gastro health magazine fall 2014

FALL 2014 ISSUE

HEPATITIS C VIRUS:

D O I H A V E I B S? I J U M P S T A R T Y O U R W E I G H T L O S S ! I P A N C R E A T I C C A N C E R

NATALIE COLECopes With Chronic Hepatitis C

Symptoms, risk factors and prevention

Current therapiesand beyond

COLORECTAL CANCER:

gut GI bleeding,diarrhea

abdominal pain,constipation,

gas

nausea,vomiting

What’s your telling you?

Cramps, bloating, vomiting, diarrhea, nausea and sharp abdominal pain can have other serious reasons lurking behind them. When home remedies and over-the-counter laxatives, pain relievers and antacids don’t seem to work, listen to your gut—visit our ER immediately.

When it goes beyond “was it something I ate” to “OMG, this is unbearable,” it’s time to visit the ER.

For answers to your health questions or a FREE physician referral, call 305-480-6666 or visit MiamiDadeHospitals.com.

Text ER to 23000 to see average wait times.Message & Data Rates May Apply. Terms & Conditions http://www.texterhelp.com/. Privacy Policy http://www.HCAEastFlorida.com/.

gut

gut GI bleeding,diarrhea

abdominal pain,constipation,

gas

nausea,vomiting

What’s your telling you?

Cramps, bloating, vomiting, diarrhea, nausea and sharp abdominal pain can have other serious reasons lurking behind them. When home remedies and over-the-counter laxatives, pain relievers and antacids don’t seem to work, listen to your gut—visit our ER immediately.

When it goes beyond “was it something I ate” to “OMG, this is unbearable,” it’s time to visit the ER.

For answers to your health questions or a FREE physician referral, call 305-480-6666 or visit MiamiDadeHospitals.com.

Text ER to 23000 to see average wait times.Message & Data Rates May Apply. Terms & Conditions http://www.texterhelp.com/. Privacy Policy http://www.HCAEastFlorida.com/.

gut

Colon cancer is the second-deadliest form of cancer in the U.S., yet it doesn’t have to be. Did you know that it’s 90 percent preventable? Screening is the key.

Colon cancer stops with youThis simple procedure – called a colonoscopy – can actively prevent colon cancer. Do it for you and your loved ones. If you are at-risk, get screened, and get on with your life!

Who should get screened?

Anyone 50 and older

People who have a family history of polyps or colon or rectal cancer

African-Americans who are 45 and older

Other minority groups where the disease is more prevalent

Simon Behar, M.D.Jose P. Ferrer, Sr., M.D.Jose P. Ferrer, Jr., M.D. Nelson Garcia, Jr., M.D.Alfredo Hernandez, M.D.Eugenio J. Hernandez, M.D.Moises E. Hernandez, M.D.Jerry Martel, M.D. Seth D. Rosen, M.D.Andrew Sable, M.D.

Galloway Surgery Center7600 SW 87th Ave., Suite 100Miami, FL 33173Phone: 786-245-6100www.gallowaysurgerycenter.com

To schedule your colon cancer screening, please call 786-245-6100

Galloway Surgery Center FP_COLOR 2012.3.indd 1 2/3/12 11:26 AM

GASTRO HEALTH Welcomes You

GASTRO HEALTH Fall 2014

9500 South Dadeland Boulevard Suite 802, Miami, FL 33156T. 305.468.4180w w w . g a s t r o h e a l t h . c o m

Designed and Published by:11900 Biscayne BoulevardSuite 100, Miami, FL 33181T. [email protected]

All rights reserved.

TM

Cover Photo: © 2003-2014 Photo Credits www.nataliecole.com

Copyright © 2014 Gastro Health, P.L. All rights reserved. This publication is published by Gastro Health, P.L., which is solely responsible for its contents. This information presented is intended only for residents of the United States. The material presented is intended only as informational, or as an educational aid, and it is not intended to be taken as medical advice. The ultimate re-sponsibility for patient care resides with a healthcare professional.

7 How Natalie Cole Copes With Chronic Hepatitis C

10 Do I Have IBS?

11 Gastro Health Physician Directory

15 Nutritional Effects of Alcohol

16 Colorectal Cancer: Symptoms, risk factors and prevention

18 Cáncer Colorrectal: Síntomas, factores de riesgo y prevención

21 Fatty Liver in Children

23 Jumpstart Your Weight Loss! It’s more than just losing weight… the ultimate goal is to improve your health and vitality

24 Anal Fissure

26 Hepatitis C Virus: Current therapies and beyond

29 Pancreatic Cancer

For nearly three decades the physicians of Gastro Health have provided high quality, committed and passionate care to our patients. This commitment of always placing our patients’ needs first is what sets us apart. Gastro Health has consistently set and met the highest standards of excellence. We strive to deliver the best patient experience possible. We understand the importance of providing high-quality care, and continually make every effort to improve the quality of life of our patients.

I am happy to announce that the South Florida Business Journal ranked Gastro Health #7 under the category of Top Physician Practices in South Florida for 2014. We are very proud of our accomplishments and growth, and it’s with great pride that we continue to add top quality physicians and providers to our group. Our team of physicians, providers and staff seek to provide outstanding medical care and an exceptional health care experience.

In this issue we are honored with a featured article from Natalie King Cole who discusses her trials and tribulations dealing with Hepatitis C. Many can live with Hepatitis C for decades with no symptoms, especially Baby Boomers. The Center for Disease Control (CDC) recommends that anyone born between 1945 and 1965 get tested for Hepatitis C. Approximately three out of four Baby Boomers are believed to have Hepatitis C. Talk to your Gastro Health physician about screening and get your test results today with just a simple blood test.

In this edition of our magazine you will find articles that are informative and helpful in discovering the great health care available to you at Gastro Health.

Thank you for your trust and confidence.

Alejandro Fernandez, MBA, CMPEChief Executive Officer

If you suffer from abdominal pain, bloating, diarrhea, and/or constipation, you may have IBS. You are not alone. 1 out of 5 Americans suffers from IBS.

IBgard® is a medical food for the dietary management of IBS

utilizing the calming effects of peppermint oil to alleviate the

discomfort related to the symptoms of IBS. Using the precision

of site specifi c targeting (SST)™ technology, IBgard® targets

the lower gut, where IBS occurs. Microspheres of ultra-purifi ed

peppermint oil are delivered quickly and reliably to the areas

where they are needed most in IBS. IBgard’s® sustained

release technology calms the angry gut®

for extended relief.

Peppermint oil has been shown in

multiple studies to be effective for

people with IBS. Ask your doctor if

IBgard is right for you.

in the dietarymanagementof Irritable BowelSyndrome (IBS).

Introducing a NEW advance

Available exclusively in the digestive aisle at

The IBgard® Difference

To learn more about IBS and IBgard,® visit us at IBgard.com

Use under medical supervision.

ANGRY GUT

CALMED GUT

CALMS THE ANGRY GUT.®

7

10

21

29

If you suffer from abdominal pain, bloating, diarrhea, and/or constipation, you may have IBS. You are not alone. 1 out of 5 Americans suffers from IBS.

