Inflammatory Bowel Diseases (IBD)

Inflammatory Bowel Diseases (IBD)

Protocol

This Inflammatory Bowel Diseases (IBD) Protocol is intended as information for Practitioners and should not be substituted for medical advice, diagnosis or treatment.

ACUTE PHASE OR EXACERBATION (FLARE)

Reduce acute inflammation and manage symptoms

Glutamine & Boswellia (BosPure® Boswellia) for Intestinal Integrity 1 serve twice daily
Lactobacillus plantarum 299v 1 serve twice daily
Meta Mag® - Magnesium Bisglycinate, Corydalis and California Poppy for Pain 1 serve twice daily
AND/OR if post-infectious or with marked diarrhoea:

S. Boulardii and Bi-07 for Management of Dysbiosis

1 capsule twice daily
Reduce pathogenic microbes and biofilm:

Small Intestinal Bacterial Control

2 capsules twice daily with food

Reduce dietary allergens / triggers

  • Gluten Free Diet for 2 weeks OR if no improvement
  • Low FODMAP Diet for 2 weeks OR if no improvement
  • Elimination Diet – 6-12 week program
OR
  • Wellness Diet (as per Wellness and Healthy Ageing Program)

 

CHRONIC PHASE / REMISSION / CORE TREATMENT

Support digestion and optimise detoxification

Gut Pathogen Elimination Program

Additional digestive support options:

Impaired gastric function – low HCl, dyspepsia

Gastric Acid Support

1-3 tablets 30 minutes after meals

Impaired intestinal digestion:

High Potency Vegetarian Digestive Enzymes

1 capsule with meals

Prebiotics to promote healthy microbiome:

MetaFibre™and EpiCor® for Gastrointestinal Health

2 level scoops in water daily

Manage CHRONIC inflammation: Regulate systemic immunity and modulate immune responses

Specialised Pro-Resolving Mediators[1] 1 capsule twice daily
Promote T-reg number, activity and function:

Lactobacillus paracasei LP-33® and Lactobacillus rhamnosus (LGG®) for Immune Control

1 capsule daily

If vitamin D low (<100nmol/l):

Vitamin D3 Capsules or Liquid

1-4 capsules (1000IU-4000IU) daily

Stimulate immunity if with underlying chronic infection or recurrent infection

Lactobacillus plantarum (HEAL 9); Lactobacillus paracasei (8700:2) and Lactobacillus rhamnosus (LGG®) to Boost Immunity 1 capsule daily
Cordyceps, Coriolus and Reishi for Immune Stimulation

Acute: 1 serve three times daily

Chronic: 1 serve daily

High Bioavailability Zinc with Vitamin C 1 serve (1/2 tsp) daily

Consume an anti-inflammatory low-reactive diet and exercise regularly

Elimination and Rechallenge Program

OR

Wellness and Healthy Ageing Program

If exacerbated by stress

Stress Less Program

 

