Inflammatory Bowel Disease with Dr. Ilana Gurevich: Rational Wellness Podcast 126
Podcast: Play in new window | Download | Embed
Subscribe: RSS
Dr. Ilana Gurevich discusses Inflammatory Bowel Disease with Dr. Ben Weitz.
[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]
Podcast Highlights
3:25 When Dr. Gurevich sees a patient with extensive GI pain and there is no frank blood, then she starts to consider the possibility of Inflammatory Bowel Ddisease. Other symptoms include anemia, nutritional deficiencies, thin, cachexic frame, and having many bowel movements with diarrhea and often containing blood, would all indicate inflammatory bowel disease like Crohn’s disease. Dr. Gurevich pointed out that patients with Crohn’s disease are at risk for obstructions, which is basically an acute abdomen that can present suddenly with a 14 out of 10 pain and often requiring hospitalization and surgery. She explained that 80% of all Crohn’s disease patients have some kind of terminal ileum involvement. With Crohn’s disease you can get a shrinking or narrowing of the lumen and eventually that narrowing can become so small that it becomes completely obstructed. Some Crohn’s patients are living with a partial obstruction where if they eat too much they can get into an acute flare of abdominal pain. Such patients can also develop strictures, which are little pieces of narrowing or thinning of the intestinal lumen and that can also lead to an obstruction. Such patients often require surgery eventually.
6:10 When Dr. Gurevich has a patient she suspects of having inflammatory bowel disease she will get a stool fecal calprotectin, which is a measure of white blood cells or neutrophils that are localized within the intestine. It is very predictive for ulcerative colitis–almost 98% predictive for ulcerative colitis, and it is somewhere between 30 and 90% predictive for Crohn’s disease. Dr. Gurevich said that with fecal calprotectin, under 50 is negative. Between 50 and 120 is borderline and over 120 is positive. Lactoferrin is another inflammatory marker that can be run as part of a stool test. For Crohn’s disease, you can look at inflammatory markers in serum, like SED rate and HsCRP.
9:39 Dr. Gurevich said that her other favorite test for monitoring patients with Crohn’s Disease is the Prometheus Labs Monitr Crohn’s Disease test that measure 13 biomarkers for mucosal healing status. It is considered 92% specific and 98% sensitive for Crohn’s Disease. Prometheus also offers the IBD sgi Diagnostic which differentiates Crohn’s from Ulcerative Colitis. Dr. Gurevich also likes to run a GI Map stool test to look for protozoans, pathogenic bacteria, fungus, and parasites. It also looks at inflammatory markers. Sometimes she will also look at food intolerances.
11:29 From a Functional Medicine perspective, we want to review their history in detail to find some of the underlying triggers, such as hormones, dysbiosis, stress, etc.
12:41 A scarred or open iliocecal valve can increase the risk of SIBO in patients with IBD. Dr. Gurevich will sometimes see patients having a flare and she will do a SIBO breath test and discover that they have IBS/SIBO and after she treats the SIBO, their IBD improves. She finds that a lot of her IBD patients end up with SIBO as well. 80% of Crohn’s patients have a some involvement of the terminal ileum and tend to get scarring or sclerosis of the terminal ileum and this often affects the ileocecal valve. This will lead to regurgitation of bacteria from the large intestine up into the small intestine leading to bacterial overgrowth leading to more inflammation.
17:17 Dr. Gurevich will sometimes use naturopathic manual techniques to close the ileocecal valve, though it doesn’t work well if there is scarring. For patients with strictures she often uses N-acetyl glucosamine because there was on study showing that it benefited such patients. She tends to use ozone for her inflammatory bowel disease patients. The goal is treat these patients aggressively so they never develop the strictures, but sometimes once they do, surgery is often the only option.
21:02 Besides SIBO, other common co-infections in patients with Inflammatory Bowel Disease are parasites and protozoa. Protozoa are often labelled on stool panels as commensals [meaning good], but Dr. Gurevich does not believe that protozoa are commensal. Helminth therapy could be effective in IBD, but it usually takes 6 months for it to be effective, according to Dr. Gurevich, so they will not help if the patient is having an acute flare.
22:38 When Inflammatory Bowel Disease patients are having an acute flare of their pain, Dr. Gurevich usually starts with diet. She likes to use the Specific Carbohydrate Diet, which is the most studied for IBD and it really meat heavy and excludes all grains and legumes, similar to paleo. There is also a semi-vegetarian Crohn’s diet, which has no meat and is heavy on grains. She will usually start with one of these two diets. Dr. Gurevich finds that her most effective treatment modality is rectal ozone, which can get some amazing results. When they are having an acute flare, they have so much reactive oxygen species, or O1s, and ozone is O3, which combines with all the O1s and renders them all into stable O2. Rectal ozone is very uncomfortable because you are shoving a bunch of gas up them and they will likely feel bloated and crampy for the rest of the day and they may have really intense bowel movements. But Dr. Gurevich said that she is able to get 70% of her IBD patients out of an acute flare up. She does find Elemental diet can also be very helpful, though by day 7, it gets tough to stomach it. L-Glutamine can also be very effective, but an effective dosage for an average 130 woman is about 27 gms per day–9 gms 3 times per day. Saccharomyces boulardii probiotics have also been shown to be helpful. For ulcerative colitis and especially for ulcerative proctitis, Dr. Gureviuch will use high dose vitamin E rectally.
