Episode 25: Abdominal Pain Due to GI Disorders | Hernia Talk LIVE Q&A

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Speaker 1 (00:00:00):

Hi everyone. We are live on hernia talk live on Tuesdays every Tuesday. As you know, share this time with me where I talk about hernias, which is my love. And then I have a special guest panelist who I respect in their field and who helps augment how much we all know about hernias. Today’s guest panelist is a very good friend of mine. Oh, before we go on this will be on Zoom for many of you as well as on Facebook Live. And after we’re done today, I will make sure it is posted on all the different online panels, including herniatalk.com and on my YouTube channel. Today’s guest panelist is Dr. Leo Treyzon. He is a very special gastroenterologist who I work with in Los Angeles. He’s a friend of mine, he is my gastroenterologist, and I also share patients with him, so he’s very well versed with the needs of our hernia patients. So without further ado, please welcome Dr. Leo Treyzon.

Speaker 2 (00:01:12):

Hi, Dr. Towfigh. Thank you for the introduction and it’s a pleasure and honor to be here and meet this new community of friends and patients and happy to help out in whatever way I can.

Speaker 1 (00:01:24):

Thank you so much. So as you know, we share a lot of patients, and one reason why a lot of my patients seek your help is because they come to me with hernia questions and problems, and a lot of it is mixed in with GI symptoms, diarrhea, bloating, constipation’s a big one. My audience knows it’s not cool to have constipation and strain when you have a hernia, so that’s another thing that I’m very in tune with. But I feel that gas gastroenterologists in general, especially in Los Angeles, are really good at colonoscopies and endoscopies, but there’s very few of them, and you’re one of them where you take the time to educate the patient, talk with the patient, and not just do procedures. I feel that GI has become such a procedural oriented specialty, which is surgery too, but what makes my practice different, and I think your practice specifically is you spend much more time talking with a patient and doing non procedural stuff which is what my patients mostly need. They don’t need a colonoscopy usually. And so I really do value the fact that you offer that to my patients. So thank you.

Speaker 2 (00:02:51):

My pleasure. Yeah, I would say that I’d say that there are really different kinds of gastroenterologists and we tend to separate ourselves into two different groups, kind of like a therapeutic interventional gastroenterologist and a diagnostic type of gastroenterologist. And I’m more in the latter group of diagnostic gastroenterology, trying to figure out what’s going on and what are the best non-surgical lifestyle kind of interventions that we could do to help people feel better. As you mentioned, there’s a lot of overlap in the things that you see and the things that I see. Yeah, I find that taking a good history understanding what the symptoms are about, not just what are the symptoms, but what the impact is on a person’s quality of life and how that affects them, what they’re scared of, what they’re hoping to accomplish. These are the things that are best done with a discussion as opposed to a camera test or an x-ray.

Speaker 1 (00:03:59):

I agree. And I think your practice is actually special in that you do have interest in nutrition, in inflammatory disorders, special diets, and how they can impact GI systems. So I think that I hope that you share a lot of that with our audience. I’m going to learn a lot. I know this hour I learned from your notes actually what you tell your patients, but we have a lot of questions. We already have tons of people coming on. In fact, multiple groups have already signed on. The Global Pelvic Health Group is also LinkedIn today, so this is great. Thank you to Tracy Cher for linking this Facebook Live with her group. But can we go through some maybe definitions first to, so that people understand there are two main words which maybe people don’t understand or have heard about. One is IBS and one is SIBO. Can you just explain those two first because they’re, they’re going to come up a couple times this hour.

Speaker 2 (00:05:08):

Absolutely. So first of all, there’s overlap between these two terms, but I’m going to define what I think is going on with each term. Irritable bowel syndrome is a condition that we could diagnose by taking a historical interview and it requires no testing whatsoever. You could describe your symptoms to me and I could say you do or don’t have this condition. And it’s basically it’s defined as chronic abdominal discomfort associated with altered bowel habit. And the key parts of that are that it’s chronic and we think of that as more than six months. So if you started developing these symptoms week, two weeks, four months ago, we really call you irritable bowel syndrome until you’ve met our kind of cutoff on time, which is six months or so. Now, obviously you could be an early IBS patient or irritable bowel syndrome patient and we can make a prediction, but it’s really when it’s more of a chronic nature this condition is also requisite that you have altered bowel habit, and that means either constipation or diarrhea. Now, there are people, and frequently some of your patients, Dr. Towfigh have alternator that go back and forth between diarrhea or constipation, and it’s hard predict when it is. Right. We also have what we call mixed types in addition to alternator where they have a set bowel habit, which is for example, constipation, but their main problem is really the pain or the bloating or something like that. So we mm-hmm call that mixed type where there’s bloat and constipation or diarrhea and pain, something like that. So

Speaker 1 (00:07:04):

There’s no study for that. There’s purely a history. There’s no blood test or x-ray. They can show IBS. We

Speaker 2 (00:07:12):

Do have some new evolving diagnostics that are reported to be equivalent to a positive test, but it’s kind of like, is there an obvious agreed upon blood test for hernia? The answer is not really. It’s kind of like a clinical thing. You have to examine it and see it and whatever. So the short answer to your question is there’s a new blood test developed by researchers at Cedar Sinai which is antibody tests,

Speaker 1 (00:07:47):

Which is our home type, our home hospital.

