If you have recently been diagnosed with an iron deficiency anemia, your provider may recommend that you see a gastroenterologist for evaluation.  The reason for this is that unless there is a reason for blood loss, such as a recent trauma or surgery or heavy menstrual cycles, the GI tract is the largest organ system to cause blood loss.

Let’s start from the beginning.  The World Health Organization defines anemia as a hemoglobin <13.0 in men and <12.0 in women.  Anemia can occur when an individual is losing blood, not making blood properly, or not absorbing iron/nutrients properly.  There are many sources or causes for bleeding stemming from the gastrointestinal tract.  This could be from bleeding colon lesions, like a colon cancer or larger polyp; a malabsorption condition, like celiac disease; or abnormalities with the bleed vessels along the GI tract.

So, where do we start?  Once a diagnosis of anemia has been made, you will be brought into the office to see one of our providers.  The provider will take a detailed personal and family history and perform an evaluation.  The examination will include a physical examination to assess the abdomen, but may also include a rectal exam to see if there are any palpable anorectal lesions or hemorrhoids and test the stool for occult, or hidden, blood.  Blood work may also be ordered to further clarify the type of anemia.  We often will want to check your iron studies, vitamin levels, and blood making ability.  Once we have that information, we can formulate a plan to evaluate the GI tract.

If you are over the age of 50 and have never had colon cancer screening (younger if there is a family history) or if you have any concerning lower GI symptoms, a colonoscopy will be the first test performed.  The colonoscopy will evaluate the entire surface space of the colon to assess for polyps, tumors, hemorrhoids, or mucosal abnormalities.  If you are not of colon cancer screening age, recently had a colonoscopy, or are having any upper GI symptoms, an endoscopy may be recommended as the first test.  The endoscopy will evaluate the esophagus, stomach, and first part of the small bowel (duodenum).  A video capsule will evaluate the remainder of the small bowel and may be recommended to finish out the evaluation after the colonoscopy and endoscopy have been performed.

In addition to finding bleeding lesions, celiac disease, or inflammatory processes, we commonly find angiodysplastic lesions in the colon or small bowel.  These lesions may also be referred to as AVMs, vascular ectasia, or spider veins.  These are swollen, fragile vessels that can easily bleed overtime causing an iron and blood loss.  Unless these are actively bleeding at the time of the evaluation, management usually includes iron repletion with oral iron supplements or iron infusions.  Sometimes we do not find any source of bleeding in the GI tract.  If the evaluation comes up negative, an evaluation by a hematologist, or blood specialist, is usually recommended.

For individuals that cannot tolerate the adverse effects of oral supplements or do not respond appropriately to oral iron repletion, we can perform iron infusions here at Hillmont GI.  If iron infusions are determined to be the best treatment for you, you will be brought into our Lansdale office’s infusion center where you will receive two 30 minute iron infusions about two weeks apart.

The esophagus is the part of the digestive tract that connects the mouth and throat with the stomach, and is commonly called the “food pipe” by non physicians. The most common condition I see in patients with esophageal problems is known as acid reflux, or GERD (GastroEsophageal Reflux Disease). In GERD, acid made in the stomach travels backwards up into the esophagus, usually causing symptoms of chest burning or pain. Besides just causing heartburn, the acid can actually cause damage to the tissue lining the esophagus, resulting in inflammation, ulcers, and scarring. Not all patients with GERD develop tissue damage, but of those that do, a significant portion can progress to a condition called Barrett’s esophagus, and some of them can then develop esophageal cancer.

When Barrett’s develops, the cells that line the esophagus change. The inner lining of the esophagus is called the mucosa, and in Barrett’s the mucosa becomes composed of cells that are normally present lining the small intestine. These cells are initially benign, but it is abnormal for them to be found there. Over time, the Barrett’s mucosa can become precancerous, a condition known as dysplasia. When dysplasia is severe, there is a high risk of cancer developing.

Barrett’s esophagus is most common in Caucasian males 50 and older, although it can occur in anyone. The main risk factor is GERD, which typically presents as frequent heartburn. Other risks include smoking, obesity, and family history. It should be tested for in someone with these risk factors, and I perform endoscopy to look for it commonly in patients with frequent GERD symptoms. Endoscopy is a procedure where I use a flexible scope which is passed through the mouth into the esophagus under sedation, and with which I can visually inspect the lining of the esophagus and take small biopsies of it. Barrett’s is diagnosed when a pathologist sees intestinal cells in a biopsy of the esophageal mucosa. The pathologist can also identify dysplasia and cancer.

