Published July 11 2016
Many people with thyroid and autoimmune thyroid conditions have gut issues, and while I’ve spoken about conditions such as leaky gut syndrome and intestinal dysbiosis in past articles and posts, I wanted to put together an article which discussed some other common gastrointestinal conditions people experience. This article is going to focus specifically on irritable bowel syndrome and inflammatory bowel disease, the latter which includes Crohn’s disease and ulcerative colitis. I’m going to start off by talking about each of these conditions, and I will also discuss some of the methods of diagnosing these. As usual I will talk about how they relate to thyroid health, and I’ll wrap things up by discussing some natural treatment alternatives to these conditions.
So let’s go ahead and take a look at each of these gastrointestinal disorders:
Irritable Bowel Syndrome. Irritable bowel syndrome (IBS) affects 7% to 21% of the general population (1). The pathophysiology of IBS is not completely understood but it appears to involve genetics, the gut microbiome, immune activation, altered intestinal permeability, and brain-gut interactions (2). IBS is a gastrointestinal condition which includes symptoms such as abdominal pain, bloating, as well as constipation and/or diarrhea. Of these symptoms, lower abdominal pain is found in just about everyone with IBS, and so if you don’t have lower abdominal pain then chances are you don’t have IBS. Other symptoms can include weight loss, anemia, nausea, and vomiting (3). Conventional treatment options include antibiotics, tricylcic smooth muscle relaxants, antidepressants, SSRIs, and agents that modulate chloride channels and serotonin (3).
IBS is categorized into subgroups based on whether the person predominantly has constipation, diarrhea, or both (1) (4). These subgroups include IBS with diarrhea (IBS-D), IBS with constipation (IBS-C), and IBS with mixed or alternating diarrhea and constipation (IBS-M). Some of the factors which can lead to the development of IBS include a gut infection, and possibly the use of systemic antibiotics (5). But there can be other potential triggers as well.
The Relationship Between IBS and SIBO
IBS symptoms are triggered by the consumption of the poorly absorbed fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) and insoluble fiber (6). I’ve written a separate post on FODMAPs entitled “Should People With Thyroid Conditions Follow a low-FODMAP Diet?“. Having problems with foods high in FODMAPs is typically associated with having small intestinal bacterial overgrowth, also known as SIBO. In a healthy person there should be a small amount of bacteria in the small intestine, but with SIBO there is an excess of bacteria in the small intestine.
The presence of SIBO can usually be confirmed with a breath test that measures the amount of hydrogen and methane gas produced by bacteria in the small intestine. If a person tests positive for SIBO then the goal should be to get rid of the overgrowth of the small intestine, which can be challenging. Antibiotics such as Rifaximin are commonly used, and while they can be very effective, they of course don’t do anything to improve the gut environment. However, the same is true with natural anti-microbials, as while these also can help to eradicate SIBO, they don’t do anything to prevent the overgrowth from coming back. And so besides trying to get rid of the overgrowth, you might need to give the person digestive enzymes, betaine HCL, and perhaps more importantly, agents to help improve gut motility. This includes prokinetics such as D-Limonene, ginger, and there is also a prokinetic herbal product called Iberogast, which includes nine different herbal extracts. Low dose naltrexone can also be an effective prokinetic.
The Role of CdtB and Vinculin In Diagnosing IBS
While it has been known for a number of years that there is a correlation between IBS and SIBO, recently the pathophysiological mechanisms have been discovered. I learned this from Dr. Mark Pimentel, and he explains how acute gastroenteritis leads to the formation of Cytolethal Distending Toxin B (CdtB) antibodies. The presence of these antibodies leads to the immune system attacking vinculin, which results in destruction of the interstitial cells of Cajal (ICC), which is a type of cell in the gastrointestinal tract that are involved in the stimulation of smooth muscle cells. So essentially this involves an autoimmune response to vinculin, which causes damage to the ICC, and this in turn leads to problems with gut motility, and this poor motility is what causes bacterial overgrowth of the small intestine. The good news is that it is now possible to measure the antibodies to CdtB and vinculin, which can help to confirm the presence of IBS. You can find out more about testing for these markers by clicking here.
Inflammatory Bowel Disease (IBD). The two most common inflammatory bowel conditions include Crohn’s disease and ulcerative colitis. IBD affects an estimated 1.5 million Americans, 2.2 million people in Europe, and several hundred thousands more worldwide (7). The incidence of these inflammatory bowel disorders is increasing, and there is no clear etiology. Some of the common symptoms include abdominal pain, diarrhea, and weight loss. However, in all likelihood the cause is due to a combination of genetics and environmental factors, with gut dysbiosis being a key element in the initiation of inflammation in IBD (8). In IBD there can also be extraintestinal manifestations (symptoms not related to digestion), such as peripheral arthritis, oral lesions, episcleritis, and erythema nodosum (9).
Inflammatory Markers Associated With These Conditions
I’m not going to get into great detail about all of the different inflammatory markers, as if you are interested in learning more about this you can visit the blog post entitled “Breaking Down The Different Markers of Inflammation“. While general markers such as C-reactive protein (CRP) and ESR are commonly elevated in these conditions, other inflammatory markers can be better indicators of IBS or IBD. In the article I discussed on the different inflammatory markers, I spoke about fecal calprotectin and fecal lactoferrin.
Both of these are markers which can help to determine if someone has intestinal inflammation. And this is the advantage they have over markers such as CRP and ESR. In other words, if someone has an elevated CRP and/or ESR, this confirms that the person has inflammation, but it doesn’t specify the location of the inflammation. On the other hand, if someone has elevated fecal calprotectin or lactoferrin then this means they have intestinal inflammation. Although these markers might be high in IBS, they are frequently normal, but are usually high in IBD. And so if either of these are elevated there is a pretty good chance that you have intestinal inflammation, and possibly IBD, whereas if these both are negative then this essentially rules out IBD. Lysozyme is another marker that is commonly elevated in IBD, although it can also be elevated in other conditions as well. Eosinophil protein X is yet another marker that might confirm the presence of inflammatory bowel disease, and some sources suggest that it might be a better marker of low grade inflammation than some of the other markers I discussed.
How Do These Conditions Relate To Thyroid Health?
Is there any correlation between IBS or IBD and thyroid health? Well, in the literature there have been a few case reports which show a possible connection between thyroid autoimmunity and inflammatory bowel disease (10) (11) (12). However, a cohort study consisting of 162 patients with ulcerative colitis only showed that thyroid dysfunction was present in four patients (3 hypothyroid and one hyperthyroid) (13). Over the years I have seen patients with thyroid and autoimmune conditions who also had Crohn’s disease and ulcerative colitis, although I can’t say that I’ve seen a high percentage of my Graves’ Disease and Hashimoto’s patients with these inflammatory bowel conditions.
On the other hand, I have been seeing more and more people with SIBO, which as I mentioned earlier is associated with IBS. The research shows a greater prevalence of SIBO in those with hypothyroidism (14) (15), which makes sense since those with hypothyroid conditions are more likely to have impaired GI motility. However, I’ve also seen a number of patients with hyperthyroidism and Graves’ Disease have SIBO as well.
Natural Treatment Solutions For IBS and IBD
Regardless of the gut condition it is a good idea to incorporate the 4-R protocol, which includes the following:
1. Remove. This applies to both foods and pathogens. For example, if someone has a food sensitivity or intolerance then of course these foods should be removed. Many are sensitive to common allergens such as gluten and dairy, and earlier I mentioned how those with IBS will usually do better on a low FODMAP diet. With regards to pathogens, small intestinal bacterial overgrowth is associated with IBS, and so this needs to be addressed. I spoke more about treating SIBO in an article I wrote entitled “SIBO and Thyroid Health“. If someone has a different type of gut infection such as Candida, H. Pylori, or Blastocystis Hominis then of course this needs to be removed. Some of the common natural anti-microbials used to remove pathogens include oregano oil, berberine, black walnut, allicin, and olive leaf.
