Blog – Precision Digestive Care

Now You Can Schedule a Screening Colonoscopy Without Seeing the Doctor First!

Posted on December 17, 2024 - 11:15 pm by Frederick Gandolfo MD

Direct access colonoscopy means you can schedule a screening colonoscopy for yourself without needing to have a preprocedure visit with the doctor. This saves you time and money, and reduces the waiting time for your procedure.

Dr. Gandolfo explains how direct access colonoscopy is a convenient way to protect yourself from developing colon cancer in this short video!

Who is eligible for direct access booking?

You are age 45-75, have no concerning symptoms, and just need a routine screening colonoscopy.
You have a history of colon cancer in your family and your primary care provider told you to get checked.
You had a colonoscopy in the past that showed polyps and you are due for another routine colonoscopy now.
You took a Cologuard test or another stool test that was positive (abnormal) and now you need a colonoscopy.

Click the button below to schedule a colonoscopy. Even if you are not sure if you’re a good candidate for direct access, we will still reach out to you to figure out the best way to get you screened and help prevent you from developing colorectal cancer!

I’d like to schedule a colonoscopy

Treating Fatty Liver Disease with Diet, Lifestyle, and Psychology

Posted on August 5, 2024 - 6:13 pm by Frederick Gandolfo MD

Did you know that more than 30% of Americans are currently diagnosed with fatty liver disease? This alarming statistic highlights the importance of understanding this condition and taking proactive steps to manage it before things get out of hand.

This article is a supplement to two episodes of Dr. Gandolfo’s podcast The Real GI Doc Show:

“The Natural Way to Treat Fatty Liver Disease at Home” Listen to the full episode here.

“The Psychology Behind Healthy Habits: Expert Tips for Real Change with Noreen Vail, PhD” Listen to the full episode here.

What is Fatty Liver Disease?

Fatty liver disease, recently renamed as Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD), is a condition where more than 5% of liver cells contain fat. This can lead to inflammation, fibrosis (liver scarring), and in severe cases, cirrhosis. The condition is closely linked to metabolic issues such as obesity, type 2 diabetes, and hypertension. Understanding these connections is crucial for effective management and treatment.

Jim’s Case: A Common Scenario

In a recent podcast episode, Dr. Gandolfo introduces us to a hypothetical patient, Jim, a 48-year-old man with prediabetes and mild hypertension. Jim’s routine blood work reveals mildly elevated liver enzymes, leading to further tests that confirm he has fatty liver disease. Jim’s history is not unique, and it serves as a reminder that many people may be living with this condition without even knowing it.

The Importance of Early Intervention

By the time fatty liver disease is diagnosed, the underlying metabolic issues have often been present for years. Early intervention is crucial. Dr. Gandolfo emphasizes that the best time to make lifestyle changes was five or ten years ago, but the second-best time is right now. This proactive approach can prevent the progression to more severe liver conditions. Early detection and lifestyle modifications can make a significant difference in the prognosis of the disease.

Natural and Effective Treatments

Dr. Gandolfo outlines two primary, cost-effective treatments for managing fatty liver disease:
weight loss and exercise.

Weight Loss: A modest weight loss of 3-5% can start the healing process in the liver. For more significant improvements, especially in cases of inflammation and fibrosis, a weight loss of 10% or more is recommended. Sustainable dietary changes are key. Dr. Gandolfo suggests finding a diet that fits your lifestyle and preferences, with the Mediterranean diet being
particularly beneficial. This diet is rich in fruits, vegetables, whole grains, and healthy fats, which can help reduce liver fat and improve overall health.

Exercise: Regular exercise, independent of weight loss, improves cardiovascular health and insulin sensitivity. Dr. Gandolfo recommends moderate exercise, such as walking, swimming, or weightlifting, for at least 150 minutes per week. Building muscle mass is also crucial, as it helps to combat insulin resistance. Incorporating physical activity into your daily routine can be a game-changer for liver health and overall well-being.

The Role of Coffee

Interestingly, Dr. Gandolfo highlights the benefits of coffee for liver health. Up to three cups of black coffee a day can reduce liver inflammation due to its antioxidant properties. However, he advises avoiding high-calorie coffee drinks that can negate these benefits. The antioxidants in coffee can help protect the liver from damage and reduce the risk of liver disease progression!

The Psychology of Creating a Healthy Lifestyle

Dr. Gandolfo acknowledges the challenge many patients face in creating and maintaining these lifestyle changes. To help make these healthy changes easier, on episode 11 of The Real GI Doc Show he interviews a special guest, Dr. Noreen Vail, a licensed psychologist with a PhD in clinical psychology. Together, they delve into the psychological aspects of making lifestyle changes, particularly focusing on fatty liver disease.

Dr. Vail introduces the transtheoretical model, a well-researched framework that outlines five stages of behavioral change: pre-contemplation, contemplation, preparation, action, and maintenance. She emphasizes the importance of assessing where a patient is on this spectrum to tailor advice effectively. For instance, a patient in the pre-contemplation stage may not be ready to hear detailed diet plans, whereas someone in the preparation stage might benefit from specific actionable steps.

