good evening and welcome to doctors on call I'm Dr Ray Christensen faculty member from the Department of Family Medicine and biobehavioral health at the University of Minnesota medical school duth campus I'm also a family doc in Moose Lake Minnesota Gateway I am your host for the program tonight on lower GI problems and please remember the success of our programs is very dependent on you the viewer so please call in your questions uh tonight and of course you can use email at ask pbsn north.org the telephone numbers can be found at the bottom of your screen our panelist this evening include Dr Jonathan Gap a gastroenterologist with Essentia Health Dr Paul Sanford an internal medicine specialist with St Luke's Internal Medicine Associates and Dr Addie vorio a family medicine specialist at St St Luke's Lester River and Mount Royal Medical Clinics our students answering the phones tonight are Reagan Carlson of sunberg Minnesota Alex Higgins of Stewartville Minnesota and sabdi Bravo of Lismore Minnesota and now on to tonight's program on lower GI problems I think I'd like to give you each a chance maybe to introduce yourself we'll start on the far side Addie tell us a little bit about your practice and where you work well I'm a primary care doctor I am a family doctor so I see Pediatrics um Women's Care and um the stages of Life all through you know the lifespan I work at St Luke's leester River and montro medical clinic and I've been in practice for 13 years now wow Paul oh I'm Paul Sanford I'm a primary care Internal Medicine doc I came here in 91 from Minneapolis and now I live in the house I grew up in Dr Gap I'm I'm uh Jonathan Gap and uh I'm a gastroenterologist at asentia uh I've been there for about a year and a half now out uh since my fellowship uh I my days mostly look like either a lot of procedures doing colonoscopies or upper endoscopies or I'm in the clinic um and I have a special interest in uh esophagus and reflux as well very good except we're on the lower GI this time I do all that too there you go Dr vorio yeah what is the lower GI what where do we want to what are we going to put into that well I I mean lower GI is the appendix part of that the appendix is part of the colon yes part of the yep right at the end yeah Dr Sanford tell us a little bit about screening uh this is something you're really interested in and I'd like to get it out there so we don't miss it yeah no colon cancer there's nobody in America that should die of colon cancer we have ways of detecting it so early that it's cured with just the biopsy on colonoscopy that Dr Gap does um you know colon oopy should start at age 45 and earlier if people have a family history of colon cancer um or if they've had previous pops so or if they have ulcerative colitis things like that so it's it's so important the colonoscopy is the gold standard these other tests not to demean them they're they're not as sensitive and specific and so get your colonoscopy Dr Gap as a gastroenterologist what's the the most common problem that you run into in the lower let's just stay with the colon uh well let's see I I I spend most of my time looking for PPS and removing them so if you call that a a problem that would be uh one of them that I address on a on a daily basis for sure uh I would say also uh uh diarrhea um is is quite a common complaint that we address in Gastroenterology and just because there's so many different causes for diarrhea um you know that can uh include somewhat of a lengthy work up in colonoscopy and upper endoscopy can be part of that what is ala of colitis Paul oh what sort of colitis it's like arthritis of the colon It's where your immune system is wrestling with your tissue along the bowel and it'll cause cramping stools that have mucus but most importantly it put people at extremely high risk of colon cancer and so people with alcer of colitis need to be followed really closely like by somebody like Dr Gap um in the old days we just took out people's large intestine and gave them a colostomy nowadays there are better ways of management and people can live a normal life Dr Gap if you want to fill that in a little bit where are we with that disease now I would say it depends on the severity of of of the disease um but for a lot of for a lot of ulcerative colitis patients we can treat them with either kind of a pill that they can take um um or sometimes they need to take medicated enemas uh depending on kind of what section of the colon is is being uh affected by ulcerative colitis ulcerative colitis doesn't always involve the whole colon it can be kind of any part um normally starting at the end at the anus and can um move proximal from there so um patients who have more of a let's say I I see a patient in the hospital who comes in with ulcerative colitis oftentimes they'll end up on uh medications that are a little more heavy-hitting and we call those uh uh biologics and so you might have heard of something like infliximab which is one that we might use and has been around for a while so you I have to throw out stool transplant also and I don't care who what do you anybody have anything that you want to add on that one yuck it's a I mean it's a procedure that has kind of progressively developed and been refined and and mainly as treatment for refractory or recurrent cicile colitis which is an antibiotic you know Associated and somewhat resistant bacteria that can form an neoline and actually cause life-threatening um sepsis which is systemic infection or you know loss of parts of the co and so so we treat with antibiotics we treat with certain antibiotics for a period of time things don't get better they continue to get it we treat with big gun antibiotics things continue to progress and people keep getting this recurrent bacteria