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

FODMAP diet and foods: Implications in health and disease

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FODMAP DIET: ROLE IN IRRITABLE BOWEL, LEAKY GUT AND ALTERATION IN INTESTINAL BACTERIA

What is FODMAP and FODMAP Diet (Gibson and Shepherd 2010)

FODMAP is an acronym applied to group of short chain carbohydrates and sugar alcohols comprised of Fermentable Oligo- Di and Monosaccharides And Polyols

Disease associations: High FODMAP diet have been implicated in the rising tide of a variety of disorders.

• Crohn’s disease
• Celiac disease
• Irritable bowel syndrome
• Chronic fatigue syndrome
• Autism

FODMAPs share thee physiological properties:

• Poor absorption in small intestine
• Osmotically active small molecules
• Rapid fermentation by gut flora: the smaller the length of carbohydrate, faster the fermentation

High luminal FODMAP foods undergo rapid fermentation and create metabolic products that predispose to enhanced intestinal permeability, altered intestinal flora, intestinal gases and predispose to small bowel bacterial overgrowth (SIBO).

Examples of high FODMAP foods/diet include:

• Fructose (fruits, honey, high fructose corn syrup)
• Lactose (diary products)
• Fructo-oligosaccharides or fructans (wheat, onions)
• Galacto-oligosaccharides or galactans ( raffinose and stachyose) contained in legumes, beans, cabbage, onions etc.
• Polyols (sorbitol, mannitol, xylitol, maltitol) contained in apples, pears, plums etc. and low calorie sweeteners. Polydextrose and isomalt are frequently used as artificial sweeteners, are poorly absorbed.

What happens when you ingest high FODMAP diet

• Excess intake and delivery of undigested carbohydrates to the colon renders them subject to bacterial fermentation.
• The metabolic fermentation products including increased organic acids (short chain fatty acids), increased surfactant activity, increased gases (hydrogen, carbon dioxide, methane and hydrogen sulfide) and gut distension injure intestinal barrier by in part causing apoptosis.
• Short chain fatty acids (SCAFAs) excess excess has been shown to increase intestinal permeability in animal models.
• The gas content of gut plays an important role in gastrointestinal symptoms.

Problems occur especially when high FODMAP diet is consumed fast:

The process if rapid, can be especially “explosive”. This occurs when large amounts of undigested carbohydrates are exposed to disproportionately high and potentially pathogenic bacteria in gut e.g. small bowel bacterial overgrowth.

Type of food versus speed

• Oligosaccharides (smaller chain length carbs) and sugars are metabolized at a much faster rate than the longer chain length molecules like dietary soluble fiber.
• The speed of bacterial fermentation and generation of metabolic products varies according to substrate (lactulose >inulin> resistant starch)
• FODMAP elimination diet plan requires global and not individual product restriction.

FOMAP drawbacks

• Low FODMAP diet diminishes access to benefits of prebiotics like fiber
• Effects of high fiber/prebiotics

1. Increased bowel fluid by osmotic effects

2. Increased motility

3. Increased generation of short chain fatty acids that serve as food for colonocytes

4. Increase in beneficial strains of bacteria like bifidobacteria.

FODMAP diet and vegetarians

• Legumes and milk products are a major source of nutrition for vegetarians.
• Since the goal of FODMAP strategy is overall reduction, greater cuts need to be made in other categories in order to accomplish the desired goals.  
• Eat good carbs!

Turning harmful effects of FODMAPs into benefits

• A lower proportion of rapidly fermentable carbohydrates along with greater amount of slowly fermentable carbohydrates have potential for ameliorating harmful effects of FODMAPs and shifting the balance towards benefits.
• For example, ingestion of raw potato starch, guar gum and arabinoxylan causes intestinal injury especially involving enzymatic activities. The deleterious effects of these foods do not occur if they are consumed along with slowly fermentable wheat bran.
• Considering the demonstrated potential health benefits of prebiotics, the harm versus benefits may be individual specific based on diet consumed, gastrointestinal flora, rapidity and amount of bacterial fermentation, and presence of comorbid conditions in the context of genetic susceptibility.

