Dr David L. J. Freed, MB, MD, MIBiol
Information for Doctors (8)
These are both diagnoses that should be made by the gastroenterology experts, since other, more sinister, diseases muat always be excluded first. Treatment, however, is as much up to the GP as the specialist, and dietary manipulations have shown spectacular success in recent years (8,9). In my view dietary eliminations should always be tried before steroids and surgery, and probably even before sulphasalazine and related drugs, since the potential side-effects of diet are milder than those of conventional treatments.
American allergist Dr Joe Miller has coined the memorable phrase "Irritable bowel and Crohn's disease are a piece of cake", and this is a reminder that the commonest incitants of these diseases are the usual constituents of cake, namely, wheat flour, sugar, egg, milk, chocolate, and fruits. To this list I would add other grains such as rye, barley and oats, plus the common legumes (peas, beans and lentils) and potato. The foods that remain permissible make up what is loosely termed a "stone-age diet", viz meats, fishes, and green-leaf vegetables. One can live perfectly healthily on this sort of diet, but it is grievously boring and socially restricting. Nevertheless, we should not allow this to stand in the way of a drug-free, non-surgical cure; if that's what it takes, that's what it takes. Much anxiety is expressed by physicians (though rarely, curiously, by surgeons) about the alleged dangers of elimination diets (10). Coming from a group of gentlemen that saturate their clients with toxic drugs at the drop of a hat, I think that is mainly humbug. However, there are such things as dietitians available to the GP, and if you feel diffident about managing the nutrition of a patient on an elimination diet, by all means call in the expert. Modern dietitians are fully au fait with the complexities of "allergy diets" and are anxious to put their expertise to use. Three weeks of diet is all you need to find out if this is going to work or not, and in that short time there is no danger of malnutrition.
If a couple of weeks on a stone-age diet doesn't stop the illness, prescribe oral nystatin also, and if that combination doesn't do the trick you will need to call for help; desensitization is going to be required.
Few patients fail to respond to that therapeutic package. I cannot say the same for ulcerative colitis, which seems genuinely to be a different sort of disease; I have far less confidence with that although some of my colleagues report success in the long-term (11).
While on the topic of disordered bowels, this will be an apt point to bring in dietary fibre. While not dissenting from the popular view on its usefulness, I must mention that "fibre" is NOT a synonym for "wheat bran". Some constipated patients find that their constipation gets worse, not better, when they consume wheat bran. This is because of the exorphins of wheat (12), which are small peptides derived from partially digested wheat protein. As the name implies, exorphins have a weak morphine-like effect, including constipation. The other effect to look out for is a state of dreamy detachment, of being an onlooker to the world (not an unpleasant sensation but decidely odd) which these patients often feel after consuming bread. You may not have heard this complained of, because patients are afraid to mention it, but it is commoner than you think.
An alternative source of dietary fibre, for those whose constipation becomes worse on taking bran, is green-leaf vegetables.
References
8) Alun Jones V, McLaughlan P, Shorthouse M: Food intolerance: a major factor in irritable bowel syndrome. Lancet 1982, ii: 115-117.
9) Alun Jones V, Dickinson RJ, Workman E et al: Crohn's Disease: maintenance of remission by diet. Lancet 1985, ii: 177-180.
10) David TJ: Unhelpful recent developments in the diagnosis and treatment of allergy and food intolerance in children. in Dobbing J (ed): Food Intolerance; Bailliere Tindall, Eastbourne, 1987, pp 203-204.
11) McEwen LM, Allergy and EPD. 2003, McEwen Laboratories, Henley-on-Thames RG9 1HX.
12) Zioudrou C, Streaty RA, Klee WA: Opioid peptides derived from food proteins: the exorphins. J Biol Chem 1979, 254: 2446-9.
