The Management of Constipation with Dr. Dipti Sagar: Rational Wellness Podcast 365

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Dr. Dipti Sagar discusses The Management of Constipation at the Functional Medicine Discussion Group meeting on May 23, 2024 with moderator Dr. Ben Weitz.  

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page.] 

 

Podcast Highlights

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Dr. Dipti Sagar is an Integrative Gastroenterologist and she is presently sharing an office with Dr. Sam Rahbar at LA Integrative GI and Nutrition in Los Angeles, California  (310) 289-8000.  You can find more information at the LAIntegrativeGI.com website.

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.

 

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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 everybody I’m Dr. Ben Weitz. Thank you for joining our functional medicine discussion group meeting.  I very much apologize for no food tonight. Unfortunately, Chop’s Eatery, who we ordered the food from, decided to go out of business yesterday.  So, sometimes stuff happens. I hope you’ll consider attending some of our future meetings. Next month we have Dr. Darren Ingalls, who’s going to be speaking about Lyme disease, and that’s going to be June 27th. July 25th, Alan Barrie on Hypothalamus, Pituitary, Adrenal Access. We don’t have a speaker yet for August.  September, we have Dr. Pimentel. I encourage everyone to participate and ask questions, and if you’re not aware, we have a closed Facebook page, the Functional Medicine Discussion Group of Santa Monica, so you can join there and we can continue the discussion. I post a lot of research studies there and have discussions about functional medicine.

I’ll be recording this event, and I’ll be posting it as part of my Rational Wellness Podcast, and you can find that on Apple Podcast, Spotify, YouTube. If you listen to the Rational Wellness Podcast, please go to Apple or Spotify, give me a five star rating, set a review, and our sponsor for this evening is Integrative Therapeutics.  I’m going to ask Steve right here to comment. Tell us about a few integrated products. Thank you, Steve. 

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Steve : Thank you. Hello. Thanks for coming. Glad to be here.  I, the topic is constipation, right? Yes. That’s not a huge thing for us. We had a great product called laxative formula.  Unfortunately, we discontinued it. We do have a really nice formula called Motility Activator that, works as a, almost like an adaptogen for the gut. And so whether you tend towards loose stools or constipation, it actually helps with both. It’s a high potency ginger and artichoke extracts.  It’s a great formula. We sell a lot of it. That’s it right now. So maybe Dr. Rahbar will, I’ll listen and learn something tonight. We’ll come up with something new. Also in the back we have some of the, we have a couple new ones. There’s a vitamin D with K. This new, we kind of got into this late, , which is how we kind of roll, but this is a good thing because we’ve, we waited until sort of the, the science was clear on which [00:03:00] nutrients and how much to use.  So it’s a really, really good formula. That’s, it’s a 5, 000 IUs of vitamin D, 180 micrograms of K2, and it’s about half the price of K Force. So if you use K Force, it’s the same formula at about 25 bucks. We also have a brand new Mag threonate that I don’t even have, it’s that new, it came on our website today.  That one is also gonna be similar, it’s a high potency Mag threonate with a low cost. And then we have samples of Cortisol Manager, which you guys all know about and also the new curcumin, which is called Curalieve.  So get those.

Dr. Weitz: And then of course, one of the main causes of constipation is, is Methane SIBO and you guys have the elemental diet. 

Steve : Yeah. So we talked a little bit about the elemental diet. It’s, this is not the place, there’s too much to go into with the elemental diet, but it’s the only Real one out there right now. I guess Mark Pimentel’s come out with one that’s close, [00:04:00] but it’s super high in carbs So if you’re interested somebody already did tonight talk to talk to me about the elemental diet We also have last one.  We have a product called Blue Heron And I’ll just it’s it’s a oldie but a goodie. And the reason it’s called Blue Heron is because Blue Herons poop a lot. So If you happen to want to try that one, it’s something we can talk about too So there you go. Thanks for coming.

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Dr. Weitz: Thanks, Steve. And so our speaker for tonight is Dr. Dipti Sagar, and she’s a integrative gastroenterologist who works with Dr. Sam Rhabar. And so why don’t you go ahead and introduce yourself, Dipti, and get started. Thank you. 

Dr. Sagar: Can you guys hear me okay? Yeah. Okay, so a very good evening to everyone. This is such an honor presenting here this evening, not only because I get to meet like minded physicians like you all, but because of how profoundly this has affected my life as a physician.  I first got introduced to holistic integrative medicine, then after several years of practice as a gastroenterologist, As a medical director in a big county hospital, doing thousands of endoscopies and coloscopies, and giving PPI to my patients like candies, I realized that a lot of my patients were not getting better.  So that made me look into what we are missing in traditional medicine. So I started to dig deeper and wanted to see some non traditional ways of treating my patients. And then I had my own journey. where I started having GI issues. Yes, a gastroenterologist with heartburn. And very quickly I realized that I could not take those medications that I was prescribing to my patients.  And that really put me [00:06:00] into this path to explore non traditional ways of healing. And I started this two year fellowship with Academy of Integrative, , , , Academy of Holistic and Integrative Medicine, where I really learned a lot, but unfortunately I could not bring those concepts into my previous practice.

But that said, I do believe that when you have an intention, the universe makes it happen for you. Just like we didn’t have a laptop today, but someone just walked in with a laptop. So when you have the intention, it happens. And I guess that’s how Dr. Rebar and me found each other and we started this collaboration together to do our practices together because of similar mindset.  And I’m really so very grateful for that collaboration because it has infused love, passion and life in medicine for me. And I really call this my rebirth as a physician. And to my surprise, my patients were very accepting of this kind of a model where I’m combining traditional medicine with holistic and complementary medicine because I thought I’m going to get so much pushback from my patients.  But instead they looked at me and said, what took you so long? This is what we have been waiting for all along. So really it changed my relationship with my patients as well. So without further ado, because I know I have to condense my 15 to 20 years of experience treating constipation into just 60 minutes, and now I actually have only 55 minutes, so let’s begin.

Dr. Weitz: Well, we have till 8:00 pm.

