Constipation with Dr. Ilana: Rational Wellness Podcast 356
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Dr. Ilana Gurevich discusses Constipation with Dr. Ben Weitz.
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Podcast Highlights
2:16 “We are living in a constipated world”, according to Dr. Gurevich. More than 35% of the US population has reported using laxatives and it’s over a $500 million a year industry.
2:44 Dr. Gurevich finds treating constipated patients much more challenging than patients with diarrhea. There are a number of patients with lifelong constipation issues and they can be very challenging patients to figure out the root cause and to resolve.
3:57 Red Flags. We need to be alert for when a patients with constipation has signs that might indicate that they need medical intervention. One red flag is when you have frank red blood in the stool, which looks like coffee grinds. This indicates either an upper GI or a lower GI bleed. It could indicate hemorrhoids or it could be colorectal cancer or inflammatory bowel disease. If you have severe pain in the GI tract or rectum or you have a spiking fever, those are both red flags. Also, if you have recent onset of fatigue and anemia, then that is a red flag that you might have GI bleeding. Now constipation can also be caused by many conditions, including diabetes, Parkinson’s, MS, and other neuropathies. There are also non-neurogenic conditions that can cause constipation, including hypothyroidism, pregnancy, and a history of binging disorders.
8:55 Idiopathic and Functional Constipation. Functional constipation is the stuff that Functional Medicine practitioners often treat, like SIBO, low fiber, slow transit, outlet constipation, dyssynergic defecation, and pelvic floor dyssynergia. Dr. Gurevich has a patient who’s in his 80s but who bikes a hundred miles per week and sits on a bicycle seat for hours per week and it causes nerve damage, which is a pelvic floor dysfunction. Switching to a recumbent bike is one good idea and seeing a good pelvic floor therapist can also really help. Dr. Gurevich also points out that when you avoid going to the bathroom when you have an urge to defecate, this can increase constipation due to nervous system feedback.
14:42 Drugs. There are a lot of drugs that can cause constipation, including anticholinergics, antihistamines, iron, opiates, some blood pressure meds, some calcium channel blockers, and NSAIDs.
15:34 Functional Constipation. These include normal transit, slow transit, and rectal evacuation disorders. Functional constipation is when our Functional Medicine strategies like fiber and bulking agents and herbal laxatives can be helpful.
Dr. Ilana Gurevich is a board-certified naturopathic physician and acupuncturist and is currently co-owner of two large integrative medical clinics, one in northwest Portland and one in northeast Portland. She runs a very busy private practice specializing in treating inflammatory bowel disease as well as IBS/SIBO and functional GI disorders. Dr. Gurevich is also one of the co-hosts of a successful podcast, Turd Nerds, along with Drs. Rebecca Sand and Ami Kapadia. Her website is OpenWellnessPDX.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure. Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting-edge health information. Subscribe to the Rational Wellness Podcast for weekly updates, and to learn more, check out my website drweitz.com. Thanks for joining me, and let’s jump into the podcast.
Hello, Rational Wellness Podcasters. Today, I’m very excited about talking about one of my favorite topics, which is constipation, and I’ve often been accused of that. We’re going to be speaking with Dr. Ilana Gurevich, and she’s one of our favorite gut health experts. Constipation occurs in up to 20% of the US population, making it the most common gastrointestinal complaint. The symptoms of constipation include the following: fewer than three bowel movements per a week, hard or dry stools often described as Type 1 on the Bristol Stool Chart if you know what that is. Straining or pain when passing stools. A feeling that not all the stool has passed. A feeling that the rectum is blocked or having to try to help yourself to pass a stool. Dr. Gurevich is a board-certified naturopathic physician and acupuncturist, and she’s the owner of Open Wellness in Portland, Oregon. She specializes in treating gastrointestinal disorders, including inflammatory bowel disease, IBS, SIBO, and other functional gastrointestinal disorders. She’s also one of the cohosts of a successful podcast, Turd Nerds, along with Dr. Rebecca Sand and Ami Kapadia. Dr. Gurevich, thank you so much for joining us.
Dr. Gurevich: This is actually one of my favorite topics, too, and as an aside, this is the most downloaded episode that we have on the podcast is-
Dr. Weitz: Oh, okay.
Dr. Gurevich: …the constipation. We are living in a constipated world, and the last time I did a data search on it, more than 35% of the US population has reported using laxatives. It’s over a $500 million industry.
Dr. Weitz: Really? 35% use laxatives. Wow.
Dr. Gurevich: Yes. Last time I looked, and that’s lots of people not reporting.
Dr. Weitz: Right.
Dr. Gurevich: Yeah.
Dr. Weitz: So in your practice, how often do you see constipation?
Dr. Gurevich: I have to say, when I get a diarrhea patient, I’m like, oh. It’s like relaxing. Diarrhea patients are generally, not always, but generally pretty easy to treat and get to the underlying cause. Constipation, it’s just a lot more nuance, and I mean, there’s a lot of underlying causes for diarrhea, but constipation can first and foremost go back to childhood. There are people walking around with lifelong constipation issues, you know what I mean? It’s difficult. You got to do a lot of history and a lot of tracking down to try to resolve it for real.
Dr. Weitz: Right. So it seems like there’s actually different forms of constipation because when you think about the fact that you have somebody, maybe who hasn’t pooed it for two or three, four days, and then somebody else who’s maybe having three or four or five bowel movements a day but has a lot of trouble getting it out and other people who it’s just a lot of strain and it seems like they almost should be described as something different.
Dr. Gurevich: Okay, so let’s start with when is constipation, not just constipation? The first thing that I always want to talk about is what we call the red flags. When is something going so wrong that you’re not looking for a laxative you’re looking for medical intervention? That’s the easiest place to start. One, either frank red blood, a significant amount or what we call melena, or coffee grinds. It looks like you have a coffee grind consistency to your stool. That right there is telling you you’re bleeding either an upper GI bleed or a lower GI bleed.
Dr. Weitz: Wait a minute, coffee grind consistency in the stool?
Dr. Gurevich: It looks like your stool has coffee grinds in there.
Dr. Weitz: So now how do you know that? Did you look at their stool or they report that?
Dr. Gurevich: No, they report. They report.
