How to Relieve Constipation/ Should I go Gluten-Free?

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Transcript

Chrissy Billau:

Welcome to Prescribed Listening from the University of Toledo Medical Center. On this podcast, we interview our experts to get the answers you need and can trust. I'm your host, Chrissy Billau, and today we are diving into some of the top Googled health questions from 2020 and 2021 with Dr. Benjamin Hart, who works in gastroenterology and hepatology at UTMC. Dr. Hart, thank you for joining us today.

Dr. Benjamin Hart:

It's my pleasure to be here today.

Chrissy Billau:

Constipation, how do you relieve it and should more folks be avoiding gluten for their gut health? Let's ask our expert. Dr. Hart, two of the most Googled health searches are, "How to relieve constipation?" and "Should I go gluten free?" Let's start with the first and just to preface this, my kids love telling me about their poop and the whole process, not just when there's tummy troubles. So I'm really happy to have this conversation with you and bring home to family dinner news that we can use. My question is how can one relieve constipation?

Dr. Benjamin Hart:

Well, this is a near and dear subject to my heart, first off. To relieve constipation, this is a very broad topic. Let's cover it in this term. When I think about constipation, there are multiple different underlying ideologies and different causes for it. So really trying to focus on those, that's really the mainstay of how I manage constipation. First answer is, don't get constipated in the first place. That's the first part of this. So that tends to mean eat lots of fiber, leafy green vegetables for your kid's sake. It's a good way to encourage them to do that and keep yourself hydrated. Those are the most important things on the front end. Now, once you've developed constipation, over the counter medications, there's enumerable number of these things that you can find. Most of them work relatively successfully.

Dr. Benjamin Hart:

Don't use them typically for more than a few days, unless somebody from my end of the field is telling you take it on a regular basis. But use it to try to get you out of one of those acute settings where you're really constipated and uncomfortable. But most of those are relatively safe and effective mechanisms to alleviate constipation initially,

Chrissy Billau:

Why do people get constipated in the first place? Because, to be honest with you, I'm lucky I don't suffer from. I remember after I had a baby, there was an issue, but other than that, it's fine. So how does that happen?

Dr. Benjamin Hart:

Again, this is varied. A number of medications are well known to cause constipation. So not just your opioids, which we're all very familiar with, but on top of it, some of the anti blood or blood pressure lowering medications, a lot of antidepressants, things like that are all known to cause constipation. So that's one component of it. Some of it's just people get dehydrated. So not drinking enough fluid over the course of the day. Our Western diet is really notorious for not having enough fiber, things like that that all lead to constipation.

Dr. Benjamin Hart:

So it's a combination of a number of things and on top of it, there are physiologic reasons for people to be constipated. So there can be issues with the pelvic floor. There can be issues with the colon just not having the adequate motility to push things forward. So when you start to really think about the underlying driving forces behind constipation, it's all over the place and very hard to really say what's right at first without a deep dive into what's going on with that particular person.

Chrissy Billau:

Oh yeah. And especially with like kids and being picky eaters. It's like, "No, you cannot have macaroni and cheese again. You have to have the vegetables." So I have more questions about constipation, but I want to step back and give a baseline. What should healthy stool firmness or consistency be? And can you figure it out by looking at it?

Dr. Benjamin Hart:

Yes. Typical healthy stools, so the thing I actually go by is what's called a Bristol Stool Chart. You can Google this. It's really easy to find, but basically it ranks bowel movements from a grade one to seven and one being firm hard pellets to seven being straight liquid. So what we tend to say is soft, smooth, somewhat mushy. That's kind of what normal should be. So firmer than that, you get kind of hard lumpy, that's constipated still. If you go to the other end where it becomes like loose firm blobs, that becomes the diarrhea end of the spectrum. So somewhere in the middle of that is where we like to have patients.

Chrissy Billau:

And how many times a day should a person poop?

Dr. Benjamin Hart:

So this is somewhat variable, but if you look at our literature and what we consider normal, one to three times a day is relatively normal.

Chrissy Billau:

Is there a way to quickly relieve constipation?

Dr. Benjamin Hart:

Yes. Again, many of the over the counter medications do work. In cases where I have patients who are severely constipated and they're in the hospital, I'll put them through a bowel prep like you would for a colonoscopy, which is a very effective way to alleviate constipation in a relatively quick manner.

Chrissy Billau:

Sounds awful.

