THE NEED FOR A PARADIGM SHIFT
IN GASTROENTEROLOGY
Dr. Harley Sobin
United Hospital System, Kenosha, WI
March 28, 2014
[email protected]
262-653-5330
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DISCLOSURES
 NONE
THE NEED FOR A PARADIGM SHIFT
IN GASTROENTEROLOGY
 WE CAN OFFER GREAT THERAPEUTIC SKILLS TO GI
PTS WITH ORGANIC DISEASE-GI BLEEDS, CROHN’S,
ETC
 IT WOULD BE WONDERFUL IF WE COULD MASTER
THE SAME THERAPEUTIC MAGIC FOR OUR PTS WITH
FUNCTIONAL AND ANXIETY DISORDERS
GASTROENTEROLOGISTS ARE VERY
WELL TRAINED TECHNICIANS
 BUT HAVE LITTLE, if any, TRAINING IN PSYCHOLOGY
COMPLEX GI PATIENTS HAVE
PSYCHIATRIC COMORBIDITIES
 FOR WHICH WE, GASTROENTEROLOGISTS, ARE
WOEFULLY UNDERPREPARED
HOW DO
GASTROENTEROLOGISTS
THINK ABOUT ANXIETY
DISORDERS
THEY DON’T!
THE FIRST INSTINCT OF A
GASTROENTEROLOGIST
IS TO ENDOSCOPE THE PATIENT
 WE TEND TO HAVE A MECHANISTIC APPROACH TO GI
SYMPTOMS
 WE WILL FREQUENTLY ENDOSCOPE OR ORDER AN XRAY OF THE PART OF THE GI TRACT CORRESPONDING
TO THE SYMPTOM COMPLEX
WE ARE TRAINED WITH TECHNICAL
SUPREMACY
 WE ARE TRAINED TO DO THE NEATEST THINGS WITH
ENDOSCOPES
OUR TECHNICAL TRICKS DON’T
ALWAYS BENEFIT PATIENT CARE
 MANY OF OUR PTS ARE UNLIKELY TO HAVE A
STRUCTURAL PROBLEM CAUSING THEIR GI
SYMPTOMS
 IF WE FIND A MINOR STRUCTURAL DISTURBANCE, IS
IT REALLY CAUSING THE PROBLEM?
CASE
 A 35 YO ANXIOUS WOMAN COMPLAINS OF
ABDOMINAL PAIN. BECAUSE OF UNREMITTING
SYMPTOMS SHE HAS A GASTROSCOPY. THE
GASTROSCOPY SHOWS MINOR GASTRITIS-NO
MAJOR ULCER. SHE BECOMES PREOCCUPIED WITH
THE FACT THAT SHE HAS GASTRITIS.
 THE GASTROENTEROLOGIST, HOWEVER, IS FULLY
AWARE THAT HE HAS “SCOPED” MANY OTHER
PATIENTS WHO TURNED OUT TO HAVE MILD
GASTRITIS WHO HAVE BEEN TOTALLY
ASYMPTOMATIC (ENDOSCOPED FOR GI BLOOD
LOSS)
 HE IS NOT CONVINCED THAT HIS FINDINGS HAVE
ANYTHING TO DO WITH HER SYMPTOMS
 HAS HER CARE BEEN HELPED?
 HINDERED?
ETIOLOGIES FOR GI SYMPTOMS
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STRUCTURAL DISORDERS
FUNCTIONAL DISORDERS
ANXIETY DISORDERS
OVERLAP SYNDROMES
TAILOR ENDOSCOPY TO ALARM
SIGNALS
 ALTHOUGH WE HAVE BEEN TAUGHT THAT
ENDOSCOPY SHOULD BE LIMITED TO CERTAIN
SYMPTOMS THAT ACT AS RED FLAGS
PRESSURE TO DO ENDOSCOPY
 IN THE GENERAL COMMUNITY THERE IS AN
EXPECTATION THAT MOST SYMPTOMS SHOULD BE
INVESTIGATED WITH ENDOSCOPY
CASE
 20 YO SINGLE MOTHER COMPLAINS OF ABDOMINAL
PAIN, CONSTIPATION, DIARRHEA, NAUSEA FOR “A
LONG TIME”. SHE CLAIMS SHE IS UNABLE TO EAT
ANY FOOD BECAUSE IT MAKES HER SICK. BUT IN
SPITE OF THAT SHE HAS NOT LOST ANY WEIGHT.
