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Gut instinct: The mind-body-GI connection with Dr. Amir Masoud
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In this episode, Hartford HealthCare’s Steve Coates talks with Dr. Amir Masoud, Co-Medical Director of the Hartford HealthCare Nuerogastroenterology & Motility Center.
What is IBS? What is GERD? Dr. Masoud answers these questions and more. He explains the function of motility - and describes the important interplay between our brain and our gut.
Check the links in this episode’s notes to learn more about Dr. Masoud and the Neurogastroenterology & Motility Center.
Follow More Life to be notified each time a new episode drops. Just search “Hartford HealthCare” on your favorite podcast platform. Thanks for listening to More Life.
VISIT: Hartford HealthCare Nuerogastroenterology & Motility Center
WATCH: Meet Dr. Amir Masoud
We've all gone through it. Think as far back as you know when the teacher calls your name in class and you get those quote unquote butterflies in your stomach, or before a big game, you feel nerves in your stomach, feel nauseated. Some people throw up. They're very famous athletes who still do that. And it's not all in the head, right? It's the interplay between the brain and gut, the brain gut access.
SPEAKER_00Butterflies in your stomach, lump in your throat? There's a reason for that, and it might surprise you. Welcome to more light. In this episode, Hartford Healthcare Steve Coach talks with Dr. Amir Masud, co-medical director of the Hartford Healthcare Neurogastroenterology and Motility Center. What is IBF and what is GERD? Dr. Massoud answers these questions and more. He explains the function of motility and describes the important interplay between our brain and our gut. Here's Dave Coat.
SPEAKER_05For those who don't know, what does a motility specialist, a motility doctor do? What are the conditions you diagnose and treat? And how is it different than going to see a GI provider?
SPEAKER_01In general, uh motility is a subspecialty of general gastroenterology. So the idea here is we typically see any disorder that a gastroenterology provider would see. However, typically ones that are a little bit more complex, a little bit more difficult to treat, and usually with an underlying what we call motility disorder, uh which signifies something wrong with kind of the functioning of the gastrointestinal tract.
SPEAKER_05So basically it is how food moves through your system.
SPEAKER_01Yeah, exactly. I mean, there's a very active nervous system embedded in the lining uh, or in, I should say, in the wall of the gastrointestinal uh system itself, and it's called the enteric nervous system. And the interplay between the nerves, the muscles, and even the functioning of the gastrointestinal tract is what makes up this discipline. And that's what we study, what we uh test, and obviously ultimately treat if there are abnormalities in that functioning.
SPEAKER_05Now, our next level setting question. The center at Hartford Healthcare is called the Hartford Healthcare Neurogastroenterology and Motility Center. So the next question is what exactly is neuro gastroenterology?
SPEAKER_01So neurogastroenterology is basically anything that deals with the interplay of the muscles and nerves of the gastrointestinal tract. So it could be anything from disorders that cause people to have difficulty swallowing, cause people to have reflux, nausea, vomiting, abdominal pain, and even what we call defecatory disorders, difficulty using the bathroom with constipation or the opposite diarrhea or even fecal incontinence.
SPEAKER_05One of the questions we got from one of our colleagues, which I was going to get into a little bit later, but the nervous system and the digestive system impacting each other, causing problems together, that's a real thing.
SPEAKER_01Yeah, I mean, it's definitely a real thing. I mean, we've all gone through it. I mean, you can think as far back as, you know, when the teacher calls your name in class and you get those quote-unquote butterflies in your stomach or before a big game, you feel nervous, nerves in your stomach, feel nauseated. Some people throw up. There are very famous athletes who still do that. And it's it's not all in the head, right? It's the it's the interplay between the brain and the gut, and what we call the brain-gut axis. In fact, a lot of the uh signaling uh hormones and signaling systems that are in the gastrointestinal tract are the same ones in the central nervous system. So it's a natural association between the two and uh overlap between those symptoms. Now, it's easy to conceptualize what's going on. It's uh treating it that takes a little bit more of a nuanced approach, and it really depends on the timing of the symptoms, the types of symptoms that uh patients complain of, and then ultimately based on the testing to see what would work. But there are a lot of different options we have uh as far as what we call modulating the function of the gastrointestinal uh tract to reduce symptoms.
