Things You're Too Embarrassed to Ask a Doctor Season 1, Episode 5: Adult GI with Dr. Vijaya Rao

[MUSIC PLAYING] You're listening to Things You're Too Embarrassed to Ask a Doctor, a production of UChicago Medicine. Each week, we'll feature one physician and ask them your most searched questions in their areas of expertise. For more information on our episodes, visit us at www.uchicagomedicine.org/podcast. Have something you're too afraid to ask your doctor? Tweet us at @tytepodcast. I'm your host Kat Carlton.

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In many offices, bathroom talk is socially considered taboo. But in Vijaya Rao's office, it's quite the opposite. As a general gastroenterologist, Dr. Rao specializes in the stomach, the small bowel, and the colon.

I see a little bit of everything, so anything from constipation to inflammatory bowel disease like Crohn's disease or ulcerative colitis, celiac disease, or just people that have abdominal pain.

As you may have guessed by now, today's show is all about gastrointestinal, otherwise known as GI, issues. We'll cover questions like, is stomach gurgling normal, what causes poop to be different colors, is that dangerous, and much, much more.

Now, when I was planning for this episode, it probably won't come as a surprise that it was difficult to find anyone wanting to go on tape asking questions about their bowel activities. But something that's searched a lot online is about the color of poop. Specifically, what does it mean if someone's poop is green?

That's a common question we get in clinic as well. People are always very concerned about the color of their poop. And the thing that I generally tell patients is, oftentimes, the color of your poop is reflective of what you ate. So when poop is green, it doesn't really mean anything dangerous or nefarious.

It's more-- it may have been that you ate more green things that day. I always tell patients that the two colors that we're actually most worried about, or I guess three, are black like tar, red like bright red stool or maroon stools, or very occasionally, a pale or a white stool. But every other color of the rainbow in between is not concerning.

And so what do those dangerous colors signify?

So black tarry stools is generally a suggestion that the patient might have a GI bleed in the upper tract, and that's why it turns black. So if you had an ulcer in your stomach, it takes a while to travel through your entire GI tract. And by the time you're pooping it out, it's black.

When you have bright red stools, then generally that means that you have something more distal, meaning something closer to your rectum or in your colon. Occasionally, bright red, especially if people are having low blood pressure or something like that, could be a sign of a very brisk upper GI bleed, and that can be a very life-threatening situation. And those are kind of the two big things. Occasionally, sometimes maroon stools could be something in the small bowel. Again, small bowel bleeds can also be black too. It kind of just depends on where it is.

Another poop-related question, this has to do with poop floating. So is that a problem? Why do people's poop float sometimes?

That's a good question too. So I think when people, generally, if they're concerned about poop floating, the question is always, is there excess fat in the stool or are people malabsorbing? In general though, excess fat in the stool comes from when your pancreas is almost completely burnt out, meaning like 90% of it is not working. And so that's a pretty rare scenario.

More commonly, that can happen when people have carbohydrate malabsorption, like if they're eating a lot of sugar or something like that, anything that's going to make your poop less dense because that's going to cause it to float. So if there's excess gas in it, that can also make it float.

So it's generally not a very concerning thing, but if you are starting to see oil spots or something concomitant with the poop floating and you have pancreas problems, then it's more of a concerning thing. Or if you're losing weight or if there's any sign of malnutrition, then it's more concerning. But otherwise, sometimes it just means that there is more gas that is within the stool that's making it float. Or sometimes, you just have been eating a lot of sugar or fatty foods that are causing it to not sink into the toilet.

So you mentioned the pancreas. What ends up causing the pancreas to burn out?

In general, there's a few different causes, but a few of the primary ones are, sometimes, when you have very severe diabetes, that can cause your pancreas to burn out. In other people who are heavy drinkers or smokers, that can cause recurrent pancreatitis or the pancreas to be inflamed over and over again, and that eventually can cause pancreatic burnout. Other causes sometimes can be genetic causes that predispose younger people to keep having these episodes of recurrent inflammation, but those are kind of the main causes, cystic fibrosis as well.

