AHN Center for Digestive Health Digestion Journal-2014

Digestion
Editorial Board
Payal Thakkar, Pharm D
Michael Babich, MD
Nitin Sardana, MD
Kofi Clarke, MD, FRCP
ACDH Medical Director’s Message
“Coming together is a beginning. Keeping together is progress.
Working together is success.”
– Henry Ford
The Allegheny Center for Digestive Health (ACDH) is pleased to share with you the inaugural edition of
our journal Digestion. It is designed to keep you informed about the center’s comprehensive clinical
care, new treatments and research in digestive system disorders, hepatology and nutrition.
In the pages ahead, you will find descriptions of our various subspecialties and how these programs are
positively impacting people’s lives and their health; a first-hand perspective from two of my colleagues
about how gastroenterology has evolved over the last 40 years; and a look into our robust fellowship
program that’s training the next generation of physicians.
At the ACDH, multidisciplinary teamwork is an integral aspect of the way we treat patients. For more
than a decade, our center has provided patients with expert, experienced and coordinated care to
treat digestive system disorders. Our nationally recognized program unites gastroenterologists,
hepatologists, colorectal surgeons, bariatric surgeons, clinical nutritionists, gastroenterology nurses,
dieticians, integrated medicine providers, transplant hepatologists, psychologists and other specialists.
As a proud part of the recently formed Allegheny Health Network, we have access to more resources
and physicians to treat patients and meet their specific needs. With seven hospitals and physician and
procedural offices throughout the tri-state area, we offer people convenient, first-rate care, close to
their homes.
I look forward to this publication becoming an asset to you and your patients. Your interest in
digestive health and your partnership in caring for patients are essential to our work at the ACDH. This
collaborative spirit both at our medical facilities with our colleagues and beyond those walls with you
will go a long way in successfully improving people’s health and well-being.
Sincerely,
Kofi Clarke, MD, FACP, FRCP (Lond)
Associate Professor, Temple University School of Medicine
Medical Director
Allegheny Center for Digestive Health (ACDH)
Kofi Clarke, MD, FRCP
Innovators in Treating Digestive System Disorders
Allegheny Center for Digestive Health (ACDH)
Every year, approximately 70 million Americans suffer from
some type of digestive, liver or pancreatic disorder –
from irritable bowel syndrome and gastroesophageal
reflux disease to celiac and Crohn’s disease to swallowing
disorders and cancer.
As the number of people afflicted with these issues has risen dramatically in the last few decades, it has
created a critical need for specialized diagnostic capabilities and innovative treatments and surgeries.
The Allegheny Center for Digestive Health (ACDH), a part of Allegheny Health Network, was created
to meet that need. It is a nationally recognized, fully integrated center that unites gastroenterologists,
hepatologists, colorectal surgeons, bariatric surgeons, clinical nutritionists, gastroenterology nurses,
dieticians, integrated medicine providers, transplant hepatologists, psychologists and other specialists
to treat digestive system disorders.
This unique approach to comprehensive digestive care provides each patient with expertise, novel
therapies and dedicated attention. The center’s team of specialists and health-care providers
coordinate all aspects of each patient’s treatment and communicate regularly with referring physicians
for a seamless continuum of care. The ACDH also has numerous locations, including at Allegheny
Health Network’s seven hospitals and at physician and procedural offices throughout the tri-state area.
To further enhance this patient-centered approach, the ACDH has created specialized divisions that
focus on subspecialties. This allows the center’s experts to provide patients with treatments and
resources specific to their needs. The ACDH’s areas of excellence include the following:
Kofi Clarke, MD, Director
Jorge Vazquez, MD,
Nutrition Specialist
Barbara Nagrant, PhD,
Clinical Psychologist
The Power of Comprehensive Focus
Amy Macklin, RD, LDN,
Celiac Dietician
Celiac Center
“Gluten free.”
It has quickly become the latest food fad, even for people without celiac disease.
But for the estimated 3 million adults and children afflicted with the autoimmune disorder, simply
giving up gluten-containing products and choosing tasty alternatives isn’t enough. Those who are
diagnosed with celiac disease need expert care and guidance to help navigate their dietary and
treatment options and manage the disorder, as well as associated nutritional problems.
“With celiac disease, gluten – which is found in wheat, barley and rye – begins to affect the lining of the
small intestine and predisposes a person to malabsorption of nutrients and causes multiple symptoms,
including abdominal discomfort. Over time, it can lead to bone disease and has been associated with
several conditions, including osteoporosis, depression, thyroid disease and foggy thinking,” said
Kofi Clarke, MD, medical director of the Celiac Center at the Allegheny Center for Digestive Health.
“Symptoms can greatly interfere with a person’s life, so it’s crucial that patients who could potentially
have celiac disease seek appropriate professional help.”
Kathy Sepesy, RN, BSN,
MEd, Coordinator
Celiac Center
The Allegheny Center for
Digestive Health Celiac
Center offers the area’s only
multidisciplinary center
for the comprehensive
management of celiac
disease. Patients’ care is
coordinated care by a
team of providers, which
includes:
• Gastroenterologist for
diagnosis and medical
support
• Specialized celiac
dietitian for supervised
gluten-free diet plan
and guidance
• An internist who is also
a nutrition expert
• Alternative medicine
specialist for effective
healing practices
• Support group
Together, this group will
work closely with each
patient through diagnosis,
dietary changes, genetic
concerns, cancer risks and
disease management of
celiac disease.
For more information
or to refer a patient
412.359.8956
In addition, people with celiac disease can develop a variety of health problems caused by
uncontrolled damage and inflammation of the small intestine, and the inability to absorb
nutrients from food. These include anemia, refractory celiac disease and intestinal lymphoma.
