How to heal a post-COVID gut
Your gut is not an innocent bystander in COVID infection and long COVID, but in fact one of the key players.
Acute COVID infection
The acute gut manifestations during COVID-19 are believed to be related to the increased expression of ACE-2 expression on the small bowel mucosa which may result in gut infection by the virus. Prolonged shedding of virus particles from the GI tract is recognized and could be responsible for some of the GI manifestations of long COVID. Finally of course the microbiome has a major role- patients with COVID have a significant loss of microbiome diversity and those with post-COVID-19 syndrome were found to have increased levels of Ruminococcus gnavus and Bacteroides vulgatus and decreased levels of important immune system modulating bugs like Faecalibacterium prausnitzii, Eubacterium rectale and bifidobacteria.
COVID-19 disrupts the gut microbiome, allowing bad bacteria to thrive and it can also affect the lining of the gut causing leaky gut (increased intestinal permeability) which may allow these bacteria to enter the bloodstream and lead to secondary infections. After COVID, the number of gut goblet cells, which produce mucus, increased. Meanwhile, the number of Paneth cells, which produce antimicrobial compounds, decreased. The remaining Paneth cells had abnormalities resembling those found in inflammatory bowel disease (IBD- Crohns and ulcerative colitis). It is all connected- these changes in the gut lining correlated with disruptions to the microbiome.
Long COVID
Nearly one in five American adults who had COVID-19 experience symptoms of long COVID. The newest data (PMID: 37848036) shows that patients with long COVID suffering from symptoms like brain fog, fatigue, or memory loss in the months or years following COVID-19 – can have a low amounts of the neurotransmitter serotonin. The study looked at patients with long COVID and found the SARS-CoV-2 virus in their stool even months after acute COVID-19 infection, which suggests that the virus remains in the gut of some people a long time after infection. This remaining virus ( a “viral reservoir”), triggers the immune system to release proteins that fight the virus, called interferons. These interferons cause inflammation that reduces the absorption of the amino acid tryptophan in the gut. Tryptophan is necessary to make serotonin, which is primarily produced in the GI tract and plays a key role in memory, sleep, digestion, wound healing, and regulating the vagus nerve that mediates communication between the gut and the brain. When tryptophan absorption was reduced by persistent viral inflammation, serotonin is depleted, leading to disrupted vagus nerve signaling, which in turn can cause symptoms associated with long COVID.
As with many other infections, COVID has the potential to trigger chronic conditions both specific to the gut and systemic, such as autoimmune disease. In fact, autoimmunity is a hallmark of post-COVID syndrome. If suffering from post-COVID gut issues, the key is to understand exactly what’s going on and get a root cause diagnosis. Throwing a probiotic at gut symptoms that are actually SIBO or gastroparesis may not help at all or even worsen symptoms such as brain fog. Therefore get a thorough evaluation for everything from autoimmune conditions to dysbiosis and leaky gut. Here is the list and how to evaluate:
COVID root cause evaluation
- SIBO: SIBO breath test to test for SIBO hydrogen + hydrogen sulfide, IMO
- Carbohydrate malabsorption: breath tests or endoscopy biopsies for disaccharidase quantification
- Dysmotility: motility disorders are evaluated based on the location
- esophageal dysmotility (symptoms include trouble swallowing, persistent reflux): endoscopy, then esophageal manometry
- gastroparesis (symptoms include upper abdominal pain, nausea, fullness/bloating): endoscopy, then gastric emptying test or smartpill
- small bowel dysmotility: consider imaging, then smartpill
- colonic dysmotility: consider imaging, colonoscopy, then smartpill or sitz marker study and anorectal manometry
- Acid dysregulation: including dyspepsia, GERD, peptic ulcer disease, consider an endoscopy to help understand the burden of inflammation and if ulcers exist, as well as high vs low acid states
- Mast cell activation syndrome (MCAS): consider blood and urine tests like tryptase and histamine as well as tests for urinary histamine metabolites
- Pancreatitis: check lipase and imaging (asap!)
