Sunday, April 27, 2008
Mastocytic Enterocolitis and five things you can do about the possible stress, food and altered gut flora link to leaky gut, IBS and IBD
Stressful life events are known to be associated with flares of both inflammatory bowel disorders (IBD) and irritable bowel syndrome (IBS) but the mechanism has been unknown. Accumulating research indicate mucosal mast cells are involved in the process through release of chemical mediators that increase gut permeability (leaky gut), cause increase intestinal contractions (cramps), increase fluid secretion (diarrhea), and inflammation of the intestine. The latter not only results in a vicious cycle of increased leaky gut allowing food and microbe proteins through the bowel wall but may trigger a chronic autoimmune or immune inflammatory process in the presence of the right genetics.
Animal studies with mice have shown increased colon paracellular permeability (CPP) from stress. The mechanism in mice is increased mucosal mast cells (MMC) and increased release (degranulation) that alter the tight junctions between intestinal lining cells resulting in leaky gut. Human studies have confirmed increased MMC concentrations in the intestine in response to stress as well as increased mast cell degranulation. The stress hormone corticotropin releasing hormone (CRH) appears to be a modulator and receptors for CRH have been found on MMC in the human intestine.
Increased MMC are a hallmark of an entity known as mastocytic enterocolitis (MEC) now linked to many cases of diarrhea predominant IBS (IBS-D). Twenty or more mast cells per high power field in either the small or large intestine, has been advocated by Jakate et al. as defining this new entity. In a little more than a year I have diagnosed almost ninety individuals with this condition by requesting a relatively new special stains on intestinal biopsies that many physicians, including most gastroenterologists are not aware is available. Some of these patients have celiac disease but continued to have symptoms despite a strict gluten free diet, including my wife. Many, if not most, have had various neurological symptoms including headaches, anxiety, and depression, and almost all have significant fatigue. Some have had biopsies done by me or another doctor in the past and the special stains had to be requested to make the diagnosis. Five of my patients are physicians themselves.
A significant number have at risk genetics for celiac disease and most who have tried a gluten free diet have responded favorably. A mast cell stabilizing medication sodium cromalyn (Gastrocrom) has helped some but has not been as effective as I would like to report and a few complained of nausea or that they felt worse taking the medication which is also quite expensive. Antihistamine blockers, both type 1 histamine receptor blockers (Zyrtec, Allegra, Claritin etc.) and type II histamine blockers (Raniditine/Zantac) generally help as does the allergy-asthma medication Singulair.
However, given that the studies indicate mast cells are both increased and release more of their chemicals in response to stress it is likely that stress management is a critical component to treatment. This theory is supported by the fact that several recent articles indicate a favorable role for cognitive therapy, antidepressants and anxiety medications and counseling in helping those with IBS and IBD. Probiotics also make sense since recent articles indicate that probiotic strains of bacteria can increase tight junctions or decrease intestinal permeability (reduce leaky gut).
Certain dietary proteins are difficult for humans to digest and may promote a leaky gut. Gluten has been shown to increase leaky gut even in people without celiac disease. Dairy proteins, especially casein, are a common cause of protein allergy or intolerance in humans. Soy protein, peanuts and other legumes are difficult to digest and have been implicated in gut injury.
That leads to a five-point treatment strategy for leaky gut due to increase mast cells exacerbated by stress, including psychological, dietary and microbial.
1. Consider strictly avoiding or limiting gluten grains, dairy, and legumes especially soy and peanut.
2. Take a probiotic daily (e.g VSL#3, Flora Q or Ultimate Flora etc.)
3. Take an antihistamine or antihistamines (Zyrtec, Zantac etc.)
4. Take a mast cell stabilizer (Gastrocrom) if you meet criteria for mastocytic enterocolitis or possibly Singulair if you have allergies.
5. Practice stress management techniques and/or get counseling for life stressors
Phenotypic changes in colonocytes following acute stress or activation of mast cells in mice: implications for delayed epithelial barrier dysfunction. Demaude J. et al. Gut 2006;55:655-661.
Corticotropin-reieasing hormone (CRH) regulates macromolecular permeability via mast cells in normal human colonic biopsies in vitro. Wallon C. et al. Gut 2008;57:50-58.
Copyright © 2008, The Food Doc, LLC, All Rights Reserved.
Scot M. Lewey, D.O., FACP, FAAP, FACOP
Gastroenterology Associates of Colorado Springs
1699 Medical Center Point
Colorado Springs CO 80907
719 387 2110 Fax: 719 302 6000
Dr. Scot Lewey is a digestive disease specialist doctor (board certified gastroenterologist) whose medical practice focuses on digestive and food related illness. Also, known as Dr. Celiac, the Food Doc, Dr. Lewey shares his experiential knowledge for a healthy gut, healthy life on-line. Start learning today from his extensive personal and professional experience. Dr. Lewey is uniquely qualified as an expert and one of the few GI doctors who is also gluten sensitive and dairy sensitive. He has nearly a quarter of century of experience in the diagnosis and treatment of food allergy & intolerance, colitis, Crohn's disease and IBS. He is married to someone who has Celiac disease. He and his family live gluten free in Colorado.
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