Free Practitioner Question of the Month – July 2017

Dr. Michael Ruscio’s Monthly – Future of Functional Medicine Review Clinical Newsletter

Practical Solutions for Practitioners

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Practitioner Question of the Month

“I truly admire your work, Dr. Ruscio. Thank you for running this practitioner case study training course. I have a question to ask regarding Jeff Finley’s enzymes and HCL question. What would you prescribe for the patient who has low stomach acid and had H. pylori and gastric ulcer in the past? Is there anything else to give to increase stomach acid? She is not tolerate to drink apple cider vinegar or lemon juice the first thing in the morning. What is the best test to measure the health of stomach lining> Secretory IgA? Here’s a little more in details. 59 years old Asian female. Her father died from aggressive stomach cancer. She had suffered from acid reflux from the age 25-30. She had a bleeding ulcer when she was 31 and recurrent ulcer 5 years ago. She found she had H. pylori when she was 41. She had done Geneva’s comprehensive stool test 7 years ago. It was negative. She took the triple antibiotic therapy. She has been gluten, dairy-free for last 5 years. She had HCL challenge by increasing the dosage of HCL every dinner. She felt warmness in the stomach after taking 7 capsules and backed down to 2. She has been taking 2 capsules with each meals for almost a year along with 2 capsules of enzymes. She currently has frequent awakening, thinning hair, and short-term memory loss. Please let me know if there is any good remedy for backing down the HCL intake and the testing to find her stomach lining status. Thank you!” – Tamie Bilazzo

Great question. And there’s a lot of nuance here. So bear with me, I’m going to try to do my best to provide you with some useful tools. But this is definitely a long answer with a lot of nuance. Okay.

So much of this process is dependent upon the patient response. It’s process driven, not protocol-driven. That’s a very important thing to establish first. There’s also a few questions to ask you to get more context. How do you know they have low stomach acid? If your only gauge is the HCl tolerance test, where you have someone take oral HCl until they feel a burning, I strongly disagree with that test, and would not recommend it in any way shape or form. So I would throw that out 100%.

Is it self-reported? Meaning, they think they have low stomach acid likely because of an article they read on the Internet. You also can’t really use that. Her history suggests she’s more at risk for having either normal or high stomach acid. Have you objectively or as objectively as you can quantify that they need HCl? Meaning, they clearly noticed their digestion is worse when they’re not on HCl. I say, “Have you done this as objectively as you can?”, because oftentimes practitioners impart a strong bias onto people, brainwashing them into thinking they’re going to need HCl, because that’s what the practitioner thinks. And that’s not a good way to get an empiric read on a treatment.

Also, is the H. pylori current? I would screen with a blood antibody test, a stool test, and a breath test, and use those in conjunction to interpret.

  1. pylori is relevant because it can cause ulcers. And it can also cause perturbations in acid levels. So it’s very important that H. pylori is addressed. It’s also important that if there’s no documentation of H. pylori, neither symptomatic or from a lab work perspective, that you don’t just assume that she has it.

Okay, a few other notes. Ulcers in the past have been flagged to be careful with HCl supplementation. Now, the Betaine HCl may have the ability to help aid in stomach healing, but there are other lower-risk interventions that can also aid with the healing. I’ll come to some of those in a moment.

The incidence of low stomach acid, in my opinion, has been grossly overreported in the natural and functional medicine health communities, but it is significantly increased in those with autoimmunity. So if she has autoimmunity, then that may support the fact, or increase the likelihood that she has actual low HCl. Based upon her history and her family history, it’s more likely, from what you told me, that she has higher HCl.

Now, you can test for stomach autoimmunity, which can underlie loss of parietal cells, and therefore loss of the ability to produce hydrochloric acid, with a blood test known as anti-parietal cell antibodies. And that can be treated with injectable B-12, as we discussed in previous editions of the review.

Bitters can be used. Digestive bitters can be used to help increase stomach acid if she doesn’t tolerate the apple cider vinegar or the lemon. But it comes back to the question of, “Does she really need those?” If she’s not tolerating those, that may be telling you that her acid is sufficient or excessive, or she has impaired health of her stomach lining or even the beginning phases of a recurrence of the ulcer. So don’t just assume she needs to increase her stomach acid. Again, there’s a strong possibility this person will not need supplemental acid, but may actually need to buffer or decrease her acid levels.

