Meet Dr. Xiao Jing (Iris) Wang- Author of Boo Can't Poo

Ever been told your pain is “just a flare,” even when your labs look calm? We sit down with Mayo Clinic gastroenterologist Dr. Xiao Jing (Iris) Wang to unpack why symptoms can linger after inflammation is under control—and what to do about it. From constipation myths to the real mechanics of bloating, this conversation reframes gut discomfort through muscles, nerves, and breath, not just meds.

Dr. Wang breaks down pelvic floor function in clear, memorable language. Learn how the puborectalis sling preserves continence, why years of urgency or “holding it” can hardwire a constant clench, and how that leads to straining and incomplete emptying. She shares practical paths to diagnosis without over-reliance on expensive tests, smart ways to find qualified pelvic PT, and simple at-home tactics like an optimized toilet posture, the “anti‑Kegel,” and biofeedback fundamentals. We also explore why J‑pouch patients need their own testing norms and a different definition of “normal.”

Then we tackle bloating. Groundbreaking research shows many visibly distended bellies aren’t full of excess gas—the diaphragm is pushing down while the abdominal wall pooches out. Dr. Wang demonstrates how diaphragmatic breathing can retrain this pattern and why yoga, gentle twists, and abdominal massage move trapped gas better than most medications. Finally, we zoom out to the brain. When the gut’s “fire” is out but the alarm keeps blaring, neuromodulators, gut-directed hypnotherapy, and virtual reality can close the pain gates. You’ll hear how VR helps patients navigate bathroom anxiety, tolerate unsedated procedures, and feel safer in their own bodies.

Finally we talk to Dr. Wang about the genesis of her children's book called "Boo Can't Poo." It's a humorous story about a constipated ghost named Boo and his efforts to get his bowels back on track. It's a great read for parents who are working to potty train their toddlers but also for all us to re-learn how to poo! 

If you’ve wondered whether your pain is real when scans look fine, this is your validation and your roadmap. Subscribe, share with a friend who needs it, and leave a review to help more listeners find practical relief and a new way to think about gut health.

Links: 

• Boo Can't Poo book
• Yoga poses for constipation- Yoga Journal
• More yoga poses for constipation- Verywell Health
• Resources on disorder of the gut-brain axis and more from GI Psychology

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Transcript

Meet Dr. Wang And Setup

SPEAKER_03 0:00

Hi, I'm Alicia. And I'm Robin, and you're listening to Bow Moments, the podcast sharing real talk about the realities of ITB. This week we talked to Dr. Xiao Jing Wang, who also goes by Dr. Iris Wang. She is a gastroenterologist at Mayo Clinic in Minnesota with a special interest in disorders of the gut brain access and treatment of pelvic floor dysfunction. She also does management of other general gastrointestinal diseases such as acid reflux and diarrhea, but she has a special interest in constipation, and we spend quite a bit of time talking to her about constipation and managing constipation. This also led her to write a very adorable book called Boo Can't Pooh, which teaches children how to poop properly. Who knew that was a thing? We had such a fun conversation with Dr. Wong. We know you're gonna adore her just as much as we did. Cheers.

SPEAKER_00 0:54

Hi everybody, welcome to Bowel Moments. This is Robin.

SPEAKER_03 0:57

Hello, everyone. This is Alicia, and we are very, very excited to be joined by Dr. Xiao Jing Wong. Did I get it? It was perfect. High fives to me. Okay. Dr. Wang, we are so excited because you are a referral to us. And so we're very, very excited to have you on the show. And you have many, many things that we have not talked about. So very excited to get to that. But unfortunately, the first question for you is very unprofessional and it is what are you drinking?

SPEAKER_02 1:23

I'm prepared. I'm prepared for this question because I was a referral of my bestie. And I love to claim him as my bestie because nobody else can, and because who doesn't love Dr. Victor's Fidre? So I am drinking flavored sparkling water, which is my ultimate advice in life. This is called cucumber harvest, is the flavor from my very well-stickered water bottle. This one's my favorite. It's Lake Superior and it says V Superior. That's amazing. That is absolutely amazing. Do you have a brand that you prefer? Of sparkling water? Not really, but the I have access to a bevy machine. So whatever flavors the machine has is what I am drinking to save on plastic and save the turtles.

SPEAKER_03 2:04

I love that. Robin, what about you?

SPEAKER_00 2:05

Unfortunately, I'm drinking coffee.

SPEAKER_03 2:07

Unfortunately.

SPEAKER_00 2:08

I haven't drank coffee in the evening when we've been recording in a while. I used to have coffee all the time, but I am happy to report is my first cup of coffee for the day.

SPEAKER_01 2:16

Impressive.

SPEAKER_00 2:17

And I'm not even trying to wean myself off of caffeine. I have just been drinking less and less caffeine, and I haven't even needed it. I haven't even noticed it. It's it's a revelation. It's a revelation.

Drinks And Warm-Up Banter

SPEAKER_03 2:28

Well, apparently I'm the only one with uh terrible vices because I'm drinking wine. So this is a new wine for me. I'm very excited. This is a blend from one of my favorite wineries. It's Vionnier and Grenache Blanc. I have not tried it yet. Who knows? We'll see. You know, I'm a Savion Blanc girl. So I think this might be a little sweeter for me, but very excited to try. So cheers, guys. Cheers. Cheers. How's it? You know, I think I'm gonna have to get used to it. I'm gonna have to get used to it. You know, I will, though. So anyway, it's not about it's not about my my wine. It's not about my wine. It is about you, Dr. Wong. So please tell us what is your connection to the IBD community and start there, and then we will come back to one of the main reasons why you were a referral.

