Re: 과민성 장증후군 케이스 리포트

[문형철]

Integr Med (Encinitas)

. 2016 Aug;15(4):49–53.

Nutritional Interventions for Gastroesophageal Reflux, Irritable Bowel Syndrome, and Hypochlorhydria: A Case Report

Kasia Kines 1,✉, Tina Krupczak 1

• Author information
• Copyright and License information

PMCID: PMC4991651  PMID: 27574495

Abstract

Chronic gastrointestinal (GI) complaints are often treated with proton pump inhibitors (PPIs), antibiotics, and other medications that offer temporary relief of acute symptoms. Although these drugs are prescribed to provide promising results, new research indicates the drug treatments often mask unresolved physiological problems and cause further complications. Complex GI cases require a comprehensive assessment and a multifaceted approach. This case reports on the development of PPI-induced hypochlorhydria secondary to a PPI prescription for unresolved gastritis in a patient with irritable bowel syndrome. The patient’s gastritis and hypochlorhydria symptoms resolved with the implementation of a comprehensive functional nutrition approach that incorporated dietary guidelines, lifestyle recommendations, and customized nutritional supplementation and herbs.

만성 위장(GI) 질환은 

종종 양성자 펌프 억제제(PPI), 

항생제, 

그리고 급성 증상을 일시적으로 완화하는 다른 약물로 치료됩니다. 

이러한 약물은 

유망한 결과를 제공하기 위해 처방되지만, 

새로운 연구에 따르면 약물 치료는 종종 해결되지 않은 생리적 문제를 가리고 

더 많은 합병증을 유발합니다. 

복잡한 위장 질환의 경우 

종합적인 평가와 다각적인 접근이 필요합니다. 

이 사례는 

과민성 대장 증후군 환자의 미해결 위염에 대한 PPI 처방으로 인한 

PPI 유발성 위염의 발병에 대해 보고합니다.

환자의 위염과 위염성 위산과다증의 증상은

식이 지침, 생활 습관 권장 사항, 맞춤형 영양 보충제 및 허브를 포함한

포괄적인 기능성 영양 접근법의 시행으로 해결되었습니다.

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Proton pump inhibitors (PPIs)—inhibitor of gastric acid production1—are amongst the top 10 most commonly prescribed drugs in the world2 for the treatment and management of gastroesophageal reflux and peptic ulcers. They are widely prescribed and available over the counter for a range of gastrointestinal (GI) conditions from heartburn to gastritis, often with little or no testing.3 A total of 25% of the general population is said to experience heartburn at least once per month.2

PPIs were first thought to have few side effects.4 New evidence, particularly with extended use, has revealed a decrease in absorption of some key vitamins and minerals, gut dysbiosis, rebound stomach acid hypersecretion, increased reflux-like symptoms, and hypergastrinemia. Hypergastrinemia may be associated with an increased risk of stomach cancer.5

The current use of PPIs often focuses primarily on symptom management rather than addressing treatable factors that have contributed to the gastroesophageal reflux, gastritis, and even peptic ulcers.6

위산 생성 억제제(PPIs)는

위식도 역류 및 소화성 궤양의 치료 및 관리를 위해

세계에서 가장 많이 처방되는 10가지 약물 중 하나입니다2.

이 약들은 널리 처방되고 있으며,

속쓰림에서 위염에 이르기까지 다양한 위장 질환에 대해 처방전 없이 구입할 수 있으며,

종종 검사가 거의 또는 전혀 없이 처방됩니다.3

일반 인구의 25%가

한 달에 한 번 이상 속쓰림을 경험한다고 합니다.2

PPI는 처음에는 부작용이 거의 없다고 여겨졌습니다.4

그러나

최근의 연구 결과에 따르면,

특히 장기간 사용 시,

일부 주요 비타민과 미네랄의 흡수 감소,

장내 미생물 불균형,

위산 과다 분비,

역류성 증상 증가,

위염과 관련된 과가스트린 혈증(hypergastrinemia)이 발생할 수 있는 것으로 밝혀졌습니다.

