Is it Celiac or SIBO? Top Updates on Gut Health

Episode Intro:

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DrMichaelRuscio:

Hey everyone. Welcome back to Dr. Ruscio Radio. Today, let’s go into a number of updates regarding gut health – some on diet and some on a grab bag of associations with SIBO – what that associates to, underlying causes, perhaps various treatments, how H. pylori associates/does not associate to various conditions. So, a grab bag of gut health dieting and other gut health association information taken from the research that I wanted to update you on.

Case Study #1: The Elemental Diet & Crohn’s Disease

DrMR:

The first one is a reassuring finding that piles onto some previous findings regarding the elemental diet. A study was published that looked at the effect of a semi-elemental diet. This is essentially what we have in our traditional or our regular Elemental Heal, whereas the whey protein-free version is fully elemental. We have a version that contains whey that is a semi-elemental diet. In this study, a semi-elemental diet was used in individuals with active Crohn’s disease. Crohn’s is an inflammatory and autoimmune condition of the intestines that leads to frequent stool, sometimes bloody stools and very frequent stools and diarrhea. This group of 144 Crohn’s disease patients were given the semi-elemental diet as a sole source of nutrition. What was found after 12 weeks (a pretty robust intervention), after the interventional period, the number of stools per day was essentially cut in half. That’s actually more than cut in half. So, that’s pretty remarkable for someone who has chronic diarrhea. Interestingly, malnutrition was decreased from 91% to 23%. Sometimes, I think people are apprehensive if a meal replacement shake (so to speak – an elemental diet) will have adequate nutrition. As I’ve discussed in the podcast before, and as I wrote about in Healthy Gut, Healthy You, we fact-checked this up, down, left, right, forward and back, and could not find any data that found nutritional deficiencies were associated with the use of the elemental diet.

DrMR:

And I would go so far as to venture that part of the reason why we’re seeing this marked reduction of malnourishment from 91% to only 23% after exclusive elemental dieting for a number of weeks was because people had less inflammation and better absorption. Let’s say a traditional whole foods or paleo diet or Mediterranean or whatever your diet of choice is – even though that may contain more nutrition from all the whole foods that you could eat on an array of foods in a diet as such, if there’s active and ongoing inflammation in the gut, then the absorption is going to be poor. So, this would be an intervention that really helps with absorption, therefore decreases malnourishment. The Crohn’s disease activity was reduced from 10 to 3, and there was a significant increase in the remission rates of the participants. So, there was essentially almost a 70% jump in remission rates.

DrMR:

This is very encouraging regarding there being no need to be alarmed about malnutrition developing with longer term use of the elemental diet. Also, as one more of a myriad of studies, finding that for the inflammation and autoimmunity as seen in inflammatory bowel disease, elemental diets can be helpful and important. Just to reiterate, this was a semi-elemental diet. I echo this because people seem to perhaps have an unjustified fear of whey protein thinking… “I can’t go out and have a whole bunch of ice cream, or I get bloated and have diarrhea. Therefore, I can’t do any dairy.” That’s at least my suspicion. Certainly, I don’t refute that there’s probably a small subset of people who are truly sensitive to whey. However, when you are careful not to lump whey in with all dairy and the fact that ours is lactose- and casein-free and not filled with other garbage as you’ll see in some other whey proteins, then the apprehensiveness regarding whey protein in a lot of cases isn’t really justified. I just echo that because I don’t think everyone needs to go fully elemental. Here’s one more data point supporting that. I’m trying to reiterate this so that people don’t have this unjustified avoidance of whey.

Case Study #2: FODMAPs, Gluten & IBS

DrMR:

Moving on… Another study is entitled ‘FODMAPs, but not gluten, elicit modest symptoms of irritable bowel syndrome: a double-blind, placebo-controlled, randomized three-way crossover trial.’ Essentially, they were comparing the effectiveness of a low FODMAP diet or a gluten-free diet for versus placebo in IBS. And they also have a reintroduction period to see if there was an improvement and then an elicitation of symptoms upon reintroduction. What they found was there was no difference between reintroduction of gluten or placebo, but there was an elicitation of symptoms when reintroducing FODMAPs.

