Join Gastro Health’s Crohn’s and Colitis Support Group

Inflammatory bowel diseases (IBD) are considered autoimmune diseases, in which our own immune system attacks elements of the digestive system. The main forms of IBD are Crohn’s disease and ulcerative colitis.

 

The difference between Crohn’s disease and ulcerative colitis is its location and nature of the inflammatory changes. Crohn’s can affect any part of the gastrointestinal tract, from mouth to anus, although a majority of cases start in the terminal ileum. Ulcerative colitis, in contrast, is restricted to the colon and the rectum. Finally, Crohn’s disease and ulcerative colitis present with extra intestinal manifestations (such as liver problems, arthritis, skin manifestation and eye problems) in different systems. Although Crohn’s and ulcerative colitis are very different diseases, both present with many of the following symptoms: abdominal pain, vomiting, diarrhea, rectal bleeding, severe internal cramps/muscle spasms in the region of pelvis, and weight loss.

 

Living with chronic diseases such as IBD can sometimes be discouraging, and patients can feel overwhelmed and have many questions regarding their disease. During the past 5 years, Gastro Health has been providing educational support group meetings for IBD patients. These meetings take place quarterly. Through our educational meetings, we have been offering patients with a variety of information on how to take care of themselves while living with this chronic illness. Our speakers have included physicians, dietitians, nurse practitioners, physician assistants and clinical nurse specialists. We have taught our IBD patients about diets and treatments, and we have also discussed the latest research studies regarding future treatments.

 

Our meetings also serve as a support group for IBD patients. Support groups are an integral part of many health care organizations and a crucial foundation for those coping with chronic illnesses. Support groups bring together those who share a common diagnosis. This gives patients a venue to exchange ideas, ways of coping, share personal experiences and most importantly, to provide emotional support. These groups are more than just a safety net for patients; they can also improve physical health and wellness of participants. Just as in all support groups, our support group is completely confidential and allows the patient to feel safe and comfortable to voice their questions and feelings. We also encourage our patients to bring any member of their family, if desired.

 

Studies show that people with chronic illnesses who attend support groups feel “less anxious, depressed and alone.” Probably the greatest advantage of support group therapy is to help the patient realize that he or she is not alone, and that there are other people who have the same problems. This is often a revelation, and a huge relief to the person.

 

While not everyone wants or needs support beyond that offered by family and friends, patients may find it helpful to turn to others outside of their immediate circle. As support group participants make connections with others facing similar challenges, they can cope better and will feel less isolated. A support group shouldn’t replace patient’s standard medical care, but it can be a valuable resource to help them cope.

 

 

As an overview the benefits of

support groups are:

 

•   Feeling less lonely, isolated or judged

•   Gaining a sense of empowerment and control

•   Improving coping skills and sense of adjustment

•   Talking openly and honestly about feelings

•   Reducing stress, depression or anxiety

•   Developing a clear understanding of what to expect while living with a chronic disease

•   Getting practical advice and information about treatment options

•               Comparing notes about coping skills, experiences and exchanging emotional support

Medidas de Calidad en Gastroenterologia

Las “Medidas de Calidad de Servicio” son usadas para evaluar la eficiencia de los servicios de salud. Las medidas utilizadas son las aprobadas por el “National Quality Forum” (NQF), una organización de servicio público sin fines de lucro o afiliación política, formada por todos los interesados en salud (consumidores y proveedores de cuidados de salud).

Estas medidas han sido creadas con el fin de generar información que ayude al consumidor a tomar decisiones basadas en información pertinente. Además, se espera que favorezcan la transparencia y responsabilidad de los proveedores de salud. En el 2011, el NQF y el Departamento de Salud y Servicios Humanos de los Estados Unidos crearon la “Estrategia de Calidad Nacional”, la cual produjo el Grupo de Medidas de Rendimiento Nacional (NPMS), un grupo de medidas de calidad que miden los resultados de salud, experiencia del servicio recibido, y recursos utilizados. La mayoría de las Medidas de Calidad usadas por el Centro para Servicios de Medicare and Medicaid (CMS) y los seguros de salud comerciales están contenidos en el NPMS.

