Disorders of intestinal transit

Chapter 10

Disorders of intestinal transit Disorders of rapid transit: Diarrhea

Overview of causes of diarrhea

Introduction

Diarrhea occurs when the net secretion of water and osmotic forces exceeds the net absorptive capacity of the bowel and the interstitial osmotic forces. The causes of diarrhea can be categorized in multiple manners: infectious vs noninfectious, disorders of absorption vs disorders of secretion, disorders of immunity, endocrine, or autonomic pathologies. From the practical clinical aspect, categorizing diarrheal disorders in the following way allows for the clearest approach to treatment:

The intestines play a key role in digestion and absorption of nutrients. Along with this comes a perfunctory requirement for defense against nonself-biological organisms and chemical entities in alimentation that may be perceived as such. Diarrheal disorders represent a compromise in one or both of these primary roles of the digestive tract. These disorders are addressed for two reasons. First, they affect the quality of life and daily activities. More importantly, they affect absorption of nutrients, growth, and regeneration of tissue. In the long term, they can be a source of degradation of the buffering capacity. These disorders offer a glimpse into local, locoregional, regional, and global aspects of the functioning of the organism with respect to both autoregulation and in the face of external and internal aggressions.

Definition Diarrhea is defined by both frequency and consistency of stool. The frequency is 3 or more stools per day of a watery consistency. In children, severe diarrhea, which may require hospitalization and intravenous hydration, is defined by the number of stools per day relative to the age (Table 10.1). Cardiac output in children is more dependent on heart rate than stroke volume, making children more susceptible to dehydration late in the course of their illness. Guarding against dehydration is more crucial in children than in adults.

1. Disorders of secretion 2. Disorders of absorption 3. Disorders of transit

Secretory diarrhea Introduction Disorders of secretion reflect hypersecretory states. Infectious agents that invade the endothelial lining of the intestines typically cause these disorders.

Acute diarrhea The release of enterotoxins by pathogenic organisms alters the rate of membrane-bound ion channels. As the rate of ion excretion into the lumen of the intestine increases, the rate of water movement increases, resulting in a flow of water and electrolytes, namely potassium and bicarbonate, that exceeds the intestine’s absorptive capacity1 (Fig. 10.1).

Chronic diarrhea TABLE 10.1  Severe diarrhea in children Age

Stool frequency

All

≥5 in 5 h or less

0–11 months

>9 stools per 24 h

12–24 months

>14 stools per 24 h

2–18 years

>19 stools per 24 h

The Theory of Endobiogeny. https://doi.org/10.1016/B978-0-12-816964-3.00010-9 © 2019 Elsevier Inc. All rights reserved.

The transition to a chronic infectious or postinfectious diarrheal state is favored by two factors: the release of cytotoxins and a dysregulated immune response by the host (cf. The Theory of Endobiogeny, Volume 2, Chapters 3–6). Cytotoxins secreted by the pathogenic organisms attract immune cells that release prostaglandins, platelet activating factor, and other factors that can create a chronic hypersecretory state.2 Both acute and chronic hypersecretory disorders can become disorders of absorption if the adaptative response 215

216  The Theory of Endobiogeny

Healthy tissue

Bacterial-induced diarrhea Increased Gl motility

Movement of Gl contraction

< 85% H2O

> 85% H2O

Extracellular pathogens

Intracellular pathogens

Ion channel

Tight junctions

AQP3

Shigella

Aquaporins Ion channels H2O AQP2

H2O H2O Aquaporins

Salmonella

Nucleus

H2O TRENDS in Microbiology

FIG.  10.1  Healthy intestinal tissue (left) maintains integrity through tight junctions. Water is exchanged across enterocytes through aquaporins. In bacterial-induced diarrhea (right), these elements are compromised. This results in entry of noncommensal organisms and loss of water into the enteric lumen, resulting in diarrhea. (Used with permission from Guttman JA, Finlay BB. Subcellular alterations that lead to diarrhea during bacterial pathogenesis. Trends Microbiol 2008;16(11):535-542. doi:10.1016/j.tim.2008.08.004.)

accelerates the destruction of, or impairs the regeneration of villi in the small intestines or columnar epithelial cells in the colon.

Pathophysiology of secretory diarrhea Anatomic From the perspective of Endobiogeny, the following can be considered: 1. Nose: hyposmia and anosmia impair the ability to detect odors associated with infected foods. Patients with anosmia have a higher incidence of food poisoning3 2. Stomach: suppression of hydrochloric acid increases risk of acute bacterial enteritis4, 5 3. Splanchnic congestion: favors a congestion of the viscera, which provides a terrain favorable to infections

Neuroendocrine factors The specific elements of the disadapted terrain are presented in Table  10.2. The specific combinations for each individual’s terrain may vary.

Clinical presentation History There is an increased volume of stool often with a foul odor. Fasting does not diminish the volume of stool output.

Seasonality The seasonality of the diarrhea at the time of onset often gives a clue to the most likely microbial origin. Viral infections can occur all year. Bacterial infections are more likely in the summer.

Disorders of intestinal transit Chapter | 10  217

TABLE 10.2  Neuroendocrine factors of infectious diarrhea Location

Factor

Activity

Effect

ANS

Para

↑

Metabolic intestinal mucosal congestion, stasis

Alpha

↑

Immunity: delayed or blocked

Histamine, autocoid

↑

Inflammatory congestion Loss of epithelial tight junction Easier translocation of pathogenic organisms

Beta

↑

Hyperglycemia: favors rapid growth of pathogenic organisms and inflammation

Cortisol

↑

Suppresses thymic immune function Hyperinsulinism Inflammation Blocked anabolism

Cortisol

↓

Insufficient mobilization of immune system

Aldosterone

↑

Endocrino-nutritional congestion of bowel mucosa Lympho-venous stasis

Gonadotropic

FSH

↑

Mucosal congestion

Thyrotropic

TRH

↑

Hyperbeta response (cf. above), insulin-linked inflammation

TSH

↑

Congestion, stasis of mucoid tissue (cf. FSH)

Thyroid

↑

Pro-inflammatory

Thyroid

↓

Impaired immunity: reduced oxidative burst, hydrogen peroxide for phagocytosis

Insulin

↑

Inflammation, or low insulin resistance may be present

Corticotropic

Somatotropic

Quality of stool ●

●

●

Nonbloody, no mucous: small intestine origin of disease Bloody, with or without mucous: large intestine origin of disease Green: rapid transit (cf. rapid transit diarrhea (RTD))

Systemic complaints Lack of fever does not rule out the presence of an infectious agent. Some organisms more typically cause fever than others: Campylobacter, Adenovirus, Rotavirus, and Cryptosporidium.

Duration of diarrhea Diarrhea lasting >14 days has an increased likelihood to occur due to a parasite, although bacteria or viruses may also be responsible for chronic infectious in some cases.

to use a target pharmaceutical antimicrobial therapy (Table 10.3).2, 6 Calprotectin is a marker of intestinal inflammation and is elevated proportional to clinical severity of infection (bacterial > viral infections).7, 8 Cultures have a low sensitivity but may be indicated in chronic diarrhea to rule out a parasitic infection.

Treatment of secretory diarrhea: General considerations Maintaining adequate hydration is capital. Therapeutic interventions should be chosen that exhibit antiinfectious properties, symptomatic relief, bowel tropism, and elements of the terrain. During the acute phase of illness, symptomatic treatment is often sufficient to restore the terrain of the patient to the prior state of function.