Speaker 2 (00:07:50):

Exactly. And one of my mentors and kind of leaders in this field, Dr. Pimentel, developed an antibody test, which looks for antibodies against vinculin as a marker of irritable bowel syndrome. There’s new and evolving things as well, such as these little sensors that you could place on belly and they could hear your bowel sounds and they could make a prediction that you have IBS with reasonable accuracy. These are kind of the evolving diagnostic tests. But what I want your audience to remember is you could kind of make this diagnosis by the following things. If you have chronic abdominal pain or discomfort and bloating, when you get full and bloated, that’s kind of like a form of pain. And it’s associated with altered bowel habit, which is either constipation or diarrhea. And if there isn’t an obvious other cause such as a bowel obstruction, cancer, whatever, then you have irritable bowel syndrome. Okay. It’s that easy. Okay.

Speaker 1 (00:08:57):


Speaker 2 (00:08:59):

Small intestinal bacterial overgrowth, S I B O, also known as SIBO, is one of the many causes of irritable bowel syndrome.

Speaker 1 (00:09:10):


Speaker 2 (00:09:11):

Okay. I’m going to go over some of the other causes of irritable bowel syndrome right now before I get back to what is SIBO. Examples of causes of irritable bowel would be lactose intolerance, fructose intolerance, stress induced irritable bowel syndrome, medication induced irritable bowel syndrome. There is insufficient digestive enzymes, there’s bile acid, mal-absorption, exocrine, pancreatic insufficiency. So we think of these 10 different conditions that could cause THE irritable bowel syndrome and small intestinal bacterial overgrowth as one of those conditions. In my personal experience, I think it’s by far the most common cause in the people that come see me. Now, maybe that’s because the easy stuff people don’t come see me for such as pure lactose intolerance, pure gluten intolerance. They’ve already kind of figured that out on their own and by the time they come to see me, I’ve filtered that out. But what we see so much nowadays is this bacterial overgrowth.

Speaker 2 (00:10:26):

And now I want to define what that is. Technically bacterial overgrowth is when there is greater than 10 to the fifth colony forming units of bacteria within the small intestine. It’s say the official definition of it, but that’s really impractical because we can’t make those kind of observations readily cause we can’t culture out bacteria readily. So instead we have this surrogate test, which is a good representation of what it would be if we did culture. That test is a breath test called a hydrogen breath test. And more commonly the version of the hydrogen breath test that is done is called the lactulose hydrogen breath test. That’s the one you and I order for our patients with suspected SIBO. There’s also other versions of it called glucose breath test, but for the most part that’s what we do. And if you want, I could explain what that test is, Dr. Towfigh.

Speaker 1 (00:11:33):

Yeah, please do. Because actually one of the questions that was presented was, why don’t enough doctors know about SIBO? I see a lot of patients from out of state now in Los Angeles, especially since Cedar Sinai is so in tune with SIBO. I feel like that term is more commonly available and used for patients, but I see a lot of out-of-state patients and I say, oh, well this sounds pretty classic for small intestinal bacterial overgrowth. And they’re like, I’ve never heard of that and I have to explain to them, et cetera. But I feel like this is a good question, which is a lot of doctors in your own specialty don’t even know about SIBO. Can you talk about

Speaker 2 (00:12:20):

That’s right. I would say whether they know about it or don’t want to kind of admit to something I is the issue at hand, and I’ll give you a couple of names.

Speaker 1 (00:12:30):


Speaker 2 (00:12:31):

I think it’s hard for older fashioned gastroenterologists to believe that there’s a way to cure or substantially improve a chronic condition with a simple treatment.

Speaker 1 (00:12:43):

Got it.

Speaker 2 (00:12:44):

Cause irritable bowel syndrome is chronic, and we think that in order to solve a chronic condition, you need a daily intervention. For example, it’s common to give antidepressants for irritable bowel syndrome, not because people have depression, but because their nerves are activated in the gut or it’s common to do a dietary intervention or maybe an anti-diarrhea or a constipation medicine. But what’s exciting about bacterial overgrowth is that of the causes of irritable bowel syndrome, it’s the only real paradigm in which you could do a one and done treatment and get substantial relief of symptoms for exactly weeks, months, or years. And that’s uncommon. And so doctors, getting back to the original question is they’re like, we just don’t believe that that could happen. And when you don’t believe in something and you don’t try it enough, you won’t see the positive benefits. So that could be why. It could be time of when they trained or what they did. And usually it’s the older doctors that don’t do as much

Speaker 1 (00:13:51):

If you, but the testing is, it’s like non-invasive. You have to breathe into a bag.

Speaker 2 (00:13:57):

What it involves is doing 10 breaths spaced over three hours, and you do it on an empty stomach, usually first thing in the morning. So you could work while you’re doing this breath test if you’re doing a home breath test like we do in our office.

Speaker 1 (00:14:12):

Wow. Home testing. That’s pretty

Speaker 2 (00:14:14):

Cool. Yeah, it’s like 90% of our tests are done at home now because we mail them a kit and they follow the instructions. And then there’s a little bit of a dietary intervention the day before where you don’t eat carbs for one day so as to not make it falsely positive. And you wake up in the morning, you do this 10 breath sequence and blowing those breaths into a bag after the first breath, there’s a sugary drink that you got to drink. It’s tastes really neutral, small, not bad for you in any way. You drink it. And then over the next 10 breaths, we see how the little bacteria in the gut metabolize that sugar if they go crazy on that sugar. And the levels of hydrogen or methane or hydrogen sulfide go up in your body and you do it earlier than when we think that liquid is in the already.

Speaker 2 (00:15:09):

Yeah. We have bacterial overgrowth with reasonable accuracy. When that’s the case, we usually offer you the different treatments for small intestinal bacterial overgrowth. And if you’d like, I could go over the three main categories of treatment. The first is antibiotics, which are antimicrobials, the second is dietary, the third is supplements. And there’s a fourth kind of category which gets at the heart of the problem in my opinion, which is things that accelerate the intestines to move better so that the problem doesn’t occur again. And we call that a prokinetic. So in my practice, what the typical pattern of treatment is when someone presents with bacterial overgrowth on the breath test and the clinical makes sense too. We give them an antibiotic for two weeks, and by the way, it’s a really safe antibiotic. What makes it safe is nature

Speaker 1 (00:16:17):

Take. They take it by mouth. The body doesn’t see, it just stays in the intestine.

