Look before you leak
The internet’s snake-oil salesmen have whipped an unproven hypothesis called Leaky Gut into a profitable yet futile diagnosis, but I strongly suggest that you study the science first.
The ever-increasing access to information has had a dramatic influence upon how we perceive our health problems, whether or not we ask for help — and, perhaps most concerning, the kind of help we seek.
A multitude of self-styled experts are out there for you to find on the internet, but fortunately Bermudians tend to be sensible and level-headed, appreciating the value of fact-based, regulated science. It has, after all, served us and our families consistently well.
Admittedly, your doctor’s investigations into your issues can sometimes appear labyrinthine and cautious.
Wouldn’t it be so much simpler if we could immediately distill your concerns into a trendy catchphrase?
And on the tip of the tongues of many patients I have seen recently has been a particularly catchy phrase by the name of Leaky Gut.
Wouldn’t it be a blessing for both doctor and patient if I could just say “Ah, yes, of course! Leaky Gut!”, and duly scribble an appropriate prescription?
But, as with so many other aspects of life in this information age, it’s complicated, and it pays to be extremely cautious. As that saying goes: “Fools rush in where angels fear to tread.”
So, my angelic readers, what exactly is this Leaky Gut and why should we be so careful? Take a deep breath because it requires serious and detailed explanation.
It would seem logical to assume that you have a food-induced problem if, after eating, you feel bloated, distended, uncomfortable or in actual pain — or even have diarrhoea.
However, those symptoms may be caused by a large and diverse range of issues.
The root could be organic — meaning some kind of damage to the structure of the relevant organ or organs.
Or it could be what we term functional in nature — meaning no inflammation or damage, bur rather an issue with the way your gut “moves” and “talks” to your brain.
For the suitably trained physician, distinguishing between organic and functional disease does not necessarily require extensive or expensive investigation.
The never-ending accumulation of science, statistics and experience — combined with taking the time to truly listen to what you say and feel — guides us towards the diagnosis.
If it were just about ticking boxes from a list on Google or doing a multiple-choice test, our life would be a lot simpler, but you would most likely get the wrong diagnosis.
And if Google, or a friend or work colleague or whichever source has made you think you have Leaky Gut, this is what you should know …
First, it isn’t in Gray’s Anatomy — the doctors’ bible, that is, not the TV series! Leaky Gut is a lay term describing a possibility based on observations of gut permeability in animal models — for instance, the microscopic study of rats’ small bowels after they have been exposed to drugs and euthanised. I used the above italics to emphasise a crucial point:
Leaky Gut is an unproven concept, and not, repeat not, a diagnosis.
In more technical terms, it describes a “damaged gut barrier” or “intestinal barrier dysfunction”. You see, a single gut-surface layer along the small and large intestinal mucosa allows for vital absorbing functions to coexist with defence against an immense variety of food and bacteria. Inflammatory, allergic or metabolic conditions or surgery can disturb this barrier and cause symptoms.
However, in the absence of structural damage, this possibility has still to be validated. There are a few studies raising the possibility that barrier dysfunction and increased cell death could occur in the earlier-mentioned functional disease, but this remains very preliminary and cannot yet be used in clinical practice.
Conditions that can cause disruption of the gut barrier are acute infections, autoimmune damage, intestinal failure, radiation enteropathy, Celiac disease and small intestinal bacterial overgrowth.
So, if you have diarrhoea, weight loss, delayed development or anaemia, you may have malabsorption, and this can be related to different structural damage caused by any or all the above diseases — and more. Malabsorption may be linked to lack of micronutrients such as iron and folate in patients with Celiac disease, or macronutrients such as fat and protein in conditions like chronic pancreatitis. Therefore, one must have nutritional deficiencies if malabsorption is present.
For instance, patients with inflammatory bowel disease like ulcerative colitis and Crohn’s have degrees of impaired intestinal permeability owing to inflammation and “damaged gut barrier”. In those circumstances, increased permeability correlates with increasingly severe diarrhoea.
