Okay, I'm going to do some diaphragmatic breathing here to get us ready. Okay, so approach to bloating and celiac disease and small bowel disorders. So how many people love seeing patients in their office that complain of bloating? Now usually when patients come to your office that complaining of bloating, you're usually the fourth provider in your office that they've seen. So hopefully I'm going to be able to give you some tools and give you some guidance on how to help work through a patient who has symptoms of bloating and give them some key tools and takeaway. What I find with this type of symptom or diagnosis is that patients are very frustrated. They feel like we're not hearing them, even though we do a lot of testing. And I think it's going to be important that we walk through them to let them know what we've ruled out and the potential causes, but also to reassure them that these are common symptoms that we see. And we can't always make everyone better. And I think as least we can find some measurements, my disclosures, at least we can find some common ground and say, I want to help you feel better. So let's start you from a starting point that you're at now, and then come up with some measurable outcomes. So this slide set is going to go over approach to generalized bloating, and then I'm going to focus on two disease states, mostly small bowel bacterial overgrowth and celiac disease. So for celiac disease, our first polling question is after symptoms onset, how many years does it take to diagnose celiac disease? How long is this diagnosis? Is there usually a delay? Very good. It's actually six to 10 years. Can you imagine that? Six to 10 years. OK, next question. When testing for celiac disease in a patient who started a gluten free diet, which a lot of our patients do, they come in already identified that gluten is the problem and they've taken it out. So how much gluten do we need to coach patients to add back into their diet before testing either endoscopically or serologically? It's actually A, three slices of wheat bread daily for one to three months. This is what the thought leaders. So this is Dr. Rubio Tapia, who is one of the thought leaders in celiac disease. And it's really, really hard to get a patient even to add a little bit back after they've taken it out and they've already identified that they have celiac disease. So I repeat this information to my patients to let them know that this is the literature, that this isn't something that I'm asking them to do that. So this is the maximum amount that we have them do it. So if we can get them to do two slices of bread for at least three weeks, then I negotiate with my patients. But I give them the guidelines and then we negotiate from that point. So we're going to talk about approach to bloating. We're going to talk about diagnosis and management of celiac disease. We're going to talk about management and surveillance strategies. And then we'll look at small bowel intestinal bacteria overgrowth, looking at how to diagnose and manage those patients. So the differential for a diagnosis for bloating is vast. And I think we all have to take a step back and then be thoughtful and mindful with our patients is also those alarm systems still carry over to approach with a patient with bloating. Do I have a 22 year old in front of my office I'm looking at across my desk who has bloating or is this a 65 year old woman that all of a sudden started complaining of bloating? So you start thinking differently on how you're going to care for these two different patients. So I'm not going to go into those specifics, but remember, this is vast and we need to be targeted and it's going to be mostly depending on the age and how are you going to approach these patients. But common disorders are, we have our food exposure. So lactose and fructose, we see this a lot in our functional bowel patients. Celiac disease is still an underdiagnosed condition. Always keep that on your radar. A small bowel bacteria overgrowth, gastroparesis, a delayed small intestinal transit. So you're going to look at their abdominal history. You're going to look at their surgery history. Mechanical obstructions or pseudo obstructions, which you're not going to be able to pick up unless you're going to be doing some advanced imaging. Pancreatic insufficiency, hypothyroidism. So you're back to looking at what type of systemic problems can cause this disorder. Ascites. So back to our lecture early in the morning, you know, does this patient have an underlying liver disease that hasn't been diagnosed? Low-level adiposity can be a condition as well that causes bloating. So getting that good history from your patients. Have you recently had weight gain? Are you exercising? Are you working on any exercise for your core? Have you stopped doing it? These are lengthy visits. And remember, our job is to uncover this. We're trying to be private detectives and we're trying to uncover, what is the potential cause of these symptoms that they're having? Diabiatric surgery or fundiplication, GI or GYN malignancy. I've had several experiences in my career where I've been the one to diagnose ovarian cancer in my patients. Because by the time they come to my office, they're complaining of bloating, maybe some