Our Gastroenterology Blog
The Patient Portal
By Kristina Englert
One of the hottest new things that you’ll hear about at probably every doctor’s office that you visit is the concept of a Patient Portal. This idea has been around for at least the past five or ten years, but new government regulations have really increased the amount of attention it is getting. Offices are required to offer access to a Patient Portal to at least a portion of their patients – which is why suddenly every doctor you see is probably handing you a piece of paper with a website and instructions on how to log in.
At which point, you are probably asking several questions: What on earth is a Patient Portal? Why am I being asked to do this again when I just signed up for one at another doctor’s office last month? Am I required to do this? How do I get registered?
These are all excellent questions.
A Patient Portal can come in many different formats, but the basic definition is that it is a way to connect to your doctor’s office securely via the internet. This means that you can view your records, send questions to your doctor, and sometimes even do things like request prescription refills or schedule appointments.
The medical world is working hard towards standardization, but unfortunately it is a work in progress. There are a wide variety of companies who offer this service, and so your family doctor may have signed you up for My Chart, but our office uses Follow My Health. Both of these share the same basic idea, but are run by two different companies. So for now, it means having to set up two different accounts, since the two different computer systems cannot talk to each other.
If the internet is not the easiest way for you to communicate with a doctor’s office, then you are by no means required to sign up for a Patient Portal account. The existing system of calling in to an office to take care of the things that you need is still perfectly functional. It is up to you to decide what the best method is for you.
There are some definite benefits to having a Patient Portal account. For starters, you can gain immediate access to your records. Without an account, you would have to call in to the office (or send a written request), and then wait until records could be copied/mailed/faxed to you. With a Portal, you can log in 24 hours a day, and instantly have what you need.
Direct communication with your physician is also a plus. Sometimes getting a lot of information over the phone can be overwhelming – just the names of medications can be difficult to catch when discussing them verbally, let alone trying to write them down along with instructions. Having a message in your Patient Portal guarantees that you can return to view the information at any time, or even share it with a family member to help you understand things that are confusing.
Several specialized requests can be made through our Patient Portal, including prescription refill requests and appointment requests. You can also use a credit card to make a payment on a balance. Demographic information like address, phone number, and even preferred pharmacy can be updated for the office.
Forms and documentation can also be sent through the Portal. For example, after you have a visit in our office, our check-out staff may hand you a piece of paper with a summary of your visit, or educational information about a new diagnosis. These can be sent to you in your Portal so that they will be waiting for you to refer to later – no chance of losing the paper in the meantime!
So, how does our Patient Portal actually work, and how do you register?
Our Patient Portal here at Digestive Disease Associates is managed by a company called Follow My Health. When you come into the office, you will be asked to provide an e-mail address. An invitation will be sent to you, and you will be given a set of instructions that tell you how to access your account for the first time. Below are two of the most common questions we get from patients about Follow My Health.
Q: I forgot my username and/or password. How do I get back in to my account?
A: When you register for your account, you will be given six options for logging in. Five allow you to use existing usernames and passwords: Facebook, Google, Yahoo, Microsoft Live, and Cerner Health. If you already use one of these types of accounts, it will make it very easy for you to log into your patient portal without having to remember another password. Do not worry that your information will be shared! For example, if you use the Facebook login, your information will never be posted to your page for anyone to see. It is just a method of logging into the account.
The last option is to create a username and password that is only used for Follow My Health. The only downside to this option is that we cannot see any of this information – so if you forget your username, we cannot help you to remember it. All we can do is completely disconnect your account and have you start over. As long as you know your username, the system will help you to remember your password using security questions.
If this is your preferred login method, we recommend that you use the first part of your email address as your username. It will not let you use the entire email address – but, if your email address is email@example.com, you could just use “digestivedisease74” as your username.
Q: I am trying to use the phone or tablet app to register and I am having problems.
A: We recommend using a regular desktop computer for the actual registration process. The phone or tablet app can be useful once the account is set up, but the registration process through the app can be difficult.
If you are having difficulty registering, you are welcome to call our office. Our Patient Portal experts will be happy to assist you with the registration process (and can even set up an account for you!), or work through any problems that you may have, once your account is set up.
It may seem like a lot of effort to get started, but a Patient Portal account can be a very useful means of communication and record-keeping. We at Digestive Disease Associates are always looking for ways to streamline the navigation process through our office and want to make your patient experience as painless and headache-free as possible. We are proud to offer our user-friendly electronic communication program to our patients, so if helpful to you, we hope you will consider registering for our Patient Portal!
Why Do We Relay??
Digestive Disease Associates and the Berks Center for Digestive Health are sponsors of Relay for Life and have their own Relay Team, known as the Gastro Gurus. We relay to fight back against cancer, which affects all of us, and to honor or remember someone we love who has been touched by cancer.
Our goal at this event is to help raise Digestive Health Awareness and spread information about getting screening colonoscopies.
The Colon Cancer Alliance reports that colon cancer is the third most commonly diagnosed cancer and the second leading cause of cancer death in men and women combined in the United States.
The American Cancer Society estimates that this year 136,830 people will be diagnosed and 50,310 will die from this disease.
The National Colorectal Cancer Roundtable members are rallying around our shared goal of reaching 80% screened for colorectal cancer by 2018. The success of this goal is dependent on a strong foundation built with support from each of you. Together we can help silence this deadly disease!
R - Reason to share awareness of the risk of colon cancer
E - Education is important to awareness
L - Loyalty to our Specialty
A - Accessibility to inform how easy it is to have Colon Cancer Screenings
Y - You
WE RELAY BECAUSE WE CARE!
Marilyn B., Danielle R., Sherry R.
By Daniel Blecker, MD
Gastroparesis means delayed stomach emptying.
The diagnosis of gastroparesis is made by evaluating patient symptoms, endoscopic findings, and radiologic findings. It means that emptying of food from the stomach into the small intestine (duodenum) is delayed in the absence of an obstruction.
A time-tested technique for diagnosing gastroparesis is a gastric emptying scan. Stomach emptying is measured over the span of 4 hours after eating a meal. Another approach to measuring gastric emptying is a pill camera study, where a pill-sized camera is ingested and allows your physicians to measure gastric emptying time.
Typical symptoms include nausea, worsening reflux, bloating, fullness after eating, and upper abdominal pain. Unfortunately, the symptoms of gastroparesis are fairly common, and can be seen in other diseases such as peptic ulcer disease.
Gastroparesis can be found in many other diseases, such as diabetes and thyroid disease. It may also occur after a viral syndrome (postviral gastroparesis), or after surgery involving the stomach (postsurgical gastroparesis). Gastroparesis may be caused by medications such as narcotics, which can also delay gastric emptying. The 3 most common instances of gastroparesis are diabetic, postsurgical, and so-called 'idiopathic', when no obvious contributing diseases or causes can be found. Most patients with gastroparesis are women, typically younger or middle-aged.
The initial approach to gastroparesis involves altering one’s diet. Small, low fat, low fiber meals, 4-5 times a day, are appropriate for patients with gastroparesis. In addition, carbonated beverages should be avoided, as should alcohol and tobacco. All these can cause alterations in stomach emptying. In diabetics it is very important to keep blood sugars under control. Medications that can affect stomach emptying, are also discontinued.
Very infrequently, patients with gastroparesis are sometimes unable to maintain proper nutrition. These patients may need additional, supplemental nutrition with feeding tubes.
Medications can be used, along with diet, to control symptoms of gastroparesis. There are various medications that you can talk to your gastroenterologist about, which can be used for this purpose. Ultimately, in patients with symptoms that cannot be controlled with diet and medication, referral to a tertiary care center that specializes in gastroparesis and that can install a gastric pacemaker (an electrical stimulator of the stomach) may be needed.
The providers at Digestive Diseases Associates are well-versed in treating gastroparesis patients. If you have symptoms concerning for this condition, call us and make an appointment so we can navigate you through testing and treatment.
Colorectal Cancer Awareness Month is Here!
MARCH IS COLORECTAL CANCER AWARENESS MONTH, the fourth most common cancer in the United States and the second leading cause of cancer death. The best way to prevent colorectal cancer is to get screened regularly starting at age 50. There are often no signs or symptoms of colorectal cancer – that’s why it’s so important to get screened.
To increase awareness about the importance of colorectal cancer screening, Digestive Disease Associates is proudly participating in Colorectal Cancer Awareness Month.
Read more about this deadly disease and how you can prevent it! Spread the word to your family and friends and help the national campaign to fight colon cancer!
Meryl Streep discusses the importance of colorectal cancer screening in this video brought to you by the Centers for Disease Control and Prevention.
Click video to play.
Click Colon Cancer Awareness Month to read more about colorectal cancer from our previous blog entry.
Dr. Aparna Mele, MD
Fecal incontinence is the inability to control your bowels. When you feel the urge to have a bowel movement, you may not be able to hold it until you can get to a toilet or stool may unexpectedly seep from the rectum inadvertently. More than 6.5 million Americans have this troublesome symptom and can affect people of all ages, including children. While more common in women and in older adults, it is however, not a normal part of aging.
Loss of bowel control can be devastating, including feelings of shame, embarrassment, and humiliation. Some don’t want to leave the house out of fear of having an accident in public, creating social isolation. Fecal incontinence can affect the quality of one’s life, but there are treatments that can improve bowel control and make incontinence easier to manage.
Damage to the anal sphincter muscles
There are ring-like muscles at the end of the rectum, called the anal sphincter muscles, which keep stool inside. When damaged, the muscles aren’t strong enough to hold the stool back and therefore it leaks out. In women, the most significant damage can occur with childbirth, especially if episiotomies were performed or forceps were used in delivery. Surgical treatment of hemorrhoids can also damage these muscles.
Damage to the nerves of the anal sphincter
Fecal incontinence can also ensue with damage to the nerves that control the anal sphincter or to the nerves that sense stool in the rectum. If any of these nerve groups are damaged, the muscle does not work properly to hold the stool back. If the sensory nerves are damaged, there is no sensation of stool, which means you don’t feel the need to use the bathroom until stool has already leaked out. Nerve damage can again be caused by childbirth, prolonged straining with defecation, a history of stroke, and other neurological diseases such as diabetes and multiple sclerosis.
Loss of storage capacity in the rectum
Normally, the rectum stretches to hold stool until it is convenient to use the bathroom. However, scarring and/or inflammation of the rectum due to radiation therapy, rectal surgery, or inflammatory bowel disease can make the walls of the rectum stiff, affecting its elasticity. When this happens, the rectum is irritated or cannot stretch normally and therefore cannot hold the stool.
Loose stool is difficult to control, especially if there is associated fecal urgency. This can drive accelerated motility of the intestine and increase the likelihood of incontinence. Even people who don’t normally have fecal incontinence can easily have accidents during periods of diarrhea.
Pelvic floor dysfunction
Any disruption of the normal functioning of the pelvic floor muscles can lead to eventual incontinence. This may include decreased anorectal sensation, decreased anal canal pressures, decreased squeeze pressures of the anal canal, a prolapse or dropping of the rectum (rectal prolapse), a protrusion of the rectum through the vagina (rectocele), and/or generalized weakness of the pelvic floor. The most common cause of these problems is again childbirth and incontinence may not manifest for decades
Treatments for fecal incontinence depend of the cause and severity of the symptoms and can include dietary changes, medication, bowel training, injectable gels to bulk the tissue in the anal canal, implantation of a neurostimulator to electrically stimulate the sacral nerves, and surgery.
