MEpedia - User contributions [en]

Small intestinal bacterial overgrowth

2018-11-25T21:28:28Z

Living with cfs me:/* References */

'''Small intestinal bacterial overgrowth''' (SIBO) is an excessive bacterial growth in the [[small intestine]] which in contrast to the [[large intestine]] in healthy individuals contains relatively small populations of bacteria.

== Prevalence ==

The rate of a positive lactulose test is low in healthy adults (0 to 20%).<ref name="Dukowicz2007">{{Citation
| last1 = Dukowicz | first1 = AC | authorlink1 = Andrew Dukowicz
| last2 = Lacy | first2 = BE | authorlink2 = Brian Lacy
| last3 = Levine | first3 = GM | authorlink3 = Gary Levine
| title = Small Intestinal Bacterial Overgrowth
| journal = Gastroenterology & Hepatology | volume = 3| issue = 2| pages = 112–122
| date = Feb 2007
| pmid = 21960820
| url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099351/
}}</ref>

== Comorbidities ==

Anecdotal reports suggest a high prevalence of SIBO among CFS patients. One study found 77% of CFS patients had SIBO and eradication lead to decrease in symptoms.<ref name="Pimentel2000">{{Citation
| last1 = Pimentel | first1 = M | authorlink1 = Mark Pimentel
| last2 = Hallegua | first2 = D | authorlink2 = David Hallegua
| last3 = Chow | first3 = EJ | authorlink3 = Evelyn Chow
| last4 = Wallace | first4 = D | authorlink4 = Daniel Wallace
| last5 = Bonorris | first5 = G | authorlink5 = George Bonorris
| last6 = Lin | first6 = HC | authorlink6 = Henry Lin
| display-authors = 3
| title = Eradication of small intestinal bacterial overgrowth decreases symptoms in chronic fatigue syndrome: A double blind, randomized study
| journal = Gastroenterology | volume = 118| issue = 4| pages = –414
| date = 1 Apr 2000
| doi = 10.1016/S0016-5085(00)83765-8
| url = http://www.gastrojournal.org/article/S0016508500837658/abstract
}}</ref> Patients with CFS have alterations in microbiota, including lower levels of bifidobacteria and SIBO.<ref name="Logan2003">{{Citation
| last1 = Logan | first1 = Alan C
| last2 = Venket Rao | first2 = A
| last3 = Irani | first3 = Dinaz
| title = Chronic fatigue syndrome: lactic acid bacteria may be of therapeutic value
| journal = Medical Hypotheses | volume = 60| issue = 6| pages = 915–923
| date = Jun 2003
| pmid = 12699726
| url = http://www.ncbi.nlm.nih.gov/pubmed/12699726
}}</ref>

Several studies have shown that up to 84% of patients with [[irritable bowel syndrome]] have SIBO<ref name="Dukowicz2007" /> and that symptoms improve after treatment<ref name="Pimentel2004">{{Citation
| last1 = Pimentel | first1 = M | authorlink1 = Mark Pimentel
| last2 = Wallace | first2 = D | authorlink2 = Daniel Wallace
| last3 = Hallegua | first3 = D | authorlink3 = David Hallegua
| last4 = Chow | first4 = EJ | authorlink4 = Evelyn Chow
| last5 = Kong | first5 = Y | authorlink5 = Y Kong
| last6 = Park | first6 = S | authorlink6 = S Park
| last7 = Lin | first7 = HC | authorlink7 = Henry Lin
| display-authors = 3
| title = A link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testing
| journal = Annals of the Rheumatic Diseases | volume = 63| issue = 4| pages = 450–452
| date = Apr 2004
| pmid = 15020342
| doi = 10.1136/ard.2003.011502
| url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1754959/
}}</ref><ref name="LinHC2004">{{Citation
| last1 = Lin | first1 = HC | authorlink1 = Henry Lin
| title = Small intestinal bacterial overgrowth: A framework for understanding irritable bowel syndrome
| journal = JAMA | volume = 292| issue = 7| pages = 852–858
| date = 18 Aug 2004
| doi = 10.1001/jama.292.7.852
| url = http://jama.jamanetwork.com/article.aspx?articleid=199251
}}</ref>, while others fail to replicate these results<ref name="Walters2005">{{Citation
| last1 = Walters | first1 = B | authorlink1 = B Walters
| last2 = Vanner | first2 = SJ | authorlink2 = S J Vanner
| title = Detection of bacterial overgrowth in IBS using the lactulose H2 breath test: comparison with 14C-D-xylose and healthy controls
| journal = The American Journal of Gastroenterology | volume = 100| issue = 7| pages = 1566–1570
| date = Jul 2005
| pmid = 15984983
| doi = 10.1111/j.1572-0241.2005.40795.x
| url = http://www.ncbi.nlm.nih.gov/pubmed/15984983
}}</ref><ref name="Parisi2003">{{Citation
| last1 = Parisi | first1 = Giancarlo
| last2 = Leandro | first2 = Gioacchino
| last3 = Bottona | first3 = E
| last4 = Carrara | first4 = M
| last5 = Cardin | first5 = F
| last6 = Faedo | first6 = A
| last7 = Goldin | first7 = D
| last8 = Pantalena | first8 = M
| last9 = Tafner | first9 = G
| last10 = Verdianelli | first10 = G
| last11 = Zilli | first11 = M
| last12 = AISGE Group
| display-authors = 3
| title = Small intestinal bacterial overgrowth and irritable bowel syndrome
| journal = The American Journal of Gastroenterology | volume = 98| issue = 11| pages = 2572–2573-2574
| date = Nov 2003
| pmid = 14638371
| doi = 10.1111/j.1572-0241.2003.08686.x
| url = http://www.ncbi.nlm.nih.gov/pubmed/15984983
}}</ref>.

