Helicobacter pylori Pathogenicity, Testing and Treatment Options

Helicobacter pylori – Pathogenicity, Testing and Treatment Options Copyright© 2015, Kurt N. Woeller, D.O., Tracy Tranchitella, N.D., and Educational ...
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Helicobacter pylori – Pathogenicity, Testing and Treatment Options

Copyright© 2015, Kurt N. Woeller, D.O., Tracy Tranchitella, N.D., and Educational Resource Association. This material may not be reprinted, distributed or used without permission.

Lecture Overview • What is Helicobacter pylori (H. pylori)? • Symptoms of H. pylori infection • Pathogenicity of H. pylori • What causes an ulcer? • Testing options for H. pylori • What is Indican?

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Lecture Overview • The role of bile acids • Using the Metabolic Assessment Profile (#101) from BioHealth Laboratory. • Other health effects of H. pylori • Naturopathic medicine treatments of H. pylori: • Step I – IV

• Antibiotic intervention

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Support Documents For Module #7 • H. pylori Treatment Options - handout • H. pylori & Digestive Treatment Additional Recommendations - handout • Lecture slides (pdf) • Lecture slides - note taking (pdf)

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What Is Helicobacter pylori?

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What is Helicobacter pylori? • Helicobacter pylori, aka. H. pylori is a gram negative bacteria that primarily resides in the lining of the stomach. • Identified in 1982, and later found to be a major cause of chronic gastritis and gastric ulcers. • H. pylori has become recognized by most everyone as an important pathogen in gastric and duodenal health problems, including stomach cancer (1). (1) Blaser MJ (2006). "Who are we? Indigenous microbes and the ecology of human diseases". EMBO Reports (10): 956–60.

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What is Helicobacter pylori? • Approximately, 85% of people harboring H. pylori in the stomach are asymptomatic (2). • In those that are symptomatic, acute gastritis, abdominal pain and nausea can occur. • In chronic situations these problems can lead to gastric and duodenal ulcerations • Those with chronic H. pylori have a 1% to 2% lifetime risk of developing gastric cancer (3). (2) Bytzer P, et.al. "Diagnosis and treatment of Helicobacter pylori infection". April 2011. Dan Med Bull. (3) Kusters JG, et. al. "Pathogenesis of Helicobacter pylori Infection". Clin Microbiol Rev (3): 449–90. July 2006.

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How Do We Get H. pylori? • H. pylori can be acquire from food, water, or eating utensils. • Saliva or other body fluids of infected people • More common in countries or communities that lack clean water or good sewage systems. • H. pylori can be acquired during childhood and people can harbor it for years before becoming symptomatic.

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Symptoms of H. pylori

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Symptoms of H. pylori (can be associated with ulcers too) • Burning and/or aching pain in stomach area • Abdominal bloating • Abdominal pain that gets worse on any empty stomach. • Nausea • Loss of appetite • Frequent burping • Unintentional weight loss

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Common Symptoms of Ulcers • In some cases ulcers do not cause symptoms. • The most common ulcer symptom when is gnawing or burning pain in the abdomen - between the navel and breastbone. • Ulcer pain often occurs between meals and in the early morning hours. It may last from a few minutes few hours.

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Less Common Symptoms of Ulcers • Belching • Nausea • Vomiting • Poor appetite • Loss of weight • Feeling tired and weak

Pathogenicity of H. pylori

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Pathogenicity of H. pylori • The pathogenicity of H. pylori is complex. This is a brief synopsis of how this bacterium invades the mucosal lining of the stomach and evades the immune system: 1. H. pylori evades the acid environment of the stomach by using flagella to burrow itself into the tissue lining of the stomach. 2. It binds itself to the inner lining of the epithelium by using an adhesion chemical called ‘adhesin.’

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Pathogenicity of H. pylori 3. H. pylori can also neutralize acid in its local tissue environment by producing an enzyme called ‘urease’ which helps to breakdown urea in the stomach to ammonia which neutralizes the acid.

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What Causes An Ulcer?

