[Music] good evening and welcome to doctors on call i'm dr mary owen faculty member within the department of family medicine and behavioral health and director of the center for american indian and minority health at the university of minnesota medical school i'm also a family physician for the fond du lac band of lake superior chippewa and i'm your host for our program tonight on lower gi problems the success of this program is very dependent on you the viewer so please call in your questions or email them to ask wdse.org the telephone numbers can be found at the bottom of your screen our panel received this evening include dr robert erickson a gastroenterologist with essentia health and dr stephanie judd irwin a gastroenterologist with luke's gastroenterology associates our medical students answering the phones tonight are sophie brow of fairmont minnesota luke lemire from deerwood minnesota and anna schuh of new all minnesota and now on to tonight's program on lower gi problems thank you for both for being here it's my pleasure thank you thank you so just to start out um basic question what's the difference between upper gi and lower gi well the lower gi generally begins where the small intestine inserts into the colon and it's generally regarded as the large intestine or colon okay good i hope that was clear to everybody so we're only working on lower gi questions tonight so when you call in or send us messages for remember that it's lower gi so dr irwin how do you distinguish irritable bowel syndrome from other gi disorders and symptoms that's a great question and one we often see in our clinic usually we look for red flag symptoms such as blood in the stool abdominal pain or cramping that doesn't improve with the bowel movement anemia weight loss these are all red flag symptoms that indicate other problems going on and oftentimes irritable bowel is a rule out disease where we rule out things like inflammatory bowel disease celiac disease and so on and then after a thorough workup can diagnose that but there is rome criteria special criteria we use to diagnose irritable bowel syndrome patients present with either constipation and or diarrhea can have alternating symptoms and usually abdominal pain if present does improve with the bowel movement oftentimes these people do undergo endoscopy and those would be normal in irritable bowel syndrome in most cases okay anything to add lacta erickson no i think she she hit it well there's such an overlap of many gi diseases um again we try to catch the things we don't want to miss things that are bad so things that are blood per rectum or pain that keeps going on weight loss there are some standard tests that will do to rule things out like to rule out celiac disease and do a cbc and do a stool test for white blood cells called calprotectin to look for inflammatory disease and as dr irwin noted we'll do colonoscopy especially we'll do colonoscopy if they're age 45 or older because that's when we begin colon cancer screening anyways but less than that if there's no warning signs then we often treat empirically can you get sometimes get blood in the stool with irritable bowel you sure can a lot of people have hemorrhoids that's probably the number one cause or if they're constipated anal fissure is quite common but we really do need to rule out things like colon cancer or polyps in patients who have blood in the stool so we consider that as a red flag symptom even if patients are young and it's intermittent uh you know it needs to be evaluated okay good to know so don't get worried immediately just go see your doctor and get checked out exactly the good news is most of the time it's not anything serious like colon cancer but something that needs to be evaluated for for sure and is uh colonoscopy the only way let's ask you dr carrickson is the colono colonoscopy the only way to catch colon cancer no there isn't so there's many tests and the one important thing about colon cancer screening is that you get some type of screening so it doesn't mean they have you need colonoscopy and i know dr irwin will get into this later as far as the age when to start but we can do tests such as colonoscopy there's stool tests for blood called fit there's another stool test with blood and dna that funny guy in the box that you see in the commercials called cola guard every test has its own advantages and disadvantages colonoscopy does however has the highest sensitivity and specificity and we can remove polyps to reduce the risk of colon cancer in the future can you tell me what you mean by sensitivity and specificity it's just our ability you can be too sensitive and pick up too many positive tests and have false positives if you crank up the sensitivity specificity is is finding finding the cancer and but you want you want to balance between the two of sensitivity and specificity thank you for that anything to add dr irwin no i think dr erickson covered it but i would just encourage patients to get a form of colon cancer screening and talk with their doctor because the best test is the test that gets done whether that's a colonoscopy or a stool based test that dr erickson mentioned now i think you mentioned 50 as the age to start i believe you did dr erickson yes we were talking before the show that the guidelines have changed so it's 45 now okay so that's what the uspst tf has uh declared that's united states preventative task force and um some insurance companies don't cover at 45 but it's that group the from 50 to 45 between 2007 and 2017 that two percent per year increased the risk of colon cancer the other age groups higher than that actually decreased by three percent so it's the one age group where it's increasing and i'm sure dr erwin you've seen some patients in that age group so that's why um if you are of that age group even in the 40s and you have some blood per rectum you know at least bring it up to your primary care physician to to get it worked up not everybody knows this but some populations as well for instance i'm alaskan native and we start screening at age 40 for our population so yeah and african americans too have a higher risk too okay yeah so start ask your doctor about it so uh one of our callers wants to know when's the age that you stop screening for colonoscopy that's a great question too so typically age 75 has been the standard age group but it's now individualized so if you're let's say