Microscopic Lymphocytic Colitis Resolved with Foundational Gut Support

Patient Summary:

Overview Context: 

• Vickie is a 51-year-old perimenopausal woman with diarrhea, abdominal pain, and bloating. She has hypothyroidism and a recent diagnosis of microscopic lymphocytic colitis.

Visit 1 – History and Exam:

Symptoms and Concerns

• Chief Complaints:
  • Diarrhea
    • Daily with intermittent postprandial total fecal incontinence
  • Abdominal pain 
  • Bloating
  • Mid-sleep awakening 
  • Orthostatic hypotension  
    • Worse with diarrhea and overhydration 
  • Anxiety 
    • Onset related to traumatic event 
  • PMS & dysmenorrhea

• Onset, Timeline and History:
  • Age 8: Experienced severe trauma which triggered onset of GI issues 
    • Chronic constipation in childhood requiring frequent use of suppositories
    • Correlation between increased stress and worsening of her stomach issues
  • Age 44: Cholecystectomy – All GI symptoms worsened after this procedure
  • Age 50: Onset of postprandial total fecal incontinence
    • Unclear trigger for onset – Severely worsened by caffeine and alcohol
    • Created extreme social stress after experiencing multiple episodes in public
    • Later this year she had COVID and experienced the “worst diarrhea ever” x 3 weeks 
  • Age 51: Diagnosed with microscopic lymphocytic colitis by local GI Doc

Past Medical History

• Prior Diagnosis:  
  • Hypothyroidism, 2019 (diagnosed by functional/integrative doc)
  • Microscopic lymphocytic colitis, 2021 (diagnosed by colonoscopy and biopsy)

• Medications:
  • NP Thyroid 30mg 
    • Multiple-dose titrations by different functional med docs 
    • Her local PCP recommends stopping – she was hesitant to discontinue
  • Progesterone & Testosterone (topical)
  • Cholestyramine

• Prior Surgical History
  • Abdominal surgery: Tubal ligation, dislocated tailbone repair, cholecystectomy

Prior Testing and Treatment History

• Prior Testing Summary:
  • Initial thyroid levels to diagnose hypothyroidism: TSH .60, Free T4 1.2, Free T3 2.3 → Initiated NP Thyroid 30 mcg
    • Follow up levels: TSH 0.25 (L), T4 1.1, T3 3.7 → Increased to 60 mcg 
    • Follow up levels: TSH 0.39 (L), T4 1.1, T3 4.2 → Decreased to 30 mcg
    • Follow up levels: T3 3.3, no TSH

• Previous Diets 
  • Helpful
    • Paleo – improved GI symptoms overall
    • Fasting or intermittent fasting – decreased her reliance on cholestyramine for diarrhea. 
  • Reactive
    • Ketogenic – increased her cholesterol significantly
    • Caffeine and/or coffee – worsens motility

• Previous Treatments 
  • Helpful
    • Magnesium – sleep 
    • Cholestyramine – initially helpful for diarrhea but stopped working after a few months of use
  • Reactive
    • Fiber – worse GI symptoms
    • NP Thyroid 30mg – started this at the same time as progesterone and testosterone… feels that this is when symptoms started to severely worsen in general. Never felt beneficial. 

Initial Impression

• Clinical Commentary:
  • What significance does her persistent anxiety and history of childhood trauma have in GI symptom severity? 
  • How necessary is her current thyroid, progesterone and testosterone supplementation if she noticed no change in symptoms with initiation of therapy? 
  • Her thyroid levels at diagnosis of hypothyroidism were within normal range according to the reference range. This challenges the accuracy of this diagnosis significantly. 
  • Although cholestyramine was somewhat helpful for her symptoms of diarrhea, it did not prevent postprandial episodes of total fecal incontinence or work towards treatment of the root cause. What else could be the etiology of her symptoms?

