Being Well 1206: Gastroenterology

[music playing]
Lori:They’re the ones who raise the bar. The ones dedicated to providing care in the
most demanding of circumstances. The ones that understand the healing benefits
of kindness and compassion. They’re the people of Sarah Bush Lincoln,
and they set the bar high. Sarah Bush Lincoln, trusted, compassionate
care, right here, close to home. Male Voice:Carle is redefining healthcare
around you. Innovating new solutions, and offering all
levels of care, when and where you need it. Investing in technology and research to optimize
healthcare, Carle with Health Alliance, is always at the forefront to help you thrive. Rameen:
Meeting the ever changing in healthcare needs of our communities. Paris Community Hospital/Family Medical Center
is now Horizon Health, with the same ownership, management, providers and employees. Horizon Health provides patient care and promotes
wellness to the communities of East Central Illinois. Jeff:
At HSHS St. Anthony’s Memorial Hospital we are at work transforming heart care, rebuilding
knees and hips, delivering new generations, and focused on providing healthcare to you. We are HSHS St. Anthony’s Memorial Hospital. Ke’an: Hi. Thank you so much for joining us today for
this episode of “Being Well.” I’m your host Ke’an Armstrong. And today we’re going to be talking about
gastroenterology. Joining me today is Dr. Kumar with HSHS Medical
Group in Effingham. Thank you so much for joining us today. Nitin: Thank you. Ke’an: Yeah, very important topic. Something that maybe people struggle with
and don’t want to let other people know. But there’s answers out there and that’s why
we’re here to tell them about it today. Nitin: Yes. Thank you for having me. Ke’an: Yeah, absolutely. So tell me, what is a gastroenterologist? What do you do? Nitin: A gastroenterologist takes care of
diseases and symptoms of the gastrointestinal tract, which means the esophagus, stomach,
colon, the small intestine, and also the liver and the pancreas. Additionally, we have specific training in
doing procedures like endoscopies and colonoscopies. Becoming a gastroenterologist involves doing
an internal medicine residency, followed by three years of training in gastroenterology
specifically, and at times an extra year of endoscopy training. Ke’an: Lots of training because there’s lots
involved in that area. Nitin: Yes, that is true. Ke’an: Yes. So folks who … you mentioned endoscopy,
I may not get all of the names right. I’m going to try here. So is that how I say it? Nitin: Endoscopy. Ke’an: Endoscopy. What is that exactly? Nitin: Endoscopy is a camera examination of
the esophagus, stomach, and the first part of the small intestine, the duodenum. It’s performed by a flexible fiber optic scope. During the procedure we can not only look,
but we can also take biopsies, which are little bits of tissue that go to a pathologist to
look at under a microscope. So if there’s a disease that we can’t see
with our eyes, a pathologist may be able to tell us what’s going on by looking at the
tissue under a microscope. And we can dilate the esophagus if it’s narrowed,
or cauterize bleeding areas if necessary. So the procedure is looking, but we can also
do a lot of things inside. Ke’an: Okay. So what would lead somebody toward getting
something like that done? Maybe some issues, symptoms that they’re having. Why would you do that? Nitin: An endoscopy can be useful to examine
symptoms of the esophagus. Like feeling that food is getting stuck on
the way down. Heartburn, reflux, pain, bleeding. It can be used to examine the stomach, upper
abdominal pain, suspicion of an ulcer, black tarry stool. It can be done to biopsy the small intestine
if we suspect celiac disease in which people can’t have gluten. So there are, there are many, many indications
to have an endoscopy because it’s a very flexible procedure. Ke’an: Okay. All right. So the scope goes in your mouth and down? Nitin: In the mouth, down the esophagus, stomach,
and into the first part of the small intestine. This is done usually under sedation. So the patient is not aware of anything. Ke’an: So is it an outpatient procedure? They don’t have to stay in the hospital for
that? Nitin: It’s generally an outpatient procedure. Ke’an: Okay. All right. So what about colonoscopy? Explain that. Nitin: Colonoscopy is similar. A fiber optic exam through a flexible fiber
optic scope. It’s a video camera look at the entire colon. If we need to, the end of the small intestine
from below. Similar to endoscopy, we can take biopsies,
we can get pieces of tissue. The indications are somewhat different. It can be done for a change in bowel habits,
but it can also be done to investigate symptoms like blood in the stool. In some cases, abdominal pain to check for
