Everyone’s talking about it: the POOP TRANSPLANT

By now I’m sure you have heard about poop transplants, officially called “fecal microbiota transplantation” or FMT. At first, you may have been completely grossed out or confused or perhaps intrigued… is this real? Does it work? And why would anyone go through this? Let’s answer some of the FAQs since one day soon... poop transplant will likely be a standard therapeutic option!

 http://www.nature.com/articles/nrgastro.2011.244

http://www.nature.com/articles/nrgastro.2011.244

 

When would one consider fecal transplant?

The only appropriate indication at this time is in patients with severe and recurrent C. difficile infection who have failed multiple attempts at conventional antibiotic therapy.

But in the future, fecal transplant may be used in any diseases associated with alterations in the gut microbiome including:

IBS (irritable bowel syndrome): reduced microbial diversity + decreased Bacteriodetes

- IBD (inflammatory bowel disease): Reduced microbial diversity

 http://www.gastrojournal.org/article/S0016-5085(13)01279-1/pdf

http://www.gastrojournal.org/article/S0016-5085(13)01279-1/pdf

- Obesity, metabolic syndrome, insulin resistance: Reversed Firmicutes:Bacteroides ratio

- Autoimmune disease (multiple sclerosis, idiopathic thrombocytopenic purpura)

- Chronic Fatigue Syndrome: reduced E Coli, overrepresented Enterococcus & Stretococcus

 

So who’s poop are you getting exactly?

Although initially family members and household contact donors were used, now there is a stool donor bank called Openbiome that offers rigorously screened, high-quality traceable poop. They put donors through a very lengthy assessment process including 200-question clinical evaluation, lab screening including over 30 stool and blood tests. Less than 3% of people actually qualify to become donors.  Finally, each sample gets a very detailed RNA sequence characterization.

 

How does the poop get transplanted?

Several routes of transplant have been reported but the optimal protocol is unclear although using colonoscopy appears to have a higher success rate than others.

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1.     Colonoscopy: For the patient, it's no different than getting your routine screening colonoscopy. After getting sedated, a colonoscope is used to spray the poop throughout the colon often starting at the end of the small bowel and including the entire colon. It has been proposed as the preferential route of delivery as it is dispensed under direct visualization to the desired areas and you can evaluate for severity of disease at the same time.

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2.     Nasogastric tube: This involves putting a thin tube down the nose so that fecal material can be delivered to the small bowel and make its way to the colon. This usually requires daily infusions for multiple days.

3.    Oral capsules: Previous studies have used up to 30 frozen capsules on two consecutive days.

4.     Enema: Not ideal, an enema usually only delivers its contents to the left side of the colon, which could possibly limit its efficacy. Not to mention its near impossible to retain an enema for 6 hours!

 

Is it safe?

In short, yes! The adverse effects are mostly the known & expected ones associated with the mode of delivery (colonoscopy, etc). General reported adverse eevents include abdominal discomfort and infection, talthough it has been suggested that FMT using full-spectrum microbiotia has a protective mechanism that prevents infection transmission (not seen with synthetic stool or probiotics).

 

Now that you understand what a poop transplant entails... perhaps the ick-factor has diminished? Keep your eyes open for more FDA approved indications and tons of research on this topic coming your way!

 

The Mediterranean Diet for your GUT

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Patients often ask me what diet to follow and whether or not to count calories, carbs, etc. Especially after watching documentaries like WHAT THE HEALTH, I’ve seen a growing interest in more of a plant-based diet, which is amazing! (I highly recommend for everyone to watch it!). Instead of following a specific diet or going through fads though, I think its best for people to concentrate on developing more of a lifestyle than a diet, such as a lifestyle that revolves around food as healthy, natural nourishment that brings you together with your friends and family. And one of the best lifestyles to follow is the Mediterranean one. In fact, the “Mediterranean diet” has a TON of science to prove its worth including the fact that 2 of the 5 “Blue Zones” — communities around the world where residents live particularly long and healthy lives — are in the Mediterranean region.  Adherence to the diet has been associated with: reduced metabolic syndrome, obesity, type 2 diabetes, reductions in overall mortality, cardiovascular mortality, cancer incidence and mortality, and incidence of Parkinson disease and Alzheimer disease and is effective in primary and secondary prevention of cardiovascular disease. Phew! I’d say that’s impressive!

 

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So, what exactly is the Med diet?

·      A TON OF: fruits, vegetables, whole grains, beans/legumes, nuts, seeds, fish, olive oil (important source of monounsaturated fat vs saturated)

·      MEDIUM: wine consumption, poultry, dairy

·      SPARINGLY: red meat, processed foods including added sugar, white bread

 adapted from the  NYPost

adapted from the NYPost

 

When I say it s not a hip trendy diet…

·      The Med Diet was first described in the 1960s by Ancel Keys after results of the epidemiological “Seven Countries Study,” which demonstrated that the populations bordering the Mediterranean Sea had a lower incidence of cardiovascular disease and cancer.

 

It’s more than a diet. It's a lifestyle.

 adapted from the  NYPost

adapted from the NYPost

·      In 2010, UNESCO described it as “the set of skills, knowledge, rituals, symbols, and traditions raging from the landscape to the table, which in the Mediterranean basin concerns the crops, harvesting, picking, fishing, animal husbandry, conservation, processing, cooking, and particularly sharing and consuming of food.

 

What are the specific evidence-based health benefits?

·      CANCER PREVENTION: Studies have found that a Med diet is associated with decreased risk for COLORECTAL, prostate, oropharyngeal, and breast cancer. In Mediterranean countries there is a lower incidence of breast, endometrial, colorectal, and prostate cancer compared with Western countries. These cancers have been hypothesized to have a relationship to diet, in that a low consumption of fruits/vegetables and a high consumption of red meat correlate with cancer incidence. By statistical modeling, some epidemiologists estimate that up to 25% of colorectal cancer could be prevented in Western countries if diets were changed to reflect Mediterranean practices

·      NAFLD (non-alcoholic fatty liver disease) is one of the most common chronic liver diseases worldwide and the spread of it in the West is strongly associated with the increasing prevalence of obesity and type 2 diabetes due to lifestyle and dietary habits. One large study found that adherence to the Med-Diet was inversely associated with insulin resistance, the main driver of NAFLD. Those with higher adherence had a progressive reduction of risk of having NAFLD and a more favorable metabolic profile including lower triglycerides and blood glucose. Another study of 4,700 adults from the NHANES cohort, showed that relationship between Med-Diet and insulin resistance may be mediated by abdominal fat. It is also a high antioxidant diet as it contains polyphenols and vitamin E, important in fatty liver as oxidative stress is one important factor implicated in NAFLD onset.

 adapted from the  NEJM

adapted from the NEJM

·      WEIGHT LOSS : A 2-year study published in New England Journal of Medicine  compared a Med diet, Atkins diet, and a low-fat diet. At the end of 2 years, the weight loss was −4.4 kg for the Med diet group. In 24 months they lost 2 BMI points and  …

o   Decreased: waist circumference, blood pressure, CRP, leptin, fasting plasma glucose and HOMA-IR, liver tests.

o   Increased: HDL, adiponectin

o   The Med diet group had a higher ratio of monounsaturated to saturated fat than the other groups (P<0.001) and a higher intake of dietary fiber (P = 0.002)

The Lancet also published about an unrestricted-calorie, high-vegetable-fat Med diet associated with decreased weight and less gain in central fat compared with a control diet. These results lend support to advice not restricting intake of healthy fats for weight maintenance.

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My gut-friendly suggestion would be to make sure any seafood/meat you eat is antibiotic-free and don't eat much of it! And try to avoid dairy. Otherwise the Med diet is as gut-friendly as they get! #gutlove

 

 

What IS the deal with the Turmeric craze & what are the health benefits???

