COVID Recovery & Rehab Series: GI and Hepatic Manifestations of COVID-19 with Reem Sharaiha, MD!: Wednesday, 7/22/2020




Evening, ladies and gentlemen, welcome to another edition of the ultimate pulmonary wellness lecture series 2020 slash COVID recovery and rehab series. My guest this evening, in addition to your friend and mine, best lawn white and your leader and mine. Karen Bishop is dr. Reem Shariah. Dr. Shariah is a gastroenterologist from Weill Cornell medical center and the author of gastrointestinal and hepatic manifestations of the 2019 novel coronavirus disease in a large co cohort of infected patients from New York clinical implications. Welcome to the show dr. Shariah. Thank you so much for being here.


Thank you for having me and thanks to all of you for also being here. That means a lot to me.


So, you know, a lot of times we hear stories, we hear reports about things, we hear results, and it’s really hard for people to know exactly what they mean. We hear numbers we hear statistics and I think that often people don’t really understand the GI system. And I think that very often people understand even less about the liver. If you could just take a few minutes to start us on the right foot and just walk us through the GI system as if we were a Skittle that just got placed in somebody’s mouth.


That used to be my favorite story when I was younger. Just sort of describing what would, yeah. That’s when I realized I wanted to be a gastroenterologist. So obviously I’m a gastroenterologist at Cornell and what that essentially means is that you need a colonoscopy. Once you hit 50 you’ll come and see us. So we basically, for the lack of better terms are glorified plumbers where we stay either tubes, stents, things up above and below people. So from either end but, but sort of seriously speaking it’s the GI system basically starts from your mouth and ends in the toilet. So you go from sort of the AIDS to Z and it basically as your mouth, your the two peer called the esophagus that the food goes down where you get reflux, that’s the area where you feel reflux the stomach. And then the small intestine that helps digest and absorb food. And then the colon where stool gets formed and comes out and the liver is kind of the garbage disposal delivery. Doctors will probably hate me for saying this, but basically it’s purifies things and turns it out. It helps absorb it’s outlet. It helps also with absorption and it has several other functions, but basically when the liver gets blocked, that’s when you become jaundice. So you’ll notice that with your eyes getting yellow or your skin getting yellow.


Thank you. And what are some of the more common conditions related to the GI system that you and others were seeing related to COVID?


So the main thing that we were seeing, which prompted the paper that we did was a lot of people would have diarrhea and and they would feel nauseous and diarrhea, but no one initially attributed it for, to Cove it. And what was interesting, we would have these daily briefs from our CEO and CEO of the hospital and the infectious disease people. And we were seeing it at a per person level. We’re seeing the diary and we’re seeing the nausea and they were telling us, and not just them, but like everyone was telling us, this is not a finding of COBIT ignore it. And when you look at people’s charts, when you started doing that, you’d see them coming in with a shortness of breath or costs and things like that. And when you look and take a deeper history, they had already started with two weeks prior or a week prior to that, then having like the diarrhea and nausea.


And I see a lot of people sort of nodding their heads. And so that made us think that there obviously is some of that. And then at the same time, sort of let’s say March, end of March, a couple of studies came out of China, sort of saying, Oh, we do have GI manifestations. Meaning people do have GI symptoms and the most common being nausea and vomiting and diarrhea, but then the lack of tastes and lack of smell were also there as well. And those together are what we sort of commonly say are the GI effects of COVID.


Do you view the lack of taste and smell being neurologic in origin or what? I mean, I know there’s a lot of stuff that’s still unknown. How, how is that explained?


It’s probably neurologic because, and I don’t, I think it’s going to take awhile for us to get the answer because you’re not gonna look at the brain unless the patient unfortunately passes. And then even then there is always the risk of passing on the infection. If someone does a poor postmortems, it’s a little bit like grim to even talk about it. But I think we’re still a ways away of, of really understanding it, but what I’ve seen and obviously I’m like one person, but when someone tells me that they’ve had the lack of taste and smell, it’s obviously something to do with the virus hitting this sort of area where you have a, where you breathe, where you smell or you taste. And that’s where it’s mostly connected to the brain. So it definitely affects that parts. And that’s definitely very specific for COVID.


A lot of people are known to presented with only GI system symptoms. How, how do you explain that? Like, in other words, is there another way that it gets into our system besides the inhaled route or B besides the mucus membrane route?


Well, it’s, it’s probably the same, right? You’re you’re inhaling stuff. So if you think of where you swallow and where you breathe, they’re two, two sort of very closely connected and you know how sometimes like, ignore the it’s a little bit disgusting, but if you can swallow your snuff essentially, right? Because you, you, you, it goes in the same track, it just goes one way or the other. And it just, just thinking about it that way the virus does the same thing. So there couldn’t go into your lungs or can go down to the the GI system and technically speaking, there’s something called an ACE receptor, that’s in your lungs. And that’s what everyone thinks COVID attaches to. And that’s why there are certain medications that people think that if you’re on it prevents COVID or prevents you from getting severe COVID. But the GI system also has a receptors. The liver system also has ACE receptors and the kidney also has AIDS receptors. So the virus kind of is what I, the only way of thinking about it is like this little stick snot that is just attaching to anything that has an ACE receptor. And the GI is just one of those manifestations.


So at the same time that we were starting to see COVID cases here in New York, did you also see kind of a rise in GI cases that you just thought were coincidental or like, was there a period when you did an associate it with COVID, but we were thinking, well, why are we are all of a sudden seeing so many people with diarrhea, nausea, vomiting.


So it’s probably more the second part. Like, we, we, we, we, we, we didn’t act at a hospital level. I mean, a lot of now looking back, there were a lot of patients who presented to the GI doctor and I, I had to actually one of my friends telling me that she had a lot of GI symptoms and then her daughter got it and her husband got it. And I was thinking, Oh, this is so strange. It could be COVID, but they there’s no age. She can’t get tested because it was too early on, which was, I think the most frustrating part of all of that. And and then we started seeing it more and more. And then from the inpatients, once that started manifesting, meaning like people would come in, they’d have severe shortness of breath. They’d have, they’d have a diagnosis of COVID and then you look back and then see the diaries. That’s when sort of people started realizing that it’s more common than people thought. And I even think to now, I mean, we reported it, but it’s probably very under reported than, than what we know it’s from. And, and it definitely precedes a lot of the other symptoms, I think.


So I have a sense that, you know, as this were any other time in history, so many of the patients that came to the ER, would have been admitted and many of them would have been admitted to the ICU. But it seems like, you know, unless you were imminently going to die within 12 hours, you were kind of sent home to, to manage this on your own. So a lot of stuff it seems got missed, and that is a particular kind of complaint and comment that I hear, especially from the long haulers. So my question is if people have these GI symptoms, what would your workup look like? So someone comes in, I’ve been nauseous, throwing up diarrhea, et cetera, et cetera. What’s where does that begin for you?


I mean, as a GI doctor, you also have to think of everything else and common things being common at the time of whatever. So if this happened in March or April COVID would be the thing. And now we’re sort of at the dip from where we were. So you start thinking about other things like mostly food poisoning, right? That’s the most common noro virus does that too. And in January, my daughter’s school shut for three days cause everyone got it. So that, that, that being said, I think if someone has symptoms and no, no, no food that’s related to it. And then someone else gets it, but not immediately, like five days later, another five days later, then you should have alarm bells to think about COVID. I mean, it’s really sad what you were saying about the, the the hospital and the ICU admissions.


Cause obviously we saw it and I don’t think even me as a doctorate, like there’s all these timelines in our head where the week before everyone was saying, yeah, it could get worse. That I’m my mom was here and I was like, I spoke to one of the pulmonary doctors. I was like, so we shouldn’t be going to a restaurant. And it just didn’t hit. I think you just, we didn’t see any patients at that point. There were two people in the ICU and everyone knew about those two people. I mean that lawyer newer shell, everyone. Yeah. Everyone knew his story knew he knew who he was in contact with. That’s how rare it was. And then literally within two, three days that just the numbers just skyrocketed and it’s really scary. And, and I think everyone was so overwhelmed that probably bad decisions were made. Like not, not, not in a very good way. And I think my hope is is that everyone recognizes it and, and that we’re more prepared. And hopefully we never get to this stage where we’re relaxed more prepared next time. But you know, the, the fact is that they had to up the ICU numbers make make an day endoscopy suite where we work, make it an ICU make other recovery areas. ICU just goes to show you how Latin, like poorly equipped we were all. At the time


What’s so crazy about it is like, as we look around, you know, this screen and we see all these people, there are people all over the country here. So it’s like, they’re hearing us talk, we’ve quieted. It. I’m like this people who like this wave hasn’t even begun yet. And it’s scary. But I was wondering, do you think that the lunch lady at your daughter’s school had anything to do with that situation? You were just,


I mean, there are a lot of talk about chicken nuggets and I was on a WhatsApp group with all the moms. I was like, guys, it’s not chicken nuggets. It’s it’s norovirus. And they initially didn’t know that I was a GI doctor. And they were like, who is she to tell us what it could be? It’s the Meghan. But it just, it just, it just fit that timeline. But it’s even now, like, at least now, I mean, I, I, wasn’t tested obviously at the time and you have this whole thing, like we’re going to see our family. Should we get tested? And now it’s so easy to get tested in New York. Obviously there’s this new backlog of waiting 10 days. And we’ve had to send our reagents to cut to like down South where they need it more where we would have a rapid test within two hours. And now they’re, we need to give that away to other places that need it more. So that’s scary that we’re still in America and we still have the like ration testing, which doesn’t make sense.


It doesn’t, I’m still thinking it could have been like a norovirus infused chicken nugget. But now a lot of people here are 20 days, 40 days, 60 days, 80 days, anyone more than 80 days show of hands more than 80 days. We’ve got people at a hundred days here who are still experiencing GI symptoms and who are still having difficulty seeing a specialist. What can these people do? And what should they ask for?


It’s crazy. I, that there’s so much we don’t know. And if anyone tells you that they know everything, they’re probably lying. But if you think of a normal GI upsets like a food poisoning or some sort of virus that goes into your system, it wreaks havoc, and then you normally have good bacteria that lines your stomach, your colon, and the intestine that helps you absorb food. And that also, so to speak gives you farty, right? That’s how people find this from the bad bacteria or the good bacteria in your system. But what happens with COVID for instance, and other viruses, is it wipes all of that out. And so then you’re left with either bad bacteria or just a bacteria. That’s not your usual. And so that can, you can start having symptoms of like intolerances to normal things like milk yogurts like all the lactose stuff like cheeses, you just can’t tolerate, you feel bloated.


You have a lot more irritation and cramping, and that might last up to three months down the line. And this is not based on COVID research. This is based on infections that happen that caused it in the GI tract. And then that’s what would happen afterwards. So I think it’s, it’s definitely there. I think there should not be. I think the other thing I was going to say, and I started talking is that like one of the nurses, when we kind of went back to work we were pushing a cart to scope a patient F on the, up on the unit. And she’s she was short, short of breath and I was like, Andrea, what’s going on? She was like, well, you know, I was out for a month and I said, you shouldn’t be back at work. And she was like, well, they cleared me.


I was like, I don’t care if they cleared you. You’re still short of breath. And now we’re now in June. So three months for her, she’s only starting to feel better. And that’s what scared me is that like, she’s, you know, healthy, no problems. Everyone says like, Oh, it should come and go. And it shouldn’t be an issue. And you see that, okay, she’s a survivor, but then it’s a survivor with all these other issues that will take a little bit longer. We’ll take a little bit longer to heal. And I think that plus the GI tract is it’s going to take a lot lower, but now with all the, all the good thing of COVID is it opened up the option of telehealth and video visits. So there shouldn’t be a wait to see a doctor, like someone should be able to be seen in 24 to 48 hours.


Is there anyone having difficulty being seen in 24 to 48 hours show of hands. Okay.


Right. And we need your name and email and we’ll make sure that should be sorted out, especially if it’s GI I’ll take care of that. We’ll we’ll, we’ll do that.


Perfect. Per anyone on page two, just to show hands one more time. Is anyone having difficulty being seen? Okay. So people are getting seen. What about over the counter medications, diarrhea, nausea, vomiting. Should, should we be going to CVS or should we, should we take a shot at managing it ourselves?


I mean, you can, the problem is is that if it’s something else and you’re treating it, you’re always gonna miss that option. So I would definitely call, I mean, common things, being common, the things that you should make sure that you’re doing is that if you’re having a lot of diarrhea and nausea and vomiting is drink lots of fluids, Gatorade, Smartwater, anything with a little bit of electrolytes and just a blended diet, like bread, rites, that kind of thing. We thought that the brat diet and, you know, just something that will calm your stomach and nothing too spicy or heavy. And you know, something like Tums can, if you’re retching or vomiting that would help calm you down. But obviously if you call the doctor, we can prescribe anti nausea stuff. I gave it to my daughter when she, when she had the chicken nuggets scenario.


And that definitely helps if you’re having a lot of diarrhea. My sort of non GI kind of holistic thing is like wash you out. Let’s get rid of all the poison. But you know, obviously if it’s happening for more than a week, then we may need to give you some empty diarrhea, medicine and things like that. And obviously we need to rule out as a GI doctor that it’s not an infection. It’s not more virus. It’s not food poisoning where you need antibiotics and things like that. So definitely if you’re having symptoms that lasts more than 24 to 48 hours, we would need to know about it.


And what would be an indication that you need to see somebody in the office as compared to just a telehealth visit?


I haven’t, no. I mean, that’s definitely changed that definition has been pushed and pushed and pushed because during the two months of the height of the pandemic, we were very strict. And a lot of things for me for instance, is we get a lab, a CT scan and then do a procedure for instance. But if someone’s having severe pain and you’re not able to get a diagnosis, that’s important if obviously they can’t do a video visit. That’s also an indication. But it’s also, if the patient wants it, then it should happen.


Can we go back to the labs please? What kind of lab testing would be kind of standard standard procedure for a patient coming in with these symptoms?


So just a full blood count, which would look and see whether you have an infection or not. We would do inflammatory markers to look for any sign of high inflammation or not. And then we look at your kidney function because if you’re having a lot of diarrhea, you might be very dehydrated. And that can go up a little bit and we’d want to know that. And then we would look at your liver, liver tests, liver function tests. So those would be the base basic ones we would do. We’d also do stool tests, obviously if you’re having diarrhea.


So complete, complete blood count kidney renal tests liver enzymes. And what, what was the fourth? I’m sorry, there was one more




So, so, okay. So, and in front of me,


That’s a stool test, so obviously if you’re having diarrhea.


Gotcha. what about the idea of so you hear stories. I heard a story about one of the national parks where they thought there was no Corona virus. They tested the sewage and they found that there was Corona virus in the sewage. That’s a scary thought, especially in New York city. What do we have to know about that?


I think one thing that this virus has brought up is how honestly how dirty we all are. Because w w in the height of the fend demic, when I would go to work, I would put myself in a Ziploc bag where a set of scrubs go in and change into a different set of scrubs. My hair would be tied in a bun. Like I would do it like a ballet, but, and changed by shoes, change, everything, not touch anything, come out, have a shower at home. And I think everyone started doing that from going to grocery, shopping, picking up food. You just realize how many surfaces you touch, how many times you touch your face. And I think a lot of diseases that we as GI people deal with is, is hand to mouth. Like there’s a bacteria that goes into your stomach called H pylori.


Then you get it to be called it fecal oral trans transmission, because you touched your hand on something who knows where that’s been, and then you put it in your mouth. And I think you just realize how maybe not so often be washed your hands and how, how dirty the surfaces are. And I think if anything comes up of this is that you realize what you need to do. I mean, the sewage part is definitely concerning, but if you practice good hand hygiene, you really wash your hands. You try not to touch your face after you’ve touched something that could be a contaminant. That should be, that should be it. That should be fine. We, as GI people were worried because we’re doing colonoscopies and the risk of then getting infected that way, but it hasn’t happened. And we would have been the high, high enough concept for that to, to occur. I think what we’re practicing now with social distancing and masking definitely reduces that because it reduces the amount of times you touch your face, but not only does it do that, you realize you’re wearing a mask. You remember to wash your hands. So it’s becoming very habit forming.


Do you think in any way people have to be concerned about using a public bathroom? Do you think there’s any way that there could be transmission in that way?


So there was a study that came out saying that the highest rate of everything is in the bathroom and the toilet. And like when you flush, it’s like in there. So I, I, I would, I mean, I went to the aquarium with my daughter the other day and needed to use the bathroom. And I was thinking that, but when you need to go, you need to go. And it’s just, it’s, it’s a risk. We take it. And unfortunately for us now in New York and long Island, their risk is really low, but had we been in the height of the pandemic, I probably wouldn’t have used it. But now, you know, that the positivity rate in New York is about one to 2%, obviously we’re lagging two weeks behind. So who knows where that is, but I think that’s an important figure to come into to, to think about when, when, when you’re making those decisions, but yeah. Bathrooms, yeah.


Given, given the choice between having a chicken and rice on sixth Avenue and 53rd street, or using an airplane bathroom, which would you, which would you rather do?


Chicken and rice.


Okay. All right. Good to know. Good to know. Can you talk a little bit about anorexia in COVID because we’ve heard a lot about loss of appetite and anorexia in the studies particularly Chinese studies, but I don’t hear anybody talking about it on the news in the same way that they do other things.


Yeah. It’s just one of those symptoms that are, that was there that is reported on the problem with a lot of the studies that have come out is it’s all retrospective, meaning we know we had it, you go back and it’s basically up to how good the chart documentation is. So what I think, because of everything that happened, no one was there at the time, logging in the patient’s symptoms as they were reporting it. And that would have been the best kind of data. So it just comes up as, as a sort of, Oh yeah, they may have had anorexia, or they may have had nausea. My feeling is that that’s probably a manifestation. When you have such severe illness, your body doesn’t want you to eat. You’re feeling nauseous. You’re not going to want to eat. You have lack of appetite, lack of taste of smell, and that all sort gives you that kind of circle.


I’m always fascinated by what people felt. So I’ve always asked them, like, what were your symptoms? And some people just said, I just didn’t want to eat. Other people would have said to me that the lack of smell was such a a new symptom. Like they just couldn’t smell food, that they couldn’t eat it. It just didn’t, it doesn’t make sense. And that’s such a weird thing to happen to have, because it’s not a common thing. You can get a bummed up nose, but to have like the true lack of tastes and smells is very different.


What do you think it, do you think for people who have preexisting GI issues like, like one, one way I’ve heard and, and I started describing COVID is that, you know, it kind of capitalizes on your weak spot. So like any weak spot you have cov is gonna find it and exploit it. So are you seeing anything special with your, let’s say inflammatory bowel disease patients, your Crohn’s patients, your ulcerative colitis patients.


So, no, which is a good thing. Cause we were worried about that population being sort of what we call immunocompromised, because they’re not, they’re taking a lot of medications that lowers their immune system and obviously no study is perfect, but we looked at that and there are other studies that came out and I’m not a hundred percent up to date on all of those studies, but the ones that came out of Cornell showed no increased risk, which was reassuring to the IBD population.


And what is, what is the role of diet like for a lot of these long haulers, like they are grasping at straws. We want anything that is going to help us reduce inflammation, build strength, get back on the road. Is there a diet you recommend, are there supplements you recommend? Are there probiotics, prebiotics?


So I, my other half of me is not just GI. I do a lot of obesity work. I don’t do as much nutrition, but with, with treating patients with obesity, you end up treating a lot of that and, and you realize that what we eat now is not what we ate when we grew up. And I know a lot of over eating is processed. Food is not sort of real food. And I think just going back to basics like the real tomato and cucumber chicken meats, like that’s just in smaller quantities and, and that you cook or you can guarantee that no one’s added things to it. Just going back to basic will definitely have definitely not in nugget form. I mean, don’t get me wrong. I love my chocolate and my cake every once in a while, but, and I think that’s okay as long as, you know, what’s in it and all of that, but the fact that a lot of whoops, sorry, the fact that a lot of that wasn’t my cue to hang up, like the fact that a lot of a lot of what we eat has a lot of additives to it.


A lot of the chicken has hormones. A lot of the animals have been altered, so to speak, to increase consumption. There’s a lot of sugar that’s been added on to things I didn’t grow up in the States, but bread in Europe. And then the middle East tastes different from the bread here in the States. Cause there’s so much sugar added. And even as something as simple as that I think just going back to basics definitely helps. I’m not going to say go plant-based cause I’m a, I love meat and I do eat meat, but just instead of every day, once or twice a week chicken fish, protein, like all these basic stuff is more important.


I just want to say we’ve lost your video. So if you would like us to have it, unless you’ve somehow just joined witness protection program. Okay.


I’m back. Is it, is it working now? I see me on zoom. I don’t. Oh, page two. Apparently Karen told me I’m in page two.


There you are. Okay. You’re back. You’re back. Okay, awesome. Can we just for a few moments talk a little bit about the liver and like you, you don’t, I mean, we do hear about liver disease, but in, in this case I’m hearing about liver injury. So what does that mean when somebody? Yeah,


So so initially when all of this happened and even our paper, we didn’t really understand what all the manifestations were and how patients would present and what it all meant. But when, when we drew blood work from patients that were severe enough to be admitted or severe enough to go to the ICU, they looked at certain markers and the liver tests were up meaning something called the AST alt some of the Billy Rubin. And and then also the kidney function can go up. But specifically with the liver, we, the, the markers are not just specific to the liver. They can also go up in muscle injury too. So knowing you, whether it’s purely liver or muscle, or just a mixture of both, and now what we understand, it’s probably more muscle related than, than liver and more of a manifestation of, of just severe viral illness rather than the liver itself. But it definitely the, the virus can cause some sort of liver elevation. It’s just not as significant as what we, what we thought.


Before I ask the next question, I’m just going to let everybody know that if you like, we’ve opened up the chat. So if you have questions, feel free to type them in and I will read them to dr. Shariah. do you have a sense of, and I know this is like the big million dollar question, but do you have a sense of what longterm effects might be with respect to the GI system?


You’ll probably get, I mean, downstream, who knows, right. It, I don’t know if we’re going to have increased in number of polyps or GI cancers or anything like that, but I think over the next six to eight months, and I’d be interested to hear what other people feel. You’ll probably be, be more intolerant to food, the IBS, like symptoms, which are the bloating discomfort with certain meals. Those are going to go up more. I I saw a patient just last week who had COVID back in March and wasn’t tested and then got confirmed from antibodies. And since then he just can’t tolerate any of the foods that he normally eats. And, and, you know, it’s been two months and he’s still like that and we’ve done every other workup to make sure it’s nothing else. And and that’s what it, so I think that’s gonna last a little bit longer.


Do you think that’s mostly inflammatory based because I have kind of an idea that like, you know, I, I view it sort of as like a house that got full of seawater and it’s like that seawater has to receive, do you think, as, as people’s overall inflammation goes away, they might get some of their, their function back.


Yeah, absolutely. It’s that and then get repopulated with, with your good bacteria. So I think I’m, I’m testing him for a bacterial overgrowth. So I’ll, I’ll fill you guys in. If I find out that he has it, because then that would mean that may, you’re getting back to your overgrowth and you need time to get back to basics, but yeah, absolutely. It’s going back and he also feels better once he just has a no alcohol, no spice, very blend diet. So it just goes to show you you’re exactly right.


And do you think people should be taking probiotics?


So there are a couple of studies that have shown no benefit whatsoever, but you know, as with everything, you’re going to find something that’s going to show benefit and something that’s going to not show benefit. And what I would say is that if you’re eating a healthy diet, having lots of yogurt, things like that, then you don’t necessarily need it. But if you need to supplement it, there are certain approved ones that you can get a prescription for. I would do that. There are some that you could sometimes, like what I tell my patients, if you have yogurt that has prebiotics and then why not just take I don’t think it’ll cause any harm as long as you’re not immunocompromised. So meaning you don’t have, you’re not on chemotherapy or not on any other medications that lowers your immune system.


Do you like VSL three?


I do. That is one of the ones that we prescribe as well.


Are there others that you might recommend to me?


The lactobacillus one, but the VSL three is probably the one, the most common that we do. And there is another one that I’m blanking out that my nurse practitioner says she gives to her kids. So maybe I’ll not, it’s not a line, it’s something she got off of Amazon. But I’ll, I’ll email that to you and you can,


The Flintstones probiotics, she’s embarrassed to tell you. So I’m going to go to some questions that were emailed to me. So two years ago I found out I have mild fatty liver fast forward to the beginning of June. When I do an ultrasound to find out I have an enlarged liver. And in may, my liver enzymes went preserved. Question does having a fatty liver predispose you to liver damage? Once a virus like COVID has attacked the liver, I’m scheduled for a fibro scan in the next month, my levels have returned to normal, except my alt, which is 48 as of mid June. So let’s start with, does having a fatty liver predispose you to liver damage?


Yes. So what it normally, if you want to think about it, two ways, the liver looks like a Brit big Brown triangle, and then if you have fat within it, just think of like your sirloin steak that has like a little bit of fat around it, and that can just make your liver a little bit bigger. And so on ultrasound, you would see that the liver is a little bit Bakker or on any type of scan, your liver numbers can go up a little bit. So they could be in the 45 50 range at that point normal being in the twenties and what could happen, which would be liver damage or what we call fibrosis or cirrhosis is that the liver gets bigger. It gets fattier. And then it becomes fibrotic, meaning it becomes very stiff and all of these sort of progressions from normal to fatty to fight neurotic, fibrotic, meaning stiff.


They can still be reversed if you lose weight and you don’t need to lose a lot of weight for that to happen, you need to lose 10% of your total body weight. So that means if you’re 190 pounds, you lose 19 pounds, the liver gets better. But what could happen over time is that that fibrosis can change into cirrhosis, which is what you hear about when people have liver transplants and liver damage and liver failure. So it’s now becoming in this space, one of the most common causes of liver transplant and liver failure is, is people with obesity because they’ve had liver, fatty liver. So it’s definitely something that you want to tackle and treat. I suspect that the question that happened is that when they got COVID, they got probably an elevation in their liver tests. And that’s the wacky stuff that you were talking about. And now the 78 is probably now going back to baseline. So it’s still a little bit high. It’s not as high as I’m assuming in the two hundreds or three hundreds, when, when that person had COVID,


Were you seeing people who had kind of like an expedited like sort of development of liver problems, like with the respiratory system, a lot of people develop fibrosis. You never had any type of respiratory issues before. Are you seeing similar sequella with the liver or


Too, too early to tell we don’t have that. I think with lungs that the good or bad about lungs is that if you have shortness of breath, it’s very noticeable. You can’t walk up the stairs like that nurse, for instance, she just couldn’t breathe. With the liver, it needs to be fairly damaged before you start seeing those manifestations. So it could be silent. It could be something that we won’t see for another year or two.


Gotcha. Can you talk a little bit please about reflux? Because one of the symptoms that we hear from people are, you know, this burning in my chest. And I, you know, I always say it between the neck and the belt. Like we have a lot of systems. We have the respiratory system, we have the GI system, we have the cardiovascular system. How do you know what is, what and what, what are you seeing with respect to GERD? And how can we distinguish that from, let’s say a cardiac issue.


So it’s very difficult to let of times we get referred. We get referred patients from the cardiologist. Who’ve had chest pain and it’s not cardiac. And, and vice versa, someone would come see us with a pain here in the chest, and they say, it gets, gets worse after food. And then you do a full GI workup and realize it’s actually, it’s actually a, the heart. And as much as it pains me to say it, the heart is more important than the stomach. So I think the most important thing would be to rule out any heart heart symptoms first that those would be things like if you’re walking, you get chest pain or chest discomfort, if it’s on exertion or you’re doing something that you normally do, and you get that, that you need to think of your heart if you’re having a meal and you lie down and get sort of a soreness of burning, that’s more likely to be food related and acid reflux. But again I would err on the side of ruling out the most important things for us, rather than saying I’ve got heartburn, and then you end up needing, you know, something more serious than that.


Yeah. I always say, if you treat it like the heart and it turns out to be that bean burrito you had at lunch, no harm done, but if you assume it’s the bean burrito and it’s really your heart, that’s a problem. Next question, as somebody who’s had COVID-19 and also has hemo chroma, ptosis, hemo Chrometa chromosome ESIS, as well as intestinal metaplasia. I’m curious what dr. Shariah’s thoughts are on the persistent elevation of ferritin and iron saturation with the virus and how this might impact the liver is phlebotomy in order.


So that is a very good question. One of the ferritin is also what we call an acute phase protein. So it actually goes up in any type of sickness and in patients with COVID, it definitely went up. So it’s one of the markers that we looked at and you could see the majority of people had a high ferritin with hemochromatosis it’s a little bit different. The ferritin is from more blood being you know, having more blood and more blood, getting absorbed into the liver and causing that kind of liver damage. I think it’s going to be a little bit different, difficult, especially in the acute phase of knowing if the ferrets and being high is from the, the hemochromatosis, the disease, or from COVID that disease. And that’s a really good question. Cause I think, I, I don’t think there’s any way of finding the differences between the two, however, once COBIT gets better, the ferritin numbers should go down and if they haven’t gone down, then that means that it’s really the liver. And I would make sure that you go see that have fetologist that you’re, that you normally see and, or the, the blood doctor, the hematologist to make sure that you do get a phlebotomy at that point.


So a blood doctor and a reptile and amphibian doctor, a turtle doctor. Gotcha. Alright, awesome. So I want to just, if you could just talk for a few, I actually meant to start with that question, but if you could just tell us a little bit about your study, what you found, what, what you think it means.


So initially the reason we did this is because the GI doctors weren’t getting enough attention now. But it’s, it’s just at the time of COVID we were seeing things that weren’t giving that, that no one was giving us attention saying, no, it’s not related to COVID. You can do it in dos copy. It’s not going to be dangerous. You, you know, there were all these things that were happening. And then the study came out of China showing that patients with GI or liver manifestations beating the nausea, vomiting and pain had worse outcomes. So we thought let’s just look at what happens at Cornell. And what we did was we looked at all patients that came to Cornell from the beginning of March to, I think the date was April 9th. And then in a weekend, we literally just looked at all the symptoms and then followed those patients to see if anything could predict whether those symptoms would mean you’d have a better disease outcome or worse disease outcome.


And when, whether having the GI symptoms meant that you would stay in the hall, you would come into the hospital or be sent home. And so we had a total of sort of over a thousand patients that we looked at and we divided them into sort of inpatient and outpatient. These are patients that had GI symptoms and that were either inpatient or outpatient. And there was what we found was that when we looked at whether they had diarrhea, for instance, being the most common about 22% of the patients who presented to Cornell had diarrhea as opposed to like 67% had a cough and 67% had fevers and about 60% had shortness of breath. So the diarrhea wasn’t as common, but again, I don’t think it was something that was picked up a lot early on if you had any of the GI symptoms, you’re more likely to be admitted.


And those are like the anorexia that you, you, you talked about and the diarrhea, and then the lack of smell and taste. And so we looked at those numbers and that’s what that came up with. And then we looked at the liver tests and again the AST was significantly up in those patients that were admitted and the ASC, like I said, it comes from the liver, but it also comes from muscle tissue as well. And we found out that people with GI symptoms were more likely to be admitted to the hospital, but they were less likely to go to the ICU or or die of COVID, which was a good thing. So maybe that meant that if you have the GI symptoms, that might mean that you would have a less of a severe course. However, what we also saw is that if you had high numbers of liver tests or the high muscle injury tests and things like that, then your outcome, you’re more likely you’re like nearly twice as likely to go to the ICU.


So GI alone, better liver, worse prognosis. Yeah. Okay. as long haulers recognizing that there’s often a very wide range of symptoms and they can vary day to day, are there any GI hepatic endocrine tests that you can recommend including blood labs or anything like that, that people should just get, regardless of whether they’re having GI symptoms?


I think the main thing, and that’s gonna show is a lot of people aren’t scared of coming to get their, for instance, screening colonoscopy. And those are basic things that you should think about. Like the long haul is to look at other things that, that could get worse if you don’t get treatment for it. And one thing is that if you have a polyp in the colon and you leave it for a very little time, that could turn into cancer. So these are things that you want to make sure that we’re watching for making sure that you, you see your doctor when you need to be when you need to be seen. And then the second thing is what we talked about beforehand is that if you have any symptom that you’re not sure what it means, and, and you’re having those persistent symptoms do come see a doctor because who knows what it might mean in the future. Again, we don’t know the longterm effects of this. It’s a very new disease and we’ll learn from you as much as you’ll help teach us. Basically,


You had mentioned before the ACE two receptors what is the, like, what does that mean in English? Like as far as like the, the mechanism of damage to the GI system, what exactly happens to the stomach, et cetera.


So, good question. This is all just based on like pathology and what people think, but essentially if you, if the ACE receptor is all around the small intestine, and if you get the virus going in that area, you’re basically getting less room for food to get absorbed and water to get absorbed. And so everything just goes through the system. So there’s a lot of inflammation, a lot of swelling of the intestinal track. And that’s why you’re getting a lot of diarrhea. Just simply, let’s say easiest way. I understand it


Just, just irritation. So that, that leads to my next question, which also is, is similar. So why is COVID causing acid reflux and people, and could this be the cause? Could it be either the cause or the result of narrowed windpipe law or esophagus? Let’s say, because, you know, we’re talking about Sophos a lot, a lot of people talk about a lump in the throat feeling thoughts.


So there is, there are some theory, although it hasn’t been that there, the virus itself is gonna, cause I guess that’s the other longterm message is that it might change the motility or the movement of, of the esophagus and stomach. And by that, like when you eat, you have an organized way of passing that Skittle down your, your, your stomach, and then in the stomach, it mixes it up and passes it through the, the rest of the small intestine. There is some theory because we’ve seen it in other viruses where that movement becomes a little bit haphazard and so food doesn’t smoothly go down and it will stay stuck a little bit longer, or you get less of a delay in emptying the food from the stomach and more chance for the food to go upwards. I think it’s still too early, but a lot of people are interested in, in in that. So they’re trying to study it, looking at motility, which is the movement of food and the movement of, of the of the GI tract to see if that’s going to be affected.


We were speaking before about the possibility of picking up COVID from, let’s say, a food delivery or eating in a restaurant thoughts on that.


I think everyone is so paranoid and practicing a lot of social distancing and hand sanitizing and mass squaring and all of that, that, that shouldn’t be that should not be a concern. I mean, the only way we will find out if it truly is a problem is if we had seen a rise in the number of cases since we opened up restaurants and we haven’t really seen that and looking at Europe, they’ve opened up restaurants and bars and they haven’t seen a rise. So that’s very reassuring. Having said that I at the moment still avoid going into crowded places. I still order food, which I wouldn’t have done maybe in March or early April. But I think that’s safe to do at the moment.


And what about the use of things like ibuprofen and other ensades? I know that these are often associated with GI issues even without COVID. Are you seeing anything related to that?


So we actually also looked when other research based. So we did this, that, that main research that you talked to, that we talked about, we did some research on the IBD looking at that increase. And then we looked at the incidents of GI bleeds and there a lot of patients at the time when they were hospitalized with COVID were put on blood thinning medications, so that increased their risk of GI bleeds. And so to us, like if you can avoid taking anything that within the blood or Advil, aspirin ibuprofen, then we should do that. Cause that obviously if you do that too much, you can increase the risk of GI bleeds, obviously in the setting of needing to thin your blood for blood clotting because of COVID you have to do it. So the way you lower your risk of bleeding is to be put on anti acids.


Now there was a study that came out last week that said that people with COVID and anti acids got a worse outcome. And there are a lot of problems with that study. I think a lot of papers are getting published on COVID because everyone’s excited. And then also everyone doesn’t know what’s, what’s good, what’s bad. And so there’s any association comes out like the ibuprofen is bad for you during COVID hydrochloric, see chloroquine is good for you and, you know, and, and so forth. But the paper that came out saying that NT acids is not good for you. There were a lot of issues. And what we, as the sort of party line from GI saying that if you need to take antioxidants to reduce the risk of bleeding, then you should take MTS is the risk of side effects. Very, very small. And that study in particular, was it done in a, in a good way to really show that answer


And are those over the counter and assets that you’re talking about?


So you can take something as simple as Tums but there are over the counter now that you can, you can buy Nexium or [inaudible] over the counter. Those are the ones that help prevent GI bleeds as over the country. You’re only allowed to take them for seven to 10 to 14 days. But if you’re on something longterm to thin the blood, then I would suggest you get your primary care doctor of gastroenterologists to prescribe that for you longterm.


When I first heard that ibuprofen could worse in COVID, I thought to myself, what a great marketing campaign by Tylenol, I was like, that’s like the best possible. I was like, these guys are really know how to do it. I have one, one more long question. Then we’re going to go to speed round. So I got sick in March confirmed positive. COVID-19 pretty sure I got it from work. I work with the public at a bank and work with all walks of life. I had all the classic symptoms, but it primarily attacked my guts, not my lungs. I had diarrhea for 40 days straight went to the hospital a few times, gave me fluid, sent me home to follow up with the GI doctor. So I did the tests I’ve done so far are as follows colonoscopy, endoscopy, stomach emptying, study stool, elastase blood work.


My doctor claims the only he saw was stomach inflammation and continues to tell me that the symptoms that I can’t continue to have, wouldn’t be from stomach inflammation. So here’s what I deal with on a daily basis that I can not get relief from nor answers nauseated off and on it intensifies. Every time I eat my bowel movements are always loose, soft, and smell like sulfur or chemicals. And I always have a metallic taste in my mouth. It’s not normal. I’ve never had these problems before I got the coronavirus. I have many other weird things too. Like hair loss, acne ulcers. If you get this question, right, you’re getting a special prize. It’s not, no, it’s not. Are you with me so far? It seems like one of those jokes where like at the end, we’re going to be like, what was the name of the bus driver? It’s not normal. I never had these problems before. I’ve got the coronavirus. I have many other weird things, too. Hair loss, acne, ulcers, headaches, et cetera. The list goes on like the rest of the long house. But my predominant problem is the GI issues. My question is, what is wrong with me? How long is this going to add at last, what would cause self? Alright, let’s go with something that you might be able to answer. So what is wrong with you? But what causes sulfur smelling stool?


So that is what so that’s what we kind of were answering earlier on. It’s the wiping of your good bacteria by bad bacteria. And this can happen with any severe diarrheal illness. So people who go to Mexico, they call it Montezuma’s revenge, where they get like severe watery diarrhea. The kids get rotavirus and it gets really, really bad diarrhea. And that’s gonna wipe your guts and you want to think of like all, everything that you’ve built for the last 40, 50 years of your gut health, with what you eat, what you normally eat is completely wiped out. And so, whatever you’re eating now, your GI system doesn’t know how to handle it. And more than that, like these bacteria that were suppressed by your normal bacteria is acting rampant and those bacteria take food out and process them and digest them. And the way I think of them as like a cartoon type bacteria that eats food and then burps it out and the bad bacteria, it gives you that bad sulfur smell.


And that can take a while to get back. I think the main thing to do would be you’ve done. Like, it sounds like a pretty remarkable workup, which is w which is a full workup. I would just definitely make sure that you don’t have any other type of GI infection with the stool test. So just to make sure that all those have been rolled out infection, that kind of way. And then the only other thing I would add to that workup is a breath test to make sure you don’t have bacterial overgrowth. Cause that could be a fixed with another type of antibiotic, but it will help you out. And then just going back to basics with what you’re eating, kind of retraining your system and then avoiding lactose based products. So no milk, no dairy, no cheese for a period of a month or two, just to see how you feel with that.


One thing we’re seeing with exercise is that sometimes people will, you know, they’ll be fine, fine, fine. Just overdo it. You know, they’ll take one step too far and then they’re in bed for a week. This is very different than what we see with most of our patients. So one of our techniques has been to kind of scale people way back, way, way back almost to doing just breathing exercises. Is that something you would recommend like to go to like almost like a, a low residue or a low fi five nine.


So I, I was gonna say that, and then I thought maybe that’s a bit too extreme, but then again, who knows what the right answer would be. If, if you, if you had a, a severe illness, like a viral illness that I would say go back to basics, and if you Google FODMAP diet, I think university of San Francisco, I think, I think it’s one of the Californias does a really good explanation of what that diet means, what it means to just go back to basics avoid things like onions, like broccoli garlic, things that are going to give you more gas, and then you can build that up gradually. So yeah, you get really good analogy.


I also don’t mind telling you that if you’re wondering what the FODMAP we describe in detail, the FODMAP diet in my book, ultimate pulmonary wellness, because we think that it’s also really good for pulmonary patients in general. So Meredith lists from from Cornell co-wrote this chapter and it’s in there Shannon, and you can actually read it right on our website for free. And in about two weeks, you’re gonna be able to read it in Spanish if you want. So, alright. Time for the speed round. I seem to now that’s just where I realized, like I have 20 minutes before my dogs make me take them outside. No, I’m just going to go. I’m just going to go to the chat now. And the speed round is really, I try to ask and get questions answered faster than these people can type them.


Otherwise we’ll never get out of here, but we have a trick it’s like when you’re on a date and you have your friend call you and tell you there’s something going on. We have Beth who, if, if I give her the signal, if she hears me say, cool, cool, cool, good. She knows what that means. Turn off the chat. Here we go. I seem to be having success among others with a low histamine diet. Could we talk about that in the context of the GI system? Is it also it, is it similarly friendly, so low histamine diet?