mild change in bowel habits, but they've had a GI workup say several years ago. So you're not worried about colon cancer, but they've had this vague pelvic pressure, this abdominal distension. And I've seen, I've made the diagnosis by ordering events in imaging of peritoneal carcinomatosis, ovarian cancer, large uterine fibroids, that may be this 20 centimeter large uterine fibroid. They're almost could be considered two months pregnant. So don't forget about your advanced imaging to help work through these patients. And some of these patients, since the symptoms are so subtle that they creep up on them. So by the time they get to you, make sure that you've done that advanced imaging. Because sometimes I've been surprised, why is it that they haven't been done yet? To make sure we're ruling out the most critical or important things that we don't want to miss. So I want to go over with you what the visceral somatic reflex is. This can occur with patients who have abdominal distension. And these are our patients who will show you pictures in the portal. So they'll show you a picture of what it looked like before and what it looked like after a meal. And what happens is that the normal amount of gas in your GI tract, you have this gaseous distension, but the normal visceral somatic reflex is that it will push it back in again. So your abdomen, your abdominal wall will accommodate this. So what happens is in normal visceral response, your diaphragm ascends. So it relaxes. And then the abdominal muscle walls will contract. But if a patient has an abnormal visceral somatic reflex, then the diaphragm will descend. So it contracts and then it pushes out the abdominal wall. So the abdominal wall relaxes. So if we take the time, which is very difficult to be able to not to explain this to the patient, but it's part of that visit. I think this is going to be more important to talk to a patient who has seen multiple providers. I think by having this information, even having this in your office or showing the chart and explaining to the patients what's happening. I've had a lot of patients become so relieved by having this physiologic information, that understanding that this is common, that some of their responses, well, why hasn't anyone told me this before? So it's an excellent reference. I want you to look at this as your takeaway and start using this additional information to guide your patients if you find that they're having these symptoms. And one of the treatments for it is diaphragmatic breathing. And there are several YouTubes that are excellent in teaching patients how to do diaphragmatic breathing, which helps relax, relax the diaphragm to help reduce that pressure. So an approach to bloating and distention. This is a great tool also to share with your patients. So number one, are there dietary culprits? And again, this is ruling out your patients though, that have alarm symptoms. Just be mindful of that. So are there diet culprits? So if there, so you want to make sure that you're reviewing those potential foods that are very common, that patients are very grateful. If you're the first person to ever identify this with patients, and remember, you want to make sure you're doing your celiac testing before you start them on the restrictive diet, because it's also going to take gluten out of their diet. And if constipation is present, so make sure that you pursue treatment and also consider pelvic floor dysfunction, because there are different types of constipation. Not only is there slow transit, chronic idiopathic constipation, but also they can get pelvic dyssynergic constipation, where the stool will transfer down into the rectum, but because of the discordant muscles, then they're not able to actually push the stool out. So think about ordering for anal rectal manometry. And if you don't have that available, then you can consider referring for pelvic floor therapy to help patients with biofeedback to help with their muscles. Are the symptoms related to small intestinal bacteria overgrowth? Depending on your practice pattern. So you want to look to see if there are potential risks for it. You know, have they had intestinal surgery before? Have they, you know, are they diabetic? Do they have inflammatory bowel disease? You know, could this be an overlap? Also could be an overlap with celiac disease or microscopic colitis. Then some practice patterns I see will consider empiric therapy and or testing. In my practice, I do testing first, so I can have a measure to start with. So I'm not also unnecessarily prescribing medications if my patients don't need it. And then are symptoms consistent with visceral hypersensitivity? Well, we spoke about that visceral somatic reflex. So this is part of that visceral hypersensitivity. And I think having that diagram now in my office and explaining to patients makes more sense to them than sitting there, you giving your dissertation on brain-gut axis and causing visceral hypersensitivity. I think looking back, I probably had more patients staring at me, me thinking that they understand. But if we think about it, it is an abstract concept. So if you have that diagram in your office of what's actually happening with their diaphragm, then I think that that's going to make more