Jill, there were a couple of questions, and I know that some of them have been answered, but I just wanted to go back to SIBO for a minute. One of the questions was asking, do we use this more as a diagnosis of exclusion? When do we start to consider SIBO in our workup of chronic diarrhea? Well, you're going to look for common things. I tell my patients common things occur commonly. So you start off with the basics for your workup for patients with chronic diarrhea. But if you see someone in your office who's diabetic, who's had some type of surgical manipulation of their intestine, then you want to keep that on their radar. So I don't consider it a, I mean, some people have, I've actually heard before they consider SIBO a myth, but SIBO is a symptom of something going on. So you want to look at your risk factors and see when it's appropriate to order for it. And then just building on that, one of the other questions was, what if we treat it? And they're still symptomatic, especially if you treat it and you test again, and they're still positive. Thoughts on the approach from there? So it's complicated. I mean, there are different types of SIBO testing. The rigorous aspect of the testing, you want to make sure that patients are not on a low FODMAP diet to make sure you get accurate testing. You want to make sure that the patients have been taking the medication appropriately before as prescribed, because sometimes I find out that patients didn't take it appropriate the first time. Also, you want to make sure that their symptoms are as managed as well as possible prior to testing. So, and it depends on the patient's comfort with the testing. I'll tell patients, just because your test is positive, doesn't mean it has to be treated at this time. It depends how uncomfortable you are or what your symptoms are happening at this time. Yeah, I agree. I'm sorry, Sarah, I was saying this is one of those diagnoses that definitely there's shared decision-making and caring for the patient. What are your thoughts? Completely agree. And, you know, I don't always retest people. So sometimes my questions are when you're on the antibiotics, how are your symptoms? And if the symptoms are better and when they stop antibiotics, they're starting to come back again. Sometimes we go towards that chronic SIBO where we might do two weeks of Zyfaxan and then two weeks off and then kind of rotate it that way. And that can make a big, meaningful difference to some people. Now, in my 13 years, I've probably only had to do that a couple of times. But I think that you really have to, like Jill said, you know, invoke that shared decision-making, really look at their symptoms, how we excluded other things. Could there be more than one thing that's going on? And are there other ways to help to control their symptoms? Absolutely. Another question for you, Jill. There was a great question that Dr. Tawani actually had put a response in, but I want to make sure everybody gets to hear it. So Barrett's esophagus and microscopic colitis, knowing that PPIs are risk factors, what's the approach to a patient who's diagnosed with microscopic colitis symptomatic and is on a PPI? Do you continue it? Do you discontinue it? Do you dose modify? What are your thoughts? So this is one of those life-threatening conditions I would consider. So if patients have high cholesterol and they're on a statin, then you don't stop the statin. Same thing with Barrett's esophagus. I mean, studies show that Barrett's esophagus, you're on a PPI for a reason to help reduce the potential risk of developing esophageal adenocarcinoma. So you continue with that lowest dose as possible to help. That's going to be chemoprotective to help your patients with Barrett's esophagus. So you keep them on the PPI. Thank you. I completely agree. That's what I would do as well. Kim, some questions, and actually maybe Jill too, there are questions about elevations in fecal calprotectin, reasons that are not necessarily 100% diagnostic for IBD. I can start with that. And then Jill, if you want to like lend into that a little bit, I think that that would be great. So fecal calprotectin is a funny test, right? So first of all, you have to be cautious when utilizing it because a few things, right? So first of all, remember fecal calprotectin is going to be elevated and has a higher sensitivity in colonic disease, not necessarily small bowel disease. So that's number one, because I've had patients who have, you know, rip roaring, you know, small bowel disease and their fecal calprotectin might actually be normal, right? So kind of keep that in mind. So more again, for more for your colonic disease, and that could be ulcerative colitis or Crohn's. The other thing I'd like to say in a false elevation, that was the question, infection. Any patient who has had a previous infection or even consideration of infection, and that could be anything, right? May have a false elevation in fecal calprotectin. Some of the