SUMMER 2017
Fatty Liver Gastrointestinal Motility Testing Clostridium Difficile Infection Transoral Incisionless Fundoplication Irritable Bowel Syndrome Helicobacter Pylori Infection Microscopic Colitis
Elisabeth Hasselbeck
SHARES HER GLUTEN-FREE ODYSSEY
BECAUSE IN CHRONIC IDIOPATHIC CONSTIPATION
You shouldn’t have to go to extremes
Does managing your constipation come with compromise? Trulance™ is a once-daily prescription medication for adults with Chronic Idiopathic Constipation (CIC) that helps provide more regular, well-formed bowel movements.
Talk to your doctor about Trulance today. Visit Trulance.com to learn more. What is Trulance? • About all the medicines you take, including Trulance (plecanatide) 3 mg tablets is a prescription and over-the-counter medicines, prescription medicine used in adults to treat a vitamins, and herbal supplements. type of constipation called chronic idiopathic constipation (CIC). “Idiopathic” means the cause Side Effects of the constipation is unknown. It is not known if Trulance is safe and effective in children less than Diarrhea is the most common side effect and can sometimes be severe. Diarrhea often begins within 18 years of age. the first 4 weeks of Trulance treatment. Stop IMPORTANT SAFETY INFORMATION taking Trulance and call your doctor right away if you get severe diarrhea. • Do not give Trulance to children who are less than 6 years of age. It may harm them. Tell your doctor if you have any side effect that • You should not give Trulance to children 6 years bothers you or that does not go away. These are to less than 18 years of age. It may harm them. not all the possible side effects of Trulance. For • Do not take Trulance if a doctor has told you more information, ask your doctor or pharmacist. that you have a bowel blockage (intestinal You are encouraged to report side effects to the obstruction). FDA. Visit www.fda.gov/medwatch or call Before you take Trulance, tell your doctor: 1-800-FDA-1088 or you can report side effects to Synergy Pharmaceuticals at 1-888-869-8869. • If you have any other medical conditions. • If you are pregnant or plan to become pregnant. Please see the following page for important It is not known if Trulance will harm your product information for patients. unborn baby. • If you are breastfeeding or plan to breastfeed. It is not known if Trulance passes into your breast milk. Talk with your doctor about the best way to feed your baby if you take Trulance. This product information is intended for US audiences only. 1-888-869-8869 I Trulance.com Trulance™ is a trademark of Synergy Pharmaceuticals Inc.
Copyright 2017© Synergy Pharmaceuticals Inc. PP-TRU-US-0370 06/17
Brief Summary of Medication Guide Trulance™ (troo’ lans) (plecanatide) tablets This information does not take the place of talking to your doctor about your medical condition or your treatment. What is the most important information I should know about Trulance? • Do not give Trulance to children who are less than 6 years of age. It may harm them. • You should not give Trulance to children 6 years to less than 18 years of age. It may harm them. What is Trulance? Trulance is a prescription medicine used in adults to treat a type of constipation called chronic idiopathic constipation (CIC). Idiopathic means the cause of the constipation is unknown. It is not known if Trulance is safe and effective in children less than 18 years of age. Who should not take Trulance? • Do not give Trulance to children who are less than 6 years of age. • Do not take Trulance if a doctor has told you that you have a bowel blockage (intestinal obstruction). Before taking Trulance, tell your doctor about all of your medical conditions, including if you: • are pregnant or plan to become pregnant. It is not known if Trulance will harm your unborn baby. • are breastfeeding or plan to breastfeed. It is not known if Trulance passes into your breast milk. Talk with your doctor about the best way to feed your baby if you take Trulance. Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. How should I take Trulance? • Take Trulance exactly as your doctor tells you to take it. • Take Trulance by mouth, 1 time each day with or without food. • If you miss a dose, skip the missed dose. Take the next dose at your regular time. Do not take 2 doses at the same time. • Trulance tablets should be swallowed whole. - Adults who cannot swallow Trulance tablets whole may crush the Trulance tablet and mix with applesauce or dissolve Trulance in water before swallowing. Trulance tablets may also be taken with water by adults through a nasogastric or gastric feeding tube. It is not known if Trulance is safe and effective when crushed and mixed with other foods or dissolved in other liquids. What are the possible side effects of Trulance? Trulance can cause serious side effects, including: • Diarrhea is the most common side effect of Trulance, and it can sometimes be severe. - Diarrhea often begins within the first 4 weeks of Trulance treatment. Stop taking Trulance and call your doctor if you develop severe diarrhea. These are not all the possible side effects of Trulance. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. How should I store Trulance? • Store Trulance at room temperature between 68°F to 77°F (20°C to 25°C). • Keep Trulance in a secure place and in the bottle or blister pack that it comes in. • The Trulance bottle contains a desiccant packet to help keep your medicine dry (protect it from moisture). Do not remove the desiccant packet from the bottle. • The Trulance bottle contains a polyester coil to help protect the tablets during shipping. Remove the polyester coil from the bottle and throw it away when you are ready to start taking Trulance. • Keep the container of Trulance tightly closed and in a dry place. • Safely throw away Trulance that is out of date or no longer needed. Keep Trulance and all medicines out of the reach of children. This is a brief summary of the most important information about Trulance. For more information: • Talk to your doctor • Visit Trulance.com • Call 1-888-869-8869 Date of Issue: 01/17 Manufactured for Synergy Pharmaceuticals Inc. New York 1-888-869-8869 I Trulance.com Trulance™ is a trademark of Synergy Pharmaceuticals Inc. Copyright 2017© Synergy Pharmaceuticals Inc. PP-TRU-US-0370
Index
Pages
Illinois Gastroenterology Digest Welcomes You
Dr. Fred Rosenberg President, IGG
Happy Summer We are excited to publish our second edition of Illinois Gastro Digest. Thank you for the positive feedback that we received about our Premiere Edition published earlier this year. This issue features several articles discussing various causes of diarrhea. Our Cover Story features Elizabeth Hasselbeck, the Emmy Award winning host of ABC’s The View. In her book, “The G-Free Diet: A Gluten Free Survival Guide”, Elizabeth describes the long personal journey to discovering her diagnosis of Celiac Disease followed by her understanding, self-empowerment and recovery. As our health care system undergoes change, the physicians of Illinois Gastroenterology are committed to the goals of value-based healthcare which strives to provide access to high quality care in the most cost-effective environment. Illinois Gastroenterology Group has received national recognition, following approval this Spring, from a Medicare Advisory Group for a value-based care model for Crohn’s Disease. Our practice is the first in the country to receive such approval. This fall, Project Sonar for Crohn’s Disease will have its final review and hopefully approval by Health and Human Services Secretary Thomas Price with projected patient enrollment in 2018.
