Laura Frado, MD

Thanks for joining in for another New York Gastroenterology Associates webinar tonight, I am excited to moderate an amazing talk with some of our teammates. That’s all about IBS imposter syndrome. What if your IBS is not really IBS?

We’re going to take a deep dove into all the things that we as a digestive team, you know, want to run through and make sure you’re not also suffering from when you get a diagnosis of IBS. So tonight we’re going to start with I’ll do some intros, give you a little housekeeping information, and then we’ll have about 40 minutes of our information and then we’ll have a Q&A session afterwards.

Now, if anyone has any questions during the session, feel free to enter them into the chat. I’ll try to answer as we go along and I’ll collect some good questions for the team to answer at the end of the of the session. If you aren’t able to stay the whole time tonight or you want to share the information later on. This will be recorded and we’ll be posting it on our Web site. So if you can’t tune in the whole time, you’ll be able to catch up later.

I apologize for your children screaming in the background. This is the fun of Zoom calls from home. But they’re okay, I promise. So a few things again. If you have any specific clinical questions, that’s not what we can really get into tonight. So definitely reach out to your doctor or set up an appointment if you’re new to New York, gastro. And we will try to help you out.

Just a little information about me. I’m one of the physicians at New York Gastro. I have been with the practice for about six years and do a lot of IBS, but a lot of other things from IBD to colon cancer screening, things like that. But I’m excited to be joined by this amazing team tonight. Who are the pros on this topic? So let me get into who they are.

So Dr. Yevgenia Pashinsky is one of our fabulous gastroenterologist in the practice. She is board certified gastroenterologist and did most of her training at Mount Sinai Hospital, where she still holds an affiliation there and does teaching of the fellows and educational activities there. She has a lot of interests in IBS and functional GI disorders and again, you know, we’re all general gastroenterologist and take care of all sorts of things.

She is joined tonight by Tamara Freuman. Ah, she is one of our wonderful registered dietitians. She has 12 years of practice experience working in clinical gastroenterology. Her practice specializes in dietary management of digestive diseases and symptoms and basically figuring out what’s going on. She did her undergrad at Duke and did her master’s in clinical nutrition at NYU. You may have heard of her or seen her in affiliation with her great book called The Bloated Belly Whisperer. And we’re very excited for her new book that’s coming out next year, I believe April called Regular. And if you can guess what that means, it’s all about pooping. So we’re all excited to see what’s going on with that.

And last but not least, we have Suzie Finkel. She’s another one of our great GI registered dietitians that we have in the practice, also specializes in the dietary management of digestive symptoms and diseases. These are smart women. Again, their resumes are amazing, has a master of science in nutrition from Columbia, and she also participates in some of our research with the Inflammatory Bowel Disease Group in our practice. And she continues to lecture at Columbia and Precepts, the nutrition interns. And she and Tamara are often participating and tons of evidence based articles and interviews and things all over the country.

So we’re so glad to have you all talking to us tonight. And without further ado, let’s get started. 

Yevgenia Pashinsky, MD

So good evening, everyone. Pardon any technical difficulties? Because we’re kind of working off one PowerPoint between all of us. So any snafus, as you know, are possible. And so tonight’s webinar is kind of a unique thing because we’re not talking about one singular topic. We’re talking about multiple different things that could be resembling something that we all know about.

So the agenda here is to discuss what IBS actually is and how one would diagnose it, how your doctor would go about it, and all the conditions that could look like IBS but are not IBS, and hence don’t respond to the usual treatment for IBS. All the different imposters that we’ll be talking about, as well as how they’re diagnosed and how treatment could be moderated by your guest, urologist and dietician. So we’re going to start with the first imposter. Well, actually, no, but I can start with the first imposter.

Sorry, I jumped ahead. So first we’re going to talk about IBS so we can differentiate from the imposters. So I’ve spent too much time on it because Dr. Frado, our moderator, has done a phenomenal job with a webinar of her own on this topic entirely. You guys are interested, it’s up.

So what IBS is is fundamentally a disorder of. Got interaction and brings up communication. So this means that there’s an abnormal response to various stimuli. For example, a hallmark being visceral hypersensitivity, which means that the stretch of the intestine aligning actually causes a much more kind of robust than expected response of discomfort in a particular individual who would have IBS. There’s multiple different factors that can drive it.

This ranges anything from food sensitivities to genetics to post infectious states and microbiome disruption. And it’s beyond the scope of our talk today. But what we should note is that this is a functional disorder and at least to date is not considered to be an inflammatory disorder to be differentiated from inflammatory bowel disease such as Crohn’s and colitis. And there’s a little asterisk next to that because there’s some data emerging that this may be more of a spectrum and changes may be coming to this talk.

But as of today, this is considered to be a functional disorder. This is also important to note. This is a considered to be a positive clinical diagnosis. This is not a toss away diagnosis. It’s not a diagnosis of exclusion. So what I hear patients say often is IBS or it’s just IBS, or it’s all in my head and it’s not. This is a real clinical diagnosis. It has real criteria, and you don’t need to have every possible condition on the planet ruled out before this diagnosis is established, because there are very clear clinical criteria for this, which is the wrong criteria, which we’ll cover in a minute. But the main things that we tend to rule out ahead of making this diagnosis is things like inflammatory bowel disease and celiac disease are the things that we tend to check for, which are done with relatively simple testing. And after that we will implement the wrong criteria, which we’ll cover momentarily.

This is also a condition that is manageable. It is not currently known to be a curable condition. It seems to be more complex than many other ones. So there are many different ways to improve one’s quality of life and improve ones symptoms. And this obviously involves our amazing dieticians for our right hand in the treatment of irritable bowel as well as multiple medication options over the counter supplemental options. And not to be forgotten, there is a huge role for behavioral therapy.

So this is CBT and gut directed hypnotherapy. Remember, this is a disorder of brain gut interaction. So involving and invoking those modulations is extremely important in this condition. So going on to the criteria and the criteria that we use. So basically everything about IBS is centered around pain that is related to the frequency and consistency, change of one’s bowel movement. So you’ll kind of keeping this in mind will realize that most people who come in or think they have IBS don’t necessarily have IBS.

So the recurrence has to be pretty consistent. So this is an average of at least one day per week in the last three months prior to your evaluation and associated with at least two or more of right a change in movement, frequency or consistency. So I think any of my patients on here recognize the Bristol stool chart really well because they use it a lot, but it’s sort of a way for us to gauge the issue. So basically an example would be I have horrible cramps and diarrhea a couple of times a week or I don’t go for three days and I have horrible crimes with that a couple of days a week. And that would be kind of what we invoke.

