Practitioner Case Study – December 2018

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

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Case study

Research

Practitioner Question of the Month

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Case Study

Patient Info:

  • John, 28yo male
  • Previous Dx
    • Ulcerative proctitis
  • Rx
    • Canasa (Mesalamine suppository)
  • Chief Complaints
    • Loose stools, 5-CO
    • Blood in stool, 3-CO
    • Stomach bloat/gnawing, 2-OC
    • Bloating, 2-OC

Visit 1 (Day 1) – History and Exam:

Initial Impression

  • John presents as a generally healthy 28yo male with a good diet, lifestyle, and outlook on health.
  • He has been dx with UC/UP recently and is on Mesalamine suppository (Canasa).
  • He didn’t respond to oral 5’ASAs. He would like to find a non-suppository and natural treatment.
  • We will work through treatments for UC and also investigate any other factors like SIBO/dysbiosis.
  • Prognosis fair to good, due to distal nature of UP.
  • Previous testing:
    • Colonoscopy to diagnose UP

Previous Diets

  • Low FODMAP – NR. Low CHO, DF/GF – helpful. (NR=non-responsive)

Previous Treatments

  • VSL#3 – MR. Canasa – helps loose/bloody stools. Lialda (oral) – NR

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

Testing

  • Aerodiagnostics Lactulose SIBO breath test
  • Diagnostic Solutions GI-Map stool test
  • Rationale:
    • The SIBO breath test is a bit of a reach, but we do know that IBS and IBD can occur together. The challenge here is ulcerative proctitis is so distal, there may be minimal involvement of SI.
    • However, it is possible, at least in theory, that the overzealous immune tone in the rectum could be driven by immune activation in the SI.
    • The GI-Map shares the same rationale, but this test also contains inflammatory markers known to correlate with IBD, and UP is a subset of IBD.
    • His other symptoms (bloating, loose stools, stomach gnawing) might all be caused by dysbiosis which these tests can find.

Recommendations

  • Diet
    • Please perform the Modified Fast for 2-4 days (see website for PDF), then
    • Return to your previous low/moderate carb paleo diet that is gluten and dairy free. You can eat more carb dense carbs (ones you tolerate) to gain weight. Consider a trial of the Paleo low FODMAP Diet
    • Please be on the diet for 2 weeks before starting the supplements, but continue diet until our follow up. Then be on the supplements for 3 weeks before following up. Please make note of changes you noticed from each one of these steps.
  • Lifestyle
    • na
  • Supplemental
    • NRT: Vitamin D/K, Omega 3-6-9 blend, Curcumin
    • GI: Lacto-Biff probiotic, S. boulardii, soil-based probiotic, gut repair cocktail
  • Rationale
    • Evidence has shown vitamin D, omega, curcumin, probiotics, and gut repair nutrient cocktails to improve IBD
    • His other symptoms (bloating, loose stools, stomach gnawing) might all improve from the above treatments

Visit 3 – Lab Interpretation and Treatment Evaluation

Subjective Assessment:

  • MF (broth) – helped a lot
  • Paleo LF diet – moderate help
  • Supplement program – very helpful, no blood and normalized stools
  • Improved:
    • no CCs for about 3 weeks
  • Same:
    • na
  • Worse:
    • na

Lab Interpretation:

  • Aerodiagnostics Lactulose SIBO breath test
    • H2: rise 34, peak 36. CH4: 6
  • DiagnosticSolutions GI-Map stool test
    • H. pylori, Calprotectin (**1590**), Occult blood
  • Dx
    • mild H2 SIBO, H. pylori, extremely high inflammation (calprotectin)

Impression:

  • 12/13/17 – John’s labs show mild H2 SIBO, H. pylori and extremely elevated Calprotectin. He has improved markedly today, all CCs improved and no further improvement needed. The Calpro is likely much improved today and methodology might be prone to false+s. Today we will maintain current plan. Then fu in 2-3 months and then first work to wean of Canasa (with GIs help) and then later to reintro diet, then finally wean off the program.
  • Note: Yet another example of how we often do not need to treat lab findings if we get the initial therapies right, in this case, diet, anti-inflammatory support, and probiotics. I hope you are seeing why I am parsimonious with my use of lab testing.

Recommendations:

  • Continue previous:
    • Diet
      • Return to your previous low/moderate carb paleo diet that is gluten and dairy free. You can eat more carb dense carbs (ones you tolerate) to gain weight. Consider a trial of the Paleo Low FODMAP Diet
    • Lifestyle
      • na
    • Supplemental
      • NRT: Vitamin D/K, Omega 3-6-9 blend, Curcumin
      • GI: Lacto-Biff probiotic, S. boulardii, soil-based probiotic, gut repair cocktail
  • Starting
    • You can use the Modified Fast periodically for a day to help calm things down, as needed.
    • continue current plan
    • keep up the good work!
  • fu: 2-3 months

Visit 4

Subjective Assessment:

  • Continuing to improve
  • Improved:
    • all CCs

Impression:

  • 4/25/18 – Continues to improve from the program. Today decided to maintain current course for a few months, allowing him a chance to assess how he does when he occasionally missed a Canasa dose. Then we will fu and work plan of dietary reintro, followed by program curtail and +/- Canasa. Will fu when he is ready to take the next step.

