February 16, 2024 • 26 mins
The GI Research Foundation was able to produce this podcast with a sponsorship from AbbVie.
With Lalitha Sitaraman, MD, Assistant Professor of Medicine, the University of Chicago Medicine
Lalitha Sitaraman, MD, one of the newest members of the University of Chicago Digestive Diseases Center, focuses her research on the connection between the nervous system and the lower intestinal tract. Disordered motility can contribute to constipation, irritable bowel syndrome, and pelvic floor disorders, and is also related to Crohn’s disease and ulcerative colitis. Learn more in this episode about this important part of digestive health and wellness, and the mind-body connection.
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 www.giresearchfoundation.org.
Written and produced by Anna Gomberg. Edited and mixed by Mike Collins-Dowden. Available on Apple Podcasts, Spotify, and everywhere else you listen.
This episode is brought to you by AbbVie. AbbVie's mission is to discover and deliver innovative medicines that solve serious health issues today and address the medical challenges of tomorrow. We strive to have a remarkable impact on people's lives across several key therapeutic areas. For more information about AbbVie, please visit us at www.abbvie.com. Follow @abbvie on Twitter, Facebook, Instagram, YouTube, and LinkedIn
#podcast #gutmotility #constipation #ibs #pelvicfloor #crohns #colitis #hope #mindbody #futureofmedicine
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
This podcast, Visceral, is a production of the GI Research Foundation.
(00:03):
The GI Research Foundation was able to produce this podcast
with a sponsorship from AbbVie.
So I think one thing that I've noticed in being a specialist
in lower motility is you're not alone and there are people who can help you.
(00:26):
Welcome to another episode of Visceral,
the podcast from the GI Research Foundation.
My name is Anna Gomberg and I'm here today with Lalitha Sitaraman.
She is the new assistant professor of medicine and gastroenterology
at the University of Chicago Medicine.
And her primary focus is motility disorders and neuro gastroenterology.
(00:47):
These are conditions which focus on the disordered connection
between the nervous system and digestive tract or conditions
of disordered muscle control and movement.
Dr. Sitaraman specializes in diagnosing and treating gut, brain
and motility disorders specifically in the lower GI tract and pelvic floor.
So welcome, Dr. Sitaraman.
We're so excited to have you here and with us at the University of Chicago.
(01:10):
I wanted to start with just a few open questions about
motility disorders in general, because we haven't really talked about this
in any of our settings, including this podcast, because we haven't really had
someone with your expertise who's been part of our center.
So can you tell us a little bit about what gut motility is
and how it affects the digestive system?
(01:32):
Sure. First of all, thank you so much for inviting me to do this podcast.
Looking forward to sharing my expertise with you.
So in a general sense, gut motility is essentially the coordination of movement
of the muscles within the GI tract.
And each section of the GI tract has slightly different movement patterns.
So your esophagus is a little bit different than your stomach,
(01:55):
which is a little bit different than your small intestine or colon
and also different from the anus and rectum.
So we kind of split them up into those different segments.
And when you become a motility specialist,
most people do an additional training for that after doing gastroenterology fellowship.
And so I did additional training.
And so I do treat primarily the colon and anorectum now,
(02:18):
but I have been trained in the entire GI tract.
I'm to evaluate those disorders.
So why is motility important and how does it affect people's digestion?
Sure. So essentially, motility is how things move.
So if you eat something, you have to be able to swallow it.
And so in the upper GI tract, being able to swallow,
(02:40):
being able to have your stomach pulverize the food and move it through the stomach,
being able to absorb nutrients through the small intestine
and then eventually being able to evacuate the byproducts of digestion.
So stool, all of that is essential to being able to function as a human being,
absorb nutrients and get rid of waste.
So when I think best studied or the esophagus and the anorectum,
(03:08):
partly because there are the majority of diseases in those realms that we know about.
And also it's easier to study because they're towards the outside of the body.
So, yeah, so the testing that we do,
we're able to check the esophagus with various maneuvers.
We're able to check the anorectum with various maneuvers and testing that way.
(03:30):
So start to finish.
How long does it take food to go from your mouth all the way out?
And in a person, when things are going well, how long does that usually take?
Sure. That takes generally between 12 and 24 hours.
That's kind of a big range.
Yes. And there are certainly some people whose colons take longer.
So, I mean, I think people will often say,
well, if I didn't have my bowel movement this morning,
(03:52):
that means that I'm constipated and it's going to be a bad day or something.
And, you know, not everyone has a daily bowel movement.
A lot of people do.
And some people have multiple in a day.
Some people have one every three days, and that can be normal for you.
So, I mean, we the gut transit time when we have when we say that something is wrong,
something is normal versus abnormal.
(04:15):
Generally speaking, it's anywhere from 12 to 24 hours from in your mouth to being out.
So is constipation a motility disorder or is it a combination of factors that
that influence that or where does that fall in the spectrum?
So short answer is yes.
So, I mean, essentially constipation can be a transit issue with a slow large intestine,
(04:40):
but constipation can also be a muscle coordination issue of movement in the anus and rectum that,
you know, if you're straining, you're not able to pass the stool, then there can be backup
and then infrequent bowel movements, struggling to have a bowel movement.
