Gastroenterology and Hepatology

Hello and welcome to your appointment in Mayo Clinic's Division of Gastroenterology and Hepatology. My name is Dr. Laura Raffals and on behalf of the Gastroenterology and Hepatology team I'd like to thank you for choosing Mayo Clinic for your care. I'd like to take a moment to share with you a few things about your consultation and care team.

In Gastroenterology and Hepatology, and at Mayo Clinic, we practice medicine as a team. Our provider team includes physicians, nurse practitioners, physician assistants, nurses, fellows and residents. Throughout your time at Mayo Clinic, you may meet with various members of this team, but all care plans are reviewed by the physician who's leading your care team. Our entire team is invested in your care and wants this to be a successful visit for you. Please know that sometimes we'll need the input of other specialists; we will coordinate these appointments and as timely a fashion as possible, and hopefully within the timeframe of your stay here in Rochester. Please be aware, however, that some specialty appointments may need you to return at a later time.

At Mayo Clinic, we practice consultative medicine. This means that our goal is to meet with you to learn about your individual needs and concerns, work very hard to address these needs while you're here, and then develop a care plan for you and your local provider to follow long term. As consultative providers we are not a replacement for your local primary care provider or gastroenterology and hepatology provider at home. If you do not have a provider at home, let us know and we will do our best to connect you with one.

We want to meet and exceed your expectations and needs today. To help us to achieve this, I encourage you to share with your provider the goals of your appointment. Tell them specifically what brought you to Gastroenterology and Hepatology, and what you're hoping to get during your appointment in GI.

The last thing I want to tell you about today is Patient Online Services. This is Mayo Clinic's patient portal, and we encourage you to sign up for a portal account. It provides an easy, convenient way to contact your care team at Mayo Clinic and gives you instant access to valuable information such as test results, appointment schedules, and notes from your care team. As you leave your appointment today, the staff at the desk can help you set up an account.

If you have any other questions or concerns during your visit to Mayo Clinic, please let us know — and thank you again for choosing Mayo Clinic for your care.

More recently, initially with case reports and some data that has now been coming out of China that there are a lot of patients who can have either recombinant GI symptoms, meaning they have lung symptoms and GI symptoms on top of that, but also there's a fraction of people, about a third, who are presenting just with gastrointestinal symptoms at presentation, and may not even have respiratory symptoms at that time and will just have GI symptoms.

The GI symptoms that we're seeing predominantly are diarrhea, nausea, and vomiting. Some studies are now showing that there are possibilities where the COVID-19 or coronavirus can be present in the stool and maybe absence in the respiratory tract. So this disease could be present in the stool first and then later on present in the respiratory tract. We do know from other diseases that bugs that are present in stool could have a fecal-oral spread. At this time, we don't know for sure if there's fecal-oral spread or not. But with caution, I think we should assume that if there is somebody who has COVID-19, their stool, just like their respiratory secretions, are potentially transferable and are potentially infectious.

We think that perhaps there may be some illnesses that could predispose people more to those. Certain people have an illness called common variable immunodeficiency, which predisposes them to getting more viral infections in the gut. And it's quite conceivable that inflammatory bowel disease patients could get this at a higher risk also.

I'm Dr. Brian Lacy, a gastroenterologist at the Mayo Clinic. I treat a number of different interesting conditions at the Mayo Clinic. I focus primarily on motility disorders and functional gastrointestinal disorders of the GI tract. That would include some of the most common functional GI disorders such as dyspepsia, gastroesophageal reflux disease, gastroparesis, irritable bowel syndrome, chronic constipation, pelvic floor disorders, and achalasia.

One of the things that sets Mayo Clinic aside, especially in my field of functional motility disorders, is that we have testing available that's not available elsewhere. Thus, when somebody comes in with symptoms of dysphagia or difficulty swallowing, we have a variety of tests, including esophageal manometry or EndoFLIP that can make an accurate diagnosis. We have the opportunity to really carefully analyze and study gastric function. So for patients with symptoms of dyspepsia or gastroparesis, we can really identify the root cause which can change therapy. And certainly a great example would be those patients with symptoms of persistent constipation who may have failed therapy elsewhere. We can really identify again the root cause for why they have constipation and using advanced technology, implement an individualized treatment program that should improve symptoms.