- Liver + biliary disease: liver tests and imaging
- Dysbiosis: consider microbiome testing
- Leaky gut: consider the lactulose:mannitol urine test
- Autoimmunity: Viruses trigger autoimmunity in those with genetic predisposition through molecular mimicry epitope spreading, and bystander activation. COVID-19 may trigger autoimmune conditions by two factors: temporary impairment of innate and acquired immunity resulting in a loss of self-tolerance to self-antigens, and an inappropriate immune reconstitution in people with predisposing conditions of autoimmunity. consider blood tests such as ANA and specific ones for condition in question considering the post-COVID prevalence: in studies, COVID-19 patients exhibited significantly higher risks of rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, dermatopolymyositis, systemic sclerosis, Sjögren’s syndrome, mixed connective tissue disease, Behçet’s disease, polymyalgia rheumatica, vasculitis, psoriasis, inflammatory bowel disease, celiac disease, type 1 diabetes
Talk to your gastroenterologist about taking a holistic approach, supporting your gut with food first, precision supplementation, and then medications as needed. Consider the following:
ACUTE COVID gut recovery & restoration
- Recovery starts when your symptoms slow down AND fever breaks AND your appetite re-appears. give your body the time it needs to ride out the acute infection before starting the following gutlove gut infection recovery & restoration protocol:
- 1st 24 hours: Start with miso soup and/or Brodo Vegan Seaweed & Mushroom Broth ; if you eat animal products you can start bone broth. Miso is a great nourishing probiotic. Once that goes down, try cooled white rice. Cooled white rice is a terrific prebiotic. Try soothing teas such as mint, fennel, ginger, and turmeric such as Traditional Medicinals, Organic Belly Comfort. Avoid caffeine. DRINK AT LEAST 2.5L of WATER. Start some gentle restorative yoga moves and meditations via the headspace app and check out Nerva.
- 2nd DAY: Now that you survived your first day of eating and drinking, its time to slowly build back that microbiome! Add natural prebiotics like plain oatmeal for breakfast, sweet potato and cooked veggies for lunch and soba noodles with tofu for dinner. keep going with miso, seaweed and bone broths and AT LEAST 2.5L of WATER. Increase movement with more yoga and continue healing the gut brain axis with meditation.
- 3rd DAY: Time to add in cultured and fermented food! Your gut should be in better shape now so add in that sauerkraut, kimchi, tempeh, natto, and more prebiotics too! Check out the gutlove diet for more ideas and recipes! DRINK AT LEAST 2.5L of WATER. More yoga & meditation!
- 4th DAY: Talk to your gastroenterologist about starting a prebiotic supplement such as 1 metamucil capsule (no fillers dyes or sugar please! this capsule is only psyllium husk and gelatin) or sunfiber and then optimizing the dosage of the prebiotic. Optimize fiber (up to 40g but slowly!, 30 different plants a week), hydration over 2.5L exercise and meditation going forward.
CHRONIC COVID gut recovery & restoration
- the gutlove diet (DM me for the full protocol) to optimize fiber (prebiotics) and probiotics and those whole body healing short chain fatty acids (SCFAs) as well as proteins and supportive amino acids
- zinc – for gut barrier recovery and immune support
- vitamin D- for gut barrier recovery and modulation of inflammatory cytokines and MCAS
- vitamin A – for gut barrier recovery and protecting epithelium and mucus integrity in the body
- vitamin C- immune defense and MCAS
- l-glutamine (amino acid)- for gut barrier recovery
- anthocyanins, polyphenols- for gut barrier recovery and antioxidant and antiinflammatory effect- through foods first, then when optimized consider quercetin which has been used in MCAS
- curcumin- for antiinflammatory effects heal with gutlove
- exercise therapy- exercise is medicine. from yoga to running, practice 30 minutes for 5 days a week
- mindfulness and meditation- this has been shown to modulate the microbiome and gut-brain axis
- sleep- you need to optimize sleep to heal. 7 hours minimum. talk to your doctor about support such as melatonin, which is used in functional medicine for COVID as well.
- acupuncture – can be great support for chronic pain, visceral hypersensitivity and symptoms
- other forms of gut-brain axis healing- CBT with a therapist, vagus nerve stimulation, gut-directed hypnotherapy
- talk to your gastroenterologist about precision probiotic supplementation that may modulate the gut-lung axis
BONUS healing recipes
Gutlove COVID recovery salad: spinach + radicchio, berries (polyphenols!), pumpkin seeds (zinc!) and tofu with a home made dressing (raw apple cider vinegar, EVOO, tahini and minced garlic).
Home-made turmeric ginger tea– buy 1 fresh turmeric root and 1 fresh ginger root, cut them up and simmer in a large pot of water for a few minutes with a dash of black pepper and then add raw honey and fresh lemon juice to taste.
Always discuss everything with a gastroenterologist to get your unique root cause evaluation and diagnosis and then integrative treatment plan- tailored to your root cause and individual factors because you cant utilize the same healing protocol in each condition! That is how you find your own gut healing pathway- and with time (and patience), will heal.