And then also there are other effects that we are learning about more with constipation,
(05:02):
especially in neuro gastroenterology is like the association with irritable bowel syndrome.
So irritable bowel syndrome or IBS can be associated with diarrhea, constipation or both.
And those like the neuron connections, the brain connection with the gut brain axis
can actually also influence bowel habits.
(05:23):
Interesting. Can you say a little more about that?
How does that work?
So it's really complicated, which is kind of fun.
No, not right now.
No, this is actually, I mean, this is where this is the exciting stuff.
So, you know, we're learning a lot about disorders of gut brain interaction.
We're learning a lot about the gut brain, the gut brain axis in a general sense.
(05:43):
And it's it's full of a lot of different factors.
So it's there's hormonal factors, not only things like estrogen, progesterone, testosterone,
and but also hormones like stress hormones like cortisol.
Sure.
We're learning those effects on the gut.
We're learning the effects of neurotransmitters on the gut like serotonin, dopamine,
neurogenergics, all those things that are in your brain that also work on those both.
(06:06):
Those brain nerves.
And then when there's imbalances in those things, there can you can develop disorders
of gut brain interaction.
So, you know, when we're trying to try and treat these these illnesses, a lot of times
we're using neuromodulators.
We're using things that attack the nerves that more than anything else in the gut, not
necessarily if you have constipation, not necessarily using something that's like a
(06:29):
laxative.
Sometimes we have to as well.
But a lot of these symptoms that are part of the disordered gut brain axis are treated
when you target the nerves, like almost that brain half of it, that those things get better.
So constipation can sometimes even be improved with just a neuromodulator.
(06:49):
That's amazing.
So wait, what are those medications that you mentioned?
What are those neuromodulating medication?
Generally, those fall under the class of antidepressants, which is actually kind of interesting.
But the reason that is, is because serotonin is in the GI tract and serotonin is also like
we call it like the the happy chemical or what you get from your runner's high or, you
(07:12):
know, endorphins.
Those are all that's all serotonin.
And most of those medications that are antidepressants are affect serotonin.
So there's serotonin reuptake inhibitors in one way or another to increase the amount
of serotonin that's available.
So in the gut, when you use those or if you use certain other similar classes of neuromodulators
(07:34):
that are fall under the category of antidepressants, they can modulate pain and sometimes help
with bowel movements.
So how do you assess and how do you what diagnostic tests can you use to assess a patient's motility?
You mentioned that it's easier to do at the top and the bottom of the GI tract.
But what are those tests that you use to look at something like that?
(07:55):
So in general sense, both of the tests that we the main procedures that we have for assessing
the motility is for the motility of the esophagus and motility of the anus and rectum.
There are a couple other things that we can do to look at stomach emptying and whole gut
(08:16):
transit.
So how we talked about how it could be 12 to 24 hours for emptying, that's based on
normals from some amount of testing we have with whole gut transit tests, which are complicated
and also one of them is being pulled from the market, unfortunately.
But not what's being pulled from the market and the entire gut motility transit time.
(08:37):
So there's something that's called a it's like a motility capsule that is to measure
whole gut transit time.
So you swallow it.
It's and then it measures how long it takes to get through the stomach, small intestine
and colon until it's out of the body.
And for some reason, I think it's just not financially usable for enough that there's
a pulling it from the market, unfortunately.
But there are other things we do, too.
(08:58):
So from testing with motility disorders, we're generally looking at using a tiny catheter
that has a bunch of press pressure sensors on it.
And it can measure both the strength and the timing of contractions in the stomach.
And it can measure the strength and the timing of contractions in the esophagus or in the
(09:23):
anus and rectum.
These are different catheters, but similar in construction.
So both of them measure with high resolution over time, measuring pressure and and essentially
changes in pressure to tell us how strong a contraction could be.
So contraction and pressure, increased pressure and certain amounts of relaxation, allowing
(09:47):
movement.
And if those things don't happen the way that they're supposed to, then that's when you
get a disorder of swallowing or that's when you get a disorder of defecation, trouble
having a bowel movement with this testing for esophageal.
You generally are swallowing liquids to watch how that movement goes.
And with bowel movements, sorry, with lower motility, you're simulating a bowel movement.
(10:11):
So there's some amount of, you know, hold tension and then that catheter will measure
how strong the muscle is.
And then it'll be like release tension.
And that kind of shows how the muscle gets back to normal or relaxes enough to be able
to for you to pass or in some people's cases not pass any stool.
This episode is brought to you by AbbVie.
(10:32):
AbbVie's mission is to discover and deliver innovative medicines that solve serious health
issues today and address the medical challenges of tomorrow.
We strive to have a remarkable impact on people's lives across several key therapeutic areas.
For more information about AbbVie, please visit us at www.abbvie.com.
Follow AbbVie on Twitter, Facebook, Instagram, YouTube, and LinkedIn.
(10:58):
It sounds like this is a lot of muscle work.
Is there physical therapy that can be applied for some of these disorders?
I know that your work sometimes focuses on the pelvic floor, but I was just curious to
know, and even from the esophageal end, is that something that people can work on or
can get because of course these are muscles we don't have conscious control over.
