The Source, Winter 2000-01

Complementary Approaches to Intestinal Disease
by Daniel T. Wagner, R.Ph., MBA, Pharm.D.

The origins of many chronic health problems can be traced to compromised digestive function. Many functional bowel diseases may be caused by exposure to toxins (free radicals), intestinal permeability defects and/or parasitic infections. These common afflictions are associated with gastrointestinal dysfunction and may independently, or in combination, lead to a cascade of chronic illness.

There is a growing body of research showing that nutritional factors and lifestyle may play a significant role in the prevention and management of chronic disorders associated with compromised digestive function. If lifesytle and dietary changes do not effectively reduce symptoms, pharmacological therapy may be warranted.

Free radical destruction is a major health issue in our country today, although it is a hidden factor that cannot be easily measured and thus is rarely discussed when assessing parameters of health. We are all exposed to a litany of free radicals every day: chemicals, pesticides, pollution, stress, smoking, drugs, and the greatest of all, radiation. I am particularly concerned about the chemicals in our food (steroids, hormones, and antibiotics lace our meat, milk and eggs) and in our environment. Approximately 3,000 chemicals are used by the food industry during processing. Toxicity due to foreign chemicals, called xenobiotics, can damage virtually all organs and systems in the body. Unfortunately, the gastrointestinal tract is the most common route of exposure to these toxins and, as a result, the integrity of the mucosal barrier is a major factor in limiting absorption and elimination. Xenobiotic toxicity is manifested in short or over long periods of time by common symptoms such as immune suppression, liver disorders, fatigue, neurologic disturbances, and most commonly, dysbiosis (a common imbalance of the intestinal microflora due mainly to the typical "American" diet).

The Commonality of Dysbiosis

In spite of our best medical advancements with drugs and surgery, there is a disconcerting success rate regarding the standard medical treatments for the millions of patients who suffer with IBS, Crohn's, colitis, and chronic dysbiosis. One of the reasons for this problem may lie in the fact that these patients do not understand the dangers of xenobiotics, and they get very little information about nutrition and the best diet that will help to alleviate their dysbiosis.

Dysbiosis may be one of the most common health problems in America today. A healthy, physiological intestinal flora is very important for a healthy organism. An unhealthy digestive system function causes diarrhea, constipation, bloating, belching, rebound acidity or flatulence. The germs form toxins which may affect the liver, interstitial connective tissue and the immune system (growth of candida/yeast). The most important first step is to correct the pH, even before tackling the digestive problems.

Gastroesophageal reflux disease (GERD) is one of the most common chronic disorder of the upper gastrointestinal tract presented to primary care physicians and gastroenterologists. It has been stated that between 20-40% of the population suffers from monthly bouts with heartburn and GERD. Although mortality is low, morbidity can be significant. Most symptoms of this disease can improve or even disappear, although some patients with GERD may require lifelong therapy. It is incumbent for the pharmacist to play an interactive role in educating and managing this disease.

We are inundated with a barrage of commercials telling us to take antacids for an upset tummy, take Pepcid or Tagamet before eating spicy food that gives us indigestion, or get a prescription from your doctor at the first sign of heartburn. Doesn't anyone inform these people that these digestive problems are probably due to too much sugar, soft drinks, dairy products, caffeine, meat, alcohol, white bread, or chocolate, and NOT due to disease? If there is one simple rule of healthy eating it is this: get the acid OUT of our body and get the alkalinity IN! This simple rule of balancing the body's acid/base levels is so essential yet too often is ignored by indifference or masked by drugs.

Most definitely I am not underscoring the increased rate of intestinal disease, but can we seriously dismiss that many digestive problems are predicated on bad eating habits and not on inherited bowel disease? It would be a prudent observation to do so.

Many times indigestion and heartburn are not due to disease states, but they can result from eating too much or too little at one time or ingesting certain offensive foods. If food sits in the stomach for some time lack of hydrochloric acid may prevent the food from being properly digested, then the sphincter does not relax which can induce a back-up of chyme into the esophagus, where a low-pH will cause burning. The point is that many times the problem may be low acidity, not hyperacidity, which is usually the most common diagnosis made by a physician. Immediately antacids or H-2 antagonist drugs are prescribed which can worsen the condition by causing maldigestion which in turn, negatively affects the pH of the GI tract and may deteriorate intestinal health.

Causes and Protocols

Here are the five leading factors that contribute to dysbiosis, indigestion, reflux, and general gastrointestinal distress:

1. Stress is a frequent contributor to GI distress. Stress management with drugs, herbals, or via therapy (exercise, yoga, meditation, dancing, support groups, etc.) are encouraged.
2. Highly acidic (low pH) foods: soft drinks (colas), white sugar, red meat, white bread and flour products, alcohol, caffeine, spicy foods, dairy products, chocolate, and fats. Eating more alkaline foods (vegetables, fruits, some whole grains) are healing to the GI tract.
3. Antibiotics are a leading contributor to eradication of bowel flora. Although antibiotics are important therapy in treating severe infections, they unfortunately not only kill the "bad" bacteria in our gut, but also the "good" stuff. Taking acidophilus, bifidis, and other probiotic support (during the full course of the antibiotic and 5-7 days afterwards) will nearly guarantee that yeast and candida will not proliferate.
4. Eating large meals and late meals. Red meat especially causes high levels of acid (which can cause inhibition of HCl production to help digest the protein load) and causes a wasting of bicarbonate- the alkali buffer of the body. More fruits and vegetables, and less proteins and fats (which are more difficult to digest) can correct this problem.
5. Cigar and cigarette smoking.

