Digestive and Liver Health OUTCOME S
2014
CONTENTS Overview
4
Behavioral Health Program
6
Colorectal Cancer Diagnosis, Treatment and Prevention
8
Crohn’s and Colitis Program 10 Esophageal Disorders Program 12 Functional Bowel Disorders Program 14 Gastroparesis and 16 GI Motility Disorders Program Hepatology Program 18 Pancreatic and Biliary 20 Disorders Program Small Bowel Program 22 Multidisciplinary Programs 24 Digestive and Liver Health Physicians 26 Patient and Physician Liaisons 27 Locations 28
The University of Michigan Division of Gastroenterology and Hepatology is one of the largest academic practices in the nation specializing in the prevention, diagnosis and treatment of disorders of the digestive tract and liver. Many of the subspecialties within our group are destination programs for GI patients with complex issues. In 2014, we saw over 34,000 outpatients and performed over 24,000 endoscopies. To provide a seamless continuum of care, we have created a culture of partnership with referring physicians and patients. Through our new patient liaison service, we offer a one-stop multidisciplinary service to manage many complex gastrointestinal and liver disorders. The philosophy of the University of Michigan Health System is practiced through scientific discovery. With tens of millions of dollars in NIH research funding, each program in our Division performs cutting-edge research in its subspecialty. Every year, our scientists and clinicians work together to achieve innovative treatment options and care. Over the last seven years, the Division conducted 328 clinical studies with the participation of 25,500 patients. This firmly establishes the University of Michigan Health System as a preferred referral center not only within Michigan, but also around the world. Many of our patients travel hundreds even thousands of miles to see our physicians in the University of Michigan Division of Gastroenterology and Hepatology. Armed with one of the most sophisticated GI physiology and manometry laboratories in the world and state-of-the-art endoscopy units, our experts collaborate with referring physicians to diagnose obscure gastrointestinal and liver disorders. Together, we provide the most innovative and effective treatments for patients. As a research institution, we are committed to finding new solutions for clinical issues. We are also steadfast in our educational mission — to develop and train the next generation of new leaders in gastroenterology and hepatology. In the last 50 years, our fellowship program has trained over 400 gastroenterologists and hepatologists, many of whom have become leaders in the field, practicing in 33 states. With our robust infrastructure, distinguished faculty and firm commitment to serve, we offer patients the most advanced, safest and evidence-based medical treatment for gastrointestinal and liver disorders. This is why Victories Start Here.
Chung Owyang, M.D. Chief, Division of Gastroenterology and Hepatology
Digestive and Liver Health Outcomes 2014 • 3
Digestive and Liver Health: Overview Partners in the Community
Commitment to Research
Founded in 1947, the Division of Gastroenterology at the University of Michigan Health System has been a resource for referring physicians throughout our region and around the world. We value these partnerships and continue to expand our services to meet the needs of their patients.
Every program within our Division is at the forefront of research in their subspecialties, whether in developing new technologies and treatment protocols or improving current therapies. Patients who come to Michigan can expect access to the latest clinical trials, which is especially ideal for patients whose options are limited because conventional therapies are no longer working.
As the second largest Digestive and Liver Health group in the country, we offer a broad base of expertise and a tremendous depth of knowledge and diversity of resources that translate into a better clinical experience for the patients and families we serve. From the most basic and common to the rare and complex, our programs specialize in the diagnosis, treatment and management of all gastrointestinal and liver disorders.
Current clinical trials related to gastrointestinal and liver disorders can be viewed at UMClinicalStudies.org.
65 14 5
+ Total Clinical
Culture of Collaboration Community is important to us at Michigan—inside and out. We enjoy working with referring physicians and their patients and collaboration is the foundation for how we provide expert and timely care. Not only do programs within our Division work closely together, but we also form partnerships with other specialties within the University of Michigan Health System to create one-stop multidisciplinary programs, many of which are Centers of Excellence.
Outpatient Clinic Visits
34,487
2014 2013 30,384 2012 32,024 2011 30,131 2010 28,880 2009 26,255 2008 23,972
Inpatient Discharges
1,115
2014 2013 1,142 2012 1,095 2011 1,153 2010 1,252 2009 1,162 2008 1,140
4 • The University of Michigan Health System
Endoscopy Procedures
24,049
2014 2013 23,917 2012 23,372 2011 23,739 2010 22,853 2009 22,128 2008 21,039
Faculty
Total Clinic Locations (including VA) Total Endoscopy Units (including VA)
Fellows Educated
43 Gastroenterology 2008–14 14 Interventional Endoscopy 2009–14 10 Liver Transplant 2008–14
Excellence in Education Our faculty members embody the spirit of the Michigan Difference. They are among the leading experts in our field with notable accomplishments that include: developing the Rome III criteria that are used by gastroenterologists everywhere to diagnose irritable bowel syndrome; participating in the development of the NIH Sponsored Guidance Document on the Treatment of Viral Hepatitis; serving as leaders (past and present) of our national societies such as the American Gastroenterological Association, American College of Gastroenterology, American Association for the Study of Liver Diseases, American Society for Gastrointestinal Endoscopy, American Neurogastroenterology and Motility Society and on the editorial teams of Gastroenterology and The American Journal of Gastroenterology. With plans to expand our fellowship program and with fourth-year options available in some of our subspecialty programs, we are dedicated more than ever to our mission of training the next generation of gastroenterologists and hepatologists. At the University of Michigan, we have a robust infrastructure, unwavering commitment and the finest faculty to pursue our clinical and research missions. Our goal is to ensure a future where we continue to refine our understanding of gastrointestinal and liver diseases through the pursuit of clinical and research excellence.
Clinical Trials Participation
Grant Funding
February 1, 2008 – December 31, 2014
2014 2013 $13,107,896 2012 $11,162,040 2011 $10,266,807 2010 $9,908,040 2009 $9,816561 2008 $7,456,611
25,636 patients
Active Clinical Trials February 1, 2008 – December 31, 2014
328 active studies
$13,818,453
Clinical Trials Revenue
$1,672,527
2014 2013 $1,061,325 2012 $1,004,133 2011 $425,908 2010 $515,432 2009 $430,375 2008 $734,776
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Behavioral Health Program The Behavioral Health Program is the latest service to be offered within the Division of Gastroenterology at the University of Michigan, further expanding our ability to provide comprehensive care from a diverse and innovative group of specialists in one location. This new program is designed to address the unique needs of patients with functional and organic GI conditions. Once referred to the Behavioral Health Program, patients undergo an extensive evaluation to determine the best course of treatment with our licensed clinical psychologist and registered dietitians specially trained in GI disorders.