diseases like Crohn’s disease and ulcerative colitis. It can be done most importantly and most commonly
for screening to check for colon cancer, and to remove polyps before they can become colon
cancer. Ke’an: Okay. When should a person start getting colonoscopies? Nitin: For screening for colon cancer, the
societies vary on their recommendations. In general age 50, but the American Cancer
Society recommends starting at age 45. Most societies recommend starting earlier
if there’s a family history. So 10 years younger than the most immediate
relative who’s had colon cancer or an advanced polyp. In some cases, societies recommend even earlier
if there is a polyp syndrome, as early as age 10. Then of course, aside from all that, if there
are symptoms that are concerning for colon cancer, like blood in the stool, weight loss
that’s unexplained, anemia, or a low blood count, low iron, these things can warrant
a colonoscopy as well. Your primary doctor can help you to examine
your family history in detail because there are certain cases in which multiple relatives
have had colon cancer, not necessarily just immediate relatives, in which a colonoscopy’s
needed earlier. Ke’an: Okay. Now is that the only screening for colon cancer
is a colonoscopy? Nitin: There are other methods for screening
as well. You can have stool tests to check for blood
or DNA that can suggest that you may have colon cancer or an advanced polyp. So there are a variety of tests for screening
for colon cancer. However, there’s a difference between screening
and prevention. A lot of the stool tests or other alternative
tests check you for colon cancer. A colonoscopy also checks you for colon cancer,
but because we remove polyps, a colonoscopy, unlike everything else, actually prevents
colon cancer from ever happening. In the United States, we take out about 10
million or more precancerous polyps every year. In a decade, we’ve taken out over 100 million
precancerous polyps in the United States. Ke’an: That’s amazing. Nitin: That is amazing. And the result has been that colon cancer
rates have declined by about half. Ke’an: Really? Nitin: They are continuing to decline steadily. So colonoscopy is the only test that checks
for colon cancer but also prevents colon cancer, and that has significant benefits at the population
level and also for individuals. Ke’an: Okay. Now I’m coming from a layman’s point of view
here. Is colon cancer the same thing as colorectal
cancer? It’s the same? Nitin: In general, yes. Ke’an: Just different ways of saying it? Nitin: Just different ways of saying it. The colon and rectum are continuous with each
other. The rectum is the little bit at the end. Colorectal cancer is an umbrella term that
covers all of that, all of those areas. Ke’an: Okay. Now is there a difference between a high quality
colonoscopy? Is it all the same thing? Or is there differences? Nitin: There are methods we can use to do
a higher quality colonoscopy. High quality colonoscopy is important because
finding precancerous polyps that are hidden, sometimes small, sometimes difficult to see,
is critical. Because left alone, if they’re not removed,
those polyps can grow, become more and more abnormal, and eventually become a cancer. So our goal is to find all the polyps and
take them out during the colonoscopy. In order to do that better, there are techniques
like water exchange colonoscopy. In which instead of putting in air or carbon
dioxide on the way in, we put water in and suction out dirty water. This results in a cleaner colon. If patients are having partial sedation or
conscious sedation, it’s a more comfortable exam. Additionally, we use carbon dioxide instead
of air when we insufflate because that results in less pain after the procedure. A slow withdrawal, carefully looking behind
all the folds is critical because polyps can hide behind the folds that are facing away
from us. It’s also important to take time in withdrawing
the scope on the way back as we look for polyps. Clean on the way in so that on the way back
we can focus on polyp detection and removal. Ke’an: Okay. Nitin: Finally we can look at certain areas
of the colon twice and make sure that we didn’t miss something. Ke’an: Yeah. Very important to make sure you’re looking
for everything while you have the opportunity. Nitin: Yes. Ke’an: So is the preparation the same for
both procedures? For the patient? Nitin: The preparation is different. For an endoscopy, patients usually just have
to stop eating at midnight on the night before the procedure. For a colonoscopy, they usually have to have
a clear liquid diet the day before the procedure and go through a bowel preparation. Now the bowel preparation is what most people
are afraid of doing or averse to doing. Because of that, people avoid having a colonoscopy. But our bowel preparations have improved dramatically
