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Interview with Dr. Jeffrey Hartford and Dr. Anubha Sinha, gastroenterologists at Hunterdon Medical Center
Dr. Robert Pickoff interviews Dr. Jeffrey Hartford and Dr. Anubha Sinha, gastroenterologists at Hunterdon Medical Center
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Dr. Robert Pickoff, Chief Medical Officer for Hunterdon Healthcare, interviews Dr. Jeffrey Hartford and Dr. Anubha Sinha, gastroenterologists at Hunterdon Medical Center. Dr. Hartford and Dr. Sinha talk about gastroenterology at Hunterdon Medical Center.
Dr. Jeffrey Hartford
Advanced Gastroenterology
and Nutrition.jpg "Dr. Anubha Sinha")
Dr. Anubha Sinha
Hunterdon Digestive Health SpecialistsTranscript
Doctor Pickoff Hello, I’m Doctor Robert Pickoff, Chief Medical Officer for Hunterdon Medical Center. Today I’m joined by Hunterdon Medical Center gastroenterologists Dr. Jeffrey Hartford and Dr. Anubha Sinha. Welcome doctors.
Doctor Hartford
Good morning Bob.
Doctor Pickoff
Could you tell us a little bit about what extra training a gastroenterologist has?
Doctor Hartford
Well, gastroenterologist, like every medical sub-specialist, once finishing medical school, goes on to a three year internship and fellowship in internal medicine, which is a broad training in internal medicine… and beyond that we go into intensive training in a fellowship program in digestive disease and also that’s the time when we learn to do the minimally invasive advanced therapeutic endoscopic procedures such as colonoscopy and upper endoscopy. But in truth, our training never really stops. With continued medical education we’re always keeping on top of cutting edge therapies for disorders… and I’m doing procedures now that weren’t even heard of at the time of my training. So, we’re always learning.
Doctor Pickoff
So, it’s a sub-specialty of internal medicine I understand.
Doctor Sinha
Yes
Doctor Pickoff
Ok, good… and what would be the most common reason that someone would seek out the help of a GI physician?
Doctor Sinha
I think there are a few common reasons I can think of. First of all is abdominal pain which is very common, second, heartburn, and third is a screening colonoscopy… and not to mention irritable bowel syndrome.
Doctor Pickoff
That’s good, and this is for… what age groups do you treat mostly?
Doctor Sinha
I know gastroenterologists usually treat patients from staring at age eighteen, but most of us… we start seeing patients in teenage group also since there is no difference in disease presentation and management of a sixteen, seventeen year old than an eighteen year old. However, when there’s a small infant, their disease presentation and management is different than adult, therefore we do have an access to pediatric gastroenterologists. They are pediatricians with advanced training in gastroenterology.
Doctor Pickoff
So we have relationships with pediatric gastroenterologists should the need arise?
Doctor Hartford
Yes we do. You know, as Dr. Sinha said, we will see patients younger than eighteen… I will see teenage patients if it’s clear that there’s some significant pathology. Much of pediatric gastroenterology is what we call functional disorders… young children with tummy aches that don’t wan to go to school… that’s a very different condition and a pediatric gastroenterologist is far better suited to take care of something like that.
Doctor Pickoff
Good. How about the difference between men and women? Do they have different GI problems?
Doctor Sinha
Certainly, not until very recently it was made aware that men and women have different GI issues. We have to understand why there is a difference. If you look at the anatomy of the women… and the digestive tract is structured differently than a male… and how their digestive tract functions in a woman is different than male. For example, woman colon is longer than male. It’s ten centimeters longer. They have more bends and twists and they have multiple surgeries in the past, like hysterectomy, C- section… caesarian section therefore there’s a technical difficulty. So doing a colonoscopy in women, we need more flexible colonoscope, better sedation… also women colon has more polyp to the proximal end of the colon… that means away from the rectum… therefore full colonoscopy is needed to detect more polyps. In men the polyps are found in the proximal and close to the rectum so partial colonoscopy or sigmoidoscopy can detect about two thirds of the polyp. Women are more sensitive to pain and air pressure, therefore, irritable bowel syndrome is more common… seventy to eighty percent of the time is women who suffers from irritable bowel syndrome… and same thing… since they are more sensitive to pain and pressure we need more, deeper sedation doing any endoscopy in a woman than male. I think the major difference arises since women go through different hormonal level throughout their life starting from menarche, pregnancy, perimenopausal and then menopausal age. In pregnancy we have high progesterone level and increase of abdominal pressure in second trimester, therefore reflux, gall bladder disease, heartburn is more common second trimester.
