Ep 137: Irritable Bowel Syndrome, how to diagnose and treat! With gastroenterologist, Dr Iris Wang (Part 2)

Episode 137 with Dr. Iris Wang, an assistant professor at Mayo Clinic and adult gastroenterologist continues her conversation to discuss the diagnosis and treatment of  irritable bowel syndrome (IBS).  We review treatment options, including laxatives, antidepressants, cognitive-behavioral therapy, and even hypnotherapy (Dr Wang is one of the few physicians who is also trained in IBS hypnotherapy!). The speakers also provide information on finding qualified providers and the use of FDA-approved apps for IBS treatment. The conversation concludes with a discussion on probiotics, peppermint oil, and the FODMAP diet as potential treatment options for IBS.

Takeaways

• IBS is a complex condition that often presents with unexplained symptoms, and diagnosing it can be challenging.
• Understanding IBS as a software issue, involving the enteric nervous system, microbiome, and vagus nerve, is crucial for effective treatment.
• Accepting the diagnosis of IBS is important for patients' well-being and recovery.
• Primary care providers can play a significant role in diagnosing and treating IBS, reducing the need for specialist referrals.
• Treatment options for IBS include antidepressants, cognitive-behavioral therapy, hypnotherapy, and dietary interventions like the FODMAP diet.
• We discussed apps to consider for treatment: 
• App based CBT: Mahana 
• App based hypnotherapy: Regulora 

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

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The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Hi everybody I'm Dr. Jessica Hochman, paediatrician, and mom of three. On this podcast I like to talk about various paediatric health topics, sharing my knowledge not only as a doctor but also as a parent. Ultimately, my hope is that when it comes to your children's health, you feel more confident, worry less, and enjoy your parenting experience as much as possible. Hi, everybody. Welcome back to part two of my conversation with Dr. Iris Wang. Dr. Wang is a gastroenterologist and she's an assistant professor at the Mayo Clinic. On today's episode, we're going to talk about one of her areas of expertise irritable bowel syndrome, also known as IBS. Now, for those of you who aren't familiar with IBS, it's actually quite common about one in 10 Americans experience IBS. Some symptoms of IBS include abdominal pain, bloating, diarrhoea and constipation. And what's so hard about IBS is there's no actual bloodwork or special tests that diagnosis IBS, is diagnosed based on symptoms. It's also quite frustrating for patients because there's no easy cure for IBS. So what I really enjoyed about talking to Dr. Wang is that she's on the forefront of treatments for IBS. And she's very optimistic about how these treatments will help her patients. As you'll hear in the interview, she's even certified in using hypnosis as a treatment option for IBS. So personally, I really enjoy learning about the various actual ways that people can seek help. Thank you, Dr. Wang for joining us, Dr. Jessica and sharing your knowledge. So let's let's segue to IBS because this is another as you mentioned earlier, it's a very common disorder of the brain gut interaction. And it's something that I see all the time as a paediatrician, especially amongst my teenagers. So first, can you explain what IBS is to listeners? And what are the symptoms that might present? Absolutely, IBS is a very complicated concept, right. And so I think there's so many different ways to think about IBS and the most common way. And the most unfortunate way is you have pain and an alteration in your bowel movements. And we can find nothing wrong on an endoscopy or a scan. And so you have IBS, right? That's most commonly what patients are hearing. And it makes it seem like a throwaway diagnosis because we can't figure out what's wrong with you. From my standpoint of things as someone who treats IBS and I may be biassed and clearly self serving here. But I think IBS is one of the most complex disorders that we have in the GI system. Because it's a disorder that has so many different potential inputs. And it's a heterogeneous this work, that means it's not just inflammation, it's not just pain, it's it's a set of symptoms that has developed because of an underlying imbalance in the overall gut brain motility. So I'll break that down a little bit. When the Rome Foundation came up with IBS criteria, it is a set, they came up with a set of symptoms. Those symptoms are pain, abdominal pain, or discomfort related to either a change in the frequency of bowel movements, a change in the form of your bowel movements, I'm actually going to give you the exact definition of IBS, just to make sure that I'm not misquoting something. I think about this, but I don't think you'll see I don't, don't tell anyone, I don't actually utilise a lot of it. And I'll tell you why. So it's recurrent abdominal pain at least a day a week associated with two or more of the following. It's related to defecation, it's associated with a change in frequency of store or associated with a change in form of school. So I didn't misquote it. So that's good. But the key thing here is that it's a symptom based criteria. It's not like ulcerative colitis, or inflammatory bowel disease, where it's a diagnosis based on what you're seeing on endoscopy and what your biopsy, right. So that symptom based criteria gets a little bit tricky. I'll just tell you what I normally see in my office, I