Digestive diseases & gastrointestinal disorders

Diagnosis of achalasia involves endoscopic assessment, motility studies and imaging with contrast esophagram and/or CT scans.

Treatment options for this swallowing disorder are:

• Endoscopically with Botox, dilation, POEM procedure
• Minimally-invasive surgery, called Heller myotomy, which cuts the tight muscle band. This can be approached laparoscopically or thoracoscopically and patients are often discharged from the hospital after a short one to two-day stay.

Bowel obstructions can be localized by imaging (MRI and CT scan).  They can also be assessed from the inside by capsule video endoscopy. Even in patients who have had previous surgeries, we can free up the bowel  laparoscopically. We leave IV fluid in the abdomen to prevent adhesion formation. A small bowel obstruction, which is a blockage in the small intestine, is usually caused by scar tissue (adhesions), a hernia, or a mass. 

Gallbladder medical issues are diagnosed through various tests. We use:

• Blood tests
• Ultrasound
• Computed tomography (CT)
• HIDA scan (cholescintigraphy)
• Magnetic resonance cholangiopancreatography (MRCP)
• Endoscopic retrograde cholangiopancreatography (ERCP)

Treatment can involve medications or antibiotics, endoscopic retrograde cholangiopancreatography (ERCP); or a cholecystectomy.

Celiac sprue is diagnosed in two ways.  We test for the presence of antibodies in blood and by endoscopic biopsies of the intestine. Although there is presently no cure for celiac disease, avoiding gluten in one’s diet ultimately repairs the intestinal lining in a majority of patients.

The cause of chronic constipation can often be differentiated by performing a series of tests. Initial treatments for constipation include:

• Behavioral modification
• Dietary and medication changes
• Laxatives

Other treatments include pelvic floor physical therapy and prescription medications.

Surgery is generally reserved for when poor colon motility has been proven and all nonsurgical options have failed. Minimal invasive surgery for constipation is done laparoscopically and involves removal of some or all of the colon, depending on the degree of dysfunction.

Cirrhosis can be diagnosed with:

• Computed tomography (CT)
• Ultrasound
• Magnetic resonance imaging (MRI)
• Needle biopsy of the liver

A new imaging technique called elastography, which can be performed with ultrasound or MRI, can also diagnosis cirrhosis.

Treatments focus on the underlying cause. Options include:

• A low sodium diet 
• Alcohol avoidance
• Rubber band ligation
• Therapeutic endoscopy
• Transjugular intrahepatic portosystemic shunt

In advanced cases, surgery or a liver transplant may be needed. 

A colonoscopy is recommended to identify colon cancer. If colon cancer is present, a workup determines what stage the cancer is in. The treatment for colon cancer depends on the stage. Surgery for colon cancer is appropriate in stage I, II and III and involves removing the section of colon containing the cancer and its associated lymph nodes. Chemotherapy for colon cancer is necessary in stage IV cancer and if there is spread of cancer cells into the lymph nodes or beyond. Each colon cancer is unique, and treatment requires an individualized approach determined by the surgeon and an oncology specialist. 

We intervene in patients who have recurrent episodes of diverticulitis. We also intervene when patients develop complications, such as perforations. The operations we offer for diverticulitis are done laparoscopically.

Accurate diagnosis for esophageal cancer is performed in three ways:

• Endoscopic biopsy (EGD)
• Endoscopic staging (EUS) 
• Endomucosal resection (EMR) with imaging

These diagnostics are used to determine the extent of the disease. They are critical to determine the best treatment strategy.

Advances in surgical techniques allow for individualized treatment strategies. We use minimally invasive thoracoscopic (VATS) and laparoscopic approaches where appropriate. 

Gallstones are typically detected by ultrasounds. Sometimes they are also noted in CT scans and MRI.  Once the gallbladder has formed stones, it will continue to form stones, even if stones are removed. Therefore the treatment is to remove the gallbladder. The laparoscopic approach has made cholecystectomy much safer and easier for recovery. Most patients go home right after the operation and are back to regular activities in less than a week.

Your doctor can look for signs of cancer through an endoscopy. If any suspicious areas are found, a piece of tissue can be collected for analysis (biopsy). Imaging tests are used to look for stomach cancer. 

The main treatment for this stage of stomach cancer is surgery. Chemotherapy or chemoradiation (chemo plus radiation therapy) may be given before surgery to try to shrink the cancer and make it easier to remove.

GERD is detected by endoscopy (EGD), manometry and 24 hour pH monitoring of the esophagus. Persistent, untreated GERD can be treated by laparoscopic or minimally invasive surgical methods. One such method is fundoplication. Most patients are discharged from hospital after an overnight stay and can return to work in about a week to 10 days.

Bleeding from the upper GI tract can be investigated and treated using upper endoscopy.  Bleeding from the lower GI tract can be addressed using colonoscopy. For bleeding from the small intestines, we can perform a video capsule endoscopy.  This process takes pictures of the small intestines to identify the source of bleeding.

Once the source is found, a specialized endoscopic procedure known as balloon enteroscopy can be performed. This locates the source within the small intestines and stops it. When bleeding cannot be stopped endoscopically, interventional radiology or other surgical techniques may be utilized.

Hepatitis can be resolve on its own or can become chronic.  When chronic, it  can progress to fibrosis (scarring), cirrhosis or liver cancer. We offer various ways to diagnose, manage, treat, and monitor hepatitis. Diagnosis can be accomplished through routine blood work but sometimes requires liver biopsy. Treatments will vary , however the goal is always to reduce inflammation and decrease the risk of progression.

Diagnosis for hepatosteatosis is often made using imaging. Rarely liver biopsy is required. Treatment involves treatment of the causative factors.

Inflammatory bowel disease (IBD) is a chronic immune condition associated with inflammation within the gastrointestinal tract. Crohn’s disease and ulcerative colitis are the most common forms of IBD. Presenting symptoms include diarrhea, abdominal pain, rectal bleeding, and weight loss. At times joint pains and skin conditions are the first symptoms of IBD.

In order to make a diagnosis of IBD, blood tests, stool tests, and dedicated imaging are performed. The imaging includes specific enterographies such as an MRI and CT that focus on the intestines. In addition a colonoscopy or an endoscopy are performed to complete the evaluation. Once the diagnosis is made, multiple treatment options are available that can be taken in pill form, IV form, or injectable forms.

When choosing the proper treatment route, multiple factors are taken into account, which always involves the patient at the center of the discussion addressing all patients questions and concerns. At times surgery is required either at the first stage of diagnosis or late into the disease. There are dedicated surgeons called colorectal surgeons that offer the latest most up-to-date surgical therapies, often using the least invasive approach such as laparoscopy. These procedures are often therapeutic and at times curative of the disease.

Although irritable bowel syndrome (IBS) can cause discomfort, it does not harm the intestines. Many people believe that IBS is the same as Inflammatory Bowel Disease, however they are not. IBS describes all patients who experience inflammation in their GI tract.

Tests for IBS may include stool sampling, blood, and X-rays. Your doctor may also do a test called a sigmoidoscopy or colonoscopy. Most people diagnosed with IBS can control their symptoms with diet, stress management, probiotics and medicine.

Blood tests may reveal liver cancer. Imaging tests, such as an ultrasound, CT and MRI, and removing a sample of liver tissue for testing (biopsy) may be recommended. If the cancerous lesion is within a defined area in the liver, surgery can be curative. Other treatment options include ablation, embolization, or both for the liver tumor(s). Other options may include targeted therapy, immunotherapy, chemotherapy (either systemic or by hepatic artery infusion), or radiation therapy.

Typically, a person is considered to have morbid obesity if their Body Mass Index (BMI) is 40 or above, or if they are more than 100 pounds overweight. BMI is calculated based on person’s height and weight.Morbid obesity can be treated effectively with laparoscopic or minimally invasive surgical techniques that involve either a sleeve gastrectomy or gastric bypass surgery. Most patients can be discharged from hospital after an overnight stay and can return to work in a week to 10 days.

Techniques used to diagnose pancreatic cancer include ultrasound, computerized tomography (CT) scans, magnetic resonance imaging (MRI) and, sometimes, positron emission tomography (PET) scans.  The main treatment for pancreatic cancer is surgery. Chemotherapy or chemoradiation (chemotherapy plus radiation therapy) may be given before surgery to try to shrink the cancer and make it easier to remove.

When pancreatic cancer has spread, there are other forms of treatment including chemotherapy (with or without targeted therapy), palliative treatments to relieve pain, such as nerve blocks, and other supportive care; palliative surgery or stent placement to bypass blocked areas in ducts or the small intestine.

The initial manifestation of pancreatitis is pain and blood tests showing elevation of pancreatic enzymes.  The severity of pancreatitis is then gauged by CT scan.  An inflamed pancreas can lead to bleeding, infection, fluid collections and necrosis. 

Management of these complications includes embolization of bleeding vessels. We use interventional radiology, endoscopy for drainage of the cysts, fluid collections, and removal of the damaged tissue. Our team of gastroenterology specialists, surgeons, and endocrinology specialists manage and treat all aspects of pancreatitis. Treatment typically includes insulin and other blood sugar controlling medications. We sometimes use pancreatic enzyme replacement and nutritional optimization.

Ulcers are most often diagnosed through upper endoscopy (EGD). A biopsy can also be taken to check for abnormal cells, cancer, or an infection with H. pylori. Most ulcers heal completely with medications. If untreated, it can cause complications like bleeding, perforation or obstruction.

Diagnosis for rectal cancer may be made by colonoscopy or physical exam. Once diagnosed, a thorough workup will ensue to determine if there is any spread of the cancer throughout the body, and also to determine the extent of the cancer within the pelvis. MRI or rectal ultrasound are used to provide preoperative staging.

