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Your Stomach and Digestive System Issues, Answered.

22 November 2016

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This month's Ask the Doctor series features INTEGRIS gastroenterologist Dr. Abbas Raza, an expert in advanced interventional gastroenterology. Do you suffer from heartburn, gas, abdominal pain or irritable bowel syndrome? Does your esophagus burn from acid reflux? Do you have rectal bleeding or diarrhea? Do you have questions about getting a colonoscopy? Do you have other stomach and digestive system issues not listed here? Then a gastroenterologist is just the doctor for you!

Here are the questions submitted by our readers to Dr. Raza throughout the month.

(Disclaimer notice: The Ask the Doctor series with Dr. Raza is intended to provide general medical information and to support the promotion of health and wellness. The answers provided by Dr. Raza do not constitute medical advice and are not intended to be a substitute for medical care or advice provided by your physician or qualified provider. Your participation in this article also does not create a physician/patient relationship, and if you have any specific questions about a personal medical matter, please consult your doctor or other professional health care provider).

1. I have chronic heartburn and reflux and have been on either Prilosec, Nexium, or Dexilant for many years. If I go without them, my heartburn is terrible as well as reflux during the night. I had bariatric surgery over 15 years ago, which definitely increases my reflux I think. I’ve heard that it is bad for your health to stay on proton pump inhibitors for a long period of time, but isn’t the risk of cancer from the reflux maybe worse for me?

Gastroesophageal reflux disease (GERD)  is a condition of symptoms and injury to the esophagus caused by percolation of stomach contents, including acid, into the esophagus. GERD is an extremely common condition. If left untreated, it can result in serious complications including esophageal ulcerations, difficulties with swallowing, bleeding, Barrett’s esophagus (a pre-cancerous condition) and esophageal cancer.

And yes, recently there have been concerns raised in several studies about the side effects of proton pump inhibitors. However, in treating this or any other disease, we have to assess the benefits versus side effects ratio. But first we need a definite diagnosis of GERD. In cases like this,  I often suggest the following tests to determine long-term treatment.

  • upper endoscopy
  • 48 hours of ambulatory esophageal pH monitoring
  • a gastric emptying study to evaluate for gastroparesis (slowed gastric emptying). This condition is common in patients with a history of  bariatric surgery.

2. I have been taking prescription acid reflux medication for over 10 years. Should I be concerned about taking this medication for so long? When I don't take it I get choked and vomit severely. Is there anything I can do other take a pill for the rest of my life?

In cases like this, the goals of treatment should be to alleviate symptoms, heal the esophageal damage caused by acid, and prevent occurrence of complications from acid reflux disease.

I would suggest making some lifestyle modifications, if applicable. These measures should include weight loss, smoking cessation, avoiding meals or eating within three hours of bedtime, and slightly elevating the head of the bed. Your doctor should review all your medications, since some medication side effects include acid reflux.

As for the long-term use of prescription acid medications, I would suggest a thorough evaluation by a physician to identify underlying issues. In cases like this, when one of my patients has a fairly severe symptomatic disease on a long-term basis, I would perform (at least) an upper endoscopy, with or without pH monitoring, to diagnose and then treat the disease.

3. I was on the acid blocker Omeprazole for seven years for heartburn. I also have chronic diarrhea. Could the two be related? If so, should I get off the Omeprazole? What else can I do for my chronic heartburn?

Yes, some proton pump inhibitors can cause diarrhea, but there are many other causes of diarrhea, too. Therefore you should be evaluated for other causes of diarrhea before attributing this symptom to the acid blocker drug. Depending on your age and other medical conditions it will be important to make the definite diagnosis by medical testing, including an upper endoscopy, with or without ambulatory pH monitoring, for acid reflux disease. Proper diagnosis is very important in cases like this where the patient has a long history of symptomatic disease, so that a long-term treatment plan can  be developed.

4. I have heartburn sometimes at night when I go to bed and my husband has it often. What should we do about it? We can't eat in the evening or we get it for sure. Are there any natural remedies for heartburn that don’t require medication?

I think lifestyle modifications should be tried first. These would include weight loss ( if overweight), smoking cession, avoidance of meals within three hours of bedtime, avoidance of tight-fitting clothing, and some elevation of the head of the bed. Try to decrease consumption of alcohol, caffeine and aggravating foods, such as fried food, onions, and citrus- and tomato-based foods. In addition to these lifestyle modifications, over-the-counter medications for reflux, such as Prilosec OTC, are available.

