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An Inside Job
Judy Shuhala, a retired schoolteacher, had recurring pain in her abdomen. With the use of an endoscope - a thin tube equipped with a tiny camera that can be passed down the esophagus - her gastroenterologist was able to identify the source of her discomfort. She had gastritis, an inflammation of the stomach lining. Because her gastritis was caused by bacteria, an antibiotic soon resolved the stomach pain. However, there was something else. During the diagnostic test, the gastroenterologist caught a glimpse of another abnormality, but it was beyond the scope's viewing range. Her doctor recommended a more sophisticated test, an endoscopic ultrasound (EUS). As the name suggests, EUS combines two technologies: endoscopy, which produces images on one television monitor, and ultrasound, which uses sound waves to create images on a second screen. Unlike traditional ultrasound, EUS can produce detailed images from within the upper and lower digestive tract. The doctor who performed Mrs. Shuhala's endoscopy did not do EUS, so she was referred to Dr. Mark Sterling, chief of gastrointestinal endoscopy at University Hospital and assistant professor of medicine at New Jersey Medical School, who has extensive training and experience with this specialized test. In October 2002, Mrs. Shuhala had EUS, which detected a polyp in her duodenum, the first part of the small intestine. "Dr. Sterling told me that, had it not been for the EUS, the polyp probably could have grown for another three to five years without being detected," says Mrs. Shuhala. "By removing it endoscopically, he was taking care of something that could have been a real problem later on." The polyp was removed in December 2002, and although Mrs. Shuhala experienced an unusual complication (her body twice rejected shunts Dr. Sterling tried to place and she developed pancreatitis), today, she "feels wonderful." For that, she credits Dr. Sterling. "He is extremely competent and compassionate," says the 56-year-old. "Dr. Sterling explained everything in layman's terms and called me personally with test results." A Dramatic Evolution
The technology available to doctors has evolved dramatically over the past 40 years, enabling specially trained gastroenterologists to perform tests and procedures that traditionally required surgery or were difficult on the patient. Take the endoscope as an example. "Basic endoscopy was introduced in the late 1960s, and about 20 years later, ultrasound was added, enabling us to look at internal GI structures as never before," says Dr. Sterling. "Now, with EUS, we can determine the extent to which tumors in the esophagus, stomach, pancreas, or rectum have spread in a less invasive way." In addition to using an endoscope to stage tumors, gastroenterologists can use the instrument to take tissue samples with fine needle aspiration (FNA). The endoscope, specially equipped with a biopsy needle, is guided to a specific site and extracts a tissue sample. One technology that has been available for about 30 years, Endoscopic Retrograde Cholangiopancreatography (ERCP), combines X-rays and endoscopy to diagnose conditions affecting the liver, pancreas, gallbladder, and the associated ducts. An endoscope is guided down the patient's esophagus, stomach, and small intestine, and dye is injected into tiny ducts to enhance their visibility on X-ray. ERCP's role has expanded, and in certain medical centers, such as University Hospital 's Therapeutic Endoscopy and GI Motility Center, it is used to place stents within bile ducts, remove difficult bile duct stones, and obtain biopsy samples.
