Video Interview with Gastroenterologist Physician, Daniel Alpert, M.D.

Hi, it's Doctor Robert Seichert with another episode of Doctor Podcasts. We've gotten some great reviews and great feedback on the 1st 2 episodes, so I'm really excited to have another episode now. If you have any feedback, please get in touch with us through Twitter. And of course, if you like our episodes, please click on the follow button on the Twitter website and also you can send us comments. My first two episodes, as you know, I spoke with eye doctors of various different specialties. Today, I'm really excited about speaking with a gastroenterologist.

Doctor Daniel Alpert, who's sitting here with me, took time out from his very busy practice to Be a Doctor podcast today, and I'm very glad that he's here. Doctor Alpert is a gastroenterologist for many years. He's an attending physician at the NYU Langone Medical Center and the NYU Grossman School of Medicine here in New York City. And Doctor Alpert is one of the top gastroenterologists in the New York City area. So I'm really excited about having him here today. Thanks very much for coming today, Dan.

I appreciate it. I have lots of questions for you and I'm sure you you have lots of interesting answers and the audience look forward to hearing about it. One of the things that I'm reading about a lot lately and also things that I see in my ophthalmology practice is I'm seeing younger patients who've gotten colon cancer occasionally, even 40 year old and rarely 30 year olds, and I've also seen this written up in the literature recently. What do you think is going on? Why is colon cancer occurring in younger people?

Well first thanks for having me I my. Pleasure. And thanks for taking the two hour drive to go from E 37th St. All the way to 39th St. That was sure. Yeah, we were lucky. It usually takes 3 or 4 hours. So it's a great opening question. It is a very hot topic and it is a real entity that we are seeing younger people under the age of 50 and often times under the age of 40 being diagnosed with colorectal cancer. And many times these cases tend to be more aggressive than cases we are seeing in older patients.

Now in terms of why this is, this has been studied and thus far the conclusions are that diet and lifestyle might be playing a huge role. Certainly the biggest predisposing factor is family history. So about 20% of these patients who are diagnosed with colorectal cancer will have a family history of colon cancer. But there are other patients where there is no family history. So what are the common denominators? So what we're seeing as risk factors include obesity. A diet that is high in fat in processed foods and perhaps low in fiber.

Certainly we are seeing people with physical inactivity being a risk factor. So the combination of diets that are high in processed foods, high in fat, low in fibers, it seems to be the are the major risk factors that we're seeing alcohol intake and cigarette smoking or other. Risk factors as well other fact that's interesting that you mentioned that because there are certain eye diseases that are also associated with obesity and inactivity and and things like that metabolic syndrome. So we recommend that patients eat lots of fruit, lots of vegetables, avoid processed food, avoid fats.

And there's increasing evidence that exercise also reduces the risk of various eye diseases, so I guess that applies to the entire body. Absolutely. So as they mentioned these risk factors as it relates to colon cancer, we could apply the same risk factors to a lot of cancers. We're seeing that all of those factors, obesity, low fiber diets are contributory. So the more quote UN quote plant based your diet is, the better off you are and those seem to be major factors. There are other reasons why that could be, but diet and inactivity can actually affect your microbiome, something I think we're gonna talk about a little bit later.

And the microbiome indirectly can increase changes within the colon such that there's increased inflammation and ultimately cancer. And typically when people develop colon cancer in the older age group. Usually cancers arise from preexisting benign polyps. The polyps that are premalignant are referred to as adenomas, and there's something called the adenoma, carcinoma sequence. And the whole rationale behind screening people is to look for polyps and to remove them in younger people, they they seem to have a different mechanism.

A lot of younger people develop colon cancer, seem to skip that adenoma sequence, so that the whole molecular activity of the cancer is different, it's just behaving differently. And maybe the microbiome is playing a role in that. So that that's really interesting. So what do you recommend is the age that people should start having colonoscopies? Because I believe colonoscopy is the best way to diagnose colon cancer. There is no doubt that the the best modality to diagnose colorectal cancer and colon polyps is colonoscopy.

That is the considered the gold standard now for the longest time the the recommended screening age for someone who's quote UN quote average. Risk was 50 and by average risk, we mean someone who does not have a family history of colon cancer. There's not a history of inflammatory bowel disease. Patients who have ulcerative colitis and Crohn's disease have an increased risk of developing colon cancer. So somebody whose average risk, no symptoms, we would say 50. But because of what we just talked about, this younger population presenting with more advanced cancers, the age was reduced to 45 for average risk individuals.

And my sense is that over time, I think that that screening age is going to be reduced even further. It took time just to go from 50 to 45 to get the insurance carriers and everyone else on board, which is it, which is, you know, part of the reality. But that doesn't mean that patients should not be screened earlier if appropriate. So I think it's an important teaching point that if a younger person has gastrointestinal symptoms, I have seen the situation where people sort of dismissed their symptoms thinking, well, I'm young, it can't be anything.

Too bad, right? But people in their 40s, thirties and even 20s are being diagnosed. So if you have blood in the stool, if there's a dramatic change in bowel habits, ongoing abdominal pain, you have to see a doctor. You should see a gastroenterologist. Great advice. Let's say you have a patient who has a family history of colon cancer. Let's say one of their parents had it, and let's say they're they're obese and overweight, maybe have diabetes. What age would you tell them to have their first colonoscopy?

