Your practitioner impression Dan appears tense and uncomfortable; he shuffles in his seat. He appears physically and emotionally uncomfortable. Seems lacking in vitality. Rating scale On a scale of 1 to 10 how would you rate the abdominal discomfort, with 10 being as bad as can be? When I get a sharp pain it is 8 out of 10 and when there is the dull ache it is about 6 out of 10.

TABLE 3.2 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Cancer and heart disease
Do you experience indigestion that is usually only related to physical activity? (angina)	No. I can often feel it when I am lying still.
Functional disease
So would you say your indigestion is not related to physical activity? (heartburn, oesophageal reflux)	I can get the pain when I am still or when I am moving but most often when I am not moving.

TABLE 3.3 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Daily activities
How often does the abdominal discomfort disturb you during the night?	If I don’t take the antacids I can be up most nights for a week and then it will settle down a bit.
Action needed to heal
What do you think is important to do for your symptoms to clear up in the short term?	Coming today to see you to help with the stomach pain and stress levels. Maybe have more medical tests to find out what the pain actually is because it doesn’t seem to be going away in a hurry.

TABLE 3.4 DAN’S SIGNS AND SYMPTOMS

Waist circumference

No abnormality detected (NAD)

he usually avoids it. Dan doesn’t drink alcohol during the week, but will relax on the weekends with a bottle or two of red wine.

Dan realises he needs to manage his stress better and is hoping that reducing his stress will improve his digestive symptoms.

Results of medical investigations

No medical investigations have been carried out yet.

TABLE 3.5 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2, 7, 8, 10, 11, 54]

CONDITIONS AND CAUSES	WHY UNLIKELY
CANCER AND HEART DISEASE
Congestive heart failure	Blood pressure within normal limits; urinalysis NAD
Cluster headaches: common to begin in males between the ages of 40 and 60; no family history associated with cluster headaches	Extremely severe headaches, stabbing and burning; usually unilateral and pain behind eye radiating to the front of the face
INFECTION AND INFLAMMATION
Kidney infection	Abdominal pain usually is lower and will radiate to lower back and groin rather than upper abdomen and shoulder; no urine crystals and red blood cells
Sinus headache: headache worse on waking in the morning	No upper respiratory symptoms mentioned, no frontal facial pain reported; need to check if dull ache is aggravated by bending
ENDOCRINE/REPRODUCTIVE
Diabetes: delayed gastric emptying and complains of early fullness, nausea, bloating	Urinalysis NAD

Case analysis

TABLE 3.6 POSSIBLE DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [2, 7–11, 55, 57, 59, 61, 65]
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
CANCER AND HEART DISEASE
Angina: brought on by physical activity and emotion; will be relieved by nitroglycerin	Burning sensation in chest, fast pulse	Usually not related to eating or abdominal symptoms; acute onset of symptoms; pain relieved by lying down
Gastric tumour: can have history of Helicobacter pylori (H. pylori) infection [67]	Pain relieved by food or antacids nausea; early satiety, weight loss, lack of appetite	May present with diarrhoea; no mention of blood or mucus in stools, abdominal distension or frequent vomiting; pain made worse or relieved by food
OBSTRUCTION AND FOREIGN BODY
Acute gallstone pancreatitis: pain in the abdomen that is radiating, nausea, decreased appetite; commonly caused by gallstones that block the pancreatic drainage; often associated with alcoholic binges	Pain in upper abdomen	Upper abdominal pain usually radiates to the lower back; usually associated with significant fever, nausea, vomiting and change in bowel motions; will usually have lower abdominal symptoms such as flatulence
OCCUPATIONAL TOXINS AND HAZARDS
*Causal factor:* Sick building syndrome	Headaches worse after working several days in a row; new buildings recently constructed	No upper respiratory complaints or fatigue reported
*Causal factor:* Eye strain	Headaches will generally occur after several days at work	Unusual unless work requires close vision or eyeglasses are not appropriate
FUNCTIONAL DISEASE
*Causal factor:* Intestinal gas: from decreased motility and overgrowth of bacteria	Indigestion	More common in the elderly, vague symptoms of abdominal discomfort; will have lower abdominal symptoms such as flatulence
*Causal factor:* Gas entrapment: hepatic or splenic flexure syndrome	Can have abdominal discomfort that is referred as chest pain	Made worse by bending over
Causal factor: Duodenal loop distention	Indigestion, nausea	Specific to right upper quadrant pain, or pain in the right shoulder
*Causal factor:* Hiatus hernia	Heartburn, indigestion when associated with oesophagitis	Heartburn is a rare symptom of hiatus hernia unless accompanied by oesophagitis
Functional gastrointestinal disorder	Can have indigestion symptoms made worse by stress	No reports of diarrhoea alternating with constipation; symptoms would be vague and non-specific if a functional disorder; usually continuous pain with no significant weight loss; will have lower abdominal symptoms such as flatulence
Heartburn: not usually related to physical activity, brought on by oesophageal spasm [53]	Burning sensation in the chest, felt when lying down, caffeine frequently causes symptoms; pain related to meals and made worse by lying down	Pain would be intermittent over several minutes and recur over long periods; pain would radiate to the neck, jaw, arms and back; pain would be felt after heavy meals and bending over; certain foods can cause and relieve heartburn
Non-ulcer dyspepsia: may have H. pylori; pain or discomfort in the centre of the chest/upper abdomen [53, 56, 58]	Upper abdominal pain, feeling full quickly after eating, lack of appetite, nausea, belching, vomiting, bloating, burning sensation in chest or abdomen	No difficulty swallowing or vomiting mentioned by Dan; symptoms at night rare with non-ulcer dyspepsia; pain is usually worse after eating and not usually relieved by antacids with non-ulcer dyspepsia; diffuse abdominal pain is more common than precise location
Reflux-dyspepsia Oesophageal reflux (gastro-oesophageal reflux disease, GORD; gastroesophageal reflux disease, GERD)/peptic oesophagitis/spasm: pain not brought on by exercise; may be precipitated by gastric juices, bile and duodenal juices and eating in general; treatment for H. pylori is not useful for reflux dyspepsia [64, 66]; more likely diagnosis if hiatus hernia present; it is possible to have symptoms of epigastric pain without heartburn and reflux in GORD/GERD [52, 55, 56]	Tightness in chest, lack of appetite, becomes full quickly; common cause of heartburn symptoms that are relieved by antacids and made worse by lying down or bending over; will have chest pain; waterbrash symptoms signifies reflux; belching	In reflux, dyspepsia pain may radiate to the back, arms and neck; usually no nocturnal pain; can get nocturnal asthma and cough; common in pregnant women; chest and upper abdominal pain will be worse on stooping and after large meals; heartburn will be experienced more frequently than once every fortnight and acid regurgitation more than once a week; will have excess belching; possible to have overlapping condition with peptic ulcer; may have associated symptoms of asthma or chronic cough
Dysmotility dyspepsia: caused by delayed gastric emptying rather than gastric hypersecretion; indigestion always brought on by eating; no H. pylori present [56]	Upper abdominal pain, nausea, early fullness, can be affected by stress; symptoms of heartburn reported	Symptoms often continuous, vomiting more than once every second month, hunger after feeling full quickly, heaviness after eating fatty foods or milk, bloating and distension in the abdomen; need to check if have any food intolerances
Causal factor: Aerophagia	Belching, heartburn symptoms, oesophageal reflux, functional GI disease
DEGENERATIVE AND DEFICIENCY
Ulcer-like dyspepsia Peptic ulcer: gastric/stomach ulcer, duodenal ulcer, oesophageal ulcer; abdominal pain may be relieved by meals; can have overlapping symptoms of heartburn; will have H. pylori infection; risk factors are age 40 years and over, cigarette smoking, use of NSAIDs, family or past medical history of ulcer disease [56, 65]	Can point to where burning epigastric pain is in the abdomen and show clearly where it is radiating to; gnawing pain; associated symptoms of nocturnal abdominal pain, nausea, decreased appetite, early satiety, weight loss; symptoms have periodicity like an ulcer and be pain-free for several weeks; can develop from chronic anxiety, tension; abdominal pain relieved by small amount of specific foods or antacids; vomiting can provide relief from pain; taking aspirin and ibuprofen for tension headaches; no significant reflux	May have vomiting on onset and previous history of ulcer disease; can have haematemesis (vomiting of blood); a common sign with a peptic ulcer is a fear to eat, but not with a duodenal ulcer; possibly has concurrent reflux dyspepsia with ulcer dyspepsia
Cervical arthritis	Headache at the base of the head/neck area	No specific neck pain reported
Anaemia: organic dyspepsia; pernicious anaemia (B12 deficiency) can cause indigestion and may develop from atropic gastritis and be linked to persistant infection with H. pylori bacteria in the stomach	Eating fewer meals, weight loss	Need to assess mineral absorption, variety of food groups, quantity of meals; usually associated with a long history of indigestion
INFECTION AND INFLAMMATION
*Causal factor:* *H. pylori:* improved by bismuth salts or antibiotics	Causes bloating, pain in the stomach; involved in peptic ulcer disease, gastric tumour	Not in oesophageal reflux or dysmotility functional dyspepsia
Gastritis: inflammation of stomach lining that can be made worse by aspirin, NSAIDs, corticosteroids, antibiotics, antiasthma agents; atropic gastritis from autoimmune destruction of parietal cells leading to lack of intrinsic factor and potentiating lack of B12	Abdominal pain, indigestion, burning; loss of appetite, sense of fullness, nausea; vomiting can provide relief from pain; taking aspirin and ibuprofen for tension headaches	Pain will be worse after eating in gastritis; often associated with alcoholism; vague indigestion is more common in gastritis rather than specific location
Giardia	Can present with upper abdominal symptoms such as nausea, bloating and persist for months	Symptoms will be persistent symptoms rather than episodic and may have diarrhoea
Chronic appendicitis	Upper abdominal intermittent pain, nausea, vomiting on one occasion	No constipation or fever
Cholecystitis: chronic and acute gall bladder inflammation	Symptoms can be vague gastrointestinal disturbance; biliary colic, right abdominal pain	The pain of gallstone colic/cholecystitis does not have periodicity like an ulcer; specific to right upper quadrant pain, or pain in right shoulder; will have lower abdominal symptoms such as flatulence
Hepatitis	Pain in upper abdomen that is radiating; nausea; loss of appetite	No increased diarrhoea or lower abdominal symptoms mentioned
Crohn’s disease	Abdominal pain; lesions can be from mouth to anus; weight loss, abdominal pain, low-grade fever and nausea; inflammation is deep and patchy	No blood or mucus in stools; no diarrhoea mentioned or recurrent episodes of watery bowel motions during day and night; no fever
SUPPLEMENTS AND SIDE EFFECTS MEDICATION/DRUGS
*Causal factor:* Drug ingestion: NSAIDs, antibiotics, potassium or iron supplements, alcohol, corticosteroids, theophylline derivatives, isoproterenol, anticholinergics	Heartburn and indigestion, can cause H. pylori negative gastritis, lower esophageal pressure; taking aspirin and ibuprofen for his tension headaches increases the risk of developing a peptic ulcer
ENDOCRINE/REPRODUCTIVE
Pancreatic disorders: chronic pancreatitis, vipoma (endocrine pancreatic tumour), Zollinger-Ellison syndrome	Symptoms of abdominal pain, episodes of pain, fatty diet; Zollinger-Ellison syndrome can present like a peptic ulcer (without H. pylori infection) with pain at night, nausea and lack of appetite	Symptoms of diarrhoea and steatorrhoea usually present; rare condition; will be from a long history of indigestion and often related to alcohol abuse
STRESS AND NEUROLOGICAL DISEASE
Migraine headache: severe painful headaches; often unilateral and located in the front and temporal regions of the head	Stress can exacerbate, can have indigestion and nausea as a complaint	Dan’s headaches not aggravated by or related to sound or light; migraine headaches usually improve upon waking and after sleep; no indication of nausea and vomiting associated with headache
*Causal factor:* Stress [25, 26]	Headaches, heartburn, indigestion
EATING HABITS AND ENERGY
*Causal factor:* Food intolerance amine/salicylate sensitivity	Headaches, drinking red wine, dairy; may be delayed sensitivity; salicylate sensitivity or overload can cause gastritis	Need to ask more regarding if the headaches are after eating particular foods that usually trigger migraine headaches
*Causal factor:* Dehydration	Lack of water in the diet, dull headaches, drinking excess tea and coffee, drinking alcohol