So how can IBS present? And obviously, you know, think about multiple forms. There is IBS, predominant diarrhea, which is something that we typically see being kind of a morning fiasco for patients where they’re going, going, going have to go a million times are really uncomfortable and then kind of settle out as a day goes on and have often issues after eating. There is the IBS with constipation. So this is patients who are really not going very much, feel bloated and have discomfort. And then there is the, you know, the ever elusive and hard to treat mixed format where patients could kind of alternate between the two things. And obviously, as we said, abdominal pain is very much related to this.

We hear patients talk about bloating a tremendous amount, even with what would be considered a normal amount of gas or a normal amount of stool present in their colon. Whether we seen on imaging or on our exam, it was actually data to see that our patients with irritable bowel are actually more visibly distended at any given moment, and they’re the common culprit triggers. As with many things in life, stress does not help this at all and is definitely known to drive issues. And then there is some of the usual foods suspects, you know, kind of the super fatty things are very bulky, high fiber foods, large portions for some people, dairy. And of course, you know, the coffee and alcohol triggers, very importantly, nighttime symptoms are exceedingly rare, if not unheard of in traditional irritable bowel.

So if we’re hearing somebody who’s having symptoms in the middle of the night that’s waking them up, that in gastro is considered to be almost an alarm symptom. So no matter what’s happening during the day, the nighttime symptoms should be fairly quiet. You know, a notable exclusion for me in my practice was somebody with clear lactose intolerance who was having milk and cookies before bed every night. And that will do it. But other than that, it really should not be happening. So what if you’re doing everything right? You know, you’re talking to the dietitian. You’re implementing the kind of IBS friendly diet. You’re trying fiber supplements that your doctor recommended. You tried anti spasm medications from your position and you’ve kind of done everything you could, but you’re not getting better. And maybe you’re also having symptoms that are beyond typical gastro things.

Maybe you’re having some skin reactions. Maybe you’re itchy when you react and have gastric problems. Maybe you get dizzy, you get palpitations, maybe there’s some nutritional deficiencies that your doctor has noted or some vitamins are low, and that’s when you have to start thinking about maybe this is not IBS and maybe we should think about some of the imposters. And this is what our amazing dietitians often point out to us when they really cross examine what’s happening.

So now I’ll get to the first imposter and like last time when I call that. So the first imposters SIBO or small intestinal bacterial overgrowth or bacterial overgrowth that comes in many names. We just like to make it four letters to make it easier. So what this is, there’s a lot of information out there and some of it is good information. Some of it is not. But SIBO is essentially an overgrowth. It is not an infection. It is your normal gut flora, whether it’s colonic flora, potentially oral flora for some people that is now setting up shop in your small bowl and it does not belong there. It does not pay rent. There does not have, you know, kind of any any dibs on that property. But it is now setting up shop and it’s a wonderful environment with a lot of fun nutrients coming through that allows for the bacteria to cause a tremendous amount of symptoms. And this would be symptoms that are very akin to IBS, as we’re going to see in a minute.

So there’s multiple reasons why this could develop. There’s tons of medical conditions that underlie it. And this is what Tamara likes to refer to as the canary in the coal mine, where this is likely the consequence of another issue. And this is why it is important to address these other issues and look for why, one, has this happened in the first place. And it is obviously known to happen with multiple conditions such as diabetes, celiac disease, autoimmune gastritis, people with motility disorders, pancreatic dysfunction. The list goes on and on and on. But figuring that out is going to be the thing that can break the cycle of symptoms. It is very much a treatable condition. And at this moment, antibiotics are the only evidence based treatment that can get rid of ones SIBO.

Contrary to a lot of information that’s out there, who knows what will happen later? But this is where we are today. Dietary interventions such as a low-fodmap diet, which many of you familiar with, are very useful. You know, the dietary interventions are very useful in helping symptom management until one can be treated. So it’s kind of a temporary measure and not meant to be a long term one. It is not meant to cure SIBO, so it would just kind of suppress the symptoms that result from it. And stressing again that identification of the cause is the best way to prevent this from becoming a recurrent long term problem. So how do you tell them apart? Right.

Both obviously can cause tons of alteration, alteration in bowel movements. And this doesn’t have to be diarrhea, it could be constipation, it could be a combination. It could present as mixed, sort of mixed SIBO. Obviously, lots of reactions happen with both of these tons of gas and bloating can happen with all of these, but how are they different? So very importantly, the response time that one gets to a particular food that is a trigger food and the response time in a SIBO patient will be technically usually faster than for other issues. So typically in this would be basically half an hour to an hour. Somewhere within that period of time is when we would expect to see some issues. There are texture differentials.

So people with SIBO, really it doesn’t matter. The texture of the food is not that important versus people with irritable bowel do much better with softer, kind of easier to chew and digest textures. Typically, mornings are the best if you’re a single patient because you have not eaten anything that would be triggering you. But they can be the absolute worst for a patient with irritable bowel. And unlike IBS, SIBO may result in one losing weight and having low vitamin B12 levels, which is often a big clue and it tip off for us. 

Suzie Finkel, MS, RD, CDN

So the number one question I probably get asked for my patients that have been diagnosed with SIBO is What can I eat to make this go away? And if you’re a patient of mine, you’ve probably heard that the answer is, quite frankly, nothing not to say don’t eat, but that there’s no one food. That can eradicate SIBO and the food is not going to make the bacteria go away. And this is important because there’s a lot of diets marketed out there. You know, say things on the Internet that will say this is the SIBO diet and, you know, just eat these foods. And that’s how we can read your body of bacteria in the small intestine.

But there’s truly no diet that’s been proven to cure SIBO or prevent its recurrence. But where diet has a role is, you know, as Dr. Pashinsky mentioned, helping to manage SIBO symptoms. If you’re waiting to start medical treatment, we have a variety of dietary strategies to help make you more comfortable.

There’s something called the Low Fodmap Diet, which eliminates a variety of these sort of gas promoting foods, right? Like traditionally gassy foods, beans and cruciferous vegetables and onions and garlic. But there’s a variety of others in this category that are sort of not intuitive, but also can promote gas in the digestive tract. And eliminating or reducing some of these foods can help. A lot of people with SIBO temporarily sometimes will do modifications to sugary carbohydrates.

That can be a trigger for some people, but we may or may not recommend diet changes depending on one. The timeline for treatment, you know, how soon are you starting on antibiotics? Let’s say if you just got a positive diagnosis and the severity of your symptoms?