Fatty Liver
6
Helicobacter Pylori Infection
7
Clostridium Difficile Infection
14
Gastrointestinal Motility Testing
18
Transoral Incisionless Fundoplication
16
Elisabeth Hasselbeck
20
Irritable Bowel Syndrome
22
Microscopic Colitis
26
Best wishes, Dr. Fred Rosenberg President, IGG Designed and Published by:
1415 S. Arlington Heights Road Arlington Heights, IL 60005
w w w. i l l i n o i s g a s t r o . c o m Copyright © 2017 Illinois Gastroenterology Group, LLC., All rights reserved. This publication is published by Illinois Gastronenterology Group, LLC., 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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All rights reserved. Cover Photo Credit: Getty Images
Our Mission “IGG is dedicated to improving the health of our patients by providing the highest quality gastrointestinal care utilizing evidence-based medicine in a safe, compassionate manner and following clinical standards as determined by available scientific knowledge, best practice and innovative treatment.�
BY: David Kim, MD Gastroenterologist / Hepatologist
SUMMER 2017 ISSUE ILLINOIS GASTRO DIGEST
Fatty Liver
F
atty liver is the general term to describe the medical condition known as non-alcoholic fatty liver disease (NAFLD). This spectrum of disease ranges from mild fatty infiltration of the liver without inflammation to more severe fatty infiltration with inflammation, fibrosis and cirrhosis which is known as non-alcoholic steatohepatitis (NASH). NAFLD was first described in 1980 and its diagnosis has steadily increased over the years. This increase directly parallels the increase in obesity in our population from 10% in 1985, to about 60% today How Does Fatty Liver Happen? The cause of fatty liver is the result of the accumulation of fatty acids in the liver. In certain individuals, these fatty acids can cause oxidative stress, or inflammation, within the liver. This, in turn, causes liver cell damage and triggers repair mechanisms which result in the deposition of scar tissue. Over time, the gradual accumulation of scar tissue, called fibrosis, can reach a more severe state known as cirrhosis.
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What Are The Symptoms?
Usually, people with NAFLD have no symptoms until they reach the more advanced stages of liver disease. At that point, patients may experience fatigue, jaundice and the accumulation of water in the abdomen called ascites.
How Is It Diagnosed?
A liver specialist can generally make a diagnosis of NAFLD based on elevated liver enzymes and the presence of other metabolic conditions, such as truncal obesity, diabetes, hyperlipidemia and hypertension. Additional blood tests and an ultrasound of the liver would be done to exclude other forms of liver disease. The presence of scar tissue, or fibrosis, can be detected and measured through biomarkers or specialized scanning devices which can measure the stiffness of the liver in response to sound waves. At times, a needle liver biopsy is done to help determine the diagnosis.
How Is It Treated?
Unfortunately at this time, there are no FDA approved medications that can treat NASH. The only proven therapy remains lifestyle modifications in the form of weight loss. This can be achieved through a
combination of exercise and healthful eating. We recommend losing 7-10% of the current body weight over 6 months to help reverse the effects of fatty liver. Calories should be limited to 25-30 gm/kg per day. This has been shown to improve fatty liver and can even reverse some of the scarring associated with the liver. In the future, we may have medications that can treat fatty liver, but in the meantime, weight loss remains the only solution. Fortunately, weight loss can have the added benefit of improving glucose control, blood pressure and cholesterol levels and will often have additional benefits of improved energy and wellbeing.
What’s Next?
If you suspect that you may have fatty liver, it would be reasonable to be evaluated by a liver specialist who can determine the degree of damage and advise you on health goals to help address this condition.
BY: Joel Lattin, MD Gastroenterologist / Hepatologist
Helicobacter Pylori Infection
W
hat is H. pylori?
For years, doctors thought ulcers were related to stress, certain foods, medications, lifestyle habits and acid. In 1982, scientists discovered H. pylori was the true cause of those ulcers, not excess NSAID use. H. pylori is a type of bacteria that lives in your upper digestive tract. This infection is common and nearly two-thirds of the world’s population is infected with this organism. The majority of individuals, however, have no clinical symptoms related to this infection.
