Probiotics

September 2017 – Probiotics

Question:

Thank-you for being available to take questions. I am 65 and have had an Ileostomy for 6 yrs. I have had Crohn’s for 35 years and Ankylosing Spondylitis for 5 or more years. So, I face many indirect over-the-counter pharmaceutical costs that I try to struggle to manage. There has been a good deal of research and excitement about the value of probiotics.

Given that probiotics are both expensive and usually reside in the large intestine, is it worthwhile for me to take them? Has there been any research on this? What have been the results?

Response:

There is not much literature on the use of probiotics in the ostomate specifically. However, there may be a place in therapy to combat bacterial overgrowth in the small intestine. Bacterial overgrowth leads to fermentation of carbohydrates, which produces gases such as hydrogen and methane. These gases can lead to irritation of the intestinal lining and inhibition of proper nutrient absorption. More research is needed, but probiotics may be useful in controlling bacterial overgrowth and improving the health of the remaining intestinal lining.

Probiotics have been available for many years, but only recently have controlled clinical trials in IBD been done.

There is growing evidence that the functioning of the immune system systemically and at the intestinal tract level can be positively altered by probiotics. Available studies of probiotics have tried to determine the mechanisms by which they work. Proposed mechanisms of action of probiotics in the intestinal tract are: secretion of antimicrobial substances to prevent growth of “bad” bacteria, to block “bad” bacteria from attaching to the lining of the intestinal tract, to strengthen intestinal tract lining integrity, and to enhance the function of the immune system in fighting “bad” bacteria. Bad bacteria is the pathogenic (disease causing) bacteria, including E. coli, Salmonella, Shigella and Vibrio cholera. There have also been clinical trials that have shown no significant benefit, but also no negative side effects.

Although probiotic use is generally considered a safe intervention in healthy individuals, there are potential negative effects, especially for those who are immune-compromised. Immuno-compromised conditions include, but are not limited to immunodeficiency diseases, malignancy, pregnancy, etc. The potential negative effect for the immune-compromised individual is sepsis, which means that the probiotic could end up being a potential source of infection that could make its way into the bloodstream. Due to the potential for serious risk, I recommend consulting your physician before taking concentrated quantities of probiotics found in tablets and capsules.

Probiotics can be found at any retail/pharmacy, usually in the vitamin aisle.

There are many different options in tablet/capsule form that are not as expensive that are worth a try. There are other sources of probiotics such as in certain yogurts and dairy products. Make sure they say that they contain probiotics on the label because not all yogurts contain probiotics.

I would recommend that everyone consult their physician prior to starting a new medication, including probiotics, to weigh the risk vs. benefit.

Most clinical studies have not focused on the probiotics role in the ostomate, but they seem to be a viable new added option in treating IBD.

Following is an informative article that you may find helpful, published in Ostomy Canada Magazine, (Ostomy Canada Society), in the Winter 2015 Edition. Written by Shabita Teja BscP (Shabita is a Medical Advisor for OCS and a member of UOA Vancouver BC Chapter)

SIBO stands for small intestinal bacterial overgrowth. Our intestines are divided into two groups – the small and large intestine (also known as the colon). The small intestine is where food is digested and absorbed and in which wave like movements help to flush bacteria into our large intestine. You have about three pounds and over 500 species of bacteria in your intestines. Among all of these bacteria, there are good guys and bad guys. If the bad bacteria take over or move into an area where they shouldn’t be in like in your small intestine, they start fermenting the food you digest, particularly carbohydrates. This imbalance is called SIBO and it occurs when bacteria overgrow in the small intestine and are in the wrong place at the wrong time. These misplaced bacteria cause a number of problems which translate to the symptoms of SIBO.

Since the bacteria are consuming our food, deficiencies in vitamins like B12 and iron occur. After eating our food, the bacteria produce gas within our small intestine causing abdominal pain and bloating, constipation, diarrhea (or both), belching and flatulence. The bacteria decrease proper fat absorption leading to fat soluble vitamin (A, D, E, and K) deficiencies and fatty stools. Bacteria also interfere with our normal digestion and absorption of food and are associated with damage to the lining of the small intestine, often known as leaky gut syndrome. Through the damaged lining, larger food particles that cannot be fully digested enter into the body and our immune system reacts to this causing food allergies and sensitivities which can manifest as chronic fatigue, headache, joint and body pain, eczema, rosacea, and even depression. Other symptoms of SIBO include heartburn, nausea, and weight loss.

