Dr. Michael Ruscio: Hey, everyone. This is Dr. Ruscio. And let’s cover a listener question today which essentially asks what to do about gut pain that usually occurs secondary to consumption of rich or fatty foods. So here I will play the question.
Listener: Hello, Dr. Ruscio. I am inquiring about a question regarding my daughter who’s 22 years old. She was diagnosed with IBS by a gastroenterologist about four years ago, I want to say. He put her on VSL 3 probiotics which did help for…
DrMR: And just as a note, VSL 3 is a Lactobacillus/Bifidobacterium predominated probiotic. It’s what I would organize in our three-category system as a category one probiotic which is a blend of Lactobacillus and Bifidobacterium probiotics, very similar to the Lacto/Bifido blend probiotic that I recommend in our store. And it’s definitely one of the more well-studied probiotics, VSL 3. And again, that’s from category one, the Lactobacillus/Bifidobacterium predominated mixture. So that’s a good place to start.
Listener: For a year or so. She was very good about taking them and so forth. Anyway. Fast forward now to present time. She is having the same symptoms of gut pain. She does not have diarrhea. She does not have constipation. I’m not sure she has IBS. I think she could have possibly been misdiagnosed. He did do a gamut of tests. Not a breath test. He did blood test, stool tests, and an endoscope. And so, anyway. So now, she’s been off the VSL for a while. She did feel some improvement but not ever complete relief. And her main problem is, as it was before and still is, whenever she eats especially rich foods and fats, but not always, it happens almost—I don’t know. Pretty much with everything, but mostly rich, fatty, creamy foods, oils, grease, that type of thing.
DrMR: And pause there for one more second to touch on something that was important which is the fact that her gastroenterologist performed an endoscopy. That’s important because one of the things that can cause gut pain is either gastritis or ulcers. And most gastroenterologists will not miss a case of ulcers or gastritis after they’ve done an endoscopy. So that’s important to have that on the table because that’s one thing that could potentially be causing this problem. With the previous endoscopy negative, then that makes it fairly unlikely that gastritis or ulcers are present.
Listener: But she gets immediate gut pain. Makes her not feel good. And it starts within a matter of minutes of eating the meal. So she’ll feel perfectly fine or whatever. And then all of a sudden sit down to eat a meal, she feels this pain. And she continues to eat or stops, whichever, but either way it lasts probably a good hour or something like that. And then it will go away, and she’s fine. So this happens all the time, and she’s tried elimination of foods and different things. And the only thing she can ascertain is that it is related to rich, fatty foods.
DrMR: Ok. Which it very well may be. Now, there’s more that we want to look into here, and I’ll let the rest of the question play before we come to any conclusions. But we do know that, of course, FODMAPs, foods that are high in fermentable substrates and are prebiotic rich have probably the best documentation to cause gut pain. But if you remember back, we had Tarek Mazzawi—he was a gastroenterologist—on the podcast who’s done some pivotal work in establishing some of the mechanisms that underlie why a low FODMAP diet is helpful for those with IBS.
But one of the things that he did in some of his studies with his group was they also infused fat into the intestine and showed that fat can also stimulate a reaction, a pain-type reaction as FODMAPs can. Now, there’s more data showing that the low FODMAP diet can be helpful. But it’s not to say that some people may not do better on a lower fat and a higher carb diet.
And all this may come down to what’s known as visceral hypersensitivity. So there may be hypersensitivity to gas and to pressure in the intestines. And that can happen even when gas levels are normal. So you mentioned SIBO a moment ago. SIBO very well could be something to investigate and to treat. However, it is possible that a SIBO breath test could be negative, yet she could still improve from a low FODMAP diet if she hasn’t tried that yet.
The low FODMAP diet and reducing high amounts of fat in the diet may work synergistically for those who are hypersensitive. And it’s my thinking that if you can find a diet that works and an approach that works, with time that hypersensitivity should become less. But let’s continue forward with her question.