The Celiac Center offers the area’s only multidisciplinary center for comprehensive
management. During a single visit to the center, patients meet with five different health-care
practitioners who address questions and concerns about celiac disease. These professionals
include a gastroenterologist, a physician who specializes in nutrition, a registered celiacspecialized dietician, an integrated medicine specialist and a representative from the local
celiac community support organization.
“It’s this specialized, multidisciplinary approach that allows us to provide patients with the
most effective means of managing celiac disease,” Dr. Clarke said.
“It’s this specialized, multidisciplinary approach that
allows us to provide patients with the most effective
means of managing celiac disease.”
– Kofi Clarke, MD, Medical Director, Allegheny
Center for Digestive Health Celiac Center
Recognizing and diagnosing celiac
Celiac disease has long been under-diagnosed because it can be difficult to recognize and
some of its symptoms are similar to those of other diseases, such as irritable bowel syndrome,
chronic fatigue, inflammatory bowel disease and intestinal infections. However, diagnosis
rates are increasing as a result of increased awareness, a better understanding of celiac disease
and the availability of reliable blood tests and small intestine biopsies.
Dr. Clarke said that celiac symptoms vary from person to person; however, common digestive
symptoms include cramp-like abdominal pain, bloating, chronic diarrhea, nausea and
weight loss. Some patients may not have any digestive symptoms, but instead experience
unexplained anemia, fatigue, bone or joint pains, bone loss, depression, anxiety, numbness in
hands and feet, menstrual disturbances, infertility, mouth sores, seizures and skin rash.
As a gastroenterologist at Allegheny’s Celiac Center, Dr. Clarke’s role is to obtain a patient’s
medical history, discuss his or her blood test results and perform an upper GI endoscopy
to confirm a diagnosis. He explained that people with celiac disease have elevated levels of
antibodies in their blood called tissue transglutaminase or endomyosium
“When it becomes evident that a patient has celiac disease, we can move forward in treating
the patient. We recommend that all celiac disease patients work on a gluten-free diet plan
under the supervision of our dieticians who specialize in celiac disease,” Dr. Clarke said.
Specialized celiac dieticians crucial to managing disease
At the Celiac Center, patients are advised by a dietitian trained specifically in celiac disease
management. It’s important for patients to receive nutritional guidance from professionals who
specialize in celiac disease because going without gluten means much more than giving up wheatbased pasta, bread, cereal and beer. Gluten is also found in products that most people wouldn’t
expect, including some marinades, broths and candy.
“I am a nutritionist who specializes in celiac disease, so I am able to give patients the added value of
what products are great-tasting, which ingredients they really need to look for on the label to achieve
the most success in controlling the disease and enjoying a better quality of life,” said Amy Macklin, RD,
LDN, a celiac dietitian who consults with Allegheny Health Network. “I provide them with shopping
tips and how to dine out, both of which help them, particularly when they are newly diagnosed. I want
them to not feel overwhelmed but to live life without limitations.”
Patients, such as Loraine Oczypok, have found great success in working closely with dietitians at the
Celiac Center to face dietary challenges head on and overcome obstacles along the way.
“A gluten-free diet is very restrictive and daunting at first, thinking about how you’re going to
incorporate into your lifestyle,” Lorraine said. “But Amy was a great help and a great source of practical
information for all the necessary changes I needed to make. The staff at the Celiac Center was very
supportive in my case. It took a long time for my blood levels to come down, even though I knew I was
doing everything right. I finally got to where I need to be.”
It’s important for patients to receive nutritional guidance
from professionals who specialize in celiac disease because
going without gluten means much more than giving up
wheat-based pasta, bread, cereal and beer.
Beyond the diet
For most patients, adhering to a gluten-free diet will eliminate symptoms and eventually heal existing
intestinal damage, Dr. Clarke said. However, some people show no improvements on a gluten-free diet.
Typically, this is because small amounts of gluten are still being consumed, possibly in hidden sources,
such as modified food starch, preservatives and stabilizers made with wheat.
“Some patients may need additional support and treatment, and the Celiac Center provides them
with a variety of treatment options and access to additional specialists – from integrated medicine
professionals to physicians specializing in nutrition,” Dr. Clarke said. “Beyond that, our patients have the
added resource of all that Allegheny Health Network has to offer in the way of expert physicians.”
When asked about the possibility of curing celiac disease, Dr. Clarke said that’s is a premature
expectation. “For now, the most important thing is for patients need to be compliant with a glutenfree diet,” he said. “In the future, as we learn more about the disease and we continue to upgrade the
science, who knows what may be up in the next 20 to 30 years.”
Paul Lebovitz, MD
Jorge Vazquez, MD
Many Reasons for Optimism
Functional Bowel Program
Barbara Nagrant, PhD
(Integrated Medicine)
Though usually benign, many patients with functional bowel disease, particularly irritable bowel
syndrome (IBS), feel helpless and frustrated. The condition can be quite challenging to cope with due
to its chronic and debilitating impact on the patient’s quality of life.
However, although IBS may be a lifelong-condition for many, symptoms can oftentimes be improved
through treatment, says Paul Lebovitz, MD, gastroenterologist and medical director of the Allegheny
Center for Digestive Health’s Functional Bowel Program.
Jennifer Whiteside, MAc
(Integrated Medicine,
acupuncturist)
“In milder cases, symptoms can often be managed by dietary changes and stress management
techniques,” Dr. Lebovitz said. “For more severe cases, certain medications may also be helpful.”