Behavioral Health Therapy
Collaborative Care
Our evidenced-based psychological interventions include:
Our specialists work closely with each other and with referring gastroenterologists to develop disease management and alternative treatment options that are designed to empower patients to take an active role in their gastrointestinal health. Patients may be referred early in their initial work with their gastroenterologist, or later when stress may begin to significantly impact their ability to cope with symptoms.
For some patients, cognitive behavioral therapy or other behavioral treatment approaches can provide better outcomes than treating GI symptoms with medications alone. Every new patient attends a comprehensive initial consultation that covers all aspects of their current state of function at the medical, psychological and social levels before an individualized treatment plan is discussed. Treatment is often short-term and patients can generally expect to see improvement within a matter of days or weeks.
• Cognitive behavior therapy for functional and chronic GI disorders • Medical hypnotherapy (gut-directed relaxation) for IBS and IBD • Stress management • Relaxation training • Adaptive behavioral modification strategies • Mental health diagnosis and treatment
“ When a patient or someone close to them is diagnosed with a gastrointestinal disorder or chronic disease, many challenges can occur beyond the physical symptoms. Taking care of one’s emotional well-being is equally as important as taking care of one’s physical well-being. Unfortunately in today’s medical world, there often isn’t time to address the social and mental effects of living with a chronic illness. This is where our program can be helpful.” Megan Riehl, Psy. D.
Director, GI Behavioral Services
6 • www.UofMHealth.org/gi
Lauren Van Dam, MS, RD, CNSC Lead, GI Nutrition Services
Medical Nutrition Therapy Patients with gastrointestinal symptoms can often find relief through diet modifications and learning which foods trigger their symptoms. Through the Behavioral Health Program, patients have the opportunity to work individually with our GI-specialized registered dietitians for guidance on following recommended diets, such as the low FODMAP diet, that can help improve their symptoms and overall quality of life. The initial consultation will include a review of the patient’s lifestyle behaviors, such as diet, meal patterns and exercise regimen. Every patient receives a customized nutrition plan tailored to their individual preferences and cooking skills, complete with examples of what to eat and how to best prepare it.
Research Highlights The Behavioral Health Program continues to grow its clinical services and assess the needs of the community it serves. The Behavioral Health specialists actively explore the importance of collaboration among psychology, nutrition and medicine by collecting data pertaining to various diagnoses, treatment plans employed, and outcome data. Additional research interests include clinical outcomes related to the use of non-pharmacological interventions for the treatment of functional esophageal and bowel disorders, the acceptability of medical hypnosis for the treatment of GI disorders and addressing the role of diet in the treatment of Irritable Bowel Syndrome and Inflammatory Bowel Disease. Our ongoing research investment is delivering significant insights in the field of GI psychology and nutrition.
Emily Haller, RDN
GI Nutrition Services
Digestive and Liver Health Outcomes 2014 • 7
Colorectal Cancer Diagnosis, Treatment and Prevention The University of Michigan Division of Gastroenterology is committed to colorectal cancer prevention and implementation of personalized surveillance for individuals at risk for colorectal neoplasia.
Colorectal Cancer Prevention and Risk Assessment Colorectal cancer screening has been proven effective in reducing morbidity and mortality. However, colorectal cancer screening is not onesize-fits-all and recommendations for which tests to order and at what frequency should be based on an individual’s personal and family history. The Division of Gastroenterology provides a wide range of services for colorectal cancer screening and surveillance. Endoscopists from our Medical Procedures Unit (MPU) offer expertise in endoscopic resection of difficult lesions, such as flat polyps and large polyps.
“ We are interested in taking care of families. So when patients have questions about their risk for cancer because of a diagnosis in a family member, that’s where our expertise comes in: making plans on how to best manage individuals according to their risk status.” Elena M. Stoffel, M.D., M.P.H.
Director, Cancer Genetics Clinical Program
8 • The University of Michigan Health System
The Direct-Access Colonoscopy Program offers referring physicians and their patients the convenience of scheduling a colonoscopy procedure directly without a prior clinic visit. Patients must be at average risk for colorectal cancer and have no gastrointestinal complaints. To review eligibility criteria and to download the scheduling requisition for DirectAccess Colonoscopy at the University of Michigan, visit www.med.umich. edu/gi/access.htm. For patients with complex personal and family health histories, or questions pertaining to their personal cancer risk, we offer clinic consultations. Individualized screening recommendations can be especially helpful for patients who have experienced a prior difficult colonoscopy. We will create an individualized plan that meets each patient’s needs, with anesthesia team support, to ensure an appropriate comfort level, from conscious to complete sedation. Since colorectal cancer screening recommendations must take into account not only the patient’s own health, but also a family history of cancer and colorectal polyps, family history risk assessment is a routine part of our consultations.
Approximately 15%–30% of patients report a family history of colorectal cancer and as many as 1 in 20 colorectal cancer cases may be associated with a hereditary cancer syndrome. The University of Michigan Cancer Genetics Program specializes in personalized risk assessment and genetic testing for patients whose family histories of cancer raise suspicion for a hereditary cancer syndrome. Cancer genetics clinical consultations include a visit with a certified cancer genetics counselor and a physician with expertise in hereditary cancers, genetic testing and cancer prevention.
“ Patients really appreciate it when I tell them that I am going to present their case at our Tumor Board with physicians from all of our various specialties and subspecialties — to know that all of these experts are going to be there putting their two cents in on what’s the best way to manage their case.” Kim Turgeon, M.D.
Associate Professor, Gastroenterology
Colorectal Cancer Treatment Multidisciplinary Colorectal Cancer Program Gastroenterologists at U-M take part in the Multidisciplinary Colorectal Cancer Program, which brings together teams of colorectal surgeons, gastrointestinal oncologists, radiation oncologists, pathologists, genetic counselors and gastroenterologists. This clinic develops treatment plans for patients with gastrointestinal malignancies. The joint review of cases by the Multidisciplinary Colorectal Cancer Tumor Board ensures that patients with colorectal cancer are offered state-of-the-art therapies and that their family histories and tumors are screened for features of hereditary cancer syndromes to identify those who may benefit from genetic evaluation. Our faculty are also engaged in research of novel endoscopic and imaging techniques for identifying colorectal neoplasms, as well as chemoprevention studies aimed at preventing their development.
Faculty Adenoma Detection Rate Overall
31.5%
Faculty Cecal Intubation Rate Overall
99%
These rates are tracked for each faculty individually and 100% are over the national benchmark guidelines.