• Differential Dx
  • Poor sleep timing / duration (mid-night awakenings)
  • Limbic imbalance (significant trauma at the onset of GI symptoms) 
  • SIBO / Dysbiosis
  • Hypochlorhydria / EPI
  • BAM (s/p cholecystectomy) 
  • Female hormone imbalance (+irregular cycle, +heavy flow, +PMS, +hot flashes) 
  • Incorrect thyroid dx and unnecessary thyroid medication (euthyroid at time of diagnosis)
  • Abdominal/pelvic adhesions (tubal ligation, dislocated tailbone correction, cholecystectomy)

• Prognosis:
  • Good

Visit 2 – Testing and Initial Treatment Recommendations

• Recommended Testing
  • Diagnostic Solutions – GI MAP

• Initial Treatment Recommendations
  • Diet:
    • Elemental Diet – 2-4 day exclusive use followed by intermittent use as desired 
    • Paleo Low FODMAP 
    • Continue Intermittent Fasting – try decreasing frequency to only 2-4 days per week
  • Lifestyle:
    • She was already doing a great job with exercise, sauna use and spending weekly time in nature. We recommended she continue these habits. 
    • Consider trying the headspace app for 10 minutes a day 
  • Treatment:
    • GI: 
      • S. boulardii, soil-based probiotics, lacto-bifido probiotic blend
        
        
      • Gut healing nutrients
        
        
    • Nutritional support:
      • Electrolyte powder
        
        
  • Followup:  6-7 weeks

• Clinician Summary
  • Stool testing was recommended in this case as opposed to empiric treatment due to the severity of her postprandial fecal incontinence with active microscopic colitis. 
  • Leading with an elemental diet is a more aggressive initial measure however it was initiated at the beginning of the treatment plan due to the severity of her symptoms and their impact on her current quality of life. 
  • Following the elemental diet, a transition to a paleo low-fodmap diet was suggested to help to further mitigate symptoms. 
  • Decrease in frequency of intermittent fasting and addition of electrolyte powder may help with symptoms of orthostatic hypotension.
  • Meditation was recommended at the initiation of this treatment plan due to the severity of her current anxiety and the clear correlation she noted with stress and trauma at onset.

Visit 3 – Lab Interpretation and Treatment Evaluation

• Subjective Assessment: 
  • Rates her health at 90% improved since last visit
  • Current Symptoms:
    • Improved: 
      • Diarrhea
      • Sleep – “Still awaken, but generally fall back asleep quickly”
      • Dizziness when standing – now happens rarely 
      • Anxiety – “Very manageable with good sleep and breathing”
      • Hypothyroidism – “I am off thyroid medication and noticed no negative symptoms after stopping.”
    • None same or worse
  • Treatment Response:
    • Paleo low FODMAP – diarrhea and gas resolved after just 5 days
    • Triple probiotics – improved sleep and energy
    • Gut rebuild nutrients – flare of symptoms
  • Notes:
    • She has stopped her thyroid medication with her PCP and has no new symptoms. She occasionally wakes up with hot flashes and has recently decreased her progesterone dose.

• Lab Results
  • GI MAP:
    • Dysbiosis
    • Elevated streptococcus spp. 
    • Low levels of H. Pylori – did not flag positive

• Lab Interpretation and Diagnosis
  • Updated Differential Diagnosis
    • Dysbiosis (confirmed x1 GI Map)
    • Incorrect thyroid dx and unnecessary thyroid medication (feeling better without rx)

• Impression:
  • Clearly doing well and should push into therapies that have been working

• Updated Treatment Recommendations
  • New Treatment:
    • Consider Limbic Retraining (Gupta Program) for further optimization
    • Continue triple probiotic therapy and elemental shakes as needed for intermittent use
    • Continue paleo low-FODMAP diet and re-introduce foods as tolerated without a worsening of symptoms
    • Continue daily meditation
    • Hold off on gut rebuild nutrients
  • Followup: 8-12 weeks

Take Home Points

• Highlighted Clinical Rules 
  • Consider pushing further into therapies that have a clear positive signal as compared to adding new therapies (e.g. doubling dose of probiotics before adding antimicrobials).
  • Low thyroid symptoms are often attributed to GI imbalances. 
  • Check initial thyroid labs in cases of ambiguous thyroid diagnosis
  • Treat diet, lifestyle and gut health before supporting female hormones. Consider non-pharmacologic approaches to addressing hormonal concerns prior to HRT.

• Clinician Commentary
  • This was a clear case of incorrect hypothyroid diagnosis and inappropriate use of thyroid replacement. 
  • The patient’s significant improvement of GI symptoms with elemental diet and probiotics was profound and part of the reasoning not to progress to other types of antimicrobial management despite GI Map findings. 
  • Limbic retraining was added to the current plan due to the clear correlation she noted with GI symptoms, stress and trauma at onset. Her noted improvement with meditation suggests that she may continue to improve by leaning more into strategies to help prevent sympathetic dominance. 
  • Female hormone adaptogens could be recommended in the future for this patient if residual night time awakenings and hot flashes occur after weaning off progesterone.