Hydration: Avoid ●

Laboratory evaluation Stool testing is generally not necessary or helpful except in cases of epidemics, chronic disease, or the need

● ● ● ●

Hyperosmotic beverages such as fruit juices Acidic beverages High-fructose fruits or honey High-fiber foods Greasy, fried, or fatty foods

218  The Theory of Endobiogeny

TABLE 10.3  Summary of secretory diarrhea characteristics by history and stool testing Stool characteristics

Small bowel

Large bowel

Appearance

Watery

Mucoid and/or bloody

Volume

Large

Small

Frequency

Increased

Highly increased

Blood

Possibly positive but never gross blood

Commonly grossly bloody

pH

Possibly <5.5

>5.5

Anion gap

Normal (<100 mOsm/kg)

Normal (<100 mOsm/kg)

Reducing substances

Possibly positive

Negative

WBCs

<5/high power field

Commonly >10/high power field

Serum WBCs

Normal

Possible leukocytosis, bandemia

Organisms

Viral Rotavirus Adenovirus Calicivirus Astrovirus Norovirus

Invasive bacteria Escherichia coli (enteroinvasive, enterohemorrhagic) Shigella species Salmonella species Campylobacter species Yersinia species Aeromonas species

Enterotoxigenic bacteria E coli Klebsiella Clostridium perfringens Cholera species Vibrio species

Toxic bacteria Clostridium difficile

Parasites Giardia species Cryptosporidium species

Parasites Entamoeba organisms

Hydration: Use ●

● ●

●

Isoosmotic beverages containing electrolytes ● Oral rehydration solutions ● Water with Schussler cell salts ● Isotonic Quinton water 9, 10 ● + Probiotics Bone broth soups Lightly cooked, easy-to-digest foods ● Boiled white rice with dill or thyme, or, seeds of cumin or caraway ● Boiled chicken breast ● Sweet potatoes, yams, parsnips Raw garlic cloves11: encourage the patient to swallow it whole and not chew it

Medicinal clay Medicinal clays such as green Illite clay are very efficient in treating infectious, secretory diarrhea12–15 1. Antimicrobial 2. Adsorb toxins, reducing toxin load

3. Absorb water, reduce stool output 4. Remineralize mucosa for wound healing

Augmenting efficacy of clay ●

●

●

●

Add 1 drop antimicrobial EO (cf. Table  10.4) to dry powder before adding liquid Prepare with medicinal tisane or hydrolat (cf. Table 10.4) instead of water Let sit in liquid for 15 min or longer before stirring again and serving13 Add ⅛ tsp. baking soda, 1 pinch sea salt with prolonged diarrhea

Acute diarrhea ●

●

1 tbsp in water, tisane, hydrolat, 1–4 h per severity of output until diarrhea resolved No vomiting ● Replace stool loss volume ● Drink as desired

TABLE 10.4  Therapeutics for secretory diarrhea Plant

Galenic

Immunity

Antiinflam.

Astringent

Antihemor.

Other

Cinnamomum zeylanicum

EO BH

Immunostimulant, gram +, gram −, antifungal, antiparasitic

●

●

●

Adrenal cortex stimulant

Eugenia caryophyllata

EO

Poly-antimicrobial

●

Ficus carica

GM

Parasites

Fragaria vesca

MT BH MS

Poly-antimicrobial

●

●

Juglans regia

MT BH MS

Antiseptic, antibacterial Antimycotic

●

●

Lamium album

MT BH MS

Lavandula angustifolia

EO MS

Antibacterial Scabicide

●

Cicatrizing ↓ Para, alpha, beta

Matricaria recutita

EO MT

EO: gram + Tisane: gram +, gram − All: antifungal, antiparasitic;

●

Cicatrizing Antispasmodic Hepato-splanchnic decongestant

Plantago major

MT BH MS

Poly-antimicrobial Immunostimulant

●

●

Salvia sclarea

EO MT BH

Poly-antimicrobial

●

●

Cicatrizing ↓ Para-alpha Muscular antispasmodic

Satureja montana

EO

Poly-antimicrobial

●

Adrenal cortex stimulant

Thymus vulgaris

EO BH

Poly-antimicrobial

Antispasmodic Epithelial regenerator

●

●

Inflam., inflammatory; Hemor., hemorrhagic; EO, essential oil; MT, mother tincture; BH, bulk herb.

Cicatrizing Glucocorticoid stimulant (−) TSH, PL, GH

●

Relaunched GH, PL

●

Hepato-renal drainer

Antispasmodic Parasympatholytic

Disorders of intestinal transit Chapter | 10  219

●

●

220  The Theory of Endobiogeny

●

Vomiting: ● Minimal quantity liquid ● Pour over ice chips and feed with a spoon ● Risk of aspiration: serve supernatant without clay present

Chronic diarrhea ●

1 tsp. in water or tisane or hydrolat, every 3–4 h until diarrhea resolved

Medicinal plants Table 10.4 summarizes the most efficient medicinal plants or products for treating acute secretory diarrhea. In bold are the most efficient and polyvalent.16–18

Chronic diarrhea: Correcting dysbiosis ● ● ● ● ● ●

Probiotics19 Raw cloves of garlic Artemisia dracunculus Syzygium aromaticum Mentha piperita18 Satureja montana

Alimentation Encourage alimentation with solid foods that are easy to digest. Avoid raw foods.

Case #1: 6-month infant with rotavirus diarrhea The infant presented with a 2-day history of 5 watery stools per day, no blood. The infant is on a mix of expressed breast milk and dairy-based formula. His mother works and he stays in day care where his mother works. He was experiencing some colicky cramping but otherwise still drinks well. He was started on the following for 5 days. The diarrhea resolved after 20 h: 1. Illite green clay: ¼ tsp. mixed with 50 mL Plantago major tisane every 3 h via bottle with nipple 2. Plantain (Plantago major) tisane: 1 tsp. dry herb steeped 6 min in 200 mL water 3. Topical abdominal rub: 1 drop Lavender EO in 1 tsp. olive oil a. Heat by friction rub in palm of hands b. Apply with gentle pressure in a clockwise, centrifugal patter (outward spiral) 4. Have mother drink the same products 5. Change supplemental formula to nondairy, nonsoy formula until diarrhea resolves

Case #2: 4-year-old with summertime diarrhea A 4-year-old boy presents with a 3-day history of watery stools, worsening with each day. His stool output has gone from 3 to 6 watery stools per day. They have a foul smell.

The mother has not noticed any mucous or blood. She offered him apple juice the first day but that worsened the diarrhea. She offered him cow’s milk on day 2 which caused some blood to appear in the stool that evening (cf. malabsorption diarrhea, below). The patient is afebrile. There is nausea but no vomiting. The mother was requested to discontinue milk and juice and only offer the following until the nausea resolved. The boy was told by the pediatrician that he was to receive a supercinnamon, awesome power-milk to drink so he could be strong. 1. White bentonite clay, pharmaceutical grade mixed with 100 mL cinnamon decoction 2. Cinnamon bark decoction: 1 stick cinnamon crushed, decocted in 250 mL water for 6–8 min 3. Stevia added to taste 4. Pour over ice chips 5. 1 tbsp (15 mL) every 5 min until 100 mL consumed 6. Repeat every 2–3 h until diarrhea resolved The patient regained his appetite the next morning. The treatment was continued for 3 total days.

Case #3: 26-year-old with chronic diarrhea A 26-year-old women presents with a 4-month history of diarrhea. She states that she traveled to Mexico to a rural part of Michoacán state on a faith-based ministry where she stayed and did acts of service for 3 weeks. At the end of her trip, she ate some poorly cooked chicken. She experienced initially bloody, mucous-containing stools for 2 weeks with 4 days of vomiting (nonbloody, nonbilious). Currently, she has 4 watery stools per day that are at times explosive. Occasionally, she notices bright red blood in her stools. She has felt fatigued ever since her illness and is starting to feel depressed. Also, she noticed that her menstrual cycles are heavier than normal and she has acne on her jaw line for the 3 days before her menstruation begins. Prior to this, she had good energy, positive mood, and a regular 28-day cycle with 4 days of moderate bleeding. She asked to not be started on any alcohol-based products as her stomach was still sensitive. She was started on the following: 1. Clay mixed 3 times per day in 150 mL water 15 min before meals a. 1 tsp. clay b. 2 drop clove EO, mix well then add water 2. Cortico-Astringent-Drainage Tisane: Plantago major 100 g, Fragaria vesca leaf 100 g: 1 tsp. steeped 8–10 min, three times per day 15 min before meals using clay water to swallow 3. Eleutherococcus senticosus dry extract 4:1200 mg: 1 capsules AM, 1 at 4 p.m. It took 18 days for her stools to become of normal consistency. She stopped the treatment 2 days after formed stools were present. The watery stools immediately returned but only at the frequency of twice per day with one normally

Disorders of intestinal transit Chapter | 10  221

formed stool. She continued the treatment for another 6 weeks and the problem resolved. Her mood and menstrual issues resolved around the same time.

Proteins ● Celiac disease

Vitamins and metals

Malabsorption diarrhea Introduction Osmotic diarrhea is a series of disorders of malabsorption. The volume of stool output is proportional to the intake of the unabsorbable substrate(s). Disorders of malabsorption are responsive to changes in diet when the origin of the hyperosmotic state is based on an inability to sufficiently hydrolyze or absorb particular nutrients. If the disorder is caused because of a general loss of enteric microvilli, only the consumption of highly broken down diet may improve the diarrhea.

Etiologies Infectious Chronic Giardia infection can cause a chronic malabsorption disorder. Postinfectious conditions.

Immune Food allergies and intolerances, especially casein and soy.

Acquired or iatrogenic Mixed ● ● ●

Enteritis, chemotherapy induced Chronic enteritis with loss of absorptive capacity Surgical ● Gastric by-pass ● Short-gut (volvulus, intussusceptions, etc.)

