Gluten-Free Corner
//
Colon Health
//
Gastroparesis Explained
Attention
Baby Boomers! New Guidelines for Hepatitis C Screenings
Preventing Colorectal Cancer Pediatric News
FOR You and Your Family
The View’s
Elisabeth
Hasselbeck Shares her Glutenfree Odyssey
Fall 2012 Issue
C onvenient &C ompassionate Galloway Endoscopy Center is an accredited surgical facility offering diagnostic and therapeutic gastrointestinal procedures in a comfortable and convenient outpatient setting. Our compassionate, bilingual staff provides top-quality care while assisting our experienced and highly skilled doctors. Best of all, because of advances in medical technology, endoscopic procedures can be safely performed outside the hospital, so you can return to the comfort of your home the same day as your procedure. You have a choice in healthcare. Isn’t it time you got treated better?
A division of Baptist Surgery and Endoscopy Centers
7500 SW 87 Avenue, Suite 101 • Miami • GallowayEndoscopy.com • 305-595-9511 A not-for-profit organization committed to our faith-based charitable mission of medical excellence
A probiotic so potent it has to be supervised and refrigerated. Very cool.
•
Up to 100 times more potent than the average probiotic
•
VSL#3 is a medical food & must only be used under
1
medical supervision •
Clinically proven in double-blind, placebo-controlled trials to provide significant benefit in the dietary management of irritable bowel syndrome, ulcerative colitis and an ileal pouch
•
Refrigerated VSL#3 contains 8 proprietary strains of live bacteria providing 112.5 billion to 900 billion CFU per serving making it one of the most potent probiotics available
1
1. Source: AC Nielsen 12.2009 Average CFU claimed by product manufacturer was approx. 4 billion CFU per capsule or tablet
For further information, please contact: Adriel De Mendoza |Territory Manager |Sigma Tau Pharmaceuticals | (305)283-9182
www.vsl3.com
Gastro Health
Welcomes You
After all the fantastic feedback we received for our 2012 issue, we have decided to turn Gastro Health Magazine into a biannual publication. The physicians and staff of Gastro Health are pleased to present our first Fall Issue. Inside you will find informative and educational articles on various digestive health topics such as inflammatory bowel disease, gastroparesis and colon health, among others. We are also delighted to feature Elisabeth Hasselbeck from The View, who shares her life experiences with celiac disease. We have included many tips on living a healthier life, and even coping with a gluten-free diet.
08
Our physicians, allied professionals and staff will continue to achieve excellence in medical care, heal and prevent illness through integrated efforts in the field of digestive care, while always caring for you and the ones you love. Alejandro Fernandez, MBA, CMPE Chief Executive Officer
6 7 8 10 12 15 16 17 21 25 26 27 29
9500 South Dadeland Boulevard, Suite 802 Miami, FL 33156 T. 305.468.4180
27 10
This magazine represents our group’s vision: to deliver quality medical care and preventative medicine to all patients; align ourselves with the finest physicians practicing medicine in South Florida; and developing ancillary services that improve our patients’ quality of care and customer experience. The physicians, nurses, nutritionists and office staff of Gastro Health seek to exceed the expectations of the patient experience by treating everyone as an immediate part of our family. Thanks to patients’ feedback, we have received a 98% satisfaction with our services – confirming the dedication to excellence within our care centers. We are proud to have several of our physicians make the 2011 US News & World Report’s prestigious Top Doctor’s List.
26
30
Inside this issue
What is Celiac Disease?
Evidence Points to Colonoscopy Elisabeth Hasselbeck Gluten-Free Odyssey The Pill Camera Dealing with Gas and Bloating What Endangers Colon Health? Are You at Risk for Hepatitis C? Gastro Health Physician Directory Investigative Overview: Gastroparesis Attention Baby Boomers Pediatric News: Coping with IBD Gluten-Free Corner What Can Remicade Do For You? Treating Hemorrhoids Designed and Published by:
www.gastrohealth.com
11900 Biscayne Boulevard, Suite 100 Miami, FL 33181 T. 305.820.0690
Cover Photo: © Sara De Boer/Corbis
info@creativemindworks.com All rights reserved.
We are here to help At Navarro Health Services we work closely with patients and physicians to ensure the best care during treatment and support:
…The name you trust, the technology you need, the care you deserve.
• All your Biologic needs. • Hep C patients • Crohns and Ulcerative Colitis patients • Financial Assistance • Nurse Assistant
We partner with health care professionals to enhance therapy / medication compliance and provide patients with resources and information necessary during treatment creating an atmosphere where patients can seek comfort and care during their treatment with an on call pharmacist.
Office: 786.220.8865 • Fax: 305.883.0652 Toll Free Ph: 855.NHS.RXRX (647.7979) • Toll Free Fax: 855.NHS.FAX1 (647.3291) Email: nhs@navarro.com Hours of Operation: Monday - Friday 8:00 a.m. – 6:00 p.m.
Offices closed on Saturdays / Sundays and major holidays, with clinical staff on call.
FREE Prescription delivery
?
Gastro Health
What is Celiac
Disease George A. Sanchez, MD Gastroenterologist
C
eliac disease is a condition in which a protein found in certain foods - gluten – causes the immune system to damage the small intestine. The small intestine is responsible for absorbing food and nutrients. However, when the lining of the small intestine is damaged this can cause problems with absorbing nutrients which is referred to as malabsorption. Gluten is found in wheat, barley, rye and several condiments, sauces and spreads. It is not clear what exactly causes celiac disease, but there is a combination of environmental and genetic factors. Celiac disease can affect both male and females of any age. Although there is no cure for celiac disease, avoiding gluten can stop the damage to the lining of the small intestine.
What are the Common Symptoms?
The symptoms of celiac disease can vary from person to person. Some people may have no symptoms, yet exhibit signs of malabsorption detected on blood tests. Others can develop a variety of gastrointestinal complaints. The most common symptoms experienced are abdominal discomfort, diarrhea, bloating, weight loss and decreased energy. There can also be other signs and symptoms of vitamin and nutrient deficiencies that can cause anemia, bone loss, nervous system disorders and skin rash. Children with celiac disease can have a poor appetite, slow growth and have difficulty gaining weight.
6 ::
GASTRO HEALTH MAGAZINE • FALL 2012
How is Celiac Disease Diagnosed?
Celiac disease can be difficult to diagnose because its signs and symptoms can resemble other conditions. However, there are blood tests available which can help make the diagnosis. These blood tests look for proteins (antibodies) that can become elevated in people with celiac disease. It is important to continue eating gluten while being tested because avoiding it can cause these proteins to become normal. If the blood test is positive for celiac disease, the diagnosis is confirmed by obtaining a sample of the small intestine. The sample (known as a biopsy) is obtained by performing an upper endoscopy and the sample is viewed under a microscope to see if there has been any damage to the lining of the small intestine. 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 a small piece of tissue from the small intestine is removed.
How is Celiac Disease Treated?
The cornerstone of treatment for celiac disease is elimination of gluten from the diet. This can be overwhelming initially because many foods that we eat and even condiments that we cook with contain gluten. Therefore, consulting with an experienced dietician can help you learn how to eat, shop and prepare a gluten-free diet.
Most patients will notice an improvement in their symptoms within two weeks. Rarely, patients fail to have improvement in symptoms despite adherence to a gluten-free diet. This is considered refractory celiac disease and requires medications which suppress the immune system (like steroids). It is important to remain on a strict gluten-free diet despite feeling well to prevent nutritional deficiencies and certain types of gastrointestinal cancer. Families should be aware of their increased risk of developing celiac disease and anyone with symptoms should be tested. Various local and national support groups help increase awareness and make living a gluten-free lifestyle achievable.
“The cornerstone of treatment for celiac disease is elimination of gluten from the diet.”
Gastro Health
Evidence Points to Colonoscopy
in Preventing Colorectal Cancer
Alfredo J. Hernandez, MD Gastroenterologist
C
olorectal Cancer, also known as Colon Cancer, is the third most common occurring cancer and the second leading cause of cancer-related deaths worldwide. There are two basic ways to screen for colorectal cancer. One way is by collecting stool specimens. The second is by evaluating the lining of the colon, which is done by having a Colonoscopy, Sigmoidoscopy, Barium Enema, or a CT Colonography. A Colonoscopy is considered the most comprehensive method to detect and prevent colorectal cancer. The procedure consists of inserting a thin, flexible tube into the rectum and evaluating the entire colon. This method allows the physician to locate and remove precancerous, or adenomatous, colon polyps.
The guidelines from the American College of Gastroenterology for colorectal cancer screening call for all average risk individuals, male and female, to undergo colonoscopy at the age of 50. Other populations with risk factors or symptoms may have varying age for colonoscopy. For example, African Americans as a subgroup are recommended for screening at age 45. Patients need to be aware that there are other methods of colorectal cancer screening if colonoscopy is not available to them. If the other methods have positive findings, however, colonoscopy will then be advised. The overall evidence continues to point to colonoscopy reducing the risk of colorectal cancer and even mortality.