One study found that a 100% of [[fibromyalgia]] patients tested positive to a lactulose breath test, indicating SIBO, and that the degree of abnormality on the breath test correlated with the amount of pain reported.<ref name="Pimentel2004" />

== Risk factors ==

Risk factors include bowel resection, bariatric surgery, disordered motility, disorders of the immune system such as [[IgA]] deficiency, [[low stomach acid]], the use of [[proton pump inhibitors]] and immunosuppressants, and recurrent antibiotic use.<ref name="Dukowicz2007" /> [[Hypothyroidism]] and T4-only [[Thyroid hormones|thyroid hormone]] replacement are both strongly associated with SIBO.<ref>{{Cite journal|last=Lauritano|first=Ernesto Cristiano|last2=Bilotta|first2=Anna Lisa|last3=Gabrielli|first3=Maurizio|last4=Scarpellini|first4=Emidio|last5=Lupascu|first5=Andrea|last6=Laginestra|first6=Antonio|last7=Novi|first7=Marialuisa|last8=Sottili|first8=Sandra|last9=Serricchio|first9=Michele|date=Nov 2007|title=Association between Hypothyroidism and Small Intestinal Bacterial Overgrowth|url=https://academic.oup.com/jcem/article/92/11/4180/2598186|journal=The Journal of Clinical Endocrinology & Metabolism|language=en|volume=92|issue=11|pages=4180–4184|doi=10.1210/jc.2007-0606|issn=0021-972X}}</ref><ref>{{Cite journal|last=Lauritano|first=Ernesto Cristiano|last2=Bilotta|first2=Anna Lisa|last3=Gabrielli|first3=Maurizio|last4=Scarpellini|first4=Emidio|last5=Lupascu|first5=Andrea|last6=Laginestra|first6=Antonio|last7=Novi|first7=Marialuisa|last8=Sottili|first8=Sandra|last9=Serricchio|first9=Michele|date=Nov 2007|title=Association between Hypothyroidism and Small Intestinal Bacterial Overgrowth|url=https://academic.oup.com/jcem/article/92/11/4180/2598186|journal=The Journal of Clinical Endocrinology & Metabolism|language=en|volume=92|issue=11|pages=4180–4184|doi=10.1210/jc.2007-0606|issn=0021-972X}}</ref>

Conditions that affect gut motility such as [[gastroparesis]] and [[celiac disease]] increase the risk of SIBO.<ref name="Dukowicz2007" /> Rates of SIBO are also higher in [[Crohn's disease]], pancreatitis, and renal failure.<ref name="Dukowicz2007" />

SIBO is more common among the elderly.<ref name="Dukowicz2007" />

== Diagnosis ==

SIBO can be diagnosed using a [[hydrogen breath test]]. The diagnosis of SIBO is controversial due to the species-dependent nature of breath tests and the lack of an agreed threshold for a positive test.<ref name="Dukowicz2007" /> It can also be diagnosed through bacterial culture, but this is rare as it requires intubation of the small intestine.

== Pathophysiology ==

Bacteria commonly implicated in SIBO include ''[[Escherichia coli]]'', ''[[Streptococcus]]'', ''[[Lactobacillus]]'', ''[[Bacteroides]]'' and ''[[Enterococcus]]''.<ref name="Bouhnik2016">{{Citation
| last1 = Bouhnik | first1 = Yoram | authorlink2 =
| last2 = Alain | first2 = Sophie | authorlink3 =
| last3 = Attar | first3 = Alain | authorlink4 =
| last4 = Flourié | first4 = Bernard | authorlink5 =
| last5 = Raskine | first5 = Laurent | authorlink6 =
| last6 = Sanson-Le Pors | first6 = Marie José | authorlink7 =
| last7 = Rambaud | first7 = Jean-Claude | authorlink8 =
| display-authors = 3
| title = Bacterial populations contaminating the upper gut in patients with small intestinal bacterial overgrowth syndrome
| journal = The American Journal of Gastroenterology | volume = 94| issue = 5| pages = 1327–1331
| date = May 1999
| doi = 10.1111/j.1572-0241.1999.01016.x
| url = http://www.nature.com/ajg/journal/v94/n5/full/ajg1999310a.html
}}</ref> Higher levels of ''Enterococcus'' and ''Stretptococcus'' have been found in [[ME/CFS]] patients.<ref name="Sheedy2009">{{citation
| last1 = Sheedy | first1 = John R | authorlink1 = John Sheedy
| last2 = Wettenhall | first2 = Richard EH | authorlink2 = Richard Wettenhall
| last3 = Scanlon | first3 = Denis | authorlink3 = Denis Scanlon
| last4 = Gooley | first4 = Paul R | authorlink4 = Paul Gooley
| last5 = Lewis | first5 = Donald P | authorlink5 = Donald Lewis
| last6 = McGregor | first6 = Neil | authorlink6 = Neil McGregor
| last7 = Stapleton | first7 = David I | authorlink7 = David Stapleton
| last8 = Butt | first8 = Henry L | authorlink8 = Henry Butt
| last9 = De Meirleir | first9 = Kenny L | authorlink9 = Kenny de Meirleir
| display-authors = 3
| title = Increased d-lactic Acid intestinal bacteria in patients with chronic fatigue syndrome
| journal = In Vivo | volume = 2009 Jul-Aug;23(4) | page = 621-8
| date = Jul 2009
| pmid = 19567398
| url = http://iv.iiarjournals.org/content/23/4/621.long
}}</ref>

== Health complications ==

The symptoms of SIBO can vary greatly depending on the severity and the species of bacterial populating the small intestine.<ref name="Parisi2003" /> Symptoms include bloating, abdominal distension, abdominal pain or discomfort, diarrhea, fatigue, and weakness.

It causes increased permeability of the small intestine.<ref>Reference needed</ref> It can cause malabsorption of nutrients including iron and [[Vitamin B12]], resulting in [[microcytic anemia]] or [[megaloblastic anemia]].