Alphabetical Reference of Nutritional Support

Formula Catch Phrase Key Benefits
Cordyceps, Coriolus and Reishi for Immune Stimulation Four clinically proven medicinal mushroom extracts effectively stimulate immunity whilst modulating inflammation, to support the resolution of chronic, latent and/or recurrent infectious conditions. Safe for use in autoimmune diseases, such as IBD.
Gastric Acid Support Hydrochloric acid and digestive nutrition to support protein digestion. Poorly digested proteins commonly trigger immune responses contributing to food allergy and sensitivity.
Glutamine & Boswellia (BosPure® Boswellia)for Intestinal Integrity Glutamine, Boswellia and nutrients blend to manage the unique impact of gut micro-organisms (biofilm) on inflamed intestinal mucosa with prebiotic, antimicrobial and anti-inflammatory activity, all of which help manage the pathophysiology of IBD.
High Bioavailability Zinc with Vitamin C Zinc and vitamin C are amongst the most critical nutrients in healthy immunity, as both are involved in wound healing, immune balance and boost resistance to infection.
High Potency Vegetarian Digestive Enzymes A non-porcine derived vegetarian digestive enzyme formula supporting pancreatic digestive capacity.
Lactobacillus paracasei LP-33® and Lactobacillus rhamnosus (LGG®) for Immune Control Two probiotic strains which help restore immune control and moderate over-active immune responses. These strains assist immune regulation by supporting T-reg cell function and increasing anti-inflammatory cytokines such as IL-10.
Lactobacillus plantarum 299v An anti-inflammatory probiotic strain to reduce the signs and symptoms of IBS and IBD. The anti-inflammatory properties of 299v have also been shown to reduce systemic inflammation (hsCRP).
Lactobacillus plantarum (HEAL 9); Lactobacillus paracasei (8700:2) and Lactobacillus rhamnosus (LGG®) to Boost Immunity A unique combination of probiotics for patients requiring immune stimulation, particularly for those with immune insufficiency, chronic recurrent infections, post viral immune depletion and other conditions associated with low immunity. This combination enhances a variety of immune responses, including T-reg and FOXP3 expressing cells, as well as increasing NK cells and phagocytosis.
Meta Mag® – Magnesium Bisglycinate, Corydalis and California Poppy for Pain A magnesium and herbal formula for acute or chronic pain management. Magnesium has been shown to block glutamate via inhibition of the NMDA receptor, thereby reducing excitatory neurotransmission. Corydalis is an effective analgesic in both inflammatory and neuropathic pain.
MetaFibre™ and EpiCor® for Gastrointestinal Health A prebiotic combination of digestion resistant starch with a proprietary yeast extract to promote the growth of beneficial flora, reduces intestinal inflammation and support healthy gut barrier function, all targets of treatment in IBD.
S. Boulardii and Bi-07 for Management of Dysbiosis S.boulardii is blended with Bifidobacterium lactis Bi-07 to address dysbiosis and help balance gut microbiota, a common imbalance in IBS.
Small Intestinal Bacterial Control A combination of phellodendron with potent essential oils to target overgrowth of flora and biofilm persistence in the small intestines, which is associated with IBS, IBD, fatigue and systemic inflammation.
Specialised Pro-Resolving Mediators SPMs are lipid mediators that promote resolution, reduce pain, encourage clearance of pathogens and mitigate pathological inflammation, without immunosuppression. SPMs regulate macrophage polarisation; triggering the switch from M1 (proinflammatory) to the M2 (anti-inflammatory) phenotype, therefore promoting resolution.
Vitamin D3 Vitamin D is essential for immune defence, as it stimulated antimicrobial peptides and WBC activity against pathogens, recruits immune defences (Th1/Th2 responses), shown to be preventative in recurrent infections and auto-immunity.

 

Supportive Lifestyle Programs

Elimination Diet

(From the Elimination and Rechallenge Program)

The Elimination Diet avoids the most common food allergies/irritants. Following the diet for 2 weeks will show if the patient has symptomatic improvements. If so, the diet may be followed with food challenges to identify dietary triggers to digestive or general symptoms.

Low FODMAP Diet

FODMAP is the acronym for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols, a group of carbohydrates that may be problematic in some individuals as they are poorly absorbed, draw water into the gut lumen and undergo rapid microbial fermentation. FODMAPs may exacerbate symptoms of altered bowel motility, bloating, pain and excessive gas production. The diet includes elimination, reintroduction and maintenance phases.

Gut Pathogen Elimination Program

A four week program specially created for those who experience ongoing or extensive digestive symptoms, or who have been identified with an imbalance in their gut flora, which can negatively impact health and wellbeing. This program helps to restore healthy gastrointestinal function and rebuild a healthy intestinal microbial balance.

Stress Less Program

Stress is a potent cause and consequence of digestive disorders. The Stress Less Program incorporates dietary and lifestyle advice alongside herbal and nutritional recommendations designed to support emotional wellbeing, mental health and therefore effective immunity.

Wellness Diet

(From Wellness and Healthy Ageing Program)

This program recommends a low-reactive, unprocessed diet with lifestyle recommendations for exercise, and effective stress management – all factors associated with healthy ageing and chronic disease prevention.