Speaker 2 (00:16:21):

Yeah. It’s a pill that hangs out just for a little while. It doesn’t get absorbed into the bloodstream, so it can’t cause bad side effects like liver, kidney, just cause it’s job in the gut. And then you poop it out and then you do that three times a day usually for 14 days. And then afterwards you have this real sense of relief from the main symptoms and then hopefully that lasts for a while. If it doesn’t, then we move on to treatment.

Speaker 1 (00:16:53):

What’s the name of the antibiotic?

Speaker 2 (00:16:56):

There’s lots of different ones. We don’t have an exclusive one that we use, but the most common one that we like is called rifaximin under the brand name Xifaxan. And depending on whether you have different types of gases and I identified on the breath test, we might do a second antibiotic with it. Those are neomycin or metronidazole? Depends on the clinical scenario. But those two are often well tolerated at low doses, which is what we do.

Speaker 1 (00:17:29):


Speaker 2 (00:17:30):

If it doesn’t work, but most of the time it does, then we offer a dietary therapy. And the dietary therapy is mostly meant to prevent the recurrence of fermentation and fer, fermentable gases in the gut. One such diet is called the low FODMAP diet. Yes. And that’s F O D M A P. That stands for fermentable, oligosaccharide, disaccharide, monosaccharide, and polyols. And this is a true

Speaker 1 (00:17:59):

Diet. Hold on. What does it stand for?

Speaker 2 (00:18:02):

Okay, it stands for fermentable, oligosaccharide, disaccharide, monosaccharide and polyols.

Speaker 1 (00:18:14):

Oh my God. Okay. Yeah, that was one of my questions. What’s a FODMAP diet? But I didn’t know what it stood for.

Speaker 2 (00:18:20):

Yeah, FODMAP sounds for these. Basically

Speaker 1 (00:18:24):

I like FODMAP better. <laugh>

Speaker 2 (00:18:27):

Mouth salad. Okay.

Speaker 1 (00:18:29):


Speaker 2 (00:18:30):

Basically it’s a bunch of small little sugar molecules that are found in healthy foods and unhealthy foods.

Speaker 2 (00:18:39):

That’s part of the confusion is people think they eat so well, meaning they eat organic and healthy and low carb, low fat, and they’re still not getting better. And they get confused by that because they say things like, I’m eating the healthiest diet, I eat so little yet, I’m still so sick. So the FODMAP diet excludes certain things and I’m happy to go over what those things are and just a sac. But basically you do that for two weeks, and the concept is you start off feeling unwell before you do the diet and then you do the diet. And if you feel great after that, then that it was something that you were previously eating that you’ve taken out that has been responsible for your improvement. So now the challenge is to figure out which one of those 20 things that we asked you to hold off on was the culprit. And the way we figure that out is by reintroducing one at a time.

Speaker 2 (00:19:39):

For example, we do one ingredient or one group of ingredients for four days in a row. And if you want from feeling amazing to again feeling irritable bowel, then we know that that’s the thing that was messing you up. At least that’s one thing that was messing you up. So for example, frequently we’ll reintroduce gluten into the diet and then you’ll get bloated again and we’ll be like, Hey, you’ve got gluten intolerance. That’s all there is to it. And that’s how we prove it to you. And then after you reintroduce gluten, then you do lactose, then you do garlic, then you do onion. And I’m happy to review with you what I think these fermentable foods are.

Speaker 1 (00:20:20):

Wow. Yeah, that’s pretty interesting. So what if you just do a fad FODMAP diet naturally if you have no IBS?

Speaker 2 (00:20:28):

Yeah. I mean in general, any

Speaker 1 (00:20:30):

Benefits to that?

Speaker 2 (00:20:31):

No, there aren’t. Okay. If you’re a healthy person, you shouldn’t eat a restrictive diet. There’s no advantage. And some of the things that we take out in the FODMAP diet are some of the healthiest foods. So we don’t want to restrict you for no good reason.

Speaker 1 (00:20:46):

No. We have some more questions regarding SIBO and IBS. So we hear the term leaky gut. How does that fit into the IBS/SIBO discussion? That’s

Speaker 2 (00:20:59):

Like another novel way of thinking about irritable bowel syndrome. And what that means is there are these tiny little pores in the intestinal walls called loose junctions. And in people who have I b s, they tend to have more of these pores and the foods that we eat and the little bacteria that are hanging out trying to digest food could go through those pores and into the circulation. And when that happens, we get these systemic symptoms of fatigue, brain fog, feeling cold, irritable rashes, just things that sound a little weird kind of systemic symptoms rather than just gut symptoms.