TABLE 3.7 DECISION TABLE FOR REFERRAL [2, 7, 8, 10, 12]

Complaint	Context	Core
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Can point to where the upper abdominal pain is • Initial sharp pain in the upper abdomen that then becomes dull • Indigestion symptoms becoming worse and more frequent • Episodic upper abdominal pain

• Dan has experienced weight loss

• Increased stress

ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE

• Indigestion that is worse at night and better with eating

• Symptoms of indigestion worse with spicy foods

• Improves with antacids

• Vomiting improved symptoms on one occasion

• Lack of appetite

• Building changes in work environment

• Tension headaches

• Excess caffeine in diet

• Changes in the work environment

• Stress with managing staff and building changes

REFERRAL DECISION REFERRAL DECISION REFERRAL DECISION

• Medical assessment for upper abdominal pain [60]

• Dietary assessment

• Stress management

TABLE 3.8 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [2, 6–10, 11, 13, 54]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE MEDICAL INVESTIGATIONS:
Abdominal inspection: guarding, rebound tenderness, palpation, abnormal pulsations (auscultation)	Signs of appendicitis, pancreatitis, kidney swelling, enlarged liver, bowel obstruction, perforated ulcer; positive Murphy’s sign for inflamed gall bladder; hiatus hernia signs, swallowed air; mid-epigastric tenderness in gastric and peptic ulcer
Full blood count	Anaemia, inflammation, allergies
C-urea breath test	H. pylori
IgG antibodies	H. pylori
CRP (C-reactive protein)	When CRP is high it can indicate a bacterial infection
Stool test	Occult blood in stool may indicate ulcer or carcinoma, H. pylori
IF NECESSARY:
Oesophageal motility studies	Cardiospasm, reflux oesophagitis
Bernstein test (dilute hydrochloric acid in the distal oesophagus)	Produce symptoms of oesophagitis
Oesophageal pH monitoring	Reflux oesophagitis GORD/GERD; may not determine oesophagitis
Endoscopy [60, 62]	Confirmation of peptic ulcer, gastric tumour, non-ulcer dyspepsia; may not always define GORD/GERD or H. pylori
GI radiographs	Oesophageal reflux, gas entrapment, gall bladder disease
Gastroscopy	Gastritis
Serum gastrin levels	To confirm or rule out Zollinger-Ellison syndrome and gastrinoma
Serum amylase	Pancreatitis
Small-bowel follow through	Exclusion or confirmation of Crohn’s disease

Confirmed diagnosis

Dan and peptic ulcer

Dan is a 40-year-old man presenting at the clinic for help with digestive discomfort, which has come and gone over the past six months. When his symptoms are bad he experiences heartburn, a gnawing pain in the centre of his chest, a sharp pain that can become dull and lasts for a couple of hours and occasional nausea. Dan can experience symptoms before eating but will become full very quickly. He has an overall lack of

TABLE 3.9 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

Complaint	Context	Core
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Dietary recommendations to reduce the inflammation and irritation of gastric mucosa • Dietary recommendations to identify and eliminate specific dietary triggers • Lifestyle recommendations to avoid potential triggers for ulcer formation and eliminate likely triggers such as aspirin and NSAIDs • Dietary recommendations to soothe and heal the ulceration, reduce acute symptoms and help prevent the recurrence of peptic ulcers • Physical therapy recommendations to help relieve and treat the symptoms • Herbal tea, powder and tonic with anti-inflammatory, anti-ulcer, mucoprotective and healing properties • Nutritional supplements with anti-inflammatory, healing, mucosal strengthening, anti-ulcer and H. pylori-inhibiting effects • Probiotic supplementation to help inhibit H. pylori, reduce inflammation and antibiotic side effects NB: Tests to monitor Dan’s vitamin and mineral levels should be done after 6 weeks and again after 8–12 weeks to ensure levels stay within normal range; dosage can be adjusted if necessary based on test results