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Disclaimer: Everything on this site is for your information only. Do your own due diligence and consult physician. The ads have potential to generate income for the blogger.

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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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Yogurt gaining popularity

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Health conscious Americans are increasingly using fermented foods ranging from yogurt to kimchee because of the potential health benefits in a variety of chronic ailments. This was reported by Chicago Tribune/Tribune Media Services (4/28/2010)

Testosterone and mortality, cancer screening in rural vs urban population

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Testosterone level:

Low testosterone levels can be double whammy! As if low testosterone levels are not bad enough for men for obvious reasons, they are also likely to increase risk of death. Khaw and colleagues based their conclusions about relationship between between testosterone concentrations and mortality in a case-control study of 11,606 men aged 40 to 79 years surveyed in 1993 to 1997 and followed up to 2003. Similar results have been recently reported by Haring and colleagues in European Heart Journal.

  

Pedometer for weight management:

If you are interested in weight management, use pedometer when walking rather than walking without one. Its use encourages more walking and more weight loss. Richardson and coleagues performed a meta-analysis of nine studies with a sample size ranged from 15 to 106, for a total of 307 subjects.  Subjects lost a mean 0.05 kg per week during the intervention. The authors concluded that pedometer-based walking programs result in a modest amount of weight loss. Longer programs lead to more weight loss than shorter programs.

Cancer screening:

Who do you think misses out on cancer screenings, rural or urban population? If you guessed rural, you may be wrong, so suggests a study from Dartmouth-Hitchcock Medical Center. Paquette and colleagues  performed a retrospective, descriptive analysis of cancer stage at presentation of rural versus urban patients with lung or colorectal cancer using the Surveillance, Epidemiology, and End Results database from the National Cancer Institute. 

Logistic regression analysis revealed that urban patients are more likely to present with late-stage colorectal and lung cancer when compared to their with rural counterparts.  Other studies suggest that the relationship between Socioeconomic status and the risk of late stage colorectal cancer varies among rural and urban populations.

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.

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.

Constipation? what and how to take care of business

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Constipation 

Author: Anil minocha MD of Shreveport, La

Overview

Constipation is the most common digestive complaint in the U.S. and affects predominantly women. It can occur at all ages. Elderly are especially prone to it.  The term obstipation is sometimes used to describe severe constipation.

Diet, medications, sednetary life style, abnormal toileting posture may be involved as causative factors. Many a times, constipation is associated with psychosocial issues and may even be associated with history of physical or sexual trauma.

What ancient medicine thinks about constipation?

Ancient medicine believes that constipation results in alteration of balance of good versus bad bacteria in gut, kinking of colon and accumulation of harmful products due to stool stasis including toxins entering into the body.

In addition to toxins entering the across the intestinal barrier into the body, there can be alterations in fermentation patterns as well as alterations in processing related to altered pattern of the fermenting flora.

Uremic toxins are generated as a result of colonic bacterial fermentation. Such toxins introduced into the body, for example, advanced glycation end products, indoles, phenols may damage a variety of blood vessels in various organs. Prebiotics and probiotics have potential to ameliorate this damage.

If true, this has potential to result in a variety of bodily dysfunction including exacerbation of uremia in kidney disorders.

Strategies for constipation

In addition to modern laxatives and prescription drugs like Amitiza and Miralax, numerous natural products in alternative and complimentary medicine are used to move bowels in patients with constipation.

An overemphasis on evidence-based analysis and aggressive marketing of newly developed laxatives has tilted the recommendations toward more expensive, but not necessarily more effective, agents. There is little shared understanding between patients and professionals about 'normal' bowel function. In addition, there is little consensus on the best treatment strategy for chronic constipation. Many of the natural or ancient bowel cleansing products  have been authenticated by clinical trials. 