DrMR:

Why I think this is important is moreso a psychological and lifestyle perspective where I do suspect that more people are avoiding gluten than need to. Certainly, we know that non-celiac gluten sensitivity is a legitimate thing. I was actually just looking up some more of the recent estimates and they are clocking in at about 5% to 6% of the population if you’re going to use the generous estimation; other studies have found it closer to 1%. So, there is something there, but it’s important to connect to a numeric risk assessment and not just say gluten is a common intolerance. It is, but unless we state the probability, people can take away from that whatever they want, right? And especially people who have IBS – a constellation of the digestive symptoms – they’re more prone to be anxious and worried about food.

DrMR:

So, they’re likely more prone when not given a specific numeric value to think that it’s very high… it’s 50%, 60%, 70% risk. So, when we understand that it’s maybe 5% to 6% (giving the most generous estimation from the various studies), I think that helps prevent people from avoiding gluten unnecessarily. And when we tie that with this study – I’m assuming in this group there was probably a number of people who were avoiding gluten because they thought they had a problem with gluten, and it may have moreso been the FODMAPs. This can be very freeing because we don’t want people to avoid foods just based upon fear. We want them to learn their body’s response in an objective, dispassionate way, so they can have the broadest diet possible and also focus on the food avoidance that’s going to help them. So, great study here showing that perhaps FODMAP intolerance is more common than gluten intolerance. This study didn’t necessarily look to prove that out, but you can interpret that from these findings.

Case Study #3: Disordered Eating & GI Disorders

DrMR:

In keeping with my last comment – ‘Prevalence of disordered eating in adults with gastrointestinal disorders: A systematic review.’ 17 studies found that the prevalence of disordered eating ranged from 13% to 55%. This is something we need to be aware of – especially clinicians. This is one reason why we at the clinic are so careful with the language that we use because we don’t want to feed any of this fear. And also, I don’t think the disordered eating is unjustifiable. I think patients are probably noticing certain foods seem to bug me and certain foods seem to be okay. However, it’s incumbent upon the clinician and healthcare educators to frame this conversation the right way. I like to think with the last study we just touched on, that was a right way to frame this; to give people a risk assessment so that they don’t revert to – “Well, this can be a problem, so it’s a problem all the time.”

Case Study #4: Constipation & Abdominal Massage

DrMR:

So, moving on now to some of the more GI focused findings… this was an interesting study — effects of abdominal massage in the treatment of constipation. This was a study of 37 patients with functional constipation that were doing abdominal massage. They were using a massage device. Other studies have found that just simple self massage with your hands also works, but there is a fairly remarkable reduction in colon transit time from 54 hours to 29 hours. So, constipation was essentially cut in half and all patients saw alleviation of their symptoms from the abdominal massage.

DrMR:

I think this is one simple, safe, cheap treatment that more people with constipation should be considering. This is something that we’ve built into the algorithm and more squarely into our recommendations at the clinic. It’s not necessarily the first thing that we recommend because diet can get you very far. There’s been several studies now showing that probiotics can help with constipation. So, we want to make sure that if there is a simple underlying cause – dysbiosis presumably treated by the probiotics… poor food choices presumably attenuated by the diet – then we start there. The further we move a patient through the algorithm, you start to get a sense for the individual system of that person. Does this person seem to only be having upper GI symptoms like GERD after we’ve navigated midway into the algorithm? Maybe this person needs HCL or maybe they have gastritis.

DrMR:

On the other hand, there could be someone who has seen all of their symptoms improve – brain fog, sleep, skin issues – but, they’re still constipated. Okay. Now, we’ll go to abdominal massage. The way I’ve described the GI algorithm in the past (and I’ll just reiterate it here briefly), consider it from the top down. You have this pathway that at the start has much more commonality, but the further you go downward, the more it branches out. It’s almost like a tree – like an upside down tree – where the trunk at the top is fairly common for most people. That’s where we start. Then, as their symptoms and their responses evolve, the branches are what the clinician in our successive follow-up visits are listening to; the changes dictate what branches we want to explore. In one case, it might be abdominal massage and in another case, it might be HCL.

