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Interviewer: Inflammatory Bowel Disease treatment options. We'll talk about those next on The Scope.

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Interviewer: Dr. John Valentine is an expert in treating inflammatory diseases of the intestinal tract including inflammatory bowel disease. Dr. Valentine, after you've been diagnosed or you've diagnosed someone, I should say, with IBD, is there a standard treatment order that you follow or what can the person expect at that point?

Dr. Valentine: Well, there used to be a misconception that you'd start with the milder medications and work your way up, but people were failing. I think the better concept is to treat to the disease severity. If somebody has mild disease, see if you can get by with some of the milder medications. If somebody has obviously severe disease, you're wasting your time starting slow and the patient's going to get into other kinds of problems. It also makes a difference if you're talking about ulcerative colitis or Crohn's disease.

Let's start with ulcerative colitis. I would like to see everybody fail a class of drugs called mesalamine back in the '50s, '60s, and '70s, a drug was called sulfasalazine. That still exists, but they all deliver the same medication to the colon. Most patients will respond well to that. There is a proportion, 30-40% of those, that that class of drugs isn't enough. Then they need to get into medications to suppress their immune system.

We may use steroids such as prednisone in patients just to get them better quicker while you want to see if the mesalamine drugs will be effective for them. But if they're not effective, then steroids can give some prompt relief, but they're not good for your long run. They are full of complications.

Then we get into what we call steroid sparing therapies, which could include azathioprine, methotrexate, or anti-TNF medications, infliximab. Vedolizumab is a newer so-called biologic, but that blocks the signal that sends the inflammatory cells to the intestine.

Interviewer: Are there any drawbacks to those medications?

Dr. Valentine: Well, with the mesalamine medications, they are very safe. Every drug has potential side effects to it, including aspirin, but these drugs, like I've said, have been around since the '50s in one form or the other. So they have a long track record and they're very well tolerated for the most part. When you start getting into the medications that suppress the immune system or blocking a key component that we have for a reason, given what we're doing to the immune system, I think there are also surprisingly well-tolerated. But you do need to be aware of potential complications.

So we avoid chronic steroids because of effects on mood. You can get depressed, trouble sleeping, get irritable. It can push you over to be diabetic if you're prone to that already, weight gain, acne, other cosmetic changes can occur, as well as osteoporosis from long-term use. So we need to avoid long-term use of steroids.

The other medications, methotrexate, azathioprine is a therapy and we'll start with those. They can reduce your white counts so you need blood monitoring. Abnormal liver tests can occur with both of those so you need to monitor the liver enzyme. Look for irritation of the liver. There's also an increased risk of skin cancers and lymphoma with patients on azathioprine. Now, it's not dramatic, but there is an increased rate and patients need to be aware of that.

So then, you get into the anti-TNF medications. These are monoclonal antibody or biologic drugs that bind the protein in your immune system called tumor necrosis factor, which is very stimulating to the immune system. While there appears to be less of a risk of malignancy with those medications, it's not zero. You need to screen patients for exposure to tuberculosis because putting somebody who has been exposed but not been treated can let the TB run wild. Screening for TB and for Hepatitis B is very important for that class of drugs.

Interviewer: Sounds like some of these cures are just about as not fun as inflammatory bowel disease is.

Dr. Valentine: Well, if you don't need to be on those medications, you shouldn't be. But I think if you need them, the benefits outweigh the risks.

Interviewer: Got you.

Dr. Valentine: While these complications can occur, they're not very common.

Interviewer: That's good. When it comes to the treatments, it's all about just managing the symptoms or is it about actually suppressing the disease?

Dr. Valentine: It's suppressing the disease. You might be able to manage the symptoms with pain medications, antidiarrheal medications, but the inflammation is still there and problems will occur.

Interviewer: Yeah, all right. So let's talk about if you're diagnosed with Crohn's Disease, then. How do the treatments differ?

Dr. Valentine: So since Crohn's Disease likes to, or commonly affects, the small intestine, the mesalamine drugs don't work very well because they're designed to deliver to the colon. In addition, with Chon's Disease, rather than being just the lining of the bowel that's inflamed, the whole thickness of the bowel wall is inflamed so you need more potent medication. Mesalamine medications don't work very well for Crohn's Disease. Very mild, colonic Crohn's, I've seen it'd be effective. But if you have more severe disease, you need to move on.

The only thing to move on now is to immunosuppressant medications. The same ones I mentioned before. The azathioprine, methotrexate, the anti-TNF drugs, infliximab, adalimumab, certolizumab, and then the vedolizumab, the one that blocks the lymphocyte traffic, has also been approved. There have not been head-to-head comparisons, but it doesn't appear to work as well as the anti-TNF medications. So because you need to get into more aggressive medication, and because of the complications with Crohn's, you don't want to let that drag out too long.

Interviewer: What's somebody's eating or their lifestyle, or are there any changes they could make there that will help inflammatory bowel disease, or is that not even related?

Dr. Valentine: There are some things you could do to help the symptoms. So when you're bowel's inflamed, especially the colon, the job of the colon is to absorb water and to hold your stool until it's a convenient time to get rid of it. When it's inflamed, it's having a hard time doing that so certain foods that pull more water into your colon are going to give you more symptoms. So we advise people with the inflammation of their colon to avoid raw fruits and vegetables, high fiber foods until we get the inflammation under control.

Once it's under control, you can add that stuff back to your diet and tolerate just like before your diagnosis. In Crohn's disease involving the small intestine, but when the whole thickness of the bowel wall is inflamed, the lumen, the center part of the intestine, actually gets narrowed. So again, bulkier, fibrous foods may have a harder time getting through the narrowing, which give symptoms of abdominal pain, distention, and if bad enough, nausea and vomiting. So again, avoiding those until we get the inflammation under control is often recommended.

Interviewer: But it doesn't actually treat the problem, which as you indicated, if untreated, could cause bigger problems?

Dr. Valentine: Correct. I firmly believe we need better dietary studies in inflammatory bowel disease, but the studies that have been done to date haven't really identified any particular diet or lack of things in your diet that causes inflammatory bowel disease.

Interviewer: Are there any other common things that patients say to you that they wonder if it will help as opposed to taking some of the medications that you recommend? And what do we know about those?

Dr. Valentine: Diet comes up a lot and I think patients are frustrated and disappointed when I can't tell them how to change their diet. Probiotic supplements also come up frequently and in the test tube, they do have anti-inflammatory activity. But there are thousands of different species and strains of bacteria within the gut.

Most of the probiotic supplements have between one to 10 species of bacteria and we don't know which ones and how many and which ones you need for which disease processes. So they won't be harmful, but I really would have difficulty going to the medical journals and finding clinical trials of probiotic supplements showing they're of great benefit.

Interviewer: What can a patient expect for the rest of their life, then, since this is something that you manage and treat throughout the rest of your life as far as dealing with inflammatory bowel disease?

Dr. Valentine: Well, the need to stay on chronic medication and keep regular follow-ups with the gastroenterologist is important. Because we can't cure this, chronic treatment is needed. Then, if you have inflammation in your colon, after you've had the disease for about 10 years, you need to get into colon cancer screening surveillance programs because of the higher rate of colon cancer that's found in these patients.

So typically, it's a colonoscopy every two to three years after 10 years, and then current guidelines recommend a yearly colonoscopy after 20 years of inflammation in the colon. So if you have Crohn's disease only in the small intestine, the rate of colon cancer is not increased. That's another reason why to determine where in the bowel the inflammation is occurring.

Interviewer: As far as my lifestyle, if I'm on the medications that are managing the symptoms, it's taking care of the inflammation, which is the root cause, life relative is normal beyond that point?

Dr. Valentine: Except for having to remember to take your medication.

Interviewer: Yes.

Dr. Valentine: That is easy to do when you feel bad, but then when you're feeling well, you have to remember to take it.

Interviewer: Take that medication and you'll be fine.

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Interviewer: Diagnosing inflammatory bowel disease, or IBD, that's next on The Scope.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: Dr. John Valentine is an expert at treating inflammatory diseases of the intestinal tract, including inflammatory bowel disease, or IBD as some people know it. First of all, is there a difference between irritable and inflammatory bowel disease?

Dr. Valentine: Those two get confused quite often.

Interviewer: Okay.

Dr. Valentine: So irritable bowel syndrome is quite common. It is not inflammatory, can give you abdominal pain, cramps, diarrhea, or constipation. But inflammatory bowel disease is an immune-mediated process that causes inflammation in the GI tract that can result in similar symptoms, abdominal pain and diarrhea. But because of the inflammation, it can also lead to bleeding in the GI tract, fevers, and complications such as development of cancer if there's long-term inflammation, and the need for surgery.

Interviewer: So it's a little bit more of a nasty character?

Dr. Valentine: Yeah, I agree.

