Additional Approaches to Severe Gastrointestinal Disease
Glycopyrrolate Injection for Travel
Glycopyrrolate injection may be useful for travel when control of gastrointestinal motility and secretions is desirable.
DMSO
1.2% DMSO subcutaneously
This would be administered twice during the first week and then once weekly thereafter.
Sulfasalazine
If sulfasalazine has not been tried, it probably should be considered.
Chlorambucil represents a different and considerably more aggressive means of reaching a similar therapeutic endpoint through immunomodulation.
Phenobarbital
Phenobarbital is a sedative and can cause a degree of ileus, as can a number of other sedating drugs, including opioids.
I have used it successfully in some of the most severe cases of diarrhea. I do not use it for mild diarrhea.
Ursodiol and Berberine
Ursodiol and berberine represent older approaches, including elements derived from Eastern medicine, aimed at supporting the liver and the enterohepatic cycle.
They may assist with gallbladder emptying and the appropriate circulation of bile acids from the liver and gallbladder into the intestine and then back through the enterohepatic circulation.
Sucralfate
Sucralfate is indicated when there is hemorrhage or significant mucosal damage involving the stomach or intestine, including the colon.
It binds strongly to proteins within damaged tissue and can adhere to areas containing blood products, creating a protective barrier over an injured gastrointestinal surface. In this way, it can essentially act as a temporary “patch” over damaged mucosa while healing occurs.
Later, material resembling flakes of sucralfate may sometimes be observed as the material separates from the healing intestinal or colonic lining.
Metronidazole and Amoxicillin
Metronidazole has useful activity within the gastrointestinal tract against a variety of undesirable anaerobic organisms and certain protozoal organisms.
It has long been marketed under the trade name Flagyl and has historically been used in the management of Giardia and other gastrointestinal protozoal infections.
Amoxicillin may also be used when Helicobacter species are suspected to be contributing to disease in the upper gastrointestinal tract, generally as part of a broader treatment protocol.
Vitamin C and NAC
There are very few biological processes that are not influenced in some way by oxidative stress.
Likewise, virtually every active biological system produces reactive oxygen species and other free radicals as part of normal metabolism and inflammation.
For that reason, antioxidant support with agents such as vitamin C and N-acetylcysteine (NAC) may be useful as an adjunct in gastrointestinal and systemic disease.
Colonic Microbial Transplantation and Ancestry
Science has not yet worked out everything about the intestinal microbiome, but several concepts are becoming increasingly important.
First, the microbiome is not simply a stew of individual bacteria and fungi.
It is better understood as an entire ecosystem—somewhat like a pond containing animals, plants, microorganisms, nutrients, water chemistry, and countless interactions among them. The intestinal environment is similarly complex.
Second, genetics and ancestry may have an important relationship with the intestinal microbiome.
Over thousands of years, different human populations may have developed relationships with particular microbial communities and ecological equilibria. Certain organisms may be especially well tolerated or supported within people carrying particular genetic backgrounds.
For example, a person of Norwegian ancestry and a person of Japanese ancestry may not necessarily provide identical biological environments for the same transplanted organisms.
For this reason, one possibility is that the most compatible microbial populations may sometimes come from ancestors, descendants, or closely related individuals who share some of the genetic and environmental factors that helped establish that microbiome.
Third, introducing organisms is only part of the process.
The beneficial bacteria, fungi, and other organisms within a microbiome must also be fed and supported. The intestinal environment has to provide the nutrients and substrates necessary for all the components of that ecosystem to remain healthy and metabolically active.
This is one reason microbial transplantation may be considerably more complicated than simply performing a high colonic containing a collection of random microorganisms.
A successful transplant requires not merely organisms, but the appropriate ecological environment for those organisms to establish themselves.
Feed the Microbiome
Once the components of a healthy microbiome ecosystem have been introduced—preferably, when possible, from biologically compatible or genetically similar individuals—the next requirement is providing the organisms with the substrate they need to survive.
We increasingly understand that diet can selectively encourage particular microbial populations.
Specific dietary fibers, resistant starches, and other fermentable substrates can support beneficial organisms, including organisms involved in the production of butyrate and other short-chain fatty acids.
Therefore, before and during a microbiome transplant, it makes sense to provide an appropriate dietary substrate and metabolic fuel for the organisms you are attempting to colonize and sustain.
In other words, it is not enough simply to put the microbiome there.
You also have to feed it.
How long does it take to affect a change in the prevailing gastrointestinal ecosystem with modifications to exercise and diet?
Pretty quickly, Doc—the gut microbial ecosystem can begin responding to a consistent dietary change within about 24–48 hours. In controlled human feeding studies, detectable shifts in microbial composition and gene activity have occurred within the first day, especially with substantial changes in fat, fiber, and animal-versus-plant foods.
But I’d separate “detectable” from “perceptible/stable.” A useful rule of thumb is:
- 1–3 days: measurable microbiome/metabolic changes can begin.
- 1–2 weeks: a sustained diet is more likely to produce a meaningful, repeatable shift in stool characteristics, fermentation, gas, bowel frequency, and microbial populations.
- 4–8 weeks: you’re getting closer to a reasonably established new ecosystem under that diet, though the person’s underlying “core” microbiome tends to resist complete remodeling.
- Exercise: generally acts more slowly than diet. Aerobic exercise studies have detected changes by about 2 weeks, with a more stable effect reported around 6–8 weeks of consistent activity.
So if you’re asking, “How long do I need to eat differently before I can reasonably say my gut ecology has changed?” I’d call two weeks the minimum believable window, and 4–8 weeks the much better window.
And the interesting bit: microbial function—SCFA production, bile-acid metabolism, fermentation patterns, etc.—may shift faster than the actual roster of organisms. So somebody can have a noticeably different intestinal environment before their microbiome sequencing looks radically different.
If you’re thinking specifically about changing diarrhea/gas/odor/stool quality by altering the intestinal ecosystem, that timeline gets even more interesting, because those effects can show up in days, well before a truly stable microbiome shift.
