Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field.

I'm Melanie Cole. And today, our discussion is focusing on GI motility and Neurogastroenterology. Joining me is Dr. Saad Javed. He's a gastroenterologist with the AHN Medicine Institute. Dr. Javed, it's a pleasure to have you with us today. We're all familiar with Gastroenterology. It's a vital specialty, but can you elaborate what really is a motility disorder?

Saad Javed, MD: Hi, Melanie. Thank you so much for having me. So, broadly defined, any alteration in the transit of gastrointestinal contents and secretions can be considered a motility disorder. Whatever the cause, the result is this loss of coordinated muscular activity in our digestive system. And this can lead to movement of food or stool that is either too fast or too slow.

I would like to highlight that symptoms attributed to suspected motility disorders are the most commonly reported symptoms in our field. Interestingly, these symptoms like dysphagia, bloating, nausea, vomiting, chronic constipation, chronic abdominal pain, chronic acid reflux, incontinence, et cetera, can affect about 40% of the population in the U.S.

Melanie Cole, MS: Wow, that's quite a statistic. So because there are so many motility disorders, and as you just mentioned, they're affecting such a wide reach of patients. So, do we have any idea of what causes these?

Saad Javed, MD: There really isn't a short answer to that question. Over the past few years, our understanding of these motility issues has rapidly evolved. We now know that certain driving factors behind these issues can include immune-mediated abnormalities. Recent infections have long been known to affect the motility of our digestive system. Psychosocial factors like our mood, our eating behaviors all have been implicated. Drugs like narcotics and marijuana products affect the way our gut moves. In addition, our genetic composition and our interactions with the environment, and of course, our own gut microbiome have all been known to influence these disease processes. And in addition, motility disorders also have a significant overlapping association with certain chronic illnesses like Parkinson's disease, diabetes, Alzheimer's, dementia, aging, and so on.

So in summary, Melanie, the interplay of mind, body, gut in many complicated ways can adversely affect the motility function of our stomach and the rest of our bowel function.

Melanie Cole, MS: Wow. We are sure learning a lot lately, Dr. Javed, about the autoimmune system, GI, the gut microbiome, the brain and gut connection. I mean, it's really just moving quickly. We're learning so much. And it is so interesting when we think of the environment. So, the other half of your subspecialty is Neurogastroenterology. Now, please explain that to our clinician listeners. What that entails is this a relatively newer area of science and subspecialty, because it's not very talked about.

Saad Javed, MD: I think you are getting the gist that our brain and our gut are very deeply and richly interconnected. And the dysfunction of this integral, what we call gut-brain axis, is what the field of neuro GI deals with. You know and I know that when our mind is upset, your gut gets upset. And when your gut is upset, your brain gets upset.

So, we as neurogastroenterologists are acutely aware that, in addition to imposing a heavy burden of illness, these disorders are complicated by decreased quality of life and work productivity, depression, weight loss, isolationism. And unfortunately, they're often ignored because of a lack of understanding of the disease mechanisms, lack of understanding of diagnostic approaches and appropriate therapy.

So actually, as early as the 11th Century, the philosopher and physician Ibn Sina, commonly known in the West as Avicenna, noted and documented this deep connection between emotional status and our GI distress. And in morden medicine, the gut-brain axis was more formally reintroduced as early as the 1880s. And finally, more concrete evidence of this axis began to accumulate only in the late 20th Century among researchers.

Melanie Cole, MS: So, it's been around more than we would necessarily think when we talk about this gut-brain axis dysfunction that you are discussing. First, I'd like you to speak about some of the diagnostic tools that you can use to help diagnose these varied symptoms because. We know that the symptoms can be so varied. They can be everything from fatigue and dizziness to stomach issues and incontinence, as you say, and bowel issues. I mean, the list really does go on. Even brain fog is involved. So, speak about how you diagnose this because it's very complex.

Saad Javed, MD: Absolutely. So, accurate diagnosis of these complicated motility disorders depends largely on clinical expertise and the availability of certain technologies. For example, at Allegheny Health Network, the modalities that are routinely involve in the diagnosis of these conditions can include endoscopic evaluation, radiographic imaging, nuclear medicine, gastric emptying scans, high-resolution esophageal manometry, high-resolution anorectal manometry. We also are able to test for bacterial overgrowth through breath testing. We're able to do wireless testing to evaluate for patient's acid burden and so on. So, a deep knowledge of these technologies as well as a good understanding of our patient's predominant features and symptoms and their biopsychosocial conditions leads us to make a concrete diagnosis.

Melanie Cole, MS: Well, certainly a complete history is so helpful. Now, talk about treatment, Dr. Javed. How are these disorders of motility and the gut-brain connection? How do you treat these?

Saad Javed, MD: Yeah. So Melanie, we work hard at not only trying to identify the root cause of our patient's illness, but also find the most suitable treatment options. A diverse spectrum of treatment options range from dietary management and interventions like cognitive behavioral therapy; neuromodulators, medicines that have historically been used in the niche of Psychiatry and Neurology, we borrow these medicines like antidepressants and anti-anxiety medicines to our benefit. Social and behavioral health support plays an important role in the treatment of gut-brain axis dysfunctions. All of this is an addition to pharmacological therapy. If not complete resolution, our goal is to always engage in a very holistic approach to improve symptoms of debilitating dysmotility, resolve the root cause if possible and, in turn, enhance the patient's quality of life, their sense of wellbeing, and their capacity to engage in everyday activities. Every patient is different. Their presentation, their clinical history varies, and every single patient requires and warrants a tailored approach.

