Don’t Scratch Your Bottom

Itching around the anal area is called Pruritus Ani. This condition is an unpleasant skin sensation that produces the desire to scratch.

Why this does happen?

There are a number of possible reasons. Some of them are moisture due to perspiration, a small amount of residual stool around the anus, hemorrhoids, fissures, fistulas, certain foods, smoking and drinking. Foods and beverages that are associated with Pruritus Ani include coffee, tea, carbonated beverages, milk products, cheese, chocolate, nuts, and spicy food. Rare anal malignancies can cause itching.

Lack of cleanliness is rarely the primary cause. Once the patient develops this condition, they have the tendency of washing the area vigorously with soap and a washcloth. This is usually counterproductive due to damage to the perianal skin and washing away protective natural oils.

Perianal dermatitis, anal warts and hypertrophic skin are other causes for this condition.
Parasites that cause anal itching are very rare in the United States.

What can be done to make the itching go away?

A careful examination by a specialist can identify a definite cause for the itching. At least half of these patients never identify the reason for their problem, but they are still treated for their symptoms. A biopsy is rarely needed in the work up of this condition. The goal should be to achieve clean, dry and intact skin.

Some general recommendations include:

  1. Avoid certain foods that cause this condition. Gradually reintroduce the offending foods; this helps identify which group is responsible and threshold for tolerance.
  2. Avoid moisture in the anal area.
  3. Avoid further trauma to the affected area. Anal hygiene is important. Use baby wipes or wet toilet paper to clean the area. Pat it dry. Never rub.
  4. Do not scrub the anal area with regular toilet paper.
  5. Minimize the use of soap in the anal area.
  6. Try not to scratch the itchy area. Scratching produces more damage to the skin, which in turn makes the itching worse.
  7. Use only medications prescribed by your physician.
  8. If symptoms persist after 6 weeks, make another appointment with your physician.

Clostridium Difficile

Antibiotic-associated diarrhea (AAD) is a diarrhea that develops in patients who are taking or have taken antibiotics. One of the most severe causes is being infected with the bacterium Clostridium difficile (C. difficile). Infected individuals tend to be older adults, particularly if hospitalized and exposed to antibiotics. There has been a rising trend of infections in younger adults from the community setting, even in the absence of antibiotics. This rise in infections has also been accompanied by more “virulent” strains which are more difficult to treat.

Symptoms

There are millions of “good” bacteria in our colons which protect us from infection. By taking antibiotics, many of these defenses are killed and opportunity arises for C. difficile. If this bacteria flourishes, it can potentially lead to severe diarrhea. These symptoms are the result of a toxin produced which injures the intestine. Symptoms can vary in intensity from very mild illness to severe life threatening conditions. These include loose stools and mild abdominal cramps to profuse diarrhea and severe abdominal pain. Other symptoms include fever, nausea and vomiting and poor appetite. Diarrhea can also include blood.

Cause

The cause of the colitis, C. difficile, is found in many parts of our ecosystem. These include soil, water and animal waste. Sometimes, we can even “carry” the bacteria in our colon without any symptoms. Highest places of infections are health care settings and facilities. Transmission is usually due to poor hand washing.

Also, as mentioned previously, the major risk factors for this illness are antibiotic use and admission to a hospital. Germs can spread easily in hospitals and can persist on many surfaces, facilitating transmission. Adequate cleaning of surfaces and hand washing is imperative, as traditional alcohol gels are not as effective against the bacteria. Also, the quantity of antibiotics one takes and the lengths of time in which they are taken also increase risk of infection. Medications which lower stomach acid, particularly proton pump inhibitors (PPI) have also been associated with higher incidence of infection. Other factors include older age, recent surgery, inflammatory bowel disease (IBD) and patients undergoing chemotherapy.

Complications

C. difficile can lead to several complications. Profuse diarrhea may predispose to dehydration and even kidney injury. With severe infection, the large intestine can become very lazy and unable to move air and stools. This scenario can lead to over distention of the colon (Toxic mega-colon) and possibly even rupture (perforation). The most severe complication can include death if not treated appropriately.

