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Dyspepsia

Dyspepsia, also known as indigestion, is a common condition. Here’s what you need to know.

Causes and Risk Factors of Dyspepsia

Dyspepsia can be caused by a number of things. Acid reflux and stomach ulcers can both irritate the lining of your stomach, leading to burning pain in your upper chest that is associated with indigestion. In the case of acid reflux, stomach acid backs up into your esophagus and causes indigestion. Some over the counter pain relievers like ibuprofen and aspirin can also cause similar issues.

Functional dyspepsia, which is recurring indigestion that doctors can’t find a clear cause for, has a number of risk factors. Women, people who smoke, people with anxiety or depression, and people with h. pylori infection tend to have a higher risk.

Symptoms

In general, there are a few symptoms that define this condition. These include a burning pain in the upper abdomen, bloating, feeling full quickly while eating, nausea, and vomiting. In many cases, these symptoms can occur after eating. However, they may also occur at other times. Most of the time symptoms are intermittent, tending to come and go.

There are a few serious symptoms to look out for. If you experience shortness of breath, bloody vomit, unexplained weight loss, or tarry stools, seek medical attention as soon as you can. These can be signs of more serious conditions.

Diagnosing Dyspepsia

Since indigestion can be caused by so many things, your doctor diagnosis it by first talking through your symptoms and medical history. They may perform diagnostic testing to figure out the exact cause as well. These tests may include blood tests, breath testing, or stool tests if they suspect a bacterial infection could be present. They can also perform an upper endoscopy to visualize your upper digestive tract and identify the cause of your indigestion. During this procedure, they may also take a biopsy to get a closer look at any potential issues.

Treatment and Prevention

There are several lifestyle changes and medications that can help with dyspepsia. Your doctor may recommend quitting smoking, eating smaller meals slowly throughout the day, avoiding caffeine and alcohol, and managing stress and anxiety. You may also try to avoid foods that tend to cause your symptoms. If stress, anxiety, or depression seems to be a cause of your symptoms, you may consider working with a therapist or another mental health professional to develop skills that improve your mental health. All of these behaviors can help improve your symptoms. They are also important preventative steps you can take to prevent dyspepsia from recurring long-term.

Your doctor may also recommend over the counter or prescription medication to help. The specific medication they recommend will depend on your symptoms. This can help with everything from acid reflux, bloating, nausea, and gas to depression and anxiety.

Our experienced team at GHP has years of experience treating patients with conditions including dyspepsia. We can help establish the best plan of care for your situation. Contact any of our office locations to learn about the options we offer and schedule an appointment today.

Colonic Ischemia: What You Need to Know

Colonic ischemia is a condition where blood flow in the colon is reduced. It can cause damage to the affected area of the colon. Here’s everything you need to know about this condition. 

Causes and Risk Factors

Colonic ischemia, as noted above, causes diminished blood flow in the colon. This can be caused by a number of things. Your risk increases if you have fatty buildups on an artery wall (atherosclerosis), extremely low blood pressure (often due to trauma, shock, surgery, or heart failure), or use cocaine or methamphetamine. Some disorders like lupus and sickle cell anemia can also be a cause of this condition. 

Colonic ischemia is more common in adults over 60 and in women. If you have had abdominal surgery, scar tissue from the procedure can also reduce blood flow in some cases. Additionally, people with IBS are more likely to develop colonic ischemia. 

Symptoms of Colonic Ischemia

Some of the most typical symptoms involved with this condition include abdominal pain or tenderness. This can be severe in some cases, and may also build gradually or occur suddenly. You can experience symptoms on the right or left side of your abdomen. Other symptoms also include nausea, vomiting, diarrhea, blood in your stool, and a feeling of urgency to defecate. 

Diagnosis

This condition is difficult to diagnose because its symptoms are also associated with a number of other disorders. Doctors diagnose colonic ischemia with a combination of medical history, a physical exam, and some testing procedures. They often start by charting your symptoms and identifying any potential risk factors. Your doctor may also check your abdominal area to identify the location of any pain. They may choose to order a CT scan to help visualize your colon and identify the cause of the symptoms. They may also perform a sigmoidoscopy or colonoscopy to see detailed images of your colon and potentially take a tissue biopsy. All of these tests are ways they can get at the underlying cause of your symptoms.  

