Transcription:
A Multidisciplinary Approach for Functional Bowel Disease Treatment

Melanie Cole (Host):  The Northwestern Medicine Functional Bowel Disease Program addresses disabling and painful bowel disorders which really can affect up to 20% of the adult population. My guests in this panel discussion today are Dr. Darren Brenner, he’s an Associate Professor of Medicine and Surgery and Dr. Jennifer Cai, she’s an Assistant Professor of Medicine and they’re both with Northwestern Medicine. Thank you so much doctors for joining us. Dr. Brenner, I’d like to start with you and kind of set the stage. What are considered functional bowel disorders?

Darren Brenner, MD (Guest):  Hi, thanks Melanie. So, functional bowel disorders funs a gamut of different illnesses that span the GI tract from the esophagus all the way down to the anal sphincter. There are predominantly defined as disorders whereby we don’t have good definitive diagnostic studies, radiologic studies, serologic studies, chemical studies to make a concrete diagnosis. So, for example, if someone walks in the door with hypertension; you can check their blood pressure and you will see that it’s high. But someone with functional bowel disorder like irritable bowel syndrome; we don’t have a test that definitively makes an accurate diagnosis. So, a lot of times, this is based on subjective analysis of a patient’s symptoms.

Host:  So, tell us a little bit about the Northwestern Medicine Functional Bowel Disease Program. It’s the first of its kind that patients have access to this entire multidisciplinary team of specialists, Dr. Brenner. How does that differentiate Northwestern Medicine? What’s so special about that?

Dr. Brenner:  Well I think it’s the fact that it’s a more integrated and collaborative program within the Northwestern Integrative Bowel Dysfunction Program. We incorporate not only gastroenterologists, but colorectal surgeons, lifestyle medicine specialists, psychologists, and dieticians in order to give or to take a more biopsychosocial approach to the patient’s symptoms or issues. We know a lot of times with functional GI disorders that diet can play a major role in the symptom profile. We are now looking at modifying that, modifying the gut microbiome. But we also know that the social or psychiatric issues like anxiety, depression and stress can worsen symptoms as well.

So, historically, people have looked at these types of disorders and just tried to treat the biological mechanisms behind them. But that’s only one piece of the puzzle. And a more global or unified treatment protocol or even diagnostic protocol can be more beneficial in terms of patient outcomes.

Host:  Well it certainly does. Dr. Brenner, I’m sticking with you for a second. So, tell us how that access benefits the patient and what impact does it have for general providers, PCPs? How is that – I mean it is such a multidisciplinary approach as you described and so comprehensive. Tell us how that works for the patient and for the PCPs.

Dr. Brenner:  Sure Melanie. So from the PCP’s perspective, a lot of times they say I’m lucky because I get to practice in an ivory tower. A lot of times they will come to conferences and lectures and say heh, I’ve got the traditional medications, or holistic therapies that I can give them over-the-counter, but I don’t have access to the dieticians or the behavioral psychologists in order to provide some of the services that you and other major academic institutions have proven beneficial. So, we are happy to offer that service.

One benefit from the patient’s standpoint I think is not only from a treatment protocol but from a time perspective. We think that patient’s time is of the utmost importance and in many instances, if you need to see a dietician or a behavioral psychologist or a gastroenterologist or a colorectal surgeon; you have to make three to four visits and especially myself living on the Northshore in the Northwest suburbs of Chicago; I know that can be very time consuming.

So, we have one specific program which again is known as the Northwestern Integrative Bowel Dysfunction Program and this program meets once a month. It’s usually for people with severe refractory pelvic floor syndromes like constipation or fecal incontinence. And within a single visit, the patient will see myself, Dr. Halvorson our colorectal surgeon if need be, Vonna our pelvic floor physical therapist, also our dietician and Dr. Sarah Quinton who heads our behavioral psychology program. So, it’s literally like getting five consults in one. But the nice thing is we are all in the room at the same time, so we are all hearing the same history, asking the same questions, bouncing diagnostic and therapeutic protocols off each other and also off the patient at the same time. So, we think that this has a more beneficial overall response and it is something we are actually looking at in clinical trials currently.

Host:  Wow, I would certainly imagine for the patient to have all of you experts sitting there at once. It really must be an amazing experience. So, Dr. Cai, Dr. Brenner was speaking about physiological and psychologically, he was talking about behavior therapists and before we talk about pelvic floor, because he mentioned that as well; why is it so important besides treating the physiological issue, whatever the problem is, but the psychological aspects of these disorders. Where does that come into play?