That's a great question. So one of the things you'd have to ask the patient is how old was the family member when they developed colon cancer? So there are recommendations that if there's a family history, that the colonoscopy should be done either 10 years earlier than the year that the person was diagnosed this way, was diagnosed when they were 45. You'd want to do it at 35 or the age of 40, whichever is. Younger, so that's sort of 1 guideline. Having a family history of colon cancer is significant, but if you have a family member who was diagnosed at an advanced age, let's say in their sixties, 70s or 80s, it doesn't quite carry the same weight as someone who had a family member who was diagnosed earlier on.

But clearly you want to be ahead of the curve and you want to be screened at least 10 years earlier than the index patient was diagnosed and. Another important point is that if there is a family history, we have genetic testing available and it can really help guide patients and doctors for how frequently they should be screened. So that's another important point. If there is a family history, especially if it's more than one relative, you definitely would want to pursue that. On that same subject, is there a time when you don't need to have colonoscopies anymore?

In other words, if you're 70 or 80 or 90, should you stop having them? Right. It's another great question. It, it has come up a lot in the news. There was, you know, not in the necessarily the medical literature, but. In in a lot of magazines, television channels, etcetera, they were sort of statements suggesting that when you're 75, you should stop having colonoscopies. So I've had numerous patients come to me and say, well, I'm 75 now, I guess I don't need colonoscopies anymore. And and the real answer is it has to be individualized to each patient, certainly if somebody is 75 and they're otherwise healthy and they do not have underlying heart or lung disease.

And let's say there's a past history of colon polyps. Or family history of colon cancer. We should not stop screening. It's not as if the risk stops when you're 75, but on the other hand, to exaggerate to prove a point. If somebody has advanced heart failure or they have metastatic cancer from some other site, or they have advanced Alzheimer's, you may not want to screen those individuals so. Partially, it's a decision that the patient makes. Sometimes patients say, I just don't want to do this anymore and if they understand the risks and benefits, I think that's fine.

But also the physician should be involved. Also, sometimes patients are just not medically fit to have a colonoscopy in terms of anesthesia, etc. So it has to be individualized. That's right. I think we should stress that colonoscopy these days is a very, very safe procedure and also it's it's not that uncomfortable with modern anesthesia techniques. Could you talk about that a little bit to encourage people to have colonoscopies, because a lot of people are just afraid of the concept. Absolutely.

So one of the biggest advances in colonoscopy was is the use of propofol. And anesthesiologists are routinely involved in most colonoscopy cases. And the sedation that's given provides deep sedation. You're asleep. You don't feel anything. You don't remember anything. It's a painless procedure. The procedure is extraordinarily safe, as in any procedure that can be risk related to anesthesia, perforation, or tears In the colons are rare complications, but they are rare. So in good hands the risk is incredibly small.

So there really is no discomfort. It is clearly the test of choices that I said when we compare people who get screened for colon cancer and we compare them to people who don't get screened. The rate of colon cancer in the unscreened group is much, much higher and that's been proven time and time again. All right. It's very important point. What about these home tests? I see a lot of commercials on TV for Cologuard, which is a popular test in a very big company. Could you talk about that a little?

Yeah, well, you know, I think for people who do not want to have colonoscopies for whatever reason, if they're fearful or they feel that perhaps medically they're not fit to have a colonoscopy, it represents. Some form of screening, but again it does not compare to colonoscopy and there are a lot of false positives and false negatives with polyp detection and even their statistic on colorectal cancer detection. The the statistic is that 92% of patients undergoing colocord who have colon cancer will be diagnosed.

But that means that eight out of every 100 patients who are tested are being told that everything is fine when in fact they have colon cancer. So it's far from a perfect test, and ultimately if the test is abnormal you're gonna need to have a colonoscopy to. Look. At further. So I think it represents some form of screening, but I don't think people should rely on it, quite frankly. There are other modes outside of colonoscopy where radiologic procedures are available. There's something called CT colonography.

We're using CAT scans to scan the colon. Again, not as precise, but it is not invasive. Still requires A bowel preparation. If something was abnormal, you'd first need to have a colonoscopy, right? What about this camera device? I hear you can swallow a small capsule which has a camera, and then it goes down your intestines. That's right. How effective is that? Well, capsule endoscopy is primarily used not to evaluate the colon. It's primarily used to evaluate the small intestine. So there are certain indications when the small intestine needs to be thoroughly evaluated.

And as you said, this capsule actually takes a video of your small intestine. So for patients who have gastrointestinal bleeding, that is of unknown ideology. We don't know really where it's coming from. And the patient has already had a colonoscopy and an upper endoscopy to look in their stomach, and we still don't have a source. A capsule looks at the remaining part of the small intestine. It's also sometimes used to evaluate patients who have Crohn's disease, who have celiac disease, who have chronic abdominal pain and diarrhea that has not been diagnosed with other modalities.

