We are pleased to announce the newest member of our team, Dr. Christopher A. Olenec, who is pleased to see patients here in Annapolis as well as our new Kent Island office. He begins on January 3, 2012 and will serve as a general gastroenterologist who specializes in Endoscopic Ultrasound (EUS).

Celiac Disease (CD) is one of the autoimmune disease processes affecting susceptible individuals with gluten sensitivity. Ingestion of gluten containing grains, especially the gliadin fraction of wheat gluten triggers the intestinal damage.  This eventually causes a spectrum symptoms ranging from a silent disease to full blown CD.

The typical intestinal damage is seen in the duodenum and upper jejunum, but the extent of this mucosal damage is highly variable and may involve the entire small bowel in some rare cases.  The other characteristic finding is that the intestinal involvement may be patchy.

The intestinal damage is characterized by loss of absorptive surface of the small intestine that in turn causes variety of nutritional deficits in the affected individuals. However, these mucosal changes completely resolve upon elimination of gluten from the patient’s diet.

It is now evident that CD is the result of an inappropriate T cell-mediated immune response against ingested gluten. In normal conditions, the intestinal surface serves as the main barrier to passage of large molecules such as gluten.  However, in CD, this barrier can no longer serve its function and an immune response to environmental antigens (i.e., gluten) may develop.

There have been tremendous amount of research and discoveries reported on CD within the past 15 years.  One example of this is discovery of the tissue transglutaminase (tTG). In 1997, Dieterich et al demonstrated that one of the targets of the autoimmune response in CD is the tTG. The demyelinating activity of this enzyme seems to generate gliadin peptides that bind to DQ2 to be recognized by disease-specific intestinal T cells.

Once considered as a rare disorder, Celiac disease (CD) used to be affecting individuals of European origin.  In the past, the diagnosis was made based on symptoms of the disease and subsequent confirmation by duodenal biopsy.  However, with emergence of newer diagnostic tools that are highly sensitive and specific there is a surge of clinically atypical or even silent forms of CD.  These serologic tests such as antiendomysium (EMA) and the antitransglutaminase (tTG) antibodies used in number of studies confirmed that CD is one of the commonest, lifelong disorders affecting humanity all over the world. 

CD is not only frequent in developed countries, but is increasingly reported in developing or underdeveloped countries in North Africa, the Middle East, and Asia.  CD contributes substantially to childhood morbidity and mortality in these countries.

In the past 3 decades, a number of epidemiologic studies have been conducted in Europe to establish the frequency of CD. One of the oldest of these studies conducted in 1950 established that the cumulative incidence of the disease in England and Wales was 1/8000, whereas an incidence of 1/4000 detected in Scotland. The diagnosis at that time was difficult due to variable symptoms and confirmed by nonspecific tests. The awareness of the disease greatly increased in 1960s when tests that are more specific became available. Consequently, in the mid 1970s the incidence was being reported in the neighborhood of 1/450-500 in studies from Ireland, Scotland, and Switzerland. This sudden jump in the number of CD cases prompted changes in the dietary habit, based on the assumption that delayed exposure to gluten could prevent the onset of the disease.  After a late introduction of gluten in infant diet, in the UK and Ireland, the incidence of CD decreased.  Unfortunately, this decrease was subsequently counterbalanced by the increase of atypical forms of CD occurring in older children or in adults.

As more sensitive diagnostic serologic tests have become available, it is now possible to evaluate the prevalence of CD (number of affected persons, including silent cases, in a defined population at a certain point in time).  The prevalence of CD throughout the world seems to be more homogeneous.  Furthermore, these screening tests showed that CD is one of the most frequent genetically based diseases occurring in 1 of 130-300 in the European population. Another interesting observation is that despite similar genetic backgrounds and environmental factors, the clinical presentation of CD may greatly diverge in neighboring countries. One example of this is Denmark, where the incidence of CD was thought to be 1/10000. This was almost 10-fold less than Finland, and 30-fold less than Sweden who share similar genetic background. Subsequent studies later on suggested that actually CD was as frequent in Denmark as other Scandinavian countries with reported prevalence of 1/500 and most cases in Denmark were undiagnosed due to lack of typical clinical symptoms. Factors such as type of cow’s milk formulas, breast feeding, age at gluten introduction, quantity of gluten and quality of cereals, and quantity of wheat gluten may all influence the clinical presentation of the disease.

There were only limited number of scientific papers published in the US in the 30 year period from 1965-1995 and based on them, CD was thought to be a rare with the prevalence of ~1: 10000. These studies were based on strict guidelines such as presence of classic gastrointestinal symptoms of CD, dermatitis herpetiformis, and positive biopsy findings. Unfortunately, by focusing on specific symptoms, these studies failed to consider the protean clinical manifestations of CD, the submerged part of the so-called Celiac Iceberg. Recently, a series of epidemiologic studies conducted using more appropriate experimental designs and powerful screening tools showed that CD is as frequent in the US as in Europe.

CD is the result of interaction between genetic (both HLA and non-HLA associated genes) and environmental factors (gluten-containing grains), therefore if one evaluates the world distribution of these 2 factors, areas at risk can be identified. We already confirmed that Europe is a high risk region. By the same token, there have been limited epidemiologic studies coming from the regions where CD has been considered rare. In fact, recent studies have shown that areas that are known to be at risk such as South America, North Africa, and Asia, CD was indeed underdiagnosed.

A seen in Europe the clinical presentation of CD varies greatly in neighboring countries which may explain the difference in prevalence previously reported. This difference stems from the fact that CD with typical gastrointestinal findings (in the intestine) is 15 times less common than CD with atypical findings (out of the intestine); therefore making the diagnosis more challenging.

The epidemiology of CD is efficiently conceptualized by the Iceberg Model, originally introduced in 1991. The prevalence of CD can be conceived as the overall size of the iceberg, which is both influenced by the genetic makeup of the population and by the pattern of gluten consumption. In many countries the prevalence of CD is in the neighborhood of 0.5-1 % of the general population. These cases make up the visible part of the iceberg. In developed countries, for each diagnosed case of CD, and average of 5-10 cases remain undiagnosed (the submerged part of the iceberg), because of atypical or unusual complaints as described above. The importance of this lies in the fact that the undiagnosed cases remain at risk for long term complications of CD. The line separating this iceberg, so called “the waterline” is dynamic and mostly depends on the physician’s intuitiveness in CD diagnosis and utilization of serologic CD markers. The availability of such diagnostic tests or lack there of, is a major problem in large areas of the world, e.g., North Africa, the Middle East, and India, where the frequency of CD is currently underestimated. Because of the variable relevance of these factors, the waterline is much more unstable than the overall size of the iceberg, thereby explaining the reported wide fluctuations of CD incidence. The intriguing question at present is whether environmental variables can influence the prevalence of CD, therefore assessing the fascinating possibility of primary prevention of this disorder.

-Ahmet Aybar, MD, FAAP

Whats Up? Media Top Docs for 2011
Nearly four decades ago, William A. Cassidy, MD founded Anne Arundel Gastroenterology Associates, P.A. on the principle of meeting the needs of a growing community. The goal was simple. By specializing in the disorders affecting the digestive tract, this group of dedicated physicians would set the standard for gastroenterology care within the community.

With its humble beginnings in Annapolis, this devoted group has grown with the community, and is now pleased to provide care for patients at three convenient locations. The expectation they have set with their patients is that of high quality healthcare with a gentle touch. They are building relationships that will last a lifetime.

These expert physicians are capable of treating digestive disorders, which include but are not limited to colon and rectal disease, ulcers and stomach disorders, colitis, Chrohn’s disease as well as liver and pancreatic disease. Each of the Board certified gastroenterologists regularly perform procedures to correct any one of these issues. However, the real passion of this group is to steadily prevent the spread of colorectal cancer with early detection through screenings.

AAGA is proud to salute three of our expert physicians chosen by the community as Top Docs for 2011 according to Whats Up? Media:

Anthony J. Calabrese, MD, FACG who has served our troops
as Chief of Gastroenterology at Andrews Air Force Base. He was
also president of the medical staff at AAMC. His expertise is
extraordinary within the field. In addition, you may see him playing the sax and clarinet in a popular big band or out on the Bay fishing.

Suzanne L. Sankey, MD is Board Certified in Internal Medicine
and Gastroenterology. A compassionate, sensitive and enthusiastic physician; she is a leader among her peers in promoting women’s health issues in the field of gastroenterology.

Charles J. Cattano, MD, FACP, FACG, AGAF, is often called
upon by universities and pharmaceutical firms to speak on his
cutting-edge treatment of liver and GI Tract diseases. His high
level of care is remarkable. He successfully practices both adult
and pediatric gastroenterology, while being the Chief of Medicine
at AAMC.

As the community evolves, AAGA will look for additional ways to serve this ever changing populace. They will continue to provide a safe, caring and compassionate environment in which patients are actively accommodated and offered the most appropriate medical care.

