October 17, 2017 at 12:52 pm #1354Elizabeth CooperParticipant
Hi, I have a 34-year-old client who had his colon removed in 2007 due to ulcerative colitis. In 2008 he had an ileostomy and the formation of an internal J-pouch. Since then he’s had trouble managing the J-pouch and has experienced loose stools and abdominal pain daily. He has taken a lot of antibiotics and has a prescription to get more when symptoms are particularly bad. Since coming to see me there has been significant improvement due to the removal of dairy. However, my client has struggled to give it up completely and is still eating dairy fairly regularly, which is causing symptoms but not consistently. Therefore, he decided to do a Cyrex cross-reactive foods test and despite reintroducing dairy every day prior to the test everything came back negative. I therefore thought it may be lactose intolerance but low lactose foods like parmesan and Greek yoghurt cause a return of his symptoms, so I’m puzzled. He also did a stool test and several of the firmicutes came back low – clostridium spp, pseudoflavonifractor spp., roseburia spp., ruminococcus spp., Lactobacillus was NG, E.coli was 1+ and bifidobacterium was 4+. There was a small amount of candida albicans at 1+ but NP. Parasites was negative. Any light you can shed on this and any supplements that may help would be gratefully received. Thanks
Posted By Elizabeth Cooper 10/17/17
March 20, 2019 at 12:54 pm #1355Carrie Decker, NDModerator
Thank you for posting this case here. It is unfortunate that despite the severity of this man’s gastrointestinal symptoms and observations of his own sensitivity to dairy that he continues to expose himself. Because of the many possible substances we can react to in foods, an elimination diet is often considered the best way to determine food reactivity. This man has basically done this, at least with dairy, and going forth has awareness that he should eliminate it, yet is unwilling to do so.
The one thought I would have concerning the reaction is that in addition to lactose, histamine may be contributing to his symptoms. Histamine is found at higher levels in aged and fermented foods like parmesan and yogurt as well as dried fruit, cured meats, and vinegar-containing foods. Histamine levels in foods also increase the longer foods are stored as it is a process of microbial fermentation and spoilage. The enzyme, histaminase, which breaks down food-derived histamine is produced in the intestinal mucosa. As this cellular layer is often damaged in inflammatory bowel disease (IBD), it is not surprising that histamine intolerance also happens to be more common in this population. The brush border lining the gut also is the location of lactase which breaks down lactose so it wouldn’t be surprising if he is reacting to non-aged or fermented dairy due to brush border damage as well.
Maintz L, Novak N. Histamine and histamine intolerance. Am J Clin Nutr. 2007 May;85(5):1185-96. https://tinyurl.com/jm8ylwu
Biegański T, et al. Distribution and properties of human intestinal diamine oxidase and its relevance for the histamine catabolism. Biochim Biophys Acta. 1983 Mar 31;756(2):196-203. https://tinyurl.com/y9n8xl7b
Qin XI, Chong WA, ZHENG L, Bing-yan TA. Determination of histamine in the fermented food by HPLC. Science and Technology of Cereals, Oils and Foods. 2012;2:012. https://tinyurl.com/y7ew9yd3
Healing the gut and supporting restoration of the brush border should be a primary consideration for someone with IBD, which obviously is what you are trying to work on him with. However, there may be some sort of disconnect in his brain as he does not understand these aspects of physiology as well, despite his disease-related complications. When he continues to eat foods which cause symptoms, inflammation and related damage is inevitably occurring in the gut. So, despite your attempts to repair or address the problem it will be difficult to shift it to a healthier state. That said, working with substances which support gastrointestinal repair, the reduction of inflammation, and the breakdown of foods may help somewhat and are all things to consider.
Epithelial Growth Factor (EGF) is a polypeptide that stimulates growth and repair of epithelial tissue such as the oral mucosa and gastrointestinal epithelium. EGF is a normal constituent of saliva production during the act of eating, is also secreted into the gut lumen and found in colostrum and milk. Salivary EGF also upregulates small intestinal absorption of electrolytes and nutrients. Michael Ash has written more about the use of epithelial growth factor in the resource “Epithelial Growth Factor for Reduced Gut Permeability / Pathogen Attachment and Nutrient Uptake” which can be found here – http://tinyurl.com/qf2qbr6. Glutamine has been shown to support integrity of intestinal permeability, as well as slippery elm powder, and N-Acetyl-D-Glucosamine.
van der Hulst RR, et al. Glutamine and the preservation of gut integrity. Lancet. 1993 May 29;341(8857):1363-5. http://tinyurl.com/nrpkbcs
On a long-term basis, butyrate may be helpful. Butyrate has been shown to promote healthy large intestinal flora and protect the mucosa from mechanical and chemical damage, as well as improve tissue integrity. Unfortunately, butyrate does have a poor smell. Some feel that this is improved by keeping the supplement in the freezer, although as the smell may lead to poor compliance it may not be something you chose to start with. A thorough article about the use of SCFAs for the management of colonic inflammation has been written by Michael Ash, and can be found on the Nutri-Link Clinical Education website: http://tinyurl.com/odk2g3u.
Supporting your client in the development of normal immune tolerance also is an important part of working with people who have autoimmune disease. As a part of a food-based support protocol, you may want to include probiotics via the stewed apple formula developed by Michael Ash that supports mucosal immune tolerance. The combination of probiotics in here also will help to shift the flora of the gut back to a more healthy and balanced population. More information about how stewed apples in combination with probiotics support mucosal healing and tolerance (as well as the recipe) can be found here – http://tinyurl.com/o9kpezx.
Although a digestive enzyme is no longer available for histamine degradation, a comprehensive digestive enzyme still may help reduce this man’s reactivity to foods. During the process of gut repair, I would recommend including it with all meals that contain foods this man questions if he is reacting to. For some, it is easier to just include it with all meals for a period of time.
Avoiding high histamine foods also should be recommended. The topic of histamine intolerance has been covered very extensively both on the Clinical Education website (https://tinyurl.com/hezm7p8) as well as in the NutriGold nutritional news (https://tinyurl.com/ybe6cjb6). In these discussions, the topic is discussed very extensively including the contributing factors and supplements that may be helpful in reducing the symptoms of histamine intolerance.
The following supplements are suggested for you to consider in light of your relevant expertise and understanding of the needs of your client or patient. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for.
Perm A Vite® (ARG): Gradually increase to 1 Tbsp daily mixed in liquid 20 minutes before meals. Contains L-glutamine and epithelial growth factor (EGF). http://tinyurl.com/37dv2cl
Butyrate (BB): 1 – 2 capsules with meals twice daily. https://tinyurl.com/keyrqz5
Digestive enzyme to consider before meals:
Full Spectrum Digest (ARG): 1 capsule shortly before meals. http://tinyurl.com/p4p65vh
For probiotics you may wish to include one of the following or all with the stewed apple recipe:
Lactobacillus GG (ARG): 1 capsule daily with small amount of food. http://tinyurl.com/mcdcpv3
Saccharomyces Boulardii (ARG): 1 capsule daily with small amount of food. http://tinyurl.com/35392bw
BifidoBiotics (ARG): 1 capsule daily with small amount of food. http://tinyurl.com/35pq3h4
Please consider these suggestions in light of the other clinical information pertaining to this individual. If you have any more information about the specific problems this individual is experiencing, further refinement of these suggestions may be considered. I hope this information is helpful, and if you have any further questions or information specific to the problems this individual is experiencing, please do provide feedback.
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