Depending on the stage of the cancer, treatment may include surgery, chemotherapy or radiation. Treatment for rectal cancer is highly individualized and requires input from the surgeon, medical oncology specialist and radiation oncology specialist. Usually a temporary ileostomy is necessary during treatment, but occasionally a permanent colostomy is required. Most surgery for rectal cancer is performed laparoscopically or robotically and overall outcomes are very encouraging.

A thorough physical exam is usually sufficient to distinguish between rectal prolapse and hemorrhoids. Once the diagnosis has been made, the treatment is almost always surgical. Several approaches exist to manage this condition,. We use resection, rectopexy, or both. Your surgeon will help you decide which approach is right for you. 

Diagnosis for Zenker’s esophageal diverticulum is made by barium esophagram and endoscopy. We offer a minimally-invasive treatment option using endoscopic transpharyngeal cricopharyngeal myotomy to cut the muscle band and provide symptomatic relieve and allow patient to safely resume eating.  Most patients can be discharged home after a short one day stay.

Interventional gastroenterology procedures are done via endoscopy. Endoscopy uses a thin, flexible tube (endoscope) with a light and camera that allows your doctor to examine the upper or lower parts of the digestive tract. With special endoscopy equipment, your doctor can not only evaluate a condition but also provide therapy.

Several locations at Atlantic Health perform endoscopy procedures. There are many types of endoscopies. Depending on the area of the body being looked at, the endoscope may be put in the mouth or anus. Sometimes, it’s put through a small cut made in the skin.

Doctors prescribe endoscopies for a variety of reasons:

• Look more closely at an area inside the body
• Take samples of abnormal tissues
• Treat certain diseases
• Remove tumors
• Stop bleeding
• Remove foreign bodies (such as food stuck in the esophagus, the tube that connects your throat to your stomach)

Preparation

If you are going to have an endoscopy, your doctor will explain to you what will be done and what to expect before, during, and after the test. They will also tell you what you need to do to prepare for the procedure. The preparation could mean that you must not eat anything for a certain amount of time, follow a liquid diet for a certain amount of time, and perhaps use laxatives or enemas.

Some of the more common interventional GI procedures include:

• Endoscopic ultrasound -  can be used to view and biopsy abnormalities of the pancreas and upper gastrointestinal tract and drain pancreatic pseudocysts
• Endoscopic mucosal resection - a procedure to remove abnormal tissues (lesions) in the esophagus, stomach and upper part of the small intestine
• Endoscopic retrograde cholangiopancreatography -  can treat blocked or narrowed bile and pancreatic ducts
• Stent placement - a procedure that uses a metal mesh or plastic tube to reopen a blocked section of the esophagus, biliary tree or intestinal tract
• Electrohydraulic lithotripsy - breaks up large bile duct stones so they can be more easily removed
• Nerve blocks - treat pain in patients with advanced GI cancer
• Closures of fistulas - which are abnormal connections between two organs in the GI tract
• Placement of fiducials - precisely mark targets for radiation therapy for cancer
• Biopsies and polyp removal during colonoscopy

These endoscopic procedures are done under sedation, allowing patients to return home and resume most normal activities the same day. 

About 20% of Americans suffer from gastroesophageal reflux disease (GERD), which causes stomach acid to leak up, or reflux, into the esophagus. While GERD is most commonly associated with heartburn — a burning sensation in the chest or throat — it can also quietly lead to a potentially dangerous condition called Barrett’s esophagus.

Barrett’s esophagus is a change in the lining of the esophagus caused by long-term exposure to stomach acid. Normal esophageal cells change into tissue that’s similar to the tissue lining the intestinal tract. In some people, this can cause a precancerous condition in the esophageal tissue called dysplasia. Dysplasia puts you at high risk for developing esophageal cancer.

To help prevent cancer in patients with Barrett’s esophagus, we offer an advanced, nonsurgical procedure called Barrx™ radiofrequency ablation.

Radiofrequency ablation uses heat energy to destroy (ablate) diseased Barrett’s tissue in the superficial lining of the esophagus. The treatment has been shown to be more than 90% effective in removing precancerous tissue from the esophagus.

How radiofrequency ablation works

Radiofrequency ablation is an outpatient procedure done under sedation. A thin, flexible tube called an endoscope is inserted into the esophagus, allowing your doctor to view and measure the abnormal tissue. The Barrx ablation device is then inserted to precisely deliver heat energy to only the diseased tissue. The tissue is destroyed and healthy tissue eventually grows back as it heals.

The procedure takes approximately 20 minutes, and you will go home the same day. Barrx therapy is repeated every three months until the lining of the esophagus returns to normal. Most patients require three or four treatments. Additional follow-up endoscopies monitor whether any Barrett’s tissue has returned.

Depending on the amount of Barrett’s tissue ablated, some patients may experience discomfort for a few days. However, most patients are back to work and other normal activities the day after their procedure.

Colonoscopy (lower endoscopy) has long been the gold standard for helping detect and prevent colon cancer, the third leading cause in the US of cancer-related deaths in women and the second leading cause in men. During the procedure, doctors can remove precancerous colon polyps before they become malignant.