Finding Relief from Digestive Issues with Dr Maged Rizk

Podcast Transcript

Nada Youssef: Hi, thank you for joining us. I'm your host, Nada Youssef, and today we have Dr. Maged Rizk, gastroenterologist here at Cleveland Clinic. And today we're taking your questions regarding any digestive issues that you may have, so make sure you leave your questions in the comments sections below and we'll try to get at as much as we can. Before we get started, please remember this is for informational purposes only and not intended to replace your own physician's advice.

Thank you so much for coming in today, Dr. Rizk.

Dr. Maged Rizk: It's a pleasure. Thank you for having me.

Nada Youssef: Sure. Now, when we talk about digestive terms, we have from swallowing issues to GERD to colon, stomach, gut issues, so if you wanna kind of start off by telling our audience what you do here and what kind of patients that you see.

Dr. Maged Rizk: Absolutely. So I've been at the Cleveland Clinic for about 10 years now. I'm a general gastro ... My practice is mostly general gastroenterology, community-based, in one of our family health centers here, although I do a lot of work here on main campus in regards to quality and clinical operation. So I do see a variety of different disease conditions, including the liver, the pancreas, things that involve the esophagus, the colon, as well as the small intestines.

Nada Youssef: Great. Excellent. Well, we'll start off by reading some questions that we actually received from our Facebook Live event page, and we'll start with [Karen 00:01:25]. Karen says, "What's the best way to deal with constipation? And it all start post-menopause."

Dr. Maged Rizk: So very common in the post-menopausal or in the peri-menopausal period for a person to develop constipation. There are hormonal changes that happen within the body that, through complex mechanisms, can exacerbate constipation. In addition, as we get older, we begin ... There's a higher likelihood of us being on medications. There's a higher likelihood for whatever reason, whether it's arthritis or whatnot, that there's an increased risk of decreased activity. And as well, our gut tends to slow down as we get older. There's the impact of gravity. And so it's not surprising that you've developed constipation. You shouldn't be alarmed by it, as long as you've had a screening colonoscopy when you've turned 50 for colon cancer screening.

A lot of it is symptom treatment, so addressing some of those things. So if you can become more active, then become more active. If you can eat between 25 and 50 grams of processed and processed fiver per day, that will help have a more regular bowel movement. In addition, you should look at your medications and see which ones might have medication side effects that they include constipation and try to address that with your primary care physician.

But in addition you can also try to take a stool softener. Once you've tried to address some of those lifestyle issues, then a stool softener such as GoLYTELY ... I'm sorry, MiraLax, polyethylene glycol, in small amounts taken daily or every other day, or titrated to a bowel movement every few days, is reasonable, as well as other different types of laxatives such as Dulcolax or even Senokot for those who are more severe. And lastly, if those over-the-counter stool softeners and laxatives are not effective, then contacting a local gastroenterologist to discuss what other pharmacologics might be helpful to address your constipation.

Nada Youssef: Now, Dr. Rizk, is it healthy to take laxatives on a regular basis?

Dr. Maged Rizk: So, laxatives, when we use the term "laxatives," we're alluding to medications that are stimulants for the bowel, and although there is a concern that a person's colon becomes more dependent on the stimulation effects of the laxative, there is no concrete evidence that there's any longterm effects that can occur due to that. And so for the right patient it's something that can be considered.

Nada Youssef: Great. And then we have [Allison 00:04:12]. "What happens if the side effects of all acid reducing medications are so profound you can't take the medications, yet the acid reflux must be treated?"

Dr. Maged Rizk: So, acid reflux also increases as we get older. Our diaphragms just, due to gravity, begin to sink a little bit, and we have an increased disposition as we get older to develop what he call "hiatal hernia." And the muscle where the esophagus and the stomach meet begins to relax transiently for extended periods of time, which can cause periods of acid reflux. Additionally, medications as well as ... can slow down the gut and predispose a person to developing acid reflux as effluent from the stomach backs up into the esophagus.

If you can't take an acid reflux medication ... So the function of an acid reflux medication typically is to bind to the acid pump in the stomach in some fashion in order to stop the production of acid. That's the primary mechanism that the medication works through, and so oftentimes we make things worse by ingesting acidic things that really the medication wouldn't really address in the first place. And so minimizing acidic foods, such as tomato-based products; such as coffee; such as soda pop or anything that's carbonated, has carbonic in it; such as wines; even, certain times, herbal supplements or herbal additives such as mint can decrease the muscle tone of the muscle is between the stomach and the esophagus and cause issues.