Diagnosis

The most common way to diagnose the bacteria is by stool tests. These lab tests identify the presence of the toxin produced by the bacteria. Usually, a colonoscopy is not needed to make the diagnosis; however, in rare cases there may be a need to look at the colon for signs of inflammation, described as “pseudo membranes.”

Treatment

The treatment of C. difficile usually involves 10 to 14 days of antibiotics. The common antibiotics include metronidazole (Flagyl), vancomycin and more recently fidaxomicin (Dificid). Severe illness not responding to medical treatment may require surgery, which includes removal of the colon. Unfortunately, the risk of re-infection is quite high, approaching one in five patients. Studies have suggested that certain probiotics may have a role in preventing recurrence.

The take home point is to avoid antibiotics if they are not absolutely indicated, as well as adequate hand washing in health care facilities. If diarrhea develops in association with antibiotic use, alert your physician as an early diagnosis. Appropriate treatment is paramount.

Probiotics in Health and Disease

People are ecosystems. A healthy adult can harbor about 100 trillion bacteria in his gut alone, which is 10 times as many as the number of cells in his body. In exchange for raw materials and shelter, the body’s commensal bacteria or “microbiome” feed and protect their hosts. The “normal” microbiome digests dietary fiber, generating short fatty acids that serve as fuel for certain cells’ metabolic needs, or are also stored as fat.

In addition to Irritable Bowel Syndrome (IBS), Inflammatory Bowel Disease (IBD), Antibiotic-Associated Diarrhea, and Infectious Diarrhea, an altered microbiome has also been associated to Atherosclerotic Heart Disease, Obesity, Diabetes, Metabolic Syndrome, Non-Alcoholic Steato-Hepatitis and various presumably “auto-immune” diseases such as Type 1 Diabetes, Eczema, Multiple Sclerosis and even Autism. Modifying microbiomes with antibiotics in specially bred mice predisposed to hardening of the arteries significantly reduces their Atherosclerosis. In Multiple Sclerosis, researchers have shown in mice that gut bacteria trigger the reaction that causes the immune system to turn against certain nerve cells and strip away their insulation in precisely the way that leads to multiple sclerosis.

If gut bacteria are making you ill, can swapping them make you healthy? The yogurt industry has been answering this question for many years. Indeed probiotics – which are live micro-organisms that when administered in adequate amounts, confer a health benefit to the host – are found in yogurt. Although it is commonly recommended as a source of probiotics, not all of the live cultures contained in yogurt survive well in an acidic environment, nor do they colonize the microbiome efficiently. Some yogurt preparations in the United States are pasteurized, which kills the bacteria. Furthermore, the residual lactose contained in yogurt can increase symptoms in patients with lactose intolerance, including those that develop secondary lactose intolerance following an episode of acute gastroenteritis.

Since yogurts are limited in the range and amount of bacteria they can transmit, different concentrated probiotic formulations have been developed and studied scientifically. Some of the most commonly available include: VSL#3, Align, Culturelle, DanActive, Mutaflor and Florastor. Unfortunately, very few studies have hinted that probiotic pills may improve your health, and scientists claim that there is not enough proof and more research is needed. Hence, these pills should not be taken unless recommended by your physician.

However, there is no harm in eating yogurt products that have “active cultures” which have probiotics in them. A low-fat yogurt can always be part of a healthy diet. The downside is that probiotics are not regulated by the FDA and therefore the manufacturers do not have to prove that the ingredients listed on the label are actually in the bottle. Furthermore, probiotics are expensive and not covered by insurance (except for VSL#3 DS in “pouchitis”) and there is a small chance that they can cause infections in people with weak immune systems.

The HALO System: Removing the Risk of Barrett’s Esophagus

Barrett’s esophagus is a condition in which the cells that normally line the lower portion of the esophagus are replaced by tissue that is usually found lower in the intestine. This process, called metaplasia, is believed in some part to occur as a result of chronic reflux of stomach acid back into the esophagus (gastroesophageal reflux disease, or GERD).  Overtime, this chronic regurgitation causes damage to the normal esophageal lining. In the body’s attempt to heal and protect, it grows different cells thus leading to Barrett’s esophagus.