Dr. Weitz: Okay, okay.
Dr. Gurevich: Look, you’re trying to figure out what’s going on. We take a peek at your poop… Please. This is my public service announcement. Please look at your poop. It gives you a lot of information. A lot of information. So if it looks like you’ve got coffee grinds in there or like coffee grind particles, that’s super important because that means that probably you’re bleeding higher up, right? That’s an esophageal bleed, a stomach bleed. If you’re having frank red blood, that’s a little bit more nuanced. If you’re having frank red blood, that generally comes off on the toilet tissue, especially after a hard or more impacted bowel movement. I’m not worried about that. That’s most likely a hemorrhoid. If it keeps going, then you want to get it checked out, but that’s a hemorrhoid. You might have some rectal itching that I’m not worried about, but if you’re having a toilet bowl full of blood, then that’s another big sign. That could be a colorectal cancer, that can be an inflammatory bowel disease. That’s a red flag.
Dr. Weitz: Yeah. Those are the two main things you’d be concerned about, right?
Dr. Gurevich: Yeah, for sure. If you’re having a new onset of rectal pains, I had a patient come to me five or six years ago, and she was an ulcerative colitis patient. She also happened to be in my community, and she was an ulcerative colitis patient, and so she was like, the bleeding I have you see, the pain I have you see? But she was describing this… The way she described her pain, it like somebody was drilling into her rectum and she was in my community, so she was really into alternative health. So she waited, waited, waited. By the time she went into the gastro, she had stage four colorectal cancer, and she was in her forties. She was in her sixties. She was very young. So that kind of rectal pain, that’s a red flag. That is not normal. Constipation does not cause that type of pain. If you are having a fever that doesn’t make sense, you’re spiking fevers left and you have constipation, that’s a red flag. And then the other thing is unexplained recent onset fatigue that’s consistent with anemia, and then you check your blood and you’re anemic, that means you’re bleeding somewhere from the GI. All of these are not the constipation we’re going to be talking about today. Those are all red flags go, you need some medical help. So that’s red flags. However, outside of red flags, constipation can be caused by a lot of things. So one thing that can cause constipation is neurogenic disorders. So Parkinson’s, diabetes mellitus, MS, any neuropathies. And in fact, there is recent data that shows that Parkinson’s, the first sign of Parkinson’s, which usually onsets in your forties is constipation, and that is-
Dr. Weitz: And that constipation occurs up to 20 years earlier than-
Dr. Gurevich: Isn’t that frightening?
Dr. Weitz: …patients are diagnosed. So then the question is, imagine if we could intervene at that point and could that even help?
Dr. Gurevich: I mean, and the problem with that-
Dr. Weitz: By way is that the Bristol Stool Chart on your-
Dr. Gurevich: Dude, I’ve got one skill, one skill to only helping people poop. That’s all I got.
Dr. Weitz: You’ve got to be a GI expert to be drinking out of a cup with the Bristol Stool Chart.
Dr. Gurevich: I clearly need some hobby. So yeah, that’s the scary thing about Parkinson’s, that a lot of these neurological disorders onset with constipation, which then you have to worry about the mental slippery slope of, okay, now I’m a middle-aged mainly woman or a middle-aged human being, and I have onset constipation. How do I not sit up in the middle of the night convinced I have Parkinson’s? Right? Okay. So those would be neurogenic disorders that onset constipation. There’s also non-neurogenic also systemic disorders, hypothyroidism, pregnancy, and then unfortunately there is a big correlation with a history of binging disorders, even either currently or in your past. So eating disorder history also can onset constipation. So that I would say is neuropathic systemic causes. Then we’ve got the idiopathic causes, which they don’t really know what to do with, but we also treat them really differently and it’s important to know. So we think about functional constipation, and then we think about idiopathic constipation. Functional constipation is the stuff that we, me and you do a really good job treating-
Dr. Weitz: Like SIBO and motility problems.
Dr. Gurevich: Low fiber, slow transit. So then we have the idiopathic, so either slow transit constipation, outlet constipation, or dyssynergic defecation, and then pelvic floor dyssynergia. So when you’re taking a history, let me give you a great patient history on this. I had a man come in to see me. He was in his eighties. This guy was a powerhouse. I think he would be… I think still he’s 82 he will bike a hundred miles a week.
Dr. Weitz: Wow.
Dr. Gurevich: Okay. So that’s important because he’s also sitting on his bottom on a bicycle for hours every week. This guy came in and he was on laxatives. They didn’t really do anything. That’s a keynote. He had tried all of the drugs. They didn’t actually improve his symptoms, and it almost seemed like his thing wasn’t like when the stool would come out because he was on so many laxatives, it would be diarrhea. It was like a Bristol Six, a Bristol Seven, and he had to spend four or five hours every morning stooling. And I’m listening to him, and he’s also talking about his rectal pain. He had been worked up at Mayo. He had gone to a pelvic floor therapist. He had taken all of the fiber and all of the all of the and it didn’t matter because what he had was not a functional constipation. It was a pelvic floor dysfunction, and this is why it’s, I think, really important to have-
Dr. Weitz: So he was damaging the nerves by being on that bicycle seat.
Dr. Gurevich: Unfortunately, I’m still treating him and he’s actually doing a lot better. That’s like he can’t. He’s like, “Why would I be alive? I want a stoma if I can’t bicycle,” which I get.
Dr. Weitz: Could he get a different kind of seat?
Dr. Gurevich: We are now negotiating a recumbent. That’s what we’re negotiating. Yeah. Because yes that’s a solution. A solution is not a seat that puts pressure on the rectum. The other thing is I sent him to a really, really good pelvic floor rectal specialized pelvic floor physical therapist. And the story that I always tell with physical therapists is when I was pregnant, I have an 11-year-old. When I was pregnant, I was reading this book about French babies don’t throw food or some kind of Europe book. And 11, 12 years ago in the book, they said in France, after childbirth, every woman goes to a pelvic floor physical therapist that’s just stuck in the medical system. And 12 years ago, I was like, pelvic floor physical therapy I’ve never heard of such a thing. At least now for me, there’s an incredible pelvic floor physical therapist, every third window. Do you guys have a bunch there too?
