gastro health magazine - fall 2012 issue

Fall 2012 Issue

The View’s elisabeTh Hasselbeck

PreVenTing ColoreCTal

CanCer

Attention BABy Boomers!

New GuideliNes for Hepatitis C

sCreeNiNGs

PediAtric news for You aNd Your familY

shares her Gluten-Free Odyssey

Gluten-Free Corner // Colon HealtH // Gastroparesis explained

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Gastro Health Welcomes You

Inside this issueWhat is Celiac Disease?Evidence Points to Colonoscopy Elisabeth Hasselbeck Gluten-Free OdysseyThe Pill Camera Dealing with Gas and Bloating What Endangers Colon Health?Are You at Risk for Hepatitis C?Gastro Health Physician Directory Investigative Overview: Gastroparesis Attention Baby Boomers Pediatric News: Coping with IBD Gluten-Free Corner What Can Remicade Do For You?Treating Hemorrhoids

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9500 South Dadeland Boulevard, Suite 802Miami, FL 33156T. 305.468.4180www.gastrohealth.com

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[email protected]

Cover Photo: © Sara De Boer/Corbis All rights reserved.

After all the fantastic feedback we received for our 2012 issue, we have decided to turn Gastro Health Magazine into a biannual publication. The physicians and staff of Gastro Health are pleased to present our first Fall Issue. Inside you will find informative and educational articles on various digestive health topics such as inflammatory bowel disease, gastroparesis and colon health, among others. We are also delighted to feature Elisabeth Hasselbeck from The View, who shares her life experiences with celiac disease. We have included many tips on living a healthier life, and even coping with a gluten-free diet. This magazine represents our group’s vision: to deliver quality medical care and preventative medicine to all patients; align ourselves with the finest physicians practicing medicine in South Florida; and developing ancillary services that improve our patients’ quality of care and customer experience. The physicians, nurses, nutritionists and office staff of Gastro Health seek to exceed the expectations of the patient experience by treating everyone as an immediate part of our family. Thanks to patients’ feedback, we have received a 98% satisfaction with our services – confirming the dedication to excellence within our care centers. We are proud to have several of our physicians make the 2011 US News & World Report’s prestigious Top Doctor’s List. Our physicians, allied professionals and staff will continue to achieve excellence in medical care, heal and prevent illness through integrated efforts in the field of digestive care, while always caring for you and the ones you love.

Alejandro Fernandez, MBA, CMPEChief Executive Officer

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Gastro Health

6 :: GASTRO HEALTH MAGAZINE • FALL 2012

What is Celiac Disease

Celiac disease is a condition in which a protein found in certain foods - gluten – causes the immune system to damage the small intestine. The small intestine

is responsible for absorbing food and nutrients. However, when the lining of the small intestine is damaged this can cause problems with absorbing nutrients which is referred to as malabsorption. Gluten is found in wheat, barley, rye and several condiments, sauces and spreads. It is not clear what exactly causes celiac disease, but there is a combination of environmental and genetic factors. Celiac disease can affect both male and females of any age. Although there is no cure for celiac disease, avoiding gluten can stop the damage to the lining of the small intestine.

What are the Common Symptoms?The symptoms of celiac disease can vary from person to person. Some people may have no symptoms, yet exhibit signs of malabsorption detected on blood tests. Others can develop a variety of gastrointestinal complaints. The most common symptoms experienced are abdominal discomfort, diarrhea, bloating, weight loss and decreased energy. There can also be other signs and symptoms of vitamin and nutrient deficiencies that can cause anemia, bone loss, nervous system disorders and skin rash. Children with celiac disease can have a poor appetite, slow growth and have difficulty gaining weight.

How is Celiac Disease Diagnosed?Celiac disease can be difficult to diagnose because its signs and symptoms can resemble other conditions. However, there are blood tests available which can help make the diagnosis. These blood tests look for proteins (antibodies) that can become elevated in people with celiac disease. It is important to continue eating gluten while being tested because avoiding it can cause these proteins to become normal. If the blood test is positive for celiac disease, the diagnosis is confirmed by obtaining a sample of the small intestine. The sample (known as a biopsy) is obtained by performing an upper endoscopy and the sample is viewed under a microscope to see if there has been any damage to the lining of the small intestine. An upper endoscopy is a procedure performed by a gastroenterologist during which a small flexible tube with a camera is introduced through the mouth and a small piece of tissue from the small intestine is removed.

How is Celiac Disease Treated?The cornerstone of treatment for celiac disease is elimination of gluten from the diet. This can be overwhelming initially because many foods that we eat and even condiments that we cook with contain gluten. Therefore, consulting with an experienced dietician can help you learn how to eat, shop and prepare a gluten-free diet.

Most patients will notice an improvement in their symptoms within two weeks. Rarely, patients fail to have improvement in symptoms despite adherence to a gluten-free diet. This is considered refractory celiac disease and requires medications which suppress the immune system (like steroids). It is important to remain on a strict gluten-free diet despite feeling well to prevent nutritional deficiencies and certain types of gastrointestinal cancer. Families should be aware of their increased risk of developing celiac disease and anyone with symptoms should be tested. Various local and national support groups help increase awareness and make living a gluten-free lifestyle achievable.

“The cornerstone of treatment for celiac disease is elimination of gluten from the diet.”

?George A. Sanchez, MDGastroenterologist

:: 7GASTRO HEALTH MAGAZINE • FALL 2012

Gastro Health

Alfredo J. Hernandez, MD Gastroenterologist

‘‘A Colonoscopy is considered the most comprehensive method to detect and prevent colorectal cancer.’’

Colorectal Cancer, also known as Colon Cancer, is the third most common occurring cancer and the second leading cause of cancer-related deaths worldwide. There are two basic ways to screen for colorectal cancer. One way is by collecting stool

specimens. The second is by evaluating the lining of the colon, which is done by having a Colonoscopy, Sigmoidoscopy, Barium Enema, or a CT Colonography.

A Colonoscopy is considered the most comprehensive method to detect and prevent colorectal cancer. The procedure consists of inserting a thin, flexible tube into the rectum and evaluating the entire colon. This method allows the physician to locate and remove precancerous, or adenomatous, colon polyps.

A recent New England Journal of Medicine article titled Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths, shows that removal of precancerous polyps through colonoscopy reduced the death rate from colorectal cancer. This study is one of the first research papers looking at how colonoscopy can not only reduce the incidence of colorectal cancer, but can actually decrease mortality or death from it. The study analyzed prospectively 2,602 patients that had initial colonoscopy and precancerous polyp removal. There were only 12 deaths from colorectal cancer reported in the group studied. When compared to a group from the general public with similar age, sex and race, the number of deaths from the disease was about 25 individuals. Resulting in the conclusion that colonoscopy reduced the incidence of colorectal cancer associated death by 53%.

The guidelines from the American College of Gastroenterology for colorectal cancer screening call for all average risk individuals, male and female, to undergo colonoscopy at the age of 50. Other populations with risk factors or symptoms may have varying age for colonoscopy. For example, African Americans as a subgroup are recommended for screening at age 45. Patients need to be aware that there are other methods of colorectal cancer screening if colonoscopy is not available to them. If the other methods have positive findings, however, colonoscopy will then be advised. The overall evidence continues to point to colonoscopy reducing the risk of colorectal cancer and even mortality.

Evidence Points to Colonoscopyin Preventing Colorectal Cancer

By Jefferson adams of Celiac.com

Gastro Health


ElisabEth hassElbEck

sharEs hEr GlutEn-frEE OdyssEy

Like so many people with celiac disease, Elisabeth Hasselbeck of ABC’s The View has a story to tell.

Like so many people with celiac disease, that story involves a long, slow, painful journey from suffering to understanding, to self-empowerment and recovery. In

between were periods of confusion, doubt, isolation and malaise. Hasselbeck describes that journey in her new book: The G-Free Diet: A Gluten-Free Survival Guide.

Hasselbeck ’s odyssey began during her sophomore year of college, when she fell ill after returning from a three-week-long trip to Belize. She was diagnosed with a severe bacterial intestinal infection which, her doctor said, was a result of her travels in Central America. The illness put in the school infirmary for nearly a week, with an immensely distended belly and a 103+ fever. Once the initial infection subsided, she was naturally relieved, and thought the worst was over. Little did she know that a long road lay ahead.

As an athlete, Hasselbeck was eager to get back into shape after she was discharged. Her body had other ideas. During this period, she says she felt absolutely ravenous, yet the only dining hall foods that seemed appealing were soft-serve vanilla frozen yogurt and Rice Krispies. Food had lost its appeal.

