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Gluten Free Diet

Golden Gate Bridge, San Francisco. (Dr. Noorali Bharwani)
Golden Gate Bridge, San Francisco. (Dr. Noorali Bharwani)

Celiac disease is a serious autoimmune condition that occurs in genetically predisposed people where the ingestion of gluten leads to damage in the small intestine.

Celiac disease and non-celiac gluten allergy should not be taken lightly.

Celiac disease is a common lifelong intestinal disorder and runs in families. A first-degree relative with celiac disease has a 10-fold increased risk of acquiring the condition.

It affects about one in 100 people. A person can be critically ill to being completely well.

The risk is increased among people with autoimmune thyroid disease (three to five per cent), type one diabetes mellitus (five to 10 per cent) and Down syndrome (5.5 per cent).

Patients with celiac disease can present with a variety of symptoms. The classical symptoms include chronic diarrhea, abdominal pain, malabsorption and weight loss.

When gluten is ingested, it causes immunologically toxic reaction in the lining of the small intestine. The toxic reaction damages the lining of the intestine thus interfering with the absorption of nutrients and leading to diarrhea and malnutrition.

How to diagnose celiac disease?

The most widely available test is the tissue transglutaminase IgA antibody test, which has an estimated 95 per cent accuracy rate. If antibody testing is negative and celiac disease is suspected, the IgA level should be measured. All adults with an abnormal screening result should undergo a small-bowel biopsy to confirm the diagnosis of celiac disease.

Celiac Disease Foundation website says first-degree relatives of people with celiac disease – parents, siblings and children should be screened.

What is non-celiac gluten sensitivity?

The term non-celiac gluten sensitivity is used to describe the clinical state of individuals who develop symptoms when they consume gluten-containing foods and feel better on a gluten-free diet but do not have celiac disease.

Research estimates that 18 million Americans have non-celiac gluten sensitivity. That’s six times the number of Americans who have celiac disease. More research is needed to understand this problem.

Besides being sensitive to gluten often these individuals experience headaches, rashes and fatigue. These individuals have no inflammation or damage to the intestinal lining as in celiac disease.

Treatment is lifelong adherence to a gluten-free diet. The follow-up is most often provided on an annual basis, and includes reinforcement of the need to adhere to a gluten-free diet, dietary review, physical examination, laboratory tests and a recommendation to join a patient support and advocacy group.

Prognosis

The long-term prognosis for celiac disease is good as long as people with celiac disease follow a gluten-free diet.

Eating out is not always easy. Sometimes, no matter how prepared and informed you are, there is not a satisfying gluten-free choice. There are two strategies to address this. The first is to eat at home prior to dining out so that your hunger is under control and you are less tempted to make unsafe menu choices. The second is to bring gluten-free foods with you such as bread, crackers or even pasta, which you can ask the chef to cook in a clean pot.

Life is not easy for people with celiac disease or non-celiac gluten allergy. Patience and perseverance with dietary choices is the key to good health.

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Erectile dysfunction can be a sign of heart disease.

Cordoba, Spain. (Dr. Noorali Bharwani)
Cordoba, Spain. (Dr. Noorali Bharwani)

From time to time most men will have problems with erection. That isn’t necessarily a cause for concern. But some men have erectile dysfunction (ED). This is when it is difficult to get or keep an erection that is firm enough for sexual intercourse.

If ED is an ongoing issue then it will cause stress, affect your self-confidence and contribute to relationship problems.

ED can also be a sign of an underlying health condition like heart disease that needs treatment.

Recently, I came across an article in Choosing Wisely (2018 article developed in cooperation with the American Urological Association) titled “Testosterone for Erection Problems When you need testosterone treatment – and when you don’t.” Here is some information from that article.

What is testosterone and does it help men with ED?

Testosterone is a male sex hormone. After age 50, men’s levels of testosterone slowly go down and ED becomes more common. But unless you have other symptoms of low testosterone, you should think twice about the treatment. Testosterone treatment usually isn’t helpful for ED irrespective of your testosterone level.

Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles and blood vessels. ED can result from a problem with any of these.

Choosing Wisely says ED is almost always caused by low blood flow to the penis. This is a result of other conditions, such as hardening of the arteries, high blood pressure, and high cholesterol level. These conditions narrow the blood vessels and reduce blood flow to the penis. Low testosterone may affect the desire for sex, but it rarely causes ED. Stress and mental health concerns can cause ED.

Testosterone replacement therapy has many risks. Do not use testosterone without medical advice.

Erectile dysfunction: A sign of heart disease?

It is important to remember that the same process that causes heart disease may also cause ED, only earlier. ED can be an early warning sign of current or future heart problems.

From a purely mechanical perspective, an erection is a hydraulic event – extra blood must be delivered to the penis, kept there for a while, then drained away. An erection may not happen if something interferes with blood flow to the penis.

ED does not always indicate an underlying heart problem. However, research suggests that men with ED who have no obvious cause, such as trauma, and who have no symptoms of heart problems should be screened for heart disease before starting any treatment. Getting the right treatment for your heart might help with ED.

Fortunately, there are several ways to combat erectile dysfunction. Simple lifestyle changes like losing weight, exercising more, or stopping smoking can help. Drink alcohol only in moderation or not at all.

Further tests or treatment might be needed if you have more-serious signs and symptoms of heart disease. If you take certain heart medications, especially nitrates, it is not safe to use many of the medications used to treat erectile dysfunction.

ED is a complex medical problem. Get appropriate medical advice before you try any medications.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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What can we learn about our heart from a cardiac stress test?

Upper Kananaskis Lake, Alberta, Canada. (Dr. Noorali Bharwani)
Upper Kananaskis Lake, Alberta, Canada. (Dr. Noorali Bharwani)

Let us start by understanding the difference between cardiac stress test and cardiac Holter monitor.

What is cardiac stress test?

Robert Arthur Bruce (1916-2004) was an American cardiologist who invented the treadmill cardiac stress test used to diagnose heart disease. Patient’s heart signals are monitored on a treadmill set at successive stages of difficulty. Bruce also created the Bruce Protocol in the early 1960s, monitoring the heart signals of a patient on a treadmill.

Why is cardiac stress test important? Some heart problems only appear when your heart needs to work harder. Cardiac stress test helps to show how your heart copes under stress.

A cardiac stress test is done in a controlled clinical environment. It measures the heart’s ability to respond to external stress.  The stress response is induced by exercise or by intravenous injection of a medication.

What is cardiac Holter monitor?

Norman “Jeff” Holter (1914 – 1983) was an American biophysicist who invented the Holter monitor, a portable device for continuously monitoring the electrical activity (ECG) of the heart for 24 hours or more. Holter donated the rights to his invention to medicine.

The test is used to identify any heart rhythm problems. The device is the size of a small camera. It has wires with silver dollar-sized electrodes that attach to your skin.

Who needs cardiac stress test?

Any person who has a worrisome symptom like chest pain – especially in older men with risk factors for heart disease. An exercise stress test is not 100 per cent accurate. But it helps decide what the next step should be.

When to get a cardiac stress test?

The U.S. Preventive Services Task Force, an independent panel that makes recommendations to doctors, urges physicians not to routinely offer exercise stress testing to people without symptoms or strong risk factors for coronary artery disease.

Main indication for ordering stress test is when a person complaints of chest pain. Chest pain is not an uncommon complaint. Chest pain can have many possible causes besides heart disease.

For example, chest pain can be due to indigestion, anxiety, or muscle injury. If your doctor finds that you probably don’t have a heart problem, you may not need a stress test at all, says Choosing Wisely (2017 Consumer Reports. Developed in cooperation with the American Society of Nuclear Cardiology).

If you do have a heart problem, your first choice should often be a simple stress test without imaging. This test has little risk and is inexpensive. It is usually accurate for people with a low risk of heart problems.

Imaging stress tests are usually safe and can use little or no radiation. But for people at low risk, the tests may produce false alarms. This can lead to follow-up tests that you don’t really need. The extra tests can expose you to more radiation. Inappropriate testing can also lead to unnecessary treatment, says Choosing Wisely.

An imaging stress test can cost 10 times more than a regular stress test. You should only get an imaging stress test when it will help your doctor manage your disease or lead you to a better treatment. Discuss your symptoms with your family doctor. We can learn a lot from cardiac stress test if appropriately ordered.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Control heartburn and acid reflux.

Calgary, Alberta. (Dr. Noorali Bharwani)
Calgary, Alberta. (Dr. Noorali Bharwani)

As you may know, heartburn has nothing to do with your heart. Heartburn is a symptom of acid reflux from your stomach to the esophagus.

Heartburn is a common gastric complaint. For example, in the U.S. it affects more than 60 million people each month. Yes, each month. When does it become a disease? When the reflux symptoms occur frequently. Then it is called gastroesophageal reflux disease (GERD). If not treated then it gets complicated.

Distinguishing between heartburn, acid reflux, and GERD may be hard, because they may all feel the same. However, understanding the differences can help a person find the right treatment. Difference lies in the severity and frequency of the symptoms and the damage inflicted by the acid to the esophagus and lungs. Yes, it can damage your lungs.

Reflux can also occur in infants. Infant reflux occurs when food refluxes from a baby’s stomach, causing the baby to spit up. This is rarely serious and becomes less common as a baby gets older. It’s unusual for infant reflux to continue after age 18 months.

Reflux in adults is fairly common. In 2005, a systematic review of population-based studies found the prevalence of reflux to be 10 to 20 per cent in Europe and North America and less than five per cent in East Asia. If reflux is not controlled then the acid will damage the esophagus causing inflammation, narrowing, ulcers and bleeding.

Managing early stage of heartburn and reflux

In early stages if occasional reflux is the only symptom then you can take care of it by simple life style changes: eat small meals, avoid any food that gives you heartburn, avoid big spicy meal, do not lie down after eating, do not smoke or drink alcohol, lose weight and use antacid, like Rolaids or Tums.

Managing late stage of heartburn and reflux

If measures like life style changes and antacids do not help then there are medications called H-2-receptor blockers and proton pump inhibitors (PPI) that can be tried.

H-2 receptor blockers

These medications reduce the production of acid in the stomach. H-2-receptor blockers include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac). H-2-receptor blockers don’t act as quickly as antacids, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours.

Proton pump inhibitors (PPI)

These pills block acid production and heal the esophagus. They are stronger acid blockers than H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Examples include lansoprazole (Prevacid 24 HR) and omeprazole.

According to Choosing Wisely (2017 Consumer Reports prepared in cooperation with the American Gastroenterological Association), in most cases, you don’t need a PPI for heartburn. More than half of the people who take PPIs probably do not need them.

You can get relief from a less powerful drug. And when you do need a PPI, you should take the lowest dose for as short a time as possible. Preferably for less than one year. Although generally well-tolerated, these medications might cause diarrhea, headache, nausea and vitamin B-12 deficiency. If you take it for more than a year then the risk of complications include: fractures, kidney problems, heart attack, dementia, pneumonia and colitis.

While you are being treated with different pills, you will probably undergo investigations like upper GI endoscopy, ambulatory acid (pH) probe test, esophageal manometry and x-ray of your upper digestive system. If indicated, your specialist will consider you for a surgical procedure.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!