Definition

Inflammatory bowel diseases (IBD) are non-specific, chronic inflammatory diseases of the GIT. The most commonly affected parts are the distal ileum and colon, but inflammation may also affect any part of the GIT from the mouth to the anus. IBD may present at any age, but onset peaks between 15 and 40 years of age. Crohn's disease and ulcerative colitis are the most common inflammatory bowel disorders seen in clinical practice.

Crohn's disease is chronic inflammation involving all layers of the intestinal wall and any part of the gastrointestinal tract – although it most commonly affects the ileum and the caecum. It is characterised by patchy mucosal lesions containing ulcers, fissures, and granulomas. The disease often presents with a pattern of intermittent remittance and relapses. Nutritional deficiencies due to malabsorption are common and developmental retardation may result in those who develop this disorder during childhood.

Ulcerative colitis is a chronic, nonspecific inflammatory bowel disease involving the mucosa and submucosa of the colon. It usually includes the rectum and is characterised by uniform and continuous ulceration, bloody diarrhoea and rectal bleeding. Recurrent inflammation may eventually lead to shortening of the colon, and with long-standing UC, the surface epithelium may show dysplastic changes. Like Crohn’s disease, ulcerative colitis often presents with a pattern of intermittent remittance and relapses.

Aetiology / Risk factors

Factors that can contribute to the incidence of IBD include the following:

Food and/or chemical sensitivities or allergies

Intestinal infections, dysbiosis and/or Leaky Gut Syndrome

Family history of IBD

History of chronic viral and/or bacterial infection – especially EBV, CMV, Yersinia enterocolitica, Pseudomonas, Chlamydia

Frequent dieting

High stress or poor stress tolerance

Highly refined sugar diet

Use of medications which reduce normal intestinal flora (e.g., antibiotics)

Jewish heritage and Caucasians are more susceptible

Living in an urban, industrialised environment

Cigarette smoking

Dietary patterns – increased sugar consumption, decreased fruit and vegetable consumption and increased trans-fatty acid consumption increases the risk for IBD

Signs and Symptoms

Common signs and symptoms of IBD include

Diarrhoea with or without gross or occult blood (occurs in the majority of patients)

Abdominal pain (often after eating and relieved with defaecation)

Abdominal distension, tenderness or pain, especially pain in the right lower quadrant

Fatigue, anaemia

Poor appetite, weight loss, malnutrition

Steatorrhoea (fatty stool)

Nausea and vomiting

Anal-rectal complications such as fistulae, fissures, or perirectal abscesses

Rectal bleeding

High fever

Tachycardia

Rectal tenesmus (sense of needing to evacuate, even when bowel is empty)

Constipation (this may occur instead of diarrhoea if rectal involvement is predominant)

Arthralgia – generalised joint pain

Diet and Lifestyle

Dietary and lifestyle guidelines that may assist in the management of IBD:

Refer to Low FODMAP diet, Gluten Free / Dairy Free diet and/or Elimination and Rechallenge program to identify specific irritants for individual patients.

Decreasing consumption of red meat, particularly lamb and beef, will help to reduce inflammatory dietary omega 6 and arachidonic acid levels.

Decrease sugar consumption and trans-fatty acid consumption.

Moderation of alcohol intake has been shown to be beneficial.

Smoking cessation is a priority in currently smoking patients.

Regular aerobic exercise (starting slowly and increasing as patient’s fitness improves) may assist.

Following the principles of the Wellness and Healthy Ageing Program – including vegetables, grains, nuts, seeds, fruit and complete proteins providing optimal micronutrient ratios.

Pathology Tests

TEST

INTERPRETATION GUIDELINES

Stool analysis

Microscopic examination of faecal sample reveals blood/mucous.

Endoscopy

An endoscope is a medical device consisting of a camera mounted on a flexible tube. Small instruments can be used to take samples of suspicious tissues through the endoscope. In gastrointestinal endoscopy, this device is inserted through the mouth or anus to visually analyse the GIT.

Barium enema

Barium sulphate, a chalky substance, is used to partially fill and open up the colon. When the colon is about half-full of barium, air is inserted to cause the colon to expand. X-rays can show diverticula, fistulae, abscesses.

