Digestion, health and nutrition: Dr. Anil Minocha, a gastroenterologist and nutritionist

Good Teeth, Gums Reduce Risk of Diseases In Distant Organs

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Why is oral-dental health so important?

Oral cavity is involved in first encounter for foreign bodies and pathogens to the respiratory and gastrointestinal tract.

• Orodental space represents the tip of the spear for most things good and bad (food, drugs, toxins, pathogens) that enter the body especially the gastrointestinal tract.
• Ironically, the status of orodental cavity may reflect the overall health including nutritional and immunological status.
• Orodental changes may be cause of effect or what is happening in the body. 

Orodental flora

Oral cavity is  “dirty”. A variety of bacteria are present including pathogens that have potential for local and body-wide repercussions.

• As many as 500 species are encountered and most of them are not pathogenic.
• In the presence of immune dysfunction, the pathogenic bacteria can become pathogenic manifesting in chronic inflammatory periodontal disease and can then affect the entire body.
• Orodental activities, as simple as chewing, flossing brushing and minor procedures like  scaling result in release of bacteria into blood circulation, although the  bacteremia is usually transient.
• However, the release of bacteria or their toxic product into the circulation have potential to seed another nidus of infection/inflammation setting off a deleterious chain reaction.

 Is localized focus of infection anywhere significant

Poor oral-dental health implies a localized focus of infection.

• The word “localized” may be a misnomer since a localized focus of infection need not have localized effects only.
• Not unlike cancer, metastasis of bacterial infection may occur in the form of bacteremia, release of bacterial toxin into the circulation.
• Metastatic inflammation describes the phenomenon wherein bacterial antigen released into circulation interacts with an antibody resulting in immune complexes that can have their own disease processes. 

Localized focus of infection: A historical perspective

Concept of localized focus of infection is not new; in fact it is rooted in history of medicine since ancient times

• Hippocrates successfully treated a case of arthritis by performing tooth extraction.
• Dr. C.H. Mayo in 1914 declared in Journal of American Medical Association that “root abscesses and pus pockets connecting them are often the source of acute and  chronic rheumatism”. 

Localized orodental infection foci

• Much of  the research has focused on periodontal lesions and their systemic effects beyond oral cavity
• Caries is also increasingly attracting attention in recent times
• WHO considers caries a global health problem 

How does focus of infection including orodental affect body

Diffusion or metastasis of bacteria, toxins and antigens into the body can initiate or worsen a distant and/or generalized illness. Affects can be far away including heart and brain

• Administration of components of normal mouth bacteria (commensal) Porphyromonus gingivalis exacerbates encephalomyelitis in mice.
• An additional concept gaining traction is involvement of RAGE. 

The emerging RAGE concept (Anger at cellular level)

RAGE (Receptor for Advanced Glycation End Products ) has been implicated in multiple disorders.

• Signaling through RAGE has been implicated as a nemesis for diverse pathologies including periodontal disease, cardiovascular diseases, complications of diabetes mellitus including diabetic vasculopathy, Alzheimer disease, cancer, and neurologic conditions.
• An excess of AGEs (Advanced Glycation End Products) has been documented  in numerous organ systems including brain of patients with autism.
• RAGE are plentiful in gums and are  released into circulation when gums are inflamed.
• AGE-RAGE axis has been postulated as the mechanism of a variety of associations of orodental diseases and increased diseases beyond oral cavity including heart, blood vessels and nervous system [Katz et al 2010].

Oral-dental lesions in GI diseases

• Concept of oral-dental lesions in gastrointestinal diseases with far-reaching effects in various parts of the body  is well established.
• Examples include inflammatory bowel disease, Behcet’s disease, celiac disease etc. 

Effects of poor health on oral cavity

In addition to gastrointestinal disorders, aphthous lesions may occur due to immune dysfunction related to infections, malnutrition, allergies, stress and hematological and malignant disorders. More details in upcoming post.

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Cognitive behavioral therapy in irritable bowel syndrome

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Cognitive behavioral therapy or CBT appears to have a direct effect on global manifestations of irritable bowel syndrome(IBS) or spastic colon. This may not correlate with resolution of psychological distress. Improvement in IBS symptoms is associated with improvements in the quality of life and the improvement in psychological distress may be a reason for, effect of or part of it.

Scientific basis

Cognitive therapy for irritable bowel syndrome results in decrease in limbic activity and improves digestive symtoms and anxiety. Thus CBT induced symptomatic improvement in IBS may be a biologically oriented change mediated by changes in neural activity of CNS foci that relate to hypervigilance and emotions.