• Recommendations to improve Dan’s diet and lifestyle

• Recommendations for Dan to exercise regularly

• Recommendation for Dan to take time out to eat his lunch slowly and in a quiet place

• Nutritional supplement recommendations to improve Dan’s general health and increase levels of essential nutrients

• Recommendation for Dan to review his work–home life balance and delegate or offload work where possible

• Recommendation for Dan to take up recreation activities outside of work to help reduce stress

• Recommendation for Dan to use stress-management techniques

• Herbal powder and tonic with adaptogenic, tonic and nervine action

• Herbal tea with nervine action

• Recommendation for a regular massage to reduce stress

• Nutritional supplement to help support Dan’s stress response

appetite and has lost weight recently. Dan says he is definitely burping more often and his symptoms can be worse when he is lying down at night. During the consultation Dan reveals that although he loves his job as a principal of a small school, he has experienced excessive stress with changes in procedures and staff as well as building renovations. He takes aspirin or ibuprofen regularly for tension headaches and has been drinking up to six cups of coffee a day and sometimes skips meals.

Dan required immediate referral and was diagnosed with a peptic ulcer, a condition involving the development of an ulcer near the acid-bearing area of the stomach, duodenum, oesophagus or jejunum. Epigastric pain that a person can point to is a key feature of peptic ulcers.

Peptic ulcers can be single or multiple open sores affecting the mucous membranes and are usually caused by failure of the digestive tract to withstand the action of pepsin and hydrochloric acid. This usually occurs because the mucous membranes become thinner, rather than as a result of excess pepsin or hydrochloric acid. A major cause of peptic ulcers is Helicobacter pylori (also known as Campylobacter pylori) infection [63]. Additional triggers include excess intake of NSAIDs, which results in thinning of the gastric mucosa and large dosages of pharmaceutical glucocorticosteroids. This influences the production of excessive quantities of pepsin, excessive long-term consumption of alcohol (ethanol) and the increased ingestion of the nicotinic acid form of vitamin B3 on an empty stomach releasing high levels of stomach acid. Stress has a significant impact on existing peptic ulcers and heartburn can be frequently experienced. Risk factors for developing a peptic ulcer are being over 40 years of age, cigarette smoking and family or past medical history of ulcer disease.

General references used in this diagnosis: 2, 6–11, 57, 59, 65

Prescribed medication

• Proton pump inhibitor: drugs that inhibit the production of gastric acid [14]

• Eradication of Helicobacter pylori using antiobiotic therapy

Lifestyle alterations/considerations

• Encourage Dan to reduce his stress levels [16–18, 25, 26]. He may find relaxation therapies such as meditation, yoga, tai chi or progressive muscle relaxation helpful to manage his stress levels.

• Encourage Dan to make the time to take a regular lunch break and eat his lunch slowly in a quiet and peaceful environment.

• Encourage Dan to find ways of reducing his work-related stress by reviewing his work schedule and workload. He may need to delegate tasks and/or enlist the help of others where necessary.

• Encourage Dan to take time away from work to enjoy other activities.

• Encourage Dan to exercise daily. Regular exercise is strongly associated with reduced stress levels [27, 28].

• Encourage Dan to stop taking aspirin or other non-steroidal anti-inflammatory medications. These are implicated in the development of peptic ulcers [15–18].

• If Dan smokes, he should stop [15–18].

• Dan may find that raising the head of his bed helps to alleviate symptoms during the night while he is in bed [10].

Dietary suggestions

• Food allergies should be tested for and managed appropriately [17, 18]. Milk should be avoided because it can significantly increase stomach-acid production [17, 18, 33].

