The current issues with the
coronavirus pandemic have understandably created some questions and stress for
many patients. Mixed messages from
health authorities and the media can certainly create problems with confusion.
Many patients on immunosuppressant
drugs are already aware that they are at higher risk of getting viral and
bacterial infections due to the medications they take. This is why there are recommendations for
patients on immunosuppressant drugs for digestive health conditions such as
inflammatory bowel disease to practice good handwashing, to notify their
physician if they are having cold or flu symptoms, and to make sure they are
up-to-date on vaccinations.
The risks of doing things (taking
medication) need to be weighed in the risks of doing nothing (not taking
medication and having a disease flareup).
The American Gastroenterological Association he has issued guidance for patients on immunosuppressant drugs with underlying digestive problems. (Link)
The Crohn’s and Colitis Foundation is also a rational source of information. (Link)
“Patients on immunosuppressive drugs
for IBD and autoimmune hepatitis should continue taking their medications. The
risk of disease flare outweighs the chance of contracting coronavirus. These
patients should also follow CDC guidelines for at-risk groups by avoiding
crowds and limiting travel.”
In summary it is advisable to continue medication for
underlying inflammatory bowel disease.
The risk of having a flare-up which can cause problems such as diarrhea,
bowel obstruction, GI bleeding is of greater health risk to a patient than the
risk of getting an infection. If
immunosuppressant medications are keeping Crohn’s and colitis under control,
this decreases the odds of needing to utilize emergency rooms, urgent cares,
and hospitals for patient. Avoiding
these locations can help a patient decrease their odds of contracting an
infection. Therefore good disease control
along with the universal precautions being advised by the CDC remained the best
defense for patients with inflammatory bowel disease.
I hope all of my patients stay well at this difficult
time.
Currently the only known treatment for celiac disease is a gluten free diet. While the diet is highly effective, many patients with celiac disease will still experience symptoms while following a gluten free diet. Some of these issues may relate to cross contamination events; some may relate to incomplete healing of the intestine causing irritable bowel like symptoms.
Larazotide is a medication currently being researched for the treatment of persistent symptoms in the setting of celiac disease in patients following a gluten free diet. It is felt to limit the inflammation from gluten exposure by tightening the junctions between the cells that line the small intestines.
I am excited about the promise of a new therapy for celiac disease and the potential to offer options other than a gluten free diet. I am also excited that Allegiance Research Specialists has partnered with us at GI Associates to be a study site for the medication.
As anyone diagnosed with celiac disease knows well, a gluten-free diet can present a challenges when having to avoid food with wheat, barley, and rye. Many other people without celiac may also choose to a eat gluten free diet for a variety of other health concerns. Whatever the reasons for adopting a gluten-free diet, the diet itself can present some nutritional challenges such as getting adequate dietary fiber. Because many gluten free breads and baked goods use substitute flours that have a higher than usual starch content and less dietary fiber than traditional multigrain breads or pastas, this can create issues with constipation.
Diet therapy is a very important element of managing all types of digestive diseases. Patients often ask me for dietary management options for issues such as constipation as an alternative to using medications. What I often counsel patients is to focus on choosing foods that are already naturally gluten free such as fruits and vegetables, which also happen to provide additional dietary fiber. In fact, I counsel all my patients – even those not on a gluten free diet – to eat a diet filled with fruits and vegetables. An easy way to remember is to “eat from the perimeter of the grocery store” as a general rule of thumb.
But what fruits and vegetables are the best to get additional fiber in your diet? While the usual suspects of broccoli, lentils, beets and apples are all great options, more exotic fruits can actually provide just as much fiber and digestive benefits when added into daily diet. In fact, some recent studies on constipation and irritable bowel syndrome have shown that Kiwifruit may be a natural remedy.
In 2 studies presented at the 2018 Digestive Disease Week, researchers in Italy and New Zealand, which perhaps non-coincidentally are the top two exporting countries of kiwi in the world) found that incorporation of kiwifruit into the diet could replace the use of daily medication for the management of digestive distress. In the studies, patients with irritable bowel syndrome, constipation, and healthy volunteers were given either 2 kiwi per day, or psyllium (fiber supplement) for 4 weeks. The results showed that the group ate kiwi had better results, with the researchers proposing that kiwis are comparable if not more effective than psyllium fiber supplements for constipation and irritable bowel syndrome.