I'm oftentimes asked about what's, what's really changed in the last decade in terms of our approach to functional gastrointestinal disorders and mental disorders. And really within the last 10 years there have been some amazing changes. These changes involve a better understanding of why these disorders occur. We can analyze patients in terms of genetic issues. We understand what role the gut microbiome plays. We understand how stress and patient's life can affect GI tract function. And that's all important to understand because now we can target that gut microbiome and modulate and change it to improve gut symptoms in patients with IBS as an example. We understand the disorders of visceral hypersensitivity and can use a number of different medications and therapies to improve chronic pain and patients with dyspepsia and gastroparesis. And finally, we have a better selection of drugs and diets that can improve patients and their symptoms of constipation or IBS or dyspepsia or gastroparesis.

One of the great things about Mayo Clinic Jacksonville is that we have a core group of physicians who focus all of their time and energy on patients with motility disorders of the GI tract and functional gastrointestinal disorders. At this time, I think we have a number of great opportunities to help patients that aren't available elsewhere. We're involved in three separate medication research studies that will be available for patients with gastroparesis that should help improve their symptoms. We frequently are asked to see patients from other health care providers because symptoms that they report overlap multiple disciplines and multiple boundaries. And so we're oftentimes asked to see patients with complex functional bowel disorders where they have overlapping symptoms of reflux and dyspepsia and constipation and IBS and persistent pain. And these symptom complexes can oftentimes be overwhelming to health care providers. And we're fortunate that we have a treatment approach that can employ health care providers across disciplines to focus on symptoms of pain, to address dietary concerns, to address maybe some underlying psychological distress, to discuss their symptoms of bloating and pain. And by using this kind of multimodal treatment approach with the use of multiple health care providers, oftentimes we're able to come up with a plan that really helps patients.

I come from Galway in the West of Ireland where celiac disease was very common when I was in medical school. We regarded it like wallpaper — it's just, there.

Celiac disease is an immune-mediated condition. So typically happens in patients who have an immune reaction to whenever they ingest gluten, which would include any foods that contain wheat, barley, or rye.

There are some people that truly have a wheat allergy. A wheat allergy does not equal celiac disease.

The wheat allergy is a very rapid response, very much like the other allergies. Celiac disease is more of a slow burn, and it can take weeks or months sometimes for symptoms to start happening in somebody when they're eating gluten.

Once they come into our clinic and they want to know, do I have celiac disease or not? What we start with is laboratory testing which includes antibodies that we typically see elevated in patients with celiac disease.

These antibodies are pretty specific for celiac disease and so long as a person is on a gluten-containing diet, then the tests are quite good.

Once we have made a diagnosis, the most important thing that we can do is to get them on the correct diet.

Patients with celiac disease need to be on a gluten-free diet. That's a medical necessity. It's not a choice. I mean, the patients who continue to have symptoms despite being gluten-free are a particular group of patients that we like to see here. We think with our multidisciplinary experienced approach that we can really drill down on what the reason for why they have continued symptoms.

Having the depth and breadth of the services that we have and just the volume of cases that we have really allows that elevation to that expertise level.

I am indeed fortunate as a gastroenterologist, as a doctor working in celiac disease, that I can work with this team. We can achieve things that I would find it very difficult to achieve elsewhere.

Hello. My name is Joe Murray. I'm a gastroenterologist here at the Mayo Clinic in Rochester, Minnesota. Today I'm talking to you about celiac disease. Celiac disease is a condition that affects primarily the small intestine. It is a reaction to proteins in wheat, barley and rye, which are sometimes termed gluten. Now what does this mean? You've probably heard of gluten from the media or reading about it in magazines. Well, gluten as a protein, when it contacts the intestine of somebody with celiac disease, it causes damage. And the damage which is the result of our body rejecting gluten, causes damage to the villi. These are little finger-like projections that line the small intestine. When this happens, at least at the beginning, there are no symptoms. And that can go on for many years. A person can have celiac disease, not know they have it, and basically have no symptoms. But then over time they can start to develop problems. The most common problem is a failure to absorb nutrients, particularly iron. So iron deficiency anemia is one of the most common consequences of this disease. What's peculiar about this is that the person develops anemia and then they take iron excess iron to try and treat it. They may not be able to absorb that either. And so that's often the first clue that somebody has this. If it becomes more severe, it can cause diarrhea, weight loss, abdominal pain, bloating, gaseousness, what we call flatulence, the abdomen can become distended, especially after meals. If it occurs in children, it can affect growth and development of the child.

