Our next speaker is going to be Dr. Taylin. She joined the USF Division of Digestive Diseases and Nutrition as a clinical assistant professor in 2019, and she is now the director of the Women's GI Clinic at USF in the Pamela Mumma Women's Health Center. In 2021, she became the program director of the USF GI Fellowship Program, and she continues to serve in this function. Most recently, she became the co-founder and co-director of the USF Neurogastro-Motility Center of Excellence in 2024. She will be doing her first discussion on pelvic floor disorders, followed by abdominal pain. Please help me welcome her. So that was a mouthful, right? Basically, I do everything motility, lower esophageal, down. We actually have esophagologists in our practice, and they love to just do esophagus up, which is really nice and simple. So I do all sorts of things from gastroparesis to chronic intestinal pseudo-obstruction, pelvic floor dysfunction, chronic constipation, IBS, the run of the mill, anything like that, and then kind of the potpourri of GI. Basically, if you don't know where to put it, it goes in Taylin's clinic, which I try to remind my colleagues that 60% of what we do in GI, even in the community, is in the disorders of brain-gut interaction. But they tend to just like, that's going over there. So let's get started. Honestly, the second talk is kind of the meatier talk. I think a lot of this is our perspective on pelvic floor, which I think is going to align really well with what you guys have been talking about. And thank you so much for the invitation to AUGS. All right. Am I? Oh, you're like, Dr. Taylin. Financial disclosures. OK, so we're going to focus on fecal incontinence and pelvic or dysenergic defecation. And we'll go over those definitions from our standpoint, from GI. We'll look at kind of a workup plan of what we focus on and how that's going to play into what you guys are doing, as well. And then we'll look at treatment orders for pelvic floor disorders. And then it's just really meant to give you a practical approach on how to intertwine the whole of the pelvic floor in a holistic way. So I always remind my fellows, before you talk about something abnormal, you've got to know what normal is, right? Like, if you don't understand what is actually happening in the rectum and with the anus, you're not going to understand how it can become abnormal and how you can have a disorder. So you guys know this very well. And I have a pointer, correct? No. Yes. Is this the pointer right here? I'm sorry. We didn't go over that. The little bottom one? OK. So obviously, you guys know all about this anatomy here. I think one thing that people forget about is that with the internal and the external and internal anal sphincters, people always focus on hemorrhoids and GI. What's interesting is that the hemorrhoidal plexus, which, by the way, we all have anal rectal veins. And that's what I like. Any time I finish colonoscopy and they go over the diagnoses and then pass it off to the post-op nurse, the first thing the nurse says is, you have hemorrhoids. And I'm like, you guys got to stop saying that. Like, who cares? Hemorrhoids are normal, right? Veins are normal in the anus and the rectum. And they provide 10% of your continence, 10%. So when people maximize this and tell me, should I get rid of them? Or, oh my god, I can't believe I have a tiny, small, internal hemorrhoid. I'm like, leave it alone. It's not bothering you. It's not bleeding. Leave it alone. Who gives a shit, right? OK. Literally. So pelvic floor, you've got your rectum. What's going to happen is that your rectum's going to sense that you've got stool that's entered. And when that happens, your internal anal sphincter relaxes. That's a smooth muscle. You don't control it. It's completely out of your control. Now, when we do anal rectomanometry and we've got a problem, we can see that the internal anal sphincter doesn't. And that's the rare, the rectoanal inhibitory reflex. If you don't see that drop in the internal anal on the topography of the anal rectomanometry, you should have a hint that maybe there's some neurological issue. The biggest, most well-known one is Hirschsprung's. So this is how we get the, ooh, maybe this person has Hirschsprung's. And maybe this is where they've got chronic constipation. So internal anal sphincter is going to relax. And then you're going to go, oh god, I got to go poop. You squeeze your external anal sphincter. I told you this mic was going to be, I get very loud. And then you go over to the toilet. You relax the external anal sphincter. And then you also have to contract. You've got to create intra-abdominal, intra-rectal pressure. And when I show you just kind of some classic manometry, you're going to see how if you're not generating that pressure, you can relax that anus as much as you want, the EAS. You don't generate that pressure, nothing's coming out. So that's also really important. So we get people who have a lot of abdominal surgeries, have a lot of pain, hernias, surgeries, whatever, you name it, scars. And they can't generate that pressure. Or they've got poor balance, weak, poor posture, all that stuff. And that's very important. And that's where our physical therapists are so crucial to what we all do. So that's normal. And then once you generate that pressure, out it comes. So let's talk about, remember, it's just two broad categories, fecal incontinence and then dysenergic defecation. Fecal incontinence is defined from our end as the inability to control or the involuntary discharge of stool. And it can be liquid or it can be solid. And there's also a small definition. Essentially, it's called gas seepage. But you can have mucus. And it has to be over three months. So that's what we consider fecal incontinence. So very much like urinary incontinence, passive or not. We have, like I just kind of went over, we have these subtypes. You've got the passive. You've got the urge. You've got the fecal seepage and the gas incontinence. Passive, you've got the involuntary discharge. I'm not going to weigh too much on this because I know you guys know. Is this? Yeah. OK. Mainly, the issue here is that you get, what am I doing? That's making it like orb. It's orbing. It's definitely orbing. Or maybe it's just me. OK. Impaired anal reflexes are really the issue here. You get sphincter dysfunction or those reflexes we talked about that are missing that can be part of why people have passive incontinence. Urge incontinence is really mainly like sphincter muscle issues or puborectalis weakness that will just loosen that angle. And so basically, you just have a weak ligament. And so you're just constantly, whenever, because you've always got stool that's building up in there. I mean, you've got about two liters that's going into your colon every day. Your colon's job is to desiccate waste. A lot of people don't realize that waste is liquid when it enters the colon. And your job, and that's where a lot of those drugs that we'll talk about later are super important in GI, those drugs are just manipulating water content. And so people who are constipated, we're trying to add more water back, right? And then the vice versa for people who have diarrhea. So you get a puborectalis weakness. Excuse me. I'm going to get this eventually, I promise. No? OK. You don't want me to speak anymore? OK. I don't know. Do I have to point to the screen? This one's moving. That one's not moving. I promise it's not me. I told you it was orbing. All right. So fecal seepage, this is impaired rectal evacuation or anal sphincter issues. And it's usually about two tablespoons of stool matter without awareness. And then we mentioned gas incontinence. We talk a lot about this, mainly with guys in our clinic. And I say this, and I know you guys know this very well, but people mistake diarrhea and incontinence all the time. So I get a lot of people who get referred. I'm in an academic center, like you heard. So I get a lot of tertiary and quaternary referrals. And people say, I've had this million-dollar workup for diarrhea. And we'll get to a section after I do this case that's coming up. And the one thing they haven't had is usually a rectal exam, not under. Under, you're snowed. So part of your sphincter is a skeletal muscle. So if it's weak and patchy, it could just be that you're just snowed. It would be like asking somebody to make a bicep while they're on the table about to get a colonoscopy. That's not going to happen. So people come, and then we talk. And I'm like, I don't think you have diarrhea. And then we get into subtypes. And so I'm on a mission with the fellows. We've got four, five next year, every year, so 15, just to try to get that to become part of what we do, asking those questions, making sure we understand the difference between incontinence and diarrhea, because there is. All right, fecal incontinence, we talked about this. I'm not going to beat it. But also, we'll look at causes of neuropathy, altered rectal or anal sensation. If you have impaired sensation, if you're hypo, hypersensitive, so the hyposensitive patient is usually the constipated patient. They have sometimes what we call a mega rectum. They can just