Restoring gastrointestinal balance after infection

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By Kellie Blake, RDN, LD, IFNCP

I recently had a patient who had experienced eight months of concerning gastrointestinal (GI) symptoms. While she had completed treatment for a suspected giardia infection post-travel to Jamaica, she was still struggling with GI symptoms and had significant anxiety related to her bowel movements. She was convinced she was still infected and her quality of life was declining.

The U.S. Centers for Disease Control and Prevention (CDC) estimates one billion people are affected by parasites worldwide. Parasitic infections are a part of life in many developing countries, most often causing impaired cognitive development and stunted growth in children. Parasitic infections are often undiagnosed in the United States, but parasites affect millions of Americans each year.

Parasites are often overlooked as a root cause of GI symptoms. However, as reported in one controlled case study in the World Journal of Gastrointestinal Pharmacology and Therapeutics, parasite testing should be standard for any patient suspected of having irritable bowel syndrome (IBS). In the study, the stool of IBS and healthy patients was investigated and Blastocystis, Cryptosporidium, and Giardia lamblia was found in 25.6, 12.8, and 8.3 percent, respectively, of IBS patients, which were all statistically significant when compared to healthy controls. The researchers concluded that parasites may play a role in the development of IBS in a considerable percentage of patients.

Early detection can be important for decreasing the course of infection, but also for diminishing the risk of IBS. Comprehensive stool testing from a company trained to look for parasites can provide the most accurate information since standard ova and parasite testing is generally unreliable.

As integrative providers, we are trained to consider parasites as a cause of a variety of complaints. Parasitic infections can mimic other disorders leading to obvious GI symptoms such as abdominal pain, gas, bloating, bloody stools, constipation, IBS, and diarrhea. Parasites can also be responsible for anemia, fatigue, sleep disturbances, teeth grinding, unexplained fever, weight loss, and anxiety.

While I do not treat patients for parasites as a dietitian, I do refer to the appropriate specialist and work with patients during and after treatment. I have found many patients struggle with the thought of having a parasite and often continue to experience many of the same symptoms even after completing herbal or pharmaceutical treatment. Helping patients recover from a parasite requires strategies to restore a healthy gut barrier and a focus on rebalancing the gut microbiome, but also involves interventions to address the mental health symptoms that can result from the parasite itself or as a consequence of the experience.

Case Study

A 34-year-old woman was referred by her infectious disease specialist for nutrition counseling due to continued GI complaints despite completion of parasitic treatment for giardia. In the months after completion of treatment, Jenna reported taking an anti-anxiety medication as well as over-the-counter laxatives and digestive relief products daily to help cope with her symptoms and while her anxiety did improve after parasite treatment, her continued symptoms were increasing her anxiety.

The patient had a history of polycystic ovarian syndrome (PCOS), attention deficit disorder (ADD), and acne, but also reported a personal and family history of autoimmune disease. She was born by cesarean section and was bottle-fed as an infant.

Prior to her parasitic infection, she had been following a ketogenic diet for one year and had lost 40 pounds, but quickly regained the weight after diet cessation. While she was not following any specific meal plan at the time of her initial assessment, she was avoiding regular soda and foods that seemed to make her symptoms worse, but she was also eating 50 to 75 percent of her meals out. She was taking stimulants, omeprazole, and birth control pills. Additionally, she had a reported a history of prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs) and proton pump inhibitors, as well as frequent antibiotic use.

My patient is 69 inches tall and initially weighed 251 pounds. She reported feeling bloated all the time and was suffering from foamy diarrhea, especially after eating fermented foods like sauerkraut. Her conventional testing including a hepatobiliary iminodiacetic acid (HIDA) scan, gastric emptying study, endoscopy, and a computed tomography (CT) scan of her abdomen and pelvis were all unremarkable.

Additionally, the patient was not sleeping well, had excess stress related to work and her health, and she wasn’t exercising due to stomach bloating. Her initial symptom score of 79 indicated severe symptoms, primarily related to poor digestion and anxiety.