위염과 관련된 과가스트린 혈증은

위암 발병 위험 증가와 관련이 있을 수 있습니다.5

현재의 PPI 사용은

위식도 역류, 위염, 심지어 소화성 궤양에 기여한 치료 가능한 요인을 다루기보다는

증상 관리에 주로 초점을 맞추고 있습니다.6

Patient Case

The patient was a 43-year-old female professional athlete, of healthy weight. She complained about anxiety, GI symptoms (dyspepsia, constant burping, abdominal pain, and constipation) and a recent diagnosis of small intestinal bacterial overgrowth (SIBO).

She had been born vaginally but was not breast-fed. She had history of allergies, childhood eczema, chronic sinusitis, asthma, repeated antibiotics much of her life, a tonsillectomy, an adenoidectomy, 2 sinus surgeries for polyps, and allergy shots during the past 2 years. She had previously tested negative for celiac disease but avoided gluten due to bloating. After she became a mother (age 39 y), with a daughter born prematurely, she developed postpartum anxiety, nervousness, and mood swings. Two years later, her father died and she developed abdominal pain, anxiety associated with a cough, and wheezing in her throat. During an emergency room visit for her symptoms, she had a normal computed tomography scan, was diagnosed with anxiety-related gastroesophageal reflux, and was given a prescription for PPIs. She did not receive any material or education related to nutritional support.

For the next 2 years, she tried 3 different PPIs, and all were minimally effective. She did note some improvement from self-prescribed dietary changes. Her anxiety continued and she developed new symptoms: a lower abdominal pain relieved only by forced burping and eating, tingling in her hands and feet, and constipation. She requested an endoscopy, which was positive for acute gastritis but negative for Helicobacter pylori, reflux, eosinophilic esophagitis, or Barrett’s esophagus. A pH monitor revealed no reflux and she was diagnosed with irritable bowel syndrome with constipation (IBS-C; Rome criteria). Laryngoscopy revealed laryngeal pharyngeal reflux and she was treated with antibiotics. She did not receive any material or education related to nutritional support.

환자 사례

환자는 

건강한 체중을 가진 43세의 여성 프로 운동선수였습니다. 

그녀는 

불안, 위장 증상(소화불량, 지속적인 트림, 복통, 변비)과 

최근 진단된 소장 세균 과다증식(SIBO)에 대해 호소했습니다.

그녀는 질로 태어났지만 모유 수유를 하지 않았습니다. 

그녀는 

알레르기, 소아기 습진, 만성 부비강염, 천식, 

평생 동안 반복된 항생제 투여, 편도선 절제술, 아데노이드 절제술, 폴립 제거를 위한 부비강 수술 2회, 

그리고 지난 2년 동안 알레르기 주사 등의 병력이 있었습니다. 

그녀는

이전에 셀리악 질병에 대한 검사에서 음성 판정을 받았지만,

복부팽만감 때문에 글루텐을 피했습니다.

39세에 엄마가 된 후

딸이 조산으로 태어나면서

산후 불안, 신경과민, 기분 변화가 생겼습니다.

2년 후 아버지가 돌아가시면서

복통, 기침과 관련된 불안, 목의 쌕쌕거림이 생겼습니다.

응급실을 방문했을 때,

컴퓨터 단층 촬영 검사 결과는 정상이었고, 불

안과 관련된 위식도 역류로 진단을 받았으며,

PPI 처방을 받았습니다.

그녀는

영양 지원과 관련된 자료나 교육을 받지 못했습니다.

그 후 2년 동안 

그녀는 3가지 다른 PPI를 시도했지만, 

모두 효과가 미미했습니다. 

그녀는 

스스로 처방한 식습관 변화로 인해 

약간의 개선이 있었다고 말했습니다. 

그녀의 불안은 계속되었고 새로운 증상이 나타났습니다: 

억지로 트림을 하거나 

음식을 먹어야만 완화되는 하복부 통증, 손발 저림, 변비. 

그녀는 내시경 검사를 요청했고, 

급성 위염은 양성, 헬리코박터 파일로리, 역류, 호산구성 식도염, 바렛 식도(Barrett's esophagus)는 음성으로 나왔습니다. 

pH 모니터 검사 결과 역류는 없었고, 

그녀는 변비성 과민성 대장 증후군(IBS-C; 로마 기준) 진단을 받았습니다. 

