What’s Really Behind IBS-D? Causes, Triggers, and Treatments (Part 1 of IBS-D series)

We map out a clear, practical way to understand IBS-D, from what it is, to how clinicians rule out the conditions that can look like it. With Dr. Anthony Lembo, we move from science to real-world next steps so you can feel more confident about diagnosis, treatment options, and hope for improvement. 

• How IBS-D is defined using stool form and pain patterns 
• When diarrhea needs more workup using alarm features 
• Common IBS-D mimickers including celiac disease, IBD, bile acid malabsorption, microscopic colitis, sucrase isomaltase deficiency and Giardia 
• What post-infectious IBS may change in the gut including immune activation, permeability, microbiome, and hypersensitivity 
• What the L-glutamine permeability study suggests and what remains unknown 
• How to approach it  a stepwise treatment IBS-D plan using lifestyle, loperamide, antispasmodics, neuromodulators, rifaximin, and other prescriptions 
• Why brain-gut behavioral therapy helps even without severe anxiety or depression 
• How we avoid the trap of endless “root cause” chasing with a confident diagnosis 

Rome V will include an update of the Rome Criteria (publication available around May 2026). 

This episode has been sponsored by Salix Pharmaceuticals. 

Follow us on social media, instagram @theguthealthpodcast, where we’d love for you to share your thoughts, questions, and experiences. 

References: 

Black CJ, Ford AC. An evidence-based update on the diagnosis and management of irritable bowel syndrome. Expert Rev Gastroenterol Hepatol. Published online January 21, 2025. doi:10.1080/17474124.2025.2455586

Marasco G, Cremon C, Barbaro MR, Stanghellini V, Barbara G. Journal of Clinical Gastroenterology Lectureship Dubai 2022 : Management of Irritable Bowel Syndrome With Diarrhea. J Clin Gastroenterol. 2024;58(3):221-231. Published 2024 Mar 1. doi:10.1097/MCG

Congenital Sucrase-Isomaltase Deficiency: What, When, and How?

Foley A, Halmos EP, Husein DM, et al. Adult sucrase-isomaltase deficiency masquerading as IBS. Gut. 2022;71(6):1237-1238. doi:10.1136/gutjnl-2021-326153

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.

Transcript

Welcome And Series Setup

Kate Scarlata, MPH, RDN 0:00

This podcast has been sponsored by Salix Pharmaceuticals. Maintaining a healthy gut is key for overall physical and mental well-being. Whether you're a health conscious advocate, an individual navigating the complexities of living with GI issues, 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.

Kate Scarlata, MPH, RDN 0:37

Hello, friends, and welcome to The Gut Health Podcast. We are your hosts. I'm Kate Scarlata, a GI dietitian.

Dr. Megan Riehl 0:44

And I'm Dr. Megan Riehl, a GI psychologist. This episode is part of a two-part series on irritable bowel syndrome with diarrhea predominance, also known as IBS-D. And Kate and I love to do these mini-series to give you a slightly shorter chunk of time as well as information. So you can tune into this maybe while you're sitting in your gastroenterologist's office thinking about what am I going to say, talking about my diarrhea. Or maybe it's easy for you to just pop it on on your morning commute. So we love that you want to listen to our longer episodes, but this is going to be a little bit shorter, but still chocked full of really good information.

Meet Gastroenterologist Dr. Anthony Lembo

IBS-D Definition And Bristol Scale

Kate Scarlata, MPH, RDN 1:26

Totally agree. And you know, we asked our listeners what they prefer, and it was really a mix. Yeah. So this way is a nice way to meet the needs of those that like the shorter little clips. So we got you. We got you. So today we're going to get into the weeds of IBS-D, including causes, triggers, and treatments. So let's introduce our expert guest today. Anthony Lembo is a nationally recognized gastroenterologist and clinical researcher specializing in gastrointestinal motility disorders, particularly irritable bowel syndrome. He is a professor of medicine at the Cleveland Clinic Learner College of Medicine of Case Western Reserve University and serves as vice chair of research at the Cleveland Clinic Digestive Disease Institute. Dr. Lembo previously spent more than two decades right here in Boston with me at Beth Israel Deaconess Medical Center, where he was director of the GI Motility Laboratory and a professor of medicine at Harvard Medical School. Over the course of his career, he's been really a leader in advancing the understanding and treatment of IBS, chronic constipation, and related functional GI disorders through clinical care, translational research, and pivotal clinical trials evaluating new medications, diet therapies, and supplements. Dr. Lembo continues to care for patients with complex motility and functional bowel disorders while leading innovative clinical research aimed at developing more personalized and effective treatments for IBS and related conditions.

Dr. Megan Riehl 3:04

Well, we are going to dive right in. So Dr. Lembo, we're going to start with what is IBS-D? And then just a few of those alarm signs when maybe it's more than IBS-D.

Alarm Signs And Key Tests

Dr. Anthony Lembo 3:17

Oh, thank you, Megan. Yes. So IBS-D stands for irritable bowel syndrome with diarrhea. So diarrhea is exactly what you what most people think of. It's generally something with loose stools. We quantitated using what's known as the Bristol Stool Form scale, which is a way for people to speak the same language. So if you have very loose stools that are somewhat unformed or very loose that is completely unformed, you'd fall into the upper ends of the Bristol stool form scale. And it's a scale from one to seven, that would be a six or seven. And if you most of your stools tend to be loose, watery, and we quantitate it by being more than 25% of the time, and not having hard stools for more than 25% of the time, you would fall into the diarrhea classification. IBS, of course, has abdominal pain. Importantly, the most important part is that the abdominal symptoms have to be associated with the bowel habits. So either the pains related to bowel movements, the frequency, the change in stool frequency, or a change in stool consistency. So that would be could be the definition of IBS. Now, typical Rome 4 definition, and there's a new Rome 4 that's just coming out that'll be similar. The frequency will change, and it'll also have more abdominal symptoms will be will be allowed with it. The

Speaker 3 5:01

other part of your question was about alarm features, because of course, those symptoms are very common in the population. The longer you have it, and that's one reason why we have the three months of these type of symptoms and the onset for at least six months, it's less likely to be due to other causes. So, first of all, I want to make sure that it's frequent enough because if I have diarrhea from uh gastroenteritis, it'll just tend to come and go. It doesn't usually linger on for most people. And then we look for other causes that could explain it, of course, because there are other causes for chronic symptoms. And the most common ones that we see in the United States would be like something like celiac disease. So we know that somewhere between around less than 5% of the population that have IBS symptoms would have uh celiac disease, but that's still fairly common. So it is recommended that you be tested for celiac disease if you meet the criteria for IBS. And it can be done with a simple blood test, so a TTG, which is an antibody test that we can offer, and so it's fairly easy to get. So we want to make sure you don't have celiac disease, which would probably be one of the more common things to look for. And then, of course, inflammatory bowel disease would be the other, particularly Crohn's disease, because ulcerative colitis, which those are the two types of inflammatory bowel disease, ulcerative colitis tends to percent with bleeding, which would be an alarm symptom, which I'll talk about about in just a minute. But we would think about Crohn's disease, which could mimic IBS. And that can be diagnosed by a simple blood and stool test. So stool tests looking for inflammatory markers. And if you have a negative stool test that's really normal, the odds of you having inflammatory bile disease would be quite low. We look for other things like bile acid malabsorption. So if someone's had a gallbladder taken out, they may be prone to having an increase in bile that occurs. So typically bile is released after a fatty meal, it mixes in with the fat, helps us to digest it. But someone who's had a cholesterol or gallbladder removed, they'll release bile throughout the day and also into the night, and that can tend to overwhelm the system because it's reabsorbed in this in the distal bowel. And when bile gets into the colon, it can cause diarrhea. So we think about that. Microscopic colitis would be another malabsorption for like lactose or other types of malabsorption, can certainly cause it in chronic infections. And the most common in the United States, the one we generally recommend, particularly if there are risk factors, would be looking for Giardia. So again, that can be pretty easy with a stool specimen. So when we evaluate someone, we tend to look for what we call alarm symptoms. So this is what we always tell people if you're having any alarm features or symptoms, please let us know. Because even though you may not have it today, you may have it later. And as I've already mentioned, blood in the stools is probably the most one of the more common symptoms that could suggest an organic disease, such as ulcerative colitis, as I mentioned, also cancers, which would be extremely rare with chronic symptoms, but something to consider. We also think about unintentional weight loss. So if someone says that they've lost more than 10% of their body mass, but that they're not trying to lose weight, then you sort of think about it. Nuance that over the age of 50 or 55, that can be considered an alarm feature. IBS tends to start at a younger age. Of course, it can start at any age, but just we start to think about whether something else could be explaining it. They have a low blood count, so someone shouldn't be anemic unless there's another explanation for it. So we do see a lot of young women that are menstruating that may have other reasons to have anemia, but you certainly want to be look into it a little bit further. If someone has a family history of the things we talked about, inflammatory bowel disease, cancer, celiac disease, then you would probably do some additional testings to see that. But when you have the symptoms of IBS, particularly the chronicity of it, no alarm features, and some limited testing would include some of the diseases we talked about, so like stool cow protecting, which is that inflammatory marker I was discussing earlier, celiac disease, maybe giardia, CBC for a complete blood count. Those are simple tests that we would tend to do in many people with IBS with diarrhea. If all those are negative, they don't have alarm features. The overwhelming odds are that you'll have IBS in fact, probably over 99% odds that this will irritable bowel syndrome. That was a long-winded answer to your question.

Dr. Megan Riehl 9:25

And I hope that was But comprehensive, and we appreciate that. And it's a good rundown to help give people a roadmap and what can feel like a really complex, and it is a complex disease.

Post-Infectious IBS And Inflammation

Kate Scarlata, MPH, RDN 9:38

Absolutely. And you don't want to miss any of those alarm features. So seeing a gastroenterologist or even a primary care doctor to really assess your diarrhea and any sort of other issues that might raise some flags that it's more serious. And then it's always important because IBS does have a lot of mimickers, and you really covered a lot of those that are really important. You know, one you didn't mention, and maybe we'll we'll touch upon that in a minute. And maybe, you know, this is kind of new is that sucrase isomaltase deficiency, you know. So let's talk about that in a minute. But I want to jump into post-infectious IBS because we know that having about a foodborne illness can trigger an IBS scenario. What happens in the gut? Does something happen to the gut after this infection? And what are the odds that someone's gonna have IBS for the rest of their life? Or is this gonna be something that will eventually kind of work out of their system? What's going on with post-infectious IBS?

Dr. Anthony Lembo 10:35

So that's a great topic because it is the one area that we have the most data for the pathophysiology, both the prevalence, et cetera, the epidemiology as well as the pathophysiology that's been worked out for post-infectious IBS. But taking a step back, it's not just post-infectious, it's actually any type of inflammation in the gut has been associated with IBS. So it seems to be one of the major causes for IBS is an inflammatory event, whether it be an infectious, inflammatory bowel disease. A lot of patients, about 20 to 25% of patients, once the IBD is quiescent, will tend to have IBS symptoms. Diverticulitis, for example, there's been nice studies looking at the prevalence of IBS after that. So almost any chronic inflammatory event and post-infectious or an inflammatory, you know, an infection event is one of them. It could be almost any type of infection. So it's been documented in postviral post, of course, bacterial infections, probably the best documented of them. Long before IBS was called irritable bowel syndrome, they used to call it post-salmonella bowel issues. Like they didn't call it irritable bowel, but post-salmonella syndrome. And they knew that people that had an infection, in that case was from Salmonella, many of them would develop long-standing symptoms. And that you asked for the number, well, it's about 10 to 15 percent will develop symptoms that will be long-lasting. And by long-lasting we mean about six months. The good news is as we follow these patients over time, and they've done this over 10 years, the rate does go down. And it tends to plateau somewhere around where the prevalence of IBS is in the population, which is kind of interesting, which has led one group to model this and show that this is probably one of the major causes of IBS. Now we know IBS is a heterogeneous disorder, there are many different causes, but this is probably a big factor, again, all types of inflammatory conditions. So what happens with post-infectious IBS? Well, we know that you get a persistent low-grade immune activation that occurs in the GI tract. What I mean by that is that if you do biopsies of patients that have post-infectious IBS, that you can measure an increased number of chronic lymphocytes. You can see also other types of enterochromaffin cells, that will be increased in patients and a change in permeability of the aligning of the GI tract as well. And that in turn will cause an increase in sensitivity to the nerve. So we talk about one of the major causes of IBS being hypersensitivity, as well as alterations in the brain-gut interaction. So the way the brain processes those signals seems to be altered, particularly in the chronic patients. So all of these factors have been shown to occur in people with post-infectious IBS, and again, occur in many other people, even when we can't document post-infectious IBS. And there in turn there will be changes to the microbiome that occur after infection, probably due to a number of factors, including changes in the motility that will occur. But again, the good news is the prevalence does go down over time. So I always tell patients that they're likely that the symptoms are probably going to be less severe over time, but it can be several years in the making.

