What’s Bugging Your Gut? Discussing Digestive Issues with Dr. Christine Lee
What’s Bugging Your Gut? Discussing Digestive Issues with Dr. Christine Lee
Nada Youssef: Hi, thank you for joining us. I'm your host Nada Youssef and you're listening to Health Essentials podcast by Cleveland Clinic. Today we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio and we're here with Dr. Christine Lee. Dr. Lee is a gastroenterologist at Cleveland Clinic Digestive Disease and Surgery Institute. Thank you so much for being here today.
Dr. Lee: Thank you for having me.
Nada Youssef: Before we begin I'm going to ask you some questions just off topic, just icebreakers if that's okay. What were you like in high school?
Dr. Lee: I was kind of quiet. I studied a lot but I enjoyed going out. I enjoy talking and spending time with friends and doing sports. I played volleyball.
Nada Youssef: Nice. What high school did you go to?
Dr. Lee: Went to a very small city in Dayton. It's called West Carrollton. Very small, but it was very nice because it was small enough that everybody knew everybody. The chief of police lived down the street. Chief of the fire department lived on the other end of the street. Everybody knew everybody.
Nada Youssef: Sounds like you had fun time. What about the best place to eat in Cleveland, Ohio?
Dr. Lee: Well, best place to eat in Cleveland. Gosh, there's many to choose from. I do eat out a lot. But I guess my favorite place would be either Bonefish Grill or Longhorn.
Nada Youssef: Would you rather live in frigid cold weather or over 100 degree hot weather and why?
Dr. Lee: Well, I guess that changes depending on where in the age spectrum you are. Right now I would pick the frigid temperature because I'm not enjoying the hot flashes.
Nada Youssef: That's honest enough. Thank you. And before we begin, please remember this is for informational purposes only and it's not intended to replace your own physician's advice. Today we're going to talk about constipation, rectal bleeding, hemorrhoids, all kinds of stuff. I kind of want to start first with, I mean, being constipated, it means your bowel movements are tough or happen less often than normal. We all go through that at some point. What is normal?
Dr. Lee: Well, that's a great question because it really varies tremendously from people to people. Your normal may not be your neighbors normal or your friends normal. What's normal is what you yourself are used to for throughout most of your life. Some people may go once a day, some people may go four times a day, some people may go twice a week. But if that's your normal and that's the way it's been for most of your adult life that you can remember, that's your normal.
Nada Youssef: I had no idea. If it was someone since long time ago they've always gone just one time a week that is regulated, that's normal?
Dr. Lee: Well, being healthy and normal sometimes there's a disconnect. But if you are talking about your normal, no one would know your normal better than yourself because that's what your pattern have been for most of your adult life. Now, whether that your normal is healthy or not is a completely different question.
Nada Youssef: Let's talk about some of the symptoms of constipation.
Dr. Lee: Common symptoms of constipation is bloating, excessive gas, whether it's flatulence or burping or what we call eructations. Anything that's you feel abdominal distensions, cramping, discomfort, pain, sometimes it's discomfort with defecation or sometimes it's discomfort with having diarrhea. Symptoms of constipation can also vary from people to people, but in general it's mostly associated with abdominal bloating, gas, maybe even loss of appetite, some nausea if it's really extreme to even eventually leading to weight loss because you just don't have the appetite.
Nada Youssef: We know some food can cause constipation, but other than food or maybe what kind of food, but why does it happen?
Dr. Lee: That's what makes this kind of interesting even though a lot of people suffer from it, there's multitude of reasons or factors that play a role in constipation. Starting with food, the common food that we know is very constipating is high protein foods and right now high protein diets are very popular. We do want to bring that out there, although that might be something that you are working out, but just be aware that it has very constipating effects.
Nada Youssef: Like a ketogenic diet?
Dr. Lee: Absolutely. Anything that has meat, eggs, high proteins, very constipating.
Nada Youssef: If someone's on a keto diet, what do they do to not be constipated?
Dr. Lee: Well, there's a lot of things to help yourself prevent or control the constipation and one would be adding a lot of fibrous foods to your diet, whether that'd be raw carrots or prunes or bran.
Nada Youssef: Raw carrots?
Dr. Lee: Yes.
Nada Youssef: Really? No idea.
