A Gut Feeling: Could This Case Really Be That Simple?

After several years of ER visits with normal bloodwork and negative CT scans, Fred Hooper ended up in my schedule a few weeks ago.

“I’ve had stomach pains for 20 years and it’s gotten worse since my colonoscopy 7 years ago”, he said.

Fred had seen an emergency room doctor more times than any of the primary care physicians he tried over the years. He described severe lower abdominal pain and bloating soon after eating, followed by small, hard bowel movements. Each episode lasted a few hours or even less.

“Do I need a colonoscopy”, he asked.

“Maybe, maybe not, but you’re almost 80 years old and you’ve had this problem for 20 years. I’d like to try something first”, I said.

“Could this be Crohn’s disease”, he asked.

“Not likely, the episodes are quite short and in 20 years, nothing bad has ever happened because of them”, I answered. Instead, I went in a different direction.

I asked, “has anybody ever talked to you about trying a milk free or gluten free diet, like avoiding bread, crackers and pasta?”

“No, but now that you mention it, I’ve noticed that dumplings and pasta tend to bother me, and I do drink milk with my meals quite often.

“Let’s do this”, I suggested, “get some bloodwork to look for inflammation and full blown celiac disease, then stop milk products for one week. If you don’t feel better, go gluten free. Avoid anything made with flour, like boxed cereals, bread, pasta, crackers and so on. And see me one week into that. I’ll let you know if there are any surprises in your bloodwork as it trickles in.”

The emergency room has a different purpose from the primary care physician. They are geared up to identify acute problems that require immediate treatment. Fred got the bloodwork and the CT scan every time to make sure he didn’t have a surgical, infectious or vascular emergency. Once he was cleared from those things, their job was always done.

The primary care doctor’s job is to listen to the patient and, in Fred’s case, consider the chronic and often functional diseases that might explain the symptoms. But Fred is a somewhat impatient man who never seemed to invest in a primary care relationship.

Primary care doctors don’t necessarily dig deep into a new patient’s chronic but not so dangerous sounding symptoms until after they have done all the mandated new patient intake items like immunizations, routine lab work, screening for depression, alcohol abuse, smoking, food insecurity and more. In Fred’s case, he says he got the impression his doctors weren’t all that interested in his symptoms.

I was interested, because I had a gut feeling his problem was probably quite simple.

The other day, a few weeks into his dietary experiment, Fred came back to see me. Guess what he told me…

I am happy to report that my gut feeling was right on, and his gut is doing much better than it has been for the past few decades.

So, does Fred have low level gluten sensitivity? Maybe, maybe not. This is still not a completely understood phenomenon, but it has definitely moved from the fringes into mainstream medicine.

The Harvard Health Blog writes “The expression ‘leaky gut’ is getting a lot of attention in Medical blogs and social media lately, but don’t be surprised if your doctor does not recognize this term.”

This phenomenon has in fact become better understood and accepted and earned endorsement by the medical establishment, gaining the more scientific name increased intestinal permeability.”

The Celiac Disease Foundation reports that people with non-celiac gluten or wheat sensitivity who don’t test positive for celiac disease sometimes in fact have a systemic immune reaction with intestinal cell damage, really blurring the line between celiac disease and non-celiac gluten sensitivity, NCGS.

Canadian Society of Intestinal Research writes that since “wheat is a complex structure with an estimated 95,000 genes”, more than humans have, many other compounds besides gluten could be the culprit in wheat sensitivity.

Empiric elimination of wheat is an easy thing patients with unexplained gastrointestinal symptoms can do on their own. We owe them that suggestion.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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