Triumph Over Diverticulitis: Nancy’s Story

There’s not much that slows Nancy Fauls down. She was one of the first female skippers to race schooners in the Pacific Northwest and knows how to stay calm and keep everything moving forward. Then in January 2019, the Port Townsend resident experienced a lower abdominal pain that was overpowering. “I’d never felt anything like it before,” she remembers. “I could hardly breathe or move. I was doubled over.”

Nancy went to the local emergency room and then to her general practitioner who prescribed antibiotics to curb bacteria growth. The medication didn’t have much impact on her symptoms and she spent several days lying flat on her back. A month later she experienced the intense pain again and her doctor referred her to Virginia Mason. Because of the distance from Port Townsend to the hospital and the severity of her pain, she was transported by ambulance and ferry boat to Virginia Mason Seattle. Diagnostic blood tests and a CT scan indicated her pain was caused by diverticulitis.

Diverticulitis occurs when a diverticulum (a bulging sac that can form on the colon wall and push outward) becomes inflamed or infected. The condition is most common in people whose diets are lower in fiber and higher in processed carbohydrates.

“Diverticulitis used to commonly be seen in patients who are 50 to 70 years old, but now we’re seeing it in younger patients,” says Virginia Mason colorectal surgeon Vlad Simianu, MD, MPH. The culprits, he adds, are often obesity, smoking and a diet of highly processed and packaged foods.

Free of diverticulitis and enjoying life again.High fiber diets can prevent the colon diverticula from forming, he says, because the fiber results in smoother elimination without the damage that can occur with the pressure on the colon that is caused by constipation. And as Nancy experienced, damaged sections of the colon wall can become thinner and burst.

“Once the disease occurs, diet changes may help the symptoms but they are no longer the cure,” says Dr. Simianu. “The truth is once you have diverticula we don’t really know what drives them to become inflamed and infected, and therefore can’t be sure whether a specific medicine or lifestyle change will prevent a flare.”

Often the diseased portion of the colon must be surgically removed.

“These days the surgery is much easier on patients,” says Dr. Simianu. “It is minimally invasive, usually requiring three to five small cuts in the abdomen, as opposed to traditional surgery which involves one large incision. Patients heal faster and their stay in the hospital is reduced.”

In Nancy’s case, the nine inches of her colon with the disease were removed using robotic technology. She was back home three days following her surgery. She’s made some lifestyle adjustments, lost 50 pounds and is enjoying an active life in the beautiful town she calls home.


A version of this story originally appeared in the Virginia Mason Health System Annual Report

Colonoscopy: The ‘Minor Inconvenience’ That Saves Lives

**By Vlad V. Simianu, MD, MPH**

Helen Nind

Helen Nind

Learning she had colorectal cancer last year surprised Helen Nind. The 55-year-old mother of two had no family history of the disease, no symptoms and generally felt healthy. But the suspicious polyp that was found and removed during her first colonoscopy proved malignant.

According to the American Cancer Society (ACS), colorectal cancer is the third most common cancer diagnosed in both men and women in the U.S. In 2019, the ACS estimates there will be more than 101,000 new cases of colon cancer and more than 44,000 new cases of rectal cancer.

Risk factors
Research has shown that links between colorectal cancer risk and a person’s diet, weight and activity level are some of the strongest for any type of cancer. Lifestyle-related risk factors include:

  • Being overweight or obese. Carrying excess weight raises the risk of colorectal cancer in both men and women, but the link seems to be stronger in men.

  • Physical inactivity. A sedentary lifestyle is associated with a greater chance of developing colorectal cancer. Being more active can help lower your risk.
  • Dietary choices. A diet high in red and processed meats may increase your colorectal cancer risk.
  • Smoking. People who have smoked tobacco for a long time are more likely than non-smokers to develop colorectal cancer and die from it.
  • Drinking alcohol. Colorectal cancer has been linked with moderate to heavy alcohol use.