Dr. Benjamin Hart:

But it's not pleasant and most of my patients do not appreciate that unless they are really backed up and uncomfortable.

Chrissy Billau:

Hundreds of millions of dollars is spent on laxatives every year and every case is different. But are there any laxatives that you would recommend for adults and children?

Dr. Benjamin Hart:

My typical place I always start is so over the counter fiber supplements. So Citrucel, Metamucil. Citrucel is Methylcellulose. Metamucil is psyllium husk. These are very safe. And then in addition to that, things like MiraLax or polyethylene glycol. These are easy to find. They're very benign and well tolerated, for the most part. I tend to start with those.

Chrissy Billau:

But you shouldn't take them, as you said, more than a few days?

Dr. Benjamin Hart:

Not typically.

Chrissy Billau:

Yeah. Don't rely on it every day.

Dr. Benjamin Hart:

Yeah. Not on a regular basis. Now, some of my patients I will have on these on a regular basis, but I really want to make sure they're at a baseline of constipation and actually require something a little bit more than nothing. Now, if it's just an acute, "I went for a few days without a bowel movement, but normally I have a regular bowel movement every day," then it's okay to take this for a limited basis to try to get things going again.

Chrissy Billau:

At what point would you consider someone as being constipated for too long?

Dr. Benjamin Hart:

This is a very good question, because it depends on what is normal for that person. If you go by what my literature would say, typically if somebody goes more than three days or two bowel movements a week, I'm considering them to be constipated and that I should be, trying to do something a little bit more aggressive. Though, normal's pretty varied by what different patients have. So I have some patients who will go once a week, once every couple weeks and sometimes it doesn't cause them any trouble and sometimes it does. So if they're uncomfortable, having nausea, things like that, then I tend to say, "Let's try to deal with this and address it a little bit more aggressively to see if it keeps you out of having some negative symptoms that are probably related to the constipation." But again, normals a broad spectrum and a broad term. So it's a little tricky.

Dr. Benjamin Hart:

And when I talk to patients about constipation, even when I ask them what is defined as constipation, it's all over the board, as far as what their symptoms are or what they may be. So trying to tease out, "Are you really constipated?" is not an easy thing to really describe or understand on a clinical basis until you really broaden your mind and ask a lot of questions about how people are having bowel movements.

Chrissy Billau:

What other questions are... Because when I look at it's like, "Well, I haven't gone in a while and I'm in pain there."

Dr. Benjamin Hart:

Yeah. So pain, if you haven't gone, if some people actually describe it as bleeding so, they might have a hemorrhoidal bleed or something like that, where they're putting a lot of pressure. I ask, "How long they spend on the toilet?" I ask, "When you do go, do you feel like you completely emptied or not?" Because sometimes patients are going every day, but they don't feel like they've actually completely gone. And that actually fits into the constipation definition. So I tend to ask a lot more questions and dig a little bit deeper to really get to the basis of this.

Chrissy Billau:

Is it true that women deal with constipation more than men do?

Dr. Benjamin Hart:

Yes. It's almost a two to one basis.

Chrissy Billau:

I knew it.

Dr. Benjamin Hart:

Yeah. I mean it's very common, much more in the women population in about approximately 30% of the female population is constipated. It's predominantly in the older population as well as the female population. And this is due to a number of things. But the things that really come to mind are things associated with childbirth in the female population. And then in the older population, things more associated with multiple medications and things like polypharmacy that all lead to this.

Chrissy Billau:

When you say polypharmacy, you mean other-

Dr. Benjamin Hart:

Multiple drugs.

Chrissy Billau:

Okay.

Dr. Benjamin Hart:

Lots of medications can cause constipation as I alluded to before. And as we get older, most of us end up on more and more medications, unfortunately and, unfortunately, those interactions can sometimes cause other side effects like constipation.

Chrissy Billau:

How can I help my child to get things moving?

Dr. Benjamin Hart:

So I'm not a pediatrician by any means. So me stating this for the pediatric population, I'm not the right person to ask but in a general basis, again, keep them hydrated. A good, healthy, broad spectrum diet. Sometimes the use of over the counter medications like MiraLax, which is polyethylene glycol, which is very benign, can be helpful. If your child hasn't had a bowel movement in several days, I'd be asking their pediatrician to see if they have a further recommendation as far as what to start with.

Chrissy Billau:

Does toilet posture help? For example, the Squatty Potty. We have one at home. You can raise your legs so you're positioned in a squat. Is that medically helpful?

