October 23, 2024 • 29 mins
Featuring: Jeffrey Nathanson, M.D., Comprehensive Gastrointestinal Health
The GI Research Foundation was able to produce this podcast with sponsorships from AbbVie and Metro Infusion Center.
In this episode, we sit down with Dr. Jeffrey Nathanson, partner and gastroenterologist at Comprehensive Gastrointestinal Health in Northbrook, Illinois. We explore bowel frequency—what is “normal” and when it may be time to consult a physician.
To access other episodes of Visceral: Listen to Your Gut and learn more about the GI Research Foundation’s support of clinical and laboratory research to treat, prevent, and cure digestive diseases, please visit https://www.giresearchfoundation.org/.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
The GI Research Foundation was able to produce this podcast with sponsorships from AbbVie and Metro Infusion Centers.
(00:10):
Welcome to Visceral, a podcast with the GI Research Foundation. Today, we're speaking with Jeffrey Nathanson, a gastroenterologist and a University of Chicago alumnus,
who practices on the North Shore in Northbrook and Libertyville at Comprehensive Gastrointestinal Health.
Welcome, Dr. Nathanson. Thank you so much for being with us today.
(00:30):
One of the reasons that we have Dr. Nathanson with us today is that he is a graduate first of Stanford University, where he went for his medical school,
but then came to the University of Chicago, where he was our resident and he was the chief resident for internal medicine,
and then became a gastroenterology fellow, where he trained for three years with our team at U of C with Dr. Rubin and Dr. Cohen and with many of our current faculty.
(01:00):
And we are just so lucky that we have such amazing providers in the greater Chicago area who are treating patients and helping patients all over access the very best quality in GI care.
So thank you very much, Dr. Nathanson. We're so happy to have you here with us today.
Well, thank you, Anna. I'm excited to be here and thank you for your kind words.
(01:22):
And I'm always excited for the opportunity to reconnect with the University of Chicago, given my many years at the university and my fond memories and my ongoing collaboration with many of the gastroenterologists.
So happy to chat and do what I can to support GIRF.
Well, we are just thrilled that you are willing to share your expertise with us.
(01:44):
One of the things that our patients talk to us a lot about is bowel frequency, which is the frequency with which patients need to eliminate or use the toilet.
And this is something that affects lots of different GI conditions, including IBD, Crohn's Disease and Ulcerative Colitis.
How does bowel frequency manifest in a disorder? And what is it like when you have normal bowel frequency?
(02:10):
Good question. So, you know, bowel frequency from one person to the next varies quite a bit.
From a medical definition, we call normal anywhere from once every three days to three times a day.
But with that being said, even within a normal range, sometimes the bowel frequency when accompanied by other symptoms such as urgency or cramping or incomplete evacuation can still be disruptive and problematic,
(02:39):
even if it technically meets that normal definition.
And certainly there are people that go less frequently or more frequently and that in and of itself can cause problems.
Yeah, there is a common misconception that people need to go to the bathroom every day, have a bowel movement every day. That is not necessarily true.
As I mentioned, what the normal range is, I do have some people that go once a week and they feel perfectly fine.
(03:03):
And they just empty once a week.
What are the conditions that are...what are the diagnoses that are connected with this issue?
Sure. So, we tend to lump people with bowel frequency issues into one of two broad categories.
So, the first and the more common is if they have, again, what we call functional or irritable bowel.
(03:26):
And that's as common as it is, it's still hard to define.
But the way I think about it is people with irritable bowel symptoms, things don't move exactly right and things don't sense exactly right.
You know, our GI tract has its own nervous system called the enteric nervous system and it has what are called motor nerves that create the forward motility of the intestinal tract, that peristaltic wave that moves things along.
(03:52):
If you can imagine a snake swallowing something and how there are...there's a propulsive force where the muscles, what are called the smooth muscles that line the intestinal tract, contract and push things along in a wave-like pattern.
(04:13):
And it's the nervous system that stimulates those muscles to contract and push things forward.
And some people, things are a little bit sluggish and in some people those waves are more frequent or stronger amplitude and things move more quickly.
(04:34):
The challenge with people with this irritable bowel condition is that there isn't a great test to diagnose it.
There isn't, we don't really have an x-ray or a blood test or a colonoscopy that says, here's the irritable bowel, the diagnosis right here, we just need to fix this.
And we are left with a symptom picture of patients who complain of things like bowel frequency or infrequency and then we have a variety of ways that we approach management of it.
(05:05):
The second is if there's some sort of inflammation going on and there are a variety of inflammatory conditions that can affect your bowel motility.
And some of the more, the ones you may be familiar or that we hear about are ulcerative colitis, Crohn's disease, celiac disease, eosinophilic disorders, microscopic colitis, and then there are a potpourri of other ones that are less common.
(05:35):
Sure.
So all of these conditions can affect motility, which is then connected to bowel frequency.
Can you speak a little bit about what motility is? Because we've talked about it on this podcast before, but I would love to hear your perspective.
