Practitioner Case Study – August 2017

Patient Info:

• Liz, 69yo female
• Previous Dx: SIBO. Gallstones. Twisted (tortuous) intestines causing pain/gas. IBS. Fatty liver. Lyme.
• Rx: N/A
• Chief complaints
  • Underweight (110lbs)
  • Nausea
  • Stomach Pain
  • Fatigue
  • Constipation
  • Bloating
  • Hot flash, low libido, vaginal dryness
  • Insomnia

Visit 1 (day 1) – History and Exam:

Liz presents as a 69yo female with good diet, lifestyle, and outlook on her health.

She has been dx with severe CH4 SIBO, but has not made much headway due to reactions to Habx. She is managing constipation with Mg and has also responded well to DGL.

Some evidence suggests high acid, but Heidelberg normal; however, she did have mild gastritis, so this might be caused by H. pylori or APCA (anti-parietal cell autoimmunity). Mild gastroparesis is also suggested, making this relevant clinically.

Her SIBO and constipation may ultimately be caused by a redundant colon/anatomy, therefore she may do well with hybrid or occasional elemental/semi-elemental diet use.

Adhesions are possible and there is some limited evidence for Lyme/metals, however we will start with GI and then re-evaluate.

Initial impression

• I think she will do well once we find the right approach to manage her SIBO, likely elemental/semi-elemental. She will likely need ongoing care as anatomy may preclude a permanent fix.
• Prognosis good to excellent with continued care.

Visit 2 (a few days later) – Testing and Initial Recommendations:

Testing

• Aerodiagnostics Lactulose SIBO breath test
• BioHeath 401H stool test
• PCO testing at LabCorp
  • CBC w Diff & platelet count
  • Metabolic Panel, Comprehensive
  • Lipid Panel
  • Iron Panel: Iron, TIBC, Iron Sat., Ferritin
  • Insulin, fasting
  • Hemoglobin A1c (HbA1c)
  • Vitamin D
  • T-4, Free (Thyroxine, Free)
  • Thyroid-Stimulating Hormone (TSH)
  • Helicobacter pylori Antibodies, IgA, IgG, IgM
  • Helicobacter pylori Urea Breath Test
  • Parietal Cell Antibodies (APCA)
• Rationale
  • SIBO testing is clearly indicated due to her history. Testing now will help to establish a baseline against which to monitor success of future treatment.
  • Because of the previously reported gastritis, it is important to fully rule out pylori. This is why in addition to the BioHealth panel, I also chose to assess this at LabCorp via blood and breath testing. APCA was also suspected, so this was included in this panel as well – remember that if this is found, it has a specific treatment, so the testing is warranted.

Recommendations

• Diet
  • First, try the Semi-elemental diet as Elemental Heal or Physicians Elemental for 2-4 days exclusively.
  • Then, experiment with intermittent fasting – which essentially means skipping a meal. If you felt well on the elemental diet, you can use one serving per day as a meal replacement to perform a daily period of intermittent fasting.
  • When transitioning back to whole foods, start on your previous SIBO diet with some carbs added back in as you previously found helpful.
• Supplements
  • GI:
    • Lacto/bifido probios blend, enzyme/bile/HCl formula, boulardii, soil-based probiotic. Bile acids.
    • Magnesium and vitamin C (slowly titrating dose upward to aid bowels).
  • Rationale
    • Because I suspected Liz may do well with elemental/semi-elemental formulations, I wanted to beta test this with a short 2-4 day trial.
    • Due to her intestinal anatomy, she may require periods of fasting to facilitate the MMC to help clean out SIBO. So, I also recommended she experiment with intermittent fasting.
    • Probiotics can stimulate the MMC and they can also combat SIBO, so they are worth a trial. Bile can function as a laxative and also kill SIBO.

Visit 3 (approx. 4 weeks later) – Lab Interpretation and Treatment Evaluation

Lab interpretation:

• Aerodiagnostics Lactulose SIBO breath test
  • H2 113, CH4 90, combo 203
• BioHealth 401H
  • HP
• LabCorp PCO
  • Liz elected to hold off on order until f/u to determine if it’s still necessary. Trying to save out-of-pocket costs.
• Summary
  • Dx: Severe combination SIBO. pylori.

Subjective Assessment:

• Semi-elemental diet formula – Helped GI
  • Has been using this formula as a meal replacement to replace dinner and liking it.
• Magnesium – rxn; nausea
• Lacto/bifido blend, boulardii – rxn; bloating, pressure, pain
• Soil based – did not try due to other rxns
• Bile acids – bowels non-responsive, may have flared GI
• Improved/Same/Worse:
  • Overall is generally the same, maybe a bit better at dinner with using semi-elemental diet.

