THE NEED FOR A PARADIGM SHIFT IN GASTROENTEROLOGY

THE NEED FOR A PARADIGM SHIFTIN GASTROENTEROLOGYDr. Harley SobinUnited Hospital System, Kenosha, WIMarch 28, 2014harleysobin@gmail.com262-653-5330

IT’S 5:30 ON FRIDAY,WHERE ARE THE BESTNEIGHBORHOOD WINE BARS? BIN 36: 339 NORTH DEARBORNPOPS FOR CHAMPAGNE: 601 N. STATEENO: 505 N MICHIGAN (INTERCONTINENTAL HOTEL)WEBSTER WINE BAR: 1480 N WEBSTERDOC WINE BAR: 2602 N CLARK STREET

DISCLOSURES NONE

THE NEED FOR A PARADIGM SHIFTIN GASTROENTEROLOGY WE CAN OFFER GREAT THERAPEUTIC SKILLS TO GIPTS WITH ORGANIC DISEASE-GI BLEEDS, CROHN’S,ETC IT WOULD BE WONDERFUL IF WE COULD MASTERTHE SAME THERAPEUTIC MAGIC FOR OUR PTS WITHFUNCTIONAL AND ANXIETY DISORDERS

GASTROENTEROLOGISTS ARE VERYWELL TRAINED TECHNICIANS BUT HAVE LITTLE, if any, TRAINING IN PSYCHOLOGY

COMPLEX GI PATIENTS HAVEPSYCHIATRIC COMORBIDITIES FOR WHICH WE, GASTROENTEROLOGISTS, AREWOEFULLY UNDERPREPARED

HOW DOGASTROENTEROLOGISTSTHINK ABOUT ANXIETYDISORDERS

THEY DON’T!

THE FIRST INSTINCT OF AGASTROENTEROLOGIST

IS TO ENDOSCOPE THE PATIENT

WE TEND TO HAVE A MECHANISTIC APPROACH TO GISYMPTOMS WE WILL FREQUENTLY ENDOSCOPE OR ORDER AN XRAY OF THE PART OF THE GI TRACT CORRESPONDINGTO THE SYMPTOM COMPLEX

WE ARE TRAINED WITH TECHNICALSUPREMACY WE ARE TRAINED TO DO THE NEATEST THINGS WITHENDOSCOPES

OUR TECHNICAL TRICKS DON’TALWAYS BENEFIT PATIENT CARE MANY OF OUR PTS ARE UNLIKELY TO HAVE ASTRUCTURAL PROBLEM CAUSING THEIR GISYMPTOMS IF WE FIND A MINOR STRUCTURAL DISTURBANCE, ISIT REALLY CAUSING THE PROBLEM?

CASE A 35 YO ANXIOUS WOMAN COMPLAINS OFABDOMINAL PAIN. BECAUSE OF UNREMITTINGSYMPTOMS SHE HAS A GASTROSCOPY. THEGASTROSCOPY SHOWS MINOR GASTRITIS-NOMAJOR ULCER. SHE BECOMES PREOCCUPIED WITHTHE FACT THAT SHE HAS GASTRITIS.

THE GASTROENTEROLOGIST, HOWEVER, IS FULLYAWARE THAT HE HAS “SCOPED” MANY OTHERPATIENTS WHO TURNED OUT TO HAVE MILDGASTRITIS WHO HAVE BEEN TOTALLYASYMPTOMATIC (ENDOSCOPED FOR GI BLOODLOSS) HE IS NOT CONVINCED THAT HIS FINDINGS HAVEANYTHING TO DO WITH HER SYMPTOMS

HAS HER CARE BEEN HELPED? HINDERED?

ETIOLOGIES FOR GI SYMPTOMS STRUCTURAL DISORDERSFUNCTIONAL DISORDERSANXIETY DISORDERSOVERLAP SYNDROMES

TAILOR ENDOSCOPY TO ALARMSIGNALS ALTHOUGH WE HAVE BEEN TAUGHT THATENDOSCOPY SHOULD BE LIMITED TO CERTAINSYMPTOMS THAT ACT AS RED FLAGS

PRESSURE TO DO ENDOSCOPY IN THE GENERAL COMMUNITY THERE IS ANEXPECTATION THAT MOST SYMPTOMS SHOULD BEINVESTIGATED WITH ENDOSCOPY