Hasselbeck grew up in an Italian-American neighborhood in Providence, RI, in a family that prized all things bread and pasta, so she wasn’t about to give up the appetite and food battle without a fight.

However, no matter what she ate nothing satisfied her hunger—and everything seemed to upset her stomach. After nearly every meal, she had the classic bloating, and sharp, gassy pains in her gut that are all too familiar to most

celiacs. Cramps, indigestion and diarrhea were familiar companions; sometimes all at once. Often, she would become too tired to move.

It was about this time that she became a contestant on Survivor: The Australian Outback. While enduring the trials of surviving in the outback, Hasselbeck was deprived of her normal, gluten-rich American diet, and forced to subsist on things she would never willingly eat at home. Yet, her symptoms were gone, and she had never felt better. Once she returned to the U.S., she narrowed the scope of her quest. She eliminated nearly everything from her diet and introduced items one at a time.

After nearly forty days basically starving herself, she sought solace in her pre-Australia diet, with dire consequences. After the joy of knowing a healthy, happy gut for the first time in years, she suddenly found herself feeling worse than ever, and spending days in her room, bedridden, save for urgent trips to the bathroom.

She saw a doctor and received a diagnosis of “Irritable Bowel Syndrome (IBS).” Suspicious of what she saw as an acknowledgement of symptoms masquerading as a diagnosis, she began to look for connections on her own.

reprinted with permission by www.Celiac.com


Gastro Health

Fortunately for Hasselbeck, she began to make a connection between the illness she had suffered for so long and the food she was eating. She noticed that when ate starchy foods, her symptoms returned with a vengeance.

An Internet search told her that she might be suffering an adverse reaction to wheat. She quickly moved to eliminate wheat from her diet. Her experience, as so many with celiac disease know all too well, was an educational one, filled with occasional episodes that left her feeling inexplicably ill.

Unable to figure out exactly what was making her sick, she undertook more research and stumbled upon some information about gluten intolerance and celiac disease.

In 2002, after five years of suffering, Hasselbeck diagnosed herself with celiac disease, an autoimmune condition triggered by gluten – the protein found in wheat, rye and barley.

Celiac disease can cause acute damage to the small intestine and the digestive system, and, left untreated, it can leave sufferers at risk for

certain types of cancer and other associated conditions. The only known treatment is a lifelong diet free from wheat rye and barley gluten. Once she realized what had been tormenting her for so many long, she set about eliminating all wheat, barley, oats, and rye from her diet.

Still, even after she made her diagnosis, she faced a long line of skeptical doctors. In fact, it was eight years after her symptoms first began until she found a doctor who was willing to listen, and who had answers.

Her move to New York City put her into contact with Dr. Peter Green, the director of the Celiac Disease Center at Columbia University, who confirmed what she’d suspected for years: Elisabeth Hasselbeck has celiac disease. After waiting for years for a sensible explanation to her symptoms, Dr. Green was the first doctor to look for the cause, not simply to treat the symptoms. Despite the same mistakes and accidents that most of us celiacs have also experienced, her perseverance paid off in the end and she remains gluten-free to this day.

“The only known treatment is a lifelong diet free from wheat rye and barley gluten.”

Gastro Health


THEPILL

caMEra

“An endocapsule is a miniature video camera that

has been incorporated into a capsule-shaped device.”

Andrew I. Sable, MDGastroenterologist

Capsule endoscopy refers to a relatively new technology that gastroenterologists use to examine the deepest portions of the digestive tract. In 1981, an Israeli engineer named dr. Gavriel Iddan began work on designing a disposable pill-sized camera that could be swallowed and would pass directly through the intestine. In 2001, after twenty years of research and development, the Fda approved the Given diagnostic Imaging system called Capsule endoscopy.

How does it work? an “endocapsule” is a miniature video camera that has been incorporated into a capsule-shaped device along with a light source, transmitter and battery. It has a biocompatible coating which allows it to be safely swallowed and pass undigested through the intestinal tract. during this journey, it transmits over 50,000 color images via radio frequency to a recorder worn on a belt on a patient’s hip or waist. the pill weights only 1/7th of an ounce and is about the size of a large vitamin. Once swallowed, the capsule moves through the intestine, naturally aided by the muscular contractions of the intestine.

since the advent of capsule endoscopy, gastroenterologists have been able to make diagnoses not previously made using conventional methods. For example, in disease such as Celiac sprue and Crohn’s disease, the endocapsule has assisted in visualizing areas that were previously unreachable without major surgery. additionally, capsule endoscopy has played a major role in advancing the diagnosis and treatment of obscure gastrointestinal bleeding. additionally, it has been helpful in identifying tumors of the small intestine and evaluating polyposis syndromes. subsequent development of an esophageal capsule also provides a modality to monitor Gerd (gastroesophageal reflux disease) non-invasively.

What to expecttypically, patients undergoing an endocapsule study will have a preparation that will consist of a brief fasting period. some physicians may also recommend a bowel prep to cleanse the small intestine before the study. this outpatient procedure will begin in your doctors office. after a brief orientation, you will swallow the endocapsule and be asked to wear a small data recorder around

What is it? What does it do?

CAPsulE ENDOsCOPY


Gastro Health

© Janssen Biotech, Inc. 2012 8/12 25RGU12016

IBD Icons is sponsored by Janssen Biotech, Inc.

Casey Abrams was compensated for his time in preparing for and participating in media interviews and events surrounding the IBD Icons awareness program.

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For every fan who registers to view Casey’s video, Janssen Biotech, Inc. will donate $1, up to $10,000, to the Crohn’s & Colitis Foundation of America in support of IBD research and education. In addition to Casey’s music video, updates from the 2011 IBD Icons fi nalists and winners on their latest endeavors to raise awareness and inspire others are also featured on www.IBDIcons.com.

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alumnus

669860_25RGU12016_v1a.indd 1 9/13/12 8:46 AM

your waist during the test. you will be able to drink clear liquids and eat a light meal about two hours after the pill has been swallowed. approximately 8 hours later, you will be asked to return to your doctor’s office so the data recorder can be removed and the images downloaded to a computer for physician viewing. the capsule will then be eliminated from your body normally in your feces during a bowel movement.

to date, well over a million endocapsules have been used in clinical practice and demonstrated the overall safety of this technology. Complications are extremely rare, especially when performed by specialists who have extensive experience with the endocapsule. Wireless capsule endoscopy is a safe, reliable, and noninvasive technology that can be very useful in the diagnosis and treatment of disorders of the esophagus and small intestine. If you are interested in this exam or think that it may be beneficial to your treatment, ask your physician for more information.

Gastro Health


Guillermo Gubbins, MD Gastroenterologist

dEalinG with Gas and Bloating

Functional gastrointestinal disorders such as Irritable Bowel Syndrome (IBS) are very common, ranking second in the causes of absence from work or

school. Bloating is one of the most common manifestations of IBS, caused by distension of the gut lumen by gas leading to pain, the sensation of bloating and visible abdominal distension. The amount of gas in your gut depends on the amount of air you swallow and bacterial production in the distal small and proximal large bowel. Increased production can be the result of bacterial digestion of carbohydrates incompletely digested by enzymes in the intestines allowing bacteria to digest them, as occurs with lactose intolerance. However, most people who complain of excessive gas and bloating do not produce more gas than the average person – they are just more aware of it because of increased sensitivity to gas, one of the hallmarks of IBS.

If you eat too fast, gulp liquids, drink lots of carbonated beverages, chew gum, smoke or swallow saliva constantly, you can end up swallowing too much air. Fortunately, most swallowed air can be eliminated when sitting up by belching.

Eating peppermint, chocolate and fats relax the lower esophageal sphincter and may help. However, if lying down some of the gas tends to pass into the intestine which can cause excessive passage of gas. This swallowed air is mainly nitrogen together with the byproducts of the digestion of carbohydrates by the intestinal flora like carbon dioxide, hydrogen and methane, which are odorless. Traces of sulfur compounds are responsible for the occasional unpleasant odor.

Most people with gas and bloating do not need to have any testing unless there are alarm symptoms such as diarrhea, weight loss, abdominal pain, anemia, blood in the stool, lack of appetite, fever or vomiting. If this is the case you should see a gastroenterologist to get further testing such as a blood test for celiac disease, a hydrogen breath test for lactose and/or fructose intolerance or even an endoscopic evaluation

of your gastrointestinal tract. Restrictions of dietary components that can lead to luminal distension, due to poor proximal absorption and subsequent fermentation by bacteria more distally in the intestines, form the basis of the low FODMAP diet approach to the management of functional gastrointestinal symptoms.