후두경 검사 결과 후두 인두 역류가 확인되었고, 

그녀는 항생제 치료를 받았습니다. 

그녀는 영양 지원과 관련된 자료나 교육을 받지 못했습니다.

In an attempt to get help with her ongoing symptoms, she consulted with a new primary care family practitioner who was board-certified in integrative medicine (American Board of Integrative Holistic Medicine). Laboratory testing revealed suboptimal B12 and magnesium, and a breath test was positive for methane, suggesting SIBO. She was started on magnesium and digestive enzymes (which improved her constipation) and was prescribed rifaximin 550 mg TID for 10 days. The medication; a low fermentable oligo-saccharides, di-saccharides, mono-saccharides, and polyols (FOMDAP) diet for SIBO; and an elimination diet decreased her complaints of gas but failed to resolve her upper and lower abdominal pains. These were relieved with only forced burping or food. Four months later, with ongoing symptoms, repeat breath test at Johns Hopkins University (Baltimore, MD, USA), she was negative for SIBO and methane. At that point, she self-prescribed probiotics, chewed ginger, and drank apple cider vinegar, all with mixed results.

Her first nutrition consultation was 2 months later in October 2015. She was anxious and, based on her GI symptoms alone, she had dyspepsia, gastritis, possible PPI-induced hypochlorhydria, and a diagnosis of IBS-C. Her diet at the time was free of gluten, dairy, and legumes. She enjoyed vegetables, could not tolerate baked goods, and craved sugar. She was a fast eater and gulped her meals.

Initially, we discontinued the patient’s daily protein shake to avoid high FODMAPs. She was inconsistent with taking probiotics but believed that the enzymes she was taking were helping with her constipation. At a follow-up 2 weeks later, the patient was provided nutritional education and a 2-week dietary plan for gastritis, including 75 mg zinc carnosine BID and 1 smoothie per day with added l-glutamine, slippery elm, GI repair powder, and low-allergenic pea protein powder. Stress management tools were provided, including breathing techniques, phone apps, and materials on binaural rhythms, all designed to reduce anxiety. The patient was educated on potential effectiveness of probiotics to encourage compliance. In addition, she was asked to chew slowly and thoroughly and to practice mindful eating.

During the third consultation 2 weeks later, her gastritis pain, wheezing, and burping had decreased, but the lower abdominal pain continued. Her fiber and food intake were both inadequate, so additional strategies for an IBS-C appropriate fiber to reduce constipation were discussed. The patient also received education on the proper preparation of legumes to support digestion and optimize absorption. She was advised to continue the gastritis protocol and incorporate mindful eating and thorough chewing at meals. Supplementation with Aloe vera juice for additional GI support and oligomeric proanthocyanidins (OPCs) for allergies and sinuses was also recommended.

Two weeks later, her stomach pain had decreased and she reported improved mastication and slower paced chewing at meals. The sharp gastritis pain had resolved completely, but the refractory lower abdominal pain remained and still required forced burping or eating for relief.

Added legumes were well tolerated and enjoyed. Her constipation improved with increased fiber in her diet. She noticed that meat was hardest to digest. The new antihistamine OPC supplement and Aloe vera juice were well tolerated. With gastritis resolved an “HCL Challenge” was done to eval‎uate suspected hypochlorhydria prior to beginning supplementation with hydrochloric acid (HCL)/betaine/pepsin.

In January 2016, she noted complete resolution of the refractory lower abdominal pain with daily HCL supplementation. She was encouraged to continue with current diet and supplements and her dose of HCL was increased in an attempt to treat her residual burping.

그녀는 현재 겪고 있는 증상에 대한 도움을 얻기 위해 

통합 의학(미국 통합 전체론 의학 위원회) 전문의인 새로운 가정의학과 전문의와 상담을 했습니다. 

검사 결과, 

B12와 마그네슘 수치가 최적 수준에 미치지 못하는 것으로 나타났고, 

호흡 검사에서 메탄이 검출되어 SIBO가 의심되는 것으로 나타났습니다. 

