Winter 2013

October 22, 2013



You can be immunized during any regular office visit
or you can come to special flu clinics at the
Hackettstown office
every Tuesday evening 5-8PM
and every Saturday 9AM to 1PM
Please call 908 850-7800 to schedule your shot
Or you could just catch the flu this winter


Irritable Bowel Syndrome (IBS) is the most commonly diagnosed adult gastrointestinal condition in America and affects 10-15% of the population. It occurs year round and accounts for up to 50% of all visits to gastroenterologists and a substantial percentage of visits to primary care doctors. The difficulty of establishing a diagnosis and the need for long term treatment are significant drivers of increasing health care costs. Studies suggest the medical bill for IBS may be as much as $30 billion annually.


What exactly is the disease and how do we go about making a diagnosis? The most basic definition of IBS is a gastrointestinal condition characterized by chronic abdominal pain and altered bowel habits in the absence of any obvious physical cause. An established definition called the Rome Criteria was published in 1992 and revised in 2005. It describes IBS as a condition with recurrent abdominal pain or discomfort, such as cramps, that last at least 3 days per month for 3 consecutive months associated with 2 or more of the following: improvement of pain with defecation, onset of symptoms associated with a change in frequency of stool, and onset associated with a change in form or appearance of stool. IBS is not associated with rectal bleeding, nocturnal or progressive abdominal pain, or weight loss.


To complicate matters, there are 4 subtypes of IBS. IBS with constipation, IBS with diarrhea, mixed IBS, and un-subtyped IBS. A second set of criteria published in 1978 provides another set of diagnostic guidelines. These include pain relieved with defecation, more frequent stools at the onset of pain, looser stools at the onset of pain, visible abdominal distension, passage of mucous, and sensation of incomplete evacuation. The more criteria are met, the greater is the likely-hood of IBS.


There are no specific lab tests or imaging procedures that can diagnosis IBS. Routine lab studies are normal; there are no signs of anemia, no abnormal chemistries, and no lab indicators of inflammation. When the clinical diagnosis remains unclear or if symptoms worsen, other testing may be needed to rule out more severe or progressive diseases. Stool cultures can identify infections. Celiac Disease testing can rule out gluten intolerance, and colonoscopy can reveal inflammatory bowel disease (IBD, Crohn’s Disease) and malignancy.


The etiology(ies)) and physiology of IBS are unclear. But understanding potential causes can help guide treatment. Decreased gastrointestinal motility with prolonged stool transit time can occur inconstipation variant IBS, whereas an exaggerated motor response to food ingestion can occur in diarrhea variants. IBS patients may also be more aware of abdominal distension and bloating. There can be intestinal inflammation, which might explain cases of IBS that develop after acute diarrhea (post-infectious IBS). Emerging data suggest that intestinal bacteria (fecal microflora) is different in patients with IBS, and there are studies of gas production by small intestine bacteria as a cause of IBS symptoms.


Food sensitivities including allergies, carbohydrate and lactose malabsorption, and gluten sensitivity (without Celiac Disease) may play a role. A genetic predisposition is under consideration, but no link has been established. Psychosocial factors and dysfunction may be a cause or an effect as with patients with IBS have greater evidence of anxiety, depression, phobias, and somatization or conversion of mental stress into gastrointestinal and other physical symptoms.


It is important to understand that IBS is a chronic but benign condition that may wax and wane but does not progress to more serious problems such as colon cancer. However, the condition is usually life-long and treatment is focused on reducing factors that lead to worse IBS symptoms and on alleviating symptoms when they occur.


With milder disease, lifestyle modifications such as diet changes (avoiding lactose or increasing fiber), increased physical activity, and reducing psychosocial stressors may be effective. With more severe illness, medications specifically directed at symptom reduction may be tried. Anti-spasmodics such as dicyclomine or hyoscyamine can be taken to reduce cramping and anti-diarrheal agents like Imodium or Lomotil can reduce the frequency of loose stool. There have also been attempts to use anti-depressant medications (in particular tricyclic antidepressants and SSRI’s such as Prozac). These seem to reduce pain by enhancing natural body chemical (endogenous endorphins) release as well as enhancing inhibitory pain pathways and blocking the pain modulator serotonin. Tricyclic antidepressants also slow intestinal transit time which may help with diarrhea predominant IBS.