Once Barrett’s is diagnosed, we have to decide what to do about it. If no dysplasia is present, then the treatment is to put the patient on an acid lowering medication called a PPI and to counsel them to stop smoking, lose weight, etc. The patient should then be entered into a surveillance program, where they have an endoscopy and biopsies done every three years to look for any signs of progression to dysplasia or early stage cancer. If these are detected either initially or on follow up, treatment consists of eradicating the abnormal mucosa by ablating or destroying it with radiofrequency energy (RFA), or removing it through the scope with EMR (endoscopic mucosal resection).  These techniques are non-surgical and highly effective, and usually done in advanced endoscopy centers.

So the main point is that frequent heartburn may be more than just a nuisance, and could be a sign of a more serious condition such as Barrett’s esophagus. While most people with GERD and Barrett’s never progress to esophageal cancer, detection, surveillance, and early treatment can be lifesaving  and prevent the need for major surgery. If you get heartburn frequently you should talk to you doctor about it.

Many people indulge in alcohol more than usual over the holidays. In general, ‘heavy drinking’ is defined as 8 or more drinks per week for women, and 15 or more drinks per week for men. Binge drinking is defined as consuming 4+ drinks on a single occasion for women, and 5+ drinks for men. It is also important to note that ‘one drink’ is classified as 12 ounces of beer, an 8 ounce glass of wine, or a 1.5 ounce shot of spirits/liquor.

Even moderate drinking can result in weight gain. Fat and alcohol are the most calorically dense (9 and 7 calories per gram, respectively) compared to protein and carbohydrates (4 calories per gram each).

Aside from contributing to a higher weight in January, overindulging in alcohol has several additional effects, particularly on the organs in the GI tract. As it travels down the esophagus, the alcohol can directly damage the squamous cells lining the esophagus, as well as contribute to acid reflux (stomach contents coming back up into the esophagus). Once it is held in the stomach, it may damage the mucous cell lining and thereby induce inflammation.

After entering the blood stream, alcohol is metabolized through the liver via multiple pathways which contribute to toxicity. The liver’s role is to filter toxins from the blood and remove them from the body. All pathways by which the liver breakdowns alcohol ultimately produce acetaldehyde, which damages tissue and cells. Heavy alcohol use or binging may also trigger pancreatitis, which is acute inflammation of the pancreas often associated with pain, nausea, and vomiting.

As many people who have binged on one-too-many cocktails at a special occasion or event have likely noticed, effects the next day often include headache, nausea, vomiting, shakiness, mood changes, and diarrhea (among others).

Longer term moderate to heavy alcohol consumption increases the risk of multiple GI cancers, particularly with drinking on a daily basis. In particular, studies have investigated an increased risk of liver cancer, a type of esophageal cancer (squamous cell), pancreatic cancer, and colon cancer.

Always consider the risks when overindulging on anything, particularly with alcohol. We at Hillmont GI hope you use this information to enjoy your holidays responsibly!

The pancreas is located in mid abdomen and produces enzymes that both help with digestion and those that help regulate sugar in our body. Pancreatitis is inflammation of the pancreas and happens when digestive enzymes start digesting the pancreas itself. It can be acute or chronic. Either can be serious and potentially lead to complications. Two common causes of acute pancreatitis include excessive alcohol use and gallstones. Most common symptoms of acute pancreatitis include severe abdominal pain sometimes radiating to the back, fever, nausea or vomiting. Most cases of acute pancreatitis require hospitalization and symptoms go away in 24-48 hours with close monitoring and aggressive hydration. Chronic pancreatitis, on the other hand, can have a complicated course requiring a prolonged hospitalization and usually needs outpatient GI follow up. Most common cause of chronic pancreatitis is heavy alcohol use. Complications of chronic pancreatitis include diarrhea, weight loss, pseudocyst formation, malignancy. At Hillmont GI we can help manage acute and chronic pancreatitis both as inpatient and as outpatient. Patients with chronic pancreatitis may need medicines to relieve pain, to help absorb fat in their diet and nutritional support. With the help of experts at Hillmont, they can not only understand pancreatitis better but also learn to manage its complications effectively.

Besma Samdani, MD

Colorectal cancer is common in the US, being the second leading cause of cancer-related deaths in both men and women. The risk for developing colorectal cancer increases as you get older. Surviving the cancer depends on the stage at diagnosis, so the earlier it is discovered, the better the chance of complete cure and survival. Most colon cancers have no symptoms until it is in the late stages.  Symptoms can include rectal bleeding (or anemia or low iron), abdominal pain or changes in the bowel pattern.  These symptoms however are quite common and most folks with these symptoms don’t have colon cancer at all.  Most importantly, essentially every colon cancer starts in a small benign growth called a polyp.  Not all polyps turn cancerous, but all cancers start as polyps.  It probably takes many years for a polyp to grow, and then many more for a polyp to turn cancerous.  If a polyp is found and removed, it can not become a cancer.