===Nutritional deficiencies===

Vitamin B12 malabsorption may be caused by competitive uptake of B12 by bacteria in the small intestine.<ref name="Dukowicz2007" /> It can also cause excess folic acid due to synthesis by bacteria in the small bowel.<ref name="Camilo1996">{{Citation
| last1 = Camilo | first1 = E
| last2 = Zimmerman | first2 = J
| last3 = Mason | first3 = JB
| last4 = Golner | first4 = B
| last5 = Russell | first5 = R
| last6 = Selhub | first6 = J
| last7 = Rosenberg | first7 = IH
| display-authors = 3
| title = Folate synthesized by bacteria in the human upper small intestine is assimilated by the host
| journal = Gastroenterology | volume = 110| issue = 4| pages = 991–998
| date = Apr 1996
| pmid = 8613033
| url = http://www.ncbi.nlm.nih.gov/pubmed/8613033
}}</ref>

In severe cases, malabsorption of fat-soluble vitamins ([[Vitamin A|A]],[[Vitamin D|D]],[[Vitamin E|E]] and [[Vitamin K|K]]) due to the deconjugation of [[bile salts]] can cause neuropathies and immune dysfunction.

SIBO can also cause carbohydrate and protein malabsorption.<ref name="Dukowicz2007" />

== Treatment ==

Standard treatment is a course of antibiotics. <ref>Reference needed</ref> The best evidence for patients without constipation is for the use of [[rifaximin]], an antibiotic that is stays in the intestine and is not absorbed in the body.<ref name="Bures2010">{{Citation
| last1 = Bures | first1 = Jan
| last2 = Cyrany | first2 = Jiri
| last3 = Kohoutova | first3 = Darina
| last4 = Förstl | first4 = Miroslav
| last5 = Rejchrt | first5 = Stanislav
| last6 = Kvetina | first6 = Jaroslav
| last7 = Vorisek | first7 = Viktor
| last8 = Kopacova | first8 = Marcela
| display-authors = 3
| title = Small intestinal bacterial overgrowth syndrome
| journal = World Journal of Gastroenterology : WJG | volume = 16| issue = 24| pages = 2978–2990
| date = 28 Jun 2010
| pmid = 20572300
| doi = 10.3748/wjg.v16.i24.2978
| url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2890937/
}}</ref> Some SIBO researchers recommend adding Neomycin to rifaxamin for patients with constipation, as neomycin appears to help kill methane-producing bacteria. <ref>{{Cite journal|last=Low|first=Kimberly|last2=Hwang|first2=Laura|last3=Hua|first3=Johnson|last4=Zhu|first4=Amy|last5=Morales|first5=Walter|last6=Pimentel|first6=Mark|date=Sep 2010|title=A combination of rifaximin and neomycin is most effective in treating irritable bowel syndrome patients with methane on lactulose breath test|url=https://www.ncbi.nlm.nih.gov/pubmed/19996983|journal=Journal of Clinical Gastroenterology|volume=44|issue=8|pages=547–550|doi=10.1097/MCG.0b013e3181c64c90|issn=1539-2031|pmid=19996983}}</ref> However, one study comparing two herbal formulations to standard treatment found herbs to be as or more effect as antibiotics for eradicating SIBO.<ref name="Chedid2014">{{Citation
| last1 = Chedid | first1 = Victor
| last2 = Dhalla | first2 = Sameer
| last3 = Clarke | first3 = John O
| last4 = Roland | first4 = Bani Chander
| last5 = Dunbar | first5 = Kerry B
| last6 = Koh | first6 = Joyce
| last7 = Justino | first7 = Edmundo
| last8 = Tomakin | first8 = Eric
| last9 = Mullin | first9 = Gerard E
| display-authors = 3
| title = Herbal Therapy Is Equivalent to Rifaximin for the Treatment of Small Intestinal Bacterial Overgrowth
| journal = Global Advances in Health and Medicine | volume = 3| issue = 3| pages = 16–24
| date = May 2014
| pmid = 24891990
| doi = 10.7453/gahmj.2014.019
| url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030608/
}}</ref>

Experts also recommend the use of [[prokinetic drugs]] or herbs for those for whom dysmotility is an issue.<ref name="Dukowicz2007" />

[[Probiotics]] may also be helpful. ''[[Lactobacillus casei]]'' has been found to improve breath hydrogen scores after six weeks of treatment.<ref name="Barrett2008">{{Citation
| last1 = Barrett | first1 = Jacqueline S
| last2 = Canale | first2 = Kim EK
| last3 = Gearry | first3 = Richard B
| last4 = Irving | first4 = Peter M
| last5 = Gibson | first5 = Peter R
| display-authors = 3
| title = Probiotic effects on intestinal fermentation patterns in patients with irritable bowel syndrome
| journal = World Journal of Gastroenterology : WJG | volume = 14| issue = 32| pages = 5020–5024
| date = 28 Aug 2008
| pmid = 18763284
| doi = 10.3748/wjg.14.5020
| url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742929/
}}</ref> There is also evidence for [[VSL #3]] in the treatment of SIBO.<ref name="Meier2003">{{Citation
| last1 = Meier | first1 = Rémy
| last2 = Burri | first2 = Emanuel
| last3 = Steuerwald | first3 = Michael
| title = The role of nutrition in diarrhoea syndromes
| journal = Current Opinion in Clinical Nutrition and Metabolic Care | volume = 6| issue = 5| pages = 563–567
| date = Sep 2003
| pmid = 12913674
| doi = 10.1097/01.mco.0000087972.83880.d3
| url = http://www.ncbi.nlm.nih.gov/pubmed/12913674
}}

</ref> However, some probiotics may exacerbate SIBO, in particular those containing [[D-Lactate]] producing strains.

== See also ==

*[[Gastrointestinal system]]
*[[Dysbiosis]]
*[[Probiotics]]

== References==
[[Category:Diagnoses]]
[[Category:Signs and symptoms]]
[[Category:Digestive signs and symptoms]]
<references />20. UHN Staff. "SIBO Treatment with Herbs Is as Effective as Antibiotics". University Health News (June 29, 2018). https://universityhealthnews.com/daily/digestive-health/sibo-treatment-with-herbs-is-as-effective-as-antibiotics-combine-with-a-sibo-diet-for-even-better-results/

Gastroparesis

2018-10-06T22:06:46Z

Living with cfs me:/* See also */ added website that has pamphlet on gastroparesis & ME. I found it really helpful!

