Diverticular Disease – Diverticulosis and Diverticulitis


When a patient comes in with abdominal pain or blood in their stool, one of the conditions that we consider is diverticulitis.  You may not have heard about diverticulitis so this will attempt to answer some questions about diverticular disease.

A diverticulum is a small pouch-like structure that sometimes forms in the muscular wall of the colon.  These little pouches often cause no pain and we become aware of them only after having a procedure such as a colonoscopy, flexible sigmoidoscopy, a barium enema or a CT scan.

What is diverticulosis?  Diverticulosis simply means that there are diverticula present.  Most people don’t have any symptoms and will remain free of symptoms throughout their life (about 15-25% of people develop diverticulitis which is more severe.  I usually think about diverticulum as small areas where the colon balloons out. These are potentially weak areas that might become inflamed or may rupture under pressure.

What is diverticulitis?  Diverticulitis is inflammation of a diverticulum that occurs when there is a thinning or breakdown of the wall of the colon.   Diverticulitis is more severe than diverticulosis because now these pouches in the colon have become irritated/inflamed/stretched because of pressure within the colon or due to hard particles of stool that become lodged inside them.  The diverticulum now becomes painful and may rupture (meaning the wall of the colon may break down and cause stool and bacteria to enter the abdomen).   Diverticulitis may also cause bleeding within the colon because there are often blood vessels in the area where diverticulum occur and they can start bleeding when the area gets inflamed.

Symptoms of diverticulitis:  The symptoms really depend on how bad the inflammation inside the colon is.  The most common symptom is pain in the left lower abdominal area.  Sometimes patients may have blood in their stool, nausea, vomiting, constipation, or diarrhea.

Classification of diverticulitis:  Simple diverticulitis is more common and usually responds well to medical treatment without needing surgery.  Complicated diverticulitis (about 25% of the cases) usually require surgery to remove the area of the colon that has become inflamed or ruptured.

Treatment:  There is usually no treatment needed with diverticulosis (diverticulum that are not inflamed are generally not painful and don’t usually cause problems).  Many medical providers however recommend increasing dietary to decrease the chances of becoming constipated.  Constipation can increase the pressure within the colon that can in tern lead to diverticulitis.    Increasing fruits, vegetables, hydration and fiber have not been proven to prevent diverticulitis however.    We used to think that patient with diverticulosis should avoid seeds and nuts because we thought they may increase the risks for patients developing diverticulitis, however research has no proven that to be false.

Diverticulitis is usually treated.  The treatment that you receive for diverticulitis depends on the severity of the symptoms.  Mild abdominal pain caused from diverticulitis can usually be treated at home with a clear liquid diet and oral antibiotics.  If the patient develops a fever greater than 100.1 degrees F, worsening or severe abdominal pain or inability to tolerate fluids then hospital treatment is usually recommended.

Hospitalization:  If you need to be in the hospital for diverticulitis you will usually not be allowed to eat or drink until you start feeling better,  and antibiotics and IV fluids are given.  If you develop an abscess inside the colon then a surgeon may need to help drain the abscess by putting a tube through the abdominal wall.

Complications:  Peritonitis is a generalized infection within the abdomen that occurs if the colon ruptures (the wall of your intestines breaks).  An emergency operation is often required in these cases to remove the area of diseased colon and reconnect the un-affected colon back together.  Sometimes these two procedures are done at separate times (the removal is done first) so that the colon is allowed to heal before reattaching the two pieces together.

Surgical treatment:  Patients who don’t respond well after medical treatment or who have repeat attacks of diverticulitis may benefit from surgery to remove the diseased area of their colon.

Bleeding from diverticulitis:  Most of the time the bleeding stops without needing any procedures but sometimes a colonoscopy or other procedures may be necessary to get the bleeding under control.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com


Rectal Bleeding – A discussion about possible causes











Photo credit:  http://www.naturalhealingsolutionsllc.com/learn-about-colon-hydrotherapy.html

Photo credit:  http://www.thenurseslockerroom.com/2013/03/sigmoidoscopy-screening-test-for.html

One of the more common problems that bring patients into the doctor believe it or not is seeing blood in the toilet, on the stool or on the toilet paper after having a bowl movement.  Since I’ve had a few patients recently who have come in because of this problem, I thought I’d discuss some possible causes.

Healthcare providers take this issue seriously because sometimes blood noticed after having a bowl movement can be a sign of colon or rectal cancer.  Fortunately, most of the time the causes of rectal bleeding is not cancer however.

Causes of rectal bleeding:

1)  Hemorrhoids:  Swollen blood vessels can occur in the rectum or anus and cause itching and/or pain and can sometimes bleed.  Usually hemorrhoids produce a blood that is described by patients as being a “bright red color.”  It may sometimes coat the surface of the stool or may drip into the toilet and turn the water red or be noticed on the toilet paper.  Hemorrhoids do not have to be painful – in fact painless rectal bleeding at the time of having a bowl movement is common in hemorrhoids.

2)  Anal Fissure:  If the lining of the anus has a tear, it can cause bleeding and sometimes there may be pain with having a bowl movement.

3)  Other causes such as infection, colitis (which could be due to an auto immune disease such as ulcerative colitis or Crohn’s disease), colon polyps or colon cancer can also cause bleeding.  If the bleeding comes from higher in the digestive system such as in or above the stomach, the blood may look dark black or have a tarry appearance.

Diagnosis/Testing:  In order to find out the cause of the bloody stools, your healthcare provider may perform some tests or refer you to a specialist to help determine the cause.  They will take into account the information you provide, your past history and symptoms as well as your age.

1)   Rectal exam:  Your healthcare provider will usually examine the rectum and look for a source of bleeding such as a hemorrhoid or anal fissure.  This may also include a digital rectal exam (where to doctor inserts a gloved and lubricated finger into the rectum to feel for possible rectal cancers).

2)  Anoscopy:  Your doctor may use a small plastic device with an attached light to get a better look for the source of bleeding.  Most of the time this is not painful (although perhaps a bit uncomfortable) and can be done in the office.

3)  Sigmoidoscopy:  This is a procedure that is usually done in an outpatient treatment center and the patient is usually not sedated.  There are rigid or flexible sigmoidoscopes.  Usually a flexible sigmoidoscope is used.  A flexible tube (it is approximately 70cm long and 1cm wide) with a tiny video camera and a light is inserted into the anus and gently into the colon while air is inserted into the colon to enlarge the area and help the doctor get a better view.  Often a biopsy (small sample of colon tissue) is taken with the use of a tiny biopsy tool.  The sigmoidoscopy allows visualization of the anus, rectum, sigmoid colon and top of the descending colon.  It does not allow visualization of the entire colon so it may miss seeing cancers, polyps or sources of bleeding in some areas.

4)  Colonoscopy:  This procedure is similar to the sigmoidoscopy but allows the doctor to examine the entire colon using a longer flexible tube. The Colonoscope (about 140cm in length) is able to reach the areas seen by the sigmoidoscope and also allows visualization of the transverse colon, ascending colon and cecum.  The patient is usually sedated during this procedure.

When to seek help:  It is impossible to know the cause of rectal bleeding without an examination, therefore everyone who has rectal bleeding should talk to their healthcare provider to help determine the cause and what examination is needed.  Even though there are common causes of rectal bleeding that are not cancerous, bleeding can be caused by cancer or precancerous conditions.

Precancerous polyps may be present in the colon for years before they become cancerous and may be removed safely from the colon, preventing them from becoming cancer.  These polyps may cause symptoms which are very similar to an innocent hemorrhoid.

I’ve met patients who have ignored rectal bleeding for years because they thought it was because they had a hemorrhoid and it turned out to be cancer.  With increased age comes an increased risk for polyps and colon cancer .

Colon Cancer Screening:  For patients who is at average risk, colon cancer screening is started by checking the stool for small amounts of blood (which may be hidden) each year starting at age 50.  It is also recommended to have your first colonoscopy at age 50 (unless you have other risk factors for colon cancer) and every 10 years thereafter unless you are at increased risk based on your family history or a previous diagnosis or biopsy result.

People at increased or high risk:

If you are at an increased or high risk of colorectal cancer, you should begin colorectal cancer screening before age 50 and/or be screened more often. The following conditions make your risk higher than average:

1)  A personal history of colorectal cancer or adenomatous polyps

2)  A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s)

3)  A strong family history of colorectal cancer or polyps

4)  A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC)

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Celiac Disease – Adopting a Gluten Free Diet to Manage Intolerance or Sensitivity

shutterstock_146760950One of the hottest topics in medicine these last few years has been the gluten free diet.  I’ve had countless numbers of patients ask me about “going gluten free” to help with weight reduction, low energy levels, gas, constipation, heart burn, or for various other reasons.  The information about gluten and reasons for avoiding it are rather widespread – some of the information released is valid while others are rumors or just downright advertising.

What is Celiac disease, gluten intolerance and gluten sensitivity?  In the medical field we refer to a condition called Celiac disease which is a condition that affects perhaps up to 1% of our population.   The affected patient’s immune system can damage their small intestine as a reaction to Gluten, a common protein found in most modern day diets. People with the condition are advised to avoid wheat, rye, barley and many prepared foods because they may feel very ill if they consume these products.

Celiac disease is also called gluten sensitive enteropathy, Celiac sprue or nontropical sprue.  Gluten intolerance may also be sometimes called gluten sensitivity, a less severe disorder that affects perhaps up to 10% of our population.  Symptoms may be milder than with Celiac disease and may affect other areas of the body in addition to the gastrointestinal tract. The definition of gluten intolerance has been changing over the years as we work to understand more about the condition.

The small intestine is the part of the body which absorbs nutrients from the food that we eat.  In patients with Celiac disease, the small intestine becomes damaged by the immune system so patients have problems absorbing nutrients from the food that they eat.  Gluten is fairly indigestible in most people and some experts believe that there is a certain amount of gluten intolerance in all of us.

What are the symptoms of Celiac disease?  Patients may experience diarrhea, weight loss, abdominal discomfort, excessive gas and vitamin/mineral deficiencies.  Patients with gluten intolerance may be more prone to osteoporosis, iron deficiency anemia, autoimmune problems with the thyroid, liver, type 1 diabetes, and nervous system problems.

In addition, patients with Celiac disease may be more likely develop lymphoma which is a cancer of the intestinal lymph system.  This is uncommon but we think that avoiding gluten can help prevent the development of lymphoma.  Celiac disease has also been associated with a skin condition called dermatitis herpetiformis.  This causes itchy, raised fluid filled areas on the skin mostly in areas such as the elbows, knees, buttocks, lower back, face, neck, trunk and sometimes in the mouth. The symptoms of this skin condition are mostly the intense itching and burning.  Once the blisters rupture, the itching is relieved but scratching the blisters can rupture them and leave dark areas of skin and permanent scarring.  Eliminating gluten for the diet may help the condition improve after several weeks of remaining on a gluten free diet.  A medicine called Dapsone may be taken to help with the itching but this medication does not help heal the intestine which was damaged by the immune system.

How can you test me for Celiac disease?  If you have symptoms that are very suspicious for Celiac disease there are a variety of tests that can help make the diagnosis in addition to being evaluated by a medical provider.  One of the gold standard tests to help us determine whether you have Celiac disease is to take a biopsy of the lining of the small intestine.  A small sample of tissue from your intestine is examined with a microscope after it has been collected during a procedure called an endoscopy.  As you can imagine, this is not a procedure that is done while patients are awake so it is usually performed in the hospital or an outpatient surgical center where nurses and other medical providers can give you medication through an IV to help make you comfortable.

There are also blood tests that can help determine whether a patient has Celiac disease.  These tests are often part of a “Celiac blood panel” but can be ordered separately.  They are antibodies called the anti-total tissue transglutaminase (TTG) and anti-endomysium antibody (EMA) total imunoglobin A (total IGA), anti DGP antibody, antigliadin antibody (AGA), anti-F-actin test and sometimes antireticulin antibody (ARA).  Your medical provider will help determine which tests are appropriate and interpret the results.

There is not a test however for gluten intolerance.  The blood tests and intestinal biopsies may be completely normal for those who have gluten intolerance but they simply feel better eating a gluten free diet.

Who gets Celiac disease?  We aren’t sure why people get Celiac disease but we think there is a genetic component.  It is rare if people from northern Asia or Southern Africa and more common in patients from Europe, North and South America, South Asia, Middle East and North Africa.

Treatment:  About 70% of people feel better two weeks after they stop eating foods with gluten.  The blood antibody levels often return back to normal as patients stop eating foods with gluten.  Gluten is the group of proteins found in wheat, rye and barley.  It’s also hidden in a large number of prepared foods and supplements.  It can be very challenging to eliminate gluten from your diet because it takes some major lifestyle changes.  It is important to avoid eating gluten and being exposed to it in the air as well.