IBS is a gastrointestinal disorder that leads to abdominal pain, altered bowel habits, increased
gas, bloating, cramping and intolerance of certain foods. It is a distinctly separate condition from
inflammatory bowel disease (IBD), which causes long-lasting inflammation in parts of the digestive
tract and includes such conditions as ulcerative colitis and Crohn’s disease.
Although IBS and IBD may generate similar symptoms for patients, they involve very different
treatments. This is why it is essential for patients to receive an accurate diagnosis from specialists who
can help to manage the condition properly.
At the Allegheny Center for Digestive Health’s Functional Bowel Program, specialists in
gastroenterology, nutrition, integrated medicine and psychology evaluate patients to formulate a
comprehensive plan for the treatment of IBS and similar debilitating disorders. The specialists are
devoted to treating patients through a collaborative effort in which the team members individually
evaluate the patients and then together, they develop a comprehensive treatment plan.
“We take a biopsychosocial approach to the disease that, put simply, considers the patient, their
disease and their social context,” Dr. Lebovitz explained. “At the philosophical level, it is a way of
learning how disease and pain are affected by various levels of organization – from molecular to
societal. In application, it is a way of utilizing each patient’s very subjective experience to provide an
accurate diagnosis and personalized care and achieve the best possible outcome.”
For more information or to refer a patient 412.359.8956
Michael Babich, MD
Jose Oliva, MD
Robin Midian, MD
A National Transplant Leader with
Exceptional Outcomes
Rad Agrawal, MD
Hepatology and Liver Transplant Program
Allegheny Health Network has one of the most successful liver transplant programs in the country and
an exceptional hepatology program that offers innovative treatments for both infectious and noninfectious hepatic disorders.
Transplant recipients at Allegheny have experienced survival rates that are above the national average
and among the best in the country, according to data from The Scientific Registry of Transplant
Recipients (SRTR). The program also has the best three-year survival rate in the state, as well as the best
one- and three-year patient outcomes in Pittsburgh.
Established in 2007, the Liver Transplant Program is approved by the United Network for Organ
Sharing (UNOS), Medicare and Medicaid. The multidisciplinary team approach includes surgeons,
hepatologists, gastroenterologists, transplant nurse coordinators, social workers, pharmacists and
other health-care professionals.
“This exceptional team of professionals collaborate consistently to develop a personalized treatment
plan for each patient and provide high-quality, compassionate, patient-focused care,” said Jose Oliva,
MD, Allegheny Health Network medical director of the Liver Transplant Program.
Cristina Strahotin, MD
Allegheny Health Network Transplant Institute’s patient
survival rate is above the national average and among the
best in the country, and we have the best one- and three-year
outcomes in Pittsburgh.
– The Scientific Registry of Transplant Recipients (SRTR)
New Innovations, More Promise for Liver Cancer Patients
Always at the frontier of basic, clinical and translational research, Allegheny Health Network physicians
and scientists conduct extensive research endeavors and clinical trials to improve outcomes. Dr. Oliva
explained how patients have direct access to some of the most cutting-edge treatments and therapies
as physicians are continually investigating new ways to improve outcomes.
“This is very much the case with treating liver cancer,” Dr. Oliva said. Allegheny Health Network is one
of a select group of medical institutions to have a program devoted solely to treating patients with liver
cancer. The specialized teams offer innovative treatment options for patients with primary liver tumors,
as well as those with disease that has metastasized to the liver from other parts of the body.
Dr. Oliva said that liver cancer patients have experienced great results from such treatments as
embolization and chemoembolization, an injection of tiny particles – which may be soaked with
chemotherapeutic agents – into the blood vessels that feed the tumor, stopping blood flow to that
part of the liver. Physicians also offer patients Yttrium-90 Radioembolization, an injection of tiny
radioactive beads directly into the tumor bed of the liver.
One of the most exciting new advancements being pioneered at Allegheny Health Network to treat
liver cancer is stereotactic body radiotherapy (SBRT). It’s a non-invasive radiation technique that
precisely delivers high doses of radiation to isolated primary or metastatic liver tumors with minimal
harm to surrounding healthy tissue. Another significant use of SBRT is as a bridge to transplant and
helping patients become eligible for transplantation by completely eliminating or shrinking the tumor
with no harm to the liver prior to transplant, said Alexander Kirichenko, MD, a radiation oncologist with
Allegheny Health Network.
“Because SBRT has pinpoint accuracy in killing cancerous cells, it spares the patient from damage to the
surrounding organs and tissues,” explained Dr. Kirichenko. “Also, the patient only has to undergo SBRT
for five days, compared to two months of conventional radiation treatment and there are fewer side
effects for the patient.
Patient-centered approach
The members of Allegheny Health Network’s multidisciplinary liver transplant team work together to
determine a detailed treatment plan for each patient’s specific needs and condition. They work closely
with patients to inform them about the details of surgery and the lifelong journey that transplant
recipients will endure.
“Our staff understands how overwhelmed patients and their families feel after being told that they
have liver disease. It then becomes our job to provide patients with extensive support and resources
to ease that burden for them,” said Cristina Strahotin, MD, Allegheny Health Network transplant
hepatologist and gastroenterologist. “We also take a proactive approach in communicating regularly
with primary care providers to keep them well informed about their patients’ condition and long-term
needs, which ensures that patients are receiving cohesive, streamlined care.
For more information or to refer a patient 412.359.6800
Manish Dhawan, MD
Abhijit Kulkarni, MD
Suzanne Morrissey, MD
No Longer Just a Scope
Shyam Thakkar, MD
Therapeutic Endoscopy Program
The endoscope has come a long, long way.