CASE 20 YO SINGLE MOTHER COMPLAINS OF ABDOMINALPAIN, CONSTIPATION, DIARRHEA, NAUSEA FOR “ALONG TIME”. SHE CLAIMS SHE IS UNABLE TO EATANY FOOD BECAUSE IT MAKES HER SICK. BUT INSPITE OF THAT SHE HAS NOT LOST ANY WEIGHT. SHE IS VERY STRESSED. HER 2 YR OLD DOESN’TBEHAVE. SHE FIGHTS WITH HER BOYFRIEND. SHEISN’T HAPPY IN HER PART TIME JOB.

SHE COMES TO THE ER FREQUENTLY COMPLAININGOF PAIN. MULTIPLE LABS HAVE BEEN NEGATIVE. A CAT SCANWAS ORDERED WITH NEGATIVE RESULTS. FINALLYSHE IS ADMITTED. HER ATTENDING IS FRUSTRATEDAND CALLS IN A GASTROENTEROLOGIST ASKING HIMTO PERFORM A GASTROSCOPY AND COLONOSCOPYBECAUSE OF THE NAUSEA AND ABDOMINAL PAIN.

ON EXAM-THE PATIENT KEEPS HER EYES SHUTDURING ABDOMINAL PALPATION. SHE CLAIMS THATEVEN LIGHT PRESSURE CAUSES EXCRUCIATINGPAIN.HOWEVER, HER ABDOMEN IS RELATIVELYBENIGN AS IS THE REST OF HER PHYSICAL EXAM . THE PATIENT IS VERY ANXIOUS, DEMANDING, ANDMAKES THE CONSULTANT ANXIOUS

GASTROSCOPY AND COLONOSCOPY AREPERFORMED AND SHOW MILD ESOPHAGEALIRRITATION AND A NORMAL COLON. HER WORK-UPIS FAIRLY UNREVEALING. THE PT IS PLACED ON ANTISPASMODICS ANDPRILOSEC. BUT SHE FAILS TO IMPROVE

SHARED FRUSTRATION NEITHER THE PATIENT NOR THEGASTROENTEROLOGIST IS PLEASED IN SUCH CASES THE PT JUST WANTS HER SYMPTOMS TO GO AWAY DOCTOR WANTS TO WASH HIS HANDS OF THE CASESAYING: “THIS IS NOT GI” OR “SHE’S JUST CRAZY”

PSYCH PATIENTS MAKE GI DOCSANXIOUS AS GI DOCS WE SHY AWAY FROM PTS WITH COMPLEXPSYCH PROBLEMS. WE DON’T KNOW HOW TO DEAL WITHTHEM. THESE PTS MAKE US UNCOMFORTABLE. WE CAN’TPROVIDE THEM WHAT THEY NEED AND YET MANY OF THE PTS WHO COME TO US HAVESIGNIFICANT PSYCHIATRIC CO-MORBIDITIES

WE ARE MUCH BETTER WITHORGANIC DISEASES GIVE US A GOOD CASE OF PEPTICULCERS, PANCREATITIS, CROHN’S,OR COLON POLYPS WE ARE MUCH BETTER PREPARED

DEALING WITH FUNCTIONAL BOWELDISORDERS AS FIBROMYALGIA IS TO RHEUMATOLOGISTS, ANDMIGRAINE IS TO NEUROLOGISTS, IBS AND OTHER GIFUNCTIONAL DISORDERS FORCE US TO DEAL WITHSYMPTOMS WHERE THERE IS NO ANATOMICABNORMALITY

MANY GI’S ( ALTHOUGH NOT ALL) ARECOMFORTABLE TREATING FUNCTIONAL BOWELDISORDERS DOUG DROSSMAN IS OUR OUTSTANDING MENTORIN THIS ARENA WE USE MEDS, DIET, EVEN PSYCHOTROPIC DRUGSTO MANAGE CHARACTERISTIC SYMPTOMCOMPLEXES

IBS-D MEDS IMODIUM,LOMOTIL. ANTISPASMODIC-BENTYL, LIBRAX, HYOSCYAMINE,DONNATAL CHOLESTYRAMINE ( 4 GRAMS IN AM),COLESEVALAM(WELCHOL-3 TABS IN AM) NORTRIPTYLINE (AND OTHER TCAS) 10 MG HS INCREASEAS NEEDED RIFAXAMIN 550MG BID-TID FOR 2 WEEKS ALOSETRON 0.5MG QD-1 MG BID UNUSUAL CIRCUMSTANCES:MESALAMINE,CROMOLYN,PANCREASE