age 80 and are really healthy without many medical problems on an individual basis if you have a 10-year plus life expectancy you could undergo colonoscopy or a form of colorectal cancer screening likewise if you have polyps there's no age cut off that we stop screening but again would be an individual basis if you have a lot of medical comorbidities your doctor may say look you know it's probably not worth undergoing procedures for some minor polyps you've had in the future anything to add dr erickson no i think she covered it well again i think i would like to emphasize that don't be afraid of colon cancer screening and some of the other tests are non-invasive and those tests are better than nothing so again bring it up to your primary care physician and it's an important part of the primary physician's job and and when you're in with your specialist too i'll bring it up also you mentioned a couple of tests the cola garden fit test and sometimes i have patients who are surprised when they learn they have to still do a colonoscopy afterwards so can you talk about that a little bit yeah any positive test any fit test or any positive coliguard does warrant a colonoscopy so that's the discussion that we have with patients before you we could do this stool test but you may end up even doing a colonoscopy anyways and a lot of patients will say i just want to be want to be done with it and just do the colonoscopy um so again there's a lot of disadvantages and advantages to each test excellent anything to add dr erwin i think you covered it well okay so we're going to switch topics what's the difference between i'll start with you dr irwin diverticulitis and diverticulosis tough question and most people get those confused so diverticulosis are little out pouchings or pockets in the colon they look almost like swiss cheese when we do a colonoscopy and for these we just recommend high fiber diet and when they get infected or inflamed or have micro perforation we call that diverticulitis so the itis is the inflammation or infected part of it and patients with diverticulitis typically have abdominal pain sometimes they have fevers the pain is typically left side of their abdomen they can have some change in bowel habits and also some blood in the stool rarely as well and that usually requires treatment with antibiotics and we diagnose it typically with a cat scan an abdominal cat scan and diverticulosis is usually asymptomatic that we find on colonoscopy and about four to five percent of patients with diverticulosis will develop diverticulitis or have episodes of diverticulitis in their lifetime so it's pretty rare most people with diverticulosis itself do just fine and you might have said this and i missed it how do you have an idea how what percentage of the population has diverticulosis quite a few usually i quote my patients by age 50 about 40 to 50 percent have it by age 60 about 60 percent 70 70 and so on so usually if patients are over 50 i say more times than not you're going to have it that will find it i don't know if dr erickson in your practice the same thing percentages yeah and it's good to know that you have it when we talk about a colonoscopy in case you have the pain and things like that but the majority of time it doesn't cause symptoms so a patient asks what many of my patients asked or uh caller asked what many ask is there a special diet in particular we used to hear all the time that you couldn't eat seeds and nuts so dr erickson there was actually a study that was performed where it didn't make a difference whether there's complications associated with diverticulosis if you ate nuts or not so you don't have to take the seeds out of your cucumbers or raspberries anymore but on the flip side though some patients will have problems with like a big bowl of popcorn or or nuts you know if you have problems with diverticulosis then then stay stay away from cucumber seeds i wouldn't have guessed that one a pretty soft little guy had some can you um dr erwin can you define anal fissure sure so an anal fissure is a small tear at the very edge of the rectum or what we call the anal verge and typically this happens due to constipation or straining so in patients who have a lot of trouble passing a bowel movement that hard stool can cause a small tear in the rectal area there and cause pain and a lot of patients describe it as a knife-like feeling when passing a bowel movement and oftentimes they'll see some blood on the tissue paper or on the stool itself typically anal fissures heal within a few days so by the time patients often get to their doctor it's gone it's hard to to visualize at that point in time but a very common thing with associated with constipation and typically we recommend high fiber diet stool softeners things like miralax that can be easily purchased over the counter after discussion with the physician and something like sits baths hot water to kind of smooth the area to treat these anything to add doctor yeah she described it well you know the muscular spasm just it's like getting cut on the end of your finger in the winter here you know where you hit it and it keeps opening up and so there are some creams dill ties and cream nitroglycerin cream and and rarely is some botox sometimes injected into the area to relax that sphincter muscle so the the edges can oppose and they can heal up but it takes a while it's it's a chronic problem it is and sometimes surgery can be necessary too for these but but thankfully it's pretty rare so one of the preventative methods or uh treatments then like you said is uh taking care of constipation so besides the treatments that are the recommendations that you had is exercise help at all it sure does exercise healthy diet drinking plenty of fluids all of those measures that are just natural measures could be extremely helpful for patients so they don't have to reach for things like miralax or other medications which are okay too but if we can avoid those that's always the best and those dietary um the bad diet like fat high fat foods high sugars low fiber foods also contribute to diverticulosis i think you mentioned it can yes and you know it constipation is sometimes just aging in the gut too you know we our gut ages is like our rest of our body does so the motility of the gut changes so um it it's not unnatural to become constipated when you get older and there you know there's some things that we can do about it yeah but good to point out so people don't feel guilty or feel like they're doing something wrong yeah so back to diverticulitis if a patient was previously years ago diagnosed with diverticulitis how long should they stay on the treatment of water and fiber i would say indefinitely i mean that's a good treatment anyway for diverticulosis and once you've had one episode of diverticulitis you are at risk of having more or you're at higher risk for that so i would say indefinitely okay anything to add avoid smoking and non-steroidal anti-inflammatories like mortar and mapperson can contribute all right current treatments for hemorrhoids that's another great question so a little bit of the same as the anal fissures that we just discussed but routine kind of over-the-counter treatments like preparation h can be helpful again high fiber foods are avoiding constipation even if you have to take laxatives like such as miralax something called sits baths or hot water bathing increases the blood flow to the rectal area and can help heal hemorrhoids and then we offer endoscopic procedures as well for patients who don't respond to these conservative measures so during a colonoscopy while patients are sedated we can do a band ligation where we put a small rubber band over the hemorrhoid and that rubber band falls off in a couple days and that helps pleat the hemorrhoid up higher in the rectum so that it doesn't cause further irritation so that's something we commonly do and see if that is ineffective or if the hemorrhoids are on the outside or the external ones which are painful then those would be referred for a surgery okay anything to add dr erickson hemorrhoids are very common it's just this venous plexus at the rectum and again as we age and we're upright they tend to fall and especially during pregnancy when the injury abdominal pressure is higher so another thing about aging in the gi tract and not to be embarrassed with and certainly work with your physician if they're bothersome and make sure there's nothing else going on as we mentioned before if there's some bleeding or things and another thing that exercise can help exercise is good exercise and not straining as much as possible yeah i don't think people often realize that i've been surprised how many my patients don't so if uh just a good general question dr erickson if i have been having more than one bowel movement per day is that a problem that is not a problem the you know the average american average is three times a week to three times a day okay so we have a lot of latitude there to being normal and so that would be within the normal limits okay uh dr irwin why does caffeine make me have to use the bathroom so often right well caffeine is a stimulator so it does stimulate your gi tract uh to cont to uh to produce diarrhea or looser stools so some patients do use it as a natural laxative um so so it's one of the stimulants one of the many things that natural remedies we use for constipation so that is in the normal range if patients have a little loose stool or feel like they need to have an urge to have a bowel movement shortly after their morning coffee okay just be aware when you're drinking your coffee all right dr erickson how is my anxiety related to my hyperactive bowels um the bowel has structure it's a structural organ it's a tubular organ the colon so it has structure but there's also function and the way that the gi tract functions is a generally peristaltic waves and there's three different types of peristaltic waves which we won't get into detail but the gi tract also is innervated by many many nerve nerves and in the endocrine system so it's it's it's not an isolated organ in itself so anxiety in itself produces a lot of extra chemicals in the body epinephrine and things like that um and that's what affects this motility and that's where you're getting an impact of anxiety with your bowels okay thank you anything to add dr irwin i think you did a great job explaining a complex subject um there is something called the the gut brain axis so some patients uh you know with anxiety uh have an overactive gi tract and we use medications for anxiety and very low dose to help with those nerve pathways in the gi tract to help calm them down essentially anything to add again again very common okay uh don't be embarrassed and we can work okay with you uh on that your primary doc or the gastroenterologist can work with you on that okay dr erickson um patients are curious about the process of prepping for a colonoscopy what to expect and um you know if you have if you see a little bit of blood if you see some mucus are those alarming are they typical um yeah the the whole concept of prepping for colonoscopy is an issue in itself and don't let that stop you from from considering colonoscopy there's there's different perhaps uh preps that um have lower volume uh that can be utilized a little bit of blood during a colonoscopy prep is not uncommon again the hemorrhoids can can act up but certainly tell your physician before you start we would look for other things mucus the colon always makes mucus and it's that mucus that sometimes it comes out so that's that's a natural product of the colon is mucus thank you for that anything to add dr irwin nope i think you explained it well but i might add most patients say that the bowel prep is the worst part of their colonoscopy so if you can get through that you can get through the colonoscopy and it's worth it it's worth cancer away exactly dr irwin tell us about crohn's disease and are there any dietary restrictions or things to think about if you have crohn's disease yeah so crohn's disease is one of the inflammatory bowel diseases the other one is ulcerative colitis and this is where you have inflammation of the top layers of the the colon it's a chronic condition we aren't sure exactly what causes it but we're thinking it's probably environmental factors that interact with your born genetics it often causes symptoms such as blood in the stool diarrhea abdominal pain when we check labs patients can be anemic or have inflammatory markers that are raised i usually recommend a blander diet if they're having a so-called flare of these symptoms but the goal would be to to be able to eat normally for the most part once the disease is under control and there's many medications that we use for this and most patients are able to live