In addition, it’s also a good idea to do things to help remove inflammation. Of course removing any problematic foods or gut infections will help greatly with inflammation. However, you also might need to take some nutritional supplements or herbs to help modulate the inflammatory process. This includes EPA and DHA, vitamin D, turmeric, and ginger.
2. Replace. Some examples of things you would consider replacing include digestive enzymes, betaine HCL, bile acids, and dietary fiber. But how do you know if you need to replace these? Well, sometimes it can be challenging to know. I commonly give digestive enzymes to my patients, as you can’t always go by symptoms. However, if someone has a moderate to severe deficiency of pancreatic enzymes they will commonly experience digestive problems such as bloating or gas a few hours after eating. On the other hand, if someone has a deficiency of betaine HCL they frequently will have a sense of fullness right after meals. Problems with bile metabolism will usually result in problems breaking down fats, and I spoke more about this in a past blog post entitled “The Importance of Bile In Thyroid Health”.
There is also a marker called pancreatic elastase, which is a pretty good marker for determining if someone has moderate to severe pancreatic insufficiency and therefore needs to take digestive enzymes. There are tests to determine if someone has a deficiency of gastric acid, such as the Heidelberg test, although doing a betaine HCL challenge test is another option, as this involves taking small doses of betaine HCL and gradually increasing it until you experience mild heartburn, and then backing off.
Those with SIBO have problems with the migrating motor complex (MMC), which affects gut motility, and this can be a big factor in the development of this condition. Earlier I mentioned a few different prokinetics which can help, including D-limonene, ginger, Iberogast, and low dose naltrexone.
3. Reinoculate. This involves taking prebiotics and probiotics. And while I do recommend for most of my patients to take a probiotic supplement, it also is a good idea to get both prebiotics and probiotics through the diet. However, this can be problematic with many people who have IBS. For example, fermented foods such as sauerkraut and kimchi are excellent sources of probiotics, but they are high FODMAP foods, and thus won’t be tolerated by most people who have IBS. Some of these people are able to take a probiotic supplement without a problem, although others won’t be able to tolerate probiotic supplements. Some prebiotic foods include asparagus, Jerusalem artichokes, and onions, although these foods won’t be tolerated by some people with IBS.
4. Repair. Since many people with these conditions have a compromised intestinal barrier, also known as a leaky gut, doing things to repair the gut is important. This includes eating foods such as bone broth and cabbage juice, and taking nutrients and herbs such as L-glutamine, zinc, vitamin A, and slippery elm.
By the way, the Institute for Functional Medicine now refers to this as the “5-R protocol”, with the “fifth R” standing for “Rebalance” through mind body medicine techniques, getting proper sleep, etc. For more information on the 4-R protocol I would read the blog post I wrote entitled “Thyroid Autoimmunity, Leaky Gut Syndrome, and the 4R Protocol“. And of course everyone should do some rebalancing as well!
In summary, many people with thyroid and autoimmune thyroid conditions have gut issues. With regards to inflammatory bowel disease, some evidence suggests that ulcerative colitis is more common in thyroid autoimmunity, although other studies dispute this. On the other hand, SIBO is associated with IBS, and the research does show a greater prevalence of SIBO with those who have hypothyroidism. I also have seen this in my patients, although I’ve also had some patients with Graves’ Disease test positive for SIBO. With regards to testing, measuring the antibodies to CdtB and vinculin can confirm if someone has IBS. Elevated inflammatory markers such as calprotectin and lactoferrin are commonly high in IBD, and are usually not elevated in IBS. As for addressing these conditions, I recommend implementing the 5-R protocol for most gut conditions, including IBD and IBS.