Interviewer: Yeah, okay. So I hear that inflammatory bowel disease is actually increasing quite a bit. Can you talk to how much?

Dr. Valentine: Well, it's increasing in both western countries, and then in countries that are now westernizing. China, India, South America are now starting to see an influx of inflammatory bowel disease and exactly why isn't clear. But because patients are diagnosed very young and we can't cure it, we can treat it, these patients are living with it. With the increased rate of new cases, some predictive modeling suggests that the number of people living with inflammatory bowel disease in North America will double in the next 10 years.

Interviewer: That doesn't sound very enjoyable for a lot of us, then.

Dr. Valentine: Well, fortunately, we have multiple treatment options. We can treat this, but we can't cure it.

Interviewer: All right. In another segment, we'll talk about treatment options for IBD. Because from what I understand, there's quite a few of them and it's probably worth its own particular podcast. So take me through the process that you'd use to diagnose someone's IBD.

Dr. Valentine: Well, typically a patient would come in with chronic symptoms. An infectious colitis, for example, of Salmonella, Shigella, the common bacterial infections, you may have similar symptoms, but they'll only last three to five days. If somebody comes in having blood in their stool, loose stools, maybe fevers and it's been going on for a couple weeks, then we start thinking about inflammatory bowel disease. Which we then need to differentiate between ulcerative colitis, which only involves the lining of the colon, and Crohn's disease, which can be anywhere in the GI tract, but tends to like the end of the small intestine, first part of the colon.

Interviewer: Are the symptoms for all those the same? Or do you use a little bit of a different diagnostic then to figure out specifically what somebody might be dealing with?

Dr. Valentine: Well, there is a tremendous overlap between the two. Where the inflammation is can make a big difference. If your inflammation is only at the very end of your small intestine, you may not have diarrhea at all. Where if the inflammation is in the rectum and lower part of the colon, then diarrhea and visible blood would be a more common feature. So we can get some hints as to which one we think it is, but we need to do some more diagnostic testing to straighten that out.

Interviewer: In addition to symptoms, are there other risk factors that you ask the patient about to help determine if that is indeed what they have?

Dr. Valentine: The risk factors don't exclude it, but it certainly increases the probability.

Interviewer: Okay.

Dr. Valentine: So the biggest risk factor we know for having inflammatory bowel disease is having a family member who has it. That being said, somebody needs to be first. But there's often a cluster of other immune-mediated diseases in the family, multiple sclerosis, rheumatoid arthritis, lupus or celiac disease. These are all different diseases that do share some genetic underpinning so that's why they tend to cluster together.

Interviewer: Do you find that patients do a pretty good job of self-diagnosing by the time they get to you?

Dr. Valentine: It depends. If they have a family member, especially a brother or sister with it, yeah, they know what the symptoms are and they come in, "I think I sort of have this." If they're the first in the family, they really don't know.

Interviewer: Okay. So what are some of the other diagnostics that you use to determine for sure if they have inflammatory bowel disease?

Dr. Valentine: Well, the number one cause of bloody diarrhea is infection so you always need to rule out infection. Sometimes, though, the infection can be the trigger. We treat that, but the inflammation won't go away.

Interviewer: Okay.

Dr. Valentine: So we have to rule out infection. The patient's age also can give you some hints.

Interviewer: Okay.

Dr. Valentine: So ulcerative colitis and Crohn's, they're a peak onset stage of 15 to 25. It can occur a whole lot younger. It can occur in the 60s. But a 25-year-old coming in with diarrhea for several weeks with blood in it, inflammatory bowel diseases goes to the top of my list.

Interviewer: Are there any tests or screenings that you use?

Dr. Valentine: A colonoscopy would be the primary diagnostic test. You want to be sure you know what you're treating, especially because some of the treatments involve immunosuppressant medications. So a colonoscopy, make sure you know whether it's ulcerative colitis or Crohn's. Make sure the pathology, what the pathologist sees under a microscope fits with that diagnosis and not some other bizarre or much less common etiologies.

If the colonoscopy doesn't reveal any problems, then imaging of the small intestine, and there are several ways of doing that. An MRI or a CT scan would be most common. Occasionally, the capsule endoscopy, but I'm really wary of people who get diagnosed based on images from a capsule endoscopy by itself.

Interviewer: Why is that?

Dr. Valentine: Lots of things can cause inflammation in the small intestine. Little discreet breaks could be caused by taking ibuprofen and similar types of medications. So when they even show these pictures to the experts, they have a hard time deciding what might be due to these ibuprofen-type medications and what might be due to Crohn's disease.

Interviewer: At this point in our conversation, if somebody is convinced at this point that they have inflammatory bowel disease, would they go to a general practitioner or their primary care physician first? Or come straight to you at this point?

Dr. Valentine: Well, like I said, need to exclude infection. So I think going to the primary care doctor to get the stool studies done to exclude Clostridium difficile infections, Salmonella, Shigella, campylobacter, the other bacteria that can cause inflammation in the colon would be the first step.

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updated: April 17, 2019
originally published: March 15, 2016

Dr. Miller: You have Barrett's Esophagus? When do you need surgery, or do you even need surgery? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.
Dr. Miller: We're here today with Dr. Courtney Scaife and she's a Professor of Surgery here in the Department of Surgery at the University of Utah. She also specializes in cancer surgery. Courtney, tell us a little about a patient who might need surgery on the esophagus. I understand that patients with Barrett's Esophagus mostly don't need surgery, but there are times when they do. When would that time be?

Dr. Scaife: Patients who have Barrett's Esophagus are usually managed by gastroenterologists. And they're well managed with oral medications or sometimes requiring interventional procedures. But if that Barrett's progresses to high-grade dysplasia or an invasive cancer, high-grade dysplasia is a pre-cancer change to the cells in the esophagus. So if a patient has pre-cancerous changes that can't be managed by the gastroenterologist's limited interventions, meaning limited intervention to the esophagus or they've regressed to full cancer, those patients do need a surgery of the esophagus.

Dr. Miller: Now, that's not typically common in Barrett's but it does occur.

Dr. Scaife: That's correct, it's uncommon.

Dr. Miller: So by the time the patient gets to you, they usually have advanced Barrett's or adenocarcinoma of the esophagus that isn't remedial by any of the topical treatments that the gastroenterologists use.

Dr. Scaife: That's correct.

Dr. Miller: And so what do you tell the patient initially and what can they expect undergoing surgery?

Dr. Scaife: The first thing that is important to evaluate is if they progressed to cancer, but it's a very early stage, they need the surgery we're talking about. If they have a slightly later stage or more advanced cancer, we routinely treat those patients with radiation and chemotherapy before surgery. There are actually two types of cancer of the esophagus, two different cellular types. And one is more likely caused by smoking, the other is the kind, adenocarcinoma that is related to Barrett's and chronic reflux. And we do treat that in more advanced stages with neoadjuvant, meaning treating the patient with chemotherapy and radiation before surgery. Therapy.

Dr. Miller: Patients can develop Barrett's Esophagus after many years of esophageal reflux or acid reflux or otherwise known as heartburn. And so if you have heartburn and you've had it for five years or over the age of 50, you should see your primary care physician to have that treated and possibly looked at by a gastroenterologist.

Dr. Scaife: Yes, we agree. And screening in patients who have chronic reflux is important to identify Barrett's and to monitor that Barrett's does not progress to those pre-cancerous or cancer changes.

Dr. Miller: Now, removing the esophagus, or otherwise known as an esophagectomy, sounds like a pretty big surgery. What would a patient expect, following that?

Dr. Scaife: It is a big surgery and, unfortunately, there are several different ways to do the operation. The operation can be done through the abdomen and the neck, it can be done through the abdomen and the chest, or it can be done through the abdomen, the chest, and the neck. And then minimally invasive techniques can be added as well. And so many surgeons use different techniques. But really there's no data that shows that either approach is different. And you want the surgeon to do the operation that they are most comfortable with and that they do that operation most frequently. But all of the techniques of the operation, the outcomes are effectively the same.

Dr. Miller: Does it at all depend on the type of patient? Their size, their body physiology? Does that sway you in terms of the type of surgery that you do if their large, small, or . . .

Dr. Scaife: Usually not. There may be some unusual cases where that influences the decision, but usually not. When we do esophagus surgery, we don't just take out a piece of the esophagus. Particularly in this case because it's for cancer. So we need a wide margin around the cancer. So effectively the patient's entire esophagus is removed. So in that approach, and the reason that all of those approaches included an abdominal portion of the surgery, is that we need to choose a part of the abdomen, another part of the intestinal track to replace the esophagus.

Dr. Miller: So it's like a graft.
Dr. Scaife: That's exactly right. So the choices most commonly are the stomach, a piece of the small intestine or the piece of the colon. And I would say, in 2015, the most common approach is to use the stomach as a replacement for the esophagus.