Dr. Benjamin Hart:

Yes. There is an indication for this. In fact, I have patients who will come in for a procedure that we use to assess constipation and sometimes I'll actually ask them to get into that position to try to help. When I was training for my motility rotation, we used that on a regular basis was the Squatty Potty. And we would try the patient to see if they would be able to pass things. And if they couldn't, we'd try the Squatty Potty first before moving on. So it does help in certain populations. And there's a reason for that. There's a muscle that's called the puborectalis. This is a sling muscle that goes from basically the pelvic bones, slings around the rectum and actually creates a kink to help basically cause an extra break for stool to come out. This has to relax. And one of the positions you can do to help relax that is actually get into that type of position.

Chrissy Billau:

At what point should you see a doctor about the possibility of constipation being something more?

Dr. Benjamin Hart:

So I always assess this whenever I see a patient first off. So if you have any sense of bleeding, that's a major red flag on my part, as far as we have to investigate to make sure there's nothing worse going on. If you've had significant weight loss. So, 10% of your body weight over the last couple months, we need to investigate further. If you have a family history of celiac disease or Crohn's disease or ulcerative colitis, let us know because we need to do a little bit more investigation to make sure there's nothing bad going on. Those are the major red flags. And again, if you're having significant pain, let us know too. That's also an important thing to consider.

Chrissy Billau:

Any food suggestions to help get things moving?

Dr. Benjamin Hart:

Sure. So again, leafy green things, vegetables. So things with fiber, things like chia seeds, flax seed, but really just trying to make sure you get a varied diet that has a significant amount of fiber to help things stay soft is important.

Chrissy Billau:

I love talking about fiber. We spoke with a cardiologist on the first episode this season and I was fascinated by the history and what he said about the benefits for heart health. So let me know if I have it right for digestion. If you don't eat enough fruit and vegetables and the like, your poop or lack thereof shows it. So getting enough fiber keeps you regular.

Dr. Benjamin Hart:

Yes.

Chrissy Billau:

Okay. Should we all be taking daily fiber supplements?

Dr. Benjamin Hart:

I would not recommend daily fiber supplements. If you are getting adequate fiber in your diet, you really don't need the extra fiber. It tends to be a little bit gassy, a little bit bloaty, people tend to find it a little bit uncomfortable. I tend not to favor it unless it's really something that's indicated. And then I would strongly recommend it as kind of my first line, before I start considering really moving to different medications or other options.

Chrissy Billau:

Would you recommend magnesium supplements?

Dr. Benjamin Hart:

Offhand without knowing if somebody's having low magnesium levels, I would not. However, there's a caveat to that because you can get over the counter medications or laxatives that are based off of magnesium. So magnesium citrate, things like that will actually help have a bowel movement. Again, I don't tell people to take these on a regular basis, more for a rescue attempt when things are pretty severe as far as their constipation goes. But again, I always recommend trying to correct electrolytes if things are a little bit abnormal to try to help the bowel move, because magnesium, for sure, does help.

Chrissy Billau:

Are there any at home remedies that you would recommend?

Dr. Benjamin Hart:

Everybody talks about things like prune juice. There's a benefit to that. And again, just trying to make sure you stay adequately hydrated. Hot coffee has shown to have a benefit. Most of us know you end up getting up, you drink your cup of hot coffee in the morning and shortly thereafter, you're headed to the bathroom. There's definitely some reasons behind that. These things all help. So things to consider when you're really trying to get into a point where you have to go, try your coffee, try your prune juice, if needed. Those things do help.

Chrissy Billau:

Does tea help?

Dr. Benjamin Hart:

So the benefit from the coffee has not been shown to be the same as tea. We still don't know exactly what that is or why it works, but it was hot coffee. And the one study that did show it was hot coffee, not cold coffee. So I don't understand exactly how or why this works the way it did.

Chrissy Billau:

That's good to know. And let's switch gears now to our other popular Googled health question, should more people be considering going gluten free for their gut health?

Dr. Benjamin Hart:

So gluten free is an interesting topic in this regard. The question really is, does the gluten cause you a problem? And that's really the truth of the matter. So patients who I absolutely recommend gluten free, which is patients with celiac disease, however, there's another population that we understand a little bit less about, but it's patients with a non-celiac, gluten sensitivity. These patients definitely probably benefit from being off of gluten. Their symptoms are considerably better so they're not having the abdominal pain, they're not feeling the nausea. Some of them complain of brain fog, things like this. Those symptoms do improve when those patients come off of gluten and come back when they start back on gluten. So we know that there's a benefit for that particular subset of people. Though, we don't really understand the underlying pathophysiology as to why that happens, but it's a clear benefit for that population.