Ultrasound

Abdominal ultrasound performed diagnostically may reveal inflammation, diverticula, and abscesses.

Full blood count

Anaemias are a cause of fatigue, and a WBC differential may indicate infection

ESR

Child: 2-15 mm/hr

Adult female

17-50 years: 3-19 mm/hr

51-70 years: <20 mm/hr

>70 years: <35 mm/hr

Adult male

17-50 years: 1-10 mm/hr

51-70 years: <14 mm/hr

>70 years: <30 mm/hr

hsCRP

An acute phase protein produced during inflammation,

Normal range 0.2 – 3 mg/L, ideally <1mg/L

Gluten sensitivity

Refer to Coeliac Disease protocol

Omega-3 Index Test

A validated test that measures red-blood cell (RBC) EPA and DHA status to personalise supplemental and diet prescriptions, as well as identifying those at risk of health conditions associated with omega-3 deficiency. An Omega-3 Index in the desirable range of 8%-12% is an indicator of better overall health.

Pharmaceutical Treatments

5-Aminosalicylic Acid Derivatives: these anti-inflammatory drugs are the first line of pharmaceutical treatment. Examples include mesalazine and sulfasalazine. Side effects include such as dyspepsia, nausea, urine discoloration, lowered sperm count, neutropenia and haemolytic anaemia.

Corticosteroids: these drugs suppress inflammation during active phases of IBD, but are ineffective for maintenance therapy. Side effects of corticosteroids are acne, increased susceptibility to infection (including sepsis), osteoporosis, hypertension, hirsutism, diabetes, glaucoma, and cataract formation.

Immunosuppressives: these are used for patients as a steroid-sparing therapy; used in conjunction with steroids. Relatively low doses of these medications are used (lower doses than in the case of organ transplantation). Examples include mercaptopurine, azathioprine, cyclosporine and methotrexate.

Biological agents: Tumour-Necrosis-Factor alpha (TNF-α) blockers are biologic medications, including Infliximab (Remicade), Adalimumab (Humira) and Certolizumab pegol (Cimzia). Designed for moderate to severe IBD for those who don't respond to or can't tolerate other treatments, and works quickly to bring on remission by neutralizing tumor necrosis factor (TNF). Not suitable for those with heart failure, multiple sclerosis, cancer or a history of cancer. Pre-requisites for these drugs are a skin test for tuberculosis, a chest X-ray and screening for hepatitis B. Possible complications of TNF-α blockers are tuberculosis and serious fungal infections. The most common side effects are skin irritation and pain at the injection site, nausea, runny nose and upper respiratory infection. Infliximab is linked to an increased risk of infection, especially tuberculosis and reactivation of viral hepatitis, and may increase the risk of blood problems and cancer. Common side effects of Certolizumab pegol (Cimzia) include headache, upper respiratory infections, abdominal pain, nausea and reactions at the injection site.

Natalizumab (Tysabri) works by inhibiting certain immune cell molecules — integrins — from binding to intestinal lining. Natalizumab is approved for people with moderate to severe Crohn's disease with evidence of inflammation and who aren't responding well to other conventional Crohn's disease therapies. Because the drug is associated with a rare, but serious, risk of multifocal leukoencephalopathy — a brain infection that usually leads to death or severe disability — you must be enrolled in a special program to use it.

Antibiotic therapy: ciprofloxacin and/or metronidazole are used in the case of an abscess, bacterial overgrowth, ileal resection and/or perianal disease. Side effects include nausea, anorexia, and paraesthesia.

Antidiarrheal drugs: may be considered for mild to moderate diarrhoea, but there is a risk of toxic mega-colon when agents that slow motility are used, particularly in the case of severe disease. Loperamide and diphenoxylate may reduce spasm; cholestyramine may reduce diarrhoea.

Footnotes

[*]Ensuring patients maintain an omega 3 index above 8% is essential to SPM production. Omega-3 status can be evaluated/monitored using the Omega-3 Index Test (refer to pathology testing section). In the instance of deficiency, consider co-prescribing an omega-3 essential fatty acid supplement.