(11:18):
Right.
So the esophagus is actually completely involuntary.
So there unfortunately is nothing you can do to do physical therapy for the esophagus.
And that the swallowing component is because of the types of muscles there are that nerve
control is just out of your control completely.
(11:40):
Now pelvic floor therapy is not just for strengthening the pelvic floor.
There is also pelvic floor therapy for relaxing the pelvic floor.
So the interesting thing about the anus and the anorectum is that that can be a learned
behavior of not actually being able to defecate properly.
(12:00):
So expelling stool is a very, very coordinated movement of generating enough force to be
able to pass stool and relaxing enough to allow stool to pass.
So being able to have both coordination of contraction and force generation and the same
time that there's generation of force, relaxation of force, that actually can be relearned.
(12:25):
And that is actually something that is we think is something that starts when people
have chronic constipation and develop a disorder of coordination in the anus and rectum, that
some of that is a learned behavior.
Some of the ways that people have been dealing with having constipation is they've relearned
how to have a bowel movement the wrong way.
(12:47):
So pelvic floor therapy, we call it pelvic floor therapy with biofeedback, there's a
way to essentially for you to see what you are doing when you are trying to simulate
a bowel movement with a small sensor that's usually placed in the body.
And it will show you why you...
In a sense, like when you are contracting too much or when you're not contracting enough.
(13:10):
And it's really, really helpful for a lot of our patients who have issues with constipation
and passing bowel movements for them to be able to have successful defecation.
The other thing that's really nice about this is that it works.
So it's a visualization of that contraction cycle or system that they can see, that someone
(13:33):
can see while they're in real time or in...
Yes.
So it's in real time.
So there's two different ways that this is often provided.
One is with either colors.
So a little light will show you if you're increasing or decreasing pressure or a tracing.
So you'll see a little line and the line will go up or down with the amount of muscle contraction
or relaxation that's occurring.
(13:54):
That's incredible.
Wow.
That's so interesting.
And what are...
So that you mentioned these ways that this can go awry, that gut motility can go awry.
Are there specific disorders that gut motility is a function of or is related to?
You've mentioned IBS and IBD.
I think another way to ask that question is how is gut motility related to both functional
(14:20):
bowel disorders and inflammatory conditions like Crohn's disease and ulcerative colitis?
So motility disorders are, I would say, probably not super implicated in inflammatory bowel
disease.
So Crohn's disease and ulcerative colitis, there can be overlap of those with other disorders
(14:41):
of gut brain interaction, and those are extremely, extremely complex.
But I think more when we're talking about issues with muscle coordination, motility
in the entire gut, there's more overlap with disorders of gut brain interaction because
those are throughout the entire gut system.
The nerves are everywhere.
(15:04):
Inflammatory bowel disease has certainly some processes of how it forms that we think could
even overlap with irritable bowel syndrome.
No, of course.
We completely know that there's so much overlap between IBD and IBS.
And I don't just mean the overlap of people not knowing which one they have and the misnomer,
(15:24):
which happens all the time, but literally IBS and IBD having both things at the same
time.
So, of course, it would seem to me that then in that way, gut motility would come into
play.
Right.
And it could be that there's some elements of the microbiome.
So different bacteria in the gut is say there's stasis from poor motility.
(15:44):
Could that be a reason that people develop IBS or IBD?
We don't know.
So there's a lot of the mechanism behind any motility disorder other than congenital, like
literally from birth problems that we know about.
We really don't have a great sense of why these things happen.
There is kind of an interesting parasite that can create problems with the motility in the
(16:14):
esophagus.
And some people are studying that parasite.
Tell me more about that.
That's amazing.
Like a parasite that people pick up in South America usually.
So it's called it's called Chagas disease.
And so this type of this parasite that causes Chagas disease can cause electrical problems
in the heart.
So it can cause complete heart block.
(16:36):
So affecting the electricity in the heart and potentially by a similar mechanism can
cause problems with motility in the esophagus and create what we call a mega esophagus.
So the esophagus stops working.
And that we're wondering is that could that be a target for trying to understand maybe
(16:56):
what happens in some of these more intrinsic conditions such as a Echolasia where the esophageal
sphincter doesn't relax?
Or could it be something in like sclerotic disorders like lupus, systemic sclerosis?
Could there be some target then for treatment maybe even to understand what we could do
(17:16):
about the esophagus?
That's fascinating.
Wow.
That's really amazing.
And that is such an interesting path for research to take in studying something like a parasitic
infection or a parasite.
You can be then developing new ideas about some of these other...
Yeah, the basics of where it comes from.
Really looks very difficult.
(17:37):
And how you could treat it potentially.
So you mentioned that many of these disorders are congenital.
So that would mean that they start from childhood.
Is that true?
Do we see a lot of pediatric patients with motility disorders?
And did that continue through adulthood?
So the ones that we know that happen and we know why they're happening are congenital.
(17:58):
The majority of motility disorders, we actually don't know why they happen.
And that's where trying to find the origin of disorders, gut pre-interaction, trying
to find the origin of chronic constipation, difficulty disorders.
We're all learning so much about that now.
