GERD Alarm Symptoms astroesophageal reflux disease a one-time EGD for screening. Risk of erosive esophagitis decreases G(GERD) is a common problem for factors for Barrett’s esophagus include the sensitivity of histopathology which patients seek care from a broad male gender, Caucasian race, obesity to reliably diagnosis concomitant GASTROENTEROLOGY array of primary care providers, medical (particularly abdominal concentration Barrett’s esophagus. Indeed, in 847 NE 19th Ave., Suite 300 subspecialists, and surgeons. It is of fat), age over 50, chronic GERD patients diagnosed with severe erosive Portland, OR 97232 estimated that 10-20 percent of people (symptoms for greater than 5 years), esophagitis who underwent repeat in Western countries have GERD, when smoking, and a family history of EGD eight weeks later, 12 percent had defined as heartburn or regurgitation at Barrett’s esophagus or esophageal Barrett’s esophagus detected after the least once a week. adenocarcinoma. erosive esophagitis had healed.

In the United States alone, GERD In 50 percent of patients with reflux accounts for over 4.5 million outpatient GERD accounts for over symptoms, the EGD is endoscopically visits annually. The majority of normal. The differential diagnosis in this these patients do not need anything circumstance can begin to broaden and more than a detailed history and 4.5 million include diagnoses such as non-erosive physical exam followed by a trial of reflux disease, esophageal dysmotility, Refer Your Patients - Your Way: anti-secretory medication, lifestyle outpatient visits annually eosinophilic esophagitis, and functional Save time and refer your patients online at modification counseling, and heartburn. At this point in the work up, oregonclinic.com/refer. appropriate clinical follow up. It is the Based on the most recent practice additional diagnostic tools that can help minority of GERD patients whom I will guidelines published in 2015 by the the clinician hone in on the diagnosis Visit oregonclinic.com to find a physician, office focus on in the remainder of this article. American Society of Gastrointestinal include esophageal manometry and 24- Endoscopy (ASGE), the routine use of hour ambulatory pH and multi-channel location and more. The clinician must distinguish between EGD is not recommended in patients impedance testing. uncomplicated versus complicated presenting with possible extra- GERD as patients with complicated esophageal manifestations of GERD In summary, while GERD is quite GERD require diagnostic evaluation. without typical GERD symptoms. Extra- prevalent, the majority of patients with Complicated GERD patients may report esophageal manifestations of GERD GERD do not need a diagnostic study dysphagia, odynophagia, persistent can include sore throat, chronic cough, to confirm the diagnosis. The astute vomiting, hematemesis, or unintentional sinusitis, asthma, hoarseness, and dental clinician, however, must recognize the weight loss. These patients require an erosions. Some of these patients will patient who potentially has complicated esophagogastroduodenoscopy (EGD) eventually need an EGD, but it should GERD as this is the patient who needs for further evaluation and possible not be the first diagnostic test of choice. additional work up. THE endoscopic treatment. Patients with uncomplicated GERD who have not Patients undergoing EGD who are FALL responded to a 4-8 week trial of anti- diagnosed with severe erosive Dr. Mark Cahill is a board- GIScope secretory medication also require a esophagitis will require a repeat EGD certified Gastroenterologist. 