(05:56):
So motility refers to movement within the GI tract and it can be abnormal really anywhere in the GI tract and that leads to symptoms.
So if there is decreased motility in the colon, we call that colonic inertia, that tends to lead to slow movement of the stool through the colon and result in constipation and constipation related symptoms.
(06:31):
On the other hand, if there is increased motility, then the stool moves more quickly through the colon and then that can create, basically overwhelm the lower GI tract, the rectum, and the anal sphincter such that people need to go to the bathroom more frequently and more urgently.
And that comes with it's again, array of issues.
(06:55):
Yeah.
What are some of those issues with increased motility?
So I think there's two aspects of that.
So number one is if there's, and that's why I mentioned earlier, it's important to differentiate the underlying etiology.
If there's an inflammatory condition that's driving the increased frequency of the bowels, for example, Ulcerative Colitis or Crohn's or Celiac, that inflammation is causing decreased absorption of the,
(07:25):
of, you know, what you eat and the stomach juices and as a result, that was called an osmotic load arrives in the lower GI tract and kind of overwhelms it and that causes things to rush through more quickly and then the resulting urge to have a bowel movement.
And symptomatically, that often manifests with people that will wake up first thing in the morning, they're jumping out of bed, they need to run to the bathroom, there may be some associated cramping or gas, they may need to go several times in a row.
(08:00):
If there's significant inflammation in the colon, for example, in some people with Ulcerative Colitis or Crohn's disease, that can lead to bleeding and because of the malabsorption component of it, that can result in potentially nutrient deficiencies and weight loss.
Obviously, all of those are potentially be serious and it's important to differentiate the cause here so that the underlying condition can be addressed.
(08:29):
So, so that's the inflammatory increase frequency.
The other end of the spectrum is the irritable bowel, increased frequency.
Again, just as disruptive, if not more disruptive to many people because often when people have that irritable bowel where the colon is more spastic and reactive and you kind of have this exaggerated response to normal bowel loads going through the intestine, people may experience cramping.
(09:04):
They may swing sometimes from having frequent bowel movements to suddenly going the other way, we call alternating bowel habits.
And you don't, it's not a malabsorptive state, there should not be bleeding of any significance so that there aren't those consequences, but in terms of the impact on quality of life, people can often really struggle and suffer with these sort of symptoms.
(09:29):
Definitely, it's really easy to see how that pattern could be so disruptive and so hard for people to live normal lives and do the things that kind of make our lives worth living like going to sporting events going to work going to school being able to be with friends go out to dinner,
have all of those experiences that are so frankly also really important to our lives as social beings.
(09:59):
I do find that these symptoms can be a major impact on people's quality of life to the point where people become prisoners to their bowels whether they're changing their whole life around the idea of when are they going to need to go to the bathroom, where is their access to a bathroom.
People will be stuck in their house in the mornings, sometimes getting up hours before they need to go to work to make sure that they're fully emptying. They will often not go out in public places, whether it's not easy access to a bathroom,
(10:33):
Eating in restaurants can be very stressful and then in the more extreme situation where someone has an episode of fecal incontinence where they lose control and are not able to get to the bathroom in time, that can be very traumatic for individuals and something that patients don't often talk about,
(10:54):
and I sometimes have to tease out of them because that's often what drives people to come see that gastroenterologist isn't just how upsetting and terrible they feel that they had an episode such as that.
Yeah. How do you make these determinations and how do you then advise patients with treatment options or what they can do to address these concerns?
(11:18):
So certainly that's the initial decision tree is what is, which of these two broad categories is this individual symptoms coming from. So often that starts just by taking a good history and listening to the patient.
Certainly if patients have certain red flag symptoms as we call them, for example, if they're having significant bleeding, if they're losing weight, if they are anemic, these raise the concern that there may be one of these inflammatory conditions.
(11:52):
But even then, not everyone with these inflammatory conditions has these other symptoms. Ultimately, to try to differentiate, we typically do need to do some objective testing and it kind of varies depending upon the presentation on the story that the patient shares.
But I would say quite commonly we will do some blood tests. We will look to see is the patient anemic. Do they have elevated inflammatory markers in their blood? We'll also do a stool test to look for an elevated inflammatory marker called a fecal cow protecting.
(12:28):
We also will often screen for celiac disease, which is not that uncommon in people with these kind of symptoms. And that that's usually done initially with a blood test.
Although if abnormal or if there's a strong enough suspicion, then we would move to doing an endoscopy, which is a camera through the mouth to look into the top of the GI tract as celiac will affect the small intestine, which you can access via the upper endoscope.
(13:00):
And then certainly when appropriate, colonoscopy camera going the other way through the anus and rectum to look in the colon to look for a cause.
Now, some of it does depend again on the story. And if there's a young person who does not have those red flags and whose story sounds most consistent with irritable bowel syndrome, and sometimes the testing initially may be limited or possibly not at all, an initial approach to management, which we can get into in a sec, maybe attempted before considering tests.
(13:37):
So some of it kind of depends on it's on a patient to patient person to person basis.