 SHE IS VERY STRESSED. HER 2 YR OLD DOESN’T
BEHAVE. SHE FIGHTS WITH HER BOYFRIEND. SHE
ISN’T HAPPY IN HER PART TIME JOB.
 SHE COMES TO THE ER FREQUENTLY COMPLAINING
OF PAIN.
 MULTIPLE LABS HAVE BEEN NEGATIVE. A CAT SCAN
WAS ORDERED WITH NEGATIVE RESULTS. FINALLY
SHE IS ADMITTED. HER ATTENDING IS FRUSTRATED
AND CALLS IN A GASTROENTEROLOGIST ASKING HIM
TO PERFORM A GASTROSCOPY AND COLONOSCOPY
BECAUSE OF THE NAUSEA AND ABDOMINAL PAIN.
 ON EXAM-THE PATIENT KEEPS HER EYES SHUT
DURING ABDOMINAL PALPATION. SHE CLAIMS THAT
EVEN LIGHT PRESSURE CAUSES EXCRUCIATING
PAIN.HOWEVER, HER ABDOMEN IS RELATIVELY
BENIGN AS IS THE REST OF HER PHYSICAL EXAM .
 THE PATIENT IS VERY ANXIOUS, DEMANDING, AND
MAKES THE CONSULTANT ANXIOUS
 GASTROSCOPY AND COLONOSCOPY ARE
PERFORMED AND SHOW MILD ESOPHAGEAL
IRRITATION AND A NORMAL COLON. HER WORK-UP
IS FAIRLY UNREVEALING.
 THE PT IS PLACED ON ANTISPASMODICS AND
PRILOSEC.
 BUT SHE FAILS TO IMPROVE
SHARED FRUSTRATION
 NEITHER THE PATIENT NOR THE
GASTROENTEROLOGIST IS PLEASED IN SUCH CASES
 THE PT JUST WANTS HER SYMPTOMS TO GO AWAY
 DOCTOR WANTS TO WASH HIS HANDS OF THE CASE
SAYING: “THIS IS NOT GI” OR “SHE’S JUST CRAZY”
PSYCH PATIENTS MAKE GI DOCS
ANXIOUS
 AS GI DOCS WE SHY AWAY FROM PTS WITH COMPLEX
PSYCH PROBLEMS. WE DON’T KNOW HOW TO DEAL WITH
THEM. THESE PTS MAKE US UNCOMFORTABLE. WE CAN’T
PROVIDE THEM WHAT THEY NEED
 AND YET MANY OF THE PTS WHO COME TO US HAVE
SIGNIFICANT PSYCHIATRIC CO-MORBIDITIES
WE ARE MUCH BETTER WITH
ORGANIC DISEASES
 GIVE US A GOOD CASE OF PEPTIC
ULCERS, PANCREATITIS, CROHN’S,
OR COLON POLYPS
 WE ARE MUCH BETTER PREPARED
DEALING WITH FUNCTIONAL BOWEL
DISORDERS
 AS FIBROMYALGIA IS TO RHEUMATOLOGISTS, AND
MIGRAINE IS TO NEUROLOGISTS, IBS AND OTHER GI
FUNCTIONAL DISORDERS FORCE US TO DEAL WITH
SYMPTOMS WHERE THERE IS NO ANATOMIC
ABNORMALITY
 MANY GI’S ( ALTHOUGH NOT ALL) ARE
COMFORTABLE TREATING FUNCTIONAL BOWEL
DISORDERS
 DOUG DROSSMAN IS OUR OUTSTANDING MENTOR
IN THIS ARENA
 WE USE MEDS, DIET, EVEN PSYCHOTROPIC DRUGS
TO MANAGE CHARACTERISTIC SYMPTOM
COMPLEXES
IBS-D MEDS
 IMODIUM,LOMOTIL.