(18:18):
So does early life trauma lead to difficulty disorders and IBS?
Yes, we know that there's interaction there.
Could PTSD also be associated with IBS?
Yes, it could be.
And is that evidence of trauma?
Is that something that is a cause maybe?
And then how do we promote resilience to have people not get affected with IBS after having
(18:45):
a traumatic event, which could be anything from a car accident to being in a war or something.
All of those things can create trauma.
And certainly the long-term effects of living with some of these disorders, we know from
talking with Dr. Bedell and other RGI psychologists that the sort of cycle of how these things
(19:06):
interact over time is also really something that is, I know, to be studied in a real paramount
importance as people live their lives.
When should a patient see you or see another gastroenterologist if they think they might
be having difficulty with their gut motility?
So just to harken back to one little thing, I want to just make sure we say that most
(19:28):
people do not have motility disorders.
Most people do not.
And congenital disorders of motility are very rare.
So most people don't have those issues.
And most people are not born with the motility disorder.
The times that you want to be worried are if you are having trouble swallowing and you're
(19:48):
having the sensation of food or medication being stuck in your throat or chest and it's
becoming progressive or persistent.
That is a time when you should see a gastroenterologist or at least talk to your primary care provider
about, is this something that needs to be evaluated further?
And that would be, I think, that's one segment of your GI tract.
(20:11):
The other half, which is the lower half, if you are having constipation that is new, so
you've never had constipation before and all of a sudden it's really becoming difficult
to have a bowel movement, if you notice there's any blood in your stool, if you're noticing
that you are feeling very uncomfortable a lot of the time, having a lot of belly pain,
(20:34):
that may be something that also needs to be investigated sooner rather than later.
First with your primary care provider, can address some of the basics of that, maybe
start that workup, do that referral for a gastroenterologist for you.
But constipation is also very, very common and constipation is not necessarily always
a motility disorder.
That is absolutely, we talk about constipation at our patient support group for patients
(20:56):
with IBD quite frequently for a disorder that is much more manifest in terms of diarrhea,
but we still talk about, especially because of the medical interventions, how constipation
can be caused by lots of different things and patients coming to figure out their body's
rhythms is really a big part of that process.
I have a question related to that support group, which is a lot of our patients with
(21:19):
IBD report kind of rapid transit issues where particularly post-surgical they feel like
they eat food and it goes right through them.
Is that something to do with motility?
Yeah, I would say yes.
So I mean, it's a little hard, rapid transit is challenging because of why it might happen.
(21:40):
So when someone who has had gut surgery, each segment of your small intestine and each segment
of your large intestine are doing a job.
So if that area is removed, the rest of the gut has to figure it out.
The good thing is the gut's pretty smart in a way.
I mean, I think it's pretty smart and it figures it out.
(22:00):
So if you have most of your colon removed, whatever is a remnant of your colon can oftentimes
pick up all the water that needs to be picked up out of that small intestinal fluid and
small intestinal products, and then you can have a solid stool.
But if you have a lot of your small intestine removed, then a lot of times there might not
(22:23):
be enough time to absorb things.
There may not be enough of an adjustment yet post-surgically for someone to have a normal
transit time.
But rapid transit is a problem for people post-surgical, people who've had bariatric
surgery and have a gastric bypass.
Those people can also have rapid transit and those mechanisms are slightly different most
(22:47):
of the time.
One of those things can be if there's like too much sugar or too much, we call it osmotic
load.
So anything that has a lot of, usually it's sugar or fake sugar, those things can go right
through you because those are not able to be absorbed immediately.
And the places that they need to be absorbed are at the front part of your small intestine.
(23:12):
And other things are absorbed in different periods, other nutrients, proteins, fats,
they're broken down in different areas and they're absorbed in different areas.
Vitamins are absorbed in different areas.
And then water is absorbed mostly in the colon.
So if you don't have enough time, then it's going to be diarrhea.
And potentially malabsorption, which is something that people worry a lot about with some of
(23:33):
these post-surgical or inflammatory conditions.
That is very instructive and very helpful.
So if there was something that you would want to tell patients who might be concerned about
constipation or esophageal symptoms, what would be one thing that you would want to
tell patients as a big takeaway regarding gut motility or just advice that you have
(23:57):
for them as a gastroenterologist who specializes in these disorders?
So I think one thing that I've noticed in being a specialist in lower motility, I'm
going to speak to that mostly, is you're not alone and there are people who can help you.
I think a lot of the patients that I see have had constipation for 10, 15, 20 years and
(24:21):
they've learned to accept it.
It's just their way of life.
They know they're going to spend half an hour, 45 minutes on the toilet.
They're probably only going to go once a week.
And that's what they've become accustomed to.
And that doesn't have to be normal.
It might be something that is manageable.
(24:43):
And so I would say if it's something you've been noticing for a long time and you find
it bothersome or distressing, don't hesitate to see a gastroenterologist because we have
things we can do.
And we're getting better about understanding the process, understanding the causes, understanding
(25:04):
the root causes as well as addressing treatments for disorders of gut re-interaction and for
constipation.
Absolutely.
I mean, I think that that's the advice that we...
I hear time and again from many of our gastroenterologists is you don't have to live like this and that
we want to help you get better.