One of the key takeaways from the episode is the significance of setting realistic goals and keeping a journal. Dr. Vail suggests that writing things down can help patients become more mindful of their behaviors and track their progress. This data can be invaluable during follow-up appointments, providing a clear picture of what’s working and what needs adjustment.

Dr. Gandolfo and Dr. Vail also discuss the common excuses patients use to avoid making lifestyle changes, such as lack of time, holidays, or injuries. They stress the importance of consistency over perfection. Missing a day of exercise or indulging in an unhealthy meal occasionally doesn’t derail progress; it’s the long-term habits that count!

Another crucial aspect covered is the role of family support. Dr. Vail advises against nagging and instead recommends a supportive approach. Encouraging loved ones to join in on healthy activities can create a positive environment that fosters change.

Finally, the episode touches on the limitations of time during medical consultations and the importance of a multi-specialty approach. Dr. Gandolfo acknowledges the challenges posed by insurance and the need for accessible pathways to dietitians, psychologists, and other specialists.

This episode is a must-listen for anyone struggling to make lifestyle changes for fatty liver disease or any other health condition. Dr. Gandolfo and Dr. Vail provide practical advice and insights that can help you overcome psychological barriers and set yourself on a path to better health.

Take Action Today

The episodes both conclude with a powerful message: Start today. Whether it’s a 15-minute walk or a small dietary change, taking immediate action is essential for long-term health. Small, consistent efforts can lead to significant improvements over time!

For more in depth information, listen and subscribe to the show here.

Medication for Fatty Liver Disease

If you have been diagnosed with fatty liver disease, there is now an FDA-approved medication called Rezdiffra available for some patients with liver fibrosis. To see if you qualify for treatment, a measurement of your liver health is taken with a FibroScan test. This simple ultrasound test is done in the office and can determine if have significant fatty liver disease, and will also measure the fibrosis level.

To make an appointment for an assessment, send us a message here or call the office during regular business hours.

Watch this video if your colonoscopy prep is not going well…

Posted on March 6, 2024 - 10:34 pm by Frederick Gandolfo MD

I made a video to help with the common problems that people encounter when preparing for a colonoscopy.

If you’re having trouble with the taste of the prep, nausea or vomiting from the prep, or the prep just isn’t working and you’re not clear, this video is for you!

Cologuard® vs. Colonoscopy: Which test is better?

Posted on September 24, 2023 - 1:25 pm by Frederick Gandolfo MD

In the US, colorectal cancer is currently the second leading cause of cancer deaths in men and women combined. Virtually all health professionals agree that screening average-risk people starting at age 45 for colorectal cancer is the best way to prevent this disease. There are a few highly effective tools available for colorectal cancer screening: This article will focus on the two most popular tests, colonoscopy and the Cologuard test.

Most people are familiar with colonoscopy, but in case you’re not…colonoscopy is a safe 15-20 minute outpatient procedure that is done using sedation (so it’s painless) that entails using a flexible scope inserted in the rectum (the end part of the colon) and carefully advanced to the cecum (the other end of the colon) to inspect the entire colon lining for the presence of polyps, tumors, and other abnormalities. A polyp is a “precancerous” growth that is common and if not removed can slowly grow and eventually may turn into colon cancer. During a colonoscopy, the doctor can both find polyps and remove these polyps at the same time. Therefore colonoscopy can both diagnose cancer and polyps, but more importantly colonoscopy can prevent colorectal cancer from occurring in the first place by removing precancerous polyps years before they would have otherwise become cancer. A normal colonoscopy typically does not need to be repeated for 10 years. If polyps are found and removed, a colonoscopy will be recommended sooner, to make sure any new polyps that grow will be found and removed before having a chance to turn into colon cancer. Colonoscopy is considered the gold-standard colon cancer prevention test and is the preferred test by most medical societies.

Image of colonoscopy with polyp removal. — Removing a precancerous polyp with colonoscopy.

Cologuard® is a non-invasive, commercially-available screening test for colorectal cancer. The test is ordered by a doctor (typically a primary care provider) and mailed to the patient’s house. When the urge to have a bowel movement strikes, the patient places the Cologuard collection device over the toilet and makes a deposit. There are a few simple preparation steps such as adding in a small amount of liquid that the company provides, and then the entire container of poop is mailed back to the company in the provided packaging. The Cologuard test looks for blood and certain DNA mutations in the stool to determine if a test is positive or negative. A week or so later the doctor gets a report indicating the result. If the test is negative, it only “protects” the patient for 3 years.

So which test is better, colonoscopy or Cologuard?

Well, it really depends on what the goals are…

As a general philosophy, it’s much more effective to prevent a disease from occurring rather than waiting for the disease to occur, then reacting to it. When the disease in question is colon cancer, preventing it starts with healthy diet and lifestyle as well as screening the population at large for polyps, the precancerous growths that cause colon cancer. To have a colonoscopy and remove a significant polyp is akin to stopping a future cancer from occurring in the first place. When effective preventive tests like colonoscopy exist, to wait until a patient has developed cancer and then treating the cancer is like waiting until you have been in a car accident to then put on your seatbelt…it’s too late. Although there are excellent treatments available for colorectal cancer nowadays, including surgery and chemotherapy, treating cancer is not the goal of screening. The goal of screening is to not develop cancer of the colon in the first place!