sense to our patients. And then consider treatment with a neuromodulator. If you're not familiar with the Rome IV criteria, you can go on their website. They have excellent resources for you and for patients, and they have an excellent resource on pharmacology. I'm breaking down the different neuromodulators and the TCAs and dosing it. And then are your symptoms consistent with this abdominal phrenic dyssynergia, which I mentioned before? Treatment for biofeedback therapy has been successful. There are documented cases. A lot of the biofeedback that you see, though, are for academic institutions or teaching institutions that have access to a GI psychologist. I wish I had access to a GI psychologist. I think sometimes we become our own GI psychologist in helping patients through the different biofeedback methods, through mindful meditation, but specifically through diaphragmatic breathing. I've started making that recommendation to my patients with functional bowel disorder and bloating more often. So to overview of CELAC disease, it's a common autoimmune disorder mediated by the damage of your small intestine in response to this dietary gluten, resulting in malabsorptive syndromes. The incidence of CELAC disease is increasing. Presenting age is between the age of 10 to 40 years. It affects 1.4% of a population. There isn't genetically predisposed associated with HLA. And for patients who have restricted gluten when they've come in, you could order a genetic test. So I'll still order a CELAC panel to look at that TTG IgA metric, making sure that you'll see in the next slide that you want to have a serum IgA level that's within normal range. Because if you don't have a serum level that's within normal range, then your IgA mediated testing is going to not be appropriate. It's not going to be a valid test for you. So the HLA testing, if you, when you do the genetic testing, educate your patients though, that you have to have both genes. You have to have both the DQ2 and the DQ8 gene present because normal carriers can have it. And it doesn't mean that they have CELIAC disease. And then also make sure you're looking at your first degree relatives and getting that good history for your patients when they come into your office. It's interesting. I go through my history of my patients. You know, they have change of bowel habits, diarrhea, bloating, you know, I'll, I think I've gotten a good family history. A lot of times I'll focus on GI malignancies, GI cancers, any, you know, inflammatory bowel disease. And when I mentioned to them that I'm gonna be ordering a celiac pain, I'm like, oh, my second cousin has celiac disease, or oh. So, so it will come up in conversation. I don't specifically, we'll ask if they have a family history of celiac disease, but it's appropriate to, but sometimes I realize that I'm forgetting to ask that. So classic symptoms are gonna be weight loss, diarrhea, malabsorption, and younger children can be growth failure, bloating, which is what we're talking about, dyspepsia. Dermatitis herpetiformis, which is the skin disorder that sometimes may be the first condition that comes up. I've had dermatologists refer patients to my office for a workup for celiac disease because of that diagnosis of dermatitis herpetiformis. Non-classical symptoms, and patients have no GI malabsorption, they may just present with iron deficiency anemia, osteoporosis, or psychiatric disorders, or headaches. I had a patient, I've had several patients that were referred to me from their psychiatrist because they ordered a celiac panel because their response, they were mentioning to my patients that they just didn't seem like the classic patient, they have depression, they weren't responding to the antipsychotic medications. So it's just impressive how this diagnosis can be so subtle that we can't uncover it. And there's a missed opportunity with their primary care. So potential celiac disease, these are the patients that have positive serologies, but their small bowel biopsies are negative. So these patients I will monitor, I'll repeat their serologies and then appropriately repeat their upper endoscopies and do small bowel biopsies, making sure that they've had adequate sampling in their small intestine to make sure you're getting the diagnosis. So who should we test? These are all the patients that I had listed previously. One thing with your patients with elevated liver enzymes, I hope all of your SMART sets, when you look at evaluating for the elevated liver enzymes that you're including a celiac panel. So within looking for Wilson's disease or alpha one, looking at autoimmune hepatitis, make sure that you've included your celiac panel within that SMART set. So how do we diagnose celiac disease? So the gold standard is the TTG, which is IgA mediated. It's preferred as a single test over the age of two years old, less often than endomycelial antibody testing. So if IgA deficient, then you want to reflex to your IgG mediated based testing. So IgA deficiency is infrequent, but it's important to remember that the IgA isotype testing may be negative. So you have to reflex to your IgA testing. So the test that's recommended is the deaminated gliadin antibody, and then you can do a TTG2 Ig test. Gold standard then is recommend