Understanding Neuro-GI and Motility Disorders

Podcast Transcript

Dr. Scott Steele: Butts & Guts, A Cleveland Clinic podcast, exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Dr. Scott Steele, the president of Main Campus submarket, colorectal surgeon here at the Cleveland Clinic in be beautiful Cleveland, Ohio. And today I'm very pleased to have our expert here, Dr. Anthony Lembo, a gastroenterologist in the Department of Gastroenterology, Hepatology, and Nutrition at the Cleveland Clinic. Also a clinical professor of medicine and our director of research in the Digestive Disease Institute. Today we're going to talk a little bit about the Neuro GI and Motility Center, Dr. Lembo, thanks so much for joining us here on Butts & Guts.

Dr. Anthony Lembo: Scott, thank you so much for having me.

Dr. Scott Steele: Super excited to talk about something that we haven't really talked about in the past few years here on Butts & Guts, and that's Neuro GI and Motility Center and kind of all that it revolves around that. But before we jump in there, can you tell us a little bit about your background? Where'd you train, where you're from and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Anthony Lembo: Sure. I'm born and raised in Massachusetts, lived in Newton, Massachusetts where I grew up. Went to school and went to college in Western Massachusetts. So lived most of my life and medical school in Boston at Tufts University. After 23 years, I decided it was time for a change and so went to UCLA for my residency and liked it so much I stayed on for fellowship, stayed on for an advanced year in neurogastroenterology and then stayed on staff for another year. But at that point with some children at hand and grandparents back in the Boston area, my wife also from Boston, we decided to go back.

So I went to the Beth Israel Deaconess, where I was fortunate enough to get a position and had a great career for 25 years. And as you know, I just recently joined last year, the Cleveland Clinic had sort of a mid to late life crisis and decided that I wanted to do something different and was recruited here and decided to make the leap. And so far so good. I've enjoyed, as you always say, beautiful Cleveland.

Dr. Scott Steele: Oh, it's fantastic to have you here and glad that you made that jump. And so today we're going to be talking a little bit about neurogastroenterological or neuro GI, if you will, motility disorders. So really at a high level, can you tell us a little bit about what we're talking about when we reference neuro GI and follow that on with a little bit about what are motility disorders?

Dr. Anthony Lembo: Yeah because neurogastroenterology is a relatively new term and we struggled to come up with terms that we could use that people would understand. So at the most highest level, it really is the study of the interaction between the neurological systems. That's either the enteric nervous system, which we often fondly call the second brain because it's the second most amount of neurons in the body, aside from the brain and the role of the autonomic nervous system, which involves the brain as well as most people don't think of is the spinal cord. That all involves the autonomic nervous. And remember, the autonomic nervous system is a system that's autonomic. We don't have direct control of it. That controls your heart and it controls your gastrointestinal tract and the two interact, so they're not separate. The enteric and the autonomic nervous system and the brain interact with each other and we're learning a lot more about that interaction. So it's the study of those disorders.

Dr. Scott Steele: So can you talk a little bit more, break that down a little bit more in terms of an impact on the GI tract? When I think about it, I think about we got to squeeze from mouth to anus, if you will, as a colorectal surgeon, but are there really brain cells that are in our guts?

Dr. Anthony Lembo: Absolutely. So again, the second brain, the GI tract can function fully on its own from a neurological point of view. It can peristals or contract, it can move, it can have sensations on its own, but it's also connected to the brain. And when we think about neurogastroenterology disorders, we're talking about disorders of motility. The way the bowel contracts, we're also talking about abnormalities in the sensation because remember, if we're feeling pain or spasms or other sensations from the GI tract, it's from the neurons, it's from the sensory neurons. So it could be abnormalities in the sensory neurons. They're all connected up through the spinal cord into the brain where it's processed and your brain has to decide is it something that's just sort of a normal function, ignore it, or do I send it to the cortex so I can make you aware that it's an issue?

