NEWS
The Vasovagal Response and IBD
by Kaitlyn Niznik (New York, U.S.A.)
Fluffy white and pink clouds, in front of a sky that shifts from dark to light blue.
As someone with several medical phobias, I have always been a fainter. Being in a heightened state of fear and stress is a recipe for disaster that usually leads to me being on the ground. It takes skill to faint and take out a row of chairs and your mother at the doctor’s office, but I like to think that I’m improving with time and therapy (see my phobias article for details). However, when I began having digestive issues in college, I started experiencing pre-syncope symptoms frequently during flareups that have lasted to this day. Doctors always told me it was a vasovagal response, so I have been asking nurses and reading up on research in the hopes of finding some answers. Though I have not figured out how to completely stop my symptoms, here is what I have found on the subject and some strategies that may help.
IBD can come with a multitude of strange and hard-to-explain symptoms with some occurring outside of the gastrointestinal system. These extraintestinal manifestations can include feeling faint during a period of intense stomach pain or dizzy during a bowel movement. The vagus nerve and parasympathetic nervous system connect the gut, heart and brain, causing a plethora of vasovagal symptoms when thrown out of balance.
For some background information, syncope is a medical term for fainting while presyncope describes the symptoms one experiences when they almost pass out - including dizziness, nausea, blurry vision, weakness, and chills or sweating. Both syncope and presyncope can be signs of different conditions, but are also strongly attributed to vasovagal syncope. Vasovagal syncope is experienced by around a third of the world and is a common symptom of dehydration, giving blood, standing up too quickly, etc. (Johns Hopkins Medicine, Syncope). According to Verywell Health, a vasovagal response can have physical triggers, such as straining during bowel movements, stomach illness, and pain, or emotional triggers like anxiety, trauma, fear, or stress (Bolen, 2025).
**It’s important that if you experience syncope or pre-syncope symptoms that you get checked out by a doctor. Tests like an Electrocardiogram, echocardiogram, tilt table test, CT, MRI, carotid artery ultrasound, and more can be used to rule out serious heart problems, seizures, or conditions like POTS.** (Johns Hopkins Medicine, Syncope)
According to the paper “The autonomic nervous system and inflammatory bowel disease,” there is strong evidence supporting the connection and interaction between the central nervous system and the intestines. When the body is triggered by high stress or chronic stress, it can have a direct effect on our gut’s inflammatory response. Vagal neurons permeate the gut wall and play an important role in the transfer of information from the gut to the central nervous system and vice versa. This connection is commonly known as the gut-brain axis. These sensitive nerve connections can even affect our perception of IBD-associated pain and disease symptoms can be exacerbated (Taylor & Keely, 2007). Our bodies need to find a balance between the nervous system and gut. Too much or too little activation can trigger responses in multiple areas of the body and have unforeseen consequences.
Some common vasovagal response symptoms are:
Tunnel vision/blurred vision
Dizziness
Weakness
Ringing in the ears
Cold or clammy skin
Feeling hot
Nausea
A temporary drop in blood pressure (Bolen, 2025)
Syncope or fainting
Short term amnesia or confusion upon waking
Brief convulsions of the limbs (Wang et al., 2024)
What can you do during a vasovagal episode?
Sit or lie down (injury prevention)
Put your head between your knees
Avoid straining
Stay hydrated
On top of those tips, this is how I deal with repeat vasovagal episodes:
Firstly, I document everything so I can give my doctor a better idea of what I experience and how frequently. A smart watch is also useful so I can keep track of my bpm. There are a few trusted friends and family members that know of my condition and the warning signs. Of course, it’s helpful if you know your own body’s warning signs - it can help you predict it before it happens.
I also keep my phone on me at all times in case I need to call for help. After a vasovagal episode, I give myself time to feel better - usually curling up on the couch with a blanket and some water. I always use electrolytes to help my body recover faster and I keep heating pads with me since I can feel cold or shaky afterwards.
Possible forms of treatment that I’ve learned about:
Medication
Physical counterpressure maneuvers (Wang et al., 2024)
Pelvic Floor Therapy
Vagus Nerve Stimulation
Psychotherapy
I found it interesting that one medical professional recommended looking into psychotherapy to address the psychosocial component of vasovagal responses. Having fainting episodes or those revolving around intense pain can be terrifying and that fear can stick around long after the incident ends. Traumatic memories of pain around bowel movements can cause increased anxiety and escalate vasovagal responses. Confronting your anxiety and the reasons behind your fight/flight/freeze can help mitigate symptoms. By always having a plan and knowing the signs, I can better prepare myself to deal with vasovagal responses.