Food lists are available emphasizing suitable alternatives, and the best outcomes are achieved in a one-to-one setting with a dietitian. Although there are no controlled studies supporting efficacy, several OTC medications are available to help reduce bothersome gas such as simethicone (which breaks up bubbles), activated charcoal (adsorbent), Beano (breaks down complex carbohydrates) and bismuth (reduce odor).

FODMAPstands for: FerMentAble OligOsAcchAriDes (fructans and galactans) DisAcchAriDe (laCTose) MOnOsAcchAriDe (fruCTose) AnD POlyOls (sorbiTol)

‘‘Most people with gas and bloating do not need to have any testing unless there are

alarm symptoms.”

‘‘The amount of gas in your gut depends on the amount of air you swallow and bacterial production in the distal small and proximal large bowel.’’


Gastro Health

excess fructose lactose fructans galactans polyols

Eliminate foods containing fodmaps

fruitapple, apricot, avocado, blackberry, cherry, lychee, nashi, nectarine, peach, pear, plum, prune, watermelon

vegetablescauliflower, green capsicum (bell pepper), mushroom, sweet corn

sweetenerssorbitol (420)mannitol (421) isomalt (953)maltitol (965) xylitol (967)

legumesbaked beans, chickpeas, kidney beans,lentils

vegetablesasparagus, beetroot, broccoli, brussels sprouts, cabbage, eggplant, fennel, garlic, leek, okra, onion (all), shallots, spring onion

cerealswheat and rye, in large amounts eg. bread, crackers, cookies, couscous, pasta

fruitcustard apple, persimmon, watermelon

miscellaneouschicory, dandelion, inulin

fruitapple, mango, nashi, pear, tinned fruit in natural juice, watermelon

sweetenersfructose, high fructose corn syrup

large total fructose doseconcentrated fruit sources, large serves of fruit, dried fruit, fruit juice

honeycorn syrup, fruisana

milkmilk from cows, goats or sheep, custard, ice cream, yoghurt

cheesessoft unripened cheeseseg. cottage, cream, mascarpone, ricotta

fruit vegetables milk products other

fruitbanana, blueberry, boysenberry, canteloupe, cranberry, durian, grape, grapefruit, honeydew melon, kiwifruit, lemon, lime, mandarin, orange, passionfruit, pawpaw, raspberry, rhubarb, rockmelon, star anise, strawberry, tangelo

vegetablesalfalfa, artichoke, bamboo shoots, bean shoots, bok choy, carrot, celery, choko, choy sum, endive, ginger, green beans, lettuce, olives, parsnip, potato, pumpkin, red capsicum (bell pepper), silver beet, spinach, summer squash (yellow), swede, sweet potato, taro, tomato, turnip, yam, zucchini

herbsbasil, chili, coriander, ginger, lemongrass, marjoram, mint, oregano, parsley, rosemary, thyme

milklactose-free milk, oat milk*, rice milk, soy milk*

cheeseshard cheeses, and brie and camembert

yoghurtlactose-free varieties

ice-cream substitutesgelati, sorbet

butter substitutesolive oil

grain foods

cerealsgluten-free bread or cereal products

bread100% spelt bread

rice

oats

polenta

otherarrowroot, millet, psyllium, quinoa, sorgum, tapioca

sweetenerssugar* (sucrose), glucose, artificial sweeteners not ending in ‘-ol’

honey substitutesgolden syrup*, maple syrup*, molasses, treacle

Foods suitable on a low-fodmap diet

*small quantities

*check for additives

Note: if fruit is dried, eat in small quantities

Guillermo Gubbins, MD Gastroenterologist

You're 50...Happy Birthday!

It's time for your first colon cancer screening

www.gastrohealth.com


Gastro Health

What Endangers Colon Health?Sedentary Lifestyle A sedentary lifestyle promotes colon cancer. Sedentary activities include things like:• Watching television• Sitting at a desk• Surfing the web Learn ways to be less sedentary:• Try to be more active during your leisure time. Find new

activities that include at least some exercise – directly or indirectly.

• Do active housework.• When it’s safe, park farther away from your destination and

walk.• Take the stairs instead of an elevator or escalator.• Go for a walk or jog during your lunch break. No time during

lunch? Go after work instead!

AlcoholAlcohol destroys folic acid, which is a key to good health. Consider supplementing your diet with 400 mcg of folic acid per day if you do not plan to give up alcohol.

Limit alcohol consumption to no more than:• 1 drink per day (women)• 2 drinks per day (men)

Excess CaloriesExcess calories usually come from energy-dense foods. These foods are usually:• Low in fiber• High in fat• High in sugar

Too Many Refined CarbohydratesChronic elevations of insulin and insulin growth factors (IGF) increase your colon cancer risk. • Eating high-sugar, refined-carbohydrate foods triggers

excessive insulin and IGF production, which can increase the growth of cancer cells in the colon.

• High-sugar, refined-carbohydrate foods include foods made with sugars and white flour. Replace these with fruits, vegetables or whole grain foods.

Red and Processed MeatsRed and processed meats contain elements that can increase your risk of colon cancer.• Eat no more than 3 ounces of beef, pork or lamb per day.

Choose chicken, legumes and fish more often.• Limit your consumption of processed meats like hot dogs,

bacon, sausage and deli meats.

Grill smart! Cancer-causing compounds are produced when meats are cooked at very high temperatures. Grill vegetables, tofu and fruit instead.If you choose to grill meat:• Use marinades• Flip frequently• Remove fat• Use foil and avoid direct flame• Do not eat charred meat

Prevent Colon Cancer!• Stay active.• Maintain a healthy weight. It is better to be pair shaped than

apple-shaped.• Eat a low-fat, high-fiber, plant-based diet.• Follow MyPlate’s advice and fill half your plate with fruits

and vegetables every day.• Get enough folate and vitamin D in your diet.• Avoid eating too much meat and meat cooked at high

temperatures. Try plant protein foods instead.• Avoid excess alcohol consumption.

For more information, check out www.preventcancer.orgCopyright 2012. Food and Health Communications. Reprinted with permission from www.foodandhealth.com

Gastro Health


A major health issue facing our country today is a silent and deadly liver disease called hepatitis C. Up to 5 million Americans have hepatitis C – four times the amount of people with HIV – and it is the leading cause of liver cancer and the

most common reason for liver transplantation in the United States. What’s more surprising is that 75 percent of people with hepatitis C don’t know they have it.

Hepatitis C is sometimes called a “silent killer” because it often has no symptoms and can go decades without being detected. In the meantime, serious liver damage or even liver cancer may occur.

Recent studies from the Centers for Disease Control (CDC) have reported that deaths from hepatitis C are on the rise. In 2007, there were 15,000 deaths in the United States from hepatitis C, surpassing the 13,000 deaths from AIDS in the same year.

People born from 1945 through 1965 have a greater prevalence of hepatitis C than the general population. In fact, 82 percent of people with the disease are baby boomers, and 75 percent of the deaths from hepatitis C occur in this group.

Those at increased risk for hepatitis C include people who had blood transfusions before 1992, people with tattoos, people who used intravenous drugs – even once – and those who work in a healthcare setting. Certain populations, including African Americans and Hispanics, are also affected by hepatitis C at a significantly higher rate than the general population.

But there is good news. For many patients, hepatitis C can be cured, unlike other chronic diseases such as hepatitis B and AIDS.

Screening for hepatitis C is not currently part of routine testing; you may think you have been tested, but chances are you haven’t. The CDC is considering whether all baby boomers should have a simple, one-time blood test to check if they have been exposed to hepatitis C. According to a CDC-sponsored study, such age-based screening could identify more than 800,000 additional cases of chronic hepatitis C infection and, when followed by treatment, could reduce the number of deaths by 121,000.

In the meantime, if you are a baby boomer or have any risk factors, make sure to ask your doctor for a simple blood test to screen for hepatitis C at your next appointment.

For more information on hepatitis C, visit www.BetterToKnowC.com.

Are You at Risk for Hepatitis C?how to Catch this silent Killer

Before It Is too late

PHYSICIANDIRECTORYGastro Health is a medical group made up of the finest physicians and allied health professionals in South Florida specializing in the treatment of gastrointestinal disorders, nutrition, and digestive health.

Our team of board-certified physicians, physician assistants, nurse practitioners, nutritionists and technicians combine their clinical expertise and experience to provide patients with quality medical and preventive care in the field of Gastroenterology.

