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This episode features Nicholas Shaheen, MD, MPH, Professor of Medicine and Chief of the Division of Gastroenterology and Hepatology in an interview with Dr. Ron Falk. They discuss several topics including heartburn, screenings for colorectal cancer, and some of the exciting things happening in this division and in the field.

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Nicholas Shaheen, MD, MPH
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Ron Falk, MD

 

“Only about sixty percent of eligible Americans avail themselves of the opportunity to have themselves screened for colorectal cancer. We can markedly decrease your chance of getting this cancer, and yet, really just through inactivity, people are missing the boat on preventing this.”

– Dr. Nick Shaheen

Falk: Hello, this is Ron Falk for the Department of Medicine at the University of North Carolina. Welcome to the Chair’s Corner.

Today we welcome Dr. Nick Shaheen who is a Professor of Medicine and Epidemiology, and the Chief of our wonderful Division of Gastroenterology and Hepatology. Dr. Shaheen is also the Director for the Center for Esophageal Diseases and Swallowing, and he serves as Senior Associate Editor for the American Journal of Gastroenterology. Welcome, Nick Shaheen.

Shaheen: Thank you.

Falk: We’re going to talk about a number of things today. Let’s start with a really common problem. A tremendous proportion of America has heartburn. What is heartburn, and when should I get worried about it and should just take my Tums?

Shaheen: Ron, that’s a great question. Americans, unfortunately, relatively indiscriminately describe any ache between their chin and their knees as heartburn. It’s actually a much more finite problem. What the problem really should be, is a burning that arises in the pit of your stomach, just below your breast bone, radiates up and under your breast bone as either a warmth or a burn that goes up toward your mouth. Often times that’s associated with regurgitation or the bringing up of contents from your stomach into your mouth. or a bitter taste in the back of your throat. If you had that constellation you really do have heartburn.

With respect to who needs to be looked at with this, that’s another important question, because forty percent of the US population has heartburn at least one time or another during a month. If you have heart burn once a month after you’ve done the pizza and beer thing, then you probably are adequately managed with some Tums.

If you are, on the other hand, having these symptoms much more than two or three times a week, that’s what we would define as significant chronic heart burn. Those patients do need to talk to their physician. Depending on what they tell their physician, and other issues with their demographics including their age, their sex, their physician may recommend to them that they have what is called an upper endoscopy, where we put a lighted tube down their throat to look for damage from the acid. That’s actually an important test, because on rare occasion, that kind of reflux can be associated with a precancerous condition known as Barrett’s Esophagus.

Falk: Before we get to scoping, what do you tell the average patient who realizes that they’re having some heartburn? What do you tell them?—simple things to do?

Shaheen: There are some wonderful lifestyle measures that can be taken that may avert the need for medication or further investigation in these patients. These include things like not eating late at night, not eating very large meals and then laying down. There’s a certain gravity component to this, because if you’re laying flat, you lose the protective effect of gravity that keeps the contents in your stomach down in your stomach. So we actually recommend to some people that they sleep on a wedge, and that that wedge elevates not just their head, but their entire torso. You can buy a wedge-shaped pillow that will start in the small of your back. We know that helps symptoms as well.

In addition to that, you can avoid foods that cause reflux. These would be things like alcohol, chocolate, fatty food, pretty much if you’re enjoying it you can be sure that it’s causing reflux. If you can minimize those things in favor of things like fruits, vegetables, low-fat food, non-chocolate items, non-acidic items, then you will do better.

Falk: If your first off-the-shelf kind of therapy of those steps don’t work, and the person’s really uncomfortable, what do you tell them to go to the drug store to get?

Shaheen: That depends on the frequency of their symptoms. If their symptoms are bothersome but relatively infrequent, a so-called PRN or “as needed” med would be fine. Those would be things like a liquid antacid or ranitidine over the counter. They’re a class of drugs called H2-blockers, things like famotidine, ranitidine—they go by the brand names Zantac, Tagamet, etc.

Falk: One of those is just as good as the other?

Shaheen: They’re all about the same, yes, within a few percent. On the other hand, if the symptoms are frequent and quite bothersome, we may suggest that the patient use a stronger class of drugs known as the proton pump inhibitors. These will be things like omeprazole, lansoprazole, and those drugs go by brand names like Nexium, Prilosec, and the like. Those drugs need to really be taken every day to be effective. It’s kind of a step up, but they’re also much more potent.

Falk: If all of those don’t work, then you’d have to argue at some point that the patient really does need to consult with their physician so that other sorts of therapy is considered.

Shaheen: Absolutely, and even if they do work, I actually suggest that they mention to their doctor that they’re on these medicines, because despite the fact that they’re getting adequate relief, they still may require investigation to make sure that they’ve got no permanent damage to their esophagus. So, absolutely discuss this with your physician.

I see way too many patients where they’ve had some bad outcome from reflux, and they knew they had reflux long in life, but never mentioned it to their doctors because Americans somehow think that this is part of the fabric of America-that we’re supposed to have reflux. You see on TV, “I Can’t Believe I Ate the Whole Thing” – the bottom line is they have to let their docs know that they’re having this problem.

Falk: How does the patient figure out whether the discomfort that they’re having is coming from reflux, from their esophagus? Or from some other part of the body like your heart, which is roughly in the same geographic terrain?

Shaheen: That is a really important question, and the reason that we call it heartburn is it is right next to your heart. In fact, heaven is full of people who thought they were having GI upset and were having a heart attack.

So my suggestion would be the following: when you initially encounter these symptoms, it’s important to tell your doctor, because depending on your cardiac risk factors and the character of the symptoms, they may require some investigation to make sure that this isn’t a heart issue. We have many people who have had heart issues that masquerade as GI upset. So absolutely, this is a discussion that needs to happen with your doctor.

Falk: Let’s move to another screening question. What you’re screening with the upper endoscopy in somebody who has reflux is you’re screening for a concern that there may be a precancerous lesion. Similarly, colon cancer screening is unbelievably important, in our state and nationwide.

Shaheen: Colon cancer screening is one of the biggest public health issues we face, and it’s an unequivocal public health success story. By that, I mean, if you get colorectal cancer screening, you will remarkably lower your risk of ever dying of this very common cancer.

Unfortunately, despite the large amount of evidence we have that shows that that’s unequivocally the case, that you can decrease your chance of dying from cancer, only about sixty percent of eligible Americans avail themselves of the opportunity to have themselves screened for colorectal cancer. We can markedly decrease your chance of getting this cancer, and yet, really just through inactivity, people are missing the boat on preventing this cancer.

Falk: The screening recommendations are what, every five years? Ten years?

Shaheen: For the average-risked individual, at age fifty we want them to have an initial exam. If that exam is negative, they don’t have to come back and see us if they’ve had a colonoscopy, which is one of only several screenings -we can talk about the choices here in a second – they don’t have to come back and see us for another ten years. So, yes, they do have to go through the prep, they have to have the inconvenience of missing a few hours of work, but if that test is clear, they’re going to do it once a decade.

It’s amazing that they’re going to get this protective effect for really, what I would consider to be a relatively low investment.

Now, there are other ways of looking for this disease. It’s not just colonoscopy. That’s the one that is most commonly used. But you can screen with fecal-occult blood testing- which just a stool sample. Now, because that’s a little less sensitive, you have to do it a little more often. However, that’s just fine too. We’re not as interested in telling the patient which test they need, as that they get a test.

Falk: And then if they find a polyp, then there is a more frequent screening need, which varies patient by patient.

Shaheen: That’s correct. If you find a polyp, you’ve marked yourself as an individual that’s at higher risk for cancer. And because of that, we’re going to follow you a little more closely, because we think that the cancer does come from these polyps. We think that the polyp is the precursor lesion for cancer. We find these precursor lesions in your colon, it does two good things for you. Number one, we remove them when we find them, which will decrease the chance that you’ll ever get colon cancer. Number two, it lets us stratify your risk-or tell if you’re at higher risk. If you are at higher risk, you’re going to come back and see us in three to five years instead of the ten years had you had no polyps.

Falk: Dr. Shaheen, with all that we know about food sciences, all that we know about changing taste, why on earth are the preps for colonoscopy so onerous? Why do they taste so unusually weird?

Shaheen: Yeah..that’s a fair question. It would be wonderful to have a better prep. I joke that someday I’m going to invent an umbrella that’s inserted and then just pulled down so you don’t have to go through the prep at all. We haven’t gotten there yet.

I will tell you that things have gotten better. There are some newer preps that involve less amounts of fluid that you have to drink, that can be taken over a little bit longer period of time. But it is an investment, you should consider it an investment in your health. It is a short-term inconvenience for a long-term gain. So while I agree that there is some hassle with getting this done, at the end of the day, it’s unequivocally worth the time and effort.

Falk: For people who have some degree of kidney ailment, the use of preparations that have lots of phosphorus in them is really not a good idea. It’s dangerous to their kidneys to drink this.

Shaheen: Exactly. When you’re talking with your primary care doctor, or your gastroenterologist who—if that’s who has prescribed this test, one of the things that you should discuss is what prep is best for me, based on my medical conditions?

Falk: We’ve talked already about two types of screening kinds of endoscopy. But there’s a whole new revolutionary field that has unfolded. Fortunately here at UNC we have some world experts, and that’s the whole concept of natural orifice endoscopic surgeries, that one can do all sorts of, what were in the past, open surgical procedures. Now, by putting a tube through natural passageways. Tell us about that whole, new field, and tell us about the experts here at UNC.

Shaheen: Perhaps of all of the advances that have occurred in gastroenterology in the twenty-five years that I’ve been involved with it, the single most exciting advance to my eye is this idea of natural orifice surgery. In the old days, when we put a tube inside someone, we were looking primarily to prevent or detect GI cancer or GI inflammatory conditions. The one thing that you absolutely didn’t want to do, you didn’t want to make a hole in the GI tract, because that was sending a patient into surgery. You had to repair that hole, and that was a major failure on the part of the endoscopist.

What a difference two decades make. Now, downstairs right now in our unit, there’s a doctor that’s purposely making a hole in the GI tract to get access somewhere else into your body that would have required a surgical incision even five or ten years ago. It’s really quite remarkable. We can get anywhere – when you think about the path of your GI tract, there are very few vital organs in your body that we can’t access through your GI tract.

The general idea here is we’re going to drive down through the GI tract to the area that’s closest to the area of interest. We’re either going to put a needle through the GI wall if we want to know what that tissue is-let’s say you have a radiographic abnormality. Or sometimes we’re going to make a slit in the GI wall to actually do surgery from inside your body, and then close that hole on the way out. We’re going to remove organs, we’re going to remove tissue, etc.

One of the world leaders of this is our Director of Advanced Endoscopy, Todd Baron, who can do miraculous things from inside your GI tract. It’s just a joy to watch. The biggest pleasure of all is it’s still in its infancy. We’re limited now only by our imagination and the tools we have available to us, and both are exploding rapidly. So I think that they’ll be a time, perhaps, for the vast majority of surgical procedures, that we will consider barbaric that we would ever cut somebody’s skin or cut through their abdominal wall to be able to get this done- “My gosh, can you believe that they did it that way? When we could have just put a scope up next to it and removed your appendix, removed your gallbladder.” It’s done for all sorts of gyn surgeries. There’s a remarkable array of things that have now been reported as having been done through the GI tract.

Falk: There’s a whole other field that has nothing to do with the GI tract, that’s invasive bronchoscopists. They’re doing the same natural orifice kinds of endoscopy too, and it’s with a bronchoscope and the lung, rather than using the GI tract. It’s a brand new, wide-open field, but it helps patients tremendously because their recovery from essentially a closed procedure, rather than an open one is remarkably better.

Shaheen: Most of these patients never know they had it done. Your insides are not wired for pain the way that your skin is. So you can make an incision in the wall of someone’s stomach as long as you close it properly, they’ll never know they’ve been incised. Most of these patients go home, believe it or not, the next day.

Falk: That’s wonderful.

Falk: There are lots of things happening in the Gastroenterology and Hepatology division. Give us some other highlights if you would.

Shaheen: One of the great pleasures of my job is getting to come to work every day and getting to deal with the folks in the division, because it really is a remarkable division, and was so well before I became the chief. This division, for a variety of historical reasons, as well as really excellent leadership before me, is one of the broadest, deepest divisions in terms of the quality of doctors that you’ll find anywhere in the country.

Our division has eighteen doctors who are named as America’s Best Doctors. That’s more than any division in North Carolina, South Carolina, Virginia, in fact all of the academic divisions combined. We have world leaders in every subspecialty in gastroenterology. So you name it-whether it’s viral hepatitis, whether it’s advanced endoscopy, functional bowel disease, inflammatory bowel disease, you will find our people leading the international studies, giving lectures at the national meetings, etc. So the quality of care that you’ll get here regardless of your ailment, I would put up against anyone in the country.

Falk: That’s a remarkable group of physicians. All of whom take wonderful care of patients. Happily, they’re also training the next generation of gastroenterologists. Tell me about those opportunities.

Shaheen: We really believe that we have three missions as a division. We’ve talked mostly about patient care, but we consider education to be a centerpiece of what we do. In fact, where most GI divisions have a single training path, if you come in as an undifferentiated general internist and you leave as a gastroenterologist. our people actually have three paths to choose from.

One is a clinical investigator path where you learn primarily how to do clinical research. Parenthetically we have maybe more people on faculty who have advanced degrees in clinical science than anyone else in the country. We’ve got the general clinical pathway, which is people who are going to take care of patients and to be leaders in their communities in North Carolina and elsewhere. Then we have our basic science pathway, during which many of these people will get PhD’s, all of them will get an advanced experience in a lab that will push them toward a career as a funded researcher in the basic sciences.

So we’ve got this whole array of training. Layered on top of that we’ve got these interesting one-year fellowships for people who are already gastroenterologists. And they say “Well, I’m a really good general gastroenterologist, but I want to be one of the world’s best inflammatory bowel disease doctors” or “I really want to be an esophageal doctor” or “I really want to be a super interventional advanced endoscopist.” These are all called “super fellowships” or advanced fellowships. We offer those fellowships as well to get people at the cutting edge of their field.

Falk: Look to the future three, four, five years out. What do you think’s going to be the most fun, new advance?

Shaheen: I think that there’s going to be an amazing intersection between the advances in endoscopy and addressing America’s biggest public health issue right now, which is obesity. There’s been a remarkable explosion in the technology to address obesity from an endoscopic perspective, and there are multiple devices that are being made to help look at this issue, about obesity, and see if we can avoid these huge disfiguring surgeries that patients are going through in order to lose weight. Perhaps something as simple as a same-day endoscopic procedure will be all that you need. Now it will never work in isolation, it will always be part of a bigger program that requires issues like looking at nutrition, almost always there’s an endocrinologist involved because diabetes and other metabolic issues are there. Many of these patients have other health problems that require other care, so it’s going to be a team approach. One integral part of that, that I think many patients are going to get, is an endoscopic intervention.

Falk: So diet, exercise, and an endoscope.

Shaheen: Right. And whether that endoscope inserts a sleeve—we’ve probably put in more endoscopic sleeves into the small intestine to change the way people absorb food. Whether it involves a space-occupying balloon in the stomach, so that you can eat less before you become full, whether it involves a changing of the anatomy of the stomach to exclude a portion of it and make the total volume of the stomach smaller. All of these are achievable now endoscopically.

Falk: Nick, thanks so much for spending time with us today.

Shaheen: It was a pleasure to do this. Thanks for having me.

 


Dr. Nicholas Shaheen is Professor of Medicine and the Division Chief for Gastroenterology and Hepatology at UNC.

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