Introduction

Dr. Bob: And welcome to The Dr. Bob Show. Thanks for taking your time to learn a little bit about making your life healthier and happier. You know, we can do that by doing the four things we start off each week. You need to be exercising 20-30 minutes and you need to do it five days a week. Be sure you start the day off with eight hours sleep. It may be hard to do, but get that sleep! You will feel so much better. Start the day off with a breakfast of fruit and fiber and most of all, what is it we like? Well, it's laughter in your life. Be sure you get enough laughter.

I'm Dr. Robert Overholt and I'll be your host for the next 30 minutes on The Dr. Bob Show. We're going to be talking about what I call the 3 D's of the GI tract and that's Diverticulosis, Diverticulitis and Diarrhea-a new cause, a very under-diagnosed cause, of diarrhea that I think will be important for you to learn about. That is-dangerous, diverticulitis or diverticulosis. And we'll discuss the treatment of those. Later on in the show we'll be talking about the difference between thyroid and parathyroid. How dangerous is cataract surgery? And we'll be talking about diabetes. Could you really have diabetes and not know it? We've got a lot of information and you'll want to stay tuned. I've got an outstanding guest. My guest is Dr. Sarkis Chobanian and Dr. Chobanian is a board-certified gastroenterologist so we'll be talking together about the 3 D's of GI disease.

Dr. Bob: We're talking with Dr. Sarkis Chobanian, board-certified gastroenterologist. Dr. Chobanian is a long time friend of mine. He's been on The Dr. Bob Show before and we've talked about colon cancer and we've talked about esophageal reflux disease and today we're going to be talking about the 3 D's. Sarkis, welcome to The Dr. Bob Show.

Dr. Chobanian: It's nice to see you Bob.

Dr. Bob: Let's talk about a couple of those 3 D's. Let's talk about diverticulitis and diverticulosis. What's diverticulosis?

Dr. Chobanian: Diverticulosis is a very common situation in many Americans. These are little pockets that form in the intestinal tract and most commonly in the colon and most commonly in the lower left colon. It is thought to be caused by inadequate fiber in the diet, a lot of pressure, therefore, in the colon. People get constipated-have a little bit sluggish bowel. That pressure causes the wall of the colon to expand and these little pockets (or hernias) to form.

Dr. Bob: Little balloons?

Dr. Chobanian: "Little balloons" is a good way of putting it.

Dr. Bob: About how big are they?

Dr. Chobanian: Oh golly, the size of a peanut or the end of a finger.

Dr. Bob: And are they dangerous?

Dr. Chobanian: They're dangerous when they get complications, most typically your other D, diverticulitis, which is an infection. They can sometimes hemorrhage. They have a little feeder artery and it can perforate, bleed massively at times, and at other times you can actually have a full thickness perforation leading to abscess and even peritonitis.

Dr. Bob: Wow! How commonly do they perforate? If there is a little weak blooming out and it's weak there, it seems they would pop easy like a balloon.

Dr. Chobanian: Well, frankly, they don't. Fewer than 10% of all patients who have the disease even get any complication. In fact, a lot of us over the age of 50 walking around out there probably have it (diverticulosis) don't even know we have it.

Dr. Bob: If we have diverticulitis, and first I want you to explain what it is, would we know that?

Dr. Chobanian: You would know it. That usually occurs because you'll get some hard material in that little balloon. That balloon doesn't have a chance to empty. Again, that pressure builds up and now bacteria cannot escape. They multiply. The colonies will grow and grow and that's where you get a terrible infection which will lead to a lot of pain.

Dr. Bob: Now, so the classic signs of diverticulitis would be…….

Dr. Chobanian: Abdominal pain usually in the left side of the abdomen, lower left corner of the abdomen.

Dr. Bob: And fever?

Dr. Chobanian: Fever. Again, if it is starting to go out through the wall of the colon, you start getting a high fever, chills, even have difficulty walking. You get a lot of irritation in the abdominal cavity.

Dr. Bob: Is it dangerous?

Dr. Chobanian: It's dangerous when it perforates. Then you will certainly need hospitalization and probably surgery and it is potentially dangerous if it bleeds although, thank goodness, most of the time bleeding will subside on its own.

Dr. Bob: What is the treatment?

Dr. Chobanian: Well, for the bleeding usually it is watching and waiting. On the other hand, if it is persistent, we can go in there with a colonoscope and sometimes attack those bleeders. A radiologist can go in with a catheter, embolize those bleeders and, of course, our surgeon is always right there in case we can't control it.

