Diarrhea related to irritable bowel syndrome is common, yet because it's a functional – not anatomical – disorder, providers frequently run more tests than necessary while patients worry and wait in discomfort. Josephina Gomez, NP, who specializes in gastroenterology, offers this crash course in getting unstuck from the evaluation process and matching patients with proven remedies, ranging from behavioral measures to supplements and medications. Hear her tip on how to deliver an IBS diagnosis so that patients feel reassured and empowered to heal.
Thank you so much, um, and I appreciate the, uh, time and space. So I am Josie Gomez. I'm a nurse practitioner over at the UCSF GI faculty practice. Uh, we're housed over on Divisadero at the Mount Zion campus. Um, I've been in GI, uh, at UCSF for 7 years now, and prior to that, 5 years at a different institution, so. Um, I, I quite enjoy it, and I quite enjoy the detective work that it entails, so, I thank you in advance for your patience and your kindness. So here we go. Wait, wait a minute. There you go. So, um, the goals and objectives today are to become familiar with the symptoms of IBS, diarrhea, and criteria for diagnosis, um, to become familiar with first line evaluation, and become familiar with therapeutic modalities, and know when to refer to gastroenterology, um. I'm going to focus on uh IBS diarrhea because of the prevalence in primary care, and what is outside the scope of his talk is IBD, celiac disease, microscopic colitis, exocrine pancreatic insufficiency, and infectious diarrhea. So, basically, we're going to uh focus on functional GI disorders, um, and what are they, and, and how do I think about this? So, when I think of functional GI I think disorders of gut-brain interaction, um, so functional, not anatomical, and how do I think about this? So I think like Goldilocks and the Three Bears, there's a component of altered central nervous processing or feedback, so hypersensitivity, um, altered motility, and possible reduced immune function. Um, other things that you can see in this spectrum is bile acid diarrhea, sometimes seen post, uh, cholecystectomy, um, and SEO or small intestinal bacterial overgrowth, uh, or a dysbiosis. And so, why do we focus on this? It's common, very common, and um can be seen very frequently in primary care and in any GI practice actually. Um, and it can be debilitating and affect quality of life. Um, patients sometimes get really frightened by how robust the symptoms are, and, and they're afraid that there's something really, really wrong with them. Um, so, with functional GI disorders, you know, we have a lot of outdated wisdom, um, and, and the poster child for, uh, functional GI disorders is IBS, um, and when I first see patients, they, they are afraid that it's a trash can diagnosis. They don't really know what's wrong with me, you know, speaking of prior evaluation. And um they've also been told all tests are normal, so there's nothing wrong with you, which is not entirely true. Um, all tests are normal and thank goodness you don't have colon cancer, pancreas cancer, um, you know, microscopic colitis, uh, anemia, all those things, but the tests don't reveal or are unrevealing for what is going on with you. So I want to point out that the new wisdom includes the Rome 4 criteria, um, and I've attached the, uh, website and some information about it, and basically it's all things functional. So this is an international think tank that has gone over. Symptoms and um outlined criteria, um, most of which is clinically based, but clinically based in the absence of alarm symptoms. And so that's, that's the big thing is in the absence of alarm signs or symptoms, biochemical data. So, um, I would encourage you to take a look at that. Um, and attendant issues that you can see are over, uh, overlying SIB, small intestinal bacterial overgrowth, and the dysbiosis, which again, um, seems to be coming up a little bit more frequently. So the purpose of Rome 4 is to provide parameters for the diagnosis of functional GI disorders. People, um, Providers, uh, often feel out of their depth when it comes to functional GI disorders. We get, um, we get roped into thinking we always have to do more diagnostics, and I think, um, one thing that I've learned in the last, you know, decade or so is that, um, We're looking at the way things function and not the way things look necessarily. So, outlining that difference for the patients can be very helpful. Um, looks like a hand, but is it working like a hand? Um, so when my brain tells my hand to do something, does the hand do what it's supposed to do? Um, and so there are other Examples of disorders of gut-brain interaction that are outlined in room 4 and things like functional dyspepsia, dyspepsia, excuse me, cyclic vomiting syndrome, irritable bowel syndrome, uh, constipation, diarrhea, or mixed, and cannabinoid uh hyperemesis syndrome. Uh, or CHS. Uh, for IBS, the diagnostic criteria, um, You have to have at least 1 day a week in the past 3 months associated with 2 or more of these. So you have to have pain. Um, there are functional disorders, uh, of bowel