November 2013

The most important thing physicians can do is listen closely to a patient’s problems, use our training to identify the source and the factors that affect it and try to guide our patients through effective solutions that fit with their lifestyle, personal beliefs and priorities.

December 5, 2013

Q:

How would you treat gastroparesis?

A:

Gastroparesis, a problem with very slow emptying of stomach contents, is a very challenging disease to treat.  The mainstay of therapy is dietary management.  A gastroparesis diet focuses on changing from the traditional three meals a day to approximately six small meals a day.  Essentially one should become a “grazer,” eating small amounts at a time to deal with the slower motility that occurs.  Strict management of blood sugar is crucial for people with diabetes, a common cause of gastroparesis.  A low-fat, low-fiber diet is also a big part of management.  Fat slows stomach emptying, which compounds the problem, though some dietitians believe that drinks like milkshakes that contain fat are less of a problem and are a source of calories when solid foods are tough to eat.  Cooking vegetables breaks down much of the fiber and can make this very important food group more tolerable.  Liquid emptying from the stomach is usually easier, even in severe gastroparesis, so when the symptoms are bad, I usually recommend switching to a liquid diet until the symptoms are better controlled.

There are unfortunately very few good medications for gastroparesis.  The only approved medication is called metoclopramide, which can have many serious side effects when used long term.  Another medication that has been studied but is not approved for use in the U.S. is domperidone.  I usually try to stop any medications that can worsen stomach emptying.  This commonly includes opioid pain medications.  Nausea is a frequent side effect of opioids, and they all worsen gut function.  I also use medications that specifically treat nausea.  Like many other physicians who treat this difficult disease, I use other strategies that have not been well-studied and are considered “off-label” (medications that are approved for different diseases) if symptoms remain severe and uncontrolled.

A very important part of therapy that is commonly overlooked is behavioral therapy.  Finding a good behavioral therapist or counselor can be a challenge, but I am lucky to know many psychologists with expertise in gastrointestinal diseases.  These strategies can add a great deal to the management of gastroparesis, and since they are not medication-based, there are no worrisome side effects.  Some alternative therapies like acupuncture and hypnosis have also been studied for gastroparesis, though the results have been mixed.

Some people cannot maintain adequate nutrition with diet and medication alone.  When this occurs, inserting a feeding tube into the stomach or small intestine can help improve nutrition, hydration and symptoms.  Though we do not offer it at Loyola, several local centers are implanting medical devices called “gastric pacemakers” into the stomach of patients with gastroparesis who have not had adequate relief with diet and medications.  The pacemakers provide electrical stimulation to the stomach, which helps relieve gastroparesis symptoms, but, contrary to popular belief, they do not actually improve stomach emptying.  While these devices provide relief to many patients with gastroparesis, they are not as effective in all types of gastroparesis, and there could be serious complications with this procedure so you should discuss this with your physician before deciding to go this route.

December 5, 2013

Q:

I have EE (eosinophilic esophagitis ) in which my esophagus is very narrow and food gets lodged in my throat from time to time. Is it best to do an elimination diet compared to an allergy scratch test to figure out if I have any internal allergies? Which one is more accurate? What is the most modern treatment for this autoimmune issue?

A:

Diagnosing the actual food allergies involved in each person’s eosinophilic esophagitis disease is difficult, as no allergy tests are without some problems in interpretation.  They also may not pick up all of one’s sensitivities.  Elimination diets can be difficult to follow, but it will likely get you closer to clinical relief than eliminating only things identified on an allergy scratch test, as many patients find other foods reliably cause problems that may not show up on the allergy test.  As for therapy, unfortunately we have not identified reliable therapy beyond steroids (either topical or pill form) and elimination or elemental diets.  Reflux disease medications are helpful for people who also have a true acid-reflux component.  Allergy medications like montelukast are often used, but there is no strong evidence they work.  There are future medications under development, but they are not available for use yet.

December 5, 2013

Q:

I have burning pain in my right, lower quadrant after a bowel movement and at night. I tried Tums and it helped a little bit. I have regular bowel movements. Do you have any suggestions?