The main symptoms of SIBO – abdominal bloating and pain, constipation, diarrhea – are those of irritable bowel syndrome (IBS) and it is now thought that SIBO is an underlying cause of IBS. In fact, SIBO has been shown to exist in 70-80% ofIBS patients. There are certain factors that increase the chances a patient’s IBS is actually caused by SIBO. For example, when IBS is developed following stomach flu or Travellers’ diarrhea, if there is a dramatic transient improvement in IBS symptoms after antibiotic treatment or if there is worsening of IBS symptoms from ingesting probiotic supplements that contain PREbiotics. Diseases associated with SIBO include celiac disease and inflammatory bowel disease (IBD) which includes Crohn’s disease and ulcerative colitis. SIBO has been reported in 25% of Crohn’s patients. Celiac patients that still have digestive symptoms even after following a gluten free diet have a high probability of SIBO.

Certain people are more predisposed to developing SIBO due to risk factors such as disordered wave like movement of the small intestine leading to an accumulation of bacteria, disorders of the immune system and conditions causing bacteria from the colon to enter the small intestine. As ostomates, we have a higher risk of developing SIBO as bacterial overgrowth increases after major abdominal surgery, specifically bowel resection. Factors that increase this risk include loss of the ileocecal valve, which is at the junction of the small and large intestine and prevents reflux of bacteria from the colon into the small intestine. Other predisposing factors include diabetic neuropathy, anatomical disorders such as diverticulae, surgical blind loops and bowel obstruction, chronic pancreatitis or low/ lack of stomach acid. Patients with Crohn’s disease are at a higher risk of developing SIBO. Furthermore, an acute flare of Crohn’s disease can mimic the symptoms of SIBO, namely abdominal pain, weight loss, diarrhea and increased frequency of bowel movements.

SIBO is now diagnosed and assessed through a non-invasive breath test which measures hydrogen and methane gases. When some bacteria digest food they produce gases. In fact, only bacteria, not humans, produce hydrogen and methane as byproducts of metabolism. Your doctor will interpret a positive or negative SIBO test by evaluating the levels of the two gases as well as the timing of when the gas levels rose.

The treatment of SIBO involves destroying the bacteria that is wrecking havoc in the small intestine. There are two options for killing the bacterial overgrowth: two weeks of a specific antibiotic called Rifaximin, or four to six weeks of antimicrobial herb- al medicine. Although both methods are effects, Rifaximin is faster in eradicating the bacteria. The other benefit to Rifaximin is that it is poorly absorbed which means it stays local to the gastrointestinal tract and doesn’t travel through the blood to affect other tissues. The herbal antimicrobials commonly used are allicin from garlic (the highest potency formula is Allimed), oregano oil, berberine, neem and cinnamon. A multicenter study found that herbal therapies are at least as effective as Rifaximin with similar response rates and safety profiles. In addition, enteric coated peppermint oil capsules have been used to treat abdominal pain associated with SIBO.

Dietary treatments work on reducing the food sources for the bacteria by feeding the person but starving the bacteria. The bacteria in SIBO eat carbohydrates primarily so all the recommended SIBO diets decrease carbohydrates in an effort to limit the bacterial food supply. The established SIBO treatment diets are:

  • Specific Carbohydrate Diet (SCD) – The SCD has a 75-84% success rate if followed strictly. The diet is explained at BreakingTheViciousCycle.info and SCDLifestyle.com
  • Gut and Psychology Syndrome Diet (Gaps Diet) – The Gaps diet is explained in Dr. Campbell-McBride’s book and at Gaps. me and GapsDiet.com
  • Low Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols (Low FODMAP Diet) – The FODMAP diet has excellent success rates for those with IBS and IBD. There is a Monash University low FODMAP diet app and visit www.gidoctor.net/client_files/file/Fodmap.pdf for more FODMAP diet information.

One has to treat the underlying factors that set the stage for SIBO to develop in the first place. This includes supporting digestion, healing the gut lining, repairing damage that SIBO has caused, rebalancing gut flora and addressing gut motility. Once SIBO has been eradicated, prokinetics should be used for at least three months to enhance intestinalmotility and prevent a recurrence. Herbal prokinetics include ginger, Iberogast and MotilPro. For additional support, probiotics can be used but they must not contain a PREbiotic. Probiotics can help to displace gas producing bacteria and help leaky gut syndrome by enhancing the gut barrier. Finally, for a more in-depth look into SIBO, visit Dr. Allison Siebecker’s website which has a wealth of information about SIBO at www. siboinfo.com. It’s important to take control of your own health and become empowered by learning about SIBO but always remember to talk to your doctor before starting any treatment protocols.