Treating Colonic Ischemia

Doctors treat this condition by helping proper blood flow return to the colon. In milder cases, this may just involve an IV to help you rehydrate. Your doctor may also prescribe antibiotics to prevent infections, and may suggest you avoid medications that constrict your blood vessels. If there is a specific underlying disorder that has caused colonic ischemia (like an irregular heartbeat), your treatment will involve treating that disorder. 

In some cases, you may also need surgery to heal. This is for severe cases where your colon has undergone significant damage. Depending on your situation, doctors may repair any holes in your colon, remove dead tissue, or remove a portion of your colon. 

Our experienced team at GHP has years of experience treating patients with conditions including colonic ischemia. We can help establish the best plan of care for your situation. Contact any of our office locations to learn about the options we offer and schedule an appointment today.

Anal Fissures: An Overview

An anal fissure is a tear or rip in the lining of the anal canal. Here’s what you need to know about anal fissures.

Causes and Risk Factors

Anal fissures are most often caused by trauma in the anal canal. They can be caused by straining during a bowel movement, chronic diarrhea, anal intercourse, childbirth, and anything else that may cause trauma in the canal. Anal fissures are most common in infants, but can occur at any age. Other risk factors include childbirth, constipation, and crohn’s disease.

Symptoms of Anal Fissures

This condition is characterized by a few symptoms. The most common symptoms include pain and bleeding with bowel movements. You may experience pain during and after a bowel movement, even hours later, with an anal fissure. Many people with this condition may notice blood on the outer surface of stool or blood on toilet paper after a bowel movement. Other symptoms can include a visible crack around the anus, burning and itching, constipation, and foul-smelling discharge around the fissure.

Diagnosis

Doctors diagnose anal fissures with a physical examination and asking about your medical history. They examine your anal region and look for a visible tear that indicates a fissure. They may be able to determine the nature of the fissure during the examination as well. An acute fissure will likely look like a fresh and more shallow tear, whereas a chronic case may have a deeper tear. Chronic anal fissures last longer than eight weeks.

Additionally, where your fissure is located will provide important clues for your doctor. Fissures that are on a side of your anal opening are more likely to be a result of an underlying condition like Crohn’s disease. If your doctor finds this is the case for you, they may order additional testing. They can perform a number of endoscopic procedures to get a closer look at the underlying issue. These procedures could include a colonoscopy, flexible sigmoidoscopy, or anoscopy, depending on other factors in your unique situation.

Treating Anal Fissures

Doctors treat anal fissures primarily by helping to make your stools softer, decreasing the pressure in the anal canal. They may recommend soaking in a warm bath (sitz bath) for 10-20 minutes per day, which can help relax your sphincter. They may also prescribe stool softeners or recommend you drink more water and eat more fiber. All of these steps can help to soften your stool and promote healing. In most cases, this can help heal an anal fissure in a few weeks.

In some cases, anal fissures can persist after these treatments. Your doctor may prescribe a topical muscle relaxant, nitroglycerin (to relax the sphincter), or other medicine to help with pain. In some cases, you may need surgery to fix an anal fissure. This is usually the case only if your symptoms are severe and chronic, and have not responded to other treatment. Surgery involves cutting a small part of the sphincter muscle to reduce spasms and promote healing. It’s very effective, but does carry a small risk of causing incontinence.

Our experienced team at GHP has years of experience treating patients with conditions including anal fissures. We can help establish the best plan of care for your situation. Contact any of our office locations to learn about the options we offer and schedule an appointment today.

A Review of Cyclic Vomiting Syndrome

Cyclic vomiting syndrome (CVS) is a condition characterized by recurring periods of severe nausea and vomiting. Read along for a review of the condition. 

Causes and Risk Factors for Cyclic Vomiting Syndrome

Cyclic vomiting syndrome is an uncommon syndrome that can affect a variety of groups of people. In many cases, it begins when children are between the ages of 3 and 7. While it tends to be more common in children, it is actually becoming more common in adults. Doctors don’t know exactly what causes cyclical vomiting syndrome. It could be a result of genetic, hormonal, or other factors. An episode of vomiting can sometimes be triggered by external conditions as well. These can be things like menstruation, seasonal allergies, a cold, hot weather, physical exertion, and eating certain foods. There is also evidence that cyclical vomiting could be linked to migraines- most children with this syndrome have a family history of migraines. In fact, this syndrome may be a migraine variant. 