Generally, you're only really aware of issues when it's going to cause harm to yourself or if you're hungry, for example, where you have to feed yourself, you're full. Otherwise, most people don't have sensations from the gut, although there's lots of information being processed and sent up. And then in the brain stem, it decides if it's important to go to the cortex for our sensation to be aware of. Abnormalities occur all along the way and it can occur from the spinal cord into the gut all the way up into the brain.

Dr. Scott Steele: So give us a few examples of these motility disorders. And do these disorders affect the full digestive tract or only specific sections?

Dr. Anthony Lembo: Yeah, so when we talk about motility, motility is really part of neurogastroenterology and they do overlap a lot with each other because there's part of it. So you could have almost a pure motility disorder where there's the abnormalities in the way the bowel contracts, but the vast majority of people will have some combination where it's both the way it contracts as well as the sensations. And then there for us is we try to figure out where is the primary abnormality occurring, is it up in the brain stem or in the brain, or is it strictly in the motor neurons in the gut or the muscles of the gut? Because you do need muscles to contract if it is a pure motility disorder.

And then most neurogastroenterology disorders are combinations. So we have disorders like irritable bowel syndrome, which I've listened to your podcast, and I love this podcast by the way, on IBS. And that really is a combination of both. There, there's dismotility, but the primary issue is more sensory because pain is really the driver for most people, but it can vary across the spectrum. It's the clinicians job is to figure out what's driving what and where do you aim your treatment, at what part of this.

Dr. Scott Steele: Okay, so I'm sitting at home listening to this podcast and I'm thinking to myself, I get tummy aches sometimes, I get bloated, sometimes, I'm constipation sometime. What other symptoms are in this and how do you diagnose a routine tummy ache from somebody that might have one of these motility or one of these neuro GI disorders?

Dr. Anthony Lembo: In gastroenterology, we're really fortunate because the vocabulary of the GI tract is really short. There's like six or seven symptoms that people have. It doesn't go beyond that. So people can be bloated, they have pain. The pain could either be crampy it or could be sharp. A couple of different features, dull, but not a lot. It's not like the skin or the fingers where it could be tremendous amount of different sensory symptoms that can come out of it. So really it's just bloating, pain, and then it's either constipation, diarrhea, alternating between them, and the vocabulary is quite short with it. So it can involve any part of the GI tract. You can have dismotility or altered sensations up from the upper esophageal sphincter right down to the anal sphincter. And sometimes it's regionalized. Oftentimes it's diffuse. And again, it depends on the process that's driving this, and that's where we still need more information because there are lots of different causes for these processes.

The way I like to tell people about it is that if you think of, well, what could be a neurogastroenterology problem? Well, if it's chronic inflammation such as inflammatory bowel disease, which is not that common compared to neurogastro disorders, then you'll see lots of inflammation. If it's a cancer or growth, you'll be able to see the cancer or growth. And beyond that, it's usually a neurogastro type issue. So if it's not inflammation or some other anatomical abnormality that's there.

Dr. Scott Steele: So how did these disorders go about getting diagnosed and what type of testing would a patient have to undergo in order to get this diagnosis? Or is it just by history and physical exam?

Dr. Anthony Lembo: So oftentimes it's history and physical exam, and if there is a motility component, which there usually is, then we can do motility tests if needed. So for example, if someone presents with constipation, they have pain and bloating. I mean, I can probably say this is irritable bowel with constipation, I won't need to measure the motility. If there's nausea, fullness, we may measure gastric emptying. So it depends on the presentation, but most of the diagnosis can be made clinically.

Dr. Scott Steele: So before we go into treatment options, let's first say, can these disorders be prevented? Are they acquired? Is it something you gain with time and get, if you will, infected with them, or is it something that patients do or were you with this and it just manifests at a different stage in life?

Dr. Anthony Lembo: Yeah, it can occur at any point in life. Usually the most common times that people get this is in young life. So usually in young adulthood, I should say, usually in the 20s and 30 is probably the peak of this. So you can acquire it and most often do acquire it. There are triggers for it. So we know that early life stress, early life major stressful events can trigger this, can trigger long-term symptoms. Probably the most common cause is post-infectious. So we have these well-documented studies showing that after an gastrointestinal infection, whether it be parasitic, bacterial, viral, or any type of inflammatory condition, whether it be diverticulitis or even inflammatory bowel disease that's now quiescent, any of those things can trigger the nervous system from things we talked about either cause an increase in what we call visceral hypersensitivity. The nervous systems triggered either in the gut or in the brain or spinal cord, and then they can manifest into long-term symptoms.