PTSD, Eating Disorders and IBS

Patient Summary: 

Overview Context: 

• Jane is an active 38-year-old female seeking guidance for symptoms related to allergies, digestive health, and PMS. She has a military background and served in Afghanistan.

Visit 1 – History and Exam:

Symptoms and Concerns

• Chief Complaints:
  • Allergies/stuffy nose/congestion/itchy eyes
    • Recently worsening with asthma-like breathing and tight chest episodes. 
  • Reflux
    • She is still having symptoms on omeprazole
    • Worse with high fat or processed foods
  • Lower abdominal pain 
  • Mixed diarrhea and constipation 
  • PMS symptoms – depression, mood swings 2 weeks prior to menses, “debilitating” cramps

• Other Symptoms:
  • Fatigue 
  • Insomnia 
  • Numbness in hands 
  • Headaches – with light sensitivity

• Onset, Timeline and History:
  • Digestive issues and allergies started at age 16. She experienced trauma in the form of physical/sexual abuse earlier that year.
  • In her 20’s, she smoked and consumed a high-processed food diet. She is now focusing on more whole foods and has quit smoking entirely.
  • Traumatic experience while deployed in Afghanistan.

Past Medical History

• Prior Diagnosis:  
  • IBS
  • GERD
  • PTSD
  • Migraines
  • Allergic rhinitis

• Medications:
  • Budesonide, Cetirizine, Azelastine (allergies)
  • Prozac (PTSD)
  • Omeprazole (GERD) 
    • Taken daily for 20 years. Recently stopped briefly and restarted due to symptoms worsening without it. 
  • Dicyclomine (abdominal cramping)

Prior Testing and Treatment History

• Prior Testing Summary:
  • Colonoscopy – no abnormal findings
  • Endoscopy – gastritis and esophagitis 

• Previous Diets 
  • Helpful
    • Gluten-Free
    • Dairy-Free
    • Low FODMAP – significantly helped GI symptoms when tried for 1 month
  • Non Responsive
    • Paleo
    • Low Carb

• Previous Treatments 
  • Helpful
    • Digestive Enzymes – intermittent past use 
    • Fiber & Prebiotics
    • Antihistamines – only medication, no herbal antihistamine trials 
  • Non Responsive
    • Probiotics – only 1 category probiotic
    • Magnesium
    • Prescription laxatives
  • Currently on many supplements: reported all relatively new, difficult to tell benefit. 

Initial Impression

• Clinical Commentary:
  • What is the root cause behind her residual symptoms on omeprazole?
  • Are her asthma-like breathing and tight chest episodes secondary to allergies as described or could it be a manifestation of some anxiety related to PTSD? 
  • Why did this patient respond to a dairy free and gluten free diet but not a paleo diet? Was she eating foods higher in FODMAP quantity during this trial?

• Differential Dx
  • Dietary mismatch (low FODMAP helpful in past, currently eating FODMAPs w/ sxs)
  • Limbic imbalance (hx PTSD, severe childhood abuse at the onset of symptoms)
  • Gastritis / esophagitis (confirmed on endoscopy – on omeprazole per GI) 
  • Dysbiosis / SIBO
  • GI pathogen / PI-IBS (hx food poisoning) 
  • Hypochlorhydria (long term omeprazole use, unclear as symptoms worsen without it)
  • Histamine intolerant / MCAS (chronic post nasal drip)
  • Female hormone imbalance (+cramps, +depression, +moodiness)
  • Nutritional Deficiencies (long term use of PPI)
  • Sleep-disordered breathing (+ braces, +deviated septum, +dry mouth, +mouth breathing, +jaw pain)
  • Heavy metal toxicity (frequently around burn pits while overseas)

• Prognosis:
  • Good

Visit 2 – Testing and Initial Treatment Recommendations

• Recommended Testing
  • Optional Diagnostic Solutions GI-MAP

• Initial Treatment Recommendations
  • Diet:
    • Paleo Low FODMAP Diet
    • Intermittent fast for 14-18 hours, 1-2 days per week
  • Lifestyle:
    • Begin a practice of mouth taping nightly to improve oxygenation throughout sleep
  • Treatment:
    • GI:
      • S. Boulardii, soil-based probiotic, lacto-bifido blend probiotic
        