How do you get infected with H. pylori?
You get H. pylori infection from food, water, or environmental exposure. It is more common in developing countries that lack clean water or good sewage systems. This infection can also be acquired through contact with saliva or other body fluids from an infected individual. Many people are infected in early childhood and the infection remains in your body for years. Doctors are not sure why many people develop no symptoms while others develop ulcers and other complications associated with this infection.
What type of symptoms does H. pylori cause?
The majority of people have no symptoms associated with this infection. Those who do have symptoms most commonly present with stomach ulcers. Symptoms of upper digestive tract ulcers include abdominal burning, bloating, loss of appetite, nausea, vomiting and gastrointestinal bleeding (passing black or bloody stools). Rarely, stomach cancer can develop in the presence of H. pylori infection.
How is H. pylori infection diagnosed?
Fortunately H. pylori infection is easy to diagnose. Several methods are used to make this diagnosis. A urea breath test is often used to diagnose this infection. This tests requires you to breath into bag. H. pylori bacteria change urea into carbon dioxide and ammonia which can be measured, indicating infection. An esophagogastroduodenoscopy (EGD) or “endoscopy” is often employed to evaluate people who have stomach complaints. This is an outpatient procedure, requiring light sedation, where your doctor will pass a small camera through the mouth into the stomach,
which can then be examined. Biopsies can be obtained which will confirm the infection. If the infection is present it can be visualized under a microscope.
Treatment for H. pylori infection
If you are infected with H. pylori, treatment is recommended. There are many different highly effective regimens used to kill this infection. Multiple antibiotics are used simultaneously to eradicate this bacteria. Curing this infection will result in healing of stomach ulcers and likely result in resolution of your symptoms. A urea breath test or stool test is often employed to confirm successful therapy. Once treated, the prognosis is excellent.
When to see a Gastroenterologist It is always appropriate to see your doctor if you have new or ongoing gastrointestinal complaints. Although H. pylori infection and ulcers associated with this infection can lead to your symptoms, many other conditions need consideration and exclusion. Your gastroenterologist can discuss these conditions with you and an appropriate diagnostic plan can be devised to help determine the etiology for your complaints.
SUMMER 2017 ISSUE ILLINOIS GASTRO DIGEST
PROVIDER
DIRECTORY
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Douglas Adler, MD Gastroenterologist
Thomas Arndt, MD Gastroenterologist
Rick Chadha, MD Gastroenterologist
Kenneth Chi, MD Gastroenterologist
Reid Glaws, DO Gastroenterologist
Sonia Godambe, MD Gastroenterologist
Sunil Joseph, MD Gastroenterologist
Amit Kalra, MD Gastroenterologist
Lawrence Kosinski, MD, MBA, AGAF, FACG
Gastroenterologist
Joseph Losurdo, MD Gastroenterologist
William Kosmala, MD Gastroenterologist
Wayne Lu, MD Gastroenterologist
Mitchell Bernsen, MD Gastroenterologist
Jennifer Dorfmeister, MD Gastroenterologist
Ronald Bloom, MD Gastroenterologist
Brian Blumenstein, MD Gastroenterologist
James Dragueski, MD Gastroenterologist
Greg Gambla, DO Gastroenterologist
Bruce Greenberg, MD Gastroenterologist
Harsh Gupta, MD Gastroenterologist
Jeffrey Jacobs, MD Gastroenterologist
Mitchell Kaplan, MD Gastroenterologist
David Kim, MD Gastroenterologist / Hepatologist
Everett Kirch, MD Gastroenterologist
Joel Lattin, DO Gastroenterologist
William Levis, MD Gastroenterologist
Kevin Liebovich, MD Gastroenterologist
Amy McKenney FNP-C
Nina Merel, MD Gastroenterologist
Darran Moxon, MD Gastroenterologist
SUMMER 2017 ISSUE ILLINOIS GASTRO DIGEST
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Rhiannon Mazenis PA-C
Vincent Muscarello, MD Gastroenterologist
Daniel O’Reilly, MD Gastroenterologist
Yogesh Patel MD Gastroenterologist
Samir Patel MD Gastroenterologist
Rajesh Pillai, MD Gastroenterologist
Baseer Qazi, MD Gastroenterologist
Fred Rosenberg, MD Gastroenterologist
Jonathan Rosenberg, MD Gastroenterologist
Karen Sable, MD Gastroenterologist
Heather Creed, FNP-C
Alan Shapiro, MD Gastroenterologist
Hadi Siddiqui MD Gastroenterologist
James Stinneford, MD Gastroenterologist
Patricia Sun, MD Gastroenterologist
Wei Sun, MD, PhD, FACG Gastroenterologist
John Vainder, MD Gastroenterologist
Jeff Victor DO Gastroenterologist
Cynthia Wait, MD Gastroenterologist
Loren White, MD Gastroenterologist
Care Centers
Accepted Insurance
Algonquin Road Surgery Center 255 W. Algonquin Road Lake in the Hills, IL 60156
North Shore Surgical Center 3725 W. Touhy Ave Lincolnwood, IL 60712
Highland Park 806 Central Ave, Suite 202 Highland Park, IL 60035
Elgin Gastroenterology Endoscopy Center 745 Fltecher Drive - Suite 201 Elgin, IL 60123
Algonquin 600 South Randal Road (Shermand Family Healthcare Facility) Algonquin, IL 60102