Foods have different consistencies and this affects how quickly it passes through the digestive system. Eating high soluble fiber foods like bananas, rice, tapioca, bread, potatoes, yogurt, and oatmeal to bulk stool can help minimize seepage and improve bowel control. Avoiding foods that can worsen the problem can also help. Caffeine, including chocolate, relaxes the internal anal sphincter. Cured meats, alcohol, spicy foods, and sweeteners like sorbitol, xylitol, mannitol, and fructose can cause diarrhea. Eliminating these foods can improve incontinence.
Your doctor can prescribe medications to treat diarrhea-driven incontinence to slow down the bowel and better control symptoms. Sometimes, bulk laxatives can help patients develop a regular bowel pattern in case incontinence results from incomplete evacuation.
Digestive Disease Associates offers a safe and painless in-office treatment involving the injection of a bulking agent into the anal canal. This reduces symptoms of seepage and it can be particularly helpful in patients with moderate fecal incontinence.
A stimulator device implanted surgically can send an electrical signal to the nerves that control the anal sphincter. This device can help reduce the number of bowel accidents and the electrical signal can be adjusted by the patient with an external patient programmer control.
Bowel training, in the form of biofeedback, can help patients re-learn how to control their bowels by strengthening and coordinating the muscles. Special computer equipment measures muscle contractions as a patients do rectal strengthening exercises (Kegels). These exercises work the muscles of the pelvic floor, including those which control stooling. Computer feedback of how the muscles are working shows whether the exercises are being done correctly for maximal strengthening. Whether biofeedback will work for a given patient depends on the cause of fecal incontinence, how severe the muscle damage is, and the patient’s ability to do the exercises.
Surgery may be an option for fecally incontinent patients who have had injury to the pelvic floor muscles, the anal canal, and/or the anal sphincter. Surgical intervention can range from repair of the damaged areas to muscle grafting, or, attachment of an artificial sphincter to removal of a portion of the colon.
We, at Digestive Disease Associates, are here to help you with your embarrassing loss of bowel control. Fecal incontinence does not have to be your silent affliction any longer. Call us for an appointment to discuss interventions that can improve your bowel control and your quality of life!
By Carl Mele, M.D.
Dysphagia, or difficulty swallowing, is a problem when liquids or solids are not transported appropriately from the mouth to the stomach. The esophagus is a tubular and muscular structure that transfers food from the back of the throat into the stomach in an intricate and rhythmic fashion. Dysphagia can be divided into different catagories:
- Oropharyngeal problems (occurring in the back of the throat, before going into the esophagus)
- Esophageal problems
- Odynophagia (pain with swallowing)
Transient and brief dysphagia may occur when eating too quickly, not chewing food appropriately, or with dry foods. However, recurrent episodes could represent more serious problems that require medical evaluation. You should see your doctor if you have repeated difficulty with swallowing, coughing while swallowing, abnormal weight loss, or vomiting while trying to swallow. If an obstruction occurs while eating, resulting in the inability to swallow any liquids or even saliva, then an immediate evaluation the Emergency Department is needed to remove the food before serious problems occur, including a perforation or hole in the esophagus.
Some causes of oropharyngeal dysphagia (occurring in the back of the throat before going into the esophagus) include:
- Neurologic disorders: Multiple neurologic problems (such as strokes, Multiple Sclerosis, and Parkinson's) can lead to problems initiating swallowing with both liquids and solids.
- Oropharyngeal tumors: Both benign and malignant lesions in the back of the throat can result in difficultly initiating swallowing.
Some causes of esophageal dysphagia are:
- Gastroesophageal reflux disease (GERD): Recurrent acid exposure to the esophagus can lead to inflammation and ultimately the formation of scar tissues and narrowing (called stricture).
- Esophageal tumor: Rarely benign lesions and more commonly malignancy tumors in the esophagus can lead to dysphagia. If treatment including surgery or radiation is required, that can also cause dysphagia during treatment or after recovery.
- Eosinophilic esophagitis: Felt to be related to food allergies, this condition results in cells, called eosinophils, depositing in the lining of the esophagus, turning the esophagus from an easily distensible tube into a stiff structure.
- Esophageal ring: A thin web of tissue (called Schazki's ring) that causes a narrowing or stricture at the bottom of the esophagus.
- Esophageal spasm: A problem with the coordinated squeezing of the muscles of the esophagus that push food into the stomach, resulting in dysphagia and pain. This condition can have several causes, including medications and acid reflux.
- Achalsia: An abnormal increase of muscle contractions at the bottom of the esophagus associated with poor contraction in the remainder of the esophagus. This can cause difficulty in swallowing with both solids and liquids
- Zenker's diverticulum: Abnormal out pouching (diverticulum) that can form in the upper esophagus.
Some causes of odynophagia (pain with swallowing) are:
- Infection in the esophagus: A yeast infection (candida) or viral infections (such as Herpes) can cause pain with swallowing.
- Medications: If certain medications (such as Doxycycline) get stuck and dissolve in the esophagus, they can cause ulcerations resulting in pain with swallowing.
Depending on the symptoms, the physicians at Digestive Disease Associates have several possible diagnostic and therapeutic solutions.
The most common test which provides the most diagnostic information and treatment options, is the upper endoscopy. This is a painless test done with sedation in which a thin flexible scope is advanced through the back of the throat into the esophagus, stomach, and duodenum. Direct visualization is the best option because biopsies can be taken and stretching or dilation of the esophagus can be performed if needed.
A non-invasive test that is performed while a patient is awake is the barium swallow. This test is done in the radiology department and involves patient participation to photograph the esophagus during active swallowing. This allows the physician to assess the esophagus for structural and functional abnormalities which are contributing to dysphagia. A patient will be asked to drink a small amount of dye, called barium, in the form of fluid or taken as a tablet, after which plain x-rays are obtained.
Additional testing called esophageal manometry can be performed in certain circumstances. During this test, small balloon is placed in the esophagus which evaluates the squeezing action of the muscles.
Treatment of dysphagia depends on the cause but options include dilation (stretching) during endoscopy, medication to decrease acid or inflammation in the esophagus, physical therapy with a speech pathologist, surgery (if cancer or mass is present), avoiding medication which effects the squeezing of the esophageal muscles, and others.
We at Digestive Disease Associates have excellent expertise in the field of esophageal disorders. We can directly intervene to improve swallowing function in many cases. Please contact our office if you or a loved one has concerns with swallowing.
DISEASES OF THE GALLBLADDER
By Christopher Ibrahim, MD
The gallbladder is a small, pouch-like organ that sits underneath the liver in the right upper quadrant of the abdomen. The gallbladder’s primary function is to store bile that is produced by the liver. Bile is a golden-brown fluid produced by the liver that is used to assist in the breakdown and digestion of fats that are ingested. The gallbladder secretes bile in response to certain triggers via bile ducts that ultimately drain into the small intestine, and as such, is part of the biliary tract.
The gallbladder is subject to a variety of conditions, ranging from common and benign, to rare and malignant:
- Cholelithiasis (commonly referred to as “gallstones”):
This is a condition where small stones form in the gallbladder. This is a very common condition and it’s estimated that 5-10% of adults have gallstones. Most patients have no symptoms and nothing needs to be done about them, but approximately 20% of patients may develop problems from their gallstones and may ultimately require a surgery to have the gallbladder removed (see below). In fact, most problems related to the gallbladder will ultimately be due to a complication from gallstones. There are many causes for the development of gallstones but it is felt to be more often associated with the female gender, obesity, age > 40 years old, and pregnancy.
- Biliary colic:
For some patients with gallstones, the stones will cause a temporary blockage of the gallbladder, which can cause pain in the right upper quadrant of the abdomen after eating fatty meals. At times it can also be associated with nausea and vomiting. As many other gastrointestinal conditions can have similar symptoms it is important to be evaluated for other causes. If your doctor feels you suffer from this condition you may need to be seen by a surgeon to have the gallbladder removed.
- Cholecystitis (an infected gallbladder):
In this scenario a gallstone will cause prolonged blockage of the gallbladder that can prevent the gallbladder from emptying. This can cause the gallbladder to become inflamed and infected. Patients will have pain in the right upper quadrant of their abdomen and they may have a fever during those episodes. Patients will frequently need to be admitted in the hospital for this, receive intravenous antibiotics, and will also need to have their gallbladder removed as well.
- Gallstone pancreatitis:
If a patient has gallstones, sometimes a small stone can pass through the gallbladder and get temporarily lodged at the bottom of one of the bile ducts. As the pancreas also drains into this region, any blockage there can lead to blockage of the pancreas and subsequent irritation of the pancreas (“pancreatitis”). If a gallstone blocks one of the bile ducts, it can lead to an infection of the duct, called “cholangitis”. A patient’s blood tests will show abnormalities in their liver and pancreas enzymes, and they may suffer from jaundice, which is yellowing of the skin and eyes. In this condition, a patient will require a procedure called an “E.R.C.P.” where a gastroenterologist will insert a thin scope through the mouth to remove the gallstone that has caused the blockage.
- Gallbladder polyps:
Gallbladder polyps are common, benign growths in the gallbladder that usually do not cause any symptoms. However, if a polyp is large, is rapidly growing, or if your doctor feels your symptoms are related to a gallbladder polyp, he or she may recommend that you be seen by a surgeon to possibly have your gallbladder removed, as there is a small chance that gallbladder polyps can become cancerous.
- Biliary dyskinesia:
This is a condition where the gallbladder may not empty its contents appropriately. Patients will often present as though they have symptoms from gallstones, but do not have any gallstones.
- Gallbladder cancer:
This is a rare condition where the gallbladder develops cancer; this is often associated with other symptoms, such as weight loss, severe loss of appetite, and other findings.
There are several tests that can be used to diagnose problems with the gallbladder:
- Abdominal ultrasound:
This is a test performed by a radiologist where a probe is gently applied to the abdomen and sound waves are used to construct an image of the gallbladder in order to look for gallstones or other problems. One of its main advantages is that it is fast, non-invasive, and does not require any radiation or intravenous dye.
- CT scan:
This is a test performed by a radiologist where the patient will lie on a table and x-rays are taken to produce a cross-sectional image of the entire abdomen. It does require a small amount of radiation and frequently requires intravenous dye.
- HIDA scan:
This is a nuclear medicine test performed by a radiologist where a very small and harmless amount of radioactive tracer is injected intravenously to look at the functioning of the gallbladder.
This is a test performed by a radiologist where magnets are used to develop imaging of the gallbladder and bile ducts. It does not use radiation.
If your doctor feels you have problems from your gallbladder he or she may send you to a surgeon to consider having your gallbladder removed. This is a common surgery and is called a “cholecystectomy”. Although the gallbladder does serve an important role in storing bile and assisting with the digestion of fat, most patients can in fact live normal, healthy lives without a gallbladder. It is estimated that approximately 500,000 patients will have their gallbladders removed each year in the United States for a variety of reasons, with the vast majority being performed laparoscopically (requiring only several small incisions, rather than a very large cut).
Providers at Digestive Disease Associates are experienced with the diagnosis and management of gallbladder disease. If you feel you are suffering from any of the above conditions or if you have any questions, please feel free to contact our office or request a referral from your primary care provider.