upper endoscopy with duodenal biopsies, even if the serologies are negative. So you want to go ahead and if you've got one marker that's positive, even if it doesn't amount to a high positive test, you want to do those upper endoscopy with multiple duodenal biopsies. All diagnostic testing should be on a gluten-full diet. And if on gluten-free diet recommend, again, that was three slices of wheat bread daily for one to three months. So I really lay heavy on the guidelines for my patients to educate them that these are not Jill Olmsted's guidelines. These are national testing, international actual guidelines. That's recommended for identifying for celiac disease. So most of you know, so upper endoscopy recommendations are one to two biopsies in the duodenal bulb and four biopsies of the distal duodenum. And I don't know about you, but some of my gastroenterologists may take one or two. So sometimes it's, we want to gently remind our colleagues or just make a note of it. Or sometimes what I'll do is just out of clinical curiosity, you know, ask my colleagues, you know, what they think about these guidelines. What do you think about, you know, potential not getting enough data to make that diagnosis, especially if you have a patient that has positive serology. So I'll make a point to bring it up to their attention that their celiac panel came back positive. And that's why I'm recommending an upper endoscopy with a small bowel biopsy. So pathology findings, you're looking at intraepithelial lymphocytes and that villus atrophy with the duodenal, villus atrophy of the duodenal mucosa. And histologically, what you'll find normal is going to be normal villa, which is to the left. They look like finger-like projections. I tell my patients, they look like sea anemones. So these little villa that are fluffy and floating, this is how we're going to absorb our nutrients through these small villa in the small intestine. And if there is a destruction of it, if they have this autoimmune disorder that's related to gluten, then these villa become flattened and there's atrophy. And then that's when you start to get malabsorptive syndrome. So Marsh criteria has four stages that the pathologist will use to actually document the stages of the destruction of the villa. I had a patient once and her TTG was over a hundred, over a hundred, so it was highly positive for celiac disease, ordered the upper endoscopy and the small bowel biopsies came back negative. And I called the pathologist and I said, could you please review these slides? I said, her TTG is over a hundred and it doesn't make sense that she's going to have a normal villa. And so the pathologist reread the slides and what he found out was that the slide, when the pathologist reviews the slides, a technician will mount those in paraffin and then they make slices of it. And what they found is that those cuts were made on a tangential line. So the cuts were made, so they appeared like the villa was higher than they actually were. So by asking a second pathologist to reread it, he confirmed that actually the patient did have celiac disease. So my pearl for you, one of the pearls today is that especially my newer NPs or PAs is if something doesn't make sense, go to that specialist and ask them to walk you through why this information doesn't look correctly. When I first started my career, I would never have thought of having the courage to call a pathologist and ask them to review the slides. So take this as a lesson to listen to yourself because you're a patient advocate. And if something doesn't look right or doesn't seem right, walk that through out loud and find an expert or second opinion to help them understand the information you're looking at. And that's even the way I'll speak with my patients during sometimes these clinical quandaries that you're in and I'll tell them, okay, well, let's just think this out loud. Let me listen to me kind of walk through this out loud and see if what I'm hearing or seeing is making sense. So non-gluten sensitivity is something that's real and it's important that we differentiate with our patients what that is. So gluten tolerance is gas, bloating, diarrhea, but it's related to, you know, if your celiac panel is negative, then you want to trial a low FODMAP diet. What's really, really, really important though is to explain to the patient that this is not meant to be a restrictive diet that you're on lifelong. And we're not good about bringing patients back and having them, guide them to reintroduce foods back in and then personalize this. So depending on the access, what you have nationally, you may have access to dieticians, you may not. Some insurance companies or Medicare fee-for-service do not have a dietician services unless they have, they're diabetic. So this falls onto us. This is our responsibility. So walk through the patients on what the intent is. And I'll, the way I approach it is that I'll have them look at the low FODMAP diet with them and I'll walk them through some common foods that can cause irritation. And then I'll say, now think about your daily diet. Is there something that's jumping out at you? Like, is there one food that right now you could take out of your diet that you think could potentially be causing gas