IBD And Gut–Brain Overlap

SPEAKER_02 3:12

Well, my connection to the IBD community is my bestie who's an IBD doctor. But that being said, I think there's a huge overlap between patients with IBD and patients with these disorders of gut brain interaction that are hallmarked by visceral hypersensitivity. And so I've had a lot of interactions, professional discussions with IBD healthcare providers where their patients have quiescent IBD but continue to have symptoms. And so that is a space that I'm particularly interested in is how do we understand those symptoms? Are they the same symptoms as somebody with IBS? And how can we optimize symptomatology for an IBD patient without kind of who doesn't need any optimization of the inflammation?

SPEAKER_03 3:53

So I am curious, and this is data you may not know off the top of your head, but how frequently are people with inflammatory bowel disease diagnosed co-occurring with something like an IBS?

SPEAKER_02 4:02

The number I don't have off the top of my head, but it's actually a really interesting and nuanced question. Because to have IBS, you you technically can't really have IBD. There was some sort of trigger, right? And so that clear diagnosis of IBS is an excludes and exclusion of organic disorders like IBD. So once you have IBD, the whatever you are left with is not really true to IBS. And so the question is, are they the same disease, right? Is it the same as somebody who had a post-infectious IBS or is it not? And I don't think we understand that quite as well yet. That being said, there's also symptoms that aren't necessarily related to hypersensitivity, right? Folks who've had IBD, particularly those who've had this disorder for a long time, have changes to their colons, have changes to their small bowels, either naturally occurring because of the inflammation or surgically. And so you would expect a different normal for these individuals, whether that's in bowel function, in bowel form, or pain, right? When the colon becomes scarred, if you will, from burning colitis, it's going to behave differently. And I don't think it's a reasonable expectation for it to ever go back to what it was before colitis took over. And so we have to kind of think about those as is this something normal for the patient or is there another disease process going on? And then is that disease the same as somebody who's never had colitis in their own?

Constipation Vs. Obstruction Basics

SPEAKER_03 5:24

I think that's really fascinating because it does remind me of like, you know, like we we lump together Crohn's and ulcerative colitis, but they act so different. They do different things. And they're kind of the same thing with other autoimmune conditions. They kind of, you know, like I think I I know a fair amount about MS just because of my dad. And there's like, you know, there's these different versions of MS, but are we really looking at the same thing or are we looking at slightly different variations of something that acts kind of similar but does different things? So I think this is it's interesting how we're learning. The more we learn about it, like you said, the more it's like, oh, well, is this really the same thing or is it not? Well, and we started out talking about kind of some some symptoms that people can have while having inflammatory bile disease that we haven't necessarily covered as much, you know, things like bloating, pain, constipation. So talk us through some of these slightly more unusual symptoms and what you know about this.

Pelvic Floor 101 And Mechanics

SPEAKER_02 6:11

So let's start with the constipation, because I love talking about constipation. And that is kind of we were talking about before we started that this is a pretty rare condition for individuals with colitis. And when individuals with colitis, especially with Crohn's, develop constipation, we actually get really worried about bowel obstruction, right? Like we worry that there's something else going on. That's not really my forte, and that's probably better served with an IBD provider to kind of work through that. You know, how do we evaluate that? When when do we think about it, right? And and maybe I will pose that the bowel obstruction symptoms are very different than classic constipation that I think about, right? We're not talking about nausea, vomiting, and ability to eat. We're talking about decreased frequency of bowel movements and increased installed firmness, right? Those are the metrics of constipation that I'll probably end up addressing. Before I get there though, I will note that we're doing some really super interesting studies looking at, and this overlaps with my research interests, looking at small bowel imaging. And can we, based on symptoms of shrinking this inferrography contrast, can we use that to assess whether somebody's about to have a bowel obstruction? And can we develop some sort of markers to predict that, right? Because I see this a lot in my patients who have bowel obstructions. That lack of predictability is so terrible for their lives that if anything we can do to kind of give them some signal, that would be really great. But that's a different topic from a different guy. I think when we talk about overlap with constipation and IBG, I think it's important to talk about pelvic floors, especially for IBG, because the pelvic floor can be involved in Crohn's and then can play a role in palitis when individuals have j pouches that form. It's really important to think about and understand what the muscles of the pelvic floor actually do. And so the pelvic floor, I explained to folks as a diaphragm that's very similar to this layer of muscles that separates our chest from our abdominal cavity. So that's a dynamic layer of muscles that usually is there to keep compartments separate, what should be up up and what should be down, down, but also allows for normal and controlled passage between those two cavities so that when we swallow, right, things can move from our chest cavity into our abdominal cavity in a coordinated fashion. The pelvic floor is very similar. It's a similar sheet of muscles that usually is static and holds up all of our abdominal pelvic organs. So our rectum, our uterus in women, and the bladder and urethra, right? But allows for controlled passage out of that abdominal cavity so that the muscles can control whether how waste is expelled and help control waste expulsion when it's not ready to be expelled. The dynamic portion of that layer of muscles is a muscle called puborectalis. And this muscle almost acts and looks like a sling around all of our pelvic organs and is usually kind of pulled up when we're all sitting here at rest. That pull-up motion takes the rectum from something that looks a little bit straight to a pulled up angle, almost like if you took a necktie, right, and pulled it outwards, it's gonna go and bend. That angle of the rectum allows us to maintain a little more continence so that you know the rectal pouch is not just kind of like going to fall out straight to gravity. In order to then effectively empty, we need to be able to relax this puberctalis muscle so that this pull effect is no longer activated and the rectum can straighten out. Okay. In pelvic floor dysfunction, this does not work. When that muscle is not able to relax like it's supposed to, individuals have to basically evacuate or poop against this very sharp angle. And that often requires a lot of pushing from their anterior abdominal wall muscles. Why this is relevant to IBD is how this muscle can become damaged, right? In IBS and other patients who don't have colitis, we see this a lot with holding behaviors as young children. We see it a lot with trauma to the area. People who ride bikes a lot actually can have this issue. And then we see it a lot with patients who have had some sort of diarrhea illness. And there is where that colitis bridge is going to happen. Because when you're going all the time, that muscle gets so irritated along with the external anal sphincters and just the perianal region in general, right? And so when that happens, our body like really learns how to hold everything in to the point that sometimes we forget how to let things out. So then that muscle becomes contracted all the time. And I tell patients, it's like if you had a, if you were holding a two-pound weight and you were doing a bicep curl, I'd probably do this for 30 minutes, no problem. But if I have to do this for 30 days, you're gonna bet that I'm going to get some sort of muscle cramp or problem in this bicep. And then occasionally I'm gonna let go. And when that let go happens, is when patients develop incontinence, right? That they were constipated and now all of a sudden they're not able to. It's a little bit of an extreme example, but this is kind of part of that spectrum of pelvic floor dysfunction I see.

