IBS Treatment: Addressing an Irritable Bowel Naturally

Hello and welcome to The Perfect Stool. This is your host, Lindsey Parsons, and today on the podcast I'm talking about a digestive disorder which affects more than 10% of the world's population, IBS, or irritable bowel syndrome. And I'm going to cover some traditional and functional medicine approaches to treatment of IBS. Testing the relationship between IBS, SIBO, and IBD. And if those initials don't mean anything to you yet, don't sweat it. I'll explain it as we go along. And there's lots to cover, but first I wanted to share with you a question from a listener. I found your podcast while searching for probiotics while taking antibiotics. I've enjoyed listening and learning and wanted to see if you have any recommendations for vaginal probiotic suppositories. I'm going through IVF and it took a long while to get over a case of persistent endometritis. My IVF doctor recommended vaginal probiotics as I prepare for an embryo transfer but didn't have any specific recommended brand. She just said get them on Amazon. I don't want to take any chances and wondered if you'd have any insight to share. So my response to her was that Grace Liu, one of my mentors, recommends Bifidobacterium longum BB536 for use intravaginally, which is in the probiotic Life Extension Bifido GI Balance. Which I can link to in the show notes. Incidentally, all the show notes are up on my website, HighDesertHealthCoaching.com. Of course, you can find them through your podcasting app too. And I told her she could try putting the whole capsule inside her vagina or taking some of the powder out and putting it up with an applicator in some type of safe gel like KY jelly, or just with her finger. And, you know, also mentioned that yeast can often overgrow in your gut after so many antibiotics like she described taking. So I also recommended that she ask her doctor about antifungals especially if she had any vaginal Candida symptoms. Okay, now all the male listeners are going, "TMI!" Back to IBS. IBS is a cluster of symptoms that include abdominal pain, cramping, or bloating that may be alleviated by a bowel movement, excess gas, diarrhea or soft stool, constipation or alternating diarrhea and constipation, and/or mucus in the stool. Other symptoms of IBS might include changes in texture and color of your stool, nausea, acid reflux, easily feeling full, loss of appetite. And then there's also non-digestive symptoms like anxiety or depression, difficulty sleeping, fatigue, headaches, an unpleasant taste in the mouth, muscle aches, sexual problems, body image issues, or heart palpitations. For most people who suffer from IBS Symptoms can be worse at times, improve at times, disappear sometimes for a period of time. And for some people, the IBS symptoms aren't severe and they can be managed with changes to their diet and lifestyle and managing stress. But for others, they can significantly impact their quality of life, like making it hard to leave the house because of urgent runs to the bathroom with diarrhea. They may even involve accidents necessitating a change of clothes. They may impact people's ability to work or be seen as reliable at work or in their social life. And unfortunately, many people suffer in silence and don't get the help they need because of the stigma or embarrassment, which is so not necessary. Please, people, get help. So IBS presents differently in different people, so clinicians organize the syndrome into 3 basic types: constipation predominant, called IBS-C, diarrhea predominant, called IBS-D, or alternating constipation and diarrhea, or IBS mixed, which is IBS-M. According to one source, as much as 12% of the U.S. population suffers from IBS, or nearly 40 million people. And women and people under the age of 45 are more prone to IBS. So it's a big problem, although you may not even know anybody who has it or admits to having it besides yourself. So you may also have heard the term SIBO, or small intestine bacterial overgrowth, and certainly if you've been listening to my show for any length of time, you have. SIBO is believed to be the most common cause of IBS, with some experts citing the figure of 60 to 70% of IBS being caused by SIBO. The symptoms of SIBO, which are bloating, constipation, diarrhea, flatulence, abdominal pain, overlap with IBS. So in some sense, you really could say they're basically the same thing, but IBS tends to be more of a traditional or allopathic diagnosis, usually of exclusion, while SIBO is used more in the functional medicine world Although now more and more gastroenterologists are using the term SIBO, the American College of Gastroenterology has put out clinical guidelines for treating SIBO, and some gastroenterologists are now using some of the same testing methods as functional medicine practitioners. Like with IBS, SIBO has traditionally been divided up into SIBO-D, SIBO-C, and SIBO-M. So you can see where suspiciously they seem to be looking like the same thing. However, the nomenclature of SIBO and the issue of whether symptoms are coming from general bacterial overgrowth has been called into question because the testing that's been used to diagnose it, which is hydrogen and methane breath testing, has neither been shown to be terribly reliable— in particular the hydrogen part, meaning that like if you test it one time and do no treatment and test 2 weeks later, you get different results— nor has it been shown to be valid in at least 2 recent studies that I know of and will link to in the show notes. Meaning that if you compare the aspirates or the suctioning of the bacteria in the small intestine, it doesn't correlate with what's showing up on breath testing or with the patient's symptoms. And then there was an article published out of Dr. Mark Pimentel's lab out of Cedars-Sinai Hospital, and he's one of the primary SIBO researchers out there. Leté et al., 2020, seems to validate the lack of validity of the hydrogen breath test in the abstract, where it says that at the 90-minute time point of the lactulose breath test, and that's considered the cutoff time for measuring gas coming from the small intestine, 'cause you drink the lactulose and then it goes through your intestines, and they think after 90 minutes it's moved to the large intestine. So at the 90-minute time point on the lactulose breath test, 4 out of 7 SIBO subjects had a rise in hydrogen, which is H2, greater than or equal to 20 parts per million above the baseline, which would mean they had SIBO per the way breath tests are currently analyzed, as compared to 2 out of 13 non-SIBO subjects had a positive breath test. So first of all, those are really small sample sizes. We're only talking about 20 total people. Only 7 on the SIBO side. So I wouldn't call this final, but at least in this study, the hydrogen breath test only correctly identified SIBO 57% of the time, and then 15% of the time gave a false positive for SIBO in someone without it, as compared to the results of duodenal aspirates, or the sampling of the cells in the first part of the small intestine, or duodenum, which is one of the main reasons I never recommend breath testing. But there was some interesting information coming from that study that included that subjects with bloating had a relatively higher abundance of bacteria from the family Enterobacteraceae, while people experiencing urgency with bowel movements had a relatively higher abundance of bacteria from the family Aeromonadaceae. Also, the subjects with what they're calling SIBO based on the quantity of bacteria in their small intestines had a 4.3-fold higher relative abundance of the phylum Proteobacteria. Averaging around 37% of the small intestine contents and that 1.64-fold lower relative abundance of the phylum Firmicutes. And they also reported the subjects with SIBO also exhibited greater urgency with bowel movement than non-SIBO subjects, which was actually the only symptom they were able to correlate from what I could deduce from reading the article to actual overgrowth, which again, in my opinion, calls into question the definition of SIBO as a state of general bacterial overgrowth. And a brief aside for people who've studied statistics, the p-value on that last item was only 0.022 versus 0.0001 for the relative abundances by family and phylum. So clearly the more statistically significant issue shown in that study is the predominance of proteobacteria and particular Enterobacteraceae and Aeromonadaceae. And further that they also found that SIBO subjects had relatively more bacteria from the genera, which is the plural of genus, by the way, Klebsiella, Escherichia/Shigella, and Actinobacter, and a couple more unknown genera. So that kind of points to which may be the troublemaking bacteria in your gut when you're having IBS symptoms. All that to say too that SIBO may not be the right word. So rather we should probably be using the term dysbiosis, which typically implies that there's an overgrowth of a particular kind of bacteria, but maybe not bacteria in general. Which may be in both the small and large intestines, or an overgrowth of yeast in your intestines, also known as SIFO, or small intestine fungal overgrowth. Or you could have an infection with a parasite under the label dysbiosis, or a general lack of diversity, or certain important species are underrepresented or extinct. However, in my experience looking at lab results of tests like the GI Map and the organic acids test, typically all three things are happening at once when you have symptoms of IBS. That being said, I have a client now who has an IBS diagnosis and symptoms, and when we did her labs, there were no overgrowth of pathogenic bacteria, no yeast overgrowth. And the funny thing was, it seems like the amino acids that I educated her about to help bring up her dopamine and serotonin levels have already positively impacted her IBS, which points to anxiety and stress as a likely root cause in her case. So you never know what you're going to find out until you test. And that, by the way, is one of the benefits of doing an organic acids test, because in addition to looking at bacteria and yeast, it It helps identify when things are going wrong with your neurotransmitters, which impact your mental health, which of course is also often impacted by gut issues. 