Research Highlights Current research studies enrolling subjects include: • a multicenter study that seeks to identify biomarkers for early detection of colorectal neoplasms • randomized clinical trials for patients (teenagers and adults) with familial adenomatous polyposis, a hereditary cancer syndrome, testing the effectiveness of various medications for slowing the progression of gastrointestinal polyps • Cancer Genetics Registry for the study of genetic factors associated with cancer risk • a Phase I University of Michigan study looking at the possible protective effects of the dietary supplement omega-3 fatty acids or fish oil on the colon • a Phase I University of Michigan study testing a new way to better identify and visualize flat or hidden polyps
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Crohn’s and Colitis Program The U-M Division of Gastroenterology’s Crohn’s and Colitis Program is a rapidly growing, internationally recognized group of clinicians, surgeons and researchers dedicated to the complete care of the complex issues associated with Crohn’s disease and ulcerative colitis (Inflammatory Bowel Disease – IBD). Faculty members perform endoscopic dilations, doubleballoon enteroscopy and chromoendoscopy to treat the complications of Crohn’s disease and ulcerative colitis. We continue to evaluate new biologics and drug therapies for optimal treatment of complex cases of IBD. We have added new faculty and staff to accommodate more than 8,000 annual referrals of patients with IBD from as far away as Jordan.
Patient Visits Per Year
Best Practices The key to the successful management of IBD is to detect inflammation as early as possible. One of the most promising trends in IBD management is monitoring levels of biomarkers of inflammation in the intestines. Often patients will have smoldering inflammation that causes damage but they will not exhibit symptoms until the damage causes an intestinal blockage, which could require surgery. Our physicians are exploring the use of innovative biomarkers and state-of-the-art imaging studies to help identify patients at an earlier stage. Great advances have been made in identifying patients who are candidates for elective surgery to remove intestinal scarring before they develop perforations, fistulas, or abscesses and require an emergency procedure. Our goal is to avoid these complications that put the patient at greater risk for infection and lengthen the patient’s recovery time. As we improve outpatient therapies, we have seen our number of hospital admissions per year per IBD patient continue to drop.
IBD Inpatient Specialty Service Our IBD inpatient specialty service delivers high-intensity care to patients during flares and helps coordinate care with our colorectal surgeons.
IBD Monitoring Tools
n Ulcerative Colitis
n Crohn’s Disease
* estimated
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In collaboration with U-M radiologists, we offer MR enterography— a sensitive and radiation-free tool for the detection of active inflammation or complications. Ultrasound is currently a research tool used to identify patients with more fibrotic, scarred intestines who need surgery rather than continuing medical therapy.
IBD School IBD School is a free series of short educational videos developed to help patients and their families better understand the complexities of living with Crohn’s disease and ulcerative colitis, and to help them make informed decisions about treatment.
To view the IBD School videos, visit www.UofMHealth.org/IBDSchool
A Crohn’s & Colitis Foundation of America sponsored research project led by Dr. Ryan Stidham is measuring blood proteins to find biomarkers to detect early signs of intestinal scarring long before patients have symptoms of obstruction.
Nutritional Services Our registered dietitians specialize in educating patients about diets that can significantly improve Crohn’s disease and ulcerative colitis symptoms, including low FODMAP, low-oxalate, low-residue and gluten-free diets.
Severe UC Protocol Patients with severe ulcerative colitis who are potential candidates for surgery will benefit from a specific protocol developed for inpatients with ulcerative colitis. Transfers for patients who are at higher risk for colectomy are available. Review the Severe UC Protocol at http://www.med.umich.edu/ibd/docs/UMSevereUCProtocol_v2.71.pdf.
Research Highlights Our current NIH-funded research studies include the diagnostic and prognostic use of biomarkers, magnetization transfer MRI, shear wave velocity ultrasound and machine learning. More than 40 IBD clinical studies are currently active, with many studies offering cutting-edge treatment to patients who have failed standard therapies. We are actively engaged in continuous quality improvement in the Crohn’s and Colitis Program and have improved our adherence to the PQRS IBD measures, bringing our pneumococcal immunization rates in patients with IBD to over 80% in 2014.
Leading Research Site The U-M Crohn’s and Colitis Program is currently participating in 55 innovative therapeutic and diagnostic research clinical studies. Many are global phase II and III treatment trials aiming to reduce disease activity for patients. As a tertiary care center, patients are often referred directly to these clinical trials. Additionally, many of the therapeutic studies offer long-term extensions allowing patients access to study medications for up to 4 to 5 years. Learn more about the IBD studies at U-M by visiting http://www.med.umich.edu/ibd/studies/index.html.
Digestive and Liver Health Outcomes 2014 • 11
Esophageal Disorders Program The Esophageal Disorders Program comprises over a dozen gastroenterologists with experience in treating patients with both routine and complicated esophageal disorders, including: • achalasia • dysphagia
• Ambulatory reflux monitoring
– Bravo® capsule pH (requires clinic consultation prior). Typically performed while off acid-reducing medications.
• eosinophilic esophagitis • GERD symptoms that have not responded to acid-reducing medications. The gastroenterologists in the program engage with other U-M experts including those in allergy, minimally invasive surgery, nutrition, thoracic surgery, pathology and radiology. Particularly challenging cases are discussed at a monthly multidisciplinary conference, so patients can benefit from input from multiple experts within and outside of gastroenterology. We take care to expedite outside referrals and communicate back to the referring physicians.
Trends in U-M Volume of Esophageal Manometry and Reflux Monitoring Procedures Impedance + pH
1000
Bravo pH Catheter pH
800
Manometry
600
400
200
0 2013
• High-resolution esophageal manometry (open access) – Traditional catheter-based pH (open access). Typically performed while not taking acid-reducing medications.
• Barrett’s esophagus
2014
Esophageal Function Testing
2012
2011
2010
12 • The University of Michigan Health System
2009
2008
2007
– Catheter-based intraluminal impedance/pH for detecting both acidic and non-acidic reflux (open access). Typically performed while taking acid-reducing medications. • Endolumenal Functional Lumen Imaging Probe (EndoFLIP) (requires clinic consultation prior) – Performed in conjunction with an EGD, EndoFLIP uses impedance planimetry to measure distensibility of the esophageal wall and cross-sectional area of the esophageal lumen. Clinical indications include: suspected atypical achalasia, dysphagia post-therapy for achalasia and dysphagia post-fundoplication.
100+ 2,000+ 100+
patients with achalasia being treated annually patients with Barrett’s esophagus have been treated at U-M patients with eosinophilic esophagitis being cared for annually
Endoscopic Therapy The U-M Division of Gastroenterology has a long experience with endoscopic eradication therapy for neoplastic Barrett’s esophagus, starting with yttrium aluminum garnet (YAG) laser ablative therapy in the 1990s. The first endoscopic mucosal resection was performed in 2005 and radiofrequency ablation soon after. In addition, we now offer endoscopic therapies for achalasia. The Esophageal Disorders Program currently has five endoscopists providing esophageal endoscopic therapy. Barrett’s esophagus eradication therapies • Endoscopic mucosal resection (EMR) – U-M has performed over 300 EMR procedures. – Low complication rates:
25% Stricture Formation (resolved with 1 dilation in 94%) 1.5% Bleeding 0.2% Perforation • Radiofrequency ablation (RFA) – U-M has performed over 200 RFA procedures.
1.3% Bleeding • CryoSpray ablation
“ Our Barrett’s Esophagus Program integrates consultative services and endoscopic therapy, along with cutting-edge patient-oriented and translational research. We aim to efficiently identify patients at high risk, prevent cancer and relieve patients of their worries.” Joel Rubenstein, M.D., M.Sc.
Director, Barrett’s Esophagus Program
Research The U-M Esophageal Disorders Program conducts ground-breaking research that is funded by the National Institutes of Health, Department of Veterans Affairs, non-profit foundations and industry, including: • Development and validation of a non-invasive tool for identifying patients at increased risk for Barrett’s esophagus, the Michigan Barrett’s Esophagus pREdiction Tool (M-BERET, learn more at http://www.uofmhealth.org/medical-services/ barretts-esophagus) • Novel endoscopic imaging techniques for identifying neoplastic Barrett’s esophagus using specific peptide dye sprays • Outcomes studies in endoscopic therapy for Barrett’s esophagus
Achalasia therapies • Pneumatic dilation — either fluoroscopically guided or with EndoFLIP, avoiding radiation exposure
• Randomized trials of novel therapies for gastroesophageal reflux
• Botulinum toxin injection
• Improving the classification of eosinophilic esophagitis phenotypes which may lead to more specific therapies
• The utility of EndoFLIP in eosinophilic esophagitis and poorly characterized forms of dysphagia
• Computer simulation modeling of strategies to control the burden of esophageal cancer
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Functional Bowel Disorders Program Functional bowel disorders encompass a broad group of conditions characterized by common gastrointestinal symptoms that are not explained by identifiable structural or biochemical abnormalities. Functional bowel disorders can affect any part of the gastrointestinal tract, from the esophagus to the anus.
Center of Excellence In the Functional Bowel Disorders Program at the University of Michigan, our multidisciplinary team is committed to efficiently making an accurate diagnosis. While there are no cures for functional bowel disorders, we leverage our high level of expertise to help patients manage their symptoms and enjoy a better quality of life. Our physicians use the Rome III criteria, developed in part by experts at the University of Michigan, to help determine functional bowel disorders and assess patient symptoms.
My GI Health Physicians from the Functional Bowel Disorders Program and the Center for Health Communications Research at the University of Michigan, in conjunction with colleagues at Cedars Sinai Medical Center in Los Angeles, California, are developing a comprehensive web-based patient-provider portal called “My GI Health.” My GI Health will allow patients to quickly and accurately convey their gastrointestinal symptom experience to their doctor before their face-to-face visit. In addition, information conveyed by the patient and customized by their doctor will provide a tailored, individualized teaching experience that will enhance the information communicated during the face-to-face visit. As physician workloads continue to increase, My GI Health will serve as an effective and practical tool to optimize the patient-provider interaction.
Expert Advice Most patients who suffer from a functional bowel disorder, such as irritable bowel syndrome (IBS) or functional dyspepsia, experience mild, intermittent symptoms that can be effectively managed with dietary and lifestyle changes, as well as over-the-counter medications. For patients who experience frequent or severe symptoms despite standard treatments, we offer state-of-the-art diagnostic testing, which helps our team make a confident diagnosis and develop the most appropriate treatment plan. Our goal is to understand each patient’s symptom experience and to improve their quality of life and ability to function through a holistic management approach.
10,000 Patients with FBD Seen in Fiscal Year 2014 Functional Dyspepsia • 25%
IBS • 50% Esophageal Symptoms • 15% Pelvic Floor Disorders • 5% Other • 5%
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Research Highlights Our physicians are actively involved in research addressing functional bowel disorders. The studies are designed to improve our ability to diagnose and treat these disorders, whether with medications, devices or lifestyle changes such as diet. We also offer ongoing trials evaluating novel medical therapies for patients with functional bowel disorders, usually chronic constipation or IBS. Other recent developments include: • clinical trials beginning for a patented device that will help diagnose a certain type of constipation • a study looking at the efficacy of the low FODMAP diet vs. standard dietary recommendations in individuals with IBS
“ Oftentimes patients with FBD are frustrated because they don’t have an identifiable structural or biochemical problem. A primary goal of the FBD Clinic is to make sure patients know that we understand that their symptoms are bothersome, take their complaints seriously and are willing to partner with them to find holistic solutions for their gastrointestinal symptoms.” William D. Chey, M.D.
Co-Director, Michigan Bowel Control Program Director, Gastrointestinal Physiology and Manometry Laboratory Director, GI Behavioral and Nutrition Wellness Program
• a study to evaluate a validated instrument that measures the quality of patient-physician interactions and establish empiric evidence to support best practices protocol
Rome III Criteria To meet Rome III criteria for irritable bowel syndrome, patients must have:
To meet Rome III criteria for functional dyspepsia, patients must have:
• symptoms that began at least 6 months ago
• symptoms that began at least 6 months ago
• stomach pain or discomfort for at least 3 days a month for the last 3 months
• one or more of the following symptoms: bothersome fullness after eating a meal; becomes full quickly while eating; pain in upper central portion of the abdomen; burning in upper central portion of the abdomen
• at least two of the following statements are true: pain is relieved by having a bowel movement; pain is linked to a change in how often there is a bowel movement; pain is linked to a change in the appearance of the patient’s stool.
• no evidence of structural disease that is likely to explain the symptoms.
Digestive and Liver Health Outcomes 2014 • 15
Gastroparesis and GI Motility Disorders Program Gastroparesis and other GI motility issues can be devastating because diagnosis is challenging and few current treatment options are available. This group of disorders include achalasia, gastroparesis, cyclic vomiting, intestinal pseudo-obstruction and slow colonic transit constipation. As obesity reaches epidemic proportions in the United States and type 2 diabetes is rising rapidly, we are witnessing a marked increase in patients suffering from symptomatic gastroparesis. Cyclic vomiting syndrome, which typically affects children and young adults, presents with clustered episodes of vomiting that do not respond to conventional antiemetics. Chronic intestinal pseudo-obstruction is a less common condition that presents with symptoms of obstruction in the absence of mechanical blockade. For unclear reasons, slow colonic transit constipation typically affects young women and has devastating ramifications. This group of disorders are difficult to diagnose and treatment is often ineffective and largely empiric in nature.