Our approach is generally to start with the most flexible diet option possible for SIBO management and then partner with your doctor to get it treated as soon as possible. So onto another impostor that we call congenital sucrase isomaltase deficiency, which is a mouthful.

It’s also known as Sucrase isomaltase deficiency, but we tend to just call it CSID for short. So thankful for acronyms because it’s a lot to say. And it was known as a very, very rare condition. But we know to affect about 1% of the US population, which is similar to celiac disease, and we have estimates that it affects up to 10% of people that have been diagnosed with IBS-D. So it does make us wonder whether there are cases that get inappropriately lumped under the IBS umbrella.

I can say that, you know, in our practice many of our providers test for it and we’re seeing it more and more. So what is it?

Sucrose intolerance is a malabsorption of diarrhea pattern that’s caused by undigested sugars due to low levels of the enzyme complex sucrase isomaltase. You can think of this as something kind of similar to lactose intolerance. It’s just a different type of sugar that gets maldigested. Some people are born with it. It can be born with low levels of sucrase, isomaltase, but you can also develop this as a result of an inflammatory condition like untreated celiac disease or active Crohn’s disease or anything else affecting the small bowel.

It’s diagnosed with something called a hydrogen breath test or from a teeny tiny biopsy performed by your doctor during an endoscopy. Sometimes before either of these things happen, we can build the hypothesis. You know, a dietician might look at your diet history and get some clues there that you might have a sucrose intolerance and we can test that out.

So how do we manage it? It’s through a prescription only enzyme called Sacrosidase. It also known as Sucraid. And that would get taken with all sucrose containing foods and drinks. So CSID is your main issue or sucrose intolerance is your main issue. This should make you feel a whole lot better and oftentimes there’s no other intervention needed. But we can also use a low sucrose diet, which I’ll talk about in a minute. If the prescription enzyme is unavailable to a patient and a very small subset of patients may have some issues around starch.

So that’s something we might manipulate in the diet as well. So is it sucrose intolerance or is it IBS? We have both on our radar. When a patient complains of chronic loose stool or diarrhea, that’s generally worse after eating a meal. And this could be a very frequent occurrence or could be more episodic. And between these diarrhea episodes, more of a constipation pattern can also be present. And another common symptom is chronic gas or bloating that occurs after eating, or a patient might observe it between meal times.

So how do we distinguish this IBS mimicker? Sucrose intolerant patients tend to not have any symptom improvement or even worse symptoms on some of the standard dietary treatments for IBS, like a low fodmap diet, which we mentioned. Patients may go on a really restrictive diet, but then their symptoms are still going strong because they continue to eat these high sucrose foods and at the same time, these patients might accidentally get better on something like a low carb diet or a Kido style diet, since it inherently becomes this lower sucrose diet as well.

We’re also looking at the clock, right, the timing of symptoms. Sucrose malabsorption is typically a 2 to 8 hour window after eating something with sucrose, and the symptom severity is often dose dependent. So more sucrose, more diarrhea. Unlike IBS, CSID can have more overnight symptoms since malabsorption from a dinner meal, for example, could hit overnight and wake a patient. So that might be one one sign right there.

CSID will also not respond to anti diarrheal agents like Imodium and stools could be light and color or get reward reported to us. Sometimes it’s burning or acidic, and it’s also a genetic disorder very often. So we’ll ask if the symptoms have been present since childhood, like you may have always had diarrhea or bloating after very sugary foods, for example. But diagnosis is also possible in adulthood, and we see that quite a bit in our practice as well.

So the treatment for sucrose intolerance, as I mentioned, is that prescription only enzyme called Sucraid. That is the main therapy. But you can think of treatment sort of like how we would treat lactose intolerance, right? This is another type of carbohydrate intolerance. And lactose intolerance would be treated with lactose avoidance and maybe supplementing with something like a lactase enzyme, you know, a Lactaid pill before eating some lactose rich meal. But the difference for sucrose intolerance is that sucrose is much more common in food than lactose. It’s kind of everywhere in the diet. And we can only get the enzyme that we need through a prescription. And sometimes it takes time for that approval to go through and all that jazz.

So we may use a low sucrose diet until the patient can get prescribed or as a supplemental tool, you know, when that enzyme is unavailable or if the sucrose intolerance is not severe. The thing about a low sucrose diet, though, is it’s not what it may sound like right off the bat, right. Sucrose is sugar. And I hear people say, you know, oh, I was diagnosed with CSID, so I’m planning to avoid sugar because I think it would be healthy to avoid dessert and candy and soda anyway.

So this sounds like an easy thing for me to do and good for health. But sucrose is naturally occurring in a lot of whole foods, right? You’ll see. Can’t really fully see on this list by just a few, you know, fresh fruits and vegetables. Carrots and onions and beans and beets and melons and oranges and not everything we sort of associate with sugar. And so in addition to many forms of sugar that are added to foods, we also have this diet that now excludes a lot of otherwise healthy foods. So eating out or buying prepared food can be really challenging on this diet. So it’s really important that we have the guidance from a dietitian if this is something that we’re going to try or implement even for a short period of time. So, you know, it’s difficult to hear adhere to on its own. But if it’s feasible for a short time, the the diet can work really well for temporary symptom management for sucrose intolerant patients.

Tamara Duker Freuman, MS, RD, CDN

Okay. So I’m going to pick up with the imposter number three, which is bile acid malabsorption. So let’s start by explaining what are bile acids.

So bile is a digestive fluid that is made by our liver and it’s sent into the small intestine after we eat a meal. And it’s used to help us digest fats. And when we are done with the digestive process, the bile that is left over in the small intestine starts getting broken down into its component parts.

One of those components are called bile acids, and the body is really efficient with these bile acids when we’re done using them and we want to reabsorb them from the small intestine back into the body so the liver can recycle them to make more bile.

There is a subset of people who are really poor recyclers and they don’t reabsorb those bile acids back into the body. So they stay into the gut, they remain in the small intestine, they travel on into the colon. Once these bile acids arrive to the colon, they can be incredibly irritating and cause secretions from the cells lining the colon. And that can lead to a diarrhea called bile acid diarrhea with a very appropriate acronym. BAD bile, acid, diarrhea or malabsorption can also happen as a side effect to common medications, especially metformin, which is used to manage prediabetes, diabetes, polycystic ovary. Syndrome.