Listener: Primarily. Again, not always because sometimes she’ll eat something that typically doesn’t bug her and then it does. But that’s rare. It’s usually the greasy stuff. She’s not lactose intolerant. She’s not glut—I’m sorry. Allergic to wheat or celiac. I can’t think of the name. Gluten-intolerant. None of that. But anyway, we just cannot figure out through elimination of foods what could be the problem and why she gets a pain in the same spot all the time when she eats right when she’s eating, within minutes. Not digestion. It can’t possibly be digestion, I don’t think, because it hasn’t been long enough. So anyway, I wondered if you could comment on what that might possibly be.
DrMR: So regarding diet, we don’t know if she’s tried a low FODMAP diet yet. She’s gone dairy-free apparently and gluten-free. Good places to start. But low FODMAP would also be very important because that, again, probably has the best documentation in terms of a dietary intervention for reducing gut pain.
Listener: If so, you can email me, reply or whatever if you don’t want to put it on air. I don’t care. I’m just trying to get some insight there. The only thing, like I say, she hasn’t had is the breath test. So I don’t know if that’s something that should be done. Ok. I appreciate your help. My email and info will be on the contact information. Thank you. Buh-bye.
DrMR: So we’ve covered a few things. But let’s come at this from a hierarchy of sequences. The hierarchy will give you a system of steps to work through rather than me through out a bunch of diagnoses and you trying to piece together how to run through those and in what order and what sequence and what have you. There could be classical IBS. There could be SIBO. Ulcers or gastritis are less likely. There could be this visceral hypersensitivity which kind of falls underneath the umbrella of IBS and of SIBO. So what do you do?
Well, we always want to start with diet. So you’ve already done a good job with eliminating two major allergens which are gluten and dairy. Great. If you haven’t yet done a low FODMAP diet, I would recommend performing a low FODMAP diet. And we have a list of those available on our website.
Now, the probiotics, you also took a good step there. And the fact that she responded to probiotics could indicate that she has dysbiosis or it could mean that the probiotics are helping via their anti-inflammatory and immunomodulatory mechanisms. However, what the missing piece there may be is not having had used a broad enough presentation of probiotics to the gut.
So you used category one, the Lactobacillus/Bifidobacterium blend as VSL 3. Good. I would also add in a category two and a category three probiotic to see if those may work synergistically to produce a better overall benefit than just the one probiotic alone.
So category two would be a Saccharomyces boulardii probiotic, and category three would be a soil-based probiotic. And we do have one of each of those probiotics in our store to help you find a good formulation for each category.
Remember—and this is very much so worth stating—that probiotics have been shown to be efficacious against SIBO. And I’m becoming more and more favorable toward probiotics, understanding that they not only help with pain and with symptom reduction, but they are antibacterial and antifungal. So if there is a degree of dysbiosis, whether it be SIBO, Candida, both, H. pylori, the probiotics have a good chance of helping to rectify that dysbiosis. So that’d be step two.
Now, there’s also the potential that she’s mal-absorbing fat. And that may be why she’s having the pain. And to the question of why this is such an instantaneous reaction between eating and then having the pain reaction, it’s not always when the food gets to a particular spot. There’s also something known as the gastrocolic reflex, meaning that when food hits the stomach, it causes a reflex in the colon. So this could account for some of that instantaneous presentation of pain.
Now, SIBO can cause fat malabsorption. So this could underlie why she’s intolerant. And that may have been why the probiotics worked. The probiotics were helping to beat down SIBO, and the SIBO was then less able to cause fat malabsorption. And she was then more able to tolerate fat. So that’s very well what may have happened.
The supplementation with a bile acid may also help. Those are some of the better places to start. To escalate therapies, you may need even stronger antimicrobial therapy to address any dysbiosis in the gut. And further yet still, she may even want to try a short course on an elemental diet to give the gut a chance to rest, for dysbiosis to quell, for hypersensitivity to kind of unwind. This kind of gives you a few different things to consider in succession.
All of this is laid out in my book Healthy Gut, Healthy You. It’ll give you exactly what to do, when to do it, and help you to navigate through this with the most efficiency and precision possible. So there’s a number of things to consider there. And I’m hoping that between a dietary modification, specifically the low FODMAP, and a more robust probiotic intervention you’ll be able to get there. But if not, there’s a few other things to consider. And hopefully that helps you and helps your daughter get healthy and get back to her life. Ok. Thanks.
I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!
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