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Now, as you recall, IBS is divided up by whether it involves diarrhea, constipation, or both. For people with constipation, it's usually caused by an overgrowth of methanogens, or methane-producing microbes. And I say microbes rather than bacteria because one of the primary ones, Methanobrevibacter smithii, is an archaeon rather than a bacteria. Rather than grouping that under SIBO-C or IBSC, the newest term being used is IMO, or intestinal methanogen overgrowth, because the methanogens may be located in both the small and large intestines, and the term SIBO has the word bacteria in it, and archaea are not bacteria. Quick science lesson, and I'm going to confess I had to look this up, but you may recall from biology class that all organisms on Earth are separated into 3 domains: Eukarya, Bacteria, and Archaea. And the singular of Archaea is archaeon, by the way, which I was saying earlier, and you may have been like, what the heck is that? And you're probably thinking, like I was, where do animals fit in there? Turns out we're under the domain Eukarya, along with plants, fungi, and protists, whatever the heck that is. But those don't come into play in gut health, so as far as I know, I don't have to know what protists are. I was a French Which you're majoring in college, by the way. So anyway, IMO, or intestinal methanogen overgrowth, can be another cause of IBS, especially if it involves ongoing constipation. And I'll also throw into the mix that breath testing that includes a third type of gas in your small intestine, hydrogen sulfide, has just come online for commercial use. So prior breath testing was for hydrogen and methane, with hydrogen typically being associated with diarrhea or mixed. And methane with constipation. But up until now, you couldn't test for hydrogen sulfide in a commercial setting. It was only available in a research setting. So this new test was developed by Dr. Pimentel, who I mentioned before, and it's called TrioSmart. And no, I'm not being paid to advertise it, although I should be. And it's available from Gemelli Biotech. And it looks like an overgrowth of hydrogen sulfide-producing bacteria is typically associated with diarrhea too. So breath tests can be done in a lab or using a home kit, which is what the TrioSmart is. And it just— for breath tests in general, not this one in particular— if you drink glucose into the test, which involves breathing into a tube and saving the results, it covers the first part of your small intestine. And if you drink lactulose into the test, it covers the lower part of your small intestine. And then Dr. Pimentel also developed a test called IBS-Smart, which tests for autoimmune markers which impact your intestinal motility, or movement, which can be a root cause of IBS originally brought on by food poisoning, which is likely the primary root cause of IBS. And which reminds me of an incident when I was living in Costa Rica in my early 20s and teaching English. My then-boyfriend and I, and who's now my husband, went away for the weekend and decided to defrost our crappy non-frost-free refrigerator because the freezer was overgrown with frost and we could barely fit anything inside it. So we decided to put bags of ice packs into our weird washing machine in which you had two different sections for washing clothes, the washing part and the spinning part, and you had to move the clothes in between those two parts. And one of them kind of looked like a cooler, or at least it was just like a there were no holes in it and it was just a deep plastic pit. So we thought we could put our cold food in there with ice, leave it for 2 days, and keep it cold enough. Mistake number 1: when we came back from our 2 days away, we found our stuff basically warm. I mean, like, warmer than room temperature, including our already open jar of mayo. So in my infinite lack of wisdom and life experience, I decided to keep it and make a heavy mayo-based dish that night— tuna salad— with it. Mistake number 2: Suffice it to say that before the night was over, both my husband and I were miserably ill with diarrhea and vomiting and just a nasty case of food poisoning, which may be at the root of— or may have been at the root of my future health issues, my SIBO diagnosis, my autoimmune stuff, and all the rest. But anyway, back to what I was saying about food poisoning. The IBS-Smart test tests for these two antibodies called anti-vinculin and anti-CDTB antibodies. Which can develop following food poisoning. And like all antibodies, they come after something. So like an autoimmune disease, like mine, Hashimoto's, you have antibodies that attack your thyroid gland. So in this case, your antibodies are attacking the cells in your intestines that impact your mi— migrating motor complex, which normally keeps the food moving steadily through your intestines. And without that movement, you can get stagnation, overgrowth, and dysbiosis. So both the IBS-Smart and Triosmart can be ordered by your regular doctor, and they may even be covered by insurance, although they're very new. So probably, you know, your traditional allopathic doctors don't know about them. Even gastroenterologists may not have heard of them, but they were developed by an MD. They are meant for use