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Case Study #5: Ulcerative Colitis & FMT

DrMR:

The next study looked the efficacy and safety of fecal transplant versus other conventional drug therapy for ulcerative colitis. This was a network meta-analysis of 19 studies. As I predicted, FMT was found to be comparable to conventional drug therapy for ulcerative colitis. I should say, as I predicted, and hopefully this will come true – the next therapy that will be given FDA clearance will be FMT for ulcerative colitis. In terms of what’s the next approval FMT will get, I’m hoping it will be for inflammatory bowel disease, and this is a good evidence point. There was no difference in the adverse events between FMT and conventional medications. That’s also important because some of the concerns that have been levied against FMT is there may be these unforeseen consequences or long-term side effects. We need more data. Fully agreed. We have more data coming in. And when considering that FMT is not necessarily going to be lifelong therapy – as would inflammatory bowel disease drugs – it seems to be more curative. Now, perhaps someone has to do a repeat FMT a few years later. There seems to be some data that may suggest that, but for the most part, the studies with FMT aren’t ongoing self- administrations. They’re front loaded – a series of FMTs over the course of a week or perhaps two weeks, and no ongoing (as compared to someone who may be taking a 5-ASA class anti-inflammatory drug forever). So, more data here coming in on FMT. Sadly, I don’t think there’s going to be any big push for pharma to get behind this, and that funding usually is helpful for things like FDA approval. So, FMT has an uphill battle to try to make its way through, but hopefully it gets there.

Case Study #6: Laryngopharyngeal Reflux

DrMR:

A study looking at diet and asking the question ‘Is diet sufficient for Laryngopharyngeal reflux (LPR or silent reflux)?’ essentially found a 74% improvement rate after six weeks on solely a dietary intervention. So, some good evidence supporting what’s not surprising – probably to me and many people who listen to the show – in that diet alone could be sufficient. Again, why we try to position the available therapeutics in a hierarchy as codified by the algorithm so that we can figure out what to do for a person and not overtreat them.

Case Study #7: Vitamin D & H. pylori

DrMR:

Another study looked at the influence of adding vitamin D to antibiotic triple therapy for H. pylori. In short, they found a slightly better outcome when the antibiotics were combined with vitamin D. This is also something I alluded to in Healthy Gut, Healthy You. We know that certain environmental factors are positive inputs for the gut. And this is why I recommended things like vitamin D, sunlight exposure, sleep, exercise, diet, probiotics all before considering things like antimicrobial or antibiotic therapy. The gut milieu… the gut environment… can become progressively healthier or progressively worse. If you’re going to use an antibiotic, you will likely have less side effects and a higher clearance rate of whatever infection you’re trying to treat – or whatever imbalance you’re trying to treat (imbalances are more common than infections) – if you lay the requisite groundwork first.

Case Study #8: SIBO & Celiac Disease

DrMR:

The next study is entitled ‘Small intestinal bacterial overgrowth among patients with celiac disease unresponsive to a gluten free diet.’ This was a case control study of 32 celiac disease patients who were unresponsive to a gluten-free diet. They were also pitted against 52 controls. What was interesting here was the SIBO positive rate for those with celiac was 31%; healthy controls was 15%. So, this further supports that those who have gone gluten-free – those who have celiac, or perhaps non-celiac gluten sensitivity (we can maybe make the same argument for that group), and haven’t responded through dietary changes – they could have underlying SIBO or other dysbiosis, which is causing their inability to fully respond to the diet. So, it’s important to keep that in mind.

Case Study #9: Acid Suppression & B12 Deficiency

DrMR:

Another study looking at long-term acid suppression with either PPIs or H2-receptor antagonists found that about 50% of the patients who were using acid suppressing therapy for over six months were deficient in vitamin B12. So, important to keep that in mind also. I think it’s important to consider using a PPI or a H2 blocker short-term, but long-term, most people will not need these. If they’re willing to make some dietary changes, they don’t usually have to be too laborious and use some other supports that are curative and can help to resolve the underlying cause of the reflux… the heartburn… whatever it is that the acid suppression therapy is being used for.