So how can you incorporate more (or any) kiwi into your diet? While some people like to eat kiwis with the skin on (myself included) and it does add some additional fiber the fuzzy skin can be peeled and still have the same effect according to Prof. Giovanni Barbara, M.D., the author of one of the studies. In addition to finding them in the produce section of your favorite grocery store, many warehouse clubs such as Costco or Sam’s Club sell kiwi in bulk. Kiwis are a great addition to any fruit salad, are delicious when incorporated in a morning smoothie (try this kid-friendly kiwi, banana, avocado and spinach green smoothie), and are even great in baked goods (try this kiwi tart, but substitute the flour in the pastry recipe for your favorite gluten-free mix such as Cup for Cup or Bob’s Red Mill). And while I doubt that there would be any dietary fiber benefits of this white kiwi sangria recipe, it looks like it would be a fun addition to any party (make kid-friendly by swapping orange juice for the orange liquor and sparkling white grape juice for the wine)!
Cesare Cremon, Juliet Ansell, Isabella Pagano, Barbara Kuhn-Sherlock, Lynley Drummond, M. Raffaella Barbaro, Eleonora Capelli, Lara Bellacosa, and others. A Randomized, Controlled, Single-Blind, Cross-Over Study Assessing the Effect of Green Kiwifruit on Digestive Functions and Microbiota in Constipated Patients. Gastroenterology, Vol. 154, Issue 6, S-565–S-566 https://www.gastrojournal.org/article/S0016-5085(18)32081-X/fulltext
Giovanni Barbara, Shin Fukudo, Lynley Drummond, Barbara Kuhn-Sherlock, Juliet Ansell, Richard Gearry. Green Kiwifruit Compared to Psyllium for the Relief of Constipation and Improving Digestive Comfort in Patients with Functional Constipation and Constipation Predominant Irritable Bowel Syndrome — Analysis of Three International Trial Centres. Gastroenterology, Vol. 154, Issue 6, S-979–S-980 https://www.gastrojournal.org/article/S0016-5085(18)33288-8/fulltext
As a gastroenterologist I spend a lot of time performing colonoscopies. As a result, I spend a lot of time talking with patients after the procedures about things I find inside their colon. Common findings on colonoscopies include colon polyps, hemorrhoids, and diverticulosis. Multiple times a day I find myself discussing diverticulosis and trying to dispel common misconceptions about it. There is a lot of confusion about diverticulosis. “You mean I can’t eat popcorn anymore?” is something patients ask me. This is not true (see below). As somebody who loves popcorn, I would never want to deny somebody the chance to eat popcorn. Let’s discuss.
What is Diverticulosis? Diverticulosis is the presence of pockets in the colon.This is due to a weakness in the wall of the colon.This is seen in over half colonoscopies (50%) and increases with age. Estimates are that 50% of people over 50 have diverticulosis; 60%of people over 60 have diverticulosis; and 70% of people over 70 have diverticulosis. Many people with these pockets do not have symptoms or GI concerns.
Picture of diverticulosis on a colonoscopy. Pockets seen indenting the wall of the colon.
What is Diverticulitis:? Diverticulitis is when 1 of the pockets becomes inflamed and infected.Only 4% of patients with diverticulosis will get diverticulitis.Even though this number is rather low, if you think about it, if half of people have diverticulosis, and 4% of people with diverticulosis eventually get diverticulitis, this means that about 2% of people will have an episode of diverticulitis sometime during their lifetime.This is why everyone seems to know at least one person who has had issues with diverticulitis.Not all attacks of diverticulitis are severe.While some may require surgery most resolve with antibiotics.(Clin Gastroenterol Hepatol. 2013;11)
Therefore:
– OSIS:Presence of the pockets.Does not mean a problem.
– ITIS:Means inflammation or infection of the pockets.
Diverticulitis typically resolves with a bland diet and antibiotics.Severe cases that result in uncontrollable abdominal pain, inability to eat, inability to pass gas or stool, or development of an abscess can require surgery and hospitalization.
There is reported higher risk of colon cancer in patients who have had diverticulitis, therefore a colonoscopy is typically advised 6–8 weeks after having an episode of diverticulitis if the patient has not had a colonoscopy in over a year.(Ann Surg. 2017;265(5):954.) It is unclear as to why this is the case. Sometimes colon cancers and diverticulitis can look similar on a CT scan.
What is symptomatic diverticular disease.?When the patient has symptoms from the narrowing caused by diverticulosis and there is no evidence of inflammation.Often causes issues with constipation and abdominal cramps.Very similar to irritable bowel syndrome.
Many patients ask:“How can I prevent problems from the pockets?”.
