Gastro Health Magazine Summer 2015

Probiotics: To Take or Not to Take?

Heartburn in Children What is Short Bowel Syndrome?

SHAKIRA Feeling Good Within

Caring for you and those you love.

Summer 20151

NAUSEA

BELCHING

BURNING

PAIN

YOUR SYMPTOMS STOP HERE When it goes beyond “was it something I ate” and over-the-counter medications don’t seem to work, it’s time to visit the ER.

For answers to your health questions or a FREE physician referral, call 305-480-6666 or visit MiamiDadeHospitals.com.

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SUMMER 2015 ISSUEGASTRO MAGAZINE

Colon cancer is the second-deadliest form of cancer in the U.S., yet it doesn’t have to be. Did you know that it’s 90 percent preventable? Screening is the key.

Colon cancer stops with you This simple procedure – called a colonoscopy – can actively prevent colon cancer. Do it for you and your loved ones. If you are at-risk, get screened, and get on with your life!

Who should get screened?

Anyone 50 and older People who have a family history of polyps or colon or rectal cancer African-Americans who are 45 and older Other minority groups where the disease is more prevalent

Simon Behar, M.D. Jose P. Ferrer, Sr., M.D. Jose P. Ferrer, Jr., M.D. Nelson Garcia, Jr., M.D. Alfredo Hernandez, M.D. Eugenio J. Hernandez, M.D. Moises E. Hernandez, M.D. Jerry Martel, M.D. Seth D. Rosen, M.D. Andrew Sable, M.D. Galloway Surgery Center 7600 SW 87th Ave., Suite 100 Miami, FL 33173 Phone: 786-245-6100 www.gallowaysurgerycenter.com

To schedule your colon cancer screening, please call 786-245-6100

GASTRO HEALTH Welcomes You

In this summer issue Gastro Health Magazine features Shakira and highlights her accomplishments of not only being a world famous singer and songwriter, but also a successful record producer, dancer, entrepreneur and most importantly, humanitarian.

Shakira’s influence transcends the entertainment world and reaches those in dire need with her Pies Descalzos (Barefoot) Foundation that today brings education and healthy nutrition to over six thousand poverty-stricken children. Her endorsement deal with Dannon further extends her reach to promote health and healthy living as she is the new spokesperson for their “Dare to Feel Good” campaign.

Gastro Health’s mission is to provide outstanding medical care and an exceptional healthcare experience. To achieve this we have made a great investment in technology and service lines. Gastro Health currently has a pathology laboratory, imaging center, infusion suites, anesthesia service team, weight loss clinic and a specialty pharmacy. Our team of physicians, providers and staff are caring and compassionate as we treat each patient as a valued member of our immediate family.

Hope you enjoy this issue and find the articles to be informative and helpful in discovering the great health care available to you at Gastro Health.

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8 Feeling Good Within 10 Probiotics: To Take

or

Not To Take?

12 Heartburn in Children 14

Gastro Health

Physician Directory

17

Cancer of the Stomach

18 What is Short Bowel

22 Anti-Inflammatory Diet 23

Announcing GastRo Health’s Specialty Pharmacy

25 Barrett’s Esophagus 26 Management of Anal Fistulas

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Thank you for your trust and we appreciate your confidence.

Alejandro Fernandez MBA, CMPE Chief Executive Officer

9500 South Dadeland Boulevard Suite 802, Miami, FL 33156 T. 305.468.4180

www.gastrohealth.com

Copyright © 2015 Gastro Health, P.L. All rights reserved. This publication is published by Gastro Health, P.L., which is solely responsible for its contents. This information presented is intended only for residents of the United States. The material presented is intended only as informational, or as an educational aid, and it is not intended to be taken as medical advice. The ultimate responsibility for patient care resides with a healthcare professional.

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Syndrome

Designed and Published by: TM

11900 Biscayne Boulevard Suite 100, Miami, FL 33181 T. 305.820.0690 info@creativemindworks.com

All rights reserved.

Cover Photo Credit: Europa Press /Getty Images

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Before you place a stent, do you look to see what’s behind it?

• More than 1 million metal stents delivered* • More than 500 clinical articles published* • More than 140 patents awarded over 20 years* • Sponsored studies in more than 20 countries exploring new indications* Why would you trust anything else?

Boston Scientific GI Stents.

Place your trust.

For more information, contact your local representative, visit www.bostonscientific.com or call 1.888.272.1001.

*Data on file ©2013 Boston Scientific Corporation or its affiliates. All rights reserved.

ENDO-196901-AA October 2013

Caring for you and those you love.

MISSION

To provide outstanding medical care and an exceptional healthcare experience.

GUIDING PRINCIPLE

We will treat each patient as a valued member of our immediate family.

CORE VALUES Care and Compassion Provide competent, individualized care in a professional, respectful and caring way.

Teamwork Recognize each other as valuable members of our healthcare team by treating one another with loyalty, respect and dignity.

Responsibility Provide excellent and efficient administrative, accounting, personnel and business management services.

Value and Excellence Develop valuable ancillary services that improve our patients’ quality of care and customer experience.

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SUMMER 2015 ISSUEGASTRO MAGAZINE

Honesty and Integrity Communicate openly and honestly, build trust and conduct ourselves according to the highest ethical standards.

Stewardship Attract and retain great talent and the finest gastroenterologists by actively promoting a professionally satisfying work environment.

Accountability Maintain mutually beneficial relationships with top referring physicians, payers, employers and health systems using performance, outcome, as well as satisfaction measurements to demonstrate accountability and improvement in our care delivery.