Doctor Hartford
You know, I think Dr. Sinha makes some very valuable points, so I’d just like to add that probably as a generalization in men, reflux disease tends to be more common… in women, obviously irritable bowel… and clearly there’s a hormonal basis for this as we see post menopausally the incidence of irritable bowel in men and women is essentially the same so there’s no question that all the points she made about hormonal changes are extremely important.
Doctor Pickoff
Interesting. Let’s talk a little bit about cancer screening. There’s certainly an increasing emphasis put on screening for GI cancers. Can you tell us what cancers are we talking about specifically when we talk about screening?
Doctor Hartford
Well it’s important to mention that March is colorectal cancer awareness month and certainly colon cancer screening is on the forefront. It’s probably one of the most important cancers to screen for because it’s so preventable. I think that I would also mention that we… while it’s not technically screening… we also, very aggressively surveil patients for esophageal cancer if they have significant reflux disease and changes that are known as Barrett’s Esophagus.
Doctor Pickoff
But we’re talking about the major screening push is for colon cancer I would think.
Doctor Hartford
Absolutely.
Doctor Sinha
Especially in March, yes.
Doctor Pickoff
And now what are the… what should people know about colon cancer screening. What are the current recommendations that primary care physicians should be speaking to their patients about?
Doctor Sinha
There are two guidelines. One is from American College of Gastroenterologists and one is from another guideline, but we strongly follow American College of Gastroenterology guidelines. Guidelines are very long, but I think I want to point out the differences that in African American, the guideline is now to screen at age forty five in men and women both. It’s no longer fifty year old in African American… however, again… at age fifty for any other age group is still the recommendation for screening colonoscopy if they are not high risk… that means no family history of colon cancer or large adenomas polyp… everyone gets screened at age fifty except for African American men and women at age forty five.
Doctor Pickoff
So what does it mean for… a person goes for their screening colonoscopy… what are they… what is the experience like? Can you just take us through…
Doctor Hartford
Well the experience, truly, should be a non-event. With proper sedation the colonoscopy should be a painless procedure. The part of the procedure, I think, that gets the most press is the preparation. The truth is… if you ask most people, they’ll tell you that, while it wasn’t any fun, it wasn’t nearly as bad as they had anticipated and was nowhere near as bad as all their friends had told them. It’s just an annoyance. I’ve never found anyone that found any prep worse than dying of colon cancer.
Doctor Pickoff
Good point. So if they undergo the screening colonoscopy at fifty, that first one is either going to have a problem or it’s going to be totally normal. If it’s normal what happens and if there is a polyp that’s discovered, what happens?
Doctor Sinha
It it’s a normal colon , then recommendation is that you are going to do next colonoscopy in ten years but keep in mind that the bowel prep was adequately examined. The withdrawal time was more than six minutes when there was no polyps… polypectomy was performed… and bowel was adequately visualized. That means that bowel prep was adequate from beginning to the end in ten years surveyless colonoscopy in average risk person, but if the polyps are found, the next colonoscopy is based on the numbers of polyp, the size of the polyp, and what was the pathology. So, in general, if there are three adenomas… adenomas polyp, which is pre-cancerous polyp, next colonoscopy should be done in three years. It it’s less than three polyp, it could be done in five years. However, there are difference… if it’s a flat polyp, or difficulty in polypectomy or removal of the polyp… next colonoscopy should be as… could be as early as six months to a year.