Dr. Bob: Do you give these people antibiotics, fluids, IV's, put them in the hospital?

Dr. Bob: Absolutely. In the hospital with diverticulitis, they will be placed at bed rest and not allowed to eat or drink anything, fed by vein and, of course, they will be given a broad- spectrum antibiotic to cover all the potential bacteria.

Dr. Bob: Now, if we could start at age ten, twenty or earlier in our life, what would you teach somebody about colon health? Does diet really help? Does exercise really help? Do certain foods really help?

Dr. Bob: Well, I think it's difficult to prove in terms of overall colon health but most gastroenterologist feel that a high fiber diet and reducing the amount of red meat in a diet is very beneficial to the colon. Also, vitamins, plenty of water, seven glasses of water a day and regular exercise. All those tricks that help keep you regular are beneficial for your colon health.

Dr. Bob: And when people have symptoms, what type of symptoms mean they need to have their colon checked?

Dr. Chobanian: Well, I think certainly if you are having rectal bleeding, that's a real cardinal symptom to go and get that checked. Any change in your bowel habit. If you've always been a regular guy, 7 o'clock in the morning you're regular, and all of a sudden you're going three days without a bowel movement, gosh, that's a change. Get that checked out as well, or a change in the size or shape of your stools.

Dr. Bob: So, stool changes and abdominal pain, you have to get those checked out. You and I were talking before the show about some new findings in an illness in the 3 D's. Tell me some history behind the new finding that may be much more prevalent in people than we ever thought before. Tell me about.

Dr. Chobanian: Yes. I think what we're getting into there is the disease has many names, unfortunately. Celiac disease is one of them. Sprue is another. Gluten sensitivity in the diet. You know how doctors are to throw words around, but this is an old disease that we feel has been under-diagnosed for years.

Dr. Bob: Why do you feel it's been under-diagnosed?

Dr. Chobanian: Well, actually we had to learn a lesson from our European colleagues. They more or less pointed out that the patients here, our patient population, many of them are from western and northern Europe, and gosh, that disease is very prevalent there. It's not very prevalent here in America or so we thought until they had to remind us to look harder for it.

Dr. Bob: And how did we find out that it may be in as much as 1% of the population?

Dr. Chobanian: Well, it took the invention of a blood test and a serologic or antibody test to begin to identify and screen these patients and, low and behold, our European colleagues were right.

Dr. Bob: What did they find? How did you test the blood? Did you go to a blood bank and just test whole bunches?

Dr. Chobanian: Yea. A blood bank, of course. They have a lot of blood samples there and this finding really interested them so they said, well, gosh, let's go ahead and do the antibody test. And, low and behold, I think they found here in America an incidence of about one in 250.

Dr. Bob: So, what does that mean to people in the United States that are having abdominal discomfort? They may have this illness?

Dr. Chobanian: They may have it and it's very common.

Dr. Bob: Is it treatable?

Dr. Chobanian: It's treatable with a special diet.

Dr. Bob: Is it easy to diagnose?

Dr. Chobanian: It's a complex diagnosis but if your doctor's on the ball, he or she can do it.

Dr. Bob: And that's what we're going to be talking about. One in 250 people! Just look around the room where you're working. Somebody may have sprue! We're going to talk about the diagnosis, how we used to do it in the past, and how we can do it now. Could you perhaps have that? Do you have abdominal bloating and overbearing cramping pain and sometimes maybe a little diarrhea? Other medical problems like maybe anemia? We'll be talking about that, very interesting, very exciting to me. But first, I want to introduce you to a person who indeed does have sprue.

A Patient's Experience with Sprue

Dr. Bob: Jennifer, when did they tell you you had sprue?

Jennifer: Two years ago.

Dr. Bob: Now when they told you sprue, what kind of symptoms were you having?

Jennifer: A lot of abdominal pain, fatigue, weight loss.

Dr. Bob: Diarrhea?

Jennifer: Yes.

Dr. Bob: A lot of diarrhea or mainly cramping pain?

Jennifer: Just mostly abdominal pain.

Dr. Bob: Now, when you started staying away from gluten, how long did it take you before you felt better?

Jennifer: A couple of weeks.

Dr. Bob: Just two weeks?

Jennifer: Yes.

Dr. Bob: What difference did that make in your life?

Jennifer: Well, I started feeling better and you know, I had a job and a family and I mean, that made all the difference in the world-that I felt like doing something.

Dr. Bob: Could you believe it when they told you all you had to do was to stop eating wheat?