“The minor inconvenience . . . is nothing compared to what the alternative might be. If they can catch a problem early, the treatment is going to be much easier.” — Helen Nind

There are also risk factors for colorectal cancer that aren’t related to lifestyle, including:

  • Age. Risk goes up with age, which is why screening colonoscopies have been recommended starting at age 50. However, due to an increase in the disease among younger adults, some national medical organizations are considering lowering the recommended age for screening.
  • Family history. Nearly one in three people who develop colorectal cancer have other family members who have had it. People with a history of colorectal cancer in a parent, sibling or child are at increased risk. The risk is even higher if that relative was diagnosed with cancer when they were younger than 45, or if more than one first-degree relative is affected.
  • Inflammatory bowel disease (IBD). Colorectal cancer risk increases if you have IBD, ulcerative colitis or Crohn’s disease.
  • Inherited syndromes. About 5% of people who develop colorectal cancer have inherited gene changes (mutations) that contribute to the disease. The most common inherited syndromes linked with colorectal cancers are Lynch syndrome (hereditary nonpolyposis colorectal cancer, or HNPCC) and familial adenomatous polyposis (FAP).
  • Racial and ethnic background. African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the U.S. Jews of Eastern European descent (Ashkenazi Jews) have one of the highest colorectal cancer risks of any ethnic group in the world.
  • Type 2 diabetes. People with type 2 diabetes are at increased risk for colorectal cancer. They also tend to have a less favorable prognosis after diagnosis.

Treatment
Helen Nind underwent robotic-assisted surgery to remove the cancerous polyp and surrounding tissue. As part of the surgery, a number of her lymph nodes were removed and examined. Unfortunately several were cancerous, requiring a regimen of chemotherapy.

When I asked Helen what she would tell someone facing colon cancer, she recommended having a family member or friend attend appointments as another set of ears. This person can also help take notes and remember information shared at the visit and ask questions the patient may not think about.

“Someone I know who had been through cancer treatment advised me to keep a diary to note any changes or health concerns,” says Helen. “I found this very helpful for recalling things when meeting with my care team.”

Screening guidelines
The current ACS recommendation is that people at average risk of colorectal cancer start regular screening at age 45. This can be done either with a sensitive test that looks for signs of cancer in a person’s stool (a stool-based test), or with an exam that looks at the colon and rectum, such as colonoscopy. As part of the screening process, all positive results from stool-based screening tests should be followed up with a colonoscopy.

Although Helen put off her colonoscopy after turning 50, she now regularly encourages people to follow screening guidelines. “The minor inconvenience of the prep was not as bad as I had thought,” she says. “It is nothing compared to what the alternative might be. If they can catch a problem early, the treatment is going to be much easier.”


Simianu_2018Vlad V. Simianu, MD, MPH, is a general surgeon who practices at Virginia Mason Hospital and Seattle Medical Center. He specializes in colon, rectal and anal cancer with an emphasis on minimally invasive techniques. Other areas of expertise include Crohn’s disease, ulcerative colitis, diverticulitis, polyposis syndromes, rectal prolapse and pelvic floor disorders. Dr. Simianu is actively conducting research on colorectal cancer and diverticulitis.

POEM Procedure is Life Changing for People with Achalasia

Sometimes you experience a health dilemma early in your life, and when you can’t find a solution, you learn to adapt. That was the case for Virgil Leedy, who lives in Weiser, a northern Idaho town with 5,500-plus residents.

Just over 30 years ago, Virgil began to have trouble swallowing. “It felt like I was pushing the food through a wall,” he remembers. He went to a local doctor and his condition was diagnosed as acid reflux. Not surprisingly, nothing prescribed eliminated the problem. Over time, Virgil adapted to the condition by chewing as thoroughly as he could. Sometimes trying to finish the meal became so painful he would have to stop.

VirgilLeedyDDI

Virgil Leedy and his wife, Marla

Finally, five years ago, a gastroenterologist in Boise determined Virgil had achalasia, an esophageal motility disorder in which a muscle at the lower end of the esophagus does not function properly and obstructs the passage of food and liquid into the stomach. Over time, the improperly functioning muscle, also known as the lower esophageal sphincter, leads to damage of the smooth muscle that makes up the wall of the esophagus. Ultimately, this damage results in a lack of peristalsis — the rippling movement that would normally move food down the gastrointestinal tract.

Individuals with this disorder find it uncomfortable to eat large meals or to eat at a normal pace. They feel like the food is getting stuck and sometimes feel the need to regurgitate. Some people work around the symptoms by sleeping sitting up or eating soft, smooth foods like ice cream. In extreme cases, the esophagus stretches and food becomes trapped inside.

The doctor who diagnosed Virgil as having achalasia told him about a new procedure — Peroral Endoscopic Myotomy (POEM) — that could provide a long-term solution. However, the procedure wasn’t available in Idaho, so Virgil was referred to Andrew Ross, MD, at Virginia Mason.