Yes. I mean, basically it’s gonna relate. It’s going to decrease your empty, your inflamma inflammation in the GI system, and that’s gonna cause less acidity and less wood going up. So it should, should help with reflux.


That was nice and speedy. All right. Studies regarding FMT and COVID so fecal. I know it knows me. I know the first one is fecal and the third word is transplant. What’s the M




Or you start, hold on. I better look it up. Hold on. Let me, let me look it up.


I just, we just say FMT so long that I forgot. Hang on.


Okay. It is fecal microbiota transplantation. It was on the tip of my tongue, but any relationship with COVID.


So I think if the patient that we’ve heard from, if longterm, they had continued to have diarrhea, it may be something to consider. It’s too early to tell, but that could be something that down the line you could give basically you’re transplanting healthy microbiota from someone else, your relative or some other random person into your own system to repopulate it with the good bacteria. So it’s going back to, we need to go back to basics. So yeah,


But again, if I could just ask in plain English, what the FMT are you talking about? What, what is, what is


That’s the one thing in GIA cannot do? But basically so it started from a C diff, which is a condition that you get with severe diarrhea from being an empty being on antibiotics. And initially the treatment used to be going on a different type of antibiotics, but some people would get severe C diff that would never go away. And I don’t know how it started, but someone said, Oh, what if we put healthy poop into someone else’s body? Like husband and wife, or I lost everyone, but essentially it works.


You’re making me feel very immature. This ladies and gentlemen, I’m sorry. I have no excuse. I should be more of a chore, but


So essentially then you, after you get the poop from the friendly relative, you would put it in through a colonoscopy, into the other patient’s buddy and patients noticed that they got better. So


Do you ever ask a question and immediately after you found out the answer it’s a real thing. It’s a real thing. So okay. So is possible for the virus to cause nausea for four months or would you look in another direction?


I would look into another direction, but it is possible if we think that there is going to be an effect on the movement and motility of the stomach, it may be something that we’re just not seeing. If you think about it, we’ve only known this virus for three months, so four months at most. So if you’re still having symptoms, I would say I would come and see us because if it’s a manifestation of something else we need to know, or if it’s a longterm effect of COVID on the GI tract, we should know as well.


They had a local test site here the other day, but I did not go. Is there a pockets of COVID showing up since I have no symptoms? What do you think about not getting tested? If I could answer that, I would say if you have no symptoms and you have no possible exposures, don’t risk the test. I went for a test. I’m sure I got COVID from, from the test because the person pulled my mask down, put a thermometer in my mouth and took my blood. They didn’t have those tables. She put my arm on her PPE. I was like, what? I was like, if I didn’t have it before, I’m sure I have it now. But I think if, if it’s, if you haven’t been out and you haven’t been exposed, then I personally wouldn’t test. What do you think dr. Schreier, if it’s the opposite of that? Yeah.


I, I would tend to agree. I mean, it’s just now, unless you need to get tested for like either exposure to other people or if, if what you’re going to do will change management that then probably not. It’s just so hard with this disease to give a right answer, because you don’t know whether you’re going to be that asymptomatic person and you’re walking down the street, giving it to someone else. I mean, that’s the whole danger of it.


Yeah. I would say that the majority of the patients that were in our community before this you know, and I’m, I’m so thankful to say we haven’t lost a single patient that I’ve heard of in our, in our cardiopulmonary community. And you know, as I say, if there’s ever been a time, like this is the first time in history that people with respiratory disease actually have an advantage over everybody else because we stayed home. We socially distance, we were really careful. But it’s, it’s tricky. I think it’s tougher sometimes on people who have never been ill before never been to a doctor before. And then all of a sudden they feel like, you know, they’re, they’re introduced to this in a very hard way. Are you seeing decreased nutrition absorption in COVID-19


Not, not in like a healthy person. We don’t know, again, longterm effects. Like, I don’t know if, if down the line six months, eight months, they’re going to have decrease in absorption of certain vitamins. That would be something useful to study and look into what, where we’re, where we’re seeing some people who need more nutritional support are people who’ve been on ventilators. And then they have feeding tubes that kind of nutrition, but not anything to do with malabsorption the same way you would get it from, let’s say a gastric bypass.


Gotcha. Thank you. Do you have a favorite do you have a favorite, like nutritional drink or something that you recommend to people like I don’t want to name any, I don’t want to lead the witness, but


No, like one of the ensures or something. I mean, I do, I do the opposite. Like I tell people to do protein shakes for weight loss or as a meal replacement. So I have a list of them. I’m not sort of married to any of them. The main thing is to look at the amount of protein that they have and the amount of sugar that they have and make sure that the sugar ratio and the carbohydrate ratio isn’t super high. Remember sugar gets feeds inflammation, and that drives that whole cycle. So you really need to be on a, a low sugar diet. If you want to decrease that whole thing


For pulmonary patients, we recommend zero carbohydrate protein powders.


Okay. I thought for a second, you were going to say, we recommend a lot of sugar. I was like, okay, we’re not going to be friends now, but


No I can get along with anybody. So no sugar, no sugar. Do you recommend low histamine probiotics?


I am not a big fan of like, I think a lot of these are going to be fads and I’m not, I’m not that type of a person. I really honestly go back to basics. If you eat regular normal food, you can supplement it with, with things. I’ve, I’ve had a lot of patients who have certain probiotics or, or things that they’ve tried to tease bruise, and it works for them. I’m always intrigued to find out more. But I don’t necessarily recommend any, any of that in particular.


You know, what I think is going to be super healthy for people that I don’t think anyone’s going to talk about, but green tea and like Roy this and things like that. I think, you know, I think that just really good for everything. I had a dog who go ahead if I’m


No, I was going to say, I agree with you. I always say I’m green tea, mint tea is very good for the stomach and ginger tea is also very good. So if you do a combination of those ginger and mint decreases the contractility of the stomach, and a lot of patients who come with IBS, there’s some medications that have mint in it. Mid tea is perfect. I mean, I give it to myself if I’m having any GI upset. Again, it’s just something natural, their green tea, so many benefits. I guess


Wirehaired Fox terrier who had bladder cancer. And the doctor told me she had three months to live. I took it to a holistic vet in Jersey. We used to go two hours. He just bumped her up green tea. She lived for three years. Now this next one, I’m not getting any money from the company, but this is just my gift to you. If you want some really good teas, Republic of tea, Republic of tea, these things, they have every kind possible and they are delicious and really high quality. Next question is my constipation related to COVID or the Metoprolol and blood thinners. They put me on


Good question. Metoprolol can cause constipation not super common have led centers shouldn’t cause constipation, I don’t know if you’re not drinking enough as you normally would have. That would, that would be one of the reasons unless there is something else going on. I would definitely have that looked into cause then you constipation, you need to make sure there isn’t anything going on. So I definitely just, especially for that Cecil mine for, for it.


I’m sorry. I just lost my spot. Is, is, is low FODMAP. Good for IBS? Yeah. Okay. Is being celiac a higher risk for COVID-19?


There is an ongoing study. I haven’t seen results. I know the celiac center from Columbia was looking into this no data that I know of.


Okay. I mean, I, I, I say all the time, like people people want to, like, if you don’t have an exposure to it, you’re not going to get it. But you know, certain things that lower your immunity or lower your defense system probably increase a little bit, you know, so no matter what it is I suffer from IBS and find that stress makes it worse. Cause COVID is causing me a lot of stress. These days have to try and relax more, but it’s not easy. Agree, but you know where you can relax, it’s a pulmonary wellness bootcamp where we have meditation, Tai Chi and Qigong can cabbage kimchi and cucumbers really helped with COVID recovery.


So we were talking about kimchi yesterday and the endo suite. I said that my roommate in med school was Korean and told me that if I ate kimchi, he’ll make me smarter. So I ate a lot of kimchi, but but I think with IBS it’s that the gut brain connection is so strong. When you notice it runners get diarrhea, you’re doing something. Sometimes before an exam, you can get diarrhea, you get anxious, your body plays into it. And so I know you said it as a, as a joke, but really like the relaxation. I don’t breathe very often


Joking at all that serious about it.


Yeah. But I think


Let’s plug, but I wasn’t a definite no, I’m a big believer in it.


I, I mean, I’m the worst at meditating. Like my family always says, you need to close your eyes and be, I have a watch that tells me it’s time to breathe. And you’re like, no. But I really, I, I truly think that, especially in, in COVID has brought out such an anxiety in people that, that I think is going to be, it’s going to be so important to do things that will help us relax and meditate, and then things that like yoga, Tai Chi green tea, anything that can relax you is, is important. I forgot.