because our colon is full of bacteria and so our colon sort of recycles bacteria it helps us digest food it helps us use all parts of our food but there are some that are what we call pathogenic or caused disease and CDE is one of those and So eventually you may ask be asked to ask your partner your family your friends whether they could give you a sample of their normal bacteria in their stool um it is not ingested orally it's ingested via a tube um and this is meant to sort of replenish your normal bacteria that can further protect you against infection anything you want to add I uh right now the only uh reason that fmt is or FAL microbiota transplant is being used this is for CF so we're not using it for ulcerative colitis yet there I know that there have been some um there been some studies on it some studies on it and it just doesn't seem like there's uh at least uh L longevity as far as the effect goes so uh as of right now it's just still for seed of colitis and the colen version for people who don't have you know severe life-threatening conditions is is taking in probiotics which are FAL bacteria love to eat and and flourish on and also or Prebiotic sorry and then probiotics which are bacteria that are found in our gut normally that we can sort of feed our gut as well Dr Sanford constipation it's not gas oh okay constipation uh what can I do if I'm still constipated after taking laxatives oh well you know hopefully the laxatives are the last place you go the first place you go is eat your fruits and vegetables just like Grandma used to tell you and try to drink lots of of fluids you know I tell my folks to take you know two quarts of anything wet a day whether it's water iced tea pop beer you know want to go with your cheeseburger but that is going to be a healthier gut lots of fiber eat your fruits and veggies dried apricots raisins laxatives you know all they're going to do is it's like a fire extinguisher you want to establish a new pattern of eating that'll make your colon happy does smoking affect the GI track and in that same line alcohol of course both of them I mean if it weren't for tobacco and alcohol I'd be selling ludifisk on the corner for a living incredible increase in risk of malignancies you know alcohol especially with the liver which is the upper end of our gastrointestinal system but tobacco you know it can be linked to colon cancer increase as well Jonathan uh can you explain the process of an endoscopy um symptoms and whatever why would you do it and what is the process sure um so and I I think what they mean by endoscopy is probably well we're doing lower GI so so colonoscopy I'm sorry get me down there too yeah yep um so the the process is um the way that it would work is we'll just go through kind of a patient flow so let's say you're coming in for your screening colonoscopy it's your first time you're 45 years old you don't have family history you're staying on top of things you come in uh into our uh kind of pre pre-procedural area and our nurses put in an IV for you and our anesthesia our anesthesia team sees you and um make sure that you're safe to receive medications to to keep you comfortable during the procedure and they bring you back to the endoscopy suite and that's where uh we start giving you the medications and normally you're either fully asleep um but breathing on your own um or you're uh or or you're slightly awake depending on what medications we give you and then um we introduced the scope of from through the anus and we go all the way around to What's called the seeum and that's where you'll find the appendix and you'll find the the small bowel running into it and that's kind of where where we normally stop sometimes I'll take a peek into the end of the small bowel as well then on the way we come back uh and look for PPS and remove those as we find them why can't you keep going uh you can go as far as a scope will let you go so sometimes we will if uh if someone is uh been having let's say uh bleeding and I don't find anything in the in the colon that's the cause sometimes I'll just keep going up as far as I can into the small bowel until I run out of uh until I run out of scope one of the social determinants of Health kind of questions uh and I don't care who jumps in on this uh where can you get a colonoscopy without insurance and how much does it cost out of pocket and then I would add on to that do you have to have that anesthesia which is expensive too so those are I I from the anesthesia standpoint I know some people have done it that's why I ask yeah so so I mean you you can do you know a partial colon which is a flexible sigmoidoscopy and sometimes do those on people without them getting anesthesia um and that can be a form of of uh colon can colon cancer screening not as good as a colonoscopy because you don't get to see the full colon um but um the procedure typically depends on you being relaxed and and most people would not be relaxed with something going into their anus and up through their erectile area so so it's much easier to get a good screening if you are provided the you know appropriate anesthesia yes and it is an excellent screen so yeah and as far as you know payment or coverage or other things most health plans do cover including public insurance I'm not aware of a a program that doesn't you know that provides them for patients without insurance um at this time and I have no idea what it would cost what age can you stop doing colonoscopies it's I mean the answer is it depends um and so you know we start talking about at age 75 and we might sort of look at someone who has a lot of Health burden of other diseases and say well you could probably stop at 75 but there are also people with a family history where we continue screening every five