What New Gut Health Research Says About IBS, SIBO, and More

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Dr Ruscio, DC:

Hi everyone. Welcome back to Dr. Ruscio, DC Radio. This is Dr. Ruscio, DC. And let’s jump in on gut health updates right from the research and with my—hopefully not too boring—insights and commentary. And boy, there’s a lot here. I’m going to try to strike the right balance of going through this high level, [while] also giving some context, but being able to keep pace with the vast amount of research being published in GI. The way I’m trying to break this down is [by doing] a monthly podcast that updates you on probiotic research, one on gut health that would be not probiotic-related, one on thyroid, and then one on “other”—this could be dietary interventions, lifestyle interventions, [or] things about environmental toxicity and mold. Okay. So let’s jump in on a litany of studies in GI care.

Dr Ruscio, DC:

The first study looked at how Rifaximin can modulate the gut microbiota to prevent hepatic encephalopathy in liver cirrhosis without causing a problem to gut diversity.

Dr Ruscio, DC:

You’ve likely heard the gut-to-liver connection and there’s also this gut-liver-brain connection. And so in this case, hepatic encephalopathy is where you have an inability to effectively filter out toxins that will naturally build up because the hepatic (or liver system) is not working at its full capacity. And Rifaximin has been successfully demonstrated—at least in a handful of studies that I’ve looked through—to help with this condition. And even, I believe, improve cognitive scores or just the subjective, “I have brain fog,” via its ability to modulate the gut-liver-brain access. And in this case, they looked at 21 patients with liver cirrhosis and they were all treated with Rifaximin while also studying their stool throughout the study. And after three months there was significant improvements, as I mentioned, in cognition (not surprising to see that) and also in blood ammonia. Not surprising.

Dr Ruscio, DC:

What was nice to see is that Rifaximin did not reduce the microbiota diversity. And this is something that I believe I mentioned in “Healthy Gut, Healthy You”—or I at least had done a YouTube video on this years and years ago now—this early hypothesis that Rifaximin might be able to reset the small intestinal microbiota. And I think that same thing obviously, and likely applies for antimicrobial therapy or potentially even elemental dieting, especially when done in the context of other healthy diet and lifestyle interventions. I see anyway, an antimicrobial having the ability to help kind of poke the microbiota or nudge the microbiota. And if you have healthy inputs occurring concomitant with that, you’re more likely going to see the microbiota reset and hopefully return to a better balance. So in this case, Rifaximin did not reduce diversity. And we could infer we could speculate that because diversity didn’t go down and symptoms cleared that if we had a more sophisticated way of measuring the dysbiosis, if any was present, we would’ve likely seen an improvement in the dysbiosis scores. That’s more theoretical, but the study finding with a few of my comments.

Dr Ruscio, DC:

[The] next study looked at IBS (irritable bowel syndrome) and the long-term risk of cancer. This was a prospective —meaning going forward in time—cohort study among half of a million adults in the UK. So this is an impressive sample size (again, about a half a million) in a 12 year followup. Now, if you’ve had IBS—meaning you’ve had bloating, diarrhea, constipation, an oscillation between the two, and abdominal pain (I would say especially if you’ve had diarrhea, and probably constipation, but I think maybe more so for diarrhea)—you’re wondering, “am I irritating and potentially damaging the lining of my intestines and putting myself at risk for colorectal cancer of some sort or other intestinal cancers?”

Dr Ruscio, DC:

And good news here. There was actually a lower incidence—a ratio of 0.79, so a reduction, a lower rate—of colon cancer, rectal cancer, and digestive cancers globally in those who had IBS. So that’s one point of reassurance. I think hopefully this should be kind of heralded in as one encouraging data point amongst the sea of things that IBS patients are inundated with [such as] gluten and mast cell and SIBO and candida. So good news here, at least from this very compelling data point, on the finding that you have a lower risk of GI cancers if you have IBS.

Dr Ruscio, DC:

[The] next study looked at curcumin and its ability to ameliorate or reduce or calm Crohn’s disease—the autoimmune inflammatory condition that affects both the small and large intestine (and potentially even the stomach and the mouth). And here’s what’s really fascinating, that this (albeit small) 30 patient group with mild-to-moderate Crohn’s disease were randomized to either get curcumin or placebo.

