Digestive Disease Week 2007

May 19-24
Washington Convention Center
www.ddw.org

Signs of DDW: Prevacid-pink buses and purple backpacks!

Topic: The gut – arguably the most dramatic organ in the body.

Attendees: 16,000 physicians, researchers and academics from around the world seeking to boost their GI IQ. Minimum Daily Pun: People with guts.

Fields: Gastroenterology, hepatology, endoscopy and gastrointestinal surgery; prevention, diagnosis and treatment of digestive disorders. DDW is jointly sponsored by four societies: American Association for the Study of Liver Diseases (AASLD), American Gastroenterological Association (AGA), American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT)

INSIGHTS:

* Vegetarian Diet Shown to Prevent Risk of Colon Cancer:
Mammas, don’t let your babies grow up to be carnivores. Okay, Willie Nelson’s version referred to cowboys. But eating healthy vegetarian diet from an early age virtually prevents the risk of colon cancer, as shown in what some top docs called a “stand-out study.”

The average person’s lifetime risk of developing colorectal cancer is 7 percent, and diet appears to play a key role. Colon cancer is the second leading cancer in the U.S., but has very low incidence in the Far East. Why such a difference? Diet? Environment?

To see if a vegetarian diet (no animal flesh) started early in life could help prevent colorectal cancer (CRC), researchers from Tata Memorial Hospital in Mumbai, India, conducted a study of 8,877 people managed in a clinical nutrition service from January 1, 2000 through December 31, 2005. The people were middle-aged. Researcher team member Dr. Yogesh Shastri, MD presented the results of the study, which was conducted in India, where more than one-quarter of residents are lifelong vegetarians due to spiritual tradition.

The Hindu believe cows are sacred. There are even some old-age homes for geriatric cattle in India. Dietary practices forbid eating animal flesh and eggs, but it is not a vegan diet since consumption of milk and milk products is allowed.

Study results:

* Colorectal cancer (CRC) appeared more frequently in the elderly and in males.

* CRC was inversely associated with vegetarian diet, lower weight and economic deprivation. This means that these folks didn’t have colorectal cancer. The inverse association of CRC and lifelong vegetarianism was observed with all the three control groups.

“A well-planned vegetarian diet is a healthy way to meet your nutritional needs,” said Dr. Shastri, currently with Johann Wolfgang Goethe University Hospital, Frankfurt, Germany. Vegetarianism starting early life appears to be a smart idea for avoiding this kind of cancer.

Dr. Shastri would like to conduct the same study in Western populations, but it is hard to find a large cohort of lifelong vegetarians in the U.S. and other western nations. Next steps, he said, will involve investigating the possible protective benefits of components common to Indian vegetarian diets such as garlic and the spice curcumin (which is not the same as cumin).

* Snack Study – Bowel Wow:
Diverticulosis is a common disease of the large intestine characterized by pouches in the colon that bulge outward through weak spots. These pouches can become inflamed, a complication called diverticulitis. Or they can bleed, sometimes profusely.

One-third of people develop diverticulitis by age 60 (most asymptomatic) and two-thirds by age 85. While most are asymptomatic, many suffer from such problems as bleeding.

Patients are typically advised to avoid nuts and seeds, even though little evidence pointed to these foods as villains. And it’s not uncommon for doctors to ask if a patient ate popcorn – and then blame the patient for such sinister snacking if and when symptoms flare.

Dr. Lisa Strate reported on a study of 47,454 men in the U.S. aged 40-75 at baseline, which was 1986, and free of diverticular disease, GI (gastrointestinal) cancer and IBD (inflammatory bowel disease) in 1986. Strate had questioned the conventional wisdom that “rough” foods would aggravate digestive disorders and diseases. “On the flip side, patients have been told to eat a high-fiber diet, but in being advised to stay away from nuts and popcorn, this gives them a mixed message.”

Data from 18 years of follow-up of this large cohort indicate that nut and corn consumption do not increase the risk of diverticular complications. In fact, those frequently consuming popcorn had a reduced risk of diverticulitis. For example, men with the highest popcorn intake – at least twice a week – had a 28% decrease in the risk of diverticulitis compared to men with the lowest intake – less than once per month.