'''Gastroparesis''' is a neuro-muscular abnormality that causes delayed gastric emptying which, in turn, causes a premature full feeling while eating, bloating, [[nausea]], [[acid reflux]], regurgitation, belching, and occasional vomiting. It is a co-morbid condition associated with [[ME/CFS]], [[Ehlers Danlos Syndrome]], and several other diseases.<ref>http://www.digestivedistress.com/sites/default/files/pdf/ibs.pdf</ref><ref>https://en.wikipedia.org/wiki/Gastroparesis</ref>

Gastroparesis may be precipitated by a viral illness such as [[Epstein-Barr virus]] or a viral infection that causes gastroenteritis or the “stomach flu." Studies have implicated an immune dysfunction, as well as, a dysfunction of the [[autonomic nervous system]] as part of the pathophysiology. It can, also, result when the [[vagus nerve]] is damaged by illness or injury.<ref>https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/gastroparesis/Pages/facts.aspx</ref> Seventy to eighty percent of individuals with primary gastroparesis are young women.<ref>http://www.digestivedistress.com/sites/default/files/pdf/ibs.pdf</ref>

There is no cure, at present, for gastroparesis, so the primary treatment is to manage symptoms with: pro-motility medications, acid-suppressing medications, antacids, and anti-nausea medications if needed. Diet, also, plays a large role in symptom control. In particular, avoid high fat and high fiber foods, eat small portions throughout the day, and use liquid food supplements.<ref>http://www.digestivedistress.com/sites/default/files/pdf/ibs.pdf</ref>

Gastroparesis is frequently misdiagnosed as [[Irritable Bowel Syndrome]] (IBS), but the chief difference is where the distress is occurring. Gastroparesis refers to a disorder in the upper digestion system, especially the stomach, whereas, IBS refers to the lower digestion system, especially the bowels. A series of tests may be necessary for determining if one has gastroparesis, including: [[endoscopy]], [[CT scan]], upper gastrointestinal (GI) series, [[breath test]], and a [[Gastric emptying study]].<ref>http://www.mayoclinic.org/diseases-conditions/gastroparesis/basics/tests-diagnosis/con-20023971</ref> The American Motility Society has established that a 4-hour “Gastric emptying test" is the standard for diagnosing gastroparesis.<ref>http://www.digestivedistress.com/sites/default/files/pdf/ibs.pdf</ref>

==Studies==
*2016, Gastric Enterovirus Infection: A Possible Causative Etiology of Gastroparesis<ref name="Barkin,2016" /> [https://www.ncbi.nlm.nih.gov/pubmed/27344315 (Abstract)]
*2004, Gastric emptying is slow in chronic fatigue syndrome<ref>Burnet, R. B., & Chatterton, B. E. (2004). Gastric emptying is slow in chronic fatigue syndrome. BMC Gastroenterology, 4, 32. http://doi.org/10.1186/1471-230X-4-32</ref> [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC544348/ (Full Text)]

==Learn more==
*[https://en.wikipedia.org/wiki/Gastroparesis Wikipedia]
*[https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/gastroparesis/Pages/facts.aspx NIH info on gastroparesis]
*[http://www.digestivedistress.com/intro Understanding Gastroparesis]
*[http://forums.phoenixrising.me/index.php?threads/gastroparesis-delayed-stomach-emptying-and-colonic-inertia.2491/ Phoenix Rising Forum on Gastroparesis]

==See also==
*[[Irritable bowel syndrome]]
*[[Small intestine bacterial overgrowth]]
*[[Nausea]]
*http://www.digestivedistress.com/sites/default/files/pdf/ibs.pdf

==References==
<references>
<ref name="Barkin,2016">{{Citation
| last1 = Barkin | first1 = JA | authorlink1 =
| last2 = Czul | first2 = F | authorlink2 =
| last3 = Barkin | first3 = JS | authorlink3 =
| last4 = Klimas | first4 = NG | authorlink4 = Nancy Klimas
| last5 = Rey | first5 = IR | authorlink5 = Irma Rey
| last6 = Moshiree | first6 = B | authorlink6 =
| display-authors =
| title = Gastric Enterovirus Infection: A Possible Causative Etiology of Gastroparesis
| journal = Digestive Diseases and Sciences | volume = 61 | issue = 8 | page = 2344-50
| date = Aug 2016
| pmid = 27344315
| doi = 10.1007/s10620-016-4227-x
}}
</ref>
</references>

[[Category:Diagnoses]]

GABA

2018-05-21T12:18:46Z

Living with cfs me:update format to be easier to read

GABA (gamma aminobutyric acid), is a neurotransmitter made from the amino acid glutamate. GABA is the chief inhibiting, or calming neurotransmitter in the brain, functioning as a brake on the neural circuitry during stress. Low GABA levels are associated with restlessness, anxiety, [[insomnia]] and a poor mood. GABA works to balance glutamate (excitatory) in the brain. GABA is the brake pedal on a car while glutamate is the gas pedal.

Supplements to support GABA & glutamate are:
amino acids GABA, L-theanine, N-Acetyl Cysteine (NAC), vitamins B6, vitamin D, magnesium, zinc, omega-3, and inositol.

Abdou AM, Higashiguchi S, Horie K et al: Relaxation and immunity enhancement effects of gamma aminobutyric acid (GABA) administration in humans. Biofactors, 2006; 26(3): 201–8

Kendell SF, Krystal JH, Sanacora G: GABAandglutamate systems as therapeutic targets in depressionand mood disorders. Expert OpinTher Targets, 2005; 9: 153–68

Kugaya A, Sanacora G: Beyond monoamines: glutamatergic function in mood disorders. CNS Spectr, 2005; 10: 808–19

Thorne Research, Inc: Gamma-Aminobutyric Acid (GABA). Alternative Medicine Review, 2007; 12(3)

GABA

2018-05-21T12:15:52Z

Living with cfs me:GABA (Gamma-Aminobutyric Acid)

GABA (gamma aminobutyric acid), is a neurotransmitter made from the amino acid glutamate. GABA is the chief inhibiting, or calming neurotransmitter in the brain, functioning as a brake on the neural circuitry during stress. Low GABA levels are associated with restlessness, anxiety, insomnia and a poor mood. GABA works to balance glutamate (excitatory) in the brain. GABA is the brake pedal on a car while glutamate is the gas pedal.