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Pathogenicity of H. pylori • How H. pylori causes ulcerations and inflammation is partly through continued biochemical changes linked to #3. • The ammonia produced by the urease enzyme is toxic to epithelial cells, and additional production of protein enzymes called ‘proteases’ leads to tight junction breakdown between epithelial cells. • The loss of tight junctions leads to a leaky gut scenario resulting in an inflammatory cascade of cell membrane degradation with the release of inflammatory signaling from tissue phospholipase enzymes. YOUR LOGO

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Pathogenicity of H. pylori • The breakdown of local mucosal tissue cells and the release of proinflammatory chemicals through phospholipase activity eventually leads to over-exposure of the stomach to the digestive chemical called ‘pepsin’ causing further tissue damage and inflammation. • As inflammation progresses, particularly near the antrum (area near the duodenum), the hormone ‘gastrin’ is released and circulated through the blood stream.

Parietal Cell

Pathogenicity of H. pylori • Gastrin stimulates stomach parietal cells which are responsible for hydrochloric acid (HCL) production. • Continued production of HCL damages the duodenum leading to duodenal ulcers.

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Extra-Intestinal Problems of H. pylori

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A. Gasbarrinia, et.al. Extradigestive manifestations of Helicobacter pylori gastric infection. Gut 1999.

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Schematic representation of the substances released by the immune system following gastric colonization by Helicobacter pylori: TNF, tumor necrosis factor; PAF, platelet activating factor; LT, leukotriene; PG, prostaglandin; IL, interleukin; INF, interferon. YOUR LOGO

Extra-Intestinal Symptoms of H. Pylori • Vascular diseases: • Ischemic heart disease • Ischemic cerebrovascular disorders • Reduced folate absorption

• Functional vascular disorders • Raynaud’s and idiopathic migraine

• Immunological diseases: • Sjogren’s Syndrome • Autoimmune thrombocytopenia

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Extra-Intestinal Symptoms of H. Pylori • Skin diseases: • Chronic urticaria • Acne roseacea • Alopecia areata • Liver and biliary tract • Other

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Stark RM, et. al. Biofilm formation by Helicobacter pylori. Lett Appl Microbiol. 1999 Feb;28(2):121-6. Helicobacter pylori NCTC 11637 produces a water-insoluble biofilm when grown under defined conditions with a high carbon:nitrogen ratio in continuous culture and in 10% strength Brucella broth supplemented with 3 g l-1 glucose. Biofilm accumulated at the air/liquid interface of the culture. Light microscopy of frozen sections of the biofilm material showed few bacterial cells in the mass of the biofilm. The material stained with periodic acid Schiff's reagent. The sugar composition strongly indicates the presence of a polysaccharide as a component of the biofilm material. Antibodies (IgG) to partially purified material were found in both sero-positive and sero-negative individuals. Treatment of the biofilm material with periodic acid reduced or abolished immunoreactivity. Treatment with 5 mol l-1 urea at 100 degrees C and with phenol did not remove antigenic recognition by patient sera.

The production of a water-insoluble biofilm by H. pylori may be important in enhancing resistance to host defense factors and antibiotics, and in microenvironment pH homeostasis facilitating the growth and survival of H. pylori in vivo. YOUR LOGO

Pattiyathanee, et. al. Roles of flagella and effect of curcumin against biofilm formation by Helicobacter pylori. African Journal of Biotechnology, 2009 • Objectives: The gastric pathogen Helicobacter pylori is shown to have alternate life style as a biofilm. In human infection, a presence of mature biofilm attached to cell surface has been shown and hypothesised that H. pylori infections resulting in gastric ulcers may be a manifestation of biofilm. Flagella have been considered to have a possible role during initial step of biofilm formation. Here we have investigated roles of three flagellar genes, including the flaA gene encoding flagellin protein, the flgR regulatory gene and the fliQ export apparatus gene, in the production of biofilm and control of adherence in H. pylori. The effect of curcumin against H. pylori biofilm formation and adherence to the human cancer cells has also been investigated. • Results: Two different types of biofilm were observed in this study, including pellicle and attached biofilm. The wild-type H. pylori 26695 and N6 strains formed biofilm and adhered to HEp-2 cells more efficiently than the isogenic mutants, including flaA mutants; PA315 and NA2, flgR mutants; PR611and NR, and fliQ mutants; PQ and NQ. These results indicate that these genes are involved in the biofilm formation and adhesion of H. pylori. Our results showed that curcumin not only inhibited bacterial growth, but also greatly decreased the number of biofilm formation and the ability to adhere to the HEP-2 cells.