And lastly, there are some complementary medicine ideas behind the use of acid in order to improve ... use acid to treat acid reflux, with the thinking that the reason acid reflux occurs is not because of too much acid but because there's a lack of the acid in terms of relative to the food that a person's eating. And so there is some complementary medicine literature around hydrochloric acid tabs, around apple cider vinegar, around other types of non-pharmaceutical treatments in order to address acid. And although the literature isn't convincing, it's relatively low risk and something that you might want to try.

Nada Youssef: Great. Thank you. Okay, and we're starting to get questions coming in live. I have [Gail 00:06:59]. "What causes gas?"

Dr. Maged Rizk: So gas is essentially caused by either the food itself or by digestion of foods by bacteria within your small intestines, at the tail of your small intestines, or in your colon. And so our gut flora likes certain types of foods. So foods that are high in sugar, foods that are carbohydrate-based, gut flora tend to metabolize a lot more. Legumes have gas-producing ingredients that when bacteria begin to digest it causes a lot of gas byproduct. And so avoiding those types of foods can reduce gas [inaudible 00:07:48].

Nada Youssef: Excellent. And now we have [Jean 00:07:50]. "What causes constant nausea whenever I eat?"

Dr. Maged Rizk: Of all the things that I see in my clinic, nausea is-

Nada Youssef: Isn't one of them?

Dr. Maged Rizk: Well, no, it's one of the most challenging, it's one of the most challenging, because oftentimes it has nothing to do with the gastrointestinal tract. It could be that there's something neurological. It could be that there's something hormonal. It could be that there is something else such as diabetes or a variety of different issues, including medications that a person is taking, that can cause nausea. And so it's important to take a very staged and structured approach when looking at what is causing nausea and starting off by looking at some of those other things after initial evaluation for common gastrointestinal issues have been excluded.

Nada Youssef: Okay, great. And now we have [Nicole 00:08:44]. "I have recently been diagnosed with gastroparesis. I'm on a GJ feeding tube. I'm a young mom who is healthy otherwise. Are there any successful treatments happening at Cleveland Clinic right now?"

Dr. Maged Rizk: So we do have a gastroparesis clinic run conjointly by Dr. Michael Cline and Dr. John Rodriguez, and there are clinical trials that are currently available for patients who meet criteria. Now I don't know in your specific situation whether or not you would be eligible for those clinical trials, but it's something that may be worth looking at by reaching out to our gastroparesis clinic.

Nada Youssef: Okay. Perfect. And jumping on to [Lori 00:09:26]. "Since raw fruits and vegetables irritate IBD, what are other options for eating healthy that won't cause a flare?"

Dr. Maged Rizk: So, the thinking behind eating a high roughage diet causing a flare in inflammatory bowel disease is that the fibrous nature of those foods can scrape against the inflammation of the colon or in the small intestines and cause irritations, or it can be bulking, and so if there's a tight area within the small bowel or in the colon it can cause pain or cause obstruction-like symptoms. And so, depending on the type of inflammatory bowel disease that you have, you don't necessary have to be as stringent to that diet, and a lot of patients who have inflammatory bowel disease can eat some fruits and vegetables in some amount.

Now, if you're a person that can't, then oftentimes boiling them, although it takes the flavor out of it and is less flavorful, it's still a way to denature the fiber in a way that allows it to be digestible and be less rough on the intestinal lining and the colonic lining.

Nada Youssef: Is there an optimal IBD diet?

Dr. Maged Rizk: So, usually the IBD diet, we talk generally as low residue diet, what we call the low residue diet. But having said that, there's no really proscribed amount of fiber that is required or suggested, just because everyone's different and because inflammatory bowel disease can impact a person from the esophagus all the way to the rectum, and so things might not be applicable for everyone.

Nada Youssef: Thank you. And jumping on to [Joan 00:11:18]. "Can you explain Barrett esophagus and any new treatments?"

Dr. Maged Rizk: Yeah. So Barrett's esophagus is a condition in which the lining of the esophagus begins to look like the lining in the small intestines, and that is thought to be due to chronic irritation of acid into the esophagus. And there are different types of Barrett's esophagus. There are Barrett's esophagus with no abnormal cells. There is Barrett's esophagus with mild abnormal cells, major abnormal cells. And then Barrett's esophagus, in rare cases, can lead to esophageal cancer.