FUNCTIONAL BOWEL DISEASEITS NOT JUST IBS ANYMORE FUNCTIONAL HEARTBURNFUNCTIONAL CHEST PAINFUNCTIONAL DYSPHAGIAFUNCTIONAL DYSPEPSIAFUNCTIONAL NAUSEA AND VOMITINGFUNCTIONAL DIARRHEA, COMSTIPATIONFUNCTIONAL ABDOMINAL PAIN

WHAT THESE ALL HAVE IN COMMON ABSENCE OF ORGANIC, SYSTEMIC OR METABOLICDISEASE TO EXPLAIN THE SYMPTOMS

USE OF PSYCHOTROPIC DRUGS INGASTROENTEROLOGY STRESS AND ANXIETY CLEARLY ARE IMPORTANT INFUNCTIONAL BOWEL DISEASE DOSAGE OF PSYCHOTROPIC DRUGS USED FOR FBDTENDS TO BE LOWER THAN STANDARDANTIDEPRESSANT DOSE MEDS SEEM TO WORK BY DECREASING PAIN,BLOATING AND SIMILAR SYMPTOMS

USE OF TRICYCLICANTIDEPRESSANTS IN IBS PTS INVARIABLY ARE STARTED ON OTHER AGENTSLIKE ANTI-SPASMODICS FIRST TCAS ARE ADDED IN MORE RESISTANT CASES WE START AT A VERY LOW NIGHT TIME DOSE ANDGRADUALLY INCREASE AS NEEDED

INCREASED USE OF PSYCHOTROPICDRUGS BY GI DOCS USE OF TCA’S IN IBS-MY FAVORITE IS NORTRIPTYLINE(START 10-20MG HS) MIRTAZAPINE FOR FUNCTIONAL NAUSEA,DYSPEPSIA ( 7.5-15MG) DULOXETINE FOR FUNCTIONAL ABDOMINALPAIN(30-60MG) VENLAFAXINE FOR FUNCTIONAL CHEST PAIN(37.575MG) INCREASED USE OF SSRI’S FOR ANXIETY

CASE A 45 YO WOMAN HAS A LONG H/O INTERMITTENTABDOMINAL CRAMPS AND DIARRHEA. 15YEARSEARLIER SOME BARIUM STUDIES AND ENDOSCOPIESWERE DONE AND SHE WAS DIAGNOSED WITH IBS.SHE WAS STARTED ON LIBRAX WITH MARKEDRELIEF. NOW 15 YEARS LATER THERE WERE NEW LIFESTRESSORS AND SEVERE ABD PAIN DEVELOPED.THIS FAILED TO RESPOND TO LIBRAX.

CASE SHE WAS EXTREMELY DEBILITATED BY HER GISYMPTOMS. WORK-UP REVEALED NO NEW PATHOLOGY WE ADDED NORTRIPTYLINE 10 MG HS THENINCREASED IT TO 20MG AND THE SYMPTOMSRESOLVED. A YEAR LATER THE PT IS WITHOUTSYMPTOMS.

FUNCTIONAL CHEST PAIN MEDS ANTISPASMODICS-BENTYL, LIBRAX, HYOSCYAMINEVENLAFAXINE -75MGCITALOPRAM 20MGTRAZADONE (75-100MG)SERTRALINE (50-200MG)IMIPRAMINE (25-75MG)DILTIAZAM( 60-90 TID) NIFEDIPINE (10-30TID)BACLOFEN 5MG TID (UP TO 20 MG TID)THEOPHYLINE

DIAGNOSING ANXIETY DISORDERS WHILE MANY GI SYMPTOMS ARE DUE TO EITHERSTRUCTURAL OR FUNCTIONAL DISORDERS SOME MAY BE MANIFESTATIONS OF AN ANXIETYDISORDER GASTROENTEROLOGISTS ARE REALLY NOT TRAINEDTO DIAGNOSE THESE