A:

It’s unusual you found relief with Tums, which is an antacid, because the location of the pain and the timing with bowel movements would not suggest there is a connection with heartburn or esophageal reflux. Unfortunately, without knowing more details about this pain, I can’t provide you with further recommendations.  In general, people who have right, lower quadrant pain can have pain from a prior surgery, Irritable Bowel Syndrome, Inflammatory Bowel Disease, constipation, gynecological reasons or other more unusual problems.  These diseases are treated very differently and you should consult with your doctor to help sort it out.

December 5, 2013

Q:

Can you give me advice on the recommended number of fat grams a woman (54 years old, 5 foot 2 and approximately 125 lbs.) should be eating to lower cholesterol levels a bit. I just received a cholesterol reading from a fasting blood draw that was more than the consistent optimal levels I’ve maintained. I understand fat intake can be about 30 percent of intake (?), but want to know how many fat grams, so I can count them.

A:

Special thanks to Elizabeth Chmel, MS, RD, CNSC, who specializes in cardiovascular and transplant nutrition, for her help in answering this question.

This is a tricky question because there are so many other things that influence the cholesterol level beyond the amount of fat you eat each day. You may not be able to lower that level by simply eating less fat. Make sure that you are looking at the “bad” cholesterol level, the LDL, before you get worried because your total cholesterol level can be elevated by having a high “good” cholesterol level, the HDL.

It is important to know that there are four major dietary fats, and they have different effects on your body. Monounsaturated fat (MUFA) and polyunsaturated fats (PUFA) are considered “healthy fats” and may improve your cholesterol levels. Examples of foods high in MUFAs may include many nuts, seeds, olive oil, canola oil, peanut oil, sunflower oil and sesame oil. Omega-3, a PUFA, has specifically been shown to help lower your risk of cardiovascular disease. More recently, research explores the ratio of Omega-6:Omega-3 PUFAs in your diet and its impact on your health.  Omega-3 PUFAs are found in foods from plants, such as soybean oil, canola oil, walnuts and flax. However, they can be found in fatty fish and shellfish, such as salmon, anchovies, herring and trout. USDA recommends 8 oz. or more of these per week. As a rule of thumb, these fats will usually be liquid at room temperature.

Saturated and trans fats are usually more solid at room temperature. Saturated fat, found in dairy products, meats, some oils (such as palm), cocoa butter and certain baked goods, may truly raise your bad cholesterol – the LDL level. According to the American Heart Association, you should limit your saturated fat intake to less than 7 percent of your daily calories, limiting your total fat to less than 25-35 percent of your total calories each day. USDA recommends that less than 10 percent of your daily calories be from saturated fat.  For someone of your size, recommended calories per day for weight maintenance with light physical activity is around 1,500 calories/day, which means you should eat less than 50 total grams of fat (30 percent) and 12-17 (7-10 percent) grams of saturated fat a day.

It’s important to remember that we need some fat in our diet because it helps to absorb fat-soluble vitamins and promotes healthy cell function, among other things. Some essential fatty acids cannot be produced by the body and need to be consumed in small amounts.

As stated earlier, this is a tricky question, as lifestyle- and non-lifestyle-related factors may influence cholesterol levels.

Another lifestyle factor, exercise, can help improve cholesterol levels. The American Heart Association recommends 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise with muscle strengthening two or more days per week.

December 5, 2013

Q:

I already know I have celiac disease, but I don’t want to go through the trouble of getting it diagnosed since I’ve been gluten-free for more than a year. What would you recommend as other treatment options?

A:

It is really important to know for sure if you have celiac disease.  The symptoms of celiac disease and gluten intolerance are identical, and they both respond to a gluten-free diet, so it’s impossible to know for sure if you have celiac disease once you’ve eliminated gluten from your diet.  There are big differences, though, in the treatment options and potential long-term diseases associated with each one.  The only treatment option for true celiac disease is a gluten-free diet.  However, if one is truly gluten-free and is still experiencing symptoms, then either the celiac disease is what we call “refractory” and may need different therapy, or your symptoms are not due to celiac disease.  People with true celiac disease are at risk for cancer if they cheat on the gluten-free diet, but people with gluten intolerance can cheat now and then without putting their health at risk.

