Gastrointestinal system

• Dan has experienced weight loss

• Increased stress

• 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

• Medical assessment for upper abdominal pain [60]

• Dietary assessment

• Stress management

• 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

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

• Eradication of Helicobacter pylori using antiobiotic therapy

• Reduce inflammation and promote healing of gastric mucosa [16, 17].

• Enhance integrity of gastric mucosa and gastroduodenal mucosal defence [16–18].

• Normalise gastric acid secretion [15, 18].

• Modulate Dan’s immune and inflammatory response [16].

• Support Dan’s stress response and help reduce his stress levels [16–18].

• Identify and reduce or eliminate contributing factors to Dan’s peptic ulcer [15, 18, 32].

• Determine whether Dan has any food allergies and manage accordingly [15, 18].

• 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].

• 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].

• Dan may find massage therapy very helpful in reducing his stress levels and improve his ability to deal with stress [29, 30].

• A course of acupuncture therapy may be beneficial [31, 32].

• Hydrotherapy would be beneficial, such as dry skin brushing every day followed by a long, relaxing bath [49].

• Try a hot trunk wrap [50].

• Briefly tread in a cold foot bath followed by a hot compress to the abdomen, contrasted with a cold compress at the end [49].

• Taking neutral temperature baths for 30 minutes improves indigestion [49].

• Alternate brief hot and cold sitz baths [49].

• Constitutional hydrotherapy for toning of digestion and stress release [50, 51].

• Possible dehydration due to lack of water

• Isolation

• Alternating diarrhoea with constipation can be signs of a more benign functional bowel disorder or serious colon cancer

• Excessive consumption of caffeine

• Lack of water

• Prefers to eat takeaway food rather than cook at home

• Digestive symptoms began when Adrian went through a divorce 4 years ago

• Not as socially active since his divorce

• Immediate referral to medical practitioner to rule out serious organic causes for abdominal discomfort, diarrhoea and constipation [67]

• Adrian needs dietary guidance and cooking/eating/drinking alternatives

• Counselling may help Adrian deal with unresolved issues from his divorce and help him move forward socially

• Lifestyle and physical treatment recommendations to reduce stress

• Recommendation for Adrian to attend counselling to deal with his emotional issues

• Recommendation for Adrian to become more socially active

• Herbal tea, tonic and tablets to support Adrian’s nervous system and stress response

• Herbal tonic or tablets with antidepressant action

NB: If Adrian decides to take the prescribed antidepressant medication his herbal tonic or tablets will need to be reformulated to exclude St John’s wort

• Identify and eliminate foods that may be causing or aggravating Adrian’s symptoms [15–18, 29].

• Reduce or eliminate symptoms of bloating, flatulence and abdominal pain [15–18].

• Reduce exaggerated gut response to stress [15–18, 26].

• Support Adrian’s stress response [16–18].

• Support normal serotonergic signalling and response [16, 17, 24, 25].

• Reduce mucosal inflammation and modulate the inflammatory response in Adrian’s gastrointestinal tract [27, 28].

• Support healthy intestinal microflora [15–18, 46].

• Determine whether Adrian has any micronutrient deficiencies; improve his diet and nutritional status [81].

• Help Adrian address his emotional issues.

• Encourage Adrian to use stress-management techniques such as meditation, yoga and other relaxation techniques [16–18, 30].

• Encourage Adrian to exercise regularly [17, 32]. Exercise will help to improve Adrian’s sense of general wellbeing and reduce stress and depression [31]. Regular physical activity is likely to provide symptom improvement [17, 32].

• Encourage Adrian to cook proper meals for himself. He may find cooking classes are beneficial and may help him to enjoy cooking.

• Encourage Adrian to seek counselling to help him deal with the break-up of his marriage. Psychotherapy [35] and cognitive behavioural therapy [33, 34] are also likely to provide ongoing benefit for his physical symptoms.

• Adrian may find hypnotherapy is beneficial [37].

• Encourage Adrian to get out socially. He may try joining a club or sporting group where he can meet new people and become less isolated. He may even find a new partner.

• Identify and eliminate any foods to which Adrian is allergic or intolerant [15–18, 29, 37]. Food intolerance is a major factor in the pathogenesis of IBS [17, 18, 29, 37]. Commonly implicated foods include barley [15, 17], chocolate [15], citrus fruit [15], coffee [15, 16], corn [15, 17], dairy food [15, 37], eggs [15, 37], garlic [15], nuts [15], oats [15, 17], onions [15], potatoes [15], rye [15, 17], soy [15], tea [15, 16] and wheat [15, 17, 37].

• Encourage Adrian to also eliminate alcohol, refined carbohydrates, sugar, fats and hot spices from his diet [15, 17, 18].

• Encourage Adrian to avoid sugar alternatives such as sorbitol, xylitol or mannitol as these may exacerbate flatulence [15].

• Encourage Adrian to eat a fibre-rich whole-food diet [15–17]. Soluble fibre is particularly beneficial to Adrian [51].

• If Adrian finds legumes and beans aggravate his symptoms, he may find them tolerable if they are soaked in water prior to cooking and the water used to soak them is discarded [15].

• Encourage Adrian to increase his intake of water [15, 16].

• Adrian will benefit from including soluble fibre in his diet [15–18, 51]. Ensure Adrian is not sensitive to cereal grains before recommending cereal fibre [16].

• Adrian could include ginger and turmeric in his diet [16].

• Adrian may find acupuncture helpful in managing his symptoms. It may also improve his general wellbeing and stress response [80].

• Massage therapy [36] or aromatherapy massage [38] is likely to help Adrian as part of a stress-management program.

• Hydrotherapy: alternating hot and cold showers to the abdomen and spine [52]. Hot trunk wrap [52]. A hot sitz bath for abdominal pain [53]. A hot apple cider vinegar and water compress on the abdomen [53]. For acute diarrhoea, brief cold sitz baths with apple cider vinegar from a few seconds up to 10 minutes every day for a week, then every second day after symptoms subside [53].

• Constitutional hydrotherapy [52, 54, 55].

• For constipation place a hot compress on the abdomen, cover it in plastic, then place a hot water bottle or heating pad on top for 12 minutes. Follow this with cold mitten friction for 30 seconds. Repeat this process three times [56].

• Take a hot shallow bath or hot foot bath for abdominal bloating and pain [56].

• To tone the abdomen when not experiencing pain, apply a cold, wet compress on the abdominal area, covered by a dry towel with an elastic bandage around the trunk at night for at least three months [53].

• Analgesics as required for the pain

TABLE 3.39 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

• Prevent bile stasis and supersaturation [14–16].

• Stimulate production and flow of bile [21].

• Increase solubility of bile [15] and solubility of cholesterol in bile [15, 19].

• Prevent further stone formation and enlargement [15].

• Reduce dietary risk factors [15–17] and improve Karin’s diet [15, 16].

• Encourage Karin to not be encouraged to use gall bladder flushing techniques because stones may lodge and block her bile duct [16, 17].

• Encourage Karin to ensure she protects her skin from excessive exposure to sunlight and avoids sunburn [15].

• Karin would benefit from dealing with her emotional stress [15]. Chronic stress can increase bile retention and inhibit gall bladder emptying [15]. Stress-management techniques would therefore be helpful to her.

• Karin may find counselling helpful to help her deal with the unresolved conflict with her parents [27].

• Karin would benefit from increasing her physical activity. Symptomatic cholelithiasis can be prevented by physical activity [26]. Regular exercise is associated with lower levels of stress and anxiety [29, 30].

• Encourage Karin to drink six to eight glasses of water every day to ensure the water content of the bile is maintained [15].

• Encourage Karin to try to include turmeric in her diet as often as possible [15]. Turmeric is a choleretic [21] and is used traditionally to improve poor digestion [21]. It has also been demonstrated to reduce gallstone size [24].

• Encourage Karin to reduce her consumption of animal protein, refined carbohydrates, sugar, saturated fats and dietary cholesterol [15, 16].

• Encourage Karin to avoid all fried foods [15].

• Encourage Karin to increase consumption of fruit, vegetables and legumes [15, 16].

• Encourage Karin to increase her consumption of foods containing omega-3 fatty acids, particularly from cold-water fish [15].

• Encourage Karin to increase her consumption of soluble fibre [15, 16].

• Determine whether Karin has any food allergies and manage accordingly [15].

• Karin could include buckwheat regularly in her diet [15]. Buckwheat enhances bile acid synthesis, reduces concentration of cholesterol in the gall bladder and decreases gallstone formation [15].

• Karin could consume 1–2 tsp of lecithin granules daily [15, 16]. The phosphatidyl choline in lecithin increases phospholipids in bile, which can improve bile solubility, therefore reducing the risk of stone formation [16].

• Karin may benefit from drinking lemon juice. Lemon juice increases hepatobiliary excretion and therefore may improve digestive function [25].

• Acupuncture may relieve Karin’s abdominal pain and nausea [22, 23]. It may also help reduce her anxiety and stress [29, 30].

• Karin may find massage helpful to reduce stress and anxiety [31, 32].

• Hydrotherapy: hot trunk wrap [33]. Constitutional hydrotherapy [33–35].

• Hot fomentations (5–10 minutes) with vinegar water alternating with cold (1–5 minutes) mitten frictions to abdomen and lower back [34, 35].