Gastroenterology

A patient presents with painless diarrhea. What should you do next?

Conditions
August 29, 2015

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

A 67-year-old woman is evaluated for a 1-year history of loose stools. She reports approximately four episodes per day without abdominal pain. She has not had nausea, vomiting, weight loss, bright red blood per rectum, or melena.

On physical examination, temperature is 36.7 °C (98.1 °F), blood pressure is 115/85 mm Hg, pulse …

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How to perform a stool transplant

Conditions
August 25, 2015

Fecal microbiota transplantation (FMT) is the process of administering a preparation of healthy donor stool to a patient with a certain disease, usually Clostridium difficile colitis, in an attempt to treat the disease.  I covered some of the basics about the microbiome and FMT in a previous article, so this will just be a cookbook-style post on how we do FMT with colonoscopy.

First, a healthy donor must be identified.  The donor …

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A patient secretly records his colonoscopy. It cost this doctor her job.

Video
June 23, 2015

A patient undergoing a colonoscopy pressed “record” on his smartphone before being sedated, hoping to capture instructions from his physicians after the procedure.  What he heard instead was shocking: “In addition to their vicious commentary, the doctors discussed avoiding the man after the colonoscopy, instructing an assistant to lie to him, and then placed a false diagnosis on his chart.”

The incident cost his …

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Lessons from my first nasogastric tube

Education
February 23, 2015

I was glad she never asked if I had done this before.

My first nasogastric tube was placed on an elderly woman with chronic liver disease. As her illness worsened, it gradually turned her skin yellow, her abdomen swollen, and her mind foggy. One day, we realized that she was at too high a choking risk to swallow her medications herself. She would need a plastic tube to do it for …

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4 reasons why fecal transplants aren’t mainstream. Yet.

Conditions
February 23, 2015

Fecal microbiota transplantation (FMT) has emerged as an increasingly common treatment for patients with refractory Clostridium difficile infection (CDI). Unlike standard antibiotic approaches, which only exacerbate dysbiosis and may perpetuate CDI recurrence, FMT restores normal gut microbial community structure and function of the gastrointestinal tract. However, a number of challenges need to be overcome before this procedure is widely accepted in mainstream clinical practice.

Before I jump into highlighting …

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Doctor, why do you enjoy practicing gastroenterology?

Physician
February 16, 2015

Whenever I am asked this question, I can’t help but think of the punchline to a joke that was once supposed to be funny but would now be considered beyond the pale in all respects, so I won’t repeat it. The punch line is: “Just lucky, I guess.” That’s the short answer to why we gastroenterologists work in our field. Despite the distasteful aspect of human waste and the perverse …

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Taking care of patients who stop caring about themselves

Education
February 13, 2015

It’s been a long day, and you just want to decompress. My boyfriend tells me about his day. I get to hear about the insane amount of reading he has to do for graduate school, or about the occasional annoying customer he’s had to deal with at his part-time job as a bank teller. When it’s my turn to decompress, I usually gripe about a patient or two from the …

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The truth about Miralax in children

Meds
February 12, 2015

Parents are appropriately expressing concern about the safety of Miralax®, a commonly used stool softener in kids, after a recent New York Times article exposed a potential association with long-term use of the drug and undesired behavioral side effects. As the article explains, the FDA has awarded a research grant to a team at the Children’s Hospital of Philadelphia (CHOP) to directly address these concerns.

Miralax® has been used …

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How much testing should you do in chronic abdominal pain?

Conditions
January 26, 2015

I see patients with abdominal pain every day. Over my career, I’ve sat across the desk facing thousands of folks with every variety of stomach ache imaginable. I’ve listened to them, palpated them, scanned them, scoped them and at times referred them elsewhere for another opinion. With this level of experience, one would suspect that I have become a virtual sleuth at determining the obvious and stealth causes of abdominal …

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The hidden costs of an inadequate bowel preparation for colonoscopy 

Conditions
January 6, 2015

Colonoscopy is the most effective test for the detection and prevention of colorectal cancer, the second leading cause of cancer death in the United States. An estimated 14 million colonoscopies are performed in the United States every year. About 20 to 40 percent of these colonoscopies have inadequate bowel preparation according to multiple studies.