elimination that do not include pain. So the first thing you ask is, is there pain? If there's no pain, it's not irritable bowel syndrome. Um, so there is a, there's a tendon pain that is related to defecation. Sometimes it gets better, sometimes it doesn't, but there's pain. It's also associated with a change in frequency in the stool. Um, and it's associated with a change in the way, uh, in the form and appearance of stool, so, And the criteria needs to be for the last 3 months with the symptom onset. The last 3 months, within the last 6 months, and there has to be a change in greater than 25% of abnormal, uh, uh, uh, greater than 25% of the stools have to be abnormal, um, and bristol type 6, and I would encourage you, and actually I put it up here as well, but once you know what it's the next slide, um. So, the, the idea is that um there's pain, it gets better, uh, possibly can get better with the, um, with defecation, sorry, there's pain related to defecation with a change in character, uh, stool character and consistency. And there are no alarm symptoms, so I cannot stress this enough, there are no alarm symptoms. Um, patients do not report anorexia. Uh, weight loss, melana or hematochezia, and melana is the black tarry stuff that comes from your upper GI tract. Hematochezia is the bright red blood from lower down. Obstructive symptoms, and obstructive symptoms are things like nausea postprandial prandialli or um feeling bloated, uh, abdominal pain associated with eating, and, um, progressive abdominal pain. And this is the Bristol stool scale, which I, uh, encourage you to, um, become familiar with, and I like it because it's shared language between, um, us and our patients. Um, so when, when you ask them about their stool output and, and frequency and consistency, they can tell you exactly what it looks like, um, and, uh, you have common, uh, common language, so that we all know what we're talking about. Um, Great. So, This is where I think a lot of um Providers get stuck is the evaluation. I know that in the infancy of my career, I ordered so many things. I ordered so many scopes and MRI's and, you know, cross sectional imaging and labs, and the bottom line is that in the, the absence of alarm symptoms and fitting the criteria of IBS diarrhea, there's really no role for routine imaging or luminal evaluation, and by that I mean um a scope. Um, what is important to do, um, in, in, in the Uh, In the era of telehealth, this is the first visit for this patient should be in person, um, because you need to do a, a, a good physical exam. So the vital signs, weight, um, you really do have to eyeball the patient, um, go over the medications, uh, and any supplements not listed on the medication list. Ask about caffeine and concentrated sugars because those can affect bowel output as well. Um, diet, fruits, um, When I was first starting out, I, I had a patient who drank 15 cups of coffee. Uh, the attending I worked with figured that out, and I went into everything else but asked about, but didn't ask about meds or caffeine or any of that stuff, and sometimes it's pretty low hanging fruit, and, and we mustn't forget to, you know, go back to the basics. So vital signs, weight, eyeballing them, medications, supplements, caffeine, concentrated sugars, diets. And if all of that comes away in an unrevealing fashion, you can get labs, so CBC to look for anemia. Um, it's reasonable to do an iron panel or ferritin. Um, it's reasonable to look for celiac disease. Now, with the celiac disease labs, they should be on gluten. Um, the, the TTG or tissue transglutaminase antibody IgA is your body's immune response to the presence of gluten, and if you're not having gluten in your system, you either don't have celiac or um you didn't have gluten, and it's hard to differentiate that if they're not on a gluten diet. Um, and when you're checking the uh TTG antibody IgA, you should also check the total IGA at least once, um, and then the CRP and ESR which are, um, Inflammatory markers. Um, I see a lot of IBD patients and the CRP is actually more sensitive for the gut, uh, with regards to using one or the other, but we, we check both. Um, for stool testing, um, it's important to check for Giardia and considering C. diff, so, When I was growing up, we were told that if patients had been out camping to check Giardia, I see Giardia all the time and nobody's been camping, so, um, we checked for Giardia, stool culture, uh, consider C. diff if they've been in the hospital or have been on antibiotics recently. And by recently, I mean within the last 6 months. Um, and we can also check for fecal calprotectin, which is looking for inflammatory, looking for, um, inflammation in the stool, uh, and it doesn't matter if the stool is formed or loose at that point. A, um, You treat anything that comes up in a, in a fecal calprotectin that's elevated um warrants a uh colonoscopy in our practice. Uh, so that is a, a, uh, referral for a colonoscopy. Um, for imaging, um, we wouldn't necessarily do anything like a CT scan, um, but, a KUB is, is super helpful, and I use a KUB to figure out the patient's colonic stool burden. So