Ken Brown
0:00 Welcome, everybody to gut check project, Episode Number 39. A super cool one because my co host is also our guest, the expert, the person that we all love whenever Eric goes out of town on a mountain biking expedition, which is what he's doing right now. So we have the super smart, super well trained Dr. Stuart Akerman as both our expert guest and our host, Dr. Akerman, thanks for coming.
Stuart Akerman
0:27 Ah, thanks for having me here. I was more than happy to pay for Eric's vacation so that I can do this.
Ken Brown
0:33 You are pretty sly like that. That's pretty interesting. You're sort of, you're sort of pushing him out. And so I think that's, you know, he thinks he's having fun.
Stuart Akerman
0:41 I made him think it was his idea. I mean, that was really what came down to.
Ken Brown
0:46 Well, in today's episode, this is really cool because when I said that Dr. Ackerman is both the co host today and our expert is because we're going to tackle a topic that a lot of people have and it is diarrhea specifically related to something called a epi exocrine pancreatic insufficiency and you're like, Huh, I saw a commercial on that. What's that? Exactly. That's what all my patients say. They're like, what is this? They come in and talk about this. So usually whenever Eric and I before we start, Dr. Akerman, what is going on with you and the Akerman family anything personal you want to share?
Stuart Akerman
1:20 Yeah, could share all kinds of things. It's been definitely interesting. And the quarantine life as we now gear up at the end of the summer trying to figure out what do the kids kids are sort of excited to go back to school not sure what they're going to do, but I never thought they'd have this problem that they've actually watched all there is to watch on TV and they need something else to do.
Ken Brown
1:44 That reminds me of I think I saw some funny video where somebody was sitting in front of in front of his computer and it goes, you've done it. You've reached the end of the internet.
Stuart Akerman
1:54 It's kinda like that. There's nothing. You only have so many subscriptions, I guess.
Ken Brown
1:58 Exactly. Yeah, well in the brown household. I took Lucas to a tournament pretty cool. in Wichita Falls, it was a well run tournament. So kudos to the tournament director out there. It was a college tournament. So Lucas out, unfortunately lost in a tough third set tiebreak to a really good player. And you know, we just kind of move on. And we got so excited to talk about what he learned from that. And then by the time we got back to Dallas, they had canceled the national tournament, which is why he was doing this to prepare for the next one. And so we're dealing with that where we try and make plans and keep these the passion up. So
Stuart Akerman
2:37 And you know, when we were talking the other night, I actually realized after we hung up that I wanted to ask Lucas, I mean, I know that it's a junior tournament. So there's no betting and things like that. But there must be some sort of handicapping system right because they are rankings. Where was he ranked in comparison to this kid who's several years older than him?
Ken Brown
2:58 Well, this was actually a college tournament. So it was for college players. And so he's 15 he played a 21 year old and actually they're just on ranking level is they were both on par so the two he's Lucas was the number one seed in the tournament. And that man was the second was the number two seed so it worked out perfect the bracket got the what I consider the two best players to play in the end. And funny you bring that up because him and I were in Panama right when COVID hit because we had to bust out a Panama he was doing what's called an ITF. And I happen to have a friend there in Panama who lives there and has been doing sort of digital marketing and all this stuff. And he was running a betting website. And he goes it's not he goes people from around the world will bet on anything. And then we started talking tennis and he goes the most rigged sport, like for betting where people like there's all kinds of junior level sports that people bet on because they know that they can kind of tilt the odds one way or the other.
Stuart Akerman
3:55 Oh my gosh.
Ken Brown
3:56 There's yeah, it was a whole new world for me. So like when you say that I kind of cringe because I was Just like oh, no, you know, we've got we're going to start like hustling you know peewee baseball and stuff like that.
Stuart Akerman
4:07 I thought I thought about how he took a, you know, someone who's I think five years or six years older than him to the brink and almost beat him.
Ken Brown
4:15 Yeah.
Stuart Akerman
4:16 But has such a competitive spirit to be upset by that.
Ken Brown
4:20 Oh, totally upset, like, on the way home just, you know, I had two match but he had two match points. I had two match points. I just, I just would have you know, I'm like, I know. I know. It's, it's life and what's really cool is that you know, you move on and do that. So I apologize a little bit if I'm a little nasally. I do not know what blew into town, but it is killing my allergies today. So and I, it's not COVID I smell great. Also two things. I don't smell great. But I can still smell things.
Stuart Akerman
4:48 Smell things
Ken Brown
4:49 Smell things. So let's get back at this. So before everybody's like, well, they're just gonna talk about their family the whole time, I want to reiterate something so we stole Dr. Akerman four years ago, three years ago.