• Drossman (2003) conducted a randomized, comparator-controlled, multicenter trial in 431 adults to examine the clinical efficacy and safety of cognitive-behavioral therapy versus education and tricyclic antideppressant (desipramine) versus t placebo in female patients with moderate to severe functional bowel disorders including IBS. Significantly higher number of patients responded in CBT group as compared to education (70% vs 37%). Desipramine was similar to placebo in intent to treat analysis.
• Kennedy conducted randomized controlled trial of the addition of nurse administered CBT to standard general practice management of IBS (antispasmodic agent mebeverine) in in primary care. The addition of CBT was significantly superior to mebeverine-only group at 3 months. Authors concluded that specially trained practice nurses can provide effective CBT to primary care patients with a clinical diagnosis of IBS, which although effective does not reduce service or social costs although the beneficial effects of the addition of CBT to antispasmodic therapy persist for up to 6 months.
• A randomized controlled trial (Ljotsson 2010) has documented that cognitive behavior therapy based on exposure and mindfulness exercises and conducted over the internet delivered via the Internet alleviating the total burden of symptoms and increasing IBS-related quality of life in patients with IBS. The treatment group reported a 42% decrease in primary IBS-symptoms as compared to 12% in controls.
• Another randomized controlled trial (Moss-Morris 2010) found that cognitive behavioral therapy based self-management in the form of a structured manual without much contact with the therapist contact is a effective for treatment of patients with IBS in primary care.
• In contrast to studies on CBT and IBS above, Boyce (2003) reported that cognitive behavior and relaxation therapy seem not to be superior to standard care alone in IBS.             

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Irritable bowel syndrome? Peppermint oil works!

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Use of peppermint oil  for irritable bowel syndrome treatment: Irritable bowel syndrome or IBS also known as spastic colon is a type of functional bowel disorder.

IBS affects 10-20 percent of the population. IBS is more common in females. Treatment options for this chronic disorder are limited. Of note, irritable bowel syndrome is not the same thing as diverticulitis.

Study to examine effect of peppermint oil in IBS: Merat et al. from Shariati Hospital, T. University of Medical Sciences performed a  randomized double-blind placebo-controlled trial to examine the efficacy of peppermint oil in  90 patients with IBS.

Methods of irritable bowel syndrome study: Patients received one capsule of enteric-coated peppermint oil (Colpermin) or placebo three times daily for 8 weeks. Clinical symptoms and quality of life were assessed at follow up visits.

Results of IBS and perppermint: The number of patients free of abdominal pain at 8 weeks increased from 0 to 14 in the peppermint oil treatment group as compared to 0 to 6 in the placebo group (p<0.001).

There was significantly  greater reduction in the severity of abdominal pain associated with significantly better quality of life in the peppermint oil  group. No significant adverse reactions were noted due to peppermint oil.

American College of Gastroenterology in its evidence based guidelines includes use of peppermint oil as one of treatment options for treatment of irritable bowel syndrome.

Do you or someone you know has irritable bowel syndrome or IBS? What treatments have you used and have they worked for you. Please sure your thoughts.

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Birth control, childhood hygiene, IBD, obesity, premature death

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According to Margie Mason of the Associated Press and published in numerous newspapers, some mullahs in Afghanistan are distributing condoms while others are quoting the holy Quran to encourage longer intervals between births.

The Food and Drug Adminsteration is recalling numerous food products because of contamination with the bacteria, various parts of media is reporting. This is used in a variety of soups, sauces, chilis, stews, hot dogs, snacks, dips, and dressings. However, this contamination has not been associated with any episodes of sickness thus far. Per the report, the FDA traced this contamination to Las Vegas-based Basic Food Flavors.

A Population-based study by Klement and colleagues from Israel and published in American Journal of Gastroenterology found that childhood hygiene Is associated With the risk for inflammatory bowel disease. Lacatos states that cold chain hypothesis is providing an even broader platform by linking dietary factors and microbial agents.

Obese children have an increased increased risk of premature death from endogenous. This was reported in the New England Journal of Medicine. Other factors for premature death included  glucose intolerance and hypertension during childhood.

Multiple studies have documented  high prevalence of malnutrition and poor intake in patients who had fallen in hospital. Nutrition assessment nutritional intervention is often neglected but should be undertaken aggressively. Family members beware: Hiesmayr and colleagues report that hospitalised patients eat less food than provided as regular meal and this reduced intake inc reases risk for death in the hospital. 

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger.

Cola fizz, rifaximin, Crohn's, vitamin D, calcium and heart

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Coffee may be friendly to the heart. According to news reports, a study found that subjects who drank  four or more cups of coffee each day had an 18 percent lower risk of hospitalization for heart rhythm disturbances.

Cola drinks, whether flat or with fizz, should not be used for hydration in kids with acute gastroenteritis, so say Reece et al in recent Archives of Diseases in Childhood based on clinical as well as laboratory evidence. Majority of children with mild to moderate dehydration can be treated effectively with oral rehydration therapy.

Acute thermal injury from ingestion of extremely hot solid food can be seen in esophagus. The patients present with acute odynophagia. Ulceration and necrosis may be seen on endoscopic evaluation of the esophagus. This was reported by Chung etal. in Journal of Korean Medical Science.

