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Does Thiopurine Therapy Increase Cancer Risk?

Does Thiopurine Therapy Increase Cancer Risk?

Patients with ulcerative colitis (UC) have a 4-fold increase in risk of lymphoma during treatment with thiopurines, compared to UC patients who have not been treated with these drugs, according to a nationwide cohort study in the November issue of Gastroenterology. The risk increases gradually with successive years of therapy, but decreases when patients stop taking the drugs.

UC is a chronic inflammatory disorder; it is commonly treated with corticosteroids, which cause a number of side effects (weight gain, mood disorders, and osteoporosis) and often lack long-term efficacy. Patients are therefore often treated with other drugs, such as thiopurines (azathioprine and 6-mercaptopurine)— purine anti-metabolites with immunosuppressive properties.

Although these drugs spare patients from the potential adverse effects of corticosteroids, they have their side effects, increasing the risk of lymphoma.

Thiopurines are also used to treat patients with lymphoproliferative disorders, including lymphoma, following organ transplantation. They are reported to increase the risk of lymphoproliferative diseases by up to 20- and 200-fold in kidney and heart transplant recipients, respectively. However, the level of risk for patients with inflammatory bowel disease (IBD) treated with thiopurines is not clear—studies have produced conflicting results.

The Veterans Affairs (VA) administration has the largest integrated health care system in the United States, serving approximately 8.3 million veterans each year. Nabeel Khan et al. used the VA population-based database to estimate the risk of lymphoma among 4734 patients with UC treated with thiopurines for a median time of 1 year.

They found that incidence rates of lymphoma were 0.60 per 1000 person-years among patients who had not been treated with thiopurines, 2.31 among patients who were treated with thiopurines, and 0.28 among patients who had discontinued treatment with thiopurines. Treatment with thiopurines was associated with an approximate 4-fold increase in the risk of lymphoma relative to patients with UC who were not treated with thiopurines (see below figure).

Incidence rate of lymphoma, stratified by age and use of thiopurines.

Incidence rate of lymphoma, stratified by age and use of thiopurines.

Khan et al. showed that risk increased with the duration of treatment—the incidence rates of lymphoma during the first year, second year, third year, fourth year, and >4 years of thiopurine therapy were 0.9, 1.6, 1.6, 5, and 8.9 per 1000 person-years, respectively. Furthermore, stopping thiopurine treatment reduced the risk of lymphoma during a median follow-up time of 3.5 years.

After adjusting for age, race, and use of thiopurines, men had a nonsignificant trend toward a higher incidence of lymphoma.

How might thiopurines contribute to development of this cancer? Decreased immune surveillance of Epstein–Barr virus (EBV)-infected B cells is one way (thiopurines been implicated in the development of EBV-positive lymphomas). They also destabilize DNA by incorporating thiopurine nucleotides during replication, which interferes with replication and repair mechanisms to cause mutations.

Khan et al. state that in the absence of a comparable therapy with a lower risk of malignancy, patients with corticosteroid-dependent IBD will still be treated with thiopurines. However, there are several approaches to reduce cancer risk. Candidates for thiopurine therapy should be selected with caution—especially older men. Patients should be assessed for thiopurine methyltransferase genotype or enzyme activity, and weight-based dose adjustments can be made. Finally, stopping thiopurine therapy after 3 years should be considered, especially for patients in long-term remission.

In an editorial that accompanies the article, Laurent Beaugerie reminds us that in patients with longstanding extensive colitis, the reduction of colorectal cancer risk may outweigh the excess risk of lymphoma from thiopurines.

Khan et al. warn that although the study is based on the largest integrated nationwide health care system in the US, it is not a population-based cohort, due to the differences between the demographics of the VA population and the general US population (specifically in age, race, and sex distribution). The VA population is predominantly composed of middle-age to older white men, which can limit the external validity of the study.

Beaugerie says that randomized, mid- or long-term strategy and benefit–risk studies on the prolonged use of thiopurines beyond 5 years, based on age, sex, and IBD phenotype, are needed.

