An integrative medicine vs. traditional medicine case study

Down to specifics: how we approached inflammatory bowel disease and multiple monthly trips to the ER

I’m often asked how Integrative (Functional) Medicine differs from caring for patients in the traditional medical system. 

I think the best way to differentiate this is through case studies. Through this process, I will describe particular cases and individual patients I’ve cared for as an integrative medicine doctor. Obviously, these cases are deidentified with specific patient information, and some of the details have been changed—but the salient facts of the case remain the same.

23-year-old with Inflammatory Bowel Disease

The first patient is a 23-year-old woman with a long history of Inflammatory Bowel Disease, and with what would be described as cyclic vomiting associated with severe lower abdominal pain. 

The vomiting was recurring on a monthly basis around the time of her period with associated severe abdominal pain, increased anxiety, and an inability to keep any food down. It required her to go to the emergency department every month, often several times, around the time of her period, because one visit did not completely control her symptoms. 

She was given various medications, including anti-emetics intravenously (IV), IV fluids, and IV narcotics to control her pain. Over the course of a year, she had found some mild alleviation of her pain and symptoms using THC, although there was also a concern that this was actually making the symptoms worse.

When we look at this case from a traditional medicine point of view, it's reasonable to assume that this young lady would be referred to several different specialists, including obstetrics and gynecology, to see if there is any gynecological reason for her symptoms due to the timing around her period. 

She would likely be re-evaluated by her gastroenterologist to see if there are any gastrointestinal triggers for her constellation of symptoms, with her severe abdominal pain and vomiting, and history of IBD. She may also be referred to a therapist for her spike in anxiety, possibly being the trigger for all the symptoms that have followed. Finally, she could be referred to an addiction specialist because of her increasing use of THC and its association with cyclic vomiting syndrome. 

In fact, she was referred to a gynecologist, gastroenterologist, and therapist using the standard traditional medicine approach in addition to visits with her PCP. 

She underwent a pelvic ultrasound by her gynecologist as well as gynecological exams and blood hormone testing. She also underwent a laparoscopic procedure to determine if there was any anatomical reason for her symptoms not discovered through her pelvic imaging studies. She was evaluated by her gastroenterologist with upper endoscopy and imaging studies, as well as laboratory panels by her primary care physician, to determine if there was any gastrointestinal cause for her symptoms. 

All of these tests resulted in no clear diagnostic cause, despite seeing multiple specialists and being prescribed multiple symptomatic medications to try and control her symptoms. Her monthly cyclic pain continued to send her to the emergency department, usually twice per month.

The integrative and functional medicine approach

When she came to see me, she brought with her a 4-5 inch stack of records she had diligently requested from all her hospital visits and specialists. Our initial evaluation lasted 2 hours, going through a detailed medical history, inclusive of family and social history, as well as a general physical exam. We then ordered several tests, including a microbiome test, baseline labs, and a functional genetics test called 3X4 Genetics. 

Once these results came back, we determined that she had a gut imbalance (dysbiosis) with elevated levels of inflammatory bacteria and low levels of beneficial bacteria, including Akkermansia, Faecalibacterium, with gut hyperpermeability (leaky gut). 

In addition, she had evidence of difficulty breaking down histamine due to variations in two genes associated with DAO and HNMT, which specifically impact proteins responsible for breaking down histamine. Other genes showed difficulty with methylation processes, and she had a lower B12 level on blood testing. She also had very low Omega-3 levels (associated with inflammation) and evidence of insulin resistance with a fasting insulin level of 65. 

Our approach was to address the above with a targeted approach as follows: 

• Repair the intestinal barrier and correct the gut imbalance

• Reduce histamine burden (genetic + dietary triggers) by initiating a low histamine diet and DAO supplement, as well as Mast cell stabilizing supplements

• Improve insulin sensitivity

• Enhance vagal tone / reduce sympathetic dominance through box breathing twice daily

• Replete micronutrient deficiencies (omega-3, D, B12)

• Reduce use of THC as a symptom control strategy

The role of Histamine

Let’s talk about histamine. Histamine is commonly known as a substance that causes allergy-related symptoms: runny nose, sinus pressure, and swollen eyes. 

While true, histamine is also a protein that impacts numerous body systems, including gastrointestinal (abdominal pain), central nervous system neurotransmitter levels (anxiety as well as vomiting), cardiovascular (rapid heart rate), and gynecologic (uterine cramps and pain). 

What is not well known is the interplay between estrogen and histamine. As estrogen levels rise, it increases the release of histamine from Mast cells. For someone with difficulty breaking down histamine, as our patient demonstrated on genetic testing, these monthly cyclic changes could trigger extreme rises in histamine flooding into her body, causing or worsening all of her symptoms.

As we started this holistic plan, keep in mind our patient has been making twice-monthly visits to the ER to control her symptoms, including vomiting and pain, for over a year. 

Results of our integrative approach

Since we initiated our approach, she has had NO visits to the ER over several months. Her symptoms are controlled at home using an escalation process to increase histamine breakdown during her cycle and continued focus on avoiding high histamine foods during the time in her cycle when her symptoms are likely to worsen. She continues to focus on her box breathing and has weaned herself off of THC as a coping strategy. 

This young woman’s case powerfully illustrates how taking a holistic approach to her constellation of symptoms can piece together a unifying cause for wide-ranging symptoms. By diligently and systematically trying to determine the root cause, we were able to provide her with a likely cause for her symptoms and a focused treatment plan to address her histamine issues. By using targeted supplements and a lifestyle focus of a low-histamine diet and mindfulness activities, we avoided focusing on managing only end result symptoms, which would be typical of the traditional medicine approach. 

If you are suffering from multiple and seemingly unrelated symptoms, you might benefit from having a visit with an integrative medicine practitioner to search for root causes and develop a personalized, holistic treatment plan.