Treating constipation predominant IBS can be more difficult. Again there is focus on increasing activity and trying to increase fiber intake in less severe cases. Some intermittent laxative use (Miralax) is acceptable but may not be effective. Previously, Zelnorm was available and effective for IBS with constipation but was pulled from the market in March 2007 due to significant cardio-vascular side effects. Two current products available, Amitiza and Linzess, both focus on enhancing intestinal fluid secretion and transit. They should be reserved for more severe cases of IBS since their overall long term safety and role in IBS is not yet clear.


There are anecdotal reports of efficacy for alternative treatments such as probiotics, peppermint oil, herbs, enzyme supplementation, and even acupuncture but their roles remain uncertain. The most interesting alternative treatment is antibiotics to reduce the amount of gas producing bacteria in the colon. Xifaxan (a nonabsorbable antibiotic) can give modest improvement in global IBS symptoms of diarrhea, pain, and bloating. However, controlled studies are inconclusive. A 2 week trial of treatment is reasonable in patients with moderate to severe symptoms without constipation who have failed standard approaches.


Ultimately, a satisfactory outcome requires an individually tailored dietary/treatment regimen and close patient-physician coordination.

Jimmy S. Chang, MD

Here are Some Tips to Make It Safe


  • Make sure costumes fit your children properly. Take care to notice that footwear fits and that no part of the costume is constricting. Costumes shouldn’t dangle or be too loose so that children could trip while walking.
  • Look for non-flammable costume materials.
  • Choose bright costumes whenever possible. If a darker costume is chosen, try to add reflective light tape to be easily seen on dark streets.
  • Some masks can block vision. Try fun, non-toxic make up instead.
  • Props such as swords should not be sharp or too large to carry.


  • Make sure pathways are cleared of toys, hoses, and lawn decorations.
  • Be sure that porch and post lights are working well. Path reflectors are useful.
  • Keep flammable objects away from the direct path of trick-or-treaters.
  • If carved pumpkins are used, try lighting them with a flashlight or battery powered flicker light. If a candle is used, be sure that it is securely placed inside the pumpkin and is placed in a safe location.
  • Keep pets inside.


  • Parents should go along with small children.
  • Older children should discuss their plans with parents and should stay in groups.
  • Only go to homes that are well lit.
  • Never go inside homes or cars for a treat.
  • Carry a flashlight with new batteries.
  • Carry a cell phone in case of emergency.
  • Try to go along sidewalks rather than walking in streets.
  • Be sure to go over treats and look for openings, tears or any suspicious looking pieces of candy.
  • Be sure to check ingredient listings if your child has food allergies.

Treats and Tricks for Halloween and Other Holidays

Halloween is just the kickoff to a season of sweet indulgences. The following tips can help keep you and your family on a healthy track through all the holidays to come.


Buy treats you do not like

If you don’t buy it, you can’t eat it! Buy Halloween candy or holiday treats that do not usually appeal to you. If you prefer chocolate, buy gummy treats or sugar-based treats; if you like sugary sweets, purchase chocolate. You will be less inclined to overindulge if what you have in the house does not tempt you.


Purchase treats the day you need them

Buy treats the day you plan to eat or distribute them. If you are buying candy or goodies for a holiday or gathering, keep them in the house for as short a period of time as possible and give away the leftovers. If you usually only have a few trick or treaters, only buy a few treats.


Consider alternatives

You and every other parent winds up throwing away most of the candy your children bring home. Pretzels, crackers, granola bars, fruit leather, books, stickers, bouncy balls, toys, and crayons are great alternatives to candy. Kids are usually thrilled to get something unusual, and again you will not be tempted to eat candy that is in the house.


Set ground rules

Come up with a philosophy for dealing with sweets and treats that everyone in the household agrees with. For example, “You can eat as much candy/dessert as you like today, and then we will donate the rest.” Another popular choice is to ration candy or desserts for a period of time. “You can have one piece of pie or one cookie each day for a week.” Make sure this philosophy goes equally for everyone in the house, parents too!


Keep healthy eating a priority

Decide the role that tempting treats will have in your family. Do not substitute treats for healthy snacks. Homemade treats let you control what goes into them. Choose holiday recipes that are low in fat and sugar and high in fruits, vegetables or whole grains. Try reducing sugar and fat by replacing them with applesauce, apple juice concentrate, or flax meal. Here are a couple of recipes.