(25:24):
And it's great to know that in this new domain for our Digestive Diseases Center, with your
expertise, we're getting even closer to that.
So thank you so much.
Thank you for having me.
Thank you for listening to this episode of the podcast, Fissure Roll from the GI Research
Foundation.
This episode was written and produced by me, Anna Gomberg, and edited and mixed by the
(25:46):
incredible Mike Collins-Dowden, who also composed our theme music.
We hope you will join us next time.
Until then, to access other podcasts and learn more about research to treat, prevent, and
cure digestive diseases, as well as access additional educational materials, please visit
the website at giresearchfoundation.org and follow us on Facebook, Twitter, and LinkedIn.
(26:07):
Thank you again to Abbvie for making this podcast possible.
This podcast, Visceral, is a production of the GI Research Foundation.
(00:03):
The GI Research Foundation was able to produce this podcast
with a sponsorship from AbbVie.
So I think one thing that I've noticed in being a specialist
in lower motility is you're not alone and there are people who can help you.
(00:26):
Welcome to another episode of Visceral,
the podcast from the GI Research Foundation.
My name is Anna Gomberg and I'm here today with Lalitha Sitaraman.
She is the new assistant professor of medicine and gastroenterology
at the University of Chicago Medicine.
And her primary focus is motility disorders and neuro gastroenterology.
(00:47):
These are conditions which focus on the disordered connection
between the nervous system and digestive tract or conditions
of disordered muscle control and movement.
Dr. Sitaraman specializes in diagnosing and treating gut, brain
and motility disorders specifically in the lower GI tract and pelvic floor.
So welcome, Dr. Sitaraman.
We're so excited to have you here and with us at the University of Chicago.
(01:10):
I wanted to start with just a few open questions about
motility disorders in general, because we haven't really talked about this
in any of our settings, including this podcast, because we haven't really had
someone with your expertise who's been part of our center.
So can you tell us a little bit about what gut motility is
and how it affects the digestive system?
(01:32):
Sure. First of all, thank you so much for inviting me to do this podcast.
Looking forward to sharing my expertise with you.
So in a general sense, gut motility is essentially the coordination of movement
of the muscles within the GI tract.
And each section of the GI tract has slightly different movement patterns.
So your esophagus is a little bit different than your stomach,
(01:55):
which is a little bit different than your small intestine or colon
and also different from the anus and rectum.
So we kind of split them up into those different segments.
And when you become a motility specialist,
most people do an additional training for that after doing gastroenterology fellowship.
And so I did additional training.
And so I do treat primarily the colon and anorectum now,
(02:18):
but I have been trained in the entire GI tract.
I'm to evaluate those disorders.
So why is motility important and how does it affect people's digestion?
Sure. So essentially, motility is how things move.
So if you eat something, you have to be able to swallow it.
And so in the upper GI tract, being able to swallow,
(02:40):
being able to have your stomach pulverize the food and move it through the stomach,
being able to absorb nutrients through the small intestine
and then eventually being able to evacuate the byproducts of digestion.
So stool, all of that is essential to being able to function as a human being,
absorb nutrients and get rid of waste.
So when I think best studied or the esophagus and the anorectum,
(03:08):
partly because there are the majority of diseases in those realms that we know about.
And also it's easier to study because they're towards the outside of the body.
So, yeah, so the testing that we do,
we're able to check the esophagus with various maneuvers.
We're able to check the anorectum with various maneuvers and testing that way.
(03:30):
So start to finish.
How long does it take food to go from your mouth all the way out?
And in a person, when things are going well, how long does that usually take?
Sure. That takes generally between 12 and 24 hours.
That's kind of a big range.
Yes. And there are certainly some people whose colons take longer.
So, I mean, I think people will often say,
well, if I didn't have my bowel movement this morning,
(03:52):
that means that I'm constipated and it's going to be a bad day or something.
And, you know, not everyone has a daily bowel movement.
A lot of people do.
And some people have multiple in a day.
Some people have one every three days, and that can be normal for you.
So, I mean, we the gut transit time when we have when we say that something is wrong,
something is normal versus abnormal.
(04:15):
Generally speaking, it's anywhere from 12 to 24 hours from in your mouth to being out.
So is constipation a motility disorder or is it a combination of factors that
that influence that or where does that fall in the spectrum?
So short answer is yes.
So, I mean, essentially constipation can be a transit issue with a slow large intestine,
(04:40):
but constipation can also be a muscle coordination issue of movement in the anus and rectum that,
you know, if you're straining, you're not able to pass the stool, then there can be backup
and then infrequent bowel movements, struggling to have a bowel movement.
And then also there are other effects that we are learning about more with constipation,
(05:02):
especially in neuro gastroenterology is like the association with irritable bowel syndrome.
So irritable bowel syndrome or IBS can be associated with diarrhea, constipation or both.
And those like the neuron connections, the brain connection with the gut brain axis
can actually also influence bowel habits.
(05:23):
Interesting. Can you say a little more about that?
How does that work?
So it's really complicated, which is kind of fun.
No, not right now.
No, this is actually, I mean, this is where this is the exciting stuff.
So, you know, we're learning a lot about disorders of gut brain interaction.
We're learning a lot about the gut brain, the gut brain axis in a general sense.
(05:43):
And it's it's full of a lot of different factors.
So it's there's hormonal factors, not only things like estrogen, progesterone, testosterone,
and but also hormones like stress hormones like cortisol.
Sure.
We're learning those effects on the gut.
We're learning the effects of neurotransmitters on the gut like serotonin, dopamine,
neurogenergics, all those things that are in your brain that also work on those both.
(06:06):
Those brain nerves.
And then when there's imbalances in those things, there can you can develop disorders
of gut brain interaction.
So, you know, when we're trying to try and treat these these illnesses, a lot of times
we're using neuromodulators.
We're using things that attack the nerves that more than anything else in the gut, not
necessarily if you have constipation, not necessarily using something that's like a
(06:29):
laxative.
Sometimes we have to as well.
But a lot of these symptoms that are part of the disordered gut brain axis are treated
when you target the nerves, like almost that brain half of it, that those things get better.
So constipation can sometimes even be improved with just a neuromodulator.
(06:49):
That's amazing.
So wait, what are those medications that you mentioned?
What are those neuromodulating medication?
Generally, those fall under the class of antidepressants, which is actually kind of interesting.
But the reason that is, is because serotonin is in the GI tract and serotonin is also like
we call it like the the happy chemical or what you get from your runner's high or, you
(07:12):
know, endorphins.
Those are all that's all serotonin.
And most of those medications that are antidepressants are affect serotonin.
So there's serotonin reuptake inhibitors in one way or another to increase the amount
of serotonin that's available.
So in the gut, when you use those or if you use certain other similar classes of neuromodulators
(07:34):
that are fall under the category of antidepressants, they can modulate pain and sometimes help
with bowel movements.
So how do you assess and how do you what diagnostic tests can you use to assess a patient's motility?
You mentioned that it's easier to do at the top and the bottom of the GI tract.
But what are those tests that you use to look at something like that?
(07:55):
So in general sense, both of the tests that we the main procedures that we have for assessing
the motility is for the motility of the esophagus and motility of the anus and rectum.
There are a couple other things that we can do to look at stomach emptying and whole gut
(08:16):
transit.
So how we talked about how it could be 12 to 24 hours for emptying, that's based on
normals from some amount of testing we have with whole gut transit tests, which are complicated
and also one of them is being pulled from the market, unfortunately.
But not what's being pulled from the market and the entire gut motility transit time.
(08:37):
So there's something that's called a it's like a motility capsule that is to measure
whole gut transit time.
So you swallow it.
It's and then it measures how long it takes to get through the stomach, small intestine
and colon until it's out of the body.
And for some reason, I think it's just not financially usable for enough that there's
a pulling it from the market, unfortunately.
But there are other things we do, too.
(08:58):
So from testing with motility disorders, we're generally looking at using a tiny catheter
that has a bunch of press pressure sensors on it.
And it can measure both the strength and the timing of contractions in the stomach.
And it can measure the strength and the timing of contractions in the esophagus or in the
(09:23):
anus and rectum.
These are different catheters, but similar in construction.
So both of them measure with high resolution over time, measuring pressure and and essentially
changes in pressure to tell us how strong a contraction could be.
So contraction and pressure, increased pressure and certain amounts of relaxation, allowing
(09:47):
movement.
And if those things don't happen the way that they're supposed to, then that's when you
get a disorder of swallowing or that's when you get a disorder of defecation, trouble
having a bowel movement with this testing for esophageal.
You generally are swallowing liquids to watch how that movement goes.
And with bowel movements, sorry, with lower motility, you're simulating a bowel movement.
(10:11):
So there's some amount of, you know, hold tension and then that catheter will measure
how strong the muscle is.
And then it'll be like release tension.
And that kind of shows how the muscle gets back to normal or relaxes enough to be able
to for you to pass or in some people's cases not pass any stool.
This episode is brought to you by AbbVie.
(10:32):
AbbVie's mission is to discover and deliver innovative medicines that solve serious health
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We strive to have a remarkable impact on people's lives across several key therapeutic areas.
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(10:58):
It sounds like this is a lot of muscle work.
Is there physical therapy that can be applied for some of these disorders?
I know that your work sometimes focuses on the pelvic floor, but I was just curious to
know, and even from the esophageal end, is that something that people can work on or
can get because of course these are muscles we don't have conscious control over.
(11:18):
Right.
So the esophagus is actually completely involuntary.
So there unfortunately is nothing you can do to do physical therapy for the esophagus.
And that the swallowing component is because of the types of muscles there are that nerve
control is just out of your control completely.
(11:40):
Now pelvic floor therapy is not just for strengthening the pelvic floor.
There is also pelvic floor therapy for relaxing the pelvic floor.
So the interesting thing about the anus and the anorectum is that that can be a learned
behavior of not actually being able to defecate properly.
(12:00):
So expelling stool is a very, very coordinated movement of generating enough force to be
able to pass stool and relaxing enough to allow stool to pass.
So being able to have both coordination of contraction and force generation and the same
time that there's generation of force, relaxation of force, that actually can be relearned.
(12:25):
And that is actually something that is we think is something that starts when people
have chronic constipation and develop a disorder of coordination in the anus and rectum, that
some of that is a learned behavior.
Some of the ways that people have been dealing with having constipation is they've relearned
how to have a bowel movement the wrong way.
(12:47):
So pelvic floor therapy, we call it pelvic floor therapy with biofeedback, there's a
way to essentially for you to see what you are doing when you are trying to simulate
a bowel movement with a small sensor that's usually placed in the body.
And it will show you why you...
In a sense, like when you are contracting too much or when you're not contracting enough.
(13:10):
And it's really, really helpful for a lot of our patients who have issues with constipation
and passing bowel movements for them to be able to have successful defecation.
The other thing that's really nice about this is that it works.
So it's a visualization of that contraction cycle or system that they can see, that someone
(13:33):
can see while they're in real time or in...
Yes.
So it's in real time.
So there's two different ways that this is often provided.
One is with either colors.
So a little light will show you if you're increasing or decreasing pressure or a tracing.
So you'll see a little line and the line will go up or down with the amount of muscle contraction
or relaxation that's occurring.
(13:54):
That's incredible.
Wow.
That's so interesting.
And what are...
So that you mentioned these ways that this can go awry, that gut motility can go awry.
Are there specific disorders that gut motility is a function of or is related to?
You've mentioned IBS and IBD.
I think another way to ask that question is how is gut motility related to both functional
(14:20):
bowel disorders and inflammatory conditions like Crohn's disease and ulcerative colitis?
So motility disorders are, I would say, probably not super implicated in inflammatory bowel
disease.
So Crohn's disease and ulcerative colitis, there can be overlap of those with other disorders
(14:41):
of gut brain interaction, and those are extremely, extremely complex.
But I think more when we're talking about issues with muscle coordination, motility
in the entire gut, there's more overlap with disorders of gut brain interaction because
those are throughout the entire gut system.
The nerves are everywhere.
(15:04):
Inflammatory bowel disease has certainly some processes of how it forms that we think could
even overlap with irritable bowel syndrome.
No, of course.
We completely know that there's so much overlap between IBD and IBS.
And I don't just mean the overlap of people not knowing which one they have and the misnomer,
(15:24):
which happens all the time, but literally IBS and IBD having both things at the same
time.
So, of course, it would seem to me that then in that way, gut motility would come into
play.
Right.
And it could be that there's some elements of the microbiome.
So different bacteria in the gut is say there's stasis from poor motility.
(15:44):
Could that be a reason that people develop IBS or IBD?
We don't know.
So there's a lot of the mechanism behind any motility disorder other than congenital, like
literally from birth problems that we know about.
We really don't have a great sense of why these things happen.
There is kind of an interesting parasite that can create problems with the motility in the
(16:14):
esophagus.
And some people are studying that parasite.
Tell me more about that.
That's amazing.
Like a parasite that people pick up in South America usually.
So it's called it's called Chagas disease.
And so this type of this parasite that causes Chagas disease can cause electrical problems
in the heart.
So it can cause complete heart block.
(16:36):
So affecting the electricity in the heart and potentially by a similar mechanism can
cause problems with motility in the esophagus and create what we call a mega esophagus.
So the esophagus stops working.
And that we're wondering is that could that be a target for trying to understand maybe
(16:56):
what happens in some of these more intrinsic conditions such as a Echolasia where the esophageal
sphincter doesn't relax?
Or could it be something in like sclerotic disorders like lupus, systemic sclerosis?
Could there be some target then for treatment maybe even to understand what we could do
(17:16):
about the esophagus?
That's fascinating.
Wow.
That's really amazing.
And that is such an interesting path for research to take in studying something like a parasitic
infection or a parasite.
You can be then developing new ideas about some of these other...
Yeah, the basics of where it comes from.
Really looks very difficult.
(17:37):
And how you could treat it potentially.
So you mentioned that many of these disorders are congenital.
So that would mean that they start from childhood.
Is that true?
Do we see a lot of pediatric patients with motility disorders?
And did that continue through adulthood?
So the ones that we know that happen and we know why they're happening are congenital.
(17:58):
The majority of motility disorders, we actually don't know why they happen.
And that's where trying to find the origin of disorders, gut pre-interaction, trying
to find the origin of chronic constipation, difficulty disorders.
We're all learning so much about that now.
(18:18):
So does early life trauma lead to difficulty disorders and IBS?
Yes, we know that there's interaction there.
Could PTSD also be associated with IBS?
Yes, it could be.
And is that evidence of trauma?
Is that something that is a cause maybe?
And then how do we promote resilience to have people not get affected with IBS after having
(18:45):
a traumatic event, which could be anything from a car accident to being in a war or something.
All of those things can create trauma.
And certainly the long-term effects of living with some of these disorders, we know from
talking with Dr. Bedell and other RGI psychologists that the sort of cycle of how these things
(19:06):
interact over time is also really something that is, I know, to be studied in a real paramount
importance as people live their lives.
When should a patient see you or see another gastroenterologist if they think they might
be having difficulty with their gut motility?
