Is it constipation? Is it diarrhea? Frankly, when a patient complains to his or her physician about GI problems, the doctor has to wonder, "Is it Irritable Bowel Syndrome?" If you alternate between infrequent and too frequent bowel movements, you may need evaluation by a gastroenterologist. An expert in all things from your esophagus through your stomach and intestines, a GI doctor can uncover the reasons behind bowel issues, including IBS.
About IBS and its symptoms
Unfortunately, no one knows the real origin of Irritable Bowel Syndrome. However, it definitely is a cluster of symptoms which millions of people in the US--more women than men--suffer, before the age of 50. The International Foundation for Gastrointestinal Disorders reports that stress appears to increase symptoms; however, anxiety and a high-pressure job or life circumstance do not actually cause the condition.
Besides constipation and/or diarrhea, individuals with IBS have:
- Bouts of gas
- Mucus in the stool
- Intolerance to a variety of foods, including those containing gluten and lactose (dairy)
- Dairy products
- Caffeinated drinks
- High fat or fried foods
- Whole grains
Wondering if you have hemorrhoids? Hemorrhoids are very common, especially among people ages 45 to 75. Hemorrhoids are inflamed and swollen veins around the anus or in the lower rectum. One of the main causes of hemorrhoids is straining when you’re trying to have a bowel movement. Other contributing factors include heredity, diarrhea, chronic constipation, pregnancy, and aging. Here's how to tell if you have hemorrhoids.
1. A lump near the anus- Although many individuals have hemorrhoids, not all experience symptoms. External hemorrhoids are felt as swelling or a hard lump near the anal area. Internal hemorrhoids protrude with bowel movements; usually, they return to the inside by themselves.
2. Painless bleeding- Hemorrhoids can cause bleeding. If you have hemorrhoids, you may see blood in the toilet bowl or on the toilet paper. Rectal bleeding is also a symptom of diverticulitis, colitis, colon polyps, and colorectal cancer. If you experience rectal bleeding, you should see a doctor. An evaluation and proper diagnosis by a gastroenterologist is important any time bleeding from the rectum lasts for more than a few days.
3. Itching around the anus- Hemorrhoids can cause severe itching around the anus. Initial treatment of anal itching is directed toward relieving the soreness and burning. Your gastroenterologist may prescribe hydrocortisone cream, gel, foam, or ointment or rectal suppositories to treat itching.
4. Pain or discomfort- Pain is a common symptom of external hemorrhoids, especially during bowel movements or when sitting. Internal hemorrhoids are typically painless, even when they produce bleeding. When hemorrhoids are painful, it’s hard to think about anything else. Your gastroenterologist may prescribe pain medication, hydrocortisone cream or rectal suppositories to ease your pain.
Why suffer? If you think you may have hemorrhoids, you should schedule an appointment with a gerontologist right away. The symptoms hemorrhoids cause are hard to ignore. Thankfully, there are many treatments that can provide relief.
Unfortunately, many of us eat the foods we crave before thinking about how it affects our digestive health. Your digestive health is directly impacted by the lifestyle you live and the foods you eat. Exercising, drinking water, and adding fiber all contribute to better digestive health. Here are five digestive problems that are caused by a poor diet.
1. GERD- GERD is a digestive disorder in which stomach acid or bile irritates the food pipe lining. Symptoms include heartburn, hoarseness, and trouble swallowing. Some foods and beverages are known to cause reflux. If you're at risk for GERD, avoid fatty foods, acidic foods, spicy foods, chocolate, and caffeinated beverages. Being overweight and obesity are also causes of GERD.
2. Cancer- Diet can also directly affect your risk of stomach and bowel cancer. Some foods, such as processed and salt-preserved foods, and red meat can increase the risk of developing stomach and bowel cancer. While others, such as vegetables and fruits, are especially potent cancer fighters. Choosing whole-grain breads, cereals, and pastas instead of refined grains, and eating poultry, fish, or beans may also help lower your risk of stomach and bowel cancer.
3. Gallstones- Slimming down (if you're overweight) and changes to your diet may help prevent gallstones. Gallstones are hardened deposits of bile inside the gallbladder. Because cholesterol plays a role in the development of gallstones, you should avoid eating too many foods that are high in saturated fat. Eating too many foods that are high in cholesterol and fat and not enough of a high-fiber diet can increase your risk of gallstones.