December 5, 2013

Q:

I have been suffering from what I believe to be celiac disease symptoms since 2007. I have seen several gastroenterologists who have not helped. I have been self-educating myself and been gluten-free since 2012. Is it worth it to keep battling with doctors and risk a gluten diet in order to properly diagnose myself, or should I continue my self-treatment path and find my own peace?

A:

It is important to truly know if you have celiac disease or gluten intolerance, or some other overlapping problem such as bacterial overgrowth or diarrheal predominant IBS.  It is important because people with true celiac disease are at risk of many serious health problems, including cancer, but those with gluten intolerance or the other potential problems are not.

I think it is worth a gluten challenge (that is reintroducing gluten into your diet for 4-6 weeks) and a formal diagnosis of celiac disease.  This is a barrier to many people who don’t want to suffer with the symptoms of celiac disease just to have a diagnosis.  I emphasize to my patients, though, that knowing whether you really have celiac disease or not will allow you to “cheat” now and then on your diet (if you are found to be gluten intolerant). You also will not continue to worry that you are putting yourself at risk of serious things down the road.

November 18, 2013

Q:

I spoke to a nutritionist recently about my frequent bouts of diarrhea and she said that I may have developed an intolerance to dairy and/or gluten. It is so difficult to change my diet that radically with a diet that often consists of fast-food lunches. Should I first rule out a medical issue or should I try eliminating these from my diet first?

A:

Regarding gluten, you should absolutely speak to a physician first.  You need to rule out Celiac disease before you eliminate gluten from your diet.  Lactose is a different story.  While there are tests for lactose intolerance, and we do offer those tests, I don’t feel it is worth the cost when one can pretty easily eliminate dairy for a month at least to see if this makes a difference.

November 18, 2013

Q:

Do you or other resources in your health system provide consultation for patients with regards to a FODMAP diet?

A:

Yes we have more than one dietitian with expertise in the FODMAP diet, and we have patient information and support for the diet, which is emerging as a valuable tool in the treatment of irritable bowel syndrome.

November 14, 2013

Q:

I’ve always had trouble with constipation and hemorrhoids. Last year I had a colonoscopy before hemorrhoid surgery and everything was negative. Surgery was painful but ultimately successful. I continue to struggle with constipation and since surgery my stool has become relatively “thin.” I am fit, exercise regularly and maintain a healthy diet. Any idea what could be causing this?

A:

If by thin you mean it is a thin shape, you could have developed a narrowing in the rectum at the site of the surgery called a stricture.  This would need to be evaluated by your surgeon.

A second potential problem is called pelvic-floor “dyssynergia,” a common underlying cause of constipation.  This is essentially uncoordinated movements of your pelvic muscles and rectum when you are trying to have a bowel movement.  Often people feel like they have to strain to force bowel movements to come out.  If this applies to you, surgery would not have fixed this problem, and it can cause ongoing constipation.  The best way to diagnose this problem is with a test called an anorectal manometry with balloon expulsion or a special MRI called a defecography.

Lastly, it is important not to forget the basics: regular water and fiber consumption.

November 14, 2013

Q:

What are the special dietary needs of someone who has had a total colectomy and anastomosis? What is the best way to deal with the needs for adequate nutrition and hydration?

A:

There is no change in the nutrition/hydration requirements after a total colectomy.  It can take quite a while for the small intestine to adapt to functioning as a rectum, though, and some people find they have looser stools, diarrhea and urgency soon after surgery.  Keep track of whether fiber is a good or a bad thing, in that some people find fiber will cause gas and diarrhea in the early stages of adaptation.  Caffeinated beverages and foods or drinks with simple sugars and sugar alcohols may also cause looser stools and bloating.  If you are having overt diarrhea, speak with your surgeon.  Also, remember the new “normal” for someone who has had a total colectomy and anastomosis is usually four to six bowel movements a day.