29:38 Biologics are immunosuppressant drugs like Humira, Remicade, and Cimzia that block part of the immune system to reduce the immunological attack on the intestinal lining in Inflammatory Bowel Disease, like Crohn’s and Ulcerative Colitis. These drugs are TNF alpha blockers. There are two new drugs, Intyvio and Stelara, that also block part of the immune system, but work via different mechanisms. Stelara blocks Interleukin 12 and Interluekin 23. Dr. Gurevich said that while biologic drugs are not perfect drugs and can have serious side effects, if a patient is well controlled with their IBD while taking a biologic and does not have significant side effects, you should most likely not take the patient off the medication. If they have been taking a biologic and then stop it, the immune is more likely to form a reaction to the medication and if they go into another flare, then then they will no longer be able to take that drug or other drugs in that category. Considering how severe Inflammatory Bowel Disease is, we should be very cautious to remove a medication that is working well.
36:25 Dr. Gurevich may look for food sensitivites with the Carol Food Intolerance Test, which is an energetic based diet created by Dr. Carol in the 1920s and taught in some west coast Naturopathic schools. Dr. Gurevich has found this method of determining food sensitivities very helpful, though she admits there is little scientific validation of it. She finds standard IgG food sensitivity panels futile since virtually all of her patients have increased intestinal permeability.
Dr. Ilana Gurevich is a board-certified naturopathic physician and acupuncturist and is currently co-owner of two large integrative medical clinics, one in northwest Portland and one in northeast Portland. She runs a very busy private practice specializing in treating inflammatory bowel disease as well as IBS/SIBO and functional GI disorders. She lectures extensively and teaches about both conventional and natural treatments for inflammatory bowel disease as well as SIBO. She is one of the foremost experts on the intersection of IBD and IBS and how treating one resolves the other. She can be contacted through her website, naturopathicgastro.com
Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.
Podcast Transcript
Dr. Weitz: This is Dr. Ben Weitz with The Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition, from the latest scientific research and by interviewing the top experts in the field. Pre-subscribe to Rational Wellness Podcast on iTunes and YouTube and sign up for my free e-book on my website by going to drweitz.com. Let’s get started on your road to better health.
Hello, Rational Wellness Podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to The Rational Wellness Podcast, please go to Apple Podcasts and give us a ratings and review. That way, more people can find out about The Rational Wellness Podcast. Also, you can go to the YouTube page and there’s a video version there, and if you go to my website, drweitz.com, you can get complete show notes and full transcript.
Our topic for today is inflammatory bowel disorders, of which Crohn’s Disease and ulcerative colitis are the most common conditions. There are also a few less common inflammatory bowel conditions, including microscopic colitis, which can only be identified upon biopsy of the intestinal wall. Inflammatory bowel disease is characterized by chronic inflammation of the gastrointestinal tract that leads to damage to the mucosal lining of this digestive tract. Crohn’s disease can affect any part of the GI tract, including the mouth, esophagus, stomach and the anus, but it most often affects the portion of the small intestine closest to the large intestine and there tends to be patchy areas of damage and the damage may reach through multiple layers of the intestinal wall. Ulcerative colitis occurs only in the large intestine and the rectum. Damaged areas tend to be continuous and usually start in the rectum and spread into the colon and is usually present only in the innermost lining of the colon.
Symptoms of inflammatory bowel disorders include persistent diarrhea, abdominal pain and cramping, bloody stools, weight loss, fatigue, among others. Anemia and other nutritional deficiencies are common. The main stays of conventional medical treatment include immuno suppressive drugs like prednisone and biologics like Humira and Remicade and surgical resection in severe cases. Dr. Ilana Gurevich is a board certified naturopathic physician and acupuncturist and is currently co-owner of two large integrative medical clinics, one in northwest Portland and one in northeast Portland. She runs a very busy private practice, specializing in treating inflammatory bowel disease as well as IBS, SIBO and functional GI disorders. She lectures extensively and teaches about both conventional and natural treatments for inflammatory bowel disease as well as SIBO. Dr. Gurevich, thank you so much for joining me.
Dr. Gurevich: Thank you so much for having me.
Dr. Weitz: Excellent. When you get a patient in your office, what makes you suspect them as having inflammatory bowel disorder?
Dr. Gurevich: At this point, my practice is really, really specialized so I’m only seeing GI based disorders and there’s a certain subset of symptoms and when you rule out if they’re having frank blood, if they’re having extensive pain, if they’re having nutritional deficiencies, anemia is one of the most common things I see, if they’re cachexic, well below a normal healthy weight, then you’re always thinking inflammatory bowel disease. It can sometimes present with constipation but that’s much more rare and then the other things you’re generally looking at, with ulcerative colitis, you’re looking for bleeding. Ulcerative colitis patients have, depending on their severity, some are between five and 30 bowel movements a day, a lot of those bowel movements are just blood or blood and mucus. Crohn’s disease presents significantly more with pain, really intense acute abdominal pain, and Crohn’s disease patients are at risk for obstructions, which is basically an acute abdomen that can present really out of nowhere and all of a sudden they have 14 out of 10 pain and they have to be hospitalized and then they have to go in for emergency surgery to resect.