Dr. Weitz: I wouldn’t say it’s that common around here and then there’s a diversity of what ends up becoming the therapy too. Some of them just have them do some of the same exercises, and I’m not sure that’s always all that effective.
Dr. Gurevich: That was his problem. He had gone to somebody who claimed they were rectal specialized. They told him to do the same things. They didn’t really do any internal work. They didn’t teach him about engaging his muscles and so when he came in to see me, he was like, been there, done that. It didn’t work.
Dr. Weitz: Right. I did the Kegels it didn’t work.
Dr. Gurevich: It didn’t work. And so then I sent him to who I personally think is the best person in Portland, and of course, she doesn’t see patients, but now she runs a clinic and she teaches her staff, and it made such a difference. They did a bunch of internal work, so they were able to release the rectal muscles. They talked to him about the bike seat, and then we changed his stool, his stooling regimen because he was basically having diarrhea but couldn’t engage his muscles. Because everybody was thinking that he had a functional constipation, but he didn’t. He had a dyssynergic constipation. So it’s really important to differentiate that.
Dr. Weitz: By the way, when I was listening to one of your podcasts about constipation, I learned something, which I didn’t know, which was that not going to the bathroom when you feel like you need to increases your risk of constipation.
Dr. Gurevich: Yes, yes. Thank you. Yes.
Dr. Weitz: And as a busy clinician, how many times am I have back-to-back consultations and I can’t go to the bathroom and I put it off?
Dr. Gurevich: And then, so let me just explain that mechanism, because that also is crazy. So you have everybody but me and you both have an internal rectal sphincter and an external rectal sphincter, right? The internal rectal sphincter is what’s going to control the entire bowel above it. The external rectal sphincter controls communication to the internal. So oftentimes the internal sphincter will be like, is this a good time? Let me just put out a little gas. Let’s see. Let me put out a little stool. And the rectal, the external rectal sphincter would be like, oh, I’m doing a podcast interview. It’s not a good time. We can’t do this right now and so it will shut it down. If you continue to do that, your nervous system learns that it’s not a good time and it will talk to the entire brain all the way down to slow down the peristalsis. So if you do not listen to your bowels when you have an urge, it will shut down the entire system and you will make yourself be more constipated.
Dr. Weitz: Wow.
Dr. Gurevich: It’s very important. And then you think, like I said, a lot of constipation starts in childhood, so kids are learning that it’s not a good time to have bowel movements and so now-
Dr. Weitz: During class or they’re… Yeah.
Dr. Gurevich: Or they’re trying to keep control. Their parents are going through a wicked divorce. This is something they can control, and now they’re setting themselves up for the entire life of being constipated.
Dr. Weitz: Wow.
Dr. Gurevich: Isn’t that crazy? It’s like a-
Dr. Weitz: So it’s a neurological thing, right?
Dr. Gurevich: Yes. And then there is some retraining that has to happen. Oh, the other thing that causes constipation is a whole hell of a lot of drugs. A lot of drugs cause constipation. The anticholinergics like the antihistamines, everybody’s all about MCAS. All of the MCAS drugs cause constipation. Iron, we all know that the rock hard iron. Opiates, some blood pressure meds, some calcium channel blockers, all of those are going to be-
Dr. Weitz: And NSAIDs.
Dr. Gurevich: All of them are going to be associated with constipation. So then you have to, as you’re taking your patient history, you’re kind of working backwards. Could this be it? Have we ruled out these things? Have we ruled out this thing? And then we go into the category of what I call or what’s called functional constipation, normal transit, slow transit, or rectal evacuation disorders. All of those would be constipation. And these are the things that I feel like this is where our therapies shine. The dyssynergic constipation, really the best solution for that is pelvic floor. Honestly, that’s kind of the only solution for that. With the constipation, the functional constipation disorders, this is when we can use fiber and bulking agents and laxatives. That’s really where our treatments work.
Dr. Weitz: Yeah. I think another interesting thing is that I’ve always tended to think that if the patients have constipation, that’s a motility problem because it’s not moving or the muscles aren’t working properly and then if they have diarrhea, then it’s not a motility problem. But actually, if the muscles don’t work, they’ll get just rampant diarrhea because it’ll go right through and when they have constipation it’s because the muscles are holding on tighter.
Dr. Gurevich: Yep. So my answer is it could definitely be a motility issue, and it could also not be a motility issue. The bowels are, it’s like this orchestra. It’s a crazy orchestra and everybody has to do their part for it’s a work, and it’s real damn easy to shut down somebody’s part.
Dr. Weitz: Right.
Dr. Gurevich: So that being said, there are some pretty good, we have options, and part of the options is how do you go one at a time? First of all, how do you work up the case? How do you work up the case?
Dr. Weitz: Yeah. Are you trying to get to the root cause? Are you going to jump in and try to treat the symptom? Are you going to wait until you correct the root cause? If there is a root cause that you can discern?
Dr. Gurevich: And then not only that but also how do you have them moving their bowels? How do you give them some symptomatic relief while you’re trying to get to the underlying cause?
Dr. Weitz: Right. And then how do you deal with the fact that they’re already using all of this stuff before they saw you?
Dr. Gurevich: Right, right, right, right. And the other thing that we know unfortunately is I feel like both me and you always come back from the microbiome like that’s-
Dr. Weitz: Of course.
Dr. Gurevich: Yeah. And a lot of the laxatives that they’re using we know are killing the microbiome, just completely decreasing diversity, changing the species that are in there and so that’s also very challenging. They’re taking laxatives because it’s so uncomfortable not to poop, and that laxative is making the problem worse, but you can’t get it with a laxative because you have to work in a microbiome. And by the way, treating constipation is never fast. I mean, it takes years. It could take years and honestly, that’s where I get a little bit lazy. And some of the drugs that we have are, they’re really, really good while we’re dealing with the underlying cause to get things moving, so at least we can keep working at it. And I have some interesting protocols, some that I’m trying that are new, some that I’ve been trying for a while. But for me, if somebody comes in once a week, maybe bowel movements, I’m going to start them on something to get them to poop right away. I’m either going to start them on some kind of bulking fiber, which works. I mean, if it’s a functional constipation patient-
Dr. Weitz: And as long as they don’t have SIBO.