• Conclusion: Curcumin has a demonstrated effect against H. pylori biofilm and shown a significant inhibitory action on adherence of H. pylori. YOUR LOGO

Curcumin 250 • Turmeric Phytosome (Curcuma longa) root, dried extract, min. 18% curcuminoids & phosphatidylcholine complex • 250mg/capsule 1 capsule twice daily with food

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Testing Options for H. pylori Detection

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Types of Antibodies • IgM - usually the first antibody produced by the immune system when encountering some type of pathogen. • IgG - antibodies produced when a pathogen is present, as well as other antigens. • IgA - antibody that is involved with protection of the lining of the nasal passages and intestinal lining from germs. • IgE - the antibody most widely known for its involvement in allergies of all kinds. YOUR LOGO

H. pylori Antibodies • Blood tests are used to measure antibodies to H pylori – IgG most commonly done for H. pylori. • “Blood tests for H pylori can only tell if your body has H pylori antibodies. It cannot tell if you have a current infection or how long you have had it. This is because the test can be positive for years even if the infection is cured. As a result, blood tests cannot be used to see if the infection has been cured after treatment.”

• Best to test for IgA, IgM and IgG - not just IgG!

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Breath Test • Breath Test (Carbon Isotope-urea Breath Test, or UBT). • Need to stop taking antibiotics, bismuth medicines such as Pepto-Bismol, and proton pump inhibitors (PPIs) up to 2 weeks before test. • Uses a urea compound that H. pylori can convert into carbon dioxide (CO2) that is then measured. • This test can identify almost all individuals with H pylori. It can also be used to check that the H. pylori infection eradicated. YOUR LOGO

Endoscopy w/Biopsy

A tissue sample is taken from stomach lining to detect the presence H. pylori. Usually a biopsy is done if endoscopy is needed for other reasons such as diagnosing an ulcer, treating GI upper GI bleeding, or overall evaluation for other diseases, i.e. cancer. YOUR LOGO

Stool Antigen

• A stool test can detect traces of H. pylori antigen in the feces. • This test can be used to diagnose the infection and confirm that it has been cured after treatment.

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Indican Testing A Marker Of Poor Protein Digestion

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Metabolic Assessment Profile (#101) – BioHealth Laboratory

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Indican • Indican is an organic compound that is naturally found in many plant species. As a dye it gives an indigo color (blue). • A percentage of the general population secretes small amount of indican in their urine as a normal byproduct of amino acid tryptophan conversion to a chemical called indole. Intestinal bacteria then convert indole to indican.

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Indican • The indican being water soluble is absorbed from the digestive system and excreted through the kidneys. • In severe tryptophan metabolism defects children can take on a ‘blue diaper syndrome’ characterized by indigo blue urine stained diapers, along with digestive problems, fever, and visual disturbances.* *Drummond KN, Michael AF, Ulstrom RA, Good RA (1964). "The blue diaper syndrome: Familial hypercalcemia with nephrocalcinosis and indicanuria; A new familial disease, with definition of the metabolic abnormality". Am J Med (6): 928–48.

