The full piece on this topic, including treatment options by a number of LAcs, will be published in the upcoming issue of The Journal of the American Society for Acupuncturists, V7,1.
By Jenn Gibbons, MSTOM, LAc
The digestive tract functions as an intermediary between the body and the external environment, taking in what it needs and expelling what it does not. To begin with, chewing food in the mouth cues the stomach to increase its production of stomach acid, which not only kills potential pathogens but also prompts the cascade of events that properly assimilates the incoming macronutrients. The pancreas then secretes enzymes and the gallbladder secretes bile to break food down into an absorbable form.
Absorption takes place through the single layer wall of the small intestine, which becomes permeable and allows these nutrients to pass into our bloodstream. The non-absorbed matter continues to move further into the large intestine as food for the microbiome or waste product to be removed. If this intestinal layer is compromised, it will become hyper-permeable and allow contents to leak into the blood.
Causes and Effects of Increased Intestinal Permeability
So what causes this layer to leak?
Anything that goes wrong above or below this absorption site can contribute to hyper-permeability. When nutrient-poor food is ingested, the body expends a lot of energy with little gain. Over time, this can lead to nutrient deficiencies and the overfeeding of the gut bacteria. When the bacteria in the upper gut are overfed, a reduction in the stomach acid can occur, thus impairing the release of enzymes and bile necessary to properly assimilate nutrients for absorption.
When the food then arrives at the absorption site and is not broken down sufficiently, it will not be absorbed. Rather, it will move into the large intestine and become food for the microbiome, leading to further bacterial overgrowth.
Bacterial overgrowth in the small intestine (SIBO) is often the cause of upper abdominal gas that can cause bloating, belching, reflux, pain, and impaired nutrient absorption. This distention often interferes with normal peristalsis and impairs the function of the migrating-motor-complex, which handles the clearing of food fragments that remain in the upper gut.
If these fragments do remain, they are fermented by local bacteria, thereby creating more gas. This can interfere with normal bowel movements and lead to constipation or diarrhea. Bacterial overgrowth in the large intestine, or dysbiosis, is often the cause of lower abdominal gas that can also lead to bloating, pain, flatulence, and bowel irregularities.
The pressure along the digestive tract is enough to increase the permeability of the absorption site but this barrier also does have a regulator. The protein zonulin modulates the opening and closing of the tight junctions at the absorption site, controlling how permeable it is. Based on research by Dr. Alessio Fasano, SIBO and dysbiosis stimulate the production of zonulin, which increases intestinal permeability.1
Identifying and Managing Leaky Gut
Gluten, one of the most commonly consumed nutrient-poor food additives, also stimulates zonulin. Dr. Fasano reports that gluten causes intestinal permeability in all of us, since humans lack the enzymes necessary to fully assimilate it. He also explains that these undigested gluten fragments are perceived as an enemy by the immune system and that, if a person has a certain genetic predisposition, they may develop celiac disease as a result of overconsumption.
Comprehensive stool analysis tests such as the GI Map from Diagnostic Solutions can determine zonulin status. Food sensitivity labs such as KBMO and Cyrex Labs can also test for a patient’s sensitivity to gluten. In addition, human leukocyte allele testing for celiac disease (HLA-DQ) can be performed to assess genetic risk.
Integrative Treatment Approaches
Regardless of the result, a functional medicine practitioner is likely to advise their patient to optimize repair by adhering to the following points:
- prioritize eight hours of quality sleep
- avoid unnecessary stress
- improve your mood
- avoid an excess of either sedentary activities or strenuous overtraining
- eat a nutrient-dense, anti-inflammatory diet that excludes acellular carbohydrates, added sugar, gluten, and any known food sensitivities.
They would also likely order both a SIBO breath test to determine whether or not there is bacterial overgrowth in the upper gut and a comprehensive stool analysis to see if there is a gut infection. This can also ascertain the state of the patient’s microbiome and indicate how well they absorb their nutrients. A thorough diet history and nutritional lab testing are also useful to determine potential nutrient deficiencies.
Chinese Medicine Perspective on Digestive Health
In addition to treatment based on the lab tests, they will often recommend that the patient optimize their stomach’s acidity by completing what is known as the “hydrochloric acid challenge” using betaine HCl with digestive enzymes. This not only protects the patient from potential pathogens but also helps to improve digestive function and thereby absorption.
In addition to advising on sleep, stress, movement and diet, Chinese medicine practitioners may also differentiate the patient’s pattern of disharmony, which allows them to further personalize their patient’s treatment plan. Reflecting on the different presentations above, a patient might present with excess in the stomach, small intestine, or large intestine. This excess may impede the descending function of stomach-qi, causing counterflow. It may also back up the liver and gall bladder, creating stagnation of qi and blood.
Patients often turn to antacids or proton-pump inhibitors to reduce their stomach-counterflow symptoms. This anchors the ascension, but it also reduces digestive strength and invites cold. When dysbiosis is present, the liver may be burdened with increased toxicity, causing qi stagnation and heat. The increase in pressure and heat throughout the digestive tract can burn off fluids reducing precious yin. The reduction in digestive function and nutrients can lead to deficiency patterns of the spleen manifesting as damp accumulation. Over time, the overworked spleen can lose support from the kidneys, which can lead to weakness along the entire digestive tract wall. This can present as a leaky esophagus or a leaky blood-brain barrier.