All About Irritable Bowel Syndrome (IBS) with Dr. Christine Lee
All About Irritable Bowel Syndrome (IBS) with Dr. Christine Lee
Scott Steele: Butts & Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.
Welcome to another episode of Butts & Guts. I'm your host Scott Steele, chairman of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Very excited to have Dr. Christine Lee here. Christine is one of our staff gastroenterologist and hepatologist, here at the Cleveland Clinic. Christine, welcome to Butts & Guts.
Christine Lee: Thank you. Thank you for having me.
Scott Steele: We'd like to have all of our guests start out, tell us a little bit about yourself. Where are you from, where did you train? How did it come to the point that you're here at the Cleveland Clinic?
Christine Lee: Well I grew up in a small suburb of Dayton. Did my entire education there from probably K through college. I went to med school at Wright State School of Medicine. Then I joined the Air Force, and I was active duty for 10 years. Finished my active duty commitment at Travis Air Force Base in California. Then from there, came to Cleveland Clinic in 2009 and I've been here ever since.
Scott Steele: Fantastic. Thank you for your service, as somebody else who had a little bit of military time. Today we're going to talk a little bit about irritable bowel syndrome. I can tell from just watching TV, there's all sorts of stuff about irritable bowel syndrome everywhere. Let's start really at the high level. What is irritable bowel syndrome?
Christine Lee: Irritable bowel syndrome is where anatomically and structurally all the parts or the organs is not diseased per se, but how they work together in coordination is a little off. It can be a wide variety of symptoms from people to people. It can just be bloating or change in bowel habits and pain, to all extremes. Where it could not only decrease your quality of life, but actually be very dysfunctional to your productivity and your family life.
Scott Steele: What are the most common types of symptoms that patient could experience, that they may wind up with a diagnosis of irritable bowel syndrome or IBS?
Christine Lee: Most of the people that come see me are due to debilitating pain, or incontrollable bowel movements, extreme urgency, frequency, and just decreasing quality of their life. Where they feel like their bowel habits or their pain rules their life.
Scott Steele: So I find it hard to believe that there's not some listener out there that's at some stage doesn't feel crampy abdominal pain, or sometimes they got a little bit of diarrhea, sometimes they have a little bit of constipation. What's the medical definition of IBS and how is that diagnosed?
Christine Lee: Well, so there is a Rome IV criteria, where you have more than one symptom per week for the last at least three months. Where you have a change in bowel habits, or pain, or sense of incomplete defecation, or difficulty with straining or achieving about movement.
Scott Steele: Could you talk a little bit more about the timeline? You just have to have one of those following conditions?
Christine Lee: Well, because it has such a wide variety of presentation, you could kind of classify it into the constipation type, there's a diarrhea type, there's a mixed type and then there's type where it has to do with a sense of incomplete effication.
Scott Steele: I heard a rumor out there that Rome IV means that all these people got together in Rome, and come up with this definition. Is that true?
Christine Lee: That's actually true.
Scott Steele: That's a good place to basically go, and determine what makes IBS. How is IBS different than IBD?
Christine Lee: IBD stands for inflammatory bowel disease. It's an organic disorder, where it's an autoimmune, and you have structural abnormalities. There's mucosal breakdown, there's ulcerations, there's inflammation that you could undisputedly see, biopsy visible on CT scans or endoscopy. You can take biopsies, and histologically you can have evidence of the pathophysiology that's going on.
For IBS, structurally, everything's intact. There is no mucosal damage. There's no mucosal inflammation. There's no breakdown, to the eye and on histologic evaluations it's normal. That's why it's considered a syndrome. However, it can be just as debilitating, because it's not the structure itself, it's how it works in coordination.
Your bowel is pretty complicated. It's not just its parts by itself. It has to actually be coordinated like a wave in a football field. You see how and when everybody stands up in a coordinated fashion, you see this wonderful wave that goes through. Your motility is about the same thing. It's not about contraction, it's not about frequency, it's not all about the waves; they all have to work together.
The strength of the contraction, the frequency, the motility, the movement, they all have to be in a coordinated fashion. Otherwise, you don't have net movement forward. And that's why IBS stands for irritable bowel syndrome, it's not an inflammatory process. It's not an organic disease per se, but it's a compilation of all the symptoms rolled up in one, that causes unwanted discomfort to the patient.