November 11, 2013

Q:

I had a section of my colon removed approximately 4 months ago. Ever since the surgery, I’ve had multiple bowel movements (10-12 per day), mucus, blood, incontinence, feeling the need to go but no BM, constant pressure in the rectum, etc. I’ve been told by my doctors that I have a small narrowing of the anastomosis and abnormal thickening of the rectum near the suture line. What do you recommend?

A:

I’m sorry you have had so much trouble after your surgery.  Unfortunately without knowing the details of your care up to this point, I can’t provide you with recommendations.  It does sound like you are struggling, though, and if you don’t feel you are getting better with your current physicians, consider obtaining a second opinion from a doctor who can review your individual circumstances.

November 11, 2013

Q:

What is your opinion on a wheat-free and gluten-free diet compared with a regular diet for someone who is not diagnosed with celiac disease?

A:

It seems like everywhere you turn there are new products to support a wheat-free/gluten-free lifestyle. This is great for people with celiac disease, but much of it is driven by people exploring whether eliminating these elements can improve such symptoms as fatigue, aches/pains, stomach discomfort, bloating, diarrhea, depression, etc.

There is minimal medical research supporting the elimination of wheat/gluten when someone does not have true celiac disease.  However, there is a subset of those with Irritable Bowel Syndrome and certain nerve diseases who may improve their symptoms by eliminating wheat/gluten.  Whether this also helps people with generalized inflammatory disorders like lupus or rheumatoid arthritis is not clear.

It is important to know that foods made with wheat/gluten contain a lot of carbohydrates that can be fermented to produce gas in the intestines, so cutting down on wheat/gluten can reduce gas and bloating (but this is really more related to the carbohydrates, not the protein part that causes trouble for celiac patients).

I tell all my patients that if cutting out certain foods makes them feel better, that’s fine, but make sure you find out whether you really have celiac disease BEFORE you stop eating wheat/gluten. Once you eliminate that from your diet, your doctor cannot tell you whether you have celiac disease.  It is important to know if one truly has celiac disease because there is an increased risk of complications such as cancer in celiac patients but not in patients with gluten intolerance.  Also, when patients eliminate wheat/gluten they usually cut back on whole grains, which have consistently been shown to improve or prevent many chronic diseases.  Think hard about whether it is truly making an impact on your health before continuing with this strategy.

November 11, 2013

Q:

I was recently diagnosed with IBD/Crohn’s. It seems as soon as I think I’m over the crisis part, I get knocked down again. Should I expect trouble, a lengthy recovery?

A:

Crohn’s disease is a lifelong condition that we can control but not cure.  There are some people who do great on minimal “maintenance” medication, but many people find the disease is very difficult to control.  It is important to think long term, since this is a disease without a cure.  Maintaining regular exercise, quitting smoking, eating well, taking your medications regularly and supporting your emotional health are important things you can do to keep the disease in remission.  If you are doing your part as best as you can but still find you have frequent “flares,” talk with your doctor about whether you need stronger medical therapy.

November 11, 2013

Q:

I have had gastric bypass and I have fibromyalgia. I’ve had constipation problems mostly since I was told I have fibromyalgia. My ferritin is low and I can’t take iron supplements orally because it brings on even worse constipation. Can this problem be treated?

A:

People who have had a gastric bypass will need lifelong vitamin and mineral replacement since your body’s ability to absorb them will be impaired.  Iron can be very difficult to replace for exactly the reason you mentioned — constipation.  Many people also have stomach pain when they take iron.  If you have tried to take iron by mouth and just can’t get over the side effects, talk with your doctor about getting IV infusions of iron.  You may find a simpler solution, though, is to work with your gastroenterologist to reduce your constipation.

November 11, 2013

Q:

I have pain on the left side of my upper belly, right under my ribs. I also have frequent constipation. Are these two things related?

A:

Possibly.  When I am trying to determine the role of constipation in stomach discomfort, I usually recommend aggressively treating the constipation until you reach regular, comfortable bowel movements. We then would see if the pain or discomfort you had been experiencing goes away.

November 6, 2013

Q:

My stomach acts up from time to time causing diarrhea to the point of having to go to the bathroom five to six times in just two hours. Celiac and Type 1 diabetes are in my family tree. I am sure I have celiac disease due to how fast food moves through me at times when I am sick, from not knowing I have eaten gluten. Should I be concerned that I may have other issues?