Now this disease was once considered very rare, but in the last probably 10 to 15 years it has become quite common. It's now being diagnosed 20 times as often as it was 30 years ago. Why is this happened? We really don't know. Some people think it might be due to a change in what we're eating or the types of foods we're eating. But really we have no idea why this increase has occurred. This increase parallels other immune diseases like type 1 diabetes and allergy disorders.

So how do we find this disease and how is it diagnosed? Well, the first test is usually a blood test. So there are antibodies that can be detected in the blood by a simple blood test. If those antibodies are positive, it indicates a high possibility of celiac disease. And then the patient usually should be referred to a gastroenterologist who will undertake an endoscopy, basically putting a tube down into the small intestine, taking some tiny pinches of tissue to test. That usually confirms the diagnosis. Now while that — it sounds pretty simple or straightforward — it can be complicated. And it's complicated, especially if somebody reduces or eliminates gluten from their diet before testing. And that can be a real challenge because the blood tests may become negative and the biopsy may normalize. So what do we do in that circumstance? Well, if the patient's been on a gluten-free diet for a year or more, it's likely that the blood tests will not be helpful. Even a biopsy may not be helpful at that time. So we do a genetic test. Now this genetic test is really helpful if the person doesn't have the genes for celiac disease. And if they don't have those genes, it makes the disease extremely unlikely to be present, and then should direct the patient and their doctor elsewhere. If they carry the genes for celiac disease, it doesn't prove they have the disease, but it means it's possible. And in that case then we often do what's called a gluten challenge, where we have to reintroduce gluten into the patient's diet and see if it produces symptoms, abnormalities on blood tests, and ultimately, can we prove it with damage on biopsies taken from the intestine.

So how many people have this disease? It's probably one in a hundred people have this disease. So the numbers vary a little. Some parts of the world have more and some less. Even in the United States, there's more celiac disease in the northern part of the United States than in the Southern states. Why that is we don't know, but it parallels other immune disorders. For example, MS seems to be more common in northern states than in southern states.

Are there complications of this condition? There can be. It's not just the symptoms I talked about: anemia and GI or digestive symptoms. It can also cause complications that can affect bone health. And sometimes we see people presenting with what we call fragile bone fractures here, from bone fragility, from osteoporosis or a bone softening known as osteomalacia. And in rare patients, it can increase the risk of certain rare malignancies, such as lymphoma or small bowel cancers. So this is not a trivial disease and it shouldn't be mixed up with people who are simply avoiding gluten for lifestyle reasons, so-called, your people who are gluten avoiders. That's not what celiac disease is. Celiac disease can be a serious illness causing substantial injury in the digestive tract and beyond the digestive tract.

Probably most challenging for celiac disease, are people who don't have any digestive complaints at all. And they present with problems such as infertility, skin rashes, recurring mouth ulcers, hair loss for example, the bone problems. We've talked about, chronic fatigue symptoms that are not at all specific for celiac disease, but can often be a significant consequence of this hidden condition. Thank you for watching.

Hello, my name is Joe Murray. I'm a gastroenterologist in the Celiac Disease Program at Mayo Clinic. One of the challenges of following our patients with celiac disease is predicting whether their intestine has healed or not. We rely on a number of things: How well has the patient adhered to a gluten-free diet? Are their blood tests positive or not? How well have they been instructed on a gluten-free diet? Are their symptoms that might suggest continued damage? It turns out that most of those are really not particularly accurate. And we have ended up routinely re-biopsying most people diagnosed as adults.