However, if you do not have malabsorption or structural damage related to inflammatory bowel disease or other organic disease, you may have a functional gastrointestinal disorder, or a disorder of the gut-brain interaction. These are gastrointestinal disorders that happen without any structural damage of the gut; there will be no abnormal X-ray results or laboratory findings to explain the symptoms. They occur because of altered sensitivity to nerve impulses in the gut and brain, and they aren’t associated with altered motility in the intestines.
FGIDs can cause symptoms ranging from heartburn, chest pain, vomiting, bloating, burping, excessive gas, abdominal distention, diarrhoea or constipation, to pain associated with diarrhoea and/or constipation — usually called irritable bowel syndrome.
There is another, thankfully less common condition of chronic or frequently recurring abdominal pain that isn’t associated with changes in bowel pattern or other conditions.
Called Caps, for centrally mediated abdominal pain syndrome, it has little or no relationship with events such as eating, defecation or menstruation. But the pain can be so all-consuming and devastating that it takes over your life.
How the body actually experiences the debilitating sensations of functional gastrointestinal disorders is instructive. Nerve impulses travel from the abdomen to the spinal cord, and then to the brain. Many different areas of the brain sense abdominal pain or discomfort. One is concerned with the location and intensity of the pain, or sensitivity to any stimulation, while another processes memories or emotions. So, because of this interconnection, the perception of pain or discomfort can be affected by emotions or life experience.
While symptoms of functional disorder can appear without apparent cause, they can also occur after traumatic events such as the death of a loved one, a divorce or a history of abuse. And during times of added stress, symptoms can worsen.
Repeated injury in the abdomen can cause nerve receptors to become overly sensitive. For instance, if someone has had multiple abdominal surgeries or infections, a later painful occurrence may feel even worse than before. Even normal abdominal activity may come to be experienced as painful. It is as if the volume has been turned up deafeningly loud on a radio. This condition is called visceral hypersensitivity.
Although the brain is also able to "turn down" those pain signals from the gastrointestinal tract, this ability is reduced in people with functional disease. So even small amounts of intestinal disturbance can be amplified to produce severe pain or discomfort (central hypersensitivity). This altered "brain-gut axis" is a failure of the brain to regulate even normal gut-nerve activity, leading to increased pain or discomfort.
Understanding how the brain can modify the pain experience — for better or worse — is essential to beginning any treatment. When someone is feeling anxious or depressed, or focusing attention on the pain, it feels more severe. Likewise, if there was a previous bad encounter with pain, the fear of recurrence can actually make it worse next time. But if a person takes steps to feel in greater control of the pain, symptoms really can improve. Relaxation training and other techniques divert attention away from the pain, as does support from family, friends and others.
And that, my dear readers and patients, is the merest glimpse of the science surrounding the so-called Leaky Gut issue. If you have reached this far, congratulations. It is undeniably complex, and there is simply no other honest or accurate way of appreciating it.
I wouldn’t dare suggest that you ignore all those pseudo-scientific internet articles designed to encourage the purchase of everything from how-to books to probiotic supplements to herbal remedies to “special” diets, such as gluten-free, low sugar and anti-fungal. But please take a healthy dose of scepticism beforehand!
There are some excellent and reliable sites, too, such as the International Foundation for Functional Gastrointestinal Disorders at www.iffgd.org.
Meanwhile, please always remember that we are blessed in Bermuda to have the qualified people and appropriate technology to detect and help. If anything above resonates with you, as a first step your GP definitely should hear.
• Suraia Boaventura Barclay, MD, is a Fellow of the American Gastroenterological Association, and is on its International Education sub-committee. She got her MD from the Federal University of Bahia, Brazil. After postgraduate study at the University Hospital Eppendorf, Hamburg, under the world-renowned professor Nib Soehendra, she was awarded her Doctorate in Clinical Gastroenterology