Overcoming IBS (Irritable Bowel) & conquering Gut Health | Dr. William Chey, MD

Understanding Irritable Bowel Syndrome (IBS)

In this video, Dr. William Chey discusses the symptoms, diagnosis, and treatment of irritable bowel syndrome (IBS).

What is IBS?

• IBS is a symptom-based diagnosis characterized by abdominal pain in association with altered bowel habits.

• Patients can have constipation or diarrhea or a mixture of both.

• Bloating is very common in IBS patients but not part of the diagnostic criteria.

• Difficulty passing gas or burping are also common symptoms in IBS patients.

Diagnosis and Differential Diagnosis

• There are no specific diagnostic tests for IBS; it is diagnosed based on characteristic symptoms.

• Patients with overlapping upper and lower GI symptoms may have other conditions such as functional heartburn or dyspepsia.

• A third of patients may experience changes in their bowel habit symptoms over time.

Treatment Options

Diet

• Low FODMAP diets can be effective for some patients with IBS.

• Other dietary interventions include increasing fiber intake and avoiding trigger foods.

Medications

• Antispasmodics can help relieve abdominal pain and cramping.

• Laxatives can help relieve constipation.

• Probiotics may be helpful for some patients.

Other Therapies

• Acupuncture has been shown to improve symptoms in some studies.

• Cognitive-behavioral therapy (CBT) can help manage stress-related symptoms.

Understanding Irritable Bowel Syndrome (IBS)

In this section, the speaker discusses the prevalence of IBS and whether it is increasing. They also talk about factors that may contribute to the development of IBS.

Prevalence of IBS

• The Rome criteria are commonly used to define IBS.

• 5-10% of the general population, depending on the country, satisfy diagnostic criteria for IBS using Rome IV criteria.

• Estimated to affect between 15 and 35 million people in the United States.

• Acute GI infections like food poisoning or travelers' diarrhea can increase likelihood of developing long-standing symptoms consistent with IBS.

• Prevalence of GI symptoms and specifically IBS symptoms have increased since the pandemic.

Factors Contributing to Development of IBS

• COVID infection could be a factor in increased prevalence or changes in diet, physical activity, psychological stress.

• Some patients reported improvement in their IBS symptoms during the pandemic due to preparing their own meals and working from home.

Age and Onset of Symptoms

In this section, the speaker talks about age and onset of symptoms for individuals with IBS.

Age and Gender

• Younger women tend to be more affected by IBS in Western countries.

• While it's more prevalent among younger people and females, it can affect any age group.

New Onset Symptoms

• New onset symptoms warrant a more detailed evaluation particularly to exclude presence of colorectal cancer.

• New screening criteria suggest doing a colonoscopy to screen for colon cancer on everybody over the age of 45.

Understanding IBS

In this section, the speaker discusses the complexity of IBS and how it is not a single disease. Rather, it is about understanding the factors that can come into play to enable the expression of symptoms in an individual.

Factors Contributing to IBS

• Abnormalities in motility, visceral hypersensitivity, altered permeability, and intestinal permeability or leaky gut are some physiologic factors that contribute to IBS.

• Food, microbiome, and bile acids are important factors that reside within the gut lumen and interact with each other to lead to activation of the immune system that resides in the GI tract as well as enteric neurons.

• Stress and food are two main triggers for symptoms in patients with IBS.

Heterogeneity of IBS

• The complexity and heterogeneity of IBS may cause it to multiply into different disorders or just be individual susceptibility causing variability.

• Over time, we have unlocked issues about overlap between celiac disease and IBS. Patients with microscopic colitis can masquerade as IBS. Bacterial overgrowth has also been discussed.

Future Diagnostic Tests for IBS

• There will be diagnostic tests that help us parse patients with true IBS more on the basis of underlying pathophysiology which hopefully links a biomarker result to a specific treatment for a specific patient.

• Doing a breath test and using antibiotics is currently closest thing but even that is highly controversial.

Gut-brain Axis Relationship

In this section, the speaker discusses the relationship between mood disorders like anxiety and gut disorders like IBS.

Relationship between Stress and GI Symptoms

• Stress and anxiety can induce GI symptoms.

• The relationship between the brain and mood disorders like anxiety and gut disorders like IBS is not clear.

