IBS: A real disease with real treatment options

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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 &2 = slow transit, constipation. Type 6&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

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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

 

Spring cleaning… for your gut! Take a 2 week breather from sugar, dairy, meat & processed foods but do NOT juice or take a multivitamin

It’s the first day of spring and I am seriously ready to come out of hibernation. I don’t know about you, but particularly the last weeks of winter are tough and I am often blowing off my diet or exercise routine, feeling like.. I deserve it! It’s awful outside! Well now we can all breathe a sigh of relief. Spring is here and sunshine is just around the corner. And what better way to greet the good weather than cleaning out your gut!

I’m only asking for 2 week. I think you’ll be hooked and keep at it but at LEAST give it 2 weeks to flush you out. Follow this high-fiber, microbiome-diversifying, poop-perfecting, cancer-preventing, low-FODMAP food lifestyle to keep your gut happy & healthy for life!

 

What do you do?

Follow the #feedyourgut diet plan for 2 weeks.

In a nutshell- cut out sugar, dairy, meat, and processed foods and BULK UP on fiber!

Check out the philosophy here: https://www.gutlove.com/the-diet/

Check out the grocery list here: https://www.gutlove.com/shopping-cart/

And follow the other tabs to great recipes!
 

What do you NOT do?

1.     DO NOT Spend a million dollars on a juice cleanse. I hate to break it to you but juice cleanses are not all they’re made out to be. They are actually INFERIOR to eating WHOLE FOODS! Here are the details:

·      Juices won’t fill you up. Without any fiber, they’ll pass right through you.

·      Extra calories. Since you won’t feel satiated, you’ll end up drinking all the juice calories PLUS whatever else you want to eat.

·      Many vitamins & nutrients are lost in the juicing process. Antioxidants + fiber are usually found in the pulp or skin of whole fruits therefore thrown out with the juicing scraps.

·      High glycemic index (GI)! Juice is a super fast, high sugar load. This means that your blood sugar will quickly spike high and then fall without the buffer of fiber. Cranberry juice has a GI of 68 while a grapefruit has a GI of 25. Look for LOWER GLYCEMIC INDEX foods to stabilize your blood sugar whether you are diabetic or not! See a list of foods & their GI from Harvard here. FYI: Several prospective studies have associated diets high in glycemic index with risk of developing type 2 diabetes mellitus, coronary heart disease, and some cancers (uptodate).

·      Juice does NOT cleanse the body of toxins! Companies love to write “detox” on every juice bottle but what does that mean exactly? No one knows!  The liver & kidney do most of the detox work in the body and juices don’t necessarily assist them. What’s the benefit from “resting” your digestive tract and creating less stool? There IS no benefit. You need healthy stool for a healthy microbiome! Great article from NYTimes here

2.     DO NOT Buy an expensive bottle of vitamins. I’m sure we were all there once. Standing in the vitamin aisle and staring down a $50 bottle of vitamins.. in awe of all the potential health benefits you may reap. Well the news flash is that there is really NO reason to take a multivitamin and if you are experiencing any certain symptoms then see your doctor, they can test you for a vitamin deficiency, and you can take a replacement pill if you NEED it! Here’s the data:

Annals of Internal Medicine, 2005

Annals of Internal Medicine, 2005

·      There is NO clear evidence of a beneficial effect of supplements on cognitive performance, memory, all-cause mortality, cardiovascular disease …and definitely not cancer!

·      In fact, clinical trials shows that β-carotene, vitamin E, and possibly high doses of vitamin A supplements increase mortality

from Sleisenger and Fordtran textbook on Gastroenterology

from Sleisenger and Fordtran textbook on Gastroenterology

·       A multivitamin does NOT WORK—some of the vitamins you are hoping to get need fat to be absorbed and many of the minerals compete for the same transporter for absorption! For example, one transport mediates absorption of iron, zinc, manganese, and copper. So if you multivitamin contains both iron and zinc, they both compete for the same transporter and therefore you DON’T ABSORB one of the two minerals!