A petición de la ley llamada Acto de  Protección al Paciente y Cuidado Asequible (Affordable Care Act) del 2010, CMS (Medicare&Medicaid) creo el sitio de internet llamado “Physcian Compare”, el cual reporta la calidad de los servicios médicos. Este sitio de internet fue lanzado en diciembre 30 del 2010, y CMS planea agregar información sobre calidad en el 2014.

La medidas de Gastroenterología del NPMS fueron desarrolladas con la cooperación de las diferentes sociedades de gastroenterología en los Estados Unidos (AGA, ASGE, ACG, AASLD), y la Fundación Americana de Crohn’s y Colitis a las medidas relacionadas a enfermedad inflamatoria intestinal (Enfermedad de Crohn y Colitis Ulcerativa).

En la actualidad, las medidas de calidad específicas a Gastroenterología tienen que ver con Cáncer Colorectal (CCR), Hepatitis C (HCV), enfermedad inflamatoria intestinal (EII), y Reflujo Gastroesophagico (RGE). Estas medidas no son el único cuidado que los pacientes con estas condiciones deben recibir, pero si son indicadores de la calidad del servicio recibido en el tratamiento de ellas.

Detección de Cáncer Colorectal

El Cáncer Colorectal (CCR) es el tercer cáncer más común en hombres y mujeres, y la segunda causa de muerte por cáncer en los Estados Unidos. El CCR se puede prevenir con la detección temprana y eliminación de pólipos adenomatosos. La colonoscopia de detección precoz de CCR/pólipos  (examen con una cámara endoscópica del colon para detección de pólipos en personas sin síntomas o historia de pólipos o cáncer) y/o vigilancia (personas con historia personal o familiar de CCR o pólipos) han mostrado que reducen el número de muertes causadas por CCR al detectar y eliminar pólipos importantes, y por diagnosticar tumores tempranos cuando aún pueden ser curados.

Es importante que pacientes conozcan lo siguiente:

A) Los pólipos adenomatosos son comunes en adultos después de la edad de 50, pero la mayoría de ellos no se transformaran en cáncer colorectal; el tipo de tejido (histología) y el tamaño determinan el riesgo de malignizarse.

B) Pólipos adenomatosos, o adenomas, representan de la mitad a dos tercios de todos los pólipos del colon, y tienen riesgo de progresar a un CCR.

C) Adenomas “avanzados” (con el más alto riesgo de cáncer) son aquellos pólipos más grandes de 10 milímetros, con tejido mostrando “displasia de alto grado”, o con un componente “velloso” (adenoma velloso, o adenoma tubulovelloso).

La Colonoscopia

En la actualidad, la colonoscopia es el mejor que se puede usar para la detección temprana de CCR y adenomas del colon en pacientes sin síntomas de 50  o más años de edad. Las medidas de calidad (ver la tabla) tratan de evaluar que la colonoscopia de detección temprana empiecen a la edad correcta. La edad de 50 años o mas es usada para pacientes sin historia personal o familiar de cáncer de colon o adenomas de colon. La edad de 40 años, o 10 años antes de la edad del caso mas joven en la familia inmediata, es usada para pacientes con CRC o adenoma de colon en un familiar de primer grado antes de los 60 años, o en dos familiares de segundo grado de cualquier edad. La recomendación de cuando repetir una colonoscopia depende de los hallazgos en la colonoscopia previa, 10 años después de una primera colonoscopia negativa, y usualmente entre 3-5 años para aquellos pacientes con pólipos dependiendo de cuantos pólipos fueron sacados y si fueron considerados como adenomas avanzados.

Tasa de Detección de Adenomas

La detección de adenomas del colon depende de la calidad de la colonoscopia. La medida de calidad llamada “tasa de detección de adenomas” (TDA) es la proporción de individuos a los que se le hacen una colonoscopia de detección temprana a quienes se les encuentra uno o más adenomas. El valor de referencia recomendado para una colonoscopia de detección temprana es una TDA de al menos 15% en mujeres y al menos 25% en hombres. Existe un aumento del riesgo de que un CCR aparezca antes de la siguiente colonoscopia cuando esta es realizada por un endoscopista con un TDA de menos de 20%.