Dr. Weitz: What happens when they get that obstruction?
Dr. Gurevich: Generally speaking, the only way to get through out of a complete obstruction is to surgically remove that part of the obstruction. If it’s a harsh-
Dr. Weitz: What exactly’s happening anatomically in that case?
Dr. Gurevich: 80% of all Crohn’s disease patients have some kind of terminal ileum involvement. The terminal ileum is the bottom of the intestine and the ileocecal valve is right there. That part can … Crohn’s disease, what happens with it, is you get this shrinking or narrowing of the lumen and eventually that narrowing gets so small that it’s completely obstructed. That then is the surgical emergency. There are lots of Crohn’s patients that are living with a partial obstruction, where all of a sudden they eat just a little bit too much or they eat something they’re not supposed to and they get into this acute abdominal pain, they start vomiting because you can’t push it through the intestinal tract so it comes back up and then it kind of passes and they slow down their eating and then they can kind of live this not very full life, where food is really well controlled or has to be really specifically controlled not to flare.
They can also develop strictures. Strictures are these little pieces of narrowing or thinning of the intestinal lumen and that also leads to an obstruction and a stricture … Where partial obstructions can sometimes be inflammatory tissue, it can also sometimes be scar tissue, and strictures are much more commonly to be scar tissue so biologic agents or steroids don’t always work to respond to these strictures to decrease the narrowing and so, for a lot of these patients, surgery is really … They’re just on a surgery track.
Dr. Weitz: Wow. How do you work these patients up?
Dr. Gurevich: The thing about inflammatory bowel disease is the GI’s a really, really complicated organ and it controls … We know that the majority of your neuro transmitters in your brain are actually made in your intestinal lumen, so hormones play a part. We know that if you have food poisoning, that actually upregulates your likelihood of developing inflammatory bowel disease. We know that if you take antibiotics, within six months you have a significantly higher likelihood of developing Crohn’s disease. We know that parasites and protozoa can trigger these kind of inflammatory responses. They can also sometimes be treatment for these inflammatory responses but sometimes they can trigger these diseases. Anything that you put into your GI track so pesticides, food coloring, preservatives, processed food that your body doesn’t react to, can cause this subacute or acute inflammatory reaction, which then puts them on a track for inflammatory bowel disease. And the likelihood of developing inflammatory bowel disease is actually on the up. We see an increase in Western cultures, we see a huge increase in cultures that never had inflammatory bowel disease that are taking up a Western diet and lifestyle, and then we see increasing amounts in just heavily medicated populations.
Dr. Weitz: Another aspect of the benefits of spreading American culture around the world.
Dr. Gurevich: Lucky us. Yep.
Dr. Weitz: What kind of testing do you do for these patients? Colonoscopy and endoscopy, of course, right?
Dr. Gurevich: That’s the gold standard. When a patient comes in to see me and if they haven’t been diagnosed, one of the first things I’ll do is a stool fecal calprotectin. This is a stool collection that’s looking for the amount of white blood cells or neutrophils that are localized within the intestine. It is very, very, very predictive for ulcerative colitis, almost 98% predictive for ulcerative colitis. It is somewhere between 30 and 90% predictive for Crohn’s disease. I think that is partially because a lot of Crohn’s patients don’t have any disease in their large intestine, they’re really just localized to their small bowel or upper GI. Those patients are not going to be great testing subjects for calprotectin. Lactoferrin is another test that we can do. For Crohn’s disease, you can look at inflammatory markers like a SED rate or a HsCRP, High Specific CRP, or also a regular CRP. The literature is a little bit mixed about which one is a better test for IBD. And then once you have a diagnosis, then-
Dr. Weitz: By the way, on a fecal calprotectin, what’s the cut off value?
Dr. Gurevich: 50 or under is negative. If you’re between 50 and 120, you’re considered borderline, and then you’re supposed to retest in six weeks. If you’re over that, then you’re considered positive and depending on how high over that you are, that’s how significant the inflammation is, with the exception of ulcerative proctitis. Ulcerative proctitis is an ulcerative colitis that is only at the bottom part of the intestinal tract and those patients just have really, really high calprotectins because all of the white blood cells are right there. We’re collecting the stool that’s right there so you’ll often see the calprotectins for these patients in the thousands and that doesn’t necessarily talk about severity of their disease. It just talks about location and the fact that we can find them really easily.
Dr. Weitz: Okay.
Dr. Gurevich: And then my other favorite test right now, actually for monitoring, for Crohn’s disease patients, is Prometheus Labs has recently come out with something called a Crohn’s monitor score, which is a blood test, which anybody who treats IBD … Patients complain about the fact that they have to collect their poop, which is gross, and then carry their poop in their purse, which is gross, to drop it off at the lab. This is a blood test, they don’t need fasting, it takes 13 separate bio markers and it’s actually considered … I think it’s 92% specific, 98% sensitive, for Crohn’s disease, which is … That’s better than a calprotectin.