commonly will see a teenager who's a little bit on the anxious side, who comes in and tells me they have stomach pain all the time. They feel bloated, they have a hard time going to the bathroom. They're always in the bathroom, and they can't figure out how to make themselves feel better. And they get frustrated because they can't actually find why they have a hard time pinpointing why these symptoms happen. But it's very real. And the parents are frustrated. They feel like doctors aren't really paying attention to their symptoms, maybe not believing their symptoms. I would say that's the common picture of a patient that I get with IBS. Would you agree with that? Do you have anything to add to that? So I think that is right, that's the bucket of patients that gets left over when we take away some of these other etiologies. Right. We we recommend checking briefly to make sure that they've had celiac testing, that they don't have enough amatory bowel disease with a simple stool test, right? We don't need to scope them. Not every one of those patients you're describing needs an upper and lower endoscopy. But yes, then then we're left with these patients who present in your office, and then several years later in my office with the same symptoms, because nobody's figured it out. And it's because there's no clear one answer. And it's because we don't have the clinically available testing. And so what I tell these patients is your symptoms are valid, and they're very, very real. Just because we don't have a test does not mean you don't have pain, or suffering or discomfort. And the reason for that is it's a software issue. It's not a hardware issue, right. It's not a blockage in the bowels, that's a hardware issue. It's not as it's not a tumour that we can find a lot of our testing right now, CT scans colonoscopy is identify hardware issues. We don't assess the software of how the nerves are firing, how the bowels are moving, what the microbiome is doing in there, those are the components that are affecting your patient or affecting our, you know, folks that suffer with IBS. And so I tell them that it's this complex interaction between the enteric nervous system, the microbiome, the vagus nerve, it is not because they're anxious, right? The anxiety doesn't help anything the anxiety contributes to contributes the worsening contributes to hyper vigilance, right, paying attention too much to those symptoms, will make them worse, you know, it doesn't mean it's mind over matter, they can just ignore it, no. But the more they pay attention to the symptoms, the more those symptoms will get worse. It's like working out a muscle, if you go to the gym, and you like do bicep curls, like your biceps are going to get bigger, period, end of story, right? If you work on memorising a play, right, you're going to be able to your brain is going to grow in that area, your neurons that are able to pull out Hamlet are going to be faster than they used to be. If you're spending your time focusing on the pain signal that's coming up from your abdomen, we've shown that the neurons actually get big, they they myelin a right, that myelin sheath gets bigger, and that signal travels faster. So not only do you feel the pain, you're it's because your brain is learning that you need to pay attention to this pain, you're teaching your brain that the pain is something important. And so then every time even a little bit of pain comes through or natural process of gut function happens, your brain is paying so much attention to it. When we call that visceral hypersensitivity. We've shown that those nerves are bigger, and the areas in the brain that pay attention to that actually grow. And you experience pain more interesting. That's fascinating. What I what I think is so interesting to hear about and I think what's so validating for patients that do have IBS, is they're looking for a test to say, look, what I have is real, do you see this test that shows a positive diagnosis for IBS. And as you pointed out, there is no blood test, there is no gi test. It's what we call a diagnosis of exclusion. We've ruled out all these other things. And so this is what it has to be. But I think what I like hearing from you, and, and correct me if I'm wrong. But as a general paediatrician, I like knowing that I can do a lot of tests and rule things out, and maybe treat them on my own without having to send them to a GI doctor. Is that right? And then if you're concerned about things like weight loss, where the pain is feeling a little more even check a faecal calprotectin to make sure that there's no inflammation in the colon. It's okay. It's quite simple. So check a stool test looking for a faecal calprotectin to make sure it's not IBD like Crohn's or ulcerative colitis? And then if I do all of those things, can I without referring to a GI doctor try to treat them as if they have IBS? Absolutely. And I think RGPS RPCVs. In the adult world, we want them to do that. Because we have found that the more specialist patients see the worst they get, and the more their pain becomes. It cyclically can worsen. And I think one thing that you mentioned that I think bears touching upon is this idea of IBS as a diagnosis of exclusion. We want to reframe that we really in GI want to treat IBS as a positive diagnosis. You meet these criteria you have if you meet IBS criteria, you have IBS, and being able to positively give patients that diagnosis with confidence. Because you see these patients, you know, they have ideas, right? And I think in the back of our minds, we're always like, but what