Supplements to support GABA & glutamate are:
amino acids GABA
L-theanine
N-Acetyl Cysteine (NAC)
vitamins B6
vitamin D
magnesium
zinc
omega-3
inositol

Abdou AM, Higashiguchi S, Horie K et al: Relaxation and immunity enhancement effects of gamma aminobutyric acid (GABA) administration in humans. Biofactors, 2006; 26(3): 201–8

Kendell SF, Krystal JH, Sanacora G: GABAandglutamate systems as therapeutic targets in depressionand mood disorders. Expert OpinTher Targets, 2005; 9: 153–68

Kugaya A, Sanacora G: Beyond monoamines: glutamatergic function in mood disorders. CNS Spectr, 2005; 10: 808–19

Thorne Research, Inc: Gamma-Aminobutyric Acid (GABA). Alternative Medicine Review, 2007; 12(3)

Silymarin

2018-05-21T11:44:33Z

Living with cfs me:Silymarin promotes liver health and helps detoxify

Silymarin (active extract of milk thistle) promotes liver health. Silymarin supports of healthy DNA function, stabilizes plasma membranes, and stimulates of liver cells. Silymarin promotes detoxification.

The active extract of milk thistle, called silymarin, is a mixture of flavonolignans, and includes silydianin, silychristin, and silybin, with silybin being the most biologically active.

www.ncbi.nlm.nih.gov/pubmed/24225033
www.ncbi.nlm.nih.gov/pubmed/21633595

Telmisartan

2018-04-30T00:23:13Z

Living with cfs me:create telmisartan page

Telmisartan is a anti-hypertension drug that has some other interesting benefits. Telmisartan enhances insulin sensitivity, increases utilization of fat as energy, and improves mitochondrial function. This last benefit is what is of interest for CFS/ME sufferers. Mitochondrial dysfunction is a theory of what causes some of the CFS/ME symptoms.

Turmeric

2018-04-30T00:08:06Z

Living with cfs me:add tumeric page

Tumeric is a flowering plant of the ginger family. Tumeric is used in Indian cuisine curries (its what makes curry yellow). Tumeric is used in Ayurvedic medicine (ancient Indian medicine). Tumeric is an anti-inflamatory. Bio-available (easily absorbable) curcumin, a chief component of tumeric, is a supplement. Curcumin extract promotes immune system health by inhibiting histamine release from mast cells. Curcumin can also benefit your brain. In some studies, curcumin supported healthy brain function and offered neuro-protective benefits. Interestingly, Alzheimer's disease is virtually unheard of in India where the populate regularly consumes tumeric.

SAM-e

2018-04-29T23:45:24Z

Living with cfs me:added SAMe page

SAMe is S-Adenosyl-Methionine. SAMe is an amino acid derivative normally synthesized in the body that may become depleted with sickness or age. SAMe helps maintain stable mood and joint function. In addition, SAMe has also shown benefits for the liver and brain. Since CFS/ME is a neuroimmune disease, SAMe may assist sufferers in overcoming some of the distressing brain function symptoms as well as providing a mood lifter. SAMe aids in the synthesis of norepinephrine, dopamine, and serotonin (neurotransmitters). SAMe also facilitates healthy methylation.

Alpha-lipoic acid

2018-04-29T23:35:31Z

Living with cfs me:added alpha lipoic acid page

Alpha lipoic acid is an antioxidant for liver and nerve health. Alpha lipoic acid is a cofactor for some of the key enzymes (alpha keto acid dehydrogenases) involved in generating energy from food and oxygen in mitochondria and thus plays a critical role in energy production within the cell’s mitochondria. Since one theory of CFS/ME is mitochondria dysfunction supplementation may aid in energy production and reduce fatigue.

Leaky gut diet

2018-04-29T22:04:44Z

Living with cfs me:added leaky gut page

The Leaky Gut diet is designed to help those with increased intestinal permeability heal their guts (intestines). Leaky gut is a condition (disease of civilization) where the holes in the intestines are too big and allow food particles and bacteria to pass into the blood stream. Leaky gut can cause fatigue, inflamation, swollen glands, and rosacea.

The following are consumed on the Leaky Gut diet: grass-fed bone broth, raw cultured dairy (ie kefir, 24 hour fermented yogurt), steamed vegetables, fermented vegetables, healthy fats, and a small amount of fruit.

Foods thought to contribute to leaky gut and eliminated on the diet are: grains, sugar (in any form), cow dairy, unsprouted grains, and GMO.

Supplements to be taken on the leaky gut diet: l-glutamine, probiotics, prebiotics, fish oil (omega 3), digestive enzymes, and aloe vera juice.

Glutamine

2018-04-29T21:51:59Z

Living with cfs me:added glutamine page

Glutamine is the most abundant free amino acid circulating in the blood as well as stored in the skeletal muscles. Glutamine is a diverse amino acid that is utilized in numerous vital functions. It is necessary for rapidly dividing cells, including those of the gut and immune system. Glutamine is used by the mitochondria in energy production and is a precursor to the neurotransmitter, glutamate. Glutamate sends signals between nerve cells, and under normal conditions it plays an important role in learning and memory

People who suffer from increased intestinal permeability (aka leaky gut) supplement with L-glutamine as it is thought to repair the intestinal tract. Leaky gut can drive fatigue and inflamation. Some CFS/ME sufferers have found some fatigue abatement by following the Leaky Gut diet.

Acetyl-L-carnitine

2018-04-29T21:16:37Z

Living with cfs me:created ALC page

Acetyl-L-carnitine is effective at carrying long-chain fatty acids across the membrane into the mitochondria where they are burned for energy production and utilized efficiently by the cells. There is a theory that ME/CFS is based in mitochondrial dysfunction. Supplementing with acetyl-l-carnitine may potentially improve energy production and lessen fatigue.