Now, you can use things that are stomach-soothing compounds, for which I’m sure you’re familiar with compounds. Designs for Health has one called GI Revive that I like, but there are definitely many companies that make gut-soothing compounds.

I’m sure you know of many gut-soothing compounds that contain things like aloe, liquorish, or marshmallow, so you can use a compound like that for gut support or gut healing. Zinc’s another one that’s often used, L-glutamine. So any combination formula that contains some of those can work. And there’s not a magic supplement for those.

And then, you could also use a natural acid-lowering compound. There’s one that is over-the-counter known as Protexin. And there’s another one known as GI Guard. And those contain melatonin and some D vitamins, and those help to lower stomach acid and have actually shown the ability to heal ulcers, in one study, equivalent only to omeprazole, which is a PPI.

In terms of a stomach lining test, I would recommend routine screenings with her gastroenterologist to check for ulcers. He probably wants to check back in with her at a recommended frequency. And I would encourage her to do that. That’s probably the best to check for things like ulcers. Also, remember that her tolerance to acid is, in part, the test. If she doesn’t respond well to taking supplemental acid, then that’s a dead giveaway that she doesn’t need it. She probably has some gastritis or some ulcerations. If she has no negative effect, it’s not a guarantee that she needs it. But keep in mind if she negatively responds to it, then that’s a dead giveaway that there’s probably either gastritis or ulcers, or beginning phase ulcers.

Gastrin is a blood marker that can be used, but it’s difficult to interpret and should only be used after H. pylori has been addressed. And that’s a blood marker. Again, her family history suggests that she might not need acid. It might be better with things that reduce reflux and also things that can help with the levels of acid in her stomach more in a dampening direction because, for example, H. pylori can either increase or decrease stomach acid. So it’s not to think that because somebody has H. pylori they’re going to need stomach acid.

Elimination diets and low FODMAP diets have also been shown to be helpful with the reflux. For ulcers, the treatment of H. pylori has been shown to be, of course, effective for ulcers. And herbal antimicrobials when paired with Saccharomyces boulardii and N-acetyl cysteine can be very effective. Now, you may also want to use acid-lowering medications, which have been shown to have 80 to 90% healing rate for ulcers when used for four to eight weeks. These are acid-lowering medications like PPIs or H2 receptor antagonists.

And then also there are the natural compounds I mentioned a moment ago. And those in one study have been shown to be equivalent to a PPI known as omeprazole. So sometimes acid lowering is okay, especially when it’s used in the short-term. You can use gut-soothing compounds, and you could also screen for autoimmune gastritis, which is the anti-parietal cell autoimmunity blood test. And if that’s found, you can support that with injectable vitamin B-12.

So the big takeaway here is you can’t let bias that is inherent in natural medicine education influence you with your care with this particular patient or client. Yes, low-stomach acid does occur. Yes, that occurrence rate is increased in those of autoimmunity. Does that mean everyone has low-stomach acid? And everyone needs supplemental stomach acid? No.

You have got to be cautious not to let a bias cloud your objectivity here. She may actually need an acid neutral or an acid-reducing intervention, and triggering H. pylori can be one way. Improving their diet, meaning getting rid of allergens, can be another way, because allergens will stimulate histamine. And histamine is what some of the acid-lowering medications actually block. So you could get to the root cause of that by reducing allergens in her diet via an elimination diet.

And there’s also the natural acid-lowering compounds and gut-soothing compounds that can be helpful. And you want to use these things and their response in conjunction to try to read if you’re moving in the right direction and then have periodic follow-ups with her gastroenterologist. Please do not fall into the thinking that you can do something like a IgG test or an IgA test and think that that’s going to be covering all your bases, because that would be a very, very ill-advised error, because I know of no documentation that shows that those tests outperform an endoscopy in identifying ulcers and helping someone get the care that they need for an ulcer.

This person having a bleeding ulcer, or a severe ulcer, and a family history of stomach cancer, you really don’t want to leave any of that to chance. So make this an integrative endeavor. Be open to the possibility that she may need an acid-lowering intervention, and that acid-lowering intervention might be as simple as diet. Or it might be treatment of H. pylori. Or it might be a natural or even a pharmaceutical agent to achieve that endpoint. And when the acid-lowering compounds are used in the shorter term, they’re much easier to justify. And the natural compounds used in the longer term may be safer. We don’t know that, but they also may be safer.