(14:07):
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Do people ever have an inflammatory condition and irritable bowel syndrome at the same time?
That's a great question. The answer is yes.
There are people with inflammatory bowel disease, again, all sort of colitis and Crohn's their symptoms may be from the inflammation itself, but not uncommonly they also struggle with irritable bowel symptoms.
(14:39):
And that's one thing that we as gastroenterologists need to differentiate in our patients who have inflammatory bowel disease what's driving their symptoms at present.
Is it inflammation or is it more of this irritability, which it does appear they are more prone to have as well.
How does diet and what people eat play into this play into these concerns and issues?
(15:02):
Another great question. Diet certainly has a factor, certainly plays a role.
And, you know, I think our understanding of diet is very much still evolving. But there is no doubt that it's an important role for both people with irritable bowel as well as with inflammatory bowel.
(15:23):
I would say in the in the those with irritable bowel syndrome.
There is a subset where diet is a major driver of their issues. Sometimes it's obvious a patient may know every time I have dairy or every time I eat onions, I get symptoms.
But sometimes it's not so obvious. So there is a well studied diet called a low FODMAP diet that's been shown to be very helpful for many people with irritable bowel syndrome.
(15:55):
And often we will start with diet and in my practice we have GI dietitians and this is one of their areas of expertise where we have a patient meet with the dietitian.
They review the diet. They will typically do a structured elimination of the high FODMAP foods and then based on the response how people feel with their symptoms and hopefully they feel better.
(16:19):
And this is where the GI dietitian is particularly helpful. They do a structured reintroduction of the of these foods because in reality, most people do fine with most of the foods on the high FODMAP list.
It's just a few that are often the culprit, but you never really know in any individual what they're going to be until you go through this process.
So clearly with diet and irritable bowel, we often will involve the dietitian. But let me also comment if I may on diet and inflammatory bowel disease.
(16:53):
Certainly, while we don't understand the precise cause of inflammatory bowel disease, and it's probably a combination of genetics and environmental triggers, there do seem to be certain foods that are more likely to trigger an inflammatory reaction and others that are helpful and protective at decreasing the likelihood of flares.
(17:21):
And this is an emerging science, but there have now been some well designed, well controlled studies, the best kind of studies that have looked at diet in the treatment of inflammatory bowel disease.
Now, in most people, it's not done in isolation, often needs to be done in conjunction with medications.
But certainly, I'll say broadly speaking, there are some specific diets, but it's kind of a Mediterranean style diet that tends to be best for people with inflammatory bowel disease.
(17:52):
And that's usually one focused on whole foods, more plant based, oil, oil and vegetables and less red meat, less processed, less dairy.
And again, that's something that working with a GI dietitian can be really helpful in elucidating.
And I would imagine people are very motivated when they're experiencing these really disruptive symptoms to think about their diet.
(18:17):
And also, the reforms that you've mentioned, the ways that people can experience an elimination diet, but then over time reintroduce some of those foods and figure out really what works for them.
I know that our dietitians, similarly, it sounds like, as with your practice, have just really great structures to help people understand the role that diet does play in their disease or their diagnosis.
(18:43):
So that's really great to hear.
I know that we've talked about low FODMAP diets in the past.
We've talked about elimination diets for IBD.
Certainly, people living with celiac disease have a very specific diet that they follow that eliminates gluten from their diet.
All of these things are, of course, again, often discussed by patients because we live, most many of us, or I live in the United States, where it does seem that our national diet is not always very helpful for GI health and wellness long term.
(19:21):
When I think of the things my kids like to eat and how orienting them to those more whole foods and maybe anti-inflammatory foods is really challenging in a world of hot dogs and french fries and fast food and pizza and all the things that are so highly palatable and maybe also not great for us.
(19:44):
So I have a very layman's question.
So I go to the drugstore and there are so many medications that I can take for diarrhea or constipation.
So why should patients, why would we not treat frequency and urgency with just taking some over-the-counter anti-diarrheal medication?
(20:09):
And how do we, or is that part of the treatment plan for people who have these symptoms and does it vary according to the disease that they have, the disease state or the syndrome having abs?
Right.
So I think you hit upon some, again, some good points here.
Certainly, I think if an individual is having GI symptoms, bowel frequency issues, I think it's really important to talk to your doctor if necessary, be referred to a gastroenterologist, defining what may be driving that will impact how we approach the treatment of that.
(20:47):
And in some people, some of the over-the-counter remedies may be not only perfectly safe, they may be the chosen therapy.
For example, loperamide or Imodium is a common over-the-counter medicine.
And in people who have increased frequency from irritable bowel, sometimes it's very effective therapy, other conditions as well.
(21:11):
But if you were to take that and you had some other underlying inflammatory conditions, sometimes that may either mask what's really going on or potentially even make it worse.
So I think the first step is always to talk to your doctor.
Sure.
I think those remedies certainly have their place, but they have to be in the appropriate patient.
(21:35):
Makes sense.
And are there prescription medications that can be used to treat disorders of motility, frequency, and urgency?