CASE 15 YO BOY PRESENTED WITH PERSISTENT NAUSEA,GAGGING, SENSATION OF LIQUIDS COMING BACKFROM HIS STOMACH INTO HIS THROAT, SORETHROAT THE SYMPTOMS HAD BEEN WORSENING OVERSEVERAL MONTHS

THE FIRST OCCURRENCE FOLLOWED A MIDDLESCHOOL BAND EVENT. PRIOR TO THE EVENT A BUSTAKING THE BAND STOPPED AT A MCDONALD’S ONTHE WAY TO THE CONCERT VENUE. PT FELT SICK AFTER EATING BUT STILL HAD TO GOAHEAD AND PERFORM NO ONE ELSE GOT SICK AFTERWARD

AFTER THE CONCERT HE STARTED HAVINGSYMPTOMS DAILY THIS LED TO MULTIPLE SCHOOL ABSENCES WHEN HE WENT TO SCHOOL HE WOULD VISIT THENURSE DAILY

AFTER SEVERAL MONTHS THE FAMILY TOOK THEPATIENT TO AN ENT SPECIALIST ENT LOOKED IN HIS THROAT AND SAID THERE WASEVIDENCE FOR ACID REFLUX PT WAS PLACED ON PREVACID WITH MINIMALRELIEF GASTRIC AND THROAT SYMPTOMS CONTINUED

PT WAS SUBSEQUENTLY TAKEN TO AGASTROENTEROLOGIST, ONE OF MY PARTNERS THE GI WAS ABOUT TO SET UP A GASTROSCOPY TOEVALUATE NAUSEA, STOMACH UPSET, AND REFLUXNOT RESPONDING TO PREVACID

THEN A PSYCHOLOGIST FRIEND OF THE FAMILYINTERVENED, SAYING THIS WAS A CLASSIC SET OFSYMPTOMS OF ANXIETY DISORDER BASICALLY PROHIBITED THE ENDOSCOPY THE PATIENT WAS REFERRED FOR AND UNDERWENTEXPOSURE THERAPY THE SYMPTOMS REGRESSED ENDOSCOPY WAS NEVER PERFORMED

A BLIND SPOT IN THIS CASE THE PATIENT’S GI SYMPTOMS WEREMANIFESTATIONS OF AN ANXIETY DISORDER THE PEDIATRICIAN, ENT AND GI SPECIALIST ALLMISSED THE DIAGNOSIS IF A PT WALKS IN COMPLAINING OF PALPIATIONS,SHORTNESS OF BREATH, OR A H/O ANXIETY ATTACKSTHE GI MAY BE ABLE TO MAKE THE DIAGNOSIS OTHERWISE, NOT LIKELY THIS REALLY IS A SORT OF “BLIND SPOT” FOR US

WE SPECIALISTS CAN BE MYOPIC IN MEDICINE WE SPECIALISTS HAVE A VERY NARROWFOCUS. THE ENT, THE GASTROENTEROLOGIST, THECARDIOLOGIST, THE PULMONARY SPECIALIST MAYALL SEE THE SAME PATIENT THROUGH OUR VERYSPECIFIC FILTERS.

THE ELEPHANT AND THE BLIND MEN

THE ELEPHANT AND THE BLIND MEN 7 BLIND MEN ENCOUNTER AN ELEPHANT ONE OF THE BLIND MEN REACHES FOR THE ELEPHANT’STRUNK, ANOTHER IT’S TUSK, ANOTHER THE EAR, AND ONE THELEG THE ONE STUDYING IT’S TRUNK SAYS THE ELEPHANT IS LIKE ASNAKE, THE ONE EXAMINING THE TUSK-THAT IT THE ELEPHANTIS SHARP-LIKE A SPEAR, THE ONE TOUCHING THE EAR-THAT THEELEPHANT IS LIKE A FAN, AND THE ONE GRABBING THE LEGTHAT THE ELEPHANT IS LIKE A TREE THE BLIND MEN ALL INTERPRET THE ELEPHANT BASED ONTHEIR NARROW EXPERIENCES

OUR LIMITED FOCI KEEP US FROMGRASPING THE GESTALT OUR NARROW FILTERS COMPROMISEMANAGEMENT OF THESE MORE COMPLEX PATIENTS WE NEED A WAY TO SEE THE BROADER PICTURE