if right, well, what if this is the one patient who doesn't have IBS? I think you you. Those of us in practice who have seen patients long enough, you know when something is different about this one case, right? That's the patient you don't give the positive diagnosis of IBS to but for the other patients who come in who are so worried who need an answer I think we can feel comfortable giving them an answer and Rome's guidance is, please give them an answer. Please tell them they have IBS. Not. We think this is IBS because it's not everything. Anything else, right, that positive diagnosis helps so much. How common is IBS? Because I think this is also really interesting. One in 10, and about 25 of 45 million people in the US, it can be as high as like in some of our studies up to 25%. It depends a lot on how we are describing it and how we are attributing it. And so those studies can be a little bit difficult to interpret when we're looking at like large population data, because it's so heterogeneous, right? And we don't know how many of the patients who were coded to have IBS do end up having a different disorder like celiac disease. But in the majority of our IBS patients, like that patient you're describing, we can be fairly confident, but I'm going to quote Harry Potter here. And there is a quote from Dumbledore that says, understanding is the first step to acceptance and only with acceptance, can there be recovery. And I feel like that just rings. So true for all of my DGI patients, if they do not accept their diagnosis, they will not get better, you can throw all of the IVs medications at them, it's not going to be as effective as if they are on board with that diagnosis. If they continue to look, to get more and more endoscopy is to get more and more CT scans to see more and more specialists and they don't accept the diagnosis that they have. They won't recover because they'll always be looking for the next thing to help them feel 100% Better. But it's not a disease that like changes overnight. It is a slow process. And with that acceptance, we can get there. I love hearing from you that I don't have to refer for an endoscopy and a colonoscopy, because I always thought that was the proper methodology. And so I think it's so much nicer and easier for parents, should they not have to go see a specialist, at least I can try to make some suggestions to help them before referring them to a specialist. Absolutely. I think we're always here, right? We can always go but it's not beneficial to have the majority of patients meaning IVs criteria. And so we don't say, you know, there's no, there's no rollout needed with endoscopy, in this case, the situations where you wouldn't think about endoscopy, our significant weight loss blood in the stools. Those are the situations where we would say yeah, we should probably do an endoscopy before we're comfortable with the IBS diagnosis. So yeah, so if it sounds like classic IBS symptoms, we can go ahead and make some suggestions. Which leads me to the elephant in the room, I think the toughest part of IBS, which is how to properly treat IBS. What are your suggestions? So IBS is a heterogeneous disorder, right? We just kind of talked about that. And part of the reason that not there's no like one drug for IBS is because there's so many different phenotypes. You can't treat IBS constipation the exact same way as you treat IBS diarrhoea because one is having too many stools, and one is not having any right. And so I think when we think about IBS treatment is really important to bucket our patients into their appropriate diagnosis. This mostly constipation, or is this mostly diarrhoea? Or actually is it mostly pain that we need to be managing, in which case then we can maybe apply something that is more readily kind of applicable to all the buckets, right. So when I think about IBS, or when I think about treating IBS, if there are constipated I work on their constipation first. Yes, there's a pain component. Yes, they're feeling more pain than they have to with those bowel movements. But until I regulate their bowel movements, that pain is not really going to get much better. So I do my osmotic laxatives, I give them a plan. And I try to keep them as regular as I can for a couple of weeks and see what happens to their pain. And often that pain starts improving because their bowels are no longer distended, they're no longer bloating, they're less fatigued because they're not carrying school around those fermenting toxins. All of those things. What are what are your favourite osmotic laxatives? I am Am I allowed to do brand names? Oh, I'm just curious, because when when parents hear osmotic laxatives, I don't know if they know exactly what that means. Yeah, so, so heavy. polyethylene glycol is my go to is the thing that I always go to, because of a number of reasons. It's a powder that dissolves in water, and it's easily titratable and it doesn't get absorbed. And so it's safe, you can't get dependent on it. And what I love is that you can control how much you use. And so for a smaller child who needs less, you can give less of that capital. In my adult patients. Some of them only need a quarter of a teaspoon, and that's what they need, but I can empower them to do I that on their own, and it's something that they can control so that they're if they're having too much, then they can skill back that medication and still get an effective bowel movement. So an osmotic laxative kind of helps us keep water in the stool, and it's really aimed at keeping schools softer. It doesn't necessarily