For decades, the flexible tube equipped with an optical system and a guiding light has been fed inside
of patients’ bodies to project internal images onto a screen seen by physicians. Adaptations have also
allowed doctors to use endoscopes for retrieving tissue, objects and staging cancer.
Katie Farah, MD
But in more recent years, endoscopes have evolved into more advanced therapeutic instruments – a
progression that has had a major impact on gastroenterology. At the Allegheny Center for Digestive
Health, physicians utilize state-of-the-art diagnostic and therapeutic endoscopy approaches for
patients with routine and complex biliary or pancreatic disorders.
Robert Kania, MD
“Many of these procedures are non-invasive or require only small incisions for quicker recoveries and
shorter hospital stays,” said Abhijit Kulkarni, MD, director of therapeutic endoscopy at the Allegheny
Center for Digestive Health. “These minimally invasive methods help our patients with acute and
chronic pancreatitis obtain a rapid diagnosis and treatment that impacts their health and lives as little
as possible.”
Marcie Mitre, MD
Pikul Patel, MD
Significant results achieved
Patients can benefit from a host of therapeutic procedures offered at the Allegheny Center for
Digestive Health, including the following:
• Endoscopic ultrasound (EUS)
Utilizing sound waves, an endoscopic ultrasound provides high-resolution images of the pancreas
and gastrointestinal tract. In fact, an EUS probe can show the pancreas in much greater detail than
any other non-surgical diagnostic test, said Manish Dhawan, MD, director of the Allegheny Health
Network Endoscopic Ultrasound Program.
“It can detect gallstones, early fibrotic changes in the pancreas, as well as tumors of the pancreas
and bile duct and metastatic liver cancer,” Dr. Dhawan said. “It also provides detailed imaging of
the gastrointestinal tract, which helps us to stage cancers of the esophagus, stomach and rectum.”
• Endoscopic retrograde cholangiopancreatography (ERCP)
This procedure helps to diagnose and treat problems in the liver, gallbladder, bile ducts and
pancreas – from finding the origins of jaundice to removing blocks in the gallbladder and bile
ducts to diagnosing pancreatic tumors. An endoscope is passed through a patient’s mouth or
through a small incision intra-operatively, and with fluoroscopic guidance. Physicians can make a
diagnosis, treat gallstones, place a stent or obtain a tissue or fluid sample.
“ERCP can be more accurate in helping us to diagnose pancreatic cancer and bile duct cancer than
CT scans,” Dr. Kulkarni said. “It’s highly accurate at diagnosing choledochocele as well.”
• Radiofrequency ablation (RFA)
An FDA-approved endoscopic technique, radiofrequency ablation (RFA) is used by
gastroenterologists to treat Barrett’s esophagus and precancerous tissue, including early
esophageal cancer. Performed on an outpatient basis, RFA involves an electrode mounted on an
endoscope to deliver heat energy directly to the diseased lining of the esophagus to destroy it. In
about six to eight weeks, new tissue grows to replace the lining that was removed.
“With this method, physicians are able to destroy abnormal tissue using radiofrequency waves in a
relatively painless fashion,” said Allegheny gastroenterologist Shyam Thakkar, MD. “This procedure
has been shown to eliminate abnormal tissue in more than 98 percent of individuals and can reduce
the risk of developing esophageal cancer.”
The Allegheny Center for Digestive Health also offers sphincter of Oddi manometry; mechanical
lithotripsy of large common bile duct stones; endotherapy for chronic pancreatitis; biliary/pancreatic
sphincterotomy; spyglass technologies; endoscopic mucosal resection; dilation; biliary mesh stent
insertion; endoscopic ultrasound with fine needle aspiration; and celiac plexus block for relief of pain
from chronic pancreatitis or pancreatic cancer.
Kofi Clarke, MD, FRCP
Paul Lebovitz, MD
Jennifer Hadam, MD
Sandra El-Hachem, MD
Expertise Makes the Difference
Inflammatory Bowel Disease Program
Inflammatory Bowel Disease (IBD) – including ulcerative colitis, Crohn’s disease and indeterminate
colitis – is a lifelong condition of the digestive tract that oftentimes strikes people at a young age.
Typically diagnosed between age 15 and 30 and after the age of 50, IBD can have an overwhelming
effect on a person’s life because the symptoms and potential consequences of treatment can be
painful and socially challenging.
Although there is no “cure” for IBD, specialists at the Allegheny Center for Digestive Health’s IBD
Program offer a host of treatments that have been proven successful in inducing and maintaining
remission and addressing other related conditions.
With an approach unique to the region, the Inflammatory Bowel Disease Program is devoted to the
collaborative efforts of gastroenterologists, nutrition specialists, clinical psychologists and integrated
medicine professionals. This comprehensive approach to IBD allows each specialist to bring options to
the table and develop a succinct treatment plan that is personalized for each patient.
“This center serves patients who frequently feel hopeless about the disease they have,” said Kofi Clarke,
MD, division director of gastroenterology. “IBD and the associated disorders can be painful, hamper
people’s lives and potentially lead to very serious complications. We have many options for patients
to reduce the inflammation that triggers the symptoms of IBD, as well as drug therapy and surgery for
long-term remission.”
Hopeless turns into hopeful
Medical options of IBD treatment include medications like steroids, which are effective in inducing
remission, and immunosuppressives/immunomodulators, which work to both induce and maintain
remission. The center has participated in several trials and continues to enroll patients in novel
medication trials for additional options. Surgical treatment possibilities include drainage of abscesses;
take down of fistulae; partial or total colectomy with an ostomy; or creation of a pouch.