Brain-Gut Interaction and Therapies

The brain-gut interaction is bi-directional, and therapies can take the form of behavioral or pharmacological treatments. Microbiome-based strategies are also being explored.

Behavioral Therapies

• Gut-directed hypnosis and cognitive-behavioral therapy are examples of behavioral therapies that can help with brain-gut interactions.

Pharmacological Therapies

• Neuromodulators such as tricyclic agents, selective serotonin reuptake inhibitors, and selective norepinephrine reuptake inhibitors can be used to treat brain-gut interactions.

Microbiome-Based Strategies

• The gut microbiome plays a role in both gut health and mental health. Probiotic supplements have been shown to manipulate anxiety and mood abnormalities in patients with IBS.

• Treating gastrointestinal conditions with probiotics can have psychological or mood effects, while cognitive-behavioral therapies can improve top-down symptoms. It's important not to get overly fixated on one approach since interrupting things at one point or another can offer benefits to some patients.

Historical Perspectives on IBS

This section discusses how the understanding of IBS has evolved over time.

• In the 1950s and 1960s, IBS was thought of as a psychological condition.

• In the 1970s and 1980s, it was recognized as a physiologic condition caused by motility abnormalities or visceral hypersensitivity.

• Now, there is an understanding that what happens in your head is important to the overall symptom experience of IBS but it's not all in your head; it's biological.

The Role of the Microbiome in IBS

This section discusses the role of the microbiome in IBS.

• Dysbiosis, an imbalance of the gut microbiome, may be an underlying explanation for IBS in some cases.

• However, it's important to note that this is only a factor in some situations and not others.

Microbiome Strategies and Evidence-Based Therapies for IBS

In this section, the speaker discusses the effectiveness of microbiome strategies and evidence-based therapies for treating IBS.

Microbiome Strategies

• 40% of patients get better with microbiome strategies.

• The microbiome strategies work for some patients, but not all.

• Rifaximin can help dramatically improve symptoms in some patients.

• A breath test can increase the response rate to rifaximin from 43% to 60-70%.

Evidence-Based Therapies

• About 50% of patients benefit from a low FODMAP diet.

• Most evidence-based therapies make only 40-60% of patients better.

• Tailoring and combining strategies can help over 80% of patients with IBS.

Integrated Care Approach

• An integrated care approach utilizing a team-based approach can improve outcomes for patients with functional GI disorders, including IBS.

• Even traditional GI-centric care can help around 60% of patients, but collaborative team-based care is more effective.

The Importance of a Multi-Disciplinary Team

In this section, the speaker discusses the importance of having a multi-disciplinary team to optimize outcomes for patients with digestive and gastrointestinal conditions.

Components of a Multi-Disciplinary Team

• A gastroenterology team, specialized dietitians, and psychotherapists are essential components of a multi-disciplinary team.

• An integrated Acupuncture Clinic is also being added to the team as an evidence-based therapy for GI conditions such as chronic constipation and nausea/vomiting.

Controversy Surrounding Acupuncture for IBS

• Studies have shown mixed results regarding the effectiveness of acupuncture for IBS symptoms compared to sham acupuncture. However, studies comparing acupuncture to usual care at baseline show benefit for overall IBS symptoms.

• Electroacupuncture has been shown to be effective in treating chronic constipation, nausea/vomiting, and chronic pain.

Value Proposition of Adding Acupuncture

• There is little downside to adding acupuncture as it is low risk and evidence-based for certain GI conditions. However, one issue in the United States is that it is usually not covered by insurance which may result in additional costs for patients.

Tests to Raise Probability of Intervention Effectiveness

In this section, the speaker discusses various tests that can be used to raise the probability that a specific intervention will be effective.

Calprotectin Stool Test and Antibody Tests

• The calprotectin stool test and antibody tests against vinculin and other molecules have been studied but their effectiveness for IBS remains unclear.

Guidelines on Testing for IBS

• The guidelines for testing for IBS are not clear and more research is needed to determine the effectiveness of various tests.

Testing for IBD and Giardia

In this section, the speaker discusses the importance of testing for inflammatory bowel disease (IBD) and giardia in patients with symptoms of IBS.

Testing for IBD

• A fecal calprotectin or CRP level can be used to exclude inflammatory bowel disease.

• At certain thresholds, a negative fecal calprotectin or CRP level can essentially exclude inflammatory bowel disease.

• Depending on where you reside, testing for giardia should also be done during summer months for patients with diarrhea.