Waiting on a Diagnosis: What You Need to Know
By Amy Schiller, B.S., MLT (ASCP) cm
If you’ve ever had an EGD or Colonoscopy, chances are you have had a polyp removed, or biopsy taken, for further study. Waiting on a diagnosis can be a time filled with anxiety. You may wonder why your physician cannot always give you immediate answers to your health concerns after your procedure is completed. Well, in order to make an accurate diagnosis, your tissue sample must undergo several steps before it is possible to be used for diagnostic interpretation.
A biopsy is a small sample of tissue taken from an area where your physician would like a more in depth look at the tissue. It is important to remember that having a biopsy taken for study does not necessarily indicate a problem. The doctor will inform you of his reasons for biopsy removal after your procedure. This tissue is immediately placed in a jar of Formalin and labeled with your patient information. Formalin is a fixative, and it will bind the proteins in the tissue to prevent the tissue from biodegrading. The specimen is then sent to the laboratory where your patient information is verified, and your specimen is assigned a unique number. A laboratory technician removes the tissue from its container and records its size, color, and any specific features. Some specimen are sectioned, depending on size, to give the doctor a deeper look at the inner cells of the tissue sample.
A tiny, plastic holder, called a biopsy cassette, is labeled with your name and accession number, and then the tissue is placed inside. These cassettes will go on a machine that processes the tissue by removing the water content of the cells and replacing it with paraffin wax. Once processing is complete, the tissue is placed in a mold and surrounded with more paraffin wax. Once the wax hardens, it can be placed on a machine called a microtome where the technician makes very fine slices of the tissue (about 1 cell layer thick). These are floated on a bath of warm water then picked up on a microscope slide. The slides are then stained with 2 separate dyes; one that stains the cells’ nuclei a dark blue color, and one that stains the rest of the cell contents various shades of pink, red, and orange.
The slide is now ready for viewing under a microscope by a Pathologist. A Pathologist is a doctor who specializes in the microscopic examination of tissue. The Pathologist will look at the types of cells present, their arrangement, and if they have any abnormalities. Normally, cells have certain characteristics that help them do their jobs. The size and shape of normal cells should be relatively uniform with other cells of their type, whereas cancer cells vary in size and shape and can be distorted. Their nuclei should have a certain shape and color and the cells should have a distinct arrangement depending on what type of cells they are. Often, nuclei of cancer cells will stain darker because they contain too much DNA. Their arrangement will be haphazard or they will not form glands when they are supposed to. Cancer cells have the ability to invade normal tissue and crowd out healthy cells. They can travel through the blood and lymph system and start growing in other parts of the body. Finding cells in areas where they are not supposed to be can be an indication of cancer. All this information is used by the Pathologist to determine a diagnosis.
A Pathology Report is generated by the Pathologist that contains your diagnostic information. This report can be difficult to understand. Your doctor will go over the results with you. Let’s take a look at some of the terms he or she may use when discussing your report:
- Adenoma: Benign tumors that arise in the cells of glandular tissue.
- Adenocarcinoma: Cancer that arises in the glandular cells of an organ.
- Atypical cells: These cells appear abnormal, but they have not become cancerous. Atypical cells have a greater potential to become cancerous over time.
- Barrett’s Esophagus: Condition which the tissue in the esophagus changes to resemble a tissue that is similar to the type that lines the intestines. It is thought to result from chronic exposure to acid from gastric reflux. This condition can be a precursor to esophageal cancer.
- Carcinoma: Cancer that arises in the epithelial cells of an organ. Epithelial cells comprise the tissue that lines the inner and outer surfaces of body organs.
- Differentiated: The degree to which the abnormal cells resemble normal cells of the same type. Poorly differentiated cells are usually a faster growing, more aggressive types of cancer whereas Well Differentiated cells usually are slower growing, with a better prognosis.
- Dysplasia/Hyperplasia: An increase in the production of atypical cells in an organ or tissue.
- Erythema: Superficial patches of redness on the skin or membranes.
- Helicobacter pylori: (H. pylori) A bacteria that attacks the lining of the stomach. It is responsible for chronic gastritis and peptic ulcers which can lead to stomach cancer.
- Lymphoma: Cancer that arises in the lymph system.
- Neoplasia/Neoplasm: Uncontrolled cell growth: it can be either cancerous or benign.
The pathologist may order additional slides to be made from your tissue for further testing with different types of stains or different methods of staining. These stains can demonstrate pathological abnormalities, such as parasites, yeasts and fungus, and certain cell molecular markers that are expressed in some cancers. Your physician will review any additional tests with you and determine any further course of treatment.
The entire process, from start to finish, can be time consuming. In most cases, we can have results within a day or two of your procedure. At DDA, we strive to achieve the most accurate results in the shortest time possible to minimize the wait time for our patients. Our lab accepts most insurance plans and is certified by the College of American Pathologists (CAP), which is the leader in advocating excellence in laboratory medicine. We are dedicated to our patients and to providing the best possible care as part of the team at DDA.
DDA salutes our US Veterans and we thank you for your service to our nation!
Navigation of Digestive Disease Associates Phone System:
WE LISTEN !!!!!
BY: Deb Sands, RN
Director of Outpatient (Hospital ) Services
Since its invention, the telephone has been an important tool in the medical practice, particularly for all physician offices. Approximately half the phone calls made to a physician office during regular consulting hours are for clinical problems and most can be handled effectively over the phone without an immediate office visit. Prior to today’s technological advancements, a physician’s office phone would be answered by a staff member, as most practices were 1 to 3 physicians and staff consisted of 4 to 6 personnel. Now, the phone is answered by a ‘voice prompt message’, giving you multiple options to choose from, in order to get your questions or health concerns addressed. The question is: WHICH DO YOU CHOOSE? The other scenario may be: a telephone operator answers the call and often expects you to know exactly with whom you need to speak! Both scenarios are challenging. It is frustrating to our patients, who are often desperate to get in contact with a live person for help with an acute illness, exacerbation of an existing condition, a medication refill, medication authorization, or an individual concern or issue with some specific suboptimal situation.
As frustrating as it is, there are benefits to the technological phone/computer advancements seen in medicine today. The changes in running a practice have become more difficult and challenging. The model of the small specialist, or general medical practice, has become obsolete in 2015, and physician practices need to have their services available in multiple locations for timely and effective administration of medical care. Rest assured, we are dedicated to the needs of our patients, and it is for this reason Digestive Disease Associates covers care of our patients in multiple locations:
Outpatient Services: office visits and procedures for ambulatory patients who are not hospitalized
- Digestive Disease Associates Medical Office (Office visits)
- Berks Center for Digestive Health (Endoscopy location)
- Spring Ridge Surgical Center (Endoscopy location)
- Reading Hospital Medical Center (Endoscopy location)
- Penn State/Saint Joseph Medical Center (Endoscopy location)
â€‹Inpatient Services: rounding on hospitalized patients and performing endoscopy procedures on a daily basis
- The Reading Hospital & Medical Center
- Penn State/Saint Joseph Medical Center
The advancements of today's phone and computer technology allows your care and medical needs to be communicated to your primary provider in the outpatient setting, or the hospital systems in reference to hospitalized care. We, as your gastrointestinal health care providers, want you, our patients, to have a positive and fulfilling experience in addressing your medical, scheduling or financial concerns. The main purpose of this blog is to assist you in navigating our office phone system. Below you will find a cheat sheet to help you understand the phone communication system for our different departments.
EXPLANATION/ CONTACTS FOR OFFICE DEPARTMENTS:
Expected Response Time
Triage - Ext. 132 & 144
Sick calls, medication refills, prep issues, medical concerns
15 minutes to 2 hours
Scheduling - Option 5 or direct dial (610) 685-4020
Schedule appointments, procedures, recall appointments
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We, at Digestive Disease Associates, are dedicated to our patients and their experience with our practice, from the first phone call to when you are walking out of the door! We are here to address our patient's needs, concerns, and questions in an efficient, respectful, effective, and timely manner. We want your experience with our practice to be positive, pleasant, and restorative in our pledge to your improved health. This starts with your first experience when calling us! You can be confident that we will handle your phone call with the utmost care to manage your needs.
Pancreatic Cancer By Dr. Nirav Shah
The pancreas is a 6 inch organ which lies horizontally behind the lower part of your stomach. The pancreas’ function is to secrete enzymes that help with digestion and also hormones that help regulate the metabolism of sugars.
Pancreatic cancer is one of the most dreadful diagnoses to deliver as a physician and one of the most difficult ones to accept as a patient. Despite medical advances within multiple medical fields, pancreatic cancer, unfortunately, still remains one of the deadliest cancers around because of its late detection. Pancreatic cancer typically spreads rapidly and is seldom detected in its early stages. This is a major reason why it's a leading cause of cancer deaths. Signs and symptoms may not appear until pancreatic cancer is quite advanced and complete surgical removal isn't possible.
There are at least 42,000 Americans receiving diagnosis of pancreatic cancer every year within the United States. It is the 4th leading cause of cancer-related deaths. Surgical resection of the tumor is the only potentially curative treatment, although at the time of presentation only 15-20% of patients are eligible to undergo surgery. Even after surgical resection, prognosis remains very poor. Five year survival rates, after surgery for pancreatic cancer located in the head of the pancreas, called pancreatico-duodenectomy (Whipple surgery), remain at 25-30% for patients with no lymph node involvement and unfortunately, only 10% in patients with disease in the adjacent lymph nodes.
The most common form of cancer of the pancreas originates in the pancreatic duct and is more commonly known as adenocarcinoma. There are other rare forms of pancreatic cancer, but adenocarcinoma is by far the most common, accounting for more than 95% of pancreatic cancers. The pancreas is divided into a head, body and tail. The majority of pancreatic cancers (~70%) originate within the head of the pancreas. Most common presenting symptoms of pancreatic cancer include upper abdominal pain, loss of appetite leading to weight loss, and yellowing of the skin (jaundice) or yellowing of the whites of the eyes. Abdominal pain is a common symptom for many other diseases, so it is important to discuss concerning symptoms with your primary care provider to assess further. There can also be new onset signs of depression and blood clots as presenting features for this cancer.
Risk factors for pancreatic cancer include genetics (5-10% of patients with pancreatic adenocarcinoma have a first degree relative with the disease), smoking, diabetes (although diabetes maybe a consequence rather than a cause of pancreatic cancer), chronic pancreatitis, pancreatic cysts, and obesity. There are inherited cancer syndromes with mutation within gene STK 11 (Peutz Jeghers syndrome) and PRSS1, SPINK1 (hereditary pancreatitis) which carry higher risk of pancreatic cancer.
Generally, pancreatic cancer is diagnosed on the basis of blood work and imaging studies. A CT scan and/or ultrasound of the abdomen is necessary to evaluate the pancreas. If there is a mass found within the pancreas on the imaging study, the next step involves a gastroenterologist performing an endoscopic ultrasound with needle aspiration of the mass to obtain tissue for diagnosis. Using information from staging tests, your doctor assigns your pancreatic cancer a stage. The stages of pancreatic cancer are:
- Stage I. Cancer is confined to the pancreas.
- Stage II. Cancer has spread beyond the pancreas to nearby tissues and organs and may have spread to the lymph nodes.
- Stage III. Cancer has spread beyond the pancreas to the major blood vessels around the pancreas and may have spread to the lymph nodes.