Libertyville 755 S. Milwaukee Ave - Suite 292 Libertyville, IL 60048
Glen Endoscopy Center 2551 Compass Road Suite 115 Glenview, IL 60025 Kendall Point Surgery Center 100 W. Fifth Street Oswego, IL 60543 North Shore Endoscopy Center 101 Waukegan Road Suite 980 Lake Bluff, IL 60044 Northwest Endoscopy Center 1415 South Arlington Heights Road Arlington Heights, IL 60005 Oak Lawn Endoscopy 9921 Southwest Highway Oak Lawn, IL 60453 The Center for Surgery 475 E. Diehl Road Naperville, IL 60563 Tri-Cities Surgery Center 345 Delnor Drive Geneva, IL 60134 Valley Ambulatory Center 2210 Dean Street St. Charles, IL 60175
Arlington Heights 1415 South Arlington Heights Road Arlington Heights, IL 60005 Barrington 27750 W. Highway 22 - Suite 150 Barrington, IL 60010 Elgin 745 Fletcher Drive - Suite 201 Elgin, IL 60123 Elk Groove 800 Biesterfield Road, Wimmer Building-Suite 304 Elk Grove Village, IL 60007
Lindenhurst 1025 Red Oak Lane - Suite 280 Lindenhurst, IL 60046 Oak Lawn 9921 Southwest Highway Oak Lawn, IL 60453 Orland Park 16525 106th Court Orland Park, IL 60464 Skokie 9669 Kenton Ave - Suite 550 Skokie, IL 60076
Evanston 800 Austin Street - West Tower - Suite 403 Evanston, IL 60202
South Elgin 2000 McDonald Road (Shermand Family Health Center) South Elgin, IL 60177
Glenview 2501 Compass Rd Suite 130 Glenview, IL 60026
St. Charles 2320 Dean St. Suite 201 St. Charles, IL 60175
Glenview 2551 Compass Road - Sute 115 Glenview, IL 60026
Billing Office 20 Tower Court - Suite C Gurnee, IL 60031
Gurnee 20 Tower Court - Suite C Gurnee, IL 60031
Palos Heights 12150 South Harlem Ave Palos Heights, IL 60463
Advocate (ACE) Aetna Ascension Health – Smart Health Ambetter (exchange thru Illinicare) Blue Cross Blue Shield Beech Street/PPO Next Cigna Choicecare PPO – POS Corvel Coventry Evolutions Harkin Health (thru UHC) Harmony-Medicaid Health Market/Interplan/ Preferred Plan HealthLink/Unicare PPO Health Smart /Preferred plan/Interplan PPO HFN,PPO,EPO, Platinum EPO Humana Advocate EPO Select/Illinois Platinum HMO Humana – HMO- POS –EPO Humana ICP - MMAI Illinicare ICP –MMAI –FHP - Exchange Land of Lincoln (exchange) Medicare Meridian AAP, FHP/ACA, ICP /MMAI Meritan Health PHCS-Multiplan Only Preferred Network Access Public Aid Railroad Medicare Senior Care Partners Tricare Health Net Unicared Healthcare
United Healthcare –PPO UMR United Healthcare Mediacre Complete United Healthcare AARP United Healthcare – All Savers United Healthcare – Compass (exchange) United Healthcare – Navigate – Core Veterans Choice MultiPlan Neighborhood Health Plan Preferred Care Partners Prestige Health Choice Simply Healthcare Sunshine Health United Healthcare Wellcare / Staywell
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SUMMER 2017 ISSUE ILLINOIS GASTRO DIGEST
72 mcg •145 mcg • 290 mcg
Brief Summary of Medication Guide LINZESS® (lin-ZESS) Capsules
®
72 mcg • 145 mcg • 290 mcg
This information does not take the place of talking to your doctor about your medical condition or your treatment.
What is LINZESS? LINZESS is a prescription medicine used in adults to treat: • irritable bowel syndrome with constipation (IBS-C). • a type of constipation called chronic idiopathic constipation (CIC). “Idiopathic” means the cause of the constipation is unknown. It is not known if LINZESS is safe and effective in children less than 18 years of age. What is the most important information I should know about LINZESS? • Do not give LINZESS to children who are less than 6 years of age. It may harm them. • You should not give LINZESS to children 6 years to less than 18 years of age. It may harm them. Who should not take LINZESS? • Do not give LINZESS to children who are less than 6 years of age. LINZESS can cause severe diarrhea and your child could get severe dehydration (loss of a large amount of body water and salt). • Do not take LINZESS if a doctor has told you that you have a bowel blockage (intestinal obstruction). Before you take LINZESS, tell your doctor about your medical conditions, including if you: • are pregnant or plan to become pregnant. It is not known if LINZESS will harm your unborn baby. • are breastfeeding or plan to breastfeed. It is not known if LINZESS passes into your breast milk. Talk with your doctor about the best way to feed your baby if you take LINZESS. Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins and herbal supplements. How should I take LINZESS? • Take LINZESS exactly as your doctor tells you to take it. • Take LINZESS 1 time each day on an empty stomach, at least 30 minutes before your first meal of the day. You should also wait 30 minutes before eating a meal if you take LINZESS with applesauce or mixed with water. • If you miss a dose, skip the missed dose. Just take the next dose at your regular time. Do not take 2 doses at the same time. • LINZESS capsules should be swallowed whole. Do not crush or chew LINZESS. o Adults who cannot swallow LINZESS capsules whole may open the LINZESS capsule and sprinkle the LINZESS beads over applesauce or mix LINZESS with bottled water before swallowing.