Testing for Giardia

• Testing for giardia can and should be done during summer months in areas where it is endemic.

• The speaker recently diagnosed a patient with diarrhea as having giardia.

Testing for Bile Acid Malabsorption

In this section, the speaker discusses testing for bile acid malabsorption and how it can help identify patients who may benefit from treatment with bile acid sequestrants.

Testing Methods

• In the United States, testing is largely done through stool collection and quantitation of bile acid levels.

• In Europe, there is a test called the SeHCAT test that can also help identify patients with evidence of bile acid malabsorption.

Treatment Options

• Patients with evidence of abnormal bile acid absorption are more likely to improve with a bile acid sequestrant like cholestyramine or Questran.

Antibody Tests: Anti-Vinculin Antibodies & Anti-Cdtb Antibodies

In this section, the speaker discusses antibody tests for IBS and their accuracy.

Anti-Vinculin Antibodies & Anti-Cdtb Antibodies

• There is evidence behind these tests, but it remains somewhat preliminary.

• Additional data from a wider audience of investigators using appropriate control groups is needed to determine how accurate the tests are.

• Almost all validation studies have been done in populations with defined disease, so it's unclear how accurate the tests are at identifying a specific diagnosis.

Zonulin Test

In this section, the speaker discusses the zonulin test and its potential as a diagnostic marker for IBS.

Zonulin Test

• Preliminary tests show that patients with IBS are more likely to have an abnormal permeability test.

• However, it's unclear whether this finding is ubiquitous enough to serve as a diagnostic marker for IBS or whether it's specific enough to distinguish from other diseases like inflammatory bowel disease.

Colonoscopy and Age-appropriate Colorectal Cancer Screening

In this section, the speaker discusses colonoscopy and its role in diagnosing IBD and colorectal cancer screening.

Colonoscopy for Diagnosing IBD

• A colonoscopy can diagnose inflammatory bowel disease (IBD).

• In the case of IBS, however, a colonoscopy is unremarkable.

Age-appropriate Colorectal Cancer Screening

• The most important thing to remember about colonoscopy is to make sure that your patients have undergone age-appropriate colorectal cancer screening.

• If you do a colonoscopy in a patient with IBS and diarrhea, it's very important to get random biopsies.

Diagnostic Yield of Colonoscopy in Patients with IBS Symptoms

In this section, the speaker discusses the diagnostic yield of colonoscopy in patients with IBS symptoms and what tests are conducted to determine if it's IBD or IBS.

Tests Conducted for IBS Symptoms

• If a patient falls into the IBS with diarrhea category, inflammatory markers such as fecal protectin or CRP are done to exclude inflammatory bowel disease. Celiac serologies are also done to exclude celiac disease.

• Age-appropriate colorectal cancer screening is done for all patients. If a colonoscopy is performed, biopsies for microscopic colitis should be taken.

• For patients with more constipation symptoms, age-appropriate colorectal cancer screening is important. CBC is also recommended to check for unexplained anemia.

Wheat Sensitivity vs Gluten Sensitivity

In this section, the speaker explains why wheat sensitivity is a more accurate term than gluten sensitivity and discusses different causes of symptoms when eating wheat.

Causes of Symptoms When Eating Wheat

• Fructans are short-chain carbohydrates that are not absorbed by the human small intestine and can cause symptoms in some patients with IBS symptoms. They're actually part of the FODMAP group.

• While gluten can cause or trigger symptoms in some patients with IBS symptoms, fructans are more likely to reproduce symptoms in these patients.

• The nocebo response can also lead to problems after eating wheat that have nothing to do with either gluten or fructans. There's no specific test right now to identify patients that have wheat intolerance since it's a heterogeneous group.

SIBO and IBS

In this section, the speaker discusses the overlap between SIBO and IBS.

Overlap Between SIBO and IBS

• There's controversy surrounding the overlap between SIBO and IBS. Some studies suggest that there's a higher prevalence of SIBO in patients with IBS symptoms, but others have not found this association.

• The speaker suggests that if a patient has persistent symptoms despite treatment for IBS, it may be worth considering testing for SIBO.

Microbiome Changes and Small Intestinal Bacterial Overgrowth (SIBO)

In this section, the speaker discusses the changes in microbiome that lead to dysbiosis and clinical problems. The speaker also talks about the best way to diagnose small intestinal bacterial overgrowth (SIBO).