Remember that antacids act like fire extinguishers. They can relieve heartburn, but repeated burns can lead to irreversible damage. Barrett’s esophagus is such a complication. In response to chronic acid injury, the lining or “mucosa” of the esophagus can change from the normal squamous lining (like in your mouth) to an intestinal type columnar mucosa. This change occurs in some patients to better resist the chronic acid injury. The importance of Barrett’s esophagus is that these altered cells also have an increased risk of becoming malignant.

Years ago, esophageal cancers were most often squamous and seen in heavy smokers and alcohol abusers. Today, although esophageal cancer is on the increase, we now see more adenocarcinomas, the cancer type related to Barrett’s. Most patients with Barrett’s do not develop esophageal cancer with current estimates of the risk estimated at less than 1% each year. But, that’s more than 30 times higher than the general population. The only way to diagnose whether a patient has developed Barrett’s esophagus is by endoscopy. While the patient is sedated, the flexible gastroscope enables the gastroenterologist to visually examine the esophagus, stomach and duodenum for changes that might indicate Barrett’s or other GI disorders like ulcers. Biopsies can be obtained to be examined microscopically by a pathologist. Most patients with a history of chronic reflux (especially middle aged men) are advised to be “’scoped”.

If Barrett’s has been found, it is advisable to re-examine the esophagus periodically to look for the development of “dysplasia”. Dysplasia refers to more serious microscopic cell changes that indicate that the risk of esophageal cancer is even further increased. The pathologist can assess the severity of any dysplasia. “High grade dysplasia” is the condition just short of diagnosing the patient with an esophageal cancer. Management decisions are guided by these biopsy reports. Neither medicines nor anti-reflux surgery have fully reversed Barrett’s changes. Various techniques aimed at destroying the Barrett’s mucosa offer no proven benefits despite their risks.

Current management of Barrett’s includes:
• Potent daily acid blocker medications to inhibit further injury.
• Endoscopic monitoring of patients with proven Barrett’s change every 1-3 years (more often if dysplasia is discovered). This hopes to find (or prevent) early and still curable cancer.
• Consideration of “chemoprevention”. Aspirin and other NSAIDs promise significant benefit against cancer development in Barrett’s.

This same effect has already been shown for colon cancer. The acid blockers used to treat Barrett’s also protect against drug irritation.

With Sincere Thanks from Dr. Cassidy

To My Valued Patients:

It is with fond memories and mixed emotions that I inform you of my retirement from active practice effective August 11, 2011. It has been an honor for me to have cared for your medical needs. I will leave with the feeling that we have accomplished a lot together, and I hope that you will continue to maintain a keen interest in your health. Taking care of you has been a privilege.  I will miss your visits.

I have had the privilege and honor to have worked with a group of very dedicated doctors that are ready to continue your care uninterrupted. You will find that their level of professionalism and service mirror what you have become accustomed to. Your medical records will remain secure here under the protection of the medical staff. They will ensure that your care remains continuous and that your healthcare needs continue to be met. Please contact the office at www.aagastro.com to schedule an appointment with one of our excellent health care providers.

I greatly value the relationship that we have built and thank you for your loyalty. The relationship I have developed with each of you over the past 35 years will always be remembered. It has been an honor having you as a patient. Best wishes.

Yours Truly,

Wm. A. Cassidy, M.D.

Congratulations. The time for your big trip has finally arrived. If your travel will take you
to a developing nation in Central or South America, the Middle East, Asia or Africa, you
are aware that certain precautions are needed so that diarrhea will not spoil your trip or
worse, seriously threaten the health of your child or spouse. How can Traveler’s
Diarrhea be avoided? Also, if the worst happens despite precautions, what can be
done to treat it?

Acute diarrheal illness is common among travelers, affecting up to half of visitors to
developing countries. Germs are the most common cause, followed by viruses and,
rarely, parasites. Most often, the source of fecally contaminated drink or food. All
water, even for tooth brushing, must be boiled or chemically treated (iodine or chlorine)
or taken from a sealed commercial bottle that you open. All cans or bottles should be
wiped clean and dried. Carbonated beverages (no ice!), coffee or boiled tea and wine
or beer are safe. All dairy products must be pasteurized. Only eat well-cooked foods
(no raw shellfish!) and fruit you peel yourself. No salads or other uncooked vegetables
are allowed and never consume street vendor food. The old aphorism is “Boil it, peel it, .
cook it or forget it.”