if they're having diarrhea, but I think it's overflow diarrhea, which is constipation with uh loose stools leaking around that, I have a KUB. It's, it's super easy, um, and patients usually can go into, at least UCSF anyway, can go in same day and get a report. Um, there's also something called a sits marker test, um, but that's more for constipation. It involves, um, swallowing a capsule with 24 or 26 radio opaque markers in it. You swallow that and then we have you take an X-ray, a KUB on day 5 to look at the distribution of the sits markers, and based on the distribution, you can figure out whether somebody has um slow transit constipation or pelvic floor dysynergia. Um, and again, I cannot stress, make sure that there are no alarm signs or symptoms, um, and they are listed here, the ones that might come up, iron deficiency anemia, um, elevated inflammatory markers, fecal calprotectin, and celiac markers are, are positive. So, now that you've got all of that and it's unrevealing and you come up with the diagnosis of IBD, I think this is where I failed as a clinician very early on in my career, which was um not being definitive. So when we have a definitive diagnosis, we want to appear calm and assured, and it can be reassuring for the patients, so. Be definitive, be empathetic, be informative, and be non-judgmental, just like we are for any other diagnosis, um. I used to say, well, you know, that didn't show anything, let's go down this, you know, avenue, and the reality of it is, it's more helpful to them if you are, if you give them a diagnosis and you're empathetic and you tell them, this is how we, this is how we plan to manage it. Um, We, yeah. Um, and the management or the therapeutic modalities really are symptom driven, so pain and stool output. Um, The first thing I go over is usually behavioral measures. Um, behavioral measures underpin everything, um, that you're going to lay on them afterwards. So the first thing I try to have them do is identify triggers. So some, uh, common ones are not getting enough, um, not getting good quality diet or hydration, sleep, stress, stress management, um. We have these uh apps now that are great. They are patient-driven and uh the, the, the, the downside is some of them have in-app costs, but, um, they can be um remarkable for CBT and symptom management, um, yoga, uh, self-hypnosis, so I, uh, I encourage you to give the patients this information as well, um, and they do work, uh, quite well, um. Following that, um, I usually talk about, uh, a little bit about diet. Um, we can do a little bit of a dairy exclusion. Uh, adults often, even adults, uh, in the United States who have grown up on milk can develop lactose intolerance, and so that's something that is not really looked at a lot. So try, a trial of a dairy exclusion can be helpful. Um, there's also something called a low FODMAP diet. It's an exclusionary app. I can never remember what uh the FODMA stands for, but it's um it's, it's an exclusionary diet that takes several months, and it's super time consuming. Um, it has been shown to be helpful, but I really There are lots of resources on the internet, but I think the best thing to do really, if they're going to be on it, is to have the patient see a dietitian. Um, it requires a lot of intensive, um, dietary evaluation, and it goes in phases, so you get rid of all the high FOD maps and then, um, you start reintroducing or liberalizing the diet by adding back foods that are, um, Foods that are higher in FOD maps that um to, to look for a, a change in symptoms. Um, and the best thing to do is, is refer them to a dietitian that is familiar with this, um, yeah. And I'm just gonna read that up, OK. So, what are fog maps, and there's a lot of information about this, um, and you can also go to Monash. Monash University in Australia, um, pioneered this diet, and they have a lot of information as well, um. So the bottom line is they're not completely digested or absorbed, and when fod maps reach the small intestine, they attract water and they're fermented by gut bacteria producing lots of gas, water, and expansion of the abdominal, sorry, the intestinal wall. If you have IBS, you can also have visceral hypersensitivity and so you have this expansion in a gut that is um sensitive and so you can have, um, Uh, exaggerated sensations of pain. Um, I have I have patients who tell me they feel like there's a zoo in there, and that's a good thing when they tell me that because I can refocus them and say, well, we know that there isn't a zoo in there, but that's what your brain is thinking, and so to your brain, that's true, um. I think it reassures patients to, to, um, to acknowledge their symptoms and normalize their symptoms. Um, OK. So, just a little bit more, um, OK, so for therapeutic modalities, um. Once you Once you go through the behavioral measures, the diet, and patients need to, um, the symptoms persist, we can go forward with medications and supplements, um, and the first thing that I usually go with is fiber, soluble fiber. Um, it's cheap, it's, uh, plentiful in the world, and it gives stools bulk. Um, so psyllium husk is