Integrative Gastroenterology Weil Integrative Medicine Library

Integrative Gastroenterology Weil Integrative Medicine Library Published and Forthcoming Volumes series editor andrew weil, md Donald I. Abrams and Andrew Weil: Integrative Oncology Timothy Culbert and Karen Olness: Integrative Pediatrics Gerard E. Mullin: Integrative Gastroenterology Victoria Maizes and Tieraona Low Dog: Integrative Women’s Health Randy Horwitz and Daniel Muller: Integrative Rheumatology Daniel A. Monti and Bernard Beitman: Integrative Psychiatry Stephen Devries and James Dalen: Integrative Cardiology Integrative Gastroenterology edited by Gerard E. Mullin, MD Associate Professor, Medicine Johns Hopkins University School of Medicine The Johns Hopkins Hospital Baltimore, MD 1 1 Published in the United States of America by Oxford University Press, Inc., 198 Madison Avenue, New York, NY, 10016 United States of America Oxford University Press, Inc. publishes works that further Oxford University’s objective of excellence in research, scholarship, and education Oxford is a registered trademark of Oxford University Press in the UK and in certain other countries © Oxford University Press, Inc. 2011 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, Inc., or as expressly permitted by law, by licence, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, Inc., at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer ____________________________________________ Library of Congress Cataloging-in-Publication Data Integrative gastroenterology/[edited by] Gerard E. Mullin. p.; cm.—(Weil integrative medicine library) Includes bibliographical references and index. ISBN-13: 978-0-19-537110-9 (alk. paper) ISBN-10: 0-19-537110-0 (alk. paper) 1. Gastrointestinal system—Diseases. 2. Integrative medicine. I. Mullin, Gerard E. II. Series: Weil integrative medicine library. [DNLM: 1. Gastrointestinal Diseases—therapy. 2. Complementary Th erapies—methods. WI 140 I605 2010] RC817.I47 2010 616.3’3—dc22 2009023877 978-0-19537110-9 ____________________________________________ 1 3 5 7 9 10 8 6 4 2 Typeset in Minion Pro Regular Printed on acid-free paper Printed in the United States of America Th is material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to off er accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side eff ects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. Th e publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or effi cacy of the drug dosages mentioned in the material. Th e authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material. To the more than 70 million Americans who are known to suff er from digestive disorders. To my loved ones for their unwavering support over the years. To the many who mentored me throughout my career. To Andrew Weil MD for selecting me to edit this textbook. And the beloved memory of my parents. This page intentionally left blank FOREWORD few years ago, a leading gastroenterologist in Tucson asked me to meet with him. Over dinner, he expressed the hope that integrative A medicine (IM) might have something to off er him. He was frustrated, he said, because, “ninety percent of the patients I see have problems that my training does not enable me to solve.” At that time, the Arizona Center for Integrative Medicine was off ering a comprehensive IM fellowship in distributed learning format to physicians and nurse practitioners. We were training family medicine doctors, internists, and surgeons, but had not yet had a GI specialist apply. Th at disappointed me, because I knew that integrative medicine could greatly enrich the fi eld of gastroenterology, increasing its effi cacy and reducing the frustration expressed by my colleague in Tucson and shared by many others. One of the core curricular areas of IM is mind/body medicine. It covers the theory and evidence base for interactions between mental/emotional states and physiology, as well as therapies that take advantage of those interactions. Steven Gurgevich, PhD, a clinical psychologist on the faculty of the American Society of Clinical Hypnosis, helped design the mind/body medicine module. He has said, “Patients with gastrointestinal problems should be seen by hypno- therapists before they go to gastroenterologists,” and over the years, I have referred many patients with GI complaints to him and other mind/body practitioners, with good outcomes. His reasoning is that the organs of the GI system, along with the skin, have the greatest amount of innervation of any organs and, as a result, are the most frequent sites of expression of stress- related disorders. Michael Gershon, MD, chairman of the Department of vii viii FOREWORD Anatomy and Cell Biology at Columbia University Medical Center, in an excel- lent book on enteric neurology, refers to the gut as the “second brain.” Many common GI disorders arise from disturbed function of the gut—in particular, an imbalance between its intrinsic motility and extrinsic control by the autonomic nervous system (oft en caused by stress-related overactivity of the sympathetic nerves). Without harmonious coordination, gut motility is abnormal and digestion impaired. In late stages of these disorders, we can visualize or otherwise detect pathological changes, but early on they present as functional complaints. Patients seek relief of GI symptoms; there are few or no measurable correlates of the symptoms. “Functional disorder” is a loaded term in conventional medicine. Oft en it is used to dismiss complaints of patients without visible pathology; at worst, it is used as a synonym for “imagined disease.” Patients are easily angered by sug- gestions that their GI problems are all in the mind. Practitioners must be able to help them understand the underlying somatopsychic mechanism that accounts for their very real symptoms. Traditional Chinese medicine (TCM) classifi es diseases as “visible” or “invisible” and postulates that all visible disease is preceded by an invisible stage, in which “energy” (chi) circulation through the body is disturbed. TCM practitioners believe that if invisible disease goes untreated (by acupuncture, herbal therapy, dietary adjustment, etc.), it will eventually produce pathological changes in the physical structure of the body. Th erefore, TCM prioritizes the diagnosis and treatment of what conventional Western medicine oft en dis- misses as functional disorders. Doctors here tend to minimize the signifi cance of these problems, in part because they fi nd it frustrating to manage them. Th eir training does not enable them to do so. Because dietary habits and other lifestyle factors can both trigger and aggra- vate this class of GI disorders, it is not suffi cient to send patients to stress- management training or hypnotherapy. Physicians must also give them specifi c recommendations about foods, beverages, physical activity, rest and sleep, and more. And they should know when the pharmaceutical drugs now so widely prescribed for GI problems are really indicated, and for how long patients should be on them. Proton-pump inhibitors for GERD and steroids for infl am- matory bowel disease may be useful for short-term suppression of symptoms, but over time the benefi t-to-risk ratio changes signifi cantly and unfavorably, and data on the risks are accumulating. Practitioners of integrative medicine are fully trained to diagnose and treat invisible and functional disease before it damages tissues and organs and requires drastic, costly intervention. Th ey work from the premise that the body can heal itself if given a chance, that mind/body interactions are real and oft en very relevant to issues of health and illness, that all aspects of lifestyle must be FOREWORD ix considered in evaluating patients, and that the doctor/patient relationship is a key factor in the outcome of treatment. In addition, they are familiar with a wide range of therapeutic options other than drugs. In recommending therapies not commonly included in mainstream practice, they pay attention to the evidence that supports them, always working from the principle that the greater the potential of a treatment to cause harm, the stricter the standards of evidence for effi cacy it must be held to. A major

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