Largest Group of Motility Experts The University of Michigan has the largest group of GI motility disorders experts in the United States. Many are opinion leaders in their subspecialties. We have a clinic specializing in innovative treatments of gastroparesis and cyclic vomiting. Our large population of intestinal pseudo-obstruction patients comes from all regions of the United States. In collaboration with our surgical colleagues and using state-of-theart technology offered by the GI Physiology and Manometry Laboratory, we treat numerous patients with slow transit constipation who do not respond to traditional laxatives.
GI Physiology and Manometry Laboratory The GI Physiology and Manometry Laboratory located in the Medical Procedures Unit performs unique diagnostic tests for patients with motility disorders: • Barostat studies measure gastric tone, which helps uncover causes for non-ulcer dyspepsia and pain. • Electrogastrography (EGG) monitors gastric pacemaker activities and is used as a tool for the diagnosis of tachygastric arrhythmias, a condition often observed in patients with nausea and vomiting. • GI manometric studies record gastrointestinal motility and help diagnose intestinal pseudo-obstruction and to differentiate neuropathic from myogenic disorders. These tests are not available in many medical centers in the United States, and only the University of Michigan offers all three in one location.
16 • The University of Michigan Health System
Research and Innovation The Division of Gastroenterology at the University of Michigan has a rich tradition of clinical research in motility disorders. Notable achievements include: • among the first to use gastric pacing as a modality to treat end-stage gastroparesis • the first to use octreotide in the treatment of intestinal pseudo-obstruction
“ GI motility disorders are common and many are debilitating. At the University of Michigan, we have the expertise, experience and state-of-the-art diagnostic facilities to diagnose and manage the most complex GI motility disorders.” Chung Owyang, M.D.
H. Marvin Pollard Professor of Internal Medicine Professor of Molecular and Integrative Physiology Chief, Division of Gastroenterology Director, Pollard Institute for Medical Research
• established the use of dopamine antagonists to manage gastric tachyarrhythmia • clinical studies to evaluate pyloric injection of Botox for the treatment of gastroparesis • key participation in the national Gastroparesis Registry • NIH grant to study the treatment of gastroparesis
Coordinated Team Approach A team of experts from different disciplines provides optimal care for patients with difficult motility disorders. The Department of Gastrointestinal Surgery provides services such as placement of pacemakers in the stomach and insertion of intestinal feeding tubes for refractory gastroparesis. A registered dietitian (RD) with specialized knowledge of GI motility disorders evaluates nutritional needs and recommends dietary changes to reduce symptoms and achieve a balanced diet. The RD also recommends enteral and parenteral nutrition regimens if this is needed. Our psychologist who specialize in the management of chronic pain can provide behavior therapy and hypnosis. The motility disorders group also works closely with their Rheumatology colleagues to care for patients with overlapping symptoms of fibromyalgia.
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Hepatology Program The Hepatology Program at the University of Michigan is one of the largest and most well-established programs in the country. We specialize in the diagnosis and management of acute liver failure, hepatitis B and C, autoimmune liver diseases, nonalcoholic fatty liver disease, cirrhosis, and complications of portal hypertension, hepatocellular carcinoma and liver transplantation.
Liver Transplantation Our Liver Transplant Program evaluates more than 300 patients and performs 60–80 liver transplants each year. To ease the shortage of organs, we use innovative techniques, such as split livers and extended criteria donors.
Viral Hepatitis Our mission is to provide state-of-the-art, innovative and compassionate care to patients affected by liver diseases through general hepatology, viral hepatitis, liver tumor and liver transplantation clinics. As part of this mission, we provide multidisciplinary care so patients can be evaluated by physicians from all appropriate disciplines during a single visit. In addition, we are actively engaged in clinical research including novel therapies, improved diagnostic modalities and better biomarkers and predictors of outcome. We welcome partnerships with referring physicians who should feel free to e-mail background documents or lab work on a specific case directly to any of our faculty before a consultation.
Cirrhosis Care Program Our Cirrhosis Care Program provides comprehensive, compassionate and personalized care to patients with cirrhosis through our clinics in Ann Arbor (Taubman Center), East Ann Arbor (Geriatric Liver Clinic), Northville and Brighton. Our team of hepatologists, nurses and mid-level providers has cutting-edge expertise and experience in providing state-of-the-art management of the complications of cirrhosis including ascites, hepatic encephalopathy, esophageal varices and hepatorenal syndrome. We offer FibroScan — a novel non-invasive device to assess liver stiffness and scarring. Patients are referred and transition to our liver transplant program smoothly once they meet the criteria for listing on the transplant waiting list.
18 • www.UofMHealth.org/gi
Our physicians have three decades of experience in hepatitis research and are world authorities in hepatitis B and C. Dr. Anna Lok, a world renowned hepatologist, is leading an NIH-sponsored team involving 21 adult and 7 pediatric sites in the US and in Toronto to develop better treatment of hepatitis B. Our physicians were involved in clinical trials that led to the approval of all-oral, interferon-free regimens. Dr. Robert Fontana reported the first case of successful eradication of recurrent hepatitis C using a combination of novel direct-acting antiviral agents and he is leading clinical studies on these new drugs in patients with decompensated cirrhosis.
Multidisciplinary Liver Tumor Program Following an evaluation, patients are reviewed by our Multidisciplinary Liver Tumor Board, with careful consideration of all treatment options presented by our experts in hepatology and surgery. A clear treatment plan is developed and discussed with referring physicians and their patients. For further information, please see page 24.
Research Highlights All patients seen in any of our Hepatology Clinics who are potential candidates for new therapies and other research protocols are referred for participation in clinical trials. This is especially true for viral hepatitis, in particular hepatitis C.
New Patient Consults and Return Visits – Fiscal Year 2014
In January 2012, The New England Journal of Medicine published the findings of a University of Michigan-led pilot study where a combination of oral direct-acting antiviral drugs successfully suppressed hepatitis C genotype 1 infection in a high percentage of patients who had not responded to previous treatment. Other clinical trials investigate new treatments for liver cancer, managing acute liver failure and cirrhosis complications, all of which give patients access to the best possible care for liver disease.
