Category: Just So You Know

Helicobacter Pylori (H. Pylori) Infection and Treatment

Helicobacter Pylori (H. Pylori) Infection and Treatment


Helicobacter pylori, also known as H. pylori, is a bacterium that is commonly found in the stomach. It is present in approximately one-half of the world’s population.

The vast majority of people infected with H. pylori has no symptoms and will never develop problems. However, H. pylori is capable of causing a number of digestive problems, including ulcers and, much less commonly, stomach cancer. It is not clear why some people with H. pylori get these conditions and others do not.


H. pylori is probably spread by consuming food or water contaminated with fecal matter. H. pylori causes changes to the stomach and duodenum (the first part of the small intestine). The bacteria infect the protective tissue that lines the stomach. This leads to the release of certain enzymes and toxins and activation of the immune system. Together, these factors may directly or indirectly injure the cells of the stomach or duodenum. This causes chronic inflammation in the walls of the stomach (gastritis) or duodenum (duodenitis).

As a result of these changes, the stomach and duodenum are more vulnerable to damage from digestive juices, such as stomach acid.

In the United States and other developed countries, infection with H. pylori is unusual during childhood but becomes more common during adulthood. However, in developing countries, most children are infected with H. pylori before age 10.


Most individuals with chronic gastritis or duodenitis have no symptoms. However, some people develop more serious problems, including stomach or duodenal ulcers.

Ulcers can cause a variety of symptoms or no symptoms at all, with the most common ulcer symptoms including:

  • Pain or discomfort (usually in the upper abdomen)
  • Bloating
  • Feeling full after after eating a small amount of food
  • Lack of appetite
  • Nausea or vomiting
  • Dark or tar-colored stools
  • Ulcers that bleed can cause a low blood count and fatigue

Less commonly, chronic gastritis causes abnormal changes in the stomach lining, which can lead to certain forms of cancer. It is uncommon to develop cancer as a result of H. pylori infection. Nevertheless, because so many people in the world are infected with H. pylori, it is considered to be an important cause of stomach cancer. People who live in countries in which H. pylori infection occurs at an early age are at greatest risk of stomach cancer.


There are several ways to diagnose H. pylori. The most commonly used tests include the following:

Breath tests — Breath tests (known as urea breath tests) require that you drink a specialized solution containing a substance that is broken down by the H. pylori bacterium. The breakdown products can be detected in your breath.

Stool tests — Tests are available that detect H. pylori proteins in stool.

Blood tests — Blood tests can detect specific antibodies (proteins) that the body’s immune system develops in response to the H. pylori bacterium. However, concerns over its accuracy have limited its use.


If you have symptoms:

Diagnostic testing for H. pylori infection is recommended if you have active gastric or duodenal ulcers or if you have a past history of ulcers.

Although H. pylori infection is the most common cause of ulcers, not all patients with ulcers have H. pylori. Certain medications (eg, aspirin, ibuprofen [Motrin, Advil], naproxen [Aleve]) can also cause peptic ulcers.

If you do not have symptoms:

H. pylori testing is usually not recommended if you have no symptoms and no past history of peptic ulcer disease. However, it may be considered for selected people, such as those with a family history or concern about stomach cancer, particularly individuals of Chinese, Korean, Japanese, or Central American descent; these groups have a higher incidence of stomach cancer.


People with a history of peptic ulcer disease, active gastric ulcer, or active duodenal ulcer associated with H. pylori infection should be treated. Successful treatment of H. pylori can help the ulcer to heal, prevent ulcers from coming back, and reduce the risk of ulcer complications (like bleeding). Guidelines in the United States and other countries recommend that patients who require long-term anti-inflammatory medications such as aspirin, ibuprofen, naproxen, and similar drugs treatment for arthritis and other medical conditions should be tested for H. pylori and if infected undergo treatment to eradicate the H. pylori infection.


No single drug cures H. pylori infection. Most treatment regimens involve taking several medications for 14 days.

  • Most of the treatment regimens include a medication called a proton pump inhibitor. This medication decreases the stomach’s production of acid, which allows the tissues damaged by the infection to heal. Examples of proton pump inhibitors include lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (AcipHex), dexlansoprazole (Dexilant), and esomeprazole (Nexium).
  • Two antibiotics are also generally recommended; this reduces the risk of treatment failure and antibiotic resistance.
  • There are increasing numbers of patients with H. pylori infection that is resistant to antibiotics, so it is important to take all the medications prescribed and to have a test that confirms that the infection has been cleared.

For H. pylori treatment to be effective, it is important to take the entire course of all medications.

Side effects:

Up to 50 percent of patients have side effects while taking H. pylori treatment. Side effects are usually mild, and fewer than 10 percent of patients stop treatment because of side effects. For those who do experience side effects, it may be possible to make adjustments in the dose or timing of medication. Some of the most common side effects are described below.

  • Some of the treatment regimens use a medication called metronidazole (Flagyl) or clarithromycin (Biaxin). These medications can cause a metallic taste in the mouth.
  • Alcoholic beverages (eg, beer, wine) should be avoided while taking metronidazole; the combination can cause skin flushing, headache, nausea, vomiting, sweating, and a rapid heart rate.
  • Bismuth, which is contained in some of the regimens, causes the stool to become black and may cause constipation.
  • Many of the regimens cause diarrhea and stomach cramps.

Treatment failure:

Up to 20 percent of patients with H. pylori infection are not cured after completing their first course of treatment. A second treatment regimen is usually recommended in this case. Retreatment usually requires that the patient take 14 days of a proton pump inhibitor and two antibiotics. At least one of the antibiotics is different from those used in the first treatment course.


After completing H. pylori treatment, repeat testing is usually performed to ensure that the infection has resolved. This is typically done with a breath or stool test. Blood tests are not recommended for follow up testing; the antibody detected by the blood test often remains in the blood for four or more months after treatment, even after the infection is eliminated.


  • Helicobacter pylori, also known as H. pylori, is a bacterium that is commonly found in the stomach. Most people infected with H. pylori have no problems. However, some people develop problems, such as stomach ulcers.
  • Ulcers may cause no symptoms, or may cause pain or discomfort (usually in the upper abdomen), bloating, feeling full after eating a small amount of food, lack of appetite, nausea, vomiting, and dark or tar-colored stools. Ulcers that bleed can cause a low blood count.
  • H. pylori can be diagnosed with a test of the blood, breath, or stool.
  • H. pylori testing is recommended for anyone with a peptic (stomach or duodenal) ulcer.
  • Anyone diagnosed with H. pylori should be treated. H. pylori treatment helps to heal the ulcer, lowers the risk that the ulcer will return, and lowers the risk of bleeding from the ulcer.
  • H. pylori treatment usually includes several medicines. At least two of the medicines are antibiotics that help to kill the bacteria. The other medication causes the stomach to make less acid; lower acid levels help the ulcer to heal.
  • Most people are cured after finishing two weeks of medicine. Some people need to take another two weeks of medicine. It is important to finish all of the medicine to ensure that the bacteria are killed.
  • Guidelines recommend that all patients treated for H. pylori undergo a breath or stool test two weeks after finishing the medication. This is done to be sure that the bacteria were killed. It is recommended that the test is performed 30 days after the treatment is completed and off proton pump medication for 1 to 2 weeks before eradication testing.

Compiled from Up To date

Author: Sheila E Crowe, MD, FRCPC, FACP, FACG, AGAF

Professor of Medicine, University of California, San Diego

Food Allergy Symptoms and Diagnosis

Food Allergy Symptoms and Diagnosis

Food Allergy Overview

Reactions to food are common and can be divided into two categories, those caused by food allergy and all other reactions. It is important to know the difference between food allergies and other illnesses or symptoms caused by foods because the management of each is different.