I recommend consultation with a dietician who specializes in helping patients with Celiac disease.  They can help patients learn what foods to avoid and what foods you need in order to get a balanced diet.

There are a large number of stores that are now offering gluten free foods in certain areas of the United States.

1)      Examples of gluten free foods are rice, corn, potato, beans, legumes (beans, etc.), nuts, seeds, and soy

2)     Foods to avoid are obviously anything with wheat, rye, barley, brewer’s yeast, oats (unless labeled gluten free), and malts

3)     Some people with Celiac disease cannot tolerate oats even if they are labeled gluten free

4)     Wine is usually gluten free unless it contains gluten free flavorings

5)     Most beers have gluten unless they are labeled “gluten free”

6)     Many people with Celiac disease have trouble with dairy products until their intestines return to normal.

7)     Make sure you are getting enough calcium and vitamin D

8)     If you have Celiac disease, you should have blood tests for iron, folic acid, vitamin B12 and vitamin D to make sure your levels are adequate.

9)     There is concern about patients with Celiac disease developing osteoporosis (low bone density) so some clinicians recommend getting a bone density test (DEXA) to measure your bone density.

I think that I may have gluten sensitivity, gluten intolerance or even Celiac disease – should I try a gluten free diet?  I suggest you talk with your health care provider and a dietician before starting a gluten free diet because cutting out gluten doesn’t mean you will be healthier.  After consultation with a medical provider, perhaps you be get tested for Celiac disease with some blood work and/or a biopsy.  If these tests are negative, you can still try a gluten free diet to see if you feel better, but I’d recommend getting help from a dietician to make sure you understand where “hidden sources” that are not obvious in the foods that we eat.  You also don’t want to miss out on the vitamins and minerals that wheat products provide.  Manufactures of gluten free products may add sugar or fat to their products to simulate the texture of foods that contain gluten have.  Gluten free products also often contain less iron, vitamin B and vitamin D than bread products so it’s important to make sure you’re getting enough of these in your diet from other sources.

Where can I find more information about Celiac disease? 

1)      American Celiac Disease Alliance:  www.americanCeliac.org

2)     American Gastroenterological Association:  www.gastro.org/patient-center/digestive_conditions/Celiac-disease

3)     Celiac Disease Foundation:  www.Celiac.org

4)     Gluten Intolerance Group of North America:  www.gluten.net

5)     National Foundation for Celiac Awareness (NFCA):  www.Celiaccentral.org

6)     National Library of Medicine: www.nlm.nih/gov/medlineplus/Celiacdisease.html

7)     North American Society for the Study of Celiac Disease:  www.nasscd.org

8)     Celiac.com:  www.Celiac.com

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

References:  Ciclitira PJ, King AL, Fraser JS. AGA technical review on Celiac Sprue. American Gastroenterological Association. Gastroenterology 2001; 120:1526

Poisonous Plants and Mushrooms

shutterstock_78360337Traveling out in the wilderness or being in a survival situation can bring people to look for or depend on plants for food/nourishment.  Sometimes these plants can be extremely poisonous and cause illness.

Anything in the correct dose can be poisonous.  “The dose makes the poison.”

I credit the information that I’ve learned and written here to Richard Clark, MD who is medical toxicologist and expert in Wilderness Medicine.

Mushroom ingestion:

It’s difficult even for a trained botanist to identify all mushroom varieties and 95% of the time the type ingested is unknown.  There are less than 100 reported fatalities related to mushroom ingestions in 25 years.  Most patients are treated at home.  Most cases reported to the poison control center were related to children, however all reported deaths were in adults.  Mushroom toxicity varies widely.  Management and prognosis often depend on the history and geographical location of the ingestion as well as the initial signs/symptoms.  The largest and most diverse group are the “little brown mushrooms.”  These are often mistaken for edible varieties.

Symptoms of toxic mushroom ingestion can be classified as early or late.

Early gastrointestinal symptoms may begin in ½ hour to 3 hours after ingestion and may be:

1)  Severe nausea, vomiting and diarrhea
2)  Stools may be bloody
3)  Symptoms may last 6-24 hours
4)  Most of the time no labs are needed, but when symptoms are severe liver enzymes may be monitored

Treatment:  Hydration and anti-nausea medication and possible narcotics for pain.