Nuts have anti-inflammatory properties, and popcorn provides helpful fiber. It’s healthy unless slathered in butter and studded with salt.

This study’s results, once peer reviewed and published, should lead to revised practice guidelines to update medical literature. Then the dietary messages could be simplified.
“We are finding non-pharmacological solutions, more and more, are helping patients. This is such an important finding since pharma solutions have side-effects and expenses,” said Dr. Maria Abrau of the Mount Sinai School of Medicine.

* Fatty Soup Curbs Appetite:
University of Texas/Galveston researchers hypothesized that an appetizer determines your overall appetite, since absorption of fat in the small intestine induces the feeling of being full (satiety) and slows down gastric emptying. Dr. Xiaohong Xu reported that 12 lean and 12 obese healthy subjects spent two sessions at the lab eating both fatty soup and protein soup, each with the same number of calories and volume. Each session consisted of a 30-minute baseline of soup consumption, a 20-minute post-soup period, an “all you can eat” pizza meal, and a 60-minute post-meal period.

Electrogastrogram – a test recording the electrical activity of the stomach – and electrocardiogram – recording electrical activity of the heart – were recorded and food intake assessed by the caloric count of the consumed pizza.

In a second study, subjects were given the soup appetizer and then taken to an “all-you-can-eat” pizza buffet together in a social setting.

Compared with the protein soup, the fatty soup reduced the amount of caloric intake by 20% at the following meal in both lean (962.0 vs. 1,188.5 calories) and obese (1,331.9 vs. 1,544.6 calories) subjects. A similar reduction in calorie intake was noted when lean test subjects ate in the social setting (1,555 vs. 1,825 calories). Also noted: significantly more food was consumed in social sessions than in the lab.

* Chronic Constipation Update and Fecal Factoids:

The breakthrough laxative PEG 3350 is newly available over the counter.

There’s a little brain that controls our bowels since our mainframe brain is usually preoccupied.

Many people “mislearn ineffective rectal emptying,” so they strain instead of contract the appropriate muscles. 50% of these folks experience chronic slow motility or transit (evacuation).

Among those for whom pelvic floor dyssynergia accounts for chronic constipation, more than half in studies have reported biofeedback the most effective solution.

Downward Motility: A problem common among many young women these days is infrequent bowel movement – once a week or less.

Chronic constipation and IBS-C (with constipation) are overlapping multisymptom disorders. Effective therapeutic options include: psyllium (an over-the-counter/OTC bulking agent); Lactulose (Rx), PEG 3350 (newly OTC), Lubiprostone (Rx), Tegaserod (Rx pending FDA review), pelvic floor retraining in patients with abnormal anorectal testing ... and for an unfortunate few, colectomy in a few patients.

* Obesity News:
Obesity in America has been increasing by 1% per year since 1980. More than 60% of U.S. adults are deemed overweight. Overweight and obesity prevalence levels in black women are somewhat higher than Mexican women, and about 25% higher than white women.

Medical complications of obesity: heart disease, pancreatitis, lung disease, hypoventilation syndrome, many kinds of cancer, cataracts, hypertension, osteoarthritis, fertility and menstruation disorders, and phlebitis.

* High Impact Economics:
Obesity generates extra loads of prescriptions: Polypharmacy, defined as more than 4 drugs prescribed during an 18-month period, shoots up along with BMI, as well as age. The direct medical costs of obesity in the U.S. have been estimated as more than $92 billion in 2002.

* Say Not Yet to Drugs:
Studies showed (as have previous studies), lifestyle modification such as much healthful eating reduce diabetes incidence and mortality rates. That’s the first line of defense, before pharmotherapy (drugs) and surgery, such as bariatric surgery. Speaking of which, advances in bariatic surgery include the Lap Band, vertical banded gastroplasty, gastric bypass, and biliopancreatic diversion with duodenal switch, with effects spanning restriction and malabsorption.

* Small Loss, Big Gain:
Modest weight loss of 5 to 7 percent reduces selected morbidities such as type 2 diabetes. One behavior modification study indicated a 5 to 10% loss of body weight can lower total cholesterol, triglycerides, LDL “bad cholesterol,” blood pressure, lower back pain, reflux, lower extremity arthralgias, and sleep apnea.