hold an abnormal amount of stool in there, over 300 cc's. And they're not getting any sensation. There's nothing that's saying, hey, you've got to go poop. That whole stool is descended in your rectum. IAS open, squeeze the EAS, run over to the toilet, expand the EAS, get that rectal pressure, poop. They don't sense that. So they can just have stacked and stacked of impacted stool that's just hanging out in the rectum. Opposite, in our incontinent patient, they have what I call a superpower gone wrong. I mean, you could put two cc's in there, and they're like, oh my god, I got to go poop. And then you show them the syringe, right? And that's what they're doing in biofeedback with fecaling incontinent patients. They show them the syringe, and they're like, I just put five cc's of water in there. Or I just put 10 cc's. This should not give you that sensation of having such an urge. And you have developed, I call it the Audubon, from your rectum to your brain. It's not this beautiful pathway that's making me spinal dorsal horn all the way up to your brain. No, it's just straight. There's something in there. I got to go to the bathroom. And that's part of the reason why these people have issues as well, because they're never really forming a full stool, and never waiting for that time, and then having a proper defecation. So again, this is why I kind of beat this in in the sense of what's normal, because then you understand what's abnormal and why. Neuropathy, any neuropathy, diabetes, it doesn't have to be anything like scleroderma. It doesn't have to be anything very dramatic, right? 60% of people have some type of metabolic disorder in the United States. It could be diabetes. So we like to make sure that we understand where these things are coming from, because if we understand where they're coming from, the etiology of these issues, then we can try to maybe reverse that if we've got some mechanisms of doing that. Diarrheal conditions. In GI, we're always thinking about, if it's true diarrhea, you've got to rule that out. Have you looked at celiac disease? Do you know what their thyroid's doing? Have they had a colonoscopy? Did you biopsy the colon, the actual rectal area? Did you biopsy the TI? Do you know if there's IBD? IBS, you're not going to see. IBS is a rule-out, right? It's everything but, with that kind of classic picture of symptomology. So we do these run-of-the-mill tests, but most of the time when these patients have come to me, they've already had all of this done. And then it's a simple, oh, let's talk about your obstetric history, which no one's asked, and that's so painful in GI for me to hear that. And then, oh, well, actually it's just involuntary incontinence, or I wake up with nocturnal stool or something like that, which is a very different issue than celiac disease, right? Okay. And then the diminished rectal capacity. It's just some people have a lot of compliance, that's your constipators, and then some people just don't have a lot of compliance of the rectum. The rectum's actually a very compliant tissue with collagen, and so you should be able to amass stool in there so that it's also desiccating in the rectum. All right. So this is my case study, and I kind of mentioned a little bit of these things. So this is a true story. This is a 55-year-old female who came in to me carrying adult diapers due to accidents. That happened with no warning. She was told that she had IBS diarrhea. IBS implies that you have some type of, it's not pain anymore, that was room three. Room four criteria is discomfort, and it's around the time of defecation. So it could worsen or improve, and it's some type of abdominal discomfort. No pain. This woman has no pain. I'm like, why did they label you in IBS diarrhea? That doesn't make any sense. So that's already my first clue that we're going down the wrong avenue, and this is why you've struggled for so long. Baseline, she's having leakage about three to four times a week following a Bristol three to four. So three to four is normal. Again, I'm like, wait, this doesn't make a lot of sense. I mean, yeah, you're having stool leakage, but this isn't sounding like diarrhea. This is not Bristol six, seven. Three to four is normal. Show the picture. Always show the picture. People think they don't have constipation, and I'm like, oh, you're making those little pellets, those little goat pellets. That's constipation, right? Or, oh, you have this loosey-goosey stuff. That's diarrhea. A picture is a thousand words for patients. Obstetrics history. I asked her, I said, how many gastroenterologists have you seen? Who's ever asked you about obstetrics history? So I gave a speech where I used this case study to a GI group in Florida, and GI is a lot of dudes, okay? It's a lot of dudes in the room, and I said, tell me one guy that would have gone to any doctor. It could have been the dermatologist, and he wasn't telling the story about 20 stitches to his perineum. 20 stitches to your penis, and you don't think that's your go-to story every day of your life, right? But nobody asked this lady about her perineal floor. I just think, I'm making a joke of it right now, but it's so sad. It's so sad that it took this woman 55, she had a military career that she had to end. It's just sad that it got to that point. So yeah, it's in jest, but I say it because these things happen, even in the best case scenarios where people had good intent. They were trying to help her. I don't think that there was malicious intent in not trying to help her. All right, so she obviously had this traumatic thing happen during a spontaneous vaginal delivery. She had a hemorrhoid surgery. You guys know how I feel about that, unless it's like a big Goomba with a thrombus, and it's the most painful thing, and you can't get rid of it, and the sits didn't work, and blah, blah. Leave your anus alone. Leave it alone. Unless you're going to pelvic PT and then manipulate it all you want. No back injuries, no neurological issues, no Coley. Coley's important for us because you get bile acid diarrhea, right? You've got no more storage unit for your bile acid. That's just, your liver's still doing its job. We gotta explain that to people. I'm like, your gallbladder was just a storage unit for bile. Now you just gotta just junk a bile just hanging in your small bowel. It's always before the food comes down. Then I say, remember in fifth grade when you took the water and the oil and you put it in the cup and it separates and you just got this big glob? That's exactly what it's like in your gut. And then that gets all the way down to your terminal ilium. You've got so much of it, it overwhelms this reabsorption area, and then in it goes into your colon, and it's an irritant. Now we all have a small amount of bile that we excrete in our poo and our urine. That's why it's yellow and brown. But we don't have an excess amount. And the moment it's excessive, just the colonocytes are like, eee, and then just a bunch of water floods. Anytime you got anything that's an irritant in the colon, you're gonna flood it out, right? Which is why when people have a viral issue or bacterial, we say, don't take Imodium. Okay, so no coli symptoms, no nocturnal symptoms. When we think nocturnal in GI, we think, ooh, IBD. We get a lot of IBD issues with nocturnal diarrhea. Obviously, no blood or mucus, because then that is alarming whenever we get blood. We always have to say, you've got to make sure you've got an updated colonoscopy. And I'm not talking two months. I'm talking like in the last six to 12 months. And you gotta make sure you have random biopsies to make sure there isn't something underlying. TSH, hyperthyroid, hypothyroid, you guys know this. It'll change the content of your endocrine system is very involved with your digestive enteric nervous system. And then A1C, you can get diabetic neuropathy, but you can get diabetic diarrhea too. All right, and then her meds were reviewed. The meds were the culprit. I always say, make sure you're going over those meds and what are they taking at home? You know, I had one kid who came to me and he had, he ended up having DILI, which is liver injury due to like a drug. And he was doing some sort of, he had constipation and he had heard that some mushroom over the counter and some combination was gonna be really helpful. He was doing just too much. And it had actually caused liver toxicity. So, you know, I was reading this morning that the supplement industry is something like $2.4 billion industry. People always think that they're not taking meds when they're taking supplements because it's natural. Cyanide is natural, PS, by the way, if you want to tell them that. So not everything that's natural is good for you. If you don't have a vitamin D issue, don't take vitamin D. Your receptor's saturated. You're just wasting your money. You don't have a calcium issue, don't take calcium. If you don't have a folic acid issue, don't take folate. If you don't have a B12 issue, don't take B12. Why are we just taking these supplements for no reason? Your body needs X. When it's reached X, you're going to shit it out or whatever. So I'm just saying, don't waste your money. So anyways, so ask