4. Ulcerative Colitis- Eating a high-fat diet increases the risk of developing ulcerative colitis. Ulcerative colitis is a digestive disease that results in inflammation and ulcers in your digestive tract. Symptoms of ulcerative colitis include fatigue, rectal bleeding, anemia, diarrhea, abdominal pain, and feeling an urgent need to take a bowel movement. It's a serious disease that can cause dangerous complications if you don't get the right treatment.
5. Diverticulosis- Diverticulosis is a condition in which protruding pockets develop in the digestive tract. These pouches form when high pressure inside the large intestine pushes against weak spots in the intestinal wall. A high-fiber diet will reduce the risk of developing diverticular disease. Symptoms of diverticulitis include abdominal pain, diarrhea, constipation, bloody stools, fever, nausea, and vomiting. Diverticulitis can become serious, requiring hospital admission.
We really are what we eat! Swap those poor eating habits over for better ones. A healthy diet provides important minerals, vitamins, and nutrients to keep the body healthy. You can start making proactive changes to your diet today that can benefit your digestive health now, and throughout your entire life.
Gallstones are a very common problem. You're at risk of developing gallstones if you're overweight or obese, female, or 40 or over. Gallstones are hardened deposits of bile inside the gallbladder. Many people with gallstones are unaware that they have them, as they produce no or little symptoms. For some people, however, gallstones can cause problems. Here are four signs and symptoms of a gallstone.
1. Abdominal Pain
Symptoms of a gallstone may include severe abdominal pain. This pain goes and comes back repeatedly. The pain often occurs after eating and can last a few hours before it resolves. Chronic, ongoing pain that persists beyond a few hours may also occur, and may indicate a severe gallbladder problem.
2. Referred Pain
Gallstone pain can cause referred pain to the upper back and right shoulder. The pain usually comes on suddenly and may last for several hours. Prescribed painkillers are used to relieve pain associated with gallstones. You may also be given advice about eating a healthy diet to help control the pain.
Jaundice is a symptom of gallstones. Jaundice is a yellowish appearance of the whites of the eyes and skin due to high bilirubin levels. If a stone moves out of your gallbladder and one of your bile ducts and blocks the bile flow, jaundice occurs. Sometimes the gallstone passes from the bile duct on its own. If it doesn't, you may need to have gallbladder surgery.
A gallstone can cause nausea and vomiting, which may relieve some of the abdominal pressure and discomfort. Pain that occurs with appetite loss, nausea, vomiting, and a fever may suggest the presence of infection or inflammation of the gallbladder. Vomiting and diarrhea also occur with food poisoning and the flu, but the pain tends to come and go rather than be constant.
If you're experiencing the symptoms of a gallstone, you should notify your gastroenterologist right away. When a gallstone blocks your bile ducts, it can cause excruciating pain, which means you need emergency care right away.
Diarrhea is very common. When you have diarrhea, your bowel movements are loose and watery. In most cases, diarrhea lasts a couple of days. Chronic diarrhea is diarrhea that lasts longer than two weeks. When diarrhea lasts for weeks, it can indicate a serious disorder. Although diarrhea is usually not serious, it can become dangerous or signal a more serious problem. Read on to find out how chronic diarrhea is treated.
1. Replacing lost fluids- Chronic diarrhea is treated by replacing lost fluids and electrolytes to prevent dehydration. Adults with diarrhea should drink water, sports drinks, sodas without caffeine, or fruit juices. Fluid can also be delivered through a vein (intravenously) if the dehydration is severe.
2. The use of medication- Your doctor may prescribe antibiotics and medications that target parasites to treat parasitic or bacterial infections. If a virus is causing your diarrhea, antibiotics won't help. Pain relief medications can help alleviate fever and pain. Your doctor may also prescribe medications to treat an underlying condition that may be causing your chronic diarrhea.
3. Treating medical conditions- How doctors treat chronic diarrhea depends on the cause. Chronic diarrhea is sometimes caused by an underlying medical condition that requires treatment. Common conditions that cause diarrhea include irritable bowel syndrome, Chrohn's disease, ulcerative colitis, inflammatory bowel disease, celiac disease, and chronic pancreatitis.
