 Hey everyone, this is Dr. Ruscio and let's cover a listener question today, which essentially asks what to do about gut pain that usually occurs secondary to consumption of rich or fatty foods. And so here I will play the question. Hello, Dr. Ruscio. I am inquiring about a question regarding my daughter, who's 22 years old. She was diagnosed with IBS biogastroenterologist about four years ago. I want to say he put her on VSL3 probiotics, which did help for you. And just as a note, VSL3 is a lactobacillus bifidobacterium-prominated probiotic. It's what I would categorize or what I would organize in our three category system as a category one probiotic, which is a blend of lactobacillus and bifidobacterium probiotics. Very similar to the lacto, to the lacto-bifidoblin probiotic that I recommend in our store. And it's definitely one of the more well-studied probiotics that is VSL3. And again, that's from category one, the lactobacillus bifidobacterium-prominated mixture. So it's a good place to start. For a year or so, she was very good about taking them and so forth. Anyway, fast forward now to present time. She is having same symptoms of gut pain. She does not have diarrhea. She does not have constipation. I'm not sure she has IBS. I think she could have possibly been misdiagnosed. He did do a gametive test. He did not a breath test. He did blood test, stool test, and an endoscope. And so anyway, so now she's been off the VSL for a while. She did feel some improvement, but not ever complete relief. And her main problem is, as it was before and still is, whenever she eats, especially rich foods and fats, but not always, it happens almost, I don't know, pretty much with everything, but mostly rich, fatty, creamy foods, oils, grease, that type of thing. Can I pause there for one more second to touch on something that was important, which is the fact that her gastroenterologist performed an endoscopy. That's important because one of the things that can cause gut pain is either gastritis or ulcers. The most gastroenterologist will not miss a case of ulcers or gastritis after they've done an endoscopy. So that's important to have that on the table because that's one thing that could potentially be causing this problem with the previous endoscopy negative, then that makes it fairly unlikely that gastritis or ulcers are present. That type of thing, but she gets immediate gut pain, makes her not feel good, and it starts within a matter of minutes of eating the meal. So she'll feel perfectly fine or whatever, and then all of a sudden sit down to eat a meal, she feels this pain, and she continues to eat or stops whichever, but either way, it lasts probably a good hour or something like that. And then it will go away and she's fine. So this happens all the time. She's tried elimination of foods and different things, and the only thing she can ascertain is that it is related to rich, fatty foods. Okay. Which it very well may be. Now there's more that we would want to look into here, and I'll let the rest of the question play before we come to any conclusions. But we do know that, of course, FODMAPs, foods that are high-informantable substrates and are prebiotic rich have probably the best documentation to cause gut pain. But if you remember back, we had Tarek Mazawi, he was a gastroenterologist on the podcast who's done some pivotal work in establishing some of the mechanisms that underlie why a low FODMAP diet is helpful for those with IBS. But one of the things that he did in some of his studies with his group was they also infused fat into the intestine and showed that fat can also stimulate a reaction, a pain-type reaction, as FODMAPs can. Now there's more data showing that the low FODMAP diet can be helpful, but it's not to say that some people may not do better on a lower fat and a higher carb diet. And all this may come down to what's known as visceral hypersensitivity. So there may be hypersensitivity to gas and to pressure in the intestines. And that can happen even when gas levels are normal. So you mentioned SIBO a moment ago, SIBO very well could be something to investigate and to treat. However, it is possible that a SIBO breath test could be negative, yet you could still improve from a low FODMAP diet if she hasn't tried that yet. The low FODMAP diet and reducing high amounts of fat in the diet may work synergistically for those who are hypersensitive. And it's my thinking that if you can find a diet that works and an approach that works with time, that hypersensitivity should become less. But let's continue forward with her question. Primarily. Again, not always, because sometimes she'll eat something that typically doesn't bug her and then it does. But that's rare. It's usually the greasy stuff. She's not lactose intolerant, she has, she's not, I'm sorry, allergic to weed or Celiac, what, I can't think of the name, gluten intolerant, none of that. But anyway, we just cannot figure out through elimination of foods what could