Crohn’s Disease

Recently, I posted about a disease called Ulcerative colitis, and briefly mentioned the related disease Crohn’s disease. Though related, the two are separate processes and deserve their own separate discussions.

Though these two diseases are part of the same group of diseases (Inflammatory Bowel Disease), each has its own symptoms, presentations, and complications. They are, however, treated similarly and by the same doctors.

Crohn’s disease is in part a result of inflammation gone haywire, and of “autoimmune response,” in which the body confuses itself for an intruder, such as a virus or infection. The body fails to recognize some of its own cells and then tries to destroy these cells, thinking that since they are not familiar, they must be invasive. In Crohn’s this “intruder” is the gut, and unlike ulcerative colitis which only involves the colon, Crohn’s can involve any part of the gut, from the mouth to the rectum. The inflammation can affect more than just the gut since this is a systemic process (involving the whole body). Thus, those affected may develop issues with the joints, eyes, and even the skin. Crohn’s can be a scary disease, especially since it never fully goes away. It can be controlled in many people, but therapies are not perfect. Without therapy, people can develop strictures (narrowing of the gut that may cause blockages), fistulas (paths between organs that do not usually go together), bleeding, pain, and infections, so avoiding treatment is not really a good option.

So, who gets Crohn’s disease, and how would you know to suspect it? The disease tends to affect both men and women, usually starting in the teenage or young adult years (around 15-35), though it can develop at any time. Stress can aggravate the disease, but it is still not known precisely why it develops in the first place. It does tend to run in families, and is more common in people of Eastern European descent, but it affects people from all over the world as well. Additionally, it is found much more commonly in developed countries.

Some symptoms to be aware of may include diarrhea that does not improve, blood in the stool, feeling an urgent need to move your bowels, feeling like you still need to go once done, abdominal pain/cramping, or even persistent constipation, especially with small thin caliber stools (many of my patients describe them being like thin snakes). Many of these patients also lose weight, and may have poor appetites as well.

You cannot prevent Crohn’s disease, and if you are concerned you may have it, you should certainly tell a doctor, as it will not improve on its own. You can find more helpful information through the Crohn’s and Colitis Foundation, linked below.


Learn about Ulcerative Colitis

Do you find yourself running to the bathroom frequently, feeling the need to have a bowel movement day and night, embarrassed to never know when you will need to go? Do you cringe and feel rather panicked, as you think there could be blood? Does your stomach wrench like its being stabbed repeatedly, with little relief as you sit and sit on the toilet, afraid to get up for fear you will just be right back? You may be suffering from an Inflammatory Bowel disease, like Ulcerative colitis, and you are not alone.

Ulcerative colitis can be a mean, cruel disease. While the verdict is still out on how we get it (genetics in part, but environmental factors play a large role), it is a treatable disease. Ulcerative colitis, or UC, is mainly an intestinal disease driven by inflammation running amuck, leading to ulcers and bleeding on the sensitive gut lining, limiting its ability to absorb, and causing pain, bleeding, and diarrhea. The pain can be excruciating, and the uncontrollable bowel movements embarrassing. You might find yourself staking out bathrooms anywhere you go, just in case. I know, because that has been me on and off since I was a teenager. The embarrassment should not mean fear to get it checked out though, as this is a serious disease, and if severe, can lead to life threatening blockages and blood loss. Beyond the gut, the disease causes inflammation as well. Your eyes, liver, joints, and skin can develop issues too!

It is not a cancer, but if not treated it does raise your risk for cancers, so it is better to know and understand your disease. In some cases, the disease can be controlled with a simple daily medication, either pills or enemas, while others may need much stronger medications to block the immune system from attacking the gut. These medications do make it much easier to get infections, but this is still less risky than remaining ill from UC. While it may sound extreme, in some cases the colon can be removed entirely, eliminating the need for medications, and eliminating the additional risks of the disease. This can be done if medications are not helping, or if you are developing signs of “dysplasia” or changes in the gut wall that are higher risk for cancers.

It is highly likely that even if you do not have UC, you probably know someone who does, or something similar. Understanding the basic issues someone might be experiencing can help you and them to be more comfortable if a problem ever arises (like a bathroom emergency when least expected!)

“What should I expect if I see a doctor?”

