The Gut Health Podcast

Diarrhea: from C.Diff to IBS-D with Dr. Jessica Allegretti

• Kate Scarlata and Megan Riehl • Season 1 • Episode 7

Share episode

Not one of us are completely immune to an occasional episode of diarrhea. Whether you can trace it back to something you ate or an uptick in stress, liquid poop is not ideal. Kate and Megan are joined by a giant in the field of gastroenterology, Dr. Jessica Allegretti from Brigham & Women's Hospital in Boston, Massachusetts to do a deep dive discussion into diarrhea.

Together, they discuss the various causes of diarrhea, from common infections and food intolerances to more chronic conditions like irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Dr. Allegretti offers valuable insights into the concerns surrounding Clostridium difficile (C. diff) infections and the complexities involved in diagnosing and treating recurrent cases. We also explore cutting-edge research of live biotherapeutic products (LBPs) and their promising role in the innovative area of fecal microbiota transplantation (FMT) with the guidance of this world-renowned expert. 

And, we couldn't discuss diarrhea without acknowledging the potential role of food, stress and the intricate relationship between our gut microbiome and our behaviors. Kate and Megan provide practical tips and tricks to the nutritional and behavioral management of this often times anxiety provoking symptom that leave all listeners feeling empowered with strategies when it comes to the runs.

Whether you've had C.Diff, are managing IBS-D or just curious about this common symptom this episode is a must listen!  Tune in for practical insights and valuable strategies to improve your well-being and gut health.

Read more:
Diagnosis and Management of Clostridioides difficile Infection in Patients with Inflammatory Bowel Disease

Yale Medicine: C. Diff Infection overview

Approach to the Patient with Diarrhea and Malabsorption

Low FODMAP tools

Diaphragmatic breathing (video by Dr. Megan Riehl)

This podcast was sponsored by Salix Pharmaceuticals 

Learn more about Kate and Dr. Riehl:

Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast

Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.

The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.

Kate Scarlata:

This podcast has been sponsored by Salix Pharmaceuticals, or a healthcare provider, you are in the right place. The Gut Health Podcast will empower you with a fascinating scientific connection between your brain, food and the gut. Come join us. We welcome you. Hello, friends, and welcome to the Gut Health Podcast, where we talk all things related to your gut and well-being.

Kate Scarlata:

We are your hosts. I'm Kate Scarlata, GI dietitian

Dr. Megan Riehl:

and I'm Dr Megan Riehl. We have a very exciting podcast for you today. We are talking about perhaps a less rated symptom, but one that can truly be embarrassing, unpredictable and sometimes tricky to treat. We're going to talk about diarrhea friends. We'll tackle different causes of diarrhea and treatments from C, diff to IBSD, with our incredible guest today, Dr Jessica Allegretti.

Kate Scarlata:

Yes, so let's get some background. Dr Allegretti is a world-renowned gastroenterologist and researcher. She serves as the medical director of the Crohn's and Colitis Center at the Brigham and Women's Hospital. Fun fact, I got my dietetics training there, so she developed and leads the hospital's fecal microbiota transplantation program yes, we are going to talk about poop transplants and she is an international expert on this topic. Her research focuses on the intestinal microbiome and the consequences of its derangement, with the goal of understanding the role of microbial dysbiosis and how it impacts disease. Welcome, Dr Allegretti.

Dr. Jessica Allegretti:

Thank you so much for having me. I'm really excited to be here to talk about my absolute favorite topic.

Dr. Megan Riehl:

Excellent, excellent, all right. So in this world of gut health, we like to bust myths and address misinformation, because there is a lot of stuff out there that is not based in science or coming from a reputable source like yourself. So, Dr. Allegretti, what is a common myth in your world of GI that you would like to bust today?

Dr. Jessica Allegretti:

Yeah, thank you for asking this and so, as you mentioned, you know, a lot of my practice is managing C diff and complicated C diff infections, and this is a disease that really does affect elderly patients, can affect anybody and I'm sure we'll get into that. But what I often see is that patients who are diagnosed with C diff really get isolated. Their families don't want to be around them. They really get isolated from you know, not invited to social events, and really I'm here to tell you that these patients are not contagious. They can be out in the world and, in fact, once you're on antibiotics and not having diarrhea anymore, it's totally fine to be around your family members, to interact with them, to have them in your homes and you really don't need to isolate from them. In fact, we are probably bigger risks to them than they are to us, you know, as people not on antibiotics with intact microbiomes and immune systems. So please and let your grandparents and parents come over for Thanksgiving. Don't isolate from them.

Dr. Megan Riehl:

All right. So people are probably already sighing a big feeling of relief and we're already bringing the community back together. So thank you.

Kate Scarlata:

I love it. All right, so I'm going to dive into just a basic question. Can you define diarrhea and how common is it?