Por último, la limpieza adecuada del colon antes de lacolonoscopía es un elemento crítico para que el examen sea exacto y costo-efectivo. El dividir el total de la preparación en dos partes iguales con la segunda parte tomada 4 horas antes de la colonoscopía, o tomar toda la preparación el mismo día del examen, ha mostrado que mejora la calidad de la preparación y aumenta la detección de pólipos importantes. n

Quality Measures in Gastroenterology

Quality measures are tools used to evaluate how well healthcare services are being delivered. The quality measures adopted are those endorsed by the National Quality Forum, a nonprofit, nonpartisan public service organization formed by all those interested in healthcare (consumers and providers of health care). Among the goals of creating these measures are to generate data that will help consumers make informed choices about their healthcare. In addition, these measures are expected to enhance transparency and accountability.

 

In 2011, the NQF and the U.S. Department of Health and Human Services created the National Quality Strategy, which resulted in the National Performance Measure Set (NPMS), a group of quality measures to assess health outcomes, patient experience, and resources used. Most of the Quality Measures used by the Center for Medicare & Medicaid Services (CMS) and commercial insurances are contained in the NPMS.

 

CMS was required by the Patient Protection and Affordable Care Act (ACA) of 2010 to establish the Physician Compare website, which was launched on December 30, 2010. CMS plans to add quality data, and will post the first set of measured data in 2014 from data collected not sooner than 2012.

 

The Gastroenterology (GI) part of the National Performance Measures Set (GI-NPMS) was developed by the cooperation among the different gastroenterology societies (AGA, ASGE, ACG, AASLD), and the Crohn’s and Colitis foundation of America (CCFA) for the measures related to Inflammatory Bowel Disease.

 

Currently the quality measures which are specific to gastroenterology have to do with Colorectal Cancer (CRC), Hepatitis C infection (HCV), Inflammatory Bowel Disease (IBD), and Gastroesophageal Reflux Disease (GERD). They are not the only care a patient with these conditions should receive, but they are indicators of the quality of care being given.

 

Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most common cancer diagnosed among men and women, and the second leading cause of death from cancer in the United States. CRC may be prevented by early detection and removal of adenomatous polyps. Screening colonoscopy refers to the endoscopic exam of the colon in people without symptoms or history of CRC or polyps, while surveillance colonoscopy refers to the same type of exam but to people with history of colon polyps or CRC. Colonoscopy has been shown to reduce the mortality associated to CRC by detecting and removing significant colon polyps, and diagnosing early lesions when they are more amenable to a curative approach.

 

The current CRC screening recommendations are based on the following:

1) Adenomatous polyps are common in adults over age 50, but the majority of polyps will not develop into colorectal cancer; tissue type (histology) and size determine their risk of evolving to CRC.

2) Adenomatous polyps, or “adenomas”, represent approximately one half to two thirds of all colorectal polyps, and are associated with a higher risk of CRC.

3) Advanced adenomas (higher risk of malignant transformation) are those polyps larger than 10mm, histologically (tissue) having high-grade dysplasia, or showing a significant villous components (villous adenoma, or tubulovillous adenoma).

 

 

Colonoscopy

 

Currently, colonoscopy is the best screening option for early detection of CRC and adenomatous polyps for asymptomatic adults age 50 or older. The CRC quality measures (see table) try to assess that a screening colonoscopy starts at the appropriate age. The age of 50 years or older is used for average risk patients, defined as lack of a personal or family history of CRC or colon adenomas.  The age of 40 years, or 10 years before the youngest case in the immediate family, is used for patients with either CRC or adenomatous polyps in a first-degree relative before age 60 or in 2 or more first-degree relatives at any age. The time interval to repeat a colonoscopy will depend on the findings, with 10 years for a negative colonoscopy, and usually between 3-5 years for those with polyps removed, depending on number of polyps and whether they were considered advanced.

 

Adenoma Detection Rate

The detection of adenomatous polyps depends on the quality of the colonoscopy. The quality measure called the Adenoma Detection Rate (ADR) is the proportion of individuals undergoing a complete screening colonoscopy who have one or more adenomas detected. The recommended benchmarks for a quality colonoscopy have been an ADR on screening colonoscopies of at least 15% in women and at least 25% in men. There is an increased risk of a CRC lesion appearing before the next screening colonoscopy is indicated when the procedure is performed by an endoscopist with a lower than 20% ADR.