Dr. Weitz: Yeah, cool.
Dr. Gurevich: Yeah and so that’s what I’ve been using now for monitoring.
Dr. Weitz: Prometheus Labs.
Dr. Gurevich: Mm-hmm. And they’re the ones … All IBD patients know them because they’re the ones who have the Crohn’s blood test to differentiate Crohn’s and ulcerative colitis. They’re also the ones that have the blood test that looks at biologic levels to see if you’re within ranges, if the drug is working effectively, and so they’re a standard lab and so that is generally my standard workup. My Functional Medicine or naturopathic workup includes stool testing for Protozoa and parasites. I’m using DNA stool testing now. It’s stool testing for inflammatory markers in the small bowel. Zonulin is one that I use a lot, even though I think literature’s a little bit mixed on it. I’m also sometimes looking at food allergies and food intolerances, not always, but sometimes, and then … What else is my workup?
Dr. Weitz: For the stool test, I think I heard you say that you’re using GI Map now?
Dr. Gurevich: Mm-hmm, that’s my favorite right now. I think that the DNA PCR is like a game changer, actually.
Dr. Weitz: Right. Cool. How do you apply a functional medicine approach to these patients?
Dr. Gurevich: I think it all comes down to the history. These people, they were not born with inflammatory bowel disease, something happened to have them develop it, and so you’re kind of figuring out when they started feeling bad, how long they felt bad, how many workups did they go through, and then based on that, you’re coming up with, ‘Okay, I think that this is a really hormonally mediated inflammatory bowel disease. We’re going to really focus on the hormones.’ Or, ‘Oh, this is a clear cut, you were over medicated, you took too many antibiotics. This is clearly a microbiome disorder and so we have to focus on that.’ Or, a lot of patients, stress is one of the things that could definitely trigger one of these acute attacks and so how are they mitigating their stress? I have patients time and again who are so well controlled. I’m running calprotectins on them every three months, I’m running Crohn’s monitor on them every three months, they’re so well controlled, and then all of a sudden a stressful event occurs and we lose control. Those people, we’re all talking about the lifestyle, are they getting counseling? How are they dealing with their stress triggers? And so, every patient’s kind of their own individual and you have to figure out why this person has inflammatory bowel disease.
Dr. Weitz: Right. I heard you speak with Dr. Narala Jacobi on her podcast last year and you mentioned that you will often see a scarred and/or open ileocecal valve and that this can play a role in increasing their symptoms by increasing the risk of SIBO in these patients. And I spoke to Dr. Pimentel a few months ago and he did not feel like the ileocecal valve plays much of a role in IBS patients. He really focuses on motility as the key cause of SIBO and when I was talking to him, he said that even patients who have had their ileocecal valve resected, removed, do not necessarily have SIBO as long as they have good intestinal motility.
Dr. Gurevich: I’ve spoken to Dr. Pimentel. I really respect the work that he did. I feel like if his theory on bacterial overgrowth holds true, it’s like a game changer. However, I feel like a lot of his research is really structured in the fact that he is trying to differentiate IBS from IBD. If you look at all of his stats and all of his slides, he’s basically like, ‘We see this in IBD people, we don’t see this in IBS people, but we see this in IBS people and we don’t see this in IBD people.’ And I have to tell you, from what I’ve read in the literature, I just don’t think that holds up. I think that what I’m seeing now, … There was this one study in 2009 that really, really old study, before I think even Pimentel started teaching, I think he was publishing a little bit then, talks about how IBS is often one of these misunderlying causes of IBD and I see this all of the time, where you see these people and you’re like, “Okay, you’re clearly in a flare, you’re in a lot of pain, you’re having diarrhea. Let’s double your biologic. Let’s triple. Okay, let’s switch your biologics. Okay, let’s add a steroid. Let’s add Budesonide.” And they’re not getting any relief and then you figure out exactly … You work them up for IBS, you find the IBS, you treat the IBS-
Dr. Weitz: You do a breath test.
Dr. Gurevich: Exactly, you do a breath test. And you treat it and they completely go into remission. I have this one patient who completely changed my … I lecture about her all the time. She changed my entire trajectory of understanding Crohn’s disease. She came in, she saw me, she was 42 years old and she had a BMI of 16, she was completely ammenorrheic for over seven years because she was so cachexic. She had such terrible inflammation in the leg, she would wear stockings, compression stockings, to keep it in, and I just happened to sit through one of Allison Siebecker, the first lecture Allison ever gave, I just attended a conference, and I was like, “Okay, let’s work you up for this.” She had been in a constant flare for, I think, 13 years. She refused any medication. She was like health guru so refused any medications but could not get rid of her flare. She was getting transfusions, she was so anemic. She was getting transfusions every three to four months because she was bleeding so heavily with the Crohn’s disease. We treated her SIBO. She has been in remission for over six years. She had no ileocecal valve. I continue to treat her SIBO, she’s on rotating herbs on a regular basis. That is the main reason why she’s in remission. There is no way that you can pretend that IBS and IBD have nothing in common.
Dr. Weitz: Well, if you think about it, Dr. Pimentel’s idea that IBS is really an autoimmune disease actually fits nicely with this and makes it even more likely that IBS is related to IBD.