In cases like these, if the symptoms don't abate after lifestyle modifications, I would suggest a physician visit for further investigation. If you have any alarming symptoms, such as difficulty with swallowing, unexplained weight loss or anemia due to painful swallowing, you should see your doctor immediately for a referral to a specialist.

5. What exactly is an adenomatous polyp? Should I be worried if my mother has them, starting in her 60s? I am 45 years old. Do you recommend a colonoscopy for me?

Adenomatous polyps are precursors to colorectal cancer. These polyps are believed to develop in a stepwise fashion as a result of a series of genetic mutations. It is widely accepted in the medical community that adenomatous polyps lead to colon cancer. This is supported by several studies, including the National Polyp Study, which found that removal of adenomatous polyps resulted in significantly lower incidence of colon cancer.

In individuals with one first-degree relative with colon cancer or tubular adenoma diagnosed before the age of 60, the risk of developing colon cancer is increased to twice that of the general population. Therefore, in cases like this, I would be in favor of a patient having a colonoscopy at age 45 rather than waiting to turn 50 (which is the age at which everyone should start getting colonoscopies). However, please know that opinions and insurance coverage may vary, so be sure to check with your primary care provider to obtain authorization from your insurance company to have a colonoscopy at age 45.

6. I think I  have hemorrhoids but I’m not sure. How can I tell, and what are the treatments?

Hemorrhoids are normally sort of vascular cushions. When these vessels enlarge, they become symptomatic. The most common symptom is painless, bright red bleeding. There are many theories for causes of symptomatic hemorrhoids. These include pregnancy, diet, straining due to constipation or weight lifting, and heredity.

Treatment of hemorrhoids is dictated by the severity of symptoms and how chronic they are. Most patients require nothing but reassurance and modification of diet. Ointments and suppositories may have a limited role in treatment, but are still widely used. If conservative treatment does not help with symptoms, other available options include rubberband ligation of hemorrhoids, or even surgery by a rectal surgeon in selected cases. In your case I would suggest using stool softeners like Colace. If you are constipated, I would also advise using Miralax powder mixed with water.

In patients who are over the age of 40 and have a family history of colon cancer, and other symptoms like changes in bowel habits, anemia, diarrhea or abdominal pain, I would recommend they undergo thorough evaluation including a colonoscopy.

7. I have diagnosed myself with irritable bowel syndrome. I have loose, runny stools several times a week, and sometimes I have abdominal pain, too. Is this really IBS?

Irritable bowel syndrome is a functional gastrointestinal disorder characterized by chronic, recurrent abdominal pain or discomfort associated with disturbed bowel habits. Most patients with IBS continue to have symptoms for many years. Most population studies have shown prevalence of IBS in up to 15 percent of adults in the U.S. The cause of this disease is poorly understood, although it is probably what we like to call "multi-factorial," because it likely involves visceral hypersensitivity and altered motility, immune activation, and stress response. Because IBS is known to cluster in families, there may be a genetic component as well.

This is one of the most difficult conditions to diagnose, even by specialists and experts. Therefore, it is not a good idea for you to diagnose this condition by yourself. There are several other diseases which may mimic irritable bowel syndrome. Most important of these conditions would be inflammatory bowel disease, celiac disease, endocrine disorders and cancer (if one has risk factors like age and family history) . Therefore, I would advise a thorough diagnostic work-up before labeling and treating yourself for irritable bowel syndrome.

8. I worry that my bowel movements aren’t frequent enough. Usually I only have to go once every two or three days. Is this normal?

While it is difficult to define constipation precisely, generally one of these symptoms is sufficient to describe constipation: infrequent bowel movements, painful passage of stool, hard consistency of stool, or difficulty in evacuating stool. Your habit of going only once every two or three days is not normal.

There are numerous causes of constipation, including endocrine disease, diabetes, medications, muscle and nerve disease, and colon cancer. In addition to increasing liquids and fiber in the diet, in cases like these I would suggest setting up a regular, dedicated time for bowel movements, preferably twice a day. Using stool softeners and Miralax  powder with water would also be helpful.

However, the most important thing for you to do is see your doctor to determine the cause or causes of your constipation so that appropriate treatment can be started.

9. I know everyone passes gas and it’s a normal body function, but I think my husband has excessive gas. It’s pretty much a constant thing every night. Is it normal that it happens at a certain time of day? Is there anything he can do to treat this in the long-term?

Excessive gas production in the gastrointestinal tract is also called flatulence. In the majority of times, this symptom is caused by involuntary swallowing of air. However, sometimes this symptom can be due to carbohydrate malabsorption, artificial sweeteners, allergies to foods like gluten, bacterial overgrowth in the intestine, or slowed gastric emptying. Any obstruction of the GI tract can also cause one to have excessive gas.