“The esophagus is a very dynamic organ,” explains Dr. Ross, the section head for gastroenterology and medical director of the Therapeutic Endoscopy Center of Excellence at Virgina Mason’s Digestive Disease Institute. “The coordinated movement of the smooth muscle of the esophagus squeezes food and liquid from the back of your throat down toward your stomach. The lower esophageal sphincter relaxes and food drops down to your stomach. It’s all automatic. The only part we control is the swallowing.

“The disruption caused by the non-relaxing lower esophageal sphincter causes the muscle contractions to become uncoordinated. In some cases, this interruption causes the contractions to stop completely and permanently.”

There are several treatment options for achalasia, including endoscopic balloon dilation, injections of Botox, surgery or the minimally invasive POEM procedure. “Because Mr. Leedy was relatively healthy, we wanted a definitive therapy that would give him the best shot at a longer symptom-free period,” explains Dr. Ross.

POEM — A Minimally Invasive Procedure

The procedure is performed by inserting an endoscope (camera) into the mouth and down the esophagus. The camera is used to create a tunnel beneath the inner lining of the esophagus and makes a pathway that can then be used to access the smooth muscle wall.

A special knife is then advanced through the end of the camera and is used to incise the the lower esophageal sphincter, thereby causing it to relax.

After this is completed, clips are placed on the lining of the esophagus to close the tunnel. The camera is then removed. The procedure typically relieves the tightness and allows the esophagus to empty more easily and the patient to resume a more normal diet.

Patients usually stay in the hospital overnight and go home the next day. “For the first time in 30 years I could drink water and have it go right down,” says Virgil. The only requirement he has now is an annual visit to Virginia Mason, with his wife, Marla. They can check in with Dr. Ross and some of the other specialists they have been seeing over the years for treatments that are not available in Weiser.

“It’s also a great excuse to check out Seattle restaurants,” Virgil says.


A version of this story also appears in the Virginia Mason Health System 2018 Annual Report. 

What Your Gut Should Tell You: Esophageal Health Requires an Experienced Team

Reflux and other esophageal issues require prompt diagnosis and treatment to prevent more serious health concerns, including chronic indigestion or rarely, cancer. The Esophageal Center of Excellence at Virginia Mason brings a multidisciplinary approach to treatment that includes experts in interventional radiology, oncology, nursing and pathology.

“Multidisciplinary care allows us to provide the treatment that is most appropriate and most effective,” says gastroenterologist Andrew Ross, MD.

stomachePublished outcomes show that innovative care at the Esophageal Center results in shorter hospital stays, better cancer survival rates and a better quality of life after surgery. “Our excellent outcomes are attributable to our commitment to clinical research and publication,” says Donald Low, MD, director, Esophageal Center of Excellence. “We are always on the forefront of research that allows us to use the newest and best treatments.”

Virginia Mason has the highest volume of esophageal resections in the Pacific Northwest, with 75 percent of patients traveling 150 miles or more to receive care. Esophageal specialists also developed the only anti-reflux procedure originating in North America.

GERD and Acid Reflux

The Esophageal Center is known for its innovative and successful treatment of the related conditions of acid reflux and gastrointestinal reflux disease (GERD), a chronic condition frequently caused by inappropriate relaxation of the lower esophageal sphincter.

GERD requires prompt treatment to avoid additional health problems that include esophageal ulcers, chronic cough, irritation of the esophagus and other serious conditions. Smoking, obesity, pregnancy and certain medications may predispose a person to experience GERD.

Symptoms of GERD include the sensation of a lump behind the breastbone, nausea after eating and heartburn. GERD is treatable in the overwhelming majority of patients with dietary and lifestyle changes, medications and/or surgical intervention.

Medications generally work by making the stomach juices less acidic. They do not fix the underlying reason for GERD, which leads to a recurrence in symptoms once medications are stopped.

There have been some controversial studies regarding the safety of long-term use of some medications to treat GERD. It is best for patients to rely on the lowest possible dose that results in control of symptoms. Concerns regarding calcium metabolism and osteoporosis mean that patients using these medications for longer periods may need to have their bone density monitored, and should check with their physician to see if tests are indicated.