So we also kind of briefly went over there being blood that ends up in poop, which is related to another question on here. People are searching, can blood in my stool kill me?

That's a very important question. So I would say the short answer is yes. Blood in your stool can kill you, but it's pretty rare that that would happen. So one of the most common things that I'll see in clinic are people that have small amounts of rectal bleeding. That generally doesn't signify anything dangerous. Usually, that's most likely hemorrhoids. Hemorrhoids are basically dilated veins that sit in the end of your rectum that sometimes are just caused by high pressure or straining, but that in itself is not dangerous.

So by dilated you mean swollen?

Swollen.

OK.

Yes, exactly. Exactly. But in certain cases, I know we talked a little bit about some life-threatening situations like if you had an ulcer that was really quickly bleeding, that's a situation that blood in your stool can be more dangerous. Sometimes people have something called diverticulosis which are basically outpouchings that are in your colon. And those tend to bleed, basically because the walls become so thin that the vessels become more prominent and they can bleed easier. And when that happens, it's a very quick bleed as well. And a lot of times, people's blood counts can drop to almost half of what it normally should be, and those can be dangerous bleeds as well.

So it's basically, those two situations could cause some quick bleeding and leading to life-threatening scenarios. And obviously, the last one, which may not lead to a quick bleed, but colon cancer. Colon cancer can sometimes cause small amounts of blood in the stool that you may not see like if you had an ulcer or a diverticular bleed. And then it's kind of important to also keep in mind what your blood count is. And so if somebody is anemic, meaning their blood count is low, and they're having recurrent rectal bleeding and their iron levels are low, that's kind of a sign that there might be something more dangerous going on.

If someone sees blood in their poop, is that a sign they should immediately call the doctor?

So I think, in general, that should be evaluated at some point. I think it varies. I mean, if somebody is passing blood and clots and they're feeling lightheaded, that is a reason to go to the emergency room. If you're seeing a little bit of blood upon wiping, again, that's most likely going to be hemorrhoidal.

I think addressing it with your physician is very important, but it kind of just varies in terms of how urgently you need to see the physician. Obviously, if it's something that you're feeling short of breath, you're lightheaded, that's something-- you need to go to the ER. If you're seeing a little bit of blood here and there, I think it's something that is definitely worth addressing with a physician, but maybe not that day.

OK. And you had mentioned one potential source of blood in the stool could be from colon cancer actually. So that's another question on here. What are the signs of colon cancer, and who gets it?

So it's such a variability in terms of signs of colon cancer, and it kind of also just depends on how advanced it is. You know, many times, we see colon cancers in patients that are asymptomatic and we'll see it on a colonoscopy. Sometimes people don't have any bowel symptoms at all. They may not have any abdominal pain. They may not have any nausea or vomiting or anything else, and they may not notice even any blood in their stools.

In fact, I just did a procedure on a patient who had extremely low blood count, extremely low iron levels, so she actually presented with shortness of breath. She didn't have any GI symptoms, but she actually ended up having a colon cancer. And we were suspicious of that because her iron levels were so low and her blood count was so low. You know, sometimes, if a colon cancer, meaning the mass which is in the lumen of the colon or the opening of the colon, if that's completely obstructing, then sometimes people will have pain or nausea or vomiting.

Other things to watch out for is an abrupt change in your stool caliber, meaning how thin your stool is. Occasionally, if people start to notice these pencil-thin stools, that could be a sign. But again, it just varies so much between patient and patient.

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So we'll move on to another area that is quite popular in search, which is diarrhea. The first question we have related to diarrhea is, are diarrhea and vomiting signs of pregnancy?

