Moodle at CCNM

Over the past several decades, we have gained immense insight into the world of the human microbiome. The observations made using techniques like Fecal Microbiota Transplant and microbial sequencing are contributing to a new paradigm of what it means to be human. We now know we are not alone in our own bodies. We are a compilation of trillions of microbes and human cells working together as an ecosystem with the bulk of this ecosystem residing in our colon. This ecosystem and the repercussions of its health are now being investigated outside the local GI system. The colonic microbiome is communicating with our brain through neuroimmune, neuroendocrine, and direct sensory input. The bi-directional role this gut-brain axis has on health expands our understanding of what GI and mental health really means.

Gastrointestinal health spans from the mouth to the anus, but rarely the tail end is talked about. During this lecture, we discuss how common GI conditions such as constipation, diarrhea or bloody stools may cause and be causing changes in anorectal health. Intimidated to take a look? We review the rectal examination, as well as prostate exam, to determine if a patient’s anorectal health may be the cause of their IBS. We will also offer both conventional and holistic approaches to help patients achieve immediate relief from their poor anorectal health as well as prevent reoccurrence of disease.

Small intestinal bacterial overgrowth (SIBO) is a syndrome in that it has multiple causes. Motility disorders are most often the underlying factors to predispose for the development of SIBO. Postural orthostatic tachycardia syndrome (POTS) leads to an imbalanced autonomic nervous system because excessive sympathetic activity overrides vagal tone. Peristalsis is reduced and SIBO may be promoted. Mast cell activation syndrome (MCAS) is a leading factor in 33% of POTS. It is also conceivable that MCAS could directly impact motility via one of 200 mediators that may reduce neuromuscular activity.  It is important to recognize POTS which has a prevalence of 500,000-1,000,000 in the US. Understanding this disease and the more prevalent MCAS (1 – 17% of the population) is critical to help many patients who otherwise suffer for decades without a diagnosis and/or effective therapy.Specific pharmaceutical medications to be discussed in both the overview and outline: rifaximin and naltrexone.

The human microbiome is an exciting and rapidly evolving space in human health. The importance of its role in gastroenterology cannot be understated. By overviewing the evolution of our understanding of this complex organ like system we can see how it fits within the naturopathic treatment paradigm of wholistic health. I will overview the basic science, clinical research, testing and disease applications.

A review of the histological variation of the GI tract with special consideration of the microbiome, immune function and neurotransmitter use and creation. Specifically, the interaction of the goblet cells, glutamate and Akkermansia muciniphila.

Lymphocytic colitis (LC) and collagenous colitis (CC) are two causes of chronic non-bloody diarrhea, and are coupled under the diagnosis of microscopic colitis (MC). These are inflammatory diseases of the colon which have no gross changes and are identified by histology alone. Dr. Sandberg-Lewis has treated a significant number of cases of MC. In this presentation he defines these conditions, explains their known etiology, risk factors and pathophysiology and focuses in more detail on the most effective standard and Naturopathic treatment and management strategies. Pharmacology is included in this discussion (drug causes of MC, dosages and tapering strategies for prescription medicines and some off label approaches.) Indeterminate colitis is also discussed – that condition that falls between Crohn’s colitis and ulcerative colitis. Even with the eclectic approach of NDs, knowing the definitive diagnosis for inflammatory bowel disease holds importance and allows you to focus your treatment toward more proven options rather than guessing. What do you do when there is no definitive diagnosis? Sandberg-Lewis attempts to demystify this – discussing his approach in these situations.

This presentation covers underlying motility disorders associated with SIBO such as abnormal MMCs, CIPO, enterocele, and bowel surgeries.

In continuing the discussion of the principle of treating underlying causes of SIBO rather than simply focusing therapy on reduction of bacterial overgrowth, we cannot overlook the thyroid gland’s role in motility. Evidence has emerged for thyroid disorders as one of SIBO’s etiologies. This presentation explores SIBO’s intersections with dysthyroidsm, and points to implications in developing effective treatment plans and strategies for prevention of recurrence. The presentation will include a brief overview of thyroid prescribing, both clinically and sub-clinically, including use of Levothyroxin, Tri-iodothyronine, dessicated Thyroid USP, and compound prescribing.

