HPI
Jason is a 39 year old male presents with a chief complaint of Irritable Bowel Syndrome (IBS), which was diagnosed by his GP approximately 10 months ago. His digestive complaints began shortly after the death of father and were compounded by the stress involved with dealing with his estate and grieving the loss. He is unable to identify any other specific triggers of his symptoms which include extreme bloating and epigastric discomfort, and abdominal distension “lasting for days” with rapid/frequent peristalsis followed by loose and urgent evacuation of the bowels. He averages about 5-6 bowel movements a day, but this appears to improve by taking Metamucil daily (reduces to 1-2 bowel movements a day). Stools are small, loose, with no blood or mucus, but occasionally can show undigested food. More rarely (about once a month) he says he can become constipated for several days at a time.
Regarding his diet and appetite, he describes himself as “a grazer”. He limits meat & seafood and craves sweets (hard candy, jujubes) and refined carbohydrates (e.g. muffin, pasta, bread, and cereal). He drinks 3 cups of black coffee throughout the day and approximately 1 L of water. Though he feels that there is a possible connection between his symptoms and his diet, he is unable to commit to an elimination/challenge diet, but would like to identify food sensitivities using food sensitivity testing. He is motivated to remove any obstacles to cure and improve his quality of life, which has been greatly affected by his condition.
He also describes his stress levels as “extremely high” due to family responsibilities such as caring for younger sister & late father’s estate, for which he describes himself as “the only one in charge”. Additionally, his aunt was recently diagnosed with pancreatic cancer. He describes his mind as “always racing” and this can often cause sleep onset insomnia with subsequently low energy levels. When asked about tools he employs for stress management he says he has “no time, interest or energy for hobbies or exercise”, but has previously enjoyed reading, listening to music, mountain biking and playing guitar to relax.
His past medical history includes indigestion and “heart burn”, which occurred daily for approximately 5 months, but which seemed to resolve 3-4 months ago and for which he managed at the time with an acid blocking medication. He has also experienced bouts of tinnitus which appear to come and go (high pitched, left sided).
Family history of cancer, heart disease (stroke), and hypertension on paternal side.
Social history: Works in an office/at a computer most days. Currently single and lives with a roommate who is main source of social connection. Consumes alcohol daily (1-3 beers in the evening), and recreational cannabis weekly. Also describes himself as a “social smoker” for the past 12 years.
Medications & Supplements: Metamucil (Psyllium) – 1 scoop (3g fiber) daily (not consistent).
Physical exam
- Height: 5’8” & Weight: 180lbs (BMI: 27)
- Blood pressure 135/80
- Heart rate 78 bpm
Abdominal exam: Tympany all 4 quadrants, pain on deep palpation in all 4 quadrants, most pronounced in left and right lower quadrants and epigastric region.
Labs and Imaging
- IgG blood draw for food sensitivity testing on initial visit.
- Consider occult blood, CBC, Comprehensive stool analysis
Working diagnosis and interpretation
- IBS (alternating, diarrhea predominant)
- DDx: Hypochlorhydria, food sensitivity or intolerance (lactose), celiac, peptic ulcer, gastritis, parasite, anxiety, depression, malabsorption syndrome, GERD
Problems List:
- Stress
- Sleep maintenance insomnia
- Fatigue
- Tinnitus
Jason’s IBS symptoms began around the same time his father died and have persisted ever since. He has had to take on a large portion of dealing with his affairs and with other family members and surely this stressful event triggered an acute flare up of digestive disturbance, possibly aggravating a tendency towards leaky gut and certain food sensitivities. Possible dysbiosis due to hypochlorhydria or food sensitivities may also be a contributing factor. Treatment goals include removing aggravating foods, healing the gastrointestinal mucosa and reducing stress levels, so that his symptomatic discomfort will be reduced.
When approaching any gastrointestinal disorder, the enteric nervous system and its relationship to the central nervous system is a key and often overlooked component of conventional diagnostic and treatment approaches. IBS patients often show abnormalities of the Migrating Motor Complex (MMC) particularly when exposed to stressful stimuli, with neural influences rather than strict myogenic factors appearing to be responsible (e.g. brain-gut interactions). It is important to remember that both diarrhea and constipation are merely symptomatic expressions of disease, and the practitioner must always consider addressing the underlying cause in order for the resolution of the condition to occur.
Stress reduction and deep breathing techniques, establishing a daily routine to align and promote healing in the body to avoid undue stressors on the body. Shifting the nervous system away from a sympathetic state will promote healing at a deeper level, while manual techniques will nurture physiological imbalance.
Treatment Plan
- Lifestyle:
- Deep breathing exercises and mindfulness practice daily.
- Food Hygiene – discussion around eating while in parasympathetic or “rest & digest” mode.
- Dietary: Assess food sensitivities with IgG blood test. Add more microbiome supportive foods, rich in pre-biotic 7 soluble fiber. Limit high fat, carbohydrate & sugary/fructose-rich food & beverages.
- Supplemental:
- Omega 3 Fatty Acids 3 g – daily.
- Probiotic—Bifidobacterium bifidus, Lactobacillus acidophilus 1:1—60 billion CFU daily to repopulate microbiome.
- Herbal:
- Bulking (Osmotic) Laxatives – Ulmus fulva (Slippery Elm) powder, 1 tsp in 1 cup cold water infusion or to morning smoothie. Linum usitatissimum (Flax seed) – 1 Tbsp, freshly ground (added to oatmeal or smoothie).
Bulking Laxative Smoothie Recipe:
- 5 g Ulmus fulva (Slippery Elm) powder
- 1 Tbsp Whole Flax Seed
- ½ tsp Cinnamon powder
- 1 fresh Medjool Date
- ½ cup water
- ½ cup Turmeric Mylk
- Optional: cocoa powder, dark leafy greens and/or berries, ½ Banana (fresh or frozen) can be added to taste
- Nervine Tonics/Relaxants & Carminatives
- Chamomile) & Skullcap – add 5 ml each of 1:2 liquid extract to 1 L water bottle and sip throughout the day.
- Kava Kava – 3 grams twice per day.
- Skullcap (1-2 g), Schisandra (2 g), St. John’s Wort (1-3 g), Saffron (0.5-1 g) daily.
- Astringents & Mucus Membrane Tonics
- Hydrastis canadensis (Goldenseal) 500 mg twice a day.
- Camellia sinensis (Green Tea) infusion, 1 tsp/cup daily (substitute for coffee whenever possible).
- Anti-inflammatories
- Turmeric – 6-12 g/day.
Note: Strong bitters and/or stimulant laxatives which contain anthraquinones and their glycosides should be avoided due to potential aggravating effects, however Yellow Dock (Rumex cripsus) may be an exception to this when used in low doses as a bowel tonic.
Progress:
1 month follow up
Jason admits to not having changed his diet or lifestyle habits much at all since his first appointment as he wished to wait for the results of his food sensitivity testing to be received first. Nonetheless, his gas and bloating have much improved (severity has decreased to 4/10 from 7), as have the consistency of bowel movements (less loose and now having 2x/day) which he attributes primarily to the probiotics and Goldenseal, both of which he has committed to taking daily, and the bulking laxative smoothie which he says he has been making at least 4-5 days out of the week. He would like to see greater improvements in his gas & bloating however, and still feels an urgency around bowel movements that disrupts his quality of life.
Confirmed food sensitivities contributing to Jason’s IBS symptoms were reviewed in this appointment and found to include – dairy, eggs, brewer’s yeast, wheat, gluten & gliadin. He was provided information and resources on alternative grain recipes. He was instructed to remove all foods for 4 weeks and that the re-introduction of certain foods may be considered upon his next consult. The prospect of a gut healing protocol was also discussed and proposed to be considered in the future.
Stress levels were still quite high (9/10), so further education around the gut-brain connection and establishing parasympathetic dominance around mealtimes was discussed. Matricaria recutita (Chamomile) & Scutellaria lateriflora (Skullcap) liquid extracts were strongly encouraged to be sipped on throughout the day in water, as well as substituting green tea for coffee whenever possible.
Suggested to continue probiotics daily & smoothie at least 3 days a week, commence Chamomile & Skullcap liquid extracts and omega 3 fatty acids, and discontinue goldenseal for the time being.
2 month follow up
Gas and bloating have continued to improve (severity 3/10) and bowel movements are generally well-formed with the occasional loose stool. Urgency has decreased as well as stress levels (8/10). Jason was not able to be as consistent with the liquid herbs as he hoped and requested a tablet instead to help increase compliance. Piper methysticum (Kava Kava) was suggested at 3 grams daily, which could be increased to 6 grams daily if desired. He found it difficult to substitute green tea for coffee and would still have 1-2 cups in the morning, but was able to switch out for his afternoon cup.
Jason was able to adhere to his elimination diet for 4 weeks but has concerns regarding the feasibility of continuing this way of eating long-term. However, he is motivated by the improvements he’s seen and is willing to continue with the treatment plan moving forward.
Suggested to continue probiotics, omega 3 fatty acids daily & smoothie at least 3 days a week, commence Kava Kava (short-term).
3 month follow up
Stress levels continue to decrease (8/10), but are also a key area of counseling in this visit as digestive symptoms continue to become less problematic. Jason’s aunt who is battling pancreatic cancer is going through an especially difficult time, and he has not been able to be maintain a complete elimination of his food sensitivities, but says he is able to adhere “about 70% of the time”.
Gas and bloating severity as well as bowel movement frequency, consistency and urgency have appeared to plateaued. He has been able to maintain his supplement and herbal protocols, and has found that Kava at 6 grams/day provides a significant improvement to his stress and anxiety levels. He feels better able to cope and establish boundaries even though the stressors in his life have not gone away.
Discussed the use of Kava on an as-needed basis during period of heightened or acute stress, and instead commencing nervine tonics such as Skullcap, Schisandra, St. John’s Wort and Saffron as more long-term nervous system strengthening and support, which may be paired with Turmeric to help reduce inflammation within the nervous system and gastrointestinal tract.