So not necessarily. Oftentimes, women complain of irregular bowel habits around the time of their menstrual cycle. And that's generally because there's a hormone-like substance called prostaglandins that are released that make our uterus contract. And that can also make the colon contract as well. And so sometimes, women will get diarrhea around the time of their menstrual cycle, but not necessarily related to pregnancy.

Vomiting, as probably most of us know, can be a sign of early pregnancy usually, but it's not really a hard and fast rule. Not every pregnant woman will get those. I think, in general, diarrhea is probably less common in pregnant women. Constipation is actually probably way more common among pregnant people because their progesterone levels rise and that predisposes to constipation.

Damn. Pregnancy sounds uncomfortable.

It does.

Why does diarrhea hurt?

So that's a good question. So I think it can be from a few reasons. So diarrhea generally is caused by some kind of inflammation in the colon, whether it's from an infection or an underlying disease. And when that happens, the lining of the colon can be inflamed, and that in itself can be painful.

Oftentimes too, there's spasm of the colon around that time too that can cause abdominal pain and that can hurt. Also too, when you have pretty significant inflammation in your rectum, which is the very end of your colon, that causes probably the most discomfort because you get a lot of urgency, and you can get some pain as well.

Here's one of my favorite diarrhea questions. Diarrhea, where does all the water come from?

So the colon is primarily where all the water is absorbed. So when your colon's inflamed, the lining is often not as effective in absorbing the water. So instead of that water being reabsorbed, the water just stays within the colon and you're basically pooping it out, so that can happen with diarrhea. Other things that can cause a lot of water within diarrhea are things that affect the small bowel.

And so the small bowel is where your nutrients are absorbed. And certain kinds of infections, inflammatory bowel disease, celiac disease, lactose malabsorption can result in residual nutrients basically being stuck, in a sense, in the small bowel lining. And what that does is actually pull water also into the lumen of the intestine, and that's why you're also having diarrhea. So I think those are kind of the two primary mechanisms as to why diarrhea contains so much water.

And then, in turn, dehydrates you.

Exactly, exactly.

Which leads me to my next question. Since it dehydrates you, will diarrhea kill you?

So that's kind of the crux of that answer. So if diarrhea is getting you to the point of dehydration and you're not seeking medical help or you're not getting resuscitated with fluids, then yes, it can. In general though, diarrhea is unlikely to kill you. I mean, I think when we think about diarrhea, most of the time it's people who kind of have the self-limited viral gastroenteritis, meaning that they'll have a few days of diarrhea and it goes away on its own.

But there are certain populations in people who might have a compromised immune system or that come to the hospital very frequently. They may be more prone to getting more dangerous infections. Something called C. diff or C. difficile is a type of infection that affects the colon and, if left untreated, sometimes can be life-threatening.

Why do people get diarrhea with a cold?

So I think there's three reasons as to why people can get diarrhea with a cold. So one is that the same viruses that cause cold symptoms can also cause gut symptoms as well. But also, sometimes people may not realize it, but when they're given antibiotics for their cold, that can be a cause of diarrhea. And also if you're taking large amounts of these over-the-counter cough syrups or cough suppressants, they can contain a lot of fructose which kind of causes you to malabsorb and also gives you diarrhea.

Will diarrhea cause high blood sugar?

So usually the opposite, actually. So diarrhea in itself does not cause high blood sugar, but if you have uncontrolled high blood sugars, that can cause diarrhea. So when you think about people who have uncontrolled diabetes, they can actually develop something called diabetic diarrhea.

And basically, that happens because, as most people know, sometimes diarrhea can affect the nerves in your hands and your feet, but it can also affect the nerves in your colon. And so that kind of leads to your colon being dysregulated and can cause irregular bowel habits. That can really go either way. It can cause diarrhea or it can also cause constipation as well.

Speaking of constipation, when I saw this one, it just made me hurt inside because we've all been there. Why am I so constipated?