It is not known if LINZESS is safe and effective when sprinkled on other foods or mixed with other liquids. See the complete LINZESS Medication Guide for instructions on taking LINZESS in applesauce, in water, or in a nasogastric or gastrostomy feeding tube. What are the possible side effects of LINZESS? LINZESS can cause serious side effects, including: • See “What is the most important information I should know about LINZESS?” • Diarrhea is the most common side effect of LINZESS, and it can sometimes be severe. o Diarrhea often begins within the first 2 weeks of LINZESS treatment. o Stop taking LINZESS and call your doctor right away if you get severe diarrhea during treatment with LINZESS. Other common side effects of LINZESS include: • gas • stomach-area (abdomen) pain • swelling, or a feeling of fullness or pressure in your abdomen (distention) Call your doctor or go to the nearest hospital emergency room right away, if you develop unusual or severe stomacharea (abdomen) pain, especially if you also have bright red, bloody stools or black stools that look like tar. These are not all the possible side effects of LINZESS. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. How should I store LINZESS? • Store LINZESS at room temperature between 68°F to 77°F (20°C to 25°C). • Keep LINZESS in the bottle that it comes in. • The LINZESS bottle contains a desiccant packet to help keep your medicine dry (protect it from moisture). Do not remove the desiccant packet from the bottle. • Keep the bottle of LINZESS tightly closed and in a dry place. Keep LINZESS and all medicines out of the reach of children. Need more information? • The risk information provided here is not complete. It summarizes the most important information about LINZESS. If you would like more information, talk with your doctor. • For the FDA-approved product labeling or for more information, go to www.LINZESS.com or call 1-800-433-8871.
© 2017 Allergan and Ironwood Pharmaceuticals, Inc. All rights reserved. Allergan® and its design are trademarks of Allergan, Inc. Ironwood® and its three-leaf design are registered trademarks of Ironwood Pharmaceuticals, Inc. LINZESS® and its design are registered trademarks of Ironwood Pharmaceuticals, Inc. Based on PI LIN105169-F-01/17 LIN105168_v2 03/17
SUMMER 2017 ISSUE ILLINOIS GASTRO DIGEST
Clostridium Difficile Infection
P
hysicians prescribe antibiotics to treat simple infections, but for some people these commonly used medications can trigger a serious infection and inflammation of the colon called clostridium difficile or C. Diff. Clostridium difficile (commonly referred to as “c diff�) is a bacteria that can live inside of the intestinal tract of a large portion of the population. It can be acquired by what is known as fecal oral transmission (examples include eating contaminated food or touching a contaminated object and putting hands in mouth). C diff is typically inactive in the presence of the normal healthy
14
intestinal bacteria (human intestines contain thousands of different strains of innocuous bacteria). However, when a person is placed on antibiotics because of a urinary tract infection, bronchitis, or a dental procedure, a large volume of those good, healthy intestinal bacteria get eliminated. When this happens, C. diff bacteria is no longer kept at bay, can multiply and release a toxin that causes diarrhea and inflammation. C. diff infections have become more common and are becoming more difficult to treat due to more potent strains of the bacteria emerging with increased overall antibiotic use.
Symptoms
The most common symptom of C. difficile infection is diarrhea. Other symptoms include abdominal pain, fever, and an overall ill feeling. If the infection becomes severe, it may cause a large swollen colon called toxic megacolon which can lead to death if untreated.
Risk Factors
One of the biggest clues that your diarrhea may be the result of a c. diff infection is recent antibiotic use. Having recently been in a hospital or nursing home can also increase the risk of c. diff transmission. Other factors that can
BY: Yogesh Patel, MD Gastroenterologist / Hepatologist
increase the risk of c. diff include being over the age of 75 and being on acid blocking medications (such as Nexium, Prilosec, or Prevacid). The diagnosis of c. diff is most commonly made by sending a stool sample to be tested for c. diff toxin. When a colonoscopy is performed in the setting of c. diff colitis, there is often a specific type of inflammation present called pseudomembranous colitis.
because of resistance, some people who get c. diff infection do not get rid of it with the first round of antibiotics, and need two or more rounds of antibiotic treatment. In recent years, the use of fecal microbial transplant (stool transplant) has been a highly effective treatment for those patients who fail to respond to traditional treatments. IGG physicians perform stool transplants with the aid of a colonoscopy, often as an outpatient procedure.
Treatment
Take Home Points
Diagnosis
C. diff treatment includes antibiotics that specifically target this bacteria. Two of the most commonly used are metronidazole (Flagyl) and oral vancomycin. Possibly
• Try to avoid antibiotics unless absolutely necessary. • Frequent hand washing with soap and water when visiting a health care
facility or after being in contact with a sick patient (alcohol based hand sanitizer does not get rid of c. diff) • C. diff infection should be suspected in the setting of a diarrhea that lasts more than 2 days especially when there has been involvement of recent antibiotics or recent hospitalization.
Contact your
doctor if you feel you should be tested.