Barrett’s esophagus itself usually causes no symptoms. It is diagnosed when a gastroenterologist performs an endoscopy on a patient to further evaluate symptoms such as chronic reflux, heartburn, or even difficulty swallowing. If your healthcare provider identifies tissue that appears abnormal, he or she will take samples to help determine if Barrett’s esophagus is present. The significance of having Barrett’s is that it is associated with a much higher risk of developing esophageal adenocarcinoma. Fortunately, even those who have Barrett’s esophagus have a very low risk (less than 0.5% of patients per year) of developing esophageal cancer.

Unfortunately, at the present time, there is no reliable way to determine which patients with Barrett’s esophagus may go on to develop esophageal cancer. It is fairly typical for a healthcare provider to recommend those who have Barrett’s to undergo surveillance of this condition with endoscopy at regular intervals. This may help to identify tissue that is dysplastic (pre-malignant).

Although commonly recommended to patients with Barrett’s esophagus, the use of antacids has not been shown to prevent the development of cancer. Treatment for people with Barrett’s esophagus and dysplasia is individualized and can vary from surgery or endoscopic resection to using photosensitizers (PDT) and radiofrequency ablation (RFA).

In 2005, the HALO System was approved for use by the FDA for the ablation of Barrett’s esophagus in those select patients who have developed dysplasia. This system uses radiofrequency to destroy Barrett’s tissue that has been previously identified during endoscopy. Even though radiofrequency has been used for many years for the treatment of Barrett’s, there has been no reliable method that was safe, effective and easy for both patients and their physicians until the development of the HALO System.

In an outpatient setting, the HALO System is used during endoscopy to destroy the Barrett’s tissue with minimal risk. It has been studied extensively in both the United States and Europe and has been shown in some studies to be over 98% effective in eliminating dysplastic tissue (pre-malignant cells).

Recent studies estimate that well over 3 million Americans over 50 years of age suffer from Barrett’s esophagus. If you have Barrett’s esophagus, speak to your Gastro Health physician to see if you may be a good candidate for the HALO System.

Have you had your flu shot

Gastro Health recommends that patients with Crohn’s Disease or Ulcerative Colitis who are taking “immunosuppressant medications” receive a yearly flu vaccination and the pneumonia vaccine every five years.

Immunosuppressant medications include the following:

  • Prednisone
  • Azathioprine (Imuran, Azasan)
  • 6-Mercaptopurine (6-MP, Purinethol)
  • Methotrexate (Rheumatrex)
  • Infliximab (Remicade); Adalimumab (Humira); Certolizumab Pegol (Cimzia)
  • Natalizumab (Tysabri)

The inactivated influenza vaccine given by an intramuscular shot, as well as the pneumonia vaccine, are both safe for patients taking immunosuppressant medications. However, live vaccinations are not safe if you are taking immunosuppressant medications.  Live vaccinations include:

  • Chickenpox (Varicella Zoster Infection)
  • Measles, Mumps and Rubella (MMR)
  • Yellow Fever
  • Intranasal Flu Vaccine (this is different from the one given by an Intramuscular injection)

If you have ANY questions or concerns, please consult your Gastro Health physician.

 

Heliobacter Pylori Testing

As previously discussed in our Fall 2012 issue, Helicobacter pylori (H. pylori)  is a bacteria found in the stomach that can cause a variety of intestinal disorders such as peptic ulcers and gastritis. This bacterium is also a very common cause for dyspepsia, a syndrome consisting of epigastric discomfort, feelings of early fullness after eating, and bloating.

For patients who do not have “alarm” symptoms such as weight loss or vomiting which require a more thorough evaluation, non-invasive testing for H. pylori can easily and effectively diagnose the presence of this bacterium. One such test that is commonly available now is a urea breath test. This test can be used to both diagnose Helicobacter pylori and confirm its eradication. The test requires a patient to provide a sample of their breath about 20 minutes after ingesting a compound. This is based on the fact that H. pylori can covert a compound called urea to both carbon dioxide and ammonia.

