Speaker 1: Hello everyone, and welcome to Talk Nerdy. Today's Monday, May fourth,
twenty twenty six, and I'm the host of the show,
Doctor Kara Santa Maria, And as always, before we dive
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Speaker 2: But for those of you who.
Speaker 1: Are in a position and who who are very you know,
selflessly and kindly, you know, patrons of the art, I'm
just one of the arts, the sciences, the arts and
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special thank you, I want to shout out the top
patrons this week. They include Chuck Blell, David J. E. Smith,
Daniel Lang, Mary Neva, Will Defraye, David Compton, Brian Holden Gabo,
jay Ulrica, Hagman, Pasqually, Jelati, Rika Maharaj, and Joe Wilkinson.
All Right, this week I had the opportunity to speak
with doctor Tricia pas Rica. She's an assistant professor of
medicine at Harvard Medical School and she's the Ask a
Doctor columnist for The Washington Post and currently she serves
as director of the Institute for Gut Brain Research at
Beth Israel Deaconess Medical Center. She has a new book out.
I think you guys are gonna love this one. It's
called You've Been Pooping All Wrong, how to Make Your
Bowel move Movements a Joy. It was just in time
for me prior to my endoscopy and colonoscopy, So yeah,
we're gonna go there without any further ado.
Speaker 2: Here she is doctor Tricia Pasricha. Well, Tricia, thank you
so much for joining me today.
Speaker 3: Thanks for having me on. Glad to be here.
Speaker 1: Yeah, I'm excited to talk about your new book, You've
Been Pooping All Wrong, how to Make Your Bowel Movements
a Joy. And it's funny because I often do you
know where in the bookstore they are shelving your book?
Speaker 2: Is it under medicine. Is it under It's not self help,
is it.
Speaker 4: I've seen it everywhere. It is a little bit of everything.
It is a little self help, it's a little science,
it's a little hardcore medicine. So I've seen it tucked
away in a corner in the back. I've seen it
at the shelves in the very front. I've seen it
in medicine. I've seen it in advice. Depends on the
whim of the bookseller.
Speaker 1: Yes, yeah, So I tend to like as a show
that started out She's like what fifteen years ago, as
a science show, and it was very heavy like physics
and chemistry and biology, and then evolved over the course
of you know, my own interests and my own academic
journey into a show that focuses a lot more on
probably social sciences and social justice and things like that.
One of the things that I tend not to do,
because I myself am a psychologist, is I tend not
to have like.
Speaker 2: Self help authors on the show.
Speaker 1: There's a whole industry, right, you know, news you can
use and very often touted by people without credentials and
and with you know, the quick fix that they're trying
to sell but that is not what this book is.
Even though the subheading is how to make your bowel
movements and joy, this book is is really a book coming,
you know, direct to you from an assistant professor of
medicine at Horror. Also, you do have a lot of
public kind of health and science communication chops because you
do the Ask a Doctor column for the Washington Post.
So oh, and of course you are the director of
the Institute for Gut Brain Research at Beth Israel. So
I think you've got all bases covered here. Clinical medicine,
so the practice side, the teaching, the research side, but
also communicating to a broader audience.
Speaker 4: Yeah, I'm exactly with you. I tend to run in
the opposite direction when someone tells me that they have
a quick fix for almost anything, and I probably have
like maybe just a handful of those in like the
entire topic of gut health. But this book does, you know,
I think a lot of different things. There's a big
section that is just about the gut brain connection. That's
what I study, that's what my lab focuses on. And
then there are practical tools and tips that can't help
you and can help actually anyone whos struggling with their
bowel habits. So it's a little bit of a little
bit of everything. I think everyone poop, so there is
something in there for everyone to learn.
Speaker 1: Yeah, yeah, I think so too. I think so even
if they have alternate ways of pooping.
Speaker 2: I do. I work in a hospital as well, and
I see a lot of people who.
Speaker 1: Have ostomes and and other you know, options that they've
had to have due to surgeries or genetic issues, but
of course they're still a poop. And so, you know,
I notice that in a lot of kind of wellness pseudoscience,
the gut brain has talked about a lot, like you
hear a lot about sort of kind of like made
up or not very evidenced based diagnoses like leaky gut syndrome.
Speaker 2: I hear a lot of my friends.
Speaker 1: I live out here in La right, so I hear
a lot of people talking about how they need to
you know, they have a fungal overload or they need
to kelate. The animal is like, oh god, oh god,
this rabbit hole is so scary. And so what a winfield?
You work in an academic and clinical area that has
been like your language has been really co opted by
Huckster's by Charlatans by pseudoscientists to try and make a
buck in the alternative wellness industry, hasn't it?
Speaker 4: Yeah, I know you've hit the thing on the nail.
Gut health is really like hashtag gut health has really
taken on a life of its own, and I see
and I understand why that has happened. I mean, gut
health problems, broadly speaking, affect a huge portion of our population.
And a big problem that I encounter as someone who
specializes in gut brain connection is that we don't do
a good job I think of explaining what is wrong
in a lot of these disorders, like, for example, irritable
bowstndrom is one of the most common disorders that I
see every day in our clinic. It effects about fifteen
percent of the population. But when I meet patients for
the first time, a lot of them will have been told, oh,
IBS means nobody knows.
Speaker 2: What's going on, exclusion.
Speaker 4: Exactly, and there's no treatment for it. We have no
idea what it is. So where do they turn?
Speaker 3: Online?
Speaker 4: And online they've actually done this study. They have looked
at how IBS is talked about on TikTok. And of course,
the majority of viral videos do not come from healthcare providers.
Speaker 3: They come from.
Speaker 4: Patients or patients influencers who are being supported by a
supplement company and who are saying, hey, by the way,
this supplement really worked for me. And when you hear
somebody really confidently telling you, one, here's exactly what your
problem is. Maybe it's leaky gut, you know, like, maybe
it's whatever it is, Like I know what this is,
and now here I have a solution and I'm telling
you it worked great for me.
Speaker 3: I mean, how enticing is that?
Speaker 4: And and for me, it's just a communication gap. Because
we know what the molecular and cellular abnormalities are in IBS.
Somehow that's up making its way to the patients. And
we also have randomized control trials and fantastic treatments for IBS. Again,
those treatments are not the ones at all that are
being talked about online and so and IBS is just
one of so many examples of gut health issues that
there's this multi billion dollar industry that is praying on
people's desperation and profiting from it. And it's it's something
that I think about every single day in my work.
Speaker 1: Yeah, so you have both an MD and an MPH.
Tell me a little bit about you know, what you
studied in school before you went to medical school, and
what you specialized in through your medical training.
Speaker 3: Yeah.
Speaker 4: I So there was probably never a time in my
life when I didn't want to be a gastroentrologist, which
I know sounds really wacky, but most people that sounds
really bizarre. But it won't sound bizarre if you know
that my dad was also a gastrotrologist, and he was
a researcher. So when I even before before I went
to med school, he was studying the gut brain connection
at a time when that field was really.
Speaker 3: Starting to crystallize for the first time.
Speaker 4: This was in the nineteen nineties and early two thousands,
so it was a really cool and exciting time, and
he was still passionate about his work and passed on
that excitement to me and my siblings. Although all of
my siblings again they ran in the other direction screaming
they did not want to be doctors. Somehow I decided
to follow his footsteps. But when I went to medicine,
I knew I wanted to do GI because I loved
it so much, and I wanted to do research too.
I mean, I think the thing about the gut brain connection,
and we can talk a lot about it. I know
that that phrase feels really vague, and it also like
is like something that my world means a lot, and
in a way it means like very little too, you know,
like the way it gets talked about like everything is
the gut brain connection.
