April 2, 2024 • 52 mins
Irritable bowel syndrome (IBS) impacts more than 45 million Americans and about 1 in 10 globally. So, if you have abdominal pain, diarrhea and/or constipation on a regular basis...you are not alone. We are thrilled to have world-renowned gastroenterologist, Dr. William Chey, on this episode to discuss this diagnosis along with common IBS mimickers. Dr. Chey is the Chief of Gastroenterology at the University of Michigan and a true physician champion for the importance of a multidisciplinary approach to the management of IBS. He discusses how this complex condition, once perceived purely as a psychosomatic disorder, has evolved into a multifaceted syndrome with new and improved treatment methods. Discover the transformative potential of dietary strategies like the low FODMAP diet, the integration of behavioral therapy along with complementary and alternative medicine (like acupuncture) into patient care, as we explore the nuances of treating IBS and its masqueraders.
Dr. Chey sheds light on the enlightening findings from a recent study on disaccharidase deficiencies, particularly the surprising prevalence of sucrase-isomaltase deficiency in IBS patients with diarrhea predominance. Gain insight into the challenges of current testing methods and the role of bile acid malabsorption, which opens the door to a more precise and personalized approach to managing unruly gut symptoms. The conversation steers toward the promise and limitations of breath tests and the significance of a Dream Team approach, blending expertise from various specialists to address the unique needs of each patient.
We also delve into the intricate relationship between small intestinal bacterial overgrowth (SIBO) and bile acid diarrhea, and the innovative work of researchers like Dr. Mark Pimentel. Dr. Chey emphasizes the growing importance of precision medicine in the field of gastroenterology and gut health, highlighting the complexities of diagnosing and treating conditions such as SIBO.
While we share a wealth of knowledge that promises to enlighten both healthcare professionals and individuals navigating the intricacies of IBS and it's common mimickers, you won't want to miss the introduction to a very special guest! Welcome Mabel June Scarlata (hint: she's the Scarlata family's new chocolate lab puppy). Don't forget to subscribe and share – your gut will thank you!
P. S. Find Mind Your Gut: The Science-Based, Whole-Body Guide to Living Well with IBS by Kate Scarlata MPH, RDN and Megan Riehl, PsyD which covers all things IBS along with IBS Mimickers in Chapter 10.
This episode was sponsored by QOL medical and Schar.
Learn more about Kate and Dr. Riehl:
Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast
Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.
The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kate (00:00):
This podcast has been sponsored by QOL Medical and
Schar.
Maintaining a healthy gut iskey for overall physical and
mental well-being.
Whether you're ahealth-conscious advocate, an
individual navigating thecomplexities of living with GI
(00:20):
issues, or a healthcare provider, you are in the right place.
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Hello friends, and welcome toThe Gut Health Podcast, where we
(00:43):
talk all things related to yourgut and well-being.
We are your hosts.
I'm Kate Scarlata, a GIdietitian.
Dr. Riehl (00:50):
And I'm Dr Megan Riehl.
We have a very exciting podcastfor you.
We are talking about irritablebowel syndrome and conditions
that may co-occur with IBS, orperhaps are an IBS mimicker all
on their own Our special guesttoday is Dr William Chey.
Kate (01:07):
He's a world-renowned gastroenterologist and the chief
of gastroenterology at MichiganMedicine.
He has authored more than 400manuscripts, reviews, chapters
and books, including more than10 national and international
clinical practice guidelines.
He's a researcher, medicalinnovator and holds several
patents.
Finally, dr Che holds severalleadership roles with national
(01:31):
gastroenterology organizationsand is a mentor and really a
dear friend of mine and Megan's.
He will delve into thediagnosis of IBS and when to
consider if something else mightbe contributing to your GI woes
.
Dr. Riehl (01:46):
So in the world of gut health, we like to bust
myths and address misinformation, because there's a lot of stuff
out there that is not based inscience or coming from reputable
sources, and when it comes toIBS, we have one of the most
credible sources in the field ofgastroenterology.
We have one of the mostcredible sources in the field of
(02:08):
gastroenterology, Dr Chey.
What is a common misconceptionabout gut health or GI disorders
that you would like to dispelfor our audience, as we kick off
our episode today.
Dr. Chey (02:15):
First of all, thanks so much for having me on your
podcast.
You've both been guests on mypodcast, Gut Talk, and we've had
some great conversations, soit's interesting to have
somebody describe this topic asstimulating.
And so you know IBS.
I think there remains a lot ofconfusion about IBS because when
(02:38):
doctors give a diagnosis of IBSto a patient, they often do it
in a situation which is reallymore default mode than feeling
really confident that a patienthas IBS.
You know they do a whole bunchof different tests.
We're going to talk aboutconditions that can masquerade
as IBS, and that uncertainty onthe part of the provider is
(03:02):
picked up very, very quickly bythe patient.
You know, if the provider isn'tsure about what's going on, why
should the patient haveconfidence that they're going to
get the right treatment?
You know, and so therein liesone of the great conundrums
related to IBS.
It's coming out of the box withthis diagnosis.
It's one of the foundationalissues that confronts providers
(03:26):
and patients.
Dr. Riehl (03:28):
Yeah, it's complex and with so many people around
the world struggling with thesymptoms that we're going to ask
you to talk about today.
I talk about this with mypatients that if you haven't
received a definitive diagnosis,you're going to keep looking,
and we want you to stop lookingunnecessarily.
Dr. Chey (03:47):
Yeah, that makes total sense.
Kate (03:50):
So can we start with just the basic what is IBS?
Dr. Chey (03:55):
Yeah, and this is an important thing to tag on to the
conversation we just had.
So, by definition, IBS is asymptom-based condition that
includes recurrent bouts ofabdominal pain and altered bowel
habits and, confusingly,patients that have diarrhea so
(04:15):
loose or watery stool,constipation, hard or lumpy
stool or a combination of bothdiarrhea and constipation can
all get diagnosed with IBS.
And it should tell you this.
One fundamental truth about IBSis it's not one disease.
It's probably a number ofdifferent diseases for which we
don't at the current time, havea definitive diagnostic test to
(04:39):
be able to put patients intotrue disease buckets, and for
that reason we have thissyndrome.
You might notice it's irritablebowel syndrome, not irritable
bowel disease, and the reasonfor that is because, as a
syndrome, it's defined by thepresence of symptoms and it
probably includes a number ofdifferent diseases for which we
can't separate at the currenttime.
Kate (05:01):
I wanted to talk to you, Dr Chey, about just how
treatments for IBS have changedsince you've been working in
this field.
I know there's been a lot ofsort of new research and new
thoughts about IBS.
What's really changed in yourcareer?
Dr. Chey (05:18):
I get asked this question a lot and I've thought
about it and it's really aninteresting evolution to think
about what's happened over thelast 30 years.
First of all, it's unbelievableto think that it's been 30
years, but it has, and thingsare so different now.
What I teach the fellows now iscompletely different than what
(05:38):
I was taught in 1990 as a GIfellow.
You know, in 1990, as a GIfellow, I was taught that IBS
was largely a psychologicalcondition, that treatments were
really predicated on finding theright medication for the right
symptoms, so an antispasmodicfor abdominal pain, an
(05:59):
antidiarrheal for diarrhea, alaxative for constipation.
It was literally at that levelof sophistication and there were
very few treatment options, ifany, at that time, that
addressed multiple symptoms inpatients with IBS.
It really was like usingmultiple medications to pick off
individual symptoms and thefield moved towards medications
(06:23):
that address multiple symptoms.
So we started to see drugs likelinaclotide, olocetron,
tagasterone, like drugs thatwould not only address
constipation or diarrhea butalso abdominal pains, in some
cases bloating.
But it was still focused almostexclusively on medications,
exclusively on medications.
And then, probably in the firstdecade of this new century, we
(06:54):
started to really see anexplosion of literature,
particularly around theimportance of behavioral issues
and the potential value ofbehavioral therapies for
patients with IBS.
And a little bit later thanthat but not too much later, but
a little bit later than that westarted to see more stuff on
diet and nutrition and inparticular around 2005, 2007,
monash started to publish aboutthe low FODMAP diet, which
(07:17):
really, I'll tell you, for mewas really an epiphany.
It really changed the way thatI thought about IBS.
To this day, we still argueabout whether food is the cause
of IBS or a trigger for IBS.
I personally favor the latter,but it really the whole idea of
FODMAPs helped me to understandthat patients have this
(07:39):
condition, ibs that's hallmarkedby visceral hypersensitivity
and abnormalities and motility,and that you know, of course, if
you have a trigger like FODMAPs, it makes sense that it's going
to exaggerate the motorresponse and the sensory
response in regards todeveloping symptoms.
And now you think about, like in2024, anybody that gives a
(08:01):
lecture on IBS is going to talkabout medications.
They're going to talk aboutdiet.
Bs is going to talk aboutmedications.
They're going to talk aboutdiet.
They're going to talk aboutbehavior.
And I dare say I literally justgave a lecture on IBS a couple
days ago and cam therapies aswell complementary alternative
medicine therapies.
Megan knows us.
We started.
We've actually voted with ourfeet.
We actually have an acupunctureclinic embedded in our GI
(08:24):
clinic now at this point we'rethe first large academic medical
center in the country to dothat.
But the feedback I've gottenfrom patients regarding the
potential benefits or thebenefits in their case of
acupuncture for their IBSsymptoms has been really
stunning to me.
I absolutely expected apositive response, but really
(08:46):
thankful patients sending mejust sort of cold, sending me
emails telling me how much it'smade a difference for them, and
so I would say that that shouldalso be part of our
armamentarium.
Kate (08:58):
I think we've seen this in the data and you know, working
with patients for 30 years nowthat have IBS they want holistic
approaches.
Most of them don't reallynecessarily want to do
medication, so I could see thembeing very happy about having I
mean, you have all of thoseservices at Michigan Medicine,
which is amazing.
(09:18):
I just wanted to backtrack alittle bit for our listeners
that might not be familiar withFODMAPs.
The low FODMAP diet is a dietthat's done in three stages.
Fodmaps are a group ofcarbohydrates that are commonly
malabsorbed we won't get intothem in detail today, but in
another podcast for sure butthese are commonly malabsorbed
carbohydrates that can triggersymptoms associated with IBS.
(09:41):
So I wanted to just kind ofdelve into this question.
You know you've got someone,you think they have IBS.
You try different therapeutics.
Nothing seems to kind of work.
Do you start thinking maybeit's something else?
