Tag Archives: gastroenterology

Chew on This!

Grandmothers the world over are the same when it comes to some things.

Sneaking candy behind mom’s back.

Big cuddly hugs.

Best. Cooking. Ever.

And advice about how to eat said cooking.

A slow eater. Credit: Håkan Svensson, Xauxa/ Wikimedia Commons

“Slow down! This isn’t a race you know! Chew each mouthful 100 times!”

Japanese grandmas are no different – and even the Japanese government has jumped on the chewing bandwagon, Dr. Masaaki Eto said at the annual meeting of the European Association for the Study of Diabetes.

Dr. Eto described his study of 9 obese – but not diabetic –  subjects with a mean body mass index 27 k/m2 (in Japan, obesity begins at a BMI of 25 kg/m2). At baseline, the volunteers’ mean fasting plasma glucose was 99 mg/dL. They all ate the same 630-calorie meal on two separate days: bread, butter, a hard-boiled egg, steamed vegetables, a banana, and milk.

On day one, they had to finish it in 20 minutes, chewing each bite 5 times. On the second test day, they ate the same meal, also in 20 minutes, but chewed each mouthful 30 times.

Dr. Eto and his colleagues measured two satiety hormones – glucagon-like peptide (GKP-1) and peptide YY (PYY) before and after each meal.

The results will please grandmas worldwide.

Chewing each bite 30 times significantly increased the levels of both hormones over chewing 5 times, said Dr. Eto of Ohu University, Fukushima, Japan.

Among the 5-chew gulpers, plasma PYY increased from 36 pg/mL to 41 pg/mL – not a significant change. But the slow chewers had quite a different outcome. “The 30-times chewing group had a significant increase in plasma PYY,” Dr. Eto said. Their levels jumped from a mean of 36 pg/mL to 66 pg/mL.

The story was repeated with GLP-1. The fast-chewers did have an increase – although not significant (5 pmol/L to 17 pmol/L).  But the slow-chewers had much better results, increasing their GLP-1 from 5 pmol/L to a whopping 29 pmol/L.

“This is the first report that thorough chewing stimulates postprandial increases in the two hormones,” Dr. Eto said. “These hormones reduce appetite and food consumption, so thorough chewing may help obese subjects to lose weight.”

Besides, he said, Japanese grandmothers “since the old days” have advised kids to do a lot of chewing.  So much so, he added, that the Japanese government has issued a recommendation to  chew each bite of food 30 times – to help avert the country’s growing obesity problem. “That is why we picked 30 times chewing,” for the study, Dr. Eto said.

Some audience members weren’t completely convinced that the good results are related to the combination of chewing and food intake. One questioned whether the mechanics of chewing was key benefit, stimulating the vagusl nerve to release GLP-1. “For instance,” he asked, “what if the subjects chewed the food and then spat it out? What would the results be then?”

To which moderator Dr. Davide Carvalho replied, “I believe chewing and spitting out the food could be the best diet we could invent.”

—Michele G. Sullivan

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Filed under Cardiovascular Medicine, Endocrinology, Diabetes, and Metabolism, Family Medicine, Gastroenterology, IMNG, Internal Medicine, Internal Medicine News, Pediatrics, Primary care, Uncategorized

What Would Jeff Spicoli Do?

If chronic pot smokers present to your office with recurrent episodes of tummy trouble, consider a diagnosis of cannabinoid hyperemesis syndrome.

Image courtesy Flickr user Torben Bjorn Hansen via Creative Commons License.

First reported in Australia in 2004, cannabinoid hyperemesis syndrome (CHS) is marked by “horrible abdominal pain, but mostly nausea, and vomiting” in chronic pot smokers, Dr. Walter J. Coyle said at a conference on primary care medicine sponsored by the Scripps Clinic.

Symptom relief comes only after patients take a hot bath or shower. Patients who experience CHS tend to be males who have been smoking “at least two bongs a day for a long time—months and months,” said Dr. Coyle, who, with Dr. Emily Singh, published the first clinical report of the syndrome in the United States. “The treatment is to quit the weed.”

 Sometimes patients take baths or showers with water so hot that it causes scald marks on the skin, Dr. Coyle said. Others refuse to curb their pot smoking. In fact, one patient told him “thanks for telling me [about CHS]. I’m not gonna stop.”

According to a 2009 article from the American Journal of Gastroenterology, the suggested pathogenesis of CHS includes “toxicity due to marijuana’s long half-life, lipophilicity, delayed gastric motility, and dysfunction of thermoregulatory and autonomic effects on the limbic system and hypothalamus secondary to the effect its active ingredient, Tetrahydrocannabinol, on the endogenous Cannabinoid receptors CB1 and CB2.”

