GI Associates is a large, broad-based gastroenterology group practice. Our members provide a depth of experience and skill in the diagnosis and treatment of common and uncommon disorders of the digestive tract and liver. We are committed to an environment that combines the best traditions of clinical medicine with the most advanced diagnostic and therapeutic tools available. Our goal is to continually integrate the most beneficial new medical practices and procedures into our everyday care of patients.

Patients are provided with the best and the most innovative treatment, as well as with the opportunity to participate in the clinical trials evaluating novel therapies.

Barrett's Esophagus

Barrett's esophagus is a condition in which the esophagus, the muscular tube that carries food from the mouth to the stomach, changes so that some of its lining is replaced by a type of tissue similar to that normally found in the intestine. This process is called intestinal metaplasia. While Barrett's esophagus may cause no symptoms itself, a small number of people with this condition develop a relatively rare type of cancer of the esophagus called esophageal adenocarcinoma. Barrett's esophagus is estimated to affect about 700,000 adults in the United States. It is associated with the very common condition gastroesophageal reflux disease or GERD.

GERD and Barrett's Esophagus

The exact causes of Barrett's esophagus are not known, but it is thought to be caused in part by the same factors that cause GERD. Although people who do not have heartburn can have Barrett's esophagus, it is found about three to five times more often in people with this condition.

Barrett's esophagus is uncommon in children. The average age at diagnosis is 60, but it is usually difficult to determine when the problem started. It is about twice as common in men as in women and much more common in white men than in men of other races.

Barrett's Esophagus and Cancer of the Esophagus

Barrett's esophagus does not cause symptoms itself and is important only because it seems to precede the development of a particular kind of cancer--esophageal adenocarcinoma. The risk of developing adenocarcinoma is 30 to 125 times higher in people who have Barrett's esophagus than in people who do not. This type of cancer is increasing rapidly in white men. The increase is possibly related to the rise in obesity and GERD. For people who have Barrett's esophagus, the risk of getting cancer of the esophagus is small: less than 1 percent (0.4 percent to 0.5 percent) per year. Esophageal adenocarcinoma is often not curable, partly because the disease is frequently discovered at a late stage and because treatments are not effective.

Diagnosis

Diagnosing Barrett's esophagus is not easy. At the present time, it cannot be diagnosed on the basis of symptoms, physical exam, or blood tests. The only useful test is upper gastrointestinal endoscopy and biopsy. In this procedure, a flexible tube called an endoscope, which has a light and miniature camera, is passed into the esophagus. If the tissue appears suspicious, then biopsies must be done. A biopsy is the removal of a small piece of tissue using a pincher-like device passed through the endoscope. A pathologist examines the tissue under a microscope to confirm the diagnosis.

Many physicians recommend that adult patients who are over the age of 40 and have had GERD symptoms for a number of years have endoscopy to see whether they have Barrett's esophagus. Screening for this condition in people who have no symptoms is not recommended.

Treatment

Barrett's esophagus has no cure, short of surgical removal of the esophagus, which is a serious operation. Surgery is recommended only for people who have a high risk of developing cancer or who already have it. Most physicians recommend treating GERD with acid-blocking drugs, since this is sometimes associated with improvement in the extent of the Barrett's tissue. However, this approach has not been proven to reduce the risk of cancer. Treating reflux with a surgical procedure for GERD also does not seem to cure Barrett's esophagus. Several different experimental approaches are under study. One attempts to see whether destroying the Barrett's tissue by heat or other means through an endoscope can eliminate the condition. This approach, however, has potential risks and unknown effectiveness.

Surveillance for Dysplasia and Cancer

Periodic endoscopic examinations to look for early warning signs of cancer are generally recommended for people who have Barrett's esophagus. This approach is called surveillance. When people who have Barrett's esophagus develop cancer, the process seems to go through an intermediate stage in which cancer cells appear in the Barrett's tissue. This condition is called dysplasia and can be seen only in biopsies with a microscope. The process is patchy and cannot be seen directly through the endoscope, so multiple biopsies must be taken. Even then, it can be missed. The process of change from Barrett's to cancer seems to happen only in a few patients, less than 1 percent per year, and over a relatively long period of time. Most physicians recommend that patients with Barrett's esophagus undergo periodic surveillance endoscopy to have biopsies. The recommended interval between endoscopies varies depending on specific circumstances, and the ideal interval has not been determined.