Dr. Miller: Do you need to use the whole stomach or part of it?

Dr. Scaife: Yes, so in order to get the stomach to reach up into the neck, to reach where you're replacing the esophagus, it's as though they've had a stomach removal or almost like a gastric bypass surgery. So their stomach is made to be a very narrow tube and pulled up into their chest so effectively they don't have a reservoir to store their meal. And so patients eat four to six frequent small meals a day instead of eating Thanksgiving dinner.

Dr. Miller: And so do they tend to lose weight in the long run?

Dr. Scaife: Fortunately, we're able to train patients to eat really well. The majority of patients that we operate on, having so many symptoms before surgery that they admit they've been eating that way before surgery. So most patients do not lose weight and actually do well after surgery.

Dr. Miller: Now, Courtney, you mentioned that there are two types of cancers encountered in esophageal cancers, and I think one is above and one is below. Does that affect the type of operation that you do?

Dr. Scaife: It does. If we frequently . . . squamous cell carcinoma, we've been mostly talking about adenocarcinoma of the esophagus.

Dr. Miller: Squamous cell is more associated with smoking and alcohol.

Dr. Scaife: That's right. So Squamous cell carcinoma more associated with smoking is frequently more in the more proximal, closer to your mouth part of the esophagus. Sometimes that can be treated with chemotherapy and radiation only. If it persists after the chemotherapy and radiation, we do an esophagectomy. And often that procedure necessitates opening the chest to get an appropriate section of the higher part of the esophagus.

Dr. Miller: Now, following a successful surgery, I imagine that one needs to go back in and look from time to time to make sure there are no complications. Is that true?

Dr. Scaife: We ask patients in their frequent clinic visits which, at minimum, are every six months, if patients are having symptoms with swallowing, symptoms with eating, weight loss or weight gain as you've mentioned, diarrhea, but most commonly, it's difficulties with swallowing or weight loss. If those patients are having symptoms, we refer them to a gastroenterologist for an endoscopy to evaluate the graft that we used to replace the esophagus.

Dr. Miller: So it sounds like the best way to keep from ending up in the office of the surgeon is to avoid smoking altogether, to drink minimally if you drink at all. And also, if you have acid reflux and are over the age of 50, to have that looked at.

Dr. Scaife: That's exactly right. And we recommend that if you have long-term reflux to have at least one screening and then follow up based on the recommendations of your gastroenterologist.

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Dr. Miller: Diverticulitis. What is it, how do you know if you have it, and would you ever need surgery for it? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: I'm here with Dr. Bartley Pickron. He is a surgeon and also specializes in colorectal surgery. He's a professor of surgery here at the University of Utah. Tell us, what is diverticulitis? How would a person know if they had that?

Dr. Pickron: Well, diverticulitis is an infection of the colon. It usually comes from infected diverticula, which are little pouches in the colon.

Dr. Miller: So when a person develops an inflammation due to an infection, what do they feel, or how do they know they might have an infection of the colon?

Dr. Pickron: The majority of the time, it starts out with pain, usually in the left side, down toward the pelvis, and the pain usually comes on pretty quickly. They usually may have fever, not much of an appetite, and just generally don't feel good.

Dr. Miller: And when should they, if they experience that, head to the doctor in your opinion?

Dr. Pickron: Well, if it's the first time, then you should really get checked out within the next couple of days. The majority of people take a week's course of antibiotics and they do well, and most people never have a problem again.

Dr. Miller: Would one ever need surgery for this? Does it ever get so bad that you would need to have part of the colon taken out where the infection occurs?

Dr. Pickron: Well, it certainly can. I mean, some people have their first episode is a free perforation, which is a life-threatening condition.

Dr. Miller: Now, perforation is described as . . .

Dr. Pickron: Basically a hole erupts in the colon.

Dr. Miller: And it leads to leakage . . .

Dr. Pickron: Leakage of stool into the abdominal cavity.

Dr. Miller: Not a good thing.

Dr. Pickron: Not good at all. And so, like I said, that's usually a life-threatening condition that has to be taken care of with emergent surgery.

Dr. Miller: What do you talk to the patient about in terms of surgical intervention?

Dr. Pickron: Well, it really depends on their symptoms. A lot of the recommendations for this disease process have changed over the last five to 10 years. And so what we are really looking at now for people who require surgery are not really the number of episodes you've had per se, but more of the people who get an episode and really never recover from it. Just have this kind of lingering left-sided pain, and just general GI discomfort.

Dr. Miller: That continues even after a course of antibiotics?

Dr. Pickron: Usually after multiple courses of antibiotics.

Dr. Miller: So then, it's time to take out part of the colon, I guess?

Dr. Pickron: Right.

Dr. Miller: And how much of the colon do you usually remove in order to repair this problem?

Dr. Pickron: I mean, on average, it tends to be anywhere from 8 to 12 inches. It really depends on the extent of the inflammation that's present compared to the healthy colon that's left, that's not involved.

Dr. Miller: And how do you do the surgery now? I understand that it's probably done laparoscopically?

Dr. Pickron: Yeah, so we have some good minimally invasive options for this. Usually, we start out with a little quarter of an inch incision in the belly button, and we're able to put a camera into the abdominal cavity and take a look around and really see where the problem lies. Then we usually make about a two-inch incision kind of just above the bikini line, and we're able to do the entire surgery through that.

Dr. Miller: So not a large incision as in the old days?

Dr. Pickron: Not at all. You can still wear your speedo if you want to.

Dr. Miller: That would be great, so . . . maybe not for me. How long does a patient plan to be off work for this, or how long can they expect the recovery to take?

Dr. Pickron: Well, a typical hospital stay is anywhere from two to four days. And then, overall recovery, kind of depending on the fitness of the patient prior to surgery, is usually anywhere from three to six weeks.

Dr. Miller: I have heard that after an episode of diverticulitis, patients have been told not to eat popcorn, or jam with seeds in it. Can you comment on that? I'm not so sure that isn't a myth.

Dr. Pickron: It is a myth and it used to be the theory that plugging these little pockets makes diverticulosis turn into diverticulitis and so the theory used to be that if you ate nuts, popcorns, or seeds that you would plug these little pockets, but there's really no scientific evidence that shows that's true. And actually, these foods are all very good fiber sources, which can actually help with the progression of diverticulitis.

Dr. Miller: So in general, you would tell patients after a bout of diverticulitis to increase fiber in their diet?

Dr. Pickron: In the acute setting, to kind of tone it down a little bit, but once they've recovered, then, yes, about 20, 25 grams a day.

Dr. Miller: So it sounds like if one has diverticulitis and it's not too severe, you're going to have that treated by your primary care physician, usually with antibiotics and rest, and then if it recurs or if it continues, if there are multiple episodes or whether it's a continuous rather nagging pain after multiple courses of antibiotics, you would recommend that the person see a surgeon, and preferably perhaps a colorectal surgeon?

Dr. Pickron: Absolutely.

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Interviewer: A study gives new insights into how good bacteria work with our body to promote digestive health - up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. "The Science and Research Show" is on The Scope.

Interviewer: A study published in Cell Host and Microbe is causing us to rethink what the immune system can do, and how it interacts with the good bacteria that live on our bodies. I'm talking with three authors on the study: senior author June Round, assistant professor of Pharmacology at the University of Utah, and co-first authors Jason Kubinak, and Charisse Peterson.
Dr. Round, what's the take home message from what you found in your study?

Dr. Round: I think the most important thing and the most interesting thing about this particular study is that it really highlights that there is a conversation between our immune system and the microbes that live on our body. It's becoming more and more clear that these microbes are very important for our health, and there's a lot of factors that shape what types of microbes can live on our bodies.
This study really highlights that our immune system has an effect on those types of microbes and that the microbes can send signals that tell our immune system how to develop, and in turn our immune system, as its developing, can also shape the types of microbes and the types of things that those microbes express.

Interviewer: Dr. Kubinak, how does that change our thinking from how we considered our microbiome before?

Dr. Kubinak: Well, I think within the last 10 years there's been a pretty significant shift in the way we view our interaction with the microbial world from initially primarily focused on antagonistic interactions where hosts and their immune systems were focused on eradicating and eliminating pathogens that make us sick. Whereas now, I think there's a renewed interest in the interaction between the hosts and microbes and how it promotes, or facilitates host health. I think our story sort of gets at that by demonstrating that the crosstalk between host and microbe generally is a health-promoting interaction.

Interviewer: So your work, in particular, addresses how the body keeps its balance of species of good bacteria intact, and you're particularly looking at one protein called MyD88. What did we know about this protein before your research?