Scott Steele: We have both healthcare providers, as well as patients, that listened to the podcast. Let's talk a little bit first from the patient aspect of it. From the patient aspect, if I'm listening to this, I'm thinking, "God, that's me. I have the crampy abdominal pain, I have all the things that she mentioned in terms of that Rome IV criteria." First, is there anything that I can do to kind of change that around on my own? Then second, when should I make a determination then, I need to go see a doctor about this?
Christine Lee: The answer to the first, the simple things that someone could do on their own would be regularity. Try to make sure that you have a regular schedule. You eat three meals a day, have a bowel movement first thing in the morning, or try to utilize the circadian rhythm where you have a bowel movement after a meal when it's convenient. Just try to exercise regularly, stress management and eat healthy. Eat lots of fiber, eat healthy foods, low on fats and low on sugars, and do those things first.
If those measures fail to improve symptoms, or you develop what we call classic alarm features like: unexplainable weight loss, bleeding, that's not just once but persistent and progressive. Fatigue, that's not just one day, but persistent and progressive. Things that you've been told. Anemia, nocturnal symptoms, escalation of symptoms that don't come and go, but come and stay, and escalate over time.
Those are what we call classic alarm features, and those you probably should seek medical attention as soon as possible.
Scott Steele: So, now from the healthcare provider's perspective, if I'm a primary care out there and not a specialist, then somebody comes in to me and they have all these things. Before I refer them, what things would you expect that a primary care doc would handle kind of on their level, before they would decide to try to advance them onto a gastroenterologist or another specialist in IBS?
Christine Lee: That's a great question. The best thing is, to actually go down to basics, sit down with a patient and talk to the patient. Find out what's really the major factor in their life. Did they just go through a divorce? Are they going through a major move? Did they just do a mission trip, and they had complete change in their diet?
Oftentimes, a lot of the patients have the answers. You just have to get it from them. A lot of times it takes a little time, but if you can sit down with them and talk with them and get a background history, that's very, very important to their overall getting well.
The second point I'd like to mention is, that not all IBS are the same. There's a huge spectrum, wide variety of symptoms. Some people's IBS may be due to stress related, some may be just hormonally related. There's more serotonin receptors in the gut than in your brain. The other things that are very simple but overlooked, are just medication side effects.
The time and era that we live in right now, so many patients are on so many medications, and some medications at the primary care doctors are not aware of. They take allergy medicines over the counter, that cause constipation drying out of the mucosa; that can cause a lot of side effects.
A lot of people are on blood pressure medicines that can change your motility and cause change in your bowel regularities. Some people have just recently gone to their GP and got an antibiotic for a UTI, and it changes your microbiome or your gut flora. So many triggers are out there for every IBS patient, it's important to sit down, and just kind of go through the alarm features or the risk factors.
Oftentimes we also see people who've had hip replacement or knee replacement, and because they've been on postop analgesics, even if it's 10 days or two weeks, that could greatly alter your bowel regularity. Then, just the fact of decreased physical activity. Because now, they can't bear weight on their hip or their knee, they're not out, they're not up, they're not walking, they're not doing their exercises. All of that plays a huge role.
I've also seen patients for second and third opinions, and for whatever reason they didn't want to give up the information they just had a liposuction, or they had a tummy tuck. All of those things play a huge role in exacerbating or triggering irritable bowel syndrome. The greatest benefit is to just sit down and talk with them, and get their background history.
Scott Steele: You mentioned some really interesting things there. One of the things I'd like to do here is, to kind of break through what's reality and what are some myths. Patients say all the time, "I swear to you, I'm not crazy. I really feel these things. I know all my tests are normal, am I crazy?" Along those lines, what is the connection between the human emotions, and all of the kind of the mental things that we go through? Anxiety, depression, or anxiousness and the gut?
Christine Lee: The neurotransmitters the, serotonin receptor is one example. We know for a fact that there's more serotonin receptors in the intestinal tract then in your brain. These neurotransmitters play a role in communication. There are people who are constipated, but they don't get that signal to their brain. They have no idea that they suffer from chronic constipation, until they present in the ER with a perforated diverticulitis.
That doesn't happen from a brief period of constipation. That's years, decades of constipation that has progressed into diverticular disease, and from diverticular disease to diverticulitis, to perforation or an abscess. Those neurotransmitter plays a huge role. In some people, their neurotransmitter communication is decreased, and they don't get that signal, so they're not aware.
On the other end of the spectrum you have people who have heightened neurotransmitter, so they feel everything. Things that are just normal bowel movement, or stool or gas passing, that you and I wouldn't even blink an eye on to them it's real. It's 10 out of 10 pain, because their neural receptors are super sensitized.