- Stage IV. Cancer has spread to distant sites beyond the pancreas, such as the liver, lungs and the lining that surrounds your abdominal organs (peritoneum).
If there is evidence of cancer beyond the pancreas into other organs such as the liver, lungs or peritoneum (lining covering the abdominal organs), or direct involvement of the mass with the nearby large vessels of the abdomen, surgery for cure can no longer be considered. If the cancer is considered operable and is located within the head of the pancreas, the standard operative procedure is Whipple procedure (also known as pancreatico-duodenectomy). In this surgery, the surgeon will remove the pancreatic head, the first part of the small intestine (duodenum), part of the jejunum, common bile duct, and part of the stomach. Outcomes of Whipple surgery were poor in the past but they are getting better. If the cancer is considered operable and is in the tail or body of the pancreas, the surgical procedure is called distal pancreatectomy, when part of the pancreas and often the spleen, is removed.
Chemotherapy combined with radiation therapy (chemoradiation) is typically used to treat cancer that has spread beyond the pancreas, but only to nearby organs and not to distant regions of the body. This combination may also be used after surgery to reduce the risk that pancreatic cancer may recur. In people with advanced pancreatic cancer, chemotherapy may be used alone or it may be combined with targeted drug therapy.
We at Digestive Disease Associates are knowledgeable and experienced in the diagnosis and treatment of this disease. Talk to your doctor if you experience unexplained weight loss, abdominal pain, jaundice, or other signs and symptoms that are causing concern. Keep in mind that many diseases and conditions other than cancer may cause similar signs and symptoms. Your doctor can refer you to us so that we can help better elucidate the cause of these symptoms.
November is Pancreatic Cancer Awareness Month. Check out the Pancreatic Cancer Action Network at www.pancan.org to find out more about this challenging disease.
Questions or comments? Please join us on Facebook.
Guts & Glory 2015
Last year brought hundreds…will this year bring thousands? Maybe that’s a long shot but we’ll tell you what and who WILL be at the Guts & Glory Health and Wellness Expo on September 19th at the Fightin’ Phils Stadium... delicious live cooking demonstrations and food samplings, fitness presentations, expert lectures, holistic wellness techniques like acupuncture and massage, a farmer’s market, garden center, kids’ obstacle course and rock climbing wall, impromptu salsa lessons, live music, and a community coming together to celebrate health!
Enjoy the tastings of Redner’s Markets, Berks County favorite, Austin’s restaurant group, My Desi Kitchen, Dundore and Heister, and Crave Cafe. Learn more about the vast offerings from our nonprofit supporters like American Cancer Society and Centro Hispano!
Get your groove on with WH Dance Academy and learn how salsa dancing is good for your health! You can enjoy a massage at Spine and Wellness’ Holistic tent or get up and move with live fitness and yoga classes from Spine and Wellness Center, Sarti’s 3rd Element, and Body Zone. Kids and adults of all ages will have a blast this year with pumpkin decorating from Riverview Nursery, a free obstacle course, Alvernia’s circuit training fitness zone, and a rock climbing wall. Food truck vendors like Souvlaki Boys and Clover Farms will line the streets outside the Stadium for when the family gets hungry, and Lancaster Farm Fresh Cooperative will have a booth selling fresh produce to take home!
Don’t forget to snap a selfie with Gutsy Girl On the Go, our mannequin mascot, who has been spotted all around town this year spreading the message of health! Get a wealth of health education and wellness tips from our many educational booths representing business and community leaders dedicated to promoting health. We will also welcome a visit from Senator Judy Schwank!!
My Gut Instinct, founded by our own Dr. Aparna Mele of Digestive Disease Associates, wants you to be healthy inside & out. This FREE Health and Wellness Expo offers the community the opportunity to learn about their own health and ways to stay healthy.
Come join our grassroots health revolution making a big buzz here in Berks County and join us in our annual expo, a large scale celebration of health! Memorialize your visit and make a commitment to improving your health by signing our Pledge Wall to tell us “your healthy” and snap a pic with our mascot, Gutsy Girl!
One and all are welcome and we hope to see you there!
By Carl Mele, MD
Diverticulosis is a very common gastrointestinal disorder that occurs in about 50% of Americans by the time we are 50 years of age. It is a condition in which pea to thimble sized out pouches develop most commonly on the large intestines or colon.
The reason why diverticulosis forms is not clearly understood but is felt to develop from areas of high pressure that pushes against weak areas in the wall of the colon. A diet high in fiber produces soft and bulky stools that are easier to push through the colon. A diet low in fiber causes harder stools that require more pressure for the colon to push, and that increased pressure is believed to cause the formation of the diverticular pockets.
Most patients do not have symptoms of diverticulosis unless the number of pockets that develop are many, called painless diverticular disease, or if an infection develops in one of the pockets, called diverticulitis. An easy way to remember the terminology is the p"o"ckets are called diverticul"o"sis and an "i"nfection is called diverticul"i"tis. Less than 10% of patients with diverticulosis develop diverticulitis. Rarely, diverticulosis can also cause acute lower gastrointestinal bleeding with several cups of bright red blood over 1-2 days.
Diverticulosis is most commonly diagnosed through a colonoscopy, barium enema, or CT scan. Diverticulitis is diagnosed by history, physical examination, and sometimes CT scan. Patients with diverticulitis most commonly have left lower abdominal pain, sometimes associated with fever and a change in bowel habits. Treatment involves a clear liquid diet with antibiotics but sometimes involves more aggressive treatment with hospitalization.
If you have diverticulosis, a diet high in fiber with possible fiber supplementation is suggested with plenty of water as these interventions can decrease the risk of developing more pockets and the risk of diverticulitis.
There are two main dietary forms of fiber; soluble and insoluble. Soluble fibers can include oatmeal, beans, certain fruits, and nuts. Insoluble fiber can include skins of fruit, seeds, and brown rice. Ideally, a diet of 30 - 40 grams of daily fiber is suggested. If that total is not reached with dietary intake then supplementation with over-the-counter products such as Metamucil or Benefiber should be considered.
Seeds, nuts, and corn do not need to be avoided if you have diverticulosis. There has never been clear evidence in studies that these products cause diverticulitis but if you have had diverticulitis in the past, dietary restrictions should be reviewed with your health care provider.
As with most things in life, regular exercise has multiple health benefits, including a possible lower risk of diverticulosis.
Frequently Asked Questions About Billing at DDA and BCDH
By: Lisa Rosselli, CPC
We understand that medical billing and insurances can be confusing, especially when you don’t feel well. Our billing staff is continually working to improve our processes to meet the needs and expectations of our patients. Listed below are some of the frequently asked billing questions that may help prepare you for your visit:
I need to have a colonoscopy. How much will it cost?
The cost will vary depending on your treatment plan. We are able to give you an estimate prior to your procedure. The estimate will consider the professional services provided by your Digestive Disease Associates physician. We recommend you contact your insurance company before your procedure for questions about what is covered and any out-of-pocket expenses such as deductible, coinsurance, and/or copayment. Our staff will gladly provide you with the procedure and diagnosis codes that you can give to the insurance representative.
Is Digestive Disease Associates the same as Berks Center for Digestive Health?
Digestive Disease Associates is a doctors’ office and Berks Center for Digestive Health is an ambulatory surgery center. You may come to Digestive Disease Associates for an office visit. Berks Center for Digestive Health is the facility where you may have your gastroenterology procedure.
I had a colonoscopy and polyps were removed. It was one procedure so why did I receive several bills?
Your Digestive Disease Associates physician who performed the colonoscopy would have billed your insurance for the professional fee. There are other entities that are integral to your procedure. Some of these may include the facility where your procedure was done, the anesthesiologist who provided your anesthesia, and the pathologist who examined your polyps. If you have questions concerning any of these services, please contact that specific provider or your insurance company.
I received a bill from Digestive Disease Associates. Can I pay it on-line?
You can pay a bill from Digestive Disease Associates on-line by visiting our website: www.ddaberks.com and selecting the Patient Portal. You can also pay on-line at www.paymydoctor.com. This information can be found on your billing statement.
I thought I was having a screening colonoscopy but it was billed as diagnostic. Why did this happen?
If you were having any symptoms, such as diarrhea, abdominal pain or rectal bleeding when your colonoscopy was ordered, it would be billed as diagnostic. A screening colonoscopy is performed on patients who have no symptoms and need to be checked for colorectal cancer or polyps. Please check with the provider who ordered the procedure if still have questions.
What are my options if I can’t pay my bill in full?
Our billing staff can work with you to arrange a monthly payment plan so you can pay your bill over an acceptable period of time.
I think my insurance requires a referral. What should I do for my appointment?
If your insurance plan requires a referral, please contact your primary care physician’s office and ask them to send one to our office before the appointment. Most referrals can be done electronically which means your primary care physician can send it directly to our office by fax or through your insurance company’s website. You can receive the highest benefits from your insurance if we have the referral for your appointment.
I have a high deductible insurance plan and I need a colonoscopy. Will my insurance pay for it?
If your plan has a deductible, it must be met within the benefit period before the insurance will pay for any covered services. We recommend you contact your insurance to verify if you have met your deductible or if there is a portion remaining.
I had a colonoscopy and my doctor wants to repeat it because he couldn’t do a complete exam. Will my insurance pay for another one?
If you had a colonoscopy and the physician was not able to visualize the entire colon due to unforeseen circumstances, we will bill it as an incomplete exam. Your insurance should allow a repeat exam, but we recommend you contact them and check your benefit plan.
Does Digestive Disease Associates participate with my insurance?
Digestive Disease Associates participates with most major insurance companies. You may contact our office to inquire or check the list of participating insurances on our website at: www.ddaberks.com listed under Office. For your convenience, we will submit a claim to your insurance for any services you receive at Digestive Disease Associates.
No matter how big or small, our billing staff is here to listen and help resolve your question or problem. Sharing your concerns give us opportunities to improve our services to patients. We are available to address your billing questions Monday through Friday, 8:00 am to 4:30 pm at 610-374-4401, option 4.
Clostridium Difficile Infection
By John Altomare, MD
C. difficile infection is a bacterial infection affecting the colon. It is one of the most common hospital-acquired infections but it is also increasingly community-acquired as well. Last year in the United States C. difficile infection incurred health care costs over three billion dollars and affected half a million people. 15,000 people die annually from this infection. The number of cases has doubled over the last generation. In sum, this is one of the most serious infections that gastroenterologists treat.
In order to become infected with C. difficile (or C. Diff as it is often called), one has to be taking an antibiotic and also be exposed to the bacteria. In the past this exposure usually occurred in hospital settings, but now at least half of all cases are from exposure in the community. Any antibiotic can increase the risk of getting a C. diff infection. Antibiotics change the populations of bacteria that live in our colon and therefore increase susceptibility to this opportunistic infection. Elderly hospital patients, as well as those in long-term care facilities, are most commonly affected by C. difficile - especially after or during the use of antibiotic medication.
The symptoms of the C. difficile infection include intractable, watery diarrhea, bloating, abdominal pain, fever, and in some cases rectal bleeding. Diagnosis of a C. difficile infection is made by testing stool for the toxin produced by the bacteria. Untreated it can lead to severe inflammation in the colon, which in some cases can result in the need for emergent surgery to remove the colon, or death. Fortunately this rarely happens, since most people receive medical treatment in time.
