Practitioner Case Study – October 2019

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

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Case Study

GI Retesting Looked Worse In A Case Where Symptoms Cleared, & Blood Markers Improved After Clearing GI Symptoms

Patient Info:

  • Radul, 32y/o, Male
  • Previous Dx
    • High blood pressure
  • Rx
    • n/a
  • Chief complaints
    • Gas – flatulence + belching
    • Bloating
    • Stomach pain
    • Insomnia (trouble falling asleep)
    • Skin inflammation

Visit 1 (day 1) – History and Exam:

Initial impression

  • Radul presents as a generally healthy 32yo male who has a good diet (AIP) and lifestyle.
  • Dx/Rx:
    • Dx: High blood pressure
    • Rx: n/a
  • Previous testing:
    • n/a
  • Onset:
    • Has a history of antibiotic use, constipation, and hemorrhoids. His symptoms started when going vegetarian and under lots of stress. They responded very well to Autoimmune Protocol (AIP) but he still has some lingering problems.
  • Family history
    • High blood pressure
  • Prior Treatments:
    • Less exercise and more sleep/meditation help.
    • Amino acids – made him bloated.
    • Probiotics – helped but may bloat him.
    • Paleo/AIP helped a lot.
  • Notes/DDx
    • Stomach pain may indicate ulcer – monitor the use of HCl.
    • Radul is also eager to dial in his carbs (amount, type) for GI symptoms and for body comp. This will be easier to elucidate after addressing any GI imbalances.
    • I anticipate typical imbalance (SIBO/dysbiosis) will be found and he will respond well to treatment.
  • Prognosis
    • Good to excellent

Previous diets:

  • Paleo/AIP – helpful, though some symptoms remain
  • Vegetarian – made it worse
  • Some foods bloat him

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

Testing

  • Tests ordered
    • CBC w/ differential, CMP, lipid panel
    • TSH, Free T4
    • Aerodiagnostics Lactulose SIBO breath test
    • Doctors Data Comprehensive Stool Analysis w/Parasitology x3
    • Optional: Diagnostechs GI:15 stool/saliva test
  • Rationale
    • Standard GI workup for SIBO and dysbiosis. 2 stool tests likely not needed, this case study was from a few years ago when I was recommending more testing
    • Standard blood chem workup, no suspicions, just a general check.

Recommendations

  • Diet:
    • Try eating more carbs before bed and see if this helps with sleep. If this doesn’t help try eating fewer carbs before bed and see if this helps.
    • Perform modified fast.
    • Next, continue with AIP reintroduction and start on a low FODMAP diet.
    • After a few weeks on whole foods, try the semi-elemental diet using the modified fast instructions as a guide.
  • NRT: Vitamin D, Magnesium
  • Adrenal: Plant-based adrenal support
  • GI: Lacto-bifido probiotic, boulardii, Digestive Enzymes
  • Note: After a couple of weeks, add in Betaine HCl and see how you feel.
  • Follow Up: Schedule once all labs are in.
  • Rationale
    • Will experiment with various carb intakes impact on sleep
    • Move from AIP to low FODMAP – might be better for GI
    • Will start with probios + enzymes and HCl, then layer in higher dose HCl to evaluate the impact

Visit 3 – Lab Interpretation and Treatment Evaluation

Subjective Assessment:

  • Better overall, but still not perfect.
  • Lacto/bifido probiotic, boulardii, and adrenal supplement all helpful.
  • Betaine HCl upset stomach – even 1 cap
  • Did not try elemental yet, will try next
  • Improved:
    • Sleep (eating carbohydrates before bed helped)
    • GI Symptoms (low FODMAP and lower-carb have helped)
  • Same:
    • n/a
  • Worse:
    • n/a

Lab interpretation:

  • Outside Labs:
    • Cholesterol 6.8-H, HDL 2.01-H, LDL 4.59-H
    • Creatinine 118-H, Gamma GT 506-H, Creatine Kinase 636-H
    • Platelets 139-L, Lymphocytes 3.4-H
    • TSH and Free T4 within normal limits
  • Aerodiagnostics SIBO breath test:
    • H2 10, CH4 3
  • Doctors Data:
    • Numerous commensal overgrowths, 1+ Candida albicans, occult blood.
    • All IBD/functional markers within normal limits.

Impression:

  • Radul is improving from diet and program – more treatment may not be needed. It was helpful to increase carbs, decrease FODMAPs and initial program. But betaine HCl aggravated the stomach. Decided on an aggressive approach; starting herbal antibiotics base with liver support and antioxidants.
  • Potential mild distal mixed SIBO (NOTE: I no longer would classify this as such*)… Potential (platelet ddx); free radical damage, infection (viral, rickettsia, bacteria)
  • Radul most likely has minor GI imbalance (potential SIBO, Candida) which will respond well to standard therapy. Since he is young and generally healthy the low platelets are likely from oxidative stress or are inconsequential but will retest after completing GI work.