give you more frequent bowel movements, but but it can because just having more water can help stimulate the core. Another one that's really good as milk of magnesia those are by to go to osmotic laxatives. So just to summarise that so at first if a patient has IBS of the constipated type, because they can be constipated, or have diarrhoea, if they're the constant media type will work on relieving their constipation. Yep, can I just say two more things about constipation treatment, of course. bisacodyl is a really good medication for adults and for kids, Senna is my other go to for when those asthmatics aren't enough, send us a little bit more gentle, a little bit more natural for parents who might prefer that route. But both of them have very good data supporting their use, and they help push things along the colon. And I'd like parents to consider enemas and suppositories. Those are not bad things. I know they're unpleasant. But sometimes you just need to go from below, right? Especially if school is impacted. If you don't clear up whatever is plugging up things from below, kids will have such a hard time going and then it'll cause pain, and then they'll retain more, and so not to kind of shy away from the enema therapy. So after we help with constipation, another popular treatment modality for IBS, our antidepressant, specifically the tri cyclic class, and whenever I tell this to a patient, it seems to throw them off a little bit, because they I think they assume that I'm thinking that their pain is anxiety related or that it's all stemming psychologically. Can you explain why that's not the case? Why antidepressants may be beneficial for for IBS? Absolutely. And that's such an important question. Because if you do this wrong, right, patients will just take it, they'll do a look at what it was for, and they'll throw it away, at least my patients will. And so it kind of goes back to what we talked about in the very beginning of this, right, that got brain interaction. And I make sure to tell my patients about that enteric nervous system, that there's an entire system of nerves that just lives in their gut. And even though it's a different nervous system, it's the same nerves, it responds to the same neurotransmitters that your brain does. And so we use these antidepressants that I usually call them neuro modulators, because that's what they do. They change how your neurons are firing, and they change the products of those neurons, right. And I tell them that it's the same neurons in your brain as in your gut. And so I'm using these medications at lower doses because I want them to target the nervous system in your gut, to turn down the volume of those pain signals. And I told them that they are at such low doses that while there might be some side effects, crossing that blood brain barrier, they're really bad antidepressants at those doses, like no psychiatrists worth their salt would recommend using 10 milligrammes of amitriptyline to treat depression. And I tell them that if I were treating your depression, I would be a terrible psychiatrist. I am not trying to treat depression, I'm trying to treat the pain in your bowels. And I show them you know, in some in in people who need more convincing, I will pull up the papers, or the guidelines that say, Look, this is a GI paper, for God pain. And this is what our society recommends as like one of the frontline medications. And that is really helpful, right? It both validates that they have a real condition because we have a guideline about it. And that this medication that I'm giving them, is very appropriately targeted to that condition. And I'm not secretly trying to treat the depression actually just call it out. I tell them, I'm not secretly trying to treat depression. And do you find that it works? How helpful is it because I have to be honest, I see, I experienced mixed reviews on how helpful it is for families. It's hard, because in the right patients, it works really, really well. But I see a lot of problems with it because of the side effects actually. Because it is it is a little bit tough to tolerate, it can cause some dryness of the mouth, it can cause a mood changes, even even at the very low doses. And so I do have trouble with that medicine with that class of medications and all of the anti psych medications actually, because even though there's good data and they do work, they can be limiting. And so this is part of the reason why I do a lot of my work in non pharmacologic therapy because I have trouble with patients who who truly need something like an antidepressant but can't tolerate one. And so then that's where things like cognitive behaviour therapy, and hypnotherapy come into play because I explained to my patients like, Okay, we need to stimulate these neurotransmitters, right? That's the whole point of giving you these medications. And I either can't give you the medications to do it because you can't tolerate it or it wasn't worth Think very well CBT and hypnotherapy try to get you to produce your own neurotransmitters and try to regulate your system that way. And so yes, it is psychology. But we're trying to use that psychology again to modulate the neurons in your system. So our number needed to treat right how many patients we need to treat to see one effective case for the tri cyclic antidepressants is one in four. But for TC for the CBT and hypnotherapy, it's also one in four. And there are no side effects. Wow. So it works. That's this is why I was like, I need to learn how to do hypnotherapy. Yeah, I'm so proud of Dr. Wang. She's actually