relatively normal lives without having these gi symptoms anything to add dr no i'd like to emphasize that last point is that you know working with your gastroenterologist and your primary care doc is to control the disease so the disease is not controlling your life exactly um and so get some help we'll be glad to help you out with it and i think that that's uh much that's more easily done these days than it has been in the past so you know even if you were diagnosed a long time ago and are afraid to go and see your doctor go back in and there might be new remedies and treatments new things to talk about with your doctor definitely new therapeutics out there with fewer side effects and so talk to your gastroenterologist about it and help you out dr irwin difference between in lower gi issues between men and women do one or one higher than the other not necessarily we probably see more irritable bowel symptoms in our female patients but that just might be male patients may not come to light as often sometimes we see more hemorrhoidal issues with female patients due to childbirth or pregnancy related issues but not necessarily that i can think of in lower gi tracts that that one's necessarily more common than the other anything to add doctors a little uptick in colon cancer in males um but that's about it so if you're male and you have blood in your stool don't ignore it get to your doctor and talk about it well going back to that whole issue of cancer again this patient or this uh caller asks if you've had polyps is the cola guard stool test okay or would the colonoscopy be required immediately yeah cold guard is not fda approved for patients who have had a history of polyps so it's it's patients who do not have a family history of colon cancer or a personal history of polyps okay anything to add nothing to add once you're once you have polyps you're you're relegated to the colonoscopy realm okay uh this caller asks what treatments are in the pipeline for ibs either of you well many different treatments i mentioned one some of the anxiety medications we use called ssris can be quite helpful but mainly it's just controlling symptoms so if you're on the constipated side we use things like miralax if you don't have issues with bloating we'll try fiber supplements likewise if you have diarrhea we'll use things to help stop the diarrhea and anti-diarrhea like ammonium and then there's other medications to help if you have cramping or spasm something called bental and then there's other dietary factors as well that can help with with symptoms like abdominal pain and bloating something called a low fodmap diet where we have you uh basically stick with low fermentable type foods so based on you know diet medications also leave a living a healthy lifestyle exercise uh it can be helpful as well getting enough sleep at night um so we talk we focus on a whole body approach when we see patients with irritable bowel syndrome anything to add that no i'd like to emphasize that in the beginning therapy compared to the start of my practice there's a lot other therapies out there but i definitely emphasize that first and but there are some other ones out there we won't get into details but healthy lifestyle this collar gets into something uh very interesting these days can antibiotics cause colitis and what they're getting to do these kill the good bacteria they're asking that question that's more and more in the news these days so i'll turn to you sure so yes in a way they definitely can kill the healthy bacteria and antibiotics put you at particular risk you probably hear it these days of c difficile colitis so this is a infection that is rampant throughout the population in hospital patients as well as in the general public so i would say unless you really need to be on antibiotics for a strong indication you know don't take them you know if you have a cold it's most likely a virus unfortunately a lot of doctors do prescribe these types of things or patients think they need them but i would really limit antibiotics unless it's a well thought decision by your physic by your personal physician anything to add dr erickson no i think that you know c diff is out there it's in everybody's colon um and it is the antibiotics that that kills the good bacteria and the c diff proliferates um there is a new therapy of the the stool transplant so patients who had suffered in the past there are some salvage therapies that we have now that pretty impressive what it what it does yeah this is such an important topic i have so many patients who don't understand why we continually say you know we don't use those antibiotics unless we absolutely need to and not just because antibiotic resistance and the colitis but also for you know weight gain that we know that they can cause a lot of other problems as well right and they change your flora and some people think that maybe even they develop irritable bowel symptoms after a course of antibiotics because their microbiota are different so definitely important to to really talk with your physician to make sure those antibiotics are warranted in the first place excellent i have one i think we have time for this question what are the causes of explosive non-diarrheal bowel movements and how to prevent them dr erickson explosive non-diarrheal bowel movements yeah usually explosive bulb movements are associated with liquidity [Music] if it was explosive non-diarrheal it could be a form of irritable bowel um it would take sitting down talking with your primary care gastroenterologist potentially getting some labs and talking about all the potential possibilities if it really is hindering your lifestyle doctor either of you any last closing moments closing thoughts last moments no i just wish everybody good health and live a healthy lifestyle exactly march is colorectal cancer awareness month and i know dr erickson as well you know please talk to your provider whether it's with one of us or your primary to get your colon cancer screening completed excellent any blood in your stools get inside get in there and see your doctor excellent i want to thank our panelists dr robert erickson and dr stephanie judd irwin and our medical student volunteers sophie brow luke lemire and anna shu please join psychotherapist dina klabau next week for a special program on children's mental health thank you for watching and good night [Music] [Music] [Music] you