  • Food allergies develop when the body’s immune system has an abnormal reaction to one or more proteins in a food. Food allergies can lead to serious or even life-threatening allergic reactions.
  • Other food reactions are not caused by the immune system. These reactions cause unpleasant symptoms and are far more common than food allergies. Examples include lactose intolerance, heartburn (gastroesophageal reflux), bacterial food poisoning, and sensitivity to caffeine, just to name a few.

Classic Food Allergies

In people with “classic” food allergies, allergic antibodies, called immunoglobulin E (IgE), develop in response to proteins in certain foods. When the person is exposed to that protein at a later time (eg, by eating peanuts), binding of the food protein to IgE triggers a release of chemicals, which cause the symptoms of an allergic reaction. This typically occurs quickly, within minutes to two hours after eating.

Sudden-Onset Symptoms

The symptoms of a food allergy can vary from mild to severe or even life-threatening. It is not always possible to predict how severe symptoms will be based upon the symptoms experienced during a previous reaction. For example, a person could have mild hives after eating peanuts on one occasion and then have an anaphylactic reaction after eating peanuts another time. However, reactions are not necessarily worse after each exposure.

The most common sudden-onset symptoms of food allergy include:

  • Skin – Itching, flushing, hives (urticaria, like mosquito bites), or swelling (angioedema)
  • Eyes – Itching, tearing, redness, or swelling of the skin around the eyes
  • Nose and mouth – Sneezing, runny nose, nasal congestion, swelling of the tongue, or a metallic taste
  • Lungs and throat – Difficulty getting air in or out, repeated coughing, chest tightness, wheezing or other sounds of labored breathing, increased mucus production, throat swelling or itching, hoarseness, change in voice, or a sensation of choking
  • Heart and circulation – Dizziness, weakness, fainting, rapid, slow, or irregular heart rate, or low blood pressure
  • Digestive system – Nausea, vomiting, abdominal cramps, or diarrhea
  • Nervous system – Anxiety, confusion, or a sense of impending doom

Associated Conditions

Anaphylaxis — Generalized anaphylaxis is the most serious type of allergic reaction and can cause life-threatening signs and symptoms, including difficulty breathing, swelling of the upper throat and/or tongue, a very rapid or irregular heartbeat, low blood pressure, or cardiac arrest (the heart stops beating).

Generalized anaphylaxis generally begins within 5 to 60 minutes of exposure to a trigger, although, rarely, symptoms begin several hours after eating. A person who develops symptoms of anaphylaxis must be treated immediately with an injection of epinephrine. Treatment of anaphylaxis is discussed separately. Many different foods can potentially trigger anaphylaxis. In adults, peanuts, tree nuts (e.g., walnuts), fish, and shellfish cause most anaphylactic reactions. In children, peanuts and tree nuts are the most common causes of anaphylactic reactions.

Allergic rhinitis and conjunctivitis — Food allergies can trigger allergic symptoms in the nose, eyes, or throat. However, these symptoms usually occur along with whole-body symptoms, such as hives, difficulty breathing, diarrhea, etc. The most common nose, eye, and throat symptoms including a runny nose, congestion, sneezing, nasal itching, itchy or watery red eyes, or voices changes.

Oral allergy syndrome — Oral allergy syndrome, or pollen-food allergy syndrome, is seen in up to 50 percent of people with allergic rhinitis caused by pollen. In this condition, people who are allergic to pollen have an allergic reaction after eating certain raw (uncooked) fruits or vegetables. The reaction is immediate and can cause itching, irritation, and mild swelling of the lips, tongue, roof of the mouth, and throat. A list of pollens and foods that cross react is available in the figures.

Risk of clinical reactivity among related fruits and vegetables

Cross-reactivity patterns in pollen-food allergy syndrome

Symptoms of oral allergy syndrome may be more noticeable during the associated pollen season. Symptoms usually resolve within minutes after the person stops eating the food. Most people have only localized symptoms (eg, in the mouth).

Less than 10 percent of people have systemic symptoms to fruits and vegetables (eg, vomiting or diarrhea), and 1 to 2 percent of people develop generalized anaphylaxis. People with a history of systemic symptoms should carry epinephrine auto injectors.

The reaction does not usually occur if the fruits or vegetables are cooked. Tree nuts and peanuts are an exception to this, meaning that anyone with a history of an oral allergy to nuts should avoid them in all forms (raw, roasted, and cooked).

Food-dependent exercise-induced anaphylaxis — There are some people who develop an anaphylactic reaction after eating a certain food and then exercising up to four hours later. A reaction can occasionally occur after exercising first and then eating. The particular food does not cause anaphylaxis if the person does not exercise. This is called food-dependent exercise-induced anaphylaxis.

The most common foods associated with this condition include wheat, celery, and seafood, although some people react after eating any food and then exercising. Not eating for several hours before exercise can usually prevent this type of reaction.


There are several conditions that may be food related, such as eosinophilic gastrointestinal disorders (eosinophilic esophagitis) atopic dermatitis (eczema).


Food allergies can occur without involving immunoglobulin E (IgE). The symptoms of this type of food allergy are usually slower to develop and longer lasting than those of classic food allergies.

The three main types of non-IgE food allergies are:

  • Food protein-induced enterocolitis
  • Food protein-induced proctocolitis
  • Celiac disease and dermatitis herpetiformis

Most of these conditions cause symptoms of the digestive system, such as vomiting, diarrhea, abdominal pain, and/or blood in the stool. Food protein-induced enterocolitis and proctocolitis are more commonly seen in infants.


Anyone who has signs or symptoms of a food allergy should see his or her health care provider. Between 20 and 30 percent of people report food allergy in themselves or their children. However, only 6 to 8 percent of children under the age of five and 3 to 4 percent of adults have a true food allergy.

Laboratory testing and/or skin testing is often used to confirm the food allergy and determine if avoidance of a particular food is necessary.

Medical history — During a medical history, the health care provider will ask questions about the person’s past allergic reactions:

  • What symptoms of food allergy did you have?
  • What particular food do you think provoked the reaction? Have you eaten this food before? Have you reacted before?
  • How much of this food did you eat?
  • What other foods did you eat at that time? Do you know all the ingredients of the food you ate? Include all foods: appetizer, main dish, sauces, dressings, breads, beverages, and side dishes.
  • How was the food prepared? As an example, could the food have been fried in oil used to prepare other foods?
  • Were any of following eaten: peanuts, tree nuts, shellfish, fish, milk, eggs, wheat, or soy?
  • How much time passed between eating the food and the first symptoms?
  • Did you exercise or exert yourself after eating?
  • Did you take any medications, herbs, vitamins, nonprescription medications, or drink any alcohol before or after eating?
  • How was the reaction treated? Did it resolve without treatment or did you take any medications? How long were the medications continued, and were there any later symptoms?

Depending upon the answers to these questions and the physical examination, the health care provider may decide to order laboratory testing. In other cases, the provider will refer the person to a specialist (allergist or gastroenterologist) for further evaluation.

Allergy testing:

Testing for food allergies often includes skin testing and/or blood tests. Depending upon the situation, tests may be done to determine if a person is allergic to pollens, insects, latex, and other allergens. However, testing is only recommended if the person is suspected to have an allergy. As an example, if a person had a reaction after eating peanuts, but has never reacted to wheat or eggs and eats them regularly, it is not necessary to test for allergy to wheat or eggs.

Skin testing:

Skin testing involves pricking/scratching the skin with a tiny probe that is coated with food extract or fresh food. The pricks are usually done on the forearm or upper back after the skin is cleaned with alcohol. The skin prick is not usually painful.

Adults and children of any age may have skin testing. The test may result in small hives (like a mosquito bite) at the site of the prick/scratch. Only a trained health care provider, usually an allergy specialist, should do skin testing. This specialist will evaluate the size of the test results to assist in making a diagnosis.

Blood tests:

Blood tests are available to assist doctors in making a diagnosis. Neither the skin test nor the blood test can be depended upon to make a diagnosis without a clinician considering the medical history and other supporting information. Blood tests are widely available and do not require an allergy specialist to perform the test. However, consultation with an allergy specialist may be recommended to interpret the results of the test.

Elimination diets:

An elimination diet is a specially designed diet that eliminates one or more foods or groups of food from a person’s diet for a period of time. The food is then added back to determine if signs or symptoms of a food allergy develop.

An elimination diet may be recommended as part of the process of determining if a person has food allergies. An allergist or dietitian must be involved in designing an elimination diet because avoiding entire groups of foods (eg, milk) could potentially lead to malnutrition, especially in infants and children. An elimination diet by itself does not often lead to the diagnosis of food allergy.

During an elimination diet, it is important to read food labels carefully. In the United States, the Food Allergen Labeling and Consumer Protection Act mandates that nutritional labels on food packages plainly identify eight specified food allergen sources (milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, and soy), although other foods may still appear under multiple names.

In addition, patients must understand that “substitute” foods, which reduce or eliminate fat or other components of a food, still contain the allergenic proteins. As an example, some egg substitutes (which are lower in cholesterol) still contain egg white proteins.

Food diary:

A health care provider may request that a person keep a complete record of everything they eat over a period of time, including all foods, drinks, condiments, and candies.

Food challenges:

If it is not clear if a person has a food allergy, based upon their medical history and allergy testing, he or she may be offered a medically supervised gradual feeding or food challenge. A food challenge may also be recommended if there is reason to believe that the food allergy has resolved. In addition, some foods such and egg and milk become less allergenic when they are extensively heated (eg, baked in bread or muffins), and a challenge may be performed to find out if the person is able to eat the food in this form. A food challenge is done by giving the person a tiny amount of the potentially allergenic food to eat.

After the person is given the first sample of food, he/she is observed for 10 to 30 minutes. If there is no reaction, a slightly larger amount of the food is given. This is continued for approximately 90 minutes or more. If the person develops signs or symptoms of an allergic reaction, the food challenge is immediately stopped.

Food challenges should only be performed in a setting where the personnel and equipment needed to treat anaphylaxis are available; this can be an office or hospital setting.

  • Preparing for the food challenge – The doctor or nurse will provide specific instructions before the food challenge. It is important to prepare by not eating or drinking for two hours before the test, and certain medications may need to be stopped days or weeks before. The person should bring their epinephrine auto injector to the food challenge in case they develop a delayed allergic reaction on the way home.
  • If there is no reaction during the food challenge – If the person did the food challenge to find out if he or she has an allergy and does not have any signs of an allergic reaction during the food challenge, he/she probably does not have an allergy to the tested food. However, the person may have allergies to other foods, so it is important to understand when/if foods should continue to be avoided.
  • If the person already has a known allergy to a food (such as egg or milk) but passes a challenge for that food in extensively heated form, he or she still needs to be careful to avoid the food in raw or less cooked form. For example, a person with a milk allergy might be able to eat bread or processed foods that contain milk but still need to avoid drinking milk and eating dairy products like cheese or yogurt. A doctor or nurse will discuss the results of the food challenge and give recommendations on what to do moving forward.


It is sometimes difficult to know if a reaction is caused by a true food allergy or a food intolerance. Anyone who has one or more of the following symptoms after eating should seek medical care:

  • Nausea or vomiting
  • Cramping, abdominal pain, or diarrhea, especially if there is blood or mucus in the stool
  • Itching or raised red welts on the skin
  • Flushed (reddened, warm) skin
  • Swelling of the lips, mouth, face, or throat
  • Wheezing, coughing, or difficulty breathing
  • Lightheadedness or passing out.

Compiled from Up To Date:
Author: Wesley Burks, MD
University of North Carolina School of Medicine

Patient Education: Obesity and Bariatric Surgery

Patient Education: Obesity and Bariatric Surgery

Weight loss surgery, sometimes called bariatric surgery, is a surgery to help you lose weight. It works by making you take in fewer calories and nutrients. Doctors use a measure called “body mass index” or BMI, to decide who can have this weight loss surgery. Your BMI will tell you whether your weight is normal for your height. (See BMI Chart in my previous postings.)

Weight loss surgery is appropriate only if you have not been able to lose weight through other means and if you:

  • have a BMI above 40 and have not responded to diet, exercise, or weight loss medicines; or
  • have a BMI above 35 and also have a medical problem related to obesity, such as diabetes, heart disease, or high blood pressure; or
  • have a BMI above 30, but only if you have certain medical conditions.

Types of Surgery

Gastric Bypass: Gastric bypass is short for “Roux-en-Y Gastric Bypass,” and sometimes called “RYGB.” For this surgery, the doctor closes off part of the stomach, leaving only a small pouch for food. Then, he or she connects the stomach pouch to the middle part of the small intestine. This allows food to “bypass” or reroute around a part of the stomach and small intestine. There are other surgeries that are simlar to gastric bypass in how they cause weight loss.

Gastric Sleeve: Gastric sleeve, also known as “sleeve gastrectomy,” is a surgery that turns the stomach into something that looks like a sleeve. In other words, the doctor removes a large portion of the stomach and leaves a narrow tube.

Gastric Balloon: For this, the doctor puts a special balloon into your stomach. He or she does this using a thin tube that goes into your mouth and down your throat. The balloon stays in your stomach for up to 6 months. While it is there, your stomach has less space for food, which limits the amount you can eat at one time.

Gastric bypass and gastric sleeve can be done as “open” surgery or as a laparoscopic surgery. For open surgery, the surgeon cuts open the belly and works on the organs directly. For laparoscopic surgery, the surgeon makes a small cut and inserts a narrow tool that has a tiny camera on the end into the belly. This tool is called a laparoscope. It allows the surgeon to see inside the belly without opening it up all the way. Then, the surgeon can do the surgery using other tools that fit through small openings in the belly and that can be controlled from the outside.

Gastric balloon is a procedure, it is not actually a surgery. It does not involve cutting the skin the way the other options do.

Each type of weight loss surgery is different and each has different benefits and downsides.

  • Gastric Bypass leads to the most weight loss and works the fastest, but it involves the most serious surgery with the highest risks. It can also cause problems in how your body absorbs nutrients. As a result, it can lead to “nutritional deficiencies,” meaning your body is missing important nutrients. This can sometimes make you sick. If you have gastric bypass, your doctor will monitor your nutrient levels afterward.
  • Sleeve Gastrectomy is safer than gastric bypass because it does not involve rerouting or cutting and reattaching the intestines, and because it is less likely to cause problems with how you absorb nutrients. It might also be safer because it does not involve any plastic materials that stay in your body.
  • Gastric balloon is becoming a more popular option for weight loss. That’s because it is safe, easy-to-do, and does not involve any cutting. But, it also does not lead to as much weight loss as the other surgical options. After the balloon is removed, some (but not all) people are able to keep the weight off.