They have more receptors than someone else and it's exponential. It's real pain, but they experience excruciating pain for things that are normally not excruciating pain for the rest of us.
Scott Steele: Walk me through a patient appointment. I come to see you cause I have IBS, I'm either referred directly, or I've seen my primary care doc. I've tried to be regular, I've tried to do all this. What's the typical patient appointment with you? Then is there any other testing or anything, that you would get on them if it hasn't been done?
Christine Lee: A typical appointment is to actually sit down, and again kind of get the background feel. How long has it been going on? How severe is it? How frequently is that occurring? How debilitating is it for that individual? Then go back, and figure out what's already been done. Do they have basic evaluations like CBC? Are they anemic, what's their weight, is the weight stable? Had they had an age appropriate cancer screening, like colon cancer screening and what not?
Then depending on their symptoms, then you tailor what other tests, if at all need to be done beyond that.
Scott Steele: Is there any invasive testing that you'll have to do at the clinic appointment, or following on from that? Is there any radiographs that is a standard workup for IBS? You mentioned that a lot of cases, many of the patients have had some of these things before they reach you, but what are the types of kind of broad range testing that they may get?
Christine Lee: Sure. We try to start with noninvasive tests first. Again like baseline chemistries, a CBC and then age appropriate screening like colonoscopies, and maybe even an upper endoscopy with small bowel biopsies, to make sure that there isn't anything microscopic, like sometimes a Celiac sprue and what not. Beyond that. There are sitz marker studies that are noninvasive, but it gives us an idea of is it a motility issue. How long does it take for something to transfer from your right colon, to mid-colon, to left colon and then exit.
Is it not a transfer issue, but is it more of a pelvic floor dysfunction, where they can't empty completely. Then there's anorectal manometry. There's barium studies that you can do to see if there's a prolapse. Or the manometry also can assess to the sphincter tone and muscle, how strong it is, or how not strong they have.
There's also MRI studies like MR enterography's, that can help for structural, anatomical abnormalities. Capsule endoscopy's can also kind of give us an idea of the small bowel. But again, those are considered a little bit more invasive, and we'd have to kind of go through the risks and benefits with the patients for those.
Scott Steele: Understanding that you said off the bat, that there's a really wide variety of presentations and symptoms that patients may have. You've done a pretty thorough job to make sure it's not medicated or inflammatory infectious, and all that stuff is ruled out. What's your general approach to treatment for these patients?
Christine Lee: What I've learned the last 13 years of doing GI, is that no two IBS patients are the same. I think my biggest pearl would be, don't try to do one size fits all to every person. Some patients may be very heavily stress mediated. Some person may be heavily neurotransmitter mediated. Some may be just medication mediated. Some people may be frequent antibiotic users, and so it's more of a microbiome problem.
Others may be more exercise, and muscle tone, and strengthening and biofeedback is their solution. So I try not to get into one size fits all for everyone, because it won't and you'll have failures. Then without results, you have lack of trust and then more frustration. You really, really need to listen to the patient, evaluate the patient, and tailor the treatment specific to that patient and their needs.
Scott Steele: Kind of running through a few of the more common things, just your initial thoughts on these. Fiber, does fiber have a role in treatment of IBS.
Christine Lee: Fiber definitely has a role, and we clearly don't get enough fiber in our diet. Recommended dose is 25 to 35 grams per day, depending on your sex, and body type, and how much calories you intake. The other thing is, that not all fibers are the same. People can be very meticulous, and count their fibers and think they meet their goal.
But some fibers are just very processed, like the soluble fibers. Extremely processed, they dissolve easily with water and you can drink it with water. It's still good, some fiber is still better than no fiber. But understand that, process fibers doesn't have as much punch as the insoluble fibers. That being said, insoluble fibers take more work. It's harder to get insoluble fiber in your diet. But they do have more of a punch. It's not all about the numbers. Did you get your requirement? It's about the quality of the fibers that you get.
The second part is activity. The muscle strength of your contraction is a huge role. You got to stay fit, try to exercise regularly, try to work on conditioning. Then lifestyle. It's difficult for the executives, because they sit most of the time where they have international travel.
Prolonged sitting, I don't mean two hours, but I mean prolonged sitting, eight to 10 hours, 15 hour flights or 10 hour board meetings. Those prolonged sittings really do aid in decreasing the motility and the muscle strength of your contraction. So, lifestyle modification.
Scott Steele: What about the anti-spasm drugs?
Christine Lee: Anti-spasm medications are great for symptom relief. If your colons are overstretched, or they're in a spasm and you're having a lot of spasm pain that's debilitating than antispasmodic plays a huge role, giving them relief. But remember that's just a symptom relief. It's not getting to the root of the problem.