Typically, when an effective prevention technique exists (like removing precancerous polyps during colonoscopy) the earlier we can screen for colon cancer the better. This is why colonoscopy is the preferred test for younger healthier people starting at age 45. Save a 45-50 year old from colon cancer and you will potentially give that person 30-40+ years of life having not developed colon cancer. Saving a 79 year old from colon cancer is still a commendable goal, however the average 79 year old typically won’t have as many quality years left “in the tank” compared to the average 45 year old.

So why does this philosophical stuff matter when it comes to picking a colorectal screening test? Well, understanding what these tests do helps you understand how to apply the proper test to your individual goal.

If this article is already too long and you just want the bottom line, here it is: Colonoscopy is the superior test for most people, especially “younger” people (age 45-mid 70s). It can both detect and (more importantly) prevent colorectal cancer. It is semi-invasive and less convenient when compared to Cologuard testing. Cologuard is an easier test but plagued by false negatives and false positives. Cologuard does not necessarily prevent cancer, it only detects cancer after cancer has occurred, or at best detects large polyps that are close to becoming cancer. Cologuard should be considered for older patients (age 75+), for patients that may not have the best overall health, or for patients who have specific reasons why they cannot have a colonoscopy.

OK, you asked for it! Here are more details, starting with the Cologuard test:

The study that determined the characteristics of the Cologuard test basically performed the test on almost 10,000 patients at average-risk of colon cancer, and then had the patients undergo colonoscopy as the gold-standard test. The results of the Cologuard test were not available to the patients or the endoscopist at the time of the colonoscopy. The major results of this study showed that the Cologuard test had a sensitivity (the amount of times it picked up colorectal cancer when cancer was indeed present) of 92%. It was far less sensitive for picking up advanced precancerous polyps, at only 42%. It turns out that sensitivity is the main thing we care about in a screening test: we want the test to miss none of the patients who have the disease. A perfect screening test would have a sensitivity of 100%, meaning that if 100 people have colon cancer and have the test, all 100 people will get a “positive” test result, meaning no false negative tests.

Sensitivity isn’t everything however…we also want a test that gives a negative result when someone does not have the disease in question. That is, if you take a group of 100 people that do not have colorectal cancer, a perfectly specific test will have 100 “negative” results, meaning no false positive tests.

What does a positive Cologuard test mean?

First and foremost, a positive result on the Cologuard test means that you need to have a colonoscopy. Not a virtual colonoscopy, or another stool test, or another scan of some sort…you need a real optical colonoscopy. Luckily, only about 4% of people with a positive Cologuard test will have cancer found on colonoscopy. 51% will have a precancerous polyp. The rest (45%) will have nothing found on colonoscopy. So to simplify even further, just a little more than half of people with positive results will have something abnormal (cancer or a polyp) found on colonoscopy.

What does a negative Cologuard test mean?

A negative test means that there is a less than one-percent chance of having cancer found on colonoscopy. However, about 34% of people with negative tests still have precancerous polyps found on colonoscopy, with the remainder (66%) of people with negative Cologuard results having truly negative colonoscopies.

What is immediately apparent from these numbers is that Cologuard rarely misses cancer. However, if we count polyps as a significant finding, there are plenty of false-positive results (45%) and plenty of false-negatives too (34%).

A word on how health insurance companies view Cologuard…

While not important to the medical reasoning behind choosing colonoscopy or Cologuard, for some people it is important to note the finances of each test. Either colonoscopy or Cologuard can be considered a screening test, and is typically covered by health insurance plans without an out-of-pocket cost. However, if a Cologuard test is positive (remember that 45% false positive rate discussed above), the insurance company now views the necessary colonoscopy as a diagnostic colonoscopy, not a screening colonoscopy. Diagnostic tests often have an out-of-pocket responsibility for the patient and in the case of a colonoscopy this can be in the thousands of dollars range. This is something rarely discussed when ordering a Cologuard test in the primary care setting, but that we often need to educate patients about when it’s time to book their colonoscopy to follow up a positive Cologuard test.

What about colonoscopy? Are there any downsides?

In good hands, colonoscopy is an excellent test—it’s the best test we have in the fight against colon cancer. However, no test is perfect and colonoscopy is no exception. Even though colonoscopy is the gold-standard test, here are some of the negative things to know about colonoscopy.

Colonoscopy requires a bowel preparation, meaning you have to take either a liquid prep or pill prep to clean out the colon the day before. It’s not painful, but prepping for a colonoscopy is far from a good time. Colonoscopy has small but real risks, such as bleeding, infection, perforation of the bowel, and anesthesia problems. However these risks are very rare, and in with a skilled team the risk of a serious complication is far less than 1 in 1,000 procedures. Colonoscopy also has a miss rate for polyps and even cancer. It is very hard to define an actual number of missed lesions because it’s difficult to perform a study on the gold-standard test (colonoscopy) as there is no better test to compare it to. That being said, colonoscopy can miss small polyps around 20% of the time, and can even miss cancer a few percent of the time. The devil is in the details however: Missing a significant lesion during an outpatient screening colonoscopy in a properly prepped patient (meaning the patient did the bowel cleanse effectively) with a doctor that performs high-quality colonoscopy (meaning the doctor spends adequate time and uses excellent technique to find and remove polyps) is quite a rare event and is something that is difficult to study given variations in quality practice between doctors even in the same community or hospital system.