Dr. Round: Its original function was assigned to recognize pathogenic organisms and basically act as the frontline detection to tell our immune system, "There is something going on here, there is a microbe here, so we better turn on our immune response and get rid of the pathogens." What we're really showing here is something very different, that detecting the microbe doesn't necessarily get rid of it here. It's actually helping to shape the types of organisms that live in the gut.

Interviewer: So how did you come to that conclusion?

Dr. Peterson: What did was we created a mouse that specifically knocked out this protein within a specific immune cell called a T cell. Then it gave us a unique opportunity to ask, what happens when this protein is absent in this immune cell and how does that affect the development of the microbiota as a whole in these animals.

Interviewer: So when MyD88 was knocked out of the immune system, it basically lead to an imbalance of the communities, the different species of bacteria in the gut. What does that do to the mouse, itself?

Dr. Round: What this lead to was that the animals themselves were more susceptible to inflammatory bowel disease, or an experimental model of inflammatory bowel disease.

Interviewer: I don't want to get too graphic, but what does that look like in a mouse?

Dr. Round: It's just inflammation within the guts of these animals. They lose weight.

Dr. Peterson: They get a severe wasting disease, and they get diarrhea.

Dr. Round: I think, for me, the most exciting part of the experiments was when we realized that this sensitivity to inflammatory bowel disease wasn't necessarily just caused by this defect that we had created in the host's immune system. One of the things that was driving this was actually this imbalance within the gut. Our ability to rescue that just by giving these mice healthy microbiota and rescue their disease susceptibility was, to me, the most exciting finding.

Interviewer: What do you mean? How did you fix the illness?

Dr. Peterson: So many people would refer to this as a fecal transplant. In the lab, we call this a microbiota transplant. You basically get rid of all those bad bugs that have developed in that animal because of their genetic deficiency and you replace them a healthy or with a balanced microbiota, so it's really a microbiota transplant. Obviously this is something that is starting to be done in people with various infections within their guts.

Interviewer: Well, right. I have to say, when I started talking about your work with other people in the office, that everyone became really excited when I said that I was going to be talking to you about fecal transplants, which sounds kind of strange. But, it's kind of this new exciting therapy that seems to have some pretty striking results in people as well.

Dr. Round: I'm glad to hear that people are excited about fecal transplants as, maybe disgusting as they sound. But to me, it makes sense. We have evolved for a very long time with these organisms, they promote our health, they're beneficial to us. So instead of using something that we chemically synthesized that's not natural, we're now using the microbiota as kind of a natural therapy to restore the balance in our bodies. So I think this is really a viable therapy in the future for multiple diseases, not just for inflammatory bowel disease.

Interviewer: I think one of the interesting parts of this study is that it really suggests that there is kind of a co-evolution between the microbiome and ourselves. How do you think about that?

Dr. Kubinak: To me, it speaks to the nature of natural selection to have driven the evolution of immune system machinery to promote benign symbiosis between us and our microbes.

Interviewer: So they're helping us, but we're also finding ways to help them.

Dr. Kubinak: Yeah, I think so. I think our immune systems have developed ways to definitely skew the community toward the presence of individuals who at the very least, are not going to cause us harm.

Announcer: Interesting. Informative. And all in the name of better health. This is The Scope Health Sciences Radio.

Your child comes to you and says they have a bellyache. Tummy aches are a common issue with kids. When to worry about that and what to do to help your child. Common Causes for Stomach Pain

So abdominal pain is something we see very often and there's a whole bunch of reasons why kids can have abdominal pain. They can have abdominal pain because they're overeating; we see that a lot usually around holidays, like Halloween, they eat too much candy. Christmas, they eat too much of the good yummy stuff that we see around the holidays. They can also have gas pains if they're drinking too much soda. They can have indigestion from spicy foods. For example, I see a lot of kids that eat hot Cheetos and then they come in and tell me that their stomach hurts. The hot Cheetos are the cause of that stomachache.

Quite often as well, I see kids coming in for stomachaches because of constipation. They'll say their stomach hurts around their belly button and then when you start asking questions about their bowel movements, it turns out they haven't gone for awhile or when they go, it's hard to get out. So ask your child if they have a stomachache, if they've pooped recently.

We are also seeing a stomach virus going around and a lot of kids will come in and say they have a stomachache, but they haven't had the vomiting or diarrhea because the stomachache just started that day and the parents are concerned. But the vomiting and diarrhea start within 24 hours of the stomachache.

A serious cause of abdominal pain that is always one that we worry about is appendicitis. And you need to worry about appendicitis if the pain is on the low right side of your child's abdomen. Your child won't hop up and down and they prefer to lie still, unable to move, even the slightest, without holding on to the lower right side of his or hers stomach.

We often see a lot of kids coming in with stomachaches at the beginning of the school year. Those stomachaches that keep coming back, they also say they're around the belly button, they feel like they're in the, quote, "pit of their stomach." That's because of stress. And kids can't really explain stress that well, they just say their tummy hurts. And kids that have recurrent stomachaches often have some sort of stressors, whether it's something going on at school or something going on at home that they're worried about. So your child continues to talk about belly pain around their belly button, ask them if they're worried about anything.

So how long does stomach pain normally last? Well, that all depends on the cause. With harmless causes, the pain is usually better or gone in about two hours. Either that or you'll see new symptoms, like the vomiting, the diarrhea, usually they'll pass gas if it's from gas pains, things like that. What if they have stomach pain from indigestion? Well the first thing they should do is just lie down. Quite often lying down and not focusing so much on the belly pain does make it better. You can give them belly rubs, you can have a warm washcloth or a heating pad on their stomach and that will make them feel better, too.

Avoid giving your child any solid foods and allow only sips of clear fluids if they're vomiting. If they continue to try and eat normally, the vomiting will continue and their stomach pain will get worse. If your child hasn't gone to the bathroom for a little while, have them go sit on the toilet and see if having a bowel movement will help with their belly pain.

And finally, we usually don't recommend giving any medication for stomach cramps unless you know the cause. Obviously if it's because of constipation and this is a chronic problem, give them their constipation medication. But if you don't know what the cause is, don't give your child Tylenol or Motrin to help the stomach pain. Try and figure out with your pediatrician what the cause of the stomach pain is so that you can help them if this happens again.

If your child has stomach pain because of stress or worry and it's something going on at school, be sure to talk with the child about what's going on and then relay those concerns to the officials at the school. Talk to the teachers, talk to the principal, see if you can resolve the problem that was causing their stomachache.

So when should you call your child's health care provider? Call immediately if the pain is severe and has lasted more than an hour or its constant and has lasted more than two hours. Or if you are worried about appendicitis or if the pain actually extends into the scrotum or testicles of boys. You may be advised to go to the children's emergency room for further testing that may not be able to be done in your doctor's office to evaluate for those serious causes that may need a surgeon.

So abdominal pain is something that again, we see very often and there are so many things that could cause it. By working with your child's doctor, you can figure out what the cause of the pain is and a plan to help your child.

updated: May 24, 2021
originally published: December 15, 2014

Dr. Miller: Bacteria that live with us in our gut, the microbiome. We're going to talk about that next on Scope Radio.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Miller: Hi. I'm here with Dr. Kathleen Boynton. She is a professor in the department of medicine, and she is a specialist in gastroenterology, diseases of the gut.
We're here today to talk about the microbiome. Kathleen, tell us about the microbiome. My understanding is that we have billions and billions of bacteria living with us, and we need them to live with us as they need us. We work in a symbiotic relationship, and when those become disturbed and the relationship between the bacteria that live normally in our gut is disturbed, that can create problems.

Dr. Boynton: Yeah, this is sort of the topic where I think where do I start with the story. We've known for a long period of time that we have bacteria in our gut. It was traditionally thought that these bacteria just helped with the breakdown of food and that they prevented more damaging bacteria from inhabiting the gut. Currently, we recognize that they do so much more. They train our immune system how to react to infection throughout the body.

Dr. Miller: So, it's not just that these bacteria create that unsavory gas that everybody talks about.

Dr. Boynton: That's right.

Dr. Miller: There's a lot more to it than that.

Dr. Boynton: Yes. They can produce a whole host of chemicals that may work in our best interest or may lead to most of the common diseases that we're seeing in our clinics these days.

Dr. Miller: We've adapted to bacteria as they have to us for millions of years. I mean they're in all animal guts. Some of our listeners might think that bacteria in our colon seems strange. In fact, that's quite normal. What is abnormal is a change in the concentration of this bacteria or introduction of other pathogenic or disease causing bacteria into that biome. Would that be right?

Dr. Boynton: That's correct.

Dr. Miller: Your area of study seems to be much more focused on new ideas about the microbiome and what that's doing for us. When that's disturbed, there could be far reaching problems that are related. Maybe you could talk about that a little bit.

