IBS digestive insufficiency

Question 1

Conjugated Bile Acid Deficiency -

Malabsorbed Substrate?

Answer 1

Fat, fat-soluble vitamins,

calcium, magnesium

Question 2

Pancreatic insufficiency-

Malabsorbed Substrate?

Answer 2

Fat, protein, CHO
fat-soluble vitamins,
B12

Question 3

Reduced mucosal digestion-

Malabsorbed Substrate?

Answer 3

CHO, protein

Question 4

Intraluminal consumption of nutrients-

Malabsorbed Substrate?

Answer 4

B12, macronutrients

Question 5

Reduced mucosal absorption-

Malabsorbed Substrate?

Answer 5

Fat, CHO, protein,
vitamins
minerals

Question 6

Decreased transport-

Malabsorbed Substrate?

Answer 6

Fat, protein

Question 7

Decreased gastric acid, IF-

Malabsorbed Substrate?

Answer 7

B12

Question 8

Rapid gastric emptying,
decreased gastric mixing-
Malabsorbed Substrate?

Answer 8

Fat, protein

Question 9

Conjugated Bile Acid Deficiency - Causes?

Answer 9

Liver disease, 
biliary obstruction, 
SIBO, 
ileal disease,
CCK deficiency

Question 10

Pancreatic insufficiency- Causes?

Answer 10

Congenital,
chronic pancreatitis,
pancreatic tumors,
hyperacidity (inactivating pancreatic enzymes)

Question 11

Reduced mucosal digestion- Causes?

Answer 11

Mucosal disease (i.e. Crohn’s, Celiac), 
brush border enzyme deficiency (i.e. lactase)

Question 12

Intraluminal consumption of

nutrients- Causes?

Answer 12

SIBO, 
parasitic infection (i.e. D. latum)

Question 13

Reduced mucosal absorption - Causes?

Answer 13

Mucosal disease (i.e. Crohn’s, Celiac),
intestinal surgery,
infections,
malignancy

Question 14

Decreased transport- Causes?

Answer 14

Lymphatic disease
venous stasis (i.e. CHF)

Question 15

Decreased gastric acid, IF- Causes?

Answer 15

Atrophic gastritis,
pernicious anemia,
prior gastric resection

Question 16

Rapid gastric emptying,

decreased gastric mixing- Causes?

Answer 16

Gastroparesis
prior surgery,
autonomic dysfunction.*

*Prior gastric surgery (involving the pylorus and or including vagatomy)-accelerated emptying and decreased time for absorption in the small bowel;
Gastroparesis - decreased gastric mixing and impaired protein and fat assimilation

Question 17

Non-invasive marker for evaluating exocrine pancreatic function

Answer 17

elastase

Question 18

food derived proteolytic enzymes

Answer 18

Bromelain (from pineapple)

• Papain (from papaya)

Question 19

How to appropriately prescribe digestive enzymes

Answer 19

Pancreatin Range:
500-2500
units/kg/meal

Question 20

How to appropriately prescribe bile salts,

Answer 20

Bile salts (ox bile): 500–1000 mg with food

Question 21

How to appropriately prescribe betaine

hydrochloride

Answer 21

Take 1 Betaine HCl tablet (350-750 mg) with a meal that contains
protein.
• If ANY negative symptoms (tingling or warmth in stomach, GERD,
diarrhea, neck ache, etc.), STOP. Experiment is over.
• If no change or feel improvement: Continue for 2 days, then h to 2
tablets at the next protein-containing meal. Increase up to 2500 mg
with meals.

Question 22

Apply select laboratory tools that can help diagnose malabsorption
and maldigestion.

Answer 22

Pancreatic Elastase - to check pancreatic function
Increased putrefactive SCFA - think hypochlorhydria
Increased fecal fat – think low bile acid

Question 23

Cholagogues gb/Choleretics (liver)

BOTANICALS

Answer 23

• Dandelion root
• Taurine
• Limonene:

Question 24

cholegogue foods

Answer 24

• Coffee
• Radishes (horse, red, daikon)
• Dandelion
• Chicory and other bitter greens
• Artichoke

Question 25

Promotility drugs

Answer 25

* Prucalopride * Low-dose naltrexone * Low-dose erythromycin * Metoclopramide

Question 26

Non-Pharmacologic Prokinetic Approaches

Answer 26

* Iberogast (adaptogenic herbal formula): * Ginger root * Tryptophan: * Magnesium citrate: * Ascorbic acid or Sodium Ascorbate * Vitamin D: Minimum D3 5,000 IU qd * Swedish bitters: * D-Limonene: 1000 mg BID * Triphala * Chinese Herbs (TJ 43) * Acupuncture & acupressure * Deep breathing/stress reduction * Exercise

Question 27

Cholagogues g/Choleretics (liver)

Answer 27

* Dandelion root (Taraxacum officinale): * Taurine: 500–1000 mg with food * Limonene:

Question 28

Foods that act as Cholagogues

Answer 28

* Coffee * Radishes (horse, red, daikon) * Dandelion * Chicory and other bitter greens * Artichoke

Question 29

Optimal stool transit time

Answer 29

12-24 hrs

Question 30

Maintaining motility w food

Answer 30

• Increased fruits, vegetables, ancient grains, beans, seeds, water • Probiotic-rich foods/fermented foods • Psyllium husks, pectin • Flax seeds (contain 6-12% mucilage), flaxseed oil • Cod liver oil • Natural colonic laxatives: Aloe vera, senna, buckthorn, rhubarb (note that anthraquinones should not be used long-term as they are stimulant laxatives) • Address root causes! E.g., thyroid, diabetes, med side effects, etc

Question 31

promotility drugs

Answer 31

* Prucalopride * Low-dose naltrexone * Low-dose erythromycin * Metoclopramide

Question 32

Non-Pharmacologic Prokinetic Approaches

Answer 32

• Iberogast (adaptogenic herbal formula): 20 drops tid • Ginger root: 1000mg 1-3x/d or 1500-2000 mg/d • Tryptophan: 1-3, 500 mg caps BID (GI motility is modulated by serotonin.) • Magnesium citrate: 250 mg 2-4x/d and/or increase dietary magnesium consumption • Ascorbic acid or Sodium Ascorbate: Up to 5 g/d • Vitamin D: Minimum D3 5,000 IU qd • Swedish bitters: Gastric - 1 Tbsp before meals • D-Limonene: 1000 mg BID • Triphala • Chinese Herbs (TJ 43) • Acupuncture & acupressure: 20-30 min, 3x/week • Deep breathing/stress reduction • Exercise

Question 33

Iberogast (

Answer 33

Prokinetic adaptogenic herbal