Play PodcastPlay Download PodcastDownload

Transcription:

Prakash Chandran (Host): Today we are going to be talking about gastroenterology, which is the branch of medicine that focuses on the digestive tract and its disorders. There have actually been a lot of advancements in diagnostic and treatment options and here with us to discuss is Dr. Mick S. Meiselman, Director of Advanced Therapeutic Endoscopy at Sierra Vista Medical Center. Pleasure to have you Dr. Meiselman. So, why don’t we start by you giving us an overview of what you do and some of the most common things you see as a gastroenterologist?

Mick S. Meiselman, MD (Guest): Great. Well first of all, I’m certainly grateful to be here and thank you very much. Okay, as you know, as you stated, I’m an advanced therapeutic endoscopist but first, let me kind of backtrack. As a basic gastroenterologist, we see diseases of the entire digestive tract. You can start with the esophagus. We see many patients, they have heartburn, trouble swallowing, patients with abdominal pain and ulcers. We do a lot of what’s called upper GI endoscopy where we take a look with a scope into the esophagus, stomach and duodenum. The patient is sedated a little bit and we put a little scope down and it has a video chip and we are able to actually visualize the esophagus, stomach and duodenum and see whether or not there’s any inflammation or tumors or even foreign bodies and all kinds of crazy things.

On the other side of the coin, we also deal with problems of the lower bowel. Patients who have constipation, bleeding in the stool, blood in the stool, and difficulty in their lower abdomen. In those we often assess with another tube, a tube through the rectum, a colonoscopy. So, we can pass that scope with a little bit of sedation all the way up the entire colon and determine whether or not there’s blockages or inflammation or polyps or growths. Now a large portion of what a general gastroenterologist does is screening colonoscopy. Patients that are 50 years of age are candidates for screening. This is screening in the sense of making sure they don’t have cancer and to remove early polyps or polyps that are precancerous. In other words, we do colonoscopies as a screening test, but it actually prevents colon cancer by removing precancerous growths. It’s worth telling the audience and highlighting that this recommendation of 50 years of age was recently cut down to 45 years of age because we found out through extensive research and databases that the risk of a patient developing polyps and cancer was just as high at 45 at it is at age 50. So, that’s kind of an overview of what we do.

Now I personally, am a specialist in diseases of the bile duct, pancreas, gallbladder and esophagus. I do what’s called advance therapeutic endoscopy and I do three major areas of focus. One of them is Barrett’s esophagus. Another scope which is called endoscopic ultrasound which allows me to assess the upper GI tract for problems with the pancreas, bile ducts as you were saying cancer is very important. And then I also do another more of a therapeutic procedure ERCP which is endoscopic retrograde cholangiopancreatography. But bottom line is, it’s a scope that goes into the duodenum and we can then work on and access the bile ducts and pancreatic ducts. But I think I have just given you an overview there highlighted by my focus which is Barret’s esophagus, ultrasound and ERCP.

Prakash: Yeah, that sounds really good and I think one thing that’s important to know that you said is that proactiveness and that the age of 45, I think all of us hear this 50 number, but the age of 45 especially with the advancements of some of the tools and procedures that you are talking about. It’s important to go in early so you can catch those things early. And you also mentioned that one of the more common things that you see and focus on is Barrett’s esophagus. So, let’s talk a little bit more about what that is and how one might screen for it.

Dr. Meiselman: Sure. Let me backtrack for a second. Barrett’s esophagus is – it’s caused by chronic gastroesophageal reflux which is heartburn, or you may not have heartburn, but certainly heartburn is a symptom of reflux. This is acid as well as some other irritants like bile that come up from the stomach into the esophagus and the patient often experiences heartburn. But they can have chest pain. They can have fullness in the throat. Reflux is actually kind of a great mimicker because it can cause – it can present in a lot of different ways. But with chronic reflux, if you have a genetic susceptibility; you can get a change in the lining of the esophagus from this chronic damage that can develop into precancer. That precancer is termed Barrett’s esophagus.

Prakash: Okay, so it actually sounds like it’s something that if you do have that chronic heartburn, if you are more susceptible for it; that going in sooner than later is important because it can turn into something or it is something that is potentially cancerous. So, let’s talk a little bit how one might screen for it. What do you do to screen for Barrett’s esophagus?

Dr. Meiselman: I think that’s a great question. Right now, we are working on other levels, but right now let’s talk about the standard of practice. What we do is we will take an individual that has reflux and if they have one of a couple other factors that make them high-risk for Barrett’s we will do screening with and upper scope, an upper endoscopy. They come into the hospital, we give them – as an outpatient – we get you in a brief little test, we give them a little sedation and then put that scope down and we can visualize the Barrett’s esophagus, we can visualize if there is – we can biopsy or visualize if there is cancerous change or even a significant precancer. Barrett’s is precancerous, but there is a middle ground that we can also look for and gives us a chance to intervene.

Now, so getting back to your question, we take people that hit 50 years of age and we then look at them, do they have one of the risk factors. The risk factors that we generally think about are tobacco, alcohol, obesity. Obesity is actually a risk factor for Barrett’s esophagus and esophageal cancer. And Caucasian. It turns out that it is much more common in Caucasians and furthermore, more common in males. So, if you have got the chronic reflux at age 50 and one of those factors that I talked about, we would like to take a look at you with a scope. The good news is, it’s really more or less a one-time procedure. If you have precancer at age 50, you have got it and we can follow you perhaps every three years. But if you don’t have precancer by the age of 50; you are really not going to get it. So, it’s really not a bad thing to do.

Prakash: Yeah, that’s good to know. And in terms of let’s say you find it at the age or before the age of 50; how do you go about getting rid of it or treating it?

Dr. Meiselman: Good question. Well the first thing you want to do is you want to stabilize the patient’s acid reflux. And acid reflux first of all is very much mechanical. The first thing we tell patients that have Barrett’s esophagus is we got to control your reflux and you are going to have to participate. What we do is we have the patient avoid eating solid foods for three hours before bed, they can have water for three hours before bed, but they must stop one hour before. So, they really can’t have any liquids – I should say any water from one hour before bed, nothing during the night. That alone really helps because reflux at night is really where the injury occurs. So, keeping the stomach empty is really pivotal. We may ask you to elevate the head of the bed and reduce your tobacco, coffee and alcohol. These are things you can do with reflux, but when you have Barrett’s, which is already a precancerous change; you can see that the stakes are a little bit higher and we really are asking for participation on the patient’s part.

Now if we diagnose the reflux and the Barrett’s and we have a positive biopsy; we then look under the microscope to see whether there is a middle ground which is called dysplasia or whether there is cancer. If the patient just has pure Barrett’s we would ask them to come back in three years. Some people say five, but generally the guidelines are three years and have a repeat endoscopy. And we would control your reflux and we would perform serial endoscopies every three to five years making sure that you don’t advance your Barrett’s into that middle ground called dysplasia or into cancer.

On the other hand, if you have the middle ground or if you have early cancer; that’s when you really like to see me. I specialize in a technique called radiofrequency ablation. This is a technique of addressing and actually removing the Barrett’s mucosa. I do it right through a scope so it’s really like an endoscopy but what we do is through the scope, through several different devices; I can use radiofrequency waves to destroy the lining that’s abnormal and then actually if we can put you on enough of the medications that we use for reflux like omeprazole or these PPIs, purple pill that type of thing; we can have you regrow a normal lining. So, actually there is a lot we can do. Even if the patient has early cancer, I have techniques that allow me to remove the cancer through a scope. So, there’s a lot we can do but it’s predicated upon a diagnosis that’s earlier rather than late.

Prakash: Yeah, that’s really good to know that there is that treatment, especially the radiofrequency ablation that you were talking about to kind of reform that lining. I kind of want to shift a little bit into the second specialty of yours which is that endoscopic ultrasound. Apart from being something that you potentially use to diagnose Barrett’s esophagus, I want to talk a little bit about using it for diagnosing and staging cancer or really anything that you might want our audience to know about this procedure or diagnostic method.

Dr. Meiselman: Right. Well, endoscopic ultrasound is my passion and that’s actually why I came here. I was the Chief of a department at Northshore University Health Systems in Chicago, but it really wasn’t available in this area and I felt that it was one of the things physicians dream about. We all dream about having the opportunity to bring technology to an area where you are really needed. So, I came here and set up the program three and a half years ago. And I would say that it probably has exceeded my expectations in terms of what we have done for patients and the value that we put forth to the community. So, I’m very proud of it.

But in that setting, what an endoscopic ultrasound is, it’s another scope, but this time it’s got an ultrasound transducer that shoots ultrasound waves and gives us a real time picture. So, as I place the scope, I am looking on one screen that shows the picture of the esophagus, or the stomach, or if I’m going into the rectum; shows us where we are. The ultrasound transducer is able to give me a picture of what’s in the bowel wall and what’s outside the bowel. So, for instance, endoscopic ultrasound is a great test or a pivotal test for identifying and screening for early cancers of the esophagus, stomach, duodenum, pancreas and even the bile duct. A great test and it allows us to – as I said, to screen particularly for patients with family histories of pancreatic cancer. It’s by far the best test you can do, but it also allows us to – if you should have cancer, to stage how deep it is so that we can determine what the appropriate therapy is. Is this something that we can remove? Is this something that needs chemotherapy, radiation? It’s really pivotal in terms of staging.

We also use it for the rectum. We don’t really go up the colon, but in the rectum, it’s key which is the lowest portion of the colon; because tumors of the rectum, the treatments vary tremendously on how deep the lesion is. So, we put the scope in, we determine how deep it goes and also if there is any spread to any lymph glands. And it really makes a difference as to whether or not the lesion can be removed by a proctoscope or a surgeon can just come in and scrape out the lesion or whether it requires chemotherapy and radiation or whether they should go right to surgery. So, very valuable in telling us if you do have a tumor, what’s the right approach.