SPEAKER_03 11:05

So pelvic floor dysfunction can happen, it sounds like anytime, and especially with our folks with inflammatory bowel disease, like you said, because of the this sort of amount that they're going. But many of our folks also have pelvic surgeries. And so anytime there's like surgery involved, I'm assuming that also causes some additional dysfunction. Is there a way around that? Like, does that just automatically happen? How do we get better at that?

SPEAKER_02 11:27

Yeah, I think awareness, right? Like knowing that this is a problem. So women tend to be more aware of this issue than men. Men don't even know they have pelvic floors most of the time, right? Like I mentioned the pelvic floor in the like that thing my wife had, right? I was like, no, you you have one too. But women hear about it in the sense of deliveries, right? When they've had vaginal deliveries, we talk about, oh, pelvic floor health. You have to do your kegel exercises. And all of that is very true. But what patients who have dysynergic pelvic floors where they're contracting when they should relax, they actually, the last thing they need is a kegel exercise. They need the anti-Kegel. They need to know how to relax that pelvic floor. And so understanding that and understanding that this may be a consequence of pelvic floor surgery helps patients proactively say, okay, well, I need physical therapy. I need to understand how this works ahead of time, or I need to be able to find someone who knows how to do this and take care of me post-um. The other caveat that I'll kind of throw in there too is that because we talked about this muscle of the pelvic floor being a sling around all of our organs, when that muscle is too tight, when it's spasming and not relaxing like it's supposed to, that can lead to a lot of other issues like urinary problems. People can't empty their bladders well because they're not letting go, and pain on intercourse, because it that that same muscle goes around the vaginal canal. So penetrative intercourse can be quite painful when you can't open up, right? And that's not a dryness problem. That's not, you know, other issues, especially pelvic force function. I have so many questions.

Dysynergia, Symptoms, And Consequences

SPEAKER_00 12:56

I don't even know where to start because I have done pelvic floor physical therapy because I have had surgeries and because we've had a couple of pelvic floor physical therapists on the show. But I wonder so can people do exercises to release, like you said, you need the opposite of the Kegel, right? So pelvic floor physical therapy is not something that is widely available yet. We're we're, you know, screaming from the rooftops, everybody needs it, trying to talk about it as much as possible. So I was so happy you wanted to talk about it. But how do we get this information to people who don't have access to care? Like, so for me, when I I live pretty rurally, and when I found a pelvic floor physical therapist, the first person I went to really specialized in pregnancy. And I went for a few times and I was like, okay, this is actually not going to help me because she has no idea what I'm going through. So I did some searching and found somebody that specialized in like recovery from like colon cancer surgery. And so when I found somebody that did that, I was like, okay, she might not know what a J pouch is, but she knows how to work with somebody who's had this kind of gastrointestinal surgery and not, you know, not having babies. So that was very beneficial for me and for her too, because she had to do some learning to find out like what actually was going on inside and help me. But I just wonder, I wonder how we help people be able to do some of these exercises on their own if they can't access care.

SPEAKER_02 14:20

I think this is amazing, right? This is a huge problem.

SPEAKER_03 14:24

So sorry, can I pause us for a second though? Because I think Robin, yes, that's a super important question. But I'm wondering if can we start with if somebody thinks they have something going on, how would they be diagnosed? Like maybe what's the diagnosis process in order to get there? And then yeah, like Robin said, like, are there are the things people can do on their own because this is not a widely, widely they're not they're not many, very many of them. Yeah. Thank you, Robin. Available service. It's a problem.

SPEAKER_02 14:49

It's like it's a it's a really big problem, right? And I wish I had a great solution for you, but I can tell you kind of how I hack it. So I'm fortunate that we have the testing available. But I will tell you that we do not need specialized testing to diagnose pelvic floor dysfunction. A good rectal exam has a positive predictive value of 97% for pelvic floor dysfunction. So if you know how to do a motility rectal exam where you're you're pretty sure you know what the muscles are supposed to feel like when they squeeze and relax, that's a diagnosis that a physician can make in the clinic. I try my, you know, every time I'm given the opportunity to talk about it, I try to teach anyone who will listen how to do one of these rectal exams. The problem then comes like what do you do after that, right? One is insurance coverage for the pelvic floor is a problem if you can even find one in the first place. Usually for insurance to cover, you do need specialized testing called an analectal monometry, which is basically like a rectal exam, but we're sticking a probe with multiple pressure sensors at multiple levels with a balloon in it to see what's happening at various levels of the rectum as you're trying to squeeze and trying to push out. And then are you able to poop out a balloon? Yeah, so that's not fun, by the way. I've had to do that twice. No, you're not supposed to push the balloon out because I didn't before I shadowed a pelvic floor PT. Like I was like, oh, people are supposed to not push reactive.

