Complicated Gut Patient

This week in our clinical discussions, where we meet and talk about case studies, we discussed a gut refractory case. It is vital in our community to be able to discuss complex cases such as this one. Keep reading to get a glimpse into our discussion. (Want to join our Incubator community? Click here to learn more.)

Gut-Based Patient

In general, if you have a patient with gut-based inflammation, you have a good feel for some ways to get started—various probiotics or glutamines and different anti-inflammatories for the gut. However, what if your go-to strategies aren't working as you would expect them to? Where do you go next, even in terms of what kind of testing comes next?

Symptoms and Test Results

In this gut refractory case, we discussed a female who had ongoing watery diarrhea. She had had a colonoscopy, ruled out IBD, and was left with even more vagueness in terms of actual diagnosis. 

In our discussion of this patient, we first covered general inflammation of the gut. Stool testing had been done, and when the test result returned and was reviewed, even though her watery diarrhea started after a particular event in time that required antibiotics for gut-based pain and diarrhea, what we were expecting to see would be potentially a pathogen that was undertreated. However, the stool test did not really note a lot of pathogenic bacteria or yeast or parasites, but there were other markers that were positive. Things like secretory IgA, for example, were extremely high. Well, that's the immune marker of the gut, which goes up when the immune system is reacting, usually to some type of infection. In addition to that, calprotectin was up, which tells us about gut-based inflammation, as does lactoferrin. And we begin to produce more lactoferrin, when we're fighting, usually bacteria. So, all of these, point to some type of infection and immune activation that would create inflammation. Yet, there was the absence of an actual pathogen on the stool test. So, we discussed that, and what that can mean.

Treatment

Continue reading for our discussion of treatment.

Resting the Gut

Based on the watery diarrhea and the way things presented, we decided that we just needed this gut to take a rest. And so we talked about, for example, an elemental diet. And again, sometimes when you're getting started, you've heard of these issues, but the actual implementation you haven't worked with yet and so just having some guidelines helps. 

We discussed if you want to use the elemental diet for more intermittent fasting and what that might look like for five days, or if you want to use it more as therapy, which is going to require more scoops. For example, if you want more of a fasting schedule, you would really only be looking at two scoops, three times a day for five days; however, you're doubling that if you're using it more as a meal replacement and not concerned with fasting. Then we talked about things that could be added to it to give it a little more calories and give people more satiety while they're getting through it and tips in terms of what makes it taste a little better. All of these things matter as we're getting started and can feel overwhelming especially when we don't have someone who's done it before and can walk us through it. So, we discussed how that as a way to rest the gut. 

Supplements

We talked about various supplements that serve as demulcents that will build the lining, and then why this presentation looked like a potential FOD-MAP patient. Every time she had sugar, even fruit, there was a level of reaction. So, fructo-oligosaccharides (FOS) seemed to be something that she was not breaking down well, and we discussed the sugar connection, some of what that means, and then how do we work with somebody like this. 

We discussed various antimicrobials that would be appropriate, and then about how Berberine would make a lot of sense for this patient. Not only was there an elevation of neutrophils, along with an increase of MPO, which can be indicative of bacteria, but also there was this elevation of secretory IgA and this feeling better after an antibiotic in the past, all clinically building the picture of some undertreated bacteria, even though it's not showing up on the stool test present. 

There were some other various markers this patient had some issues in terms of LP(a) and insulin. Since Berberine helps in those areas as well, we found this to be a good choice as a broad-spectrum antimicrobial that we can expect to improve diversity and deal with dysbiosis, and at the same time, deal with some of the cardio-metabolic issues she was having. We discussed that importance of improving diversity; some choices out there have as many as 18 strains in them. 

We talked about the importance of immunoglobulins really supporting the local immune system of the gut, but also walling off bacteria and directly dealing with the symptom that this patient was having, which was diarrhea. Immunoglobulins, like IG 26, are so effective in terms of decreasing diarrhea. 

Other Issues

Then what do we do about this patient’s energy issues? We've got to really double down on multi, making sure things are getting in. Then we discussed some of her poor insulin response and what might be done around that as well. 

Finally, there was an early a.m. elevation of cortisol. The rest of the time her cortisol was normal. So, we talked about how that a.m. stress response could be contributing to her loose stools. In fact, morning was her worst time of the day. 

Conclusion

This patient presented us with another opportunity to walk through this complex case and see what the next steps would be that weren't redundant or previously tried and how a lot of the components in her whole picture really fit together to help move her forward and help us know how to move her forward. 

These are the kinds of topics that we discuss every week during our clinical curriculum piece. I really have a lot of fun with that, and I hope to see you there soon. 

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