Dr. Lee: A lot of fibrous foods that are difficult to digest or break down that hold a lot of water content is very helpful from a diet standpoint. The other things that you can help yourself to treat or prevent constipation is physical activity. The more you're up and moving around will definitely help prevent or treat constipation. The more sit down jobs tend to have a lot more issues in the long run of you're always sitting due to your job or executive positions where you're going to meetings or flying in a constricted place. That can definitely exacerbate or bring on constipation issues.
Nada Youssef: So you need to be moving.
Dr. Lee: You've got to be moving. Yes, and moving. Stand or walk or run or exercise. Any kind of motion will stimulate motility in your abdominal area. So that's always very helpful.
Nada Youssef: With constipation, something like medications. I remember when I had my children, they gave me percocet and that made me very constipated. What do you do about that? Do you take laxatives with that like MiraLAX or how do you kind of balance that out?
Dr. Lee: Right now in this era that we live in a lot of people, there's medicines for everything. Hypertension is very rampant in the United States so most people are on some form of antihypertensive medication. A lot of medications that patients are on unfortunately have unwanted side effects of constipation, whether it's a blood pressure lowering or allergy medication or even people with maybe some anxiety or depression or pain issues. A lot of those medications are very helpful for what they treat but they do come with a price which may cause some constipation.
Nada Youssef: How about dehydration?
Dr. Lee: Dehydration definitely can exacerbate constipation or bring it on and make your constipation worse. But just drinking water alone isn't a very good option to treat or come back constipation 'cause if you drink a lot of water, it can actually go to your kidneys and you urinate it out and therefore sometimes it doesn't actually go to where you need it to go. Hydrating is important.
Preventing dehydration is good, but hydration in a more continuous throughout the day is much more helpful than saying at five o'clock, oh shoot, I didn't drink anything at all so I'm going to jug down a liter of water 'cause then you'll just actually eliminate that through your urinary system and it really won't even get to your GI tract.
Nada Youssef: How about with fiber? People that take me be fiber supplements or whatever drinks are out there. Is it okay to take it daily? Is there such thing as too much fiber?
Dr. Lee: Fiber is very safe. Most of the fibers that we consume from diet maybe are indigestible fibers and the fiber supplements most people go and purchase over the counter like psyllium husk type of fibers. They are unabsorbable nondigestible fibers. They are very healthy and as long as you are taking it with water, it should not cause harm. But that being said, it's important to bring to light constipation is multifactorial. So just adding fiber alone may not be sufficient to help you in your constipation. If your constipation has to do with motility issues then just adding fiber alone won't make anything move.
Nada Youssef: What is the first thing to do if you get constipated?
Dr. Lee: If it's your first bout, then you want to ... Usually when patients see me, I draw on a piece of paper stair steps and explain to them it's escalation of therapy. Being conservative I like to start with the smallest gun to get the job done. Usually the smallest step would be fiber diet wise. They can add prune juice, prunes, bran, carrots, watermelon if it's in season. Any kind of fruits and vegetables that are high in water content and high fibers, that may alone help.
A lot of people do apples and grapefruit and navel oranges in the winter and in the Summer obviously you have a lot more options. You've got bing cherries, you've got peaches, you've got anything that has a skin peel on it is always helpful. You want to keep the fruits and veggies with the peel on will be very helpful. That's my first step. If that alone isn't enough to “put the fire out” then we'd go up a step. The next step would be you purchasing insoluble fibers, whether that's psyllium husk fibers.
The biggest mistake I see in practice is that patients come to me and say, “I've tried that, it didn't work.” A lot of times you want to just sit down and say, how much did you do and how long did you try it? You have to understand fiber, especially the psyllium husk fibers. They are also a small gun, so it may be helpful in a low level constipation. It may or may not be enough for you so you have to adjust the dose. A lot of people are very timid and shy.
They feel like it could do their body harm with the fiber, but understand you can do more harm by not treating the constipation. The complications of untreated or poorly managed constipation leads to diverticulosis or diverticular disease, which can lead to diverticulitis. You can have ischemic colitis, you can have perforation. There's quite a bit of damage that can be done with untreated constipation. You have to outweigh the risks and benefits and clearly the benefits of taking fiber supplement greatly outweigh their risks.
Nada Youssef: If someone's constipated all the time and they're always taking something like MiraLAX or something, is that okay? Cause I mean it sounds like fiber might be safer than MiraLAX.