SPEAKER_05Staying on the subject, so patients come to you with problems in their digestive system that are being caused by problems in their nervous system or issues with their nervous system. You have a holistic approach at the center, correct? Where you have different specialists working together.
SPEAKER_01Yeah, we really have to, you know, personally we have to wear a lot of different hats and then obviously work with a lot of our colleagues in different disciplines. Uh, like you touched upon, diet is always a huge factor in things. And obviously the uh behavioral aspect is also important. So we work with behavioral specialists. There's a lot there are, you know, pelvic floor therapists, there are physical therapists, there are even, you know, surgeons and other gastroenterologists that we work with, endocrinologists, pulmonologists. I mean, we really span multiple different disciplines and uh and areas to, you know, ultimately get people feeling better. I mean, that's the whole goal of things.
SPEAKER_05What are some common ailments that you're seeing that are coming into your center? I'm thinking, you know, reflux, GERD, things like that.
SPEAKER_01Yeah, we see everything that a gastroenterologist would see. Um, basically, uh, like you said, GERD, heartburn, uh, difficulty swallowing, nausea and vomiting, gastroparasis, constipation, fecal incontinence, diarrhea. You know, we see also some of the what we call atypical manifestations of these common disorders. So, for example, for GERD, patients who have really bad throat clearing or a lump in their throat that just won't go away, patients even with lung disease and chronic cough uh thought to be from reflux, patients with uh, you know, difficulty swallowing from a variety of things, uh, as simple as a stricture from reflux or an anatomical factor, or even a rare disorder that we're seeing a lot of in our center. And, you know, uh the incidence is increasing across the country called acalasia, which is basically uh, you know, an abnormality in the way that the esophagus is functioning. I mean, we really do see a lot. We see, you know, quote unquote, everything. It's easy to come up with a diagnosis. Uh, how to fix it is is where, you know, where we uh really kind of put up our points, so to speak.
SPEAKER_05Let's talk a little bit about diagnostics. When people come into the center with with a condition, what what could they be looking at as far as diagnostics and testing?
SPEAKER_01We have a completely state-of-the-art and fully outfitted center. We have two uh fully functioning uh motility labs in the state. I mean, if there is a motility test that will get an answer to help somebody suffering, we have it. We not only have been doing um, you know, motility tests such as monometry for the esophagus and monometry for the analektum in addition to reflux testing, but we're also a very early adopters of some of the newer technology, including something called endoflip, which is an endoscopic motility assessment. We're able to see uh, you know, test patients for reflux also with endoscopic means. I mean, we really uh do have it all. And for some of the more complex cases, we also have uh some dedicated testing, for example, uh something called antraduodenal monometry and colonic monometry, which really is not widespread. There are very few centers around the country uh and no uh standalone health centers like our own that have it outside of an academic practice.
SPEAKER_05Okay, now the I'm asking for a friend part of the podcast. Uh had some feedback from some colleagues or maybe even me. Some of these are my questions as well. So the first question, or the probably the most common question that I've gotten, is about IBS. What is IBS? Why is it so common? Is there a cure for IBS, or is it just a situation where people have to manage it?
SPEAKER_01Yeah, I think irritable bowel syndrome is a catch-all diagnosis. You know, uh we generally think of IBS as a group of disorders. Um, it's probably uh a lot of unyeth to be classified or characterized disorders that have no way, you know, no better way of describing them. So we put them in the I, you know, quote unquote IBS basket. But you know, the long and short of it is we we think of these as functional GI disorders, where if you were to do a conventional assessment of the gastrointestinal tract based on these symptoms, you would find nothing organically wrong. And we're talking about uh endoscopy, for example. Somebody who comes in with abdominal pain, you put a scope in, and you see nothing wrong. You take that a little bit further with some other testing, and if you can't find an abnormality there, we generally think, okay, well, clearly the patient is having significant symptoms. We can't see what it is, so it's probably in this basket of irritable bowel syndrome. However, I will say, and this is where you know our uh kind of special expertise comes into play, a lot of times it's not so much that there is quote unquote nothing wrong, but more about we're not able to see what is going on or what is wrong. Uh so a lot of times we'll have to deploy different types of testing or even some what we call empiric management strategies to try and, you know, kind of test to treat or test to diagnose, where, you know, we start somebody on a therapy with an idea of what is going on, and based on the response, are able to either one, make the patient feel better and therefore solidify the diagnosis or move on to something else. So I think uh the reason why it's so uh widespread, first of all, is because it's probably encompassing a lot of different things. And then the other thing is because of what we touched upon earlier, that whole interplay between the brain uh and gut, the brain gut axis. Stress is, uh I mean, there's stresses are going anywhere. And no, you know, especially with things that are happening now, things that have happened over the past two years, plus, I mean, stress levers are going uh, you know, through the roof. So it makes sense that a lot of uh, you know, these disorders of uh brain gut access are becoming much more prevalent because of that.