Jennifer Cai, MD (Guest):  You know Melanie, that’s a great question. I think one example that we can look at is IBS. It can be very helpful to address not just the GI symptoms associated with IBS whether they be diarrhea or constipation but also to address the pain symptoms that these patients have and oftentimes it’s related to their disease, to the hypersensitivity and the overdrive of the autonomic nervous system. And so, using behavioral health therapists, and their different techniques such as cognitive behavioral therapy or gut directed hypnotherapy in concert with pharmacologic therapy; it can provide an additional benefit to these patients.

Dr. Brenner:  Melanie, I agree with everything that Dr. Cai said. You know a lot of people when we talk to them about behavioral therapies including the cognitive behavioral therapy and hypnotherapy; they see this as a lot of voodoo or mumbo jumbo that we are just bringing up because remember, a lot of these patients have been told that a lot of their symptoms are all in their heads. So, when you predispose them to that thought process and you start talking about psychological interventions; they can sometimes lose faith in not only the diagnosis you are giving but the treatment protocols. It’s very important for our audience to know that there have been numerous randomized, double blind placebo controlled trials that have shown that behavioral therapy and hypnotherapy can be very effective.

Now the placebo in these trials are usually education groups but there is some benefit to that as well. In fact, Northwestern was one of the two institutions that spearheaded the largest NIH trial to date looking at the effects of cognitive behavioral therapy for treating IBS showing that it’s very, very effective and that people can get very good responses in a short period of time, only four sessions. More recently, we’ve shown that if patients respond; there’s no decay out to at least a year so they have those four sessions and they are doing better. The vast majority still feel good at the end of the year without any further interventions. And we know along that brain-gut interplay that newer technologies are coming to pass to improve the symptoms that Dr. Cai talked about specifically pain.

And there is now a wealth of literature at least initial trials showing that people can use virtual reality to treat pain in everything from functional bowel diseases to cancer. And soon we hope to be enrolling patients at Northwestern into a virtual reality study for irritable bowel syndrome as well.

Host:  That really is fascinating doctors, both of you because I read that NIH study and so many women and men suffer from these types of disorders and they are told that it’s all in their head and so, working that way is so beneficial. Now Dr. Cai another area that Dr. Brenner mentioned is nutrition and of course diet plays such a role in our gut health. Tell us about the importance of having a nutritionist be part of an IBS patient treatment plan.

Dr. Cai:  So, having a registered dietician or a nutritionist engage in the treatment plan of IBS is really critical. I think one example of this is in the administration of a low FODMAP diet and FORMAPs are essentially carbohydrates which are difficult to digest. They go into the colon where bacteria causes fermentation. And then that creates gases which can result in the patients feeling their symptoms of abdominal pain, and bloating. And so patients often will come into clinic complaining or feeling like they have “failed” after trying to manage this really complicated diet by themselves wither with the aid of handouts or their own online research.

But the benefit of having a dietician who is trained in GI disorders is that they are able to help these patients really personalize their dietary therapy to maximize the chance that it will work. And so one example is that we often focus on the elimination portion of these diets. Because that’s when we get rid of the foods that are potentially causing the problem. But we know that patients shouldn’t stay on this type of restricted diet forever. And so, what’s equally if not more important is the reintroduction phase where these foods are gradually re-added to the diet to see if they can be tolerated or if they reproduce symptoms.

And it’s in this process, that takes time and takes effort and it’s when the expertise of the dietician is really crucial to the success of not only the treatment plan but also of that patient’s ability to maintain that diet for the future.

Dr. Brenner:  Melanie I agree. One of the benefits of having a registered dietician is that they really focus on this subset of practice. As Dr. Cai mentioned, we talk about the low FODMAP diet being beneficial for irritable bowel syndrome but one of the concerns we have is where patients get their information regarding these diets. And I can tell you that the internet is not a panacea. Recently there was a study published in the American Journal of Gastroenterology that looked at recommendations for low FODMAP diets and we found even at the academic level of three major centers of excellence; that the recommendations for low FODMAP diets were more discordant than concordant meaning that the three academic centers agreed less on what constituted a low FODMAP diet than they agreed. So, you really want to have someone in place at your institution that knows a lot about this and is probably doing some clinical research with this to give the patient the likelihood of the best outcomes.