A recent New England Journal of Medicine article titled Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths, shows that removal of precancerous polyps through colonoscopy reduced the death rate from colorectal cancer. This study is one of the first research papers looking at how colonoscopy can not only reduce the incidence of colorectal cancer, but can actually decrease mortality or death from it. The study analyzed prospectively 2,602 patients that had initial colonoscopy and precancerous polyp removal. There were only 12 deaths from colorectal cancer reported in the group studied. When compared to a group from the general public with similar age, sex and race, the number of deaths from the disease was about 25 individuals. Resulting in the conclusion that colonoscopy reduced the incidence of colorectal cancer associated death by 53%.
‘‘A Colonoscopy is considered the most comprehensive method to detect and prevent colorectal cancer.’’
GASTRO HEALTH MAGAZINE • FALL 2012
:: 7
Gastro Health
Elisabeth Hasselbeck
Shares HER Gluten-free Odyssey By Jefferson Adams of Celiac.com
Like so many people with celiac disease, Elisabeth Hasselbeck of ABC’s The View has a story to tell.
L
ike so many people with celiac disease, that story involves a long, slow, painful journey from suffering to understanding, to self-empowerment and recovery. In between were periods of confusion, doubt, isolation and malaise. Hasselbeck describes that journey in her new book: The G-Free Diet: A Gluten-Free Survival Guide. Hasselbeck ’s odyssey began during her sophomore year of college, when she fell ill after returning from a three-week-long trip to Belize. She was diagnosed with a severe bacterial intestinal infection which, her doctor said, was a result of her travels in Central America. The illness put in the school infirmary for nearly a week, with an immensely distended belly and a 103+ fever. Once the initial infection subsided, she was naturally relieved, and thought the worst was over. Little did she know that a long road lay ahead. As an athlete, Hasselbeck was eager to get back into shape after she was discharged. Her body had other ideas. During this period, she says she felt absolutely ravenous, yet the only dining hall foods that seemed appealing were soft-serve vanilla frozen yogurt and Rice Krispies. Food had lost its appeal.
8 ::
GASTRO HEALTH MAGAZINE • FALL 2012
Hasselbeck grew up in an Italian-American neighborhood in Providence, RI, in a family that prized all things bread and pasta, so she wasn’t about to give up the appetite and food battle without a fight. However, no matter what she ate nothing satisfied her hunger—and everything seemed to upset her stomach. After nearly every meal, she had the classic bloating, and sharp, gassy pains in her gut that are all too familiar to most
celiacs. Cramps, indigestion and diarrhea were familiar companions; sometimes all at once. Often, she would become too tired to move. It was about this time that she became a contestant on Survivor: The Australian Outback. While enduring the trials of surviving in the outback, Hasselbeck was deprived of her normal, gluten-rich American diet, and forced to subsist on things she would never willingly eat at home. Yet, her symptoms were gone, and she had never felt better. Once she returned to the U.S., she narrowed the scope of her quest. She eliminated nearly everything from her diet and introduced items one at a time. After nearly forty days basically starving herself, she sought solace in her pre-Australia diet, with dire consequences. After the joy of knowing a healthy, happy gut for the first time in years, she suddenly found herself feeling worse than ever, and spending days in her room, bedridden, save for urgent trips to the bathroom. She saw a doctor and received a diagnosis of “Irritable Bowel Syndrome (IBS).” Suspicious of what she saw as an acknowledgement of symptoms masquerading as a diagnosis, she began to look for connections on her own.
Gastro Health
Fortunately for Hasselbeck, she began to make a connection between the illness she had suffered for so long and the food she was eating. She noticed that when ate starchy foods, her symptoms returned with a vengeance. An Internet search told her that she might be suffering an adverse reaction to wheat. She quickly moved to eliminate wheat from her diet. Her experience, as so many with celiac disease know all too well, was an educational one, filled with occasional episodes that left her feeling inexplicably ill. Unable to figure out exactly what was making her sick, she undertook more research and stumbled upon some information about gluten intolerance and celiac disease. In 2002, after five years of suffering, Hasselbeck diagnosed herself with celiac disease, an autoimmune condition triggered by gluten – the protein found in wheat, rye and barley. Celiac disease can cause acute damage to the small intestine and the digestive system, and, left untreated, it can leave sufferers at risk for
certain types of cancer and other associated conditions. The only known treatment is a lifelong diet free from wheat rye and barley gluten. Once she realized what had been tormenting her for so many long, she set about eliminating all wheat, barley, oats, and rye from her diet. Still, even after she made her diagnosis, she faced a long line of skeptical doctors. In fact, it was eight years after her symptoms first began until she found a doctor who was willing to listen, and who had answers. Her move to New York City put her into contact with Dr. Peter Green, the director of the Celiac Disease Center at Columbia University, who confirmed what she’d suspected for years: Elisabeth Hasselbeck has celiac disease. After waiting for years for a sensible explanation to her symptoms, Dr. Green was the first doctor to look for the cause, not simply to treat the symptoms. Despite the same mistakes and accidents that most of us celiacs have also experienced, her perseverance paid off in the end and she remains gluten-free to this day.
“The only known treatment is a lifelong diet free from wheat rye and barley gluten.”
Reprinted with permission by www.Celiac.com
GASTRO HEALTH MAGAZINE • FALL 2012
:: 9
Gastro Health
THE
PILL
CAMERA
Capsule Endoscopy
Andrew I. Sable, MD Gastroenterologist
“An endocapsule is a
miniature video camera that has been incorporated into a capsule-shaped device.” What is it?
What does it do?
Capsule endoscopy refers to a relatively new technology that gastroenterologists use to examine the deepest portions of the digestive tract. In 1981, an Israeli engineer named Dr. Gavriel Iddan began work on designing a disposable pill-sized camera that could be swallowed and would pass directly through the intestine. In 2001, after twenty years of research and development, the FDA approved the Given Diagnostic Imaging System called Capsule Endoscopy.
Since the advent of capsule endoscopy, gastroenterologists have been able to make diagnoses not previously made using conventional methods. For example, in disease such as Celiac Sprue and Crohn’s disease, the endocapsule has assisted in visualizing areas that were previously unreachable without major surgery. Additionally, capsule endoscopy has played a major role in advancing the diagnosis and treatment of obscure gastrointestinal bleeding. Additionally, it has been helpful in identifying tumors of the small intestine and evaluating polyposis syndromes. Subsequent development of an esophageal capsule also provides a modality to monitor GERD (gastroesophageal reflux disease) non-invasively.
How does it work?
An “endocapsule” is a miniature video camera that has been incorporated into a capsule-shaped device along with a light source, transmitter and battery. It has a biocompatible coating which allows it to be safely swallowed and pass undigested through the intestinal tract. During this journey, it transmits over 50,000 color images via radio frequency to a recorder worn on a belt on a patient’s hip or waist. The pill weights only 1/7th of an ounce and is about the size of a large vitamin. Once swallowed, the capsule moves through the intestine, naturally aided by the muscular contractions of the intestine.
10 ::
GASTRO HEALTH MAGAZINE • FALL 2012
What to expect
Typically, patients undergoing an endocapsule study will have a preparation that will consist of a brief fasting period. Some physicians may also recommend a bowel prep to cleanse the small intestine before the study. This outpatient procedure will begin in your doctors office. After a brief orientation, you will swallow the endocapsule and be asked to wear a small data recorder around
Watch
Gastro Health
CASEY ABRAMS’ IBD-inspired Music Video
Join the fan club today at www.IBDIcons.com Musician and American Idol alumnus Casey Abrams has created an original song and music video inspired by his personal experience with inflammatory bowel disease (IBD) and the people he met through the national disease awareness campaign IBD Icons. Join the fan club at www.IBDIcons.com for exclusive access to Casey’s music video dedicated to the IBD community. your waist during the test. You will be able to drink clear liquids and eat a light meal about two hours after the pill has been swallowed. Approximately 8 hours later, you will be asked to return to your doctor’s office so the data recorder can be removed and the images downloaded to a computer for physician viewing. The capsule will then be eliminated from your body normally in your feces during a bowel movement. To date, well over a million endocapsules have been used in clinical practice and demonstrated the overall safety of this technology. Complications are extremely rare, especially when performed by specialists who have extensive experience with the endocapsule. Wireless capsule endoscopy is a safe, reliable, and noninvasive technology that can be very useful in the diagnosis and treatment of disorders of the esophagus and small intestine. If you are interested in this exam or think that it may be beneficial to your treatment, ask your physician for more information.
For every fan who registers to view Casey’s video, Janssen Biotech, Inc. will donate $1, up to $10,000, to the Crohn’s & Colitis Foundation of America in support of IBD research and education. In addition to Casey’s music video, updates from the 2011 IBD Icons finalists and winners on their latest endeavors to raise awareness and inspire others are also featured on www.IBDIcons.com.
IBD Icons is sponsored by Janssen Biotech, Inc. Casey Abrams was compensated for his time in preparing for and participating in media interviews and events surrounding the IBD Icons awareness program.