* Common Sense Bite:
Which is the best diet? One study indicated (drumroll, please) it’s the one you’ll adhere to.

* 10 Behavioral Strategies to Improve Weight Management – from the Pros:

1. Self-monitoring: Record “what, where and when” of eating and physical activity – a diary.

2. Goal setting: Set specific short-term targets in eating and exercise. Too often we just fantasize about the long-term, seemingly elusive goals.

3. Stimulus control: Identify triggers associated wit poor eating and physical activity, and design strategies to break the link.

4. Cognitive restructuring: Change perceptions, thoughts and beliefs that undermine weight control efforts, and develop realistic personal expectations about weight loss.

5. Problem solving: Analyze situations preventing maintenance of a healthier lifestyle and identify possible solutions. Planning, not willpower, is the key to weight management. It’s a philosophy, folks.

6. Relapse prevention. Anticipate and “develop skills” to prevent lapses (such as during travel, celebrations, bad mood, and other vulnerable states).

7. Stress management: Avoid things that trigger dysfunctional eating. (Time for a job change?)

8. Contingency management: Use tangible and verbal rewards to increase performance of specific behaviors or when specified goals are reached. Not food, we presume.

9. Social support: Get friends and family to support, not sabotage.

10. Ongoing contact: Visits, phone calls, e-mail with doctors, office staff and others who help you pursue recommended lifestyle changes.

Adapted from American Heart Association and American College of Cardiology Foundation literature.

* More Aphorisms:
1. Less food, less illness. 2 Better food, better health. 3. More exercise, more out of life. From “Diet, Exercise, and Behavior Modification” presented by Harvard Med School’s Dr. George Blackburn during the “Brain or Gut” session.

* Healthy Stuff:
Whole grains, plant oils, vegetables and fruits, nuts, legumes. How much is enough: Peanut butter’s OK – in a ping pong ball dose, not by the jar.

* Magic Belly Bullets? Adapted from “Gut Hormones and Appetite Control” by Drs. A.M. Wren and S.R. Bloom in the May 2007 issue of Gastroenterology) Orlistat inhibits dietary fat absorption, resulting in losses of up to 4% of body weight over diet alone in a two-year period. It also results in deficiency of fat-souble vitamins and GI side effects that can make life uncomfortable. Then there’s sibutramine, a serotonin and norepinephrine reuptake inhibitor (say that 3 times fast) that acts in the central nervous system to reduce energy intake and increase energy expensiture ... while boosting incidence of hypertensio and tacycardia (not good for the heart). The new rimonabant, a cannabinoid (no, not cannabis) CB1 receptor antagonist, has demo’d effectiveness but many drop out due to anxiety and depression.

So how about a better way to regulate appetite? Satiety signals offers promise. Ghrelin, the hunger hormone, appears to regulate preprandial (pre-meal) hunger. It also influences long-term eenergy balance. Ghrelin levels are low in obese people and higher in lean folks. It’s hoped that ghrelin will be a method, or a model for a method, for altering gut hormones to send “fullness” signals.

Ghrelin is currently a “drug target,” meaning that you can bet companies are working to harness it for weight control pharma and thus monetize it.

Back to the article. An interesting exerpt near the end: “It has been suggested that a cause of the current obesity epidemic may be that modern processed foods bypass our natural satiety mechanisms. Low-fat diets are the most well-established means of dietary weight loss. It has been reported that weight loss in resonse to a low-fat diet does not produce the expected elevation in plasma ghrelin. This may be due to an increase in the proportion of calories consumed as carbohydrate that more potently suppresses ghrelin per calorie consumed than does fat. High-protein diets have also become popular in reent years as a means to promote satiety and weight loss. Diets high in protein have recently been reported to...enhance satiety more effectively than other macronutrients.... It is an intriguing possibility that designer diets may help promote the mmost favorable gut hormone profile to allow sustained weight loss.

