Anal fissures are caused by decreased blood flow to the anal tissue. They can be acute or chronic, but are frequently very painful and can cause bleeding as well. They are commonly caused by constipation and straining. An examination of the area is necessary to make a diagnosis, and topical medications are prescribed to improve blood flow and alleviate symptoms.

Celiac disease is an autoimmune disorder where the body reacts to gluten in the diet and causes damaging inflammation in the intestines. This can cause a variety of symptoms, most commonly bloating, diarrhea and can even cause anemia.

Gluten intolerance is not an inflammatory condition, however it does cause very similar symptoms as celiac disease. Gluten intolerance and celiac disease should be evaluated and distinguished from one another, as the management of the two does differ slightly.

Constipation is one of the most common symptoms that we treat in our office. There are many different potential causes for constipation, including medication side effects, metabolic disturbances, anatomic abnormalities, neurologic disorders and irritable bowel syndrome. It is important to take a thorough history and perform an examination to determine the etiology.

Colonoscopy is sometimes indicated as well in the evaluation of chronic constipation. Just as there are many different causes for constipation, there are myriad treatment options, and they must be tailor-fit to the patient through a close relationship with their gastroenterologist.

Diarrhea is a very common symptom that we treat in our clinic. Diarrhea is generally broken down into acute diarrhea (lasting less than 2 weeks) and chronic diarrhea (lasting greater than two weeks). A thorough history and physical exam, along with blood tests and stool studies is usually indicated to determine the cause of diarrhea. Sometimes, upper endoscopy and colonoscopy is necessary to perform in order to determine the cause. There are multiple medications that work well for diarrhea, but determining the cause is the most important step in choosing the right treatment.

Many patients at one time or another complain of a sensation of food not passing down into their stomach normally. Sometimes they have to drink

water to help the food pass, and sometimes even water feels like it is not going down normally.

Patients can also have coughing or aspiration with eating or drinking. It is important to figure out if the problem is at the top (oropharyngeal dysphagia) or at the bottom (esophageal dysphagia) of the swallowing process. A thorough history and physical exam, and usually an endoscopic evaluation is needed to determine the cause which can be anatomic, functional, inflammatory, and sometimes malignant in nature.

The terminology of diverticulosis, diverticulitis and diverticular bleed causes confusion for patients and doctors alike. Basically, diverticulae are tiny little pouches in the colon that are commonly seen on imaging or on colonoscopy. Their presence increases with patient age. By and large these small pouches in the colon cause no problems and you wouldn’t even know you had them.

They can, however, cause two complications: diverticulitis and diverticular bleeding. Diverticulitis (-itis always means inflammation) occurs when one of these small pouches becomes inflamed and infected. This inflammation usually causes pain and sometimes cause fever and diarrhea.

Depending on the severity of symptoms, diverticulitis may need to be treated with antibiotics, and sometimes requires a CT scan to determine the extent of inflammation. Diverticular bleeding occurs when a small vessel near a diverticula begins to bleed. These can vary from relatively minor and self-limited to much more significant and even life threatening. Any time there is bleeding from the colon a colonoscopy should be performed, not only to identify the source of bleeding but also to intervene and stop the bleeding.

Similar to abdominal pain, many different GI issues can cause gas and bloating. Patients usually report the symptoms are worse after eating, and can cause significant abdominal distension to the point where “it looks like I’m pregnant after eating.” This can be painful or painless, but is generally disturbing for the patient. Some common reasons for gas and bloating are dietary allergies (lactose intolerance, gluten intolerance), irritable bowel syndrome, small intestinal bacterial overgrowth (SIBO), and celiac disease.

A careful history and physical exam, along with blood and stool tests and sometimes take-home breath testing are needed to arrive at a diagnosis and determine a treatment plan.

Reflux symptoms are described in various ways and interestingly tends to be described differently in different cultures. “Heartburn” is the most common description we hear in the office, but GERD (gastroesophageal reflux disease) can present as chest pain after eating, chronic cough, wheezing, bitter taste in mouth, epigastric abdominal pain, and many other descriptions

and symptoms. A careful history and physical exam and identification of symptom triggers can be enough for diagnosis in some patients. Some patients only need to avoid those trigger foods, others benefit from lifestyle changes (sitting upright after eating, not eating right before bed), and some may require medications or endoscopic evaluation.