Jennifer: Well, I had a lot of denial about it because you know, I am a pasta and bread person and…

Dr. Bob: Does that mean no pizza?

Jennifer: No pizza.

Dr. Bob: Does that mean eating no sandwiches with bread?

Jennifer: That's right.

Dr. Bob: How about weight and how about your feelings as a person?

Jennifer: Well, my weight is steady. I'm maintaining a certain weight.

Dr. Bob: Were you losing weight before?

Jennifer: Oh, yes, fast.

Dr. Bob: And how much weight had you lost?

Jennifer: I lost 60 lbs. in about three months.

Dr. Bob: What would be your advice to somebody that has chronic fatigue, weight loss, cramping pain and diarrhea?

Jennifer: You need to go see your GI doctor.

Dr. Bob: Thank you Jennifer. Abdominal pain, weight loss, sometimes those are scary symptoms. They certainly need to be evaluated and I am glad that you've got such as treatable problem.

Dr. Bob: Sarkis, let's get back to sprue.

Dr. Chobanian: Sprue.

Dr. Bob: So it's "sprue" now. We used to call it a whole bunch of names that you mentioned earlier. What are the symptoms of sprue first of all?

Dr. Chobanian: Well, it can be very subtle. Diarrhea is usually a predominant symptom although some people have no symptoms. You can also have abdominal pain but it's not really dramatic. Just a little bit of an ache or a cramp, also gas and bloating are common.

Dr. Bob: When they have those symptoms, you know, how will they suspect they've got something bad going on? Or is the pain bad or should just anybody that has cramping, abdominal pain be checked for this?

Dr. Chobanian: No, certainly not but in conjunction with some other findings on the lab or physical examination, the doctor's suspicion has to be fairly high and that's why we like to educate the doctors first, more so than the patients.

Dr. Bob: And what are some of the things that we find in laboratory work? Do these people get osteoporosis?

Dr. Chobanian: Osteoporosis that may occur at an early age or perhaps when it's not in the family needs to be checked out… If you're a young 40-year old female, maybe you're not blonde and blue eyed and nobody else in your family had osteoporosis, gosh, there is a real hint.

Dr. Bob: What other hints?

Dr. Chobanian: Unexplained anemia, particularly iron deficiency anemia. Now of course for a lot of patients, that can be due to blood loss to the GI tract through the uterus or through the kidneys, but in patients who have unexplained iron deficiency anemia, that is another major red flag.

Dr. Bob: Anything else-osteoporosis, anemia…

Dr. Chobanian: Also, neurologic symptoms.

Dr. Bob: Oh, really? What type of neurologic symptoms do they get?

Dr. Chobanian: Something called ataxia which is difficulty walking or difficulty with the co-ordination of grasping things.

Dr. Bob: So, sort of hidden things? Blood work, calcium, are there any problems with that?

Dr. Chobanian: Calcium can be low. Of course, you can be anemic, have low iron, low hemoglobin…

Dr. Bob: Now, how did we use to diagnose this, because I remember in training talking about sprue. I didn't know it was this common but we used to diagnose it by… what was the old fashion method?

Dr. Chobanian: Well, unfortunately, it was a long tube to get a good piece of the small intestine.

Dr. Bob: You had to take a biopsy.

Dr. Chobanian: A biopsy and it was done awake and we needed to get way down into the small intestine-it was very uncomfortable. We really didn't like to have our patients go through that.

Dr. Bob: Now, when you got a biopsy, what did it look like? How did it change? What was its characteristic?

Dr. Chobanian: Of course, we don't have a slide for you right now but you know, the lining of the intestine, it looks like little fingers, like little sea anemone fingers. That's what's normal and that's where the protein and carbohydrates are absorbed. In a sprue patient, pretend like your fingers have been amputated, and the intestines are not able to absorb all the nutrients. Well now, the nutrients just bounce off. You have malabsorption and, ultimately, diarrhea.

Dr. Bob: And the diagnosis now-how do we do it? We don't have to go down and get a biopsy?

Dr. Chobanian: Well, that's still the gold standard. However, the biopsy is much much easier nowadays because you're put to sleep and it's done with an endoscope, the usual stomach tube. It's really a piece of cake but we have these wonderful antibody tests, a blood test that can be sent off to special laboratories and screened for the presence of sprue.

Dr. Bob: Now, what is the antibody test?

Dr. Chobanian: There are many different types. The most common one is the anti-gliadin antibody. Gliadin is a component of wheat which is actually thought to be the cause of sprue itself.

Dr. Bob: Now, that's "g l i a d i n," gliadin?

Dr. Chobanian: Exactly right.

Dr. Bob: So, you get antibodies against that.

Dr. Chobanian: Right, and gliadin is a component of gluten.

Dr. Bob: So, that's why we have to put people on the kind of diet I've heard about, a gluten-free diet. What does that mean, a gluten-free diet?

Dr. Chobanian: A gluten-free diet is doable but it takes a lot of work and it's not a lot of fun at the beginning because I think a lot of us enjoy our carbohydrates-cookies, and cake, and candy, bread, pasta. Well, you can still have those items but they have to be specially made, not with wheat flour, rye flour, or barley. So, the patients do have a diet of ….

Dr. Bob: Mainly boring…

Dr. Chobanian: Yea, it's good foods but in terms of grains, they can have corn, some of them can have oats, and some other unusual grains that don't seem to have the same chemical combination as wheat.

Dr. Bob: What do patients notice when they go on a gluten-free diet? Can they tell right away? How long does it take before they start improving?

Dr. Chobanian: It can be anywhere from days to weeks and it is fairly dramatic. They will notice that a lot of their GI symptoms disappear almost overnight. The diarrhea goes away and most gratifying, if you have young people who have lost weight all of a sudden, that weight begins to magically reappear.

Dr. Bob: Now, if I was on a gluten-free diet and I went to the Pizza Parlor and there was a pizza there that had crust that was made from flour, what would happen if I eat one piece of pizza.

Dr. Chobanian: Well, everybody is different. Some people can get away with occasional cheating. For other people, though, cheating can make them dramatically ill and it would take weeks or months to get them back into remission after going back on a gluten-free diet. The most common reason that patients have problems with this is either they have intentionally or unintentionally cheated on their diet.

Dr. Bob: Now, let's talk about some of the history again. You mentioned something about World War II?

Dr. Chobanian: It was very interesting. During the Nazi occupation of Holland in World War II, there was a group of kids who had a "wasting" disease. Well, low and behold, because of the occupation no one had access to cereal-breakfast cereal-during the war. The normal kids, of course, lost weight and they did poorly, but the kids in Holland who had sprue actually put on weight even though they weren't getting cereal and bread in the morning. A very astute Dutch pediatrician noticed this and then after the War noticed that when these same kids, his "wasting" kids he called them, got access to bread and cereal again, well, gosh, instead of gaining weight, they began to lose weight. So, he put two and two together and he was really the one who was the modern father of celiac disease.

Dr. Bob: Let's summarize. Tell me about the patient, the symptoms and the diagnosis and the treatment if you can in a period of about 30-45 seconds.

Dr. Chobanian: O.K., we'll try. Any age group, either sex, can have anywhere from subtle symptoms-bloating, gas, little bit of pain, diarrhea-to unexplained anemia, unexplained liver test abnormalities, maybe a little bit of clumsiness in walking and grasping things. Go to your doctor, get the blood test as a screening test and then if you have it, go through the biopsy. With the modern way of doing a biopsy, you have nothing to fear-you will be put to sleep. It's easy and painless and then this can be treated for life with a special diet.

Dr. Bob: And it's an anti-gliadin antibody blood test?

Dr. Chobanian: Exactly.

Dr. Bob: Sarkis, one in 250 people have this? We need to really be more aware of this. Thank you for challenging us to look for that abdominal pain that somebody has who is losing weight, doesn't feel good. It may be sprue. Thanks so very, very much.

Dr. Chobanian: Thanks for inviting me.

Dr. Bob: We'll come back later and we're going to be talking about other medical problems-the difference between thyroid and parathyroid disease, some other problems that you might be having. You stay tuned.

Conclusion of Interviews
Dr. Bob: I want to thank Dr. Malcolm Foster for a wonderful discussion on peripheral vascular disease. It may be a wake-up call for you and me that hardening of the arteries is going on some place else in the body.

Hallerin Hill: Faced with the symptoms of heartburn, upset stomach, diarrhea, nausea it's very tempting to reach for an over-the-counter pill or tablet, like one of these, just to make the symptoms go away. In fact, more and more Americans are doing just that. It is estimated that Americans spend 5 billion dollars a year just to treat their heartburn and indigestion with over-the-counter medications. If you look on the shelves of your local supermarket or pharmacy you'll see a wide variety of these medications. We've all heard of Pepcid AC, Tagamet, Zantac. These medications all reduce the amount of acid that is produced by the stomach. The symptom-reducing type of heartburn medications are antacids such as Tums, Rolaids, Maalox, and Mylanta. These neutralize the acid in the stomach. As with any drug, these over-the-counter medications may not be for everyone. So, be careful, make sure you look at the active ingredients because they could interact with other medications. Now, if you're having heartburn or indigestion on a regular basis, like once or twice a week, you'll want to check with your doctor because that could be an indication of something much more serious. Stay healthy. For the Dr. Bob Show, I am Hallerin Hilton Hill.