Dr. Gurevich: As long as they can tolerate it, the bulking agents are like Rebecca Sand always says, “I think psyllium and water can put me out of business.” So I’m going to start them on a bulking agent, or I’m going to start-
Dr. Weitz: Now if you suspect they have SIBO are you using PHGG?
Dr. Gurevich: So what I’m going to do is I’m going to test. If they have any of that middle… So whenever I start taking a history with a patient, I’m always listening and I’m like, does this sound like a small bowel presentation? Does it sound like a large bowel presentation or does it sound like an upper GI? Upper GI would be reflux, esophagitis. Small bowel would be a lot of bloating. Some periumbilical pain, large bowel, they don’t have any bloating, but they have dysfunction in their evacuation, either diarrhea or constipation. If it’s sounding small bowel, I’m always going to start there. I’m going to work my way from the top going down.
And so if it sounds like it’s bloating, SIBO, distension, I’m going to work them up right away. I’m a big fan of testing. I’ve been in practice too long to believe that it sounds like… So I’m going to give you… Going to save us any time or money. So if it’s SIBO, great, we’re going to start there. And sometimes treating SIBO is enough, and sometimes there’s other small bowel disorders that are not bacterial, like a fungal disorder or… So in my opinion, I do see chronic fungal overgrowth in the smaller large intestine causing constipation in the chronic. In the acute, it generally causes diarrhea.
Dr. Weitz: How do you diagnose the fungal overgrowth? Because stool tests seem to underreport it.
Dr. Gurevich: Yeah, I think well, remember with stool tests, you’re only looking at what’s happening in the stool. So that’s a great question. Candida is at least findable-ish through Quest, Labcorp. Some of the functional lab tests there is Candida, IgA, IgM, IgG, and Candida Immune Complex. And those, I think, so one panel is the IgM, IgG, and IgA, and then the other one is the Candida immune complex. Those, I mean, there’s data going back to 1952 [inaudible 00:21:26]-
Dr. Weitz: What about that compared to organic acids test?
Dr. Gurevich: So that’s the thing that I’m just starting to believe exists. So I’m a terrible person to ask because I’m just right now being like, oh, I think there might be some use in this organic acid thing.
Dr. Weitz: Wait a minute, you’re just figuring that out. Come on.
Dr. Gurevich: It just doesn’t have as robust a data set behind it.
Dr. Weitz: Right. Of course. Yes. Right. Yeah.
Dr. Gurevich: And so I’m hard-pressed telling a patient who’s dropping money on me to then drop money on my favorite stool test because I think there is good data on a lot of the markers on the stool panel to then drop another 400 bucks. But I think it exists. I think it’s valid. I think it does help. And so that’s the line that I’m walking now. I’ll always do the blood, the Candida, IgA, IgM, IgG, and the immune complex. I’ll always do that, but that is sensitive only for Candida. And we both know there’s a whole lot of other funguses out there besides Candida.
Dr. Weitz: Right. And then anytime I see fungus, I’m always want to suspect the possibility there could be mold as well.
Dr. Gurevich: Which also I’m just finally starting to admit exists. But yeah, and that I see causing chronic constipation.
Dr. Weitz: Another whole layer.
Dr. Gurevich: Yeah. Another whole layer, and that like it’s really-
Dr. Weitz: I really think that we have to think in terms of layers.
Dr. Gurevich: I could not agree more. Yep. Okay. So if it’s SIBO, if it’s SIFO, I’ll try to work that up. If there isn’t a lot of small bowel stuff, then that brings me back to the large bowel and the large bowel, really, I’m looking at some kind of stool testing. And I personally am a big fan of provocation, which I think not everybody agrees with me about, but so provocation basically-
Dr. Weitz: Yeah, you’ve mentioned that before. Yeah.
Dr. Gurevich: I’d like to give people high-dose enzymes for 10 days before they take the stool test because I’m trying… Because I know biofilms and I know things hide underneath there. So I’m a big fan if I’m going to drop that much money if I’m going to convince them to drop that much money on a test, I kind of want to see what’s hiding underneath that [inaudible 00:23:38]-
Dr. Weitz: Now, have you ever run that by the stool testing folks to see if they think it could affect it?
Dr. Gurevich: That’s a good question. No, I haven’t. That’s a great question because I have a pretty good relationship with my stool company-
Dr. Weitz: Okay. I’m going to email Tom Fabian after this.
Dr. Gurevich: Yeah, I mean, that’s a company that I use too. I have a pretty good relationship. I’ve never asked them.
Dr. Weitz: Yeah, I know when it comes to the mold testing, a lot of doctors like to do a glutathione provocation thing, and they specifically recommend not doing that.
Dr. Gurevich: What do you do? Do you provoke the OAT test? Do you have them to stop their supplements for the OAT test? What do you do for that?
Dr. Weitz: I usually don’t provoke.
Dr. Gurevich: Okay. Do you find anything?
Dr. Weitz: Yeah.
Dr. Gurevich: Yeah. Okay.
Dr. Weitz: Yeah, quite a bit. Yeah, but I don’t know. I’m not so sure how effective the various biofilm-busting agents are either. I’ve gone back and forth on that. The enzymes are great. I’m not sure the enzymes are doing anything. I got to go to the next level. And then I don’t know. Do I really want to put everybody on Bismuth and then where do you go?
Dr. Gurevich: Yeah. So I mean, I will say that I have played around with all of them. I’ve played around with the enzyme class. I’ve played around with the OTC with Bismuth, and then I’ve played around with the prescription. I feel like the one I can hang my hat on the most is the prescription. And so I don’t really-
Dr. Weitz: That’s the Paul Anderson one.
Dr. Gurevich: That’s the Paul Anderson one. Yeah. Unless they’re not local and they don’t have access to a compounding pharmacy. I am generally, I’m using the pharmaceutical one. And is it a hundred percent reliable? No, nothing… I mean, it’s medicine, nothing is.
Dr. Weitz: Right.
Dr. Gurevich: Do I get improvement? I mean, I think 65. 65%, 70%. I can get some kind-
Dr. Weitz: Oh, that’s a pretty high percentage.
Dr. Gurevich: Yeah. That’s not bad.