IBgard® is a medical food for the dietary management of IBS

utilizing the calming effects of peppermint oil to alleviate the

discomfort related to the symptoms of IBS. Using the precision

of site specifi c targeting (SST)™ technology, IBgard® targets

the lower gut, where IBS occurs. Microspheres of ultra-purifi ed

peppermint oil are delivered quickly and reliably to the areas

where they are needed most in IBS. IBgard’s® sustained

release technology calms the angry gut®

for extended relief.

Peppermint oil has been shown in

multiple studies to be effective for

people with IBS. Ask your doctor if

IBgard is right for you.

in the dietarymanagementof Irritable BowelSyndrome (IBS).

Introducing a NEW advance

Available exclusively in the digestive aisle at

The IBgard® Difference

To learn more about IBS and IBgard,® visit us at IBgard.com

Use under medical supervision.

ANGRY GUT

CALMED GUT

CALMS THE ANGRY GUT.®

MISSIONTo provide outstanding medical care and an exceptional healthcare experience.

GUIDING PRINCIPLEWe will treat each patient as a valued member of our immediate family.

Care and CompassionProvide competent, individualized care in a professional, respectful and caring way.

TeamworkRecognize each other as valuable members of our healthcare team by treating one another with loyalty, respect and dignity.

Responsibility Provide excellent and efficient administrative, accounting, personnel and business management services.

Value and ExcellenceDevelop valuable ancillary services that improve our patients’ quality of care and customer experience.

Honesty and IntegrityCommunicate openly and honestly, build trust and conduct ourselves according to the highest ethical standards.

StewardshipAttract and retain great talent and the finest gastroenterologists by actively promoting a professionally satisfying work environment.

AccountabilityMaintain mutually beneficial relationships with top referring physicians, payers, employers and health systems using performance, outcome, as well as satisfaction measurements to demonstrate accountability and improvement in our care delivery.

CORE VALUES

Caring for you and those you love.

FALL 2014 GASTRO HEALTH MAGAZINE 7

HOW

COPES

NATALIE COLE

WITH CHRONIC HEPATITIS CBy Gina Roberts-Grey

Hepatitis C is killing more Americans than HIV, according to the Centers for Disease Control and Prevention. One of the millions infected is singer Natalie Cole. In this Lifescript exclusive, she reveals how she’s living with and managing her chronic hepatitis C...

Trouble is no stranger to multi-Grammy-winning singer Natalie Cole. She lost her iconic father, Nat King Cole, when she was just 15, and struggled with drug abuse for years, which she described in her autobiography Angel on My Shoulder (Grand Central Publishing). After going through rehab for drug use in 1983, Cole thought she put the dark days behind her.But in 2008, a diagnosis of the liver disease hepatitis C brought them home again.Hepatitis C is a viral infection that damages the liver and other organs. It may lead to a liver transplant or even death. In fact, Cole got a transplant in 2009, but not for a new liver. Because of chronic hepatitis C, both her kidneys had begun failing, and she received a new kidney. “I’ve been so fortunate to have learned so much from my past experiences,” she says. “So I knew there was a lesson to learn from this too.” Too many patients suffer with chronic hepatitis C in silence, Cole says. And many more unknowingly live with the liver disease because they’re afraid of being tested and facing a lifetime with chronic hepatitis C. “I want people to know you can live with hepatitis,” she says. “And there are remarkable treatments available to help you do just that.” In this exclusive interview, Cole reveals her life with chronic hepatitis C and how she managed the guilt of knowing her past most likely contributed to her developing the disease.

GASTRO HEALTH MAGAZINE FALL 20148

Were you having any hepatitis C symptoms before your diagnosis?I had virtually no symptoms. There was no warning or any signs – which really made the diagnosis a shock.

If you weren’t having hepatitis C symptoms, what led to the diagnosis?I was in the studio recording “Still Unforget-table” in 2008 and had a hernia that needed to be [treated with surgery]. As is the case with most surgical procedures – even minor ones – my doctor ordered routine blood work beforehand. The results came back and the

doctor said my blood count wasn’t great and that I needed to see a kidney specialist.

Were you anxious?At that point, I wasn’t really worried. Then when the doctor said, ‘You might have hepatitis C,’ I said, ‘What?’ I was completely and totally shocked.

What went through your mind when you heard you had chronic hepatitis C?It’s scary. Your liver is so vital to your health and the thought that I had [hepatitis C] was unnerving and terrifying. I didn’t see it coming, so I was really quite upset.

Did the doctor offer possible causes for contracting the liver disease? I’ve been very open about my heroin use of over 25 years ago. The sharing of needles and other paraphernalia involved with drug use is the most common way to get this disease. It wasn’t a stretch to connect those dots. That’s why when [the doctor] told me I had hepatitis, I thought Oh my, don’t tell me that this [hepatitis C virus] was able to live in my body for 25 years and now my past is coming back down on me.

Did you feel guilt about your drug abuse and consequent diagnosis?I’m usually the type to say, ‘I’m just going to fight and live in the present.’ I can’t be bothered beating myself up with guilt. Once I got sober, I learned guilt is just too stressful. I take full responsibility for anything I’ve done in my life and the consequences – so there’s no room for guilt. But I got very angry. Then I started worrying.

What did you worry about?I worried how my diagnosis would affect my life and career. What would treatment involve?I was very scared.

What angered you?I was so angry at myself, but I realized there’s no point on dwelling on the ‘should haves’ and getting stuck on anger or worry. So I refocused on ‘What are we going to do to get me healthy?’ I needed to focus on ‘What’s the treatment?’ Even if a person does dwell on anger, guilt or whatever, in the meantime, they need to get treatment.

How were you treated for chronic hepatitis C?I was treated with interferon and that was very intense. [Editor’s note: Interferon, a cytokine protein the body produces, is the most common treatment for hepatitis C. It fights the virus by boosting the immune system and slowing its replication, according to National Digestive Diseases Information Clearinghouse (NDDIC).]

Did the treatment affect the quality of your life?Oh yes! The quality of my life changed during treatment. I lost weight and was very weak. I was extremely fatigued and, at one point, dehydrated. For a while I couldn’t stand, let alone sing. But I continued to work as much as possible, even though that wasn’t easy.


How did you combat fatigue?I slept whenever possible – right until I had to put makeup on and go on stage. My attitude also helped. I was determined and believed in myself and my faith. I knew I would overcome hepatitis. I just needed to do one step at a time and allow myself to rest if I needed to.

Did your family or friends help?My family and friends were amazing. I couldn’t imagine going through what I did without them by my side. One of my oldest and dearest friends was with me every step of the way. (We had our kids six days apart, and have been through everything since.) She would sleep over, wait on me, go to the doctor with me – she was

phenomenal. It’s important for women facing any health crisis to have that sort of support. That’s critical to recovering physically and emotionally and getting through treatment.

How have chronic hepatitis C and its treatment affected your career?When you’re going through something like this, you must have a positive attitude. If people see you feeling pitiful, then they feel bad. If you look bad, they won’t enjoy themselves around you, whether you’re a performer or not.I wanted to give the audience a good time and didn’t want to make them feel bad for me. I knew I had to get out there and do the best I could.

Are you still being treated for chronic hepatitis C?Yes, but thankfully the treatment is much better. Now, I just take one pill a day for hepatitis. I take it and go on with my day without thinking much about it again. The quality of my life is the same as it was before diagnosis, if not better. I travel and perform, and feel great.