Treatment for Dysplasia or Esophageal Adenocarcinoma

If a person with Barrett's esophagus is found to have dysplasia or cancer, the doctor will usually recommend surgery if the person is strong enough and has a good chance of being cured. The type of surgery may vary, but it usually involves removing most of the esophagus and pulling the stomach up into the chest to attach it to what remains of the esophagus. Many patients with Barrett's esophagus are elderly and have many other medical problems that make surgery unwise; in these patients, other approaches to treating dysplasia are being investigated.

Source: NIDDK.

Colon Polyps

A polyp is extra tissue that grows inside your body. Colon polyps grow in the large intestine. The large intestine, also called the colon, is part of your digestive system. It's a long, hollow tube at the end of your digestive tract where your body makes and stores stool.

Are polyps dangerous?

Most polyps are not dangerous. The great majority of polyps are benign, which means they are not cancer. But over time, some types of polyps can turn into cancer. Usually, polyps that are smaller than a pea aren't harmful. But larger polyps could someday become cancer or may already be cancer. To be safe, doctors remove all polyps and test them.

Who gets polyps?

Anyone can get polyps, but certain people are more likely than others. You may have a greater chance of getting polyps if:

  • you're over 50. The older you get, the more likely you are to develop polyps.
  • you've had polyps before.
  • someone in your family has had polyps.
  • someone in your family has had cancer of the large intestine.

You may also be more likely to get polyps if you:

  • eat a lot of fatty foods
  • smoke
  • drink alcohol
  • don't exercise
  • weigh too much
    • How can I prevent polyps?

    Doctors don't know of any one sure way to prevent polyps. But you might be able to lower your risk of getting them if you:

    • eat more fruits and vegetables and less fatty food
    • don't smoke
    • avoid alcohol
    • exercise every day
    • lose weight if you're overweight

    Eating more calcium and folate can also lower your risk of getting polyps. Some foods that are rich in calcium are milk, cheese, and broccoli. Some foods that are rich in folate are chickpeas, kidney beans, and spinach.

    Some doctors think that aspirin or other medicines might help prevent polyps. Studies are under way. Because you have had up to a few polyps, your doctor will recommend another colonoscopy in 3-5 years to look for new polyps. However, if you had many polyps, you may need another exam in just one year. Source:http://digestive.niddk.nih.gov/ddiseases/pubs/colonpolyps_ez/

    Diverticulosis

    Many people have small pouches in their colons that bulge outward through weak spots, like an inner tube that pokes through weak places in a tire. Each pouch is called a diverticulum or if are more than one are called diverticula. The condition of having diverticula is called diverticulosis. About half of all Americans age 60 to 80, and almost everyone over age 80, have diverticulosis. When diverticula become infected or inflamed, the condition is called diverticulitis. This happens in 10 to 25 percent of people with diverticulosis. Diverticulosis and diverticulitis are also called diverticular disease.

    Illustration of the colon (large intestine) and an enlargement of it showing diverticula
    What causes diverticular disease?

    Though not proven, the dominant theory is that a low-fiber diet is the main cause of diverticular disease. The disease was first noticed in the United States in the early 1900s. At about the same time, processed foods were introduced to the American diet. Many processed foods contain refined, low-fiber flour. Unlike whole-wheat flour, refined flour has no wheat bran. Diverticular disease is common in developed or industrialized countries--particularly the United States, England, and Australia--where low-fiber diets are common. The disease is rare in countries of Asia and Africa, where people eat high-fiber vegetable diets. Fiber is the part of fruits, vegetables, and grains that the body cannot digest. Some fiber dissolves easily in water (soluble fiber). It takes on a soft, jelly-like texture in the intestines. Some fiber passes almost unchanged through the intestines (insoluble fiber). Both kinds of fiber help make stools soft and easy to pass. Fiber also prevents constipation.

    Constipation makes the muscles strain to move stool that is too hard. It is the main cause of increased pressure in the colon. The excess pressure might cause the lining of the colon to bulge out and become diverticula. Diverticulitis occurs when diverticula become infected or inflamed. Doctors are not certain what causes the infection. It may begin when stool or bacteria are caught in the diverticula. An attack of diverticulitis can develop suddenly and without warning.

    Most people with diverticulosis do not have any discomfort or symptoms. However, symptoms may include mild cramps, bloating, and constipation. Other diseases such as irritable bowel syndrome (IBS) and stomach ulcers cause similar problems, so these symptoms do not always mean a person has diverticulosis. You should visit your doctor if you have these troubling symptoms. Increasing the amount of fiber in the diet may reduce symptoms of diverticulosis and prevent complications such as diverticulitis. Fiber keeps stool soft and lowers pressure inside the colon so that bowel contents can move through easily. The American Dietetic Association recommends 20 to 35 grams of fiber each day. The table below shows the amount of fiber in some foods that you can easily add to your diet.