With the program’s global approach, patients can receive direct access to professionals who can assist
them with dietary needs, coping mechanisms and pain relief. The IBD Program’s team of nutritionists,
integrated medicine specialists, nurses, psychologists and clergy work with patients to address every
need in dealing with their conditions. They answer questions, offer support and provide effective
therapies.
To improve the understanding of IBD and further enhance the collaboration with all specialists
involved in patient care, the Allegheny Inflammatory Bowel Disease Program conducts a monthly
multidisciplinary conference to discuss challenging cases in IBD. The team includes pathologists,
colorectal surgeons, radiologists, gastroenterologists and IBD nurses. Community partners and
primary care providers are invited to these meetings to learn about the latest approaches to
treating IBD.
“As we learn more about the disease, we are beginning to better understand that several factors play a
role in IBD,” explained Dr. Clarke. “Although not completely defined, there is a genetic predisposition,
which – in conjunction with likely intestinal bacterial dysbiosis – sets of disease. In addition,
environmental factors, previous exposure to certain medications, childhood immune exposure,
infection and stress are all associated with the disease and can trigger symptom flare-ups.”
Women and IBD
Although inflammatory bowel disease can afflict anyone, women of child bearing age face additional
challenges. The disease can have significant implications on a woman’s ability to conceive, as well as on
the course and outcome of pregnancy, said Sandra El-Hachem, MD, gastroenterologist who specializes
in treating women with IBD.
Dr. El-Hachem and other specialists at the IBD Program address the specific and complex needs of
women suffering from the disorder.
“This encompasses managing issues of fecundity and fertility, safety of medications during pregnancy
and breastfeeding, perinatal care, bone health, addressing sexual dysfunction, as well as other
psychosocial ramifications associated with the disease,” Dr. El-Hachem said.
The program offers unique services for female IBD patients, including a close collaboration with
colorectal surgery, high-risk obstetrics, urogynecology, rheumatology and other specialties; access to
endoscopic ultrasound technology to evaluate perianal disease; use of chromoendoscopy in high risk
patients to detect precancerous changes of the mucosa (dysplasia); nutrition expert that specializes in
malabsorption and short gut syndrome; and a psychologist who offers an integrated approach in the
management of stress, anxiety, depression and pain.
New Hope for Crohn’s Patient
Nicholas Hillebrand was just 11 years old when he first experienced
symptoms of Crohn’s disease.
“It was difficult knowing that I wasn’t a normal kid,” said, Nicholas,
now 36 and living in South Fayette Township with his wife and
two children. “I would have to put my favorite activities on hold
because of Crohn’s.”
For the next nine years, Nicholas visited a variety of doctors and
tried different medications. But nothing seemed to work. Then he
learned how the Allegheny Center for Digestive Health (ACDH) was
helping many patients with Crohn’s disease to better manage their
illness. Nicholas made an appointment and met with Paul Lebovitz,
MD, a gastroenterologist at the ACDH.
“Dr. Lebovitz instantly put me at ease,” said Nicholas. “He was very
down-to-earth and clearly explained what the center could do to
help me. I also was impressed with how much he cared about my
well-being.”
Nicholas is one of the approximate 1.4 million Americans who
have some type of inflammatory bowel disease (IBD). In the case
of Crohn’s disease, the transmural inflammation of the digestive tract’s lining causes symptoms such as
abdominal cramps, persistent diarrhea, fever and fatigue.
“Like many other young patients, Nicholas learned how to cope with his disease,” says Dr. Lebovitz. “But
it was obvious that Crohn’s disease was disrupting his quality of life. Our goal was to put his disease into
remission.”
For Nicholas, surgery was one of his best options because his Crohn’s disease had reached an advanced
stage. In 2000, he had a successful ileocolectomy procedure at Allegheny General Hospital. During this
procedure, a surgeon removed a diseased section of Nicholas’ bowel and reattached the healthy ends of
his intestines. Nicholas soon noticed a remarkable improvement in his condition. In addition, he gets an
intravenous infusion of REMICADE® at Allegheny General Hospital every eight weeks.
“My quality of life has improved tremendously since the surgery. I have been largely symptom-free for a
number of years,” says Nicholas. A graduate of Westminster College, he is co-owner of Don’s Appliances,
a highly successful appliance retailer with three locations in the Pittsburgh area. In his free time, Nicholas
enjoys running, hiking and biking, as well as relaxing with his family and friends.
Because people with IBD have a slightly higher chance of developing colorectal cancer, Nicholas has a
colonoscopy every two years. A beacon of hope, Nicholas often talks with people who are newly diagnosed
with Crohn’s disease to offer encouragement and support.
“I tell patients not to be afraid. With the proper treatment, you can have a good life. Above all, I tell patients
that just because they have stomach issues, that doesn’t mean they are different than anyone else. Crohn’s
disease hasn’t changed who I am; in fact, I think it has made me an even stronger person.”
For more information or to refer a patient 412.359.8900.
Ask for the Inflammatory Bowel Disease Program.
Barbara Nagrant, PhD
Jennifer Whiteside, MAc
The Impact of Complementary Healing
Integrated Medicine Program
Treating digestive disorders oftentimes takes more than just strictly a medical strategy. It takes
focusing on the patient’s big picture – from the pain and sickness to the feelings of unhappiness
and depression.
To offer patients complementary approaches to treating their particular digestive disorder, the
Allegheny Center for Digestive Health works closely with the Allegheny Health Network Integrated
Medicine Program. This is where patients can receive ancient healing practices combined with
conventional medicine and behavioral and holistic healing practices.