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Indican • Because digestive tryptophan is converted to ‘indoles’ than to indican, measuring indican in excess can be an indirect marker of digestive system bacterial overgrowth, and possibly the presence of H. pylori. • Small amounts of indican are normally found in the urine, but the amount can increase with high protein diets and/or maldigestion of protein. • H. pylori can be one cause of protein maldigestion. If protein is not digested appropriately (HCL imbalance) intestinal bacteria act upon this protein leading to putrefaction, increased indole production, and increased conversion to indican. YOUR LOGO

Causes of High Indican • Low stomach acid via destruction of parietal cell activity or antacid use (proton-pump inhibitors). • Poor protein enzyme production from the pancreas • Malabsorption syndromes, i.e. Hartnup disease which is a rare amino acid absorption condition. • Bacterial overgrowth of the small intestine (SIBO). • Intestinal obstruction • Intestinal parasites and/or yeast infections • Liver disease

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Link Between H. Pylori and High Indican • Certain H. pylori strains produce ‘effector’ molecules which alter the function of parietal cells leading to achlorhydria.* • Poor HCL production can lead to inefficient protein digestion which increases the chances of protein putrefaction in the digestive system and over-production of indican, particularly if there are other opportunistic infections, i.e. parasites, clostridia bacteria in the digestive system. • H. pylori pathogenicity is so complex that it is possible for H. pylori to induce hypo-secretion, hyper-secretion, and normal production of hydrochloric acid.** *Cave DR. Yale J Biol Med. Helicobacter pylori and its interaction with chief and parietal cells. 1996 Jan-Feb **H. Jablonowski. Gut. 1994 Jun; 35(6): 755–757. Effects of Helicobacter pylori on histamine and carbachol stimulated acid secretion by human parietal cells. YOUR LOGO

The Role of Bile Acids

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The Role of Bile Acids • Bile acids make up a larger pool of bile secretions produced from the liver. • The liver processes many endogenously produced chemicals from our general circulation including electrolytes, cholesterol, various metabolic acids, and bilirubin which are excreted into the biliary tree and out into the lumen of the digestive system in a concoction called bile.

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The Role of Bile Acid • Bile acids play a critical role in digestive health • They are responsible not only for the digestion (breakdown) of fats from our diet, but absorption of the fat soluble vitamins necessary for overall health – Vitamin A, E, D, and K. • For example, without proper vitamin K absorption our blood clotting ability is compromised, and without adequate vitamin A the mucosal lining of the digestive system and membranes of the respiratory system are more porous increasing the chance of systemic infection. YOUR LOGO

The Role of Bile Acid • Bile (including bile acids) is used to remove waste material from the body out of the digestive system in the form of stool. • If bile composition is compromised and bile acids are not being produced in an adequate function the ability to detoxify toxins is greatly compromised. • Bile is the main route of cholesterol excretion from the body. The bile helps to make the cholesterol more aqueous and easier to eliminate. With poor bile acid production cholesterol becomes less soluble and it has the tendency to accumulate in the biliary system primarily creating stones in the storage organ called the gallbladder. • Poor liver function with inefficient cholesterol solubility is a direct cause of gallstones. YOUR LOGO

Urinary Bile Acids • Large amounts of bile are secreted into the intestines on a daily basis, but only small amounts are lost from the body. The main reason for this is the vast majority of bile that is distributed in the duodenum is then reabsorbed from the last part of the small intestine (ileum). • The blood supply from this region of the small intestine is taken back through the liver where the liver cells called hepatocytes reabsorb the bile to resupply the bile acid pool. • If damage has occurred to the liver cells whether by infection, inflammation, etc. much of this bile acid is leeched into the general circulation. YOUR LOGO

Lipid Peroxides

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Antioxidant Supplementation

2 capsules once to twice daily

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Naturopathic Treatments For H. pylori

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Naturopathic Treatment for Helicobacter pylori • Step I: Eradicate H. Pylori • Step II: Improve Digestion and Absorption • Step III: Restore and Maintain Normal Gastric Mucosa • Step IV: Prevent Relapse

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Eradicate H. Pylori with Botanicals Step I (Treatment Course Is Typically 4 to 6 Weeks)

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Botanicals for the Treatment of H. Pylori • Mastic Gum – gum resin from the mastic tree (Pistacia lentiscus). Studies show it has a direct effect on killing H. pylori. Traditionally used as an antiseptic, food antioxidant, flavoring additive, chewing gum, breath freshener, remedy for stomach pain, indigestion and peptic ulcers. • Dosage: 1000+mg daily