4. The use of probiotics- Your doctor may recommend probiotics to treat diarrhea. Probiotics are good bacteria that are very similar to the bacteria that are already in your body. Probiotics reduce the growth of harmful bacteria and promote a healthy digestive system. If your gastroenterologist recommends probiotics, talk with him or her about how much probiotics you should take and for how long.
Chronic diarrhea can affect your daily activities and make life frustrating and miserable. Don't hesitate to contact a gastroenterologist about diarrhea. A visit to the gastroenterologist will bring all the relief you need, with little hassle or expense.
Having trouble going to the bathroom? Find out what might be to blame.
Constipation is an annoying and embarrassing problem that all of us will experience at some point. Constipation is when you are unable to have a bowel movement or you have trouble passing stools. If you are having less than three bowel movements a week then you could be dealing with constipation.
This problem isn’t usually something to worry about, as it usually resolves itself on its own. Of course, there are times in which you may want to turn to a gastroenterologist for care.
What causes constipation?
This usually happens when the stool moves too slowly through the digestive tract, making it difficult to expel. Causes of constipation include:
- Poor diet
- Bowel obstruction
- Anal fissures
- Bowel stricture (narrowing of the colon)
- Conditions that affect the nerves of the colon or rectum (e.g. stroke; Parkinson’s disease)
- Weak pelvic muscles
- Hormone changes due to pregnancy, diabetes, or certain thyroid disorders
There are also certain factors that can increase your chances for chronic constipation:
- Age (older adults are more likely to experience constipation)
- Not getting enough fiber in your diet
- Living a sedentary lifestyle
- Taking certain medications (e.g. antidepressants; blood pressure medications)
- Certain mental health disorders such as depression
How can you prevent constipation?
If you deal with constipation regularly there are some ways to help lessen the chances for this problem. Make sure that you are drinking enough water throughout the day and include a lot of fiber-rich foods in your diet such as whole grains, fruits and vegetables, and beans. Stay away from processed foods, and make sure you are staying active.
When should I see a doctor?
It’s a good idea to give your GI doctor a call if you’ve been experiencing constipation for over 3 weeks or if lifestyle modifications such as drinking more water or adding more fiber to your diet just aren’t working. It’s also important to see a specialist as soon as possible if your constipation is accompanied by pain or if you see blood on the toilet paper (this could be a sign of hemorrhoids or an anal fissure).
If you are experiencing chronic or severe constipation it’s a good idea to turn to a GI specialist who will help you get to the root of the problem and help get your digestive tract moving in the right direction.
This diagnostic procedure could determine the root cause of your digestive issues.
An upper endoscopy is a simple procedure in which your gastroenterologist will insert a small, flexible tube that contains a camera in the mouth and guide it carefully into the upper digestive tract (stomach and small intestines). Why is this outpatient procedure performed? Many reasons, actually. Your gastroenterologist may recommend getting this procedure if there are signs of bleeding within the upper digestive system.
An endoscopy is also a great tool for being able to detect inflammation within the digestive tract, as well as ulcers and tumors. You may benefit from an endoscopy if you are experiencing:
- Difficulty swallowing
- Chronic heartburn
- Abdominal pain
- Chest pain
- Nausea and vomiting
An upper endoscopy is a much better and more accurate diagnostic tool for detecting growths and other abnormalities within the lining the digestive system than x-rays. Furthermore, many gastrointestinal issues can often be treated during the endoscopy. This includes the biopsy and/or removal of polyps, opening up narrowed areas of the esophagus or stomach, removing objects or obstructions within the intestinal tract or stopping a bleed.
Before your procedure, your gastroenterologist will give you detailed instructions to follow. This includes not eating or drinking anything for eight hours before your endoscopy. Patients with certain conditions such as a history of endocarditis (an infection of the heart valve) or those with artificial heart valves may need to take antibiotics beforehand to reduce their risk for an infection. Patients who take medications may still take their medication before the procedure with a little bit of water.
An endoscopy is performed under sedation so you won’t feel anything or remember the procedure. It’s important that you bring someone with you who will be able to drive you home afterwards, as sedation’s effects can last up to eight hours after. Prior to the procedure, a local anesthesia may be sprayed in the back of the throat to numb the area. You will then receive a combination or pain and sedation medication through an IV. Then the thin endoscope will be placed in the mouth and directed through the esophagus into the stomach. The procedure takes approximately 15-20 minutes.