Works Cited:
Bolen, B. (2025, October 30). Common causes and triggers of the vagal response. Verywell Health. https://www.verywellhealth.com/vasovagal-reflex-1945072
Syncope (fainting) | Johns Hopkins Medicine. Johns Hopkins Medicine. (n.d.). https://www.hopkinsmedicine.org/health/conditions-and-diseases/syncope-fainting
Taylor, C. T., & Keely, S. J. (2007). The autonomic nervous system and inflammatory bowel disease. Autonomic Neuroscience, 133(1), 104–114.https://doi.org/10.1016/j.autneu.2006.11.005
Vagus nerve: What it is, function, Location & Conditions. Cleveland Clinic. (2022, November 1). https://my.clevelandclinic.org/health/body/22279-vagus-nerve
Wang, J., Li, H., Huang, X., Hu, H., Lian, B., Zhang, D., Wu, J., & Cao, L. (2024, April 10). Adult vasovagal syncope with abdominal pain diagnosed by head-up tilt combined with transcranial Doppler: A preliminary study. BMC neurology. https://pmc.ncbi.nlm.nih.gov/articles/PMC11005138/#:~:text=The%20value%20of%20HUT%20combined,the%20adoption%20of%20safety%20measures
Featured image from Henrik Dønnestad on Unsplash.
An overview on Artificial Intelligence in Medical Research
by Akhil Shridhar (India)
A photo of a laptop with multi-colored computer code on the screen.
As an Inflammatory Bowel Disease (IBD) patient and someone who works in the technical field, I'm often curious about the use of new technology in the diagnosis and management of our condition. With seemingly new advancements happening at a breakneck speed, it's hard to keep track of all that's changing, but there's one thing that seems to have everyone's attention. A recent research paper titled "The global academic distribution and changes in research hotspots of artificial intelligence in inflammatory bowel disease since 2000" provides a comprehensive overview of the growing role of Artificial Intelligence in IBD care. In this article we will explore the key findings from the paper, its potential benefits for patients, and important challenges and ethical considerations to keep in mind.
AI in Medical Research
Artificial Intelligence (AI) refers to computer systems capable of simulating human decision-making skills such as, learning from experience, recognizing complex patterns, making predictions, and even refining their accuracy as new data emerges. Unlike traditional software systems, AI can process massive volumes of medical information from sources such as scans, lab tests, electronic health records, and even genetic sequencing. A practical example in IBD care is AI-powered analysis of colonoscopy images. Here, advanced algorithms can help distinguish subtle signs of inflammation or precancerous changes, sometimes even better than the human eye, leading to earlier and more precise diagnosis. These technologies are not only expanding potential research frontiers but are also beginning to find real-world applications in clinical settings.
Brief summary of the research paper
The reviewed paper takes a global perspective, analyzing more than 1,100 published studies on the interplay between AI and IBD from 2000 to 2024. It demonstrates an exponential increase in AI-related research since 2020, driven by technological advances and the push for precision medicine. American institutions, led by leaders such as Harvard University, have made major contributions, with notable engagement from European and Asian centres as well. The paper identifies several hotspots in AI and IBD that have a high impact:
Radionics: Using AI to interpret medical imaging, especially endoscopy and MRI scans.
Natural Language Processing (NLP): Leveraging AI to extract valuable insights from clinical notes, electronic health records, and even patient self-reports.
Predictive Modelling: AI tools that forecast treatment success, likelihood of complications, and need for surgery, all based on a patient's unique profile.
Genomic and Microbiome Research: Harnessing AI to sift through complex genetic and microbiome data for new biomarkers and therapeutic targets.
Personalized Medicine: Integrating diverse patient data streams to create custom care strategies for each IBD patient.
Despite these impressive developments, the paper also points out the need for collaboration between doctors, data scientists, and policymakers to ensure safe and effective implementation.
Benefits for Patients
The true power of AI for patients with IBD lies in its ability to deliver personalized and proactive care, with real-world breakthroughs already emerging. For example, AI-driven systems that analyze colonoscopy images and histological samples in real time are already in use. Physicians now can also use AI models that integrate patient's genetic information, environmental factors, and responses to prior treatments, allowing them to recommend therapies with the highest likelihood of success right from the start. One such machine learning study had accurately predicted response to biologics like infliximab and vedolizumab, minimising delays and reducing risk of adverse effects. Other examples include wearable devices powered by AI that can monitor symptoms and biomarkers continuously, alerting patients and care teams to possible flare-ups before they become too severe. In a very recent ground breaking discovery, researchers at UC San Diego used AI to unravel the cause of chronic inflammation in Crohn's disease after 25 years, revealing the critical role of the NOD2 gene's interaction with a gut protein, Paving the way for new treatments that could directly target the root causes of IBD.
Major clinical trials are now recruiting more diverse patient groups, streamlining data collection, and thus providing tailored interventions thanks to AI algorithms that group participants based on truly representative characteristics. These advances mean patients are no longer just passive recipients of generic care, instead AI allows for better treatment plans that adapt as their condition changes, delivering a future where uncertainty and trial-and-error are replaced by precision, speed, and hope.
