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GI Conditions/Patient Education

Celiac Sprue

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CRC Screening and Prevention

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Food Allergy

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Irritable Bowel Syndrome

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Non-Alcoholic Fatty Liver Disease (NAFLD)

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Celiac Sprue
What is celiac sprue?
Celiac sprue, aka celiac disease or gluten sensitive enteropathy, is an inflammatory disease of the small intestine due to exposure to gluten in the diet.
What is gluten?
Gluten is a component of dietary grains, notably wheat, rye, and barley. It is also commonly found in small quantities of prepared foods as an additive.
What symptoms are associated with celiac sprue?
Although commonly diagnosed by gastroenterologists, celiac disease is a systemic disorder and can result in neurologic symptoms, skin rash, joint problems, and infertility. It is more commonly diagnosed due to the presence of weight loss, diarrhea, anemia, and/or vague abdominal pain.
How common is celiac sprue?
It is common in the United States and Western countries. Prevalence can approach 5-15% in certain at risk populations, notably Caucasian females with a 1st degree family member with the disease. 0.5% to 1% of the population have positive blood tests for celiac sprue.
How is celiac sprue diagnosed?
Simple blood tests termed celiac serologies can be suggestive of celiac sprue, and a small intestinal biopsy is confirmatory. Most require that both tests be positive in order to establish the diagnosis.
What does one do if results of blood tests and biopsy are discordant?
Patients with discordant serologies and biopsy results need to be followed over time and retested at a later date if symptoms persist. Both celiac blood tests and biopsies can be falsely “negative” or normal if testing is done while an individual is following a gluten-free diet.
How is celiac sprue treated?
All symptomatic patients with celiac sprue should adopt and follow a gluten free diet. Consultation with a registered dietician is invaluable in educating patients about gluten containing products, particularly additives in processed foods. Grocers are capitalizing on the gluten-free market and making it easier for consumers to follow a gluten free diet.
Cirrhosis
What is cirrhosis?
Cirrhosis occurs when the normal liver cells are replaced by scar tissue which can cause liver dysfunction.
What does the liver do?
The liver is the largest solid organ in the body. It plays a vital role in regulating numerous processes in the body, including storage of nutrients, filtration of the bloodstream, digestion, and fighting off infection.
How is cirrhosis diagnosed?
Cirrhosis is confirmed with liver biopsy. However, clinicians can commonly diagnose cirrhosis based on interpreting physical exam findings and lab and X-ray data after taking a detailed history.
What are the most common causes of cirrhosis in the U.S.?
Viral hepatitis, alcohol, and non-alcoholic fatty liver disease. It is a common misconception that cirrhosis equates to excessive alcohol usage.
Does cirrhosis cause any symptoms?
Patients with cirrhosis are commonly free of symptoms and referred to as being in a “compensated” state of disease. “Decompensated” cirrhosis manifests in symptoms of a failing liver, notably fluid retention, gastrointestinal bleeding, or changes in personality or cognition. The latter is termed hepatic encephalopathy and ranges in severity from subtle word-finding problems to overt unresponsiveness.
Are there any options for treatment of cirrhosis?
In a few circumstances, cirrhosis can be reversed by treatment of the underlying disease. More commonly, cirrhosis is not reversible. Focus shifts to prevention and identification of complications of liver disease, notably gastrointestinal bleeding and liver cancer.
When does liver transplantation need to be considered?
Any individual with “decompensated” cirrhosis of any severity should at least be considered for liver transplantation.
Can liver cancer be prevented?
Liver cancer cannot be prevented. Any patient with cirrhosis, regardless of cause, is at increased risk for primary liver cancer. Similar to the role of mammography in the detection of breast cancer, various X-ray technologies can be used to screen for liver cancer. Liver cancer is treatable at an early stage and can often be used to increase an individual’s standing on a waitlist for liver transplantation.
CRC Screening and Prevention
Who should be considered for colon cancer screening?
Colon cancer screening should be offered to any individual at or around the age of 45. Some are screened earlier or more frequently due to family history or personal history of gastrointestinal disease.
What tests exist for colon cancer screening?
Colonoscopy, stool testing for blood, barium enema, and flexible sigmoidoscopy have been available for decades. Newer alternatives for colon cancer screening include CT colonography and stool DNA testing.
Are the newer technologies superior to colonoscopy?
No. While the image quality is improving, CT colonography exposes patients to radiation and offers no therapeutic benefit for polyp removal. Additionally, CT does not use any sedation and still requires a prep. Stool DNA testing is not widely available, and its utility has not been established. Colonoscopy remains the optimal strategy for colon cancer screening and prevention. It allows the entire colon to be seen and all visualized polyps removed. Because it is effective at colon cancer prevention, studies have confirmed that colonoscopy reduces both incidences of colon cancer and deaths from colon cancer.
Is colonoscopy perfect?
Colonoscopy is not perfect. Significant polyps can be missed in 6-12% of colonoscopies, and the procedure can result in rare complications. Endoscopic technique and adequacy of bowel prep/cleansing remain focal points of any good colon cancer prevention/screening program.
How does one accomplish adequate colon preparation?
Horror stories exist about colon preps for colonoscopy. Typically a patient will abstain from solids for 24 hours prior to the exam while taking in clear liquids. Traditional large volume purges can be difficult to tolerate due to volume and lack of palatability but still are well tolerated by many. Alternative options exist and can be discussed with a gastroenterology specialist.
How often is a colonoscopy required?
In the absence of colon polyps or a family history of early colon cancer, colonoscopy is recommended every 10 years.
Food Allergy
How common are adverse reactions to certain foods?
20% of individuals report unpleasant symptoms after eating specific foods.
How are adverse reactions to food classified?
These are classified as either immune-mediated (true food allergy) or non-immunologic. The latter is more common and synonymous with food intolerance.
What foods are most commonly implicated in true immune-mediated food allergy?
Cow’s milk, eggs, peanuts, shellfish, and seafood.
What symptoms can result from exposure to a food allergen?
Only 50% of individuals with food allergy have GI symptoms at exposure. The skin, respiratory tract, and cardiovascular system can also be involved, either in isolation or together with the GI tract.
What is the most common food intolerance?
Lactose. It results when an individual lacks specific small intestine enzymes which allow breakdown of lactose in dairy products. It is more common in those with African, Native American, or Mediterranean descent. Lactose intolerance can result in bloating, gas, and diarrhea on lactose exposure.
Can other carbohydrates cause similar problems?
Sorbitol and fructose are commonly found in processed food and juices are fermented by bacteria in the colon and can cause identical symptoms when ingested in large quantities.
Do all dairy products result in symptoms in those with lactose intolerance?
No. Some dairy products such as yogurt are low in lactose and should not cause symptoms in lactose intolerant individuals. Severe symptoms from these is more suggestive of irritable bowel syndrome.
GERD
What are Acid Reflux and GERD?
Acid reflux (also known as heartburn), which is most commonly recognized as a burning sensation in the chest beneath the breastbone or the upper abdomen. Acid reflux occurs when stomach acid splashes up in the esophagus: the muscular tube that connects the throat to the stomach. GERD is an abbreviation for gastroesophageal reflux disease, a condition that refers to damage to the lining of the lower esophagus GERD occurs as a result of frequent or prolonged exposure to stomach acid.
When should I be concerned about Acid Reflux?
Everyone experiences mild heartburn from time to time. If the symptoms progress or keep occurring over a long period of time, however, you should consult your doctor
What causes Acid Reflux?
Acid Reflux is caused by the malfunction of a valve called the lower esophageal sphincter (LES). This area of the esophagus is supposed to open to allow food and liquid to pass into the stomach and quickly clamp shut to keep stomach acid from flowing back into the esophagus.