Dr. Megan Riehl 13:58

I remember that one of our colleagues, Dr. Bill Chey, taught me a long time ago about you can give patients with post-infectious IBS some hope because of that spontaneous recovery research that's been done, that you know they may just get better. And so I like to bring that up with patients that that's possible. Absolutely.

Gut Permeability And L-Glutamine Study

Speaker 3 14:17

And I think it's probably worth just mentioning for this, the audience, that there was a study that looked at the role of improving the permeability of the gut in patients with post-infectious IBS. And so what they used was an amino acid called L-glutamine and gave it to patients that had documented post-infectious IBS and increase in permeability. So it turned out to be about half of those patients that had documented post-infectious IBS. And they were able to show in that study, which obviously needs to be replicated, that the reduction and improvement in the permeability correlated with improvement in their IBS symptoms. So I think you know there are some treatments again for IBS in general, but maybe in specific for post-infectious.

Kate Scarlata, MPH, RDN 15:05

Yeah, I love that glutamine study. And I know there was a lot of research, even in IBD with glutamine, a long time ago, back in my early stages of being a dietitian. In IBD, Walter Willett at the Brigham and also at Harvard was doing a lot with L-glutamine. It's an amino acid that is really important for cell, you know, the gut turnover and keeping the gut healthy. It is interesting to see that it had some effects on that post-infectious IBS model.

Speaker 15:39

Abdominal pain and diarrhea from IBS-D getting in the way. You may find relief with Xifaxan with an 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, and antibiotic agents, or any components of Xyfaxin. Tell your doctor right away if your diarrhea worsens while taking Xifaxan is this might be a sign of a serious or even fatal condition. Tell your doctor if you're 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.

Kate Scarlata, MPH, RDN 16:25

So let's just talk a little bit about CSID because I know that this is something that you're very well aware of. And Bill Chey and Brooks Cash just have done some research looking at prevalence in patients with IBSD and developing sucrose isomaltase deficiency. And I think this is really interesting and maybe tied into that inflammatory component that we see in these post-infectious patients. But I love your intel on this because I don't think a lot of consumers or patients have ever heard about sucrase isomaltase deficiency. And, you know, it is an IBS-D mimicker that we're really just starting to really understand about. And this is more of an acquired form that we're seeing in adults, I think, with IBS-D, not the congenital form that you're typically born with and is quite severe. But can you elaborate on that?

Dr. Anthony Lembo 17:13

Yes, I mean I think I don't think a lot of clinicians are familiar with CSID. So, and CSID, of course, stands for congenital sucrase isomaltase deficiency. And as you said, for the adults, much of it's probably acquired. So we don't we wouldn't necessarily call it CSID. You know, we call it SID. And the isomaltase is just because that's how that comes out, it has to be broken down. They come from the gene, it comes out as one compound, and then it's actually broken down. It's not as common as lactase deficiency or some of the other disaccharidase deficiencies, which I think you know most of us are aware of. And consequently, most people are aware of. So I think for example, lactose, if you know many people get symptoms, and then it's usually not a surprise to them, and they're all they're very aware of it. For some of the other poorly digested small carbohydrates, for example, for example, fructose, for example, like I'd say less people are are aware of it, but we know that large quantities of fructose can induce symptoms. Some people are not aware of it, and I think even fewer are aware of the role of sucrase deficiency. So sucrase, of course, is needed to break down the disaccharidase. And without it, when when it's depleted, then you can get an increase in symptoms, just like you would with lactose or fructose or anything else that's not well absorbed by the GI tract, and it causes an osmotic effect within the colon, and that in turn can cause gas and bloating because the bacteria will digest it and cause release these byproducts, which in turn cause a you know more osmotic load within the colon, can cause bloating and diarrhea, et cetera, with it. So it's not just the sucrase deficiency, it's just the one that we're not people are not aware of. So, which as you alluded to, Bill and others, and we've done this too, and when I was in Boston, looking at the prevalence of sucrase deficiency by breath testing, and I and Bill and others have looked at the role of biopsies and showing what was surprising to a lot of us was that it was higher than we really expected it to be. And now some studies have shown that people do not respond well to a low FODMAP diet, for example, may actually be deficient in this. And studies have shown that a small but a notable number of patients with IBS-D may also have some of the genetic predisposition towards having sucrase deficiency. So, yes, it's I think it's an important area, one we need to be more attuned to. The treatment would be exactly the same as it would be for like lactase deficiency. First, try to remove it. It's a little harder than lactose, though, because sucrose is found in a lot of different foods. And then, of course, like lactose, there's also an enzyme that you can take that can help digest the product as well, so you don't develop these symptoms. So, yeah, so it's an interesting area. And I did allude to lactose, but I was thinking more broadly.

Stepwise Treatment Plan For IBS-D

Kate Scarlata, MPH, RDN 20:04

Most definitely. I think it is much more prevalent, obviously, but I wanted to bring it up because I think it's just I like these new novel research projects that are out there. And I think, you know, it was like 7% of the people they studied, Dr. Cash, Dr. Chey, that had IBS-D, it was a pretty high number within that cohort of patients. So something to think about sucrase isomaltase deficiency, not the congenital form necessarily, but more of an acquired form. And as Dr. Lembo mentioned, it has this is an enzyme complex that helps you digest sucrose, which is found certainly in our sweets and delicious ice creams and things that we love, but also naturally in some fruits and vegetables. And it also, because it has that isomaltase piece, there is some starch digestion that might also be affected in those that have that deficiency. So a little sidebar, but I think an important one, you know, just put it out there, right? That's right.

Dr. Megan Riehl 21:03

Now, let's say we have the privilege of going to see Dr. Lembo in clinic, and I've got IBS-D. Dr. Lembo, talk to us a little bit about what treatment looks like. How do you decide diet, medications, behavioral strategies? Where do you go for patients? How do you begin?