Stuart Akerman
5:01 Five years ago.
Ken Brown
5:02 Holy cow time passes fast. We stole him from New York because he is a specially trained expert in advanced endoscopy. So he does the things that most of us have not been trained in. And a lot of that involves the pancreas. So you and I got to talking and we had a patient recently who showed up to have her endoscopy done and she said, Hey, do I have this? And I called you in and you looked at that unlike epi exocrine pancreatic insufficiency, I'm like, man, if these drug companies are spending so much time advertising for it, we better just address this head on and let's just have an episode you're a pancreas expert. I'm more of a lumenologists is how I like to consider myself and so the lumen I like colons and I like stomachs and and hemorrhoids but you are an advanced trained person that everybody if you have a pancreas call up Dr. Akerman and make sure that your pancreas is okay. So hat you know, that's what I'm saying.
Stuart Akerman
5:58 Yeah, so this is definitely something that's getting a lot of press. And, you know, if you look around TV, internet, I mean, it feels like the ads are just constantly jumping at you. And it's something that it gives everyone pause that has diarrhea. And, you know, there are different estimates, but more than 5% in a conservative estimate more than 5% of the population deals with chronic diarrhea in some form. And you know, 5% is a lot of people and not everyone gets to the bottom of what's going on with them and gets that relief and that, that feeling that they know exactly what it is and how to deal with it. And for years, pretty much we knew about inflammatory bowel disease and knew how to evaluate for it and rule it out. And then there's kind of a short list, you know, all we look for what we have, you don't have any of that you probably have IBS.
Ken Brown
6:51 Oh the famous, you probably have IBS, so that's my world where everybody comes says, I have IBS and if you're somebody if you're 20% of the population that suffers from irritable bowel syndrome. It can be diarrhea, constipation or mixed. And you may be one of those frustrated people that you go into your doctor, you have an endoscopy, colonoscopy and some bloodwork you get pat on the head and you go good news. It's just IBS you leave and you're still miserable. And I think that's why there's so many commercials going on here where it's like, look, maybe we're not thinking hard enough on some of this stuff, my world is SIBO bacterial overgrowth, your world is pancreas, and so that's why you're the expert on this. And so, let's do let's not make this too sciency. I know that we all you're still in the office. I love that you just got done doing telemedicine. And if anybody, doc, go to Dr. Akerman's website, set up a telemedicine visit if you're concerned about this, because he's the expert. So let's hop right in. I'm going to start interviewing you less as a co host more as an expert. So what is your standard workup? I'm gonna start from the beginning on diarrhea. Somebody comes in and said I've had diarrhea for two weeks, do you care? Do you like that you call that chronic diarrhea versus the person says I've had diarrhea for a year?
Stuart Akerman
8:07 Right. So that's actually a great way to start the question because what makes something chronic? And it seems to be accepted that if it's four weeks or longer, you're dealing with chronic diarrhea. So the first thing I want to do when a patient comes in, I want to get a sense of what this means to them when they say they have diarrhea. That means 10 different things to 10 different people. And that could be part of the reason why it's so difficult to get the right workup. It's it's trying to fit a square peg into a circle hole. And you got to make sure that everything lines up. So one of the most important things to do is get a sense from the patient. What's bothering them, what does it mean to them? Are you saying you have diarrhea because your stools are loose? Are you saying you have diarrhea because you go 10 times a day? How does it work? Is it when you eat if you don't eat you're fine? Do you go no matter what you wake up five times a night to go to the bathroom even though nothing else has been going on? These are things that you can tease out that might send you along different paths in the workup.
Ken Brown
9:10 And when you say tease out, that's the art of somebody that understands their craft really well. This is why we can still do telemedicine and be effective because that history, the patient history tells a story, you have become a detective. And you're going to get to the bottom of this. All those questions you just asked, are all things: have you traveled? Has this happened? Do you wake up at night? Those are all the same things I ask. So you start kind of moving to this area. So all right. So I'm going to play patient, I'm going to say I've had this for six months. I don't wake up. I use the restroom afterwards. And I just feel like I'm not absorbing things.
Stuart Akerman
9:50 Right. So that is definitely a classic paradigm for epi. And, you know, I think it's important that we kind of define what that means if you have exocrine pancreatic insufficiency. I thought about it this morning. And I was trying to think about what would be a good way to explain it that would really resonate with our viewers as to how you might have epi. I think, I think the classic reason to have is you burnt out your pancreas, you have chronic pancreatitis, the pancreas is very scarred, it can't work. I think it's very easy to understand that if your pancreas is impaired in some way, that the function of it isn't going to be that great either.
Ken Brown
10:32 So let me let me stop you right there because we're going to get into that in a second because we're gonna start with step one. Step one is you're a pancreas expert. Why are people using this acronym epi? Because the pancreas does a lot of really important things. It has the endocrine function, and it has an exocrine function define what those two are.
Stuart Akerman
10:52 Sure. So the endocrine function is essentially your insulin. So if your endocrine function is impaired, that means You have a low insulin level. And that's actually what type one diabetes is, right? You're not making enough insulin. So the answer is how do you fix that? Take insulin, right? If your pancreas can't produce it for you, you can take it and essentially help it out. That's the endocrine side. The exocrine side when we talk about pancreatic exocrine insufficiency is related more to direct digestion of carbohydrates, fats, and to some degree proteins. And those are what are called lipases, proteases and amylases. And there are varying concentrations of each of them that are spit out by the pancreas in response to stimulus which is eating.
Ken Brown
11:42 So I eat something I eat a hamburger, I've got bun, meat, cheese, eat it, swallow it.
Stuart Akerman
11:50 Well, that's you. I wouldn't have cheese in there. But that's me.
Ken Brown
11:54 But so we've got protein, fat and carbs and through really beautiful complex signaling the pancreas then releases these digestive enzymes.
Stuart Akerman
12:04 Correct.
Ken Brown
12:05 Known as the execution portion of it.
Stuart Akerman
12:07 Correct.
Ken Brown
12:08 Okay. So exocrine portion. So if I have an exocrine insufficiency, meaning maybe I'm not putting out enough enzyme,
Stuart Akerman
12:18 Right? So either you're not putting out enough, or maybe you're not getting to the point of the bowel where you would do that, for instance, in surgical procedures that bypass the area where you would spit out the exocrine pancreatic enzymes, you'll end up with an insufficiency which essentially boils down to a mal digestive disorder.
Ken Brown
12:45 So a malabsorption. So people don't are not getting these nutrients. So we've got an exocrine pancreatic insufficiency: epi. So when I do my workup, and I go, you know, Dr. Akerman, it looks like there's some unusual things going on with this patient that I think I need your assistance with. They are low on their vitamin K, their vitamin E, their vitamin D, they've got, they're describing oily stools. That is how I've been classically taught what epi is. What the commercials are saying is they're casting a broad net. They're like if you've got bloating, abdominal cramping, and change in bowel habits, ask your doctor about epi. And I'm gonna close this out as to why I think they're casting such a broad net in the end, but we're going to still talk about the physiology pathophysiology. So it sounds a lot like irritable bowel syndrome, these commercials.
Stuart Akerman
13:42 Right, and and there's tons of overlap. So if I had to say, what's the single largest diagnosis or the largest swath of patients with a specific diagnosis that are going to overlap, it's going to be irritable bowel, right. You're bloated, you're gassy. You're having loose stools. You don't quite feel good after you eat. These are all signs of both irritable bowel because of a sensitivity issue when you eat, but also a malabsorptive this issue at the same time, so those symptoms alone won't quite make it. What you alluded to is someone who has fairly advanced disease so that when they eat, they really aren't producing any enzymes. So everything's going to come out in particular fat. So those fat soluble vitamins A, D, E, and K, are going to be more susceptible to deficiencies, and you'll actually sometimes see what looks like fat or oil droplets in the bowl with the stool because you can't absorb the fat appropriately.
Ken Brown
14:44 Yeah, exactly. I and this isn't just an issue of a gastroenterologist when I was looking this up I got on YouTube to see like what other people have said about this. And my friend and author Rob Wolf, he, he was doing a whole thing a q&a. And that was a question. I'm seeing all these commercials coming up on this on his YouTube channel. He was like this is coming up a whole lot. And so he addressed the exact same thing and discussed the endocrine the exocrine. So shout out to him for taking that on because it's, it's clearly reaching the masses right now. So, we just want to demystify this, talk about now we know what the symptoms are, which can be pretty broad. Let's talk about some causes. So you were getting into the causes before. So let's talk about causes of what can actually cause true exocrine pancreatic insufficiency. And then we'll talk about non pancreatic causes, and then talk about diagnosis and then ultimately, the treatment. Sound fair?