in the last 10 or 20 years. It used to be a gallon of salty fluid that
no one liked. It was hard to keep it down. Now we’ve gone to lower volumes of Gatorade
and MiraLax, which is tasteless. Then there are prescription preparations available
that are as little as two cups in size. So this has made getting a colonoscopy done
much easier and much more pleasant. So there are a lot of options now for that. Ke’an: Right. Well, you hear a lot of people saying, “I’m
not going to do that. I’m not going through that. I’ve heard horror stories.” So good news to come. It’s not as bad as what it may have sounded
in the past. Nitin: That’s right, yes. Ke’an: So talking about the endoscopy and
around this region. How does someone know? Maybe it’s just heartburn. I don’t know. Maybe it’s just something I ate not agreeing
with me today. How do you know when there’s a real problem? And how to know when to go to the doctor? Nitin: That can be challenging. A lot of patients have heartburn from time
to time. Especially with certain foods, or large meals,
or when lying down. It can be difficult to decide when is that
enough that it’s a problem? Certainly if using a medication, it’s a proton
pump inhibitor like Omeprazole, Nexium, Prevacid, Prilosec, Pantoprazole, Lansoprazole. If using a medication like that for four to
eight weeks is not effective, that’s a sign that an endoscopy is a good idea. To check for esophageal cancer or Barrett’s
esophagus or other concerns that develop from acid reflux that causes heartburn. A lot of times acid reflux or reflux of bile
or pancreatic enzymes can be occurring silently and we don’t feel the burning. So it’s also a good idea to watch for other
symptoms. Difficulty in getting food down, or weight
loss that’s unexplained, a low blood count, throwing up blood, or having black tarry stool. It’s a good idea if there are any worries
to talk with a primary care doctor about whether an endoscopy is a good idea. To see if there’s something more going on
like an ulcer in the esophagus, inflammation of the esophagus, Barrett’s esophagus, a stomach
ulcer. Ke’an: All right. Now what is Barrett’s esophagus? I’ve never heard that term before. Nitin: Barrett’s esophagus is perhaps the
link between heartburn and esophageal cancer. Esophageal cancer is usually found at a later
stage. It’s usually found at a stage where the optimal
treatment that we would like to do is no longer an option. Barrett’s esophagus is a change in the surface
of the lower esophagus, the part of the esophagus that is most exposed to stomach acid, bile,
pancreas enzymes. We think that perhaps stomach acid exposure
in the lower esophagus causes the esophagus to change, and that change leads to a higher
risk of esophageal cancer. We think that’s where most lower esophageal
cancer comes from. That change, if found, should be monitored. Because the risk of cancer of the esophagus
is somewhere between one a 100, to one in 500 per year, that will convert from Barrett’s
esophagus to esophagus cancer. In the meantime, before that change happens,
we hope that we can find dysplasia in the Barrett’s esophagus. We monitor for dysplasia with biopsies every
year or every few years. If we find dysplasia, then we take action
to prevent it from becoming cancer. Ke’an: Okay. When you say dysplasia, explain that to folks. Nitin: Dysplasia is a term that pathologists
use when they’re looking at the tissue under a microscope. It’s a change that is halfway to cancer. So when they find dysplasia, they grade it
as a low grade dysplasia or a high grade dysplasia. Depending on what they find, we determine
what we need to do. Whether it’s closer monitoring or sending
them to get their Barrett’s esophagus ablated. Sometimes in rare cases, severe cases, we
have part of the esophagus removed. Especially if there’s an early cancer that
we can’t remove with other means. In order to prevent an esophageal cancer that
spreads. Ke’an: Hmm, okay. Now if you were to remove part of the esophagus,
can a person still function by eating food and swallowing? Does it affect a person’s daily living? Nitin: In general, it does have a big effect
on a person’s daily living and every case is different. But in general, a surgical removal of part
of the esophagus results in dramatic change in quality of life. So we try to prevent that by finding Barrett’s
esophagus early. Once we’ve found Barrett’s esophagus by finding
dysplasia early, so that that never needs to be done. We want to avoid that surgery. Ke’an: Right. Sounds like that. You mentioned earlier celiac disease and folks
who can’t eat gluten. We’ve talked about heartburn and acid reflux. Is it all dependent on what we eat, and what
goes in our body, and how our body reacts to that? And talk about celiac disease in that fold,
if you would? Nitin: Sure. So heartburn and reflux are not terribly dependent