Host:  What a good point that you both made. So, Dr. Brenner tell us about some of the clinical trials you and your colleagues at Northwestern Medicine are involved in. Any recent discoveries or findings you can share and while you are doing that, please give us a brief synopsis of your talk on anorectal disorders at the upcoming ANMS Annual Meeting.

Dr. Brenner:  So, we’ve been involved in a lot of clinical trials here recently at Northwestern. We previously talked about the cognitive behavioral trial and forthcoming will be the trial using virtual reality to treat irritable bowel syndrome. We have also worked on trials of specific pharmaceuticals. There is a medication called plecanatide which we trialed for people with irritable bowel syndrome with constipation and were able to show that this improves global IBS with constipation symptoms but also subsyndromic symptoms including bloating distension, sensations of incomplete evacuation and improving quality of life.

Most recently, we completed a study with a medication called eluxadoline which is FDA approved for the treatment of irritable bowel syndrome with diarrhea specifically looking at patients who have failed an over-the-counter antidiarrheal therapy called loperamide. That was important because a lot of people and specifically patients want to use over-the-counter agents first. And historically, we always compare the medications that we do in these trials to placebo but sometimes we need better real world analyses of what’s going to happen to these individuals when they take these drugs in a real world setting.

And so what we did is we took people who had tried the over-the-counter, failed that, used this new therapeutic called eluxadoline and found that it was effective for these patients as well. Moving forward, we are looking again at quality of life outcomes with respect to patients we are seeing in our integrated bowel dysfunction program. We are also going to be using a drug that is FDA approved for treating chronic constipation and irritable bowel syndrome with constipation to try and treat constipation in individuals with cystic fibrosis as there are currently no drugs that are FDA approved for this indication. We are also working with a couple of other pharmaceutical companies on drugs for a disorder called gastroparesis.

Host:  Dr. Cai, first last word to you. Tell us what you would like other providers to know about the Northwestern Medicine Functional Bowel Disease Program and when you feel it’s important that they refer.

Dr. Cai:  So, great question. I think functional GI disorders are very common and primary care physicians are often the first line who see these patients. But there are some alarm features that if present should prompt a referral to GI, including bleeding, or weightloss, evidence of iron deficiency anemia, or if they have a family history of inorganic disease like cancer or inflammatory bowel disease. And so these symptoms could indicate that there’s another etiology that we should be ruling out either with endoscopy or colonoscopy or additional imaging before we label it as a functional disease.

And I’ll just add that there are also a number of conditions that primary care physicians and other specialists often see that have a significant functional GI component. A few that come to mind include Ehlers Danlos Syndrome and scleroderma where 90% of scleroderma patients actually have some degree of GI involvement and half of them are actually symptomatic with some of the conditions that we’ve talked about today. And so even though these patients have another underlying disorder; they can still really benefit from seeing GI motility specialists for their GI symptoms and sequelae.

Dr. Brenner:  You know Jennifer, I agree. I think we are here to kind of cover the gamut of what we can do for our colleagues who also practice general medicine and gastrointestinal medicine and all the other subspecialties as well. But also for our patients. And I like to look at it as kind of a place they can come for any types of interventions that they need. Sometimes patients are just referred to us because their doctors want to confirm the diagnosis. And that’s fine. Other times, they are referred for diagnostic testing and we are honored and able to offer esophageal testing from manometry to pH impedance to FLIP to motility testing including smart pill, breath testing for small intestinal bacterial overgrowth and carbohydrate malabsorption. And then anorectal testing for constipation and fecal incontinence.

So, we are happy to do that testing and then take over the patient’s care if our colleagues would like. Or to just do the testing again because they don’t have that available to them. Finally, again, we pride ourselves on that multidisciplinary biopsychosocial approach. We do feel it’s probably the best way to treat a patient overall.

Host:  Great information and what a fantastic multidisciplinary comprehensive program. Both of you, thank you so much for joining us today and sharing your expertise. That wraps up this episode of Better Edge, a Northwestern Medicine Podcast for physicians. For more information on the latest advances in medicine; please check out www.nm.org to get connected with one of our providers. If you as a provider found this podcast as informative as I did, please share with other providers so they know when to refer. Share with your friends and family on social media because this is really important information that we can all learn together from the experts and don’t miss all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole.