Gastrointestinal

Health
A Nutritional and Functional
Perspective
You are what you eat
Consequences of GI Dysfunction
 Malnutrition and Consequences
 GI Symptoms/ Signs and Disease
 Immunological (Autoimmune Disease Atopy)
 Toxic load
 Chemical overload of liver/ systemic detoxification
 Endotoxins
 Sensitivities
 Salicylates, Amines, Sulphites, Nitrite, Benzoates
 Inflammation and Insulin Resistance
 Gut Brain Connection
 Digestive Physiology
 Cephalic Phase
 + gustatory and oral
 - stress / Sympathetic Nervous System

 Gastric Phase
 Gastrin
 Glucose dependant insulinotropic peptide GIP

 Gastroenteric Plexus

 Intestinal Phase
 Gastrin
 Functions
 HCl ( parietal cells)
 Pepsinogen
 Trophic to mucosa
 LOS sphincter tone

 Stimulus
 Vagal
 Distension myenteric plexus
 Free AA chemoreceptors
 Gastrin Inhibition
 Sympathetic Nervous System
 GIP , GLP-1 Oxyntomodulin
 From undigested carbohydrates in SI, LI
 Intestinal Phase
 Triggered by acidic chyme in duodenum
 Persists due to myenteric plexus
 Releases CCK, Secretin, GIP
 Trigger release of
 Pancreatic enzymes and Bicarbonate
 Bile
 Picolinic Acid
 Satiety and inhibition of gastric secretion and motility
 B12 binding to intrinsic factor in alkaline environment
 Gastric Acid Function
 Activation of pepsinogen for protein digestion
 Release of B12
 Anti-infective including reduction in H Pylori
 Mineral and B12 absorption
 Triggering Intestinal phase of digestion
 Hypochlorhydria
 Associated with
 ageing 50% > 60 yo
 Sympathetic stimulation / stress / pain

 Protein Depletion

 Chronic illness pain

 Zinc B1 and B6 deficiency

 Proton pump inhibition

 H2 Receptor blockers
Hypochlorhydria associated disease
 Autoimmune disease
 AS, RA, SLE, thyroid disease, Rosacea, Psoriasis
 Inflammatory Bowel Disease (UC and Crohn’s)

 Coeliac

 Atopic Disease
 GI disease
 IBS, Dyspepsia, GORD
 Gastric Ca
 Hypochlohydria Symptoms
 Bloating and Epigastric discomfort
 Burping Flatulence
 Protein Intolerance
 GORD
 Nausea
 Dysmotility
 Symptoms of Dysbiosis SIBO
 Food intolerance ( systemic and GIT)
 Hypochlorhydria Signs
 Tongue and Geographic
 Bloating
 Epigastric and central abdo tenderness
 Rosacea and malar capillary dilatation
 Signs of Nutrient Depletion
 Protein and FEA
 Zinc

 Iron
Tongue Signs
 Maldigestion Factors
 Hypochlorhydria
 Pancreatic Dysfunction
 Inadequate Bile production or release
 Inadequate mastication
 Sympathetic Parasymapthetic Imbalance
 Stress, Thyroid Dysfunction, Nutrient Deficiency
 Drugs Chemotherapy Radiotherapy
 Villous Atrophy, Mucosal damage and permeability
 Transit time and Dysbiosis
 Basic Concepts and Overview
 Sympathetic Parasymapthetic Imbalance
 Hypochlorhydria and Maligestion
 Malabsorption
 Dysbiosis
 Raised Intestinal Permeability ( Leaky Gut)
 Immune Dysfunction Imbalance
 Food Intolerance
 Specific Diseases
 Malabsorption Factors
 Maldigestion
 Transit time
 Reduced surface area (Coeliac, tropical sprue)
 Mitochondrial dysfunction for active
absorption
 Dysbiosis
 Abnormal number of bacteria parasites fungi in gut
 Inadequate Normal Flora
 Associated Systemic Disease
 Autism (Clostridia, Enterococci and Fungi)
 Chronic Fatigue Syndrome Fibbromyalgia, IBS
 Enterococci and E Coli
 Autoimmune Disease
 RA, Ankylosing Spondylitis,
 SIBO
 Atopy
 Obesity and Insulin Resistance
 Dysbiosis what new
 Quorum Effects
 Interaction of Diffuse Millieu and effects on
Immunity , Mucous production and Lysis
(Crohns)
 Biofilms
 Intracellular Bacteria ( escaping immunity)
 CFS Fibromyalgia IBS and
Mood
 Decrease E Coli
 Decrease B2, CoQ10, Folate, Tyrosine, Tryptophan
 Impaired mitochondrial energy