Rifaximin therapy results in clinical improvement in patients with Crohn’s disease as reported by Shafran et al. in Digestive Diseases and Sciences. As such, it may be another option for use for induction and maintainance of remission in Crohn's disease.

Vitamin D deficiency is a growing epidemic and may contribute to multiple ailments including making people more susceptible to Crohn's disease. This was concluded by recently Wang et al as published in the Journal of Biological Chemistry.

Two systemetic reviews on effect of calcium and vitamin D supplementation on heart have been published in recent Annals of Internal Medicine. In accompanying editorial, Guallar and colleagues argue that available evidence in favor of vitamin D supplementation is far more promising than for other vitamin and mineral supplements.

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Digestion, Health & Nutrition                          Facebook Dr. Anil

Anil Minocha Disclaimer: Everything on this site is for your information only. I am not your doctor or pharmacist. Please consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger

 

Fiber formula diet prevents gut infection

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The gastrointestinal tract is full of bacteria, more so in colon than other parts of gut. Normal bacteria play a variety of beneficial roles in the body including enhancing immune function and preventing infections.

Clostridium difficile (C. difficile) is a common cause of nosocomial diarrhea including antibiotic-associated diarrhea. Lately, this bacteria has become increasingly virulent resulting in increased relapses as well as greater morbidity and mortality. The recurrences of Clostridium difficile infection can be so severe that total bacterial flora replacement or transplant from healthy donor may be needed.

A less recognized cause of Clostridium difficile diarrhea, in addition to use of proton pump inhibitors or PPIs like Nexium, Prevacid, Protonix or Prilosec etc., is the increasing use of elemental diets in formula  fed hospitalized patients over extended periods. Since most if not all of the elemental diet is absorbed in the small intestine, it deprives the colonocytes as well as the colonic bacteria of their source of nutrition. These sources of nutrition in a healthy diet include prebiotics like dietary fiber, fructo-ogosaccharides, and resistant starch.

Dr. O’Keefe states that lack of bacterial fermentation in the colon leads to suppression imbalance of good versus bad bacteria or dysbioisis. The good bacteria include butyrate-producers and bifidobacteria. Such dysbioisis is unhealthy and leads to permissive environment for C. difficile which overwhelms the gastrointestinal immune defenses. This allows these harmful bacteria to colonize and proliferation leading to infection.

As such,a change of tube feeding formula from elemental diet to a prebiotic or fiber containing diet as soon a possible has potential to reduce the prevalence and severity of C. difficile induced infection.

Have you or someone you know has suffered from C. difficile diarrhea caused by bacteria or other factors? If so, how was it treated. What do you think about fiber rich diet for health? Please share your thoughts and ideas

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger.

Turmeric, curcumin in ulcerative colitis

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Turmeric curry powder in inflammatory bowel disease 

Curcumin is a biologically active phytochemical component in turmeric or yellow curry powder and has been found to be effective in numerous diseases including cancer. Ulcerative colitis (one form of inflammatory bowel disease) may be one of those conditions with proven benefit.

The study below was discussed at one of the sessions at the annual Digestive Diseases week (2008) which is the largest gathering of the gastroenterologists in the world. The two panelists (Dr. Koratz from UCLA and Dr. Mullen from Johns Hopkins) gave two thumbs up to this study of turmeric and endorsed its used in ulcerative colitis.

Hanai and colleagues studied the effect of turmeric (curcumin) as a maintenance therapy for ulcerative colitis in a randomized controlled fashion. They reported their findings in the journal Clinical Gastroenterology & Hepatology in a study titled, "Curcumin maintenance therapy for ulcerative colitis: randomized, multicenter, double-blind, placebo-controlled trial."89 with ulcerative colitis in remisssion participated in the study. Patients received curcumin (1g twice a day) or placebo in addition to the standard treatment (sulfasalazine or mesalamine) for 6 months.

Of the patients receiving curcumin, 5% relapsed as compared to 21% in the placebo group.

The investigators concluded that curcumin seems to be a promising and safe medication for maintaining remission in ulcerative colitis. 

What are your thoughts on the above study and the action of a "natural remedy" being endorsed at a prominent medical scientific meeting? Please share your thoughts.

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Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger. 

Nurses smell stool for diarrhea cause: nursing nose makes odiferous diagnosis

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 Nurses nose superior diagnostic tool 

Can nurses smell the diagnosis better than doctors and tests? Especially by smelling stool for cause of diarrhea?

Nurses have long been contributing to astute observations that have stood the test of time. A shining example is Sister Mary Joseph's nodule.

All diarrheas are not the same and nurses can smell and actually diagnose the cause for diarrhea. An early diagnosis can help early specific treatment.

While rotavirus gastroenteritis appears clinically to be similar to other types of diarrhea, nurses were able to correctly diagnose Rotavirus as the cause in 69% on the bases of the stool smell alone. This was reported by Poulton and colleagues in the Archives of Diseases in Childhood.