SPEAKER_00 16:13

Is that I did not know that because I was trying really hard to push the balloon out and I couldn't.

Diagnosis Without Fancy Tests

SPEAKER_02 16:19

So as part of my fellowship, I went to shadow pelvic PT and they're they're like counseling their patients on okay, just breathe, take deep breaths, let it happen. I'm like, what? Who lets it happen?

SPEAKER_01 16:32

Sorry. So damn. But that's part of the reason we're gonna talk about this book I wrote because like who gets taught this kind of thing? Back to the question at hand. You wanted to know where to find pelvic PCD.

Finding And Accessing Pelvic PT

SPEAKER_02 16:45

So I don't know if you guys are aware of the Herman and Wallace website. Is that something you've come across? So Herman and Wallace is a really great website because they help train pelvic physical therapists. And so, as part of their website, they have a find a provider option with a zip code function so that you can try to find someone who is specialized in pelvic floor PT closer to you. Not all pelvic PTs are trained the same. Different pelvic PTs are able to do different levels of retraining. When we talk about the gold standard of retraining, we're really talking about biofeedback, where there's a probe at the bottom and a sensor on the outside that can actually tell you whether that muscle you're trying to learn how to relax is relaxing because we don't know what that feels like naturally, right? Our body just kind of does it on its own. It's kind of like the upper diaphragm. We can breathe without thinking about it. But when we need to, we can take that deep breath, right? Or we can alter our breathing pattern by doing this mind over matter to overtake that muscle. We knew the same thing on the pelvic floor. We just need to learn and retrain our bodies like what that actually feels like. So biofeedback is really the standard, but that takes specialized equipment that is really not even available to most PTs in the community. So if the pelvic floor is issue is really bad, tertiary care center might be worth it to try to find that diagnostic, learn what that feels like, and then practice on your own. For milder things, finding someone who is specialized in pelvic floor work, like Robin mentioned, whether that is, you know, from colon surgery or from kind of constipation or pelvic pain from intercourse, right? It's the same muscle. Those individuals are really well equipped to kind of retrain those muscles. And if you don't have access to any of that, there's actually a couple of websites that I'm happy to share with you guys where there are pelvic PTs who can share this info online. The one that I've met with has a subscription program that I'll sometimes send my patients to, just so they have some information on what they could be doing, what exercises might be helpful. There's a lot of yoga poses that can be helpful, yoga breathing can be helpful. And then she actually does PT on telehealth, which, you know, it's probably better than nothing. And then one last level for my patients with kind of mild pelvic floor dysfunction, where I feel like they could just use a little help. I actually just have them get a toileting stool and have them position their feet so that they're in a squat position, so that their knees are above the level of the belly button and they lean forward about like 30 degrees or so. And that optimized pooping position can actually help overcome mild pulvic floor dysfunction.

SPEAKER_03 19:12

That's very simple and exciting to hear because you're right. Like unfortunately, if people don't have it, at least it's a good place to start. And if that's still not helpful, then that's certainly the time where, like, okay, you probably probably need some additional intervention. Do you notice a difference in, you know, because we have a lot of folks that we've talked to with jay pouches. So do you notice a distinct difference between people who have had a jay pouch and that have pelvic floor dysfunction? Does that like add to the trauma, add to the fun that happens?

SPEAKER_02 19:38

That's an excellent question. I don't have an excellent answer for you because this is an area of active research that some of my colleagues have been looking into. Because we don't think that folks with pouches should be measured by the same pelvic floor metrics as somebody without a pouch. Because part of the anal rectal medometry measurement is interrectal pressure. And folks with J pouch do not generate the same intra rectal pressure as somebody with a rectum. And so, what is actually normal for someone with a J pouch? We don't have that yet. This is so good.

Tools, Biofeedback, And Home Hacks

SPEAKER_00 20:10

I'm sorry to interrupt you, but that makes so much more sense because both of those, both times I had the monometry test, I didn't have a colon, colon. But I had the first time I didn't have a pouch, I had about four inches of rectum. And then the second time I had my J pouch. So I mean, I know I have pelvic floor dysfunction, but it would make sense that I would fail the monometry test because I don't have I don't have all my my interior redesign doesn't allow it to function that way.

SPEAKER_02 20:38

Exactly. It's even more important for you to be able to relax the bottom because you can't generate as much pressure from the top. Yeah. If I can find the publication, I'd be happy to share with you guys whether our group has actually published any of that normative data. Because I know they're working on working on it.

SPEAKER_03 20:54

Dr. Wong, this is absolutely fascinating. And if you can find that publication, we'll definitely share with the group and put it in the show notes and keep up with this because I think there's a lot of information that's helpful. But I definitely want to make sure we're going to talk two different areas. First one I want to make sure we talk about now is that you did write a book. And I thought this was super interesting. And the other little snippets I've I've picked up here and there, and when I was doing a little bit of research about you before we talked to you, is that your comment was people don't teach you how to poop. And so you wrote a very delightful children's book called Boo Can't Pooh. So tell us about this book. Where did this come from? And tell us all about this experience of writing a book. Yeah. So it came from thanks for asking.

J‑Pouch Nuance And Testing Limits

SPEAKER_02 21:32

It's like uh the proudest thing I've produced besides my child. So it came out of this, like a little bit out of this like realization, right? That nobody ever talks about how this pooping thing should happen. We just kind of assume that everybody can do it because everybody at some point goes into the bathroom and empties their bowels, right? But in seeing a lot of patients with constipation and having this discussion over and over again with them about their pelvic floors and about what's supposed to happen, I kept getting this. Response of how come nobody's told me about this, right? I am X years old. How did I get to this point and nobody's talked to me about this? And so I would jokingly tell them, I should write a children's book about it so that I can hit people early. And it was kind of a joke that I would just like say at the end of clinic. But then I had a child and I was doing a lot of reading to him and children's book literature has become so good. You know, there's like this series called General Chemistry for Babies. And I was like, if they can teach babies quantum physics and general chemistry, I should be able to teach a baby how to poop, right? And then as he started potty training, I was like looking at the literature on potty training and I was like, there's nothing. It's just like poop in the toilet, but nobody goes over how you poop in a toilet, right? Or like everybody poops.