Once we have excluded any disease, this symptom can be treated with dietary modifications and some lifestyle changes, including stress reduction techniques. Also, some antibiotics have been shown to reduce intestinal gas production.

Therefore, in cases like this, I would suggest a visit to the doctor to make sure there are no treatable conditions. Once this evaluation is complete I often recommend a visit to a dietitian who can help those who suffer from excessive gas make dietary changes to help reduce gas production.

10. As I get older, I have acid reflux that wakes me almost every night. What can I do about it? It’s much worse than standard heartburn, I think. Should I be worried?

Gastroesophageal reflux disease (GERD) is a very common disease. Classic symptoms are usually heartburn, and/or regurgitation of food. If this disease is not diagnosed and treated appropriately,  it can result in some serious problems, including esophageal ulcerations, difficulty with swallowing, Barrett’s esophagus (a pre-cancerous condition) and esophageal cancer. There are some extra gastrointestinal manifestations of this disease as well. These include chest pain, chronic cough, asthma, dental cavities, hoarseness of voice and chronic sinusitis.

In cases like this, I would suggest lifestyle modifications, including achievement of ideal BMI (body mass index), smoking cession if applicable, avoidance of meals within three hours of bedtime, and slight elevation of the head of the bed. Some medications can cause or make acid reflux worse, so I encourage patients to review their medications with their doctor. I also encourage my patients to decrease use of carbonated beverages, caffeine, citrus- and tomato-based foods, and (of course) fatty and large meals.

When a patient has symptoms of heartburn that are longstanding and worsening with advancing age, I would recommend a direct visualization by endoscopic examination to assess the severity of the disease, to exclude any complications and to formulate a long-term treatment goal. An upper endoscopy is a routine and safe procedure when performed by a well-trained and qualified physician specializing in gastroenterology.

11. What is diverticulitis, and how do you know if you have it? Is it preventable? How is it treated?

A diverticulum is a circumscribed pouch or sac that either occurs naturally or is created by herniation of the first mucosal lining of the GI tract through a defect in the muscle wall layer of the intestine. Multiple diverticulum are called diverticulosis. When these diverticula get infected it's called “diverticulitis," an acute, painful disease.

Although the specific cause of diverticulitis is unknown, the development likely involves mechanical, environmental and lifestyle factors. Contributing factors include age older than 50, obesity, sedentary lifestyle, corticosteroids, use of NSAIDs, smoking, constipation and excessive alcohol consumption. Therefore, this condition is partially preventable by modifying these factors (except for age). In western societies, 95 percent of diverticula are located on left side of the colon.

Mild diverticulitis is treated on an outpatient basis with clear liquids or a low-residue diet for a few weeks, as prescribed by your doctor. After complete resolution of the acute event, the colon should be evaluated by a colonoscopy, barium enema, or CT colography to ensure absence of other diseases of the colon, including cancer.

Moderate-to-severe disease is usually treated on an inpatient basis, with nothing by mouth, intravenous fluids, antibiotics, pain control and a CAT scan to assess for any local complications, such as abscess formation and/or perforation. In these complicated cases surgical intervention generally becomes necessary. Once again, after resolution of the severe episode, one should  have a colonoscopy, barium enema, or CT colography about four weeks later.

Abbas RazaAbbas Raza, M.D., is the director of the advanced diagnostic and interventional gastrointestinal endoscopy program at INTEGRIS Nazih Zuhdi Transplant Institute. He brings extensive training and experience in the gastroenterology field. Upon completion of his internal medicine residency at the University of Tennessee College of Medicine, Dr. Raza was selected as a gastroenterology/hepatology fellow at the University of Oklahoma Health Science Center in Oklahoma City. He continued his advanced gastroenterology training as a Fellow at Thomas Jefferson Medical College and University Hospital in Philadelphia. Dedicated to specialized training in advanced interventional endoscopies, his focus included therapeutic ERCP and endoscopic ultrasonography. His contributions in the field of gastrointestinal endoscopy have earned Dr. Raza the selection of Fellow of the American Society of Gastrointestinal Endoscopy.

Certified by the American Board of Internal Medicine and Gastroenterology, Dr. Raza’s professional interests and experience include:

  • Early diagnosis, staging and treatment of pancreatic cancer
  • Prevention, screening, diagnosis and staging of gastrointestinal cancer
  • Diagnostic and therapeutic ERCPs
  • General and interventional gastrointestinal endoscopy
  • Endoscopic ultrasonography
  • Capsule endoscopy