Clostridium difficile diarrhea can be devastating and prompt treatment may help attenuate the seriousness pending results of investigations. Johansen and colleagues studied diarrheal stool sample and found that nurses could identify Clostridium difficile toxin positivity in 31 out of 37 cases yielding a sensitivity and specificity of 84 and 77% respectively. The authors concluded that there is a characteristic “Clostridial odor” that helps nurses identify the cause.

These results of the odiferous diagnosis were confirmed in a study by Burdette and Bernstein and published in the journal Clinical Infectious Diseases.

Do you believe the data above that nurses have sharper noses and can actually identify cause of diarrhea? Do you think it is nurses are predominantly women and that women are more perceptive than men? Please share your thoughts. 

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Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger. 

 

Organic food heals Crohn’s disease

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Organic food—expensive! Should we eat this expensive organic food for better health in Crohn’s?

Study question: Would organic diet be better for healing Crohn’s?

Gasche and colleagues from Austria tested the hypothesis that organic diet is better for treating Crohn’s disease.

Patients with Crohn’s received organic diet or a control diet (low-fiber, low-fat, and high-carbohydrate). Outcome measures included MRI, endoscopy, Crohn's Disease Activity Index (CDAI), and the Inflammatory Bowel Disease Questionnaire (IBDQ).

Organic food diet showed improvement in their intestinal lesions not seen in patients assigned to a high-carbohydrate diet. The investigators concluded that food as part of the modern Western lifestyle may cause persistence of intestinal Crohn's lesions.

Diet and environmental have been linked to risk for Crohn’s disease. Diet and environment are not mutually exclusive. The increase in incidence of Crohn’s disease in recent decades suggests environmental risk factors associated with a Western lifestyle may contribute to Crohn’s disease.

What kind of diet do you prefer? Would you be willing to spend more for organic food in your diet based on this study?

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger. 

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Diet Crohn’s disease risk

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Diet as risk for Crohn’s disease?

Over the years, some dietary foods predominant in vegetables and fruit have been thought of as protective. In contrast, fatty foods have been thought as increasing the risk for Crohn's disease. The literature however has been inconsistent. As such, the controversy continues as the precise cause of Crohn’s disease remains an enigma.

Dr. D’Souza and colleagues from Canada reported the results of their study in Inflammatory Bowel Diseases 2008. They examined the dietary patterns and risk for Crohn's disease in children in a case-control study fashion. Subjects included newly diagnosed Crohn’s disease compared with population and/or hospital-based controls.

Dietary patterns were assessed using a food frequency questionnaire. The study comprised of 149 cases of Crohn’s disease and 251 controls.

Girls consuming diet consisting of meats, fatty foods, and desserts had an increased risk by 4.7 fold. In contrast, boys and girls enjoying diet consisting of vegetables, fruits, olive oil, fish, grains, and nuts had a the risk decreased substantially.

The authors concluded that specific dietary patterns could be associated with higher or lower risks for Crohn’s disease in children.

Do you or someone you know has Crohn’s disease? What are your thoughts on the relationship of diet and Crohn’s disease or ulcerative colitis?

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 Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger. 

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Chronic abdominal pain or IBS in kids

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Chronic abdominal pain, IBS or irritable bowel syndrome in children is a major, perplexing problem. Some have it as abdominal colic, others get termed as "irritable bowel syndrome" or "spastic colon". A recent study published in Archives of Disease in Childhood, December 2007  showed that chronic abdominal pain or tummy ache occurs in 33% girls and 13% boys of 11-14 years of age.

What works for abdominal pain in kids? Only a parents knows the magnitude of the problem of abdominal pain and how nerve-wrecking it can be for the entire family. They try all sorts of things, medicines, healers and frequently no relief. Usually no physical abnormalities are found despite extensive investigations. Now there is hope if you like to think outside of the box.

A recent study double blind randomized controlled trial compared usual medical treatment with gut directed hypnosis. The study titled " Hypnotherapy for children with functional abdominal pain or irritable bowel syndrome: a randomized controlled trial" was published in the prestigious journal Gastroenterology.

The investigators found that gut directed hypnosis was significantly superior to standard medical therapy. In fact the relief of chronic abdominal pain was sustained at 12 months in hypnosis group versus standard therapy (85% versus 25%) even though hypnosis sessions occurred for only 3 months.

Do you or someone in your family have chronic abdominal pain? Have you tried alternative therapies like hypnosis, cognitive behavioral therapy? If not, would you try hypnosis if other therapies are not working for you?

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 Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger.

DIET FOR CROHN'S DISEASE PATIENTS

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A patient with Crohn's disease (aka regional enteritis which is one part of chronic inflammatory bowel disease, the other one being ulcerative colitis) asked me, "what kind of diet should I eat and what should I avoid?". By the way, the term Crohn's diease should not be confused with irritable bowel syndrome or diverticular disease.