Vinpocetine

2018-04-29T21:03:18Z

Living with cfs me:created vinpocetine page

Vinpocetine enhances cerebral blood flow by dilating blood vessels and reducing blood viscosity. Vinpocetine enhances cerebral metabolism by helping to maintain healthy blood flow and oxygen utilization.

5-Hydroxytryptophan

2018-04-29T21:00:12Z

Living with cfs me:revised wording on improvements in symptoms

5-HTP (5-Hydroxytryptophan) is an endogenous precursor to Serotonin. (Serotonin is a neurotransmitter found primarily in the digestive tract and central nervous system.)

5-HTP supplementation in fibromyalgia patients is associated with considerable improvements in anxiety, pain intensity, quality of sleep, fatigue, and the number of tender points. As there seems to be an overlap in symptoms between CFS/ME and Fibromyalgia, CFS/ME patients should try supplementing, in conjunction with their physicians' advice, with 5-HTP to see if the quality of sleep improves and lessened fatigue is experienced.

5-Hydroxytryptophan

2018-04-29T20:58:34Z

Living with cfs me:added 5-htp page

Hormone

2018-04-29T20:32:32Z

Living with cfs me:Added a hormone page

Hormones:

Anecdotally, some sufferers of CFS/ME find help in supplementing with Melatonin. Melatonin, also known as N-acetyl-5-methoxy tryptamine, is a hormone that is produced by the pineal gland in animals and regulates sleep and wakefulness. Those supplementing with Melatonin report better, deeper sleep. Sufferers report the effect of Melatonin supplementation is not immediate and should be tried for a few weeks before determining if it mitigates sleep problems. Supplementation can range from 1 mg/day to 10 mg/day and perhaps higher as studies involving breast cancer patients have supplemented with 20 mg/day. Melatonin supplementation should be done in conjunction with your physician's advice.

Vitamin D would also be a good hormone to supplement for ME/CFS sufferers. Low Vitamin D has been linked to many diseases including MS (multiple sclerosis which like ME is a neuroimmune disease). Optimal Vitamin D range is 50 – 80 ng/mL. Vitamin D can be tested with a simple, inexpensive blood test by a physician. A good process to follow is to have your physician test your Vitamin D level and then begin supplementation. Typical supplementation varies by individual and ranges from 1,000 IU per day to 10,000 IU per day. After supplementing for 90 days, have your physician retest and continue this process by increasing your dose until you reach at least 50 ng/mL on your test.

Restoring youthful hormone levels may be helpful for those sufferers over 25 years of age, as hormone levels peak in late teens/early 20s. Restoration should only be done with bioidentical hormones. Hormones to ask your physician about should include DHEA, Testosterone, Progesterone, Estradiol, Estriol, and Pregnenolone. Estriol and Estradiol are typically supplemented in an 80/20 ratio. Hormone level can be assessed via urine, saliva, and blood. Each type of test has pros and cons.

Post-exertional malaise

2018-04-29T19:41:12Z

Living with cfs me:/* Possible causes */

'''Post-exertional malaise''' (PEM) is a worsening of many [[ME/CFS]] symptoms as a result of physical or mental exertion. Patients, ME/CFS organizatons, clinicians and researchers that work in the ME/CFS field often referred to it as "the marker," i.e., the main symptom that differentiates [[ME]] and [[CFS]] from other fatiguing illnesses. PEM can last for days to weeks after the exertion.<ref name="JohnsonCsymptoms" /><ref name="FightFatiguePEM" />

Worsening symptoms include [[chronic fatigue]], flu-like symptoms, brain fog ([[cognitive dysfunction]]), [[unrefreshing sleep]], chronic pain, [[orthostatic intolerance]], [[neurally mediated hypotension]], [[POTS]] and more. "As with the severity, the exertion needed to trigger PEM theories case-by-case. For some, it might kick in after a little bit of exercise on top of a day's regular activities. For others, is incredible as it may seem, it can just take a trip to the mailbox, a shower, or sitting upright for an hour." <ref>[https://www.verywell.com/what-is-post-exertional-malaise-716023 What Is Post-exertional Malaise - Very Well - Adrienne Dellwo]</ref><ref>[https://www.verywell.com/post-exertional-malaise-715670 Post Exertional Malaise - Very Well - Adrienne Dellwo]</ref><ref>[http://www.webmd.com/chronic-fatigue-syndrome/chronic-fatigue-syndrome-symptoms Chronic Fatigue Syndrome - Web MD]</ref><ref>[http://solvecfs.org/wp-content/uploads/2013/10/pem-series.pdf PEM Series - Solve ME/CFS - Jenny Spotila]</ref> Onset of PEM can be delayed 24-72 hours.<ref>[http://www.whathealth.com/awareness/event/internationalcfsmeawarenessday.html What Health - International CFS/ME Awareness Day 2017 - CFIDS Association of America]</ref>

A 2016 DePaul University study focused on deciphering if post-exertional malaise was a generalized, full-body fatigue and/or a muscle-specific fatigue. The results suggested that PEM is composed of two empirically different experiences, one for generalized fatigue and one for muscle-specific fatigue.<ref name="McManimen, 2016" />

==2015 Institute of Medicine report==
[[File:2015 IOM report PEM chart.png|right|frame|PEM chart from the 2015 Institute of Medicine report]]

This landmark report published in 2015 by the [[United States]] [[Institute of Medicine report]], which assessed all the evidence available, concluded:

<blockquote>"There is sufficient evidence that PEM is a primary feature that helps distinguish ME/CFS from other conditions"</blockquote>

Pages 84-86 of the report describe the evidence for post-exertional malaise in ME/CFS patients.<ref>[http://www.nap.edu/read/19012/chapter/6?term=exercise#84 Institute of Medicine report pages 84-86, search term exercise]</ref>

==Prevalence==

==Symptom recognition==
===Required===

*In the [[International Consensus Criteria]], postexertional neuroimmune exhaustion is required for a diagnosis of ME.
*In diagnosing [[Systemic Exertion Intolerance Disease]] (SEID).