With numerous office locations, endoscopy centers, diagnostic imaging, pathology laboratory, in-office infusion therapy, and affiliations with South Florida’s premier hospitals – Gastro Health continues to achieve excellence in medical care.

Gastro Health

18 :: GASTRO HEALTH MAGAZINE • FALL 201218 ::

Jose A. Lavergne, MD *Gastroenterologist Care Center 7

Pedro J. Greer Jr., MD *Gastroenterologist Care Center 11

James S. Leavitt, MDGastroenterologist Care Center 1

Alfredo J. Hernandez, MD *Gastroenterologist Care Center 11

Marc Lederhandler, MDGastroenterologist Care Center 1

PHYSICIAN DIRECTORY

Francisco J. Baigorri, MD *Gastroenterologist Care Center 1

Marc S. Carp, MDGastroenterologist Care Center 6

Jose P. Ferrer, Sr., MD *Gastroenterologist Care Center 3

Simon Behar, MD *Gastroenterologist Care Center 3

John P. Christie, MDColorectal Surgeon Care Center 1

Nelson Garcia Jr. MD *Gastroenterologist Care Center 8

Guillermo Gubbins, MD * Gastroenterologist Care Center 10

Lewis R. Felder, MDGastroenterologist Care Center 7

Daniel Gelrud, MD *Gastroenterologist Care Center 1

Gustavo Calleja, MD *Gastroenterologist Care Center 1

Jose P. Ferrer, Jr., MD *Gastroenterologist Care Center 3

Harris I. Goldberg, MDGastroenterologist Care Center 1

Eugenio J. Hernandez, MD *Gastroenterologist Care Center 3

Barry E. Brand, MDGastroenterologist Care Center 2

* Habla Español

Moises E. Hernandez, MD *Gastroenterologist Care Center 3

Richard E. Hernandez, MD *Gastroenterologist Care Center 5

Eduardo Krajewski, MD *Colorectal SurgeonCare Center 9

Robert C. Lanoff, MD *Gastroenterologist Care Center 2

Jerry Martel, MD, MPH *Gastroenterologist Care Center 8


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Flavia Mendes, MD *Gastroenterologist Care Center 1

Alfredo Rabassa, MD *Gastroenterologist Care Center 1

Eduardo Ruan, MD *Gastroenterologist Care Center 1

Pedro Morales, MD *Gastroenterologist Care Center 8

Ricardo J. Roman, MD *Gastroenterologist Care Center 7

Andrew I. Sable, MDGastroenterologist Care Center 2

Brett R. Neustater, MDGastroenterologist Care Center 7

Seth D. Rosen, MDGastroenterologist Care Center 2

* Habla Español

Gastro Health

S. Lawrence Rothman, MDGastroenterologist Care Center 1

Arie Slomianski, MD *Gastroenterologist Care Center 1

David A. Sommer, MDGastroenterologist Care Center 2

Howard I. Schwartz, MDGastroenterologist Care Center 1

Javier L. Parra, MD *Gastroenterologist Care Center 1

Neil E. Rosenkranz, MDGastroenterologist Care Center 2

Marcos Szomstein, MD *Colorectal SurgeonCare Center 9

Andres I. Roig, MD *GastroenterologistCare Center 3

Somal S. Shah, MD *GastroenterologistCare Center 11

Daniel Seckinger, MDRadiologist Imaging Medical Director

Stefania L. Vernace, MDGastroenterologistCare Center 1

George A. Sanchez, MD * GastroenterologistCare Center 1

Antonio Martinez, MDPathologist Pathology Medical Director

Gastro Health


Darlene Boytell-Perez, ARNP * Rebecca Karousatos, MS, RD, LDN

Kayce Tugg, MSN, RNRonal R. Ricano, PA Hengameh Shahidpoor, ARNP

Ellen Matas-Sosa, PA-CAmber M. Abraham, PA-C

Rachael Robinson, RN

Sabrina Kaplan, PA-C*

Hernando Mispireta, ARNP *

All ied Healthcare Staff

Care Centers Insurances

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AARP Medicare CompleteAetnaAmerican Heritage Life InsuranceAmerican Medical SecurityAvMedBaptist Executive HealthBeechstreetBlue Cross Blue ShieldCignaCoventry Health CareDimensions HealthFirst Health NetworkHumanaHumana Champus TricareMail Handlers Benefit PlansMedica Health PlanMedicare Part BMultiPlanNeighborhood Health PlanOneSourcePreferred Care PartnersUnited HealthcareVISTA Health Plans

Care Center 1 Main Office7500 SW 87 Avenue, Suite 200Miami, FL 33173305-913-0666

Care Center 1 Satellite Office6141 Sunset Drive, Suite 301Miami, FL 33143305-913-0666

Care Center 29555 N. Kendall Drive, Suite 100Miami, FL 33176305-273-7319

Care Center 38950 N. Kendall Drive, Suite 306-WMiami, FL 33176305-596-9966

Care Center 415955 SW 96 Street, Suite 205 Miami, FL 33196 305-468-4191

Care Center 57765 SW 87 Avenue, Suite 105Miami, FL 33173305-274-0808

Care Center 61400 NE Miami Gardens Drive; Suite 221North Miami Beach, FL 33179305-949-2020

Care Center 7 Main Office16855 NE 2nd Avenue, Suite 202North Miami Beach, FL 33162305-770-0062

Care Center 7 Satellite Office #15803 NW 151 Street, Suite 105Miami Lakes, FL 33014305-770-0062

Care Center 7 Satellite Office #221110 Biscayne Boulevard, Suite 206Aventura, FL 33180305-770-0062

Care Center 88200 SW 117 Avenue, Suite 110Miami, FL 33183305-274-5500

Care Center 9 7765 SW 87 Avenue, Suite 212Miami, FL 33173305-596-3080

Care Center 101150 Campo Sano Avenue, Suite 300 Coral Gables, FL 33146 305-662-6170

Care Center 113661 S. Miami Avenue, Suite 805 Miami, FL 33133 305-856-7333

Imaging Center7500 SW 87 Avenue, Suite 200-AMiami, FL 33173305-468-4190

Infusion Center7500 SW 87 Avenue, Suite 200-AMiami, FL 33173305-913-0660

Pathology Laboratory9000 SW 87 Court, Suite 110Miami, FL 33176305-468-4194


Gastro Health

INvEStIgAtIvE OvErvIEw:GASTROPARESIS

Gastroparesis can be literally translated to mean “stomach paralysis.” In this disorder, there is an abnormal or absent motility of the stomach. This is a common disorder which is most frequently associated with diabetes. However, in

approximately 50% of individuals, other factors may play a precipitating role. For example, underlying medical conditions such as scleroderma and hypothyroidism may be associated with decreased gastric motility. Also, common neuromuscular disorders such as Parkinson’s disease and spinal cord injuries may be associated with gastroparesis. A thorough review of all medication is important given that many medications may lead to decreased gastric and intestinal motility. For example, narcotics, certain anti-hypertensive medications (such as diltiazem and verapamil), hormones (progesterone), and levodopa (used for Parkinson’s disease) have all been associated with decreased gastric motility.

SymptomsSymptoms of gastroparesis include bloating, nausea, and early fullness particularly with the ingestion of fatty meals and high-fiber foods such as raw fruits and vegetables. Many individuals also experience accompanying upper abdominal pain and reflux symptoms. Vomiting of undigested foods several hours after their ingestion is highly suggestive of underlying gastroparesis. Some individuals may eventually experience weight loss due to malabsorption of nutrients or diminished food intake from their underlying symptoms.

DiagnosisDue to the fact that the symptoms of gastroparesis are often associated with other upper digestive tract disorders, endoscopic (upper endoscopy) and/or radiologic tests (upper GI series) are often ordered to exclude alternate diagnoses. However, the most commonly ordered exam used to diagnose gastroparesis is a gastric emptying scan. During this exam, which is performed in a nuclear medicine department, a standard meal (usually consisting of an egg substitute) mixed with a small amount of radioactive material is ingested. The emptying of this meal from the stomach over a 4-hour period is determined. The amount of time required for the patient’s gastric emptying is then compared to control population. Of interest, new technologies such as a wireless capsule (SmartPill®) are being used to measure gastric emptying through the use of different information including: pH, temperature and pressure changes.

Treatment Diet remains one of the mainstays of treatment for gastroparesis regardless of its cause. In general, individuals with gastroparesis should avoid fatty foods and fibrous foods (raw fruits and vegetables) which take a longer time to digest. Also, rather than eating three meals a day, affected persons should eat smaller, more frequent meals. Diabetics must maintain adequate control of their blood glucose whose elevation may lead to a decrease in gastric emptying. Currently, there are three medications that can be used to treat gastroparesis: metoclopramide, domperidone and erythromycin.

METOCLOPRAMIDE stimulates gastric contraction and also possesses anti-nausea effects. However, it has been linked to severe side-effects including a possibly irreversible facial twitching called tardive dyskinesia. For this reason, its long-term use is minimized or limited.

DOMPERIDONE is similar to metoclopramide, but is not associated with neurologic side-effects due to the fact that it does not act on receptors in the brain. Unfortunately, it is not readily available in the United States, but can be found in South America, Canada, and Europe. ERYTHROMYCIN is a commonly used antibiotic that binds receptors in the stomach call motilin receptors. Stimulation of these receptors leads to gastric contraction and improved gastric emptying. However, erythromycin is only effective for brief periods of time.

Lastly, Iberogast is a liquid herbal supplement that has been used in Europe for over 4 decades and has been shown to improve gastric motility is small studies. Rarely, individuals may need to consider invasive procedures such as a gastric pacemaker that has been shown in some studies to improve the symptoms. In summary, gastroparesis is a common condition leading to altered gastric motility. Although diabetes is its most common cause, other contributing causes should not be excluded. Diet and various medications often lead to marked symptomatic improvement.

Nelson Garcia, MDGastroenterologist

Gastro Health


Important Safety Information About CIMZIA® (certolizumab pegol)

To lessen signs and symptoms of moderate to severe Crohn’s Disease in adults not helped enough by usual treatments.

What is the most important information I should know about CIMZIA?CIMZIA is a prescription medicine that affects your immune system. CIMZIA can lower the ability of the immune system to fight infections. Serious infections have happened in patients taking CIMZIA, including tuberculosis (TB) and infections caused by viruses, fungi, or bacteria that have spread throughout the body. Some patients have died from these infections. Your doctor should test you for TB before starting CIMZIA. Your doctor should monitor you closely for signs and symptoms of TB during your treatment with CIMZIA.Certain Types of CancerThere have been cases of unusual cancers in children and teenage patients using TNF-blocking agents. CIMZIA is not approved for use in pediatric patients. For people taking TNF-blocker medicines, including CIMZIA, the chances for getting lymphoma or other cancers may increase. People with RA, especially more serious RA, may have a higher chance for getting a kind of cancer called lymphoma.Before starting CIMZIA, tell your doctor if you:• Think you have an infection. You should not start taking

CIMZIA if you have any kind of infection, are being treated for an infection or have signs of an infection such as fever, cough or flu-like symptoms or if you get a lot of infections or have infections that keep coming back.

• Have any open cuts or sores• Have diabetes or HIV• Have TB, or have been in close contact with someone with TB• Were born in, lived in, or traveled to countries where

there is more risk of getting TB. Ask your doctor if you are not sure.

• Live or lived in certain parts of the country (such as the Ohio and Mississippi River valleys) where there is an increased risk for getting certain kinds of fungal infections (histoplasmosis, coccidioidomycosis, blastomycosis). These infections may develop or become severe if you take CIMZIA. If you do not know if you have lived in these types of areas, ask your doctor.

• Have or have had hepatitis B• Have or have had any type of cancer • Have congestive heart failure• Have seizures, any numbness or tingling, or a disease

that affects your nervous system such as multiple sclerosis• Are scheduled to receive a vaccine. Do not receive a live

vaccine while taking CIMZIA• Are pregnant, planning to become pregnant, or

breastfeeding. CIMZIA has not been studied in pregnant or nursing women.

• Especially tell your doctor if you take: Kineret® (anakinra), Orencia® (abatacept), Rituxan® (rituximab), Tysabri® (natalizumab), or another TNF blocker. You have a higher chance for serious infections when taking CIMZIA with these medicines. You should not take CIMZIA while you take one of these medicines.

After starting CIMZIA, if you get an infection, any sign of an infection including a fever, cough, flu-like symptoms, or have open cuts or sores on your body, call your doctor right away. CIMZIA can make you more likely to get infections or make any infection that you may have worse. Patients 65 years of age or older, patients with other long term medical conditions, or taking certain other drugs that affect the immune system, such as corticosteroids or methotrexate, may be at a greater risk of infection.What are the possible side effects of CIMZIA? CIMZIA can cause serious side effects, including:Heart Failure including new heart failure or worsening of heart failure you already have; Nervous System Problems such as Multiple Sclerosis, seizures, or inflammation of the nerves of the eyes; Allergic Reactions. Signs of an allergic reaction include a skin rash, swollen face, or trouble breathing; Hepatitis B virus reactivation in patients who carry the virus in their blood. In some cases, patients have died as a result of hepatitis B virus being reactivated. Your doctor should monitor you carefully during treatment with CIMZIA if you carry the hepatitis B virus in your blood; Blood Problems. Your body may not make enough of the blood cells that help fight infections or help stop bleeding; Immune reactions including a lupus-like syndrome. Symptoms include shortness of breath, joint pain, or a rash on the cheeks or arms that worsens with sun exposure.Call your doctor right away if you develop any of the above side effects or symptoms.The most common side effects of CIMZIA are: upper respiratory infections (flu, cold), rash, and urinary tract infections (bladder infections).Other side effects have happened in some people including new psoriasis or worsening of psoriasis you already have and injection site reactions. You are encouraged to report negative side effects to FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.OXO, Good Grips® and the associated logos are registered trademarks of Helen of Troy Limited and are used under license.© 2012 UCB, Inc. All rights reserved. CCD224-0712C

Please see Brief Summary on following pages.

Prefilled syringe designed for comfort and control in partnership with

Gastro Health (Oct - Dec)

Visit cimzia.com/CDCall 1-877-55CIMZIA

• CIMZIA is not a steroid; it is a prescription biologic treatment that is injected.• CIMZIA can be injected at home or at your doctor’s office every 4 weeks after initial dosing.• CIMZIA is indicated to lessen signs and symptoms of moderate to severe Crohn’s disease

in adults not helped enough by usual treatments.

Ask your doctor if CimziA may be right for you. Please read important Safety information on the adjacent page.

In a clinical trial, more patients who responded and continued on CIMZIA versus placebo showed noticeable improvement in signs and symptoms of moderate to severe Crohn’s disease at 26 weeks. Your results may vary.

Cimzia. Noticeable Crohn’s symptom relief.


Cimzia. Noticeable Crohn’s symptom relief

Can you trust your gut?

Gastro Health


Product developed and manufactured for:UCB, Inc., 1950 Lake Park Drive, Smyrna, GA 30080 U.S. License No 1736

Cimzia® is a registered trademark of the UCB Group of companies. © 2011 UCB, Inc., Smyrna, GA 30080 All rights reserved.

Printed in the U.S.A. CCD123-0911

Consumer Brief Summary for Cimzia® (certolizumab pegol)CONSULT PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION.Read the Medication Guide that comes with CIMZIA before you start using it, and before each injection of CIMZIA. This brief summary does not take the place of talking with your doctor about your medical condition or treatment.What is the most important information I should know about CIMZIA?CIMZIA is a medicine that affects your immune system. CIMZIA can lower the ability of the immune system to fight infections. Serious infections have happened in patients taking CIMZIA. These infections include tuberculosis (TB) and infections caused by viruses, fungi or bacteria that have spread throughout the body. Some patients have died from these infections.• Your doctor should test you for TB before starting CIMZIA.• Your doctor should monitor you closely for signs and symptoms of TB during treatment

with CIMZIA.Before starting CIMZIA, tell your doctor if you:• think you have an infection. You should not start taking CIMZIA if you have any kind

of infection.• are being treated for an infection• have signs of an infection, such as a fever, cough, flu-like symptoms• have any open cuts or sores on your body• get a lot of infections or have infections that keep coming back• have diabetes• have HIV• have tuberculosis (TB), or have been in close contact with someone with TB• were born in, lived in, or traveled to countries where there is more risk for getting TB.

Ask your doctor if you are not sure.• live or have lived in certain parts of the country (such as the Ohio and Mississippi River

valleys) where there is an increased risk for getting certain kinds of fungal infections (histoplasmosis, coccidioidomycosis, or blastomycosis). These infections may develop or become more severe if you take CIMZIA. If you do not know if you have lived in an area where histoplasmosis, coccidioidomycosis, or blastomycosis is common, ask your doctor.

