SIBO Case Study

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BioHealth Laboratory’s Clinical Resources CASE STUDY. The case study contains Patient Complaints, Patient Description, History of Present Illness, Past Medical History, Dietary History, Social History, Physical Exam/Observations, Additional Lab Testing, Patient Test Results, Plan of Action Based on Clinical Presentation and Lab Test.

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BioHealth Laboratory | 23900 Hawthorne Blvd 150 Torrance CA 90505 800-570-2000 USA/Canada | 307-212-6600 | www.biohealthlab.com BioHealth Laboratory’s Clinical Resources CASE STUDY Small Intestine Bacterial Overgrowth SIBO Patient Complaints: • Abdominal pain – particularly in the midsection of abdomen below the sternum. • Heartburn – particularly when constipated • Never feels like she fully digests food • Carbohydrate foods such as rice corn and other grains exacerbate digestive problems. • Ongoing bloating with periods of signifcant foul-smelling gas • Tends towards constipation with bouts of loose stools • Burning in rectum with loose stools Patient Description: • Luiz is a 54-year-old Hispanic female 5 feet 2 inches tall 165 lbs BMI 22. • Luiz is married with two children aged 6 and 8 years old. Her children are very active in sports so this keeps her busy during the week and on the weekends. Luiz’s husband is a truck driver so his work schedule is erratic and Luiz is often the only person available to tend to their children. Because of her busy lifestyle she confesses to eating out at fast food restaurants but she does try to obtain healthier items. Also her digestive problems have forced her to avoid a lot of carbohydrate-type foods. • Luiz is a stay-at-home mother but does some part-time work for an insurance company while her two sons are at school. • Luiz’s husband does not sufer from the same digestive problems and she reports no problems with her two boys either. • Her prior health concerns are unremarkable. However she does remember getting ‘food poisoning’ approximately two years ago where she experienced diarrhea fever and severe nausea for approximately three days. This acute event seemed to pass on its own but over the next few months she began to sufer with increasing digestive bloating constipation and periodic loose stools. Other than her primary complaint she has no additional health issues. • Prior to the food poisoning episode Luiz had been taking over-the-counter Tums for heartburn before her primary care doctor prescribed Nexium. History of Present Illness: • A few months after the food poisoning incident she began experiencing increasing digestive bloating constipation and loose stools. The rectal burning began to occur about three months after the loose stools occurred and has been a consistent problem ever since. She still takes Nexium and only experiences heartburn when she is constipated. • The loose stools seem to occur about every two to three days following increasing difcultly moving her bowels. Her PCP recommended fber supplementation but this just makes her bowel symptoms worse. • She never feels like she digests food well but everything seems to cause bloating. She does express that corn and corn products rice and bread products make her bloating much worse. • Gas and bloating have been ongoing for several years and are worse with starchy foods too. • She doesn’t express any recent weight loss. In fact she feels as though she is carrying about 10 to 15 lbs. more weight than she is accustomed to despite the fact that she has had to alter her diet because of the ongoing bowel issues. • Her diet is limited on a lot of carbohydrate foods which makes it difcult based on her Mexican heritage. However she admits to ‘cheating’ with her diet because she really likes beans rice and corn products. Introduction Luiz presents for a consultation with a number of moderate digestive health complaints including abdominal bloating poor digestion heartburn and constipation which alternates with loose stools. She has seen a number of health practitioners including her primary care physician who state she sufers from irritable bowel syndrome. She has tried a course of Elavil which is known to help with improved bowel transit time and Amitiza which is primarily used for IBS with constipation. Both have proven unsuccessful in relieving her discomfort. She even tried an over-the-counter peppermint oil supplement which she read was helpful for IBS. This was unsuccessful too.

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BioHealth Laboratory | 23900 Hawthorne Blvd 150 Torrance CA 90505 800-570-2000 USA/Canada | 307-212-6600 | www.biohealthlab.com Past Medical History: • Frequent use of OTC acid blockers for relief of symptoms associated with heartburn x 4+ years. • No prior hospitalizations or surgeries. • Previous use of Amitiza and Elavil for GI issues. Dietary History: • Breakfast – cofee and cream orange juice fruit and eggs. Frequently skips breakfast because of bloating. • Lunch – salad chicken bread periodically • Dinner – beef or chicken mixed vegetables. Mexican-style dishes but she tries to reduce corn beans and grain products. • Snacks/desserts – potato chips yogurt • Beverages – cofee two cups daily water diet soda Social History: • No smoking or drug use • No alcohol use Physical Exam/Observations: • Pleasant quick wit with good memory recall • Moderately overweight • Abdominal distension from sternum to pubic region • Mild epigastric pain upon palpation • Moderate to severe discomfort with palpation of mid-gut and ileocecal valve area • Reduced bowel sounds in all four quadrants Patient Test Results: • Stool Analysis from PCP: • Negative OP • Negative giardia and cryptosporidium antigen • H. pylori antigen – negative • Blood Tests from PCP: • H. pylori IgG – negative • Comprehensive Metabolic Profle – normal • Liver enzymes – AST slightly high GGTP and Alkaline Phosphatase normal. • Gliadin negative • Transglutaminase negative • Food IgE Panel: • All normal General Impressions: Luiz’s symptoms of heartburn digestive pain and bloating and constipation with bouts of loose stools are highly suspicious of small intestine bacterial overgrowth SIBO likely of predominant methane type but possibly mixed methane + hydrogen. The palpation evidence of mid-section discomfort and ileocecal valve discomfort point towards SIBO as well. There are other things in her history which point towards SIBO too: • Increased bloating and overall worsening of digestive symptoms with carbohydrate consumption. • Onset after ‘food poisoning’ and the concurrent use of acid blockers also point towards SIBO. It is certainly possible that H. pylori and/or parasitic infections could be an ongoing problem too but with the recent tests from her PCP showing negative H. pylori stool antigen and IgG antibody along with negative antigen and stool OP for parasites it’s likely these entities are not present. The ‘food poisoning’ event could have been parasitic as Giardia is known to trigger SIBO in some people by disturbing the function of the ileocecal valve which prevents normal large bowel fora from back-fushing into the small intestine. It is also known that gastroenteritis from viruses and certain bacteria can do the same thing. Due to the level of stress that Luiz experiences with this ongoing problem and fnancial constraints at home the priority for testing is focused on SIBO assessment. Initial Plan of Action: Luiz will need to do a Small Intestine Bacterial Overgrowth screen from BioHealth Laboratory. This breath test analyzes for the production of both methane which primarily causes constipation and hydrogen which primarily contributes to diarrhea. The analysis is excellent at determining the production of these gases and then charting the results to determine at what level they are produced. Treatment is then based on primarily methane production hydrogen production or both. Dietary measures will be implemented to improve the overall quality and balance of her food choices. Individuals with SIBO are almost always bothered by carbohydrate foods and products as these become fermentable sources of gas production in the small intestine. Also acid blockers such as Nexium Protonix Prilosec and Prevacid only complicate the problem as another component of SIBO is poor digestion. Her H. pylori tests were negative so the absolute need for ongoing acid blocking medication is questionable and it is possible much of her epigastric discomfort is coming from back pressure due to gas production in the small intestine. Because of her constipation it will be important to use prokinetic products to enhance the activity of peristaltic activity in the small intestine. Also people with constipation type SIBO often need to adjust their bowel movement posture to enhance easier evacuation of their bowel. A squatting stool can be utilized which improves the position while on the toilet for easier stool passage.

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BioHealth Laboratory | 23900 Hawthorne Blvd 150 Torrance CA 90505 800-570-2000 USA/Canada | 307-212-6600 | www.biohealthlab.com Additional Lab Testing: • SIBO 900 Test: Lactulose challenge • SIBO 901 Test: Glucose challenge Patient Test Results: • Overview of Luiz’s SIBO 900 test: • As suspected Luiz’s SIBO test shows elevated methane considered to be high with a smaller overall production of hydrogen. • The more common scenario for SIBO is for hydrogen to be high and methane either normal or mildly high. • Because of the predominant elevated methane this more than likely explains her constipation pattern. The periodic loose stools could be coming from the hydrogen but also from a bowel evacuation pattern from poor ileocecal valve function and overall small and lower bowel irritation. • Luiz’s rectal burning associated with loose stools is likely caused by an acidic stool and overall bowel toxicity from decompartment problems between the small and large bowel. Also SIBO gases of hydrogen and methane can disturb pancreatic enzyme production specifcally afecting the enzymes that break down disaccharides. Plan of Action Based on Clinical Presentation and Lab Test: • Dietary intervention: • SIBO patients often do better with incorporating a specifc program reducing fermentable carbohydrates found in various foods or food-based supplements or products. Luiz is given information to follow the dietary program called ‘The Specifc Carbohydrate Diet. ’ • Exercise: • 30 to 45 minutes of focused interval training four to fve days per week. For SIBO it is important to increase activity levels to improve function of the autonomic nervous system and promote bowel stimulation. • Lifestyle: • Bed by 10 pm and incorporate relaxing activities to decrease sympathetic nervous system activity. Supplement Program: • Support Digestion – 1 capsule 3x/day with breakfast lunch and dinner. Wean of Nexium for one week prior to starting Support Digestion and while taking one teaspoon of Swedish Bitters in ½ cup of warm water found at most health food stores prior to food. • Ibergast or other botanical formula to improve motility – 60 drops in warm water before bed. • Magnesium Citrate or Oxide – 400 mg nightly. • Warm glass of water upon waking with one teaspoon Swedish Bitters which helps to increase peristaltic activity. • Interphase Plus – 2 capsules 2x/day between meals. • Allimax – one capsule 3x/day after meals. • Intestinol – 2 capsules 2x/day after meals. • Support Liver – 3 capsules per day with breakfast. • All products to be introduced one at a time over several days to make sure Luiz can tolerate all of the supplements in the program.

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