I am Dr.
Angelina Sereno, and I'm a gastroenterologist.
And MedStar Georgetown University Hospital.
In addition to General Gastroenterology, I see patients with motility disorders.
So common conditions I see in the clinic include swallowing disorders
such as achalasia, esophageal spasm, acid reflux.
I also see patients with cyclical vomiting syndrome, gastroparesis, small
intestinal bacteria overgrowth, and those with constipation, fecal incontinence.
So I love gastroenterology for a lot of different reasons.
I'm really fascinated by the whole digestive system
from when you swallow food to how it moves through your GI tract.
I just think that food is such an important part of who we are
and our identity.
And I want people to
have a good relationship with food and to feel comfortable.
And what I also love about
gastroenterology is the relationships I build with patients.
I feel like I really get to know them and can have a real impact
on their quality of lives.
We get to do endoscopies and colonoscopies, which are really hands on.
So, we take a camera and we look inside the GI tract and I feel like we can really
have a tangible effect on patient care that way.
There's a lot of new technologies and new ways to measure areas of motility.
One is the Endoflip.
It's a new device that measures how the esophagus moves.
And we get to do this during an endoscopy and it gives us a lot of information.
What's interesting about the field of motility and what's growing is that
we used to just take a look inside with a camera,
and if everything was structurally normal and we didn't know
what was contributing to your symptoms, we may say something like irritable bowel.
But now we can dive deeper into figuring out what's going on
by measuring motility.
And in the past 20 years, the field has advanced so much
and we have a lot of new tests to measure our motility.
Georgetown provides state of the art care.
We have cutting edge technologies,
and Georgetown is like a community.
All the doctors and nurses and tech,
we all work very closely together,
and we really look at the patient
not just as a disease process, but as the person as a whole.
And we really want to see how their disease is affecting
their quality of life and really help improve that.
Generally
and broadly speaking, motility refers to how food moves through the G.I.
track.
So, from when you swallow
food through how it goes down your esophagus, into your stomach,
through your small intestine and colon. In order for the food to move through
and be digested appropriately, it depends on muscles and the nervous system,
so the muscles create movements
which are called
contractions or peristalsis, and that's to keep everything going
from your esophagus down.
So, if there's any issues with the muscles or the nerves in your GI tract,
that may cause a motility disorder,
which basically means slowing down of the movement.
And that can lead to side effects such as...in your esophagus
if there's a motility disorder, you may feel like food is getting stuck
or you have difficulty swallowing.
The signs
of a motility disorder really affect on which GI segment is affected.
So, if your esophagus has a motility disorder,
you may feel like food is moving slow, like food is getting stuck
in your esophagus, or you may have chest pain or acid reflux.
If there is a motility disorder of your stomach, meaning
that the food is not emptying appropriately out of your stomach,
you may feel full easily.
You may have some nausea, vomiting.
If there is an issue with your colon, you may feel constipated.
There is not just one simple answer that causes motility disorders.
It's often generally a combination of genetics or environmental exposures.
There's also certain conditions that can predispose you to motility
disorder, such as diabetes or thyroid disease
or autoimmune diseases as well, such as lupus, scleroderma
and even neurological problems like Parkinson's can cause motility disorders.
Usually, in order to diagnose a motility disorder,
I would start with an endoscopy and colonoscopy, and that's
when we take a scope with a camera and we go inside and look.
And that's just to make sure that structurally there is nothing wrong,
such as Crohn's disease, ulcerative colitis or a cancer.
We also use imaging like ultrasounds and CAT scans,
and this again is just to make sure that nothing is causing your symptoms.
If all that is normal, we may start to think about a motility disorder
and then we have certain tests depending on which segment of the GI
tract is affected to test the motility
in order to test the esophagus.
You think of the esophagus
as like a long tube that moves the food from your mouth down into your stomach.
And in order to move it down, we need muscles to be working appropriately
to create contractions or peristalsis, and then at the end of your esophagus,
you have what's called a lower esophageal sphincter.
And this has to open in order to let food move from the esophagus into the stomach.
So, if there's any issues with the muscles or the sphincter,
you may have a motility problem in your esophagus.
So, there's a couple of ways that we can test for this.
One is done by radiology, where you can drink some contrast and they take x-rays.
This is called an Esophagram.
But the way that a gastroenterologist can test your motility is through
two different studies.
One is called high resolution manometry and one is called EndoFlip.
With the high resolution manometry, a patient's awake
during this study. We take a very thin catheter that has sensors on it
and we place in the patient's nose and it goes down into their esophagus.
This shouldn't cause any pain,
it may just cause some throat irritation while you're awake.
When this catheter is in place,
we have a patient drink water.
And as the water is moving down the esophagus, the sensors can pick up
on how the contractions are, how the muscles are in the esophagus.
It also gives information about the lower esophageal sphincter that needs to open
appropriately to let the food from the esophagus into the stomach.
So, just with this test, which takes about 15 or 20 minutes,
we can get a lot of information about how food is moving down your esophagus.
So, that's one way.
And that's when the patient's awake.
Another new exciting, tool we have is called EndoFlip.
And this is a way that we can measure the motility of the esophagus
during an endoscopy. So, while the patient is sedated,
again, we take a very similar catheter that has sensors on it with a balloon,
and we place it in their mouth and it goes down their esophagus.