Carbohydrates ● ●

Lactose intolerance Malabsorption disorders (i.e., fructose, glucose, and galactose)

Proteins ● Milk-protein allergy enteropathy Lipids ● Chronic pancreatitis

Congenital Mixed: carbohydrates and lipids ● ●

Cystic fibrosis Schwachman-Diamond syndrome (amylase deficiency)

Carbohydrates ● ●

Congenital lactase deficiency Congenital sucrase-isomaltose deficiency

Deficiencies ● Glutamine ● Niacin ● Folate Excess ● Vitamin C ● Niacin ● B3 ● Copper ● Tin ● Zinc

Pathophysiology of malabsorption diarrhea Anatomic Malabsorption disorders occur in the small intestines because of the role of the brush border and auxiliary glands (pancreas, liver, gallbladder, and to a certain extent stomach and mouth) in the hydrolysis of complex nutrient molecules into their basic, absorbable components.

ANS: Parasympathetic The role is generally compensatory and not causative (cf. RTD for the role of the autonomic nervous system). It plays a role in congestion for reconstruction. A predominance of vagal tone favors shortened transit time and insufficient time for digestion of nutrients.

Emunctories and auxiliary organs The primary role of digestion is with the stomach, liver, gallbladder, and exocrine pancreas. The primary role of the small intestines is to absorb the food broken down by digestive juices. Insufficiency of digestive juices relative to the surface area of the villi and the transit time (para) can cause an osmotic diarrhea. ● ● ● ●

Liver-gallbladder: fat management Pancreas: carbohydrates, lipids, and proteins Stomach: hydrochloric acid insufficiency: proteins Parotids, submandibular glands: carbohydrates and lipids

Serotonin As an autacoid, it prolongs parasympathetic function in the motricity of the intestines. As a peripheral enteric hormone, serotonin shortens transit time, worsening the problem of hyperosmolarity.

222  The Theory of Endobiogeny

Endocrine

Diet: Carbohydrates

The role of particular hormones depends on the etiology and may be causative or compensatory. The discussion below addresses the endocrine factors associated with acquired blunting of intestinal villi. Intestinal villi have a high turnover rate because of the intensity of the aggression faced by the small intestines from external aggressions and the quality of digestive secretions. This also makes them acutely affected by decompensation of the normal turnover mechanisms. In the demand for regeneration of the microvilli, sufficient metabolic estrogen activity is required, thus the gonadotropic axis will be the primary axis of dysfunction.

Avoid ●

● ●

●

Eat ●

●

Clinical assessment History Evaluate the quality of the stool and abdominal symptoms (Table  10.5). Evaluate the diet to rule out the consumption of hyperosmotic foods, either quantitatively excessive, or qualitatively excessive for the patient’s Endobiogenic terrain.

Focus on short-chain fatty acids (SCFA) and mediumchain triglycerides (MCT). SCFA aid in colon and systemic health.21 MCT is directly absorbed into the blood stream without aid of bile as an emulsifier (Table 10.7).22

Diet: Proteins

Evaluate signs of digestive juice insufficiency.

● ●

●

A diet rich in low fiber, complex carbohydrates ● White rice ● Potatoes (not yams) A diet rich in low fructose foods (Table 10.6). Berries are well tolerated, will not induce diarrhea in moderate amounts and have antioxidant properties20

Diet: Fats

Physical exam ●

High glycemic carbohydrates (semolina pasta, white bread, and sweets) High fructose fruits and honey (if necessary) Nonfermented dairy (it may be necessary to avoid fermented dairy, i.e., yogurt as well) Cheeses: exception: 24-month aged Parmigiana Reggiano cheese

Ensure sufficient acid for the digestion of proteins in the stomach

Oral: enlargement of parotids, submandibular salivary glands, and dilation of opening of the canal of Stensen Abdomen: borborygmus Congestion: liver, exocrine pancreas, and duodenum hepato-splanchnic Perineal: excoriation of skin, anal irritation

● ●

●

Eat ½ lemon with pith and skin before a meal 1 tbsp apple cider vinegar in warm water 15 min before a meal Betaine hydrochloride

Suggest easy-to-digest proteins that are ●

Treatment of malabsorption diarrhea The general approach to dietary modification is to encourage the slow and thorough chewing of food and mixing with salivary enzymes. “Drink your food and eat your beverages.”

●

Baked, boiled, broiled, or grilled ● Legumes: lentils, black beans (use with caution with carbohydrate enzyme insufficiency and dysbiosis or bloating) ● High purine fish: sardine, herring, tuna, salmon ● Fowl: turkey >chicken > duck ● Red meat: lamb > goat > beef Raw: sprouts: alfalfa, broccoli, radish, etc.

TABLE 10.5  Symptoms related to malabsorption diarrhea Stool

Nutrient intolerance

Watery

Carbohydrates

●

Abdominal Bloody

Lipids Proteins Giardia

Steatorrhea

Distention

Pain

●

±

●

●●

●

●

Nausea

Vomiting

●

● ● ●

Perianal excoriation

● ●

Disorders of intestinal transit Chapter | 10  223

Neuroendocrine

TABLE 10.6  A list of low fructose foods Fruits

Vegetables

Others

Pineapples

Asparagus

Eggs

Berries

Leafy green vegetables

Chicken, duck, turkey

Lemon and lime

Celery

Sardines, herring, anchovies

Rhubarb

Mushrooms

Bison: pasture raised, grass fed

Potatoes Root vegetables: parsnips, turnips, beets

Medicinal plants Astringents See “hypersecretory diarrhea.” Emunctory support Ensure good hepatobiliary-pancreatic support and select plants with cicatrizing properties16–18 (Table 10.8).

Summary of plants with exocrine pancreatic tropism by enzymatic activity When a specific type of food is identified as causing the secretory diarrhea, in addition to minimizing or avoiding that food for 6–12 weeks, medicinal plants with specific substitutive activity can be selected. Table 10.9 summarizes the specific substitutive activity of common medicinal plants with exocrine pancreatic tropism.16, 17

Regeneration of epithelial surface ● ●

Ficus carica GM Remineralization ● Argillite clay ● Equisetum arvense ● Urtica dioica root

ANS: reduce global autonomic activity, favoring plants that are spasmolytic and/or with an intestinal tropism. In addition to those noted above: ● ●

Matricaria recutita Artemisia dracunculus

Case study: Postviral gastroenteritis malabsorption The patient is a 23-year-old graduate student. He suffered from a mild case of viral gastroenteritis with nausea, vomiting, and diarrhea that lasted for 4 days. As he started to eat his normal diet again, he started experiencing diarrhea again. However, this time, it was bloody as well as watery. He experienced abdominal distention that worsened throughout the day. He started on an elimination diet and found that avoiding brown rice and fruit and animal proteins completely resolved the issue. However, he stated that he ate “like a cave man” and did not wish to avoid animal proteins. The patient was diagnosed with postviral denudation of the intestinal villi and insufficiency of amylase, disaccharidases, and protease enzymes. He was started on the following: 1. Diet a. Juice of 1 lemon diluted half strength before meals b. Fish: sardines, herring, and anchovies c. Fowl: broiled or grilled d. Berries and sprouted pumpkin seeds e. Low fructose vegetables f. Avoidance: everything else 2. Tincture: Raphanus niger MT 60 mL, Alchemilla vulgaris MT 50 mL, Copper oligo 10 mL, Dose: 2 mL twice per day before lunch and dinner 3. Tisane: Plantago major 100 g, Avena sativa 100 g: 1 tsp. steeped 6–8 min in 1 cup water, twice daily before meals 4. Clay 1 tsp. in chamomile tea (1 tsp. flowering tops steeped 12–15 min in 1 cup water and used to hydrate clay) at bed time

TABLE 10.7  Short- and medium chain fatty acids appropriate for malnutrition Fatty acid

Example

Source

Absorption

Short chain

Acetic acid Butyric acid Proprionic acid

Pectin: blackberries, carrots Fructo-oligosaccharides, inulin: Jerusalem artichoke, onions, leeks, asparagus

Large intestine (production and absorption)

Butyric acid

Kombucha Parmigiano Reggiano cheese, aged 24 months or longer

Small intestines

Coconut oil Olive oil

Small intestines

Medium chain

224  The Theory of Endobiogeny

TABLE 10.8  Medicinal plants with emunctory and astringent properties Plant

Hepato-biliary

Exocrine pancreatic

Intestines

Other

Arctium lappa

Choleretic Hepato-protectant

Dual pancreatrope

Reduces inflammation by immuno-modulation

Cutaneous drainer

Alchemilla vulgaris

Choleretic

Astringent

Antiinflammatory Cicatrizing Hemostatic

Agrimonia eupatoria

Stimulates hepatobiliary secretions

Dual pancreatrope

Astringent

Portal decongestant Cicatrizing

Fumaria officinalis

Choleretic Hepatic drainer

Drainer

Drainer

Spasmolytic: Sphincter of Oddi

Juglans regia

Stimulates hepatic macrophages

Dual pancreatrope

Astringent

Antiseptic Cicatrizing

Plantago major

Induces hepatic enzymes

Carbohydrates

Astringent Antiinflammatory

Antiinfectious Hepato-renal drainer

Salvia sclarea

Choleretic

Stimulates flow of secretions

Astringent

Para-alpha sympatholytic Muscular antispasmodic Cicatrizing

Proteases

Lipase

TABLE 10.9  Substitutive pancreatic actions of medicinal plants Plant

Amylase

Disaccharidases

Plantain (Plantago major)

●

●

Milky oat (Avena sativa)

●

●

Rye bud (Secale cereale)

●

●

Fig bud (Ficus carica)

●

●

●

Papaya leaf (Carica papaya)

●

●

●

Pineapple (Ananassa sativa)

●

●

●

●

●

Alfalfa (Medicago sativa)

●

The patient started introducing bison and apples after 8 weeks with only mild distention and slightly loose stools. After 12 weeks, he tolerated all foods again. After 16 weeks, he discontinued all treatments.