Doctor Pickoff
So are all polyps pre-cancerous?
Doctor Hartford
No, all polyps are not pre-cancerous, and I tend to divide polyps into pre-cancerous and non, or more trivial polyps. I think that’s somewhat simplistic but valuable… and then the pre-cancerous polyps, as Dr. Sinha was pointing out, can be a wide spectrum… from low grade, to very aggressive polyps. The only thing that I would also add to what Dr. Sinha had outlined was… if there is a significant family history, then typically, even with a normal examination, I would not recommend someone go beyond five years before having follow-ups if they do have a significant family history.
Doctor Pickoff
So, in theory, anyone who’s over fifty should have already had a discussion with somebody about having a screening colonoscopy… and there’s no reason why colon cancer should really exist.
Doctor Hartford
Well colon cancer is almost completely preventable, and that’s the important message. Now there… in the cases of very early colon cancer… those cases may never be diagnosed… early enough… unfortunately because insurance doesn’t cover evaluation in young individuals. It’s not the first thing on someone’s mind that this could be colon cancer. Certainly colon cancer increases with age, but there are cases that we’re finding in the twenties and thirties, and I think every gastroenterologist, given the opportunity, if someone has any kind of symptom, will really aggressively surveil a forty year old because we know that we’re going to be picking up people who might not make it to age fifty.
Doctor Pickoff
I see, and I assume the screening recommendations are the same for males and females…
Doctor Sinha
Correct.
Doctor Pickoff
Even though, anatomically, as you have pointed out, they are different.
Doctor Sinha
And of course, in women, sigmoidoscopies, not considered to be helpful… partial…
Doctor Pickoff
And what about the small intestine. How is that... how is that examined? There is… there are some malignancies that occur there and other disorders of the small intestine… but that’s not amenable to the colonoscopes, so how do we do that?
Doctor Sinha
Small bowel is the middle portion of the bowel. The upper is your stomach. The lower that we know of is colon and the small bowel is the middle portion of the digestive tract… and the reason we have difficulty in visualizing, is there is several feet long. So we… there are two ways to examine small bowel. One is the direct way. One is indirect way. In the direct way we have something called enteroscopy, which is a flexible tube… very long… is the same way that we do upper endoscopy… goes through the mouth, passes the stomach, and enters the one third of the proximal or closer small bowel. But the problem is two third of the small bowel is not visualized… then at Hunterdon Medical Center we have balloon enteroscopy. It’s the same enteroscope, but it has balloon at the end and which allows us to go approximately two third of the small bowel… and this is a direct way of examining small bowel. And if pathology is seen, like a polyp, ulcer, or a tumor, or celiac disease, we can directly biopsy it and send the specimen. There’s an indirect way at Hunterdon Medical Center which is your capsule endoscopy, which is a small camera that patients swallow, and in six to eight hours, picture are taken of the small bowel and then it’s downloaded in the computer. It is very non-invasive, however if the pathology’s found, we have to go towards a direct way of biopsying it through the scope or through even surgery. There are… radiologists also does something called CT Enterpscope, or CT Enterography where the contrast is given and the small bowel is evaluated, but there is a risk of radiation in that, but it certainly could be done.
Doctor Pickoff
Is this a frequent issue of having to examine the small intestine?
Doctor Hartford
I think with the… as technology comes along, you find more reasons to use it and we’re using it more often, diagnosing people with difficult to diagnose Crohn’s Disease or occult bleeding… so I think that… now that we have the ability to image… directly image… many of these areas of the colon, we’re using the technology more, though certainly small bowel cancers are far far less common than the colon.
Doctor Pickoff
So that’s not really a screening, per se, it’s really actively pursuing a problem…
Doctor Hartford
Actively pursuing a clear cut problem, yes.
Doctor Pickoff
What about… we’ve heard about something called virtual colonoscopy. What is that?