 Reduced serotonin and dopamine

 Increased biogenic amines and lactate

producing bacteria eg Enterococci
 Lactate excess
 Amines (Migraine anxiety and Brain fog)
 Raised Intestinal Permeability
 Leaky Gut contributors
 Stress, cortisol
 Alcohol
 Gluten
 Food allergens intolerance
 Ischaemia
 GI Inflammation (IBD, Coeliac, ICU, Cholera)
 Toxins (Zonulin)
 Dysbiosis
 Nutrient Deficiency
 Immune Deficiency ( IgA)
 Drugs, Salicylates, Food chemicals, Casomorphin
Leaky Gut
 Leaky Gut Effects
 Malabsorption
 Immune Stimulation (IgG)
 Inflammation cytokine release and Oxidation
 Auto immunity
 Allergy / Atopy
 Toxin Absorption/ Load
 Mitochondrial Dysfunction
 Bowel Irritability and altered transit time
 Pain constipation and Diarrhoea
 Immune Dysfunction
 > 70% of Immune system in Gut
 Peyers patches, Dendrites and M cells
 Development of Oral Tolerance (Toll like receptors)

 Gut Flora modulate TH1/ TH2 balance

 Dysbiosis Associated with atopy
 Immune Activation associated with
 Maldigestion, hypochlorhydria and leaky gut
 Auto immunity cross reactivity , lectins
 Food Intolerance
 Casein (casomorphin)
 Gluten( glutamorphin) and fermentation products
 Food Additives (sulphites
 Salicylates
 Amines
 FODMAPS
 Oxalates
 Increased Dysbiosis eg candidiasis Specific
Carbohydrate Diets
 Coeliac Disease
 Allergy to gluten: protein in wheat oats, barley
and rye.
 Compare with Gluten Intolerance.
 The “Great Imitator” (In past centuries,
Syphilis was the “Great Imitator”.)
 Many presentation: only 43% present with gut
symptoms.
 10-18% anaemia, 20% tiredness,
 MJA 2004;180:524-26
 Coeliac
 1/ Gastrointestinal: Liver Disease, “Transaminitis”, Hepatitis,
Fatty Liver, Primary Biliary Cirrhosis, Cirrhosis, Recurrent
Aphthous Mouth Ulcers, “Irritable Bowel Syndrome“,
Lymphocytic Gastritis, Ulcerative Jejunitis, Reflux
Oesophagitis, Adenocarcinoma of Small Bowel.
 2/ Neurological: Peripheral Neuropathy, Epilepsy, Ataxia,
Myelopathy, in fact any Neurological condition of Unknown
Origin.
 Antigliaden antibodies cross-react with Perkinje cells in the
cerebellum causing Gluten Ataxia.
 3/ Psychiatric: Depression, Schizophrenia
 4/ Endocrine: Type 1 Diabetes, Infertility in Men and
Women, Recurrent Abortions, Thyroid Disorders, Addison’s
Disease
 Coeliac
 5/ Renal: IgA Nephropathy
 6/ Haemopoietic: Anaemia (iron, folate and vitamin
B12 deficiency), Coagulation Disorders from Vitamin
K Deficiency, IgA Deficiency, Hyposplenism, T-cell
Lymphoma.
 7/ Locomotor: Osteopoenia, Arthralgia/arthritis
 8/ Dermatological: Dermatitis Herpetiformis,
Psoriasis, Brown Pigmentation of Face and Buccal
Mucosa
 9/ Dental: Defects in Tooth Enamel
 Liver Detoxification
 1/ Does coffee keep you up all night?
 2/ Are you a 2 pot screamer?
 3/ Are you affected by strong smells,
perfumes, the detergent aisle in the
supermarket?
 4/ Are you more sensitive to drugs and
medicines than other people
Why the Medical Profession hasn’t
heard about probiotics
 Probiotics prevent antibiotic
associated diarrhoea (AAD)
 Metanalysis of 25 RCTs
 probiotics significantly reduced the relative risk of AAD
 RR = 0.43, 95% CI 0.31, 0.58, p < 0.001).
 Three types of probiotics significantly reduced the
development of antibiotic-associated diarrhea.
 Saccharomyces boulardii,
 Lactobacillus rhamnosus GG
 probiotic mixtures.
 (McFarland 2006)
Probiotics improve acute diarrhoea
in children
 Recent review found the therapeutic effects of
probiotics in children with acute diarrhea were
 Moderate
 Strain- dependant (LGG, L. reuteri, B. lactis Bb12)