Dr. Gurevich: Totally, a thousand percent. Crohn’s patients, 80% of them have some kind of involvement in their terminal ileum, right? Which basically means, if you have scarring or sclerosis of that part of your intestine, motility is going to be affected. There is no way … Functionally, that ileocecal valve is supposed to be a one way, everything dumps, and back pressure has a close up. These people who have a scarred or inflamed terminal ileum and ileocecal valve, you’re getting a ton of regurge. That is a large bowel. Pimentel himself cites 10 to the third, bacteria in the small bowel tend to the twelfth bacteria in the large bowel. It is regurging right up into the small intestine and then it’s like the wise world west. There’s all of this room, everybody’s bringing their family, everybody’s reproducing. Of course, you get bacterial overgrowth and then that bacterial overgrowth, of course, causes inflammation within the lumen. Of course.
Dr. Weitz: Right. And I also heard you say that sometimes you use naturopathic manual therapy techniques.
Dr. Gurevich: That sometimes can be really, really helpful. I’d say less for inflammatory bowel disease patients because of the scarring. In the studies, there’s only one study, I feel like, and it is was a teeny tiny type study, that said that it can turn over strictures, which is using N-acetyl glucosamine. I don’t know if that’s played out for me in my clinical practice but I have that one study so I try it on all my stricture patients. I use a lot of ozone for my inflammatory bowel disease patients, which I think it’s the best treatment that I have. It’s very uncomfortable but it’s a really effective treatment but even that sometimes [inaudible 00:18:07] the strictures. But you know, I think the goal is treat them aggressively so they never develop the strictures but sometimes once they do, surgery’s the only option.
Dr. Weitz: What about those techniques for using manual massage type techniques for breaking up scars in intestines?
Dr. Gurevich: The clear passage stuff, is that what you’re thinking about?
Dr. Weitz: Yeah.
Dr. Gurevich: They work on … And I center them a lot. They are incredible at adhesions. Scar tissue that forms from the outside. They do not have … I think, they themselves, will not say, and I personally have not seen them do great with strictures and I think it’s just different mechanism of action. A stricture, it’s inside the lumen, and so you have more localized … There’s more of an inflammatory cascade there and so, because of that, using manual therapy to break up adhesions is not going to work because that’s not the underlying cause.
Dr. Weitz: Right.
Dr. Gurevich: But I will say, one of the things that I do have my patients do all of the time, post surgery, is go to Clear Passage to get the adhesion worked on because the adhesions predisposed to a second surgery for a different underlying cause. And so, inflammatory bowel disease patients will constantly go … I think they have, on average, somewhere between two and five years before they’re expected to have a follow up surgery and so if you use the Clear Passage, Clear Passage does have the studies to show that their manual work decreases the likelihood of repeat surgeries because they’re cleaning up the adhesions.
Dr. Weitz: I’ve really been enjoying this discussion, but I’d like to pause for a minute to tall you about our sponsor for this podcast. I’m proud that this episode of the Rational Wellness Podcast is sponsored by Integrative Therapeutics, which is one of the few lines of professional products that I use in my office. Integrative Therapeutics is a top tier manufacturing of clinician design, cutting-edge nutritional products with therapeutic dosages of scientifically proven ingredients to help our patients prevent chronic diseases and feel better naturally. Integrative Therapeutics is also the founding sponsor of TAP Integrative. This is a great resource for education for practitioners. I’m a subscriber to TAP Integrative. There’s videos. There’s lots of great information constantly being updated and improved upon by Dr. Lise Alschuler who runs it.
One of the things I really enjoyed about TAP Integrative is that it includes a service that provides you with full copies of journal articles, and it’s included in the yearly annual fee. If you use a discount code Weitz, W-E-I-T-Z, you’ll be able to subscribe for only $99 for the year. Now back to our discussion.
Dr. Weitz: Besides SIBO, what are the most common co-infections that you’ll see with your IBD patients? I saw an article by Jill Carnahan, where she talked about parasites, Candida, and also Epstein Bar virus.
Dr. Gurevich: I definitely see parasites and protozoa but parasites are definitive as bad, protozoa is often labeled as commensal. I really can’t believe that. As a rule, I think that protozoa should not be within the system and there was a really interesting IBS study in 2014 that looked at protozoa being the underlying cause for a lot of IBS like symptoms.
Dr. Weitz: Well, there are some people claiming that parasites should be part of our system too and even using worm therapy.
Dr. Gurevich: I actually, and I mentioned that earlier, helminths are really interesting. The problem with helminths in IBD is it takes six months for them to become effective.
Dr. Weitz: Okay.
Dr. Gurevich: And so, if they’re in the middle of a flare, you’ve got six months and the likelihood that you can make it through six months without a, obstructing, and b, ending up on some kind of immunosuppressive modality, you would have to have a willpower of like a bull to be able to make it through. But helminths are really, really interesting and protozoa, I don’t think I would use parasites as. I think there are good worms, I think there are bad worms. I think good worms don’t reproduce within us, we can help them shift the microbiome and the environment, bad worms reproduce very aggressively and invitably will cause obstructions.
Dr. Weitz: Right, okay. What are your favorite options for when patients have acute flares?
