Navigating IBS with Dr. Zach Spiritos

Clinical Topics

Jun 18

Written By Liz Rohr

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Show notes:

IBS in Primary Care: What to Test, When to Refer, and How to Help Patients Feel Better

Irritable bowel syndrome (IBS) is one of the most common—and often frustrating—conditions seen in primary care. Patients may come in with chronic abdominal pain, diarrhea, constipation, bloating, or a mix of symptoms, and many have already been told that their testing is “normal.” So how do you confidently evaluate IBS, rule out more serious conditions, and help patients move forward?

In this episode, Liz talks with neurogastroenterologist Dr. Zach Spiritos about the real-world approach to IBS, including the underlying pathophysiology, common diagnostic pitfalls, practical workup strategies, and treatment options that go far beyond medication alone.

In this episode, we discuss:

What IBS is—and what it isn’t
The role of the gut-brain axis, visceral hypersensitivity, and the microbiome
Common conditions that can mimic IBS, including celiac disease, bile acid malabsorption, pancreatic insufficiency, and microscopic colitis
Which tests primary care clinicians can order before referral
Red flags that warrant further evaluation
Why endoscopy is often overused in IBS workups
Dietary approaches, including the low FODMAP diet
The role of sleep, stress, anxiety, and GI-focused behavioral therapies
Practical treatment options for IBS-C and IBS-D
How to talk with patients when testing is unrevealing without making them feel dismissed

Whether you're a new NP or an experienced clinician, this episode offers practical strategies to help you approach IBS with greater confidence and compassion.

Resources mentioned in this episode:

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Liz Rohr (they/she) (00:01.342)
Well, thank you so much for being here. Can you give a little introduction of yourself and a little bit about your background, whatever you want to share for the people?

Zachary Spiritos (00:10.837)
Yeah, I'm Zach Spiritos. I'm a GI doctor, but I focus on neuro gastroenterology. I trained at Duke and then I was in a practice within UNC for a while. And then I branched off and started my own practice where we take care of challenging chronic GI conditions, dysautonomia like POTS and like mass cell disorders. And we see a lot of people who are bendy and have hypermobility and Ehlers-Danlos as well.

Liz Rohr (they/she) (00:40.0)
Awesome, awesome. And that's how I found you is through your Instagram. Tell me your Instagram handle again. It's just your name, right? Cool, cool. And what are the things you cover on your Instagram that people aren't familiar with your work?

Zachary Spiritos (00:45.759)
Yeah, Dr. Zach Spiritos

Zachary Spiritos (00:52.223)
Yeah, we highlight a lot of the challenging things in gastroenterology. I would argue that, I wouldn't argue there is data that say that about 50 % of people that walk into a GI clinic and get the smorgasbord of testing walk out without a real diagnosis, without a true diagnosis or an IBS diagnosis. And they're just kind of left scratching their heads because they're like, I

Liz Rohr (they/she) (01:08.204)
Yeah. Yep.

Zachary Spiritos (01:14.549)
guess I'm thrilled that it's not cancer or Crohn's disease, but I'm kind of left directionless at this point in time. And so I try to fill in some of those gaps because that's the world in which I work and which I live. And we also talk about mast cell activation because I see a lot of that in clinic and dysautonomia as well. As a neuro gastroenterologist, I see a lot of issues with the nervous systems, both kind of how...

It affects the way the GI system moves, but also the way the GI system is sensed and felt and perceived. And I treat pots as well. So we talk about those things.

Liz Rohr (they/she) (01:47.406)
Oh my god, amazing. And you and I chatted before the podcast, before this recording that I want to talk to you about like literally all the things. I just want to download your brain. It's so wonderful. And I really I would love to touch on POTS and dysautonomia. I think for this episode, we're going to focus on IBS and maybe we can touch a little bit more back on that at the end. But that's amazing. So how did you go? Just a quick question before we get into it. How did you go from kind of general practice into neuro gastroenterology? Like, did you do any extra training or?

fellowships or just kind of like your own study? Like how did that work out for you?

Zachary Spiritos (02:21.089)
It's a really good question. So I did my GI training at Duke and then I was always, I always wanted to do like the functional IBS stuff. Like I just love how you kind of have to understand the whole person to treat the condition. Cause not everybody's IBS plan is the same. And I just loved kind of getting to know the person and creating individualized treatment plans. I also really like motility. So I'd read a lot of our motility studies to see how the esophagus works or doesn't work. And I created a motility lab where,

Liz Rohr (they/she) (02:24.878)
Mm-hmm.

Zachary Spiritos (02:50.995)
I was at UNC. So I was always interested, but I didn't do an extra fellowship. There are neurogastroenterology fellowships. I did not do one. I think I was kind of a late bloomer and really kind of attended all the meetings and read all the things and met with the experts in the field. And that's kind of how I ended up where I am. I did a lot of kind of the IBS work or the functional work where people have all the tests and they're all effectively unrevealing for, you know,

Liz Rohr (they/she) (02:59.928)
Yeah.

Liz Rohr (they/she) (03:04.366)
Totally.

Liz Rohr (they/she) (03:08.27)
Totally.

Zachary Spiritos (03:17.257)
can't kind of explain the breadth of symptoms that patients are feeling. And then I always, there's always about 30 to 40, 50 patients that I just could never make sense out of. And they had all young women and they had loads of symptoms and in various different organ groups, whether it's brain fog.

Liz Rohr (they/she) (03:26.382)
Mm-hmm.

Zachary Spiritos (03:33.151)
tinnitus, migraines, endometriosis. was like, goodness, this just doesn't make any sense. And that's when I discovered mast cell activation. And that's a huge part of my clinic today because I do think it's a growing, it's kind of, it's the prevalence is rising and I'm not quite sure why, I there's theories. And so that's become a lot of my clinic these days as well.

Liz Rohr (they/she) (03:47.352)
Yeah.

Liz Rohr (they/she) (03:52.032)
Yeah, that's awesome. That's very cool. So yeah, let's jump into IBS. So I think that I guess for context, so this podcast is for nurse practitioner, new grads primarily, but it's also spans nurse practitioner students all the way through experienced clinicians to people who've been in the field for 20 years and just like listening to the podcast, which is wonderful. So those are the people are talking to, but it's really like the context is really like in primary care, I feel and my personal experience as well is that like I have patients who

have some sort of GI issue and exactly like you said, like it's sort of like either vague or we don't understand it or we do like litany of tests or we send them to GI and it's sort of still like, ugh, like what's going on? this just IBS? Like what is, like let's just start with the foundations of like, is IBS and what is it not?

Zachary Spiritos (04:37.835)
So IBS stands for Irritable Bowel Syndrome, right? And it's a syndrome. It doesn't really have any diagnostic underpinnings. You just kind of have to rule out everything else. And so IBS is described by a change in bowel habits, whether that's diarrhea, constipation, or mixed with associated pain. Pain is a cardinal symptom of Irritable Bowel Syndrome. So if it's painless, it's not IBS, so to speak. And it's chronic, so it lasts over six months. And...

So that's the general gist of it. Everybody's different. generally speaking, your pain is somewhat associated with your bowel habits, whether that it gets better, it gets worse, but that relationship is present. And when someone comes into your clinic, I guess when someone has IBS, what's the pathophysiology? What does that actually mean on a biochemical?

Physiologic basis and so like broad strokes. It's a combination of dysbiosis, which is microbiome Increased intestinal permeability or leaky gut and visceral hypersensitivity and because where you feel everything a lot more like if I have You know if I eat too much chipotle and I have loose stools It doesn't cause me pain but for people who have IBS they have pain because those nerves that are sending signals from the gut or the enteric nervous system

Liz Rohr (they/she) (05:38.062)
Mm-hmm.

Zachary Spiritos (05:59.17)
to central nervous system are communicating pain and the brain is unable to kind of tune that out, right? The brain needs to know if you get stung by a jellyfish or you get run over by a car. It doesn't need to know if you're constipated, but you're, you know, you're,

your GI tract is sending these pain signals to your brain. The question is, why does that happen? And there's a lot of kind of different ways to get there. We know that childhood trauma plays a big role into the development of irritable bowel syndrome. And I think that has a big role in maladaptive behavior responses to kind of disordered bowels where you are

you're more prone to feel that more and you're just not able to kind of, you sense a lot more pain when you otherwise aren't able to. It's just kind of that, we know that increased childhood trauma increases your risk for irritable bowel syndrome. And then there's recurrent antibiotic use over years and years and years can certainly do it. kids who have a lot of sinus infections or pneumonias or, know.

Liz Rohr (they/she) (06:51.534)
Mm.

Zachary Spiritos (07:07.947)
put on antibiotics or certainly set up for it. And there's usually one big trigger, like a big surgery or a stress event that kind of tips people over the edge and they're living in this world of IBS. Yeah, but everybody's, you can develop after infection. But everybody's route is different. And so sorry to touch on that last point. The most common way people develop IBS is post-infectious. So it's usually after a big GI bug But it's more nuanced than that. It's usually in the context of kind of

Liz Rohr (they/she) (07:16.431)
interesting.

Liz Rohr (they/she) (07:29.87)
Mm.

Zachary Spiritos (07:36.416)
Yeah, psychological trauma as a child or as an adult, a lot of stress, insomnia. So it's kind of the smorgasbord of this psychological foundation and then some biological hit on top of it. So when we approach IBS, we kind of approach it from a biopsychosocial model where we take into consideration.

all the biology that went into this and the psychosocial factors as well to kind of see what buttons we can press to get people feeling better.

Liz Rohr (they/she) (08:08.238)
Absolutely. And you said post-infectious is typically a GI infection? Is that what you? Yeah, cool. So I guess from that, thank you so much for that. I'm such a nerd. And like all of that, I'm like, oh, how beautiful. I mean, not beautiful for the patients, obviously, but it's like so, it feels so good to talk through. From that kind of perspective, what is, especially if thinking about newer clinicians, like what is like a...

Zachary Spiritos (08:11.659)
Typically.

Liz Rohr (they/she) (08:34.572)
I'm thinking about the history. Like when you have a patient that comes in and is like, I think I have IBS or like, have diarrhea, I have constipation, my stomach hurts. Like maybe just start with that. Like I know that's a big question, but like, how would you approach that? How do you recommend that people approach that patient versus how you see in primary care also? Like I would love to hear a little bit of pet peeves in there too, if you have any.

Zachary Spiritos (08:53.569)
I always start with the narrative to see how they got there because it's really really important like when's the last time you felt good is one of the first questions I ask because it started somewhere right and you know your You know if this started, you know part of IBS is ruling out other things that can mimic those symptoms Like is this bile acid malabsorption, right? So did this all happen after your gallbladder was taken out?

Did you get a Roux-en-Y gastric bypass? And now you have bile acid malabsorption or you have exocrine pancreas insufficiency. So you have to get the context of the symptoms. So when did this all start? And if they're like, it just kind of started, like dig into that. Like what was going on? Like how was your job, your relationships? Like get into their childhood, their eating habits, their antibiotic use to kind of build a story there. And then in terms of kind of diagnosing

Liz Rohr (they/she) (09:35.714)
Yeah.

Zachary Spiritos (09:50.26)
IBS, you by syndrome, you it's, you gotta get a sense if they have pain or not. And is it associated with their bowel habits? It's usually the pain is, usually the pain is kind of staccato, it kind of comes and goes, it's not usually this constant pain that's around the clock. It is usually related to, yeah, their bowel habits usually gets better or sometimes it gets worse.

And then get a sense of like what are the triggers like this stress make it worse like is the consistent is the pain? Constant every day or there are variables that change how severe is so we know that a poor night's rest will make pain related to IBS worse the next day and so get into their sleep and just kind of Understand their story And you also it's really important to rule out things that look like irritable bowel syndrome, right? So there's a lot of them

Liz Rohr (they/she) (10:44.3)
Yes. You feel free to jump in if you want. I mean, I don't want to make you like textbook yourself of like, here are the 28 differentials, but I love it.

Zachary Spiritos (10:44.737)
You know.

Zachary Spiritos (10:50.719)
No, no, it's great. Yeah, and so if you want to talk about the differential diagnosis, like bile acid malabsorption is one. And so typically it's after.

colicis after a cholecystectomy where you're unable to handle that kind of non-stop bile content or the, you know, your gallbladder's supposed to store bile, but if it's no longer there, your liver is constantly kind of spilling bile into your intestines and a lot of it is absorbed in the terminal ilium, but the bile that isn't kind of creates this colitis, not anything that could be seen on endoscopy or even biopsy, but it also accelerates colonic transit time.

And there's exocrine pancreas insufficiency that can happen in those who have chronic pancreatitis, who have had diabetes, what's a CFTR mutation, cystic fibrosis. Yeah, so that can cause that as well. Small intestinal bacterial overgrowth is one, two.

Liz Rohr (they/she) (11:54.499)
my gosh, I really want to get into that, but I'm going to try not to get sidetracked. If you have any quick thoughts about SIBO that would be.

Zachary Spiritos (11:57.378)
Medications, right? Medications can cause both constipation and diarrhea, like magnesium supplements, probiotics. People take probiotics all the time, unnecessarily, you know.

Liz Rohr (they/she) (12:10.702)
interesting.