What are some of the signs andsymptoms that you see in
practice that you say, hey,there's something else going on?
Dr. Chey (10:06):
Yeah, this is a really important question, because
there are two parts to thisquestion.
The first part is what is thepatient, upon your first seeing
them, that you should reallythink hard and long about
providing a diagnosis of IBS.
And then, what do you do aboutthe patient that isn't
responding?
(10:26):
Do you worry more about that?
You're missing something else,or should you be thinking
differently about how toapproach their treatment?
So, taking on the first thing,who are the patients that
deserve a more detailedevaluation when you first see
them?
That you think they might haveIBS, but, but you're not sure.
To me, patients that have moresevere symptoms, patients that
(10:53):
have symptoms beyond the breadthof the normal IBS patient, I
think deserve a more thoughtfulapproach and more detailed
workup coming out of the box.
Also, patients that haveso-called warning signs or alarm
features.
This is by no means a perfectscience, but it does help to
identify patients who deserve amore detailed initial workup, as
opposed to the moresymptom-based approach and
(11:15):
limited workup that we do formost patients with IBS that
don't have warning signs oralarm features.
So what are those warning signsor alarm features?
Well, first is evidence ofgastrointestinal bleeding
Patients that tell you thatthey're seeing blood with their
stool, having black stool.
You should take much moreseriously.
In addition to that, patientswith unexplained iron deficiency
(11:38):
anemia are another group thatagain you have to take seriously
.
That again you have to takeseriously.
The society guidelines, ACG,AGA all recommend a detailed
structural evaluation for everypatient with unexplained iron
deficiency anemia.
Significant unexplained weightloss is also an important
warning sign or alarm feature,and most people talk about that.
(12:01):
It'd be wonderful to give youan evidence-based threshold, but
probably on the order of around5 to 10 pounds of unexplained
weight loss you should beinterrogating more carefully.
Another really importantwarning feature it's not really
a sign or a symptom, but it's afamily history of
gastrointestinal malignancy.
(12:23):
And here we are doing thispodcast in March and it's
Colorectal Cancer AwarenessMonth, and so I'm just going to
give my plug that obviouslyeverybody that's over the age of
45 should be undergoing someform of colorectal cancer
screening.
By the way, that doesn't meanthat it has to be colonoscopy.
You know, average risk patientscan be tested with FIT or
(12:45):
Cologuard and that's perfectlyadequate.
But those patients with warningsigns should get a colonoscopy.
But it's not just colon cancerthat's important from a family
history standpoint.
Remember that patients with afirst degree relative that has
inflammatory bowel disease alsohas an increased risk of IBD,
and then patients with a firstdegree relative with celiac
(13:06):
disease also have an increasedrisk of celiac disease.
So you should always ask aboutcolorectal cancer, IBD and
celiac disease as part of yourscreening process when you're
seeing a patient that you aresuspicious might have IBS.
Kate (13:22):
Can you just elaborate on FIT and Cologard for the
listeners that might not knowabout those products?
Dr. Chey (13:33):
Sure or genetic markers genetic changes in stool
samples that identify patientswho are more likely to have
either adenomatous polyps orcancer.
It's another method and, as Imentioned a moment ago, it's
really intended for average riskpatients.
Patients that have had aprevious history of adenomas or
(13:57):
a family history would not beappropriate for stool-based
testing, but for those thatdon't have a family history and
don't have a history a personalhistory of cancer or adenomatous
polyps so-called average riskpatients a stool-based test is
perfectly adequate.
Kate (14:13):
Perfect, and so I'm having my colonoscopy next week, just
so you know, good girl.
Just to get back to the initialquestion beyond alarm features,
is there something else thatprompts you to start thinking
mimickers, no family history, noalarm features.
Is there some red flags thatsay, hmm, there's something else
(14:36):
going on?
Dr. Chey (14:38):
I'm glad you came back to this because I forgot a
really important alarm featurethat I think there's confusion
about, and this is a reallyimportant point you know people
always talk about.
You might notice that I did notsay nocturnal pain, and yet if
you read a lot of reviewarticles and certainly some of
the older literature, they allrefer to pain that awakens you
(14:59):
at night as an alarm feature oralarm symptom.
It turns out that's not true.
The studies that have looked atthis there's multiple studies
that have looked at this havefound that the likelihood of
having organic disease is nodifferent between patients with
IBS symptoms that don't havepain that awakens them at night
versus those that do so.
Pain that awakens them at nightversus those that do so.
(15:20):
Pain that awakens you at nightis not an alarm symptom, but
diarrhea that awakens you atnight is a very potent alarm
symptom, and that's alsosomething that answers the
question that you just raised.
What is a red flag for me thatreally gets my ears up in clinic
is when a patient tells me thatI have to get up at night with
(15:40):
diarrhea.
That is almost never IBS.
I mean occasionally it'll turnout that way, but almost never
Almost always, a patient thattells you that they're having
episodes of diarrhea at nightwill have some other organic
disease, and so those arepatients that I pay particularly
close attention to in terms ofmaking sure they don't have any
(16:02):
of a variety of diarrhealillnesses, some of which we'll
talk about today.
Kate (16:06):
What are some of the most common IBS mimickers that you
see in your practice?
Dr. Chey (16:12):
It's funny because the things that we providers and
patients know about the mostthey're important to know about,
but they're not necessarily themost prevalent.
So, for example, almosteverybody knows about the
overlap between celiac diseaseand IBS.
In fact, we've published a lotof papers about that.
You know, we published one ofthe original meta-analyses
suggesting that we should belooking for celiac disease in
(16:35):
patients with IBS symptoms.
We're also, though fortunatelyor unfortunately, one of the
first ones to publishprospective real-time clinical
trials showing that theprevalence of celiac disease was
not that different than theprevalence of celiac disease in
the general population.
And, by the way, what is thatnumber?
(16:56):
The number is probably 1% orless.
So so you definitely will seeit if you look for it.
But think about it.
That means that you're going tohave to test 100 IBS patients
and, by the way, it's IBS-Dpatients, for the come up to me
and say you know, you wrote allthese papers about how we should
(17:20):
be testing for celiac diseasein IBS patients.
I test every one of my IBSpatients and I never find celiac
disease, and my response tothem is you're right, you will
have to test 100 patients tofind one with celiac disease.
Actually, the true number isprobably more on the order of
around 150.
So it's not that you'll neverfind it, it's just that you
(17:44):
won't find it that often.
But why is it worth doing?
Because celiac disease is aprofoundly important diagnosis
to make.
It's not a diagnosis that youwant to miss.
Why?
Because there are so manydownstream consequences to not
making the diagnosis of celiacdisease.
Being misdiagnosed as IBS whenyou have celiac disease could
(18:07):
potentially have catastrophicconsequences for the patient 5,
10, 15 years down the road,including an increased risk of
cancer.
So it's just not a diagnosisthat we can afford to miss.
So, even though it's not thatcommon, it's important to look
for Things that are more commonare things like microscopic
colitis.
(18:28):
That's still missed a lot,although less often now than 10
years ago.
But microscopic colitisprobably is going to be present
in somewhere between 3% and 5%of patients with IBSD symptoms
that don't have warning signs,by the way.
So for those patients that havenocturnal diarrhea, for those
(18:49):
patients that are not respondingas well as you might expect to
some Imodium or other treatmentsfor IBS-D, think about
microscopic colitis.
Make sure that if a patientgets a Flexsig or a colonoscopy
that they get random biopsies tobe sure that you've excluded
microscopic colitis.
(19:10):
Bile acid diarrhea is alsoreally common.
Put it this way, bile acidmalabsorption is probably
present in 20% to 25% of IBS-Dpatients.
Now the degree to which thatbile acid malabsorption is
responsible for the patient'ssymptoms is still a bit unclear.
But even if 50% of thosepatients, their symptoms are
(19:35):
related to the bile acidmalabsorption, that's a lot of
patients.
So I think we're going tocontinue to see research on this
topic, which is very important,and we'll gain a clearer
understanding of exactly howoften we should be turning to
bile acid sequestrants like thecholestyramine or cholestepalam
(19:56):
or cholestopal.
That's definitely something.
And then small intestinalbacterial overgrowth, or SIBO,
is another thing that we thinkabout, or we're talking about a
lot, and there's a lot ofcontroversy about whether SIBO
is the same thing as IBS orwhether SIBO is a completely
separate and distinct diseasefrom IBS.
(20:18):
The truth is probably somewherein between, like always.
And then other things likedisaccharidase deficiency.
I'm sure we'll talk about that.
That's a really interesting anda really rapidly evolving topic
.
But I do want to say one wordabout the IBS-C group because if
(20:39):
you think about it, everythingI've said up to this point has
been focused on IBS-D and that'spelvic floor dysfunction, and
the three of us have had manydiscussions about this and it's
so gratifying to start to seethe ship turn in terms of
gastroenterologists and even, Idare say, in some cases, primary
care physicians, starting tothink about that as an
explanation for refractorysymptoms in patients with IBS-C
(21:02):
who don't get better withlaxatives.
That's primarily whereclinicians and patients should
be starting to ask questionsabout this.
Possibility is if you haveconstipation-related symptoms,
with or without abdominal pain,and you've tried a variety of
laxative therapies and nothinghas worked pelvic floor
dysfunction or an evacuationdisorder the inability to be
(21:25):
able to fully evacuate stoolfrom the rectum goes way up on
your list of possibilities.
Dr. Riehl (21:31):
And that then adds to the team right.
So we have pelvic floorphysical therapists that are
life-changing for patients, andso the team widens a bit with
some of our constipationpatients.
But you bring up such a goodpoint in terms of looking for
other options for these patientsthat are totally suffering.
Dr. Chey (21:50):
It really speaks to this point that again, in 2024,
it takes a village.
Ibs therapy is no longerfocused solely on the
gastroenterologist, which is,you know, in 1990, the treatment
of IBS was almost entirelyfocused on the
gastroenterologist.
You know, thegastroenterologist I sort of
(22:12):
think of as more now as thecaptain of the team.
The gastroenterologist stillplays an incredibly important
role, arguably the mostimportant role in terms of
coordinating the care betweenthe various stakeholders.
But the gastroenterologist in2024, for the complex or
(22:32):
severely affected IBS patient,is sorely inadequate.
Dr. Riehl (22:36):
And you make the best point that providing that
definitive diagnosis for thepatient is really the starting
point.
They're not going to believeyou when you say you know, I've
got this GI psychologist you cango talk to.
