Gastroenterology

Gastroenterologists and physicians writing on KevinMD about digestive disease: colonoscopy and when to stop screening, celiac disease and gluten, the liver, pancreatic enzyme insufficiency, the tests marketed for leaky gut, and what patients are fed in hospitals. Board-review cases make up part of this archive. One maintained record draws on this archive: Cancer: what physicians say, in their own words.

Increasing hospital revenues through urgent care referrals

Trudy Lieberman

Patient

August 7, 2014

Not long ago, Tracy Hume, a freelance writer who lives in Greeley, Colorado, sent me an email posing this question: “Do ER-affiliated urgent care providers ever try to escalate patients to the ER when it is not medically necessary?”

It seems that over the July 4th weekend, Tracy’s teenage son was complaining of a headache, nausea and abdominal pain, and was vomiting. He doesn’t complain much, she said, so thinking that …

Law and medicine are more intertwined than they should be

Michael Kirsch, MD

Physician

August 1, 2014

I’m a law abiding blogger. Laws are meant to be obeyed. If an individual opposes a law in a free country, then he should operate within the system to modify it. I recognize that even in free societies, certain laws are so unjust and in violation of natural law that that the citizenry may be justified in relying upon other measures to affect necessary reform.

I’m not suggesting that an unwelcome …

A short term focus on costs is expensive in the long run

Adam Philip Stern, MD

Physician

August 1, 2014

Mr. D was my patient in the partial hospital program for the chronically and persistently mentally ill, and he was barely maintaining the level of functioning necessary to remain outside of the inpatient unit. A middle aged man with long-term psychotic and depressive symptoms, Mr. D’s care was made even more complicated by an extensive history of alcohol dependence and intravenous drug use that had left him with a severely …

Sometimes there is no substitute for a face to face visit with a doctor

Michael Kirsch, MD

Physician

July 24, 2014

A 32-year-old woman recently came to see me for an opinion on stomach pain. Why would I refuse to see her again? Abdominal pain is an everyday occurrence for a gastroenterologist. She was accompanied by her mother. I had never met this woman previously.

She had suffered abdominal pains for as long as she could remember. She recalled frequent visits with the school nurse when she was a young girl.

She has abdominal distress …

Medical judgment is paramount

Michael Kirsch, MD

Physician

July 16, 2014

The world is asunder. Iraq is sinking into a sectarian abyss. ISIS, a terrorist group, now controls a larger territory than many actual countries. Russia has swallowed Crimea and has her paw prints all over eastern Ukraine. China is claiming airspace and territories in Southeast Asia increasing tensions with Japan, Vietnam and the Philippines. The Israeli-Palestinian peace process is in another deep freeze. Terrorists in Sudan and Nigeria are kidnapping …

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Medical judgment is paramount

Treating hepatitis C: Is sofosbuvir worth it?

Ashish Advani, PharmD

Medications

July 14, 2014

In 2011, Food and Drug Administration Commissioner Margaret Hamburg remarked upon a “new direction in the treatment of hepatitis C,” as a success rate of approximately 70% marked a significant improvement over the previous rate of approximately 50%, and suggested a cure was in sight.

Today, that cure has been realized as Sovaldi (sofosbuvir), a novel agent, has shown a success rate of 95% in clinical trials. Sofosbuvir comes without the …

Guessing if medications are covered by a patient’s insurance company

Michael Kirsch, MD

Medications

July 7, 2014

One of the frustrating aspects of medical practice is trying to decide if the medication I am prescribing is covered by the patient’s insurance company. Even with the advent of electronic medical records, which should be able to determine this, we are often left to hope and pray.

Here’s how it works. Individual insurance companies have formularies — lists of approved drugs — that they encourage patients and their physicians to use. …

Medical educators: A subtle difference in wording makes a difference

Ryan Madanick, MD

Medical Education

July 1, 2014

If you pay close attention to medical education and training, you have surely read something like this as an goal or learning objective: “Manage inflammatory bowel disease and its complications.”

However, this is not exactly what our goals should be. One push in the patient-centered care community has been changing the focus from managing the disease to managing the patient who has (or might have) the disease. The difference in wording is subtle, but it gets more …

Gluten sensitivity is an elusive concept in clinical medicine

Brian J. Secemsky, MD

Conditions and Diseases

July 1, 2014

As a resident of San Francisco (and with Los Angeles just a drive away), I cannot escape the food hate. Whether it be a campaign against cooked provisions, farmed products or anything of solid consistency, I cannot help but wonder if any possible benefit of these diets outweigh the risk of missing out on amazing grub.

But what about gluten-free diets?

Gluten sensitivity

Gluten, a protein found in foodstuffs such as wheat, barley …

IBD versus IBS: The difference is everything

Sophie M. Balzora, MD

Conditions and Diseases

June 24, 2014

The New York Times recently published two articles in a series about inflammatory bowel disease, or IBD, in hopes to destigmatize the disease, and to broadcast medical and surgical advancements that have worked to change how we conceptualize IBD. I applauded the Times for highlighting what can be a debilitating disease for the 1.4 million Americans who are afflicted with it, and thought: Finally! IBD is getting the attention it deserves.