Long-term GERD can, in rare cases, lead to the development of esophageal cancer. Patients with long-term (greater than 5-10 years) of symptoms, especially middle-aged white men, should ask their doctor about undergoing an endoscopy to evaluate for pre-cancerous changes of the esophagus. Patients who develop difficulty swallowing, weight loss, blood in the stool or anemia should see their doctor immediately.

Barrett’s Esophagus

Barrett’s Esophagus is a condition of GERD that occurs when the tissue in the esophagus begins to take on the characteristics of the tissue in the intestines. Although this is considered a pre-cancerous condition of the esophagus, most patients with Barrett’s esophagus will never develop esophageal cancer in their lifetime. In patients with Barrett’s esophagus, routine exams of the esophagus and upper digestive systems may help ensure that any cancerous or pre-cancerous cells are found and treated early.

Esophageal Cancer

Esophageal cancer patients who have undergone surgery at Virginia Mason have some of the best reported outcomes in the world. An analysis of one 20-year period (1991-2011) showed a postoperative mortality rate of less than 0.5 percent compared to the national rate of 8.9 percent.

In addition, recent data from the National Cancer Data Base demonstrate that patients at Virginia Mason have better esophageal cancer survival rates at every stage of the disease. Physicians from around the world have visited Virginia Mason to study the clinical pathways that have led to the best possible management of esophageal cancer.

This management includes regular multidisciplinary cancer conferences and support groups that benefit patients, physicians and staff, who gain better insight into and understanding of specific esophageal disorders. At Virginia Mason, care supported by an esophageal cancer nurse navigator and continuous communication help ensure the best results, and ultimately the best quality of life for patients.


The Esophageal Center of Excellence provides comprehensive care for a range of esophageal and gastrointestinal issues. If you have questions or are experiencing symptoms, please call us at
(206) 223-2319.

Good Medicine and Perseverance: A Winning Strategy for Inflammatory Bowel Disease

srfc_danielle_foxhoven_5_4-3-15Playing competitive soccer for most of her 26 years, Dani Foxhoven knows something about pain. Bumps and bruises are routine; rolled ankles are hardly unique. In high school, Dani made a slide tackle to block a shot, the ball fracturing her femur just above the knee (she made a full recovery). Then there’s the pain that has nothing to do with the game, but everything to do with a chronic condition known as inflammatory bowel disease (IBD). Diagnosed only a few years ago, Dani recalls having what may have been symptoms in childhood.

“In elementary school I always complained about stomach aches,” says Dani. “And I actually had ulcers, but my parents were very health conscious, and raised my brother and me to eat healthy and take care of our bodies. I think that’s why I did as well as I did as long as I did.”

After racking up local and national awards playing high school soccer, Dani won a scholarship to the University of Portland. While becoming one of the university’s all-time highest scoring players, Dani battled recurrent, debilitating gut pain. She talked to her trainers and school nutritionists, eliminated many foods and learned how to time her eating.

“My weight fluctuated like crazy, but besides pain there wasn’t any way to tell what was going on,” says Dani.

After college Dani was drafted into a professional soccer league that soon folded, which led to her decision to play women’s soccer in Russia. The rigid schedule, controlled diet and stress from being out of touch with family took a major toll on Dani’s health. She came home 20 pounds lighter and with a disturbing new symptom: blood in her stool.

As Dani began her professional U.S. soccer career with the Portland Thorns, she saw a gastroenterologist who suspected ulcerative colitis, a primary form of IBD. At first Dani’s inflammation pattern indicated proctitis, a type of colitis that affects only the rectum. Trying different treatments that should have worked, Dani’s flare-ups still felt out of control. After pushing through a championship season despite strength-sapping pain, Dani was traded to the Seattle Reign in 2013. Desperate to find another doctor, she landed in the Digestive Disease Institute at Virginia Mason (DDI).

At first, Dani’s care was all about tests to look for damage in her digestive tract, and she had it: her disease had spread to her colon. Bleeding had caused Dani’s red blood cells to dip well below normal levels. Gastroenterologist Elisa Boden, MD, knew Dani needed a new strategy.

“The way Dani’s disease spread is fairly rare, but it was important to identify because it changed the treatment plan,” says Dr. Boden. “We combined oral and topical anti-inflammatory compounds, which Dani responded to. Just as she does in her career, she has persevered and worked hard to manage her symptoms so that they don’t get in her way.”