Dr. Jessica Allegretti:

Yeah. So it's incredible to me how I would say misunderstood diarrhea is. I think many people patients I take care of really don't know what I mean when I say that, and so I would say, just out the gate, what I often will ask patients is if I was to put your poop in a cup, does it take the shape of a cup or does it have its own shape? Right, you're really looking at unformed loose stool, and you know I will often examine the sample myself because you'll be surprised. So people don't really know what the definition is, and so I would say the traditional definition is loose stools, liquid or watery bowel movements. Right, it can be discussing the consistency and really the increase in frequency as well, and, as I'm sure we'll get into, there's lots of reasons why you can have diarrhea, but this is an extremely common condition. If we think about worldwide acute diarrheal illnesses that are really mostly infectious in nature, there's about 1.7 billion cases of diarrhea every year worldwide, so this is a common problem.

Kate Scarlata:

Amazing. That is amazing that it impacts so many people. Is it more in underdeveloped countries? Is that a bigger problem with different parasites and things?

Dr. Jessica Allegretti:

Yeah, it's interesting. So I mean certainly, depending if you're discussing the developing world versus the other areas around the world, you're looking at different prevalences of different types of diarrhea. Certainly, world you're looking at different prevalences of different types of diarrhea. Certainly, it's still a big problem in the development world as well, but probably with regards to infectious disease complications, certain viruses, norovirus, adenovirus, for example we see a lot of that in developing nations.

Kate Scarlata:

Interesting. So what are some of the common sort of sources or underlying causes of diarrhea in your practice?

Dr. Jessica Allegretti:

Yeah, so I think there's always several buckets that you can put patients in when they're presenting with diarrhea. That I think through when I'm thinking through. What's the differential, for this Infection certainly is always high on the list that you need to rule out and that can be viral bacterial parasitic, and there's a number of tests that we can run to rule that out. Food intolerances certainly. Could this be dietary-mediated medications. So certain medications can have many GI side effects and we know certainly antibiotics can lead to diarrhea. That's always the first question I ask. But then certainly underlying GI disorders like irritable bowel syndrome, like inflammatory bowel disease, celiac disease, bile salt, diarrhea, there's a number of conditions that we can assess for. And so when I'm seeing somebody out the gate, these are a lot of the things that I'm thinking through when I'm running through the history. But my practice by far and away is inflammatory bowel disease and C diff infection, which is what I tend to focus on.

Dr. Megan Riehl:

Okay, thank you. So now I get to let you really dive into the weeds here and let's talk what is C. diff diarrhea and start to tell us about how you treat it?

Dr. Jessica Allegretti:

Yeah, so C diff. I think there's so many misconceptions about C diff. I think it's really complicated, you know, for being a bacteria that's been around for a while. You know it's identified in the fifties. I think there's still a lot of challenges in both diagnosing and treating this patient population. And so C diff is a bacteria, it's a gram-positive organism that is everywhere. It's in our environment.

Dr. Jessica Allegretti:

If I was to take all the meat out of the grocery store and culture it, a lot of it would have C diff spores in it. So C diff is around. When you're eating, a lot of it would have C diff spores in it. So C diff is around. When you're eating, you're swallowing spores. It comes in two forms a spore form and then a vegetative form. So the natural life cycle is you're swallowing these spores, you're pooping them out, you're going about your day and you can be colonized with this organism with really out any consequence. And throughout your life you will be colonized and decolonized again and you may never know. Throughout your life you will be colonized and decolonized again and you may never know. And what happens under the right circumstances in the gut, usually if you take an antibiotic and get rid of some of the protective bacteria that we have, that is, keeping C diff in its niche and its ecosystem. It will then take the opportunity to vegetate and release a toxin, and it's actually the toxin that makes you sick, not the bacteria itself. So when we're testing for this, we're really actually looking for the presence of toxin, and that's why testing actually can be quite nuanced, because not all tests that are available actually look for the presence of toxin, and so it can be really challenging to distinguish colonization from actual infection, and I think that's where somebody like myself can really help come in and try to differentiate.

Dr. Jessica Allegretti:

What happens is, if somebody is colonized and there's really another source of diarrhea, the antibiotics are probably not going to work to treat that cause of diarrhea, and the patients don't know why they're getting better. And I've often had patients come to me saying well, I have refractory C diff, nothing works. I'm here to tell you there is no such thing as refractory C diff. C diff responds to antibiotic therapy, if not entirely, at least partially, and so if you are not having any response to the therapy that's being prescribed to you, that should be a red flag to both you and your provider that there's something else going on. That was missed. But, that being said, the mainstay of therapy in fact the only thing we have to treat C diff right now is antibiotics. There are several guidelines, both from the Infectious Disease Societies and the GI Societies, that recommend either vancomycin or fadaxomycin as first line. So those are both two great antibiotic choices.

Dr. Jessica Allegretti:

The issue with this organism is that both those antibiotics do a great job at treating the disease. However, because of that spore form that this organism can take, there is a high likelihood of recurrence, meaning you take the antibiotic, you feel better and then somewhere days to weeks later, the diarrhea just comes back unprompted. You know it's not like you took another antibiotic or something else happened, it just comes right back. Most commonly that happens between week one and week four of completing your antibiotic course. So that's the time you really want to be vigilant and keeping an eye on your symptoms.