        
      • Gut healing nutrients
        
        
    • Stop previous supplementation due to unclear effectiveness 
    • Continue medications
  • Followup:  6-7 weeks

• Clinician Summary
  • Stool testing was recommended as optional due to recent previous testing prior to our appointment (endoscopy/colonoscopy/blood work). Overburdening the patient financially with further testing was not the goal as there were many commonly effective empiric treatments that had not yet been implemented. 
  • Returning to a paleo low-FODMAP diet was an easy decision as she had found it to be effective for symptom management in the past. This was recommended as a temporary treatment approach, not a long term solution to her symptoms. 
  • A trial of mouth taping here was also recommended as a trial due to her progressively worsening fatigue. 
  • Triple probiotic therapy was a foundational starting point as she had only briefly tried a few grocery store probiotics in the past. 
  • She was in counseling and felt stable on Prozac. As anxiety and PTSD symptoms were not a part of her concerns on intake, we didn’t make any adjustments to this plan. Building rapport and trust with the patient was the foundational goal of the first appointment in addition to helping her presenting symptoms.

Visit 3 – Lab Interpretation and Treatment Evaluation

• Subjective Assessment: 
  • Rates her health at 50/100 and says her symptoms are mostly the same. 
  • Current Symptoms:
    • Improved:
      • Bowel movements
    • Same:
      • Reflux
      • Allergies
  • Notes:
    • She opened up during our second appointment and expressed a history of binge eating disorder. She reported that she is active in support groups for it online. We discussed food-related stress and she reports struggling with making food changes because of harsh self-talk surrounding body image and guilt. 
• Lab Results
  • Patient did not perform stool testing

• Impression:
  • Will loosen diet recommendations today to a standard low-FODMAP template with a goal of 80% compliance at maximum. The idea behind reducing the paleo template portion of the diet was to expand the types of foods for her to choose from. 
  • We discussed the potential benefit of an elemental diet on her GI symptoms with the recommendation of intermittent use at first. She was open to this idea and felt it would be something she felt comfortable trying without concern of flaring her binge eating tendencies. 
  • Will continue the probiotics and add an anti-histamine protocol.

• Updated Treatment Recommendations
  • New Treatment:
    • Expand diet to standard low-FODMAP diet 
    • Elemental diet – intermittent use 
    • Start herbal histamine support protocol
      • Goal is to find 2-5 agents that help with symptoms
      • May include vitamin C, quercetin, resveratrol, Mirica, AllQlear, Perimine, etc.
    • Continue triple probiotic therapy
  • Followup: 8-9 weeks

Visit 4 – Follow-up Visit and Treatment Evaluation

• Subjective Assessment: 
  • Current Symptoms:
    • Improved:
      • Diarrhea –  “I have noticed that my diarrhea has gotten better and my stools are a lot more solid”
    • Same:
      • Most IBS symptoms
      • Allergies
    • Worse:
      • Reflux
  • Treatment Response:
    • Elemental 2 day reset to hybrid – significant improvement in diarrhea
    • Herbal antihistamine protocol – no change in allergies

• Impression:
  • Due to improvement with elemental diet, I will recommend leaning more into an antimicrobial approach with our herbal antimicrobial protocol.
  • She endorsed persistent stress around health challenges and their impact on her daily quality of life.

• Updated Treatment Recommendations
  • New Treatment:
    • Limbic retraining with the Gupta Program
    • Add herbal antimicrobial protocol
      
      
      
  • Followup: 8-9 weeks

Visit 5 – Lab Interpretation and Treatment Evaluation

• Subjective Assessment: 
  • Rates her current health at 70/100 and 40% improved since the last visit.
  • Current Symptoms:
    • Improved:
      • IBS
      • Allergies – “I only have issues when I eat processed foods”
    • Treatment Response:
      • Gupta program – really helpful. She mentioned that she didn’t realize how much her thoughts were impacting health.
      • Herbal antimicrobials – decreased IBS symptoms and allergies
    • Notes:
      • At this appointment she says she feels amazing. 
      • She reports her eating habits have normalized and she remains symptom free most of the time. She has continued challenges with symptoms after restaurant food.