Dr. Lee: Then that's my third step. It's a step up. If somebody said, hey, I've done the diet. I do as much fiber as my daily activity allows and then I do the metamucil and I don't do the teaspoons. I'm doing the heaping tablespoons and I do it every day and I do it more often than not. In a cupboard it doesn't help, you actually have to take it. If they've done their due diligence and they still are unhappy or have not reached the results that they were looking for, then it's time to step up another level.
The next level would be MiraLAX and that is very easily purchased over the counter. What's important to keep in mind is that it's not digestible and it's not absorbable through any human intestinal wall. Whatever you take by mouth will come out the other end. So you don't have to worry about, oh, is bad from my body? Can I do this long term? Will I get addicted? It's not a narcotic. You really won't get addicted to it because you can't digest it.
Nada Youssef: So your body won't get used to it either?
Dr. Lee: No, because you can't digest it and it actually comes out. Now, you might find some people say, well, it used to work like a charm but now I have to take more or it doesn't work. You do see that, but that's also because over time people age and as we age our metabolism slows down and our motility slows down and our muscles fall down. The amount that worked before, the fire power you needed to get the job done needs to be increased when you have a bigger fire to deal with.
People think, oh, I must be getting addicted. I must be getting dependent. I'm so worried. That's not what it means. It just means we're getting older and so we just need a little bit more firepower. That means you may have to increase the dose, but that is not a worrisome sign at all.
Nada Youssef: Very good to know. What is considered severe or chronic constipation and when to call a doctor?
Dr. Lee: Severe has different meanings. Severe is if you're doubled over and you can't even walk straight or you can't eat, then obviously that's severe. You can't really put a time limit on that and that would be acute severe constipation. Chronic would be if you've had symptoms that repeatedly recur at least once a week for at least three months or that would be classified as chronic.
Nada Youssef: You said once a week for three months, if it's happening once a week for three months?
Dr. Lee: If it's happening at least once a week and it keeps happening at least once a week for at least three months, then you already meet the definition of chronic.
Nada Youssef: If all fails can constipation cause rectal bleeding?
Dr. Lee: Definitely yes. The stool is actually pretty caustic. I think every mother will remember when their kids were in diapers. If for whatever reason you didn't catch it so fast enough and they sat on their soiled diaper, their skin gets really broken down. Just you could imagine if you're holding the same stool in your rectum for hours and days and it can cause quite a bit of irritation and skin breakdown. It can cause fissures, it can cause hemorrhoids. It can cause a lot of rectal bleeding.
Nada Youssef: With rectal bleeding, how can someone know what is causing the rectal bleeding? We're just kind of taking a left turn. When to worry 'cause other causes can, just like you said, the hemorrhoids, it can be fissures. How do we know if it's the constipation?
Dr. Lee: It is pretty difficult because not all diseases have read the textbooks so they don't present in a classic fashion. But if we were to say they presented in classic fashions, the classic alarm symptoms would be things where you have a rectal bleeding but it doesn't happen just once, it happens repeatedly. Because at the end of the day, organic diseases they don't come and go. They come and stay and they just get bigger and bigger and bigger.
Obviously there's some exceptions to the rule, but if diseases were behaving classically out of a textbook then you should see persistence. Meaning red rectal bleeding may be just on the toilet paper, then it's on the sides, then it's on the bowl. But it doesn't really take a holiday or vacation. It doesn't really go away. It just gets worse and worse. That would be the worst alarming symptoms.
If you have an occasional rectal bleeding on a toilet paper once a month or once a year, then that's less worrisome. Now, that doesn't mean that all of those should be ignored. Obviously, in the medical field it's a little bit different. In the judicial system they're all innocent till proven guilty. But in the medical field we have to assume they're all guilty until proven innocent. The reason why is even if it's one person out of a thousand, it's not acceptable to lose that person or miss that person.
Any person that comes through the door I have to think the worst thing. What could this be? Could be cancer, it could be proctitis, it could be all sort of colitis, it could be all sorts of organic disorders. I have to make sure that I have all of those pathologic diseases up front in my mind to make sure and eliminate those one by one just so that we don't miss that one person. Because even if it's one in a thousand that's not acceptable.