within the traditional medical community versus the more functional medicine tests like the GI Map or the organic acids test. So anyway, I'll put those links in the show notes. They kind of instruct you on the site about how to print some out and show it to your doctor to get the test. The long and short of it is what you'll find out by doing an IBS-Smart Test is whether or not you have an autoimmune issue provoking your IBS, which you'll need to address after you kill any dysbiotic microorganisms by using something called a prokinetic. And that's a drug or a natural substance like ginger that helps intestines to move. So some of the prescription medicines used as prokinetics are called low-dose erythromycin, which you may be familiar with as an antibiotic, but it's not at that low doses. Low-dose procalipride and low-dose naltrexone, and then one nutraceutical one called Iberogast. So if you do seem to have a recurring problem even after you've had SIBO or IBS or dysbiosis treatment, try taking ginger pills before bed or have a cup of ginger tea in the evening after dinner to stimulate your migrating motor complex as you sleep. And of course, sleep on an empty stomach, please. Or if those don't work, you may need to get a prescription to deal with your motility issues, so you may need to see a doctor who specializes in this, or convince your regular one to prescribe something they know nothing about. That's always fun. Or you can just skip the test, cure your IBS, and wait and see if it comes back quickly. And if it does, you probably need to take a prokinetic. But at minimum, once you have cleared up your IBS or dysbiosis, you should make sure you don't eat more frequently than every 4 to 6 hours, so you always give your stomach a chance and your intestines a chance to clear out. You don't eat at least 2 hours before bed, and you go at least 12 hours at night without eating to allow your intestines to clear out. Let the migrating motor complex do its job. So we've talked about dysbiosis being a root cause of IBS and maybe even covering 60-70% of it. So what about the rest? Well, it could be related to other things like adhesions or bands of scar tissue from a surgery, inflammation, or an injury that's keeping your intestines from moving properly. It could be from Ehlers-Danlos syndrome, which is a hyperflexibility condition that can impact your intestines. It could be from hypothyroidism blood sugar issues, type 2 diabetes, drugs that you are taking or took, Lyme disease, or various autoimmune diseases like scleroderma or rheumatoid arthritis. Or it could be coming from a traumatic brain injury, which I talked about with Dr. Corey Deacon in episode 20, which can also impact your migrating motor complex. All those things I just mentioned can impact your migrating motor complex ultimately, or your vagus nerve, which innervates your migrating motor complex. Now, IBS versus IBD. This is an important thing because they have very similar names. Just a brief interlude to address that. IBS, irritable bowel syndrome. IBD, irritable bowel disease. IBD is that umbrella term which describes the digestive disorders caused by inflammation of the bowel and autoimmune diseases that affect the gut and intestines, including Crohn's disease, ulcerative colitis, and microscopic colitis. IBD symptoms are typically more serious and less common than IBS symptoms. And may include loss of appetite, blood in the stool, nutrient deficiencies brought on by malabsorption. Anyway, I've done some other shows on IBD, including the episode right before this, as well as episodes 10 and 15, so you can check those out if IBD is your issue. But let's move on to diagnosis and treatment of IBS. So given how common it is, I'm sure you're anxious to get on to how to treat it, especially if you have it. But before I dive into the discussion about treatment, I should mention that typically doctors will give a diagnosis of IBS once they've excluded everything else, including IBD, which usually involves putting you through an endoscopy, or putting a camera down your throat to look at your esophagus, stomach, and the upper part of the small intestine, and a sigmoidoscopy or colonoscopy, where they put a camera through your rectum to look at your colon, or for sigmoidoscopy, further up into your small intestine. And that's one of the reasons that Dr. Pittman-Tayl has developed the tests I mentioned above, to spare you having to have the entire length of your intestine scoped. So if you're about to have one of those things to determine whether you have IBD or IBS, you should ask about those tests because that's the moment to stop the pain, right? But typically if the endoscopy and colonoscopy are negative and you still have ongoing gut symptoms including abdominal pain for at least 12 non-consecutive weeks out of the previous year, characterized by change in how often you have a bowel movement and that bowel movement is not normal, then you may end up with a diagnosis of IBS. Now, if you see a functional medicine practitioner with an IBS diagnosis or symptoms, depending on those symptoms, you will likely be asked to either do a PCR-based stool test like the Diagnostic Solutions GI Map or Doctor's