The lining of the stomach is protected from digestive acid, but the lining of the esophagus is not. So, when the LES does not close properly and acid flows back into the esophagus, its lining can become inflamed causing esophagitis, readily seen on upper endoscopy.
When do I know if it is heartburn or GERD?
In general, if your symptoms are severe, frequent or getting worse, you need to be seen by a medical professional. Some indications that you may need an evaluation are: • If you take antacids 3 or more times a week, • If you take heartburn medicines other than antacids, • If heartburn interferes with your daily activities, • If your symptoms usually occur after meals, • If your symptoms interfere with your sleep, or • If medicine only helps relieve your symptoms for short periods of time.
What can I do to treat GERD?
A combination of lifestyle changes and medications is usually sufficient to control most individuals who suffer from GERD. Medications such as Ranitidine or Zantac may be used in milder cases and Omeprazole or Prilosec may be required for moderate to severe cases.
How can I change my lifestyle to improve my symptoms?
• Avoid caffeine, alcohol, tobacco, fried/fatty foods, chocolate, and peppermint • Minimize foods that may otherwise be healthy such as citrus, marinara sauce, garlic, and onions
• Eat smaller meals and avoid eating within three hours of bedtime • Raise the head of the bed to 6 to 8 inches to keep fluids out of the esophagus using gravity
• Avoid activities such as bending or stopping and wear loose clothing
Are there any complications from GERD?
Complications occur when GERD is severe or long-standing. The constant irritation of the esophagus by stomach acid can lead to inflammation, ulcers, and bleeding. Over time, scarring and narrowing of the esophagus can also develop, making it difficult to swallow foods and even resulting in an obstruction. This narrowing is called a stricture. Some patients develop a condition called Barrett’s esophagus, which is a precancerous condition.
Does my hiatal hernia need to be repaired?
Some patients with GERD may need surgery to strengthen the LES. This procedure is called fundoplication. This surgery is now usually done by laparoscopy. This is a newer type of minimally invasive surgery, performed with a tiny incision at the naval and a few needle points in the upper abdomen. The patient usually returns home 1-2 days after surgery, with few problems. Surgery, however, should not be considered until all medical treatments have been tried. Surgery is often seriously considered for an otherwise healthy patient when the disease is severe, or the patient wants to avoid the expense or regimen of long-term treatment with medications.
Irritable Bowel Syndrome
Is there a treatment for IBS?
Eating a diet high in fiber can be helpful. Over-the-counter bulking (insoluble fiber) agents such as psyllium mucilloid (Metamucil, Konsyl) or methylcellulose (Citrucel) serve to hold water and help IBS patients with constipation. Natural foods such as oatmeal, bran layers of cereal grains, fruits and vegetables (soluble fiber). You may also benefit from eating smaller, more frequent meals to minimize the “spastic” response.