GASTRO HEALTH MAGAZINE • FALL 2012
:: 11
Gastro Health
Dealing with
Gas and Bloating
F
unctional gastrointestinal disorders such as Irritable Bowel Syndrome (IBS) are very common, ranking second in the causes of absence from work or school. Bloating is one of the most common manifestations of IBS, caused by distension of the gut lumen by gas leading to pain, the sensation of bloating and visible abdominal distension. The amount of gas in your gut depends on the amount of air you swallow and bacterial production in the distal small and proximal large bowel. Increased production can be the result of bacterial digestion of carbohydrates incompletely digested by enzymes in the intestines allowing bacteria to digest them, as occurs with lactose intolerance. However, most people who complain of excessive gas and bloating do not produce more gas than the average person – they are just more aware of it because of increased sensitivity to gas, one of the hallmarks of IBS. If you eat too fast, gulp liquids, drink lots of carbonated beverages, chew gum, smoke or swallow saliva constantly, you can end up swallowing too much air. Fortunately, most swallowed air can be eliminated when sitting up by belching. Eating peppermint, chocolate and fats relax the lower esophageal sphincter and may help. However, if lying down some of the gas tends to pass into the intestine which can cause excessive passage of gas. This swallowed air is mainly nitrogen together with the byproducts of the digestion of carbohydrates by the intestinal flora like carbon dioxide, hydrogen and methane, which are odorless. Traces of sulfur compounds are responsible for the occasional unpleasant odor.
12 ::
GASTRO HEALTH MAGAZINE • FALL 2012
Most people with gas and bloating do not need to have any testing unless there are alarm symptoms such as diarrhea, weight loss, abdominal pain, anemia, blood in the stool, lack of appetite, fever or vomiting. If this is the case you should see a gastroenterologist to get further testing such as a blood test for celiac disease, a hydrogen breath test for lactose and/or fructose intolerance or even an endoscopic evaluation
‘‘The amount of gas in your gut depends on the amount of air you swallow and bacterial production in the distal small and proximal large bowel.’’
Guillermo Gubbins, MD Gastroenterologist
of your gastrointestinal tract. Restrictions of dietary components that can lead to luminal distension, due to poor proximal absorption and subsequent fermentation by bacteria more distally in the intestines, form the basis of the low FODMAP diet approach to the management of functional gastrointestinal symptoms. Food lists are available emphasizing suitable alternatives, and the best outcomes are achieved in a one-to-one setting with a dietitian. Although there are no controlled studies supporting efficacy, several OTC medications are available to help reduce bothersome gas such as simethicone (which breaks up bubbles), activated charcoal (adsorbent), Beano (breaks down complex carbohydrates) and bismuth (reduce odor).
FODMAPstands for: Fermentable Oligosaccharides Disaccharide Monosaccharide And Polyols
(fructans and galactans)
(lactose)
(fructose)
(sorbitol)
‘‘Most people with gas and bloating do not need to have any testing unless there are alarm symptoms.”
Gastro Health
Foods suitable on a low-fodmap diet fruit
vegetables
fruit banana, blueberry, boysenberry, canteloupe, cranberry, durian, grape, grapefruit, honeydew melon, kiwifruit, lemon, lime, mandarin, orange, passionfruit, pawpaw, raspberry, rhubarb, rockmelon, star anise, strawberry, tangelo
vegetables alfalfa, artichoke, bamboo shoots, bean shoots, bok choy, carrot, celery, choko, choy sum, endive, ginger, green beans, lettuce, olives, parsnip, potato, pumpkin, red capsicum (bell pepper), silver beet, spinach, summer squash (yellow), swede, sweet potato, taro, tomato, turnip, yam, zucchini
Note: if fruit is dried, eat in small quantities
grain foods cereals gluten-free bread or cereal products bread 100% spelt bread rice oats polenta other arrowroot, millet, psyllium, quinoa, sorgum, tapioca
milk products milk lactose-free milk, oat milk*, rice milk, soy milk* *check for additives
cheeses hard cheeses, and brie and camembert yoghurt lactose-free varieties
other sweeteners sugar* (sucrose), glucose, artificial sweeteners not ending in ‘-ol’ honey substitutes golden syrup*, maple syrup*, molasses, treacle *small quantities
ice-cream substitutes gelati, sorbet butter substitutes olive oil
herbs basil, chili, coriander, ginger, lemongrass, marjoram, mint, oregano, parsley, rosemary, thyme
Eliminate foods containing fodmaps excess fructose fruit apple, mango, nashi, pear, tinned fruit in natural juice, watermelon sweeteners fructose, high fructose corn syrup large total fructose dose concentrated fruit sources, large serves of fruit, dried fruit, fruit juice honey corn syrup, fruisana
lactose
fructans
vegetables asparagus, beetroot, broccoli, brussels sprouts, cabbage, eggplant, fennel, garlic, cheeses soft unripened cheeses leek, okra, onion (all), shallots, spring onion eg. cottage, cream, cereals mascarpone, ricotta wheat and rye, in large amounts eg. bread, crackers, cookies, couscous, pasta milk milk from cows, goats or sheep, custard, ice cream, yoghurt
fruit custard apple, persimmon, watermelon
galactans legumes baked beans, chickpeas, kidney beans, lentils
polyols fruit apple, apricot, avocado, blackberry, cherry, lychee, nashi, nectarine, peach, pear, plum, prune, watermelon vegetables cauliflower, green capsicum (bell pepper), mushroom, sweet corn sweeteners sorbitol (420) mannitol (421) isomalt (953) maltitol (965) xylitol (967)
miscellaneous chicory, dandelion, inulin
GASTRO HEALTH MAGAZINE • FALL 2012
:: 13
You're 50... Happy Birthday!
It's time for your first colon cancer screening
www.gastrohealth.com
Gastro Health
What Endangers Colon Health? Sedentary Lifestyle
Red and Processed Meats
Learn ways to be less sedentary: • Try to be more active during your leisure time. Find new activities that include at least some exercise – directly or indirectly. • Do active housework. • When it’s safe, park farther away from your destination and walk. • Take the stairs instead of an elevator or escalator. • Go for a walk or jog during your lunch break. No time during lunch? Go after work instead!
Grill smart! Cancer-causing compounds are produced when meats are cooked at very high temperatures. Grill vegetables, tofu and fruit instead. If you choose to grill meat: • Use marinades • Flip frequently • Remove fat • Use foil and avoid direct flame • Do not eat charred meat
A sedentary lifestyle promotes colon cancer. Sedentary activities include things like: • Watching television • Sitting at a desk • Surfing the web
Alcohol
Red and processed meats contain elements that can increase your risk of colon cancer. • Eat no more than 3 ounces of beef, pork or lamb per day. Choose chicken, legumes and fish more often. • Limit your consumption of processed meats like hot dogs, bacon, sausage and deli meats.
Alcohol destroys folic acid, which is a key to good health. Consider supplementing your diet with 400 mcg of folic acid per day if you do not plan to give up alcohol. Limit alcohol consumption to no more than: • 1 drink per day (women) • 2 drinks per day (men)
Excess Calories
Excess calories usually come from energy-dense foods. These foods are usually: • Low in fiber • High in fat • High in sugar
Too Many Refined Carbohydrates
Chronic elevations of insulin and insulin growth factors (IGF) increase your colon cancer risk. • Eating high-sugar, refined-carbohydrate foods triggers excessive insulin and IGF production, which can increase the growth of cancer cells in the colon. • High-sugar, refined-carbohydrate foods include foods made with sugars and white flour. Replace these with fruits, vegetables or whole grain foods.
Prevent Colon Cancer!
• Stay active. • Maintain a healthy weight. It is better to be pair shaped than apple-shaped.
• Eat a low-fat, high-fiber, plant-based diet. • Follow MyPlate’s advice and fill half your plate with fruits and vegetables every day.
• Get enough folate and vitamin D in your diet. • Avoid eating too much meat and meat cooked at high temperatures. Try plant protein foods instead.
• Avoid excess alcohol consumption.
For more information, check out www.preventcancer.org Copyright 2012. Food and Health Communications. Reprinted with permission from www.foodandhealth.com
GASTRO HEALTH MAGAZINE • FALL 2012
:: 15
Gastro Health
?
Are You at Risk for HepatitisC
A
major health issue facing our country today is a silent and deadly liver disease called hepatitis C. Up to 5 million Americans have hepatitis C – four times the amount of people with HIV – and it is the leading cause of liver cancer and the most common reason for liver transplantation in the United States. What’s more surprising is that 75 percent of people with hepatitis C don’t know they have it.