about the stuff that's. GI, we're a funny group. I mean, like you guys, we have no holds barred. I get patients who come in, they're really shy, and they're like, oh my god, I'm so sorry I have to say this. And I'm like, listen, I dare you to gross me out. I dare you to gross me out. Try it. Let's see if you can actually gross me out. It's never going to happen. So that kind of lightens the room and gets them to talk. OK, so she's previously tried failed psyllium, over-the-counter paramide, and bile binders. None of these things have worked. Because again, she doesn't have IBS. That's why it doesn't work. What would you do next? I gave you the hint earlier. It's not a test. What do you do? What do you do? Rectal, finger in the butt. Yes, finger in the butt. I use my middle finger. Why do I use my middle finger? Longest. Thank you. Yes. The fellows are like, are you flipping everyone off when you're doing a rectal? And I'm like, no, you idiots, it's your longest finger. It's going to give me just a little bit more information. Why wouldn't I do that? Duh. OK, so we have this amazing quote from this gastroenterologist who said, don't just perform a DRE during endoscopy, because is it really a DRE, or is it just a generous lubrication workout? And I would say to you, it's a generous lubrication workout. I don't really get any information when somebody, unless I'm looking for a fissure, and I couldn't get them to relax, that's the perfect moment to look for a fissure. They're, again, propofoled out, they're snowed, the milk of amnesia is working, and you can look in there and see if you missed something that you couldn't get them to show you in the clinic visit. So that is a useful moment for the DRE. Otherwise, other than telling me I may have a stricture or an obstruction, it's of no utility. So this is just a great study by one of my mentors, Dr. Rao, who looked at who does DREs. And the more years you've had since graduation, the less you do them. And I just think it's so sad. These guys right here, convenience can only do at colonoscopy. Limited value, outdated, not useful, what? Again, these are gastroenterologists. This is sad. And this is not an old study. This is sometime in the last five years. So she had a perineal scar. She had a weak anal tone at rest with an almost patchless anus. And I'm like, OK, well, the spigot's open, right? It's kind of like wondering why the toothpaste is just, you're squeezing the toothpaste. You got no cap on. You're like, why is the toothpaste coming out? Right? But I mean, so I do a lot of analogies, like I'm making jokes. But I do a lot of analogies with my patients. I'm sure you guys do too, because they just, it's like going to the mechanic, and he's talking all sorts of stuff. And you're like, I don't know what that means. You've got to make it relatable for them. And so I, and I'll bring out, actually, my anal rectal manometry nurse. She went and bought me toothpaste. So I showed up, and she had like toothpaste. I'm like, oh my god, thank you. So now I bust out that toothpaste. And I'm like, we're going to, you're going to look at this. I'm going to take the top off. And I'm going to squeeze. And we're like, do you get it now? You have no anus sphincter, right? So this is what we've got to work on. OK. All right. This is case number two. And then I'll put it together for fecal incontinence. She's 86. She places daily pads due to leakage, because she believes that she has got a gluten intolerance. Everybody thinks they've got a gluten intolerance. And I'm sorry for those of you who have gluten intolerance. There is such a thing as gluten insensitive. There is such a thing as being genetically predisposed to having celiac disease, but not actually having it and manifesting it. Celiac disease means you have small bowel disease. You can actually see it. And you can biopsy it. And you get villus atrophy from this. But anyways, she's 86. And I don't know, she's on TikTok or whatever. And she thinks she has gluten intolerance and hemorrhoids. She thinks she has hemorrhoids. I'm going to cut to this part right here, where I do her rectal. And she's got rectal, like she just has a full-on rectal prolapse. And she's been told she has hemorrhoids. I'm like, these are, this is not a hemorrhoid. This is just your anus, that your rectum is just out, inside out. She didn't believe me. I said, can I see your phone? I'm going to take a picture and a video of this so that you can have it and you can see it. So I did. And then I showed her and explained it. Because again, people, you guys know this. There's some, you can't be curious about down there. You can never put a mirror down there. You can't do a squat. You can never like, no, right? So this poor 86-year-old woman, it's affecting her quality of life. She's a golfer. She wants to be out there. She thinks she has hemorrhoids. She's like, I need a hemorrhoid surgery. Again, you don't. You have a rectal prolapse. That's a different issue. OK, so this is just to remind you that not all diarrhea is diarrhea. Sometimes it's an anatomical issue like this. And not all diarrhea is IBS. Sometimes it's a little bit more thoughtful, right? And it could be sphincter issues. This is, and I'm not going to go over each of these, because we've talked a lot about this stuff. But this is just a nice little chart going over neuropathy that can impact the sphincter and the rectum, medical disorders, Parkinson's. I have a lot of Parkinson's patients. And they range from overflow diarrhea, which is paradoxical diarrhea, to just having just dysmotility, pure dysmotility. And they get impaction, and then just overflow over that. You've got people who've had trauma. So they get all sorts of spinal cord injuries and issues like that. You get muscular abnormalities. So you can have puborectalis defects or OB trauma or prolapse like this patient. You can have anatomical issues like fissures or other rectal causes and perianal rectal causes. Stool characteristics is really important. We'll go over that in a second. And then I mentioned drugs and why that's important. And then elderly. And then who are you dealing with? Do you have a patient who has neurodevelopmental delay? And this is the reason. They may be digging in their rectum. And they're trying to disimpact. And so you've got to think outside the box on how you're going to deal with this type of diarrhea, which isn't really diarrhea. All right. So when do we do testing? And then we'll go into what kind of testing. So it really honestly has to do with the stool consistency and the picture of what the patient is telling me. So if the diarrhea is the primary reason it's true diarrhea, then I would, again, stool studies, evaluate for some of those metabolic issues we've mentioned, look for bacterial overgrowth, some type of intolerance to a disaccharides, for example, lactose. Colonoscopy to look for mucosal disease or other issues. And then if it's FI without diarrhea, that's when I go into the structural and the physiologic testing, which I'm going to show you. One side note on SIBO, because also everybody on TikTok thinks they have SIBO. SIBO is the fifth domino. This is how I explain it. You don't have SIBO as the primary anything. It's not like you just woke up one day and you're like, I got SIBO. That's not how it works. The microbiome is a very complex thing. And we are just sort of on the precipice of understanding it. So I always, when people come in and they show me stool studies I'm like, that's just looking at your colon bacteria. You don't know anything about your small bowel. Small bowel is way longer. This is where all this is happening. Also, we're starting to look at the microbiome and talking about it as a metabolic kind of thing. So what's the metabolome of this colony of diarrhea? What's it doing? What's it saying? Is it emitting a cytokine? Is it talking to a macrophage? Did it stimulate neutrophils to come in? Are the nerve endings now on fire and sending information to the spinal dorsal horn and going up to the brainstem or the cerebral cortex? There's a lot of stuff. And we're in the primitive stages of all of this. So I just think that every test that we have, even a breath test, I'm like, it wasn't really telling me. I don't know. I think we'll look back 10 years from now and we'll just be like, oh, wasn't it so cute how we used to do this? Because we just don't know enough about the microbiome. You're born with your, you develop your microbiome in the beginning. Were you a spontaneous vaginal delivery? Did you go in and out of the hospital when you were a kid? Did you take a ton of antibiotics for ear infections? Did you have siblings? Did you eat dirt as a kid? Or did you grow up in a house where everything was Clorox? All of that stuff makes up what your microbiome is. Your microbiome stays put. Then what changes is, essentially, think of it as skyscrapers. You either have this amount or this amount. And things kind of change the colony, the amount. And if you change the amount of the colony, other things go great. And it's just a garden. It's like if you were to remove a plant, something's going to grow in that spot. So it's the same premise. And I liken it to that, and