Lactose-Intolerance

Question

Dear expert team,
I suffer from CF, am 32 years old and have had a transplant of the lungs and liver nearly 3 years ago. I am doing very fine and I can follow my former full-time job again for 2 years now. However, I have an unpleasant problem.
Since my transplant surgery I do not tolerate milk anymore (milk, yoghurt, white cheese). About 10-15 minutes after eating I have strong stomach pain, which does not occur from the fat content as I take enough Kreon. In former times I was able to consume such food in great amounts.
The symptoms point at a lactose-intolerance and I have done a blood test and a breathing test. These have both been negative. Furthermore, I had an endoscopy of the stomach, small intestine and colon done, which turned all out to be without a pathologic finding.
In case I eat lactose-free food or probably take lactase tablets, the problems do not occur.
My question is, if the problems can occur due to the new liver, the immunosupressive drugs or due to the CF itself and therefore resulting lack of enzyme effectiveness (however though there are enough enzymes there) and what I should do now the best. Restarting eating the food again because there is no positive testing is for sure not a solution. Hope you have an answer,
Yours sincerely,

Answer

Hello,
you report that you tolerated lactose-containing food before your combined lung- and liver- transplant without problems and that since the transplantation you get strong abdominal pain about 10-15 minutes after the intake of yogurt, white chesse and milk. A performed Lactose-breathing test and and endoscopy of the stomach and small bowel turned out ot be normal.
Due to your case history with primary tolerance of lactose-containing food it could only be a so-called secondary, meaning aquired, lactose-intolerance in your case. If the breathing-test has been performed correctly and a tissue sample investigation from the small-intestine has been done and in case the latter was normal, then also a secondary lactose-intolerance can be excluded.
It could then be speculated that because of the transplantation (here especially the liver transplantation) an impairment of the tolerance of milk products result in your case. This could be the protein or the fat.
You should perform the following test on food tolerance: extremely fermented hard cheese (old gouda) does contain nearly no lactose. If you react on this kind of cheese, the problem must be with the protein or fat from the milk. In case you tolerate this cheese and also do not react to the lactose-free products one can buy, then the lactose-breathing test has been judged wrongly or it could not be pathologic because your intestinal flora does not contain hydrogen-producing bacteria (e.g. caused by intensive and frequent antibiotic therapies). In this case there would after all be a secondary lacotse intolerance in your case. It can be clarified with a lactulose-breathing test rapidly, if your intestinal flora contains hydrogen-producing bacteria or not. On the other hand, if you cannot tolerated the old gouda or the lactose-free products it has to be clarified if you have acquired a cow's-milk protein allergy. As you are for sure still under therapy with immunsuppressive drugs, the common skin and blood tests do not work here. One can then only clarify this with an oral provocation with milk-protein powder.
It can also for sure be that the fat content of the milk products cause the problems after the liver transplantation. Then you should also have problems after eating other food with similar fat content. You can see that the case is not so easy. You should therefore discuss the whole problem with an experienced gastro-enterologist and dietician and have the respecitve tests done.
Yours sincerely,
Prof. Dr. H.-G. Posselt

21.09.2010