The decision about which type of surgery to have is important. Discuss your choices with your doctor. If you have different options, ask the following questions.

  • About how much weight can I expect to lose with each option?
  • How long will it take me to lose the weight?
  • What are the risks of each option for someone like me?
  • What changes will I need to make to my diet and lifestyle with each option?

Whatever you decide, make sure your surgeon is experienced with weight loss surgery. Also, check with the staff at your treatment center, or make sure it is a certified “Center of Excellence.” Those centers have a team of nurses and doctors who specialize in taking care of patients like you. If you are unsure about your decision, you can ask for an opinion from another doctor. Most hospitals that have experience with weight loss surgery offer patient education sessions where you can learn more about weight loss surgery and the options you have.

In addition to helping you lose weight, surgery can help improve or even get rid of certain health problems including:

  • diabetes
  • high blood pressure
  • high cholesterol
  • sleep apnea, a condition that causes you to stop breathing for short amounts of time while you sleep.

The risks of surgery are different depending on the following.

  • What type of weight loss surgery you have.
  • Whether your surgery is open or laparoscopic.
  • Your age and overall health.
  • How experienced your surgeon is.

In general, the risks could include:

  • Bleeding
  • Infection inside the belly or in the wounds from surgery
  • Leaks from the incisions on the stomach or intestine
  • A blockage or tear in the intestines
  • Problems with the heart or lungs
  • Gallstones
  • Nutritional problems
  • Severe diarrhea
  • Need for more surgery

As with any kind of surgery, it is possible for these procedures to lead to serious problems or even death. Death following weight loss surgery is very rare. But it’s still important to talk to your doctor about all the possible risks of each type of surgery.

You will need to eat healthy foods that “work with” your surgery. For example, you should choose foods high in protein and low in fat and calories. You should also avoid liquid foods that are high in calories, such as ice cream. If you eat the wrong things, you could hurt your chances of losing weight.

If you have weight loss surgery, you will need to avoid certain foods that could make you sick. Plus you will probably need to take special multivitamins with minerals. That’s because weight loss surgery, especially gastric bypass, can make it hard for your body to get all the nutrition it needs. You must keep taking vitamins for the rest of the life. Your body will always need them to stay healthy.

Adopted from Up-to-Date Education Basics.

2018 Cholesterol Clinical Practice Guidelines: Synopsis of the 2018 American Heart Association/American College of Cardiology/Multi society Cholesterol Guideline

2018 Cholesterol Clinical Practice Guidelines: Synopsis of the 2018 American Heart Association/American College of Cardiology/Multi society Cholesterol Guideline

CLINICAL GUIDELINES |4 JUNE 2019 Annals Of Internal Medicine

According to the Centers for Disease Control and Prevention, heart disease is the leading cause of death in the United States, including for African American, Hispanic, and white persons (1) and for both women and men. The leading cause of death attributable to cardiovascular disease (CVD) in the United States is coronary heart disease (43.8%), followed by stroke (16.8%)—the 2 components of fatal atherosclerotic CVD (ASCVD) (2). The economic impact of ASCVD is large: It accounted for 14% of total health expenditures in 2013 to 2014, more than any major diagnostic group.

The American Heart Association and American College of Cardiology (AHA/ACC), with the support of 10 collaborating organizations, have recently released their 2018 cholesterol guideline (3). In addition, they have released a companion special report on the use of risk assessment tools to guide decision making in primary prevention 


The guideline endorses a heart-healthy lifestyle beginning in childhood to reduce lifetime risk for ASCVD. It contains several new features compared with the 2013 guideline. For secondary prevention, patients at very high risk may be candidates for adding nonstatin medications (ezetimibe or proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) to statin therapy. In primary prevention, a clinician–patient risk discussion is still strongly recommended before a decision is made about statin treatment. The AHA/ACC risk calculator first triages patients into 4 risk categories. Those at intermediate risk deserve a focused clinician–patient discussion before initiation of statin therapy. Among intermediate-risk patients, identification of risk-enhancing factors and coronary artery calcium testing can assist in the decision to use a statin. Compared with the 2013 guideline, the new guideline gives more attention to percentage reduction in low-density lipoprotein cholesterol as a treatment goal and to long-term monitoring of therapeutic efficacy. To simplify monitoring, nonfasting lipid measurements are allowed.

Synopsis of Recommendations

1. Healthy lifestyle over the lifespan. A healthy lifestyle reduces ASCVD risk at all ages. In younger persons, healthy lifestyle can reduce development of risk factors, can prevent the need for subsequent statin use, and is foundational therapy for ASCVD risk reduction. In young adults aged 20 to 39 years, an assessment of lifetime risk facilitates the clinician–patient risk discussion and emphasizes intensive lifestyle efforts. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome.

2. Use of maximally tolerated doses of statins in secondary prevention of ASCVD. In patients with clinical ASCVD, the guideline recommends reduction of low-density lipoprotein cholesterol (LDL-C) levels with high-intensity or maximally tolerated statin therapy. The more LDL-C is reduced during statin therapy, the greater the subsequent risk reduction will be. High-intensity statins typically reduce LDL-C levels by an average of at least 50%, which is an attainable goal in most patients with ASCVD.

3. Use of nonstatin medications in addition to statin therapy for patients at very high risk for ASCVD. Very high risk is defined as a history of multiple major ASCVD events, or 1 major ASCVD event and multiple other high-risk conditions. In very-high-risk ASCVD, the guideline recommends an LDL-C threshold of 1.8 mmol/L (70 mg/dL) as reasonable for adding a nonstatin medication (ezetimibe or proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) to maximally tolerated statin therapy. In patients who had very high risk, had a baseline LDL-C level of approximately 1.8 mmol/L (70 mg/dL), and were receiving statin therapy, addition of ezetimibe reduced risk for major events by 2 percentage points (6). Two RCTs recruited patients at very high risk who were receiving maximally tolerated doses of statins, had LDL-C levels greater than 1.8 mmol/L (70 mg/dL) (average, about 2.3 mmol/L [90 mg/dL]), and were treated with PCSK9 inhibitors for approximately 3 years (7, 8). Addition of PCSK9 inhibitors reduced risk for subsequent ASCVD events by about 15%. On the basis of these RCTs, the guideline states that addition of ezetimibe to maximally tolerated statin therapy is reasonable when LDL-C levels are 1.8 mmol/L (70 mg/dL) or higher. In patients at very high risk whose LDL-C levels remain above this threshold while they receive maximally tolerated statin and ezetimibe therapy, the guideline suggests that a PCSK9 inhibitor is a reasonable addition, although long-term safety (>3 years) is uncertain and cost-effectiveness was low at mid-2018 list prices. Some prescription programs have recently been initiated to reduce the cost of PCSK9 inhibitors. As cost decreases, cost-effectiveness will increase (9).

4. Severe primary hypercholesterolemia, often starting in childhood. In patients with primary, severe hypercholesterolemia (LDL-C level ≥4.9 mmol/L [≥190 mg/dL]), calculating 10-year ASCVD risk is not necessary. Maximally tolerated statin therapy is required to reduce LDL-C levels toward a lower risk range. If the LDL-C level remains at or above 2.6 mmol/L (100 mg/dL), adding ezetimibe is reasonable. If the patient still has an LDL-C level above this threshold while receiving a statin plus ezetimibe and has multiple factors that increase subsequent risk for ASCVD events, a PCSK9 inhibitor may be considered, although long-term safety (>3 years) is uncertain and economic value is low based on list prices from mid-2018.