Stuart Akerman
15:41 Right. Yeah, that sounds great. So pancreatic causes probably the single biggest cause would be chronic pancreatitis. So chronic pancreatitis is an issue where you start laying down scar tissue within the pancreas. And, you know, it doesn't in general happen overnight. I mean, you could theoretically get a major inflammatory episode or a trauma, that that could really give your pancreas a hit all in one fell swoop. But, in general, this is something that happens over time. It's kind of like laying the groundwork and the scaffolding and eventually it keeps building up. So...
Ken Brown
16:19 Why...you deal with the pancreas, you deal with pancreatitis. What is pancreatitis? And why do I care about that?
Stuart Akerman
16:26 So there's two kinds of pancreatitis. There's acute pancreatitis and chronic pancreatitis, and they're not the same thing. And they're often confused and they're actually distinct entities. They can relate to each other. But the mechanisms are different. When you have severe pain, and you show up to an emergency room and they do a CAT scan and tell you oh, you got acute pancreatitis. What that means is your pancreas is inflamed. It might be swollen, there's a lot of fluid around it. It's an inflammatory process. But when you have chronic pancreatitis chronic pancreatitis means that it's scarred, it's shriveled. The word they use a lot of times is atrophied, or sometimes calcification. Now you can have both. You can have chronic pancreatitis and have a pancreas that's a little bit shriveled and then gets inflamed. And we call that acute on chronic pancreatitis and it may make your threshold to get acute pancreatitis a lot lower.
Ken Brown
17:25 And people that have ever had this are nodding going, that's not fun at all. pancreatitis is a very serious issue.
Stuart Akerman
17:31 Yeah, we don't wish it upon anybody.
Ken Brown
17:33 No, not upon anybody. Okay, so that's what pancreatitis is. As a gastroenterologist that deals in this what, what are some of the causes of chronic pancreatitis? Actually, I think that I mean, acute and chronic, the causes are the same. It's just the repetity of insults correct.
Stuart Akerman
17:52 For the most part, I'd say you know, the, the two most common causes for acute pancreatitis in America are Alcohol and gallstones. And if you continue to get like you said if you continue to get acute injury is acute pancreatitis, you're going to keep developing more and more scars as a result and you'll end up with chronic pancreatitis. I'd say one thing that has not really been shown to cause acute pancreatitis, but is very much in the conversation for chronic pancreatitis is smoking. We have patients who have chronic smoking over time. Never had an acute pancreatitis episode ever develop EPI or chronic abdominal pain and in the process of the workup are found to have chronic pancreatitis and the risk factor they have is chronic smoker.
Ken Brown
18:42 That's something that I've never actually come across and do you have an etiology of why you think smoking does that?
Stuart Akerman
18:48 So it's tough to say but I mean, we do know that physiologically, smoking does lead to scar it's been seen in many organs.
Ken Brown
18:56 So hold on, let me write this down. So smoking is not good for you. Is that what you're saying?
Stuart Akerman
19:00 I think it's something I'm pretty comfortable putting my stamp on as a physician.
Ken Brown
19:04 I mean we're in a really political environment. You better feel strong about it.
Stuart Akerman
19:09 Yeah, I don't know. I don't want any of the big tobacco companies coming after me. I'd say from a from a medical perspective, there's not much good that comes from it.
Ken Brown
19:20 Okay. So mostly from just the inflammatory process.
Stuart Akerman
19:23 It seems to be, it seems to be, but it's been it's been linked to many cancers and various organs that are unrelated to each other and chronic scar. We've seen that too the pancreas being one of them.
Ken Brown
19:36 Okay, so pancreatitis of the acute can lead to chronic correct. So if you have an acute episode, you may end up with a slightly chronic one. If you continue to drink or smoke, you can end up developing this. Are there any other disease states related to chronic pancreatitis?
Stuart Akerman
19:55 So there's a there's a viral states we have something called tropical pancreatitis not really seen so much in North America. More more seen in the in the eastern countries. One of the autoimmune disease. The pancreas is one of the organs that can be affected by autoimmune disease. So patients who already have one autoimmune disease be that autoimmune thyroid disease, rheumatoid arthritis or other arthritities these are always more susceptible to getting a second autoimmune disease and the pancreas and sometimes the liver are the ones that we deal with. And then actually high triglyceride levels. That's actually the number three it's a distant third in comparison to the first two but that's the third most common reason for recurrent pancreatitis is hypertriglyceridemia or high triglyceride levels and you know, I'm not talking like you know, you got a little bit of an elevation and your doc tells you that you probably should cut down on the fast food and maybe exercise a little more but significantly elevated sometimes in the thousands,
Ken Brown
21:01 So my experience has been and you've seen so much more of this, but it seems like these are young people with a some sort of genetic issue and they have these hypertriglyceridemia. And it's usually really bad that first episode. Have you seen similar episode or similar findings?