Recommendations:

  • Continue the previous program
  • Starting
    • reduce dose to probiotics to once per day
    • fu: 2-6 months

Dr. Ruscio’s Comments

It’s been 7 months and I haven’t seen John, so I am assuming he has done great and was able to gradually wean off Canasa and maintain his improvements. Perhaps he occasionally needs a dose or two, but again I am assuming no news is good news since the last time we saw him he was doing great.

This is another case where we did not need to treat the lab findings. In fact, I would guess that if he aggressively treated SIBO with antimicrobials and high doses of additional anti-inflammatory cocktails, it may have flared him. Yes, labs can help, but don’t use them as a crutch instead of relying on good clinical common sense and logically applying the available treatments.

I am also suspicious that the calprotectin on some functional labs is overly sensitive. There have been a number of cases where the functional lab’s calprotectin did not match the clinical picture nor the LabCorp or Quest calprotectin I have ordered in tandem in some cases. This is just something to be aware of so as to prevent potential overreacting.

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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Discussion

I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!

14 thoughts on “Practitioner Case Study – December 2018

  1. So because he was feeling good, you chose to not address the h pylori? Or rather the probiotics were really how you addressed it before knowing?

  2. So because he was feeling good, you chose to not address the h pylori? Or rather the probiotics were really how you addressed it before knowing?

  3. As a patient for many many years of multiple doctors I would never assume that not hearing means that things are good.While I know in many cases not hearing does mean this, I think you will find for many chronic patients when we cannot find some kind of win or improvement we tend to slip back to what is known. As in I will tend to revert to what I know makes me feel one specific way, that way might not be great but it is known and more secure. Thus it can lower my anxiety about my health and give me a way to deal with only one set of known effects vs all new and interesting ones.

    Dealing with chronic issues is day to day for many of us. We wake up and wonder if the day will hold anything other than issues caused by our symptoms. If I am trying a new regiment of options I will need to wait to try them based on potential side effects or the dreaded unknowns. This prolongs my potential resolutions I might find from these options. But if I do not do this I increase my overall anxiety and loss of work or other work related issues based on those unknowns. We ride this roller coaster daily. Sometimes we have to get off and take a break, even if that break is at a place that still has us feeling miserable daily.

    I am curious about why more Dr’s do not “prescribe” for lack of a better word more exercise, I see FM’s doing this but rarely do I see conventional med Dr’s doing this, also equally important is stress management. The worst part about both of these is that they are easily the hardest to actually do for most to include me. But as you state tests and pills are not always or many times the answer. Where as diet and health are clear major life transitions that can lead to real long term results.I am very interested in how overall medical depression affects our overall health. I know I suffer from some sort of this as when you never really win, no matter how tough you might be it has negative effects.

    All this brings me back to the point of not hearing back possibly not meaning what you hope it does mean. When I visit Dr’s these days after years of visits and only minimal answers, while I want to be there and want to try to get more answers, I also do not want to be there at all sub concisely. And then when I am gone I try the suggested solutions and if i see little to know help I tend to revert. I am curious how many other patients might see this same reversion but if there is a way to break that to keep the patient better on track. Maybe the future of medicine is in the follow up, and the follow up would assist many in staying on track. I find humans in general can adapt to most things. Pain, suffering, death, natural disasters etc, its usually tomorrows news in a week or so after it happens. Much like nobody cares today what happened in Alaska the other day after a 7.0 earthquake I think many chronic suffers will continue to feel miserable as long as it is less miserable that last week. A plan to check back with patients is a double edged sword in FM I also feel as for some it might be a positive while others might view it as pushy sales tactics. All items to be evaluated. Since I can only speak for myself I would think if I was called back after a set course of time it would force me to do one of a few things, admit I suck and did none of the things asked for by the Dr., or actually admit to improvement, or kick me back into gear as I am in a chronic medical issue slump that I need help getting back out of and back on track.

    This all can be small parts of the Dr Patient relationship that is key to trusting Dr’s in general and thus trusting their decisions on plans to help each patient. Well that and a way to prescribe several other things like less stress, more exercise and the ability to stick to long term plans that do not have immediate results in some sort of easy to swallow pill form would be very helpful.