5. Adults aged 40 to 75 years with diabetes mellitus and an LDL-C level of 1.8 mmol/L (70 mg/dL) or higher. In these patients, the guidelines recommend starting moderate-intensity statin therapy without the need to calculate 10-year ASCVD risk. In patients with diabetes and higher risk, especially those who have multiple risk factors or are aged 50 to 75 years, use of a high-intensity statin is reasonable to reduce the LDL-C level by at least 50%.

6. Clinician–patient risk discussion. In adults aged 40 to 75 years who are evaluated for primary ASCVD prevention, the guidelines continue to recommend a clinician–patient risk discussion before statin therapy is started. Risk discussion should include review of major risk factors (such as cigarette smoking and elevated levels of blood pressure, LDL-C, hemoglobin A1c level [if indicated], or calculated 10-year risk for ASCVD), risk-enhancing factors (see recommendation 8), the potential benefits of lifestyle and statin therapies, the potential for adverse effects and drug–drug interactions, consideration of costs of statin therapy, and patient preferences and values in shared decision making.

7. Adults aged 40 to 75 years without diabetes mellitus who have LDL-C levels of at least 1.8 mmol/L (70 mg/dL), and a 10-year ASCVD risk of 7.5% or higher. In this population, the guidelines recommend moderate-intensity statin therapy if a discussion of treatment options favors statins. Patients without ASCVD are categorized and stratified for risk by age, coexisting conditions, and risk factors (Figure). When those with diabetes or LDL-C levels above 4.9 mmol/L (190 mg/dL) are excluded, RCT evidence for the benefit of statin therapy in persons aged 40 to 75 years continues to accumulate (10). Patients in this age range are triaged into 4 categories of 10-year risk for ASCVD: low (<5%), borderline (5% to 7.4%), intermediate (7.5% to 19.9%), and high (≥20%). In the latter category, the guideline recommends high-intensity statin therapy because of its proven benefit. Evidence from RCTs supports the efficacy of statin therapy for patients whose 10-year risk is 5% or higher. Nonetheless, in those with borderline or intermediate risk, clinical judgment is required to initiate statin treatment on the basis of risk–benefit considerations and patient preferences.

8. Decision making in primary prevention in adults aged 40 to 75 years. The guideline endorses a 3-tiered decision process for treatment in adults aged 40 to 75 years with borderline (5% to 7.4%) or intermediate (7.5% to 19.9%) risk for ASCVD. The decision process begins with estimation of 10-year risk. As in prior guidelines, 10-year risk of 7.5% or higher does not result in automatic statin assignment. To personalize risk, the current guideline recommends evaluation of risk-enhancing factors—that is, stable factors that associate with ASCVD beyond the major risk factors incorporated into the risk calculator. These include family history of premature ASCVD; LDL-C levels of 4.1 mmol/L (160 mg/dL) or higher; metabolic syndrome; chronic kidney disease; history of preeclampsia or premature menopause (in women); chronic inflammatory disorders; high-risk ethnicity, such as South Asian ancestry; triglyceride levels persistently elevated above 2.0 mmol/L (175 mg/dL); and, if measured, elevations in apolipoprotein B (may be especially useful if hypertriglyceridemia >2.3 mmol/L [>200 mg/dL] persists), high-sensitivity C-reactive protein levels of 19.0476 nmol/L (2.0 mg/L) or higher, lipoprotein(a) levels with elevations above 125 nmol/L (50 mg/dL) (especially useful in those with a family history of premature ASCVD), or reduced ankle–brachial index. Presence of risk-enhancing factors in patients at intermediate risk favors statin therapy. In addition, if risk status remains uncertain, measurement of coronary artery calcium (CAC) can be considered.

9. CAC scoring to improve risk stratification. In adults who do not have diabetes, are aged 40 to 75 years, have LDL-C levels of 1.8 to 4.9 mmol/L (70 to 189 mg/dL), and have a 10-year risk of 7.5% to 19.9% as estimated by the pooled cohort equations (PCEs), but who are uncertain about statin benefit, CAC scoring may help resolve the uncertainty. If the CAC score is 0 Agatston units, statin therapy may be withheld or delayed, except in cigarette smokers and those with a strong family history of premature ASCVD or diabetes. A CAC score of 1 to 99 units favors statin therapy, especially in patients older than 55 years. For any patient, if the CAC score is at least 100 Agatston units or is at or above the 75th percentile, statin therapy is indicated unless otherwise deferred by the outcome of a clinician–patient risk discussion.

10. Follow-up for adherence and adequacy of response. The current guideline continues to recommend assessment of adherence to medications and lifestyle and percentage change in LDL-C level at 4 to 12 weeks after statin initiation or dosage adjustment; this assessment should be repeated every 3 to 12 months as needed. Clinicians may often underestimate adherence unless specific questions are asked (11).

Patient Education: Diet and Health

Patient Education: Diet and Health

The food choices we make can have an important impact on our health. However, expert opinions continue to change about which and how much of these foods are optimal.

FRUITS AND VEGETABLES — Several studies have demonstrated important health benefits of eating fruits and vegetables.

  • Increased intake of fruits and vegetables is linked to a lower risk of premature death.
  • Fruits and vegetables decrease the risk of cardiovascular diseases including coronary heart disease (CHD), stroke, and death from CHD.
  • High intake of fruits and vegetables may reduce the risk of developing cancer. Tomato and tomato-based foods may be beneficial at lowering the risk of prostate cancer.
  • Recommended intake is at least five servings of fruits and/or vegetables every day.

FIBER — Eating a diet that is high in fiber can decrease the risk of coronary heart disease (CHD), colon cancer, and death. Eating fiber also protects against type 2 diabetes and eating soluble fiber (such as that found in vegetables, fruits, and especially legumes) may help control blood sugar in people who already have diabetes.

The recommended amount of dietary fiber is 25 grams per day for women and 38 grams per day for men. Many breakfast cereals, fruits, and vegetables are excellent sources of dietary fiber. By reading the product information panel on the side of the package, it is possible to determine the number of grams of fiber per serving.

GRAINS AND SUGAR — Whole grain foods (like 100 percent whole wheat bread, steel cut oats, and wild/brown rice) should be chosen over foods made with refined grains (like white bread and white rice). Regularly eating whole grains has been shown to help weight loss and lower the risk of diabetes. Regularly consuming refined grains and added sugars has been associated with weight gain and increased risk of diabetes.

FAT — Eating foods higher in healthy fats and lower in unhealthy fats may reduce the risk of coronary heart disease (CHD).

The type of fat consumed appears to be more important than the amount of total fat. Trans fats should be avoided in favor of polyunsaturated fats, particularly those polyunsaturated fats found in fish (omega 3). Other sources of polyunsaturated fats that may be beneficial include certain oils, nuts, and seeds (like corn oil, flax seeds, and walnuts).

Trans fats appear on food labels as “partially hydrogenated oils” and are solid at room temperature. They are found in many margarines and commercial baked goods as well as in oils kept at high temperatures for a long period, such as frying vats in fast food restaurants.

Although saturated fats (found in animal products such as cheese, butter, and red meat) have typically been viewed as unhealthy, and monounsaturated fats (found in combination with other fats in many oils, such as olive oil) as healthy, newer evidence suggests that saturated and monounsaturated fats do not significantly increase or decrease the risk of CHD, although saturated fats raise cholesterol levels.

If cutting back on certain fats, it is important not to replace them with refined carbohydrates (eg, white bread, white rice, most sweets). Increases in refined carbohydrate intake may lower levels of high-density lipoprotein (HDL) cholesterol (good cholesterol), which actually increases the risk of CHD.