So that's probably, I would say, top five most common questions that I get. In this country, constipation is incredibly, incredibly common. And I think the reason for that is really, because of our diets. In general, this country has a huge fiber deficit. Our goal fiber intake should be about 25 to 30 grams a day. And they've done studies, and most patients get maybe seven to 10 grams of fiber per day. And they'll think that they're eating fiber, but when you're really kind of scrutinizing your diet, you're not really getting that much.

You'll have people that come in and be like, well, I eat a lot of salads. And I'll go through their diet, and they'll be like, well I had a chicken Caesar salad. And I'll be like, that actually has no fiber in it because all it is is lettuce, which has no fiber, and it's chicken and it's cheese and it's dressing. And it's to no fault of the patients, just the American diet tends to be very fiber-poor.

So what are some things people should be eating to try to avoid constipation?

That's a great question. So replacing maybe your breakfast, whatever you eating, with oatmeal. If you had a cup of oatmeal, it's about four grams of fiber, making sure that you are eating a lot of fruits and vegetables. On average though, a cup of any given vegetable is probably about four grams of fiber, so you're making sure that you need to eat a lot of it.

Probably some of the foods that give you the biggest bang for your buck though are things like lentils. If you cook a cup of lentils, there's almost 20 grams of fiber in that one cup. And so that's a pretty easy way of getting your fiber intake and eating that as a side dish along with a protein or something like that for dinner.

Another one in the kind of same family, is stomach gurgling normal?

So stomach gurgling is normal. So in general, that's how our stomach propels food from our stomach into the rest of our intestines, so that in itself is normal. It's generally never a sign of anything dangerous. It's more of an annoyance rather than anything else.

Does your stomach gurgle only when you're digesting or does it gurgle when you're hungry too?

It can gurgle when you're hungry. It can gurgle when you're digesting. There's not a great rhyme or reason for when it does that, but those are probably the two biggest scenarios, when you're hungry and it's trying to signal you to eat something or when it's moving things along.

But it's not a sign of any kind of danger.

It's not.

Good to know. Switching gears a little bit here, we have one more question, which is probably my favorite on this whole list, which relates to stomach ulcers. This question is, are stomach ulcers contagious from kissing? And why don't you start by just kind of giving an overview of what stomach ulcers are, why people get them.

So stomach ulcers, basically, are breaks in the lining of your stomach. They can go anywhere from being just a couple of millimeters to very large like multiple centimeters. Those predispose to bleeding, and that's why they can be dangerous.

There are two main causes of stomach ulcers. One is an infection called H. pylori, which I'll talk more about in regards to whether or not they can be contagious. And the other one is a class of medications called nonsteroidal anti-inflammatory medications. And basically, those are like Advil, Aleve, ibuprofen. And those all can damage the stomach lining and cause ulcers as well.

So if you're just taking Advil and you kiss someone and you have an ulcer from that, then no, it won't be contagious. But if you have an infection called H. pylori, which can cause ulcers, that could be contagious from kissing. H. pylori is an infection that can affect your stomach. And there's not great data to show exactly how it's transmitted, but it is thought that there is some oral-oral transmission. People that are living in close quarters with each other generally all have it, so that potentially could be contagious from kissing.

Well, that's all the questions that I have. Anything else you want to let people know in order to make them kind of more comfortable to come to their doctors with these questions?

I would say that they can always come to the doctor with these questions because we hear this all day, and so there's nothing on this list that would be embarrassing. There's nothing we haven't heard before. In fact, these are things that we generally hear over and over again, so these certainly aren't questions that they should be sheepish about asking.

Great. Well, thanks so much, Dr. Rao for your time today.

No problem. Thank you for having me.

Once again, I'm Kat Carlton and you've been listening to Things You're Too Embarrassed to Ask a Doctor. Music from today's episode is by Blue Dot Sessions. For more information on our show or to submit your own question, visit www.uchicagomedicine.org/podcast or tweet us at @tytepodcast.

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