I appreciate it, but you don’t have to copy and say everything I say, dr. Shariah. so you know, another thing is that, you know, this disease is so sympathetically mediated by the sympathetic nervous system and the breathing exercises, the quieting of the system really brings out the parasympathetic nervous system and that rest digest and healing. So there’s definitely something to that. Next question. I’m on day one, 56, only 12 of those days have not included diet, no preexisting conditions, no meds, whole food diet, less than 20 carbs per day, BMI 24. I just started getting positive reagent UA for Billy Rubin. Can this cause diarrhea?


So the diarrhea had just started or?


Nope, I’m a, well I’m on day one 56 only. Wait, wait, I’m sorry. I’m sorry. I, they, they correct it down the road. I’m on day one, 56, only 12 of those days have not included diarrhea. Oh wow. Existing conditions, no meds, whole food diet, less than 20 carbs per day. BMI 24. I just started getting positive reagent UA for Billy Billy Rubin.


So I mean, that might help, but it’s honestly, it’s a little bit unusual that it lasted this long. I would hope that you’ve had a full workup at this point just to make sure that we’re not missing anything. But there are other anti inflammatory things or supplements that we can give that hopefully should decrease the rate of diarrhea. It shouldn’t have gone on this long.


Yeah. That’s a long if your pulmonary function test is fine, but you still have shortness of breath at times while eating and doing nothing. Can you talk about how GI GERD might affect things after COVID pneumonia and asthma? Basically shortness of breath after eating, which wasn’t there before Kobe, but did have GERD before COVID.


So I’m, I’m stumped by this question. Cause I think it may be mostly related to the shortness of breath rather than the guards, because when you’re eating, you have to stop breathing. And so if you don’t have that good of a lung function or it hasn’t completely recovered back to normal, it’s going to muddy the water a little bit. So it’s going to be a little bit of both.


I’m also going to say, you know, throw out the possible mechanical obstruction. So like if you have a meal you know, the, the abdominal contents are pushing up against the diaphragm and the diaphragm has to work harder. We take a breath, so maybe try, you know, smaller meals, less gas producing meals you know, in any increase in, in intrabdominal pressure is going to increase intrathoracic pressure. Alright. We are almost there. I’m going to, I’m gonna hang on one second. I’m going to turn off commenting and then we’re going to go, do you can you talk about the connection between the GI tract and kidney function? Why would a post COVID person have trouble staying hybrid a hydrated? Sorry.


So it’s more related to the fact that if the swollen test and when you absorb a lot of the food absorb something like liters of fluids a day. And if you lose all of that, because you’re having diarrhea, that means your kidneys are getting dry. So it’s more of a function of you don’t have enough of blood or fluid in your, in your system as a whole. So the kidneys essentially shrivel up and when they shrivel up the kidney tests go up and that was one of the signs. When you have bad diarrhea, your kidney tests can go up, but you could also have it with bad nausea and vomiting or severe dehydration, you would get the same results.


Yeah. I have IPF after a failed illness and fund placation I’m prescribed lansoprazole 30 milligrams twice a day. I was told that this is bad for bone strength. What do we do?


Stay on the anti acids because that is going to help your IPF more than not being on it. The risk of osteoporosis is so hyped up. It basically doubles the risk, but if your risk is one in a hundred thousand, it doubles it, meaning it goes up to two and a hundred thousand. So it’s still very, very small. And the risk of getting more reflux and acid onto the lungs to worse than the IPF is much higher.


That’s an incredible number. I didn’t realize that that was the change in risk. Also dr. Robert Kaner, who was my go to guru for interstitial lung diseases after getting the right diagnosis, his number two piece of advice is make sure you get your reflux treated so really important. I had a colonoscopy as I had a colonoscopy and I was told I have small intestine inflammation waiting for biopsy results. What could this mean?


Oh, a number of things I wouldn’t even the small intestine inflammation is probably in the you had an upper endoscopy as well. That could mean, you know, it could be something as simple as celiac disease and inflammatory bowel disease, or which we don’t know is that continuous inflammation from COVID, which will probably maybe be able to tell you a little bit more about in a year’s time.


Do you I mean, just shooting from the hip right now. I mean, I know there’s no answer to this, but I’m gonna ask anyway, do you think any of the medications that are used, like in the treatment of, let’s say Crohn’s or colitis will ultimately be helpful in the GI things that we’re seeing with Kobe?


Yeah, because the, we really did see that IBD patients were less likely to come in. IBD patients are more often on steroids and then the, the, the UK study that came out, showing that taking steroids will be helpful. And so probably a lot of the other stuff, the anti inflammatory stuff will probably be used. Some of it already is being used in trial format. So I think the it’s still early, but probably is the answer probably. Yes.


Okay. I’ve had the loss of taste and smell since March was sore throat. Having an could be Monday to see if anything’s going on, but can I expect this loss of taste or smell to ever come back? The doctors here in Florida and not really believers, so don’t know how to approach this.


So I think that’s an interesting question. A lot of people get that result within two to three weeks. We’ve had some patients where it’s lasted a lot longer. I’m curious though, it’ll be interesting to see if your symptoms correlate with a high PCR, for instance. So if the, if you, you, you still get tested and you’re tested positive. Does that have any correlation? I don’t think we know any of that yet.


Do you have any experiencing gastro symptoms very late in the long haul, experienced symptoms, edge of nausea, edge of nausea? I’m not sure what that means, but not hungry, very noticeable constriction and tightness and circling middle and abdomen seeming trouble processing food. So do you see late onset GI symptoms and COVID


Again, it’s hard to know from the data that we have. I think that a lot of times we’re getting is early symptoms and then they come into hospital, but it could also be that you get the shortness of breath and then gets the, the, the GI symptoms afterwards. I think if it’s going to affect you and affect the GI symptoms, it just will wreak havoc every everywhere in whatever order at once


You get a swelled head, but somebody wrote amazing what a fantastic guest. Can she speak on the connection between histamine reactions and intolerance and the gut


Now you’re going to change your mind. But I essentially, there’s a lot of data on, on his Simien on inflammation and the GI guts. The key thing with all of this is that, and that can cause some, some issues with with how you’re feeling or how you manifest in terms of the bloating diarrhea, discomfort, and sort of going again like the same, I guess, the same message going back to basics going back to plant based foods or clean non-processed foods decreases inflammation, low sugar, decreases all of that. And that, that would be the most helpful.


This is a great, fascinating question of which I don’t know if there’s an answer, but how are the, how are the GI systems connected to all the other nervous system and inflammatory conditions in long haul? COVID a larger issue such as Vegas nerve disruption, dysautonomia pots, Emmy CFS, chronic fatigue.


So that’s a, that’s a great question. I mean, the GI system has one of the biggest complex of, of nerves attached to it. And no one really understands how it fully functions. There are different nerves that affect the esophagus different nerves that affect the small intestine and the, and the large intestine. And if truly is what we’re saying is that COVID affects the, the the brain, the nose. It probably affects some some connection to the GI system. We just, it’s too early to tell exactly what and where I think just, just from understanding the type of questions we’re getting, it seems like that there is some sort of motility motor motility issue that happens with COVID just, just by the questions we’re getting. And also it seems like it truly is behaving like a viral Rhoda type scenario where you’re getting severe diarrhea. It really washes out your good bacteria and you really need to go back to basics. I think none of, I would need to look back at a lot of the studies that have been published, but I don’t think there’s anything on longterm manifestations of, of GI and COVID. And I think that’s a very important thing to look into


Are FODMAP and histamine diets consistent with each other or low.


Yeah, I mean, yes. In, in, in some ways, right. Fund map is going back to basics sensitive [inaudible] and going back to the basic basics of food. Right. And then, and then you introduce things more complex. So you’re really doing a sort of cleansing anti inflammatory type thing. So there is definitely some sort of a connection there. And that will, they definitely are sort of synonymous with each other.


Does it also have to do with that? I heard of something called low residue diet where I, I think there’s just less physical scraping on the inside of the GI system.


Yeah. So we give that to patients when you’re recovering from an injury from sort of a sickness or inflammatory inflammation where we don’t want it to be too complex for the body to work super hard, to digest the food. And we just want it to get absorbed. It’s kind of going back to basic baby food. And, and that would definitely help, especially at the beginning.


If we’re talking about motility, why can we be constipated for days and then have diarrhea for days, and then bounce back and forth with no relation to food intake?