Data's Comprehensive Stool Analysis with Parasitology, a SIBO breath test, and/or an organic acids test. And the results of those tests will give your practitioner a lot more data about what's actually at the root of your issues, because really IBS is kind of a meaningless diagnosis because it's really just the exclusion of everything the traditional medical world knows how to treat. And once you got diagnosis, you're more or less— it's very little they have to offer you, let's put it that way. So in terms of treatments, a traditional gastroenterologist with a positive breath test or based on symptoms may prescribe you antibiotics, in particular one called Rifaximin or Xifaxan, which is an antibiotic that only impacts the bacteria in the intestinal tract. It is ridiculously expensive though. Last I checked, it was about $1,750 for a 2-week course. So if your insurance won't cover it or your doctor doesn't even know what that is, you may wanna go the herbal antimicrobial route. And there are some other antibiotics that may be helpful, and some of them are used in conjunction with Rifaximin, including neomycin, metronidazole, Augmentin, Bactrim, and nitazoxanide. However, although antibiotics may reduce your symptoms in the short term, they may actually just end up further stressing the gut lining and your microbiome, or they may cause or increase fungal overgrowth, which can cause a relapse or worsening of symptoms in the long term. So rather than taking an approach, naturopaths and other gut health practitioners prefer antimicrobial nutraceuticals for the most part because they simultaneously address both bacterial and fungal overgrowth. Typical antimicrobial herbs used for dysbiosis include berberine, allicin derived from garlic, oregano oil, and uva ursi. And hydrosol silver is also used, and bismuth. One of my favorite protocols that kills both bacteria and yeast is using the Candida Actin BR and AR products. But if you're thinking of taking those, you should get help because number one, for dosing, but also because the die-off or a Herxheimer reaction can be unpleasant or even dangerous if you have severe overgrowth of bacteria or yeast. And Herxheimer reaction is when you have flu-like symptoms as you begin to kill the things in your intestines. And then once you have dislodged the bacteria and yeast, you want to use probiotics and prebiotics strategically to help reset your microbiome in an effective manner so it doesn't come back. Some additional supplements that may be effective in addressing IBS symptoms or the root cause of the IBS, whatever that may be, include betaine HCl and digestive enzymes, especially if there is evidence of a lack of stomach acid or pancreatic enzymes respectively on the GI MAP. And if there's evidence of leaky gut, like food intolerances or low gut immunity indicated by low secretory IgA on the GI MAP, L-glutamine powder and an IgG product like Mega IgG or Mega Mucosa can be helpful. And then there are some supplements that help soothe and lubricate or reinforce the mucous lining of the digestive tract, like aloe vera, which is also great for constipation, as well as marshmallow root, DGL, and slippery elm. And Atrentyl is a great over-the-counter medication that's really helpful with constipation, and it consists of various plant polyphenols. I've had recently good success with that with a couple different clients. And another really good one for helping with bloating is peppermint oil, which is good to take prior to meals. I keep that on hand when I start to have a touch of bloating. And one of my prior guests from episode 20, and the person who's most questioned the whole SIBO diagnosis, Lucy Meiling, PhD, Lindsey Parsons, PhD, believes that treatment shouldn't focus on quelling bacterial overgrowth by antibiotic means. Rather, she focuses on the depletion of the short-chain fatty acid butyrate, which is the food for the cells lining the colon, while glutamine, by the way, is the food for the cells lining the small intestine. So antibiotics, gut infections, low fiber intake, and stress are all factors that can deplete gut butyrate, causing oxygen leakage into the gut and then encouraging gut dysbiosis. Which is characterized by an overgrowth of facultative anaerobes like proteobacteria, which can survive in the presence of oxygen. So instead of antibiotics, Lucy recommends treating fungal gut infections, eating plenty of fiber, managing stress, and getting plenty of regular exercise. Speaking of which, a study published in the American Journal of Gastroenterology in 2011 found that increased physical activity improves GI symptoms associated with IBS and improves quality of life to such a great extent that exercise should be utilized as a primary treatment for symptoms associated with an irritable bowel. So if you're thinking of supplementing with butyrate and some more advanced interventions that Lucy recommends, I'd suggest you do it under the care of an expert gut health practitioner, such as myself. I have personally found though that supplemental butyrate is one of the most helpful things for me in keeping my bloating in check and keeping my stool at a nice Bristol number 3. In case you're not familiar with