Letters

Now, we're going to be talking about questions from you, the viewer. One question is...

Letter #1: . "Dr. Bob, what is the difference between the thyroid and the parathyroid gland? I thought they were the same."

Response #1: Well, it's a good question but they are not the same. Both are in the neck. The thyroid gland sits in the neck. It's about the size of my thumb, half of my thumb, on the side, and it produces a thyroid hormone. The thyroid hormone is responsible for metabolism. So, an overactive thyroid gland makes us hypermetabolic, makes us nervous, makes us run, makes us energetic, makes us perspire, makes the hair thin. We're just a bundle of nerves all the time; we eat a lot of foods but don't gain weight. So, if somebody is just talking a mile a minute like sometimes I do, they might have an overactive thyroid. The other one, underactive thyroid, hypothyroidism is the other way around. People are just tired. Their voice gets sort of hoarse. Their skin gets dry and coarse. Their hair gets brittle and they just don't feel good. Hoarseness is a big thing that they have.

Now, the parathyroid gland sits behind the thyroid and its responsible for calcium and phosphorous in the bloodstream. Now, usually we can find either an overactive or underactive parathyroid gland. Frequently overactive makes the calcium go too high in the bloodstream and can cause lots of symptoms that people have. An underactive parathyroid gland results in not enough calcium in the bloodstream and we get tingling and sometimes cramps of the extremities. Most commonly it would occur after thyroid surgery where somebody inadvertently took out the parathyroids also. So, parathyroids: calcium and phosphorous. Thyroid has to do with how much energy you have.

Letter #2: "Dr. Bob, how dangerous is cataract surgery?"

Response #2: Well, you know anytime somebody is going to operate on my eyes, I want to know that answer too and the ophthalmologists absolutely amaze me with what they do with surgery. They do it under huge magnification and also have computer or mechanically controlled ways to take out a cataract. Now, cataract is cloudiness of the lens that we have in the eye and they simply remove that lens and put in another lens and close it up. This is done under local anesthesia so really there're not a lot of problems. Infection would be one that we would worry about afterwards. If you had an illness such as a cough where everytime you coughed, it increased the pressure in your eye, that could make things go wrong. Your doctor will talk to you about those. If you've got cataracts and you can't see and everything is sort of cloudy like you're looking through a glass pane and it is really cloudy there and you just can't see colors good, and there is halo vision when you're driving at nighttime, see a doctor and get a new light in front of you. Get that cataract taken care of.

Letter #3: "What's the best medicine, Vioxx or Celebrex?"

Response #3: Now, most people know that Vioxx and Celebrex are medicines for pain and for arthritis. They've taken over the medicines that we used to have which are still quite good. Aspirin is an excellent medication, but aspirin sometimes causes people to have heartburn, indigestion and sometimes some GI bleeding. So, we went to the Ibuprofen family and there are several medicines like Ibuprofen that indeed were better. They worked great on joint pains and on inflammation. They did a super duper job but the problem again was the stomach. And then they came up with two medicines, Vioxx and Celebrex. They're called COX 2 inhibitors. And really what they do is they allow prostaglandins to protect the stomach, but work as an anti-inflammatory medicine against arthritis and against pain. Both are good. Flip a coin. Vioxx and Celebrex-both good medications. They don't bother the stomach as much as the others and they work well for arthritis and inflammation, sore joints, sprained ankles, that sort of thing.

Letter #4: "Dr. Bob, is it true that people can have diabetes and not know it?"

Response #4: Well, 16 million Americans have diabetes but only 8 million know it and those that don't have just a very small elevation of their blood sugar but they are getting damage to their blood vessels, vision, kidneys, and heart. Have your blood sugar checked and let your doctor tell you if you have diabetes and pay attention.

Closing

Dr. Bob: That's all the time we have. I hope you've enjoyed this show as much as I have. Remember, be sure that you're exercising. Start the day off with eight wonderful hours of sleep and a good breakfast but most of all, we hope you have laughter in your life.

If you have a question for Dr. Bob, write to The Dr. Bob Show - 6700 Baum Drive, Suite 1, Knoxville, TN 37919 or send your e-mail to letters at letters@drbobshow.com