GASTRO MAGAZINESUMMER 2015 ISSUE

7

Feeling GoodWithin

by Michelle Menéndez

Over the course of her career the singer, songwriter, record producer, dancer, philanthropist, entrepreneur and mother has always been in tune with a higher calling.

“I always ask myself, what is the real purpose to my life? I always knew it was not to shake it endlessly, you know what I mean?”

Shakira has won two Grammys, eight Latin Grammys, four World Music Awards, three American Music Awards and five Billboard Music Awards to highlight a few. But perhaps more fulfilling on a humanitarian level are the efforts she has placed in the Pies Descalzos (Barefoot) Foundation which she started at age 18. Currently it provides education and healthy nutrition to over six thousand poverty-stricken children in Colombia and is expanding its work around the globe with newly launched projects in Haiti and South Africa.

Her latest endorsement deal certainly constitutes healthy nutrition as well. Last year Dannon announced a global partnership between Activia and Shakira for its new “Dare to Feel Good” campaign with the slogan, “Feeling Good Starts from the Inside.”

“This new campaign demonstrates the connection between how you feel when your digestive system is working well with your overall well-being,” said Jeffrey Rothman, VP of Marketing at The Dannon Company. “Like no one else in the world, Shakira’s

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SUMMER 2015 ISSUEGASTRO MAGAZINE

performance illustrates how feeling good on the inside can help you feel wonderful overall.’’

Born on February 2, 1977, in Barranquilla Colombia to a Lebanese Father and Colombian mother, Shakira’s Latino and Arabic heritage can be noted in her music. When she was four, her father took her to a local Middle Eastern restaurant where she first heard the music that propelled her to start dancing on the table. It was then she realized she wanted to be a performer. At the age of eight she wrote her first song and signed her first record deal at 13. Her successful albums can be credited to her strong vocals and her popularity to her signature hipshaking belly dance moves based in her Lebanese heritage. Shakira says she learned this form of dance (to overcome her shyness) by trying to flip a coin with her belly.

Since launching her music career Shakira has become a true global superstar. According to Sony, she is the highest-selling Colombian artist of all time, having sold between 50 and 60 million records. According to Nielsen Broadcast Data Systems, “Hips Don’t Lie” was the most-played pop song in a single week in American radio history.

She has topped the charts in 55 countries and is the “most liked” person on Facebook.

In 2011 Shakira was appointed by President Obama to the President’s Advisory Commission on Educational Excellence for Hispanics and has

also been honored at a UN ceremony for creating the Pies Descalzos Foundation.

The non-profit opened its eighth school last year, the sixth in Colombia. Shakira has also been honored as a guest at the University of Oxford to give a speech about her work with children and education. She was chosen by the Oxford Union and now joins the ranks of Albert Einstein, Mother Teresa and the Dalai Lama XIV as a chosen speaker, while Forbes ranks her the #58th most post powerful woman in the world.

Now proud mother of two, when asked if motherhood changed her perception of life and the world she replied, “Absolutely. For one thing, it shows you a whole other dimension to love that’s like nothing else. But there are also other, smaller changes that although they don’t seem as profound, carry significant weight too. Since I became a mom, it’s obligated me bit by bit to reevaluate my priorities; I no longer sit in a studio till 3 a.m. tweaking a single drum line, because I’ve had to learn to let go of the reins a little bit. Now I have a family at home, and they need me. But instead of feeling like I’ve had to choose between one and the other, having a child

has really helped me reorganize my time and give everything I do more purpose -- it’s brought more discipline and structure to my life, which have contributed to an overall feeling of balance.”

Similarly to how Luca Casaura, Activia Global VP of Marketing at The Dannon Company mentioned, “There’s no one better than Shakira to represent the importance of inner health. She perfectly exemplifies how feeling good on the inside is essential to her self-expression as a world-famous performer.”

Dannon Dairy is the worldwide leader in yogurts, fermented fresh dairy products with probiotics and other specialized fresh dairy products.

Their mission is to bring health through food to as many people as possible.

“I believe that taking care of your inner health is the key to personal well-being and dance in one way to communicate that synergy of feeling good within...”

-Shakira

GASTRO MAGAZINESUMMER 2015 ISSUE

9

Robert Lanoff, MD Gastroenterologist

Probiotics:

To Take or Not to Take?

When to Take Probiotics Probiotics are used in a variety of GI disorders such as IBS and IBD. IBS is a disorder of unknown cause, but contributing factors can include psychological and emotional stress or an ‘oversensitive’ GI tract. Some studies have shown that the composition of bacteria in patients with IBS is different than in healthy people. Probiotics may help decrease the symptoms of gas and bloating by restoring normal bacterial balance. IBD (Ulcerative Colitis and Crohn’s) is thought to be caused by an excessive immune response to antigens in the gut of those who are genetically predisposed to it. At this point, the role of probiotics in their treatment is still ill-defined. Some studies have shown that probiotics reduced the risk of antibiotic associated diarrhea, yet other studies have found that it works no better than a placebo. Clearly, more research is needed.

About Probiotics

What are Probiotics?

The World Health Organization defines probiotics as live organisms (bacteria or yeast) which, when administered in adequate amounts, confer a health benefit. The public is exposed to pervasive claims for probiotics, by a multibillion dollar industry, without clear guidance or convincing raw data. Ads promise that probiotics will fortify digestion, strengthen immunity, curb colds and flu, promote weight loss and even protect against periodontal disease- but what are we to believe and where is the evidence?

Probiotics come in a range of formulations including capsules, powders, yogurts and fermented milks or fruit drinks. The most commonly used probiotics are lactobacillus and bifidobacteria as well as certain yeasts. At this time, probiotics are not regulated by the FDA and ad claims that probiotics “support good digestive health” are basically unproven.

Probiotics are generally thought to be safe when taken by healthy individuals but there are concerns about its use with infants and patients with compromised immune systems. There are also side effects to be considered such as overstimulation of the immune system, fatigue, pruritis (itching) and diarrhea.

The Gastrointestinal System

The Bottom Line

The GI tract is a highly evolved system designed to allow nutrient digestion, absorption and waste disposal. Over 10 trillion microbes (comprised of 500 species) live in the GI tract and can weigh up to three pounds. In fact, bacterial cells outnumber human cells by a ratio of 10:1. Gut bacteria help to maintain gastrointestinal health and their composition is influenced by factors such as age, diet and disease.

There is increasing interest in the relationship between gut bacteria in human health and disease. Possible future indications for the use of probiotics for mood disorder, obesity, autism and dementia are being evaluated.

The gut immune system differentiates between bacteria to be tolerated and bacteria requiring an immune response. An inappropriate immune response to certain bacteria may be a significant component in several diseases, such as Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD). Probiotics are thought to rebalance the microflora in the colon and may possibly modify the gut’s immune response.

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There are many questions regarding the usefulness of probiotics in GI disorders. While there is some evidence to support a role in some conditions, at this time probiotics should be considered as a supplement to conventional therapy. There is a strong need for targeted studies to test specific strains for particular conditions and to ascertain appropriate doses and administration.

Check with your gastroenterologist to see if probiotics would be beneficial and safe for you.

GASTRO MAGAZINESUMMER 2015 ISSUE 11

Enrique Hernandez-Sanchez, MD Pediatric Gastroenterologist

He rtburn in children

Not normal, and not always caused by acid reflux!

Heartburn is defined as a burning sensation in the chest caused by the regurgitation of acid contents from the stomach into the esophagus.

Heartburn is a quite common symptom among grown-ups. Approximately 10-20% of adults suffer from it while only 2-5% of children report having this symptom.

It is common knowledge that heartburn is associated with gastroesophageal reflux disease (GERD), also known as acid reflux, but very few people know that heartburn can also be caused by other conditions such as an allergic process in the esophagus called eosinophilic esophagitis, or even an infection caused by a fungus called candida esophagitis. The best way to explain eosinophilic esophagitis is to call it “asthma of the esophagus” since it shares many features with asthma: It can affect you at any point in your life, occurs in people with food or environmental allergies, you may have it and not know you do and it can produce narrowing of the food pipe (wind pipe in the case of asthma) if not treated.

Symptoms vary according to age and include feeding problems such as extremely picky eaters in toddlers, isolated vomiting in school-age children and heartburn along with difficulty swallowing in teenagers.

Some of the medications used to treat eosinophilic esophagitis are similar to those for asthma, albeit they are swallowed and not inhaled.

Candida esophagitis is caused by overgrowth of a fungus that is normally present in the GI tract. Factors such as repeated use of antibiotics, inhaled or swallowed steroids, use of mouthwash or a weak immune system will allow it to grow out of control. Antifungal drugs are needed to stop the infection, such as Fluconazole.

My main goal in writing this article is to raise awareness among parents that if a child or teenager is complaining of heartburn, even if occasionally, it means their esophageal wall has sustained enough damage to expose their pain receptors (called nociceptors), and they need to be seen by pediatric gastroenterologist.

An upper endoscopy with biopsy will be

12 SUMMER 2015 ISSUEGASTRO MAGAZINE

frequently needed to differentiate between acid reflux, allergic esophagitis or candida esophagitis. This is a very simple test done while the child is sedated where we introduce a small tube with a camera to observe the lining of the GI tract and obtain pictures and small samples called biopsies. These biopsies are “read” by pathologists who can identify the cause of the esophagitis and allow the doctor to prescribe the correct treatment.

Keep in mind that heartburn can improve. If treated with over the counter medications such as ranitidine (Zantac), famotidine (Pepcid), omeprazole (Prilosec), lansoprazole (Prevacid) or esomeprazole (Nexium). However, the baseline disease is usually not controlled and it will continue to advance. That is why it is critical that any child with heartburn be evaluated by a specialist as soon as possible.

Remember, the words “heartburn” and “child” should not be mentioned in the same sentence unless the word “not” is included in the same sentence!

PHYSICIAN DIRECTORY

GASTRO MAGAZINESUMMER 2015 ISSUE 13

PHYSICIAN DIRECTORY

Simon Behar, MD * Gastroenterologist Care Center 3

Barry E. Brand, MD Gastroenterologist Care Center 2

Lewis R. Felder, MD Gastroenterologist Care Center 7

Edward Feller, MD Gastroenterologist Care Center 15

Jose P. Ferrer Jr., MD * Gastroenterologist Care Center 3

Pamela L. Garjian, MD* Gastroenterologist Care Center 16

Daniel Gelrud, MD * Gastroenterologist Care Center 1

Harris I. Goldberg, MD Gastroenterologist Care Center 1

Pedro J. Greer Jr., MD * Gastroenterologist Care Center 11

Mitchell Gregg, MD Radiologist Imaging Center

Guillermo Gubbins, MD * Gastroenterologist Care Center 10

Eugenio J. Hernandez, MD * Gastroenterologist Care Center 3

Moises E. Hernandez, MD * Gastroenterologist Care Center 3

Francisco J. Baigorri, MD * Gastroenterologist Care Center 1

Richard E. Hernandez, MD * Gastroenterologist Care Center 5

Gustavo Calleja, MD * Gastroenterologist Care Center 1

Jose P. Ferrer Sr., MD * Gastroenterologist Care Center 3

Roberto Gonzalez, MD * Gastroenterologist Care Center 1

Alfredo J. Hernandez, MD * Gastroenterologist Care Center 11

John Ibarra, MD* Radiologist Imaging Center

Marc S. Carp, MD Gastroenterologist Care Center 6

Nelson Garcia Jr., MD * Gastroenterologist Care Center 8

Ruben Gonzalez-Vallina, MD * Pediatric Gastroenterologist Care Center 13

Enrique Hernandez-Sanchez, MD* Pediatric Gastroenterologist Care Center 14

Raghad Koutouby, MD Pediatric Gastroenterologist Care Center 12

* Habla Espa単ol

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

Oscar Loret de Mola, MD* Pediatric Gastroenterologist Care Center 17

Jerry Martel, MD, MPH * Gastroenterologist Care Center 8

Curtis L. McCarty III, MD Pathology Medical Director Pathology Laboratory

Flavia Mendes, MD * Gastroenterologist Care Center 1

Pedro Morales, MD * Gastroenterologist Care Center 8

Brett R. Neustater, MD Gastroenterologist Care Center 7

Khristian Noto, MD * Colorectal Surgeon Care Center 9

Javier L. Parra, MD * Gastroenterologist Care Center 1

Rodolfo Pigalarga, MD* Colorectal Surgeon Care Center 9

Alfredo Rabassa, MD * Gastroenterologist Care Center 1

Andres I. Roig, MD * Gastroenterologist Care Center 3

Ricardo J. Roman, MD * Gastroenterologist Care Center 7

Seth D. Rosen, MD Gastroenterologist Care Center 2

Neil E. Rosenkranz, MD Gastroenterologist Care Center 2

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

Arie Slomianski, MD * Gastroenterologist Care Center 1

Marcos Szomstein, MD * Colorectal Surgeon Care Center 9

Stefania L. Vernace, MD Gastroenterologist Care Center 1

Eduardo Krajewski, MD * Colorectal Surgeon Care Center 9

S. Lawrence Rothman, MD Gastroenterologist Care Center 1

Somal S. Shah, MD * Gastroenterologist Care Center 11

* Habla Espa単ol GASTRO MAGAZINESUMMER 2015 ISSUE 15

ALLIED HEALTHCARE STAFF

Yamila Akmuradova PA-C * Darlene Boytell-Perez, ARNP * Care Center 11 Care Center 1

Ellen Matas-Sosa, PA-C Care Center 1

Jose A. Miguel, PA-C * Care Center 1

Sabrina Kaplan, PA-C * Rebecca Karousatos, MS, RD, LDN Kathy Kim, Pharm D * Care Center 1 Specialty Pharmacy Care Center 1

Carol Hernandez, PA-C Care Center 1

Jessica Jairala, PA-C * Care Center 1

Ronal R. Ricano, PA-C * Care Center 11

Yetzabel Rizo, ARNP * Eugenia Riccombeni, RD, LDN * Noe Tacoronte, PA-C * Care Center 3 Care Center 1 Care Center 1

Care Centers

INSURANCES

Care Center 1 Main Office 7500 SW 87 Avenue, Suite 200 Miami, FL 33173 305-913-0666

Care Center 7 Satellite Office #1 5803 NW 151 Street, Suite 105 Miami Lakes, FL 33014 305-770-0062

Care Center 13 9260 SW 72 Street, Suite 217 Miami, FL 33173 305-271-7330

Care Center 1 Satellite Office 6141 Sunset Drive, Suite 301 Miami, FL 33143 305-913-0666

Care Center 7 Satellite Office #2 21110 Biscayne Blvd, Suite 206 Aventura, FL 33180 305-770-0062

Care Center 14 9980 Central Park Blvd N., Suite 316 Boca Raton, FL 33428 561-206-6064

Care Center 2 9555 N. Kendall Drive, Suite 100 Miami, FL 33176 305-273-7319

Care Center 8 8200 SW 117 Avenue, Suite 110 Miami, FL 33183 305-274-5500

Care Center 15 8353 SW 124 Street, Suite 203 Miami, FL 33156 305-259-8720

Care Center 3 8950 N. Kendall Drive, Suite 306-W Miami, FL 33176 305-596-9966

Care Center 9 7765 SW 87 Avenue, Suite 212 Miami, FL 33173 305-596-3080

Care Center 16 8353 SW 124 Street, Suite 108 Miami, FL 33156 305-669-1115

Care Center 4 15955 SW 96 Street, Suite 307 Miami, FL 33196 305-468-4191

Care Center 10 475 Biltmore Way, Suite 207-A Coral Gables, FL 33134 305-662-6170

Care Center 17 7775 SW 87 Avenue, Suite 120 Miami, FL 33173 305-274-8243

Care Center 5 7765 SW 87 Avenue, Suite 105 Miami, FL 33173 305-274-0808

Care Center 11 3661 S. Miami Avenue, Suite 805 Miami, FL 33133 305-856-7333

Imaging Center 7500 SW 87 Avenue, Suite 202 Miami, FL 33173 305-468-4190

Care Center 6 1400 NE Miami Gardens Drive, Suite 221 North Miami Beach, FL 33179 305-949-2020

Care Center 11 Satellite Office Florida International University 885 SW 109 Avenue, Suite 131 Miami, FL 33199 305-856-7333