* The Pediatric Obesity Crisis:

Obesity in children is increasing almost as fast as in adults. In 2000, 14% of adolescents were found to be obese. There is great regional variation. For example, the average prevalence for the state is higher than the national average. Within Texas, is also significant variation, with the highest levels near the Mexico border, suggesting increased susceptibility of Mexican Hispanic obesity.

Obesity, deemed by the medical establishment as a disease, is associated with a myriad of life-threatening and life-altering co-morbidities, which are causing a crisis in the the health system. The problem is worsening. Up to 25% of obese children show evidence of impaired glucose intolerance implying they are developing type 2 diabetes. Some 22% of children in Texas are obese. With Houston having 1 million children, a conservative estimate of 55,000 children in this single city are developing diabetes. This will weight heavily on the health care system.

Another serious co-morbidity of obesity is nonalcoholic fatty liver disease (NAFLD). In one study, 15.7% of child tested at an obesity clinic in Texas had aminotransferases levels greater than 1.5 times normal. 87.5% of this test group showed evidence of fibrosis, and two children already had early cirrhosis. Hypertension, hypoventilation, and sleep apnea are other associated diseases.

* Diarrhea is No Joke:

Inadequate water and sanitation is a “Silent Humanitarian Crisis.” 42% of the world’s population lack even pit latrines, and 17% have no source of safe drinking water.

Diarrhea’s dire consequences include stunting growth in children aged 2-7; cognitive impairment in ages 6 to 12. While deaths due to diarrhea in terms of years of life lost has been decreasing, morbidity (years lost to disability) is on the upswing. There are genetic factors to diarrhea.

Traveler’s Diarrhea: By far, the most cases occur in Latin America, Africa, and Southern Asia. Per one public service campaign: “Diarrhea is no laughing matter.”

* The Runs?

In the 1960s and 1970s, the British Olympic Team took oral sulfonamides plus streptomycin during competition in high-risk regions. The U.S. and Australian teams took only a sulfa drug. They ”experienced diarrhea vastly in excess of the British team.” However, this advantage didn’t translate for medals for the British.

* New IBS (Irritable Bowel Syndrome) Therapies:

Two 12-week, independent studies involving more than 1,100 adults showed patients who received lubiprostone were nearly twice as likely as those who did not receive the treatment to report moderate or significant relief of IBS symptoms. Endpoints included abdominal discomfort, stool consistency, straining and others.

In another study, patients who received linaclotide experienced a significant acceleration of ascending colon emptying and overall colonic transit as well as a significant improvement in stool consistency, stool frequency, ease of passage and time to first bowel movement.

* Hypnotherapy Helps Kids with Digestive Disorders: Hypnotherapy has been effective for adults with IBS, but can it work with kids? To find out, researchers conducted a randomized controlled trial with 53 patients between eight and 18 years old with functional abdominal pain (FAP) or irritable bowel syndrome (IBS). The regimen: six half-hour hypnotherapy sessions over 3 months. Endpoints were pain intensity, pain frequency and other symptoms, such as nausea, headache and appetite, which were recorded at baseline, one, two, and three months after randomization and 6 and 12 months after therapy. Researchers defined “cure” as those who experienced greater than 80% improvement in pain. Children were instructed to “go to your favorite place” and engage in other exercises.

Hypnotherapy cured 59% of the patients, vs. 12% who received conventional therapy. After one year, the figures were 85% and 25%, respectively. Patients who received hypnotherapy also experienced less pain after treatment, per researcher Arine Vlieger, M.D. Among benefits, she noted, hypotherapy is more kid-friendly than medication.

* Perianal Milestone: A recent study used adipose-derived stem cells to treat painful perianal fistulas in patients with and without Crohn’s disease. A fistula is like a boil near the anus, and these holes are very hard to close; this disease has great morbidity. 70% of patients experienced healing with this new technique vs. 16% with the traditional therapy using fibrin glue,.

* Inflammatory bowel disease – IBD – is an umbrella term referring to a group of disorders that cause inflammation of the intestines, including ulcerative colitis, diverticular disease and perianal fistula. Nearly one million Americans experience recurring or chronic IBD each year (so you are not alone).