other things that I had, I can just tell you a little bit about it, that patients who have pseudopelvis. So patients who have pseudopelvis in their colon will sometimes always have an elevated fecal calprotectin. So even though, you know, and again, this is something we know we work for monitoring and our stride guidelines, but again, we might see an elevation in this fecal calprotectin. And I always kind of go back and look at the colonoscopy report if the patient is feeling really great. And then I recognize that they have a very long segment or, you know, that there's, there's pseudopelvis. I keep that in mind. Some other small things, I'm doing some, you know, just my own for patients who randomly get a fecal calprotectin check before they come in and see me. There's sometimes, I know Jill talked a little bit about microscopic colitis, sometimes very low level fecal calprotectin can be a little bit over a hundred in microscopic colitis. Now I do not hang my hat on that and those patients need further evaluation. The other thing I want to tell you is that I've also seen there's data that suggests that even patients with colon cancer may have a very mild elevation in fecal calprotectin. So again, not that I hang my hat on using that as a diagnosis, but I will tell you if a fecal calprotectin is greater than 250, it makes me very suspicious for underlying inflammation after I have ruled out infection. Jill, do you have anything else to add to that? No, you're, you're absolutely complete. And I think that's one of the biggest misnomers with the calprotectin is that people feel that it gives you any type of intestinal inflammation, but it is only limited to colonic inflammation. So if you're worried, you're seeing a young patient who is changing bowel habits and their calprotectin is normal, you still have to keep in the back of your mind, you have to rule out small bowel disease and rule out Crohn's disease in case there's some type of, you know, abdominal pain component or especially weight loss. Thank you, ladies. Sticking with the stool tests, there's a question about patients who you're looking for pancreatic insufficiency. So that pancreatic elastase, why are we looking to bulk the stools and do the test on firm stools? So I'll answer that, that my simplest response is that you want to make sure that you're getting a good sample and it could be sampling error if there's too much liquidity in the stool to get an accurate reading. So Jill, you know, I was super fortunate enough to ask by the American Nurse Association to actually do a little lecture on EPI and part of, you know, and that is going to come on a podcast soon enough, but also making a tool for primary care nurse practitioners and PAs, which is super awesome. But with that, you know, the part of making it the form stool is remember that if the stool is loose, it's diluted and that diluted stool in itself will not give you an accurate result of what we're looking for when it comes to pancreatic insufficiency. Sarah, I also thought that there was a question on there about repeating the test, you know, and I don't, and Jill, I don't mean to, I don't want to step on your toes. When it comes to repeating the test, there's no utility in repeating the test, whether you're on enzymes or not enzymes, by the way. So once you've actually verified that you have done the test and it is a formed stool, sometimes I'll repeat it, just like Sarah mentioned, I'll repeat it to make sure, you know but then also I do not repeat the test, even if they're on pancreatic enzymes, that's not going to tell you how to dose your pancreatic enzymes or not, you know, so there is no utility in repeating that test. Yep, exactly. So elastase, remember it's just an enzyme and that enzyme is not directly impacted by pancreatic replacement. So when you put them on crayons, on pepper, whatever, it's not actually going to change that result. The fecal fat may, if you can convince somebody to do a 72-hour fecal fat, or even a 48-hour fecal fat, and you put them on pancreatic enzyme replacement therapy, that may be impacted, but you're not going to see the difference in the fecal elastase itself. Sorry, I was losing my battery. Someone's got to plug Jill in, Jill needs to be plugged in. You've been gone for two days, I don't blame you, I need to charge you up too. Kim, there's a question that says gold standard for Crohn's disease, and I believe that they're talking about imaging, just based on the time of when the question was asked. Sure, sure. So I think two things when it comes to gold standard and, you know, diagnosis of Crohn's disease. Remember, I think that maybe I was saying that a little fast though, if you're thinking about perianal or pelvic pathology, it needs to be an MRE, right? So those are like the gold standard, but also for our younger or pediatric population, right, I would also say an MRE is when we come for our gold, like diagnostic, you know, kind of testing. When