Challenges and Ethical Concerns
As with any transformative technology, AI's use in IBD is not without challenges. Large volumes of high-quality, diverse medical data are needed to train reliable AI systems. This reliance raises complex issues regarding data privacy, security, and ownership, patients must be confident that their sensitive health information is protected and not used improperly. Ethical concerns also emerge related to transparency and fairness, patients and clinician need to trust that the algorithms are accurate and unbiased, and able to explain their reasoning in clear and understandable terms. Additionally, there's a critical need for clinicians and engineers to collaborate, ensuring the tools are clinically valid, user-friendly, and integrated seamlessly into everyday practice.
Patients have an important voice in this process. Their engagement can help shape AI systems that uphold dignity, equity, and respect for individuals' needs. Robust ethical oversight and ongoing dialogue will be essential to fully realize the benefits of AI-driven IBD care without unintended consequences.
Conclusion
The integration of AI into the realm of IBD is more than a technological milestone, it represents a profound shift toward truly personalized and proactive patient care. When thoughtfully and ethically implemented, AI can transform how patients experience their diagnosis and treatment by giving them access to faster, more precise answers and by tailoring therapies to fit their unique profile. It can reduce uncertainty, limit experimentation with medications, and empower patients with timely information to manage their health confidently.
For those like us living with IBD, this means not only improved clinical outcomes, but also a higher quality of life, less anxiety, fewer hospital visits, and more meaningful engagement with their healthcare team. With collaboration, transparency, and a patient-first approach, AI has the power to turn hope into progress for those touched by IBD. The ultimate benefit is a healthcare journey that is safer, simpler, and more compassionate with innovation guided by empathy.
Sources:
1. Artificial intelligence in inflammatory bowel disease: Current applications and future directions - https://pmc.ncbi.nlm.nih.gov/articles/PMC12576597/
2. Distinct colitis-associated macrophages drive NOD2-dependent bacterial sensing and gut homeostasis - https://www.jci.org/articles/view/190851
Image from @lucabravo on Unsplash.
Fatigue and IBD
by Aiswarya Asokan (South India)
An image of a person in bed. They are under the blankets, and have covered most of their face with a pillow. Their arm lays on top of the blanket, holding a pair of glasses.
Check out Aiswarya’s presentation slides on fatigue & IBD! She shares about the prevalence of fatigue, types of fatigue, risk factors, the impact fatigue can have on IBD patients, and some suggestions for managing fatigue.
Mental Health and IBD: An Infographic
by Lexi Hanson (Missouri, U.S.A.)
A light yellow background with pink-orange text reading “mental health and IBD.” There are pink graphics of an intestine and a brain on either side of the text.
A light yellow background with pink-orange text and pink graphics of an intestine and brains. Text included below.
Some connections between Mental Health and IBD (sources included below):
Some evidence supports a reciprocal relationship between mental health and disease activity. Depression is more consistently linked to outcomes than anxiety.
Mental health issues are strongly linked to relapse and recurrence. Stress-related cytokine production likely contributes to inflammation. Anxiety and depression affect treatment adherence, leading to worse outcomes.
Psychiatric comorbidities remain a major driver of poor outcomes and healthcare costs despite advances in treatment.
A light yellow background with pink-orange text and pink graphics of a smiling intestine and brain. Text included below.
Some Daily Habits to Help your Mental Health:
☐ Take medications as prescribed
☐ Eat balanced meals that support your gut health (avoid known triggers)
☐ Drink enough water throughout the day
☐ Practice 5–10 minutes of relaxation (deep breathing, meditation, or gentle stretching)
☐ Check in with yourself emotionally (How am I feeling today?)
☐ Engage in light physical activity if able (walk, yoga, stretching)
☐ Prioritize 7–9 hours of quality sleep
☐ Write down one thing you’re grateful for today
A light yellow background with pink-orange text (included below).
Sources:
Mental Illnesses in Inflammatory Bowel Diseases: mens sana in corpore sano. Bartocci et al. 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10145199/
Consensus Statement on Managing Anxiety and Depression in Individuals with Inflammatory Bowel Disease. Hinnant et al. 2025. https://academic.oup.com/ibdjournal/article/31/5/1248/7739104
https://www.crohnscolitisfoundation.org/patientsandcaregivers/mental-health
Internalized stigma in IBD, mental health, and quality of life: A study review
by Aiswarya Asokan (South India)
Scrabble tiles spelling out “mental health” sit on a white background. A branch with leaves is in the upper right corner.
Living with IBD comes with a lot of constraints that no one prepares you for. Every time one goes through a major life transition like starting college, joining work, or getting into a relationship, adapting to the changes is never easy. It’s often difficult to fit in due to our IBD, which in turn puts us under a lot of stress and anxiety. Research indicates that bowel-related issues are a widespread cultural taboo and historically, IBD has been seen as “psychosomatic,” further stigmatizing the condition.
