January 17, 2013 · 10:10 am

Treatment-resistant Chronic Constipation: Sign of an Underlying Motility Disorder

Deborah Bethards, M.D.

Deborah Bethards, M.D.

Most gastroenterologists have encountered patients who complain of chronic constipation. Colonoscopy shows no anatomical abnormalities. Nonetheless, conservative treatment with laxatives and bulking agents brings only temporary, minor relief. After several failed treatment attempts, the patient is distressed, uncomfortable and anxious; the gastroenterologist is frustrated. Deborah Bethards, M.D., a gastroenterologist at Penn State Hershey Medical Center’s Neurogastroenterology and Motility Clinic explains, “Failure of conservative treatment to resolve constipation should be a red flag. With no other detectable abnormality, the possibility of a chronic pelvic floor disorder that primarily affects women—known as dyssynergic defecation—should be considered.”

With this disorder, the rectosigmoid area does not function properly so that during attempted defecation, paradoxical anal contraction occurs, and pelvic floor muscles fail to relax. The result is that stool is retained in the rectum. If left untreated, complications such as fecal impaction, rectocele, megacolon, and fecal incontinence may occur. Continue reading →

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January 16, 2013 · 10:10 am

Cancer Genetics Program Expands as Universal Screening for Lynch Syndrome Considered

The Penn State Hershey Cancer Genetics Program was developed in 1998 to provide genetic counseling services to individuals concerned about a personal or family history of cancer. New patient appointments typically involve the development of a three- or four-generation family pedigree, education about various risk factors for developing cancer, and discussion regarding risks, benefits, and limitations of genetic testing, if appropriate. Options to manage one’s increased risk for cancer are reviewed, including dietary and lifestyle changes, as well as enhanced surveillance, chemoprevention, and prophylactic surgery.

Over the past fourteen years, nearly 300 patients have been identified to carry a genetic predisposition to cancer. Hereditary gastrointestinal cancer syndromes identified include not only the more common ones such as Lynch syndrome, FAP, and MYH-Associated Polyposis (MAP), but also the more rare conditions such as Cowden syndrome (or PTEN Hamartoma Tumor syndrome), Peutz-Jeghers syndrome, and Hereditary Diffuse Gastric Cancer syndrome. Continue reading →

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January 15, 2013 · 10:09 am

Coordinated GI Cancer Care from Diagnosis to Long-term Survival

Gastrointestinal (GI) cancers are among the most complex malignancies to treat; often, patients present with advanced disease and survival rates tend to be low. In 2005, a small group of hepatobiliary surgeons at Penn State Hershey Medical Center came together and formed the Liver, Pancreas, and Foregut Tumor Program to deliver state-of-the-art, multidisciplinary care for this difficult to treat patient population. The group has grown over the years to include four hepatobiliary surgeons: Kevin Staveley O’Carroll, M.D., Ph.D., director of the Liver, Foregut and Pancreas Program; Niraj J. Gusani, M.D., M.S., F.A.C.S.; Jussuf T. Kaifi, M.D., Ph.D.; and Eric T. Kimchi, M.D., F.A.C.S.

The multidisciplinary and coordinated nature of the program is unique to the central Pennsylvania region. Patients admitted into the program receive coordinated care from a team of surgeons, gastroenterologists, hepatologists, medical oncologists, radiation oncologists, radiologists, geneticists, and psychiatrists. Diagnostic questions are optimally clarified by modalities such as endoscopic ultrasound and computed tomography, with expert gastrointestinal pathologists providing immediate interpretation when biopsy procedures are necessary, resulting in high diagnostic accuracy with less repeat procedures. Such facets of the program allow surgeons to optimally address the challenges of tumor removal in these cases. Continue reading →

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January 14, 2013 · 10:09 am

Tackling Difficult Pediatric Feeding Problems: A “Whole Child” Approach

Douglas G. Field, M.D.

Douglas G. Field, M.D.

Proper daily nutrition is a necessary part of growth and development and usually a source of comfort and pleasure. But for many pediatric patients with congenital or acquired medical issues or behaviorally-based impairments, “Feeding problems can be a source of stress for patients, parents, family members, and may endanger the child’s overall health and development,” according to Douglas Field, M.D., a pediatric gastroenterologist and medical director of the Penn State Hershey Pediatric Feeding Program.