years there are persons who've had pups that we continue screening and it depends on your quality of life you know if you would treat a colon cancer and you're kind of in that in between period of time I usually ask patients you know if you would treat a colon cancer do you want to continue your screening to help you know determine whether you have risks or not so you've opened up the pop question uh what are pops and pop well think of the pop as a meaty mushroom along the pipe of your large intestine and you know there there are multiple different types the hyperplastic pops are little Barnacles that Dr Gap will snip off and you don't have to do anything more adenomatous Pops are ones that if you leave them in the intestine there's a 50/50 chance I'll turn into cancer within 5 to 7 years that approxim imately correct yeah usually well normally we say more like 10 to 15 which is why you can go 10 years if you've got a normal Co yeah and then you have the other more dangerous ones they're called cile adenomatous or malignant polyps where if it's early colon cancer you know you have to decide whether to try to do it with the scope or do take a surgery and take out a hunk of the large intestine where the cancer is and then reconnect the two ends of the colon and not only does the type of pup determine you know your risk but also the amount of pups you have um determines risk and and it's gotten I would bet much more complex than when I started with regards to the numbers and types of pups and how often we would repeat screenings it is a procedure that has proven its worth and certainly one that it's just because of where it is I think that's the biggest problem with it but it's a excellent excellent procedure yeah um if a person eliminates junk food will that eliminate GI problems so we're looking a little at the upper GI but we're our focus is lower and I'm not sure to what they refer I mean certainly they their GI track gets more healthy with the elimination of refined carbohydrates and you know other things such as Smoked Meats and other things but um your gut health depends on a variety of things it depends on your stress in your life it depends on who you are genetically it depends on your diet composition John I there's a question I'm not even sure how to put this one out but the Vagas nerve in my mind is pretty much upper GI I don't think that's lower GI so we're not with that and then the next question how does the seos muscle affect the bowel and I'm I don't have an answer I don't think it does I wouldn't I wouldn't really say that it does yeah I mean obviously there are muscles in the p us which physical therapists are very used to dealing with that can cause pain or cause discomfort and therefore affect a person's ball habits but there's no direct yeah and if we're going to talk about you know constipation and we're going to talk about muscles I mean I think uh and you you mentioned the pelvic floor then we can talk about things like uh coordination of those muscles so sometimes if you're taking your laxatives and you're still constipated sometimes we start to wonder well maybe you don't coordinate those muscles in the right right way and then it's actually becomes then you don't it might not be a medication that you need but a pelvic floor physical therapist retrain those muscles to coordinate things in the right way and that can also be a treatment for constipation as well and and we do see like things like child birth or multiple child birst affect your you know sort of where your organs fall at rest and different Kinks and turns and and whether they you know sort of balloon out in certain areas affecting your ability to excrete waste M rectal bleeding um the question kind of starts out with more coffee ground which I would assume would be more upper GI uh but actual rectal bleeding um I don't Addy do you want to take that one on lower GI bleeding is typically a red or maroon color it typically has a a blood color to it because it hasn't been through sort of chemical processes from the upper GI and it needs to be evaluated regardless of how um what age you are and so things we ask in the office would be is it painful is it non-painful can you you know feel things there what is your family history um we can take a look in the primary care office so we not only look externally but we use something called an anoscope which I call the sort of the speculum of the anus um and we're able to sort of go in and look at certain areas in the first 4 Ines of the GI tract from below to see if there are hemorrhoids or if you had Fishers and Fishers are giant crevasses in sort of the external part of the anus that can be quite painful and bleed and the bleeding looks different probably from further up versus right at the anal area yep so Hospital GI bleed um scoping right away it really depends on on the rate of the bleed because the other important thing whenever you're doing a colonoscopy is uh being able to see we can't see through mud so uh so it's important that uh often times you be able to uh take the full bowel prep beforehand and we can give that quickly if we need to um um so but in the hospital if if it's a high rate bleed and that can be from something for if we're talking lower GI that can be often times from uh diverticulosis a diverticular bleed that's kind of the most common one that we run into um often times we'll give you the the bowel prep is is over a couple of hours and then you'll be going for a colonoscopy quite shortly yeah and I think in discussing you know Diverticulitis and diverticulosis it's important for patients to know that if you have an episode and you're treated either by your primary doctor or through the ER it's important you follow up with your gastron neurologist um in the