs, or bismuth
– Expensive
• Serology
– IgM increased in acAve infecAon, low sensiAvity
– IgA more specific (children) but lower sensiAvity 70%
– IgG best overall S&S (85%/70%) but cannot demonstrate eradicaAon
• Stool anHgen
– SensiAvity and specificity 90% before and aqer treatment
– May be affected by PPIs, anAbioAcs, bismuth, or bleeding ulcers
• “Test of Cure” – UBT or stool anAgen no sooner than 4 weeks aqer
compleAon of tx
H. Pylori
• Most common bacterial infecAon in the world

• Present in 30–40% of US populaAon
• Affinity for stomach mucosa
• Disrupts permeability of GI tract
• Induces sustained immune response = inflammaAon
• May progress from gastriAs to malignancy
• Molecular mimicry results in systemic autoimmune disease
H. Pylori and autoimmunity
The prolonged interacHon between the bacterium and host

immune mechanisms makes Helicobacter pylori (H. pylori) a
plausible infecHous agent for triggering autoimmunity.
hpp://www.ncbi.nlm.nih.gov/pubmed/24587626
H. Pylori Treatment
• No single drug cures H. pylori infecAon
• Treatment involves taking mulAple medicaAons
for 7 to 14 days
• Primary Treatment for H. pylori infecAon
– Triple Therapy: PPI, clarithromycin, and amoxicillin, or
metronidazole for 14 days
– Quad Therapy: PPI or H2RA, bismuth, metronidazole,
and tetracycline for 10–14
– SequenHal therapy: PPI and amoxicillin for 5 days
followed by a PPI, clarithromycin, and Anidazole for an
addiAonal 5 days
• Many cases of resistance so must re-‐test for cure
hpp://gi.org/guideline/management-‐of-‐helicobacter-‐pylori-‐infecAon/
H. Pylori Treatment
• Natural Treatments for h. pylori

– *MasAc gum 2000 mg twice daily
– Zinc Carnosine 75 mg twice daily
– Berberine 250–1000 mg twice daily
– Bismuth Citrate 125–250 mg twice daily
• Treatments for mucosal healing
– *Deglycyrrhizinated Licorice (DGL) extract 250–1000 mg before meals
– *L-‐glutamine powder 3 grams 2–3X daily
– Aloe liquid or capsules
– Marshmallow root infusion
MasAc gum has bactericidal acAvity on H. pylori in vivo.
Oral ZnC decreased gastric (75% reducAon at 5 mg/ml)
and small-‐intesAnal injury (50% reducAon in villus
shortening at 40 mg/ml; both p<0.01).
hpp://gut.bmj.com/content/56/2/168.abstract
H. Pylori and Systemic Disease
• Ischemic Heart Disease and Cardiovascular Disease

• ITP – Idiopathic Thrombocytopenia Purpura
• Iron-‐deficiency anemia
• Idiopathic Anterior UveiAts
• Autoimmune thyroid disease
• MALT lymphoma
• Autoimmune atrophic gastriAs
H. Pylori References
• hpp://www.ncbi.nlm.nih.gov/pubmed/24574745
Other bacteria associated with
systemic disease
• Klebsiella pneumonia – spondyloarthriAs (SA)
– hpp://www.ncbi.nlm.nih.gov/pubmed/23781254
• Yersinia enterocoliAca – autoimmune thyroid disease
• Campylobacter jejuni – reacAve arthriAs
• Salmonella – reacAve arthriAs
Other bacteria associated with
systemic disease
• E. coli – HemolyAc uremic syndrome
• Candida albicans – Crohn’s disease
• Strep Pyogenes – RheumaAc Fever
• Mycoplasma & Chlamydia pneumoniae – mulAple sclerosis
• Citrobacter, klebsiella, proteus – Rheumatoid ArthriAs
Case #2 bloaAng and diarrhea
• 27 y/o female presents with faAgue and severe

bloaAng aqer meals, frequent diarrhea and eczema
• Childhood treated for many ear infecAons
and strep throat up to 10X in one year
• Many environmental allergies and
frequent migraines
• Diagnosed 2 years ago with Hashimoto’s
thyroidiAs, went on autoimmune
paleo diet, lost 40#
Bacterial and fungal dysbiosis
Pathophysiology,
evaluaAon, and
treatment of
bloaAng: hope,
hype, or hot air?
Let’s talk about SIBO
• Small intesAnal bacterial overgrowth (SIBO)

– Abnormally large numbers of bacteria (at least 100,000 bacteria
per ml of fluid) are present in the small intesAne
• Signs & Symptoms
– BloaAng, abdominal discomfort, diarrhea, abdominal pain,
belching, gas
– Anemia, B12 deficiency, malnutriAon, reduced bile acids,
steatorrhea, weight loss, food allergies, brain fog, systemic
inflammaAon, chronic faAgue, restless leg syndrome
– Also associated with micronutrient deficiencies (B12, A, D and E,
iron, thiamine, nicoAnamide)
CondiAons associated with SIBO
• Achlorhydria • Chronic PancreaAAs
• Hypochlohydria • Chronic ABX use
• PPIs • IgA Deficiency
• DysmoAlity • Celiac Disease
• MalnutriAon • Crohn’s Disease
• Collagen vascular disease • Short Bowel Syndrome
• Immune deficiency • Non-‐alcoholic steatorrhea
• Bowel ResecAon • Cirrhosis
• Bariatric surgery • Fibromyalgia
• Advancing Age • Rosacea/acne
• Rosacea paAents have a significantly higher SIBO
prevalence than control
• EradicaAon of SIBO induced complete remission of
cutaneous lesions
SIBO
• Diagnosis
– **Breath test for hydrogen/methane
• H>20, M> 3 Combo >15
– Organic acids – not diagnosAc
– Stool test – not diagnosAc
• Diet IntervenAons = FODMAP
– Fermentable Oligo, Di, Monosaccharides and Polyols. Family of poorly
absorbed, short-‐chain carbohydrates
• Lactose,
• Fructose,
• Fructo-‐and galacto-‐oliogsaccharides (fructans and galactans)
• Polyols (sorbitol, mannitol, xylitol and malAtol)
SIBO Treatment
• MedicaAons 10-‐14 days
– Xifaxan 550mg TID x 10-‐14 days
– Metronidazole/Tinidazole or Neomycin are alternaAves for methane
producers
– Pro-‐kineAc agents (Reglan or domperidone) may help moAlity
• Herbal Treatments 4-‐8 weeks
– Berberine up to 5 grams daily (500mg-‐1500mg BID/TID) x 4-‐6 weeks
– Oregano 200mg TID x 2-‐6 weeks
– Garlic (tx methane bacteria) Allimed 450mg BID x 4-‐6 weeks
– NEEM
– Olive Leaf
– Artemesinin
– Monolaurin
– Biofilm disruptors
– ProbioAcs may be contraindicated because SIBO oqen involves an
overgrowth of D-‐lactate-‐producing species
• Elemental Diet x 2 weeks
hpp://www.nejm.org/doi/full/10.1056/NEJMoa1004409
Hypochlorhydria
• Empiric tesAng with Betaine HCl

• Heidelberg tesAng
• Low serum zinc
• Low serum ferriAn
• B12 deficiency
• Gluten sensiAvity/celiac disease
Hypochlorhydria
Common Symptoms PotenHal antecedents

• BloaAng or belching • Vegetarian lifestyle
immediately aqer meal • Aging
• Weak, peeling, or cracked • FasAng
fingernails • Viral or bacterial infecAon
• Acne or Rosacea • Any debilitaAng chronic
• Undigested food in stool condiAon
• Iron or B12 deficiency • Chronic PPI, H2 blocker or
• Chronic intesAnal infecAons anA-‐acid use
• MulAple food allergies
Hypochlorhydria
• Treatment:
– Betaine HCl with or without Pepsin

• InstrucHons
– Take 1 HCI capsule with your next large meal Ideal
Aming is 0-‐10min prior to meal
– At every meal aqer that of the same size take one more
capsule/tablet
– ConAnue to increase the dose unAl you reach seven
capsules/tablets or when you feel a warmth in your
stomach, whichever occurs first
Case #3 ConsApaAon
• 31 y/o female diagnosed with Lupus in
2002 – presents with chronic consApaAon,
reflux and abdominal pain
• History of taking methylprednisone and
methotrexate for SLE
• Complains of weight loss; recently down to
81 pounds, 5’6”
• Frequent migraine headaches, insomnia,
depression and anxiety
• Daily consApaAon and abdominal bloaAng
• Current Meds: Amitriptyline, Valtrex, OCP
Case #3
• Diet – raw juices in am, craves sweets frequently

• PMHx – Bipolar depression, narcolepsy, SLE, migraines,
insomnia, IBS-‐C, GERD, Raynaud’s syndrome
– Many courses of anAbioAcs over lifeAme
• PSHx – T&A
• FHx – mother hypertension,
father hemochromatosis & diabetes
• Social – married w/ 3y/o and 6 y/o children
• All – sulfa
Candida present
Diagnosis of Fungal Dysbiosis
• Stool profile -‐ culture

• Urinary Organic Acids
– Arabinose
– Citramalic Acid
– Beta-‐Keto Glutaric Acid
• Immune response – serum
– Candida IgG, IgA, IgM
– Candida anAgen
Candida colonize mucosal
surfaces, causing no
pathology to host.
Environmental factors (abx
or immunosuppression)
may trigger yeast to form
invasive hyphal form.
Cytokiness (IL-‐6 and
IL1beta, TGF beta)
produced in response to
recogni8on of hyphal
forms but not yeast forms
Symptoms of Fungal Dysbiosis
– FaAgue
– Poor Memory, “Spacey”
– Insomnia or Hypersomnia
– Anxiety
– Mood Swings
– Muscle and Joint aches and pains
– Alcohol intolerance
– Pruritus/rash
Risk factors for Candida
• Up to 60% of healthy people are asymptomaAc carriers of

Candida spp. (as a commensal in the gastrointesAnal tract)
• Non-‐albicans strains of Candida reported to be increasing
• RISK FACTORS
– Broad spectrum anAbioAcs
– Diabetes
– CorAcosteroid treatment
– Immuno-‐compromised
– Pregnancy or hormone replacement, including OCP
– General debility or extremes of age
– High stress

“Candida” Diet
• Eliminate all sugar & refined grains:

– Fruit juice & high glycemic fruits
– All grain flours
– No sugar, honey or sweeteners
• Paleo-‐style organic animal protein, lower
carbohydrate, high healthy fat diet, adequate fiber
• Avoid fermented foods including alcohol
• Avoid moldy foods & yeast
Treatments for Fungal Dysbiosis
• MedicaAons
– Fluconazole or Itraconazole 200mg qod or daily
• Monitor LFTs and give silymarin 250mg BID
– NystaAn 500,000 units 1-‐2 caps TID
– Compounded Oral Amphotercin B 200mg TID
• Herbs and herbal combinaAons
– Undecylenic acid
– Caprylic Acid
– Garlic
– Berberine
– Oregano
– Pau D’ Arco
– Olive Leaf
PracAcal SoluAons for ConsApaAon
• Use magnesium citrate 500-‐1000mg daily or unAl normal,

soq bowel movements at least 1 X daily
• Add powdered Ascorbic Acid 5–15 grams daily to
bowel tolerance
• Start every morning with a tall glass of warm water or
8–12 oz of coffee may also be helpful
• Try a few tablespoons of extra virgin olive oil, several Ames
daily on an empty stomach
• Mix 2 TBSP of ground flax or chia seed into water & sAr,
let sit for 10 minutes, sAr & drink on an empty stomach
hpp://www.npr.org/blogs/thesalt/2013/09/17/223345977/
auto-‐brewery-‐syndrome-‐apparently-‐you-‐can-‐make-‐beer-‐in-‐your-‐
gut
FermentaAon
• When bacteria or yeast exist in the small intesAne, foods may
be fermented instead of being digested
• Main fermenters are enterococcus, streptococcus and
prevotella (bacteria) and candida (yeast)
• When foods get fermented they produce many toxins
which have to be detoxified by the liver cytochrome P450
detox system
– Alcohols -‐ ethyl alcohol, propyl alcohol, butyl alcohol. Metabolized by
stage I liver detox to acetaldehyde, propylaldehyde, butylaldehyde
and possibly formaldehyde
– Noxious gases such as hydrogen sulfide, nitric oxide, ammonia and
possibly others
– Odd sugars such as D-‐lactate. This right handed sugar cannot be
detoxified by lactate dehydrogenase, a liver enzyme.
We discuss the influence of histamine on a number of
gastrointesAnal disorders, including food allergy,
scombroid food poisoning, histamine intolerance, irritable
bowel syndrome, and inflammatory bowel disease.
Case #4
FaAgue, weight loss, diarrhea
• 26 y/o female with ongoing faAgue. Has
6 mo/old infant and by 2 pm feeling totally
exhausted… Gallbladder removed last year
– “I’ve always had stomach problems and now
feeling sick, nauseous constantly”
• Recently lost addiAonal 10# below pre-‐
pregnancy weight without trying and
decided to quit breas•eeding
• GI –nausea, bloaAng, stomach pain, diarrhea
daily, no heartburn; noAcing undigested
food in stool
• Travel to Mexico last year
Case #4
• PMHx – hypothyroid
• PSHx – cholecytsectomy 25 y/o
• FHx – mother melanoma age 10 y/o; father gallbladder issues
• Allergies – none
• MedicaAons
– Synthroid 50 mcg daily
– OrthEvra
• Married with 6 mo old infant
• Diet -‐ Standard American Diet, drinks soda
Summary of Parasite treatments
• B. hominis – metronidazole or Anidazole +/-‐ SMX/TMP

• Dientamoeba fragilis – Iodoquinil or Anidazole
• Cryptosporidia – Alinia
• Enteromibius (pinworm) – PinX or albendazole
• Giardia – Metronidazole or Tinidazole
• Entamoeba histolyHca – Iodoquinil
• Worms or helminths – Mebendazole/albendazole
Case #5 acute delirium
• 69 y/o male here with son presented post-‐

hospitalizaAon for acute delirium, diarrhea
following UTI
• History of recovering alcoholics both
son & father
• Hospitalized for acute delirium 7 days
• Current poor short term memory
• Daughter has gene for celiac disease
and all children follow gluten-‐free diet
Case #5
PMHx PSHx
• Parkinson’s Disease • Endarterectomy
• History of alcoholism • Prostate TURP
• History of TIA 1990s FHx: Father died of leukemia,
mother died breast CA;
• Prostate CA 2010 brother & sister commiped
• Restless Leg syndrome suicide. Another brother had
• Chronic back pain & joint cocaine addicAon.
pain Social – 1 ppd smoker; Past
history of alcohol use. Sober
• Psoriasis since 2002

Celiac Disease
• Lab Results
– PosiAve TTG IgA
– PosiAve anA-‐gliadin anAbodies
– HLA typing done and posiAve DQ2 homozygous
– No intesAnal biopsy done but gluten removed from diet with
posiAve response
– Vitamin D = 19
• Typical work-‐up to rule out celiac disease
– Deamidated gliadin IgG, IgA; TTG IgA; Assue
transglutaminase (tTG) anAbodies; total IgA, HLA typing for
celiac DQ2/DQ8; +/-‐ endomysial anAbodies

Gluten sensiAvity: from gut to brain
Gluten sensiAvity … is characterized by abnormal

immunological responsiveness to ingested gluten
in geneAcally suscepAble individuals…in some
individuals, gluten sensiAvity was shown to
manifest solely with neurological dysfuncAon.
hpp://www.thelancet.com/journals/laneur/arAcle/PIIS1474-‐4422(09)70290-‐X/abstract
Celiac disease is associated with various
extraintesAnal manifestaAons, including
neurologic complicaAons such as neuropathy,
ataxia, seizures, and neurobehavioral changes.
hpp://www.ncbi.nlm.nih.gov/pmc/arAcles/PMC2111403/
Non-‐Celiac Gluten SensiAvity:
The New FronAer of Gluten Related Disorders
Non Celiac Gluten sensiAvity (NCGS) originally described in the

1980s and recently a “re-‐discovered” disorder characterized by
intesAnal and extra-‐intesAnal symptoms related to the ingesAon of
gluten-‐containing food, in subjects that are not affected with
either celiac disease (CD) or wheat allergy (WA).
hpp://www.mdpi.com/2072-‐6643/5/10/3839
Symptoms improve or disappear when gluten is withdrawn
from the diet, and recur if gluten is reintroduced.
Laboratory tests are usually unhelpful for diagnosis, although
~50% of paAents are posiAve for IgG anAgliadin anAbodies.
Necator americanus and gluten microchallenge
promoted tolerance and stabilized or improved all
tested indices of gluten toxicity in CeD subjects
Future…
hpp://www.jopinie.nl/wp-‐content/uploads/2012/01/Science-‐2013-‐de-‐Vrieze-‐954-‐7.pdf
Free Resources for Professionals: hPp://www.jillcarnahan.com/about-‐us/prac88oners/
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Beyond

• ProbioAcs, such as biﬁdobacteria and lactobacillus species

• Lifestyle change – restore balance

• Most common bacterial infecAon in the world

The prolonged interacHon between the bacterium and host

• Natural Treatments for h. pylori

• Ischemic Heart Disease and Cardiovascular Disease

• 27 y/o female presents with faAgue and severe

• Small intesAnal bacterial overgrowth (SIBO)

• Empiric tesAng with Betaine HCl

Common Symptoms PotenHal antecedents

• Diet – raw juices in am, craves sweets frequently

• Stool proﬁle -­‐ culture

• Up to 60% of healthy people are asymptomaAc carriers of

• Eliminate all sugar & reﬁned grains:

• Use magnesium citrate 500-­‐1000mg daily or unAl normal,

• B. hominis – metronidazole or Anidazole +/-­‐ SMX/TMP

• 69 y/o male here with son presented post-­‐

Gluten sensiAvity … is characterized by abnormal

Non Celiac Gluten sensiAvity (NCGS) originally described in the

US Client Services: 800-­‐522-­‐4762

We look forward to hearing from you!

•January 2015: GI Eﬀects Case Studies and Report Reviews

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• Stool proﬁle -‐ culture

• Use magnesium citrate 500-‐1000mg daily or unAl normal,

• B. hominis – metronidazole or Anidazole +/-‐ SMX/TMP

• 69 y/o male here with son presented post-‐

US Client Services: 800-‐522-‐4762