The majority of C. diff infections, fortunately, can be treated on an outpatient basis. One usually does't have to be admitted to the hospital to be treated. It will usually respond to oral antibiotics. We also recommend people use probiotic agents.
C. difficile infection is typically treated with an antibiotic. Metronidazole is usually the first choice in antibiotic treatment, and is effective in about 75% of cases. If the metronidazole fails, oral vancomycin is very effective up to 98%. A third antibiotic, Dificid, is also highly effective, but it is very expensive. Its advantage is that it is associated with a lower rate of infection recurrence.
In addition, probiotic agents can be helpful, both at preventing C. difficile infection when on antibiotics, and clearing the infection if you have it. Probiotics can be found in many sources, including yogurts, smoothies, cheeses, and pills. Some probiotic supplements contain a yeast called Saccharomyces boulardi, which has been shown to prevent C. difficile infection from coming back once it is eradicated. Probiotic drinks like Kefir have been shown to be effective both in clearing the bacteria and preventing its recurrence.
Unfortunately 2-5% of patients infected with C. diff will develop recurrence or become chronically infected. This is when you have the infection three or more times. Risk factors for recurrent C. diff include repeat rounds of antibiotics, chronic steroid medications, inflammatory bowel diseases, including Crohn's and ulcerative colitis, patients on immunosuppressive medications, like chemotherapy for cancer or anti-rejection medications after an organ transplant, and HIV patients who have a suppressed immune system.
Patients with recurrent or chronic C. difficile infection are treated with extended periods of targeted antibiotics for C Diff, sometimes for months.
Despite prolonged antibiotics, in some patients, the infection recurs when the medications are stopped. An alternative therapy to prolonged antibiotics therapy is a fecal transplant. This involves taking stool from a healthy donor and putting it into the patient's colon who has recurrent or chronic C. difficile infection. While this at first may sound quite unappealing and downright unpleasant, it should be kept in mind that this simple intervention is highly effective at getting rid of the C. difficile infection permanently. This method has been used for over 30 years and has been studied extensively with very good results and is typically safe. At Digestive Disease Associates, I exclusively perform this treatment and have had great success with our patients.
Typically the donor is a healthy patient who does not have a lot of medical problems, and usually either a first degree family member such as a spouse, sibling, or child; or a close friend who is willing to help.
An interested patient with his or her donor is usually then set up to see me and we all meet during an office visit to screen the donor and to discuss the procedure. Preliminary donor screening involves being tested for a variety of infections including C. difficile, Salmonella, E coli, various viral hepatitis, including HIV. If the donor tests negative for all of these infections, they are approved to become a suitable stool donor. The donor does not have to undergo any invasive procedures. They only have to undergo blood tests and supply us with stool . After the donor passes the testing requirements, I ask them to collect their stool over several days prior to the fecal transplant procedure.
We usually perform the fecal transplant at the time of a colonoscopy. The patient with recurrent C. difficile infection must prepare the day before for a typical colonoscopy with a clear liquid only diet for 24 hours and a full bowel prep the night prior. The donated stool is then mixed with sterile salt solution and subsequently, during the colonoscopy, this mixture is then flushed into the colon of the infected patient.
The donated stool mixture provides the infected person with healthy good bacteria that helps to restore the healthy bowel flora and keep the C. difficile from coming back. Fecal transplant is effective in about 95% of patients with recurrent C. difficile infection after only one treatment. The good news is that most insurance companies will cover this procedure. Typically the patient's symptoms resolve within the first 24 to 48 hours after fecal transplant.
Alternatively, rather than undergoing a colonoscopy the patient can do fecal transplant using fecal enemas, which have also been shown to be highly effective as well.
Prevention is a critical mechanism to stop this infectious epidemic. The importance of fastidious hand-washing cannot be emphasized enough. C. difficile infection is spread by a fecal-oral route. If we wash our hands regularly, especially when we come in contact with a hospital or medical facility, we can significantly reduce the spread of C. difficile. Additionally I want to stress the proper and appropriate use of antibiotics. The need for antibiotic therapy should be weighed carefully and the shortest duration possible should be prescribed. There should be a clear cut indication for antibiotic use based on a careful discussion with your physician, with the lowest doses necessary used as well as the shortest effective course. Keep your gut healthy by avoiding the regular use of ibuprofen, which can eradicate the healthy bacteria living in our digestive tract, and generously eat probiotic and prebiotic (food that feeds our healthy bacteria) foods to maintain these healthy bacterial populations.
OPEN ENDOSCOPY ASSESSMENT
By Marcia Price
If you have never heard the term Open Endoscopy Assessment, let me take a few minutes to introduce you to the process.
Here we go…..
OK, today is your birthday and you just hit that 50 year old milestone. Well, happy birthday, but now it is time for your Screening Colonoscopy.
I’m sure many of you have seen the media ads about Colon cancer being the #1 cancer killer in America. Still, many people just wait until their primary care doctor or gynecologist bring it up before even considering scheduling a colonoscopy! If you haven’t already called us for an appointment, I guarantee your doctor will be sending us a referral to make you that appointment. Unappealing as it may seem, don’t fret----this is a life-saving exam and remember, we are all working together to help prevent Colon Cancer.
The good news is, whether this is your first time for a screening colonoscopy or if you are due for a recall colonoscopy, we can eliminate the inconvenience of coming in for an office visit prior to your procedure. This assessment is a phone interview by one of our qualified staff members. Oh wait, one minor catch…you must be a healthy person with NO complicated medical history and you must be under the age of 80. Rules are rules, true, but mostly they are there for your benefit and safety.
Whether you call us or we call you, we would like to make this process as simple as possible, by having you speak to only one person from start to finish.
We will start by asking you demographic information, which will include name, address, telephone numbers and insurance information. The next step will be a series of medical history questions about you and your immediate family members, types of surgeries you had in the past, some social information, and a complete list of your medications and allergies.
Now that you know this in advance, please have that information available for the call. It is a good practice to have the information written down and carried in your wallet at all times. We all know no matter what doctor’s office or hospital you go to, they will all ask the same information - and now you are all prepared to hand them that paper folded up in your wallet and make life easier for yourself.
OK, we are almost finished. After we collect the information, we will schedule your procedure with one of our Board Certified physicians on a day and time that works best with your schedule. During this part of the discussion, you will be informed of the bowel prep you will be asked to use for your procedure. A few days after the conversation, you will receive an envelope of important information in the mail. Please be sure to open the envelope and read the entire contents at least a week prior to your procedure. The envelope will contain your prep instructions and prescription if appropriate, a brochure “Understanding Colonoscopies”, and information about the facility.
Some important information to remember:
- You must have a responsible driver 18 years or older accompany you and take you home
- You cannot drive the remainder of the day due to the sedation administered during the procedure
- You may not use public transportation unaccompanied
- Follow the instructions regarding when to STOP eating and drinking prior to the procedure.
If you wish to set up your screening colonoscopy, please call us at 610-374-4401 option 5.
Thanks for taking the time to read this post. We sincerely hope that you will find your experience with Digestive Disease Open Endoscopy Assessment department to be nothing short of pleasant and we are always here to help!
Peptic Ulcer Disease
by Adam Spiegel, DO
Peptic ulcers are found in the stomach and/or beginning part of the small intestine (duodenum). Peptic ulcers are defects, or breaks, in the tissue wall, and can be superficial or extend deep into the wall. Sometimes, these ulcers cause no symptoms. However, more commonly, patients experience abdominal pain, usually located in the upper abdomen in the midline below the breast bone. Occasionally the pain can localize to the right or left side of the abdomen. The pain can be burning, gnawing, and hunger-like, or vague and crampy.
The most common peptic ulcer complication is bleeding, which can be microscopic causing low blood counts (anemia), or overt, with blood in the stool or vomiting blood. A less common peptic ulcer complication is a perforation, where the ulcer creates a full thickness hole in the stomach or duodenum. Ulcer perforation can require emergency surgery.
The two most common causes of peptic ulcer disease are infection with the bacteria Helicobacter pylori (H. pylori), and chronic ibuprofen and/or aspirin use. Other contributors to peptic ulcer disease are acid hypersecretory diseases, cigarette smoking, excessive alcohol consumption, steroid use, and extreme stress. There is no great data that specific foods are associated with peptic ulcer disease.
H. pylori is a bacteria which was discovered to be a cause of peptic ulcer disease in 1984. H. pylori is acquired from the environment, from sources such as food and water. For unclear reasons, not everyone who has an H. pylori infection will develop ulcers. H. pylori can be diagnosed through a variety of tests. After it is detected, it can be successfully eradicated with antibiotics. Testing after H. pylori treatment is normally performed to confirm that the bacterial infection was cured.
NSAIDS (nonsteroidal anti-inflammatory drugs) are commonly used for the treatment of pain and inflammation and many are available over the counter. Some examples of NSAIDs are aspirin, indomethacin (Indocin), ibuprofen (Motrin or Advil), naproxen (Naprosyn or Aleve), Mobic, diclofenac, Toradol, and Celebrex. Tylenol (acetaminophen) is not an NSAID and is not associated with peptic ulcer disease. It is estimated that over 30 billion doses of NSAIDs are consumed annually in the United States. The risk of NSAID induced ulcer complications is higher in those who take NSAIDs chronically and those who take both aspirin and other NSAIDS. The risk is also higher in the elderly and those taking corticosteroids (prednisone) or blood thinning medications such as Plavix, Effient, Brilinta, Coumadin (warfarin), Xarelto, Pradaxa, or Eliquis. The risk of ulcer complication can be higher when NSAIDs are combined with SSRI medications (antidepressants such as Prozac, Zoloft, Lexapro, or Celexa) or the osteoporosis drug Fosamax. The use of enteric-coated or buffered aspirin also does not substantially reduce the risk of peptic ulcers.
The diagnosis of a peptic ulcer is definitively established by direct visualization during upper endoscopy. Upper endoscopy is a procedure where a thin scope with a camera is inserted through the mouth and into the esophagus, stomach, and small intestine. The procedure is performed under anesthesia. During endoscopy, an ulcer that is actively bleeding, or has a high risk finding associated with bleeding, can be treated by the gastroenterologist during the procedure. If endoscopic therapy cannot control ulcer bleeding, then other modalities, such as interventional radiographic embolization and/or surgery may be necessary.
Management of a peptic ulcer is also focused on eradicating the contributing factors. Everyone with a peptic ulcer should be tested for H. pylori. Those who had been using NSAIDs should be advised to stop permanently as a previous history of ulcer disease increases the risk of recurrent ulcers. The risks and benefits of stopping aspirin or any blood thinning medication need to be considered and it will be necessary to get the input of the patient’s medical team, including their primary care physician, cardiologist, and any other doctors prescribing these medications. Smoking cessation and limiting/avoiding alcohol should be stressed.
All patients with peptic ulcers (or those who present with bleeding suspected to be due to a peptic ulcer) should immediately be started on acid suppressing medication. The most effective class of acid lowering medication to facilitate ulcer healing are the proton pump inhibitors (PPIs). PPI medications include Omeprazole (Prilosec), Pantoprazole (Protonix), Lansoprazole (Prevacid), Nexium, Aciphex, Dexilant, and Zegerid. PPIs work more effectively than H2 blocking drugs (Pepcid or Zantac).