SPEAKER_01 22:47

And it's like, okay, but like people don't. So what do they do? So I like was joking about this. And then one Saturday was like, I was like reading a lot of Dr. Seuss, right? That I could rhyme. And so I wrote this book and it wasn't very good. But then I kept like editing it and I was like, oh, these rhymes don't sound bad.

Boo Can’t Pooh: Why And How

SPEAKER_02 23:07

And then I made Victor listen to it, and he was like laughing in my office. And I was like, oh, this might be something good, right? And so I I finished it and started shopping it around places. And I was like, I got this. I'm a mom, I'm a Mayo Clinic GI doctor, I can market myself. Like, who's not gonna want to publish this book? I sent this inquiry in, and they were like, I sent it to Mayo Clinic Press, and they were like, why? Why is it a ghost? Like, Dr. Seuss can rhyme, but it's not for everybody. And I was like, wow. Ouch. And I want to say, I'm gonna go on the record and say that this editor is now my favorite human being next to the other editor I'm about to mention. Because she didn't say no. She just she said, maybe not right now, and put my manuscript into a pile. And I was like, okay, fine. So I went online and I tried to figure out how to publish a children's book. And did you know that it's like nearly impossible? And so it's like winning the lottery. Like, I feel like I won the lottery, quite literally, even though it does not pay like the lottery. But I learned that if you don't have a children's book agent, nobody will talk to you. And to get a children's book agent, you just have to kind of cold email them. And all of their websites say, if you don't hear back from me in six weeks, I'm not interested. So they won't even send you a rejection and they'll just ignore you. So I spent about 18 months or so, like every six weeks to eight weeks, I would send myself a reminder email to send out to another batch of agents, my like little pitch email, and it would be like silenced, and I would like lick my wounds a little bit, and I would think about giving up. And I'd be like, uh, let's just try. Like, what's the harm? Right. So I kept doing this and nobody, no, like literally nobody wanted it. And then one day I won the lottery because Mayo Clinic Press hired this children's book editor who had a history of a GI condition. And she picked up my manuscript and she was like, This is good. And they emailed me and was like, Are you still interested? And I like still telling this story, right? It was just like this the joyful moment of like, I cannot believe this is real. And I still cannot believe this happened. And so I owe her everything. And we were able to get this through. I got a really great illustrator. And I think in in getting to talk about this too, right? Not only do I get this opportunity to teach kids how to poop, but I get to talk about the poop. And I get to let kids talk about the poop. And, you know, kind of bringing this back to IBD, uh, one of the most devastating things I saw and I still see is when like a 20-something year old comes into my clinic and says, Yeah, I've been bleeding for months, years. This has been happening. And I didn't know how to talk about it. I didn't know how to tell anybody about it. Or I didn't think I could because I was embarrassed, right? And that is just not okay. Like this is a thing that we do every day. And so I think somewhere along the line, somebody gave me, it wasn't, it was not my idea, but gave me the slogan of breaking the poo taboo. And that has just been like my campaign slogan. And that's what I want to do with this book.

SPEAKER_00 26:03

I love that so, so much. I mean, even as somebody living with IBD for 26 years now, even with my parents, like they talk about it, and my mom will be like, Don't talk to my dad, don't talk about that at the table, or you know, something like that. I'm like, I literally talk about poo every day of my life. And both of my children who are adults now, like talking about poo is a normal, like, how is your how is your bowel movement? How does it look? Everything okay in there? They're not scared to talk to me about these things. They're in their mid-20s and they've both had a couple of colonoscopies at this point. You know, so it's like we talk about it all the time, which I don't know, that may be unfortunate when people think that you talk about poop all the time, but also like you have to, you have to be able to talk about it because it's it's a measure of your health. Like looking at your poop and what's in the toilet is a measure of your health.

SPEAKER_03 26:54

Now I'm curious how to poop. I guess I have to buy the book, right?

unknown 26:58

There you go.

SPEAKER_03 26:59

All right, I'll add it to my shopping cart. Because you're right. Nope, nobody told me anything about this. And especially, you know, being also in Minnesota, I'm like, we're also a very like stoic people that don't talk about this. And so I think this is awesome as a way to get them started. Because you're right, that everybody poops book is fine. It's a nice start. But yeah, not everybody does it the right way. And how would you know? How would you ever know that? Like, I mean, we've talked about this. Like, I don't have inflammatory bowel disease, and I'm definitely on the like opposite end of things. And so I don't think I probably do this correctly either. So I really I really am gonna buy this book.

SPEAKER_02 27:32

It doesn't go over all the mechanics, right? It's it's still aimed at a three to six-year-old range, but secretly it's also for their parents because it goes over things like eat fiber, get exercise, drink water. Those are the good things that we need to do to have a bound with that, right? But I love it when I have people who text me and it's like, my son, who is three, just said I'm gonna eat vegetables because Boo told me to. And I'm like, yes, that is the best win ever.

Breaking The Poo Taboo

SPEAKER_03 27:58

That's awesome. Oh, this must be so rewarding to hear from people that like that read your book and they get something out of it. What other feedback have you gotten? What other reactions have you gotten from folks?

SPEAKER_02 28:09

It's been a lot, uh, a lot of really positive feedback. I'm I'm very grateful for that. A lot of like their children are willing to like that, they don't poop without it, right? They keep it in the bathroom, and I'm like, oh, it's like a poop security blanket. This is great.

unknown 28:23

All right.