A natural supplementation protocol for many intestinal problems (including IBS) would consist of the following:

1. An exclusion diet that may encourage eating more fiber. Psyllium husk is preferable (20-30 grams a day). Remember the golden rule of fiber- fiber only exists in plant foods; there is absolutely NO fiber in any form of meat, milk or dairy, seafood or eggs. Increased fiber may be contraindicated in patients with diarrhea.
2. Identify food allergies or sensitivities. Food allergies are highly common in America today, and they are infrequently recognized by the medical doctor. The best and most non-invasive means is to try an Elimination Diet for two weeks to see if any particular food group is giving you problems. The most common groups of allergic foods are: dairy products, wheat and gluten, eggs, sugar, citrus, nuts and soy.
3. Add acidophilus/FOS to your diet to aid in the integrity of the microflora of the bowel. Two or three teaspoonfuls a day is very beneficial.
4. Try taking digestive pancreatic enzymes (bromelain or papaya) 10-20 minutes before ingesting large meals to aid in digestion and decrease inflammation. These simple and safe enzymes work wonders in helping your food digest more naturally.
5. Carminative herbs have an antispasmodic effect on the GI tract, and they can help relieve gas, improve digestion and bile flow. The most effective and common carminatives are chamomile, fennel, ginger and peppermint.
6. Sedative or nervine tonic herbs, including valerian and St. John's wort.

Other helpful recommendations for specific and ongoing problems.

• Deglycyrrhizinated Licorice (DGL) helps in healing ulcers at doses up to 760mg 3 times a day, however, licorice may increase blood pressure.
• Betaine HCL with meals aids in protein digestion and reduces food sensitivities through proper digestion, especially when low stomach acid is the problem.
• Buffered vitamin C at doses of 500-3000mg per day can do wonders in settling down an active and spasmodic stomach. It also helps to alkalize the GI tract.
• Aloe vera juice can aid in constipation and acts as a mucilage which helps to coat the mucous membranes of the esophagus, stomach, and intestines for better elimination. Aloe vera also has significant healing powers on the body.
• Magnesium at doses of 200-500 mg per day can help with relaxing the smooth muscles around the stomach and GI tract. Magnesium also aids in constipation.
• A mild laxative like Senna may be indicated for constipation. Eating more fiber and drinking more water is crucial.

With the increasing rates of morbidity and mortality from degenerative diseases there appears to be a toxicological as well as a gastrointestinal explanation. A prudent approach to this problem may be twofold. A comprehensive approach to the management of these disorders with medicines and surgery is still the mainstay of treatment, however, a more non-invasive approach including modification of diet, lifestyle, environment and supplementation may also be required. Integrative medicine recognizes both and finds a medium for the patient to begin healing. The main point is that there may be no ONE treatment protocol for a disease, because each patient is different. Individualizing treatment for the patient with a disease, and not treating the symptoms of a disease that has inflicted a patient, should be the goal of integrative and a more holistic style of medicine.

Inflammatory Bowel Syndrome and Common Diseases Associated With IBS

Irritable bowel syndrome (IBS) is a common but chronic, relapsing gastrointestinal disorder that negatively affects the motility of the small intestine and large bowel. It is associated with variable degrees of abdominal pain, constipation, diarrhea, nausea, dysphagia, urinary urgency, indigestion, spastic colitis, mucous colitis, intestinal neurosis, and largely as a reaction to stress in a susceptible individual. The major manifestations to trigger IBS events are discrete episodes of gastroenteritis, courses of antibiotics, and food allergies or sensitivity such as lactose malabsorption. IBS afflicts up to 20% of the general population, although only 25% of this group seek help. It appears to affect 3 times more women than men.

Diagnostic procedures can be quite extensive and painful. Ask anyone who has been through a colonoscopy, procosigmoidscopy, barium enema or rectal biopsy.

Ulcerative colitis and Crohn's Disease are collectively known as inflammatory bowel disease, or IBD. Although the two illnesses are related, they have distinctive features. Ulcerative colitis is characterized by chronic mucosal inflammation of the rectum and large intestines that usually occurs with acute symptoms. Bloody diarrhea is the most prevailing symptom accompanied by pain and fecal urgency. Crohn's Disease is a chronic transmural inflammation (i.e., cells throughout the wall are affected) involving any or every part of the gastrointestinal tract.

The exact etiology of these diseases is unknown, however both diseases are thought to be auto-immune in nature. Other factors include genetics, immunopathology and infection. Tissue injury associated with inflammation, as in the case of ulcerative colitis, has been linked to tissue damage sustained through the inflammatory process. Inflammation is usually initiated by the presence of an antigen that may be chemical or biological in nature.

Because both diseases are inflammatory responces, it stands to reason that anti-inflammatory agents would be the primary treatment. The first-line of therapy is aminosalicylates (Azulfidine). If they prove ineffective, second-choice therapy is corticosteroids. Immunosuppressive agents such as azathioprine and cyclosporin can be used in the case of corticosteroid dependency.

Nutritional approaches can be a major factor in helping the patient cope with the seriousness and potential crisis of their disease. It has been proposed that if absorbable carbohydrates are not consumed (complex carbohydrates, not refined), colitis might be exacerbated because colonocytes will be deprived of their primary energy source: short-chain fatty acids. These fatty acids might be beneficial in the topical treatment of distal colitis. Fish oils, or eicosapentaenoic acids might be effective in ulcerative colitis because they divert arachidonic acid metabolites away from pro-inflammatory leukotrienes to ones that are less inflammatory. The benefits of essential fatty acids is well documented although more long-term clinical studies are needed.

Treatment form a holistic point of view can include: modifying the diet, identifying allergies, decreasing refined sugar intake, supplementing with friendly bacteria, and identifying and treating psychological factors.

Diet modification for IBS or IBD through the eyes of a conventional doctor usually involves increasing dietary fiber. This can be helpful, however wheat in wheat bran (the most commonly ingested fiber) is also the second most allergic food. People suffering from constipation can benefit from increasing their daily water intake and increasing fiber in their diet, but fiber may adversely affect those with diarrhea. B-complex vitamins may be supplemented to help proper absorption and restore proper muscle tone. B vitamins also help the body deal with stress, an important contributor to IBS. Garlic also aids in digestion and destruction of toxins in the colon. Aloe vera juice has shown to elicit a healing affect on the digestive tract.

Food allergies, sensitivities, and intolerance are important factors in IBS and IBD. Identifying, desensitizing and eliminating the offending food can be key ingredients to controlling and minimizing the negative symptoms. Recent studies reveal that a majority of IBS sufferers have at least one food allergy and some have multiple allergies. The most common allergies are dairy products, wheat and sugar. Other foods that trigger symptoms include onions, chocolate, yogurt, coffee, citrus, barley, oats and corn. By taking the time to notice which foods aggravate the patient's symptoms, a very positive effect can be measured.

Summary

Irritable bowel syndrome and disorders adversely affect quality of life. The lack of a marker for the illness can hinder diagnosis and performance of clinical studies to evaluate the efficacy of drug therapies. The efficacy of current available drug therapies is limited. Innovative alternative and natural approaches are a valuable adjunct in the treatment of intestinal problems and diseases. The role of diet, psychological factors, food sensitivities and allergies, fiber, carminative herbs, vitamins, and acidophilus should not be undermined by the medical community simply because it is not "accepted" protocol.

The pharmacist is well-positioned to screen patients with symptoms of irritable bowel syndrome and encourage an appropriate course of action in seeking professional help. Providing pharmaceutical care to these patients can improve treatment outcomes, but also providing integrative approaches to treatment can improve not only symptoms but quality of life.

References

AphA. Special report: treatment innovations for irritable bowel syndrome. Brochure for continuing education for pharmacists, 2000.

Barilla, J. The balance of the bugs. Better Nutrition, Oct. 1999. pp. 54-58.

Bone, K. Phytotherapy and irritable bowel syndrome. British Journal of Phytotherapy, Vol. 4, No. 4, pp. 190-198.

Drossman, DA. Irritable bowel sydrome. Intestinal Fortitude, Vol. 10, No. 1, 1999 pp. 1-3.

Leaky gut syndrome. Managing the cascade of health consequences. Tyler Inc.,1998.

Lebovitz, PJ. Complementing traditional medical options for patients with IBD. Crohn's & Colitis Foundation of America, lecture, May 6, 2000. Pittsburgh, PA.

Mesbahi M, Louie SL, Gill MA. Treatment of ulcerative colitis. U.S. Pharmacist, May 2000, pp. HS35-45.

Smith C. Astroesophageal Reflux Disease. U.S. Pharmacist, Dec. 1999, pp. 77-87.

Starbuck, J. Treating children's intestinal problems. Nutrition Science News, Oct. 1998, Vol. 3, No. 10, pp. 544-550.

Van den Bossche, J. Irritable bowel syndrome. Alive #205, Nov. 1999, pp. 26-27.

Dr. Dan Wagner is a natural and clinical pharmacist and herbalist from Pittsburgh, PA. He owns "NutriFARMACY" - Western Pennsylvania's only all-natural pharmacy. In 2000 his natural pharmacy practice was awarded the Dupont Pharmaceuticals "Innovative Pharmacy Practice of the Year Award.". Dan does extensive research on plant medicines in the rain forests of Africa and Central and South America. He integrates his passion for natural medicine by selling quality herbs and supplements, coupled with professional consulting on the use and misuse of drugs/herbs/vitamins/nutrition. Visit Nutri-farmacy's website at www.nutrifarmacy.com for more articles and information, or call toll-free 1-877-289-7478.

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