Typically, the treatment for Barrett's esophagus, once the diagnosis is made, is really just about screening at a proscribed interval depending on the type of Barrett's esophagus that you have. So in patients who have no abnormal cells the interval is a lot less than a patient who has a lot of abnormal cells, or what we call high-grade dysplasia. And the treatments that are available for each of them begin to vary, so a patient who has significant abnormal cells needs to be screened or surveyed much more frequently but then can have different types of treatments, from mucosal resection, so where we actually go in and just take off the lining of the esophagus that has the Barrett's; to radio frequency ablation, where we burn off through a balloon-type catheter the lining of the esophagus; to cryotherapy, which uses cold liquid in order to freeze the lining of the esophagus to cause it to slough off and regenerate anew without the Barrett's esophagus.

Nada Youssef: Great. Excellent. Very informative. So [Jenny 00:13:07] is jumping onto IBS question. "How do I know if I have IBS?" And I know with IBS you can have symptoms from diarrhea or constipation. It could be from stress or not. So I know it's a very general term, but if you can talk more about that.

Dr. Maged Rizk: Yeah, so irritable bowel syndrome ... First of all, I want to say that it's a very common condition. It's more prevalent in females compared to males, relative to males. We're not exactly sure why that is. Having said that, about 30% of females in the U.S. population have some sort of irritable bowel symptom. One important thing is to first rule out whether or not there's a dietary issue that may be causing your symptoms. You may have, and typically what we say is non-concerning abdominal symptoms, which are either associated with diarrhea, constipation, or mixed.

And so it's important, number one, to know that a lot of times extensive studies are not necessary, especially if you fit the pattern for irritable bowel syndrome. And number two, it's important to exclude some dietary things, so sometimes an elimination diet is helpful, and sometimes it can be a good idea to screen for an allergy to gluten, for example, through a simple blood test. And lastly, the proscribed treatment for irritable bowel syndrome is oftentimes symptom-related and kind of understanding a person's condition, working through that condition, and kind of symptomatically managing it as needed.

Nada Youssef: Now, with intermittent fasting, I've heard many things that it's good for your digestive system. Is that something that would be not treatable but would help someone with irritable bowel syndrome?

Dr. Maged Rizk: So, you know, I don't know if we've seen any studies that have looked at intermittent fasting as a therapy for the treatment of irritable bowel syndrome. I do know that there are certain types of diets that are helpful in identifying whether or not a patient has triggers that are dietary. So for example, the most common is what we call the FODMAP diet. F-O-D-M-A-P diet, and that stands for fructans, oligosaccharides, disaccharide, monosaccharides, and polyols, which are different types of sugars or sugar-based particles that are common in certain types of foods and oftentimes can cause symptoms. And so going on a FODMAP diet can oftentimes be helpful. Obviously if you don't have symptoms when you eat, then there's probably some sort of dietary trigger, but I don't know whether or not prolonged fasting is a therapeutic option.

Nada Youssef: Okay. And I know you talked about apple cider vinegar earlier.

Dr. Maged Rizk: Sure.

Nada Youssef: And I feel like I read a lot about it, and I was wondering does it help with microbiomes? Is that what it's called? Or the mother's ingredient? Can you tell me a little bit more about that and if that is good for your gut?

Dr. Maged Rizk: So, again, the literature out there is not very strong in terms of being able to support it, but the thinking behind it is that because of the acid in the apple cider vinegar as well as the mother, the yeast, that's in the apple cider vinegar that's ... oftentimes it can help with digestion, the acidic part, the acid portion of the apple cider can help with the digestion, and the yeast component of the mother can assist as natural probiotic. [inaudible 00:16:59] there are many people worldwide that swear by it. Like I said, there's not a lot of great studies around it, but it is thought to help in ... It's something that, again, is low risk. It might be something worth trying.

Nada Youssef: Great. Okay, and then I have [Adrian 00:17:17]. "I have a bowel movement maybe once or twice a week, and it has been like that for all of my life. Is that normal or just me? Or am I in trouble for the rest of my life?" And that's kind of, when we asked the question earlier you mentioned age. You mentioned medications. But if someone's, like Adrian, is having this kind of issue all their life, could that be normal?

Dr. Maged Rizk: Adrian, you are normal. That is absolutely okay. Everybody has a different normal, and as long as this has been the way it's always been for you, I wouldn't try to go chasing your tail on this.

Nada Youssef: Okay, good. And we'll jump on to [Lesley 00:17:55]. "What is the best probiotic, in your opinion?"