Dr. Jessica Allegretti:

And we know about 20% of people will ultimately recur after a first course of antibiotics. I'm here to tell you we don't know why people recur. We don't know. There's nothing I can tell you to look out for. There's no specific risk factors that lead to recurrence, and that's a lot of the work I actually do is trying to figure out how can we predict better and more quickly who's going to recur and who's not. But ultimately, once you do recur, we know that having a second, third and fourth recurrence becomes exponentially more likely. And so, once you're down that pathway, you need a treatment strategy, which again is always an antibiotic. But then you need a preventative strategy as well, and there are several things that we can do to actually prevent recurrences.

Dr. Megan Riehl:

So this is the hot topic, right, FMT, and let's just dive right into that.

Dr. Jessica Allegretti:

Yeah, thank you, Megan, for bringing this up. A lot of ways to prevent C diff. Well, I shouldn't say a lot. There are several ways to prevent C diff and FMT is by far and away, I think, the most common. You know, in the last decade at least. So, if you're not familiar, FMT, or fecal microbiota transplantation, is literally the installation of microbial communities from the gut of a healthy donor into a patient's GI tract and so, just like if you were to get blood from a blood bank for a blood donation, we get stool from a stool bank and it's aggressively screened for everything, including SARS-CoV-2, including monkeypox and some of the emerging pathogens. It can be administered either in pill form or in a liquid preparation that is typically administered via a colonoscopy or as an enema, and the way that we do this is you complete your course of antibiotics. We want to see that your symptoms have calmed down. We do a washout because you don't want any antibiotics on board when you're putting that good bacteria in, and then we will perform the FMT. The window of recurrence for C diff is eight weeks, meaning we're going to watch you really closely for eight weeks. If you get to that eight week mark and you're still feeling good, you are done. This is not a chronic condition. This is not something that's going to hang over your head forever. Your risk goes back to baseline, but we're going to watch you really closely. In that eight weeks FMT is highly successful, but it is not a hundred percent, as nothing is. So this yields about, depending on which studies you read, between a 75% and 80% success rate at preventing a subsequent recurrence, which is very good. However, if you do recur within that eight-week period, often we'll repeat this, and that can be done again with pills or colonoscopy, depending on the patient's preference be done again with pills or colonoscopy, depending on the patient's preference.

Dr. Jessica Allegretti:

Now, what's exciting about these last couple of years is that we now have FDA-approved products as well. So I've been performing FMT which is not FDA-approved and never will be, unfortunately, for the last almost 12 years now under a policy called enforcement discretion from the FDA. So what this means is that the FDA has stated that this is investigational but because of the need, they allow us to perform this for clinical care under this policy, as long as we state that it's investigational and discuss the real and theoretical risks with our patients before performing it, and it can only be done in the setting of recurrent C diff infections or C diff not responding to standard antibiotics. So you can't offer FMT for anything, unfortunately, I know I would say that's another myth. Busting opportunity here is that a lot of patients reach out to me because they want FMT for lots of indications and unfortunately we cannot offer it for really anything other than C diff not responding to standard antibiotics under this policy of enforcement discretion.

Dr. Jessica Allegretti:

But what's been exciting in these last couple of years is there have been two FDA-approved products for the prevention of recurrent C diff. One is VOWST or FMT excuse me, fecal microbiota, spores, live- brpk they have very long names for Vowst, and then also Fecal Microbiota Live, jslm or REBYOTA, and so these are both donor-based products, meaning donors were screened, the product was created from donor material. One is a pill product and the other is an enema-based product, and so what's great now is that we've got options. We've got options for patients, and what's nice about how those two products are labeled is they don't have a mandate on how many recurrences the patient has to have. It's just really for the prevention of recurrency diff. So I can start to offer some of these things a bit earlier in the disease paradigm and not have to wait until somebody has suffered three or four recurrences.

Dr. Megan Riehl:

So this is great in terms of, you've said, the number of people that have diarrhea, and then we've got a huge prevalence of people that are living with IBS with diarrhea. But what you're also helping our listeners to understand is that not everybody with IBS, with diarrhea or just diarrhea is going to be a candidate for this, and I think you know that's something. Unfortunately, when people get on the internet and you know you're feeling desperate for resources. You see FMT and it looks so appealing. The statistics and data, as you're pointing out, are really promising, but this is very much for those patients with C diff that are getting these results in this treatment.

Dr. Jessica Allegretti:

Correct, and I have these discussions almost daily, you know, and again, I treat patients with both IBS as well as inflammatory bowel disease, and I think that there is clinical trial data in both spaces, and so it's not surprising that patients are excited about this option. And I think a lot of patients will say to me well, I really do feel better when I take antibiotics or probiotics, and so there must be a microbial pathogenesis to my disease, and they may be right. But I think right now that the FMT and these microbiome-based therapeutics, or LBPs, which is generally what this class of therapies is being called now live biotherapeutic products, is really again only indicated for C diff. But there is clinical trial interest, there is definitely investigations ongoing into other GI diseases, and so I think in the future we certainly may have options that expand beyond C diff. We just don't have them right now.

Dr. Megan Riehl:

Okay, and so antibiotics may be the treatment for C diff initially. I know people are going to be curious about this. I hear this in my clinic Are there any antibiotics that make you more at risk for developing C diff?

Dr. Jessica Allegretti:

Yeah, this is a question I get again every day. You know, like what's a safe antibiotic? Which one is the better antibiotic? What I would say to that, and what I tell all my patients, is there is no such thing as a safe or good antibiotic with regards to C differex, although there are certainly some that are worse.

Dr. Jessica Allegretti:

And so the first thing that I tell my patients is if you really have an infection, we don't want to not treat it. Right, you need to treat an infection if you have it, but what we want to do is avoid unnecessary antibiotic use. You know, especially in cold and flu season, z-pak prescriptions run rampant. Right, but if you have a viral infection, you don't need antibiotics. So it's important to advocate for yourself and always ask the question do I need this? Is there really a bacterial infection that we're treating? Because sometimes there isn't and you don't. So we want to avoid unnecessary antibiotic use, because all antibiotics essentially confer some risk, although there certainly are some that are worse.

Dr. Jessica Allegretti:

Clindamycin is by far and away the worst antibiotic you can take with regards to C diff risk. It's essentially like pathognomonic. With C diff, you took clindamycin, the risk is high, and so, certainly if you have any underlying GI pathology, if you're immunosuppressed, if you've had C diff before, this is an antibiotic you're going to definitely want to avoid. And I will say the most likely place you're going to get clindamycin is at your dentist's office, and so if you have a tooth abscess or you're undergoing a dental procedure and clindamycin is mentioned, I would say this is something that you may want to bring up and ask if there's an alternative.

Kate Scarlata:

Perfect, yeah, that's good information. So I'm just wondering with our listeners when they're at the doctors, when do they really bring up diarrhea? Like what are the red flags that? Ooh, this really needs to get clinically worked up. This isn't just like an occasional episode of diarrhea when they overate. What's prompting a clinical workup in your eyes?

Dr. Jessica Allegretti:

Yeah, absolutely.

Dr. Jessica Allegretti:

I mean, as somebody who assesses diarrhea every day, you know.

Dr. Jessica Allegretti:

I think that's honestly one of the main reasons why I went into GI, because I saw so many young people, and especially young women, who were embarrassed to talk about this, who you know would be suffering unnecessarily because they just didn't feel comfortable bringing it up. So one of my goals was to create a safe space where it would be comfortable to discuss these things, and I always say all of my patients universal, both men and women always apologize to me before they start to tell me about their symptoms. I'm like please stop apologizing. This is my whole job is to hear about this. So you do not need to apologize to your physicians for discussing your bowel habits. This is what we want to know about. But I would say there are definitely some red flags blood in the stool, weight loss, diarrhea that wakes you up from sleep, that sensation wakes you up and you have to run to the bathroom. Those are things that really should prompt an early workup, and so if you're experiencing any of those, that is a definite call to your doctor and need to be evaluated.

Kate Scarlata:

So you've talked a little bit about infectious diarrhea and, I think, about patients that have diarrhea and grab the Imodium, grab the Kaopectate. Is that a good thing if maybe an infectious source is present? What do you do with that recommendation?

Dr. Jessica Allegretti:

Yeah, it is tough and I do think that this space is evolving as well. I think, generally speaking, if somebody has an infectious diarrhea we do say to avoid antidiarrheals because you want to sort of get those toxins out of you, you want to kind of let it run its course, and so other types of symptomatic therapies, obviously staying very hydrated even something like a Pepto-Bismol is probably a little bit gentler on your system than, say, an Imodium. But I would say after about 48 or 72 hours, if you're not getting any better, even with just a brat diet and hydration, again that would prompt a workup. Because if you do have an infection it would be helpful to know so we could tailor the therapy and help keep you comfortable.

Dr. Jessica Allegretti:

In the setting of C diff, for example, we definitely don't recommend Imodium upfront. However, once we get somebody on antibiotic therapy for about 48 or 72 hours and things start to calm down, then we actually can safely use some Imodium to just help again improve the patient's quality of life, keep them comfortable. So there is a way to do it safely. But I would say, especially if the diarrhea sort of comes out of nowhere, you're worried that maybe you either ate something you know you have a food poisoning event or people around you are sick and it does seem infectious, I would hold off and really focus on diet hydration. Wait about 48 to 72 hours and again, if it's not getting better, get an assessment.

Kate Scarlata:

Yeah, that's important. I think you know we have access to so many things over the counter and just once again, talk to your doctor before you start mucking around with diarrhea.