All of these facts support why colon cancer screening is so important.  Screening means that testing is performed before symptoms start.  We tell people all the time, we don’t want to find colon cancer in anyone, we want to prevent it in the first place.  Colonoscopy is best test at detecting polyps and cancer and the only screening method that can actually prevent colon cancer because it allows the doctor to detect and remove polyps during the same procedure.  Stool testing does not.  CT and X-ray colon testing does not.

If you do not get a colonoscopy, you have about a 1 in 20 chance of getting colon cancer in your lifetime.  Getting a colonoscopy brings that chance much closer to zero.  The doctors at Hillmont GI detect polyps in about 35-40% of patients who come here for screening colonoscopies, which is above the average of GI specialists across the nation. We also offer our patients a complimentary shuttle to and from their procedure, along with an ‘Open Access’ form that allows patients without symptoms to skip the office visit prior to their procedure.

One of the hottest topics in Gastroenterology is the microbiome, or the bacteria and other organisms that normally live in the gut of every human.  This is composed of over 1,000 different bacterial species and together can weigh more than 4 pounds!  Changes in the composition of the microbiome is related to a number of diseases.  The composition of the microbiota is also related to how healthy an individual may be.  However, the microbiota is a very delicate balance in terms of the number and the individual species.

For example, a more and more common problem that we see in our patient’s is diarrhea, excessive flatulence, abdominal bloating and sometimes nausea.  Although these symptoms are not specific, they can be related to a disease state called small intestinal bacterial overgrowth, or SIBO, for short.  When your doctor has a suspicion of SIBO, they may want to utilize a breath test to discover the cause of these symptoms.  Breath Testing is utilized to help diagnose the bacterial overgrowth or intolerance to certain sugars.  The test measures the amount of hydrogen in your breath after the administration of certain sugars, which goes up in different conditions.  Normally, there is not very much hydrogen in your breath.  If bacterial overgrowth is found, the number of bacteria can be reduced by nonabsorbable antibiotics and thereby return the patient to normalcy.  Similarly, the breath tests can be used to detect an intolerance to lactose, a sugar in milk, or intolerance to fructose, a sugar that is common in fruits.  Appropriate treatments in terms of avoidance of the sugars can then be undertaken.  The breath test does take some time but is a noninvasive way of diagnosing a number of GI issues.  Most gastroenterology offices now include hydrogen breath testing in the office in order to aid in the diagnosis of various GI complaints.

Fatty liver disease is the build of up fat in the liver.  It can be caused by excessive alcohol consumption or can be associated with other metabolic co-morbidities such as diabetes, hypertension, or hyperlipidemia as is the case for non-alcoholic fatty liver disease.  This build up in fat can cause inflammation or irritation of the liver which, if left untreated, can cause cirrhosis or liver cancer.  Currently there is no medication for fatty liver disease.  Treating non-alcoholic fatty liver disease is multifactorial, but weight loss through diet and exercise are usually the first interventions recommended.   Losing 10% of your body weight is a good first goal for weight loss.  This can be done by creating a calorie deficit in limiting calories consumed or expending calories through exercise.   Dietary modifications for fatty liver disease often include limiting the amount of calories, saturated fats, and fructose consumed and focusing on a diet high in fiber, lean proteins, and polyunsaturated fatty acids.

The Mediterranean Diet is great for this!   It is based on the traditional cuisines of countries bordering the Mediterranean Sea.  The diet is high in vegetables, legumes, fruits, whole grains, beans, nuts, seeds, and olive oil!  Some key components of the Mediterranean diet include eating vegetables, fruits, whole grains, and healthy fats daily.  Fish, poultry, beans, and eggs should be eating weekly.  Dairy products should be eaten moderately.  A limited intake of alcohol, particularly red wine, may also be part of the diet, but be sure to talk to your health care provider on whether alcohol can or should be included in your diet.

Making dietary changes of any kind are hard.  Some easy ways to start adding the Mediterranean Diet into your daily regimen is think about adding foods rather than thinking about what you have to limit!  Start with adding a fruit or vegetable to every meal and snack.  Incorporate whole grains into your diet by using whole grain breads or pastas and using brown rice rather than the “white” alternatives (white bread, regular pasta, or white rice).  Limit the amount of red meats and start eating more lean meats such as chicken or turkey.  Snacks can include nuts and berries.  Even a small amount of dark chocolate is allowed!