So a lot of reasons which is why it’s really important to make sure that there’s nothing like a cancer brewing in there. Cause that would be the one thing that you want to avoid and something that you can treat easily found early. Other things that can cause it is that you get, this is a bit too graphical, but everyone hopefully is eaten and not gonna have food in front of them. But sometimes if you have a lot of constipation


Anyway, that’s why they showed up for this meeting. They want answer. So help us out.


You’re going to feel more nauseous, but basically a lot of stool gets backed up and you get seepage of, of of, of liquid after it. And sometimes you have what we call overflow. So that can be just severe constipation manifesting as diarrhea, but not really. And so what you need to do in that scenario is making sure you have a lot of fiber in your diet so that you go more regularly. So you don’t have that alternation between diarrhea and constipation which is kind of like not intuitive when you think about it, but that’s usually the treatment for it. But other things like a blockage can do that, which is why really making sure that you get that looked up and worked up as important.


Any, there’s only a few more questions. I just don’t want death threats if I don’t get to all of them, any advice on relief from the quote Globus sensation and or throat tightening sensation.


So the Globus is related to that dysmotility or self the GI motility that, that I think we’re seeing a lot of. And then it has something to do with reflux. And it’s basically instead of food, traveling down the gut like this, it’s just getting stuck in a certain area or just food. Is it moving as easily? And I’m hoping that if it’s like an insult to the system, that it should recover over time, we just don’t have enough information to see if that’s going to get better over time without sort of having, you know, having information from people like you.


We talked about weight loss. What about weight gain? Taking out the lack of activity from the equation? What is causing stomach bloating? Some of us look like we’re pregnant. Are you able to talk about the elevated [inaudible] in people or the onset of diabetes?


So I don’t necessarily think it’s related to COVID per se, but the bloating is, is, is different, right? The bloating can be just gas in your stomach and small intestine give. And instead of the irritable bowel symptoms that people are getting from, again, going back to bad bacteria, producing that selfer gas, all of that. And that gives you that bloat bloated bloatedness high A1C and putting on weight, unfortunately is just a function. I mean, there was a running joke, the COVID-19 or the COVID 15 of people just gaining weight, just being at home, sitting, not really moving as much as they used to. And that in of itself will cause weight gain will cause the fatty liver that we talked about earlier, and then it will also cause the A1C to go up. The A1C is a marker for diabetes. So if that is going up, that means the type of foods you’re eating is also high in sugar, high in carbs, and that you’re also gaining weight. And that could also cause that increase as well.


Are you able to talk about hormones being out of whack, potentially related to the thyroid and reports of thyroiditis extreme, low energy menstruation, et cetera,


In general or relation to COVID COVID? I think the thyroid gets upset, so to speak in any type of insult to the system, right. It’s going to affect you causes a lot of inflammation. Your thyroid goes out of, as everything gets better, that too should get better. But if you think of it, it can go, I can go off for instance, in things like pregnancy, right? It’s a it, and then it may go back to normal or it may not. And that could be something that you would have had a pre like a predisposition towards thyroid being often. Then COVID just pushed you kind of over the edge. So it’s important that you check those immediately and then check it again, six weeks in six weeks and then get followed by an endocrinologist because it could get better. But if it doesn’t, you need to be on maybe supplemental medication.


If the breath test shows bad bacteria, is there a treatment?


Yeah, there are several treatments. One that’s approved, but not necessarily always by the insurance is an antibiotic [inaudible] which is basically a bacteria that people used to give for Traveler’s diarrhea. And it’s a bacteria, it’s an antibiotic that has a very low side effect profile. It does not get absorbed by the GI system. So it just works on the GI tract. So we found it very helpful and very useful


Instead of green tea. Do you recommend green tea extract? E G C G. And how many milligrams per day?


So one of my patients asked me that as well, and yes, I don’t know the, I don’t know the milligrams of fan. I had to Google it in, in the clinic visit as well. But absolutely right. It’s it’s green tea, green tea extract. So people have green tea, candy, whatever sort of floats your boat sometimes like instead of mint, you can have, the mints can be as, as long as you’re taking that in it’ll help


Mint ginger causes bleeding in people with platelet disorder. Any other suggestions?


I think ginger and very, very small quantities like in a tea or a mint should not cause that much of an increase in bleeding, but it depends how bad your platelet function is. So that would be something to look into. But if, if that is definitely a concern and you’ve tried everything else, I would do something that you would have to check your platelets more frequently as you’re trying different treatments to see if, if the platelets truly go down.


All right, last question. I have an umbilical hernia, which is being monitored. I was told to follow the low FODMAP diet to keep it at Bay. Any other advice I take medication, which makes my constipation worse


From, for the umbilical hernia or a hiatal hernia.


This says umbilical.


So the umbilical hernia would something around your belly button that would come out or go in depending on certain movements, carrying heavy things, gaining weight. So things that would make it go better is if you again, lose weight and don’t carry heavy things. And those, those types of things that would help that Mo more than anything else.


All right. I feel like I’ve gone 10 rounds with the champ. Thank you so much. You are very smart, very smart, very impressive. You knew. I don’t think we stumped you at once. So thank you so much for your time. Thank you so much for your time for your energy, for your enthusiasm. And I, I told you guys that within about four hours of getting like five names, I had the whole Cornell team jumping on board. So we appreciate that so much. We learned a lot. We went to school tonight and it, it really means a lot. I learned a lot. And thank you. That’s Renee and his wife what’s happening there. That they had a little romantic moment. You couldn’t wait that the webinar’s ending. You couldn’t hold back for 30 more seconds for God’s sake. Holy cow. I’m happy to see it. How now, now you’re getting interviewed. All right. Unmute. How long have you been married for if you’re married? Me, Renee, Renee, these two, that that’s not enough a queen. I can’t ask the guest that


We are married. How long? Whereas three years we, I came to live with him already for six years.


Yeah, I will. Yes, I will. One day, one day, I thought you were going to say we’ve been married for three years, but it feels like 30. So here we go. I want to say thank you so much to dr. Shariah. I want to end if you want to leave, you can leave, but I would like to do a breathing and meditation exercise to calm the gut, just a special one for the gut. And then after I will be telling around, I’ll be doing around gastrointestinal stand up comedy and I’ll be telling my funny GI stories.


Well, definitely I’ll definitely stay for that, but I just want to also say thank you so much for the invitation. And I am learning a lot, especially this last hour just turned the types of questions that you guys are asking. It just means a lot of things. That means we there’s so much. We don’t know. And there’s so much we’re going to learn over the next year or so. And it really is important that people like you tell us the story and keep telling us what you’re feeling.


You are welcome to join us any time I’m waiting. Gentlemen, close your eyes, everybody take one. Nice deep breath in through your nose. Blow it out, Jeremy, through your mouth. Nice deep breath in through your nose. Blow it out through your mouth. As you breathe in. Imagine taking in power and peace and calm. And as you blow out, let your stress leave with it. As you breathe in, raise your head up, look up to the sky, stretch your neck and say thank you. Because even though the times are tough, life is still beautiful. Low out. As your head comes down, stretch the back of your neck. Nice deep breath in raise your shoulders up to your ears and blow out.


Nice deep breath in through your nose and squeeze your shoulder blades together in the back. Cause your head drops back and then relax your shoulder blades, let your head hang down. And if, and only when you’re ready, open your eyes and come back to this space with calm. I’m going to give just two quick, funny GI stories. So one is a chicken McNugget story. When I was working EMS, I got called to a special event in central park because apparently somebody ate an entire nugget at once, which they’re not that big. I mean, it’s easy enough to do. But it went down his trachea instead. So they called me from a different ambulance because they knew, I knew how to do chest physical therapy. So we put the guy on his side and banged on his back for about 15 minutes and sure enough, he coughed up the whole nugget and then ate it again.


And then I have one other one, which is that I was in the back of a cab and speaking of street meat, I got a shish kebab and I started to choke on the shish kebab. Like literally I had no air moving. And I said to myself, I said, well, I panicked. And I said, wait, I gotta come up with a plan right now. And I was going to get out of the taxi and knock on the, on the taxi driver’s door. I was hoping he didn’t take off when the light turned green and I was gonna, I was thinking of him giving me the Heimlich maneuver. And then I said, you know what? I will never live this down. It was on fifth Avenue. So I just had another piece of shish kebab in it, like a pool ball. It knocked the sip, the first one down and I saved myself. So feel free to try that at any time. One more time. I’m going to unmute everybody so that you can verbally say, thank you. Thank you.