So that's where Capsule comes in. Do any of those Capsule movies wind up on Twitter? Hopefully not. Hopefully not. Hopefully not all right. Sounds good. Another topic, I see patients, when I see patients, I take a careful medical history because some medical conditions affect the eyes and so on. So I see a lot of patients in the last few years with irritable bowel syndrome. Can you explain what that is and what the symptoms are and what? You sure about it? Sure. So irritable bowel. Syndrome is probably the most common diagnosis A gastroenterologist sees.

It's been said about 20% of all visits to a gastroenterologist office revolve. Around the irritable bowel syndrome, and it's what's referred to it sort of a functional disorder, meaning that there are no structural abnormalities that we can diagnose. In other words, there's no test that tells us a patient has irritable bowel syndrome. So what is it exactly? Usually it's a syndrome of chronic abdominal discomfort or pain, oftentimes bloating. It can be associated with alterations in bowel habits.

So there's what's referred to as diarrhea, predominant, irritable bowel syndrome, Constipation, predominant, IBS pain predominant, and we believe that a lot of patients who have this might have. Dietary issues, sometimes emotional factors, anxiety or depression can be contributing factors. But again we're beginning to learn more and more about the microbiome, its influence on irritable bowel syndrome that you know, in our colon we have about 40 trillion microbes running around. There's a lot of stuff And that some people who have irritable bowel syndrome might have a quote UN quote, imbalance or dysbiosis of good versus bad bacteria.

So that's also sort of affecting. Treatment that sometimes we will treat these patients with non absorbable antibiotics that just stick to the gut and try to get rid of these quote UN quote bad bacteria. But it's a very common condition. It's not serious or dangerous. It doesn't predispose to. Very annoying though. But very annoying could be it can cause a lot of distress for patients. It could affect their lives and impact their lives tremendously. It does require a lot of patience on the part of the patient and the physician because there's a lot of empiric therapy.

So we try very basic. Things in the beginning. Diet. Manipulation. Try to avoid fatty foods, increase fiber intakes. Sometimes that works, when it doesn't, we try other things. So it's a process, but it's a very common. Malady, right? I've seen recently again commercials on TV for drugs for irritable bowel. Or are there drugs that work for? That well, you might be referring to inflammatory bowel disease for, you know, so inflammatory bowel disease is a different entity. That is, these refer to conditions where there's inflammation in the GI tract.

That's different. Exactly. It's different. Includes Crohn's disease and ulcerative colitis and there has been an explosion of drugs where we refer to as biologic therapies. Here, there are ways that we can make definitive diagnosis based on findings on colonoscopy, CAT scan, MRI, even blood tests and stool tests are helpful. But yes, there has been an explosion. But for irritable bowel patients, there are treatments, but not the treatments that you're seeing advertised on television. It's a different entity, but it's an important point because sometimes it's hard to make the distinction between who has irritable bowel syndrome and who has inflammatory bowel disease.

So it requires a careful history and sometimes tests are required to make that distinction because there are conditions that can mimic IBS or irritable bowel that are not irritable male, and again you would need to do a colonoscopy sometimes to tell. Sometimes, sometimes, sometimes with it's not obvious, a colonoscopy can absolutely help make the diagnosis or rule things out for sure. That's very interesting. What about you mentioned in inflammatory bowel disease? There are two types. There's Crohn's disease and ulcerative colitis.

Can you explain the difference between those two? Sure, it's. And sometimes the differences between the two can be subtle. And in fact, there's even a third entity, which is referred to as indeterminate colitis, where patients have features that might have a little bit of both. But with ulcerative colitis, ulcerative colitis technically will only involve the colon. Whereas Crohn's disease, in theory could affect any part of the gastrointestinal tract from the mouth to the anus. So that's one difference.

Another difference is that when Crohn's disease occurs, typically the inflammation is transmural, meaning that it goes across the wall of the intestinal tract, and as such it can cause other complications such as fistulous tracts. Strictures, abscesses. That typically does not occur with ulcerative colitis. I see. And then there are other features. Ulcerative colitis tends to occur in the colon in a continuous fashion. Crohn's disease tends to can be an Apache distribution. Those are some of the major differences between the two.

I would call for many years of theory that they might be infectious conditions, possibly some bacteria or maybe a virus. Is is that been proven at all or still not? There have been tons of studies over the years that have tried to implicate specific microbes. Going back decades, tuberculosis and other bacteria, but we've not really been able to identify a specific bug. However, it gets back to the microbiome again that we believe that people with inflammatory bowel disease may have microbiomes that have different concentrations of different bacteria that could be contributory factors there.

There were others, there were genetic factors as well. But the microbiome is something that's being studied extensively. Yeah. What's interesting is I I have some patients who have these inflammatory bowel conditions and very, very rarely they can get inflammation in their eyes as well. That's right. Very rare, but I have a few patients with. Absolutely. So you know, so these are inflammatory bowel diseases. And sometimes the inflammation is not always just confined to the bowel. Sometimes when there's activity, we have what we call extra intestinal manifestations.

People can develop arthritis. Uveitis, which is in an eye condition, episcleritis, they can develop something called primary sclerosing cholangitis, which affects the bile ducts, can be very serious, which in fact can lead to cirrhosis and liver cancer. So there are a lot of of these extra intestal manifestations and ultimately these are inflammatory diseases. So the root of treatment is really to target this inflammation. Interesting. What about the autoimmune theory of these conditions that it's your immune system that's gone awry and somehow attacking your intestines?

That's exactly right. So that there might be certain antigens or proteins within the bowel that your body or immune system is recognizing as foreign and inappropriately attacks it, right. So and that's why drugs like steroids and other immunosuppressants can be very effective for shortterm relief because you're suppressing that autoimmune antiinflammatory response. So the drugs that are available for Crohn's and ulcer of colitis are immunosuppressants. They can be. There are immunosuppressants, drugs that include Prednisone or other drugs that do what Prednisone does of imuran or azathioprine and six, mercapto appearing our names of some of the older generation immunosuppressants.

I'm seeing ads on TV again for those a lot, yes. But over the past decades, there have been these newer drugs that are targeting specific inflammatory cytokines or markers that fluctuate throughout the colon and we try to target those. Drugs as well. So these are pretty common conditions if they're doing a lot of TV advertising, right? Absolutely. And and for those people, people who are affected, it really has a tremendous impact on their lives. And again, there are more and more drugs being marketed and there's an explosion of drugs over the last few years.

And a lot of people are suggesting that ultimately a lot of these drugs will be combined together to optimize treatment because even though these drugs are terrific and have helped so many people, the response rate. For most of these drugs, is somewhere in the neighborhood between 30 and 45%, so there's still a lot of people do not have the kind of response we'd like to see. Right. You mentioned the word microbiome a few times in relation to these various conditions. Can you just explain what that means?

Because I think many people or many of my patients don't realize that there's trillions of bacteria living in their intestines and. Could you just explain that? Yeah, I mean, a lot of people really don't know is I think the microbiome is still in its infancy in terms of understanding it. But basically there's a whole other universe in your gut of all of these microbes. And as I said, about 40 trillion would be the average, most of them being bacteria, some viruses, some protozoa or fungi. And it creates an important balance, we believe for all kinds of things.

It's sort of a regulatory mechanism and the microbiome can be affected by diet. We believe we're coming to learn certainly with antibiotic usage. We even believe that mood can affect the microbiome. So it's very fascinating and basically at this point, I don't think there's any disease that's not going to be studied as it relates to the microbiome. There is, we believe, implications with regard to cancer and cancer treatment, inflammatory conditions, so it's a fascinating area. So basically, there are lots of different types of bacteria, and if you're lucky you have the right ones that live happily in your body.

They don't bother you, you don't bother them. But other people have. Too many of 1 type and not enough of another. The bacteria release chemicals and enzymes that can get into your body. That's right. And one of the things that we think is really important in terms of having a healthy microbiome is having a diverse microbiome. And we think that that is connected to diet. So for people who have a diet that's varied and healthy, that actually can help promote a healthy microbiome. And for people who eat the same type of food, you know, let's say processed food or fast food, their microbiome might be very narrow in its spectrum and this can impact health.

So if too many of 1 type of nasty bacteria overgrows and kills other bacteria, that might be bad because they're releasing all sorts of chemicals into your body that affect. Various other organs. That's right. And it raises some of the things that we sometimes do or sometimes patients do even without physicians. Probiotics, the concept there is to try to alter that balance. There are certain antibiotics that are referred to as non absorbable anthrax. They go to work in the gut with no place else and hopefully they get rid of some of those bad bacteria.

And then there are certain conditions, believed or not, where people have something called a fecal microbial transplant. We really try to transplant and give them a whole new microbiome, and that is being studied and it is used in certain conditions. There's a particular infection called Clostridium difficile, which is related to antibiotic usage, and sometimes when people have really severe cases that don't respond to typical treatments, fecal microbial transplants are being used and successfully.

Right. I've actually had a few patients who told me they had that they caught a Clostridium difficile infection while they were in a hospital for some other reason, didn't respond to any antibiotics, and they actually had a fecal transplants, right? Somebody else that's right to give them new bacteria to kill the difficile bacteria. Exactly right. It's pretty fascinating. Right. So we can kind of use these bacteria in helpful ways. Yeah. Who would have ever thought? Yeah. Now you brought up the the probiotics, which again many of my patients take because I take a history of what medications people are using because they can affect the eyes.

So I noticed in the drug stores, probiotics, the whole counter of them, and they're very expensive. Yes, some of my patients swear by them and say they feel so much better. Others say, I don't know, it doesn't do anything right. What's the story with probiotics? The honest truth. The honest truth? Well, in terms of, you know what, science has proven where they're helpful, it's only really a few indications. Clostridium difficile prevention, probiotics are used. There's a condition called pouchitis, which is when patients have ulcerative colitis and they've had surgery.

There's something called a pouch and sometimes that gets inflamed. Probiotics have been shown to have a statistically significant impact on those two conditions. And also in pediatric patients there's something called necrotizing enterocolitis where probics might be helpful. But aside from that, there is no real substantial literature to suggest that they help. Having said that, anecdotally I have seen where sometimes Probics can help patients and whether it is really the effect of the probiotic or placebo effect is.