-Your doctor will ask you about your bowel movements, you diet, and other symptoms. They will probably do a quick exam of your bottom, usually including a rectal exam if you are comfortable allowing this (it helps to rule out other things that can be bleeding, like hemorrhoids). In some cases, you may be in too much pain, and that is ok.

-You will typically be scheduled for a colonoscopy. This is a procedure done under sedation or anesthesia, where a camera on a small tube is inserted into your bottom to look at the colon and take tissue samples to figure out what is wrong. The hardest part is preparing for the examination (you need to clean the food out of your bowels by drinking a special laxative mix, but only under the guidance of your health care provider). Most people do not even realize the exam is started by the time it is over.

Have more questions, or not ready to talk yet? Find out more at these reliable sites:,,

Learn about Dysphagia

Imagine for a minute the following:

You are at a dinner. Maybe its Sunday dinner with your Aunt Margie, who makes that fantastic lasagna but refuses to give you her recipe. Maybe its that work potluck you’ve been meaning to attend, but you haven’t had the energy until today. Or maybe it’s that upscale steakhouse, with the dimly lit, dark wooded dining room, celebrating an anniversary. The aromas of fresh breads, a cooling pie, or roasted meats and zesty spices wafting around you. You all sit down to eat, and you excitedly dig into that dish you had been eyeing, as your mouth waters in anticipation. You are not disappointed, as you gulp down the first delicious morsel. But then it happens. “Not again” you might mutter, realizing you have done this before and had hoped would not have this happen again.

It’s stuck. You can feel it, tight, in the middle of your chest. The pain is dull, burning, and you start to feel anxious. You try to swallow again, but it does not budge.

You or someone you know, may have experienced a version of this above scenario, and if so, you are not alone. Many people will at some point experience trouble swallowing in one way or another. Most frequently, larger, solid foods are the culprits, but all foods, or at times even liquids, can be to blame.

Trouble swallowing is also known as “dysphagia” and is an issue frequently managed by Gastroenterologists. It is a sensation of food sticking in the throat, or even trouble swallowing food. There are many causes, but overall these can be broken down to 2 main groups. Blockages/mechanical issues, or nerve and muscle problems. These may be issues with the mouth/upper throat and its ability to initiate the swallow, or with the throat itself (also called your esophagus) and its ability to pass food through to the stomach. Blockages may be from narrowing (as from frequent reflux, medications, or infections) or even from tumors in some cases. Nerve issues may happen after a stroke, or may be a sign of a more general disease of the nerves.

Dysphagia becomes more common as we age, and up to 10% of adults over 50 have dysphagia. These numbers are likely low, as many people might not know to seek help for these issues. While everyone likely has an occasional issue with swallowing, persistent or regular issues certainly warrant an evaluation. And food stuck? That is an emergency, and should be managed by a professional, so head to your nearest Emergency Room.

Help is available, and with appropriate evaluation, most problems with swallowing can be identified and improved. Additionally, ignoring such issues can put someone in a worse situation. If you are unable to swallow properly, the food can go into the lungs, leading to infections. If food sticks in the esophagus or is forced out, it could cause irritation, or even lead to rupture without appropriate care!

Evaluation for swallowing issues comes in many forms, but usually entails imaging of the throat while swallowing to see how your muscles and nerves move, or an EGD (esophagogastroduodenoscopy) or “upper endoscopy”, where a camera looks at the throat via the mouth to look for any blockages. These cameras are attached to tubes through which small tools can be introduced to remove stuck food, to stretch narrow areas, or even to take small samples if something does not look quite right. These procedures are generally painless, and quick.

When To See Your Doctor:

  • IMMEDIATELY if food has become lodged in the throat and will not pass.
  • ASAP if you are having to modify your diet (blending food, avoiding solid food) or if you are frequently coughing/choking when you try to eat
  • OR if you have a concern about swallowing issues



Dysphagia. Philip E. Jaffe MD, in Decision Making in Medicine (Third Edition), 2010

MICHAEL R. SPIEKER. Evaluating Dysphagia. Am Fam Physician. 2000 Jun 15;61(12):3639-3648.

World Gastroenterology Organization Global Guidelines Dysphagia Global Guidelines & Cascades Update September 2014

Constipation, Laxatives, and You

Laxatives have a bad name in our popular culture, as something used in pranks or designed to be used only in extreme circumstances. However, what you don’t know about laxatives just might be preventing you from feeling better every day.