Definitely, there's a role for medications.
Again, as we've discussed and I keep harping on, it depends upon the underlying cause with inflammatory conditions.
(21:57):
Many will require medications, although some can be managed just with diet interventions, celiac disease being the classic example where the elimination of gloom itself will control the disease.
But other conditions like, for example, ulcerative colitis and Crohn's will typically require medications as part of a multi-pronged approach to therapy.
(22:19):
And then in the other category, again, are irritable bowel syndrome or functional GI symptoms.
There are a whole host of different medications, several prescription medications that either slow motility, increase motility, and they do so by different mechanisms.
Sometimes they work on the associated pain or bloating.
(22:41):
And then I'll also mention, in addition to some of the, quote, unquote, medications, there are some supplements.
So people often talk about supplements and probiotics.
This is an area where there's a lot out there and not a ton of science, but in selective situations.
There is some evidence for the use of certain supplements and certain medications.
(23:05):
For example, I'll just mention one, curcumin, which is the active ingredient in turmeric, has some anti-inflammatory benefits and has been shown to have benefit in treating patients with ulcerative colitis.
So that's something that's over the counter, but again, should be recommended by your physician.
And we've talked a little bit about the probiotic-prebiotic relationship in people's guts and also the difference between getting some of those probiotics through diet rather than through a supplement.
(23:40):
Do you have any recommendations about probiotics, prebiotics, in diet and supplement form?
Good question. I would say there's a lot out there, not a lot with a bunch of evidence. There are selective situations where I do recommend them, but it's patient and situation-specific.
So, you know, it's hard to make an overriding statement there.
(24:06):
I would say that there's not any evidence. Some people come in and say, you know, should I take a probiotic just to be healthy for my gut?
Sure.
And there's really no evidence you need to do that. You can get all of the healthy benefits to your intestinal tract just with diet.
So that's where I say, hey, you know, as you just mentioned, there's a lot of foods out there, lots of a variety of types of fiber and other food sources that provide prebiotic, which helps promote healthy and diverse microbiome.
(24:36):
So, you know, I tend to focus more on diet in that situation.
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(25:06):
Please visit us at MetroInfusionCenter.com to learn how you can participate.
There was one takeaway that you wanted to give to people who are listening to this episode. What would you want them to take away from all of the different topics that we've talked about today?
I would say, coming back to the theme of the day of bowel frequency, you know, a lot of people struggle and they don't have to.
(25:37):
We have a, you know, A, as I mentioned, it's important to sort out what are you driving the symptoms, but there's lots of things that can be done to help people.
These are symptoms that can have major impact on one's life. It's not something people want to talk about. They're often embarrassed. They may feel shame.
And we as gastroenterologists are here. We can help.
Certainly, if people have had a negative experience where they've been told, and this is kind of a, you know, hopefully the field of gastroenterology and medicines will be on this, but in the past, at times, there have been, I've had many patients that they've been told, oh, well, it's just IBS.
(26:12):
That's not important and it's dismissive.
And IBS can, or irritable bowel can be extremely disruptive to one's life. And the great, great majority of the time, we can help people.
Are they going to have, quote unquote, perfect bowel movements and no issues? Maybe not.
But the realistic goal of having people such that their GI and their bowel issues are mostly pretty good here and there.
(26:41):
They may act up, but there's kind of a management plan to get on top of it and calm things down so that it doesn't spiral.
We can and should be able to achieve that goal working collectively and cooperatively with our patients.
That's a wonderful message. And honestly, we talk all the time about patients advocating for themselves and finding the care that they need to get better and to not settle for
(27:10):
feeling just okay, but to feeling really, really great. And I know that Dr. Nathanson, you and your colleagues as well at Comprehensive Gastrointestinal Health are part of the wonderful infrastructure we have here in
Chicago land that helps to support that goal. So I'm so grateful to you for sharing some of your time with us today. I'm so grateful that you are still such an important part of our University of Chicago GI community.
(27:38):
And I'm so happy that we were able to really discuss all of these issues related to both functional and inflammatory bowel disorders, which are really, I think, a lot of what people who are listening to this role want to talk about.
So I'm very, very, very grateful to you. So thank you so much.
(27:59):
Well, thank you. Thanks for the opportunity. And I'm so, it's encouraging to me to hear that there's lots of ways to reach patients and certainly podcasts and what you do and what GIRF does is a wonderful way to connect with patients outside of the traditional
doctor-patient in-the-office interaction. So thank you.
(28:20):
Well, the GI Research Foundation is truly the engine that is driving a lot of this innovation and we're really lucky to have them in our corner. So thank you so much. And I hope we get to talk to you again soon.
Wonderful. Thank you too.
Thank you for listening to this episode of the podcast Visceral from the GI Research Foundation. This episode was written, edited and produced by me, Anna Gomberg, and edited and mixed by Luke Pacholski . Special thanks to the talented Michael Collins Dowd, who composed our theme music and executive producer Brittany Zelvin.