Speaker 3 21:23

It'll depend on the individual, depends what they've tried before and what type of symptoms they have. But usually we'll start with the simple things, which we call sort of lifestyle modifications, and that would include diet. And there would also include exercise and sleep, making sure that we maximize their lifestyle to the extent that we can. That'll be our first treatment, and we can talk more about the dietary stuff if you want to discuss that afterwards. But from there, we'll move on to slowing down the gut. So one of the first line agents would be a loperamide. Which is a peripherally acting mu-opioid agonist. And so it stimulates that receptor, which we all know will slow down the intestine. And usually it's a low dose, and we'll just start one or two tablets, comes in two milligram tablets over the counter, and try to slow down the gut a bit. It doesn't tend to help abdominal pain. So if a patient presents with more pain-related symptoms, we may want to add something to help with the pain. And that would be something like an antispasmodic, would be one of the first agents. So in here in the United States, we have several anticholinergic-based antispasmodic agents, hyoscyamine and dicyclomine would be the most commonly used ones. And these can also be helpful for people with diarrhea because anticholinergic will tend to slow down the gut as well. And sometimes that combination, making sure that they don't become too constipated, may be sufficient. Peppermint oil would be an additional anti-spasmodic agent. It doesn't have effects on the bile habits, but it can be pretty well tolerated. So let's start with those medications. From there, we may add some prescription medications. And again, it'll depend on the predominance of their symptoms. So, for example, if someone has predominant pain symptoms, we may add like a tricyclic antidepressant to reduce that hypersensitivity we talked about earlier. And tricyclics are known as neuromodulators. They work peripherally and centrally, and they sort of reduce the firing of the nerves, particularly the sensory nerves, so it can reduce the abdominal pain that someone may experience. If bloating is a predominant symptom, for example, then we may add some rifaximin, which is a poorly absorbed antibiotic that can reduce symptoms of IBS, including bloating, diarrhea, and abdominal pain associated with it. And that's a two-week course of an antibiotic. It can be given two additional times based on the FDA recommendations. And from there, there would be other medications like eluxadoline is also an FDA-approved medication. It's a combined opioid medication, so it has some mu-agonism and kappa agonism as well as delta. That combination has been shown, at least in animal models, to not cause as much constipation, but also reduce pain. And so that's led to the being approved for the use of an IBS-D. It's important, though, that patients who do not have a gallbladder or have excessive alcohol use, and that would be defined as three or more drinks per day, don't take the medication because it can affect the biliary system and can increase the risks of sphincter of oddi dysfunction as well as pancreatitis associated with that. As a third line agent, we may add a 5-HT3 antagonist. So that's a serotonin type 3 receptor antagonism, and that can help slow down the gut and reduce abdominal pain. The one that's approved for IBS with diarrhea in women is called alosetron, and it is associated with ischemic colitis, so for that reason, it's recommended only in women with IBS because that's where most of the studies were done, only after they've tried other therapies or failed other therapies associated with IBS. But actually, if you titrate the dose up, you can avoid the constipation associated with it, but still one in a thousand may develop ischemic colitis. But it is readily reversible, although we don't like that to happen to people, but it is, I'd like to tell patients that it's reversible for them. So those are the major like prescription medications. Of course, there will be others that we use occasionally, but those will be the major. And then, as you mentioned, we have the psychological treatments or behavioral type treatments, and those can be extremely helpful for all subtypes of patients, and it doesn't just have to be those with very severe disease, and certainly not those with severe psychological issues. It's not a it's not based strictly on whether you have anxiety or depression. We know that this disorder of the brain-gut axis is clearly involved in many patients. Doing this behavioral therapy can be very helpful, often with the psychologist, also through apps, and then Brennan Spiegel has shown that you know virtual reality can be used as well. And we hope to see more studies on that in the not too distant future. Cognitive behavioral therapy and hypnosis will be the two of the best studied behavioral treatments that we have available today.

Is Long-Term Loperamide Safe

Dr. Megan Riehl 26:36

Yes. So Dr. Lembo has worked with one of my esteemed colleagues, Dr. Sarah Ballou, in the past who delivers those brain gut behavioral therapies, as well as I know that you've consulted with Kate on several patients from a dietary perspective. So, you know, when you're living with diarrhea, a team approach is really the key. I also get patients that are anxious about remaining on these antidiarrheal medications. Some of them feel like we're just putting a cork in it. And is there a problem with that? And so, you know, what's the difference between kind of slowing digestion and then actually getting to the root and calming that overreactive gut?

Avoid Endless Testing With Confidence

Dr. Anthony Lembo 27:16

So using a low-dose loperamide, for example, which is the most commonly used mu-opioid, peripherally acting mu- opioid agonists, is safe at the recommended doses and can be used long term. It's been up on the market for many, many years. And even before that, people were using using it to reduce diarrhea. So it's it's going to be well tolerated, it's safe. They can use it long term. I agree with trying to look for the root cause of it, and then we that's what we were talking about earlier about bile acid malabsorption, you know, the poor digestion, et cetera. There are other areas to look at, and some people even look at bacterial overgrowth, et cetera, and that you know you can explore those different areas, but you really want to get the symptoms under control in patients. And when you don't find another treatable cause, which is by far the most common scenario that we see in our clinic, because again, it's probably this disorder of brain-gut interaction. If it's a post-infectious etiology, you have a hypersensitivity occurring, you know, you can treat it with tricyclics that may help. And obviously, adding a mu-op would be very helpful for patients. And I think they again they can do it long term. These are generally low doses and very safe.

Kate Scarlata, MPH, RDN 28:29

You know, we kind of talked a little bit about this, but we see it all in practice where patients get really into this panic mode of the root cause and you know naturopaths, worried about cycle, learn something on TikTok. Stress, am I cursed? You know, how do we help manage that cycle and try to help get them answers, but at the same time know when to kind of reel them in a little bit or avoid the chasing 17,000 gastroenterologists for their diagnosis and symptoms?