Constipation is an extremely common problem. We know at least 7% of American adults have significant recurrent constipation. We estimate that the real numbers are closer to 30-40%, and that most of us just don’t know it! We define it with the “Rome Criteria,” a set of guidelines for gastrointestinal disorders, and the definition actually covers a lot of people. If you have two or more of the following, you are, in fact, also constipated.

  1. Less than three bowel movements per week
  2. At least one episode of incontinence per week
  3. Painful, lumpy, or hard bowel movements
  4. Large diameter stools

Constipation is insidious because it can be chronic and it sustains itself. The colon’s job is to hold stool and reabsorb water. If at any point stool sits too long, it becomes hard and dense as the water reabsorbs. In addition, you know you have to go because your colon stretches. However, you can ignore that signal, and for individuals who are constipated, their colon gets more and more stretched out, meaning you don’t even feel like you need to go until you have a large amount of waste to get rid of.

So how do we fix this? Laxatives. Improving your diet with fiber and increased water intake will only go so far, and usually is better for prevention than for treatment of constipation. Instead we recommend varying types of laxatives, which have varying types of side effects.

Our mainstay is Miralax. Miralax and its cousins are a chemically inert, non-absorbed powder which you mix into a beverage. It is of a class called “osmotic laxatives,” meaning that the powder holds water in the intestine, keeping everything hydrated and soft. It is mainly side effect free, although does have some associated bloating for some people, with the worst problem being that if you take too much, you may get diarrhea. It takes about 6 hours to work, and works best if drank quickly. Other laxatives in this class include magnesium citrate, milk of magnesia, and lactulose. These should be the baseline of any attempt to solve your constipation, and it should be kept in mind that you should stay on these for quite some time, to give your colon time to unstretch.

Stimulant laxatives work by triggering the colon itself to move. They don’t soften stool, but encourage you to have a bowel movement. These are the ones that work a bit more like the movie version, where they can cause some cramping and the urge to go emergently if too much is taken. However, they often work really well in conjunction with an osmotic laxative. Examples include dulcolax or senna (aka, Ex-Lax).

In the worst case scenarios, there are some new prescription treatments (Linzess and Amitiza) which work by increasing the amount of fluid your intestines secrete, thus keeping stool hydrated and soft. If basic measures are not working for you, discuss further options with your physician.

Say Goodbye to Bloating: the FODMAP diet and how to use it

Bloating and gas are quite prevalent.  To some degree that’s normal, as in our intestines need nourishment, this results in the production of small amounts of gas.  Passing small amounts of gas up to 20 times per day is considered normal and healthy.  However, this benign process can, and does, go wrong for many of us, producing the sensation of bloating, foul smelling gas, and sometimes even diarrhea or severe abdominal pain.  This is especially predominant in individuals with Irritable Bowel Syndrome (IBS).

Bloating is the sensation of gas causing your intestines to stretch more than usual.  This happens when either the mix of bacteria in your intestines are not ideal, or if your diet provides too many of the substances that bacteria turn into gasses (specifically known as “fermentable” sugars).  These are related issues, as the old saying “you are what you eat” also applies to the bacteria in your gut, and your diet will cause shifts in the bacteria.

The low FODMAP diet boils down to decreasing specific types of carbohydrates that are poorly absorbed by your intestine and thus become nutrients for bacteria.   These foods were identified as a result of research into treating IBS, and examining why the “trigger foods” caused gas and bloating.  Basically, the combination of certain poorly absorbed sugars and large populations of the bacteria that consume them (and then produce large amounts of gas), causes bloating and discomfort.

While some foods on the list to avoid with a low-FODMAP diet are obvious, others are not.  Peaches, garlic, honey, and apples have all been identified as problematic as well as cauliflower, cabbage, ice cream and baked beans, among others. But does this mean that if you are stricken with gas and bloating you need to eliminate foods on the entire list?

The quick answer is no, but it’s a bit of a process. Depending on the severity of your symptoms, we will sometimes recommend starting by eliminating the entire list.   This is designed both to make you feel better, and to help promote changes to your microbiome (the bacteria that live in your intestine).  We also may recommend a pro-biotic or pre-biotic to help adjust those bacteria.  But if it resolves your issues, we frequently will start to add foods back in, to figure out what specific sugars your body doesn’t tolerate.  Remember that the interaction between the sugar and the bacteria is somewhat specific, so you may not respond to all FODMAP foods the same.   For those of us with less severe symptoms, we will often try to eliminate the more obvious dietary triggers until the issue is resolved.  This approach is effective with up to 80% of patients showing improvement in symptoms of bloating and abdominal pain on a partial or complete low FODMAP diet.