To learn more about this, I read a paper titled “The mediating role of psychological inflexibility on internalised stigma and patient outcomes in a sample of adults with inflammatory bowel disease.” This study was conducted to examine the relationship between ‘psychological inflexibility’ (when someone struggles to adapt to challenges, avoiding emotions or feels stuck) and ‘internalized stigma’ (when individuals adopt negative societal beliefs or shame as their own, and devalue their identity) on health outcomes. The authors looked at outcomes like mental distress (depression, anxiety, stress), health related quality of life, self-efficacy, self-concealment (hiding personal information that is distressing or negative from others), beliefs about emotions, and fatigue (physical and mental) in adults with IBD using an online survey of 382 participants.
This study suggested that:
Adults with IBD who had higher rates of psychological inflexibility also had higher rates of internalized stigma, negative beliefs about their emotions, self-concealment, mental distress, fatigue, and impaired quality of life.
Psychological inflexibility was inversely related to committed action, stigma resistance, and IBD self-efficacy.
Adults with IBD who had higher rates of internalized stigma also showed higher rates of mental distress, self concealment, negative beliefs about their emotions, fatigue, and poor health-related quality of life.
Internalized stigma was inversely correlated to stigma resistance, IBD related self-efficacy, and committed action.
Participant’s age and educational level showed an inverse correlation with their psychological inflexibility. Their IBD severity (in the past 3 months), the presence of an ostomy, and their COVID-19 self-isolation status were positively correlated.
Internalized stigma was higher for individuals with an ostomy, those currently taking steroids, who had experienced severe IBD in the past 3 months, and who were more self-isolated, whereas educational level was inversely correlated.
Other interesting insights from this study:
Individuals who face discrimination regarding their IBD, who are less able to employ ‘flexible’ responses may spend more energy avoiding stigmatizing experiences, making it harder for them to engage in meaningful activities.
New research indicates that general familiarity with IBD can help reduce public stigma; highlighting the importance of IBD awareness campaigns to increase public understanding of IBD, thereby reducing stigma.
These study findings suggest that lower levels of internalized stigma is associated with increased psychological flexibility and better patient outcomes. Modalities of therapy like ‘Acceptance and Commitment Therapy’ (ACT) – which aim to increase psychological flexibility by changing individuals’ relationship with their thoughts, feelings and behaviors – may be a helpful intervention.
Personally, years of living with IBD have enabled me to build a circle of people where I can take my armor off. But still, going through repeated flares, body image issues, breaks from education, social isolation, and being under steroids takes a toll on my mental health and quality of living. Often the medical team's support stops once your blood counts are under control, leaving us with the responsibility of picking up ourselves and moving on with the new normal.
Citation:
Reynolds DP, Chalder T, Henderson C. The mediating role of psychological inflexibility on internalised stigma and patient outcomes in a sample of adults with inflammatory bowel disease. J Crohns Colitis. 2025 Apr 1:. doi: 10.1093/ecco-jcc/jjaf055. Epub ahead of print. https://pubmed.ncbi.nlm.nih.gov/40168103/
Photo from “Total Shape” on Unsplash.
Disability & IBD: A summary and thoughts on “Measuring Disability in IBD: The IBD Disability Index”
by Lexi Hanson (Missouri, U.S.A.)
A brown wall with a white spray-painted ‘disabled’ symbol.
In his article “Measuring Disability in IBD: The IBD Disability Index,” Colombel discusses how IBD is viewed in literature and society. He mentions that IBD has received limited attention due to two main reasons. First, IBD has been considered less disabling compared to other chronic diseases, like multiple sclerosis, leading to underestimation of its impact. Second, there has been confusion in the literature about the true definition of "disability" in relation to IBD, with many definitions that do not align with the World Health Organization's (WHO) standard.
Disability, according to the WHO, refers to the objective problems patients face across various health domains, which is distinct from subjective quality of life. Challenges specific to IBD, such as access to toilets and dietary restrictions, affect disability, and Colombel argues, should still be measured using the same WHO definition applied to all diseases.
To address this gap, the IBD disability index was developed through a comprehensive process, including a systematic literature review, patient interviews, an expert survey, and a cross-sectional study across multiple continents. The final index incorporates a range of factors such as sleep, energy, body image, pain, and environmental influences (e.g., access to healthcare). It aims to provide a standardized measure of disability in IBD patients.
The IBD disability index is currently being validated and is expected to help in clinical trials and research. Some questions in the index include sleep, body image, and pain. Once validated, Colombel believes it could influence patient care by raising awareness about disability in IBD and guiding healthcare interventions. It could also help identify predictors of disability and support the development of strategies to prevent disease progression and long-term disability.