RED MEAT — It is now well-established that regularly eating red meat, particularly processed meats (like salami, pepperoni, and ham), is detrimental to health. It increases the risk of numerous diseases such as cancer, cardiovascular disease, and diabetes.

FOLATE — Folate is a type of B vitamin that is important in the production of red blood cells. Low levels of folate in pregnant women have been linked to a group of birth defects called neural tube defects, which includes spina bifida and anencephaly. Vitamins containing folate and breakfast cereal fortified with folate are recommended as the best ways to ensure adequate folate intake.

ANTIOXIDANTS — The antioxidant vitamins include vitamins A, C, E, and beta-carotene. Many foods, especially fruits and vegetables, contain these vitamins as well as have additional antioxidant properties. Studies have not clearly shown that antioxidant vitamins help prevent disease, specifically cancer, and some studies show they may cause harm. There is no evidence to support taking antioxidant vitamin supplements, except for individuals who have specific vitamin deficiencies.

CALCIUM AND VITAMIN D — Adequate calcium and vitamin D intake are important, particularly in women, to reduce the risk of osteoporosis. A health care provider can help to decide if supplements are needed, depending upon a person’s dietary intake of calcium and vitamin D. Although the optimal level has not been clearly established, experts recommend that premenopausal women and men consume at least 1000 mg of calcium per day and postmenopausal women should consume 1200 mg per day. No more than 2000 mg of calcium should be consumed per day.

For vitamin D, 800 international units (20 micrograms) per day is recommended for adults over 70 years old and postmenopausal women. For other adults, the optimal intake is not clearly established, but 600 international units (15 micrograms) per day is generally recommended.

ALCOHOL — Moderate alcohol intake may reduce the risk of heart disease. However, drinking is also associated with many adverse events. Regularly drinking alcohol increases the risk of breast cancer in women; cancers of the mouth, esophagus, throat, larynx, and liver; other illnesses such as cirrhosis and alcoholism; and injuries and other trauma-related problems, particularly in men.

Based on the trade-off between these risks and benefits, the United States Dietary Guidelines recommend alcohol intake in moderation, if at all. This means no more than one drink per day for women and up to two drinks per day for men. Those who do not drink alcohol do not need to start.

Drinking is discouraged for those under 40 years who are at low risk of cardiovascular disease because the risks are likely to outweigh the benefits in this group.

CALORIC INTAKE — Of all aspects of diet, calories are possibly the most important when it comes to good health and preventing disease. Too many calories lead to weight gain and obesity. Excess weight is linked to premature death as well as an increased risk of cardiovascular disease, diabetes, hypertension, numerous cancers, and other important diseases.

The total number of calories a person needs depends upon the following factors:

  • weight
  • age
  • gender
  • height
  • activity level

GENERAL RECOMMENDATIONS FOR A HEALTHY DIET — Eat lots of vegetables, fruits, and whole grains and a limited amount of red meat. Get at least five servings of fruits and vegetables every day. Tips for achieving this goal include:

  • Make fruits and vegetables part of every meal. Eat a variety of fruits and vegetables. Frozen or canned can be used when fresh isn’t convenient.
  • Eat vegetables as snacks.
  • Have a bowl of fruit all the for kids to take snacks from.
  • Put fruit on your cereal.
  • Consume at least half of all grains as whole grains (100 percent whole wheat bread, brown rice, whole grain cereal), replacing refined grains (like white bread, white rice, refined or sweetened cereals)
  • Choose smaller portions and eat more slowly.

Cut down on unhealthy fats (trans fats and saturated fats) and consume more healthy fats (polyunsaturated and monounsaturated fat). Tips for achieving this goal include:

  • Choose chicken, fish, and beans instead of red meat and cheese.
  • Cook with oils that contain polyunsaturated and monounsaturated fats, like corn, olive and peanut oil.
  • Choose margarines that do not have partially hydrogenated oils. Soft margarines (especially squeeze margarines) have less trans fatty acids than stick margarines.
  • Eat fewer baked goods that are store-made and contain partially hydrogenated fats (like many types of crackers, cookies, and cupcakes).
  • When eating at fast food restaurants, choose healthy items for yourself as well as your family, like broiled chicken or salad.
  • If choosing prepared or processed foods, choose those labeled “zero trans-fat.” They may still have some trans-fat, but likely less than similar choices not labeled “zero.”

Avoid sugary drinks and excessive alcohol intake. Tips for achieving this goal include:

  • Choose non-sweetened and non-alcoholic beverages, like water, at meals and parties.
  • Avoid occasions centered around alcohol.
  • Avoid making sugary drinks and alcohol an essential part of family gatherings.

Keep calorie intake balanced with needs and activity level.

Gutchek Introduction

Gutchek Introduction

Twenty-three years ago, I started writing articles to give updates to my fellow colleagues under the banner “JUST SO YOU KNOW.” As president of Unity Hospital medical and dental staff, these articles were hugely popular and have become my tradition ever since. In late 80s and early 90s, I was writing articles regarding common GI medical issues to educate our physicians under the name GUTCHEK as newsletter. Once I had set up our practice website in late 90s, articles were then posted under and were enjoyed by patients and physicians alike.

Now as a retired Gastroenterologist, I am beginning a new chapter as a blogger. Going forward, will contain common digestive disease-related pearls for the benefit of patients. Also, this website will periodically post articles of medical and non-medical interest from other sources as well. I will offer surveys time to time. will offer free information to the general public about their digestive disorder symptoms. Within Monroe County, I will be able to provide support about seeking experts in the area.

I am open to suggestions as to what other content to include on

Tarun Kothari, MD, FACG, FACP

Disclaimer Notice: and the information contained within is provided for general education and informative purposes only. Articles do not constitute medical advice. Please consult with your own health care provider for proper diagnosis and treatment.

Guideline Issued for Treatment of Mild, Moderate Ulcerative Colitis

Guideline Issued for Treatment of Mild, Moderate Ulcerative Colitis

Guideline Issued for Treatment of Mild, Moderate Ulcerative
A new clinical guideline from the American Gastroenterological
Association (AGA) published Dec 18 in Gastroenterology focuses
on the medical management of patients with mild-to-
moderate ulcerative colitis (UC).

To inform the guideline, Siddharth Singh, MD, from the University of California in San Diego, and colleagues compiled the clinical evidence in accordance with the Grading of Recommendations

Assessment, Development, and Evaluation framework.
In the guideline, Cynthia W. Ko, MD, from the University of
Washington in Seattle, and colleagues note that most UC patients
have a mild-to-moderate course characterized by periods of
activity or remission. For patients with extensive mild-to-moderate UC, using standard-dose mesalamine or diazo-bonded 5-ASA is recommended rather than low-dose mesalamine, sulfasalazine, or no treatment. Rectal mesalamine should be added to oral 5-ASA for patients with extensive or left-sided mild-to-moderate UC.

High-dose mesalamine with rectal mesalamine is recommended
for patients with mild-to-moderate UC with suboptimal response to standard-dose mesalamine or diazo-bonded 5-ASA. Once-daily
dosing is recommended rather than multiple-daily dosing for
patients with mild-to-moderate UC being treated with oral
mesalamine. For induction of remission, standard-dose oral
mesalamine or diazo-bonded 5-ASA is recommended rather than
budesonide MMX or controlled ileal-release budesonide.

“We identified several knowledge gaps and areas for future research in this patient population,” Ko and colleagues write. “Due to evidence gaps, the AGA makes no recommendation for use of probiotics, curcumin, or fecal microbiota transplantation in patients with mild-to- moderate UC.”