certified in hypnotherapy. And how many of you exist out there? I love that you took the time to get certified in hypnotherapy. It was fun. It was it was it's such an amazing tool. I would highly recommend it for any practitioner interested. Then the big question I have is where can they find somebody who is qualified in CBT AND and OR hypnotherapy for IBS? Tell everybody, where can they go to get help? So that that's like the million dollar question, right? Because we just talked about how there aren't that many of us available. So for there's going to be a lot more gut trained psychologists. So there is a field now called psycho gastroenterology. And these are psychologists who are already trained in general psychology, but then focus on gut symptoms. Those are the people that can be really, really, really helpful for these conditions. The Rhone Foundation has a subsidiary called the role cycle gastroenterology group, very long word. But if you go on their website, there's actually a find a provider option and you can search for Providers by ZIP code. And these are all people who are kind of involved in continuing their learning and providing they truly truly care about improving overall symptoms and also quality of life for our patients with any TBI not just ideas for hypnosis. The organisation is called the American Society of Clinical hypnosis or a s ch. And if you go on their website, they also have a finder provider option so that you can find Clinical Hypnotherapist right, these are not staged hypnotherapist all of these people have to have some sort of licence to practice medicine within their field, whether that's social work, nursing, an MD etc. And so they're kind of safe to save to go with these people, because they're all trained and licenced. What I find fascinating. And I would love for you to mention the new FDA approved apps that people may be able to find so that they don't have to find a physician. They don't have to leave their home. I think this is a really fascinating option for people. Yeah, it's a great option. And I love that you brought it up, because what people will find when they go on these websites is that when they search by zip code, there are some zip codes that have a lot of providers and some that have no providers that they're able to access. And so that's where these digital apps really came into play. Because we realised that there was such a need, that these therapies work, but that patients couldn't get to them. And so there's two apps on the market that are FDA approved. There's a couple of other ones on the market that are kind of providing similar things with good evidence but hasn't gone through FDA approval. The two that are FDA approved one is called Mo is from Ohana and that's ma H A N A Meccano therapeutics, they are an app based CBT programme. And so they because they're FDA approved, they do require a prescription from a provider. But that can be done electronically through most of the electronic medical records and prescribers can go to their website to learn how how to do that. The app based hypnotherapy utilises the one that's FDA approved utilises the same hypnotherapy script. So it's actually a standard script that was tested. Right. So we know this is the one that works. It is recorded, it's this really delivered app is called regular Laura, and our eg U L. O Ra. And it's from a company called Madami health. So those are the two FDA approved apps that are kind of generating a lot of evidence around their use. That's amazing and still showing efficacy even without seeing a provider in person. Correct? Yeah, there's gonna be some patients who don't do as well with apps based on their needs, right. And so it is important to think about whether this is the right thing for you and your child, etc. But it is still quite safe. And I think the big things that I worry about is if there is an underlying psychiatric disorder, I would not send them to an app based hypnosis, I would send them to a provider, or if there's any sort of PTSD, I would want them seen by provider. Yes, I mean, personally, I always lean towards treating patients in person but it's just nice to know when there are such few providers that are versed in CBT, and hypnotherapy for IBS that there are some other options that parents and families can look towards. Exactly, absolutely. Now, what about things like probiotics, peppermint oil, other non pharmacologic options to help with IBS that I often see recommended by gi doctors? The probiotic, I think, is the same conversation we had about probiotics and constipation. Could it work, possibly for certain patients, if we're going to if a patient really wants to try it, I tell them to go ahead, but to select something with at least three strains of bacteria in it, and to not try it for more than six, eight weeks, because if it's not working by then it's probably not going to work. And they should just come up with peppermint oil, on the other hand, has a really good data for IBS. So this is peppermint oil that's inherently formulated, right. And that's actually really important to note, because if you just drink peppermint oil or drink peppermint tea, it can actually worsen reflux, because it can increase kind of relaxation of that upper esophageal sphincter. And so we don't want that we don't want to contribute to more problems. And so the peppermint oil that's available on the market as a medication for IBS is coded so that it doesn't activate until it gets into the stomach. And what it does is kind of like it's called an anti spasmodic. So it smooths