Rapid transit diarrhea Introduction RTD is a functional disorder of hyperfunctioning of the motricity of the enteric system.

Pathophysiology Neurologic Most typically those affected by RTD are vagotonic with hyperfunctioning para ≫ hyperfunctioning alpha. External or internal aggressors relaunch alpha, with a sufficiently strong beta response that the cycle of para-alpha-beta remains entrained until there is a sufficient reduction of alpha-sympathetic tone. The most common type of aggression is an anticipatory anxiety related to performance (examinations, public speaking, artistic performance, etc.).

Disorders of intestinal transit Chapter | 10  225

Iatrogenic Laxatives, magnesium products, including antacids, opiate withdrawal.

●

Autonomic nervous system ANS: reduce global ANS, favor plants that are spasmolytic and/or with an intestinal tropism16, 17

● ● ●

Introduction Constipation is one of the most common digestive complaints. It is defined as23, 24.

Treatment

●

Constipation: Disorders of delayed or dysfunctional transit

●

Matricaria recutita Angelica archangelica Artemisia dracunculus Origanum majorana

Alpha-sympatholytics with digestive tropism16, 17 ● ● ●

Melissa officinalis Salvia sclarea

Hard stools are not a sine quo non of constipation, as a patient may have normally formed stools that are difficult to pass due to obstruction or neuromuscular defects. The etiology of constipation is not always the colon or even the pelvic floor, but may be due to dietary, lifestyle, or psycho-emotional issues that impact the locoregional function of the colon and the demands that are placed on it during adaptive and adaptative states, or as a matter of adaptability. Constipation should be placed within the context of local, locoregional, regional, and systemic dynamics of the Endobiogenic terrain of each patient.

General alpha-sympatholytics16, 17 ●

●

≥3 months duration ≥2 of the following symptoms: ● Delayed transit: ≤2 bowel movements per week ● Altered consistency: stools that are: ▪ Hard and dry and/or ▪ Painful to pass ● Increased effort: straining to evacuate stool ● Blocked passage: sensation of anorectal obstruction ● Lack of completion: sensation of incomplete defecation ● Self-intervention: manual stimulation of defecation Insufficient criteria for irritable bowel syndrome

Inhalation during stress: ● Cananga odorata EO ● Citrus aurantium amara EO Oral ● Ilex aquifolium GM ● Leonurus cardiaca MT, FE, BH

Pathophysiology Lifestyle Encourage active ways of managing anxiety: breathe work, meditation, mindfulness, etc.

Broadly speaking, constipation can be divided into two general categories: primary and secondary. Primary causes are colonic in nature. Secondary causes are extra-colonic (Fig. 10.2).

Constipation

Primary: Colonic

Secondary: Extra-colonic Structure and function

Metabolic

Behavioral Latrogenic

Transit

Obstructive

Structural Functional

Normal

Slow

Structuro-functional

Connective tissue Food sensitivities

FIG. 10.2  Nosologic categorization of constipation according to the colonic vs extracolonic origin of pathophysiology. See text for details. (© 2015 Systems Biology Research Group.)

226  The Theory of Endobiogeny

Primary causes are divided into two subtypes: disorders of transit and obstructive disorders. Disorders of transit are further divided into disorders of normal and slow transit. Secondary causes are numerous and include regional and systemic physiologic disorders and behavioral factors that affect colon motility. There is considerable overlap between causes. For example, some secondary disorders result in normal transit constipation (NTC), others in slow transit constipation (STC). It is important not to be too categorical when evaluating the causes of constipation.

Normal transit constipation NTC is the most common type of constipation. The patient has 3 or more stools per week, but the stool is difficult or painful to pass. There is no sensation of colorectal fullness, nor is there a feeling of abdominal fullness.23

Etiology Etiology of NTC is variable and may involve one or more of the following factors.

Diet ● ●

●

Insufficient intake of fiber Insufficient intake of water for the endobiogenic equilibrium of the patient Disorders of fluid management (cf. Endocrinometabolic below)

Enteric ecology ●

Dysbiosis

Emunctory Insufficiency of bile excretion due to: ●

●

Autonomic nervous system ● Parasympathetic insufficiency: diminished rate of bile production ● Alpha-sympathetic excess: permits tonic closure of sphincter of Oddi ● Beta: blocked or insufficient for excretion of bile Gonadotropic ● Estrogen excess: diminishes biliary secretion ● Progesterone excess: favors biliary stasis

Physical examination Stool is not palpable in the distal colon. Evaluates for locoregional and global signs of ANS dysfunction. Palpate gallbladder points on abdomen, legs, and feet; evaluate hepatopancreatic blockage.

Treatment: General considerations Constipation is a phenomenon more than it is a disease. The causes are many and thus the best approach will vary based on the etiology. The most common causes of constipation are due to imbalances in the ecology of the intestine, dietary, and lifestyle factors. Thus, the first approach should address these imbalances.

Symptomatic Glycerin suppositories It is suitable for occasional use, up to 3 times per week for all ages. It creates an osmotic diuresis and acts as a lubricant for the passage of stool.

Stimulant laxatives Stimulant laxatives offer short-term relief from constipation, but can cause bloating, gas, and spasmophilia.

Endobiogenic treatment of terrain Water The consumption of water does not in and of itself guarantee improved consistency of stool, although dehydration can favor reduced water content in stool in order to conserve total body water. The movement of water is based on its osmolality and pH. In order of preference12, 13: 1. Alkaline spring waters 2. Artesian well water 3. Distilled water: not recommended; if only safe water available, enhance mineral content: a. Schussler cell salts b. Argillite clay

Diet Because dietary factors are the most common causes for constipation, they are the most efficient and safest longterm approach to treatment.

History

Soluble fiber

Perform a detailed evaluation of the frequency of defecation, ease of passage, and quality of stool. Evaluate for symptoms of dysfunctional ANS activity, excessive estroprogestive state (e.g., strong premenstrual syndrome (PMS) symptoms in women), or iatrogenic causes such as oral estro-progestive contraceptive pills.

A diet rich in fiber is the best way to assure adequate colonic motility.25 There are two types of fiber: soluble and insoluble. Soluble fibers dissolve in water, are fermented in the colon and can serve as prebiotics. They may slow the movement of food through the colon. Soluble fiber foods can be used effectively for NTC disorders. Soluble fibers

Disorders of intestinal transit Chapter | 10  227

are typically found in the pulp, and insoluble fibers in the skin of foods.26 The skin of every fruit and vegetable should be eaten whenever possible, including the skin of gourds such as acorn squash. Patients with a history of a low-fiber diet are advised to start at 5–10 g/day and increase to a goal of 30–40 g/day. Patients should drink 6 glasses of water per day, and add 1 additional glass (250 mL) per 10 g fiber after the first 10 g/day.

TABLE 10.10  High fiber foods by category of food—cont’d Legumes

Lentilsa a

Black beans

a

Pinto beans

a

Kidney beans

Vegetables

13

Navy beans

1 cup

11

a

1 cup

6

1 cup

16

1 cup

9

1 cup

7

1 cup

6

Broccoli

1 cup

4

Spinach, cookeda

1 cup

4

Pistachiosa

4 oz

12

Hazlenutsa

4 oz

9

Pumpkin seedsa

4 oz

4

Almondsa

4 oz

2.5

Grapefruita

1

14

1 med

12

1 cup

8

1

5

1

5

1

4

1

4

1

4

2

4

4

3

Split peas

a

Kale

a

Yam

a

Fruits

a

Avocado

a

Raspberries a

Pear

a

Apple

a

Banana

a

TABLE 10.10  High fiber foods by category of food Category Grains

Food

Serving

Bran cereal

1 cup

Barley

1 cup

Bulgur

1 cup

Freekeh

Blueberry a

Orange

Fiber (gm)

a

Figs, dry

20

a

Dates

14

15

1 cup

a

Honey is a natural demulcent. Being rich in fructose and water,27 it can also serve as a mild osmotic diuretic (combine with sesame or olive oil) and consume in between meals for best effect.