“ When I started my training in hepatology, there was no treatment for hepatitis B and no diagnostic test for hepatitis C — it was called non-A, non-B hepatitis then. Most patients with hepatocellular carcinoma presented late with tumors that involved most of their liver. They rarely survived more than 6 months. Witnessing the transformation from an elusive condition ‘non-A, non-B hepatitis’ to being able to diagnose hepatitis C and now to curing more than 90% of patients with just one pill once a day for 12 weeks is amazing. For hepatitis B, while current antiviral treatment cannot eradicate hepatitis B virus, seeing that long-term viral suppression can reverse cirrhosis and decrease the risk of hepatocellular carcinoma is very gratifying. Instead of 10-cm tumors with vascular invasion at diagnosis, most hepatocellular carcinomas we now see are less than 2 cm and survival of patients with these small tumors is often more than 5 years. Advances in hepatology have been breathtaking and I am so pleased to see that members of our team have played pivotal roles in these advances.” Anna S. F. Lok, M.D., F.R.C.P.
Director, Clinical Hepatology Program Alice Lohrman Andrews Research Professor in Hepatology Associate Chair for Clinical Research
New Consults
Return Visits
Brighton Hepatology Clinic
136
193
Canton Hepatology Clinic
44
193
Livonia Hepatology Clinic
66
107
Taubman Hepatology Clinic
1,128
3,590
Liver Transplant Clinic
241
2,107
Liver Tumor Clinic
167
337
*Advanced Hepatology Clinic available in Grand Rapids.
Training in Hepatology Gastroenterology Fellows can extend their fellowship to a fourth year for transplant hepatology training in our Hepatology Program. We currently admit two fellows for this additional training each year. For the last several decades, our Hepatology Program has trained many hepatologists serving in the community. Many continue their professional growth through participation in our annual postgraduate courses.
Learning More About the Liver The Hepatology Program, in collaboration with the Veterans Affairs Ann Arbor Healthcare System, produces a monthly educational video series as part of the SCAN-ECHO Liver Program. Learn more at www.med.umich.edu/hepatology/ Digestive and Liver Health Outcomes 2014 • 19
Pancreatic and Biliary Disorders Program Patient Volume Per Year ERCP
1,100
(endoscopic retrograde cholangiopancreatography)
EUS
1,200
Our multidisciplinary team provides minimally invasive diagnostic and treatment options that are not widely available for pancreatic and biliary disorders, performed by experienced gastroenterologists with high patient volumes in these procedures. We partner with referring physicians to take care of patients with disorders related to the pancreas and bile duct.
Specialized Care
(endoscopic ultrasound)
Our pancreatic and biliary experts work closely with many other experts in gastroenterology and throughout the University of Michigan Health System to provide a comprehensive continuum of care for patients, including: • hosting monthly joint conferences to review complex cases with pancreatic and biliary surgeons • consulting with liver transplant surgeons and transplant hepatologists to address the most common post-transplant complication, which occurs in the biliary tract • treating pancreatic duct stones in conjunction with urologists • working with radiation oncologists to guide fiducials through an endoscope to help them localize and radiate pancreatic tumors.
“ We strive to give the highest quality patient care we can by being very knowledgeable about our specialty and offering the most cutting-edge therapeutics available. All of our procedures carry risk and our experts have the experience and wisdom to know when to use them and when not to.” Grace H. Elta, M.D.
Director, Pancreatic and Biliary Disorders Program Professor, Gastroenterology Director, Medical Procedures Unit Associate Chief of Clinical Programs
20 • The University of Michigan Health System
Specialty Procedures The size of our faculty and patient volume allows us to offer specialty procedures for pancreatic and biliary disorders not available anywhere else: ERCP, endoscopic ultrasound, endoscopic suturing to close fistulas, over-the-scope clip to close large defects and cholangioscopy—a miniature endoscope that provides direct visualization of the bile duct.
On-Site Pathology For endoscopic ultrasound procedures where we perform fine-needle aspirates, a cytopathologist is present to review the cells immediately under a microscope to determine if the specimen is adequate. This produces a higher yield and reduces the number of repeat procedures, creating a better patient experience overall.
Direct-Access Endoscopic Ultrasound
Research Highlights
To expedite patient care, referring physicians are welcome to schedule endoscopic ultrasound procedures directly and without need of prior consultations. The endoscopic ultrasound is performed by a full-time Pancreatic and Biliary Disorders Program faculty member. Our faculty are always available to provide consultations on the endoscopic ultrasound findings. Contact the Endoscopy Call Center at (734) 936-9250, option #1, to schedule an appointment.
Our faculty are at the forefront of groundbreaking research, such as the first clinical trial to clearly demonstrate effective prevention of post-ERCP pancreatitis published in The New England Journal of Medicine. This disabling condition is a serious complication of ERCP, affecting 1 in 4 high-risk patients and our study showed that it may be significantly reduced with a single-dose, low-cost medication.
Interventional Endoscopy Training Gastroenterology Fellows can extend their fellowship to a fourth year for biliary and pancreatic interventional procedures, including enteral stent placement, esophageal endoscopic mucosal resection (EMR), ERCP and endoscopic ultrasound. We currently admit two fellows for this additional training each year. This program has trained many interventional endoscopists practicing in Michigan and elsewhere in the United States.
One of our physicians has an ongoing research grant to identify biomarkers that may help to detect pancreatic cancer at an earlier stage. As part of another multicenter trial, our physicians are collaborating with a group of mechanical engineers to develop a sensor technique to determine stent patency.
M-LINE 800-962-3555 • 21
4,300
Small Bowel Program number of Video Capsule Endoscopy procedures performed in the last decade
Indications for Video Capsule Endoscopy:
Until recently, the small bowel was a difficult part of the gastrointestinal tract to evaluate and treat. Great advances in imaging technology and treatment options over the last decade have improved our ability to help patients living with small bowel diseases.
Obscure gastrointestinal bleeding Iron deficiency anemia Suspected or established Crohn’s disease Polyposis syndrome surveillance Intestinal tumors Celiac disease
The Small Bowel Program at the University of Michigan specializes in the diagnosis and treatment of conditions of the small intestine. We work closely with other specialty services in the Division of Gastroenterology, including the Crohn’s and Colitis Program, to provide state-of-the-art assessment, treatment and care of patients. We offer minimally invasive treatments that are not widely available to diagnose and treat bleeding in the small bowel.