Dr. Weitz: How long are you comfortable using a heavy metal like Bismuth for?
Dr. Gurevich: So Bismuth goes back like in Chinese medicine I was once lecturing at a conference and I was like, you know who used Bismuth? Ayurvedic medicine in Chinese medicine and they’re the oldest medicine in history. And then Eric Yarnell, who’s a pretty incredible naturopath and herbalist was like-
Dr. Weitz: I’ve heard of him-
Dr. Gurevich: …actually, the Egyptian medical system is the oldest system in medicine. They have books going back. And I was like, of course, Eric Yarnell knows that, but probably it’s used for a long time both in Chinese medicine and in Ayurvedic medicine. Is there a toxicity to it? Yes, absolutely. But you have to use it for a long time and from what I understand-
Dr. Weitz: And a long time is how long?
Dr. Gurevich: Nine months to a year. From what I understand, based on Dr. Anderson’s work is the thing about that compound, the bis-Thiol compound when you match the Bismuth with the Alpha-lipoic acid is it makes this bigger molecule so it even less so go systemic, even if they’re having intestinal permeability. So it’s safer.
Dr. Weitz: Yeah, I’ve heard him… I have talked to him before and he said that.
Dr. Gurevich: Yeah, so I’m just banking on that. However, I am a really, really big fan of breaks and I like to pulse, and so I’ll give it for three months. Okay, let’s take a break. Is it doing anything? What’s going on? Let’s take a break from everything. Where are you really without the $8,000 of support? Okay, we’re not anywhere. Let’s go back or oh my God, we’re done. Go be free, eat fermented food. We’re good. So that’s where I am with that.
Dr. Weitz: And then sometimes you get patients who say, “That’s it. I’m never eating those foods ever again.” And you have to convince them. No, it’s really important. No, I’m fine. I’m fine. I feel good.
Dr. Gurevich: Yeah. I am always like before the 1940s, there was not a single civilization in the whole world in the history of the whole world that did not utilize fermentation as their main system of preservation. Not in the whole world and then in the 1940s, we did two things at the same time, discovered antibiotics and discovered refrigeration. That is the beginning of our chronic health issues.
Dr. Weitz: Great. So now you’ve got this patient with constipation and you’ve decided it’s in the category of uncertain, right? It’s not an obvious SIBO, it’s none of the worrying signs of colon cancer or some of the other things. Where do you go next with that?
Dr. Gurevich: So if it’s the small bowel stuff looks pretty clean, I’m going to do a large bowel stool assay. That’s what I’m going to do. I’m going to look at what is going on with the microbiome. Are there any chronic infections that I can correct? Sometimes if you know chronic parasites will cause constipation, they just cause a pretty stark shocking difference of the microbiome. So depending on what comes up on the stool test, I will continue to move forward from there. If there’s something in the microbiome that looks funny, any of my big biofilm disrupt or any of my big biofilm pathogens, I’ll treat that. And then if that doesn’t work, then I’m like, I don’t understand what’s happening. So then I’m back to like, okay, is there a traumatic thing here? Could this be some mental emotional constipation? Is there a pelvic? Maybe it doesn’t present like a dyssynergic constipation, but I should probably get you assessed with a pelvic floor therapist.
Maybe what we need to do is, maybe what this is this is a hyper sympathetic overload. You literally have never given yourself enough time to poop, right? Or your stooling posture is atrocious. You’re in there on your phone, you’re Instagramming, and it’s all making you anxious, and then you’re in the story. You know what I mean? You’re never going to poop that way. Sometimes that’s the problem. It’s so nice when that’s the problem and so we do all of that hygiene stuff. We make sure their hydration is in check. We make sure their diet is in check. I personally will push, I want probably somewhere between 35 to 40 grams of fiber a day. You know I got-
Dr. Weitz: That’s really hard to get.
Dr. Gurevich: I know. I mean, you can do it with supplements and it doesn’t taste good.
Dr. Weitz: I don’t think you can do it without supplements to get to 40 grams.
Dr. Gurevich: Not in today’s diet, but I want to rule all of that stuff out. You know what I mean? I want to make sure that the low-hanging fruit is taken care of. And if I’m still stalled out, then, so the new thing that I’m playing with, my favorite, favorite conference on the whole planet is called the Gastro Association of Naturopathic Physicians.
Dr. Weitz: The what? The what?
Dr. Gurevich: The Gastroenterology Association of Naturopathic Physicians, the GastroANP, which I’m clearly very biased because I’m a board-certified naturopathic gastroenterologist. I’m clearly biased, but we put on a yearly conference every year. This year it’s in Seattle, I think last weekend of October. And it’s really, really cool because you get a bunch of people presenting data, but a bunch of people presenting straight-up nature cure. It’s really herbal. It’s great. But there was a lecture last year, Dr. Janel, Dr. Kathleen Janel. She calls herself GI Janel, and she presents it on a protocol that I had never been exposed to before her using MSM or a high-dose sulfur. And this is really interesting. You haven’t heard this either, huh?
Dr. Weitz: No.
Dr. Gurevich: Okay. So we listened to her talk while we were… Four of us were driving back to Portland, and we had it going on the car radio and somebody would say something, everybody is in the car, would be like… You’re hanging on the edge of her seat because it was such a mind-blowing protocol. But this is what I’ve been putting in. This is my newest discovery. Discovery. Kathleen Janel told me how to do it I didn’t discover it.
So the theory is because of antibiotic use, because of pesticides, preservatives, all of that, what happens, and I’m hoping I’m not butchering this, it’s not my theory, it’s her theory. So hopefully I’m not butchering it, but what happens is you have sulfur-fixing bacteria within your microbiome normally like it’s a healthy thing, but because we’re exposed to all of these antibiotics and pesticides and preservatives, those antibiotic and all of those, by the way, are just antibiotics. They’re just antibiotics that you put on plants or antibiotics that you put in food to prevent other bacterial growth. All of that kills off the sulfur-fixing bacteria and that’s really important because the sulfur-fixing… Sulfur is the third most abundant mineral in your whole body.
Dr. Weitz: So does fixing sulfur lead to hydrogen sulfide?
Dr. Gurevich: No. But when you kill… Thank you that you’re exactly going the right direction. When you kill off all of that sulfur fixing the bacteria, sulfur is so important that the body actually then up regulates the sulfur-producing bacteria and that’s what leads to hydrogen sulfide. Absolutely. Absolutely. And so what Dr. Janel was talking about is doing this very, very slow titration. Very slow titration up using MSM. The MSM is mono… I don’t know what it stands for, but it’s sulfur the SSL. So doing this very, very slow titration, up to sulfur, building up on the sulfur. And then it’s like, it’s almost like when you have that much sulfur localized, it pickles the hydrogen… Sorry, the sulfur-producing bacteria, and you can reverse the microbiome to get that sulfur-fixing bacteria back.
However, and this is a big, however, the other thing that sulfur does is it’s like the main thing that fuels our detox pathways. And so I have definitely seen, if you go too fast and I’m just supercharging your detox pathways and it’s not very clean in there, you are going to feel bad. Fatigue, brain fog, nausea, you’re just going to… I’m just pushing your detox, but your body’s not ready to detox. You’re bloated and constipated and so this is the new thing I’m playing with very, very slow titrations, like a pinch.
Dr. Weitz: You ever look at food sensitivities?
Dr. Gurevich: I don’t.
Dr. Weitz: Okay.
Dr. Gurevich: I feel like I’m like, my practice is all GI. I’m usually their sixth stop not their first stop and so-
Dr. Weitz: They’ve already done food sensitivity testing and-
Dr. Gurevich: Everybody in my practice has intestinal permeability. They’re seeing me. So it’s just a really expensive way of telling me what they’re eating.
Dr. Weitz: Right. In other words, what you’re saying is if they have leaky gut, then most likely all the foods they’ve been eating recently or a lot of them are going to show positive on a food sensitivity test.
Dr. Gurevich: Exactly. That’s exactly what I’m saying. Yes. So why am I going to make them drop more money on that and then I’m going to give them anxiety?
Dr. Weitz: What about trying to analyze motility and doing some sort of test for intestinal motility?
Dr. Gurevich: So if I can get it covered, absolutely I think it’s worth it. If I can’t get it covered, then I think I just have to make the assumption and put in some of those prokinetics and see if it gets us anywhere. Sometimes it does, sometimes it doesn’t but the testing for gastroparesis is notoriously 75% unresponsive so-
Dr. Weitz: So are you talking about anorectal manometry or are you talking-
Dr. Gurevich: No, I’ll definitely send for… If you’re looking at is the small bowel, is the stomach dumping? Right? There are tests that you can look at to see how fast the stomach is dumping out. Those are 75% on-
Dr. Weitz: Is that where you swallow one of those capsules?
Dr. Gurevich: I think they give you something radiographic and then they’ll take x-rays of you to see how quickly you’re descending or they can give you a smart pill. And a smart pill will go through there and it’ll look at the pH and it’ll look at the motility and all that.
Dr. Weitz: Somebody was telling me they saw some sort of presentation with Dr. Satish Rao and that there’s some sort of a capsule that stimulates motility. It’s like a treatment.
Dr. Gurevich: Oh, yeah, yeah, yeah. It’s the new one. I’ve tried it. I tried it-
Dr. Weitz: Oh, you tried it?
Dr. Gurevich: Yeah. I only have five patients. I don’t have a big… All of them it was like a whomp whomp. What is it called? It’s like a vibration it basically you swallow it and you swallow it at bedtime and it literally vibrates in the intestine. And so it should you to cause you to upregulate your peristalsis. Every single and I’m only trying and these are my most chronic of my chronic mainly with those people, I’m mainly… What they report is, oh yeah, I could totally feel it vibrating. It didn’t make me poop anymore, but I could feel it vibrating. They call a bunch of them actually, I have multiple patients who refer to it as my little [inaudible 00:36:51]-
Dr. Weitz: Are you part of a study or how-
Dr. Gurevich: No, no, I have the most chronic patients. And I’m like, let’s try this new intervention.
Dr. Weitz: Is it on the market?
Dr. Gurevich: Yeah. Yeah. I can email you what it’s called. Yes, it’s definitely on the market. I’ll email you what it’s called.
Dr. Weitz: Thank you.
Dr. Gurevich: They don’t even I think it’s not a drug. Do they [inaudible 00:37:11]-
Dr. Weitz: Right. Right. It’s a medical device I would think, right?
Dr. Gurevich: It’s a medical device. Yeah, yeah.
Dr. Weitz: Yeah.
Dr. Gurevich: So I haven’t seen anything. There’s a new one that it’s like something you put on your ear. What’s that one for? No, maybe that’s the nausea one. They’re coming up with some really interesting new things. We’ll see how they pan out.
Dr. Weitz: Interesting. I know we’ve been looking for a non-invasive test for motility for years, and there’s really not one. I remember at one time Pimentel was working on something to do with acoustics and sound, and I don’t think it ever panned out.
Dr. Gurevich: It’s hard. This population is hard. Really it’s like… That’s when I have a diarrhea I mean, I’m saying diarrhea I’m like, oh, I got this. Usually not always but you know-
Dr. Weitz: So in terms of interventions for some of the idiopathic patients, you were talking about fiber and then you were talking about laxatives. What kinds of laxatives do you tend to go to first?
Dr. Gurevich: I mean, I’m a naturopath, so I like either magnesium or I like my herbs. Some of the herbs-
Dr. Weitz: And you use mag citrate?
Dr. Gurevich: I either use mag citrate, if they’re unresponsive then I’ll go on to mag oxide. It really depends and some people you know interestingly-
Dr. Weitz: You feel like mag oxide is stronger than citrate?
Dr. Gurevich: I do, but it’s oftentimes too strong.
Dr. Weitz: And when you do citrate, what’s a typical dose switch for you?
Dr. Gurevich: So what I generally say is it can take up to three days to go from the mouth to the toilet. So for the first three days, try 150. Okay, we’re nowhere go to 300. Okay, we’re nowhere. Go to 450, find your dose, titrate up. Everybody is different. So that’s what I’ll do for mag citrate. That’s also what I’ll do for mag oxide and you know what else is really interesting is I will say that I don’t think every… I think for the magnesiums you should try to use capsules or powders because the technology to keep a tablet together is definitely affecting the way that tablet degranulates in your system. And so I don’t actually… I’ve seen 800 milligrams of tablet mag citrate do nothing but 150 of capsule mag citrate and they’re like having diarrhea. So I do think what you’re taking matters and then we’ve got great herbs, we’ve got some really, really good herbs.