that's how I explain it. Anyway, so it's the fifth domino, it's not the first. Figure out what the etiology is to SIBO. And then there is something, just in case you hear this and you're like, what is that? So methanogenic overgrowth. That's just another ICD-10 code. Essentially, it is a subtype. So it's bacterial overgrowth, but methane-producing, rather than bacterial overgrowth, which tends to be hydrogen-producing. And then there's a third subtype that's just come out, which is hydrogen 2-sulfide. So there are a lot of things that are coming out. And I think this is ever-evolving. All right. And then fructose and lactose, we can actually test these. So we'll do small bowel biopsies. You can do disaccharides enzymes. You biopsy, put it on a frozen specimen, send it off. And they actually measure how much of the lactase you have. Now, lactase, I wouldn't get someone to do an EGD and say, this is how we determine that. You can just do a dairy trial. Diarrhea? You got it. But for somebody who might have a maltase, sucrase, palatinase, like one of these weird enzymes that you don't know how else to measure, it's a great thing. For me, in my realm, where sometimes I don't know what else to do, it's so satisfying. And then we put these people on sucrose, or sucrase, excuse me, to help them deal with the sucrose. Or we do a dietary modification. And boom, they feel great. I had a 76-year-old man who had diarrhea his entire life. And he went on sucrase. And he is just like a new man. It's just very satisfying. All right. Enterectomenometry. So there is, as of two years ago, a protocol called the London Classification Protocol, which was an attempt to standardize what's going on in all of these offices. Because everyone, it's user-dependent. I'm just going to tell you that. And you're looking at anal sphincter. You're looking at the reflexes. We talked about that. We're looking at rectal sensation. We do that with the balloon who's hyper, hyposensitive. Remember, hypersensitive are going to be your diarrhea, fecal incontinent. Hyposensitive, those are your constipated patients. And then compliance, it's also the same. Constipated, they're very compliant. And hypocompliant, those are your diarrhea. It's standardized. So you do the same thing for every single person. And that's the hope, is that the more you standardize it, the better the outcome of the test will be. I will tell you, biofeedback works, and you know this, because in the test, you can actually get someone to change their topography and their manometry findings. So one of the things we try really, really hard is people will be like, am I doing it right? And we're like, you know, even if they're not, if there's nothing happening, we're all looking going, that's the reason. But you can't say anything, because then you're going to change the test. And you can actually change it with one coaching. You can get them to squeeze harder. You can get them to contract. So you want to get as much of the normal as you can. And remember, these people are in their left lateral position. Nobody poops that way. There's nothing natural about this test. We stuck a catheter up your bum. There's a balloon. You're in some paper pants. You don't know what's going on back there. You hear some whisperings. You're like, oh, god. And then you keep, everybody keeps thinking the worst is coming with anal rectal manometry. And they're like, that was it. And I was like, yeah, my middle finger was bigger than this little thing right here. It's not a big deal. Anyway, and then there's a balloon expulsion test. So what that is, is just, again, similar size type catheter. There's a little balloon. We fill it with usually 50 or 60 cc's of warm water to try to stimulate the rectum. And then you get a little paper coat. And then you walk off to the bathroom. We give you a minute to poop out on your own. You can use a Scotty Potty, but we want to know, because then that tells us that you're changing the angle of things. And so that's a very key, hey, you need some pelvic PT. And then we see whether or not you can pull it out. And if not, we just deflate the balloon, and out it comes. You can predict who's going to be able to balloon expulse and who won't. Very telling. Now, the part and the reason that the balloon expulsion is there is because, again, the test is on the left lateral side. And so it's not a normal way to go to the bathroom, especially around people. So when you ask people to bear down, that can also be a reason why you get an abnormal test. All right, this is what we look at. So you essentially get a bunch of line graphs. And we've turned it into topography. It's really nice to see. So you've got a baseline pressure. Blue means nothing. This is your rectum. Your rectum's above here. When you go back to this, you can see that there's actually two little impedance pressure measurements here. And then there's 10. So what you get is you'll get pressure that's generated here. And I'll just come into it. So heat, heat, heat means tight, tight, tight, right? And this makes sense. So you've got some baseline pressure. We're not all pooping. I'm going to get this by then. We're not all pooping on ourselves right now, right? So you've got some baseline anal pressure. And then I ask you to squeeze. And if you have that catheter in, this is what would happen if you've got a normal squeeze. So good. You did a good job. What's wrong with this one? So this is the normal, and this is the abnormal. What's wrong? I asked the person to squeeze. What happened? There's no squeeze. So what is this patient? Can you predict who this patient is? What do they have, like their clinical picture when they come in? I can't hear you guys. Fecal incontinence, right? And it could be any of those etiologies that we looked at. We don't know what the etiology is, but we're predicting that this is a person who's fecally incontinent. You are correct. All right. Fecal incontinence is not the only test. It's our favorite test. It's easy. It's non-invasive. But you also have anal, EMG. You've got TAMs. This is a really cool sort of new arena. And they actually use it a lot for improving and neuromodulating without using the drugs. They just do a lot of motor evoke potential. So essentially, you place these large magnets, and you try to figure out where on the lumbar sacral region you get the biggest motor potential. And you look at your calf to see where you get that actual reflex. And that's where you focus the energy. But what we notice in fecally incontinent patients, and this is, my goodness, this is the, I'm going to get it. This is a normal patient. Look at when they're actually having a motor evoke potential. Look at this patient, much longer. So you know you've got to squeeze your anus, but it took a lot longer for it to happen. And it might be weaker as well, too, the amplitude of that squeeze. So this is how this can be really helpful if you're having some issues. We also do endoscopic anal ultrasounds, rigid or non. We'll do anal MRIs. And then dynamic MRIs, our best friend, right? Everybody loves a dynamic MRI, except for the patient. Fecally incontinent, I tell them, I'm like, this is the worst part of any of the stuff I'm going to make you do. That's the worst part, right? Anything else, you're sleeping, the catheter is so easy. So conservative treatments, you always got to make sure you do the ABCDEF. So make sure that you're addressing the etiologies, and make sure that you're bulking up the stool, psyllium. What's the goal fiber for somebody who's around the age of 50, male or female? What's the goal? You guys know? 50. It's high. It's really high. So we don't need enough fiber. Fiber's great. It's just going to, if you've got diarrhea, it coalesces the stool, kind of puts it in a little. Again, school project, if they don't believe you, little cup, leave it on the kitchen counter, come back in an hour, mix it with your psyllium that you got at Costco. It's just a jellified clump. That's your stool. Or vice versa, if you're constipated, it draws water in. So it's the best of both worlds. And in those IBS mixed patients, that's really honestly what we've got to work with a lot of the time. Make sure you're controlling bowel consistency. I'll go over some of these medicines later when we talk about other things. And I'm sorry, I didn't make this slide very well. I apologize. Dietary modifications, remove the culprit if you've got it. I have one lady who had true diarrhea, no incontinence. We did a DRE. She had had a traumatic brain injury, and her husband was always trying to spoil her. And she loved Starbucks, Mocha Latte, Chaka, whatever, I don't know, some crazy Starbucks drink. I don't drink coffee. I know, you're surprised. But regardless, she was drinking some crazy amount. I don't even know how they were funding this, like seven a day. Yeah. You know what else is in that drink? A lot of sugar. Yeah. And you know why people feel better when on a FODMAP diet? Because you're not eating a ton of sugar. That's it. I mean, and that's where that whole like I think I'm gluten intolerant No gluten like a croissant is delicious, but there's a lot of stuff in there That's not really that great for