* Cancer-Busting Berries: Researchers are studying black raspberries for chemopreventive effects – in this case, for their potential prevent carcinogen-induced cancer in the esophagus and colon.

* Breakthroughs in Endoscopic Imaging: Small bowel imaging has undergone a dramatic revolution, now with full endoscopic access a reality. Capsule endoscopy is now the method of choice for evaluating the small bowel in patients with obscure GI bleeding. Those around the corner include new endoscopic imaging systems such as narrow band and multiband imaging, capsules used in the esophagus and double balloon enteroscopy. Other coming technologies: a new breed of self-advancing or assisted endoscopes that may fundamentally change with gastrointestinal endoscopy is performed.

* Insides Exposed! Introducing the new PillCam SB2 Video Capsule – the new capsule has a 25% wider view, the upshot: it doubles the viewable small bowel surface area. It’s about the size of one of those Mexican jumping beans that were given out as party favors in the olden days. A new study indicated that the camera could be adapted for use in very young children – an important finding that may help youngsters who have internal bleeding.

* Question of the Week: Constipation gets no respect. Clearly, the GI medical establishment regards such disorders as constipation more seriously than those outside the specialty – and the public. Why do some diseases win more serious attention and attract a greater cash infusion than others? Marketing plays a major role, as it does in just about everything in society.

* Breathe! Abdominal breathing exercise can help prevent and treat gastroesophageal reflux disease. The lower esophageal sphincter and diaphragm play a key role in preventing gastroesophageal reflux disease (GERD). In a recent study, professional vocalists were recruited to test an exercise regimen focusing shifting from chest to abdominally-driven breathing.

* It’s where you live and who you are:

Prevalence of adenomas (usually benign or precancerous polyps), and advanced neoplasms, was significantly lower in normal weight women then in overweight and obese women, and in men of any size.

Racial and geographic disparities are glaringly evident in opportunities for life-saving surgerical treatment for liver cancer (hepatocellular carcinoma), said Dr. C.J. Sonnenday. “We’ve seen a three-fold increase in liver cancer, believed to be due to the increasing incidence of Hepatitis C.” There are few effective therapies; most die from the disease. Ablation for small tumors and liver transplantation for those whose cancer is caught early.
Significant racial and regional disparities exist in using surgery to fight HCC. People tend to stay in their own area for medical care.

Blacks and Hispanics are 30% less likely to be treated. These populations tend to go to the doctor and go for screenings less often. However, it may be that many are not offered therapy by their physicians. Younger tend to go in more often. White Americans are twice as likely to get a liver transplant than blacks. As the procedure gets more complex , the disparities broaden.

Why? Don’t know; more “grassroots studies” are needed.

Incidence of proximal colon cancer is on the rise for Af-Americans, black men in particular. Needed: more screening opportunities ... and, we believe, diet education.

As for age: elderly patients are more likely to die from colorectal cancer than their younger counterparts, many have relatively good life expectancy following surgery.

* GI Screening: Racing Time or Wasting Time?

Dr. Herbert Chen spoke on new imaging techniques. His team’s study involved appendicitis, one of the most common operations. Diagnosis pre-surgery is very difficult. Consequently, half the time when an appendectomy is performed,the appendix is found to be normal. This wastes dollars, time and compromises the patient’s health. And surgical complications can be as high as 6%.

However, delays often have dire consequences. Computerized tomography – the CT scan – became popular for routine use in the late 1990s as an imaging modality. It has 98% accuracy in diagnosing appendicitis.

His team conducted a study in which 62% of test subjects had CT scans prior to surgery. The finding: the potential delay in getting to the OR adversely affected the outcome. The delay is usually due to the need for the patient to first drink the oral contrast fluid.

* Hole-istic Medicine: NOTES – Natural Orific Translumenal Endoscopic Surgery – is a new technology expected to revolutionize endoscopy as well as surgery. It’s minimally invasive, like laparoscopic surgery in the abdominal cavity, except that NOTES requires NO incisions in the abdominal wall. It uses a transgastric, transcolonic, transvaginal or transurethral approach to enter the peritoneal cavity. Where it’s at now: gastroenterolosists are teaming up with laparoscopic surgeons to develop lab protocols.