Doctor Hartford
Virtual colonoscopy is a specialized CT scan which allows a radiologist to image the colon. I think that it is only a diagnostic test and the problem is that most of the papers coming out are reflecting the latest generation scanners, the most sophisticated radiologists reading them and in the real world that’s not often what you find in the community. I think that people were trying to embrace the concept because they thought you don’t have to use… I don’t want to have that colonoscopy. I hear the prep’s no fun. Well the truth is you have the same prep for a virtual scan. They put a balloon catheter into your rectum and distend your colon with air, and that’s an unpleasant experience, and the truth is they’ve had perforations related to that. And then you’re exposed to a significant amount of radiation, and if anything is found… whether it be clearly a polyp, or often times stool mistaken for a polyp, you need to go on and have a colonoscopy. So I think that in certain circumstances, where colonoscopy is technically very difficult, a virtual scan might have a advantage… but the truth is that most insurance companies aren’t covering this study now either.
Doctor Pickoff
If you go for that second colonoscopy you have to be re-prepped.
Doctor Hartford
Have to go through the prep all over again, correct.
Doctor Pickoff
But you’re not sleeping for the virtual colonoscopy.
Doctor Hartford
No, you’re not.
Doctor Pickoff
Ok
Doctor Sinha
That’s the difference that I would like to point out is… only difference between virtual colonoscopy and optical colonoscopy, that we do regularly, is sedation is not needed for virtual colonoscopy. So if there is a high risk patient, either due to breathing difficulties or cardiac or heart problem and they are not fit for sedation, and they do require colonoscopy, then we can start with virtual colonoscopy and if certain, significant pathology is found we can accept the risk of sedation and go to conventional colonoscopy.
Doctor Pickoff
I see. Let’s just move on to some general issues that people would be interested in. What would be some issues that… of urgency that may require… might require the immediate attention of a gastroenterologist?
Doctor Hartford
I think that some of the issues we find, obviously, are bleeding, either vomiting blood or blood pass from below… I think that every Thanksgiving we’re confronted with food impactions. People end up with food lodged in their esophagus and that’s an emergent situation. I think that we don’t see it nearly as much as previously but perforated ulcers… which often present initially to a gastroenterologist and then go on to a surgeon. Biliary disease… gallstones in the bile duct, a condition we call colangitis, which can be a life threatening infection… Dr. Sinha may have some to add.
Doctor Sinha
I think ischemic bowel which is less… decrease blood flow to the gut is also very… is a medical emergency because it can bulk and become necrotic and gangrenous. Is it a heart condition… or low blood pressure can cause decreased blood flow and can present with acute abdominal pain and ischemic gut. Also I think certain time, abdominal pain is very… requires immediate attention as emergency, such as appendicitis, diverticulitis, or even bowel obstruction. This is also… these are all medical emergencies… besides what Dr. Harford…
Doctor Pickoff
Most of which, I would assume, present with pain basically… abdominal pain… and or bleeding.
Doctor Sinha
Abdominal pain and bleeding… in women I also see abdominal pain where I have picked up couple of ectopic pregnancies
Doctor Pickoff
Ok… we hear a lot about reflux disease and heartburn and purple pills and all of those things. Can we… can you just give us a couple of pearls about this in terms of how it affects people and what they should be looking for and what’s to be done about it?
Doctor Hartford
I think reflux disease, many years ago, was looked at as a nuisance. People walked around with their Tums… their Rolaids… and they sort of lived that miserable existence and that was their… they thought their miserable rotten life. The truth is that reflux disease can lead to very serious problems. Chronic reflux disease or acid reflux can lead to changes in the lining of the distal esophagus and develop a pre-cancerous condition called Barrett’s Esophagus. Esophageal cancer rising out of Barrett’s Esophagus is one of the fastest growing cancers we’re seeing in this country. So I think that because of the vast numbers of people who have reflux disease, Barrett’s Esophagus and screening for Barrett’s… or surveillance for Barrett’s Esophagus, once diagnosed, is extremely important because esophageal cancer, not diagnosed at screening… in other words, people present with severe advanced symptoms… the five year survival is essentially zero… yet disease followed and surveiled and acted upon early can have almost a seventy five percent five year survival. So it’s critically important.