Also remember that there are some things here that genetics may be working against us. She may have environmental triggers that are triggering a lot of acid release or environmental triggers like diet, but also allergens, which can also stimulate histamine, which may increase stomach acid release. And that, looked at in conjunction with the density of her parietal cells, may make her have a high tendency toward acid oversecretion, which may be why she has ulcers. So we want to do everything we can to modify the items like diet and using soothing compounds to help. But she may ultimately need some type of acid lowering in the long-term if you’ve done everything else and she still has recurring ulcers.

So hopefully this is helpful. This is a hairy one. This is not an easy one. And a lot of this is process-driven, not protocol-driven. But hopefully, this gets you pointed in the right direction. Okay, keep us posted. Thanks.

practice tip

Practice Tip

“Hi Dr. Ruscio, As a clinic tip, can you speak to how your office handles the Intake Q questionnaires and applications to be a patient? Are these sorted and eventually uploaded to your EHR? What EHR/EMR do you use?” – Christa Biegler

Great question, Christa! We use IntakeQ for HIPAA-compliant online forms. And as part of our screening process, or in order to apply to become a patient, we ask someone to fill out a short questionnaire. And I ask a few important questions:

  1. What are your chief complaints?
  2. What other therapies have you done?
  3. Do you have any other comments or questions?

And this gives me a very important assessment of, generally speaking, are they in the right office?

Now, those are screened by our medical assistant, as I’ve trained her on what to look for. And to be truthful, this is actually very easy. If you’ve had a medical assistant or office staff working with you for a little while, they pretty much know what type of patients you typically see. And it should be pretty easy for them to be able to pick out when someone’s presenting with something highly unusual.

So our medical assistant screens these forms. If she’s unsure, then she sends it directly to me to review. But 90% of these, you can easily review and make a decision on. Then, it gets filed under their chart. And this essentially becomes the chief complaint section of their paperwork. And paperwork is essential. Having well-constructed paperwork has reduced my exam time by at least 50%, but at the same time, it has increased the quality. I update my paperwork one to two times per year. I’m always cutting out the things that I’m not finding very helpful, and trying to include and focus on the things that I need. And it was actually very freeing.

Several years ago, when I first decided to abandon the paperwork I was using from some functional medicine seminar, it was because I found it cumbersome. I found there was a lot of questions that I wasn’t even using. But it’s funny. There’s this condition and belief that it must be good. And as soon as I was able to just say, “I want to have my paperwork be customized to the things that I want to know and not what some seminar guru recommends,” my paperwork became shorter, much more powerful, and much more impactful. And the results allowed me to give much more efficient and quality care.

Now, a few examples of things to consider adding to your paperwork would be the evidence-based thyroid questionnaire that we discussed, I believe, in the January edition of the review, which gave you thirteen questions, 2 or 3 of which were very indicative of predicting thyroid disease. And then, also, we had discussed that there were three symptoms that were shown to be anywhere between 60 to about 90ish percent predictive of anti-parietal cell autoimmunity.

So these are things that we should be constantly incorporating into our paperwork so that we have highly impactful questions that we’re asking that flag, “This person is expressing a high risk for thyroid disease” or “This person is expressing a high risk for anti-parietal cell autoimmunity.” So hopefully, that helps you with initial intake screening paperwork.

And then, what I use for electronic health records is actually Excel. And I know that sounds archaic. I am in the process of looking into an actual electronic health record system, and when I do select one, I’ll make an announcement about that. The reason why I haven’t is, I had been using Excel my whole life for many things, and when I first started in the practice, I didn’t have a lot of money, and I didn’t want to buy a program. And it seemed like all the good EHRs were expensive. So I started using Excel, and we got pretty well-accustomed at using Excel in the office. It actually works really well.

And then, the situation became there was other things that were more important over the past couple of years than updating from Excel to an electronic health record system. The research studies that we’ve been performing, my review of the medical literature, the podcast, the website, speaking engagements — those have all been more impactful, more important, and higher on the priority list. Hopefully, now that things will settle down after the book, I plan again on getting an EHR. And I will keep you guys abreast of that.

So great question, Christa. Hopefully, that helps.

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