it, the Bristol Stool Chart rates stool from 1 to 7, and a 3 or 4 is considered normal. But I'd much rather a 3 than a 4, personally. Now, in terms of diet, one of the most commonly recommended diets for IBS is called low FODMAPs, which stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. Say that 3 times fast. I'll say it again though: fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. And on that diet you eliminate gluten, dairy, a wide selection of fruits and vegetables, and the omnipresent ingredients garlic and onion, including their powders. So try to go out to eat on that diet. I can tell you, I've done it many times. You can basically order a chicken or a steak salad with oil and vinegar for dinner. And if you're a vegetarian, you can order a plain lettuce salad, maybe with some cucumbers. That's about it. It's tons of fun. But the low FODMAP diet shouldn't be used long term, or it may result in the extinction of vital gut microbes. Rather, it's best used to precede treatment to reduce symptoms as a self-diagnostic tool. So if you do better on it, then you know your issue is at least partially bacterial, and to temporarily deplete the microbes that cause problems so your killing regime will be more successful. Or it can be used as an elimination and reintroduction diet to see which of those substances most affect you if you have a pretty mild case and you just want to try and manage it by diet. But again, you need to have complex carbohydrates and fiber and such in your regular diet, and that the low FODMAP diet is, is pretty much devoid of fiber. So it does— it's very effective in getting the bacteria to die down. And there's other diets out there that are even more restrictive, like the specific carbohydrate diet or the biphasic diet. But honestly, I think low FODMAPs is already a lot to ask of people, so I generally just go the route of treating the underlying cause of IBS symptoms rather than playing out a difficult diet like low FODMAPs. And honestly, by the time most of my clients find me, they're usually reduced to a diet consisting mostly of vegetables, meat, and fat in their desperation to find a solution. So I'm not inclined to ask them to restrict their diet even further than that. If you have a mild case of what seems like IBS, you may just be toughing it out thinking the symptoms are tolerable but manageable. But be careful, because my gut issues preceded my autoimmune issues, and I know they're related. So Dr. Alessio Fasano, pediatric gastroenterologist and research scientist and the founder of the University of Maryland Center for Celiac Research, believes that 3 factors are at the center of all autoimmunity issues, which are genetic susceptibility, antigen exposure, which means something that you're reacting to, and increased intestinal permeability. Given that you find increased intestinal permeability in IBS and dysbiosis, and once you have the permeability, the antigens start coming in contact with your immune system. It's not surprising to find that IBS and dysbiosis are common underlying causes of autoimmune conditions. Although that association, how it all works, isn't entirely clear, what is clear is that with its high likelihood of generating a leaky gut, it is important to address IBS for the prevention and treatment of autoimmunity. But if it's past that point, and in addition to IBS you already have an autoimmune condition, don't worry, they can often be reversed. And that's one of the things I was able to do for for myself and that I do with my clients. So if you have IBS or some other gut issue or an autoimmune disease and you wanna chat about it and see if health coaching might help you, you can set up a free 30-minute breakthrough session with me from the link in the show notes. And then I also wanted to let you know that I am going to be on another podcast talking general gut health, and that will be a great intro podcast for the non-gut health mini experts I fancy are in my audience, which is to say those of you who may get a bit confused or overwhelmed with some of my podcasts. It's going to be published on December 1st, so if you want to check me out, it's called The Passionate Health Advocate Show, and I'll include link in the show notes. So if you subscribe to it now, you won't miss my episode. And here's a little promo for that show so you'll know more about it.

Frustrated with your pain or injury? That sucks, but I'm here to help. Hi, my name My name is Denise Duchêtleur, and I'm a bodyworker and educator. Why is it so hard to find the care we need to feel better? Most of my clients have asked that question for years until we started working together. Now I'm going to help you find those answers. I'll explore different health disciplines and chat with talented practitioners. We'll share insights and practical advice to help you get the results you need to feel good again. Because seeking the right care for your health can be a pain in the arse. But with me, your wellness journey will turn into a fun-filled adventure. Buckle up, baby, for the Passionate Health Advocate Show.

Great.

Well, I hope you check that show out. And now thanks for listening. And here's wishing you all the perfect stool.