 

Lastly, an adequate bowel preparation (cleansing) is a critical element in the accuracy and cost-effectiveness of CRC screening. Either splitting the preparation in 2 equal parts with the second part taken four hours before the colonoscopy, or taking the entire preparation the same day of the procedure, have been shown to improve the quality of the preparation and increase the detection of significant polyps. n

 

Research: Be Part of the Answer

By: Ivette de Pool

 

The National Institute of Health defines clinical trials as research studies that test how well new medical approaches work in people. Each study answers scientific questions and tries to find better ways to prevent, screen for, diagnose, or treat a disease. Clinical trials may also compare a new treatment to a treatment that is already available.

So why should you participate in research? Have you ever considered it? Being a part of research is necessary to bring about advancements in the medical field. Without studies and potential volunteers, scientists will never really know how the body fully functions. Advancements in medicine have all come about because someone just like you decided to make a difference.

Participating in a clinical trial is a major decision and should be considered with plenty of time. When an individual agrees to participate in a research trial, this process is called “Informed Consent.” By signing the Informed Consent, the participant is agreeing to all the terms and conditions set forth in the protocol.

At Gastro Health, our mission is “to provide outstanding medical care and an exceptional healthcare experience.” We believe that clinical research is vital in order to fulfill our mission. For over two decades, the physicians at Gastro Health have been involved in clinical research studies, aiming to restore the way we think about research in general. Only by clinical trials and research is it possible to find newer, more innovative therapies. Focusing on education about clinical trials allows for the advancement of new discoveries that will aid in the treatment of diseases for generations to come.

 

If you haven’t already done so, now is the time to consider being a part of medical research. Currently, Gastro Health Research offers several study opportunities in the following treatment areas:

  • Crohn’s Disease
  • Ulcerative Colitis
  • Capsule Endoscopy
  • Anemia
  • Colorectal Cancer Screening
  • Clostridium Difficile Associated with Diarrhea (CDAD)

 

Eligible participants may even receive compensation for their time and travel.  To learn more about Gastro Health’s research studies, please contact: (786)456-8676 or visit our website at www.gastrohealth.com/research. Clinical research trials can potentially aid in the saving of lives and improve overall health.

 

Be part of the answer; be part of the change.

Participate now!

 

 

 

Sacral Nerve Stimulation: A New Effective Option for the Treatment of Fecal Incontinence

Fecal incontinence is the involuntary loss of fecal material through the anus. Both continence and defecation are very complex functions, involving multiple muscles and nerves to work together in a very sophisticated way.

It is estimated that at least 18 million Americans suffer from this problem and it is not surprising that they do not want to talk about it with anybody, not even with their physicians which they might see often and regularly for other health problems. On the other hand, physicians don’t usually ask about this issue either, unless they are specialists. That is why it is thought that the real magnitude of this condition is largely under-estimated.

Fecal incontinence weighs down heavily on these patients’ lives; they feel alone, anxious and humiliated. Many prefer to remain confined in their houses and adjust their social and professional lives to avoid embarrassment. In other words, the disease wins.

Common Causes

The most common causes of fecal incontinence are anal sphincter damage due to trauma, previous rectal surgery or vaginal delivery; or damage to the pudendal nerves (the nerve that controls the pelvic floor muscles and transmit the sensation from the rectal area to the brain) either from trauma, pregnancy or diabetes. Female patients are especially vulnerable because of the stress and possible injuries that pelvic muscles and nerves withstand during pregnancy.

Treatment

Because of its complexity, it is extremely difficult to manage fecal incontinence. Even though we have the capability to comprehensively study the physiology and anatomy of the anorectal sphincter and pelvic floor muscles, treatment very often consists of simple diet modification (fiber supplements and anti-diarrhea medications), pelvic floor physical therapy (Biofeedback), or complex surgical procedures when there is obvious and severe muscle damage.

The Sacral Nerve Stimulator, or InterStim Therapy, represents a real breakthrough in our ability to treat fecal incontinence. In the appropriate patient, chronic stimulation of the sacral nerve has been proven to decrease at least half the number of weekly episodes of fecal incontinence in 70-90% of patients, and has also proven to completely cure it in about 30-50% of them.

InterStim Therapy is a two-stage, minimally invasive procedure performed in same-day surgery under local anesthesia and sedation. The first step consists of the implantation of a small wire in one of the openings of the sacral bone, which is then connected to a temporary portable stimulator. The patient goes home and records the number of episodes of incontinence for about two weeks. If the stimulation is effective, a second procedure is performed to implant the permanent stimulator.