Dr. Benjamin Hart:

The other patient population that I consider talking about this in, is patients who have irritable bowel syndrome. There are numerous studies about different types of diet in that population. And the one that I think the most literature covers is what's called the FODMAP diet. Gluten falls into that FODMAP category and may be contributing to some of those symptoms. So it's worth a try in that group.

Chrissy Billau:

In my own Googling, I found that that diet reduces symptoms of irritable bowel syndrome by up to 86% of people. Is that right?

Dr. Benjamin Hart:

I don't know if it's 86%, but it is significant. And the studies have been very robust for studying the FODMAP diet. It's a multi-phase process to really get somebody onto the FODMAP diet. So the first phase is go FODMAP free for a period of time. And then we go into a reintroduction phase as far as trying to identify the certain subsets of FODMAPs that contribute to symptoms. Once we've narrowed things down, we then will reintroduce and reincorporate a more complete diet eliminating those specific FODMAPs that are triggering symptoms for that person.

Chrissy Billau:

Okay. And for people who haven't heard of FODMAP, it's F-O-D-M-A-P. What is that?

Dr. Benjamin Hart:

It stands for fermentable oligo polyols and dials. These are basically sugar components in your diet that are not well digested and often processed and fermented by your gut bacteria in a way that either cause gas or can cause irritation or inflammation.

Chrissy Billau:

So essentially it's a low FODMAP diet. Like trying to get rid of it. Is that gluten?

Dr. Benjamin Hart:

So gluten, in and of itself, is a protein. It's a storage protein in certain types of grains. So in wheat, barley, rye a little bit to a degree in spelt, but, in and of itself, it by and large is not a FODMAP, but the components of wheat are often in the FODMAP diet. So it is a contributing factor, but, in and of themselves, they're not completely related.

Chrissy Billau:

What does gluten do to your body for people who don't understand when people say, "I can't have gluten."?

Dr. Benjamin Hart:

In the patients who have the non-celiac gluten sensitivity, we don't really know exactly what it causes to their body. In patients with celiac disease, what it ultimately creates is it causes auto antibodies. So your body, the way it processes the gluten, ends up with creating antibodies basically to your small bowel wall and end up targeting the cells there and actually cause inflammation over time that actually causes those cells to be very inflamed and ultimately atrophy, which leads to diarrhea, malnutrition, and a whole other host of problems down the road.

Chrissy Billau:

Why do you think people who don't have an allergy or sensitivity to gluten think they need to be avoiding it?

Dr. Benjamin Hart:

This falls into more of a trend within the diets. Right now, there are lots of fad diets that are going around. The Mediterranean diet was a thing not too long ago. Now people are doing Keto diets and very primitive types of diets as well, trying to eliminate a lot of extra components to their meal or non-natural ingredients. Gluten is, I think, falls into one of those categories as far as one of those fad diets that's going around and is popular. And I think the benefit is that there are a number of people out there who do benefit from this diet. So it does catch on and people tend to propagate, "It worked for me. So maybe it'll work for you," and again, there's enough patients out there that actually do benefit from this diet that I think it's taken off and it's probably here to stay.

Chrissy Billau:

But just because it works for your friend, doesn't mean it's going to work for you. You need to talk to your doctor.

Dr. Benjamin Hart:

No, I mean, people do try this through trial and error and some people do benefit. And if I have a patient who comes to me, as long as they don't have a family history of celiac disease and/or we've tested them for celiac disease and they're negative, but they still benefit in terms of their symptoms get better off gluten, I'd say, "Go ahead, stay off gluten. I'm fine with that. You should be fine with that if you feel better." But I'm not going to tell somebody off the street just to, "Go gluten free and see if that makes you feel better," without doing a little bit more digging.

Chrissy Billau:

Yeah. Making things like this understandable is sometimes the hardest part because the body is a very difficult thing for many people to really understand how it works. I'd like to explore a few other topics and these are just going to be a few random ones I throw at you. How important is the time of day that you poop? Right away in the morning or is the evening before bed better? And can you change the cycle? For example, if you want to avoid going at school or work?