• Zinc Carnosine – specific for killing H. pylori. Reduces symptoms of gastritis associated with H. pylori and promotes healing. Often used is combination with ‘Triple Therapy.’ • Dosage: 75mg - 100mg per day YOUR LOGO

Botanicals for the Treatment of H. pylori • Bismuth Citrate – can reduce levels of H. pylori and help to heal gastritis and ulcers by providing a protective coating to the stomach mucosa. Not effective as a monotherapy; often one part of ‘Triple Therapy.’ Works by inhibiting bacterial uptake of iron. • Dosage: 250mg BID

• Berberine – alkaloid compound found in barberry, Oregon grape, goldenseal, coptis and phellodendron. Antibacterial activity against H. pylori which in turn decreases gastritis and reduces overall effect of infection. • Dosage: 300mg BID Duration of Treatment with Botanicals is 4-6 weeks. Formulas need to be taken on an empty stomach. YOUR LOGO

Botanicals for the Treatment of H. pylori • DGL – Deglycyrrhizinated licorice; soothing to the gastric mucosa and reduces the ability of H. pylori to colonize. Can be taken as a chewable tablet or as part of a combination formula. • Dosage: 1500mg per day • Methylmethioninesulfonium, aka Vitamin U - though not a true vitamin. Found in high concentration in cabbage juice. Antiulcerogenic and protective to the gastric and intestinal mucosa. • Dosage: 200 mg per day • Vitamin C – suppressive effect against the proliferation of H. pylori. Best used as adjunctive therapy with other treatments. • Dosage: 2-5 grams per day in divided doses.

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Pyloricil • 1 Capsule Contains:

• Zinc (as Carnosine) 8.5mg • Mastic Gum Extract 250mg • Berberine Sulfate Hydrate 150mg. • Bismuth Citrate USP 125mg • Zinc Carnosine 37.5mg

• Dosage: 2 capsules BID between meals.

www.biomatrixone.com

www.emersonecologics.com 65

GastroMend-HP • Serving Size: 4 capsules • Amount Per Serving:

• Vitamin C (as Ascorbic Acid) 500mg • Deglycyrrhizinated Licorice (DGL) 1500mg. (Glycyrrhiza glabra)(root)(8:1) • Mastic Gum 1000mg. (Pistacia lentiscus)(gum & resin) • Methylmethioninesulfonium 200mg (Vitamin U). • PepZin GI® (Zinc-Carnosine) 75mg

• Dosage: 2 capsules BID between meals.

www.designsforhealth.com

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Matula Herbal Formula Tea • Combination herbal tea of wild olive, wormwood, aloe, thorn tree and crataegus. • Wild Olive – antibacterial, antiparasitic, antifungal • Wormwood – antibacterial, antihelmintic, antiparasitic • Aloe – astringent, antibacterial, emollient, cell proliferent. • Thorn tree/Crataegus – many forms of each of these plants. Full botanical name not given. Thorn tree could be a common name for a type of crataegus. Hawthorne berry is a form of crataegus and commonly used in cardiac conditions for its relaxing effect on smooth muscles. YOUR LOGO

Matula Herbal Formula Tea • Comes as a one month supply of 60 teabags. • Dosage: 2 cups of tea per day away from food. • Recommended to steep for 7-8 minutes to get more from the teabag. • May need to treat longer than one month. www.ulcer-cure.com

Cost: $180 + Shipping 68

Botanicals, Foods and Supplements for H. pylori • Cranberry Extract – prevents adhesion of bacteria to stomach wall. • Dosage: 500-1000 mg per day

• Garlic – antibacterial effect. • Dosage: 2 raw cloves per day

• Broccoli Sprouts – contains isothiocyanate sulphurophane which reduces the level of H. pylori and decreases symptoms of gastritis. • Green Tea – catechins and epigallocatechins (EGCG) shows antibacterial activity in vitro and in vivo studies. Also inhibits the vacuolization of H. Pylori. YOUR LOGO