    Amount of Fiber in Some Foods

    Fruits

    apple

    1 medium

    		  

    4 grams

    peach

    1 medium

    		  

    2 grams

    pear

    1 medium

    		  

    4 grams

    tangerine

    1 medium

    		  

    2 grams


    Vegetables

    acorn squash, fresh, cooked

    3/4 cup

    		  

    7 grams

    asparagus, fresh, cooked

    1/2 cup

    		  

    1.5 grams

    broccoli, fresh, cooked

    1/2 cup

    		  

    2 grams

    brussels sprouts, fresh, cooked

    1/2 cup

    		  

    2 grams

    cabbage, fresh, cooked

    1/2 cup

    		  

    2 grams

    carrot, fresh, cooked

    1

    		  

    1.5 grams

    cauliflower, fresh, cooked

    1/2 cup

    		  

    2 grams

    romaine lettuce

    1 cup

    		  

    1 gram

    spinach, fresh, cooked

    1/2 cup

    		  

    2 grams

    tomato, raw

    1

    		  

    1 gram

    zucchini, fresh, cooked

    1 cup

    		  

    2.5 grams


    Starchy Vegetables

    black-eyed peas, fresh, cooked

    1/2 cup

    		  

    4 grams

    lima beans, fresh, cooked

    1/2 cup

    		  

    4.5 grams

    kidney beans, fresh, cooked

    1/2 cup

    		  

    6 grams

    potato, fresh, cooked

    1

    		  

    3 grams


    Grains

    bread, whole-wheat

    1 slice

    		  

    2 grams

    brown rice, cooked

    1 cup

    		  

    3.5 grams

    cereal, bran flake

    3/4 cup

    		  

    5 grams

    oatmeal, plain, cooked

    3/4 cup

    		  

    3 grams

    white rice, cooked

    1 cup

    		  

    1 gram

    Source: United States Department of Agriculture (USDA). USDA Nutrient Database for standard reference. Available at www.nal.usda.gov. Accessed September 19, 2001.

    Your doctor may also recommend taking a fiber product such as Citrucel or Metamucil once a day. These products are mixed with water and provide about 2 to 3.5 grams of fiber per tablespoon, mixed with 8 ounces of water. Until recently, many doctors suggested avoiding foods with small seeds such as tomatoes or strawberries because they believed that particles could lodge in the diverticula and cause inflammation. However, this is now a controversial point and no evidence supports this recommendation. Individuals differ in the amounts and types of foods they can eat. If cramps, bloating, and constipation are problems, your doctor may prescribe a short course of pain medication. However, many medications affect emptying of the colon, an undesirable side effect for people with diverticulosis.

    Points to Remember
    • Diverticulosis occurs when small pouches, called diverticula, bulge outward through weak spots in the colon (large intestine).
    • The pouches form when pressure inside the colon builds, usually because of constipation.
    • Most people with diverticulosis never have any discomfort or symptoms.
    • The most likely cause of diverticulosis is a low-fiber diet because it increases constipation and pressure inside the colon.
    • For most people with diverticulosis, eating a high-fiber diet is the only treatment needed.
    • You can increase your fiber intake by eating these foods: whole grain breads and cereals; fruit like apples and peaches; vegetables like broccoli, cabbage, spinach, carrots, asparagus, and squash; and starchy vegetables like kidney beans and lima beans.
    • Diverticulitis occurs when the pouches become infected or inflamed and cause pain and tenderness around the left side of the lower abdomen.
    Source: NIDDK.

    Gastritis

    Gastritis is not a single disease, but means inflammation of the stomach lining. Gastritis can be caused by drinking too much alcohol, prolonged use of nonsteroidal, anti-inflammatory drugs (NSAIDs), or infection with bacteria such as Helicobacter pylori. Certain diseases, such as pernicious anemia, autoimmune disorders, and chronic bile reflux, can cause gastritis as well. The most common symptoms are abdominal upset, indigestion, or pain. Other symptoms are belching, abdominal bloating, nausea, and vomiting or a feeling of fullness or of burning in the upper abdomen.

    Treatment usually involves taking drugs to reduce stomach acid and thereby help relieve symptoms and promote healing. (Stomach acid irritates the inflamed tissue in the stomach.) Avoidance of certain foods, beverages, or medicines may also be recommended. If your gastritis is caused by an infection, that problem may be treated as well. For example, the doctor might prescribe antibiotics to clear up H. pylori infection. Once the underlying problem disappears, the gastritis usually does too.