1,500
Our team of gastroenterologists has extensive experience with small bowel procedures and ranks among the country’s best in the field. Our surgeons specialize in small bowel diseases and our pathologists, who review unusual findings on biopsies, have extensive small bowel experience.
number of Double Balloon Enteroscopy procedures performed since 2007
Indications for Double Balloon Enteroscopy: Treatment of bleeding lesions seen on Video Capsule Endoscopy Assessment of abnormal GI imaging or abnormal Video Capsule Endoscopy findings Dilation of small bowel strictures Retrieval of retained foreign objects Localization and marking of lesions prior to surgical resection
The Small Bowel Program conducts ongoing clinical research, particularly in the area of investigating improved techniques for assessing the source of obscure gastrointestinal bleeding. 22 • www.UofMHealth.org/gi
Pill Camera Technology The advent of video capsule endoscopy (VCE) more than a decade ago—the technique used to view the small bowel through the lens of an ingestible pill-sized video capsule—more than a decade ago gave physicians an unprecedented look into the small bowel and opened the door to vastly improved imaging, diagnosis and treatment of its conditions. This device has evolved into the first-line diagnostic tool for evaluation of the small bowel and is indicated for patients with various small bowel conditions including obscure gastrointestinal bleeding or unexplained iron deficiency anemia. VCE is also an essential technique for evaluating cases such as suspected Crohn’s disease or indeterminate colitis. Patients with polyposis syndromes or suspected polyps and tumors can be screened with VCE and avoid more invasive studies.
“ Our primary goal in the Small Bowel Program at U-M is to provide the best, most comprehensive, stateof-the-art care to patients with small bowel diseases and our physicians and staff are committed to this purpose. Because we have highly dedicated and expert doctors with more experience in small bowel procedures than any other institution in the state, we are privileged to be able to offer a unique and focused approach to patients who may benefit from our program.” Laurel R. Fisher, M.D.
The University of Michigan has performed 4,300 capsule endoscopy procedures. This technique may also have use in select patients with celiac disease or unexplained symptoms of pain or diarrhea.
Director, Small Bowel Program
Double Balloon Enteroscopy The University of Michigan performed the first Double Balloon Enteroscopy in the state in 2007 and remains the only center in Michigan that consistently offers this advanced procedure. Double Balloon Enteroscopy is the treatment arm of the Small Bowel Program and more than 1,500 procedures have been completed at U-M. With this procedure, our specialists are able to treat bleeding vessels in the small bowel, obtain tissue for diagnosis, dilate strictures, remove foreign objects and mark locations for future surgical intervention.
Digestive and Liver Health Outcomes 2014 • 23
Multidisciplinary Programs One of the hallmarks of the University of Michigan Health System is our commitment to multidisciplinary care for patients. We work together within our Division and across the Health System to create a holistic, seamless continuum of care for patients with gastrointestinal and liver disorders. Several programs bring together diverse expertise to focus on patients with specific conditions, to streamline their care and to improve their overall experience. Three of our multidisciplinary programs include:
New Patient Consults and Return Visits – Fiscal Year 2013
395 626 478
New Consults
Return Visits
Number of Patients Reviewed by the Liver Tumor Board
24 • The University of Michigan Health System
Multidisciplinary Liver Tumor Program The Multidisciplinary Liver Tumor Program brings together specialists from hepatology, surgery, diagnostic and therapeutic radiology, radiation oncology and medical oncology. This team of specialists evaluates liver tumors, including when there is suspicion of isolated liver malignancy such as primary or secondary liver cancer. The team collaborates to create unified and individualized treatment plans for patients with liver tumors. Treatments we use include liver transplantation, surgical resection, chemoembolization, radioembolization, radiofrequency ablation, external radiation, and systemic chemotherapy. Our program is designed to create the best experience for patients by arranging single-day appointments with the appropriate specialists. We hold weekly tumor boards to discuss the most appropriate treatment for each patient in a multidisciplinary setting. Referring physicians are welcome to attend tumor board meetings and we have begun to offer remote tumor board evaluations for providers at outside centers. The Multidisciplinary Liver Tumor Program offers cutting-edge technologies, such as TheraSphere radioembolization with yttrium-90 particles. We are pioneering stereotactic body radiation therapy (SBRT) for liver cancer and have treated over 125 patients with this noninvasive method; one of the largest experiences in the United States. We are one of a few sites nationwide to perform liver transplantation for cholangiocarcinoma. We also conduct many clinical studies in patients with liver cancer.
Fecal Transplant Program
Michigan Bowel Control Program
The Fecal Transplant Program is a cross-division collaboration between Gastroenterology and Infectious Diseases. Fecal transplants are relatively new, but published reports show that this procedure is an effective treatment for recurrent C. difficile infection, with success rates exceeding 90%.
The Michigan Bowel Control Program is a nationally recognized center of excellence that includes specialists from gastroenterology, urogynecology, colorectal surgery, physical medicine, physical therapy, nutrition and behavioral medicine. Our team provides care for patients with refractory constipation, fecal incontinence and other pelvic floor disorders.
A fecal transplant attempts to restore a patient’s bacteria to healthy levels by introducing donor stool through a standard colonoscopy. This procedure may also help protect against future C. difficile infection. The main focus of the Fecal Transplant Program is to leverage the expertise at the University of Michigan Health System to optimize a safe and effective protocol for this procedure. Potential candidates are identified from our gastroenterology or infectious disease practices. Patients then undergo extensive screening, along with their donor, before the procedure is performed.
Founded in 2005, the Michigan Bowel Control Program began with the recognition that patients with chronic constipation, fecal incontinence and/or urinary incontinence are best served by integrated, multidisciplinary care. Over the years, the program has achieved impressive growth from 50 new patient evaluations in 2005 to 450 new patient evaluations in 2014.
Unique Assets of the Michigan Bowel Control Program: • Dedicated nursing support with specialized expertise in pelvic floor disorders • State-of-the-art GI Physiology and Manometry Laboratory that performs over 4,000 manometric procedures, colonic transit studies and breath tests per year • Expert GI nutrition counseling by registered dietitian • Evidence-based behavioral therapies provided by GI psychologist • Comprehensive physical therapy and biofeedback programs
M-LINE 800-962-3555 • 25
Digestive and Liver Health Physicians Gastroenterology Chung Owyang, M.D. Chief, Division of Gastroenterology and Hepatology Leslie B. Aldrich, M.D. Michelle A. Anderson, M.D., M.S. Alan W. Barbish, M.D. Aarti Oza Bedi, M.D. John M. Carethers, M.D. Joan W. Chen, M.D., M.S. William D. Chey, M.D. Duyen T. Dang, M.D. John Del Valle, M.D. Matthew J. DiMagno, M.D. Grace H. Elta, M.D. Shanti L. Eswaran, M.D. Laurel R. Fisher, M.D. Shail M. Govani, M.D. William L. Hasler, M.D. Tadd K. Hiatt, M.D. Peter D.R. Higgins, M.D., Ph.D., M.S. John Y. Kao, M.D. Albert C. Kim, M.D. Joseph C. Kolars, M.D.