SPEAKER_02 28:24

I like bill myself as the baby shower gift of the year and the toileting book of the year or the bathroom book of the year. Like people make coffee books, right? I made a bathroom book and I'm so happy about that. You are the poo guru. I'll I'll take it, right? I'm not sure that I can take that title, but I think there are other people who probably deserve that more than me. Um but I'm proud of that.

SPEAKER_01 28:47

It's yours, though. It's yours. Pooh guru. Yeah.

SPEAKER_02 28:50

And I think there's been, you know, a couple of comments on the Amazon page, for example, of people who have had children who have had difficulties, right? And they they can actually see themselves in the book and say, hey, this helped me. I did breathe, I did relax, I did like these things, and now it's been going better, or they're more willing to try. And that's really the goal, right? That the kids are more willing to try because it's a thing that that happens sometimes. And constipation can hurt. And so giving kids the language to say, okay, maybe my belly hurts because of this, and this is how I might be able to fix it, and is is great to have achieved. People underestimate how much stool and gas can hurt, right? Like, I I mean, people get sent to the emergency room for gas pain. Like it's not, it's like no joke. Like it can hurt a lot. And so it's really important to acknowledge that.

SPEAKER_03 29:41

Very, very, very true. And I just thought that you're you're helping to get that language to the kids ahead of time so that they can help identify what it is that they're experiencing. Is it bloating? Is it gas? Is it pain? Is it, you know, where does it hurt? So I think that that's that's great to be able to provide that language to kids because I mean that's what we are supposed to teach them. You know, here's how we talk about our emotions, here's how we talk about things. If you don't provide the language, then you just get the same like it hurt. Well, why, where, what?

SPEAKER_02 30:05

I've gotten a couple of angry emails that now they have to talk about poop all the time. And I I don't take them as angry. I'm just like very proud of that that now they have to talk about poop as much as I do. It's an important topic.

SPEAKER_03 30:17

We talk about poop all the time. Yeah, as we should.

SPEAKER_00 30:19

I feel like this is a good transition because you touched on gas pain, and I know that you wanted to talk about bloating, and I was very excited about you wanting to talk about bloating. So can we talk about bloating now? Bloating.

Bloating As A Muscle Problem

Diaphragmatic Training And Yoga

SPEAKER_02 30:32

Let's talk about how bloating is also a muscle problem. Yes, please. Because just like the pelvic floor, right? I think I have learned a lot in the last like several years of being a full-fledged like GI attending about how little I know about external medicine. Like I've done all this training for internal medicine to realize that I've forgotten how the muscles work to contribute to symptoms and have been working very hard to relearn all of that. And and this this does play a role, I promise. So I'm gonna take you back like a couple of decades to this group in Barcelona. This gentleman called Fernando Aspiros used to train at Mayo Clinic and went back to Barcelona and decided to start his lab and decided that bloating was the symptom that he was going to tackle. I am such a fangirl. People like fangirl rock stars, like I think all research. So he went and developed this CT scan with his radiology team in Barcelona, and they were able to quantify the amount of gas that they saw in an abdominal cavity utilizing like specialized radiology techniques. And his initial thought was let's quantify how much gas is causing distension in our patients who bloat and their bellies look like they're pregnant, right? They go from flat to pregnant throughout the day. And what they did was they would image patients at baseline when they felt really, really good. And then the second they felt bloating, they would come into the lab and get another CT scan. And his initial set of experiments were like completely unremarkable. And he was finding that there was no significant increase in gas in the majority of these individuals, that they would maybe increase like 500 mls. 500 mls is like a syringe this big, right? Like that's nothing compared to the amount of distension these patients were actually seeing. And they were able to measure that and like document that they weren't, nobody was making anything up, right? Their bellies were coming out, but there wasn't more gas. And so initially they thought that maybe something was wrong, their spin fail, et cetera. They looked back and on their scans. And what they actually realized that what was happening in 85% of these patients, maybe 10, 15%, actually did have an increase in the amount of gas they were generating. But in the vast majority, what was happening was that the diaphragm, instead of rising upwards to accommodate that gas in the abdominal cavity, was pushing down to decrease the real estate. And then that anterior abdominal wall was pouching out. And they saw this reliably over and over again in these patients who didn't have extra gas. So then they did a number of experiments to prove that this is the problem, right? Including doing electromuscular myography, EMGs, of the diaphragm and showing that the diaphragm was contracting when it should have been relaxing and vice versa. And they did the same thing on the anterior abdominal wall and showed that it was relaxing instead of kind of holding in like it showed up. And most recently, their series of experiments also included the anterior of the chest wall and showed that those intercostal muscles that are also related in breathing was being tightened so much when patients bloated that it actually mimicked asthma state. And so when patients tell you that they bloat so much that they cannot breathe, it's because their muscles are so tight that they're actually being utilized and their diaphragm has pushed all the way down. So there's no more room left to take a breath, right? Your diaphragm's all the way down, you can't use that to breathe. And now your intercostals are all tensed up, right? And so actually it does become really difficult. But all of this is a muscle problem. It's an abnormal response to gas distending the intestines, such that instead of making room for that gas, we are kind of our muscles are pushing them out. So really, really fascinating work that they've been able to reproduce over and over again. And they've actually recently now developed a biofeedback technique to fix it. Here in the States, we don't really have that clinically available just yet. I was um fortunate enough to go learn it from them. And again, a band girl all over the place. But it was like so cool to hear him tell the story and then like to learn about this technique, which actually works so well, BT dubs. But here in the States, what we use in us is an approximation of that. We use diaphragmatic breathing. Diaphragmatic breathing kind of utilizes the concept that we're trying to breathe into our belly so that our bellies come out and then deflate our bellies so that they go all the way back in. In doing that movement, we're trying to get that diaphragm to move more instead of being stuck in one position and reset. The biofeedback technique that this group has developed is a little bit more nuanced so that you're actually retraining that diaphragm to move up and down better and to make space. And the reason why it works, I mean, I've just I've seen it work in patients who are pretty distended when they come in, even if they're at their like two or three, I'm feeling muscle tension and I'm able to get their abdominal wall relaxed and their bellies go flat. It's it's amazing. I've been talking a lot, but I'm gonna make one last point here that we see this a lot in patients who have had abdominal wall trauma. So whether that's because of a surgery, right, laparoscopic ports, pregnancy, where the that rectus diathesis happens and the rectus muscles weaken and don't quite go back, and in bowel surgeries. And then in people with pelvic floor dysfunction, they tend to use a lot of their core to help them evacuate. And that can kind of cause some of this muscle dysfunction as well.