Speaker 1 (00:21:43):

So actually a lot of what we do is her new pair with Mesh, and there are subset of patients that react to the Mesh and it’s more of a autoimmune or what we feel an autoinflammatory response. And they get that brain fog, rashes, joint pains, kind of chronic fatigue. Yes. Headaches, a lot of bloating weird neuropathic symptoms that go away once you remove that implant. So explain to me again, this concept. So how is the, oh, and by the way, the doctor we spoke to who’s one of the leaders, he’s talked to the FDA and everyone about this issue with implant reactions bloating and nausea, and IBS is a very prominent feature of these implant reactions. So what’s the reaction? Is it this kind of leaky gut or irritable bowel syndrome as a secondary problem to the systemic reaction

Speaker 2 (00:22:45):

Going on with the Mesh thing, and I’m not knowledgeable enough about Mesh, but I would say that there is an immune reaction that happens to foreign body introduction. And even though you have an inert foreign body, it’s still possible to react. Correct. Now, when we have leaky gut within the gut, we are having an immune reaction that generates those tiny little cuts that is intestinal permeability, pores to open up. And I think what’s going on is that Mesh might be generating a response like that in the body because we know that we could generate leaky gut phenomenon even if we do nothing to the gut. If you have other kind of stressors or if you take other kind of medicines, it could generate leaky gut. If you get an intravenous formulation, it could elicit these kind of responses. Without knowing enough about Mesh, I would wonder if there’s some sort of cross immune reaction that’s happening for you to know the biggest immune organ in your body is the digestive tract. True. So whether the site of inflammation is within the gut or outside the gut, we think the gut often reacts to these external cues too.

Speaker 1 (00:24:07):

Very good point. Very, very good point. Other questions, have you ever seen cyber linked to mold toxicity or mold exposure?

Speaker 2 (00:24:17):

Yes. We should also say that there’s different kinds of overgrowth. So there is bacterial overgrowth, and then there’s fungal overgrowth, which we refer to as SIFO, small intestinal fungal overgrowth, SIFO.

Speaker 1 (00:24:33):


Speaker 2 (00:24:34):

Unlike where the advances we’ve made in bacterial overgrowth with the breath testing, it’s a little bit harder to prove SIFO. The main ways we do better with the invasive fungal aspirates through an upper endoscopy also has its own problems. And then secondary ways that we do it is by doing stool cultures and looking for fungus. And sometimes we have to take a leap of faith based on the historical background of what people describe. And what I mean by that is if they have other forms of mold overgrowth, if we could see mold in other body parts, if they’re exquisitely sensitive to sugars and candida kind of things, then we could kind of rationalize that and we could do an intervention against fungal growth based on the clinical background. So we don’t have great diagnostic capabilities in 2020 for fungal overgrowth. Your original question and by the way, thrush in the mouth is not adequate enough to diagnose fungal overgrowth in the body. A lot of people have that. If you take an inhaler for asthma, you’ll probably have thrush. Got it. Okay. But what I want to say is that in 2020, we just don’t have great ways of figuring that out, and we kind of have to rash reason it through.

Speaker 1 (00:26:04):

We have two questions on food allergy testing. Does food allergy testing give you any information to help address IBS or no?

Speaker 2 (00:26:14):

In short answer, no. Okay. The reason for that is food allergy is not one of the forms of the irritable bowel syndrome. It’s a distinct condition. The symptoms of food allergy are quite different than the symptoms of irritable bowel. Now, you could have someone that’s got two things. For example, if I’m allergic to kiwi, I might also have lactose intolerance and have IBS from that. Okay. Food allergy is different. Food allergy, extremely easy to diagnose. We have blood tests and skin pricks. Right. Okay. The symptoms of food allergy are hives, rashes throat swelling, lip swelling, watery eyes, occasionally nausea and vomiting, occasionally excruciating abdominal pain. Occasionally, I know your patients with hernia often get excruciating abdominal pain, so I don’t want them to focus on that. That’s a rare manifestation of allergy, but it’s easy to differentiate food allergy from IBS. What is very hard to do is to differentiate food sensitivity from IBS.

Speaker 1 (00:27:28):

Okay. Got it. It what

Speaker 2 (00:27:29):

I want your patients to know, and this might be a little contentious, Dr. Towfigh, is that the food sensitivity testing that is commonly done in my opinion, doesn’t really accurately get to the heart of what’s going on in people’s bodies. I think doing a careful history and dietary review is a better way to figure out what people are food sensitive to. And a dietitian nutritionist are probably better at it than the fancy, really expensive food sensitivity tests that are so popular nowadays.

Speaker 1 (00:28:10):

Going back to the FOD, going back to the FODMAP diet. So just to clarify, is it not healthy? Is one of the questions, is it not healthy to remain on a FODMAP diet for a long period of time?

Speaker 2 (00:28:23):

In general, we’re not excited about it. Now. Some people really need it in order to avoid pain and suffering, but in a perfect world, we would like for it to be a short-term intervention. And I like to think of the FODMAP diet as a test more than a treatment because it tests what you’re sensitive to. Now it does that by making you feel better along the way, but there are some downsides to being on a highly restrictive diet for a long time. Just real briefly, one of those things is emotional baggage and emotional strain. All the stresses.

Speaker 1 (00:29:03):

What do you mean? What are you talking about? I’m just kidding.

Speaker 2 (00:29:07):

When you’re always eating and fearful that you’re going to just mess everything up, that eventually ends up leading to disordered eating. Mm-hmm. And this population that you and I deal with a lot is because these people have been suffering so much, they’ve developed these aversions and habits, and it often leads to disordered eating, which we care about. Number two, it might not be nutritionally complete with time. You might not be getting adequate vitamins and minerals. Got it. Argue back and forth amongst the doctors, how much time is required. What I want you to know is in general, it’s a good thing to do for two to six weeks as the testing phase. And then there’s a reintroduction phase that last about also six weeks. And that should be it. If you’ve figured out that you’re exquisitely sensitive to all FODMAPs, then that’s a person who needs to be continuous dietary surveillance and doctor surveillance. Correct. But these diets are meant to be done on your own. You don’t need a doctor to do this.

Speaker 1 (00:30:10):

We have a question about a patient who says that she has I B S and has many food intolerances. She also has an I G A deficiency and was told that she has SIBO, the small intestinal bacterial overgrowth when treated with Xifaxan. The antibiotic that you mentioned. She feels better though. She’s never had the breath test. Her doctor now wants her to take Xifaxan once a month for two or three days to keep things in check. Does that sound acceptable? You ever heard of that kind of maintenance Xifaxan?