Motility is the movement of food from one place to another along the digestive tract. When a person has difficulty swallowing food or excreting waste, there could be a motility problem. "Manometry is a specialized test that gastroenterologists use to record muscle pressure within the esophagus or anorectal area, essential information for the diagnosis of esophageal disorders such as achalasia, the failure of the lower esophageal sphincter muscle to relax, and problems such as fecal incontinence or constipation-related rectal outlet obstruction," says Dr. Sita Chokhavatia, director of gastrointestinal motility and an associate professor of medicine at New Jersey Medical School. The specialized tests and procedures available to gastroenterologists have come a long way, with more to follow. Photodynamic therapy is one of the new treatments that will soon be available to patients with certain types of Barrett's esophagus or GI tumors at University Hospital, says Dr. Sterling. Photodynamic therapy uses lasers to destroy the precancerous esophagus cells (identified by a photosensitive chemical marker), but leaves normal cells alone. Tests That Aren't Hard to Swallow
The endoscope is a valuable tool for gastroenterologists, but like anything, it has limitations. "The endoscope allows us to view the esophagus and the stomach very well and even into the first half of the small bowel," says Dr. Sterling. "However, there's a significant percentage of the small bowel that can't be seen with a traditional endoscope." Capsule endoscopy was developed to provide images of the entire small bowel in a non-invasive way. For this procedure, the patient swallows a vitamin-sized capsule containing a minuscule video camera and radio transmitter and wears a monitoring belt equipped to receive the images captured as the camera travels through the body. The data recorder's information is downloaded onto a computer, where the images can be reviewed by the gastroenterologist; meanwhile, the camera-containing capsule is excreted by the patient. "Capsule endoscopy could well be the 'colonoscopy of the future,' but for now, the FDA has approved it for specifically for evaluating the small bowel," says Dr. Sterling. "It could be used to identify arteriovenous malformations - abnormal vessels that can cause bleeding in the colon; small bowel tumors; and Crohn's disease or chronic anemia."
People with recurrent heartburn- when stomach acid backwashes up into the esophagus and throa - sometime need to undergo a 24-hour pH test that monitors acid levels in the esophagus. The higher the acidity, the more likely that gastroesophageal reflux disorder (GERD), is the underlying condition. GERD can lead to more serious conditions, such as Barrett's esophagus - precancerous changes in the esophageal lining -or dysphagia, difficulty in swallowing. The traditional pH test involves threading a catheter into the patient's nose and down the throat; the catheter is attached to a special monitor, which is worn by the patient for 24 hours. A newer alternative eliminates the catheter completely. Instead, the gastroenterologist, using an endoscope, attaches a small capsule to the wall of the esophagus. The capsule transmits signals to a special receiver during the 24 to 48 hours of the test; afterward, the data is downloaded to a computer at the doctor's office and the capsule naturally disengages from the esophageal wall and is eliminated from the body. "The catheter pH test, while accurate, is difficult for some patients. They either eat differently during the test because of the catheter or are embarrassed to go out in public," says Dr. Sterling. "The catheter-free system compares quite well with the traditional test and has been well received by patients." Palliative Care for Cancer Patients Gastrointestinal tumors can block critical passageways in the digestive system, making it impossible for the patient to swallow or defecate, depending on the obstruction's location. Through stent placement, gastroenterologists can often improve the quality of life for people with terminal cancer. "These patients might have obstructions that are not operable or they are too sick for surgery," notes Dr. Sterling. "By the proper placement of stents, we can open up these passageways so patients can eat or defecate again. In certain cases of colon cancer, stenting can be used together with surgery and the lesion can be removed." While stents do not cure cancer, he says, patients' remaining weeks or months are made more bearable because they do not have to rely on feeding tubes for nourishment or permanent colostomy to remove waste. Jaundice is often a difficult problem for patients with pancreatic cancer, causing a loss of appetite and itching. Stents can be placed endoscopically within blocked bile ducts to drain them, relieving the jaundice. Pancreatic cancer can also be quite painful, and sometimes the pain is not adequately relieved by medication. An alternative is celiac nerve block, a procedure that that can be performed by gastroenterologists, interventional radiologists, or anesthesiologists. "With EUS guidance, the location of the pain is identified, and certain agents, such as alcohol or a steroid, are injected into the nerve," says Dr. Sterling. "The area then becomes numb, bringing significant pain relief." * * * Gastroenterologists are able to perform procedures that certain other specialists, such as interventional radiologists and surgeons, also offer. At University Hospital, these specialists often work together. After Mrs. Shuhala's polyp was discovered, Dr. Sterling sent her for a surgical consultation to determine the best way to remove it. Even when endoscopic intervention was indicated, Dr. Sterling scheduled her procedure at a time when the surgeon could be available. "I don't work in an isolated fashion," he says. "I work together with specialists in other fields to provide the best overall results for the patients." Dr. Sterling is available for consultations regarding advanced or unusual gastrointestinal disorders. You may contact him at (973) 972-6077.
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