Here is a quick pros and cons table to help clarify all of the above

Measure	Colonoscopy	Cologuard®
Prevention of colon cancer?	Yes	Not really
Repeat a normal test every	10 years	3 years
Overall convenience	Bowel prep and 1 day off work	No prep but have to handle stool
Overall invasiveness	Moderately invasive	Not invasive
Accuracy	Very accurate	Not very accurate
Biggest upside of the test	Better cancer prevention and accuracy	Easy and can do it at home
Biggest downside of the test	Bowel prep and less than 0.1% chance of complications	Lots of false positives that will require a colonoscopy anyway

How do I choose between colonoscopy and Cologuard in my practice?

I typically reserve Cologuard testing for patients that just need to know if they have cancer right now, and are not in good condition to undergo colonoscopy due to other major health issues. A patient that has not been screened recently who is approaching 80 years old, and who has one or more major cardiovascular or pulmonary issues is a good candidate for Cologuard testing. For pretty much everyone else, colonoscopy is by far the better test.

References:

Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Multitarget stool DNA testing for colorectal-cancer screening. N Engl J Med 2014;370:1287-97.

Cologuard website: http://www.cologuardtest.com/current-patients/how-to-use

Cologuard is a registered trademark of Exact Sciences Corporation.

Fatty liver disease and the FibroScan® test

Posted on August 1, 2023 - 12:52 am by Frederick Gandolfo MD

Fatty liver disease is very common and can lead to serious health problems if ignored. Here is how to calculate your risk of having complications from a fatty liver, and how to find out if you would benefit from FibroScan testing.

What is fatty liver?

Fatty liver is a very common condition in the US, with an estimated prevalence of 40% of the population. Also known as hepatic steatosis, this condition is characterized by the presence of excess fat storage in the liver. If the liver holds on to enough excess fat, it can become enlarged, inflamed, and lead to more severe liver problem in the future. Recently, fatty liver was renamed to steatotic liver disease (SLD) to avoid the stigma associated with the word “fatty” but this change in nomenclature will take many years to catch on and most people will continue to refer to this condition as fatty liver disease for the foreseeable future.

What causes fatty liver?

Most cases of fatty liver are related to a condition called nonalcoholic fatty liver disease (NAFLD) which was also recently renamed to metabolic dysfunction-associated steatotic liver disease (MASLD), but excess alcohol use is another common cause of fatty liver disease, as are many other liver conditions.

Who gets fatty liver?

Risk factors for developing fatty liver disease include diabetes, obesity, having other metabolic diseases such as high blood pressure, high cholesterol, or high triglycerides, or drinking excess alcohol (more than 2-3 drinks a day for men, or more than 1-2 drinks a day for women). Overall the metabolic dysfunction that leads to fatty liver is characterized by insulin resistance, low or dysfunctional muscle mass, and the inability to properly dispose of (meaning burn or store properly in liver or muscle) excess calories taken in from food sources.

Now let’s look at the main risk factors for fatty liver disease in more detail:

Diabetes: About 70% of patients with type 2 diabetes have fatty liver. Diabetics are the highest risk group of people to develop fatty liver.

Obesity: Living with obesity is a risk for fatty liver also. The easiest way to define obesity is to use the body mass index, or BMI, with a BMI greater than 30 defining obesity. Being overweight, meaning your BMI is between 25 and 30, is also a risk factor for fatty liver, especially if you have other metabolic risk factors.

Use this calculator to determine your BMI

Alcohol: Alcohol use is a major cause of fatty liver disease, as well as alcoholic hepatitis and cirrhosis. The type of drink doesn’t matter, as a standard serving of beer (12 oz), wine (5 oz), and liquor (1.5 oz) all contain the same amount and type of alcohol. What really matters is the amount of alcohol consumed weekly, and the time (months to years) that this consumption goes on for. To illustrate this point with some real numbers, men < 65 years old are at risk of alcoholic liver disease by drinking more than 14 drinks per week, or more than 4 drinks per occasion, and women or people >65 years old are at risk by drinking more than 7 drinks per week, or more than 3 drinks per occasion. If these numbers seem low, that should drive home the point that alcohol is a toxin to the liver and should be significantly limited or better yet completely eliminated from the diet. Some people are more susceptible to the damaging effects of alcohol than others: In fact, cirrhosis can occur in up to 30% of people who consume only 2-3 drinks per day for many years.

Are there symptoms of fatty liver disease?

Often thought of as an asymptomatic condition, fatty liver disease actually does have several associated symptoms:

Abdominal pain: Typical pain from fatty liver is mild, dull, nagging and located in the right upper abdomen. Sometimes the pain is felt in the right flank and/or in the back too. The pain can be worse with bending forward, and is sometimes more noticeable in the evenings.

Fatigue: Since it’s an inflammatory condition, fatty liver can cause a feeling of generalized fatigue.