And again, while they're sleeping, we inflate the balloon slowly.
And in inflating the balloon almost acts like a food bolus.
So, if there is a food or this balloon in your esophagus
is to stimulate contractions so we can, again,
see if the muscles are working appropriately in the esophagus.
And we can also see if the lower esophageal sphincter is opening
appropriately.
Conditions that when the esophageal sphincter
maybe doesn't open appropriately, that maybe signifies
something like achalasia or a major swallowing disorder.
Achalasia is
a rare swallowing disorder that often presents as feeling like foods
getting stuck chest pain, nausea and vomiting.
And it's thought to be due to damage of the nerves at
the lower esophageal sphincter.
So, the sphincter is not relaxing appropriately
so it's very tight.
So, when you swallow food instead of easily moving
from your esophagus into your stomach, it feels like it gets stuck.
So, we can diagnose as a couple of different ways
with the manometry study or the EndoFlip.
There are various treatments for achalasia.
There are treatments
that you can do during an endoscopy, and then there are surgical options.
So, during an endoscopy, one treatment option is what's called a pneumatic dilation.
And it's basically taking a large balloon and inflating it in the esophagus.
And hopefully the goal is to tear some muscles of the lower esophageal sphincter.
By tearing this, we hope that the lower esophageal
sphincter will relax appropriately so that when you swallow food
the food can move easily down the esophagus into the stomach.
During an endoscopy as well,
we can consider injecting Botox at that sphincter.
Botox also acts to relax the sphincter.
Other treatment options include
what is called a myotomy, which it can be a surgical option
in which a surgeon can cut the muscles at the sphincter
to help with the symptoms as well.
Acid reflux
is a very common problem that we see as gastroenterologists,
and people will typically describe heartburn or regurgitation.
And sometimes people think that they're having heartburn
if they're having a chronic cough or throat irritation.
And we're just not sure if that's truly acid reflux or not.
So, we have a couple of different tests to measure acid reflux.
One is called the Wireless Bravo capsule, and this is done during an endoscopy,
and then...while the patient's asleep. And the other is called
a pH impedance study, which is done while the patient is awake.
So, I can start with the pH impedance study.
So again, it's a very thin catheter that has sensors on it
and we place it in their nose and it goes down their esophagus
and the patient actually goes home with this catheter.
It shouldn't cause any pain.
Maybe just a little bit of nose irritation or throat irritation.
But because this catheter is in place with all these sensors,
we can get a lot of information for 24 hours about whether there is acid
moving from the stomach into the esophagus.
Furthermore, the patient, for the duration of study,
can press a button every time they feel like they have heartburn.
And then we can see in real time if there's actually acid
reflux at that time.
So, it gives a lot of data about whether a patient's symptoms are truly acid reflux.
The Bravo Wireless capsule is
another test that we can do while the patient's sleeping.
We do an endoscopy and then we place a very small capsule
that has a sensor on it on their esophagus.
They shouldn't feel this capsule on their esophagus.
After the endoscopy, they can wake up and go home
and this test can last them anywhere to 48 to 72 hours.
And again, because of this capsule that has a sensor on it, we can measure
whether there is true acid reflux during the duration of the study,
and then eventually a capsule just falls off the esophagus
and the patient will just have a bowel movement. That's how
the capsule is eliminated.
An anorectal manometry
is an important test for patients with constipation and fecal incontinence.
So it measures how the muscles and nerves
are working in the rectum and the anal sphincter.
So, normally when you have a bowel movement, the rectum has to push,
which is the end of the colon, has to push the stool through,
and the anus, which is at the end of the rectum,
has to open or relax to let the stool through.
Sometimes when patients are trying to have a bowel movement,
without even realizing it,
they may actually be contracting all of the muscles in their pelvic floor.
So, it's almost as if you're pushing against a closed door
and their anus is not relaxing appropriately to let stool out.
And that can lead to, for example, constipation.
So, how we measure this is through the anorectal manometry,
which is a very thin catheter, again with sensors that's placed in the rectum.
And then we have the patient
while they're awake, push and bear down as if they're having a bowel movement.
And with all these sensors, we can see how the muscles and the nerves
are working in the rectum and anal sphincter.
So, we can see
if they're appropriately contracting and relaxing to have a bowel movement.
If we find that you are actually contracting muscles
when you should be relaxing,
the treatment is what's called biofeedback or pelvic floor physical therapy.
So, basically you work with a pelvic floor physical therapist and they go over tips
and tricks on how to relax and have a bowel movement
appropriately.
In order to fix a motility problem,
it's really important
to get to the root cause of what's actually causing your symptoms.
Again, it depends on which segment of your GI tract is affected.
If it's your esophagus and you're having difficulty swallowing
and you have something such as achalasia, there are treatments such
as pneumatic dilations or sometimes even surgery to help your symptoms.
If there is an issue with your stomach not emptying appropriately,
we do have medications
which are called prokinetics, which basically help speed things
along to help empty your stomach quicker so you don't have symptoms of bloating.
If there's an issue with constipation or fecal incontinence that we can identify
on the anorectal manometry, we often recommend biofeedback.
But with any motility problem, it's really important to work
in a multidisciplinary way.
So, I work very closely with primary care doctors, surgeons, physical therapists,
nutritionist to try to help them improve motility disorders.