In clinical practice, while the index may not be used daily, it could inform clinicians to ask patients about issues that affect their disability, improving patient care and satisfaction. Measuring disability in IBD will ultimately lead to better understanding and management of the disease, enhancing both clinical outcomes and quality of life for patients.
My thoughts:
This is so fascinating to me, as someone with IBD. The comparison of how disabled someone is based on how impacted they are by their circumstances – and if they can make it through the cut-throat application process to be considered “truly” disabled by the government – seems to lead to isolation of people with chronic conditions like IBD.
When we’re quick to make comparisons or “rank” disability, we alienate others who may not experience disability exactly as we do, but who still may understand our lifestyle or lived experience more so than able-bodied individuals.
I also think there's a unique aspect of being in "remission" with IBD that others don’t always understand, which makes it complex. Sometimes, my IBD impacts me more than it might seem to others, but because the effects aren’t always visible, it’s a concept that can be difficult for people to fully understand.
Having an "index" to show how IBD affects people's lives could really help shine a light on the struggles many face. It could be a way to put into words the challenges that aren’t always visible, making it easier for others to understand just how much this condition impacts daily life – especially in contexts like healthcare appointments, where patients sometimes feel their experiences are not being heard or validated by providers.
Encouraging healthcare providers to use a client-centered, holistic approach when listening to us can lead to a healthier relationship with the healthcare field, and additions like training and feedback surveys could also help in this aspect. In the meantime, we can start by sharing our IBD experiences (through blogs, videos, campaigns, or social media), to help others understand the real-life impacts of IBD, in hope that spreading awareness and knowledge provides some insight into what we go through!
Citation: Colombel JF. Measuring Disability in IBD: The IBD Disability Index. Gastroenterol Hepatol (NY). 2013 May; 9(5): 300-2. https://pmc.ncbi.nlm.nih.gov/articles/PMC3740806/
(Image from Unsplash)
Revolution in Diet Therapy for Inflammatory Bowel Disease: A distilled summary
A Summary of Revolution in diet therapy for inflammatory bowel disease - Melton - 2024 - JGH Open - Wiley Online Library
By Peter Park, Plano Texas
Disclaimer: This piece is not intended to serve as medical advice, but as a reflection on strategies for patient advocacy. Always talk to your GI provider before making any changes to your diet, medication regimen, or any other aspects of your health care.
This is a review article that compiles several studies which center around how diet interplays with Crohn's disease and colitis. Articles are subcategorized by well known factors that contribute to inflammation including meat, dairy, additives, and fiber. Articles and studies are also graded on academic rigor with the gold standard being a randomized control trial and lower quality studies being observational data.
Exclusive Enteral Nutrition (EEN)
First, the article talks about EEN. What is EEN? EEN stands for Exclusive Enteral Nutrition, which means nutritional resources come from a liquid formula for 6-8 weeks (gross). EEN has been shown to achieve clinical remission similar to corticosteroids in pediatric populations. Adult populations seem to follow a similar trend.
Compared to steroids, using a EEN liquid formula based diet is way better to remove the potential harmful side effects of steroids. More specific data shows that factors such as male sex, younger age, milder disease, and certain microbiome profiles respond better to EEN. One criticism can be the healthy user bias where study participants are naturally going to be healthier people and that the person who can tolerate EEN for 6-8 weeks may just be a more self-disciplined person with less financial or social barriers, and overall healthier person.
Partial Enteral Nutrition (PEN)
Let’s be real. Would you sign up for a smoothie-only diet for 6-8 weeks? Authors looked into other diet options such as PEN or Partial Enteral Nutrition where only a portion of food intake is liquid formula and the rest is unrestricted food intake. However, studies have not been promising in PEN’s ability to reduce inflammatory markers such as fecal calprotectin or CRP. Whether that's because of poor ability to stay on that diet or whether that's because of the diet itself is hard to say.
Crohn’s Disease Exclusion Diet (CDED)
Crohn’s Disease Exclusion Diet (CDED) uses 50% PEN and permits only certain foods in three phases:
Phase 1 - Chicken breast, fish, lean meats, olive oil, onion, potatoes, rice, tomatoes
Phase 2 - certain legumes, fruits (blueberries, kiwis, and peaches), vegetables (broccoli, cauliflower, sweet potato, and zucchini), oats, whole-grain bread and pasta
Phase 3 - can introduce foods such as alcohol, coffee, dairy, grains, and seafood
Foods to avoid in ALL phases - Process meat, artificial sweeteners, seeds, emulsifiers, and preservatives
CDED has been shown to reduce inflammatory markers but has yet to be validated in a larger scale study.
Find more information about the Crohn’s Disease Exclusion Diet on the Nutrition Therapy for IBD website.