SPEAKER_05With IBS, it's as you said, it's a very mysterious or hard to identify. You know, if people are having that discomfort, bloating, you know, symptoms attributed to it, when should they come to you? When should they talk to their physician about it?
SPEAKER_01Yeah, you know, the way we diagnose and classify IBS in general is based on symptoms and length of symptoms and the characteristic of those symptoms. So again, it's you know, a lot of very well-established gastrologists got together in a very fancy room in Rome and came up with criteria to, you know, make these objective diagnoses based on subjective symptoms. So the idea here is it's all about the symptoms. So in my book, if you're bothered by it and it's taking up a lot of cognitive load, you're thinking about it a lot, it's affecting your day-to-day, there's no reason to delay. You should see a uh a gastroenterology uh provider soon, sooner rather than later. I mean, if you can feel better, why not, you know, uh shoot for that?
SPEAKER_05One thing that a lot of people talk about, and I don't think a lot of times they don't want to get a diagnosis or they don't get a diagnosis. This question comes in. I occasionally get heartburn after I eat. Is that acid reflux? And when should I see a doctor? So I guess the question is, what is acid reflux? Is it heartburn? What is GERD? Is it similar? And when is it time to see a doctor?
SPEAKER_01Yeah, I literally could give a two-hour talk just about what is GERD. Um, I think heartburn and GERD are often thought of as the exact same thing, whereas I uh tend to think that there's a lot more uh subtleties there. There are a lot more factors to think about. Heartburn is what it sounds like. It's a symptom, right? GERD is a process. GERD is anything coming from the stomach into the esophagus, causing whatever, any kind of symptom. So if I'm coming into the office and I say, oh, I have this chronic cough, you could have GERD. If I say, Oh, I'm on the lung transfer transplant list because my lungs are failing, that could be GERD as well. Whereas, you know, classic heartburn after eating is also GERD, meaning it's stuff coming from the stomach into the esophagus, but it's causing, you know, more classic chest pain symptoms or burning symptoms. Now, it's important to understand that everybody has GERD. In fact, when we do our reflux studies on patients, we have a certain number of reflux episodes, particularly after eating, that we accept to be normal within normal limits. Um and it has nothing to do with the acid, it's just a frequency thing. Now, if you are not on any acid suppression and you eat or going to eat a meal, that solid food is going to get mixed in with your gastric acid. The stomach is made to function uh based on how much food you give it. It, you know, basically digests that by squeezing, by secreting acid, the acid breaks it down. So it is an organ that produces acid. It's supposed to have acid. So acid is not the problem. The problem is when the acid gets into the esophagus and causes the burning. So after every meal, we all have these processes that happen that cause us to have reflux. Now, if those become more frequent, we tend to feel it more. Or if the acid contact time is a little bit longer, such that you have damage to the lining of the esophagus, uh particularly in the bottom of the esophagus, then every reflux episode becomes a little bit more painful because think of it as like, you know, the lining being a little raw, so to speak. So it is normal to have reflux. And then the question is, when do I see somebody? Well, if it becomes more a frequent thing. I mean, if you're having reflux after every meal, uh reflux symptoms, I mean, like heartburn after every meal, there again, no need to delay, and you should probably be seen sooner rather than later because, like I said, a lot of times it's not all about the acid, and we can't just be on acid suppression all the time because again, acid is important. We need it. Our bodies make it for a reason. So shutting it off indiscriminately is probably not the right answer.