For patients without any symptoms, nothing really needs to be done.Healthy lifestyle advice in regards to diet, exercise, and maintaining a healthy body weight is always suggested.I often say, “If I find diverticulosis, I tell you to eat more fruits and vegetables.If I don’t find diverticulosis, I tell you to eat more fruits and vegetables.”
Smoking, obesity, lack of dietary fiber, and lack of physical activity are all associated with problems from diverticulosis.
Nuts and seeds?Everyone seems to have an elederly relative who would not eat berries or popcorn.This is based on old misconceptions and medical myth. A large medical research study showed that nuts and seeds do not cause episodes of diverticulitis. (JAMA. 2008;300(8):907).In fact, high-fiber diets have been shown to be preventative of diverticular disease.There may be a subset of patients who have trouble with high residue foods.I typically advise patients that see a direct correlation to things like nuts and popcorn and attacks of diverticulitis to avoid these foods.If these foods are generally not a bother, there should be no restriction on the consumption of high amounts of roughage, seeds, nuts.
Eating the jumbo bucket of movie popcorn and getting sick does not mean you have diverticulitis. It means you ate way to much popcorn. Moderation in all things is best.
Fiber?Increasing dietary fiber or fiber supplementation is typically advised for patients with symptomatic diverticulosis.This is based on the fact that there is an inverse correlation between fiber intake and complications from the diverticula.
Probiotics? There is some medical evidence, albeit week evidence that probiotic supplementation may also help with symptoms from diverticular disease.(Therap Adv Gastroenterol. 2013 May; 6(3): 205–213.) If a patient has symptoms from diverticular disease I do advise trying probiotics.If a trial of probiotics for 2–4 weeks tends to help with the symptoms I advise continuing them.If the trial of probiotics does not help with the symptoms I typically advise stopping them as the evidence is not strong.Lactobacillus probiotics have been studied the most for this.
Hopefully this helps explain those pesky pockets in the colon.
There are a lot of questions now about the class of acid reflux medications called proton pump inhibitors (PPIs). PPIs include Prilosec (omeprazole), Nexium (esomeprazole), Prevacid (lansoprazole), and Protonix (pantoprazole). As acid reflux and stomach ulcers are common health conditions, many people take these medications. There have been several news stories raising concerns about these medications and many patients coming to see me in the office ask me about these drugs,
Why do people take PPI medications? Common reasons to take PPI medications include:
Acid reflux – Medication reduces stomach acid, and hence helps the symptoms of burning and discomfort.
Stomach ulcers- By reducing stomach acid, the PPI helps ulcers heal. Can also prevent recurrent ulcer bleeding in people that need to take blood thinners and medications like aspirin or ibuprofen (NSAIDs)
Upper abdominal pain (also known as dyspepsia)- medication for a short duration can relieve discomfort in the upper gut.
Barrett’s esophagus– reduced acid helps eliminate damage to esophagus tissue.
There are some clear health benefits to a PPI medication. Acid reflux can be associated with a condition call Barrett’s esophagus which can lead to esophagus cancer. Severe issues with acid reflux can cause pain, sleep disturbance, and poor quality of life. Stomach ulcers can cause internal bleeding.
So what are the risks?
A study in the journal JAMA Neurology (JAMA Neurol. 2016;73(4):410-416. doi:10.1001/jamaneurol.2015.4791) raised concerns that PPI use may be associated with dementia. The researchers obtained data on patients in a German health insurance plan and compared the rates of dementia on patients that took PPI to patients that did not take PPI. They did find that there was a weak statistical association with higher rates of dementia in patients on PPI medications. The issue with this study is that the patient’s on PPI medications in the study also had higher rates of stroke, heart disease, and use of multiple medications which can also cause dementia. These sort of research studies need to be interpreted with caution. A correlation does not equal a cause. You can ask my children to tell you about this. If you wear the green Packer jersey and they win this week, it does not mean that the Packers will win again next week if you wear the same jersey. Correlation does not equal cause. (Reference: 2016 NFC Championship game)
What should you do if you are on a PPI?
The most important thing to do would be to talk with the doctor prescribing the medication. If you are taking over the counter PPI medications, you should consider discussing your symptoms with a doctor. Even though I do not think the study on dementia was well designed and valid, I do like that the study has opened many discussions and has encouraged patient’s to ask questions. “Why am I taking this medication, doc?” is a question you need to know the answer for every pill bottle in your medicine cabinet.
For patients with GERD, I typically advise them to try and go off PPI medication and see how they feel. I advise this more for cost and simplicity; not due to concerns about dementia. If frequent issues with reflux return, then resuming the PPI for 2-4 weeks at a time for treatment tends to control the symptoms. This works for most patients. For patients that have issues with symptoms multiple times a week whenever they are off PPI, long term use may be indicated.
For patient’s with Barrett’s, it is advisable to stay on the medication as Barrett’s can cause cancer.
For patient’s that take blood thinners and have had issues the stomach ulcers in the past, there is a clear benefit to remaining on the medication.
What is rebound reflux?
Sometimes stopping PPI medication abruptly can cause what is called a rebound reflux. After long term PPI use, patients can have a temporary increase in reflux symptoms. This will typically resolve with time. Sometimes weaning the dose of the medication or changing to every other day dosing first can help with rebound. Using milder over the counter antacids can also help with this while coming off PPI.
My advice is in line with the American College of Gastroenterology’s recommendations. For more information:
There are a variety of tests available for celiac disease. Confirming a diagnosis of celiac disease is important, as there can be some implications of a confirmed diagnosis of celiac disease versus “gluten intolerance”. Patients with celiac disease are at risk for certain types of cancers, nutritional problems, and diminished bone density. Knowing for sure is very important as patients with a confirmed diagnosis of celiac disease require monitoring by a physician. Patients with celiac disease also need to be 100% gluten-free in regards to diet.
“Gluten intolerance”, also known as “non celiac wheat sensitivity”, causes people health issues or digestive distress when they are exposed to gluten. People with gluten intolerance do not have a confirmed diagnosis of celiac disease. Patients with gluten intolerance do not always need to be 100% gluten-free. Patients with gluten intolerance do not require the same level of monitoring that a patient with celiac disease would require. Both conditions can make people feel rather sick. The symptoms of gluten intolerance can mimic other serious health issues, hence it is important to seek a formal opinion from a doctor.
Simply feeling better on a gluten-free diet does not constitute a diagnosis of celiac disease.
Given these factors, formal testing is important. There are 2 types of tests for celiac disease. It is important to know that both are measuring the body’s response to gluten. In order for proper testing and confirmation of a diagnosis of celiac disease, the patient must be exposed to gluten.
1. Labs. A tissue transglutaminase antibody is most sensitive lab test for celiac disease. There are older antibody tests that are still available. We typically only use these older antibodies in certain clinical situations.
2.Biopsies of the small intestine. A biopsy of the small intestine enables the doctor to see how the small intestine is reacting to gluten. Biopsies of the small intestine are the most accurate test. The endoscopy will show breakdown of the intestine lining and the biopsy will show inflammation as well as breakdown of the intestine cells. An adequate number of biopsies is required to make a proper diagnosis. Typically this is 6 specimens. Biopsies are taken during an upper endoscopy procedure.
Endoscopic pictures and biopsy example of celiac disease.
I typically advise patients not to start a gluten-free diet until they have at least considered laboratory testing for celiac disease. If somebody is already on a gluten-free diet the standard labs and biopsies are rendered inaccurate. There is a genetic test we can do for celiac disease but this only rules out celiac disease it does not rule it in. Establishing a diagnosis of celiac in a patient already on a gluten-free diet requires the patient to ingest at least one serving of gluten per day for at least 4 weeks in order to measure the body’s response to gluten.
The bottom line is to consult with a physician on testing for celiac prior to starting a gluten free diet.
Video of me discussing these tests can be found here.
I am a board certified gastroenterologist working in Southeastern Wisconsin with GI Associates. I have a special interest in celiac disease and gluten related issues.
After being in GI practice for several years my wife began having digestive issues. Evaluation eventually led to a diagnosis of celiac disease ( TTG over 100 and severe villous atrophy on biopsy). We were shocked. As a Gastroenterologist I was knowledgeable about the diagnosis of celiac and I knew that a strict gluten fee diet was needed. I had no idea what it was like for a patient and a young family to navigate the diet and lifestyle. The experience of being on the “other side of a diagnosis” was difficult. On our journey, my wife taught me so much about handling a difficult diagnosis with grace. We have used what we have learned to share with my patients more practical approaches to handling celiac disease and gluten free diets. The learning curve can be steep but, we hope that we can ease some of the initial shock and help you to feel empowered to put you on the path to good digestive health.
Overall, this experience has given me a unique perspective. As a GI specialist, this drives my desire to focus on the latest science and research surrounding celiac disease. As a supportive family member, it has helped me learn the day to day struggles of living with a chronic GI illness that must be managed with a strict diet. I hope to share in my experience as both a physician and as a family member. This blog will focus both on science as well as day to day life with celiac disease and other digestive health problems.