1 cup

a

Grean peas

Honey

15

13

a

Nuts

1 cup

1 cup

Chick peas

Fructose is a monosaccharide that is absorbed both by passive diffusion and via a glucose symporter. Fructose is the sweetest of all monosaccharides, but has a low glycemic impact, thus it is safe to use with type two diabetics subtypes a and c (according to the theory of Endobiogeny, discussed elsewhere). When the concentration of fructose is sufficiently elevated, it overwhelms the absorptive mechanisms and becomes an osmotic diuretic in the colon. Thus, while most fruits, gram per gram are not as high in fiber as vegetables, the combination of high water content, soluble fiber (pulp), insoluble fiber (skin), and fructose content makes them an excellent method for improving both transit time and stool consistency (Tables 10.10 and 10.11).23, 26

15

a

Lima beans

Fruit

1 cup

a

Gluten-free.

8

Bold, high in protein.

1 cup

7

3 tsp.

7

Quinoaa

1 cup

6.5

Whole wheat spaghetti

1 cup

6

1 cup

4.5

Groats (Kasha)

1 cup

4.5

Ezekiel bread

2 slices

4

Fermented foods offer a natural source of bioavailable commensal organisms, reflecting the external ecologic terrain as well as the internal terrain of the organism. Thus, fermented foods are best chosen that are produced locally with soilbased organisms. Some examples of fermented foods by region of the world:

1 cup

4

●

1 cup

4

1 cup

3.5

Flax seeds

a

Buckwheata a

a

Oats, raw a

Corn

a

Brown rice

Fermented foods

Asia: ● Food: tempeh, miso, soy sauce, tamari, natto, kimchi (cabbage) ● Drinks: Pu-erh tea, kombucha (fermented tea beverage)

228  The Theory of Endobiogeny

TABLE 10.11  Best fruits for constipation by season of growth Spring

Summer

Autumn

Winter

All year juices

Grapes

Strawberries

Apples

Grapefruit

Prune

Watermelon

Figs

White grape

Watermelon juice

Pomegranate

Apple

Pears Quince

● ● ● ● ●

●

Caucuses: kefir, yoghurt India: idli, dosas Africa: injera (bread made from teff) Americas: sourdough bread, buttermilk Middle East: Torshi (pickled, fermented vegetables), dugh (fermented yogurt drink), kashk (fermented whey made from dugh), shubat (fermented camel milk) Europe: Jamón ibérico (Iberian ham), pepperoni, salami, sauerkraut, prosciutto, crème fraîche, skyr (Icelandic whey-yogurt), kvass (fermented rye beverage), Cidre poiré, cornichons

●

●

Dose: ● 0–11 months: ¼ tsp. ● 12–23 months: ½ tsp. ● 2–4 years: 1 tsp. ● 5–7 years: ½ tbsp ● 8 years and older: 1 tbsp Frequency: 1–2 times per day followed by 250 mL of spring water if it does not interfere with sleep and urinary habits ● AM before breakfast ● Before bed

Summary of dietary approach for NTC Probiotics Probiotic organisms can be administered in powder or tablet form when a more aggressive correction of the gut flora is required. Both bacterial (i.e., Lactobacillus ssp. and Bifidus ssp.) and fungus (i.e., Saccharomyces boulardii) can be used.28–31 They can reduce the frequency of glycerin suppository use.32

1. Extra-virgin olive oil: 1 tbsp in AM followed by a glass of water with lemon juice 2. Water: 6–10 glasses per day 3. Soluble fibers: 30–40 g/day 4. Fermented foods: 2 servings/day

Lifestyle ●

Cleansing diets Cleansing diets, performed around the changing of the seasons with seasonal fruits and vegetables can be helpful for maintenance of health and bowel regularity: ● ● ●

Grape cure Apple-sardine diet Fruit-vegetable-brown rice diet

●

Movement: regular exercise, yoga, and other meditative movement practices can aid in the stimulation of normal colonic motricity34, 35 Sleep: restorative sleep, starting from 11 p.m. and continuing through 5 or 6 a.m. can improve the efficiency of hepatobiliary and colonic activity, respectively

Medicinal plants

Oils

The choice of medicinal plants depends on the etiology of constipation. Some general guidelines for the most common types are presented.

Oils can aid in the passage of stool in two ways: choleresis and as a lubricant.33

Restoration of gut ecology

● ●

Choleretic: olive oil Lubricating: ● Olive: best general oil ● Sesame: children full of energy and anxious adults ● Borage oil: obese individuals ● Flax oil: obese individuals, asthmatics, inflammatory disorders

Essential oils are efficient for this purpose:16, 17 ●

● ● ●

Artemisia dracunculus (tarragon) EO, MS: use in cases of spasmodic colon Syzygium aromaticum (clove) EO Mentha piperita (peppermint) EO Satureja montana (savory) EO: with an infective component, or for blocked or delayed beta

Disorders of intestinal transit Chapter | 10  229

Emunctories Use plants that favor hepatobiliary drainage, cholagogues and choleretics.16, 17 In estrogenic females and obese patients, avoid using aggressive choleretics at first ● ● ● ● ● ●

Carduus marianus (milk thistle) Cynara scolymus (artichoke) leaf Mentha piperita (peppermint) Raphanus niger (black radish) Rosmarinus officinalis (rosemary) Taraxacum dens leonis (dandelion)

hot dogs. This has been her general diet. She started eating salad at a salad bar but it did not help with her constipation. When she was asked to describe her salad she said, “Iceberg lettuce, croutons, bacon bits, and blue cheese dressing.” The patient was asked to do the following in an incremental fashion since she was not used to eating a high-fiber diet with plenty of water: ●

Demulcents Demulcents are mucoprotective agents that relieve pain and inflammation of the mucous membranes.16, 17 ● ● ● ● ● ●

Althea officinalis (marshmallow) Glycyrrhiza officinalis (licorice) root Trigonella foenum graecum (fenugreek) seed Plantago ovata (psyllium) seed: also mucilaginous Honey + sesame oil Glycerin: helpful for children for a short period of time

● ●

Laxatives Favored for dry stools in patients who often are overweight, and/or consume excessive amounts of animal proteins and fatty animal-based foods16, 17; exam: red tongue with yellow coating ● ● ●

Taraxacum officinale (dandelion) root Berberis vulgaris (barberry) root Cascara sagrada (cascara) bark

Treating anal fissures ● ●

● ● ● ●

Peanut oil 1 mL Clay: 1 pinch ● Optional: baking soda: 1 pinch if experiencing burning Lavender EO 1 drop Mix well Rinse anus with warm water, lightly pat dry Apply mixture to anus AM, afternoons (after defecation) and before bed

● ●

Week 1: ● Fruit-vegetable-brown rice diet × 6 days ● Olive oil and 6 glasses of water per day ▪ AM: 1 tbsp olive oil +1 glass water 15 min before meal ▪ 2 glasses water between breakfast and dinner Week 2: flax bread, 2 squares per day (10 g fiber) Week 3: ● 1 cup puréed sweet potatoes 2–3 per week (6 g fiber) ● 1 cup hummus 2–3 times per week (6 g fiber) ● Buckwheat, 1 cup once 2–3 times week (4 g fiber) ● Continue with 2 pieces of flax bread (10 g fiber per square) ● Smoothie for breakfast (17 g fiber): ▪ Protein powder, 1 scoop ▪ ½ Avocado (6 g fiber) ▪ ½ cup frozen raspberries (4 g fiber) ▪ 1 cup kale (7 g fiber) ▪ Dilute with unsweetened vanilla almond milk to taste Week 4: 1 serving of fermented food 4 times per week Week 6: movement ● Standing up every 55 min and walking around for 5 min ● 20 min of brisk walking 4 times per week with a friend

By week 3, she started having 1 stool per day but it was still painful. By week 12, she was passing 2 stools per day that were no longer painful.