IBD stands for inflammatory bowel disease. It is an auto-immune disease that, as the name suggests, causes inflammation throughout the GI tract. Typically inflammation causes abdominal pain and diarrhea. Sustained inflammation over a long period of time can lead to complications of IBD including intestinal stricturing (narrowing), bowel obstructions, intestinal

perforation, and GI cancers. Therefore, it is extremely important to establish a diagnosis and begin treatment to control inflammation as early as possible.

IBD is generally broken down into two types: Crohns Disease and Ulcerative Colitis. Crohns disease can affect the entire digestive tract from the mouth to the anus. It can follow a relatively mild course or cause serious complications requiring surgeries and very potent medications.

Ulcerative colitis is another type of IBD and typically only affects the colon. Similar to Crohns disease the disease course can be relatively mild or quite severe, requiring surgery and potent medications. Regardless of the type of IBD, patients with Crohns disease or Ulcerative Colitis should have a close relationship with their gastroenterologist in order to control inflammation, manage symptoms, prevent the long-term complications of IBD and to screen for cancer.

Irritable bowel syndrome is a very common diagnosis that is given to patients with GI complaints. However, it is a diagnosis that should be thoroughly investigated prior to establishing. The technical definition of IBS is the following adominal pain more than once per week for the last three months plus, plus two of the following:

• pain is related to bowel movements; it either gets better or worse after bowel movement

• pain is associated with a change in stool frequency (ie going more or less often)

• pain is associated with a change in stool consistency (ie hard stool or liquid stool).

An important caveat to this definition is that another organic cause of the pain should be ruled out first. Many patients come to the office with a “diagnosis” of IBS but have not undergone a thorough evaluation for some of the other conditions (celiac disease, IBD, or infections for example).

Therefore, we always take a diagnosis of IBS with a grain of salt until we have performed the appropriate work-up and made sure there is not another explanation for their symptoms.

There are multiple medications that are effective for both IBS with diarrhea predominance and constipation predominance, as well as for the mixed-type IBS. Sometimes it takes a few visits to titrate or change the medication, but IBS can be well controlled by gastroenterologists.

H pylori is a type of bacteria that lives in the intestines, most commonly in the stomach. Some patients that have H pylori have absolutely no symptoms, and others have severe abdominal pain and gastric ulcers. It is not well understood why H pylori infections cause symptoms and ulcers in some patients and not others. What is known however is that H pylori, is left untreated, can sometimes cause cancer (it is a “carcinogen.”) Therefore, it is important to treat an H pylori infection with antibiotics, and to confirm after treatment that the bacteria is no longer present. This can be done through endoscopic biopsy, breath test or stool test.

Hemorrhoids are caused by engorgement, or filling, of blood vessels in the rectum. The blood vessels in the bottom of the rectum serve to pad the rectum, but sometimes when these vessels become overfilled with blood they can cause complications, like bleeding or pain. Constipation and straining to defecate are two conditions that increase the likelihood of these vessels becoming filled with blood, and therefore treatment of constipation is an important part of hemorrhoid therapy.

Hemorrhoids can be visible on the outside of the anus, or can be tucked inside and not visible. They can also sometimes prolapse out of the rectum. If there is bleeding, a colonoscopic evaluation to confirm that hemorrhoids are responsible for the bleeding is indicated, which will also rule out other possible causes (malignancy, diverticular bleed, etc). If pain is the predominant symptom, it can be managed with topical treatments. Rarely do hemorrhoids require surgery.

Typically when a patient thinks about GI bleeding they think about bright red blood in the toilet bowl. However, there is a condition called “occult GI bleeding” which means that the blood is either in such small quantities or digested to the point where it is not recognizable in the toilet. GI bleeding can be acute and severe, or chronic and mild, but in both cases it can lead to anemia and warrants an endoscopic evaluation to determine the etiology. If both upper endoscopy and colonoscopy do not reveal a source of the bleeding, a video capsule endoscopy can be performed to evaluate the remaining small bowel for the source of bleeding.