During this test, a patient will ingest a detectable type of carbon called an isotope. If H. pylori is present, this isotope will incorporate into carbon dioxide and will then be detectable in the patient’s breath. There are two commercially available tests, and the only difference between these tests is the use of a radioactive isotope in one of the tests. It should be noted that the amount of radiation used in the test is essentially equal to the normal radiation a person is exposed in their daily life.

The urea breath test has a reported sensitivity and specificity of 95%, meaning the chance of a false positive test is very low. False negative tests can also occur, especially if a patient is being prescribed certain medications. The two classes of medications that can cause false negative results include antibiotics and proton pump inhibitors (PPIs) such as Nexium or Prilosec. These medications will suppress but not completely eliminate the presence of H. pylori in the stomach. In order to eliminate this risk, a patient must not use antibiotics for four weeks and PPIs for two weeks prior to undergoing the test.

Another option in terms of non-invasive evaluation is the use of an H. pylori stool antigen test. The antigen is essentially a marker for the presence of active bacteria. This test offers a similar accuracy as compared to urea breath testing in detecting the bacteria. However, it has a slightly higher chance of a false positive result in comparison to the urea breath test, and a similar chance of a false negative result. The main advantage of stool antigen testing is that it is slightly less costly as compared to the breath test.

The urea breath test is an increasingly common way for physicians to safely and accurately diagnose the presence of H. pylori in the most cost effective way possible. The increasing use of this test will undoubtedly lead to this bacterium to be more easily identified and thereby allow more and more patients to reap the benefits of treatment.

Introducing Our New Patient Portal

Gastro Health has undertaken an ambitious program to improve customer service and streamline business processes using state-of-the-art technology. We are happy to announce the release of our patient portal.

Our patient portal looks much like a website, but the similarities end there. A website offers a static user experience while our web-based patient portal, intimately connected to our electronic health record, is an important gateway into our medical practice for our patients. Our portal provides a secure, HIPAA compliant, two-way communication channel between our patients and us, their health care providers. Unlike our practice’s office operations, the portal provides convenient, 24-hour self-service options. It allows patients to handle business and clinical interactions with our practice at their convenience and allows our staff to respond in an appropriate non-urgent manner.

While the features of portals may vary, the options typically allow patients to complete, manage, or communicate with their provider regarding:
• Registration
• Financial clearance
• Medical history
• Appointment scheduling requests and confirmations
• Appointment recalls for preventive and other recommended care
• Test results notification and tracking
• Patient – health care provider communication
• Online bill payment
• Prescription renewal

We believe that an interactive web portal can help answer a number of commonly asked questions, and also allows our staff to work on more productive endeavors such as patient education, patient services, collections, and insurance follow-ups. It provides enhanced services to the patients 24 hours a day, 7 days a week and improves our patients’ experience with Gastro Health.

Regardless of the specific functionalities, patients find value in a well-designed and functional patient portal because they feel like they are participating in their care process and have been given a greater menu of choices. A 2008 survey by the Commonwealth Fund found that 94 percent of consumers rated easy access to their own medical records as either “important” or “very important” to them.

Gastro Health’s patient portal will streamline access to our practice by offering patients self-serve access to many of the functions and information that they most value from health care providers. A recent survey by the Deloitte Center for Health Solutions found that nearly 80 percent of healthcare consumers were interested in gaining access, through their physicians, to an integrated medical record containing their test results, physician visits and other information. Three out of four surveyed wanted their physicians to provide online services to schedule appointments, get test results, access medical records and exchange E-mail.

Confirming the attitude of consumers to embrace portals, Intuit Health concluded that 72 percent of consumers would use a tool to help them pay their medical bills, easily communicate with physicians, make appointments, and obtain lab results online. Portals can meet all of these patients’ needs – and more.

Portal Benefits
A patient portal creates a single, customizable point of access to applications and information thereby providing tremendous value to our patients and our practice by strengthening physician-patient relationships, securely sharing information, improving practice operations and cost savings, improving accuracy, and increasing access while decreasing waiting times.