Patients can partake in holistic psychology services, acupuncture, relaxation therapies, yoga, tai chi,
massage therapy, dietary supplements and nutritional counseling to maximize health and wellness
and minimize the effects their disease has on their lives.
“When regularly practiced, these therapies have been shown to reduce anxiety, depressive symptoms
and stress, ease pain and strengthen the immune system,” said Barbara Jean Nagrant, PhD, licensed
psychologist with the Allegheny Health Network Integrated Medicine Program. “We have also seen a
decrease in the need for pain medications in some of our patients.”
For more information or to refer a patient 412.359.8951
The Evolution of Gastroenterology
through Four Decades
With knowledge, comes progression. With progression, comes change.
One place where this cumulative effect is exceptionally prevalent is across the ever-evolving landscape
of medicine.
Radheshyam Agrawal, MD, gastroenterologist at Allegheny General Hospital for 40 years, has had a
firsthand look at the evolution of health care. Retiring from medicine in June of this year, Dr. Agrawal
reflected on the time when he commenced his career in gastroenterology.
“When I was a fellow in 1973, I was the only fellow. I had to cover the patients on the floor, see patients
in the office and complete procedures,” Dr. Agrawal said. “Today, we have 16 physicians and 12 fellows
in our group and the possibilities are endless as far as the resources we have to diagnose and treat our
patients.”
Ricardo Mitre, MD, who has been practicing gastroenterology since 1976, concurred with Dr. Agrawal in
his assessment of the vast developments in medicine.
“In the 1970s, endoscopic procedures were mainly diagnostic.” Dr. Mitre said. “For example, if a
medium or large size polyp was detected with a colonoscopy, the polyp would be removed surgically.
Similarly, if a patient had a bleeding ulcer, this too was treated surgically.”
A decade later, technology advanced to a point at which therapeutic endoscopy could be used to
remove polyps and to treat bleeding ulcers, rather than requiring surgery, Dr. Mitre explained. Then
the submarine technology of sonography was adapted to medical use, and physicians could image
gallstones and tumors.
“From there, computerized tomography, nuclear scintigraphy, and endosonography were developed
and lesions that were expected could be confirmed, and also significant lesions that were unexpected
could be detected,” Dr. Mitre said. “This decreased the need for exploratory laparotomy. Advanced
imaging modalities have allowed us to establish an accurate diagnosis in a rapid and non-invasive
manner.”
Dr. Agrawal, who was recently appointed professor emeritus at Temple University School of Medicine,
went on to say that the teaching of gastroenterology has also changed significantly over the last
40 years. He explained how he and fellow medical students were trained in internal medicine and
gastroenterology in order to treat everything related to the digestive system – from the stomach and
bowel to the liver and pancreas.
“Now,” Dr. Agrawal said, “there are so many subspecialties in medicine that he and other
gastroenterologists refer many patients to other physicians who have extensive knowledge about their
particular conditions.”
Dr. Mitre agreed, explaining how he used to manage not only patients’ gastrointestinal and hepatology
illnesses, but also other medical conditions, including diabetes and hypertension. He laughed when he
thought about the only times that he would consult with another specialist was on a pharmacological
question or when surgical intervention was needed.
“Now we have, for example, hepatologists who are gastroenterologists who focus primarily on the
liver,” Dr. Mitre said. “Our patients are closely followed by internists and primary care physicians
and by specialists, such as cardiologists, nephrologists and oncologists in order to receive the most
appropriate care.”
One aspect of medical practice that Dr. Mitre misses is having more time to sit and talk with patients
and their families.
“Knowing the patient and the patient’s family are still very important to the application of medicine
because they help us to make informed decisions about what is best for the patients’ lives and they
often provide informative clues that lead to the diagnosis,” Dr. Mitre said.
But neither Dr. Mitre nor Dr. Agrawal would choose to go back because with years of gained
knowledge comes new, lifesaving advances.
Dr. Mitre adds, “Although there have been significant changes in the way we practice because of
insurance and the business aspect of medicine, the technology we now have is fabulous. You can save
a patient now that you couldn’t before and that’s priceless.”
Teaching the Next Generation of Innovators
Gastroenterology and Hepatology Fellowship Program
Providing up-to-date, data-driven, comprehensive care is always tied to continuing education, research
and training of the next generation of physicians. Allegheny Health Network’s training program for
fellows is based on a simple premise that physicians utilize what has already proven successful, but
continue to look for even better answers and solutions.
Michael Babich, MD
(Program Director)
That’s the foundation of a teaching hospital, said Michael Babich, MD, program director of the
Allegheny Health Network Gastroenterology and Hepatology Fellowship Program.
“Because we are committed to academic and medical excellence by always staying on top of
innovative technology and the latest medical advances, we are able to attract some of the most
talented fellows to our program,” Dr. Babich said.
Allegheny Health Network offers a three-year, ACGME-accredited gastroenterology and hepatology
training program. Faculty provide a comprehensive educational environment that combines clinical
experience with lectures, conferences, teaching rounds, research and an up-to-date application of
gastroenterology literature, Dr. Babich explained.
Suzanne Morrissey, MD
(Associate Program
Director)
“We also stress the role of gastroenterologists as consultants and how they need to develop the skills
necessary to communicate effectively with referring physicians,” Dr. Babich said.
The training program has been divided into 17 areas in the Gastroenterology Core Curriculum,
and into 19 core knowledge areas requiring achievement of competency as defined by the ACGME
subspecialty program requirements, encompassing the breadth of knowledge and skills required
for the practice of gastroenterology. These areas include not only the traditional curricular content
of gastroenterology and hepatology but also associated disciplines such as nutrition, pathology,
radiology, surgery, endoscopy and research.
