Colon cancer in most people begins as a small benign growth in the lining of the colon called a polyp. A polyp can slowly grow in size without causing symptoms, and transform from a benign to a malignant tumor (cancer) that has the ability to invade neighboring tissue and spread to distant locations. This process usually takes about 10 to 15 years.
Symptoms and signs of cancer of the colon include rectal bleeding, change in bowel habits,change in stool caliber, abdominal pain and anemia. These signs and symptoms may not develop until the cancer is far advanced.
Colon cancer is preventable and potentially curable if found early through screening.In the case of colon cancer, the population at risk is any man or woman age 50 or older. Younger individuals may be at risk as well if they have a family history of colon polyps or colon cancer. Screening modalities include checking the stools for “invisible” traces of blood, examining the colon with a scope (flexible sigmoidoscopy or colonoscopy), imaging the colon (air-contrast barium enema, or CT colonography) and soon to be available tests that check the stools for DNA alterations associated with pre-cancerous or cancerous lesions.
Colon cancer screening with colonoscopy allows your physician to detect and remove pre-cancerous, benign polyps thus preventing the development of cancer. It also allows the detection of cancer at an early potentially curable stage
Treatment for colon cancer is based upon the stage and location. It usually includes surgery to remove the part of the colon that contains the cancer. In advanced stageschemotherapy may be recommended.
In the case of rectal cancer, surgery may require the construction of a colostomy. Radiation may be employed in addition to chemotherapy and surgery to treat rectal cancer.
GERD tends to occur when there is a failureof the barrier mechanism between the esophagus and the stomach as a result of a malfunction of the muscular sphincter, or flap, at the bottom of the esophagus, failure of the esophagus to promptly clear or neutralize the refluxed noxious material coming up from the stomach, or failure of the normal protective mechanisms built into the esophageal lining. Oftentimes, it is a combination of factors that cause GERD in anyone individual.
A hiatus hernia is commonly found in patients with GERD. It is a protrusion of the upper portion of the stomach through the diaphragm muscle into the chest cavity. This can contribute to disrupting the gastro-esophageal barrier mechanism and when large and fixed can function as a reservoir above the diaphragm from which gastric fluid can more easily travel up into the esophagus then drain downwards.
The amount of acid reflux required to cause symptoms varies from person to person. Esophageal damage is more likely to occur with more frequent or more prolonged acid reflux episodes.
Diagnosis of GERD is usually made based upon the presence of typical symptoms (heartburn, acid regurgitation) and response of symptoms to acid reducing agents. Upper endoscopy or EGD, where a camera is used to look into the esophagus, is another way of evaluating the problem. It allows the detection of ulceration and complications including strictures, Barrett’s esophagus and esophageal cancer. Sometimes, when the symptoms are not typical and the diagnosis is not clear, direct measurement of acid exposure of the esophagus is required.
Mild symptoms are usually treated with lifestyle modifications such as weight loss, smoking cessation, avoiding fatty foods and caffeinated products and avoidance of late meals consumed close to bedtime. Mild cases may be treated with Histamine blockers such as Zantac or Pepcid. In more severe cases treatment is with medications called Proton Pump inhibitors (PPIs) such as Prilosec, Protonix,Aciphex, Prevacid, Nexium, Dexilant etc.In most patients symptoms can be controlled with these medications. PPI medications also promote healing of the esophageal lining, and prevent complications. Surgery is rarely needed to treat GERD.
Complications such as scarring and blockage of the esophagus are usually treated with dilation (stretching) of the esophagus. Patients diagnosed with Barrett’s esophagus should be observed with periodic EGD and biopsies of the abnormal lining to look for a change in the cells called dysplasia that puts them on a closer path to becoming cancerous. When dysplasia is found,more frequent monitoring or other treatment modalities may be recommended.
Dysphagiaor difficulty swallowing is a symptom that requires evaluation particularly when solid food hangs-up or gets stuck in the throat or behind the breastbone. This usually indicates that there is a blockage in the esophagus, usually by scar tissue and rarely by cancer. Evaluation is best done by an EGD. On occasions a barium swallow (x ray) may be done.
The symptoms of this disease include diarrhea, bloody bowel movements, abdominal pain, nausea and vomiting, weight loss, malnutritionand growth retardation in young people. Extraintestinal symptoms can occur sometimes and involve the joints, skin, eyes, and liver.
The inflammation with Crohn’s disease can lead to complications such as blockage of the intestine from scarring, abscesses (pockets of infection/inflammation) and fistulas, which are abnormal tracts that connect different organs (intestine to bladder, intestine to vagina, intestine to skin). Abscesses and fistulas develop as a result of perforation of the inflamed bowel wall.
Although there is no cure for Crohn’s disease, treatment focuses on putting the disease in remission with steroids (like Prednisone) and biological agents belonging to a class of monoclonal antibodies called anti-TNF agents (like Remicade, Humira, or Cimzia), maintaining the remission with immunomodulators (like Imuran, Purinethol or Methotrexate) and/or biological agents, and treating complications with surgery (obstruction), interventional radiological drainage of abscesses, biological agents or surgery (fistulas).
New classes of biological agents are expected to be available soon that will increase our ability to effectively treat this disease especially in severe cases and cases that are refractory to currently available treatment.
The treatment options will be tailored to your particular problems. Please see www.ccfa.org for more information on treatment options.
The symptoms of this disease usually include bloody diarrhea abdominal cramping. This disease is usually diagnosed during a colonoscopy or sigmoidoscopy. Extraintestinal symptoms may occur and involve the joints, skin, eyes or liver.
A rare life-threatening complication can occur rarely in patients with severe disease called toxic megacolon where the colon dilates significantly and can rupture.Another concern in patients with longstanding disease is the increased risk of colon cancer, which is why these patients are monitored with periodic colonoscopies (surveillance colonoscopies) and biopsies.
Treatment focuses on putting the disease in remission with a class of non-steroidal anti-inflammatory agents called the aminosalicylates (i.e.Asacol, Lialda, Apriso) with steroids (i.e. Prednisone) or with biological agents belonging to a class of monoclonal antibodies called anti-TNF agents (i.e. Remicade, Humira, or Simponi) and maintaining remission with aminosalicylates, immunomodulators (i.e. Imuran or Purinethol) and/or biological agents.Rarely surgery is performed to remove the colon usually because of severe uncontrolled disease, toxic megacolon or the finding of dysplasia (microscopic changes in the cells that put them on a path to becoming cancerous) or cancer on the surveillance colonoscopy.
New classes of biological agents are expected to be available soon that will increase our ability to effectively treat this disease especially in severe cases or cases refractory to currently available treatment. Treatment will be individualized for each patient. Please see www.ccfa.org for more information on treatment options.
Approximately 300 million people are infected with this infection worldwide.
In the United States, Hepatitis B is usually acquired through blood-to-blood contact with an infected personduring intravenous drug use, tattoos, blood transfusion, hemodialysis, needle-stick or through sexual contact with an infected person. Mother to infant or vertical transmission at the time of birth is the most common mode of transmission in other countries.
The virus lives mainly in the blood and the liver and can cause two different phases of infections.
The acute phase of the infection especially if acquired in adulthood causes symptoms including flu-like symptoms, jaundice, abdominal pain and can last days to weeks.Most acute infections resolve without treatment. In these patients the virus is cleared, the liver heals, and the patients become immune against re-infection. About 10 percent of adults cannot clear the virus and theyproceed to a chronic infection.
The chronic phase is usually silent with no significant symptoms except for some fatigue, but can, over a period time, lead to complications such as cirrhosis, liver failure and liver cancer.In chronic Hepatitis B, the virus may be multiplying at low levels (low replication). In these patients there is little circulating virus in the blood and little inflammation in the liver. In these patients treatment is usually not recommended. In other patients the virus may be multiplying at high levels, and the patient’s immune system may be responding to this by causing significant inflammation and damage to the liver. In these patients treatment is recommended in hope of putting them in a low replication state or better yet clearing the infection.
Most patients who acquire the infection in infancy or childhood have few or no symptoms and most of them go on to develop chronic infection. These patients tend to have high levels of virus multiplication (replication), but do not suffer much inflammation or damage to their liver because their immune system tolerates and does not react to the infection. Treatment is not indicated in these patients, but monitoring is recommended as this situation may change and the immune system tends to awaken at some point.
The infection can be detected through various blood tests.
Treatment, when indicated for chronic hepatitis,involves taking a weekly shot of pegylated interferon for 48 weeks or an antiviral pill medication (i.e.Viread or Baraclude) for several years.
Because patients with chronic Hepatitis B are at increased risk for liver cancer, they should have periodic screening with a blood test (AFP) and an ultrasound of the liver.
Hepatitis B can be prevented through vaccination. Vaccination is recommended for everyone but especially for high risk groups (health care workers, intravenous drug users, hemodialysis patients, promiscuous individuals and travelers to endemic areas)
The infection is transmitted via blood during IV drug use, tattoos and blood transfusions before 1990 or accidental needle-stick injury. Transmission during sexual intercourse or during childbirth is less likely.
Most patients infected with Hepatitis C go on to develop a chronic infection. The infection tends to be silent and cause no significant symptoms except for fatigue. After several years chronic infection can lead to cirrhosis, liver failure and liver cancer. This progression is accelerated in men compared to women and in alcoholics.
The infection is detected using various blood tests. It is currently recommended by the CDC that patients born between the years 1945 and 1965 get screened for Hepatitis C.
There are several genetic variations of the Hepatitis C virus called Genotypes. The genotype helps determine the appropriate type and duration of treatment and likelihood of responding to the treatment. Genotype 1 is the most common in the U.S.
For about 20 years treatment relied on a combination of Interferon or Pegylated Interferon (injection) and Ribavirin, which had some anti-viral effect, but mostly empowered the patient’s own immune system to fight the infection. These were given for 24 or 48 weeks and were frequently difficult to tolerate due to side effects. Under the best conditions, a cure (termed sustained viral response or SVR) could be achieved in about 50 percent of people with Genotype 1 and 80 percent in those of Genotypes 2 and 3. Patients with high viral concentration in the blood (viral load), cirrhosis and certain ethnic groups did less well. In recent years newer classes of drugs were developed that can be termed direct-acting antivirals and disruptthe ability of the virus to multiply and develop. These allow eradication of Hepatitis C in most patients regardless of the viral load, genotype, presence of cirrhosis and ethnic groups.Current cure rates (SVR) are reaching 80 to 90 percent of those treated. With these new medications treatment duration is shorter. Direct-acting antivirals are taken by mouth. They have fewer side effects and are expected to replace Pegylated interferon and possibly Ribavirin.
There is no vaccine at present to prevent Hepatitis C infection.
Although once thought to be a rare disorder it is now believed to affect approximately 1 in 140 people in this country.
Patients with this disorder can be asymptomatic or can suffer from diarrhea, weight loss, abdominal pain, bloating, iron deficiency anemia, osteoporosis (bone loss), skin rash termed dermatitis herpetiformis and abnormal liver enzymes. Other extra-intestinal symptoms have been attributed to celiac disease.
A small percentage (less than 10 percent) of patients diagnosed with the irritable bowel syndrome may have celiac disease.
Celiac disease can usually be detected by a simple blood test. Endoscopy with small intestinal biopsy helps confirm the diagnosis. Genetic testing is also available and can help rule out the disease when the diagnosis is in question.
