Advances in Gastroenterology Over a 36-Year Career

by Seth Rosenzweig, MD

To paraphrase a very old advertisement, “When Mike Baxter talks, everyone listens.”

When Mike asked me to write this article about changes in the field of gastroenterology over the 36 years of my career in Berks County, and despite my aversion to writing, saying no was not an option. Choosing how to narrow this topic down was also impossible. Despite the occasional perception that we are just proceduralists, most of us chose this career for the mix of cognitive and procedural aspects, as well as the opportunity to develop longterm relationships with our patients. We also get to work with multiple organs and multiple other specialists, so there is a lot of crossover. Rather than just writing free-form, I am going to start with endoscopy and then work my way down the GI tract as an anatomic tour that is extensive but not all-inclusive.

Endoscopy: Development of video-endoscopes in the 1980s revolutionized visualization of mucosa, both for the endoscopist and the endoscopy nurses (who could now see what we were seeing and help us look for colon polyps). No longer did we have to look through a tiny eyepiece in the head of the scope. Therapeutic endoscopy developed, with availability of cautery devices, Epinephrine injection and through-the-scope clips dramatically increasing the ability to control GI bleeding without need for surgery. Esophageal varices can now be banded and eradicated with rubber bands rather than being sclerosed with a toxic liquid. Larger lesions can now be removed with endoscopic mucosal resection, also reducing need for surgical resection. Artificial intelligence devices have augmented colon polyp detection, raising adenoma detection rates (an accepted marker of colonoscopy quality). Endoscopic ultrasound (EUS) has become routine, for evaluation of submucosal lesions of the upper GI tract, pancreatic lesions, and fine detail in the biliary tree. ERCP has become a routine method for removing common bile duct stones and stenting inoperable malignant bile duct strictures, and cholangioscopy can now be done to directly visualize the bile ducts during ERCP. Double balloon enteroscopy, still done mostly at highly specialized centers, can reach the entirety of the small bowel for both diagnostic and therapeutic purposes.

Seth Rosenzweig, MD, began his Gastroenterology career with the Digestive Disease Associates group in Reading immediately following completion of his Fellowship at Yale University in 1987. Prior to that he completed his undergraduate training at Yale University followed by Medical School at Columbia University and an Internal Medicine Residency at University Hospitals of Cleveland/Case Western Reserve University.

Rather than return home to Long Island, he joined as the fourth member of the DDA group and now completes his clinical practice after 36 years. He continues to share his knowledge and skills as faculty in the Reading Hospital/Tower Health GI Fellowship.

Anyone who has been a patient or a colleague of Seth knows that it is just not what he knew or what he did, but how he did it that made him a model for all of our physicians. His qualities of personal warmth, light humor and complete dedication to his profession served us all well.

Seth is truly both a gentleman and an excellent physician. We congratulate Seth on this next life step and more time with his family and friends.

Esophagus: Proton Pump Inhibitors (PPIs) first became available in late 1989 and have revolutionized the treatment of acid reflux disease and other peptic disorders. Aggressive surgical treatment with esophago-gastrectomy for dysplastic Barrett’s esophagus, and even T1a esophageal cancers, is a thing of the past. Ablation therapy for Barrett’s with low-grade and high-grade dysplasia is successful in eradication 80-90% of the time and T1a cancers can be removed with endoscopic mucosal resection. Eosinophilic esophagitis came on our radar screen, and treatment has evolved from swallowing fluticasone from an asthma inhaler, to PPIs, to a new and highly successful biologic agent (dupilumab).

Stomach: H. pylori was discovered and was affirmed to be a pathogen responsible for gastritis, many peptic ulcers, and Class 1 carcinogen. Antibiotic options to eradicate this organism, in addition to acid reducers, have revolutionized treatment of peptic ulcer disease.

Small intestine: We now have much better recognition of the high prevalence of celiac disease and its myriad presentations.

Colon: Colon cancer screening has (thankfully) become routine, and we are developing greater recognition of the need to order genetic testing to look for hereditary syndromes. Better data on diverticular disease has led to a higher threshold to recommend surgical resection for recurrent diverticulitis. Colonoscopy preps are more palatable (but still a lot to drink!).

Inflammatory bowel disease: Biologic agents have been revolutionary. Infliximab became available in 1998, and we now have a multitude of agents for both Ulcerative Colitis and Crohn’s disease. Unfortunately, they all have TV advertisements to go along with them. Hospitalization rates for IBD are much lower.

Pancreas: Unfortunately, pancreatic cancer survival rates are still poor, but it appears that there are vaccines on the horizon that may greatly change this. Recognition of the importance of pancreatic cysts has evolved over the last ten years or so, and hopefully following these aggressively may allow for early detection or prevention of some pancreatic malignancies.

Hepatobiliary: The story of Hepatitis C has followed the arc of my career. At the beginning, we had non-A, non-B hepatitis (no one knew what that was exactly). Then the Hepatitis C virus was discovered, and testing came along. Interferon treatment was developed, but the eradication rate was only 15%. Then came addition of Ribavirin, followed by a few years of triple therapy (NEVER well tolerated, by patient or physician). For about the last nine to ten years we have had the new oral agents, and the therapeutic nightmare is over. Treatment is extremely well-tolerated, eradication rates are well over 90%, and the Hepatitis C epidemic has been replaced by the non-alcoholic fatty liver disease (NAFLD) epidemic. This is still evolving and therapy beyond addressing risk factors is on the horizon.

In looking at all of this, I fully realize that this list is not exhaustive, and I have not mentioned the evolving issue of the gut microbiome. There is also a lot that has not changed. There is still a person/patient on the other side of everything that we do, and regardless of all the technological advances we still need to tend to their needs and explain what we do in their terms and to the best of our ability. Additionally, we continue to collaborate with a wide variety of other providers, from primary care to multiple medical and surgical subspecialties, to Pathology and Radiology. I also need to give a lot of credit for my career longevity to my colleagues at Digestive Disease Associates (now actually US Digestive HealthWyomissing, but always DDA to me). Aside from the immense satisfaction of caring for my patients, it has been the friendships and teamwork there that have made 36 years go by in a flash.

Finally, I want to look to the future. The one missing link in our practice was a teaching program. We began our ACGME-accredited GI fellowship at Reading Hospital in July 2020, and our first two fellows graduate at the end of this month. Andy Lee and Oluwaseun “Sho” Shogbesan are the first two fellows in our program, and we are intensely proud of them and the standard they have set. With ongoing success of the program, we will be able to continue to recruit GI physicians and provide the highest quality GI care for Berks County.