How do you stay healthy?I’m not doing anything different than before I was diagnosed. I eat what I want and feel very blessed that I’m not on steroids and that my liver has healed 80%. I take medicine for my kidney, so I don’t reject the transplant.

What prompted you to take your diagnosis public?I didn’t want anyone telling my story for me. Because the treatment that I was on was so debilitating, people or the paparazzi might see me in a wheelchair, looking frail and on oxygen.I knew they might start making up stories, so I released a statement and put the word out on my terms. That [quickly] calmed down rumors. Going public saved me from having the press perform their own diagnosis and make up conditions or stories about my health. I also did it to raise awareness for this very preventable disease.

What does it mean to you to be a voice for chronic hepatitis C patients? It would have been much more difficult to do without the constant love and support of family and friends. Unfortunately, I know that a lot of people don’t have that outlet or resource, so I’m trying to help them by bringing attention and awareness to the disease. I don’t want anyone to feel ashamed, or think they have to go through this alone. Hopefully, I’ll inspire others with the disease. I hope that by going public with my health and by continuing to talk about hepatitis, people realize there are support group sessions or treatment options too. And know they can live an unforgettable life despite having hepatitis.

Copyright 2014 Lifescript


Pamela L. Garjian, MD Gastroenterologist

Irritable bowel syndrome is a common functional gastrointestinal disorder that can affect up to 20% of the adult population. It is predominantly seen in women, but can also occur in men. Symptoms might include abdominal pain, bloating, diarrhea, constipation and

mucous. In fact, there is a specific set of standards called the ROME III criteria that your physician may use to make a diagnosis. It includes the presence of abdominal pain for at least three days a month out of the last three previous months (and these symptoms must have started at least six months before). Additionally, a patient must have two or more of the following symptoms:

• Improvement of pain with bowel movements • Change in bowel movements • Consistency or frequency

As opposed to another disease called inf lammatory bowel disease (IBD), IBS is the presence of a multitude of GI symptoms where the intestinal tract is not damaged. Other associated IBS symptoms include the feeling of an incomplete bowel movement, passing mucus, predominant diarrhea, predominant constipation or alternating diarrhea and constipation, bloating and/or gas.

What causes IBS? The cause of IBS is probably multifactorial. It is believed to include problems with the brain gut signal, motility disorders, contractions and spasms such as hyper or hypo-active gut, hypersensitivity of the intestines (especially the stretching of the walls of the intestines), bacterial overgrowth (possibly of the small intestine), genetics, food sensitivity and disordered body chemicals. Some studies suggest that up to 60% of patients with IBS predominant diarrhea have had an infectious gastroenteritis preceding their symptoms. Essentially, IBS is a complicated disorder.

How is the diagnosis made?The diagnosis of IBS is one of exclusion, which means that the doctor might run some tests to exclude other organic diseases such as gluten intolerance, lactose intolerance, inflammatory bowel disease (which includes Crohn’s disease and ulcerative colitis), food allergies, sorbitol intolerance, H. pylori, gallbladder disease, ulcer disease, chronic constipation without IBS, eosinophilic enteritis and infectious colitis. It is important that there are no “alarm symptoms” that might suggest a different diagnosis such as fever, rectal bleeding, weight loss, anemia or low red blood cell count, family history of colon cancer, family history of celiac disease or inflammatory bowel disease. Tests might include a sigmoidoscopy, colonoscopy, stool studies, blood tests and breath tests. How is it treated?Diet and lifestyle modifications may play a role and may be helpful for some patients. Certain diets have claimed to alleviate symptoms associated with IBS (such as the FODMAP diet). However, this has caused much controversy because up to two-thirds of patients with IBS will respond to dietary changes. Additionally, some foods are unpredictable because of their inconsistency in triggering IBS. Medication such as prescription anti-spasmodic medicines, over-the-counter probiotics, fiber, prescription antibiotics and mental health therapy may all be helpful. Diet and NutritionDiet may play an important role in IBS and a food diary may be helpful and can help determine what triggers your symptoms. Furthermore, it is a possibility that a patient with IBS may have an additional digestive problem such as lactose intolerance. A low FODMAP diet has been getting a lot of attention over the last several years and usually restricts gluten, fructose, sorbitol, sucrose and lactose. FODMAPs include foods such as wheat, barley, rye, legumes, mango, honey, pears, apples, mushrooms, cauliflower, onions, sugar-free candies, gum, garlic and lactose. Although this is a very restricted diet, some studies suggest that it may be helpful. Other possible dietary restrictions may include a low-fat or PALEO diet.

SummaryIBS is a common but complicated constellation of many symptoms that may have several possible causes. Treatment needs to be tailored to the individual patient. Your gastroenterologist along with your input may be able to help you sort out these details. It is important however not to mistake a more serious organic illness as IBS. Furthermore if long-standing IBS symptoms change, then testing may be required to exclude another disease process. Consulting with your gastroenterologist is an important part of the diagnosis and treatment of this condition.

Do I Have IBS?

PHYSICIANDIRECTORY

PHYSICIAN DIRECTORY

Francisco J. Baigorri, MD *Gastroenterologist

Care Center 1

Marc S. Carp, MDGastroenterologist

Care Center 6

Jose P. Ferrer Sr., MD *Gastroenterologist

Care Center 3

Simon Behar, MD *Gastroenterologist

Care Center 3

Nelson Garcia Jr. MD *Gastroenterologist

Care Center 8

Lewis R. Felder, MDGastroenterologist

Care Center 7

Daniel Gelrud, MD *Gastroenterologist

Care Center 1

Gustavo Calleja, MD *Gastroenterologist

Care Center 1

Jose P. Ferrer Jr., MD *Gastroenterologist

Care Center 3

Barry E. Brand, MDGastroenterologist

Care Center 2

* Habla Español

Harris I. Goldberg, MDGastroenterologist

Care Center 1

Guillermo Gubbins, MD * Gastroenterologist

Care Center 10

Roberto Gonzalez, MD * Gastroenterologist

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Moises E. Hernandez, MD *Gastroenterologist

Care Center 3

Richard E. Hernandez, MD *Gastroenterologist

Care Center 5

Eduardo Krajewski, MD *Colorectal Surgeon

Care Center 9

Edward Feller, MDGastroenterologist

Care Center 15

Pamela L. Garjian, MD*Gastroenterologist

Care Center 16

Alfredo J. Hernandez, MD *Gastroenterologist

Care Center 11

Ruben Gonzalez-Vallina, MD * Pediatric Gastroenterologist

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Eugenio J. Hernandez, MD *Gastroenterologist

Care Center 3

Robert C. Lanoff, MD *Gastroenterologist

Care Center 2

Mitchell Greg, MD Radiologist

Imaging Center

Pedro J. Greer Jr., MD *Gastroenterologist

Care Center 11

Enrique Hernandez-Sanchez, MD* Pediatric Gastroenterologist

Care Center 14

Raghad Koutouby, MD Pediatric Gastroenterologist

Care Center 12

John Ibarra, MD* Radiologist

Imaging Center

Jose A. Lavergne, MD *Gastroenterologist

Care Center 7

Flavia Mendes, MD *Gastroenterologist

Care Center 1

Alfredo Rabassa, MD *Gastroenterologist

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Eduardo Ruan, MD *Gastroenterologist

