IBS digestive insufficiency Flashcards
Conjugated Bile Acid Deficiency -
Malabsorbed Substrate?
Fat, fat-soluble vitamins,
calcium, magnesium
Pancreatic insufficiency-
Malabsorbed Substrate?
Fat, protein, CHO
fat-soluble vitamins,
B12
Reduced mucosal digestion-
Malabsorbed Substrate?
CHO, protein
Intraluminal consumption of nutrients-
Malabsorbed Substrate?
B12, macronutrients
Reduced mucosal absorption-
Malabsorbed Substrate?
Fat, CHO, protein,
vitamins
minerals
Decreased transport-
Malabsorbed Substrate?
Fat, protein
Decreased gastric acid, IF-
Malabsorbed Substrate?
B12
Rapid gastric emptying,
decreased gastric mixing-
Malabsorbed Substrate?
Fat, protein
Conjugated Bile Acid Deficiency - Causes?
Liver disease, biliary obstruction, SIBO, ileal disease, CCK deficiency
Pancreatic insufficiency- Causes?
Congenital,
chronic pancreatitis,
pancreatic tumors,
hyperacidity (inactivating pancreatic enzymes)
Reduced mucosal digestion- Causes?
Mucosal disease (i.e. Crohn’s, Celiac), brush border enzyme deficiency (i.e. lactase)
Intraluminal consumption of
nutrients- Causes?
SIBO, parasitic infection (i.e. D. latum)
Reduced mucosal absorption - Causes?
Mucosal disease (i.e. Crohn’s, Celiac),
intestinal surgery,
infections,
malignancy
Decreased transport- Causes?
Lymphatic disease venous stasis (i.e. CHF)
Decreased gastric acid, IF- Causes?
Atrophic gastritis,
pernicious anemia,
prior gastric resection
Rapid gastric emptying,
decreased gastric mixing- Causes?
Gastroparesis
prior surgery,
autonomic dysfunction.*
*Prior gastric surgery (involving the pylorus and or including vagatomy)-accelerated emptying and decreased time for absorption in the small bowel;
Gastroparesis - decreased gastric mixing and impaired protein and fat assimilation
Non-invasive marker for evaluating exocrine pancreatic function
elastase
food derived proteolytic enzymes
Bromelain (from pineapple)
• Papain (from papaya)
How to appropriately prescribe digestive enzymes
Pancreatin Range:
500-2500
units/kg/meal
How to appropriately prescribe bile salts,
Bile salts (ox bile): 500–1000 mg with food
How to appropriately prescribe betaine
hydrochloride
Take 1 Betaine HCl tablet (350-750 mg) with a meal that contains
protein.
• If ANY negative symptoms (tingling or warmth in stomach, GERD,
diarrhea, neck ache, etc.), STOP. Experiment is over.
• If no change or feel improvement: Continue for 2 days, then h to 2
tablets at the next protein-containing meal. Increase up to 2500 mg
with meals.
Apply select laboratory tools that can help diagnose malabsorption
and maldigestion.
Pancreatic Elastase - to check pancreatic function
Increased putrefactive SCFA - think hypochlorhydria
Increased fecal fat – think low bile acid
Cholagogues gb/Choleretics (liver)
BOTANICALS
- Dandelion root
- Taurine
- Limonene:
cholegogue foods
- Coffee
- Radishes (horse, red, daikon)
- Dandelion
- Chicory and other bitter greens
- Artichoke
Promotility drugs
- Prucalopride
- Low-dose naltrexone
- Low-dose erythromycin
- Metoclopramide
Non-Pharmacologic Prokinetic Approaches
- Iberogast (adaptogenic herbal formula):
- Ginger root
- Tryptophan:
- Magnesium citrate:
- Ascorbic acid or Sodium Ascorbate
- Vitamin D: Minimum D3 5,000 IU qd
- Swedish bitters:
- D-Limonene: 1000 mg BID
- Triphala
- Chinese Herbs (TJ 43)
- Acupuncture & acupressure
- Deep breathing/stress reduction
- Exercise
Cholagogues g/Choleretics (liver)
- Dandelion root (Taraxacum officinale):
- Taurine: 500–1000 mg with food
- Limonene:
Foods that act as Cholagogues
- Coffee
- Radishes (horse, red, daikon)
- Dandelion
- Chicory and other bitter greens
- Artichoke
Optimal stool transit time
12-24 hrs
Maintaining motility w food
• Increased fruits, vegetables, ancient grains, beans, seeds, water
• Probiotic-rich foods/fermented foods
• Psyllium husks, pectin
• Flax seeds (contain 6-12% mucilage), flaxseed oil
• Cod liver oil
• Natural colonic laxatives: Aloe vera, senna, buckthorn, rhubarb (note that
anthraquinones should not be used long-term as they are stimulant
laxatives)
• Address root causes! E.g., thyroid, diabetes, med side effects, etc
promotility drugs
- Prucalopride
- Low-dose naltrexone
- Low-dose erythromycin
- Metoclopramide
Non-Pharmacologic Prokinetic Approaches
• Iberogast (adaptogenic herbal formula): 20 drops tid
• Ginger root: 1000mg 1-3x/d or 1500-2000 mg/d
• Tryptophan: 1-3, 500 mg caps BID (GI motility is modulated by
serotonin.)
• Magnesium citrate: 250 mg 2-4x/d and/or increase dietary
magnesium consumption
• Ascorbic acid or Sodium Ascorbate: Up to 5 g/d
• Vitamin D: Minimum D3 5,000 IU qd
• Swedish bitters: Gastric - 1 Tbsp before meals
• D-Limonene: 1000 mg BID
• Triphala
• Chinese Herbs (TJ 43)
• Acupuncture & acupressure: 20-30 min, 3x/week
• Deep breathing/stress reduction
• Exercise
Iberogast (
Prokinetic adaptogenic herbal
