Framework for Treating GI Issues

As an educator at IFM’s GI Advanced Practice Module (APM), Tom Sult, MD, is an expert in treating simple and complex gastrointestinal problems. In this video, he explains the DIGIN framework, a cornerstone of GI treatment.


At IFM, we use the DIGIN model to try to customize and individualize the treatment.

D: The ‘D’ stands for digestion. When I’m thinking about digestion, I’m thinking about everything from chewing our food—which almost no one does properly—to hormone reflexes such as the cholecystokinin cycle, which releases pancreatic enzymes and things like that. There’s a lot to think about under digestion. I think about how we might optimize the digestive pieces.

I: The next thing I think about is intestinal permeability. The intestinal lining, that one-cell thickness, is really the only thing that is keeping 50 to 70% of your immune system from having unregulated interactions within your intestinal lumen. Keeping a healthy intestinal lining is critical to maintaining a normal healthy immune response.

G: The next area I think about is the gut microbiota or the microbiome. We’re really the product of our three genomes and the environment. We don’t think about it much, but we really have three genomes: we have the nuclear genome, the mitochondrial genome, and our microbiome genome, and it is our environment washing over those three genomes that really gives us our phenotype. This gut microbiota becomes an important part of treating not just IBS but really any complex chronic disease.

I: The next thing I think about in our DIGIN model is the ‘I,’ which is inflammation and immune. 50-70% of the immune system lines the gut. It’s mostly associated with the gut-associated lymphoid tissue [GALT]. Abnormal interactions between the immune system and the gut luminal content can result in things like molecular mimicry, which can result in autoimmune processes and perpetuate inflammation. Managing inflammation within the GI tract is critical to managing not just gastrointestinal disease like IBS, but also systemic disease like other autoimmune processes, arthritic processes, things like that.

N: Then the last area is the enteric nervous system or nervous system. The enteric nervous system is governing all the processes within the gut. When you think about it, it’s a little odd that a quadriplegic who can’t even breathe has a totally normally functioning gut. This is because of the part of the autonomic nervous system called the enteric nervous system. The enteric nervous system coordinates everything within the GI track. It coordinates digestion, the secretion of enzymes, the secretion and release of hormones, and peristalsis and mass movement.

Without optimizing the DIGIN processes, we’re not going to get lasting outcomes in IBS, or any other GI or autoimmune disease for that matter.

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