Field, along with Keith Williams, Ph.D., B.C.B.A., director of the pediatric feeding program and practicing behavioral psychologist, have tailored the program to provide diagnostic, treatment planning, and interventions for children with problems ranging from food refusal to motor impairments that hinder proper swallowing. Prior to their appointments at Penn State Hershey, both Field and Williams worked in the Pediatric Feeding Disorders Program at the Kennedy Krieger Institute in Baltimore, Maryland. Continue reading →

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August 20, 2012 · 4:42 pm

Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection: Minimally Invasive Techniques for Resecting GI Mucosal Tumors

Major advances in the development of endoscopic devices and techniques over the past fifteen years have introduced endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) as standard of care for the safe and effective removal and/or definitive staging of mucosal lesions of the esophagus, stomach, duodenum and colon, often eliminating major surgery as first-line management. Gastroenterologists at Penn State Hershey Medical Center including Abraham Mathew, M.D., Matthew Moyer, M.D., and Charles Dye, M.D., have become leading clinicians and active researchers in these techniques, performing several hundred EMR procedures annually. Mathew explains, “EMR is the more widely used of these techniques for removal of smaller tumors or lesions [<2.5 cm]. With EMR, normal saline or hydroxy propyl methylcellulose, dilute epinephrine and methylene blue are injected into key areas of the submucosal space beneath the tumor, strategically positioning the tumor and separating it from the bowel wall; the tumor can then be resected with less risk of thermal or mechanical damage to the muscularis propria. With ESD, a more aggressive technique for removal of larger, more invasive tumors, the surgeon uses specialized devices to tunnel into the submucosal plane to dissect the tumor en block. Incisions are closed endoscopically with sutures or clips.”

A colon mass lesion in the process of being resected by ESD.

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· 4:41 pm

Addressing Patient Nutritional Needs in Complex Abdominal Surgery and Intestinal Failure

The pre-treatment nutritional status of patients with acute abdominal injury, or chronic gastrointestinal (GI) illness plays a large role in post-surgical course of recovery. Likewise, their ability to obtain nutrition after treatment significantly impacts long-term health outcomes and quality of life.

David Soybel, M.D.

Physicians at Penn State Hershey Medical Center and Penn State College of Medicine are investigating how to better detect and address nutritional needs before and after major complex GI surgery. According to David Soybel, M.D., “A significant proportion of patients with complex medical histories have pre-existing deficiencies in specific micronutrients such as zinc, copper, selenium, and magnesium. Major procedures place high demands on already compromised micronutrient stores, and often put these patients into a state of ‘micronutrient distress’ that may be associated with longer and more complicated recovery.”

Soybel’s research aims to establish methods to routinely detect and treat these deficiencies in high-risk patients, both before and after surgery. “Pre-surgical recognition of micronutrient deficiencies would provide the opportunity for micronutrient repletion and other interventions, and better prepare patients to get well post-surgery,” says Soybel. “Likewise, in acute situations, recognition of such deficiencies and rapid intervention could help patients better recover after emergency procedures.”

Gordon Lee Jensen, M.D., Ph.D.

Based in State College and one of few physicians in the country who specializes in management of intestinal failure, Gordon Lee Jensen, M.D., Ph.D., explains, “In the past, many of these intestinal failure patients would have died or become indefinitely dependent on intravenous, total parenteral nutrition (TPN). But now, because of new medications and advances in medical nutrition therapy, some can eventually come off of TPN and lead more normal lives. Today, TPN is more often a temporary supportive measure. Successful transition off of TPN depends on a number of factors. If a patient has at least 100 cm of small bowel length and a portion of intact colon (or at least 150 cm of small bowel and no functional or intact colon), and residual disease is controlled, then the odds are favorable for them to eventually adapt to enteral or oral nutrition.” Continue reading →

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· 4:40 pm

Identifying Gene Expression Profiles Linked to Cancer Development in Barrett’s Esophagus

Douglas B. Stairs, Ph.D.

Douglas B. Stairs, Ph.D.

The rising incidence of Barrett’s esophagus (BE) over the past two decades, coincident with increases in obesity, chronic heartburn, and gastroesophageal reflux disease, has focused attention on questions about how to monitor and treat these patients. About four in 1,000 BE patients annually develop esophageal adenocarcinoma (EAC), a 30- to 40-fold greater risk than in the general public. EAC, in turn, is linked to five-year survival rates of only about 20 percent. While early identification of high-risk BE patients is critical to improve EAC survival, factors predictive of cancer progression have not been identified. Continue reading →

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