Speaker 3: Everything's your microbiome, you know.
Speaker 2: But there was.
Speaker 4: Really so much that we've understood about it, and yet
also so much that we need to still learn about it.
And so I knew I wanted to do research, but
I spent some time doing basic science. I worked at
the NIH. I actually lived in the NIH like cloister
building for a year of my life. It was delightful,
and I was working with mice and living with other students.
But then I ultimately decided that that wasn't how I
wanted to spend the rest of my life. I wanted
to do more translational and epidemiological research. So that's why
I got the MPH, And the reason I did that
was to really one understand how these large cohort studies
are done, because that's a big way that we can
do some hypothesis driving research. For me, that meant I
had to do a deep dive into biostatistics and epidemiology
and I spent a year. And there's like lots of
different ways you can do an MPH. Some people study
more on the social sciences side and ethics. Mine was
really more into the epidemiology and biostatistic side of things.
But it taught me how to use these biostatistical methods
to do my own research studies later when I got
my own funding from the NIH. So now I'm studying,
of all things, Parkinson's disease. And Parkinson's disease is one
of those things that a lot of people are like, wait,
why are you, as a gastroentrologist studying that, of all things?
And it's because Parkinson's disease is one of those diseases
that fits so squarely within the gut brain axis. It's
the disease that we used to think of as being
primarily within the brain, and now, over the last couple
of decades, we're realizing that at least for a subset
of patients, it probably starts in the gut, and we're
understanding how those two systems, the central nervous system and
the enteric nervous system, which is the millions of neurons
that live in our gut, how they communicate with each other,
and how possibly diseases can spread between them. And so
that's what I study now, and I do. It's like
you said, I do a little bit of everything. I
have a lab where I study large population databases. I
bring that back to patients that I see in my
clinic and I recruit them for my trials. We're looking
at bios specimen. And then in my limited spare time,
I also write the Aska Doctor column, where I try
to take some of that data and take some of
the questions that my own patients are giving me, like
the kind of things that you've been talking about, like
leaki gut. People come in and ask me about that,
and I say, okay, like this is a great question.
More people should know what leaki gut is and what
leaki gut is not.
Speaker 3: But it's the kind of thing that you know, you
have fifteen minutes with.
Speaker 4: A doctor in an appointment, like you're going to talk
about your kolonosko, but you're not going to talk to
them about supplements for leaki gut and instead you're gonna
get that information on TikTok. So I try to meet
patients where they are, which is online, and it is
on TikTok, it is on Instagram.
Speaker 1: Yeah, yeah, you know it's it's there's so much to unpack,
and I'm curious how I even want to like structure
this and dive in.
Speaker 2: But I'm gonna get personal. I often like to get
personal on the.
Speaker 1: Show, and I'm going to think about the sort of archetype.
I'm assuming you know that you have certain types of
patients that you see, certain types of individuals who both
come to the clinic but also are consuming content online.
I would describe myself personally as somebody with just like
I don't know, like an iron gut, Like I can
eat whatever I want. I like my poops are pretty normal.
Sometimes my poops aren't normal, but I never get like
stressed by that, because that's what life is. I love dairy.
My body's like dairy. I feel great after I eat dairy,
which is like just weird. And then I, for some reason,
have had a long history of dating serious partners who
have like the equal and opposite problem is me their
guts are there, and I personally believe that there is
a deep connection to their mental health and to their
anxiety disorders between their gut issues, and a lot of
it becomes can be a challenge in relationships when it's confusing.
How much of the gut concern or preoccupation is based
on intolerable symptoms, which is completely fair, nobody should have
to suffer at the hands of their gut, And how
much of it is based on worry or an extra
layer of interpretation of what some of their symptomatology means.
Speaker 2: So I'm curious from you.
Speaker 1: There is just a certain amount of like human variability, right,
Like we all want to be somewhat normal, but every
once in a while you're gonna get diarrhea and it
doesn't mean you're dying.
Speaker 4: Yeah, you've hit on I think one of the biggest
topics in the field, which is how much of our
gut troubles start in the brain, how much of it
start in the gut? How much of our brain troubles
start in the brain, how much of it starts in
the gut? Right, And you've also hit on, like I think,
like a bigger sociological problem, which is why is it
that people would gut trouble always marry people without gut
trouble advice time, you know, like people will come in
to my clinic having been dragged in by their partners
and they're like, no, I'm completely normal, I've normal habits,
and their partners like, are you kidding me?
Speaker 3: You are not normal? And sometimes you don't know.
Speaker 4: I mean, I think this is like our society's problem
because we just don't talk about this as much as
we should. But you just don't know until you marry
someone how different your bowel habits are from other people.
And then you're like, wait a minute, like you you
don't have to poop every time you drink milk.
Speaker 3: Like right, or like this whole time.
Speaker 1: Or like, dude, you should not spend forty five minutes
in the bathroom like yeah, yeah, every event.
Speaker 3: Yeah it's not too you are.
Speaker 4: It's like how your brothers were too, and you think
that's fine and actually, no, my friend, that's not normal.
But you know, like if we were to say, you know,
the way, okay, the way the gut brain connection had
been thought of for more than one hundred years was
really in terms of how the brain impacted the gut.
So like if you go back in time, there were
these accounts in the late eighteen hundreds of doctors who
observed through whether it was like in a war zone
where people had injuries and they could actually like look.
Speaker 3: In the abdomen.
Speaker 4: They would see that when people were under duress, under stress,
your gut starts to move. It increases what we call
the motility or the movement of your gut. And that
is the part I think of the gut brain connection
that's probably the most intuitive to most people because we
live with that in day to day life, Like when
we're stressed, we perceived these changes almost immediately in our guts.
And this is something that I studied and got me
really excited in the field, Like actually way back in
high school. But I was trying to understand what causes
gut feelings, like why do people get those butterflies in
their stomachs when they're stressed. And what I found is
that when we're stressed, we produce this hormone that starts
from signaling through our amygdala, which is you know, as
you know, this emotional processing hub our brains, but it
sends this cascade eventually, this hormone called cordicotroph and releasing
hormone actually grinds the stomach to a halt. It grinds
that movement to a halt, so you're not contracting at
a regular rhythm, and you go into this chaotgorithm, which
for some people feels actually like you're suddenly feeling a
little nauseated because your stomach's not moving things forward.
Speaker 1: But it was this kind of like during a fight
or flight experience, like when you're actually acutely stressed, your
body is like I don't need to put my resources
into digestion right now.
Speaker 4: Yes, that's exactly right. And there's actually an interesting A
lot of this came from other labs out of UCLA,
and I ask someone like, evolutionarily, why is it that
we when we're stressed, our stomach stop moving, but paradoxically,
our colons start to contract. The final part of our
colon starts to contract for quick which is also why, yes,
you feel nauseated, but yes, you also often have to boop,
like right about to go on stage, and it's like, wait,
what's going on?
Speaker 1: And that's one hundred percent the only time I have that.
I don't have it anymore. But when I used to
be a singer for some reason. Oh only when I
would say the minute before I go on stage to
saying I'm gonna poop myself. And then of course it
goes away once you're doing it.
Speaker 3: You didn't have to poop after all.
Speaker 4: Like it only hit before my turn a karaoke Like, yeah,
this is a real phenomena, and we all like I
used to get this like.
Speaker 3: Before big presentations.
Speaker 4: And what actually also is happening, and this is something
I learned, is that we actually do when we're stressed,
experience this thing called increased intestinal permeability where the cells
that are lining the gut actually do open up their
little gaps that open up between those cells. And this
concept of increased intestinal permeability that happens with stress, it
actually happens when we eat. Sometimes it happens to all
this during the day. That's the concept that is real.
