The esophagus is a 1 foot tube that connects the back of the throat to the stomach and propels the food bolus by way of sequential contractions.
Heartburn = Acid Reflux (GERD)
Heart burn is one of the most common patient complaints. If not caused by heart disease, it is usually caused by acid reflux from the stomach into the esophagus. A person may either produce too much acid but, more commonly, the valve that separates the esophagus from the stomach (the lower esophageal sphincter) is either too weak or it opens up too frequently for too long (for reasons that are not well understood). Certain foods and products may open that sphincter: high caloric meals (fats), cheese, chocolate, caffeine, alcoholic beverages and nicotine. Acidic foods (citrus fruits and juices, tomatoes and pasta sauces) may cause heartburn by their own acidity. Being overweight may cause reflux because the increased amount of fat in the abdominal cavity increases the pressure onto the stomach. Therefore, treatment of reflux disease is directed at weight reduction, nicotine cessation, avoidance of large meals (especially late at night), and avoidance of any kind of food that may bring about heartburn symptoms. However, many patients will require the addition of medications. For occasional heartburn, over-the-counter antacids (Maalox or Mylanta) or H2-blockers (Zantac or Pepcid) may be used. For more persistent symptoms prescription proton pump inhibitors (PPIs) may be needed: Prilosec (also available as over-the-counter, OTC), Prevacid, Protonix, AcipHex, Nexium and Kapidex). A minority of patients (less than 10%) will not respond adequately to life style modifications and medications and may require a simple laparoscopic surgery (Nissen fundoplication) – especially when a large hiatal hernia is present. If ‘alarm symptoms’ (difficulty swallowing or weight loss) are present a patient must immediately seek medical advice.
Gastroesophageal Reflux that is not Acid-related
A percentage of patients (less than 15%) may have untreated reflux that is not acid or that have treated reflux (with any of the above mentioned PPIs) that does not adequately respond to treatment. These patients have so-called non-acid reflux. There are no good medications or behavioral changes to improve their reflux. These patients may benefit from minor surgery, the laparoscopic Nissen fundoplication. Not many centers are able to assess non-acid reflux. Dr. Lenz, sub specializing in the esophagus, has the technology to do so. He is currently the only gastroenterologist in private practice to offer this evaluation.
The definition of a hiatal hernia is that a small portion (or sometimes a large portion) of stomach has slipped above the level of the diaphragm and now is in the chest. This can occur with age or with loosening of the ligaments around the esophagus at the level of the diaphragm. A hiatal hernia is extremely common: one third of the U.S. population (100 million people) may have a hiatal hernia. Not everybody with a hiatal hernia has reflux disease or heartburn. However, most people with heartburn, especially if severe and persistent, will have a hiatal hernia. A minority of patients may need to have the hernia repaired by laparoscopic Nissen fundoplication.
Prolonged acid reflux or a strong family history of acid reflux may predispose a patient to develop Barrett’s esophagus. Barrett’s is a condition in which the lining of the lower end of the esophagus has changed from pink to a salmon color; that is, from squamous to adenomatous epithelium. Rarely (in less than 1% per year), this adenomatous epithelium may progress to esophageal cancer. Therefore, patients with prolonged (more than 5 years) acid reflux or those with a strong family history of acid reflux (and its complications such as Barrett’s, cancer or stricture) should undergo an upper endoscopic examination. Recommendations vary but any patient with reflux after the age of forty (40) should probably undergo an upper endoscopic examination. Patients who have been diagnosed with Barrett’s should have periodic follow up endoscopies to detect early precancerous changes and thereby prevent major surgery for cancer. Depending upon the length of the Barrett’s segment, surveillance endoscopies should be carried out every 1-5 years.
There are two types of esophageal cancer: squamous and adenomatous. Squamous esophageal cancer occurs primarily in the mid esophagus and is related to heavy smoking and heavy drinking. Adenomatous esophageal cancer occurs primarily at the end of the esophagus (near the stomach) and is primarily related to acid reflux (although nicotine and alcohol may further increase the cancer risk). If caught early enough, surgery may be curative. However, most cancers are not detected early as the patient presents with difficulty swallowing and/or weight loss. Therefore, most patients will need chemo and radiation therapy with or without subsequent surgery. There are no early warning signs. To minimize the risk of esophageal cancer, a patient should not smoke, should drink alcoholic beverages in moderation only and should have acid reflux controlled.
Difficulty Swallowing (Dysphagia)
There are two primary types of dysphagia: difficulty swallowing solids (much more common) and difficulty swallowing liquids (much less common). In decreasing order of frequency, dysphagia to solids is caused by a benign ring at the end of the esophagus (Schatzki’s ring, always associated with a hiatal hernia), a stricture (narrowing) from acid reflux or esophageal cancer. The treatments are esophageal dilation (stretching the ring), treating acid reflux and dilation, and cancer therapy and dilation, respectively. Dysphagia to liquids only is primarily caused by Achalasia, a benign condition in which the esophageal contractions (pump function) have been weakened and the lower esophageal sphincter may not open up. The cause is unknown. Treatment consists mainly of cutting the tight sphincter open surgically (laparoscopic Heller myotomy) or performing a dilation or injecting Botox into the sphincter. A relatively new entity that can cause dysphagia (more to solids than to liquids) is Eosinophilic esophagitis. This benign condition for which endoscopic evaluation is needed may be a food allergy. Evaluation by an allergist may be appropriate and treatment is done with a swallowed synthetic steroid with/or without acid suppression. A complication of dysphagia is that a food bolus may get stuck in the esophagus requiring emergent endoscopic bolus removal. Therefore, earlier rather than later should a patient with dysphagia seek medical attention to obtain either a barium swallow (x-ray study) or an upper endoscopy.
The stomach primarily serves as a receiving bag for ingested foods and by secretion of acid and vigorous contractions it pre digests protein and grinds the food particles into smaller pieces, respectively. A person can live without a stomach.
Ulcers occur when the tissue lining (mucosa) breaks down resulting in a ‘crater.’ Most ulcers are localized at the end of the stomach (antrum) and at the very beginning of the small intestine (duodenal bulb). In the past, most ulcers were caused by the bacterium H. pylori but today, most ulcers are caused by arthritis and pain medications called non-steroidal anti inflammatory drugs (NSAIDs): Aspirin, Motrin, Ibuprofen, Aleve, Naprosyn, Voltaren, etc. Additional risk factors include: nicotine, older age, female gender, prednisone usage and other serious illnesses such as arthritis, asthma, COPD, emphysema and cardiovascular diseases. Diet, alcohol and every day life stresses do not cause ulcers. However, stress may cause ulcer-like pain and hard liquor may cause upper abdominal distress but neither cause ulcers. While the blood thinner Coumadin and the anti platelet agent Plavix do not cause ulcers, both agents can make an ulcer bleed more vigorously. Bleeding and less commonly perforation (a hole and not just a crater in the lining) are the most severe complications requiring endoscopic and surgical treatment, respectively. All ulcers associated with H. pylori need to be treated for this infectious agent with acid suppression and multiple antibiotics for 10-14 days. The treatment for ulcers associated with NSAIDs is complex. In some patients, the NSAID needs to be stopped temporarily or indefinitely. In other patients, the NSAID may be resumed but only under the ‘protection’ of a potent acid suppressive medication such as a PPI. In general, as patients get older, especially thin females, they become much more sensitive to NSAIDs and Aspirin even at a low dose such as an 81 mg baby Aspirin.
While a lot of hard liquor and some inadvertently ingested chemicals may cause gastritis, the most common cause of chronic gastritis is the bacterium H. pylori. Whether H. pylori-associated chronic gastritis causes upper abdominal symptoms is controversial. However, if there is no other cause to blame for the patient’s symptoms treatment for H. pylori is reasonable. After all, H. pylori may cause gastric cancer and gastric lymphoma in a very small number of patients.
Gastric Cancer and Lymphoma
In Western countries, the incidence of gastric cancer has decreased dramatically over the past century. This was due to the advent of refrigeration (no need for cancer causing preservatives) and to improved hygiene (decreased rate of infection with H. pylori). There are no early warning signs for gastric cancer. Patients usually present with weight loss and vague upper abdominal pain or early satiety. But again, gastric cancer is very uncommon in the U.S. In Japan and other parts of the world, gastric cancer is so common that endoscopic screening programs have been implemented. The only chance for cure is surgery. On the other hand, gastric lymphoma may be cured with antibiotics (if small) or with chemo therapy (when large).
The small intestine is about 15-18 feet long and is responsible for the absorption of nutrients, vitamins and minerals. It is fairly ‘clean’ and given the length of this organ, not much goes wrong in the small intestine. Cancers and lymphoma occur rarely. Crohn’s disease may affect the small intestine (primarily the very end, the terminal ileum) and this will be discussed in the colon section. There are rare conditions of poor absorption but the two more common ones will be discussed here.
The ability to digest dairy (to break down the milk sugar lactose) decreases with age in every person, albeit at different speeds. Some will become lactose intolerant in their teenage years while others (the majority) will die before developing symptoms. The most common symptoms include indigestion, bloating, diarrhea and weight loss. While specialized and expensive breath tests are available, most physicians make the diagnosis by taking a careful dietary history and by a 2-3 week elimination trial of dairy: primarily milk, cheese, butter and ice cream. Once the diagnosis is established, the patient may then have dairy with the supplementation of the enzyme lactose in the form of Lactaid tablets. Many patients will tolerate a small amount of dairy or some, but not all, dairy products. Milk may be substituted with soy milk and Lactaid milk.
Celiac disease, also called Celiac sprue and gluten sensitivity/intolerance is an autoimmune disease affecting primarily people from northern European descent. Symptoms are similar to those of lactose intolerance: indigestion, bloating, diarrhea and weight loss. In addition, patients may be anemic or have skin changes. The diagnosis can be made by a simple blood test or, if the blood test is equivocal, by endoscopy and duodenal biopsy. Treatment is purely dietary avoiding gluten containing grains: wheat, rye, barely and oats; the latter may be reintroduced later on. It is important to note that gluten may be hidden in a variety of products: beers, soups, candy, drink mixes, sauces, lipstick, nutritional supplements, salad dressings, and soy sauce.
The colon is about 4-5 feet long. The primary function of the colon is to remove water from the stool thereby decreasing the volume of the 2 quarts liquid stool at the beginning of the colon to a 6-7 ounces stool column at the end of the colon.
Colon Polyps and Cancer
Colon cancer is the second most common cause of cancer death (after lung cancer) in the United States. Aside from cervical cancer, colon cancer is the only preventable cancer in the human body. The other cancers for which there are screening recommendations, breast and prostate, cannot be prevented; they can barely be detected at an earlier stage. This makes colon cancer (along with cervical cancer) unique. There are two broad forms of colon cancer: those that occur in families (10%) and those that occur sporadically (90%). All cancers are caused by a variety of gene alterations that result in unrestraint growth. Almost all colon cancers arise from colon polyps, growths that measure 5-50 mm (1/4 inch to 2 inches) in size. These can be removed by colonoscopy thereby preventing cancer from developing. Most polyps grow slowly and some may even regress (go away). However, it is now recommended that all people undergo colon cancer screening, preferentially by way of colonoscopy every ten years beginning at age 50. Patients with a family history of colon cancer or polyps may need to start screening earlier and at more frequent intervals (2-5 years). Like stomach and esophageal cancers, colon cancer does not have any early warning signs. Rectal bleeding and anemia are late signs and a so-called “change in bowel habits” is a very non-specific sign. Screening for colon cancer by way of colonoscopy is not perfect. First, not all small polyps and all flat cancers can be detected and second, in rare instances a cancer can develop in a very short period of time (less than 2 years). Nevertheless, it is estimated that screening colonoscopy decreases deaths from colon cancer by 60-70%. This compares favorable with screening mammography that decreases deaths from breast cancer by 25-30%. Cigarette smoking, overweight and a diet high in red meats may increase the risk of colon cancer. On the other hand, no minerals, vitamins or supplements have been shown to decrease the risk for colon cancer. Only Aspirin has been shown to decrease the risk for colon cancer slightly.
Diverticulosis is a benign condition occurring in most people after age 60. It is characterized by small pockets on the wall of the colon, primarily the sigmoid colon. These pockets usually do not cause any abdominal symptoms but once they rupture and become infected (diverticulitis) they can cause abdominal pain in the left lower side or above the pubic bone, fever and an increased white blood cell count. Diverticulitis, when mild, can be treated as outpatient with antibiotics and a bland diet but when severe, liquids only and intravenous antibiotics are needed. If diverticulitis occurs more frequently or if a patient has one severe bout of diverticulitis surgical treatment with removal of the diseased segment of colon needs to be considered. There is no specific diet that may prevent the recurrence of diverticulitis. However, we know from experience that some patients get diverticulitis after ingestion of sharp edged particles such as larger seeds, nuts, corn or popcorn. In general, constipation should be avoided by adhering to a high fiber diet sometimes supplemented with a commercial fiber product such as Metamucil.
Inflammatory Bowel Diseases
Ulcerative colitis and Crohn’s disease are inflammatory bowel diseases of unknown cause. Both are considered autoimmune diseases. Like for any autoimmune disease, there is a genetic predisposition (Whites and Ashkenazi Jews) and an environmental factor; the environmental factor is unknown but it may be an infectious agent (i.e., a virus or bacterium), a chemical or a nutrient. Both diseases occur primarily at younger age although any age group can be affected. Ulcerative colitis presents with diarrhea, rectal bleeding and urgency and is present only in the colon. Crohn’s disease presents with abdominal pain, bloating, diarrhea, rectal bleeding and anal fistulae and may occur in the colon, the small intestine or in both. The principles of treatment are almost identical but they vary according to the location of the disease. The spectrum of medical treatment is quite broad: 1. Oral and rectal anti inflammatory agents such as prednisone and mesalamine; 2. So-called immune modulators such as azathioprine and methotrexate; 3. Biologic agents such as the anti-TNF alpha monoclonal antibodies. Some patients will require surgery such as simple removal of a short segment of bowel (for Cohn’s disease). Other patients may require removal of the entire colon if ulcerative colitis symptoms cannot be controlled with medications or if cancer develops in the diseased colon. In adults, there are no diets that positively or negatively affect the disease process itself. However, patients with a narrowed segment of small bowel may not tolerate large amounts of roughages and patients with continued diarrhea should not eat foods such as hot salsa that may aggrevate the diarrheal problem. Interestingly, cigarette smoking has an adverse effect on Crohn’s disease but a beneficial effect on ulcerative colitis; of course, the latter fact should not be used to encourage smoking or to discourage smoking cessation.
Irritable bowel Syndrome (IBS)
This is one of the most common conditions a gastroenterologist may encounter on a daily basis. It is a functional bowel problem primarily of the colon where structural, anatomic abnormalities are absent; i.e., no tumors, no ulcers, no rectal bleeding, no real weight loss, no fever, no laboratory or imaging abnormalities. The functions that may be abnormal are the bowel movements: too fast = diarrhea, too slow = constipation, simultaneous contractions or cramps = pain. In the U.S., IBS primarily affects younger females while in other cultures such as India, IBS primarily affects males. Some symptoms may be similar to those of lactose intolerance, Celiac disease or ovarian cancer. In younger patients, the diagnosis can frequently be made without much testing by taking a careful history for the Manning criteria: 1. Abdominal pain aggravated by food intake; 2. Discomfort relieved by bowel movements; 3. Sense of incomplete bowel evacuation; 4. More bowel movements with onset of pain; 5. Looser stool with onset of pain; 6. Smaller, thinner stools often broken up in pieces; 7. Symptoms aggravated by stress. In older patients, more serious diseases may need to be excluded first by laboratory tests, endoscopy, colonoscopy or x-ray studies. Stress, anxiety and depression are not necessarily the cause for IBS (the cause is unknown), but they certainly may exacerbate or aggravate the symptoms. Also, large, fatty meals and caffeine may cause symptoms of abdominal pain and diarrhea. The treatment should be as natural as possible as IBS can be a long term problem and there is no magic bullet for this condition – it is not really a disease. Enough sleep and a balanced life style are important. Stress reduction whenever possible should be encouraged. Eliminating foods that may worsen the symptoms and smaller meal sizes should be tried. Reassurance that this is a condition that does not lead to any serious illness is important as well. Exercise and ‘one dose of fun per day’ and taking a vacation can not be over emphasized. For specific symptoms ‘medical band aids’ can be offered: anti diarrheal agents for diarrhea, a high fiber diet and extra fiber or a laxative for constipation, and anti spasmodic agents for abdominal cramping. In some patients, anxiety and depression may need to be treated first. A good and close relationship with a gastroenterologist, however, should be one of the pillars of the treatment plan.
Diarrhea is bowel movements that are too loose or too frequent and this may be different from patient to patient. If associated with rectal bleeding or fever or significant malaise, an infectious cause or inflammatory bowel disease need to be considered first. Rarely do polyps and colon cancer cause diarrhea. Most forms of diarrhea, however, are functional in nature and relate to IBS. Lactose intolerance and Celiac disease need to be ruled out. A quite common cause for diarrhea in older people is the entity called microscopic colitis. This is a fairly benign condition of unknown cause characterized by inflammatory cells in the colon lining. As the name implies, the diagnosis can only be made underneath a microscope and therefore a colon biopsy is needed obtained either by colonoscopy or by sigmoidoscopy. Fatty, foul smelling and floating stools suggest either mal absorption due to small bowel disease or mal digestion due to pancreatic disease and enzyme deficiency. Unless a specific cause can be identified, treatment consists of anti diarrheal medications (Immodium AD and Lomotil), changes in diet or muscle relaxing agents for the bowel. Not to forget, some medications can cause diarrhea including supplements that contain magnesium.
Constipation is defined as fewer than 3 bowel movements per week or very hard stools and difficulty in elimination. Rarely, a mechanical blockage or a sharp angle at the colon outlet may be the cause. Such conditions require surgical treatment. In most patients there is no cause to be identified. Identifiable causes may be a lack of fiber in the diet, medications such as opiate narcotics or other medical conditions such as Parkinson’s disease. Treatment consists of a high fiber diet supplemented with a commercial fiber product and adequate hydration. The latter is frequently difficult in the elderly. If this does not result in improvement, newer laxatives that are not habit forming and that do not damage the colon lining can be obtained over the counter (Miralax) or by prescription (Kristallose, Amitiza). Again, stress reduction, yoga, exercise and a healthy diet should be the main stay of the treatment plan.
Bloating and Gas or Flatulence
Bloating is frequently a symptom that is difficult to treat unless one finds a specific cause such as bacterial overgrowth due to small bowel disease, lactose intolerance or Celiac disease. Gas producing legumes such as beans, broccoli, cauliflower and cabbage may need to be avoided or reduced. Artificial sweeteners can cause gas and bloating. Some patients may benefit from Probiotics or a course with a non-absorbable antibiotic. Sometimes bloat symptoms are due to a gas bubble in the stomach. This may be caused by excessive use of carbonated beverages or by inadvertent air swallowing. Causes for excessive air swallowing (followed by subsequent frequent belching) are poor eating habits (eating fast, not chewing carefully and talking with food in the mouth) as well as stress and anxiety. Appropriate behavioral modifications need to be instituted.