Fellows provide care for patients in the hospitals’ intensive care units – including medical, cardiac,
surgical, cardiothoracic, neurosurgical and trauma units – as well as continuity care to ambulatory
patients. Fellows will have the opportunity to participate in various subspecialty clinics, including
functional bowel syndrome, irritable bowel disease, Celiac disease and liver transplant.
“We also ensure that our fellows gain procedural experience in general endoscopic procedures
and exposure to advanced procedures, such as endoscopic ultrasound and endoscopic retrograde
cholangiopancreatography,” Dr. Babich said. “We find this a crucial aspect of preparing these
physicians to continue on as leaders in their field.”
“Because we are committed to academic and medical
excellence by always staying on top of innovative
technology and the latest medical advances, we are able to
attract some of the most talented fellows
to our program.”
– Michael Babich, MD, Program Director, Allegheny Health Network Gastroenterology and
Hepatology Fellowship Program
Katie Farah, MD
(Associate Program
Director)
Elie Aoun, MD, MS
(Director of Fellowship
Research
Recent ACDH Published Articles
Agrawal R, Morrissey S, Thakkar S (2012). Gallbladder disease. In: Pitchumoni CS, Dharmarajan TS, eds. Geriatric
Gastroenterology. First edition. 421-428.
Aoun E, Slivka A, Sanders MK. Cholangiocarcinoma arising in type IV choledochal cyst in a patient with
pancreaticobiliary maljunction: Case presentation and review of the literature. Practical Gastroenterology.
2012; 36:28-33.
Barrie A, Mourabet ME, Weyant W, Clarke K, et al. Recurrent blood eosinophilia in ulcerative colitis is associated
with severe disease and primary sclerosing cholangitis. Dig Dis Sci. 2013; 58:222-228.
Clarke K, Baidoo L. Methicillin-resistant Staphylococcus aureus (MRSA) colitis – Is there a problem? Int J Colorectal
Dis. 2012; 27:417-418.
Clarke K, Regueiro M. Stopping immunomodulators and biologics in inflammatory bowel disease patients in
remission. Inflamm Bowel Dis. 2012; 18:174-179.
Eric E, Jackson S, Thakkar S, Smith D, Finkelstein S. Correlation of the presence and extent of loss of
heterozygosity mutations with histological classifications of Barrett’s esophagus. BMC Gastroenterol. 2012; 12:181.
Hadam J, Aoun E, Clarke K, Wasko MC. Managing risks of TNF inhibitors: An update for the internist.
Cleve Clin Journal Med. 2014; 81:115-127.
Hashash JG, Holder-Murray J, Aoun E, Yadav D. The McKittrick-Wheelock syndrome: A rare cause of chronic
diarrhoea. BMJ Case Rep. 2013. doi:pii: bcr2013009208.
Lu X, Aoun E, Morrissey S. Primary hepatic gastrinoma presenting as vague gastrointestinal symptoms.
BMJ Case Rep. 2012. doi:10.1136/bcr12.2011.5327.
Lu X, Aoun E. Complications of acute pancreatitis. Practical Gastroenterology, 2012; 36:11-22.
O’Connor R, Agrawal S, Aoun E, Kulkarni A. Biliary stent migration presenting with leg pain. BMJ Case Rep. 2012.
doi:pii: bcr-2012-007588.
Sardana N, Agrawal R, Aoun E. Where’s the ulcer? Spontaneous bleeding from a Zenker’s diverticulum.
BMJ Case Rep. 2014.
Schuerle T, Aoun E. Genetic mutations, polymorphisms, and pancreatitis. Practical Gastroenterology.
2012; 36:36-40.
Schuerle T, Aoun E, Clarke K. Pseudomelanosis duodeni in a postrenal transplant patient. BMJ Case Rep. 2013.
doi:10.1136/bcr-2013-200466.
Schuerle T, Aoun E, Farah K. Small cell carcinoma of the oesophagus: A rare cause of dysphagia.
BMJ Case Rep. 2013. doi: 10.1136/bcr-2013-200468.
Shah RJ, Smolkin M, Ross AS, Kozarek RA, Howell DA, Bakis G, Jonnalagadda SS, Al-Lehibi AH, Hardy A,
Morgan DR, Sethi A, Stevens PD, Akerman PA, Thakkar SJ, Yen RD, Brauer BC. A multi-center, U.S. experience
of single balloon, double balloon and rotational overtube enteroscopy-assisted ERCP in long limb surgical bypass
patients. Gastrointest Endosc. 2013; 77:593-600.
Shinde T, Dhawan M. The role of endoscopic ultrasound in pancreatic diseases. Practical Gastroenterology.
2012; 36:16-27.
Singh S, Aoun E, Thakkar S. Endoscopic management of a major bile duct stricture from surgical clips following
laparoscopic hemicolectomy. BMJ Case Rep. 2013. doi:10.1136/bcr-2012-007982.
Strahotin CS, Babich M. Hepatitis C variability, patterns of resistance, and impact on therapy. Adv Virol.
2012. doi: 10.1155/2012/267483.
Wallace D, Dang N, Dhawan M, Kulkarni A. Diagnosis of a patient with primary pancreatic lymphoma.
Gastroenterol Hepatol. 2012;8:850–852.
Wallace D, Morrissey S. Endocrine tumors of the pancreas. Practical Gastroenterology, December 2012.