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Turmeric is everywhere these days. You can even order a Turmeric latte in some Starbucks and Whole Foods! So why exactly has is Turmeric so hot right now- does it even have evidence based health benefits, and for what? Let’s get into it.

Turmeric is a spice derived from the tropical plant Curcuma longa, a member of the ginger family (Zingiberaceae). Curcumin, the principal curcuminoid found in turmeric, is generally considered its most active ingredient). In addition to its use as a spice and pigment, turmeric has been used in India  and China for medicinal purposes for centuries. Recently, evidence that curcumin may have anti-inflammatory and anticancer activity has lead to its discovery in mainstream culture, media, and diet.

What is it good for???

1. Functional dyspepsia:

- How does it work? Turmeric has been found to increase biliary secretion, promote contraction of the gallbladder, and act as an antispasmodic.  

- Research: In a placebo-controlled trial performed in Thailand, turmeric (2 g/day) was found to significantly improve dyspeptic symptoms (P = 0.003)

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2. Inflammatory bowel disease: Ulcerative Colitis

- How does it work? Turmeric prevents formation of free radical species, inhibits lipopolysaccharide-induced nitric oxide synthase (iNOS) gene expression, decreases TNF-α and IL-1β production,  inhibits nuclear factor (NF)-κB activation and cytokines thought to be necessary to IBD; and if thats not enough-- inhibits the synthesis of proinflammatory prostaglandins and leukotrienes.

- Research: An RCT of 43 patients who had UC in remission received curcumin enema for 6 months and compared results with patients who received placebo, 4.65% of those receiving curcumin suffered relapse versus 20.5% of individuals who received placebo.

 adapted from drweill.com

adapted from drweill.com

3. Colon cancer prevention:

- How does it work? Curcumin decreases inflammation and expression of inflammatory COX-2 and endogenous DNA damage in adenomatous (pre-cancerous)tissue.

- Research: Studies have shown  turmeric to have chemopreventive activity in mouse models of familial cancer syndromes where it inhibits the development of intestinal adenomas.

4. Liver fibrosis

- How does it work? TGF-beta is a major cytokine involved in the promotion of fibrosis and scarring of the liver that leads to cirrhosis.

Research: Curcumin may block TGF-beta signaling and has been found to reduce the severity of steatohepatitis (inflamed fatty liver) in mice.

BUT HOLD ON A MINUTE…

- Optimal doses of curcumin for cancer chemoprevention or therapeutic use have NOT been established.

- Safety has not been established in pregnancy/lactation

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- Adverse side effects have been reported, including nausea, diarrhea, abdominal pain, headache, rash, yellow stool

- Turmeric inhibits platelets therefore increases risk of bleeding in people taking anticoagulants or antiplateltes agents (aspirin, Plavix, Coumadin, etc)

Conclusion: Enjoy your Turmeric latte but don't buy into the hype yet. Hopefully more research on it soon! #gutlove

Low FODMAP diet is great for IBS... but make sure you add a prebiotic + probiotic!

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IBS is thought to affect up to 15% of the population and is characterized by abdominal pain, bloating, gas, and alternating bowel habits. The low FODMAP (fermentable, oligo-, di-, mono-saccharides, and polyols) diet is commonly used as a first-line therapy and restricts dietary intake of fermentable short-chain carbohydrates including the oligosaccharides, fructans, and galacto-oligosaccharides (GOS). FODMAPs are foods (ex. cow milk, wheat) that cause symptoms due to poor absorption in the small intestine, resulting in an osmotic effect increasing water delivery into the gut, and rapid fermentation by the colonic microbiota leading to A LOT OF GAS. This extra water and gas production distends the bowel, worsening the symptoms of IBS. FODMAPs also have effects on gut microbiota, immune function, and mucosal permeability that could also affect IBS symptoms. Reducing dietary intake of FODMAPs provides an improvement of IBS symptoms in the majority of patients. In fact, up to 50% of patients with IBS-D had adequate symptom relief of their pain and bloating.

One issue with the low FODMAP diet is that it is ‘anti-prebiotic’ in the effect it has on raising stool pH and reducing stool Bifidobacteria in the microbiome as well as short-chain fatty acids like butyrate which are important to colonic epithelium and barrier function. Low concentrations of bifidobacteria have been associated with higher pain levels in IBS. What can you do about this? Take a prebiotic & probiotic while you’re on low FODMAP!

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1. Probiotic: Studies have shown that co-administration of the probiotic VSL#3 increased numbers of Bifidobacterium species in the microbiome, compared with placebo, and may be given to restore these bacteria to patients on a low FODMAP diet. In addition, Align contains Bidifobacterium and could be considered if VSL#3 is too pricey.

2. Prebiotic: Studies showed the prebiotic B-galacto-oligosaccharide resulted in significantly greater symptom improvement between controls (30.4%), those on the low FODMAP diet alone (50%) and those on the low FODMAP diet + prebiotic (66.7%). Other prebiotics to consider are prebiotin and benefiber.

So if you suffer from IBS and are on a low FODMAP diet, make sure you're protecting your micro biome's diversity with a pre & probiotic! 

Stop eating EMULSIFIERS... today!!!!

It’s almost impossible to avoid all the chemicals and artificial food additives in the inflammatory and disease-provoking western diet but today you can make one extremely important decision—stop eating EMULSIFIERS. I was surprised to find emulsifiers lurking in my pantry snuck into baked goods that were otherwise  touted as being healthy (low calorie, dairy free, etc). Take this weekend to review the ingredients of food you are eating  and TOSS anything with emulsifiers... to prevent gut inflammation, leaky gut, metabolic syndrome, obesity and cancer!

What are emulsifiers?? They are chemicals that are added to processed foods to enhance texture and stabilize processed foods, leading to extended shelf-life. There are many and have unappetizing chemical names like soy lecithin, distilled monoglycerides, and cellulose gum.

Why are they bad??

 adapted from  University of Michigan

adapted from University of Michigan

1. Emulsifiers directly influence your microbiome & create inflammation in the gut. Emulsifiers decrease the diversity of the microbiome and directly break down the protective mucosal lining of the gut so that microbes get closer to the cells lining your gut which activates the gut immune system and results in gut inflammation, changes in metabolism and ultimately chronic gut inflammatory diseases, an altered microbiome and leaky gut. Studies have shown that hat administration of emulsifiers resulted in microbiota encroaching into the protective mucus, alterations in microbiota composition, including an increase of bacteria that produced proinflammatory flagellin (FliC) and lipopolysaccharide (LPS), and development of chronic inflammation. Such inflammation was associated with metabolic disease and increased incidence/severity of overt colitis in susceptible animals.

2. Emulsifiers influence your microbiome to promote metabolic syndrome. Metabolic syndrome is a risk factor for chronic diseases such as diabetes, obesity and heart disease and inflammatory bowel disease (IBD).

3. Emulsifiers create the ideal conditions for triggering colon cancer. A study found that after 3 months of feeding animals emulsifiers they showed changes in their gut microbes that were consistent with promoting tumor growth. The higher levels of inflammation created by the microbial changes are a  perfect cancer-growing environment.

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What can you do to protect yourself from gut inflammation, leaky gut, and chronic GI diseases?

READ EVERY LABEL & EVERY INGREDIENT!!! 