So a lot of people use metformin and sometimes that can cause bile acid malabsorption. If you’ve lost part of the end of your ilium, which is part of your small intestine, you might lose some of the surface area required to reabsorb some of these bile acids. Or if you lose your gallbladder, you have your gallbladder removed. In a procedure called a cholecystectomy, you could also develop bile acid diarrhea from that bile acid diarrhea is pretty darn common for something you’ve probably never heard of. And the best estimates we have suggest that up to 25% of people who have been diagnosed with IBS-D may actually have bile acid diarrhea instead.

Or in addition, it affects about 6% of people who do have their gallbladder removed, possibly even more. It’s probably a conservative estimate. The reason you’ve probably never heard of it and we don’t talk about it all that much is because until very, very, very recently, there hasn’t really been an available diagnostic test in the U.S. for doctors to test for bile acid malabsorption. And at least in my career in GI practice, the way that we typically get to a diagnosis of bile acid malabsorption is somebody with an IBS diagnosis tries every single diet, every single medication, all the hypnotherapy, everything, and literally nothing is better.

And then finally we throw up our hands. We’re like, Well, let’s just try a bile acid binding medication, and within three days they’re cured. And so often it has become sort of this like Hail Mary diagnosis. Recently, there have become some diagnostic stool tests that have been validated, and we’re hoping to see that they’re going to be rolled out for clinical use pretty soon. And we hope to be able to catch this condition much earlier in the process.

For people, it is a really treatable condition with a medication or I guess a class of medication called bile acid sequestrants. These are basically medications that bind to these really irritating bile acids so that when they get to the colon, they don’t bother you and cause those irritating secretions. When you get your bile acid meds, you might work with your doctor or your dietitian to kind of play around with how best to dose them to control your symptoms. If you take too much at once, sometimes you can find it constipated. If you don’t take them enough throughout the day to cover all your meals, you might be kind of well controlled in the morning, but then have breakthrough symptoms at night. And so sometimes you might take little doses two or three times a day rather than one big dose a day. You got to play around with it a little bit, but, you know, that’s an art and science kind of thing.

How do we tell bile acid malabsorption apart from IBS? They’re actually really hard to tell apart. They’re both characterized by chronic loose stools and or diarrhea. But and, you know, sometimes gas and bloating urgency is a really common symptom of bile acid diarrhea or I guess bile acid malabsorption, even if the stool is formed. Right. So some people aren’t actually having diarrhea, but they have a ton of urgency. And again, bile acid malabsorption doesn’t respond to diet change, with the exception of if you tried to do a really low carb, high fat diet, you would probably feel a lot worse. So in other words, high fat diets can make it worse, but it’s not like a low fat diet will make you feel 100% good. All better. Sometimes bile acid malabsorption can produce stools that are kind of a sticky, messy, tarry smear, hard to wipe texture, which is super unpleasant for people. And sometimes the stools might be especially foul smelling, not always. 

Yevgenia Pashinsky, MD

Imposter number four. So this is pelvic floor dysfunction P of D pelvic floor disorder nerja and something that used to be very kind of hush hush and not talked about a lot and thankfully is being discussed much more openly and there’s more and kind of people are kind of looking into this and actually caring about this being an issue.

So basically what this means is that one has difficulty coordinating or controlling the muscles of the pelvic floor. Now, the pelvic floor is a sort of complex network of muscles that involves rectal, anal, perineal, vaginal and females genital urinary. It’s your hips, it’s your low abs. All of this is part of your pelvic floor and obviously is involved in not only defecation but also urinary and sexual function. And it is actually quite common both in men and women.

So it’s not a female only problem. It is estimated to be about 50% or more of all patients that present to us with chronic constipation and difficulty and thought to be probably about 70, 75% of patients who have difficulty defecating as part of their presentation. It seems like a very simple concept, right? It’s like, what do you mean? How can I go to the bathroom? Wrong and just, you know, you go.

But there’s apparently many ways, right? So there’s at least four different ways of kind of not doing that exactly as one should in terms of which muscles are being mis coordinated and how and this could be both obviously the functional problems of muscle coordination as well as some structural issues with pelvic prolapse, which is more likely in women, rectus heels, etc.

Treatment for this condition is. Related, most importantly, to physical therapy, because we have to retrain the muscles to work properly and to coordinate stool evacuation properly. So this is pelvic floor physical therapy, which I know sounds very strange. And, you know, the way some patients have described it is, you know, sort of repeat potty training as an adult. And this is both, you know, manual work, biofeedback, etc. and there are some pharmacological options that we could use for some people. Conditions can go along with it. And very importantly, there are definitely dietary interventions that can be used in cake as well.

So how do we tell these two apart? Both irritable bowel with constipation and pelvic floor dysfunction will present with hard stool and infrequent stools as well. Infrequent urge to move your bowels and always feeling incomplete regardless of the movement you had. They both present with a good amount of bloating and gassiness, which tends to progress and get worse throughout the day. But the difference is that those with pelvic floor dysfunction tend to never do quite well.

Even when laxatives are used, even when laxatives are used at high dose, so becomes sort of an all or nothing because you have to overcome the door that is not opening as it should. So what we see often as patients, they all get laxatives are working. You know, I have diarrhea every day and then I’m done, which is not exactly what we’re aiming for either.

Patients with pelvic floor problems tend to strain and have a difficult time even when the stool is normal and soft and there’s often continence problems. And unlike those with irritable bowel or typical gastro disorders or typical constipation, a high fiber diet actually worsens things significantly and people feel more bloated because you’re sort of adding more cars to a traffic jam as I’m borrowing this quote from somebody else. But this ends up what’s happening.

We tend to see a lot of stool build up if we image these patients with something like an x-ray and obviously we get clues from patients having other issues. So this is sexual dysfunction, this is urinary problems as well as ironically TMJ. So tooth grinding, which is correlated a lot with clenching the pelvic muscles as well. 

Suzie Finkel, MS, RD, CDN

So what can we do with our diet for pelvic floor dysfunction? You know, the thing about it is this chronic evacuation issue that tends to get overlooked, as Dr. Pashinsky mentioned. So if you had it, it’s very possible or have it. I should say it’s very possible.

You’ve been struggling with it for years and years. And the answer you might have been told over that time is to eat more fiber, which is a common recommendation for lots of GI conditions, whether or not it’s appropriate or not. But the thing about fiber is, you know, its def place is the toilet, right? If someone said to me recently it’s the ocean. But regardless, the point is that fiber doesn’t live in us so we have to poop it out. And if you have an issue with hearing the rectal muscles, then excreting fiber as you continue to add more and more fiber, you know, can be this uphill battle to feel better. And our patients with disinterred defecation, your type of pelvic floor dysfunction can come to us with a colon full of stool, and they’re exceptionally uncomfortable and frustrated because the fiber is just sort of piling on through the day with literally nowhere to go.