 ANTISPASMODIC-BENTYL, LIBRAX, HYOSCYAMINE,
DONNATAL
 CHOLESTYRAMINE ( 4 GRAMS IN AM),
COLESEVALAM(WELCHOL-3 TABS IN AM)
 NORTRIPTYLINE (AND OTHER TCAS) 10 MG HS INCREASE
AS NEEDED
 RIFAXAMIN 550MG BID-TID FOR 2 WEEKS
 ALOSETRON 0.5MG QD-1 MG BID
 UNUSUAL CIRCUMSTANCES:
MESALAMINE,CROMOLYN,PANCREASE
FUNCTIONAL BOWEL DISEASE
ITS NOT JUST IBS ANYMORE
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FUNCTIONAL HEARTBURN
FUNCTIONAL CHEST PAIN
FUNCTIONAL DYSPHAGIA
FUNCTIONAL DYSPEPSIA
FUNCTIONAL NAUSEA AND VOMITING
FUNCTIONAL DIARRHEA, COMSTIPATION
FUNCTIONAL ABDOMINAL PAIN
WHAT THESE ALL HAVE IN COMMON
 ABSENCE OF ORGANIC, SYSTEMIC OR METABOLIC
DISEASE TO EXPLAIN THE SYMPTOMS
USE OF PSYCHOTROPIC DRUGS IN
GASTROENTEROLOGY
 STRESS AND ANXIETY CLEARLY ARE IMPORTANT IN
FUNCTIONAL BOWEL DISEASE
 DOSAGE OF PSYCHOTROPIC DRUGS USED FOR FBD
TENDS TO BE LOWER THAN STANDARD
ANTIDEPRESSANT DOSE
 MEDS SEEM TO WORK BY DECREASING PAIN,
BLOATING AND SIMILAR SYMPTOMS
USE OF TRICYCLIC
ANTIDEPRESSANTS IN IBS
 PTS INVARIABLY ARE STARTED ON OTHER AGENTS
LIKE ANTI-SPASMODICS FIRST
 TCAS ARE ADDED IN MORE RESISTANT CASES
 WE START AT A VERY LOW NIGHT TIME DOSE AND
GRADUALLY INCREASE AS NEEDED
INCREASED USE OF PSYCHOTROPIC
DRUGS BY GI DOCS
 USE OF TCA’S IN IBS-MY FAVORITE IS NORTRIPTYLINE
(START 10-20MG HS)
 MIRTAZAPINE FOR FUNCTIONAL NAUSEA,
DYSPEPSIA ( 7.5-15MG)
 DULOXETINE FOR FUNCTIONAL ABDOMINAL
PAIN(30-60MG)
 VENLAFAXINE FOR FUNCTIONAL CHEST PAIN(37.575MG)
 INCREASED USE OF SSRI’S FOR ANXIETY
CASE
 A 45 YO WOMAN HAS A LONG H/O INTERMITTENT
ABDOMINAL CRAMPS AND DIARRHEA. 15YEARS
EARLIER SOME BARIUM STUDIES AND ENDOSCOPIES
WERE DONE AND SHE WAS DIAGNOSED WITH IBS.
SHE WAS STARTED ON LIBRAX WITH MARKED
RELIEF.
 NOW 15 YEARS LATER THERE WERE NEW LIFE
STRESSORS AND SEVERE ABD PAIN DEVELOPED.
THIS FAILED TO RESPOND TO LIBRAX.
CASE
 SHE WAS EXTREMELY DEBILITATED BY HER GI
SYMPTOMS.
 WORK-UP REVEALED NO NEW PATHOLOGY
 WE ADDED NORTRIPTYLINE 10 MG HS THEN
INCREASED IT TO 20MG AND THE SYMPTOMS
RESOLVED. A YEAR LATER THE PT IS WITHOUT
SYMPTOMS.
FUNCTIONAL CHEST PAIN MEDS
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ANTISPASMODICS-BENTYL, LIBRAX, HYOSCYAMINE
VENLAFAXINE -75MG
CITALOPRAM 20MG
TRAZADONE (75-100MG)
SERTRALINE (50-200MG)
IMIPRAMINE (25-75MG)
DILTIAZAM( 60-90 TID) NIFEDIPINE (10-30TID)
BACLOFEN 5MG TID (UP TO 20 MG TID)
THEOPHYLINE
DIAGNOSING ANXIETY DISORDERS
 WHILE MANY GI SYMPTOMS ARE DUE TO EITHER
STRUCTURAL OR FUNCTIONAL DISORDERS
 SOME MAY BE MANIFESTATIONS OF AN ANXIETY
DISORDER
 GASTROENTEROLOGISTS ARE REALLY NOT TRAINED
TO DIAGNOSE THESE
CASE
 15 YO BOY PRESENTED WITH PERSISTENT NAUSEA,
GAGGING, SENSATION OF LIQUIDS COMING BACK
FROM HIS STOMACH INTO HIS THROAT, SORE
THROAT
 THE SYMPTOMS HAD BEEN WORSENING OVER
SEVERAL MONTHS
 THE FIRST OCCURRENCE FOLLOWED A MIDDLE
SCHOOL BAND EVENT. PRIOR TO THE EVENT A BUS
TAKING THE BAND STOPPED AT A MCDONALD’S ON
THE WAY TO THE CONCERT VENUE.