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Various natural products against constipation include the following:

• Senna: Senna alata (L.) Roxb. is a plant and it is a frequent component of natural bowel moving products. Its laxative activity is supported by scientific findings. Ayurvedic herbal remedy, Miskakasneham has been shown to be effective and safe as Sofsena, a conventional senna-based laxative.
• Aloe: Controlled trials have demonstrated that aloevera when combined with celandin and psyllium group, bowel movements results in more frequent and softer stools while reducing laxative dependence in patients with chronic constipation.
• Cascara Sagrada: It is an anthraquinone-containing stimulant laxative. The dried, aged bark of this tree has been used for thousands of years by both native and immigrant Americans Anthraglycosides are responsible its laxative properties. It acts by increasing intetinal secretions, inducing intestinal peristalsis and promoting bowel evacuation.
• Chinese Rhubarb: Ancient chinese believes in expelling pathogens regardless of hard stool early during course of illness and expelling pathogens with rhubarb is essential.
• Slippery Elm Bark: It is an herbal product with antioxidant properties with potential for reducing inflammation in the gut. In vitro data suggests that it scavenges superoxide dose-dependently and that the oygen radical release from biopsies is reduced after incubation with this herb.
• Olive oil: It is an ancient laxative. One study found that 97.7 percent of subjects with more than three defecations a week had a high intake of virgin olive oil. Oilve oil has also been used as enema in combination with other softeners: like paraffin oil and gycerine mixed with water is effective in difficult cases of constipation.
• Peppermint oil: Peppermint oil is beneficial in improving symptoms of irritable bowel syndrome including abdominal pain.
• Bentonite clay: Randomized controlled trials have shown that treatment beidellitic montmorillonite is effective in constipation predominant irritable bowel syndrome.
• Probiotics: Use of probiotics including Lactobacillus have been shown to be effective in constipation. One double blind pacebo controlled trial in kids with constipation showed that the use of probiotic Lactobacillus casei resulted in a higher defecation frequency, greater rcentage of treatment success, less use of glycerin enema less hard stool as compared to he placebo group.

Do you or someone you know has constipation? What do you think is causing it and how do you treat it? Please share your thoughts.

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. 

Constipation? Is your colon kinky? Dolichocolon

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Dolichocolon causes constipation-is it true? What is dolichocolon anyway. What is the evidence to support its role in constipation?

The Dolichocolon concept was the brainchild of Arbuthnot Lane and is based on the the theory that kinking of colon leads to constipation. While colon is like a country road with its own twists and turns (and of course each "colonic country road" is different), the Lane theory suggests that gravity leads to unnatural "kinking" or twisting initially in the fixed parts of colon on the left side. It gradually progresses upward and proximally causing elongation and further kinking.

In fact, Lane was a proponent of colonic resection or a byepass. While initially colonic resection became very popular, it came into disrepute in the early 20th century and now is performed in rare selected cases only.

Lets face it-the concept of dolichocolon or kinking causing a partial bowel obstruction appears simple, straightforward, appealing and plausible (perhaps too simple and straightforward). Furthermore, theoretically speaking, the kinking along with elongation of colon has potential for increased fecal stasis in colon leading to increased water absorption from the fecal contents resulting in "drier" stool and constipation.

However, scientific data to support theoretical concepts above is lacking. At the same time, constipation does not appear to be correlated with colonic length and surgery is not beneficial in cases of colonic "kinks" unless a volvulus is present.

 And click here to read about best toilet posture.

Do you or someone close to you have constipation? What is the cause of constipation in your opinion? Does the Lane's theory of dolichocolon make sense and sound believable to you? Please share your thoughts.

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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Constipation, kinky colon and fecal stasis 

Gut smells like nose olfaction. Really?

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Gut has a nose and can smell! You have heard of ”gut reactions” and “my gut tells me”. Can the gut smell? Could these "gut reactions" be mediated via smelling function of the gut?

Braun and colleagues from Germany recently studied whether nasal olfactory (smell) receptors are present in human gut and whether odorants present in spices, fragrances, detergents, and cosmetics can cause release of neurotransmitters like 5HT or serotonin. As you know, serotonin regulates intestinal motility as well as secretions and is involved in pathogenesis of vomiting, diarrhea, and irritable bowel syndrome as well as psychological conditions like depression.