SPEAKER_00 35:31

I mean, I have to really fight not to turn this into like a medical consult for myself. Because recently, probably a year ago, ish, my pain was really bad. Like I thought I was having another flare. And after months and months, I found out I actually had SIBO. And that was the worst gas and bloating that I had ever had. But because I went through that, I now can recognize the difference between gas pain and like what my Crown's pain would be, or you know, something like that. So I my question in here is is can you teach people to notice the difference? Like, can they immediately recognize, oh, this is what's happening, it's gas pain, and I need to do this specific kind of breathing to fix it? Or does it take a while? Do they not understand that that's happening?

Gas Movement, Poses, And Massage

SPEAKER_02 36:23

I think that's a difficult question to answer on a wide basis. Yeah. I think it depends on how in tune you are with your body and your pain and how much you're willing to take to understand it. Because I think you can. I think you can identify because I've heard enough patients say it to me that they know when it's gas pain and they know when they just kind of it's trapped and it's painful. But there are other people who confuse that for appendicitis and they go to the HD every single time, right? And there's nothing you can really do to prove it to them unless someone who really understands that this could be gas and explain it to them and then make the gas go away and it gets yeah, right. Like that's sort of the point is that when you were diagnosed, you had an answer that you could inchor to this pain experience you were having, and then it went away and you went back to a different pain experience, which I'm sorry about, but you have to go back to a different pain experience. But you got that like feedback, and that doesn't happen with some people, right? They don't get a diagnosis and there's some pain and they don't know. Or every time they are in gas pain, they get treated for a Crohn's flare, so they think it's a Crohn's, you know, because maybe nobody took the time to consider that it could be another source of pain. Or some patients just really want that workup, right? So there's different layers to this. But the the simple answer to your question is yes, I think it is possible with the right level of introspection and kind of awareness of what your body is feeling. But we can talk about other ways to pass the gas pain as well, right? Besides this breathing technique, because I have a very strong bias favoring yoga as a mechanism for passing gas. Like the happy baby pose is called that for a reason. I was just about to say that happy baby, right? And the the inversions, like I don't know how anybody does yoga in in public in a group setting, to be very honest with you. For sure. For sure. So I actually have a list of yoga poses for gas that I give to my patients so that they can kind of move themselves through these poses and try to get the gas moving forward. So trapped gas and kind of this bloating distension pain can also be treated differently, right? Because I just told you a lot of that distention, there's actually not a lot of gas involved, but that's different from gas when it becomes trapped in the intestines and kind of does a lot of this distension type discomfort. That kind of gas can be kind of moved along, expelled, abdominal massage is really good for that. And all of those things together can help a patient feel better for no medications. None of them work anyways for gas.

SPEAKER_00 38:46

I you definitely did lots of yoga to try to move the gas through. And I I wish I could remember the name of the pose right now. I'm gonna have to look it up and tell you the one that worked the best. But happy baby is top of the list. Happy Baby is hard because it does work well, but there are individuals who can't get into that post.

SPEAKER_02 39:02

Yeah. And so we have to modify sometimes. But you just do diaphragmatic breathing, lying on your back, knees bent and slightly like hip width apart and then slightly open. Like they don't have to be frog posed, slightly open. And then you breathe deep into the belly up and down. You can actually feel a little softening of the pelvic floor that way, and that can help expel the gas too.

SPEAKER_03 39:22

I think this is so fun to hear like ways to be able to retrain. I did do a quick search for your pop sugar yoga for gas. So I will be sure to share that in the the notes as well with folks because I do think this is this is helpful. I would imagine any pose that kind of lets your lets your belly kind of hang and like down or like that lets your belly expand is probably a good one. So I'm thinking like what is yogi squats and stuff like that too. But you're right, like not everybody can do that.

SPEAKER_01 39:46

The twisting motions are also really good for that because it kind of helps compress, right? And like moves things along physically.

SPEAKER_00 39:53

It's the bow pose that I I would like go between happy baby and the happy baby and then knees and chest and couple twists and then the bow pose. That's impressive that you can do a bow pose. I'm impressed with myself when I do it too. I'm not gonna lie to you.

VR, Hypnosis, And Pain Modulation

SPEAKER_03 40:09

One last very, very random question for you is when I was looking at your bio, one of the things you were talking about for working with patients with various issues is virtual reality. Talk about why, how, talk about this. What what do you use this for? How is this used?