 PT FELT SICK AFTER EATING BUT STILL HAD TO GO
AHEAD AND PERFORM
 NO ONE ELSE GOT SICK AFTERWARD
 AFTER THE CONCERT HE STARTED HAVING
SYMPTOMS DAILY
 THIS LED TO MULTIPLE SCHOOL ABSENCES
 WHEN HE WENT TO SCHOOL HE WOULD VISIT THE
NURSE DAILY
 AFTER SEVERAL MONTHS THE FAMILY TOOK THE
PATIENT TO AN ENT SPECIALIST
 ENT LOOKED IN HIS THROAT AND SAID THERE WAS
EVIDENCE FOR ACID REFLUX
 PT WAS PLACED ON PREVACID WITH MINIMAL
RELIEF
 GASTRIC AND THROAT SYMPTOMS CONTINUED
 PT WAS SUBSEQUENTLY TAKEN TO A
GASTROENTEROLOGIST, ONE OF MY PARTNERS
 THE GI WAS ABOUT TO SET UP A GASTROSCOPY TO
EVALUATE NAUSEA, STOMACH UPSET, AND REFLUX
NOT RESPONDING TO PREVACID
 THEN A PSYCHOLOGIST FRIEND OF THE FAMILY
INTERVENED, SAYING THIS WAS A CLASSIC SET OF
SYMPTOMS OF ANXIETY DISORDER
 BASICALLY PROHIBITED THE ENDOSCOPY
 THE PATIENT WAS REFERRED FOR AND UNDERWENT
EXPOSURE THERAPY
 THE SYMPTOMS REGRESSED
 ENDOSCOPY WAS NEVER PERFORMED
A BLIND SPOT
 IN THIS CASE THE PATIENT’S GI SYMPTOMS WERE
MANIFESTATIONS OF AN ANXIETY DISORDER
 THE PEDIATRICIAN, ENT AND GI SPECIALIST ALL
MISSED THE DIAGNOSIS
 IF A PT WALKS IN COMPLAINING OF PALPIATIONS,
SHORTNESS OF BREATH, OR A H/O ANXIETY ATTACKS
THE GI MAY BE ABLE TO MAKE THE DIAGNOSIS
 OTHERWISE, NOT LIKELY
 THIS REALLY IS A SORT OF “BLIND SPOT” FOR US
WE SPECIALISTS CAN BE MYOPIC
 IN MEDICINE WE SPECIALISTS HAVE A VERY NARROW
FOCUS. THE ENT, THE GASTROENTEROLOGIST, THE
CARDIOLOGIST, THE PULMONARY SPECIALIST MAY
ALL SEE THE SAME PATIENT THROUGH OUR VERY
SPECIFIC FILTERS.