Dr Ruscio, DC:

And after three months of supplementation, the curcumin group—and not the placebo group—had a higher clinical remission rate of 40% compared to 0%. And also a reduced endoscopic remission rate. Meaning when [they] did [their] endoscopy, there was a 15% remission as compared to a 0% remission. And there were no adverse effects. So just one more data point at how effective natural medicines can be, and [how] helpful they may be for certain GI conditions (in this case the autoimmune condition of Crohn’s). Now, again, caveats apply. It’s a 30 patient study, however, this was randomized and blind. So, [I] don’t think we need a huge pile of evidence to say, “take a few capsules of curcumin per day.” Right? [Curcumin is] inexpensive and has multiple health benefits.

Dr Ruscio, DC:

The next study looked at the effect of fecal microbiota transplant (that’s the turkey baster with someone else’s poo) on irritable bowel syndrome and performed an updated systematic review and meta-analysis. They looked at 19 studies that used FMT in IBS patients, and they compared it to placebo. And I think the placebo here is really important because obviously the more intensive the intervention, the more likely the placebo or the higher the placebo could be. So when compared to placebo, FMT led to an improved quality of life. However, there was no difference in IBS symptom severity. And this does partially map on to my clinical observation—which is going to be imperfect, but just to share it—we’ve seen patients at the clinic who’ve, in my opinion, done FMT far too early in the interventional hierarchy (meaning it’s probably one of the last things one should do) and they’ve come in reporting no improvements. And in a couple cases, maybe even feeling worse.

Dr Ruscio, DC:

And so that does match with what this meta-analysis is finding. I think this is even more salient now than ever just so people don’t rush to FMT because it’s cool. I mean, it’s life saving for antibiotic-resistant C. Diff. treatment. And there’s progressively impressive data pouring in for inflammatory bowel disease, but perhaps not for IBS. And the rules might be different in IBS. And who knows, maybe this finding will be challenged in another few years with an updated meta-analysis that finds benefit, but at least right now, the takeaway is FMT (the fecal microbiome transplant where you take healthy donor stool and give it to someone who has a condition, in this case IBS) may improve your quality of life. So that’s something. But there was no difference in the IBS symptoms specifically. So something to keep in mind.

Dr Ruscio, DC:

The next study looked at the low FODMAP diet [versus] usual dietary advice for the treatment of refractory gastroesophageal reflux disease (GERD). And this was an open label study, so there was no blinding. So that does reduce the validity of the findings. But the individuals were randomized, wether they were standard [diet], low fat diet with head elevation at sleep, or low FODMAP. And in this case, there was no difference between the response rate of groups at a 30 day check-in. It was coming close to being statistically significant—37.5% response versus 20%—but it was not significant. So just one data point here to share, and that a low FODMAP diet may not be a cure-all, but certainly something to consider if you have GERD.

Dr Ruscio, DC:

The next study is also interesting, or at least to me. I guess it’s all relative. A gluten-free diet was examined in the context of postural orthostatic tachycardia syndrome (POTS). And this is a condition in which people have—said simply—low blood pressure, they can have fasciculations or pounding heart, and it can be an unpleasant symptom picture. And Leonard Winestock has done some research in this, I believe using LDN as a treatment and also high doses of salt. And certainly I’ll second the salt can be helpful, at least seemingly so in this cohort.

Dr Ruscio, DC:

And this was a retrospective (so going back in time) examination of 20 patients with POTS and without celiac who followed a gluten-free diet. 11 patients were diagnosed with MCAS and 8 had Ehlers-Danlos. In fact, I wouldn’t be surprised if this study was published by Winestock. Let me just give that a quick gander. Okay, it was not. But I know Leonard does work with MCAS and with POTS and with GI so I wouldn’t have been surprised. But he is not one of the authors on this paper. So in any case, after four weeks on a gluten-free diet patients experienced a 34% reduction in their POTS symptoms. So that is great to see and a data point for, as we’ve talked about, going through the gluten trial. But remember to do it objectively.

Dr Ruscio, DC:

Another study, looking at if a galactooligosaccharides prebiotic intervention can improve stool frequency and the microbiota in self-reported constipation. This was done via a randomized control trial, so there was a placebo arm. And 5.5 grams of this prebiotic per day, or a higher dose [of] 11 grams, was compared to placebo. So this is good dosing. Five grams is probably enough to be a sweet spot—I wrote about this in “Healthy Gut, Healthy You” —that that’s the dose at which you’ll see some benefit, but you don’t risk some of the negative and adverse events.