Diets for Ulcerative Colitis
There's exciting new evidence in ulcerative colitis that indicates that high levels of Hydrogen sulfide (H2S) can increase disruption of the microbiome and cause injury to the colon. Fecal transplant has also been shown to be more impressive and impactful in reducing inflammatory markers when paired with a plant based and low protein based diet. The Mediterranean diet has also shown to improve inflammatory markers but it still seems unsure whether the Mediterranean diet alone is causing this or whether it's the removal of the standard American diet which is known to be high in fats and protein.
I personally want to focus not on any specific diet but the overarching data that seems to indicate that avoiding processed foods, especially processed meats, can help to reduce inflammatory markers. Whether that reduces symptoms from a subjective patient point of view is a little harder to capture in the data. So far, the evidence is clear: There is no evidence that IBD can be treated with diet alone.
Our disease as IBD patients is still a medical disease that requires specific medications and Hopefully we can continue to see more diet and nutritional studies as we all have personal common-sense-knowledge that diet does impact our flares.
One of the best ways to personalize your own flares is to capture a food journal where you can document certain food triggers that occur with flares. This can be really useful in bringing to your gastroenterologist or other specialist, in order to develop a diet plan that works for you. There’s real hope in using food as part of your treatment plan, and with the right approach, it could help you feel more in control of your IBD.
Featured photo by Dana Tentis from Pexels.
Entering Defense Mode! The Gut-Brain Response To Perceived Toxins
By Zahraa Chorghay, Montréal
It’s an uncomfortable feeling, your insides pushing upwards through you, making you retch, sometimes resulting in you vomiting the contents of your digestive system, and other times, just persisting within you. When you’re nauseous, it’s difficult to think about anything, much less do something. You just hang in there, praying for that sensation to disappear (either on its own or with medication), or ffs to just throw up already, so you can finally stop feeling utterly disgusting.
Nausea is a common complaint not only in people with inflammatory bowel disease (IBD) but across many different conditions like “stomach flu” and other infections, sensitivity to strong smells, morning sickness during pregnancy, or even in response to certain medical treatments (such as in cancer). There is a lot of advice floating out there on what you should or shouldn’t do to deal with your nausea (e.g., NHS, accessed 2024).
Here, I focus on the why and how of retching, nausea, and vomiting by discussing [just some of] the basic neurobiology underlying these uncomfortable symptoms.
Defending against toxins
When a toxin is sensed in your gut, your brain goes into defense mode and orchestrates retching, nausea, and vomiting behaviours. This coordinated response does not only expel the toxin from your body, but also helps prevent future exposure to that toxin by forming an unpleasant association between the toxic substance and your bodily response.
Typically, a toxin will get into your gut through contaminated food that has toxin-producing bacteria, or through direct ingestion of a harmful substance. For example, during excessive drinking, your liver can get overloaded and unable to successfully filter out all of the alcohol from your blood (Cleveland Clinic, accessed 2024). Sensing the elevated blood alcohol levels, your brain triggers its coordinated motor responses such that you throw up, removing excess alcohol from your body. Furthermore, earlier episodes of inebriation teach you how much alcohol is too much for you (i.e. how many drinks does it take before you start throwing up or pass out?), so you are less likely to consume excessive liquor in the future.
Additionally, in autoimmune diseases like IBD, the body mistakes its own tissue as pathogenic, so the nausea you experience in IBD may be from your body mistakenly assuming you were exposed to toxins. In response, as it does during toxin exposure in an otherwise healthy body, the brain triggers retching, nausea, and vomiting.
The gut-brain pathway
The defensive response relies, firstly, on receptors in your gut and other peripheral regions of your body detecting the toxin, such as when the toxin has a chemical structure that can bind to a chemoreceptor (chemical receptor), changing its conformation (shape). This change then leads to a cascade of chemical signals in your gut cells, which then relay the information through the vagus nerve to the brainstem. In the brainstem, a region called the dorsal vagal complex (DVC) acts as the brain’s relay centre, receiving information from your organs as well as sending information to other brain regions, including the ventral medulla and hypothalamus (Hornby, 2001). These areas of the brain coordinate retching, nausea, and vomiting behaviours.
For example, Xie et al. (2022) studied the toxin-induced defensive response by injecting mice with a bacterial toxin called Staphylococcal enterotoxin A (SEA). In these mice, in response to SEA, gut enterochromaffin cells release a molecule called serotonin. (Yes, this is the same serotonin you may have heard of as the “feel good” chemical in the brain! But here, serotonin has a different function as a gut messenger.) Serotonin release then activates sensory neurons in the vagus nerve, which carry the information to a specific subset of neurons in the DVC. These brainstem DVC neurons in turn activate a specific neuronal population in the medulla. Together, the DVC and medullary neurons coordinate motor signals, sent also via the vagus nerve to the site of action in the body, thus inducing the mouse’s retching behavior.
Keeping this cascade of signals in mind, newer medications to prevent nausea or vomiting are designed to act on receptors in vagal nerve endings or in the DVC. For example, you can prevent vomiting through blocking neurokinin-1 receptors (NK1R) in the DVC or by activating cannabinoid receptors (CB1R) – also in the DVC – using the active component of marijuana called THC (delta(9)-tetrahydrocannabinol).
