Kelsey Marksteiner: What a unique situation here. Let me think about this for a minute. She only has her small intestine. The whole colon has been removed. Yeah, that is a little tricky with the bacteria… or with SIBO, I guess. I don’t know. Probably you have not tested her for SIBO, I would imagine, but if you take out the colon, I would assume you kind of take out, for the most part, the microbiome. I mean, we have microbiome colonies, basically, in quite a few places. We have colonies in our lungs, we have colonies in our skin, so it’s not just the gut microbiome that we have to think about. It’s all those other microbiomes as well. But I would imagine if you take out a colon, you’re taking out the microbiome… in the gut, at least.
So your question is, where else would that bacteria go? I think it would just be gone, theoretically. Unless she had SIBO to begin with … I wouldn’t say that it’s necessarily indicative that she has to have SIBO. I think it is possible that she would not have SIBO.
This person is saying, “She was empirically treated for SIBO with rifaximin, but had a reaction, so stopped treatment. No test yet.” What kind of reaction did she have? That would be helpful for me to know. I don’t know if it was just like an allergy or anything or if there was some sort of reaction that would actually … because sometimes when you treat SIBO, people can have reactions that they just don’t feel very well, so I would be curious to know what type of reaction that is.
So I think, no, it’s not necessary for her to have SIBO if the colon was taken out and she only has the small intestine, so I would do some testing for her.
Then your second question is, “What would you be doing for her in terms of diet?” Good question. This depends on what her symptoms are.
OK, a quick aside here. It says, “The reaction to rifaximin: Patient felt like it was allergic, like an IgE reaction.” All right, so that makes a little bit of a difference here, in that it doesn’t seem like it was related to actually killing off bacteria. Yeah, I think she definitely could have SIBO, but I’m not 100 percent that she would have to have SIBO. My other question is, do you have her on a low-FODMAP diet now? It sounds like maybe you do. Also, what are her symptoms like?
Oh, “Not yet on low FODMAP,” but thinking about it, it sounds like.
OK, so what are the symptoms that she’s having digestively? Are there any, or are we just trying to prevent these polyps from coming back? While you answer that, I will think about, diet-wise, what I would do, but it does depend on those symptoms as well. I mean, starting just from a really anti-inflammatory type of diet, I think, is a great place to begin. That would be your standard, typical Paleo kind of diet, which I assume you probably have her on already. You could try low FODMAP, but again, it would be dependent on the symptoms as to whether I think that would be helpful.
So this person is saying, “She’s currently mashing all food, has constipation and acid reflux.” Yeah, the constipation and acid reflux are two key indicators for me to start thinking about SIBO. I would say that it’s possible that she has SIBO, and I definitely would test her for that.
Lauren is actually saying to me now that Chris has talked about before that there’s evidence that the small intestine partially takes over the role of the colon when the colon is removed. Yeah, that actually does make a lot of sense. In that case, I wonder how difficult it would be to actually test for SIBO if that’s the case because then you would imagine that there is more, obviously, bacteria in the small intestine than there is usually because it’s taking over that role. I’ve never dealt with this. This may actually be a good question for Chris in terms of the testing piece because I don’t know how that affects the testing. I would imagine that you would probably get a positive test maybe even regardless of whether it’s actually causing a problem or not, but given her symptoms, I do think that empirical treatment is potentially not a bad idea, just because she has these symptoms that are very much related to having SIBO. Given that and that given that she has had a reaction to the rifaximin, you could maybe try the herbal protocol and see if she does well on that and see if any of her symptoms improve.