How to Catch this Silent Killer Before It Is Too Late
Hepatitis C is sometimes called a “silent killer” because it often has no symptoms and can go decades without being detected. In the meantime, serious liver damage or even liver cancer may occur. Recent studies from the Centers for Disease Control (CDC) have reported that deaths from hepatitis C are on the rise. In 2007, there were 15,000 deaths in the United States from hepatitis C, surpassing the 13,000 deaths from AIDS in the same year. People born from 1945 through 1965 have a greater prevalence of hepatitis C than the general population. In fact, 82 percent of people with the disease are baby boomers, and 75 percent of the deaths from hepatitis C occur in this group. Those at increased risk for hepatitis C include people who had blood transfusions before 1992, people with tattoos, people who used intravenous drugs – even once – and those who work in a healthcare setting. Certain populations, including African Americans and Hispanics, are also affected by hepatitis C at a significantly higher rate than the general population. But there is good news. For many patients, hepatitis C can be cured, unlike other chronic diseases such as hepatitis B and AIDS. Screening for hepatitis C is not currently part of routine testing; you may think you have been tested, but chances are you haven’t. The CDC is considering whether all baby boomers should have a simple, one-time blood test to check if they have been exposed to hepatitis C. According to a CDC-sponsored study, such age-based screening could identify more than 800,000 additional cases of chronic hepatitis C infection and, when followed by treatment, could reduce the number of deaths by 121,000. In the meantime, if you are a baby boomer or have any risk factors, make sure to ask your doctor for a simple blood test to screen for hepatitis C at your next appointment.
For more information on hepatitis C, visit www.BetterToKnowC.com.
16 ::
GASTRO HEALTH MAGAZINE • FALL 2012
PHYSICIAN DIRECTORY Gastro Health is a medical group made up of the finest physicians and allied health professionals in South Florida specializing in the treatment of gastrointestinal disorders, nutrition, and digestive health. Our team of board-certified physicians, physician assistants, nurse practitioners, nutritionists and technicians combine their clinical expertise and experience to provide patients with quality medical and preventive care in the field of Gastroenterology. With numerous office locations, endoscopy centers, diagnostic imaging, pathology laboratory, in-office infusion therapy, and affiliations with South Florida’s premier hospitals – Gastro Health continues to achieve excellence in medical care.
PHYSICIAN DIRECTORY
Gastro Health
Francisco J. Baigorri, MD * Gastroenterologist Care Center 1
Simon Behar, MD * Gastroenterologist Care Center 3
Barry E. Brand, MD Gastroenterologist Care Center 2
Gustavo Calleja, MD * Gastroenterologist Care Center 1
Marc S. Carp, MD Gastroenterologist Care Center 6
John P. Christie, MD Colorectal Surgeon Care Center 1
Lewis R. Felder, MD Gastroenterologist Care Center 7
Jose P. Ferrer, Jr., MD * Gastroenterologist Care Center 3
Jose P. Ferrer, Sr., MD * Gastroenterologist Care Center 3
Nelson Garcia Jr. MD * Gastroenterologist Care Center 8
Daniel Gelrud, MD * Gastroenterologist Care Center 1
Harris I. Goldberg, MD Gastroenterologist Care Center 1
Guillermo Gubbins, MD * Gastroenterologist Care Center 10
Pedro J. Greer Jr., MD * Gastroenterologist Care Center 11
Alfredo J. Hernandez, MD * Gastroenterologist Care Center 11
Eugenio J. Hernandez, MD * Gastroenterologist Care Center 3
Moises E. Hernandez, MD * Gastroenterologist Care Center 3
Richard E. Hernandez, MD * Gastroenterologist Care Center 5
Eduardo Krajewski, MD * Colorectal Surgeon Care Center 9
Robert C. Lanoff, MD * Gastroenterologist Care Center 2
Jose A. Lavergne, MD * Gastroenterologist Care Center 7
James S. Leavitt, MD Gastroenterologist Care Center 1
Marc Lederhandler, MD Gastroenterologist Care Center 1
Jerry Martel, MD, MPH * Gastroenterologist Care Center 8
* Habla EspaĂąol
18 ::
GASTRO HEALTH MAGAZINE • FALL 2012
Gastro Health
Antonio Martinez, MD Pathologist Pathology Medical Director
Flavia Mendes, MD * Gastroenterologist Care Center 1
Pedro Morales, MD * Gastroenterologist Care Center 8
Brett R. Neustater, MD Gastroenterologist Care Center 7
Javier L. Parra, MD * Gastroenterologist Care Center 1
Alfredo Rabassa, MD * Gastroenterologist Care Center 1
Ricardo J. Roman, MD * Gastroenterologist Care Center 7
Andres I. Roig, MD * Gastroenterologist Care Center 3
Seth D. Rosen, MD Gastroenterologist Care Center 2
Neil E. Rosenkranz, MD Gastroenterologist Care Center 2
S. Lawrence Rothman, MD Gastroenterologist Care Center 1
Eduardo Ruan, MD * Gastroenterologist Care Center 1
Andrew I. Sable, MD Gastroenterologist Care Center 2
George A. Sanchez, MD * Gastroenterologist Care Center 1
Howard I. Schwartz, MD Gastroenterologist Care Center 1
Daniel Seckinger, MD Radiologist Imaging Medical Director
Somal S. Shah, MD * Gastroenterologist Care Center 11
Arie Slomianski, MD * Gastroenterologist Care Center 1
David A. Sommer, MD Gastroenterologist Care Center 2
Marcos Szomstein, MD * Colorectal Surgeon Care Center 9
Stefania L. Vernace, MD Gastroenterologist Care Center 1
* Habla Espaùol GASTRO HEALTH MAGAZINE • FALL 2012
:: 19
Gastro Health
Allied Healthcare Staff
Amber M. Abraham, PA-C
Darlene Boytell-Perez, ARNP *
Sabrina Kaplan, PA-C*
Rebecca Karousatos, MS, RD, LDN
Ellen Matas-Sosa, PA-C
Hernando Mispireta, ARNP *
Ronal R. Ricano, PA
Rachael Robinson, RN
Hengameh Shahidpoor, ARNP
Kayce Tugg, MSN, RN
Care Centers Care Center 1 Main Office 7500 SW 87 Avenue, Suite 200 Miami, FL 33173 305-913-0666
Care Center 7 Satellite Office #2 21110 Biscayne Boulevard, Suite 206 Aventura, FL 33180 305-770-0062
Care Center 1 Satellite Office 6141 Sunset Drive, Suite 301 Miami, FL 33143 305-913-0666
Care Center 8 8200 SW 117 Avenue, Suite 110 Miami, FL 33183 305-274-5500
Care Center 2 9555 N. Kendall Drive, Suite 100 Miami, FL 33176 305-273-7319
Care Center 9 7765 SW 87 Avenue, Suite 212 Miami, FL 33173 305-596-3080
Care Center 3 8950 N. Kendall Drive, Suite 306-W Miami, FL 33176 305-596-9966
Care Center 10 1150 Campo Sano Avenue, Suite 300 Coral Gables, FL 33146 305-662-6170
Care Center 4 15955 SW 96 Street, Suite 205 Miami, FL 33196 305-468-4191
Care Center 11 3661 S. Miami Avenue, Suite 805 Miami, FL 33133 305-856-7333
Care Center 5 7765 SW 87 Avenue, Suite 105 Miami, FL 33173 305-274-0808
Imaging Center 7500 SW 87 Avenue, Suite 200-A Miami, FL 33173 305-468-4190
Care Center 6 1400 NE Miami Gardens Drive; Suite 221 North Miami Beach, FL 33179 305-949-2020
Infusion Center 7500 SW 87 Avenue, Suite 200-A Miami, FL 33173 305-913-0660
Care Center 7 Main Office 16855 NE 2nd Avenue, Suite 202 North Miami Beach, FL 33162 305-770-0062
Pathology Laboratory 9000 SW 87 Court, Suite 110 Miami, FL 33176 305-468-4194
Care Center 7 Satellite Office #1 5803 NW 151 Street, Suite 105 Miami Lakes, FL 33014 305-770-0062
20 ::
* Habla Español
GASTRO HEALTH MAGAZINE • FALL 2012
Insurances
AARP Medicare Complete Aetna American Heritage Life Insurance American Medical Security AvMed Baptist Executive Health Beechstreet Blue Cross Blue Shield Cigna Coventry Health Care Dimensions Health First Health Network Humana Humana Champus Tricare Mail Handlers Benefit Plans Medica Health Plan Medicare Part B MultiPlan Neighborhood Health Plan OneSource Preferred Care Partners United Healthcare VISTA Health Plans
Investigative Overview: Gastroparesis
Gastro Health
Treatment
Nelson Garcia, MD Gastroenterologist
G
Diet remains one of the mainstays of treatment for gastroparesis regardless of its cause. In general, individuals with gastroparesis should avoid fatty foods and fibrous foods (raw fruits and vegetables) which take a longer time to digest. Also, rather than eating three meals a day, affected persons should eat smaller, more frequent meals. Diabetics must maintain adequate control of their blood glucose whose elevation may lead to a decrease in gastric emptying. Currently, there are three medications that can be used to treat gastroparesis: metoclopramide, domperidone and erythromycin.
astroparesis can be literally translated to mean “stomach paralysis.” In this disorder, there is an abnormal or absent motility of the stomach. This is a common disorder which is most frequently associated with diabetes. However, in approximately 50% of individuals, other factors may play a precipitating role. For example, underlying medical conditions such as scleroderma and hypothyroidism may be associated with decreased gastric motility. Also, common neuromuscular disorders such as Parkinson’s disease and spinal cord injuries may be associated with gastroparesis. A thorough review of all medication is important given that many medications may lead to decreased gastric and intestinal motility. For example, narcotics, certain anti-hypertensive medications (such as diltiazem and verapamil), hormones (progesterone), and levodopa (used for Parkinson’s disease) have all been associated with decreased gastric motility.
Symptoms
Symptoms of gastroparesis include bloating, nausea, and early fullness particularly with the ingestion of fatty meals and high-fiber foods such as raw fruits and vegetables. Many individuals also experience accompanying upper abdominal pain and reflux symptoms. Vomiting of undigested foods several hours after their ingestion is highly suggestive of underlying gastroparesis. Some individuals may eventually experience weight loss due to malabsorption of nutrients or diminished food intake from their underlying symptoms.
Diagnosis
Due to the fact that the symptoms of gastroparesis are often associated with other upper digestive tract disorders, endoscopic (upper endoscopy) and/or radiologic tests (upper GI series) are often ordered to exclude alternate diagnoses. However, the most commonly ordered exam used to diagnose gastroparesis is a gastric emptying scan. During this exam, which is performed in a nuclear medicine department, a standard meal (usually consisting of an egg substitute) mixed with a small amount of radioactive material is ingested. The emptying of this meal from the stomach over a 4-hour period is determined. The amount of time required for the patient’s gastric emptying is then compared to control population. Of interest, new technologies such as a wireless capsule (SmartPill®) are being used to measure gastric emptying through the use of different information including: pH, temperature and pressure changes.
Metoclopramide stimulates gastric contraction and also possesses anti-nausea effects. However, it has been linked to severe sideeffects including a possibly irreversible facial twitching called tardive dyskinesia. For this reason, its long-term use is minimized or limited.
Domperidone is similar to metoclopramide, but is not associated with neurologic side-effects due to the fact that it does not act on receptors in the brain. Unfortunately, it is not readily available in the United States, but can be found in South America, Canada, and Europe.
Erythromycin is a commonly used antibiotic that binds receptors in the stomach call motilin receptors. Stimulation of these receptors leads to gastric contraction and improved gastric empt ying. However, erythromycin is only effective for brief periods of time. Lastly, Iberogast is a liquid herbal supplement that has been used in Europe for over 4 decades and has been shown to improve gastric motility is small studies. Rarely, individuals may need to consider invasive procedures such as a gastric pacemaker that has been shown in some studies to improve the symptoms. In summary, gastroparesis is a common condition leading to altered gastric motility. Although diabetes is its most common cause, other contributing causes should not be excluded. Diet and various medications often lead to marked symptomatic improvement. GASTRO HEALTH MAGAZINE • FALL 2012
:: 21
Gastro Health
To lessen signs and symptoms of moderate to severe Crohn’s Disease in adults not helped enough by usual treatments. Important Safety Information About CIMZIA® (certolizumab pegol) What is the most important information I should know about CIMZIA? CIMZIA is a prescription medicine that affects your immune system. CIMZIA can lower the ability of the immune system to fight infections. Serious infections have happened in patients taking CIMZIA, including tuberculosis (TB) and infections caused by viruses, fungi, or bacteria that have spread throughout the body. Some patients have died from these infections. Your doctor should test you for TB before starting CIMZIA. Your doctor should monitor you closely for signs and symptoms of TB during your treatment with CIMZIA. Certain Types of Cancer There have been cases of unusual cancers in children and teenage patients using TNF-blocking agents. CIMZIA is not approved for use in pediatric patients. For people taking TNF-blocker medicines, including CIMZIA, the chances for getting lymphoma or other cancers may increase. People with RA, especially more serious RA, may have a higher chance for getting a kind of cancer called lymphoma. Before starting CIMZIA, tell your doctor if you: • Think you have an infection. You should not start taking CIMZIA if you have any kind of infection, are being treated for an infection or have signs of an infection such as fever, cough or flu-like symptoms or if you get a lot of infections or have infections that keep coming back. • Have any open cuts or sores • Have diabetes or HIV • Have TB, or have been in close contact with someone with TB • Were born in, lived in, or traveled to countries where there is more risk of getting TB. Ask your doctor if you are not sure. • Live or lived in certain parts of the country (such as the Ohio and Mississippi River valleys) where there is an increased risk for getting certain kinds of fungal infections (histoplasmosis, coccidioidomycosis, blastomycosis). These infections may develop or become severe if you take CIMZIA. If you do not know if you have lived in these types of areas, ask your doctor. • Have or have had hepatitis B • Have or have had any type of cancer • Have congestive heart failure • Have seizures, any numbness or tingling, or a disease that affects your nervous system such as multiple sclerosis • Are scheduled to receive a vaccine. Do not receive a live vaccine while taking CIMZIA • Are pregnant, planning to become pregnant, or breastfeeding. CIMZIA has not been studied in pregnant or nursing women.
• Especially tell your doctor if you take: Kineret ® (anakinra), Orencia® (abatacept), Rituxan® (rituximab), Tysabri® (natalizumab), or another TNF blocker. You have a higher chance for serious infections when taking CIMZIA with these medicines. You should not take CIMZIA while you take one of these medicines. After starting CIMZIA, if you get an infection, any sign of an infection including a fever, cough, flu-like symptoms, or have open cuts or sores on your body, call your doctor right away. CIMZIA can make you more likely to get infections or make any infection that you may have worse. Patients 65 years of age or older, patients with other long term medical conditions, or taking certain other drugs that affect the immune system, such as corticosteroids or methotrexate, may be at a greater risk of infection. What are the possible side effects of CIMZIA? CIMZIA can cause serious side effects, including: Heart Failure including new heart failure or worsening of heart failure you already have; Nervous System Problems such as Multiple Sclerosis, seizures, or inflammation of the nerves of the eyes; Allergic Reactions. Signs of an allergic reaction include a skin rash, swollen face, or trouble breathing; Hepatitis B virus reactivation in patients who carry the virus in their blood. In some cases, patients have died as a result of hepatitis B virus being reactivated. Your doctor should monitor you carefully during treatment with CIMZIA if you carry the hepatitis B virus in your blood; Blood Problems. Your body may not make enough of the blood cells that help fight infections or help stop bleeding; Immune reactions including a lupus-like syndrome. Symptoms include shortness of breath, joint pain, or a rash on the cheeks or arms that worsens with sun exposure. Call your doctor right away if you develop any of the above side effects or symptoms. The most common side effects of CIMZIA are: upper respiratory infections (flu, cold), rash, and urinary tract infections (bladder infections). Other side effects have happened in some people including new psoriasis or worsening of psoriasis you already have and injection site reactions. You are encouraged to report negative side effects to FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. OXO, Good Grips® and the associated logos are registered trademarks of Helen of Troy Limited and are used under license. © 2012 UCB, Inc. All rights reserved. CCD224-0712C
Please see Brief Summary on following pages.
Prefilled syringe designed for comfort and control in partnership with
22 ::
GASTRO HEALTH MAGAZINE • FALL 2012
Can you trust your gut? Cimzia. Noticeable Crohn’s symptom relief relief. In a clinical trial, more patients who responded and continued on CIMZIA versus placebo showed noticeable improvement in signs and symptoms of moderate to severe Crohn’s disease at 26 weeks. Your results may vary. • CIMZIA is not a steroid; it is a prescription biologic treatment that is injected. • CIMZIA can be injected at home or at your doctor’s office every 4 weeks after initial dosing. • CIMZIA is indicated to lessen signs and symptoms of moderate to severe Crohn’s disease
in adults not helped enough by usual treatments.
Ask your doctor if CimziA may be right for you. Please read important Safety information on the adjacent page.