Symptoms

There are a number of symptoms associated with this syndrome. The condition creates recurring periods of severe nausea and vomiting. These episodes can last anywhere from a few hours to days. Between episodes, people with the condition do not typically experience symptoms, or experience milder symptoms. Episodes tend to be very similar for each individual as well. The episodes often start around the same time, last a similar period of time, and have the same symptoms. Your episodes may start with nausea and sweating at first. You may become so nauseated or experience such severe vomiting that you become incapacitated as well. Other symptoms can include dizziness, headaches, abdominal pain, diarrhea, gagging, sensitivity to light, and a lack of energy. Some children who have cyclical vomiting syndrome outgrow it as they age, but may develop migraines. 

Diagnosing Cyclic Vomiting Syndrome

Doctors diagnose CVS with a combination of an exam, talking through your medical history, and some testing. They will want to know details about your episodes like the symptoms involved and patterns in the episodes to gather information. Your doctors may also perform imaging testing like an endoscopy or a CT scan to visualize your gastrointestinal tract and identify any blockages or other conditions. They can also pursue motility testing to evaluate the movement of food through your body and find any possible digestive disorders. Overall, doctors will use a variety of methods to rule out other potential issues or disorders before diagnosing cyclical vomiting syndrome. 

Complications and Treatment

CVS can cause dehydration, since the body loses fluids due to vomiting. Additionally, the acid from vomit can cause tooth decay. This condition can also cause inflammation in the esophagus due to recurring damage.

Treating this condition involves a combination of managing symptoms and preventing episodes by identifying and avoiding triggers. Your doctor may prescribe anti-nausea medication, stomach acid suppressants, pain relief drugs, or migraine medication to manage symptoms. Additionally, they will work with you to figure out what tends to trigger vomiting episodes. You should avoid the things that tend to cause an episode, whether it’s a particular food, stressor, or environmental factor. Long-term, having a strong support system and a plan for good preventative measures is key to managing CVS.

Our experienced team at GHP has years of experience treating patients with conditions like cyclical vomiting. We can help establish the best plan of care for your situation. Contact any of our office locations to learn about the options we offer and schedule an appointment today.

 

Sphincter of Oddi Dysfunction

Sphincter of Oddi dysfunction is a condition in which the muscle between the bile duct and pancreatic duct does not open like it should. This results in digestive juice backup. Here’s an overview of the condition. 

Causes and Risk Factors

The sphincter of Oddi is a smooth muscle that surrounds the end of the common bile duct and the pancreatic duct. It opens and closes to allow bile and pancreatic juice to flow into the intestine for digestion. This muscle can develop the inability to properly function in some cases. The exact cause of the condition is unknown, but there are a few things that seem to increase risk. For one, people who have had a gallbladder removal seem to be at a higher risk of this condition. It is also more common in middle-aged women. 

Symptoms of Sphincter of Oddi Dysfunction

A key symptom of this condition is recurring pain attacks in the upper right abdomen. The pain tends to be steady, and may be aggravated by eating fatty foods. It may also worsen with the use of opiates. Given the condition’s association with gallbladder removal, doctors are often on the lookout for these sorts of recurring symptoms for patients who have recently undergone that procedure. If you have undergone a gallbladder removal and have recurring upper abdominal pain, it could be a sign of this condition or another issue. Contact your doctor if you are experiencing recurring pain following the procedure. 

Diagnosis

Doctors diagnose sphincter of Oddi dysfunction in a few different ways. As mentioned before, if you have recently had a gallbladder removal and have recurring upper abdominal pain, doctors may suspect this condition and investigate. There are several noninvasive testing options available. Doctors may order a blood test to measure enzyme levels in the liver and pancreas. They may also perform an ERCP to check the drainage times and functioning of your pancreas and bile ducts. Additionally, they can perform manometry during the ERCP to measure the sphincter’s function by evaluating pressure changes. Manometry is often considered one of the best ways to test for this condition. 