the muscles in the system so that they don't contract as strongly. And it's got some decent evidence around its use. So where will they find that it's actually available over the counter? It there's a couple of formulations for it, that are like kind of branded, but it's available at health food stores, it's available like at a CVS or, you know, a Walmart, in their digestive products aisles. The other couple of things, there are other kinds of formulated medications. One is called IV guard or FD Guard are the are the names of these medications. But they're formulated with not just peppermint oil, but also Caraway oil. And Caraway. In addition to peppermint, those two together has been shown to have some smooth muscle relaxing effects, antioxidant effects, and has been helpful for IBS. So those are more natural products that can be tried. I have a colleague that just has patients brew Caraway into a tea and drink that, because there's no there's no real harm to that doesn't taste great, but there's no harm to it. And with caraway, you're not going to risk upsetting the upper GI tract. Last thing about peppermint oil is I do need to put out an advisory that this is food safe peppermint oil, right, either get the capsule, or if you want to try it on your own, that's great, but do not ingest the stuff that is meant for infusers. Because it looks very similar or the diffusers, right, the enrollment therapy peppermint that is not safe for consumption, it will not help you. Yes, it will make things worse. So be very, very careful because sometimes it's hard to tell with peppermint oil, which which one it is. And now lastly, tell me about the FODMAP diet, because this is something that people talk a lot about. This is a big, this is a I noticed this is the crux of a lot of advice for families with for patients with IBS in terms of treatment, how should families go about looking at a FODMAP diet? Yeah, absolutely. I think that we have some good evidence for the FODMAP diet. And the thought behind that is that these FODMAPs are foods that are difficult for our GI system as human beings to digest. And they can be then left over for the gut bacteria to ferment and to overgrow and cause a lot of symptoms because there's extra osmosis or kind of things in the in the bowels that allow for a lot of water to hit the bowels. It can feed that bacteria. And so then you're thinking that they're the thinking is that it drives some low grade inflammation in the system and contributes to the pain, you'll find that the FODMAP camps can be there's a lot of variation on how much stock people put into the FODMAP diet depending a lot on their practice. But I think to like take it up a higher level. It's a restrictive diet that's meant to remove a lot of foods that are potentially insulting to the GI tract to allow it temporarily to heal. The key word here is that it needs to be a temporary measure. And there's a restrictive phase where you cut out all the FODMAPs. And then there's a reintroduction phase where you slowly add back foods that to see whether or not they're tolerable to the system. A couple of caveats around that. One is we highly recommend doing this with the guidance of a dietitian and not to do it on your own. There's a lot of nuances. There's a lot of questions. It is not an easy diet to follow. It's actually it's much harder than a gluten free diet because not only do you cut out gluten, you cut out all of these other things. And so if you're able to do what dietician support that is what we highly recommend. Now, similar to finding Good psychologists, not everyone can find a good dietitian, not everyone has time to go see a good dietitian. So there are apps available for that as well. Monash University has a FODMAP app, they're the ones that kind of put the FODMAP diet on the map, which university sorry. So they're called Monash University MO, N A, S H. And they're, I think, based in Australia. And they, they're the ones who did a lot of studies around the FODMAP diet. And so they put out this app, where you can check with whether something is a high FODMAP food or low FODMAP, food, etc. And that can be kind of helpful, so that you at least have something to to guide without having to Google every single ingredient in every single food. reintroduction is really, really important. And then, if it's not working, please reintroduce right, I think I find that, again, the danger with a lot of these dietary eliminations is that you can eliminate down to a low FODMAP diet. But in some patients, if it doesn't work, we'll say okay, well, it didn't work, I'm just gonna start eating everything again. But there's a group of patients who will say, Well, that just means I need to be more restrictive and keep cutting out foods. And that puts them in a very challenging situation. Because as you cut out foods, the longer you go without a food, the less able you are going to be to digest it. So true, that's That's very true. I know with lactose specifically, if you stop, if you cut out dairy altogether, you'll start making the enzyme the lactase to break down lactose. And when you reintroduce lactose, you really will feel really bad stomach ache. So I think that's such an important point that it's not meant to be forever. You don't want to stay restricted forever, you do want to reintroduce. And when you do reintroduce, think about the fact that you haven't been using this enzyme, or the bacteria colonies that have been helping you digest are now dwindling, because they haven't been fed for so long. And so you can't expect to be able to eat it. Eat