CELIAC SPRUE TESTING for Irritable Bowel Syndrome patients

Utility of celiac sprue evaluation in North America

A new study in ACG Jan 2017

The results of this updated systematic review and meta-analysis demonstrate that the pooled prevalence of a positive serological test for CD in individuals with suspected IBS is between 2.6 and 5.7%, and the OR for a positive test was up to threefold higher among those meeting criteria for IBS. e pooled prevalence of biopsy-proven CD was similar, at 3.3%, and again this was significantly more common in those with IBS-type symptoms, with an OR of almost 4.5. However, in some of our analyses when only North American studies—or when only studies conducted in the general population—were considered, the odds of a positive serological test for CD and of biopsy-proven CD, were no longer signi cantly greater. is suggests that the utility of screening for CD among individuals reporting, or presenting with, symptoms compatible with IBS in these settings is less clear.

NO CLEAR UTILITY IN TESTING Irritable Bowel Syndrome patients for celiac sprue.

Utility of celiac sprue evaluation in North America

The results of this updated systematic review and meta-analysis demonstrate that the pooled prevalence of a positive serological test for CD in individuals with suspected IBS is between 2.6 and 5.7%, and the OR for a positive test was up to threefold higher among those meeting criteria for IBS. e pooled prevalence of biopsy-proven CD was similar, at 3.3%, and again this was sig- ni cantly more common in those with IBS-type symptoms, with an OR of almost 4.5. However, in some of our analyses when only North American studies—or when only studies conducted in the general population—were considered, the odds of a positive serological test for CD and of biopsy-proven CD, were no longer signi cantly greater. is suggests that the utility of screening for CD among individuals reporting, or presenting with, symptoms compatible with IBS in these settings is less clear.

NO CLEAR UTILITY IN TESTING Irritable Bowel Syndrome patients for celiac sprue

  • Testing for celiac sprue is common in the USA. 
  • Most patients did not have celiac sprue  

Functional Dyspepsia

What is new?

This is a rapidly evolving field. Historically, Functional Dyspepsia has been classified under the “junk” label of “functional”. That is another way to say: we don’t know. Fortunately, some doctors are trying to move this discussion into a scientific direction. So here are current thoughts.

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Functional Dyspepsia is pain in the Epigastrium, with or with out Nausea and vomiting. It can also be associated with abnormal motility as measured by Gastric Emptying Studies.

So what is causing Functional Dyspepsia. It looks be a neuropathy of the gut, we think –  this idea remains to be determined. May be a muscular problem of the gut. 

In cases of idiopathic Functional Dyspepsia, abnormal Gastric Emptying Study is common – in 20 % of cases. The GES is not reliable though.  Please do not put all your expectations on these results. You have to look at the whole patient.

SUMMARY

  • there is no good evaluation tool to define Functional Dyspepsia
  • no reliable treatment options, yet
  • no good assessment tool.

reminds me of the Cisapride debacle


Furthermore: Gastroparesis is NOT just more severe Functional Dyspepsia.
Key concepts to consider:

  • Accommodation
  • Rapid Emptying
  • if there is > 25% of food in the stomach at 4 hours with a Gastric Emptying Study, more likely to be significant or severe  – also more likely to respond to treatment

TERMINOLOGY
– Gastric Failure
– Post Prandial Gastric Distress
Overlap of symptoms are common:

  • anxiety
  • depression
  • dyspepsia

Think about treatment for mood disorders


NEW: Gastroparesis Breath Test
Advanced Breath Diagnostics: Brentwood, TN 

  •  in office
  • May be useful, but not available yet in my office – can not endorse at this time 

TREATMENT options

  • Buspar
  • Mirtazepine

Pain Medicine Debacle

Pain Management: the error of their ways

Controlling pain has always been a primary goal of clinicians. It is my conviction that the discovery of Ether was the single most important discover in medicine (closely followed by the germ theory and antisepsis theory). Getting control of chronic pain continues to be a major conundrum.