Diagnosing SIBO

• There is no consensus on the best way to diagnose SIBO.

• Two ways of diagnosing SIBO are through an upper endoscopy and aspiration of fluid from the small bowel for quantitative culture or a breath test where you give a carbohydrate substrate and look for an increase in breath hydrogen or methane excretion as a reflection of fermentation of the carbohydrate in the small intestine.

• The speaker's personal bias is to do a breath test because it increases the likelihood of response, reduces cost, and avoids giving broad-spectrum antibiotics.

Histamine Intolerance

In this section, the speaker discusses histamine intolerance and its overlap with IBS.

Histamine-containing Foods

• A survey conducted by Magnus Simren´s group found that 84% of patients with IBS identified food as an important trigger for their symptoms.

• Carbohydrates were found to be most likely to reproduce a patient's IBS symptoms followed by histamine-containing foods.

Histamine and FODMAP diets

In this section, the speaker discusses the role of histamine and FODMAP diets in IBS.

Histamine Diet

• Excluding foods with high levels of histamine may be helpful for some IBS patients.

• There is little credible scientific evidence to support a low histamine diet as an effective treatment for IBS.

FODMAP Diet

• FODMAP stands for fermentable oligo, di, monosaccharides and polyols. These are short chain sugars that can trigger symptoms in IBS patients.

• The elimination phase of the low FODMAP diet involves restricting intake of these sugars to improve symptoms. This phase lasts between two and six weeks.

• After the elimination phase, individual foods containing specific types of FODMAPs are reintroduced to determine a patient's sensitivity.

• The final phase involves personalizing an individual's diet based on their sensitivities identified during the reintroduction phase.

Low FODMAP Diet Effectiveness

• The low FODMAP diet is associated with symptom improvement in 50 to 70 percent of IBS patients during the elimination phase.

• A study conducted over four years found that over 80 percent of patients were able to reintroduce and personalize their diets after completing the elimination phase.

Importance of a Diverse Balanced Diet

In this section, the speakers discuss the importance of a diverse balanced diet and how it can impact gut health and overall health.

Fructans as the Most Important Category

• Both studies found that fructans were by far and away the most important category in terms of triggering IBS symptoms.

• Garlic, onions, and wheat are some examples of foods that fall under this category.

Importance of Experimentation

• Restriction phase should be viewed as a diagnostic test to determine whether you're sensitive to FODMAPs or not.

• The end game is to figure out what your low FODMAP diet is, not just the FODMAP restriction for everybody but what foods you need to restrict to be able to get back control of your life and not suffer incessantly with your symptoms.

• Patients should experiment with reintroducing foods at set intervals just to make sure that they understand how much they can get away with before it causes problems or if maybe it doesn't cause problems anymore.

Impact on Microbiome

• The more restrictive your diet is, the more restricted your microbiome is, and diversity in terms of your microbiome is a very important factor in determining not just gut health but also overall health and metabolic health.

Rehabilitation Possibility

• There isn't enough information available yet about whether foods that cause intolerance are outlawed for life or if there's a possibility of rehabilitation through gradual ramping up with cultivating microbiome species.

The Low FODMAP Diet and Alternative Diets for IBS

In this section, the speaker discusses the effectiveness of the low FODMAP diet in treating IBS symptoms. They also mention that while the diet works for around 50-60% of patients, there are still a significant number of patients who do not respond to it. The speaker suggests that alternative diets such as the Mediterranean diet may be effective for these patients.

Effectiveness of Low FODMAP Diet

• Around 50-60% of patients on low FODMAP get better.

• However, 40-50% of patients don't get better on a low FODMAP diet.

• Patients put on a low-FODMAP diet have food-related symptoms triggered or worsened by eating a meal.

Importance of Low FODMAP Diet

• The low FODMAP diet is important because it makes around half of the patients better.

• It opened our eyes to the fact that diet interventions can be valuable parts of treatment plans for IBS.

Alternative Diets for IBS

• Researchers are excited about using the Mediterranean diet as an alternative to the low FODMAP diet.

• A study is being conducted comparing the effectiveness of both diets in treating IBS symptoms.

• The goal is to identify other ways in which we can manipulate diets to benefit patients with IBS who don't respond to a low FODMAP diet.