Stuart Akerman
21:18 Yeah. And occasionally, it's so bad that we actually have to do almost a dialysis type procedure to get the triglycerides out of their blood, just so that it stops inflaming their pancreas and they can get over it. And then from there, we can try medications to keep it down. But yeah, sometimes it's just so overworked that they're just in the throes of it and we just have to break that cycle.
Ken Brown
21:43 And then last thing is that I have a large inflammatory bowel disease, population Crohn's disease, and it has been associated with that. Is that just part of the autoimmune process that you were just talking about?
Stuart Akerman
21:52 Yea it seems to be that there's some some part of the autoimmune cascade there because we do know, you know, as much as we know so much about Crohn's disease. There's so much that we don't know. But it's it's fairly clear at this point that there's an autoimmune component in addition to environmental ones. And it's possible that that overlap is where the elevated pancreatitis risk comes because we do see what's called igg mediated which is another way of saying autoimmune disorders of the pancreas and bile ducts and liver in relation to Crohn's and ulcerative colitis.
Ken Brown
22:26 The infamous before you arrive. Dr. Goldsmith, make sure you're checking igg four on that person.
Stuart Akerman
22:32 Yeah.
Ken Brown
22:32 Subtype that could potentially affect the pancreas.
Stuart Akerman
22:34 There's a method to it.
Ken Brown
22:36 Yeah. All right. So now I'm worried. I've got some I smoked a cigarette yesterday. I had had a drink of my buddies. I go poop and my my stool is floating. This is kind of a trick question. Is that pancreatic insufficiency?
Stuart Akerman
22:55 Not necessarily. I mean, everyone's entitled to have floating poops every once in a while. More commonly, it's actually related to just some gas that's stuck in the stool and therefore it's not truly as solid as it may look. And it's floating, any kind of, you know, malabsorptive issue, even if it's transient, like something you ate that you didn't quite digest well, or maybe you had a passing viral illness can cause very similar symptoms. So the chronicity establishing that this has been going on is a really major piece of the puzzle before you go down that road to worry about it.
Ken Brown
23:27 So I throw that out there because I was traveling and I got called by some men's health or something, hey, we're doing this article on stools. But we want you to comment on what is floating stools mean, so I had to like sit in an airport, you know, log into their Wi Fi and then like type this response and it was about air. And because of that I came across an article when when we were preparing for this epi that a very fun I call this my fun stool fact it's that many people believe that floating stools is related to pancreatic insufficiency or malabsorption. The reality is stools sticking to the toilet bowl have been more associated with steatorrhea or more lipid or more you're passing oil and fats. So I thought that was kind of fun.
Stuart Akerman
24:09 It greases that adherence to the bowl.
Ken Brown
24:11 Isn't that funny? So I have all these patients go I saw my stool floating and I'm like, okay, that's right. All right. So...
Stuart Akerman
24:18 I'm curious to know what your Google searches look like now that you did that in a in an airport.
Ken Brown
24:23 Oh, forget about the Google searches. You got to see the ads I'm getting. I'm being haunted by some really scary ads right now. But the good digital marketers to profile me and then track me down. So so we know what pancreatic insufficiency is. I want to know, are there some other things that can cause similar looking symptoms before I make an appointment with Dr. Stuart Akerman to really determine if I have this are there non pancreatic causes that can do stuff like this?
Stuart Akerman
24:58 Yeah, and that's the idea we talk about when you see when you see any kind of provider about building what's called a differential diagnosis. So differential diagnosis being these are the, all the things in the realm of possibility might be going on. And we need to have a plan of attack to figure out which ones make more sense and which ones don't. And in this situation, you got to think about IBS, you got to think about celiac disease, you got to think about bile salt diarrhea, then there's your sort of very random ones, like neuro endocrine tumors, IBD doesn't really play in usually, in most cases, but if you have some mild Crohn's disease of the small bowel and may be essentially causing a malabsorptive problem, the symptoms might overlap. And that's where the art of medicine really comes in. You know, rather than saying, well, why don't we just test for everything and see what sticks. You really sit there and take everything into account of your patient. So that you can make a more focused differential diagnosis. How often are they going? What does it look like? Is it waking them up at night? What medications are they taking? Is there something new or different that might be causing the problem? Have they recently traveled? And you take all that into the hopper and see what comes out.