A:

There are several different reasons for why you may have your symptoms, which could include anything from diarrhea-type IBS to celiac disease to bacterial overgrowth to other reasons.  With your family history, you should at least be tested for celiac disease and potentially several other causes of diarrhea.  It is very important to know for sure if you have celiac disease, so do not avoid eating wheat until you see a doctor to discuss testing.

November 6, 2013

Q:

I have too much of a problem going to the washroom. I have been diagnosed with diverticulitis. What is the best thing to do to find some relief?

A:

Diverticulitis is a sudden infection in an outpouching of the colon called a diverticulum.  This is usually a very painful problem with fever that requires antibiotics.  What you are probably describing is diverticu”losis,” which is the presence of several diverticulae, or outpouches in the colon (not an infection in them, which is diverticu”litis”).   There is no way to get rid of the diverticulosis without surgery, but for most people it is not the diverticulosis that is causing the problem.  Many people with diverticulosis have constipation, and if so, you should try the things I mentioned in an earlier question about natural ways to manage constipation.  If this doesn’t work, you should see a physician.

November 6, 2013

Q:

For the last month I have been getting bloated and this occurs more at night. Is there anything I can do?

A:

Nighttime bloating is the most common pattern of bloating.  Simple things to look for are foods that can increase bloating like carbonated sodas, beer, artificial sweeteners, dairy products (if you are lactose intolerant), beans and vegetables such as broccoli, cabbage and cauliflower among many others.  Bloating can also occur from simply overeating at night, which is when many people have their largest meal.  If this is a new problem for you and it continues, you should see a doctor.

November 6, 2013

Q:

I have been diagnosed with gluten intolerance, but the doctor only ran amylase and lipase and IgG on wheat and gluten. Should I insist that other blood work be done and, if so, which tests?

A:

The first test recommended by most GI societies to screen for possible celiac disease (NOT gluten intolerance) is called a tissue transglutaminase IgA test.  If you think you are gluten intolerant, your physicians should definitively rule out celiac disease first.  The gold standard to diagnose celiac disease is not a blood test, though.  The definitive test for celiac disease is to obtain biopsies of the lining of your small intestine during an upper endoscopy.  It is very important for anyone who thinks they could have true celiac disease to have it ruled out BEFORE you start avoiding wheat.  If you start early before you have the right tests, your doctor will not be able to tell you whether you have celiac disease or not.  There is no accepted way to diagnose gluten intolerance.

November 6, 2013

Q:

What are the symptoms to IBS? And how can I find out if I have it?

A:

Common symptoms of IBS are bloating, abdominal pain, a change in the appearance of your stools and diarrhea or constipation, or both.  The key is the pattern to each of these symptoms.  The patterns are what physicians use to determine whether one has IBS or whether there is something else going on.  A physician should help determine whether or not you have IBS, because the symptoms of IBS can mimic many other diseases that may need further investigation or treatment.

November 6, 2013

Q:

I’ve had acid reflux for years. I’ve been taking Nexium for years as well, but my stomach is still not feeling 100 percent. I really would like to know what type of food I can eat for breakfast, lunch and dinner.

A:

Often people with acid reflux have overlapping problems with food intolerances, dyspepsia, bloating and IBS.  The first thing you should do is start a detailed food diary to see if you can identify patterns in what makes you feel the way you do.  There are very few absolute foods (that is, foods you always should eat or never should eat), so each person needs to go through this for themselves.  Also, you will find that some foods can be “safe” on some days and “not safe” on others.  While this can be very frustrating, most people find a food diary helpful in guiding what they eat.  Registered dietitians can be a great resource because they can help you fit your findings to a healthy diet.

November 6, 2013

Q:

I have acid reflux and no medication is working for me. I have about three episodes a week and I can’t eat anything. Symptoms are also getting worse. I’m worried about stomach and esophageal cancer. What should I do?

A:

You should definitely see a doctor to discuss your concerns.  There are other reasons besides traditional “reflux” that can cause your symptoms, and depending on how long you have had your symptoms and what you have tried, it may be time to do more testing to ensure nothing else is going on.