Speaker 2 (00:30:43):

So that’s an unusual dosing pattern, but my hunch is that it would work. There’s so many hand created, personally created dosing regimens of Xifaxan. And by the way, this patient has figured out and the doctor has figured out that it’s recurrent and it’s common. So if you could come up with a strategy of how to keep it at bay using safe medicines, even though that is off-label use, what they’re doing is not the way it’s meant to be done. It sounds like a reasonable kind of thing.

Speaker 1 (00:31:20):

Now this is something that I really would like to discuss because there’s a lot more questions will become with it, which is what’s the relationship between SIBO and chronic pelvic pain, especially in women endometriosis and even just having surgery? Does that contribute to SIBO, not just hernia surgery, but surgery?

Speaker 2 (00:31:40):

Yeah. Why don’t we go through each one one by one. Yes. Okay. So is there a relationship between chronic pelvic pain and SIBO? And the answer is yes, there is. People with chronic pelvic pain often tend to take medicines in order to treat it. For example, things that slow down the intestines or maybe people with pelvic pain have simultaneous constipation or diarrhea that overlaps. And there’s usually a high concordance with bacterial overgrowth if tested the pelvic pain, it’s the pain response or the experience of pain does not make SIBO, or at least not that I know of. Okay. So it’s not like just being in pain here all the time, mentally perceiving it will make SIBO happen. But there’s often an overlap in terms of, Hey, if I took people with pelvic pain and checked them for SIBO compared to people who don’t have pelvic pain and check them for SIBO, I know which group is going to have more pelvic pain patients.

Speaker 2 (00:32:51):

Number two, endometriosis very high concordance between endo and SIBO also. Yeah, that’s what I read. That’s so interesting. And also between adenomyosis of the uterus and SIBO, and as you know with endo patients, there’s also, there’s often adeno as well. But with regard to that the reason might be because with endo, there’s these deposits in the abdominal cavity in the peritoneum. Yes. Makes things sticky. Parts of bowel are stuck to each other where there’s tugging on bowel by the endometrial deposits that leads to a chronic dismotility state altered motility, also known as peristalsis or the natural contractions of the intestines. And so that is one mechanism by which endo causes SIBO. There’s a second mechanism, and that is endo is a central nervous system activating condition, meaning we know that patients have different perceptions of pain than people who don’t have endo. Okay. They rank on a different level because they’ve been in pain for so long that they have a different relationship with pain.

Speaker 2 (00:34:13):

When you have a different relationship with pain, you’re more likely to experience irritable bowel syndrome because you have what’s called visceral hypersensitivity. That means the nerves are just activated in a different way. That’s why one of the core tenets of endometriosis treatment is also treatment of central nervous system activation, meditation, yoga, massage, even meds for central nervous system activation. And then lastly, there’s an evolving role for what’s called mass cell activation syndrome. So we know that around the endometrial deposits in the peritoneum, which is the lining of the abdominal area there, when you have these endometriosis deposits, if you were to biopsy that area and send it for surgical pathology evaluation, Dr. Towfigh, and you asked the pathologists to look at how many nerve cells there are around the endometrial deposits compared to how many nerve cells there are in places there you will see an over accumulation of nerve cells right near the endometrial deposit. So it’s like they’re ready to feel pain, these people with endo. Wow. Okay. So that’s the third. And there’s probably more too a as to why there’s a concordance between endo and SIBO. And then what’s the role of surgery and SIBO? Well, here’s the thing is that if your intestines stop moving, you’re going to build up the natural bacteria that you have and you’re going to overgrow your intestine most likely. Not always, but often. And so people that get surgery often have temporary freezing of their intestines. They’re just not moving as quickly as they need to, which is why we often have to give a stimulant to help them move, to give them constipation treatments to move.

Speaker 2 (00:36:27):

Cause when you inflate the belly with all the gas, it kind of gets stunned for a little while and it’s slow to resolve. You would know better than I would on that, but there’s a lot of reasons. And then look, if you’re having surgery, it means usually you have some pain problem. People with pain often take pain meds. Pain slows the gut. I mean pain meds slow the gut, and they’re often responsible for the overgrowth of bacteria.

Speaker 1 (00:36:55):

What about the antibiotics? Most surgeries, we give some antibiotic as a prophylaxis to prevent wound infection. And even colonoscopies you’re on certain antibiotics. Can those change the bacterial growth patterns and contribute to SIBO?

Speaker 2 (00:37:13):

Excellent question. So just as a point of clarification, we don’t give antibiotics for colonoscopy. We don’t do that. But we do give antibiotics in the perioperative period for major surgeries or even sometimes minor surgeries where there’s risk of infection

Speaker 1 (00:37:29):

A lot. We do a lot of antibiotics.

Speaker 2 (00:37:31):

I don’t think that those perioperative short courses, especially Ancef or Keflex, which is the one that is often given, tend to induce SIBO. Okay. Yeah. The one that I feel can disrupt the balance of the natural balances in the gut are things like Cipro Levaquin. These ones tend to be bigger kind of actors in this space. Now, most of the time you’ll give it, you’ll do just fine. But there are a subset of P patients who were fine before they ever got the antibiotic. Then you do it and it’s like things are totally different after. Hopefully it goes back to normal. But I’m sure you’ve seen those people too. Everything was great. They had an ear infection, they got an antibiotic, and things were never the same again.

Speaker 1 (00:38:22):

They are dental or something like that. And then they’ve been bloated ever since. And exactly the typical story I hear is that they wake up flat and then the minute they brush their teeth or drink their first glass of water, like whoop, they look pregnant. And it’s a more significant bloating than a little bit of bloating from eating too much.

