Scott Webb (Host): If you've ever wondered what the difference is between Irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD), this is the right podcast for you. I'm joined today by Dr. Eric Steinberg. He's a board-certified gastroenterologist practicing at Franciscan Health.

 This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, it's nice to have you here today. We're talking about IBD and IBS, so that's inflammatory bowel disease and irritable bowel syndrome and, you know, what they are, what are the differences? How do you, diagnose, how do you treat, all that good stuff. So just as we get rolling here, what are the risk factors for each of those conditions?

Dr. Eric Steinberg: The risk factors for inflammatory bowel disease can be other autoimmune diseases or, traditionally, Crohn's disease was thought to be almost exclusive in Ashkenazi Jews. And now, we find it in all populations really. But for the most part, irritable bowel syndrome can occur in any individual. It is a syndrome of unhappiness with your bowels and how they work. So, there's no specific group of patients that have irritable bowel syndrome, although some populations, some countries have different frequencies of irritable bowel syndrome. For example, in India, males tend to have more irritable bowel than women. And in our country, women tend to have it more than men or maybe are reporting it more than men. We're not really sure.

Host: Yeah, I do find that, Doctor, that sometimes it's hard to know, is it that you know one population has it more or do they just go see the doctor more? Do they just report it more? So, hard to know for sure, but it makes me wonder like what are the conditions that affect our bodies and gut health when we think about both IBD and IBS.

Dr. Eric Steinberg: Well, diet has a lot to do with it, obviously. And there's some concern that our diets have changed in the last 50 or 60 years to a point where they are altering our natural microbiome that the bacteria that exists happily in our colon are being affected by the foods we eat. And that's being explored with research. And it's not uncommon for us to have a patient modify their diet to improve their symptoms. But I think that, also, we know that smoking affects inflammatory bowel disease a great deal. Certain dietary practices should be avoided in inflammatory bowel disease. So, probably, the biggest factor that affects both these conditions is what we eat.

Host: What do they say, doctor? We are what we eat. And you've used the word sort of happiness or unhappiness, especially related to IBS. And knowing some folks that have IBS like my son, that's how he would describe it. Just sort of unhappy bowels with him and maybe food choices that he's made. So, let's talk about diagnosis. Is this, you know, patient history? There's some tests involved. Like, how do you diagnose?

Dr. Eric Steinberg: The diagnosis can be very elusive for a lot of these conditions. And they're actually quite different in their pathophysiology, meaning-- it's a big word-- but it basically means the way that the body is reacting to certain stimuli and the way the body reacts to the environmental triggers. For example, inflammatory bowel disease, it is an inflammatory condition, meaning that the colon itself is inflamed. If you look at it, it looks like a sore throat almost. It's red, it's angry, it's unhappy. But irritable bowel syndrome, the colon looks essentially normal and doesn't really have anything that is obvious even on biopsy to suggest that there's inflammation. So, there's a pretty big distinction.

It's unfortunate that the nomenclature is IBS versus IBD, it's a different set of letters, but it's actually an enormous difference in conditions. Very confusing for patients, because, you know, it seems like alphabet soup to them. But the fact of the matter is they are very unique conditions. You can have irritable bowel syndrome if you have IBD, but you generally don't have IBS and have inflammatory bowel disease, meaning that patients who have this inflammation can have the same symptoms of irritable bowel syndrome and, even after we treat the inflammation, continue to have symptoms of irritable bowel syndrome.

But if you have irritable bowel syndrome, generally, the implication is that you have excluded other conditions and it's a diagnosis of exclusion. So that if you have irritable bowel syndrome, you generally won't have any inflammation in your intestines.

Host: Yeah. And it's good that we have experts, you talked about diet earlier. I also want to talk about stress. So, maybe diet, stress and the roles that they play in helping us to manage these conditions.

Dr. Eric Steinberg: Well, both conditions are triggered by stress. Stress can alter the immune system and the inflammatory response. And so, patients who have stress are possible patients who have exacerbation of their inflammatory bowel disease. But stress is a major player in creating irritable bowel syndrome symptoms.