(28:52):
We hope you will join us next time. Until then, to access other episodes and learn more about research to treat, prevent and cure digestive diseases, please visit the website at giresarchfoundation.org and follow us on Facebook, Twitter and LinkedIn.
Please like and subscribe to Visceral on all your favorite podcast platforms. Until next time, listen to your gut.
Thank you again to our sponsors, AbbVie and Metro Infusion Centers.
The GI Research Foundation was able to produce this podcast with sponsorships from AbbVie and Metro Infusion Centers.
(00:10):
Welcome to Visceral, a podcast with the GI Research Foundation. Today, we're speaking with Jeffrey Nathanson, a gastroenterologist and a University of Chicago alumnus,
who practices on the North Shore in Northbrook and Libertyville at Comprehensive Gastrointestinal Health.
Welcome, Dr. Nathanson. Thank you so much for being with us today.
(00:30):
One of the reasons that we have Dr. Nathanson with us today is that he is a graduate first of Stanford University, where he went for his medical school,
but then came to the University of Chicago, where he was our resident and he was the chief resident for internal medicine,
and then became a gastroenterology fellow, where he trained for three years with our team at U of C with Dr. Rubin and Dr. Cohen and with many of our current faculty.
(01:00):
And we are just so lucky that we have such amazing providers in the greater Chicago area who are treating patients and helping patients all over access the very best quality in GI care.
So thank you very much, Dr. Nathanson. We're so happy to have you here with us today.
Well, thank you, Anna. I'm excited to be here and thank you for your kind words.
(01:22):
And I'm always excited for the opportunity to reconnect with the University of Chicago, given my many years at the university and my fond memories and my ongoing collaboration with many of the gastroenterologists.
So happy to chat and do what I can to support GIRF.
Well, we are just thrilled that you are willing to share your expertise with us.
(01:44):
One of the things that our patients talk to us a lot about is bowel frequency, which is the frequency with which patients need to eliminate or use the toilet.
And this is something that affects lots of different GI conditions, including IBD, Crohn's Disease and Ulcerative Colitis.
How does bowel frequency manifest in a disorder? And what is it like when you have normal bowel frequency?
(02:10):
Good question. So, you know, bowel frequency from one person to the next varies quite a bit.
From a medical definition, we call normal anywhere from once every three days to three times a day.
But with that being said, even within a normal range, sometimes the bowel frequency when accompanied by other symptoms such as urgency or cramping or incomplete evacuation can still be disruptive and problematic,
(02:39):
even if it technically meets that normal definition.
And certainly there are people that go less frequently or more frequently and that in and of itself can cause problems.
Yeah, there is a common misconception that people need to go to the bathroom every day, have a bowel movement every day. That is not necessarily true.
As I mentioned, what the normal range is, I do have some people that go once a week and they feel perfectly fine.
(03:03):
And they just empty once a week.
What are the conditions that are...what are the diagnoses that are connected with this issue?
Sure. So, we tend to lump people with bowel frequency issues into one of two broad categories.
So, the first and the more common is if they have, again, what we call functional or irritable bowel.
(03:26):
And that's as common as it is, it's still hard to define.
But the way I think about it is people with irritable bowel symptoms, things don't move exactly right and things don't sense exactly right.
You know, our GI tract has its own nervous system called the enteric nervous system and it has what are called motor nerves that create the forward motility of the intestinal tract, that peristaltic wave that moves things along.
(03:52):
If you can imagine a snake swallowing something and how there are...there's a propulsive force where the muscles, what are called the smooth muscles that line the intestinal tract, contract and push things along in a wave-like pattern.
(04:13):
And it's the nervous system that stimulates those muscles to contract and push things forward.
And some people, things are a little bit sluggish and in some people those waves are more frequent or stronger amplitude and things move more quickly.
(04:34):
The challenge with people with this irritable bowel condition is that there isn't a great test to diagnose it.
There isn't, we don't really have an x-ray or a blood test or a colonoscopy that says, here's the irritable bowel, the diagnosis right here, we just need to fix this.
And we are left with a symptom picture of patients who complain of things like bowel frequency or infrequency and then we have a variety of ways that we approach management of it.
(05:05):
The second is if there's some sort of inflammation going on and there are a variety of inflammatory conditions that can affect your bowel motility.
And some of the more, the ones you may be familiar or that we hear about are ulcerative colitis, Crohn's disease, celiac disease, eosinophilic disorders, microscopic colitis, and then there are a potpourri of other ones that are less common.
(05:35):
Sure.
So all of these conditions can affect motility, which is then connected to bowel frequency.
Can you speak a little bit about what motility is? Because we've talked about it on this podcast before, but I would love to hear your perspective.
(05:56):
So motility refers to movement within the GI tract and it can be abnormal really anywhere in the GI tract and that leads to symptoms.
So if there is decreased motility in the colon, we call that colonic inertia, that tends to lead to slow movement of the stool through the colon and result in constipation and constipation related symptoms.