About 20 years ago, a Harvard researcher published a series of articles on the problem of pain. In particular, control of pain in the post operative patient. His conclusions led to a much greater awareness of our inadequate use of pain medicines in patients following surgery. These conclusions were extrapolated to chronic out patient care – a crucial mistake in logic. That scientist and recently apologized for his research. Why? because his conclusions were used by self interested individuals to justify the over prescription of higher and higher doses of narcotic pain medicines. Now we have a major epidemic of pain medicines – leading to severe side effects, up to and including death.

Over that time, doctors and nurses had to take extra, mandated, courses on pain management. The only bullet points that I could get from those conferences were: 1. Don’t under-treat, or you can be sued. 2. Don’t give too much, or you will lose your license. This left us with a very narrow corridor of treatment options. Referrals to pain specialists soared.

**IMPRESSIONS AND RECOMMENDATIONS: **

  1. Chronic pain is a tough problem to treat. We are in need of better solutions.
  2. Narcotics are a rarely the best option, use only when nothing works.
  3. Living with a little pain is better than the side effects from Narcotics
  4. Anyone can get addicted, given enough time and doses (do not believe that some humans are immuned to addiction – those individuals are rare or non existent).
  5. As I have stated before, be skeptical of research that may be tied to the pharmacy or food industry. Those studies need extra evaluation and analysis before meaningful conclusions can be made.

The Conspiracy to make us obese

The Conspiracy to make us obese

If you have been watching the news, you will read that the Sugar industry conspired, with researchers at Harvard, to hide the fact that sugar is the most significant cause of obesity. We were taught that “fats” were the main culprit. Now we find that those researchers were paid to falsify data. JAMA Intern Med. Published online September 12, 2016. doi:10.1001/jamainternmed.2016.5394

For the past 20 years, I have been wondering and declaring my instinctual concerns that industry was trying to fatten us up, with the goal that we would then waste money on Weight Loss programs and surgery. Now I discover that my instincts were mostly right (a good education in scientific logic has its benefits).

**How do we judge this issue? What are we to do? **

  1. Do not always trust Academic Physicians: they are paid well for their results. Financial biases have been and continue to be significant.
  2. Disclosure of financial relationships matter.
  3. Know the basic research data, or find someone who does? If human studies do not correlate to basic research mechanisms, then be skeptical of the conclusions.
  4. The name institutions in our culture (Harvard, Stanford, etc…) are not always the best source of new or better ideas. With the internet and sharing of ideas and information, more creative individuals are getting their opportunity to share their ideas. Read companion article on the Pain Medicine Debacle.

Essential Oils

I get this question every day. I would rather talk about religion or politics (not really), butthis is what occupies the interests of people.

What is the issue?

Do they work?

Yes, probably. But how?

I did some deep research into the matter, trying to understand the issues (pubmed.com). Here are my conclusions:

  • There is not much data
  • They do seem to help anxiety symptoms and other neurologic symptoms.
  • They do not cure cancer or Crohns Disease.
  • We do not have a mechanism to explain how they help.

How might Essential Oils work?

  • they smell nice
  • through the olfactory gland, may act on the Central Nervous System, relieving anxiety symptoms and other brain related symptoms.
  • the brain can have indirect effects on other systems in the body, even the immune system

Conclusions:

  • We need more research.
  • No harm noted, so spend your money as you wish.
  • Don’t expect insurance to pay for it.
  • Avoid pyramid schemes selling Essential Oils, you can save money by shopping online. 

Omeprazole and Dementia

Omeprazole and Dementia

A doctor told me today that her patient is on Omeprazole and Zantac for her Barretts esophagus. She is 92 years old. I was then told that Proton Pump Inhibitors and H2 blockers cause dementia.

Now for the facts.

  • Proton Pump Inhibitors may cause dementia in 1.7 % of patients. It may be mediated by vascular changes
  • There is absolutely no evidence that Zantac or Pepcid cause dementia. Check out PUBMED

How did this error in information occurs?

  • Journalistic hubris. They combined all acid reducers together, regardless of mechanism.

Conclusion:

Okay to take Zantac. 
Try to get off of Proton Pump Inhibitors