Pelvic Floor Disorders: Common, Undetected Problems

Pelvic floor disorders are the “Don’t Ask, Don’t Tell” of gastroenterology, colorectal surgery and urogynecology. “Patients don’t volunteer information about urinary incontinence, fecal or anal incontinence, or constipation.

Likewise, most physicians don’t ask the detailed questions needed to make the correct diagnosis,” says Deborah Bethards, M.D., of Penn State Hershey Gastroenterology and Hepatology. Bethards says, “These disorders are seen even among active younger women. A recent study showed that over one-third of female triathletes had at least one pelvic floor disorder symptom.”

According to this report, 37 percent of the women experienced anal incontinence.1 These data indicate that physicians should have pelvic floor problems high on their radar. To increase detection, Bethards stresses the importance of asking the appropriate questions. “A complaint of ‘constipation’ is an opportunity to ask about chronicity, frequency, stool characteristics, whether they strain or sit for a long time, and if they feel incomplete evacuation. Different symptoms point to distinctly different problems such as dyssynergic defecation, which can be found in up to 50 percent of patients referred to tertiary care centers for chronic constipation.2 These are problems that a change in diet or even medication won’t really address,” says Bethards. Continue reading

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Surgical Diverticulitis Associated with TNFSF15 Gene Single Nucleotide Polymorphism rs7848647

Diverticular disease is a common gastrointestinal disorder seen in over half of all United States adults over the age of sixty years, with approximately 5 percent of the population requiring surgery. According to Walter Koltun, M.D., F.A.C.S, F.A.S.C.R.S., chief, division of colon and rectal surgery at Penn State Hershey Medical Center, “We’re beginning to understand that diverticulitis is caused by a mix of genetic and environmental factors. A strong genetic component for diverticular disease was demonstrated in twin studies done in Europe, showing that about 50 percent of diverticular disease susceptibility is genetically based. We also know genetic influence is complex, and related to multiple genes.” The overall mix of genetic and environmental factors associated with the development of diverticular disease helps to explain the wide phenotypic variation physicians observe clinically, ranging from asymptomatic to life-threatening. Continue reading

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The CHARM Trial: CHemotherapy for Ablation and Resolution of Mucinous Pancreatic Cysts

CHARM image 1

76-year-old female with a 4.2cm mucinous (premalignant type) pancreatic cyst (white arrow) prior to EUS-guided chemoablation in the Penn State CHARM trial.

Pancreatic cysts are incidentally detected in 5-20 percent of patients over the age of sixty-five who undergo CT or MRI imaging, and the majority of these cysts are comprised of premalignant type mucinous cysts. While their detection may lead to early treatment or prevention of pancreatic cancer, effective and safe management poses a challenge. “Current guidelines,” explains Matthew T. Moyer, M.D., of Penn State Hershey Gastroenterology and Hepatology, “call for ongoing radiographic surveillance or surgical resection of these premalignant lesions; however, both options have significant limitations, risks, and costs.” Pancreatic surgical resection is associated with a 2 percent risk of mortality and an estimated 30 percent risk of serious complications. Continue reading

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Interferon-Free Regimens Offer the Potential of Hepatitis C Cure

For a quarter century, hepatitis C was a dreaded diagnosis, linked to long, grueling treatment regimens and poor outcomes. Dramatic gains, however, have been witnessed since the approval in 2011 of the protease inhibitors boceprevir and telaprevir – the first of the “directly acting antiviral agents.”

“With the addition of boceprevir or telaprevir to interferon and ribavirin, cure rates of about 70 percent were seen after only six months of treatment,” says Ian Schreibman, M.D., of Penn State Hershey Gastroenterology and Heptology. The fast pace of successful drug development has not slowed, and now interferon-free regimens are being studied, with cure rates of more than 90 percent. “We’ve turned the tables on hepatitis C. The potential to completely eliminate it is now on the horizon, similar to what occurred with polio during the twentieth century,” says Schreibman. Continue reading

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Advances in Treating Esophageal Perforation

Decisions regarding the treatment of patients with an esophageal perforation or spontaneous rupture are usually tackled in the emergency care setting. In recent years, the viable treatment options for patients with such life-threatening problems have expanded with development of new techniques and more widespread use of collaborative care.