So just to harken back to one little thing, I want to just make sure we say that most
(19:28):
people do not have motility disorders.
Most people do not.
And congenital disorders of motility are very rare.
So most people don't have those issues.
And most people are not born with the motility disorder.
The times that you want to be worried are if you are having trouble swallowing and you're
(19:48):
having the sensation of food or medication being stuck in your throat or chest and it's
becoming progressive or persistent.
That is a time when you should see a gastroenterologist or at least talk to your primary care provider
about, is this something that needs to be evaluated further?
And that would be, I think, that's one segment of your GI tract.
(20:11):
The other half, which is the lower half, if you are having constipation that is new, so
you've never had constipation before and all of a sudden it's really becoming difficult
to have a bowel movement, if you notice there's any blood in your stool, if you're noticing
that you are feeling very uncomfortable a lot of the time, having a lot of belly pain,
(20:34):
that may be something that also needs to be investigated sooner rather than later.
First with your primary care provider, can address some of the basics of that, maybe
start that workup, do that referral for a gastroenterologist for you.
But constipation is also very, very common and constipation is not necessarily always
a motility disorder.
That is absolutely, we talk about constipation at our patient support group for patients
(20:56):
with IBD quite frequently for a disorder that is much more manifest in terms of diarrhea,
but we still talk about, especially because of the medical interventions, how constipation
can be caused by lots of different things and patients coming to figure out their body's
rhythms is really a big part of that process.
I have a question related to that support group, which is a lot of our patients with
(21:19):
IBD report kind of rapid transit issues where particularly post-surgical they feel like
they eat food and it goes right through them.
Is that something to do with motility?
Yeah, I would say yes.
So I mean, it's a little hard, rapid transit is challenging because of why it might happen.
(21:40):
So when someone who has had gut surgery, each segment of your small intestine and each segment
of your large intestine are doing a job.
So if that area is removed, the rest of the gut has to figure it out.
The good thing is the gut's pretty smart in a way.
I mean, I think it's pretty smart and it figures it out.
(22:00):
So if you have most of your colon removed, whatever is a remnant of your colon can oftentimes
pick up all the water that needs to be picked up out of that small intestinal fluid and
small intestinal products, and then you can have a solid stool.
But if you have a lot of your small intestine removed, then a lot of times there might not
(22:23):
be enough time to absorb things.
There may not be enough of an adjustment yet post-surgically for someone to have a normal
transit time.
But rapid transit is a problem for people post-surgical, people who've had bariatric
surgery and have a gastric bypass.
Those people can also have rapid transit and those mechanisms are slightly different most
(22:47):
of the time.
One of those things can be if there's like too much sugar or too much, we call it osmotic
load.
So anything that has a lot of, usually it's sugar or fake sugar, those things can go right
through you because those are not able to be absorbed immediately.
And the places that they need to be absorbed are at the front part of your small intestine.
(23:12):
And other things are absorbed in different periods, other nutrients, proteins, fats,
they're broken down in different areas and they're absorbed in different areas.
Vitamins are absorbed in different areas.
And then water is absorbed mostly in the colon.
So if you don't have enough time, then it's going to be diarrhea.
And potentially malabsorption, which is something that people worry a lot about with some of
(23:33):
these post-surgical or inflammatory conditions.
That is very instructive and very helpful.
So if there was something that you would want to tell patients who might be concerned about
constipation or esophageal symptoms, what would be one thing that you would want to
tell patients as a big takeaway regarding gut motility or just advice that you have
(23:57):
for them as a gastroenterologist who specializes in these disorders?
So I think one thing that I've noticed in being a specialist in lower motility, I'm
going to speak to that mostly, is you're not alone and there are people who can help you.
I think a lot of the patients that I see have had constipation for 10, 15, 20 years and
(24:21):
they've learned to accept it.
It's just their way of life.
They know they're going to spend half an hour, 45 minutes on the toilet.
They're probably only going to go once a week.
And that's what they've become accustomed to.
And that doesn't have to be normal.
It might be something that is manageable.
(24:43):
And so I would say if it's something you've been noticing for a long time and you find
it bothersome or distressing, don't hesitate to see a gastroenterologist because we have
things we can do.
And we're getting better about understanding the process, understanding the causes, understanding
(25:04):
the root causes as well as addressing treatments for disorders of gut re-interaction and for
constipation.
Absolutely.
I mean, I think that that's the advice that we...
I hear time and again from many of our gastroenterologists is you don't have to live like this and that
we want to help you get better.
(25:24):
And it's great to know that in this new domain for our Digestive Diseases Center, with your
expertise, we're getting even closer to that.
So thank you so much.
Thank you for having me.
Thank you for listening to this episode of the podcast, Fissure Roll from the GI Research
Foundation.
This episode was written and produced by me, Anna Gomberg, and edited and mixed by the
(25:46):
incredible Mike Collins-Dowden, who also composed our theme music.
We hope you will join us next time.
Until then, to access other podcasts and learn more about research to treat, prevent, and
cure digestive diseases, as well as access additional educational materials, please visit
the website at giresearchfoundation.org and follow us on Facebook, Twitter, and LinkedIn.
(26:07):
Thank you again to Abbvie for making this podcast possible.
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