Dr. Maged Rizk: So, the studies have shown that in certain types of populations of post-infectious conditions and patients with certain types of irritable bowel syndrome that probiotics containing bifidobacterium, lactobacillus, and [inaudible 00:18:19] ... Those two specifically are the ones that I would recommend in terms of making sure that if you're buying a probiotic to kind of look and make sure that you have those in there.

Nada Youssef: Can you find that in any foods that ... Like yogurt? Is yogurt something?

Dr. Maged Rizk: Yeah, so yogurt would have a lot of lactobacillus, and is something that would ... Especially if you can make it at home. It's amazing how if you get the right set-up, one gallon of milk translates to 25 small cups of yogurt, and if done naturally can be very helpful.

Nada Youssef: Perfect. Okay, and [Bonnie 00:19:00]. "I have GERDs. Is it a good idea to take tumeric, since it's a spice?"

Dr. Maged Rizk: Yeah, so there's not a lot of data around tumeric in terms of its ... whether or not it helps GERD. Tumeric, as far as I'm aware of, does not worsen GERD. Having said that, it's ... Every person is different, and like I said, if you're looking for it as a therapy for GERD, it's usually thought of as having a natural anti-inflammatory effect. The mechanism for that is something that I'm not aware of how that works, but it's ... A lot of people have been eating tumeric for many, many years, for millennia, and it's low-risk, so if it's something that you want to try, I think that's something that's reasonable.

Nada Youssef: Great. And now, we always tie in the diet to every disease that we talk about. So I have [Gary 00:19:54]. "What is the one best food overall that you would name as a top digestive food for all?" So in other words, how could you basically prevent digestive discomfort with your diet?

Dr. Maged Rizk: So again, everybody is different, and so I think at some point it's important to consider doing an elimination diet and figuring out what works best for you. Generally, sugar-based or carbohydrate-based foods can cause high amounts of gas, bloating, IBS-like symptoms, but everybody is different. A lot of people have problems with raw fruits, raw vegetables. Sometimes I suggest what I call a full elimination diet, which is a white protein, white rice, and water diet for a duration of two weeks. So white protein would be chicken, lean pork, lean fish, as well as turkey. You can bake it, grill it, broil it, or boil it, but you shouldn't pan fry it, stir fry it, or fry it outright. No breading, no sauces, no gravies, no ketchup, no mustard, no teriyaki sauce, no sauces of any kind. And white rice cooked in chicken broth or water, and water. So no fruits, no vegetables, no breads, no pastas, no coffee, no tea, no dairy ...

Nada Youssef: That sounds kind of strict.

Dr. Maged Rizk: It's a terrible diet. You'll remember to hate me at some point. It's usually for a duration of two weeks, and...

Nada Youssef: Well that's not too bad if it's two weeks.

Dr. Maged Rizk: Right, so ... And it's not ... It's a terrible diet. It's not good for you in the sense that it's not balanced, but it's a diagnostic test that we use. And if after two weeks a person has improvement in their symptoms, especially if you have severe IBS or ... then you can begin to add a food group every two to three days and assess whether or not you're having ... your symptoms are starting to come back. And symptoms can be constitutional. They can ... It could be fatigue. It could be tiredness. It doesn't necessarily have to be gastrointestinal.

Nada Youssef: And again, it depends on the person.

Dr. Maged Rizk: It depends on the person.

Nada Youssef: Okay. And how about ... I've read a lot about ketogenic diet, 'cause I know you're talking about carbs and sugar, so I was thinking [inaudible 00:22:00] the ketogenic diet and you're supposed to eliminate all sugar, most carbs, high fat, high protein. Can you speak to that at all with relation to digestive?

Dr. Maged Rizk: Yeah, so, generally speaking, a ketogenic diet, the major concern with that is sometimes there is the concern of kidney dysfunction that can happen with a ketogenic diet, and the fact of the matter is the body does need a little bit of sugar, the right type of sugar, in order for it to function. Especially your neurological system needs fat, it needs a little bit of sugar, and so do our different blood cells as well. And so I typically, if you want to use that as a short-term stimulant for your metabolism that's something that you could consider, but it's not something I would recommend longterm.

Nada Youssef: Okay. Thank you. Jumping on to [Tiffany 00:23:00]. "What type of treatment plan would you offer for recurring colitis?"

Dr. Maged Rizk: So colitis, I'm not clear in terms of what you're referring in terms of colitis. A lot of people call irritable bowel syndrome "colitis." A lot of people. But there's also ulcerative colitis, and so I'd have to ... I'd need more information in order to be able to adequately answer that question.