Dr. Benjamin Hart:

As far as the time of day, honestly, it doesn't really matter. As long as you're comfortable and going when you need to go. It gets a little hard to change somebody's schedule and cycle, just because once we kind of get regular, you tend to stay pretty regular and people tend to become creatures of habit. And things like your morning coffee are going to help dictate when you're going to go, unfortunately. So it's really hard to sometimes change that around a little bit. But again, I tend to plan a little bit around when my daily bowel movement's going to be and try to anticipate, "Okay, it's probably going to be in this ballpark. I'm going to make sure I'm a little bit more free at that time just to make sure I can find a little bit of room to go to the bathroom."

Chrissy Billau:

How bad is it for your system to hold it?

Dr. Benjamin Hart:

Well, I tend to tell my patients when you have that urge, don't hold it because that urge is only going to last for a certain amount of time. And once it goes, you tend not to get it back for a while. And the problem associated with that becomes you become more constipated, which ultimately just progresses and gets worse over time the more you do that. So I tend to tell my patients, "When you get the urge, please try to go. Don't linger on the toilet when you do. Go spend five, 10 minutes there. If you don't, that's fine. But I want you to try to go when you do get that urge."

Chrissy Billau:

Yeah. And especially with talking to anybody who you don't want to go in like a public restroom. But it's like, well, what's the children's book? It's like, Everybody Poops. I remember that one. It happens. It's natural. It's okay.

Dr. Benjamin Hart:

Yep. Exactly.

Chrissy Billau:

What are foods that cause or alleviate gas?

Dr. Benjamin Hart:

Well, these are a lot of different foods. It really depends on what your system is. So a lot of the different sugars in our diet, the non-absorbable sugars are really well known for causing gas. Carbonated beverages are really well known for causing gas. Certain types of fiber, unfortunately, are also well known to cause gas. So anybody who's eaten a couple Fiber One bars is pretty well aware that that is a problem. So things like that. Again, if you're lactose intolerant, it's going to cause gas. It'll probably cause some other things too. And there are other types of components. So FODMAPS that are often associated with causing gas. So again, not always a problem, but it can sometimes be a little bit excessive or cause social issues. So that's the time where I try to say, "Okay, what are you eating? Can we adjust your diet in a way that's going to be a little bit less gassy or gas forming?"

Chrissy Billau:

Well, in the same question for acid reflux, what are foods that cause or alleviate acid reflux?

Dr. Benjamin Hart:

Well, acid reflux is a totally different subject. So things like caffeine, acidic foods, so marinara sauce, tomatoes, chocolate, unfortunately can worsen reflux, which is a pretty well established thing. Those are the major ones. Oh, alcohol. Alcohol, and caffeine. So those are the other big ones.

Chrissy Billau:

Is it true that irritable bowel syndrome is one of the most common disorders seen by doctors?

Dr. Benjamin Hart:

So yes. It really is. In your standard family medicine practice or standard primary care practice, GI complaints, particularly irritable bowel syndrome, tend to make up probably on the scale of 10 to 20% of their practice in terms of complaints that come in on a regular basis. When you get to a GI practice, they tend to make up about 30-50% of a standard GI practice. And if you get into a more specific GI practice like mine, where I'm focused on GI motility and functional bowel disease. So I see a lot of IBS. I see a lot of constipation. That tends to make up probably between 60 and 80% of what I see on a daily basis.

Chrissy Billau:

Wow. So for people who aren't familiar, what is IBS and how do you get rid of it? Because I know we've talked a lot about constipation.

Dr. Benjamin Hart:

So IBS is really what we consider a disorder of the mind-gut axis at this point and what it is is hypersensitivity of the GI nerves. So our gut contains probably the second highest concentration of nerves in the body next to the brain. And sometimes crosstalk between these two systems gets a little abnormal in a way that it's not communicating very well. This leads to hypersensitivity, typically resulting in pain that is associated with a bowel movement. So the pain is going to change when you have a bowel movement. It's either going to get worse or better. And when the symptoms all started, you had a change in terms of consistency or frequency in bowel movements. And that's really going off of what we call a Rome IV criteria, which is a group that's got together and started defining these functional bowel disorders. And what we now consider these disorders of mind-gut axis.

Dr. Benjamin Hart:

But those are the criteria as far as what would define IBS. There's a couple different flavors in terms of constipation mixed or diarrhea. And in addition to that, there's some time requirements, things like that, as far as fitting the actual definition. The other issue is there needs to be an absence of red flags. So, things that make me concerned that there's something worse going on. So is there bleeding? Do you have a family history of things that are worse? Like, Crohn's or ulcerative colitis or celiac disease, history of colon cancer, things like that, which would prompt me to say, "Should I investigate further by doing a colonoscopy and taking a look and doing some blood work to make sure everything checks out okay. Before we really call it that and then decide what to do?"