===Optional===

*In the [[Fukuda criteria]], the symptom of post-exertional malaise can be used to help form a diagnosis.<ref>[http://www.cfids-me.org/cdcdefine.html The CDC (Fukuda 1994) Definition for Chronic Fatigue Syndrome]</ref> Unusually, it is not a required symptom for diagnosis.
*In the [[Canadian Consensus Criteria]] PEM is an option with an and/or with fatigue although most researchers require PEM.
*In the [[Holmes criteria]], prolonged (24 hours or greater) generalized fatigue after levels of exercise that would have been easily tolerated in the patient's premorbid state is an optional criteria for diagnosis, under the section ''Minor Symptom Criteria''.<ref>[http://www.cfids-me.org/holmes1988.html The 1988 Holmes Definition for CFS]</ref>

==Notable studies==

*2016, [https://www.ncbi.nlm.nih.gov/pubmed/27557649 Deconstructing post-exertional malaise: An exploratory factor analysis.] <blockquote> "Abstract: Post-exertional malaise is a cardinal symptom of myalgic encephalomyelitis and chronic fatigue syndrome. There are two differing focuses when defining post-exertional malaise: a generalized, full-body fatigue and a muscle-specific fatigue. This study aimed to discern whether post-exertional malaise is a unified construct or whether it is composed of two smaller constructs, muscle fatigue and generalized fatigue. An exploratory factor analysis was conducted on several symptoms that assess post-exertional malaise. The results suggest that post-exertional malaise is composed of two empirically different experiences, one for generalized fatigue and one for muscle-specific fatigue."<ref name="McManimen, 2016" /></blockquote>
*1999, [https://www.ncbi.nlm.nih.gov/pubmed/10209352 Demonstration of delayed recovery from fatiguing exercise in chronic fatigue syndrome]
*2013, [http://www.tandfonline.com/doi/abs/10.1080/21641846.2013.838444 Post-exertion malaise in chronic fatigue syndrome: symptoms and gene expression], ''Meyer et al'', 2013<ref name="MeyerJ2013" />
*2015, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4761639/#!po=2.51799 Myalgic Encephalomyelitis: Symptoms and Biomarkers], ''Jason et al'', 2015<ref name="JasonL2015bio" />
*2015, [http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0145453 Changes in Gut and Plasma Microbiome following Exercise Challenge in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)], ''Shukla et al'', 2015<ref name="ShuklaS2015" />

[[File:2010 VanNess Post exertional worsening of symptoms chart.png|right|frame|Post-exertional worsening of symptoms, VanNess et al 2010.png]]<ref name="VanNess2010" />

==Notable articles==

*Nov 4, 2016 [http://www.medscape.com/viewarticle/871482#vp_1 Postexertion 'Crash,' not Fatigue per se, Marks Syndrome], MedScape By: Miriam Tucker

*Dec 30, 2015 [http://me-cfs.se/blogg/suggestion-to-replace-pem-by-par/ Suggestion to replace PEM (Post Exertional Malaise) with PAR (Post Activity Relapse)], ''ME Blogg'', 2015<ref name="MEBlogg2015" />

==Talks & interviews==

*2016, [https://www.youtube.com/watch?v=ux93w7yGQ5g&feature=youtu.be Inducing Post-Exertional Malaise in ME/CFS: A Look at the Research Evidence] ([[Peter Rowe]])
*2015, [https://www.youtube.com/watch?v=vfmrPd4-rIE Post-Exertion Malaise: The Intersection of Biology and Behavior], ''[[Dane Cook]], [[Solve ME/CFS]]''<ref name="CookD20151119v" />
*2015, [https://www.youtube.com/watch?v=F1PP21TmUPs 72. Gene-expression and exercise / Gen-expressie en inspanning – dr. Lucinda Bateman] ([[Lucinda Bateman]], [[Science for Patients]])
*2013, [https://www.youtube.com/watch?v=zZ8aPYihkpQ CFS gene expression after exercise (part 1)] ([[Lucinda Bateman]])
*2012, [https://www.youtube.com/watch?v=B20H1u1LjCE&feature=youtu.be Top 10 Things You Should Know About Post-Exertional Relapse] ([[Staci Stevens]])

==Possible causes==
Dysfunction of the ATP ADP cycle. Dr. Sarah Myhill has developed a test to assess ATP profiles. www.healthrising.org/forums/resources/hips-overview-of-dr-myhills-atp-work-in-chronic-fatigue-syndrome-me-cfs.390/

==Potential treatments==

==Learn more==

*[http://www.whathealth.com/awareness/event/internationalcfsmeawarenessday.html International CFS/ME Awareness Day 2017 - What Health] (PEM Definition Included) [[CFIDS Association of America]]
*[http://solvecfs.org/wp-content/uploads/2013/10/pem-series.pdf Post-Exertional Malaise in Chronic Fatigue Syndrome], ''[[Jennie Spotila]], [[Solve ME/CFS]]'', 2010<ref name="SpotilaJ2010" />
*[http://solvecfs.org/post-exertional-malaise-cause-and-effect/ Post-Exertional Malaise: Cause and Effect], ''[[Jennie Spotila]], [[Solve ME/CFS]]'', 2012<ref name="SpotilaJ20120523" />
*[http://chronicfatigue.about.com/od/cfsglossary/g/malaise.htm Definition of Post-Exertional Malaise], ''About Health'', 2015<ref name="AboutHealthPEM" />
*[https://www.youtube.com/watch?v=ckT9BbSH0Lo Post-Exertional Malaise] Video, ''[[ME/CFS Ghost]]'', 2016<ref>[https://www.youtube.com/watch?v=ckT9BbSH0Lo Post-Exertional Malaise - The ME/CFS Ghost]</ref>
*2016, [http://www.healthrising.org/blog/2016/07/04/exercise-intolerance-fibromyalgia-chronic-fatigue-pots-explained/ The Exercise Intolerance in POTS, ME/CFS and Fibromyalgia Explained?]