Antispasmodic medications can help relax the muscles in the wall of the colon, reducing the bowel pressure and interrupt cascades or cramping. Exercise is very beneficial in helping the bowel relax even during non-exercise periods.

Stress reduction techniques are helpful but may be different for each patient.
Are there different Kinds of IBS?
Although IBS can be thought of as one disorder, health professionals categorize IBS into three different conditions: Diarrhea Predominant Irritable Bowel Syndrome (IBS-D), Constipation Predominant Irritable Bowel Syndrome (IBS-C) and Alternating Irritable Bowel Syndrome (IBS-A). There are prescription medications that may be used for IBS-C and IBS-D, while IBS-A relies more on fiber and antispasmodics agents. Other disorders and diseases may masquerade as IBS and can be resolved, while IBS requires long term changes in lifestyle. You should consult your health care provider to determine which therapy is right for you.
Irritable Bowel Syndrome is not a disease
Although the symptoms of IBS may at times be severe, the disorder itself is not a serious one. There is no actual disease present in the colon. In fact, an operation performed on the abdomen would reveal a perfectly normal appearing bowel.

The syndrome is considered a functional disorder. The condition usually begins in young people, usually below 40 and often in the teens. The symptoms may wax and wane, being particularly severe at some times and absent at others. Over the years, the symptoms tend to become less intense or lifestyle changes used as a coping mechanism minimize the problem.
How did I get IBS?
Some investigators believe that IBS may occur after exposure to an intestinal virus. Others with IBS know that stress is a major contributor to the severity of IBS symptoms. Episodes of IBS may be triggered by preservatives or flavor enhancers such as MSG.
Why does Irritable Bowel Syndrome cause pain?
The colon, the last five feet of the intestine, serves to dehydrate and store the stool so that, normally, a well-formed soft stool occurs. The colon also quietly propels the stool from the right side over to the rectum, storing it there until it can be evacuated. This movement occurs by orderly contractions of the colon. With IBS the colon will contract in a disordered fashion leading to spasms that may be prolonged or severe. Some IBS patients may experience bloating or cramping while others may encounter abdominal distress which can be severe. It is not unusual to see mucous in the stool.
What is Irritable Bowel Syndrome?
Irritable bowel syndrome (IBS) is known by an assortment of other terms: spastic colon, spastic colitis, mucous colitis and nervous or functional bowel. It is thought of as a disorder of the large intestine (colon), although other parts of the intestinal tract may also be involved.
Non-Alcoholic Fatty Liver Disease (NAFLD)
What is non-alcoholic fatty liver disease (NAFLD)?
NAFLD is a liver disease characterized by fat deposition in the liver. It has a spectrum of severity based on liver biopsy appearance and symptoms.
Is NAFLD common?
Yes. When using ultrasound alone for detection, its prevalence approaches 50% of primary care patients. Only a percentage of these go on to have progressive liver disease.
Why do people get NAFLD?
NAFLD commonly occurs in association with some or all of the components of the metabolic syndrome:

1. Central obesity 2. Hypertension
3. Diabetes or glucose intolerance 4. Low HDL/High LDL

It is seen that diet and lifestyle choices over years play a contributing role to its development and evolution.
What is NASH?
NASH is an acronym for Non-Alcoholic Steatohepatitis. It is the most severe form of NAFLD and is often progressive, resulting in cirrhosis and its complications. Its microscopic appearance is virtually indistinguishable from alcoholic liver disease, and differentiation requires a detailed history.
Are there any risk factors for developing more severe NAFLD or NASH?
Body mass index (BMI), diabetes, level of liver enzymes, and Hispanic race.
Do all patients with NAFLD need a liver biopsy?
No. Labs and ultrasound can usually determine if a patient has fatty liver disease. Liver biopsy can diagnose NASH, which is important, particularly in younger patients. Identifying NASH is important because it places patients in a higher risk subgroup and justifies a more aggressive treatment strategy.
Are there any treatments?
Treatment primarily centers on lifestyle modifications, particularly related to caloric consumption and exercise/energy expenditure. High fructose corn syrup consumption and fast food intake have both been linked to NAFLD. A rigorous program of caloric restriction to 1500 kcal daily and 200 minutes of low impact exercise/week resulted in regression of NASH on liver biopsy.
What about medications?
No medications have been proven to universally work in NAFLD. Some studies suggest benefit of vitamin E, but this should only be used under the direction of a provider familiar with NAFLD.
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