You know, I think you have IBS.
It has to be.
You have IBS, I have a teamthat I work with.
We will all help you.
Let's explore what theseoptions are.
(22:58):
I'm confident that we can getyou feeling better.
Dr. Chey (23:01):
I always say to people too, that when I'm teaching
fellows about IBS, I say thinkabout what we say to an IBS
patient.
Typically, I think you have IBS.
It's a condition defined by thepresence of abdominal pain and
altered bowel habits.
The good news is that it's notassociated with cancer or other
(23:24):
organic diseases.
The bad news is we don't knowwhat causes it.
We don't know what the besttreatment for it is, and you're
going to have it for the rest ofyour life.
Dr. Riehl (23:34):
Yay, think about how that would make you feel Woo-hoo
.
Dr. Chey (23:38):
How could you walk away from that interaction with
anything but just despair?
Think about this you have IBS.
It's a condition for which wehave an immensely growing
understanding and for thatreason and understanding that
there are lots of reasons whypatients have IBS symptoms, we
have a team of individuals thatcan provide a variety of
(24:02):
different treatment options foryou.
We will use those stakeholdersto tailor an individualized
treatment program for you andthere's a very high likelihood
probably a greater than 80%chance that we will be able to
make your symptoms moremanageable.
What a different message, right.
Dr. Riehl (24:25):
Same disease.
Yeah.
So for any listeners out there,if you've heard anything but
that very expert delivery of thediagnosis, think about Dr Chey
in your head when you thinkabout your IBS diagnosis.
There's an incredible amount ofuncertainty that comes if you
don't receive a diagnosis likethat.
Certainty that comes if youdon't receive a diagnosis like
that.
And so we do want to instill alot of hope for people that you
know we can help you live wellwith IBS.
(24:45):
So thank you for that, Dr.
Chey.
Kate (24:47):
Absolutely.
We need a dream team approach,right?
We talk about that a lot inMind your Gut.
It's not just one person likeyou know, it's a team sport
Moving just into mimickers.
Again, I wanted to talk becausethere's a lot sport Moving just
into mimickers.
Again, I wanted to talk becausethere's a lot of sort of
misinformation about parasiticinfections but then sometimes
parasitic infections can mimicIBS.
What type of parasiticinfections do you think about
(25:11):
that might mimic IBS-D and whenor what would be some things
that you would think about.
That would you know.
You'd say, oh, this might be aconsideration in this particular
patient.
Dr. Chey (25:23):
In the United States, the big one to really think
about and consider and evenidentify like we probably
identify at least a few patientsa year with Giardia.
Giardia is a very importantparasitic infection to be aware
of, particularly in certainparts of the country Like, for
example Megan and I are fromMichigan.
(25:43):
Well, in Northern Michigan andsome of the lakes there will be
outbreaks of Giardia, so it canpresent with all the symptoms
that seem identical to IBS.
Most of the time, by the way,though, the symptoms will be
much more severe, butoccasionally you'll get a
patient who, for whatever reason, doesn't express the full-blown
(26:04):
illness and has symptoms moreakin to IBS.
So, as part of an earlyevaluation, in places where
there is the possibility ofendemic parasitic infection,
it's reasonable to do a GI PCR,which would include a screen for
Giardia.
Dr. Riehl (26:21):
What do you think about the patients that come in
with the wide-sweeping stoolstudies that they've sent in
stool to a company and it'sanxiety-provoking.
But, as an expertgastroenterologist, tell us a
little bit about what patientsmay or may not be getting from
that.
Dr. Chey (26:39):
So I get asked this a lot and I get asked this a lot
by patients who bring me thosereports, and conceptually the
concept is really interestingand I think potentially at some
point in the future may beactionable.
Right now the problem is that alot of the microbiome analysis,
the metabolome analysis, is notadequately validated and really
(27:03):
don't know how to interpret it,and that's true too of a lot of
proteases.
There's a whole wide range ofdifferent things that people are
testing for in stool now, bythe way, all founded in
conceptual models which couldmake sense to IBS, but not
necessarily human studies thatmake clear that that kind of
(27:24):
testing is valuable to excludethis disease or that, or
certainly to identify patientsthat would benefit from this
supplement or that, which isusually how this works.
I hope this doesn't come off astoo inflammatory, but one of
the business models that goesunspoken, of course, is that you
(27:45):
do the testing and then youorder supplements from your own
shop for which there's a profitmargin.
I'm not saying that that's theonly reason why providers do
this.
I know for sure that's not thecase but it does create a bit of
an intrinsic conflict ofinterest.
So, bottom line right now,there are things in those tests
(28:07):
which are valuable.
So for example, iron studies,certain studies of vitamins can
be helpful, but a lot of it, andin particular a lot of the
stuff that's really foundationalto the testing right now, I
think in, at least in my mindhas not been adequately
validated.
So the microbiome metabolomeanalysis, those types of things
(28:29):
I think could be valuable, but Idon't think we know that
they're valuable yeah so ifyou're coming in with that big
supplement list and maybethey've been on it for a month
or two.
Dr. Riehl (28:43):
One thing that we talk about is it probably isn't
the right thing for you and wehave to pivot.
So before shelling out moremoney, it's always a good idea
to check in with agastroenterologist.
A little further about that.
Kate (28:59):
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It's here our book baby, Mind Your Gut
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Kate (31:06):
That's right, Megan.
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Dr. Riehl (31:40):
The book is available in our show notes as well as at
all major book retailers, sowe're going to pivot also to an
area of research that you'vecertainly been doing a lot in.
When might you consider sucroseisomaltase deficiency, and how
common is this?
What are the red flags thatwe're looking for?
Dr. Chey (32:02):
Yeah.
So right now, there'sincreasing focus on sucrose
isomaltase, and our group willdefinitely take some credit or
fault for that.
People are talking about it.
I think it's a valuable topicfor us to be discussing as a
scientific community, but thereare a lot of unanswered
questions, and we'll get intothat in a second.
What I do want to do, though,is to say that one thing that
(32:24):
I've learned from doing researchin this field is that we
probably need to broaden the waythat we look at.
We probably need to broaden theway that we look at
disaccharidase deficiencies,rather than just sucrose
isomaltase deficiency.
So, in other words, there are awhole bunch of different
disaccharidases.
The one that everybody knows themost is lactase, and remember
(32:46):
that lactose is part of theFODMAP family, so it's been
acknowledged as a potentialtrigger for IBS symptoms for
many, many years.
This is not new information.
Now, sucrose is not part of theFODMAP approach, which is one
of the reasons why it's such aninteresting part of the
(33:07):
discussion as we move forward,because, intuitively, since
sucrose is not part of theFODMAP family at least the
traditional FODMAP family thatwe think about in the low FODMAP
diet if a patient does notrespond to the low FODMAP diet,
it would make sense that there'san increased likelihood of
(33:30):
sucrase deficiency, sucraseisomaltase deficiency and
therefore what happens issucrose, which is typically not
a FODMAP, when you have thatenzyme, in the absence of the
enzyme, becomes a FODMAP.
In other words, it's exactlythe same as if you don't have
lactase.
And in fact, in a post-hocanalysis from one of our
(33:51):
randomized controlled trials,that's exactly what we found is
that there was a more thantwo-fold increased likelihood of
response to the low FODMAP dietif you didn't have mutations of
the sucrose isomaltase gene.
So that was an interestingtidbit of information.
We just finished a study wherejust this can be an oral
(34:11):
presentation at DigestiveDiseases Week in May, reporting
data from a large-scaleprospective study using
disaccharidase assay todetermine the prevalence of
different disaccharidasedeficiencies in the US.
And what we're going to reportis that sucrose is a multi-ase
deficiency is present in around8.5% of isolates, which is much
(34:36):
higher than we thoughtpreviously.
Think about this.
Remember we said before celiacdisease is less than 1%.
We look for that in every IBSpatient.
Sucrose is a multi-asedeficiency is present in 8.5% in
over 200 patients that weenrolled from all over the
United States.
By the way, in fairness, youhave to say this.
(34:57):
Does that mean, like, for those8.5% of individuals that have
sucrose isomaltase deficiency,does that mean that that is
responsible for their symptoms,similar to what we talked about
with bile acids?
Not necessarily so.
It can be true and unrelated,right?
So that's one of the nextthings that we really need to
(35:18):
study.
We need to understand when is aduck a duck?
I don't think we know thatright now.
I think the other thing torealize that complicates this
discussion and this is whyresearch is so much fun is
because you answer one questionbut you create 10 others.
Realize this is that sucroseisomaltase deficiency, the
(35:39):
majority of the time, occurswith other enzyme deficiencies,
so 8.5% is not patients thathave just sucrose isomaltase
deficiency.
Those are people that havepalatinase deficiency, lactase
deficiency, so a lot of thepatients that have SID have
(36:00):
other disaccharides deficiencies, and the degree to which you
can fix one and make thesymptoms better is not clear.
So we have so much to learn,but what's fair to say is that
disaccharidease deficiencies ingeneral should be on our radar
screen.
It should be something thatwe're thinking about as an
(36:20):
important trigger for symptomsin patients with IBS.
Dr. Riehl (36:25):
How do you test for that and what might be a
treatment?
Dr. Chey (36:30):
So right now the gold standard test is biopsies from
the proximal small intestine andthen sending them to a
specialty laboratory todetermine the level of enzyme
activity in association with thedifferent disaccharidases, and
there are sort of internationalstandards that have been
established for the differentenzymes.
(36:51):
People also talk a lot aboutdoing breath tests to identify
patients with sucrose isomaltasedeficiency.
Unfortunately, those are muchless well-studied or validated.
In fact, I'm telling you thatour data is the first
large-scale data in adults fromthe United States using
disaccharides assay large-scaledata in adults from the United
(37:14):
States using disaccharide assay.
So again, one of the things weneed to do next is try to really
more carefully validate theother tests that might be used
to identify these patients inclinical practice.
Part of our abstract that we'representing at DDW did evaluate
a C13 sucrose breath test andunfortunately found it to not be
terribly accurate.
So we'll have to see if othersreplicate that data and I'd like
(37:37):
to see additional testing withother forms of breath tests,
more traditional sucrose breathtesting.
Kate (37:43):
Just a quick question when you looked at these individuals
with IBS and checked theirDysac assays, were they IBS-D?
Predominant Is diarrhea, sortof the like ooh, these patients
might have it versus someonewith constipation.
Or I'm just thinking red flagsfor someone that might be
thinking, hey, I might havesucrose isomaltase deficiency.
