Pictured: Something you might need if you actually had a leaky gut.  Click to embiggen.  Weirdo.

Pictured: Something you might need if you actually had a leaky gut. Click to embiggen. Weirdo.

We are at a disadvantage. We have to rely on reality to validate the practice of medicine. Anatomy, physiology, pharmacology, chemistry, the basic sciences that made up the first two years of medical school education and a huge chunk of pre-med. And we have to rely on the truth, as slippery a concept as that can be. I can’t just make up a disease or a therapy.

It would be so much easier to not have to worry about reality in deciding on a disease and treatment for people with symptoms.

I came across “Healthy Life: Leaky Gut Syndrome” in my feeds. I am always attracted to exclamation marks! They must mean something important! Or surprising to the author!

It’s called “leaky gut syndrome” and patients say it can wreak havoc on everyday life, but some doctors say there’s no such thing!

Some doctors. Must be that pesky 10% percent or so of obstructionist doctors who don’t recommend Tylenol or Advil.

Judging from PubMed, if you are going to rely on reality and science as your basis for the diagnosis for leaky gut syndrome, it would be more accurate to say that because of an almost complete lack of supporting basic science and few therapeutic clinical trials showing no effect, virtually no physician who has an understanding of the gastrointestinal physiology gives the disease credence.

Which is why is Leaky Gut a disease diagnosed and treated by naturopaths.

A household name in the ND world. Exclamation mark.

If leaky bowel is treated at The Center for Integrative Medicine of the Cleveland Clinic and promoted by Dr. Oz you know there is little legitimacy. The company you keep, birds of a feather, and all that.

What is leaky gut syndrome? The theory is that tight junctions of the bowel break down and food “wiggles though” into the blood stream and interacts with the immune system. Rather than being exposed to its elemental components, the immune system is presented with large chunks of undigested foie gras, Twinkies, Jiff (objectively the best peanut butter) and beer (am I over sharing?) as well as bacteria, parasites and, of course, toxins. These substances then interact with the immune system in dysfunctional ways to cause a host of symptoms and diseases, from diabetes to multiple sclerosis to autism.

Alterations in intestinal permeability can occur in patients with inflammatory bowel disease, sprue and other diseases. But as is often the case in pseudo-medicines the concept is used with less-than-perfect accuracy until:

The topic is further confused by use of the term “leaky gut syndrome” within the lay and alternative medicine communities, and even by some physicians, and claims that this is responsible for a dizzying array of disorders, including chronic fatigue syndrome, fibromyalgia, allergies, depression, and skin disorders.

The diagnosis is made on the basis of a variety of non- specific symptoms and occasionally as a lactulose-mannose assay:

Remarkably, several internet vendors promoting leaky gut syndrome treatments also provide mail-order lactulose-mannitol assays. Thus, patients may arrive with their own lactulose:mannitol data.

Remarkably. I had to smile. Occasionally real physicians wander into the morass that is alternative diagnosis and treatment and are shocked, shocked, to find inadequate medical diagnosis and treatment. Louie would certainly understand.

Leaky gut is treated with the 4 Rs (a perfect therapy for Talk like a Pirate day):

Remove certain foods. Replace with digestive enzymes. Re-inoculate using a high dose of probiotics and Repair with glutamine

All of these interventions are without good support in the scientific literature or clinical trials that I could find. Glutamine to treat leaky bowel, as an example, has zero hits for clinical trials. Not even a bad case report or series in a low impact journal. For SCAMs that is remarkable. Usually there is at least a horribly done clinical trial or some case reports to support pseudo-medical interventions. I have been looking at SCAMs for years and it is rare to find so little supporting information for a therapy.

…the leaky gut cures being sold at a variety of internet sites and alternative medicine stores should be considered with caution. None have been tested in randomized clinical trials, and they may do more harm than good.

As is noted:

Leaky gut symptoms aren’t unique. They’re shared by other problems, too. And tests often fail to uncover a definite cause of the problem. That can leave people without a diagnosis and, therefore, untreated.

It’s crucial, Kirby says, to find a doctor who will take time with you and take your concerns seriously.

Take your concerns seriously, yes, but not necessary agree with the diagnosis of leaky gut.

As I have mentioned in the past, I never deny that a patient is suffering or claim that their suffering is not real. I am also not a fan of psychosomatic illness, although I have no doubt that the there is some interaction between the brain and a variety of symptoms.

Still, I wonder if patients who seek care from pseudo-medicine providers respond differently to their symptoms. It has always been curious to see how people with ostensibly-identical illnesses respond differently.

Perhaps those seeking care for their leaky gut and other pseudo-diagnoses are different, but not with their gut.

IM (Integrative Medicine) patients reported higher levels of perceived stress, pain, and depressive symptoms, and lower levels of quality of life compared with national norms. Per provider reports, 60% of patients had at least one of the following: stress (9.3%), fatigue (10.2%), anxiety (7.7%), depression (7.2%), and/or sleep disorders (4.8%). Pain, having both physiological and psychological components, was also included and is the most common condition treated at IM clinics.

And how much of these diseases are taught to the patient by both the culture and the pseudo-medical provider? Is leaky gut or chronic Lyme and response to therapy partially a learned response? I came across a recent a PLOS-ONE article “Multi-Acupuncture Point Injections and Their Anatomical Study in Relation to Neck and Shoulder Pain Syndrome (So-Called Katakori) in Japan.”

Katakori is a symptom name that is unique to Japan, and refers to myofascial pain syndrome-like clinical signs in the shoulder girdle.

Katakori is a culture-bound syndrome. There are quite a few other culture-bound syndromes, ranging from fan death to koro to bouffée délirante. People may have unique reactions to stress and other symptoms that are culturally determined and approved.

One of the constant topics of discussion is why these pseudo-medical diagnoses and treatment persist despite a lack of scientific validation. If you put “culture-bound syndrome” into Pubmed there is very little concerning US culture-bound syndromes, the references mostly concern the process in immigrants to the US. But there is no reason the US should not have its own culture-bound syndromes.

To quote the Wikipedia:

A culture-specific syndrome is characterized by:

  1. categorization as a disease in the culture (i.e., not a voluntary behavior or false claim);
  2. widespread familiarity in the culture;
  3. complete lack of familiarity or misunderstanding of the condition to people in other cultures;
  4. no objectively demonstrable biochemical or tissue abnormalities (signs);
  5. the condition is usually recognized and treated by the folk medicine of the culture.

and

The term culture-bound syndrome denotes recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered to be “illnesses,” or at least afflictions, and most have local names. Although presentations conforming to the major DSM-IV categories can be found throughout the world, the particular symptoms, course, and social response are very often influenced by local cultural factors. In contrast, culture-bound syndromes are generally limited to specific societies or culture areas and are localized, folk, diagnostic categories that frame coherent meanings for certain repetitive, patterned, and troubling sets of experiences and observations.

Sound familiar? Chronic Candida, chromic Lyme, leaky bowel, gluten sensitivity, electromagnetic sensitively and many of the syndromes covered by this blog would seem to meet the definition, and are perhaps a good conceptual framework for understanding these processes. I’ll leave that to the anthropologists and psychologists to sort out. This is Science-Based medicine after all, but it is fun to participate in some wild-ass speculation now and then.

Self-aggrandizement

For those of you who were unable to make it NECSS in April, there are now three videos featuring SBM speakers available for your entertainment. I am competitive as all get out and want these videos to be the most watched from NECSS. Get to work.

More videos to come.

 

 

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.

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