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James S. Leavitt, MDGastroenterologist

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Pedro Morales, MD *Gastroenterologist

Care Center 8

Andrew I. Sable, MDGastroenterologist

Care Center 2

Marc Lederhandler, MDGastroenterologist

Care Center 1

Brett R. Neustater, MDGastroenterologist

Care Center 7

S. Lawrence Rothman, MDGastroenterologist

Care Center 1

Arie Slomianski, MD *Gastroenterologist

Care Center 1

David A. Sommer, MDGastroenterologist

Care Center 2

Howard I. Schwartz, MDGastroenterologist

Care Center 1

Jerry Martel, MD, MPH *Gastroenterologist

Care Center 8

Javier L. Parra, MD *Gastroenterologist

Care Center 1

Neil E. Rosenkranz, MDGastroenterologist

Care Center 2

Marcos Szomstein, MD *Colorectal Surgeon

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Andres I. Roig, MD *Gastroenterologist

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Somal S. Shah, MD *Gastroenterologist

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Stefania L. Vernace, MDGastroenterologist

Care Center 1

George A. Sanchez, MD * Gastroenterologist

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Antonio Martinez, MDPathology Medical Director

Pathology Laboratory

Oscar Loret de Mola, MD* Pediatric Gastroenterologist

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Rodolfo Pigalarga, MD*Colorectal Surgeon

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Ricardo J. Roman, MD *Gastroenterologist

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Seth D. Rosen, MDGastroenterologist

Care Center 2

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Khristian Noto, MD *Gastroenterologist

Care Center 9

Curtis L. McCarty III, MD Pathologist

Pathology Laboratory

Nicole Costa, ARNP* Care Center 12

Darlene Boytell-Perez, ARNP * Care Center 1

Rebecca Karousatos, MS, RD, LDNCare Center 1

Kayce Tugg, MSN, RNImaging Center

Ronal R. Ricano, PA-C* Care Center 11

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ALLIED HEALTHCARE STAFF

Care Centers INSURANCES

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Care Center 1 Main Office7500 SW 87 Avenue, Suite 200Miami, FL 33173305-913-0666

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Imaging Center7500 SW 87 Avenue, Suite 200-AMiami, FL 33173305-468-4190

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Jeffrey Tamayo, RD, CSSD, LDN Registered & Licensed Sports Dietitan/Nutritionist

NUTRITIONAL EFFECTS OF

A few cocktails can easily equal up to an entire meal worth of calories, yet lack the sufficient nutrients.

Alcohol is a part of many social events. Whether it is dinner with family and friends, sporting events or a night out at a club, it is always easy to find a reason for a drink. However, we rarely think of how alcohol affects our diet or the risks associated

with this indulgence.

Calories provide energy for our bodies to function. We get them from carbohydrates, protein, fat and alcohol. However, calories from alcohol are considered “empty calories” because they do not provide sufficient vitamins and minerals. In short, they are high in calories, low in nutrients and can lead to weight gain. A 12 oz. beer has about 150 calories and an 8 oz. frozen daiquiri can have more than 400 calories. A few cocktails can easily equal up to an entire meal worth of calories, yet lack the sufficient nutrients.

To make matters more complicated, alcohol can also interfere with the body’s ability to process and store nutrients by damaging the liver and

other organs. Excessive alcohol drinking can lead to cirrhosis, fatty liver, obesity and other disorders. Since alcohol is metabolized in the liver, years of heavy drinking can cause alcoholic cirrhosis. Fatty liver can occur because alcohol interferes with the metabolism of fatty acids which promotes the accumulation of fat in the liver. Too much alcohol can lead to abdominal obesity, commonly known as a “beer belly.” Obesity increases the risk for type 2 diabetes, hypertension and cardiovascular disease.

Nutritional deficiencies are more common among alcoholics, but they can also be found in people who drink alcohol on a regular basis. When replacing the food in our diet with alcohol, we can deplete the body of key vitamins and minerals such as folate, vitamin B12 and vitamin A.

Alcohol is not essential in our diet and can end up causing serious health issues. If you choose to drink alcoholic beverages, do so in moderation. Here are some dietary guidelines to help you consume alcohol more responsibly:

• Moderation – one drink per day for women and up to two drinks per day for men. • Serving size for an alcoholic beverage • 12 oz. of beer or wine cooler • 8 oz. of malt liquor • 5 oz. of table wine • 1.5 oz. of 80 proof distilled spirits (gin, vodka, whiskey, etc.) • If you are not able to restrict your alcohol intake, you should not be drinking at all. • Keep water available to quench your thirst.• Learn to sip your drink to make it last longer.

ALLIED HEALTHCARE STAFF


Colorectal Cancer:

Dr. Andres Roig, MDGastroenterologist


Colorectal cancer (CRC) is a common cancer originating from the colon or rectum. In the United States it is the third most common type of cancer (excluding

skin cancers) and is the second leading cause of cancer related deaths. For the year 2015, it is estimated that about 140,000 new cases of CRC will occur. Out of these new cases, approximately 50,000 will result in death. Although CRC is very common in the United States, it is also one of the most preventable cancers due to the fact that many screening modalities are available to detect it at an early stage.

How does colorectal cancer (CRC) develop?

CRC originates from cells in the large bowel. Throughout an individual cells life, mutations accumulate in its DNA. These mutations make cells heartier and enable them to grow a little bet ter than the normal surrounding cells. Eventually these cells expand into a little mound in the interior of the colon. This little mound is called a polyp. Not all polyps will turn into cancer, but if left inside the colon for long time, some can transform and become cancerous. In the majority of cases this process is very slow and can take anywhere from 10 to 15 years. Sometimes the process can take place quicker, particularly when there is a strong family history of CRC.

What are the signs and symptoms of CRC?

In most instances there are no specific symptoms. This is usually the case for pre-cancerous polyps and small colon cancers. As the cancer grows, telltale signs begin to appear. These include blood in the stool, a change in bowel habits (progressive constipation), changes in the shape of the stool such as thinning in size, weight loss and fatigue. Fatigue can be a sign of anemia which frequently occurs in CRC due to slow blood loss. Sometimes anemia is the earliest presentation of CRC.

Risk factors for CRC.

Risk factors can be divided into those that can’t be controlled and those that can. Within the factors that cannot be controlled the main one is age. CRC becomes more common as people get older. The risk begins to increase after the age of 40 and rises significantly at ages 50 to 60. The risk doubles with each following decade. Other important factors that cannot be controlled include a family history of polyps or CRC, other cancers such as uterine cancer, a personal history of colon rectal polyps, personal history of inflammatory bowel disease and inherited CRC syndromes such as hereditary non-polyposis colorectal cancer syndrome (HNPCC). Risk factors that can be controlled include the factors that are linked to things you do which increase your risk for CRC such as consuming a diet high in red meats and processed meats, cooking meat at high temperatures such as in a grill (increased temperature can create toxins that cause mutations in cells), a sedentary lifestyle, obesity, smoking and excess alcohol use.

How can CRC be prevented?