Endoscopy Overview

Endoscopy Overview

ENDOSCOPY OVERVIEW — An upper endoscopy, often referred to as endoscopy, EGD, or esophago-gastro-duodenoscopy, is a procedure that allows a physician to directly examine the upper part of the gastrointestinal (GI) tract, which includes the esophagus, the stomach, and the duodenum (the first section of the small intestine)
The physician who performs the procedure, known as an endoscopist, has special training in using an endoscope to examine the upper GI system, looking for inflammation (redness, irritation), bleeding, ulcers, or tumors.
REASONS FOR UPPER ENDOSCOPY — The most common reasons for upper endoscopy include:

●Unexplained discomfort or pain in the upper abdomen.
●GERD or gastroesophageal reflux disease (often called heartburn.)
●Persistent nausea and vomiting.
●Upper gastrointestinal (GI) bleeding (vomiting blood or blood found in the stool that originated from the upper part of the GI tract). Bleeding can be treated during the endoscopy.
●Iron deficiency anemia (low blood count associated with a low iron level in the blood) in someone who has had no visible bleeding.
●Difficulty swallowing; food/liquids getting stuck in the esophagus during swallowing. This may be caused by a narrowing (stricture) or tumor or because the esophagus is not contracting properly. If there is a stricture, it can often be dilated with special balloons or dilation tubes during the endoscopy.
●Abnormal or unclear findings on an upper GI x-ray, CT scan, or MRI.
●Removal of a foreign body (a swallowed object).
●To check healing or progress on previously found polyps (growths), tumors, or ulcers.

ENDOSCOPY PREPARATION — You will be given specific instructions regarding how to prepare for the examination before the procedure. These instructions are designed to maximize your safety during and after the examination and to minimize possible complications. It is important to read the instructions ahead of time and follow them carefully. Do not hesitate to call the physician’s office or the endoscopy facility if there are questions.
You may be asked not to eat or drink anything for up to eight hours before the test. It is important for your stomach to be empty to allow the endoscopist to visualize the entire area and to decrease the possibility of food or fluid being vomited into the lungs while under sedation (called aspiration).
You may be asked to adjust the dose of your medications (such as insulin) or to stop specific medications (such as blood thinning medications) temporarily before the examination. You should discuss your medications with your physician before your appointment for the endoscopy.
You should arrange for a friend or family member to escort you home after the examination. Although you will be awake by the time you are discharged, the medications used for sedation may cause temporary changes in the reflexes and judgment and interfere with your ability to drive or make decisions (similar to the effects of alcohol). Patients who receive sedation are often required to be accompanied home after the procedure.

WHAT TO EXPECT DURING ENDOSCOPY — Prior to the endoscopy, the staff will review your medical and surgical history, including current medications. A physician will explain the procedure and ask you to sign consent. Before signing consent, you should understand the benefits and risks of the procedure, alternatives to the procedure, and all of your questions should be answered.

If you are going to receive sedation for the procedure, an intravenous line (a needle inserted into a vein in the hand or arm) will be inserted to deliver medications. You may be given a combination of a sedative (to help you relax) and a narcotic (to prevent discomfort), or other medications that are commonly used for sedation.
Your vital signs (blood pressure, heart rate, and blood oxygen level) will be monitored before, during, and after the examination. The monitoring is not painful. Oxygen is often given during the procedure through a small tube that sits under the nose and is fitted around the ears. For safety reasons, dentures should be removed before the procedure.

Although most patients are sedated for the examination, many tolerate the procedure well without any medication. Usually, these patients are given a medication to numb the back of their throats (either a gargle or a spray) just prior to the endoscopy to prevent gagging during the passage of the instrument. This may be offered to patients felt to be at higher risk for receiving sedation. Otherwise, if you are interested in having your endoscopy in this sedation-free manner, you should discuss this with the doctor beforehand to see if this is a possibility for you.

THE ENDOSCOPY PROCEDURE — The procedure typically takes between 10 and 20 minutes to complete. The endoscopy is performed while you lie on your left side. A plastic mouth guard is placed between the teeth to prevent damage to the teeth and endoscope.

The endoscope (also called a Gastroscope) is a flexible tube that is about the size of a finger. The endoscope has a lens and a light source that allows the endoscopist to see the inner lining of the upper gastrointestinal (GI) tract, usually on a TV monitor. Most people have no difficulty swallowing the flexible Gastroscope because of the sedating medications. Many people sleep during the test; others are very relaxed and generally not aware of the examination.
An alternative procedure called trans nasal endoscopy may be available in some facilities. This involves passing a very thin scope (about the size of a drinking straw) through the nose. You are not sedated but a medication is applied to the nose to prevent discomfort. A full examination can be performed with this instrument.
The endoscopist may take tissue samples called biopsies. Obtaining biopsies is not painful. The endoscopist may also perform specific treatments (such as dilation, removal of polyps, treatment of bleeding), depending upon what is found during the examination. Air or carbon dioxide gas is gently introduced through the endoscope to open the esophagus, stomach, and intestine, allowing the endoscope to be passed through these areas and improving the endoscopist’ s ability to see completely. You may experience mild discomfort as air is pushed into the stomach and intestinal tract. This is not harmful; belching may relieve the sensation. The endoscope does not interfere with breathing. Taking slow, deep breaths just before and during the procedure may help you to relax.

RECOVERY FROM ENDOSCOPY — After the endoscopy, you will be observed for a period of time, generally less than one hour, while the sedative medication wears off. Some of the medicines commonly used cause some people to temporarily feel tired or have difficulty concentrating. You typically will be instructed not to drive and not to return to work for the balance of the day of the procedure.

The most common discomfort after the examination is a feeling of bloating as a result of the air introduced during the examination. This usually resolves quickly. Some patients also have a mild sore throat. Most patients are able to eat shortly after the examination.

ENDOSCOPY COMPLICATIONS — Upper endoscopy is a safe procedure and complications are rare. The following is a list of some possible complications:
●Aspiration (inhaling) of food or fluids into the lungs, the risk of which can be minimized by not eating or drinking for the recommended period of time before the examination.
●Reactions to the sedative medications are possible; the endoscopy team (doctors and nurses) will ask about previous medication allergies or reactions and about health problems such as heart, lung, kidney, or liver disease. Providing this information to the team ensures a safer examination.
●The medications may produce irritation in the vein at the site of the intravenous catheter. If redness, swelling, or discomfort occurs, you should call your endoscopist or primary care provider, or the number given to you at discharge.
●Bleeding can occur from biopsies or the removal of polyps, although if bleeding occurs, it is usually minimal and stops quickly on its own or can be easily controlled.
●The endoscope can cause a tear or hole in the area being examined. This is a serious complication but fortunately occurs extremely rarely.
The following signs and symptoms should be reported immediately:
●Severe abdominal pain (more than gas cramps)
●A firm, distended abdomen
●Any temperature elevation
●Difficulty swallowing or severe throat pain
●A crunching feeling under the skin of the neck

AFTER UPPER ENDOSCOPY — Most patients tolerate endoscopy very well and feel fine afterwards. Some fatigue is common after the examination, and you should plan to take it easy and relax the rest of the day.
The endoscopist can describe the result of the examination before you leave the endoscopy facility. If biopsies have been taken or polyps removed, you should call for results at a time specified by the endoscopist, typically within one week.