 Dose-dependent

 Greatest when given early

 Significant only in watery diarrhea and viral

gastroenteritis but not in invasive bacterial diarrhea
 (Szajewska 2005)
Probiotic effects are dose and strain
dependant
Prevention of acute diarrhea caused
by viral or bacterial infection

 Most studies demonstrate benefit

 Beneficial effects
 Decreased frequency of infections,
 Shortening of the duration of episodes by 1–1.5 d
 Decreased shedding of rotaviruses
 Promotion of systemic or local immune response
 Increase in the production of rotavirus-specific antibodies
 (de Vrese 2007)
Prevention of acute diarrhea caused
by viral or bacterial infection
 Demonstrated for a number species
 Lactobacillus rhamnosus GG
 L. casei Shirota,
 L. reuteri
 L. acidophilus spec.
 Bifidobacterium animalis ssp. lactis BB-12
 E. coli
 Enterococcus faecium SF68
 Saccharomyces boulardii
 (de Vrese 2007)
IBD is associated with dysbiosis
 Changes in microflora in UC patients
 Increased pro-inflammatory bacteria
(Enterobacteriaceae)
 Increased Bacteroides fragilis within the mucosa

 Decreased protective bacteria (lactobacilli and

bifidobacteria)
 (Wang 2007) (Cummings 2003)
 Probiotics and IBD
 Review 46 clinical trials.
 23 RDBCT
 8 open-label randomized controlled.
 In 14 nonrandomized trials, outcome was successful.
 Ulcerative colitis
 Probiotics beneficial in 12 of 16 RCT
 Crohn's disease
 Only 2 of trials of probiotic therapy were successful.
 No superiority of any probiotic was clearly evident,
 multi-agent mixture, VSL3# may be better suited in ulcerative colitis
and pouchitis
 Lactobacillus rhamnosus GG appears less useful in IBD especially
Crohn's disease.
 (Heilpern 2008)
 Probiotics and IBD
 Literature review of probiotics in IBD
 A probiotic effect is strictly restricted to one
defined strain and cannot be generalized from
one to another
 VSL#3 efficacious in pouchitis
 Escherichia coli Nissle 1917 efficacious in the
prevention of recurrence of UC
 (Seksik 2008)
Probiotics Improve Allergic Rhinitis
 Probiotics improve
 frequency of symptoms
 level of bother