If the fictional character Jeff Spicoli from the 1982 film “Fast Times at Ridgemont High” were to visit his physician with telltale signs of CHS, one wonders how that dialogue might go.

 SPICOLI: Gnarly stomach trouble, Doc. Really cramping my style. Can’t surf. Can’t impress the ladies.

SPICOLI’S DOCTOR: The only way you’ll get better is if you quit smoking pot. Is that something you’ll consider?

SPICOLI: Um, dude. I don’t think so.

SPICOLI’S DOCTOR: But if you quit you’d be able to master the ocean waves and you’d have good breath for the ladies.

SPICOLI: I didn’t think of that. You’re smart, Bud. Let’s party!

— Doug Brunk (on Twitter@dougbrunk)

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Filed under Drug And Device Safety, Family Medicine, Gastroenterology, IMNG

What’s Your IQ (Ick Quotient)? Or, Is Fecal Transplant for You?

Everyone has an ick quotient, and it varies from person to person. Mine was tested recently while watching a cooking show in which an elegant Italian woman prepared a delicious-looking meal featuring … rabbit. My ick quotient has so far stopped me short of eating rabbit, but Lorenza certainly made it look appealing. And if I suffered from chronic Clostridium difficile infections, and she told me that eating Thumper would clear it up in a day, I might well give it a try.

More patients with chronic C. difficile might have the option to put their ick quotients to the test and consider fecal implantation, if more physicians and health care providers are willing to push the limits of their own ick quotients and perform the procedure.

courtesty of flickr user Sweet Freak (creative commons)

During a press briefing at the annual meeting of the American College of Gastroenterology, Dr. Lawrence J. Brandt of Albert Einstein College of Medicine in New York, said the procedure has become so commonplace that his nurses have become inured to it, and no longer have to draw straws when a patient arrives for fecal implantation. He is getting about 3 calls a week with inquiries about it, he added.

Fecal transplant is exactly what it sounds like: taking the fecal contents from a healthy person and transplanting it into a C.difficile patient — via delivery methods that include nasogastric tube, enema, and oral capsules — to get rid of the C.diff and restore the sick person’s healthy gut bacteria. That sounds revolting to many people, including doctors and health care workers. But according to Dr. Brandt, the implantation is safe, easy, and inexpensive. And the limited patient data show a cure rate of nearly 100%, with patients reporting that they feel better as soon as the next day.

Dr. Brandt said that his first choice for a fecal transplant donor is an “intimate contact.” (I doubt this crosses the mind of many couples during the “in sickness and in health” part of the wedding vows.) He also has had donors who are siblings, nonrelated household contacts, and friends.

Stay tuned: Although the largest reported case series numbers fewer than 20 patients, Dr. Brandt said that perhaps clinicians should consider fecal transplant as therapy for chronic C. difficile. If they can get over the ick factor, that is.

 –Heidi Splete (on twitter @hsplete)

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Filed under Gastroenterology, IMNG, Infectious Diseases

Is a Picture Worth a Thousand Good Colonoscopy Preps?

From Digestive Disease Week, New Orleans, Louisiana:

Getting patients to do the proper prep for a colonoscopy remains a problem for gastroenterologists. To try to clear up the confusion, some doctors are doing what they can to create patient education materials that take health literacy into account.

One talk at this year’s Digestive Disease Week described the success of educational colonoscopy prep material aimed at a 5th or 6th grade level.

Dr. Brennan Spiegel of the West Los Angeles Veterans Aaffairs Medical Center and his colleagues developed a booklet using both text and pictures to explain the correct preparation, after conducting interviews with patients and providers to identify common barriers. The brochures include capital letters and Xs through pictures of what not to eat or drink, as well as pictures and descriptions of what “clear” fluids are.

For example, “if you can read newspaper through it, it’s clear (picture and description of apple juice). If not, it is not clear (picture and description of orange juice).

The materials also showed a picture of the same stretch of curvy, country road on a clear, sunny day, and during a snowstorm, to illustrate why proper prep is important:  A clear colon is easier for the doctor to “drive” through.

courtesy of flickr user texxxx2005 (creative commons)

courtesy of flickr user Arul Jegadish (creative commons)

In the study presented at the meeting, the researchers randomized 93 colonoscopy patients to receive the new material and 106 controls to receive standard prep instructions. Prep quality was rated using a tool called the Ottawa score. The average Ottawa scores were significantly higher among patients who received the new booklet, even after controlling for multiple variables.

Clinicians, are you developing any new material to improve the quality of your patients’ colonoscopy preps that takes health literacy into account? What works well in your practices?

— Heidi Splete (on twitter @hsplete)

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Filed under Family Medicine, Gastroenterology, IMNG, Internal Medicine, Uncategorized

Them’s Fightin’ Words

From the Digestive Disease Week, New Orleans.