Sponsor:

Abdominal pain and diarrhea from IBSD getting in the way, you may find relief with Xifaxan with an X. Xifaxan Rifaximin is a treatment for adults with irritable bowel syndrome with diarrhea. Xifaxan Rifaximin is a treatment for adults with Irritable Bowel Syndrome with Diarrhea. Visit xifaxan. com/ IBSD for the PI or talk to your doctor. Don't use Xifaxan if you have a history of sensitivity to rifaximin, rifamycin antibiotic agents or any components of Xifaxin. Tell your doctor right away if your diarrhea worsens while taking Xifaxan, as this may be a sign of a serious or even fatal condition. Tell your doctor if you are pregnant, plan on becoming pregnant or nursing. If you have liver disease, taking warfarin or other medications, some medications may increase the amount of Xifaxan in your body. Most common side effects are nausea and an increase in liver enzymes.

Sponsor:

Xifaxin.

Kate Scarlata:

Okay, so I know this is sort of my area of expertise, but I'm just curious as, as far as dietary measures, you mentioned the BRAT diet, which is bananas, rice, applesauce and toast. It's kind of an old therapeutic regimen for diarrhea. But are there other common dietary culprits that you see in your practice?

Dr. Jessica Allegretti:

Yes, I would say both dietary culprits. And then obviously we use diet as a therapy as well, right To help with symptoms. So I think it's on both ends and I think I'm very fortunate that I get to partner with amazing dietitians as well. So I think if you're fortunate enough to have that in your practice, that's amazing. But I think, especially if you have a chronic diarrheal disorder, I think working with a nutritionist who has expertise is obviously best case scenario.

Dr. Jessica Allegretti:

But certainly there are things I'm asking about when somebody is newly presenting. And so I would say some of the culprits certainly are, I think, like the classics are dairy and lactose intolerance, gluten sensitivities, a lot of those fake sugars, the sorbitols, the xylatols. I think a lot of people don't realize even that they're consuming them. Maybe you chew a lot ofols. I think a lot of people don't realize even that they're consuming them. Maybe you chew a lot of gum or you suck a lot of those hard candies mindlessly and you don't even realize it. Certainly people who drink a lot of carbonated beverages sometimes that can really cause some real intolerances.

Dr. Jessica Allegretti:

And so these are some of the things I go through in my checklist. We use a lot of the low FODMAP diet in our practice too, again, as and. So I always think about all the things that are high in FODMAPs and I start to go through them with patients and we think about how much of this are you actually eating? Do you cook with garlic and onions every single day? Especially if they're also complaining a lot of bloating and gas in addition to their diarrhea. So these are some of the checklists I start to go down just to try to get a sense of what's going on with the patient at home, to try to see if there may be a dietary culprit. But I would love to hear, Kata, from you if you do anything different in that regard. I'm sure you do.

Kate Scarlata:

No, I mean, you really hit some top dogs. I think the sugar-free gum and mints is really. It's funny because patients will be coming in. They'll be chewing gum or popping the mints constantly, so that is definitely one that can be a real problem. I'll do a little recap at the end of our little session on some of the things, but I think you hit on definitely some of the top things and the low FODMAP diet certainly can. You did good, I did it.

Dr. Megan Riehl:

Nice job, Dr. Allegretti.

Kate Scarlata:

Yeah, so we'll talk a little more about that, but we'll get into some of the deets. But yeah, I'm obviously a proponent of a low FODMAP diet for diaries, particularly in IBS.

Dr. Megan Riehl:

I also that coffee, the caffeine, oh yes.

Dr. Jessica Allegretti:

Thank you. The coffee yeah yeah, coffee makes everyone go to the bathroom, right? I mean like that's one of its greatest functions, and so I think too, people often don't realize that, especially if you're having your cup in the morning and then multiple iced coffees throughout the afternoon, then maybe you're putting milk in it and you're putting like big sugar in it. There's a lot of things that could be going on there.

Dr. Megan Riehl:

That's right. That's right, all right. So with IBSD, we know it's common. We've had several DGBI disorder of gut brain experts on the podcast already, so we know it's common. And we also have talked a little bit about overlapping diagnoses such as IBD, inflammatory bowel disease and celiac disease. So what are some of the common strategies in your patient group and in your clinic that you use to help treat these overlapping conditions with IBSD?

Dr. Jessica Allegretti:

Yeah, it's interesting. I see a lot of IBSD in my practice. One because there is so much overlap in inflammatory bowel disease and I always tell patients one of my jobs when they're presenting with new symptoms is to sort of distinguish if they're inflammatory symptoms or functional, and so that's sort of the first part of the workup. But also in a C diff population, even post-FMT, about 40% of patients will have post-infection irritable bowel syndrome, and so this is extremely common. And so even if they really did not have any GI issues before the C diff, many of them will have what looks to be very classic IBSD after, even once the C diff is completely gone. And it can be, I would say, jarring to the patient because they think the C diff is back or they're worried that it hasn't cleared. But really this is sort of the sequela of that underlying infection, and so I do manage a lot of this in sort of various different buckets and so working it up and ensuring that that's in fact what you're treating, I think is really important. I also do a lot of reassurance. Reassurance and I'm sure you guys have chatted about this with other guests, but I find, especially in my population, because I treat so many young women, a lot of women have been dismissed as well. It's just IBS, right, and so they feel like that's almost a bad word. When you say that it's like, well, you're, then I'm not going to get any help or I'm not going to get any treatment. And so I do a lot of reassurance that these symptoms are real, that even though I can't see it, there's no positive test, right, it's really more of a diagnosis of exclusion, because the testing all comes back negative. That that I think you know, to really empower the patients that this is real, that we're going to treat this, and then there are a lot of therapies that we can use.