Nada Youssef: Okay. Great. And [Oscar 00:23:23]. "There are studies on proton pump inhibitors increasing the risk of gastric cancer. What is your opinion on this?"

Dr. Maged Rizk: I am not aware of any studies that increase the risk of ... of proton pump inhibitors increasing the risk of gastric cancer. I do know ... And that could just be my own negligence or ignorance. I do know that they have been tied to, in large population studies, to Alzheimer's, neurodegenerative disorders, heart conditions, as well as there is the known risks that can occur in terms of causing diarrhea, kidney issues in certain types of patients, but I'm not aware of gastric cancer.

Nada Youssef: Okay. Thank you. And then I have [Brandon 00:24:12]. "I'm taking antibiotics, and one of the side effects I'm having is loose stool." Probiotics?

Dr. Maged Rizk: So, antibiotics, while you're ... If you're having the diarrhea while you're taking the antibiotic, very common, best thing you can kind of do is change the way you eat, increase the amount of fiber that's in your diet. [inaudible 00:24:32] kind of increase a little bit more bulk in there. If you're talking about diarrhea that's occurred since you've taken antibiotics, then you should be tested ... and this is new, then you should be tested for a bacteria that's opportunistic in the gut called clostridium difficile, or C. diff, and if that's not ... if that's negative, then a probiotic. In those cases there have been studies that have shown that there is some benefit to that.

Nada Youssef: Okay. Excellent. And, let's see. [Dedeen 00:25:06]. "I've had [H-plurry 00:25:08] ..." H. pylori? Is it pylori? "... twice. Can I prevent it again?"

Dr. Maged Rizk: The question with H. pylori is whether or not H. pylori causing you to have any clinical issues, and oftentimes H. pylori, especially in the developing world is exceptionally common and people will have it almost their entire life and really be asymptomatic carriers. And so the fact that a person has H. pylori doesn't mean you have to treat the H. pylori. And so there are only a ... There's certain conditions such as gastric cancers, lymphomas, certain populations that are at higher risk where you would consider treating the H. pylori. Patients who have an ulcer disease, documented ulcer disease, where you would treat the H. pylori. Otherwise, I think oftentimes we kind of chase our tails in terms of trying to get rid of it when we don't necessarily have to.

Nada Youssef: Okay, great. And then we have room for one more question. We have [John 00:26:12]. "My CT scan detected fatty liver last month. Can I drink beer or wine during the holidays?"

Dr. Maged Rizk: Yeah. So, a little bit of beer, a little bit of wine shouldn't be an issue. Obviously fat in the liver can be due to drinking a large amount of alcohol over a long period of time, but also can be caused by metabolic issues such as obesity, such as diabetes, and so you'd have to discuss with your doctor which one they believe it to be and whether or not there's any liver enzyme elevations that might suggest inflammation and make the adjustments. So if it's diabetes or a metabolic syndrome such as obesity, then probably weight loss is gonna be your biggest bang for your buck. If it's alcohol consumption, then you may have to change your approach to that as well.

Nada Youssef: So the answer is, "Yes, in moderation."

Dr. Maged Rizk: Yes, in moderation.

Nada Youssef: Great. Okay, well that's all the time we have for today, but before I let you go do you want to tell our audience anything that maybe we haven't touched on?

Dr. Maged Rizk: There's a recent study that came out that suggested that there was an increased risk of colon cancer in younger patients, age 20 to 45, and I know there's been a lot of press about it. The increase was from 3.9 per 100,000 to 4.2 per 100,000, so it's a small increase. We don't know why that is. We don't know whether colon cancer in young folks is a new type of colon cancer. We don't know whether or not it's some of the environmental things and nutritional trends that we're seeing in America that may be contributing to this, such as the obesity crisis and the increased risk of cancer. So a lot of folks asks whether or not they should be screened. This study doesn't really change our approach to screening and surveillance for colon cancer, but it does raise our radar in terms of being able to watch on a population-based way whether or not this is a real trend and what possible etiologies could be.

Nada Youssef: Great. Thank you so much.

Dr. Maged Rizk: Thank you.

Nada Youssef: And make sure you guys tune in Monday. We're gonna be with chef Jim Perko one more time preparing some holiday desserts that you and your family can enjoy this holiday season. And for more health tips and information, make sure you follow us on Facebook, Twitter, Snapchat, and Instagram @ClevelandClinic, just one word, and thank you so much for watching. We'll see you next time.