 

Spring cleaning for your gut does NOT mean a million dollar juice cleanse & vitamin splurge. Save money AND save your gut. #happyspring

LAXATIVES 101: Your guide to pooping when you're not

So you’ve mastered your pooping ritual and are going like a boss every morning after breakfast. THEN IT HAPPENS. Maybe you had to travel and switch time zones, maybe you had to take an exam and have been stressed out, maybe you changed your diet, maybe you just forgot to drink water all day. Suddenly, you’re bloated, gassy, your head hurts. Yup, you’re constipated. I’m going to help get you through it. Here is absolutely everything you need to know to get back in the poop groove.

1st cover your bases

  • Make sure you’re following the pooping ritual described on the “poop” section of this website and make time to poop in the AM after meals when colonic motor activity is highest.
  • Optimize your water & fiber intake (wheat bran, beans/hummus, citrus, apples, broccoli)! And don’t forget about prunes!
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Next, add a Bulk-forming fiber supplement

  • Ex. Benefiber (wheat dextrin) 1 tbsp 1-2x/day with a huge glass of water. Or Metamucil
  • How does it work? The fiber absorbs water to form a liquid that promotes peristalsis and reduces transit time in colon
  • How fast does it work? 12-72hrs
  • Side effects are mild but worse if you don’t drink enough water. Some bloating and gas, especially in the beginning. Go slow.
  • This is your rock. Consider taking this regularly to ensure perfect poops.

Need backup… for your backup? Next try Miralax (Polyethylene Glycol 3350).

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  • Start with 17 g powder dissolved in big glass of water once a day and increase up to a maximum of 34 g daily or decrease as necessary
  • How does it work? It’s an osmotic agent that absorbs water to increase colon distension and stimulate peristalsis. Also increases poop mass.
  • How fast does it work? 24-96hrs
  • Side effects are mild but can include bloating and gas.
  • You can take this on a regular basis and know it’s safe. I mean, we use it in mega doses for colon prep before colonoscopy.

 

OK, it’s been 1-2 days & that didn’t work. I need to go NOW.

If you need to go NOW like TODAY, then try one of these:

1. Stimulant laxatives: Bisacodyl (dulcolax), Senna (Senokot)

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  • How does it work? Alters water and electrolyte transport in the colon wall and directly increase intestinal motor activity and peristalsis by irritating the smooth muscle and nerves of the intestine
  • How fast does it work? 6-12hours
  • Side effects: Diarrhea and abdominal pain even with a couple doses.
  • Do NOT take these long term—they lead to dangerous electrolyte abnormalities, salt overload, and even colonic INERTIA—a scary term that means your colon motility slows down to the point that it STOPS. Its surgical management at that point.
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2. Milk of magnesia or Magnesium citrate

  • How does it work? It’s an osmotic agent that absorbs water to increase colon distension and stimulate peristalsis. Also increases poop mass.
  • How fast does it work? 30minutes – 6hrs
  • Do NOT take if you have kidney problems!
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If you need to go NOW like this MINUTE, then try a Suppository

  • Glycerin or bisacodyl, either one works. Keep it in your rectum for a good 15 minutes if you can.
  • How does it work? Glycerin an osmotic agent that absorbs water to increase colon distension and stimulate peristalsis. Also increases poop mass.
  • How fast does it work? 15-60min
  • Side effects minimal if used infrequently. Abdominal cramps, rectal irritation, feeling of incomplete evacuation

 

If it’s been DAYS & you may just die of constipation then an enema is just the thing you need.

  • Enemas should only be used to prevent fecal impaction if you have several days of constipation and are miserable.
  • If that’s the case buy a mineral oil enema or use tap water
  • How fast does it work? 2-15 minutes
  • Side effects: abdominal cramps, diarrhea, rectal leakage

 

Don’t waste your time:

  • Colace (docusate sodium): this is a STOOL SOFTENER. It’s not for constipation per se, but to prevent straining while pooping and help with hard, dry stools in a very weak way. This is for HEMORRHOIDS.
    • How does it work? Lowers surface tension of stool, allowing water to enter more easily
    • How fast does it work? 12-72hrs
  • Lactulose (synthetic sugar): Although effective, this med just comes with tons of side effects, tons of  bloating and gas
    • How does it work? Its an undigested sugar that keeps water and electrolytes in the gut lumen
    • How fast does it work? 24-48hrs

 

Last, but not least at all. Actually super important:

If your constipation becomes more frequent or severe, see you doctor! There are plenty of diseases that cause constipation. There are also more powerful drugs your doctor can give you once you make sure nothing else is going on.