Chrissy Billau:

When you're talking about the gut-brain axis, does that mean sometimes it's in your head? It's anxiety?

Dr. Benjamin Hart:

Well, I don't really consider this a true disease, but it is a disorder and it's related to the nerve interactions between the brain and the gut. So if you were running a race and you rolled your ankle or sprained your ankle mid-race, most people are able to fight through it. They're able to calm those nerves down and say, "This doesn't hurt as much as it does," and you're able to fight through it. The same type of interaction happens as we're going throughout our day. Our body's suppressing different nerve symptoms and saying, "This is normal. This is okay." But at some point that breaks down and gets a little deranged in terms of those signals are amplified and that dampening system isn't working the way it should. And patients will become very, very hypersensitive to these types of symptoms.

Dr. Benjamin Hart:

So that happens a lot with irritable bowel syndrome. There's things like functional dyspepsia or certain types of like a globus sensation, where you feel like somethings stuck in your esophagus. Those types of symptoms are often related to this type of system where the dampening system isn't quite working the way it should. So this is the brain-gut axis when we start talking about it. This can often be amplified by things like anxiety or depression. And sometimes patients end up scanning their body, looking for symptoms, multiple times a day saying, "Is there something wrong?" And they're going to try to find something and once they find something, then they start to perseverate on it. And it kind of spirals out of control to the point where they are now really focused on this symptom and it becomes the dominant symptom in their life.

Dr. Benjamin Hart:

So there's lots of different techniques that we use to try to help break that cycle. So things like TCAs or tricyclic antidepressants. We now call them neuromodulators in this setting because they help modulate that neuronal interaction and help dampen that system. Other things, like behavioral therapy, so cognitive behavioral therapy, hypnotherapy, and other versions. So things like that. Getting a behavioral therapist is often helpful in these types of settings. And I actually am trying to find better people in that particular niche to help me to work on trying to alleviate this. What I do is actually kind of an interesting combination of a gastroenterologist. A little bit of a psychiatrist and a little bit of a neurologist in terms of how I look at all of these things and how I try to manage them.

Chrissy Billau:

So when you use an antidepressant and you have a patient use that to help manage what's happening, has it shown that it helps alleviate what they're going through, their symptoms?

Dr. Benjamin Hart:

So, I mean, the literature is very clear as far as certain types of these work, very well. Knowing them and knowing the side effects of them also does matter a fair bit, because some can be quite constipating. Other ones are a little less so and some can actually cause other symptoms that are, unfortunately, potentially negative and sometimes not. So I tend to think very carefully about how I use these in the right patient in the right time and try to navigate trying to find the right side effects to actually help with other symptoms they may be having so that I try to be very thoughtful as far as what I use and when I use it.

Chrissy Billau:

I've been reading that you bring up colon cancer. I've been reading that colon cancer rates are up in young adults. Can you talk about what's happening there?

Dr. Benjamin Hart:

So we really don't know why it's up. We do see a fair bit of colon cancer in young adults. More recently they've lowered the screening guidelines. So instead of 50, we're now screening people at 45. But still, we all know patients who have come in in their early thirties and twenties who've had colon cancer. We still don't understand why because it seems to be isolated cases. They don't have a strong family history or anything like that, but there are cases. I'm not sure if it's just that they're more well identified or if that there truly is a true increase. I'm not sure about that part of it. But again, if you have red flags as far as symptoms go, please come talk to your doctor. We need to investigate a little bit further to try to prevent anything really bad developing.

Chrissy Billau:

Like bleeding in your stool?

Dr. Benjamin Hart:

Yeah. If you're bleeding in the stool, it's something we need to talk about and decide if we should investigate further.

Chrissy Billau:

When should people get screened for colon cancer, both for just by your age or if you have a family history.

Dr. Benjamin Hart:

So if you have a family history that is a little bit more complex. So right now we screen everybody based off of just the general population starts at 45. Now, if you have a family history of colon cancer, we recommend starting at 40 or 10 years earlier than your family member's diagnosis. So if you had a family member diagnosed at 37, we want to start 10 years ahead of that. Now, if you had a family member with a colon cancer at 52, we're going to start at 40. So it's really dependent on what the family history is and whether or not you have a family history of certain types of syndromes that are associated with colon cancer. Those ones, the screening, depending on which syndrome vary pretty dramatically, but often can start much earlier.