Prakash: Yeah, it seems like it’s great that Sierra Vista has the cutting-edge or the latest in the cutting-edge technology thanks to you kind of bringing it to the forefront and it really gives you that accurate picture of everything that’s going on. I just want to ask one more question about this. You mentioned kind of the age of 45 at getting these things checked out, but as with like for example, I’m in my late thirties; how do I be proactive about something like this? Do I go into – for example, Sierra Vista and say heh, I want to make sure to get tested with the endoscopic ultrasound method. What would you recommend?

Dr. Meiselman: Well the first thing is that if you are thinking about these things, you have to adopt a healthy lifestyle, okay? Because we want to prevent even the earliest forms. I think, and I don’t want to minimize that. I think that people need to take responsibility, keeping your weight into an ideal body range, not only is good for your heart and your self-esteem; but we now know that excessive fat distribution in the body is cancerogenic. So, there’s a reason for people to keep their weight into the normal body weight or to keep their weight into an ideal range. There’s a reason to eat right and there’s certainly a reason to avoid tobacco and alcohol. Tobacco is a generalized carcinogen, very bad for the GI tract, very bad for pancreatic cancer and esophageal cancer, colon cancer. And alcohol doesn’t help you either. Now of course, alcohol in moderation is one thing, but significant amounts if alcohol are an issue. So, I think that as a patient, you need to number one, if you are having symptoms that are anything more than very sporadic, I mean anything that repetitive, any symptoms that are occurring weekly; you have got to go to your primary doctor or seek one of our gastroenterologists. I think really that’s the first step. I think we all need to exercise for quality of life, but also exercise I really believe helps your immune system and it’s an important part of remaining healthy.

Prakash: Staying fit is something – that’s really your best medicine and being proactive with your health. So, I want to shift a little bit to the third technique that you work on and I know for short it is called ERCP, but doctor, I’m going to let you say the full name and then maybe tell us a little bit about what it is and what you use the procedure for.

Dr. Meiselman: Sure. ERCP stands for endoscopic retrograde cholangiopancreatography. Now this is a procedure that’s more widely available. EUS for instance, we are the center in the central coast of California for sure. We see patients from 100-150-mile range. ERCP is more widely available but what we offer at Sierra Vista are all the complexities of ERCP, the real high-grade ERCP and I will go into that. But ERCP we pass a scope down and what we can actually do is we can get into the bile duct and get x-rays and determine whether or not the different problems that the patient is experiencing is related to bile duct stones, now you can have stones in your gallbladder but stones in the bile duct are actually probably in many ways even worse. You can have stones in the bile duct and we can diagnose them and then actually treat them right through the scope. We actually take little devices through channels in the scope where we can cut open the – it’s called a sphincter that leaves from the duodenum which is the intestine up into the bile duct. We can cut that open and then use other devices to enlarge that opening and actually remove stones.

Now often we see neoplastic or tumor blockages of the bile duct and it’s very important to open the bile duct because remember, the bile duct connects the liver to the intestine. And the liver secretes bile which helps in digestion. But it also secretes toxins. It’s one of the ways that a liver will get rid of toxins is to pass them through the bile duct into the intestine and out the stool. So, if the bile duct is blocked and that’s usually heralded by jaundice or yellow jaundice; we can actually get in through a scope and put a stent or a plastic tube or a metal tube and relieve the obstruction and restore the physiology somewhat more normally.

We can also – so it treats both stones and blockages. What we do also, and to a very large extent more than most universities is we actually use what’s called cholangioscopy. What we do is we take the general scope that we have that accesses the outside of the bile duct and we pass through one of the channels a tiny scope that actually let’s us look inside the bile duct and see what is really happening more so than any x-ray or ultrasound or any other approach. It allows us to directly biopsy or take samples of the tissue. We have had in the last month, we have seen so many esoteric diseases of the bile duct and we were talking about this at our community tumor board and everybody understood, he said well you know people talk about there being only 28 of these ever reported and we have seen two in the last two weeks. And I said well, when you have the technology; you find these things that heretofore were really rare or just not understood and so we are very grateful that we have the technology that we have – there is nothing we need. We have got everything that you can get. We can put lasers up there to dissolve stones and make diagnoses that we couldn’t make before, so I’m in a grateful position to be able to offer that.

Prakash: Dr. Meiselman thank you so much. I think a recurring theme for all of us is just to hear how far technology has come, not only in diagnosing, but actually treating what’s going on. For a referral to a board-certified physician please call the Sierra Vista Regional Medical Center and Twin Cities Community Hospital Physician Referral Line at 866-966-3690. My guest today has been Dr. Mick S. Meiselman. I’m Prakash Chandran. Thank you so much for listening.