Dr. Chey (38:04):
That's a really important question.
I'm glad you asked that becauseI should have made that more
clear.
Our study was in patients withIBS-D symptoms by the Rome
criteria.
So what we found in preliminarysort of observational
retrospective studies is thatthe patients to worry about with
dissect deficiency definitelyhad diarrhea.
(38:24):
That's sort of the hallmarksymptom that people have always
talked about for many decades.
But what we also found in ourresearch was that abdominal pain
and bloating were just ascommon as diarrhea.
So that's why we focused onIBS-D, because if you think
about it, that's IBS-D, it'sabdominal pain, bloating and
diarrhea.
So the prevalence of SID is8.5% in IBS-D patients by Rome
(38:51):
criteria.
Dr. Riehl (38:52):
Okay, how about bile acid malabsorption of bile acid
diarrhea?
When might you consider this aspart of the clinical picture?
Dr. Chey (39:01):
Yeah, there's been a lot of chatter about this as
well, and I mentioned earlierthat there's data, predominantly
from the Mayo Clinic,suggesting that anywhere between
20-25%, maybe even up to 30%,of patients with IBS-D have
evidence of bile acidmalabsorption.
Again, it doesn't prove causeand effect necessarily, but it
(39:22):
is measurably abnormal inpatients with IBS-D.
That's sort of all comersPatients in which you should
think about it even more so areafter cholecystectomy.
So if a patient has had aprevious cholecystectomy,
independent of whether they haveabdominal pain or not, if they
have diarrhea you should bethinking about bile acid
(39:45):
malabsorption.
There's also, interestingly, arelationship between SIBO and
bile acid diarrhea, becausebacterial overgrowth so bacteria
in the small bowel, candeconjugate bile acids
prematurely in the smallintestine, converting bile acids
to a form that are more likelyto induce diarrhea primary bile
(40:07):
acids and so therefore patientswith SIBO are more likely to get
bile acid diarrhea Also.
The last category that isreally important, particularly
for listeners that are havingproblems with diarrhea is if
you've had surgery to remove thelast part of your small
intestine, the ileum, thatactually is a huge setup to
(40:31):
develop bile acid diarrheabecause in the ileum there are
receptors called IBATs ilealbile acid transporters that
reabsorb bile acids and if youremove the ileum, you remove
those IBATs and you're not ableto reabsorb the bile acids
before they get to the colonwhere they induce secretion of
(40:53):
fluid and stimulate contractileactivity in the colon that
causes diarrhea.
Dr. Riehl (40:59):
What might a patient look for for treatment for that?
Dr. Chey (41:02):
Right now the primary treatment for bile acid diarrhea
is to give the patient a bileacid sequestrant.
This is a resin that absorbsexcess bile acids in the fecal
effluent and in that way reducesthe burden of bile acids that
get to the colon.
That can cause diarrhea.
Dr. Riehl (41:22):
So another example of it may be medication, it may be
lifestyle, it may be nutrition,but figuring out more of that
root cause is really importantbecause you can't keep going
without that medication.
It's really needed.
Dr. Chey (41:37):
No question about it.
You can see, as we're talkingabout this, we're slowly, at a
snail's pace, moving towardsmore of a precision medicine
kind of model, which is reallywhere we want to go right.
We really want to move fromthis sort of empiric treatment
based on a patient's symptoms towe do this test to determine
(41:59):
whether the patient has thisdisease and for that disease
it's this therapy.
By the way, patients thatlisten to me talk about this
always get really excited andthink well, why is my doctor
doing this right now?
Well, to a large extent, docsdon't have the capability or the
training to do this right now.
So this is very much a story inevolution.
(42:19):
It is getting better.
It's going to get even betterover time, but it will take time
.
Dr. Riehl (42:25):
Okay, so one of our last IBS potential mimickers
you've mentioned it smallintestinal bacterial overgrowth.
It's complicated, right, and sowhere do you think we are right
now in terms of the patientsthat Google this and bring this
to your office and they'recurious about it?
What are you looking for andhow might you treat it in your
(42:45):
clinic?
Dr. Chey (42:46):
Well, there's little doubt that this exists.
There's little doubt in my mindthat there are patients that
have a transposition of bacteriainto the small intestine that
leads to a variety of clinicalconsequences, and those clinical
consequences can oftentimesoverlap significantly with IBS,
particularly IBS-D, but in somecases perhaps IBS-C too.
(43:10):
We can talk about that.
The fundamental way that we arelooking at small intestinal
bacterial overgrowth at thecurrent time, I think in five
years will be almost entirelyantiquated.
So you know, one of thecommittees that I'm sitting on
right now is called the LuminalMicroenvironment Committee for
the Rome Foundation,microenvironment committee for
(43:35):
the Rome Foundation.
So we're writing the chapterfor the Rome 5 compendium on the
importance of the luminalmicroenvironment, and one of the
things that we're spending themost time talking about is the
microbiome and the smallintestine and large intestine
and SIBO in particular, andwe've had a lot of discussions
about this a group of keyopinion leaders from all over
the world that know a lot aboutthis.
Literally, this is what they doin terms of research in their
(43:57):
clinical practice, and I thinkthere's an increasing mindset
I've been saying this for manyyears, by the way.
I'm glad that it seems to begetting more popular is that
defining SIBO purely on thebasis of quantity of bacteria in
certain parts of the smallbowel.
That may very well be part ofthe definition, but it's
(44:21):
probably missing a big part ofthe issue at hand, which is what
bacteria are there and what arethey doing.
So it may be the constituentsand the metabolomic consequences
that are as or more importantthan the actual quantity of
bacteria.
And so right now we're reallyjust at a stage where we're just
(44:43):
defining what are the bacteriathat are present in patients
with SIBO and what are theydoing compared to healthy
controls.
So we're very much at an earlystage in this discussion, but I
bet the way it's going to settleout is that it won't just be by
quantity of bacteria that we'redefining SIBO.
(45:03):
So we're still at very earlystages.
But, that said, I do want togive a shout out to Mark
Pimentel, because Mark reallyhas suffered the slings and
arrows of thinking differentlyand you know, while he and I
have certainly had ourdisagreements in terms of you
(45:24):
know, the way that we look atthe world and look at SIBO and
IBS, we wouldn't even be havingthis discussion if it weren't
for Mark Pimentel.
You know he's a true leader,you true leader in terms of
research in this field and atrailblazer, and, again,
definitely has paid his dues forthinking differently.
I do want to just give himcredit for that for sure.
Dr. Riehl (45:46):
Our listeners are in for a treat because we're going
to have a really, I think,provocative conversation with Dr
.
Pimentel in an upcoming episode.
Kate (45:55):
Oh, yeah, thanks for the teaser.
Bill yes, absolutely, he is amaverick and I'm glad you see it
that way as well, because Iknow he's had a lot of criticism
and he just keeps fighting andgets scrappy and is showing a
lot of really interesting data.
So gets scrappy and is showinga lot of really interesting data
.
Dr. Chey (46:13):
So, yeah, and he's been right a lot more than he's
been wrong.
I mean, I think, if you reallyput things on the scale, yeah,
he's been wrong about somethings, but he's been right
about a whole bunch of thingsand you know, and I think you
have to give him credit for thatI mean the whole refection
story and the way that we treata subset of patients with IBS.
(46:33):
I mean you have to give morecredit for that, that's science,
right trial and error.
That's right.
Kate (46:39):
So if you've tried traditional testing and
treatments for the symptomsyou're experiencing without any
benefit, don't be afraid to askyour physician about some of the
IBS mimickers we have discussedtoday on this episode.
They can help you, and the moreyou know, the more you're able
to advocate for yourself.
Dr. Riehl (46:57):
Yeah, you know, as we've talked with Dr Chey today,
he points out that diagnosis iskey and, as we've all
identified in so many GIconditions and really with gut
health generally, that a lot oftimes people need a dream team.
And that dream teammultidisciplinary,
patient-specific, really is suchan incredible importance in
(47:20):
really getting you down thatroad of improving your symptoms,
and especially with mimickers,where you might think you have
one thing and it actually turnsout to possibly be something
else or something in addition.
So when we think about thedream team, as we've talked
about, the addition of an RD canprovide really necessary
nutrition therapy which can be agame changer, especially with a
(47:44):
diagnosis such as Celiacdisease.
And in some cases not only doesa GI psychologist join the team
to provide brain, gut,behavioral therapies and these
therapies can improve symptoms,coping, social support, but we
can also dive a little deeperinto aspects of grief and, as
(48:06):
we've kind of talked about today, when you have a diagnosis and
again I'll just use Celiacdisease as an example where
really the treatment is arestrictive diet, it's saying
goodbye to gluten and we want tonormalize that.
Grief can be a part of that andsome of the aspects of grief
that come with this are justdetection and decision fatigue.
(48:27):
So does something have gluten?
Where do we find it?
What can I eat?
And this can really happenacross the lifespan, from
parents that are helping theirchild navigate a diagnosis like
this all the way up throughgoing off to college and then
living on your own.
So keep in mind that you arenot alone with these diagnoses,
(48:48):
and we really want to stress theimportance of that.
And we really want to stressthe importance of that.
Now, as you all know, guthealth matters.
Our dear friends, and so manygood things in life can boost
our gut health, from the foodsthat we eat, to the people that
we spend time with, to theevents that boost all of our
endorphins, and nothing willboost endorphins like what we
(49:12):
are going to share with you next.
So, Kate, do you have some newsfor us?
Kate (49:17):
Well, we have just had such overwhelming positive
response to the Gut HealthPodcast and we really appreciate
all of your support.
We're just so excited.
It's been amazing, okay, okay,so should I tell them?
You should tell them all right.
Dr. Riehl (49:36):
We've decided to expand our team and we thought
that we could use a little extrahelp with the podcast content
and marketing.
So please join Kate and I witha big hello to yes, we have a
new team member.
Kate (49:54):
This is Mabel June.
You know she might be a littleunqualified, I don't think so.
Dr. Riehl (50:01):
I mean she's already diving into the microphone.
Kate (50:04):
I mean that's right, I think you know what she's going
to ramp up in no time, right nowshe literally is trying to get
the headphones on.
Dr. Riehl (50:12):
She wants her own microphone, so we're going to
have to get another Shure MV7because that's what we use
around here.
But she is looking like she isready to go for episode four and
with all of our hearts burstingand already excited to hear
about Mabel's first month duringour next episode.