Dr. Boynton: Yes. That's exactly correct. What is so surprising to us is that a disruption or disturbance in the microbiome can literally create diseases that are remote from the gut. There are studies on diabetes that talk about it's associated with a disturbance in the microbiome, or autism, or Parkinson's. Traditionally, we had thought that those were two independent organs that never spoke to each other.

Dr. Miller: These are concepts that we still need to prove, right, those associations...

Dr. Boynton: That is correct, yes.

Dr. Miller: ...epidemiologic or population based associations. I would suspect that there's still work that needs to be done in that area.

Dr. Boynton: Oh, much work that needs to be done. The fundamental issues are not even addressed. We don't know what those bacteria are. We don't know how many of them have any role in our health and well being. As general concepts, we can determine that some people have a reduction in the diversity of the bacteria, and that that is definitely associated with a lot of the diseases that we study in the gut and outside the gut.

Dr. Miller: Irritable bowel is a problem for a lot of people. I know you deal with that in your practice. Is there an association between abnormalities in the microbiome and irritable bowel disease that we know about, or is that still too early to say?

Dr. Boynton: Probably the biggest association we've identified is with inflammatory bowel disease. In that case, your immune system is attacking the bacteria. The bacteria lies on the surface of the intestine. Those patients get inflammation.
Recently, there has been identification of a gene marker, that means a genetic malfunction, in patients who have irritable bowel. That's different than inflammatory bowel. Those patients have a disturbance in their microbiome coupled with the fact that they have leakiness in the gut, which means all those chemicals made by this abnormal microbiome have the ability to leak out of the gut and travel around and cause a lot of uncomfortable associations for IBS patients.

Dr. Miller: Some of the patients that I see will come in asking about leaky gut. Is that related to an abnormality in the microbiome? Can you talk about that a little bit for folks that are listening.

Dr. Boynton: Yes. We don't know a lot about leaky gut, because it's a brand new phenomenon. We know it exists. We know that in concept our gut should be what we call impenetrable, meaning that it doesn't allow chemicals that are made in the gut to escape and get to the rest of the body.
We also have realized that common things we do in our culture, for instance taking an aspirin or a non-steroidal, can lead to this leakiness. All the sudden the foods you eat may get into your bloodstream, or the chemicals made by your microbiome. In association to that, we've noticed that some of the chemicals that are made by the microbiome have the ability to create the symptoms that are part of irritable bowel.

Dr. Miller: For folks that are listening, what should they take home from this? Should they be thinking about taking probiotics? Is that something that patients should do to keep their microbiome health, or are we not yet at that stage where we can say?

Dr. Boynton: We have a lot of pieces. We think we can put them together. We think it makes sense. But, there are so many fundamental aspects that we still don't know. We don't know what the critical bacteria are in terms of each of these diseases. We don't know when they're in the pill form and you swallow them, do they even make it out of the stomach, or does the acid break it down. The companies that are producing probiotics are right in the sense that we think there is a future for probiotics, but we don't know which ones and in what format.

Dr. Miller: Still a lot of work to be done.

Dr. Boynton: A lot.

Dr. Miller: It sounds like the microbiome, if I think about it simplistically, is a nice coating in the gut to protect the lining so that barrier remains permeable only to certain things that get into our system that we need and keeps a lot of perhaps bad things, pathogens and toxins, out. Without that bacteria layer which primarily resides in the colon, we could be in trouble.

Dr. Boynton: Absolutely. In addition, the microbiome helps us absorb our calories, and probably most importantly to people who have immune related diseases, it trains our immune system. It teaches the immune system this is something that's called a pathogen, meaning a bad thing, I have to destroy it, versus this is part of my body, I need to ignore it. It may be that defects in this training process are what lead to immune related diseases. It doesn't figure out the distinction.

Dr. Miller: To wrap it up, it sounds like the microbiome is extremely important. We've known that for a long time. How we can help maintain a healthy microbiome, there remains work to be done, and future research is underway.

Dr. Boynton: That's correct.

Dr. Miller: Thank you very much.

Announcer: TheScopeRadio.com is University of Utah health sciences radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Dr. Miller: Heartburn, when does that become a concern, next on The Scope Radio.

Announcer: Medical news and research from University of Utah Physicians and Specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Miller: Hi, this is Tom Miller, and I'm here with Dr. Kathleen Boynton, and she is a doctor in the Department of Medicine and she is a gastroenterologist, a specialist in gut disorders. And she is also an associate professor. She is here today to talk about heartburn.
Kathleen, when is heartburn... everybody gets heartburn, right? I mean, you have that big chili cook-off and a couple of hours later you're really resenting that and you're reaching for the sodium bicarbonate, or you're going for Tums. How often would one have heartburn and not be worried about it? Or conversely, when should somebody worry that they're having heartburn too often?

Dr. Boynton: Well the truth is nobody has ever done the study where they say this frequency equals a severe disease. But generally I tell people, if you're having it two to three times a week that's probably enough to see your physician. The other concern of course is if you come from a family with a history of esophageal cancer, perhaps any degree of heartburn is enough to see somebody.

Dr. Miller: I know a lot of patients will have heartburn maybe three times a week, and then they just have gone to the store and they've bought several different kinds of antacids. If that works, do you still think they need to see a physician?

Dr. Boynton: I think that they do, because we know that the way you feel doesn't necessarily match what's going on inside your gut. And your concern is to prevent the complications that are irreversible, that are related to heartburn.

Dr. Miller: Long-term heartburn, what are those complications?

Dr. Boynton: You can get scar tissue in the esophagus. The esophagus is made to be elastic, so if you inadvertently swallow a big piece of food it can still distend, stretch the esophagus and pass down into the stomach. If you get scar tissue it cannot pass, and we see obstructions all the time when we're on call, where somebody has a piece of meat, say, that's stuck in the esophagus and won't pass.

Dr. Miller: Then long-term heartburn can lead to scarring of the esophagus, the narrowing of the esophagus so that you can't pass food and is a dangerous situation.

Dr. Boynton: Right.

Dr. Miller: Now what about this term called Barrett's esophagus? Some patients will come in and they've read about it on the Internet or heard it on TV shows about Barrett's esophagus and its relationship to heartburn.

Dr. Boynton: Yes. Barrett's is a concerning change in the tissue and it develops as a result of exposure to acid, which causes inflammation. Inflammation means that the tissue has to regrow. And sometimes the tissue makes a mistake and it grows to look more like the tissue we see in the stomach, and then duodenum. And the problem with that is a small percentage of those people that have that Barrett's tissue will go on to develop esophageal cancer. So our question is when we see a patient with heartburn, are they somebody that may have Barrett's? How do we decide whether or not to investigate that?

Dr. Miller: Now there are age cutoffs I think; the older a person is the more likely a physician is likely to recommend diagnostics. Can you talk a little bit about that and when you decide as a gastroenterologist that a patient might in fact need a study, or a look down to see what that tissue looks like, to see if they have Barrett's esophagus?

Dr. Boynton: In medicine we have what are called guidelines, and they are in part based on associations, because we want to be efficient and not do unnecessary testing on patients. The recommendation is that in a white male over the age of 40 who has a history of heartburn that we do an endoscopy, and the endoscopy helps us. We can see the Barrett's tissue; it looks different from normal tissue.

Dr. Miller: Now the endoscopy, can we just clear that up for some people. That's a tube that goes down with a light on the end of the scope and they can actually see the tissue in the esophagus. They could even take biopsies.

Dr. Boynton: Right. And based on those biopsies we can tell someone whether or not they have Barrett's disease. If they have Barrett's then we recommend that they be monitored with endoscopy and the frequency can be in a year, or it could be every three years, depending on the profile.

Dr. Miller: Now the physician might also decide there's treatment, and are there effective treatments for heartburn that can make it better?

Dr. Boynton: Absolutely. And they are even available over the counter. The most effective are what we call the proton pump inhibitors, and there is a whole bunch of those. But the one that's over the counter is omeprazole, or Prilosec, and that's probably the most frequently used drug.

Dr. Miller: When you go you grab the omeprazole and it's probably cheaper, right?

Dr. Boynton: Yes.

Dr. Miller: And taking that daily, I think, is pretty much what's prescribed for people who have heartburn three or more times a week. And I've found most patients do very well with that; it's very effective.

Dr. Boynton: Yes.

Dr. Miller: And it stops heartburn in its tracks.

Dr. Boynton: Yes, that's correct.

Dr. Miller: Now what happens if a person is taking one of these medications and they're breaking through?

Dr. Boynton: Well in the doctor's brain, when they see those patients, what they are wondering is first of all do I have the diagnosis correct. Is this still acid? But assuming that it is still acid, we will increase their medication. If that doesn't work there is even surgery that will fix the underlying mechanical problem that causes reflux.

Dr. Miller: Now how often in your experience would a patient not respond to medication to reduce or to eliminate heartburn and need to go on to surgery? How often does that happen?