So it’s not uncommon for us to do this kind of fiber make over in someone’s diet and food texture and food volume are really what we’re looking at here. We’re thinking about what’s physically going through your plumbing and if there’s an issue at the very end, we’re trying to avoid that traffic jam with the fiber that could be maybe very coarse, you know, or bulky, generally insoluble fiber can leave you with this mountain of stool that you can’t really evacuate easily if there is an issue with the anal rectal muscles.

So there’s softer fruits and softer vegetables that we can still be, you know, leveraging in one’s diet. Things that have a lower residue can make things more comfortable and easier to pass. So we’re basically looking to see if the volume of fiber in your diet matches your capacity to empty it.

And depending on the nature of your pelvic floor dysfunction, we might use some over-the-counter bulking agents or laxatives to help as well. 

Tamara Duker Freuman, MS, RD, CDN

Okay, so the next IBS imposter is something called histamine intolerance. So histamine is a molecule that is made within our body by certain white blood cells, including mast cells and basophils and histamine is part of the injury repair response.

It’s part of the allergic response histamine, a sort of this molecule that rushes to a site of injury or rushes to that mosquito bite and kind of causes the blood the blood vessels to get a little leaky. So all the white blood cells can kind of get to the site of attack or get to the site of insult and kind of start the healing process. And so histamine is that molecule that allows more fluid to get out of the blood vessels and things start to swell up. I look at the site where histamine is being directed. Right. And that’s why mosquito bites swell up or injuries get a little bit swollen during that process and then the histamine kind of recedes and things go back to normal.

Histamine also has physiological functions in the GI tract, and so some histamine is also part of regular GI maintenance. For example, histamine causes some stomach acid secretion normally and appropriately. And so histamine also does act on the gut and can cause swelling and inflammation within the GI tract when there’s too much of it.

So in someone who has histamine intolerance, what may be going on is when you either when you have too much histamine abounding in the body or you eat foods that naturally have pre-formed histamine in it. For example, fermented foods, cured meats, aged cheeses, leftovers, not so fresh, fresh wine. There’s just some foods that are naturally high in histamine. And then these start to go into the gut whether or not there’s already an elevated amount of histamine in the gut from a body that over produces that. If you don’t have the capacity to break down that histamine fast enough via an enzyme called Deyo, the histamine starts to accumulate in the gut and you start to get these localized symptoms of bloating, cramping, discomfort of sort of histamine overload within the GI tract, because histamine also can cause stomach acid release.

Sometimes when people are having a histamine reaction, they might also feel acid reflux, indigestion. Maybe their chest is tightening a little bit. There are also histamine receptors in other parts of the body. And so if the body is overproducing histamine and not breaking it down fast enough outside the GI tract, we could see reactions happening in the skin itchiness, hives, rashes, swelling in the face. You might have a rapid heart rate. You might kind of get some neurological symptoms. Cloudy thinking, brain fog, headaches. And so people with histamine overload or histamine intolerance could experience GI symptoms as well as non GI symptoms.

Now again, it could be a really simple thing just related to I ate more histamine than I have an enzyme to degrade or could be a more complex disorder where the body is actually overproducing it. These are things like mass cell activation, basophilia or carcinoid tumors, which are neuroendocrine tumors that release histamine regardless of the cause of your histamine overload or your histamine symptoms.

The treatment, at least from a diet perspective, is a lower histamine diet where we teach you about what foods are higher and lower in histamine and kind of steer you towards the lower histamine ones. We might give you some supplements of diet, which is an enzyme that helps degrade histamine in the gut so it doesn’t accumulate. And your doctor may or may not treat you with various types of antihistamine medications or other immune mediating medications if your body is itself just overproducing histamine, I think I kind of mentioned this on the previous slide, so we’ll kind of move on, except to say that we do see in our clinical practice a subset of patients who have SIBO, small intestinal bacterial overgrowth that was described earlier by Dr. Pashinsky, who seem to present with symptoms of histamine intolerance, whether or not it’s related to eating high histamine foods. So they might eat like a high fodmap food and then get all sorts of like, you know, itchiness or bloating or acid reflux or some of these other histamine symptoms.

And then we test for SIBO and find that they have bacterial overgrowth. We treat the SIBO and then the histamine symptoms go away. This hasn’t really been well-studied. We have a hypothesis within our practice that what may be going on here is that because we know that certain of the bacteria implicated in SIBO are prolific histamine producers, it is possible that a subset of people with SIBO are actually just walking around with higher than normal levels of histamine in the gut. Or when you feed those gut bacteria that are overgrowing, they reward you with excess histamine and then you get these sort of histamine overload symptoms.

Telling histamine tolerance apart from IBS isn’t terribly difficult, while the GI symptoms are somewhat similar. Cramping, pain, bloating, urgency. Histamine intolerance often has extra GI symptoms or symptoms outside the GI tract, like those ones I described earlier, whether it’s the skin issues, the fuzzy thinking, the brain fog, swallowing, tightness, things like that, as well as resolution of symptoms with an antihistamine.

So regular IBS symptoms typically don’t respond to like Claritin or Zyrtec or Pepcid. And so the other thing to think about is if you have a histamine intolerance and someone thinks that you have IBS and puts you on a low fodmap diet, you might actually feel a lot better and be possibly worse because some low-fodmap foods are very, very high in histamine, whereas some of the highest fodmap foods that should bother you if you have IBS are actually really low histamine and may be incredibly well tolerated. So if you’re like, oh my safe vegetables are brussel sprouts and cauliflower, and my worst vegetable is spinach. I mean, it might not be IBS. So that’s something that we might use as dietitians to try to differentiate.

A low histamine diet, Internet, not a great source. There’s a lot of conflicting information also because it’s really hard to kind of measure histamine content of foods because it varies based on the sample and its age and its processing. But there’s a couple of naturally high histamine fruits and vegetables. Not too many soy foods and yeast extract can be high in histamine, but really the main source of histamine in the diet are fermented foods, pickled foods and cured foods. A lot of fermented Asian condiments, aged cheeses, cured meats, a charcuterie platter with a glass of red wine would probably knock you out if you had a histamine intolerance.

And so a low histamine diet would really steer you more towards a lots of fresh, low histamine, fruits, vegetables, grains and fresh fresh proteins as meat and animal protein ages leftovers with each passing day in the fridge do develop more and more histamine. So we do a little love hygiene around how to store leftovers in the freezer rather than the fridge that you don’t waste food.