(50:33):
Bill, we thank you for joiningus.
We certainly learned a lot aswe wrap up this episode.
What is something that youprioritize when it comes to your
overall health and wellness?
Dr. Chey (50:46):
Increasingly as I get a bit older, it's really time
with my family.
When I was younger I didn'tfully appreciate how important
that is.
But as you get older I thinkeverybody realizes time really
speeds up.
What you think is like sixmonths down the road is just
around the corner.
It just literally comes up onyou out of nowhere.
(51:07):
So prioritizing those momentsthat you can spend with your
family I think are so incrediblyimportant.
Kate (51:16):
Love it.
A big thanks to our guest, Dr.
Chey.
We value your expertise andwillingness to spend some time
with us and our audience on ourpodcast.
Next up we are talking aboutsmall intestinal bacterial
overgrowth in the small bowelmicrobiome with Dr.
Mark Pimentel from Cedars-Sinaiin Los Angeles.
Dr. Riehl (51:36):
So make sure you subscribe, follow and like The
Gut Health Podcast.
Your support means the world,our friends.
Thank you for joining us as wegrow this gut health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media @The Gut Health
(51:57):
Podcast, where we'd love for youto share your thoughts,
questions and experiences.
Thanks for tuning in, friends.
This podcast has been sponsored by QOL Medical and
Schar.
Maintaining a healthy gut iskey for overall physical and
mental well-being.
Whether you're ahealth-conscious advocate, an
individual navigating thecomplexities of living with GI
(00:20):
issues, or a healthcare provider, you are in the right place.
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Hello friends, and welcome toThe Gut Health Podcast, where we
(00:43):
talk all things related to yourgut and well-being.
We are your hosts.
I'm Kate Scarlata, a GIdietitian.
Dr. Riehl (00:50):
And I'm Dr Megan Riehl.
We have a very exciting podcastfor you.
We are talking about irritablebowel syndrome and conditions
that may co-occur with IBS, orperhaps are an IBS mimicker all
on their own Our special guesttoday is Dr William Chey.
Kate (01:07):
He's a world-renowned gastroenterologist and the chief
of gastroenterology at MichiganMedicine.
He has authored more than 400manuscripts, reviews, chapters
and books, including more than10 national and international
clinical practice guidelines.
He's a researcher, medicalinnovator and holds several
patents.
Finally, dr Che holds severalleadership roles with national
(01:31):
gastroenterology organizationsand is a mentor and really a
dear friend of mine and Megan's.
He will delve into thediagnosis of IBS and when to
consider if something else mightbe contributing to your GI woes
.
Dr. Riehl (01:46):
So in the world of gut health, we like to bust
myths and address misinformation, because there's a lot of stuff
out there that is not based inscience or coming from reputable
sources, and when it comes toIBS, we have one of the most
credible sources in the field ofgastroenterology.
We have one of the mostcredible sources in the field of
(02:08):
gastroenterology, Dr Chey.
What is a common misconceptionabout gut health or GI disorders
that you would like to dispelfor our audience, as we kick off
our episode today.
Dr. Chey (02:15):
First of all, thanks so much for having me on your
podcast.
You've both been guests on mypodcast, Gut Talk, and we've had
some great conversations, soit's interesting to have
somebody describe this topic asstimulating.
And so you know IBS.
I think there remains a lot ofconfusion about IBS because when
(02:38):
doctors give a diagnosis of IBSto a patient, they often do it
in a situation which is reallymore default mode than feeling
really confident that a patienthas IBS.
You know they do a whole bunchof different tests.
We're going to talk aboutconditions that can masquerade
as IBS, and that uncertainty onthe part of the provider is
(03:02):
picked up very, very quickly bythe patient.
You know, if the provider isn'tsure about what's going on, why
should the patient haveconfidence that they're going to
get the right treatment?
You know, and so therein liesone of the great conundrums
related to IBS.
It's coming out of the box withthis diagnosis.
It's one of the foundationalissues that confronts providers
(03:26):
and patients.
Dr. Riehl (03:28):
Yeah, it's complex and with so many people around
the world struggling with thesymptoms that we're going to ask
you to talk about today.
I talk about this with mypatients that if you haven't
received a definitive diagnosis,you're going to keep looking,
and we want you to stop lookingunnecessarily.
Dr. Chey (03:47):
Yeah, that makes total sense.
Kate (03:50):
So can we start with just the basic what is IBS?
Dr. Chey (03:55):
Yeah, and this is an important thing to tag on to the
conversation we just had.
So, by definition, IBS is asymptom-based condition that
includes recurrent bouts ofabdominal pain and altered bowel
habits and, confusingly,patients that have diarrhea so
(04:15):
loose or watery stool,constipation, hard or lumpy
stool or a combination of bothdiarrhea and constipation can
all get diagnosed with IBS.
And it should tell you this.
One fundamental truth about IBSis it's not one disease.
It's probably a number ofdifferent diseases for which we
don't at the current time, havea definitive diagnostic test to
(04:39):
be able to put patients intotrue disease buckets, and for
that reason we have thissyndrome.
You might notice it's irritablebowel syndrome, not irritable
bowel disease, and the reasonfor that is because, as a
syndrome, it's defined by thepresence of symptoms and it
probably includes a number ofdifferent diseases for which we
can't separate at the currenttime.
Kate (05:01):
I wanted to talk to you, Dr Chey, about just how
treatments for IBS have changedsince you've been working in
this field.
I know there's been a lot ofsort of new research and new
thoughts about IBS.
What's really changed in yourcareer?
Dr. Chey (05:18):
I get asked this question a lot and I've thought
about it and it's really aninteresting evolution to think
about what's happened over thelast 30 years.
First of all, it's unbelievableto think that it's been 30
years, but it has, and thingsare so different now.
What I teach the fellows now iscompletely different than what
(05:38):
I was taught in 1990 as a GIfellow.
You know, in 1990, as a GIfellow, I was taught that IBS
was largely a psychologicalcondition, that treatments were
really predicated on finding theright medication for the right
symptoms, so an antispasmodicfor abdominal pain, an
(05:59):
antidiarrheal for diarrhea, alaxative for constipation.
It was literally at that levelof sophistication and there were
very few treatment options, ifany, at that time, that
addressed multiple symptoms inpatients with IBS.
It really was like usingmultiple medications to pick off
individual symptoms and thefield moved towards medications
(06:23):
that address multiple symptoms.
So we started to see drugs likelinaclotide, olocetron,
tagasterone, like drugs thatwould not only address
constipation or diarrhea butalso abdominal pains, in some
cases bloating.
But it was still focused almostexclusively on medications,
exclusively on medications.
And then, probably in the firstdecade of this new century, we
(06:54):
started to really see anexplosion of literature,
particularly around theimportance of behavioral issues
and the potential value ofbehavioral therapies for
patients with IBS.
And a little bit later thanthat but not too much later, but
a little bit later than that westarted to see more stuff on
diet and nutrition and inparticular around 2005, 2007,
monash started to publish aboutthe low FODMAP diet, which
(07:17):
really, I'll tell you, for mewas really an epiphany.
It really changed the way thatI thought about IBS.
To this day, we still argueabout whether food is the cause
of IBS or a trigger for IBS.
I personally favor the latter,but it really the whole idea of
FODMAPs helped me to understandthat patients have this
(07:39):
condition, ibs that's hallmarkedby visceral hypersensitivity
and abnormalities and motility,and that you know, of course, if
you have a trigger like FODMAPs, it makes sense that it's going
to exaggerate the motorresponse and the sensory
response in regards todeveloping symptoms.
And now you think about, like in2024, anybody that gives a
(08:01):
lecture on IBS is going to talkabout medications.
They're going to talk aboutdiet.
Bs is going to talk aboutmedications.
They're going to talk aboutdiet.
They're going to talk aboutbehavior.
And I dare say I literally justgave a lecture on IBS a couple
days ago and cam therapies aswell complementary alternative
medicine therapies.
Megan knows us.
We started.
We've actually voted with ourfeet.
We actually have an acupunctureclinic embedded in our GI
(08:24):
clinic now at this point we'rethe first large academic medical
center in the country to dothat.
But the feedback I've gottenfrom patients regarding the
potential benefits or thebenefits in their case of
acupuncture for their IBSsymptoms has been really
stunning to me.
I absolutely expected apositive response, but really
(08:46):
thankful patients sending mejust sort of cold, sending me
emails telling me how much it'smade a difference for them, and
so I would say that that shouldalso be part of our
armamentarium.
Kate (08:58):
I think we've seen this in the data and you know, working
with patients for 30 years nowthat have IBS they want holistic
approaches.
Most of them don't reallynecessarily want to do
medication, so I could see thembeing very happy about having I
mean, you have all of thoseservices at Michigan Medicine,
which is amazing.
(09:18):
I just wanted to backtrack alittle bit for our listeners
that might not be familiar withFODMAPs.
The low FODMAP diet is a dietthat's done in three stages.
Fodmaps are a group ofcarbohydrates that are commonly
malabsorbed we won't get intothem in detail today, but in
another podcast for sure butthese are commonly malabsorbed
carbohydrates that can triggersymptoms associated with IBS.
(09:41):
So I wanted to just kind ofdelve into this question.
You know you've got someone,you think they have IBS.
You try different therapeutics.
Nothing seems to kind of work.
Do you start thinking maybeit's something else?
What are some of the signs andsymptoms that you see in
practice that you say, hey,there's something else going on?
Dr. Chey (10:06):
Yeah, this is a really important question, because
there are two parts to thisquestion.
The first part is what is thepatient, upon your first seeing
them, that you should reallythink hard and long about
providing a diagnosis of IBS.
And then, what do you do aboutthe patient that isn't
responding?
(10:26):
Do you worry more about that?
You're missing something else,or should you be thinking
differently about how toapproach their treatment?
So, taking on the first thing,who are the patients that
deserve a more detailedevaluation when you first see
them?
That you think they might haveIBS, but, but you're not sure.
To me, patients that have moresevere symptoms, patients that
(10:53):
have symptoms beyond the breadthof the normal IBS patient, I
think deserve a more thoughtfulapproach and more detailed
workup coming out of the box.
Also, patients that haveso-called warning signs or alarm
features.
This is by no means a perfectscience, but it does help to
identify patients who deserve amore detailed initial workup, as
opposed to the moresymptom-based approach and
(11:15):
limited workup that we do formost patients with IBS that
don't have warning signs oralarm features.
So what are those warning signsor alarm features?