Studies have found that increased body weight can raise predisposition for CRC. This link seems to be stronger in men, particularly when the increased weight is distributed around the waistline. Other studies show that consuming diets low in vegetables and whole-grains can predispose to CRC. Finally, polyps and CRC are found more frequently in individuals with

low levels of physical activity. To help prevent colon cancer begin with behavior modification. Increase your physical activity. Scheduled episodes of vigorous activity several times a week may be more beneficial than moderate activity on a regular basis. Eat more vegetables, fruits and whole-grain foods while consuming less red meats and processed meats. Make it a key goal to lose weight: increase your aerobic exercise and focus on losing the fat around the waistline. Lastly, participate in CRC screening programs. The incidence and mortality rate of CRC has dropped in the last several years, possibly due to multiple available screening methods capable of detecting precancerous lesions. A colonoscopy is the best screening method since it can look at the whole colon, detect polyps and remove them during the same procedure. It is recommended that people with no family history of CRC have their first colonoscopy at age 50. If no precancerous polyps are seen the colonoscopy can be repeated in 10 years. Patients with a strong family history of CRC should undergo their first colonoscopy sooner, and patients with a history of precancerous polyps should have their follow-up colonoscopy done at shorter intervals. Talk to your primary care doctor or get referred to a gastroenterologist to find out when and how often you should get screened for CRC.

“In the United States it is the third most common type of cancer (excluding skin cancers) and is the second leading cause of cancer related deaths.”



GUIDELINES FOR COLORECTAL CANCER SCREENING

PATIENT DESCRIPTION EVALUATION INDICATED

LOW RISK

AGE 50No Risk Factors

Colonoscopy beginning at age 50 (For African Americans beginning

at the age of 45)

Family history of colon cancer or polyps

Colonoscopy beginning 10 years younger than the age the

relative was diagnosed

HIGH RISK

Blood in stool or iron deficiencyanemia, rectal bleeding,

or a change in bowel habitColonoscopy now

Ulcerative Colitis or Crohn’s Disease

Yearly colonoscopy, after 10 years of disease

Personal history of colon canceror polyps

Regular screening colonoscopy asdetermined by your physician*

OTHERINDIVIDUALIZED APPROACH

Other gastrointestinal symptoms which may include; abdominal pain, narrow stools, constipation, diarrhea, "gas" or bloating, Family history of breast, gynecological, abdominal,

colon or other gastrointestinal cancers

*Call Gastro Health and discuss with your physician

GUIDELINES FOR COLORECTALCANCER SCREENING


Cáncer Colorrectal:

Dr. Andres Roig, MDGastroenterologist

Síntomas, factores de riesgo y prevención

El cáncer colorrectal es un cáncer común procedente del colon o recto. En los Estados Unidos es el tercer tipo de cáncer más común (excluyendo el

cáncer de piel) y es la segunda causa principal de muerte por cáncer. Para el año 2015 se estima que aproximadamente 140.000 nuevos casos de cáncer colorrectal se producirán. Fuera del total de estos nuevos casos 50.000 resultaran en muerte. Aunque el cáncer colorrectal es muy común en los Estados Unidos es también uno de los más prevenibles debido al hecho de que existen muchas modalidades de cernimiento para detectarlo en una etapa temprana.

¿Cómo se desarrolla el cáncer colorrectal?

Se origina de células individuales del intestino grueso. A lo largo de la vida de una persona las células acumulan mutaciones en su código genético. Estas mutaciones hacen que las células crezcan con mas rapidez que las células adyacentes normales. Eventualmente estas células se expanden a un pequeño montículo en el interior del colon o recto. Este pequeño montículo se llama pólipo. No todos los pólipos se convertirán en cáncer, pero algunos, si se dejan crecer en el interior del colon por mucho tiempo, pueden transformarse en un cáncer. Este proceso en la mayoría de los casos es muy lento y puede tomar de 10 a 15 años. A veces el proceso puede llevarse a cabo más rápido, sobre todo cuando hay una fuerte historia familiar de cáncer colorrectal.

¿Cuáles son los signos y síntomas del cáncer colorrectal?

En la mayoría de los casos no hay síntomas específicos. Este suele ser el caso con los pólipos precancerosos y también los pequeños cánceres de colon. A medida que crece el cáncer muestras indicadoras comienzan a aparecer. Estos incluyen sangre en las heces, un cambio en los hábitos intestinales (estreñimiento progresivo),

cambios en la forma de las heces, como heces más finas; también la pérdida de peso y fatiga. La fatiga puede ser un signo de anemia. La anemia es frecuente en el cáncer colorrectal debido a la pérdida de sangre lenta. A veces la anemia es la presentación inicial del cáncer colorrectal.

Los factores de riesgo para cáncer colorrectal

Los factores de riesgo se pueden dividir en aquellos que no pueden ser controlados y aquellos que pueden ser controlados. Dentro de los factores que no se pueden controlar el principal de ellos es la edad. Cáncer colorrectal se vuelve más común con la edad. El riesgo comienza a aumentar después de los 40 años, incrementa de manera significativa a las edades de 50 a 60, y se duplica con cada década siguiente. Otros factores importantes que no pueden ser controlados incluyen antecedentes familiares de pólipos precancerosos o cáncer colorrectal, otros tipos de cáncer como el cáncer de útero, antecedentes personales de pólipos de colon rectal, enfermedad inflamatoria intestinal, y síndromes de cáncer hereditario como el síndrome de cáncer colorrectal hereditario sin poliposis. Los factores de riesgo que se pueden controlar incluyen factores que están vinculados a las cosas que uno normalmente puede hacer pero que aumentan el riesgo de cáncer colorrectal, como el consumo de una dieta rica en carnes rojas y carnes procesadas, cocinar carnes a altas temperaturas como en una parrilla (aumento de la temperatura puede crear toxinas que causan mutaciones en células), el estilo de vida sedentario, la obesidad, el tabaquismo y el consumo excesivo de alcohol.

¿Cómo se puede prevenir el cáncer colorrectal?

Los estudios han encontrado que el incremento de peso corporal puede predisponer al cáncer colorrectal. Este enlace parece ser más fuerte en

los hombres, particularmente cuando el aumento de peso está distribuido alrededor de la cintura. Otros estudios muestran que las dietas de bajo consumo en vegetales y granos enteros pueden predisponer al cáncer colorrectal. Finalmente, pólipos precancerosos y el cáncer colorrectal se encuentran con mayor frecuencia en las personas con bajos niveles de actividad física. Para ayudar a prevenir el cáncer colorrectal se puede comenzar con la modificación del comportamiento. Aumente su actividad física. Episodios regulares de actividad vigorosa varias veces a la semana es tal vez más beneficioso que la actividad moderada en base regular. Coma más verduras, frutas y alimentos integrales y consuma menos carne roja y carne procesada. Ponga como objetivo clave bajar de peso: aumente el ejercicio aeróbico y enfóquese en la pérdida de la grasa alrededor de la cintura. Por último, participe en un programa de cernimiento para cáncer colorrectal. La incidencia y la mortalidad de cáncer colorrectal se ha reducido en los últimos años posiblemente debido a los múltiples métodos de detección disponibles que son capaces de encontrar las lesiones precancerosas. La colonoscopía es el mejor método de cernimiento ya que puede ver todo el colon, detectar pólipos y removerlos durante el mismo procedimiento. Se recomienda que las personas con antecedentes familiares de cáncer colorrectal tengan su primera colonoscopía a los 50 años y si no hay pólipos precancerosos que se repita la colonoscopía cada 10 años. Los pacientes con una fuerte historia familiar de cáncer colorrectal deben someterse a su primera colonoscopía antes, y los pacientes con antecedentes de pólipos precancerosos deben tener su colonoscopía de seguimiento realizado a intervalos más cortos. Hable con su médico de atención primaria o sea referido a un gastroenterólogo para determinar cuándo y con qué frecuencia debe hacerse una prueba de cernimiento para cáncer colorrectal.