Case Study #10: Celiac, IBS & low FODMAP

DrMR:

The next study looked at (keeping with the last one) adults with celiac disease with persistent IBS symptoms and if a low FODMAP diet could help them. 15 patients who had celiac and concurrent IBS were put on a low FODMAP diet. After four weeks, 53% of the patients experienced relief. So, even more evidence that if someone has gone gluten-free and hasn’t seen full responsiveness, there are other things we should consider. These are exactly what we integrate into the GI algorithm at the clinic, which would be low FODMAP – see how that goes – and then probiotics next. Remember, probiotics have well over 20 clinical trials showing they can resolve SIBO.

DrMR:

So, just a few context points for how we’re tying all this together. This is important because every time I read one of these studies, I’m checking in my mind – ‘Is this falling in alignment with the system that we have…the algorithm that we’re using? Or does this require us to modify the algorithm? When there was enough data and enough observation on abdominal massage, that gets put into the model. This isn’t just science for the sake of scientific peacocking, it’s really what’s being used to help constantly tweak, update, inform and modify the model that we’re using at the clinic.

Case Study #11: Resistance Exercise & PTSD

DrMR:

Now, this next study isn’t GI focused, but it was interesting. The study was entitled ‘Dosage of resistance exercises in fibromyalgia: evidence synthesis for a systematic literature review up-date and meta-analysis’ and they looked at nine clinical trials. Essentially, when compared to the control group, resistance exercise had a significant reduction in pain when performed at a moderate to high intensity. Paradoxically, moderate to high intensity resistance training improved fibromyalgia pain. I have a theory on this, and I think this also applies for how exercise helps prevent PTSD and (I would infer) limbic imbalances. I think neurologically… psychologically… an intense exercise stimulus helps to reset and buffer stress. It’s a healthy stressor. If you’re worried all day about unhealthy stressors – psychological stress, whether you’re someone overseas at war, if you’re someone maybe feeling like you’re at war with your body because you have chronic brain fog like I had or chronic IBS, whatever it is – and you have no counter balancing, intense, healthy stressor as exercise is, I think that is part of what opens the door and allows things like PTSD and limbic imbalances to form.

DrMR:

I think it’s likely what helped prevent that from happening to me. I can clearly remember back to thinking, “Man, if I could exercise like three times per day, I feel like I’d never feel poorly” because exercise always gave me a reset, cleared out my mind and just got me back to feeling normal. That wasn’t possible, but I just remember thinking that. Remember, there is evidence showing that those who exercise have a lower likelihood of forming PTSD after they’ve been subjected to a significant stressor. So, just want to loop that in there.

Case Study #12: GERD & H. pylori

DrMR:

The next study – A systematic review with meta-analysis on the association of H. pylori infection with gastroesophageal reflux (or GERD/heartburn). I won’t go through all the details here, but the way this breaks down is actually counter to conventional thinking, which is that H. pylori did not increase risk of GERD. In fact, there was a trend in the data where H. pylori colonization was actually associated with a lower prevalence of GERD. This is interesting. I’m not really sure what to make of this, but I guess the one thing for clinicians to take home would be – you may not have to beat on the drum too hard of H. pylori if someone has GERD, and you may not need to be so laborious in your assessment for GERD. Oftentimes, I will be more meticulous in my workup for H. pylori, if someone has GERD, especially if it’s recalcitrant or non-responsive. Instead of ordering just a stool test, I’ll also order a breath test in tandem with it. I used to also request or run the antibodies. I don’t think that’s necessary. You can make a case for it. I think between a good stool test, especially for using PCR since it’s more sensitive, and a breath test, you have a good double check system in place. However, this is making me rethink how necessary that may be in that specific population of those with GERD.