The treatment is a gluten-free diet and treatment of any nutritional deficiencies. On this diet symptoms usually improve within weeks. Dietary non-compliance is the most common reason for persistent symptoms.
A small percentage of patients are truly refractory to a gluten-free diet. These are sometimes treated with steroids, immunomodulators or even anti-TNF agents.
Rare complications of celiac disease include severe ulcerative inflammation of the small bowel and small bowel cancer.
Please see Celiac Disease Foundation for more information at www.celiac.org .
There are two main types of esophageal cancer.Adenocarcinoma accounts for about70 percent of cases. It develops in the lower portion of the esophagus and is related to GERD and Barrett’s esophagus (see above section on GERD). It tends to occur in white males over age 50.Squamous cell carcinoma affects the upper portion of the esophagus. The major risk factors for squamous cell carcinoma are smoking and excessive alcohol consumption. It is more common in African-Americans.
Dysphagia, or difficulty swallowing solid food, and weight loss are common symptoms of esophageal cancer. Patients may also note chest pain, vomiting or bleeding.
The diagnosis is usually made during an upper endoscopy. Once a diagnosis is made patients usually undergo a work-up to determine the extent of local invasion and distant spread of the cancer (stage of the cancer). This usually includes a CT scan, endoscopic ultrasound of the tumor and sometimes a PET scan.
Treatment is usually based upon the stage of the cancer and may include chemotherapy, radiationand possibly surgery. At times, particularly in advanced cases where the disease is not curable, a stent may be inserted to allow swallowing. In addition, a feeding tube may be inserted in the stomach (PEG) to maintain nutrition, and hydration and provide an access for medication administration.
Acute pancreatitis is an inflammatory disease of the pancreas.It is usually caused by alcohol abuse or gallstones that form in the gallbladder. Gallstones travel down the bile duct and occlude the pancreatic duct as they are trying to exit from the bile duct causing pancreatitis in the process. There are other less common causes of pancreatitis including abdominal trauma, certain medications and severe elevation in triglyceride concentration in the blood.
Symptoms of acute pancreatitis are severe abdominal pain just below the breastbone that radiates to the mid back. There is usually associated nausea and vomiting. The pain is usually severe enough to require admission to the hospital.
Complications of acute pancreatitis include large fluid collections, infections, gastrointestinal bleeding and damage to other vital organs (lungs and kidneys).
The treatment is mainly fasting and large amounts of fluid through an IV. For most people hospitalization is usually only a few days.
For some people, the disease can be severe and lead to death of pancreatic tissue (necrosis) and as mentioned, damage and failure of other vital organs (lungs and kidneys). In these patients treatment often involves, in addition to fasting and IV fluids, nutritional support, antibiotics and sometimes respiratory support and dialysis. A procedure called ERCP to remove a stone lodged in the bile duct may be recommended. Severe (necrotizing) pancreatitis is a life-threatening disease.
Chronic pancreatitis occurs when the pancreas is subjected to chronic injury with inflammation or recurrent acute injury with inflammation over an extended period of time. This eventually leads to scarring and loss of functioning pancreas cells.
The cause is usually chronic alcohol abuse. Smoking is another risk factor for chronic pancreatitis. Genetic conditions including cystic fibrosis are additional causes of this disease.
Chronic pain in the upper abdomen is a common symptom of this disease. With loss of more than 90 percent of pancreatic tissue, the gland fails in carrying out its functions of digestion and blood sugar regulation. This leads to diarrhea, weight loss and brittle diabetes.
Chronic pancreatitis also puts patients at risk for pancreatic cancer.
Treatment usually focuses on controlling pain, providing pancreatic enzyme supplements and treating diabetes with insulin. Complications such as bowel and bile duct obstruction require surgery.
Cigarette smoking is a known risk factor for pancreatic cancer. The risk is equivalent in men and women.