Suzie Finkel, MS, RD, CDN

So our last but not least imposter is Nickel Allergy, which is very specific and interesting. I would assume most people are unfamiliar with it, but if you happen to have it or know about it, I’d love to hear from you. I think we all love to hear from you.

So we refer to this condition as systemic Nickel Allergy Syndrome, or SNAS another acronym for you all tonight. And unlike some other allergies, this can look pretty similar to functional GI symptoms alongside contact dermatitis. It can look like nausea, heartburn, distention, abdominal pain, diarrhea or constipation. Not what you might think of when you think of an allergy to a metal. Right. But there is some early research, you know, now, and it’s nice. And see, I would say that Nickel sensitivity might be higher among IBS patients compared to the general population, and some patients with IBS type symptoms might also experience this inflammatory response to dietary nickel.

One study of IBS patients who are sensitized to nicel experienced significant symptom improvement on a low nickel diet. And in another small study, researchers found that patients with well-controlled celiac disease that still had IBS type symptoms after being on a strict gluten free diet may have been reacting to what they called nickel overload and significantly improved on a low nickel diet as well.

So these are really small studies, but it’s encouraging that we might know more in several years. In the meantime, working with a board certified allergist to get skin patch testing done and or a low nickel diet might be helpful for IBS symptoms that are refractory to the typical interventions. You know, you meet with a gastroenterologist, you’re meeting with a dietitian, you’re trying some things out for what seem like IBS symptoms not responding.

We could look into a low nickel diet based off of, you know, a detailed history alone. nickel Protocol involves not just avoiding naturally high nickel foods, but doing things like limiting canned foods and using non stainless steel cookware and certain boiling or cooking cooking techniques, all of which have been shown to lower the nickel content of food as well.

So how do we tell them apart acid versus IBS? You know what’s common among them is the presence of food triggered symptoms that seem very consistent with functional GI disorders like functional dyspepsia, which can be like nausea and heartburn and classic IBS symptoms, which can look like bloating, abdominal pain and diarrhea or constipation.

How do we distinguish this IBS mimicker? So first we’re going to ask if you have an allergic nickel sensitization already. We might ask if you’ve been to an allergist or have any known issues with metals. Sometimes a patient might be like, Well, yes, I have some jewelry reactions, and then we raise a little red flag there. But we’re otherwise identifying dietary triggers that are different from IBS. Mainly high nickel foods trigger SNAS, and they’re often these IBS safe foods like oatmeal and buckwheat and almond and sesame and raspberries. And then the timing of SNAS reactions can also look different. This can be extremely rapid sometimes, like within minutes after eating. And also sometimes patients with SNAS have other, more systemic symptoms that aren’t really IBS hallmarks.

So dietary treatment for SNAS is a low nickel diet and some supportive nickel reducing eating practices for patient. For many patients, nickel sensitivity is going to be dose dependent. The clinical analogy is like this invisible bucket, which is sort of true for histamine as well, fills up through the day. Once that bucket overflows, a patient will become symptomatic. So a nickel elimination diet with reintroduction can help to determine the tolerance of nickel foods. There’s low, medium, high nickel quantity, and we can use it to to also just simply come. Firm, whether we think SNAS may be present at all.

Nickel avoidance is tricky because it’s in tons of plant foods like grains and beans and chocolate and protein powders and various fruits and vegetables and some very specific proteins like certain shellfish. I feel like I just scared all the chocolate lovers because they get very scared when I bring up anything related to chocolate. But this is why we work with patients to tolerate favorite foods, right? There is ways that we still try to incorporate these things. And so alongside dietary nickel reduction, we recommend some specific metals to cook with and eat out of and some cooking methods that can lower nickel content that I mentioned. You know, we have a trip trick for tap water and lots of tools to help along with some of the elimination process.

So it’s a difficult diet to follow, but if you have snacks, then it can help you feel better pretty rapidly. And we’re here to help make it practical for you. 

Tamara Duker Freuman, MS, RD, CDN

Okay. So I’m the one is going to bring it home. What I’ll say is there are a lot of conditions that look like IBS, that sound like IBS, that quack like IBS, but that are not IBS. And I think really the advantages of a practice like New York Gastro Associates is this really unique, close collaboration between gastroenterologists who have access to some of the more specialized diagnostic testing, as well as in-house dietitians.

We’re really expert in GI that all of us working together as a team can spot and diagnose in IBS Imposter pretty quickly. So if you are someone who has been carrying a diagnosis for many, many years of IBS and just aren’t better, you know, most people with IBS respond reasonably to at least something either to diet or to meds or to behavioral therapies or some combination.

Very, very few people have such bad IBS that literally nothing helps at all. And if you are someone who’s carrying an IBS diagnosis and you have tried a lot of different things and nothing has helped at all, you should not settle for that. You know, there may be something else going on. And you know, these are six of the more common IBS mimickers or is there are other ones that are even more unusual than these, but these are pretty darn common.

You saw some of these these incidence rates that we shared with you. And so don’t give up if you’re not feeling better, don’t give up. You know, we can take another look with a fresh set of eyes at your conditions, at your diet, at your medical history and the medications and what testing has been done, what testing hasn’t been done. And see if we can possibly tease out an IBS impostor that is plaguing you and come up with a new approach for management that maybe you haven’t tried yet. So with that, I’m going to turn it over to Dr. Frado for the Q&A. 

Q&A Section

Laura Frado, MD

Thank you all. That was wonderful. We have some great questions coming in. Again, folks, just remember, specific questions about your detailed symptoms are best answered in an office visit so we can really take a history, know your whole story and give you the best advice we can. Just like on our side, if you’re still struggling with symptoms, that’s what we’re here for. This is very daunting to figure out on your own. We’re giving you a lot of information. We’re just to educate you that these things are out there. But let us help you kind of work work through what’s going on. Okay. So a few people asked, is there a test for IBS? Just baseline, you know, is there anything we can do just to say, boom, do I have IBS or not? And we kind of touched on this, but the main thing is, you know, we want to rule out a few conditions, especially if it’s an IBS or diarrhea type presentation like celiac or inflammation, but otherwise it’s very much just based on your symptoms. And that’s why having a discussion with us where we take a great history can kind of give you that actual diagnosis, which is very relieving to know you actually have something that is causing your symptoms. And there’s things we can do to to work on it. We have a bunch of questions about SIBO. So. Would someone mind kind of filling us in on what the SIBO test entails. 