we're looking at that from a gold standard perspective, those would be the ones that I could call gold standard. And the only other thing I would say is that, you know, kind of a gold standard would be if you have an acute patient who's got like fever, weight loss, really bad belly pain, this is a CT, everybody, like we don't wait to do an MRE, right? Because we also, I work in the community, I'll tell you the first time I ordered an MRE, my radiologist, I had to go down and make sure they were comfortable even doing an MRE. I think I actually asked them, how many have you read, right? Just to make sure I was doing the right test for the right patient. Because if they said that, Kim, I'm not super familiar, I'm going to do a CTE instead, I'm not going to do an MRE, right? So these are things that we really, I think we as APPs need to be considerate of. Yeah, and kind of on that MRE topic. So somebody who has a new diagnosis of Crohn's disease, MRE shows a small bowel disease with structure, assuming that you put them on therapy, what timeframe would you repeat that imaging? Yeah, super. So this kind of goes off about like kind of, and I know, I know steroid guidelines, like looking at everything from utility, where are we moving with that, right? So, of course, my question would be, so with your Crohn's disease, the only way you diagnosed it with your MRE, right, is that your, is that your kind of index test, right? If that's your index test, then you start your therapy. And if it's Crohn's disease, and again, that's what I would tell you, this is an advanced patient, right? If they've got a stricturing type phenotype, the patient should not have to earn their drug. So they should automatically be put on an advanced therapy. With that being said, you know, I usually wait to, you know, are there any other kind of non-invasive testing that we could do? So again, was there a vial elevation in CRP? Traditionally, then if that was my only diagnostic test, then I would treat it just like I would a colonoscopy, right? If I'm going to do a colonoscopy at 12 months, to reassess disease activity, after I started someone on therapy, I'm not going to do an MRE every six months, it's too costly, and it's a lot of money. So I would do it at the year mark, unless, here's my caveat, the patient is still symptomatic, right? So if I need to like check something off because there's symptoms, then I'm going to do so, but then I might use it at my year mark, just like I would a colonoscopy to reassess disease activity as well. Any role for video capsule endoscopy in that situation? So if they have a stricture, because I heard you say stricture right there, that makes my ears go off, I have a patient right now with a retained capsule, so I think like my heart's pounding a little bit. So with that, you know, first and foremost, right, do a patency capsule if you're going to consider it. If it's a long stricture, and again, if that's a long stricture, my answer is no, my answer is absolutely not, don't do a capsule. You already know what that looks like, right? Treat them first. But I will tell you from a capsule utility perspective, Sarah, this is a great question. Sometimes the only way I diagnose patients, you know, and again, we look at those patients who maybe have a, you're thinking that they have it, right? So maybe they've got a little, you know, like a fecal calprotectin that maybe comes back at 200, and they have signs of abdominal pain, a little bit of weight loss, right? But their colonoscopy, upper scope is totally normal. I've even had MREs that have really shown nothing. We do a capsule endoscopy. And then again, that intraluminal view provides a completely different picture of what's actually going on inside, right? And that completely changes my management. And again, for those patients, there, I do the same thing. At one year after being on advanced therapy, I go back and then I check to see what does this capsule now look like. But for a stricture patient, no. Unless I got a surgeon on speed dial. Unless you're looking to localize the stricture for the surgeon. Exactly. Say that. That's my spot, right? Surgeon, then where to go. Yeah, right. Jill, I'm going to come back to you about SIBO again. And so there was a question about treating SIBO empirically. And there is an example here that I'm just going to try to shorten a little bit. Patient really has the complaint of heaviness and bloating, is being treated adequately for constipation with Linzess and Miralax, responding well to that. In order to do the treatment, she'd have to stop the laxatives. So they're a little bit reluctant to, I'm sorry, in order to do the testing, they'd have to stop the laxatives, a little bit reluctant to do that. So in that case, would you consider empiric treatment? I try not to do empiric treatment because you may be exposing patients to unnecessary antibiotics. So that's how I guide my patient through that conversation. Yeah, and at our