Chrissy Billau:

What kind of syndromes?

Dr. Benjamin Hart:

So syndromes like FAP or familial adenomas polyposis, Lynch syndrome, things like that. Those syndromes are well associated with colon cancer and require us to start screening earlier.

Chrissy Billau:

I know a lot of the treatments have improved over the years for all the different kinds of cancer that you can live with cancer. How is the treatment for colon cancer?

Dr. Benjamin Hart:

So colon cancer, by and large, I haven't seen a huge increase in terms of how the long term treatment has gone as far as people living with it longer if it reaches stage 4 colon cancer where it's metastatic. The advantage is we are very effective at screening for colon cancer early and have actually shown a huge improvement in terms of people developing colon cancer just through screening and routine colonoscopies and things like that, where we actually go in. We find the polyps that eventually change into colon cancer and remove them before they become a problem. But once it turns into that stage 4 colon cancer where it's spread in the body, unfortunately, the medications haven't shown a huge improvement in terms of putting it into remission for a long time.

Chrissy Billau:

Now, for folks out there, there are companies out there who were if you send them a sample of your poop, they test it and tell you something. Do you support people doing that?

Dr. Benjamin Hart:

The short answer, yes. Those tests are beneficial. Several of them have been validated to function as colon cancer screening, the caveats to that being if you have had a family history of colon cancer, if you're bleeding, if you personally, or family members have had a history of colon polyps, it's better to get the colonoscopy. However, these tests are validated. They do show benefit in terms of being able to identify patients that are at higher risk for colon cancer and get them to us so that we can actually do a colonoscopy and look. That said, there are times where those tests are not ordered on the right patient in the right time and sometimes do miss things, unfortunately. But every test always runs the risk and benefits of, "Will it miss something versus will it catch something?"

Dr. Benjamin Hart:

And we consider that in everybody. And that's why when I say, there's a certain time and place for it. It's got to be the right patient and the right time. But that's the long and short of it. And I think on a general more population base, a lot of those tests are cheaper and more efficient than doing colonoscopies on everyone. So as much as it pains me to say, "Don't get a colonoscopy and those tests work," I do actually recommend it because there are definitely communities where the access to a colonoscopy is not there. And in the sake of getting an adequate screening and trying to do something in the sake of saving our healthcare dollars, it's not a bad option.

Chrissy Billau:

Okay. Based on what you do, you have to have a certain sense of humor. I mean, if you're at a party and people like, "We just want to ask you a few questions," and then it devolves into other things, because everybody has questions about it. Why did you choose this career?

Dr. Benjamin Hart:

Well, my career path to get to this tickle was a bit of a meandering road, honestly. But once I got into medical school and I found that I tend to favor being on the procedural end of things. But at the same time, like the continuity and the thought provoking components from internal medicine, for me, this was the perfect marriage of both of those. And then on top of it, I just found I enjoy it. And once I found I enjoyed it I was like, "This is the career for me." And then it was more of a fight to actually get through the door as far as being able to enter this field and I feel it's a privilege to be able to actually do what I do.

Chrissy Billau:

But you have to have a sense of humor for it?

Dr. Benjamin Hart:

Absolutely.

Chrissy Billau:

So piggybacking on the Google searches, I want to ask you, Dr. Hart, what is the most common question you get from your patients and what is your answer?

Dr. Benjamin Hart:

My most common question is, "I'm really constipated and what can I do about it?"

Chrissy Billau:

So Google's right. Everybody's asking that question. And so you tell them everything we've talked about, drink more liquids, eat more fiber?

Dr. Benjamin Hart:

I mean, most of the time, by the time my patients are coming to me, they've been to multiple other doctors and they've talked about constipation. I'm a little surprised when they haven't, to be completely honest or when I pick it up on a screening colonoscopy that they haven't talked to a doctor about it. And one of my questions before I take anybody back is, "Are you having problems with diarrhea, constipation, other than the diarrhea we just gave you to get through this prep?" If they say "yes," I'm like, "Oh, okay, let's talk about this a little bit more and we'll investigate." And then I typically have them follow up with me in clinic. And we come up with a regimen relatively quickly. But most of my other patients that see me in clinic, if I haven't caught them on that end, they tend to come after having tried numerous things.