Dr. Anthony Lembo 29:02

Yeah, I think that's extremely important that we give a confident diagnosis. There's enough literature, there's enough experience to tell patients that you know this is what they have. And yes, there could be some of these other etiologies that can contribute to their symptoms, but for the majority of people, it's a disorder of this brain-gut interaction, that the way the signals are processed somewhere along the line from the gut all the way up to the brain, and there's no need, and we you know, doing a fifth CAT scan is not going to yield etiology, a third colonoscopy is not gonna be appropriate for that individual. So I think, but it has to be the clinician that's confident on their diagnosis. I've been there, done that, I've seen that, you've had the appropriate evaluation. Let's move on to start treating you appropriately. Now, patients will have anxiety over this, and anxiety and depression are common in IBS and likely to do with some of the pathophysiology, at least some of the amplification that can occur in patients, because we do see it so commonly with it. But I think, you know, that I think you need to be confident. Now, for example, if I have a patient that has other chronic pain syndromes, you know, for example, fibromyalgia, chronic migraines, etc., it's helpful to show them look, this really is a signal or a clear indication that there's altered processing of pain signals, most likely at that point up in the in the central nervous system area. So let's focus treatment on dampening that hypersensitivity. And that can be with behavioral therapy plus you know the neuromodulators. And we mentioned the tricyclics. We'll use others like some of the SNRIs, like duloxetine, or even some other medications, depending on the presentation of the patient. But probably the best tolerated would be the low dose tricyclics. At least that's the what's recommended as first line for patients. So confidence is, I think, important.

Speed Round And Personal Takes

Dr. Megan Riehl 31:01

Definitive diagnosis, confidence and hope. And that is a pretty good recipe for getting people feeling better. So this was a fantastic talk, a very nice overview of IBS-D and strategies. And we're gonna just really quickly get to know you very fast in a speed round before we let you go. So, Dr. Lembo, if you weren't gastroenteorlogist, what would you be doing with your life?

Dr. Anthony Lembo 31:30

I was gonna be an astronomer when I went to college. And I went to a small liberal arts school in western Massachusetts that was very strong in astronomy and ended up taking a number of classes in astronomy, but realizing it was gonna be hard for me to make a living doing that, and eventually found my way into medicine. So I probably would have been an astronomer.

Kate Scarlata, MPH, RDN 31:50

I love that. That's a great answer. Okay, let's get into uh what is the biggest gut health myth that you want to bust?

Dr. Anthony Lembo 31:58

That you have to have a ball movement every day, and if you don't, taking laxatives is appropriate. That's not the way it you see this advertised all the time, and that how you have a month worth of stool or 10 pounds, that's not true. So please do not take laxatives simply because you're not having a bowel movement every day.

Dr. Megan Riehl 32:19

Good one. And what's something that instantly lowers your stress level?

Dr. Anthony Lembo 32:25

Running in the woods. I love trail running. Spend much of my time doing trail running, less so in Cleveland, although I because I have to now drive to one of the parks, but where I lived in Boston, we had trails right out my back door. So I love doing that.

Kate Scarlata, MPH, RDN 32:41

Yeah, I'm a nature girl. I like being out there too. So what's your hot take on probiotics? Yes or no for IBS?

Dr. Anthony Lembo 32:49

Maybe. I do recommend them to some patients, but I tell them about the gaps in our knowledge for them, and we do it on a trial basis. I mean, not long term, so I want to make sure the patients are not taking them, spending their money for years just because I recommended it, but as a trial to see if it helps them. I think we need better research. I know that's an easy answer, but we do need further guidance for patients with it.

Dr. Megan Riehl 33:17

And finally, do you like spicy food or are you a mild food guy?

Dr. Anthony Lembo 33:22

Spicy all the way. In fact, I'll be stopping tonight to pick up some Thai food, and it'll be not heavy spice, but it'll be moderate.

Kate Scarlata, MPH, RDN 33:31

That's perfect. That's perfect. Thank you so much for coming in, sharing your expertise. We are so appreciative. And for our listeners, please subscribe, like, and share The Gut Health Podcast.

Dr. Megan Riehl 33:44

And check out series number two coming up very soon. Yes. Thank you. 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.