Additional resources are available at:

Colon Cancer: Symptoms to Look For and How Screening Can Save Your Life

It’s the middle of the day and a couple of us are standing glued to the TV screen in the corner of a large room. But instead of a live look in at a sports event, what we’re seeing is live footage of the inside of Mr.Johnson’s colon.

Mr.Johnson had recently turned 50 and his primary care doctor had sent him for a screening test for colon cancer. He was scheduled for a colonoscopy, a test where a camera is inserted through the rectum and advanced through the colon to look for any abnormal lesions that might represent cancer. Most cases of early stage colon cancers are found through this method of screening and these patients often don’t have any symptoms. For Mr.Johnson, we found some abnormal lesions which we were able to remove during his colonoscopy. Once biopsy results came back, he was scheduled for a repeat colonoscopy in a few years’ time as was consistent with his findings.

We soon moved on to see clinic patients and Ms.Carter was next on the list. She had been recently admitted to the hospital with abdominal pain, nausea and vomiting and was found to have advanced colon cancer. She was 63 years old and had not gotten any colon cancer screening previously, reasons for which were unclear. To treat the cancer, she underwent extensive surgery and now was in clinic to discuss her options regarding chemotherapy. She looked weary and not ready to have this conversation. And maybe she would not have had to have this conversation if she was more aware of the risk of colon cancer and the appropriate screening recommendations for people in her age group.

These two cases seen within hours of each other represent different ends of the spectrum of how patients with colon cancer may first present. But it also highlights the important role of patient education and screening about colon cancer which may lead to early recognition of colon cancer.

Patients with colon cancer can present with a variety of symptoms. Some of these include bleeding noticed in the stool, stomach ache or bloating, weight loss and changes in bowel habits. The changes in bowel habit can include constipation or diarrhea that lasts multiple weeks. Sometimes routine lab tests showing low blood counts, also called anemia, can also point towards non-obvious bleeding from the colon which can point towards colon cancer. This can lead to symptoms of fatigue and weakness. Patients who present with some of these symptoms and then go on to be diagnosed with colon cancer often have a more advanced disease because the symptoms are often caused by the increasing size of the cancer.  But it is important to realize that most of these symptoms can be seen with many other conditions that are not cancer related and are much more benign. It is best to seek care from your primary care provider when experiencing these symptoms to figure out the underlying cause.

Screening for colon cancer is first recommended at age 50 by the U.S Preventive Services Task Force.  But it is important to note that this age recommendation is not a one size fit all and can be different for you depending on your or your family’s past medical history. For instance, if you have a relative who was diagnosed with colon cancer at a young age or if you have a genetic disease that puts you at higher risk for colon cancer then you may need to get colon cancer screening at a much younger age then 50. For optimal medical care, it’s best to discuss your risk of colon cancer and the screening guidelines that you should follow for colon cancer with your primary care provider.

Certain lifestyle choices have also shown to decrease your risk of colon cancer. Increased physical activity and a diet high in vegetables, fruits and fiber can possibly lower your risk of colon cancer. On the other hand smoking, obesity and diabetes may increase your risk of colon cancer. Effects of processed or red meat are less well known but also could possibly increase the risk of colon cancer.

This is the discussion that we had with Mr.Johnson after we gave him news of his colonoscopy findings. This is the discussion that every adult patient should have with their primary care provider. In the U.S. not everyone who should be getting colon cancer screening is getting one so it is important for patients to be informed and ask their doctor about their risk and need for colon cancer screening. If we can better educate our patients and our medical community then we can hope for more cases like Mr.Johnson and less of cases like Ms.Carter.


Patient names mentioned in the article have been changed to protect patient privacy.



Bellyaches: Red Flags and Reasons to See a Doctor

Modern life is busy, and visits to the doctor are generally the furthest thing from efficient.   Figuring out just when to see your physician is a challenge, especially in the internet era, in which we can convince ourselves in 5 minutes of googling that our minor nausea is in fact a rare parasite only found 5000 miles away.   With that in mind, today we will cover a few of the prototypical “red flags” for abdominal pain, and what you should do if these symptoms are happening to you.