In your practice, 6% of your patients, or more, have Non-Celiac Gluten Sensitivity (NCGS). Confused the difference between NCGS, non-celiac wheat sensitivity, gluten allergy, wheat food sensitivity, wheat allergy and celiac disease? Dr Shaver discusses diagnosis and reviews the research about this relatively new condition, named in 2011. There are important ethical issues to discuss with your patient prior to prescribing any of the current gluten-free diets (Keto, Paleo, Low Fodmap, Anti-Inflammatory, Wahls, etc.) if one has not thoroughly tested for NCGS and celiac disease.

I will use a case of a 62 yo female with intestinal methanogen overgrowth and chronic unresolved dental infections to illustrate the importance of oral abscess as a source of GI microbiome issues. Her endodontist had told her that there was no remaining infection. I had treated her for over a year with some moderate-good responses to treatment before further investigating the oral issues. The investigation was prompted by a relapse of her symptoms despite significant improvement in breath test results. On referring her for a second dental opinion, 5 areas of infection were found along with a stray bone fragment from a previous dental extraction. After just a few injections of ozone into the infected areas and removal of the bone fragment, she had total normalization of her GI and systemic symptoms.I will demonstrate the use of a relatively simple applied kinesiology technique that I use to investigate the presence of significant dental health issues in my GI patients.

Outlet dysfunction constipation is commonly overlooked cause of chronic constipation. This group of conditions is often a consequence of poor coordination of colonic, abdominal, pelvic and rectal musculature resulting in ineffective or incomplete expulsion of stool during defecation. This can be caused by weak colonic contractions, rectal hyposensitivity, rectal outlet obstruction, poor lower abdominal muscle recruitment, increased ano-rectal muscle tone or anismus. It is estimated that about 50% of those with outlet dysfunction constipation also suffer from slow transit constipation. Outlet dysfunction constipation should be evaluated first in-office with a detailed history and physical examination. Further evaluation by a pelvic floor physical therapist or GI motility specialist is often warranted. Dr. Kimball discusses when to refer and common treatment approaches performed by specialists. Treatment of outlet dysfunction constipation requires a coordinated and personalized approach to treatment to achieve resolution. As part of this presentation, Dr. Kimball reviews the application of behavioral modifications, dietary modifications, physical therapy, nutritional supplements, pharmaceuticals and biofeedback therapy to address outlet dysfunction constipation disorders. Also discussed is the use of osmotic laxatives, stool softeners, enemas, colonic secretogogues: linclotide and lubiprostone, muscle relaxants: tizanidine and cyclobenzaprine, and botulinum toxin injection.

Parkinson’s disease has long been considered a neurological disorder. Yet, people with Parkinson’s exhibit both motor and non-motor symptoms, only some of which are brain derived. As we learn more and more about Parkinson’s, the gastrointestinal influences on disease is becoming increasingly clear. Not only do people with Parkinson’s experience constipation, there’s evidence that Parkinson’s may originate in the gut. In this seminar, we examine the gut-brain axis in Parkinson’s. We discuss microbiome influences on Parkinson’s, gut contributions to neuroinflammation, and strategies to balance the gut-axis in Parkinson’s disease.

Over the last 20 years, probiotic research has increased exponentially. This has been mirrored by an explosion of probiotic products in the marketplace. With the sheer choice of probiotic supplements and foods available on the market today, it can be challenging for health professionals to sort through each manufacturers’ claims of superiority. In this presentation, Dr Hawrelak will examine the concept of probiotic strain specificity and discuss the shifting paradigm in probiotic prescribing from “re-seeding” to choosing the strain with the desired action for treating specific conditions. He will also share some tips to help clinicians navigate through probiotic marketing claims.