Complications and Treatment

Depending on the specifics of your condition, doctors may pursue different treatment options. In non-severe cases, doctors may first prescribe medication to control pain and prevent spasms. Another treatment option is a sphincterotomy. This is a surgical procedure in which doctors cut the muscle to provide relief and ensure there are no stones in your gallbladder or bile ducts. This is often successful in treating symptoms from the condition. Up to 70% of patients experience long-term pain relief. However, it is a difficult procedure with a significant risk of complications. As many as 5-15% of patients who get this surgery experience complications like mild pancreatitis, and might need to stay in the hospital to recover. It can also cause scarring around the incision. As such, doctors only recommend a sphincterotomy if other treatment options have not been successful. 

Our experienced team at GHP has years of experience treating patients with conditions like sphincter of Oddi dysfunction. We can help establish the best plan of care for your situation. Contact any of our office locations to learn about the options we offer and schedule an appointment today.

Fecal Transplant: What You Need to Know

A fecal transplant is a procedure in which stool from a healthy donor is transferred to your GI tract. Here’s an overview of the procedure and what you can expect. 

What is a Fecal Transplant? 

Fecal transplants are used to help treat a bacterial infection condition called C. difficile colitis. This condition involves inflammation in the colon as a result of the C. difficile bacteria being present. It can cause diarrhea, fever, and pain, and can be severe if untreated. In some cases, this condition is a complication of antibiotic treatment- antibiotics may have killed off too many good bacteria in your GI system. It can also be caused by ingestion of the C. difficile bacteria itself. In any case, a fecal transplant can help. Doctors often first attempt to treat C. difficile colitis with antibiotics, but if the condition recurs they may shift to a fecal transplant. 

Before the Procedure

Leading up to a transplant, you will have to meet with your doctor to confirm that it’s the best option. You will need a stool donor as well. In some cases, you may be tasked with finding your own potential donor. There are also organizations that gather qualified donor samples for use. 

Doctors evaluate stool donors through a rigorous screening process. Many factors can disqualify potential donors, including recent antibiotic exposure, a recent tattoo or piercing, a history of drug use, a chronic GI disorder, or a history of high-risk sexual behavior. When a donor is a potential match, doctors will also screen them for infectious pathogens. They perform blood and stool tests to look for things like Hepatitis, HIV, parasites, and multi-drug-resistant organisms.

In the days leading up to the actual procedure, you’ll need to follow a few guidelines as well. You should not take any antibiotics in the two days before the transplant. You will have a liquid diet and will need to take a laxative or enema the night before the procedure as well. Follow your doctor’s specific instructions for the best outcomes. 

During the Fecal Transplant

You will need someone to accompany you on the day of the procedure, as you will be undergoing anaesthetic. Doctors use a colonoscopy as the method to transplant the stool. As such, normal colonoscopy procedures are followed (you can read more here). You’ll be under anaesthesia as doctors use an endoscope to enter your GI tract and perform the transplant. The donor stool is deposited in your colon during this process. This healthy donor stool is then able to help replenish the balance of bacteria in your gut. 

After the Procedure

Since this procedure involves a colonoscopy, you’ll have to recover from sedation immediately after the transplant. It can take around an hour to recover. Once recovered, your doctor will discuss how the procedure went with you. Sedative effects can linger for about a day, so you should avoid making important decisions or operating machinery for 24 hours afterwards. Make sure the person who brought you to the doctor’s office also takes you home, as you should not drive. 

This procedure is highly effective at preventing a recurrence of C. difficile. A number of studies have shown around a 90% rate of success. This is a largely effective treatment option to solve issues with C. difficile colitis long-term. 

Our experienced team at GHP has years of experience treating patients with conditions like C. difficile colitis. We can help establish the best plan of care for your situation. Contact any of our office locations to learn about the options we offer and schedule an appointment today.

 

What is a Hiatal Hernia?

A hiatal hernia occurs when part of your upper stomach bulges out through an opening in your diaphragm. Here’s what you need to know about this condition. 

Causes and Risk Factors

Most often, a hiatal hernia is caused by an increase in pressure in the abdominal cavity. This cavity is in the middle of your body and holds many vital organs like your kidneys, liver, and small intestine. Pressure can come from a few things, including physical strain, coughing, vomiting, or strain during a bowel movement. In any case, the pressure causes the stomach to push through the diaphragm in your upper abdomen, causing a hiatal hernia.

People at risk for this include overweight people, smokers, and people over 50. Additionally, some pregnant women develop this condition. However, anyone at any age can develop a hiatal hernia.