BY: Kenneth D. Chi, MD Gastroenterologist / Hepatologist
Transoral Incisionless Fundoplication
SUMMER 2017 ISSUE ILLINOIS GASTRO DIGEST
(TIF) : A Treatment Option for GERD That May Be Right For You
A
pproximately, 20% of the adult population in the United States has symptoms of gastroesophageal reflux disease (GERD), with more than three million new cases diagnosed every year according to the National Institute of Diabetes and Digestive and Kidney Diseases. Although primarily treated as an outpatient illness, GERD is responsible for about four million hospitalizations annually. Medication therapy is the mainstay of treatment for GERD, and a whopping 64.6 million
16
prescriptions are written for this disease each year in the U.S. alone at a total cost of over $30 billion. Also known as heartburn or acid reflux, GERD is caused when acid and other stomach contents escape the stomach and irritate the esophagus (food pipe). Normally, food and liquid travel down the esophagus in a one-way direction into the stomach which is coordinated by a one-way valve located between the esophagus and
the stomach. When people experience symptoms of GERD, this one-way valve turns into a two-way valve, allowing stomach liquid and contents to reflux up the food pipe and cause symptoms. The most common symptoms of GERD are acid indigestion and heartburn. Some people experience more severe symptoms such as chest pain, hoarse voice, and regurgitation of food. Typically, mild symptoms will improve with over-the-counter medications or
lifestyle changes such as weight loss, avoiding food triggers (spicy or greasy foods) and overeating. However, if GERD symptoms do not improve with OTC treatment, last longer than two weeks, or cause any difficulty in swallowing, it is best to seek medical attention from a gastroenterologist. Any difficulty in breathing, or vomiting blood should be considered a medical emergency, and prompt medical attention is required. The mainstay of treatment for GERD is medication. Many people are familiar with antacids, H2-blockers, and proton pump inhibitors (PPIs), many of which are now available over the counter. In general, these medications work very well and provide quick relief and symptom control for the majority of people. Unfortunately, there are some patients who require these medications long-term , despite efforts to change lifestyle. In recent years, with the increasing scrutiny of possible sideeffects linked to heartburn medications, many patients are seeking alternative treatments.
For patients that are seeking an alternative to the requirements of long-term medication use or are wary of invasive surgery options, a relatively new endoscopic treatment is now available. Transoral Incisionless Fundoplication, or TIF, is an endoscopic treatment that actually fixes the mechanical reflux problem (similar to a surgery) but without incisions or a surgical operation. The procedure takes about one hour to perform and is done during an endoscopy procedure with a special device that is able to fix the two-way valve and make it work like a one-way valve again. This is all performed using the camera inside the stomach while under general anesthesia. In addition, TIF can also fix small hiatal hernias (less than 2cm in size) during the procedure. There are no incisions which results in a faster recovery without any scars. There are also fewer adverse events and complications compared to traditional surgery. In fact, some patients can go home on the same day as the procedure.
A growing number of medical studies demonstrating the effectiveness of the TIF procedure have been published over the past seven years. Long-term results are promising, showing 75% of patients are able to completely eliminate PPI medications after this procedure. The TIF procedure, however, is not for everyone with difficult to mange GERD symptoms. A careful evaluation by your gastroenterologist must be done in order to see if you qualify for the procedure. The procedure may not be appropriate in patients who are overweight and have a BMI greater than 35 or have a hiatal hernia greater than 2cm in size. Other factors include age less than 18, pregnancy or other medical conditions which would prohibit performing the procedure. If you are interested in TIF, and would like to see if you are a candidate for this procedure, contact an Illinois Gastroenterology Group gastroenterologist to see if you qualify.
BY: Wei Sun, MD
SUMMER 2017 ISSUE ILLINOIS GASTRO DIGEST
Gastrointestinal Motility Testing
M
otility or functional gastrointestinal (GI) disorders can be the underlying cause in approximately one-third or more of patients who present with GI symptoms. Until recently, it was thought that these disorders lack a well-defined pathophysiology or specific therapy. However, a careful assessment by your gastroenterologist, coupled with specialized diagnostic tests, can be very useful in diagnosing and appropriately managing these patients. The digestive tract is lined with muscles that control the motor function of the esophagus, stomach, small bowel, colon and the rectum. Disorders of gastrointestinal (GI) motor function and transit are common and the routine endoscopy is frequently unrevealing. By using specific tools, motility testing can help one to diagnose and manage those disorders. The most common motility test is esophageal manometry. Manometry is an outpatient test which measures the strength and muscle coordination of your esophagus when you swallow. It is used to identify problems with movement and pressure in the esophagus when endoscopy or x-ray fails to establish a diagnosis. An important indication for esophageal manometry is in patients with gastroesophageal reflux disease (GERD)
18
who fail to respond to medication. Testing is often performed prior to antireflux surgery which is performed to exclude alternative diagnoses, such as scleroderma or achalasia and to ensure the esophageal peristalsis is preserved. Patients with chest pain not responsive to acid reduction therapy, difficulties in swallowing or sensations of food sticking in the esophagus may also indicate an esophageal motility disorder.
pressure, acidity, and temperature as it passes through the body. Once the capsule is swallowed, the patient goes home. The test data is then transmitted to a small recorder carried by the patient and provides the information needed to evaluate for gastroparesis. The Smart Pill can also be used to measure motility disorders of the small intestine and the colon.
Gastroparesis is a common motility disorder of the stomach. Gastroparesis most often occurs when the nerves of the stomach are damaged or don’t work properly. Diabetes is the most common known cause of gastroparesis, however it can also occur after stomach surgery or in association with Parkinson’s disease and some medications, especially narcotic pain medications. However, often the cause cannot be determined.
Fecal incontinence is a common disorder which can be the result of a long history of constipation with prolonged straining at defecation, causing anal sphincter and/or nerve damage. Many clinical conditions can cause constipation, e.g. hormonal changes, neurological disorders, medications, diet, and pelvic dysfunction. Transit through the colon can be measured with the Smart Pill, and the pelvic floor function is measured with anorectal manometry.
While gastroparesis is frequently recognized with x-ray and endoscopy, specialized testing may sometimes be needed such as a gastric emptying scan or the use of the “Smart Pill”. In the gastric emptying scan test, food containing a small amount of an inactive radioactive substance is eaten. This substance in the stomach can be imaged, allowing a doctor to see and measure how quickly the meal leaves the stomach. The Smart Pill is a new procedure in which a pill sized, disposable capsule measures
This outpatient procedure determines the strength of the anal sphincter, rectal sensation, and coordination between the bowel and the sphincter muscle. Manometry can also be used for biofeedback training in the treatment of certain pelvic floor dysfunctions.
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.
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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.
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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.
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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 lander her in the school infirmary for a week with an immensely distended belly and a 103+
Hasselbeck grew up in an ItalianAmerican 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 preAustralia 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. 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 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
BY: Jonathan Rosenberg MD
Irritable Bowel Syndrome reductions in quality of life and work productivity.6 In the US, total yearly costs associated with IBS have been estimated to be $30 billion. 7
IBS-D has often been underdiagnosed or misdiagnosed by physicians resulting in patients suffering for years. This results in suboptimal management of these patients and a significant burden on both patients and the healthcare system.
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The management of IBS-D typically includes lifestyle/diet modifications as well as over-the-counter or prescription pharmacologic therapies. However, many existing therapies only address single symptoms (i.e. either abdominal pain or diarrhea) rather than providing effective relief of the multiple chronic symptoms of IBS-D. Newer IBS-D therapies are targeted to address the multiple symptoms and chronic patterns of IBS-D. The physicians of Illinois Gastroenterology Group (IGG), in partnership with SonarMD, a software and platform development company, have developed a cloud-based Care Management Platform currently focused on improving patient access, care coordination, and illness management among patients with IBS-D. Through participation in this free program, patients receive a set of questions each month about their current IBS-D symptoms, delivered as a text and/ or email. The survey answers are applied to an algorithm that allows physicians to track the health condition of people with IBS-D. IGG is the only group in the country currently offering this groundbreaking patient engagement platform for patients as part of their routine IBS-D care. Speak to your IGG physician to see if the Sonar IBS-D platform might address your needs.
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rritable bowel syndrome with diarrhea (IBS-D) is a chronic bowel disorder characterized by abdominal pain and diarrhea.1 IBS affects 1015% of adults in the US2 and patients with IBS-D commonly experience multiple bothersome symptoms, including diarrhea, abdominal pain, urgency, and bloating. Symptoms can be mild and intermittent but can often be severe or continuous.3,4 The symptom burden experienced by patients with IBS-D has a significant impact on healthcare costs and is associated with significant 22
References: 1 Longstreth GF et al. Gastroenterology 2006; 130: 1480–1491 2 Canavan C et al. Clin Epidemiol 2014; 6: 71–80 3 Drossman DA et al. Am J Gastroenterol 2011; 106: 1749–1759 4 IBS Patients: Their Illness Experience and Unmet Needs. International Foundation for Functional Gastrointestinal Disorders (IFFGD). 2009. Available at: http://www.iffgd.org/images/library/General_Interest/ IBSUnmetNeeds_Final.pdf 5 Buono JL et al. Accepted to J Manag Care Spec Pharm, Oct 2016 6 Buono JL et al. J Manag Care Spec Pharm, 2015; 21(10 Suppl):1-85 7 Lembo AJ. Pract Gastroenterol 2007; 31, 3–9
Dr. Jonathan Rosenberg, M.D. Selected as a Future Leader by The American Gastroenterological Association
“We are proud to announce the 2017 AGA Future Leaders, who have been recognized as rising stars of our field,” said Suzanne Rose, MD, MSEd, AGAF, co-program chair for the AGA Future Leaders Program. “As a membership society, AGA relies heavily on the engagement and expertise of volunteer leaders. The AGA Future Leaders program provides the unique opportunity to begin cultivating the future leaders of AGA and the field of gastroenterology.”
DR. JONATHAN ROSENBERG SELECTED AS A FUTURE LEADER BY THE AMERICAN GASTROENTEROLOGICAL ASSOCIATION Gurnee, IL (March 1, 2016) — Illinois Gastroentrology Group (IGG) announced today that Jonathan Rosenberg, MD has been selected to participate in the American Gastroenterological Association (AGA) Future Leaders Program. Dr. Rosenberg joins 17 other early career gastroenterologists who were selected for this competitive program based on their current achievements, dedication to advancing the field, and potential for future success. “I am honored to be selected into the AGA Future Leaders Class of 2017,” said Dr. Rosenberg, “I look forward to building upon IGG’s national leadership in value-based medicine, clinical practice, and patient engagement technology.”