Importantly, while scientists have made strides to understand the gut-brain pathway, including the impact of the gut microbiome, we still have many knowledge gaps. The mechanisms underlying gut sickness responses are a subject of active investigation, and can lead to recognizing new therapeutic targets to dissipate the discomfort of nausea in IBD, infection, oncology, and beyond.
Featured photo by MART PRODUCTION from Pexels
Patient Summary on the AGA Clinical Practice Update on Diet and Nutritional Therapies in Patients With Inflammatory Bowel Disease
By Peter Park, TX, USA
Obligatory Disclaimer:
This article is strictly for educational purposes. This article is not to be used or relied on for any diagnostic or treatment purposes. This information does not create any patient-physician relationship and should not be used as a substitute for professional diagnosis, treatment, and/or management. Please consult your health care provider before making any health care decisions for guidance about any specific medical condition. References and links to third parties do not constitute an endorsement or warranty of any kind by Crohn’s & Colitis Young Adults Network (CCYAN).
Who is AGA?
The American Gastroenterological Association (AGA) is a professional organization focused on digestive health. They bring together doctors, researchers, and others interested in stomach and intestine problems, including IBD (Inflammatory Bowel Disease). The AGA publishes scientific journals, holds meetings, and works to improve patient care.
How was this study done?
Experts (doctors, researchers, and others) in IBD performed a review of existing research articles and studies alongside expert opinion to provide practical guidance on diet and nutritional therapies in IBD patients.. This received peer review both internally within AGA and externally outside of AGA.
This was not a formal systematic review, meaning they cannot recommend the strength of any singular suggestion.
Key Points:
There has not been sufficient data to suggest a singular TRUE diet.
According to the AGA, if there was one diet for patients to start from, then it would be the Mediterranean Diet which is “rich in a variety of fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins and low in ultraprocessed foods, added sugar, and salt for their overall health and general well-being”.
Low amounts of red meat have been associated with decreased flares in patients with ulcerative colitis.
Crohn’s, Stricture subtype
Some Crohn’s patients can develop strictures which narrow the tunnel of the colon that can increase the risk of inflammation with certain harder-to-digest foods.
AGA recommends decreasing fibrous foods and raw vegetables that are easier on the colon to channel through all the way to the rectum.
Feeding tube feedings should be discussed with the doctor on staff as there are several specific clinical guidelines.
AGA recommends that patients share this document with their doctor on the most updated guidelines.
Vitamins
Patients with IBD are at higher risk for low levels of Vitamin D, B12, and iron.
AGA recommends to speak with your doctor on monitoring levels regularly.
Involving the professionals
Diet can be complicated by malnutrition, short bowel syndrome, enterocutaneous fistula, and/or requiring more complex management.
AGA recommends involving a registered dietitian to help patients in individualizing their diets.
Summary
Managing IBD requires a multifaceted approach that goes beyond medical interventions. Dietary adjustments, stress management, medication adherence, and regular follow-ups with healthcare providers are essential components of effective management. Additionally, having a supportive network of peers who can offer empathy, understanding, and practical advice can significantly enhance the quality of life for young adults living with IBD.
In conclusion, the key takeaway for young adults struggling with IBD is the recognition of its complexity and the importance of assembling a supportive team, including a GI doctor, registered dietitian, and peers from organizations like CCYAN, to navigate the challenges of living with this chronic condition.
Information in forming this article was taken from the 2024 AGA Clinical Practice Update on Diet and Nutritional Therapies in Patients With Inflammatory Bowel Disease: Expert Review
Source: Hashash, J. G., Elkins, J., Lewis, J. D., & Binion, D. G. (2024). AGA Clinical Practice Update on Diet and Nutritional Therapies in Patients With Inflammatory Bowel Disease: Expert Review. Gastroenterology, 166(3), 521–532. https://doi.org/10.1053/j.gastro.2023.11.303
Featured photo by picjumbo.com from Pexels.
AIBD 2021: Session III: C - Innovations and Approaches in IBD Care for Children With IBD
By David Gardinier
Disclaimer: This article was written after attending AIBD 2021; all information is presented as an attendee to the conference, not as a presenter.
While I was looking forward to pretty much every presentation at AIBD, I was especially interested in Session IIIC: Innovations and Approaches in IBD Care for Children With IBD. With an all star lineup of presenters including Dr. Eric Benchimol, Dr. Lindsey Aldenberg, Dr. Sandra Kim, Dr. Andrew Grossman, and Dr. Kevin Mollen, this session was a must see for me. Not only were the presenters themselves exciting, but their topics explored the growing world of pediatric IBD management. There was a lot of information, so I’ve decided to summarize the presentations in this session and highlight the key findings and takeaways.