Dr. Sagar: All right, so I’m going back. Let’s see. There we go. So my collaborators for this presentation is Dr. Rahbar and Dr. Erdman.  So, as a gastroenterologist, I can very well relate to the first statement, which is that no organ in the body is so misunderstood, so slandered, and maltreated as the colon. And as physicians and providers, some of you probably working in a hospital setting, could relate to the second statement, that besides death, constipation is the big fear in hospitals.  So what is the goal of today’s presentation? We are going to understand the pathophysiology of constipation. We are going to learn about diagnosis, management, presentation and pattern recognition, association with gut microbiome, as well as other illnesses.  And we are going to understand the principles of management.  Let’s talk a little bit about the disease burden.  So, it affects about 10-20 percent of the population, and to be honest, it’s very underdiagnosed because a lot of the patients, they don’t even come to physicians for this, and they just think that this is normal, or they just have to live with it.  So this is just reported 10-20%.  It does affect the quality of life [00:09:00] in a similar way to congestive heart failure or rheumatoid arthritis. About 700,000 individuals present in the ER for constipation every year in the United States. And can you imagine, like, 10 billion is spent annually on laxatives?

Okay. So, when a patient walks into your office, and probably your 10th or 15th or 20th patient of the day, and they say, Doc, I’m constipated. That’s when all hell loose break, loose break, right? And you’re like, I’m ready to quit medicine, right?  But to be honest, it doesn’t have to be that way. And today I’m going to equip you with tools that you can use so that you know exactly what questions to ask this patient, what tests to order, and how to manage them, so that it doesn’t have to be that difficult. So when you walk out of this room today, you’ll be more confident in taking care of these kind of patients, okay? [00:10:00] So as we discussed, consultation is common, but it is challenging, and we have to have a systemic approach in evaluating these patients, so that we can treat them effectively.  However, I wish it was this easy. It’s not. So, what are the few questions that you’re going to ask the patient?  I’m going to give you two questions, which is going to kind of open your mindset as to where, which direction you would be going. The first question is, is it infrequent passage of stool?  That means they are not moving their bowel every day, or they are taking two, three days to move their bowels.  If that’s happening, if the patient said yes, then you have to stop thinking about slow transit constipation. That means the transit of the colon is not as well. 

The second question is, do you have difficulty with evacuation? Because if this is the problem, that they are not able to evacuate, then the problem is not because of the [00:11:00] transit, but you have to start thinking about obstructive defecation.  And one of the most common ones is pelvic dyssynergia. I’m going to go into details of all of this, but this, these two questions will kind of help you understand which direction you have to go. Also remember that constipation can be a distractor. That means there could be a lot of underlying chronic systemic conditions, the presenting symptom of which is constipation.

So you have to explore that. Just don’t think it’s constipation and just laxatives. We have to do more tests. We have to dig deeper into the root cause of that constipation. So this is a simple list, but it’s not complete as you can see, there’s a variety of conditions that can cause constipation. It could be hormonal imbalance like diabetes, hypothyroidism.  It could be problems with the uterine. Honestly, this meditation list is pretty short. It’s not a complete list, but these are the [00:12:00] common medications that can give constipation. So you have to ask the patient, did you change your medication recently? Is there something new that was added? And even old medications can take like a year or so, like calcium cannel blockers do have constipation, so we have to take that history.

Neurological disorders like Parkinson’s disease, spinal cord disorder, myopathic disorders, and of course we have to think about structural disorders like colon cancer, rectocephaly, things like that.  So what’s the next question?  Is this chronic constipation?  Is it because, you know, you were admitted to the hospital, had a surgery or a c section and you got morphine, maybe that’s why you’re constipated, then that’s not chronic, right?  That’s related to the opioid execute. So how would you know if it’s a chronic constipation? Well, if the constipation is present for at least three months for a duration of six months, that’s how we define chronic. And if it’s chronic, then you have to ask this question. Is it Functional Constipation or is it IBS [00:13:00] Constipation?

I actually got this slide from Gastro of 2020 and it summarizes very nicely what’s the difference between Functional Constipation and IBS Constipation. So with Functional Constipation, about 25 percent or more of the times they will complain of straining, lumpy stool, sensation of incomplete evacuation.  Very important, use of fingers to dis-impact yourself. This is extremely important and especially, I see this a lot of time in women and I’m passionate about it because middle aged women, they will come to you saying that they have been constipated all their life. And it started at the age of 18 and they have never had a regular bowel movement.  The very next question that I always ask them, do you ever use your finger to dis-impact yourself? And if the answer is yes, you already know that you’re dealing with an obstructive defecation, most likely pelvic dyssynergia. Okay, so that’s one point. And then in those cases, you [00:14:00] will never have loose stool.  They will always complain of hard, lumpy stool. As compared to IBS constipation, where it will always be associated with some kind of abdominal pain which is relieved with defecation.  The stools would be either infrequent or inconsistent and about less than 25 percent of the time they will say that they have a loose stool.  So loose stool is present in IBS but not in the functional constipation.

So, the chronic constipation could be either normal transit, slow transit, , dyssynergic defecation, or it could be a combination of the two. It could be slow transit with dyssynergic defecation. So a little bit about the slow transit, it is also called a lazy bowel syndrome, and as we said, there is decreased motility of the colon.  The etiology is really very poorly understood, but there could be a lot of things at play, like lack of fiber, it could be autonomic neurology, the interstitial cells of Cajal are actually the colonic pacemakers, and [00:15:00] sometimes abnormalities of those can decrease the motility. And we cannot undermine the role of, neuroendocrine, systems like pancreatic polypeptides, serotonin, because those also play a role in the colon’s motility.  This is different from obstructive dedication, as I said, and with dysnergia, especially in women, there is a problem with the pelvic floor which cannot relax, or it could be a spasm of the anal sphincter. Decreased rectal sensation, where even though stool is present in the rectum, they don’t feel the urge because the sensation is less.

So that can also happen. And then weakness in the pelvic floor, if they have multiple vaginal delivery, during this difficult childhood, they could have things like rectocele, internal collapse. And when you have, these things, they can either cause a physical blockage to evacuation, or sometimes they form these pockets, and that traps the vagal contents, causing obstruction.