Pruritis: This is the fancy term for itchy skin. It’s typically mild or nonexistent in most people with fatty liver, but occasionally itchy skin becomes a problem with advanced fatty liver disease.

Metabolic dysfunction: While not technically a symptom, metabolic dysfunction is often the root cause behind the common complaints of the feeling of inability to lose weight, bloating, low energy, poor sleep, and so-called “brain fog” that often is associated with underlying insulin resistance and poor metabolic health. The onset of fatty liver is often one of the first measurable signs that something is very wrong.

Why is fatty liver dangerous?

By itself, having fatty liver alone increases your risk of several other non-liver related conditions, most notably heart disease, stroke, cancer, and also increases all-cause mortality (the risk of death in general). In non-diabetics, having fatty liver greatly increases the chance of developing diabetes in the future by contributing to a condition known as insulin resistance.

However, in some people with fatty liver disease, the liver cells become chronically inflamed. Blood tests may show elevated liver numbers (AST and ALT) because the damaged liver cells are leaking their enzymes into the blood. When liver inflammation from fatty liver occurs, it is called nonalcoholic steatohepatitis, also known as NASH (this condition was also renamed recently to metabolic-dysfunction associated steatohepatitis, or MASH).

Left alone for a few years, people with inflamed fatty livers can slowly develop scar tissue in the liver called fibrosis. This scarring is the body’s attempt to repair the chronic inflammation from the inflamed liver cells. However unlike inflammation from a wound or surgery which typically gets better as time passes, the inflammation from NASH is ongoing, causing the body to lay down scar tissue in the liver for years and years. The end result of this process of progressive fibrosis of the liver is cirrhosis, or end-stage scarring in the liver that causes permanent dysfunction of the liver.

How do I know if I have fatty liver or liver fibrosis?

Despite the above symptoms, most people with fatty liver disease or liver fibrosis are walking around living their lives without a clue that there is liver damage happening behind the scenes.

Occasional blood testing to measure the liver enzymes is a decent way to evaluate for fatty liver disease. However, many patients with fatty liver disease and even patients with advanced liver damage may have completely normal liver function tests. An abdominal ultrasound, CT scan, or MRI can often suggest fatty liver too. However none of these methods are very accurate in identifying patients with advanced fatty liver disease, and liver biopsy remains the gold standard test for diagnosis of fatty liver, liver fibrosis, and cirrhosis. However liver biopsy is invasive, sometimes painful, costly, and has significant risks like bleeding.

A more sophisticated test for fatty liver disease and liver fibrosis is called FibroScan. A FibroScan test is a type of ultrasound test that measures the physical properties of the liver to determine liver fat content and liver stiffness. FibroScan can be thought of as a non-invasive liver biopsy and it samples a larger area of liver tissue when compared with a traditional needle biopsy.

How does FibroScan work?

Fibroscan is painless, non-invasive, and takes about 5-10 minutes to perform. It is similar to a traditional ultrasound as it uses a small ultrasound probe to locate the liver, but instead of taking images of the liver, FibroScan is used to measure certain properties of the liver tissue instead.

FibroScan measures liver steatosis, meaning how much fat is contained in the liver. So instead of a traditional ultrasound or CT scan that just states (for example) mild fatty liver, or severe hepatic steatosis, FibroScan will produce a numerical value that corresponds to the amount of steatosis (fat) in the liver. This number is more accurate than just estimating the severity based on traditional imaging, and can be used to follow a patient’s progress as time goes on. When the steatosis number goes up, the fatty liver is becoming more severe. If the patient is successful in treating their fatty liver, we can watch the steatosis number improve which is proof that the disease is improving.

More importantly, FibroScan allows the measurement of liver fibrosis. This is the value that we truly care about, as fibrosis (liver scarring) is what ultimately correlates with all the bad outcomes of liver disease. If a patient is developing fibrosis, we need to take more drastic action to prevent the fibrosis from progressing into liver cirrhosis over the next few years. FibroScan measures fibrosis by calculating liver stiffness. To do this, the ultrasound probe will send a small pulsed vibration (it feels like a mild tap on the body) through the liver, and measure how fast the liver moves after this small vibration. The vibration wave will pass very quickly through a stiff liver, which means the liver tissue is fibrotic. The vibration wave will pass more slowly through healthy and pliable liver tissue, meaning no fibrosis is present.

Here is an analogy for how the FibroScan measures liver stiffness: Think of tapping your knuckle on a stiff surface like your kitchen table…the force travels rapidly across the table and if someone puts their ear to the other side of the table they would hear the tap almost instantly as it is transmitted through the table. Now try this same experiment on your couch cushion. This is a pliable (not stiff) surface, and the force of your tapping knuckles will be dissipated by the movement of the couch cushion and barely audible to a person with their ear on the couch. That’s how FibroScan works to measure liver stiffness and calculate liver fibrosis.

Who should get a FibroScan test?

There are several indications for FibroScan. Since fatty liver disease is severely underdiagnosed in the population (meaning many people are walking around with significant liver disease and don’t know about it), many of the major medical societies have recently changed their guidelines to push for early detection and treatment of fatty liver disease.