Well, first is evidence ofgastrointestinal bleeding
Patients that tell you thatthey're seeing blood with their
stool, having black stool.
You should take much moreseriously.
In addition to that, patientswith unexplained iron deficiency
(11:38):
anemia are another group thatagain you have to take seriously
.
That again you have to takeseriously.
The society guidelines, ACG,AGA all recommend a detailed
structural evaluation for everypatient with unexplained iron
deficiency anemia.
Significant unexplained weightloss is also an important
warning sign or alarm feature,and most people talk about that.
(12:01):
It'd be wonderful to give youan evidence-based threshold, but
probably on the order of around5 to 10 pounds of unexplained
weight loss you should beinterrogating more carefully.
Another really importantwarning feature it's not really
a sign or a symptom, but it's afamily history of
gastrointestinal malignancy.
(12:23):
And here we are doing thispodcast in March and it's
Colorectal Cancer AwarenessMonth, and so I'm just going to
give my plug that obviouslyeverybody that's over the age of
45 should be undergoing someform of colorectal cancer
screening.
By the way, that doesn't meanthat it has to be colonoscopy.
You know, average risk patientscan be tested with FIT or
(12:45):
Cologuard and that's perfectlyadequate.
But those patients with warningsigns should get a colonoscopy.
But it's not just colon cancerthat's important from a family
history standpoint.
Remember that patients with afirst degree relative that has
inflammatory bowel disease alsohas an increased risk of IBD,
and then patients with a firstdegree relative with celiac
(13:06):
disease also have an increasedrisk of celiac disease.
So you should always ask aboutcolorectal cancer, IBD and
celiac disease as part of yourscreening process when you're
seeing a patient that you aresuspicious might have IBS.
Kate (13:22):
Can you just elaborate on FIT and Cologard for the
listeners that might not knowabout those products?
Dr. Chey (13:33):
Sure or genetic markers genetic changes in stool
samples that identify patientswho are more likely to have
either adenomatous polyps orcancer.
It's another method and, as Imentioned a moment ago, it's
really intended for average riskpatients.
Patients that have had aprevious history of adenomas or
(13:57):
a family history would not beappropriate for stool-based
testing, but for those thatdon't have a family history and
don't have a history a personalhistory of cancer or adenomatous
polyps so-called average riskpatients a stool-based test is
perfectly adequate.
Kate (14:13):
Perfect, and so I'm having my colonoscopy next week, just
so you know, good girl.
Just to get back to the initialquestion beyond alarm features,
is there something else thatprompts you to start thinking
mimickers, no family history, noalarm features.
Is there some red flags thatsay, hmm, there's something else
(14:36):
going on?
Dr. Chey (14:38):
I'm glad you came back to this because I forgot a
really important alarm featurethat I think there's confusion
about, and this is a reallyimportant point you know people
always talk about.
You might notice that I did notsay nocturnal pain, and yet if
you read a lot of reviewarticles and certainly some of
the older literature, they allrefer to pain that awakens you
(14:59):
at night as an alarm feature oralarm symptom.
It turns out that's not true.
The studies that have looked atthis there's multiple studies
that have looked at this havefound that the likelihood of
having organic disease is nodifferent between patients with
IBS symptoms that don't havepain that awakens them at night
versus those that do so.
Pain that awakens them at nightversus those that do so.
(15:20):
Pain that awakens you at nightis not an alarm symptom, but
diarrhea that awakens you atnight is a very potent alarm
symptom, and that's alsosomething that answers the
question that you just raised.
What is a red flag for me thatreally gets my ears up in clinic
is when a patient tells me thatI have to get up at night with
(15:40):
diarrhea.
That is almost never IBS.
I mean occasionally it'll turnout that way, but almost never
Almost always, a patient thattells you that they're having
episodes of diarrhea at nightwill have some other organic
disease, and so those arepatients that I pay particularly
close attention to in terms ofmaking sure they don't have any
(16:02):
of a variety of diarrhealillnesses, some of which we'll
talk about today.
Kate (16:06):
What are some of the most common IBS mimickers that you
see in your practice?
Dr. Chey (16:12):
It's funny because the things that we providers and
patients know about the mostthey're important to know about,
but they're not necessarily themost prevalent.
So, for example, almosteverybody knows about the
overlap between celiac diseaseand IBS.
In fact, we've published a lotof papers about that.
You know, we published one ofthe original meta-analyses
suggesting that we should belooking for celiac disease in
(16:35):
patients with IBS symptoms.
We're also, though fortunatelyor unfortunately, one of the
first ones to publishprospective real-time clinical
trials showing that theprevalence of celiac disease was
not that different than theprevalence of celiac disease in
the general population.
And, by the way, what is thatnumber?
(16:56):
The number is probably 1% orless.
So so you definitely will seeit if you look for it.
But think about it.
That means that you're going tohave to test 100 IBS patients
and, by the way, it's IBS-Dpatients, for the come up to me
and say you know, you wrote allthese papers about how we should
(17:20):
be testing for celiac diseasein IBS patients.
I test every one of my IBSpatients and I never find celiac
disease, and my response tothem is you're right, you will
have to test 100 patients tofind one with celiac disease.
Actually, the true number isprobably more on the order of
around 150.
So it's not that you'll neverfind it, it's just that you
(17:44):
won't find it that often.
But why is it worth doing?
Because celiac disease is aprofoundly important diagnosis
to make.
It's not a diagnosis that youwant to miss.
Why?
Because there are so manydownstream consequences to not
making the diagnosis of celiacdisease.
Being misdiagnosed as IBS whenyou have celiac disease could
(18:07):
potentially have catastrophicconsequences for the patient 5,
10, 15 years down the road,including an increased risk of
cancer.
So it's just not a diagnosisthat we can afford to miss.
So, even though it's not thatcommon, it's important to look
for Things that are more commonare things like microscopic
colitis.
(18:28):
That's still missed a lot,although less often now than 10
years ago.
But microscopic colitisprobably is going to be present
in somewhere between 3% and 5%of patients with IBSD symptoms
that don't have warning signs,by the way.
So for those patients that havenocturnal diarrhea, for those
(18:49):
patients that are not respondingas well as you might expect to
some Imodium or other treatmentsfor IBS-D, think about
microscopic colitis.
Make sure that if a patientgets a Flexsig or a colonoscopy
that they get random biopsies tobe sure that you've excluded
microscopic colitis.
(19:10):
Bile acid diarrhea is alsoreally common.
Put it this way, bile acidmalabsorption is probably
present in 20% to 25% of IBS-Dpatients.
Now the degree to which thatbile acid malabsorption is
responsible for the patient'ssymptoms is still a bit unclear.
But even if 50% of thosepatients, their symptoms are
(19:35):
related to the bile acidmalabsorption, that's a lot of
patients.
So I think we're going tocontinue to see research on this
topic, which is very important,and we'll gain a clearer
understanding of exactly howoften we should be turning to
bile acid sequestrants like thecholestyramine or cholestepalam
(19:56):
or cholestopal.
That's definitely something.
And then small intestinalbacterial overgrowth, or SIBO,
is another thing that we thinkabout, or we're talking about a
lot, and there's a lot ofcontroversy about whether SIBO
is the same thing as IBS orwhether SIBO is a completely
separate and distinct diseasefrom IBS.
(20:18):
The truth is probably somewherein between, like always.
And then other things likedisaccharidase deficiency.
I'm sure we'll talk about that.
That's a really interesting anda really rapidly evolving topic
.
But I do want to say one wordabout the IBS-C group because if
(20:39):
you think about it, everythingI've said up to this point has
been focused on IBS-D and that'spelvic floor dysfunction, and
the three of us have had manydiscussions about this and it's
so gratifying to start to seethe ship turn in terms of
gastroenterologists and even, Idare say, in some cases, primary
care physicians, starting tothink about that as an
explanation for refractorysymptoms in patients with IBS-C
(21:02):
who don't get better withlaxatives.
That's primarily whereclinicians and patients should
be starting to ask questionsabout this.
Possibility is if you haveconstipation-related symptoms,
with or without abdominal pain,and you've tried a variety of
laxative therapies and nothinghas worked pelvic floor
dysfunction or an evacuationdisorder the inability to be
(21:25):
able to fully evacuate stoolfrom the rectum goes way up on
your list of possibilities.
Dr. Riehl (21:31):
And that then adds to the team right.
So we have pelvic floorphysical therapists that are
life-changing for patients, andso the team widens a bit with
some of our constipationpatients.
But you bring up such a goodpoint in terms of looking for
other options for these patientsthat are totally suffering.
Dr. Chey (21:50):
It really speaks to this point that again, in 2024,
it takes a village.
Ibs therapy is no longerfocused solely on the
gastroenterologist, which is,you know, in 1990, the treatment
of IBS was almost entirelyfocused on the
gastroenterologist.
You know, thegastroenterologist I sort of
(22:12):
think of as more now as thecaptain of the team.
The gastroenterologist stillplays an incredibly important
role, arguably the mostimportant role in terms of
coordinating the care betweenthe various stakeholders.
But the gastroenterologist in2024, for the complex or
(22:32):
severely affected IBS patient,is sorely inadequate.
Dr. Riehl (22:36):
And you make the best point that providing that
definitive diagnosis for thepatient is really the starting
point.
They're not going to believeyou when you say you know, I've
got this GI psychologist you cango talk to.
You know, I think you have IBS.
It has to be.
You have IBS, I have a teamthat I work with.
We will all help you.
Let's explore what theseoptions are.
(22:58):
I'm confident that we can getyou feeling better.
Dr. Chey (23:01):
I always say to people too, that when I'm teaching
fellows about IBS, I say thinkabout what we say to an IBS
patient.
Typically, I think you have IBS.
It's a condition defined by thepresence of abdominal pain and
altered bowel habits.
The good news is that it's notassociated with cancer or other
(23:24):
organic diseases.
The bad news is we don't knowwhat causes it.
We don't know what the besttreatment for it is, and you're
going to have it for the rest ofyour life.
Dr. Riehl (23:34):
Yay, think about how that would make you feel Woo-hoo
.
Dr. Chey (23:38):
How could you walk away from that interaction with
anything but just despair?
Think about this you have IBS.
It's a condition for which wehave an immensely growing
understanding and for thatreason and understanding that
there are lots of reasons whypatients have IBS symptoms, we
have a team of individuals thatcan provide a variety of
(24:02):
different treatment options foryou.
