Advances in treating digestive diseases

How has the practice of gastroenterology changed most dramatically?

The most dramatic change is that there are now excellent ways to make diagnoses. Before we had rigid scopes that were difficult to operate and a little bit hazardous to the patient. They did not provide nearly as much information as the modern devices do. We mainly relied on the patient’s clinical history, laboratory tests, and the GI series, which used x-rays to diagnose problems in various parts of the digestive system.

The endoscope enables us to look in the digestive tract, take biopsies and accurately diagnose ulcers. We now use endoscopes to take biopsies to look for the bacterium H. pylori, which is a major cause of ulcers.

Colonoscopy has revolutionized the early detection of polyps. People who have colonoscopies and have polyps removed have a much lesser incidence of colon cancer.

Another breakthrough is capsule endoscopy. The first to use this technology is southern California. It’s a little capsule, about the size of a large vitamin pill, but it has a complete lighting and transmitting system that provides images of the entire small bowel.

Historically, the small bowel has been hard to access. You had a scope that looked at a short portion of the small bowel. But this capsule looks at the entire small bowel, taking over 50,000 pictures over eight hours (one picture every three seconds or so). The patient takes the capsule in the morning and goes through the day normally. He or she wears a belt that has sensor arrays so it can pick up the data from the capsule. After eight hours have gone by, the patient removes the belt and the physician can review all the photos from the inside of the small bowel on a computer screen and make a diagnosis.

CAT scans, for example, are highly-refined and provide excellent visualizations of the pancreas. We can see pancreatitis (inflammation of the pancreas) and the things that lead to pancreatitis, such as gallstones. We can also see cancer of the pancreas in various forms.

CAT scans also enable us to look at various areas of the esophagus. It’s been very helpful in working with Crohn’s disease and colitis.

The next generation of imaging technology is still being developed. Where was it going?

We now have virtual colonoscopy — which can make beautiful pictures of the colon with a high degree of accuracy, especially for polyp detection — rivaling conventional colonoscopy. The problem is that if you see a lesion or a suspect polyp using this technique, you still have to do a biopsy using conventional colonoscopy.

Advances in imaging have led to a revolution in the ability to diagnose. Imagine, in terms of treatments, you have seen a lot of advances from pharmaceutical manufacturers.

H2 blockers and proton pump inhibitors (PPIs) have been two of the most significant advancements in treatment options. H2 blockers are drugs that prevent or block the production of gastric (stomach) acid. These drugs are used to heal ulcers and relieve the symptoms and pain associated with gastroesophageal reflux disease (GERD). H2 blockers are available over-the-counter (OTC) or in prescription doses. They are highly effective and are excellent in treating and preventing ulcers. We can also treat most cases of GERD very effectively with PPIs. This is important because we now know that some people with GERD that is not properly treated can develop a pre-cancerous condition called Barrett’s esophagus.

Where are the frustrations or challenges in treating GI diseases?

One of the biggest frustrations is that 15 percent of the people who have irritable bowel syndrome (IBS) have a lot of cramps and diarrhea or constipation in some cases. We still do not have a clear understanding of why the bowel is so unusually active in IBS sufferers — why there is such increased motility (bowel movement). Newer drugs are becoming more and more effective, but I think the treatment options for IBS are still less than adequate and that’s a frustration.

GI bleeding is also frustrating. NSAIDs are very useful in controlling arthritis, but they can create ulcers that lead to GI bleeding. They knew COX-2 NSAIDs were thought to lessen the risk of developing ulcers but recently some of them have been found to lead to coronary disease.

Another big frustration is cancer of the pancreas. It still has a five-year cure-rate of only one to two percent. Finding the people who have it and diagnosing them in time to help them is still a challenge. We have better chemotherapy for it, but it’s still not enough to cure the disease.

Another challenge is diagnosing esophageal cancer early enough. With early detection, it often can be treated effectively with chemotherapy in combination with surgery.

A developing problem is non-alcoholic fatty liver disease (NAFLD), which is becoming very common due to the epidemic of obesity, even in young kids. People who are obese are also have high blood pressure, diabetes, or a tendency toward diabetes, and they are at risk for NAFLD.