on diet. A lot of times heartburn and reflux reflects
being upward movement of stomach contents into the esophagus. Is due to a hiatal hernia in which the stomach
has slipped upwards partially above the diaphragm and part of the stomach is now in the chest. When there is a hiatal hernia like that, the
diaphragm is no longer pinching the junction of the esophagus and the stomach. In other cases, the esophagus is not functioning
well, and we all have some degree of reflux, and the esophagus clears it. But if the esophagus doesn’t do that, then
we may notice more heartburn. Diet can affect these things by increasing
the symptoms. It may, if you have a large meal and the large
meal doesn’t leave the stomach very well, result in prolonged heartburn. If you have a meal right before eating and
you lie flat, the lack of gravity will allow food and liquid to move up your esophagus. So in some sense, diet can make an impact
on heartburn and reflux. Large meals, eating right before bed time. But in other ways, people with heartburn and
reflux have a physical defect that diet will not necessarily affect. Ke’an: But diet does affect celiac disease? Nitin: Yes, diet greatly affects celiac disease. Celiac disease is a disease in which the immune
system attacks the gastrointestinal tract. It does that after it’s exposed to gluten
in our diet. So gluten intake can result in subsequent
and prolonged attack by the immune system on the body long after the gluten has passed
through. So in a patient diagnosed with celiac disease,
a gluten free diet is essential. By gluten free, we mean really gluten-free. We had a patient who was sharing a toaster
with her husband. She was having gluten free bread, but just
the exposure of her bread to the toaster where her husband was having normal bread, resulted
in visible damage on biopsies of her small intestine. Ke’an: Really? Nitin: So the only treatment for celiac disease
is a strictly gluten free diet forever. At least for now. We can monitor the results on biopsies, and
we can see the improvement in the intestine when the patient enacts a gluten free diet
in celiac disease. Ke’an: Okay. Talk to me about irritable bowel syndrome. Nitin: Irritable bowel syndrome is an issue
of function rather than structure. There is no structural abnormality in the
intestine, but there is a functional abnormality and that results in symptoms. A syndrome is a collection of symptoms, rather
than specifically a disease on its own. In diagnosing irritable bowel syndrome, we
have to eliminate other possibilities. It is a diagnosis of exclusion. There are also criteria, Rome criteria, which
need to be met. But we have to eliminate bacterial overgrowth,
celiac disease, and other diseases, which may be causing these symptoms. Before we can confidently say that someone
has irritable bowel syndrome. Once we make a diagnosis of irritable bowel
syndrome, then our goal is to control the symptoms of the disease as best we can. Ke’an: So is syndrome and disease two different
things when it comes to irritable bowel? Nitin: Yes. So there is an irritable bowel syndrome, which
is a group of symptoms. Our goal is to eliminate diseases which may
be tricking us into thinking that a patient has irritable bowel syndrome, when in fact
they may actually have a disease like celiac disease or inflammatory bowel disease. Ke’an: It sounds like it could be complicated
trying to figure out exactly what may be going on within a person’s body. Is it take a number of tests? A long time? Is it a short time sometimes? Talk to me about the timeframe on trying to
figure out exactly what’s going on with a person’s body. Nitin: Yes. So the diagnostic process varies. It varies based on a patient’s risk factors,
their general health, sometimes their age. In some cases, a diagnosis is easier to make. In other cases, because we’re concerned and
our pretest probability is high, we are more concerned about diseases other than irritable
bowel syndrome. So the diagnostic process varies tremendously,
but in general, it does require a good number of tests to confidently exclude diseases like
celiac disease, inflammatory bowel disease, small intestinal bacterial overgrowth. Which may make us think that someone has irritable
bowel syndrome when in fact they have something we can treat and in some cases, cure. Ke’an: Okay, now is irritable bowel treatable
or curable? Or both? Nitin: Irritable bowel syndrome is treatable
chronically. If there is an underlying disease process
like bacterial overgrowth, then bacterial overgrowth can be cured. And perhaps the symptoms that we were attributing
to suspected irritable bowel syndrome will vanish. Ke’an: Okay, good to know. Because there’s ways that you can help people’s
lives. Because it really does, it takes over sometimes. Nitin: It can. Ke’an: A person’s life and makes them miserable. Nitin: Yes, irritable bowel syndrome can be