We will use those stakeholdersto tailor an individualized
treatment program for you andthere's a very high likelihood
probably a greater than 80%chance that we will be able to
make your symptoms moremanageable.
What a different message, right.
Dr. Riehl (24:25):
Same disease.
Yeah.
So for any listeners out there,if you've heard anything but
that very expert delivery of thediagnosis, think about Dr Chey
in your head when you thinkabout your IBS diagnosis.
There's an incredible amount ofuncertainty that comes if you
don't receive a diagnosis likethat.
Certainty that comes if youdon't receive a diagnosis like
that.
And so we do want to instill alot of hope for people that you
know we can help you live wellwith IBS.
(24:45):
So thank you for that, Dr.
Chey.
Kate (24:47):
Absolutely.
We need a dream team approach,right?
We talk about that a lot inMind your Gut.
It's not just one person likeyou know, it's a team sport
Moving just into mimickers.
Again, I wanted to talk becausethere's a lot sport Moving just
into mimickers.
Again, I wanted to talk becausethere's a lot of sort of
misinformation about parasiticinfections but then sometimes
parasitic infections can mimicIBS.
What type of parasiticinfections do you think about
(25:11):
that might mimic IBS-D and whenor what would be some things
that you would think about.
That would you know.
You'd say, oh, this might be aconsideration in this particular
patient.
Dr. Chey (25:23):
In the United States, the big one to really think
about and consider and evenidentify like we probably
identify at least a few patientsa year with Giardia.
Giardia is a very importantparasitic infection to be aware
of, particularly in certainparts of the country Like, for
example Megan and I are fromMichigan.
(25:43):
Well, in Northern Michigan andsome of the lakes there will be
outbreaks of Giardia, so it canpresent with all the symptoms
that seem identical to IBS.
Most of the time, by the way,though, the symptoms will be
much more severe, butoccasionally you'll get a
patient who, for whatever reason, doesn't express the full-blown
(26:04):
illness and has symptoms moreakin to IBS.
So, as part of an earlyevaluation, in places where
there is the possibility ofendemic parasitic infection,
it's reasonable to do a GI PCR,which would include a screen for
Giardia.
Dr. Riehl (26:21):
What do you think about the patients that come in
with the wide-sweeping stoolstudies that they've sent in
stool to a company and it'sanxiety-provoking.
But, as an expertgastroenterologist, tell us a
little bit about what patientsmay or may not be getting from
that.
Dr. Chey (26:39):
So I get asked this a lot and I get asked this a lot
by patients who bring me thosereports, and conceptually the
concept is really interestingand I think potentially at some
point in the future may beactionable.
Right now the problem is that alot of the microbiome analysis,
the metabolome analysis, is notadequately validated and really
(27:03):
don't know how to interpret it,and that's true too of a lot of
proteases.
There's a whole wide range ofdifferent things that people are
testing for in stool now, bythe way, all founded in
conceptual models which couldmake sense to IBS, but not
necessarily human studies thatmake clear that that kind of
(27:24):
testing is valuable to excludethis disease or that, or
certainly to identify patientsthat would benefit from this
supplement or that, which isusually how this works.
I hope this doesn't come off astoo inflammatory, but one of
the business models that goesunspoken, of course, is that you
(27:45):
do the testing and then youorder supplements from your own
shop for which there's a profitmargin.
I'm not saying that that's theonly reason why providers do
this.
I know for sure that's not thecase but it does create a bit of
an intrinsic conflict ofinterest.
So, bottom line right now,there are things in those tests
(28:07):
which are valuable.
So for example, iron studies,certain studies of vitamins can
be helpful, but a lot of it, andin particular a lot of the
stuff that's really foundationalto the testing right now, I
think in, at least in my mindhas not been adequately
validated.
So the microbiome metabolomeanalysis, those types of things
(28:29):
I think could be valuable, but Idon't think we know that
they're valuable yeah so ifyou're coming in with that big
supplement list and maybethey've been on it for a month
or two.
Dr. Riehl (28:43):
One thing that we talk about is it probably isn't
the right thing for you and wehave to pivot.
So before shelling out moremoney, it's always a good idea
to check in with agastroenterologist.
A little further about that.
Kate (28:59):
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Kate (31:06):
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Dr. Riehl (31:40):
The book is available in our show notes as well as at
all major book retailers, sowe're going to pivot also to an
area of research that you'vecertainly been doing a lot in.
When might you consider sucroseisomaltase deficiency, and how
common is this?
What are the red flags thatwe're looking for?
Dr. Chey (32:02):
Yeah.
So right now, there'sincreasing focus on sucrose
isomaltase, and our group willdefinitely take some credit or
fault for that.
People are talking about it.
I think it's a valuable topicfor us to be discussing as a
scientific community, but thereare a lot of unanswered
questions, and we'll get intothat in a second.
What I do want to do, though,is to say that one thing that
(32:24):
I've learned from doing researchin this field is that we
probably need to broaden the waythat we look at.
We probably need to broaden theway that we look at
disaccharidase deficiencies,rather than just sucrose
isomaltase deficiency.
So, in other words, there are awhole bunch of different
disaccharidases.
The one that everybody knows themost is lactase, and remember
(32:46):
that lactose is part of theFODMAP family, so it's been
acknowledged as a potentialtrigger for IBS symptoms for
many, many years.
This is not new information.
Now, sucrose is not part of theFODMAP approach, which is one
of the reasons why it's such aninteresting part of the
(33:07):
discussion as we move forward,because, intuitively, since
sucrose is not part of theFODMAP family at least the
traditional FODMAP family thatwe think about in the low FODMAP
diet if a patient does notrespond to the low FODMAP diet,
it would make sense that there'san increased likelihood of
(33:30):
sucrase deficiency, sucraseisomaltase deficiency and
therefore what happens issucrose, which is typically not
a FODMAP, when you have thatenzyme, in the absence of the
enzyme, becomes a FODMAP.
In other words, it's exactlythe same as if you don't have
lactase.
And in fact, in a post-hocanalysis from one of our
(33:51):
randomized controlled trials,that's exactly what we found is
that there was a more thantwo-fold increased likelihood of
response to the low FODMAP dietif you didn't have mutations of
the sucrose isomaltase gene.
So that was an interestingtidbit of information.
We just finished a study wherejust this can be an oral
(34:11):
presentation at DigestiveDiseases Week in May, reporting
data from a large-scaleprospective study using
disaccharidase assay todetermine the prevalence of
different disaccharidasedeficiencies in the US.
And what we're going to reportis that sucrose is a multi-ase
deficiency is present in around8.5% of isolates, which is much
(34:36):
higher than we thoughtpreviously.
Think about this.
Remember we said before celiacdisease is less than 1%.
We look for that in every IBSpatient.
Sucrose is a multi-asedeficiency is present in 8.5% in
over 200 patients that weenrolled from all over the
United States.
By the way, in fairness, youhave to say this.
(34:57):
Does that mean, like, for those8.5% of individuals that have
sucrose isomaltase deficiency,does that mean that that is
responsible for their symptoms,similar to what we talked about
with bile acids?
Not necessarily so.
It can be true and unrelated,right?
So that's one of the nextthings that we really need to
(35:18):
study.
We need to understand when is aduck a duck?
I don't think we know thatright now.
I think the other thing torealize that complicates this
discussion and this is whyresearch is so much fun is
because you answer one questionbut you create 10 others.
Realize this is that sucroseisomaltase deficiency, the
(35:39):
majority of the time, occurswith other enzyme deficiencies,
so 8.5% is not patients thathave just sucrose isomaltase
deficiency.
Those are people that havepalatinase deficiency, lactase
deficiency, so a lot of thepatients that have SID have
(36:00):
other disaccharides deficiencies, and the degree to which you
can fix one and make thesymptoms better is not clear.
So we have so much to learn,but what's fair to say is that
disaccharidease deficiencies ingeneral should be on our radar
screen.
It should be something thatwe're thinking about as an
(36:20):
important trigger for symptomsin patients with IBS.
Dr. Riehl (36:25):
How do you test for that and what might be a
treatment?
Dr. Chey (36:30):
So right now the gold standard test is biopsies from
the proximal small intestine andthen sending them to a
specialty laboratory todetermine the level of enzyme
activity in association with thedifferent disaccharidases, and
there are sort of internationalstandards that have been
established for the differentenzymes.
(36:51):
People also talk a lot aboutdoing breath tests to identify
patients with sucrose isomaltasedeficiency.
Unfortunately, those are muchless well-studied or validated.
In fact, I'm telling you thatour data is the first
large-scale data in adults fromthe United States using
disaccharides assay large-scaledata in adults from the United
(37:14):
States using disaccharide assay.
So again, one of the things weneed to do next is try to really
more carefully validate theother tests that might be used
to identify these patients inclinical practice.
Part of our abstract that we'representing at DDW did evaluate
a C13 sucrose breath test andunfortunately found it to not be
terribly accurate.
So we'll have to see if othersreplicate that data and I'd like
(37:37):
to see additional testing withother forms of breath tests,
more traditional sucrose breathtesting.
Kate (37:43):
Just a quick question when you looked at these individuals
with IBS and checked theirDysac assays, were they IBS-D?
Predominant Is diarrhea, sortof the like ooh, these patients
might have it versus someonewith constipation.
Or I'm just thinking red flagsfor someone that might be
thinking, hey, I might havesucrose isomaltase deficiency.
Dr. Chey (38:04):
That's a really important question.
I'm glad you asked that becauseI should have made that more
clear.
Our study was in patients withIBS-D symptoms by the Rome
criteria.
So what we found in preliminarysort of observational
retrospective studies is thatthe patients to worry about with
dissect deficiency definitelyhad diarrhea.
(38:24):
That's sort of the hallmarksymptom that people have always
talked about for many decades.
But what we also found in ourresearch was that abdominal pain
and bloating were just ascommon as diarrhea.
So that's why we focused onIBS-D, because if you think
about it, that's IBS-D, it'sabdominal pain, bloating and
diarrhea.
So the prevalence of SID is8.5% in IBS-D patients by Rome
(38:51):
criteria.
Dr. Riehl (38:52):
Okay, how about bile acid malabsorption of bile acid
diarrhea?
When might you consider this aspart of the clinical picture?
Dr. Chey (39:01):
Yeah, there's been a lot of chatter about this as
well, and I mentioned earlierthat there's data, predominantly
from the Mayo Clinic,suggesting that anywhere between
20-25%, maybe even up to 30%,of patients with IBS-D have
evidence of bile acidmalabsorption.
Again, it doesn't prove causeand effect necessarily, but it
(39:22):
is measurably abnormal inpatients with IBS-D.
That's sort of all comersPatients in which you should
think about it even more so areafter cholecystectomy.
So if a patient has had aprevious cholecystectomy,
independent of whether they haveabdominal pain or not, if they
have diarrhea you should bethinking about bile acid
(39:45):
malabsorption.
There's also, interestingly, arelationship between SIBO and
bile acid diarrhea, becausebacterial overgrowth so bacteria
in the small bowel, candeconjugate bile acids
prematurely in the smallintestine, converting bile acids
to a form that are more likelyto induce diarrhea primary bile
(40:07):
acids and so therefore patientswith SIBO are more likely to get
bile acid diarrhea Also.
The last category that isreally important, particularly
for listeners that are havingproblems with diarrhea is if
you've had surgery to remove thelast part of your small
intestine, the ileum, thatactually is a huge setup to
(40:31):
develop bile acid diarrheabecause in the ileum there are
receptors called IBATs ilealbile acid transporters that
reabsorb bile acids and if youremove the ileum, you remove
those IBATs and you're not ableto reabsorb the bile acids
before they get to the colonwhere they induce secretion of
(40:53):
fluid and stimulate contractileactivity in the colon that
causes diarrhea.
Dr. Riehl (40:59):
What might a patient look for for treatment for that?
Dr. Chey (41:02):
Right now the primary treatment for bile acid diarrhea
is to give the patient a bileacid sequestrant.
This is a resin that absorbsexcess bile acids in the fecal
effluent and in that way reducesthe burden of bile acids that
get to the colon.
That can cause diarrhea.
Dr. Riehl (41:22):
So another example of it may be medication, it may be
lifestyle, it may be nutrition,but figuring out more of that
root cause is really importantbecause you can't keep going
without that medication.
It's really needed.
Dr. Chey (41:37):
No question about it.
You can see, as we're talkingabout this, we're slowly, at a
snail's pace, moving towardsmore of a precision medicine
kind of model, which is reallywhere we want to go right.
We really want to move fromthis sort of empiric treatment
based on a patient's symptoms towe do this test to determine
(41:59):
whether the patient has thisdisease and for that disease
it's this therapy.
By the way, patients thatlisten to me talk about this
always get really excited andthink well, why is my doctor
doing this right now?
Well, to a large extent, docsdon't have the capability or the
training to do this right now.
So this is very much a story inevolution.
(42:19):
It is getting better.
It's going to get even betterover time, but it will take time
.
Dr. Riehl (42:25):
Okay, so one of our last IBS potential mimickers
you've mentioned it smallintestinal bacterial overgrowth.
It's complicated, right, and sowhere do you think we are right
now in terms of the patientsthat Google this and bring this
to your office and they'recurious about it?
What are you looking for andhow might you treat it in your
(42:45):
clinic?
Dr. Chey (42:46):
Well, there's little doubt that this exists.
There's little doubt in my mindthat there are patients that
have a transposition of bacteriainto the small intestine that
leads to a variety of clinicalconsequences, and those clinical
consequences can oftentimesoverlap significantly with IBS,
particularly IBS-D, but in somecases perhaps IBS-C too.
(43:10):
We can talk about that.
The fundamental way that we arelooking at small intestinal
bacterial overgrowth at thecurrent time, I think in five
years will be almost entirelyantiquated.
So you know, one of thecommittees that I'm sitting on
right now is called the LuminalMicroenvironment Committee for
the Rome Foundation,microenvironment committee for
(43:35):
the Rome Foundation.
So we're writing the chapterfor the Rome 5 compendium on the
importance of the luminalmicroenvironment, and one of the
things that we're spending themost time talking about is the
microbiome and the smallintestine and large intestine
and SIBO in particular, andwe've had a lot of discussions
about this a group of keyopinion leaders from all over
the world that know a lot aboutthis.
Literally, this is what they doin terms of research in their
(43:57):
clinical practice, and I thinkthere's an increasing mindset
I've been saying this for manyyears, by the way.
I'm glad that it seems to begetting more popular is that
defining SIBO purely on thebasis of quantity of bacteria in
certain parts of the smallbowel.
That may very well be part ofthe definition, but it's
(44:21):
probably missing a big part ofthe issue at hand, which is what
bacteria are there and what arethey doing.
So it may be the constituentsand the metabolomic consequences
that are as or more importantthan the actual quantity of
bacteria.
And so right now we're reallyjust at a stage where we're just
(44:43):
defining what are the bacteriathat are present in patients
with SIBO and what are theydoing compared to healthy
controls.
So we're very much at an earlystage in this discussion, but I
bet the way it's going to settleout is that it won't just be by
quantity of bacteria that we'redefining SIBO.
(45:03):
So we're still at very earlystages.
But, that said, I do want togive a shout out to Mark
Pimentel, because Mark reallyhas suffered the slings and
arrows of thinking differentlyand you know, while he and I
have certainly had ourdisagreements in terms of you
(45:24):
know, the way that we look atthe world and look at SIBO and
IBS, we wouldn't even be havingthis discussion if it weren't
for Mark Pimentel.
You know he's a true leader,you true leader in terms of
research in this field and atrailblazer, and, again,
definitely has paid his dues forthinking differently.
I do want to just give himcredit for that for sure.
Dr. Riehl (45:46):
Our listeners are in for a treat because we're going
to have a really, I think,provocative conversation with Dr
.
Pimentel in an upcoming episode.
Kate (45:55):
Oh, yeah, thanks for the teaser.
Bill yes, absolutely, he is amaverick and I'm glad you see it
that way as well, because Iknow he's had a lot of criticism
and he just keeps fighting andgets scrappy and is showing a
lot of really interesting data.
So gets scrappy and is showinga lot of really interesting data
.
Dr. Chey (46:13):
So, yeah, and he's been right a lot more than he's
been wrong.
I mean, I think, if you reallyput things on the scale, yeah,
he's been wrong about somethings, but he's been right
about a whole bunch of thingsand you know, and I think you
have to give him credit for thatI mean the whole refection
story and the way that we treata subset of patients with IBS.
(46:33):
I mean you have to give morecredit for that, that's science,
right trial and error.
That's right.
Kate (46:39):
So if you've tried traditional testing and
treatments for the symptomsyou're experiencing without any
benefit, don't be afraid to askyour physician about some of the
IBS mimickers we have discussedtoday on this episode.
They can help you, and the moreyou know, the more you're able
to advocate for yourself.
Dr. Riehl (46:57):
Yeah, you know, as we've talked with Dr Chey today,
he points out that diagnosis iskey and, as we've all
identified in so many GIconditions and really with gut
health generally, that a lot oftimes people need a dream team.
And that dream teammultidisciplinary,
patient-specific, really is suchan incredible importance in
(47:20):
really getting you down thatroad of improving your symptoms,
and especially with mimickers,where you might think you have
one thing and it actually turnsout to possibly be something
else or something in addition.
So when we think about thedream team, as we've talked
about, the addition of an RD canprovide really necessary
nutrition therapy which can be agame changer, especially with a
(47:44):
diagnosis such as Celiacdisease.
And in some cases not only doesa GI psychologist join the team
to provide brain, gut,behavioral therapies and these
therapies can improve symptoms,coping, social support, but we
can also dive a little deeperinto aspects of grief and, as
(48:06):
we've kind of talked about today, when you have a diagnosis and
again I'll just use Celiacdisease as an example where
really the treatment is arestrictive diet, it's saying
goodbye to gluten and we want tonormalize that.
Grief can be a part of that andsome of the aspects of grief
that come with this are justdetection and decision fatigue.
(48:27):
So does something have gluten?
Where do we find it?
What can I eat?
And this can really happenacross the lifespan, from
parents that are helping theirchild navigate a diagnosis like
this all the way up throughgoing off to college and then
living on your own.
So keep in mind that you arenot alone with these diagnoses,
(48:48):
and we really want to stress theimportance of that.
And we really want to stressthe importance of that.
Now, as you all know, guthealth matters.
Our dear friends, and so manygood things in life can boost
our gut health, from the foodsthat we eat, to the people that
we spend time with, to theevents that boost all of our
endorphins, and nothing willboost endorphins like what we
(49:12):
are going to share with you next.
So, Kate, do you have some newsfor us?
Kate (49:17):
Well, we have just had such overwhelming positive
response to the Gut HealthPodcast and we really appreciate
all of your support.
We're just so excited.
It's been amazing, okay, okay,so should I tell them?
You should tell them all right.
Dr. Riehl (49:36):
We've decided to expand our team and we thought
that we could use a little extrahelp with the podcast content
and marketing.
So please join Kate and I witha big hello to yes, we have a
new team member.
Kate (49:54):
This is Mabel June.
You know she might be a littleunqualified, I don't think so.
Dr. Riehl (50:01):
I mean she's already diving into the microphone.
Kate (50:04):
I mean that's right, I think you know what she's going
to ramp up in no time, right nowshe literally is trying to get
the headphones on.
Dr. Riehl (50:12):
She wants her own microphone, so we're going to
have to get another Shure MV7because that's what we use
around here.
But she is looking like she isready to go for episode four and
with all of our hearts burstingand already excited to hear
about Mabel's first month duringour next episode.
(50:33):
Bill, we thank you for joiningus.
We certainly learned a lot aswe wrap up this episode.
What is something that youprioritize when it comes to your
overall health and wellness?
Dr. Chey (50:46):
Increasingly as I get a bit older, it's really time
with my family.
When I was younger I didn'tfully appreciate how important
that is.
But as you get older I thinkeverybody realizes time really
speeds up.
What you think is like sixmonths down the road is just
around the corner.
It just literally comes up onyou out of nowhere.
(51:07):
So prioritizing those momentsthat you can spend with your
family I think are so incrediblyimportant.
Kate (51:16):
Love it.
A big thanks to our guest, Dr.
Chey.
We value your expertise andwillingness to spend some time
with us and our audience on ourpodcast.
Next up we are talking aboutsmall intestinal bacterial
overgrowth in the small bowelmicrobiome with Dr.
Mark Pimentel from Cedars-Sinaiin Los Angeles.
Dr. Riehl (51:36):
So make sure you subscribe, follow and like The
Gut Health Podcast.
Your support means the world,our friends.
Thank you for joining us as wegrow this gut health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media @The Gut Health
(51:57):
Podcast, where we'd love for youto share your thoughts,
questions and experiences.
Thanks for tuning in, friends.
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