Ken Brown
26:18 Now that is an absolutely great answer. So there are non pancreatic causes. So if you're having something like this, go to a very experienced board certified gastroenterologist to ask all those questions and figure out where, okay, so now the patient's seen you, you've asked the questions, you're still very suspicious. What do you do with the patient then if you're still concerned that this could be epi exocrine pancreatic insufficiency?
Stuart Akerman
26:46 So nowadays, there's actually a really nice, really easy test that you can do as sort of your gateway for epi evaluation, and that's called a pancreatic elastase. It's actually a stool study. To sort of say it in a quick blunt way, if your pancreas is working, you should be making so much excess enzyme that you should be pooping it out. And we would love to test that. And basically you send a stool sample, they check for this pancreatic elastase. And your levels should be really, really high if things are working well. You should be doing so well, your your pancreatic elastase rich. But if that number is coming down, if that number is lower, that's a sign that you're just not functioning appropriately, you're not able to produce enough to meet demand. And that's where the concern for epi comes in.
Ken Brown
27:40 So a couple things I love about that. Number one, you said we would love to test that. So for everybody listening, when you see a gastroenterologist, and you go, oh, I'm so embarrassed about talking about this. No, we love to hear that because when you go, doc, I don't want to. I'm super embarrassed, but when I go poop, it looks like you poured olive oil in there, I'm like, yes, do you have a picture of it? That's awesome. Let's talk about that. So when you say we love to test that, the beauty of elastase the test that researchers have figured out is that it remains essentially intact. Elastase one remains intact through the digestive process. So your pancreas puts it out and you can look at that. So when you're low, you're definitely low. It's not like your body's absorbing it. It's that it should be in the stool, one particular part of the elastase. So pancreatic elastase. That's awesome. Because for boards, meaning like when all of us take our medicine boards, they always ask the really hard questions like, hey, you're worried about chronic pancreatitis? Should you do these other invasive tests? So you've been trained in all these invasive tests, one of the few doctors in the DFW Metroplex that have I think there's just a handful or however many of you guys exist, which are the advanced endoscopists have actually been taught this stuff. So in case you're at an academic center in case you get an elastase, which is up is there ever a reason to do one of these invasive tests?
Stuart Akerman
29:03 So if the elastase is up, that's normal.
Ken Brown
29:05 I'm sorry. Low, yea low.
Stuart Akerman
29:07 Yeah. So just to just to clarify that, so if it's up, that's where you want to be, right? Like I said, you want to be elastase rich, but if it's a low, because the most common reason for epi is chronic pancreatitis, and often on the standard cross sectional imaging studies like CT scan, and MRI, the only way they're really diagnosing chronic pancreatitis is if you have some of the signs of full blown advanced pancreatitis like shriveling of your pancreas, or calcification, so if you don't have those, it just means that you we know you don't have advanced chronic calcific pancreatitis, but it's a spectrum of disease. And we don't know if you've got mild or moderate disease just based on an MRI or CT and that's where endoscopic ultrasound comes in. Because endoscopic ultrasound where we're using endoscopy with an ultrasound probe attached to the bottom allows us to look at the pancreas from the inside sort of to get almost to...
Ken Brown
30:09 Let me clarify here so you've got our standard endoscopic equipment. And on the very end, a very really cool special tiny ultrasound. So if you have ever had an ultrasound on your gallbladder from the outside or if you've ever had a baby and they ultrasound, you're taking an ultrasound inside the body which is...
Stuart Akerman
30:31 And you say it a lot more eloquently than I do. I usually just say it's a endoscope with a little nubbin on the tip. That's an ultrasound.
Ken Brown
30:40 Well, I mean, the reason why I think you always downplay this particular aspect but even me as a gastroenterologist, I call you up all the time and I say, hey, I've got this does this warrant an endoscopic ultrasound and I would do that with some other partners in our group, Dr. Goldsmith, Dr. Bob Anderson. People like that. I'm like, hey, I have a young man for no reason developed pancreatitis doesn't warrant an ultrasound. And the reason why I bring this up because a lot of people never talk about this. It's a very relatively safe non invasive procedure compared to other things to do.
Stuart Akerman
31:13 Yeah, when I speak to patients, I pretty much tell them the risk profile is no different than having a regular endoscopy. There's no risk to your pancreas from the ultrasound waves. They're just sonic waves. So we don't have to worry that by evaluating we could potentially cause trouble.
Ken Brown
31:31 Yeah. So when I see these commercials ask your doctor about epi. The next thing they should say is either I'm gonna learn about epi, or I'm just gonna send them to Dr. Akerman so that he can figure out if it's something that needs an eus or not.