Visit cimzia.com/CD Call 1-877-55CIMZIA
Gastro Health Consumer Brief Summary for Cimzia® (certolizumab pegol)
CONSULT PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION. Read the Medication Guide that comes with CIMZIA before you start using it, and before each injection of CIMZIA. This brief summary does not take the place of talking with your doctor about your medical condition or treatment. What is the most important information I should know about CIMZIA? CIMZIA is a medicine that affects your immune system. CIMZIA can lower the ability of the immune system to fight infections. Serious infections have happened in patients taking CIMZIA. These infections include tuberculosis (TB) and infections caused by viruses, fungi or bacteria that have spread throughout the body. Some patients have died from these infections. • Your doctor should test you for TB before starting CIMZIA. • Your doctor should monitor you closely for signs and symptoms of TB during treatment with CIMZIA. Before starting CIMZIA, tell your doctor if you: • think you have an infection. You should not start taking CIMZIA if you have any kind of infection. • are being treated for an infection • have signs of an infection, such as a fever, cough, flu-like symptoms • have any open cuts or sores on your body • get a lot of infections or have infections that keep coming back • have diabetes • have HIV • have tuberculosis (TB), or have been in close contact with someone with TB • were born in, lived in, or traveled to countries where there is more risk for getting TB. Ask your doctor if you are not sure. • live or have lived in certain parts of the country (such as the Ohio and Mississippi River valleys) where there is an increased risk for getting certain kinds of fungal infections (histoplasmosis, coccidioidomycosis, or blastomycosis). These infections may develop or become more severe if you take CIMZIA. If you do not know if you have lived in an area where histoplasmosis, coccidioidomycosis, or blastomycosis is common, ask your doctor. • have or have had hepatitis B • use the medicine Kineret® (anakinra), Orencia® (abatacept), Rituxan® (rituximab), or Tysabri® (natalizumab) After starting CIMZIA, if you get an infection, any sign of an infection including a fever, cough, flu-like symptoms, or have open cuts or sores on your body, call your doctor right away. CIMZIA can make you more likely to get infections or make any infection that you may have worse. Patients 65 years of age or older, patients with other long term medical conditions, or taking certain other drugs that affect the immune system, such as corticosteroids or methotrexate, may be at a greater risk of infection. Certain types of Cancer • There have been cases of unusual cancers in children and teenage patients using TNF-blocking agents. • For people taking TNF-blocker medicines, including CIMZIA, the chances of getting lymphoma or other cancers may increase. • People with RA, especially more serious RA, may have a higher chance of getting a kind of cancer called lymphoma. See the section “What are the possible side effects of CIMZIA?” for more information. What is CIMZIA? CIMZIA is a medicine called a Tumor Necrosis Factor (TNF) blocker. CIMZIA is used in adult patients to: • Lessen the signs and symptoms of moderately to severely active Crohn’s disease (CD) in adults who have not been helped enough by usual treatments. • Treat moderately to severely active rheumatoid arthritis (RA). It is not known whether CIMZIA is safe and effective in children. What should I tell my doctor before starting treatment with CIMZIA? CIMZIA may not be right for you. Before starting CIMZIA, tell your doctor about all of your medical conditions, including if you: • have an infection. (See, “What is the most important information I should know about CIMZIA?”) • have or have had any type of cancer • have congestive heart failure • have seizures, any numbness or tingling, or a disease that affects your nervous system such as multiple sclerosis • are scheduled to receive a vaccine. Do not receive a live vaccine while taking CIMZIA. • are allergic to any of the ingredients in CIMZIA. See the end of this Brief Summary for a list of the ingredients in CIMZIA. Tell your doctor if you are pregnant, planning to become pregnant, or breastfeeding. CIMZIA has not been studied in pregnant or nursing women. Tell your doctor about all the medicines you take including prescription and nonprescription medicines, vitamins and herbal supplements. Your doctor will tell you if it is okay to take your other medicines while taking CIMZIA. Especially, tell your doctor if you take: • Kineret® (anakinra), Orencia® (abatacept), Rituxan® (rituximab),Tysabri® (natalizumab). You have a high chance for serious infections when taking CIMZIA with Kineret®,
24 ::
GASTRO HEALTH MAGAZINE • FALL 2012
Orencia®, Rituxan®, or Tysabri®. • A TNF blocker: Remicade® (infliximab), Humira® (adalimumab), Enbrel® (etanercept), Simponi® (golimumab). You should not take CIMZIA, while you take one of these medicines. How should I use CIMZIA? CIMZIA is available as a lyophilized powder for reconstitution or a prefilled syringe. If your doctor prescribes the lyophilized pack, CIMZIA should be injected by a healthcare provider. If your doctor prescribes the prefilled syringe, see the booklet called “Patient Instructions for Use” packaged in your CIMZIA prefilled syringe kit for complete instructions for use. Do not give yourself an injection of CIMZIA unless you have been shown by your doctor or nurse, or they can train someone you know to help you with your injection. CIMZIA is given by an injection under the skin. Your doctor will tell you how much CIMZIA to inject and how often, based on your condition to be treated. Make sure to keep all of your injection and follow-up appointments with your doctor. What are the possible side effects of CIMZIA? CIMZIA can cause serious side effects including: See “What is the most important information I should know about CIMZIA?” • Heart Failure including new heart failure or worsening of heart failure you already have. Symptoms include shortness of breath, swelling of your ankles or feet, or sudden weight gain. • Nervous System Problems such as multiple sclerosis, seizures, or inflammation of the nerves of the eyes. Symptoms include dizziness, numbness or tingling problems with your vision, and weakness in your arms or legs. • Allergic Reactions. Signs of an allergic reaction include a skin rash, swelling of the face, tongue, lips, or throat, or trouble breathing. • Hepatitis B virus reactivation in patients who carry the virus in their blood. In some cases patients have died as a result of hepatitis B virus being reactivated. Your doctor should monitor you carefully during treatment with CIMZIA if you carry the hepatitis B virus in your blood. Tell your doctor if you have any of the following symptoms: • feel unwell • tiredness (fatigue) • poor appetite • fever, skin rash, or joint pain • Blood Problems. Your body may not make enough of the blood cells that help fight infections or help stop bleeding. Symptoms include a fever that doesn’t go away, bruising or bleeding very easily, or looking very pale. • Immune reactions including a lupus-like syndrome. Symptoms include shortness of breath, joint pain, or a rash on the cheeks or arms that worsens with sun exposure. Call your doctor right away if you develop any of the above side effects or symptoms. The most common side effects in people taking CIMZIA are: • upper respiratory infections (flu, cold) • rash • urinary tract infections (bladder infections) Other side effects with CIMZIA include: • Psoriasis. Some people using CIMZIA had new psoriasis or worsening of psoriasis they already had. Tell your doctor if you develop red scaly patches or raised bumps that are filled with pus. Your doctor may decide to stop your treatment with CIMZIA. • Injection site reactions. Redness, rash, swelling, itching or bruising can happen in some people. These symptoms will usually go away within a few days. If you have pain, redness, or swelling around the injection site that doesn’t go away within a few days or gets worse, call your doctor right away. Tell your doctor about any side effect that bothers you or does not go away. These are not all of the side effects with CIMZIA. Ask your doctor or pharmacist for more information. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. General information about CIMZIA Medicines are sometimes prescribed for purposes that are not mentioned in Medication Guides. Do not use CIMZIA for a condition for which it was not prescribed. Do not give CIMZIA to other people, even if they have the same condition. It may harm them. This brief summary summarizes the most important information about CIMZIA. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about CIMZIA that is written for health professionals. For more information go to www.CIMZIA.com or call 1-866-4CIMZIA (424-6942). Always keep CIMZIA, injection supplies, puncture-proof container, and all other medicines out of the reach of children. What are the ingredients in CIMZIA? CIMZIA lyophilized powder: Active ingredient: certolizumab pegol. Inactive ingredients: sucrose, lactic acid, polysorbate. The pack contains Water for Injection, for reconstitution of the lyophilized powder. CIMZIA prefilled syringe: Active ingredient: certolizumab pegol. Inactive ingredients: sodium acetate, sodium chloride, and Water for Injection. CIMZIA has no preservatives. Product developed and manufactured for: UCB, Inc., 1950 Lake Park Drive, Smyrna, GA 30080
Cimzia® is a registered trademark of the UCB Group of companies. © 2011 UCB, Inc., Smyrna, GA 30080 All rights reserved. Printed in the U.S.A.
U.S. License No 1736
CCD123-0911
Gastro Health
Crohn’s relief with all year co-pay savings Save on your CIMZIA® prescription
co-pay savings card BIN: PCN: GRP: ID #:
004682 CN ECXXXXXXX XXXXXXX
Please see back for complete eligibility rules. Please see accompanying complete Prescribing Information.
Get up to 12 months of CIMZIA with no out-of-pocket costs.* Go to cimzia.com/CD To lessen signs and symptoms of moderate to severe Crohn’s disease in adults not helped enough by usual treatments. Serious infections have happened in patients taking CIMZIA, including tuberculosis (TB) and infections caused by viruses, fungi, or bacteria that have spread throughout the body. Some patients have died from these infections.
Please see Brief Summary on previous page. *Subject to eligibility. Restrictions may apply. In 2011, 96.8% of CIMZIA Co-Pay Savings Card users paid no out-of-pocket costs.
Attention
Baby Boomers
I
n August 2012, the Centers for Disease Control issued new guidelines for screening of the Chronic Hepatitis C infection. The previous guidelines had targeted only persons thought to be at high risk, such as those who received a blood transfusion prior to 1992, used intravenous illicit drugs, were on hemodialysis, had HIV disease, known exposure to the virus, or born to a mother with known hepatitis C. However, now the new recommendations state that any person born between 1945 and 1965 should be screened once, regardless of risk factors.