Dr. Jessica Allegretti:

I think that in itself goes a long way, but we certainly use diet, as we just talked about. We use a lot of low FADMAP diet in our practice and again, I work really closely with an awesome nutritionist who helps us manage these patients and we talk about, you know, avoiding those food triggers, as we just went through. I think the mainstay of what we use is a lot of fiber, you know, soluble fiber, especially post-FMT. I think this is probably the first thing I get patients back on One. It's great for your microbiome. We know that this is really dietary fiber is the food that your microbiome wants. You know it's like a really effective prebiotic, and so, and also two, it's probably one of the only therapies that manages both diarrhea and constipation. And so really getting patients on a good bowel health regimen that includes fiber.

Dr. Jessica Allegretti:

And I would say too a lot of patients will tell me I eat a lot of fiber. I always think no one can eat enough fiber. I always think Paleolithic man was eating tree bark. We can't be doing that. So most people need supplementation of some kind, especially if you're battling an underlying GI disorder. And so we work on that.

Dr. Jessica Allegretti:

And I always think, too a lot of patients don't appreciate that if you are using fiber, you have to be drinking water. Water and fiber go hand in hand, and if you're not drinking the water you're not getting the benefit of the fiber. So I really prescribe water in a real way and I want patients to tell me truly how many ounces they're drinking. And so that's usually, I always say, like phase one, step one, and then we step up to other types of therapies like antidiarrheals, even imodium, as we just discussed. I use a lot of bile acid sequestrants in my patient population, so cholestyramine Questran. It comes in a pill and a powder form, so we use a lot of that. That can work tremendously well, and then I think that's sort of like step two, and then you know as we go down the pipeline there's certainly other prescription-based therapies that I use a lot and are safe to use in IBD as well. So I think there's a lot of layers to IBSD management and you can kind of step up to see what the patient's needs actually are.

Dr. Megan Riehl:

Great. And then we've also got our gut-brain therapies.

Dr. Jessica Allegretti:

Of course. How could we not mention that. Critical?

Dr. Megan Riehl:

Critical right, so we'll talk a little bit more about that. I think in a little bit some of the strategies that I might recommend for some patients. Now the gut-brain microbiome access this is certainly a topic of your research and there's some very interesting scientific adventures out there that are happening in this area of research. Can you describe what we're learning about this interrelationship between our gut microbes and the brain and the gut microbiome?

Dr. Jessica Allegretti:

Yeah, absolutely, it really is fascinating. I think science has come a long way, but we still have so much to learn, and I think I've always been a believer that the brain and the gut are connected. I think you know, a nervous stomach, like all of those things, those phrases exist for a reason, and when your brain is stressed, your gut is stressed, and so I think we see that in practice and I think that's why the work you do, megan, is so critical, because, again, understanding that connection and understanding your own triggers and then how to deal with them really can actually help tremendously the GI symptoms, and so I think partnering actually in that regard is one of the best things that we can do really to get our patients all the way there. I think the medications alone are never enough, right. I think it's diet and the behavioral health. I think all of that, you know, really is a holistic approach to managing these patients.

Dr. Jessica Allegretti:

But I think from the microbiome standpoint, it's really fascinating.

Dr. Jessica Allegretti:

You know we're learning so much, even from animal models, about how behavior and certain behaviors can actually be mediated by the gut microbiome. You know, I would say there's always this amazing animal study that has not been replicated in humans yet, but that really it's the brave mouse experiment, where they have a sort of a timid mouse who won't climb out onto a platform and a very brave mouse who will. They actually do fecal transplants from each other on these animals and you actually can see the behavior phenotypes switch, and so to me that's incredible. And so there is clearly microbiome pathogenesis here. I think how we're actually going to implement that into human disease I think is still evolving. We are seeing FMT and other microbiome therapeutics already being assessed for other neurologic conditions, psychiatric conditions. So I think not just you know well beyond GI, I think again modulating the microbiome in other disorders, especially those that are sort of brain-gut connected, we're really starting to see some problems. So I think this is a really interesting and exciting area of exploration, but again, we still have so much to learn.

Dr. Megan Riehl:

Yeah, it's fascinating, our brave mice. Look at them go, I know so being brave, being resilient. Stress let's talk about it real quick. Stress and diarrhea how do you talk to your patients about how these emotional factors can increase diarrhea?

Dr. Jessica Allegretti:

Yeah. So I mean I bring it up to patients. I think one recognizing and having the patients recognize that it is linked to their symptoms. I think for some people it can be eye-opening. No one's ever said that to them.

Dr. Jessica Allegretti:

Think about when your symptoms are the worst. Is it when you're stressed, when something bad has happened in your life, when work is kicking up? Think about that. And then are you avoiding leaving your house? Are you, you know? Are you now having a more avoided behavior because of it?