Dr. Gurevich: Diet is always key for what I do. If they’re willing to do a specific carbohydrate diet, I think that’s the best studied. There’s also this other diet called semi-vegetarian Crohn’s diet, which is basically exactly the opposite of SCD. SCD is really meat heavy, very paleo, no grains. The semi-vegetarian Crohn’s diet is like a macrobiotic, really grain heavy, no meat like diets. That one’s been studied, I think, mainly in Korea. If they are willing to give me a diet, I want them to give me a diet. At this point, in my practice, ozone is my go to. ozone, rectally, is amazing. It’s super uncomfortable. The theory of ozone, the reason why I find it so effective … Or what I do in my practice is I’ll start by either running a Crohn’s monitor or a calprotectin before we start any kind of treatment because I want a baseline and then as soon as we get that result, we’ll start treatment.
When I start with ozone, you take oxygen through an oxygen tank and you put it through an ozone generator and it uses electricity to break up those very stable bonds and so what happens with those bonds is, we know about 20% of them reform in the ozone or O3, which is super, super, super unstable. In fact, if you leave that ozone in a bag, at the end of 30 minutes, it’s going to be all oxygen because all of those third electrons are going to find each other. If you administer it rectally, what happens is because they’re in an acute flare, they’re having all this chronic inflammatory cascade and so what’s happening is they have all these reactive oxygen species, or O1s, that are just looking to unbreak their bonds and that’s causing the inflammation. If you insulffate rectally ozone, that O3 finds those reactive oxygen species and, just like that, immediately it’s an anti-inflammatory. It works really, really quickly, it is very, very safe. However, it is so uncomfortable. It’s really a borderline torture. Maybe that’s extreme.
The large intestine, it’s supposed to squeeze and push things out and I am having them put in 750 ccs of gas up and so what they get is bloating, obviously, cramping. Oftentimes, they’ll have intense bowel movements because the large intestine is getting the receptor, the information, to stretch, which is making it purge. It will, at 750 ccs, which is what I use for Crohn’s patients, they are burping up ozone. It is literally going up their entire GI system, which means for the rest of that day, they are feeling gassy, bloated, distended, crampy. It’s not comfortable. I don’t use this treatment for my IBS people but IBD, if I can give them this ozone, which we know, rectally, is 100% safe, and we know that because they recently did an animal study, not a human study, but an animal study. If I can give them that instead of a steroid or a biologic, for me it’s a no brainer. And it doesn’t work across the board but I’m going to say 70% of my population, I can get into a remission with it.
Dr. Weitz: What about elemental diet?
Dr. Gurevich: Elemental diet, it’s always a trick for me, what is more torturous? Putting a bunch of gas up your butt and getting bloated and distended or drinking … This drink tastes great, day one, minute one. Day seven, minute God knows what, it’s borderline torture. But if they’re not willing to do the gas, I’ll totally go elemental diet. Glutamine has the potential to be really, really effective. The dosage for glutamine is about 27 grams. That’s nine grams, three times a day, for somebody who’s my build. That’s a really high dose. Glutamine does not dissolve really well in water, it doesn’t taste bad, but some people consider that torture, some people get really good efficacy from it. Saccharomyces boulardii has really good potential to get people into remission. For ulcerative colitis, there’s lots of good studies on the mixed probiotics. They used to study VSL3. Now that product is re marketed as vis biome, but that is another really … For UC, that’s something that I always try. Vitamin E. Vitamin E, rectally.
Dr. Weitz: Really? Interesting.
Dr. Gurevich: And they have studies on it actually. For ulcerative proctitis, vitamin E is generally … Also, for ulcerative proctitis patients, I’ll start there. Basically, you use Now brand has this 54,600 IU per dose of vitamin E. It’s got no fillers, no carrier oils, it’s a-
Dr. Weitz: Are you talking about D Alpha or mixed tocopherols?
Dr. Gurevich: I think it’s DL, I think.
Dr. Weitz: D Alpha? Okay.
Dr. Gurevich: Yeah. It’s definitely rectally at that time, like a retention enema, about csc.
Dr. Weitz: Oh, so it comes in an enema or it-
Dr. Gurevich: No, it comes in … It’s like $15 a bottle. It just comes as-
Dr. Weitz: So, liquid, okay.
Dr. Gurevich: Yeah, and you give patients syringes and if they want rectal catheters, I can give them that too. But that’s where I’ll usually start with ulcerative proctitis patients, if I work them up and it looks like they have a microbiome inflammatory based ulcerative proctitis.
Dr. Weitz: What about curcumin, which is the original TNF alpha blocker?
Dr. Gurevich: I’m using turmeric instead of curcumin, mainly because I … Did you read that study? It was actually done with the … It was this Indian PhD, who was the guy who originally did all the curcumin research. He turned around and he repeated his research like 20 years later, using curcumin-free turmeric because in India, the turmeric market got so large. So India was sitting with all of this curcumin-free turmeric.
Dr. Weitz: What to do with it?
Dr. Gurevich: Totally and he was like, “Let me study it.” And it was as efficacious and it’s cheaper. Yes, I totally use turmeric. I use turmeric more. Ill use it sometimes acutely. I’d never seen it, alone, get somebody out of a flare but I’ll use it as my, “This is what you’re on indefinitely until you don’t flare again”, protocol.