associated with significant distress, significant interference with daily activities. So successful treatment of irritable bowel
syndrome is usually life changing for people. Ke’an: Absolutely. Now I’ve heard a term called diverticulosis. What is that? Nitin: Yes. Diverticulosis is the formation of diverticula
in the colon. Diverticula are divots in the colon that form
over time. About half of people have them by age 50,
about 80% of people have them by age 80. We think that this has something to do with
diet. Perhaps it’s low fiber, although that’s controversial
right now. As these diverticular form there is risk for
two things. One is bleeding. As the diverticular get deeper, they may erode
into a blood vessel resulting in painless, large volume bleeding that should be attended
to in the emergency room to see if IV fluids are necessary. Blood transfusion is necessary. It may be necessary to rule out a cause for
bleeding as soon as possible, like a growth or a tumor. But in general, the bleeding does not recur
and is self-limited. Diverticulitis is an infection of a diverticula
and that occurs when the diverticula becomes impacted. Sometimes there can be a micro perforation
or a perforation of the colon in that area. In which a hole forms in the diverticulum
and stool contents go into the abdomen. The patient can get an abscess. In those cases, antibiotics are necessary. Usually with diverticulitis, we do a colonoscopy
when the diverticulitis has quieted down to exclude the presence of a tumor or something
else that needs to be attended to. Ke’an: Okay. We’ve got a couple of minutes left and on
my list here I have something called gastroparesis. Nitin: Yes. Ke’an: Explain that. Nitin: Gastroparesis is a very common cause
for nausea, especially in patients with diabetes. It’s a result of the stomach not emptying
properly and when food stays in the stomach for an hour, two, three, four hours frequently
nausea results, sometimes heartburn and reflux is a result. This can be treated with medication and in
rare cases, interventions such as a venting tube, a venting feeding tube. Sometimes surgery or placement of a stimulator
is needed. But in patients with prolonged nausea, it’s
worth checking for. Ke’an: Yeah, absolutely. Well, like I said, we have a couple of minutes
left. Is there anything that we haven’t covered
that you’d like to get out to our viewers right now? Nitin: One thing that we are doing as gastroenterologists
is treating obesity and weight management. So there are a number of endoscopic options
for weight management. Including intragastric balloons, which are
balloons that are placed in the stomach, take up space, and can result in significant weight
loss while they’re in place. Usually we work with those patients to implement
diet and lifestyle monitoring so that they can maintain the weight loss long term. Additionally, there are feeding tubes which
can be placed and then some of the food can be removed. The stomach can be sutured into a smaller
size. So there are a number of emerging endoscopic
options for weight management. Ke’an: It sounds like new treatments, different
things to help people in lots of difficult situations. Nitin: Yes. Ke’an: Well, we’ve gotten a lot of information
out to our viewers today. I want to thank you so much for being a part
of “Being Well” and taking the time to talk to our viewers today. Nitin: Thank you. It’s been a pleasure. Ke’an: Thank you. And thank you very much for tuning in for
this episode. We hope that you have found it useful and
very informative, and we’ll see you next week. Jeff:
At HSHS St. Anthony’s Memorial Hospital we are at work transforming heart care, rebuilding
knees and hips, delivering new generations, and focused on providing healthcare to you. We are HSHS St. Anthony’s Memorial Hospital. Rameen:
Meeting the ever changing in healthcare needs of our communities. Paris Community Hospital/Family Medical Center
is now Horizon Health, with the same ownership, management, providers and employees. Horizon Health provides patient care and promotes
wellness to the communities of East Central Illinois. Male Voice:Carle is redefining healthcare
around you. Innovating new solutions, and offering all
levels of care, when and where you need it. Investing in technology and research to optimize
healthcare, Carle with Health Alliance, is always at the forefront to help you thrive. Lori:They’re the ones who raise the bar. The ones dedicated to providing care in the
most demanding of circumstances. The ones that understand the healing benefits
of kindness and compassion. They’re the people of Sarah Bush Lincoln,
and they set the bar high. Sarah Bush Lincoln, trusted, compassionate
care, right here, close to home. [music playing]

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