Case Study #13: IBS & Aloe Extract

DrMR:

Now, this next study is also worth a mention. I’ll just truncate this a little bit, but aloe extract improves symptoms in IBS patients with diarrhea. It’s a post hoc analysis of two randomized, double-blind control trials, where they looked at 213 patients with IBS. The aloe extract was associated with improved symptoms only in the IBS-D (diarrheal) subtype. I am not clear what Monash University’s perspective is on this, so I’m not sure if this has been verified, but to my understanding aloe is (or may be) high FODMAP. Some people will avoid aloe and say, “Well, it’s high FODMAP and I have IBS… and all of IBS is underlied by SIBO… and SIBO can be fed… ” This is where I think it’s really important to be careful not to think too mechanistically because it is possible that something that is higher in FODMAP could actually help you. This is one example.

DrMR:

Another much more egregious example is thinking that probiotics shouldn’t be used for SIBO, even though the overwhelming majority of data have shown that probiotics can be quite helpful for SIBO. So, I mention this just because I’ve seen patients in the clinic who haven’t wanted to use something like our gut reparative formula because there’s some aloe in it. “Aloe is high FODMAP – shouldn’t I not use this?” And most patients have been fine when I’ve explained to them that doesn’t seem to be a problem, but there have been some for whom they were uncomfortable and I’m not going to force anyone, but I leave those consults saying, “Oh, geez. This person is getting in their own way psychologically.” They’re so afraid based upon this speculative piece of mechanism that they’re unwilling to try something that could very likely help them. This is another good example of that.

DrMR:

So for patients out there – if you trust your provider and your provider is saying something that may seem a little counterintuitive, just remember that if they’re staying abreast of the science, they’re likely a few steps ahead of you. Or the way they’re parsing the value of whatever science is coming through the research feed… that may be something that you haven’t been doing, right? So, mechanism will always be trumped by outcome. So, in this case, irrespective, even if aloe was the highest FODMAP food on the planet – if we have studies showing that impatience with IBS or SIBO are improving from taking aloe, then that’s information that should guide our decision making.

Dr Ruscio Resources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to DrRuscio.com/resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of the fact that we deliver cost-effective, simple, but highly efficacious, functional medicine. There’s also my book – Healthy Gut, Healthy You – which has been proven to allow those who’ve been unable to improve their health (even after seeing numerous doctors) to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our probiotic line and other gut supportive and health supportive supplements. We now offer health coaching. If you’ve read the book or listen to a podcast like this one, or are reading about a product and you need some help with how/when to use, or how to integrate with diet, we now offer health coaching to help you along your way. Finally, if you’re a clinician, there is our clinician’s newsletter – The Future of Functional Medicine Review. I’m very proud to say we’ve now had doctors who’ve read that newsletter find challenging cases in their practices, apply what we teach in the newsletter and have been able to help patients who were otherwise considered challenging cases. Everything for these resources can be accessed through DrRuscio.com/resources. Alrighty – back to the show.

Case Study #14: SIBO & Heart Failure Prediction

DrMR:

The final study here is entitled ‘Association of Small Intestinal Bacterial Overgrowth With Heart Failure and Its Prediction for Short-Term Outcomes.’ This was a cross-sectional study of 287 heart failure patients, and they were given a lactulose breath test. 45% were positive using the North American consensus guidelines, which is important to mention because that’s going to have the more stringent cutoff. Even though I’ve criticized lactulose for having a false positive rate, it’s my feeling that with the updated consensus interpretation criteria, and you’re cutting off the read at 90 minutes, that should counter a fair amount of these false positives. That hasn’t, to my knowledge yet, been demonstrated scientifically,. However, it makes sense that if the glucose is much less likely to make it into the large intestine, but the lactulose is likely to make it into the large intestine, what you don’t want to do is see a spike on the SIBO breath test that’s occurring in the large intestine and mistakenly say, “Ah, that’s SIBO.” This is why the cutoff interpretation window was shortened from 120 to 90. That’s what’s taking place in this study. It makes it more accurate, at least ostensibly.