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Fecal transplant needs careful, measured approach

American College of Gastroenterology » News
Fecal transplant needs careful, measured approach

“We need to be thinking as scientists as well as clinicians and to a phased approach to using this in the future,” David T. Rubin, MD, FACG, co-director, Inflammatory Bowel Disease Center, University of Chicago Medicine, said while delivering his portion of the American Journal of Gastroenterology Lecture during the American College of Gastroenterology Annual Scientific Meeting. Rubin was joined by Stephen M. Collins, MBBS, department of medicine, McMaster University in Hamilton, Ontario, in giving the lecture on the emerging role of the microbiome in the pathogenesis and management of inflammatory bowel disease.  Healio (10/16)

Exercise Could Protect You From Esophageal Cancer

Making sure to get that workout in could help lower your risk of developing esophageal cancer, according to a new study.

Mayo Clinic researchers found an association between physical activity and risk of the cancer, with physically active people having a 32 percent lower risk of developing one of the two forms of esophageal cancer, called esophageal adenocarcinoma. Huffington Post (10/14)

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What to do About Gastric Polyps

What to do About Gastric Polyps

When clinicians detect a gastric polyp during endoscopy, they are faced with many questions: does the polyp need to be excised, or can a biopsy sample be collected and analyzed? Which polyps should be biopsied? Should patients then be followed, and how? In the November issue of Clinical Gastroenterology and Hepatology, Yasser H. Shaib et al. attempt to provide some practical answers to these questions.

A gastric polyp is an abnormal growth from the gastric mucosal membrane. Detection of stomach polyps prompts concerns about histology, cause, progression, and possible treatment.

The overall incidence of gastric polyps has increased in North America, and there has been a shift in the proportions of types detected—clinically inconsequential fundic gland polyps have become the most prevalent, whereas those associated Helicobacter pylori-induced gastritis (hyperplastic and adenomatous polyps) have become less common. In contrast, in East Asia, Latin America, and possibly Africa, where H. pylori infection and chronic gastritis are still common, and larger proportions of gastric polyps are either hyperplastic or neoplastic.

In their Perspective article, Shaib et al. discuss the features, diagnostic criteria, and management strategies for different types of gastric polyps.

For example, fundic gland polyps (see below figure), which are usually multiple, small (less than 1 cm), and smooth, should be biopsied upon detection, but large polyps (>1 cm in diameter) should be removed.

Endoscopic view of multiple fundic gland polyps in a patient taking proton-pump inhibitors.

Endoscopic view of multiple fundic gland polyps in a patient taking proton-pump inhibitors.

Fundic gland polyps are often detected in patients who have taken proton pump inhibitors for prolonged time periods. Shaib et al. propose that when more than 20 polyps are present, or their size is larger than 1 cm, patients should be asked to stop taking these drugs, to see if the polyps regress.

The authors also provide advice for diagnosis and management of hyperplastic gastric polyps, gastric adenomas, gastrointestinal stromal tumors, inflammatory fibroid polyps, gastric neuroendocrine tumors.

Shaib et al. remind us that no polyp is an island unto itself—after polyps are removed or sampled, the non-affected gastric mucosa should be inspected and biopsy samples should be collected and examined.

Few data are available on short- or long-term outcomes of gastric polyps, so no evidence-based guidelines exist. Shaib et al. suggest that patients undergo surveillance endoscopy within 1 year of detection of non-fundic gland polyps, to check for recurrence. Patients with high-grade dysplasia or early-stage cancer should be followed for at least 2–3 years, at short intervals (6 months). Gastric carcinoids managed endoscopically (usually type 1) should be followed via endoscopy, every 1–2 years.

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Don’t Let GERD Go Unchecked

Get Yourself Checked Out, acid reflux surgery in North Texas, help with acid reflux in DallasAcid reflux or GERD, if unchecked, can cause some serious health problems, so why risk it?  Here are two major medical conditions you may experience if you never get your symptoms looked at by a doctor.

Barrett’s Esophagus

A condition that occurs if the lining of the esophagus is changed to a state similar to the linings of small intestines. Although not everyone who is diagnosed with Barrett’s esophagus suffer from the acid reflux, those with acid reflux have a greater chance of getting this condition. Those suffering from this condition have high chances of getting terminal cancer. Men are more affected with this condition than women. The average age of the diagnosis of the esophagus condition is 60 years old.