As an example, in a case of Boerhaave syndrome (emetogenic esophageal rupture) recently encountered at Penn State Hershey Medical Center, a middle-aged woman presented to the emergency department medical team with unrelenting, severe, upper abdominal and pleuritic lower chest pain after a long night of emesis. Contrast radiography and computed tomography revealed a distal esophageal perforation, a complex pleural effusion, and associated mediastinal air (Figure 1), prompting emergent consults to gastroenterology and thoracic surgery. Medical Center surgeons and gastroenterologists chose to deploy a removable, fully covered, self-expanding metal esophageal stent across the esophageal disruption (Figure 2). This was positioned to arrest mediastinal contamination due to leakage of esophageal contents into the pleural space and periesophageal tissues. The stent type, diameter and length are individualized to each patient; getting the right “fit” is critical to exclude the lesion and achieve stable placement.

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Advanced Endoscopic Procedures to Diagnose and Treat Gastrointestinal Stromal Tumors (GISTs)

Important advances over the last decade in our understanding of gastrointestinal stromal tumors (GISTs) have opened the door to earlier diagnosis, innovative treatment, and improved patient survival. Most often occurring in the stomach, GISTs are thought to arise from the interstitial cells of Cajal, and are marked by mutations in the c-kit proto-oncogene, which expresses CD117, linked to the potential for malignancy.

Raquel Davila, M.D., gastroenterologist from Penn State Hershey Gastroenterology and Hepatology notes, “Gastroenterologists and surgical oncologists at Penn State Hershey Medical Center routinely use endoscopic ultrasound (EUS), with or without fine needle aspiration (FNA) for GIST diagnosis and to rule out other diagnoses, such as lymphoma. EUS can delineate the gut wall layers, which is helpful to identify the location of the tumor; a GIST appears as a hypoechoic solid mass, most often in the fourth layer of the GI tract wall, the muscularis propria, and less commonly in the second or third layers [muscularis mucosae and submucosa, respectively].”

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Per-oral Endoscopic Myotomy (POEM) for Treatment of Achalasia

New approaches to treating achalasia, a neuromuscular condition marked by difficulty swallowing, successfully reduce esophageal sphincter pressure, while avoiding the need for laparoscopic surgery. The standard surgical option for achalasia is Heller myotomy, a laparoscopic procedure in which the muscles of the lower esophageal sphincter are divided to provide durable reduction in esophageal sphincter pressure. Other effective treatments include esophageal dilation with large balloons, which has high recurrence, and Botox injection, which is much less durable.

According to Eric M. Pauli, M.D., a general surgeon at Penn State Hershey Medical Center, “A newer, incision-free, per-oral endoscopic myotomy (POEM) technique shows promise as a safe, effective alternative.” In his animal lab, Abraham Mathew, M.D., gastroenterologist from Penn State Hershey Gastroenterology and Hepatology, initially developed transesophageal endoscopic dissection techniques in a porcine model specifically aimed at reaching the esophageal muscle.1 Physicians in Japan were the first to perform the technique in humans.2 POEM is now performed in a small number of centers in the United States and around the world,3 and the Medical Center was the first to use this technique in Pennsylvania. Dr. Pauli notes, “This is an exciting opportunity to treat achalasia patients using no incision; the procedure is completely endoscopic and yields intermediate-term results equal to those of a Heller myotomy.”

Per-oral Endoscopic Myotomy (POEM)

Figure 1: Sub-mucosal tunnel creation extending towards the GE junction.4
Figure 2:
Circular muscle fibers division maintaining intact longitudinal fibers beneath.4

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