Dr. Boynton: I don't have exact numbers, but it's under 10% of patients. Sometimes patients will elect to have the surgery for lifestyle reasons. They just don't want to be on a medication long term, and that's a valid consideration.

Dr. Miller: So it sounds like the take-home points are; one, if you're having heartburn more than three times a week, you should probably see your physician and have him decide if additional diagnostic studies should be done; or if they would just go ahead and prescribe a medication, such as omeprazole that would eliminate the heartburn. And if you're having heartburn and you're taking a medication for heartburn, you really should probably see your physician about it for additional diagnostic studies.

Dr. Boynton: Right.

Dr. Miller: Thank you very much.

Dr. Boynton: You're welcome.

Dr. Miller: The ScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interviewer: Sometimes when you start eating healthier, you feel worse at first. Today, common negative reactions, which are short-term, to eating healthier. Is it normal when someone goes from not eating to eating healthy to feel some negative side effects?

Staci McIntosh: It depends on where you're coming from and where you're going. What did you eat before and how much did you change that? The more you change your diet, the more adjustment time will be necessary

Interviewer: How about from not too healthy to really healthy?

Staci McIntosh: Expect a couple of weeks. It's going to take some adjustment for sure.

Interviewer: What about some specific symptoms?

Staci McIntosh: So a lot of times our gut is populated with bacteria . . . Well, it's always populated with bacteria, and it gets specific to the types of foods that we're eating. When you change that and you're eating more fruits or vegetables then the type of bacteria that populates your gut is going to change with it, and that takes an adjustment period, and that will result in gas, and bloating, and a change of the population of that bacteria.

Interviewer: If you already said this, I'm sorry, but so the bacteria probably helps you digest, and you need to get the right kind for the food.

Staci McIntosh: Exactly, we all have bacteria in our gut, and it's part of our happy gut flora, and there's a healthy population of a variety of bacteria, and then there's not so much of a healthy population.

Interviewer: So you've got to get rid of the fast food bacteria and get some fresh fruit bacteria in there?

Staci McIntosh: You're introducing the good bacteria as you eat more fruits and vegetables, and then that's going to start changing the whole flora.

Interviewer: What about constipation and diarrhea is that the same thing going on there?

Staci McIntosh: Some of it will be. Some of it may be that you've gone from a low fiber diet to a pretty high fiber diet without a transition period, and without enough water during that time. So I always recommend that if someone's going from a pretty low fiber diet, so the average American eats 13 grams of fiber a day, and the average recommendation is between 25 and 38 grams a day.

Interviewer: Wow so almost half.

Staci McIntosh: So we're a pretty low fiber community in general so if we're going from a low fiber diet to a high fiber diet, we need a little transition period, and we need to increase the amount of water and activity that we're doing so that it helps get things healthy and not result in constipation.

Interviewer: Is that another enzyme issue?

Staci McIntosh: It's not an enzyme issue. Because we don't digest fiber so there's no enzyme to digest fiber, but it's just a matter of the fiber sucks in water and that's what helps make an easier stool to pass, but if you don't have the extra water for it to suck in then it becomes constipation.

Interviewer: All right, what about like brain fog? I feel like when I start my new diet sometimes I get brain fog. I'm not as sharp as I used to be. What could be going on there?

Staci McIntosh: You know I would have to find out more about what you were eating before and then what you changed to. I would expect, I expect to hear those kind of questions sometimes when I have a patient who's going to a low carbohydrate diet, or going to a paleo diet, or going to some extreme diet where they don't have enough carbohydrates intake, and then it will make you feel like a brain fog because you don't have enough basic glucose in the brain.

Interviewer: So you can eliminate too many carbohydrates?

Staci McIntosh: Absolutely.

Interviewer: What about fatigue and low energy is that a carbohydrate issue again?

Staci McIntosh: Yeah your basic, your primary source of fuel for every cell in the body is glucose.

Interviewer: Could it be just more calories could be the solution for something like that or does it need to be carbs?

Staci McIntosh: It needs to be glucose, you're going to use glucose for your brain, you're going to use glucose for energy for every cell in the body, and you can get that glucose from breaking down glycerol from fatty acids, or from turning amino acids into glucose, but that's just another step that your body has to go through.

Interviewer: Got you.

Staci McIntosh: So if it has available glucose then you have available energy for the cells.

Interviewer: What about headaches what could cause that if you're changing from one philosophy of eating to another?

Staci McIntosh: A lot of different things. So sometimes if people are going into using a lot of non-nutritive sugar replacements, so saccharin, aspartame, all those type things. If you would normally drink soda and then you go to a diet soda that can give people headaches a lot of times, and also if you're going to a really low carbohydrate diet your brain uses glucose, and every cell in your brain uses glucose, and it wants glucose, and if you don't have enough glucose available if you're on either a very low calorie diet, you're not getting enough fluids, or you're not getting enough glucose regardless of the calorie amount that would be a typical recipe for a headache.

Interviewer: Okay, how about extreme cravings? Now all of a sudden I want everything that's not good for me anymore.

Staci McIntosh: That's human nature.

Interviewer: Is that what that is?

Staci McIntosh: Yeah that's human nature. As soon as you say you can never have chocolate again that's all you're going to think about.

Interviewer: Yeah, so that's why it's probably good to maybe allow yourself a little.

Staci McIntosh: That's why everything in moderation.

Interviewer: A little taste, all right. What about going through withdrawals of things like caffeine, or sugar, are there withdrawal symptoms to those types of things?

Staci McIntosh: Absolutely, when you look at someone's MRI scan, for example, and you look at the result that it has on the brain for sugar versus nicotine it's the same area of the brain that gets stimulated so it does trigger, certainly not an addiction like nicotine would, but it's triggering the same areas of the brain so you can experience those withdrawals.

Interviewer: All right and some headaches might be caused by getting rid of the bad stuff and you're actually going through withdrawals, like . . . wow.

Staci McIntosh: Sure.

Interviewer: When somebody goes on a new diet what words of advice do you have for them to get through this process, because I imagine some of these things actually stop people from eating better?

Staci McIntosh: Absolutely, I say one step at a time, don't change everything overnight, if you have gained excess weight you gained it one gram at a time let's think about losing it one gram at time not changing everything all at once, and keeping in mind that eating is a basic enjoyment of life. If you're changing to a diet that is really not that enjoyable then why do that? Why not just start on something that you plan to do the rest of your life because it's healthy, and it's enjoyable, and you and your entire family can do it?

updated: February 17, 2023
originally published: February 26, 2014

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Scot: You end up with some stomach pains and it's always hard to know if it's something you ate, or if you're paranoid like I am you assume it's food poisoning, or E. Coli, or something worse like the latest stomach bug that you read about in the news. What I'm looking for is a breakdown, an easy to remember symptoms that can help the average person decide if it's something to worry about or if it will pass. I'm here with Dr. Troy Madsen Emergency Medicine at the University of Utah Hospital. Dude what's wrong with my stomach? How common do you see stomach issues in the ER?

Dr. Troy Madsen: Extremely common. It's a very large number and I expect when I work a shift in the ER I'm going to see at least a handful of people that are there because they're having some abdominal pain.

Scot: How about a breakdown of easy to remember symptoms that can help like the average person like me decide if it's something to worry about, or if it's something that will pass, or if it's something that I can take some Tums for.

Dr. Troy Madsen: You know when people come in the ER that's the question in their mind. Do I really need to be there for this? And we see a lot of people in the ER who probably just have some kind of a stomach virus. You know the number one thing I would say is if you're really concerned come to the ER. I don't want to tell you not to come because your judgment is certainly better that just, than hey this, this, this and this.

Scot: Better safe than sorry.

Dr. Troy Madsen: Yeah, but there are some rules of thumb that can help you to try and decide is this really serious or not. One thing that is a real red flag is if you're in your car, let's say someone's driving you somewhere because you're just kind of feeling nauseated, you're going to the pharmacy to get something, and every bump you hit in your car makes your stomach just hurt like crazy that's a bad sign.

Scot: Okay.

Dr. Troy Madsen: Because then I worry whatever's going on in your abdomen if it's your appendix, or your gall bladder has gotten so inflamed and infected that it's actually infected the lining of your abdomen and that's what causes that really severe pain.

Scot: Okay.

Dr. Troy Madsen: So that's a big reason to come in right there.

Scot: So if bumps are hurting you when you're in the car...

Dr. Troy Madsen: Yeah.

Scot: ...that's a warning sign?

Dr. Troy Madsen: You're hitting the bump your abdomen just hurts like crazy with every bump come in.

Scot: All right, what are some other stomach issues and symptoms?