We recently had the opportunity. in collaboration with investigators from California to look very carefully at a new type of test. It's called an array, peptide array test, that doesn't just look at one test, but can look at hundreds or even more tests simultaneously. And we were using this to examine the immune reactions in patients with celiac disease. Our initial work suggests that this approach might be quite accurate to diagnose celiac disease. But more importantly — or at least more relevant to our discussion today — it seemed to be a very good predictor of whether the intestine had healed or not. This is something that most studies have found — blood tests — that celiac blood tests are not particularly good at. We are hopeful if this work can be confirmed, that it would be a way to assess or predict whether there is continued damage in the intestine of a patient with treated celiac disease. Thank you.

Hi, I'm Dr. Amy Oxentenko. On behalf of two of my coauthors, Dr. Amrit Kamboj and Dr. Patrick Hoversten, I'd really love to spend a few minutes talking to you about an article that we recently published in the Mayo Clinic proceedings, and the paper was on chronic abdominal wall pain. Chronic abdominal wall pain is something that we see fairly frequently in our GI practice, moreso in the outpatient setting compared to in an inpatient setting. But chronic abdominal wall pain is something that we see in patients who've had chronic abdominal pain that seems elusive to any workup; they typically will undergo extensive workup with laboratory studies, radiographic studies, endoscopic evaluations. And then they're sent to us because no one can figure out what is the source of their abdominal pain.

So chronic abdominal wall pain is one of these diagnoses that you can make if you take a very careful history and target your physical examination. So chronic abdominal wall pain typically results from some entrapment of the cutaneous nerve of the abdominal wall. So this may result after an abdominal surgery where the nerves can be disrupted from surgical incisions. We can also see it as result of hormonal changes. And so patients will typically note that their abdominal pain is quite focal. Most the time — upwards of 40% of the time — it will be in the right upper quadrant, or it may be in an area of the surgical scar. And when you ask the patients to show you where the abdominal pain is, they can typically point with one or two fingers, particularly where their pain is most intense. They may also report certain activities that might worsen their pain, such as lying on the side where this abdominal pain is. Anything that pushes on their abdominal wall in that area may be irritating. Anything that stresses are tenses the abdominal wall can also cause them to have exacerbation of their pain. So those are important things to ask about in terms of the history.

Now, the examination is crucial to helping make this diagnosis. You're obviously going to do a full comprehensive history and examination. But one thing you can specifically do during the examination is called a Carnett sign. And so how you can evaluate a patient for a positive Carnett sign or the presence of a Carnett sign is to first have them lay supine on the table relaxing their abdominal wall. I usually first have a patient show me specifically where their pain is. And again, they often can point with one or two fingers, localizing their pain. So first I will palpate in that area of tenderness or pain that they have pointed out to me and ensure that I'm in the correct location. I'll typically keep my fingers right in that area of maximal tenderness while their abdominal muscles are relaxed, then I would I will have them do is either lift their head, off the bed, almost like an abdominal crunch. Or you can also have them raise their legs off the bed, whichever is easier for them, so that their abdominal wall muscles are tense. Typically in chronic abdominal wall pain, the patient will report worsening of their abdominal pain when you're tensing the abdominal musculature. Then what you'll have them do is relax the abdominal wall again and they're painful typically lesson if it's related to chronic abdominal wall pain. So again, a positive Carnett sign would be someone who has worsening of their abdominal tenderness in a focal area with tensing of their abdominal wall musculature and then improvement of their discomfort when they relax or abdominal wall musculature. So again, the history is critical. The examination really can help pinpoint this diagnosis.

When it comes to management then, the first thing is to reassure patients that this is something that is not going to lead to morbidity or mortality; it certainly can have a significant and impact on their quality of life. And that's what we're here to help improve and make their symptoms better. So first of all, reassurance is key. They can try over-the-counter or topical anesthetics, such as a pain patch, also known as a Lidoderm patch. These can now be obtained over the counter, which I think is very helpful. Some patients may find help with the heating pad or other abdominal binders to take some of that irritation off the abdominal wall. But most patients, when they've come to seek the attention of a medical specialists may benefit both diagnostically and therapeutically from a trigger point injection. So what a trigger point injection is, is a needle that is, and we use an anesthetic agent like a lidocaine derivative as well as a steroid, corticosteroid agent mixed together and again inserted into the area of maximal tenderness. This may or may not be done with ultrasound guidance to better localize the tip of the needle. And again, some patients will get immediate relief of this with the anesthetic agent, and then over subsequent days, we'll find additional relief as that corticosteroid takes effect. We know that some patients may need a repeat trigger point injection months or years down the line if their abdominal wall pain recurs, that many patients may have lasting benefit from this modality.