you right and I say that I'm French, so I promise you I grew up on croissants All right diet are they doing stuff or they said they're just sleeping a sedentary lifestyle Or they're just not doing they just watch TV all the time right all that is gonna affect your guy if you're not moving You're guess I'm moving I get marathon runners. They're like I'm having issues. Well. Yeah, I mean you're just like we're running 15 miles a day Yeah, absolutely We're bipedal creatures right we're not quadrupeds anymore. I saw sometimes I hate social media, but I love this one. It was like humans don't make any sense Why is the pelvic floor where it is and then they did this and then just put the human on there as a quadruped? And they're like aha It makes sense now I get the pelvic floor so we're bipedal creatures And we're just at the mercy of gravity down there We just are so a runner is gonna have issues potentially too, and then biofeedback All right advanced treatments have to do with maybe you know injectables We also do sphincteroplasty with our colorectal surgery buddies or artificial bowel sphincters are used and then sacral neuromodulation We kind of talked about that So this is actually going out. This is called Celesta. It's kind of going out of favor in GI and this is You've all seen lip plumper This is anal plumper I'm not kidding so it goes proximal to the anal verge you do it in a 12 3 6 9 you can do it in The clinic you get an anal speculum, and then you just put it proximal to that anal verge They can't feel it, and you just plump it up now. This is a person who needs to have Really great manipulation under a pelvic floor if you give this to the person who has never done any pelvic PT You're now obstructing their rectum and their anus. How are they gonna relax it right? So you gotta be really thoughtful about who you use it for This is a endo anal ultrasound just to show you like no amount of kegels and pelvic PT and biofeedback It's gonna change this look at that you see right there in the anterior portion of your EAS This is somebody who probably had obstetrics trauma, so that's a scar That's fibrous tissue fibrous tissue is not muscular tissue you cannot contract fibrous tissue so Again, this is why sometimes when people are like not getting better You have to start thinking outside the box a little and then Lastly you guys know very much about this. I do recommend this I also recommend SNS to patients a lot for especially my older patients who don't do really well with pelvic PT or Who are just ready they're ready to go to that step already, and they want to do pelvic PT So there's not really one-size-fits-all It's kind of what this is all cemented to show you this energy defecation, okay? You understand the normal. This is essentially when there's a mismatch in the coordination this will go quicker You're either not contracting the intra anal or intra abdominal pelvic muscles to generate pressure to poop out or you're Squeezing your anus when you shouldn't be so it's a mismatch And then you just have to find the pattern and then you can say to your pelvic PT What's the pattern what are they doing and what should we focus our treatments on? So we don't really know why people get pelvic dyssynergia We think that it's probably one of these reasons, so is it too much straining? To expel your hard stools over time and so now you just you're just pushing everything and that's usually what I see It's like a chronic constipator over time, and they're just pushing and pushing and pushing and now they're just recruiting Recruiting every muscle and you can see it on DRE when you ask them to squeeze they squeeze their glutes they squeeze their hamstrings I'm like mm-hmm missy you didn't squeeze your anus at all and it's tight tight tight right you're not relaxing it So you're just squeezing other muscle grits Unclear we think that there's some association with like stuff that began at childhood poor toileting behaviors people have shy Bowels you've all grown up with somebody like that you may be somebody like that who didn't want to use the bathroom at school Well if you ignore the urge You're gonna. You're gonna lose that reflex and that reflex may or may not come back So really important if you have children just make sure that you're really you know trying to like Make sure to tell them it's very important We have one pelvic PT at USF, and she's like my kid doesn't want to poop in public She's like hell. No you're gonna poop in public dammit. I think that's gonna make another problem, too, but just be aware Be aware, and then you know it may be again trauma There's something that happened there, and then an unknown cause we do see a higher prevalence with opiate or poor posture And then high-risk women endometriosis Women over men history of psychological disorders or some type of functional pain disorder All right, we talked about the rectal exam we talked about anal rectal manometry I kind of mentioned her shrugs in there too and the sensory Impairment and the compliance and all that and this stuff that you can gain from that test We talked about why balloon expulsion is added to the test because it's in the privacy of the toilet They can do it on their own It's kind of telling us and you can predict who would and then the other is you know you want to know Do you have colonic hypomotility as well so a sitzmarker even though a really old test is actually really useful Defecography or a dynamic MRI and then the EMG of the pelvic floor and I mentioned that a little bit These are the subtypes we don't use these anymore But I wanted to show it to you so you understand kind of what we're looking at so and I apologize I went over here I'm giving you guys some love So type one you're bearing down But but you're pooping okay, tell me how you're gonna get the toothpaste out when this is like you just put the cap on You put the cap on and you're like. I'm gonna get that toothpaste out. Dr.. Talon. Hell. No you're not okay number two What happened? Why are you not? There's no pressure here. You're generating no intra-abdominal pressure right, but you're doing a decent Job not great. It's not my favorite. I'm still seeing a little too much red So there's some paradoxical action, but you've got no adequate pushing force and unable type three Maybe you're generating something. I mean it's definitely not blue anymore. I see some green I'd love it to be a little bit more like this And you relax this but the problem is that this Doesn't overcome this right, then it's just a matter of numbers like math if you generate 40% 40 millimeters of mercury here, and this right here is measured at 70 you have a negative 30 You can't push across something. That's higher. You've got to generate more force up here To get the stool out So this looks like a mild version like they're doing a good job But they're just not generating enough pressure and then for they're not there's nothing happening here Nothing nada, and then yeah, they're demonstrating maybe you know something here, but honestly It's not any different than baseline, so I wonder if this is a person who doesn't have neuropathy Okay, we've gone away from these types like we don't really stick to that But this is to give you an idea because there's a lot of art in manometry Some places will just do the computer like whatever is the computer generated. I tend to not do that I just don't think it tells the full picture And again, you don't know what's going on like you don't know if they coach them or not All right, no one test is sufficient for either fi or for dysenergic defecation. That's just the bottom line of that I want you to know An occurrence of a pattern is not does not mean that you have a diagnostic dysenergic defecation again Because you can coach somebody into something so just be aware like don't slam-dunk like you know put somebody in a room and close The door it's probably a house that can go in the house of dysenergic defecation that it moves all around And then you know the confidence though does increase if you start to have multiple tests that are kind of showing you the same thing that's when we start to say oh, I think you have a Dysenergic defecation with propulsive issues or something like that or contraction mixed coordination issues or hyper tonic Hyper contractile anal sphincter, so that's what the London classification is also done It's tried to give us the terminology to really be very mindful so that we can help our colleagues and our physical therapist Standard treatments, I mean, you know it's the same thing every single time are you doing enough adequate intake are you taking fiber? Are you avoiding constipating medicines? Are you exercising? Are you titrating your laxatives? Are you toilet training? Are you not ignoring the stimulus? I mean how many people know this like you poop on the weekend But at four o'clock in the morning when you have to rush into a surgery or you got to go and you got to make Five lunches and your husband forgot this or your wife forgot this and you know I mean There's just so many things going on in the morning that you just might not have time to kind of check in with the body And that's a lot of what pelvic PT