• have or have had hepatitis B• use the medicine Kineret® (anakinra), Orencia® (abatacept), Rituxan® (rituximab), or

Tysabri® (natalizumab)After starting CIMZIA, if you get an infection, any sign of an infection including a fever, cough, flu-like symptoms, or have open cuts or sores on your body, call your doctor right away. CIMZIA can make you more likely to get infections or make any infection that you may have worse. Patients 65 years of age or older, patients with other long term medical conditions, or taking certain other drugs that affect the immune system, such as corticosteroids or methotrexate, may be at a greater risk of infection.Certain types of Cancer• There have been cases of unusual cancers in children and teenage patients using

TNF-blocking agents.• For people taking TNF-blocker medicines, including CIMZIA, the chances of getting

lymphoma or other cancers may increase.• People with RA, especially more serious RA, may have a higher chance of getting a

kind of cancer called lymphoma.See the section “What are the possible side effects of CIMZIA?” for more information.What is CIMZIA?CIMZIA is a medicine called a Tumor Necrosis Factor (TNF) blocker. CIMZIA is used in adult patients to:• Lessen the signs and symptoms of moderately to severely active Crohn’s disease (CD)

in adults who have not been helped enough by usual treatments.• Treat moderately to severely active rheumatoid arthritis (RA).It is not known whether CIMZIA is safe and effective in children.What should I tell my doctor before starting treatment with CIMZIA?CIMZIA may not be right for you. Before starting CIMZIA, tell your doctor about all of your medical conditions, including if you:• have an infection. (See, “What is the most important information I should know

about CIMZIA?”)• have or have had any type of cancer• have congestive heart failure• have seizures, any numbness or tingling, or a disease that affects your

nervous system such as multiple sclerosis• are scheduled to receive a vaccine. Do not receive a live vaccine while taking

CIMZIA.• are allergic to any of the ingredients in CIMZIA. See the end of this Brief

Summary for a list of the ingredients in CIMZIA.Tell your doctor if you are pregnant, planning to become pregnant, or breastfeeding. CIMZIA has not been studied in pregnant or nursing women.Tell your doctor about all the medicines you take including prescription and nonprescription medicines, vitamins and herbal supplements. Your doctor will tell you if it is okay to take your other medicines while taking CIMZIA. Especially, tell your doctor if you take:• Kineret® (anakinra), Orencia® (abatacept), Rituxan® (rituximab),Tysabri® (natalizumab).

You have a high chance for serious infections when taking CIMZIA with Kineret®,

Orencia®, Rituxan®, or Tysabri®.• A TNF blocker: Remicade® (infliximab), Humira® (adalimumab), Enbrel® (etanercept),

Simponi® (golimumab).You should not take CIMZIA, while you take one of these medicines.How should I use CIMZIA?CIMZIA is available as a lyophilized powder for reconstitution or a prefilled syringe. If your doctor prescribes the lyophilized pack, CIMZIA should be injected by a healthcare provider. If your doctor prescribes the prefilled syringe, see the booklet called “Patient Instructions for Use” packaged in your CIMZIA prefilled syringe kit for complete instructions for use. Do not give yourself an injection of CIMZIA unless you have been shown by your doctor or nurse, or they can train someone you know to help you with your injection. CIMZIA is given by an injection under the skin. Your doctor will tell you how much CIMZIA to inject and how often, based on your condition to be treated. Make sure to keep all of your injection and follow-up appointments with your doctor.What are the possible side effects of CIMZIA?CIMZIA can cause serious side effects including:See “What is the most important information I should know about CIMZIA?”• Heart Failure including new heart failure or worsening of heart failure you already

have. Symptoms include shortness of breath, swelling of your ankles or feet, or sudden weight gain.

• Nervous System Problems such as multiple sclerosis, seizures, or inflammation of the nerves of the eyes. Symptoms include dizziness, numbness or tingling problems with your vision, and weakness in your arms or legs.

• Allergic Reactions. Signs of an allergic reaction include a skin rash, swelling of the face, tongue, lips, or throat, or trouble breathing.

• Hepatitis B virus reactivation in patients who carry the virus in their blood. In some cases patients have died as a result of hepatitis B virus being reactivated. Your doctor should monitor you carefully during treatment with CIMZIA if you carry the hepatitis B virus in your blood. Tell your doctor if you have any of the following symptoms:

• feel unwell • tiredness (fatigue) • poor appetite • fever, skin rash, or joint pain• Blood Problems. Your body may not make enough of the blood cells that help fight

infections or help stop bleeding. Symptoms include a fever that doesn’t go away, bruising or bleeding very easily, or looking very pale.

• Immune reactions including a lupus-like syndrome. Symptoms include shortness of breath, joint pain, or a rash on the cheeks or arms that worsens with sun exposure.

Call your doctor right away if you develop any of the above side effects or symptoms.The most common side effects in people taking CIMZIA are:• upper respiratory infections (flu, cold) • rash• urinary tract infections (bladder infections)Other side effects with CIMZIA include:• Psoriasis. Some people using CIMZIA had new psoriasis or worsening of psoriasis

they already had. Tell your doctor if you develop red scaly patches or raised bumps that are filled with pus. Your doctor may decide to stop your treatment with CIMZIA.

• Injection site reactions. Redness, rash, swelling, itching or bruising can happen in some people. These symptoms will usually go away within a few days. If you have pain, redness, or swelling around the injection site that doesn’t go away within a few days or gets worse, call your doctor right away.

Tell your doctor about any side effect that bothers you or does not go away.These are not all of the side effects with CIMZIA. Ask your doctor or pharmacist for more information.Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.General information about CIMZIAMedicines are sometimes prescribed for purposes that are not mentioned in Medication Guides. Do not use CIMZIA for a condition for which it was not prescribed. Do not give CIMZIA to other people, even if they have the same condition. It may harm them.This brief summary summarizes the most important information about CIMZIA. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about CIMZIA that is written for health professionals.For more information go to www.CIMZIA.com or call 1-866-4CIMZIA (424-6942).Always keep CIMZIA, injection supplies, puncture-proof container, and all other medicines out of the reach of children.What are the ingredients in CIMZIA?CIMZIA lyophilized powder: Active ingredient: certolizumab pegol. Inactive ingredients: sucrose, lactic acid, polysorbate. The pack contains Water for Injection, for reconstitution of the lyophilized powder. CIMZIA prefilled syringe: Active ingredient: certolizumab pegol. Inactive ingredients: sodium acetate, sodium chloride, and Water for Injection. CIMZIA has no preservatives.

CIMZIA_BriefSummary.indd 1 9/30/11 11:20 AMGastro Health (Oct - Dec)

Get up to 12 months of CIMZIA with

no out-of-pocket costs.*

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BIN: 004682

PCN: CN

GRP: ECXXXXXXX

ID #: XXXXXXXPlease see back for complete eligibility rules.

Please see accompanying complete Prescribing Information.

co-pay savings card

Please see Brief Summary on previous page.*Subject to eligibility. Restrictions may apply. In 2011,

96.8% of CIMZIA Co-Pay Savings Card users paid no out-of-pocket costs.

To lessen signs and symptoms of moderate to severe Crohn’s disease in adults not helped enough by

usual treatments.

Serious infections have happened in patients taking CIMZIA, including tuberculosis (TB) and infections

caused by viruses, fungi, or bacteria that have spread throughout the body. Some patients have died

from these infections.

Go to cimzia.com/CD

Crohn’s relief with all year co-pay savings



Gastro Health

Get up to 12 months of CIMZIA with

no out-of-pocket costs.*

Save on your CIMZIA® prescription

BIN: 004682

PCN: CN

GRP: ECXXXXXXX

ID #: XXXXXXXPlease see back for complete eligibility rules.

Please see accompanying complete Prescribing Information.

co-pay savings card

Please see Brief Summary on previous page.*Subject to eligibility. Restrictions may apply. In 2011,

96.8% of CIMZIA Co-Pay Savings Card users paid no out-of-pocket costs.

To lessen signs and symptoms of moderate to severe Crohn’s disease in adults not helped enough by

usual treatments.

Serious infections have happened in patients taking CIMZIA, including tuberculosis (TB) and infections

caused by viruses, fungi, or bacteria that have spread throughout the body. Some patients have died

from these infections.