Hiatal Hernia Symptoms

It’s fairly common for people with a hiatal hernia to experience no symptoms at all. In many cases, you may not know you have one until your doctor finds one during an exam or procedure for another purpose. This is often the case for smaller hernias that don’t cause issues in your body. However, larger hernias may impede certain functions and are more likely to lead to symptoms. For those who do experience symptoms, some of the most common are GERD-like symptoms including heartburn, regurgitation, acid reflux, and pain in the esophagus. This is because the hernia can allow food and acid to back up into your esophagus. Some other symptoms include chest pain, shortness of breath, feeling full soon after eating, vomiting blood, or passing black stools. 

Diagnosing a Hiatal Hernia

Doctors diagnose hiatal hernias in a few different ways. They may perform an upper endoscopy to visualize your upper digestive tract and identify any signs of the hernia. Another test they use is called a barium swallow test. Here, you drink a special liquid that coats your digestive tract, which doctors then visualize by taking an x-ray. They can also use esophageal manometry to measure the strength and coordination of your esophagus. 

Complications and Treatment

In the majority of cases, hiatal hernias don’t cause any issues and thus don’t require treatment. If you have GERD-like symptoms, doctors will likely use treatment methods used to manage GERD itself. They may recommend lifestyle changes like decreased portion sizes, losing weight, limiting acidic foods, quitting smoking, and eating well before you lie down to sleep at night. They may also recommend over the counter antacids to neutralize stomach acid, or medications that reduce acid production. 

In some cases, if these treatment methods do not improve your situation or if a hernia is severely constricting your esophagus, you may need surgery. In this procedure, doctors pull your stomach down into your abdomen and improve the valve at the bottom of your esophagus. This provides a long-term solution which prevents food and acid from backing up into your esophagus.  

Our experienced team at GHP has years of experience treating patients with conditions like hiatal hernias. We can help establish the best plan of care for your situation. Contact any of our office locations to learn about the options we offer and schedule an appointment today.

Wilson Disease

Wilson disease is a rare inherited condition that causes copper to build up in your body. It can cause a range of liver, neurological, and psychological issues over time. Here’s what you need to know about this disease.

Causes and Risk Factors

This is an inherited disease, meaning it is passed down in families genetically. It is passed down as an autosomal recessive trait. To develop the disease, you must have a copy of the mutated gene from both parents. If only one parent has the defective gene, a child will not have Wilson disease. You are at a higher risk of Wilson disease if you have a parent or sibling with the condition. If you know you are a carrier of the defective gene, you should be aware that you could pass it to your children as well.

Symptoms of Wilson Disease

People with Wilson disease often develop symptoms between the ages of 5 and 35. However, it is possible to experience symptoms within the age range of 2 to 72. Symptoms occur due to copper buildup in the body, which is what this disease causes. When copper builds up in the brain, liver, and eyes, it can lead to various symptoms. Liver disease is most often the first feature of Wilson disease in children and teenagers. Symptoms associated with this include jaundice, lack of appetite, and abdominal swelling. People diagnosed later in adulthood are more likely to have developed neurological and psychological symptoms. The symptoms associated here include problems with speech or physical coordination, uncontrolled movements, mood swings, depression, and anxiety. Many people with Wilson disease, at all ages, develop golden-brown pigmentation around the corneas as well.

Diagnosis

Diagnosing Wilson disease is often challenging since its symptoms are also caused by other liver diseases. Some of the behavioral changes that develop in people with the condition are hard to link to Wilson disease as well. One way doctors can diagnose the disease is during an eye exam using a microscope with a light source. They look for golden-brown pigmentation around your corneas (called Kayser-Fleischer rings) and a specific type of cataract associated with the disease. In fact, in some cases doctors find Wilson disease during routine eye exams.

Doctors can also use blood tests to measure copper levels in your blood, and can use urine samples to measure copper levels in your urine. They can also pursue a liver biopsy to get a sample of your liver to analyze in the lab. If you have parents or siblings with Wilson disease, doctors may suggest genetic testing to screen for the mutated gene that causes the disease.

Complications and Treatment

Over time, Wilson disease can be very serious or even fatal if left untreated. People with the condition can develop cirrhosis (liver scarring), liver failure, kidney problems, neurological problems, psychological issues, and blood problems. Ultimately, the copper buildup that results from the disease can cause severe or fatal damage to the brain, liver, and other organs.