When Dani was sidelined by attacks, Dr. Boden and the DDI team worked to recalibrate her medicines and shorten her downtime. Nutrition therapy boosted Dani’s depleted red blood cell count and iron stores to give her more energy. While Dani admits her IBD has been no easy ride, she credits the collaboration and support from Dr. Boden and the DDI team for not only helping her get better, but for giving her hope that she always could.

“Dr. Boden hit on all aspects of my illness, asking about everything, not just what I felt in my gut,” remembers Dani. “I learned what throws me off course, like being emotionally stressed. I can do things differently. If that doesn’t work I know there’s something new Dr. Boden can try, and I’ll eventually be well again.”

Blaire Burman, MD, Brings Intervention and Hope to East Africa

 

Dr. Burman treating a patient in Tanzania, Africa.

Dr. Burman treating a patient in Tanzania, Africa.

Blaire Burman, MD, always had a feeling she’d become a doctor, but it was living in South Africa that sealed the deal. In 2001, funerals from AIDS deaths were weekly occurrences, compelling Dr. Burman to volunteer with children made orphans by the disease. She sought her education in the U.S., double majoring in pre-med and African studies, resolved to someday return to the region.

After completing her internal medicine residency and fellowship in gastroenterology and hepatology, fate intervened to send Dr. Burman to the East African country of Tanzania. A surgeon she knew was connected to a hospital in the port city of Dar es Salaam, where a group of Tanzanian physicians had obtained a working endoscope. The lack of equipment like endoscopes is a big reason digestive disease experts can rarely successfully volunteer in developing countries. With the ability to scope and perform procedures on the esophagus, Dr. Burman saw possibilities for diagnosis and treatment.

What didn’t seem possible was the age of the patients. Advanced liver disease, including cirrhosis and liver cancer, was showing up in children. The main culprits were untreated viral hepatitis, long-term parasitic infections and conditions related to AIDS. A diagnosis would typically go untreated, but gastrointestinal bleeding, a lethal complication of disease, is where endoscopy could make a life-saving difference.

“Every day I would do about 10 upper endoscopies,” says Dr. Burman. “We placed bands to ligate esophageal bleeding and clips to stop bleeding from peptic ulcer disease. A lack of equipment could mean using a colonoscopy-sized tube for the throat, which I had to do on a 10-year-old boy, with no sedation. The nurses helped calm him, but I was blown away at how stoic the patients could be.”

Dr. Burman split her days between teaching and performing endoscopy and rounding, seeing patients in a part of the hospital dedicated to advanced gastrointestinal disease. Hospital conditions were dire. Unless families bring food, there is none; patients must pay for everything out of pocket, including fluids, equipment and medicines. If a patient can’t afford the banding kit to treat internal bleeding, they will die.

Far from being overwhelmed by the suffering and loss, Dr. Burman sees a critical role for herself and physicians like her to extend life and offer comfort to a growing group of patients in East Africa. For reasons not fully understood, esophageal cancer is epidemic in the region. With no treatment, the esophagus closes up, causing a horrific death. The insertion of an esophageal stent maintains the opening, so patients may continue to eat and drink.

“The stents aren’t a cure, but it’s a way to help send them home to their villages and families, so they don’t die in the city among strangers,” says Dr. Burman. “It’s rewarding to provide relief through palliative care, which doesn’t really exist in Africa.”

Dr. Burman notes that the few esophageal stents the hospital can order come from India, at a cost of about $200 apiece. In the U.S., they cost closer to $2,000. On the other hand, drugs to treat hepatitis B, a leading cause of gastrointestinal cancer in Africa, are relatively cheap. But only patients receiving government-funded drug treatment for HIV get the bonus of being cured of hepatitis B, which succumbs to the same drugs.

“There are many parts of Africa that still don’t receive resources from the developed world,” says Dr. Burman. “I get a lot of emails asking when I can come back. Someday I hope to return and translate the skills I’ve gained to continue teaching and treating patients.”

Blaire Burman, MD, is director of Virginia Mason’s new comprehensive Hepatitis C Clinic focused on multidisciplinary care, promoting liver health and achieving a cure. The Hepatitis C Clinic team within the Liver Center of Excellence provides comprehensive diagnosis, evaluation and treatment for patients with all stages of chronic hepatitis C. For more information, please call (206) 223-2319.

A version of this article was originally published on Virginia Mason’s internal news site.