also teaches our patients give yourself a little bit of time Just for you so that you can sense these things and don't ignore the urge And Then advanced treatments. These are just to tell you we don't use Botox The only way I would use a Botox on a patient who had a tight sphincter Would be that nerd developmental child or adult that is trying to dig out I'm probably not going to be able to teach that coordination that needs to happen I'm gonna I'm gonna have to think outside of the box relying on Botox for somebody who can follow instructions I don't think is the way to go. So this is not something we recommend psychotherapy, absolutely Because of the reason that I told you like there's a lot of stuff that's intertwined with psychological disorders in DGBI sacral nerve modulation Absolutely, especially if you've got somebody's got neuropathy and there's something that we can make their perineal massage. Oh Yeah, I mean I'm in the right room right the I love you massage if you can stimulate that peristalsis That's wonderful. And by the way, the colon does not do peristalsis. It does something called segmentation up down up down ascending colon Transverse descending and by the way, I built like the most beautiful colon right? It's not like that. It's like Sometimes I like finish a colonoscopy and my hand is so tight. I have to like tell the patient afterwards I'm like, can you imagine you're just a piece of poop and you're just trying to like find out And you're like, where's the out I don't know where the out like sometimes I don't know where the in is right It's like imagine that so I might tell them that Surgery is the last resort. It's like a cold day in hell and you've like, you know bound my hands behind my back Where I say to somebody we're gonna do surgery. It's just really like it's hard for me to imagine those moments I get a lot of people come to me having had a surgery what I see I just end up with people who end up With small bowel constipation, right and we didn't really fix the issue PT biofeedback That's the jam all the randomized control trials tell us that's where it's at I don't have to go through this but it's better than peg It's better than diazepam. It's better than sham therapy. It's better than standard therapy a one-year outcome It's better like home versus office actually doesn't really make a big difference if you could teach it to them They can go home and do it. We know that and The this for us is evidence type 1 grade a I mean, we're we're on this same way You guys are on this. We're all on the same train Take home points not one test defines Fi not one test defines dysenergic defecation DRE is crucial It can you know help you towards a diagnosis and a treatment especially if you've got somebody who has been seen multiple times by many many different patients about people providers and Needs you to think outside the box Historical clues that goes with these the physical exam as well, too And then biofeedback do it love it live it, right? I mean, that's it's the first preferred treatment for us as well Okay, I've talked and talked and I'll talk some more Do you guys have questions? Do you need a break? You Yeah, you want to keep going? Okay. All right all right, so we're gonna go over novel and non for pharmacologic and non pharmacologic treatments for Abnormal pain and IBS and and really kind of focus on disorders of brain gut so I put this up here because I want you guys to remember that the patient physician or patient provider is Is if it can be a vicious cycle and it's actually it should be like there's another I have another algorithm That's a triangle and it's at the bottom Your relationship with someone in your ability to build trust with them is key to you taking any treatment further and helping them especially when it comes to this arena because this is the We're gonna think outside the box do clinical trials But also maybe drug you and nobody wants that that to be the first thing and I don't want it to be the first thing either but we may need to use a neuromodulator so knowing and understanding that that relationship is key and building and knowing you might not get in on the first go-around is Really important and you guys know that as well There's lots of emergent treatments. We're gonna go over these for IBS. So our known pharmacopharmaco therapy that we have so I put together the guidelines for AGA American College of Gastro and American Gastro Association here and the ones in red are going to be the ACG and you'll see they have different like for example, alicitron is conditional here for AGA and conditional for ACG, but then they have different quality of evidence. So I'll tell you there is an algorithm. I'm not gonna go over this and you know in super detail we'll kind of mention a lot of these things, but Even our algorithms and even our guidelines that we love tell us two different things. So there is More than one way to skin this cat. That's essentially what I'm trying to say. Okay We have a IBS algorithm essentially all IBS patients, you know The provider relationship with patients education and reassurance Lifetime modifications dietary modifications the basics and then we go down the C we go down the D and it just depends Did you try an osmotic if you're constipated? Have you tried fiber? Have you tried diet, right? All these things are really important and then we get into the secreted gogs. These are linac latai. These are Lubu pro stone This is to nap in or a new kid on the block. IBS Rella. These are manipulating water content and Vice versa on the other side. We're doing the opposite We're again manipulating water content, but slowing the gut down or acting on new receptors and making it sluggish So it's not having all these peristaltic segmentation Contractions and then for the patients that get down here and they're still persisting with symptoms This is when we start to think. Okay, maybe I need to add a neuro gut modulator Maybe I need to think about psychotherapy some gut behavior Thing that I can help the patient with overall and that's where we're gonna focus I put this up here just to show you so lenac latai and placenta tide So we've got true Lance and we've got lens s they've got different doses. They are GC activators on this receptor and they are secondarily activating the CFTR gene and then basically then it's just like Chloride if you manipulate chloride, which is a negative ion sodium follows you have sodium chloride. That's salt water follows Again water comes back into the loom and mixing the softer stool here to nap in or is the new kid on the block? It's acting on a different receptor and h e3 and then Luby Prostone is amethyst that it acts directly on the chloride channel receptor We're manipulating ions Microbiology This is ten apineur, which is also known as it's Rella. It's came out this last year very effective It's shown that patients actually have you know, statistically well from baseline have a complete spontaneous bowel movement Over their baseline and then also abdominal symptoms improve for this patient population as well too and global symptoms improve So I like it. I'll tell you that it's like anything You're not gonna get it approved unless you tried everything else, right? It's just like it's like anything else that we're now all dealing with So they're gonna make you run through lens s and amethyst because they're the old kids on the block Unfortunately, those two are so effective. They cause a lot of explosive diarrhea. They cause a lot of cramping Then you go to trulance and you're like, but it acts on the same receptors lens s It's just it's like you feel like you're hitting your head against the wall sometimes and I understand that So this is that algorithm like we've tried treated you with all these other things and now you're still some Symptoms you still have symptoms, excuse me. And so now we start to think about well, what can we do? So we are trying to change your pain regulation We are trying to decrease the afferent signals that are coming from your enteric nervous system and to downgrade it and that's what CBT does as well to this is going to affect your motility your secretion and your pain and Overall, we're hoping that it modulates and causes some cell regrowth as well, too And evidence-based medicine is very restricted in these situations So this is all really a lot of like expert consensus and this is case series and just what we do in clinic This is that Algorithm was talking about where down here is this is the foundation of everything and I'll know and the fellows are like But you didn't mention blah blah and I'm like that patient was not receptive to us going here They're not receptive to me putting them on mirtazapine or saying hey, I'm gonna put you on quetiapine and then they google it They're like it's an anti psychotic I'm not psychotic and I'm like that's I never said you were psychotic, right? You got to like wean them into this dip their little toe So I'm gonna go over kind of how we do these neuro gut modulators. This comes from Rome Rome is our every X amount of years, like every decade or so, they get together and all the experts make a decision about what we're going to call