그녀는 

마그네슘과 소화 효소(변비 개선)를 복용하기 시작했고, 

10일 동안 리팍시민 550mg을 하루에 2번 복용하도록 처방받았습니다. 

이 약물과 SIBO에 대한 저발효성 올리고당, 이당류, 단당류, 폴리올(FOMDAP) 식이요법, 

그리고 배변을 촉진하는 식이요법은 그녀의 가스 관련 불만을 줄여주었지만, 

상복부와 하복부 통증은 해결하지 못했습니다. 

이 통증은 억지로 트림을 하거나 

음식을 먹었을 때만 완화되었습니다. 

4개월 후, 증상이 지속되면서 

미국 메릴랜드주 볼티모어에 있는 존스 홉킨스 대학에서 호흡 검사를 다시 받았을 때, 

그녀는 SIBO와 메탄에 대해 음성 판정을 받았습니다. 

그 시점에서 그녀는 프로바이오틱스를 자가 처방하고, 

생강을 씹고, 

사과 식초를 마셨지만, 

모두 결과가 좋지 않았습니다.

그녀의 첫 영양 상담은 2015년 10월, 2개월 후였습니다. 

그녀는 불안해했고, 

위장 증상만으로 소화불량, 위염, 

PPI로 인한 저염산증, 

과민성 대장 증후군 C형 진단을 받았습니다. 

당시 그녀의 식단은 

글루텐, 유제품, 콩류를 포함하지 않았습니다. 

그녀는 야채를 좋아했고, 

구운 음식은 견디지 못했으며, 

설탕을 갈망했습니다. 

그녀는 빨리 먹는 편이었고, 식사를 꿀꺽꿀꺽 삼켰습니다.

처음에는 

FODMAP 함량이 높은 것을 피하기 위해 

환자의 일일 단백질 셰이크를 중단했습니다. 

그녀는 프로바이오틱스 복용에 일관성이 없었지만, 

복용하고 있는 효소가 변비에 도움이 된다고 믿었습니다.

그녀는 채식주의자였지만, 

육류, 생선, 달걀, 유제품을 먹었습니다. 

2주 후 후속 검사에서 환자는 

위염에 대한 영양 교육과 2주간의 식이 계획을 제공받았습니다. 

여기에는 75mg의 아연 카르노신 BID와 

하루에 한 번씩 l-글루타민, 미끄러운 느릅나무, 위장 회복 분말, 

저자극성 완두콩 단백질 분말을 첨가한 스무디 1잔이 포함되었습니다. 

호흡법, 전화 앱, 양이진 리듬에 관한 자료 등 불안감을 줄이기 위해 고안된 스트레스 관리 도구가 제공되었습니다. 

환자는 프로바이오틱스의 잠재적 효과를 교육받았고, 

이를 통해 치료에 대한 순응도를 높일 수 있었습니다. 

또한, 천천히 그리고 철저하게 씹고, 마음 챙김 식사를 실천하도록 요청받았습니다.

2주 후 세 번째 상담을 진행했을 때, 

위염으로 인한 통증, 쌕쌕거림, 트림은 감소했지만, 

하복부 통증은 계속되었습니다. 

환자는 섬유질과 음식 섭취량이 모두 부족했기 때문에, 

변비를 줄이기 위해 과민성 대장 증후군 C형에 적합한 

섬유질을 섭취할 수 있는 추가적인 전략에 대해 논의했습니다. 

또한, 환자는 소화를 돕고 흡수를 최적화하기 위해 

콩과식물을 적절하게 준비하는 방법에 대한 교육을 받았습니다. 

그녀는 위염 치료법을 계속 따르고, 

식사할 때 주의 깊게 먹고, 

천천히 씹는 습관을 들이도록 조언받았습니다. 

추가적인 위장 지원을 위해 알로에 베라 주스를 섭취하고, 

알레르기와 부비동에 좋은 올리고머 프로안토시아니딘(OPCs)을 섭취하는 것도 권장되었습니다.

2주 후, 그녀의 복통은 줄어들었고, 

그녀는 식사할 때 씹는 습관이 개선되었고, 

씹는 속도가 느려졌다고 보고했습니다. 