In my experience, this procedure has given amazing results. It has been a privilege to see patients that were uncomfortable and self-conscious from just going out for dinner become confident again, taking back their lives and living them to the fullest. Everything starts with the little step of realizing that you do not have to suffer in silence and that there is a lot we can do. Let’s talk about it.

The New Face of Intestinal and Multivisceral Transplantation

By: Rodrigo Vianna and Thiago Beduschi

The first isolated intestinal transplant was described almost 50 years ago and it has been 30 years since the first multivisceral transplant was performed. Even though there has been remarkable progress after four  decades, intestinal transplantation remains a rare event and is only performed by a handful of centers throughout the world. Improvements in surgical techniques, critical care, immunosuppressive drugs, and immune-monitoring combined with a better understanding and management of the complications have resulted in excellent outcomes in the modern era, even comparable to other solid organ transplants.

In the last decade, new indications have come along with improvements in outcomes. Other than the traditional patient with short-gut syndrome and life-threatening complications from the total parenteral nutrition (TPN), indications now include:

• Complex porto-mesenteric thrombosis (where liver transplant is not technically possible)

• Slow growing and non-resectable intra-abdominal tumors (neuroendocrine/ desmoid tumors)

• Gastrointestinal pseudo-obstruction (and other severe dysmotility disorders)

• Abdominal catastrophes (trauma, open abdominal cavity, multiple enteric fistulas)

• Quality of life

Peri-operatory mortality is rare in experienced hands and hospital stays have been decreasing drastically, with several patients leaving the hospital in less than three weeks with no central lines and complete enteral autonomy.

Most of the patients achieve enteral autonomy in two to three weeks after the transplant and do not require any additional nutrition or hydration other than by mouth.

Intestinal transplantation has proved to be cost effective when compared to TPN. After two and half years, transplant becomes cheaper than all the costs related to parenteral nutrition. Quality of life is another point in favor of transplant. Patients report going back to their regular activities. Freedom from lines and their complications is one of the highlights for patients.

Intestinal and multivisceral transplantation is not free of complications. One of the main factors affecting the final outcome is the patient condition at the time of the surgery. Patients coming from home perform much better than patients coming from the hospital at the time of transplant.

 

For this reason, early referral to a specialized intestinal transplant center is fundamental for better outcomes. It is common to be referred patients who already have limited vascular access, TPN induced liver disease and multiple infections. In some cases, complete lack of central venous access can preclude the transplant.

 

Intestinal and multivisceral transplantation has now evolved to be a valid therapy for complex patients, restoring the physiology of the abdominal cavity, the ability to eat and at the same time eradicating the baseline disease.

What is Eosinophilic Esophagitis?

Eosinophilic Esophagitis (EoE) is a chronic condition in which the immune system causes inflammation to the esophagus – the tube which carries food from the mouth to the stomach. In EoE, the lining of the esophagus has certain cells called “eosinophils” which cause inflammation and do not let the esophagus function properly. Eosinophils are allergy cells that normally are not seen in the esophagus. The exact cause of EoE is unknown, but it is thought to be related to allergies, in particular food allergies.

 

What are the common symptoms?

The symptoms of Eosinophilic Esophagitis can vary with age. Adults and teenagers usually develop symptoms of trouble swallowing as the most common symptom. It can begin with difficulty swallowing solid food or even the feeling as if food is getting stuck in the throat or chest.  Other people can experience chest or upper abdominal pain, and possibly chest burning known as heartburn. In children, it usually presents with different symptoms such as refusing to eat solid foods, nausea or vomiting, and also abdominal pain. Patients with Eosinophilic Esophagitis can have other allergic disorders such as asthma, hay fever, or eczema.

 

How is Eosinophilic Esophagitis diagnosed?

Eosinophilic Esophagitis can be challenging to diagnose at first because it can resemble other conditions. However, the best available test to check for this condition is an upper endoscopy with biopsy. An upper endoscopy is a procedure performed by a gastroenterologist during which a small flexible tube with a camera is introduced through the mouth and passed into the esophagus. The lining of the esophagus can be looked at and a small piece of tissue from the esophagus is removed (biopsy).  The sample of the tissue obtained is then sent to a pathologist to view under a microscope and determine if you have Eosinophilic Esophagitis. At times, blood tests can show elevated levels of eosinophils, but this alone does not make the diagnosis.