Nada Youssef: And you're able to diagnose them to find out if it's constipation or something more serious by asking them about their bathroom habits or just questions?
Dr. Lee: For the most part we can get a good clinical educated guest just by asking the questions. But obviously the definitive finding would be doing a colonoscopy or an examination of something that would give us a visualization to make sure that it's not cancer or a bleeding polyp or AVM. If we can get visual verification that it's just a fissure or a hemorrhoid or an ulcer, that would be a more evidence to prove innocence.
Nada Youssef: And speaking of hemorrhoids, can we talk about what they are and what causes them? I've heard that we all have hemorrhoids all the time, is that true?
Dr. Lee: Absolutely. We all have veins in our rectum, all of us do. It's kind of like having pores on our skin. We all have pores. Sometimes if the pore gets clogged and inflamed and irritated, it swells up and becomes a pimple. Hemorrhoids, I explain to my patients, we all have veins in our rectum. It just when we're constipated or we're ill or for whatever reason they get irritated, inflamed and engorged, and they pop up like blueberries and that's what we call a symptomatic hemorrhoids. But basically hemorrhoids are just engorged inflamed veins.
Nada Youssef: And there's internal and there's external? When we say internal, external, I'm trying to think of if you're talking about external, it is outside the anus I'm guessing?
Dr. Lee: Yes.
Nada Youssef: Do you treat them both the same then?
Dr. Lee: No. Being a GI we do colonoscopies. When we go in to do an anoscopic evaluation, we can clearly see a dentate line and that's where the internal mucosa ends and the external skin begins. Anything above the dentate line or inside the dentate line is called internal hemorrhoids. Those are the ones that most patients have no idea that they have. They're like, listen, I know my body, I don't have hemorrhoids 'cause it's not there.
Well, you can't feel internal hemorrhoids unless you stick your entire finger up there and kind of swish it around because you can't see them. You can't feel them when you wipe and you don't generally feel them because the internal pain receptors are very different than your skin. The external hemorrhoids are what most patients are very much aware of 'cause they can feel it when they wipe, they bleed easily every time they wipe 'cause they're irritating it and they tend to be much more painful. Most external hemorrhoids are not unknown to the patient, but internal hemorrhoids could be completely unknown to the patient.
Nada Youssef: With the internal hemorrhoids, how do you diagnose that? Is there then a testing that you'd have to do with the doctor's office?
Dr. Lee: That's right. There's an anoscope you can do in the doctor's office without any anesthesia. But from a Gi standpoint, we generally diagnose that when we do our colonoscopies are sigmoidoscopies.
Nada Youssef: Now, is there any way to treat hemorrhoids at home?
Dr. Lee: Number one would be prevention. Kind of like back to my back to my analogy of acne. Don't put your dirty hands all over your face, make sure you wash. Back to the hemorrhoids, you want to avoid being constipated. You want to avoid prolonged sitting, you want to avoid a poor perfusion. You want to exercise, you want to weight loss if you're overweight. Try not to sit for 8, 10 hours a day and try to avoid constipation by adding fiber and improving your defecation.
Nada Youssef: How do I go and have my bowel movement if I have hemorrhoids and it hurts?
Dr. Lee: That's why the prevention is key. But once you have the hemorrhoids, you need to recognize whether you realize it or not, you do suffer from constipation because you wouldn't have had the hemorrhoids in the first place. You want to add the fiber, add MiraLAX if you need to, you want to soften your stools and the most important thing is you can't push so you can't try that hard.
I always tell my patients, when you sit and you try to have a bowel movement, it doesn't happen the first five to seven minutes, you have to abort. Get up, walk around, drink a warm cup of coffee, try again. But just sitting there longer just to get the job done actually causes more damage because you're pushing, you're going to pop another hemorrhoid or you're going to cause a rectal prolapse. You don't want to over push.
Nada Youssef: That's good that you said that because sometimes when my kids they're like my stomach hurts and they're sitting on a toilet and they can't push for any reason. They're sitting there trying to push, I get worried that they could end up with a hemorrhoid or something like that.
Dr. Lee: Or fissure, they can actually tear.
Nada Youssef: Let's talk about that. Anal fissures, how is it different than hemorrhoids and how do I know what it is?
Dr. Lee: The hemorrhoids are all vascular related so they're veins. Fissure, I always tell patients you have two sets of lips, you got one set here once entered the other end. And just like lips, they get chapped, they get dried. Certain time of the year where it's really cold and everybody has the heat on and everyone's taking hot showers, they tend to dry out more. And then depending on your daily hygiene habits, some people over aggressively wipe because they want to be extra clean and that just really just rubs all your natural oils and it really dries your skin out.
Then you're more prone to having fissures. Fissures are like having paper cuts in your lips. They're extremely painful. They're never unknown to the patient. They'll be the first to tell you. They'll generally describe when they have a bowel movement, they feel like they're pooping glass. It's just like paper cuts. They're very small but they're mighty. They hurt.
Nada Youssef: So when you wipe, wipe gently.
Dr. Lee: You got to wipe gently and the French do it well. They have the bidet. If you are one of those that are over wipers, you're really better off after a defecation. You just hop in the shower and just rinse things off because you're not over aggressively wiping with a paper product. The other thing is the hygiene products, you want to make sure they're not scented or colored because anything that smells nice has perfume and anything that has perfume is alcohol base which will dry you out even more.
Nada Youssef: Is there anything else it can cause? Anal fissures?
Dr. Lee: Majority of fissures are due to mechanical traumas, they're wiping too hard or they're nail digging or they were so constipated, they were trying to pass large stools to when it ripped. But there are organic diseases that cause fissures. The first one that comes to mind would be autoimmune disorders like inflammatory bowel disease, specifically called Crohn's disease.
Now that really has nothing to do with anything that I just said, it has to do with your immune system attacking your mucosal lining and your mucosa breaks down and you get fissures from that standpoint. That's not because they're overly wiping in any way, that's an organic disorder that really does need to be identified and that can be treated.
Nada Youssef: I feel like I've been saying it wrong, is it fissures? So to heal from them, is that just kind of like hemorrhoids? Just leave them alone, clean them and just leave him alone.
Dr. Lee: Fissures you kind of have to figure out how you got them. If it's because you are over wiper 'cause you have a little bit of OCD, then it's just more of a behavioral issue. If it's because you just need to put a little bit of vaseline or lou, that's the way to go. If it's because you're passing large stools, then you want to treat that by adding prunes or metamucil or MiraLAX. If you're getting the fissures from Crohn's disease, then the modality would be treat the Crohn's which is an immune modulating agent. Once you get the Crohn's in remission, those fishers will heal and go away.
Nada Youssef: Well, is there anything else that we have not talked about that you would like to talk about when it comes to constipation or hemorrhoids or what to tell people that are watching or listening and how to prevent it from happening?
Dr. Lee: Constipation is very rampant. It happens to just about all of us. It's not if, it's just matter of when and it happens earlier depending on your genetics and your body habitus and your lifestyle. But eventually it gets to most of us. You want to promote motility or mobility. You want to get up and move, exercise whenever you can, eat fibrous foods. Know that it's going to happen. The hardest people to treat are the ones in denial.
They've been in the ER with diverticulitis and they had colonoscopies that showed diverticulosis and they have hemorrhoids, but they feel that they're not constipated or they don't get that signal so they're completely oblivious to the fact that they're constipated. It just happens. Proactive prevention is the biggest thing that you could do for yourself, but if it does come on, try to recognize that and then treat that right away with all the things that we talked about with.
Nada Youssef: Okay. Doctor Lee before I let you go, what is diverticulitis 'cause I know you've mentioned that a few times and could happen from constipation. I kind of want to talk about what that is first.
Dr. Lee: Sure. I try to explain to my patients your colon's like a highway. If you think of your colon as a highway, diverticulosis with an O is the potholes that you get from wear and tear. If your GI doctor after colonoscopy or your primary doctor after getting a CT says you have diverticulosis, that means you have chronic constipation whether you knew it or not.
Again, if I took your colon out, put it on a table and filleted it open and say, hey, this is a highway, diverticulosis with an O would be the potholes. Diverticulitis with an I, one letter change makes a whole of a lot of difference. Diverticulitis with an I means that pothole or that pouching got impacted with stool and now it's infected and it's trying to burst. Two different things. Diverticulosis with an O means you've got potholes in your colon.
Diverticulitis with an I means that potholes in trouble, it's either infected, filled with pus, and there's a concern that it might rupture or perforate. Usually diverticulitis majority of it is diagnosed in the emergency room because they present with severe abdominal pain, maybe nausea, maybe vomiting, fevers, pain like you've never experienced before.
Nada Youssef: In the abdominal area?
Dr. Lee: Yes, and most patients intuitively will end up in the ER saying, hey, something's not right and they'll generally diagnose that through a CAT scan.
Nada Youssef: That CAT scan, it's not like a colonoscopy that you would need to get for diagnosis?
Dr. Lee: Diverticulitis is actually a contraindication to do and that's because you don't want to instrument that person and blow it up with air because you're already at risk for perforation. And also there's a risk of infection because it's filled with pus. If you suspect diverticulitis, the diagnostic test of choice would be with a CT scan and not to be instrumented.
Nada Youssef: If you are thinking that you may have diverticulitis or diverticulosis, it's basically stomach pain, nausea. Is it Kinda like the same symptoms for both or there's different stool formation?
Dr. Lee: Yes. A lot of diverticulosis are what we call not symptomatic. They may not even be aware of it. It's just having the potholes. It's only when it gets infected generally that goes without being noticed. They will know it's sharp, severe abdominal pain like they've never had. Patients are very much aware that something is seriously wrong and they just know to go to the ER and they get a CAT scan.
Nada Youssef: It can happen from anything else besides constipation or is that the only thing that can cause it?
Dr. Lee: Yeah, you can't get diverticulitis without diverticulosis first. You generally can't get diverticulosis without the constipation.
Nada Youssef: And what is the treatment for those two?
Dr. Lee: The treatment for diverticulitis, if it's severe, they will hospitalize you to make sure you don't perforate and you get IV antibiotics. If it's mild or moderate, it can be treated with just oral antibiotics and they get sent home. And if it's really mild, you can actually get by without any antibiotics and they just give you something to clean out your colon to treat your constipation, go lightly or a laxative.
Nada Youssef: Now, I've heard someone that mentioned they had diverticulitis and they had mucus in the stool. Is that a symptom?
Dr. Lee: Mucus gets a little bit of a bad rap. What happens is your colon mucosa is the inner lining skin and we all produce mucus. Some people genetically produce more mucus than others, but mucus in itself is not pathologic. Pus is very pathologic, but mucus is actually your body's way of trying to protect itself. If you have a piece of stool that's stuck on a wall and it's having a hard time getting off, your mucosa produces mucus, makes it slimy and slippery then it falls off and it goes. Actually mucus is your friend. You want it to be there because it's trying to help you. Otherwise people would be having-
Nada Youssef: Really hard stools.
Dr. Lee: Exactly right and you may not have to be blocked but part of the stool is stuck on a wall and it can cause quite a bit of irritation and skin breakdown if that didn't happen. But because we have pores in our mucosa, it can produce mucus just like anywhere else, like in our nose, or back of our throat and that mucus actually can be helpful.
Nada Youssef: If pus is out with the tool, doesn't it kind of look the same as mucus? I mean, that's kind of what I'm imagining or is it different color or does look the same?
Dr. Lee: It can look pretty similar, that's what makes it a little bit trickier. But the clinical setting would be very different. Generally mucus you'll have constipation symptoms, but pus, you're pretty sick. You're going to have fevers and you have a white count. You're just not going to be feeling well. I don't mean mildly, it will be pretty drastic.
Nada Youssef: All right, well thanks for stretching that question for me a little bit, just had to get into that before we go and thank you so much for the time.
Dr. Lee: That's a very common question between the diverticulitis and diverticulosis, everybody gets that a little confused but they're pretty distinctly different.
Nada Youssef: Thank you so much for your time today.
Dr. Lee: Of course, it's my pleasure.
Nada Youssef: It's been a pleasure, thank you. And for more information on Cleveland Clinic Digestive Disease and Surgery Institute, visit clevelandclinic.org/digestive and to schedule an appointment with the Cleveland Clinic Digestive specialist, please call (216) 444-7000 and thanks again for listening to us today. To listen to more of our podcast specials with our Cleveland Clinic experts, please make sure you go to clevelandclinic.org/hepodcast or you can subscribe on iTunes. And for more health tips and information, make sure you're following us on Facebook, Twitter, Instagram, and Snapchat @clevelandclinic Just one word. Thank you, we'll see you again next time.
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