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Food regulations limit the amount of each emulsifier present in a particular food but don't restrict the number of emulsifiers allowed.Luckily, most labels actually have the emulsifier labeled as “emulsifier”. But here are some other scientific names to look out for and avoid: 

IMG_0879-1.JPG
  • Bread

    • Dough strengtheners (diacetyl tartaric acid esters and sodium or calcium stearoyl-2-lactylate)

    • Dough softeners (mono- and diglycerides of fatty acids)

  • Chocolate

    • Lecithin

    • Sorbitan tristearate

    • Ammonium phosphatide

  • Ice cream, sorbet, milkshakes, frozen yogurt

    • Mono and diglycerides of fatty acid, lecithin and polysorbates

  • Margarine

    • Mono and diglycerides of fatty acids and lecithin. Citric acid esters of mono and diglycerides,  polyglycerol esters.

  • Processed meat

    • Mono and diglycerides of fatty acids and citric acid esters

  • Baked good

    • Soy lecithin, distilled monoglycerides

In general, these are all processed foods that you should avoid anyway if you're following the #feedyourgut diet to keep obesity, inflammation, and cancer at bay. Toss: processed bread, margarine, mayonnaise, creamy sauces, candy, processed salad dressing, cream cheese, and ALL packaged processed foods

Take home point: #EATREALFOOD. #gutlove

 

 

 

 

 

August is Gastroparesis Awareness Month!

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Patients with gastroparesis may experience symptoms for 5 years before they finally get correctly diagnosed... FIVE YEARS!

Gastroparesis literally means “paralysis” of the stomach. GI motility is complex. It involves  coordination of both the sympathetic and parasympathetic nervous systems, neurons, and “pacemaker cells” as well as the smooth muscle cells of the gut. You can imagine a lot can go wrong here and lead to disordered and delayed gastric emptying. Gastroparesis is a condition that is not really well understood or known among both doctors and patients. Let's get the facts straight!

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What is gastroparesis? A syndrome of delayed gastric emptying which means that food and liquid does not leave the stomach as quickly as it should and therefore sits in the stomach causing symptoms like nausea, vomiting, early satiety, bloating, upper abdominal pain.

Is it common? More than we think! It happens in about 10/100,000 men and almost 40/10,000 women. (sorry ladies!)

Why does it happen?? Most of the time, we don’t know! The top 3 reasons it happens are: 1. No reason found 2. Diabetes 3. After surgery. Also important contributors are medications, and especially opiates so avoid at ALL costs! Interestingly in smokers, it could be a clue of an underlying lung cancer, so get checked out if you're at risk!

What are the symptoms? Nausea (93% of people affected), vomiting (up to 84%), abdominal pain (up to 90%), early satiety (up to 86%), fullness after eating, bloating, and even weight loss.

What's the workup?

1. Endoscopy to make sure there are no obstructions and sometime you see food remaining in the stomach after a long fast that is abnormal.

2. Gastric emptying study. This involves eating a low fat meal with imaging (no radiation) immediately after eating a meal and then again at 1, 2, and 4 hours.  A positive study is when >10% remains after 4 hours or >60% after 2 hours.

3. Consider wireless motility capsule and breath test such as the 13-C-Spirulina Gastric Emptying Breath Test,.

Treatment

The cornerstones of treatment are diet, diabetes control, and hydration and if those don’t work… medications. 

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1. Diet

- EAT THIS: LOW-FAT (Fat slows gastric emptying even more!)

- DON'T EAT THIS: Acidic, spicy, non-soluble fiber foods (check out the fiber page here) & roughage-based foods, carbonated beverages (aggravate gastric distension)

- Small, frequent meals 4-5x/day

- If still a lot of trouble tolerating food, blend/puree food as gastric emptying of liquids is often preserved

2. NO alcohol or smoking! They decrease contractility and delay gastric emptying even more!

3. Hydration & nutrition

- With a lot of vomiting, one may be at risk for low potassium and dehydration

- Make sure to drink a lot of liquids and take oral vitamins as directed by a doctor

3. Control your blood sugar!

- High blood sugar slows gastric emptying so make sure you talk to your doctor about the right meds for you. Sitagliptin (Januvia) for example, does not have an effect on gastric emptying.

If you tried all of the above suggestions and are still having trouble then talk to your doctor about meds. Some of the prokinetic/promotility options you may hear about:

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- Don't forget about acupuncture! In a study, acupuncture improved symptoms of postprandial fullness, early satiety, and bloating as compared with sham treatment control

 

Treatment may not be a quick fix and need time. Less than a third of gastroparesis patients had significant symptom relief after treatment. Importantly one study showed that factors associated with NO symptom relief included being overweight/obese with BMI>25, smoking history, and use of pain medications. 

Don't suffer for 5 years! Get tested, diagnosed and treated today!

Fatty liver: the newest metabolic epidemic

Ten years ago, no one thought about the consequences of having fat in your liver. In fact, tons of people were labeled with “cryptogenic” cirrhosis or cirrhosis of unknown etiology because we had no idea fat could cause such harm. Now we know basically all of those cirrhosis cases were due to metabolic syndrome and fatty liver, officially referred to as nonalcoholic fatty liver disease (NAFLD). Fast forward to today, and fatty liver is the biggest, most worrisome liver condition out there and has already surpassed hepatitis C as the top top reason adults are listed for liver transplant.

How big is this problem, you ask? It is THE most common liver disorder in Western industrialized countries, where the risk factors for fatty liver are all too common. In fact, in the U.S., up to almost 50% of patient have fatty liver. HALF of the country!

The reason this is a BIG DEAL is because fat in the liver may lead to bad consequences including:

- Cirrhosis (end stage liver disease), especially in people with diabetes, abnormal liver tests, overweight/obesity, heavy alcohol use

- Liver cancer: the risk of cancer among those with cirrhosis was12.8% over 3 years

- Increased risk of death and cardiovascular disease

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So know the risk factors and protect your liver from fat! Excess calorie intake, unhealthy diet, and physical sedentariness remain the main drivers of NAFLD, modulated by gene/behavior interaction.

- Central obesity (“apple shape”)

- Type 2 diabetes

- High triglycerides or low HDL (“good” cholesterol)

- High blood pressure

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But if you are one of the millions of people in the U.S. that end up getting diagnosed with fatty liver, then this is one of the few diseases in medicine that you can really turn around WITHOUT MEDICATION! Here's the treatment plan:

1. Lose weight!

- If you are overweight or obese (BMI>25 kg/m2), THIS is your motivation to lose weight!

- Weight loss & increased physical activity leads to sustained improvement in liver tests, liver disease stage, insulin levels, and quality of life in patients withfatty liver

- A 5% reduction in BMI is accompanied by 25% reduction in liver fat on MRI, up to complete normalization of liver triglycerides in a few weeks

- Lose 1-2lbs/wk (rapid weight loss is dangerous!)

- Use all your tools! Diet, exercise, medications, bariatric therapies including intragastric balloons, incision-less sleeve gastroplasty...

2. Vaccinate!

- Protect your liver from other liver diseases such as hepatitis A & B

3. Prevent cardiovascular disease- the risk is high!

- Optimize blood sugar control in diabetes, treat high cholesterol, talk to your doctor!

4. Avoid alcohol

- Swap out cocktails for mocktails and instead enjoy some liver health!

-Check out this awesome NYTimes article "These Drinks Have a Secret" with tips

So talk to your doc if you're suspicious you may be harboring fat in your liver-- there's A LOT you can do to prevent & reverse it! #gutlove

 

 

When food gets stuck in your esophagus... it may be EOE! (Eosinophilic Esophagitis)

I would have never believed you if you told me I would spend many late nights during my GI fellowship fishing food out of someone’s esophagus. Eosinophilic esophagitis? I had never even heard about it during medical school! And here I was getting phone calls on a regular basis about someone swallowing a piece of food and just not being able to get it down (not even able to swallow their own saliva!) and coming in at any hour of the day to get an upper endoscopy and get the food out! Since I had not even heard about it in medical school- I wonder how many readers are hearing about EOE for the first time right now? Once considered rare, EOE is one of the MOST common conditions diagnosed in kids with eating problems and adults with problems swallowing. Let’s get to know EOE.

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What IS EOE???

 adapted from NEJM

adapted from NEJM

  • Eosinophilic esophagitis is a chronic, immune-mediated esophageal disease with symptoms related to esophageal problems and eosinophil-predominant inflammation. The inflammatory triggers are usually foods.  Reflux must always be ruled out first!

What are the symptoms??

  • In kids: feeding problems, vomiting, and abdominal pain
  • In teens/adults: trouble swallowing and food impaction

Risk factors?

  • IMMUNE SYSMEM DISRUPTION
    • It’s all about building a good healthy immune system from day 1!
    • Altered stimulation of the immune system at an early age and lack of exposure to bacteria and a weak microbiome play a role. 
    • Birth by c-section, premature delivery, antibiotic exposure during infancy, food allergy, lack of breast-feeding, and living in an area of low population density have all been associated with EOE.
  • GENETICS
    • There's a genetic predisposition with a ~2% risk of inheriting it from family
  • ALLERGIC DISEASES
    • It's common for EOE to coexist with asthma, eczema, rhinitis, and food allergies

How to find out if you have it?

  • Talk to your gastroenterologist!
  • Most likely you will need to undergo upper endoscopy with biopsy
  • If positive, your GI will send you to an allergist for food allergy testing to understand what allergen is driving the inflammation.

What is the treatment for EOE?

 adapted from NEJM

adapted from NEJM

1. Diet: Get rid of the allergen! A 6 food elimination diet can be helpful- getting rid of super allergenic foods like wheat, milk, soy, nuts, eggs, and seafood.

2. Drugs: Calm down the inflammation. Swallowed steroids are the way to go and decrease esophageal scarring

3. Dilation: If you are found to have esophageal narrowing, the GI doc can open it up during endoscopy with a balloon

 

It is SO very important to get diagnosed!  Longstanding untreated EOE can lead to esophageal narrowing, food impaction, malnutrition and even esophageal perforation!

Don’t ignore that food isn’t going down smoothly and get checked out thoroughly- avoid getting that urgent overnight endoscopy for a food impaction!

Helicobacter pylori (“H. pylori”)- an all too common cancer-causing GI infection

You would think with all the acid in your stomach it would be an awful place for bacteria to live, but there’s one bacteria that LOVES it and commonly infects the stomach causing trouble - H. pylori. It’s worth dedicating a post to this bug because it is actually extremely common, and can cause all sorts of trouble such as inflammation (gastritis), peptic ulcer disease… and even cancer. In fact, the International Agency for Research on Cancer declared H. pylori to be a group I human carcinogen for gastric adenocarcinoma and it is also a risk factor for gastric mucosa-associated lymphomas (MALT lymphomas). So it is extremely important we all know about H. pylori considering how common it is. Here’s are the facts:

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How common is it really, and who gets it??

·      H. pylori is THE MOST COMMON chronic bacterial infection in humans, found worldwide and in all ages

·      Conservative estimates suggest 50% of the world's population is affected

·      Infection is more frequent and acquired at an earlier age in developing countries with up to 80% infected before age 50

 Adapted from  Nature

Adapted from Nature

·      In the US, it is more common during adulthood: ~10% in ages 18-30 and 50% in people older than 60 years old

Is it contagious?

·      Probably! Experts believe there is person-to-person transmission of H. pylori through fecal/oral or oral/oral exposure. This is supported by clustering of infection within families- if your family member is positive, consider getting tested!

·      It’s in the water: Contaminated water in developing countries may serve as an environmental source of H. pylori- kids who swim in rivers, streams, pools, drink stream water, or eat uncooked vegetables are more likely to be infected.

Risk factors

·      Overcrowding especially densely populated housing, increased number of siblings, sharing a bed, lack of running water, poor childhood hygiene practice

Prevention

·      Improvement in sanitation

·      Avoid salted food, which increases the  possibility of persistent infection as well as has a synergistic interaction to increase the risk of gastric cancer

Talk to your gastroenterologist to get tested if you …

·      Have a history of or current peptic ulcer disease (PUD)

·      Suffer from abdominal symptoms (abdominal pain, bloating, gas, nausea, early fullness, etc.)

·      Are planning to take daily aspirin or nonselective nonsteroidal anti-inflammatory drugs (NSAIDs: ibuprofen, motrin, aleve, advil, etc.) to reduce the risk of ulcer bleeding

·      Have been diagnosed with iron deficiency anemia

·      Have a condition with low platelets called idiopathic thrombocytopenic purpura (ITP)

Importantly, ALL patients with a positive test of active infection with H. pylori should be offered treatment!

Don’t let this cancer-causing bug go untreated!

Small intestinal bacterial overgrowth (SIBO): when your microbiome moves north & gets out of control

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Bloating, gas, abdominal discomfort, diarrhea… who doesn’t experience those pesky symptoms from time to time. Could it be IBS? Possibly—but up to 84% of patients who met IBS diagnostic criteria actually had small intestinal bacterial overgrowth (SIBO). SIBO is when the bugs from your colon makes their way up to your small intestine therefore taking up a lot more space to digest and ferment food and create tons of gas and bloating.

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 Adapted from JAMA

Adapted from JAMA

When we talk about the microbiome, we are mostly referring to the bugs that live in the very end of your small intestine and colon. There are very few bugs in your stomach or duodenum (1st portion of your small bowel) due to acidity and peristalsis. Then there are 10,000 aerobes in the mid-distal jejunum, 10^9 (1 billion) mixed bugs in the terminal ileum, and 10^12 (1 trillion) anaerobes in the colon. In SIBO, due to certain risk factors, there is backward movement of these bugs up the GI tract where they're not supposed to be, causing inflammation like colitis that can even mimic a Crohn’s flare.

What are the risk factors for SIBO?

  • Functional/motility disorders: IBS, opiate use, radiation, scleroderma, diabetes
  • Altered anatomy: adhesions/scar tissue from previous surgery, radiation, Crohn’s/Ulcerative Colitis, small bowel tumors, small bowel diverticulosis,  gastric bypass surgery
  • Pancreas problems and cirrhosis change the composition of digestive enzymes and bile, allowing microbes to grow
  • Immune disorders: IgA deficiency, HIV
  • Low gastric acid levels, often seen with chronic anti-acid use

As usual, the key is PREVENTION!

  • Avoid opiates/narcotics, benzodiazepines and other drugs that slow down your gut
  • Avoid chronic anti-acid use (nexium, Prilosec, etc)- If you need it, discuss the appropriate dose and duration with your doctor
  • Have good control of your diabetes and Crohn’s/Ulcerative Colitis if you have it

How is it diagnosed?

 Adapted from JAMA

Adapted from JAMA

  • Hydrogen and methane breath tests: when one eats a carb such as glucose, your gut bugs process it and produce hydrogen or methane. Usually this happens way down your GI tract, but if you have an overgrowth of bacteria in your small intestine then you can detect increased amounts of hydrogen and methane in your breath
  • Labs: Anemia with decreased vitamin B12, low protein and fat-soluble vitamins, Increased folate, increased fat in your stool signifying malabsorption

**After diagnosis: make sure your doc investigates WHY you got SIBO. For example, endoscopy may be necessary to look for Crohn’s disease of the upper GI tract.