Symptoms related to pancreatic cancer are usually dependent on the location within the pancreas. Pain in the upper abdomen is a common symptom and usually indicates locally advanced disease. A patient can also have a loss of appetite and weight. If the cancer develops in the area of the pancreas known as the head, it can block the bile duct from draining bile from the liver and causing jaundice and itching.
The cancer is usually found on a CT scan or ultrasound. Endoscopyand/or endoscopic ultrasound are often performed to obtain a biopsy from the mass and confirm the diagnosis. The CT scan and the endoscopic ultrasound also provide a sense of the stage of the disease (size of the tumor, extent of local invasionand spread of the cancer).
If found in an early stage treatment includes surgery to remove the cancer. If the mass is in the head of the pancreas an operation called a Whipple’s procedure where the head of the pancreas, duodenum, gall bladder,bile ducts and sometimes the lower part of the stomach are removed in one block. If the mass is in the body or tail of the pancreas the surgery is a distal pancreatectomy, which is removal of that portion of the pancreas and usually the spleen.
In many cases (80 percent) the cancer is found to be advanced at the time of diagnosis and therefore not curable. In this situation treatment is usually with chemotherapy and radiation therapy to slow down the growth of the tumor. Complications such as bile duct obstruction and duodenal obstruction are treated with stent placement or surgery to bypass the obstruction.
Symptoms include intermittent pain usually in the lower abdomen. The pain is often alleviated by defecation. Patients may have predominant diarrhea, or constipation, or they may alternate between diarrhea and constipation. Other symptoms include bloating, fecal urgency, excessive mucus production with the stools. Symptoms may be aggravated by stress, anxiety/depression or fatty food.
The diagnosis of IBS is based upon a compatible history of chronic symptoms as mentioned above, in the absence of “alarm signs and symptoms” including newonset of symptoms in a patient older than 50 years of age, pain that awakens at night, blood in the stools, weight loss, fever or chills and anemia.
Treatment focuses on controlling symptoms. It can range from dietary and lifestyle changes, to over the counter remedies such as probiotics, fiber supplements, antidiarrheals and laxatives. Treatment can also include prescription medications such as antispasmodic, anticholinergicmedications, low-dose antidepressant medications, a 5-HT3 antagonist (Alosetron/Lotronex), selective chloride channel activator (Lubiprostone/Amitiza) or a guanylatecyclase C agonist (Linaclotide/Linzess), non-absorbable antibiotic (Rifaximin/Xifaxan).
Treatment is tailored to each patient based on their set of symptoms.
Each year 2.5 million Americans visit a healthcare provider about constipation.
Constipation is more common in women, older sedentary individuals or individuals whose diet is low in fiber.
Constipation of recent onset especially in a person older than 50 years of age should be investigated to rule out an obstructing lesion in the colon. Long-standing constipation in an otherwise healthy individual younger than 50 years of age, is probably functional and without underlying serious disease. Certain medical conditions can cause constipation including diabetes and hypothyroidism. Certain medications can cause constipation including narcotic pain-killers, certain blood pressure medications or iron supplements.
Colonoscopy should be performed to rule out structural disease (such as an obstructing tumor) in individuals with constipation who are older than 50 years of age (if not done as part of routine screening) and in individuals with alarm signs and symptoms such as new-onset of constipation, rectal bleeding, weight loss and anemia.
Studies to evaluate the motility of the colon (transit study/Sitzmarker study), or the anorectal function and pelvic floor function (anorectalmanometry and defecography) are reserved for severe cases that are refractory to treatment.
Treatment usually starts with eating high fiber foods, exercisingand increasing fluid intake.If this doesn’t relieve the problem then over the counter stool softeners (docusate sodium) and laxatives are used. Laxatives include osmotic laxatives such as Lactulose or Miralax, saline laxatives such as milk of magnesia or magnesium citrate. Other options include Lubiprostone/Amitiza a selective intestinal chloride channel activator or Linaclotide/Linzess, a guanylatecyclase C agonist. If not improved, a stimulant laxative such senna or bisacodyl will be of benefit but can have side effects.
