A one-stop digestive ‘shop’

This complex part of the anatomy can be affected by dozens of conditions and diseases at any age.

By JUDY SIEGEL-ITZKOVICH
DR. ARIELLA SHITRIT (photo credit: Judy Siegel-Itzkovich )
DR. ARIELLA SHITRIT
(photo credit: Judy Siegel-Itzkovich )
From the mouth and throat to the other end of the human body, the digestive system, which is an impressive 10 meters long (straight in some places and coiled in others), transports and collects food and drink, processes it, distributes nourishment and eliminates the rest. This complex part of the anatomy can be affected by dozens of conditions and diseases at any age that can cause discomfort, disability, suffering and even death.
Thus is it not surprising that last year, Jerusalem’s Shaare Zedek Medical Center decided to turn its small and relatively inactive gastro department into the country’s first “Digestive Disease Institute,” a one-stop shop bringing together all aspects of treatment. Other hospitals are likely to eventually follow suit, just as many have done in cardiology and other specialties.
The field of otolaryngology (ear-nose-and-throat) and dentistry handle everything from the neck upwards, but gastroenterology covers the vast majority of the digestive system. SZMC’s multidisciplinary approach is reflected in the fact the institute’s medical staffers meet together weekly to discuss the most difficult cases in the many fields covered.
PROF. ERAN GOLDIN
PROF. ERAN GOLDIN
This integrated approach would not have been possible if Prof. Eran Goldin, who was for 20 years head of gastroenterology at the Hadassah University Medical Center in Jerusalem’s Ein Kerem, had not decided to move to SZMC, taking with him three other senior department physicians in various sub-specialties.
Hadassah was shocked by the sudden announcement of the four physicians’ impending departure, and it took time to recover, find a new head and restructure its department. Goldin’s replacement at Hadassah is Prof. Ran Oren, who had been head of the institute of gastroenterology at Tel Aviv Sourasky Medical Center (Ichilov Hospital) since 2004 before moving to Ein Kerem.
Hadassah veterans said they are happy with the new senior management after a number of distinguished specialists were brought in, and say the department has recovered and is prospering.
Goldin is also happy at SZMC.
“Our service has quintupled in the number of patients we now have – tens of thousands of outpatients and inpatients a year,” Goldin told The Jerusalem Post in an interview and tour of the expanded and well-equipped institute.
Born in Argentina and still speaking with a slight South American accent, Goldin arrived in Israel at the age of 23 with a medical degree.
“After Hadassah, I came to Shaare Zedek for a dream, a life project, to set up the first digestive disease institute in Israel. I wanted it to be like those at the famed Cleveland Clinic and Mayo Clinic in the US. We have a total of more than 50 physicians and 100 inpatient beds, plus a day hospital section. All medical staffers that deal with digestion – including imaging, pathology, oncology and gastrointestinal diseases – would be congregated in the same place. We built new suites and clinics on the fourth floor. But buildings don’t make the real difference; it is the people.”
The “tragedy of medicine in Israel and elsewhere,” Goldin continued, “is that patients often go to one doctor to consult and then to another and are told the opposite. They fall between the cracks.
Here, we are interdisciplinary.”
Although there is an alphabet soup of digestive disorders, from abdominal adhesions to Zollinger-Ellison syndrome, the largest number of patients suffer from forms of inflammatory bowel disease (IBD). This term includes a group of disorders in which the intestines become inflamed – red and swollen – probably as a result of an immune reaction of the body against its own intestinal tissue.
Two major types of IBD are described: ulcerative colitis (UC) and Crohn’s disease (CD) – and it seems they are more common among Jews, especially Ashkenazim, than among the general world population due to genetic influences. Gradually, said Goldin, it began to affect Sephardi Jews as well, and due to dietary changes it has spread to China and the developing world.
Now Ethiopian Jews are among the institute’s patients.
“They never suffered from it before, but the immigrants adopted a Western diet that included junk food,” explained Goldin. “So environment is involved as well as genetics.”
As the name suggests, UC is limited to the colon (large intestine). Although Crohn’s disease can involve any part of the gastrointestinal tract from the mouth to the anus, it most commonly affects the small intestine and/or the colon.
When there is severe inflammation, these diseases are considered to be in an active stage. When the degree of inflammation is less or absent, the person usually is free of symptoms is said to be in remission. Researchers do not yet know what causes inflammatory bowel disease.
Therefore, IBD is called an idiopathic disease (disease with an unknown cause).