Treatment

  • 1st, treat the underlying disease. Ex. For slow GI motility,  discuss a pro-kinetic (reglan, erythromycin) or a pro-peristaltic drugs (octreotide) with your doctor
  • DIET! A high-fat, low-carbohydrate, low-fiber, dairy-free diet is key.
    • Carbs are the main nutritional source for bacteria, so diets should be low-carb.
    • Fat is not metabolized by bacteria therefore may lessen production of gas, bloating, discomfort.
    • Lactase deficiency develops in many patients with SIBO, so get tested for lactose intolerance with a breath test and avoid dairy if positive
  •  ANTIBIOTICS: Most patients need treatment with antibiotics to reduce the troublesome gut flora, at least 7-10 days but may require months or repeated treatments. Rifaximin (1650 mg/day), a nonabsorbable antibiotic, may be 1st choice as there is less clinical resistance.
  • Prebiotics & probiotics may be helpful but evidence is limited and therefore use as primary treatment is not recommended

It's more common than you (or your doctor) may think! Always get to the bottom of your symptoms!

#loveyourgut. #listentoyourgut.

Leaky gut—is it really a thing? And if so, how do I fix the leak??

Leaky gut is EVERYWHERE these days. And you CAN NOT ignore it. Because every blog will convince you that you have it… gas and bloating? Tired? Headaches? Sounds like me! The truth is, leaky gut is most definitely a real entity. And it has definitely been associated with many real diseases in the medical literature: infectious diarrhea, inflammatory bowel disease (Crohn’s disease, ulcerative colitis), IBS, small intestinal bacterial overgrowth (SIBO), celiac disease, liver disease, and food intolerances and allergies.

 

What’s leaking where??

 adapted from Nature Reviews

adapted from Nature Reviews

You may think that your skin is the most exposed part of your body to the external environment, but in reality, the gut has a surface area of 200m2 that is constantly exposed to bacteria, food, and digestive products. Where do we NOT want these things to go? Through the wall of the GI tract and into our blood stream. The gut barrier separates out in the bad from the good, so the nutrients get absorbed into the gut wall and any pathogens stay in the gut and get excreted. The gut barrier is made up of your microbiome and mucus layer, then a tight epithelial cell layer, and then within the gut wall there is a micro immune system as the last resort to keep bacteria at bay. When those 4 factors are strong, then you have a tight impermeable gut. BUT when something happens to one of the key players… then things in the GI tract leak into the gut wall and blood stream, activating your immune system and creating inflammation.  (Read this for more details)

                                       

So how do I stop my gut from leaking?

1.     Before you make any moves, make sure you see your gastroenterologist and get checked out for associated diseases such as Celiac disease, Crohn’s Disease, and Ulcerative Colitis. Once you’re cleared—fix that leak!

2.     While you’re seeing your GI-- Get checked for a Vitamin A deficiency. Vitamin A-deficient diets cause alterations in the commensal bacteria and impairs the intestinal barrier by changing mucin dynamics and expression of defense molecules

3.     Strengthen your microbiome! Key here is prevention- avoid unnecessary antibiotic use. For probiotic sources, natural is always preferred –EAT your probiotics in foods! As for supplements, Lactobacillus and Saccharomyces boulardii have both been shown to reduce intestinal permeability.

4.     Avoid alcohol! Ethanol directly disrupts intestinal epithelial tight junction integrity, resulting in endotoxemia, which is suggested to play a key role in alcoholic liver disease ,

Screen Shot 2017-05-29 at 8.25.12 PM.png

5.     Avoid a calorie-rich high-fat high-carb Western diet! The Western diet enhances intestinal permeability resulting in metabolic endotoxinemia (toxins in the blood)

6.     Avoid sugar, especially fructose! Fructose-induced fatty liver disease is associated with increased intestinal permeability, leading to an endotoxin-dependent activation of liver cells that increase inflammation and fibrosis. Feeding mice a fructose solution was associated with the loss of the tight junction proteins in the small intestine and an increase of bacterial endotoxin in the systemic blood.

7.     Make sure your body is making tons of short chain fatty acids, i.e. EAT MORE FIBER!! These organic acids like butyrate are made by microbiome fermentation of undigested dietary carbohydrates (FIBER!) in the colon. Studies have shown that IBD and IBS patients have a reduction of butyrate-producing bacteria, known to improve intestinal barrier function.

8.     Prebiotics! Prebiotics have a stabilizing effects on the intestinal barrier and have been found to protects against salmonella infections and against barrier impairment in experimental pancreatitis. See my post on prebiotics for more!

9.     Avoid NSAIDs—all non-steroidal anti-inflammatory drugs (NSAIDs) increase small intestinal permeability and cause inflammation

10.   Eat more Quercetin! The flavonoid quercetin and its metabolite increase epithelial resistance.  It is found in: citrus fruits, apples, onions, parsley, sage, tea, red wine, olive oil, grapes, dark cherries, and dark berries such as blueberries, blackberries, and bilberries

11.   Ask your GI doc about Lubiprostone (Amitiza). Lubiprostone improved intestinal permeability in a prospective randomized study.

12.   If you’re having infectious diarrhea, talk to your GI about trying a mucosal protector. Sucralfate and bismuth protect the epithelial cells from gastric juice and digestive enzymes. There are also new intestinal barrier modulator drugs and medical foods in the pipeline, such as gelatin tannate and EnteraGam

 

Don't let expensive "Leaky Gut" programs and fad diets fool you-- just stick to the tips covered above and see how you feel! Gutlove will get you that tight gut you want!

Diverticulosis... What is it & how to prevent it!

 adapted from JAMA.com

adapted from JAMA.com

Who’s heard of diverticulosis? And who can remember whether they have it or not!? It must be one of the most common, yet one of the most poorly understood diagnoses out there. Considering all the harm it can cause, it’s worth getting into the details of what these colon outpouchings are all about!

What is a diverticulum? A pouch-like protrusion or pocket of the colon wall at points of weakness in the colon wall.

What is diverticulosis? The presence of diverticula, from one to many! It could be a diagnosis you receive after a routine screening colonoscopy causing no symptoms or it could be causing an infection or bleed. Most of them are found on the left lower side of your colon.

What complications are associated with diverticulosis? The two big ones are infection (“diverticulitis”) in up to 25% and bleeding (“diverticular bleed”) in up to 15%.

ds00070_an01934_im00887_divert_s_gif.ashx.jpg
  • Diverticular bleeding is painless rectal bleeding (maroon or bright red blood) due to small arteries (blood vessles) in the wall diverticulum that get injured as the wall gets thinner.
  • Diverticulitis is abdominal pain (usually left lower abdomen) and fever due to an inflamed diverticulum. This can be caused by increased pressure in the colon or hard pieces of stool, that can become lodged in the diverticulum. This can cause infection, abscesses, colon perforation and other not-so-nice things.

Is it common?  Yes, with increasing age. Less than 20% of people age 40 have it but up 60% of people age 60. There is more diverticulosis in countries with a Western lifestyle.

Most importantly-- how does one prevent diverticulosis???

- High fiber diet- Dietary fiber can bulk the stools and possibly prevent development of new diverticula, diverticulitis, or diverticular bleeding. In a cohort study that included over 47,000 men total dietary fiber intake was inversely associated with risk of symptomatic diverticular disease.

- Avoid fat & red meat- same study as above showed that risk of diverticular disease significantly increased with diets high in total fat or red meat.

- Run & jog! Vigorous physical activity appears to reduce risk of diverticulitis and diverticular bleeding. In a prospective study of 48,000 men without colonic disease at baseline, risk of developing symptomatic diverticular disease was inversely related to overall physical activity.

- Maintain a healthy weight! Obesity has been associated with an increase in risk of diverticulitis and diverticular bleeding. One study showed the risk of both diverticulitis and diverticular bleeding was higher with larger waist size.

- Quit smoking! Current smokers are at increased risk for perforated diverticulitis and a diverticular abscess.

