Digestive Wellness: Strengthen the Immune System and Prevent Disease Through Healthy Digestion, Fourth Edition (118 page)

Take calcium-magnesium citrate.
Anecdotally, many people have found that calcium-magnesium supplements prevent or alleviate the muscle spasms associated with IBS. Take 500 to 1,000 mg calcium, and 300 to 750 mg magnesium. Be aware that too much magnesium will cause diarrhea.

Inflammatory bowel diseases (IBD) include four distinct illnesses: ulcerative colitis, Crohn’s disease, microscopic colitis (lymphoid and collagenous), and ischemic colitis. Each of these diseases has slightly different characteristics, although the treatment for all of them is aimed at reducing inflammation. IBD affects one million
to two million Americans; ulcerative colitis rates are about 2 people per 1,000; and Crohn’s disease rates are about 1.7 per 1,000. Rates have risen since 1940 and are rising in other parts of the world where Western diets are becoming the norm. Most cases are diagnosed before age 40. IBD tends to run in families and is more prevalent among people of Jewish descent. There is a higher incidence of IBD in women who take oral contraceptives. Women with a history of IBD or with a family history of IBD may want to choose a different form of birth control.

In all types of IBD, looking for underlying causes or triggers is important. Using the DIGIN model can be extremely useful.

IBD shares many of the symptoms of IBS, but they are very different problems. IBD involves inflammation of the digestive tract, which can occur anywhere from the mouth to the rectum. Malnutrition and malabsorption are common in people with active IBD. Symptoms include abdominal pain, bloody diarrhea, and cramping. If you are having these symptoms, go see your physician. These symptoms may also be accompanied by fever, rectal bleeding, abdominal tenderness, abscesses, constipation, weight loss, awakening during the night with diarrhea, and a failure to thrive in children. Symptoms come and go and can go into remission for months or years. About half of the people with IBD have only mild symptoms. People with IBD often develop complications, which include inflammation of the eyes or skin, arthritis, liver disease, kidney stones, and colon cancer.

IBD is considered an autoimmune disease (your body begins attacking itself). The causes are many and have produced much debate. Current theories suggest that Crohn’s and ulcerative colitis have a genetic component, which is triggered to a greater or lesser extent by either infection, a hypersensitivity to antigens in the gut wall, an inflammation of the blood vessels that causes ischemia (a lack of blood supply to the tissues), or food sensitivities. The genes known to be associated with Crohn’s disease include NOD2 (also known as CARD15), ATG15L1, IL23R, and IRGM, which all have to do with innate immunity. The NOD gene apparently gives the person a rapid response to gut bacteria and/or their toxic by-products, which causes an overstimulation and production of NF-kappaB and cytokine, which stimulate inflammation. The NOD gene is found in only 10 to 15 percent of people with Crohn’s. Obviously, much work still needs to be done to explore the genetics of IBD.

IBD is not caused by emotional illness or psychiatric disorder, though the condition may cause emotional problems because of its chronic nature, painful episodes, and lifestyle limitations. Prolonged treatment with steroid medications can cause side effects of depression, mania or euphoria, and bone loss.

There is a lot of research indicating that dysbiosis plays a significant role in IBD. Since the gut microbiome is the center of our immune system, this makes sense. Studies have reported increased levels of gram negative anaerobic bacteria, such as Bacteroides species, and lower levels of Bifidobacteria species in Crohn’s disease, ulcerative colitis, and pouchitis (infection of the diverticula). E. coli has also been implicated in Crohn’s disease. We need a lot more research on the use of probiotics, prebiotics, treating known infection, and breaking up the biofilms with probiotics, enzymes, and fiber in these conditions.

The most common microbes involved are E. coli, staphylococcus, streptococcus, proteus, Mycoplasma pneumoniae, Chlamydia psittaci, Clostridium difficile toxin, and Coxiella burnetii. Bacterial infections occurred in one-quarter of all recurrence of IBD.

There is even research implicating poor dental hygiene with increased risk of IBD. Apparently bacterial infection in the mouth can lead to IBD. Brush your teeth—it helps prevent heart disease, too. (See
Chapter 29
for more on cardiovascular disease.)

At Digestive Disease Week in 2009, Henrick Nielsen, M.D., of Denmark, presented a study where he reviewed citizens’ health records. People who had previously had food poisoning (salmonella and campylobacter) had 2.5 times increased risk of developing IBD over the next 15 years. A flare-up of symptoms commonly occurs with infections.

Ulcerative colitis is a continuous inflammation of the mucosal lining of the colon and/or rectum. In the descending colon it is sometimes called left-sided disease, and in the rectum it is called distal disease, ulcerative proctitis, or proctosigmoiditis. If sores are present, they are shallow, and it is generally milder and easier to treat in the rectum. The most common symptoms are abdominal pain, diarrhea, and blood in stools that is maroon colored.

Of people with ulcerative colitis, 20 to 25 percent eventually require surgery because of massive bleeding, chronic illness, perforation of the colon, or risk of colon cancer. Five percent of people with ulcerative colitis ultimately develop colon cancer, and the degree of illness correlates with its incidence. For example, cancer levels aren’t higher for people who are affected only in the rectum and distal end of the colon.

The current medications for ulcerative colitis have focused on decreasing inflammation and TNF-alpha. Drs. O. Brain and S. P. Travis at Oxford Radcliff Hospital
suggest that this may be wrong. They postulate that defects in barrier function (leaky gut) and innate mucosal immunity (such as a poor ability to kill bacteria) may be the primary causes. These issues then lead to inflammation. If they are correct, then building immunity and healing a leaky gut play a leading role.

The most common symptoms of Crohn’s disease include abdominal pain, diarrhea, weight loss, and malnutrition. Crohn’s disease can occur anywhere along the digestive tract, from mouth to rectum, but is most common in the colon and ileum near the ileocecal valve. It is sometimes called right-sided disease. Frequent symptoms are fevers that last 24 to 48 hours, canker sores in the mouth, clubbed fingernails, and a thickening of the GI lining, which may cause constrictions and blockage. Inflammation develops in a skip pattern, a little here and a little there, and goes more deeply into the tissues than with ulcerative colitis. In later stages, it can form abscesses and fistulas, little canals that lead to other organs or form tiny caves. If they become serious, surgery may be recommended. If you require surgery for Crohn’s disease, it is important to know which part of the intestines were removed and which nutrients may have inadequate uptake. (See
Figure 2.1
for an absorption chart.)

Research implicates measles as a possible cause of Crohn’s disease. British scientists found measles virus in diseased parts of the colon, while Swedish researchers found a high incidence of Crohn’s disease in people who were exposed to measles in utero. Another British study showed that people who had received live measles vaccines had a threefold increase of Crohn’s disease, while ulcerative colitis rose by two and a half times. This study did not prove that the bowel disease was actually caused by measles, only that there was a correlation.

Some people with Crohn’s disease have flare-ups in a seasonal cycle, which suggests an allergy component to the illness. While studies have shown that allergy is a factor in a small number of people, a survey of members of the National Foundation of Ileitis and Colitis showed that 70 percent of people with IBD listed other symptoms that were probably allergy related. This led one researcher to say “inflammatory bowel disease is just another possible facet of allergy.” Mold sensitivity and allergies to candida and other types of fungus have also been proven to provoke IBD symptoms.

Microscopic colitis is a newer diagnosis. It is characterized by diarrhea, cramps, and abdominal pain. The diarrhea may be continuous or can come and go. There can also
be fatigue, fever, or joint pain. When a colonoscopy is done, all looks normal, yet when cells are biopsied under a microscope inflammation is seen. Microscopic colitis is often misdiagnosed because a biopsy is needed to make a definitive diagnosis. Microscopic colitis doesn’t appear to morph into Crohn’s disease, ulcerative colitis, or cancer. There is some genetic component; it often runs in families.

There are two types of microscopic colitis: collagenous colitis and lymphocytic colitis. In collagenous colitis there is a thickening of the collagen layer in the colon and an increase in inflammatory cytokines. There may also be an increase in lymphocytes, a type of white blood cell. Lymphocytic colitis is characterized by increased numbers of intraepithelial lymphocytes (IELs), which are specific types of white blood cells. This results in watery, nonbloody diarrhea. About half of people have a sudden onset and know exactly when it began. A common trigger is dysentery, giardia, or other intestinal infection.

There are several theories about the origins of microscopic colitis. Some believe it is an autoimmune disease; others suggest that it is caused by a virus, bacteria, or bacterial toxin; and another theory is that it is aggravated or triggered by use of NSAIDs. Probably it’s a combination of these that triggers the illness. Like Crohn’s disease and ulcerative colitis, microscopic colitis can come and go with flare-ups and healing.

Both types are most often seen in middle-aged women, but they can be found in men, women, and children of all ages. Some cases resolve on their own without any treatment. Fiber and fluids are recommended. Sometimes people might be given a medication to stop the diarrhea. Saccharomyces boulardii is a probiotic that is useful for diarrhea from all causes. If the flare-up is severe, anti-inflammatory drugs, steroids, or antibiotics may be used.

Ischemic colitis typically occurs in people over the age of 60 and is associated with cardiovascular disease. It occurs when blood flow from arteries to a part of your colon is reduced. Most often this is due to atherosclerosis, a buildup of fatty deposits in your artery. This results in inflammation that can cause temporary or permanent damage to your colon. It can occur anywhere but most often happens on the left side of the colon. When this occurs on the right side of the colon, it can be more serious because the same arteries also feed the small intestine. The most common presentation is abdominal pain, rectal bleeding and often urgent bowel movements, nausea, diarrhea, or vomiting. This usually presents as a flare-up and then subsides. Treatment is typically rest, lots of fluids, and possibly IV antibiotics. Once treated, this typically doesn’t recur.

Ischemic colitis can also be caused by or related to other conditions, including vasculitis (inflamed blood vessels), diabetes, blood clotting, radiation treatment to the abdomen, infections (such as Clostridium difficile, shigella, or E. coli), and dehydration. In rare cases medications can precipitate ischemic colitis, including use of birth control pills, estrogen replacement, NSAIDs, migraine medications (trip-tan and ergot types), antipsychotic drugs, pseudoephedrine, alostron (Lotronex for IBS), and cocaine.

Where this takes us on a practical level is to look at what we can do to have a healthy gut bacterial environment. Numerous studies have shown that use of probiotic supplements is beneficial for people with IBD. They have been shown to help maintain remission of flare-ups in Crohn’s disease, ulcerative colitis, and pouchitis. Probiotic bacteria, like L. acidophilus, bifidobacteria, and the Nissle strain of E. coli, provide competition for other microbes and push them out. Commensal bacteria stimulate our immune response, increase beneficial antibodies such as sIgA, IgM, and IgG, balance pH, and enhance tight junction integrity. Probiotic therapy with E. coli strain Nissle has been shown to be effective in treatment for ulcerative colitis and was found to be equivalent to the drug mesalamine for short-term maintenance of the disease and after use of steroid treatment for remission. VSL#3 is a formula with eight different probiotic species that has been used for pouchitis.

Much more research needs to be done on IBD and probiotics. Different combinations will work for different people and to greater or lesser effect. You’ll have to experiment with different brands and see which are most helpful. Remember to begin with a small dosage and increase slowly. You are changing your gut ecology and you want to do it gradually. You can think of them as a medicine that you’ll probably need to take daily for life.