Síntomas, factores de riesgo y prevención

DIRECTRICES PARA LA DETECCIÓN DEL CÁNCER COLORRECTAL

DESCRIPCIÓN DEL PACIENTE EVALUACIÓN INDICADA

BAJO RIESGO

EDAD 50No hay factores de riesgo

Colonoscopia comenzando a los 50años (Para los afroamericanoscomenzando a la edad de 45)

Familiares con antecedentes de cáncer de colon o pólipos

Colonoscopia comenzando 10 años antes a la edad del familiar que fue diagnosticado

ALTO RIESGO

Sangre en las heces o anemia por deficiencia de hierro, hemorragia rectal o un cambio en los hábitos intestinales

Colonoscopia ahora

Colitis Ulcerosa o Enfermedad de Crohn Colonoscopia anual, después de 10 años de enfermeda

Antecedentes personales de cáncer de colon o pólipos

Colonoscopía regular segúndetermine su medico*

OTROENFOQUE INDIVIDUALIZADO

Síntomas gastrointestinales que pueden incluir; dolor abdominal, heces estrechas, estreñimiento, diarrea, “gas” o inflamación, así como antecedentes familiares de cáncer de

seno, ginecológico, abdominal, colon y otros cánceres gastrointestinales

*Llame a Gastro Health para consultar con su médico

DIRECTRICES PARA LA DETECCIÓN DELCÁNCER COLORRECTAL


Copyright @2014 Gastro Health, P.L all rights reserved. This publication is published by Gastro Health, P.L which is solely responsible for its contents. This information presented is intended only for residents of the United States. The material presented is intended only as informational, or as an educational aid, and is not intended to be taken as medical advice.The ultimate responsibility for a patients care resides with a healthcare professional.

1-855-GASTRO1 www.gastrohealth.com

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Gastro Health Pediatrics is composed of the finest physicians and allied health professionals specializing in gastrointestinal disorders, nutrition, and digestive health.

Oscar Loret De Mola, MD7775 SW 87 Avenue, Suite 120

Miami, FL 33173 | 305.274.8243

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Miami, FL 33173 | 305.271.7330

GASTRO HEALTH PEDIATRICSNEW KIDS ON THE BLOCK


Nonalcoholic fatty liver disease (NAFLD) is an accumulation of fat in the liver. Over the last decade, it has become the most common cause of chronic liver disease in children. NAFLD is estimated to affect close to 10% of the American

population between the ages of two and 19 years, and this figure increases 30-40% among obese children. Insulin resistance is almost a universal finding in pediatric NAFLD, and consequently, several of the clinical features associated with insulin resistance such as, obesity, diabetes mellitus, dyslipidemia, hypertension, obstructive apnea and gallstones are common comorbidities in children who suffer from NAFLD.

NAFLD includes a wide spectrum of liver damage ranging from simple, uncomplicated steatosis (fatty liver) to nonalcoholic steatohepatitis (NASH), to advanced fibrosis (scar tissue) that can lead to cirrhosis, which in turn can lead to liver failure and loss of liver function.

The American Academy of Pediatrics has recommended that serum aminotransferases (ALT and AST) should be performed in all overweight children starting at the age of ten if their BMI is >95% or between 85-95% with risk factors. The ALT and AST are to be checked in addition to the fasting glucose and the lipid profile. The diagnosis of NAFLD requires: 1) Confirmation of diffuse fatty infiltration of the liver in imaging studies regardless of the AST and ALT levels, the most common use modality is a liver ultrasound.2) Average daily ethanol consumption of less than ten grams in the appropriate age group and social setting.3) Appropriate exclusion of other liver diseases such as viral hepatitis, Wilson’s disease, alpha-1-antitrypsin deficiency, autoimmune hepatitis and studies to investigate standard metabolic/inborn error panel.4) Verification that medicine intake is not causing liver injury. 5) Some patients may require a liver biopsy.

Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years. In 2012, more than one third of children and adolescents were overweight or obese. The rising number of obese children explains the recommendations given by the American Academy of Pediatrics.

“The Natural History of Nonalcoholic Fatty Liver disease in Children: A Follow-Up Study for up to 20 Years” is a recently published article where 66 patients were monitored for up to 20 years in order to observe the natural history of NAFLD. The study revealed two important facts. Firstly, NAFLD in children is associated with a significant shorter long-term survival rate. Secondly, two of the 66 children studied developed liver cirrhosis. The most common presenting symptoms were: abdominal

pain, fatigue, hepatomegaly (enlarged liver), splenomegaly (enlarged spleen) and acanthosis nigricans. Treatment for NAFLD and NASH:• Lose weight through a healthy diet and increased physical activity. In most cases the liver injury is reversible if it is in the early stages and no scarring is present.• Vitamin E has shown to improve fatty liver in some children. It is not yet clear why it does not work for everyone, but genes and other risk factors might play a role.

Some Useful Tips:• Encourage your child to follow a healthy, portion-controlled diet with low amounts of saturated fats and refined sugars.• Avoid large portion sizes and sweetened drinks like soda. Limit the amount of meals eaten at fast food restaurants since this food is usually high in fat.• See a dietician who will help guide healthy diet choices.• Increase your child’s physical activity and outdoor play. • Have the hepatitis A and B vaccines updated to avoid potential injury to the liver caused by these viral infections.

Acknowledgements:I would like to thank Dr. Diana Lopez Garcia in the preparation of the article.

Oscar Loret de Mola, MD Pediatric Gastroenterologist

Fatty Liver in Children


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INTRODUCING OUR NEW PATIENT PORTAL ONGASTROHEALTH.COM

YOUR WEIGHT LOSS!JUMPSTART

For 68% of South Floridians, healthy weight loss is the key to achieving optimal health and overall well-being. “Eat less, eat better and exercise more!” sounds simple, but it’s not. If it were, obesity would not be among our nation’s leading challenges effecting the health of its citizens and its financial future.

The first line of treatment for many chronic diseases, including gastrointestinal diseases, is therapeutic lifestyle changes. “Lifestyle changes” is not something you can prescribe like a statin. With patient’s long-term outcomes and results in mind, Gastro Health physicians have decided to once again go beyond managing symptoms and focus on creating optimal health.Gastro Health’s “Health & Weight Loss” coach and nutritionists provide guidance, motivation and accountability to all patients looking to achieve a healthier lifestyle change!