급성 위염으로 인한 통증은 완전히 사라졌지만, 

복부 아래쪽에 남아 있던 통증은 여전히 존재했고, 

이를 완화하기 위해 억지로 트림을 하거나 음식을 먹어야 했습니다.

콩과식물을 추가한 식단은 잘 견디고 즐겨 먹었습니다. 

식이섬유 섭취량이 증가하면서 변비도 개선되었습니다. 

고기가 가장 소화하기 어렵다는 것을 알게 되었습니다. 

새로운 항히스타민제 OPC 보충제와 알로에 베라 주스는 잘 견뎌냈습니다. 

위염이 해결되면서 

염산(HCL)/베타인/펩신 보충제를 시작하기 전에 의심되는 

저염소화증(hypochlorhydria)을 평가하기 위해

 “HCL 챌린지”가 실시되었습니다. 

2016년 1월, 

그녀는 매일 HCL을 보충하면서 

완치된 난치성 하복부 통증을 확인했습니다. 

그녀는 현재의 식단과 보충제를 계속 유지하도록 권장받았고, 잔

존하는 트림 증상을 치료하기 위해 HCL의 복용량을 늘렸습니다.

Epilogue

After another month, the patient contacted the functional nutritionist to advise that she had stopped HCL during another phase of antibiotics prescribed to treat her sinusitis. The lower abdominal pain returned, although this time without wheezing or burping. Approximately 30 days later, she sent another e-mail update stating that she was back on HCL (as well as a postantibiotic probiotic) and that the abdominal pain resolved again.

에필로그

한 달이 지난 후, 

환자는 기능성 영양사에게 연락을 취해 

부비동염 치료를 위해 처방받은 항생제의 다른 단계에서 HCL을 중단했다고 알렸습니다. 

이번에는 쌕쌕거림이나 트림이 동반되지 않았지만, 

하복부 통증이 다시 나타났습니다. 

약 30일 후, 

그녀는 HCL(+항생제 투여 후 프로바이오틱스)을 다시 복용하기 시작했고,

복부 통증이 다시 사라졌다는 내용의 이메일을 또 한 번 보냈습니다.

Patient Perspective

After being told I had IBS when several tests came back normal, I was determined to find the cause of my gut issues. The most valuable information and guidance came from working with my functional nutritionist. I can now live my life normally with no worries that I will have pain after I eat. After 2 years of mystery pains, I am pain free. I am forever grateful.

환자의 관점

여러 가지 검사를 통해 정상이라는 진단을 받은 후, 저는 장 문제의 원인을 찾아야겠다고 결심했습니다. 기능성 영양사와 함께 일하면서 가장 유용한 정보와 지침을 얻었습니다. 이제는 식사 후에 통증이 생길까 봐 걱정하지 않고 정상적인 생활을 할 수 있게 되었습니다. 2년 동안 계속되었던 미스터리한 통증이 사라졌습니다. 정말 감사한 일입니다.

Discussion

Biomedical research has historically supported the hypothesis that heartburn is caused commonly by excessive stomach acid (often combined with a lax gastroesophageal sphincter tone). Suppression of acid production with PPIs to alleviate symptoms is the current standard of care. The use of PPIs (prescription and over the counter) to block stomach acid production is widespread and has been popularized by television advertisements. Stomach acid contains HCL, which is a digestive fluid secreted by stomach parietal cells that breaks down dietary proteins. Gastroesophageal reflux caused by regurgitation of HCL acid into the esophagus increases the risk of esophagitis, Barrett’s esophagus, and even esophageal cancer, and that is the main reason why PPIs remain the standard of care for any reflux.

Reflux can be caused by various factors and, depending on the cause, improved or eliminated without medications. For example, it can be caused by an erratic or weak lower esophageal sphincter, pressure from abdominal fat, hiatal hernia, or bile reflux. Moreover, overconsumption of fat in a meal can cause overexcretion of HCL, which can be mistaken for primary overproduction of HCL (hyperchlorhydria). Overuse of antacids and diet-induced hyperchlorhydria can lead to medication-induced hypochlorhydria. It is common to confuse reflux symptoms for hyperchlorhydria, when the symptom may actually be associated with hypochlorhydria.

Hypochlorhydria has detrimental health effects with long-term use, including autoimmune disorders.7 HCL plays a key role in many physiological processes; it triggers intestinal hormones; prepares folate and B12 for absorption; and is essential for the absorption of minerals, including calcium, magnesium, potassium, zinc, and iron. Lack or suppression of HCL has been associated with increase in osteoporosis; bone fractures; and impaired absorption of B12, iron and magnesium.8 HCL also prevents the overgrowth of pathogens in the upper GI tract, so hypochlorhydria can be a risk factor for SIBO.9 HCL is also responsible for breaking down dietary proteins aiding in the prevention of food allergies associated with incomplete digestion of protein. Acid-blocking medications are widely available and, despite the fact that they were initially approved for short-term use, they are often taken for extended periods, even years.

토론

의학 연구에 따르면, 속쓰림은 일반적으로 과도한 위산(위식도 괄약근의 이완과 함께 발생하는 경우가 많음)이 원인이라는 가설이 뒷받침되어 왔습니다.

현재 표준 치료법은

위산 생성을 억제하는 PPI를 사용하여 증상을 완화하는 것입니다.

위산 생성을 차단하기 위해 PPI(처방약 및 일반 의약품)를 사용하는 것은 널리 보급되어 있으며,

TV 광고를 통해 대중화되었습니다.

위산에는 위벽 세포에서 분비되어 식이 단백질을 분해하는 소화액인 HCL이 포함되어 있습니다.

HCL산이 식도로 역류하여 발생하는 위식도 역류는

식도염, 바렛 식도, 심지어 식도암의 위험을 증가시킵니다.

이것이 PPI가 역류에 대한 표준 치료법으로 남아 있는 주된 이유입니다.

역류는 다양한 요인에 의해 유발될 수 있으며, 원인에 따라 약물 없이도 개선되거나 사라질 수 있습니다. 예를 들어, 불규칙하거나 약한 하부 식도 괄약근, 복부 지방의 압력, 위식도열공탈장, 담즙 역류 등이 원인일 수 있습니다. 또한, 식사 때 지방을 과다 섭취하면 HCL의 과다 분비를 유발할 수 있으며, 이는 일차성 HCL 과다 생성(과염산혈증)으로 오인될 수 있습니다. 제산제의 과다 사용과 식이 유발성 과염산혈증은 약물 유발성 과염산혈증을 유발할 수 있습니다. 실제로 과염산혈증과 관련이 있을 수 있는 역류성 식도염 증상을 과염산혈증과 혼동하는 경우가 흔합니다.

저염소산혈증은 장기간 사용 시 자가면역질환을 포함한 건강에 해로운 영향을 미칩니다.7

HCL은 많은 생리학적 과정에서 핵심적인 역할을 합니다.

장내 호르몬을 유발하고,

엽산과 비타민 B12의 흡수를 돕고,

칼슘, 마그네슘, 칼륨, 아연, 철분 등 미네랄의 흡수에 필수적입니다.

HCL의 부족 또는 억제는 골다공증, 골절, 그리고 비타민 B12, 철분, 마그네슘의 흡수 장애와 관련이 있습니다.8 HCL은 또한 상부 위장관 내 병원균의 과다 증식을 방지하기 때문에, 저염소산혈증은 SIBO의 위험 요소가 될 수 있습니다.9 HCL은 또한 단백질의 불완전한 소화와 관련된 음식 알레르기의 예방에 도움이 되는 식이 단백질의 분해에도 관여합니다. 산성 차단제는 널리 사용되고 있으며, 처음에는 단기 사용을 위해 승인되었음에도 불구하고, 종종 수년 동안 장기간 복용하기도 합니다.

Functional medicine is an approach used to address underlying causes of disease, using a systems-oriented approach engaging patient and practitioner in a therapeutic partnership shifting the traditional disease-centered focus of medical practice to a more patient-centered approach.10 Functional nutrition is aligned with the functional medicine model and shares an emphasis that food is medicine, that a healthy GI tract is a critical foundation for health, and that many chronic complaints are linked to a compromised GI tract. Functional nutritionists use an evidence-based approach and are trained to assess patients empirically, symptomatically, and in response to specific dietary interventions, lifestyle changes, and dietary supplements.