Fiber and Its Effects on Digestion

In this section, the speaker discusses how different types of fiber affect digestion differently. They explain that fermentable fibers like inulin do not add bulk to stool but instead act as prebiotic fibers that can have a laxative effect. The speaker also discusses the differences between types of fiber and how they affect digestion.

Fermentable Fibers

• Fermentable fibers like inulin do not add bulk to stool.

• Inulin is a FODMAP, universally non-digested, non-absorbed by the human small intestine, and deposited in the colon where it may or may not be fermented to gas and short-chain fatty acids.

• Inulin acts as a prebiotic fiber that tends to favor the growth of certain organisms and leads to fermentation byproducts which can have a laxative effect.

Differences Between Types of Fiber

• Different types of fiber are quite different from each other.

• There are dramatic differences in fermentability and solubility that affect the performance of fiber from one person to another.

• Bran is discussed as an example of how different types of fiber affect digestion differently.

Bran and Probiotics for IBS

In this section, the speaker discusses the use of bran and probiotics for treating IBS.

Bran for IBS

• The evidence for bran and IBS is not compelling.

• Coarse bran has an irritant effect in the colon and will stimulate people to go to the bathroom more often, while fine bran can be constipating.

• For constipation, finely ground bran is not recommended.

Probiotics for IBS

• The ACG and AGA guidelines on IBS did not favor widespread use of probiotics for IBS based on current evidence.

• There is some evidence for individual probiotics such as bifidobacterium infantis 35624 and VSL number three, but most literature is not scientifically rigorous.

• Outside of a clinical trial, probiotics are not recommended as routine treatments for patients with IBS.

• Some probiotic strains may improve emotional function in patients with IBS. However, using an empiric approach of picking one or several strains does not make sense since patients have unique microbiomes.

• Profiling the microbiome will help better understand what a patient needs. However, tests available now are questionable in terms of robustness of results and veracity of recommendations.

Fermented Foods and IBS

In this section, the speaker discusses the safety and potential health benefits of consuming fermented foods in relation to IBS.

Safety and Benefits of Fermented Foods

• Consuming fermented foods has little downside as people have been eating them for millennia.

• Fermented foods are safe and may offer some health benefits.

Trying Probiotics for IBS

In this section, the speaker suggests trying probiotics for IBS but recommends giving it a time limit of two to four weeks before moving on to other strategies if there is no improvement.

Trying Probiotics

• It's worth trying probiotics for IBS.

• Give yourself a time limit of two to four weeks.

• If there is no improvement after two to four weeks, move on to other strategies.

Summary of IBS

This section provides a summary of what was covered about IBS in the video.

Heterogeneous Condition

• IBS is not one disease but rather a heterogeneous condition.

• Some people have predominantly constipation, others have predominantly diarrhea, and some have both.

• Other symptoms like bloating, gas, anxiety, and depression are also common.

Definition of IBS

• The definition of IBS is abdominal pain coupled with altered bowel habits.

Causes and Triggers of IBS

• Causes of IBS can vary from person to person.

• The most common triggers are food and stress.

Conditions that Mimic or Coexist with IBS

• Conditions that often mimic or coexist with IBS include inflammatory bowel disease, celiac disease, non-celiac wheat intolerances, SIBO (small intestinal bacterial overgrowth), among others.

• There are specific tests for several of these conditions.

Therapeutic Strategies

• There are mainly three pillars of therapeutic strategies: diet, behavioral therapy, and pharmaceutical agents.

• Diet includes the low FODMAP diet.

• Behavioral therapy includes hypnosis and cognitive-behavioral therapy.

• Pharmaceutical agents include antibiotics, laxatives, and antidepressants.

• Probiotics and acupuncture may have some benefit in some cases.

Combining Approaches

• Each strategy in isolation can help some people (around 50%).

• The real power is in combining approaches where we see a success rate of 80% or higher.

Low FODMAP Diet

• Low FODMAP diets are evidence-based and help between 50% to 70% of people.

• The dietary restriction is the beginning, not the end. There's also a reintroduction phase and a personalization phase.

• Over 80% of patients are able to reintroduce many foods and tolerate them just fine.

Working with a Team

• Ideally, we want to work with a team that includes gastroenterologists, registered dietitians, and behavioral therapists.

• These resources exist out there so if one thing doesn't work for you it doesn't necessarily mean there's no hope.