be the problem and why she gets a pain in the same spot all the time when she eats. Right when she's eating within minutes, not digestion, it can't possibly be digestion, I don't think, because it hasn't gone, you know, hasn't been long enough. So anyway, I wondered if you could comment on what that might possibly be. So regarding diet, we don't know if she's tried a low FODMAP diet yet. She's gone dairy-free, apparently, and gluten-free, good places to start, but low FODMAP would also be very important, because that, again, probably has the best documentation in terms of a dietary intervention for reducing gut pain. If so, you can email me, reply or whatever if you don't want to put it on air. I don't care. I'm just trying to get some insight there. The only thing, like I say, she hasn't had is a breath test. So I don't know if that's something that should be done. Okay. I appreciate your help. My email and info will be on the contact information. Thank you. Bye-bye. So we've covered a few things, but let's come at this from, you know, a hierarchy of sequences, because the hierarchy will give you a system of steps to work through rather than me throwing out a bunch of diagnoses and you trying to piece together how to run through those in what order, in what sequence, and what have you. There could be classical IBS, there could be SIBO, ulcers or gastritis are less likely, there could be this visceral hypersensitivity, which kind of falls underneath the umbrella of IBS and of SIBO. So what do you do? Well, we always want to start with diet, right? So you've already done a good job with eliminating two major allergens, which are gluten and dairy. Great. If you haven't yet done a low-fob-map diet, I would recommend performing a low-fob-map diet. And we have a list of those available on our website. Now the probiotics, you also took a good step there and the fact that she responded to probiotics could indicate that she has dysbiosis, or it could mean that the probiotics are helping via their anti-inflammatory and immunomodulatory mechanisms. However, what you may, or the missing piece there may be, is not having had used a broad enough presentation of probiotics to the gut. So you used category one, the lactobacillus bifidobacterium blend as VSL3. Good. I'd also add in a category two and a category three probiotic to see if those may work synergistically to produce a better overall benefit than just the one probiotic alone. So category two would be a saccharomyces bilarity probiotic and category three would be a soil-based probiotic. And we do have one of each of those probiotics in our store to help you find a good formulation for each category. Remember, and this is very much so worth stating, that probiotics have been shown to be efficacious against SIBO. And I like, I'm becoming more and more favorable toward probiotics, understanding that they did not only help with pain and with symptom reduction, but they are antibacterial and anti-fungal. So if there is a degree of dysbiosis, whether it be SIBO, Candida, both H-pylori, the probiotics have a good chance of helping to rectify that dysbiosis. So that'd be step two. Now there's also the potential that she's malabsorbing fat, and that may be why she's having the pain. And so the question of why is it such an instantaneous reaction between eating and then having the pain reaction? It's not always when the food gets to a particular spot. There's also something known as a gastrocolic reflex, meaning that when food hits the stomach, it causes a reflex in the colon. So this could account for some of that instantaneous presentation of pain. Now SIBO can cause fat malabsorption. So this could underlie why she's intolerant. And that may have been why the probiotics work. The probiotics were helping to beat down SIBO, and the SIBO was then less able to cause fat malabsorption, and she was then more able to tolerate fat. So that's very well what may have happened. The supplementation or supplementation with a bile acid may also help. And those are some of the better places to start. To escalate therapies, you may need even stronger antimicrobial therapy to address any dysbiosis in the gut. And further yet, still, you may even want to try a short course on an elemental diet to give the gut a chance to rest for dysbiosis, to quell, for hypersensitivity kind of unwind. And this kind of gives you a few different things to consider in succession. All of this is laid out in my book, Healthy Gut, Healthy You. It'll give you exactly what to do, when to do it, and help you to navigate through this with the most efficiency and precision possible. So there's a number of things to consider there, and I'm hoping that between a dietary modification, specifically the low-fat map, and a more robust probiotic intervention you'll be able to get there, but if not, there's a few other things to consider. And hopefully that helps you and helps your daughter get healthy and get back to her life. Okay, thanks.