So, how do you [00:16:00] identify patients with primary functional chronic constipation? So again, as we said, thorough history taking, asking them everything, when it started, frequency, medication. The visceral stool chart, honestly, we should all have this in our office, a big one on the wall. If you don’t have it, please carry it in the size of a pocket.

A picture. The reason is that I feel like whether you’re having soft or hard stool is a very relative term, which is soft or, , you know, formed for one person can be like a loose stool for another. So this picture kind of generalizes it so that it’s very uniform for everyone. And if your patient says that the stool looks like type 1 or type 2, you have to start thinking about slow transit constipation because why?

It takes, that means the stool is passing through the colon. For a long time. And what is the role of colon to absorb water from the stool, right? So if it stays in the colon for a longer time, your stool is going to get harder and harder And that’s why they have type 1 and 2, [00:17:00] then you have to think about slow transit.

This, the third thing that you have to think is I cannot actually, tell you how important a pelvic floor and anorectal exam is that you need to do on all your patients with chronic constipation. And I’m going to tell you six points that you need to look when you’re doing that rectal exam that’s going to give you so much clues as to what’s happening with the patient.

And then, ultimately you have to do the anorectomy for these patients to differentiate slow transit from pelvic dyssynergia, and we’re going to talk about that as well. So digital rectal examination. So the first thing, the very first thing is inspection. So even before you put the finger into the rectum, you have to separate, the cheeks with both your hands and look around.

What are we looking at? We are looking at external hemorrhoids. Is there a bulge? We are looking for internal hemorrhoids, which are prolapsed. We are looking for any irregularities because [00:18:00] then you have to start thinking about rectocele. You have to look at the vaginal area. Is there a vaginal prolapse?

You have to look at? If there is a scar, are we dealing with the anal fissure? Are the holes around? Are we looking at fistula? Right? So inspection is very important. We look at those things. The second thing is sensation. So we are going to do the endocritoneus reflex. So usually I use a Q tip. So one end has a cotton and the other end is like wooden and we are going to check that sensation in all the four quadrants at 9 o’clock, 12 o’clock, 3 o’clock, and 6 o’clock positions.

And if there is a contraction of when you do the, the reflex there, it’s normal. However, if you don’t see any contraction of the skin, then you use the wooden side. And if you see contraction now, then it is, abnormal or impaired. And the absent is when you, even with the wooden side, you cannot see any, , contraction.

Next is palpation. So when you insert the finger, you have to see the consistency of the stool. Is it a hard stool? Is the patient [00:19:00] impacted? If yes, then yeah, you’re thinking about obstructive defecation. Is there a liquid stool? Or is it no stool? So patient is constipated, but there is no stool. So yeah, this is slow transit constipation then, because the stool hasn’t come to the rectum yet.

So that gives you some clue, and if you have done enough rectal exams, you would know what a normal resting sphincter tone is, right? So that is something that we need to feel at rest, and after that, you tell the patient to squeeze very hard for 30 seconds, because you’re checking if they have enough strength, if there is enough squeeze there.

If not, you have to start thinking about problems with the sacral nerve and, , probably get an MRI. The next, we are going to ask the patient to push down, , thinking that your, finger is actually a stool and they have to evacuate it. Before the patient starts doing that, you have to put the other hand onto the patient’s belly, okay?

And then you ask them to push down. When the patient is contracting the lower abdominal muscles, [00:20:00] the sphincter in your finger should feel relaxed, right? However, if there is opposite, that means the sphincter is tightening and the abdominal muscle is relaxing, it’s a problem. If both of them is relaxing, that’s a problem.

If both of them is contracting, that is also a problem. So if you see any of this, you already is thinking in terms of pelvic dyssynergia and the next step would be to, do an anorectomy. So when you do the push down, you have to see what’s the push and pull. You have to see if the sphincter is relaxing or not, and you also see if there is a perianal descent or not.

So balloon expulsion test is a useful test to test that. I recommend doing it in the office. We do it combined with anorectal immunometry, where you insert a balloon with a catheter and fill the balloon with 50 ml of water. The patient is supposed to, expel it within 60 seconds. If they are not able to do it or take longer, then again you have to start thinking about therapeutic disinertia.

We always combine this. with anorectal [00:21:00] myelometry in our office setting. I’m not going to talk about that because Dr. Edmund is going to go into the details of how we do that after my talk, so you’ll get some overview there. Let’s get to the cheese effect, the treatment. Alright. Okay. So if you have diagnosed a patient with pelvic dyssynergia, , we recommend doing a pelvic floor physical therapy.

There are several exercises that we can recommend to the patient to strengthen their pelvic floor. And I know I said women, but men can also have pelvic floor abnormalities and dyssynergia. So there are crucial exercises for men as well that we recommend to our patients. This was a good study, which was published in the Clinical Gastroenterology in 2023, an office based point of care test that predicts treatment outcomes with community based pelvic floor physical therapy in patients with chronic constipation.

It’s very interesting that we used this [00:22:00] special balloon, and it’s a foam based balloon. As you can see, when it’s deflated, it looks like that, and then you inflate it with water. The benefit of this is that the consistency feels like that of stew. So it doesn’t feel like water or air for the patient, so it’s more natural for them because it has a consistency of stew.

I always believe in going back to the basics before we start, you know, the big guns. So lifestyle, we always start with this, right? Are we drinking enough water? 60 to 80 ounces of water or fluid every day. Are you getting enough exercise? You know, because if you are moving, your colon is moving. Are you having enough fiber in your diet?

Start small. I start with one fruit every day. So I tell the patient maybe have one apple, plum, apricot, any fruit which is like high fiber with the skin for breakfast every day. Start there and see how you do. Because sometimes that’s enough, you know. [00:23:00] And then this is, , something which I always encourage my patient that a lifestyle change, which is free of cost.

And trust me, your patients will be, their ears will be all open. They wanna know what that is. You ask them to drink a big glass of warm water every morning, okay? So there is no, you don’t have to buy anything. It’s free of cost, but it’s so helpful for patients with constipation. What it does is, because the water is warm, it’s going to cause basal dilatation, so it’s increasing the blood circulation to your gut, right?