Otherwise, in terms of diet, I’d definitely be making sure that she does have some probiotics. I do think that could help. And again, I think your thinking here is good, in that they’re more transient, they’re not necessarily taking up residence, but it probably could help somewhat with the constipation. My usual recommendations for constipation, I’ll just tell you, are as follows, but it does differ a little bit in this scenario because of the unique situation this person is in. Typically what I will do is at least rule out SIBO, if not treat for SIBO if the person has it. And if someone has methane-positive SIBO, that’s, of course, usually more related to constipation, so it definitely wouldn’t be surprising if the person has constipation. It’s very, very common with constipation patients. So treating for SIBO or at least ruling it out would be step number one. Then from there, I would usually start with prebiotics and soluble types of fiber and also really make sure that the carbohydrate intake is high enough, because a lot of times and especially if the person has a history where they’ve said to you, Oh, you know, I started doing low carb, or I started doing keto or Paleo or whatever, and all of a sudden—or even over the course of six months or a year or something like that—I started to get constipated and I haven’t been able to fix it since. That, to me, is a key indicator that their carb intake is too low, and once they start to actually increase their carb intake, their constipation just goes away. Carbs help to bring water into the large intestine, and of course, that’s going to help with stool movement. That would be the second thing I would do, make sure carb intake is good. Then, like I said, really focus on prebiotics and just soluble fiber intake in general because stool is made up of dead bacteria… or a lot of it is, anyway, so you need to actually have good amounts of probiotics, so good bacteria in the large intestine. If you don’t, a lot of times that can be problematic as well, so you could do stool testing to confirm this person doesn’t have a lot of good bacteria, but I don’t think there’s any harm in trying prebiotics or adding some extra soluble fiber. If they’re not getting enough carbohydrates in general and you’re increasing carbohydrates, they’re going to, by default, be getting more soluble fiber anyway. Both of those things I don’t think are harmful, so you could just try increasing those.
That’s just with normal, regular constipation, no surgeries to think about here. In that case, it certainly does make it a lot more difficult, and I’m potentially not the right person to be asking this to. I would definitely bring this up to Chris or Amy as well, but for me, I would probably really tailor the diet to symptoms. I would try a low-FODMAP diet. I certainly don’t think it’s a bad idea, but sometimes I’ve actually had that make constipation worse for some people, and that’s because they’re not getting prebiotics in the diet anymore. In that case, it can be somewhat problematic because you’re not feeding that good bacteria, which is then turning into stool when it dies off. I would try it, but don’t be surprised if it makes her worse. You know, I would definitely obviously make her aware of that fact, that it may make her worse but we actually won’t know until we just try it, and it may make her better. You do want to try that and see if it helps. Usually I don’t recommend long-term low-FODMAP diets, but in this case, if it worked for her, I probably would just have her stay on that fairly long term just because this is a very unique situation that we’re dealing with and we don’t really have the best protocols to deal with something like this.
Definitely submit the question to Chris or Amy as well, specifically asking about testing for SIBO in this case, because if it is shown that the small intestine takes over part of the role of hosting the microbiome when the colon is removed, I would imagine that makes SIBO testing very, very difficult. In this case, I would probably say it might be worth trying an empirical round of herbal antimicrobials since she had a reaction to the rifaximin and see if that helps.
This person is also saying, “For the same person, she has type 2 diabetes and fat malabsorption.” OK, so is she on a lower-fat diet. That would be one of my first questions. I assume probably because if she was eating a lot of fat, I would imagine she wouldn’t be having constipation quite as much because it would just kind of push things through her very quickly. OK, yes, a lower-fat diet. Has she tried sort of a medium-fat diet? That would be another question because, again, this is just such a unique situation, so it’s a little bit unique here. No, she hasn’t tried a medium-fat diet. I would maybe try that, honestly, because it’s going to help the constipation. You don’t want to make her have really uncomfortable digestive symptoms, but it actually may help the constipation to have a little bit of extra fat in the diet just because it’s going to help move things along. For some people, there can be a very fine, fine line between not having digestive symptoms and then going way towards the other end of the spectrum with diarrhea or things like that. So I would maybe try a little bit higher fat ratio here.
This person is asking, “Do you favor MCT for fat?” For fat malabsorption, yes, in general. That’s going to be a lot better tolerated. But in this case, because this is a weird case here, I would actually say you don’t want to do things that are more easily digested because we’re kind of using the fact that she is malabsorbing fat, likely because of the digestive situation currently where she doesn’t have a colon, in our favor to help the constipation. I’m just thinking through how I would do this. I would definitely try the herbal antimicrobials first just to see if that helps anything. If that alone starts to kind of fix the constipation and starts to kind of fix the acid reflux, I would just pretty much stay there and assume that it was bacterially related. If it doesn’t seem to do anything, then I would use the fat malabsorption in her favor to help move things more quickly through the digestive system. I know that sounds a little weird because you would assume, of course, that you don’t want to give someone who is malabsorbing fat more fat because they’re obviously not going to absorb it, but in this case, the fact that they’re not absorbing it makes things move more quickly through the digestive system, which may help with the constipation symptoms. So you could try that.