Medication: The Race from Beaker to Bedside

By Arielle Kloss ***

Percent of persons using at least one prescription drug in the past month: 48% (2005-2008) Photo credit: CDC/ Amanda Mills

Percent of persons using at least one prescription drug in the past month: 48% (2005-2008) Photo credit: CDC/ Amanda Mills

Ever wonder about the journey those pills you swallowed this morning took before getting to you? How the contents of the capsule went from mixing in a beaker to becoming a once-a-day regimen for your headaches and stomach issues? This process is like trying to wake up in the morning without coffee — long, complicated and often ending in failure. Once a company discovers a compound that has potential to become a marketable drug, the process becomes similar to a relay race. There are checkpoints, obstacles and competition involved in the drug companies’ race to get medications approved by the Food and Drug Administration (FDA). Get on your mark. Get set. Go!

Companies must first show that the medication is safe before they can even think about giving it to humans. This involves determining the basic physical, biological and chemical characteristics of the compound, potential toxicities, route of administration, and starting doses. Animal models are used to gain the above understanding about the investigational medication. After the evidence shows that the drug is safe and possibly efficacious, the company files an Investigational New Drug Application with the FDA. The FDA then has 30 days to give it’s disapproval. If the FDA does not disapprove, the company can begin clinical studies.

On to the next set of obstacles! Human clinical trials involve three to four phases, all of which have different objectives. Phase I is the first challenge, aiming to determine a safe dosing range in a small amount of healthy volunteers, about 20 to 100 people. There is close monitoring by medical personnel, and the studies often occur in special testing facilities to ensure subject safety and controlled environments. This phase must show that the drug is safe first and foremost. If so, the study can expand to include a few hundred healthy study participants with the target disease. This is what happens in phase II. This stage aims to establish efficacy in the target disease and to continue determining appropriate dosing. These studies also often involve a placebo control. After the above two phases have sufficient data, companies can initiate the final stage required before submitting for FDA approval.

Take a breath; we are getting closer to the end of the race. Phase III trials sometimes involve thousands of participants from around the world who are likely to undergo the treatment once it is on the market. The goal of this phase is to show long-term safety and efficacy, and assess the treatment risk-to-benefit relationships. The Digestive Disease Institute at Virginia Mason is involved in many of these types of trials, closely monitoring patients as they take their experimental medication. We compile data collected from the patients, including drug side effects, vital signs and any other pertinent information about their experience taking the medication. Drug companies wait to collect our data that they need to make the final push to the end.

Finally, the finish line is in sight after the phase III data show good results. The companies submit a New Drug Application to the FDA, who must actively approve the medication to be available on the market. Congratulations, you’ve finished! Only a small amount of research efforts make it to this point, however. The many steps increasingly introduce variables that could affect the efficacy or safety of the drug, forcing companies to terminate their studies and go back to square one. Millions of dollars are spent throughout these phases in the hope that the drug will pass each checkpoint. Even after reaching the market, the FDA is free to ask companies to complete phase IV trials to compare the medication to other drugs on the market and determine additional safety information. Whew!

So the next time you grab your morning medication from the bedside table, think about the energy that went into making those pills available. The industry involves coordinators, study participants, scientists and a lot of funding that contribute to developing a successful drug. While there is critique about pharmaceutical companies and the high cost of medication, think about the research and development efforts that often fail and the costs of bringing one little pill to the market. I invite you to imagine different ways that the process could work, perhaps methods that could lower prices or promote cooperation among the competing companies. This is an interesting and hot topic for discussion so challenge yourself to ponder the possibilities. How would you change the race?

***

Arielle is a clinical research assistant with the Digestive Disease Institute at Virginia Mason.

Love Your Liver: Two Ways to Prevent Liver Damage

By James Bredfeldt, MD **

James Bredfeldt, MD

James Bredfeldt, MD, Digestive Disease Institute

Drugs can be our friends, but also they can be your liver’s enemy. You may be ingesting some medications that might harm your liver and be unaware of that potential. So, let’s discuss two of these possibilities:

Acetaminophen and the Liver

Acetaminophen is a commonly used medication for pain control and fever reduction. Acetaminophen is found in over-the-counter (OTC), nonprescription medications either in single tablets or in combination with other medications, usually “cold” remedies. It is also used in prescription medications, in combination with narcotic pain medications; for example, hydrocodone-acetaminophen (Vicodin) or oxycodone-acetaminophen (Percocet).