It's physiological that has been co opted by social media
to mean leaky gut, and it's taken on like a
lot of other interpretations and meanings and values that that
it didn't really start as.
Speaker 1: But wait, so this is a normal physiologic function that
happens during stressful periods. But also just as as the
overall function of digestion, and people talk about it like
it's a syndrome.
Speaker 4: Yes, and in fact all of us at some point
during the day would have measurable increases in our intestinal
permeability that it turns out when we're stressed. The hypothesis
is that because this is happening, and it's you know,
in theory like allowing the passage of molecules in and out,
that can help protect us. Because this is occurring during
times of stress, it would actually behoove you. It would
help your body to try to eliminate all food and
all antigens out by pooping, by like not pushing more
food downwards to your colon. Because we know that you
have increased intestinal permeability, we don't want any antigens to
come in and potentially enter the blood dream during this
time when we're particularly vulnerable.
Speaker 3: So that's the idea about.
Speaker 4: Why our guts suddenly go a ride during moments of stress.
Speaker 3: But it's usually short lived.
Speaker 4: It's usually not something that will stick around for the
next several hours. Like you said, as soon as your
like segment is over on stage, suddenly you don't have
to poop after all and things kind of go back
to normal, but there is as you said, this idea
of leaky gut is a chronic syndrome. And you know,
like I've seen these videos on social media too where
someone will be like, do you have brain fog?
Speaker 3: Are you bloated?
Speaker 4: Must be leaky gut, and then you're like, wait, yeah,
I am bloated.
Speaker 3: I do have brain frog.
Speaker 4: Because these are very common problems that people experience, and
then somebody gives you a concrete answer and it kind
of has this certainly sounds scientific when they explain like
what could be happening. It's easy to latch onto this
as an idea, but it's really you know, it's like,
for example, if you have an infection and your white
blood cell count is elevated, the problem is not that
your white blood cell count is elevated. That's going to
be elevated in a lot of different conditions. The problem
is the infection and we just anchor on the leaky
gut part of it. We're missing what's what is driving it.
And that's if you try to do yeah, like, don't
solve the leaky gut, try to solve what is the
upstream driver of this? Issue, but instead we've landed there,
we've anchored there, and then of course there's this whole
industry of unregulated supplements that will try to solve it,
which you know there's not great data for.
Speaker 1: Right, So you've got a twofold problem here. You've got
the preying on individuals, which we see all the time
in the beauty industry and in a lot of like
wellness industries, the praying of individuals by pathologizing a normal
biological function. And then the secondary problem is maybe you
are somebody who suffers from chronic stress and now we're
talking you know, a Robert Sapalski wyzy bris don't get
ulcers situation where like a lot of physiologic things are
going wrong. But ultimately this quote normal biologic function does
have a protective mechanism. This is part of your immune
system and it's there to protect you. It's just chronic
stress is really.
Speaker 2: Bad for us.
Speaker 1: And we have all of these acute functions that we've
evolved that when we turn them on in the long
term start to wreak havoc. But the problem there, you're right,
is not solving the biological marker of the stress. It's
reducing the stress.
Speaker 4: Yeah, reducing the stress or I mean there's it's you know,
in my world, bloating can happen for one hundred different reasons,
brain fog fatigue can happen for a hundred different reasons.
Of course, we'd oh, no, it could be stress, it
could be something different, and I it's not. It's it's
happened to me, like on more than one occasion that
people have come to me having tried supplements at home
for leaky gut, and it turns out they the whole
time they had something like celiac disease, they had something
that we could have ben should have diagnosed earlier if
they had just come in to see a gastorentrologist and
we had done sort of like a let's start from scratch,
let's do this whole work up, rather than like let's
anchor onto this idea that we saw that was so
convincing on you know, want talk. And I think people
forget sometimes that it's horrible it and a lot of
these tests and supplements they feel really medical, like you know,
like these microbiome testing kits or these supplements for leakigat.
Speaker 3: They feel medical. But and yet like just to remember at.
Speaker 4: The end of the days, you know, these are not
regulated the same way as medications are. Like these they
haven't undergone like phase one, two through four, all these
clinical trials the way you think, even though the marketing
and the conversation around them feels like hardcore science, sometimes
it's actually not.
Speaker 1: Yeah, And I think that's that's a larger point that
is important to I will do the quick and dirty,
because anybody who listens to my other show, The Skeptics
Guide to the Universe, knows that we hound on this
all the time. But like the very rhetoric that big
pharma or big medicine doesn't want you to know, and
here are the real things, and here are the things
that I'm trying to sell you. The reason that that
can work so well is because a lot of people
do have difficult experience dances with the medical system. We
know that you know, managed care is very problematic in
this country. But ultimately, if there is a treatment available,
your physician knows about it, and your physician can read
about the trials that were undergone for that treatment or
that procedure or whatever to become FDA approved. So the
frustrating thing for me is when people go, oh, I'm
over here, I'm quote alternative medicine. I'm offering you an alternative. Really,
the doctors in big pharma are trying to get rich
off of you, And I'm like, no, no, actually, that real
treatment is subsidized by your insurance company. The thing they're
trying to sell you will never be covered by your
insurance because it is not a real treatment.
Speaker 4: Yeah, and you pay hundreds and thousands of dollars.
Speaker 2: Yeah. Yeah. And it's the very rhetoric.
Speaker 1: It's sort of the trump of it all of like
not me him, you know, it's like the very rhetorica. Well,
really is that the medical system is predatory and all
they want to do is make money and they don't
when when they're doing the same thing and in some
ways in an even more egregious way because it's the wild,
wild West.
Speaker 2: So that's my schpiel.
Speaker 3: Yeah, I fully agree, I fully co sign your spield.
Speaker 4: But you know, it raises a really good point, which
is that you know, because this is this is how
we framed this gut brain connection for so long. And
I'm talking about like during the nineteen fifties, we were
studying stress and constipation and diarrhea and motility. We really
internalized this idea that problems in our gut are in
our heads, and that was the conversation in mainstream medicine
for a century.
Speaker 3: Like I said, and it's hard because the last.
Speaker 4: Twenty or so years, we have lots of experimental mechanistic
data and couple with epidemiological studies that show that actually
a lot of anxiety and depression and neurodegenerative disorders actually
start in the gut and fuel the anxiety and depression
rather than as a result of said anxiety and depression.
But that narrative, that older narrative that this is all
in your head, is so pervasive. It's what people hear,
whether those words are explicitly used, that I get why
they're turning towards somebody who listens, somebody who says, you know,
you're not crazy, you have real problems, and here's the
real solution, even though the real solutions are not real,
and the problems are identifying are not the actual problems.
It feels really validating to say, yeah, all of these
doctors who before didn't believe me or thought that I need.
What I needed was an antidepressant, and certainly maybe you
did that would have helped, but it wasn't the whole picture.
It is really validating to hear somebody say I have
a solution that nobody's told you, and you suddenly feel
like wait, like they have been gatekeeping. And so it's
also this like big kind of social problem that we
have to deal with in our field, Like it's a
reckoning that we have to come with that our messaging
has just been not deliberately incorrect. It was based on
real data and real science. But the newer science, which
is now not even that new. We're talking about like
twenty thirty years old data, it just hasn't caught up
in the popular popular mention culture. Because when I hear
about the gut brain connection on social media.
Speaker 3: It's still the same old stuff.
Speaker 4: It's still people talking about stress and anxiety causing gut
trouble and.
Speaker 3: All of that is true.