And secondly, because it’s warm, it’s also stimulating peristalsis. So extremely helpful if the patient is kind of dealing with a slow transit kind of situation. , fiber, I’m especially a big fan of bulk forming fiber, but remember not all fiber is the same. There could be soluble fibers and insoluble fiber.

Psyllium is my favorite. It is also a prebiotic because it’s broken down by gut microbiomes into postbiotic metabolites like starchy fatty acids, [00:24:00] which in turn is helpful for gut, brain, gut, lung, and gut liver access. So extremely helpful, the patients have to drink enough water with the fiber for them to work.

And remember that fiber can sometimes cause gas and flatulence, so not every fiber is good for everyone. So your patients have to try different ones to see which one works best for them. So outlet obstruction, again, we talked about high fiber will work for those patients as well. , because sometimes the sensation in the rectum, as I said, is decreased.

So your job is to bulk up the stool so that the rectum is stretching more than usual. So that they have the sensation that now they have to go. So that’s why even fiber works in outlet obstruction. Sometimes we do warm water rectal irrigation. Biofeedback, very helpful in patients with NSMIS and reduced rectal sensation.

This is something we offer in our office setting as well. , Botox injection into the pubertalis, psycho, psychological counseling, pelvic floor [00:25:00] rehabilitation as I said. Surgery is the last resort, but you have to remember that about 50 percent of your patients will have recurrence of symptoms in six, in four years.

And therefore, again, going back to the basics and doing the basic stuff is more important.

I usually get asked, like, when I’m going to order the MRI. Honestly, whenever you feel that there is an organic abnormality, like you’re thinking about a rectocele, or a prolapse, or intersusception, that’s when you get an MRI. A few words about the laxatives. Osmotic laxatives really works well. Magnesium is one of my favorites.

And the docoset is actually a lubricating laxative, but only use that for a short term. I do not like to put the patient’s long term on that. And laxatives like Senna and Dopset, , they can cause a lot of cramping. So I usually don’t recommend that. And you can use the rectum forms too, if that’s what is preferred.

A few words about magnesium, because I love magnesium, but you have to remember that not all [00:26:00] magnesium salts are the same. So if the patient is having a constipation problem, We prefer to give Magnesium Citrate or Oxide, but some of my patients, for example, my all time favorite is Magnesium Glycinate. And especially in middle aged women, in perimenopausal women, somebody who’s like 50 years old, having constipation, but at the same time they’re having perimenopausal symptoms like hot flushes, anxiety, not able to sleep at night, I always combine magnesium glycinate.

Because it has a very calming effect on the nerves, especially in that patient population. So if you combine Magnesium Citrate with Magnesium Glycinate, in those patient population, you will see significant improvement, not only in terms of constipation, but also relaxing the pelvic floor, because it has a calming effect, the glycinate.

So just a few words about, the medication. So we have Elitesia, Lenz’s, TruLenz, and Multigridly. , I’m just going to say that all of this [00:27:00] works by increasing the colonic transit. So honestly, if you are having a patient with slow transit constipation, you can consider them, definitely. They are peptides.

But remember, we always need to have a discussion with the patient and not everyone is ready to try medications. If by your physical examination and your test you have established that this patient has pelvic dyssynergia or obstructive defecation, you do not want to use this because there is no problem with the colonic transit in those patients, right?

So be very careful because if there is an obstruction and you use this, it can be very uncomfortable for the patients. Again we are not without side effects. Sorry the slide is not very clear, but this is the um. Published in 2007, the side effects of amethysia, like abdominal pain, cramps, diarrhea, flash lens, , lenses, and the true lens, same kind of a side effect.

This is the new kid on the block, IBS Ryla. , it is minimally absorbed, and it’s a small molecule inhibitor of sodium hydrogen [00:28:00] exchanger isoform 3. It is recently FDA approved for iiv constipation. You give 50 milligram twice a day with meals and again, it has side effects, diarrhea, ulence, and oph pharyngitis.

So this is another option that we can use. So as a holistic gastroenterologist, I always try to think out of the box what is it else that I can give offered to my patient because not medication has less side effects and more effective. I’m going to share some of my tools with you. And this is one of my favorites, it’s Triphala.  If any one of you are familiar with Ayurvedic medicine, you would know that this is a very potent herb, which is used in Ayurvedic medicine. It’s a combination of three herbs, Hari Taki, Devi Taki, and Amla. And it’s used in Ayurvedic traditional, medicine for years for treating constipation and inflammation.  I’m very fascinated with Ayurvedic medicine, so if you know about [00:29:00] it, in Ayurvedic medicine, you classify individuals based on their doshas. And the doshas is kind of their personality or how the body works, and there are three types of doshas.

As you can see, Triphala kind of works in all the three doshas. In fact, in India, Triphala is not only used for constipation, it’s also used for weight management. So people use Triphala to lose weight, effectively without any side effects. So I offer this to my patients, usually it’s taken half to one teaspoon, you have to drink it with warm water.

Especially if you are treating constipation at night time, it’s great. , it also comes in pill form. I do like powder form. But if you’re doing the pill, it’s like 750 mg or something like that. But it has no side effects. Very potent. The other one is, use of MCT oil. So, MCT oil [00:30:00] is the same as coconut oil, but it has the medium gene fatty acids, which is more potent because it has 90 plus, as compared to coconut oil.

And how it works, it works by loosening the stool and lubricating the lining of the colon so that it’s easier for them to pass the stool. Vibrating Capsule, this is another service that we offer in our office as well. This was a study that was published by Rao 2023, and it showed that Vibrating Capsule was superior to Placebo Capsule.  It improved constipation symptoms and quality of life, and it was very safe and well tolerated. The patients inject one capsule, for five days in a week. And this study was for eight weeks, and it showed that they, improved bowel movements to one to two bowel movements every week. So the most common side effect of the vibrating capsule was the sensation of [00:31:00] vibration, which 11 percent of the patients felt, but none of them quit the study because of that sensation, so it wasn’t that bad.  So, However, you have to keep in mind that there are some contraindications. For example, you cannot give this, give this in pregnant patients, if the patient is needing a lot of MRI studies, what we recommend is that patients should be able to evacuate all the capsules before they go for the MRI.

And for the same reason, because of obstruction or a diverticulum, you don’t want the capsule to get stuck. So they, you have to rule that out before you give it to the patient. And, , remember that the capsule has to reach the colon. to start vibrating for it to be effective. So if your patient has gastroparesis, that will not be a great candidate because it will not be like, the capsule might start vibrating even before they go to the colon.

So you don’t want to, you want to exclude those patients. And then those are nerve stimulators, pacemaker, and defibrillators. We don’t want to give them those. So the, this is a study showing the benefit [00:32:00] of Nalgimidine, which is a re opioid antagonist in patients with cancer, so more like more opioid or morphine induced constipation have shown benefit with that one.

I’m a strong believer of the brain gut connection, the vagus nerve. So it starts origins, it has an origin in the brain and it goes all the way into your colon. The rectum, however, is innervated by the sacral plexus. However, I do believe that there could be sometimes a miscommunication between the vagus they are not communicating very well, and that can cause constipation.

And as you can see, the vagus nerve can aid in digestion, it can increase gastric juice, it can promote gut motility. So yes, if you stimulate the vagus nerve, your patients with autonomic neuropathy or decreased parasympathetic tone could actually have improvement in constipation. So, this is a stimulator that we also offer in our office, very easy to use, there are several locations.

There is another study which is showing the benefit of [00:33:00] transcutaneous auricular vagal nerve stimulation on abdominal pain and constipation in patients with IBS constipation. So, you can use the vagus nerve stimulation either in the neck or, the yellow circle around the, , in the ear, you can use there to stimulate the vagus nerve.

But do you really need a device to stimulate the vagus nerve? Not really. You can tell your patients to do these things that will stimulate vagus nerve activation like meditation, exercise, singing, massage, cold plunges in Lake Tahoe, splashes of cold water, breath work, yoga, intermittent fasting, and just hugging each other more often is going to stimulate your vagus nerve.

So we have been proving the wrong way in America all along, right? So, the right way to poop is by squatting, because when you’re sitting, the puborectalis muscle has an acute angle, as you can see here. So it’s really difficult for the [00:34:00] stool to go all the way when you have that acute angle. And that angle really becomes straight when you’re squatting.

So I really, for all my patients with constipation, I tell them that they should be squatting, because squatting is the only natural edification process. And we should really be doing this. Sometimes there is a deficiency of bile in your gut and that can cause constipation. And there comes the role of a bile acid transporter inhibitor when I feel like this is the cause because this medication can decrease bile acid absorption and increase the colonic bile acid.

And that in turn is going to accelerate the colonic transit. So this was a study that was published in Practical Gastroenterology by Virginia Schur, , about almost a decade back. And she talked about the Bell’s palsy of the gut. So when you have Lyme disease, you [00:35:00] have Bell’s palsy, which is the paralysis of the seventh cranial nerve, and you have this drooping of the face.

And the similar kind of presentation can happen in the gut, where the nerve endings get paralyzed, and doesn’t move as well. So, in all clinicians with constipation, please ask them about, you know, the history of Lyme disease, like, did they have a history of tick bite, did they go hiking, camping, and had any target lesions?  Because, yeah, the constipation, in Lyme disease is a real deal. There are other studies here which are showing kind of a similar presentation of Lyme disease as constipation.

Dr. Weitz: Could I ask a quick question? Yeah. With respect to bile.

Dr. Sagar: Yeah.

Dr. Weitz: What about the use of herbal bitters to stimulate bile production or using ox bile as a supplement?

Dr. Sagar: Absolutely. Yes, you can definitely use bitters and we use that in our clinic setting too. You can use that to stimulate the production of bile. Absolutely. So use that. But that’s another option that I showed you. [00:36:00] Does that answer your question?

Dr. Weitz: Yes.

Dr. Sagar: Very good. So, not only constipation, but as you can see, Lyme disease can affect other, can cause other GI symptoms like bloating, abdominal pain, irritable bowel movements.  So obviously, keep that in mind, you know, just like whenever a patient with multiple GI issues comes to your clinic, start thinking about Lyme disease as well. Leg poisoning is another one, , it can cause constipation, so any patient with constipation I always check their venous leg levels, to see if, leg toxicity is the cause.  Autonomic neuropathy, again can cause constipation, and the treatment is really sacral neuromodulation, so in patients with Parkinson’s disease and Alzheimer’s disease we have to think of that. And then the gut microbiome. This is really important because they are the keystone species in the ecosystem.  And, these are the organisms that really help define an entire [00:37:00] ecosystem. And not only the gut, but several organs in your body have microbiomes. including your hair, nostrils, skin, vagina, oral cavity, esophagus, the composition of the bacteria is very different. For example, in your skin there is more actinobacter as compared to your colon which has more bacteroids and fumigators.

So it’s very different. It’s like really a whole ecosystem there. However, the gut microbiome is affected by a variety of things. It can be affected with your diet. We recommend a high fiber fermented diet if you want to improve your gut microbiome. It’s also related to physical activity. Use of antibiotics is going to affect it.

Hormones, for example, if a woman is on oral contraceptive pills, it’s going to affect their gut microbiome and cause constipation. Stress, because when you’re stressed out, the gut releases CRF. which increases the cortisol level and down regulates your immunity, and thus making you more prone to, stent infections.

Early [00:38:00] life trauma, if you have pets, the use of prebiotics, heavy metals, and, , you know, the pesticides, like glyphosate, all of this can affect your gut microbiome. This is a very small list of what a disruption of gut microbiome can do to you. I don’t have, this is beyond the scope to kind of list everything, but this is just a small list.

And really, when you have a disrupted gut microbiome, which is producing a lot of methane, there is an immune dysregulation that happens and immune suppression associated with vector like Borrelia, Balesia, and Boltonia can happen. For example, if you have, a methane producing bacteria, retinobradylbacter smelii, that is really linked to constipation, and that methanogen can also be seen in colon cancer, in colonic polyposis, in ulcerative colitis, and in diverticulitis.

Dr. Weitz: Can I, can I ask another question? Yeah. Methanobrevibacter Smithii, so [00:39:00] that shows up on a stool. We, we do a lot of GI map stool tests.

Dr. Sagar: Mm

Dr. Weitz: hmm. And methanobremy factor shows up.

Dr. Sagar: Yeah.

Dr. Weitz: Ideally, it should be below detectable levels, but very frequently, it’ll be above that. It may not necessarily be in the red.  Is that something that we should be concerned about?

Dr. Sagar: Very good question. So we never look at one thing only, right? Of course. So it’s always a whole clinical picture. Whenever we have a patient like that, you have to see what are the symptoms. Are they constipated? Are they bloated? Do they have a rash? Do they have food allergy? I would probably do a SIBO test.  I’ll probably look at the gut microbiome. I’ll look if they have leaky gut syndrome. So a combination of all of that. And based on what you found, we are going to treat that. We never usually give antibiotics targeted to just that bacterial, but yeah, if you have a clinical picture of SIBO or SIFO or leaky gut, then we do address that.

Dr. Weitz: Right, because there’s a bit of a [00:40:00] controversy now about methane SIBO or EMO because now it’s recognized that it can exist not just in the small intestine, but in the colon as well.

Dr. Sagar: Yeah, it can. 

Dr. Weitz: And the question is, you know, is seeing methanobrevibacter smithii on a stool test, can that be used to diagnose methane SIBO?

Dr. Sagar: I would say it would support the diagnosis, but you have to obviously combine that with the breath test and the clinical picture. But for example, , a load of, like when I’m talking about bloating and constipation, so everything is assigned and then you have to combine those, , the points that you’ve collected to make your clinical judgment.

Speaker 8: Right.

Dr. Sagar: So if you see something like that, definitely that’s going to alert your mind to see if this is like, aha, Methane, SIBO, and you’re probably going, it’s going to prompt you to do further testing, like a breath test, for sure.

Dr. Weitz: Okay. When you do the breath test. Do you recommend three hours or two [00:41:00] hours?  We do it for three hours. For three hours, okay. It’s alright, it’s two hours. Two hours. Two hours. Yeah. Because there’s this whole issue, how do you diagnose, , methanoprebi bacter overgrowth, EMO, in the colon? So we would either need a stool test or we would need a three hour breath test.

Dr. Rhabar: I don’t have a microphone, but I speak loudly.  I mean, as you put everything together, it has never been a necessity to check the colon. I mean, I’ve talked to other GI doctors. I don’t find it very helpful to go to three hours just to look for excess methane. There would be some other indicators that methane could be a problem. The other thing I think it is probably going to touch base, is that methane will be back to its beauty age.  Methane will be a killer. You know, microbe. Okay. And, , you have to remove the oxygen from the gut environment. And generally when you see this all way, look for a fungal marker. You’re going need to sit on organic acid. You’re [00:42:00] gonna see it on the same GI map you’re gonna see on stool culture. You’re gonna see fungal antibodies, is all the clinical picture basically speaks of that scenario.  And just as another commented, I practically would never treat a SIBO with methane directly. Targeted towards the SIBO, we generally target the fungi first before you attack the methane, okay. Because the potential for giving antibiotics and switching the microbiome to a more fungal predominant is very high.  And if physicians follow the patient, they’re going to see that the effect of the benefit from the SIBO treatment is generally temporary. It’s going to come up with some other recurrence if the fungus is not addressed.

Dr. Weitz: , Sunomidressum can currently address the fungus first with something like Nystatin or

Speaker 11: would

Dr. Weitz: it?

Dr. Rhabar: Well, I mean, there are many ways to address that and it probably is another hour or two to have a discussion. Yeah. , but the short [00:43:00] version is that we treat the fungi first with Diatin, the antifungals that would be appropriate for that patient. Biofree musters. And then if we plan to treat the SIBO, then I usually keep the patient on an antifungal concurrently.  Otherwise, in my experience, you’re going to get a microbiome switch. You’re going to you’re going to have fungi have more accuracy because of their behavior. And you know, even though some of this is not completely U. S. literature, but there’s information out there from the Europeans that we have

Dr. Weitz: to

Speaker 11: get through.

Dr. Weitz: What’s your favorite biofilm busting strategy?

Speaker 11: How about we let you finish up the presentation? 

Dr. Sagar: I have a tweet for you at the end.

Speaker 11: Okay.

Dr. Sagar: Because you asked me that question.

Speaker 11: Thank you.

Dr. Sagar: Alright, so let’s get back here. So we have, we always have those patients who are constipated and they’re also bloated, right?  So that’s like a perfect combination. [00:44:00] But remember that not all bloaters are the same. And how do we differentiate that? So you could have some patient who would have constipation and bloating, but they will also see that I always have rumbling, like my stomach makes so much of noises that my partner who is sitting across the table can hear that, right?  And then when you put the stethoscope into the belly of that patient, you’re going to hear a lot of noises. As compared to silent bloaters, where they would see that they are pretty big, like bloated, But they don’t hear anything, like there is no rumbling, and when you put your stethoscope into the belly of those patients, it’s pretty silent.

So that tells you that probably the colon is not moving as well as it should. So it is probably a slow transit. Again, there could be an upstream problem, because the classic definition of SIBO is abdominal pain, bloating, constipation, and diarrhea. So, [00:45:00] if you have a patient who is constipated and bloating, I do recommend doing the SIBO testing.  And, again, a huge list of things that, , would indicate a SIBO breast test, including constipation. And I wanted to bring your attention to this, the yeast, , function, because when you have a fungal overgrowth of the yeast, um and Overgrowth, that can drive a Th17 response, which can sometimes protect from pathogens, but when you have a disregulated Th17 response, it can cause inflammation, it can cause leaky gut, it can upregulate the immune system, and cause autoimmune conditions and, , constipation as well.

So, we are going to have, a case presentation, just to kind of keep up our interest. So I have a very lovely 40 year old female who presented with multiple GI symptoms. She had indigestion, constipation, dyspepsia, flashlights, malaise, fatigue, [00:46:00] distention, so she was bloated, she had nausea. When we did the breast test, she had a methane sequoia test, which was abnormal, and then when we did the food allergy testing, she was allergic, she was allergic to multiple food items.

We did the Heidenberg gastric pH testing which showed some bile reflux and pyrolytic insubstituency. This stool test showed some Klebsiella, so she has a dysploric, , gut microbiome, and there was some candida in the stool as well. We did the urine mycotoxin screen and she was, , highly abnormal. The gluotoxin levels were 18 times that of the normal.

The live screen was positive as well. This is her endoscopy picture and this is the stomach. Usually, the stomach should not have this yellow stuff. So this is bile. When you see that, it means that there is a bile reflux and bile really has no business in the stomach. It is supposed to be going into the small [00:47:00] bowel and downstream from there.

So this patient, just to make you understand, the bile is produced over here. So, for the bile to go back into the stomach, it has to pass the pylorus, and usually that’s not the normal route. The bile should be produced and go down over here. So whenever you have a case like this, where a patient has bile reflux and constipation, the upper GI and the lower GI, you really have to target the middle man here, which is the small bowel.

So, this patient was treated for SIBO, for fungal overgrowth, and she was also treated for SIBO. With that treatment, her constipation significantly improved. And there was a special thing that we used on her, which did not only address the C4, the bacterial fungal overgrowth, but also the constipation. So to answer your question, we used Diamethaceous Earth in her case.

So Diamethaceous Earth, not only helps with the C4 treatment [00:48:00] because it’s a biofilm buster, but also with constipation. So what is Diamethaceous Earth? Well, we all love the ocean in Southern California, right? So when you go to the ocean and you look at the bottom of the ocean, there are these dye atoms and there are these crustacean organisms which were made into food grade and used as a biofilm.

So it kind of detoxifies the colon and cleanses it. So, the biofilm is disrupted and also it helps patients with constipation. So this really helped our patient therapy. So take home message is always do a thorough rectal exam in all your patients with chronic constipation. We have to stop thinking about pelvic dyssynergia because it is very common and underdiagnosed.

We have to consider balloon expulsion test with anorectal manometry in all our patients. It’s going to help you differentiate slow transit from obstructive defecation. Constipation is a very common problem and sometimes you, it’s a distractor, that [00:49:00] means there is something else going on with the patient and they present as constipation.

So we have to wear our detective hats and get to the root cause of what’s causing the constipation. And SIBO whenever you have a patient with abdominal pain, bloating, constipation, diarrhea, food allergies. Methane SIBO is associated with agonist constipation. And if you have a negative febrile test in patient with bloating, bile reflux, and IBS constipation, it may indicate the presence of a fungal overgrowth and febrile.  Thank you so much for your attention. And with that I’ll come to the end of my presentation. I’ll be happy to take any questions, but I know that Michael has prepared some slides for anorectal manometry too. So in the interest of time, I’ll have him come over and do his presentation.

Michael: Thank you for being patient.  And I’m Michael [00:50:00] Erdman. I work with Dr. Sagar and Dr. Rahbar and I’m going to give a very brief talk on anal rectal manometry because that’s what I do in the office. And it’s very interesting when you have certain cases of chronic constipation, it’s a very useful tool. So the purpose of my little brief talk is to, make you very aware of why you should refer some of your patients for this test.  that’s the button there. So brief objectives, basically just to, you know, get that message across the importance of ARN. And pretty much what Dr. Sehgal was saying, you know, one in three patients with the first line treatments for chronic constipation failed treatment. They’re the ones that you start thinking about, you know, The indication of, you know, wanting to assess their pelvic floor and to get them a anal retinometry so that you can see if they have a functional defecatory issue.

And why? And it’s basically because laxatives and fiber [00:51:00] therapies are not as effective as biofeedback and pelvic floor physical therapy. John’s already gone over this, so I’ll skip past it. and also the buzzwords in a clinic, the digital facilitation of defecation. These things you always think, anal rectal manometry, pelvic floor, physical therapy, and biofeedback.

The detailed rectal examination can actually pick up about 70 percent of cases of dyssynergia. And that’s what an ARM machine looks like. And these are the types of tests that you, , the ways that you can analyze a patient’s, , issues. So the first thing you look at with ARM is the anal sphincter pressure.

And then after that, their ability to squeeze and how effective the sphincter is at doing that. , the next thing would be looking at the myenteric plexus, and the recto anal inhibitory [00:52:00] reflex, which is abnormal in patients with Hirschsprangs, for example. The sensory motor response with hyposensitive patients that have a distended rectum.

Rectal compliance, which is, , something that you see, , that’s all about the pliability of the rectum, and whether, , , for example, elderly patients have a stiffer colon, and, , patients with Hirschsprung’s, for example, would have a more distended rectum. And then there’s the defecation tests, which is all about disinertion defecation, which is the really interesting bit.

So this is pretty much what you’re dealing with with ARN. You’re looking at a lot of, a lot of graphs. And there are four balloons attached to this catheter and they’re positioned posterior, anterior, left and right of the internal anal sphincter. And they’re color coded and then the colored heads come up on a graph.

So. When you ask a patient to squeeze, you’ll see the activity of [00:53:00] that and you’ll see the anal sphincter response. So a squeeze initially is a biphasic wave pattern. There’s initially a big spike, and then there should be this prolonged duration when you ask someone to try and squeeze for 20 seconds. If they have problems with incontinence, they’re not able to do that.

This is actually a reasonable squeeze pressure. It’s not too bad. This is a much better squeeze pressure. It’s not entirely symmetrical, but they can sustain it for 20 seconds, so that’s totally normal. So these are the kind of things I want you to see with what the, what the testing is for your patients.

Someone who has a low squeeze, , that’s a very poor effort of a squeeze, can be poor compliance. Then you start thinking neurological problems, damage to the sphincters. If it is poor compliance, they do well with biofeedback, which is something that we offer in the office. Whenever you look at someone’s ability to squeeze, you look at the cough reflex as well because [00:54:00] you see them together.