Zachary Spiritos (12:11.457)
like if it constipates you that causes, you know, constipation and pain. So really get into their medication history, you know, diuretics can cause constipation. So really kind of get into when this all started and kind of go over their medication history. Microscopic colitis tends to affect, you know, women in their fifth, sixth, seventh, eighth decade of life. It is profound diarrhea with sometimes some discomfort as well.

that has to be diagnosed with colon with biopsies. Celiac disease, my gosh, celiac disease. So yes, you need a screen for celiac disease and one can do so with a blood test with an IgA and a tissue transglutaminase IgA. If their IgA levels are low, which can happen in those with celiac disease, you can check a DGP IgG or a DGP IgA and their DNA, which is their, you know, look for the DQ, genotypes that predispose for celiac disease.

Those are the biggest ones off the top of my

Liz Rohr (they/she) (13:04.598)
Yeah. And what I guess like from your perspective, when you were in either, it sounds like people are pretty self-selected when they get to your clinic now in terms of specialty of like they've already been through the first step of GI and then they kind of come to you is my guess. Is that, you say that's pretty accurate? So.

Zachary Spiritos (13:21.887)
Yeah, now they've seen seven doctors before they've seen this. Unfortunately, I to run more tests, but one more thing is chronic infection is the other one. not giardia, cryptosporidium, chronic parasitic diseases also can cause IBS type symptoms. Sorry.

Liz Rohr (they/she) (13:26.602)
Right.

Liz Rohr (they/she) (13:38.005)
interesting. Yeah, so I guess, I guess what it has me thinking about is when we're in primary care, and we're seeing these patients maybe for the first time. It's just so heartbreaking. I'm sorry, getting distracted thinking about the patients that are like, you know, like the seventh, the seventh person that you've seen, like, that's just so hard. But if we go back and we think about the kind of the initial, and we have somebody who's in primary care, taking these histories, kind of like deciding how they're going to do the workup, and then they send to GI.

when you were in that general GI practice, what did you see that you wish people did differently or you were glad that people did? Like, I'm really glad that they tested for celiac, for example. I'm really glad that they asked these history questions. what are some examples of things that, because I think that that's a real frustration for both new grads and experienced nurse practitioners is just like, well, what is it that the GI wants me to have done first versus they need to be done when they're at the GI? And so it's just, I'm just trying to bridge this gap here. And I feel like there's, I would love to hear your thoughts about that.

Zachary Spiritos (14:35.169)
So you really are sending people to a GI doctor to get an endoscopy, right? So what has to be done? Like, lot of workup doesn't require endoscopy. And I'm sorry, just to go back to the IBS, you want to screen for red flags. So blood in your stool, unintentional weight loss, anemia. Hypoalbuminemia isn't technically one, but if they're hypoalbuminemic, you have to ask why. And you're thinking more of like IBD, like Crohn's disease or something like that.

Liz Rohr (they/she) (14:38.754)
Okay.

Liz Rohr (they/she) (14:45.955)
Mm-hmm.

Yep.

Liz Rohr (they/she) (15:02.658)
Yeah. Cool.

Zachary Spiritos (15:05.257)
cancer. Yeah, so you know when you go to a barber you're gonna get a haircut. So you send them to a GI doctor, they're gonna get scoped, right? So what can find on endoscopy that you can't do with non-invasive tests? Not a lot, right? You can, you know, if you have a high suspicion of Crohn's, these are all sort of colitis, you probably want a colonoscopy for biopsies. Microscopic colitis is one, but for the majority of these conditions you can screen through blood tests or stool tests. So you know the

Liz Rohr (they/she) (15:12.791)
Mm-hmm.

Zachary Spiritos (15:33.154)
The tests that I would start out with are a tissue transglutaminous IgA and a total IgA for celiac disease. I would get a CBC and a chemistry. Whether you need CRPs, I think it's probably overused. don't think I would harp on that. I think there are better tests, namely a fecal calprotectin, which is a very sensitive marker of inflammation. It's mainly in the colon, so if you have any small bowel disease, it may not show up.

Liz Rohr (they/she) (15:49.485)
Yeah.

Liz Rohr (they/she) (15:53.422)
Yeah.

Zachary Spiritos (16:00.594)
Fecal elastase is not a bad test either looking for exocrine pancreas insufficiency That said it can be falsely low just because of it in a dilute stool So if you're having lots of watery diarrhea that elastase can be low, but it's just because it's it's kind of diluted So that is not it is not equivalent to like that is not necessarily Diagnostic of exocrine pancreas insufficiency. I'm of the mindset that everybody with EPI has to have a story like

Diabetes, know, ruin my gastric bypass. there has to be the pancreas doesn't poop out on its own. There are idiopathic cases like idiopathic, but that's a story. But yeah, fecal elastase taste is one fecal fat spot fecal fats not terrible either. It can give you a sense of is a small bowel disease. for bile acid malabsorption, I do like the seven alpha C four, I believe it's called. I got a.

Liz Rohr (they/she) (16:52.472)
Hmm, I'm not familiar with that one.

Zachary Spiritos (16:54.975)
Yeah, it, I forget how it works. They have more elegant testing for bile acid malabsorption in Europe. It actually looked for kind of, they kind of evaluate the enteropathic circulation of bile, but the 7-alpha-C4 is a test that is used. You can send it to Mayo. A lot of big academic centers have it and is pretty good for bile acid malabsorption because not only does that happen post-cholecystectomy, but you can also get idiopathic as well, which is related to fiber, fibroblastic blastic growth factor 19. And that helps regulate how much

Liz Rohr (they/she) (17:19.308)
Yeah.

Zachary Spiritos (17:24.899)
bile is made by the liver. So yeah, so there's, would do that as well. And IBS all is probably going to be negative. Maybe the elastase is a little bit low, just if they're having a lot of diarrhea. But that's the testing I would start with. And you know, if someone is due for a colonoscopy because they're, you know, of the age where they need screening, then you can send them to a GI doctor. But you can do that workup on your own without a GI doctor. Like that's, that's the array of testing they'll do plus an endoscopy. But

Liz Rohr (they/she) (17:33.283)
Yeah.

Liz Rohr (they/she) (17:39.256)
Yeah.

Liz Rohr (they/she) (17:45.645)
Yeah.

Zachary Spiritos (17:54.334)
I would argue that if those tests are negative, the yield of endoscopy is pretty darn low.

Liz Rohr (they/she) (17:57.219)
Yeah.

Yeah, yeah. Thank you so much for that. That's so thorough. And I just want to add a note for the NP students who are feeling a little overwhelmed by that. I talk a lot about when people are first in practice that there's kind of like the A through D of like, here's core, what we need to know. And then we kind of expand our practice as we go. So feel free to ask for help if you're feeling overwhelmed by those labs. But that's really great. I mean, I think that there's this.