Go to cimzia.com/CD

Crohn’s relief with all year co-pay savings


AttentionBaby Boomers S. Lawrence Rothman , MD

Gastroenterologist

In August 2012, the Centers for Disease Control issued new guidelines for screening of the Chronic Hepatitis C infection. The previous guidelines had targeted only persons thought to

be at high risk, such as those who received a blood transfusion prior to 1992, used intravenous illicit drugs, were on hemodialysis, had HIV disease, known exposure to the virus, or born to a mother with known hepatitis C. However, now the new recommendations state that any person born between 1945 and 1965 should be screened once, regardless of risk factors.

The new guidelines were adopted for several reasons. Firstly, 75% of those with hepatitis C were born in those years. Also, more than half of people with hepatitis C are unaware that they have it. Complications and deaths from chronic hepatitis C are on the rise. It has been shown that screening is cost-effective and saves lives. Finally, new treatments can cure up to 75% of chronic hepatitis C cases.

Screening involves a simple blood test performed only once. Normal results of so-called liver function blood tests do not rule out hepatitis C. Up to 50% of persons infected can actually have normal results of these tests.

Hepatitis C is a virus that attacks the liver. It is mainly transmitted through contaminated blood. Hepatitis C can be present and actually cause no symptoms for many years, even decades, and has therefore been called the “silent epidemic.” Up to 20% of those infected will develop severe scarring and liver impairment known as cirrhosis of the liver and a significant percentage of these will develop primary liver cancer. Chronic hepatitis C is the most common indication for liver transplantation in the United States. It is the cause of up to 15,000 yearly deaths, with the number expected to rise. So, if you were born between 1945 and 1965 and wish to be screened, please call a screening hotline or be sure to set up an appointment with Gastro Health by calling (305)468-4180.

CDC issues new guidelines for Hepatitis C screening for the ”Boomer” Generation (1945-1965)

Gastro Health


Raghad Koutouby , MD Pediatric Gastroenterologist

I t is never easy to learn that you have a chronic illness, especially as a child. It can make them feel afraid, sad, nervous, or just “different.”

Children with Inflammatory Bowel Disease (IBD) face the challenge of an unpredictable and potentially embarrassing disease. They may be embarrassed about their symptoms or frequent visits to the bathroom, and they may fear being the target of the “bathroom humor” that is popular amongst children. In addition to the embarrassing symptoms, short stature and delayed puberty, simply having a chronic illness may contribute to feeling “different” from peers.

Participation in school and social activities may be adversely affected. IBD clearly has the potential to impact psychosocial functioning. Children with IBD appear to be at risk for more difficulties in psychosocial functioning than healthy children, although the problem reaches clinical significance in only a subset.

The difficulty experienced by children with IBD is generally similar to that experienced in other chronic health conditions. In the area of behavioral/emotional functioning, mood and anxiety disorders are most common.

Children with IBD are at increased risk for problems in social functioning, but the nature of their social difficulties is unclear. Mixed results have been found in the areas of family dysfunction and body image, and limited research exists in the areas of stress and coping, self-esteem, and eating problems.

Signs of Difficulty CopingWatch for any of these behaviors, which may indicate that your child is having trouble transitioning to life with IBD:• Difficulty sleeping• Poor eating habits• Persistent sadness, frequent crying• Lack of interest in usual activities and

hobbies

Helping Your Child CopeIf your child seems to be having trouble dealing with his or her IBD, parents and trusted adults can be a great source of comfort and help. Keep the lines of communication open, and be sure to let the child know:• It’s normal to feel sad or anxious about

IBD• With IBD treatment, most kids lead

normal, active lives• It’s important to talk about your feelings

with a parent or a doctor• Anything you share with a doctor is

confidential and private—he or she can’t tell anyone else without your permission

• Kids are different for all kinds of reasons—you’re great the way you are!

myIBDA great resource for children and families to track IBD symptoms is “myIBD”. This free app can be downloaded from the app store for use on a handheld device such as iPod/iPad /iPhones or Android Smartphones.

This app has provided a novel way of empowering young patients and their families to come to terms with the diagnosis of IBD. It enables patient-driven learning by engaging children/teenagers and allowing the contemporaneous symptom monitoring and documentation of adherence to prescribed medication. This application has given young patients and their families the opportunity to preview/review the information given during the face-to-face meeting with their physician. The app includes a feature to monitor disease activity and treatment compliance in real time as well as educational videos and links. This has allowed young patients to take control of their symptom reporting, to generate a clinical summary-PDF prior to follow-up in the IBD clinic and to actively prepare for a transition to adult care.

Coping with IBDGastro HealthPediatric News


Gastro Health

Rebecca Karousatos, MS, RD, LDN

Gluten-Free Corner Gluten-free dining can be enjoyable, healthy and nutritious. More restaurants and food companies are becoming in tune with the special dietary needs of the Celiac Disease population. Here, you will see a list of some restaurants that provide a “gluten-free” menu; be sure to let your server know that you have a food allergy to wheat, barley, rye and malt. Also included is a healthy gluten-free grocery list.

There are several resources out there to further guide your dietary needs, including the highly-recommend-ed book “Gluten-Free Diet” by Shelley Case, RD.

Enjoy and healthy dining!

glutEN-FrEE FrIENdlY rEStAurANtS

glutEN-FrEE grOCErY lISt

• Romano’sMacaroniGrill–variouslocations• BJ’sBrewhouse–TheFallsShoppingCenter• P.F.Chang’s–variouslocations• Fleming’s–CoralGables• CaliforniaPizzaKitchen–CoralGables• YardHouse–CoralGables• OutbackSteakhouse–variouslocations• Carino’s–Doral

BReaD/GRainS• corntortillas• ricecrackers• gluten-freecereal• buckwheat• quinoa• rice• flax

FROzen• vegetables• fruits• gluten-freeicecreamor

sherbet• gluten-freewaffles• gluten-freefrozen

dinners/pizza

MeaT/PROTein• fish/shellfish• hotdogs• cannedtuna• tofu• poultry• lunchmeat• beef

CanS/JaRS• vegetables• fruits• beans• gluten-freesoup• applesauce• pastasauce• cannedmilk• nutbutters• jamhoney

BeveRaGeS• coffee/tea• gluten-freebeer• juice• water

DaiRY• milk• whippedcream• cheese• sourcream• butter/margarine• eggs• yogurt• gluten-freepudding

SnaCKS• ricecakes• riceorsoycrackers• sunflowerseeds• popcorn• driedfruit• cornchips• Jell-O

COnDiMenTSanDBaKinG• whiteorredwinevinegar• shortening• olive,canola,or

vegetableoil• saladdressing• spices• cornstarch/meal• gluten-freeflour• cocoa• syrup• xanthangum

FRuiT/veGGieS• fruits• vegetables• herbs

• Chipotle–variouslocations• Carrabba’s–variouslocations• YogurtLand–SouthMiami• nakedPizza–CoralGables• RosaMexicano–Brickell• Crave–CoralGables• PizzaFusion–MiamiBeach• Thrive–MiamiBeach

UNITED WE HEAL

PhysiciansMedical Oncology & HematologyFederico Albrecht, MD Frances A. Behrmann, MD Peter L. Citron, MD Fernando I. de Zarraga Jr., MD Steven G. Fein, MD Sara M. Garrido MD, FACPLeonard A. Kalman, MD Paul R. Kaywin, MD Alberto F. Larcada, MD Antonio F. Muina, MDLisa Reale, MDMichael B. Troner, MD Antonio Ucar, MD Siddhartha A. Venkatappa, MDHoward W. Wallach, MD FACPGrace Wang, MD

Radiation OncologyAndre A. Abitbol, MD, FACRO Allie M. Garcia-Serra, MD Alan A. Lewin, MD, FACR, FACPSteven J. Olszewski, MD Maria-Amelia M. Rodrigues, MD

Diagnostic CenterSteven A. Christie, MD

Pediatric OncologyDoured Daghistani, MD

Locations• Baptist Medical Arts Building, Suite 300E, 603E and 905E• South Miami Hospital Medical Arts Building, Suite 601• Baptist Hospital of Miami Radiation Oncology• South Miami Hospital Radiation Oncology• Diagnostic Center, 9035 Sunset Drive, Suite 102

To learn more, visit www.Miamicancer.com or call (305) 595-2141

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QCP™ and the QCP™ logo are trademarks of the American Society of Clinical Oncology, Inc. Used with permission.

cancER doEsn’t dEfinE ME,

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With advanced Medical specialties behind me, so is my cancer.As a cancer survivor, I endured the physical and emotional battle with cancer and won. Every day, my doctors help other cancer patients become survivors by delivering comprehensive, compassionate cancer care. They helped me understand my cancer type and explained the latest therapy options for my disease. They took the time to answer all of my questions. Together, we developed a program to fight my cancer using proven treatments. The care I received helped me beat cancer and get my life back.


