IBS within the IBD: Part 3
In this third part of the article Dr. Weiner illuminates how IBS (Irritable Bowel Syndrome) is now appreciated for containing an inflammatory component and can be part of IBD (Inflammatory Bowel Disease) with a case study and his overall assessment. He explains the relationship between IBS (Irritable Bowel Syndrome) and IBD to offer a deeper understanding of these conditions.
This original article was published on January 11, 2016 at ndnr.com. It is the fourth part of our new in depth series of posts exploring IBS (Irritable Bowel Syndrome), IBD, and SIBO, all still very relevant in 2019.
The previous posts in the series were about Treating IBD. Look forward to additional articles in this series on the differences between IBS, IBD, and SIBO, Use of Elemental Diets in IBS and IBD, and additional videos and summary articles including posts related to Chinese Medicine and Acupuncture as treatments for IBS, IBD, and SIBO.
Gary Weiner, ND, LAc
A CASE STUDY
Eileen, a charismatic 35-year-old female, presented in 2014 with mild-moderate distal colitis and complaints of constant gas, bloating, and irregular bowel movements alternating between loose and mildly urgent stools, or frequent constipation with ineffectual urging. She had been managing her IBD using only a Specific Carbohydrate Diet (SCD)33 that was self-implemented in 2013. Diagnosed in 2011, she had failed trials of mesalamine (5-aminosalicylic acid), when the diagnosis was moderate-severe, and she declined stepping up to azathioprine, as recommended by her gastroenterologist to address ongoing urgency, frequency, and hematochezia. Historically, the onset of her disease had been gastrointestinal infections, treated in 2007 and 2010 after periods of travel in the Third World. She had also taken doxycycline for 2 years in her 20s for acne.
On the mesalamine, her FC had been 298 µg/g (normal <50), signaling the failure of the drug to adequately manage intestinal inflammation; however, the SCD remarkably normalized FC and improved Eileen’s bowel condition. From Eileen’s point of view, however, this was nothing to celebrate, as she unsustainably maintained remission of her more troubling symptoms (including bloody bowel movements and more intense pain) by mainly eating only 4 SCD-legal foods: chicken, ground beef, zucchini, and spinach; other foods brought on an intensification of symptoms. Like many, she was unable to progress beyond a limited phase of the diet. Consequently, her BMI dropped to 19.3, and while in an estrogen-dominance pattern for years, she was beginning to develop increasing irregularity of her menstrual cycle, in the direction of amenorrhea. This was distressing, as she was hoping to become pregnant. Her TSH was also rising, and her body temperature was decreasing.
Eileen represented a subset of patients who through the SCD are able to achieve symptomatic improvement and a decline in inflammatory markers (achieving some degree of mucosal healing) but remain unable to advance into the subsequent phases of the diet (thereby increasing the diversity, complexity, and quantity of foods, and cooking styles) without experiencing increases in urgency, abdominal discomfort, bloating, abnormal stooling, or other symptoms. Her gastroenterologist offered to recommence an oral 5-ASA drug and a topical mesalamine, as the 2 together promised greater efficacy then either alone,34 and because her disease had been localized to the left side on her most recent colonoscopy. Or, she could step up to azathioprine, which she rejected years earlier.
Tasked to help Eileen sort through the decision-making and coordinate with her gastroenterologist, I interpreted that signs and symptoms of both IBS and IBD – along the pathophysiological continuum – were coexisting. While Eileen’s original disease was a left-sided colitis, her self-management appeared to have regressed it down to a distal and mild-to-moderate stage, but not without costs (weight loss, menstrual dysregulation, subclinical hypothyroidism, and a mild but persistent anxiety with insomnia). If you “tease out” the symptoms, Eileen was displaying more of an IBS pattern than a predictably IBD pattern. There was no blood, fever, intense abdominal pain, extreme urgency and frequency, or the nocturnal symptoms associated with IBD. Nor did we see IBD’s extraintestinal manifestations. Instead, Eileen displayed the alternation of loose stools and constipation, gas and bloating, mild anxiety with insomnia, and menstrual dysregulation, often associated with IBS. Her antibiotic history was common to both IBS and IBD, but her history of GI infections was notably a keynote for the development of post-infectious IBS (PI-IBS). She also admitted to irregular bowels since she was very young. Examining her medical records, the most recent colonoscopy showed that histologically she was in remission.