Diet, nutrition and Crohn's disease

The issue of diet in Crohn's disease is a tough one since there are not many good studies to help guide a recommendation. In general, it is a good idea to avoid anything that makes your gut go awry. In addition, I would suggest the following:

1. Studies  implicate diets rich in sugar, iron and aluminum in the pathogenesis of Crohn's disease. Thus, in the absence of evidence otherwise, it may be prudent to keep this in mind as we eat and drink everyday. 

• Avoid refined sugars which are abundant in sweets, candy and carbonated beverages.
• Talk to your doctor before taking iron supplements to make sure you indeed need them.
• Tea, and some herbs and leafy vegetables are high in aluminum naturally. Food processing contributes to aluminum in diet. Aluminum in diet may also come from dood additives, bakery products, powdered foods and drinks, and processed cheeses. Aluminium in food may also be derived from aluminum utensils and cans/cartons. The degree to which these contribute to aluminum in food is controversial.

In most cases of flare up of Crohn's disease, it might be prudent to eat low fiber, low lactose diet and avoid irritants like alcohol, tomatoes, spicy foods, and caffeine.

Similar dietary precautions for Crohn's disease would apply to patients with ulcerative colitis also.

Most importantly, always talk to your doctor before imposing any dietary restrictions in any sort of health condition, including Crohn's disease or ulcerative colitis.

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Home Page         Facebook Anil Minocha

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger.

IRRITABLE BOWEL SYNDROME

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IBS and how to manage it medically or by complimentary and alternative medicine

Irritable bowel syndrome (IBS) or spastic colon affects 5-20 percent population. It is likely that you or someone you know has irritable bowel syndrome. But what is this irritable bowel syndrome or spastic colon or IBS?

Irritable bowel syndrome

IBS is a symptom based diagnosis of unclear etiology. It should not be confused with diverticulosis or diverticultis. Irritable bowel syndrome is probably is not a single disease. More likely, IBS is comprised of multiple diseases, all lumped into one at the present time for lack of understanding its pathogenesis. Infantile colic is considered by many to be a variant of IBS in infants and kids.

Features of irritable bowel syndrome and Rome criteria

Irritable bowel syndrome is a functional disorder characterized by chronic (at least three months in the preceding one year) abdominal pain and a disturbance of bowel habit. The disturbed bowel habit of IBS may manifest as diarrhea, constipation or alternating diarrhea with constipation. Pain frequently improves with defecation.

A waxing and waning pattern of symptoms is seen in most patients. The precise conglomeration of symptom complex is defined under ROME III criteria.

What causes irritable bowel syndrome?

• The pathogenesis of irritable bowel syndrome remains an enigma and no single etiology fits all cases. IBS is predominantly seen in young females but can be seen in adults of any age and either sex. It is more prevalent among Caucasian Americans than African Americans.
• Motility disorder has been frequently implicated; however no consistent motility pattern can be demonstrated.
•  Visceral hypersensitivity (pain with a stimulus not severe enough to cause pain in healthy subjects) is seen in many patients.
• Autonomic dysregulation has also been implicated. A dysfunction of 5-HT system is supected in many cases. Stress does not cause it but does tend to exacerbate symptoms. Food allergy or intolerance may be present in some cases.
• Many patients attribute the onset of disease to a bout of flu-like illness e.g. viral gastroenteritis, travelers diarrhea.
• Low grade inflammation in the gut can be documented in many cases.
•  Several authors claim small intestinal bacterial overgrowth to be the cause in most cases of IBS although these observations have not been confirmed by others.

My opinion: IBS occurs when there is a perfect storm of combination of increased intestinal permeability (Leaky gut) and low grade inetestinal inflammation,  altered gut bacteria and some harmful factor in gut lumen in a patient with genetic predisposition. The role of diet in at least affecting the IBS manifestations can not be emphasized enough.

Note: The leaky gut, inflammation and altered bacteria can affect not only the gut but also systems far away including the brain.

IBS medical consensus

Overall, in the absence of clear cut cause, a bio-psychosocial model for pathogenesis for irritable bowel syndrome has been proposed. This model emphasizes the role of mind-body interactions with the environment.

In this context, it should be noted that there is an increased prevelance of certain chronic pain disorders in IBS patients, e.g. functional dyspepsia, fibromyalgia, chronic fatigue syndrome, interstitial cystitis, chronic back pain etc.

Diagnostic strategy for irritable bowel syndrome

While the diagnosis of irritable bowel syndrome should be positive, physicians frequently perform studies to exclude any treatable cause. The work up for IBS should be individualized and may include complete blood count (CBC), routine chemistries and stool studies. Flexible sigmoidoscopy or colonoscopy may be performed depending upon age and risk for colon cancer and suspicion for alternative diagnosis like inflammatory bowel disease (Crohn's disease and ulcerative colitis).

Celiac sprue should be excluded by antibody testing for anti-tissue transglutaminase antibody. The use of anti-gliadin antibody has recently seen a resurgence with the identification that many IBS patients get relief from gluten free diet.

Lactose hydrogen breath test may be done to exclude lactose intolerance. Small bowel bacterial overgrowth can be excluded by hydrogen breath test or cultures of small bowel aspirate.