Pathology Laboratory 12485 SW 137 Avenue, Suite 103 Miami, FL 33186 305-468-4194

Care Center 7 Main Office 16855 NE 2nd Avenue, Suite 202 North Miami Beach, FL 33162 305-770-0062

Care Center 12 8525 SW 92nd Street, Suite C-11A Miami, FL 33156 305-512-3345

Kayce Tugg, MSN, RN Imaging Center

Specialty Pharmacy 7500 SW 87 Avenue, Suite 202 Miami, FL 33173 305-468-4199

AARP Medicare Complete American Heritage Life Insurance American Medical Security AvMed Baptist Executive Health Beech street Blue Cross Blue Shield Cigna Coventry Health Care Dimensions Health First Health Network HealthSun Health Plans Humana Humana Champus Tricare Magellan Healthcare Mail Handlers Benefit Plans Medica Health Plan Medicare Part B Molina Healthcare MultiPlan Neighborhood Health Plan Preferred Care Partners Prestige Health Choice Simply Healthcare Sunshine Health United Healthcare Wellcare Only accepted at our Pediatric Care Centers * Habla Espa単ol

Moises E. Hernandez, MD, FACP, GACG Gastroenterologist

C ncer of the Stomach Affecting 25,000 individuals a year and the cause of approximately 11,000 annual deaths, stomach cancer, also known as gastric cancer, is relatively new in the United States.

95% of these cancerous tumors, or adenocarcinomas, are the second most common cause of cancerrelated deaths worldwide. They can be divided into two classes, the first being gastric cardia cancer which occurs in the top portion of the stomach near the junction of the esophagus, and the second type is non-cardia gastric cancer which may be found in all other areas of the stomach.

Adenocarcinomas develop in the cells lining the innermost (or mucosal) layer of the stomach making precancerous lesions rarely detected since symptoms are difficult to detect at early stages.

Yet, overall gastric cancer has shown a decrease in occurrence, specifically non-cardia gastric cancer because of better diet, better food refrigeration and the use of antibiotics for treatment.

One major cause of gastric cancer is the Helicobacter pylori bacteria infection, specifically distal gastric cancer. It is also associated with gastric mucosa and with lymphoid tissue (MALT) lymphoma, another type of gastric cancer. Men have a higher risk of developing this type of cancer and other risk factors include chronic gastritis, smoking, diet, blood group type, as well as inherited cancer syndromes.

The great majority of people infected with Helicobacter pylori never develop neoplasia, the formation of such tumors.

Upper endoscopy (EGO) is the most important diagnostic test for the detection of

gastric cancer, as well as endoscopic ultrasonography (EUS) which aids in the diagnosis and staging of gastric cancers. Via these procedures biopsies can be obtained for analysis. The use of the aforementioned modalities such as imaging studies and CT scanning help arrive at a clinical staging of the disease and determination of whether surgery should be considered or not.

Generally, survival rates are reported to be around 30% within the first five years, a modest improvement over the last couple of decades with initial staging remaining the key factor for such increase.

Identification of individuals at increased risk, or those with unexplained symptoms should be aggressively evaluated as early endoscopy saves lives.

Survival rates strongly depend on the extent of how far the cancer has spread at the time of surgery.

GASTRO MAGAZINESUMMER 2015 ISSUE 17

Pedro Morales, MD Gastroenterologist

What is Short Bowel Syndrome?

Short Bowel Syndrome (SBS) is a condition in which the body cannot properly absorb nutrients because part of the small intestine is missing. Adults have 480cm of small intestine divided into duodenum, jeunum and ileum. The last part of the ileum connects with the colon through a valve called ileo-cecal valve and its function is to prevent the backflow of contents from the colon to the small intestine.

When the small intestine measures 180cm there is a risk of developing SBS, but at 60cm or less, regardless of the presence of the colon, the patient becomes dependant on parenteral nutrition (non-oral intake) since there is not enough intestine to allow minimum digestion and absorption. This state is also known as intestinal failure.

What are the causes of SBS in adults?

Surgical resection of small bowel:

Obstruction (thrombosis or embolism) of the mesenteric arteries that supply blood to the intestines. This leads to gangrene (dead tissue) and emergency resection.

Crohn’s disease causing repeated and multiple resection of small bowel.

Major trauma.

Strangulated large hernias.

Inflammation of the intestines secondary to radiation therapy (radiation enteritis).

What are the common symptoms?

In general, each part of the intestines has a specific role absorbing specific nutrients, vitamins and minerals. Some implications of the disease will depend upon the part of the intestines that have been removed. The most common and general symptoms of SBS are diarrhea with large amounts of fat, weight loss, abdominal pain, gas, bloating, fatigue and weakness.

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There may be other symptoms related to a specific vitamin or mineral deficiency: Dermatitis (fatty acids), inflammation in the mouth and tongue (niacin, riboflavin), neurological problems (Vitamin E), pallor and weakness (iron deficiency) among many others.

Implication of the site of intestinal resection: The symptoms associated with bowel resection are highly dependent upon the physiology of the remaining small bowel, since each bowel segment has unique characteristics for absorption. Once a segment is removed, the remaining intestine will compensate the absence of the other, a process called “adaptation,� that usually lasts up to a year. Most of this intestinal adaptation occurs in the ileum.

The ileum is capable of undergoing marked adaptation by an increase in the villus surface area (increase the size of the lining), increase intestinal length, diameter and motor function.

All these structural changes lead to an enhancement of nutrient uptake in the remaining segment of the bowel.