this food again, like immediately, right? Some foods you'll be able to, but it is okay to not be able to tolerate that food immediately. And it is okay to reintroduce slowly at small quantities. And that's where your dietitian support can be really helpful is to know what's normal, what's not normal to be reacting? Should I keep going? Should I cut it back out? Right? Those are questions that parents, patients, they need guidance, what a dietician colleague can be super helpful. What I just learned from you that I that I honestly didn't realise was I thought that patients who had IBS would be sensitive to those particular foods for a long period of time, potentially indefinitely. But that's so interesting that really, you're just allowing the gut to heal, and then you should be able to read and then you should be able to reintroduce Yeah, that's the thought, I kind of liken it to if you had a cut on your hand, right, if you have a big cut on your hand, and you put on like a, like a wool glove, that's going to hurt. But it's not because of the glove, right? It's not because of the food you're putting into the system, it's because you have a cut on your hand, it's because your bowels are overly sensitive. Whereas if you put on a silk glove, which is like a low FODMAP food, then you're not going to have as much pain, right? Because again, it's not the glove, it's your hand. And so if you let your hand heal, then you're going to be able to put that little glove back on again, and tolerate it a lot better. I love hearing this because I feel like a lot of parents face frustration when their kids have IBS, they almost can feel hopeless. But this is leaving me with the opposite impression that there really is so much we can do and that it is a condition where we can heal our patients. I see patients get better, right? This is not a lifelong diagnosis. It can be it can turn into that. But our overall big statistics will say about a third of patients will recover. And so it's important to think about that, but it's a long journey. It's not take a pill and this will go away, right? It's not like taking an antibiotic where you go on this therapy, and all of a sudden you feel better most of the time. And out of curiosity, those two thirds of patients that don't recover. Do you feel like they've tried all the available modalities? And they still haven't recovered? Or? Like is, yeah, yeah. Okay, so this is interesting. So there's hope there's a lot of things that we can try. But just to be aware that it does take time to feel better to have patients with IBS. Well, thank you so much. And also, it's so helpful to have physicians like you that are so dedicated to finding treatments because that gives me a lot of optimism that those numbers are are only going to get better and better. That's very kind of you. Thank you. So just to conclude, do you have any final thoughts for parents to offer them support for their kids overall? Well being their overall gi health any concluding thoughts that we did not talk about? Yeah, I think if I may, right, as an adult gastroenterologist, sometimes I don't want to provide like paediatric centric Advice. But I can tell you what I see on my end when those kids grow into adults, and well meaning parents can sometimes help too much. And I would love parents to think about empowering their children, right? empowering them to own their own symptoms, giving them grace to allow them to be constipated here and there. And, of course, you know, age appropriate old enough child to give them autonomy over their symptoms, right that they can, if they are okay, living with their belly pain. Not asking about whether or not they still have belly pain, right? Because because we talked about this idea of hyper vigilance of hyper focus of anxiety, worsening things, right, and parents who means a lot, and I'm guilty of this myself, right. My kid had a fever yesterday, and I asked him at least five times what hurts What hurts, and he's like, nothing, I'm fine. But that's what we want to do as parents is make sure our kids are fine. But I think that in a DJ VI, like IBS, in particular, continuing to ask continuing to ask them to monitor their symptoms, know that that can actually make things worse. And so sometimes it helps for the parents to take a step back to like, do the breathing with their kids to say, okay, maybe we need to do the rest and digest activation, we don't need to be focusing and worrying and monitoring the bowel movements with a stool chart and tracking things so carefully, right, we can just let things be and see how they are overall, I'm not phrasing this terribly well. But I want to reassure parents, that your kids are resilient, that they will be okay that they can understand, you know, above a certain age, their own symptoms. And if you provide them with some guidance, and ask them to be the ones to check in with you, that can empower them to really take control and to manage their own symptoms and help them get better. Very well said, I agree giving kids agency and control over their own health, I think will be very helpful for the entire family. I agree. Well, thank you so much for your expertise. This has been so helpful, and I learned a lot. So thank you so much. Thank you so much for having me. It's a real honour to be here and thanks for giving me the space. Thank you for listening. And I hope you enjoyed this week's episode of Ask Dr. Jessica. Also, if you could take a moment and leave a five star review wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr. Jessica See you next Monday.