Letter From The Doctor

Welcome to my world of gastroenterology!

I have been in private practice since 1991, specializing in gastrointestinal disorders. I am a Board Certified Internist and Gastroenterologist.

As an Attending in Gastroenterology, my hospital affiliations in New York City include: Lenox Hill Hospital, Beth Israel Medical Center and New York University Medical Center. I hold a position as Clinical Assistant Professor of Medicine at New York Medical College. Additionally, I am associated with the Kips Bay Endoscopy Center, a state-of-the-art endoscopic facility where most out-patient procedures are performed.

I practice "old-fashioned" medicine combined with the latest of technology. When you come to my office for an appointment, you are seen by me personally and not a nurse or physician's assistant. My staff and I make every attempt to insure quality and continuity of care.

There are two practice locations, 80 5th Ave in New York City and in Poughkeepsie, New York located 75 mile north of the metropolitan area in the beautiful Mid-Hudson Valley. While my practice mainly serves the New York metropolitan and surrounding tri-state areas, I welcome patients from all over the globe. Accommodations can be arranged in coordination with visits and testing.

Offices are equipped with state-of-the-art medical instruments including video endoscopic equipment, breath testing for lactose intolerance and bacterial overgrowth, ambulatory acid and nonacid reflux monitoring (Sleuth-Zephyr Impedance System) for gastroesophageal reflux, infrared coagulation for the nonsurgical treatment of hemorrhoids, as well as colon cancer screening by colonoscopy.

While While my primary interest is in reflux disease (a.k.a. GERD, heartburn), I do manage a broad spectrum of gastrointestinal disorders. I offer incisionless, surgical procedures to control reflux such as the EsophyX TIF (Transoral Incisionless Fundoplication) and EndoCinch. Additionally, I offer the BARRX radiofrequency ablation therapy and endoscopic mucosal restection (EMR) to treat the premalignant condition of Barrett's Esophagus. The newer endoscopic assisted, incisionless surgical procedures are changing the way we manage the chronic reflux patient that is not always controlled by the usual medicines. I also work very hard to make the diagnosis of difficult to treat reflux as well as atypical reflux.

Should you have any questions or wish to schedule a visit, feel free to contact me.

Sincerely,
A.A. Starpoli, MD

View Dr. Starpoli's Resume!

Everyone occasionally has heartburn. This occurs when stomach acid flows backward into the esophagus, the food pipe that carries food to the stomach. People usually experience heartburn after meals as a burning sensation or pain behind the breast bone. Often, regurgitation of food and bitter-tasting stomach acid accompanies heartburn. Antacids or milk temporarily relieves heartburn for most people.

Why Does Heartburn Occur?
To understand heartburn, let us look at the body's anatomy. The esophagus carries food and liquid to the stomach. A sphincter, or muscular valve, is located at the end of the esophagus at the border between the esophagus and stomach. Known as the lower esophageal sphincter (LES) this muscle contracts much the same as the anus does. The sphincter should maintain a certain pressure to keep the end of the esophagus closed so that stomach juices are not admitted. The LES muscle should only open when food is passed into the stomach.

However, the LES muscle does not always work perfectly. It is felt that the problem is with inappropriate, transient relaxations of this sphincter valve that result in reflux. Sphincter function can be easily overcome by a number of factors, the most common being eating a large meal. Along with swallowed air, a large meal causes an upward pressure in the stomach to rise, thereby overpowering the LES muscle. Other factors that reduce the LES pressure and allow reflux are:

• Nicotine (cigarettes)
• Fried or fatty foods
• Chocolate
• Coffee
• Citrus fruits and juices
• Peppermint
• Pregnancy
• Lying flat
• Hiatus hernia
• Certain prescription medications

Swallowing difficulty, medically termed dysphagia, can arise for a variety of reasons.  Firstly, reflux alone can disturb the muscular contraction or motility of the esophagus and interfere with the passage of liquids and solids.  Often, when reflux is controlled, these symptoms will disappear.

The inflammatory response of the esophagus from chronic reflux can lead to the formation of a ring of scar tissue at the end of the esophagus where it meets the stomach, an area know as the gastroesophageal junction (the location of the LES), that can lead to a mechanical obstruction causing difficultywith swallowing solids.  This entity is known as an esophageal ring or a Schatzki Ring.  In some cases the ring needs to be disrupted in order to resolve the blockage.

Of course with chronic reflux comes the risk of esophageal cancer and although the risk is low, it is very real.  Such tumors can cause significant blockage and bleeding.  The cancers are diagnosed most often by way of video upper endoscopy.  A person presenting with new-onset swallowing trouble, a history of reflux, bleeding, and weight loss should seek a medical evaluation immediately.

There are a variety of primary esophageal motility disorders that cause swallowing trouble.  Achalasia is a disorder that can be quite insidious and involves that loss of motility in the body of the esophagus and the lower esophageal sphincter (LES)fails to relax.  The physical presentation can look like reflux because the patient does not clear contents of the esophagus and those materials can backwash into the upper esophagus and mimic GERD. The diagnosis of Achalasia is made by way of esophageal manometry whereby the wave forms  of the esophagus are measured to make the diagnosis.  Achalasia can be treated surgically (laparoscopically) or by balloon dilation of the lower sphincter.

There are other esophageal motility disorders that can be described by esophageal manometry and they include diffuse esophageal spasm that is often associated wit noncardiac chest pain, the Nutcracker esophagus, and Ineffective Esophageal Motility.  Esophageal motility studies ( manometry) will require the passage of a small caliber tube into the esophagus through a nasal passage.  The test takes about 20-30 minutes to complete and is well-tolerated.  It is performed as an out-patient.