Gastro Health

what can remicade Do For You?

So your GI doctor says to you, “I think we should use Remicade to treat your IBD (Inflammatory Bowel Disease). We can set you up to do convenient

in-office infusions.” Your brain suddenly goes into overdrive. You have so many questions! What is Remicade? How is it given? What is an in-office infusion? What are the side effects? Don’t fret. Read on and you will find the answers to all of these questions, and more.

Remicade (Infliximab) is an immunosuppressive prescription drug used to treat autoimmune diseases, such as Crohn’s Disease, Ulcerative Colitis, Rheumatoid Arthritis, Psoriatic Arthritis and Anklylosing Spondylitis. This autoimmune response is caused by too much of a protein called tumor necrosis factor-alpha (TNF-alpha) circulating in the body. High levels of this protein cause the body’s immune system to mistakenly attack and destroy cells in the body.

In the case of Ulcerative Colitis (UC), the attack occurs in the large intestines. In Crohn’s disease, the gastrointestinal tract from the mouth to the anus is assaulted causing inflammation. This can lead to symptoms of diarrhea, abdominal pain and GI bleeding. Remicade blocks the TNF-alpha protein produced by the immune system. This reduces inflammation and puts the Crohn’s and UC into remission. Remicade has been used to treat over 1 million patients with autoimmune diseases and has been studied for over 17 years.vRemicade is given by intravenous (IV) infusion, which means it is administered directly into a vein in the arm or hand. For over 10 years, Gastro Health has been performing safe, efficient and cost effective in-office Remicade infusions.

The Remicade is administered by experienced infusion Registered Nurses who provide not only the treatment and patient education but also act as a patient advocate, helping the patient navigate through the healthcare system.

The infusion takes approximately two hours. The first three infusions (the induction doses) are given within a six-week period. After that, the maintenance infusions are every eight weeks. The physician can alter this schedule depending on the response to treatment. Most patients see symptom improvement after the first three infusions, but some patients see results after the very first infusion.

Upon arriving to the infusion center, the patient will be registered and escorted to the infusion room where there are comfortable lounge chairs. This can be a time to meet other people with a similar diagnosis, support each other and make new friends. A general health assessment will be performed along with the monitoring of vital signs. The dose of Remicade will be calculated by the RN based on the patient’s weight, and then an IV will be started in the hand or arm. The medication will be mixed once the IV has been started, and the IV bag containing the Remicade will be connected and infused via the IV. Vital signs will be monitored throughout the infusion. During the infusion and for a period of time afterwards, the nurse will also closely monitor for signs of any problems.

At the conclusion of the infusion, the IV will be removed from the arm or hand. The patient can schedule the next infusion prior to leaving the infusion center. The infusion is non-sedating,

so once the infusion is complete the patient can enjoy the rest of their day.

Although the commitment to receiving Remicade infusions maybe long-term, most patients are very happy that they have this treatment available to them and have had significant improvement in their quality of life. So if your doctor recommends Remicade infusions, don’t fret – look forward to being taken care of in a supportive environment by your very own patient advocate, an opportunity to meet folks that have the same disease you have and most importantly, look forward to an improved quality of life.

Remicade (Infliximab) is an immunosuppressive prescription drug used to treat autoimmune diseases, such as Crohn’s Disease, Ulcerative Colitis, Rheumatoid Arthritis, Psoriatic Arthritis and Anklylosing Spondylitis.

Kayce Tugg, MSN, RN

Gastro Health Infusion Team From left to right:Karla V. Ruiz-Tamayo, RNKayce Tugg, MSN, RN, AOCNCarmen Carvajal, BSN, RN, CPN

Gastro Health


trEAtINg

HEmORRHOIDs Hemorrhoids are a normal part of the

human anorectal anatomy. They do not constitute a disease unless they become symptomatic. The prevalence

of symptomatic hemorrhoids in the United States is reported to be 4.4%, affecting men and women equally. Hemorrhoid disease accounts for 3.2 million ambulatory care visits, 306,000 hospitalizations and the issue of over 2 million prescriptions a year. Hemorrhoids, when symptomatic, can be treated successfully. Treatment can be divided into four different steps:

Step 1: Dietary and Lifestyle ModificationConstipation is one of the most common causes of symptomatic hemorrhoid disease. Dietary management with increased fiber and water intake is the primary noninvasive mean to treat constipation.• Psyllium is the principal fiber supplement

used in concert with water to add moisture to the stool, ameliorating constipation.

• Other alternative medications include witch hazel, horse chestnut, ginger root, butchers broom, rutin, hesperidin and diosmin – all mainly used in homeopathic medicine.

Step 2: Topical AgentsMost of the creams, ointments and suppositories prescribed for the treatment of symptomatic hemorrhoids contain corticosteroids. They are good for the short-term treatment of the hemorrhoid flare, but its chronic use is discouraged do to the possibility of permanent damage to the perianal skin. They could also promote opportunistic infections such as fungal dermatitis. Some creams are mixed with local anesthetics such as lidocaine and pramoxine, which could give short-term relief. Other alternative medications that are used locally are astringents such as Witch Hazel (Hammamelis Virginiana), Aloe Vera and phenylephrine.

Step 3: In-Office ProceduresThe goal of in-office procedures is to ablate the vessels involved and fix the sliding hemorrhoidal tissue back onto the muscle wall of the anal canal with minimal pain. These procedures include: SCLEROTHERAPy: indicated for grade 1 and 2 internal hemorrhoids. It involves a submucosal injection of a sclerosant at the apex of the hemorrhoid and usually causes thrombosis of the vessels with shrinkage and fixation.

RuBBER BAND LIGATION: the most commonly used in-office procedure, indicated for internal hemorrhoids grades 1, 2 and 3. Ligators deploy a rubber band around a hemorrhoid pedicle. The procedure is usually painless and takes only a few minutes to perform. The ligated tissue usually necroses and sloughs in 3-4 days, causing elimination of the redundant tissue and fixation.

INFRARED COAGuLATION (IRC): produces an infrared light which penetrates the tissue and converts to heat, promoting coagulation of the vessels and fixation. It is usually indicated for small bleeding internal hemorrhoids, grade 1.

ELECTROCOAGuL ATION AND BIPOL AR COAGuLATION: indicated for small bleeding internal hemorrhoids, relies on coagulation and fixation as other techniques. It is somehow less effective and more painful than RBL and IRC.

DIREC T-CuRREN T EL EC T ROT HER A Py (uLTROID): is similarly applied through a probe placed via an anoscope into the mucosa at the apex of the hemorrhoid. It is a lengthy procedure and reapplications to the same site are sometimes required. THROMBECTOMy: usually indicated for the therapy of small thrombosed external hemorrhoids. The procedure usually does not excise the involved hemorrhoid complex, but rather evacuates the blood clot beneath the anal skin, relieving the tension and pain immediately.

Step 4: Surgical treatmentSeveral options and techniques are available for the surgical treatment of symptomatic hemorrhoids. They include: DOPPLER GuIDED HEMORRHOIDAL ARTERy LIGATION: using a Doppler transducer, the hemorrhoidal arteries are identified and ligated. It causes less pain than a traditional surgical hemorrhoidectomy, but sometimes, the large prolapse of grade 4 internal hemorrhoids or the prolapsing of large external hemorrhoids are difficult to address.

ExCISIONAL HEMORRHOIDECTOMy: several techniques exist to excise the hemorrhoid tissue, including: the closed or Ferguson, the open or Milligan-Morgan, the Nd-YAG laser, and the use of energy instruments such as the Harmonic Scalpel and Ligasure. Postoperative pain and prolonged healing time are some main disadvantage. Long-term results are usually excellent.

STAPLED HEMORRHOIDECTOMy: also known as PPH (procedure for prolapsed hemorrhoids), thought to decrease the amount of postoperative pain. A portion of the rectal mucosa and submucosa close to the apex of the hemorrhoid pedicle is excised and stapled again. The hemorrhoids are re-suspended and brought back into the anal canal. A major drawback of this technique is that the procedure does not treat the large external hemorrhoids and associated tags sometimes present. The use of PPH is limited to patients with large grade 3 and 4 internal hemorrhoids

Eduardo Krajewski, MDColorectal Surgeon

Web site: www.salix.com 8510 Colonnade Center Drive, Raleigh, NC 27615 Tel • 866.669.SLXP (7597) ©2012 Salix Pharmaceuticals, Inc. All rights reserved. Printed in USA. SAL 11/93

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