As patients are given more responsibility for their own health care costs, we at Gastro Health, feel that we must provide both quality and cost efficiencies in order to compete. Portals offer the transparency expected by a new breed of health care consumers who demand value and access. Forester Research analyst Elizabeth Boehm, who researches the role of online services in health care, concludes: “You wouldn’t consider not having a phone system, and the generations that are coming up are going to think it’s ridiculous not to be able to communicate via computer.”

So, we ask that you enroll in our patient portal. Go to our website (www.gastrohealth.com), visit our offices, or call us so you can create your username and password TODAY.

Start taking an active role in your healthcare!

Do You Know What a Mid-Level Provider Is?

Mid-level providers, such as Nurse Practitioners (NPs) and Physician Assistants (PAs) are an integral part of the medical team, working autonomously under the supervision of physicians to diagnose, manage, and treat a variety of medical conditions in settings such as primary care, surgery, and various subspecialties including gastroenterology.

At Gastro Health, PAs and NPs diagnose and treat a wide range of digestive and liver diseases. As highly trained licensed medical providers, NPs and PAs evaluate patients in both office and hospital settings. They perform physical exams and also order and interpret tests that include necessary labs, imaging, and procedures. They also prescribe medications to treat various medical conditions. Mid-level providers are fundamental in educating patients on their illnesses, as well as counseling patients on the importance of screening tests such as colonoscopies.

In the upcoming years, medical institutions will certainly see an increasing number of patients due to a growing population and the implementation of the Affordable Care Act. This will create an even greater demand on quality health care providers. With the expansion of health care, PAs and NPs will continue to play a key role as part of the health care team. Through preventative care, mid-level providers can focus on promoting health in a cost-effective way, while continuing to provide exceptional health care to patients alongside their physician counterparts.

Could I Have a Fatty Liver? Why Should I Care?

Nonalcoholic Fatty Liver Disease (NAFLD) is the term used for the buildup of extra fat within liver cells in individuals who consume little or no alcohol. This buildup of fat can cause inflammation and fibrosis (scarring) of the liver.

NAFLD is extremely common, and it is recognized as the most common liver disorder in western countries, including in adolescents and preadolescents. It affects about 1 in 25 adults in the United States (3 to10 times more common than Hepatitis C). NAFLD is diagnosed in approximately 8 out of 10 patients who are evaluated for abnormal liver tests.

What Causes Fatty Liver?
The exact cause is not known, but the main risk factors include obesity or overweight; diabetes; high cholesterol and/or triglycerides; and high blood pressure. Rapid weight loss and poor eating habits, as well as medications, may also cause fatty liver even in patients without those risk factors.

Most of the time, NAFLD does not cause any serious liver problems and most people with fatty liver will live as long as those without it; however, the disease can progress, leading to inflammation of the liver tissue, which is also called Nonalcoholic Steatohepatitis (NASH). The persistent inflammation can cause scarring, which ultimately can lead to cirrhosis of the liver. Patients with cirrhosis may develop complications such as liver cancer and liver failure, and may need liver transplantation. It is difficult to predict the course of this disease, but we know that patients who are older, diabetics and/or obese are the ones at higher risk for worse disease.

Why Should You Ask Your Doctor About Fatty Liver?
Fatty liver is usually silent; it causes no signs or symptoms until it is very advanced. It is commonly first noted by the finding of abnormal liver tests on routine blood work. If diagnosed early, liver damage can be prevented.

If your doctor suspects that you may have fatty liver, you will need blood tests to help exclude other causes of liver disease. Imaging studies (such as ultrasound) will likely be ordered and they may show fat accumulation in the liver. In some cases, a liver biopsy may be needed to confirm the diagnosis and/or to determine the severity of the disease.

Is There a Cure?
NAFLD cannot be cured, but it can be controlled, and prevented. There is no medication proven to effectively treat fatty liver disease. The treatment/prevention is focused on diet and exercise, aiming gradual weight loss and tight control of the associated conditions, such as diabetes, high blood pressure and high cholesterol/triglycerides.

If you have been diagnosed with fatty liver, you should strive to maintain a healthy weight with balanced diet and exercise; limit alcohol intake; only take medicines that you need and follow dosing recommendations; see your doctor regularly and consider a consultation with a liver specialist.