Scott Steele: I used to see a lot of TV commercials from various pharmaceutical companies that would advertise a pill. Are they around anymore?
Christine Lee: They definitely had a role. There were some that were really good. The serotonin receptor drugs. Unfortunately they're no longer available in the US, so I think they are working on cousin variations of those serotonin receptors that's in line, to be available very soon. They're just cleaning up the side effects, so that it's not only helpful but safe for the community. The other medications, again, it has to tailor to their specific symptoms.
If they're fast transit, then medications that work on slowing down would help. If their trouble is that it's actually slow transit, then those drugs would not be in their best favor.
Scott Steele: I've gone and seen a doctor, how can they then gain control over their IBS type symptoms?
Christine Lee: I think if it's something mild, where you can work on the things that we talked about. Like improving their diet, making sure you have regular exercise, hydrating well and getting the required fiber that you should consume. If that helps, then that's all you need.
If it's beyond that, then you really do need to establish a good rapport with your primary care doctor, or a gastroenterologist or a physician that they have a good relationship with. Understand it's not going to be a onetime visit. It didn't take one day for them to develop to the point where they are. It may take several visits over a long period of time to get improvements.
But it's about getting a good idea as far as what their symptoms are, and then targeting those symptoms, and learning their triggers, and avoiding their triggers; figure out what therapy works best for them.
Scott Steele: Is there any association between IBS and cancer?
Christine Lee: There's not an organic relationship with IBS and cancer, but that being said, a lot of people with IBS may develop depression, and they take other medications which could add into more stress and more comorbidities. It would be more of, not a direct cause and effect, but association.
Scott Steele: Yeah, it's just something that we always want to make sure, that we're doing our average risk and advanced risk colorectal cancer screening. Talking a little bit more about risk factors, is IBS something that affects adults only?
Christine Lee: Well, that's a great question. Oftentimes when I see patients, they will tell me they've had it their whole life. That's the common theme. They can't pinpoint exactly when it started it. It's almost like your hair growing. It starts very slowly and insidiously, to a point where now it impacts their life. They do remember a certain point, but they can't pinpoint the exact time that it started.
But most patients will tell you they've had this their whole life. It involves a wide range of patients from children all the way to adulthood.
Scott Steele: We know that constipation is pretty common in kids. For the parents listening out there, is this just something that they should bring up to the pediatrician, or to their primary care provider? Or is this something that they need to say, "Oh my gosh, my child has a little bit more constipated, or a little bit more crampy, a little bit more bloaty," and get them in right away.
Christine Lee: Oh, get them in. Prevention is the key. Your colon is a muscular organ, that has great stretch, kind of almost like pantyhose. But if you overstretch or over-abuse for too long, it loses elasticity, it loses that recoil. By the time they come to me, it's more about symptom management.
But if you get this early on and establish the diagnosis, and jump on the treatment right away, prevention is key. Before you lose elasticity, you lose that recoil. You lose muscle tone, or the ability to sense that they're constipated. Prevention is huge. So I would highly recommend getting in with your pediatrician and work towards prevention.
Scott Steele: We'd like to end up with some quick takes. Just some things get to know you just a little bit better. First of all, what's your favorite sport or activity?
Christine Lee: My favorite sport's volleyball.
Scott Steele: What's your favorite meal?
Christine Lee: Italian.
Scott Steele: And what is the last book that you read?
Christine Lee: Little Women, with my daughter, Caroline.
Scott Steele: That's fantastic. You grew up in Dayton, but tell us something that you like here, about living in Cleveland.
Christine Lee: It's the community. I grew up in a small suburb, where the community was outstanding; everybody knew everybody. Then I spent the next 10 years in active duty Air Force, and that's an amazing community. It's a tight network where everybody has everybody's back, and everybody knows everyone.
Cleveland has been the same for me. The patient population I serve, is the community that I live then. They're my neighbors, they're my family, they're my friends, they're my friends' family. The community out here is just amazing.
Scott Steele: That's fantastic.
To learn more about IBS, please download our free Bowel Disorders Treatment Guide at clevelandclinic.org/boweldisorders. To make an appointment with a Cleveland Clinic specialist, please call 216.444.7000. That's 216.444.7000. Please also consider subscribing to the Butts & Guts podcasts in iTunes, and leave a rating or review. Christine, thanks so much for being here as a guest on Butts & Guts.
Christine Lee: Thank you for having me.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.