==See also==

*[[Exercise]]

== References ==
<references>
<ref name="AboutHealthPEM">{{citation
| author = About Health
| title = Definition of Post-Exertional Malaise
| date = 8 Oct 2015
| url = http://chronicfatigue.about.com/od/cfsglossary/g/malaise.htm
}}</ref>
<ref name="CookD20151119v">{{citation
| last1 = Cook | first1 = DB | authorlink1 = Dane Cook
| title = Deciphering Post Exertion Malaise: The Intersection of Biology and Behavior
| type = video
| journal = Solve ME/CFS
| date = 19 Nov 2015
| url = https://www.youtube.com/watch?v=vfmrPd4-rIE
}}</ref>
<ref name="FightFatiguePEM">{{citation
| author = Fighting Fatigue
| title = Post-Exertional Malaise – A Hallmark Symptom of ME/CFS
| access-date = 29 March 2016
| url = http://www.fightingfatigue.org/post-exertional-malaise-a-hallmark-symptom-of-mecfs/
}}</ref>
<ref name="JasonL2015bio">{{Citation
| last1 = Jason | first1 = LA | authorlink1 = Leonard Jason
| last2 = Zinn | first2 = ML | authorlink2 = Marcie Zinn
| last3 = Zinn | first3 = MA | authorlink3 = Mark Zinn
| display-authors =
| title = Myalgic Encephalomyelitis: Symptoms and Biomarkers
| journal = Current Neuropharmacology | volume = 13(5) | page = 701-734
| date = September 2015
| doi = 10.2174/1570159X13666150928105725
| url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4761639/#!po=2.51799
}}</ref>
<ref name="JohnsonCsymptoms">{{citation
| last1 = Johnson | first1 = C | authorlink1 = Cort Johnson
| title = Health Rising: ME/CFS Symptoms
| access-date = 29 March 2016
| url = http://www.cortjohnson.org/about-chronic-fatigue-syndrome-mecfs/symptoms/
}}</ref>
<ref name="McManimen, 2016">{{Citation
| last1 = McManimen | first1 = SL | authorlink1 =
| last2 = Sunnquist | first2 = ML | authorlink2 = Madison Sunnquist
| last3 = Jason | first3 = LA | authorlink3 = Leonard Jason
| title = Deconstructing post-exertional malaise: An exploratory factor analysis.
| journal = Journal of Health Psychology | volume = | issue = | page =
| date = 2016
| pmid = 27557649
| doi = 10.1177/1359105316664139
}}
</ref>
<ref name="MEBlogg2015">{{citation
| author = ME Blogg
| title = Suggestion to replace PEM by PAR
| date = 30 Dec 2015
| url = http://me-cfs.se/blogg/suggestion-to-replace-pem-by-par/
}}</ref>
<ref name="MeyerJ2013">{{citation
| last1 = Meyer | first1 = JD | authorlink1 = Jacob Meyer
| last2 = Light | first2 = AR | authorlink2 = Alan Light
| last3 = Shukla | first3 = SK | authorlink3 = Sanjay Shukla
| last4 = Clevidence | first4 = D | authorlink4 = Derek Clevidence
| last5 = Yale | first5 = S | authorlink5 = Steven Yale
| last6 = Stegner | first6 = AJ | authorlink6 = Aaron Stegner
| last7 = Cook | first7 = DB | authorlink7 = Dane Cook
| display-authors =
| title = Post-exertion malaise in chronic fatigue syndrome: symptoms and gene expression
| journal = Fatigue: Biomedicine, Health & Behavior | volume = 1 | issue = 4 | page = 190-209
| date = 2 Oct 2013
| doi = 10.1080/21641846.2013.838444
| url = http://www.tandfonline.com/doi/abs/10.1080/21641846.2013.838444
}}</ref>
<ref name="ShuklaS2015">{{Citation
| last1 = Shukla | first1 = SK | authorlink1 = Sanjay Shukla
| last2 = Cook | first2 = D | authorlink2 = Dane Cook
| last3 = Meyer | first3 = JD | authorlink3 = Jacob Meyer
| last4 = Vernon | first4 = SD | authorlink4 = Suzanne Vernon
| last5 = Lee | first5 = T | authorlink5 = Thao Lee
| last6 = Clevidence | first6 = D | authorlink6 = Derek Clevidence
| last7 = Robertson | first7 = CE | authorlink7 = Charles Robertson
| last8 = Schrodi | first8 = SJ | authorlink8 = Steven Schrodi
| last9 = Yale | first9 = S | authorlink9 = Steven Yale
| last10 = Frank | first10= DN | authorlink10= Daniel Frank
| display-authors = 3
| title = Changes in Gut and Plasma Microbiome following Exercise Challenge in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)
| journal = Plos One | volume = 10(12) | page =
| date = 18 December 2015
| pmid =
| doi = 10.1371/journal.pone.0145453
| url = http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0145453
}}</ref>
<ref name="SpotilaJ2010">{{citation
| last1 = Spotila | first1 = JM | authorlink1 = Jennie Spotila
| title = Post-Exertional Malaise in Chronic Fatigue Syndrome
| journal = Solve ME/CFS
| date = 2010
| url = http://solvecfs.org/wp-content/uploads/2013/10/pem-series.pdf
}}</ref>
<ref name="SpotilaJ20120523">{{citation
| last1 = Spotila | first1 = JM | authorlink1 = Jennie Spotila
| title = Post-Exertional Malaise: Cause and Effect
| journal = Solve ME/CFS
| date = 23 May 2012
| url = http://solvecfs.org/post-exertional-malaise-cause-and-effect/
}}</ref>
<ref name="VanNess2010">{{Citation
| last1 = VanNess | first1 = M | authorlink1 = Mark VanNess
| last2 = Stevens | first2 = S | authorlink2 = Staci Stevens
| last3 = Bateman | first3 = L | authorlink3 = Lucinda Bateman
| last4 = Stiles | first4 = TL | authorlink4 = TL Stiles
| last5 = Snell | first5 = CR | authorlink5 = Christopher Snell
| display-authors =
| title = Postexertional malaise in women with chronic fatigue syndrome
| journal = Journal of Women's Health | volume = | issue = | page =
| date = February 2010
| pmid = 20095909
| doi = 10.1089/jwh.2009.1507
}}
</ref>
</references>

[[Category:Signs and symptoms]]