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.
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.”