Dr Ruscio, DC:

The finding in this study, after three weeks of supplementation, there was no significant difference between the three groups. So the galactooligosaccharides (the prebiotic) did not lead to an improvement in those with constipation. Although I should say to the best of my knowledge, that the trend is that prebiotics have been shown to improve constipation. Perhaps not as much as fiber, but that’s just one study looking at prebiotics for constipation.

Dr Ruscio, DC:

Here is actually a very interesting study: predictors of symptomatic specific (or symptom-specific) treatment response to dietary interventions in irritable bowel syndrome. These investigators wanted to see if the GA map dysbiosis test, which comes from Norway—and we’ve had some of the authors behind that test on the podcast in the past—could predict responsiveness to a low FODMAP diet or a traditional diet.

Dr Ruscio, DC:

And here’s what’s fascinating here and why I have continually tried to give you the honest take on how much we can take away from testing. 67 patients with IBS were randomized to a low FODMAP diet or a traditional diet for four weeks. Here were the factors associated with more symptomatic improvement: those who had less severe dysbiosis actually had more symptomatic improvement and those who higher energy intake at baseline also experience more improvement. Now the higher energy intake (the more food they ate) that kind of makes sense, right? These are people who are presumably eating more food and probably eating more processed food. It’s a loose presumption, but I think a somewhat safe one to make. So they had more room for improvement in cutting stuff out of their diet, which they would from any dietary intervention.

Dr Ruscio, DC:

But what’s perplexing, potentially, depending on your paradigm, if it’s “test, test, test, test, we can’t do anything without the tests,” then it would be highly perplexing to you to see less severe dysbiosis associated with a better response to a low FODMAP diet. And this is likely because it’s not always that simple and a test can’t tell you everything. So I think it’s really important for us to continue to keep that in mind with weighting tests as one fourth of the data needed to make a decision—and be careful to keep it at that one fourth and not make it the primary data point we use to make decisions. There’s also one other interesting note here in that more baseline psychological stress was associated with less symptomatic improvement, so important to keep that in mind. And [it’s] one of the reasons why we start with this model of diet, lifestyle, and gut health interventions. And so lifestyle would be the thing here to address in tandem with diet.

Dr Ruscio, DC:

The next study was also on the low FODMAP diet, and it was looking at low FODMAP with and without gluten and its impact on IBS. This was a double blinded placebo randomized control trial. 49 patients with IBS were randomized to a low FODMAP diet with gluten-free powdered rice or a low FODMAP diet with gluten. And here’s what’s interesting, both groups had similar rates of IBS improvements, abdominal pain improvements, abdominal pain frequency, and also improvements in distension. So important to keep that in mind. Now, I should also disclose there was a trend toward greater improve in the gluten free group, but it was not statistically significant. So perhaps there were some in this examination who were a bit gluten sensitive, but it didn’t tend to be a large enough difference to register as statistically significant.

Dr Ruscio, DC:

So how I interpret this is perfectly in alignment with the way we’ve discussed diet in the past—potentially avoid gluten but listen your own body. And also probably best to try to listen to your own body when you’ve cleared out some of the other stuff upstream, so to speak, in that you’re addressing your lifestyle as we learned in the last study. You’re potentially using probiotics or even the novel triple probiotic therapy, you’ve addressed any suspected or confirmed dysbiosis or overgrowth, and now you don’t have all this up and down—your symptoms are somewhat consistent. So you have a somewhat clean, healthy baseline against which to now do a gluten reintroduction and hopefully do it without this nocebo expectation. “Oh my God. Everyone’s telling me how bad gluten is.” And so then you have one bite and you feel a little bit tired the next day for 30 minutes and, “whoa, it’s a gluten.” Which I make fun of this, but I’ve gone through this exact thing myself. So I’m making fun of myself in terms of how much you can skew your ability to look at things objectively if you’ve been exposed to a lot of one sided conversation as it pertains to gluten.