Before we get into the details, we need to review something called the FIB-4 score. This simple non-invasive scoring system was derived to help see who is at risk of more advanced liver disease (fibrosis). It requires only a few values available from routine blood tests: platelet count, AST, and ALT. You can calculate your FIB-4 score below.

If your FIB-4 score is low (less than 1.3), you have a low risk of liver fibrosis.

If your FIB-4 score is high (greater than or equal to 1.3), you are at higher risk of liver fibrosis and more testing is needed.

So who should check their FIB-4 score?

Patients who are obese: In patients with obesity (BMI>30), and the presence of two or more metabolic risk factors (high blood pressure, high triglycerides, low HDL cholesterol, prediabetes), the FIB-4 score should be used to determine who needs further testing with FibroScan.

Patients with type 2 diabetes: All type 2 diabetics should be screened using the FIB-4 score, even without having other risk factors like obesity or metabolic syndrome.

If you are in one of the two groups above, and your FIB-4 score is greater than or equal to 1.3, you should get a FibroScan for further assessment of your liver.

Who else should get FibroScan testing?

Patients with elevated liver function tests (LFTs): If your liver tests are significantly elevated, you should have a complete evaluation to determine why this is the case. This typically involves further blood testing, ultrasound imaging, and often a FibroScan.

Patients with abnormal liver imaging: If you already have signs of fatty liver, fibrosis, or other signs of liver disease on imaging, you should consider FibroScan testing to better clarify your risk of developing more advanced liver disease.

Patients who consume a significant amount of alcohol: If you are worried about your drinking, or consume more than 21 drinks per week for a man, or 14 drinks per week for a woman, you should consider FibroScan testing to determine if you have fatty liver disease, fibrosis, or cirrhosis.

Conclusions

Fatty liver disease is very common and is a major risk factor for developing more severe liver diseases like fibrosis and cirrhosis. Most patients with diabetes, and many patients with obesity and other associated metabolic health problems have fatty liver disease. Alcohol is also a strong risk factor for developing liver disease. You can check the two most important measures of your liver health (steatosis and fibrosis) with a quick non-invasive FibroScan test.

Precision Digestive Care is the first practice in the Huntington area to offer FibroScan testing. This test is covered by most insurance plans. If you are in need of a FibroScan test, please contact us to schedule.

VIDEO: Colonoscopy prep with pills only! All about Sutab!

Posted on April 3, 2023 - 12:54 pm by Frederick Gandolfo MD

The colonoscopy prep experience is by far the worst part of the whole procedure. For years, patients have been asking “Isn’t there a better way to do the prep?”

Well, now there is! There is a prescription bowel prep called Sutab that I have been using for the past two years for most of my colonoscopy patients. Sutab comes in a kit which includes 24 pills and a container to measure the water, and it couldn’t be any easier to take. Most of my patients that have used the older liquid preps in the past are pleasantly surprised after using Sutab for the first time!

Here is a short video I made showing you how to use Sutab. I also cover the diet you should follow to make sure your “clean out” is as clean as possible, and how to handle the common side effect of all bowel preps…nausea.

Understanding How to Prevent Diverticular Disease

Posted on October 22, 2020 - 10:24 am by Frederick Gandolfo MD

Diverticular disease is the term that covers both diverticulosis and diverticulitis. While almost everyone has heard these terms, many people still mix up the difference between diverticulosis and diverticulitis. Furthermore, there is a lot of misinformation out there regarding these common conditions, so it’s time to review what is new in the world of diverticular disease!

Let’s start with some basics: The tiny pockets that occur on the outside of the colon that we call diverticula are actually better described as pseudodiverticula (false diverticula) due to the fact that they only contain the inner two layers of the colon wall, called the mucosa and submucosa.

These inner two layers that form the lining of the bowel become pseudodiverticula by herniating through small natural weak points in the muscle layer of the colon. The weak points exist as natural openings where small blood vessels called vasa recta penetrate the bowel wall to feed blood to the inner layers of the colon. For various reasons that we will cover below, the inner mucosal and submucosal layers of the colon can pop through these openings and luckily will become contained by the outermost layer of the colon (called serosa) to form a small pocket, now called a diverticula.

Since pseudodiverticula is a mouthful, people just refer to these pockets as diverticula. The condition of simply having these small pockets is called diverticulosis.

Diverticulosis is typically asymptomatic, but can also cause several symptoms. Minor symptoms of constipation and chronic left lower abdominal discomfort may be related to diverticulosis and are thought to be caused by altered colon motility (loss of normal movement), narrowing of the colon, loss of compliance (lack of “stretchiness”) of the left side of the colon, and mild inflammation of the bowel in the affected area. The symptoms of diverticulosis often overlap with symptoms of a condition called irritable bowel syndrome (IBS).

The more severe complications of diverticulosis are diverticular bleeding and diverticulitis.

Diverticular bleeding is typically painless and may present as massive bleeding. Fresh red blood is usually passed from the rectum as one of the small penetrating vasa recta arteries ruptures and bleeds into the bowel lumen (inside the colon). Diverticular bleeding often results in hospitalization, and may require blood transfusion and/or procedures to control bleeding such as colonoscopy, angiography with embolization, and even surgery if the bleeding does not stop. Fortunately, most cases of diverticular bleeding are self-limited, that is, the bleeding stops on its own and the treatment mainly consists of supportive care.

