38 year old man  with colitis, depression and hypertension

38 year old man presenting with: -

  • Recent diagnosis of Crohn’s disease. He had been experiencing 3 months of right lower quadrant discomfort and intermittent diarrhoea with weight loss. He was diagnosed by colonoscopy.
  • He initially thought that his symptoms were related to job stress. He has started to drink more in the evenings, no longer works out, and has lost his interest in food and social events.
  • The Crohn’s disease was initially managed with corticosteroids which resulted in resolution of the diarrhoea. He is now taking mesalamine. His weight loss has stabilized, but he still has some lower right abdominal discomfort and loose stools. His gastroenterologist wants to start him on methotrexate. The patient wants to avoid this if possible.
  • At his recent visit to this gastroenterologist, his blood pressure was elevated at 156/102. He notes that at prior physicals, his blood pressure has been in the high 140’s over low 90’s.
  • Systemic: He feels tired most days. He reports getting about 6 hours of sleep but does not wake rested.
  • Gastrointestinal: He currently has discomfort in his lower right abdomen which seems to be present most of the time. Sometimes it is worse in the evening. He has 2 to 3 loose, but formed, bowel movements daily.
  • HEENT: He has frontal/temporal headaches every 3rd day or so. He takes 800mg ibuprofen to relieve the headache.

Family History:

  • Father had coronary stent placement at age 60.
  • One older brother has high blood pressure

Social:

  • Lives with his wife; no children. Describes his marriage as “fine”.

Exercise:

  • He does not exercise regularly except for yard work on the weekends

Diet:

  • B: no breakfast, 1 coffee latte
  • L: work cafeteria sandwich with an apple
  • D: Chicken, salad, potato or rice. Beer x 2 –4 cans
  • Sn: Occasional chips or pretzels

Vitals:

  • bp=152/96 p= 82 rr=m 16 t = 98.6
  • Abdominal exam reveals tenderness to palpation in lower right quadrant with firmness to palpation; no discrete masses
  • Recent CBC revealed macrocytic anaemia (rbc4.0 and MCV 102) and slightly elevated white blood cell count at 11,000

Chemistries demonstrated:

  • low albumin (3.0 g/dL) (rr3.5 –5.5)
  • low normal B12 at 220 pg/mL (rr>200)
  • elevated C-reactive protein at 4.0 mg/L (rr1 -3)
  • elevated ESR (sedrate) at 24 mm/hr(rr0-22)
  • At the time of diagnosis of the Crohn’s disease, his serum tested positive for antibodies to Saccharomyces cerevisiae [ie, anti-S cerevisiae antibodies (ASCA)]

 

Assessment Considerations:

  • Comprehensive nutritional profile, especially fat soluble nutrients, including essential fatty acids.
  • Hormonal workup for testosterone and DHEA to rule out hypoandrogenism.
  • Salivary cortisol to assess adrenal reserve.
  • IgG RAST, Gliadin Antibodies.
  • Candida Antibodies (serum) and stool fungal cultures.

Insights, Tips and Perspectives:

  • Go easy on oral nutrients at fist as bowel tolerance may be limited. Increase as tolerated.
  • Remember scope of practice: know “when to hold and when to fold” on holistic management--always ensure that the patient is followed by their gastroenterologist for medication management and disease status assessment.
  • Consider low dose naltrexone (LDN) unless the patient is on immune suppressants or biologicals.
  • Enlist the cooperation of family members for support in implementing diet and lifestyle changes.
  • Frequent monitoring of diet compliance by an experienced nutritionist, as diet is crucial to success.
  • Be prepared to modify diet in line with patient’s response; not all patients respond to the “orthodox” Specific Carbohydrate Diet.

Management Considerations:

  • Consider parenteral nutrients (B12 and especially magnesium which might ameliorate headaches and lower blood pressure).
  • Discontinue the NSAIDs (Ibuprofen).
  • Specific Carbohydrate Diet with decreased alcohol consumption.
  • Curcumin for gastrointestinal anti-inflammatory effects, anti-depressant actions, and vascular benefits. Also, melatonin for sleep and gastrointestinal support. Omega-3 fatty acids for mood, vascular support and gastrointestinal effects.
  • Initiate androgen replacement if indicated.
  • Alcohol reduction to 2 drinks per day maximum preferentially of red wine rather than beer given the (+) ASCA, the history of hypertension, and sleep disturbance.
  • Reduction in processed foods to lower Na+ intake to approximately 2 grams per day and referral to nutritionist to integrate a DASH and Carbohydrate Specific diet.
  • Nutritional supplementation to include: methylated cobalamin and folate, as well as Co-enzyme Q10, and magnesium - if intracellular levels are low, dose as the intravenous form to reduce risk of exacerbating diarrhoea

Initiation of stress reduction techniques such as breathing techniques, Cognitive Behavioral techniques, Yoga/Tai chi/Qi Gong

Last modified: Friday, 26 April 2019, 1:51 PM