Treatment of irritable bowel syndrome

The management of IBS patients follows a step-wise fashion and is largely symptom based. Realistic goals need to be established. Reassurance with a lot of hand-holding goes a long way in helping patient cope with the symptoms of IBS.

Placebo response rate in irritable bowel syndrome may be as high as fifty percent. 

Role of Diet: An often an forgotten factor in management

• High fiber diet and fluid are frequently prescribed as first line of treatment for IBS of all types. Much of positive data about fiber in IBS pertains to Isubghulla type.
• Patients with diarrhea may be helped by lactose-avoidance.
• Patients can frequently identify provoking factors and need to abstain
• Gluten-free diet helps many patients.
• Other exclusion diets are also helpful including the  FODMAP diet.

Role of GI medications

Over the counter laxatives or  prescription medication Zelnorm are used in cases with constipation predominant IBS. Of note, Zelnorm was withdrawn from US market on March 30, 2007 because of unacceptable side-effects. Lubiprostone is available.

Constipating agents like Imodium and Lomotil may be needed in patients with diarrhea predominant IBS. Lotronex is useful for diarrhea-predominant IBS but has high risk for ischemic colitis. Its availability is limited and its use in IBS has largely been abandoned by most physicians in the US.  Its is not to be used for irritable bowel syndrome of constipation type.

Antispasmodic agents e.g. Bentyl are frequently prescribed for abdominal pain associated with irritable bowel syndrome but provide only limited benefit at best.

Peppermint oil, A time proven remedy:

Peppermint oil is effective based on literataure as stated in guidelines by the American College of Gastroenterology.

Probiotics: Multiple studies have now documented beneficial effects of probiotics in IBS. Note, that all probiotics are not created equal and results depend on the species/strain used.

Treat SIBO if present: Small bowel bacterial overgrowth is treated with antibiotics. Rifaximin, a gut selective antibiotic is frequently used. Probiotics have also been shown to heal small bowel bacterial overgrowth and may have less adverse effects overall as compared to antibiotics.

Role of antidepressents in irritable bowel syndrome

Low dose tricyclic antidepressants (e.g. imipramine, desipramine) raise the pain threshold and are frequently prescribed to IBS patients not responding to above strategies; however their side-effects can be problematic.  Although frequently prescribed, there is less data about the use of newer antidepressant agents like SSRIs for management of IBS.

CAM therapies

Several trials have documented positive impact of probiotics in IBS patients. Cognitive behavioral therapy, hypnosis, IBS classes, yoga, Chinese herbal medicine etc have  also been used successfully in irritable bowel syndrome. Limited data points to efficacy of melatonin (over-the-counter sleep-aid) in IBS. A Mayo Clinic (Rochester) study showed that St John's wort does not have beneficial effect.

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Celiac disease or sprue

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Historical perspective

• This disorder is also known as gluten-sensitive enteropathy or nontropical sprue. It was initially suggested by Aretaeus from Cappadochia (Turkey) in the 2nd century AD. Samuel Gee in his 1888 report entitled "On the Coeliac Affection" provided the first modern version of the disease.
• Willem K Dicke, a Dutch pediatrician is credited with describing the association of bread and the celiac disease. His initial observations were confirmed since symptoms improved during food shortages during the World War II.

The disease

• It is a disorder of malabsorption due to sensitivity to gluten contained in wheat, rye and barley. The tolerance to oats is variable and may depend on the amount of oats ingested.
• As many as one in 150 healthy persons have the diagnosis based on antibody testing. It is more common among Caucasians although it may occur in other races. However most are asymptomatic.

Clinical manifestations

• Age of presentation and the symptoms are variable. Symptoms may start in early childhood or later on in adult life. While diarrhea, fatty stools, weight loss are seen in typical patients, some may present only with unexplained iron deficiency anemia.
• Still others may mimic irritable bowel syndrome. Thus patients with diarrhea predominant IBS should have blood tests for celiac disease.
• Neurological problems (depression, anxiety, seizures), menstrual abnormalities, arthritis, and reduced bone mineral density, diabetes mellitus, chronic liver dysfunction, thyroid disease (over or underactive), infertility, may be seen. There is high rate of selective IgA deficiency, dermatitis herpetiformis , myocarditis, lymphoma and cancers of gut.

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Diagnosis

• Serological tests can be done by looking for IgA endomysial antibody (IgA EMA), IgA tissue transglutaminase antibody (IgA tTG) IgA antigliadin antibody (IgA AGA) IgG antigliadin antibody (IgG AGA).
• Currently anti-tTG antibody test is believed to be the most cost-effective antibody test with high sensitivity and specificity above 90 percent. IgA endomysial antibody (IgA EMA) is at least equally good if not better, but is somewhat more expensive.
• Antigliadin antibody tests have high false positive rates with poor predictive value and no longer recommended. Routine screening for celiac disease using these tests is not recommended.
• The diagnosis of celiac disease must be confirmed small bowel biopsies which can be done during endoscopy. The biopsies are usually undertaken only in symptomatic patients.