Dr. Jessica Allegretti:

And I think patients often will say to me this is the first time you know I'm having this realization. So I think, just having the time set aside to actually have those conversations upfront, and then really recognizing that I can't just manage the diarrhea, we have to manage your stress as well. We have to manage your behavior, we have to help that aspect, otherwise we're never going to get all the way there. And so I think, again, really emphasizing that as a really important part of their therapy plan is really important and also de-stigmatizing it right, because I do think too, a lot of patients may say, well, like I'll take whatever medication you prescribe, but like I'm not going to go talk to a therapist. You know I've certainly heard patients say that to me, and so I'll explain that again a lot of their GI symptoms are being, you know, modulated by their mental health, by their stress, and that I can't do my job if we don't also address that.

Dr. Jessica Allegretti:

And I think when it's phrased in that way, I think patients are a lot more open, although I will say, I think today, luckily, I think many patients are very interested in mental health support and I think it really is an important part of GI care. Thank you for acknowledging that. Absolutely the hugely important part. And I think, just a little plug for our center we really feel, again, that all new patients coming through should meet not only with their healthcare provider but also with a nutritionist and with a psychologist, which we're in the process of hiring now, yay, so that's really a whole package. I think you really need that whole holistic approach and everyone's going to have different needs, right? I mean, you may not need to meet with a psychologist every time you come in and you may not need a dietitian every time, but you know, I think everyone is going to be different and some people may need those much more than others and I think, again, it's really hard for us to do our jobs if these other aspects aren't being addressed in a meaningful way.

Kate Scarlata:

Yeah, we call that the dream team and mind your gut, you know getting that dream team in place and it does make a difference and I think it lets you do your job. We can do our job, the psychologist can do their job. Maybe a pelvic floor physical therapist is brought in too. Yes, that's really nice when you can bring collaborative care, absolutely. So I just wanted to quickly regroup with the nutritional lens for diarrhea, and Dr Allegretti did a great job reviewing some of the key things and factors that I would also address, but I'm going to just go through these a little bit.

Kate Scarlata:

So lactose is the sugar in milk. It's commonly malabsorbed and when we think about restricting lactose, you don't necessarily have to restrict all dairy. It's really this milk sugar that's problematic. So things like aged cheeses, butter, very little lactose, milk, drinking a cup of milk, having some pudding or ice cream it's going to have a lot more. So milk and the things that are watery have more lactose, so keep that in mind.

Kate Scarlata:

Fructose can be a problem too, especially when it's an excess of glucose in a food. So some of the things to keep in mind fructose is a small carbohydrate. Like lactose drags water into the gut, so things like agave syrup that are added to a lot of more like health food type products honey, high fructose corn syrup that you may find in a lot of convenience foods, but even apples, watermelon, pears those all have excess fructose, so those can be problematic as well. Caffeine we talked about that. That can stimulate that gut motility and when you have diarrhea you want things to be a little bit slower. Give the colon some chance to absorb some of the extra fluid in the colon. If you're speeding things up, that's a problem.

Kate Scarlata:

Alcohol can be a big problem. So if you're a big weekend warrior drinker and you notice a big uptick in diarrhea on the weekends, hello, people pay attention to your alcohol consumption because that also is a GI irritant but also can really trigger diarrhea, particularly when we're overdoing it. And then Dr Allegretti did a great job talking about sugar alcohol. So these are your sorbitol, your xylitol, maltolol in your sugar-free gum and mints, also naturally found in some foods. So prunes, for instance, great remedy if you're constipated. It also has natural sugar alcohols.

Kate Scarlata:

Drags a lot of water in the gut, causes diarrhea. So stone fruits are in that family as well. Cauliflower, celery, even a little sweet potato, might have too much sugar alcohol for you. A dietitian can help you identify these foods and food triggers for you. But that's just a little quick recap. And then one last one that I think I actually had an issue with this, and that is wheat bran, whole wheat breads, whole grain crackers. I ate a whole box of wheat thins in a car ride and yeah, don't do that. That might trigger a little bit of diarrhea, so that could be a problem as well. That's sort of a little regroup on diarrhea and diet and I'll move on to Dr Riehl for maybe some behavioral therapies for diarrhea.

Dr. Megan Riehl:

Yeah. So thanks for bringing that up, being mindful of those car snacks before you take a family vacation. I have to appreciate Dr Allegretti mentioning creating a safe space to talk about some of these things. So, again, we don't tend to share our diarrhea woes when we're at a cocktail party or at our kid's soccer game, but being able to talk with your doctor about this and how stress affects our body, and when we are stressed and stress can come from all over the place stress hormones like cortisol and adrenaline can stimulate our intestines and speed up bowel movements, which leads to diarrhea stimulate our intestines and speed up bowel movements, which leads to diarrhea. And so the relationship between stress and diarrhea also is individual and complex.