and bloating or diarrhea? And then look at the MonashFODMAP.com. That's an excellent resource for you. So management, you want a knowledgeable dietician, educate them about the disease process. This is lifelong adherence. Introduce them to advocacy groups. And this is a long-term follow-up, a multi-disciplinary approach. So refractory celiac disease, these are not common but they are different two types. And these patients, if they don't respond to a gluten-free diet, there's actually type two can have a mortality up to five years. Monitoring is so key for celiac disease. We need to get these patients back into our office. We need to monitor also for micro and macronutrient deficiencies. Concurrent disorders can overlap with lactose intolerance, IBS, and also small bowel bacteria overgrowth and microscopic colitis, which I mentioned. And then patient education is imperative and we are the perfect skillset to do this. So we're going to take that extra time to guide our patients, to be able to educate them on the importance of this gluten adherence. So small bowel bacteria overgrowth, clinical syndrome, you have this excessive bacteria in the small bowel, it causes malabsorption and it can cause this immune activation. Symptoms are common, this bloating, gas, diarrhea, constipation. I will have some patients come into my office first visit. This is the first test that they want ordered. And I kind of take a step back with them. I'm like, well, okay, let's go ahead and let me walk you through common. Common things occur commonly. So let's make sure we rule out some other conditions first. I said, but this is part of my differential and this is something that we will talk about. So there's diagnostic testing. It's to look for glucose, hydrogen, or lactose hydrogen. And the test that I use in my practice is called a TRIO-SMART. So it measures hydrogen methane and hydrogen sulfide. These are common disorders that are associated with SIBO, which you're going to see from looking at the beginning slide, it also overlaps with bloating. So SIBO causes bloating and these all overlap with these symptoms. Management of the symptoms. There are two different types you want to look at. These are the guidelines for sulfide. Hydrogen and hydrogen sulfide. And then for methane, intestinal methanogenic overgrowth. And so these are the recommendations for the different antibiotics. Case presentation that will wrap up this presentation for you this morning. So 45 year old female presents with over 10 years of bloating and diarrhea. You had the colonoscopy done previously and the biopsies were negative for collagenous colitis and microscopic colitis. Routine blood work was within normal range. Stool studies were within normal range. So now you're seeing her in your office for the first time, say six months after this previous GI evaluation. So you go through, you do a chart review and you thought, well, gee, she hasn't had a celiac panel done. So you emphasize to continue and or restart gluten products over the next four to six weeks. And then you explained to her that you're going to go ahead and order a celiac panel, but if it's negative, this is what else I'm thinking about. So always keep your patients in the know of what you're thinking about, what's on their mind. Because number one, it reassures them that you know what you're doing and that you're being thoughtful and mindful about them. So your TTG level came back, it just lit up. It was over a hundred and reference range of normal is less than 15. So, and your immunoglobulin IgA was within normal range. So you're like safe, like, okay, good. I can trust this test. So you make the diagnosis of celiac disease. So what's next, the gold standard, you want to order an upper endoscopy and a small bowel biopsy. And sure enough, small bowel biopsy results show that there was increased enteroepithelial lymphocytes and there was villus atrophy of the duodenum. So the first thing you're going to do is refer to a dietician, but you're going to start them on a gluten-free diet and you're going to give them some national resources like the National Celiac Association. And you're going to do some routine testing. You're going to test for those micronutrients. So practice pearls, patient education, anticipatory guidance on regarding symptoms and bloating. These are patients that are going to be sending you multiple portal messages. So you may need to make sure that you're giving them a plan and mutually agreed upon measurements of success. That's how I describe my patients. Like, what do you want to see improved in your life to know that you're feeling better and moving forward? Identify those alarm symptoms and tailor your workup, assess serologies, do adenobiopsies, refer to an experienced dietician if they're available. And also there are hidden gluten products that you're going to find in cosmetics, lip balm. So there are other gluten products that can be hiding in there that you need to counsel your patients to avoid and schedule that routine follow-up and visit. Don't let these patients have a diagnosis of celiac disease and then get lost to follow-up. Thank you very much.

bloating

celiac disease

small bowel disorders

differential diagnoses

gluten sensitivity

patient-centered care