The consequences of the resection of specific parts of the intestines: Jejunal resection Here is where most nutrients (lipids, carbohydrates, proteins, vitamins and minerals) are absorbed. A marked reduction in their absorption is seen with very modest adaptative changes, though with time some will occur to compensate for its loss.

Ileal resection Here is where Vitamin B12, bile acids and fluids are absorbed. The ileum also regulates the speed of the intestine by slowing down gastric emptying to facilitate absorption of nutrients in the small bowel, a process called “ileal brake,” mediated by hormones secreted by its cells. Finally, loss of the valve that connects the terminal ileum with the colon (ileo-cecal valve) will be associated with a reduction in the intestinal time which impairs nutrient absorption, as well as loss of the barrier that prevents colonic material to reflux back into the ileum. This leads to an increase in bacterial population in the small bowel which causes malabsorption as well.

Colon resection Here is where water, electrolytes and short chain fatty acids are absorbed, as well as up to 15% of energy requirements, primarily from fermented carbohydrates. This colonic property is used in patients in whom a large small bowel resection was done with a normal remnant colon. By increasing carbohydrates, the colon is capable of increasing absorption from 15 - 50% of energy requirements. This provides a great compensatory mechanism, a good example also of “adaptation.” For the above reasons, patients are more likely to tolerate small bowel resection when they have an intact colon.

How is SBS treated?

Once SBS is suspected in a patient, treatment begins as soon as possible. The likelihood of a successful transition from parenteral (venous infusion, also called total parenteral nutrition or TPN) to enteral (oral formulas or elemental food) feeding will depend upon the length and the segment of small bowel left, the presence or not of the colon and the ileo-cecal valve and at last the intestinal adaptation of the remaining bowel.

The process called “intestinal rehabilitation� refers to the multidisciplinary approach aimed at improving intestinal function and the decrease of parenteral nutrition dependency in a patient.

This approach is nutritional, pharmacological and sometimes surgical. The goal is not only to free the patient from parenteral nutrition, but also avoid intestinal transplantation. No treatment is successful without patient education and understanding of the disease; this allows them to participate in their management plan as well as their close family members. It also allows them to set realistic expectations in terms of dietary modifications which are necessary to maximize nutritional benefits, minimize symptoms and avoid nutrient deficiencies.

2. Medications: A. Antidiarrheals: loperamide, codeine and diphenoxylate.

B. Antisecretory Agents: ranitidine, omeprazol (decrease acid) or octreotide (reduces fluid loss and slows transit, but slows adaptation process).

C. Antibiotics: decrease bacterial overgrowth that contributes to diarrhea and decrease nutrient absorption (ciprofloxacin, metronidazol or rifaximin).

D. Bile Sequestrants: agents that decrease diarrhea (cholestyramine).

E. Growth Factors: agents that promote and enhance adaptation beyond normal limits, increasing intestinal absorptive capacity and decreasing the need for parenteral nutrition support.

E.1 Glucagon like peptide-2 (GLP-2): Teduglutide (GattexR), approved by the FDA recently for the treatment of SBS. E.2 Glutamine and Growth Hormone (experimental).

F. Supplementation: vitamins such as B12, A, D, E, K and minerals, potassium, chloride, magnesium, calcium, zinc, iron and selenium.

3. Surgical procedures: Refers to specific types of surgical intervention that can contribute to the enhancement of the absorptive surface area and/or decrease in intestinal transient time. Some of them are: A. In case of intestinal obstructions: lyses of adhesions.

B. Reversal of an ostomy (colostomy or ileostomy).

C. Restoration of intestinal continuity.

1. Enteral feeding:

4. Small bowel transplantation:

Should be introduced as soon as possible to promote intestinal adaptation since it stimulates release of digestive juices, hormonal secretions and maintains the integrity of the gut barrier and its inmmunoregulatory mechanisms. The goal is to taper parenteral nutrition and slowly start oral feedings. Initially, an elemental diet in continuous fashion increases absorption of lipids, proteins and net energy. Later on, a complex diet also in a continuous fashion promotes and facilitates intestinal adaptation thereby accelerating progression to oral feedings. Bolus feeding should be introduced slowly and progressively.

Patients tend to tolerate complex carbohydrates much better than simple ones as well as fatty food. Ideally, nutrition should be frequent (every 2-3 hours), balanced with proteins, carbohydrates, with lipids (40% at least) and without hypertonic beverages (sodas or juices) or high carbohydrate feedings.

Only reserved for patients with SBS who are not candidates for parenteral nutrition that have developed complications from it. It is done only in highly specialized centers across the country.

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What are the complications of SBS in adults?

If none of the treatments or options explained before work in a patient, the consequences of SMB are in a short term and can include dehydration, and electrolyte imbalances (loss of potassium, calcium and magnesium), as well as disequilibrium of the pH of the body (alkalosis or acidosis).

For mid and long term, osteoporosis due to calcium and Vitamin D malabsorption, kidney stones, increase of acid production in the stomach and decrease in gastric time leads to ulcers formation.

Online information for patients: The Oley Foundation: www.oley.org American Society for parenteral and Enteral Nutrition: www.nutritioncare.org Short Bowel Syndrome Foundation: www.shortbowelfoundation.org Short Bowel Support: www.shortbowelsupport.com

Eugenia Riccombeni, RD, LDN Registered Dietician

In the past few years, it has become clear that chronic inflammation can be the root of several diseases such as cardiovascular disease, cancer, diabetes and irritable bowel disease among many others. We commonly think of inflammation as a response to sudden injury, irritation, burn and/or surgery. But in reality stress, dietary choices, genetic predisposition, lack of exercise and exposure to toxins can contribute to chronic inflammation. Being able to identify specific foods and how they influence the inflammatory process is the best strategy for managing and reducing longterm disease risks.

protein sources and switch to low-fat dairy products. Include healthy plant based protein like nuts, beans and seeds which can also provide a good amount of dietary fiber.