Speaker 4: But when you see the other side of it, how
the gut influences the brain, it's either limited or it
is oversimplified into stuff like oh, yeah, take two cups
of blueberries a day, and you know what, use your
risk of demension And it's like okay, you know, yes,
it's a healthy eating pattern is absolutely associated with a
lower risk of dimension, and there's a lot of data there,
but it becomes so oversimplified that it's also easy to
dismiss then too.
Speaker 1: Yeah, I worry about the pendulum being too extreme on
either side. And this is some you know, this is
coming from somebody who's a clinical existentially oriented psychologist working in.
Speaker 2: A medical establishment.
Speaker 1: So like, I see what happens when we think about
mental health in a purely medicalized way, and I also
see what happens when we completely remove mental health from
the equation, which should not happen. And so I'm so
curious about how you, I guess, grapple with the fact
that sometimes these things are inextricably linked. Of course, we
want to validate people and say, yes, it's not all
in your head. There's a lot going on here physiologically
that we want to work on. And at the same time,
if you are struggling with undiagnosed or untreated anxiety, or
you have long had a lot of control issues around
your bathroom habits, you may have developed a pretty severe
anxiety disorder that is now related to your your digestive system,
and both of those things have to be you know,
grappled with totally.
Speaker 4: And I think a lot of what I do when
I see patients and just you know, to give you
some context. Usually I'm not the first opinion, you know,
like the way my clinic is structured. I'm very very specialized,
So usually people will have seen a couple of different
doctors before they get to me, And what I have.
Speaker 3: To do is usually kind of rebuild a little bit of.
Speaker 4: Trust and say a lot of what you're saying, and
I'll give you, like one example that I often explain
to people about how these things are linked. Take irritable
bowels in because it's just such a kind of quintessential example.
One of the things that we know through research studies,
and you can take these pathological specimen and do the
stains and find this is that the nerve cells in.
Speaker 3: The gut specifically.
Speaker 4: Are triggered at a lower threshold than in people who
don't have irritable bowel syndrome, and these nerve cells then
send pain signals up to the brain. For kind of
the normal movements of digestion, like the gurgling of the
food passing through. These are things that cause a little
bit of distension in everybody, but we wouldn't perceive it.
But if you have irritable bowel syndrome and your nerves
are hyper sensitive, you're going to perceive that as painful.
And there's a lot of reasons why this happens. Sometimes
it's an infection, Like one out of four people who
get something like neurovirus will go on to develop irritable
bowl syndrome because there's been so much inflammation to those
nerves that even when the virus itself is well out
of your system, the nerves have been changed and damaged.
Speaker 3: And I have a loved.
Speaker 1: One who, yeah, who claims that like that, that is
where like he had a really bad case of quote
unquote food poisoning. Yes, ever since then he has to
take a bunch of fiber every morning or he doesn't
feel right during the rest of the day. And I've
a long grappled with like how much of that is
a narrative? How much of that is you trying to
make sense of something that's hard to make sense of,
And how much of that is treatable you know, is
diagnosable and treatable.
Speaker 4: You That is a classic story. And actually it's nice
when somebody can even identify the trigger. Sometimes we don't
know what the cause is, it can, but we do
know that early childhood trauma, and I'm talking about emotional
trauma or physical trauma like of an illness or stress,
this can do it. But now picture that, whatever the
trigger is, you've been living with this hyper sensitive gut
that is perceiving pain multiple times a day, which nobody
else perceives. And over time, very naturally a consequence of
that is that you're going to become hyper vigilant. You're
going to be wondering and worrying when is this next
pain signal going to come? Could I even eat this food?
Or is it going to send me into a pool?
And you're worried about it quite understandably, And the more.
Speaker 1: It turns into behaviors that are really problematic, like it
turns into sometimes not just avoidance and restriction with food,
which can cause nutritional deficits and downstream psychiatric problems, but
also oh wait in the car, I'll be right there, No,
I promise, I'm coming. I just need to try and
go to the bathroom before we go. Like just a
lot of fear around leaving and coming and going and
resistance which can be really disruptive to know the flow
of a family for example.
Speaker 4: Oh my gosh, I'm so glad that you said that, because, yeah,
the social consequences are really devastating and isolating. It's like
you said, people just say, you know what, I'm going
to cancel these brunch plans. I'm not going to take
my dog for a walk because I don't know what
the bathroom situation is going to look like five minutes
from now.
Speaker 3: Wherever we are.
Speaker 4: And it is really isolating, it's embarrassing, and it's not
a surprise to me that in irritable bowl syndrome there
are high rates of anxiety and depression.
Speaker 3: But if you take a step back, there are high rates.
Speaker 4: Comparably high rates in so many other chronic illnesses, like
lumatoid arthritis, for example, for which we think we have
a very good understanding of the path of physiology. But
in irritable bowl syndrome, when someone has a lot of
anxiety and depression, we often put a lot more blame
on the anxiety and depression as the cause rather than
as a consequence. And it's like I said, it's really
in some cases neither. It's just part of a vicious loop,
and many of my patients, if they're not already on
an anti anxiety or anti depressive medicine, I usually encourage
it because we need to think about treating the central
nervous system and the enteric nervous system together. It's very
difficult to just say we're going to just treat the brain.
We're just going to treat the gut, and that's going
to fully stop it. You need to stop the signals
everywhere you can. And in fact, a lot of the
therapies that we give people in IBS we're originally designed
as antidepressants. Like you you know, you might tricyclic. Antidepressants
are a very common therapy, and IBS they do not
do a fantastic job treating your depression. They work weekly
to treat depression, but they're not anyone's first line usually
for that.
Speaker 2: But they do a.
Speaker 4: Fantastic job of rewiring the nerves and the gut to
just raise that threshold at which they fire and signal
pain up to the brain.
Speaker 1: Well, that's fascinating, and there are of course so many
non I guess medical therapeutic approaches that you know are ancillary,
like they're adjunctive. I would never say, have therapy to
fix your ibs. But when we talk about the depression
and the anxiety and really just a lot of like
the behavioral restrictions that can sort of border line. Yes
they're like anxiety functions, but they can borderline on some developed,
sort of obsessive, compulsive types of behaviors. There's just so
much that we can do with behavior change to improve
the quality of somebody's life. And I almost wish that
we had more like psychologists embedded in GI clinics for that.
Speaker 4: Oh my gosh, we have we have two really want
and I.
Speaker 3: Think that, yeah, there's no way.
Speaker 4: I mean, I think there's no way our center could
run if we weren't multidisciplinary. And like they offer CBT
all the time, they do cut hypnotherapy, and these are
things that I think are critical to the care of
a patient. But if you just say what you need
is CBT without giving people a little bit of this
background about the cycle and how this is a two
way street between the brain and the gut, sometimes that'll
be perceived is, oh, you're telling me, like what I
need is therapy, and and I, yes, I am telling
you that therapy will help you. But not because I'm
dismissing the reality of your symptoms. So the context and
just putting it in perspective will make all the difference.
Because even when I bring up these tricyclic antidepressants and
I don't give enough of a background about the why,
people will hear you're telling me I need an anti
depression medicine because you think this is only depression and.
Speaker 3: It's not true.
Speaker 4: And on the flip side, I also tell people, like,
separately from your gut symptoms, we have to treat your anxiety,
like we need to take this, you know, anti anxiety
medicine if that's what's the right choice for you, because
why would we not. We would never withhold an anti
depression medicine, an anti anxiety medicine for any other condition.
You know that where it's just it's part of the
it's part of your overall well being. So you really
need to think about both sides of it, and and
I do all the time. And it's but you know,
like you go on social media, this is not the
conversation that you can convey in sixty seconds in a
real What you can convey is like, try this abdominal
massage and show you how to do it, and like, Okay,
there's like very weak but not zero evidence for abdominal
massage for constipation. I feel pretty meh about it, but
like that's not what our whole conversation about IBS should
ever be.