Fortunately, Wilson disease is treatable. Doctors first prescribe medications that reduce copper levels in your body and prevent future buildup. It is likely that you will have to take a course of medications for the rest of your life to help manage copper levels in your body. Often, symptoms begin to improve once you start treatment. Your doctor will also instruct you to avoid certain copper-rich foods like shellfish, and may need to avoid alcohol if you have suffered liver damage from the condition. In more severe cases, you may need a liver transplant if you have suffered significant liver damage.

Our experienced team at GHP has years of experience treating patients with conditions including Wilson disease. We can help establish the best plan of care for your situation. Contact any of our office locations to learn about the options we offer and schedule an appointment today.

Welcome Dr. Luckett!

Gastroenterology Health Partners is pleased to announce that Robert Tyler Luckett, MD will be joining our practice. Dr. Luckett is currently finishing a gastrointestinal and hepatology fellowship at the University of Louisville and will join GHP in June.

GHP continues to lead the Kentuckiana region with its structure as a large, independent, GI-subspecialty private practice. Dr. Luckett’s addition to the team will contribute to the continued improvement of quality, cost, and access that sets GHP apart.

Read on to learn more about Dr. Luckett’s background.

A Look at Primary Sclerosing Cholangitis

Primary sclerosing cholangitis (PSC) is a chronic disease that damages your bile ducts. This is an uncommon disease, and is most likely to occur in people who have inflammatory bowel disease (IBD). Here’s what you need to know about PSC.

Causes and Risk Factors

There is no clear cause of PSC in general. It’s possible that it can occur in people who have a genetic predisposition to the disease when their immune system responds to a toxin or infection. We do know that PSC tends to occur mostly in people with IBD, which includes ulcerative colitis and Crohn’s disease. PSC tends to occur more often in men and people with Northern European heritage, and is most often diagnosed between 30 and 40 (though it can occur at any age).

Symptoms of Primary Sclerosing Cholangitis

In people with PSC, their bile ducts become blocked by inflammation and scarring over time. PSC is a very slowly progressing disease- many people do not have any symptoms until several years into having the disease. Symptoms of PSC early on include itching, fatigue, and abdominal pain. As it progresses, symptoms can include weight loss, fever, an enlarged liver or spleen, and night sweats. Depending on the person, these symptoms can appear more quickly or slowly.

Diagnosing Primary Sclerosing Cholangitis

In many cases, doctors diagnose PSC incidentally while doing blood testing or an X-ray for an unrelated condition. This is due to the often slow progression of PSC symptoms (as mentioned before)- many people do not have any PSC symptoms that would lead them to go to their doctor. However, there are a few diagnostic tests doctors use to identify this disease. They can perform a blood test to check your liver function, which can support a PSC diagnosis. Additionally, they may take an MRI of your bile ducts to visualize them and identify any signs of PSC. Finally, if other diagnostic testing is inconclusive, they may perform a liver biopsy by removing some liver tissue with a needle and testing it in a lab.

Complications and Treatment

People with PSC and IBD are at an increased risk of colorectal cancer. They also have an increased risk of bile duct cancer and cirrhosis. As such, they should consult closely with a medical provider to monitor their condition over time.

Treating PSC involves first managing the symptoms and mitigating complications from the disease. Doctors can treat itching with specific medications they can prescribe. Sometimes, backed up bile (due to narrowed ducts) can cause recurring bacterial infections; in this case, doctors may prescribe antibiotics. Bile ducts can also become blocked due to scarring and inflammation in people with PSC. Doctors can either place a stent in the bile duct or dilate the bile duct with an endoscopic procedure. However, blockage can sometimes be a sign of cancer or a precursor to liver failure. In serious cases of PSC, you may need to pursue a liver transplant. This is the only way to fully treat the disease.

There are some lifestyle changes you can make to help manage PSC as well. Avoid alcohol, maintain a healthy weight, get vaccinated against Hepatitis A and B, and follow your doctor’s prescriptions carefully. A combination of lifestyle changes and treatments targeting both symptoms and potential complications is often the best course of action for people with PSC. You should consult with your doctor to establish the best plan of care.

Our experienced team at GHP has years of experience treating patients with liver conditions. We can help establish the best plan of care for your situation. Contact any of our office locations to learn about the options we offer and schedule an appointment today.