You could definitely give some MCT because we do, of course, want her to actually be absorbing some fat because that’s going to help her absorb other micronutrients, so we don’t want her to be on a really low fat diet and not really getting any fat at all. The MCT would be good for that purpose, where we want her to actually be absorbing some of that fat because it’s much easier for someone with fat malabsorption to absorb MCT oil. Then in terms of actually helping the constipation, you could give her just other normal types of fat that are not as easily digested to help move things along.
This person is saying that this woman has type 2 diabetes—sorry, I just read that—and now they’re asking what ratio of macros would be a medium-fat diet. This would depend on where she’s at right now. If you could give me an idea of how much fat she’s currently eating, that would be helpful. Really I would just go slightly above where she is right now. I’m just saying medium-fat diet because you said she’s on a low-fat diet, so what I mean by that is just to increase the amount of fat slightly and see how that changes anything for her. But again, I would definitely explore the SIBO side of things first just because we know that her symptoms are related to having SIBO, and we could definitely add MCT oil if she’s not taking any already because I wouldn’t want her on a super-low-fat diet without getting any fat that is absorbed.
I’ll give you a minute here to think through how much fat she’s currently getting. As you do that, I’m trying to think if there’s anything else that I would do. It sounds like you’re concerned about the macronutrient ratios because she has type 2 diabetes and fat malabsorption, and that certainly makes life a little bit difficult when you’re trying to come up with the right ratio of what this person should be eating. With carbohydrate intake, I would totally play that to where she’s at blood sugar wise right now. If she’s eating a sort of moderate-carbohydrate diet but blood sugar is all over the place, she’s not well controlled, then of course, we need to either play with balancing the carbohydrate intake, meaning making sure that she’s getting some degree of fat when she’s eating it and she’s definitely getting protein so she’s never eating carbohydrate by itself. That’s going to help to sort of balance out blood sugar levels. But if that doesn’t work either, then you may need to consider lowering the carbohydrate intake. If you’re lowering carbohydrate intake, you’re going to have to make up those calories somewhere, provided that she’s right now eating a calorically appropriate diet, which is another big question. She may not be. But if she is and you’re taking out carbohydrate, you need to replace that with something. Usually that something would be fat, but in this case, obviously that’s a little bit more difficult. I would consider getting it from fat, maybe in the form of MCT oil since that’s a little bit more well tolerated, but also again considering a little bit higher “normal” type of fat diet and actually hoping that that will help with the constipation.
Good luck with this one. It’s definitely an interesting case here. I would definitely, again, bring it up to Chris and Amy just to see if there’s anything they would add here, but that’s where I would start.
You’re also asking about supplements, saying curcumin as an option. Definitely. Anything antiinflammatory, I think, is going to be really helpful. Usually to prevent polyps and that kind of stuff, I would be focusing on making sure the microbiome is in a good place, which is, again, difficult here because we don’t really know how the small intestine kind of takes over the role of the microbiome when the colon is gone. It’s sort of unknown as to how you can improve that, but I would still think about it as you think about feeding the microbiome in the large intestine. Again, going through a SIBO kind of protocol in this case because the testing is probably not going to be all that helpful and seeing if that helps, that would also kind of get rid of any “bad” bacteria in the microbiome, which we’re now assuming has kind of migrated to the small intestine. And then from there, if that seems to help, I would try prebiotics and things like that to make sure that the microbiome is actually doing well even though it’s in a different place now. I would also try increasing carbs a little bit, but you have to, again, really play that to the blood sugar levels.
I hope that helps. I know this is complicated, especially to get this person as a new client. That’s really tough. But feel free to bring this case back in the future as you start to try things, and we can brainstorm from there.