Always remember that small changes can lead to big rewards.  Consistency is key!

The Dangers of Fad Dieting By Dr. Steven Nack

The incidence of obesity is rising rapidly in this country.  It seems like everyone is looking for an easy way to lose weight.  This has resulted in a profusion of fad diets which guarantee easy and rapid weight loss.  Let’s get it straight- weight loss, especially durable weight loss, is not easy.

There are many fad diets out there.  Many will result in rapid weight loss.  Most will not result in durable weight loss.   In other words, the weight loss won’t last.  How many times have you seen someone lose a ton of weight and then 6 months later is back to the same old weight they started at??

These diets can promote unhealthy eating habits.  They often do not meet proper nutritional standards.  They make you lose water weight and muscle mass, NOT fat.

Here are some examples that have been popular over the past few years:

• 5 Bite Diet
• Acai Berry Diet
• Apple Cider Vinegar Diet
• Atkins Diet
• Beverly Hills Diet
• Cabbage Soup Diet
• Detox Diet
• Grapefruit Diet
• Hollywood Diet
• Liquid Diet
• Low Carb Diet
• Paleo Diet
• South Beach Diet

Most overweight people eat for the wrong reasons. Fad diets don’t address any of these points. If you truly want to lose weight and keep it off you need to change your lifestyle.  Talk to your physician or healthcare professional.  Seek out a registered dietician or nutritionist.  Get advice on proper nutrition for weight loss.  Get advice on a proper exercise program.  Behavior modification is very important.  If you are experiencing issues with digestion from weight fluctuation or change in diet, consult a Gastroenterologist if the symptoms persist.

What is your next step when diagnosed with either IBS or IBD??

In my previous blog post, ‘A Physician’s Take on IBS Versus IBD,’ the dramatic differences between these conditions were outlined and can be viewed HERE.

After your evaluation and diagnosis findings by a professional care provider, a treatment plan can seem daunting. Fortunately, both IBS and IBD treatments have benefitted from many years of experience, and rigorous research backs the steps needed for your success.

IBD inflammation needs to be treated with specific anti-inflammatory medications or sometimes even stronger medications that decrease the autoimmune response. Sometimes this involves pill medications and sometimes IV infused medications. You need to be monitored over time to make sure your treatment is adequate to completely heal and also prevent future inflammation. You need to have more frequent monitoring due to an increased risk of colon cancer.

IBS treatment revolves around symptom management with the goal of preventing symptoms so that you can have a more discomfort free day as well as helping symptoms dissipate quickly when they occur. This can involve bowel movement regulating agents such as fiber, dietary changes such as a low FODMAPS diet, and other medications such as anti-spasm treatment and some that work directly on the intestinal tract to either increase or decrease movement based on your symptoms.

Unmanaged IBS and IBD symptoms can impact your quality of life. Both conditions can be managed very effectively if you address your symptoms, obtain appropriate diagnosis and follow a healing treatment plan. If you feel you are experiencing any IBS issues or IBD warning signs please do not hesitate to get in touch. We will be happy to partner with you and look forward to helping you along the path to better health.

Patients frequently come to see me looking for relief of their symptoms of chronic bloating, abdominal pain and gas. Many people want a quick fix such as a pill that will relieve their symptoms. Many over the counter products advertise themselves as providing that relief, only to prove to be a disappointment to those suffering. What I generally tell my patients is that relief is possible, but requires some work on their part. One of the mainstays of treatment is dietary modification. It should seem obvious that gut related symptoms are strongly influenced by the substances that we introduce into our GI tract. Modification of our diet by eating foods that promote gut health and avoiding those that have an adverse impact can significantly alleviate symptoms of abdominal pain, bloating, gas, and diarrhea.

A diet low in “FODMAPs” can be particularly helpful to some people with these symptoms. FODMAPs are certain types of carbohydrates and alcohols that are “fermentable oligo-, di-, or monosaccharides and polyols”. Many common foods contain them, and it is thought that they may cause symptoms by drawing water into the GI tract and creating gas when fermented in the bowel. Examples include wheat, onions, garlic, apples, peaches, beans, lentils, and dairy and others. A study in the well respected medical journal Gastroenterology demonstrated significant improvement in irritable bowel symptoms in patients who followed this diet for at least a week. My own experience is that many of my patients who have these symptoms feel much better when they follow the diet. Those that don’t may be suffering from other problems or have other food intolerances. Patience and working together with your gastroenterologist will usually get the problem solved.