It is important that patients remain on their PPI medication after an ulcer is found to help the ulcer heal, as well as to help prevent the development of additional ulcers. This is especially important in patients who must remain on aspirin or blood thinning medications. It is also important for those who are at increased risk of developing an ulcer to take a daily PPI medication for protective (prophylactic) purposes.
For unclear reasons, PPI medications have gotten a lot of bad press lately. I want to emphasize that the PPI drugs continue to be one of the safest, and most effective, class of medications since their FDA approval in 1988. Thanks to this class of medication, there has been a significant reduction in complications related to peptic ulcer disease and acid reflux disease over the years. PPIs should be taken chronically in those who clearly need them, i.e. those who are at increased risk of peptic ulcer disease and ulcer bleeding. There are other indications for chronic use of PPI besides peptic ulcer disease. If you have any concern that you could have peptic ulcer disease, or questions about taking a PPI chronically, please schedule an appointment to see us at Digestive Disease Associates to learn more and assess your risks.
What You Need to Know Before Your Procedure:
REMEMBER TO READ YOUR INSTRUCTIONS WELL IN ADVANCE!
By Barbara Oryszczycz, RN
Nurse Manager, Berks Center for Digestive Health (BCDH)
Reading your instructions prior to the day of your procedure is very important. There are many things involved in scheduling an endoscopic procedure. Reading your instructions at least a week prior to the day of service allows YOU, the patient, to call us if you need clarification or have particular questions or concerns that need to be addressed ahead of time. Important topics we want to highlight and point out to your attention include:
Every patient receives anesthesia for their procedure, unless the patient specifically requests no sedation. Therefore, we have very stringent, non-negotiable rules regarding your oral food and drink intake (NPO or nothing by mouth status). If you are scheduled for either an upper endoscopy or a colonoscopy, you absolutely may not have anything to eat or drink the day of your procedure, except clear, ie see-through/transparent liquids, and you can have these liquids earlier than 4 hours prior to your report time. When you are at the 4 hour mark, prior to your report time, you may then have nothing more to drink and must keep your stomach absolutely empty. Our written instructions given to every patient clarify what are considered ‘clear liquids’. While sedated, patients are unable to protect their airway or clear fluid on their own, so a full stomach or retained fluid in the stomach may cause the fluid to go into your lungs, leading to serious complications such as respiratory compromise and aspiration pneumonia, which could warrant hospitalization and the need for mechanical ventilation on a respirator.
Pay attention to instructions on medications prior to the day of starting your colon preparation. There are certain medications that need to be held for a period of time. Important medications are iron supplements and blood thinners. Iron supplements may appear as old blood in the GI tract. Anticoagulants and anti-platelet medications, collectively called blood thinners, can increase the risk of procedural bleeding, especially if therapies are performed during your endoscopic procedure, such as when tissue is removed (biopsies or polyp removal) . Insulin or any oral diabetic meds have their own special instructions. Providers who monitor your blood sugars should help regulate medication prior to your procedure. No insulin or diabetic meds should be taken the day of your procedure to prevent low blood sugars. Another element that may alter findings are certain food dyes. Red or purple food dye should be avoided as they can cause the fluid inside your digestive tract to look bloody.
Your colon prep is carefully chosen based on your age, health and symptoms; past medical history; and affordability and insurance coverage. A specific instruction sheet accompanies your particular preparation and the details should be read carefully, as your directions are individualized for you and also based on the date and time of your scheduled procedure. Taking the prep properly allows the doctor to thoroughly perform the exam. If there is improper colon cleansing, the visual field is compromised, therefore possibly missing an accurate diagnosis. Maximizing your intake of plent of clear liquids on your prep day will ensure cleansing of your colon. Clear liquids help hydrate and liquefy your stools and accelerate your response to the prep. NO SOLID FOODS SHOULD BE CONSUMED THE ENTIRE DAY PRIOR TO YOUR COLONOSCOPY. Not following these specific steps regarding colon preparation may result in excess retained stool that impedes the ability to complete the exam. The doctor would then be forced to cancel the procedure and then you would subsequently have to repeat the entire prepping process on another day. The drawbacks again would include another prep day, lost time at work, social constraints surrounding finding another driver to bring you for your procedure, re-submitting a request to schedule this procedure to your insurance company, and then scheduling issues that may arise.
Responsible party/ Driver
Having a driver over the age of 18 is crucial before we proceed with your test. Remember you will be receiving sedation and will be considered to be “under the influence”. The patient cannot drive for the remainder of the day or operate any dangerous equipment. If you arrive for the procedure without a driver, the options will be to reschedule, have the procedure un-sedated, or you trying to find a driver last minute. There is a service available at our center, with a patient incurred cost. Public transportation is only allowed if you are accompanied by a responsible adult who will sign your discharge paperwork.
A language barrier should not deter your need to examine and study all of your instructional paperwork, If you cannot read the provided paperwork, please find someone who can review the written details with you at home. If you were seen in the office, we have Spanish-speaking staff members who can help, and interpreter services are available upon request. Family members are encouraged to accompany you on the day of the procedure to assist with interpreting.
Day of procedure
Arriving on time for your procedure is critical. Remember the physician has a schedule that does not have much room for flexibility and is imperative that our schedule runs on time. Physicians will return to the office to see other patients, if there is a no-show or cancellation. Therefore, if unable to keep an appointment or if you are running late, it is a courtesy we ask of you to please notify our Center, so our physicians’ schedules can be accordingly adjusted and other patients may be accomodated. Being late also impacts other patients. We here at BCDH pride ourselves on delivering high quality and timely patient care and our ability to uphold this goal is dependent on YOU.
On the day of procedure you will need to bring:
- Insurance card
- Advance directives if one is available
- Names of your referring doctors who you would like a copy of your report sent to
- Your photo ID.
Having these items with you will help expedite your admission process.
BCDH strives to allow adequate time for each individual patient, and the safety of each patient is our first and foremost goal. Arriving on time allows for you to be ready well in advance for your procedure and facilitates the transfer of information between your nurse, anesthesia team, and your assigned physician, giving everyone the time to review all of your information and allow any last minute questions you might have prior to having your procedure.
Please remember: Be well-prepared, listen to and read your directions carefully, and reach out to us in advance with your questions, so that you can come to your procedure stress-free and have a positive experience with us. Following your instructions makes your procedure experience much easier for your doctor, our staff, and most importantly YOU!!!
Alcoholic Liver Disease
by Ravi Ghanta, MD
Alcoholism and alcohol abuse are among the most common, devastating, and costly problems in the United States. Nearly 88,000 people (approximately 62,000 men and 26,000 women) die from alcohol-related causes annually, making it the third leading preventable cause of death in the United States. In 2012, 5.1 percent of the burden of disease and injury worldwide was attributable to alcohol consumption. Globally, alcohol misuse is the fifth leading risk factor for premature death and disability; among people between the ages of 15 and 49, it is the first.
Alcohol contributes to over 200 diseases and injury-related health conditions, most notably alcohol dependence, liver cirrhosis, cancers, and injuries. In 2013, of the 71,713 total liver disease deaths among individuals aged 12 and older, 46.4 percent involved alcohol. Drinking alcohol also increases the risk of cancers of the mouth, esophagus, pharynx, larynx, liver, and breast. The economic burden from excess alcohol intake is great, costing the US approximately $185 billion per year, in increased health care costs, crime, and lost productivity.
How does alcohol hurt your liver?
When you drink alcohol it is quickly absorbed directly into your blood stream and then passes through the liver. Since the liver sees the highest concentrations of alcohol, it is one of the organs in the body most prone to developing alcohol related problems.
Almost all excessive drinkers will develop the first stage of alcoholic liver disease called fatty liver which can disappear, once patients stop drinking excessively. If patients continue drinking excessively then a proportion (around 20-30%) will develop the next stage of alcoholic liver disease- alcoholic hepatitis. In this condition, the liver becomes inflamed and in its extreme form, patients can die of liver failure. An even smaller proportion of patients (around 10%) will develop a permanently scarred and damaged liver (cirrhosis), if they continue to drink excessively. Why certain heavy drinkers remain at the stage of fatty liver and others progress to alcoholic hepatitis and cirrhosis is not known at present. Undoubtedly, however, the more you drink, the greater the frequency and duration of heavy drinking, and the more likely you are to develop the more advanced forms of disease.
Unfortunately most people with alcoholic liver damage have few symptoms until the disease is far advanced. The first specific symptoms of liver disease such as jaundice (whites of the eyes turn yellow, and in more severe cases, the skin does too) don’t appear until more serious liver damage has occurred. The symptoms can vary from one person to another and range from discomfort, nausea and pain all over the abdomen, to profound and progressive jaundice which may lead to death.
Treatment, as with all stages of alcoholic liver disease, is to stop drinking alcohol which, in the majority of patients with the milder forms of the disease, will lead to resolution of the condition. Patients with the more severe forms of alcoholic hepatitis, with signs of profound jaundice and abnormal blood clotting, require admission to hospital. There is a significant risk that the liver will go on to develop cirrhosis, if drinking alcohol continues. The onset of cirrhosis is usually silent with few early warning symptoms. Cirrhosis is the result of continual long term liver damage. Cirrhosis is irreversible, even if drinking is stopped. This doesn’t mean that it’s too late to stop drinking, because stopping drinking will slow down or even halt further damage, allowing patients to remain stable and safely live with cirrhosis and its associated reduced liver functioning, for many years.
There may or may not be visible signs of liver damage. Part of the palms of the hand may be red and mottled and the fingernails partly white. Other signs of a long term heavy drinker are enlargement of male breasts which may be tender, a swollen abdomen, thinning body hair and weakness and wasting of the muscles. The most important part of treatment in all forms of alcoholic liver disease is to stop drinking, preferably for life. The amount of alcohol that it is safe to drink varies from one person to another but should be limited to 1 drink or less daily. Diet is also important - eat a well balanced diet, if necessary with supplements prescribed by a doctor, as alcoholism wastes the body and strips it of vital nutrients and vitamins.
Unfortunately, no specific treatments have been shown to improve the outcome of patients with established cirrhosis. Stopping drinking, therefore, remains the mainstay of treatment, along with standard therapy for the complications of cirrhosis. For some people with cirrhosis who develop life threatening complications, liver transplantation is an option. Many factors must be taken into consideration, including the ability or inability to stop drinking alcohol; the detrimental effects that alcohol has already had on other parts of the body, such as the heart and brain; a patient’s social network and support system; and the patient’s general health and whether he/she is strong enough physically and mentally to withstand such a major surgical procedure plus the long term postoperative medications needed for life. Most people will have stopped drinking for at least six months before being accepted for liver transplantation.
We here at Digestive Disease Associates are well trained in alcoholic liver disease and care about you and your liver health. Please practice moderation in your drinking habits and be cognizant of alcohol’s effects in your body. Contact us if you have concerns about your liver or your GI tract!
For more information, please visit: www.niaaa.nih.gov, official website of National Institute on Alcohol Abuse and Alcoholism
No Shows and Cancellations
By Christy Yoder, RN MSN CASC CPHQ
Director of Outpatient Clinical Services
You have often heard the saying, “Time is money”. Everyone wishes they had more time, and yet there never seems to be enough of it. Medical offices plan time very carefully. We set aside rooms, equipment and paid personnel specifically for each appointment. We make considerations for patient conditions and how long a visit is expected to take. Often times, our schedules are booked up for months. Two things that negatively affect our office schedule are no-shows and late cancellations.