I suspected increased intestinal permeability, dysbiosis, and stress as root causes of her symptoms, so the initial goals for this paient included:

• A full elimination diet for eight weeks excluding gluten, dairy, soy, red meat, pork, corn, chocolate, caffeine, inflammatory oils, food dyes and additives, peanuts, and shellfish
• At home stomach acid testing to determine adequacy of hydrochloric acid, however the patient was unable to complete this test
• Nutritional supplementation to include Vitamin D3 and K2, a probiotic, magnesium glycinate, L-glutamine powder, and vegetarian digestive enzymes
• Exercise to include the spin bike and/or walking for 10 minutes after every meal
• Sleep hygiene techniques to include getting in bed before 10:30 p.m.
• Stress management techniques to include a five-minute meditation twice per day in the early morning and at lunch time
• Comprehensive stool testing, which patient initially declined due to cost

After four weeks, the patient reported cooking all her own meals and she had lost 10 pounds, felt more energetic, and her skin was clearer. Sleep was still inadequate, but she was exercising at least five days per week and she was trying to be more consistent with the meditation. She stated her level of GI discomfort was “somewhat better,” but certain acidic foods still caused symptoms. Overall, she felt her bowel movements and premenstrual syndrome symptoms had improved. Her symptom score had gone from 79 to 22 indicating much improvement, but continued moderate symptoms.

Initial follow-up goals for the patient included:

• Continuation of the elimination diet for four more weeks
• Addition of one-half teaspoon cinnamon per day and one quarter cup walnuts per day to target suspected insulin resistance and PCOS
• Focus on at least seven hours of restful sleep per night
• Continue all previous goals and supplements
• Comprehensive stool testing and the GI Map was completed

After a total of eight weeks, my patient had lost a total of 20 pounds and reported having more energy, her stomach was pain-free, and the bloating was much improved. She was having one to two normal bowel movements daily and noted that she felt good overall.

The patient did well with the elimination diet but was consuming a lot of fruit and had been drinking diet soda. She had continued her exercise regimen, was trying to get in bed before 11:00 p.m., and had been meditating. Her symptom score was 24 indicating continued moderate symptoms. The results of her GI Map indicated no inflammation or parasites, but her pancreatic elastase was inadequate and she had an overgrowth of opportunistic bacteria, as well as high levels of bacteria common in those with autoimmune conditions.

Final follow-up goals for this patient included:

• Transition to an anti-inflammatory, low glycemic food plan moderate in healthy fat with the modifications including adding eliminated foods back in one at a time, but continue to be gluten, dairy, and refined carbohydrate free; eat a larger breakfast with smaller, more frequent meals thereafter; limit fruit to two servings per day; avoid soda of any kind, sparkling water given as an alternative; and eat good quality, fatty fish at least twice weekly.
• Digestive enzyme changed to an option appropriate for pancreatic enzyme insufficiency.
• Sodium butyrate added to fuel commensal bacteria.
• Multivitamin and chromium added to fill the gaps and to target PCOS.
• Continue magnesium, vitamin D3 and K2, and the probiotic.
• Lab work to include full thyroid panel including thyroid antibodies, vitamin D, fasting blood sugar, fasting insulin, HgbA1c, and triglycerides.

The patient said she plans to obtain the recommended lab work and states she is feeling better. Her anxiety and mood are much improved and she is no longer obsessed with her bowel movements.

While it can take time to repair and restore the gut after a parasitic infection, once the actual gut healing has been accomplished, patients can still struggle with the mental and emotional impact. Providing personalized nutrition and lifestyle-related strategies to target both GI symptoms and mental health can bring about complete healing.

References

Lipski, E. (2020). Digestive Wellness (5^th Ed.) McGraw Hill.

Jadallah, K. A., Nimri, L. F., & Ghanem, R. A. (2017). Protozoan parasites in irritable bowel syndrome: A case-control study. World journal of gastrointestinal pharmacology and therapeutics. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5680167/

U.S. Centers for Disease Control and Prevention. About Parasites. Retrieved from: https://www.cdc.gov/parasites/about.html

Editor’s note: This article was originally published on January 8, 2021.