(06:31):
On the other hand, if there is increased motility, then the stool moves more quickly through the colon and then that can create, basically overwhelm the lower GI tract, the rectum, and the anal sphincter such that people need to go to the bathroom more frequently and more urgently.
And that comes with it's again, array of issues.
(06:55):
Yeah.
What are some of those issues with increased motility?
So I think there's two aspects of that.
So number one is if there's, and that's why I mentioned earlier, it's important to differentiate the underlying etiology.
If there's an inflammatory condition that's driving the increased frequency of the bowels, for example, Ulcerative Colitis or Crohn's or Celiac, that inflammation is causing decreased absorption of the,
(07:25):
of, you know, what you eat and the stomach juices and as a result, that was called an osmotic load arrives in the lower GI tract and kind of overwhelms it and that causes things to rush through more quickly and then the resulting urge to have a bowel movement.
And symptomatically, that often manifests with people that will wake up first thing in the morning, they're jumping out of bed, they need to run to the bathroom, there may be some associated cramping or gas, they may need to go several times in a row.
(08:00):
If there's significant inflammation in the colon, for example, in some people with Ulcerative Colitis or Crohn's disease, that can lead to bleeding and because of the malabsorption component of it, that can result in potentially nutrient deficiencies and weight loss.
Obviously, all of those are potentially be serious and it's important to differentiate the cause here so that the underlying condition can be addressed.
(08:29):
So, so that's the inflammatory increase frequency.
The other end of the spectrum is the irritable bowel, increased frequency.
Again, just as disruptive, if not more disruptive to many people because often when people have that irritable bowel where the colon is more spastic and reactive and you kind of have this exaggerated response to normal bowel loads going through the intestine, people may experience cramping.
(09:04):
They may swing sometimes from having frequent bowel movements to suddenly going the other way, we call alternating bowel habits.
And you don't, it's not a malabsorptive state, there should not be bleeding of any significance so that there aren't those consequences, but in terms of the impact on quality of life, people can often really struggle and suffer with these sort of symptoms.
(09:29):
Definitely, it's really easy to see how that pattern could be so disruptive and so hard for people to live normal lives and do the things that kind of make our lives worth living like going to sporting events going to work going to school being able to be with friends go out to dinner,
have all of those experiences that are so frankly also really important to our lives as social beings.
(09:59):
I do find that these symptoms can be a major impact on people's quality of life to the point where people become prisoners to their bowels whether they're changing their whole life around the idea of when are they going to need to go to the bathroom, where is their access to a bathroom.
People will be stuck in their house in the mornings, sometimes getting up hours before they need to go to work to make sure that they're fully emptying. They will often not go out in public places, whether it's not easy access to a bathroom,
(10:33):
Eating in restaurants can be very stressful and then in the more extreme situation where someone has an episode of fecal incontinence where they lose control and are not able to get to the bathroom in time, that can be very traumatic for individuals and something that patients don't often talk about,
(10:54):
and I sometimes have to tease out of them because that's often what drives people to come see that gastroenterologist isn't just how upsetting and terrible they feel that they had an episode such as that.
Yeah. How do you make these determinations and how do you then advise patients with treatment options or what they can do to address these concerns?
(11:18):
So certainly that's the initial decision tree is what is, which of these two broad categories is this individual symptoms coming from. So often that starts just by taking a good history and listening to the patient.
Certainly if patients have certain red flag symptoms as we call them, for example, if they're having significant bleeding, if they're losing weight, if they are anemic, these raise the concern that there may be one of these inflammatory conditions.
(11:52):
But even then, not everyone with these inflammatory conditions has these other symptoms. Ultimately, to try to differentiate, we typically do need to do some objective testing and it kind of varies depending upon the presentation on the story that the patient shares.
But I would say quite commonly we will do some blood tests. We will look to see is the patient anemic. Do they have elevated inflammatory markers in their blood? We'll also do a stool test to look for an elevated inflammatory marker called a fecal cow protecting.
(12:28):
We also will often screen for celiac disease, which is not that uncommon in people with these kind of symptoms. And that that's usually done initially with a blood test.
Although if abnormal or if there's a strong enough suspicion, then we would move to doing an endoscopy, which is a camera through the mouth to look into the top of the GI tract as celiac will affect the small intestine, which you can access via the upper endoscope.
(13:00):
And then certainly when appropriate, colonoscopy camera going the other way through the anus and rectum to look in the colon to look for a cause.
Now, some of it does depend again on the story. And if there's a young person who does not have those red flags and whose story sounds most consistent with irritable bowel syndrome, and sometimes the testing initially may be limited or possibly not at all, an initial approach to management, which we can get into in a sec, maybe attempted before considering tests.
(13:37):
So some of it kind of depends on it's on a patient to patient person to person basis.
(14:07):
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Do people ever have an inflammatory condition and irritable bowel syndrome at the same time?
That's a great question. The answer is yes.
There are people with inflammatory bowel disease, again, all sort of colitis and Crohn's their symptoms may be from the inflammation itself, but not uncommonly they also struggle with irritable bowel symptoms.