Speaker 2 (00:38:43):

Yeah, they look pregnant. They

Speaker 1 (00:38:44):

Look pregnant. Male or female. Yeah,

Speaker 2 (00:38:47):

Definitely something we hear. And I want to also take that point. That’s a really helpful feature for us to think about SIBO, because if you’re bloated all the time, if you look pregnant when you wake up in the morning, yeah, it almost sounds a little bit different than SIBO.

Speaker 1 (00:39:01):


Speaker 2 (00:39:02):

It’s usually food will induce it when it gets really bad. Even water starts pissing off the bacteria and causing you to understand. And you’re right, that’s a really common thing. We hear that as the day goes on, people feel worse. Usually their best time of day is in the morning before they eat.

Speaker 1 (00:39:21):

So there we have multiple questions about surgery and hernia repairs and Mesh, and whether adhesions or stickiness of the intestines because of surgery or even to the Mesh because you can get a he just without Mesh, obviously, in addition to with Mesh. Whether that contributes, I would say for sure. Now the majority of people that I see who have IBS type symptoms don’t actually have an intestinal mechanical problem. In other words, if you operate on them, they’re intestines are not obstructed or at all. And it may be multifactorial, but what are your thoughts about IBS after surgery, either due to Mesh or adhesions to the Mesh or adhesions from the operations itself?

Speaker 2 (00:40:12):

So with regards to adhesions, there’s a lot of people who have adhesion. Pretty much A lot of people who have major abdominal surgery, especially with peritonitis or a leakage or advanced, they tend to form adhesions, but not all of them develop irritable bowel syndrome. And why certain people do and certain people don’t, is hard for me to figure out in general.

Speaker 1 (00:40:36):


Speaker 2 (00:40:37):

<laugh> when you know, tend to, for upper abdominal surgeries like let’s say gallbladder or esophageal gastric surgeries done under the diaphragm, the IBS symptoms are not as common. It’s usually pelvic kind of surgeries for whatever reason. That tend to be my experience at least more associated with that. I agree with you that there’s no mechanical obstruction in these people with adhesions, at least not occasionally. We clearly get mechanically obstructed people. Yeah. It’s not going to be obvious on it’s going to take someone like you. I know you look at all your films really carefully and you see those, those subtle phenomenon or this whatever the subtleties of hernia are. So similarly we have to look at with our radiologists like what those subtleties of adhesion bowel disease are. Correct. And often we have to take a history of what that feels like for them too. But the short answer is I don’t think adhesions often cause irritable bowel syndrome. I think adhesions often cause pure pain. Okay. As opposed to the, I’m getting diarrhea and constipation. Business bowel disease people are pain patients. They’re not ultra bowel habit patients as much. There’s always variations in those groups.

Speaker 1 (00:42:06):

And the reason why lower abdominal or pelvic surgery causes more obstructions or pain or an adhesions has to do with where the small intestines tends lie. And we are upright beings. So because we’re upright, a lot of the adhesions, well, a lot of the intestines laying in the lower abdomen and adhesions occur from the surgeon doing an operation at the area of the procedure. So if you’re doing a pelvic surgery, you’re going to have bleeding inflammation and then healing in the pelvis. And that makes places very sticky. Inflammation makes it sticky, and now you have intestine in the vicinity and it can get stuck there. So we see more from a surgeon’s standpoint, we see more mechanical obstructions from people who’ve had pelvic surgery, whether it’s colorectal or GYN than from other elective operations. So that’s kind of a question here about again, the whole issue of slowed motility, whether it’s due to adhesions or Mesh or endometriosis. What about this idea of ileocecal valve dysfunction and visceral manipulation? Can you comment on those two as a cause and a treatment of Absolutely.

Speaker 2 (00:43:30):

Okay. So as a definition, ileocecal valve is a one-way valve that allows small intestinal contents to come into the colon and then go down and you poop it out. It rests in the right lower quadrant, kind of like where the appendix is right around here. And it is a valve that should not let stuff from the colon come up north into the small intestine. It should only allow southward flow. Okay. Correct.

Speaker 1 (00:44:08):

Meaning unidirectional. Yeah,

Speaker 2 (00:44:10):

Exactly. Okay. So if you’ve got a dysfunctional valve, the implication is that it allows things to come from the colon into the small intestine. I personally don’t think that the ileocecal valve is a highly relevant factor in of bacterial overgrowth. And the reason I say that is even when we do a resection of the colon, A right hemicolectomy, and we remove the last part of the colon and the last part of the intestine, we put ’em together. Not all those patients get SIBO and they may have bidirectional flow. Now they’re more often likely to, people talk about, it’s my belief that the people who talk about ileocecal valve dysfunction tend to be the same people who do the visceral manipulations or that condition. And to a surgeon, everything looks like a surgical problem to a visceral manipulator, everything looks like that kind of thing. And gastroenterology, everything looks like SIBO. Just kidding. But <laugh>

Speaker 1 (00:45:21):


Speaker 2 (00:45:23):

That we’ve met a lot of people who have totally widely patent ileocecal valves mean wide open, such as a Crohn’s disease patient, and they’re not complaining of SIBO. And I will say this, everyone who has asked me to do an evaluation of their ileocecal valve competence, and they’ve never had Crohn’s, they’ve never had surgery to the area. Every time we do it, we find that it looks beautiful and we think it works beautifully too. So it’s a low yield kind of thing. That’s the downside in doing a visceral manipulation for ileocecal valve dysfunction. No, no. So I say, Hey, if it works, go for it. If anything works and it’s safe, go for it.