Botanicals, Foods and Supplements for H. Pylori • Red Wine – the polyphenols of resveratrol and tannic acid show antibacterial activity, inhibited H. Pylori urease activity, inhibited vacuolization, and reduced gastric mucosal damage and symptoms of gastritis. • Manuka Honey – has bacteriostatic properties against H. pylori due to osmotic effect of sugars and hydrogen peroxide (H202) content produced by glucose oxidase added by the bees. • Dosage: 1-2 tablespoons per day YOUR LOGO

Botanicals, Foods and Supplements for H. Pylori • Spirulina – algae product high in polysaccharides; high anti-adhesive properties. Studies show a 90% decrease in adhesion of H. pylori when administered 3x/week for 4 weeks before exposure. • Probiotics – inhibits adhesion to gastric mucosa, decreases bacterial colonization and gastritis. Strains studied: Bifidobacter, Lactobacillus acidophilus, Lactobacillus caseii, Bacillus subtilis. • Cabbage Juice – rich in Vitamin U (methylmethioninesulfonium), anti-ulcerogenic. YOUR LOGO

Address Biofilms with Enzymes • H. pylori secretes a biofilm to protect itself from stomach acid which can make it resistant to treatment and elimination. • H. pylori can be easily suppressed, but difficult to eradicate. May need to treat longer than prescribed, i.e. additional weeks. • Address biofilms with enzymes while treating the H. pylori with antibacterial herbs to improve outcomes. YOUR LOGO

Addressing BioFilm Biofilm Treatment Options (choose one): • Interphase – 2 capsules between meals BID • Interphase Plus – 2 capsules between meals BID • Nattokinase – 100 mg between meals BID • Serrapeptase – 100 mg between meals BID NOTE: Not to be used when taking blood thinners such as Coumadin, Plavix or Ticlid.

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Improve Digestion and Absorption Step II

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Digestive Enzymes Do We Use HCL? • H. pylori can exert a variable effect on gastric acid secretion. • Some have excess acid, while others have hypochlorhydria. • General Rule: Do not use HCL if known ulcers exist and/or patient has severe gastritis. Need to reduce H. pylori, heal ulcers and soothe gastritis before adding HCL to the program. • Treatment of H. pylori can increase the secretion of HCL, however, some with longstanding infections and chronic gastritis may never regain the ability to produce adequate HCL. YOUR LOGO

Signs and Symptoms of Low HCL • Low serum ferritin • Low serum B12 • Low folic acid • Low copper, calcium • SIBO – gas, bloating, maldigestion • Feeling of food, especially high protein meals, staying in stomach too long. • Frequent gut infections (bacterial, viral, parasitic)

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Swedish Bitters • Dosage:

• 2 teaspoons in warm water 15 minutes before a meal.

• Can also be taken in warm water in the morning to stimulate movement of GI tract. Check online or local health food store

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Fermented Foods

Add one to two heaping tablespoons to meals

Rich in enzymes and natural bacteria 78

Digestive Enzymes w/HCL

www.biomatrixone.com

Take 2 capsules with meals 79

Digestive Enzymes w/HCL Amount Per Serving (1 capsule):

• Betaine HCL 200 mg • GastroENZ™ Proprietary Blend 180 mg. • Ox Bile Extract, Protease (DPPIV), Amylase, Pepsin, Protease SP, Glucoamylase, Lactase, Acid Protease, Invertase, Lipase. www.designsforhealth.com

Take one capsule with a meal 80

Restore and Maintain Normal Gastric Mucosa Step III

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Restoring Healthy Gastric Mucosa • L-Glutamine Powder – 2.5g to 5g per day. Healthy cell production of intestinal mucosa, enhances gut barrier function and influences gut immune response. • Lactose-free Colostrum – 2,000mg to 6,000mg daily. Supports optimum immune function and intestinal health. • Curcumin – 250mg to 1000mg + daily. Reduces inflammation. Inhibits biofilm formation and adherence of H. Pylori. • N-acetyl-cysteine (NAC) – 500mg to 1000mg daily. • Vitamin A – 5000 IU per day. • Zinc Carnosine – 75-150 mg per day. YOUR LOGO

