Associates in Gastro | Volume 3

Volume 3

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Issue 1

In This Issue Your Liver Delivers Protect it From Harm

The ABC’s of Hepatitis Colonoscopy

A Close Examination of The Colon

PREP IS A SCIENCE. MoviPrep® has been specifically designed to include a delicate balance of fluids, electrolytes, and prep solution volume. Getting the science right means getting the prep right for your procedure.

THE

SAFETY OF PEG

95.6%

EXCELLENT OR GOOD CLEANSING OF THE COLON

THE

TOLERABILITY

when split-dosed1

OF

2L

CONTRAINDICATIONS MOVIPREP® is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, gastric retention, ileus, toxic colitis or toxic megacolon, or hypersensitivity to any components of MOVIPREP. Please see Brief Summary of complete Prescribing Information for MOVIPREP on reverse.

Reference: 1. Di Palma JA, Rodriguez R, McGowan J, et al. A randomized clinical study evaluating the safety and efficacy of a new, reduced-volume, oral sulfate colon-cleansing preparation for colonoscopy. Am J Gastroenterol. 2009;104:2275-2284.

Web site: MoviPrep.com 8510 Colonnade Center Drive, Raleigh, NC 27615 Tel·866.669.SLXP (7597). MoviPrep® is a registered trademark and PM | AM Split Dosing™ is a trademark of Salix Pharmaceuticals, Inc. © 2014 Salix Pharmaceuticals, Inc. All rights reserved. Printed in USA. MOV13-0214

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Aspiration Patients with impaired gag reflex and patients prone to regurgitation or aspiration should be observed during the administration of MoviPrep. Use with caution in these patients.

MOVIPREP® (PEG-3350, sodium sulfate, sodium chloride, potassium chloride, sodium ascorbate and ascorbic acid for oral solution, 100g/7.5g/ 2.691g/1.015g/5.9g/4.7g) The following is a brief summary only. See complete prescribing information on www.moviprep.com or request complete prescribing information by calling 1-800-508-0024.

INDICATION AND USAGE MoviPrep is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults 18 years of age or older.

CONTRAINDICATIONS MoviPrep is contraindicated in the following conditions: • • • • • •

Gastrointestinal (GI) obstruction Bowel perforation Gastric retention Ileus Toxic colitis or toxic megacolon Hypersensitivity to any components of MoviPrep

WARNINGS AND PRECAUTIONS Serious Fluid and Electrolyte Abnormalities Advise patients to hydrate adequately before, during, and after the use of MoviPrep. If a patient develops significant vomiting or signs of dehydration after taking MoviPrep consider performing post-colonoscopy lab tests (electrolytes, creatinine, and BUN).

Fluid and electrolyte disturbances can lead to serious adverse events including cardiac arrhythmias, seizures and renal impairment.

Patients with electrolyte abnormalities should have them corrected before treatment with MoviPrep. MoviPrep should be used with caution in patients using concomitant medications that increase the risk of electrolyte abnormalities [such as diuretics, angiotensin converting enzyme (ACE)-inhibitors or angiotensin receptor blockers (ARBs)] or in patients with known or suspected hyponatremia. Consider performing pre-dose and postcolonoscopy laboratory tests (sodium, potassium, calcium, creatinine, and BUN) in these patients. [See DRUG INTERACTIONS] Cardiac Arrhythmias There have been rare reports of serious arrhythmias associated with the use of ionic osmotic laxative products for bowel preparation. Use caution when prescribing MoviPrep for patients at increased risk of arrhythmias (e.g., patients with a history of prolonged QT, uncontrolled arrhythmias, recent myocardial infarction, unstable angina, congestive heart failure, or cardiomyopathy). Pre-dose and post-colonoscopy ECGs should be considered in patients at increased risk of serious cardiac arrhythmias.

Seizures There have been rare reports of generalized tonic-clonic seizures and/or loss of consciousness associated with use of bowel preparation products in patients with no prior history of seizures. The seizure cases were associated with electrolyte abnormalities (e.g., hyponatremia, hypokalemia, hypocalcemia, and hypomagnesemia) and low serum osmolality. The neurologic abnormalities resolved with correction of fluid and electrolyte abnormalities.

Use caution when prescribing MoviPrep for patients with a history of seizures and in patients at increased risk of seizure, such as patients taking medications that lower the seizure threshold (e.g., tricyclic antidepressants), patients withdrawing from alcohol or benzodiazepines, or patients with known or suspected hyponatremia.

Renal Impairment Use with caution in patients with impaired renal function or patients taking concomitant medications that affect renal function (such as diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or nonsteroidal antiinflammatory drugs). Advise these patients of the importance of adequate hydration, and consider performing pre-dose and post-colonoscopy laboratory tests (electrolytes, creatinine, and BUN) in these patients.

(Colonic) Mucosal Ulceration, Ischemic Colitis and Ulcerative Colitis Osmotic laxatives may produce colonic mucosal aphthous ulcerations and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Concurrent use of stimulant laxatives and MoviPrep may increase the risk and is not recommended. The potential for mucosal ulcerations resulting from the bowel preparation should be considered when interpreting colonoscopy findings in patients with known or suspected inflammatory bowel disease.

Use in Patients with Significant Gastrointestinal Disease If gastrointestinal obstruction or perforation is suspected, perform appropriate diagnostic studies to rule out these conditions before administering MoviPrep. If a patient experiences severe bloating, abdominal distension, or abdominal pain, administration should be slowed or temporarily discontinued until symptoms abate.

Use with caution in patients with severe ulcerative colitis.

Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency Since MoviPrep contains sodium ascorbate and ascorbic acid, MoviPrep should be used with caution in patients with glucose6-phosphate dehydrogenase (G-6-PD) deficiency, especially G-6-PD deficiency patients with an active infection, with a history of hemolysis, or taking concomitant medications known to precipitate hemolytic reactions.

Contains Phenylalanine Phenylketonurics: Contains aspartame 233 mg per treatment which corresponds to 131 mg of phenylalanine per treatment (after hydrolysis of the aspartame molecule in-vivo to aspartic acid and phenylalanine).

ADVERSE REACTIONS Clinical Studies Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

In the MoviPrep trials, abdominal distension, anal discomfort, thirst, nausea, and abdominal pain were some of the most common adverse reactions to MoviPrep administration. Since diarrhea was considered as a part of the efficacy of MoviPrep, diarrhea was not defined as an adverse reaction in the clinical studies. Tables 1 and 2 display the most common drug-related adverse reactions of MoviPrep and its comparator in the controlled MoviPrep trials.

Table 1: The Most Common Drug-Related Adverse Reactions1 (≥ 2%) in the Study of MoviPrep vs. 4 Liter Polyethylene Glycol plus Electrolytes Solution

Malaise Nausea Abdominal pain Vomiting Upper abdominal pain Dyspepsia 1

2

MoviPrep® (split dose) N=180 n (% = n/N)

4L PEG + E2 N=179

35 (19.4) 26 (14.4) 24 (13.3) 14 (7.8) 10 (5.6) 5 (2.8)

32 (17.9) 36 (20.1) 27 (15.1) 23 (12.8) 11 (6.1) 2 (1.1)

n (% = n/N)

Drug-related adverse reactions were adverse events that were possibly, probably, or definitely related to the study drug.

4L PEG+E is 4 liter Polyethylene Glycol plus Electrolytes Solution

Table 2: The Most Common Drug-Related Adverse Reactions1 (≥ 5%) in the Study of MoviPrep vs. 90 mL Oral Sodium Phosphate Solution

Abdominal distension Anal discomfort Thirst Nausea Abdominal pain Sleep disorder Rigors Hunger Malaise Vomiting Dizziness Headache Hypokalemia Hyperphosphatemia

MoviPrep® (evening only) (full dose) N=169 n (% = n/N)

90 mL OSPS2 N=171

101 (59.8) 87 (51.5) 80 (47.3) 80 (47.3) 66 (39.1) 59 (34.9) 57 (33.7) 51 (30.2) 45 (26.6) 12 (7.1) 11 (6.5) 3 (1.8) 0 (0) 0 (0)

70 (40.9) 89 (52.0) 112 (65.5) 80 (46.8) 55 (32.2) 49 (28.7) 51 (29.8) 121 (70.8) 90 (52.6) 14 (8.2) 31 (18.1) 9 (5.3) 10 (5.8) 10 (5.8)

n (% = n/N)

Drug-related adverse reactions were adverse events that were possibly, probably, or definitely related to the study drug. In addition to the recording of spontaneous adverse events, patients were also specifically asked about the occurence of the following symptoms: shivering, anal irritations, abdominal bloating or fullness, sleep loss, nausea, vomiting, weakness, hunger sensation, abdominal cramps or pain, thirst sensation, and dizziness.

2 OSPS is Oral Sodium Phosphate Solution

1

Isolated cases of urticaria, rhinorrhea, dermatitis, and anaphylactic reaction have been reported with PEG-based products and may represent allergic reactions.

Published literature contains isolated reports of serious adverse events following the administration of PEG-based products in patients over 60 years of age. These adverse events included upper gastrointestinal bleeding from a Mallory-Weiss tear, esophageal perforation, asystole, and acute pulmonary edema after aspirating PEG-based preparation.

Postmarketing Experience In addition to adverse reactions reported from clinical trials, the following adverse events have been identified during postapproval use of MoviPrep. Because they are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These events have been chosen for inclusion due to either their seriousness, frequency of reporting or causal connection to MoviPrep, or a combination of these factors.

Cardiovascular: Tachycardia, palpitations, hypertension, arrhythmia, atrial fibrillation, peripheral edema.

General: Hypersensitivity reactions including anaphylaxis (some of which were severe, including shock), rash, urticaria, pruritus, lip, tongue and facial swelling, dyspnea, chest tightness and throat tightness. Fever, chills and dehydration.

Nervous system: Syncope, tremor, seizure.

Renal: Renal impairment and/or failure.

DRUG INTERACTIONS Drugs That May Increase Risks Due to Fluid and Electrolyte Abnormalities Use caution when prescribing MoviPrep for patients with conditions, or who are using medications that increase the risk for fluid and electrolyte disturbances or may increase the risk of adverse events of seizure, arrhythmias, and prolonged QT in the setting of fluid and electrolyte abnormalities. Consider additional patient evaluations as appropriate. [See WARNINGS] Potential for Altered Drug Absorption Oral medication administered within 1 hour of the start of administration of MoviPrep may be flushed from the gastrointestinal tract and the medication may not be absorbed.

USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C. Animal reproduction studies have not been performed with MoviPrep. It is also not known if MoviPrep can cause fetal harm when administered to a pregnant woman or can affect reproductive capacity. MoviPrep should be given to a pregnant woman only if clearly needed.

Nursing Mothers It is not known whether this drug is excreted in human milk.

Because many drugs are excreted in human milk, caution should be exercised when MoviPrep is administered to a nursing woman.

Pediatric Use The safety and effectiveness of MoviPrep in pediatric patients has not been established.

Geriatric Use Of the 413 patients in clinical studies receiving MoviPrep, 91 (22%) patients were aged 65 or older, while 25 (6%) patients were over 75 years of age. No overall differences in safety or effectiveness were observed between geriatric patients and younger patients, and other reported clinical experience has not identified differences in responses between geriatric patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

PATIENT COUNSELING INFORMATION • Advise patients who require a diet low in phenylalanine that MoviPrep contains aspartame – a maximum of 233 mg per treatment. This sweetener, after hydrolysis in the body, provides 131 mg of phenylalanine to the patient.

• Ask patients to inform you if they have trouble swallowing or are prone to regurgitation or aspiration.

• Instruct patients that each pouch needs to be diluted in water before ingestion and that they need to drink additional clear liquids. Examples of clear liquids are: water; clear fruit juices without pulp including apple, white grape, or white cranberry; strained limeade or lemonade; coffee or tea (Do not use any dairy or non-dairy creamer); clear broth; clear soda; gelatin (without added fruit or topping); popsicles (without pieces of fruit or fruit pulp).

• Inform patients that oral medications may not be absorbed properly if they are taken within one hour of starting each dose of MoviPrep.

• Tell patients not to take other laxatives while they are taking MoviPrep.

• Tell patients that MoviPrep produces a watery stool (diarrhea) which cleanses the colon before colonoscopy.

Advise patients receiving MoviPrep to adequately hydrate before, during, and after the use of MoviPrep. Patients may have clear soup and/or plain yogurt for dinner, finishing the evening meal at least one hour prior to the start of MoviPrep treatment. No solid food should be taken from the start of MoviPrep treatment until after the colonoscopy.

• Tell patients that the first bowel movement may occur approximately 1 hour after the start of MoviPrep administration. Abdominal bloating and distention may occur before the first bowel movement. If severe abdominal discomfort or distention occurs, stop drinking MoviPrep temporarily or drink each portion at longer intervals until these symptoms diminish. If severe symptoms persist, notify your health provider.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

For additional information, call: 1-866-SLXP(7597) To report adverse events, call: 1-800-508-0024 Manufactured for: Salix Pharmaceuticals, Inc. 8510 Colonnade Center Drive Raleigh, NC 27615 www.salix.com © 2013 Salix Pharmaceuticals, Inc. All rights reserved.

MOV-RALAB7-092013

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5653 Frist Blvd.

Summit Medical Center, Suite 530 Hermitage, TN 37076 615-885-1093 | www.associatesingastro.com

In This Issue

Welcome To Our Practice!

This is our third edition to our Gastroenterology Magazine and we are very excited to not only provide you with important healthcare information but also a way for you to get to know our practice a little better. We hope you find the information useful and informative.

5 Your Liver Delivers Protect it From Harm

7 The ABC’s of Hepatitis 9 Colonoscopy A Close

Examination of The Colon

11 Physician Directory 14 Our Services 15 National Dress in Blue Day Proclamation

16 Celiac Disease: The Basics and Beyond

18 Healthy Family Recipes 20 Why Eat Fiber?

In this edition you will find information about ongoing medical research and how it can benefit you the patient as well as other articles about digestive health. We also have included some delicious easy to follow healthy recipes.

The physicians and staff at Associates in Gastroenterology have been providing services to the Middle Tennessee area for the past 18 years.

Providing quality healthcare is our primary goal, specifically as it relates to your digestive system. We hope to provide this care in a comfortable and pleasant environment that is convenient for you. As part of that commitment we have recently opened a second office in the Mt. Juliet -Wilson County for the convenience of those living and working in that area.

We not only have a commitment to our patients, but also we have a commitment to our referring physicians. We work closely with them to provide thorough and timely communications allowing for complete continuity of your healthcare needs.

We utilize Associated Endoscopy Center as another convenience for our patients. This outpatient center allows us to perform endoscopy procedures in a state of the art setting with highly skilled and trained clinical endoscopy staff while maintaining a convenient, compassionate and warm setting.

Associated Endoscopy is recognized and accredited by AAAHC as a high quality, state of the art outpatient center. It is located immediately adjacent to our clinical practice.

We not only have a commitment to our patients, but also we have a commitment to our referring physicians. We work closely with them to provide thorough and timely communications allowing for complete continuity of your healthcare needs.

We hope you enjoy reading our magazine and we hope you will always consider us as your first choice for you digestive healthcare needs.

Associates in Gasteroenterology magazine is designed & published by Ink Publishing and Design.

To advertise in the next issue please contact: Sarah Gaither at 502•271•1166 www.inkmagazine.com

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Sincerely,

G. Whit James, M.D.

Chief Manager, Associates in Gastroenterology

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YOUR LIVER PROTECT IT FROM HARM

Your liver works hard to protect your health. It’s a rugged, strong organ. But certain things—like alcohol, drugs, viruses, and excess weight—can damage it. You may not even realize when your liver is struggling, because liver disease usually has no symptoms until the problem becomes severe.

Help your liver to guard your health by avoiding the things that might cause it harm.

The liver is the largest organ inside your body. It’s about the size of a football, and rests just under your ribs against the right side of your stomach.

“The liver performs an amazing set of functions that keep you healthy,” says Dr. Jake Liang, a liver specialist and researcher at NIH. Your liver helps fight infections. It cleans your blood by getting rid of your body’s natural waste products and other harmful substances, including alcohol and drugs. “The liver also transforms the foods you eat into energy and nutrients your body can use, and it regulates how nutrients flow to different parts of the body when needed,” Liang says.

Your liver can keep working even if part of it is damaged or removed. But if it starts to shut down “Although liver disease often has no symptoms, warning signs can include a swollen abdomen, nausea, itching, or jaundice”

are caused by viruses (certain kinds of hepatitis), and some are related to your behavior. Certain liver diseases go away on their own. Others can last a lifetime and cause serious illness.

Although liver disease often has no symptoms, warning signs can include a swollen abdomen, nausea, itching, or jaundice (having a yellow tint to the skin and the whites of the eyes).

An increasingly common type of liver disorder known as fatty liver disease, affects both children and adults. A healthy liver contains just a little fat or none at all. But too much fat buildup in liver cells can cause swelling and damage. Over time, the excess fat can lead to cirrhosis, liver cancer, and even liver failure.

“Estimates vary, but 2 different studies in the past decade suggest that about 30% to 45% of Americans have excess fat in the liver,” says Dr. Yaron Rotman, an NIH specialist in fatty liver disease. “It’s also becoming a huge problem for children and teens.”

Drinking too much alcohol can cause fatty liver. But a growing number of people who drink little or no alcohol are also being diagnosed with fatty liver.

“The rise seems to be tied to the nation’s obesity epidemic,” says Doo.

completely—a condition known as liver failure— you can survive for only a day or 2 unless you get emergency treatment.

Studies suggest that fatty liver disease now also affects about 1 in 10 children nationwide. As with adults, most children with fatty liver disease are overweight and resistant to insulin, a critical hormone that regulates energy.

Many things can affect liver function. Some liver problems are inherited from your parents, some

In its early stages, fatty liver disease usually has no symptoms. It’s often first detected by blood

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tests for liver function. But these tests can’t tell the difference between mild fatty buildup and more serious damage. And some people with fatty liver disease can have normal blood tests. The only sure way to diagnose the severity of fatty liver disease is by getting a liver biopsy. For this test, a doctor inserts a thin needle through the skin and into the liver to remove a small piece of tissue for analysis.

“To treat fatty liver disease, we recommend lifestyle changes: Weight loss for people who are overweight, and exercise and a healthy diet to help reduce fat” There are currently no approved medications for fatty liver or its more severe form called NASH, or non-alcoholic steato-hepatitis.

“To treat fatty liver disease, we recommend lifestyle changes: Weight loss for people who are overweight, and exercise and a healthy diet to help reduce fat,” Rotman says. “In many patients, just a 5-8% reduction in body weight will translate into a large improvement to liver damage.” For people with alcohol-related fatty liver, stopping alcohol use can reverse or prevent further liver injury.

Another common type of liver disease—known as viral hepatitis—can be caused by at least 5 different viruses, named hepatitis A, B, C, D, and E. These infections can injure your liver and keep it from working properly.

“Collectively, about 20% of people worldwide may be affected by a hepatitis virus infection,” Liang says. “It’s a major public health problem.” The most common types in the United States are hepatitis A, B, and C.

Article source: National Institute of Health

Each hepatitis virus causes a different form of liver disease. All the viruses can trigger acute, or shortterm, hepatitis. Hepatitis B, C, and D can also cause chronic hepatitis, in which the infection lasts a long time, sometimes for your whole life.

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People are often exposed to hepatitis A and E viruses through contaminated food or water. “The other hepatitis viruses often pass through some type of break in the skin barrier, sometimes by injections or by close contact with blood or other body fluids,” Liang adds. Hepatitis B, C, and D can spread through sexual contact.

Because many infected people have few symptoms, they may not realize they have viral hepatitis. They

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can spread the infection to others without even knowing it.

Viral hepatitis is often treated with antiviral medications. Hepatitis A, B, and D infections can be prevented by vaccines. Practicing good hygiene— such as washing your hands and avoiding contact with infected blood—can also help block the spread of viral hepatitis.

Another potentially dangerous type of liver disease can be caused by taking certain drugs or supplements. “It’s important to be aware that a lot of drugs can cause liver injury,” Liang says. “This especially can be a problem for people who are taking several different medications.”

Taking too much acetaminophen (Tylenol) is the most common cause of sudden liver failure. “It’s particularly dangerous if you mix alcohol with acetaminophen or certain other drugs,” Liang adds.

Talk with your doctor or pharmacist about all the medications you take and how they might affect your liver.

Maintain a healthy weight, stay physically active, and limit your alcohol use. Keep your liver healthy, and it will protect you for a lifetime.

Did you know you can get hepatitis through close personal contact with a person who has the infection?

WHAT IS HEPATITIS? Hepatitis is a liver disease that makes your liver swell and keeps it from working correctly. Several viruses cause hepatitis. The most common types are the hepatitis A, B, and C viruses.

HOW COULD I GET HEPATITIS?

Hepatitis

A

Hepatitis A is spread through food or water contaminated by feces from a person who has the virus. You can get hepatitis A by eating food prepared by someone with the virus. You can also get it by drinking water in parts of the world with poor sanitary conditions.

You cannot get hepatitis A from: • being coughed or sneezed on by an infected person.

• sitting next to an infected person.

• hugging an infected person.

• a baby cannot get hepatitis A from breast milk.

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Hepatitis

B

Hepatitis B is spread through contact with an infected person’s blood, semen, or other body fluid. You can get hepatitis B by having sex with an infected person without a condom, sharing drug needles, or sharing a toothbrush or razor with an infected person. A woman with hepatitis B can give the virus to her baby at birth.

You cannot get hepatitis B from: • shaking hands or holding hands with an infected person • being coughed or sneezed on by an infected person • hugging an infected person • sitting next to an infected person • sharing spoons, forks, and other eating utensils • drinking water or eating food • a baby cannot get hepatitis B from breast milk.

Hepatitis

C

Hepatitis C is spread through contact with an infected person’s blood. You can get hepatitis C by sharing drug needles or getting pricked with a needle that has infected blood on it.

You cannot get hepatitis C from: • shaking hands or holding hands with an infected person • being coughed or sneezed on by an infected person • hugging an infected person • sitting next to an infected person • sharing spoons, forks, and other eating utensils • drinking water or eating food • a baby cannot get hepatitis C from breast milk.

HOW WILL I KNOW IF I HAVE HEPATITIS? Hepatitis can make you feel like you have the flu. You might: • feel tired • muscle soreness • feel sick to your stomach • have a fever • lose your appetite • have stomach pain • have diarrhea • dark-yellow urine • light-colored stools • yellowish eyes and skin, called jaundice

Some people who have hepatitis have dark-yellow urine, light-colored stools, or yellowish eyes and skin. Some people don’t have any symptoms.

If you think you might have hepatitis, go to your doctor for a blood test.

time, hepatitis B or C can cause your liver to stop working. If that happens, you will need a new liver.

HOW CAN I PROTECT MYSELF FROM HEPATITIS? You can get vaccines to protect yourself from hepatitis A and B. You can also protect yourself and others from hepatitis A by washing your hands after using the toilet and before fixing food or eating.

You can protect yourself from hepatitis B by using a condom when you have sex, not sharing drug needles with anyone, and not sharing a toothbrush or razor with anyone who might be infected.

No vaccine for hepatitis C exists. You can protect yourself from hepatitis C by wearing gloves if you have to touch someone’s blood, not sharing drug needles, and not sharing a toothbrush or razor with anyone who might be infected.

HOW IS HEPATITIS TREATED? Most people who have hepatitis A get well on their own after a few weeks. If you have hepatitis B or C, your doctor will give you shots of medicine. Over

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COLONOSCOPY

A Close Examination of the Colon

What is A Colonoscopy?

This medical procedure enables a physician to directly examine the inside of your colon (large intestine). A colonoscopy is an outpatient procedure performed in a hospital and takes up to sixty minutes.

How does it work?

During the colonoscopy, your physician will place a flexible tube in your rectum. This tube is the diameter of a finger and several feet long with a bright light on one end. As the lighted end of this flexible tube is moved through your colon, the physician examines the inside of the colon closely on a television screen.

During the colonoscopy, your physician can: • Locate sources of abnormal bleeding • Remove tiny pieces of tissue through the tube (a biopsy) for further study under a microscope.

• Remove certain types of polyps (polypectomy) • Identify inflamed areas

How will I Prepare for my Colonoscopy?

You will need to take off work the day of the procedure. Since you will be sedated during the procedure, a friend or family member must drive you home afterwards.

Your physician will tell you how to clean out your colon during the one to two days before the test.

You will take no food or drink by mouth after midnight on the night before your colonoscopy, of for at least six hours prior to the procedure.

Ask your doctor for a more specific time to begin fasting. This will vary depending on the time of day your colonoscopy is scheduled.

You should take your regular medications up until the time of your procedure. If you are on insulin or a diabetes pill let your doctor know so they can tell you how to adjust your dose to accommodate this procedure.

Tell your doctor if you are on blood thinners, aspirin, or any other arthritis medicines. Your physician may give you special liquids or medications to assist the cleansing process.

What Happens During The Procedure?

You will wear a gown and lie on the examination table on your left side with your knees pulled up.

Your heart rate, blood pressure, and the amount of oxygen in your blood will be monitored during the procedure. You will be given intravenous medicine to make you sleepy.

You may feel some pressure or cramping as your physician inserts the flexible endoscope. As the physician closely examines your intestinal wall, the enodoscope moves further into your large intestine.

If you feel more discomfort, tell the physician and medication will be given to decrease the discomfort.

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What Happens After the Colonoscopy?

Article Source: National Institute of Health

After your examination is finished, you will be taken to a recovery room for about an hour where you will wake up. Most patients do not remember the procedure after the medication has worn off. Your physician will go over the exam results with you and whomever will be driving you home. If a biopsy was taken or any tissue removed, these results will be discussed at a later date after the pathologist has carefully examined the tissue.

Potential Complications

Colonoscopy and polypectomy are safe and are associated with minimal risk when performed by physicians who have been specially trained and are experienced in these endoscopic procedures.

One possible complication is perforation, in which a small tear through the bowel wall allow leakage of intestinal fluids. It may be managed with antibiotics and intravenous fluids although surgery is usually required.

When you are fully awake, you can drink something and be taken home. From the time you walk. From the time you walk in the door on the morning of your colonoscopy until the time you go home will be about 2 to 4 hours.

Respiratory arrest from the medication given may occur. Localized irritation of the vein may occur at the site of the medication injection. A tender lump may develop which may remain for several weeks to several months but goes away eventually.

If you were referred to us for this procedure, the results of your colonoscopy will be sent to the referring physician. If you have any questions about the procedure after you leave the hospital, you may call the physician who performed it.

Other risks include drug reactions and complications from unrelated diseases such as heart attack or stroke. Death is extremely rare, but remains a remote possibility.

You will be able to return to work and your normal activities the day after your colonoscopy.

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Colonoscopy is the only test that can detect and prevent colon cancer in just one procedure, yet 40 percent of at-risk individuals are not getting screened.

The critics feel that it’s an unnecessary procedure, because pre-cancerous polyps often present no symptoms. Others have concerns about the cost of admission, but when it comes to saving your life, it’s well worth the ticket price.

Colon Cancer is the third deadliest form of cancer, yet when caught early, has a 90 percent survival rate. If you’re 50 or older (45 for African Americans) or have a family history of polyps or colon cancer, it’s show time.

Join us at www.associatedendoscopy.com and www.stopcoloncancernow.com and find out why your colonoscopy is the must-see of the year.

Associated Endoscopy 5653 Frist Blvd., Suite 532 | Hermitage, TN 37076 (615) 861-8540 | www.associatedendoscopy.com

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Kevin Finnegan, M.D. Whit James, M.D. Donald Lazas, M.D.

Sue Lee, M.D. Raj Patil, M.D.

PHYSICIANS DIRECTORY

5653 Frist Blvd.

Summit Medical Center, Suite 530 Hermitage, TN 37076 615-885-1093 | www.associatesingastro.com

Dr. Whit James Dr. James’ great grandfather and father were physicians. He chose medicine because it blended science (his favorite subject) and the art of communication. He received his bachelors degree from the University of North Carolina and his medical degree from Wake Forest University. He did his internal medicine residency at Jefferson Medical College in Philadelphia. While at Jefferson, he was influenced by Dr. Willis Maddrey to pursue gastroenterology. Dr. James completed his fellowship in gastroenterology at Rush University in Chicago. Dr. James is board certified in gastroenterology. He enjoys family activities, gardening, and swimming. Dr. James is active in the TN chapter of the Crohn’s and Colitis Foundation of America.

Dr. James has previously been selected by the employees and staff of Summit Medical Center as the physician of the quarter.

Dr. Donald J. Lazas Dr. Lazas is a native of Washington, D.C. He received his medical degree from George Washington University School of Medicine and completed residency and fellowship training at Walter Reed Army Medical Center. For the next 9 years, he served as a physician in the Army Medical Corps and was honorably discharged with a rank of Major. He subsequently entered private practice and joined Associates in Gastroenterology. Dr. Lazas is board certified in Gastroenterology and is a Fellow of the American College of Physicians. He and his wife Kathy have five children and they enjoy spending time with family and close friends. Dr. Lazas’ hobbies include music, fitness training and athletics and boating.

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PHYSICIANS Dr. Sue Lee Dr. Lee is a native of Korea. She received her medical degree from Emory University in Atlanta, where she also completed a fellowship in gastroenterology. She numbers among her outstanding teachers Dr. Jonas Shulman (“an excellent clinician: intelligent; caring; a no-nonsense approach and lots of common sense”). Before starting private practice, Dr. Lee taught at Emory University and Vanderbilt University.

She is board certified in gastroenterology. Dr. Lee’s husband is a cardiologist in Nashville. She and her family enjoy traveling. Dr. Lee has previously served as the Chairman of the Department of Medicine at Summit Medical Center.

Dr. Sushil Raj Patil Dr. Patil is a native of Cookeville, Tennessee. He graduated from the University of Tennessee in Knoxville. He pursued his medical education at the University of Tennessee Memphis and then completed his fellowship in gastroenterology at Rush University Medical Center in Chicago. Dr. Patil is board certified in gastroenterology. Dr. Patil enjoys biking, traveling and spending time with his wife and two children.

Dr. Kevin Finnegan Dr. Kevin Finnegan is a board certified Gastroenterologist who completed his medical school training at Indiana University. He completed his residency and a fellowship in Gastroenterology at Vanderbilt University. He is board certified in gastroenterology and joined our practice in 2010 after being in private practice for three years in Indiana. Dr. Finnegan and his wife have three children. Their life is filled with many children’s activities and family time together.

Associates In Gastroenterology | www.associatesingastro.com

13

OUR SERVICES

| Colonoscopy

| Esophageal pH Monitoring

| Colon Cancer Screening

| Capsule Endoscopy

| Upper Endoscopy

| ERCP (Endoscopic Retrograde

| Outpatient Endoscopy Center

Cholangio-Pancreatography)

Visit our website to download Patient forms before your next visit.

5653 Frist Blvd.

Summit Medical Center, Suite 530 Hermitage, TN 37076 615-885-1093 | www.associatesingastro.com

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Associates In Gastroenterology | www.associatesingastro.com

National Dress in Blue Day! March is National Colorectal Cancer Awareness Month.

Don’t forget to dress in blue!

Governor of Tennessee Bill Haslam with Karol Sanders, RN and Dr. Finnegan.

March 7 is officaially “Dress in Blue Colorectal Cancer Awareness Day” in Tennessee.

Associates In Gastroenterology | www.associatesingastro.com

15

CELIAC DISEASE: The Basics & Beyond

Celiac disease is a condition in which the immune system responds abnormally to a dietary protein called gluten, which is found in rye, wheat, barley as well as a multitude of prepared foods, medications and supplements. It is an autoimmune disorder which affects approximately one in every 100-200 individuals. It affects both men and women and can present at any age.

It has been recognized in individuals of European, Middle Eastern, Asian, South American and North African descent and is rare in those of Afro-Caribbean and Japanese descent.

The abnormal immune response that occurs with Celiac disease can cause damage to the lining

By Dr. Finnegan of the small intestine, which is the portion of our digestive system responsible for absorbing

the nutrients from our food – therefore, damage to the lining of the small intestine can lead to difficulty absorbing important nutrients, which is referred to as malabsorption.

The symptoms of celiac disease are wide ranging and vary from one patient to another. In its mildest form, there may be little or no symptoms whatsoever. However, even if you have no symptoms, you may not be absorbing nutrients adequately, which can be detected with certain blood tests. Common symptoms of Celiac disease include diarrhea, weight loss, abdominal discomfort, excessive gas/bloating, and certain vitamin deficiencies.

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Some conditions are more common in people with Celiac disease, including: -- Osteopenia or osteoporosis (weakening of the bones) -- Iron deficiency anemia (low blood count due to lack of iron)

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-- Diabetes mellitus (type I or so-called juvenile onset diabetes) -- Thyroid problems (usually hypothyroidism or underactive thyroid) -- A certain skin disease called dermatitis herpetiformis

More people than ever are online and the numbers continue to grow exponentially.

-- Nervous system disorders The diagnosis of Celiac disease can be difficult because the signs and symptoms are similar to other conditions. However, testing is available that can distinguish Celiac disease from other disorders.

A blood test can determine the blood level of antibodies (proteins) that become elevated in people with Celiac disease. Over 90 percent of people with untreated Celiac disease have elevated antibody levels, while these levels are rarely elevated in those without Celiac disease. Before having this test, it is important to continue eating a normal diet - avoiding or eliminating gluten could cause the antibody levels to be normal, delaying the diagnosis.

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The diagnosis of Celiac disease cannot be made by a blood test alone. If your blood test is positive, the diagnosis must be confirmed by performing an upper endoscopy, which involves examining the upper part of the gastrointestinal system with a small, flexible lighted tube that contains a camera. Tissue samples (biopsies) are obtained at the time of the upper endoscopy and are then examined under a microscope by a pathologist to determine if the changes of Celiac disease are present.

Treatment of Celiac disease involves the lifelong elimination of gluten from your diet as even small amounts can aggravate the disease. Maintaining a gluten free diet is a challenging task that may require major lifestyle adjustments. Consulting with an experienced dietician not only can help you learn what foods to avoid but also how to maintain a gluten free diet and identify those foods to add for a nutritionally balanced diet.

“Treatment of Celiac Disease involves the lifelong elimination of gluten from your diet as even small amounts can aggravate the disease.”

Fortunately, maintaining a gluten free diet has become easier due to the rising popularity of gluten free foods among those with Celiac disease, non-celiac gluten sensitivity, and wheat allergies. Gluten free substitute foods are now widely available in supermarkets, restaurants, health food stores, and on-line.

Additional information regarding Celiac disease, its symptoms, diagnosis and treatment can be found at: www.celiac.org and www.celiaccentral.org.

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YOU ARE NOT ALONE! We are here to support the 30,000 Tennesseans suffering from Crohn’s disease and ulcerative colitis. CCFA offers resources for patients including: •

Take Steps Walk: May 30, 2015

•

Nashville Patient Education Program: November 2015

•

Royal Flush Casino Night: November 2015

•

Monthly Support Group Meetings

•

Power of Two: One-on-one patient support

116 Wilson Pike Circle, Suite 205 Brentwood, TN 37027 615.356.0444 • Tennessee@ccfa.org www.ccfa.org

Associates In Gastroenterology | www.associatesingastro.com kimad.indd 1 2/4/2015

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12:44:02 PM

Pasta Primavera

Pasta, Vegetables and a sprinkle of cheese makes this a child-friendly classic that adults will love too.

Prep Time: 5 minutes Cook Time: 20 minutes Yield: 4 Servings Serving Size: 2 cups pasta and vegetables 1. In a 4-quart saucepan, bring 3 quarts of water to a boil over high heat.

2. Add spaghetti, and cook according to package directions. Drain.

3. Meanwhile, combine olive oil and garlic in a large sauté pan. Cook until garlic is soft, but not browned (about 30 seconds).

4. Add mixed vegetables, and cook until vegetables are soft, but not browned (about 3-5 minutes).

5. Add diced tomatoes, tomato juice and pepper. Bring to a boil. Reduce heat, and simmer for 5 minutes.

6. Add spaghetti and parmesan cheese. Toss until the pasta is hot and well mixed, and serve.

Parmesan Green Beans

Ingredients:

Each serving provides:

8 oz Dry whole-wheat spaghetti 1 tbsp Olive oil 1 tsp Garlic, minced (about 1/2 clove) 4 cups Assorted cooked vegetables - such as red pepper strips, broccoli florets, carrot sticks, or green beans (leftover friendly) 1 can (151/2 oz) No-salt-added diced tomatoes 1 can (51/2 oz) Low-sodium tomato juice 1/4 tsp Ground black pepper 1/4 cup Grated parmesan cheese

Calories 319 Total Fat 6 g Saturated Fat 2 g Cholesterol 4 mg Sodium 127 mg Total fiber 12 g Protein 13 g Carbohydrates 59 g Potassium 596 mg

Percent Daily Values are based on a 2,000 calorie diet

A side dish so tasty, children won’t even know it’s good for them!

Prep Time: 5 minutes Cook Time: 8 minutes Yield: 4 Servings Serving Size: 1 cup green bean mix 1.

2.

3.

4.

Combine olive oil and garlic in a large saucepan. Cook until garlic is soft, but not browned (about 30 seconds).

Add onion, and continue to cook for about 5 minutes over medium heat untill soft.

Add green beans and chicken broth. Bring to a boil and simmer for 2 minutes, until the beans are heated.

Sprinkle with parmesan cheese and pepper, and serve.

Ingredients: 1 tbsp Olive oil 1tsp Garlic, minced (about 1 clove) or 1/4 tsp garlic powder 1 Small onion, thinly sliced (about 1/2 cup) 1 bag (16 oz) Frozen green beans 1 cup Low-sodium chicken broth 1/4 cup Grated parmesan cheese 1/4 tsp Ground black pepper

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Vitamin A 140% Vitamin C 160% Calcium 15% Iron 20%

Associates In Gastroenterology | www.associatesingastro.com

Each serving provides: Calories 95 Total Fat 5 g Saturated Fat 1 g Cholesterol 4 mg Sodium 117 mg Total fiber 3 g Protein 5 g Carbohydrates 9 g Potassium 293 mg

Vitamin A 15% Vitamin C 25% Calcium 10% Iron 4% Percent Daily Values are based on a 2,000 calorie diet

Mexica Lasagna

This quick and festive twist on lasagna will make your family cheer “olé!”

Prep Time: 10-15 minutes Cook Time: 30-50 minutes Yield: 8 Servings Serving Size: 1 square 1. Preheat oven to 400 °F 2. Lightly spray a 9 x 13 inch baking pan with cooking spray. Place two to three corn tortillas on the bottom, trimming as necessary for a good fit.

3. Add beans, 1 cup tomato sauce and 1/2 cup grated cheese. Top with two to three more corn tortillas.

4. Add 1 cup tomato sauce. Top with two more corn tortillas.

5. Add chicken and 1 cup tomato sauce. Top with two more corn tortillas.

6. Add 1 cup tomato sauce, 1/2 cup cheese and cilantro.

7. Bake for 30 minutes, or until the cheese is melted and browned and chicken is reheated.

8. Let stand for 5 minutes. Cut into eight even squares and serve.

Baked French Tost Fritters

with Apples & Bananas

Ingredients:

Each serving provides:

10 6-inch corn tortillas 2 cups Canned low-sodium black beans, rinsed 4 cups Chunky Tomato Sauce (homemade sauce can be found in last years Gastro Health publication) 11/2 cups Monterey Jack cheese, grated 1 bag (10 oz) baby spinach leaves, rinsed 2 cups Grilled chicken, diced (leftover friendly) 2 tbsp Fresh cilantro, rinsed, dried, and chopped (or substitute 1 tsp dried coriander)

Calories 304 Total Fat 10 g Saturated Fat 4 g Cholesterol 52 mg Sodium 275 mg Total fiber 6 g Protein 23 g Carbohydrates31 g Potassium 550 mg

Vitamin A 80% Vitamin C 15% Calcium 30% Iron 15% Percent Daily Values are based on a 2,000 calorie diet

Add fruit to your meal with this heavenly, melt-in-your-mouth dish.

Prep Time: 15 minutes Cook Time: 20 minutes Yield: 4 Servings Serving Size: 1 fritter 1. Preheat oven to 400 °F. Place a large baking sheet in the oven to preheat for about 10 minutes.

2. Assemble fritter sandwich, with 1/2 tablespoon of peanut butter on each slice of bread, two apple slices and six banana slices in the middle of each sandwich.

3. Combine ingredients for the batter and mix well.

4. Spray a nonstick baking sheet with cooking spray.

5. Dip both sides of fritters in the batter and place fritters on preheated baking sheet. Bake for 10 minutes on each side, or until both sides are browned. Serve immediately.

Ingredients:

Each serving provides:

For sandwiches: 8 slices Whole-wheat bread 1/4 cup Creamy peanut butter 1 Apple, rinsed, peeled, cored and sliced into 8 rings 2 Bananas, peeled and cut into about 12 thin slices each

Calories 332 Total Fat 10 g Saturated Fat 2 g Cholesterol 0 mg Sodium 374 mg Total Fiber 7 g Protein 14 g Carbohydrates 50 g Potassium 543mg Vitamin A 4%

For batter: 3 tbsp Egg substitue (or 1 egg white) 1/4 tsp Ground cinnamon 1 tbsp Brown sugar 1/4 cup Fat-free evaporated milk

Vitamin C 2% Calcium 10% Iron 15% Percent Daily Values are based on a 2,000 calorie diet

Associates In Gastroenterology | www.associatesingastro.com

19

why eat

FIBER?

By Cassandra Cox

N

utritionists and health care practitioners often recommend a high fiber diet to their clients.

Touted for its benefits to the cardiovascular system, experts suggest fiber will help us maintain healthy cholesterol levels, support a healthy blood sugar balance and provide benefits to our intestinal tract. In particular, fiber can provide benefits to our intestinal tract by helping promote regularity and assist with the normal detoxification process that takes place in our colon.

Fiber is the indigestible parts of plants. There are two types of fiber, soluble and insoluble. Both types of fiber are needed in a healthy diet, because each type of fiber provides a different benefit to the healthy body. Let me offer a simple illustration: imagine your typical kitchen sponge. It has two sides, each of which serves a purpose to properly clean your sink of dishes. The soft absorbent side of the sponge can represent soluble fiber. The scrubby side of the sponge represents insoluble fiber.

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Soluble fiber is found in foods such as fruit pectin. It dissolves in water, forming a gel and absorbs water soluble materials such as cholesterol and excess toxins.

This can assist body’s natural process of elimination.

It also provides food for intestinal flora, promoting a healthy intestinal environment. By absorbing liquids, soluble fiber can help form our stool, alleviating bothersome problems such as occasional diarrhea.

The scrubby side of the sponge represents insoluble fiber, which is also known as roughage. This is found in foods such as bran and fibrous fruits and vegetables. This type of fiber provides bulk to the bowel, sweeping clean the intestinal wall, and helping to promote regularity.

Balanced correctly, soluble and insoluble fiber work together, like a sponge and a scraper to help maintain the digestive tract. A diet rich in fruits, vegetables and grains will give you a ratio of roughly 25% - 35% soluble fiber and 65% - 75% insoluble fiber.

easy ways to eat

MORE FIBER Adding fiber to your diet may be easier than you think. Here are some tips that can help you get started: • Substitute high-fiber foods (whole-grain bread, brown rice, fruits and vegetables) for lowfiber foods (white bread, white rice, candy and chips).

• Try to eat more raw vegetables and fresh fruit, including the skins, when appropriate. Cooking vegetables can reduce their fiber content, and skins are a good source of fiber.

• Eat high-fiber foods at every meal. Bran cereal for breakfast is a good start, but try to include some fruits, vegetables, whole-grains and beans in your diet as well.

Two notes of caution: be sure to increase your fiber intake gradually, giving your body time to adjust; and drink six to eight 8-ounce glasses of fluids a day.

how much fiber

DO I NEED? The table below gives the recommended total fiber intake for men and women.

Age

Men

Women

19-50

38 grams/day

25 grams/day

Over 50

30 grams/day

21 grams/day

However, the average American man consumes only about 18 grams of fiber each day, and the average American woman consumes only about 14 grams of fiber each day.

how much fiber

Article source: Article base.com

AT ONCE? Gradually. Too much too soon can cause a bloated feeling and abdominal cramps. It may take several weeks to add the recommended amount of dietary fiber to your diet. While you’re working on it, be sure to add plenty of fluids.

Associates In Gastroenterology | www.associatesingastro.com

21

1 MOST PRESCRIBED,

#

BRANDED BOWEL PREP KIT1

A CLEAN SWEEP

EFFECTIVE RESULTS IN ALL COLON SEGMENTS >90% no residual stool in all colon segments compared to Standard 4-Liter Prep2*†‡ · These results were statistically significant in the cecum (P=.010)2*§ · Significantly more subjects in SUPREP® group had no residual fluid in 4 out of 5 colon segments2*‡ Help meet Gastroenterology Quality Improvement Consortium (GIQuIC) benchmarks for 85% quality cleansing3 with the split-dose efficacy of SUPREP ® Bowel Prep Kit.4 *This clinical trial was not included in the product labeling. †Standard 4-Liter Prep [sulfate-free PEG electrolyte lavage solution]. ‡Based on investigator grading. §Statistically significant difference.

References: 1. IMS Health, NPA Weekly, March 2015. 2. Rex DK, Di Palma JA, Rodriguez R, McGowan J, Cleveland M. A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage solution as preparation for colonoscopy. Gastrointest Endosc. 2010;72(2):328-336. 3. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53. 4. SUPREP Bowel Prep Kit [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2012.

©2015 Braintree Laboratories, Inc.

16-00590

March 2015

IMPORTANT SAFETY INFORMATION SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache.

Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.

BRIEF SUMMARY: Before prescribing, please see full Prescribing Information and Medication Guide for SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution.

INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prep Kit is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Pre-dose and post-colonoscopy ECG’s should be considered in patients at increased risk of serious cardiac arrhythmias. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare.

Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance. Pregnancy: Pregnancy Category C. Animal reproduction studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive capacity. Pediatric Use: Safety and effectiveness in pediatric patients has not been established.

Geriatric Use: Of the 375 patients who took SUPREP Bowel Prep Kit in clinical trials, 94 (25%) were 65 years of age or older, while 25 (7%) were 75 years of age or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose (2-day) regimen were observed between geriatric patients and younger patients. DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP may not be absorbed completely. ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Oral Administration: Split-Dose (Two-Day) Regimen: Early in the evening prior to the colonoscopy: Pour the contents of one bottle of SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume only a light breakfast or have only clear liquids on the day before colonoscopy. Day of Colonoscopy (10 to 12 hours after the evening dose): Pour the contents of the second SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least two hours prior to colonoscopy. Consume only clear liquids until after the colonoscopy.

STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185

For additional information, please call 1-800-874-6756 or visit www.suprepkit.com

©2015 Braintree Laboratories, Inc.

00590_SUP_R01_Ad_Size2_8.5x11.indd 3

16-00590

March 2015

4/2/15 1:03 PM

5653 Frist Blvd.

Summit Medical Center, Suite 530 Hermitage, TN 37076

NOW SERVING YOU AT: Tri-Star Summit Medical Plaza 660 South Mt. Juliet Road St. 120 Mt. Juliet, TN 37122

AIG Research Services 5653 Frist Blvd Suite 730 Hermitage, TN 37076

Board Certified Gastroenterologists Serving your digestive health needs since 1995!

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