- Avoid certain drugs such as anti-inflammatory drugs (“NSAIDS” Motrin, Aleve, Ibuprofen, etc), steroids, and opiates that are associated with an increased risk of diverticulitis and diverticular bleeding.

- Check your Vitamin D level! Higher levels of vitamin D associated with a reduced risk of hospitalization for diverticulitis.

 

 adapted from livestrong.com

adapted from livestrong.com

*ALERT!* Dispelling the Myth: Nuts, corn, seeds and popcorn are not associated with an increased risk of diverticulosis, diverticulitis or diverticular bleeding. In a study of 47,228 men there was an inverse association between the amount of nut and popcorn consumption and the risk of diverticulitis.

Screen Shot 2017-05-21 at 4.20.38 PM.png

 

CANCER PREVENTION: One of the most IMPORTANT take-aways from this post is that if you develop diverticulitis, you absolutely must get a colonoscopy 6 weeks after symptoms resolve. This is to rule out colon cancer. An analysis of registry data showed that patients hospitalized for diverticulitis were 2x as likely to develop colon cancer in the next 18 years than those without diverticulitis, and over 50% of colon cancers were diagnosed within 1 year of diagnosis of diverticulitis.

 

'Roid rage & Anal care: lets talk about hemorrhoids!

Happy Mother’s Day! Dedicating this post to a super common #momprob—hemorrhoids.

What are hemorrhoids? Hemorrhoids are veins in the anal wall. They can become dilated, engorged with blood, and even form a blood clot.

Are they common? Studies show the prevalence of symptomatic hemorrhoids is 4.4% but it is likely much, much higher. Peaks between age 45-65.

Risk factors? Older age, pregnancy, pelvic tumors, prolonged sitting, straining, chronic constipation, diarrhea, and anticoagulation/antiplatelet therapy

Tell me more about hemorrhoids in pregnancy?! 35% of women studied experienced anal issues postpartum, with 20% having thrombosed external hemorrhoids and 15% having anal fissures. Larger infants and traumatic delivery are possible risk factors

Screen Shot 2017-05-14 at 5.15.22 PM.png

Symptoms? Bleeding, prolapse, itching and pain if there is a thrombosis (hard blood clot)

 

There are 2 types of hemorrhoids- internal and external. Let's get into the detail. 

Internal hemorrhoids

- originate above the dentate inside the rectum  (“superior hemorrhoidal plexus”)

- not seen from outside unless the prolapse (fall out)

- not sensitive to pain, touch, or temperature

- CAUSE:  loss of connective tissue support and resulting prolapse, so veins are more susceptible to trauma from straining or passing of hard stool

- More likely to cause symptoms with constipation, loose stools, or if you sit on the toilet for prolonged periods of time

- Types

  1. grade I may bleed but do not prolapse
  2. grade II protrude with pooping and reduce spontaneously
  3. grade III prolapse and require manual reduction
  4. grade IV remain prolapsed, high risk for blood flow to get cut off

External hemorrhoids

- below the dentate line(“inferior hemorrhoidal plexus”)

- seen and felt from outside

- Can be extremely painful if they get thrombosed (blood clot) and will feel hard, look blue.

 

Treatment:

INCREASE water intake (6-8 glasses daily)

- INCREASE fiber intake with a high-fiber diet or fiber supplement (20-30 g daily) (keep a fiber diary!)—this is a lifetime commitment as it will prevent recurrence of these bothersome little piles

Screen Shot 2017-05-14 at 5.53.47 PM.png
Screen Shot 2017-05-14 at 4.55.49 PM.png
  • A meta-analysis of seven trials found a significant and consistent benefit from fiber supplementation in improving bleeding (RR 0.50, 95% CI 0.28-0.68)

- AVOID straining and prolonged time on the toilet (if you use the squatty potty it will help!!)

- If stools remain hard, start stool softeners (docusate sodium, "Colace"), and if that doesn't work-- add polyethylene glycol 3350 ("miralax")

-  Proper anal hygiene! Delicate washing of the anal area and avoidance of aggressive wiping with harsh tissue (itching is usually due to fecal soiling of the perianal area!)- splurge on the good super soft toilet paper! A topical astringent such as witch hazel is great for cleaning and getting your bum so fresh & so clean, clean!

- Sitz baths (literally a “sitting bath” for your bum)

Screen Shot 2017-05-14 at 6.04.19 PM.png
  • Just pour warm water (don’t add anything) into a basin (or buy a kit at a drugstore) and sit your bum in it for 10-15min 2-3x/day
  • You can also just fill up a bathtub with 2-3 inches of warm water and sit in it
  • Afterward, towel or blow dry (low heat!) the anus area well to avoid moisture retention which can lead to symptoms
  • Relieves irritation, pain, and itching by relaxing the internal anal sphincter and improving blood flow to the anal mucosa

- Topical creams such as Preparation H Cream (phenyleph-min oil-petrolatum) or Anusol-HC cream (glucocorticoid-based) may temporarily improve pain or itching (use for one week MAX)

- When medical treatment fails, talk to your doctor about aggressive treatment...

  • Rubber band ligation (grades 2 or 3 internal hemorrhoids)
  • Sclerotherapy (grade 1 and 2 bleeding internal hemorrhoids)
  • Infrared coagulation (grades 1 or 2 bleeding internal hemorrhoids)
  • Surgery (grade 4 (sometimes 3) internal hemorrhoids or painful thrombosed external hemorrhoids or failed all other conservative therapy).

Hemorrhoids are the WORST. Prevent them with proper anal care as outlined above and keep that anus looking & feeling good!  

 

Antibiotics + probiotics = protect your colon from C. difficile

 adapted from the CDC

adapted from the CDC

Those who read this blog know that there is NOT a lot of evidence behind probiotic use except in very specific situations. There is one situation where using probiotics could possibly SAVE YOUR COLON.

Clostridium difficile, C. difficile or C. diff, is a stubborn, hard-to-treat super-bug that causes symptoms from diarrhea to life-threatening colitis. Normally, the trillions of gutbugs in your strong healthy microbiome work with your immune system to keep C. diff at bay. But in the setting of antibiotic use, your good bacteria is killed off and that allows C. diff to flourish, take over and secrete dangerous toxins. These toxins cause serious inflammation in the colon that causes diarrhea and in severe situations, severe infection (sepsis) possibly requiring surgical removal of your colon (resection) and even death.

 Ley,&nbsp;Nature Medicine 2014

Ley, Nature Medicine 2014

Do you know anyone who’s been infected with C. diff? Chances are you have, as it is now common in the community as well as hospital settings. In fact, the incidence of C. difficile infection has more than doubled over the past ten years in the U.S.

Well we can’t sit back anymore and let this bug claim more colons and destroy more lives. There is something so simple that EVERYONE needs to do EVERY TIME THEY TAKE AN ANTIBIOTIC—START A PROBIOTIC. In hospitalized adults, studies show probiotics reduce the risk of C. diff by over 50% when taken within 2 days of the first antibiotic dose. Here's the way it works: Under normal conditions, the microbiome eats sialic acids (food) from the gut lining. When the resident microbiota is wiped out by antibiotics, sialic acids are left uneaten creating a window of opportunity for C. difficile to eat them up and subsequently grow and multiply. Probiotics and fecal transplantation both play the same helpful role of taking over the job of the native microbiome and eating up the sialic acids before C. difficile can get to it, therefore preventing infection. 

The optimal dose, duration or bug is not set in stone but consider the following:

 florastor.com

florastor.com

- Lactobacillus kefir strains in fermented milk produce proteins that fight off C. difficile toxins (look for dairy-free options! as long as they say specify Lactobacillus on the nutrition facts)

- In powder form, Saccharomyces boulardii (FlorastorMax powder satchets-- FYI they do NOT require refrigeration) makes an enzyme that can fight off C. difficile toxins.