(14:39):
And that's one thing that we as gastroenterologists need to differentiate in our patients who have inflammatory bowel disease what's driving their symptoms at present.
Is it inflammation or is it more of this irritability, which it does appear they are more prone to have as well.
How does diet and what people eat play into this play into these concerns and issues?
(15:02):
Another great question. Diet certainly has a factor, certainly plays a role.
And, you know, I think our understanding of diet is very much still evolving. But there is no doubt that it's an important role for both people with irritable bowel as well as with inflammatory bowel.
(15:23):
I would say in the in the those with irritable bowel syndrome.
There is a subset where diet is a major driver of their issues. Sometimes it's obvious a patient may know every time I have dairy or every time I eat onions, I get symptoms.
But sometimes it's not so obvious. So there is a well studied diet called a low FODMAP diet that's been shown to be very helpful for many people with irritable bowel syndrome.
(15:55):
And often we will start with diet and in my practice we have GI dietitians and this is one of their areas of expertise where we have a patient meet with the dietitian.
They review the diet. They will typically do a structured elimination of the high FODMAP foods and then based on the response how people feel with their symptoms and hopefully they feel better.
(16:19):
And this is where the GI dietitian is particularly helpful. They do a structured reintroduction of the of these foods because in reality, most people do fine with most of the foods on the high FODMAP list.
It's just a few that are often the culprit, but you never really know in any individual what they're going to be until you go through this process.
So clearly with diet and irritable bowel, we often will involve the dietitian. But let me also comment if I may on diet and inflammatory bowel disease.
(16:53):
Certainly, while we don't understand the precise cause of inflammatory bowel disease, and it's probably a combination of genetics and environmental triggers, there do seem to be certain foods that are more likely to trigger an inflammatory reaction and others that are helpful and protective at decreasing the likelihood of flares.
(17:21):
And this is an emerging science, but there have now been some well designed, well controlled studies, the best kind of studies that have looked at diet in the treatment of inflammatory bowel disease.
Now, in most people, it's not done in isolation, often needs to be done in conjunction with medications.
But certainly, I'll say broadly speaking, there are some specific diets, but it's kind of a Mediterranean style diet that tends to be best for people with inflammatory bowel disease.
(17:52):
And that's usually one focused on whole foods, more plant based, oil, oil and vegetables and less red meat, less processed, less dairy.
And again, that's something that working with a GI dietitian can be really helpful in elucidating.
And I would imagine people are very motivated when they're experiencing these really disruptive symptoms to think about their diet.
(18:17):
And also, the reforms that you've mentioned, the ways that people can experience an elimination diet, but then over time reintroduce some of those foods and figure out really what works for them.
I know that our dietitians, similarly, it sounds like, as with your practice, have just really great structures to help people understand the role that diet does play in their disease or their diagnosis.
(18:43):
So that's really great to hear.
I know that we've talked about low FODMAP diets in the past.
We've talked about elimination diets for IBD.
Certainly, people living with celiac disease have a very specific diet that they follow that eliminates gluten from their diet.
All of these things are, of course, again, often discussed by patients because we live, most many of us, or I live in the United States, where it does seem that our national diet is not always very helpful for GI health and wellness long term.
(19:21):
When I think of the things my kids like to eat and how orienting them to those more whole foods and maybe anti-inflammatory foods is really challenging in a world of hot dogs and french fries and fast food and pizza and all the things that are so highly palatable and maybe also not great for us.
(19:44):
So I have a very layman's question.
So I go to the drugstore and there are so many medications that I can take for diarrhea or constipation.
So why should patients, why would we not treat frequency and urgency with just taking some over-the-counter anti-diarrheal medication?
(20:09):
And how do we, or is that part of the treatment plan for people who have these symptoms and does it vary according to the disease that they have, the disease state or the syndrome having abs?
Right.
So I think you hit upon some, again, some good points here.
Certainly, I think if an individual is having GI symptoms, bowel frequency issues, I think it's really important to talk to your doctor if necessary, be referred to a gastroenterologist, defining what may be driving that will impact how we approach the treatment of that.
(20:47):
And in some people, some of the over-the-counter remedies may be not only perfectly safe, they may be the chosen therapy.
For example, loperamide or Imodium is a common over-the-counter medicine.
And in people who have increased frequency from irritable bowel, sometimes it's very effective therapy, other conditions as well.
(21:11):
But if you were to take that and you had some other underlying inflammatory conditions, sometimes that may either mask what's really going on or potentially even make it worse.
So I think the first step is always to talk to your doctor.
Sure.
I think those remedies certainly have their place, but they have to be in the appropriate patient.
(21:35):
Makes sense.
And are there prescription medications that can be used to treat disorders of motility, frequency, and urgency?
Definitely, there's a role for medications.
Again, as we've discussed and I keep harping on, it depends upon the underlying cause with inflammatory conditions.
(21:57):
Many will require medications, although some can be managed just with diet interventions, celiac disease being the classic example where the elimination of gloom itself will control the disease.
But other conditions like, for example, ulcerative colitis and Crohn's will typically require medications as part of a multi-pronged approach to therapy.