following months after that because we do see that some colon cancers or colon pups can lead to diverticulitis episodes Paul what are diverticula they're caves when along the pipe of the large intesting you have these little outcroppings of of tissue of a hole it's like a little deadend piece of bowel and they just happen more in our culture because we eat refined processed foods in Vietnam the Philippines it's non-existent well it's rarely existent but but anyway diverticuli often don't cause any problems but if they get infected because of impacted stool or you know microscopic Trauma from a fishbone it can cause life-threatening sepsis so are there dietary restrictions if you have diverticulite no eat all the gravel and fruits and vegetables you want the rougher the better I don't know do you disagree with that no moving things through quickly is key I I think people for were told for a long time to avoid nuts and things with seeds but then you're you're missing out on a lot of great healthy snacks and we and it in the end it didn't seem to matter if you ate those things so keep eating those healthy snacks nuts peanuts and bit Foods I've we spent many years doing that yeah yeah yeah popcorn don't eat popcorn it's that's okay it's okay just eating Foods as close to the way Mother Nature Made them as possible is always good for all of your body so we left people hang a little bit what causes sea diff well it's a one of you guys overgrowth of a opportunistic bacteria claustrum deficit if you've been giving people antibiotics to treat their pneumonia or whatever infection if it kills off the happy part of our microbiome the bacteria that help us to live then claustrum defil will take over and it is a bully it will just knock around your intestine it can cause something called megacolon it can be fatal and unfortunately they're not a lot of antibiotic options besides vamy and rarely um metronidazol but but yeah it just it's a booger and we've seen more and more of it and that that would be why your doctor you know sees you for your cold and at 5 to seven days says well I think this will pass and we don't have to use you know antibiotics to treat this this it does not look bacterial and that's why we're constantly every day as primary doctors making that decision is to lower your risk of side effects from antibiotics yeah fewer antibiotics the better what are the treatments for hemorrhoids we'll just move it down to that end don't grunt yeah no just preventing constipation don't strain I don't first first the fiber the fiber uh I think a lot of is under underestimated uh I think you get people on a good fiber supplement if they can't get it all uh through diet you know I don't most people are not getting their 25 to 30 grams of fiber that they're supposed to be getting every day and so if you start on a supplement um um I think that uh for a lot of people their hemorrhoids will improve some people it's it's they're they're they're too large they're too severe and then uh you're talking about uh you know hemorrhoid banding um which uh can sometimes be done by a gastroenterologist or biocar rectal surgeon um and uh if if if they're very severe then there's hemorrhoid ectomy is kind of the next and last final step but that's that's a pretty involved procedure in an operating room and so we try to we try to do what we can before we reach that point can diverticulitis lead to cancer no indirectly yes probably directly no I mean anything that causes inflammation for years and years can and the GI check just con chronically sort of overturning its cells that's the purpose of it is to make more cells to continue to operate um but directly no but it is important after an episode of diverticulitis to get that follow up colonoscopy done if you if if you haven't had one done two years previously to that because sometimes it can Herald like you were saying earlier a colon cancer um or the beginning of one just a little step aside celiac disease maybe sprew couple comments large intestine small intestine small in yeah I don't I'm not large we still even though we have you know a population that could have more prevalence of that we still think it's a fairly rare thing and and there by and far there's probably more people with a a perceived gluten intolerance than a actual true gluten allergy so we have we have good tests to sort of determine that but you do have to be eating sort of the foods to do screening um we do see people with sprew you know we have we all have several patients that are practice with Celiac sprew which is true you know gluten allergy and then they have you know bloody stools or they lose weight or they have iron deficiency associated with these things so it's not a disease that is subtle I would say um but it is something we look for when we can't figure oh what's going on Paul a 30 second closure o on bowel Health oh a happy bowel we we've talked quite a bit around things but just a summary of what you would do in the office or say I just say what I've been saying this evening listen to Grandma eat your fruits and vegetables five different colors of fruits and vegetables a day eat your whole grains peanuts dried apricots raisins that's going to be the best way to have a happy bowel avoid processed foods try not to have too many cheeseburgers every day keeping stools soft yeah fluids fiber yep I want to thank our panelists tonight Dr Jonathan Gap Dr Paul Sanford and Dr Addie vitorio and our medical students Reagan Carlson Alex Higgins and Sab sabdi Bravo please join me again next week for a program on neurologic problems headaches stroke Ms and Alzheimer's disease when my panelists will be Dr fum jov uh Dr Chris T and Dr John Wood thank you so much for watching and have a great night thank you panel good job