So a cough reflex, when someone, when you ask someone to cough, the abdominal pressure rises and then the anal sphincter muscle contracts. So it’s intact, with patients that have upper motor neuron lesions, and then it’s not if it’s a chordaequine lesion. So when you look at someone who has a poor squeeze and a normal cough reflex.

you think it could be poor compliance, or it could be a central motor pathway issue. And then the other way around, it would be, if it’s a poor squeeze and there’s no cough reflex, then you think an issue, for example, with the sacral reflex. This is a very high squeeze. Now, you see this in male patients that have chronic pelvic pain.

When they have a high squeeze, they usually have a very tight anus. I said that on camera. And, , you see that and typically they also have type 1 dyssynergic defecation, which is something that I’ll [00:55:00] show you. Rectal sensation is another part of the test. This is your ability to see how your patient has, what they can feel, as you inflate this balloon inside them and the balloon gets bigger and bigger.

And you say, let me know when you first feel it. Let me know when it gives you a desire to have a bowel movement. Let me know when you can’t take it anymore and you need to run to the bathroom and let me know if you have any pain. If they have pain, you stop. This is an example of someone who’s actually hypersensitive because they had a desire to go, and then with a very similar pressure, they had urgency.

You use this test to look for hyposensitivity and hypersensitivity. Hyposensitivity, they would not be able to recognize two of these sensory tests. For example, if they can’t feel anything in the beginning, you see that with diabetes. If they don’t feel a desire for, or urgency, for example, that’s with [00:56:00] constipation.

So I’ll skip this bit. , the sensory motor response. That’s when you inflate the balloon. Someone should have a urgent desire to go to the bathroom. If they don’t, that’s a sign of hyposensitivity. And then the myenteric plexus, which is that the neurons and ganglia in between the longitudinal muscles and the circular smooth muscles that work with peristalsis.

There’s a lovely test with the A RM, which is the recal anal inhibitory reflex. When you inflate the balloon, what you should see is a relaxation of the internal aim sphincter, and this is how it looks. So you have a nice increase in the rectal balloon. You know, it’s been pumped up here. and then you see a decrease of all the anal sphincter muscles.

This is a very good example of an intact rectal anal inhibitory reflux. And that’s how it also shows itself with ARN. It’s the same way. You can see all the internal anal sphincter muscles [00:57:00] relaxing at that point there. Compliance. This is all about, like I was saying, the kind of ability for the, , , rectal space to.

accommodates the increase of the stool in that zone and it changes as we get older and also with scarring to the rectum and it’s, , there’s actually a higher compliance with megarectum and faecal impaction. And then this is what dyssynergia looks like, which is really what our talk is all about, in regards to ARN, so What should normally happen is you ask someone to push when they try and poop, they push, and then the anal sphincter muscles relax.

So this would be a normal looking defecation on ARN, and this is how it would look on, on the report. Dyssynergic defecation, there’s four types. The [00:58:00] first, this is type one. It’s where you ask a patient to push and they can push really well. that the anal sphincter tightens up, right? So the pressure rises instead of falls and that’s, that’s very abnormal.

Type 2 at the top would be they don’t have a very good push and the anal sphincter muscle tightens up inappropriately. Type 3, They have a very good push and the sphincter doesn’t really tighten up. It doesn’t really do anything at all. And then type four, nothing’s working. You know, they can’t push and they can’t relax the anal sphincter.

So this is a case that I had where a patient came in with a hugely abnormal squeeze pressure reaching, you know, 300, , points on the squeeze, which is super high, like really damage your finger on a retinal [00:59:00] examination. And he was very proud of that. And then, , you know, when you, when, when he did his dis inertia defecation test and I asked him to try and replicate having the bowel movement, the balloon inflates.

And as it, as he’s pushing, you see the anal sphincter muscles are rising as well. So this is type one. Dyssynergic defecation. So if I go back to where we were, that’s what we’re looking at here, right? So you had a type 1 dyssynergic defecation with the balloon inflated and not inflated. So he was, he came back and had biofeedback with us.

Biofeedback is very similar to ARN. They look, they can look on a screen so they can see they’ve got a catheter in the bottom and they can push and when they push they can see the rectal pressure rise. and they can also play around with their pelvic floor and try and work out how to make the anal sphincter relax.

The first time he [01:00:00] came in was on the left, and you can see this was after multiple rounds, he couldn’t quite get it. On the third session, he came in with a higher anal sphincter pressure than he did on the first, the first attendance, but he had a perfect correction of his dyssynergia. Which is amazing, you know, and these, these are patients who have huge problems pooping for a very long time, right?

So, moments like this are great, and that’s the benefit of anal retinometry, that’s the benefit of biofeedback. Typically, they do much better when they have pelvic floor physical therapy at the same time. And so, then the balloon expulsion test we’ve already gone over, and I’ve already mentioned this, And Dr.

Sehgal already mentioned this article, but what was interesting, in addition to what’s already been said, is it also mentions the importance of paying attention to squeeze pressure, squeeze duration, [01:01:00] especially with an abnormal balloon expulsion test. It indicates a very good response to pelvic floor physical therapy and biofeedback.

The problem with the reports is it’s very, it can give you a mental block trying to figure out what’s going on. So Dr. Rabar and I, a couple of years ago, had had enough, and we came up with our own version, which, so now whenever people come to see us for ARN, we send them home with a lovely report. It goes to the practitioner.

Any questions you can get in touch with us. And it’s very informative so much so that the company, , Purchase the report from us as well. So now everyone has access to it, but it’s another way, a very informative way of understanding the outcome of your patients that you refer. So just to clarify once more, chronic constipation cases that fail that trial, [01:02:00] you think ARM, balloon expulsion testing, because it’s thought that there’s 50 percent of these cases out there that are actually functional, , dyssynergic problems, and only 2 percent are tested with anal retinometry.  The most important thing is getting these patients the treatment that they actually need. Biofeedback, pelvic floor physical therapy, that’s what it’s all about. As rapidly as possible. And treatment, you can actually help dyssynergia cases up to 90 percent of the time. So, it’s very valuable. And that’s actually the end of my talk on Anal Rectal Manometry, and I just came up with that.

 

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Dr. Weitz: Thanks 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, cardiometabolic 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.