Diarrhoea and bacterial Diarrhoea and bacterial dysbiosis dysbiosis

Ann Walker Ann Walker PhD MCPP MNIMHPhD MCPP MNIMH

Case: IBSCase: IBS

Patient details

First visit 24 June 2005

Advice/ Treatment

Outcome 5 August 2005

LP female 62 yrs BMI 27 Generally in good health Diet: low in F&V and dairy Drugs: Atorvastatin

Loose stool 3-4 x day for 3 yr Occ anal leakage Flatulence, bloating PMH OA (hands) Stress in past Hyper- cholesterolaemia Constipation in past

Diet: ↑F&Veg when able Supplements: None Herbal medicine Rx1 Hebe Tarax rad ‘Bowel’ mix Rx2 Rasp leaf/mint

15g as inf Rx3 Slippery elm tabs 4 bid

Problem cleared in 8 days! Completely back to normal Going without fear to the theatre: “Wonderful - can’t remember lasts time I had a normal stool” Signed off

Case study IBS in long-term PxCase study IBS in long-term PxPatient details

Returned Px June 2008

Advice/ Treatment

10 days later

RW 85 yr woman Long-term patient originally consulting 2000 for skin rash Diet : vegetarian low in omega-3, dairy Drugs: Aspirin Disoprolol Lisinopril

IBS started suddenly 1 mo ago with flatulence and loose stools PMH Skin problems much better Diabetes controlled by diet History of Angina & Osteoporosis Shoulder pain

Diet: ↓seeds oils (omega-6) Supplements: multi vit/min Vit C Ca+Mg Flax seed oil (EPA) Algal DHA Herbal medicine Hawthorn Red yeast rice Wormwood complex Tablets 2, three times a day for 10 days

IBS cleared completely – no further prescription was necessary Support for general and cardiovascular health continues

Case: Fatigue (with IBS)Case: Fatigue (with IBS)

Patient details

First visit 27 Jul ‘08

Advice/ Treatment

Outcome 1 Aug ‘08

KH female 40 yrs BMI 21 Stressed mother of 2 and teaching assistant Diet : low in dairy, F&V and oily fish

Low vitality, ‘foggy’ head, cries easily, anxious, IBS for 18 yrs (diarrhoea, indigestion, bloating) Restless legs palpitations, PMS-A,D,H, Premenstrual: mastalgia/ severe headaches/ obsessive thoughts

Diet: ↑F&Veg ↓seeds oils(omega-6) ↑oily fish Supplements: multi vit/min Vit C Ca+Mg Mg Omega-3/ 2 g Herbal medicine ‘Vitality Mix’: Eleuthero Rehmannia Glycyrrhiza Withania Cimicifuga

IBS symptoms much worse Wormwood

complex 2 tds for 10 days

“Follow-up Digestive” Mix: Hebe Potentilla Dioscorea Elettaria 10 ml bid

KH outcome a five weeks laterKH outcome a five weeks later

No indigestion, no bloatedness – absolutely No indigestion, no bloatedness – absolutely normal GI tract for one whole week normal GI tract for one whole week ““Miracle – can’t believe it” Miracle – can’t believe it”

Normal cycle – much less PMS, energy good and Normal cycle – much less PMS, energy good and not a single headache. No ‘fog’ in head. Feels not a single headache. No ‘fog’ in head. Feels more relaxed and confident. No obsessive more relaxed and confident. No obsessive thoughts. thoughts. ““I feel like the easy-going person before I started the I feel like the easy-going person before I started the

family”family” Treatment continued with the “Vitality Mix” for one Treatment continued with the “Vitality Mix” for one

more month and then signed offmore month and then signed off

Wormwood complex*Wormwood complex* HerbsHerbs::

WormwoodWormwood ((Artemisia absinthiumArtemisia absinthium) ) ≡≡ dry herb100 mg dry herb100 mg StemonaStemona ((S. sessilifoliaS. sessilifolia) ) ≡≡ dry root 1.0 g dry root 1.0 g Black WalnutBlack Walnut ((Juglans nigraJuglans nigra) ) ≡≡ dry fruit hull 100 mg dry fruit hull 100 mg Clove essential oilClove essential oil 20 mg 20 mg

Actions:Actions: anthelmintic, carminative and anthelmintic, carminative and digestivedigestive