Dr Ruscio, DC:

So next study. This is an interesting study also, and this was a paper published by Row and Pimentel—both of which have been on the podcast. And I actually really appreciate what this study was attempting to do. The study looked at a single fasted methane test—or methane sample—as a way of diagnosing methane SIBO. And what they found was using a cutoff of the 10 parts per million, a single methane measurement had a sensitivity of 86, which is good, and a specificity of 100, which is great. And antibiotics as a follow up treatment to this lab finding led to a decrease of a repeat measure of a single sample methane.

Dr Ruscio, DC:

So why this is great is because it could simplify SIBO testing. Now this works in the context of methane, but not really for hydrogen. And this is because methane, most of the time to an overwhelming degree, presents with a very flat-line presentation. And this seems also to be the way hydrogen sulfide works. So it is possible to simplify the way we’re doing the testing. So I vastly, vastly appreciate Row and Pimentel’s study here. And I want to acknowledge, I’ve criticized some of their points on various items on the podcast before but I always do my best to give someone credit when I agree—and then also criticism when I don’t—and in this case, Bravo. Well done.

Dr Ruscio, DC:

And for those who methane SIBO is expected or suspected, predominantly those who have constipation, we might be able to vastly simplify the testing that the person does. And this might be especially helpful if you’re trying to track [if you] got the methane down to below 10 over time. Now that being said, we haven’t found the need to do serial repeat testing essential. There are some cases wherein we’ll be a little bit more diligent about maybe doing one retest, but I don’t think the right approach is to test every month or every six weeks [where] every time you do a course of antimicrobials or antibiotics, “got to retest, got to retest, got to retest.” [This] was echoed by a systematic review a few years ago that found or concluded that the need to perform serial repeat SIBO breath tests has not been demonstrated.

Dr Ruscio, DC:

And what I, and we at the clinic, are doing is using one or two SIBO tests in the care model but we’re really using symptoms to help us determine when we want to retest. So we’re treating, listening to any individual symptoms, modifying the treatment further, checking back in [to see] how are the symptoms doing, [and] we continue to modify until we get to a point where we’re satisfied or we’re confused. And that’s when the testing, I think, has the most utility.

Dr Ruscio, DC:

In the next study, a vitamin D supplementation was used in people with IBS, and it was shown to have no effect on symptom severity and quality of life. This was looking at 135 patients with IBS. They were given placebo or vitamin D at 3000 IUs, which is not a huge dose, but it’s enough to have an effect. And importantly, 60% other participants were vitamin deficient or insufficient at baseline. Now in the vitamin D group—because remember this is a placebo versus control—at the 12 week follow up, they did have higher vitamin D blood levels, but there was no difference in IBS symptom scores or in quality of life.

Dr Ruscio, DC:

So this study counters what some other studies have found, which is that vitamin D—in this case cannot but others have found can—help IBS. So what do we do with this? Well, we would wait for a meta-analysis to be published on this topic so we can see what the overall trend in the data is. And also realize that vitamin D is one thing of many that can be done for IBS, but in and of itself (no shocker here) may not be enough to resolve or notably improve IBS in all subjects or all cases.

Dr Ruscio, DC:

Now on the other side of the vitamin D coin here, the next study looked at the effect of vitamin D supplementation on blood markers in ulcerative colitis. This is similar to Crohn’s disease, inflammatory bowel disease subset, presents slightly differently. And this was *drumroll* a meta-analysis. So we have seven studies looking at about 540 patients and examining the effect of vitamin D on ulcerative colitis. The vitamin D supplementation led to lower ESR scores, lower CRP score. (Both of these are inflammatory markers), but no difference in disease severity. So good news and tepid news, I guess. lower inflammation, but not enough to lead to an improvement in disease severity.

Dr Ruscio, DC:

So I think we’re making this case that vitamin D is something to consider, but certainly we should give it the appropriate waiting. It’s one thing of a few background factors that may have a minimal impact and probably should be in play because sleep plus vitamin D plus exercise can start to accrue (at least in my opinion). But we also want to be careful not to say, “I know that you’ve got ulcerative colitis, but we’ve really got your vitamin D up and you’re not going to need the Humira.” I mean, that’s going too far. So, hopefully that makes sense, but does provide a little bit of context.