Doctor Pickoff
So is that a… Barrett’s Esophagus that you mentioned is a… the result of reflux… long term reflux… or can it happen in the absence of really a person knowing that there’s a problem?
Doctor Hartford
Well, I think that occasionally we’ll be surprised that someone will have very minimal symptoms yet significant reflux changes. It’s very hard to predict the severity of disease based on someone’s symptoms, and some people don’t even know what reflux is. In other words, you ask them, “Do you have heartburn?” They don’t know what you’re talking about. So typically you can have very low grade symptoms. Those people are hard to diagnose though because they never come to a physician complaining of a problem.
Doctor Pickoff
But it’s not screening in the sense of … people should have an endoscopy to look into the esophagus from time to time just to check….
Doctor Hartford
It’s not a pure screening… it’s based on symptoms.
Doctor Pickoff
OK, I mean that’s an important distinction… just for colonoscopy… just to go back to that for a second. Everyone should have the screening colonoscopy. You could have a pre-cancerous polyp with absolutely no symptoms. Is that…
Doctor Sinha
That’s correct.
Doctor Pickoff
OK, so that’s the important distinction. And is there… the current treatments for reflux disease… I know that there are medical treatments and surgical treatments for that. The gastroenterologist would be the person to kind of monitor reflux, treat it, and then help the patient on to the next step if it’s necessary?
Doctor Sinha
That’s correct. So first I think we divide reflux as mild, moderate, or severe. It it’s mild we just recommend dietary changes, lifestyle changes… which means encouraging them to stop smoking, lose weight, don’t take food product that can cause more reflux such as caffeine, peppermint, citrus food… and if the symptoms are not controlled then we do give short course of acid suppression pills. And if they continue to have symptoms, we go up and then put them in four to six months resume and then see how the reflux symptoms disappear or not. But one is like if the reflux symptom continues for five years with or without alarming symptoms, certainly ASGE recommends that people age above fifty should need an upper endoscopy to rule out Barrett’s Esophagus, like Dr. Hartford was mentioning. But anytime during their reflux symptoms, if they develop any alarming symptoms such as food getting stuck in the esophagus… pain… upper endoscopy is needed.
Doctor Pickoff
I see.
Doctor Hartford
You know, I think the point Dr. Sinha made is something that’s very often overlooked by primary care physicians who are usually the first people to see people with reflux… and some gastroenterologists… that there can be a significant role for behavioral modification… elevating the head of your bed, weight loss, dietary modification, and often times we can minimize or eliminate symptoms. As gastroenterologists, often we see the more severe cases who’ve already failed treatment with their primary care doctor, so we tend to see a skewed population.
Doctor Pickoff
The other major disease that was mentioned is inflammatory bowel disease, but what is that? How would somebody know that they should be concerned about that and what do we do about it?
Doctor Hartford
Inflammatory bowel disease is a… basically two sister disorder… something called ulcerative colitis and Crohn’s disease. They’re auto-immune disorders. In other words, it’s your body reacting against yourself. The symptoms can be quite similar or quite diverse, often presenting with some degree of abdominal pain… change in bowel habits. I think any change in bowel habits where blood is passed or when blood work suggests that there’s underlying inflammation, should trigger and evaluation for ulcerative colitis or Crohn’s disease. They’re disorders that I think are fairly complex and involved and maybe discussion beyond the scope of what we can talk about here, but I think that certainly in the susceptible population… often teens or early twenties or mid sixties… those are disorders that should be looked for.
Doctor Pickoff
I see.
Doctor Sinha
Specially like if any patient suffers from chronic diarrhea … either it’s non-bloody or bloody… or chronic abdominal pain… painful rash in the skin… or joint problems. This could be… all be early signs of inflammatory bowel disease or Crohn’s disease.