    Source: NIDDK.

    Heartburn, Hiatal Hernia, and Gastroesophageal Reflux Disease (GERD)

    Gastroesophageal reflux disease, or GERD, occurs when the lower esophageal sphincter (LES) does not close properly and stomach contents leak back, or reflux, into the esophagus. The LES is a ring of muscle at the bottom of the esophagus that acts like a valve between the esophagus and stomach. The esophagus carries food from the mouth to the stomach. When refluxed stomach acid touches the lining of the esophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion. Occasional heartburn is common but does not necessarily mean one has GERD. Heartburn that occurs more than twice a week may be considered GERD, and it can eventually lead to more serious health problems.

    What are the symptoms of GERD?

    The main symptoms are persistent heartburn and acid regurgitation. Some people have GERD without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. GERD can also cause a dry cough and bad breath.

    What causes GERD?

    No one knows why people get GERD. A hiatal hernia may contribute. A hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest. The diaphragm helps the LES keep acid from coming up into the esophagus. When a hiatal hernia is present, it is easier for the acid to come up. In this way, a hiatal hernia can cause reflux. A hiatal hernia can happen in people of any age; many otherwise healthy people over 50 have a small one.

    Other factors that may contribute to GERD include

    • alcohol use
    • overweight
    • pregnancy
    • smoking

    Also, certain foods can be associated with reflux events, including:

    • citrus fruits
    • chocolate
    • drinks with caffeine
    • fatty and fried foods
    • garlic and onions
    • mint flavorings
    • spicy foods
    • tomato-based foods, like spaghetti sauce, chili, and pizza
    How is GERD treated?

    Depending on how severe your GERD is, treatment may involve one or more of the following lifestyle changes and medications or surgery.

    Lifestyle Changes
    • If you smoke, stop.
    • Do not drink alcohol.
    • Lose weight if needed.
    • Eat small meals.
    • Wear loose-fitting clothes.
    • Avoid lying down for 3 hours after a meal.
    • Raise the head of your bed 6 to 8 inches by putting blocks of wood under the bedposts--just using extra pillows will not help.

    Medications

    Your doctor may recommend over-the-counter antacids, which you can buy without a prescription, or medications that stop acid production or help the muscles that empty your stomach. 2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), impede acid production. They are available in both prescription strength and in lower dose over the counter. These drugs provide short-term relief, but over-the-counter H blockers should not be used for more than a few weeks at a time without consulting a physician. They are effective for about half of those who have GERD symptoms. Many people benefit from taking H2 blockers at bedtime in combination with a proton pump inhibitor.

    Proton pump inhibitors include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), which are all available by prescription. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost everyone who has GERD.

    Because drugs work in different ways, combinations of drugs may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, while the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production.

    Source: NIDDK

    Hemorrhoids

    What are hemorrhoids?

    The term hemorrhoids refers to a condition in which the veins around the anus or lower rectum are enlarged. Hemorrhoids may result from straining to move stool. Other contributing factors include pregnancy, aging, chronic constipation or diarrhea, and anal intercourse. Hemorrhoids are either inside the anus (internal) or under the skin around the anus (external).

    What are the symptoms of hemorrhoids?

    Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani), have similar symptoms and are incorrectly referred to as hemorrhoids. Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go away within a few days. Although many people have hemorrhoids, not all experience symptoms. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. However, an internal hemorrhoid may protrude through the anus outside the body, becoming irritated and painful. This is known as a protruding hemorrhoid. Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external hemorrhoid. In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Dr aining mucus may also cause itching.

    How common are hemorrhoids?

    Hemorrhoids are very common in both men and women. About half of the population have hemorrhoids by age 50. Hemorrhoids are also common among pregnant women. The pressure of the fetus in the abdomen, as well as hormonal changes, cause the hemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem.

    What is the treatment?

    Medical treatment of hemorrhoids is aimed initially at relieving symptoms. Measures to reduce symptoms include warm tub baths several times a day in plain, warm water for about 10 minutes application of a hemorroidal cream or suppository to the affected area for a limited time. Preventing the recurrence of hemorrhoids will require relieving the pressure and straining of constipation. Doctors will often recommend increasing fiber and fluids in the diet. Eating the right amount of fiber and drinking six to eight glasses of fluid (not alcohol) result in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Eliminating straining also helps prevent the hemorrhoids from protruding. Good sources of fiber are fruits, vegetables, and whole grains. In addition, doctors may suggest a bulk stool softener or a fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel).

    How are hemorrhoids prevented?

    The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing stools that are softer and easier to pass.

    Source: NIDDK.
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