I think that's a little bit of the challenge for like newer grads, but also just not knowing in primary care what's like expected beforehand and just feeling that confidence of interpreting those tests. Like, you know, having up to date or dynamed or something like that and finding your references and make ordering those tests. It's sort of just getting comfortable with interpreting them as well. And I guess I'm wondering too, like when, when people go to GI, do they also do those workups or is it kind of just like usually they're jumping straight into endoscopies or

Like, I guess like as an experienced clinician, I'm hearing what you're saying of like, we can do so much of that in primary care. Is it frustrating for general practice GIs for primary care not to order those things? Or is there kind of like a bare minimum that we should be ordering, right? Like the, so for like the bile acid challenges, like maybe that's a little bit more of like a GI specialist versus like bread and butter primary care. Like you really should be ordering the fecal Calprotectin kind of thing. Cool, good to know.

Zachary Spiritos (19:19.391)
You should order all of these things. There's really no reason. Like the GI doctor is just going to scope them. Like they'll order some other things, but they're just going to scope them, right? Like just order. Yeah. Screen for red flags and then do that, you know, and then, and run those tests, you know, basic blood work, seven alpha C four fecal, cal protectin,

Liz Rohr (they/she) (19:26.863)
I see, I see. That's like their go-to is just the scope first. And then they're like, well, this didn't work out. So go on back to internal med kind of thing.

Zachary Spiritos (19:46.86)
Fecal, you you can do a spot fat, although that's kind of, I'll take that back. I don't want to do that one. The elastase and you're good. Like that's all you need. If there red flag symptoms, endoscopy, right? If it's, the labs are positive, endoscopy, but it doesn't necessarily have to trigger an endoscopy for everybody. It is such a limited test. It really is. And I think a lot of my GI colleagues would get very mad at me for saying this, but it is overused. is.

Liz Rohr (they/she) (19:50.67)
Okay.

Mm-hmm.

Liz Rohr (they/she) (20:03.222)
I see.

Liz Rohr (they/she) (20:09.486)
Yeah.

Zachary Spiritos (20:12.709)
overuse, right? Like, what is it diagnosed? Microscopic colitis. It's not going to happen if it's not typical. I've seen one male with it, but females, 60s, 70s, 80s, profound diarrhea, know, inflammatory bowel disease, but you'll kind of get it. If it's ulcerative colitis, they're pouring blood out, right? Crohn's is a little bit more, it's tough to diagnose, but there are more kind of subtle findings there. know, fecal caprotectin,

other kind of biomarkers, but there are people that kind of slip through the cracks because it can be distributed throughout. It could be in the small bowel, it could be in the proximal colon. That's a little more tricky to diagnose. But yeah, the endoscopy is usually superfluous. You can do a lot of non-invasive testing. And look, if you need help with, if you get these tests and you go, it's IBS, I need help with therapy, then you can send it to a GI doctor. They'll probably scope them anyway.

Liz Rohr (they/she) (20:53.602)
Yeah.

Zachary Spiritos (21:04.715)
But that may be a reason to refer if you're not comfortable managing it. But we can talk about management strategies as well if you want.

Liz Rohr (they/she) (21:07.596)
Right. Totally, totally. I think I just want to pause on the endoscopy because I think that there's a conception among a lot of maybe providers too, but for patients, I think that there's this expectation of like, how could you know if I think a lot of patients know that that test exists and they sort of expect, well, you have to see it. How could you know without seeing it? So.

So it's helpful to hear you say that because it's sort of like further encouragement for patients of like, actually it's a pretty limited test. Actually, I mean, I guess could you expand on that a little bit in terms of like when we send people for endoscopies, like what are they actually finding or what are they looking for and what are they able to find? And especially in plain language for the patients.

Zachary Spiritos (21:50.272)
Yeah, so absolute indications for endoscopy. Difficulty swallowing, like 100 % you need an endoscopy. Abdominal pain, not so much. Like the yield is just really, really, really low. We do upper endoscopies for pain all the time for like dyspepsia. We're looking for one thing, H. pylori and ulcers, right? So you screen it for NSAID use and you do a stool test to look for H. pylori. You don't need the endoscopy, but we do it all the time, right?

Liz Rohr (they/she) (22:08.408)
Yeah.

Liz Rohr (they/she) (22:18.114)
Yeah. Yeah.

Zachary Spiritos (22:19.681)
But generally speaking, sometimes pain. If they're having profound diarrhea, like probably need endoscopy I'm talking like 12 times a day where it's like, but you can also do stool tests that kind of start there. But unintentional weight loss, especially in someone who is of the age where they're due for a colonoscopy. Blood in the stool is a big one.

But generally speaking, I'm sorry, just to boil it down, difficulty swallowing, unintentional weight loss of the age where you need a colonoscopy or has a significant family history of colon cancer, blood in your stools. Those are the hard indications right there. Or like abnormal imaging that shows a mass, obviously. But for symptoms alone, that's where I would stop. And then pain is a good question mark. Like I would argue that there are higher yield tests for pain besides the endoscopy.

Liz Rohr (they/she) (23:06.275)
Yeah.

Zachary Spiritos (23:13.397)
And not all pain is created equal. Like if you have pain up here, that's called dyspepsia. You know, the guidelines would say they need an endoscopy. I think you could, I'm totally okay with doing an endoscopy in that situation. You're looking for ulcers and H. pylori. Gastric cancer is so incredibly rare in this country that it's just kind of not even on the differential. Obviously if there are red flag symptoms, you know, you should go take a look. But yeah, that's it. That's it. And then obviously colon cancer screening, which is incredibly important. But for symptoms alone,

Liz Rohr (they/she) (23:25.879)
Right.

Liz Rohr (they/she) (23:34.99)
Totally.

Liz Rohr (they/she) (23:40.78)
Yeah, I love that.

Zachary Spiritos (23:42.889)
It's just not, it's obviously dependent on the symptom, but for symptoms alone, mainly pain and maybe changes in bowel habits, the endoscopy is not the highest yield test out there.

Liz Rohr (they/she) (23:52.985)
That's great. I really love how you broke that down just like so simply because I think that it can feel a little mysterious sometimes when you're not in GI every single day to like, I don't know, just it's just so it's so bread and butter for you and it's so clear. So I appreciate the clarity on that. So it sounds like, I mean, I would, I would feel pretty confident talking with a person with IBS about their, from this conversation alone, like I think I probably feel pretty comfortable talking about IBS, but like, I guess I'm thinking about

The situation, so I'm in a medical situation where I've gone through a lot and it's like, you're fine, you're fine, you're fine. So I can, I first hand know the frustration of what it feels like of like, we looked at it for everything and there's nothing. How do you talk to patients? Like, do you have any thoughts on how to talk to patients in a way that's like, hey, we did all these tests and there's nothing wrong with you, quote unquote, that makes them feel still like.

they're not hopeless or they're not crazy or there's still something we can do for like, how do you first, I guess we'll talk, I would love to get into the management pieces, but like, what is that conversation like for you or what's an example of how you talk to patients that still validates them without making them feel like there's nothing, you know.