• Impression:
  • She felt that her marked improvement compared to previous visits was largely due to the limbic retraining. She reported that her relationship with food and with herself was beginning to improve.

• Updated Treatment Recommendations
  • New Treatment:
    • Complete 2nd month of herbal antimicrobial protocol
      
      
      
    • Continue the Gupta Program exercises
    • Expand diet as tolerated
  • Followup: 8-9 weeks or as needed

Take Home Points

• Highlighted Clinical Rules 
  • Exhaust low risk, empirically informed treatments prior to the consideration of testing to guide/modify treatment recommendations.
  • Remember that lab tests only tell about 25% of the whole clinical picture. Good history taking, physical exam (when necessary), and assessment of prior treatment response supplies 75% of the information needed to make informed treatment decisions. 
  • Many therapies have more support to be used empirically as compared to being guided by lab results (e.g. probiotics for mood support).

• Clinician Commentary
  • Therapeutic nutrition plans can often add an extra layer of stress in people with a challenging relationship with food. Aggressive nutrition plans are likely not the most therapeutic in these individuals. 
  • In this case, she did not endorse that she had a history of binge eating disorder on her intake questionnaire or in our first visit together. It took building rapport and asking individualized questions about challenges with the initial plan to help create space and a sense of safety for this discussion to take place. 
  • In patients who have experienced trauma around the onset of symptoms, addressing sympathetic dominance as part of a well-rounded treatment plan may be a crucial step in making initial and lasting progress with symptom resolution.

Connection between adverse childhood experiences, anxiety, and IBS

Clinical Take Home Points

Study Purpose

• Review the prevalence of anxiety and adverse childhood events (ACE) in IBS patients vs. healthy controls

What Does The Evidence Suggest?

• IBS patients have more ACE and generalized anxiety
• Higher ACE may lead to higher anxiety around IBS symptoms

Study Details

Title: Relationship between adverse childhood experiences and illness anxiety in irritable bowel syndrome – The impact of gender

Methods

• Multi-center cross-sectional study of 127 IBS patients and 127 healthy controls
• Measured illness anxiety, childhood adverse events, and generalized anxiety severity 

Results

• IBS patients had a higher prevalence of adverse childhood experiences, depression, general anxiety, and illness anxiety.
  • “Compared to HCs, IBS patients were characterized by higher prevalence for adverse childhood experiences (63.8% vs. 48.0%, p = .02, OR = 1.33) and increased levels of illness anxiety (p < .001).”
• Depression affects many with IBS.
  • “The prevalence of clinically relevant comorbid depression (PHQ-9 cut off ≥ 10) among IBS patients was 41.8%.”
• There was a weak correlation between ACE and illness anxiety. 
  • “Taking into account gender specific effects, there was a significant correlation between adverse childhood experiences and illness anxiety in female IBS patients, but not in male (r = 0.242, p = .03 vs. r = 0.162, p = .29). However, after controlling for depression and anxiety, this correlation disappeared.”

Authors’ Conclusions

• “Our study suggests that ACE and illness anxiety are significantly increased in IBS patients compared to HCs. In women, there is a possible association of ACE and levels of illness anxiety, which might be linked to anxiety and depression as well.”

Interesting Notes

• Authors also note the role of limbic imbalance in IBS.
  • “Central sensitization is a proposed physiological phenomenon in which central nervous system neurons become hyper-excitable, resulting in hypersensitivity to both noxious and non-noxious stimuli. An essential pathophysiological role seems to be played by the amygdala, an important limbic structure, which is affected by chronic stress and associated increased glucocorticoid levels, leading to increased visceral sensitivity. The resulting altered balance of stress modulation may be an important aspect in changes in gastrointestinal motility, colorectal hypersensitivity and gastrointestinal mucosal dysfunction and thus contribute significantly to the pathogenesis of IBS.”

Other Relevant Studies

Title: Adverse Childhood Experiences

• 1 in 6 people have had 4+ adverse childhood experiences.
• “More than 60% of adults report having at least 1 adverse childhood experience and 17% report 4 or more adverse childhood experiences.”

How This Changes Clinical Practice

Clinical Takeaways

• ACE is common, especially among those who suffer from functional GI disorders like IBS.
• Consider screening for emotional/physical trauma to see who may benefit from something like limbic system retraining.