SPEAKER_02 40:24

Yeah, I'm gonna throw out there too that I also do hypnotherapy for my patients. You're a jack of all trades. I I dabble in in interesting things that help my patients. Because there isn't a lot, right? Besides a pill, and the pills come with side effects, and people don't want those, and so I have to find other things to get them. So, and these things work. And the reason they work is because, like going way back to what we talked about at the beginning, right? There's this issue of pain sensation, is what we're dealing with in irritable bowel syndrome and these disorders of gut brain interaction. And often it's because I I I love this analogy from Lori Kiefer, who's one of our best GI psychologists for IVD-related GI issues, right? And she likens it to a fire at a fire alarm. So for IVD patients, like their colitis was this fire. And we use medications, we were able to put out the fire, but the alarm is still on and is still glaring. And we need to modulate those nerves and tell the signaling to quiet down that we don't need to pay as much attention to our bowels anymore, that our gate theory of pain, right? That the pain gates at the spinal cord level can close and we don't need to pay attention to all these signals that are coming that used to be filtered out, but because there was a fire, stopped being filtered out because we have to pay attention. So we use a lot of medications to do that, these neuromodulators that are also labeled antidepressants, because they work in the same enteric nervous system as they work in the central nervous system. We're not trying to secretly treat anybody for depression. It's just how neuromodulators work, right? It's just how the neurotransmitters work. But because the medications can have side effects, I tell folks that these alternative things that we do, that we study, are like using your body's own mechanisms to turn on neurotransmitters to rewire those nerves and turn off the fire alarm or turn down the fire alarm. So both virtual reality and hypnosis utilize the same kind of cognitive behavior therapy concepts to get our bodies to quiet down the signals and quiet down the symptoms. With hypnosis, we induce what's called a trance state where patients are pretty aware, right? You're not, nobody's clucking like a chicken, nobody does anything that they don't want to do. But when they are in trance, they're a little bit more susceptible to suggestion and susceptible to changes happening in their body. And we give them signals and suggestions to rewire, to not pay so much attention to signals that they don't need to pay attention to, but to still be aware of signals that are important, right? And so we don't want to shut everything off. We just want to turn down what doesn't need to be heard. With virtual reality, it's a little bit of a similar concept. We can deliver those same therapeutics, but there's a lot of people who don't want to do hypnosis, right? They don't want to be in a trance, but being in virtual reality actually puts them into a very similar state where they can be more suggestible and they can rewire their brain. So Brennan Spiegel over in Cedar Sign, who's really pioneered a lot of this work, Dr. Spiegel, also a big fan of this, he has developed this entire suite of virtual reality for IBS specifically, where you actually walk into this virtual clinic, you have an education module with like a three-dimensional like brain gut access in front of you, and they're like explaining it to you. You can play with it. You can do exposure therapy where you're like in a toilet stall within virtual reality, and it guides you through breathing, guides you through feeling okay and not feeling like hyped up because you know it's a public toilet and you couldn't find one and all of those feelings that accompany patients who have bowel issues, right? And then there's also that meditative process that can use CBT and kind of counsel you to learn how to live with the symptoms so that they can improve, right? We're not just asking patients to live with it, but actually learning to live with the symptoms helps turn down the signal. And that's a really important. Concept. We're not dismissing it. We're just teaching the fire.

SPEAKER_03 44:03

That's really, really cool. I think the virtual reality thing, I think is something that we'll see being used more and more within healthcare. I mean, because they even talk about using this to just get people up and walking after surgeries or helping kids with pain control and anxiety as they're going into medical procedures. So I do think this is this is something we're going to see being used much more. Also, I know they're using it and they we've started using it for people with addiction issues too. So they could help kind of get used to being in environments that were triggering for them. So I think there's there's lots of ways this can be used for sure. So super cool.

SPEAKER_02 44:36

We're actually using it in our endoscopy suites very soon to help people who want to do unsedated colonoscopies or unsedated outbursts. We've been using it to help patients tolerate monometry testing where we're putting probes in noses, for example, without sedation and helping people with IVs. All of that has been pretty well received.

VR In Clinics And Procedures

SPEAKER_03 44:53

Oh, I love that. I love that. Especially, you know, I'm thinking of when we talked to Tiffany Taft about, you know, how traumatic it is to get an NG tube. Is there a way to be able to use something like VR to help people work through that moment or be, you know, kind of like you said, get into that more meditative state to be able to deal with that and and hopefully alleviate some of this medical trauma? Wow. Super cool.

SPEAKER_00 45:15

Yes. And I have done unmedicated scopes before. I would have loved to have had VR. I stopped doing that. I did like three, yeah, three or four of them years ago because I was like, oh, I don't need it. It's I don't have my whole colon. It's fine. And now I will never do it on Medicaid again.

SPEAKER_02 45:31

Well, if you want to try it with VR.

SPEAKER_00 45:34

I'm so sorry I have to say this. But thank you so, so much, Dr. Wong, for coming on, for listening to your friend, Victor, Dr. Shadid. We had so much fun talking to you, and you're so interesting. But it is time for me to ask you the last question. And that is what is the one thing you want the IBD community to know? And it can be for patients or like your fellow providers.

SPEAKER_02 45:55

I want them to know that not all pain is a flair. And I'm sure that many in the IBD community already know this, but it is well documented to have symptoms after control of disease. And that doesn't mean you're crazy. It doesn't mean you're making it up. It doesn't mean it's in your head. There is real pain that is left, even though the disease is controlled. And so that pain needs to be treated differently. It does not need steroids, it does not need more inflammatory control, but it also doesn't need to be dismissed. That is real pain, and we can help you.

SPEAKER_03 46:23

I love that. That's so important. Dr. Wong, thank you so much. This was such a joy to talk to you. And I can definitely understand why you and Dr. Shadit are besties, because like you guys seem awesome to hang out with. Thank you. Thank you again for being on the show. Thank you, everybody else, for listening. And cheers, everybody.

SPEAKER_02 46:38

Cheers, everybody, for having me. Cheers. Hello, this is Dr. Wong. If you enjoyed this episode, please rate, review, subscribe, and share it with your friends.