Speaker 2: Right, right.
Speaker 1: I mean, I think it's so important the point that
you made that it bears repeating that sometimes these nuanced
discussions that occur in clinical settings when they when we
as practitioners aren't careful with our language, when we don't
have the training, and when we're not conferring with you know,
a multidisciplinary team, but the patient can hear is.
Speaker 2: It's all in your head? And that is so invalidating. Yeah,
it's not all in your head.
Speaker 1: It's all of the above, and you can't tease any
of this stuff apart. And I think that's I wish
that we could start working towards that being a part
of our social vocabulary, is that your mental health and
your physical health are one in the same, like they Yes,
it's the one you cannot them apart.
Speaker 4: I mean, one way I think about it is I
explain people how to people how pain signaling works right
from your body, Like there is a neuron a nerve
cell in your gut that is reacting to some trigger.
And whether that trigger is something in your food, or
it's an infection, or it's distension, it's something. And that
trigger then acts on the nerve selling your gut, which
then sends another signal to a nerve selling your spinal cord,
and it sends another signal up to your brain. And
then there's these different parts of the brain that react,
and maybe they cause nausea, maybe they cause this pain.
But our medicines can treat any point in that signaling pathway.
Some of the medicines will treat primarily the nerve cells
in the gut. Some are going to treat the brain.
But it's important to remember pain only exists if your
brain decides that it's there, you know. And so like
some of our medicines that primarily treat the brain, it's again,
it's not because we're saying it's all in your head.
It's because that is the final pathway and pain perception,
and that can be a powerful way to help you
feel better, even if we're not necessarily directly targeting that.
And I have lots of patients who I've referred to
my excellent colleagues in GI psychology who work with me,
and they'll say, like, you know, we've tried all these medicines.
It was the cognitive behavioral therapy that moved the needle
for me, like for the first time, it was a
gut hypnotherapy. It was something that I couldn't offer with
a treatment that targeted the gut. But they would have
never been even open to trying those things had we
not explained the physiology of how our bodies work.
Speaker 1: You know, what's really like what you're bringing me to
an important I think growth edge for myself right now,
where on the one hand, you're validating something that I've
long thought was like a personal thing that I want
to bring up in a second. And but on the
other hand, you know, as a psychologist, like I should
know better, but I think you are reinforcing to me
that the perception and the experience, you know, the phenomenology
of the individual who has these just you know, horrific
gut problems is these they are getting actual signals in
their brain that are telling them panic. You're very sick
right now, something is very wrong you. You can't leave
the house right now. It could be disastrous for you.
Or whatever the case may be. When I think we
struggle sometimes because we're all very you know, golden rule,
and you know, a big part of our job is
to take the frame of another individual. And I think
one of the things that I've struggled with personally, less
so professionally, but personally is that I think I probably
have the opposite I probably have very dull signals to
my brain. And so when I have to go to
the bathroom, I'm like, oh, there it is, gotta go
to the bathroom. I'll be right back, and then I
go and I'm done, and the rest of the time
I don't think about it. And sometimes my guts are
a little angry, and I'm like, oh, I think my
guts are a little angry.
Speaker 2: Huh.
Speaker 1: And then I just get past it. And it's very rare.
When people say, oh, I was so bloated yesterday, my
common reaction will be, I don't know what that means.
Speaker 2: Yeah, I've never felt that.
Speaker 1: I know what it feels like to have eaten too much,
but I've never been like, I'm having a really blowdy day,
Like I physically could not describe that to you. So
it's hard for me to empathize with an individual who's like, oh,
I just feel off, like my guts feel slugged.
Speaker 2: I'm like, what are you talking about? Your guts are gutting.
Let's just get to.
Speaker 4: Yeah, it's I don't think you're you're alone. I mean
I think that this is a big It's.
Speaker 3: Why being a doctor is so difficult.
Speaker 4: Is I think we or any kind of clinician in
your shoes, in anyone who has to care for people
who have diseases that we don't ourselves necessarily have. It's
hard to imagine. And I think something that strikes me
often and helps ground me is that, actually, almost like
what you were saying about what occurred to your acquaintance
is that so many of my patients will say I
was exactly like you. I was high functioning, I had
a gut of steel. Then one day this thing happened.
I got sick on a cruise and or I got
you know, I ate some weird takeout and nothing has
been the same since. And you meet them and you're like,
you know, this could be met this could have happened
to me, you know, but it just for whatever, like
for whatever reason, luck like it didn't happen but it's
not that you were necessarily was, And afferently there are
patients who have been dealing with this since childhood too,
But it's really just the luck of the draw. And
it's not until I think I got really really nauseated
during my pregnancies, and that was and I thought I
considered myself very empathetic to my patients. I deal with
not all the time in my practice with patients.
Speaker 3: But it wasn't.
Speaker 4: Until I got really sick that I just was so
able to internalize how miserable that is. Like, however miserable
I thought it was because I flattered myself I'm so empathetic.
I couldn't until I felt it and lived it, you know.
And so like it's for good reason that like in
our practice sometimes we tell like a lot of the
procedures and tests we tell patients to undergo when we're
in training as g fellows, we do them to ourselves
just so that we know exactly what it is that
we're telling patients, like, oh, this is no big deal.
We're just gonna put a little probe through your nose,
or we'll do the battle prep for your cakelnosophy, like
we do it so that we can live it and.
Speaker 3: Share it back.
Speaker 4: But it's empathy is a really hard like I'm still learning.
It's not it we have easy skill, always practice, and
it is not. I often will say, you're right, it's
a skill. It's not like a talent. It's something you
have to practice all the time. And I think, you know,
another layer just came up that you mentioned, and I
can't help but see a parallel with something that a
lot of my listeners are familiar with because several years ago,
so I work in a cancer center, so it was
I don't work in a cancer center.
Speaker 2: Because of this.
Speaker 1: This happened while I was working in a cancer center,
but I was one of the unlucky few for whom
HPV turned into add no carcinoma in situ, and luckily
we caught it early. Luckily I was able to have
a hysterectomy remove any of the traces. You know, my
chance of a recurrence is very, very low because it
hadn't invaded the basement member and you know, some people
call it like cancer stage zero, all these things. But
one of the things I remember thinking at the time,
and it just reinforces what I often say to my
patients anyway, Is that like you did not ask for this, Like, yes.
Speaker 2: I had HPV.
Speaker 1: Okay, people could talk about lifestyle or not, like I
not exactly. I was pre vaccine, so let's be you know,
let's be honest. We did not have the protections that
we have now. But ultimately, it is a luck of
the draw if your body just clears the virus, which
most people's uh do, or that it continues to mutate yourselves.
It's the same thing with cancer, and it's the same
thing with these gi issues. Like I've had NORO three times,
I don't have any lasting problems from neurovirus. I can
empathize with the pain of having neurovirons.
Speaker 3: Yeah, I didn't wish that one on my enemy.
Speaker 1: My no is the sickest I have ever been in
my entire life. Luckily only for like two days. But yeah,
it didn't stick with me. But you're right, it could
just like you know, somebody's HPV could turn into cancer.
Just like all of these things that we moralize as
a culture have nothing to do with decision making. Want
what did I do to deserve that deserve has nothing
to do with it.
Speaker 2: It just happened.