Hemorrhoids are blood vessels (veins) on the inside of the anal canal that have become enlarged. They can bleed, burn, itch or when acute they can be painful. Risk factors are constipation, overweight, pregnancy and vaginal delivery. However, they are very common in many people. Hemorrhoids should be evaluated from the outside (external) and from the inside (internal) by inspection and an anoscopy or flexible sigmoidoscopy, repectively. Most hemorrhoids, even mildly bleeding ones, do not need any treatment unless they cause symptoms such as pain, burning or itching. Small hemorrhoids can be treated with ointments and suppositories while medium sized hemorrhoids may require an office procedure such as the application of a rubber band. Large hemorrhoids or acutely thrombosed (clotted) hemorrhoids may need surgical excision.
The pancreas is the major digestive organ in the human body producing most of the digestive enzymes and insulin to control the blood sugar. Pancreatic disorders are much less common. Abdominal pain originating from the pancreas usually is experienced in the upper abdomen and frequently radiates to the back.
Pancreatitis means inflammation of the pancreas and it can be mild or life threatening. The two most common causes of pancreatitis are gallstones (in women) and alcohol (in men). The former usually requires removal of the gallbladder and rarely becomes chronic while the latter necessitates abstinence and it can become a chronic problem. Unfortunately, once a patient has chronic pancreatitis even complete alcohol abstinence is not a guarantee for cure. There are other rare forms of pancreatitis that can be caused by medications or they are caused by an autoimmune process or they are hereditary.
Pancreatic cancer is the most serious cancer in the human body as it can rarely be completely cured. The cause is unknown but cigarette smoking, diabetes and chronic pancreatitis are risk factors. A patient with pancreatic cancer may present in one of two ways. Painless jaundice (yellow skin and dark urine) suggests the cancer is in the head of the pancreas blocking the flow of bile from the liver. If the tumor is small and has not spread surgery (Whipple procedure) can be curative. Abdominal pain radiating into the back suggests the cancer is in the body of the pancreas and has already involved the nerves. While complete removal of the pancreas is sometimes considered, most patients will undergo a mild form of chemo therapy.
With the wide spread use of imaging studies (CT scans and ultrasound) cysts (empty or fluid filled holes in the pancreas) frequently are incidental findings and usually benign. On occasion they can grow or they represent early stages of a cystic tumor. They are usually followed for a few years by CT scan, MRI or ultrasound and if stable they are left alone. Larger cysts are sometimes removed. Cysts usually do not cause pain.
The gallbladder is a pear shaped organ that sidetracks the bile coming from the liver. The gallbladder concentrates the bile and releases it after food intake; primarily after fatty foods. One can live without a gallbladder as is testified by the annual removal of about 600,000 gallbladders in the U.S. alone.
The four “Fs”, female, fat, fertile and fair, are the primary risk factors for gallstones; and so are pregnancies, rapid weight loss or being Native American. Patients with gallstones usually present with pain in the upper abdomen that may radiate into the right back and frequently occurs 2-3 hours after a meal or in the middle of the night. Severe gallstone disease may also be associated with fever and jaundice. Treatment consists of laparoscopic removal of the gallbladder.
The functions of the liver are multiple: Synthesis of proteins and clotting factors, metabolism of all nutrients, synthesis of bile and cholesterol, storage of sugar in the form of glycogen, detoxification and export of toxins via bile into the intestine.
