ACG REPORT: D-IBS TREATED EFFECTIVELY WITH LEAP

Hey BonnieNice to see youYes been busy beeHave some great things to discuss since we started doing cytokine assays on IBS subjects last year, found some very enlightening things, which will out as time passes.Slso have winderful new anecdotes from when those hurricanes last year (both eyewalls passed rioght over my house) and how they tore the roof off my house (with me in it) and all the "excitment" such near-death experiences bring.Not a hurricane hit in that area of Florida for 40 years...so I move there and sure enough (2) direct hits in a row in the same season weeks apart.Anyway I'll come back and share a tale or two with you when I have time...also some interesting stuff about what happens to those patients with the positive breath tests you speak after they have been on oligoantigenic diet for awhile...they normalize..???!!!Stay tuned...see you soon MNL

Been on the road a week now so much housekeeping work to do! here are a few quick shots.1. "What about IBS-C?"In vivos studies show there is no pattern of cellular inflammatory infiltrate or mucosal changes which could be linked to local alteration of response to benign ingested antigens in the so called C-IBS population.In vitro only a subpopulation, those with serious issues with comorbid F.A.P., show any significant loss of oral tolerance to benign antigens.It's a different disease.Post-inflammatogenic (post infectious gastritis IBS onset) D-IBS'ers have a specific characterstic inflammatory pattern esp. in the small bowel compared to the D-IBS patients with no history of a precursor "gastritis".The neuroimmune mediators which are liberated my gut muclsal immunocytes and circulating immunocytes (activated T cells moving thorugh the gut lymphatics and systemic lymphatics, granulocytes in the plasma, even platelets in some people but not much incolvement buy eosinophils for example) are mediators which are specifc to the adaptive immune response to NON BENIGN ANTIGENS (pathogens).The array of cytokines and lymphokines (subclass) cause local symptoms associated with D-IBS and the systemic symptoms we often feel as the episode comes on (chills, clamminess, fog-brain, hot flashes, many others)along with the eventual cramps and diarrhea.The very absecne of these symptoms in the so called C-TYPE is indicative of the lack of abundant release of these mediators.The "cyclics" typicall belong to the D-IBS population....there is behavioral response pattern that can be seen in many D'types which inevitably leads to the cycle of diarrhea-constipation-diarreha-constipation which can be broken when you can diminish or remove altogether the d episodes...that removes the event which precipitates the ensuing constipation which then precedes the next diarrheci episode.2a. "I asked my gi doc last week if I could possibly have fructose malabsorption, her reply was, just don't eat any fruits and see."Hidden message: "I did not buy one of those machines and don't want to send you to someone else", though the answer is not 100% off base. IF you eliminate fructose from your diet 100% for a week to 10 days, and your symptoms subside, then you reintroduce it and you have symptoms which reappear there is about a 50% chance you suffer fructose maldigestion. On the other hand it could be one of several other problems which would not require the removal of all fructose...or even any. So you could just flip a coin too and be 50% right.2b. "Then I asked her about bile malabsorption she said no one in Canada is doing these tests anymore, they stopped 15 years ago. Huh?"I don't know about up there but I do know that SeHCAT Testing was really hard for me to find for a patient I had (the wife of an NFL Major Executive who I beleived was suffering from bile acid malabsorption, not IBS). I could not get this lady tested anywhere down here ven at the medical schools.So we just had her doc do trial with bile acid sequestrant (Questran). HAH!!! Give them biy a cee-gar.I would say you try this only if you have symptoms of bad frequent diarrhea episodes which do not fit the ROME criteria...for example she did not have a lot of pain with her episodes and even though she also had loss of oral tolerance, it could have been a consequence of the BAM and if the BAM were treated her tolerance might increase.Indeed this worked well...her LEAP diet ws first and got her half way there, Questran got her the rest of the way...then later on restest she had regained some tolerance and was able to reintroduce some foods in moderation.3. "She just wanted to do the colonoscopy, which was done yesterday. After the procedure was completed and upon waking up she said everything was fine and to see her in 3 weeks for the biopsy results"If she is to follow the current clinical guidelines (as they exist in US and Canada) once the pt is referred to her and if you had any of the red flags then she did need to do a scope. One can never really fault a GI doc for scoping an IBS patient....even though rarely (2%) does the diagnosis change or another nasty found.At least you know that you got no polyps!In the meantime, if you do have symptoms specific to ROME I and no red flags you may want to consider oligoantigenic diet therapy as it is efficacious.IF on the other hand you have more what seems to be "functional diarrhea" it is not undreasonable to do a trial bile acid sequestrant. "EMPRICAL TREATMENT" IS the way the "opinion leaders" say to approach the syndrome...meaning try this try that try again as long as it is something WE tried first LOL!4. "What Stephanie is going to regular school now?"LOL how fast they grow up eh?Yep she is the terror of her first grade class! Just the other day I got another note from the teacher that she had to "pull a red card" (bad behavior be separated) again.On inquiry she stated that "Adam was not nice to me. He made fun of my toof." (she has 3 babyteeth gaps and looks like, well...listen)What did he say?"Adam said I look like the Pirates of The Caribean"So what did you do?"I pirated him!"How did you do that?"I smack him in the mouth with my sword!" as she waves her empty fist around like Johnny Depp and POW in my face.She has a tendency to "pirate" those who challenge her.We have to work on bow pirates trade insults for insults, and swords for swords, not swords for insults. 5. "And Really?! The breath tests noormalized? That is incredible. By what mechanism-did they replace the bacteria or by some immune system mechanism?"Sometimes it appears that dysbiosis of course can be responsible for the loss of oral tolerance. The system of oral tolerance to benign antigens requires not only the proper immunocytes, antibodies, and intact transport mechanisms across the mucosa and into the lymphatics but intact flora as well.Sometimes it appears the root of the problem lies first within the activated T cell system and sometimes first within the flora. Remeber this is a process of DAMPENING an normal inflammatory repsonse when a BENIGN ANTIGEN is seen in the ingested goop, and inflammatory respopnse which is NOT DAMPENED and allowed to proceed when a BAD ANTIGEN is ingested.The mediators released can alter gut wall integrity and lead to further systmeic activation and they can be recovered from the luman (in jejunal washings) wherein chronic presence of some interleukins, designed to make the body a bad place for pathogens to live, can also knock-off some of the symbiotic bacteria as well.You can end up with a "cycle" which began either with disruption of the flora (lots of broad specturm antibiotics) or disruption of the primary adaptive immuen response (Tcells armed against benign antigens for some reason). even occassionally actual allergy (IgE specific to the antigen).Based on what is known, versus what is speculated, so far about oral tolerance one thing is clear...the adverse environment in the gut created by an inflammatory response can alter the flora, or altered flora can lead to an un-dampened inflammtory response to benign antigens.IF we remove the antigens which are provoking the reaction (ie: preventing a blunting of the normal adaptive immune response) then all returns to normal in the gut and the environment for the symbiotic bacteria to reproduce faster than they are being killed is restore.In time the flora should return to normal, the breath test should normalize. This will happen in some...but it is so early in coming to understand the whole process there is no way to tell yet who is who and which from what.At least we can identify benign antigens which the person has lost tolerance to and get them away from the GALT, thus keeping the horse in the barn.MNL