 

How is Eosinophilic Esophagitis treated?

The treatment of Eosinophilic Esophagitis involves diet changes and medications which help control symptoms. As an initial approach, certain foods that commonly cause allergy are avoided in order to improve symptoms. These may include milk, egg, soy, peanuts, shellfish, and wheat. Patients can be sent to an experienced dietician to help with learning how to shop and substitute foods. Otherwise, patients can be referred to an allergist for further testing to determine food allergies.

There are also different medications used to treat Eosinophilic Esophagitis. One common medication is called “Proton Pump Inhibitor” (PPI), which is commonly used to treat acid reflux. This medication blocks acid, which can trigger symptoms or contribute to the inflammation. Other medicines used include steroids, which help reduce inflammation and therefore improve symptoms.  In some patients with EoE, inflammation may progress and cause narrowing of the esophagus which is known as an esophageal stricture. This is treated by performing an upper endoscopy and widening the esophagus, called dilation. Eosinophilic Esophagitis has become more commonly recognized and visiting your doctor can lead to its discovery.

Women’s Corner – More Options than Fiber and Water

Many women suffer from constipation and hemorrhoids.We now have several new medications for constipation.They are Linzess and Amitiza. As women get older,constipation becomes more common. Most women try to increase water intake and fiber however, in certain individuals, this is not enough. With these new treatments which come in pill form, constipation can be treated easily. In addition, after childbirth or when suffering with constipation, women typically develop hemorrhoids. We have several medications to treat hemorrhoids. We also have a new method of performing an old procedure. Hemorrhoid ligation can now be performed in the office.
The new method is quick and painless. Please call with any questions or to make an appointment to discuss these new medications or hemorrhoid ligation.

Women's Corner - More Options than Fiber and Water

Gluten Reality & Myths

Gluten – once a relatively obscure protein found in the grain products and known only to gastroenterologists, dieticians, and a few patients diagnosed with Celiac disease – has become a hot topic during the last few years. It is now purported to be the cause of many health problems for some people, and its avoidance is touted as the secret to a long, healthy, and happy life. Let’s try and separate the hard hard facts, possibilities and myths.

Gluten is found in several types of grains – barley, rye, oats, and wheat. Pure oats do not contain gluten, but those in commercially processed food often do. Gluten is what gives many of our favorite foods their body and texture, like in cookies, breads, pizza dough, and pasta. It can also be found in beer. It is ubiquitous in most of our diets.

When a person’s immune system reacts to the gluten protein, Celiac disease occurs. The normal lining of the small intestine has innumerable microscopic finger-like projections called villi; these projections increase the surface area of the intestines to maximize absorption of nutrients. When Celiac disease occurs, the villi are attacked by antibodies and destroyed, flattening out the villi and resulting in decreasing the absorptive capacity of the intestines. Although there is not a strict family link to the condition, there is a genetic basis which, combined with as of yet undefined environmental factors, means that often more than one family member may be affected. There can be many consequences of this condition including chronic diarrhea, iron deficiency, various vitamin deficiencies and calcium malabsorption, to name a few. Symptoms may include gas and bloating, diarrhea, abdominal pain, and weight loss. It can also cause a skin condition called dermatitis herpetiformis which appear as small clear pimples. Celiac disease can be found in adults as well as children. Some of the symptoms can mimic other conditions such as Irritable Bowel Syndrome (IBS), Crohn’s disease, Ulcerative Colitis, and lactose or other food intolerances. The diagnosis is made by blood tests combined with a biopsy of the first part of the small intestine called the duodenum. This can be done during an upper endoscopy. If a patient with Celiac disease has been following a strict gluten-free diet for 6 or more months, both the blood tests as well as the biopsies may look normal.

The treatment for Celiac disease is simple yet difficult – avoid foods that contain gluten. This is simple because there are no other restrictions or medications; it is hard because gluten is in many of the foods that make up our daily diets. It is hidden in sauces, drinks, and even in some medications.

People with Celiac disease become excellent label and menu readers. There are a host of gluten-free products available at the super market and online – breads, cookies, pastas and yes, even beer. Many restaurants now also feature gluten free items. With the avoidance of gluten, the damage to the small intestines is repaired and the symptoms and nutritional issues resolve.