How the program works • Replace your current unhealthy snacks with great tasting sweet or salty options (over 60 options!) that will satisfy your cravings while keeping nutrition values in check.• Add one complete meal replacement per day, or • Replace two meals per day to enable faster, yet healthy weight loss results.

• Your coach will be a key success factor. You will get weekly one-on-one meetings to keep you motivated and help you focus on your goals.• Your coach will send daily educational and motivational videos while providing you with access to our patient weight loss portal. There you will have the opportunity to watch your personal library of videos, chat with other dieters and pre-order everything you will need to succeed.

With the right coach, it’s a simple plan to follow. Once your have achieved your goal weight, it is much easier to make “healthier” food choices. Our approach will help you reach your goal quickly and motivate you to implement a healthy lifestyle.

To schedule a complimentary consultation call: 305-913-0677 or email [email protected]

Melany graduated in 2014 with a BS degree from FIU with a major in dietetics and nutrition, and a minor in psychology. She has a passion for health, fitness, nutrition and helping others to achieve their weight-loss goals so that they can also enjoy a healthy lifestyle and achieve an optimum overall well-being.

Caring for you and those you love

Copyright © 2014 Gastro Health, P.L. All rights reserved. This publication is published by Gastro Health, P.L., which is solely responsible for its contents. This information presented is intended only for residents of the United States. The material presented is intended only as informational, or as an educational aid, and it is not intended to be taken as medical advice. The ultimate responsibility for patient care resides with a healthcare professional.

Gastro Health bel ieves in pricing transparency and educating its patients on the alternatives avai lable, in order to provide them with the best options for their healthcare. For more information cal l 1-855-GASTRO1 or visit www.gastrohealth.com .

WHAT IS THE COST OF A COLONOSCOPY OR AN ENDOSCOPY?

SCREENING VS DIAGNOSTIC Is the colonoscopy being done as a screening or to diagnose a symptom? Endoscopies are always considered to be a diagnostic procedure. Authorization does not guarantee payment. A colonoscopy may be considered a screening if a patient has no symptoms. Guidelines recommend that adults age 50 and older have a screening colonoscopy. In the event that a polyp or abnormality is found, the colonoscopy will now be considered a diagnostic procedure and your insurance may cover less of the cost.

INSURANCE DEDUCTIBLES, OUT-OF-POCKET, AND AUTHORIZATIONSHave you reviewed your insurance policy or contacted your insurance carrier? Your cost will vary depending on your insurance benefits and the services rendered. Your insurance will determine what your expense will be and we encourage you to contact your carrier for more information.

THE COST OF A COLONOSCOPY OR UPPER ENDOSCOPY DEPENDS ON NUMEROUS FACTORS

COLONOSCOPY PREP$20-$110

Depending on the preparation your doctor prescribes and

amount covered by your insurance.

PATHOLOGY LABORATORY

$100-$300 Per Biopsy

PHYSICIAN PERFORMING COLONOSCOPY OR

ENDOSCOPY$950-$1,100

ANESTHESIA SERVICES

$300-$600

HOSPITAL FACILITY FEE$3,900-$9,700

orENDOSCOPY CENTER

$1,975-$2,175

V 1.0

Melany Doucette Health & Weight Loss Coach


ANAL FissureEduardo Krajewski, MD

Colorectal Surgeon

An anal fissure is no more than a tear or cut of the anal skin below the dentate line in the anal canal, usually very small in size. This injury can cause severe and disabling pain

to the patient. Symptoms include rectal bleeding and painful burning sensations after defecation that could last from several minutes to hours.

Fissures are mainly caused by trauma to the anal canal, such as, with the passage of hard stool. Other theories, such as ischemia to the posterior midline of the anus, have been entertained. Fissures are usually located in the posterior midline of the anus, but can also be seen in the anterior midline and in both locations at the same time. When a fissure is located off the midline of the anus, the clinician should investigate for other potentially complicated disease processes, such as Crohn’s disease, trauma, tuberculosis, syphilis, HIV/AIDS or anal carcinoma. The diagnosis of the fissure is usually suggested by the description of the patient’s symptoms and is easily confirmed by physical examination. Usually, other means of examination such as a digital rectal examination and anoscopy are not required and can actually be very painful for the patient.

The treatment of an anal fissure usually goes directed towards relieving the hypertony of the internal sphincter muscle that is associated with the condition. Fiber supplements, stool softeners and laxatives are also prescribed as needed. The treatment is also divided into medical or surgical. With the medical therapy, the aim is to chemically induce a relaxation of the internal sphincter muscle, while the aim of the surgical therapy is to mechanically cause that same effect.

The medications more widely used for the treatment of anal fissures are topical anti-inflammatory agents such as hydrocortisone.

In addition, sphincter relaxants such as nitrate formulations, oral and topical calcium channel blockers, adrenergic antagonists, topical muscarinic agonists, phosphodiesterase inhibitors and the use of botulinum toxin are implemented with success cure rates that range from 50 to 80%.

Historically, surgical techniques have had a high success rate in treating this condition, as other techniques such as anal dilatation and posterior sphincterotomy have been largely abandoned due to their side effects that cause fecal incontinence in particular. The American Society of Colon and Rectal Surgeon’s Practice

Parameters for the Management of Anal Fissures recommends Lateral Internal Sphincterotomy as the surgical treatment of choice in medically refractory anal fissures, in which a small portion of the left aspect of the internal sphincter muscle is divided to achieve the desired mechanical relaxation needed to help the fissure heal.

Despite the mixed results with medical therapy, it is our practice to step up treatment options. From the use of topical anti-inflammatories to sphincter relaxants to surgical therapies, treatment options depend on the patient’s potential risk for fecal incontinence.

“The diagnosis of the fissure is usually suggested by the description of the patient’s symptoms and is easily confirmed by physical examination.”

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The Hepatitis C Virus (HCV) is a major global public health concern. It is a serious and complex blood-borne virus that manifests itself through

complications of the liver. If left untreated it can cause significant and potentially fatal damage, possible hepatic carcinoma and other complications leading to a need for transplantation. The World Health Organization (WHO) estimates that 150 million people worldwide were chronically infected with HCV in 2011. The virus is responsible for 350,000 deaths globally with 10,000 - 16,500 deaths each year in the United States. Up to 90% of those infected with hepatitis C do not clear the virus and become chronically infected. In the

United States, nearly four million people are chronically infected. The HCV virus is most commonly detected in people who are 40 to 60 years of age, reflecting higher rates of infection during the 1970’s and 1980’s. Recently, both the Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Service Task Force have encouraged HCV screening among Baby Boomers (those born between 1945 and 1965).

Treatment modalities for HCV have advanced incredibly in the last 25 years since HCV infection was identified in 1989. We witnessed the first approved treatment with Interferon (IFN-a) in 1991, and then seven years later Ribavirin (an antiviral) was approved in combination with Interferon. Both of these drugs were revolutionary at the time because they inhibited viral replication. However, although this was an incredible advancement, there were several side effects such as fatigue, flu-like symptoms and

depression. Additionally, the body’s response to IFN-a was not as efficient and effective as some had hoped. A decade would pass until we had an improved delivery method of Interferon. Pegylated Interferon (IFN-a) was introduced in 2001 and resulted in the interferon’s ability to stay in the body longer. However, the side effects in treatment still persisted.