THE ELEPHANT AND THE BLIND MEN
THE ELEPHANT AND THE BLIND MEN
 7 BLIND MEN ENCOUNTER AN ELEPHANT
 ONE OF THE BLIND MEN REACHES FOR THE ELEPHANT’S
TRUNK, ANOTHER IT’S TUSK, ANOTHER THE EAR, AND ONE THE
LEG
 THE ONE STUDYING IT’S TRUNK SAYS THE ELEPHANT IS LIKE A
SNAKE, THE ONE EXAMINING THE TUSK-THAT IT THE ELEPHANT
IS SHARP-LIKE A SPEAR, THE ONE TOUCHING THE EAR-THAT THE
ELEPHANT IS LIKE A FAN, AND THE ONE GRABBING THE LEGTHAT THE ELEPHANT IS LIKE A TREE
 THE BLIND MEN ALL INTERPRET THE ELEPHANT BASED ON
THEIR NARROW EXPERIENCES
OUR LIMITED FOCI KEEP US FROM
GRASPING THE GESTALT
 OUR NARROW FILTERS COMPROMISE
MANAGEMENT OF THESE MORE COMPLEX PATIENTS
 WE NEED A WAY TO SEE THE BROADER PICTURE
 IT IS CLEAR THAT MANY OF OUR PATIENTS WOULD
BENEFIT FROM SEEING A BEHAVIORAL HEALTH
SPECIALIST
THE IDEAL WORLD
 TAKE MY PATIENT NEXT DOOR TO THE PRACTICING
PSYCHOTHERAPIST
 OR EXPECTATION OF EVERY PATIENT BEING SEEN BY
A PSYCHOTHERAPIST AS CO-MANAGER
DOESN’T EXIST
IN THE COMMUNITY
ROADBLOCKS TO CO-MANAGING
WITH PSYCHOLOGISTS
 GI MAY BE UNAWARE OF NEED FOR PSYCH HELP
 PATIENTS ARE VERY RESISTANT TO THE IDEA OF
SEEING A PSYCHOLOGIST
 ACCESS TO A PSYCHOLOGIST BECAUSE OF
INSURANCE/FINANCIAL/GEOGRAPHIC REASONS MAY
BE A LIMITATION
PROBLEMS GETTING THE PATIENT
TO “BUY IN”
 PATIENTS ARE FREQUENTLY RESISTANT TO THE IDEA
THAT THEIR SYMPTOMS ARE RELATED TO ANXIETY
OR DEPRESSION
 THEY GET ANGRY “THAT DOCTOR IS JUST LABELING
ME AS A CRAZY PERSON”
 TEND TO RESENT AND LOSE FAITH IN THE
GASTROENTEROLOGIST
15 YO BOY - PATIENT FOLLOW-UP
5 YEARS LATER
 HE IS DOING WELL.
 HIS THROAT AND GI SYMPTOMS OCCUR RARELY.
WHEN THEY DO HE LABELS THEM AS ANXIETY AND
SELF MANAGES THEM
 WHEN THE SYMPTOMS FIRST STARTED HE WOULD
DRY HEAVE UPON ENTERING AN AIRPORT. NOW HE
CAN FLY ALONE FOR 14 HOURS WITH NO PROBLEM
 CURRENTLY DOING WELL AS A PRE-MED STUDENT IN
A LARGE MIDWEST UNIVERSITY
MY RUDE AWAKENING AS A
GASTROENTEROLOGIST
PATIENT IS MY SON
CHANGES I HAVE MADE
 I ENTER INTO MOST NEW PT ENCOUNTERS ASKING
MYSELF IF ANXIETY OR DEPRESSION IS PLAYING A ROLE
 I INFORM THE PT EARLY ON THAT WE MAY NOT FIND A
STRUCTURAL EXPLANATION FOR THE SYMPTOMS
 I INFORM THEM OF THE DUALITY OF MIND-BODY
MEDICINE. SYMPTOMS MAY BE ANXIETY DRIVEN.
 I SUGGEST THAT THEIR SYMPTOMS MAY BE IMPROVED BY
MEETING WITH A BEHAVIORAL HEALTH SPECIALIST
ACTION FOR THE FUTURE
 WE REALLY NEED MORE EDUCATION IN OUR GI
TRAINING PROGRAMS ABOUT PSYCHOLOGY. THERE
IS A PAUCITY OF LECTURES ON PSYCHOLOGY AT
OUR NATIONAL CONFERENCES
 IDEALLY THERE SHOULD BE BEHAVIORAL
HEALTH SPECIALISTS TO JOIN US ON
ROUNDS, OR IN A NEARBY OFFICE
OR HOSPITAL SETTING
WHAT YOU COULD DO AS PSYCH
PROFESSIONALS
 SPEAK AT NATIONAL GI MEETINGS
 GET INVOLVED WITH WORKSHOPS FOR/WITH
GASTROENTEROLOGISTS
 PRACTITIONERS-GO TO YOUR LOCAL GI AND LET HIM
KNOW HOW YOU CAN ASSIST
 IDEAL WOULD BE TO HAVE A BEHAVIORAL HEALTH
SPECIALIST SHARE TEACHING ROUNDS IN THE
HOSPITAL
THANKS FOR YOUR ATTENTION
TIME FOR HAPPY HOUR
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



BIN 36: 339 NORTH DEARBORN
POPS FOR CHAMPAGNE: 601 N. STATE
ENO: 505 N MICHIGAN (INTERCONTINENTAL HOTEL)
WEBSTER WINE BAR: 1480 N WEBSTER
DOC WINE BAR: 2602 N CLARK STREET