Zachary Spiritos (25:02.953)
Yeah, it's a good question. And I think if I see a pain, so I don't do endoscopy anymore. I've cut that up. But when I was doing endoscopy, I would say, OK, this is like what I'm thinking about your case. And this is our treatment strategy. We're going to get some blood tests. We'll get some stool tests. We'll maybe do an endoscopy. And if that endoscopy is negative, then I think it's this. And I will say, OK, well, it's something called IBS, or functional abdominal pain, or functional GI condition. And I will go into the pathophysiology of it.

And I think explaining what's happening, like the science behind it, like somehow validates it. And then I simultaneously will just say that our testing stinks. The endoscopy looks for structural lesions. The body is infinitely complex. And there are some things, namely like the wiring.

Liz Rohr (they/she) (25:44.184)
Hahaha!

Zachary Spiritos (25:53.718)
The plumbing is looking at the GI tract, but the electricity is what really matters, right? So when you have migraines, right, is there a test for that? No, but we believe it happens, right? Diabetic neuropathy, really painful. We don't have a test for that, right? So their pain disorders are categorically different. They're neuropathic. It involves...

Blood flow and nerve but kind of how nerve send signals and we don't have good tests for that I said if we did have a test for it It'd be a functional MRI your brain that would show something light up and in the you know the pain processing areas which can demonstrate kind of that you have pain from GI you know GI source, but obviously we're not doing that because it's helpful and won't change therapy, but I basically simultaneously like I believe you this is We see this every day In fact, this is the most common thing that we see in GI clinic is people that have symptoms that don't have any core

on our kind of garbage tests. They're just not very good tests. I'm sorry. Structural lesions are there. It's a layup when you see it, but the body is so much more complex than that. And then you normalize it, right?

Liz Rohr (they/she) (26:53.421)
Yeah.

Zachary Spiritos (26:57.609)
Over half the people in our clinic have conditions like this. If someone comes into GI clinic with symptoms, only 40 % will get an answer on our initial testing, whether that's ultrasound or endoscopy. And I think that percentage goes down even further when you're talking about like IBS types of pain here and changes in bowel habits. So.

Yeah, and that's kind of how I go about it and describe what's happening on a pathophysiologic level to say, like, I get what's going on here, and there's a lot of things that we can do to make you feel better. You know, the beautiful thing about IBS is there's not just one treatment approach. You when you talk about peptic ulcer disease, like, there's kind of only a couple things we can do to treat it. Answer, like, there's the limited thing. But in IBS, we can talk about...

Liz Rohr (they/she) (27:35.598)
You're right.

Zachary Spiritos (27:40.149)
Brain gut therapy whether it's like hypnosis or cognitive behavioral therapy working on your street sleep working on your anxiety working on your depression working on your diet Medical therapies if you want to do that supplements like there's so many different ways that we can kind of get at this If you truly live in this this world

Liz Rohr (they/she) (27:57.283)
That's awesome. Sorry, I just want to pause for second. Can you hear that background? Can you hear the lawnmower outside? Okay, cool. I'm still figuring out my setup at my house. So I'm glad. Sorry, let me just get my thoughts together one second.

Zachary Spiritos (28:02.783)
Mm, yep.

you

Zachary Spiritos (28:11.989)
Take your time.

Liz Rohr (they/she) (28:19.086)
I just, really, I really love how you're starting you like that conversation you're starting even before you start the testing process. Like I think that that's such a big thing. think that, yeah. So I think that there's like the three parts that kind of came out to me is like, first we're talking about it at the initial workup, which I think is hard if we're not feeling super confident with our diagnostic skills of IBS versus the other things, right? Speaking specifically to newer clinicians.

But the more confident I think we can feel in our initial workup of these conditions of like, this is probably IBS. And then we have a conversation with them beforehand. We do our testing. We let them know here are the potential outcomes. And then once we talk about the outcomes, I believe you. And I love those stats too of just like, you know what, a huge percentage, whether it's 40 % is saying yes specifically to a patient or just like, yeah, that's most people that come in with a GI thing are not going to have a quote unquote answer.

But I still believe you and there things that we can do for you. So that's really wonderful. And I think that's a great segue into the kind of like management. So I guess if we're thinking about the person that came to us, we did our thorough history. It didn't include dyspepsia. Let's just say that. Like we'll just say that it was like a, I don't know, what's like a typical presentation that you would see for someone like a first time coming in?

Zachary Spiritos (29:17.589)
Yeah.

Zachary Spiritos (29:31.904)
Yeah. You know what? I've just been dealing with GI stuff for the last couple of years. You know, it just I have always had like a sensitive belly and

Liz Rohr (they/she) (29:37.56)
Mm-hmm.

Zachary Spiritos (29:43.158)
You know, when I travel, my bowels lock up, I'm home, I just kind of like, the first thing I have to do is run to the bathroom and it's urgent and I have to get there right away. And I have to kind of like, I can't start my day without going to the bathroom a couple of times. And I go, I don't get it all out. I go like two or three more times and goodness, it hurts. Like I just, I just kind of, it cramps and it hurts. and then I, it's, it's tough for me to leave because I'm worried about going to the bathroom. I know where every bathroom is in at work.

Liz Rohr (they/she) (29:55.822)
Mm-hmm.

Zachary Spiritos (30:12.383)
I position my office closest to there because I'm always worried of incontinent episodes. I often skip dinner. If I go out with friends, I have to skip dinner because I may have to run to the bathroom afterwards. That's kind of a history that you get. And they're worried about their, not only worried about their symptoms, but the social consequences, the psychosocial consequences of their symptoms as well. That's kind of the history that, I mean, there's obviously the constipation variety and there people that kind of go back.

Liz Rohr (they/she) (30:26.574)
Totally.

Zachary Spiritos (30:38.079)
forth and say you know what I did I'm assuming it's really get worse when like I travel like my in-laws come to visit or You know, I'm under deadline my symptoms get worse

Liz Rohr (they/she) (30:44.781)
Ha

Liz Rohr (they/she) (30:51.746)
Yeah, well, that's really helpful to paint that picture. So if you have this person come in and then you've gone through that kind of all the initial history questions, there's no red flags, you decide what testing you're going to do, you have that conversation with them of like, this is, you know, it sounds like this is what it is, we're going to do these tests to make sure that it's, you know, whatever, we might do these. And then you do the tests and they come back, they come back all negative, it sounds like for the most part when you see these patients, it's like nothing.

And so when you have that happen, what is your kind of like next step in terms of like the management? I think that so many people are like, what meds can I do? But it's lot bigger than that.

Zachary Spiritos (31:31.571)
Yeah, get into like what makes their day crappy.

Liz Rohr (they/she) (31:35.404)
Yes, yeah, so it's getting into those pieces.