Hard to say. It's hard to say and hard to know, but that's what the statistics or the data shows to date. There are certain situations where I recommend them. Sometimes when people have a GI bug and they have diarrhea and you don't want to necessarily give them more antibiotics and until you know exactly what the pathogen is. Sometimes probiotics I find, do help seem to lessen the course or the severity. And there are people who sort of echo that sentiment, but the data is not strong. What's actually in the probiotic pill that you're taking?

Can you explain that? I mean, they're just different strains of bacteria. Good bacteria, quote, UN quote, big good bacteria. Bifidobacteria probably being the most important one. But there are other strains. Of course, there are some people who take these probiotics who are healthy and they just say, well, I'm gonna take probiotics because I wanna stay healthy, right? But I would not recommend that, because who's to say that your microbiome, if you're not having any symptoms, is just as good as you know doesn't need to be altered with.

Right. That's similar to the vitamin debate should you'd be taking a vitamin every day. Is that helpful or not? I guess the different thoughts and opinions about that, right? But you know, if you know it's one thing, if you're having symptoms, want to try something. But for those people who are healthy, I wouldn't necessarily recommend it. But at the same time, what we see, we don't see much harm being done by probiotics, but sometimes we don't necessarily see much good either. Right. What about Another thing I see more of is patients who have a fatty liver problem.

Can you explain what that is? That seems to be something that's increasing in frequency as well, absolutely. It's a huge topic now And so the story behind fatty liver, but you know, originally we knew about fatty liver is related to alcohol, right? And one of the first stages of alcoholic liver disease was fatty liver, which was considered to be a reversible stage of fatty liver. So if you stop drinking at that point, you would do better. And then we began to recognize that some people develop fatty liver even when they didn't drink alcohol.

Who are these people? Well, it tends to be the same risk factors that cause diabetes, cardiovascular disease, what we refer to as the metabolic syndrome. So people who are overweight, who eat a diet that is poor, perhaps a lot of fat, perhaps foods with a high glycemic index, a lot of sugars or starches, when and this is referred to as Nash, non alcoholic, steato, hepatitis. And originally it was thought that this is a benign condition it would never cause. Chronic liver disease was not an issue.

So if you had a fatty liver we wouldn't really make too much of a deal about it. But now we've come to realize that that is not true that a lot of people have fatty liver. Some of those people will go on to develop fibrosis so that there's chronic inflammation and scarring. And then some of those patients can go on to develop cirrhosis, which is an irreversible stage of liver disease. And if you have cirrhosis from whatever cause, you're at increased risk of liver cancer or paddle cellular carcinoma.

So we've really started to target these patients and the treatment has to do a lot with the same thing. A primary care doctor would tell their patient who has diabetes or high cholesterol that you need to lose weight, need to eat healthfully, you need to have a high fiber diet and try to cut out bad sugars and starches and fats. And we have all kinds of different tools to evaluate these patients. The fatty liver means there's deposits of fat inside the liver that don't belong there. That's right, that's right.

So, and oftentimes you can see it on ultrasound, it's a very good, easy way of diagnosing it. So if a patient has abnormal liver function tests or a doctor is suspicious that a patient has fatty liver, and ultrasound will often show evidence of fat depositing in the liver. And that and of itself may not be a bad thing but over time the chronic deposition of fat leads to inflammation and fibrosis and perhaps cirrhosis. So this is a huge area of investigation right now and it's one of the leading causes of chronic liver disease and even liver transplantation.

I'm. Again, ads on TV. I see this new ad for some liver pill. Keeps your liver healthy. Have you see? I forget what it's called. It's on TV. There isn't such a pill, is there that, that? Not that I'm aware, no. In fact there there are no drugs right now that are approved for the management or treatment of fatty. There's a lot of studies being done. So right now the treatment really comes down to weight loss, healthy activity, physical activity that's really comes down to. Same thing that works for every other disease.

Right. So that's what we're beginning to see. This is all sort of part of the metabolic syndrome and now the liver is no longer being left out of that conversation. That's what it comes down to. Another thing that I see a lot of advertised on TV as well as patients who have it is gastroesophageal reflux disease or heartburn or acid stomach. It's referred to. There seems to be more. Of that as well, there's a lot. Yeah. So that's another very common disease state that gastroenterologists see. It's extraordinarily common, not just gastroenterologists for primary care physicians.

And that's the condition where acid from the stomach is inappropriately getting up into the esophagus. And sometimes that can cause symptoms, although sometimes it may not. There's something referred to as silent reflux. The classic symptoms would include heartburn, the sensation of a burning sensation in your chest, or regurgitation. But there are a lot of patients who may have symptoms that are not, quote UN quote, classic. They could range from a chronic cough, chest pain, hoarseness, sometimes even sinus issues can be related to reflex.

Now what's the significance of all of this? Now some people are under the impression now if I have heartburn, it's not a big deal. I'll take an antacid, and if I get better, who cares? Well, the real issue is that if you have chronic reflux that occurs over prolonged periods of time, it could inflame the lining of the esophagus. And that chronic inflammation can lead to changes in the cells of the esophagus, something referred to as Barrett's esophagus, which is considered a precursor to something called dysplasia, which is a precancerous condition to esophageal cancer.