* Colon Screening Resource:

Colon Cancer Screening: Preparing for a Better Outcome. Vital information for patients preparing for a colonoscopy on DVD from TriLyte and Schwarz Pharma. www.TriLyte.com. This short video educate patients on the colonoscopy procedure and tips for preparing for the big event.

* Show Floor Digest:

Exhibit booths offered an eclectic combination of laxatives, pharma representatives dispensing claims and in some cases, beach towels and coffee mugs bearing images of colons (healthy ones, I think), and all manner of colon-clogging candy, corn-syrupy sodas, and frozen dairy snacks. And remarkable internal surveillance devices for technicolor tracking the roller-coasting snake of the human intestinal tract.

Psyllium and probiotics samples ran amok at this high-fiber event. You can now eat your candy and void it too. Consider the Attune line of candy bars formulated with live active cultures that claim to balance the digestive system and boost the immune system. These beneficial cultures are probiotics. They help you absorb nutrients from your food. “It’s like yoga for your insides,” claims the marketing brochure, which adds that its Chocolate Wellness Bar tunes up your digestive system, enabling it to hit on all 5 cylinders. Clearly, the marketing team understands America’s obsession with all things automotive.

* Pro Probiotics: If you’re interested in probiotics – “good” bacteria – check out Natren products at www.natren.com. Founded more than a quarter-century ago by Natasha Trenev, this probiotic pioneer makes its products, many nondairy, in California.

Natren products include supplements packed with the superstrains Bifidonate (B. bifidum, discussed during some presentations at the conference) and Bulgaricum to aid digestion and health, skin exfoliates, and CanineDophilus, FelineDophilus and EquiFlora. Natren micro-enrobes bacteria in oxygen-free sunflower oil, which separates the beneficial bacteria, keeping them strong and shielding them from stomach acid. These probiotics have tested effective against Helicobacter pylori, yeast overgrowth and urinary tract infections ... also inhibits E.coli, clostridium difficile, salmonella, staph, aspergillus ochraceus, diarrhea, cramping and farting (oops, flatulence).

* Battle of the Bugs: Antibiotics kill all bacteria, good and bad, which is why the body is so often knocked out of whack after antibiotic treatment ... and also why we now face increasing strains of antibiotic-resistant bacteria. (Too complex to explain here; there’s plenty about that on the web.) An unbalanced GI tract is vulnerable to illness, bloating, gas, chronic diarrhea and constipation, and vaginitis.

* It’s Alimentary: The portion of the alimentary canal extending from the stomach to the anus and, in humans and other mammals, consisting of two segments, the small intestine and the large intestine.The small intestine consists of the duodenum, the jejunum and the ileum. The duodenum, about a foot long, begins at the pyloric sphincter of the stomach and curves around the pancreas on the right side of the anterior part of the abdomen. It receives the ducts of the biliary system and the pancreas. The jejunum and ileum are nearly 20 feet long and form a much-coiled tube that empties at right angles into the large intestine through the ileocolic valve (see illustration). The large intestine, or colon, consists of the ascending, transverse, descending, and sigmoid regions, and the terminal rectum, empties into the anal canal.

* Look for Experience When Getting a Colonosopy: Suck-Ho Lee presented study results indicating that technical competence in colonoscopy screening requiires the experience of at least 150 screenings.

* Improving Colon Cancer Detection Rates: Roy Soetikno discussed an effort to decrease the 22% miss rate. Study conclusions: Using currently available colonoscopy with wide-angle view (170 degrees) and high resolution, they established a 0% miss rate for colorectal neoplasm/sign adenoma and 11% for overall adenoma. Narrow band imaging did not significantly improve the miss rate compared to white light.

* Watch Out:
The recent China food adulteration exposés sounded a wake-up call to those listening. Think about the source of things that you stick in your body. Be advised that many food companies merely market and merchandise from the U.S. and source out their food processing (and folks, that goes for more than pet food). This is not to say that U.S.-made products are always safe, since news reports have shown otherwise ... and today’s pop-culture obsessed and corporation-controlled media outlets barely skim the tip of the iceberg.