26 • www.UofMHealth.org/gi
Richard Kwon, M.D., M.S. Robert Towner Lapp, M.D. Beth R. Manoogian, M.D. Sean T. McCarthy, M.D. Stacy B. Menees, M.D., M.S. Juanita L. Merchant, M.D., Ph.D. Michelle M. Muza-Moons, M.D., Ph.D. Timothy T. Nostrant, M.D. (Retired) Swati G. Patel, M.D. Anoop Prabhu, M.D. D. Raani Punglia, M.D. Andrew D. Rhim, M.D. Michael D. Rice, M.D. Megan E. Riehl, Psy.D. Rafat S. Rizk, M.D. Joel H. Rubenstein, M.D., M.S. Richard J. Saad, M.D., M.S. Sameer D. Saini, M.D., M.Sc. James M. Scheiman, M.D. Philip S. Schoenfeld, M.D., M.S.Ed., M.Sc. Neil M. Sheth, M.D. Elizabeth K. Speliotes, M.D., Ph.D., M.P.H. Ryan W. Stidham, M.D. Elena M. Stoffel, M.D., M.P.H.
Mimi S. Takami, M.D. Andrea Todisco, M.D. D. Kim Turgeon, M.D. Akbar K. Waljee, M.D., M.Sc. Erik-Jan Wamsteker, M.D. Thomas D. Wang, M.D., Ph.D. John W. Wiley, M.D.
Hepatology Frederick K. Askari, M.D., Ph.D. Hari S. Conjeevaram, M.D., M.S. Robert J. Fontana, M.D. Lisa M. Glass, M.D. Hellan K. Kwon, M.D. Anna S. F. Lok, M.D., F.R.C.P. Neehar Parikh, M.D. Mina K. Rakoski, M.D., M.Sc. Pratima Sharma, M.D., M.S. Grace L. Su, M.D. Andrew W. Tai, M.D., Ph.D.
Lisa Sylvest, R.N. Patient Liaison Lisa Sylvest, R.N. has been in the role as Digestive and Liver Health Patient Liaison since January 2012. Prior to this, Lisa was a nurse with Digestive and Liver Health for 20 years and brings more than 30 years of clinical nursing experience to her role. If you need to know which of our faculty treats a particular diagnosis, performs a particular procedure, or your patient’s condition requires an earlier appointment time, Lisa is available to answer your questions and assist you. She works closely with our scheduling staff to make sure patients are scheduled with the right specialist in the right time frame. Lisa will also review any records required for the visit and work with referring physician offices to gather any additional information needed for the patient’s appointment. If a patient is traveling a long distance to Ann Arbor, Lisa will help coordinate anticipated procedures or referrals to other U-M specialists. To request assistance with a patient call M-LINE at 800-962-3555 or e-mail Lisa at lsherwoo@umich.edu.
To make a referral or speak with one of our specialists, contact M-LINE 24 hours a day, 7 days a week.
M-LINE 800-962-3555 For additional referral information, see the UMHS Health Provider website.
www.UofMHealth.org/provider
Rob Simsick Physician Liaison The University of Michigan Health System Physician Liaison team is dedicated to providing personalized service to community-based physicians. Rob Simsick serves as the U-M Digestive Health and Adult Liver Transplant primary liaison and is available to visit community-based physicians’ practices. He will work to understand each practice’s patient care needs and will share information on services, treatment options and clinical trials from the many specialty clinics within the Division of Gastroenterology. He can also facilitate outreach opportunities by our clinical faculty. Our goal is to improve the coordination of care for you and your patients. If you would like Rob to contact you, please call M-LINE at 800-962-3555 or e-mail him at rsimsick@umich.edu.
Digestive and Liver Health Outcomes 2014 • 27
Locations University of Michigan Division of Gastroenterology provides patient-centered, collaborative medical care at a variety of hospitals, health centers and outpatient clinics in Michigan. For more information about the locations listed below, visit www.UofMHealth.org/our-locations. Ann Arbor U-M A. Alfred Taubman Health Care Center
Brighton U-M Brighton Health Center
Livonia U-M Livonia Center for Specialty Care
U-M Briarwood Health Associates
Canton U-M Canton Health Center
Northville U-M Northville Health Center
Dexter U-M Dexter Health Center
Saline U-M Saline Health Center
U-M Comprehensive Cancer Center U-M Domino’s Farms – Colorectal Cancer Genetics Clinic U-M East Ann Arbor Health and Geriatrics Center Veterans Affairs Ann Arbor Healthcare System
28 • The University of Michigan Health System
Grand Rapids St. Mary’s Health Care – University of Michigan Health System Advanced Hepatology Outreach Clinic
Executive Officers of the University of Michigan Health System Marschall S. Runge, M.D., Ph.D., Executive Vice President for Medical Affairs James O. Woolliscroft, M.D., Dean, U-M Medical School T. Anthony Denton, J.D., MHA, Acting Chief Executive Officer, U-M Hospitals and Health Centers Kathleen Potempa, Ph.D., Dean, School of Nursing
The Regents of the University of Michigan Michael J. Behm Mark J. Bernstein Laurence B. Deitch Shauna Ryder Diggs Denise Ilitch Andrea Fischer Newman Andrew C. Richner Katherine E. White Mark S. Schlissel (ex officio)
The University of Michigan, as an equal opportunity/affirmative action employer, complies with all applicable federal and state laws regarding nondiscrimination and affirmative action. The University of Michigan is committed to a policy of equal opportunity for all persons and does not discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, height, weight, or veteran status in employment, educational programs and activities, and admissions. Inquiries or complaints may be addressed to the Senior Director for Institutional Equity, and Title IX/Section 504/ADA Coordinator, Office for Institutional Equity, 2072 Administrative Services Building, Ann Arbor, Michigan 48109-1432, 734-763-0235, TTY 734-647-1388, institutional.equity@umich.edu. For other University of Michigan information call 734-764-1817. © 2015 Regents of the University of Michigan.
To make a referral or speak with one of our specialists, contact M-LINE 24 hours a day, 7 days a week.
M-LINE • 800-962-3555 For additional referral information, see the UMHS Health Provider website:
www.med.umich.edu/umhs/health-providers www.UofMHealth.org/gi