Speaker 4: Yes, Yes, I'm so glad you said that, Yeah, because
I mean I think sometimes when you make these diagnoses,
that's the first thing people wonder is like, but why me,
what did I do? And even in the GI scenarios, Yeah,
sometimes we identify a cause. Usually it's a cause that
you didn't control, Like, right, you didn't choose to eat
the takeout that, like, I mean whatever, Like that's not
that's something you could have prevented. But sometimes it's like,
you know, maybe you had some genetic predisposition, like maybe
you had some connective tissue disorder, maybe there was something
in your childhood which obviously you didn't control.
Speaker 3: Like we sometimes just.
Speaker 4: Also just don't know, and it can be so frustrating
to people. And then you couple that with the fact
that this is this is specific to a lot of
our GI problems, which is that a lot of your
tests are normal. Like, you are miserable, you're suffering, you
are really begging to get your doctor to empathize with
you and help you. And what your doctor does sometimes
is you know, like your colonoscopy is negative, your blood
tests are negative, and that feels really invalidating. I mean,
that is the how we define ibs is that these
tests have to be quote normal, and then and then
you really just feel like nobody gets me, nobody's believing
in this, and then of course you turn to the
online problem. But that's that's the issue in GI right now,
which I think we're going to see a lot of
transformation in the next ten years. It's not that the
tests are normal, it's not that anyone's trying to gate
keep the science. It's more that the types of abnormalities
I'm talking about, like, for example, the threshold at which
the nerves fire. Yeah, we can very elegantly show that
in a research study where we take these full thickness
biopsies out and we measure it, but it's not the
kind of test you can just get at the bedside.
And I think in the next ten years we're going
to get those tests to the bedside and we're gonna
be able to do that robustly. But in the meantime,
there's there's lots of third parties will promise tests that
do that right now, but they don't.
Speaker 2: Yeah, and that's that's what's so dangerous.
Speaker 1: When we're talking about you know, the cutting edge research,
like the research that you do the opportunities that are
available to patients, which you know, every day there are
new therapies all of the time. I see this all
the time right in a cancer center, Like I have
patients who are failing out of you know, they're on
third and fourth and fifth line treatments and there and
by the time they fail out of their last one,
there's like a.
Speaker 2: Whole new drug on the market. They're like, oh, yeah, thanks,
that's good timing.
Speaker 1: And this happens a lot just because of the speed
of innovation, but it can be frustrating when something seems
like you said reasonable and maybe even the evidence is
starting to point in that direction, and then like a
Silicon Valley startup is like, don't worry, we figured it out.
But yeah, you know, sometimes it's just Elizabeth Holmes right,
like it's not real and I think we have to
be careful about them.
Speaker 4: And then you get some abnormality on some test, and
then it's like, well, what do you do with that info?
And usually what you do with that info is then
you pay that company even more for their proprietary targeted
supplement that will you know, suppose look at those addnirmalidies
and you just you go down this expensive rabbit hole
that that doesn't help people as much as it should.
Speaker 2: Yeah, yeah, and you know.
Speaker 1: Okay, So I have little experience with GI other than
experience through working with patients, but more like personal experience
of people in my life and people who I love
having a lot of GI concerns. I want to ask
you about something personal. And the reason I want to
do it on the podcast is because it's a It's
an experience that I know there will be people listening
going okay, I'm dealing with the same thing. So thank
you for bringing this out.
Speaker 2: Lad. So I'm forty two.
Speaker 1: I have never had any GI problems whatsoever, but I,
for now quite some time, have had a history of
low iron borderline iron deficiency, anemia right low ferretin, high
binding capacity, oh like bound iron, but never like changes
to my blood cells because of it. And then I've
also just had like B twelve deficiency out the you know.
So I'm constantly seeing my hematologists getting tested, and then
about once a year I have to get an iron
infusion maybe once every couple of years, I have to
get B twelve shots.
Speaker 2: Finally, she's like, you're going to GI. You're getting a
colonoscopy and an endoscopy.
Speaker 1: We've got to figure out because I don't have a period,
because I don't have a uterus and I eat meat,
so we're like, what is going on here. I've just
spoken to my GI. She has told me about my prep.
I am getting the tests on a book eighting congression.
This will be my first time, so I'm hoping you
can share with us. And she did share some really
interesting things about all the new preps that are available.
I'm planning on doing one where it's basically.
Speaker 2: Just like a bunch of positive.
Speaker 1: No. I don't want the pill one. I want the
laxatives with the electrolyte drink. Oh yeah, yeah, yeah, yeah,
that's my go to because I've had surgery.
Speaker 2: I'm all about that.
Speaker 1: That osmotical accidive and I love me some pedia a yeah.
But she also was talking about how if we don't
see anything, you know, She's like, all biopsy anything I see,
I'll take samples, I'll look for h Pylorial'll do all
this stuff. If I don't see anything, then you got
to come back and swallow a camera because we're not
going to reach your whole small intestin. So yeah, I'd
love for you to help demystify in these last several minutes.
What this so common test is that almost everybody has
to undergo when they have GI issues. What it can
tell us, what it can't tell us, what the experience
is like, oh my, because it's a brave new world
it is.
Speaker 4: And I'm so happy you asked about this. This is
like the perfect thing, and I talk about it.
Speaker 2: She said, which like I didn't know I get propofall.
This is amazing. I get to go full sleeps.
Speaker 4: Well, you know, I will say that I think there's
a lot of sometimes anxiety and dread about the kolonoscopy
because people often hear about the klonosopy's experience from their
dads or their moms. And I remind people like, this
is not your grandfather's prep. This is not your grandfather's kolonoscopy. Yes,
most of my patients, especially the ones who get propofol,
first of all, they wake up and they say when
are we getting started? And I'm like, hey, we did it.
Speaker 3: It happened.
Speaker 4: You're done, Like congrats, like it already happened. It was
over so fast, and they're like, I had the best
sleep of my life.
Speaker 2: That's what everybody says.
Speaker 1: It was like a really nice nap, right because we're
not using the well I shouldn't say we some places
probably still are. But the verse said fentanyl combo. That's
that's the WU that you see in all the TikTok videos.
Speaker 2: Yah, we use.
Speaker 4: Both, like we do some combination of like so it
depends on the patient and what they want.
Speaker 3: Like so we you know, like we do what you know,
all of them.
Speaker 4: But it's it's way easier, I think than it used
to be, like twenty thirty years ago. And part of
the reason it's easier now is because the prep can
be so much easier, Like there is a still a
world where you might be told, yeah, I still need
to this like huge like four liters of liquid, and
we can talk about like I have some great strategies
for how you can make that less miserable, which is
I will say, like the number one, two and three
thing is to put it on ice and drink it
through a straw. Like if you just do those things,
you'd be amazed at how quickly you're bypassing your olfactory system.
The ice like completely kills the taste and you can
just you can get rid of that. You can down
it pretty fast if you do that. But I also
tell people, okay, do the opposite, like warm it up,
mix that powdery prep into like a nice fu broth
or some of your like, like mix it in with
a ramen noodle packet and have it as a soup.
And that tastes great too, So you don't It doesn't
have to just be you sipping this like chalky, yucky
clear liquid.
Speaker 3: You can mix it into jell o.
Speaker 4: Jello is one of my favorite tips because even though
you are not supposed to have solids, Jello obviously like
turns immediately into like liquid as long as it's not
red jello. Nobody wants to You're not supposed to have
anything red or colored, but it can make it can
make the prep pretty easy. And for anyone who's on
the fence about like well why should I do a
colonoscopy when I can just do a stool kit, your
case is a little bit different because this is different
than a colon, like a colon cancer screening.
Speaker 2: Right, I'm for and this is just my normal time
to go get more.
Speaker 4: Yes, I have no symptoms, I have no any meadversity.
When you find differency. It makes sense to do what
you're doing and check for hi lory, make sure there's
not microscopic blood lass.
Speaker 3: So it's a little bit different.
Speaker 4: But otherwise I often get this question about, like why
the colonoscopy. It seems like it's a lot of work,
right because you have to if you're getting in athesia,
you kind of have to take the rest of the
day off. You're not supposed to drive. It's like, you know,
it's like a it's a somewhat big deal, although not insurmountable.
Speaker 3: Well, the reason is that the stool.
Speaker 4: Kits where you like poop in a box, you mail
that box back. It's like anonymous packaging. There's nothing embarrassing.
Speaker 2: About it at all.
Speaker 4: Very straightforward is that those toolkits are just detecting cancer.
And people need to remember that the colonoscopies are not
really there to detect cancer, like they do an excellent
job of that, but they're there to prevent cancer. Colonoscopies
it's like that HPV vaccine. It is doing something that
we have so few test modalities therapies and are in
our in all of medicine that will prevent cancer. And
this is one of them because we go in there
and we look for polyps. Polyps are these pre cancerous
growths that can become cancer, and we know about five
to ten percent of them will become cancer if we
do nothing about them. Well, we go in before that happens,
We take them out and we say, great, come back
and you know, seven to ten years, we'll see you
then and we've just wiped out the problem before it starts.
Whereas with a stool kit you may have polyps. You
you maybe have really gnarly polyps that are on the
pathway to become in cancer, but that stool kit test
will come back negative because they're not cancer, but they're growing.
They're there, and we're going.
Speaker 1: To just testing shedding cells at that point, like it's
testing your own own biology in your poop, which most
of your poop is not you, but there's some of
you in your poop that it's testing exactly.
Speaker 2: Okay.
Speaker 4: So that's my argument and my push to like, if
you're somebody who's doing this just for colon cancer screening,
always go for the colonoscope if you can, because it's
it's more than screening, it's it's prevent prevention.
Speaker 1: Yeah, and so when you when you do take the polyp,
like somebody, let's say somebody does have polyps. Okay, don't
freak out, like it's people get polyps. You you remove
the polyps, then you send them to pathology and you
actually look at whether or not they are pre cancers exactly.
Speaker 4: Yeah, and you're right, like, no reason to freak out.
Most of us, over the course of our lifetime will
develop polyps. Polyps happen for a lot of different reasons,
but usually the result of some form of inflammation. And
you know, for example, we know that different types of
foods do it right, Like processed meats will probably increase
you risk of polyps. Smoking of course increases your risk
of polyps. So but you know, even if you're like, well,
I'm I'm pretty healthy, I don do anything, you may
just be pretty genetically predisposed and you're gonna get pops.
So most of us get them, and five to ten
percent of them, so not all, but a notable percentage
go on to become cancer. So then we take them out.
They're small, you don't feel it at all, Like this
is like the easiest procedure in the world. We just
kind of grab them we pull them out, and then
we send them to our pathologists and they look at
them under the microscope and they say, basically, based on
how it looks under the microscope, whether it has features
that we would consider higher risk, like more on that
pathway getting closer and closer to a cancer type appearance,
and how many polyps you had, how big they were,
we make a decision about when you should come back
for your next screening Kladoski. So if you have nothing,
or maybe just one or two really tiny, safe looking ones,
we'll say come back in seven to ten years. But
if you have some kind of larger ones or ones
that have some concerning features under the microscope, we might
even say, hey, come back in one year, come back
in three years, just to make sure, because if you
have those types of polyps that seem to be a
little bit more concerning, it sort of means that you're
somebody who might grow polyps like you might just like
if we wait too long, another polyp might grow in
the meantime, and we don't want to miss it, so
that's why we tell you to come back sooner.
Speaker 1: Yeah, So this sounds like it's so similar for women
to a PAP test and to a colposcopy follow up,
and to you know, this is how I knew that
I because I had an abnormal PAP, because I had
abnormal glandular tissue, Like exactly, you catch it early, you
prevent the cancer from growing, and then you don't have
to get the chemo or the radiation or the invasive surgeries.
And so yeah, I mean, gosh, prevent you know whatever.
An ounce of prevention is worth a pound of cere.
Like we all know this, but in practice that's really important.
I got to ask before we continue this is is
there a world in which because if I only needed
a colonoscopy, I was going to ask if I could
do it without anesthesia, because I would prefer no anesthesia always.
Speaker 2: But I knew with an endoscopy that I.
Speaker 1: Did not want to even remotely have that conversation colonosteres.
Speaker 2: Are they painful or do they just feel weird?
Speaker 3: It's a good question.
Speaker 4: You know in other countries that it's actually normal to
not get sedation, I will say, and like sometimes when
me and my fellow physicians need to undergo our colonoscopies,
we often choose to not get sedation because we're so curious,
we want to like watch along really closely.
Speaker 1: Yeah.
Speaker 4: Yeah, so it's a choice you can make. But I
will say that people tend to want the sedation and
it's not you know, colonoscopies shouldn't be painful, but it
can be uncomfortable because one thing that causes the discomfort
is that in order to get a good look, we're
puffing up usually carbon dioxide, Like we put in a
little bit of air CO two to puff up your
colon so we can look in all the nooks and crannies.
But one of the most uncomfortable sensations to human beings
in real life is mechanical.
Speaker 2: Stretch to step yeah.
Speaker 4: Yeah, And so it's not like we're like causing harm
per se, but that is it can be perceived is
very very uncomfortable, and people don't like that.
Speaker 1: And so like it's like a laparoscopy where they just
like blow you up so they can do this surgery.
Speaker 4: Yeah yeah, but from within and then you know, your
body absorbs the YO two very quickly and it like
and or you'll pass all that gas as soon as
you wake up. So it's it's not like a long term,
it's not causing any long term issues at all. It's
just a little gas. But that's not like pleasant, I
will say, But but I do think like, yeah, you could,
you could do it without the station and and and
it could be like I've seen, I've I've done it
on patients of that station and it's totally fine.
Speaker 3: The upper endoscopy.
Speaker 4: I have seen once somebody come in and say I
absolutely don't want it, and we've powered through it, like
you just have to fight.
Speaker 1: Your dad did, like like a crazy person. He like
he did his colonoscopy once and was like under like
twilight and was like that wasn't so bad. I want
to just do it. And they were like, well, we
need to do an end too, and he was like, yeah,
let's just do both.
Speaker 2: And they were like are.
Speaker 1: You sure, and he goes that was a mistake, but yeah.
Speaker 4: Like unless there's a really good reason why, like you
have to be very it's more than willpower to overcome
that gag reflex. But when you even have just like
the twilight, which is the you know, the medaz or
fentonal combination, it goes down.
Speaker 3: The scope goes down very quickly.
Speaker 4: The gag reflex part of it is just a couple
of seconds, like it's very quick and then and then
it's it's all over. And frankly, yeah, I would take
if I've had an endoska people inspy, I took the
sedation like I I there's no reason, there's no reason
not to.
Speaker 3: I've seen I've.
Speaker 1: Been around kids when they have to get an ENNG.
I've been around you know, like.
Speaker 2: Oh yeah, it can be kind of traumatic.
Speaker 1: So you know, know thyself and know how you how you.
Speaker 2: React to your gag reflex.
Speaker 4: I honestly think that that is the best thing. Like
I think you know yourself, like you know, am I
somebody who has a high or low threshold for pain? Discomfortable?
And if you're like, you know what, I know myself.
I don't want to take that. It's like, don't don't
like try for the first time in your life to
do something risky on the day of your klenoscopy. Yes,
like you know, I like, make it easy on yourself,
make it easy on the team. And let's just like
we're here to screen you, you know, like we're just
trying to get rid of your polyps and get you
on your day.
Speaker 1: And so what about for folks like who are in
my shoes. Let's say nothing comes back. They don't see anything,
and they're like, we want to dig a little deeper.
There is a test where you have to swallow a
camera in the office.
Speaker 4: Yes, so this is I mean, this is kind of
an exciting relatively new kids called capsule endoscopy. So this
is something that we do often for cases where we
worry that there may be some source of microscopic bleeding
somewhere in the gut. But remember the colonoscopy. Your colon's
about a meter long, give or take, and it goes
all the way up. The scope can go all the
way up to the colon and usually just the first
couple of inches of the end of your small bell.
And when we do an upper endoscopy, it goes through
your esophagus, your stomach, and we get a nice good
look at the first part of your small bell.
Speaker 3: But that leaves feet.
Speaker 4: And feet of small bell that we haven't gotten a
good look at because the scopes are just not going
to be long enough to get to the middle portion
of your gut. That's where the capsule dscoy comes in.
You swallow this capsule that has a camera at the
end and it floats along through your stomach, through your
small bun, and it's taking a picture the whole time,
like a video which we then watch later sped up,
of course, because otherwise we've been there for forty eight hours.
Speaker 3: Looking at the screen.
Speaker 4: But we watch it sped up, and we have you know,
we can detect do we see a flash of red anywhere?
Do we see erosions? Any ulcers that we think could
be the cause polyps too? Sometimes we you know, rarely,
but we see them in the small val.
Speaker 3: So it's a great test. And then if we see.
Speaker 4: It, we can say, Okay, the exact location is probably
somewhere in this part of the small bowel. Then we
can think about what is the tool that we're going
to use to get to that exact part of the
bowl that we need to get to.
Speaker 1: Yeah, curious, how do you know where you are if
you're like on a on a voyage through the alimentary canal?
Like you know, how do you know like where you're
stopping to see that little flash of red?
Speaker 3: Oh you are?
Speaker 4: You're you're asking questions like a good gi fellow. And
the way we know is because we actually your body
has a couple of landmarks for one, and that can
kind of tell us, like give us clues about where
we are, Like when we start to we will know
when we look at the image whether the folds look
like your stomach, or whether the folds look more like
small ball, or whether they look like you're colon. And
then we also know kind of based on really how
long the capsule has been transitting, we can approximate how
long it should have taken to get through your small
valel and like, so we're never like, oh, yeah, you're
exactly like, you know, twelve feet in three inches, Like
it's never going to be that close, but we can
get a pretty good guess.
Speaker 1: It's just so fascinating, how you know, every day it
does feel like they're are new diagnostic tools, new therapies,
new information is coming out both at the individual level
and the population level.
Speaker 2: There's so much here.
Speaker 1: And I have to say I usually would never recommend
another book during the author interview for your book, but
I can imagine that you have read it. If you haven't,
you need to read a Gulp by Mary Roach.
Speaker 3: Oh, I've read it and I love it. She's amazing,
brilliant writer. That's a brilliant book.
Speaker 1: And so I feel like they go hand in hand, right,
because the one is her curiosity as a journalist and
in no way an expert interviewing experts and trying to
answer questions. And then you've got the other side of
the coin, which is an expert in so many different
aspects of the gut sharing. But in a way that
is comparable, I think to Mary's style, where it's like
really accessible, it's interesting, it's funny, you're not afraid to
just like use plain language, which is so incredibly important, demystify,
take the taboo away from pooping.
Speaker 2: We all do it, guys. It's like the Kid's book,
Everybody poops.
Speaker 1: You don't have to hide each other.
Speaker 3: There's no greater honor than to be compared to Mary Roach.
Speaker 4: And what I love about her is that, like she
has a just absolutely brilliant sense of humor, like that
comes through in like every single chapter, and so I
think that's also what makes it funny.
Speaker 3: And I think if you're gonna do gut healths.
Speaker 4: For a living like you, you kind of have to have
a sense of humor to engage people and like make
people want to want to stay glued.
Speaker 1: Absolutely, So I got to ask if there's, you know,
a big takeaway. There are a lot of takeaways here,
but let's say your average person listening to this podcast
is like, Okay, maybe they've had some gut issues and
they haven't really followed up with their doctor.
Speaker 2: Or maybe they're like em.
Speaker 1: Probably should have gotten that colonoscopy, probably didn't want to,
or maybe they are crippled in pain all the time,
they've not gotten the answers that they're looking for and
they've sort of given up hope.
Speaker 2: What would the advice be.
Speaker 1: For a listener of the show right now, a reader
of the book who's like, I need help and I'm
I'm kind of losing hope about that help.
Speaker 4: Yeah, to two things. One, I think the biggest advice
for everybody is to get help. And that sounds very simple,
but one in three people will avoid seeing their doctor
because they're so embarrassed about their bowel symptoms. So really
overcoming that stigma is the first step, and saying I'm
going to talk to my doctor about this. I'm not
going to just normalize or brush aside this bloating, this
discomfort that I live with because it's not a big
enough deal yet I don't want to embarrass myself. If
it's bothering, you get the help. And then the second
part of this is if you've done that, you've tried
to get help and you feel like my doctor isn't
listening to me or I'm not the treatment options just
don't seem to be getting anywhere. Ask your doctor if
they can refer you to a gastroentrologist one, and then
even beyond that, maybe you need a neuro gastrentrologist, which
is somebody who really subspecializes in in the gut brain connection.
And that's you know, we're the few the proud, but
we really do see the cases that are are hard
or to treat, and people should know that. Like, there's
a lot of data about how we can treat a
lot of these disorders, but sometimes you just need somebody
who's really well versed in the data.
Speaker 2: Yeah.
Speaker 1: Yeah, Oh, it's so important just to just to be
aware of that we can't we can't make decisions when
we don't have the information available to us. And so
it's important even to know that your specialty exists and
that if you're hitting a wall, there are still options
out there. Like, I hate it, but we have to
be our own best advocates in the healthcare system. Nobody's
going to take on that role for us. And so
you know here here like you deserve to be heard,
you deserve to get help. You do not have to
go through life suffering in silence. And also, I gotta say,
colon cancer is rising. We know this. We could talk
about the reasons for it, We could talk about all
of that, but like, get tested people, especially if you're
in that bracket where you should have already gotten your colonoscopy,
where you should be following up. And I would say
the same thing to young people. You know, get your
pap smear, do the things that you need to do,
get your mammogran women when you turn forty, Yes, prevention
is so much easier. I am a huge testament to that.
You know, I did have to have surgery. It was scary.
And at the same time, who is my life better
without a uterus?
Speaker 2: Right? It's like way better.
Speaker 1: And now I know I'm not gonna get cervical cancer
because I don't have a SERFX right, all of those
selves have been removed from my body and I'm you know,
my risk is just in the toilet now when it
was signal. I mean, it was almost a geary tea
that I would end up with invasive carsonoma before. So
that's that conversation we had about polyps. I think, you know,
as as important as the whole conversation has been and
I think validating and hopefully very personal for a lot
of listeners.
Speaker 2: There's also some real life saving advice and hear you guys,
so listen.
Speaker 1: Up and everybody, you should pick up the book. It's
it's out now. It's called You've Been Pooping All Wrong
How to Make your Bowel Movements a Joy by doctor
Tricia Pasricha. Thank you so so much for being here.
Speaker 3: Oh my gosh, this was such a pleasure. Thank you
for having me.
Speaker 1: Oh it was wonderful. And everybody listening, thank you for
coming back week after week. I'm really looking forward to
the next time we all get together to talk.
Speaker 2: Mardie