Acute diarrhea lasts less than 14 days and usually only lasts a few days. Most cases are due to infection caused by eating or drinking contaminated food or water. Diarrhea usually begins in 12 hours to four days of exposure. Diarrhea can be mild to severe and patients can become dehydrated. Abdominal pain, cramping, fever and vomiting can also accompany the diarrhea.
Investigation of the diarrhea with stool tests is not needed unless the diarrhea is bloody or purulent, the symptoms are severe and protracted, the patient has fever or chills and the abdominal exam is concerning.
Treatment is usually based upon the idea of preventing dehydration until the infection resolves. In most cases this can be accomplished with oral fluids. A combination of water with salt and sugar is considered the best for rehydration. In some cases IV fluids is required. Antidiarrheal medications such as Imodium or Pepto-bismol are considered safe if there is no fever and stools are non-bloody. Antibiotics are not recommended in most cases of acute diarrhea.
Chronic diarrhea is defined as diarrhea that has lasted at least four weeks. A wide range of problems cause chronic diarrhea. These include Irritable Bowel Syndrome, Inflammatory Bowel Disease, Celiac disease and medication side effects. Treatment is usually based upon finding the underlying cause. This will usually include evaluation of diet and medications and possibly stool studies and colonoscopy. Treatment is directed to the underlying cause. If none is found, and the patient has no alarm signs or symptoms, antidiarrheals can be employed.
Predisposing factors for NAFLD include obesity, the “Metabolic Syndrome” including hypertension, diabetes or insulin resistance and high cholesterol. Most patients with NAFLD have no symptoms and have normal, or slightly elevated liver function tests (ALT, AST).
Most patients with NAFLD will not progress into more serious liver disease. However, in a small proportion of patients,fat in the liver cells is associated with inflammation a condition called Steatohepatitis or NASH. NASH can progress to cirrhosis, liver failure and liver cancer.
Many drugs have been studied in NASH patients, including vitamin E, Metformin, Thiazolidiediones and others, with variable inconclusive results. There are no currently FDA-approved medications to treat NASH. Treatment is mainly weight loss through low fat diet, caloric restriction and aerobic exercise. In patients who qualify for bariatric surgery, this may be considered. In patients with the metabolic syndrome hypertension, diabetes and hypercholesterolemia should be adequately controlled. Hypertriglyceridema should be treated. Medications that could be contributing to NASH should be discontinued or switched.
Most ulcers are caused by either a bacterial infection known as Helicobacter pylori or from over the counter pain medications called Nonsteroidal Anti-inflammatory medications (NSAIDs). The H. pylori bacteria is very common and most people with the infection have no symptoms and may never develop an ulcer.
People with peptic ulcers will typically have pain in the upper abdomen. The pain may improve after eating. Patients can also have nausea, heartburn and belching. Some patients will have no symptoms.
Complications from ulcers include bleeding (vomiting coffee ground material or blood or passing black tarry stools), perforation (forming a hole through the stomach or intestine), obstruction or blockage.
Diagnosis is usually made on upper endoscopy (See upper endoscopy). It can sometimes be diagnosed on barium upper GI series.
The goals of treatment are to heal the ulcer and prevent its recurrence. Ulcers can be healed with acid reducers including histamine blockers like Zantac or Pepcid. Most physicians today use more potent drugs called proton pump inhibitors (PPIs) like Prilosec, Nexium, Protonix, Prevacid, Aciphex and Dexilant. Preventing ulcer recurrence is done by eradicating H. pylori infection if present, or discontinuing NSAIDs if in use.
In terms of the complications, ulcer bleeding is usually controlled with endoscopic treatment (cautery or application of clips and sometimes in combination with epinephrine injection). Perforation and obstruction caused by ulcers are usually treated with surgery.