Christopher Cutler, Author at Granite Peaks Gastroenterology of Utah

When Heartburn is More than Simple Indigestion

Posted on June 11, 2019September 12, 2019 by Christopher Cutler

How do you know when heartburn or “indigestion” is something more and needs to be treated? The gastroenterology specialists at Granite Peaks GI take time with their patients to determine if such symptoms may be a result of Gastroesophageal Reflux Disease (GERD). One of the red flags is heartburn occurring more than twice a week; although you can have GERD without the presence of heartburn. “If it is GERD, it needs to be diagnosed so further damage to the esophagus is minimized. There are also simple steps that can be taken to manage the disease and immediately improve one’s quality of life,” says Dr. Cutler, who explains more about the disease in the Q & A below.

What is GERD?

When we eat, food is carried from the mouth to the stomach through the esophagus. At the lower end of the esophagus where it joins the stomach there is a ring of muscle cells called the lower esophageal sphincter (LES). After swallowing, the LES relaxes to allow food to enter the stomach. Then, the LES contracts to prevent food and acid from traveling back up into the esophagus. GERD occurs when the LES weakens, allowing stomach contents and acid to back up into the esophagus, causing troubling symptoms or complications.

Who gets GERD and when should you see a doctor?

GERD affects ten million adults in the United States on a daily basis. People prone to developing it include those who are overweight, smokers or drinkers, and pregnant women. If symptoms are prolonged, or if you are unable to control the symptoms with lifestyle modifications and/or medications, you should see a gastroenterologist. Do so immediately if you have these warning symptoms: throwing up blood, passing black stool, difficulty swallowing, unexplained weight loss, or anemia.

What happens if you don’t treat GERD?

Untreated GERD may lead to the following complications: a narrowing of the esophagus which causes difficulty swallowing, ulcers which can cause bleeding, aspiration of acid into the lungs which may cause pneumonia or asthma, Barrett’s esophagus which is a precancerous lining of the esophagus, and esophageal cancer.

How is GERD treated?

Lifestyle modifications, such as the following, can help decrease symptoms: raising the head of the bed (placement of 6-inch blocks under the head of the bed), waiting at least three to four hours after eating before lying down, avoiding tight-fitting clothing, avoiding smoking and alcohol, losing weight, and eating smaller, more frequent meals. Foods that can commonly aggravate GERD include: fatty foods, chocolate, peppermint, alcohol, caffeine, and citrus drinks. There may be other foods specific to each patient. Medication can also be used to help treat this condition, including antacids such as Mylanta or Maalox, H2 blockers such as Zantac or Tagamet, and proton pump inhibitors (PPIs) such as Prilosec or Prevacid.

How is GERD diagnosed?

Your doctor may be able to diagnose this condition based upon your symptoms and response to therapy. If you have any of the classic warning symptoms mentioned above, your doctor may recommend an upper endoscopy. An upper endoscopy is a painless procedure performed under moderate sedation where a tiny lighted camera is passed through your mouth into your esophagus. Your gastroenterologist will be able to see whether there is damage to your stomach or esophageal tissue, and will be able to recommend a treatment plan to address your specific condition.

Talk to the experts at Granite Peaks Gastroenterology at our Sandy or Lehi office to help relieve your symptoms and determine the best course of action to treat your GERD.

Treating IBS with Cognitive Behavioral Therapy

Posted on January 8, 2019August 13, 2019 by Christopher Cutler

By Christopher Cutler, M.D.

Irritable bowel syndrome (IBS) affects 10-15% of adults in the United States. It is a functional disorder of the gastrointestinal tract characterized by abdominal pain and altered bowel habits. IBS is usually treated with dietary modifications and medications directed at underlying symptoms (diarrhea, constipation, abdominal pain, bloating). Patients may also receive benefit from antidepressants, probiotics, and antibiotics. But what about patients with refractory symptoms that do not respond to traditional therapies? What are their options? One promising alternative to consider is cognitive behavioral therapy (CBT). CBT is a short-term therapy (4-10 one hour sessions with a therapist) that focuses on modifying behaviors and altering dysfunctional thinking in hopes of improving mood and GI symptoms.

The Brain-Gut Connection

In patients with IBS, there is dysregulation of the gut brain axis, a complex neurologic communication between the brain and GI tract. Stress and psychological factors can directly influence gut function via this pathway, contributing to IBS symptoms. Patients with IBS have an increased tendency to experience pain in response to normal bowel function. This may be attributed in part to abnormal pain processing in the brain. People affected by IBS also have a fear of bowel symptoms and associated avoidance of situations where symptoms may occur. It is a vicious cycle since symptoms themselves become a stressor, and this anxiety contributes to increased gut pain sensitivity and altered motility causing worse GI symptoms and worse anxiety.

Given the importance of brain-gut interactions in IBS, psychological interventions are an effective option for this condition. These modalities may include cognitive behavioral therapy, hypnotherapy, and mindfulness. CBT has been the most extensively studied with more than 20 published randomized clinical trials showing relief of IBS symptoms in 50-70% of patients. These benefits are frequently maintained for up to one year after therapy.

Treating IBS with CBT

CBT involves relaxation strategies such as specialized deep breathing. This increases the patient’s awareness of the connection between distorted thinking patterns, stress, and digestive symptoms. CBT also helps patients develop coping strategies by encouraging them to shift from a solution-focused approach to a self-management approach to deal with this chronic condition. CBT also uses exposure techniques which involve facing situations the patient avoids because of fear of symptoms. With time, avoidance behaviors decrease and the thought of symptoms being harmful is reduced.

The American Gastroenterology Association recommends psychological interventions for patients with moderate-to-severe IBS who do not respond to standard medical therapies, and for patients for whom psychological factors exacerbate their symptoms. CBT is an effective treatment option for patient with IBS, and its use to treat this disorder is becoming more widely accepted. The physicians at Granite Peaks are experts in the diagnosis and therapy of IBS and are eager to help you. Please call us to discuss traditional and alternative strategies to help you manage your IBS symptoms.

IS IT CELIAC DISEASE?

Posted on July 10, 2018April 18, 2019 by Christopher Cutler

By Christopher Cutler, M.D.

Many people with celiac disease present with classic gastrointestinal symptoms such as diarrhea, gas, bloating, abdominal pain, and weight loss. However, other people have no GI complaints and may present with non-specific symptoms, making the diagnosis of celiac disease very difficult. The following is a list of some conditions which, if unexplained by other diseases, should raise the suspicion of celiac disease:

Iron deficiency anemia – Celiac disease may lead to a reduced absorption of iron. It may also cause malabsorption of other nutrients required for red blood cell production, including vitamin B12 and folate. Typical symptoms of anemia include fatigue, weakness, and poor exercise tolerance.

Elevated liver enzymes – Many patients with chronically abnormal liver enzymes undergo an extensive evaluation with no cause found. Celiac disease should be considered.

Neurologic or psychiatric symptoms – Some patients with celiac disease have been found to have significant structural and functional brain deficits on MRI. These patients may experience unexplained headaches, impaired balance or coordination, peripheral neuropathy (burning, tingling, or numbness in the hands and feet), seizures, depression, or anxiety.

Weakening of the bones – Celiac disease can lead to malabsorption of vitamin D. Patients with celiac disease should be screened for osteoporosis.

Dermatitis herpetiformis – This is a skin condition which causes itchy fluid-filled bumps, most commonly found on the elbows, forearms, scalp, back, and buttocks. Approximately 85% of people with dermatitis herpetiformis have underlying celiac disease.

Menstrual and reproductive issues – Who would think to blame these issues on a gastrointestinal disease? But women with celiac disease may have a later onset of menstrual periods, earlier menopause, infertility, recurrent miscarriages, pre-term deliveries, and low birth weight infants.

Arthritis – There is an increased prevalence of osteoarthritis in people with celiac disease.

Oral disease – Patients who present with discolored teeth, enamel loss, or a painful tongue, unexplained by other diseases, should be tested for celiac disease.

Miscellaneous – Celiac disease has also been associated with type 1 diabetes, autoimmune thyroid disease, cardiomyopathy, and pancreatitis.

If you have any of the above conditions which cannot be explained, I strongly encourage you to follow up with the doctors at Granite Peaks Gastroenterology to be tested for celiac disease. A simple blood test is all it takes.

Who Should Be Screened For Liver Cancer?

Posted on January 8, 2018February 13, 2019 by Christopher Cutler

By Christopher S. Cutler, M.D.

The American Cancer Society estimates that 40,000 Americans will be diagnosed with liver cancer this year, and 28,000 will die from this disease. But routine screening of the general population is not recommended. So who should be screened?

The following people should be screened for liver cancer:
All people with cirrhosis (severe scarring of the liver) from any cause should be screened.

The following people with chronic hepatitis B should be screened:

Asian males > 40 years of age
Asian females > 50 years of age
People with a family history of liver cancer
African Americans
Caucasians with a high viral load and active inflammation for several years (start screening men > 40 years of age and women > 50 years of age)

How should patients be screened?
Screening should be done with an ultrasound every 6 months. Some experts also recommend checking a blood test called an alpha-fetoprotein (AFP) every 6 months. Adding an AFP to an ultrasound increases detection rates, but it also increases costs and false positive rates.

What should be done if a nodule is seen on ultrasound?
If the nodule is < 1 cm, an ultrasound should be done every 3 months until the nodule is proven to be stable or disappears (up to 24 months).

If the nodule is > 1 cm, a CT scan or MRI should be obtained, with a possible biopsy thereafter.

Learn more about liver diseases and diagnosis.

To request an appointment with one of our gastroenterologists, please click here.

10 FAQs about Helicobacter pylori

Posted on July 10, 2017April 18, 2019 by Christopher Cutler

By Christopher S. Cutler, M.D.

1) What is Helicobacter pylori? Helicobacter pylori (H. pylori) is one of the most common bacterial infections in the world, present in half of the population. The prevalence of H. pylori is generally lower in the United States than in many other parts of the world. It is more common in African Americans and Hispanics than in Caucasians. H. pylori is found in the stomach and is a very common cause of peptic ulcer disease.

2) How is it spread? The route by which the infection is spread is unknown. People could be infected by contaminated water in developing countries. Person to person transmission probably also occurs. The infection is usually acquired in childhood. Risk factors include low socioeconomic status, increasing number of siblings, and having an infected parent. Reinfection is rare, seen in less than 2% of persons per year. A repeat positive test for H. pylori usually signifies a recurrence of the bacteria which was not adequately treated.

3) What can H. pylori infection lead to? pylori infection may cause:
• peptic ulcer disease
• chronic gastritis
• gastric cancer
• gastric MALT lymphoma.

4) What are common symptoms of H. pylori? Symptoms that patients experience are usually from an ulcer caused by H pylori. These can include: upper abdominal pain, bloating, feeling full after a small meal, poor appetite, nausea and vomiting, intestinal bleeding, and fatigue from anemia.

5) Who should be tested for H. pylori? There is no reason for universal screening in North America. The following conditions warrant testing for H. pylori:
• active peptic ulcer disease
• a past history of peptic ulcer disease if cure of H. pylori has not been documented
• low grade gastric MALT lymphoma
• early gastric cancer resected during an endoscopy
• dyspepsia (upper abdominal pain) in people younger than 60 years old with no other worrisome symptoms
• prior to starting chronic treatment with NSAIDs or low-dose aspirin
• unexplained iron deficiency anemia
• idiopathic immune thrombocytopenia in adults

6) What tests can be performed to diagnose H. pylori?
• upper endoscopy with stomach biopsies – shows active infection, sensitivity of 95%
• urea breath test – shows active infection, sensitivity up to 95%
• stool antigen test – shows active infection, sensitivity of 94%
• blood test for H. pylori antibody – this can’t distinguish between active and past infection

7) What interferes with testing for H. pylori? The following may decrease the sensitivity of H. pylori tests:
• active bleeding from an ulcer
• use of a proton pump inhibitor (Prilosec) within 1-2 weeks of testing
• bismuth or antibiotic use within 4 weeks of testing.

8) How is H. pylori treated? All patients with documented H. pylori infection should be offered therapy.
• Triple therapy consists of: a proton pump inhibitor twice daily, amoxicillin 1 gram twice daily, and clarithromycin 500 mg twice daily, all for 14 days. Eradication rates are approximately 80% with this regimen. If the patient is allergic to penicillin, metronidazole 500 mg three times daily can be substituted for amoxicillin. Previous exposure to clarithromycin reduces the efficacy of this regimen.
• Quadruple therapy consists of: a proton pump inhibitor twice daily, bismuth subsalicylate 300 mg 4 times daily, metronidazole 250 mg 4 times daily, and tetracycline 500 mg 4 times daily, all for 14 days. Eradication rates are approximately 91% with this regimen.
• There are multiple other drug regimens, utilizing antibiotics such as levofloxacin, that may be used depending on antibiotic resistance and prior response to the above.

9) Should patients be tested to prove eradication of H. pylori? Yes, especially because of increasing antibiotic resistance. This can be done with gastric biopsies during an endoscopy, with a urea breath test, or with stool antigen testing. Patient should be off of proton pump inhibitors for 1-2 weeks and off of bismuth and antibiotics for 4 weeks prior to testing. If someone has failed 2 courses of antibiotics, consideration should be given to an endoscopy with gastric biopsies for H. pylori culture and sensitivity.

10) Who is Barry Marshall? Barry Marshall is an Australian physician who won the Nobel Prize in Medicine for his discovery of Helicobacter pylori and its role in gastritis and peptic ulcer disease. This was one of my favorite stories in medical school. Dr. Marshall had an endoscopy performed which was normal. He then drank a broth of H. pylori bacteria. A few days later he developed nausea, vomiting, bloating, and bad breath. On day 8 he had a repeat endoscopy showing severe gastritis and a biopsy showing that the H. pylori had colonized his stomach. His work changed the perception that ulcers were simply due to stress.

Click here to learn more about common GI conditions. Schedule an appointment with Granite Peaks Gastroenterology.

Risk Factors for Stomach Cancer

Posted on November 8, 2016April 18, 2019 by Christopher Cutler

By Christopher Cutler, M.D.

November is Stomach Cancer Awareness Month. Approximately 22,000 people are diagnosed with stomach cancer every year in the United States, and 11,000 die from it. The physicians at Granite Peaks Gastroenterology would like to make you aware of the risk factors for stomach cancer:

Age, gender, race – Stomach cancer most commonly affects people in their 60s and 70s. Men are two times more likely to develop stomach cancer than women. Stomach cancer is more common in African Americans, Hispanics, and Asians than in Caucasians.

Salt – The risk of stomach cancer increases with a high intake of salt and salt-preserved foods (salted fish).

Nitrates – Nitrates are a natural component of some foods and are also used as a food additive. Diets that are high in processed meats have been associated with a higher rate of stomach cancer. In fact, processed meats (ham, bacon, sausage, jerky) are classified as a group 1 carcinogen.

Diets low in fruits and vegetables – Eating fruits (especially citrus) and vegetables is protective against stomach cancer, possible decreasing the risk by 30-40%. The protection against stomach cancer provided by fruits and vegetables is probably related to their Vitamin C content, which is thought to decrease the formation of carcinogens in the stomach. Cooked vegetables do not offer as much protection as raw vegetables.

Obesity – Excess body weight (BMI greater than 25) is associated with an increased risk of stomach cancer. This risk increases with increasing BMI.

Smoking – The risk of stomach cancer is increased 1.53 fold in smokers, and this risk is even higher in men. The risk decreases after 10 years of smoking cessation.

Alcohol – Heavy alcohol consumption may be a risk for stomach cancer.

Helicobacter pylori – This bacteria, which is present in the stomach of half the world’s population, is a common cause of ulcers and stomach cancer. H pylori is a group 1 carcinogen and may increase the risk of stomach cancer six fold. There is a reduced incidence of stomach cancer after successfully treating H pylori with antibiotics.

Epstein Barr Virus – It is estimated that 5-10% of stomach cancers in the world are associated with this virus.

Occupational exposure – Occupations such as mining, metal processing and rubber manufacturing may increase the risk of stomach cancer.

Gastric surgery – The increased risk of stomach cancer after stomach surgery may be due to the regurgitation of bile and pancreas juice into the remaining stomach.

Blood group – Individuals with blood group A have a 20% increased risk of stomach cancer compared to those with blood groups O, B, and AB.

Family history – This accounts for up to 10% of cases of stomach cancer. There are also many inherited cancer syndromes (Lynch Syndrome) which increase the risk of stomach cancer.

Pernicious anemia – Also known as Vitamin B12 anemia, this may increase the risk of stomach cancer 2-6 fold. Some societies recommend a one-time screening endoscopy in these people to identify pre-cancerous lesions.

Screening everyone for gastric cancer in this country is not recommended. Screening with an endoscopy should be considered for high-risk groups, such as those with a history of: pernicious anemia, adenomas in the stomach, intestinal metaplasia of the stomach, familial adenomatous polyposis, or Lynch Syndrome.

If you have any questions about stomach cancer or its risks, please be sure to contact your medical provider at Granite Peaks Gastroenterology.