Digestive functional troubles and pain from mouth to anus: how to understand, treat and cure.*|
"Open the eyes and you shall see"
Functional diseases, pain and irritable organs are poorly understood, and therefore treated with suboptimal results. In fact, they are studied individually although numerous publications confirm their association with other digestive and extra-digestive dysfunctions. These associations favor a common cause.
Deductive studies, starting with a symptom and trying to understand its mechanism, fail because the mechanisms are complex and also possibly because various mechanisms may cause the same consequences.
I follow an opposite, inductive way. As a hepatologist, I understand quickly that treating the consequences of alcohol was inefficient, unless alcoholism itself and its causes are taken into account. It became clear that depression was the most important mechanism of alcohol craving. I developed therefore, along 25 years, a diagnostic and therapeutic system.
Starting with coccygodynia, it appeared that bodily signs of depression were numerous, frequently evocative and even specific. The association with psychic classical signs, association of signs with each other and the simultaneous disappearance with antidepressants, led me to the following conclusion: depression is a neuro-biochemical syndrome with multi-systemic consequences. The reason this has been overlooked lies in the divergence between neuro-bio-chemical scientific evidence and the day-to-day practice and concepts of dichotomy between soul and body in a platonician point of view. Therefore, depression has been considered more and more as purely psychic, forgetting the concept of endogenous depression and bodily manifestations, formerly well known.
Diagnostic systems used in psychiatry are designed to be specific but fail to define non-depression. As a consequence they are not sensitive. The vast majority of functional digestive troubles appear to me to be the direct consequence of a neurological dysfunction. Cure by antidepressants has confirmed my point of view.
The reason the efficiency of antidepressants is overlooked in many studies lies in the inability to foresee the efficiency and optimal dosage of each medication. So, a given dose of a given molecule improves only part of the patient. If the medication is not tolerated, it is going to be inefficient: change it. Any molecule has a threshold dose (for example, 25 to 50 mg/d for tricyclics), below this dose there is no effect at all (but amitryptiline).
If the medication is efficient, effect increases with dosage until a maximum is reached (a variable from almost nothing to perfect equilibration of depression). In the latter case, carry on a minimum of 6 months before slowly tapering dosage, checking that no sign reoccurs. In the former, change the molecule and try again. Sometimes many medications are efficient; sometimes only one works.
I usually start with a tricyclic, mainly amoxapine 25mg then 50 mg. Tricyclics lead to dry mouth and constipation only when badly tolerated (change molecule) or supra-optimal dosage (taper dosage). I find the following to be the most efficient: clomipramine, imipramine, maprotiline, dosulepine, escitalopram, sertraline, fluvoxamine, and venlafaxine.
An optimal dosage leads frequently to partial effect. If you change the molecule you take the risk of a loss of efficiency if you need to use it again. If you don't change it is impossible to reach a perfect equilibration with this medication and moreover the result is frequently unstable. The logical solution is associating a second molecule to the former. Any risk of association is low in practice, especially if patients are informed and the doctor easy to reach.
I used to associate different classes of drug. The result of this is sometimes inhibition (1+1=0) or no effect at all (1+1=1) requiring change of the new molecule. However, the effect is sometimes additive (1+1=2), requiring the usual dosage of the new molecule, or it can be potentiating (1+1=3), requiring a low initial dosage of the new molecule. In associations I prefer as the second molecule: venlafaxine, mianserine and moclobemide (the latter with special caution).
With the present method, I am able to cure durably more than 90% of digestive functional troubles, together with associated signs: bodily, psychic and relational, as well. It is easy in 70% of cases, a bit difficult in 10%, difficult in a further 10% and problematic in the last 10%. Patients eventually do well as a whole, which is the real task of medicine.
Owing to my private practice, I am unable to perform studies necessary to prove this method. However, importance of results seems worth trying it. Risk of trying does not exist and potential efficiency is revolutionary. Remain taboo!
Bernard Maroy MD
Methods to diagnose associated depression are detailed in my previous article "How to recognize depression in gastroenterological practice".
A large bibliography can be obtained on request or from my book "La Dépression et son Traitement : aspects méconnus" (In French). 2005. L'Harmattan. Paris. An abstract of the book is available in English on my website under the heading "Depression F&E".
This article was first published on GastroHep.com on the 4th of May 2010