2O15 diagnostic EGD. Patients who are at in 8-12 weeks to rule out underlying (503) 692-3750 risk for Barrett’s esophagus require Barrett’s esophagus. The presence oregonclinic.com/GITualatin Diet in GERD Patients Should You Refer to a Gastroenterologist? There are many factors that may contribute The foods and beverages most commonly In This Issue to the development of gastro-esophageal associated with GERD include: reflux disease (GERD). Coming up with »» High fat foods Diet in GERD Patients Patient with the appropriate diet and lifestyle changes »» Spicy foods heartburn or Alarm generally involves discovering what works »» Citrus and tomato products GERD Alarm Symptoms Yes Refer to a symptoms? Gastroenterologist best for your patients. While there is no proven »» Caffeinated and decaffeinated beverages regurgitation diet for GERD, there are many foods that may »» Carbonated beverages Basics for Managing aggravate symptoms. »» Alcohol a Patient’s IBD No »» Chocolate »» Onions Direct Access Clinical No, »» Peppermint Counsel on lifestyle changes Colonoscopy In addition to working with a gastroenterologist, & initiate medical therapy response? poor response your patient may greatly benefit from seeing a New Providers nutritionist to develop a diet plan that works for Maintenence them. For more information, visit Yes, good response therapy, lowest oregonclinic.com/nutrition effective dose

THE GI SCOPE • FALL 2O15 THE GI SCOPE • FALL 2O15 Sergio Crespo, MD Adam Silverblatt, MD Dr. Crespo completed his Dr. Silverblatt completed his Basics For Managing a Patient’s IBD NEW fellowship at the Mayo Clinic internship, residency, and training f a patient of yours has been IBD have low vitamin D levels, making supplemented with oral or IV forms of PROVIDERS in 2011 and has co-authored at OHSU. He serves patients at Idiagnosed with Inflammatory one think low vitamin D levels may be a iron. Vitamin B12 levels should also be numberous articles. He serves our Barnes Road location. Bowel Disease (IBD), including risk factor for developing IBD. checked, especially if the disease is patients at our Barnes Road Ulcerative colitis or Crohn’s disease, affecting the small intestine, or if there location. a gastroenterologist has likely done A patient’s vitamin D level should be was a previous ileal surgery. various tests to help diagnose the checked and supplements offered if Tesslyn Keim, PA-C Sophia Lichenstein-Hill, FNP, DNP condition and determine the severity levels are low. If the patients has used The Oregon Clinic now offers of the disease. There are many corticosteroids, has a maternal history appointments with a registered dietitian Tesslyn graduated from the Sophia has her Doctorate medical and surgical options to control of osteoporosis, is post-menopausal, to IBD patients at our gastroenterology University of Utah with her of Nursing Practice and has symptoms and to heal inflammation of or malnourished, they are at risk for locations. Talk to your patient about Masters of Physician Assistant volunteered with the Peace Corps the GI tract. developing osteoporosis. If they have getting scheduled. Studies. She is bilingual in in Panama in the past. She serves any of these risk factors, request a bone English and Spanish and serves patients ar our Tualatin and This may involve the use of density assessment (DEXA bone scan). To quote Benjamin Franklin, “an ounce our Gateway location. Oregon City locations. immunomodulators such as If they are using prednisone consider of prevention is worth a pound of cure.” azathioprine, mercaptopurine or taking calcium in addition to vitamin D. These precious words sums up the Terrance James, NP methotrexate; or biologic therapy such importance of health maintenance when Would you like additional information on as Remicade, Humira, Cimzia, Simponi, Colorectal Cancer Screening it comes to compehensive IBD care! Terrance completed his Master Stelara, Tysabri and Entyvio. If your patient has chronic ulcerative of Science in Nursing at Johns our new providers? colitis, or Crohn’s colitis, they will need Hopkins University, focusing on Make sure that you help your patients an annual or bi-annual colonoscopy Dr. Donald Lum is a board- family and pediatric nursing. He Visit oregonclinic.com/GI to see areas of interest, address these five health maintenance 8-10 years after they are diagnosed. certified Gastroenterologist. serves patients at our Gateway video interviews, and referral information. issues: If they are on biologics or immune (503) 963-2707 location. modulators make sure they are getting oregonclinic.com/GIGateway Vaccinations annual PAP smears, and that they are Vaccinations are a key issue in receiving annual skin cancer screenings keeping good health that should not by a dermatologist. be overlooked. Although updating Live