November 6, 2013

Q:

Do you treat patients with severe acid reflux?

A:

Yes, I do, as do many of my partners here at Loyola.

November 1, 2013

Q:

I have had constipation all my life and nothing works. What’s wrong with me?

A:

Constipation results from many different kinds of problems. Some people feel “constipated” when their intestines work normally, and the problem may be more in the way the nerves in the intestines talk to their brain. Another more rare cause is that the movement in the colon, or the “motility”, is excessively slow. This could be from faulty nerves or muscles, and it can be a very difficult problem to treat. Finally, a common cause of constipation that many people don’t know about is called dyssynergia, or “outlet dysfunction”.

I usually explain this with an example from pediatrics. When children have a painful, hard bowel movement, they can learn that having a bowel movement “hurts” and thus decide to ignore the urge to have a bowel movement. Over time, this causes the reflex that makes a bowel movement happen to become faulty and severe constipation occurs. Essentially the body works against itself by tightening muscles that should be relaxed in order for a bowel movement to occur. The person is usually not aware this is happening and spends an excessive amount of time in the bathroom straining to force a bowel movement to happen. The good news is that there are simple tests to help sort out why someone is constipated and usually good therapies to improve it.

November 1, 2013

Q:

What natural things can I do to make my bowel movements more regular?

A:

There are many things that a person can do to make their bowel movements more regular without the use of medications. It is really important to drink plenty of fluids. Water is the best, but other beverages can work, too, as long as they are not loaded with caffeine or sugar. As one ages, the thirst sensation goes down, so you may need to stick to a schedule of water drinking or set daily targets. Being active throughout the day is also important since one’s stomach muscles can stimulate the intestines inside the body to move.

Listen to your body and visit the bathroom when your body tells you to go; don’t avoid going in public bathrooms if it’s really the right time. If you cannot bring yourself to go in public bathrooms, get up early before you go to work and have something to eat. Most people will have an urge to have a bowel movement first thing in the morning, and eating starts a natural reflex to have a bowel movement. Give yourself plenty of time for this to happen before you go out. Lastly, eat plenty of whole, unprocessed vegetables, fruits and grains, which contain abundant natural fiber. The standard American diet is full of processed, chemical-laden foods that lack natural fiber. Natural fiber (both soluble and insoluble) helps reduce your risk of many diseases and keeps your bowel movements regular.

November 1, 2013

Q:

I have reflux disease and have been advised to avoid certain foods. Will eating those foods harm me?

A:

The foods that are most often associated with reflux include spicy foods, caffeine, citrus fruits or acidic foods like tomatoes, peppermint, chocolate and rich, fatty foods. Many of these foods are cultural staples and we love to eat them. The cost, in terms of discomfort, can be great for a person with esophageal reflux. Even “normal” people who don’t experience heartburn on a regular basis can get heartburn after eating a big serving of pizza. Avoiding these foods will help decrease the symptoms of reflux disease, and in some studies can decrease the amount of acid exposure in the esophagus. Our understanding of just how much food “indiscretions” can actually cause physical damage (beyond simply worsened symptoms) is limited, though. Therefore, if you really can’t live without your spicy foods or chocolate, indulge only on rare occasions.

November 1, 2013

Q:

There are so many different diets out there, and I just want to know what to eat. Can you help me?

A:

The good news is that there is no perfect diet. The bad news is that there is no perfect diet. The amount of information and misinformation on the Internet can be overwhelming for anyone. When one doesn’t have a specific medical condition, the best advice I can give is to base about half of what you eat on vegetables and fruits, then add some lean protein, whole grains and (sparingly) healthy fats in the form of nuts and the right oils. There are some medical conditions that can respond to a specific diet, though, and it is worth discussing this with your doctor. Most of the people I see have a GI illness and want advice on the right foods to eat in the setting of digestive discomfort. While we have some advice to give that is based on good research, we are still in early stages of tailoring individual diets. It is important, though, to discuss any diet you are thinking of trying with your doctor as many “diets” have big nutritional holes and could put your health at risk.