Stuart Akerman
31:46 Yeah, and I love talking about it. I you know, it's not to say that every single person who walks into the office and says, do I have epi. I'm going to go say, well, let's run the gamut. Let's do every test. Let's figure it out. You need an endoscopy before I can answer that, I'm gonna sit there and talk to the patient and get a sense of is this diarrhea or not? Because probably one of the more common scenarios is they don't actually have diarrhea. They might have some mild bowel habit changes, that to them feels like it's diarrhea, but you can tease out right away. Maybe it's a supplement, maybe they're taking a sugar substitute that doesn't agree with them, and they're mal absorbing it. And if by pulling that out, all of a sudden, magically, their stools are better. You know, there's not not every time is the diarrhea warranting of this large workup. But the flip side to that is patients who have carried this diagnosis of IBS for years. Well before we had good endoscopic ultrasound, well before we had pancreatic elastase and some of the other stool tests that we use nowadays, it might be that in 1995, that was the best we could do to say hey, you have IBS. And now, in 2020, we have a lot of a lot more tools at our disposal to maybe fine tune that and get them the right diagnosis and therefore a better treatment regimen that's going to make them feel better.
Ken Brown
33:12 Absolutely. So I have these people that come in and we, I ask all those same questions and we go through that, did you have a significant change? Remember that some of the other non pancreatic things like bacterial overgrowth, SIBO can actually cause...also. So now this kind of comes to the point of okay, we've talked about what it is we've looked at how to diagnose it. And now I'm, I'm my question to you, because I'm obviously biased, and it's a leading question here. Why are the drug companies spending? I'm gonna say, I mean, we advertise and I know what it costs to advertise, I'm gonna say 10s of millions of dollars, saying ask your doctor about epi, why are they doing that?
Stuart Akerman
33:53 Well, I mean, you know, death to leading question. You know, there's money to be made, right? Anytime. There's money to be made. But I think one of the biggest reasons is, is that it's been so low key and under diagnosed for so long that the potential for a patient base that doesn't even know they exist, is I don't want to say infinite because there's only so many people, but it's vast. So all these people who may never have been brought to get one of these pancreatic enzyme replacements, and therefore not spend money on a therapy that potentially could help them, all of a sudden, now the curtains are drawn, right, the doors are open, and they have this whole new potential patient base to help.
Ken Brown
34:41 Absolutely, much like celiac disease where we said, Oh, it's so rare, and then we realize, Oh, no, we went from, you know, .04% of the population to 1%, to oh, possibly 3% and so on and so on. So I agree with that. I also did a little experiment here. The pancreas, the pharmaceutical pancreatic enzymes. which are available can be a little expensive. And that's something that I think it needs to be addressed here. Because if doctors go oh, this sounds like I think my opinion is that these commercials are drawn to say if you have change in bowel habit bloating, talk to your doctor about epi. That's a loaded question. You're telling the patient to drive the doctor and say, well, I don't know what the heck, let's try it. So on good Rx, if you pay cash, the starting dose of the major pancreatic enzymes, which are porcine and bovine derived, meaning pig, and/or cow derived, this was a little shocking to me, it's basically about averages to about $10 per pill. So if you start out the starting dose, that's going to be $2,700 a month, if you go to the maximum dose, that's going to be $5,400 a month, cash price, lots of things involved. Fortunately, we both work with these companies and they do amazing jobs of trying to give refunds and things like that. So kudos to that. I'm a little bit scared that they're going to get a bunch of doctors that knee jerk and say well try this and see what happens. That's one of my issues.
Stuart Akerman
36:07 Yeah. So I do think it's important to have a diagnosis to be working with, rather than the let's throw it out them and see if it works approach, specifically for that purpose because it's expensive. But if you know that it's going to get your patient the symptom relief that they need, you're going to fight for that patient, you're going to talk to their insurance company, you're going to talk to the pharmaceutical company. They do like you mentioned, they do have robust programs for patient assistance, but that doesn't cover everybody. If you're going to them and saying, hey, I want to see if it works, it's going to be hard to justify spending $2,000 a month on that. But if you go to them and say hey, this lady has a pancreatic elastase that's super low. She's got all the right symptoms. On imaging. It looks like her pancreas doesn't quite look right. She's got mild or moderate chronic pancreatitis, this is your patient. This is the patient that's going to derive benefit from your drug. They want that because it does cut both ways. Right? You have a patient that does really well, that patient is going to tell everyone about how awesome they're doing on this drug because they got the right diagnosis. That's gonna help them just as much as any marketing they do on Facebook or Google.