The dictionary defines no-show as a person who reserves a space but does not use it or give it up for someone else to use. Late cancellations are those times when a patient calls us to cancel but within 24 hours of the scheduled appointment. Both are equally detrimental to our day’s schedule and our goal of timely service to all.
In order to prevent forgotten appointments we send an automated reminder call to every patient. So, when a patient does not give us sufficient notice, it is unfair to other patients who have to wait for an extended time to have an appointment. Additionally, it is difficult to maintain a medical relationship with patients who do not attend scheduled visits. Medical conditions require continued care and active participation from patients. In order to be engaged in the process, patients need to be seen by a provider.
Digestive Disease Associates and Berks Center for Digestive Health have policies in place for patients who have frequent no shows and late cancellations. While we do not charge for missed appointments, we do track them. Each patient is given an opportunity to reschedule these types of missed appointments twice. After the third time, a patient may be dismissed from our specialty practice and provided information about other providers outside of our area who can deliver care.
We encourage all of our patients to give our office at least 24-48 hour notice, if unable to attend a scheduled appointment. Not only is this considerate, this notice allows us to serve more patients in a timely manner and keeps the costs associated with medical care under control. Most importantly, it allows us to give our patients the highest quality care. We know how hectic life can be, and we are committed to making our practice convenient and accessible to all. Please help us run smoothly by communicating with us in a timely way when you cannot make your appointment.
May is Celiac Awareness Month
by Dr Aparna Mele, M.D.
Celiac disease is a genetic disease, affecting estimated 1 in 133 Americans, or about 1% of the population. This autoimmune disorder is signified by an allergy to gluten, a protein found in wheat, rye, and barley, that when ingested, leads to damage of the lining of the small intestine. This process then interferes with the adequate absorption of nutrients from food, which can lead to multiple vitamin deficiencies and malnutrition.
Celiac disease is hereditary, meaning that it runs in families. People that have a first-degree relative with celiac disease have a 1 in 10 risk of developing it themselves. This condition can develop at any age after a person starts eating foods or taking medicines that contain gluten. Left untreated, celiac disease can lead to additional serious health problems. These include vitamin and mineral deficiencies, the development of other autoimmune disorders like Type I diabetes and multiple sclerosis, osteoporosis, thyroid disease, dermatitis herpetiformis (an itchy skin rash), anemia, osteoporosis, infertility and miscarriage, neurological conditions like epilepsy and migraines, and intestinal cancers.
There are no pharmaceutical cures for this condition, and currently, the only treatment for celiac disease is lifelong adherence to a strict gluten-free diet. People living gluten-free must avoid foods with wheat, rye and barley.
Celiac disease can be difficult to diagnose because it affects people differently. Currently, there are about 300 known symptoms which may occur in the digestive system or other parts of the body. Some people with celiac disease may have no symptoms at all, however everyone with this disease is at risk for long-term complications, whether or not they display any symptoms. Symptoms include, but are not limited to nausea, erratic bowel movement patterns, bloating, abdominal pain, joint and muscle pain, fatigue, migraines, missed menses, infertility, and mood disorders.
Who should get screened? Children older than 3 and adults experiencing symptoms of celiac disease, first degree relatives of individuals with diagnosed celiac disease, and individuals with a related autoimmune disorder.
Testing can involve a blood test that detects antibodies related to an abnormal immune response. If this test is positive, a gastrointestinal doctor can perform an endoscopy with biopsies to confirm there is inflammation in the lining of the small intestine.
There is a subset of patients diagnosed with “gluten sensitivity”. The symptoms of gluten sensitivity are similar to those of celiac disease. People who are gluten sensitive experience symptoms in response to eating gluten, but do not have intestinal damage and will test negative for celiac disease antibodies. This condition could actually represent evolving celiac disease.
There has been a surge of interest in a gluten free diet, with the market for gluten-free products now exploding. It is unclear why this is so, but many people may perceive a gluten-free diet to be healthier. So, is there actually a health benefit to adopting a gluten-free diet if you are not allergic to gluten? In other words, what is wrong with the whole world going “gluten-free”??
To start with, a gluten elimination diet is highly restrictive, and also eliminates many common and nutritional foods. While gluten itself may not offer special nutritional benefits, the many whole grains that contain gluten do. Gluten-containing grains are rich in a multitude of vitamins and minerals, such as B vitamins and iron, as well as fiber. Numerous studies have repeatedly shown that whole grain foods, as part of a healthy diet, may help lower the risk of heart disease, diabetes, and some cancers. The 2010 Dietary Guidelines for Americans recommends that half of all carbohydrates in the diet come from whole grain products. Some whole grains that do not contain gluten include amaranth, millet, and quinoa, but they are less commonly found and can be costly.
A gluten-free diet is a complete dietary overhaul, and requires fastidiousness in all food choices. Most gluten-free alternatives, such as pasta or bread, are considerably more expensive that their conventional counterparts. Furthermore, the American Dietetic Association in 2005 issued a report warning that gluten-free products tend to be low in a wide range of important nutrients, including B vitamins, calcium, iron, zinc, magnesium, and fiber. Unless you genuinely have celiac disease or gluten sensitivity, there is not a good reason to take the risk of these deficiencies and radically change your eating patterns.
The allergy to gluten is ALL or NONE and there is little point in eliminating just some gluten, either symptomatically or medically. For people who are sensitive, even trace amounts can cause damage to the small intestines. Strict 100% adherence is critical to healthy well-being in affected individuals.
The basis of a healthy gluten-free diet, as with any diet, should be natural foods. Lean meats and fish, fruits and vegetables, and low-fat dairy products are all safe for people with celiac disease. Grains that don’t contain gluten, such as quinoa and amaranth, are another healthy option. More and more products are being made with such grains, from breads to cereals to pastas.
Clinical trials are currently underway for drugs that may help ease celiac disease and a vaccine for celiac disease is also under investigation. These treatments are unlikely to cure the condition entirely, but may lessen the damage caused by “cheating” with occasional gluten intake. People with celiac disease will continue to have to eliminate wheat products from their diet. Fortunately, growing awareness of the prevalence of these conditions should continue to make that challenge easier.
If you think you may be harboring an allergy to gluten or have concerns over symptoms that could reflect celiac disease, contact us here at Digestive Disease Associates for further evaluation and to get tested!
Infection with the hepatitis C virus (HCV) is a silent epidemic. About 3.2 million Americans are infected with HCV and more than half of them are unaware. The majority of people infected with HCV are unaware because signs and symptoms do not usually develop until their liver disease is advanced.
HCV is nearly 4 times more prevalent than HIV and hepatitis B. People with HCV are at risk for developing cirrhosis, liver failure and liver cancer. By 2007, more people died from HCV than from HIV.
Up until 2012, screening guidelines for testing individuals for HCV were only for those with identifiable risk factors such as a history of intravenous drug use, tattoos and blood transfusions prior to 2009. However, more recent data has found that 75% - 80% of people with HCV were born between 1945 and 1965. Because of this, the Centers for Disease Control and the US Preventative Services Task Force have recommended that all people born between 1945 and 1965 receive a one-time screening for hepatitis C.
The goal is to identify individuals infected with Hepatitis C and offer them treatment to eradicate the virus. New treatment regimens can cure >90% of infected persons. With this treatment, HCV related deaths can be reduced over the long term.
Digestive Disease Associates is currently involved in a study designed by the Chronic Liver Disease Foundation to offer free screening to individuals who were born between 1945 and 1965. Each site has been asked to screen 500 people who fall into this age range and have not been previously tested for hepatitis C. Only about 100 openings remain for this free screening. Interested individuals should phone our Research Coordinator, Faye Gehris, LPN for more information or to schedule an appointment. She can be reached at our office number, 610-374-4402, extension 224; or at cell number 267-241-5790.
April is Esophageal Cancer Awareness Month!
Esophageal cancer represents 1.1% of all new cases of cancer in the United States. Compared to other cancers such as prostate, breast, lung, and colon cancer, it is relatively rare. It is the 18th most common cancer in the United States. Although there has been an increasing trend in the incidence of esophageal cancer, the risk of developing it is still low. Based on 2009-2011 data, approximately 0.5% of men and women, will be diagnosed with esophageal cancer in their lifetime. In the United States, an estimated 18,170 were diagnosed in 2014, and an estimated 15,450 died of the disease. Worldwide, an estimated 482,300 new cases occur annually. Esophageal cancer represents the tenth leading cause of cancer death in the United States. It is a cancer of older people, with the highest occurrence between 65 and 74 years of age.
The highest rates are found in southern and Eastern Africa and Eastern Asia. In these areas risks factors are thought to include poor nutritional status, low intake of fruits and vegetables, and drinking beverages at high temperatures. In the low risk area such as the United States, smoking and excessive alcohol consumption account for 90% of the type of esophageal cancer called squamous cell carcinoma. Squamous cell carcinoma is also found more commonly in African Americans and Asians.
In addition, smoking and alcohol or risk factors for other cancers including head and neck and lung cancer. Head and neck cancers may be found in approximately 10-15% patients diagnosed with esophageal cancer.
For the past 3 decades, the frequency of adenocarcinoma of the esophagus, the other type of cancer of the esophagus, has increased dramatically, and has overtaken the previously more common squamous cell carcinoma. Adenocarcinoma of the esophagus is more common in white males, and men compared to women. A major risk factor for adenocarcinoma is chronic heartburn symptoms from acid reflux. Most cases of adenocarcinoma arise from Barrett's esophagus, which is due to reflux disease. In addition, smoking also increases the risk of adenocarcinoma of the esophagus, as does obesity.
Although the risk of developing esophageal cancer is greatly increased among patients with newly diagnosed Barrett's esophagus as compared to the general population, it is still overall low. Of concern is the presence of high grade dysplasia, or atypical cells on biopsies taken of Barrett's esophagus.
As far as protective factors, a diet high in fiber, fruits and vegetables has been found to be protective against esophageal cancer. Minimizing central obesity also protects against ongoing unchecked injury from acid reflux and therefore Barrett’s esophagus and esophageal cancer. Obesity, tobacco, and diets excessively high in dietary cholesterol and protein are associated with an increased risk.
Patients with esophageal cancer may be unaware of their diagnosis until the cancer expands to a size where it impedes the flow of food through the esophagus. This usually occurs when the diameter of the esophagus is narrowed to less than 13 mm, indicating advanced disease. At this point weight loss, anorexia also occur. Early symptoms can be subtle- transient sticking with solid dry foods may occur, and patients may adjust their diet. Other symptoms can include chest discomfort or burning. In advanced disease, patients may be unable to handle their own saliva and may regurgitate secretions and food into their lungs leading to aspiration pneumonia. Hoarseness may occur if the laryngeal nerve is involved. The cancer may bleed, leading to chronic anemia. In late stage disease, there can be an abnormal communication between the trachea and the esophagus, as the cancer erodes through the esophageal wall, which may manifest as cough induced by swallowing and subsequent pneumonia.
Tests that can be used to detect esophageal cancer include a barium swallow or upper GI series, or an upper endoscopy. Once the cancer is diagnosed, the most important next step is to determine whether or not it has spread beyond the esophagus. Further tests to determine this may include a CT scan of the chest abdomen and pelvis, and an endoscopic ultrasound, which is a specialized endoscopic procedure which allows staging of the cancer, to determine the feasibility of surgery.
Cancer confined to the esophagus is associated with a higher survival rate. The spread to lymph nodes is a powerful predictor of survival-patients who undergo surveillance are less likely to develop nodal involvement than those whose cancers are discovered due to symptoms. Cancers of the esophagus are staged according to depth of invasion of the esophagus, ranging from superficial T1 tumors, to T4 tumors involving adjacent structures. The 5 year survival rate of people with esophageal cancer located only in the esophagus is 40%, for regional spread is 21%, and for distant disease is 4%.
Treatments for esophageal cancer include surgery, with a so-called esophagectomy and removal of the cancerous part of the esophagus and reattachment to the stomach.
Other treatments include radiation therapy, laser therapy, chemotherapy, and placement of an esophageal stent either for palliative purposes, or to improve swallowing during therapy.
Options for early stage esophageal adenocarcinoma include radiofrequency ablation therapy and endoscopic resection.
Radiofrequency ablation, involves the inflation of a balloon catheter within the esophagus at the site of Barrett's esophagus, and applying radiofrequency energy, ablating the Barrett's mucosa. After this initial treatment, another endoscopy is performed, usually at 12 weeks, to determine the need for further therapy.
Endoscopic mucosa resection involves removing early cancer or precancerous lesions (so called high-grade dysplasia). This is done through an endoscope, by gastroenterologists specializing in this procedure. Unfortunately, there can be complications to this treatment including bleeding, perforation, and the subsequent occurrence of strictures (or scarring) in the esophagus. However, all of these complications can be safely managed, usually without the need for surgery.
One may decrease the risk factors associated with esophageal cancer by:
- Getting screened for Barrett’s esophagus with an upper endoscopy especially with years of chronic heartburn or acid reflux
- Lifestyle modifications such as increasing the amount of fruit and vegetables in the diet, decreasing fat and animal protein intake, and increasing fiber in the diet
- Decreasing alcohol consumption and avoiding tobacco
- Exercise and controlling obesity
Esophageal cancer is the fastest growing cancer in the United States and is easily treatable if found early. If you are having regular heartburn symptoms, don’t suffer. Come see us for further evaluation and treatment and spread the word about the importance of early detection and treatment!
On line resources include the Esophageal Cancer Action Network @ ecan.org, cancer.net (American Society of Clinical Oncology), cancer.org (American Cancer Society), cancer.gov (National Cancer Institute)
Have questions or comments? Please join us on our Facebook page.
Join us for two informative nights on TV and Radio!
Dr. John Altomare will be on BCTV tonight at 8 p.m. discussing colon cancer prevention. He will be interviewed by Dr. Lee Radosh on Medicine in the News. BCTV is Channel 15 on Comcast Reading, Channel 965 on Comcast Southern Berks, and Channel 19 on Service Electric cablevision.
Dr. Aparna Mele will be on WEEU 830 Radio on Wednesday night from 6 – 7 p.m. Again, the topic will be colon cancer prevention.
Hope you can tune in!
As we encourage our patients to get screened during Colon Cancer Awareness Month, it’s important to provide some education regarding how these procedures are billed and processed by insurance companies. While the Affordable Care Act (ACA) has helped to provide better benefits to patients for preventative services (like a screening colonoscopy), there are still plenty of twists and snags along the way when it comes to processing an insurance claim.
To start, there is some important terminology that needs to be understood before contacting your insurance company to find out what sort of benefits your plan provides. Most insurances divide colonoscopies into two categories. The first is diagnostic, which means that the patient is having a symptom like diarrhea, constipation, or rectal bleeding to name a few. The second is screening (or preventative), which means that the patient is having the colonoscopy simply due to age and not having any symptoms.
Traditionally, a diagnostic colonoscopy is processed like any other medical charge, and can be applied to a patient’s coinsurance and deductible. The ACA requires insurance companies to pay for screening colonoscopies at 100%, with no patient responsibility. However, there is a third gray area – what is generally known as a high risk colonoscopy. Insurances can consider a colonoscopy to be high risk if the patient isn’t having any symptoms, but has something in their background that is a red flag – for example, a personal history of colon polyps or cancer, or even a family history of colon polyps or cancer. Insurances have the ability to put a high risk colonoscopy on either side of the fence as far as payment – some consider these to be screening, and others consider them to be diagnostic.
To throw one last wrench into the mix – what happens when a patient comes in for a colonoscopy as a screening, but during the procedure the doctor finds a polyp? This is another situation where an insurance company can decide to process as either screening or diagnostic, depending on their policy.
As you’ve figured out by now, determining how your procedure will be paid before it happens can be extremely confusing. The single most important thing that you can do is call your insurance company at least a week before your procedure to ask them exactly how your plan covers this very important test. Below is some information that will assist you in making the call and interpreting the information that they give to you.
#1 – Procedure Codes
A procedure code (or CPT code) is a code used by physicians to tell the insurance company what exactly the doctor did during your visit. The important procedure codes to remember when talking about screening colonoscopies include:
G0121 This is a procedure code which is used by Medicare and some commercial insurance carriers. It is used to describe a screening colonoscopy done for a patient who had no symptoms prior to the procedure, was not considered high risk, and had a completely normal procedure (i.e. no polyps found). It is covered at a frequency of every 10 years following the month in which the last screening colonoscopy was performed.
G0105 – This is a procedure code used by Medicare and some commercial insurance carriers. It is used to describe a colonoscopy done for a patient who was considered to be high risk prior to the procedure (i.e. family or personal history of colon polyps or cancer, chronic inflammatory bowel disease). As with the G0121, it is only used for a completely normal procedure. It is covered at a frequency of once every 24 months.
45378 – This is the standard procedure code for a diagnostic colonoscopy and is accepted by all insurance carriers. It can be used in several ways. Most often, it is used to describe a colonoscopy done for a patient who was having symptoms prior to the procedure. It can also be used for screening and/or high risk patients whose insurance company does not accept either of the “G” codes noted above. This is again used for a completely normal procedure only.
#2 – Diagnosis Codes
A diagnosis code (or ICD-9 code) is a code used by the physician to tell the insurance company why the doctor saw you for a visit. The important diagnosis codes to remember when talking about screening colonoscopies include:
Keep in mind that family history includes first degree relatives only – that includes parents, siblings, and children. Relatives such as grandparents, aunts/uncles, or cousins do not meet the criteria for family history.
Now that you have all of the terminology, you’re ready to call your insurance company and find out how your procedure will be covered. First, let them know you are planning to have a colonoscopy done. Using the list above, give them the appropriate diagnosis code for the procedure. If more than one applies to you, give all appropriate codes to the insurance company. They should be able to tell you (based on that information) how your procedure will be covered. Second, ask them what happens if a polyp is found during the procedure. Will they process the insurance claim as a screening, or will they now process as diagnostic?
If this is not your first colonoscopy, make sure to tell your insurance company the date of your last procedure. Most insurance companies have limitations on how often a screening colonoscopy may be done (as discussed above).
One last thing to think about when talking with an insurance company. Some representatives will tell you something along the lines of “well, if your doctor codes it correctly, we’ll pay it as a screening at 100%, no patient responsibility”. Be very careful how you interpret that sentence! We are legally required to report to the insurance exactly what was done – so if we find a polyp during the procedure, we have to include that on your insurance claim. To change or eliminate information to get a claim paid differently is considered to be insurance fraud. We are always willing to review a claim for accuracy once it has been processed by the insurance company, and sometimes we can make simple adjustments based on the plan that you have and the codes that they accept – but we cannot make any fraudulent claims.
Our billing department is happy to answer any questions that you may have about your procedure, and they can be reached at 610-374-4401 option 4.
March is Colorectal Cancer Awareness Month and it brings with it a chance to increase disease awareness, education, and support for one of the most deadly, yet most preventable, cancers in the US.
As pointed out by the Colon Cancer Alliance, “the dangers, prevention, and treatment of colon cancer are still not widely known and are not discussed because colon cancer affects a part of the body that people often find embarrassing and are even forbidden to talk about”. Colon cancer is the second leading cause of cancer death in men and women in the US. It affects approximately 150,000 people a year, one third of which will die of the disease. At least 85% of colorectal cancers are sporadic, that is, occurring in an individual without a family history of colon cancer, and the risk of colon cancer increases with every decade of life.
Interestingly, the incidence of this disease in individuals under age 50 (early onset disease) is increasing, with more than one tenth of diagnosed colorectal cancers occurring in this population. New research indicates that the incidence of early onset colon cancer among patients younger than age 50 has been rising at an annual rate of 1.5% per year, compared to an annual decrease of 3.1% among older individuals over the past decade. Furthermore, individuals with early onset disease tend to have larger tumors that are more likely to metastasize. Although the overall rate of cancer in this population remains low, the trend is alarming and warrants further investigation.
Colorectal cancer remains one of the most preventable diseases in the US. Almost all colon cancers start out as a small growth called a polyp, which progresses to cancer over time. So if you have polyps, they can be removed before they turn into cancer.
How do you know if you have polyps? Most polyps do not have any signs or symptoms. The best way to find out if you have polyps is to have a doctor look inside your colon. This is done by a simple test called a “COLONOSCOPY”. During a colonoscopy, not only will polyps be detected, but they can be removed at the same time. Being in a regular screening program, having repeat colonoscopies every 3-10 years (depending on an indivudual's own findings), and awareness of family history, can prevent this disease.
Thanks to widespread use of colonoscopies, the incidence and mortality rates of this disease are decreasing among those older than 50 years. They are, however, increasing in younger individuals, for whom screening use is limited and key symptoms may go unrecognized. Most people should be screened with colonoscopy starting at age 50. There are some risk factors for which screening should begin earlier in life. If someone has a family history of colon polyps or cancer they should start the screening process earlier. It is important to discuss your health with your family members. You should ask your parents and siblings if any of them had colon polyps that were removed. This is important information in determining when to have a colonoscopy, but many people do not share this information readily.
Remember that most colon cancers can be prevented with screening and the BEST screening method is the colonoscopy. Prevention is achieved by having a colonoscopy to detect colon polyps and have them removed before they turn into colon cancer. Eating a healthy diet rich in fruits, vegetables, whole grains, and legumes, and limiting fat intake can reduce the risk of colon cancer. Tobacco in any form and in any amount can increase the risk of polyp formation and development of colon cancer. Daily exercise and maintaining an ideal weight will independently and collectively decrease cancer risk.
Colorectal Cancer Awareness Month provides the chance to break down barriers and open the door to communication about a highly preventable, treatable, and beatable disease. So start the conversation, spread the word, wear a blue ribbon, support awareness, and schedule a colonoscopy for you and those you love.
Let’s beat Colon Cancer!
Aparna Mele, M.D.
Welcome to the Blog of Digestive Disease Associates
Digestive Disease Associates would like to welcome you to our blog. Here you will find informative and useful postings about gastroenterology and our practice.
At Digestive Disease Associates we believe that educated patients are better prepared to make decisions regarding the health of their digestive system. Our blog was designed to provide you with the latest gastroenterology developments and valuable health advice from our dedicated team.
Digestive Disease Associates hopes you find our blog to be a great resource for keeping up to date with proper digestive health care and treatments.
We welcome all comments and questions.
-- Digestive Disease Associates
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