center, we actually don't stop the laxatives if they're on them chronically. If it's something that they're taking like a bowel prep or they took once and they don't typically take, we do ask that they wait a little while. If it's something they take every single day, we actually don't stop them. I didn't think that we did either. Any options for pancreatic enzyme replacement therapy that does not contain pork? No. The answer to that is no. Yeah, the answer to that's no, actually. I'm sorry, Jill, I didn't mean to jump in on that, but I actually know this answer. But I do want to let you know that there are caveats to that, that there has been approval by rabbis and others because they recognize from a religious perspective, this is the only therapy that is utilized to treat this condition, but all of them contain pork. And upon the recent podcast, that was actually included in what we had discussed in that. But yes, they all do. And Kim, those new medications that are coming out that will be subcutaneous, any citrate free options? So to be honest with you, you know, Vito, there is a tiny, tiny amount of citrate in them, but not enough that it would cause injections like reaction. And again, infliximab, I actually am not 100% sure because of the fact I haven't seen it yet. And it's not available in the United States just yet. And I know that they changed most of our adalumumab ones, of course, are available citrate free. So, yeah. Two options. There's another question about a young Crohn's patient had been off Stelara for four months while she transitioned from pediatric to adult GI. She had a flare during this time. What's the proper way to restart her on her medication? There's a lot of, a lot of elements in here, right? I'm assuming that this patient, of course, had a clinical response to begin with because they had been on the therapy for a long time, right? If they've been off the therapy for four months, right, so we're about two doses behind. There is data that actually suggests reinducing a type of patient like this. And I would actually tell you, I would probably reinduce this patient. I would give them another loading dose first of ustekinumab, right, that weight based dose, and then get them right back onto their subcutaneous dosing every eight weeks, as long as the patient had a clinical response prior to that, because likely there's just no drug. I mean, you could check a drug for utility, but what's the point? They don't have any drug at this point. So but if they had a clinical response, do we know and is there data that says you can reinduce these patients? The answer is yes. But I would be really tight on the patient if we were going to give them this drug again to make sure that they're going to respond. But I would make sure I saw them more frequently, make sure I check non-diagnostic markers, non-invasive biomarkers. I apologize. And then, of course, if I saw no improvement or no change or being able to get them off of steroids, which I assume that they're on right now because they're flaring, I would be really more aggressive considering this is also a pediatric patient. I'm giving them on an alternate therapy as well. Great, thank you. One more question before we go to break. I've seen conflicting reports on bimodal peaks for IBD. Our second to fourth decades and then sixth decade seen in both Crohn's and UC. Ah, you know, and I think that, again, I give a big sigh because I'm actually seeing a lot more in my more mature population now than I've ever seen. So I know we've always been taught this bimodal. And you're right. Sometimes we see earlier onset for our Crohn's patients, you know, but for ulcerative colitis, it's more common to see this bimodal. I'll be honest with you. I think, Sarah, I talked last year about a patient, a ninety nine year old or ninety year old, I think I said, who had fulminant ulcerative colitis and was not me. And this is not uncommon anymore that I'm seeing 60, 70, you know, and again, 60 of that, that six decade, but 70 and 80 year old also with it. So I know that traditionally we see the bimodal. But what I what I think the point of that is, think about it in your younger population, right? This 20, 30 population and then again, that six decade. And so and again, is there conflicting data? I mean, there's all kinds of data. So I kind of always keep it in my wheelhouse, to be honest with you, no matter what age they are. Yeah, I actually was thinking of you about a month ago. I saw two patients back to back in their 70s, new diagnosis of IBD. And so I don't know. Is it that we are on more medications now? We're living longer. I don't know what the differences are, but I agree it happens. And so we can't rule it out, although it may not be the rule. Thank you both. This was really an excellent session. Great discussion. Thank you to our audience for submitting those questions.

gastrointestinal health

SIBO

chronic diarrhea

pancreatic insufficiency

Crohn's disease