DEAR DOCTOR/Dr D. Nageshwar Reddy, Chairman and Chief of Gastroenterology, AIG Hospitals, Hyderabad
When we talk about gastroenterology, it includes liver disease and luminal (involving the intestine) gastroenterology. In luminal gastroenterology, the most common ailments seen in India are irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), inflammatory bowel disease and then cancers like those of the stomach and colon. One of the reasons for the high incidence of these cases in India is our lack of hygiene, which is why we are more prone to infections and have a very high incidence of Helicobacter pylori infection (which causes gastritis, peptic ulcers and certain types of stomach cancer). Also, our gut flora is different from that of people in the west. That has a lot of influence on the intestine. And, we may have genetic susceptibility to a few disorders. Like, in some areas, we have a very high incidence of gastric cancer; in some other areas, we see more cases of oesophageal cancer.
The gender tilt
IBS is more prevalent in women. But this gender predominance is cancelled out by the fact that in India more male patients visit hospitals than female patients. So if we take hospital statistics, it looks like the figures are same for both. But if you go into the community, you see that most women face this problem. That is because women are more prone to stress, and the way the body reacts to stress differs in men and women. And that reaction results in IBS.
Covid-19 manifestations
About 30 per cent of Covid-19 patients come with gastrointestinal symptoms. About 10 per cent show only gastrointestinal symptoms, and not cough or respiratory symptoms. Gastrointestinal symptoms include nausea, vomiting, lack of appetite, diarrhoea and abdominal pain. Some patients develop liver hepatitis. And, in rare cases, we have also come across pancreatitis.
Pandemic and protocols
During the lockdown, people visited hospitals only if they had a serious disorder that was causing them significant discomfort. Those with minor disorders stayed away because of fear of hospital infection. Also, I think everybody was worried about how to deal with coronavirus. That is the reason why in the first few months of the pandemic, we saw more emergency cases, like gastrointestinal bleeding, and fewer elective procedures.
This pandemic has changed our approach to patients in terms of scheduling. Patients are given specific appointments so that the hospital is not crowded. All patients and attendants have to take precautions in terms of masks, physical distancing and hygiene. Everybody is checked for temperatures. Screening of patients and attendants is very high as this helps us to check the spread of infections. The health staff is also provided with double-layer of protection. While initially only emergency procedures were done, we have now started doing elective procedures.
Innovative procedures
One of the procedures that we did during the lockdown involved a unique technique to treat a two-year-old boy with achalasia cardia. Owing to the rare disorder, the boy from Bihar had difficulty in swallowing food. Achalasia cardia is a disorder where the muscle in the lower end of the oesophagus becomes tight. And the patient’s condition can deteriorate rapidly. We used a revolutionary technique called POEM—peroral endoscopic myotomy—wherein we opened the lower end of the oesophagus using an endoscope. The patient can start swallowing food from the very next day. Our unit has handled the maximum number of achalasia cardia cases in the world. We have done over 5,000 cases in the last eight years. We train at least 400 doctors every year in this technique. So, people all over the world have now picked up this technique.
Another procedure that we are first in the world to do is GERD X. One of the commonest problem we saw in our patients during the pandemic is gastroesophageal reflux disease. These patients are normally treated with PPIs—proton pump inhibitors—to decrease acid. But if used for around five to seven years, PPIs can have side effects, ranging from renal failure and decrease in bone density to bone fracture, dementia and cancer of the stomach. So most patients are reluctant to use PPIs for long. GERD X is a minimally invasive endoscopic procedure for treatment of refractory or PPI-dependant GERD patients. We stitch the oesophageal sphincter, which is a small valve between the stomach and the lower end of the oesophagus. Through the endoscope, we close that opening to a calibrated amount so that acid reflux does not occur. And these patients need not take any medication. Our experience with this procedure has shown that we can stop PPIs in 80 per cent of the cases or patients can make do with a small dose of medication. So, this is very effective and is going to replace surgery in most of the cases.
The other advancement has been in bariatric surgery, where surgeons laparoscopically remove part of the stomach to reduce weight. Now we have a technique where the stomach can be endoscopically stitched to reduce its size. It is called the Endomina System, which was developed by a hospital in Brussels, Belgium. We are the only hospital in India to use this technique. This is again an outpatient procedure.
For good gastro health
Maintaining good hygiene is important. We know that most infections occur because of contaminated food and water. The problem now is the high intake of junk food, which results in fatty liver and can lead to liver cirrhosis and gastrointestinal problems. So avoiding junk food and eating healthy, high-fibre food is very important. Regular exercise has shown to prevent not only conditions like fatty liver, but also gastrointestinal cancers. Finally, avoid smoking and have alcohol in moderation or avoid it completely. These are general precautions, but for gastrointestinal health these are very important and can save lives.
-As told to Susamma Joy Kurian