Slow transit constipation Introduction STC is defined as passing <3 bowel movements per week without urgency but with increased straining. There is often a feeling of abdominal fullness.24

Case study: NTC

Pathophysiology

A 42-year-old women presents with a history of chronic constipation. She states that ever since she was 4 she has experienced constipation. She passes 1 stool every 2 days, but with difficulty. The stool occasionally scrapes her anus and causes bright red blood to appear on the toilet paper when she wipes. Ever since she was 3 years old, she started craving macaroni and cheese, pasta with cheese, pizza, and

Dysfunction is functional in nature: altered motricity of the colon. Etiology of STC favors a greater role of the autonomic nervous system and peripheral thyroid activity. The factors noted for NTC may also be present but to a greater degree of severity. In the general plan of the general adaptation syndrome, adaptability and adaptative states, a certain

230  The Theory of Endobiogeny

level of ­autonomic activity is solicited to regulation and ­re-equilibrate endocrine activity based on the demands of the organism. The impact of this demand for augmented autonomic function may affect the digestive tract for three reasons: (1) the global intensity of ANS function affects the intestinal transit and the general rate of excretion of digestive secretions, (2) colonic transit is delayed in order to augment the absorption of nutrients from specific segments of the colon for adaptative needs (cf. inflammatory bowel disorders), or a combination of the two. Occasionally one may find a state of true vagotonic deficiency. More commonly, alpha is excessively elevated is greater than para at the level of motricity and delays diminishes the basal rate of motricity installed by para. Beta is blocked or insufficient from the elevated alpha, impairing peristalsis.

TABLE 10.12  Some ANS findings in slow transit constipation Region

Hyperalpha > hyperpara

Mouth

Saliva stringy ± dilated opening of canal of Stenson

Abdominal tenderness

Gallbladder point (sphincter of Oddi)

ACTH: ileocecal, rectosigmoid colon FSH: ascending, proximal transverse colon LH: distal transverse, proximal descending colon TSH: splenic flexure colon TRH: hepatic flexure colon GH: mid-descending colon PL: distal descending colon

Neurologic

Glabellar tap: rapid lower eye lid response

Glabellar tap: TRH: flutter pre- or posttap DTR: TRH: brisk response

Extremities

Tender pelvic congestion point

Physical exam One may note abdominal bloating and palpable stool in the distal colon. Evaluate for signs of elevated autonomic function (cf. The Theory of Endobiogeny, Volume 1, Chapter 1) and neurologic function rooted in thyrotropic dysfunction resulting in spasmophilia (cf. The Theory of Endobiogeny, Volume 1, Chapter  11). Findings related to colon oversolicitation by central endocrine factors may or may not be present. When they are, they help determine a more comprehensive approach to treatment of the global terrain (Table 10.12).

Hands cool ± moist Feet colder than hands ± moist

Treatment Dietary approach for STC: Insoluble fiber Insoluble fiber does not dissolve in water and is metabolically inert. It acts as a bulking agent, drawing in water and stimulating the colon through a mild irritant effect. It is best used with STC. The skins of fruits and vegetables contain insoluble fiber. In summary, patients should be encouraged to consume plenty of water, insoluble fiber, fermented foods, and oils.26

Psychological and lifestyle Because of the predominance in autonomic and adaptative physiology, regulation of this tone is important. Therapies can be divided into three groups: psychological, psychophysiological, and psycho-mechanical. In the first group is cognitive behavioral therapy (CBT).36 CBT helps shift the framework of perception that installs an adaptative physiology. In the second group is biofeedback37, breath work, and other techniques that modify heart rate variability as a marker of autonomic tone.36 They reduce global alpha-sympathetic tone, improving the normal autonomic cycling and hence colon motricity, offering a feeling of empowerment for the

Endocrine

patient with respect to emotional state and bowel function. In the third group are exercises with breath work, such as yoga and Tai chi.34, 35 Certain yoga asanas (poses) and movements can assist through compression-relaxation on intestinal muscular tension and regulation of ANS tone through breath work with respect to colon motricity and spasmophilia.

Enteric ecology Cf. Normal transit constipation.

Emunctory Cf. Normal transit constipation.

Correcting the autonomic terrain Parasympathomimetics16, 17 ● Syzygium aromaticum (clove) ● Fumaria officinalis (fumitory)

Disorders of intestinal transit Chapter | 10  231

● ●

Mentha piperita (peppermint) Rosmarinus officinalis (rosemary)

Alpha-sympatholytics16, 17 ● ● ●

Origanum majorana (marjoram) Citrus aurantium (neroli, petitgrain) Melissa officinalis (lemon balm)

Para- and alpha-sympatholytics with intestinal tropism16, 17 ●

Matricaria recutita (German chamomile)

Antihistaminics with intestinal tropism16, 17 ● ● ●

Agrimonia eupatoria (agrimony) Fumaria officinalis (fumitory) Plantago major (plantain)

Beta-mimetics16, 17 ● ●

Cinnamomum zeylanicum (cinnamon) Satureja montana (savory)

Mineral ●

●

Hypercalcemia ● Remove or diminish iatrogenic sources of calcium: antacids, supplements, etc. Hypokalemia ● K oligoelement 2 droppers BID AM and qHS ● Potassium-rich foods

Enemas An enema is a water-based hyperosmotic treatment that is forcefully entered into the distal colon, stimulating a bowel movement. Coffee grounds offer the advantage of also stimulating peritoneal “dialysis” with removal of toxins. Enemas are more helpful for STC, with dilated colon and mild to moderate obstructive disorders. They can result in electrolyte depletion and dehydration with excessive use.

Case study #1: STC in a 5-year-old girl A mother brings her 5-year-old in for complaint of constipation and said that she was “sick of the dog and pony show” it took to get the child to stool. She had one older and one younger child who both were perfect at going to the bathroom, she pointed out in front of the child. The child stools 3 times every 2 weeks. The stool is so large, it clogs the toilet at least twice per month. The mother states that she is an avid juice and water drinker (4 cups per day) and likes to eat carrots and apples. She often complains of tummy pain

that diminishes her appetite. She has a history of recurrent otitis media treated 4 times with antibiotics. She has chronic nasal congestion with clear discharge. It takes about 45 min for the little girl to wind down and sleep at night. On physical examination, she appears slightly thin, pale, and gangly. She has reddish-purple infraorbital discoloration. Her palate is ischemic and pale. Her tonsils are congested, 2+ with crypts. The opening of the canals of Stensen are dilated, right > left. Superficial veins are apparent on her eyelids and chest. She is not compliant with a full abdominal exam but stool is palpated in the descending colon. One may conclude that her constipation is slow transit due to elevated alpha ≫ para. This terrain also explains her recurrent otitis and physical exam findings. One may also conclude that there is an element of stool withholding that has to do with a power struggle between the mother and the daughter. The patient was treated with the following: 1. Inulin powder: ½ tsp. in each cup of apple juice 2. Hepatobiliary-pancreato-ENT: Agrimonia eupatoria 40 g, Avena sativa 40 g, peppermint 40 g: ½ tsp. of mixture steeped 4–6 min in 120 mL water, drink three times per day before meals 3. ANS-sleep: Tilia tomentosa GM 50 mL, Rosmarinus officinalis GM 10 mL, 2 droppers before bed By 4 weeks, stool frequency improved to 4 times in 2 weeks. By 12 weeks, it improved to every other day (7 times per 2 weeks) but was still large and hard. The patient had less defiance tendencies toward her mother, but it persisted to some degree nevertheless. In addition, stool frequency did not improve beyond this even after 3 additional months of treatment. At 6 months of treatment, the mother agreed to go to behavioral counseling with her daughter for dyadic relationship management. After 6 weeks of counseling that included a reward system and body awareness skills, the girl felt comfortable to stool daily without further prompting. The treatment of inulin, tisane, and tincture were continued for another 6 months, then discontinued without any further need for treatment.

Case study #2: STC in a 39-year-old man A 39-year-old man presents on September 18 with a 4-week history of constipation. He states that he has been regular most of his life. For the last month, he stools every 3–4 days. He has a feeling of fullness, complains of feeling toxic and tired and experiences pain but then relief once he does pass the stool. He admits to having inserted his finger in his rectum to stimulate the passage of stool on two occasions. When you look at his chart, you note that his birthday is on October 27 and that he will turn 40 years old. He states that he was an easy child, a good sleeper, and eater. He ­describes his parents as loving with no childhood trauma he can recall.