Acetaminophen has the potential to cause serious and fatal liver damage in certain circumstances. When the total daily dose is under 3,000 mg, the potential for liver damage is quite low. When the daily dose begins exceeding 4,000 mg, the potential for liver damage exists, especially when used in those amounts over consecutive days.

Caution should be shown when taking acetaminophen while consuming alcoholic drinks at the same time. Less than three alcoholic drinks a day, preferable none, should be consumed while using acetaminophen, even less than 3,000 mg a day. One alcoholic drink equals 4 ounces of wine, 1 ounce of spirits (such as whiskey, vodka and gin), or 12 ounce bottle of beer.

The important things to remember about acetaminophen are:

  • Read the labels on OTC medications that contain it
  • Consult with your pharmacist about prescription narcotics that may contain it
  • Limit daily acetaminophen amounts to 3,000 mg
  • Avoid alcohol consumption while using this drug

Herbal Agents and the Liver

Many individuals use OTC “natural,” or herbal, agents. I often hear the comment that patients don’t want to use prescription medications as they contain “chemicals.” Herbal agents are nothing more than “chemicals” that are produced by plants, rather than by chemists!

Because it is “natural” does not mean that liver damage can’t happen. Here is a list of some herbal agents that are known to cause serious liver damage: black cohosh, comfrey, ginseng, greater celandine, Jin Bu Huan, Kombucha tea, misteltoe, Sho-saiko-to, pennyroyal oil (squawmint oil), sassafras, senna, and skullcap and valerian combined.

One challenge often faced is many of these agents may be listed under an alternative name, often its botanical name, which then becomes quite complicated for identification. So, it is important to ask questions, and even a web search might be beneficial and liver saving.

Love your liver!

**

When not practicing gastroenterology and hepatology, Dr. Bredfeldt enjoys supporting his alma mater, the University of Kansas.

Do You Take Probiotics When You Travel?

TravelForeign travel and gastric distress is not a nice combination. I know this from personal experience – my first trip abroad (Italy) was marred by the worst case of “sour stomach” I’ve ever suffered. I blame some grapes I munched on, but it could have been anything. The only silver lining is that I came back from my trip weighing less than when I left – not an easy feat when visiting a country known for its fabulous food finds and perfect pasta dishes.

While I’d love to be adventurous like Anthony Bourdain, I can’t get over the memory of experiencing total intestinal betrayal during my first ill-fated trip to Italy. I’ve become a safety-first traveler when it comes to precautions against stomach trouble: using hand sanitizer, eating only cooked foods and eyeing eateries with suspicion.

Another item I’ve come to rely on during adventures is a probiotic dietary supplement. Probiotics are helpful microorganisms (mostly gut-friendly bacteria) used to promote digestive health by assisting the body’s naturally occurring gut bacteria. The theory is that taking probiotics helps populate your gut with happy, healthy bacteria to help fight bad bacteria or unfamiliar flora you may encounter during travel. Traveler’s diarrhea occurs when bad bacteria, parasites or viruses enter the gut and upset the natural balance.

“There are many kinds of probiotics with very little data to support using specific ones,” says Carol Murakami, a gastroenterologist with the Digestive Disease Institute. “It’s a challenge in verifying which ones are truly useful in travel because of the many travel destinations and different bugs people may encounter while traveling.”

So, I know taking probiotics won’t protect me from a run-in with norovirus or other bugs that bring about barfing. However, if taking probiotics supports a happy balance in my gut, then I feel it’s worth having a little extra help when traveling overseas. What do you think: Is using probiotics helpful during travel or just one more thing you must remember to pack?

Do you have questions about using probiotics during travel or everyday life?

Get the real scoop from Virginia Mason gastroenterologist Carol Murakami, MD, as she hosts a Twitter chat on probiotics Monday, July 8, from noon to 1 p.m. Pacific time. Follow @VirginiaMason and use #AskVM. Details: http://ow.ly/mluhY

What Causes Inflammatory Bowel Disease?

 By Michael Chiorean, MD **

Ulcerative colitis and Crohn’s disease are the most common forms of inflammatory bowel disease (IBD). While the cause of IBD is unknown, there are a number of hypotheses trying to explain an association between changes in the environment, genetics and immune dysregulation and the development of IBD. Although a definitive explanation is lacking, the environment is likely to play an important role since nothing else can have such a dynamic nature that explains the increased frequency of IBD over the last few decades. The human genes, in comparison, have not changed substantially in the last 25,000 years.