SPEAKER_05Okay, now probably the worst segue in the history of this podcast or perhaps any podcast, but constipation. When is it a problem? It is sometimes debilitating for some, sometimes it's just irritating for others, but it can be a problem. When should somebody come to see you when they're constipated?
SPEAKER_01You know, I I think anything is a problem when it's a problem to you, right? So the idea is a lot of these disorders aren't ones that are going to shorten your life, right? So a patient who is really constipated and has a bowel movement a week and is miserable until they do and you know, strains, they're not going to, you know, quote unquote die early from that, but they're going to be miserable for a lot of the time. So seeking a medical opinion, a workup is probably better earlier rather than later. Now, I will say that oftentimes as a gastroenterologist, we think of constipation differently than what a patient will feel or will uh call constipation. So uh we think of it as frequency in addition to the characteristic of the stool. A lot of times I'll have a patient who comes in with what I call constipation and says, I have a bowel movement every day. What are you talking about? But they're having some secondary problems from incomplete evacuation. And then, you know, we uh we kind of have to make uh some uh headway there to figure out what's going on and improve uh, you know, the bowel frequency and uh consistency. So as far as you know, constipation or even looser stool or you know, frequency and stool, I think it it comes down to what one person's normal is and the deviation from that normal such that it's causing any kind of problem, be it symptoms, be it, you know, cognitive burden and overload and stress. A lot of our patients, especially with you know underlying disorders like, you know, Parkinson's, for example, or uh, you know, on chronic um medication for pain or or or whatever, come in with debilitating constipation. I mean, they're in the bathroom all morning, all day, just miserable, trying to, you know, trying to relieve the bloating and pressure. So that's the one extreme. Whereas in the on the other extreme, you have patients who just can't leave because every five minutes they have to they feel the urge to use the bathroom. So a lot of these things are, like you said, very personal, right? Uh nobody's volunteering this information to their primary care provider or, you know, even to their spouse. But when they come and see us, uh we really do see how taxing it is on a you know physical and emotional level. So getting to the bottom of things very quickly is our always our goal. And uh, you know, effectively treating symptoms can really uh change uh things and and be a you know, quote unquote game changer and really improve quality of life.
SPEAKER_05And you touched on it a little bit though, as most people will look at digestive issues, motility issues. Oh, it's something personal I can manage. But you touched on it a little bit that some of these symptoms, while it may be IBS, it might be something else, they could be symptoms of something else, whether it could be cancer. Probably not, but it could be. And so I I would think your advice to them would be don't wait.
SPEAKER_01Yeah, in in general, you know, we're all all our bodies are the way I at least I think about it is you know, we grow up with certain routines, with certain environmental, familial, and you know, kind of personal uh uh factors that cause our GI systems to be kind of calibrated to a certain speed, so to speak, right? So our day-to-day, we you know go to the bathroom, we do all these things without even think without even really thinking about it. When that changes, something has happened to cause that change. And I will say most times it is probably something very benign, even though the symptoms are troublesome, but very rarely it can be something that's a little bit more nefarious. Now, the classic example is somebody in the right age group. You know, we're talking over the age of 50, 60, and they have a sudden change in their bowel habits such that they're having a really hard stool, may even see some blood in their stool. And that's a classic kind of scenario that we as gastroenterologists think about to show how a symptom can be an indicator of a really bad kind of underlying process. And in this case, it would be, you know, a consideration of cancer. Um, a lot of other times, you know, difficulty swallowing. So I've had patients who I've talked to and say, yeah, I have heartburn, blah, blah. And then you say, Well, do you have any difficulty getting food down? I say, yeah, here and there, but it's not a big deal. It's been getting a little bit worse, but I figure it's just because of the reflux. And you put a scope down, and this is somebody who's had a reflux for years, turned into Barit's esophagus, which is a precancerous condition, and now they have esophageal cancer. Now that's not to say that everybody with reflux, even if you've had reflux your whole life, you're going to have esophageal cancer, but it's just an example of one, this patient's been suffering for longer than they needed to be. And then two, obviously suffered a complication that probably could have been avoided. Plus, you would have had all that suffering off your plate anyway. So in my in my mind, it's we're calibrated to a personal normal. And when that normal changes or we're deviating from it, then it's uh it's always time to seek uh healthcare uh provider uh assistance or opinions.