These investigators found 4 olfactory receptors in human gut. Odorant ligands of the these olfactory receptors via cascade of events lead to serotonin release thus have potential to affect gut function.

The authors concluded that odorants present in the gut/intestinal lumen may stimulate 5HT/serotonin release via these olfactory receptors in gut mucosa. Some physicians especially gastroenterologoists do use antidepressants including SSRIs for the treatment of intestinal conditions like irritable bowel syndrome, cyclic vomiting and abdominal migraine.

Now based on this article, could you also legitimately say, “my gut can smell it” in addition to “my gut reaction is” and “my gut tells me”. 

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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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Glutamine, immunity and gut immune system

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Immune system in the gut? Glutamine for gut immunity?

Lets first discuss immunity especially gut health and immunity.

Gut and immune system: Did you know that as much as 25-75% of our immune system is located inside our gastrointestinal system? Immune system is spread throughout body in an effort to have immune defenses all around for our protection. In fact, it is one of the largest organ systems in our body and serves to protect us from forces outside as well as within.

Non-immune system in gut: In addition to our GI immune system, our non-immune defenses include the gut flora, physical barrier between the luminal contents and inside of our body, chemical barrier as well as gut motility that helps to keep things moving down and out as in good sanitation.

The Gut barrier function: The intestinal wall acts as a barrier to the noxiuos luminal contents. It is also involved in transport of nutrients. At the same time, intestinal wall is also helping with immunological surveillance since the gut is constantly exposed to injurious agents like toxins etc.

Role of diet: Based on above, dietary modifications by altering the intestinal milieu have potential to alter the expression of genes in the epithelium.

What does glutamine have to do with immunity? Additional glutamine may be one way to boost one’s immunity. Studies have documented that feeding additional glutamine can improve immune function, reduce complications and hospital stay and perhaps improve survival in sick patients. The results are best seen when glutamine is combined with other immune-nutrients.

How does glutamine work? It is an energy source for immune cells as well as gut enteroicytes. It is required for synthesis of nucleotides and proteins etc. In addition, it enhances T and B-cell function, facilitates phagocytosis as well as bacterial killing.

Do you believe in nutritional supplements? Do you take glutamine or any other nutritional supplements? Does this article change your mind in any way? 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.

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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What is colitis, diverticulitis and diverticulosis?

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Colitis, diverticulitis and diverticulosis are not the same

Terms like colitis, diverticulitis, diverticulosis and irritable bowel syndrome, spastic colon can be confusing. Colitis, diverticulitis, IBS, irritable bowel syndrome, spastic colon although different are often used interchangeably by some people.

Colitis

Colitis means inflammation of the colon or large intestines. Colitis may be acute or chronic and may occur due to infections, drugs, toxins, ischemia, radiation therapy etc. Colitis may also be a manifestation of chronic IBD or idiopathic inflammatory bowel disease (ulcerative colitis and Crohn’s disease).

Diverticulosis

Diverticulosis is the presence of divertculi (plural for diverticulum), usually in the colon. The colonic divertculosis is very common in the western society presumably because of lack of fiber in diet.

As many as 50% or more may have colonic diverticulosis by the age of 50 years and this number may exceed 80% by the time one reaches the age of 80 years. Usually these diverticuli are asymptomatic and an incidental finding on barium enema or colonoscopy.

In a minority of cases, they may cause complications such as diverticulitis and gastrointestinal bleeding etc which may even become life-threatening.

Diverticulitis

Diverticulitis occurs as a result of micro-perforation in the colon at the site of diverticulum. It is usually on the left side of colon and usually contained giving rise to localized infection and inflammation. This usually responds to medical measures including antibiotics. Interventional radiology techniques are sometimes used.

At times, such a perforation may form an abscess, cause bacteremia and become even become life-threatening. Surgery may be needed in severe cases.

Diverticular bleed

Diverticular bleed occurs more commonly from right sided diverticulosis. It is usually painless and massive and usually requires hospitalization and blood transfusions.