Yevgenia Pashinsky, MD

So I can jump on this one? So there is kind of various versions of this that we do, but all of them involve a at least a three hour a test that could be done either in one of our offices, or we could send you home with a kit after having one of our staff explain to you exactly how to do it. And it involves you drinking a sugar solution. And the type of sugar solution may differ based on your underlying medical issues and symptoms and our suspicions. And then you collect samples of your exhaled breath. It sounds very daunting, but it’s not that complicated over a three hour period in sort of intervals of about 20 minutes apart. And then, you know, if you’re in the office, you’re done thereafter, and otherwise you drop the sample off to us and we run the test and do an interpretation and then let you know if that is positive. So it’s very noninvasive, it’s very easy, it has no risks and it mainly is just an annoying 3 hours. But you know, if you’re doing it at home, it’s a great idea to reorganize your closet or your kitchen. And if you’re in the office, it’s a good time to catch up on your emails. 

Laura Frado, MD

A few people are asking, you know, if there are any changes that need to be done before. See about testing, specifically about antacids and if those need to be held or not. What would you say about that? 

Yevgenia Pashinsky, MD

We give you guys very detailed directions before SIBO test. So there are certain medications that can interfere. Big things, you know, is not having any antibiotic or probiotic exposure ahead of your test. There’s also issues with major laxative use in a kinetic format or having, let’s say, a colonoscopy done or a bowel cleanse done right beforehand. Antacids are kind of less of an issue. There’s a couple of details that also relate to diet, smoking and exercise, which I know seem like they shouldn’t really matter, but they do. And you’re provided with all of these detailed directions ahead of time with exactly how long you need to be off certain things. But it’s not a very long amount. 

Laura Frado, MD

And a few people asked about treatment for SIBO. It’s very specific based on the results we get from your test. Obviously there are some standard antibiotics that are often used because of their safety profile. But again, the the team will come up with what’s the best regimen for you. Our hope is that you do a round of antibiotics and then get off of them. Some people do have recurrent symptoms, so we will treat them again or with a different round of antibiotics. One patient asked or one attendee asked, What about chronic antibiotics, SIBO? Any thoughts on that? Dr. Pashinsky. 

Yevgenia Pashinsky, MD

So as I mentioned, so obviously we don’t love the idea of chronic antibiotics for anyone, for any real reason. And there are very few medical conditions that truly require chronic antibiotic use. Usually these are major immune deficiencies that require prophylaxis sort of end stage aids. And there’s cirrhosis is another one where chronic antibiotics are used. There are some people who have SIBO that is not sort of has a risk factors are not modifiable. So we know that certain people will keep getting it over and over. So we find the cause and we know that that cause is not something we can change. For example, people have had surgery for their Crohn’s or develop it because they’ve had an Ileocaecal resection and or you know, people with strictures that cannot be modified in those cases. We work with you on an individual basis to come up with the least amount of antibiotic exposure to find a happy medium. But this is an extremely rare scenario and it would not be continuous antibiotics. It will mostly be sort of intermittent ones to control symptoms and recurrences. 

Laura Frado, MD

And I would second that. If you have a if you’re just being kept on antibiotics long term, make sure they’ve done the deep dove to figure out the underlying cause of the thiebaud. Some of it is very treatable. The underlying reason, be it a motility issue or something like that, when you manage that, it’s less likely for the SIBO to refer people over again asking about probiotics in regards to SIBO and IBS type treatments, which we do not recommend, as well as herbal treatments that are out for SIBO. One of the dieticians talk about those treatments. 

Tamara Duker Freuman, MS, RD, CDN

Oh, I’ll talk about the airball. So I want to say it’s 2016. There was a study published in some sort of journal, I don’t think it was a very reputable journal and the title of the study was Herbal Remedies As Effective as Rifaximin and Treating SIBO Well, that certainly sounds like herbal remedies are as effective as an antibiotic in treating SIBO. When you read this actual study, the study showed no such thing. Okay? In this particular study, they took a bunch of people, they diag, they went through a bunch of charts and they kind of diagnosed people with SIBO using a nonstandard criteria. So basically a criteria that we would not consider necessarily diagnostic placebo. And these are the SIBO patients. And then they give them some of the people got a course of antibiotics rifaximin, which was lower than the standard dose that is typically used to treat SIBO. And then a group of people got random herbals. They didn’t all get the same protocol. People just got kind of different random herbals. And then they kind of look to see like, who got better, who didn’t get better. And they said that, you know, the herbal people got as well as the, you know, the antibiotic people. But the results were not statistically significant. So if you actually have studied statistics or you read research, you know, that lack of statistical significance means that the results you saw in the study were not likely to be replicated in larger populations. They were likely to have occurred by chance because the sample size is so low that you couldn’t get a reliable result. So between the fact that the patients in that one study probably didn’t have SIBO or some of them didn’t, they weren’t given a standard kind of typical dose of antibiotics and the results didn’t show any statistical significance. This is not a strong case for herbal antibiotics. And this one study has been the basis of an entire cottage industry of herbal regimens that are making a lot of people selling them incredibly rich and making a lot of our patients incredibly frustrated and out hundreds of dollars, months of their lives wasted on these regimens that don’t actually treat SIBO. And a lot of the herbs that are being marketed as antimicrobials have literally never been tested in human beings and shown to have an anti-microbial effect the most that they’ve ever done a show like on surfaces, like on a table when they put thyme oil on some bacteria on a table, it seems to kind of suppress the bacteria. But that’s really different than showing that it has an antimicrobial effect in the human body with all of the levels that we have going on in there. So it’s a really shady cottage industry that antibiotics, we just don’t recommend it. We wish that they worked. We wish we could tell you that that was an option. We wish we could. We can’t because we follow evidence based practice at NYGA. So that was my rant. I’m coming off of the soapbox now. 

Laura Frado, MD

We all agree with you. And on the same wavelength with probiotics, just there’s not great data that helps these syndromes. There are few very specific conditions that we do use them for. For example, if you’ve had your colon resected and you have a pouch and you’re having symptoms, sometimes we’ll use specific probiotics for that sort of condition. But there aren’t it’s not a generalized recommendation to use probiotics. They may actually make your SIBO worse. And so if someone had asked you all just don’t use probiotics, and the answer is correct, yes, we do not recommend probiotics. 

Yevgenia Pashinsky, MD

And the way I tend to kind of describe it to patients is, you know, if you have some sort of reason that your small bowel is much more hospitable to bacteria proliferating, and that is causing you to be symptomatic, you know, throwing a few billion more of them in there is not like, you know, kind of the good fighting, the evil bacteria. This is just other foreign bacteria that are now being thrown in and maybe they’ll survive. Maybe they won’t. You know, there are some people who just take probiotics, who don’t have SIBO, who don’t have any issues, and they swear that they’re feeling amazing on them. So there’s no harm to someone. I won’t take away things tht work, but there is no the evidence is out there for very few conditions. And see, most definitely not one of them. 