  4. As a patient for many many years of multiple doctors I would never assume that not hearing means that things are good.While I know in many cases not hearing does mean this, I think you will find for many chronic patients when we cannot find some kind of win or improvement we tend to slip back to what is known. As in I will tend to revert to what I know makes me feel one specific way, that way might not be great but it is known and more secure. Thus it can lower my anxiety about my health and give me a way to deal with only one set of known effects vs all new and interesting ones.

    Dealing with chronic issues is day to day for many of us. We wake up and wonder if the day will hold anything other than issues caused by our symptoms. If I am trying a new regiment of options I will need to wait to try them based on potential side effects or the dreaded unknowns. This prolongs my potential resolutions I might find from these options. But if I do not do this I increase my overall anxiety and loss of work or other work related issues based on those unknowns. We ride this roller coaster daily. Sometimes we have to get off and take a break, even if that break is at a place that still has us feeling miserable daily.

    I am curious about why more Dr’s do not “prescribe” for lack of a better word more exercise, I see FM’s doing this but rarely do I see conventional med Dr’s doing this, also equally important is stress management. The worst part about both of these is that they are easily the hardest to actually do for most to include me. But as you state tests and pills are not always or many times the answer. Where as diet and health are clear major life transitions that can lead to real long term results.I am very interested in how overall medical depression affects our overall health. I know I suffer from some sort of this as when you never really win, no matter how tough you might be it has negative effects.

    All this brings me back to the point of not hearing back possibly not meaning what you hope it does mean. When I visit Dr’s these days after years of visits and only minimal answers, while I want to be there and want to try to get more answers, I also do not want to be there at all sub concisely. And then when I am gone I try the suggested solutions and if i see little to know help I tend to revert. I am curious how many other patients might see this same reversion but if there is a way to break that to keep the patient better on track. Maybe the future of medicine is in the follow up, and the follow up would assist many in staying on track. I find humans in general can adapt to most things. Pain, suffering, death, natural disasters etc, its usually tomorrows news in a week or so after it happens. Much like nobody cares today what happened in Alaska the other day after a 7.0 earthquake I think many chronic suffers will continue to feel miserable as long as it is less miserable that last week. A plan to check back with patients is a double edged sword in FM I also feel as for some it might be a positive while others might view it as pushy sales tactics. All items to be evaluated. Since I can only speak for myself I would think if I was called back after a set course of time it would force me to do one of a few things, admit I suck and did none of the things asked for by the Dr., or actually admit to improvement, or kick me back into gear as I am in a chronic medical issue slump that I need help getting back out of and back on track.

    This all can be small parts of the Dr Patient relationship that is key to trusting Dr’s in general and thus trusting their decisions on plans to help each patient. Well that and a way to prescribe several other things like less stress, more exercise and the ability to stick to long term plans that do not have immediate results in some sort of easy to swallow pill form would be very helpful.

  5. Hi Dr Ruscio,
    Thanks for the great content.
    Quick q on the gut repair cocktail, i’ve not come across this in your book and therefore wondered what circumstances you may favor the use of this along with the other supplements?
    Thanks,
    Ed.

    1. My pleasure. I’ll be touching on this in a future podcast, but in short
      -I usually use gut repair cocktails end phase (after diet, probios, Habx…)
      -althought in some cases, especially those with non-GI symotms and/or histamine like reactions I have will occasionally use them earlier.

      In those responding to front-line therapeis, I wait and see if more support is needed. Or, in those who I feel need more, or would like to be more aggressive, I’ll use earlier.

      Hope this helps!

    2. My 2 cents. I have observed less die off reactions if use the “gut repair cocktails” prior to antimicrobials so have taken to starting them alongside diet and probiotics especially in the more severe cases..

      Dr. R – have you always called it a cocktail? It’s actually kinda hilarious – my patients are going to love it if I tell them I’m giving them a cocktail.. 🙂

  6. Hi Dr Ruscio,
    Thanks for the great content.
    Quick q on the gut repair cocktail, i’ve not come across this in your book and therefore wondered what circumstances you may favor the use of this along with the other supplements?
    Thanks,
    Ed.

    1. My 2 cents. I have observed less die off reactions if use the “gut repair cocktails” prior to antimicrobials so have taken to starting them alongside diet and probiotics especially in the more severe cases..

      Dr. R – have you always called it a cocktail? It’s actually kinda hilarious – my patients are going to love it if I tell them I’m giving them a cocktail.. 🙂

    2. My pleasure. I’ll be touching on this in a future podcast, but in short
      -I usually use gut repair cocktails end phase (after diet, probios, Habx…)
      -althought in some cases, especially those with non-GI symotms and/or histamine like reactions I have will occasionally use them earlier.

      In those responding to front-line therapeis, I wait and see if more support is needed. Or, in those who I feel need more, or would like to be more aggressive, I’ll use earlier.

      Hope this helps!

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