232  The Theory of Endobiogeny

On physical examination, one notes dark circles under his eyes, which he says is also new for the last 3 weeks. His saliva is stringy and thick and not abundant. When you comment on this, he notes that his saliva has always been abundant, fluid, and easy to swallow. His liver is slightly full but not enlarged. It’s tender on palpation in the s­ uperior-medial portion and the gallbladder point is tender. The rest of his examination is unremarkable. The context of this new-onset constipation is the chronobiologic unfolding of genital recycling that occurs sometime between 38 and 42 years of age. In this case, it is occurring on the cusp of his 40th birthday. The unfolding begins approximately 2.5–3 months before one’s birthday. The second nested chronobiologic context is seasonal adaptation. The autumn adaptation begins in preautumn, around August 18, which is the day of onset of the constipation. It is also 2.5 months before his 40th birthday. Within the milieu of two nested chronobiologic demands the patient had an insufficient adrenal cortex adaptation to recalibrate both the seasonal cortisol demand as well as the genital recycling demand for adrenal androgens. Thus, the dark circles under the eyes. A hyperalpha response was solicited to support adrenal cortex response. Thus, one notes in the thickening saliva, full liver with superior-medial tenderness (vascular congestion) and constipation. There is also an insufficiency of choleresis, which is contributing to the constipation. Recall that bile has a mild laxative effect. A symptomatic approach to treatment will be to use osmotic diuretics and choleretics. A treatment of the terrain will start with adrenal cortex support with a special consideration for adrenal androgens. Alpha-sympatholytics will also need to be employed because they have installed themselves within the bowel motricity in a manner that needs to be disengaged from the organism. Hepatobiliary drainage will complement the treatment. 1. Lemon juice treatment TID × 1 week before meals: adrenal cortex support (vitamin C), sustains transition from alpha to beta, stimulates hepatic flow, cholagogy, and choleresis, general hepatobiliary drainage a. ⅓ cup organic, fresh squeezed lemon juice (2 medium sized) b. ⅛ cup water for dilution c. Cayenne pepper, 6 dashes d. Sea salt, 1 pinch e. Betula pubescens GM D1: 6–10 drops 2. ANS-adrenal cortex tincture: 4 mL BID before meals through January 18 to sustain the full adaptation of adrenal cortex function. a. Sequoia gigantea GM 80 mL b. Quercus pedunculata GM 80 mL c. Ilex acquafolium GM 40 mL

d. Passiflora incarnata MT 40 mL e. Lavender EO 4 mL f. Cinnamon leaf EO 2 mL 3. Hepatobiliary tincture: 3 mL before lunch and before dinner until March 30 to support genital recycling and prespring catabolic discharge. a. Raphanus niger MT 80 mL b. Taraxacum officinale MT 80 mL c. Carduus marianus MT 80 mL Thanks to the lemon juice treatment the patient started defecating daily within 24 h of treatment. By the 5th day, the stool was slightly loose and the patient was defecating 3–4 times per day. However, the patient saw this as a detoxification response and felt energized and focused. The patient continued the treatment until the dates instructed. By early December, the dark circles resolved. By early March, he noted his saliva was more abundant again.

Secondary causes of constipation Structural Obstructive disorders of the distal colon can result in delayed evacuation of stool. Examples include pelvic basin neoplasms, volvulus, and uterovaginal prolapse.

Structuro-functional Structuro-functional disorders are disorders of the functionality of intestinal motility and contraction due to tissular and organic structural insufficiencies. Megacolon, chronic laxative use, Hirschsprung’s disease, and ultrashort-segment Hirschsprung’s disease are three examples. The latter may take over a decade to diagnosis and will present as constipation refractory to standard-of-care treatments. If typical therapies fail to resolve constipation over a 1–2 year period of time, referral to a gastroenterologist with colonoscopy and biopsy may be indicated.

Functional Pelvic floor dysfunction may occur as a result of injury to the sacral nerves and certain plexi involved in coordinating defecation. This may occur from stretch injuries from repeated pregnancies, spinal cord lesions, outlet obstruction, strokes with diminished blood flow to the respective nerves, and familial dysautonomia syndrome.

History Patient will complain of prolonged or excessive straining, incomplete evacuation of stool. Or they will report the use of intravaginal pressure and/or digital evacuation of stool.

Disorders of intestinal transit Chapter | 10  233

Treatment

Pathophysiology

Manual therapies, such as visceral manipulation and acupuncture can be helpful.38, 39

The stool accumulates in size and becomes progressively dry. When the stool finally passes, it is hard and painful, often resulting in anal tears. A vicious cycle then begins in which stool is withheld because of the pain associated with the prior experience (cf. adults, below).

Metabolic Diabetes mellitus. Poorly managed diabetes can result in an autonomic neuropathy due to glycalation-related damage.40, 41

Treatment Support the restoration of myelination and nutrition of the nerve. Improve glycemia and reduce oxidative damage. 1. Alpha-lipoic acid: 2000 mg per orum TID × 4 weeks, then 1000 mg PO BID × 5 months 2. Liposomal curcumin 5 mL BID × 6 months 3. Neuro-Lymphatic tincture: 3–4 mL BID × 6 months a. Vaccinium myrtillus MT 200 mL b. Vinca minor MT 160 mL c. Melilotus officinalis MT 120 mL d. Cypress EO 6 mL e. Marjoram EO 4 mL

Connective tissue and immune disorders Various connective tissue disorders may result in fibrosis of segments of the intestines: scleroderma, amyloidosis, multiple sclerosis, etc.

Treatment The treatment needs to be specified to the specific type of disorder. The tincture below is a general approach to both fibrosis and sclerosis with drainage of connective tissue and the ground matrix. 1. Fibro-sclerosis tincture: 3–4 mL twice per day a. Alnus glutinosa GM 60 mL b. Ribes nigrum GM 20 mL c. Ilex aquifolium GM 60 mL d. Betula pubescens GM 60 mL e. Viscum album GM 40 mL

History The history is notable for one or more of the following: 1. “Man-sized” stools 2. Repeated clogging of toilet with plumbing-related expenses 3. Passing of odiferous flatus for several days that can “clear a room” before finally passing a stool 4. A series of small, soft stool of poor consistency or smearing of stool on underwear due to involuntary passage before passing the large, hard stool. This represents the passage of fresh, normally formed stool around the partial blockage of the large, hardened stool. 5. Bright red blood on wiping (due to anal fissure)

Treatment 1. Laxatives: foods or supplements 2. Dyadic behavioral counseling: parent-child interactions42 3. Body-sensing and awareness skills for the child to avoid withholding43 4. Acupuncture44

Behavioral: Adults Withholding of stool in adults can arise from childhood issues as noted above. If the onset is in adulthood, look for rectosigmoid and anal pathologies. When this area is already inflamed or injured, the passage of stool aggravates the condition. Thus, a withholding pattern begins that creates a cycle of pain and further withholding. Examples of such pathologies are inflammatory bowel disease with incomplete healing of ulceration, abscesses, anal fissures, and thrombosed hemorrhoids.

History Bright red blood is reported on wiping, but not in the toilet.

Behavioral: Children

Treatment

There are only two things that a toddler can control in their lives: what goes in their mouths and what comes out of their anus. Children may diminish consumption of fluids, and withhold stool for two general reasons: (1) due to a desire to not discontinue engagement in an enjoyable activity, or (2) as an expression of autonomy against the will of the mother.

Specific to the etiology. Behavioral counseling45 and biofeedback training may be required.43

Food sensitivities Food sensitivities, mediated by IgA or IgG phenomenon, may present with constipation (normal or delayed transit).

234  The Theory of Endobiogeny

In the case of nursing infants, the mother’s dietary intake should be taken along with the infant’s when considering an elimination diet.

Iatrogenic A number of commonly prescribed medications can affect bowel motricity.

Psychiatric 1. Antidepressants (tricyclics, MAO inhibitors) 2. Psychotropic medications

Autonomic 1. Sympathomimetic drugs 2. Anticholinergics 3. Opioids

Metalotherapy 1. Iron 2. Bismuth

Hydroelectrolyte 1. Antacids (aluminum and calcium compounds) 2. Calcium channel blockers

Immunologic 1. Nonsteroidal antiinflammatory drugs (NSAIDs)

Functional 1. Cholestyramine 2. Stimulant laxatives, chronic use

Conclusions Disorders of intestinal transit fall into two general categories: rapid transit (diarrhea) and normal/slow transit (constipation). The etiologies are varied from infectious to autonomic to systemic disorders. For each type of transit disorder, there are particular signs and symptoms associated with it. This allows the Endobiogenist to personalize therapy with the most targeted dietary, lifestyle, and medicinal plant therapies.

References 1. 2.

Guttman JA, Finlay BB. Subcellular alterations that lead to diarrhea during bacterial pathogenesis. Trends Microbiol. 2008;16(11):535–542. Schiller LR, Pardi DS, Spiller R, et al. Gastro 2013 APDW/WCOG Shanghai working party report: chronic diarrhea: definition, classification, diagnosis. J Gastroenterol Hepatol. 2014;29(1):6–25.