Antioxidants are essential in our diets to delay or prevent cell damage. Fruits and vegetables have a wide variety of antioxidants and phytonutrients which can fight cell damage and disease. Choose fruits and vegetables The anti-inflammatory diet, similar to the Mediterranean diet, from all parts of the color spectrum, is a way of selecting and preparing foods that will allow a control and reduce inflammation, provide steady energy, a wide variety of vitamins and minerals, dietary fiber, essential fatty acids and protective phytonutrients.

Antioxidants are essential in our diets to delay or prevent cell damage

When following an anti-inflammatory diet you need to choose a variety of foods, eat an abundance of fruits and vegetables, decrease the consumption of processed foods, consume as much fresh and whole foods as possible and try balancing each meal with most food groups. The goal of this diet is to reduce pain, discomfort and prevent further damage caused by inflammation and chronic disease.

Start out by reducing the amount of pro-inflammatory nutrients consumed per day. For example, avoid consuming an excess of calories which can lead to an accumulation of fatty tissue which leads to obesity. A diet high in refined sugars and starches can also lead to obesity, metabolic syndrome and type 2 diabetes. Try consuming whole grains like brown rice and bulgur which are rich with fiber and have a low glycemic load. Reduce your intake of saturated and trans fatty acids by increasing omega 3 fatty acids, increase intake of heart healthy oils such as flaxseed or olive oil, choose lean

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especially berries, tomatoes, carrots and dark leafy greens. Green tea and dark chocolate enjoyed in moderation are also good options to increasing antioxidant intake which can ease chronic inflammation.

Lastly, staying properly hydrated is essential for your body to function properly and reduce inflammation.

Aim for approximately six to eight glasses of water a day. If it becomes difficult to reach that goal, try infusing your water with pieces of fresh fruits and herbs to give it a refreshing kick.

Gastro Health Supports You! Living with a chronic disease can sometimes be overwhelming and can cause patients to feel distressed and confused. At Gastro Health we pride ourselves in supporting our patients.

Our support groups were created to educate our attendees on the latest treatment options, while eliminating some of the anxiety they may feel. We want our patients to know they are never alone. Gastro Health supports you!

Ariana Belsky Marketing Coordinator

are set up in a question and answer format, while others are structured as a lecture. Regardless of the structure, patients will have the ability to get answers to their questions and always walk away with more information about their disease. Our support groups are open to everyone; you don’t need to be a Gastro Health patient in order to attend. All of our support groups occur after work hours (7pm) and include food and refreshments.

About our Support Groups Each support group is led by a Gastro Health provider. This means that there is always a Gastro Health Physician, Physician Assistant, Nurse Practitioner, Registered Nurse, or Registered Dieticians present to answer any concerns you may have. This is a huge incentive for patients who may have a question about their disease, medication, or treatment plan and do not necessarily need an appointment to see their physician. There is never a cost to attend our support groups.

We structure each support group differently. Some of these meetings

Types of Support Groups Gastro Health currently has two types of support groups:

Crohn’s Disease and Ulcerative Colitis Hepatitis C These support groups alternate and meet three to four times a year. We are working on adding additional support groups as well.

Please contact Ariana Belsky at abelsky@gastrohealth.com for more information.

Announcing Gastro Health’s Specialty Pharmacy We are excited to announce the launch of Gastro Health Specialty Pharmacy (GHSP). We provide therapy management solutions for patients with chronic and complex conditions including Crohn’s disease, ulcerative colitis and hepatitis. The unique relationship between your provider and our pharmacy sets us apart from other specialty pharmacies and enables us to provide patients with a tailored and comprehensive approach to their care.

Due to the restrictions on highly specialized medications, obtaining third party approval can take time.

Fortunately, our Specialty Pharmacy is able to reduce the time it takes to receive authorization of benefits.

Because our pharmacy team has direct

Kathy Kim, Pharm D Specialty Pharmacy Manager

access to your clinical team and pertinent medical records, third party payers receive the records they require to approve therapies quickly.

By avoiding the need to request information from your doctor’s office, the time in which your therapy is approved is significantly reduced. In addition, we also work in conjunction with our infusion departments.

If a treatment requires infusion, our pharmacy will work with a patients desired infusion location and coordinate the details for their medication delivery. Gastro Health Specialty Pharmacy will not only specialize in specialty drugs, but will also carry all other medications prescribed to them by their Gastro Health clinical team. These include medications used to treat acid reflux, colonoscopy preparations and much more.

Patients will have the convenience of having their medications shipped directly to them at no charge. The pharmacy will also offer refill reminders and contact your provider when a prescription renewal is necessary. Gastro Health Specialty Pharmacy will integrate all of your gastroenterological needs under one roof.

To find out more information about Gastro Health Specialty Pharmacy contact us at: 305.468.4199 GASTRO MAGAZINESUMMER 2015 ISSUE 23

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and

Roberto Gonzalez, MD Gastroenterologist

Barrett’s Esophagus What are the symptoms?

There are usually no symptoms from the change in the cell lining in Barrett’s esophagus. Most people diagnosed usually visit their doctor for symptoms of heartburn, acid reflux or trouble swallowing.

