From the esophagus to the rectum, the human GI tract can face a variety of complications. Learn how a gastroenterologist saves lives by treating problems in this system of complex organs.
Eating is as natural as breathing. Every living thing must ingest food in some manner in order to exist.
Because of the highly complex manner in which food is absorbed into a human body, it’s not surprising that this process can encounter obstacles and develop problems. From the point where food goes into the body to the point where it is eliminated, the human gastrointestinal (GI) system is as complicated and prone to disease as any other. Trouble can start at any point throughout the system’s winding and complex organs.
After food is swallowed, it enters the esophagus, where it is gently moved down to the stomach. It’s along this sensitive, flexible tube that digestive trouble can result from invasive conditions such as heartburn, otherwise known as acid reflux.
The term ‘gastroesophageal’ refers to the stomach and esophagus, while reflux means “to flow back or return.” Therefore, gastroesophageal reflux is the return of stomach contents back up into the esophagus. In normal digestion, the lower esophageal sphincter (LES) opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Damage occurs when the LES is weak or relaxes inappropriately.
Dr. Chandrashekhar Thukral, a board-certified gastroenterologist with Rockford Gastroenterology Associates who practices at Rockford Memorial Hospital and other medical centers, says cases of acid reflux and gastroesophageal reflux disease (GERD) have increased as the population has become more obese.
“Being overweight and smoking are associated with an increased risk of developing acid reflux,” says Thukral. “Presence of hiatal hernias can contribute to acid reflux. Furthermore, obesity can worsen these hernias, which in turn can exacerbate reflux symptoms. The stomach is designed to handle acid, but the esophagus is not. When acid escapes upward into the esophagus, it can cause inflammation in the delicate tissue.”
Acid reflux may cause symptoms such as heartburn, chronic cough and a sour taste in the mouth. But it also may be silent. Prolonged, untreated acid exposure in the esophagus can lead to a complication called Barrett’s esophagus.
In Barrett’s esophagus, normal tissue lining the esophagus changes to tissue that resembles the lining of the intestine. It’s estimated that about 10 percent of people with chronic symptoms of GERD develop Barrett’s esophagus. This condition does not have any specific symptoms, although patients may experience symptoms related to GERD.
Barrett’s esophagus increases a person’s risk of developing esophageal adenocarcinoma, a serious, potentially fatal cancer of the esophagus.
Although the risk of this cancer is higher in people with Barrett’s esophagus, the disease is still rare, says Thukral. That risk is about 0.5 percent per year for people with Barrett’s esophagus.
“Caucasian men over the age of 50 who’ve had acid reflux for a long time are at the highest risk for developing Barrett’s esophagus,” Thukral says. “Because of this possibility, we recommend that patients who fall into this category have an endoscopy at least once to help identify if they have Barrett’s. If Barrett’s esophagus is found, then we enroll these patients in a surveillance endoscopy protocol so cancer-type changes can be identified early and be treated. Unfortunately, once this cancer develops, the prognosis is usually poor.”
Ulcers of the stomach and small intestine can affect people of all ages and are a common reason for referral to gastroenterologists. Thukral says public education and awareness plus the increased use of acid-suppressing medications have helped to reduce the disease burden.
“We don’t see complications related to peptic ulcers as much as we used to in the past,” Thukral explains. “Ulcers are usually caused by two entities. One is an infection with the bacterium Helicobacter pylori that responds well to a short course of multiple antibiotics and an acid suppressant. The other cause is the use of anti-inflammatory drugs including over-the-counter medicines such as Advil and Aleve. Untreated stomach ulcers can lead to abdominal pain, anemia and, in some cases, massive gastrointestinal bleeding. Usually, bleeding ulcers are treated through endoscopy and application of clips and cauterization.”
Thukral explains that, in extreme cases of bleeding that cannot be stopped by endoscopic intervention, surgical intervention may be required. Given the widespread use of over-the-counter pain medications, simultaneous use of acid suppressing medications is recommended to prevent ulcers, especially in the elderly and those who use these pain medications chronically.
From the stomach, food moves down the digestive tract into the small intestine. Thukral says a number of diseases can affect the small intestine including celiac disease.
“Public awareness of celiac disease has grown as more people have been accurately diagnosed with this condition. This has led to proper labeling of foods in grocery stores and in restaurants,” Thukral says. “Gluten exposure leads to inflammation in the small intestine which causes bloating, diarrhea, anemia and malabsorption. Celiac disease is easily treated by changing the patient’s diet to eliminate all forms of gluten, which is found in wheat-based products. This means removing breads, pastas and other foods that contain wheat, barley and rye.”
Crohn’s disease is a form of inflammatory bowel disease that affects both the small and large intestine. More than a half-million Americans deal with Crohn’s disease on a regular basis. While the cause is not clear, this inflammation may be the result of genetics, environmental factors or an abnormal immune response. Along with abdominal pain and cramping, Crohn’s disease damages the lining of the intestines and can lead to frequent diarrhea, rectal bleeding and weight loss.
Thukral says that, in contrast, ulcerative colitis, which is another form of inflammatory bowel disease, affects only the colon and rectum. This affects only the lining of the colon wall, whereas Crohn’s disease can damage the entire thickness of the small intestinal or colon wall.
“Many people are probably unaware that gastroenterologists also treat diseases of the liver, pancreas and bile duct,” Thukral says. “The liver can be adversely affected by a variety of agents including alcohol, drugs, viral infections and excessive fat. Prolonged damage to the liver leads to irreversible scarring which is called cirrhosis. In some cases, cancer may also develop in the liver. The most common bile duct disease that we encounter is obstruction with gallstones.”
Thukral says fatty liver disease is becoming more common, mainly because of the rapidly rising rates of obesity. Fatty liver can also develop because of excessive alcohol use. Infection with the hepatitis B and C viruses are other causes of chronic liver disease that we see in our country.
“Prolonged injury to the liver causes it to become inflamed,” Thukral says. “As this process continues, healthy liver tissue is replaced by scar tissue, which is irreversible.”
Once this irreversible scarring occurs and cirrhosis develops, patients manifest a plethora of symptoms including fatigue, weight loss, anemia, gastrointestinal bleeding, itching, jaundice, confusion and infections. Cirrhosis is usually diagnosed based on a careful history, physical exam, blood tests and, in some cases, a liver biopsy. Thukral says total or partial liver transplants are among the main treatments for patients with cirrhosis and end-stage liver disease.
“Of course, it can take time to find a perfect match for a liver transplant, which comes from a deceased donor,” he says. “The advantage of partial transplants is that, while the donor still must be a match, the liver tissue comes from a living donor.
“Obesity, alcoholism and viral hepatitis do take time to cause significant damage, and it takes many years for cirrhosis to develop,” Thukral adds. “Today, we have effective treatments for hepatitis C that have been developed over the past few years. Now, it means taking a pill a day with good results, a greater than 90-plus percent cure rate.”
Better still, he says, the newer anti-hepatitis C medication has minimal side effects. Successful eradication of this virus, which affects up to 3.5 million Americans, will lead to a substantially improved quality of life for these patients.
Cancer can occur in any part of the digestive tract, from the throat to the rectum. Thukral says it’s less common in the small intestine than in the colon.
“This is why screening colonoscopies are important,” he says. “We can remove polyps that could have developed into cancer.”
In many cases, the first treatment option after medications fail to ease symptoms or cure the conditions for GI diseases, is surgery.
For Dr. Barry Barnes, a board-certified general surgeon at FHN Memorial Hospital in Freeport, surgeries involving the GI system begin at the top, with the stomach.
“I don’t perform surgery on the esophagus,” Barnes explains. “That specific surgery is done by a thoracic surgeon. My surgeries focus on severe ulcerations and cancer of the stomach. Because there are advanced medications that work well on stomach ulcers, I don’t operate on them as often as I did 30 or so years ago. Ulcers are normally treated with medications first, but if they fail to relieve the pain, surgery is the next option to help patients get relief.”
When patients are diagnosed with a perforated ulcer, which can happen when an ulcer grows to the point where it creates a hole in the stomach lining, surgery may be necessary to repair it. Barnes says this procedure typically involves sewing the hole closed.
In cases of bleeding ulcers, gastroenterologists will first try to stop the bleeding using a laser during an endoscopy, threading a flexible tube with a light, camera and tiny instruments through the mouth and down into the stomach. If that doesn’t resolve the bleeding, Barnes may be called in to do a partial gastrectomy to remove that part of the stomach.
“Fortunately, new medications have made this kind of surgery less common,” Barnes says. “It’s important for patients to contact their doctors as soon as they begin to feel discomfort.”
Disease and unhealthy conditions in the intestinal tract may also require surgery.
“Surgeries in the small intestine usually are scheduled for obstructions and perforations,” Barnes says. “While cancer does not occur in the small intestine as often as in the colon, we do sometimes see it, including in pediatric cases.”
Barnes adds that conditions in the small intestine that may require surgical treatment include those that lead to infection, inflammation bowel diseases, peptic ulcers, diverticulosis and cancer. These surgeries are focused on removing compromised sections and rejoining the intestine.
The larger intestine, or colon, and the rectal area differ and require unique procedures.
“In the colon, we operate on bowel obstructions and cancerous tumors, resectioning the colon and removing the problem,” Barnes explains. “Whether or not the patient needs a colonostomy depends on how large a section must be removed. Again, many colon surgeries are needed to address perforations and obstructions. These can happen when the bowel is not properly cleaned out and profuse bleeding occurs.”
For cancers of the GI system, chemotherapy and radiation are supplementary treatments that aid in curing or controlling cancer’s progress. Depending on what stage the cancer is at when discovered, these treatments can prove beneficial when applied before or after surgeries. Choices for therapies depend wholly on the type and location of the cancer as well as the patient’s auxiliary health conditions, age and ability to tolerate the treatment.
One factor remains constant regardless of where cancer is found along the digestive system’s winding pathway: the earlier it is diagnosed, the better the odds are for curing it.
Regular physical examinations and screenings play a vital role in keeping the GI system healthy and the patient happy.