Majority of such bleeds stop spontaneously. Endoscopic and interventional radiology techniques can help stop bleeding in some cases, otherwise they may need surgery. Recurrent cases may need suregry.

Do you or someone you know has colitis or diverticulosis? What has been your experience with these terms? Please share your thoughts.

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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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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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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.

Bacteria for your infant's colic?

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Infantile colic is a difficult problem, vexing both to parents and physicians. The cause is thought to be excess intestinal gas. On the lines of irritable bowel syndrome or IBS, new research indicates that probiotic bacteria help in kids with colic.

Probiotics or "good bacteria" that tend to maintain a healthy balance of good versus bad bacteria in the gut. They are being increasingly have been found to be useful for treatment of various illnesses, both gut and non-gut related.

Dr. Savino and colleagues from the University of Turin in Italy conducted a randomized placebo controlled trial to study the effect of Lactobacillus reuteri. Their findings were published in the journal Pediatrics (January 2007).

The study cohort consisted of 90 breast fed babies who were administered either the probiotic or the common over the counter anti-gas medication known as simethicone for 28 days. Mothers refrained from ingesting cow's milk in their diet. Baby crying times were assessed.

The daily median crying time at day 28 was 145 minutes/day in placebo group as compared to only 51 minutes/day in the probiotic group. 95% babies were termed as responders among the probiotic group in contrast to only 7% in the placebo group.

The mechanism of action of the probiotic in such conditions remains to be established. Possible mechanisms include immune-modulation and enhanced peristalsis thus affecting the balance of the gut flora and reduced triggers for abdominal pain.

Do you or someone close to have kids? Do any of them have colicky problems? What remedies have you tried for such episodes?

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.

Is melatonin useful in irritable bowel syndrome?

Melatonin in IBS or spastic colon

Irritable bowel syndrome continues to baffle the medical establishment because of lack of effective treatments. Now comes study suggesting that the naturally acting substance (melatonin) helps in ameliorating this vexing problem.

What is melatonin? It is a naturally occurring hormone in all living beings. It is synthesized in the brain (pineal gland), gastrointestinal system and retina from an amino acid tryptophan. In addition to its role in wake-sleep cycle, it is a powerful antioxidant, stimulator of immune system. It is sold over the counter as a natural sleep remedy.

Dr. Saha and colleagues from PGIMER in Chandigarh, India studied the role of melatonin in IBS patients. They published their findings in Journal of Clinical Gastroenterology (January 2007).

These investigators conducted a randomized controlled trial of the use of melatonin or placebo in 18 patients with IBS. They found that use of melatonin for 8 weeks significantly improved overall IBS score. The extracolonic IBS score was also significantly improved as compared with placebo. In addition, use of melatonin resulted in improvement in quality of life score to 43.63% as compared to 14.64% in placebo group.

Do you or someone you know has IBS? Do you find the currently available treatments effective? Have you ever used any natural remedies for anything including IBS?

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.

Hypnosis for IBS: Does it work?

Hypnotherapy benefits for irrirtable bowel syndrome

Irritable bowel syndrome (IBS) or spastic colon can be very difficult to treat in many patients. There is paucity of medications available, and many of the strategies used actually have not been shown to be of benefit. Hypnosis has been gaining a lot of attention lately for this vexing problem.

Dr. Roberts and colleagues from the University of Birmingham in United Kingdom conducted a randomized controlled trial to evaluate this hypnotherapy as a complementary therapy and published their data in the British Journal of General Practice .

Patients with IBS who had failed conventional treatment were included in the study. Patients in the study group received five sessions of hypnotherapy in addition to their usual management. Usual and conventional treatment was administered to the control group.

These investigators found that after a period of 3 months, significantly greater improvements were seen in the intervention group. This included improvement in pain, diarrhea and overall symptom scores . Quality of life was not improved. While the improvement in symptoms was not maintained over long-term, the patients in study group were significantly less likely to require medication, and the majority felt that their condition had improved.

Do you or someone you know has IBS? What treatments have worked for you? What are your thoughts on hypnosis or other forms of complimentary and alternative medicine?