In fact, patients who have anxiety, patients who have a lot of mental unsettledness can have this so-called brain-gut axis disconnection, meaning that there are nerve fibers within the intestines that are sensitized to things and signals coming down from the brain, and it alters motility and the functional ability of the bowel to do what it's supposed to do, which is pass things along almost like a conveyor belt. So, it jams up the conveyor belt, if you will, and causes this problem.

So with that said, you asked about testing and there's a variety of different tests. Blood tests, stool testing and, of course, a colonoscopy, are helpful. But getting a good history is important. We know that patients with irritable bowel syndrome have a lot of psychosocial unrest at times. And it's not uniformly the case, but it's estimated that up to over 40% of patients who have advanced irritable bowel syndrome, meaning that it alters their ability to perform their daily activities, have had some sort of childhood abuse or even sexual abuse that is affecting their gut in sort of a devastating way.

Host: Yeah. Yeah, I've done podcasts on that, Doctor, the sort of the brain-gut connection, if you will. And that's maybe beyond the scope today. But good to understand that all of these things could exacerbate IBS or IBD, be it stress, diet, smoking, all of that, childhood traumas perhaps. So then, let's talk about what we can do at home as folks who may have been diagnosed with one or both, perhaps, to sort of prevent flareups.

Dr. Eric Steinberg: Well, obviously, diet has a great deal to do with it. And for my patients who have inflammatory bowel disease, I usually recommend a low-residue diet, meaning that the gut is already inflamed and unhappy with having to work extra hard so that a low residue diet is actually preferred. Unlike what we normally tell people, we generally want them to have more fiber in their diet. In patients who have inflammatory bowel disease, we want them to actually have less fiber in their diet, so their intestine doesn't have to work as hard through an inflamed condition.

Now, IBS is a little different. We actually want them to have fiber because we feel that that for a lot of patients promotes more regular bowel movements and reduces the length of time that things are not moving if they have a component of irritable bowel syndrome, which is constipation, and patients who have diarrhea, we'd sometimes even encourage fiber to pull water, to absorb water and to help bulk up the stool. So, it depends. And then, fiber supplementation is something that many patients, that's one of the first questions they have, is which fiber supplement should I take? And I usually say avoid cilium, which is metamucil in favor of things like citrucel, which is a synthetic fiber supplement, it's methylcellulose that produces less gas. And for a lot of the patients who have irritable bowel syndrome, the big issue with them isn't so much the altered bowel habits as much as the bloating and the gas that they experience.

Host: Yeah. It feels to me, Doctor, like this is a major quality of life thing for a lot of folks and that maybe they don't seek medical attention when they should or in a timely fashion. So, what would be your best recommendation then? Like, when is it time that we reach out to someone like yourself?

Dr. Eric Steinberg: Well, I think if it's altering the patient's ability to function, meaning that they can't go to work, they're missing time from work. In fact, irritable bowel syndrome is one of the more common reasons why people do not attend work. But more practically, there are red flag signs that would make you want to see a gastroenterologist more quickly, unexplained weight loss, profuse diarrhea, blood in the stool.

Other things, some people can develop nutritional deficiencies. For example, one of the things that we're taught or what the American College of Gastroenterology encourages in patients with irritable bowel syndrome before making the diagnosis, one of the first diseases we should exclude is celiac disease, which is a fairly common disease in the United States. And it can lead to nutritional deficiency, including iron deficiency. So when we have a patient who has iron deficiency, even if they're not really having any major symptoms and they have no other reason for losing iron, such as a severe menstruation in women. We want to explore that and do some additional testing to evaluate for these conditions. So, to answer the question, there's a lot of data that you have to provide for the provider to help guide not just how you treat them, but also how you diagnose them.

Host: Right. Yeah, let's talk about that. Let's talk about treatment. We've talked about things we can do to help ourselves, right? So, eat better, eat different things. Obviously, quit smoking, manage our stress levels, those kinds of things. But in general, maybe you can take us through sort of the path of treatment for most folks.

Dr. Eric Steinberg: Well, for inflammatory bowel disease, the treatment is trying to reduce inflammation. This unexplained miscommunication of the immune system to recognize the gut as something foreign, meaning that you're having a reaction, almost like you are rejecting a transplanted organ. And so, part of the immune suppression is generally to try to calm down that miscommunication.

Now, there are other medicines we use. There's a certain type of medicine called a mesalamine, it's a local anti-inflammatory. And it works fairly well for a type of inflammatory bowel disease called ulcerative colitis, not as effective for Crohn's disease, which is a different but sister disease in that it's also immune-mediated.

And so, we have a variety of different medications. But again, it's designed to reduce that inflammation, that angry, unhappy intestinal wall. As opposed to irritable bowel syndrome, where the intestine is not inflamed in any way, it's just squeezing in an odd manner. It's either it's sluggish or it's overactive and it's causing discomfort. Because of the huge variety of different presentations for irritable bowel syndrome, they've developed criteria to define irritable bowel syndrome. They call it the Rome criteria. And I think what it was, was a bunch of gastroenterologists wanted a trip to the Vatican and wanted a little time with in Rome, so they chose that place as the place where they would make the decisions on how to define irritable bowel syndrome. And the practicality of it is what they wanted to do is have some criteria to enroll patients in studies. So, these studies could be used to find treatments and to explore effective, drugs that might help. So, there's very sort of stringent rules to diagnose it in the true sense of the Rome IV criteria. But they're more or less to enroll patients in studies. And a good clinician can probably detect an irritable bowel syndrome just by history alone.

Host: Yeah. It makes me wonder when we think about, like, is it possible for us to prevent, you know, either or both of these in ourselves? You know, is there a family history, genetic component to IBS and IBD? Like, what can we do to never have to suffer from either of these?

Dr. Eric Steinberg: For inflammatory bowel disease or IBD, we believe about 15% of patients have some genetic predisposition, meaning that if your aunt had Crohn's disease, you might end up with ulcerative colitis or Crohn's. But the majority of patients just don't have that family history. For irritable bowel syndrome, what we believe is it's more of a learned behavior, almost if somebody says, "Oh, it runs in my family," we haven't really found that there's actually a genetic relationship of irritable bowel patients, but that there's sort of a learned behavior. In other words, if a child wants attention, it says, "Mommy, my tummy hurts" and gets that attention, that almost reinforces-- I'm not going to say to ignore it, but that is a common way that some people go on in families to, you know, sort of continue this irritable bowel syndrome. Of course, it's such a common condition. And then, there's certain, you know, social and economic factors that affect whether or not you have a risk for irritable bowel syndrome.

What we don't know yet is does the increased use of antibiotics that's seen more frequently we're giving out antibiotics to young kids that probably have viral infections nowadays, just because we want to give them something, we're trying to stop that. But could that be affecting gut flora, the microbiome there, the little world of bacteria? Could that be altering how they function within the host, within the patient? So, lots of information there we still don't know.

Host: Yeah. And I'll just give you a chance here, Doctor, at the end, you know, we're kind of covering the headlines and the basics today, but final thoughts, takeaways for now on IBS and IBD.

Dr. Eric Steinberg: Well, I think with both conditions, you really have to have a good relationship, a trusting relationship with the provider. But I think a lot of it is also , there are so many factors in treatment, for both conditions, not just the patients understanding of the disease, but also we have this other as providers, this enormous problem where we try to partner with insurance companies to get certain medications for treatment, not just for inflammatory bowel disease, although there are great new medicines out there. But even for irritable bowel syndrome, there are several medicines that are available that we just can't get through insurance companies very easily and it frustrates the patients. but some of my office staff will be on the phone for two, three hours trying to get approval for a medication. And that's really a challenge for, I think, everyone in the business right now, not just in Gastroenterology, but in every form of medicine. We hit so much resistance. So, that's a real challenge for the patient.

And I think also patients have to take a certain ownership, modify their diet, reduce their tobacco consumption, and listen to the doctor. Avoid things like NSAIDs, like Advil, motin, ibuprofen over-the-counter, unless you absolutely have to. Those things can trigger various reactions within the gut that are undesirable.

Host: Yeah, obviously, things that we could do ourselves. So, it starts by, you know, reaching out, seeing a specialist, going through the process of diagnosis and treatment, and then doing things to help ourselves, whether that's behavior, lifestyle, eating habits, smoking, whatever it might be. Good stuff today. Thank you so much.

Dr. Eric Steinberg: You are very welcome.

Host: For more information, please visit franciscanhealth.org and search IBS or irritable bowel syndrome. And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.