The Nutritional Supplement

History of present illness:

• 49 year old woman of Finnish ethnicity with longstanding digestive symptoms
• 3 years ago, she developed symptoms of bloating and pain in the lower abdomen along with an inability to empty her bladder. Diagnosed by colonoscopy with ileitis
• She was prescribed mesalamine anti-steroidal anti-inflammatory and her symptoms almost completely resolved
• She also strictly avoided gluten which she had more or less avoided for the prior 7 years given a strong history of celiac disease in her immediate family
• She continues the mesalamin at 1.2mg daily
• Appendectomy in her 20s
• 2 years ago she was diagnosed with breast cancer and underwent bilateral mastectomies followed by radiation therapy
• Developed esophageal reflux during radiation therapy and flare of the ileitis
• The reflux persists to the current time – symptomatic relief from deglycyrrhizinated licorice and chewable calcium
• 2 years ago, IgG4 food allergy panel revealed significant reactions to: dairy, eggs, banana, cranberry, pineapple, sesame seed, mushroom, watermelon. She has avoided these foods since the test
• 1 year ago, she underwent bilateral oophorectomy and hysterectomy as she could not tolerate tamoxifen (aggravated esophageal reflux, nausea, bloating and another ileitus flare)
• Endoscopy 1 year ago revealed gastritis, hiatal hernia and no evidence of celiac disease
• 10 months ago, hydrogen breath test revealed peak hydrogen of 52 ppm (rr <20ppm) and methane of 0. She started herbal antimicrobial supplement, betaine HCL and FODMAP diet for 5 months, then stopped
• She experienced some relief for 2 months, but then bloating worsened and she experienced lower abdominal tension
• Throughout, she has one to two well-formed bowel movement most days, but occasionally passes excessive gas
• 1 month ago, ultrasound failed to identify cholelithiasis or cholecystitis
• Nonetheless, she avoided all fat for one week. Bloating resolved initially, but then returned.
• Currently, she continues to experience reflux and daily bloating

Family & Lifestyle History:

• Father died at age 63 from a stroke. He was an alcoholic and smoker
• Mother is age 74, in good health. She was diagnosed with colon cancer age 63 – in remission
• 3 siblings – all in good health
• Works as a vet tech
• Lives with her husband – good relationship
• Low self-reported stress
• Avid horseback rider
• Sleeps x 7 h/night
• Walks 4-5 x/week; horseback rides3 times per week; yoga weekly
• 15 pack year history – quit 20 years ago
• Avoids gluten and food allergens, eats small meals, averages 5 servings vegetables daily, 2 cups of coffee daily
• No alcohol

 Objective Findings:

• Most recent CBC: WBC 2.7(L), RBC 3.8(L), HGB 12.7(L), MCV 102.6(H), MCH 33.1(H), Basophils 0.1(H), Basophils % 3.2(H)
• WBCs have been low, at this same level, for the past year
• One year ago, patient had elevated microsomal TPO antibodies of 219, with TSH of 3.64(N), total T4 6.9(N), free T4 1.3(N), free T3 2.6(N), morning cortisol 11.9(N)
• Current thyroid panel (she is on replacement): TSH 4.42(N), free T4 1.2, free T3 2.4
• Other current labs (all within normal reference range): c-peptide 2.8, PTH 50, vit D25OH 56.4, Glucose 86, Hgb A1c 5.4, Sodium 142, Potassium 4.3, AST 18, ALT 14, Bilirubin 0.7
• Patient is currently taking betaine, vitamin C, vitamin E, Vitamin D, Flavonoid blend, Melatonin, Calcium and Magnesium and Betaine HCL

 Assessment Considerations:

• The patient appears to have Megaloblastic anaemia, which needs to be investigated further. Could use methyl malonic acid serum or urine to assess B12 levels which will also indicate folate status. Rule out other causes of hyperandrogenism, e.g. Cushing’s syndrome, adrenal tumours, etc.
• The thyroid may be undertreated, reassess dosing
• May be hypochloridic – consider HCL challenge or Heidelberg test
• Should consider H. Pylori testing with upper GI
• Assess for diaphragmatic tension of hiatal hernia

 Insights, Tips and Perspectives:

• Complex patients are often dealing with separate problems that are not interrelated. So it’s important to keep a differential that is flexible and horizontal across several domains
• This would be a patient who would greatly benefit from coordinated care across specialties including Gastroenterology and Cancer Survivorship

Management Considerations:

• Needs a better plan to address hiatal hernia (visceral manipulation, heel drops, breathing exercises)
• May have suboptimal digestion due to history of trauma, radiation; may need gall bladder support, brush border enzyme support, microbiome support, optimized Gastric cell function
• Consider reassessing or retreating for SIBO as this may need more addressing
• Consider reassessing ileitis to measure progression or regression of disease
• Consider if she is meal spacing to allow for optimization of migrating motor complex function