Impression:

• As previously dx, we found severe SIBO today. In the past, she has not reacted well to Habx, so we will use a semi-elemental diet as full SIBO treatment today. Previously reported gastritis likely due to HP we found today. However, we should test for APCA today also, since she has not yet as I requested. Relapse in future may be due to tortuous/redundant colon, so repeat/ongoing treatment may be needed. Also, bear in mind adhesions if non-responsive. Liz may have reacted to several items in her program, so I will have her isolate and experiment before next f/u.

Recommendations:

• Spend a few weeks experimenting with items in your program to isolate for reactions before moving to the exclusive elemental/semi-elemental diet.
• Experiment with the lacto/bifido and boulardii probiotics for a few more days to determine if these are helping or not.
• After this, perform 2 weeks exclusively on the semi-elemental (Elemental Heal) or fully elemental (Physicians Elemental).
• Perform the testing before your next visit.
• F/u: just before ending the two weeks on the elemental diet.

Visit 4 (6 weeks later)

Subjective Assessment:

• Using ½ of the listed dose of Lacto/bifido probios and boulardii probios – helpful
• Enzyme/bile/HCl blend and/or bile acid formula – appear to cause the rxns
• Semi-elemental formula – felt noticeably better
• Improved:
  • Pain, bloating, nausea
• Same:
  • Diaphragm pain, back pain, constipation
• Worse:
  • Fatigue

Lab interpretation:

• LabCorp PCO
  • BUN/Creatinine 33-H, Albumin 5-H, A/G Ratio 2.5-H
  • APCA – normal

Impression:

• Ruled out APCA, will monitor BUN and Albumin. Lacto/bifido and boulardii are tolerated. Semi-elemental appears to be overall helpful, but causing slight rxn; Physicians Elemental might be better (will have her try today). Will continue to 3rd week elemental diet and then start on prokinetics and retest SIBO and blood chem.

Recommendations:

• Continue
  • Lacto/bifido and boulardii
• Starting
  • Perform a third week on the elemental/semi-elemental diet, experiment with the Physicians Elemental.
  • Then transition to the SIBO prep diet and retest. And start on the following:
  • Once you have finished the elemental diet, start on prokinetic MotilPro or Iberogast.
• Retesting
  • Aero Lactulose SIBO test
  • PCO testing at LabCorp
    • CBC w Diff & platelet count
    • Metabolic Panel, Comprehensive

Visit 5 (6 weeks later)

Subjective Assessment:

• Semi-elemental was more tolerated than Physicians Elemental
• Iberogast – no reaction, no improvement
• Generally better than at last
• Improved:
  • Nausea, fatigue (slightly), bloating, insomnia
• Same:
  • Weight, constipation
• Worse:
  • Burping, stomach pain, hot flashes, fluttering in ear, red irritated eyelids

Lab interpretation:

• Aero Lactulose SIBO test
  • H2 100, CH4 9
• PCO testing at LabCorp
  • Normal
• Summary
  • Dx: Severe H2 SIBO
  • Methane now normalized

Impression:

• SIBO labs show remarkable (roughly 80 point) drop in CH4. Blood chemistry also normalized. Liz appears generally improved, but might be expressing symptoms of: HP, hyperacidity/gastritis. Today we will be starting Habx for H2 and adding pylori synergist. Will be continuing hybrid use of semi-elemental diet; she may need this in the long term due to anatomy. Because of history of gastritis and symptoms, also consider starting acid reducing intervention should symptoms persist once established HP is cleared. Retest for HP today at end of Habx, consider SIBO retesting then also.

Recommendations:

• Continue
  • Lacto/bifido and boulardii
  • MotilPro or Iberogast
  • Hybrid use of semi-elemental diet
• Starting
  • H2 SIBO and HP antimicrobials
    • Herbal antimicrobial blend, Oregano, NAC
  • F/u: 4-5 weeks

Dr. Ruscio’s Comments

This is a case we are still working through, but I wanted to share it for a few reasons. Also, in a few months I will follow up on this case in a future edition. The main lessons from this case:

• Even though a fully elemental diet is purported to be ‘better’ for SIBO, I have often found that patients prefer a semi-elemental diet. The clinical research treating Crohn’s disease show equivalent effectiveness. I have found them equally effective for SIBO.
• Sometimes SIBO and HP both need to be treated for adequate response. It appears Liz’s SIBO symptoms have improved, but may require directed HP treatment to respond fully. Her history of gastritis make addressing HP highly supported. I usually wait until SIBO has been resolved before I retest HP, because many SIBO treatments will also treat HP and because SIBO is usually the harder of the two to clear.
• Also, sometimes SIBO requires multiple rounds of treatment or more than one treatment approach to fully resolve. In this case, methane responded strongly, but the hydrogen may require a different approach.

Oftentimes findings on a CBC w/diff and/or metabolic panel return to normal upon retesting and don’t require any direct treatment. In this case, the BUN/Creatinine, Albumin, A/G Ratio returned to normal with no direct treatment.

I’d like to hear your thoughts or questions regarding any of the above information. Please leave comments or questions below – it might become our next practitioner question of the month.

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