things, what are going to be the characteristics of those things that define it as a diagnosis, and then that is helpful. So that's how we come up with the IBS criteria, and it changes from room two, three, four, and five is coming out soon. So Dr. Dressman is one of the leaders of this. And this is a really lovely little algorithm that he put together. We use these drugs like candy, so SSRIs, TCAs, tetracyclics, so think mirtazapine, and SNRIs. And then we augment. And the reason we can augment is that we use very low doses of these drugs. We don't go to the max. You can't go to the max on a TCA. Tricyclic is an old drug. When you look at this next one right here, look at why tricyclic's effective. Tricyclic by the way is like, that's the first thing I go to, and I usually go with the oldest, amyltryptoline. Why? Because you're hitting all the receptors. And you don't know what receptor is actually driving the pain for that patient. And so if you throw the spaghetti at the wall, you're likely to get something to stick. And then you get into the more, you know, very selective stuff, and that's when it becomes a little bit harder. So I really love a TCA, a low dose. Amyltryptoline's really nice because it comes in a liquid, and for people who don't like pills or people who have PEG tubes or something like that and are dysphagic, that's a nice alternative. When you get into imipramine and zipramine, these are the newest TCAs, like the youngest of the whole group, you get a lot less of the anticholinergic side effects, so you can go up on the doses. And I'm talking like, I start teeny tiny, I start 10, cut it in half, and they'll tell me I'm still drowsy. I'm like, cut that in a fourth, if you can. Crush, sprinkle a tiny bit into your coffee in the morning, just start somewhere, and then we'll slowly work, take it at night, it's going to make you lethargic, it's going to help you sleep, right? A lot of these people don't sleep very well. So TCAs are great for that. Mirtazapine's an excellent agent if somebody has a combined nausea, vomiting. If they're losing weight, I love that for a patient who's got pain, nausea, vomiting, they've got some weight loss, this is going to be excellent, it's going to stimulate appetite stimulation. But it's very helpful for people also for sleep, and it's using sleep medicine, remeron. So it's got a lot of uses, and it's used in a lot of different specialties. SSRIs, I limit to people who have an anxiety, right, OCD, or you walk in the room and you can feel the tension, you could cut it with a knife. So for me, an SSRI is really useful for that patient to help them, because part of it probably has to do with releasing a lot of that stress and that anxiety which is playing out in their gut. And then SNRIs, if there's a pain that we haven't been able to target with TCAs, neuropathic pain, fibromyalgia, SNRIs are really useful for this. So this is kind of how we make a decision, but again, it's very patient, per patient, and it's depicting whatever's going on in their life. And then we augment with some atypicals, so if you've got somebody who's got, you know, maybe some neuropathic pain that you couldn't deal with with this, maybe you're thinking a delta ligand, pregabalin, gabapentin, Lyrica, et cetera. Maybe you've got somebody on a TCA and the pain's doing great, but that's not really doing enough for the anxiety, or you've got some phobic features, so maybe you add the SSRI. Bupropion, Buspar, we love that. It also helps with fundal accommodations, actually helps your stomach relax, so people who are gastrophoretic don't have a lot of that tone. Maybe that can help them to eat a little bit more and feel a little more secure around food and decrease some of the ARFID symptoms they might have, like restricted food intake. And then you think about other things. Is nausea the issue? Is sleep also an issue? So I spend a lot, in that physician relationship in the beginning, I spend a lot trying to just get to know the patient. What do you do? What's your work? What's your home life like? Because sometimes there's some things that you're not going to be able to, I have a patient who is a gastrophoretic with IBS and central sensitization syndrome issues, and she lives in a trailer with no plumbing, and she has a PEG tube, and I'm like, where do you go from that? So I keep telling you, take, do, whatever, but unless I know what your limitations are, I'm not going to be able to help you, so it's very important. And then we'll focus on this in a second, just psychological treatments. We actually do have a GI psychologist at our institution that works in our neuro-gastro-motility clinic with me, and my colleague who is our GI surgeon, and then we have a nurse practitioner who specializes in GI motility from mouth to anus. I mentioned a lot of this, like, why do we augment? I just want to focus on a lot of people get nervous about serotonin syndrome. That's very rare, and at the doses that we're using, it's highly unlikely to happen. Now for some people, if they're still concerned, I'll say, you know, if they have a psychiatrist that's already involved, I'll say, go back to your psychiatrist and tell them what I'm thinking and see if they're okay with this, and maybe they even decrease the dose of something else as we augment this. And we kind of, like, make a, you know, balance the scale here. I do use it a lot in people who have refractory GI issues because I can't get them past the pain. That's all they can focus on is their quality of life and the pain. And then these are just some examples that I've already mentioned, like how I would put these together, so you can refer back to this. Mirtazapine. This is a lovely RCT, looking at eight weeks with mirtazapine, mean age, 38. So primary outcome was for people to have a reported change, so this is placebo and with mirtazapine. And essentially people just, the baseline is people had improvement, significant in pain, severity, frequency. And when people feel better, right, like if you're not sleeping, which by the way is a torture technique, you're, everything is going to be, it's going to be awful, right. So I focus, that's why I spend a lot of time focused on these things. But people felt better. Now adverse events with this is that sometimes people have too much weight gain and now they come back to you and say, I'm getting too much weight, you got to come off the mirtazapine. I hate when they say that, but it is what it is. Pregabalin as a delta ligand, so versus placebo, this is a 12-week trial, again an RCT. This is for people who are having IBS over three times a month. So the pregabalin arm, this is your placebo, and pregabalin showed a lovely, again, statistically significant, sorry, statistically significant arm. So pregabalin is definitely of use. It's probably not my first go-to though, because it's very sedating and you have to use pretty high doses, right, TAD 900, that's hard. General recommendations, I say lower modest dosages is arguably the most convincing for patients and have the most benefit. And SSRIs can also be recommended. Augmentation is always useful, especially when you want to target different mechanisms of action, and that allows you to keep the doses really low so people don't have those side effects. Treatment, I usually continue treatment. A lot of patients will say, can I stop it? I'm like, well, I mean, you were basically not living a human life before this, so I mean, go right ahead. Like, if you want to stop it and see what happens, great. Maybe you've built some other ways of handling stress during this time frame that you can now rely on these things. Let's do it. I'm here for you, and if something happens, we'll go back, right? And I think, again, it's that patient-relationship-provider relationship. And then this is just about adherence and just being there for them. Novel therapies. I'm almost done, guys. Abastin is an H1 antagonist that's been looked at for reducing pain in IBS, and the theory is that it sensitizes certain receptors that will actually help you to decrease pain. So they took 55 IBS patients, 62% of them were women, about 35 mean age, randomized them to Abastin or placebo for 12 weeks, and those that were treated with the H1 antagonist had at least considerable relief of symptoms, 46 to 13. So very, very, something that's hopeful for us to look at. And then gradual and significant decrease of abdominal pain scores we're seeing with Abastin over placebo. This is not something, these are kind of in the clinical trial ages, right? This is, again, something that's very primitive. We look at these things. And it's just like supplements. The reason supplements are very, still people love, is because sometimes they do work, right? So that's why, and we don't know who is gonna benefit or what. So this is another MOA that we're looking at. This is looking at cannabinoid receptors, and it's trying to activate this on different types of cells that are in your gut wall, the epithelial cells, your immune cells, your afferent nerves. And my hypothesis is maybe you can attenuate, again, to decrease that nociception that's happening, so you decrease that brain-gut interaction. This is the phase