Doctor Pickoff
I see
Doctor Sinha
Also perirectal inflammation… fistula abscesses… this all needs evaluation for inflammatory bowel disease.
Doctor Hartford
Crohn’s disesease is also a disorder that’s very often missed in the pediatric population. Often they’ll present with minimal symptoms other than perhaps failure to thrive… starting to drift off their growth curve. That’s something that needs to be thought of and looked for.
Doctor Pickoff
Is there a cancer risk associated with any of these as well?
Doctor Sinha
Yes, cancer risk is associated with Crohn’s disease and ulcerative colitis both. The more, the longer the duration of the inflammation and more the colon is involved, more the risk of the cancer is.
Doctor Pickoff
That’s important. What’s…anything new and exciting coming up on the horizon for us in gastroenterology that we can look forward to?
Doctor Sinha
I think gastroenterology is going to be very exciting and we’re going to have very good future, specially a couple of things that I can think of. We have narrow band imaging and confocal imaging which allows us to detect pre-cancerous changes in the mucosa or in the polyp or in the Barrett’s Esophagus very early so we can target biopsy and find the disease and detect the disease very early on and we can save lives. Second thing is capsule colonoscopies on horizon. A capsule would be swallowed and in two hours it’ll reach colon and start taking pictures for six to eight hours. We can, again, download these images and see if a polyp is found or not. That avoids the risk of sedation and radiation. It’s used in Europe right now but it’s not FDA approved. Other thing we’re looking forward to is hep c treatment and new promising drugs are going to come out very soon and the cure and success rate is close… is going to be close to eighty or ninety percent. Other thing is something called notes… N-O-T-E-S… natural orifice transluminal endoscopy. This is a very new procedure coming up in next few years and we are… we will be using natural orifice such as umbilical, vagina, mouth, and avoiding skin incision to take gal bladder or hernia repair or spleen or appendix… has not been done yet in United States but still is done in European countries and experimental at the time.
Doctor Hartford
I think other things that are on the forefront… is trying to approve the existing technology we have. Colonoscopy is extremely effective for diagnosing and preventing distal cancers. The results for proximal cancers in the cecum and the right colon are very disappointing when you look at the numbers. Now some of that may just be an inadequate study, but some of it is, technically it’s more difficult to see behind the folds in the right colon and there’s a new piece of equipment called a third eye endoscope which actually allows you to pass something through the biopsy channel and it flips backwards. It’s like the rear-view mirror and allows you to look behind the folds. That’s not approved yet. In the absence of that, a technique that I’ve been using is to actually retroflex the scope in the cecum so we’re looking back on ourselves and pull the scope backwards, and it gives us a much better view because that’s been the shortcoming of colonoscopy… that we’re missing too many abnormalities in the right colon. I think, other things that we’re doing, fairly aggressively at Hunterdon, is stenting… stenting obstructed colons and preventing patients to have to have colostomies. I think that we’ve had tremendous success with that and I think that, as Dr. Sinha mentioned, one of the things that’s going to cause a lot of new techniques to evolve is bariatric surgery. The bariatric patient very often has a stormy course postoperatively and we have to realize that nationwide they’re performing more bariatric surgeries right now than they are taking out gal bladders. So it really is something on the forefront, and once you’ve compromised the stomach, it makes it much more difficult to the biliary tree or the gastric remnant… and new procedures are being done with… aided with surgeons going through the stomach with an endoscope, or through the biliary tree through the liver.
Doctor Pickoff
That’s terrific. I want to thank you both for participating in the podcast. Thank you Dr. Hartford and Dr. Sinha. If you would like more information on this topic, you can visit the Hunterdon Healthcare Web site at www.hunterdonhealthcare.org and if you have any suggestions for future topics that you’d like to hear discussed, you can email me, Dr. Pickoff, from the podcast home page. Thanks very much for listening.