Mushroom ingestion with late gastrointestinal symptoms:  may begin 6-12 hours after ingestion.

Mainly differentiated between 2 varieties – Amanita/Galerina and Gyromitra.  There are several liver toxic Amanita species:  phalloides, virosa, verna.  They have a greenish color cap and like to live under oak trees.  They are the most common vegetable cause of human death in the USA.  Phase 1: 8-12 hours after ingestion – abdominal pain, vomiting and diarrhea.  Phase 2:  Begins 12-36 hours after ingestion and patients may actually improve.  Phase 3:  2-6 days after ingestion, the patient may get severe liver death and kidney disease.  There are no antidotes available.  Treatment is supportive care and organ transplant if necessary.

Several species may look like a morel (Morchella esculenta) and are the esculenta, infula, ambigua.  These false morel may be edible in some parts of the U.S.  In areas where they are toxic, the toxins may sometimes be destroyed by cooking.  Symptoms including nausea, vomiting, diarrhea seizures and possible liver damage begin 6-12 hours after ingestion. Treatment:  Rehydration, activated charcoal, benzodiazepines, pyridoxine.

Plant induced itchy rash (contact dermatitis):

1)  Poison Ivy
2)  Poison Oak
3)  Poison Sumac

Exposure to mango, pistachio and cashew can also cause the reaction.

50% of the population is highly sensitive.  Oils on plant turn black on contact with air.  These plants are found in all 48 continental states.  P. Ivy is mostly in the eastern states, P. oak is mostly in the west and Sumac is mostly in the southeast.

Severe cases can progress to a severe type 1 hypersensitivity reason.  Symptoms usually begin with 2-4 hours after exposure and may include:

1)  Redness
2)  Itching
3)  Blisters
4)  More severe cases may cause fever, nausea, vomiting, dehydration
5)  Skin infection secondary

Treatment:  prevent severe symptoms by early washing with soap and water (toxin is oily).  Treat with systemic corticosteroids and topical lotions, steroid creams and antihistamines.

There are several products that help prevent exposure to the plants by wearing them – including barrier creams, lotions or sprays – these are poorly protective.  Stoko Gard Outdoor Cream provides great protection if washed off by 8 hours post-exposure.  IvyBlock is another product that can provider good protection.

The “Unknown” Berry Ingestion:  Most of these are non-toxic but can cause gastrointestinal illness.  Large quantities of almost any plant can cause nausea/vomiting.Decontamination with pumping the stomach or charcoal is rarely needed.  Rehydrate and give anti-nausea medicines or benzodiazepines for seizures or agitation.

Holly:  Over 300 species, causes nausea, vomiting and diarrhea.  Treat with rehydration

Pokeweed:  Native to Eastern USA along roads and moist areas.  Rapid onset of severe nausea, vomiting and diarrhea.  Treat with rehydration.

Castor bean:  Grows wild in southern California.  The seed is the most toxic part.  Whole seeds are “nontoxic” except for severe gastroenteritis.  Treat with rehydration.

Jequirity bean:  Native to Florida and the Keys.  The bean is the toxic portion of the plant.  Causes severe nausea, vomiting and diarrhea.  Treat with rehydration.

Ricin and Abrin:  Two of the most toxic substances with the highest concentration in the seeds.  Intoxications result in multisystem organ failure.  Seed coat must be destroyed.  There are few if any reported cases of fatalities when seeds ingested

Water Hemlock (Cowbane, false parsley):  Grows throughout the USA along roads and ditches and is often mistaken for wild carrots or wild parsley.  It was used extensively for suicide in ancient Greece.  Most lethal plant in North America.  Tuberous root.  Causes rapid onset of seizures.  Treat with airway protection and anticonvulsants.

Nicotine:  Found in woodlands and along roads.  Poisoning from touching on the skin, inhalation or gastrointestinal exposure.  Rapid onset of severe nausea, vomiting, diarrhea, headache, dizziness, confusion, seizures and possible coma and paralysis.

Jimson Weed:  Grows along roads and fences throughout the USA.  Seeds are particularly potent.  Mind altering properties noted in ancient literature.  Seeds contain atropine (50-100 seeds may contain 3-6mg).  Anticholinergic toxicity.  Treat with sedation and possibly physostigmine.

Foxglove, Lily of the Valley, Oleanders:  Contain heart glycosides that can lead to stopping of the heart, rapid pulse, or arrhythmias.

Hellebore:  Found in moist woodlands of eastern and western USA.  Used as a sneezing powder.  Can cause nausea, vomiting, low blood pressure, slow heart rate and heart dysrhythmias.

Aconite (Monkshood, wolfsbane):  Can cause cardiotoxicity (dysrhythmias) or neurotoxicity (paresthesias).  Treat with lidocaine and supportive care.

Rhododendron including azaleas and laurels:  Leaves and flowers contain small amount of Andromedotoxin or grayantoxin that can cause cardiac dysrhythmia but there has only been one reported case in the last 20 years.

Unknown plant ingestion with patient having seizures:  Wide differential of plants that cause this.  Symptoms can advance quickly.  Often symptoms begin with nausea and vomiting and can progress to coma and paralysis.

There are many other plants that are toxic.  Please contact your medical provider or your local poison control center.  There are more than 40 nationally certified and they are open 24 hours/day and staffed by specialists in poison information.  There is backup from medical toxicologists.

If you have a poison exposure or question, the poison helpline number is:  1-800-222-1222 and is available 24/7 365 days of the year.  Also, the American Association of Poison Control Centers website has some valuable information as well:  http://www.aapcc.org/dnn/default.aspx

If you are interested in learning more about wilderness medicine, a great resource for information is the wilderness medicine society:  http://www.wms.org/

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Gluten Free Travel Tips

For a variety of reasons, some patients prefer a gluten-free diet.  I am not promoting a Gluten-Free diet here, but just pointing out what some patients are doing and some ways to continue to be Gluten-Free if that is your choice.

Gluten is a protein that is found in foods processed from wheat and related grains including barley and rye.  It gives a kind of chewy texture to many of the food products that we eat.

1)   The Airlines are not “Gluten Friendly” so it’s safe to assume that you’ll need to pack your own pic-nick style meals.  Bringing fruits, nuts, tail-mix, cheeses and meats that you would normally eat at home and pack them into soft-sided cooler type containers or your carry on bag.

2)   Packing your own nutritional supplements containing digestive enzymes may be helpful if you can’t be entirely sure that the food your eating is totally free of glutens.  Digestive Gold is one supplement may be helpful.  Your local health-food store or Amazon.com may have digestive enzymes, but your favorite drug store may not.

3)   Cook for meals yourself.  When you travel, consider renting a place with a kitchenette if you can so you have the space available to create your own meals that you know are gluten free.

4)   Find a decent grocery store with a good deli instead of eating out at restaurants and fast food joints.  That way you can make your own salads, buy some meats and cheeses and create something both tasty and healthy.

Eating gluten free is definitely more work, but for those of us with Celiac Disease, on dietary restrictions or who just want to eat healthier I think the advance preparation is worth the investment.

For more information about the Gluten Free Diet, check out the Mayo Clinic Article – Gluten-Free: What’s Allowed, What’s Not: http://www.mayoclinic.com/health/gluten-free-diet/my01140

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

The Cough – Possible Causes and Treatment Options


Cough is actually the body response to help clear particles and secretions from the lungs and help prevent infection.   A cough everyone once in awhile is normal, however if it continues it can be due to an infection (viral or bacteria), allergic reaction, acid reflux, a medication reaction or asthma.

A cough where there is no production of mucus is sometimes called a “dry” cough as opposed to a “wet” or “productive” cough that is associated with mucus production.

Possible causes of cough include:

1)   An infection of the airways or lungs

2)   Postnasal drip – mucus from the nose drips down or flows along the back of the throat and drain into the bronchioles of the upper airway and can cause irritation and cough

3)   Asthma or COPD (emphysema) can create cough and make it hard to breathe

4)   Acid reflux is when acid that is normally in your stomach backs up into the esophagus (the tube that carries food from your mouth to your stomach)

5)   Medication reaction – this happens with about 10% people who take ACE inhibitors for blood pressure

6)   Smoking cigarettes

7)   Cancers – A cancer of the lung or upper airway can cause a cough, but cancer is a less common cause than those other possibilities listed above

Testing:  There are some tests that can be done in addition to a medical provider performing a thorough examination.

1)   Chest X-ray

2)   Breathing tests – these are also called pulmonary function tests and can be helpful to diagnose asthma or chronic lung disease such as emphysema

3)   Allergy skin test – these tests are helpful to find out if there is an environmental allergic that could be causing symptoms including cough

4)   CT or Cat scan of the chest or sinuses – this is sometimes done to get a detailed view of the structures inside the chest and can be more useful if there are abnormalities that are seen on chest x-ray that are difficult to visualize.  The sinuses are also examined using a CT scan and for individuals with sinus pressure/pain and cough it may help determine whether surgery may be helpful

5)   Bacterial culture – sometimes a culture of the mucus (sputum) is done to determine the type of bacteria that are present within the lungs

6)   Bronchoscopy – a test where a physician inserts a special scope with camera down the throat and into the upper airways of the lungs to look for abnormalities

7)   Nasopharyngoscopy – a test where the ear/nose/throat physician inserts a scope with camera through the nose and down into the throat to examine the areas of the nose, throat and larynx, trachea and vocal chords to look for abnormalities

8)   pH probe – a test that involves putting a tube in the mouth and down into the esophagus to look for acid entering the esophagus and causing cough

Cough treatments:  There are many treatments for cough and we usually tailor the treatment to the individual patient depending on the cause of the cough.  Possible treatments might include antibiotics if the cause is a bacterial infection, a bronchodilator, if the cause is asthma, an acid reducer if the cause is stomach acid, or antihistamines if the cause is excess mucus production from allergies.  If the cause is an allergic reaction or side effect, that medicine or substance is avoided.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Hemorrhoids – A pain in the Rear

shutterstock_125891585Hemorrhoids are a common problem in both men and women who come to see their primary care or urgent care doctor.  Hemorrhoids are enlarged or swollen veins in the lower rectum.  They can cause pain, itching and rectal bleeding.  Sometimes you can feel or see hemorrhoids around the outside of the anus.  Other times they may be hidden from view inside the rectum (internal hemorrhoids).

They are more common in older individuals and patients during and after pregnancy, those with diarrhea or constipation or in people who sit for prolonger periods of time.


1)   Anal pain or itching

2)   Tissue bulging around anus

3)   Painless rectal bleeding

4)   Difficulty cleaning or leakage of feces after bowl movement

Diagnosis:  Your healthcare provider will examine the rectum and anus to inspect for hemorrhoids.  This exam may include inserting a gloved finger into the rectum.  The reason for the digital exam is to inspect for possible rectal cancers and also to collect any stool that’s present and test for blood.  If there is blood present, your healthcare provider may use a special tube called an anoscope, that is clear and allows visualization of the rectum/anus.

Treatment:  If hemorrhoids are diagnosed, one of the most important steps is avoiding constipation because they can lead to rectal bleeding or tearing the anus (called a fissue).  Also, it is important to avoid pushing or straining during bowl movements because that can worsen existing hemorrhoids and risk causing development of additional hemorrhoids.  Reducing constipation can be done by:

1)   Increasing fiber – increasing fruits and vegetables contain fiber.  In addition fiber supplements such as Metamucil may be helpful.

2)   Laxatives – These are not “addictive” or increase your risk of constipation in the future.

3)   Warm sitz baths – soaking the rectal area in warm water for 10 minutes 3x/day improve blood flow by relaxing the internal anal sphincter.

4)   Topical treatments – Suppositories are creams with hydrocortisone may be helpful to relieve pain, itching and irritation.

More invasive procedures:

1)   Rubber band ligation – a rubber band or ring is place around the base of the internal hemorrhoid which restricts the blood supply to that area.  This shrinks the hemorrhoid and reduces it.

2)   Laser surgery – uses a laser or infrared light to destroy internal hemorrhoids

3)   Sclerotherpay – a chemical solution is injected into the hemorrhoidal tissue causing it to break down and form a scar

4)   Surgery – hemorrhoidectomy is the treatment of choice for patients with large internal hemorrhoids.

A gastroenterologist is a doctor who specializes in the gastrointestinal tract.  If you are looking for a gastroenterologist in your area, the American Gastroenterological Association has a locator:  https://secure.gastro.org/GILocator/locator.asp

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com