She has been tested for celiac disease, Crohns disease and Ulcerative colitis which were all negative. She has been to several different specialists and she has seen no improvement. All her colonoscopies and endoscopies are normal and her doctors have basically no direction to point her in.
And so in today’s video I want to unpack some areas that need to be explored behind the reasons of IBS and diarrhea some of lab testing markers that are important to evaluate for these problems.
Perhaps you are watching today’s video and you yourself are struggling with diarrhea and the frustrations of not having any answers.
Perhaps you too are afraid to leave your house, (you can’t go on vacations) and if you do your worried about being caught out in public and having an accident in your pants- and with that the embarrassment.
So I want to talk about some additional problems that many doctors and GI specialists simply don’t bother looking into.
What I find is that many patients who have frequent diarrhea will get a colonoscopy, in many case, the colonscopy doesn’t show your typical lesions as those seen in Crohns or Ulceratice Colitis and so you walk out of your doctor’s office being told to eat more fiber. Relax more and stick to a regiment of medications (that stop the diarrhea) but still haven’t isolated the underlying root cause.
And that advice of eating more fiber is not always the best advice. And the other thing is how are you supposed to relax when your whole life has been disrupted because of diarrhea. So that’s just unrealistic.
One of the things I like to do with a patient is run a functional stool test. This stool test is unlike any conventional testing your doctor’s office offers
Heres why, several tests we offer through our practice allow us to use PCR testing technology. Whats great about this is that is allows us to gain Insight into the gut flora by identifying more than 24 Commensal Bacteria targets.
This allows us to look at the kinds of bacteria, the number of good bacteria and the overall the biological diversity. I like to think of the terrain of the gut like a rainforest.
A Healthy rainforest has a very high biological diversity. There is a eco system in your intestines and if this eco system becomes strained or stressed because of an overgrowth of yeast, bacteria, parasites, fungus or medications, steroids, etc the eco system loses its homeostasis and balance and that loss of balance will show up in a number of ways. The symptoms of (diarrhea/constipation) is not as important as the functional disruption to the microflora.
The other thing about these tests is that it looks at various Biomarkers indicating how well you break down food, how well you are breaking down fats and proteins. Things like Pancreatic elastase, short chain fatty acids, Protein Products, putrefactive short chain fatty acids and things like N-Butyrate. This is especially important when it comes to people struggling with diarrhea.
Just for a minute think about what’s happening with diarrhea. You have food that is not being properly digested, moving through the intestines too quickly and this leads to malabsorption of nutrients that are realty intended for cellular healing.
If we are going to focus on repairing your body, how important and vital is it to understand where the breakdown in digestion process is occurring?
The last piece of these tests look at the potential issues with intestinal inflammation and immunology. These markers like Calprotectin, Lactoferrin, Eosinophil Protein X, Secretory IgA
These markers can track a patient’s progress to the level of inflammation and irritation in the intestines.
These kinds of test offer so much more than the kind of testing ran by conventionally trained doctors. Rather than looking for just a bacteria or an infection we are getting a glimpse into the actual mechanics of GI function.
So this is what we call a functional stool test, because it evaluates various functions and how well your body is executing those functions.
So lets dive into some of reasons behind IBS diarrhea.
#1 cause of chronic diarrhea is Intestinal Dysbiosis
Now I have done several video specific to this topic of Intestinal Disbiosisand I would encourage you to learn about the many causes behind disbiosis.
But for many people who already have IBS, the treatments and medications you have received up to this point in your life are often the very causes of the condition your are tyring to get help you with…. Which Is ironic if you ask me.
Here’s the thing, research has shown time and time again, that people with IBS have decreased populations of the good colonic bacteria. The good guys have been beaten down.
Now it’s the good bacteria throughout your GI tract that serve numerous roles.
Many of these good bacteria prevent bad bacteria from colonizing and taking over the gut, some maintain the ph ( by producing lactic acid), some produce immune system fighting cells like SIgA, and others make enzymes and B vitaminsthat are crucial to the immune system and the mental health of a person.
One thing we know for certain about the gut microbiome is that when the balance shifts towards disbiosis, a wide variety of common illnesses including not only IBS and IBD can occur but things like Autoimmune Disorders, Diabetes, Cardiovascular Disease, Kidney disease, skin conditions, Depression and the list goes on and on.
You can go to google and search any of these conditions on PubMed simply by typing in the condition the word microbiome and the word PubMed.
Continuing and diving further into the causes of Diarrhea includes something known as Bile Acid Malabsorption.
Bile acids or bile salts are nature’s laxatives, they are made in your liver and then secreted from the gall bladder into the small intestines after meals.
It is these bile salts that are responsible for the digestion and absorption of fatin the small intestines. So if you have a lot of fat not being digested and absorbed its going to end up in your stool. The second point to remember about these bile salts is that 95% of bile salts are reabsorbed in the last portion of your small intestines.
This is important because if they fail to be reabsorbed (and pay attention here) then they enter large intestines and when they enter the large intestines, they stimulate water secretion and intestinal motility. This is what causes the symptoms of chronic diarrhea.
Now….One thing I forgot to mention, is that you are probably taking medications that bind up your bile acids.– These are drugs called bile acid sequestrants. And the problem with them is that they often lead to all sorts of problems with the absorption of vitamins ADEK.
So your diarrhea may be coming from a problem with the liver, the gallbladder, or a problem with the reabsorption of the bile salts in the small intestines. And guess what…. The distal portion of the small intestines is like the last frontier when it comes to imaging it’s not an area that can easily be accessed.
Another common cause of Diarrhea is Small Intestinal Bacterial Overgrowth otherwise known as SIBO
I wont talk to much about SIBO because I have done a lot of videos and even dedicated a part video series that covers everything from what it is, to the testing of it to why antibiotics are not allways the best treatment advice for this condition.
But real quickly, Small intestinal bacterial overgrowth (SIBO) is a condition in which excessive amounts of bacteria from the large intestines migrate up through illeocecal valve and take up residence in the lower portion of your small intestines where they don’t belong.
Some people with SIBO have constipation and some have diarrhea but majority have bloating, and notice that when they eat starchy carbohydrates, or If they take probiotics they feel very bloated. The symptoms of SIBO vary depending on the type and amounts of microbes present in the small intestine.
Remember what we said earlier, 95% of your bile salts are reabsorbed in the small intestines and that if we don’t reabsorb those salts they get dumped into the large intestines where they cause diarrhea.
So if you now have an infection in the small intestines aka SIBO, not only will you not reabsorb those bile salts but you are also going to create all sorts of vitamin deficiencies such as ADEK, B12and other B vitamins.
And the last consideration when it comes to diarrhea is a commonly overlooked area which is autoimmunity.
Now you might be thinking, Dr Hagmeyer my doctor tested me for Crohn’s, Celiac and he even tested me for Ulcerative colitis and those have all been ruled out. Are you saying that the cause of my diarrhea is from an autoimmune disease? And the answer is yes.
New research shows that some patients who have IBS have an autoimmune variant that was initiated after an infection this is being called Autoimmunity Induced- Post infection IBS.
This is due to the work of Dr Mark Pimantel from Cedars Sinai Medical Center.
His research shows that In about 10-20% of people and this number could be growing, an attack of gastroenteritis (food poisoning, travel to another country, water contamination, etc) may be followed by persistent diarrhea and abdominal pain.
Another words there is no sign of continued infection, but the symptoms of diarrhea persist months or even years.
Research suggests that this post infectious diarrhea is associated by a mild inflammation in the bowel and often has a systemic effect on the body leading to symptoms of anxiety, depression.
This is something I have seen quite often with my patients who have diarrhea, have tested negative for Celiac, Crohn’s, Diverticulitis and UC but yet they had markers indicating intestinal inflammation such as Lactoferrin, Eosinophil protein X and Calprotectin levels.
So this test that specifically looks at this possible contributing cause to diarrhea is a blood test that identifies anti-Cdtb stands and anti-vinculin antibodies
Heres what happens….. you get a bout of food poisoning or get exposed to a toxin that is produced by E. coli, Salmonella, Shigella or Campylobacter called Cdt-B toxin. It stands for (Cytolethal Distending Toxin B).
You break out with the typical symptoms of watery diarrhea, maybe you are throwing up, maybe you have a fever.
The antibodies produced attack the Cdt-B toxin but it also attack a protein within the lining of the intestinal tract call vinculin.
Vinculin helps these cells connect and communicate electrical signals to contract your smooth muscle allowing peristalsis.
If vinculin is damaged or destroyed, the electrical signal telling the muscle in your gut to contract and propel food, waste and bacteria are disrupted this can lead to depending on the kinds of bacteria either diarrhea or constipation.
Points To Remember
So in closing today’s video I know we unpacked a lot of information there are couple things I want you to remember about chronic diarrhea.
#1 Disbiosis, Bile acid malabsorption, SIBO, Autoimmunity caused by past infection are all thing that need to be considered when someone with diarrhea feels like they have hit a plateau or is not seeing improvement in their health.
#2 its important to understand the root cause of your diarrhea and the root cause in one person may not necessarily be the root cause in a person with identical symptoms. This is why I don’t suggest you embark on this journey alone.
#3 We talked about the various testing needed to help uncover some of those root cause. We talked about the microbiome, we talked about pancreatic elastase, we talked about inflammatory markers, we talked about SIBO, we talked about CTD-b and vinculin.
#4 For many people with diarrhea, we get so hung up on diet that all of these things we talked about today go undetected and If you have changed your diet and you still are not noticing a difference, its time to look into some of these other mechanisms. Don’t give up on your diet because this is where it all starts but work with someone who can help you navigate through this very complex condition.
Until Next time, take care.