If you are experiencing symptoms of bleeding, ulcers, or other issues within the digestive system, an endoscopy can be an amazing tool for determining what’s going on and what can be done to treat the problem.
Ulcerative colitis is a type of inflammatory bowel disease (IBD) that causes severe and even bloody diarrhea that can result in abdominal pain and unexpected weight loss. While people have probably heard about Crohn’s disease more often than they have ulcerative colitis, this condition actually affects as many as 907,000 of the 1.6 million Americans living with IBD.
While ulcerative colitis can happen to anyone, a gastroenterologist most often diagnoses it during a person’s later teen years or by early adulthood. While there is no definitive cause of ulcerative colitis, a family history of this condition can certainly increase your chances of developing this chronic GI problem.
Those with ulcerative colitis experience diarrhea, which can be bloody at times. Some patients may experience rectal pain, occasional constipation, abdominal discomfort, fever, or weight loss. In order to diagnose this gastrointestinal issue, a GI specialist will often need to perform imaging tests such as a CT scan or run an endoscopy to check the health of the gastrointestinal tract and to look for signs of ulcerative colitis.
While there is currently no cure for this condition, there are certainly an array of medications and treatment options available to help you keep your symptoms and flare-ups in check. The type of treatment plan that your GI doctor will create for you will depend on the type and severity of your symptoms.
The main goals of treating ulcerative colitis are to reduce inflammation within the colon while also speeding up the remission process and making sure that your symptoms stay in remission for as long as possible. Of course, it is still possible, even with the right medication, to experience symptoms.
Common medications for treating ulcerative colitis include:
- Antibiotics: to target any infections within the GI tract
- Aminosalicylates: to treat mild to moderate inflammation within the colon
- Corticosteroids: for short-term treatment of moderate to severe symptoms
- Biologics: to target a specific protein, which leads to inflammation
Sometimes, over-the-counter medications and supplements may be used in conjunction with prescription medications. These may include vitamins and nutritional supplements, pain medications and antidiarrheal. If your ulcerative colitis doesn’t respond to these medications then you’ll want to discuss the benefits with your gastroenterologist of getting surgery to remove parts of the colon or rectum to alleviate severe or persistent symptoms.
C. difficile (Clostridium difficile) is an infection that should be talked about more often than it is despite the fact that it infects half a million Americans each year. While C. diff bacteria can be found within the gut of healthy individuals the healthy gut bacteria work to keep the potentially harmful bacteria in check. C. diff spores can be found in our environment through the air we breathe, or even the clothes on our back or the foods we consume. This is usually how we end up with C. diff in our guts.
However, sometimes circumstances arise in which C. diff bacteria are able to multiply within the gut. This most often occurs in someone who is taking antibiotics because while antibiotics are being used to fight an infection it can also kill off some of the healthy bacteria in our gut.
Unfortunately, C. diff bacteria are resistant to many kinds of antibiotics, giving it free range to thrive and multiply quickly within the gut. These bacteria, particularly in larger numbers, can also produce toxins. It’s usually the toxins themselves that lead to symptoms such as diarrhea, stomach cramps, nausea, and fever.
C. diff infections can range from mild to severe. In milder cases, patients may liken their symptoms to an infection within the stomach (also known as gastroenteritis). These symptoms may be mild and self-limiting, lasting anywhere from a couple of days to multiple weeks. Usually, medication or treatment isn’t needed in order to treat the infection.
However, those dealing with severe diarrhea, blood in the stool, severe abdominal pain, fever, and dehydration should seek the care of a gastroenterologist as soon as possible. While these symptoms can be indicative of several different gastrointestinal issues, if you suspect that you might have a C. diff infection it’s important that you seek immediate medical treatment.
Since most people have C. diff within their gut, if it isn’t causing any issues then no treatment is necessary. As we mentioned before, those dealing with minor symptoms may be able to let the issue run its course. Those with severe infections may need to be hospitalized. If you are still taking the antibiotics that may have caused this problem then you will most likely need to stop taking it so that the healthy gut bacteria have a chance of returning and making the gut healthier.
Those with severe diarrhea or colitis (inflammation of the colon) may be prescribed very specific antibiotics known to kill the C. diff bacteria. In the meantime, make sure you are drinking enough water and fluids to keep your body hydrated. If diarrhea is severe, your doctor may need to give you fluids and nutrients through an IV.