Dr. Weitz: Right. I’m seeing mastic gum and then there’s this herb that I’ve seen mentioned called Thunder God Vine.
Dr. Gurevich: I’ve never heard of that. There is a really interesting study on wormwood, artemesia on about keeping IBD … I have a couple of bad track records with using artemisia and getting really high LFTs, which once you discontinue, the liver function has to resolve. I’m a little bit wary.
Dr. Weitz: Okay. Can you talk about the use of biologics and some of the risks associated with taking them and coming off them?
Dr. Gurevich: Yes. Actually, I feel like this is a little bit of my soap box. Biologics are really serious medications. They are immuno suppressants so they really dull the immune system, dulling the immune system then theoretically dulls the response of the neutrophils and lymphocytes that are attacking the lumen of the patients and actually, the way that helminths work, is by giving the immune system something else to attack so that it’s not attacking itself.
Dr. Weitz: Right.
Dr. Gurevich: Biologics, especially with peds, but even with adults, I’m very slow to start somebody on a biologic. I’m fortunate enough to live and work in Portland, Oregon, where I have a good gastro group that I refer to, that refers to me, and so they feel a little bit sometimes more comfortable holding off on the biologics. Some patients find because maybe they don’t want to be on biologics. They have a lot of serious side effects, about one in a thousand people will end up with some kind of lymphoma or cancer, higher likelihood of infections and sometimes they don’t work. However, and this is where my soapbox kicks in-
Dr. Weitz: And as we can see, biologics basically are blocking part of the immune system.
Dr. Gurevich: And in the past, with Crohn’s disease patients,-
Dr. Weitz: And we’re talking about drugs like Humira and Remicade and there was a whole series of-
Dr. Gurevich: Humira, Remicade and Cimzia are all TNF alpha inhibitors, so that’s where curcumin works on that. There’s two new ones that are out, which is Intyvio and Stelara. Intyvio is large bowel only and Stelara just came out, it’s a new one for Crohn’s. They are all monoleukocyte inhibitors, I think, which is exciting because in the past, we had one mechanism of action. If you didn’t respond, you’re done. They would try you on those three drugs in that order and then you’re done. Now, we have these two other drugs. I think Intivio, 40% efficacy of bringing you into remission so not great stats but if it works, it works. But the most important things is these drugs are biologic mimickers, right? They mimic the biology of the system, which means that, one, your immune system might form a reaction to them, and two, if you take them out of the system and the person goes into a flare, there is a significantly higher likelihood that when you put it back into the system, they’re going to form a reaction to that drug and then this really, really great tool that was working to keep the people out of a flare and keep them in a remission is no longer an option and a lot of the other drugs in the same class that are slightly different might also not be an option.
Dr. Gurevich: If a patient comes in, and is well controlled and doesn’t have side effects on a biologic, it’s not going to be my advice to get off the biologic.
Dr. Weitz: Yeah, I’ve had patients come in and every time they take their biologic, they got such a severe skin breakout and had to take prednisolone just to take the biologic.
Dr. Gurevich: Yeah, absolutely. By no means is a biologic a perfect treatment for inflammatory bowel disease but if it is a perfect treatment and you’re in a total remission, I’m hard pressed to say, “You need to come off this biologic.” I am going to give you everything we can to decrease likelihood of developing a lot of these lymphomas, other ways to mitigate the immune system, get them on a clean diet, try to clean up their exposures and do everything else in my field of ability but I am going to be hard pressed to say, “God, you have been controlled, why would I stop that?” Because this disease is terrible.
Dr. Weitz: So, why is it that they’re more likely to react to the biologic if they stop it and bring it back?
Dr. Gurevich: Because now the immune system, which was suppressed, is unsuppressed and so revving and as the biologic is fading out of their system, the immune system can tack onto that protein and then up regulate the immune response so when they see it again, they’re much more likely to form a reaction.
Dr. Weitz: I see. Interesting.
Dr. Gurevich: One of the ways that we use biologics, or the standard medical community uses biologics, is they’ll match it with immuno suppressants. Back when I was diagnosed 25 years ago, we had three drugs that I could choose from. We had Prednisolone, we had Mesalamine, and then we had 6MP, which is also called Imuran or Azathioprine. They’re all the same drug class. The studies have proven out of the last 20 years that those drugs are actually not very effective for treating inflammatory bowel disease but what they will do is they will use combination therapy. They’ll start somebody on a biologic and then also start them on immunosuppressants to decrease the immune system even more from forming a reaction against the biologics. Biologics are not good. Immuno suppressants are awful. Liver inflammation, liver swelling, infections, cancers, they’re awful, and so these patients will get started on double treatments and then nobody takes them off. And so, when I was putting together my very long presentation for Nirala Jacobi’s masterclass on IBD and I was just looking through the literature on what studies have they looked at on how long somebody should be on these immune suppressants and how effective they are.