It is not uncommon to see PPI-induced hypochlorhydria in patients on long-term PPIs. The “HCL Challenge” followed by supplementation (HCL/betaine/pepsin) is usually well tolerated and when used appropriately can stabilize physiological processes, support nutrient assimilation, and aid in the digestion of proteins (providing amino acids and preventing food allergies). It also helps prevent pathogenic infections through a restoration of a more normal GI microbiome. The resolution of this patient’s symptoms (including the forced burping) suggested that her gastritis and hypochlorhydria had resolved. Probiotic supplementation was also used to rebuild the microbiome severely affected by years of antibiotics and stress.

The simple noninvasive “HCL Challenge” can be used when hypochlorhydria is suspected. The patient starts with 1 capsule of betaine/HCL/pepsin (650–750 mg) with a meal containing protein and increases the dose to tolerance (a healthy stomach may produce 1.5 L of gastric acid daily).11 Heartburn, heat, or abdominal discomfort at a given dose will indicate an excessive dose, although heartburn with 1 capsule indicates normally secreted HCL, and the highest asymptomatic dose becomes the baseline dose for HCL supplementation, depending on the protein content of meals. The “HCL Challenge” is contraindicated in patients with active gastritis, esophagitis, or duodenitis.

Limitations

It is difficult to determine the mechanisms leading to the resolution of individual symptoms in a system-oriented approach to treatment with multiple interventions. It appears that the combination of therapies were associated with this patient’s successful outcome.

Conclusion

This case report demonstrates the complex nature of chronic conditions in patients, recognizing that some of the medications used to manage symptoms may actually create new medical imbalances. This is not atypical of the clinical practice of a functional nutritionist. In this case, the patient’s GI complaints resolved and, in the process, the patient became empowered to maintain her health.

Figure 1.

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Patient Timeline

Abbreviations: IBS-C, irritable bowel syndrome with constipation; CT, computed tomography; PPIs, proton pump inhibitors; FP, family physician; ABIHM, American Board of Integrative Holistic Medicine; CDAS-2, Comprehensive Digestive Stool Analysis 2.0; FODMAP, fermentable oligo-saccharides, di-saccharides, mono-saccharides, and polyols; SIBO, small intestinal bacterial overgrowth; OPC, oligomeric proanthocyanidins; HCL, hydrochloric.

Acknowledgements

This case report followed the CARE guidelines for case reports. Kasia Kines and Tina Krupczak are doctoral students in clinical nutrition at the Maryland University in Integrative Health (Laurel, MD, USA). The authors wish to acknowledge David Riley, md, for his support with this case report.

References

• 1.Weekes LM. Proton pump inhibitors: Too much of a good thing? Med J Aust. 2015;202(9):464. doi: 10.5694/mja15.00477. [DOI] [PubMed] [Google Scholar]
• 2.Imhann F, Bonder MJ, Vich Vila A, et al. Proton pump inhibitors affect the gut microbiome. Gut. 2016;65(5):740–748. doi: 10.1136/gutjnl-2015-310376. [DOI] [PMC free article] [PubMed] [Google Scholar]
• 3.Reimer C. Safety of long-term PPI therapy. Best Pract Res Clin Gastroenterol. 2013;27(3):443–454. doi: 10.1016/j.bpg.2013.06.001. [DOI] [PubMed] [Google Scholar]
• 4.Jackson MA, Goodrich JK, Maxan ME, et al. Proton pump inhibitors alter the composition of the gut microbiota. Gut. 2016;65(5):749–756. doi: 10.1136/gutjnl-2015-310861. [DOI] [PMC free article] [PubMed] [Google Scholar]
• 5.Haastrup P, Paulsen MS, Begtrup LM, Hansen JM, Jarbol DE. Strategies for discontinuation of proton pump inhibitors: A systematic review. Fam Pract. 2014;31(6):625–630. doi: 10.1093/fampra/cmu050. [DOI] [PubMed] [Google Scholar]