How is it diagnosed?

If you have symptoms of GERD with any risk factors, a gastroenterolgist can perform an upper endoscopy to look inside your esophagus and determine if you have the changes of Barrett’s esophagus. It’s a painless procedure and requires sedation. If necessary, sometimes a small piece of the abnormal tissue can be taken (a biopsy) so that it can be studied under a microscope to confirm the diagnosis.

How is it treated?

“

The most important form of treatment and prevention is to change your diet and avoid foods that cause acid reflux.

”

Common foods to avoid are tomato-based foods and sauces, citric juices, coffee, caffeine, chocolate, alcohol and foods high in fat. Changes in lifestyle are also important. Such changes are to quit smoking, eat smaller meals and not to lie down soon after eating a meal.

What is Barrett’s esophagus?

The esophagus is the tube that connects the mouth to the stomach while Barrett’s esophagus is a pre-cancerous condition of the esophagus. In this condition, the lining of the lower esophagus changes in form to look more like the lining of the stomach. This change is a result of years of cell injury from acid reflux into the esophagus from the stomach. The change in the cell lining is a defense mechanism against acid injury because the cells that line the stomach are more resistant to acid injury.

Unfortunately, these new cells have a risk of becoming cancerous due to the repeated injury from the acid.

Who is at risk?

Anyone with a long history of heartburn symptoms or gastroesophageal reflux disease (GERD). It is more common in men than in women and it is also more common in people of Caucasian descent but can occur in any ethnicity. People who smoke are at higher risk than non-smokers as well.

The use of medications to reduce acid production from the stomach can also help decrease the injury to the lining of the esophagus. Some of these medications are available without a prescription, but you should still consult a gastroenterologist about their use. In select cases where medications do not help, there may be some surgical procedures that can.

You may require surveillance of the abnormal lining with periodic upper endoscopy and repeat biopsy. If pre-cancerous changes are detected on biopsy during endoscopy, then it may be possible to remove or destroy the abnormal tissue during an upper endoscopy. This form of treatment should only be performed by gastroenterologist who has experience and performs the treatment regularly.

Summary

Barrett’s esophagus is a chronic, pre-cancerous condition of the esophagus caused by repeated injury to the lower esophagus from acid reflux. It is diagnosed by upper endoscopy and if present should be treated early to prevent the formation of esophageal cancer. If you have a long history of heartburn, acid reflux, trouble swallowing or any of the risk factors listed above, please talk to your primary care physician or get referred to a Gastroenterologist to discuss your risk.

GASTRO MAGAZINESUMMER 2015 ISSUE 25

Khristian Noto, MD Colorectal Surgeon

Management ofAnal Fistulas Most fistulas are preceded by an infectious process called abscess, but most abscesses are not associated with fistulas. If a fistula is found during the drainage of an abscess, it is often better to drain the abscess and place a loose rubber band, known as a Seton, through the tunnel (to keep it open and avoid a recurrence of the infection) until the inflammation has resolved. This allows better assessment of the fistula to determine the best treatment for it. In some instances simple fistulas involving little or no sphincter muscle can be treated at the same time as the abscess.

A

nal fistulas are common conditions that require specialized care by a surgeon well trained in the management of anorectal problems. An anal fistula is a tunnel covered with rectal and skin lining called epithelium that presents either as an acute infection or recurrent pain and passage of purulent secretion. Patients presenting with recurrent abscesses are often suspected to have a fistula as the underlying cause. Most fistulas are believed to be related to an infection in an anorectal mucus secreting gland that spreads and forms a tunnel lined with granulation or inflammatory tissue that fails to close after the infection has cleared. But fistulas at times can also be associated with other diseases like Crohn’s disease, pilonidal disease, hydradenitis, trauma or cancer.

They are more commonly found in males than in females and are present more often in the third to fifth decade of life.

Proper examination of an anal fistula involves evaluation of the perianal skin by carefully feeling the area with the use of specialized probes. Some imaging techniques like MRI and Endoanal Ultrasound are useful sometimes in the evaluation of complex and recurrent anal fistulas.

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The best way of getting an anal fistula to heal is called Fistulotomy. It consists of laying open the tissues over the fistula, removing its lining and allowing it to heal on its own (also called healing by secondary intention). More often than not the muscles tasked with keeping the anal orifice closed (called sphincters) are involved in the fistula. If a significant amount of these muscles must be cut to treat the fistula, the patient may develop incontinence. In those cases the use of a less effective, but function preserving sphincter sparing technique is preferred.

There is wide variety of sphincter sparing procedures available, results may vary widely from one study to another likely due to several factors including patient population differences, variability of fistula classification, inadequate follow up, surgeon preference and skills. Some of the most common sphincter sparing procedures performed are Advancement Flaps which consist on mobilization tissues to close the internal orifice. A LIFT procedure involves accessing the fistulous tract between the sphincter muscles, then it is divided and ligated. Cutting Setons are strings passed through the tract around the sphincter muscles, then the seton is slowly tightened over several weeks to allow for the slow division of the muscle, preventing its ends from springing apart which is often cumbersome and a painful process. Bioprosthetic Plugs can be placed in the fistulous tract to induce healing, this techniques comes to replace the use of Fibrin Glue. The use of Fistulotomy with Immediate Reconstruction of the muscle and Fistulectomy are less commonly used.

The simplest method of managing a fistula with sphincter preservation is a Permanent Loose Seton, which preserves continence and prevents most infections but it is not well tolerated by most patients. There are multiple variations of these procedures and their use depends on the particular characteristics of each patient.