An unknown factor/agent (or a combination of factors) triggers the body’s immune system to produce an inflammatory reaction in the intestinal tract that rages uncontrollably. Because of the inflammatory reaction, the intestinal wall is damaged. This leads to bloody diarrhea and abdominal pain.
Genetic, infectious, immunologic and psychological factors have all been implicated in influencing the development of IBD. There is a genetic predisposition or susceptibility to the development of IBD.
But the triggering factor for activation of the body’s immune system has yet to be identified. As the intestines are always exposed to things that can cause immune reactions, researchers’ more recent thinking is that there is a failure of the body to turn off normal immune responses.
IBD should not be confused with irritable bowel syndrome (IBS), a condition characterized most commonly by cramping, abdominal pain, bloating, diarrhea and constipation.
“It’s a functional problem of the gastro system whose parts don’t work together properly,” said Goldin. “There is oversensitivity, but it’s not disease and not progressive.
It can hurt quality of life.”
This condition (IBS) affects about one in five people in the developed world, more often women than men, and usually appears before the age of 35. IBS causes a great deal of discomfort and distress, but it does not permanently harm the intestines and does not lead to serious diseases, such as cancer. Most people can control their symptoms with diet, stress management and prescribed medications. The institute has numerous outpatients at its clinics who suffer from IBS.
Often, anti-inflammatory steroids are used to control disease attacks and were once used as a maintenance drug, but today, biological medications such as TNF inhibitors are increasingly used. Severe cases may require surgery, such as bowel resection or a temporary or permanent colostomy.
A new SZMC institute clinic that is unique in the country is IBD MOM, which caters specifically to young women with inflammatory bowel disease who want to or have become pregnant. Dr.
Ariella Shitrit, a senior gastroenterologist who is modern Orthodox and the mother of five, heads the clinic.
She came to Shaare Zedek as an intern soon after receiving her medical degree at the Hebrew University- Hadassah School of Medicine.
“It is a very interesting field,” said the physician, who deals with gastrointestinal disease so intensively that “it seems to me that everyone has it.”
Gastro symptoms and diseases do not turn her stomach.
“IBD does not harm fertility per se,” she said, “but if a woman has active disease, it should be stabilized before she gets pregnant.
Abdominal adhesions from the disease or operations can make getting pregnant a problem. At Shaare Zedek, we perform in-vitro fertilization for such patients with good success rates. Quite a few IBD patients deliver by cesarean section, but we have been able to reduce the percentage.”
Women who lose a lot of weight and then miss their menstrual periods can then obviously suffer from infertility. IBD can also affect men’s fertility.
Shitrit encourages breastfeeding, even by mothers that have to take medication for IBD. Most IBD drugs do not affect breast milk or the developing fetus.
“Nursing a baby can even protect against the future development of IBD in the child. Pregnancy itself, she said, can have a positive or negative effect on the disease, so the timing of pregnancy is important.”
Goldin and Shitrit noted that the special clinic has considerable numbers of haredi women patients with IBD who want to become or are pregnant and want large families.
“We have them coming from all over, not just Jerusalem,” Shitrit said. “The institute also treats children with gastroenterological problems.
Most gastro patients are ambulatory, but if inflamed intestinal tissue is really diseased, it has to be surgically removed.”
Another digestive disorder with a genetic and autoimmune component that seems to be more common today than in previous years is celiac disease, which can appear at any age. Celiac damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate gluten – a protein in wheat, rye, barley and some other grains and that may also be found in everyday household products such as medicines, vitamins and lip balms. One out of 130 people or so may be affected, but among those who have a first-degree relative with it, as many as one in 22 people may have it.
When people with celiac disease eat foods or use products containing gluten, their immune system responds by damaging or destroying the villi (tiny, finger-like protrusions lining the small intestine that digest food). Without healthy villi, a person can become malnourished, no matter how much food he consumes.
Although celiac symptoms include abdominal bloating and pain, chronic diarrhea, vomiting, constipation, weight loss and changes in the stool, some patients don’t notice anything out of the ordinary. Goldin said when no other explanation can be found for a patient’s anemia, they should be tested for celiac disease – a simple blood test looking for specific antibodies.
The only treatment for celiac disease is a gluten-free diet, which – if carefully observed – will stop symptoms, heal existing intestinal damage, and prevent further harm.
Goldin and Shitrit concluded that the institute is putting more emphasis than before on research into digestive diseases.
“We are doing 20 studies right now,” the institute chairman said. “There are more cases of IBD, but there is definitely hope for people to live normal lives.”