Indications: Indications: Traditionally these herbs have Traditionally these herbs have therapeutic activity useful in the elimination of therapeutic activity useful in the elimination of harmful parasites from the gut and to ease harmful parasites from the gut and to ease symptoms of flatulence and colicsymptoms of flatulence and colic

*Mediherb

Wormwood Indications:Wormwood Indications:

Anthelmintic - used since ancient times Anthelmintic - used since ancient times and is currently utilized in many countries and is currently utilized in many countries throughout the world throughout the world Experimental evidence confirms this propertyExperimental evidence confirms this property

Appetite loss, disturbed digestion, Appetite loss, disturbed digestion, flatulence and disordered bile flow flatulence and disordered bile flow Clinical trials have demonstrated the ability of Clinical trials have demonstrated the ability of

wormwood to increase the flow of gastric wormwood to increase the flow of gastric enzymes, pancreatic enzymes and bileenzymes, pancreatic enzymes and bile

Research on WormwoodResearch on Wormwood

Steroid-sparing effect:Steroid-sparing effect: Omer B et al Phytomedicine. 2007;14:87Omer B et al Phytomedicine. 2007;14:87 40 Crohn’s patients on steroids given wormwood (3 40 Crohn’s patients on steroids given wormwood (3

x 500 mg/day) or placebo for 10 weeks and x 500 mg/day) or placebo for 10 weeks and steroids tapered off to zero by week 10 steroids tapered off to zero by week 10

From week 8-20 remission recorded in 65% From week 8-20 remission recorded in 65% patients on wormwood but none on placebo patients on wormwood but none on placebo

Anti-inflammatory effectAnti-inflammatory effect: : Lee HG et al. Ann N Y Acad Sci. Lee HG et al. Ann N Y Acad Sci. 2004;1030:5552004;1030:555

Wormwood flavonoid (p7F) reduces pro-Wormwood flavonoid (p7F) reduces pro-inflammatory mediators: COX-2, PGE,inflammatory mediators: COX-2, PGE,,, iNOS/NO, iNOS/NO, TNF-alphaTNF-alpha

Low toxicity:Low toxicity: Muto T, et al J Toxicol Sci. 2003;28:471Muto T, et al J Toxicol Sci. 2003;28:471

NOEL (no-effect-level) in rats was >1.27 g/kg/dayNOEL (no-effect-level) in rats was >1.27 g/kg/day

Black Walnut HullsBlack Walnut Hulls

Key Constituents Naphthoquinones including juglone and

plumbagin Anthelmintic Activity

In vitro studies show that plumbagin inhibits the motility and hatching of nematodes

Stemona – Stemona – Bai BuBai BuS. japonicaS. japonica or or S. sessilifoliaS. sessilifolia or or S tuberosaS tuberosa

Actions:Actions: Respiratory relaxant: bronchodilator, expectorant, Respiratory relaxant: bronchodilator, expectorant,

antitussive, demulcentantitussive, demulcent Anthelmintic and antiparasiticAnthelmintic and antiparasitic Insecticidal Insecticidal Anti-infective: antibacterial, antifungalAnti-infective: antibacterial, antifungal

Indications Indications Bronchitis, dry cough, whooping cough, croup, Bronchitis, dry cough, whooping cough, croup,

lung TB lung TB intestinal parasites, ringworm, pinworm, intestinal parasites, ringworm, pinworm,

trichomoniasis, schistosomiasis, giardiasis, trichomoniasis, schistosomiasis, giardiasis, cholera, dysentery, typhus, yeast/fungal infections cholera, dysentery, typhus, yeast/fungal infections

Topically for parasitesTopically for parasites

Holmes, P Jade Remedies: a Chinese herbal reference for the West Vol 1

StemonaStemona

Active compounds:-Active compounds:- Alkaloids:Alkaloids:

• Tuberostemonine, protostemonine, stemospironine, Tuberostemonine, protostemonine, stemospironine, maistemonine, sessilistemonamines A-C, maistemonine, sessilistemonamines A-C, dihydrostemoninine dihydrostemoninine

Bibenzyls:Bibenzyls:• stilbostemins M-O, stilbostemins B, D and G, 3,5-stilbostemins M-O, stilbostemins B, D and G, 3,5-

dihydroxy-2'-methoxy bibenzyl, 3,5-dihydroxy bibenzyldihydroxy-2'-methoxy bibenzyl, 3,5-dihydroxy bibenzyl Dihydrostilbenes:Dihydrostilbenes:

• stilbostemins H, Istilbostemins H, I Dihydrophenanthrenes: Dihydrophenanthrenes:

• stemanthrene E, stemanthrenes A and C stemanthrene E, stemanthrenes A and C

Yang XZ et al. J Asian Nat Prod Res. 2007, 9: 261Yang XZ et al. J Asian Nat Prod Res. 2007, 9: 261Wang P et al. Chem Biodivers. 2007; 4 :523Wang P et al. Chem Biodivers. 2007; 4 :523

Stemona researchStemona research

Antitussive effects Yang XZ Planta Med. 2009;75:174Yang XZ Planta Med. 2009;75:174

The main alkaloidal constituents, showed The main alkaloidal constituents, showed significant antitussive activity animal modelsignificant antitussive activity animal model

Antibacterial effectsAntibacterial effects Zhang TZhang T et al. J Asian Nat Prod Res. 2007, 9:479et al. J Asian Nat Prod Res. 2007, 9:479

The ‘bibenzyls’ showed strong antibacterial The ‘bibenzyls’ showed strong antibacterial activities against Staphylococciactivities against Staphylococci

Clove bud essential oilClove bud essential oil History of useHistory of use: Cloves (: Cloves (Syzygium aromaticum)Syzygium aromaticum) has long has long

been used in Ayurveda and Western herbal medicine as been used in Ayurveda and Western herbal medicine as a carminative and aromatic and more recently as an a carminative and aromatic and more recently as an antihelminticantihelmintic

ConstituentsConstituents: phenylpropanoids such as carvacrol, : phenylpropanoids such as carvacrol, thymol, eugenol and cinnamaldehyde thymol, eugenol and cinnamaldehyde

ActionsActions: antimicrobial, antioxidant, antifungal and : antimicrobial, antioxidant, antifungal and antiviral activity, antiinflammatory, cytotoxic, insect antiviral activity, antiinflammatory, cytotoxic, insect repellent and anaestheticrepellent and anaesthetic

Therapeutic indications in GI tractTherapeutic indications in GI tract: nausea, flatulence, : nausea, flatulence, dyspepsia, abdominal colic/ pain dyspepsia, abdominal colic/ pain

ResearchResearch: effective against some parasites, pathogenic : effective against some parasites, pathogenic bacteria, Herpes simplex, hepatitis C viruses as well as bacteria, Herpes simplex, hepatitis C viruses as well as drug-resistant Staphylococcidrug-resistant Staphylococci

Chaieb K Phytother Res. 2007 Jun;21(6):501-6Chaieb K Phytother Res. 2007 Jun;21(6):501-6

In vitro Research on Clove oilIn vitro Research on Clove oil

Antimicrobial activity: Antimicrobial activity: Fu Y, et al Phytother Res. 2007;21:989

Both clove and rosemary eo’sBoth clove and rosemary eo’s showed antimicrobial showed antimicrobial activity against activity against Staphylococcus epidermidisStaphylococcus epidermidis, , Escherichia coliEscherichia coli and and Candida albicansCandida albicans but clove oil but clove oil was strongestwas strongest

Anti-protozoal (trypanosome) activity: Anti-protozoal (trypanosome) activity: Santoro GF et al. Exp Parasitol. 2007;116:283Santoro GF et al. Exp Parasitol. 2007;116:283 Clove oil more potent inhibitor of trypanosome growth Clove oil more potent inhibitor of trypanosome growth

than basil or yarrow eo’s [Trypanosoma spp cause than basil or yarrow eo’s [Trypanosoma spp cause Chagas disease and sleeping sickness]Chagas disease and sleeping sickness]

Synergy with antibioticsSynergy with antibiotics: : Betoni JE, et al. Mem Inst Oswaldo Cruz. 2006;101:387 Betoni JE, et al. Mem Inst Oswaldo Cruz. 2006;101:387

13 antibiotics 13 antibiotics ±± 8 plant extracts including clove oil, 8 plant extracts including clove oil, garlic, lemongrass, ginger and mint tested against garlic, lemongrass, ginger and mint tested against Staph aureusStaph aureus. Clove oil showed the greatest . Clove oil showed the greatest synergism with antibioticssynergism with antibiotics

Development of understanding of Development of understanding of aetiology of IBSaetiology of IBS

1970s Low fibre diet

1980s (early) Food intolerance

1980s (late) Exclusion diets

1990 Not allergy

2000s Dysbiosis : large and small intestine

after John Hunter

Blastocystis sppBlastocystis spp

““Blastocystis spp are parasites found throughout the world. Little is known about how they are transmitted to humans. Some people who are infected have symptoms and some do not. Treatment is available but is not always effective.” (CDC) (CDC)

Sometimes called Sometimes called B. hominisB. hominis, but actually comprises, but actually comprises several species which can infect humans, farm animals, several species which can infect humans, farm animals, birds, rodents, reptiles, amphibians, fish, and even birds, rodents, reptiles, amphibians, fish, and even cockroachescockroaches

Infection with Infection with BlastocystisBlastocystis can produce the disease can produce the disease Blastocystosis with symptoms of abdominal pain, Blastocystosis with symptoms of abdominal pain, constipation, diarrhoeaconstipation, diarrhoea

Blastocystis is notoriously difficult to eradicate: Blastocystis is notoriously difficult to eradicate: treatments in combination and rotated may helptreatments in combination and rotated may help

Dientamoeba fragilisDientamoeba fragilis

A protozoal parasite found in the GI tract of some people, which it causes gastrointestinal upset in some but not others

Infection is can cause symptoms of abdominal pain, diarrhoea, weight loss, and fever

Hebe salicifoliaHebe salicifolia ( (H. strictaH. stricta) - Koromiko) - Koromiko

Renowned for its effectiveness in treating Renowned for its effectiveness in treating diarrhoea diarrhoea Several of the growing tips are placed in the mouth, Several of the growing tips are placed in the mouth,

chewed, the saliva swallowed and the leaves spat out chewed, the saliva swallowed and the leaves spat out

Used in Christchurch hospital NZ during the Used in Christchurch hospital NZ during the Spanish ‘flu epidemic Spanish ‘flu epidemic

New Zealand soldiers in the overseas 2New Zealand soldiers in the overseas 2ndnd World World War with dysentery sent home for Hebe leaves War with dysentery sent home for Hebe leaves which was said to be ‘very effective’which was said to be ‘very effective’

Hebe: History of Use in NZHebe: History of Use in NZ In 1895, it was listed in the UK Extra In 1895, it was listed in the UK Extra

Pharmacopoeia as an import from New Zealand, Pharmacopoeia as an import from New Zealand, “used there and in China, as a remedy for “used there and in China, as a remedy for chronic dysentery and diarrhoea” - it was deleted chronic dysentery and diarrhoea” - it was deleted from later editionsfrom later editions

Tincture 1: 5 - was kept in stock by the leading Tincture 1: 5 - was kept in stock by the leading druggists in the colony druggists in the colony Dose ½ to 1 drachm (Dose ½ to 1 drachm (≡≡ 2.5 – 5 ml) 2.5 – 5 ml) The leaves were also chewed as a remedy for The leaves were also chewed as a remedy for

diarrhoea diarrhoea An infusion or decoction was used for epidemic An infusion or decoction was used for epidemic

infantile diarrhoeainfantile diarrhoea The plant was used by both settlers and MaoriThe plant was used by both settlers and Maori

http://www.herbdatanz.com/nz_botanic1.htm

Hebe: constituentsHebe: constituents

Hebe salicifoliaHebe salicifolia hebeoside (2'-beta-xylopyranosyl-verbascoside)hebeoside (2'-beta-xylopyranosyl-verbascoside)

Hebe strictaHebe stricta Two phenylpropanoids derivatives have been isolated Two phenylpropanoids derivatives have been isolated

from methanolic extracts from methanolic extracts • forsythiaside, 3,4-dihydroxy-(3- phenethyl-0-a-L-forsythiaside, 3,4-dihydroxy-(3- phenethyl-0-a-L-

rhamnopyranosyl-(l->6)-4-0- caffeoyl-P-D-rhamnopyranosyl-(l->6)-4-0- caffeoyl-P-D-glucopyranoside, and the uncommon glucopyranoside, and the uncommon

• 3-methyl-3-(6-O-caffeoyl-P-D-glucopyranosyloxy)- 3-methyl-3-(6-O-caffeoyl-P-D-glucopyranosyloxy)- pentan-5-olide pentan-5-olide

Hebe salicifoliaHebe salicifolia

Actions:Actions: Astringent, antispasmodic, slows peristalsis Astringent, antispasmodic, slows peristalsis

Indications:Indications: GI tract:GI tract: dysentery, "summer sickness", diarrhoea, dysentery, "summer sickness", diarrhoea,

cholera, said to stimulate appetite and promote bile cholera, said to stimulate appetite and promote bile flow flow

External:External: as a poultice for skin diseases and ulcers, a as a poultice for skin diseases and ulcers, a decoction for haemorrhoids, mouthwash, gargle, decoction for haemorrhoids, mouthwash, gargle, bruises, varicose veins bruises, varicose veins

Pregnancy:Pregnancy: infusion given to expectant mothers to infusion given to expectant mothers to bring on an easy and rapid childbirth. Vaginal bring on an easy and rapid childbirth. Vaginal application of leaves for heavy bleeding application of leaves for heavy bleeding

Other Uses:Other Uses: kidney and bladder problems kidney and bladder problems

Case: Px with metformin-induced IBSCase: Px with metformin-induced IBS

Patient details

Follow-up June 2006

Advice/ Treatment

Outcome

AW - Man 71 yrs BMI 28 High CVD risk factors and type 2 diabetes 1st seen 2004 Drugs Indapamide Ezetimibe Cardiocor Aspirin Thyroxine Rosuvastatin

Had IBS/ ‘colitis’ induced by Metformin 4-5 bowel movements a day, watery stool Had various tests and specialist appointments but no answer

oily fish, dairy ↓alcohol ↓seeds oils Supplements: multi vit/min Vit C, vit E Ca+Mg Omega-3 Herbal medicine ‘Diabetes control’ Potentilla tr 20 after each motion Rasp leaf 30 g as infusion

14 Sept 2006 Problem lessened but not resolved Rx1 Agrimony + Mint tea 30 g as infusion/day Rx2 Slippery elm capsules 4, bid 18 Sept 2006 Desperate: unremitting diarrhoea and mucosal inflammation 6-Weeks WEED and FEED programme……. WORKED!!!

Weed and Feed Diet*Weed and Feed Diet* Reducing starch, sugar and alcohol from Reducing starch, sugar and alcohol from

the diet diminishes the food source of the the diet diminishes the food source of the pathogenic bacteria pathogenic bacteria

Increase the following foods: Increase the following foods: Meat, fish, beans, peas, nuts, vegetables, Meat, fish, beans, peas, nuts, vegetables,

salads, fruitsalads, fruit Reduce the following starchy foods: Reduce the following starchy foods:

Bread, potatoes, chips, rice, pasta, cereals, Bread, potatoes, chips, rice, pasta, cereals, cakes, biscuitscakes, biscuits

*Adapted from Kerry Bone’s modification of Hein Zeylstra’s protocol

Weekend “WEED” days

Rx1• Uncaria (Cat’s claw) • Tabebuia spp (Lapacho)• Commiphora (Myrrh)• Baptisia (Wild indigo)• Berberis vulgaris (Barberry)• aa / 10 ml bid

• Anti- microbial (pathogenic bacteria, yeasts and protozoa)

Rx2• Garlic tablets - 2 bid

• Garlic helps to restore normal bowel flora by inhibiting ‘pathogenic’ bacterial growth

Weekdays “FEED” days

Rx1• Slippery elm

capsules 5 bid with plenty of water

• Slippery Elm contains mucilage (polysaccharides) which acts as a pre-biotic – supporting the growth of gut friendly organisms such as pro-biotics

Rx2• Vitanox tablets 2

bid

• Grape Seed and Green Tea inhibit the regrowth of pathogenic bowel flora but do not seem to inhibit healthy flora

Rx3• Grape seed extract

(Colladeen) 1 bid

• Given to boost the strength of the Vitanox tablets

ConclusionConclusion

IBS can be caused by a wide range of micro-IBS can be caused by a wide range of micro-organisms, which are difficult to characteriseorganisms, which are difficult to characterise

Herbs can stabilise the gut flora by inhibiting the Herbs can stabilise the gut flora by inhibiting the growth of:-growth of:- Pathogenic/ commensal bacteriaPathogenic/ commensal bacteria YeastsYeasts ProtozoaProtozoa

Not every herbal ‘regime’ will be successful in all Not every herbal ‘regime’ will be successful in all cases – this is why it is helpful to have several cases – this is why it is helpful to have several alternativesalternatives