SPEAKER_05Another question from our colleagues Are some motility disorders inherited? And how can I know if I will be inheriting those? Is there any way to tell?
SPEAKER_01No, it's not it's not the same as some of these other inherited uh, you know, disorders where we do genetic testing and then figure that you know the person's risk is higher or lower based on the results of that testing. There are associations, you know, certain uh disorders have been described to have a familiar predominance. However, for example, you know, there is supposed to be a genetic uh link in acalasia, but it's such a rare disorder that it again, if you know, you have five brothers or five sisters and one of them has acalasia, it doesn't mean that you know any one of the other four is going to have it. So there are some associations uh that have been uh teased out over the years, but nothing concrete as far as, you know, oh, your risk now of this disorder is higher. However, there are some genetic disorders that have uh, you know, among the symptoms associated, gastrointestinal uh complaints. So, you know, a classic thing would be some of these connective tissue disorders. And if there is a familial risk of connective tissue disorder, you may have a gastrointestinal dysmotility. So it's not so much as the disorder itself, like gastropresis, reflux, whatever, but the underlying process that can manifest with gastrointestinal complaints.
SPEAKER_05Obviously, food, nutrition, what you put into your body has a huge impact on your digestive health. Are there any magic foods? What are some foods, the diet that that you would really recommend for people who are having digestive issues or trying to prevent them?
SPEAKER_01Yeah, I think we really have to, you know, tailor it to the patient. If it was this is bad, this is good, everybody would should be eating the exact same thing. But we know that what works for one person isn't going to work for the other. So one of the uh, you know, kind of newer things that have uh come about over the past maybe uh decade or so is a what we call a low FODMAPS diet. So this is a group of different things that when they enter the gastrointestinal tract can be broken down and release gas. And the thought is that with that gas release and the you know processing of these substances, it can cause significant symptoms. So a low FODMAPS diet uh would basically cause less symptoms because you're limiting these things. But again, it's not everything because if you look at a low FODMAPS uh diet uh kind of menu, you'll see that there really isn't much you could tolerate. So working through the different options, I think, is the key. Um obviously the classic uh and simple low-hanging fruit would be, you know, lactose intolerance. So well, you know, if if you have to rush to the bathroom every time you have a pint of ice cream, stop eating ice cream. Um whereas, you know, some of the other uh things that have an overlap between motility and uh kind of an autoimmune would be something like Eosinophilic esophageitis or even celiac disease, uh, where it's uh an allergy to a specific food either type or food group uh with celiac diseases, gluten with EO E. It could be a number of different things. Uh, you know, there are typically six different uh foods that could be implicated. So a lot of times it's it's basically working through symptoms, uh very detailed patient histories. Very, you know, the way we kind of do it is we have patients write down Their symptoms, their diet in detail. I even have them write the brand name of things that they're eating so that we can see if there is anything there that um is underrecognized. You'd be surprised how many things actually contain lactose without advertising. You just be surprised how much uh how many things uh have soy in them without you know really being advertised. So a lot of times it's an investigation on our part, a little bit of uh detective work to get to the bottom of things, but eventually we get there and and patients are better for it.
SPEAKER_05Doctor, how do patients get to the center? How do they get referred to the center? Is it through their GI provider? Is it through primary care? Can they direct refer?
SPEAKER_01All the above. So we see all patients. Um, you know, we've had patients who have uh, you know, obviously recognized some of these symptoms in themselves after, you know, a quick Dr. Google search and and have made their ways uh you know to us. However, we also get a lot. I think the bulk of our referrals come from other gastroenterologists, and then obviously from some of these other disciplines that we've talked about, like pulmonary rheumatology, ENT, endocrine, a lot of these other uh disciplines also refer a lot of patients, in addition to obviously primary care.
SPEAKER_05Doctor, thanks so much for your time.
SPEAKER_00Thank you. Steve Coates and Dr. Amir Masood. Check the links in this episode's notes to learn more about Dr. Massoud and the Neurogastroenterology and Motility Center. Follow More Life to be notified each time a new episode drops. Just search Hartford Healthcare on your favorite podcast platform. For Hartford Healthcare, I'm Enron DePierre. Thanks for listening to More Life.
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