DrMR:

Anyway, coming back to the central premise here, SIBO was found to be an independent risk factor for cardiovascular death and rehospitalization. However, this is only for methane SIBO. I want to be careful because I don’t want people who have methane SIBO to freak out, but we want to share this data and just make people aware of the fact that your gut has an impact on your heart. We shouldn’t solely be looking at, let’s say, a cardiovascular lipid profile. There has been some other data showing that probiotics can help with inflammation. I believe there was also a study that found some parameter or outcome relative to cardiovascular health that also improved on Saccharomyces boulardii. So, don’t let these findings become dissettling. It’s just one more evidence point for how important it is to invest and attend to your gut health if you’re looking to be globally healthy – including from a cardiovascular perspective. It’s not to be interpreted where if you have methane SIBO, you should be fearful about that because there’s obviously a lot that can be done. If you’re even thinking about your gut health and taking steps, then I would argue you’re very far ahead of the pack and doing much more than most.

Episode Wrap-Up

DrMR:

That is a number of updates from the research on gut health and a few related items. I hope that you guys are enjoying these podcasts and they’re not getting too deep, but I try to weave in along with the science and some narrative regarding application and interpretation. And remember, this is all progressively informing our clinical model, and I’m so proud about what we’re doing at the clinic. So if you, a friend, a client, a patient or loved one is in need of help, we would love to assist them over at The Ruscio Institute for Functional Medicine. All right, guys – I will talk to you next time. Bye-bye.

Outro:

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• Clinical and Nutritional Impact of a Semi-Elemental Hydrolyzed Whey Protein Diet in Patients with Active Crohn’s Disease: A Prospective Observational Study
  • 144 Crohn’s disease patients, given exclusive semi-elemental diet as sole source of nutrition
  • After 12 weeks:
    • Average number of stools per day decreased (from 4.6 stools/day to 1.7 stools/day)
    • Reduction of malnourishment (91.4% to 23.9%)
    • Reduced disease activity (10.2 to 3.7)
    • Significant increase in remission (5.6% to 71.8% of participants)
  • Commentary: This study suggests out a few points:
    • A semi-elemental diet can be as effective as a fully-elemental diet
    • A long-term exclusive semi-elemental dieting does not result in malnutrition. In fact, a significant reduction in malnourishment occurred in this study. 
    • Elemental dieting results in a significant reduction in disease activity in IBD

 

• FODMAPs, but not gluten, elicit modest symptoms of irritable bowel syndrome: a double-blind, placebo-controlled, randomized three-way crossover trial
  • Aim: to see if high intake of FODMAP, gluten, or placebo increased IBS symptoms
  • Cross-over study of 103 mod-severe IBS patients randomized to high FODMAP, high gluten, or placebo diet x1 week → separated by one week washout→ switched to another intervention
  • At end of the study, FODMAPs caused the greatest increase in IBS symptom severity
  • NO difference between gluten or placebo
  • Commentary: FODMAPs can be problematic for IBS symptoms.

 

• Prevalence of disordered eating in adults with gastrointestinal disorders: A systematic review
  • 17 studies
  • Prevalence of disordered eating ranged from 13-55%
  • Commentary: There is a high prevalence of eating disorders in those w/ GI disorders

• Effects of Automatic Abdominal Massage Device in Treatment of Chronic Constipation Patients: A Prospective Study
  • 37 patients w/ functional constipation
  • All patients received device-assisted automatic abdominal massage for 15 min twice daily
  • After 14 days, colon transit time improved from 54 to 29 hours
  • ALL patients were alleviated of symptoms after treatment

 

• Efficacy and safety of fecal transplantation versus targeted therapies in ulcerative colitis: network meta-analysis
  • 19 studies
  • FMT was comparable to other UC pharmacological therapies
  • NO difference in adverse effects between FMT and meds
  • Commentary: FMT was comparable to other UC meds in achieving clinical remission. 

 

• Is Diet Sufficient as Laryngopharyngeal Reflux Treatment? A Cross-Over Observational Study
  • 50 patients w/ LPR started on low-fat/high-protein diet
  • After 6 weeks, 74% saw significant improvement in symptoms
  • Commentary: Diet can have a significant positive effect on LPR symptoms.

 

• Influence of adding vitamin D3 to standard clarithromycin-based triple therapy on the eradication rates of Helicobacter pylori infection
  • 150 patients w/ H. pylori gastritis treated w/ clarithromycin-based triple therapy and randomized to Vit D x1 month or no additional treatment
  • After 4 weeks post-antibiotics, H. pylori eradication was HIGHER in the vitamin D addition group (88% vs 74%)
  • Commentary: Addition of Vit D can possibly improve H. pylori eradication when given w/ traditional antibiotic therapy. 