The AGA Future Leaders Program was created in 2015 to identify early career gastroenterologists who have the potential to make a significant impact on the specialty. The program provides a pathway within AGA for selected participants who seek opportunities to support the gastroenterology profession, advance their careers, connect with potential mentors and develop the leadership skills necessary to serve AGA. During this year-long program, participants will receive leadership training and work closely with AGA mentors on projects linked to AGA’s Strategic Plan. Learn more about the AGA Future Leaders program, including the mentors, faculty and program alumni, at http://www.gastro.org/ about/initiatives/aga-future-leadersprogram. IGG is a regional medical practice comprised of board certified private practice gastroenterologists and allied professionals. We are dedicated to improving the health of our patients by providing the highest quality gastrointestinal care
utilizing evidence-based medicine, following clinical standards as determined by available scientific knowledge, best practice and innovative treatment. Learn more about IGG including providers, services, locations, and research opportunities at https:// www.illinoisgastro.com/ About the AGA Institute The American Gastroenterological Association is the trusted voice of the GI community. Founded in 1897, the AGA has grown to include more than 16,000 members from around the globe who are involved in all aspects of the science, practice and advancement of gastroenterology. The AGA Institute administers the practice, research and educational programs of the organization. www.gastro.org.
Support Illinois Gastro Group
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at the Glenview Take Steps for Crohn’s & Colitis on 6/25/2017
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ach step we take brings us closer to a cure for digestive diseases like Crohn’s and ulcerative colitis. Please help our team support the Crohn’s and Colitis Foundation of America (CCFA) by donating toward our fundraising goal for this year’s Take Steps Walk. Your donation will directly impact critical research projects, as well groundbreaking patient programs like Camp Oasis, a summer camp just for kids with Crohn’s and colitis. You can also join us as a member of our team — we’d love to have you! Be a part of the nation’s largest event supporting vital research, treatment, and life-enriching programs for people with inflammatory bowel disease (IBD). Our walk includes food, music, and family activities that brings people from all across the community to join together in fun, solidarity, and purpose. The more money we raise, the closer we will be to making life more manageable
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for patients who live with these diseases every day. Please join our team or donate to our efforts to support CCFA in finding cures!
WE
FOCUS ON
YOU
At Illinois Gastroenterology Group, we are committed to providing personalized, high quality care in a convenient, lower cost and friendly environment. That’s why we offer the professional screening procedures you can receive at a hospital in the convenience of our local outpatient surgery centers. If you are over 50, and haven't yet had a screening colonoscopy, begin the new year by scheduling yours with an IGG physician.  Visit our website below to find one of our many practice locations, conveniently located throughout the Chicagoland area. Or, if you prefer, contact us to schedule an appointment at 855.455.4278 (855) ILL-GASTRO
www.illinoisgastro.com
BY: Sonia Godambe MD
Microscopic Colitis
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The diagnosis of microscopic colitis is made on biopsy from the colon. While the colon will look normal, biopsies will show distinct features in lymphocytic and collagenous colitis. Wren’s doctor placed him on Imodium. He had also tried cholestyramine (Questran) and bismuth subsalicylate (Pepto Bismol). Wren’s symptom did not improve and he returned to Illinois where he was staying for the summer. He was then placed on a course of budesonide, a corticosteroid, and after a couple weeks, his diarrhea resolved. “It worked for me, but it took a couple months, and it was expensive,” said Wren, who took the medication for four weeks. He was then tapered off the budesonide over a couple weeks and now does a high fiber diet with Imodium and probiotics as needed. He reports he feels back to normal.
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hen William Wren began having diarrhea in 2011, he thought it was from something he ate. Eight weeks later, he became concerned when his symptoms had not improved. So he went to see a Gastroenterologist in Arizona. Mr. Wren then 66 years old, underwent a colonoscopy and was told he had microscopic colitis. “I had never heard of (microscopic colitis) at all,” said Wren. Microscopic colitis is a chronic inflammatory disease of the colon that encompasses both lymphotic and collagenous colitis. Patients usually have watery, non-bloody diarrhea with 26
an average of 4-9 bowel movements a day. However, some patients have been known to have a larger volume of diarrhea with rare amounts of up to 2 liters of stool daily. Patients may also have abdominal pain, nausea and weight loss. Microscopic colitis most commonly affects middle age adults with the mean age of diagnosis at 65. However, in 25 % of cases, the diagnosis is made in patients less than 45 years of age. Microscopic colitis is more commonly found in women. While the cause is not known, it is thought to be an immune response in a patient who may have a genetic predisposition. Medications such as NSAIDS, like ibuprofen, have also been thought to be a cause or trigger of microscopic colitis, although no definite evidence has been found.
Treatment for microscopic colitis is aimed at resolving the diarrhea and improving quality of life. Scheduled Imodium is the first line of therapy many times for mild to moderate symptoms. If this fails, patients may be put on budesonide for 4 to 8 weeks until diarrhea improves. Other commonly used medications include cholestyramine and bismuth subsalicylate. It is also recommended to avoid medications that can trigger the colitis such as ibuprofen and to quit smoking. While Mr. Wren has not had any recurrence of symptoms, it is possible to get recurrent flares of microscopic colitis. These flares can be re-treated with the medications used in the past. If symptoms do not improve, it is recommended to check for other causes of diarrhea, such as celiac sprue which has been an associated condition. “Periodically, I will get diarrhea that will last for a day and I will take an Imodium and it will resolve,” says Wren, “but nothing like before.”
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TOGETHER WE CAN BEAT CROHN’S The right support makes a difference. That’s why for over a decade, at UCB, Inc. we have been supporting the Crohn’s community online at CrohnsandMe.com. You can find tips, recipes, stories from others in the community, and educational info about the disease. Visit CrohnsandMe.com or our Crohn’s and Me Facebook page to learn more!
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