There are two ways in which pain presents, acute and chronic.  First, let’s talk about the acute issues.  Acute sharp pain in your abdomen is generally worrisome, and depending on the degree of pain is enough to warrant a doctor’s visit all on its own.  However, the things that should get you mobilized to the emergency room include vomiting blood, inability to tolerate liquids, vomiting bile (bile will look green, either dark or very bright), or uncontrollable vomiting.   While I think most people know to go to the ER if they start vomiting blood, it’s important to know that this can be a manifestation of many diseases, and acutely life threatening.  If this happens to you, especially if there is no inciting factor (like having a nosebleed and swallowing a lot of blood) you need to head to the ER straightaway.

If you are unable to tolerate liquids, you need to present to the ER even if nothing serious is happening, as dehydration can absolutely become serious, and it raises the possibility that a serious medical issue is occurring.  This is the same reasoning behind seeing a doctor for uncontrollable vomiting. We can do something about it, and it can be dangerous or indicate that something serious is happening.  Vomiting bile is concerning for something called an “obstruction” in which a section of the intestine is blocked.  If you block the way out, everything comes back up the way in, and you will see significant abdominal pain, vomiting, and vomiting of bile.

Lastly, it’s worth noting that if you have severe abdominal pain associated with high fever, this could also indicate a serious infection, and you should see a physician.

Chronic abdominal pain works slightly differently.  Many of the causes of chronic pain are relatively benign, like functional abdominal pain, gas, or constipation.  However, there are many red flags that clue you in to needing to get to the doctor.  First and foremost, weight loss. If you are having chronic abdominal pain and unintended weight loss, you need to see a physician.  There are many possible causes of this, and many of them are quite unpleasant (such as celiac disease or inflammatory bowel disease), so getting to the doctor ASAP is a must.

Second, the location.  A persistent pain in your right upper quadrant could indicate an issue with your liver or gall bladder, which are slightly more important areas than your left lower side, which is most likely affected by gas pain.  As always, if your pain is really severe, go see a doctor even if the area of the pain isn’t too high risk.

Third, the timing.  If pain is waking you up from sleep, that’s a big deal.  A lot of abdominal pain can feel excruciating but once you’ve gone to sleep you can rest easy (see: Gas).  This usually indicates that you do not have a severe problem.  However, if pain persistently wakes you up, that is a great reason to drop into your doctor.

Last but not least is the presence of other symptoms.  Chronic abdominal pain with new or unexplained rash, unexplained fevers, ulcerations in your mouth or other sensitive areas, or joint pain is much more likely to be caused by a systemic illness like an autoimmune disease, and definitely suggests it is time to make the trip your doc.

You Think What You Eat: Mental Health and Prebiotics

Have you ever had a gut feeling? How about an emotion you feel in your gut? We love to discuss how our thoughts and emotions impact our intestinal. I have seen patients who “stress barf” and folks whose reflux increases when they are anxious. I’ve seen patients who manifest their fears and worries as abdominal pain or diarrhea. All of that makes sense, as the gut contains over 500 million neurons through which emotional distress can induce changes in your intestines that upset your tummy. However, most of us never thought it could go the other way and that the gut can also influence how you think. Most of us turn out to be wrong!

In recent years we have investigated the makeup of the microbiome, the large community of “commensal” (essentially friendly) stop bacteria that live in your intestines and help you digest your food. These bacteria have an impact on more than just food, and have been implicated in influencing things ranging from nutrient absorption to autoimmune diseases to mental health. There is enough new and interesting information about the microbiome to write a book (and people are), but one of the most fascinating recent developments is the

evolution of our understanding of prebiotics, which are nutritional components that promote the growth of certain especially friendly bacteria.

Even more fascinating, we have found that these prebiotics and their action on your microbiome can have positive effects on both perception of anxiety and on one of the main biological signifiers of stress, cortisol. Cortisol is a hormone which serves a vital purpose in our biology, but when stressed your body releases more of it, generating some of the physical symptoms of stress and anxiety. A group of enterprising researchers decided to test the effects of prebiotic compounds, specifically Bimuno-galactooligosacharrides (B-GOS). This compound had previously been known to increase the presence of friendly species of bacteria such as Lactobacilli and Bifidobacteria, two bacteria that are markers of gut health.