S. Lawrence Rothman , MD Gastroenterologist
CDC issues new guidelines for Hepatitis C screening for the ”Boomer” Generation (1945-1965)
The new guidelines were adopted for several reasons. Firstly, 75% of those with hepatitis C were born in those years. Also, more than half of people with hepatitis C are unaware that they have it. Complications and deaths from chronic hepatitis C are on the rise. It has been shown that screening is cost-effective and saves lives. Finally, new treatments can cure up to 75% of chronic hepatitis C cases. Screening involves a simple blood test performed only once. Normal results of so-called liver function blood tests do not rule out hepatitis C. Up to 50% of persons infected can actually have normal results of these tests. Hepatitis C is a virus that attacks the liver. It is mainly transmitted through contaminated blood. Hepatitis C can be present and actually cause no symptoms for many years, even decades, and has therefore been called the “silent epidemic.” Up to 20% of those infected will develop severe scarring and liver impairment known as cirrhosis of the liver and a significant percentage of these will develop primary liver cancer. Chronic hepatitis C is the most common indication for liver transplantation in the United States. It is the cause of up to 15,000 yearly deaths, with the number expected to rise. So, if you were born between 1945 and 1965 and wish to be screened, please call a screening hotline or be sure to set up an appointment with Gastro Health by calling (305)468-4180. GASTRO HEALTH MAGAZINE • FALL 2012
:: 25
Pediatric News
GastroHealth Health Gastro
Coping with IBD Raghad Koutouby , MD Pediatric Gastroenterologist
I
t is never easy to learn that you have a chronic illness, especially as a child. It can make them feel afraid, sad, nervous, or just “different.”
Children with Inflammatory Bowel Disease (IBD) face the challenge of an unpredictable and potentially embarrassing disease. They may be embarrassed about their symptoms or frequent visits to the bathroom, and they may fear being the target of the “bathroom humor” that is popular amongst children. In addition to the embarrassing symptoms, short stature and delayed puberty, simply having a chronic illness may contribute to feeling “different” from peers. Participation in school and social activities may be adversely affected. IBD clearly has the potential to impact psychosocial functioning. Children with IBD appear to be at risk for more difficulties in psychosocial functioning than healthy children, although the problem reaches clinical significance in only a subset.
The difficulty experienced by children with IBD is generally similar to that experienced in other chronic health conditions. In the area of behavioral/emotional functioning, mood and anxiety disorders are most common. Children with IBD are at increased risk for problems in social functioning, but the nature of their social difficulties is unclear. Mixed results have been found in the areas of family dysfunction and body image, and limited research exists in the areas of stress and coping, self-esteem, and eating problems.
Signs of Difficulty Coping
Watch for any of these behaviors, which may indicate that your child is having trouble transitioning to life with IBD: • Difficulty sleeping • Poor eating habits • Persistent sadness, frequent crying • Lack of interest in usual activities and hobbies
Helping Your Child Cope
If your child seems to be having trouble dealing with his or her IBD, parents and trusted adults can be a great source of comfort and help. Keep the lines of communication open, and be sure to let the child know: • It’s normal to feel sad or anxious about IBD • With IBD treatment, most kids lead normal, active lives • It’s important to talk about your feelings with a parent or a doctor • Anything you share with a doctor is confidential and private—he or she can’t tell anyone else without your permission • Kids are different for all kinds of reasons—you’re great the way you are!
myIBD
A great resource for children and families to track IBD symptoms is “myIBD”. This free app can be downloaded from the app store for use on a handheld device such as iPod/iPad / iPhones or Android Smartphones. This app has provided a novel way of empowering young patients and their families to come to terms with the diagnosis of IBD. It enables patient-driven learning by engaging children/teenagers and allowing the contemporaneous symptom monitoring and documentation of adherence to prescribed medication. This application has given young patients and their families the opportunity to preview/review the information given during the face-to-face meeting with their physician. The app includes a feature to monitor disease activity and treatment compliance in real time as well as educational videos and links. This has allowed young patients to take control of their symptom reporting, to generate a clinical summary-PDF prior to follow-up in the IBD clinic and to actively prepare for a transition to adult care.
26 ::
GASTRO HEALTH MAGAZINE • FALL 2012
Gastro Health
Gluten-Free Corner Rebecca Karousatos, MS, RD, LDN
Gluten-free dining can be enjoyable, healthy and nutritious. More restaurants and food companies are becoming in tune with the special dietary needs of the Celiac Disease population. Here, you will see a list of some restaurants that provide a “glutenfree” menu; be sure to let your server know that you have a food allergy to wheat, barley, rye and malt. Also included is a healthy gluten-free grocery list. There are several resources out there to further guide your dietary needs, including the highly-recommended book “Gluten-Free Diet” by Shelley Case, RD.
Enjoy and healthy dining!
Gluten-Free Friendly Restaurants • Romano’s Macaroni Grill – various locations • BJ’s Brewhouse – The Falls Shopping Center • P.F. Chang’s – various locations • Fleming’s – Coral Gables • California Pizza Kitchen – Coral Gables • Yard House – Coral Gables • Outback Steakhouse – various locations • Carino’s – Doral
• Chipotle – various locations • Carrabba’s – various locations • Yogurt Land – South Miami • Naked Pizza – Coral Gables • Rosa Mexicano – Brickell • Crave – Coral Gables • Pizza Fusion – Miami Beach • Thrive – Miami Beach
Gluten-Free Grocery List Bread/Grains
• corn tortillas • rice crackers • gluten-free cereal • buckwheat • quinoa • rice • flax
Frozen
• vegetables • fruits • gluten-free ice cream or sherbet • gluten-free waffles • gluten-free frozen dinners/pizza
Meat/Protein • fish/shellfish • hot dogs • canned tuna • tofu • poultry • lunch meat • beef
Cans/Jars
• vegetables • fruits • beans • gluten-free soup • apple sauce • pasta sauce • canned milk • nut butters • jam honey
Beverages
• coffee/tea • gluten-free beer • juice • water
Dairy
• milk • whipped cream • cheese • sour cream • butter/margarine • eggs • yogurt • gluten-free pudding
Snacks
• rice cakes • rice or soy crackers • sunflower seeds • popcorn • dried fruit • corn chips • Jell-O
Condiments and Baking
• white or red wine vinegar • shortening • olive, canola, or vegetable oil • salad dressing • spices • cornstarch/meal • gluten-free flour • cocoa • syrup • xanthan gum
Fruit/Veggies • fruits • vegetables • herbs
GASTRO HEALTH MAGAZINE • FALL 2012
:: 27
UNITED survival does. cancER doEsn’t dEfinE ME,
WE HEAL Physicians
With advanced Medical specialties behind me, so is my cancer. As a cancer survivor, I endured the physical and emotional battle with cancer and won. Every day, my doctors help other cancer patients become survivors by delivering comprehensive, compassionate cancer care. They helped me understand my cancer type and explained the latest therapy options for my disease. They took the time to answer all of my questions. Together, we developed a program to fight my cancer using proven treatments. The care I received helped me beat cancer and get my life back.
Medical Oncology & Hematology Federico Albrecht, MD Frances A. Behrmann, MD Peter L. Citron, MD Fernando I. de Zarraga Jr., MD Steven G. Fein, MD Sara M. Garrido MD, FACP Leonard A. Kalman, MD Paul R. Kaywin, MD Alberto F. Larcada, MD Antonio F. Muina, MD Lisa Reale, MD Michael B. Troner, MD Antonio Ucar, MD Siddhartha A. Venkatappa, MD Howard W. Wallach, MD FACP Grace Wang, MD
Radiation Oncology Andre A. Abitbol, MD, FACRO Allie M. Garcia-Serra, MD Alan A. Lewin, MD, FACR, FACP Steven J. Olszewski, MD Maria-Amelia M. Rodrigues, MD Diagnostic Center Steven A. Christie, MD Pediatric Oncology Doured Daghistani, MD
Quality Cancer Care: Recognizing Excellence
QCP™ and the QCP™ logo are trademarks of the American Society of Clinical Oncology, Inc. Used with permission.
Locations • Baptist Medical Arts Building, Suite 300E, 603E and 905E • South Miami Hospital Medical Arts Building, Suite 601 • Baptist Hospital of Miami Radiation Oncology • South Miami Hospital Radiation Oncology • Diagnostic Center, 9035 Sunset Drive, Suite 102
To learn more, visit www.Miamicancer.com or call (305) 595-2141
Gastro Health
What Can Remicade
Do For You? Kayce Tugg, MSN, RN
Remicade (Infliximab) is an immunosuppressive prescription drug used to treat autoimmune diseases, such as Crohn’s Disease, Ulcerative Colitis, Rheumatoid Arthritis, Psoriatic Arthritis and Anklylosing Spondylitis.