Triphala is great. Cooked Dahuang so in Chinese medicine, Dahuang is rhubarb. Sorry. So you can have the raw rhubarb, which is really purgative, and then you can have the cooked rhubarb and so cooked rhubarb is going to be a little bit more gentle. There’s also this great study that I stumbled upon that it actually changed how I do some things where they use this Chinese herbal formula, Bu Zhong Yi Chi Tang, which is so B-U Z-H-O-N-G Y-I C-H-I, Tang T-A-N-G. And it was a 2300-person study out of China where they used a slight modification of this classical Chinese herbal formula. And the herbal formula is actually, interestingly enough, it almost lifts your organs. That’s the energetics of it.
But there’s this great study that showed that it greatly improved functional constipation. So Bu Zhong Yi Chi Tang is now in my rotation. If I can do it as a powder, I’ll do it as a powder kind of tastes like spicy dirt. So yeah, I’ll definitely work on the herbal aspect of things. I like to avoid the stent of the cascaras because that’s going to cause more harm in the long run. But if I can’t, we’ll visit those a little bit and then I think my favorite Dr. Sand, when she was my resident, she sold me on prucalopride or Resolor or Motegrity, and that one is still… That one the data on it says the worst, the constipation, the better it works and so that’s still my favorite drug if I can get it to work [inaudible 00:41:19]-
Dr. Weitz: Prucalopride that’s your favorite drug?
Dr. Gurevich: Favorite. Favorite. Yep. And I put it in the category of naturopathic drugs because generally-
Dr. Weitz: Why is that a naturopathic drug?
Dr. Gurevich: That’s a great question because it does not have a lot of side effects. It has been shown in one study in particular, I think it was a mouse study, that it actually re-heals the nerves that innervate the large bowel. And so if you’re dealing with neurological stuff, and I have been able to put patients on prucalopride for three to five years and then be able to take them off and they can have spontaneous bowel movements on their own. And the worse your constipation, the better it works. The worst, most intractable constipation, those people end up getting spontaneous bowel movements, which might be like-
Dr. Weitz: Is that usually get that covered by insurance and if not, how much does it cost?
Dr. Gurevich: So in the US, I don’t know if you’ve heard our system’s kind of broken. Have you heard? So US, it’s still only brand. It was released in 2019. So it won’t be generic until 2026 or ’27. But out of Canada, you can get it for sometimes under a hundred bucks.
Dr. Weitz: Okay.
Dr. Gurevich: Yeah. So that’s kind of what I’m doing-
Dr. Weitz: Apparently, they’re starting to negotiate for lower drug prices, but-
Dr. Gurevich: Yeah, by saying you should buy your drugs in Canada.
Dr. Weitz: So where do you go to next is in terms of-
Dr. Gurevich: So God, if I am stalling out there, then I’m probably going to refer to one of my colleagues to work up Lyme because Lyme has a huge GI component and I’m just not skilled there. I’m going to probably have one of my chronic toxicities and then mold, that’s where I’m going to go next. Yeah.
Dr. Weitz: Yeah. I’ve definitely found constipation to be an effective mold.
Dr. Gurevich: Yeah. So that’s probably if I stall out, then they’re going to get referred there. And then-
Dr. Weitz: So when you work them up for SIBO, which SIBO breath test? So you using the Trio-Smart, are you using the two-breath test?
Dr. Gurevich: So we have a machine in the clinic if they’re constipated or mixed, I feel pretty comfortable using my machine. If it’s unclear, it might be a hydrogen sulfide picture I’ll send out for Trio-Smart. I don’t know. I’ve never seen a hydrogen sulfide come back positive. Have you?
Dr. Weitz: I have, yes.
Dr. Gurevich: A lot or a few?
Dr. Weitz: A few.
Dr. Gurevich: Yeah. I’ve never seen one. So it makes me, with my diarrhea patients, I’m kind of like, is it worth the extra [inaudible 00:43:59]-
Dr. Weitz: Do you still use a flat line as a way to diagnose hydrogen sulfide on a two-breath test?
Dr. Gurevich: I mean, if they have a flat line in their diarrhea, then I’m going to say we maybe should try Bismuth. Let’s see what happens. Yeah. And at those higher-
Dr. Weitz: So it sounds like you don’t have much confidence that that’s necessarily hydrogen SIBO, but you think it might be hydrogen sulfide SIBO?
Dr. Gurevich: Yeah. I feel like I wish I was so excited about Trio-Smart, I was so excited and I still run them. I probably still run a handful of every week. I just was… I have yet to see. How long has that test been out? Two years?
Dr. Weitz: I think so. That sounds right.
Dr. Gurevich: I’ve yet to see a positive hydrogen sulfide.
Dr. Weitz: Do you find when you use the Trio-Smart that it underreports methane?
Dr. Gurevich: No, actually I was finding that at first. I do feel like they’ve corrected that formulation.
Dr. Weitz: Okay.
Dr. Gurevich: Yeah. I am seeing a lot more methane positives on my SIBO test probably within the last year. So from March of last year, I feel like something changed in their settings.
Dr. Weitz: Now, what do you think about the concept of using a stool test to partially diagnose IMO?
Dr. Gurevich: Pimentel always teaches that the small intestine, your small intestine has more to do with the small intestine of a mouse than it has to do with your own large intestine. So you are seeing, okay, you have a stool test and you are seeing the Desulfovibrio or the, sorry, the [inaudible 00:45:34]-
Dr. Weitz: Methanobrevibacter smithii-
Dr. Gurevich: Methanobrevibacter. Yeah, yeah, yeah. I don’t know if it’s enough. I don’t know if it would change my treatment enough, but I don’t know if it’s enough for me to make it… I don’t feel comfortable calling it IMO. How about that? I think that if there’s a very clear designation of this is how we designate it, it’s seeing over 10 within the first 90 minutes, I’m more likely to just use that designation because that’s the designation that’s been set for us.
