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Technology tackles difficult digestive problems

Medicine@Yale, 2008 - Nov Dec


Patients who chronically suffer from such common digestive problems as heartburn, bloating or trouble swallowing often try unsuccessfully to manage the symptoms on their own. When, in frustration, they seek the help of a physician, the outcome can be equally disappointing, because these disorders are notoriously difficult to diagnose.

Yale Medical Group’s new Gastrointestinal Motility Program, in collaboration with Yale-New Haven Hospital, hopes to change that. The multidisciplinary program, one of the first of its kind in Connecticut, brings together a team of eight gastroenterologists, surgeons, pathologists and radiologists to provide the latest diagnostic and treatment services to patients with hard-to-diagnose gastrointestinal disorders.

The program provides evaluation for a wide array of common and rare gastrointestinal disorders including achalasia (difficulty swallowing food); gastroesophageal reflux (heartburn); gastroparesis (weak stomach); fecal incontinence; intestinal pseudo-obstruction (abdominal bloating and pain); small intestinal bacterial overgrowth, or SIBO; and constipation.

Anish Sheth, M.D., the program’s director and an assistant professor of medicine at Yale, says the program, launched in July, was created in response to patient need. “We’re seeing increasing numbers of patients with motility disorders—reflux-related diseases, problems swallowing and constipation,” he says. “But there really wasn’t either the expertise or the focus to offer a program to help these patients.”

Many gastrointestinal symptoms are caused by the way the intestine’s muscles and nerves work together to move food down the GI tract. These conditions are grouped under the term “motility disorders.” Traditionally, physicians use an endoscopic evaluation to make a diagnosis. The problem, according to Sheth, is that while endoscopies provide a good visual picture of the GI tract, they often are ineffective in diagnosing motility disorders, which are caused by weak or uncoordinated intestinal function. “The intestines are essentially nerve and muscle,” Sheth says. “When they don’t function properly, even though everything may look okay, that often is the cause of the patients’ symptoms.”

Sheth’s program offers recently developed, specialized tests to diagnose these elusive symptoms.

The Bravo pH monitoring system, a catheter-free instrument that measures acidity levels in patients suspected of having gastroesophageal reflux disease (GERD), is a small capsule attached to the wall of the esophagus. It transmits data to a pager-sized receiver, which is worn by the patient for 48 hours. During the test, the patient pushes a button whenever he or she experiences symptoms, so doctors can see if the symptoms correlate with episodes of acid reflux. When the test is over, data from the receiver is downloaded to pH analysis software, where it is analyzed.

The SmartPill capsule, a new technology available at only about a dozen medical centers around the country, is an ingestible device that measures pressure, pH and temperature as it moves through the GI tract, allowing physicians to identify where abnormalities in intestinal transit are located. The SmartPill transmits information to a data receiver worn by the patient. After the capsule has passed from the body, the patient returns the receiver to the physician, who is able to display and analyze the data within minutes.

Impedance monitoring is a catheter-based system that enables doctors to diagnose non-acid reflux, in which bile or other digestive fluids other than stomach acid enter the esophagus. The patient wears the monitoring system for 24 hours, and pushes a button whenever he or she experiences symptoms. Physicians then download and analyze the data to determine whether the reflux is acidic or non-acidic and whether the symptoms correlate with incidents of reflux. Other motility tests offered by the program include high-resolution esophageal manometry for evaluation of swallowing difficulty; anorectal manometry with biofeedback for the evaluation and treatment of constipation and fecal incontinence; and hydrogen breath testing for the diagnosis of bacterial overgrowth.

Because of these and other new tools, advances in the diagnosis of GI disorders have outpaced treatment, Sheth says. “We’re able to diagnose and explain things much better than we were 10 years ago, but treatment needs to catch up.” He’s hoping Yale’s Gastrointestinal Motility Program will become a center for cutting-edge research and testing. “We have a couple of protocols ongoing and I anticipate this center becoming a leader in clinical trials for motility disorders.”

The motility program treats adult patients, and collaborates with specialists from pediatrics when necessary. Given how many people suffer from gastrointestinal disorders, Sheth predicts a sharp jump in referrals once community physicians become aware of the program’s existence.

“It’s an exciting area of research and clinical care,” he says.” It’s an area where technology is advancing and where there’s long been a need.”

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