Speaker 1 (00:46:06):

Sure. And honestly, if you have a hernia or if you had a hernia surgery, also that visceral manipulation is perfectly fine and safe. We have a couple questions about adhesions and how to prevent adhesions. Surgery will cause more adhesions. Some surgery causes less. So the less we think the less you touch the bowel especially with gloved hands because there’s talk sometimes on the gloves or powders the less adhesions. So in general, laparoscopic and robotic surgery causes much less adhesions than open. Also less bleeding, you have the less adhesions. So an emergency surgery or a bloody operation will cause more adhesions than a more elective less bloody operation. So those are two ways to reduce the chances of adhesions after surgery. Infection, inflammation can cause adhesion. Let’s say you had appendicitis that’s going to cause adhesions or an ulcer, like a bad ulcer and then surgery is necessary for a critical adhesion. But just having adhesions with no symptoms, there’s no indication to have surgery. Just wanted to clarify that.

Speaker 2 (00:47:27):

Yeah, I would agree with

Speaker 1 (00:47:28):

That. Yeah. Okay. So here’s a comment more from one of our experts in she’s part, she’s a really amazing force in the pelvic floor dysfunction world. Tracy’s chair. She says, as someone who has been trained in visceral manipulation, I truly believe it’s more about affecting the parasympathetic nervous system than opening valves. What are your comments on that?

Speaker 2 (00:47:54):

Yeah, I totally agree. There’s a lot of autonomic dysregulation in mm-hmm. I B s patients. That’s why they kind of sometimes talk about fast heart rate light headedness. Okay. Things like that. So yeah, I would agree with Tracy. That is something that would make sense to me on a physiologic level.

Speaker 1 (00:48:21):

The question

Speaker 2 (00:48:21):

You say, I do want to just shout out to our manipulators of the organs. It does work. Okay. Yes. And what I mean by that is there are other forms of medicine where people are really trained to do manipulations well of the abdominal organs, and it really does help with gas movement of bowels. And it’s not uncommon to solve people’s problems with constipation in a small subset of people through these visceral manipulations. You just need to know someone expert at it and familiar with what they do. Great.

Speaker 1 (00:48:57):

Agreed. Here’s another question. Is abdominal pain in addition to rectal urgency, a prerequisite for diagnosis of diarrhea? Predominant IBS I have diarrhea for decades duration or can isolated chronic diarrhea be with severe rectal urgency? Be okay? This is weird. Oh, they’re talking about diarrhea, predominant diarrhea versus diarrhea. Predominant IBS.

Speaker 2 (00:49:27):


Speaker 1 (00:49:28):

You So you need to have rectal urgency necessarily, or not necessarily?

Speaker 2 (00:49:32):

No. In order to have IBS, you don’t need to have rectal urgency, for example. You could just have liquidity, but there’s no urgency that every morning at eight o’clock or so, you’re going to go to the bathroom and it’s going to be liquid. Yeah. So you don’t have to have it be urgent. But the urgent is often a freaking component of the presentation.

Speaker 1 (00:49:55):

And what’s the definition of diarrhea? Some people just a loose bowel movement, they’ll be like, oh, I’ve got diarrhea as a surgeon, I’m always worried about a postoperative infection, like a clostridium difficile associated diarrhea. So I ask, is it watery and how many times a day? So if it’s more than three times a day and it’s watery, then I get worried about c diff. Otherwise I don’t worry about it. But what’s your definition of diarrhea when you’re talking about IBS diarrhea or diarrhea? Predominant IBS,

Speaker 2 (00:50:29):

Different things to different people. For example, it would be a frequency issue. If you go more than three times a day, we would mm-hmm. Often consider that a diarrhea patient. Okay. Okay. Or if you have liquidity of stool, that could be a diarrhea patient or if you have urgency. Okay. But let’s say you only go once a day and it’s formed, but you better run to get there, or you are going to poop all over yourself. We would kind of consider that a diarrhea person too. So what I’m trying to say is it means different things to different people, but in my mind, I would think of those people as a diarrhea kind of patient. Now, there are other conditions that cause chronic diarrhea, urgency, and multiple bowel movements a day. And it’s not just I B S T that mainly it’s lymphocytic or collagenous colitis. And that condition is when you do a colonoscopy and everything looks normal on the colonoscopy and you take a biopsy and look under the microscope, you could see these inflammatory cells called lymphocytes and they could cause a deposition of a collagen band, which is like a protein band, and just really hard to absorb your nutrients in that. So those people can have the symptoms that your questionnaire was asking about.

Speaker 1 (00:51:52):

Well, interestingly, there is a question on that. What about lymphocytic and collages colitis? I was biopsied for this, but only from the rectum. Is that adequate? Or should the GI colonoscopist sample sample more diffusely within the colon?

Speaker 2 (00:52:08):

I could answer that. So if they found the condition on the rectal biopsies, then it’s adequate. Okay. Most of the time when you have this condition, most of the time it’s diffuse. Okay. But we know that there’s a significant of proportion of people that if you only did a mini colonoscopy, which we call a flexible sigmoidoscopy, yeah. You’re going to miss it. So if that person had normal non-diagnostic biopsies, that is inadequate to exclude microscopic colitis.

Speaker 1 (00:52:42):

Oh, okay. Good to know. This is another question about that ileocecal valve question. This patient has constant pain in the ileocecal valve area, tugging and stabbing after a bowel movement that lasts all day. So bowel movement. But then there’s this right lower quadrant tugging and stabbing appendix is normal. Is this more of an IBS issue? And should the ileocecal valve be checked? Also? Apparently she also had a femoral hernia, which was incarcerated and then repaired so that the femoral hernia has been addressed, but now she still has this retinal pain with bowel.