 Reduce IL4

 Increase IFN gamma

 Increase TGF B
 (Peng. 2005) (Ishida.2005) (Kirjavainen 2003) (Aldinucci
2002)
 Probiotics reduce clinical excema
but not IgE or skin prick test
 Prospective DBCT of the effects of daily L. casei for
the first 6 months of life
 159 infants of mothers with a first-degree relative with
atopic disease
 Reduced the prevalence of eczema by 50% at age 2 and 4
years
 (Kalliomaki 2003)
 RDBCT 925 infants at risk for allergic disease
 Fed placebo or a mix of four probiotics or a prebiotic for 6
months
 At 2 years of age active treatment reduce the rates of
atopic eczema
 (Kukkonen 2007)
 Probiotics protect against viral
respiratory illness
 Daily ingestion of probiotics resulted in fewer
lost days of school because of viral respiratory
illness
 (Hatakka 2001)
 DBCT study of 479 adults showed that,
although daily ingestion of lactobacilli and
bifidobacteria had no effect on the frequency
of common colds, it reduced their mean
duration by 2 days.
 (de Vrese 2006)
Probiotics may benefit duration and
severity of respiratory tract
infections
 Review of 14 RCTs
 Reduction in the severity of symptoms related to RTIs was
noted in five of six RCTs
 Three of nine RCTs that provided relevant data, the clinical
course of RTIs was shorter in the probiotic arm, whereas
no difference was found in the remaining six RCTs
 Conclusion, probiotics may have a beneficial effect
on the severity and duration of symptoms of RTIs but
do not appear to reduce the incidence of RTIs.
 (Vouloumanou 2009)
 Probiotics and Surgery
 Probiotics/symbiotics have may prevent postoperative
infections in abdominal surgery (biliary cancer, liver
transplantation, and pancreaticoduodenectomy).
 Major infections reduced were pneumonia, urinary tract
infection, wound infection, intra-abdominal abscess, and
cholangitis.
 Meta analysis of 9 perioperative probiotics RCTs
(733 patients)
 reduced overall infections [odds ratio (OR) = 0.26]
 length of antibiotic treatment need (OR = -4.01)
 reduced length of postoperative hospital stays (OR = -2.7)
 (Pitsouni 2009)
 History
 Food Diary
 Oral reactions
 Gut Reactions
 ENT Hx ( Dairy)
 Antibiotic Use
 Chemo RadioRx
 Systemic Sx , Dermatitis, Atopy
 Examination
 Hypochlorhydria signs
 Bloating and Bacterial Overgrowth
 Tenderness
 Chest GORD and Asthma
 Nutritional Deficiency and Body Composition
 Auto immunity
 Testing
 H Pylori ( serology, Urea Breath Test)
 Coeliac Testing
 Scopes
 Breath Tests ( lactulose Hydrogen, lactose)
 Stools (M/C/S) CDSA Reducing Substances
 Intestinal Permeability
 Urine Organic Acids
 IgG/ IgA, IgE food antibodies
 Elimination and Challenge testing
 Functional Liver Detoxification Profile
 Management
 Diet LSD ( additive/ refined sugar free limited
grain no alcohol ), nutrients, protein, fibre
 Elimination Diets
 Probiotics (Seed) and Prebiotics ( feed)
 Heal Gut Wall
 Zinc , Vit A, Glutamine, N acetyl Glucosamine
 Aloe, Slippery Elm , Licorice, Marshmallow Ginger
 Biooflavonoids
 Sucralfate
 Management
 Support Digestion
 Acid Supplementation
 Betaine or Glutamine HCl, Vinegar Ascorbic Acid
 Acid Stimulators
 Herbal Bitters, Gentian
 Zn , B1, B6, B5, Choline,
 Pancreatic Enzymes

 Secretin, Bethanechol, Neostigmine

 Management
 Treat Dysbiosis
 Specific Carbohydrate Diet
 Fermented Foods and bone broths
 Legumes
 Balance pH, Energy Support, Heavy Metals
 Specific Treatments ( Directed and Blind)
 Antifungals
 Herbs ( olive leaf, Rosemary, Essential Oils, wormwood)
 Oregano
 Antibiotics
 Management
 Stress Management
 Exercise
 Sleep

 Meditation Tai Chi Yoga

 Biofeedback
 Management
 Immune Support
 Eliminate Allergens
 Low Dose Naltrexone

 Colostrum

 Probiotics to balance Th1/Th2

 Zinc Vitamin C
 Management Detoxification
 Enhance Detoxification Phase 2
 Glutathionation: Brassica, citrus peel, dill, carraway, GSH,
NAC, St Mary’s Thistle (Milk Thistle) B2, B6, Zn Lipoic Acid
 Glycintion: glycine
 Sulphation: cysteine, methionione, taurine, garlic, onions,
SAMe
 Glucuronidation: Fish oils, cigarette smoke, oestrogens, citrus
peel, caraway, dill,
 Turmeric induces Phase 2 generally
 Dandelion
 Turmeric
 Remove Toxins or Toxic Source (diet/ dysbiosis)
Detoxification Phase 2 Inhibitors
 Glutathionation: Selenium, B2, Zn deficiency,
Glutathione deficiency
 Glycination: Low protein diet
 Sulphation: Aspirin, NSAIDs, yellow food
dye, molybdenum deficiency
 Glucuronidation: Aspirin, probenecid
 Liver Detox Phase 1 Inducers
 Drugs: alcohol, nicotine, Phenobarbital, steroids
 Foods: Brassica, high protein diet, oranges and
tangerines
 Herbs: Caraway and Dill seeds
 Toxins: Carbon tetrachloride, exhaust fumes,
paint fumes, dioxin, pesticides
 Nutrients needed
 Protein Vitamin B and C
 Copper Zinc Magnesium
 Liver Detox Phase 1 Inhibitors
 Drugs: benzodiazepines, antihistamines,
cimetidine, ketokonazole
 Foods: naringenin (from grapefruit)
 Herbs: Curcumin, capasaicin, cloves
The doctor of the future will give
no medicine, but will interest the
patient in the care of the human
frame, in diet, and in the cause
and prevention of disease.”
Thomas A Edison (1847-1931)