Dr. Megan Riehl:

There's a lot of different factors that we've talked about today antibiotic use, nutrition, and then we've got stress. And so, while just as I'm talking and our listeners are listening, think about this for yourself. Listeners, how are you doing with the management of your stress? Because it can really change our eating habits. So, for example, when we're really stressed, we might be more prone to reach for that carton of Ben and Jerry's and before you know it, it's gone. You're eating more processed, high-fat foods, foods of convenience, if you're feeling exhausted from your stress, it's easier to pull through McDonald's and grab a cheeseburger as opposed to getting home and preparing something. So that stress can really drive our behaviors. And what I'll also say is that the three of us here going through this podcast today, as well as every single listener, is not immune to stress, and so this is our opportunity to really recognize that having your toolbox ready to go and practicing stress management techniques regularly is so helpful for really just a healthy lifestyle that makes you less prone to GI distress.

Dr. Megan Riehl:

Before I give you some tips and tricks of ways that I like to practice relaxation, something that I go through with a lot of my patients when we're meeting and I'm actually prescribing relaxation as an intervention for their IBS, or even for IBD and other digestive issues is the idea that it's not wasted time to sit and be present and build out space for your relaxation practices. A lot of times, people are like I'm just sitting here doing nothing. I've got things to do, I am running from place to place to place, and so here are some suggestions that you might start to incorporate or maybe you're just going to pat yourself on the back because you're already doing these things, but a couple of things that we can all do for relaxation. So one of my favorite things to do is especially if I'm at my desk and I'm working quietly turning on a music app and listening to piano covers of current music. So that's just kind of a peaceful type of music. There's no words. I still am able to focus on my tasks, but I feel like I'm relaxing Diaphragmatic breathing. Nobody listening is going to be surprised that I mentioned this, because we can do it in a variety of settings, with our eyes closed or kind of folded into your day.

Dr. Megan Riehl:

Also, thinking about things that you can do throughout the day is body scanning. So everybody, do this with me. Think about what your shoulders are doing right now. Chances are you can drop them down away from your shoulders, pull your chest back, open your hands and your mind. Think about just letting go, letting go of stress, letting go of tension.

Dr. Megan Riehl:

And then a final suggestion is getting outside for fresh air, taking a walk. Leave the earbuds behind, don't be trying to multitask while you're out there, just kind of taking in the sounds of nature being present, even if it's a five-minute walk. This is going to help with your overall digestion and wellness. So the takeaways here? Managing stress through relaxation, body movement, exercise, healthy lifestyle habits. They're helpful from a stress management perspective, for our general life and functioning, but also so profoundly helpful for our GI health. So hopefully, this has empowered you with a few strategies. And now, Dr Allegretti, we've learned a lot from your expertise today and, as we wrap up this episode, we like to ask all of our guests the following question Dr Allegretti, what is something that you prioritize when it comes to your overall health and wellness?

Dr. Jessica Allegretti:

First of all, I feel like I just learned so much from both of you, so thank you both. And for me you know I am a newish mom, I have a three-year-old and I think to just like learning how to find myself and make space for myself with a young child at home, which I'm sure a lot of people listening I'm sure struggle with. For me it was always about physical movement and exercise and just figuring out when to do that and how to get it done. And you know I used to do a lot on the weekends, but once you have a young child, your weekends are no longer yours. So scheduling exercise into my workday, putting it on my calendar like it's an appointment, has really helped me, and also recognizing like it doesn't have to be the craziest workout you've ever done. You know, even if it's just doing something is better than doing nothing, and so that's really what has helped me, I think just maintain sanity and overall health through the pandemic and also through early motherhood.

Kate Scarlata:

Yeah, I can relate to that. You know my kids are grown now, but we would put exercise on our calendar like a doctor's appointment.

Kate Scarlata:

You have to you know the things that matter to you, the important things. Sometimes I would just say do something fun, you know, and plan something fun because you need fun date nights, whatever it is, but just to really like wrap up and enjoy life and all of that stress reducing right when you're taking care of yourself. So huge thanks. This was amazing. Talk about learning a lot. I learned a lot from you today, dr Allegretti, and really appreciate the work that you're doing, moving the bar and really understanding the gut microbiomes role here in GI conditions, and your name is world-renowned for this work, so it is quite amazing. So thank you.

Kate Scarlata:

Next up we have the sports dietitian for the Kansas City Chiefs, eslie Bonsey, and she's going to join us to discuss the role of exercise in GI distress. So this will be a really interesting. Maybe we'll get a little you know, taylor Trav info. You never know. We'll try to dig a little deep, but this will be a really excellent and informative podcast coming up at you next. So thank you, try to dig a little deep, but this will be a really excellent and informative podcast coming up at you next. So thank you and thanks again, dr Allegretti, for an amazing podcast.

Dr. Jessica Allegretti:

Thanks for having me.

Dr. Megan Riehl:

Thank you for joining us as we grow this gut health community. We hope you enjoyed this episode and don't forget to subscribe, rate and leave us a comment. You can also follow us on social media at the Gut Health Podcast, where we'd love for you to share your thoughts, questions and experiences. Thanks for tuning in, friends.

People on this episode

Head Shot

Kate Scarlata

Host
Head Shot

Megan Riehl

Host