45 healthy volunteers took supplements or a placebo for only 3 weeks, and the findings were striking. The volunteers took tests measuring their response to certain pieces of information, either positive or negative. The people who had taken B-GOS showed a reducedemotional response to negative information, and a more powerful response to positive. Not only that, but their levels of cortisol dropped significantly. This is thought to happen as result of the B-GOS being fermented into short chain fatty acids, which may have anti-inflammatory effects that reduce feelings of anxiety or stress.

Now, it is definitely worth noting that this does not replace seeking appropriate care for mental health issues. However, the implications are still quite amazing. Your diet can literally impact your mental health, improving your response to emotional stressors and likely improving your quality of life. Not too shabby for simple dietary supplement!

Acute Gastroenteritis: The Do’s and Don’ts of Diarrhea

We’ve all felt it— that wiggling, cramping feeling in your stomach that hints, “Today may not be a great day.” Then the confirmation arrives in the form of sudden onset diarrhea, abdominal pain, nausea and vomiting. It’s official: You have acute gastroenteritis or AGE.

AGE is defined by the symptoms of sudden onset diarrhea, nausea, and vomiting, and remains one of the most common illnesses in the United States, affecting over 179 million Americans annually. It costs the US over 1 billion dollars in treatment fees alone, not to mention the hit we take from lost days of work. Plus, AGE symptoms are miserable. However, as a gastroenterologist, I know we can actually do quite a bit to help ourselves feel better. Here’s how.

Despite the frequency and discomfort of this disease, AGE remains undertreated in the United States, and misconceptions abound.  To set the record straight, let’s start at the cause. AGE is caused by a broad range of pathogens—from viruses to bacteria to parasites. But 78% of all global AGE stems from the same six culprits: Shigella, Rotavirus, Adenovirus, some subspecies of E. Coli, Cryptosporidium, and Campylobacter.  In the US, we also see big bursts of Norovirus, which causes the epidemic form of gastroenteritis (aka the cruise ship horror stories).

With three of the top six causes being bacterial, you’d think the answer to AGE would be antibiotics.  Well, so did the medical community, but it turns out we were wrong.  In the vast majority of cases, antibiotic use actually prolongs the course of illness, and can even worsen symptoms (although in certain rare cases antibiotics are necessary). Since the most common side effects of antibiotics are upset stomach and diarrhea, maybe this isn’t such a surprise.

Even though buying Cipro online isn’t going to be of much use, we do have other medicines and approaches that can be literal life savers, or at the least can get you back to normal faster and help avoid ER visits and hospitalizations for diarrhea.

First, it is worth asking your doctor about prescription Zofran to help with nausea and vomiting, as well as improving your appetite. Zofran works by blocking a specific receptor in your brain that’s tied to nausea. Then, an over-the-counter H2 blocking medication like Zantac or Pepcid will improve abdominal pain by acutely decreasing acid production.  Stronger medications like omeprazole (a PPI) don’t work as quickly, so aren’t ideal.

Once you’ve fixed your stomach, focus on your intestines. Oral rehydration with a fluid containing sugar and salt (like Gatorade or Pedialyte) is key. This activates the sodium/glucose cotransporter in your intestines and helps replenish electrolytes and fluids.  Rehydration also helps with nausea by blocking the part of your metabolism that generates ketone bodies, which at high concentrations can make you want to vomit and suppress your appetite.

After you’re rehydrated, it’s time to start eating again.  Eat anything you like that wouldn’t give you an upset stomach on a normal day. Many physicians still recommend the BRAT (Banana, Rice, Applesauce, Toast) diet, but since there’s no definitive data behind this protocol, if you don’t like it, don’t worry. Just getting any food in you is helpful because a rapid return to eating has been proven to improve recovery time – possibly by providing the nutrition your intestine needs to heal itself.

Finally, starting a probiotic containing Lactobacillus GG has been shown to be very helpful, with people recovering about a day faster.

You might notice I didn’t put Loperamide (aka Immodium) on my list.  Immodium works by decreasing the movement in your intestines. While this can decrease the total volume of diarrhea, it will likely worsen cramping and bloating, and in kids has been associated with severe complications.  We highly recommend avoiding these medications if at all possible.