Yesterday I got an email from Beppe. He had been to America and wanted me to know that his bowel problems were now cured. He wanted his experience to be passed on to others, who may have the same problem. Had I missed something, given the wrong advice? I was curious. So I called him back.
It was two years ago when we last met. He had driven up to Sheffield to seek help for his ongoing symptoms of severe diarrhoea. He was an energetic, fit looking man of about 50; a second generation Italian entrepreneur; somebody used to sorting things out. Only this time he had a problem he could not sort out.
His diarrhoea was provoked by meals, but not necessarily every meal. He described how he could pass enormous quantities of stool often covered with an oily sheen. There was no blood in the stool but he occasionally passed large amounts of foul smelling mucus. He had not lost weight. On the contrary, he thought he had gained a bit and should go to the gym again.
Beppe had consulted several high profile gastroenterologists and dietitians. They had tested him for coeliac disease, colitis, Crohn’s Disease and Cancer of the Colon. All the tests were negative. He had tried many different treatments. A low FODMAP diet was not very effective, Colesevelam (a bile acid sequestrant in tablet form) did nothing, amitryptiline gave him more time to get to the loo, but nothing had made a dramatic improvement.
Beppe had wondered whether he might have dumping syndrome, a combination of nausea, abdominal cramps, light headedness and diarrhoea caused by unregulated rapid emptying of food from the stomach.
The early symptoms of dumping, which occur during the first half an hour are induced by distension of the small intestine due to the rapid entry of food and the osmotic attraction of water. Later symptoms are caused by rapid absorption of glucose, which causes a surge of secretion of insulin and a rebound hypoglycaemia. His dumping, if that is what it is, are undoubtedly related in part to the vagotomy and pyloroplasty, carried out to treat chronic peptic ulceration some twenty years previously. Vagotomy reduces acid secretion and the pyloroplasty opens up the gastric outlet, allowing food to drain rapidly into the small intestine.
There is, however never just one factor involved in the genesis of disease and Beppe had lived for many years without such severe symptoms. Something else must be involved. Could this be the subsequent removal of his gall bladder, causing an additional unregulated leakage of irritant bile acid into the small intestine, which, when combined with rapid small intestinal transit, would have led to bile acid malabsorption? Or could it also be his frenetic life style and the recent changes that had taken place in his life?
A tearaway in his youth, Beppe now owns a Ferrari and lives life in the fast lane. He runs several businesses and travels around the country constantly. Did he keep himself extra busy to avoid painful or depressing thoughts of his mother’s recent death from bowel cancer or his responsibility for his disabled sister? Was Beppe worried that he too might have cancer? He thought not. He prided himself in being the sort of capable person who didn’t let things upset him. Nevertheless, he was prepared to go to any lengths and any expense to find an answer to his problem.
He asked me to suggest a diet that would sort him out. The combination of an inhibition of acid secretion, rapid small bowel transit, leakage of bile acid and a stressful life style would make his bowel very sensitive to those poorly absorbed foods that would retain fluid in the gut. These include milk and cream, certain fruits (apples, pears and stone fruits), beetroot and onions. Bile acid malabsorption might also make him very sensitive to fats and I suggested he could restrict red meat, cheese, cream, and high fat sauces and dressings and ‘ready meals’ that contain substantial amounts of fat. He might also restrict his intake of coffee and alcohol, both of which can stimulate the gut.
But just as there is not one factor causing Beppe’s illness, there is also not one treatment. How he eats his food and leads his life is also important. I suggested he should allow time to eat and digest his meals. He should use mealtimes to relax and not eat on the hoof. The same might apply to the way he leads his life: he should not just power through, but relax, listen, take stock and think about things.
Medications could also help. In particular I recommended that he sprinkle granules of Guar gum on his food in order to increase its viscosity and slow down gastric emptying. I also suggested Questran to treat bile acid malabsorption, starting with 1 sachet before the main meal of the day and half before smaller meals, then adjusting the dose to match the size of the meal and the response of the symptoms. Questran, unlike Colesevelam, is prescribed as granules and it is easy for the patient to adjust the dose. Treatments often work better when patients understand the rationale and are ‘in charge’
Unfortunately, Beppe’s doctor would not prescribe Questran. So Beppe threw money at his problem and went to America, where they diagnosed bile acid malabsorption and prescribed – yes, you’ve guessed it, Questran! He is now sorted.
But just as one extra factor can tip a person into illness, one treatment may tip them back into health, but these may not involve the same mechanism. In Beppe’s case, although mopping up bile acid did the trick, the passage of time allowed Beppe to cope with his mother’s death and not need to work so hard.