Dr. Benjamin Hart:

So my questions then get a little bit more deep in terms of asking, "What have you tried? What did it do? Have you tried this? Have you tried that? What changes have you had?" Are there any other things in your history that make me a little bit more concerned about other components of this? Do I need to worry about whether or not the muscles at the lower end are actually coordinating properly or moving the way they're supposed to? Because that's another big component of it that happens in a significant number of my patients in terms of, "You've got two anal sphincter muscles. Sometimes they actually squeeze when they're supposed to relax. And that's a problem because that's like squeezing a tube of toothpaste against a cap you just tightened. Nothing's going to go anywhere and you're probably going to be pretty uncomfortable.

Dr. Benjamin Hart:

So that does happen. Sometimes trying to identify those patients, which is why some of the other techniques I use in my clinic and some of the testing I do, helps me tease those patients out so that I can get them to the therapy they actually need to try to help alleviate that. But that's step three and four down the road. The first place we always start is, "Let's try some simple laxatives." There's a whole host of these options. See where that goes. If that becomes a problem, we'll dig a little deeper and try to go further to try to find what's going on.

Chrissy Billau:

For folks with the muscle issues, is it exercises that help or is it surgery?

Dr. Benjamin Hart:

So no, it's not surgery. It really is physical therapy with a specific focus on things like biofeedback, where they're given a monitor, they're given some sensors that actually tell them those muscles are relaxing so they can physically see that the monitor says, "You're relaxing those muscles right now. That you're doing the right thing," so that they can actually retrain those muscles to behave the way they're supposed to.

Chrissy Billau:

So let's talk about some elements of your practice. What have you been working on lately?

Dr. Benjamin Hart:

I have a couple different arms that are going right now that are kind of exciting to us. The first one being anorectal manometry, which is really that test to look for whether or not those muscles are moving in the wrong way. So basically patients come in. It's a little catheter probe that goes up from below, unfortunately. It's got a little balloon on it and it has little pressure sensors. And we ask patients to go through certain maneuvers, squeeze, push, things like that, as well as blowing up the balloon to check for nerve reflexes, things like that within the lower rectal canal in the anus. And these help us try to determine whether or not those muscles are responding appropriately. If they're relaxing or tightening at the wrong times. Helps us evaluate things like incontinence a little bit better as well as helps us understand if their nerves and muscles that are coordinating in the way they're supposed to.

Dr. Benjamin Hart:

That's a test that's been around for a long time, however, it's not been greatly available in the Toledo area for a very long time. So it's something we are offering now. And so far we've been doing this for about six months now.

Chrissy Billau:

Oh, so this is new equipment you invested in?

Dr. Benjamin Hart:

It's new equipment we've invested in and it's changed how I've managed a lot of patients just in the last couple months.

Chrissy Billau:

And how are patients responding to it?

Dr. Benjamin Hart:

Patients are responding very well.

Chrissy Billau:

That's exciting for our region and the people who are looking for answers and an alternative way to help make this stop.

Dr. Benjamin Hart:

I'm really happy because right now, when I was running into these patients who were not responding very well, I'd end up having to send them to Ann Arbor, Cleveland, Columbus to really try to get to a clinical trial if they needed it. Now I'm happy to be able to at least offer something here in the Toledo area.

Chrissy Billau:

What is one thing you would like to tell your patients relevant to your specialty or just in general?

Dr. Benjamin Hart:

The big thing, please come see a GI doctor if you're having any of those red flags. So if you're bleeding, if you are having GI complaints, plus a family history of Crohn's disease, ulcerative colitis or celiac disease, come talk to us. We want to make sure that we're not missing something. And if you're having weight loss, things like that, we want to make sure we're not missing a colon cancer that could be causing big problems down the road. That's my big takeaway is please. We want to make sure we're doing right by you and we don't want to miss something important. So if you're having symptoms, please let us know so we can try to help you.

Chrissy Billau:

How can people schedule an appointment with you?

Dr. Benjamin Hart:

Calling UTMC to just schedule an appointment. I have availability. I'm happy to take on new patients whenever. So I'm more than thrilled to see somebody new.

Chrissy Billau:

Well thank you Dr. Hart. That's all for this episode of Prescribed Listening from the University of Toledo Medical Center. Thank you for listening. If you like this episode and I hope you did, subscribe to hear more on your favorite podcast platform and join us next week for another episode where we tackle more of the top Googled health questions.