• Fermented milk products, such as yoghurt containing live cultures of bifidobacteria and lactobacillus, may be helpful [16, 34, 35]; although, if Dan is allergic or intolerant to dairy products he should avoid them [17, 18].

• Encourage Dan to increase consumption of soluble fibre from fruit and vegetables [16–18].

• Encourage Dan to avoid foods that he knows aggravate his symptoms, and also avoid refined sugars [16, 17].

• Encourage Dan to avoid coffee, alcohol and chocolate [15].

• Encourage Dan to avoid spicy foods, spearmint, peppermint, fatty foods, carbonated beverages, orange juice and tomato juice [10].

• Cabbage and other cruciferous vegetables should be included in Dan’s diet every day [16–18]. The juice of half a head of cabbage or eating the cabbage raw may be beneficial during an acute episode [16, 18]. Cabbage can help prevent recurrence of ulcers [16] and has ulcer healing properties [17, 18].

• Encourage Dan to eat bananas every day. Bananas stimulate gastric mucosal cell growth and help maintain the protective layer on the gastric mucosa [17, 18]. Banana is also helpful to relieve acute symptoms of dyspepsia and heartburn [16].

• Ginger tea may reduce symptoms of dyspepsia [16, 18].

• One tablespoon of unpasteurised Manuka honey taken on an empty stomach at bedtime can relieve ulcers [16].

• Encourage Dan to increase his intake of foods rich in vitamin A. Vitamin A helps maintain the integrity of the mucosal barrier and protect gastric mucosa from damage [16, 17, 19, 22].

• Encourage Dan to reduce consumption of fatty foods and saturated fat [15, 16] and increase consumption of foods containing omega-3 fatty acids [16]. Olive oil is a good choice due to its antioxidant properties [16]. Diets high in olive oil are associated with a higher percentage of ulcer healing and reduced ulcerogenesis from NSAIDs [16].

• Encourage Dan to consume garlic and onions every day [18]. Garlic is effective against Helicobacter pylori [19]. If Dan’s reflux symptoms persist he may find avoiding garlic and onions reduces oesophageal pressure and therefore symptoms of reflux [10].

• Encourage Dan to take lecithin granules daily. The phosphatidylcholine in lecithin is gastroprotective [17, 44].

Physical treatment suggestions

TABLE 3.10 HERBAL TEA

Alternative to coffee
HERB	FORMULA	RATIONALE
Chamomile flowers Matricaria recutita	2 parts	Anti-inflammatory [16, 19, 20]; spasmolytic [16, 19, 20]; carminative [16, 19, 20]; antimicrobial [19, 20]; alpha-bisabolol in chamomile promotes tissue granulation and tissue regeneration in ulcers [19, 20, 36]; chamomile can prevent formation of ulcers [19, 36] and reduces healing time [19, 36]; anti-inflammatory action interrupts tissue destruction cycle and provides symptomatic relief [16]
Ginger root powder Zingiber officinale	½ part	Anti-nausea [19, 20]; anti-ulcer activity [19, 20]; anti-inflammatory [19, 20]; analgesic [19, 20]; inhibitory effect on H. pylori [19, 37]
Lemon balm Melissa officinalis	1 part	Anti-inflammatory [19]; analgesic [19]; antispasmodic [19, 21, 23]; antimicrobial [19, 23]; anxiolytic [19, 23]; sedative [19, 21, 23]; beneficial for gastrointestinal conditions associated with nervousness or anxiety [19, 21]
Chickweed Stellaria media	2 parts	Demulcent [19, 23]; antiulcer [23]; beneficial in gastric irritation [23]
Infusion: 1 tsp per cup – 1 cup 3–4 times daily

TABLE 3.11 HERBAL POWDER

HERB	FORMULA	RATIONALE
Deglycyrrhizated licorice root powder [15, 18] Glycyrrhiza glabra	1 part	Anti-inflammatory [19, 20]; mucoprotective [19, 20]; promotes mucosal repair and reduces symptoms of active ulcers [19, 20]; antimicrobial [19, 20]; anti-H. pylori properties [38]; adrenal tonic [20]
Slippery elm bark powder Ulmus fulva	1 part	Nutritive demulcent [19, 21]; emollient [19, 21]; traditionally used for inflammatory conditions of the gastrointestinal tract [19, 21] and for dyspepsia [19], gastric reflux [19] and peptic ulcers [19]
Marshmallow root powder Althea officinalis	1 part	Demulcent [21, 23]; emollient [21, 23]; vulnerary [21, 23]
One heaped teaspoon mixed to a smooth paste with a little water 3 times daily before meals. Two heaped teaspoons in water can be taken as required to alleviate acute symptoms of heartburn.