Inadequate bowel preparation is costly to the patient, the health care system, and society.

In one study, poor …

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The era of trial and error medicine needs to be over

Meds
November 7, 2014

We always want to get it right the first time when treating patients, but the truth is this is difficult. When there is uncertainty of disease course and prognosis, multiple treatment options, and variable responses to therapy this becomes even more challenging.  Our typical strategy to making it “just right” isn’t too different from Goldilocks. We have mild treatments (too cold), and aggressive treatments (too hot), and even in the …

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Law and medicine are more intertwined than they should be

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 …

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Young patients with adenomas: Who should get genetic testing?

Conditions
March 20, 2014

While it is unusual for gastroenterologists to see colorectal tumors in patients under the age of 50, and even more uncommon before the age of 40, it does happen, so patients need to be aware of their risks. Colorectal tumors in young people are often detected either through symptom evaluation or because of a colonoscopy performed for an underlying risk factor, most commonly a family history of colorectal cancer (CRC).

During …

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Treating a symptom is not the same as treating a disease

Conditions
March 6, 2014

Physicians and patients collaborate to treat symptoms. This is not newsworthy and even sounds appropriate. Isn’t that what doctors are trained to do? It is but I’m not sure this should be a central focus of our healing mission. Treating a symptom is not the same as treating a disease.

For example, if an individual is having abdominal discomfort, pain medicine should not be the first responder, even if this would …

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The transition from chief resident to attending

Education
January 28, 2014

During my year as a chief resident, I have the privilege to attend on the general medicine service for 8 weeks. I recently completed 4 weeks and, as expected, found myself in an entirely new realm of patient care and accountability. I would be remiss without recalling a few of the pivotal lessons and poignant moments that stand out.

Transitioning from resident to attending inevitably results in greater scrutiny. Despite my best …

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Patients sometimes have good reasons to refuse colonoscopies

Conditions
January 22, 2014

Many times over the years, I have witnessed the following scenario in my exam room.

Here’s the set up of this one act play.

Characters:

Elderly patient
Attentive daughter
The doctor

Scene 1

I’m seated at my desktop computer. The patient is seated before me. The patient’s daughter is seated next to her mother.

A patient comes to see me in the office with medical issues that strongly suggest that a colonoscopy should be performed. As an aside, …

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Proton pump inhibitors and B12 deficiency: What to do now

Meds
December 19, 2013

We can now add vitamin B12 deficiency to the growing list of risks of long term use of the proton pump inhibitors (PPIs).

The New York Times had an article outlining the evidence that prolonged use of both proton pump inhibitors (PPIs) like Prilosec, Protonix, Prevacid and others, as well as the less potent H2 blockers like Zantac and Pepcid, can lead to vitamin B12 deficiency.  This is in addition …

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The personal costs of a living donor liver transplantation

Physician
December 5, 2013

Partial liver donation is the only life-saving deed that a non-surgeon can do for another person suffering from end stage liver disease. On the other hand, a major operation on a healthy individual with no indication for surgery has been viewed by society with caution and skepticism.

One could wonder why a young, healthy individual would succumb to an elective high risk procedure. Simple answer: they want to save a life. …

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Obamacare covers screening colonoscopies, with a catch

Conditions
October 25, 2013

“An ounce of prevention” we all know is good medicine. An example is colonoscopy. It was time for mine so after some lengthy procrastination I called and set up an appointment which I soon found a perfectly good reason to postpone for a few weeks. A common occurrence. The government wants me (and you) to not procrastinate, at least not because of the cost. The Affordable Care Act (or Obamacare) …

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A gastroenterologist dishes on unnecessary colonoscopies

Physician
September 9, 2013

We gastroenterologists are regularly summoned to bring light into dark places. We are the enlightened ones who illuminate anatomical shadows. Sure, we have tunnel vision, but we like to believe that we can think broadly and creatively as well.

We are the scope doctors.

We are commonly consulted by primary care physicians and hospitalists to perform colonoscopies, upper endoscopies (EGDs) of the esophagus and stomach and other gastrointestinal delights. We deliver a …

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