Dr. Weitz: Have you experimented with the new portable breath test?
Dr. Gurevich: Oh, I have some patients who do it.
Dr. Weitz: Yeah, I just got one, and one of my patients was using it and got me one. I just started fooling around with it. It’s kind of cool.
Dr. Gurevich: And is it?
Dr. Weitz: Yeah.
Dr. Gurevich: What are you learning?
Dr. Weitz: Well, I mean you can do breath tests all day. You can do it after you eat certain foods, you can… It’s kind of cool.
Dr. Gurevich: It’s like another wearable, it’s like a device.
Dr. Weitz: Well, it’s a device you blow into it but right now I’m testing it on a few patients who are doing the Trio-Smart and using this side by side so I can get a sense of how accurate we think it is.
Dr. Gurevich: I can’t wait to hear that. That’s my question. Yeah, that I can’t wait to hear the result of.
Dr. Weitz: But it’s kind of a cool concept and for 250 bucks, which is less than the cost of one SIBO breath test, you can use it over and over.
Dr. Gurevich: Yeah, totally. Totally.
Dr. Weitz: You can see how certain foods react.
Dr. Gurevich: Yeah, I can see the appeal of it. I can totally see the appeal of it.
Dr. Weitz: Yeah.
Dr. Gurevich: Yeah.
Dr. Weitz: All right, so what else haven’t we talked about? What about probiotics for constipation?
Dr. Gurevich: Okay. So I definitely prefer fermented food over probiotics, generally speaking, and I think that probiotic-
Dr. Weitz: Why is that?
Dr. Gurevich: Mainly, I think of probiotics like air conditioning when you’re taking it it’s really helpful if you stop taking-
Dr. Weitz: What?
Dr. Gurevich: Yeah. Yeah.
Dr. Weitz: Probiotics like air conditioning.
Dr. Gurevich: Yeah. Yeah. When the air conditioner is running, you’re nice and cool, but when you turn it off, you’re hot again. You know what I mean? When you’re taking probiotics, it’s really doing something, but when you turn it off, it’s gone. Right? So I think-
Dr. Weitz: Oh, come on. It’s got to do more than that.
Dr. Gurevich: I’m more likely to land on fermented food and the other thing is I played around, I feel like when probiotic research was first starting and we were studying all these multi-strain probiotics, I was seeing a lot more efficacy when it was robust. And now everybody’s trying to get into the game and patent one single bacterial species. And I’ll look at the studies and I’ll say, “Oh, I have a patient that presents with just like this group that had really good response to this strain. So let me give you this one strain.” And I’m just not seeing it play out like it does in the literature. So when I go-
Dr. Weitz: But there seems to be more and more of those types of studies and-
Dr. Gurevich: Like the single strain?
Dr. Weitz: Yeah, exactly.
Dr. Gurevich: There’s so many. So many. And yet I’m-
Dr. Weitz: And sometimes having amazing effects for specific conditions and-
Dr. Gurevich: I just don’t. I’m a clinician. I tried to publish some of my ozone data. I had a researcher be my resident for a year and she was like, “Ilana, dude, there’s nothing to publish here. There’s too many protocols at the same time. You’re not doing…” Research wants to study one thing. I’m like, okay, who’s the patient in front of me? Let me do that. So I just didn’t see it play out. And so it kind of turned me cold a little bit. And then I go back to the beginning of time, fermentation was the way we preserve food. So do I think there’s a role for probiotics in constipation? Yeah, I do and I’ve definitely seen it help, but I feel like I’m much more likely to teach them how to eat so that we can change the microbiome in the long run.
Dr. Weitz: Yeah. I worry about fermented foods because how do you know which bacteria are growing and how do you know they have anything to do with the bacteria you really want to encourage in your microbiome? And then you maybe look at some of the commercial products like yogurts and stuff, and they have these strains that are not the strains that we’re really concerned about.
Dr. Gurevich: See, I actually go about it the exact opposite way. I’m like, you know what the problem is to think that we know anything about the GI microbiome. You know what I mean? We don’t know anything. We only admitted that it was important in the last seven years, maybe 10 years we only admitted it was important.
Dr. Weitz: Come on. Akkermansia is the key to everything.
Dr. Gurevich: Well, only if you’re talking to the Akkermansia people, but if you talk to the MegaSpore people, then Bacillus is the key to everything. You know what I mean? It depends on who you’re talking to and so that’s honest where I’m like, lacto-fermented this was how preserved food and we were a whole lot healthier. So that’s where I… I don’t know if I’m right, the thing I always say is, you put a hundred of us in a room, you get 80 good treatment plans and 70 of us are correct. I don’t know.
Dr. Weitz: Right. All right, good. I think we pretty much covered what we wanted to cover. Any other final thoughts you have… What?
Dr. Gurevich: If one person poops better we have won.
Dr. Weitz: That’ll make this country better.
Dr. Gurevich: That’s right. One at a time.
Dr. Weitz: Okay. So how can listeners, viewers find out about you, get in touch with you, find out about your programs?
Dr. Gurevich: Okay, so I’m about to launch my new business, which is killing me very quickly. The clinic I’m hoping is openwellnesspdx.com. We’re hoping to launch it April 15th. And then if you like how I sound, me, Dr. Sand and Dr. Kapadia talk about poop all day long on the Turd Nerds podcast. So that’s really… I mean, that’s us doing this every other week basically.
Dr. Weitz: Right. By the way, I don’t know if you noticed, but there’s several pet waste removal companies that use the same name.
Dr. Gurevich: We found one. We only found one, and then we found another podcast called the Nerd Turd, but I think it’s a plumbing podcast. So we’re the Turd Nerds.
Dr. Weitz: Great. Thank you, Ilana.
Dr. Gurevich: Thank you so much for having me. I’ll see you later.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. If you would like to work with me personally to help you improve your health, I do accept a limited number of new patients per month for a functional medicine consultation. Some of the areas I specialize in include helping patients with specific health issues like gut problems, neurodegenerative conditions, autoimmune diseases, cardio-metabolic conditions, or for an executive health screen. And to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. Please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111 and we’ll set you up for a new consultation for functional medicine and I look forward to speaking to everybody next week.