Zachary Spiritos (31:37.58)
What is like, is it like, do have good days and do you have bad days? Like, what does a day look like? like I go once. Like, why do you go once that day? Like, it because you didn't sleep all the night before? Is it because you weren't stressed? Is it because it's the weekend, right? And you're not at work, right? And so, or is it like pervasive? It's every day, right? And they always talk about sleep. I find that these people are in like sympathetic overdrive and they get to bed and they just cannot sleep, right? So.

Liz Rohr (they/she) (31:41.228)
Mm-hmm.

Liz Rohr (they/she) (31:52.747)
Right.

Zachary Spiritos (32:03.775)
You got to work on all the things you got to work on their sleep. You got to work on. so, yes. So trying to identify their triggers first. Then I talk about diet.

Liz Rohr (they/she) (32:12.93)
I was just gonna say, people, I think a go-to is a food diary. But yeah, go for it.

Zachary Spiritos (32:17.865)
Yeah, so the food hour is tricky in IBS because the foods that cause the symptoms are typically like eight to twelve hours beforehand because all the business is done in the colon like all the It's the it's that's when

kind of things start hurting is when these food particles enter the colon. So it's usually like eight to 12 hours later. So it's tough, but I do recommend the food diary. A low FODMAP diet is nice. It needs to be done cautiously because it can lead to over restriction. just you want to create a plan that not only helps them feel better, but helps them feel better for the next 50 years, right? And so you don't want to lose the

Liz Rohr (they/she) (32:53.134)
And I imagine it would add stress too. And so stress is a trigger and they're like, what is a FODMAP diet and what foods have it? Cause I've looked at that and it's like, all right, this is interesting.

Zachary Spiritos (33:02.177)
I definitely break it down to why FODMAPs can be problematic and they can be problematic in both IBS diarrhea and constipation. So FODMAPs stand for fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols These are poorly absorbed carbohydrates that when they enter the colon, they effectively act as fast food for the bacteria that live in your colon. They ferment it into gas causing kind of distension of the bowel and then pain. And it can also lead to, it's an osmotic kind of laxative and pulls water into your intestines, leading to

diarrhea. But they also, if you have the constipation kind of subtype, that leads to just distension of the bowel and more bloating, which can be quite painful. So the low FODMAP diet limits kind of the gas formation and the stretch of the colon. There's one study that says that it actually decreases intestinal permeability and leaky gut. I don't know what to make of that data right now. But basically, that's the gist of it. It just decreases the kind of the tension on the intestines that can lead to a lot of pain.

those with IBS. But yeah, so it's a tremendously challenging diet to follow. There's a modified low FODMAP diet as well, where you only cut out the most like the typical aggravators, which are fructans, which unfortunately is like, unfortunately, it's the garlic and the onions, the galacto oligosaccharides, which is the beans, you could probably do that. And then the mannitol, which is like cruciferous vegetables and mushrooms. So there's various, various, like, you know,

I'd probably send them to a dietitian because there needs to be done in a stepwise process where you eliminate foods over a couple of weeks, introduce them. I've made a nice handout that I talk to my patients about, but always if they are able to and their insurance, they can find a GI dietitian that takes their insurance, that's always nice as well.

Liz Rohr (they/she) (34:35.661)
Mm-hmm.

Liz Rohr (they/she) (34:47.765)
Yeah. Yeah. So it sounds like, we're assessing what the triggers are, we're gathering information about the food, considering the FODMAP diet. What are some of the other things that you're doing for the management for people? And are you doing it kind of in that route? Or what if the dietician is not an option? you kind of like, people are like, what meds can I take right now? Yeah.

Zachary Spiritos (35:10.529)
Maybe people are already doing the diet, right? People are kind of doing the right thing. Like I don't nickel and dine them like if they're like eating lots of lactose, right and like maybe lactose intolerant, right? Like or they eat just they put garlic on everything. It's like, okay. Well, let's just focus on that right now. So I usually do a food diary and it's like what are they eating and if there's nothing like egregious I probably don't go down that route because if you're like like eliminating one piece of toast that they eat for lunch, it's probably not going to move the needle a lot. But if like there's a lot of like

Liz Rohr (they/she) (35:16.268)
Mm-hmm.

Liz Rohr (they/she) (35:25.856)
Yes. Okay.

Liz Rohr (they/she) (35:32.824)
Okay.

Liz Rohr (they/she) (35:38.124)
rate.

Zachary Spiritos (35:40.53)
they're chewing gum full of sorbitol all day or they're drinking a lot of lactose or they eat tons of broccoli every night and put garlic and everything and onions and everything like like i had a lot of italian patients like that was what they did every day well that's probably where we should start and but you also have to see like if they're open to that right you can't push this agenda on them if they don't want to change that right because they're not your plan is only as as

Liz Rohr (they/she) (35:54.254)
Yeah.

Liz Rohr (they/she) (36:02.934)
Absolutely. I appreciate you putting that in there. It's their life.

Zachary Spiritos (36:09.245)
They want it so it's it's shared decision making as well So you have to kind of get a sense of what they want to do too. if you find that stress is a big kind of either factor here Or there's a lot of stress around their symptoms, know You can you can work in a psychologist as well to work on cognitive behavioral therapy and they work on you know, I am not a psychologist by any means but there's a lot of kind of catastrophic thinking and all or nothing thinking about their symptoms like

Liz Rohr (they/she) (36:11.672)
Yes.

Zachary Spiritos (36:36.969)
If don't get my bowels out this morning, my day is ruined. That kind of, potentiates the anxiety that makes the bowel symptoms even worse. Or if I don't go to the bath, if I like, if I bloated all, or if I eat this, like my day is done and I'm never going to recover. And so it's untangling those kind of those thoughts and those feelings. Cause that can make the symptoms even worse. And hypnosis is kind of a nice data driven tool as well.

Liz Rohr (they/she) (36:53.26)
Yeah.

Liz Rohr (they/she) (37:03.608)
That's great. That's great.

Zachary Spiritos (37:05.089)
GI psychology is a telehealth based psychology group that kind of offer services to all states. They're wonderful. There's also at home hypnosis services. There's an app called Nerva that has data behind it. If someone wants to try that on their own, have to be very self motivated, obviously. So yeah, so I get it. And if they have anxiety that like is pathologic, right? And they meet criteria for general anxiety disorder, like you can talk about medications if they want to go down that route too.

Liz Rohr (they/she) (37:20.214)
Yeah, that's great to know.

Liz Rohr (they/she) (37:32.864)
Right, right. Yeah, and I, what do you ever have people with the, I'm recalling a patient from a couple of years ago and I cannot remember the med off the top of my head, was it Dicyclomine Does that make sense? Do you, how, what is your experience with that? Or like, how do you, what do you think about patients taking that? Yeah.