And esophageal cancer is a terrible cancer, and the incidence of esophageal cancer is rising in this country. It's most common in white obese males, but everyone is at risk. So there seems to be a shift, or some people are suggesting there should be a shift as to how aggressively we should screen these patients. Because we're starting to see people who have esophageal cancer, who had reflux but were never diagnosed with Barrett's esophagus. So the question is, is Barrett's, are we missing Barrett's esophagus or are there other histologic or cellular changes that are taking place that might be a predisposing risk factor that we're missing?

The bottom line is, if you have Reflux or Heartburn, don't Pooh Pooh it. Don't dismiss it. You should have it checked out. It's important. Right. Just a reminder, I haven't been in medical school in a while. The esophagus, just a reminder, connects the back of your mouth and throat to your stomach. That's right, it's a food pipe. It's the food pipe. Exactly. That's right. And that's where the cancer can occur. That's right. And so it's a food pipe. It's about, you know, to the to the tip of the the proximal part of the top part of the stomach, about 40 centimeters.

And besides cancer, there are other things that reflux can do. So sometimes the chronic exposure of acid can actually narrow the lumen of the esophagus. So if you think of the esophagus as a tube, sometimes that tube gets narrowed and people develop strictures. And then what happens is that sometimes food gets caught in these strictures. We used to refer to it as steakhouse syndrome because the classic situation is somebody's, you know, at a steak dinner and they're having a good time and maybe they're not being very careful with the size of the of the steak that's going down there, Gullet.

And the next thing they know, you know. So you know, you have to be careful. Now, besides medication, diet actually plays a big role again, and that's important. And I always tell patients for kid with them that anything that is pleasurable or enjoyable can cause reflux. So it can range from from alcohol of any variety, including beer, wine, caffeine, fatty foods, fried foods, chocolates, spicy foods, acidic foods. It's a long list. So basically you just want to eat carrots and lettuce, basically.

That's yeah, maybe it's an occasional piece of chicken if you're behaving so that's part of it. And then, and for some people, just adjusting their diet might be enough. But for others, medication is necessary and there are different classes of medications and there's some controversy about long term use of some of the medications we used called proton pump inhibitors, which are the strongest or most potent medications and they work the best. But there have been some concerns raised about long term use, although most gastroenterologists really view them as generally safe drugs.

But at the same time, if somebody doesn't need to be on it chronically, it's the doctors responsibility to try to de escalate or de prescribe once the patient's symptoms are under control. So it's something that we have to always be mindful of. Interesting. A lot of lot of conditions that affect the gastrointestinal, yes, Yes, it's a long list. Keeps you busy. Now the hottest topic, and the reason I really have you here today, is I want to know about gluten because everybody now is gluten free. Gluten is like the worst enemy in the world.

What's the story with gluten? Why did I never hear about it for decades and all of a sudden now everybody has a gluten? Sensitivity or a problem, right? It's pretty amazing actually. If you go into a large supermarket, there are often entire aisles that are just dedicated to gluten free foods. Now, gluten was really made famous by a disease called celiac disease, which again is an autoimmune disease, and it's a kind of an interesting disease. When you ingest gluten, which is sort of a protein mix that's seen in wheat and barley, rhye and oats, people develop this autoimmune reaction.

And if you remember high school biology, in the intestine there are these little finger like projections called villi and they're there to help absorb nutrients. And in people have celiac disease, they have antibodies that are present that produce this sort of destruction of villi and what's referred to as lymphocytosis. There's infiltration of white blood cells and the absence of villi causes patients to have these unpleasant symptoms of bloating gas and diarrhea. So that is clearly a gluten related disease.

And the treatment for celiac disease is to be strictly gluten free. And in fact, when people go into remission from being gluten free, the single biggest reason why they flare is because unknowingly there is some gluten getting past their lips. So even when people are exquisitely careful, they can have relapses. Often occurs in restaurants setting where you know the perhaps the kitchen is not being very, very careful in this course contamination. Now for the rest of the world, why do they need to be gluten free, right.

So we don't really know, you know, and it's sort of a fad. When you look at the number of people who have celiac disease, it's a small percentage. The literature will say 1%, two percent, 3%. I don't think it's more than that. In my experience and this issue of gluten intolerance, it's sort of a controversial topic. I mean, I sort of believe that it can exist, that people, when they have gluten, it just doesn't agree with them. They don't actually have the autoimmune disease. But I think that it has taken on a life of its own to be gluten free.

There are certain athletes that are gluten free, right? They feel that it helps their performance. And again, whether this is sort of placebo effect or not, we don't know. But it's also not necessarily the best thing to be gluten free if you don't have to be because there are certain nutrients that people are deficient in when they're sometimes gluten free. So if you don't have to be gluten free, you shouldn't be. But there are patients I've encountered through the years who insist that they have gastrointestinal symptoms that respond only to eliminating gluten from their diet.

And if they do, and they feel better, it's hard to argue with that, right? Go with it. I go with it. Yeah, the bottom line is, if it makes it feel bad, that's right exactly. But there is a blood test to to check for the celiac. That's right. So for people who have that, you're absolutely right. So for people who have celiac disease, it's a great screening test. There are blood tests that are antibodies that are only present in people should only be present People have celiac disease although and is something called transglutaminase anti that's very specific for celiac, there are others that are not quite as specific or sensitive.

So it's a good screening test. Although we consider the definitive way of making the diagnosis, having the patient undergo an upper endoscopy and biopsying the small intestine and looking for the classic histologic features which are the absence of villi. Those little finger like projections I was telling you about and something called intra epithelial lymphocytosis is infiltration of. Of a certain type of white blood cells, that's a definitive way, but the blood tests are very helpful for monitoring patients and diagnosing patients, absolutely.

All right. That's great. Can you explain what upper endoscopy is? Sure, I should not have assumed that everyone knows. So an upper endoscopy is like a colonoscopy, but we're looking at the another orifice. So it's an examination where a flexible tube is inserted into the mouth. And again, this test is also done under sedation with propofol and it gives us the ability to examine the esophagus, just the food pipe that leads into the stomach. And we can evaluate the stomach and conditions of the stomach including but not limited to peptic ulcer disease, Helicobacter pylori, which is a bacterium that can cause peptic ulcer disease, cancers of the stomach and esophagus.

And then we can also look at the small intestine where we can diagnose things like celiac disease or digestive enzyme deficiencies referred to as diacrodase deficiencies. So an upper endoscopy is actually a really important tool that gastroenterologists use all the time. And it's also done on their propofol. Propofol is a great drug. I use that often when I do eye surgery on patients who are extremely nervous. They love it. They don't feel anything. They wake up feeling refreshed, like from a long nap.

It's a great drug. It is great. You know, it's interesting because there are some people who are so nervous and reluctant when they're having the procedure. And then when the procedure is over, they'll often say that was awesome. That was the best sleep I've ever had. I feel so good. Can we do this again? So, you know, the thought of a colonoscopy endoscopy is actually much worse than the actual procedure. It's actually, yeah. Right. So you mentioned a few procedures that gastroenterologists do.

Can you tell us what you do during a week, what procedures you do, what, what types of patients you see, how your time is? Yeah. I mean, I would say you know there there's a typical work day may involve starting off rounding in the hospital and then coming back to the office and gastroenterologists. I mean, there are I would say two major divisions of what we do. There is consultative work where we're seeing patients in the office who are presenting with new complaints or issues or we're following up on patients who already have diagnosis.

And then there are times we have to do procedures on patients to help make those diagnosis. So a lot of my time, the majority of my time is spent seeing patients in the office. And then there are three days a week or three mornings a week where we do procedures, Some of the tests that we mentioned, upper endoscopy, colonoscopy, we also do capsule studies and there are other tests that gastroenterologists do. There are tests that include something called ERCP, endoscopic ultrasound, liver biopsies.

And then there are specialists within the world of gastroenterology and there are specialized tests of the esophagus. And it's a fascinating feel and that's why I love it. It's a combination. It involves so many different organs. When you think about it's the esophagus, the stomach, the small bowel, the large bowel of the colon, the liver, the pancreas and and that's what makes it so interesting to me. Yeah. We spoke about different cancers that are occur in different parts of the gastrointestinal tract.

I'm also hearing and seeing more patients who have pancreas cancer, yes. Why is that? Do we know? Well, I mean, I think we're getting better at diagnosing it. We have good imaging, but it's a horrible disease. I mean, my own father had it, was diagnosed with it. And oftentimes, unfortunately, people are diagnosed by the time they're diagnosed. The cancer is already at least locally advanced. There have been tremendous strides made, I would say over the best of the past decade in terms of treatment.

So for those people who are able to have what we call resectable disease, there is surgery, Whipple procedure, which is major surgery. But I have observed that a lot of the chemotherapeutic regimens have improved and there are people who are living longer, but we have MRCP's and ERCP's and endoscopic ultrasounds. These are all different modalities that we have to diagnose and follow people with pancreatic disease. There any risk factors for pancreas cancer that we can avoid or not? We're not really.

It means there. There certainly could be genetic or family history can be one factor, like in a lot of cancer. Certainly cigarette smoking has been implicated, alcohol has been implicated. Sometimes there are certain conditions of the pancreas, they are rare, something called hereditary pancreatitis, which can lead to pancreatic cancer. So genetic factors certainly play a role. Does alcohol you can. Well, alcohol certainly can cause something called pancreatitis, both acute pancreatitis and chronic pancreatitis.

So people who have a history of significant alcohol abuse and pancreatic injury can secondarily often go on to develop pancreatic cancer. The pancreas also produces insulin, which controls your blood sugar as well. So the pancreas is a complicated organ. That's right. So that's right. There were endocrine cells like insulin and then there were exocrine cells, enzymes that are produced that help aid in fat digestion. So when you have a pancreas that's not working, it can cause all kinds of issues, including diabetes, including a terrible diarrhea, Recalls the adorrhea, where you're malabsorbing fat and you have diarrhea on that part.

Because if you have a damaged pancreas, it's going to impair your ability to properly digest fat. So that's specifically for people who have chronic inflammation of their pancreas. Right. Speaking of diabetes again comes up in various disease states. I have patients now, I'm sure you do, who are taking Ozempic Wigovy. Moon Jarro to to lower their blood sugars, keep their weight down. And some of my patients tell me they've tried it and had stomach issues and problems. Or are you seeing some of that?

Yeah. I mean, of course, as a gastroenterologist, I'm not necessarily prescribing these drugs, but I see patients who were on them. And the most common side effects that we see are happen to be gastrointestinal. Sometimes people complain of nausea, sometimes vomiting, crampy, abdominal pain, diarrhea. So sometimes these medications patients need to be adjusted. Sometimes these side effects are transient and people sort of get better. But we do see that and actually one of the drugs that you mentioned, Ozempic, can actually increase the risk of pancreatitis as well.

That's more significant. So for patients who had a history of pancreatic disease, we'd want to be careful about using those drugs. That's interesting. What new things are coming up in gastroenterology? That you think will impact how you treat patients in the next let's say three to five years. Well, I think I think if we can pick any organ system, there are advances going on in all, I think we touched on some of them and certainly there is an explosion of new drugs for the management and treatment of inflammatory bowel disease and the treatment of those conditions is rapidly rapidly changing.

And now we use different drugs that have different mechanisms of action and I think we're going to see these drugs being combined to get better results. So I think that's certainly one area irritable bowel syndrome, which is not necessarily a serious or dangerous condition, but impacts people. I think the microbiome might play a big role there and will influence how gastroenterologists practice. And we touched upon fatty liver and fibrosis of the liver and how that's going to impact

incidence of cirrhosis and chronic liver disease. And I think that's going to be an explosion of treatments to address that as well, besides just diet and lifestyle. Changes I know at NYU at the NYU Langone Hospital Medical Center and NYU Grossman School of Medicine. They're doing a lot of new types of imaging to help diagnose some of these conditions. Yeah, I mean, yeah, I mean NYU has done a tremendous job in gastroenterology. We have specialty centers and inflammatory bowel disease, liver disease, esophageal disease, and we also have a lot of great radiographic technology to use.

So for instance, in the case of the liver, there's something called Mr. elastography where we're using Mr. technology, we can actually measure the stiffness of the liver and that's thought to correlate very well with the patient's underlying liver disease. When we talked about screening the colon, CAT scans now incorporate something called enterography, where we can now really visualize the intestinal tract a lot better than we used to. And for people who are not able or do not want to have regular colonoscopies, there's something called virtual colonoscopy.

And I believe NYU is one of the first centers to to do that where we can really look at somebody's colon and see whether there are polyps are gross and they do a terrific job. So yeah, there's a lot being done at the Medical Center. Do you think the imaging will ever replace colonoscopy or no, I don't think it will, simply because colonoscopy has the advantage of being diagnostic and therapeutic. At the same time, we have the ability to take biopsies to remove polyps and that's the advantage. But for.

SO while you're there, you can, if you see something suspicious, you can biopsy it at the same time as opposed to having imaging and then they have to go to you to get the biopsy, right. So if you have imaging and something as seen that's abnormal, you will first need to have a colonoscopy. And even the virtual examinations do require preparation, which is probably the most difficult part of having a colonoscopy. So it means having two preparations instead of 1. But there are certain circumstances where it is helpful and it is necessary and it's a nice tool for us to have.

That's great. So we've covered a lot of topics in gastroenterology. And how many years of training after college did it take for you to become a gastroenterologist? Well, so. So there's medical school. So I guess so that's four years. Before that's four. When I went, I guess I got away with something because we had medicine residency which is 3 years. Now GI fellowship is 3 years. When I went it was two years and then there are fellowships now where people even go beyond the three years. There are subspecialties within gastroenterology, so.

So you did four years of medical school, then three years of residency. So your board certified in internal medicine as well as gastro. And then you did two years of fellowship, correct? So that's only nine years. I know, I know. I got to a crazy I know, I know. By the time you were done, you're almost ready to retire. I know. I mean, listen, I mean, that's one of the things that people don't necessarily appreciate. But yeah, it's a long road. It's a long, hard road and residency, it ain't easy because your typical work week, it's not a nine to five situation.

We like to call it the Days of the Giants. But you know, you would go in on a Monday if you were on call that night. You started Monday morning and you didn't come home until Tuesday night. And if you were working in the ICU or the CCU, you know, you were on call again every third night. So the whole pattern repeats itself. So yeah, it's it's, you know. Right. I did a medical internship before my ophthalmology residency and I was on call every 3rd weekend where I would start work Saturday at 8:00 AM and work through Monday 5:00 PM.

And occasionally there were weekends where there was very little sleep and I'm sure you experienced the same thing. That's probably. Too much. And they've now restricted that, which is a good idea. It's a good thing. Yeah, it's a good thing. The main teaching hospital, NYU, is Bellevue, and that's a busy place. And we've instituted night floats, which is better? It's more humane and I think people are more likely to function more better, quite frankly. So I think it's a good thing. Well, this is a been a a great discussion.

I really want to thank you for taking time to come here and explain all these things. I I think the audience will learn a lot from this and if you have any comments or suggestions, please get in touch with with us, we'd appreciate it. And I'm looking forward to some more doctor podcasts coming up very soon. Thank you. Thank you, Rob. Thanks for having me. All right.

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