Recommendations

Continue:

  • Probiotics, digestive enzymes, adrenal support, vitamin D, magnesium

New:

  • GI: Herbal antibiotics base protocol, liver/gallbladder support
  • NRT: Immune/liver support supplement
  • Discontinue betaine HCl

Follow up: 4-5 weeks


Visit 4

Subjective Assessment:

  • Semi-elemental diet – was constipated and slightly bloated, but helpful after, bloating is decreased. Felt very hungry on the modified bone broth fast. He has noticed some high FODMAP foods bother him.
  • Improved:
    • Bloating, gas, GI discomfort
    • Sleep
  • Same:
    • Fatigue
  • Worse:
    • n/a

Impression:

  • Radul continues to improve with the addition of herbal antibiotics. The semi-elemental diet also seems helpful. Today ending herbals, starting melatonin, and will have him continue the foundational program, then f/u in 1-2 months and decide on retesting, program curtails and/or additional treatment.

Recommendations:

  • Continue:
    • Probiotics, digestive enzymes, adrenal support, vitamin D, magnesium
  • New:
    • Diet: Consider using a semi-elemental diet as a method to increase calorie intake as well as for meal replacement for intermittent fasting.
    • NRT: melatonin, as needed
  • Discontinue:
    • Liver/gallbladder support, immune/liver support, herbal antibiotics
  • Follow Up: 4-8 weeks

Visit 5

Subjective Assessment:

  • Feeling much better. It’s been months since the last food reaction. Melatonin is helping with sleep. FODMAP reintroduction had some limitations.
  • Improved:
    • Bloating, gas, GI discomfort
    • Sleep (still occasional insomnia)
    • Fatigue
  • Same:
    • n/a
  • Worse:
    • n/a

Impression:

  • Radul is going great and has maintained all previous improvements. Sleep is not perfect, however. Will start on Pregnenolone/DHEA now for additional energy support, and will retest and then follow up. Will start the program and plan to curtail at follow up.

Tests Ordered:

  • CBC w/ differential, CMP, lipid panel
  • TSH, Free T4
  • Doctors Data Comprehensive Stool Analysis w/Parasitology x3

Recommendations:

  • Continue:
    • Probiotics, digestive enzymes, adrenal support, vitamin D, magnesium
  • New:
    • Adrenal: Pregnenolone/DHEA (1-3 months)
    • Sleep: Try up to 12 mg of Melatonin for nights when it’s hard to sleep. If something stronger is needed, try OTC Unisom.
  • Follow Up: 1-3 months, after re-testing has been performed.

Visit 6

Subjective Assessment:

  • Still feeling well and doing great overall. Certain carbs can aggravate the gut.
  • Improved:
    • Bloating, gas, GI discomfort
    • Sleep
    • Fatigue
  • Same:
    • n/a
  • Worse:
    • n/a

Lab interpretation:

  • Outside Labs:
    • Mostly normalized. Normalization of: platelets, creatinine, creatinine kinase, GGT
    • Abnormal/High: Lymphocytes, Total cholesterol, LDL, LDL/HDL ratio 4.6 (average: 4.4)
  • Doctors Data:
    • Less commensal dysbiosis, but now has 1 dysbiotic bacteria present.
    • 1+ Candida albicans now cleared.

Impression:

  • Today’s labs show GI that might have worsened, but hard to say. Blood labs have mostly normalized other than lymphocytes, total cholesterol, LDL, but LDL/HDL ratio is good (4.3).
  • Radul has maintained improvements and is sleeping even better now with mindfulness practice. Today will start on Selenium and CoQ10 as cardio prevention (Radul is concerned due to family history). Will work to curtail the program.

Recommendations:

  • Continue:
    • Adrenal support, vitamin D, magnesium
  • New:
    • Experiment with lacto/bifido probiotic and boulardii on/off as needed.
    • Cardio health: Selenium, CoQ10
  • Discontinue:
    • Pregnenolone/DHEA, melatonin, digestive enzymes.
  • Follow Up: 2-4 months

Dr. Ruscio’s Comments

  • Simple case of treating dysbiosis.
  • Doctors Data GI labs might have been considered worse (he went from no dysbiotic organisms positive to 1 positive at retest even though symptoms improve. This showcases caution with treating labs only.
  • Bloodwork imbalanced mostly cleared after GI work, mostly a bit of noise remained on lipid panel that was not concerning in aggregate

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!

12 thoughts on “Practitioner Case Study – October 2019

  1. I have a patient whom I’d like to recommend start an antimicrobial protocol. She has tested positive for SIBO in the past and felt best while taking rifaxamin. She has a tree nut allergy and in the protocol in your book,1b, 2a, ‘and 2b all contain black walnut hull. Are there other products you would recommend in the case of a tree nut allergy? She is already doing probiotics, tried many diets, and didn’t have success with digestive enzymes. Thanks!