Dr Ruscio, DC:

Okay, another great study here: the effectiveness of rotating versus single course antibiotics for SIBO. 223 patients with SIBO diagnosed by a glucose test were treated with either a single antibiotic or rotating antibiotics for 10 consecutive days. And not surprising the rotating antibiotic group had a higher rate of clinical remission—70% versus 50%. And clinical remission, of course, was associated with improvements in quality of life and bloating. This lines up perfectly with the protocol we use at the clinic—and also I laid out in “Healthy Gut, Healthy You”—which is rotating the formulas or changing them from first month to second month. And the theory here was always well, if there are certain bacteria and potentially even fungi that are somewhat resistant (let’s say to oregano), we can switch from oregano to burberine or black walnut or caprylic acid or whatever the agent is.

Dr Ruscio, DC:

But if we’re getting different sorts of antimicrobials in the system, at least in theory, that should allow for a better ability to have the impact of correcting the overgrowth or potentially dysbiosis or potentially a pathogen than would one single antimicrobial or antibiotic alone. Now that was theory, but it also, especially with the herb antimicrobials, it’s not a theory we need much evidence to support. You’re going to end up similar in cost when you rotate from one to the other. There’s no detriment to it. Other than people have to switch from one bottle to the other. Perhaps with antibiotics, you can make a little bit more of an argument to be a bit more cautious with that. But anyway, it’s a justifiable theory and it’s nice to see at least one data point showing that antibiotic rotation is more effective than a single antibiotic.

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Dr Ruscio, DC:

And this next study—coming a little bit higher up in the GI to the throat—looking at Barrett’s esophagitis, they wanted to see what happened and what was the risk associated with having Barrett’s esophagitis. And Barrett’s is essentially this visible tissue change in the lining/tissues of the throat and these changes can lead to dysplasia and that dysplasia can end up becoming precancerous or cancerous. So this is something to keep eyes on, of course, and these researchers wanted to see, “well, we know that there is this risk, but let’s quantify the risk,” which I applaud because knowing what your level of risk is matters a whole heck of a lot. So in this case, 985 Barrett’s esophagitis patients were followed for about eight years and 67 were diagnosed with high grade dysplasia or cancer. And the progression rate to cancer was 0.78 per patient year.

Dr Ruscio, DC:

And the authors commented that the risk of progression to pre-cancer or cancer in those with Barrett’s is low. So, this is reassuring. Now it should not be interpreted as, “well, my GI says I have Barrett’s and he’s always trying to give me PPIs. I don’t like the guy. I’m not going to go back.” Do not do that. I always recommend to follow up with whatever interval and assessment your conventional GI is recommending. However, you have some agency in terms of how you want to proceed with things.

Dr Ruscio, DC:

And if nothing else, this gives you a more clear understanding, at least from this one data point. Having a larger data set here would give us more confidence. A thousand individuals is something that’s going to give us a degree of proximity, but from a public health perspective, a larger sample size would make me feel better about the level of confidence I give to this observation. But nonetheless, in a fairly well performed trial, one can at least understand that the risk to progression to cancer is low. So what this should do is help allay and quell fear, but not stop you from acting. So hopefully that makes sense, but just to trying to parse that as best I can.

Dr Ruscio, DC:

And the next study here, a randomized, double-blinded placebo-controlled pilot study looking at the effects of an enzyme on symptoms in IBS patients. And this is an alpha-galactosidase. And so in this case, 20 patients with IBS were randomized to placebo or essentially AG. And what they found here was no difference in GI symptoms or hydrogen or methane levels between groups.

Dr Ruscio, DC:

And why I think this is important is I have some budding concern that as more enzymes are popping on the market—and this is something I discuss in “Healthy Gut, Healthy You” regarding gluten digesting enzymes—that people are falling into placebo and confirmation bias. We know the placebo effect in IBS trials, at least according to a meta-analysis from a couple years ago, clocks in at about 45%. Now this is in randomized controlled trials that are attempting to get rid of the placebo effect. So presumably we could double that if someone read, “this enzyme is really helpful, Mary Smith used it and she loves it. You should try it.” Okay. And then they read a bunch of reviews on the product page [saying] “oh, this was great.” So the amount of placebo there has got to be substantially higher than in a randomized control trial.

Dr Ruscio, DC:

And I think what’s happening with some of these enzymes is people are truly getting placebo benefit and I guess that’s okay. The one gripe I would take is, how expensive is the enzyme and are these being used— hopefully with the healthiest perspective on placebo [of] using it for good rather than gain—for a while and [with the goal to] then try to ween yourself off?