- And important to know- Lactobacillus and Bifidobacterium colonize the intestine regardless of antibiotic use at the same time (antibiotics won't kill the probiotic)

Other preventive measures to avoid C. diff include using antibiotics only when absolutely needed (viral infections do NOT require antibiotics) and wash your hands often!

SO. Next time you have a sinus infection, UTI, or anything requiring antibiotic use-- DO NOT leave the pharmacy without a probiotic and start it right away with your antibiotic, taking it right inbetween antibiotic doses. 

#respectyourcolon #protectyourcolon

Happy Earth Day! Save the planet...AND your colon at the same time!

Today is the perfect day to self-reflect & review your carbon footprint and come up with things you can do to help preserve mother earth. One of the most helpful things you can do is REDUCE OR STOP EATING RED MEAT due to its colossal carbon footprint. But consider this-- not only will you help save the planet, you'll also decrease your own risk of colon cancer!  If you've read my blog then you might already know-- red meat and processed meat are actually carcinogens and increase the risk of colon cancer.  Here's the scoop:

Stop red meat --> save your planet

- Greenhouse gas emissions ranking

Screen Shot 2017-04-22 at 2.20.09 PM.png
  • Lowest impact: beans, fish, nuts and egg
  • Medium impact: Poultry, pork, milk and cheese
  • HUGE impact: beef, lamb and goat. (Yes, consider beef the new Hummer SUV)

-Beef uses 28x more land per calorie consumed and 2-4x more freshwater than the average of other livestock categories

- We waste SO much meat — we throw away ~20% of what we produce — so all that carbon was generated for nothing!

Stop red meat --> save your colon

Screen Shot 2017-04-22 at 2.18.46 PM.png

As per the The International Agency for Research on Cancer (IARC), the cancer agency of the World Health Organization (WHO):

- Processed meat is carcinogenic to humans (Group 1), based on sufficient evidence in humans that the consumption of processed meat causes colorectal cancer.  Each 50 gram portion of processed meat eaten daily increases the risk of colorectal cancer by 18% (the more you eat, the higher your cancer risk). To put it in perspective, other Group 1 carcinogens= ionizing radiation, tobacco, mustard gas, Orange I…

- Red meat is probably carcinogenic to humans (Group 2A), based on limited evidence that the consumption of red meat causes cancer in humans and strong mechanistic evidence supporting a carcinogenic effect.  This effect was observed mainly for colorectal cancer but associations also seen with pancreatic cancer. To put it in perspective, other Group 2A carcinogens= biomass fuel emissions, DDT, nitrogen mustard...

Screen Shot 2017-04-22 at 2.17.02 PM.png

So next time you feel tempted to order that burger... be mindful of the effect it will have not only on your colon... but on your planet! 

Respect your gut. Respect your planet. 

 

 

 

 

Up to 1/3 of people with suspected IBS actually have fructose intolerance

Up to 20% of people in the US have IBS. But with appropriate workup, about 1/3 have been reported to actually have fructose intolerance. Fructose is a sugar that can cause a lot of digestive problems. It is a monosaccharide carbohydrate that is NOT easily absorbed in the gut.  This intolerance leads to abdominal pain, bloating, gas, flatulence, distension, nausea and diarrhea. Sounds like symptoms that may mimic many other diseases, like IBS, SIBO etc, right? Well that’s why many of these patients undergo a whole slew of tests like endoscopy, CT scans, blood and stool tests and when these tests come back negative, then they often mislabeled as functional dyspepsia or bloating or irritable bowel syndrome (IBS) and sent on their way. Infrequently do doctors actually think of fructose malabsorption. 

   
  
 
  
    
  
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  Choi et al. AJG 2003

Choi et al. AJG 2003

Absorption of fructose is an active, energy dependent process and therefore our bodies are limited in digesting and absorbing it. Malabsorption means the fructose stays in the gut lumen and generates an osmotic force which moves water into the lumen to help move the fructose down to the colon, where it is fermented by bacteria, making a whole lot of gas. This gas and excess fermentation leads to abdominal pain, excessive gas and bloating... especially in patients with visceral hypersensitivity.

   
  
 
  
    
  
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     Ebert et al.&nbsp;Molecular and Cellular Pediatrics 2016

Ebert et al. Molecular and Cellular Pediatrics 2016

Screen Shot 2017-04-15 at 1.00.32 PM.png

Why is this so important to discuss? Because fructose is hiding in so many foods. It is naturally present in a variety of foods but also produced enzymatically from corn as high fructose corn syrup (HFCS), commonly found in things like soda and snuck into all sorts of foods. According to the USDA, HFCS consumption has increased for more than 1000% in the past and this rise in fructose consumption may have resulted in a rise in fructose malabsorption

 

So do YOU have fructose malabsorption? To diagnose this condition, you can either take a fructose breath test for a formal diagnosis or just commit to a trial of fructose dietary elimination and see how you feel!

 

The FRUCTOSE elimination diet:

 Examples of high fructose corn syrup (HFCS)-containing foods

Examples of high fructose corn syrup (HFCS)-containing foods

1. First and foremost: Ditch ANY product with high fructose corn syrup

- Sauces & condiments like BBQ sauces, Heinz® Ketchup, jams/jellies, salad dressings

- Flavored dairy: chocolate milks, ice cream, yogurts, coffee creamer

- Sweetened juice, energy/sports drinks, soda

- Baked goods & snacks: breads, cake, donuts, granola bars, breakfast cereal, cereal bars, chips, cookies, crackers, nutrition bars

- Frozen food (TV dinners, pizzas)

2. Read the label! "fructose" or "crystalline fructose" finds its way into tons of foods.

3. Avoid sweeteners! It may sound tough but once your palate gets used to unsweetened food, you won't miss it! AND you'll shed a ton of weight.

  • Honey
  • Agave syrup
  • Invert sugar
  • Maple-flavored syrup
  • Molasses
  • Palm or coconut sugar
  • Sorghum

#feedyourgut #eatrealfood #gutlove

 

 

IBS: A real disease with real treatment options

Screen Shot 2017-04-02 at 4.24.46 PM.png

Irritable bowel syndrome is a real disease. Too often I’ve had patients tell me they had debilitating abdominal pain with a change in bowel habits, had a couple tests done, and then were dismissed by their doctor since no obvious source was found. Don't let that happen to you!  IBS is a complex, multifactorial disorder that confuses people and doctors.. Factors that increase the risk of developing IBS include genetic, environmental, and psychosocial factors. Factors that trigger the onset or exacerbation of IBS include a previous GI infection, food intolerances, chronic stress, diverticulitis, and surgery. This results in altered GI motility, increased response in your gut to pain, increased intestinal permeability, immune activation, altered microbiome and disturbances in brain gut function.

Here is what needs to happen in the workup and management of IBS:

1. Make sure it is IBS and not anything else

First, go see your doctor and don't try to manage this on your own. You need to make sure that there is no other disease contributing to abdominal pain and altered bowel habits such as Inflammatory Bowel Disease (Crohn's disease; ulcerative colitis), Celiac disease, lactose and fructose intolerance, and microscopic colitis to name a few. You will need a GI doc to evaluate the need for an endoscopy/colonoscopy.

Once other diseases are ruled out, then IBS is made by fulfilling the following: IBS is an functional bowel disorder with recurrent abdominal pain at least 1 day per week in the last 3 months associated with 2 or more of the following criteria:

1. Related to bowel habits (constipation, diarrhea or both)

2. Associated with a change in stool frequency

3. Associated with a change in stool form/appearance (Bristol stool scale)

 

2. Determine the types of IBS you have

   The Bristol Stool Form Scale. Type 1 &amp;2 = slow transit, constipation. Type 6&amp;7= fast transit, diarrhea      Adapted from Lacy et al. Gastro 2016

The Bristol Stool Form Scale. Type 1 &2 = slow transit, constipation. Type 6&7= fast transit, diarrhea

Adapted from Lacy et al. Gastro 2016

IBS-C: mostly constipation: > 25% bowel movements are Bristol types 1 or 2 and < 25% are Bristol types 6 or 7.