IT IS CLEAR THAT MANY OF OUR PATIENTS WOULDBENEFIT FROM SEEING A BEHAVIORAL HEALTHSPECIALIST

THE IDEAL WORLD TAKE MY PATIENT NEXT DOOR TO THE PRACTICINGPSYCHOTHERAPIST OR EXPECTATION OF EVERY PATIENT BEING SEEN BYA PSYCHOTHERAPIST AS CO-MANAGER

DOESN’T EXISTIN THE COMMUNITY

ROADBLOCKS TO CO-MANAGINGWITH PSYCHOLOGISTS GI MAY BE UNAWARE OF NEED FOR PSYCH HELP PATIENTS ARE VERY RESISTANT TO THE IDEA OFSEEING A PSYCHOLOGIST ACCESS TO A PSYCHOLOGIST BECAUSE OFINSURANCE/FINANCIAL/GEOGRAPHIC REASONS MAYBE A LIMITATION

PROBLEMS GETTING THE PATIENTTO “BUY IN” PATIENTS ARE FREQUENTLY RESISTANT TO THE IDEATHAT THEIR SYMPTOMS ARE RELATED TO ANXIETYOR DEPRESSION THEY GET ANGRY “THAT DOCTOR IS JUST LABELINGME AS A CRAZY PERSON” TEND TO RESENT AND LOSE FAITH IN THEGASTROENTEROLOGIST

15 YO BOY - PATIENT FOLLOW-UP5 YEARS LATER HE IS DOING WELL. HIS THROAT AND GI SYMPTOMS OCCUR RARELY.WHEN THEY DO HE LABELS THEM AS ANXIETY ANDSELF MANAGES THEM WHEN THE SYMPTOMS FIRST STARTED HE WOULDDRY HEAVE UPON ENTERING AN AIRPORT. NOW HECAN FLY ALONE FOR 14 HOURS WITH NO PROBLEM CURRENTLY DOING WELL AS A PRE-MED STUDENT INA LARGE MIDWEST UNIVERSITY

MY RUDE AWAKENING AS AGASTROENTEROLOGISTPATIENT IS MY SON

CHANGES I HAVE MADE I ENTER INTO MOST NEW PT ENCOUNTERS ASKINGMYSELF IF ANXIETY OR DEPRESSION IS PLAYING A ROLE I INFORM THE PT EARLY ON THAT WE MAY NOT FIND ASTRUCTURAL EXPLANATION FOR THE SYMPTOMS I INFORM THEM OF THE DUALITY OF MIND-BODYMEDICINE. SYMPTOMS MAY BE ANXIETY DRIVEN. I SUGGEST THAT THEIR SYMPTOMS MAY BE IMPROVED BYMEETING WITH A BEHAVIORAL HEALTH SPECIALIST

ACTION FOR THE FUTURE WE REALLY NEED MORE EDUCATION IN OUR GITRAINING PROGRAMS ABOUT PSYCHOLOGY. THEREIS A PAUCITY OF LECTURES ON PSYCHOLOGY ATOUR NATIONAL CONFERENCES IDEALLY THERE SHOULD BE BEHAVIORALHEALTH SPECIALISTS TO JOIN US ONROUNDS, OR IN A NEARBY OFFICEOR HOSPITAL SETTING

WHAT YOU COULD DO AS PSYCHPROFESSIONALS SPEAK AT NATIONAL GI MEETINGS GET INVOLVED WITH WORKSHOPS FOR/WITHGASTROENTEROLOGISTS PRACTITIONERS-GO TO YOUR LOCAL GI AND LET HIMKNOW HOW YOU CAN ASSIST IDEAL WOULD BE TO HAVE A BEHAVIORAL HEALTHSPECIALIST SHARE TEACHING ROUNDS IN THEHOSPITAL

THANKS FOR YOUR ATTENTIONTIME FOR HAPPY HOUR BIN 36: 339 NORTH DEARBORNPOPS FOR CHAMPAGNE: 601 N. STATEENO: 505 N MICHIGAN (INTERCONTINENTAL HOTEL)WEBSTER WINE BAR: 1480 N WEBSTERDOC WINE BAR: 2602 N CLARK STREET

the same therapeutic magic for our pts with functional and anxiety disorders the need for a paradigm shift . our technical tricks don’t always benefit patient care a 35 yo anxious woman complains of . work-up revealed no new pathology we added nortript