Treatment

• Strict gluten free diet is cornerstone for therapy. Some patients with severe refractory disease require corticosteroids and other immunosuppressive agents. Relapse despite strict adherence to diet raises red flags for the possibility of cancer.

Do you or someone you know has celiac disease? If so, what are the day to day challenges you face at work or home? If you have been diagnosed with irritable bowel syndrome with diarrhea, have you been excluded for celiac disease?

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Food allergy and intolerance

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Adverse reaction to food may result from food aversion, intolerance or immune-mediated reactions.

Food allergy is characterized by a specific immune-mediated reaction related to ingestion of food. It is not related to physiological effects of food.

Food intolerance is not immune-mediated; rather it is an abnormal reaction to food, e.g. lactose intolerance. Non-immune adverse reactions to food include intolerance to lactose, jitteriness due to caffeine, toxic reaction to fish poisoning. There may also be psychological distaste or loathing for certain foods.

Although 20% of adults complain of some form of food allergy, objective confirmation by double blind food challenge studies suggest that to be true only in a small minority of population (1.4%).

One study showed that 28% of kids report food allergy, although only 8% can be confirmed by objective testing. Most of these were due to sensitivity to cow's milk. Over one third of kids with atopic dermatitis or eczema have food allergies.

After cow's milk, the commonest food allergies in kids include eggs (2.6% in kids below 2.5 years) and pea-nuts (0.4-0.6% in kids below 18 years of age).

The prevalence of food allergies appears to be increasing worldwide.. The prevalence of peanut allergy has doubled over the last 20 years. In addition, the severity and the multiplicity of food allergies appears to be rising.

This rise in food allergies may be explained by the hygiene hypothesis, i.e. lack of infectious stimuli during early growth period leads to lack of environmental education and dysregulation of immune system.

Symptoms of immune mediated food allergy can include urticaria, flushing, difficulty breathing, rash, abdominal pain, vomiting, diarrhea, intestinal bleeding, low blood pressure etc. Death may occur in severe cases.

Allergy skin tests for foods are positive in about 40-50% cases, but are not recommended for routine use. Negative skin prick tests have predictive value of 95% while positive tests must be evaluated further since their predictive value is only 45-50% without a specific history. IgE ImmunoCAP blood tests may be valuable for decision to re-challenge. While false positives occur frequently, false negative tests results are uncommon.

It should be noted that the presence of IgG to foreign proteins is not abnormal and does NOT diagnose food allergy.

In case of severe allergic reaction in kids, think of milk, egg and peanuts. In contrast, peanuts, tree nuts and shell fish account for large number of cases among adults.

Nutritional counseling plays an important role in treatment of IgE or immune mediated food allergy. Of course, any acute reaction needs to be treated if and when it occurs.

Always keep epinephrine handy and go to the nearest emergency room. Some experts recommend that in addition to epinephrine, the patient should always have an histamine-1 blocker, histamine-2 blocker drug as well as prednisone for immediate use.

Non IgE mediated food allergy may be evaluated by elimination diet, complete blood count, endoscopic biospy to exclude eosinophilic gastroenteritis. Skin tests for delayed hypersensitivity (intradermal tests and patch tests) are not useful for broad application.

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Risks of acid blocking PPI heartburn drugs keep piling up

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Side effects of acid suppression by proton pump inhibitors

 Proton pump inhibitors or PPIs (Prilosec, Prevacid, Nexium, Protonix, Aciphex) have been a big boon to the chronic heartburn or GERD sufferers.

These PPI drugs started with a black box label warning of serious consequences of cancer to being used indiscriminately almost like a candy. Data indicate that a substantial proportion of long-term PPI users do not have a clear indication for their therapy and there is thus room for reduction or rationalization of treatment.

Long term use of proton pump inhibitors is providing us increasing information on their potential harmful side effects. Recent data about PPIs suggests the following:

1. Increased risk of serious intestinal infections with Clostridium difficile bacteria
2. Increased risk of bone fractures
3. Bad breath
4. Pneumonia
5. Bacterial overgrowth
6. Diarrhea and microscopic colitis
7. Vitamin B12 deficiency
8. Chronic muscle disease (myopathy, polymyositis)

Click to read about  How to Stop Heartburn: Simple Ways to Heal Heartburn and Acid Reflux

 Read about Dr. Minocha's article on PPIs and C. difficile infection 

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Time from food to feces

How much time does it take from ingestion of food to the time it is expelled in stool? I was recently asked by one of the print media regarding this question raise by one of its readers. This may be not a question for dinner table, but if you want to know, read on.

The time it takes for food to travel from mouth through the gastrointestinal tract and come out through anus is known as bowel transit time. This time depends on multiple factors including person's diet and medications as well as diseases he/she may be having.