3. Santos DV, Reiter ER, DiNardo LJ, Costanzo RM. Hazardous events associated with impaired olfactory function. Arch Otolaryngol Head Neck Surg. 2004;130(3):317–319. 4. Canani  RB, Cirillo  P, Roggero  P, et  al. Therapy with gastric acidity inhibitors increases the risk of acute gastroenteritis and community-acquired pneumonia in children. Pediatrics. 2006;117(5):e817–e820. 5. Leonard  J, Marshall  JK, Moayyedi  P. Systematic review of the risk of enteric infection in patients taking acid suppression. Am J Gastroenterol. 2007;102(9):2047–2056 [quiz 2057]. 6. Sell  J, Dolan  B. Common gastrointestinal infections. Prim Care. 2018;45(3):519–532. 7. Duman  M, Gencpinar  P, Bicmen  M, et  al. Fecal calprotectin: can be used to distinguish between bacterial and viral gastroenteritis in children? Am J Emerg Med. 2015;33(10):1436–1439. 8. Shastri YM, Bergis D, Povse N, et al. Prospective multicenter study evaluating fecal calprotectin in adult acute bacterial diarrhea. Am J Med. 2008;121(12):1099–1106. 9. Guandalini S, Pensabene L, Zikri MA, et al. Lactobacillus GG administered in oral rehydration solution to children with acute diarrhea: a multicenter European trial. J Pediatr Gastroenterol Nutr. 2000;30(1):54–60. 10. Guandalini S. Probiotics for prevention and treatment of diarrhea. J Clin Gastroenterol. 2011;45(suppl):S149–S153. 11. Colin-Gonazlez  AL, Santamaria  A. Garlic, gastrointestinal protection and oxidative stress. In: Gracia-Sancho  J, Salvado  J, eds. Gastrointestinal Tissue: Oxidative Stress and Dietary Antioxidants. Elsevier; 2017 [chapter 20]. 12. Charrié J-C, Clairemont de Tonnerre M-L. Se Soigner Toute L’année au Naturel. France: Prat Editions; 2017. 13. Charrié  J-C, Souffland-Groussard  M, Bartczak  S, Paslin  D, Lapraz  JC. Les clés de L’alimentation Anti-cancer et Maladies Inflammatoires, Infectieures, Auto-immune. France: Terre Vivante Editions; 2017. 14. Morrison KD, Underwood JC, Metge DW, Eberl DD, Williams LB. Mineralogical variables that control the antibacterial effectiveness of a natural clay deposit. Environ Geochem Health. 2014;36(4):613–631. 15. Williams LB, Metge DW, Eberl DD, et al. What makes a natural clay antibacterial? Environ Sci Technol. 2011;45(8):3768–3773. 16. Duraffourd  C, Lapraz  JC. Traité de Phytothérapie Clinique: Médecine et Endobiogénie. Paris: Masson; 2002. 17. Lapraz  JC, Carillon  A, Charrié  J-C, et  al. Plantes Médicinales: Phytothérapie Clinique Intégrative et Médecine Endobiogénique; 2017. 18. Sen  S, Chakraborty  R. Herbs, gastrointestinal protection and oxidative stress. In: Gracia-Sancho  J, Salvado  J, eds. Gastrointestinal Tissue: Oxidative Stress and Dietary Antioxidants. Elsevier; 2017 [chapter 19]. 19. Guarino A, Guandalini S, Lo Vecchio A. Probiotics for prevention and treatment of diarrhea. J Clin Gastroenterol. 2015;49(suppl 1):S37–S45. 20. Sangiovanni E, Fumagalli M, Dell’Agli M. Berries: gastrointestinal protection against and oxidative stress and inflammation. In: GraciaSancho  J, Salvado  J, eds. Gastrointestinal Tissue: Oxidative Stress and Dietary Antioxidants. Elsevier; 2017 [chapter 18]. 21. Deleted in review. 22. Bach AC, Babayan VK. Medium-chain triglycerides: an update. Am J Clin Nutr. 1982;36(5):950–962. 23. Lacy BE, Mearin F, Chang L, et al. Bowel disorders. Gastroenterology. 2016;150(6):1393–1407.

Disorders of intestinal transit Chapter | 10  235

24.

Simren M, Palsson OS, Whitehead WE. Update on Rome IV criteria for colorectal disorders: implications for clinical practice. Curr Gastroenterol Rep. 2017;19(4):15. 25. Yang J, Wang HP, Zhou L, Xu CF. Effect of dietary fiber on constipation: a meta analysis. World J Gastroenterol. 2012;18(48):7378–7383. 26. Dreher  ML. Whole fruits and fruit fiber emerging health effects. Nutrients. 2018;10(12). 27. Pasupuleti VR, Sammugam L, Ramesh N, Gan SH. Honey, propolis, and royal jelly: a comprehensive review of their biological actions and health benefits. Oxid Med Cell Longev. 2017;2017:1259510. 28. Russo  M, Giugliano  FP, Quitadamo  P, Mancusi  V, Miele  E, Staiano A. Efficacy of a mixture of probiotic agents as complementary therapy for chronic functional constipation in childhood. Ital J Pediatr. 2017;43(1):24. 29. Mirghafourvand  M, Homayouni Rad  A, Mohammad Alizadeh Charandabi S, Fardiazar Z, Shokri K. The effect of probiotic yogurt on constipation in pregnant women: a randomized controlled clinical trial. Iran Red Crescent Med J. 2016;18(11):e39870. 30. Mezzasalma  V, Manfrini  E, Ferri  E, et  al. A randomized, double-blind, placebo-controlled trial: the efficacy of multispe­ cies probiotic supplementation in alleviating symptoms of irritable bowel syndrome associated with constipation. Biomed Res Int. 2016;2016:4740907. 3 1. Choi JS, Kim JW, Kim KY, Lee JK, Sohn JH, Ku SK. Synergistic effect of fermented rice extracts on the probiotic and laxative properties of yoghurt in rats with loperamide-induced constipation. Evid Based Complement Alternat Med. 2014;2014:878503. 3 2. Jin L, Deng L, Wu W, Wang Z, Shao W, Liu J. Systematic review and meta-analysis of the effect of probiotic supplementation on functional constipation in children. Medicine (Baltimore). 2018;97(39):e12174. 3 3. Ramos CI, Andrade de Lima AF, Grilli DG, Cuppari L. The shortterm effects of olive oil and flaxseed oil for the treatment of constipation in hemodialysis patients. J Ren Nutr. 2015;25(1):50–56. 3 4. Evans S, Lung KC, Seidman LC, Sternlieb B, Zeltzer LK, Tsao JC. Iyengar yoga for adolescents and young adults with irritable bowel syndrome. J Pediatr Gastroenterol Nutr. 2014;59(2):244–253.

35.

Zhou C, Zhao E, Li Y, Jia Y, Li F. Exercise therapy of patients with irritable bowel syndrome: a systematic review of randomized controlled trials. Neurogastroenterol Motil. 2018;e13461. 36. Jang  A, Hwang  SK, Padhye  NS, Meininger  JC. Effects of cognitive behavior therapy on heart rate variability in young females with constipation-predominant irritable bowel syndrome: a parallel-group trial. J Neurogastroenterol Motil. 2017;23(3):435–445. 37. Turnbull GK, Ritvo PG. Anal sphincter biofeedback relaxation treatment for women with intractable constipation symptoms. Dis Colon Rectum. 1992;35(6):530–536. 38. Xiong F, Wang Y, Li SQ, Tian M, Zheng CH, Huang GY. Clinical study of electro-acupuncture treatment with different intensities for functional constipation patients. J Huazhong Univ Sci Technol Med sci. 2014;34(5):775–781. 39. Zhang  T, Chon  TY, Liu  B, et  al. Efficacy of acupuncture for chronic constipation: a systematic review. Am J Chin Med. 2013;41(4):717–742. 40. Haines  ST. Treating constipation in the patient with diabetes. Diabetes Educ. 1995;21(3):223–232. 41. Ihana-Sugiyama N, Nagata N, Yamamoto-Honda R, et al. Constipation, hard stools, fecal urgency, and incomplete evacuation, but not diarrhea is associated with diabetes and its related factors. World J Gastroenterol. 2016;22(11):3252–3260. 4 2. Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: evidencebased recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258–274. 4 3. Ahadi  T, Madjlesi  F, Mahjoubi  B, et  al. The effect of biofeedback therapy on dyssynergic constipation in patients with or without irritable bowel syndrome. J Res Med Sci. 2014;19(10):950–955. 4 4. Broide  E, Pintov  S, Portnoy  S, Barg  J, Klinowski  E, Scapa  E. Effectiveness of acupuncture for treatment of childhood constipation. Dig Dis Sci. 2001;46(6):1270–1275. 4 5. Chattat R, Bazzocchi G, Balloni M, et al. Illness behavior, affective disturbance and intestinal transit time in idiopathic constipation. J Psychosom Res. 1997;42(1):95–100.