Luckily, most people dealing with this infection will be able to fully recover, even if they don’t get treatment; however, those who are older or have a weak immune system should seek medical attention as soon as possible if they suspect an infection. While symptoms can be unpleasant, they will usually go away in a few weeks.
Do you find that most mealtimes end up being ruined by gnawing, nagging heartburn? While most people will experience heartburn at some point during their lifetime, if you are someone who suffers from this problem several times a week then you may just have a digestive disorder known as gastroesophageal reflux disease (GERD).
What is GERD?
Whenever you eat food, it travels from the esophagus to the stomach. Once food enters the stomach, the stomach produces acid to break up the food. Of course, in healthy individuals the food travels from the stomach to the intestines; however, if you have GERD then the acid and food contents actually flow back up to the esophagus from the stomach, irritating the lining of the throat and causing a nasty case of heartburn.
What are the symptoms?
Heartburn is a classic symptom of GERD. Heartburn is a burning in the chest that also affects the lining of the throat. Heartburn sometimes produces an acidic or bitter taste in the mouth. Symptoms may get worse if you eat a big meal, consume something spicy or lie down immediately after eating.
How is GERD diagnosed?
In some situations a gastroenterologist may be able to determine that you have GERD based on the symptoms you describe and through a simple physical exam; however, sometimes a diagnostic test is required in order to determine whether your symptoms are truly caused by GERD or something else. An upper endoscopy is one common diagnostic procedure performed to check for signs of inflammation or damage to the lining of the esophagus, which are indicative of GERD.
What are my treatment options?
Your treatment plan will most likely consist of lifestyle modifications and medications.
If you are overweight or obese you may be at a higher risk for developing GERD. It’s important to lose that excess weight and to maintain a healthy weight to reduce your symptoms. Quit smoking if you are currently a smoker. Make sure to eat slowly and eat smaller meals. Don’t lie down immediately after eating and eat about three hours before going to bed.
Also, there are certain foods that can trigger heartburn symptoms including chocolate, caffeine, alcohol, tomato sauce, garlic, or fatty and spicy foods. Limit or avoid any of these foods if they are known to cause you heartburn.
Those with milder symptoms may be able to use an over-the-counter antacid or medication to manage their symptoms; however, if symptoms are moderate-to-severe, or if you have damage to the lining of the esophagus, then you’ll need a stronger medication to reduce or even prevent the production of stomach acid until the damage has healed.
If you deal with heartburn on a regular basis or can’t seem to get heartburn under control it’s important that you turn to a GI doctor who can help you find the proper treatment option to prevent digestive complications and to make mealtimes more enjoyable again.
Hepatitis C is an infectious disease that causes liver inflammation, sometimes leading to serious liver damage. Most people have no symptoms right after they have been infected, and since any symptoms are likely to go away in a few weeks, you may not know you have Hepatitis C for a long time. Here are the most common signs of Hepatitis C.
Jaundice is a yellowish appearance of the whites of the eyes due to high bilirubin levels. Normally bilirubin gets broken down in the liver and released from the body in the stool. But if the liver is damaged, it cannot properly process bilirubin.
2. Dark Urine
Urine naturally has some yellow pigments called urobilin or urochrome. The color of the urine can vary when certain medications are taken and when foods of certain types are consumed. Chronic dark-colored urine can be related to serious liver conditions, including Hepatitis C and cirrhosis.
3. Chronic Fatigue
The severity of this fatigue differs from person to person. Some individuals are able to work, but then feel burned out in the evening. Some people spend a large amount of time sleeping. However, someone people feel very tired after a good night's sleep. The fatigue associated with Hepatitis C often improves with treatment.
4. Aches and Pains
Some people with Hepatitis C experience abdominal pain. Many suffer from aches and pains in their joints. A variety of different joints can be involved but the most common are in the wrists and hands. The pains can range from mild to severe. In such cases, medications can be used to ease the pain.
5. Poor Appetite
Loss of appetite implies that hunger is absent. Your appetite may worsen if you have cirrhosis or liver failure. Loss of appetite can also be caused by other diseases and conditions. Some of the conditions can be temporary, such as appetite loss from the effects of medication.