If you are more susceptible to such infections or their effects because of underlying
illness, very young or advanced age, the use of medications that reduce stomach acid,
inflammatory bowel disease or celiac sprue, your doctor may advise the use of
prophylactic antibiotics. Currently, the standard medical advice for most people is to
use antibiotics only if symptoms develop; but a new antibiotic, Rifaximin, is being tested
for efficacy and safety as prophylaxis against bacterial diarrhea for most travelers to
developing countries. Most individuals should take prescription antibiotics on the trip
just in case. The choice of medication depends upon the time of year, the area
visited, and individual factors. Consult your doctor at least six weeks before travel; you
may also need vaccinations.

Despite all your precautions, you may wake up several days after beginning your
vacation (or even shortly after returning home) with aches, nausea and vomiting,
cramps and diarrhea. The most important part of treatment is to maintain hydration.
Water is sufficient for most adults, but infants and children and elderly or infirm persons
should be given oral rehydration salts in boiled or treated water. The salt specimen is
specific by the World Health Organization and packets are widely available overseas at
stores and pharmacies. Continue to eat because it helps maintain or restore intestinal
tissue. The antibacterial supplied by your doctor should be started promptly, but if
serious symptoms such as high fever, intense pain, or bloody diarrhea develop, seek
local medical care. Anti-diarrheals such as loperamide (Imodium) may decreased
cramping and the number of stools but will not abbreviate the illness and should be
avoided with the “serious symptoms” mentioned above. The probiotics that have been
tested were not effective and Pepto-Bismol was only moderately helpful.

For additional information, such as specific risks in a particular country, consult the
CDC at http://www.CpC.gov/travel. Remember, travel abroad is often a source of unforgettable and unique experiences. These few precautions will make the trip more safe and enjoyable for all.

Listen to Dr. Jackson’s Pod Cast: Obesity and Your Liver
(you may also “right click” the link and hit “save as” to save the file for later listening)

Over the past decade, obesity rates in the Unites States have increased. Worldwide, 315 million people are estimated to be obese. The cases of obesity have doubled in the United States, where as many as 20 percent of males and 25 percent of females are classified as obese. The rising rates of obesity are linked to an increased consumption of processed foods, and a lack of sufficient physical activities. The instances of obesity are more common in women than men, which is most likely due to men’s ability to store more lean muscle than fat tissue.

In addition, obesity rates are higher amongst minorities and the poor. The highest occurrence of obesity is seen in people with both the lowest incomes levels and educational training. Several studies have shown that low income families, which are typically comprised of minorities and women, most often choose an energy-dense diet. An energy-dense diet is comprised of processed foods, from which the energy is derived from fats and sugars.

Body mass index (BMI) is the accepted measure for defining obesity; but this measurement can be unreliable for very muscular and/or extremely tall individuals. A normal BMI range is 18.5 to 24.9. A BMI of 25 to 29.9 is overweight, above 30 is obese, and above 40 is classified as morbid obesity. The distribution of body fat is also important and is associated with increased medical problems. Central obesity (apple shaped) is linked more to heart disease than gluteo-femoral obesity (pear shaped). Therefore, waist size, which is a good measure of increased intra-abdominal fat, is useful in predicting whether people are overweight or obese.

Obesity greatly increases the risk for multiple medical problems, such as diabetes, elevated cholesterol, high blood pressure, cancer, and non-alcoholic fatty liver disease (NAFLD).
NAFLD resembles alcohol-induced liver injury despite little or no alcohol consumption. NAFLD ranges from simple fatty liver to steatohepatitis (inflammation) followed by fibrosis (scarring) and finally cirrhosis (end-stage liver disease). This progression occurs particularly in obese individuals with central obesity. The body produces more insulin, which leads to an increase in fatty acids that are directly toxic to the liver or leads to oxidative stress on the liver.

Diagnosis is based on history, as well as the exclusion of other causes of liver disease. The gold standard for diagnosis is a liver biopsy. Due to medical intervention, only a small fraction of diagnosed patients progress to end-stage liver disease. Effective treatment to avoid reaching end-stage liver disease are weight reduction, antioxidants such as Vitamins C and E, and insulin-sensitizing medications such as metformin, pioglitazone, and rosiglitazone. The goal of these treatments is to reduce potential risk factors such as obesity, hyperlipidemia and poor diabetic control.

So, how can we combat obesity? As consumers we need to be better educated about healthy eating habits and food choices from an early age, especially since the obesity epidemic is also affecting our children. To maintain healthy diets among all socioeconomic groups, we need to insist that healthy foods are accessible and affordable in all communities.

Obesity is not just a social or medical issue, but is now a major public health problem which is shortening our lifespan, reducing our quality of life, and changing the economics of the United States. If we do not change the culture in our society, and make a conscious decision to change the quality and quantity of the foods we and our children now eat, it will adversely affect us later.