The Inside Tract
Written by Rebecca Budde • Photography by Jason Johnson
Acid reflux, sour stomach, diarrhea, abdominal pain,constipation, burping, gas and bloating aren’t suitable topics for dinner conversations. Unfortunately, these symptoms can be signs of more serious issues that need to be discussed in a conversation with a gastroenterologist.
Approximately 60-70 million Americans are affected by digestive diseases, including Crohn’s Disease, Inflammatory Bowel Disease, Irritable Bowel Syndrome, cancer, fatty liver disease, pancreatitis, gall stones, ulcerative colitis, GERD, ulcers, hepatitis and celiac disease, according to the National Institutes of Health.
SIU’s physicians in the Division of Gastroenterology (GI) and Hepatology see patients with these symptoms each day. They encourage those who have symptoms to seek the advice of a physician to avoid future life-threatening illnesses. The SIU team of five GI physicians, one hepatologist and three nurse practitioners use tools unique to the region, and in some case, unique to even the Midwest to diagnose and treat a wide array of gastrointestinal complaints and diseases. "Our physicians are trained in the specialties and subspecialties that serve as a core for a regional referral center," says Mei Chris Huang, M.D., Ph.D., associate professor of internal medicine and chief of the Division of Gastroenterology.
Bouts of abdominal pain and acid reflux led Barbara Hirsch, 76, of Springfield, to seek help at SIU. Hirsch’s MRI results showed a suspicious nodule on her pancreas. "Anything we see on the pancreas, we get worried about, because pancreatic cancer can be deadly," says Aman Ali, M.D., assistant professor of internal medicine.
To determine if the nodule on Hirsch’s pancreas was cancerous, Dr. Ali performed an endoscopic ultrasound (EUS), a procedure that combines endoscopy and ultrasound. More advanced than a traditional ultrasound, EUS allows physicians to study the layers of the intestinal wall, lymph nodes and blood vessels. For the procedure, Dr. Ali inserted a probe with a transducer at the tip into Hirsch’s abdomen. The transducer placed in proximity to the organs produces an accurate and detailed image of the organs and the walls of the organs.
EUS is mostly used for determining staging of cancer lesions outside of the intestinal tract, but can also help determine the best therapy or procedure to use for a pre-cancer or early cancer diagnosis. In Hirsch’s case, EUS determined that her pancreatic lesion was benign. However, with the good news also came some troubling news —a nodule in her stomach.
Dr. Ali discussed the options with Hirsch, but he also told her about a new, advanced, non-surgical procedure only available in the region at SIU, called endoscopic submucosal dissection (ESD). ESD is unique from other endoscopic procedures because it goes below the mucosa (submucosa) and teases out the lesion away from the muscle. The physician can visualize the muscle at all times to make sure it isn’t breeched. The cuts are made laterally as well as deeply to be sure there is no cancer or pre-cancer left behind, and then the tumor is suctioned out and sent to pathologists. "There is no ambiguity when a tumor is removed this way," Dr. Ali says. "We take out the entire lesion and know exactly where the cancer is or isn’t."
From Hirsch’s perspective, ESD meant no surgery, no pain and one procedure. "Dr. Ali told me every single thing that would happen," she says. "I got to go home afterwards and live my normal life."
Dr. Ali is one of only a handful of other physicians in the United States performing ESD, and he is the only physician performing this procedure in Illinois. "It’s an exciting time for us to be able to do this non-surgically and with no pain," Dr. Ali says. "The best thing about this procedure is that patients go home with no tubes or infections. They’re back on their feet in a matter of days. From the patients’ standpoint, it’s a night and day difference."
A similar technique, Endoscopic Mucosal Resection (EMR) can also be used for diagnosing, staging and treating smaller, superficial tumors in the gastrointestinal tract. EMR is typically used for pre-cancerous or early-stage cancers. Like ESD, a tube with a plastic cap goes into the mouth, into the GI tract and snares the tumor.
Endoscopic procedures make sense for patients with suspected cancer or pre-cancerous tumors. "If you have the choice of the same treatment with no scars or pain, of course, endoscopy is the way to go," Dr. Ali says. "Prior to these procedures, patients were often subjected to surgery only to find out that surgery probably wasn’t necessary. If we can, we perform an endoscopic procedure, which is safer and has fewer complications than surgery."
Hirsch is pleased with the results of her ESD. "I went home the next day and didn’t have to worry about having a tumor anymore," she says.
Even less invasive is the antacid, Nexium ®. With revenues of $6.3 billion, Nexium® is the second highest selling drug in the United States. The sixth most prescribed medication in the U.S. is omeprazole (generic Prilosec®), with 53.4 million prescriptions, and this number does not include over-the-counter sales, according to IMS Institute for Healthcare Informatics.* Physicians warn that though antacids and other medications can reduce discomfort caused by chronic heartburn or gastroesophageal reflux disease (GERD), they may mask more serious problems.
Those who suffer from these conditions may have permanent damage to the GI tract and are at increased risk for Barrett’s esophagus, a condition where the lining of the esophagus is damaged by stomach acid, often leading to cancer of the esophagus. "We believe that reflux disease can cause Barrett’s esophagus, which can turn into cancer," says Mehrdad Saliminejad, M.D., assistant professor of internal medicine, specializing in gastroenterology. "Esophageal cancer is one of the fastest growing cancers in the U.S."
SIU offers a new treatment option for those with Barrett’s esophagus, which is easily diagnosable and treatable, according to Christopher Mogren, nurse practitioner in SIU’s gastroenterology division. BARRX ablation can prevent the tissue from developing into cancer by removing the abnormal cells and allowing new, healthy cells to replace them.
Abigail Stickels, age 20 of Springfield, found herself in the emergency room with severe nausea, vomiting, abdominal and back pain. After a sonogram showed that she had gallstones, she sought the advice of Madalina Butnariu, M.D., assistant professor of internal medicine specializing in gastroenterology. Dr. Butnariu performed an endoscopy to rule out obstructions caused by loose gallstones, internal complications from a previous surgery and other possible causes for the pain, such as ulcers.
Some patients with situations similar to Stickels may undergo a retrograde cholangiopancreatography (ERCP). ERCP is a minimally invasive procedure using endoscopy and fluoroscopy, a type of continuous x-ray using a radiographic dye, for better visualization to diagnose and treat conditions in the biliary or pancreatic ductal system, mainly the bile ducts and main pancreatic duct. The physician passes a thin, flexible tube with a camera through the mouth of the sedated patient. The tube continues down the esophagus, into the stomach and through the pylorus and duodenum. The dye is injected into the openings of the common bile duct and pancreatic duct to allow obstructions, perforations or other problems to be seen on a screen.
Gallstones that have emerged from the gallbladder can obstruct a duct, causing great pain such as Stickels experienced. Using ERCP, the physician can often determine the location of the stone and remove it, enlarge a narrow duct or stretch and opening to allow better motility or insert a stent to assist with bile drainage.
Fortunately, Stickels had no obstructions and has had only minor discomfort since her initial visit to the emergency room, and, in her case, removing her gallbladder seems to be the best option. Dr. Butnariu was able to guide Stickels to make the decision to have laparoscopic surgery to have her gall bladder removed.
Many healthy adults take regularity for granted. But gastro-intestinal (GI) problems can cause a poor quality of life in those who suffer from irregularity and motility problems. Motility of the stomach and intestines refers to the contractions of the muscles in the GI tract that move food and waste along. Compromised motility can result in an array of symptoms such as pain, bloating, discomfort, constipation or diarrhea. These symptoms often progress into more serious disorders such as GERD, intestinal obstruction, small bowel bacterial growth or fecal incontinence. Those who suffer from motility issues can be evaluated using advanced manometry, and Manuel A. Amaris, M.D., assistant professor of internal medicine, is the only NIH trained physician performing advanced manometry in Springfield.
Though it may be slightly uncomfortable for some patients, manometry is a safe, low-risk procedure with many benefits. A thin tube is passed through the mouth or nose into the stomach (or into the rectum for lower GI or pelvic floor disorders) to test if the sphincters and muscles are contracting and relaxing properly and at the proper time. The results can be seen in clear, hi-definition reports. "The reports can either confirm that surgery will be well-tolerated by the patient or save a patient from unnecessary surgery," Dr. Amaris says.
One of the more common problems caused by pelvic floor issues is constipation, especially in females. "Constipation in females is often wrongly believed to be a ‘normal female issue," says Dr. Amaris. Chronic constipation leads to other issues later in life, such as rectal seals, dilation of the colon, discomfort and other symptoms similar to Irritable Bowel Syndrome. "Severe constipation is distressing and disabling; there is a lot of stigma, and people don’t volunteer information to their primary care physician," Dr. Amaris says.
Dr. Amaris has teamed up with other SIU physicians in uro/gynecology, colorectal surgery and physical therapy to offer a multi-disciplinary approach to treating those with pelvic floor issues. Physical therapy often helps some patients to strengthen and learn when to relax their pelvic floor muscles. "It’s a very dramatic change in quality of life," Dr. Amaris says.
What’s good for the gut can be great for the quality of life of a GI patient. The innovative services offered by SIU’s physicians can quell nagging physical issues and resolve digestive stressors that keep a person from enjoying a good meal, a carefree night out and a more comfortable life.
*Footnote citation: "The Use of Medicines in the United States: Review of 2010," April 2011.
Hepatologist Dr. Javadi is a Leader in Liver Care
Second only to the skin, the liver is the largest organ in the body, and it performs many tasks, making sure the body absorbs everything it needs to function and removes toxins from the body. Fariba Javadi, M.D., assistant professor of internal medicine in SIU’s gastroenterology and hepatology division, is the only fellowship-trained hepatologist in the area helping patients with acute and chronic liver diseases, including Hepatitis B and C, as well as alcoholic and fatty liver.
While Dr. Javadi works with general hepatology patients with acute problems, she also works with the transplant centers in St. Louis and Chicago for patients who have chronic liver problems. "More than 16,000 people a year need a liver transplant, and many of these cases could have been prevented," Dr. Javadi says. "When patients with liver disease get sick, they get very sick. Patients with liver failure have a very high death rate."
Her management of cirrhosis encompasses liver cancer screening and transplant evaluation, including pre- and post-liver transplant care.
Two of the liver’s greatest foes: fat and alcohol. Alcoholic liver disease and fatty liver disease usually don’t have symptoms, but toxins such as alcohol or fat in the liver cells cause inflammation or hepatitis. With continued excessive alcohol consumption, worsening fatty liver disease from poorly controlled diabetes, high cholesterol or obesity, the disease progresses to cirrhosis of the liver. Fat causes the liver to release enzymes that over a period of years will cause scarring. Javadi believes that the average person lacks knowledge about fatty liver disease. "If you have visceral fat, fat around the middle, it usually means you probably have a fatty liver as well," Dr. Javadi says. "Fat is not benign. I think if people knew that, it would change their thinking and their actions."
The good news is that reversal of fatty liver is possible, according to Dr. Javadi. "There is no treatment for fatty liver, but regular checkups with your primary care provider, keeping blood pressure and cholesterol down and managing diabetes will help. Just losing 5% of your body weight can make a drastic difference."