Support Mucosa

www.BioMatrixOne.com

3 capsules twice daily 15 minutes before meals 83

Prevent Relapse Step IV

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Preventing Relapse • Do follow up testing 4 weeks after treatment. The reason for the delay in testing is if there is any H. pylori left, you want to give it time to proliferate so that it can be picked up on testing. • Continue with digestive enzymes, foods and botanicals long-term (at least 2 to 3+ months) that have an inhibiting effect on H. pylori colonization. • Test and treat all family members if possible • If ‘Triple Therapy’ was implemented, follow up with a botanical program to reduce antibiotic resistance. YOUR LOGO

What About Multiple Infections? H. pylori Plus… • Clostridia: • Begin clostridia intervention with botanicals (6-8 wks) • Treat H. pylori (4-6 wks) • Add digestive enzymes with HCL when appropriate

• SIBO: • SIBO appropriate diet • Treat H. pylori • Add digestive enzymes with HCL when appropriate

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What About Multiple Infections? H. pylori Plus… • Parasites: • Where is the patient more symptomatic? Upper GI or lower GI? If upper GI, treat H. pylori first. If lower GI, treat parasite. Can have crossover with treatment if patient tolerates. • Retest for Parasite + H. pylori 4 weeks after completing H. pylori program.

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What About Multiple Infections? H. pylori Plus… • Candida: • • • •

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Begin H. pylori treatment and see how patient tolerates Start anti-candida remedies Introduce digestive enzymes if appropriate Continue with anti-candida remedies, but retest H. pylori 4 weeks after completing H. pylori treatment program.

H. Pylori Treatment Antibiotic Options

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‘Triple Therapy’ • Administer triple therapies for 10-14 days • The treatment options are typically: • Omeprazole (Prilosec), Amoxicillin, and Clarithromycin (Biaxin). • Bismuth subsalicylate, Metronidazole (Flagyl), and Tetracycline. • Lansoprazole (Prevacid), Amoxicillin, and Clarithromycin (Biaxin).

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Prevpac PREVPAC: • Lansoprazole (Prevacid) 30mg delayed-release capsule. • Amoxicillin 500mg capsule • Clarithromycin (Biaxin) 500mg tablet Dosing – for 14 days: • One Prevacid BID • One Biaxin BID • Two Amoxicillin BID YOUR LOGO

Helidac HELIDAC: • Bismuth subsalicylate 262.4mg chewable tablet (#112). • Metronidazole 250mg tablet (#56) • Tetracycline 500mg capsule (#56) Dosing – for 14 days: • Two (2) bismuth chewable tablets QID • One (1) tablet Metronidazole QID • One (1) capsule Tetracycline QID Taken with H2 Antagonist, i.e. Tagamet (Cimetidine) for treatment of duodenal ulcer. YOUR LOGO

Gain access to comprehensive testing including Organic Acid, Comprehensive Digestive Stool Analysis, Adrenal Hormone, Hair, Amino Acid, etc. • • • • • •

All tests kits sent to your home or office No doctor visit needed for ordering Each lab reviewed personally by integrative medicine doctor Written lab review provided with recommended action steps based on lab test markers Access to professional line supplements Great Plains Laboratory, BioHealth Laboratory, Doctors Data, ZRT, etc.

www.labtestsplus.com for a complete list of lab tests available . YOUR LOGO

Module #8 Topic • “Dietary Intervention for Chronic Bowel Problems – The Role of Diagnostic Testing, Special Diets, and Trial Elimination of Offending Foods.” • The role of dietary intervention in improving chronic gastrointestinal disorders. • Overview of Special Diets: • Food IgG Elimination • Gluten Intolerance versus Celiac Disease • The Specific Carbohydrate Diet (SCD) • Gut Associated and Psychology Syndrome Diet (GAPS) • Feingold versus Failsafe Diets • FODMAPS Diet YOUR LOGO

Thank You Kurt N. Woeller, D.O. & Tracy Tranchitella, N.D. www.GIMasteryCourse.com [email protected]