an example. I just use Metamucil, but really it's psyllium husk. Um, we don't even really encourage, I don't even really encourage Metamucil. There's just too much stuff in it. I just tell them to get a giant tub of psyllium husk, um, at Trader Joe's or whatever store they go to, um. And we would have you start um with one dose, whatever the bottle says, and then titrate um as needed to get the out uh to get to the goal of the frequency and consistency of the stool that the patient would like. Um, also, there's something called IBguard, uh, peppermint oil, and it helps with bloating and pain. Um, it is actually a, um, proprietary blend of caraway seed oil and peppermint oil, and helps a lot with bloating, distention, um, and some visceral hypersensitivity. The difference between this and peppermint oil or peppermint tea in any other form is it's formulated to release after it leaves the pylorus, I think, so, um, it's not destroyed by gastric acid. Um, also, loperamide or Imodium, uh, for pain and cramping, um. Loperamide can be used long term and can be used preemptively, so patients can use it as a response to having diarrhea and to anticipate diarrhea, so it helps free them up for social events and um allows them to leave the house without being so afraid, helps with urgency as well. If symptoms persist, um, we can also use a low dose tricyclic antidepressant such as desipramine or nortriptyline, um, with help, uh, and these help with stool output, pain, and cramping. Um, I usually don't go above 150 mg, um, of desipramine or nortriptyline, but I would consider, um, getting a baseline for, uh, assessment of the QT interval. Uh, if they're older or if they have, um, other issues, cardiovascular issues, or if they have, um, other medications that could increase the QT interval like ondansetron. Uh, so I have many patients who are on an antie-emetic like Ondansetron and on something like a TCA. Uh, again, you can also use another, um, option for medications would be anti-spasmodics such as dicyclomine or hyoscyamine, um, which can help with pain and cramping and stool output. Um, these are anticholinergics and so there are dose-related side effects such as blurry vision, dry mouth, constipation, urinary retention. I would use them in caution with older patients. Um, uh, in the older men, I worry about urinary, um, uh, retention. Um, but the big things are constipation, um, and, uh, dizziness with, with the older folks. Um, and then you have your bile acid sequestrants. Uh, in primary care, you probably use them a lot for lipid disorders, um, but We in GI use them for um binding bile acids if somebody has diarrhea that, uh, especially if they've had a cholecystectomy. So the gallbladder holds bile um and pumps it out on a um uh On a uh On demand basis when you eat. Now, the liver makes bile, and if you don't have a, a gallbladder to collect it, it just kind of flows and can um pull water into the, into the gut, and you have diarrhea associated with bile acids. The, um, the ones I use are Questran or Welchol, um, and they bind the bile acids and it can give you a little bit better, um, uh, it can solidify the stool a little bit. Um, and then just touching on something called, uh, rifaximin placebo, sorry. Oh, before I go into the rifaximin placebo, I tell my patients that they don't always have to be on all of these medications. Um, I I tell them that behavioral measures um are almost always uh a good thing that they've got to um uh stay with those as much as possible, and then we develop a toolkit so that they are comfortable, uh, and are kind of who they want to be out in the world. Uh, and sometimes fiber is enough, and sometimes we have to do a couple of more things. Things and sometimes I try it for a few months and when the patients feel like they don't wanna do it anymore, they come back and see me and, and we, um, we wean medications. Um, I usually want patients to feel really pretty good about 6 months, um, if they're desirous of weaning medication, I want them to feel really good for about 6 months and then come back and, and, and revisit the plan. Um. Rifaximin or Xifaxan, um, is FDA approved for traveler's diarrhea, uh, and I think, yeah, traveler's diarrhea, but we also use it or have used it, uh, for a long time for dysbiosis. Um, so with colonic dysbiosis, you can have an increase in symptoms, uh, and if we're talking about diarrhea, increased diarrhea, gas, and distention. Um, we like rifaximin because it's safe, it's super well tolerated, and um, it is gut specific, so the dose is 550 mg, um, 3 times a day for 2 weeks. I discourage patients from taking. Like, um Oh my gosh, from taking probiotic supplements, they can eat probiotic foods, but um, I, I have them stay away from probiotic supplements while they're on the rifaximin. Um, I think that's it. And, um, the resources that are super easy for you and quite common, you can have up to-date, uh, Rome Foundation, Monash University, and the American Gastro Association, and of course us over at UCSF. We are, um, happy to field questions and, and, and see your patients, um. Yeah, I think that's it. I think that's it.