So I hope those are a few helpful tips to educate you about abdominal wall pain. Again, this is a common diagnosis that we see in the outpatient setting, especially for those patients who have really not come to an understanding of why they're having abdominal wall pain or abdominal pain despite an extensive evaluation. So this is something for both the patient and the clinician to keep in their back pocket as something to consider for those patients. Thank you.

Hi. I'm Dr. Amy Oxentenko. I'm here today to talk about a paper that I recently published with two of my colleagues Dr. Amrit Kamboj as well as Dr. Thomas Cotter on Helicobacter pylori infection. So one of the reasons that we decided to write this review is that Helicobacter pylori infection is very common and in fact is one of the most common infections that we see worldwide. As a gastroenterologist and as primary care physicians this is something that we deal with regularly in our office because it's the most common cause aside from NSAID therapy in courten causing peptic ulcer disease.

We know that Helicobacter pylori infection can cause only peptic ulcer disease but dyspeptic symptoms in some patients and in a small percentage of patients can lead to gastric cancer or gastric lymphoma. We can diagnose h pylori infection through a variety of modalities including stool studies breath tests or more invasive studies such as with an EGD where we might take biopsies or do special tests on tissue sampling from the stomach mucosa.

Most patients that can be diagnosed with Helicobacter pylori through non-invasive means and that means either through a stool test or an in-office breath test and both of those tests will determine active infection and I think that's really important because there is a blood test for Helicobacter pylori infection but that does not test active infection that tests whether you've ever had Helicobacter pylori infection so it's not a great marker of active disease and so we've really stopped using that as commonly in our clinical practice.

Once someone has been diagnosed with Helicobacter pylori really the important focus in today's stage day and age is determining the best therapy for that Helicobacter pylori infection because we want to do whatever we can to achieve the best eradication rates. What's happened over time is our success in eradicating Helicobacter pylori infection in any individual has decreased over time and that is because the bacteria has become more resistant to certain antibiotics and specifically clarithromycin which was one of the key antibiotics that we've always used to treat this infection has had growing levels of resistance which means that more and more patients have a type of Helicobacter pylori that will not respond to clarithromycin therapy. Because of this what we see is we have more and more patients that are not eradicated once we've done what we think would be successful therapy for them requiring us to retreat them with another course of an antibiotic regimen.

So when we're making a decision of what to treat a patient with a few things are taken into consideration. First we look at a patient's allergies to make sure they're not allergic to penicillin because amoxicillin is one of the antibiotics that are commonly used in some of the therapies for Helicobacter pylori infection. The other thing to consider is whether a patient has either lived in an area where there's high clarithromycin resistance but also have they been exposed to antibiotics that contain clarithromycin type antibiotics because if that is the case they are more likely to have resistant Helicobacter pylori infection that may not respond to a clarithromycin based regimen.

So new guidelines have come out in recent years suggesting that some of the tried-and-true quadruple therapies which include a proton pump inhibitor metronidazole tetracycline and pepto-bismol or bismuth therapy is probably one of the most helpful therapies in terms of giving you successful eradication. Once we've treated a patient and oftentimes we will treat them for up to 14 days in order to achieve the best eradication rates that we can we want to make sure that we have eradicated the bacteria fully. In order to do this we typically will do testing no sooner than four weeks after the completion of therapy typically again that can be done with either an in-office breath test or a stool test both of which will show if there's active Helicobacter pylori infection still present or not. If it is still present than an alternative course of retreatment would be recommended again assessing for eradication after the completion of that subsequent therapy.

So I hope this has been a helpful review knowing that Helicobacter pylori infection is a common infection can lead to peptic ulcer disease most commonly but rarely can lead to malignant complications such as lymphoma and gastric cancer. Because of those things it's really important that we not only treat it effectively but make sure that we've treated it successfully in all patients who undergo Helicobacter pylori therapy. Thank you.