Speaker 2 (00:53:24):

This is a little bit an atypical thing because to have right lower quadrant pain just after a bowel movement, and that’s a little weird. I would say there’s a couple of possibilities here. I question whether she has ad adhesions in this area from previous surgery, other surgeries she might have had, not necessarily the femoral hernia repair. Correct. And if she hasn’t had a colonoscopy, it would seem reasonable that that should be discussed. And then if not that an evaluation for bacterial overgrowth sounds prudent. I also want to say that there is this entity that I deal with a lot, which is pelvic floor dysfunction. I I’m sure UC does. Yeah. And you could have a lot of different causes of lower quadrant discomfort. Okay. The second those common place for endometriosis to be identified is in the right lower quadrant. When you take away the uterus in the ovaries area, if you were look elsewhere in the total abdomen, it would be the second most common is right lower quadrant. And as you know yourself, sometimes when you do an endometriosis excisional surgery, you often take out the appendix too, because there’s a high proportion of involvement inside the appendix. Correct. So it’s not just enough to look at imaging in order to figure that out. And then things that mimic right lower quadrant pain in my life are ilio psoas muscle tenderness. So if you’re an avid exerciser, you’re a big time spinner, think about whether you might have that. A good pelvic floor therapist could help you with that issue if you have hip pain,

Speaker 1 (00:55:18):


Speaker 2 (00:55:19):

That could be referred to the inner groin. So if you’re an older person with risk factors for hip pain, think about that. Or even a younger person,

Speaker 1 (00:55:26):

And we have a specialist for that coming up in a couple weeks.

Speaker 2 (00:55:30):

Oh, cool. Yeah. So I would say common things being common SIBO, that person needs to think about SIBO, they need to think about adhesion, they need to think about those kind of things. And SIBO seems like such an easy low-hanging fruit thing to Sure,

Speaker 1 (00:55:51):

Sure. Talking about colonoscopies I get this question a lot. Is it safe to undergo colonoscopy with a hernia? Or even after a hernia repair?

Speaker 2 (00:56:01):

We should talk about what kind of hernia they’re referring to. But if it’s gigantic abdominal wall hernia and things like that, which is really rare, massive, where just everything needed to get mobilized in order to solve that I would say it’s very safe to do a colonoscopy or after. Yeah. What would you say, Dr. Towfigh?

Speaker 1 (00:56:26):

So colonoscopy is of the colon, and in general, the colon is not usually involved in either adhesions or most hernias. The one exception is a large scrotal hernia on the left side, in which case a sigmoid colon can get involved in it. In those cases, I would not recommend a colonoscopy, but that’s not necessarily the majority of patients. Also, hernia surgery, whether it’s abdominal wall or groin should not interfere with any colonoscopy. So I would say with the exception of a really large scrotal hernia on the left side, which includes the left colon in it all other hernias or hernia surgery, patients can safely undergo colonoscopy.

Speaker 2 (00:57:19):

Dr. Towfigh are most of the large scrotal hernias, small bowel herniations or a large bowel,

Speaker 1 (00:57:25):

They’re almost always small bowel.

Speaker 2 (00:57:27):

Yeah. So yeah, we’re talking about a low up, a very rare thing, and then it’s even rarer for large bowel to herniate through it. So it’s probably likely that most people could think that a colonoscopy is a safe thing to do before and after. I’d hate for them to walk away thinking, oh, there’s this dangerous test called colonoscopy.

Speaker 1 (00:57:47):

One question, which has been asked multiple times from Tracy, from her patients is, so as you know, gastroenterologists do colonoscopies and endoscopies, general surgeons do as part of their training as a mandatory part of their training. And then colorectal surgeons also do colonoscopies, but usually not endoscopies. Does it matter who does it? Has there been any studies showing one better than the other?

Speaker 2 (00:58:16):

There are studies that show it. And in general, the rankings go like this gastroenterologist, colorectals, and then general surgeons. Yeah. But there are certainly some general surgeons who are exquisite at doing this test. They’re just super skilled with their hands and they’re capable of doing it. And they’ve done thousands of these. Mm-hmm. <affirmative> tests. And there’s gastroenterologists who are new to doing it and not good at it, and they have sloppy techniques. So in general getting it done with a qualified competent physician who’s done adequate numbers is probably going to do fine. Now, a bigger thing to consider is if you’re a diarrhea predominant patient, it’s common for colorectals general surgeons and even some gastroenterologists to forget to do biopsies because they say it looked normal. Oh, well, from microscopic colitis, you can’t rely on the looks to be able to diagnose that condition. And it’s mandatory to take biopsies a patient. And yeah,

Speaker 1 (00:59:24):

I must say I learned a lot and we had really, really great questions. Lot of involvement. This is obviously something that hits every single patient, not just for new patients, but it’s really kind of frustrating when you’re dealing with GI symptoms that may or may not be from the hernia, the her or the hernia surgery. And I really appreciate, I’m very lucky that I have specialists like you that I can relate to and refer to. So lots of kudos coming from to you from online. Thank you Dr. Treyzon, as I mentioned earlier, is my gastroenterologist. So I do respect your expertise and you’ve been great with my patients. As you can tell. He’s very caring and very knowledgeable. So I don’t want to take up too much more of your time, but thank you so much for being on this and I’m going to say goodbye. And to the rest of you, I’ll make sure sometime tonight we’ll get everything loaded up online and on YouTube and on herniatalk.com. And I hope you join me again next week for another great guest and expert in their field. And as you know, I love everything hernia related. I find these very fun. I hope that you do too. And I just want to say thank you everyone again, thank you to Dr. Treyzon. I really appreciate it.

Speaker 2 (01:00:53):

Thank you very much.