Laura Frado, MD

Yeah. I like to hope that in ten years the way we analyze our microbiome will be better. We’ll be better able to line you up with a probiotic that works for you. But why does why is one probiotic good for everyone? We all have different microbiomes and it’s such a drop in the bucket with how much bacteria actually have in your system. So save your money. 

Yevgenia Pashinsky, MD

And plug four for tomorrow’s webinar on care and feeding of your microbiome, which is also of that kind of dives into all of this in great detail. 

Laura Frado, MD

Ultimately, yes, that funny one hasn’t missed any of our prior webinars. They’re all links to it on our website. Let’s talk briefly. We only have a few minutes left, but let’s talk briefly about a little bit more about histamine intolerance. These people have a lot of questions about that. Is there a specific test for histamine intolerance or is it basically just based on history? 

Yevgenia Pashinsky, MD

So there is there’s a lot of history, but as far as sorry, tomorrow I was like, I dropped it. I’m going to I’m going to I’ll stop on my soapbox. But the things that we tend to check is there is histamine in trip taste levels that you can check. But just because they’re low does not mean or they’re normal does not mean that you can have intolerance. It’s a very kind of big spectrum of different histamine disorders out there. We touched on simple histamine intolerance as opposed to, let’s say, nasal activation or massive psychosis, which is slightly different. And this tends to be people who are, you know, sort of clinically atopic. A lot of times these are people with allergies in general. And a lot of times I think somebody asked about different times of year are life, and some people do have flare ups at certain seasons, so we definitely see a lot more flare ups in the spring and fall, kind of probably related to all the histamine flying around in general that just kind of overloads the system. But those are kind of the main things that we check for at the moment. 

Tamara Duker Freuman, MS, RD, CDN

Yeah. Those are the in the in the alternative medicine world. You know, I’m seeing a little bit of, you know, some doctors or naturopaths are checking blood levels or serum levels of the DAO enzyme and using that to diagnose histamine intolerance. If it’s low, that hasn’t yet been validated. So we don’t know of low blood levels of DAO correlate to low levels of DAO because really, if it’s a histamine intolerance, your DAO levels in the gut would be what would dictate how much histamine you can degrade. So we don’t know yet if low blood levels mean that you would be histamine tolerant. Maybe, you know, in a couple of years from now we can make that correlation and validate that as a marker, and that would be terrific. For now, we just don’t have that. And so the way that we would typically figure it out is, you know, do you respond well to a low histamine diet, plus or minus antihistamines or DAO, And like I said, you know, with a lot of these conditions within like a week or two of the diet, you know, like this isn’t something that’s going to take weeks and months. It’s usually within two weeks you’ll have an answer. 

Laura Frado, MD

A few more questions in regards to, you know, working up for the pelvic floor dysfunction and as well as if you could give just a very brief example of what pelvic floor physical therapy entails. And I know you also, Dr. Pashinsky had a great webinar all about this, so even more deep dove into it there. But if you could just give us a quick synopsis of what goes on there. 

Yevgenia Pashinsky, MD

Yeah. So so if you guys want to hear me and Stacey Levine, who is an amazing PT, you know, kind of yap about this for an hour, you know, feel free to tune in. So the first and most simple kind of test that a GI might do during a visit is actually a rectal exam. It’s as simple as kind of doing a, you know, gloved finger exam where we ask you to do certain maneuvers like squeezing, pushing, breathing. And we kind of get a sense of whether you’re coordinating your muscles correctly. You may think you are and you may not be. The more in-depth tests are an interactive one on which you which is a simple, you know, not the most fun, but a pretty simple balloon test in the office. So it’s a little catheter that’s entered rectally. Once again, this is a ten minute risk free test, and that measures your rectal sensation, your rectal size, as well as all of your muscle coordination by different sensors. And we kind of get an idea of how does one do this wrong in so many different ways? And last but not least, is the MRI different cognitive tests if we’re suspecting a structural issue or a major prolapse problem, this is an MRI exam done by radiology where something similar sort of happens with you pushing in an MRI machine, which would obviously explain in more detail to those who need it. So all very sort of noninvasive, really a little bit strange but noninvasive tests that give us a lot of information. And in physical therapy, you know, initially there’s a lot of talking and a lot of understanding. But this involves breathing techniques. This involves manual work and massage, both in the rectal area as well as the abdominal area. This involves teaching you how to sit position properly, and this can be biofeedback where a device can sort of tell you if you’re coordinating well. So you’re getting kind of in real time response as to whether you coordinated your muscles properly. And people usually see a good amount of progress within, you know, roughly six or eight sessions of beat. I’ve had recently a few people that were actually much better within three or four sessions where their mechanics and their bowel symptoms improved tremendously. So it’s something very worthy to to check out. 

Laura Frado, MD

Very, very helpful. Thank you. Anything else you guys want to just bring up? I mean, one one thing I always like to point out when we’re having talks about this is just red flag symptoms that would make me want to say definitely come see us and talk to your doctor. You know, any blood in the stool, any weight loss, abdominal pain that’s out of the ordinary. A lot of things that we ran through when we did the jump were unsure of a lot of these things, like lab abnormalities and things like that. But even your IBS symptoms that aren’t showing any of these things, you should come see us and we can just kind of help guide you to work through. Maybe it’s one of these impostors that actually has a great, easy treatment and your life will be a lot better. So I think I think we covered some of the big questions I ran through. I don’t want to keep you guys here all night once tonight. But again, reach out to us. We’re here to help. We have a big team besides just the four of us. And we’d love to see you. 

Suzie Finkel, MS, RD, CDN

And I would just add, you know, I think we we provided so much information tonight and definitely it’s intended to make you feel hopeful about any symptoms that you’re having, that there’s other things we can look into. There’s dietary therapies, there’s medical therapies. It’s not to make you feel overwhelmed. I know we have a lot of anxious patients out there that are trying to figure out your symptoms. It’s not to say, oh, my gosh, maybe I have this or maybe I have this and to worry about it, but to think, oh, maybe I have this and maybe I can treat this and feel better, you know, between all of us, there’s so much expertize and we’re definitely willing to work with anyone to say, let’s not accept these really uncomfortable symptoms that are either IBS or they’re mimicking IBS, and let’s figure out what’s going on there. 

Laura Frado, MD

Okay. Well, thank you, everyone. And hope everyone has a great night.