two trial, and essentially it just showed that these patients actually had a benefit. So they're looking in this, and they're moving forward with phase three. Glutamine's been looked at for permeability, intestinal permeability. That's gut leakage. Everybody thinks they have a hole in their gut. You would be septic. That's not what we're talking about. We're talking about epithelial tight junctions, adherens, occludin, all that stuff. It's much more microbiology than more electron microscopy when we say those things. Glutamine has been shown, as well, to decrease a lot of different points, secondary endpoints, like daily bowel movements, the Bristol school scale, the intestinal permeability, which they actually can measure in urinary lactose versus mannitol ratios, so you can see how much people are excreting. And it normalized in patients that were on glutamine, meaning that we think that if you're on this, we could maybe improve your tight junctions and so less stuff is leaking out, which is lovely. But more RCTs have to be done now to validate this. This is showing you abdominal distension went down and pain frequency and severity and quality of life. And so all these things improved in the patients that were on post-glutamine, their quality of life. This means that their quality of life impacted by pain went down. That's what that means, okay? And then satisfaction with bowel habits, as well, too. And lastly, the vagal nerve system. So you have a vagal nerve, and it's gonna go up your nucleus tractus into your central autonomic network and then into your brain, and it acts on all these different areas, the amygdala and the hypothalamus, and a lot of these areas have to do with emotional regulation, which is why a lot of MRI studies that look at IBS patients can predict who's gonna have IBS and not. They have a lot of activity on these functional MRIs in certain regions, so we know this is somebody, again, who has a lot of communication between the nervous system and the brain, more so than the regular population. And that's probably why they've got this superpower gone wrong again. So what we're trying to do is, right here, descending modular fibers from your brain stem can alter your sensitivity. So we're trying to tamponade that information that's coming from your nervous system. How do we do it? So there's all sorts of devices, and this is a study, it's called IBS Stim, right here, and it's actually been looked at only in its FDA-approved for kids 11 to 18. They're doing studies now on the West Coast looking at adults to see if we can get the same outcome. And they stimulate the auricular branch of the vagus nerve, so something that we can access that's peripheral. That's why those little bracelets that sometimes people wear, that's because there's a branch here so you can kind of push on that. You can get a sensory vagal impact around the heart and around the neck, so there's some handheld. I showed you a handheld device, like right here. Sorry. Right here is a handheld device. So there's all sorts of different ways of doing this, and neurology is really interested in this as well with migraines, so this is very useful. But we stimulate this branch, and we looked at, we do different voltage for different pulses, and what we do is we put these needles within about 1 to 1.5 millimeter of the actual vascular bundle of the auricular vagal branch, and we create this little field effect around the ear, and it stimulates the brain to, again, down-regulate that information, which is just phenomenal, right? And what they showed is that over time, in 104 adolescents, they had worse decreasing pain scores that at four weeks and at follow-up were continued. They wore them. They wore like a little hat when they went into the, you know, into the shower, and they just like wore their little, for four weeks. And again, they looked at abdominal pain score decreased 60%, 22, 58, 29, so I think this is obviously another avenue, and in GI, this is an arena that we're really exploring. This is another version. They did sham versus a handheld, and then it again showed that it not only helped with pain, but it increased complete spontaneous bowel movements and improved their quality of life and decreased their IBS symptom scores. So this is something we're looking at. And the last thing, and we do a lot of this, all of us do, is gut brain behavior, cognitive behavioral therapy. You know, we're putting all of it together, and what you'll see, I'm going to skip to this really quick. What you'll see is that, right, you've got your null line right here. There's not one single one that's better than the others, essentially what this forest pot is telling you. So like, whether you do group CBT or you do CBT via the phone or you do CBT on your phone with like Noom or whatever, like all these other things that are coming out, we've got a lot of these in our arena, they're all effective. And it's because it's all helping you to modulate and deal with that stress and all those triggers. And that's why when somebody says, I want to come off the drug, I'm like, okay, but you've got to like put in this effort on this other side as well too. And to go back to this, this is just like how we figure out who does what and who gets to, it just depends on if we're not getting to those areas. I mean, we have a lot of patients who have GI-specific anxiety and they have central sensitization syndromes and they keep going under the knife and thinking if they get another laparoscopic surgery it's going to solve something. So these are those patients that are in that severity group where I would say you've got to, it's going to take a village, absolutely. And that's it. This is just like a little brief different versions of these that we have on our end. There's way more coming out. I use a lot of these. They have a lot of codes for patients where they can get like a little week trial or something. Some insurances are taking these, so that's very helpful. So your take home points, I think you guys, we went over a lot of this. There's some novel therapies, we talked about glutamine and I really think the vagal nerve stimulation is something that's going to be a big hot topic in GI this year. And then the brain-gut therapy, and that's why it's lovely if you've got, you're making a community with GI and Neurogyne and that's how we help patients because we can't be in silos anymore. It's not going to work anymore. I have talked a lot. That's it. Break? Questions? Anything? I can, you know, you can do both. Kind of a question or comment. Yes. Go for it. Social media is making it into the exam room a lot these days. One of the things that I, my patients are coming to me with is parasite cleanses for hormones. And like the, I don't even remember what it's called, but like clean out of the bowels that they're doing on their own. Yeah. Yeah. I mean, my answer is just kind of like, no. My answer is no. I'll explore things with them because again, I think that we're like building that relationship is really important. Like if I go and I just say, you're a dota bird, they're going to walk out the door. Like that's not a relationship that's ever going to work. Like why are you researching this? What is it that's not worked in the past? What is it that makes you concerned about parasites? Let's go back. Did you do, do you do missionary trips to Africa and live out, you know, whatever, 10 times a year? Okay. Maybe. Maybe we need, right. Like I'll just go back and see if I could tweeze out some of those, those things. And then I'll tell you there's some times where I just, I've got this one lady who thinks that she's infested with worms and she'll show me like a little, you know, little thing on her shirt. And she's like, it's a worm. And I'm like, that's lint. And then we just, we go round and round. And then finally I just have to say, you know what, we're living in two different realities. That is a parasite to you and this is lint to me. And I was like, you know what, let's treat your constipation. How about we meet in the middle? Right. So I don't have a perfect answer. I will tell you social media is, oh yeah, yeah, yeah, absolutely. People love anything that's over the counter and natural and that's going to fix every, we're all, there's a reason why this, you know, the, the salesmen back in the day with their little bag and all the different oils, like, I mean, we're all subject to that, right? That's what social media does to all of us. I think I want to buy that pair of shoes. I don't know why, but I want to, right? We all, and, and that's where we're getting a lot of that information. So I think, again, that patient relationship and trying to tell them like, I don't have, and just being honest, I don't have information on parasite cleansing and parasites aren't known to cause constipation. Parasites cause diarrhea. Here's some like basics, blah, blah, blah. I think that's where you start. Yeah.

motility disorders

pelvic floor dysfunction

neurogastroenterology

brain-gut interaction

fecal incontinence

dyssynergic defecation

diagnostic advancements

anal rectal manometry

cognitive behavioral therapy

multidisciplinary approach

digestive health