There are other causes, and I know diet is one we always talk about these days and more and more data showing the mechanism behind how diet can trigger a symptom. The current model includes a process that involves increasing permeability of the gut, oftentimes through an infectious event, but it can be other types of events as well. And then the exposure of the antigen, which in this case would be the food, and then developing that sensitization and long-term, getting symptoms from that. Well-described in the animal model, you can't necessarily prove that in the human model, but there are signs and features that are very consistent with the animal model to suggest that may be part of it in some people.

Dr. Scott Steele: Interesting. So truth or myth, truth or myth, diet changes can often help manage symptoms?

Dr. Anthony Lembo: Truth. So diet is a big factor. We spend most of our time discussing diet, I've just described a mechanism how diet can cause symptoms. There are many other mechanisms. The diet is the primary determinant of your microbiome, and the microbiome has been shown over and over to be contributory in many of these disorders. So it is very, very true.

Dr. Scott Steele: So what are some of the treatment options for motility disorders? And if we go a little bit further than that, are most of these medical or are they surgical?

Dr. Anthony Lembo: Vast majority are medical rarely surgical. So first it starts with lifestyle modifications and these can reduce symptoms and some of them can help any of us reduce symptoms, reducing stress, increasing sleep, exercise, as well as dietary modification. And oftentimes there are different diets. We can't get into the great detail with them, but just the common sense, eating a healthy Mediterranean-type diet that's broad-based so to improve your microbiome is going to be very important for these patients.

So the lifestyle comes first and then it depends on the symptoms and there if it's upper gut, there's different drugs. If it's upper gut, it could be antacids, it could be prokinetic agents. If it's small bowel, sometimes this is associated with bacterial overgrowth from dismotility. So in those cases it can be either diet or probiotics or even antibiotics can be given to patients. And for lower gut, oftentimes these people present with alteration of bowel habits, whether tends towards diarrhea or constipation, or both.

And there we would direct treatments based on their underlying bowel habits. For people where pain is the predominant symptom, there we deviate a bit. So there we would add something like what we call neuromodulators. And these are medications that are directed at the nervous system to reduce the firing at the afferent nerve level and they can reduce pain, also effects on the central as well. So these are drugs that would be like the tricyclic antidepressants or the SNRIs or things like Gabapentin, things like that, that have been shown to improve pain, not specific for the gut, but also for other parts of the body as well.

Dr. Scott Steele: So in previous episodes, we've touched a little bit on the gut-brain connection, and I encourage all of our listeners to go back to some of the interesting past episodes, but it seemed that this may also come into play with some of these motility disorders. So can you share a little bit more about how stress impacts these symptoms and then the role of a behavioral therapist?

Dr. Anthony Lembo: Sure. So stress, which we all experience in our lives has significant effects on the gut in health and as well as disease. And one of the primary models for studying these disorders is for stress, that is as an animal model where they would stress an animal and the animal will poop, and they actually count the number of pellets that occur. In humans the same type of thing occurs, had been shown for decades and decades from the 50s where if you were to stress a human, stress anybody, a normal person, that they would get increased spasms and contractions of the gut as well as increased blood flow to the gut. And again, that's in health. And we know for many people on the stressful events, they'll get urgency, sometimes they get diarrhea associated with it. How many times do you hear about people vomiting before stressful events?

So all that can occur. And these are people that do not have underlying disorders. In a lot of these neurogastro disorders like IBS or gastroparesis, stress that can be even exacerbated. So if you look at IBS, if you put an IBS person under stress, they have even more contractions of their bowel for it. And in the animal model as well as probably the humans too, the mechanism of that has been worked out. It's driven by, as you imagine, by a neurotransmitter and the neurotransmitter in animal model is neurotensin, so among others, but neurotensin's the major driver, you can block it and to describe the animal model, you can block those pellets by giving them a neurotensin blocker. And so there's great progress being made. And of course those are not on the market yet, but those are things that could potentially work in the future.