And, of course, nobody’s done big studies on them. They’re a little bit smaller studies but what the literature has panned out is it is only effective if you do Remicade. If you do Humira, because Remicade is 75% human mimicker, 25% mouse genes. Humira’s 100% human mimicker and so if you give Remicade, because of those mouse genes, you’re much more likely to form a reaction obviously because the body’s much more likely to react to a mouse protein. And after six months, it has no efficacy and the studies that they did outside of-
Dr. Weitz: You have to restrict cheese intake, in that case. I’m just kidding.
Dr. Gurevich: Sometimes you do for other reasons.
Dr. Weitz: The mouse, the cheese. Yeah, okay. Sorry.
Dr. Gurevich: The side effect profiles, the way they did the study is, is they did biologic followed by immuno suppressant, or biologic and immuno suppressant together, and they did it over two years and so the side effect profiles appeared almost identical because everybody got the immuno suppressants. And so, generally, if I’m going to counsel, I’m going to counsel. If they can, they’re okay with injections, Humira’s a better option and I don’t counsel to do immuno suppressants usually.
Dr. Weitz: Okay. Now, you mentioned, with respect to diet, food sensitivities. How do you sort through that and are there certain … You mentioned two completely different types of diets, paleo type of diet, which restricts grains and legumes and things like that, and then you also mentioned more of a vegetarian type of diet.
Dr. Gurevich: What I use in my practice is called the Carol Food Intolerance Test, which nobody has heard about unless they’re a naturopath who graduated from one of the west coast schools. It is this really, really kooky energetic based diet that Dr. Carol created it in the 1920’s. We do it in basically the same ways. For me, I think there’s no studies on it, there’s no science on it, but for me, clinically, it’s one of the ways that I’ve been able to keep my disease in remission and I feel like it’s kind of often the most accurate. I don’t use any of the IGG … I don’t use any of those tests. I find that those, in my clinical practice, are futile. My entire population has intestinal permeability. They have intestinal permeability because they’re seeking out my treatment and waiting to get in with me for appointments, right? So, that test is just going to do a good job really telling me what they’re eating. I don’t use that test at all. I think elimination is probably the gold standard and so what I’ll do is I’ll start them on SCD if they’re okay with meat and I think it’s better studied. If I can get them into remission, great. If I can’t or if they hate me, I’ll start them with the other one. I’ll flip.
Dr. Weitz: Have you used Low FODMAP?
Dr. Gurevich: Yes, definitely, and I feel like what I’ll do is I’ll put them on any diet. I’ll put them on a restricted diet, either SCD, whatever they want to start with, until they’re able to get into control and then once they’ve been in control for a little while, … It’s not sustainable to do that diet for the rest of your life. I call that diet a skeleton and then we want to build … We want to put the meat in the muscle and skeleton. Introduce, challenge, did you do okay? Great. Introduce, challenge, did you do okay? No? Okay, stop. Go back to where you just ended, let’s give it a couple of days. Okay, now you’re ready. Introduce, challenge. I want them to figure out what they can eat and what they can’t eat.
Dr. Weitz: If you do an elimination diet, how many foods do you eliminate?
Dr. Gurevich: All of the main intolerances. Dairy, gluten, eggs that are not organic, soy, corn, nightshades, sugar. The standard anti-inflammatory diet.
Dr. Weitz: How often do you find that gluten and dairy need to be kept out?
Dr. Gurevich: Not as much as I would have expected.
Dr. Weitz: Okay.
Dr. Gurevich: I feel like people who react know right away. Not as much as I would expect.
Dr. Weitz: Okay. How often do you find heavy metals or mold as co-factors?
Dr. Gurevich: I think I am probably under treating and under testing because there is this entire theory about fungus being one of the big underlying causes of Crohn’s disease and I think that I’m not paying enough attention to it, if I’m honest.
Dr. Weitz: Right. Well, it’s a lot of stuff to pay attention to.
Dr. Gurevich: Yeah, that’s true.
Dr. Weitz: Okay. I think those are the main question I had. I thought that was a good interview.
Dr. Gurevich: Thank you. You are also extraordinarily researched. I’ve been listening to a lot of your podcasts.
Dr. Weitz: Oh, you have?
Dr. Gurevich: Yeah, you are extraordinarily researched. I don’t know how you find time to do it.
Dr. Weitz: I just don’t sleep.
Dr. Gurevich: Great, that’s healthy. Totally no side effects to that.
Dr. Weitz: Exactly. How can our viewers find and get hold of you and find out about your programs? I know you have this IBD course, right? That’s available through Nirala.
Dr. Gurevich: Yep it’s SIBO Doctor Master Course through Nirala Jacobi. I think you Google that. That is going to be … I do my final interview with her tomorrow. It’s going to be five and a half hours just on inflammatory bowel disease. I do a lot of teaching and a lot of lecturing around. You can find me at my website, is naturopathicgastro.com and I still see patients and I also have some residents who work under me where if people don’t want to wait, they can absolutely … The residents run all of their cases through me and so we work on the cases together but it’s a lot cheaper and it’s a lot easier to get in with them.
Dr. Weitz: Awesome.
Dr. Gurevich: Thank you.
Dr. Weitz: So much.
Dr. Gurevich: That was so fun. Thank you.
Leave a Reply
Want to join the discussion?Feel free to contribute!