Gastrointestinal Activities such as Digestion, Absorption and Elimination are ongoing processes we take for granted. Optimal function of these processes is the basis for good health. Attention to the process of Gastrointestinal Function is essential in a good prevention program as well as an illness treatment program.  We assess gastrointestinal function through history, physical examination and laboratory testing. The intensity of laboratory testing is driven by the persons’ symptoms and health background. The components of the functional assessment of gastrointestinal function will be discussed.

Dysbiosis:

Is the biomass of living organism within the GI tract well balanced?

There are more living organisms in our GI tract than cells in our body. We live in symbiosis with these bacteria. They provide benefit to us such as aiding in the digestive process and providing nutrients to the cells that line our gastrointestinal tract. In addition, a healthy balance of living organisms protects us from disease causing organisms. We provide benefit to them by providing a safe haven and plenty of nutritional matter.

Dysbiosis occurs when the biomass is unbalanced. Unfriendly bacteria cause acute illnesses such as gastroenteritis. There can be overgrowths of unfriendly bacteria, fungi/yeast, or parasites that cause symptoms related to the GI tract such as bloating, diarrhea, and pain. These unfriendly organisms can cause activation of the immune system and barrier function impairment.

Two thirds of our immune cells reside around our intestines. This protects us from the bacteria and toxins within the digestive tract. When the immune system is chronically activated because of dysbiosis it can accelerate aging and produce chronic diseases.

Our intestinal tract serves as a barrier. It lets nutrients and water in and keeps toxic materials, bacteria, yeast and virus out. The barrier can be disrupted from an acute process such as a viral or bacterial infection. Chronic problems such as food sensitivity, toxin exposure or chronic infection can also injure the barrier. When this occurs toxins can penetrate the barrier, causing immune activation and chronic health problems.

This can result in symptoms and disease outside of the GI tract. Symptoms might include cognitive impairment ,(“brain fog”), headache, chronic sinusitis, asthma, abdominal pain, bloating, bowel pattern abnormalities, chronic prostatitis, female problems such as interstitial cystitis, pelvic pain, endometriosis and PMS and arthritis. In my clinical experience more than two thirds of people with chronic health conditions have dysbiosis and intestinal permeability disorders contributing to their problems.

Identifying an abnormal pattern and correcting it is a key element of functional medicine. We can recreate balance by removing the undesirable organisms and restoring the desirable bacteria while supplying nutrients to optimize the barrier function.

 Historical Factors that Suggest Dysbiosis:

The use of medications such as steroids, (prednisone), or antibiotics is commonly associated with dysbiosis.

Prior Gastrointestinal Infections with persistent post infectious symptoms such as abdominal bloating, excessive intestinal gas or bowel pattern irregularity are signs that dysbiosis may be present. This often occurs in individuals who travel to places where the water or food quality is compromised. It is also seen in individuals who care for small children in a day care center.

Gastrointestinal Surgery, Chemotherapy and or Radiation Therapy are common associated with the development of dysbiosis.

Symptoms and Signs of Dysbiosis:

The classical symptoms are abdominal bloating, abdominal discomfort, and bowel pattern irregularity. As mentioned before, dysbiosis can contribute to health problems related to any system in the body.

• Psychological symptoms may include depression, Attention Deficit Disorder, and hyperirritability.
  

• Neurological symptoms may include headache, dizziness, and cognitive dysfunction, (poor memory and or brain fog).
  

• Respiratory symptoms may include chronic rhinitis, chronic sinusitis, and asthma. Cardiovascular problems may include palpitations, arteriosclerosis and heart attack, (the chronic inflammatory response may contribute to narrowing of the arteries or arteriosclerosis).
  

• Gastrointestinal symptoms and diseases such as stomach ulcers, ulcerative colitis and Crohn’s disease are often associated with dysbiosis. When dysbiosis is not the direct cause of a disease, it can be a contributing factor in symptom severity and disease persistence.
  

•  Female health problems include PMS, menstrual irregularity and infertility. There is a possibility that chronic yeast overgrowth contributes to problems such as endometriosis and fibroids. Chronic interstitial cystitis is often improved by normalizing the bowel flora.
  

• Male health problems include chronic prostatitis. Abnormal growth of bacteria in the stomach may lead to stomach cancer. Abnormal patterns of bacteria in the colon may increase the risk to colon cancer, particularly if the healthy bacteria that produce a gut nutrient called butyric acid are diminished.
  

• Allergic illnesses such as eczema can be associated with dysbiosis.

Musculo-skeletal problems such as arthritis, chronic myofascial pain syndrome and fibromyalgia are associated with dysbiosis.

Tests that look for dysbiosis:

• Cultures of the stool: These tests look for parasites, abnormal bacteria and overgrowth of fungi or yeast. When abnormal organisms are identified, sensitivity testing to determine the most effective treatment can be done.
  

• Urinary Organic Acid Analysis: This is another way at looking at GI function. Metabolic by-products of parasites, yeast or pathogenic bacteria can be measured in the urine. 
  

• Candida Immune Complexes: This is a blood test. We look for yeast protein that has attached to antibodies made by the patients’ immune system against the protein.  These complexes can identify the individual who is having a problem with intestinal yeast overgrowth and excessive permeability.

Treatment Strategies:

• Removal of undesirable organisms is the first step. This can be done with prescription medications and or herbal products.
  

• Whenever there is dysbiosis, we are concerned about secondary factors that may impair immune function.
  

• We look at toxic load, (heavy metals such as mercury, pesticides, and herbicides) and attempt to reduce the toxic load. This results in a restoration of immune function.
  

• We look at metabolic balance particularly glucose insulin metabolism. Abnormal Glucose/Insulin Metabolism, (the Metabolic Syndrome), is a common contributing factor to dysbiosis.
  

• We look for hormonal imbalance. An estrogen dominant state can predispose to yeast overgrowth.
  

• We look for food intolerances, allergies or toxicities. By removing the food from the diet we can improve immune function and facilitate the resolution of dysbiosis. Adherence to the proper diet is critically important in a successful outcome. While a bacterial or parasitic infection can be treated with appropriate medication and herbal products, a yeast infection requires dietary change to be treated effectively. There is no compromise on this point.

At an appropriate time in the course of treatment we recommend supplementation with healthy bacteria, (probiotics), and the supplements that support these healthy bacteria, (prebiotics).

We consider nutritional insufficiencies. As an example, a sub group of the population has a relative insufficiency of a B vitamin called biotin. In such individuals, supplementing with biotin will result in a resolution of chronic yeast infections.

Support with immunity enhancing supplements can be helpful in treating and preventing this problem.

Treatment must be individualized based on the patients’ unique needs.

Intestinal Permeability:

The intestinal tract lining is as large as a tennis court and as thin as your eyelid. The lining of the intestinal tract is a selective barrier. It serves to prevent undesirable substances from entering the body while allowing desirable nutrients into the body. When it is not functioning well it can allow undesirable molecules into the body. This is known as Barrier Function Impairment or “Leaky Gut Syndrome”. This can cause symptoms of illness, provoke immune activation, and lead to disease processes.

Historical Factors that Suggest Leaky Gut Syndrome:

Factors that may raise the suspicion of Leaky Gut Syndrome include a history of major trauma or burns, gastrointestinal infections, dysbiosis, the use of certain medications such as Cortisone derivatives, (prednisone) and NSAIDs. The NSAIDs are the anti-inflammatory medications that include aspirin, ibuprofen, and naproxyn. It also includes the newer versions of this class of medications such as Celebrex and Vioxx. A history of food allergy or sensitivity should also alert one to the possibility of Leaky Gut Syndrome.

Leaky Gut Syndrome can be associated with a variety of illnesses including: Attention Deficit Disorder, Autism like symptoms, Arthritis, Chronic Fatigue Syndrome, Food Allergies and Intolerance, Inflammatory Bowel Disease, Irritable Bowel Syndrome, Multiple Chemical Sensitivies, Chronic Skin Conditions such as eczema, psoriasis, hives and acne.

Leaky Gut Syndrome can sometimes be associated with chronic health problems: Aging, HIV, Alcoholism, Cancer, Celiac Disease, Crohn’s Disease, Cystic Fibrosis, Parasitic infections of the GI tract, chronic hepatitis, Ulcerative Colitis, Chemotherapy and Radiation Therapy.

Symptoms and Signs of Leaky Gut Syndrome:

There are a variety of non-specific symptoms that may be associated with Leaky Gut: fatigue, fever, abdominal pain, abdominal discomfort, bloating, diarrhea, cognitive dysfunction, and generalized weakness. 

Tests that look for Leaky Gut Syndrome:

The Intestinal Permeability Test is an effective and highly reliable way to diagnose this problem. It is not an insurance covered test. It is very valuable in guiding therapy and following a disease process.

Treatment for Leaky Gut Syndrome:

• Remove the stimulants to dysfunction whether it is abnormal organisms, offending foods, medication and or supplements.
  

• Replace healthy living bacteria that may be missing.
  

• Repair the intestinal membrane by supplying appropriate nutrients. These may include nutrients such as glutamine for the small intestine and water soluble fiber plus healthy bacteria for the large intestine.

Adequacy of Digestive Juice Production:

Hydrochloric Acid:

The stomach secretes Hydrochloric Acid, (HCL). Food entering the stomach activates the secretion. The action of Hydrochloric Acid continues the process of food digestion started in the mouth with the chewing process and the action of salivary digestive enzymes.  A conservative estimate is that one in ten people over age 50 do not make an adequate amount of hydrochloric acid. This can lead to poor absorption of certain nutrients and to bacterial overgrowth of the small intestine. This can lead to the Gut Fermentation Syndrome. This is a syndrome manifested by bloating and excess gas after a meal.

 Historical Factors that suggest inadequate HCL:

The use of antacids or acid suppressing medication will reduce HCL production. Individuals who experience bloating and abdominal discomfort after a meal may benefit from HCL supplementation.

Symptoms and Signs of HCL insufficiency:

• Inadequate HCL secretion may be associated with a variety of symptoms including fatigue, bloating, bowel pattern irregularity, excessive abdominal gas, and heartburn.
  

• Tests that look for adequacy of HCL are difficult and expensive. One test is called the Heidelberg test. The patient swallows a radio telemetry capsule. It sends a message to an instrument that interprets the acidity of the stomach. The stomachs ability to make acid can be challenged by having the patient drink a bicarbonate mixture. This is a functional test of the adequacy of gastric acid. Since it is expensive and cumbersome to perform, I prefer a clinical trial based on the history and the individual symptoms.

Treatment for HCL Insufficiency:

• Herbal bitters are a traditional product that can improve digestive processes in general and increase HCL production.. The individual uses between 5-30 drops of “bitters” tincture in a small glass of water prior to a meal. It is important to taste the bitter taste in order to get the benefit of herbal tincture. The taste of the bitters sends a message to the digestive nervous system that activates the digestive process.
  

• Betaine HCL is available in capsules. It is taken at the start of the meal. The dose is increased gradually until the person achieves benefit. The dose is 1-6 capsules. Should symptoms of heart burn develop the individual is advised to stop using the product and consult their health care practitioner.

Pancreatic Enzyme Production and Function:

Historical factors that suggest inadequate pancreatic enzyme production:

Pancreatic enzyme production can decline with age and chronic illness. One theory on the development and spread of cancer held by those in the Complimentary/Alternative Medicine field is that inadequacy of pancreatic enzyme production may be related to the development and spread of cancer. Supplementation with pancreatic enzymes is the mainstay of one successful Complementary/Alternative medicine cancer therapy protocol. Inadequate production of pancreatic enzymes can lead to poor digestion of food. This can lead to dysbiosis, intestinal permeability, and food sensitivity and intolerance.

Signs and Symptoms of Pancreatic Enzyme Deficiency:

Insufficient production of pancreatic enzymes can lead to poor digestion and absorption of nutrients. This can lead to a variety of chronic health problems as discussed above. One classic symptom is the production of fatty, foul smelling stools. This is due to the inadequate digestion of protein and fat.

Functional Tests for Pancreatic Enzyme Function:

There are no simple functional tests for adequacy of pancreatic enzyme production. When history and symptoms suggest a possible deficiency a therapeutic trial is indicated.

Treatment of Pancreatic Enzyme Deficiency:

Pancreatic Enzymes are made by a variety of manufacturers. They are typically made from bovine, (cattle), or porcine, (pig) pancreatic material. The best manufacturers use organic sources. Great care has been taken to avoid sources that may have infectious contamination.

Vegetable source Digestive Enzymes are also available and quite useful.

The typical dose is one to three capsules taken towards the end of the meal. I have found that the product that works best for any individual can vary. It is therefore worthwhile to try two or more products before concluding that enzyme supplementation is not valuable for you. Consulting with a health care practitioner is particularly useful in this situation.

Food Allergy, Sensitivity and Intolerance:

The foods we eat can create health problems. There are many possible causes.

There may be individual intolerance do to a lack of specific digestive enzymes, (lactose intolerance). Symptoms typically occur within hours after the ingestion of the offending food and are primarily related to the GI tract.

In some individuals a specific component of food may be toxic. A classic example of this is Celiac Disease due to sensitivity to the protein in grains called gluten. These people are typically chronically ill with recurrent diarrhea and difficulty in maintaining weight. The secondary symptoms of this condition are non-specific and can include fatigue, increased susceptibility to infection and cognitive dysfunction.

Classical allergic reactions occur in a small percentage of the population. These reactions are often abrupt in onset and produce severe symptoms. An example would be the development of hives after eating peanuts.

Non-allergic immune activation can cause delayed reactions. These reactions are difficult to relate to the ingestion of food since they can occur days after the food ingestion. The symptoms of this type of reaction are extremely variable and can involve all organ systems.

Examples of symptoms of Non-Allergic Immune Activation, (IGG Food Allergy), include:

• The classical symptoms are abdominal bloating, abdominal discomfort, and bowel pattern irregularity
  

• Psychological symptoms may include depression, Attention Deficit Disorder, and Hyperirritability.
  

• Neurological symptoms may include headache, dizziness, and cognitive dysfunction, (poor memory and or brain fog).
  

• Respiratory symptoms may include chronic rhinitis, chronic sinusitis, and asthma. Cardiovascular problems may include palpitations and atypical chest pains.
  

• Gastrointestinal symptoms include heartburn, bloating, intestinal gas, constipation and diarrhea.
  

• Female health problems include PMS and Chronic interstitial cystitis.
  

• Male health problems include chronic non-bacterial prostatitis.
  

• Allergic illnesses such as eczema, rhinitis and conjunctivitis can be associated with food sensitivity.
  

• Musculo-skeletal problems such as arthritis, chronic myofascial pain syndrome and fibromyalgia are associated with food sensitivity

Functional Tests for Food Sensitivities:

The elimination diet is an inexpensive but difficult process. The common allergy/sensitivity producing foods are avoided for two to three weeks. Changes in symptoms patterns are observed. The foods are then added back into the diet in a gradual fashion to see if the symptoms are worsened. When a food is identified as a problem it is with held from the diet for four to six weeks and then reintroduced in a more gradual manner. Often the food can be tolerated if eaten in smaller quantities and less frequently. This process is best done under the supervision of a health professional.

Food Allergy Testing using blood samples is more expensive but much easier to accomplish. These tests are not always reliable, however.

Electro-Dermal testing is a bioelectric technique. There is reasonable scientific evidence that this type of testing can help individuals identify offending foods. It is expensive. A typical session will take 30-60 minutes. Approximately two thirds of patients benefit from this method.  There are strategies using this technique that address the individual sensitivity to the food and allow the individual to consume the food in small amounts within one week. That makes this technique interesting and worth the effort.

Treatment of Food Sensitivity Problems:

Avoidance of the offending food is the simplest method of treatment. In some instances the offending food may be reintroduced on a more limited basis. In other instances the food must be avoided permanently. This is particularly true in the case of celiac disease.

Food Sensitivity and Intolerance is often accompanied by other problems such as an inadequacy of digestive juices and dysbiosis. Correction of these underlying problems will result in an improvement in tolerance to the offending foods.

Gastrointestinal Motility Problems:

The most common manifestations of these problems are diarrhea and constipation. We have dealt with a variety of functional problems that can cause diarrhea. Constipation is a common problem at all ages. A normal bowel pattern in a health person, eating a high fiber diet and drinking adequate amounts of water is one or two bowel movements per day. There is a great deal of variability in this normal range. A person who is not having a daily bowel movement suffers from constipation.

Treatment of Constipation:

Review the prescription medication you are taking with your physician. Many medications cause constipation. When possible, choose an alternative that does not have this side effect. There are OTC vitamins, minerals, neutraceuticals and herbal products that may cause constipation.

Eat a high fiber diet. A high fiber diet is characterized by one to two servings of grains each day and two to four servings of fresh fruits and vegetables per day. Fiber supplements can be very useful for some individuals. They can be water insoluble, water soluble or mixed. I generally suggest using a water-soluble fiber supplement such as Herb Bulk or OptiFiber SCFA. Should this not work or should it produce symptoms of bloating or gas we switch to a water insoluble supplement such as Ultra Fiber. Each person is different and must find the foods and nutritional supplements that work best for them.

Drink an adequate amount of water. Typically four to eight glasses per day. The amount depends on age, underlying health problems and activity level.

Exercise daily! I am always amazed at how a simple walk will improve chronic bowel dysfunction. There are special yoga practices that can help bowel dysfunction as well.