    1. Hi Jamie,

      If you check on page 278 of the book in the orange “gut geeks” box, you’ll see his alternative recommendations: berberine, allicin, and atrantil. Hope this helps!

  2. I am working with a young lady with a history of anorexia nervosa. Her GI symptoms include gas, bloating, diarrhea, abdominal pain. Her appetite is suppressed. Her zinc levels are very low and I know this is incredibly important in digestion, hunger cues, and the psychiatric symptoms of anorexia nervosa. Oral supplements haven’t even budged her blood levels. I’m working on getting her an IV infusion. We have been working through the first steps with dietary changes, but I’m treading very lightly due to her history. I am a psychiatric NP so I don’t feel out of my league here, but just cautious about telling to avoid certain foods as it may trigger disordered eating behavior. She is working with a therapist as well. Digestive enzymes have helped some and I have jumped ahead including spore based probiotics. I guess my biggest question is around antimicrobials. I think we need to do them based on the continued GI symptoms not improved by diet. Her parents are hesitant about the cost and they’d like to explore prescription options. I am encouraging the broad spectrum antimicrobials as they cover so many of the bases, as opposed to the prescriptions. My question is, if we don’t do the antimicrobials then what about just sticking with the probiotics longer? Microbiome labs has some interesting protocols combining a few different kinds, but it’s six months long….

    1. Great questions. This probiotic only approach can work as evidenced by some of the case studies I’ve published here. I would use all 3 of our probiotics together, this can be power and is evidenced-based. Hope this helps.

  3. Good case, it illustrates the value of paying attention to overall clinical picture and not getting hung up on single lab markers. I would like to ask about the DHEA/pregnenolone you put him on. Do you typically test these levels before treating or, because this was short duration and he is young, you felt comfortable with a trial of these? Also, can you comment on the dose of melatonin? Thank you

    1. Thanks. I never test any more. If you can point me to one study which has shown testing is required, I’m happy to look. My candid take is testing for adrenal support is a carry over from the last generation of FM docs that is simply unnecessary at current. Melatonin was either 1mg or 3mg capsules, no strong thoughts on dose.

  4. Good case, it illustrates the value of paying attention to overall clinical picture and not getting hung up on single lab markers. I would like to ask about the DHEA/pregnenolone you put him on. Do you typically test these levels before treating or, because this was short duration and he is young, you felt comfortable with a trial of these? Also, can you comment on the dose of melatonin? Thank you

    1. Thanks. I never test any more. If you can point me to one study which has shown testing is required, I’m happy to look. My candid take is testing for adrenal support is a carry over from the last generation of FM docs that is simply unnecessary at current. Melatonin was either 1mg or 3mg capsules, no strong thoughts on dose.

  5. I have a patient whom I’d like to recommend start an antimicrobial protocol. She has tested positive for SIBO in the past and felt best while taking rifaxamin. She has a tree nut allergy and in the protocol in your book,1b, 2a, ‘and 2b all contain black walnut hull. Are there other products you would recommend in the case of a tree nut allergy? She is already doing probiotics, tried many diets, and didn’t have success with digestive enzymes. Thanks!

    1. Hi Jamie,

      If you check on page 278 of the book in the orange “gut geeks” box, you’ll see his alternative recommendations: berberine, allicin, and atrantil. Hope this helps!

  6. I am working with a young lady with a history of anorexia nervosa. Her GI symptoms include gas, bloating, diarrhea, abdominal pain. Her appetite is suppressed. Her zinc levels are very low and I know this is incredibly important in digestion, hunger cues, and the psychiatric symptoms of anorexia nervosa. Oral supplements haven’t even budged her blood levels. I’m working on getting her an IV infusion. We have been working through the first steps with dietary changes, but I’m treading very lightly due to her history. I am a psychiatric NP so I don’t feel out of my league here, but just cautious about telling to avoid certain foods as it may trigger disordered eating behavior. She is working with a therapist as well. Digestive enzymes have helped some and I have jumped ahead including spore based probiotics. I guess my biggest question is around antimicrobials. I think we need to do them based on the continued GI symptoms not improved by diet. Her parents are hesitant about the cost and they’d like to explore prescription options. I am encouraging the broad spectrum antimicrobials as they cover so many of the bases, as opposed to the prescriptions. My question is, if we don’t do the antimicrobials then what about just sticking with the probiotics longer? Microbiome labs has some interesting protocols combining a few different kinds, but it’s six months long….

    1. Great questions. This probiotic only approach can work as evidenced by some of the case studies I’ve published here. I would use all 3 of our probiotics together, this can be power and is evidenced-based. Hope this helps.

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