The Nutritional Supplement

48 year old female from New Hampshire presenting with bloating and GI discomfort

• Two years ago, she began to experience bloating and pain in lower abdomen along with inability to empty her bladder.
• She sought gastroenterology workup and ileitis was diagnosed by colonoscopy.
• After diagnosis, she was prescribed the mesalamine anti-steroidal anti-inflammatory, Lialda®. Symptoms were almost completely resolved for about 1 ½ years.
• Of note, many family members have coeliac disease and the patient has been on a gluten-free diet x 10 years. Her bloating and pain are improved when she is off of gluten.
• 6 months ago, she again developed bloating and right-side lower and upper abdominal pain.
• She has stressful work dynamics and feels that with the stress, she experiences abdominal reactions - specifically, she feels an uncomfortable tension in her mid and lower abdomen.
• At night, she experiences bloating. Bloating resolves for the most part by the morning. Bloating appears unrelated to eating. She has no heartburn or eructation, no burning.
• She tends towards constipation and has one bowel movement daily.
• Her next chief concern is painful joints. She has experienced right knee pain and also intermittent right and left hip pain. She has been experiencing more fatigue lately and feels that her muscles are generally tender and sore.
• Finally, she notes that with the elevated work stress combined with her symptoms of abdominal discomfort, fatigue and pain, she ‘self-medicates’ with sugary snacks and gluten-free pastries. As a result she has gained approximately 10 pounds in the last 4 months.

Review of Significant Systems:

Systemic:

• Moderate fatigue especially as the day progresses

Neurological:

• Anxiety and Stress related to work dynamics

Gastrointestinal:

• Bloating that worsens over the course of the day
• R. sided abdominal discomfort unrelated to meals or bowel movements
• Constipation: one bowel movement most days with taking a probiotic and fibre

Musculoskeletal:

• Arthralgia – migratory

Endocrine:

• Sugar cravings with self-reported hypoglycaemic periods occurring most late afternoons

Past medical history:

• Includes right oophorectomy 5 years ago due to endometriosis

Family History:

• Father: Deceased age 63 from CVA; alcoholic and smoker
• Mother: Alive age 74; in good health. Hx colon cancer; diagnosed age 63 - in remission

Social History:

• Works as a Vet Tech and enjoys her work. Works 35-40h/week.
• Married without children; describes her marriage as supportive and 'great'.

Sleep:

• 6-7h/n. Wakes frequently secondary to hip pain.

Exercise:

• 4-5 x/week: walks, yoga x 30-60min.

Typical Daily Diet:

• B: smoothie with cup raw milk, 1 cup frzn berries, almonds, GF muffin, coffee
• L: salad with protein (eggs, pork, beef), crackers
• D: pork, beef, chicken or fish with veggies, potato or rice, ice cream
• Sn: candy bars, GF cookies, apples, grapes
• Beverages: water, diet soda (limits to once daily), no alcohol

Assessment Considerations:

• Based on the patient’s history ulcerative colitis appears to be the first consideration by the patient’s primary physician. This should be objectively documented via 3 day GI stool test with parasitology and GI inflammatory markers (Calprotectin, Eosinophil Protein X)
• The patient history shares some common findings with chronic Lyme: migratory arthritis affecting large joints particularly the knees, fatigue and anxiety.
• Considering that the patient has experienced a reduction in her bloating and pain when on a gluten free diet and the fact she has a family history of celiac disease, I recommend ordering celiac antibody test (Tissue Transglutaminase Antibodies (tTG-IgA). I would also consider immunological reaction to gluten/gliadin via DGP-IgG (Diamidated Gliadin Peptide IgA and IgG. I prefer to have objective evidence.
• Insights, Tips and Perspectives
• Rule out iron deficiency anaemia by ordering ferritin, iron, TIBC, and % saturation.
• Order HgbA1c.
• Order serum methylmalonic acid.
• C3d, CD57, C4a, C3a should be considered in the preliminary diagnosis of Lyme.
• The reference laboratory tests that I would order include: CBC with diff, HgbA1C, lipid panel, vitamin D, ANA, thyroid panel with antibodies, LDH, magnesium, CMP, iron and TIBC, ferritin, ESR, CRP, and perhaps lipase and amylase.
• An adrenal panel with a 4 point cortisol saliva and DHEA test would be helpful.
• I also would do a urine analysis due to the fact that she said she had trouble emptying her bladder.
• I would always request the entire set of prior lab tests to see what was ordered and what was not ordered. I don’t assume it was as thorough as I would like it to be.
• Anaemia, or low red blood cell count from iron deficiency, is a common problem caused by celiac disease. With a primary diagnosis of celiac, we will commonly see weight loss not weight gain
• I would ask the patient if she remembers a tick bite and/or a bull’s-eye rash.
• From the onset, one would assume ulcerative colitis is the diagnosis to focus on, however, there were some subtle hints that led me down a different path such as living in New Hampshire, working as a Vet Technician, and migratory arthralgia. Elevated C3d immune complexes should make one suspicious of Lyme. However, CD57 and Complement C4a would help in the differential diagnosis.

Management Considerations:

• While I am waiting for the results of the patient’s labs, I would have her start a Paleo light eating plan. This would include eliminating grains, dairy, eggs and nuts for 90 days.
• If I objectively document chronic Lyme, I would start the patient with botanicals. These would include:  Andrographis paniculata (andrographis), Fallopia japonica (Japanese Knotweed) and Uncaria tomentosa (Cat’s claw).

I would focus on reducing her stress through instructions on meditation, yoga and even recommend she look into HeartMath technology.  HeartMath is a stress management system that helps you synchronize your brain and heart for optimal stress resistance and mental performance.