News and Events
ACDH Physicians Receive Awards of Excellence
• Research work on Matrix Metalloproteins in tissue specimen in patients with Inflammatory Bowel
Disease by Kofi Clarke, MD, in conjunction with the department of pathology was awarded a
poster of distinction at Digestive Diseases Week in Chicago in May 2014.
• Abhijit Kulkarni, MD, was given the Courage Award by the National Pancreas Foundation for the
outstanding work he has done in pancreatology. The award was presented to Dr. Kulkarni at the
Duquesne Club on June 21, 2013 at the Courage for a Cure Fundraiser.
• The tribute to Excellence Award from the American Liver Foundation in 2013 was awarded to Jose
Oliva, MD. This award honors an individual’s dedication and commitment to fighting liver disease.
Dr. Oliva follows in the footsteps of his colleagues, who have been honored with this award in the
past, including Martha Loeffert, RN, Michael Babich, MD, and Paul Lebovitz, MD.
• Paul Lebovitz, MD, was recognized by the American Liver Foundation for his commitment and
dedication.
• Radhu Agrawal, MD, has been appointed by the governor to serve on the Governor’s Advisory
Commission on Asian American Affairs.
First Center in State to Perform Minimally Invasive Procedure for Swallowing Disorder
An Allegheny Health Network multidisciplinary team of physicians and nurses are the first in
Pennsylvania to offer per-oral endoscopic myotomy (POEM), an innovative, minimally invasive surgical
approach to treat the achalasia. The swallowing disorder affects the ability of the esophagus to move
food toward the stomach.
POEM enables physicians to effectively treat achalasia without making any incisions in the patient’s
skin. Employing the NOTES philosophy (natural orifice translumenal endoscopic surgery), physicians
use an endoscope to access the esophagus via the patient’s mouth. Surgical instruments are passed
through the endoscope, and the myotomy is performed internally, without disruption to the skin.
For more information on the POEM trial at Allegheny Health Network, contact Katherine Nega at
412.578.1343 or [email protected].
ACDH Medical Director to Speak at PA Society of Gastro Conference
Kofi Clarke, MD, medical director of the ACDH, will speak at the Pennsylvania Society of
Gastroenterology meeting at Nemacolin Woodlands on Sept. 21. His presentation is titled, “New
Treatments in IBD: When, Whom and How.”
Frontiers in Gastroenterology
This annual conference, held in November, will provide an overview of common gastrointestinal
conditions and will showcase some of the most current advances in therapeutic endoscopy with
special attention to pancreaticobiliary procedures. Using both didactic sessions and live endoscopy
feeds, the latest developments in the fields of gastroenterology, hepatology and advanced endoscopy
will be showcased.
Big Blue Quest
Twenty-three staff members participated last April in the Big Blue Quest, an annual fundraiser
to promote awareness that colon and rectal cancers are preventable, treatable and beatable.
Approximately 350 people ran or walked the course. ACDH, a sponsor of the event, supported a silent
auction of baskets made by our staff (raising almost $1,000) and contributed more than $2,000 total.
The event raised more than $40,000, which will be used to support awareness and research efforts.
Celebrating a Gluten-Free Lifestyle The Allegheny Center for Digestive Health is hosting “Celebrating a Gluten-Free Lifestyle” on Sept. 25
in McCandless. At this free conference, developed by the Allegheny Health Network Celiac Center’s
team of expert medical professionals, attendees will be educated about gluten-free living, have their
questions answered by physicians and dietitians during an informal session and sample gluten-free
food choices. More details at www.pittsburghceliac.org.
Gluten-Free Pantries in the Greater Pittsburgh Region
In June of 2010, the ACDH hosted a conference to bring together community leaders, residents and
members of the Greater Pittsburgh Community Food Bank (GPCFB) to explore ways to supply glutenfree food to local food pantries. A committee was formed from this meeting, and with the help of
the GPCFB, six food pantries have been designated as gluten-free sites for those with celiac disease.
Volunteers at these six pantries have been educated about label reading and gluten-free food choices,
and have served many families over the last few years.
Food collections have continued on a regular basis at various businesses, and donation sites have
been hosted at many different celiac events in the Pittsburgh area. To date, more than $6,000 in food
products and about $2,500 in cash donations have been generously donated by Pittsburgh residents.
The six gluten-free food pantries include:
North Hills Community Outreach
1975 Ferguson Road
Allison Park, PA 15101
412.487.6316
East End Cooperative Ministries
250 North Highland Avenue
Pittsburgh, PA 15206
412.361.5549
West Hills Food Pantry – Sharon Community Presbyterian Church
522 Carnot Road
Coraopolis, PA 15108
412.262.4930
Brentwood Presbyterian Church Food Pantry
3725 Brownsville Road
Pittsburgh, PA 15227
South Hills Interfaith Ministries (SHIM)
5301 Park Avenue
Bethel Park, PA 15102
412.854.9120
Squirrel Hill Community Food Pantry
828 Hazelwood
Pittsburgh, PA 15217
412.421.2708
Our partners in
Allegheny Health Network
Gastroenterology
Jefferson Hospital
Renee Flannagan, MD
Pikul K. Patel, MD
Mon Valley Hospital
Jennifer L. Hadam, MD
John R. Hauser, MD
Deepti Dhavaleshwar, MD
Renee Flannagan, MD
Pikul K. Patel, MD
Allegheny Valley Hospital
Kenneth A. Glick, MD
Hyman D. Lipsitz MD
Jennifer Hadam, MD
John R. Hauser, MD
Kenneth A. Glick, MD
Hyman D. Lipsitz MD
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An equal opportunity employer. All rights reserved.
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