Pediatric IBD Year in Review
Presented by Eric Benchimol, MD, PHD, FRCPC
Dr. Benchimol had the herculean task of presenting a yearly review of 2021 in just a 20 minute time slot, and he nailed it! Some of finding over the last year include:
COVID 19
Lower risk of severe COVID-19 in patients on a biologic
Higher risk of severe COVID-19 in patients taking steroids
Patients reported high amount of fear regarding developing COVID-19 and attending medical facilities
Evidence suggests a third dose of the COVID-19 vaccine will likely be needed to maintain antibody levels in IBD patients
Growth in children with IBD has improved over the last 10 years
The racial disparity between steroid prescriptions in black and white children has lessened dramatically over the past 10 years
The STRIDE-2 publication better defines targets of treatment in pediatric IBD
Diet and IBD: Translating Research into Real-Life Practice
Presented by Lindsey Aldenberg, DO
Dr. Aldenberg presented on my favorite topic: diet and IBD. I was so excited to hear this talk, and even more excited to share the key takeaways with you below:
The incidence (number of new cases) of IBD is increasing worldwide, and closely mirrors industrialization
The genetic contribution to the development of IBD is at most 30-40%; this leaves environmental factors, including diet, to make up the remainder
The gut microbiome is dysbiotic (abnormal) in patients with IBD, and diet plays a key role in shaping the gut microbiome
Ultra-processed foods have been associated with development of IBD in recent studies, and this may be due to food additives that disrupt the microbiome and the strength of the gut barrier
Exclusive Enteral Nutrition is an effective therapy in pediatric IBD and is often used as an alternative to corticosteroids or as a bridge to other therapies, medication, or whole food therapeutic diets.
The results of the DINE-CD study, which compared the mediterranean diet with the specific carbohydrate diet, showed that there was no significant difference between the diets when looking at clinical remission and inflammation.
Dr. Aldenberg’s take home points from DINE-CD were that the mediterranean diet may be a great option for IBD patients, and both the mediterranean diet and specific carbohydrate diet might have a greater effect on symptoms than inflammation
The Crohn's Disease Exclusion Diet was effective in lowering measures of inflammation in IBD, and there appears to be a response as early as 3 weeks in patients on the Crohn’s Disease Exclusion Diet or Exclusive Enteral Nutrition
There may be a subset of IBD patients who have disease that responds well to diet therapy, and this needs to be further explored with more research
Cost and Access to Care in Pediatrics
Presented by Sandra Kim, MD
Dr. Kim discussed the urgent need for better access to care for IBD patients and put a spotlight on one of the largest barriers for patients: cost. Some of the highlights from the talk are:
If patients cannot access their doctors, treatments, and medications, then the advances we are making matter less and have less impact
Cost is the biggest delay in receiving care as reported by patients
Per patient costs are greater in children vs adults with IBD
The costs for IBD patients has risen primarily due to pharmaceutical costs, of which biologics are the largest contributor
The group most affected by financial stress are families within the 50-100k earning bracket
Delays in prior authorizations have lead to an increased use in steroid use, which is a medication that pediatric IBD providers try to avoid prescribing
The concept of Step Therapy/Fail First by insurers is harmful to our patients. This policy requires patients and providers to use mandated therapies rather than those that the doctor/providers believes will be most effective. This can lead to delays in the patient getting the therapy that works best for them, and may result in a longer and more difficult path to remission
Advocacy for change in cost and patient access can be done at a individual, state, and national level
The “Safe Step” act of 2021 will allow for a clear, transparent appeals process to request exemption among other advances. Keep an eye on this bill
Social media is a platform we can use to advocate for lower costs and improved patient access
Don’t Be Late to the Party: When to Call Your Surgeon
Presented by Kevin Mollen, MD
Dr. Mollen touched on the importance of getting the surgeon involved early in the care of IBD patients. Some of points I found most important are:
Many studies highlight that surgery is a major cause of anxiety for patients with IBD
Patients often view surgery negatively prior to the operation, but afterwards view surgery positively; patients often wished that they had considered surgery earlier
A multidisciplinary approach to surgical care has been shown to improve preoperative optimization of surgery, decrease surgical complications, and likely improve patient satisfaction
An early consult with the patient allows the surgeon to:
Set expectations
Lower anxiety
Optimize the patient preoperatively
Plan the surgery at the optimal time
A poor nutritional status prior to surgery is associated with prolonged hospital stay, postoperative complications, and delayed recovery of bowel function. Short term nutritional interventions may be used to improve nutritional status prior to surgery
Any patient with UC that is admitted to the hospital for an acute flare should receive a consult from the surgeon due to the high likelihood of needing surgical interventions
In summary, it is key to communicate with the surgeon to develop a plan based on the patient’s goals to improve patient and parent satisfaction. Surgeons are a key part of the IBD multidisciplinary team