Zachary Spiritos (37:52.898)
It's okay, it's safe. it'd be used for people, it's an anticholinergic medication, it should just help colon spasm less. So if someone has a lot of frequent loose stools, like it can take the edge off for sure. It's rather safe, rarely can cause constipation. It's an anticholinergic, so maybe be careful in your older patients, but it's...

Liz Rohr (they/she) (37:58.339)
Mm-hmm. Yeah.

Zachary Spiritos (38:12.353)
And everybody gets on it, right? If someone has pain, they go to the ED, they're left with a prescription of Dicyclomine. So if it was really all that, no one would have IBS. So maybe like an adjunct in your toolbox to kind of slow things down a little bit. It can help with post-prandial diarrhea. the accentuated gastrocolic reflex when people eat and they have to poop immediately afterwards, it can the edge off that as well. Definitely not a fix, I would say. It's just kind of a tool box.

Liz Rohr (they/she) (38:18.53)
Yeah. Yeah. Yeah.

Liz Rohr (they/she) (38:29.443)
Yeah.

Liz Rohr (they/she) (38:34.316)
Yeah. that's great. That's great. For sure. For sure. I think it's, yeah. And I think it's helpful to also have that conversation with patients of like, no, no, aren't meds that are a fix, unfortunately.

Zachary Spiritos (38:48.577)
Yeah, well, and so there are FDA approved medications for IBS now.

Liz Rohr (they/she) (38:52.182)
Yeah, do you want to talk about those?

Zachary Spiritos (38:54.049)
Sure, So depends if you have IBSC or IBSD. There are medications for, yeah, so the ones for, they both have good data behind it.

So IBSC medications are, I mean Linzess is the most commonly known one. It's called a secretagogue, so it's Miralax on steroids. It brings a lot of water into the intestines, but it also has analgesic properties, so it can help with pain, whereas Miralax doesn't. We'll get things going, but it doesn't really help with the pain component of things. Amitiza in the same realm. Tends to cause a little bit more nausea than Linzess, so I'd lean towards more Linzess Trulance is one too. And then there's a newer one on the block called Ibserela.

which has a different mechanism of action. And yeah, those work well. They help people poop and they sometimes make them feel better. But again, I would never do medications without addressing the other parts of it. I always go into their mental health, their sleep, and their diet as well. It's for IBSD, you have less of a menu there, but Viberzi is one.

Liz Rohr (they/she) (39:49.269)
Absolutely.

Liz Rohr (they/she) (39:54.06)
Absolutely.

Zachary Spiritos (40:00.544)
You can't take it if someone has more than two to three drinks of alcohol a day or have had their gallbladder taken out before because of a risk of pancreatitis. And that tends to be beneficial too.

Liz Rohr (they/she) (40:11.244)
Yeah. Do you have any, so I want to touch back on, I'm thinking about other things that patients have tried where they're like increasing either their, I want to go back to what you said about probiotics, but I also don't want to forget about fiber. Patients sometimes will start to increase their fiber intake. Do you find that that is helpful for people or not helpful or like any sort of thoughts around that? Like the fiber supplementation?

Zachary Spiritos (40:32.801)
I think it's very helpful. It just has to be done carefully because some people say fiber hurts because fiber can be, fiber is meant for your gut. Like it's meant for your colon. It's not meant for you. And so it feeds your gut microbiome and so it can cause bloating. And so people that are hypersensitive, you have to be wary of that. So you can just target more fiber sources that are less bloatogenic.

Liz Rohr (they/she) (40:42.86)
Hahaha

Zachary Spiritos (40:57.441)
And so yeah, so that's where working with a dietician is really helpful. You know, there's different fibers for different people. And so, you know, if someone is constipated, you know, I think a low dose, actually for diarrhea as well, fiber can is really nice. You know, the soluble fiber helps kind of, it's, it's, it's, if you ever put, if you're taking water and put it in Metamucil, it just, it just gunk's up, right? So it gives your stool bulk and it can absorb some of the extra water.

Liz Rohr (they/she) (41:18.006)
Yeah. Yeah. Yeah.

Zachary Spiritos (41:26.005)
The insoluble fiber just kind of helps pull things through. So that's more for your constipation subtype. But when you eat fiber, when you eat fibrous foods, there's always a little bit of both in there. So try to get healthy amounts of fibers good. And just kind of start, if you don't eat a lot of fiber, start low and go slow and have a plan. I tend to talk a lot about fiber with my patients and see how we can get them up to a reasonable amount without kind of overdoing it. A lot of people get intimidated by it because the broccoli's make them hurt. Apples make them hurt.

Liz Rohr (they/she) (41:53.198)
you

Zachary Spiritos (41:53.44)
But we can find low fermentation fiber sources that kind of agree with your system in terms if you're looking for a supplement You know Metamucil is great. It's a you know, it's has added in there, but it is kind of a low fermentable soluble fiber source

Liz Rohr (they/she) (42:04.867)
the go-to.

Liz Rohr (they/she) (42:09.57)
Nice. Yeah. And what were your thoughts about probiotics? I was surprised to hear you say that many people are taking probiotics and they shouldn't be or they're overdoing it. Tell me your thoughts on that. I feel like there's a lot of talk about probiotics and it's like, just take probiotics and I'll fix everything.

Zachary Spiritos (42:20.713)
So I think, yeah.

Fixing so are we we're saying that your problem is due to dysbiosis, right? So what do? It starts with the data. So the data is very mixed, right? So if it worked for IBS, the data would be amazing, but it's very very mixed because the people who it works for They are missing the strain at the dose that probiotics work for that the the probiotic that they're taking there are

Liz Rohr (they/she) (42:34.339)
Hahaha

Liz Rohr (they/she) (42:40.664)
Mm-hmm.

Zachary Spiritos (42:53.173)
kind of I have a probiotic guide that if someone wants to use a probiotic, there are probiotics that we can use for certain situations. But how do they work? know, they, you know, if you take probiotics in all likelihood, they're probably not inhabiting your colon. They're probably they're passerbys. So you're just renting them at the price of 50 bucks a month. Okay. While they're in there, they're giving good things to your colon.

And so there are probiotics that can give short chain fatty acids to your colon, which is the good stuff that your colonocytes love. And that can help your colon move, right? So probiotics can work for that. But I can also accomplish that goal with two kiwis a day and some fiber and movement for not 50 bucks a pop.

If you want the, you know, if you're on antibiotics, there are probiotics that are good in that situation. You know, if you want to, you know, yeah. So if you want to prevent like C. diff, like I'm all for taking probiotics there. If you want to, if you're travelers, diarrhea, like there's decent data there, but for like a chronic condition, the data just isn't there. tend to follow the data and we don't have the technology to say, okay, we tested your microbiome. Your symptoms are due to this deficiency. Now take this probiotic.

Liz Rohr (they/she) (44:04.066)
Yep. Right.