IBS-D: mostly diarrhea: > 25% bowel movements are Bristol types 6 or 7 and <25% bowel movements are Bristol types 1 or 2.

IBS-M: mixed bowel habits: > 25% bowel movements are Bristol types 1 or 2 and > 25% bowel movements are Bristol types 6 or 7

IBS-U: unclassified: if you meet diagnostic criteria for IBS but cant categorize your bowel habits into 1 of the 3 groups

 

3. Treatment for all types of IBS

- increase exercise!

- reduce stress! Cognitive behavioral therapy, hypnosis, and various relaxation methods reduce muscle tension and autonomic arousal that are involved in IBS symptoms

- improve your sleep habits

- increase/supplement dietary fiber (specifically SOLUBLE fiber)

- DIET! eat a low gluten, low FODMAP diet (FODMAPS are highly fermented, gas-producing foods) see the #feedyourgutdiet page! 

 

4. Specific treatment for IBS subtypes

Screen Shot 2017-04-02 at 4.04.50 PM.png
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Many patients don’t like the idea of starting an antidepressant for IBS and believe that they are getting labeled as having a psychologic issue instead. The truth is, antidepressants are extremely effective medications for chronic abdominal pain in IBS. Although antidepressants were developed for depression, at lower doses they were found to be great pain relievers (also used in migraines, neuropathy, fibromyalgia). They work at the level of the brain and spinal cord to block pain messages between the GI tract and the brain, thereby reducing visceral hypersensitivity and normalizing the brain-gut function.

The jury is still out on probiotics, folks.

#gutlove: Feed it, clean it, inspect it, respect it.

ACID REFLUX or GERD: what is it and how to avoid taking meds!

Lifestyle changes. I’m sure you’ve heard your doctor suggest lifestyle changes if you’ve spoken to them about acid reflux. But what exactly does that mean?? Everyone may know not to lay down right after eating as you could just imagine the acid and partially digested food forcing its way past your lower esophageal sphincter (LES), irritating your esophagus, and sometimes even ending up in your mouth! No the best feeling. So many people medicate with anti-acid medications like Nexium. But now we’re learning that staying on these medications long term is not good and associated with increased risk of infections like C. difficile diarrhea, malabsorption of key nutrients and minerals like magnesium, possible increased risk of fractures and even dementia and kidney disease. So lets try to avoid them!

Lets start with the basics:

What is GERD?

Gastroesophageal reflux disease (GERD) is movement of gastric juice from the stomach up into the esophagus. There is an antireflux barrier which is made up of the LES and diaghragm at the gastro-esophageal junction to prevent this from happening but it can be compromised in the following ways:

  1. Occasional relaxation of the LES
  2. Anatomic disruption like a hiatal hernia
  3. Obesity
  4. Pregnancy hormone changes
  5. Low pressure of the LES       
  • This includes strain-induced reflux when the LES is overcome and "blown open" by an abrupt increase of intra-abdominal pressure, i.e. lying down after eating
  • Tobacco, chocolate, carbonated beverages, and right lateral decubitus position directly lower LES pressure 

What are the symptoms?

10-20% of the Western world have GERD so know what to look out for! Heartburn, regurgitation, chest pain, trouble swallowing, chronic cough, asthma, laryngitis, sometimes abdominal pain, nausea, vomiting, bloating and belching…even waking up during the night gasping for air and having a choking sensation!

How do I get diagnosed?

See your doctor to make sure it actually IS GERD!  Be sure to bring a food/drink diary to see how your symptoms correlate with mealtimes and certain foods. Your doc may recommend lifestyle changes and/or try you on an acid suppressant and see how you respond and if you respond well, its clear. If not- you may need an endoscopy, esophageal pH monitoring or other testing.

Now to those LIFESTYLE CHANGES!

1.     WEIGHT LOSS! WEIGHT LOSS! WEIGHT LOSS! Probably your MOST EFFECTIVE option. Extra weight increases intraabdominal pressure so that gastric contents break past the LES and into the esophagus. Bariatric treatment like surgical gastric bypass has been demonstrated to be effective in reducing GERD. Losing ~ 10–15lbs decreases the occurrence of frequent heartburn by approximately 40%.

2.     STOP TOBACCO AND ALCOHOL. They loosen tension of the upper esophageal sphincter and cause hoarseness, postnasal drip and shortness of breath by irritating the mouth, larynx and trachea

3.     ELEVATE THE HEAD OF THE BED 6-8in- especially if you have nocturnal or laryngeal symptoms (cough, hoarseness, throat clearing). Use blocks or foam wedges under your mattress.

4.     FOOD RULES:

  • DO NOT LAY DOWN OR EXERCISE UNTIL 3 HOURS AFTER A MEAL
  • NO LATE NIGHT MEALS: Eat at least 3 hours before you go to bed
  • NO SUPERSIZED MEALS: Try eating 5-6 small meals a day instead of 3 big ones!
  • NO FAKE FOOD! Many commercially produced foods and drinks are treated with acid-containing substances to enhance flavor and shelf life (see the #feedyourgut tab!!!)
  • AVOID TRIGGER FOODS! The usual culprits are: caffeine, coffee, chocolate, spicy foods, carbonated drinks, raw onion, garlic highly acidic foods such as citrus/oranges and tomatoes, peppermint, and fatty foods (they take the longest to digest).
  •   EAT HIGH FIBER FOOD- Fiber enhances digestion, reducing pressure on the LES and can aid in weight loss. (see the #feedyourgut tab!!!)

If you DO need a Rx don’t forget there are plenty to chose from!

1.     Antacid (Tums)

  •  For on-demand symptom relief
  • Onset of action: 5 minutes
  • How do they work? Neutralize gastric pH, decreasing exposure of esophageal mucosa to gastric acid during reflux.

2.     Surface agent (sucralfate/Carafate)

  • Onset of action: 1-2hrs
  • How do they work? Adheres to mucosal surface, promotes healing, and protects from peptic injury
  • Short duration of action & limited efficacy
  • Safe to use so usually used in pregnancy
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3.     Alginate (Gaviscon)

  • Onset of action: 3-4min
  •  How do they work? It’s a polysaccharide derived from seaweed that forms a viscous gum that floats within the stomach and reduces the aftereating acid pocket in proximal stomach. Good for mild reflux.

4.     Histamine 2 receptor blockers (famotidine /Pepcid)

  • Onset of action: 2.5hrs
  • Usually only work up to 6 weeks
  • How do they work? Block acid secretion by blocking H2 receptors on the parietal cell

5.     Proton pump inhibitors (esomeprazole/Nexium)

  • Onset of action: 1-2 hrs
  • How does it work? Blocks gastric acid secretion by inhibition of the H+/K+-ATPase in the parietal cell
  • Its the STRONGEST anti acid medication but with the most side effects.
  • Usually only used when the above options fail. Take it at the lowest dose available for the shortest time available and make sure to take it correctly—on an empty stomach 30min before breakfast!

Why are we talking about this? Because chronic acid reflux leads to Barrett’s esophagus which puts you at higher risk for esophageal cancer. So manage your GERD early to prevent cancer later!

The resources referenced above:

ACG GERD guidelines

AGA GERD guidelines

NYTimes

Uptodate.com

Gastroenterology & Hepatology: Advances in GERD