Colonoscopy Overview

Colonoscopy Overview

COLONOSCOPY OVERVIEW — A colonoscopy is an exam of the lower part of the gastrointestinal tract, which is called the colon or large intestine (bowel). Colonoscopy is a safe procedure that provides information other tests may not be able to give. Patients who require colonoscopy often have questions and concerns about the procedure.
Colonoscopy is performed by inserting a device called a colonoscope into the anus and advancing through the entire colon. The procedure generally takes between 20 minutes and one hour.
Other tests that are sometimes used to screen for colon cancer, like virtual colonoscopy (also called CT colonography),

More detailed information about colonoscopy is available by subscription..
REASONS FOR COLONOSCOPY — The most common reasons for colonoscopy are:

●To screen for colon polyps (growths of tissue in the colon) or colon cancer
●Rectal bleeding
●A change in bowel habits, like persistent diarrhea
●Iron deficiency anemia (a decrease in blood count due to loss of iron)
●A family history of colon cancer
●A personal history of colon polyps or colon cancer
●Chronic, unexplained abdominal or rectal pain
●An abnormal x-ray exam, like a barium enema or CT scan

COLONOSCOPY PREPARATION — Before colonoscopy, your colon must be completely cleaned out so that the doctor can see any abnormal areas. This is vitally important to increase the chances that your doctor will identify abnormalities in your colon. If your colon is not completely cleaned out, the chances your doctor will miss abnormalities increases. Your doctor’s office will provide specific instructions about how you should prepare for your colonoscopy. Be sure to read these instructions as soon as you get them so you will know how to take the preparation and whether you need to make any changes to your medications or diet. If you have questions, call the doctor’s office in advance.

You will need to avoid solid food for at least one day before the test. You should also drink plenty of clear fluids on the day before the test. You can drink clear liquids (a liquid you can hold up to the light and see through) up to several hours before your procedure, including:

●Clear broth (beef, chicken, or vegetable)
●Coffee or tea (without milk)
●Gelatin such as Jell-O (avoid red gelatin)

Avoid drinking red liquids. Your doctor may also ask you to avoid high fiber foods including seeds and nuts for the week before the procedure.

To clean the colon, you will take a strong laxative and empty your bowels. You may be asked to take the entire preparation the night before the test, or you may be asked to take it in two doses, with the second dose taken four to six hours prior to the colonoscopy. Taking the preparation in two “split” doses may help get the colon even cleaner. This may require you to wake up early in the morning to complete the preparation. The instructions you are given will tell you how you should take the preparation.

A commonly used preparation is a 4-liter (1 gallon) solution that is purchased at the pharmacy with a prescription. There are several low-volume (2- to 3-liter) preparations on the market as well. Some doctors prefer citrate of magnesia (also called magnesium citrate), a 300 mL (10 ounce) bottle that requires no mixing and is over-the-counter. Packets of powdered laxative are available that are mixed with a smaller volume of water. Sodium phosphate-based preparations are now usually avoided due to concerns over safety.

Refrigerating the solution can make it easier to drink, but do not put ice in the solution since it will melt and you will have to drink even more fluid. Drinking the solution through a straw, adding sugar-free powdered flavor packets (ex. Crystal Light), and taking half the preparation the night before and the other half later (four to six hours before your colonoscopy) may also make it easier to drink. Drinking this solution may be the most unpleasant part of the exam. Watery diarrhea is the desired result. This may occur shortly after drinking the solution or may be delayed for several hours. The result should be diarrhea that looks like urine. If you become nauseated or vomit while drinking the solution, call your doctor or nurse for instructions. Tips that can help with nausea and vomiting include temporarily stopping drinking the solution, walking around, and resuming drinking at a slower pace.
Medicines — You can take most prescription and nonprescription medicines right up to the day of the colonoscopy. Your doctor should tell you what medicines to stop. You should also tell the doctor if you are allergic to any medicines.

Some medicines increase the risk of heavy bleeding if you have a polyp removed during the colonoscopy. Ask your doctor how and when to stop these medicines, including warfarin/Coumadin, Clopidogrel/Plavix, or any other anticoagulant (blood thinning) medicine. Do not stop these medications without first talking with your doctor.
Transportation home — Most patients are given a sedative (a medicine to help you relax) during the colonoscopy, so you will need someone to take you home after your test. Your doctor may prefer that an anesthesiologist administer the sedative and monitor you during the colonoscopy. Although you will be awake by the time you go home, the sedative/anesthetic medicines cause changes in reflexes and judgment that can interfere with your ability to make decisions, similar to the effect of alcohol. You will not be able to drive home or go back to work after the examination if you received sedation for the procedure. You should be able to return to work the next day.

WHAT TO EXPECT — Before the test, a doctor will review the procedure with you, including possible complications, and ask you to sign a consent form.

An IV line will be inserted in your hand or arm. Your blood pressure, heart rate, and breathing will be monitored during the test.

THE COLONOSCOPY PROCEDURE — You will be given fluid and medicines through the IV line. With sedation/analgesia provided during the colonoscopy, many people sleep during the test, while others are very relaxed, comfortable, and generally not aware. Your doctor may request an anesthesiologist give you an anesthetic agent (for example, Propofol), which is a stronger sedative and will put you to sleep while you are being closely monitored.

The colonoscope is a long black flexible tube, approximately the diameter of the index finger. The doctor will gently pump air or carbon dioxide and sterile water or saline through the scope into the colon to inflate it and allow the doctor to see the entire lining. You might feel bloating or gas cramps as the air opens the colon. Try not to be embarrassed about passing this gas (it is just air), and let your doctor know if you are uncomfortable. You may feel like you have to go to the bathroom, which is a normal feeling during the procedure.
During the procedure, the doctor might take a biopsy (small pieces of tissue) or remove polyps. Polyps are growths of tissue that can range in size from the tip of a pen to several inches. Most polyps are benign (not cancerous). However, some polyps can become cancerous if allowed to grow for a long time. Having a polyp removed does not hurt.

RECOVERY FROM COLONOSCOPY — After the colonoscopy, you will be observed in a recovery area, usually for about 30 to 60 minutes until the effects of the sedative medication wear off. The most common complaint after colonoscopy is a feeling of bloating and gas cramps. You should pass gas and not feel embarrassed doing this either during or after the procedure. This will relieve your feelings of bloating and cramping. You may also feel groggy from the sedation medications. You should not return to work, drive, or drink alcohol that day. Most people are able to eat normally after the test. Ask your doctor when it is safe to restart aspirin and other blood-thinning medications.

COLONOSCOPY COMPLICATIONS — Colonoscopy is a safe procedure, and complications are rare but can occur:
●Bleeding can occur from biopsies or the removal of polyps, but it is usually minimal and can be controlled.
●The colonoscope can cause a tear or hole in the colon. This is a serious problem that sometimes requires surgery to repair, but it does not happen commonly.
●It is possible to have side effects from the sedative medicines like nausea or vomiting.
●Although colonoscopy is the best test to examine the colon, it is possible for even the most skilled doctors to miss or overlook an abnormal area in the colon.
You should call your doctor immediately if you have any of the following:
●Severe abdominal pain (not just gas cramps)
●A firm, bloated abdomen
●Rectal bleeding (greater than a couple of tablespoons [30 mL])

AFTER COLONOSCOPY — Although many people worry about being uncomfortable during a colonoscopy, most people tolerate it very well and feel fine afterward. It is normal to feel tired afterward. Plan to take it easy and relax the rest of the day.
Your doctor can describe the results of the colonoscopy as soon as it is over. If s/he took biopsies or removed polyps, you should call for results within one to two weeks if your doctor has not already contacted you.