Dr. Troy Madsen: So some other things are think about the right side of your abdomen. If you're having a lot of pain on the right side, so if you feel it on your right upper side that's your gall bladder, your right lower side that's your appendix, and then people who are otherwise healthy those are the two big things I look for. The left side of the abdomen not a whole lot going on over there. The right side those are the two big things that cause problems. So if you push in that right side of your abdomen and the right upper side hurts, the right lower side and that hurts, that's something you need to come in for. You may have an infection in your gall bladder or your appendix.

Scot: So if the rights not right go to the ER.

Dr. Troy Madsen: That's a good way to remember it.

Scot: Well good. So but the left side it's interesting if you have severe pains on the left side what could that be then?

Dr. Troy Madsen: It can be a number of things, and if it's an older person I worry about an infection in the colon, usually that's more people who are 55 and older. Something called Diverticulitis. If it's down really low and you're a female I worry about the ovaries, maybe an ovarian cyst, or something twisting there, but usually with the ovary it's going to be really severe pain, but if it's just some kind of vague pain over on that left side of your abdomen usually not something to be too concerned about. Again use your judgment to see how you're feeling overall but the right side's the side that really gets me concerned as a doctor.

Scot: How do I know if I've got food poisoning? That's always a big question for me. Is it just upset stomach or food poisoning?

Dr. Troy Madsen: The only real way we can say, "Hey it was food poisoning." Is if there were several people who ate the same thing who were having the same symptoms. There's no real test we do for it. Most cases of food poisoning are going to pass within 12 to 24 hours. You're probably going to feel miserable. If you feel just so miserable that you're not keeping any fluids down, if you're dehydrated that's a reason to come in to the ER because we'll give you IV fluids, get you some nausea medication to try and help you feel better.

Scot: What about cramps, gas bubbles, like your stomach feels rock hard?

Dr. Troy Madsen: Yeah.

Scot: Are those major concerns or is it just gas?

Dr. Troy Madsen: You know most of the time it's just gas. A lot of times it's just some kind of viral infection that's making things feel kind of crumby. You can try some over-the-counter medications see if that helps you out, see if you can wait it out. Again if you're getting those real bad symptoms a lot of pain, just getting dehydrated because vomiting is associated with it, or diarrhea, other reasons to come to the ER, but you know that's a lot of what we see is exactly what you're describing, and you know most cases are probably okay to wait it out a day or two.

Scot: All right one more, so if it's food poisoning usually it will pass 12 to 48 hours you said?

Dr. Troy Madsen: Yeah usually yeah.

Scot: All right, what about if it's something more dangerous, E. coli, is there any sort of difference in the symptoms between the or maybe the latest bug that you hear about in the news that's going around?

Dr. Troy Madsen: Yeah you know those are things that sometimes something will come out in the news people will get really concerned, but E. coli is a very serious thing. It's not a lot that we see it but the big thing that we see with it is that often times bloody diarrhea that's kind of the classic thing we see with the most severe cases of coli.

Scot: With stomach issues what should one do to kind of take care of an issue themselves if they believe it's not a major issue, if it's on the left side, maybe it's gas, what would you recommend?

Dr. Troy Madsen: Yeah again try some over-the-counter stuff, maybe some Pepto Bismol, something like that to help with some of the symptoms, some of the cramping, drink fluids, don't force feed yourself, you know don't make it so you're just drinking so much fluid that you're vomiting it up, which I've seen some people do, try and stay hydrated. And again if things are just getting to a point where it is very dehydrated, you just feel absolutely miserable feel free to come to the ER. We can make sure nothing more serious is going on and get you the treatment you need.

Scot: What's the difference between using an antacid and like a Pepto Bismol?

Dr. Troy Madsen: An antacid is going to be more specific just for acid production in your stomach. So let's say you've got a little bit of a stomach virus that's just causing some irritation in the stomach where Pepto Bismol is going to be a little bit better at controlling things like diarrhea, you know controlling maybe some more nausea, more issues with cramping, where if it's just acid where you feel like kind of a burning feeling kind of going up in your chest you're probably fine just taking an antacid like Maalox, or Tums, or something like that.

Scot: What about a gas bubble?

Dr. Troy Madsen: Gas bubble, you know for that kind of thing where you're having a lot of gas and cramping Pepto Bismol is going to be better. An antacid usually is not going to do a whole lot for that.

Scot: All right dude thank you for telling me what's wrong with my stomach.

Dr. Troy Madsen: My pleasure

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Julie Kiefer: Within each one of us are bacteria that live in our mouth, skin, gastrointestinal tract and on all exposed surfaces of the body, but contrary to common belief, most of these bacteria are actually good. Dr. June Round professor of Pathology studies how our body interacts with these microorganisms and how these microorganisms interact with us. Dr. Round how many of these bacteria live in our bodies?

Dr. June Round: There are billions of these bacteria that live on our bodies. There's actually more bacteria on our bodies than our own human cells. So, we're actually more bacterial than we are human.

Julie Kiefer: So if the body tolerates such a huge bacterial population, they must be doing something useful. What are they doing?

Dr. June Round: In animal models, we have shown that these bacteria are important for development, especially immune system development. There are some studies that show that the bacteria are important for brain function. So they've been implicated in diseases like autism. Some studies have shown that of course digestion is really dependent on these particular bacteria that live on our bodies. So there's a whole range of implications and we're just beginning to find out the importance of some of these bacteria.

Julie Kiefer: Right, and some of the first clues you got were by working with these special mice called "Germ Free Mice." Can you talk about what that is and what happens to them?

Dr. June Round: They are born and reared in completely sterile environments. So they've never seen a single bacteria, a virus or any foreign microorganism. They live in these little plastic bubbles. So, they're essentially "bubble mice." If you take these mice and compare them to animals that have... We call them "conventionally colonized," which means they have thousands of organisms on their bodies. If you compare them to these regular animals, they have a lot of developmental defects.
So there are a few things, like they have to take in more food or more calories to maintain the same body weight, which is not surprising. These organisms are important for digestion. They also have defects like a smaller heart. They are more anxiety prone. If you look at their immune system it's completely defective. So if you challenge them with any bad or pathogenic microorganism, these animals are highly susceptible to those infections. All of this is suggestive that the microbiota, or the commensal microbes are very important for our development and our health.

Julie Kiefer: And commensal microbes, that means those the good... Well, we thing they're good. The bacteria that reside in our body, that live in our body.

Dr. June Round: That's right. I probably should have defined that earlier. Yeah, the commensal microbes, when I say that, I'm referring to those organisms that we are born with.

Julie Kiefer: So your specialty is investigating the interaction between these microbes and the immune system. Can you talk about that research?

Dr. June Round: We're especially focused on immune system development within the intestine and how the microbes that live on our bodies shape those responses. So the diseases that we're really interested in are diseases like inflammatory bowel disease, colorectal cancer. We even have one of the projects in the lab that's focused on Multiple Sclerosis, so that's actually not an intestinal disease, but there's a pretty tight connection between Multiple Sclerosis and the intestine.
Some of the models that we use are animals where we have gotten rid of specific immune system genes and then we ask, "How does that influence what microorganisms can colonize us?" It's actually a two-way street. The microbiota can influence our development but then our genetics can actually influence what type of microbes can live on our bodies. Again, we can use these germ free mice to put in specific microorganisms and ask, "Is it this organism that can protect from colon cancer? Or does this organism exacerbate colon cancer?" So we can really tease apart the systems in germ free mice as well as in organisms that we've isolated from humans.

Julie Kiefer: Right. So there are many, many species of bacteria in our bodies. How many, about? Or do we know?

Dr. June Round: So the estimates are... Any one person is probably walking around with about 500 to 1000 different species and of these species there can be hundreds of different strains. So that's the current estimate in a human, at least.

Julie Kiefer: So how do you figure out which ones to test in your experiments? If you're introducing one back, how do you know which one is the interesting one?

Dr. June Round: That's actually a really good question, Julie. I get that question a lot. What most people have done, and one of the things that we've done as well, is to start looking at the differences between people who are healthy and people with Inflammatory Bowel disease. With the current technology we're able to basically understand all of the different organisms that are colonizing various people. So what we do is we take, "What organisms are colonizing healthy people?" and "What organisms are colonizing people with the disease?" and we ask, "What's different?" Specifically, I'm interested in the organisms that are colonizing healthy people that are gone in people with disease, suggesting perhaps that the people with disease are lacking these "good organisms."
We found several strains of bacteria. One of the organisms that we work with in the lab is called Bacteroides fragilis. We can take these organisms that are in healthy people, put them in the germ free mice, induce disease and ask, "Does this protect during these disease models?" So, that's how we start to focus our attention. In turn there are also organisms that colonize people with disease that are not found in healthy people. We can ask in our animal models, if we take that one organism that this diseased person has, put it into our germ free disease animal systems, "Do you induce disease?" In many cases, it does seem to be true. So, that's how we begin to focus our attention on these organisms.