Ken Brown
37:26 Yeah, absolutely. Now I'm gonna ask you a question that I don't think there's an answer because I tried to look this is more of a opinion. I get asked all the time by my patients. Well, do you want me to try this I do a lot of sampling and pancreatic enzymes because I believe that there are other these extra pancreatic causes which can actually affect your pancreatic enzymes. And they will say oh, I'm already on this life extension digestive enzyme. Look, here's the label it has it says it has lipase says it has tryptase says it has amylase I have contacted them. I've contacted the pharmaceutical companies and I'm like, can you please give me a statement to define plant based digestive enzymes versus the pharmaceutical bovine and or porsine? Have you ever thought about that before?
Stuart Akerman
38:17 So I have, and I can't answer it. It's gonna it's gonna sound like I'm skirting the issue. The short answer is I can't. But what I can say that I've seen with many of these, when patients come to me and say, oh, I have this naturally derived one that I'm using, very often, the amount of enzyme that they're taking is significantly lower than what we know they need. So we talk about standard dosing in the order of thousands 70,000 100,000 units with each meal. And in many of these, they'll show me yeah, I'm taking a hit. Four capsules, and each capsule has 1000 or 3000 units. So they're getting significantly under dosed. And this is not unique to say, oh, you know, plant based ones are just not quite as strong as some of the other ones that are produced by the pharmaceutical companies. I get this from second opinion and third opinion patients sometimes who say, I have chronic pancreatitis, I have pancreatic insufficiency. The enzymes don't work for me, what am I doing wrong? And eight out of 10 times nine out of 10 times the answer is really simple. You're under dosed. Because we're not trained as as as patients to think I need to take six or eight or 10 pills a day for this problem. We want the one pill or the one pill twice a day. And that's how we're conditioned to think is a standard regimen which is true of most medications. But in this situation because the problem is every time you eat you mal absorb, you need to take something every time you eat. And if we gave you the correct amount of enzyme in one capsule, you'd choke on it because it would be huge! So we got to break it down and give you smaller capsules. But it's just math. So you got to take enough capsules to give you the amount of enzyme you need with each meal.
Ken Brown
40:26 That is great. That is a great answer. All right, Dr. Akerman. I think that we have taken on a pretty big topic and done it in a relatively quick expeditious manner. I want to thank you so much for taking the time. Where can people contact you because they're right now going, I have that somebody's sitting on a toilet, eating a hamburger smoking a cigarette going, it's sticking to the bowl. Oh, man.
Stuart Akerman
40:50 Living life.
Ken Brown
40:53 How do they find you?
Stuart Akerman
40:55 So the easiest way is to go through my website. It's www.stuartakermanMD.com. And there's a an appointment tab and a contact us tab. Either one works great and my staff will get the request and contact you right away.
Ken Brown
41:14 And I will say that we are part of a great group digestive health associates of Texas and we funnel or at least in this area, everyone funnels these tough cases. Dr. Akerman and you're obviously getting a great idea of his personality and he treats all his patients phenomenally but he's also endoscopically fantastic. I want to do a quick shout out once again, I mentioned him earlier but Rob Wolf, author podcaster and influencer. He, I loved that he did a whole episode on epi but more than that, I want to shout out to him because my son at this tournament in Wichita Falls, it was 103 degrees. The heat index is 110 and my son uses his lmnt element, electrolytes while he's out there hitting. So maybe that's one of the reasons why a 15 year olds taking on a 21 year old so thank you at Rob Wolf. And finally go to kbmdhealth.com. Download a free understanding your endocannabinoid system, even if you don't want to understand that the reason why is because then we can stay in touch. And you can ask questions like this like, hey, can you ask Dr. Akerman should I be worried that there's pancreatic cancer in my family? Hey, can you ask someone so we have access to experts, we can do this. Can you ask Rob Wolf, I want to do a keto diet. What do I do with this? So these are ways to stay in touch we want to interact. As always, whenever we mention anything, we're two doctors, but we are not your doctor. So this is for advice for entertainment. If you do have any of these issues, please discuss with your doctor. We are not giving medical advice. And finally, much love to everyone that listens to this, watches this. And please share, like, do a little thumbs up on wherever it's supposed to happen, like all the podcast platforms. So all in all, I think this is a great way to clarify something that has been very vague in the mainstream media. Thank you once again, Dr. Akerman.
Stuart Akerman
43:13 Thanks for having me.
Ken Brown
43:15 Bye, everybody. Stay safe.
Transcribed by https://otter.ai