6. Low-grade Fever
Everyone gets a fever from time to time. Most usually don't indicate anything serious. However, some people with Hepatitis C experience a low-grade fever (fever up to 102°F). You should book an appointment with a doctor if you've had a fever for more than three days.
7. Cognitive Changes
Some people with Hepatitis C experience problems with concentration, short-term memory, and completing complex mental tasks such as mental arithmetic. Studies have shown that about half of those with Hepatitis C experience cognitive disturbances.
Many people are surprised to learn that they have been infected with Hepatitis C. Some people feel overwhelmed by the changes they need to make in their lives. At a time when life feels out of control, remember that you can take an active role in your health- and your life.
Hepatitis C Facts
- ~3.5 million Americans live with HCV infection.
- >15,000 Americans will become infected with HCV every year.
- >15,000 Americans will die every year from complications of HCV.
- 80% of people who get exposed to HCV will develop a chronic infection.
- HCV is acquired through direct exposure to blood of someone who is infected.
- 15-30% of people with chronic HCV will develop cirrhosis or other complications, most after more than 20 years.
- HCV with heavy alcohol use increases the risk of cirrhosis 100-fold
- Currently, no vaccine is available.
A renaissance in the treatment of Hepatitis C Virus (HCV)
Twenty-five years of HCV’s dark ages are over. Plagued by poor understanding of HCV, primitive and barbaric treatments (specifically interferon) with significant toxicity and limited success were all we had to offer—until now. In 2009, scientists discovered how to replicate HCV in mice, opening the doors to a renaissance in HCV drug development.
The new age Hepatitis C treatment
Within the past year, interferon-free drug regimens for every genotype (sub-type of HCV) have come to market. While we are still gaining important experience with these drugs, a few things are clear: The new HCV drugs are very effective with greater than 90% cure, even in those with cirrhosis, and are easy to take with minimal side effects. Better yet, several additional drugs are currently under study with very promising results; the near future will offer even more effective, shorter, easier, and less costly treatment regimens.
Hepatitis C genotype 1 (and 4)
Type 1 HCV accounts for more than 70% of infections in the United States and traditionally was very resistant to treatment. Harvoni© became available October 10th, 2014 representing the first interferon-free regimen consisting of one pill (containing ledipasvir and sofosbuvir) taken once a day for 12-weeks with >94% clearance. Side effects include headaches and fatigue, but not a single study participant stopped the drugs due to side effects—a gigantic leap forward compared to interferon-based treatments. More recently, Viekira© and Olysio-Sovaldi© treatment regimens were approved, with the promise of several more to come in 2015.
Hepatitis C genotype 2 and 3
Approval of Sovaldi© in combination with Ribavirin© has improved cure rates for HCV genotypes 2 and 3 from 70% to greater than 90%. However, this combination eliminates the need for interferon, but still relies on ribavirin—a drug with the potentially serious side effect of anemia (low red blood cell counts.) Better regimens, which avoid both interferon and ribavirin, are just around the corner.
Who should get treated for hepatitis C in this new era?
With such great new medications, it would seem that everyone should get treated, except for one serious problem: cost. The new drug regimens cost in excess of $80,000; it would cost 280 billion dollars (for the drugs alone) to treat every American with Hepatitis C. Obviously, insurance companies have balked at the thought of an $80,000 drug, and perhaps rightfully so. Less than a third of all persons infected with HCV will ever develop cirrhosis or complications—treatments should be offered to patients who are at a high risk of developing cirrhosis. Fortunately, for most it takes 30 years or more to develop cirrhosis. See a Gastroenterologist to determine if, and when, treatment might be needed.
There has been some excitement lately since the FDA recently approved ColoGuard, a genetic test performed as an additional testing option for colon cancer screening. Dr. Kevin Rufner has outlined the benefits and cost comparison for this test. To read his article, click on the document link below.
Welcome to the Blog of Colorado Gastroenterology
Colorado Gastroenterology would like to welcome you to our blog. Here you will find informative and useful postings about gastroenterology and our practice.
At Colorado Gastroenterology we believe that educated patients are better prepared to make decisions regarding the health of their digestive system. Our blog was designed to provide you with the latest gastroenterology developments and valuable health advice from our dedicated team.
Colorado Gastroenterology hopes you find our blog to be a great resource for keeping up to date with proper digestive health care and treatments.
We welcome all comments and questions.
-- Midtown Medical Center
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