Zachary Spiritos (44:05.249)
My bullish on probiotics? Absolutely. Do I support you if I want to take it? 100%. Is it the first thing I do? Not really. You know, so if you take antibiotics, say, want to, you know, I work in a hospital setting. I'm sure I'm colonized with C. diff. I really don't want to get it. I'm taking Augmentin for whatever reason. By all means, take a probiotic. Traveler's diarrhea. Take a probiotic. But for...

Liz Rohr (they/she) (44:11.629)
No.

Zachary Spiritos (44:28.747)
for most people with chronic GI symptoms, I don't think for that price point the yield is there. But I'm painting with a broad brush here and people that really benefit from it, so I don't want to kind of poo-poo what's going on with them either. I just think for that price, it's just you're...you better get a lot back, and I just don't think either is being that great.

Liz Rohr (they/she) (44:45.358)
Totally, I appreciate that. Well, yeah, so I'm just thinking about, are there any other kind of thoughts you want to add for people in primary care managing IBS, like any other kind of like pet peeves or pearls of practice or, yeah, just any sort of thoughts you have.

Zachary Spiritos (45:08.629)
Yeah, I think I would just encourage you to do your own workup. The GI doctors don't have any special tools that you guys don't have. I wouldn't come and consider a colonoscopy as a special tool, but it is, you know, I would do the workup first and really just, you know, listen to your patients because they will tell you.

What buttons the push? it a stress anxiety thing? Is it a food thing? Or are they just like, I'm desperate for a medication and there's a lot of medications that one can use. I would just tailor your workup. Like there's no protocols here. I would listen to your patients, tailor the therapeutic interventions to them, listen to them in terms of what they want to do.

And then create a plan together and then follow them over time and over time try to get them on the most liberal diet possible Get their confidence back eating again, right when they go out to dinner and they go to Olive Garden. It's probably not great for FODMAPs but Like I did it yes, like you did that's awesome like now let's build on that confidence and we're on a roll here and So you just you just kind of you got to take those little wins and set expectations. Like this is not gonna

Liz Rohr (they/she) (46:04.078)
I was gonna say that's a lot of garlic in.

Zachary Spiritos (46:17.607)
Fix itself in this a chronic issue chronic issues take time, right? They're not infections where you take an antibiotic and they get better like It will require time and a thoughtful approach and hand holding because there's no promises here So you start something touch base with them see how they're doing follow up with them and then tweak the plan based on what's working. What's not

Liz Rohr (they/she) (46:20.355)
Yeah.

Liz Rohr (they/she) (46:36.822)
Yeah, and actually that reminds me, how do you have that setting expectations conversation? Because it is a chronic condition. Are you setting up goals with people and just like, we'll just see how good we can get this? Versus like, yeah, how do you set that expectation? How do you have that conversation with people? Yeah. Yeah.

Zachary Spiritos (46:54.325)
say, I don't know. Like I said, there's so much unknown in this, right? There's not. And that's what you know, this isn't a broken ankle. This isn't a pneumonia. We just don't know where this is going to go. There's no amazing data points to say, if I do this, you're going to get 100 % better. So what I do is I talk to my patients a lot and I say, okay, we're gonna start this. I need three weeks of data points to see if this is because you know, if you start like Linzess like you'll know pretty quickly if this is right for you.

Liz Rohr (they/she) (47:07.298)
Yeah. Yeah.

Zachary Spiritos (47:21.663)
Your FODMAP diet for example, for like, that's the one intervention you're doing. four weeks of data to see if this is working. And if it's not, then we're not on the right path. So just encourage communication because there's nothing promised here. You're working and setting, you're deciding on interventions based on pattern recognition and their story. And that's great, but those aren't firm data points that will, you know, a hundred percent informed treatment success.

Liz Rohr (they/she) (47:27.0)
Right. Right.

Liz Rohr (they/she) (47:49.592)
Totally.

Zachary Spiritos (47:49.696)
And then if you talk about neuromodulators, which is like a whole different conversation about IBS, like amitriptyline, disipramine, Cymbalta, that all have their role for kind of pain disorders of the gut, you you have to be like, okay, like, we'll try this, but like, you know, I don't know if this is going to work. I'm hopeful because I see this work all the time, but you are categorically different than Kevin than I saw last week with similar symptoms. So I don't know if you're going to metabolize the drug the same, if we're on the right track. So keep me posted. And I'll say, you know,

two to three weeks, let me know how this is working. That depends on kind of what we do, because everything requires a certain amount of data points to see. If you're on Cymbalta, you probably need like four to six weeks to see if that's working. based on what you're doing, would just say encourage them to follow back up with you and say, OK, if this isn't working, will pivot and try something else. So it's not all doom and gloom if it doesn't work, because you have to. You can't be so confident that this is going to work, because that's just a lot of uncertainty in this space. So sets make patients like this may not work. But know what? There's counters to this. And we will continue to work.

Liz Rohr (they/she) (48:40.098)
Right. Right.

Zachary Spiritos (48:46.879)
and grow and I will learn more about your body and you as we kind of start this therapeutic journey together.

Liz Rohr (they/she) (48:53.568)
Absolutely, I love that. Yeah. so it's, and I mean, it's kind of just like any chronic pain where you're talking about, what, what, how is this impacting you? What are your goals? What are you willing to do? You know, because not just because you want to help them achieve X, Y, Z goal doesn't mean that they want to. So if you're like, well, you know, they want to keep their FODMAP diet. They want to keep going to Olive Garden all the time. Right. But like, what can we do else, you know, otherwise that might help them. It's like, is it about, you know, the stool?

habits, is it about the pain experience, is it about the quality of life, the social experience, like that kind of stuff. So having those conversations, being really candid, and I really appreciate that. I don't know, because I think that there's so many, unfortunately, so many clinicians out there that are like, it's gonna, this is what it is, and this is how it's gonna go, and that's just not realistic. But we also wanna give patients hope that there are a lot of interventions that could work. We just have to figure out what they wanna work on and keep going, sounds like.

Zachary Spiritos (49:48.053)
Very well said. Yeah, absolutely.

Liz Rohr (they/she) (49:49.966)
Cool. Cool. Well, thank you so much for your time. Any sort of, where can people find you? So you said that already, but just recap maybe. You're on Instagram, I know, but I don't know if you're anywhere else.

Zachary Spiritos (49:56.502)
yeah. We're on a TikTok as well. have someone else doing that for me. It's Dr. Zach Spiritos. I run a clinic called Ever Better Medicine that we are licensed in North Carolina, Illinois. We'll treat kind of complex chronic GI conditions, also mast cell activation syndrome and dysautonomia, including POTS.

Liz Rohr (they/she) (50:18.296)
Beautiful. Thank you so much.

Zachary Spiritos (50:20.31)
Yeah, absolutely. Thanks for having me.

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Liz Rohr