Dr Ruscio, DC:

And hopefully what would happen there is a person would finally eat the food they’d been avoiding or potentially not needing to avoid because they were able to tolerate the food just with the help of the placebo. I shouldn’t say just because the placebo does have a notable impact, but hopefully when they wean off it—if they have the expectation that they do not have supplement dependency—they could come off the enzyme and not nocebo themself into having freak reactions again. So anyway, this is something just to put on people’s radar. It is one trial. It is a small trial. If other data comes in that finds different enzymes, be effective, I’m all for it. We are currently looking into some enzymes to help with FODMAP tolerance, but we’ve got quite a bit of filtering to do there before we pick a formula. But just want to impress upon you to be careful with enzymes because I think they run the risk of placebo.

Dr Ruscio, DC:

All right, let’s go through one or two more. This next study was a meta-analysis looking at the association between microbiota diversity—how healthy is your gut ecosystem in terms of the flora—and psychiatric illness. This looked at 34 studies and over 1500 patients versus 1400 controls. And they found that those with psychiatric illness had a lower microbiota diversity score and richness score.

Dr Ruscio, DC:

So this does showcase the gut-brain connection. And you know, it’s a chicken or the egg here in my mind. Certainly we see imbalances in the gut present with brain fog and depression and what have you. But it’s also possible that the imbalance here could be in the brain, and that’s impacting things like sleep things like happiness and stress levels, and that has an impact on the microbiota. So the causality here has not been fully flushed out. There is some pretty compelling initial data, as we’ve discussed, that probiotics can improve depression and anxiety. So that’s hopeful, but I just want to be careful not to overrepresent (as much of a gut geek as I am) that we should interpret this finding as being a kind of one way relationship in this case from gut to brain.

Dr Ruscio, DC:

[The] next and final study for this podcast, the association between EPI (exocrine pancreatic insufficiency) and nutrient deficiencies. And in this case, they looked at 112 patients with suspected maldigestion. They were tested for EPI or exocrine pancreatic insufficiency and for micronutrients and they found a high prevalence in this cohort of 36% (probably because they were selecting for patients with I’m assuming chronic diarrhea, given the suspicion of maldigestion). And those with the EPI had a much higher rate of micronutrient deficiencies, 41% as compared to 5% in the controls. And the most common deficiencies were selenium and magnesium. Now remember that this is one condition I interpret in context. And I think that we end up seeing improvements in pancreatic insufficiency—or at least some of the symptoms associated with it and therefore the absorption—as we go through our gut care model.

Dr Ruscio, DC:

And we did discuss in the podcast before, a study that found probiotic supplementation improved micro nutrient status. So I don’t want to overrepresent the ability of just one intervention (probiotics) to rectify nutrient insufficiencies, but that’s one data point we should put on the table. And we should remember to, as best we can, try to treat deficiencies upstream via absorption via gut health, and maybe not be overly concerned about drilling down into minutia of testing. And we have discussed in the past—and if we have not yet, we’ll do it more thoroughly because this is something that we’ve been discussing with the research team—what are the best micronutrient tests and how to tackle those. And it essentially nets out to looking at symptoms is generally the better approach than testing the levels directly.

Dr Ruscio, DC:

Okay. Well those are a number of updates on gut health. I hope that was helpful and look forward to chatting with everyone next time. Alright. Take care. Bye bye.

Outro:

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• Rifaximin Modulates the Gut Microbiota to Prevent Hepatic Encephalopathy in Liver Cirrhosis Without Impacting the Resistome
  • Prospective study, 21 patients w/ liver cirrhosis in remission from hepatic encephalopathy (HE)
  • All were treated w/ Rifaximin (400 mg TID), stool samples collected throughout the study   
  • After 3 months, there were significant improvements in:
    • Blood ammonia (54.1 to 25.6 µmol/L)
    • Cognitive function 
  • Rifaximin treatment did NOT reduce microbiota diversity
  • Commentary: Rifaximin treatment led to improved cognition and significant reductions in blood ammonia. 

 

• Irritable bowel syndrome and long-term risk of cancer: a prospective cohort study among 0.5 million adults in UK Biobank
  • Prospective study of 449,595 participants, 22,338 (5.0%) w/ IBS
  • After a ~12 year follow up, IBS patients had a lower rate of:
    • Digestive cancer (HR 0.79)
    • Colon cancer (HR 0.75)
    • Rectal cancer (HR 0.68)
    • Cancer-related mortality (HR 0.83) 
  • Commentary: IBS does NOT increase rates of GI cancer and is actually associated w/ a LOWER rate of GI cancer. 

 

• Highly Bioavailable Curcumin Derivative Ameliorates Crohn’s Disease Symptoms: A Randomized, Double-Blind, Multicenter Study
  • 30 patients w/ mild-to-moderate Crohn’s Disease, randomized to placebo or curcumin (Theracurmin® 360 mg/day)
  • After 3 months of supplementation, the curcumin group had:
    • Higher clinical remission rates (40% vs 0%)
    • Reduced endoscopic remission rate (15% vs 0%)
    • No adverse effects
  • Commentary: Another data point suggesting curcumin may be helpful in IBD. 

 

• Efficacy of Fecal Microbiota Transplantation in Irritable Bowel Syndrome Patients: An Updated Systematic Review and Meta-Analysis
  • 19 studies using FMT in IBS patients
  • Compared to placebo, FMT led to:
    • Improvement of quality of life 
    • No difference in IBS symptom severity
  • Commentary: While FMT is an effective tool for C. diff. Infection, it remains a last line therapy for managing IBS. 

 

• Low FODMAPs diet or usual dietary advice for the treatment of refractory gastroesophageal reflux disease: An open-labeled randomized trial
  • Open-label study of 31 GERD patients refractory to PPI therapy
  • Randomized to standard diet (low-fat diet, head of bed elevation) or low FODMAP diet
  • After 30 days, there was NO significant difference of response rate between the two groups (37.5% vs 20%)
  • Commentary: Even though the differences were NOT statistically significant, there was a trend towards low FODMAP being superior. 

 

• Gluten-free diet in postural orthostatic tachycardia syndrome (POTS)
  • Retrospective study of 20 patients w/ POTS and without Celiac disease who followed a gluten-free diet 
  • 11 patients had MCAS, 8 had hypermobile Ehlers-Danlos syndrome
  • After 4 weeks of a gluten-free diet, patients had improved POTS symptom score (-34% reduction)
  • Commentary:  This study introduces bias by having patients fill out a pre-questionnaire AFTER the study is done. 

 

• Prebiotic Galacto-Oligosaccharides Impact Stool Frequency and Fecal Microbiota in Self-Reported Constipated Adults: A Randomized Clinical Trial
  • 132 adults w/ constipation, randomized to:
    • Placebo
    • Low dose Galacto-Oligosaccharides prebiotic (GOS) (5.5 g/d)
    • Or high dose GOS (11 g/d)
  • After 3 weeks of supplementation, there was NO significant difference between the 3 groups
  • Commentary: GOS did NOT lead to improvement in those w/ constipation. 

 

• Predictors of Symptom-Specific Treatment Response to Dietary Interventions in Irritable Bowel Syndrome
  • Aim: Investigate predictors of symptom improvement after dietary change in those w/ IBS
  • 67 IBS patients, randomized to low FODMAP diet or traditional diet x4 weeks
  • Factors associated w/ more symptom improvement:
    • Less severe dysbiosis (per GA-map Dysbiosis test)
    • Higher energy intake at baseline (less food restriction)
  • More psychological distress associated with LESS symptom improvement
  • Commentary: Those who may respond better to a low FODMAP (or another IBS diet) include: those w/ less dysbiosis, less anxiety, and who are able to tolerate more foods at baseline.

 

• The effect of low FODMAP diet with and without gluten on irritable bowel syndrome: A double blind, placebo controlled randomized clinical trial
  • 49 IBS patients, randomized to a:
    • low FODMAP diet w/ gluten-free powder (rice powder) 
    • or low FODMAP diet w/ gluten powder (5g/d)
  • Both groups had similar rates of:
    • Improved IBS symptoms (-32% gluten vs 49% gluten-free group)
    • Abdominal pain intensity (-45% vs -52%)
    • Abdominal pain frequency (-26% vs -46%)
    • Distension (-29% vs -63%)
  • Commentary: Even though there was a trend towards greater improvement in the gluten-free group, this difference was NOT statistically significant. 

 

• A Single Fasting Exhaled Methane Level Correlates With Fecal Methanogen Load, Clinical Symptoms and Accurately Detects Intestinal Methanogen Overgrowth
  • Assessed the viability of using a single fasting breath methane level to diagnose intestinal methanogen overgrowth (IMO)
  • Using the cutoff of ≥10 ppm, a single methane measurement had a:
    • Sensitivity of 86.4% 
    • Specificity of 100% for diagnosing IMO
    • And was associated with constipation
  • Antibiotics led to a decrease of the fasting single methane measurement
  • Single methane measurement was associated with higher stool M. smithii levels
  • Commentary: A single methane breath level may be an accurate predictor of IMO, and correlates w/ M. smithii levels in the stool. 

 

• Vitamin D supplementation in people with IBS has no effect on symptom severity and quality of life: results of a randomised controlled trial
  • 135 IBS patients, randomized to placebo or Vit D (3,000 IU/d)
  • 60% of participants were vitamin D deficient or insufficient at baseline
  • After 12 weeks, the Vit D group had:
    • Higher Vit D blood levels
    • NO difference in change of IBS symptoms score (-62 vs -75 in placebo)
    • NO difference in quality of life (-7.7 vs -11.3 in placebo)
  • Commentary: This study showed NO beneficial effect of Vit D for IBS. 

 

• Effects of vitamin D supplementation on blood markers in ulcerative colitis patients: a systematic review and meta-analysis
  • 7 studies, 539 participants, examining effect of Vit D on ulcerative colitis
  • Vitamin D supplementation led to:
    • Lower ESR (effect size -1.1)
    • Lower CRP (-0.4)
    • No difference in disease severity
  • Commentary: Vit D supplementation led to improvement of inflammatory markers but no change in disease activity in those w/ ulcerative colitis. 

 

• The effectiveness of rotating versus single course antibiotics for small intestinal bacterial overgrowth
  • 223 patients w/ SIBO (by glucose breath test)
  • Patients were treated either with a single antibiotic (quinolone or azole) or rotating antibiotics (quinolone and azole, one after the other) for 10 consecutive days per month for 3 months. 
  • The rotating antibiotic group had higher rate of clinical remission (70% vs 50.8%)
  • Clinical remission was associated with an improvement in quality of life and bloating
  • Commentary: Rotating antimicrobials may be superior for treating SIBO. This study showed an association between the eradication of SIBO and the improvement of quality of life and bloating. 

 

• Barrett’s esophagus surveillance in a prospective Dutch multi-center community-based cohort of 985 patients demonstrates low risk of neoplastic progression
  • 985 Barrett’s esophagus patients followed x7.9 years
  • 67 patients were diagnosed with high-grade dysplasia or cancer
  • Progression rate to cancer = 0.78% per patient-year
  • Commentary: Risk of progression to pre-cancer or cancer in those w/ Barrett’s esophagus is low. 

 

• A randomized double-blind placebo-controlled crossover pilot study: Acute effects of the enzyme α-galactosidase on gastrointestinal symptoms in irritable bowel syndrome patients
  • 20 patients w/ IBS, randomized to placebo or α-galactosidase enzyme (Nogasin®, 1200 GaIU/meal) x3 standardized meals, then crossed over to other treatment arm
  • Breath test measured every 30 minutes x7.5 hrs
  • No difference in GI symptoms or hydrogen/methane levels between groups
  • Commentary: In this cross-over pilot study, α-galactosidase enzyme was not superior to placebo. 

 

• Perturbations in Gut Microbiota Composition in Psychiatric Disorders: A Review and Meta-analysis
  • 34 studies, 1,519 patients w/ psychiatric illness, 1,429 control participants
  • Those w/ a psychiatric illness had a lower microbial diversity and richness in most but not all psychiatric diagnosis
  • Commentary: This highlights the gut-brain connection. 

 

• Yield of testing for micronutrient deficiencies associated with pancreatic exocrine insufficiency in a clinical setting: An observational study
  • 112 patients w/ suspected maldigestion tested for exocrine pancreatic disease (EPI) and micronutrient deficiencies 
  • 36.6% had EPI
  • Those w/ EPI had a much higher rate of micronutrient deficiencies (41.5% EPI, vs 5.6% non-EPI)
    • Most common micronutrient deficiencies: selenium, magnesium
  • Commentary: Micronutrient deficiencies are relatively common in those w/ EPI.

• Dr. Ruscio’s, DC Resources