No, this is not a trick question & it’s certainly not a silly one. IBS, as many of us know, has a very loose diagnostic criteria: visceral hypersensitivity coupled with altered motility in the absence of organic disease. Hence it tends to ‘loosely’ fit a vast number of patients struggling with GIT issues. The differential diagnostic algorithm all health professionals are encouraged to use for patients presenting with GIT issues leads us to this IBS label, just as soon as we’ve excluded the red flags. But this ‘early opt out’ according to many experts, including Schiller et al in the American Journal of Gastroenterology, tends to propagate the illusion we’ve reached our diagnostic destination: practitioners stop thinking about the ‘why’ & stop looking for the real drivers & causes, which is the key to shifting the refractory patient into remission.
For those presenting with chronic diarrhoea, Bile Acid Diarrhoea (BAD) is in the diagnostic algorithm & there is strong evidence it’s at play in almost half of these patients!
It’s just that BAD, is the next station along the line after IBS-D, which means most clinicians have sadly disembarked already 🙁
Bile acids, as key biological agents, in both the behaviour & health of the gut & metabolic dx, are getting a lot of attention right now. While Bile acid malabsorption (BAM) in disorders of the small intestine such as Crohn’s & undiagnosed or refractory Coeliac dx, as well as other miscellaneous GIT disorders that clearly disrupt the bile acid balancing act of the gut-liver axis, have been known for a long time, there’s a new kid on the gut block, previously only known as the idiot, I mean, idiopathic BAD. But us idiots have finally worked it out! This is not about malabsorption but about excess production of bile acids and this pathophysiology is drastically over-represented in IBS-D patients.
And knowing if your IBS-D patient has a ‘BAD-thing’ going on, every researcher wants you to know, is game-changing. Explaining the strong heritability of this particular IBS subtype and the reason so many patients are refractory to standard IBS approaches.
We need to use distinctly different dietary strategies when IBS is BAD. Once again patients are our greatest teachers & I’ve relished the excuse one practitioner and her patient gave me to deep dive into the enormous body of BAD research, that is ‘so hot right now’! The way I look at, ask questions about and assess patients with chronic diarrhoea, especially IBS-D, is forever changed 💪🙏
When is I.B.S. B.A.D?
This is not a trick question. Up to 50% of all patients diagnosed with IBS-D actually have bile acid diarrhoea (BAD) underpinning their digestive complaints as well as some patients with unresolving diarrhoea post-cholecystectomy and gastro. Knowing which ones do and how to manage this, which requires distinctly different approaches from our general management of IBS, is the key. As always, good lessons come from those we learn in the clinic and this story starts with a patient and how we came to recognise the BAD in her belly.
You can purchase When is I.B.S. B.A.D? here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.
Well, this is different, now I’m watching you! 😆 In early 2021 we released our very popular MasterCourse I: Comprehensive Diagnostics, as a ‘self-paced’ online offering for the many who missed out on attending live in 2020. Many have grabbed this opportunity with both hands (& a headset and some hardcore Do Not Disturb! signs) but we know that for some, doing the entire course on your own, >24hrs of video presentations, can be a tad onerous & overwhelming. We want to remove these barriers and empower & upskill as many practitioners in pathology interpretation as are keen, and as a means to achieve this, we’re offering the MasterCourse I Watch Party. So bring your bhujia and a beverage and let’s do this!!
Practitioners who sign up for this will be able to watch each session’s video replay live with other practitioners and have the opportunity to ask Rachel questions & participate in case discussions at the end. Another key detail is that we will run the sessions weekly, so that the full course is covered in just 6wks, from July 8th to August 12th.
MasterCourse I: Comprehensive Diagnostics LIVE WATCH PARTY
24 hours of live Zoom sessions + Bonus sessions!
8, 15, 22, 29 July & 5, 12 August on Thursday at 3.30pm to 7.30pm AEST.
Each Thursday, the video presentation for that week will be played so we can watch it together. Then Rachel will open up her webcam and mic, inviting you to do the same, to participate in a Q&A as well as set case discussions. When you register, you get immediate access to watch our preliminary/preparatory sessions, prior to 8 July: Accurate Pathology Interpretation Starts Here and the RAN Patient Pathology Manager Tutorial.
Below is an overview of the Watch Party schedule.
Week 1 – 8 July | SESSION 1: Acid Base Balance & Electrolytes
Week 2 – 15 July | SESSION 2: Renal Markers
Week 3 – 22 July | SESSION 3: Liver Enzymes
Week 4 – 29 July | SESSION 4: Lipids & Glucose
Week 5 – 5 August | SESSION 5: Immune Markers
Week 6 – 12 August | SESSION 6: Haematology
“I thought my pathology skills were pretty up there until I did Rachel’s Diagnostic Masterclass course! Nothing like being knocked off my perch by a literal avalanche of new information, especially when it comes from the most commonly tests that we all use so often. The course has been a fantastic learning opportunity for me, and has since helped me pick out many intricacies in cases that have previously been missed.