 

• Small intestinal bacterial overgrowth among patients with celiac disease unresponsive to a gluten free diet
  • Case control study of 32 Celiac Disease patients unresponsive to gluten-free diet, 52 healthy age- and sex-matched controls
  • SIBO positive rates per lactulose breath test:
    • 31% of Celiac Disease
    • 15% of healthy controls
  • Commentary: Celiac disease patients unresponsive to gluten-free diets had a x2 higher rate of SIBO compared to healthy controls. SIBO may be a reason for symptoms despite a gluten-free diet. 

 

• Effect of long-term acid suppression therapy with proton pump inhibitors or H 2 receptor blockers on serum vitamin B 12 levels in elderly population
  • 70 patients >60 yo on long-term PPI or H2-blocker use (>6 months)
  • ~50% of the patients were either “deficient” (less than 200 pg/ml) or “insufficient” (200 to 300 pg/ml) in serum vitamin B12 levels
  • Commentary: Nearly half of long-term PPI or H2-blocker users had insufficient B12 levels.

 

• Adult celiac disease with persistent IBS-type symptoms: a pilot study of an adjuvant FODMAP diet
  • 15 patients w/ Celiac Disease (CD) w/ concurrent IBS put on a low FODMAP diet
  • After 4 weeks, 53% had relief of symptoms
  • Commentary: This study supports the use of a low FODMAP diet for those w/ IBS symptoms despite a gluten-free diet. 

 

• Dosage of resistance exercises in fibromyalgia: evidence synthesis for a systematic literature review up-date and meta-analysis
  • 9 RCTs
  • Compared to the control groups, resistance exercise had a significant reduction on pain when performed at:
    • Moderate-to-high intensity
    • 1-2 sets of 4-20 reps, 2x per week
    • For total of 8-12 weeks
  • Commentary: Paradoxically, higher intensity resistance exercises can improve fibromyalgia pain levels. 

 

• Systematic review with meta-analysis: association of Helicobacter pylori infection with gastro-oesophageal reflux and its complications
  • Aim: to examine association between H. pylori infection and GERD symptoms and erosive esophagitis
  • 11 observational studies of H. pylori and GERD
    • 7 studies: H. pylori associated w/ LOWER rates (OR 0.74) 
    • 4 studies: NO association 
  • 26 studies of patients w/ GERD symptoms:
    • H. pylori associated w/ LOWER rates (OR 0.7)
  • 9 studies showed NO association between H. pylori and Barrett’s esophagus
  • Commentary: H. pylori infection/colonization appears to be associated w/ decreased odds of GERD symptoms and erosive esophagitis, as well as lower rates of Barrett’s esophagus (contrary to popular thought). 

 

• Aloe barbadensis Mill. extract improves symptoms in IBS patients with diarrhoea: post hoc analysis of two randomized double-blind controlled studies
  • 213 IBS patients from two different RCTs combined
  • Aloe extract therapy associated w/ improved IBS symptoms only in IBS-D type (not other IBS types)
  • Commentary: Aloe may be an effective strategy to improve symptoms in IBS-D.

 

• Association of Small Intestinal Bacterial Overgrowth With Heart Failure and Its Prediction for Short-Term Outcomes
  • Cross-sectional study of 287 heart failure patients
  • Given lactulose breath test
  • 45% SIBO+ (using North American Consensus)
  • SIBO was an independent risk factor for cardiovascular death and rehospitalization (HR 2.13)
    • Association only for CH4 predominant SIBO (not hydrogen SIBO)
  • Commentary: This study highlights the gut-cardiovascular connection. There is a higher prevalence of SIBO in those w/ heart failure. 
    • However, a weakness of this study was that it used a lactulose breath test (instead of glucose). 
    • Dr. Rusico wanted to point out that the newer guidelines restrict the test interpretation window to the first 90 min, thus reducing likelihood of false positives (remember, older guidelines and some labs, would use 120 interpretation window).

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