Melanie Cole, MS: Well, it certainly is interesting, complex, and so many advancements in your field now, Dr. Javed. It's really an exciting time in the GI world. And as we think of motility disorders and GI disorders, IBS comes to mind. It's really common. Can you speak to other providers and clinicians about irritable bowel syndrome, causes, management? I'd like you to even speak about who it seems to affect the most, because I've seen girls in their 20s and 30s, I mean, I have just seen the gamut of patients with IBS.

Saad Javed, MD: Absolutely. Thank you for bringing that up, Melanie. April happens to be IBS Awareness month, so this is very topical and very much a timely talk. IBS stands for Irritable bowel syndrome, and this is a GI disorder that is characterized by chronic abdominal pain and altered bowel habits in the absence of a structural or an anatomical cause.

 The Rome Foundation, which is a multinational group of scientists and clinicians, defines the criteria for an IBS diagnosis as recurrent abdominal pain at least one day a week in the last three months that is clearly linked to defecation or change in the frequency or appearance of our bowel movements. IBS can manifest with constipation-predominant symptoms, diarrhea-predominant symptoms, or a combination of both.

There seems to be this ongoing debate as to what causes IBS. And despite extensive research, a very clear, a very unifying cause for IBS is still not very evident. But there are a lot of theories that help us approach patients and manage them. Some symptoms may be precipitated by abnormal underlying motility or spasms, which are uncontrolled contractions within the muscles of the gut. And that explains why certain IBS treatment approaches like antispasmodic medications and fiber, both of which can help regulate contractions of the colon, can relieve symptoms.

Many studies have revealed that a major component could be visceral hyperalgesia or visceral hypersensitivity, which is basically this heightened sensitivity of the nerves supplying our gut. The thought is that nerve endings in the gut perceive and relay excessive painful signals to otherwise normal stimuli like movement of the food or stool through our gut, gas and distension, and so on. And that is why, as I mentioned earlier, some patients with severe IBS can feel significantly better when they're treated with these neuromodulators, medicines that decrease pain perception in the intestine and within our brain.

Some people with predominantly diarrheal or bloating symptoms could have an underlying condition called small intestinal bacterial overgrowth, where there is a surplus or over proliferation of bacteria in the small intestine. While it's unclear whether bacterial overgrowth can be a cause of IBS, we know that those with IBS are more likely than others to test positive for bacterial overgrowth. So, what that means is certain subset of patients might respond after antibiotic treatment that focuses on bacteria within the small intestine. In the same vein, while we are talking about underlying causes for IBS in particular and gut-brain axis disorders in general, underlying sleep disturbances, anxiety and phobias have also been shown to be independent risk factors for development of IBS.

Food intolerances, I mentioned earlier, recent infections and exposure to antibiotics, underlying inflammatory processes have all been implicated in the genesis of IBS. And as I mentioned earlier, because IBS presents in so many ways, whether it's diarrhea-predominant features or constipation-predominant features, depending on these subtypes, the diagnosis, the management, the long-term care for these patients can vary a lot.

Melanie Cole, MS: Dr. Javed, this is really such a great topic, and as we get ready to wrap up, I'd like you to speak to other providers about the quality of life for patients with GI issues, the intersection of the gut-brain axis and the importance of a multidisciplinary team, because when you are dealing with all of the symptoms you've been describing, there's help all around at the AHN Medicine Institute.

Saad Javed, MD: IBS is a chronic, lifelong condition. The burden of chronic pain and these chronic symptoms takes a toll on the minds and bodies alike. Within our network, we approach to bring the right care providers together within a variety of evidence-based pathways to help our patients navigate these lifelong challenges.

For example, we encourage our patients always to have an open discussion with their providers about the role of stress, depression, and anxiety that they could be having on their symptoms. We can then decide the best course of action together. I work very closely with our chronic condition specialty team, which includes dedicated behavioral health specialists, dieticians, and pharmacists that work very closely with our patients, under the coordination of a skilled nurse navigator. I also work closely with our enhanced pain management program, which uses methods like acupuncture, medical massage therapies, cognitive behavioral therapy, medical marijuana, and some more novel pain management approaches.

Our behavioral health associates have embedded an empowered relief program in our clinical pathway, which is an evidence-based single session pain class that can rapidly equip patients with pain management skills. In addition, we make sure that our patients' behavioral health needs are being met. We encourage them to be plugged into our anxiety and depression programs so that we, in addition to dealing their pharmacological issues, offering them pharmacological support, we are approaching them in a more holistic and integrative fashion.

Melanie Cole, MS: Very well said, Dr. Javed. Thank you so much for joining us today and sharing your incredible expertise in this fascinating topic. For other providers and to learn more or to refer a patient to Dr. Javed, please call 844-MD-REFER, or you can visit ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole