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A burning topic: heartburn and GERD

by Dr. Vinod C. Thakkar

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02/04/2015 News-Sun pg 1 Highlands Health section, click here for full article.


Heartburn is that burning sensation many of us periodically experience. But when it is persistent, then you may have a chronic condition called GERD. Twenty percent of adult Americans experience heartburn at least twice a week. The most common symptoms include:

• A bitter taste in your mouth.

• A burning sensation in the back of the throat.

• Pain or pressure in the chest causing discomfort.

LES: the problem point

We have a muscular ring, a valve, between the end of the esophagus and the beginning of the stomach called the lower esophageal sphincter muscle – the LES. Its job is to keep stomach acid in the stomach. But in some of us, the LES may not prevent stomach acid from backing up into the esophagus. The result is heartburn, and potentially GERD (gastroesophageal reflux disease). GERD occurs when stomach acid or, occasionally stomach content, frequently flows back into the esophagus. The persistent reflux backwash irritates the lining of the esophagus and causes the condition called GERD.


Occasional heartburn is a common digestive condition that many of us experience from time to time. When it is chronic, or when it interferes with your daily life, you should be referred by your doctor to a digestive specialist, a gastroenterologist.

Most people, under a gastroenterologist’s supervision, an manage the discomfort of heartburn and GERD with lifestyle changes and over-the-counter medications. But some people with GERD may need stronger prescription medications, or even surgery, to reduce symptoms.

More serious symptoms include acid regurgitation, difficulty swallowing (dysphagia), vomiting blood or having black, tarry stools, frequent choking, recurrent throat stricture or hoarseness due to acid reflux.

If left untreated, the lining of the esophagus can be damaged, causing a precancerous condition called Barrett’s esophagus. Early detection is highly desirable as the potentially resultant malignancy is sometimes lethal.

In addition, GERD is associated with such extra-esophageal manifestations such as asthma, laryngitis, chronic cough, and ear/nose/throat problems.


Initial treatment of GERD includes:

Dietary changes: Avoiding acidic and fat-laden foods; reducing caffeine, alcohol, and carbonated drink consumption.

Lifestyle changes: avoiding overeating; refraining from eating before bedtime; elevating the head of the bed; losing weight, especially if obese; stopping smoking.

Follow on treatments may include:

Certain doctor-recommended OTC medications and/or prescription drugs; or surgery, such as fundoplication, to correct the anatomical defects causing the problem.


If you are self-medicating for heartburn two or more times a week, or if you still have symptoms after taking over-the-counter or prescription medications, you need to see a doctor and perhaps be referred to a digestive specialist, a gastroenterologist. Frequent episodes of heartburn or acid indigestion may be symptomatic of a more serious condition that could worsen if not treated.

Dr. Vinod C. Thakkar is a board certified gastroenterology and internal medicine physician. This information is not intended to prevent, diagnose, treat or cure your condition.


Endoscopic Ultrasound (EUS) – What is it?

Why is it important to you?

by Dr. Pankaj J. Patel 

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What Is Endoscopic Ultrasound (EUS)

EUS is an examination with a special endoscope fitted with a small ultrasound transducer device on the end, used to look inside the layers of the wall of the gastrointestinal tract and visualize the surrounding organs including the pancreas, liver, gallbladder, spleen, adrenal glands and surrounding nodes of the chest/mediastinal areas. The scope is inserted by a specially trained physician into the mouth or anus.

EUS uses a flexible endoscope which has a small ultrasound device built into the end and can be used to see the lining and wall of the digestive tract. EUS allows your doctor to examine your esophageal and stomach linings as well as the walls of your upper and lower gastrointestinal tract. The upper tract consists of the esophagus, stomach and duodenum; the lower tract includes your colon and rectum.

The ultrasound scope component produces high frequency sound waves that create high quality visual images of the digestive tract which extend beyond the inner surface lining and also allows visualization of adjacent organs. Endoscopic ultrasound examinations (also called endoluminal endosonography) may be performed through the mouth or through the anus. EUS, which is performed under sedation and on an outpatient basis,  is well-tolerated by most people.

Because the EUS can get close to the organ(s) being examined, the images obtained with EUS are often more accurate and detailed than images provided by traditional ultrasound which must travel from the outside of the body.

EUS can also be used for tissue sampling. Under the continuous real-time ultrasound guidance during EUS, a thin needle can be advanced into these organ structures by the physician  to obtain an aspirate sample of the tissue. This technique is known as a fine needle aspirate (FNA). The cells obtained from the FNA can be placed on a slide and analyzed by a pathologist for abnormalities such as cancer. The cell analysis is called cytology.

EUS with FNA has revolutionized the ability to diagnose and stage cancers of the gastrointestinal tract and assess the pancreas, allowing evaluation of abnormalities such as tumors and cysts. Gastrointestinal cancers can be looked at with EUS and their depth of penetration into the intestinal wall can be determined. Suspicious appearing lymph nodes and other tissues can be biopsied using EUS/FNA.


When/Why Is Endoscopic Ultrasound Used?

EUS provides your physician with more information than other imaging tests like CT/abdominal ultrasound by providing detailed images of your digestive tract. Your doctor can use EUS to diagnose certain conditions that may cause abdominal pain or abnormal weight loss.

EUS is also used to evaluate known abnormalities, including lumps or lesions, which were detected during a prior endoscopy or were seen on x-ray tests, such as a computed tomography (CT) scan. EUS provides a detailed image of the lump or lesion, which can help your doctor determine its origin and help treatment decisions. EUS can be used to diagnose diseases of the pancreas, bile duct and gallbladder when other tests are inconclusive or conflicting.

EUS helps your physician determine the extent of spread of certain cancers of the digestive and respiratory systems. EUS allows your doctor to accurately assess the cancer’s depth and whether it has spread to adjacent lymph glands or nearby vital structures, such as major blood vessels. In some patients, EUS can be used to obtain a needle biopsy of a lump or

lesion to help your doctor determine the proper treatment without requiring surgery, and often preventing unnecessary follow on high risk surgeries.

The uses for EUS are still being developed. Currently, it is being utilized in some of the following situations:

  • Staging (identifying extent of progression) of cancers of the esophagus, stomach, pancreas and rectum.
  • Staging of lung cancer via sampling of mediastinal nodes.
  • Evaluating chronic pancreatitus and other masses or cysts of the pancreas.
  • Studying bile duct abnormalities including stones in the bile duct or gallbladder, or bile duct, gallbladder, or liver tumors, recurring pancreatitus, unexpected weight loss, and cholangiocarcinoma.
  • Studying the muscles of the lower rectum and anal canal in evaluating reasons for fecal incontinence.
  • Studying ‘submucosal lesions’ such as nodules or ‘bumps’ that may be hiding in the intestinal wall covered by normal appearing lining of the intestinal tract.
  • Staging rectal cancer and neoendocine tumors that are carcinoid.
  • To diagnose diseases of the pancreas, bile duct and gallbladder when other tests are inconclusive.
  • To provide a minimally invasive method for acquiring tissue samples from gastrointestinal tumors and lymph nodes that may not be easily accessible by other methods (i.e. radiographic or surgical guidance). Fine Needle Aspiration (FNA) can be performed by passing a biopsy needle down the channel of the endoscope and across the intestinal wall under ultrasound guidance to obtain tissue for the diagnosis.
  • As a therapeutic tool for treating both solid and cystic tumors of the pancreas, alleviating intractable abdominal pain secondary to advanced pancreatic cancer, and obtaining access to the bile ducts and pancreatic duct in cases of failed ERCP.


Cancer staging

Staging of cancer, i.e. the process of finding out how much cancer there is in the body and where it is located, is becoming a very important use of EUS. The prognosis of a cancer victim is related to the stage of the cancer at the time of cancer detection. For example, early stage colon cancer refers to cancer confined to the inner surface of the colon before it is spread to adjacent tissues or distant organs. Therefore early stage colon cancer can be completely resected with good chances for cure. However, if cancer is detected at later stages, the cancer tissues may have  have already penetrated the colon wall and invaded neighboring organs and lymph nodes, or have spread to distant organs such as liver and lungs. Complete surgical excision becomes highly unlikely. EUS can provide information regarding the depth of penetration of the cancer and spread of cancer to adjacent tissues and lymph nodes, information useful for staging and developing a treatment plan..


What Happens During an Endoscopic Ultrasound?

EUS is an outpatient procedure typically done in an ambulatory surgery center. A person undergoing an endoscopic ultrasound has certain advance preparatory dietary cleansing and fasting requirements, and restrictions on certain medications. The patient will be sedated prior to the procedure. After sedation, the doctor inserts an sterilized  endoscope into the person’s mouth or rectum. The doctor will observe the inside of the intestinal tract on a TV monitor and the ultrasound image on another monitor. Additionally the sound wave testing may be used to locate and help take biopsies (small piece of tissue to examine via microscope by a pathologist). The entire procedure usually takes 30 to 60 minutes, recovery is typically quick,  and the patient can go home the same day of the procedure. While, as with any medical procedure, there are certain risks, for EUS the complication risk is low, and are more than offset when balanced with the many benefits derived  and the higher risks of alternative procedures.


A specialist in digestive diseases ( a gastroenterologist) or lung disease (a pulmonologist) with special training in EUS will interpret the EUS images. A doctor trained in analyzing biopsies (pathologist) will report the test results if the patient has had fine-needle aspiration. The referring primary care doctor discusses any important findings, recommendations, and next steps with the patient after conferring with the specialists.


Who does EUS?

Endoscopists are highly trained physician specialists. After completing the traditional three years of Gastroenterology Fellowship in an accredited medical  teaching program, there is an additional 2 years of training in EUS/Advanced Procedures like ERCP. In addition, the American Society for Gastrointestinal Endoscopy (ASGE) requires documentation of specific training in GI endoscopic procedures.  ASGE physicians and surgeons are qualified to perform procedures including upper gastrointestinal (GI) endoscopy, flexible sigmoidoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and EUS.


Dr. Pankaj J. Patel (of Thakkar, Patel & Avalos) is a board certified gastroenterology and internal medicine physician, who is trained in EUS. He is the only physician offering this special procedure in the Highlands County area.


Colonoscopy can prevent up to 90 percent of colon cancer

by Dr. Martin E. Avalos

Special to Highlands Health

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02/25/2015 News-Sun, Highlands Health section, click here for full article.

March is National Colorectal Cancer Awareness Month, which means there is no better time to learn the facts about colon cancer and get tested. It could save your life.

Colorectal cancer (cancer of the colon or rectum) is now the second cause of cancer death in the United States. It’s nearly equally deadly in men and women and yet it is highly preventable and often curable when detected early. It is most common after the age of 50, but it can also affect younger people.

Most early colon cancers produce no symptoms. This the reason why screening is very important. Possible symptoms that should prompt a doctor visit include new onset of abdomen pain, change in stool shape or caliber, blood in stool and change in bowel habits with new onset diarrhea or constipation. Most colon cancers originate from polyps, which are abnormal growths in the colon wall. If polyps are present and not removed they may turn into cancer. Screening exams can detect precancerous polyps so they can be removed before turning into cancer. Approximately more than 75-90 percent of colon cancer can be avoided by early detection and removal of colon polyps.

A colonoscopy every 10 years is the preferred screening and prevention test for colon cancer. It is considered the “gold standard” because it allows the physician to examine the entire colon and to identify and remove (biopsy) colon polyps at the same time without the need for a follow-on procedure or test.

For normal risk individuals, a colonoscopy is recommended beginning at age 50 — age 45 for African Americans, since they have a higher incidence of colon cancer at a younger age. Colonoscopy is recommended for any age in individuals who are considered high risk including personal or family history of colon polyps or cancer, hereditary forms of colon cancer and predisposing chronic bowel conditions like ulcerative colitis and Crohn’s disease.

While colonoscopy is the most effective test for colon cancer, other screening options are available. The Fecal Immunochemical Test (FIT) can be performed yearly. It detects hidden blood in the stool and if positive requires the performance of a colonoscopy. Alternative tests include Fecal DNA testing (Cologuard) every three years and CT colonography or “virtual colonoscopy” done every five years.

They are available for patients who decline colonoscopy, but if the tests are positive,or if polyps are noted, a regular colonoscopy is required, anyway.

Training and experience of the endoscopist are critical to a thorough colonoscopy. Gastroenterologists in general receive a special training in colonoscopy and by far perform more colonoscopies than any other speciality. Make sure the physician doing your colonoscopy is board certified, does a large number of procedures each year, is able to examine the entire colon and has a low complication rate.


By the numbers

The American Cancer society indicates only about 60 percent of adults of screening age are up to date on their colon cancer screening, and many have never been screened at all.

So, while more than 4 million Americans get colonoscopies annually hoping to avoid colon cancer, the CDC indicates that every year 140,000 Americans are diagnosed with colorectal cancer, and more than 50,000 die from it — many of which are preventable.

Dr. Martin E. Avalos is a gastroenterology and internal medicine physician in Highlands County. This information is not intended to prevent, diagnose, treat or cure your condition.


Dietary fiber: the importance of roughing it

by Tammy Chaundy

Special to Highlands Health

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03/11/2015 News-Sun, Highlands Health section, click here for full article.

“Eat more fiber” is one of the mantras of digestive health because it is so good for you in so many ways.

What is it?

Also known as “roughage,” fiber is edible portions of plants foods that you don’t digest or absorb, so, it serves as “bulk” and passes through your digestive tract and is excreted.

Fiber is of two types: soluble, meaning it dissolves in water, and insoluble which means it doesn’t.


Where do I get it?

Good sources of soluble fiber include apples, carrots, peas, beans, barley and psyllium. The latter is a seed husk that’s used in over-the-counter dietary aids such as Metamucil. It is a binding agent that beneficially affects certain digestive processes.

Insoluble fiber is found in wheat bran, flax seed, whole grains, nuts, and vegetables such as cauliflower and many types of beans. It is an enabler that promotes the movement of foods through the digestive tract.

Some healthy foods contain both, such as many legumes, oatmeal, whole grain foods, brown rice, barley, etc.


Why do I want it?

Proper fiber consumption provides many benefits, starting in childhood and lasting throughout life. It facilitates bowel movements by both preventing constipation while also relieving diarrehea. With proper water consumption,it increases stool size, softens it and makes it easier to pass. It relieves loose, watery stools by absorbing water and adding form and bulk.

Beneficial effects include preventing constipation and reducing risks of hemorrhoids, diverticulitis, irritable bowel syndrome and possibly colon cancers. Because of its bulk, fiber helps makes you feel full and can play a part in weight control, and because its typically low in calories it further contributes to weight reduction.

Because of its density, fiber, especially soluble fiber, slows metabolism and digestion and helps diabetics with slower rates of sugar absorption to maintain lower sugar levels. Soluble fiber affects the way nutrients and chemicals are processed in the digestive tract and has been found to lower blood cholesterol levels, and for some, it may reduce blood pressure and the risk of stroke.

While the best sources are natural foods, convenient sources of fiber include cereals such as Fibre One, All-Bran or Bran Buds. By themselves or mixed in with your favorite supplements such as Benefiber, Metamucil, FiberCon, or Citrucel that you mix with water or your beverage of choice, these are excellent and proven sources of fiber. Theses supplements are also available in capsules and as health bars.

So, to recap, here’s why this easy-to-get, inexpensive “health food” is so important in your diet:

• Heart health: reduced risks of heart disease, blood pressure, stroke, heart attack.

• Weight management: increased feelings of fullness; slowed digestion, prolonging satiation.

• Diabetes: slower absorption of sugar to help blood sugar level control

• Gallstones and kidney stones: reduced risk through blood sugar regulation.

• And my favorite … Digestive system: lower risk of diverticulitis, hemorrhoids, irritable bowels syndrome and constipation; helps relieve diarrhea.


Tammy Chaundy, FNP-C, AGACNP-BC is a board certified gastroenterology and internal medicine nurse practitioner with Thakkar, Patel & Avalos. This information is not intended to prevent, diagnose, treat or cure your condition.



Pill Cam – not just sci-fi

by Dr. Pankaj J. Patel   (Thakkar, Patel & Avalos MDs)

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The inside tract

Capsule endoscopy, aka “pill cam”, is a  small bowel endoscopy procedure that is a safe, simple way to view your entire small bowel. Seeing the three portions of the small intestine (the duodenum, jejunum, & ileum) can give your doctor needed insight – and give you confidence in your treatment plan.

With this micro technology, you don’t have to go through a lengthy, uncomfortable procedure. You simply swallow a pill capsule, about the size of a large vitamin capsule. The miniature disposable camera, has its own light source and a radio transmitter, and simply passes through the digestive system and is excreted.

The device enables a trained specialist, a gastroenterologist physician, to directly view your entire small gastrointestinal tract  – and see problems that are beyond the reach of other imaging methods or traditional endoscopy.

The process

 Capsule endoscopy doesn’t require sedation, ingesting contrast media, or inserting tubes into your digestive tract. Only fasting for 10 hours before the procedure (generally overnight) is usually required – no other preparation.

Sensors are placed on your abdomen (adhesive stick on’s), then the video capsule is swallowed with water. It passes naturally through your digestive tract while transmitting video images to a recorder that you the patient wear on a belt close to the waist.The patient typically is able to eat four hours after the capsule camera ingestion, and can move around freely throughout the process. The examination is over approximately eight hours after capsule intake.The camera capsule is disposable and passes naturally with a bowel movement, typically without feeling any pain or discomfort. There is no recovery time and no need to retrieve or return the capsule.

After procedure completion, the recorder and sensors are be removed and the images made available for the gastroenterologist, to review.

The risks of the small bowel capsule endoscopy procedure are minimal, especially when compared with the substantive noninvasive diagnostic benefits.


The benefits

Undergoing a comprehensive digestive tract examination can be extremely important. Using this patient-friendly technology, physicians can now directly visualize the  esophagus, small bowel,  and colon. Capsule endoscopy is an  accurate, non-invasive visualization examination to detect abnormalities  in the small colon such as ulcers, tumors, strictures, and polyps – the first step in preventing cancer. It is an important medical diagnostic tool in the treatment of Crohn’s disease and small bowel cancers. And, it is commonly used to search for a cause of bleeding in the small intestine. Pill cam – a high tech medical tool, not just sci-fi.


Dr. Pankaj J. Patel (of Thakkar, Patel & Avalos) is a board certified gastroenterology and internal medicine physician, who is specially trained in advanced digestive diagnostic procedures.