Fatty Liver Diseases
Alcoholic and non-alcoholic fatty liver diseases are the most common causes of liver disease in western societies. Occasionally, right upper abdominal ‘liver pain’ can be found but usually the fatty liver is diagnosed at a time of a routine blood test or during an ultrasound examination. Too much alcohol (more than 3-5 drinks, beers or glasses of wine per day) may lead to liver disease. There seems to be a genetic predisposition who does and who does not get liver disease such as hepatitis and cirrhosis. There are some people who can drink quite a lot and never get liver disease while others, especially smaller persons and women, can get liver disease at more moderate alcohol consumption. There is a health benefit to some alcohol intake but the so-called therapeutic window is very narrow: 1-2 drinks or glasses of wine per day for men but only one such beverage per day for women. Once alcoholic liver disease has turned into alcoholic hepatitis (inflammation) and cirrhosis (scarring), the liver may never return to normal function even after alcohol cessation. Nevertheless, with alcohol cessation some liver function can improve; this and a nutritious diet are the only treatment for alcoholic liver disease. Non-alcoholic fatty liver disease (NAFLD) is caused by overweight, diabetes, high blood lipids and the so-called metabolic syndrome. People with the metabolic syndrome have a relative resistance to the hormone insulin and develop fatty deposits in the liver. On occasion, a thin person with the metabolic syndrome may get NAFLD. Treatment of NAFLD is diet, exercise and weight reduction. Very obese patients with NAFLD may benefit from gastric bypass surgery or a laparoscopic band procedure (‘Lap-Band’).
Viral Hepatitis A, B and C
These three most common causes of viral hepatitis are quite distinct. Hepatitis A is food and water borne and occurs only in the acute form: a patient may have fever, body aches, yellow skin and dark urine. This condition improves over a period of a few weeks and never becomes chronic. In children, the infection frequently goes unnoticed while in adulthood a rare patient (less than 0.01% or 1 in 10,000) can die from it or need liver transplantation. A vaccine is available and especially travelers into ‘third world’ countries and all patients with chronic liver disease should be vaccinated. Hepatitis B is transmitted by ‘dirty needles’, tainted blood products, sexually (especially in HIV-infected patients) and at birth to the baby. About 80% of patients with Hepatitis B will clear the virus and develop immunity. Twenty percent of patients will develop chronic liver disease and some will develop cirrhosis and/or liver cancer and may die from the disease. Asians born in Asia or born to the first generation of Asian mothers harbor a high risk for chronic Hepatitis B; it is estimated that 15% of Asians in San Diego county may carry the virus and these patients need to be tested. Treatment will be offered to certain patients once they reached a certain phase of this chronic disease. Expertise for treating patients with Hepatitis B is definitely required. A vaccine is available and is now part of childhood and pre college vaccination. Hepatitis C is primarily transmitted through blood products and ‘dirty needles’ and rarely through sexual intercourse but not through household contacts. Rarely, babies born to mothers with Hepatitis C, especially those with HIV co-infection, may develop chronic Hepatitis C. Unlike Hepatitis B, after an acute bout of Hepatitis C, 80-90 percent of patients will develop the chronic stage. Most patients (about 80-90) will not develop complications such as cirrhosis and liver cancer and die from other causes, especially those who were infected early in life, females and those with a healthy life style. However, overweight, alcohol and other illicit drugs can adversely affect the outcome of chronic Hepatitis C. There is no vaccine available. Complex treatments associated with significant side effects can be offered to selected patients who are likely to advance to more severe disease. Often, a liver biopsy is needed to make a decision for or against treatment. Only experts should be engaged in treating patients with Hepatitis C. As with chronic viral Hepatitis B, chronic Hepatitis C does not cause any symptoms. Therefore, most patients will be diagnosed at the time of an abnormal liver test during a routine laboratory evaluation. Both chronic hepatitis B and C can go unnoticed for decades until for whatever reason a liver blood test is obtained; i.e., before major surgery, before donating blood, as part of a routine physical or insurance evaluation. Today, chronic viral Hepatitis C is the most common cause for liver transplantation in western countries and an increasingly common cause for liver cancer.