Small intestinal bacterial overgrowth, or SIBO, is a relatively recently recognized cause of GI symptoms. Bacteria is typically not present in large amounts in the small intestine, but it is ubiquitous in the colon. When bacterial overgrowth occurs in the small intestine, these bacteria are exposed to relatively undigested foods, which contain carbohydrates and sugars that bacteria love. When the bacteria digest these products they create a significant amount of gas, which for the patient can cause distressing bloating, pain and distension following a meal. It can also cause diarrhea, and in rare cases can cause vitamin and mineral deficiency. SIBO is typically diagnosed with a take-home breath test kit, and is treated with a course of antibiotics.

A hiatal hernia is a type of internal hernia that occurs where the esophagus meets the stomach. The top of the stomach can shift, or “herniate” upwards through the diaphragm, which changes how the esophagus functions. In a normal state, the lower esophagus has a “sphincter” that prevents acidic liquid from the stomach from refluxing into the esophagus. When there is a hiatal hernia present, the sphincter doesn’t function as well and acid can more easily enter the esophagus. Some patients have no symptoms and no issues with a hiatal hernia, while others can develop severe inflammation and erosion of the esophagus, or even bleeding at the site of the hernia. A hiatal hernia is usually diagnosed on endoscopy, and is managed conservatively with medications and lifestyle modifications. In extreme circumstances when the hernia is very large or is causing significant symptoms, surgery is indicated.

Peptic ulcer disease is a fancy way of saying “stomach ulcers.” Stomach ulcers can occur for a variety of reasons, for example H pylori infection, medication use (ibuprofen, aspirin, clopidogrel), stress or severe illness. Stomach ulcers can usually be managed with antacid medications, but sometimes cause bleeding. Generally an endoscopy is needed to diagnose stomach ulcers and sometimes to treat the ulcers if they are bleeding.

Barrett esophagus (BE) is a pre-cancerous condition of the esophagus that is thought to be caused by longstanding reflux of gastric acid or bile into the lower esophagus. Over a long period of time, that acid or bile causes inflammation in the esophagus, and in turn the esophagus lining changes to become similar to the stomach lining, which is used to bile and acid being present. This is the first step in a series of changes in the esophagus that eventually can lead to esophageal cancer. Once identified, BE must be thoroughly evaluated for changes of “dysplasia” which is another step toward cancer. Early identification of BE is essential, as early intervention with medications and lifestyle changes can be curative. It is important to establish a routine surveillance endoscopy schedule to ensure the esophagus lining is not progressing toward cancer and is responding well to treatment.

The screening colonoscopy is one of the most important interventions that doctors in any field have developed in order to prevent cancer. Screening for colon cancer typically occurs at the age of 50, although there are many situations in which a patient should have an earlier exam. Some examples of reasons an earlier exam is warranted include a family history of colon cancer, a personal history of IBD, or for diagnostic purposes for recent bleeding, abdominal pain or unexplained weight loss.

Although many patients are reluctant to have a colonoscopy and sometimes delay them, it is extremely important to have them done on time, in order to catch polyps before they become cancer.

At Park Slope Gastroenterology, the screening colonoscopy is performed with anesthesia, under the care of a board certified anesthesiologist. A flexible rubber tube with a light and a camera at the tip is inserted into the rectum while you are asleep, and the entire colon is carefully examined for the presence of polyps, inflammation, diverticulae, hemorrhoids, or masses, and biopsies are taken of anything abnormal. If a polyp is found it is usually taken out entirely. Following the procedure, Dr. Kingsbery will let you know when you will need to repeat the exam, depending on the findings.

An important quality measure in determining effectiveness of screening colonoscopy is the adenoma detection rate, or ADR. For gastroenterologists, the American College of Gastroenterology recommends a gastroenterologist have an ADR of 25% in men and 15% in women. Dr. Kingsbery has an ADR of >40%. In addition, new tools such as artificial intelligence can augment the ADR.