Diverticulitis is the term used to describe inflammation of a diverticula and the surrounding segment of colon. This is typically quite a painful process and is often associated with a fever, sometimes constipation, and decreased appetite. The abdominal pain from acute diverticulitis is often present in the mid lower abdomen, the left lower abdomen, or a combination of both of these sites.

Laboratory testing in acute diverticulitis will often reveal an elevated white blood cell count and elevated inflammatory markers such as C-reactive protein (CRP). A CT scan of the abdomen and pelvis is the diagnostic test of choice, and will reveal a thickened and inflamed bowel wall, often with inflammatory changes extending outside the bowel wall into the surrounding fatty tissues, and possibly with evidence of “microperforation” or other complications. Treatment typically involves antibiotics, bowel rest or a limited diet, and local management of any complications (such as draining an abscess). Eventually surgical resection may be needed in cases of complicated or recurrent diverticulitis.

Now that we have reviewed the basics, I would like to cover some of the common questions that I get asked by patients about diverticular disease.

How did I get diverticulosis?

Diverticulosis is often though of as a disease of Western society, and is associated with several diet and lifestyle factors. Most notably, diverticular disease is associated with a low-fiber diet, a diet high in processed foods and red meat, a sedentary lifestyle, obesity, and smoking.

However, diverticular disease also has a genetic component. It is likely that genetic factors and lifestyle factors both play a role in developing diverticular disease.

Age is also a factor: The older you become, the higher the likelihood that you will develop diverticulosis!

Is there a special diet to follow for diverticulosis?

Yes! To prevent diverticulosis, you should eat a high-fiber diet of mostly plants, whole grains, and legumes. A high-fiber diet means about 30 grams of fiber a day for women, and about 35 grams of fiber a day for men, but more is better (to a point).

However, a high-fiber diet is not the whole picture! It is also important to eat anti-inflammatory foods such as seeds, nuts, fish, and olive oil! Diverticular disease is an inflammatory process, and foods like red meat, processed meat (bacon etc.), and processed carbs (sweets, snack foods, fast foods, etc.) are pro-inflammatory and can cause issues like diverticulitis to occur more frequently.

Can I eat seeds and nuts if I have diverticulosis?

Yes you can! It is not necessary to avoid seed and nuts if you have diverticular disease. Probably the best evidence we have that seeds, nuts, corn, and popcorn do not cause complications in patients with diverticular disease comes from a study published in JAMA in 2008 showing that not only was intake of nuts, seeds, popcorn, and corn NOT associated with developing diverticulitis, but in fact the opposite was true. Eating more seeds, nuts, corn, and popcorn actually seemed to be associated with LESS of a chance of developing diverticulitis! These foods are thought to be somewhat anti-inflammatory, and therefore may protect against diverticulitis.

What other lifestyle factors should I consider if I have diverticulosis?

The big four things to consider with diverticular disease (and every other disease) are smoking, alcohol use, obesity, and exercise.

Smoking: Bad in every way and increases inflammation throughout the body. Smoking is associated with diverticulitis. Smoking is also associated with poor wound healing after surgery. Don’t do it! (If you’re serious about quitting, ask your primary care doctor for help.)

Alcohol: Not great for your colon and can sometimes cause inflammation in the bowel. To be enjoyed sparingly.

Obesity: Associated with total-body inflammation and correlated with diverticular disease. Increases risk of surgery if needed for diverticular disease. (If you suffer from obesity, the best time to start working on your weight was 10 years ago, and the second best time is today! Check out my simple starter plan here.)

Exercise: Aside from the role of exercise in weight loss, exercise also promotes a healthy colon, and can help keep your other healthy lifestyle changes in check by creating a positive-feedback cycle. Try to do a little exercise every day, or at least four days a week!

Does diverticulosis ever go away?

No, not really. Once the pockets are there, they don’t regress and disappear. They’re similar to wrinkles in that way. However, the goals are to prevent new diverticula from forming and to prevent the pockets that are there already from worsening or developing complications such as diverticulitis.

Following a healthy diet and lifestyle is still important, even if it won’t turn back time and remove the diverticula from your colon! In fact, it is estimated that you can reduce your risk of developing diverticulitis by up to 75% by following the basic diet and lifestyle advice above!

New knowledge about diverticular disease

“Old School”	“New Knowledge”
Diverticulosis is caused by constipation	Diverticulosis may be associated with constipation but no causative role has been established
Diverticulosis is caused by a lack of dietary fiber	Diverticulosis is related to a low-fiber Western diet, but fiber may not be the most important factor
Seeds and nuts are dangerous and should be avoided!	Eat as many seeds and nuts as you want. The more the better actually!
Diverticular disease affects elderly people only	Diverticular disease is common in young people (especially men) and the prevalence is rising!
Diverticular disease just happens to people randomly	There is a strong genetic predisposition to diverticular disease. It might be your parents fault!
Diverticular disease is due to small pockets herniating through the colon wall, a purely mechanical process due to high pressures in the colon	Diverticular disease is an inflammatory condition, and there are chronic cellular changes found throughout the entire colon wall
Lifestyle and diet are not associated with diverticular disease	The Western diet and lifestyle (obesity, smoking, high red meat intake, alcohol use, and physical inactivity) dramatically increases the risk of diverticular disease!