There is a great deal of person to person variability and in fact, even when tested in same person, the results can vary from day to day. Persons ingesting high fiber diet may have quicker transit while patients taking medications that slow down gut are likely to have longer duration. A variety of tests are employed to look at bowel or gastrointestinal transit time.

One of the tests involves ingestion of non-absorbable radio-opaque markers. These markers start appearing in stool about 15 to 24 hours after ingestion. In the simplest form of this test, the markers are given only once. An x ray is done before ingestion, and then on the fifth day to look for any residual markers.

In most normal healthy subjects, the markers are usually completely evacuated by about 48-72 hours. If however by the fifth day, over 20% of the markers are still in the gastrointestinal system (gut), that is considered definitely abnormal.

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A surprise date on colonoscopy

I was asked to perform a colonoscopy on a young female day care worker. She had been complaining of abdominal discomfort, nausea and irregular bowel habit for months. Her physical examination was essentially unremarkable. Our clinical impression was that she probably had irritable bowel syndrome but she had not responded to usual measures.

The colonoscopy prep was poor and made the examination difficult. When the scope reached cecum, we found worms floating around.  This is pinworm or Enterobius vermicularis. The diagnosis was confirmed by microscopy. 

Besides frequently being asymptomatic, the most common manifestation is perianal itching. However, it has potential to cause a wide range of gastrointestinal and nongastrointestinal manifestations, including potentially life-threatening illnesses.

Did you or someone you know had this worm infection as child, or rarely even an adult? Feel free to share your story.

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger

Proton pump inhibitors and diarrhea

Clostridium difficile-associated diarrhea usually occurs as a result of antibiotic use and can be potentially life threatening. The role of body defenses especially gastric acid secretion as a risk factor has not been fully elucidated.

Proton pump inhibitors (PPI: Nexium, Prevacid, Protonix, Prilosec, Aciphex) are frequently prescribed for acid reflux, peptic ulcers etc. They act by causing suppression of gastric acid secretion which is an important component of defense mechanism against infections.

Dr. Yearsley and colleagues studied the impact of acid blockade by chronic PPI therapy as a risk factor for development of C. difficile diarrhea and published their findings in the journal Alimentary Pharmacology Therapeutics (August 2006).

These investigators performed a case controlled study with 155 C. difficile diarrhea patients. They found that among the C. difficile-associated diarrhea group, 41% had received acid suppression with PPIs 26% of controls. This translates into the fact that chronic PPI therapy almost doubles the risk of C. difficile diarrhea.

Click to read about  How to Stop Heartburn: Simple Ways to Heal Heartburn and Acid Reflux

Take home message: Since antibiotics are the predominant cause of C. difficile associated diarrhea, the risk of concurrent therapy with PPI should be carefully weighed in patients taking antibiotics.

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger

Irritable bowel syndrome (IBS) and chinese herbal medicine

Irritable bowel syndrome is a common functional bowel disorder and there has been a great  need for good effective treatments.

Chinese herbal medicine has been suggested as treatment for Irritable bowel Syndrome. Randomized controlled trials have yielded conflicting results. The main reason for the conflicting reasons may be due the differences in patient populations and the herbs studied. We will review two such studies here.

Bensoussan and colleagues from Australia published their findings in the prestigious Journal of American Medical association.  They conducted a double-blind  randomized placebo controlled trial. A total of 116 patients based on Rome criteria were recruited. They were divided into three groups.  Patients were randomly assigned to individualized Chinese herbal formulations, a standard Chinese herbal formulation, or placebo for 16 weeks.

The authors found that as compared to placebo, the patients in the active treatment groups (standard and individualized chinese herbs) had significant improvement in bowel symptom scores as rated by patients and by gastroenterologists. Similarly, there was significant global improvement as rated by patients and by gastroenterologists. There was a decrease in degree of interference with life caused by IBS symptoms as assessed by patients themselves. Chinese herbal formulations individually tailored to the patient was as effective as the standard treatment. However, at 14 weeks after completing the therapy, the effects were sustained only in the individualized treatment group.

A more recent study by Leung and colleagues from the Chinese University of Hongkong studied only patients with diarrhea predominant IBS. In their study titled, "Treatment of diarrhea-predominant irritable bowel syndrome with traditional Chinese herbal medicine: a randomized placebo-controlled trial" , they demonstrated that Chinese medicine does not have any benefit over placebo.

These investigators studied the effectiveness an ancient herbal Chinese formula in patients with diarrhea-predominant IBS. Patients were recruited based on the established Rome II criteria and confirmation by a herbalist. 119 Patients received a standard preparation of TCM extracts containing 11 herbs or a placebo for 8 weeks. Patients were followed for further 8 weeks after the treatment.

The authors found no significant difference in the proportion of patients with global symptom improvement between the Chinese medicine and placebo groups at week 8 as well as at week 16. There was also no difference in individual symptom and the quality-of-life scores between the two groups. The authors concluded that the use of this herbal formulation for diarrhea-predominant IBS did not lead to symptom improvement.

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger