GIT - Lecture 5 Flashcards
What is HYPOCHLORHYDRIA ?
At what pH is it considered to be HYPOCHLORHYDRIA?
Hypochlorhydria = low stomach acid production characterised by a fasting gastric pH above 3.0 (1.5–3.0 is considered normal). Stomach acid does not get acidic enough to break down food coming in.
What are the key signs and symptoms of hypochlorhydria?
- Gas and bloating (often <30 minutes after eating), heartburn, sensation of fullness after meals (food is coming back up because the stomach is churning too hard), foul smelling stools (protein not digested well – trucker stools), diarrhoea, nausea after taking supplements (because when you put a stomach in and you cannot break down the mineral from its bond it create nausea), food allergies, atopic conditions, brittle nails (not absorbing mineral very well).
- Nutrient deficiencies (malabsorption) e.g., iron, zinc, folate and B12 – stomach acid role with IF to absorb B12.
What are the key nutrient deficiencies of hypochlorhydria?
Nutrient deficiencies (malabsorption) e.g., iron, zinc, folate and B12 – stomach acid role with IF to absorb B12.
What is the pH for achlorhydria, hypochlorhydria and hyperchlorhydria?
- Achlorhydria = absence of stomach acid→gastric pH >7.0
- Hyperchlorhydria = a gastric pH <1.5, normally without consequences unless other conditions present; e.g., GORD.
- Hypochlorhydria = a gastric pH >3.0
What are the consequences of hypochlorhydria? x6
- Reduced mineral absorption - calcium ↓ bone density, iron → anaemia
- Protein putrefaction - colorectal cancer
- H. pylori infection
- SIBO
- poor pancreatic juice and bile flow (lipase, amylase, elastase)
- B12 deficiency (IF)
Causes to hypochlorhydria?
Chronic stress – excessive fight and flight
Anorexia, starvation – stomach damage (the stomach wall atrophies and the cell that make the stomach wall might die and never grow back which make these person at risk of low stomach acid for the rest of their lives).
Stomach surgery, PPI LT use
Natural approach to hypochlorhydria?
- Chew thoroughly, avoid overeating and drinking with meals. Smell food, observe it, cook the food with strong herbs and spices for aroma.
- Avoid lots of water with meal
- Take slightly acid things with the meal like ACV and lemon juice
- Slow cooking proteins (so they are already pre-digested
- Apple cider vinegar (1–2 tsp) diluted in a little water before meals.
- Zinc and B6-rich foods – essential to make stomach acid
- Bitter reflex – when we taste something bitter we start producing digestive juices and saliva to start the digestive process.
- Bitter foods and herbs stimulate digestive secretions (incl. HCl):
- Bitter greens e.g., rocket, chicory, dandelion leaf, watercress.
- Herbs: Gentian, dandelion, goldenseal, barberry bark — stimulate the Vagus nerve (although energetically cold).
- Alternative herbs: Fennel seed, cardamon, citrus peel, ginger (these are energetically ‘warming bitters’, so good if excess cold / aggravated Agni / Spleen Qi deficiency) + clear gases.
Supplement for hypochlorhydria?
Supplementing with Betaine HCl: a basic protocol for suspected meal-time hypochlorhydria. Betaine come from ACV – provide more acidity for digesting meal. Often found with pepsin that helps protein digestion.
If we chose to use this, use natural processes first.
* Begin by taking 1 capsule containing 350–750 mg Betaine HCl with a protein-containing meal (>500 kcal+).
* If no discomfort (tingling / burning), increase mealtime dose by 1 capsule every 2 days (max. 3 g) until dose results in tingling or warm sensation (it is not a discomfort!), then reduce dose by 1 capsule.
* Use this dose at subsequent meals with the correct dose
What cautions with Betaine HCl?
Betaine HCl/ Pepsin is contraindicated with some drugs and peptic ulcers
HCl irritate sensitive tissues and is irritative to the teeth
Capsule should not be emptied in food or dissolve in a glass
Should not be given on an empty stomach unless food follow immediately
smaller meals require smaller doses
What is Exocrine pancreatic insufficiency (EPI)? What is the result of that?
A deficiency of exocrine pancreatic enzymes needed to maintain normal digestion resulting in nutrient (especially fat) malabsorption.
Lipase, amylase and protease
What are the common signs and symptoms of Exocrine pancreatic insufficiency (EPI)?
- Bloating / belching / flatulence 1–2 hours after eating.
- Steatorrhoea (excessive fat in faeces; i.e., greasy or floating stools). A type of diarrhoea (frothing, foul smelling, pale, floating and break on contact with the bowl).
- Drowsiness after meals.
- Food intolerances.
- Low zinc, B12 and folate absorption.
- Symptoms of IBS, candidiasis or SIBO
What are the common causes of Exocrine pancreatic insufficiency (EPI)?
- Chronic stress — ↓ Vagus nerve activity. If you are in chronic stress dysfunction you’ll get digestive disturbances (low stomach acid, low pancreatic juices, low motility that can become high motility because of enzyme probles), IBS is linked with poor vagus nerve activity.
- Hypochlorhydria — ↓ CCK stimulation.
- Chronic diseases: cystic fibrosis (very low pancreatic enzyme function and have to take supplement for the rest of their life), chronic pancreatitis, obstructive pancreatic tumours, GI surgery (resection), diabetes mellitus type 1 especially (some autoimmune samage can also damage the exocrine functions).
- Damaged small intestinal wall (e.g., coeliac, IBD) — ↓ CCK production and ↓ pancreatic stimulation.
- Xenobiotics (pesticides, herbicides, phthalates, BPA) can inactivate pancreatic enzymes.
- Microbial interactions: SIBO (although it could be a cause or effect) can deconjugate pancreatic enzymes; dysbiosis. If you have SIBO they can deconjugate pancreatic enzyme and make them work not very well.
- If you do a stool test you can measure pancreatic elastase 1 – if come up low it shoes the person need digging to work out why it is low and support.
what is the stool test indicator for Low pancreatic function?
Low pancreatic function is indicated by low pancreatic elastase-1, a marker found in most comprehensive stool tests.
Naturopathic approach to pancreatic insufficiency
- Don’t overeat, chew adequately, avoid snacking between meals (to give anough time for the process to work well).
- Correct stomach acid levels.
- Stimulate the Vagus nerve to activate the parasympathetic nervous system:
- Deep (diaphragmatic) breathing before meals.
- Osteopathy
- Gargle, hum or sing. Activation of the back of the throat – 5min a day.
- Laughter and social enrichment.
- Using bitters such as gentian, artichoke and dandelion.
- Pancreatic enzyme replacement therapy (PERT)
What 2 types of Pancreatic Enzyme Replacement Therapy (PERT) exist and how they differ?
How do you take the enzymes?
When to avoid PERT?
- A wide range of enzyme formulations are available on the market, each different in terms of type, origin and dosage.
- Animal-derived (pork pancreatin) has been the standard of care in conventional medicine providing amylase, lipase and protease. Stronger.
- Plant-based and microbe-derived enzymes appear to offer advantages, e.g., better acid stability, broader range of enzymes, more variants and wider pH range.
- Take enzymes with the first bite of a meal and consider adding extra enzymes during, or at the end of a meal depending on the meal size and duration, e.g., if the meal is:
‒ <15 minutes — take all at the start of the meal.
‒ 15–30 minutes — take half the enzymes at the start and half in the middle of the meal.
‒ >30 minutes — take a third at the beginning, middle and end of the meal. - The rationale is to mimic endogenous secretion whereby enzyme secretion increases as more food is ingested.
Avoid digestive enzymes in cases of ulceration
What is bile insufficiency ?
Bile insufficiency = a condition whereby bile synthesis and / or bile flow (note — bile should be quite ‘thin’) is compromised affecting one’s ability to digest, absorb and utilise fatty acids from the diet. Similar to low pancreatic function symptoms.
Key signs and symptoms of bile insufficiency?
- Steatorrhoea: Constipation or diarrhoea. Might have a yellow colour.
- Intolerance to fatty foods / nausea when eaten. How does the client feel after a fatty meal.
- Bloating, excess flatulence and cramping around small intestine area (look similar to IBS).
- When bile is into the small intestine the bacteria start deconjugating it and then it is put back in circulation and recycled. But create metabolites. Bile acts as a laxative – too much => diarrhoea and not enough => constipation and methane producing becterias.
Stool test indicators (accompanying key symptoms) of bile insufficiency?
- Low / absent bile acids (accompanied by key signs / symptoms — as zero can be normal if very efficient at resorbing bile salts). Can be normal or abnormal – depends on the signs coming with it could be bile insufficiency and you want to support bile production.
- High faecal fats (steatocrit – hard to measure and depend on meal) — indicates fat malabsorption. Can be a guide if you look at the whole picture.
Common causes of bile insufficiency?
- Long Term Low dietary fat intake => train the body not to release bile
- Impaired liver function and obstructed bile ducts (gallstones, NASH (fatty liver), inflammation of the liver).
- Obesity (shown to have ↓ postprandial bile acid response)
- Oestrogen dominance (↑ liver production of cholesterol which thickens bile and also slows the excretion of oestrogen — a viscous cycle!) – if bile is too thick it does not work very well.
- Other GI conditions e.g., cholecystectomy (gall bladder removal – not enough bile production in meal because you cannot store the meal or have bile dropping between meal on empty intestine – have more small meals), coeliac disease, Crohn’s disease, chronic pancreatitis, SIBO (chicken or egg – could be low bile create SIBO or SIBO prevent the proper feedback system).
- Low HCl (reducing CCK and hence bile release) – needs the trigger
Implications of long-term bile insufficiency?
- Deficiency of fat-soluble nutrients:
– Vitamins A, D, E, K; essential fatty acids, phytonutrients (e.g., beta-carotene) – low vit D despite supplementation. - Hormone imbalances (i.e., associated with poor oestrogen clearance).
- Hypercholesterolaemia. You can get rid of excess cholesterol in the bile and then binds to fibre and gets excreted
- Compromised liver detoxification. Some toxins stay fat soluble and need exit via the bile and if bile function is impaired create backlog in the liver and create inflammation in the liver and a vicious circle. Over exposure to toxins in the liver.
- SIBO and dysbiosis (bile has antimicrobial effects, detoxifies bacterial endotoxins and stimulates peristalsis). When someone has SIBO can get a bile insufficiency.
- Gallstones or inflammation of the liver or pancreas. Will create issue with bile flow.
Natural approach to bile insufficiency?
– Adequate hydration — at least 6‒8 glasses per day. You need water to make bile.
– Avoid processed food, trans fats and refined sugar. Saturated fat and trans fats create stress on bile production as will induce a lot of bile flow – will sometimes not be enough for what is there. Refined sugar can interrupt the whole metabolic process.
– Chew slowly and thoroughly (until food is liquid). DO the bitter foods, smelling meal, not too much fat in the meal.
– Diaphragmatic breathing — massages the liver, ↑ bile production. Help move the liver and the gallbladder. See an osteopath if diaphragm is blocked.
What 2 nutrients are key bile component + what food source?
↑ taurine and choline foods (key bile components – bile salts get conjugated to these to work), or supplement.
Taurine rich food : Seaweed, scallops,
clams, tuna, salmon, turkey / chicken thighs.
Choline rich food: Wheat germ, kidney beans, broccoli, Brussel sprouts, quinoa, beef liver, eggs,
What are choleretic and cholagogue-rich foods and herbs for bile insufficiency?
choleretic = ↑ bile production
Foods: Radish, cucumber, bitter melon, onion, kidney beans, ACV.
Herbs: Gentian, artichoke leaf,
barberry bark, dandelion root.
cholagogue = ↑ bile flow
Foods: Apples, artichoke, beets, bitter greens, celery, fennel.
Herbs: Milk thistle, turmeric,
ginger, dandelion greens, fenugreek (fenugreek removes cholesterol from bile to ↑ bile acid concentration by 4x).
Take herbal choleretics and cholagogues within 30 mins of starting a meal
What is the mucosal barrier ?
Mucosal barrier = mucus covering the entire GIT provides a thick barrier between the immune-stimulating contents of the outer world and the multitude of immune cells in the gut wall (1st line of defence). Mucous in different parts of the GIT has different thickness
What is the mucosal barrier ?
Mucosal barrier = mucus covering the entire GIT provides a thick barrier between the immune-stimulating contents of the outer world and the multitude of immune cells in the gut wall (1st line of defence). Mucous in different parts of the GIT has different thickness
What is the composition of the mucosal barrier?
Mucus contains water (96–98%), glycoproteins called mucins (give structure to the water – viscosity and stickiness and trap, IgA (made by epithelial cells) and anti-microbial peptides such as α and β defensins (innate immune system)
in which condition does the mucosal barrier becomes very thin causing inflammation?
- In ulcerative colitis, it has been observed that the inner mucosal lining becomes permeable (thin) = large amount of bacteria in close contact with host tissues = inflammation.
what is metabolic endotoxaemia ?
- A disturbed mucosal barrier can lead to bacterial translocation and the leakage of LPS → metabolic endotoxaemia – too many LPS (outter cell wall of bacteria ending up in the system => inflammatory response – linked with diabetes, autoimmune, Alzheimer’s, Neurodegenerative disease, depression). It can be the start of intestinal permeability.
How to support the mucosal barrier ?
- Feed the correct bacteria and avoid things that are detrimental on the mucosal barrier.
- Optimise dietary fibre (because if you don’t feed the bacteria, they can eat your mucins!). Dysbiosis.
- A diet rich in polyphenols (plant chemicals associated with all the colours of the rainbow) — feeds commensal bacteria (including the important ‘keystone’ bacteria Akkermansia spp.) and protects the mucin lining; reduces inflammation.
‒ Green tea, blueberries, cranberry, blackcurrants, pomegranates. Blue and red colours. - Mucopolysaccharides (carbs with a mucous component in them) such as slippery elm, marshmallow root, liquorice and flaxseeds, seaweed.
- Fucoidans, which are polysaccharides, in seaweeds and algaes
What is mucin?
glycoproteins found in mucus
What is Intestinal tight junction permeability ?
Intestinal tight junction disassembly contributes to ↑ LPS load and excessive immune reactions.
How to support the intestinal epithelial barrier? x3 nutrients
‒ Glutamine — supplemented or from food, e.g., cabbage juice, spirulina, asparagus.
‒ Zinc carnosine (for epithelial cells), vitamin A, vit D (for epithelial barrier) and N-acetyl glucosamine (tightness of gut barrier).
‒ Bone broth (rich in glycine), collagen.
What to look for on test for in Intestinal tight junction permeability ?
- Look for the missing of Akkermansia because if missing it gives you a risk factor of poor mucosal balance.
- Look for Ruminococcus gnavus (R.gnavus) or R.torques in high amount
- Absence of diversity in Bacteriodes sub-groups can cause the bacteria to become more mucin-degrading – eat the mucosal barrier if no source of fibre in the diet! If you are on a Keto diet you must take fibre supplements to protect your mucosal barrier and avoid metabolic endotoxemia.
- Zonulin (stool) – protein marker when the gut junctions are open -> intestinal permeability – but could also be negative on test… Zonulin can be tested via the serum.
- ‘Cyrex Labs Array 2’ (serum antibodies) – gives an idea if there is intestinal permeability
- Drinks a small sugar and if gets through intestinal barrier will show in urine
- You will get in clinics first a lot of sign and symptoms:
- Is the client presenting a chronic disease
- Metabolic endotoxemia
- C reactive protein raise between 2.5 and 5
What is secretory IgA in the mucosal barrier? What is its role ?
Secretory IgA = resides in the mucosal lining and protects the intestinal epithelium from toxins and pathogenic microbes through a process called ‘immune exclusion’ (promoting the clearance of antigens by blocking their access to epithelial receptors). SIgA can also communicate with our immune system to monitor diseases and microbes.
what is the process that promotes the clearance of antigens by blocking their access to epithelial receptors? what immunoglobulin is responsible for the process in the mucosal barrier?
immune exclusion
Secretory IgA
What is the issue with low IgA
Low SIgA: Increases the risk of GI infections including SIBO. Covid, etc. Viruses can get deeper faster because the mucosal barrier is not there to prevent that.
What can low IgA be caused by?
- Low SIgA can be caused by: Ongoing emotional / physical stress, NSAIDs and antibiotics. Often the reason is chronic stress, toxic stress, problem with the mucosal barrier, celiac disease. Constant exposure to antibiotics
How to naturally increase IgA?
- Address stress.
- Address poor mucosal barrier
- Saccharomyces boulardii (a non-pathogenic yeast) – beneficial yeast for travellers diarrhea, fungal infection, etc. Increase secretory IgA production and is anti-inflammatory – pro biotic.
- Mushrooms (esp. medicinal varieties due to the ↑ beta-glucans).
- Vitamin A (needed for the transport of SIgA over the mucosal lining).
- Vitamin D3 (upregulates SIgA expression).
- Zinc
- Polyphenols (e.g., green tea, cocoa, pomegranate) – increase SIgA and protect mucosal barrier
- Chlorella and Spirulina.
- Probiotics and prebiotics.
- Echinacea spp. Andrographis, Astragalus
What is the elimination diet ?
The elimination diet is the most cost-effective way of identifying a food allergy or intolerance.
* It involves first removing the suspected food(s) from the diet for a period of time and monitoring any change in symptoms.
* The potential offending food is then reintroduced and symptoms are monitored to confirm sensitivity.
What are the most common food causing immune reaction?
gluten (sometimes it might be the fodmap the issue and not the gluten itself) and dairy, corn and soy, eggs, nuts, beef, pork, yeast, citrus, nightshades, chocolate and coffee
What are the 3 stages of the elimination diet and what is their respective length?
Stage 1 (days 1–2) Detox * Increase fruits, vegetables, gluten-free wholegrains, healthy fats, water intake, herbal teas.
* Remove processed foods, confectionary, chocolate, additives, caffeine, etc.
Stage 2 (days 3–14) Elimination * Above, plus remove all suspected foods for 2 weeks (can be done one at a time). If symptoms don’t improve by 3rd week consider other possible triggers.
Stage 3 (days 15 onwards) Reintroduction
(one food at a time!) * Eat the ‘challenge’ food 2–3 times a day for 1–3 days.
* If you notice any symptoms, remove the food and wait for symptoms to completely disappear before challenging the next food.
* If the food does not cause a reaction, it is safe to keep in your diet for the rest of the programme.
* If a food causes a reaction, keep out of the diet for 3 months before challenging again.
What is the 5 stages of the 5R protocol?
Remove What may need to be removed to support healthy GI function? (e.g., offending foods or pathogenic bacteria).
Replace What may need to be replaced to support healthy GI function? (e.g., digestive enzymes, bile salts, stomach acid).
Reinoculation What may be needed to reestablish a healthy balance of microflora? (e.g., reinoculation with pre- and / or probiotics).
Repair What may be needed to regenerate and repair a healthy mucosal layer? (e.g., specific nutrients / phytonutrients).
Rebalance What lifestyle changes may be needed to support gut healing? (e.g., stress reduction, addressing work / life balance).
Describe the Remove stage 1 of the 5R protocol
Remove – 2-3 weeks:
* Foods may be the most important offending agents.
* Remove dietary irritants; i.e., processed food, food additives, sugar, alcohol, caffeine, carrageenan (quite irritant to the guts) etc. => like a simple detox in a way
* Personalised diet; i.e., remove food allergens / foods that trigger an intolerance (e.g., dairy, gluten), low FODMAP, low histamine, specific carbohydrate diet etc.
* Avoid toxins; i.e., pesticides (eat organic), plastic / tinned packaging, non-filtered / distilled water, chemically-laden beauty products.
* Avoid unnecessary drugs; (e.g., NSAIDs) which can damage the GI mucosa / function.
Give an example of herbs that are for the Remove phase of the 5R protocol
o Anti-microbial
o Anti-bacterials
o Anti-parasitics
o Anti-fungals
o Anti-viral
o Anti-microbial herbs (i.e., broad spectrum) — berberine (goldenseal), garlic, oregano, uva ursi.
o Anti-bacterials — e.g., oregano oil, berberine, garlic, neem.
o Anti-parasitics — e.g., black walnut hulls, wormwood, oregano, neem, clove buds, pumpkin seeds.
o Anti-fungals — e.g., oregano oil, caprylic acid, grapefruit seed extract, garlic.
o Anti-viral — e.g., olive leaf extract, nano silver, elderberry, echinacea.
What digestive secretion to replenish during phase II (REPLACE) of the 5R protocol ? x3
- Stomach acid secretions — e.g., digestive bitters, betaine HCl.
- Pancreatic support — e.g., bitters, pancreatic enzymes, plant-based enzyme formulas, less frequent meals.
- Bile support — e.g., choleretics / cholagogues, ox bile.
Give pre/probiotics example for the 5R protocol phase III Reinoculate ? What are SIBO Safe prebiotics?
- Probiotics: Cultured vegetables, fermented foods and drinks (such as sauerkraut, kimchi, kefir – if not on a non-histamine diet), probiotic supplements e.g., Lactobacillus and Bifidobacterium spp.
- Prebiotics: Foods rich in fructans, fructooligosaccharides (FOS), inulin e.g., chicory, leeks, onions, Jerusalem artichokes. SIBO safe prebiotics – PHGG, galacto-oligosaccharides.
- Use the prebiotics for the targeted bacteria you want to repair
In phase 4 (Repair) of the 5R protocol, which nutrients for the epithelial tight junctions?
- For epithelial and tight junction support: L-glutamine, N-acetyl glucosamine, quercetin, zinc, EFAs (incl. EPA / DHA), B vitamins, D vitamins, vitamin A, collagen, bone broth, aloe vera (↑ fibroblast collagen synthesis and inhibits COX).
In phase 4 (Repair) of the 5R protocol, which nutrients for the mucous barrier?
- Supporting the mucous barrier: Demulcent herbs rich in mucilage. slippery elm, liquorice, marshmallow root, oats, aloe vera juice, meadowsweet. Fibre. Polyphenols (↑ keystone bacterial species = ↑ mucin + SIgA). Polyphenols rich food.
In phase 4 (Repair) of the 5R protocol, which nutrients for increasing IgA?
- Increase SIgA where needed (e.g., S. boulardii) and reduce inflammation (e.g., curcumin – amazing for the gut). Vit A and D, Zinc.
What lifestyle choices x3 to pay attention to in phase 5 of the 5R protocol, rebalance?
- Address stress; breathing exercises, nervines and adaptogens, e.g., passionflower, ashwagandha, etc.
- Practise good sleep hygiene.
- Undertake regular exercise.
What specific conditions (x4) need more time for the 5R protocol?
- Parasites or worms often need a second phase of antimicrobials to prevent eggs hatching. Either do 10 days on, 10 days off, then repeat or hold out the treatment for a whole 4 weeks. So repeat 2x because eggs can hatch in that time. That is the minimum. OR you could do a straight 4 weeks to make sure you get the eggs.
- SIBO / strong dysbiosis may need 4 weeks of anti-microbials and also a repeat.
- Deficient microbiomes will take time to repair / re-inoculate, so do for a minimum of 4 weeks.
- Food intolerances need the gut wall to be repaired before reintroducing; a minimum of 6-week intervention is often needed.
What is dysbiosis?
‘Dysbiosis’ = an imbalance in the colonies of the bowel flora, leading to a potential disruption in both local and systemic health.
what is the causes of dysbiosis (Aetiology)?
- Poor diet (highly processed, ↑ refined carbs, ↓ fibre, ↓ polyphenols).
- Intestinal / oral infections. A pathogen can cause an imbalance with the rest of our gut microbes – need to be removed before finding the balance again.
- Medications: Antibiotics / antacids / OCP.
- Chronic stress (e.g. = ↓ digestive secretions).
- Low digestive secretions (e.g. HCl, bile).
- C-section, non-breastfed.
- GI surgery and abdominal scar tissue.
- Note: These factors should be extracted from your case taking.