Albeit …

Cancer screening in those with metastatic disease

Don S. Dizon, MD

Conditions and Diseases

June 18, 2014

“Your cancer has come back.”

These are words no one treated for cancer wants to hear, yet they are words I have said far too often in my own career. In this case, I had said this to a patient I had cared for ever since her initial diagnosis. At that time, she had stage III breast cancer. After her surgery, …

Esophageal cancer: How far should we screen?

Julian A. Abrams, MD

Conditions and Diseases

June 1, 2014

The incidence of esophageal adenocarcinoma has increased more than five-fold over the past four decades in the U.S. While the rate of rise in incidence of esophageal cancer has slowed somewhat in recent years, this malignancy is still associated with a dismal prognosis. Barrett’s esophagus, the precursor lesion to esophageal cancer, is easily identifiable on routine upper endoscopy and can be monitored for the development of precancerous changes. We generally …

MKSAP: 51-year-old woman with diarrhea and bloating

mksap

Conditions and Diseases

May 31, 2014

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 51-year-old woman is evaluated for a 6-month history of diarrhea and bloating. She reports four to six loose stools per day, with occasional nocturnal stools. She has had a few episodes of incontinence secondary to urgency. She has not had melena or hematochezia but notes an occasional oily appearance to the …

Curing hepatitis C, but at what cost?

Albert Fuchs, MD

Conditions and Diseases

May 27, 2014

In the contest to get a creative name, few pathogens have done worse than hepatitis C. In the 1970s there were two known viruses that caused hepatitis: liver inflammation. You might have already guessed that these two viruses were called hepatitis A and hepatitis B. It was known at that time that people sometimes developed hepatitis after blood transfusions and that the majority of those patients tested negative for hepatitis …

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Curing hepatitis C, but at what cost?

Maybe doctors should have disclaimers

Michael Kirsch, MD

Physician

May 27, 2014

Why does is seem that so much information given to us comes with disclaimers? The weight loss product ads on TV that promise more than they will deliver, are always accompanied by 5 nanosecond disclaimers in a font size that can’t be discerned by the human retina stating that the results are not typical.

It seems deceptive to be advertising a product by showcasing a performance that the vendor admits is …

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Maybe doctors should have disclaimers

When should we test for celiac disease?

Sophie M. Balzora, MD

Conditions and Diseases

May 26, 2014

May marks Celiac Disease Awareness Month, with the goals of raising awareness of the disease and its potential health complications, and also to help elucidate which patients warrant diagnostic testing for the disease.

A few days ago on Twitter, I noticed that #glutenfree was trending (again). It is fascinating to observe how gluten-free businesses are beyond booming as diseases and conditions such as celiac disease, wheat allergy, and non-celiac gluten intolerance …

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When should we test for celiac disease?

Our broken medical malpractice system from a moral perspective

Michael Kirsch, MD

Physician

May 7, 2014

Remember personal responsibility? There actually was an era of responsibility when folks admitted when they screwed up and didn’t blame others for their own mistakes. I know this may seem incredible to the younger generation who simply assume that when something goes wrong today, it must be someone else’s fault. In today’s culture, this is not scapegoating, but the pursuit of justice. Welcome to the era of big victim.

In the …

A patient’s role in ensuring high quality colonoscopy

Douglas K. Rex, MD

Conditions and Diseases

April 29, 2014

The American Cancer Society recently released important new data showing that the rate at which people are diagnosed with colon cancer in the U.S. has dropped 30% in the last ten years for those aged 50 and older. Much of this decline was attributed to the widespread uptake of colonoscopy screening. Colonoscopy is the only screening test that examines the entire colon and allows removal of precancerous polyps in the …

We have performance measures based on rather weak evidence

Robert Centor, MD

Physician

April 25, 2014

Recently, we had a wonderful reception at the American College of Physician’s Internal Medicine 2014. Sitting with leadership colleagues we had a wonderful conversation about how medicine changes. One colleague gave the example of ulcer disease. Those who trained in the 1960s and 1970s know most of this history, but it actually goes back to the early part of the 20th century.

Consider the Sippy diet, the Bilroth II, highly selective …

Why is hepatitis C underreported?

Kristina R. Chacko, MD

Conditions and Diseases

April 25, 2014

Hepatitis C virus (HCV) continues to be the number one cause of cirrhosis and liver cancer and the primary indicator for liver transplantation in the United States, yet it remains vastly underdiagnosed.

More than three million people in the U.S. are infected. Guidelines support widespread screening for HCV, and excellent treatments are now available.

So the question remains: Why is HCV underreported?

When “good” news disguises bad

A recently published Read more…

Why is hepatitis C underreported?