What had been a semiquiet scuffle emerged into a loud and very public battle for supremacy between the gastroenterology/endoscopy community and the anesthesia community this week when leaders from professional societies for the specialties took pot shots at each other at a well-attended plenary session here.

Via Flickr Creative Commons user mikebaird

For years, gastroenterologists have sedated their colonoscopy patients with a variety of opiates and benzodiazepines. But a few years ago, when it looked like propofol was a better, more cost-effective sedative, many began switching to that agent, which generally had been used only in operating rooms.  Anesthesiologists were not asked to the colonoscopy party, except in some states (like New York), where it was the custom.

Anesthesiologists were not happy about being cut out of a potentially vast new revenue stream. At least, that’s what the endoscopists claim. The anesthesia community has maintained that it’s not safe for other physicians — or nurses — who have not received specific training in airway management to be sedating patients “deeply,” which they claim propofol does.

Dr. Alexander Hannenberg, president of the American Society of Anesthesiologists, told the attendees that his group’s stance might be seen as self-serving, but that it was truly a bid for safety.  Physician offices generally aren’t regulated by state agencies and endoscopists just aren’t capable of multitasking, he said, asking how could they monitor anesthesia and the colon procedure simultaneously?

One can imagine how well that comment sat with the endoscopists.

Dr. Douglas Rex, one of the nation’s most respected colonoscopists, who conducted a review of 600,000 endoscopist-administered cases that showed no safety issues, said Dr. Hannenberg’s contentions were outright baloney.  Dr. Rex accused the ASA of having fabricated the notion of “deep sedation,” which he said the Medicare program adopted, without any scientific evidence to back the idea.

In December, Medicare issued a “clarification” that “deep sedation” should be administered, essentially, only by anesthesiologists or nurse-anesthetists. Another thorn in endoscopists’ side.

Dr. Rex also accused the ASA of having co-opted the FDA and its advisers, helping to defeat approval (read about the FDA’s recent denial here) of an automated sedation device, Sedasys, that endoscopists could use without anesthesiologists’ help. Sedasys maker Johnson & Johnson is appealing.

His conclusion was that gastroenterology, which is fragmented into four different societies, basically had been outspent and outmuscled by a better-organized, deeper-pocketed anesthesiology community.

Should medical societies be so openly warring over what appears to be primarily a turf issue? Let me know what you think.

— Alicia Ault (on Twitter @aliciaault)

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Filed under Anesthesia and Analgesia, Gastroenterology, Health Policy, IMNG, Internal Medicine, Practice Trends

Star Power and Digestive Disease

From Digestive Disease Week in New Orleans, LA: 

courtesy of flickr user Crafting with Cat Hair

Never underestimate the power of celebrity. Today at Digestive Disease Week, I heard a presentation that reported on the first year of activity for a Web site called sedationfacts.org. The Web site’s goal is to educate clinicians and the public by providing the latest evidence-based data on endoscopic sedation. The site is a joint effort of several organizations: American Society for Gastrointestinal Endoscopy, American Gastrointestinal Association Institute, American College of Gastroenterology, and Society of Gastroenterology Nurses and Associates, Inc. 

Basically, the news is great. The site is averaging 5,000 visits per month. But Dr. Jenifer Lightdale of Children’s Hospital Boston, who presented the findings, noted that visitors to the site also include individuals who want to know about the sedation medications themselves. In particular, the Web site traffic report showed a huge spike in July 2009, the month after Michael Jackson’s death, when even my mom learned how to pronounce propofol

Obviously, some of those visitors weren’t googling “propofol” because they were interested in endoscopic sedation, but Dr. Lightdale’s data showed that visitors to the Web site were clicking on an average of 3.3 pages per visit. So, thanks to star power, some of these chance visitors might end up learning something before they click away.

If a dramatic celebrity death ends up teaching someone something about endoscopic sedation, maybe that will make the difference between that person going for a screening colonoscopy that might identify cancer, vs. skipping the appointment because he or she is afraid of the procedure or its side effects. I heard several doctors, in presentations and in comments, note that fear remains one of the key barriers to getting patients to come in for screening colonoscopies. 

Alternatively, perhaps we are due for another celebrity colonoscopy. It has been quite a while since Katie Couric showed off her colon on national TV. Harry Smith did his personal sequel to Katie’s Colon earlier this year, but maybe the public would pay more attention to someone with more sex appeal. Brad Pitt, are you listening? 

 –Heidi Splete (on twitter @hsplete)

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Filed under Anesthesia and Analgesia, Drug And Device Safety, Family Medicine, Gastroenterology, IMNG, Internal Medicine, Primary care, Uncategorized