S
o your GI doctor says to you, “I think we should use Remicade to treat your IBD (Inflammatory Bowel Disease). We can set you up to do convenient in-office infusions.” Your brain suddenly goes into overdrive. You have so many questions! What is Remicade? How is it given? What is an in-office infusion? What are the side effects? Don’t fret. Read on and you will find the answers to all of these questions, and more. Remicade (Infliximab) is an immunosuppressive prescription drug used to treat autoimmune diseases, such as Crohn’s Disease, Ulcerative Colitis, Rheumatoid Arthritis, Psoriatic Arthritis and Anklylosing Spondylitis. This autoimmune response is caused by too much of a protein called tumor necrosis factor-alpha (TNF-alpha) circulating in the body. High levels of this protein cause the body’s immune system to mistakenly attack and destroy cells in the body. In the case of Ulcerative Colitis (UC), the attack occurs in the large intestines. In Crohn’s disease, the gastrointestinal tract from the mouth to the anus is assaulted causing inflammation. This can lead to symptoms of diarrhea, abdominal pain and GI bleeding. Remicade blocks the TNFalpha protein produced by the immune system. This reduces inflammation and puts the Crohn’s and UC into remission. Remicade has been used to treat over 1 million patients with autoimmune diseases and has been studied for over 17 years. vRemicade is given by intravenous (IV) infusion, which means it is administered directly into a vein in the arm or hand. For over 10 years, Gastro Health has been performing safe, efficient and cost effective in-office Remicade infusions.
The Remicade is administered by experienced infusion Registered Nurses who provide not only the treatment and patient education but also act as a patient advocate, helping the patient navigate through the healthcare system. The infusion takes approximately two hours. The first three infusions (the induction doses) are given within a six-week period. After that, the maintenance infusions are every eight weeks. The physician can alter this schedule depending on the response to treatment. Most patients see symptom improvement after the first three infusions, but some patients see results after the very first infusion. Upon arriving to the infusion center, the patient will be registered and escorted to the infusion room where there are comfortable lounge chairs. This can be a time to meet other people with a similar diagnosis, support each other and make new friends. A general health assessment will be performed along with the monitoring of vital signs. The dose of Remicade will be calculated by the RN based on the patient’s weight, and then an IV will be started in the hand or arm. The medication will be mixed once the IV has been started, and the IV bag containing the Remicade will be connected and infused via the IV. Vital signs will be monitored throughout the infusion. During the infusion and for a period of time afterwards, the nurse will also closely monitor for signs of any problems.
so once the infusion is complete the patient can enjoy the rest of their day. Although the commitment to receiving Remicade infusions maybe long-term, most patients are very happy that they have this treatment available to them and have had significant improvement in their quality of life. So if your doctor recommends Remicade infusions, don’t fret – look forward to being taken care of in a supportive environment by your very own patient advocate, an opportunity to meet folks that have the same disease you have and most importantly, look forward to an improved quality of life.
Gastro Health Infusion Team From left to right: Karla V. Ruiz-Tamayo, RN Kayce Tugg, MSN, RN, AOCN Carmen Carvajal, BSN, RN, CPN
At the conclusion of the infusion, the IV will be removed from the arm or hand. The patient can schedule the next infusion prior to leaving the infusion center. The infusion is non-sedating, GASTRO HEALTH MAGAZINE • FALL 2012
:: 29
Gastro Health
Treating
H
Hemorrhoids
emorrhoids are a normal part of the human anorectal anatomy. They do not constitute a disease unless they become symptomatic. The prevalence of symptomatic hemorrhoids in the United States is reported to be 4.4%, affecting men and women equally. Hemorrhoid disease accounts for 3.2 million ambulatory care visits, 306,000 hospitalizations and the issue of over 2 million prescriptions a year. Hemorrhoids, when symptomatic, can be treated successfully. Treatment can be divided into four different steps:
Step 1: Dietary and Lifestyle Modification
Constipation is one of the most common causes of symptomatic hemorrhoid disease. Dietary management with increased fiber and water intake is the primary noninvasive mean to treat constipation. • Psyllium is the principal fiber supplement used in concert with water to add moisture to the stool, ameliorating constipation. • Other alternative medications include witch hazel, horse chestnut, ginger root, butchers broom, rutin, hesperidin and diosmin – all mainly used in homeopathic medicine.
Step 2: Topical Agents
Most of the creams, ointments and suppositories prescribed for the treatment of symptomatic hemorrhoids contain corticosteroids. They are good for the short-term treatment of the hemorrhoid flare, but its chronic use is discouraged do to the possibility of permanent damage to the perianal skin. They could also promote opportunistic infections such as fungal dermatitis. Some creams are mixed with local anesthetics such as lidocaine and pramoxine, which could give short-term relief. Other alternative medications that are used locally are astringents such as Witch Hazel (Hammamelis Virginiana), Aloe Vera and phenylephrine.
30 ::
GASTRO HEALTH MAGAZINE • FALL 2012
Eduardo Krajewski, MD Colorectal Surgeon
Step 3: In-Office Procedures
Step 4: Surgical treatment
Sclerotherapy: indicated for grade 1 and 2 internal hemorrhoids. It involves a submucosal injection of a sclerosant at the apex of the hemorrhoid and usually causes thrombosis of the vessels with shrinkage and fixation.
Doppler Guided Hemorrhoidal Artery Ligation: using a Doppler transducer, the hemorrhoidal arteries are identified and ligated. It causes less pain than a traditional surgical hemorrhoidectomy, but sometimes, the large prolapse of grade 4 internal hemorrhoids or the prolapsing of large external hemorrhoids are difficult to address.
The goal of in-office procedures is to ablate the vessels involved and fix the sliding hemorrhoidal tissue back onto the muscle wall of the anal canal with minimal pain. These procedures include:
Rubber Band Ligation: the most commonly used in-office procedure, indicated for internal hemorrhoids grades 1, 2 and 3. Ligators deploy a rubber band around a hemorrhoid pedicle. The procedure is usually painless and takes only a few minutes to perform. The ligated tissue usually necroses and sloughs in 3-4 days, causing elimination of the redundant tissue and fixation. Infrared Coagulation (IRC): produces an infrared light which penetrates the tissue and converts to heat, promoting coagulation of the vessels and fixation. It is usually indicated for small bleeding internal hemorrhoids, grade 1. Electrocoagulation and Bipolar Coagulation: indicated for small bleeding internal hemorrhoids, relies on coagulation and fixation as other techniques. It is somehow less effective and more painful than RBL and IRC. Direct- C u rrent E lectrotherap y (Ultroid): is similarly applied through a probe placed via an anoscope into the mucosa at the apex of the hemorrhoid. It is a lengthy procedure and reapplications to the same site are sometimes required. Thrombectomy: usually indicated for the therapy of small thrombosed external hemorrhoids. The procedure usually does not excise the involved hemorrhoid complex, but rather evacuates the blood clot beneath the anal skin, relieving the tension and pain immediately.
Several options and techniques are available for the surgical treatment of symptomatic hemorrhoids. They include:
Excisional Hemorrhoidectomy: several techniques exist to excise the hemorrhoid tissue, including: the closed or Ferguson, the open or Milligan-Morgan, the Nd-YAG laser, and the use of energy instruments such as the Harmonic Scalpel and Ligasure. Postoperative pain and prolonged healing time are some main disadvantage. Long-term results are usually excellent. S tapled Hemorrhoidectom y: also known as PPH (procedure for prolapsed hemorrhoids), thought to decrease the amount of postoperative pain. A portion of the rectal mucosa and submucosa close to the apex of the hemorrhoid pedicle is excised and stapled again. The hemorrhoids are re-suspended and brought back into the anal canal. A major drawback of this technique is that the procedure does not treat the large external hemorrhoids and associated tags sometimes present. The use of PPH is limited to patients with large grade 3 and 4 internal hemorrhoids
A New Year, a New Chance to
Take Charge of Your Health Get this free, easy-to-read guide to a potentially life-saving procedure • Addresses the most common fears and misconceptions associated with colonoscopy • Answers universal (and some notso-universal) questions about the colonoscopy experience • Empowers you to talk to your doctor and get screened with more confidence
Don’t wait— learn more today.
DOwNLOAD THe bOOK FOr Free AT www.Colonoscopy ForDummies.com Early screening may help prevent colon cancer—
PASS ALONG THIS LINK!
Brought to you by
Web site: www.salix.com 8510 Colonnade Center Drive, Raleigh, NC 27615 Tel • 866.669.SLXP (7597) ©2012 Salix Pharmaceuticals, Inc. All rights reserved. Printed in USA. SAL 11/93 For Dummies is a registered trademark of Wiley Publishing, Inc.
New
Leave questions in the past. Get answers to why response to infliximab may be lost. PROMETHEUS® Anser™ IFX measures both serum infliximab levels and antibodies to infliximab in the same sample, providing valuable information to help guide your treatment decisions for patients who lose response to infliximab. Order PROMETHEUS Anser IFX if you suspect your IBD patient has lost response to infliximab. Call Client Services at 888-423-5227. www.anserifx.com PROMETHEUS, the Link Design, For the person in every patient, ANSER, and the ANSER design mark are trademarks or registered trademarks of Société des Produits Nestlé S.A. Vevey, Switzerland. ©2012 Société des Produits Nestlé S.A. Vevey, Switzerland. All rights reserved. IFX12042 08/12 A Nestlé Health Science Company
9410 Carroll Park Drive San Diego, CA 92121 888-423-5227 • 858-824-0896 fax
www.prometheuslabs.com