Dr. Scott Steele: Gosh, it's so interesting to me, especially when we think about the fight or flight type one and having a bowel movement, not having a bowel movement under stress and different interactions between that. Just fascinating. The body is just fascinating. So you mentioned a little bit before about stress, behavior therapists and everything. Can you talk a little bit about the benefit of working with a multidisciplinary team of physicians and caregivers when dealing with these type of disorders?

Dr. Anthony Lembo: Sure. Yeah. And I didn't answer your other question about behavioral therapists. We work very closely with behavioral therapists and that is an important... We talked about the role of stress. That is, it's important people to do that. It's not only stress, there are other factors and things that they do, but stress is a big component of it. So we're a specialized center, so we have a Neurogastroenterology Motility Center with specialists that just see these type of patients. We have behavioral therapists, we have nutritionists that work with us. And so we're very fortunate here at the Cleveland Clinic. That’s not always available, but for really the patients that have severe disease that's refractory, they are probably best served with the multidisciplinary approach to involve both the psychological as well as the nutrition and the drug treatments, the physical part too. So I think that's going to be an important component.

I will say that there are new advances. So digital health is really the rage these days. And for irritable bowel syndrome, which is one of the more common neurogastroenterology disorders we see there are two FDA-approved apps that are available for this and two that are not approved but are available for the public to use, specific for irritable bowel, but they can be used in other disorders. And we're about to start a multi-center trial with Cedars-Sinai looking at the role of virtual reality, which is really just a very aggressive form of behavioral therapy as well as education, diet, where the patient is immersed in this environment for short periods of time and preliminary data suggests that it can be very powerful for people that don't have access to a Cleveland Clinic nearby. This might be a good treatment for them.

Dr. Scott Steele: That's fantastic, and I'm glad that there's some advances on the horizon coming at us. So now it's time for our quick hitters, a chance to get to know our guests a little bit better. So first of all, salt or sweet?

Dr. Anthony Lembo: Sweet.

Dr. Scott Steele: Fantastic. Second of all, what is your first car?

Dr. Anthony Lembo: I know you ask that question to a lot of people. So I was prepared for that. My first real car was a white Integra, so it was a Acura Integra. I bought it in Los Angeles and drove it for seven years there and then brought it back to Boston and kept it for another five, six years after that. It was a stick shift. Loved that car.

Dr. Scott Steele: Fantastic. And so another question I'd like to ask for our listeners out there, what's a must-see place that either you've been to or maybe that you're thinking about going?

Dr. Anthony Lembo: Oh, there are so many of them, Scott. I would say Maui would be my must go-to place. Beautiful place been. There's several times. It's just so hard to get to. I would go every year if I could, but living on the West Coast made it a lot easier. I think it's a beautiful place and must-go.

Dr. Scott Steele: Fantastic. Fantastic. And finally, if you could go back to yourself maybe graduating from medical school and just starting off your internship, what's some advice that you would give to yourself?

Dr. Anthony Lembo: I would encourage myself to enjoy life more. I think we all work too hard and I think I would just tell myself that you don't need to work quite as hard and you should take more time for yourself.

Dr. Scott Steele: Fantastic. So give us a final take-home message to our listeners regarding either neuro GI, or motility disorders in general.

Dr. Anthony Lembo: There's a lot of advancements in the field. I think the thing I hear from people is that it really is an area that very little is known about, but I think that's not true. We're making incredible advances. There are new treatments, there's lots of good things on our horizon for these disorders.

Dr. Scott Steele: That's fantastic. And so to learn more about Neuro GI and Motility Disorders Clinic, or to schedule an appointment for treatment at the Cleveland Clinic, please call 216.444.7000. That's 216.444.7000. You can also visit our website at clevelandclinic.org/digestive. That's clevelandclinic.org/digestive. Tony, thanks so much for joining us on Butts & Guts.

Dr. Anthony Lembo: Thank you, Scott for having me. Appreciate it.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.