Recently, there have been a number of conditions ascribed to gluten without having Celiac disease. “Non-celiac gluten sensitivity” has become a commonly described condition to explain a variety of symptoms such as chronic abdominal pain, fatigue, constipation, or diarrhea, immune dysfunction, depression and a general lack of wellbeing. There are a few scientific studies to support the connection between these non-specific symptoms with gluten, but many people swear they feel better after removing it from their diet.

Other than the inconvenience of following the diet, there is no harm in removing gluten from one’s nourishment – so if it makes a patient feel better. it should not be discouraged. Because a strict gluten-free  diet usually contains fewer calories, it often leads to weight loss. Losing weight is beneficial for many people and often weight loss alone will give people a sense of feeling healthier and having more energy.

If you suspect you have Celiac disease or non-celiac sensitivity- discuss it with your physician. Appropriate testing as well as proper nutritional counseling can then be arranged.

 

Advanced Endoscopic Techniques at Gastro Health

By: Javier L. Parra

As gastroenterologists, there are times when the tools available can’t give us enough information, or reach deep enough to treat the problems that our patients suffer from. Therefore, over the past few decades, a field of advanced endoscopy has developed to help gastroenterologists reach deeper and obtain better information, as well as treat difficult conditions through natural orifices, while avoiding surgery.

In this article, I will elaborate on two of these techniques, although all advanced endoscopic procedures are available at Gastro Health.

Device Assisted Enteroscopy

“Entero” is derived from the Greek word “enteron” for intestine, “-oscopy” is derived from the Greek word “skopos” for looking/observing. Hence, enteroscopy is a procedure performed to visualize the intestine. Particularly, the small intestine.

On average, an adult human has about 15 feet of small intestine, where most of the digestion and absorption of nutrients takes place. The small intestine used to be considered a black box, in the sense that because it was difficult to visualize and obtain tissue from. In the past, ropes with weights were given to the patient in order to have them defecate them after a few days, then endoscopes were attached to them as they were pulled out of the patient’s mouth. This was called rope-way enteroscopy. Fortunately, these techniques have significantly evolved, and we can now use a longer, flexible, high definition camera that is inserted under sedation and has the ability to obtain biopsies, open narrowing’s and take out large polyps. These devices are used in association with a sleeve, or overtube that has a balloon, or a spiral. The balloon can be inflated, or deflated; the spiral can be rotated and the sleeve can be moved back and forth on the scope, in order to help advance the scope through the intestine. To try to visualize this, imagine you are pleating the small bowel onto itself, much like an accordion.

The majority of patients undergoing this type of procedure are those with obscure gastrointestinal bleeding. Those that have had anemia of unknown origin with some evidence of blood loss through the gastrointestinal tract can have small blood vessels that are very superficial and delicate and will bleed slowly, causing the patient to have anemia. Cauterization of these vessels can be performed. Others have had abnormal imaging studies, such as CAT scans, MRIs, or even capsule endoscopies, which have to be confirmed with direct visualization. Lymphomas, muscular tumors, cancers and inflammatory bowel diseases, such as Crohn’s disease can be diagnosed with device assisted enteroscopy.

 Cholangioscopy

This technique is used to access the bile duct with a small scope that goes through the working channel of another scope. This is called a mother-daughter system, where the mother scope is used to access the bile duct with wires, while the physician performing the procedure interprets x-ray images. Once the daughter scope is advanced, direct visualization of the bile duct and its lining, as well as its contents is possible. This technique is useful in diagnosing biliary tract cancers, as it allows the gastroenterologist to direct their forceps to obtain samples from the abnormal areas, as opposed to directing a brush to the abnormal appearing area on an x-ray.   Also, it allows us to treat difficult to withdraw bile duct stones with a technique called lithotripsy. Thin and long catheters are advanced through the daughter scope and into the bile duct, where they apply shock wave, or laser energy in order to destroy these stones. Foreign bodies can be removed, and suspicious areas examined with this technique as well. Once again, this advanced endoscopic technique can avoid the patient a delay in diagnosis and also can treat difficult biliary diseases that were previously considered to need surgery.

In conclusion, gastroenterologists have seen the evolution of endoscopy to be able to help patients obtain an accurate, prompt diagnosis and to avoid more invasive procedures, such as surgery. These procedures used to only be available at university-based institutions, however, at Gastro Health, fellowship trained physicians have made these widely available to our community.