Julie Kiefer: You've discovered that one of these species can protect from Irritable Bowel Syndrome, I believe?

Dr. June Round: Yeah. Inflammatory Bowel.

Julie Kiefer: I'm sorry Inflammatory Bowel syndrome. Do you have a sense of how that works?

Dr. June Round: Those are the studies that I did as a post-doc that we've carried on in the lab here. That organism is called Bacteriodes fragilis. I mentioned that one earlier, or B. fragilis. If you colonize animals with this organisms, and it doesn't even need to be a germ free animal. You can actually give it on top of the regular, conventional organisms that these mice have. This is much like a treatment with a probiotic. When you induce Inflammatory Bowel disease, or IBD, then you can actually protect these animals from the development of that disease.
What's more, is that we identified this particular organism makes a sugar molecule that it puts on its surface, it's a polysaccharide, and this one molecule when taken away from this organism and colonize these animals they are no longer protected. So, we identified that it's the specific molecule that this bug makes that is actually influencing the protection. We've identified that it's a particular T-cell subset that this commensal organism can influence that causes protection.

Julie Kiefer: So do these results suggest ways that we can treat IBD in humans?

Dr. June Round: Probably one of the most important implications, I think, from those studies is that these organisms have evolved these very specific molecules to influence our biology. The reason I find it really exciting is that we can actually purify that molecule away from that bug and we can get all of the same effects. So, I know people are a little leery of taking a pill with a bunch of live bacteria in it. With these studies we've shown that we can actually identify these molecules and potentially use those as therapies, as opposed to colonizing people with bacteria and doing that, you can actually control the amount that you give. Once you get colonized with a bacteria, it's actually very hard to get rid of it. So that's why I think those studies are particularly exciting, is because we can now isolate those and use them as therapies.

Julie Kiefer: One of the interesting things is, we have the pathogenic bacteria, the ones that make us sick and then these commensal bacteria that don't. So they must interact with the immune system differently.

Dr. June Round: Yeah. So that's actually one of the central questions in my lab... The main function of the immune system is to discriminate what is self and what is non-self. In discriminating between non-self, which would be anything foreign on your body, such as a bacteria, the immune system has to make a choice between, "What do I react against? What's bad?" and then, "What is helping me? Or what should I tolerate?" so to speak. So anytime you eat piece of food and your body doesn't react to it. It tolerates it.
So the same is true for the commensal organisms. Our body has evolved mechanisms to distinguish between what is good and what is bad. In part, these bacteria express different molecules that can tell our immune system, "I'm a good one." And the bad ones don't necessarily tell us that they're bad, but they elicit responses that our body knows are bad.

Julie Kiefer: If this goes wrong, could this be the basis for some of these auto-immune diseases?

Dr. June Round: Yes. That's exactly right. Especially in the case of Inflammatory Bowel disease one of the major thoughts about why this disease happens is because our body loses its tolerance to all of those commensal microbes that are living within the intestine. So now we have an immune system with tons of immune cells hanging out within the intestine and now all of a sudden all of them are starting to attack these good bacteria. Since you can never really get rid of these good bacteria, it's a constant war zone. You have the immune system continually mounting these inflammatory responses. If you have chronic inflammation, that can lead to other disease like colorectal cancer. Ten percent of people who have IBD go on to develop cancer. With respect to IDB, that is one of the major reasons IBD happens, because you lose tolerance to those good microbes.

Julie Kiefer: It seems like there's been a rise in IBD and disease like this in the population. Is that true? Is there an explanation for that?

Dr. June Round: So this was a phenomenon that was noticed, maybe about a decade or so ago. David Strachan was actually the first person who noticed that over the course of maybe 20 to 30 years that auto-immune diseases especially were increasing at a very rapid rate. They were increasing over such a short period of time that it couldn't have been due to genetic drift or changes in the population. These were diseases such as Inflammatory Bowel disease, Multiple Sclerosis, allergies, asthma... Even if you look over that short period of time, obesity, which is not considered an auto-immune disease, dramatically increased in these populations. Diabetes is another one. The hypothesis there is that something environmental must be triggering this.
Coincident with the increase in these auto-immune diseases was the heavy use of antibiotics. Of course, antibiotics are great because we got rid of all these terrible disease like Polio and Tuberculosis. They eradicated them from our societies but they also, at least the hypothesis is, that the heavy use of antibiotics and increased use of sanitation conditions in these Western societies also got rid of all of our good microbes. Antibiotics have no way of discriminating between pathogenic versus commensal organisms. Every time you take a dose of antibiotics, you're also getting rid of a lot of the bacteria that live on your body. Then the thought was that by increasing our sanitation, getting rid of all these good microorganisms that we're predisposing ourselves to increased auto-immunity.

Julie Kiefer: If that's true, you would think that people in third-world countries who don't have access to the same sanitation or to antibiotics, they might have these diseases less frequently. Do we know if that's true?

Dr. June Round: That is true. So if you go and look at the rural countries that don't take these antibiotics they don't suffer from diseases like Inflammatory Bowel disease, Diabetes or obesity even. They just don't have the same problems that we do. Of course, they're oftentimes suffering from pathogenic infections but the fact is true that they don't have these problems.

Julie Kiefer: Right. There are trade-offs.

Dr. June Round: Yes. There are trade-offs.

Julie Kiefer: That's fascinating. I mean, it's hard to think about how things like obesity fit in to the picture. Can you talk about that a little bit?

Dr. June Round: Sure. So this is not my research focus in this particular lab, but a lot of people have been studying how the microbes in our gut can influence obesity. Because wouldn't everybody love to take a pill that causes them to lose all the weight? The fact is that the microbiota is very important in how we digest our food. The food that we intake is also a fuel source for the microbes. So let's say you eat a lot of fat in your diet, and you're going to have microbes that are really good at metabolizing that fat.
Some can do it better than others. So if you happen to be colonized with some organisms that are really good at extracting a lot of energy from that fat, that's also more energy your body gets. So the microbes get it but also your body gets it. So if you don't use that energy then it gets stored as fat. The thought is that... The interesting part is that they can take microbes from people who are obese, stick them into germ free mice and then those germ free mice, even though they're eating the same food, they begin to start getting fatter. There are a lot of studies supporting this notion that the microbes that live in your gut can actually just help you extract more energy and then make you gain weight.

Julie Kiefer: So you're not just feeding yourself, you're feeding these little microorganisms within you too.

Dr. June Round: That's right.

Julie Kiefer: What are your thoughts about using antibiotics, or cleaning your hands with alcoholic cleansers?

Dr. June Round: I certainly wash my hands, but I don't use those cleansers and I don't have my kids use them either. Because I do think that we get a lot of our microbes from our environment. I think that that is important. I do buy into this idea. Another thing is that, especially for kids, a lot of parents, if their kid gets an ear infection, they will go to the doctor and request antibiotics. That's something that I haven't pushed for my children. I make them suffer a little bit longer, not take the antibiotics and clear the infection themselves. There's these startling studies out there that there are correlations between a lot of these auto-immune diseases and the number of times you've taken antibiotics as a youth. So people who have taken antibiotics up to four or five times, they tend to develop diseases like Inflammatory Bowel disease later in life. Because I'm raising young children who are in this window, I am concerned that if I give them too many antibiotics, I could predispose them to these diseases later.

Julie Kiefer: It seems like the healthcare field has already some of these findings into consideration. I've noticed just in the last few years, that doctors are more reluctant to prescribe antibiotics right away. Can you think of other examples where the healthcare field is really being proactive in how they think about the good bacteria?

Dr. June Round: One thing that comes to mind, prominently because I talk to my colleagues about it a lot, is this fecal transplant idea. A lot of people, especially gastroenterologists who treat people with Inflammatory Bowel disease, are really starting to think about whether or not they can just replace the bad organisms in their patients with IBD by just giving them a fecal transplant from someone who is healthy. This has already been done several times for Clostridium difficile infections and this has worked in human populations where people who are suffering from Clostridium difficile, which is a pathogen that goes into the intestine and basically causes a lot of diarrhea and pain for a lot of people. They can get rid of the infection simply by taking a person who's not infected and performing a fecal transplant. So people are starting to think about these things when it comes to disease like Inflammatory Bowel disease. It's just replacing the bad organisms with good ones from other people.

Julie Kiefer: So it looks like we may be on the cusp of some big changes in how we deal with IBD and similar diseases. Do you think that's true?

Dr. June Round: I absolutely think that's true. Yes, I think the old way of going in and just obliterating all the microbes with antibiotics is hopefully going to be a thing of the past and that we're going to start to better understand how we've co-evolved with our commensal microbiota. Then we'll start to use them as kind of natural therapies.

Announcer: Interesting, informative and all in the name of better health. This is The Scope Health Sciences Radio.