(22:19):
And then in the other category, again, are irritable bowel syndrome or functional GI symptoms.
There are a whole host of different medications, several prescription medications that either slow motility, increase motility, and they do so by different mechanisms.
Sometimes they work on the associated pain or bloating.
(22:41):
And then I'll also mention, in addition to some of the, quote, unquote, medications, there are some supplements.
So people often talk about supplements and probiotics.
This is an area where there's a lot out there and not a ton of science, but in selective situations.
There is some evidence for the use of certain supplements and certain medications.
(23:05):
For example, I'll just mention one, curcumin, which is the active ingredient in turmeric, has some anti-inflammatory benefits and has been shown to have benefit in treating patients with ulcerative colitis.
So that's something that's over the counter, but again, should be recommended by your physician.
And we've talked a little bit about the probiotic-prebiotic relationship in people's guts and also the difference between getting some of those probiotics through diet rather than through a supplement.
(23:40):
Do you have any recommendations about probiotics, prebiotics, in diet and supplement form?
Good question. I would say there's a lot out there, not a lot with a bunch of evidence. There are selective situations where I do recommend them, but it's patient and situation-specific.
So, you know, it's hard to make an overriding statement there.
(24:06):
I would say that there's not any evidence. Some people come in and say, you know, should I take a probiotic just to be healthy for my gut?
Sure.
And there's really no evidence you need to do that. You can get all of the healthy benefits to your intestinal tract just with diet.
So that's where I say, hey, you know, as you just mentioned, there's a lot of foods out there, lots of a variety of types of fiber and other food sources that provide prebiotic, which helps promote healthy and diverse microbiome.
(24:36):
So, you know, I tend to focus more on diet in that situation.
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(25:06):
Please visit us at MetroInfusionCenter.com to learn how you can participate.
There was one takeaway that you wanted to give to people who are listening to this episode. What would you want them to take away from all of the different topics that we've talked about today?
I would say, coming back to the theme of the day of bowel frequency, you know, a lot of people struggle and they don't have to.
(25:37):
We have a, you know, A, as I mentioned, it's important to sort out what are you driving the symptoms, but there's lots of things that can be done to help people.
These are symptoms that can have major impact on one's life. It's not something people want to talk about. They're often embarrassed. They may feel shame.
And we as gastroenterologists are here. We can help.
Certainly, if people have had a negative experience where they've been told, and this is kind of a, you know, hopefully the field of gastroenterology and medicines will be on this, but in the past, at times, there have been, I've had many patients that they've been told, oh, well, it's just IBS.
(26:12):
That's not important and it's dismissive.
And IBS can, or irritable bowel can be extremely disruptive to one's life. And the great, great majority of the time, we can help people.
Are they going to have, quote unquote, perfect bowel movements and no issues? Maybe not.
But the realistic goal of having people such that their GI and their bowel issues are mostly pretty good here and there.
(26:41):
They may act up, but there's kind of a management plan to get on top of it and calm things down so that it doesn't spiral.
We can and should be able to achieve that goal working collectively and cooperatively with our patients.
That's a wonderful message. And honestly, we talk all the time about patients advocating for themselves and finding the care that they need to get better and to not settle for
(27:10):
feeling just okay, but to feeling really, really great. And I know that Dr. Nathanson, you and your colleagues as well at Comprehensive Gastrointestinal Health are part of the wonderful infrastructure we have here in
Chicago land that helps to support that goal. So I'm so grateful to you for sharing some of your time with us today. I'm so grateful that you are still such an important part of our University of Chicago GI community.
(27:38):
And I'm so happy that we were able to really discuss all of these issues related to both functional and inflammatory bowel disorders, which are really, I think, a lot of what people who are listening to this role want to talk about.
So I'm very, very, very grateful to you. So thank you so much.
(27:59):
Well, thank you. Thanks for the opportunity. And I'm so, it's encouraging to me to hear that there's lots of ways to reach patients and certainly podcasts and what you do and what GIRF does is a wonderful way to connect with patients outside of the traditional
doctor-patient in-the-office interaction. So thank you.
(28:20):
Well, the GI Research Foundation is truly the engine that is driving a lot of this innovation and we're really lucky to have them in our corner. So thank you so much. And I hope we get to talk to you again soon.
Wonderful. Thank you too.
Thank you for listening to this episode of the podcast Visceral from the GI Research Foundation. This episode was written, edited and produced by me, Anna Gomberg, and edited and mixed by Luke Pacholski . Special thanks to the talented Michael Collins Dowd, who composed our theme music and executive producer Brittany Zelvin.
(28:52):
We hope you will join us next time. Until then, to access other episodes and learn more about research to treat, prevent and cure digestive diseases, please visit the website at giresarchfoundation.org and follow us on Facebook, Twitter and LinkedIn.
Please like and subscribe to Visceral on all your favorite podcast platforms. Until next time, listen to your gut.
Thank you again to our sponsors, AbbVie and Metro Infusion Centers.
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