The course structure was great, the level of detail was right up my alley, and the case studies were entertaining (in true RA fashion). Once again Rachel has increased my knowledge base, and help me provide way better service to my patients.” – Rohan Smith, Naturopath
Join Rachel on MasterCourse I: Comprehensive Diagnostics Watch Party and register here.
MasterCourse I is a pre-requisite to join MasterCourse II which will be delivered live in 2022.
What does lockdown look like for you? More time spent…
A) Learning or
B) Losing sleep over things outside of our control or
C) Losing days just watching Tik Tok
I’m choosing ‘A’ and I know I’m keeping good company because last week many of my ‘nearest and dearest’ gathered on 2 occasions for some serious extra brain gym. The first was the ACNEM Fellowship Community of Practice that I had the privilege to co-chair with Dr. William Ferguson. A fantastic new initiative by @ACNEM to offer more hands-on mentoring and support to their doctors.
The second, our own Give-back-Gratitude Live Q & A for our Update in Under 30 Subscribers where I used the time to check-in and see if we could further the learning offered by our monthly audios and clinical tools.
Having all of those who attended, in my ‘home’ was a fabulous contrast to our social distancing ‘new norm’, and seeing all those lovely faces and buzzing brains behind them, warmed the cockles of my cortex!
For those of you that couldn’t make our UU30 date, I wanted to share a few things we learned in lockdown this week:
- Copper can be absorbed through the skin and penetrate to deeper layers potentially increasing serum levels but the degree of uptake is highly variable and more likely with prolonged contact e.g. jewellery and pastes not showers etc
- Just like the Zn:Cu, when reviewing patients’ albumin:globulin, we must first look at each value individually and consider causes and consequences of low or high values, otherwise we can ‘miss the message’
- When understanding labs of anybody who is not a couch potato we need to ditch reference ranges based on the general population because they essentially are…couch potatoes and ask ourselves 3 questions: 1) Who is this person outside of being ‘sporty’ 2) What is the nature of their sportiness because exercise ain’t exercise in terms of physiological effects and 3) When are the tests being done in relation to any exercise
On that last note, I am so thrilled to be able to share my brand spanking new presentation The Impact of Exercise on Pathology Tests – Beyond Artefact to Understanding which I put together B.C. (Before COVID19) for a NZ speaking engagement. This actually has been one of the most satisfying areas of research to expand my own knowledge in…explained a LOT about what labs go whacky (and why and how to navigate around and through this) not just in what you might call ‘real athletes’ but in weekend warriors, crossfit crazies, MIL (men in Lycra) and the increasing number of middle-aged or older women who just love pounding the pavement. Know the types? Our clinics are full of them…it is time to learn their labs properly.
The Impact of Exercise on Pathology Tests – Beyond Artefacts to an Understanding
Overwhelmingly when we look at our patients’ labs we compare their results with a reference range derived from ‘the general population’ aka couch potatoes! Therein lies our first problem. Exercise is recommended for health but we don’t know what this ‘looks like’ in terms of labs. The reference ranges reflect and assume ‘average’ muscle mass & haemodynamics & ‘average’ nutritional requirements in people consuming the SAD (standard Australian diet) none of which apply to the exercise enthusiast, weekend warrior, least of all the professional athlete! Given an increasing number of our patients are embracing exercise, this is an important instruction in what healthy looks like, how to make meaning of otherwise meaningless comparisons and ultimately enable you to distinguish between what is healthy exercise-induced adaptation, an artefact and an actual aberration that flags possible negative impact of emerging pathology for other reasons.
Click here to add The Impact of Exercise on Pathology Tests to your online RAN Library.
For all UU30 Subscribers
the full Live Q&A Recording is now available in your ‘active content’ of your online account.
I had the privilege of presenting at the Integria GIT Symposium last weekend. For those of you who attended, you’ve gone back to your clinic with a bunch of new ideas and inspiration I hope…oh and a new respect, terror and watchfulness for threadworm thanks to me! In my presentation I outlined the many presentations of this infestation, what to watch for and the risk of chronic recurrence due,in particular, to a reduced ability for some individuals to produce chondroitin sulfate which renders the GIT environment hostile to worms.
Chronic threadworm is a huge & grossly under-recognised issue in paediatrics, often presenting as behavioural & cognitive disorders (and these can be severe), bruxism, enuresis etc. of course, but another presentation typically missed is vulvovaginitis, vulval pain or UTI like sx in young girls. (more…)