The Perfect Fall Snack


  • 2 cups crisscross of corn and rice cereal (such as Crispix)
  • 1 cup tiny pretzel twists
  • ½ cup reduced-fat wheat crackers (such as Wheat Thins)
  • ½ cup reduced-fat cheddar crackers (such as Cheez-It)
  • 1 ½ tablespoons low fat butter, melted
  • 1 tablespoon ginger stir-fry sauce (such as Lawry’s)
  • 1 teaspoon chili powder
  • 1 teaspoon ground cumin
  • ¼ teaspoon salt
  • Cooking spray



1. Preheat oven to 250º.
2. Combine the first 4 ingredients in a bowl. Combine butter, stir-fry sauce, powder, cumin, and salt; drizzle over cereal mixture, tossing to coat. Spread mixture into a cookie sheet coated with cooking spray. Bake at 250º for 30 minutes or until crisp, stirring twice.


Pumpkin Cookies


  • 1 box Spice Cake Mix
  • 1 Can Pumpkin (15 oz, the small one)
  • 1 cup Chocolate chips, chopped nuts, or raisins



1. Preheat oven to 350˚F. Spray baking sheets with cooking spray.
2. In a large mixing bowl, combine cake mix, pumpkin and if desired, chocolate chips, nuts or raisins, until well blended.
3. Drop by large spoonfuls onto baking sheet. The cookies don’t flatten and will come out pretty much how they look on the pan.
4. Bake about 12 min. You can bake longer or shorter for different size cookies. These are really hard to burn!

Melissa Libert, DO



Many breastfeeding women are incorrectly advised to stop taking necessary medications or to discontinue nursing because of potential harmful effects on their infants. A new clinical report, “The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics,” published by the American Academy of Pediatrics (AAP) is a long overdue update on drug and vaccine exposure during lactation.

Not all drugs are present in clinically significant amounts in human milk or pose a risk to infants. Certain classes of drugs can present problems, either because they accumulate in breast milk or have adverse effects on a nursing infant or mother.

The most common products of concern include pain medications, antidepressants, drugs for substance/alcohol abuse or smoking cessation, x-ray contrast medium or isotopes, and herbal preparations. By and large the study reaffirmed that most medications and immunizations are safe for use while nursing and indicated that non-essential exposure to contrast media or radio-isotopes be deferred until after lactation when possible.

Interestingly, prescription drugs used to stimulate lactation were generally found to be unsafe and/or ineffective. Non-prescription and herbal products, used by up to 43% of nursing mothers, aren’t much better. Safety data is lacking for many common herbal products (chamomile, black cohosh, blue cohosh, Echinacea, ginseng, gingko, St John’s wort, valerian) and some (kava, yohimbe, fenugreek) are known to have serious side effects. Additionally, a recent GAO study found that 16 of 40 common, commercially available herbal supplements contained pesticide residues.

Bottom line: Even though most drugs and therapeutics are safe and should be continued while nursing, it pays to be careful. Call us if you have questions about any medication (prescription, OTC, or herbal) you take while nursing.

The full report may be found in:
Pediatrics Vol. 132 No. 3 September 1, 2013
pp. e796 -e809
(doi: 10.1542/peds.2013-1985) 

The National Institutes of Health (NIH) has a comprehensive online database available at LactMed ( The site is designed for physicians but is light on medical jargon and can be readily used by most adults.

Allen Menkin, MD


From the Editor


There are events in nature and human endeavor that pass unnoticed but are later recognized to have had enormous significance. It happens in sports, politics and economics; and it happens in science and medicine. One such event may have occurred in the last year.

Two unrelated studies concerning human papillomavirus (HPV) recently appeared in medical journals. The first article was published in the Journal of Infectious Diseases by researchers at the Centers for Disease Control and Prevention. The second article stemmed from research at Temple University and the University of Pennsylvania and was published in the Annals of Neurology. These reports may be seminal for doctors and patients, but have received scant professional or public attention.

The studies indicate that HPV 16 (one of the viral strains prevented by Gardasil) can be transmitted by a pregnant woman to her fetus (vertical transmission) and seems to cause a form of brain damage and intractable epilepsy that we considered a sporadic birth defect of unknown etiology.

If confirmed, the studies will have extended our understanding of the role silent viral infections play in central nervous system disease. More importantly, we will have simultaneously found the cause of a tragic disease, and have safe, effective prevention in our office freezer.

Astute readers will recognize Dr. Libert’s article on Halloween safety as a re-run. Mea culpa; it still seems timely.

From all of us at Plaza, have a happy and safe Halloween

Allen Menkin, MD



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