Summary

Diverticulosis and diverticulitis are very common diseases. Many people have mild cases of diverticular disease and never need medical attention, but there are several common complications of diverticulosis that do require medical attention and can be quite dangerous.

Overall, the paradigm is shifting and we are beginning to think of diverticular disease as a type of inflammatory condition with a genetic predisposition, rather that purely a mechanical problem related to constipation and high pressures in the colon.

Following a healthy diet and lifestyle can dramatically reduce your risk of suffering complications from diverticular disease, so make sure to eat your vegetables, limit processed foods and red meat, get a little exercise every day, stop smoking, and work on maintaining a normal body weight.

Everyone should know these key facts about colorectal cancer

Posted on March 15, 2019 - 1:55 am by Frederick Gandolfo MD

March is Colorectal Cancer Awareness Month, so I made this infographic to highlight the key facts that everyone should know about colorectal cancer!

For much more about this and other important health topics, please visit my informational site Retroflexions.com!

Fermented dairy products like kefir may reduce the risk of colon cancer!

Posted on July 3, 2018 - 7:19 pm by Frederick Gandolfo MD

Fermented dairy sounds rather disgusting, as the name suggests something akin to spoiled milk, but in reality most fermented milk products are actually quite delicious! Fermented dairy products are foods like yogurt, cheese, sour cream, and kefir among others. The process of fermentation is usually done by bacteria such as Lactobacillus species, and results in a product that is more shelf-stable than milk, while retaining all of the protein and other substances that give milk its healthy reputation. Fermented dairy has been enjoyed by people dating back to about 10,000 B.C., so that trendy kefir stuff you are now seeing at the local food store is really nothing new…

Please click here to read the full article on my informational site ‘Retroflexions.’

American Cancer Society recommends colorectal cancer screening to begin at age 45

Posted on June 2, 2018 - 10:39 pm by Frederick Gandolfo MD

On May 30, 2018, the American Cancer Society (ACS) released new guidelines regarding colorectal cancer screening for the average-risk individual. The big news is that they now recommend that screening for colorectal cancer begin at age 45 rather than age 50. This reduction in the starting age was in reaction to recent data showing that colon cancer is increasing in younger Americans for unclear reasons. By screening people at a younger age, the hope is that we can detect and prevent colon cancer in more people.

The ACS states that 20% of new cases of colorectal cancer occur in the younger-than-55 crowd. Furthermore, despite a general downward trend in colorectal cancer in the over-50 population, the risk is actually rising slightly in the subgroup of people aged 50-54. These are the cases of cancer the new guidelines are trying to prevent. The ACS is pragmatic in acknowledging that people don’t typically sign up for a colonoscopy exactly on their fiftieth birthday…in fact many wait a few years or more after age 50 to get screened. By pushing the starting age up by 5 years there will likely be a benefit to these patients who would otherwise be late to the colonoscopy party.

The consequences of these recommendations are potentially huge. If these guidelines are followed, an estimated twenty million additional people are now eligible for colon cancer screening. However, the ACS does not specify any one best choice for colorectal cancer screening and states that colonoscopy, stool DNA testing (Cologuard), virtual colonoscopy, and stool testing for occult blood with Guaiac-based tests or FIT testing are all equivalent. I think that by now we know that all tests are not really equivalent, with colonoscopy being the gold-standard test, but with millions of people not getting any type of screening at all, any test is better than nothing.

“My thirties are going great! And in a few short years, I’ll need my first colonoscopy!”

A few caveats about these new recommendations:

The ACS states that the recommendation to start screening at age 45 is a qualified recommendation, meaning that there are clear benefits of screening at this younger age but there is less certainty about the exact risk-to-benefit ratio of the recommendation. This is opposed to a strong recommendation, which means the benefit is clear and almost everyone should do it. (Beginning screening at age 50 remains a strong recommendation from the ACS.)
Other guideline-producing organizations such as the US Preventive Services Task Force (USPSTF) have not changed their recommendations for colorectal screening, which still remain at age 50 to start.
Just because the American Cancer Society changed the recommendation to age 45, doesn’t mean that insurance companies are going to cover the testing! This is perhaps the most interesting part of these new guidelines…who is going to pay for this?
Starting screening earlier is definitely going to pick up and prevent more cancers than starting later, however is 45 the best age to start? Surely starting at 44 would pick up even more cancers! I bet starting at 40 would pick up even more than that! What I’m trying to illustrate is how there can be a slippery-slope with these type of recommendations: You will always find more cases of colorectal cancer if you start looking for it in younger and younger people. At what point do the risks of screening more and more people start to outweigh the benefits? Only time and more research will help answer this question.
What about the truly early-onset colorectal cancer patients? These are patients diagnosed in their twenties and thirties…how do we detect them before they develop the disease? I doubt anyone will recommend starting routine screening colonoscopies at age 18! This very young onset colorectal cancer may just behave differently than the typical sporadic colon cancer that develops later in life. We need to develop different ways of finding the young patients at risk, and determine why the risk is rising in the younger population.