Practitioner Case Study – March 2017

Patient Info:

• Lori, 50yo female
• Previous dx
  • SIBO, polycystic kidney and liver disease, unknown connective tissue disease, heavy metal toxic
• Rx: Xifaxan
• Chief complaints:
  • Bloating
  • Polycystic liver/kidney disease maintenance
  • Acid reflux
  • Unidentified connective tissue disease
  • Allergies; congestion, post nasal drip

Visit 1 (1/29/16) – History and Exam

Lori presents as a happy 50yo female with a healthy diet and lifestyle balance, but is a very chronic case.  She has had multiple surgeries for internal adhesions, scarring, and cysts.

She is now presenting after working with many conventional medical providers and was encouraged to seek additional council with our clinic from Dr. Mark Pimentel.  She is a bit of a blank slate because her internal anatomy was just recently altered (hopefully for the better) via a recent abdominal surgery to reduce connective tissue impairment of her GI.  This may change how well she responds to treatment (including those she has had not responded to in the past).  She has also had her gallbladder removed and has liver disease.

She has previously responded well to high dose HCl and bile.  Also to the elemental diet as Vivonex Plus.  Xifaxin’s effect and that of probiotics was unclear.  Low dose erythromycin has not helped.  She has also previously responded well to metal detox.  SIBO has not retested positive in the past, making me think there is more than SIBO present.

I am unclear how much I can help due to altered anatomy and connective tissue disorder.

Initial impression

• Lori is an unusual case. The fact that she has no gallbladder and liver disease suggests she may do especially well with supplemental bile. Of course, abdominal adhesions are highly suspected, both due to her connective tissue disease and due to her recent surgery.
• Even though she has tested negative recently for SIBO, there may be another form of dysbiosis present; SIFO or H2S SIBO or fungus….
• She presented with many oral caries, so I recommended some general oral health practices. She is on far too many supplements, but had done a good job with determining what foods seemed to work for her.

Visit 2 (2/15/16) – Testing and Initial Recommendations

Testing

• AeroDiagnostics SIBO breath
• Medical Futures urinary H2S test
• BioHealth 401H stool test
• Genova Organix Dysbiosis urine test
• DiagnosTechs GI-15 stool/saliva test
• LabCorp
  • Comprehensive blood panel
  • Full GI panel
  • *too many markers to list here

Recommendations

• Diet: continue with the diet you have found helpful.
• Lifestyle: work to find the minimal amount of self-prescribed supplements needed.
• Oral Health: oil pulling, mouth wash, probiotic toothpaste.
• GI: High dose HCl, bile, Iberogast. Lacto/Bifido probiotics, S. boulardii probiotic, digestive enzyme formula.
• Perform a consultation with ClearPassage to see if you are a candidate for their therapy to break down abdominal/pelvic adhesions.

Visit 3 (5/6/16) – Lab Interpretation and Treatment Evaluation

Lab interpretation:

• Summary
  • Yersinia, light candida, borderline H2 SIBO, and bacterial dysbiosis. High HbA1c, ferritin, and potential anemia.  Low WBCs.  Potential IBD.
• AeroDiagnostics Glucose SIBO breath
  • Normal
• Medical Futures urinary H2S test
  • Inconclusive
• BioHealth 401H stool test
  • Light candida
• Genova Organix Dysbiosis urine test
  • Bacterial – Phenylacetate, p-Hydroxybenzoate,
• DiagnosTechs GI-15 stool/saliva test
  • Normal
• LabCorp
  • Comprehensive blood panel
    • Hemoglobin A1c 5.9-H, Ferritin 267-H, Cholesterol 233-H, LDL 132-H
    • WBC 2.5-L, MCV 103-H
  • Full GI panel
    • Yersinia IgA, IgG
    • AMCA antibodies
      • 
      • 
      • 

Subjective Assessment

• ‘Feeling about the same as last visit.’
• Had a negative bloating reaction to Iberogast.

Impression:

• Lori’s case is an unusual one due to previous surgery and other dx, but we have found some minor GI findings today that when treated may yield improvement. The ferritin may be caused by inflammation, so monitor before considering low iron diet.
• So far no change symptomatically, but hoping today’s plan will yield improvement, but I also anticipate reactions along the way.
• Lori was found to be an excellent candidate for ClearPassage therapy.

Recommendations

• Continue previous
  • Diet: continue with the diet you have found helpful.
  • Oral Health: oil pulling, mouth wash, probiotic toothpaste.
  • GI: High dose HCl, bile. Lacto/Bifido probiotics, S. boulardii probiotic, digestive enzyme formula.
• See your primary care doctor regarding your low white blood cells.
•  GI:
  • Herbal antimicrobial protocol for SIBO
  • Semi-elemental diet; use daily to replace up to 50% of your daily meals
• Discontinue Iberogast
• Move forward with ClearPassage therapy
• Follow up in 4 weeks

Visit 4 (7/1/16)

Subjective Assessment:

• Overall, feeling 20-25% better compared to last visit.
• Feels like probiotics are working well.
• Starting care at Clear Passage on July 6^th.
• Herbal antimicrobials are helpful.
• Semi-elemental diet caused flare. Homemade elemental diet caused flare.
• Bloating improved by 50% other than flares noted above.

Impression:

• Probiotics and antimicrobials are working. Elemental/semi-elemental diets are not tolerated.  Hopeful ClearPassage therapy will yield significant improvements.

Recommendations:

• Continue previous
  • Diet: continue with the diet you have found helpful.
  • Oral Health: oil pulling, mouth wash, probiotic toothpaste.
  • GI:
    • High dose HCl, bile. Lacto/Bifido probiotics, S. boulardii probiotic, digestive enzyme formula.
    • Herbal antimicrobial protocol for SIBO.
  • ClearPassage therapy.
• Discontinue semi-elemental and elemental diet use.
• Follow up in 4 weeks.

Visit 5 (7/29/16)

Subjective Assessment:

• Just finished first 20hr session with ClearPassage. Feels another 20% better from this.  CP therapist feels she is responding very well.
• Less bloating and cramping. Still does have some pain and bloating, but much improved.

Impression:

• We are on the right track, the combination of probiotics, HCl, bile, antimcirobials, and abdominal adhesion therapy has provided the greatest overall level of improvement Lori has obtained in several years.
• We will have Lori finish her current round of antimicrobials and then follow up 4 weeks later. We will not use a prokinetic due to previous negative response.

Recommendations:

• Continue previous
  • Diet: continue with the diet you have found helpful.
  • Oral Health: oil pulling, mouth wash, probiotic toothpaste.
  • GI:
    • High dose HCl, bile. Lacto/Bifido probiotics, S. boulardii probiotic, digestive enzyme formula.
    • Herbal antimicrobial protocol for SIBO.
  • ClearPassage therapy.
• Follow up in 4 weeks after you’ve finished your antimicrobials.

Visit 6 (9/9/16)

Subjective Assessment:

• Is maintaining her previous improvements.
• Seems to be making gradual improvements from month to month.

Impression:

• We are on the right track, the combination of probiotics, HCl, bile, antimcirobials, and abdominal adhesion therapy has provided the greatest level of improvement Lori has obtained in several years.

Recommendations:

• Continue previous
  • Diet: continue with the diet you have found helpful.
  • Oral Health: oil pulling, mouth wash, probiotic toothpaste.
  • GI: High dose HCl, bile. Lacto/Bifido probiotics, S. boulardii probiotic, digestive enzyme formula.
  • ClearPassage therapy.
• Follow up in 2 months.
• Retest previous bloodwork.

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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