Fortunately, HCV treatment regimens saw a breakthrough in 2011 when the first direct-acting agents were approved in combination with Interferon and Ribavirin for genotype 1 HCV infection. “We are now going to get into an era of using combinations of direct-acting antivirals,” said Luis Balart, MD, chief

of gastroenterology and hepatology at Tulane University School of Medicine in New Orleans. In December of 2013, the United States Food and Drug Administration (FDA) approved sofosbuvir (a nucleotide polymerse inhibitor of the HCV NS5B enzyme) as part of the first ever Interferon (IFN) free regimen for HCV. This was a major breakthrough because those who were not eligible for interferon due to contraindications now had a mode of treatment. Sobosbuvir was approved for use in combination with ribavirin for adults with HCV genotypes 2 or 3, and in combination with pegylated interferon (PEG-IFN) and ribavirin (RBV) for adults with HCV genotypes 1 or 4. This drug approval came several weeks after the approval of Simeprevir (a HCV NS3/4A protease inhibitor) which treated patients with HCV genotype 1 in combination with PEG-IFN and Ribavirin.

Despite the fact that the current standard of care for genotype 1 includes combination of

PEG-IFN and ribavirin, the approval of these two new drugs represents a shift in the treatment paradigm for patients with chronic hepatitis C. These two types of Direct Acting Antivirals (DAA’s) are playing a role in bringing about important therapeutic advances, particularly for IFN-free treatment modalities.

In the next six months to five years, a number of new DAA’s are expected to receive the FDA approval for hepatitis C. According to Donald Jensen, MD, director of the Center for Liver Disease at the University of Chicago, “Five to ten new HCV treatment regimens currently stand a good chance of being submitted for FDA approval in the next few years.” These new treatment modalities have high sustained virologic response (SVR) rates, meaning that they have a high success rate. Not only are they effective at treating HCV, but they are given in shorter duration with minimal side effects when compared to IFN based treatments. Moreover, the traditional risk factors thought to portend poor outcomes in HCV patients (past treatment responses, gender, high baseline HCV RNA, advanced fibrosis/cirrhosis and genotype-IL28B- non CC genotype) may have no effect with the new DAA agents.

“There are multiple, oral, interferon (IFN) free DAA regimens in late stage clinical trials with high SVR rates,” said Mark Sulkowski, MD, Medical Director of the Viral Hepatitis Center in the Divisions of Infectious Diseases and Gastroenterology & Hepatology at Johns Hopkins School of Medicine in Baltimore. These include the Gilead-based regimen of sofosbuvir plus ledipasvir, with or without GS-9669; Abb Vie’s ABT 450/r plus ABT267 and ABT333; Boehringer Ingelheim’s faldaprevir plus deleobuvir, with or without PPI-668; Janssen’s simeprivir and samatasvir plus TMC647055/r; Merick’s MK 8742 plus MK 5172; Bristol-Myers Squibb’s daclatasvir plus asunaprevir and/or

Hepatitis C Virus:

Darlene Boytell-Perez, ARNP Nurse Practicioner

Current therapies and beyond

“The HCV virus is most commonly detected in people who are 40 to 60 years of age, reflecting higher rates of infection during the 1970’s and 1980’s.”


with BMS 791325. Not to mention the already filed and awaiting FDA’s “stamp of approval” for several DAA’s that will be on the market within the next six to twelve months.

These new DAA’s can be classified into three groups: protease inhibitors, polymerase inhibitors and NS5A inhibitors. All of the new agents target specific processes of the HCV life cycle. The treatment strategy involving these new agents is to include drugs that attack at least two different HCV targets in a single regimen. The challenge for the clinician will

be to scrutinize the drug combinations and select the best regimen, such as assessing whether some populations may benefit from eight or 24 weeks of therapy, or the addition of ribavirin. However, the bottom line is that an extremely simple, safe and effective therapy for HCV genotype 1 infection is here. Given the dramatic advances in the treatment of HCV infection, identification of patients with hepatitis C may provide an opportunity to cure patients and greatly reduce the health care burden associated with the complications of liver disease.

Finally, it is important to remember to ask your gastroenterologist if there are any new treatment options that are right for you. Gastro Health has been a long time leader in hepatitis treatment and expects to offer these new treatment combinations in the near future. At Gastro Health we remain up to date with current and future treatment remedies and offer quarterly support groups in order to effectively care for you and those you love.


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PANCREATIC CANCERThe pancreas is an important organ

responsible for the production of enzymes necessary for the digestion of food and insulin (a hormone that

controls sugar levels in the blood). Pancreatic cancer is a disease in which malignant cells form in the pancreatic tissues. Risk factors for developing pancreatic cancer include smoking, diabetes, obesity, chronic pancreatitis and certain inherited conditions.

SymptomsInitially pancreatic cancer tends to be silent but as it grows symptoms develop. Unfortunately, by the time symptoms develop the cancer has probably grown outside of the pancreas. The symptoms depend on the location of the cancer. If the tumor is in the body of the pancreas, the patient will have belly or back pain and weight loss. Pancreatic cancer of the head of the pancreas tends to cause weight loss, belly or back pain, jaundice (yellow skin and eyes), dark urine, itching or light colored stool.

Is pancreatic cancer increasing?Pancreatic cancer has a poor prognosis and its incidence has been increasing over the last 15 years. Although it is not clear why this is happening, pancreatic cancer ranks fourth in cancer related deaths. By the year 2030, it is believed that pancreatic cancer will fall shortly behind lung cancer as the second highest cause of cancer deaths.

There are several reasons for the increase in pancreatic cancer. Firstly, there has been a rise in obesity and diabetes which are both risk factors for the disease. Secondly, the incidence of colon and breast cancer has been decreasing because of effective screening practices. The incidence of colon cancer in older adults has decreased 30% over the last decade because of the increasing use of colonoscopy as a screening tool. Thirdly, the general population has a higher life expectancy and pancreatic cancer is more common to develop later in life.

How is pancreatic cancer diagnosed?The pancreas is a very difficult organ to image and obtain tissue from. This makes it very difficult to diagnose. After a patient develops symptoms suggestive of pancreatic cancer, the primary doctor will obtain a full medical history, physical exam and then he may order a CT scan or a MRI. After that, the doctor will refer the patient to see a gastroenterologist with expertise in pancreatic diseases. A biopsy will be obtained using an Endoscopic Ultrasound (EUS) or with an ERCP (an endoscopic procedure that accesses the bile and pancreatic ducts). One of the main objectives for the imaging studies and EUS is to determine whether the cancer can be removed by surgery.

TreatmentsThe best treatment for pancreatic cancer depends on how far it has spread, or the stage it is in. Early stages can be treated with surgery. When the tumor has spread beyond the pancreas, then surgery is not possible. Other treatment modalities such as chemotherapy and radiation therapy can extend survival.

SummaryPancreatic cancer is a common cause of cancer related deaths and its occurrence has been increasing over the last 15 years. Early diagnosis is crucial and it is imperative to consult with a physician who has experience with pancreatic cancer.

“By the year 2030, it is believed that pancreatic cancer will fall shortly behind lung cancer as the second highest cause of cancer deaths.”

Dr. Daniel Gelrud, MDGastroenterologist


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