Vaccines Disqualifiers for DAC vaccinations are important for everyone, Smoking Cessation »» Chicken Pox (Varicella) Direct Access Colonoscopy those with IBD are often taking This is very important for those with »» Shingles (Zoster) n the United States, colorectal cancer colonoscopy (DAC) program for patients medications that increase infection risk. Crohn’s disease. Using tobacco Patient has insulin »» Measles/mumps/rubella (MMR) (CRC) is the third most common cancer to get screening colonoscopy exams There are two factors that determine if products makes treatment of Crohn’s I 1 dependent diabetes diagnosed among men and women, without a pre-procedure office visit. a patient can get vaccinated: whether disease very challenging. Involvement Non-Live Vaccine and the second leading cause of cancer they are receiving immunosuppressant of a pulmonologist may be necessary to Patient is on blood »» Diphtheria and pertussis (Tdap, deaths. CRC can predominantly be Instead of an office visit, a patient who 2 or biologic therapy for IBD or not, and assist with smoking cessation and lung thinners every 10 years) prevented by the detection and removal meets criteria can schedule a phone their age. See a list of live and non-live cancer screening. »» Influenza (yearly flu shot, of adenomatous polyps. Adenomatous consult at their preferred number, and go vaccines to the left to help inform your Patient has recent avoid intranasal if you polyps are generally accepted as a through a short pre-colonoscopy medical patients of the right vaccines for them. Diet 3 cardiac, pulmonary, or aremmunocompromised) precursor lesion to colon cancer. questionnaire. This typically takes 15-30 While eating certain foods is not known neurological issues »» Human Papillomavirus (HPV) minutes. The colonoscopy procedure and Vitamin D to cause IBD, a healthy, balanced diet »» Hepatitis B A screening colonoscopy can detect bowel prep instructions are discussed Many studies have shown a link will help make sure that your patient Patient has a BMI »» Hepatitis A early-stage colon cancers, and detect during the interview, and the colonoscopy 4 between low vitamin D levels and is getting essential vitamins and other greater than 35 »» Meningococcal (college and remove adenomatous polyps. The appointment is scheduled. The IBD. Some researchers feel having nutrients. A visit with a dietitian should students and military recruits) American Gastroenterological Association colonoscopy bowel prep instructions are IBD symptoms may cause you to stay be considered and often is essential in Patient has inability to »» Pneumococcal pneumonia (AGA) guideline recommends getting a also available at oregonclinic.com/GI. 5 indoors and eat less. Other studies have managing IBD. Iron levels should be ambulate a block (booster every 5 years) screening colonoscopy starting at age 50. shown newly diagnosed patients with checked regularly, and may need to be If one has a family history of colon cancer If patients would like a pre-procedure Patient does not speak or colon polyps, a colonoscopy may be visit to discuss symptoms, that can also 6 English recommended sooner. A colonoscopy be easily arranged. We hope that our Refer Your Patients - Your Way is also recommended after any positive DAC program provides easier access to Patients has GI fecal occult blood test (FOBT) or fecal colonoscopy exams for our patients. symptoms of vomiting, Save time and refer your patients directly through your EMR system, online at immunochemical test (FIT). 7 diarrhea, blood in oregonclinic.com/refer, or by phone. stool, constipation, One of the largest patient barriers to etc. WEST SOUTH EAST VANCOUVER colonoscopy exams is loss of work hours. Dr. Stephen Chen is a board- Barnes Road Tualatin Gateway Mill Plain The Oregon Clinic has made a concerted certified Gastroenterologist. Patient has (503) 297-8081 Newberg Milwaukie (503) 963-2707 effort to provide greater convenience and (503) 692-3750 8 unexplained weight Oregon City (503) 963-2707 patient access to screening colonoscopy oregonclinic.com/GITualatin loss (503) 692-3750 exams. We now have a direct access

THE GI SCOPE • FALL 2O15 THE GI SCOPE • FALL 2O15 THE GI SCOPE • SUMMER 2015