Diet
MP900438778
Diet, the Western kind in particular, is usually a primary suspect. Consumption of a diet rich in red meats, in contrast to a vegetarian diet, may be a risk factor. How diet can change the gut bacteria or the immune system in a way to promote IBD is unclear. Furthermore, despite false claims in social media, there is no diet that can improve or “cure” IBD, with the exception of artificial (elemental) diet in young children. Due to its poor taste, this often has to be given through feeding tubes directly in the stomach which is very poorly tolerated long term. It is advisable that patients with IBD follow a generally healthy diet, including a balanced intake of meats, fruits and vegetables. Favoring lean meats, such as fish or chicken, over red meat may be good advice. In contrast, other nonconventional diets such as the special carbohydrate diet or restrictive diets may be detrimental by leading to malnutrition, sometimes severe. Lactose (dairy)-free or gluten-free diets are generally better tolerated, without being necessarily safer or healthier for patients with IBD. There is also no harm in these diets, so patient preference may play a role in this choice.

Drugs
Other possible risk factors that have been the subject of debate are certain drugs such as non-steroidal anti-inflammatory drugs (NSAIDs, like aspirin and ibuprofen) and oral contraceptives; the use of both has increased substantially in the last century. While the association of chronic NSAID use with flares of IBD appears certain, no such certainty exists in regards to contraceptive use and, therefore, no specific recommendations exist. I tend to reassure my patients in regards to contraceptives and let them choose the method that best fits their lifestyles. We have to remember that these are some of the most commonly used medications worldwide, while the number of IBD cases remains relatively small (approximately 1 in 500 people in the U.S.).

Smoking
MP900341702Smoking is a definite risk factor for Crohn’s disease, while it may be somewhat protective against ulcerative colitis. The harmful effects of smoking are evident not only in Crohn’s disease but also in an increased risk of almost every cancer, as well as heart disease, stroke and dementia. Smokers with inflammatory bowel disease, and Crohn’s patients in particular, should make every effort to quit.

Stress
Stress is ubiquitous as a consequence of our increasingly busy, productive and sometimes chaotic lives. It has been linked to a large number of diseases, called psychosomatic disorders, as well as IBD. Stress may cause disease exacerbations in certain predisposed individuals. There have been studies describing disease flares related to natural disasters, and I occasionally see patients who have predictable flares around stressful events, such as final exams. A stress-free world is not only unrealistic, but medications that help relieve stress, such as anti-anxiety drugs, have no effect on IBD flares – even in patients who experience high anxiety levels related to their diseases or lifestyles. That said, the majority of patients can learn to cope with stress with or without medical assistance, and this leads to an improved quality of life.

Genes
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There is no human disease where genes have not been incriminated at least to some extent. In fact, we are the expression of a complicated genetic code which has been developed and perfected over millions of years. There are more than 25,000 genes in the human body and the genetic material present in every human cell, if stretched in a single string, is several miles long. So it comes as no surprise that certain genetic “accidents” happen and some of them may predispose a person to IBD. More than 100 genes have been associated with Crohn’s disease and almost 50 with ulcerative colitis, with some overlap between the two. This means genes alone are probably not the most important factor in IBD, otherwise we would have only one or two genes responsible, like with hemochromatosis or cystic fibrosis. There is probably more than one way for people to get IBD, which is a topic of intense research these days. The bottom line is that IBD as a whole is only weakly hereditary. In fact, less than 10 percent of first degree relatives of patients with IBD also carry the disease, a little more in Crohn’s than ulcerative colitis. Even in identical twins the concordance rate is only 30 percent for Crohn’s and about half that for ulcerative colitis.

In conclusion, we may not know what causes IBD or disease flares, but we are beginning to understand the complex interactions that exist between the human genes, the environment, normal and abnormal microbial flora, and the immune response in the gut. We are still far away from a unifying theory of IBD, and therefore a treatment that might provide a cure. Until then, we have good medications that can treat the disease and keep it in remission as long as people stay on them and new medications are constantly being developed, some with very promising results. So, stay tuned, there is a fair amount of light at the end of the IBD tunnel.

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Michael Chiorean, MD, is a gastroenterologist with the Digestive Disease Institute at Virginia Mason. He specializes in inflammatory bowel disease, Crohn’s disease, ulcerative colitis, C Difficile, gastrointestinal bleeding and small bowel endoscopy.