The trillions of microorganisms in your gut form a beautiful and staggeringly complex ecology that we are just learning how to see. This new learning affects our understanding of how our separation from the wild has set us up for the epidemic of hyper-inflammatory conditions which we're facing. This presentation explores new and old therapeutic interventions for inflammatory bowel disease, including food, probiotics, fecal transplant, helminths, and antimicrobials; all ways to influence the forest of the gut.

This presentation reviews the latest update from the Bastyr research group and affiliated international naturopathic researchers focused on whole systems naturopathic approaches to irritable bowel syndrome (IBS). Specifically, one of only a few expert consensus panels on naturopathic medicine was completed recently - The Expert Consensus for Naturopathic Approaches to IBS. A shocking 42 items of consensus were agreed upon leading to a real possibility of an external valid randomized trial of Naturopathic Approaches to IBS in the future. Our progress on the largest international observational study of naturopathic medicine to-date (the IRCNAC-IBS study) and the consortium supporting it – the first ever, international research consortium of naturopathic academic clinics – will be reviewed. Additionally, we discuss findings from the first fully naturopathically designed and executed Cochrane Review – Biofeedback to Treat IBS.

Impaired intestinal motility leads to dysbiosis and predisposes to SIBO. When motility impairment is severe, gastroparesis may result, in turn leading to malnutrition, frequent nausea and vomiting. Impaired motility can also lead to osteroporosis, anemia and other complications. This presentation discusses numerous botanical options for restoring impaired gastric and intestinal motility, and shows why acid-blocking drugs may contribute to motility disorders. Dr. Stansbury also details how the hormones motilin and ghrelin – the hunger hormone – may offer some benefits.

Small Intestinal Bacterial Overgrowth (SIBO) is a complex condition that is often caused by several factors or triggers. From dysmotility, to digestive deficits, microbiome dysregulation and structural components, finding the underlying cause is key in resolving chronic SIBO cases. Most of us have had opportunities to work with SIBO patients that don’t seem to improve even with well thought out treatment plans. In this presentation, Dr Jacobi explores the contributing factors through which SIBO develops and presents itself by reviewing challenging cases from her practice.

Small Intestinal Bacterial Overgrowth can create an inflammatory state in the gut that reduces the ability to digest dietary histamines. For those with histamine intolerance, this can trigger more inflammation both in the gut and systemically, leading to a variety of histamine-mediated symptoms. In this presentation we will discuss how histamine dysregulation and intolerance in those with SIBO is assessed and managed in this highly sensitive population.

In continuing the discussion of the principle of treating underlying causes of SIBO rather than simply focusing therapy on reduction of bacterial overgrowth, we cannot overlook the thyroid gland’s role in motility. Evidence has emerged for thyroid disorders as one of SIBO’s etiologies. This presentation explores SIBO’s intersections with dysthyroidsm, and points to implications in developing effective treatment plans and strategies for prevention of recurrence.  The presentation will include a brief overview of thyroid prescribing, both clinically and sub-clinically, including use of Levothyroxin, Tri-iodothyronine, dessicated Thyroid USP, and compound prescribing.

In this overview of Small Intestinal Bacterial Overgrowth Dr. Shaver outlines the various signs and symptoms, their causes as well as the underlying causes of SIBO. The breath and serum testing options are discussed as well as the analyses thereof. Treatment option include pharmaceuticals such as rifaximin, metronidazole and neomycin, as well as antibiotics which do not seem to fully address SIBO such as amoxicillin, and ciprofloxacin. The many herbal antibiotics are reviewed as will be the elemental diet, with attention to when to prescribe such antifungals as nystatin and fluconazole, or herbal equivalents. When to use prokinetics such as prucalopride, erythromycin and naltrexone will is also discussed. Foods that play a role and various diets are reviewed. There are various associated diseases and syndromes linked to SIBO as well as obstacles to successful treatment and when to prescribe medications such as nitazoxanide, tinidazole, albendazole, mebendazole, metronidazole.