Barrett’s esophagus is a difficult problem to diagnose. It cannot be diagnosed accurately since it has no symptoms and blood tests and physical examinations cannot accurately determine if this condition is present. The only proven way to diagnose it is a biopsy and upper gastrointestinal endoscopy.

Erosive Esophagitis

This is the other risk faced by those suffering from the acid reflux condition. It occurs if the acid from the stomach will back up into the esophagus and irritate it. It is very common in those who are suffering from acid reflux. Those suffering from this condition experience several symptoms such as trouble with swallowing, oral lesions, and a burning sensation in throat.

In order to detect it, the doctors perform a barium swallow or endoscopy. Barium is a chemical and it helps the x-ray to see inside of you. If untreated, it may cause intense discomfort and malnutrition as well as dehydration.

Contact us to get acid reflux help in Dallas today if you’re experiencing any discomfort. Now is always better than later.

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Vitamins vs. Acid Reflux

vitamins for acid reflux disease, DallasReflux.comGERD (Gastroesophageal Reflux Disease), also known as acid reflux, is a condition where the contents in the stomach normally end up chronically back in the oesophagus. This causes burping, heartburn, nausea, sore throat, coughing, chest pains and vomiting. 

But, you’re on this website so you already know all this. What you want to know is what can you do to make things better right now.

Below are some vitamins that can help to prevent acid reflux, or at least slow it down.

Vitamin U 

Also known as S-Methylmethionine but commonly referred to as vitamin u. Its use was uncovered when M.D. Garnett Cheney was experimenting with it in the form of fresh cabbage juice and found that it could be used to heal peptic ulcers. 

Vitamin B1

Insufficiency of Thiamine (Vitamin B1) normally causes beriberi that normally results in vomiting and weak muscles. Taking B1 vitamin aids the esophagus sphincter and also relives most of the stomach acid that had backed up. 

Vitamin B5

Also known as pantothenic acid, the vitamin is vital for healthy muscles and skin. It helps out with the condition as it works on the muscular valve which controls the esophagus sphincter and in turn it prevents the acid from going back to the throat. 

Vitamin B12

Vitamin B12 deficiency is one of the symptoms of acid reflux. Taking the vitamin is important as it helps the digestive system since it aids in the breaking down proteins. 

Vitamin B6

Also known as pyridoxine, this is a vitamin that helps in the metabolism of proteins, fats and carbohydrates. It is also vital for the growth of new cells. It is important for the replacement of the cells that are destroyed by the condition to ensure that they continue working the way they are supposed to without ant complications. 


Most doctors after studying the condition for a long time through treating several patients agree that acid reflux is one of the ways that the body states that there is something off with a person’s general health. This is because most patients with the reflux normally have a deficiency of various vitamins especially the B complex. For this reason, it is therefore recommended that the patients are put on a daily regimen of taking vitamins that will help people with their insufficiencies.

Ultimately, GERD surgery will stop your discomfort, but taking vitamins for acid reflux is still a smart option.

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Life, After Acid Reflux

personQuick Acid Reflux Refresher

Acid reflux, also known as GERD, is a medical condition that occurs when the stomach’s acidic contents are pumped back into the esophagus leading to discomfort and pain. In most cases, reflux results from weakening of the sphincter muscle, lying between the esophagus and stomach.

Acid reflux surgery is recommended for those who have used all the nonsurgical treatments without success, including changes in diet and medicines. The surgery is mildly invasive and its success rate can go up to 80%.

Once the surgery is completed, the patient will be discharged from the hospital the next day. The patient is advised to stay at home away from work for a couple of days. After one week, the patient may feel strong enough to resume his/her normal activities as long as he/she adopts the right recovery measures.

Post-Acid Reflux Surgery Recovery

Post-Operation Diet

Once the patient recovers from the surgery, their post-surgical diet becomes the most crucial part of their recovery. After the surgery, the diet will slowly be changed from liquid to normal soft meals over the following weeks. Following this diet strictly hinders esophagus and stomach distention and aids in healing the stomach.

For a day or two of post-surgery procedure, acid reflux experts advise patients to take a clear liquid diet consisting of broths, juice, gelatin and decaffeinated tea. For the following three to four days, a liquid diet is advised; this could include plain yogurt, ice creams, strained soups and milk. If the recovery process is going on well, one may start to add soft foods into their diet, including cheeses, pancakes, soft breads, finely diced or ground meat. The patient can resume normal diet after about 8 weeks.

During recovery, the patient should keep off chewy breads, tough meat cuts, spicy foods, caffeine, alcohol, raw vegetables, fatty foods, or seeds, since they may be hard on their stomach and hard to digest. Moreover, keep off carbonated beverages or foods that produce gas as they fill the stomach with air, thereby causing pressure on fundoplication. Eating many smaller meals promotes healing and prevents distention.

Physical Activity During Recovery

One may not be in a position to perform difficult activities after surgery because it may injure the incisions and even extend the recovery period. But a patient must be physically active to keep the body moving and also make them feel healthier during recovery. They may begin to walk short distances to prevent pneumonia and blood clot incidences.

During the initial two weeks after surgery, one may begin to do simple aerobic activities such as jogging to elevate the levels of energy, burn fat and promote flexibility. One should however be careful with healing incisions. Several strenuous exercises such as lifting weights, swimming and cycling should be done only when one is physically and mentally well. The doctor may take a thorough examination before one is allowed to begin daily exercises.

The body will recover and heal well when one is asleep, hence ensure you get adequate rest during the day and a good sleep all night long. Moreover, stick to a healthy diet after surgery. Well-balanced wholesome diets offer the body the necessary nutrients it needs to restore itself. Strictly follow the directions of the surgeon to make the recovery process comfortable and relaxing. To further discuss life post-surgery, contact the North Texas acid reflux experts here at Ihde Surgical Group today.

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Avoid Acid Reflux With These Healthy Foods

preventing acid reflux disease, acid reflux in Dallas,

Ingesting Aloe Vera can reduce common acid reflux issues.

For all you Dallas acid reflux sufferers out there, if you decide to implement the following 10 healthy foods into your daily diet, you can avoid many of the common ailments associated with this disease.

While there are some foods that can be triggers for heartburn, the following ones can be used to prevent it – sort of the yin to their yang. That bad sensation and the horrible taste that you sometimes get in your mouth after eating certain foods can be thing of the past if you follow this article closely.

1. Aloe Vera

Aloe Vera is known to bring many benefits for different things. Its liquid form or the leaves can work well to treat acid reflux and it can be found in health food stores or groceries. You can use it in your meals for foods that require a thickener for liquids.

2. Bananas and Melon

Bananas can be great, but they must have a pH of 5.6 to treat the condition. Even if most people have experienced positive results, experts say that one percent of them have opposite effects. Just like bananas, melon is good for most people (, but for one to two percent works differently). The pH of Melon must be 6.1. Cantaloupe, honeydew and watermelon are also included.

3. Turkey or Chicken

Boiled, grilled, baked or sauteed turkey or chiken can be awesome choices, but the skin must be removed due to its high content in fat.

4. Fish and Seafood

These two ingredients can also be baked, sauteed and grilled. Fried ones are not good. Shellfish such as lobster and shrimp may be awesome meals for this purpose. The best fish can be the wild type and the one that is farm-based should be avoided if possible.

5. Roots and Greens

Almost any green and root vegetable is recommended. Good examples can be asparagus, broccoli, cauliflower and green beans.

6. Salad

Salad is one of the most important foods for people who have acid reflux. But, the following things should not be included: fat dressings, onions, cheese and tomatoes. Dressings that contain some fat or acids could be used, but only up to one tablespoon.

7. Rice and Couscous

Couscous, also called semolina wheat and rice (the brown one would be preferred) can be complex carbohydrates to use for a healthy anti-acid reflux meal.

8. Celery and Parsley

Parsley has been used since a lot of time for healing purposes in diseases of the stomach. Parsley can added for seasoning or garnish. Celery contains a lot of water and does not contain calories at all. Celery is also a suppressant of appetite and a wonderful source of roughage.

9. Oatmeal

Many nutritionists recommend oatmeal for healthy breakfasts or snacks and a good filling. You can combine oatmeal with raisins without worries, as it can absorb the acid from the raisins very efficiently.

10. Ginger 

Ginger can be one of the best ingredients against heartburn. Since ancient times, it was utilized for stomach and intestine related conditions. The ingredient is also an anti-inflammatory. Cooked, or in a smoothie, the root can be delicious, but it must be peeled and sliced.

If you are in the Dallas-Fort Worth area and suffer from acid reflux, please don’t hesitate to contact us.

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In North Texas and Need Acid Reflux Surgery?

Suffering from heartburn or indigestion and don’t really understand what’s going on?, acid reflux surgery in North TexasThe most efficient way of treating reflux symptoms is by stopping the acid secretion completely in your stomach. People normally experience constant irritation including pain in the inner walls of the esophagus and in the abdomen, this is the major symptom of acid reflux. The pain can sometime be unbearable and most people will resort to surgery as their only option.

However, there are some cases where prescribed medicine should be just enough to alleviate the pain. If not, the doctor will most likely recommend acid reflux surgery to which there are many benefits that the patient can obtain from this.

The main reason as to why the surgery is recommended is when the initial treatments for the acid reflux have failed to work. This means that as a patient you will continue to experience the same symptoms even after using drugs. You may also consider surgery if you don’t want to rely on medication for the rest of your life. Ineffective medication obviously means that you need a more permanent solution.

Acid reflux surgery involves the repairing of valves in the stomach so that the acid is blocked completely from entering the esophagus. Once your current condition has been considered and the doctor thinks you are qualified for the surgery, then the decision to go forward or not can be made.

The benefits of acid reflux surgery are vast. The major benefit is that you will experience less discomfort as most of the patients that undergo the surgery never experience heartburn again. It is also known that more than half of the patients who undergo this surgery get cured from respiratory problems such as asthma that is a result of the acid reflux.

Additionally, you should know that bile reflux is a condition that can lead to cancer, and in this case the surgery is the ideal option to avoid all cancerous possibilities.

There are two main methods that are used when performing reflux surgery. These are the fundoplication and the intraluminal endoscopic acid reflex surgery. The first method is done by tightening the esophagus walls so that the pressure on the lower esophageal sphincter is increased. This will make it harder for the acid in the stomach to come upwards. The other method uses the same procedures, but the difference is that an endoscope is used this time. The two options are effective and safe with a typically short recovery period.

If heartburn, GERD or other symptoms of acid reflux are hindering your life, check into Ihde Surgical Group and our acid reflux surgery procedures today.

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The Difference between Heartburn and GERD

heartburnandgerdphotoPretty much everyone has dealt with heartburn at one time or another. That burning in your chest or throat that won’t seem to go away without medicine is uncomfortable and frustrating. Many times, you can pin point something that you ate that triggers the heartburn, but sometimes, it seems to come from nowhere, or perhaps from simply overeating. There is a difference between the occasional heartburn and GERD, however.

GERD stands for Gastroesophageal Reflux Disease. It occurs when there is damage or weakening of the muscle that works like a door to seal off the stomach contents from the esophagus. This muscle is known as the Lower Esophageal Sphincter or LES. If it does not work properly, the stomach contents rise up into the esophagus on a regular basis, creating that dreaded heartburn feeling daily, pretty much with no regard to what types of foods are consumed.

While most every person with GERD will experience severe heartburn, there are other symptoms than can be present with the disease as well. These could include issues with the throat like laryngitis, hoarseness of speech, sore throat, a lump in the throat sort of feeling, or a persistent dry cough. GERD sufferers may also suffer from bad breath, an increase in saliva, nausea, and earaches. Those with the disease who also suffer from asthma will likely have more problems with their asthma than ever before. GERD not only worsens the symptoms of asthma, but medication for asthma tends to worsen the symptoms of GERD as well.

If you feel like you may have Gastroesophageal Reflux Disease, take the time to see a specialist and have it checked out. You don’t have to live with the problem forever. Sometimes, the right medication is all you need, or if the problem is severe, there is a surgery available that can eliminate the issue for good.

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