TABLE 3.12 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

Made with ethanolic extract herbal liquids (alcohol removed)
HERB	FORMULA	RATIONALE
Meadowsweet Filipendula ulmaria	70 mL	Anti-inflammatory [19, 23]; analgesic [19, 23]; gastroprotective [19, 23]; normalises stomach acid [16]; promotes healing of stomach ulcers [19, 39]; positive effect on antioxidant status of gastric tissue [40]; traditionally used for dyspepsia, heartburn and hyperacidity [21, 23]
Golden seal Hydrastis canadensis (cultivated/plantation source)	40 mL	Antimicrobial [19, 23]; mucous membrane trophorestorative [19, 23]; anti-inflammatory [19, 23]; vulnerary [19, 23]; bitter tonic [19, 23]; traditionally used for dyspepsia and gastritis [41]; beneficial for peptic ulcers [23]; inhibits growth of H. pylori [48]
Siberian ginseng Eleutherococcus senticosus	30 mL	Adaptogenic [19, 20]; immunomodulator [19, 20]; tonic [19, 20]; beneficial to improve stress response and increase energy levels [19, 20]
Skullcap Scutellaria lateriflora	30 mL	Nervine tonic [23]; spasmolytic [23]; mild sedative [21, 23]; traditional indications include nervous tension and anxiety [21, 23]
Rhodiola Rhodiola rosea	30 mL	Adaptogenic [42]; tonic [42]; traditionally used to treat fatigue, depression and nervous system disorders [42]; effective in reducing symptoms of generalised anxiety disorder [43]
Dosage:	200 mL	Dose: 10 mL twice daily before meals

TABLE 3.13 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
Supplement providing a daily dose of approx 2000 mg vitamin C, 500 IU vitamin E, 5000 IU vitamin A, 2000 mg mixed bioflavanoids and 10 mg elemental zinc in divided doses [17, 18]	Vitamins C, E and zinc enhance wound healing and recovery [17, 18, 22, 24]; zinc supplementation reduces the incidence, severity and number of gastric lesions [17, 18]; lower levels of vitamin C have been found in people with peptic ulcers [68]; bioflavanoids have anti-allergic properties [18, 22]; may inhibit H. pylori [18] and help prevent ulcer formation [18]; vitamins A [18, 24] and E [18] help maintain integrity of the mucosal barrier
Omega-3 fish oil 3 × 1000 mg capsules twice daily [17, 19]	Anti-inflammatory [17, 19, 22]; protective against peptic ulcer disease [17]
L-glutamine 1500 mg daily in divided doses [18]	Protects gastrointestinal mucosa from damage and promotes repair [19, 45]; indicated for use to prevent and heal peptic ulcers [22, 45]
High-potency practitioner-strength multivitamin and mineral complex providing therapeutic doses of B-group vitamins Dosage as recommended by manufacturer	B vitamins are beneficial to support Dan’s stress response [19, 22]; a broad-spectrum multivitamin and mineral supplement can help increase levels of essential nutrients and antioxidants which may be deficient due to Dan’s diet and lifestyle
High-potency practitioner-strength probiotic supplement containing therapeutic levels of human strain Lactobacillus and Bifidobacterium organisms [46, 47] Dosage as recommended by manufacturer	Probiotic supplementation can inhibit H. pylori [46, 47] and in combination with antibiotic therapy may increase its eradication rate [46, 47] and reduce antibiotic side effects [46]; probiotics can stabilise gastric barrier function [46] and decrease mucosal inflammation [46]