I ran an FC, which came back at <15.6 µg/g. I also ordered CDtB and anti-vinculin antibody tests, showing elevated optical densities of 3.105 and 1.58, respectively; these served as a confirmation of IBS. A lactulose breath test was ordered and demonstrated 32 ppm H2 at 120 minutes, with 0 ppm CH4 (positive for SIBO). I also ordered serum tests that were negative for ESR and CRP, and a salivary hormone test, which showed a typical estrogen dominance picture in the luteal phase of Eileen’s menstrual cycle, but also estradiol levels nearing the bottom of the reference range, and uniformly suboptimal levels of cortisol in all 4 zones of the diurnal adrenal study. Suboptimal body temperature and TSH levels pointed further to subclinical hypothyroidism.
From the foregoing findings, I concluded that Eileen’s symptoms were not directly related to an exacerbation of her IBD, but were rather signs and symptoms of the IBS at the other end of the continuum – an IBS that was either contained within the IBD, or produced by it. I shared my opinion that I did not believe that escalating up the steps of the IBD medication paradigm in the “management” of IBD was the best next move, but instead suggested that we might try to address bowel “function” in the wider context of the IBS, as well as the rest of her “whole person” presentation affecting “function.”
Eileen’s treatment plan included many components phased over the subsequent 3 months: 550 mg rifaxamin TID for 14 days; followed by continuation of 4.5 mg [low-dose] naltrexone at bedtime (utilized for its proposed ability to increase endorphin levels and decrease proinflammatory cytokines,35 as well as for its function in supporting the migrating motor complex); a mixed probiotic formula; brush-border support with digestive enzymes and glutamine; counseling related to mindfulness-based stress reduction (MBSR); 150 mg of bovine adrenal extract with an additional 80 mg of adrenal cortex BID, and 30 mg daily of transdermal progesterone applied vaginally during the luteal phase of her menstrual cycle.
She was also given acupuncture weekly to address anxiety and to provide constitutional support. When her body temperatures were not rising to normal and she complained of cold intolerance with continued suboptimal TSH levels, I also added 16.25 mg USP thyroid. There is a high degree of correlation between IBD and thyroid problems.36 In addition, Eileen was given further dietary support, implementing SCD correctly to assure successful “phase expansion” with the foods.
Three months later, Eileen’s follow-up lactulose breath test was normalized, and she reported an amelioration of all abdominal symptoms, 1-2 well-formed stools daily, and a consistent ability to expand through phases of the diet, even though it took 6 months for her to reach the later phases of the SCD that allowed her to enjoy raw fruits and vegetables, whole nuts and seeds, beans, and even occasional fried food – all without GI consequence. As in many IBD cases, it is often necessary to introduce oral medications or supplements carefully, 1 at a time, to determine tolerance. While each of the agents used appeared to add a degree of improvement in Eileen’s case, the completion of treatment with rifaximin for SIBO was the decisive turning point. After this, the patient’s symptom pattern shifted in the direction of healing, supported further by additional interventions, including hormonal augmentation. Apparent restorative alteration of the microbiome appeared to promote food tolerance, weight gain, and neuroendocrine balance, ending the anxiety pattern and insomnia.
After 6 more months, Eileen announced regularity in her menstrual cycle, rising energy, increasing body temperature, excellent sleep, and expressed the joy of being healthy and of achieving a stable pregnancy. As in many cases of IBD, getting at the IBS within it can be the starting point of stimulating the vis medicatrix naturae for the best of possible outcomes.
This is the third part of a multipart article by Dr. Gary Weiner.
Dr. Gary Weiner, ND. L.Ac. is the medical director of Pearl Natural Health in Portland, Oregon, where he has developed an alternative and complementary care program for inflammatory bowel disease. He graduated from NCNM in 1997 and completed a 1-year residency in family medicine. He has served as adjunct faculty and clinical supervisor at NCNM, and is on the medical advisory board of the Northwest Crohn’s and Colitis Foundation of America. He is a sought after speaker and lecturer on IBD< IBS and SIBO, speaking to both naturopathic and conventional medical doctors. Dr Weiner lives with his wife and daughter.
Stay tuned for the publication of further articles in the series on IBD, IBS and SIBO. Full reference list available at the original source.