Johns Hopkins Magazine -- April 1997
Johns Hopkins Magazine

APRIL 1997




H E A L T H    A N D    M E D I C I N E

Helping Patients to Maintain Their Dignity

The digestive system, it is probably fair to say, is not among the topics etiquette experts recommend for breaking nervous lulls in dinner party conversation. "Did I ever tell you about my incontinence?" is not an icebreaker.

"G.I. problems are awkward," says Marvin Schuster. "People view it as a very primitive problem. Our first lesson in socialization and self-control is potty training."

Schuster unabashedly addresses such issues. After all, he's co-authored a book on fecal incontinence (Keeping Control: Understanding and Overcoming Fecal Incontinence, Johns Hopkins University Press). While not a bestseller, it is the definitive work on the subject, featuring techniques pioneered by Schuster that are the only alternative to diapers or surgery for many of the 5 percent of Americans with fecal incontinence.

Schuster, who is president of the American College of Gastroenterology, has also conducted numerous studies on gastrointestinal disorders ranging from uncontrollable reflux to paralysis of the stomach. Last fall, he became the first director of the new Gastrointestinal Motility and Digestive Disorders Center, a research and patient care facility at the Johns Hopkins Bayview Medical Campus.

Among his patients, Schuster is most famous for his compassion, for helping patients maintain their dignity while confronting symptoms that can be humilitating and socially stigmatizing.

Schuster is a psychiatrist as well as a gastroenterologist, and much of his research combines the two fields. "Probably in no other organ system is there a more intricate relationship than that between the gastrointestinal tract and the mind," he notes.

It was through his interest in psychiatry that Schuster decided to test the unconventional technique known as biofeedback in treating certain gastrointestinal disorders.

In 1974, Schuster slid a catheter through his nose and down his throat all the way to his lower esophageal sphincter (LES). The LES is a muscle that prevents the stomach's contents from refluxing back up into the esophagus. In a disease called gastroesophageal reflux, the LES fails, and patients experience symptoms ranging from heartburn to uncontrollable vomiting.

At the end of the catheter, a pressure transducer measured the pressure of Schuster's LES. That information was then displayed on a meter, which Schuster watched while he tried to learn how to contract and relax his LES. "My job was to make the needle go up," he says.

Medical tradition said it could not be done. The LES is under control of the autonomic, or involuntary nervous system. In other words, it works independently, contracting when the stomach contains food.

Nevertheless, Schuster managed to contract his LES. "It was a lot of work. I ended up sweating," he recalls. But after some practice, he got it. Within an hour, he learned to double the pressure readout.

Schuster has since tested biofeedback for controlling several other sphincters, and always experiments on himself first. He struggles for words to describe how biofeedback works. "It's almost by insight," he says.

Schuster does not prescribe biofeedback for patients with gastroesophageal reflux, however, since there are now medications that work just as well. But biofeedback is still unsurpassed for one GI disorder: fecal incontinence.

Patients from all over the world have visited Schuster to gain (or regain) control of the external sphincter that enables continence. Seventy percent of patients with severe daily incontinence master the technique, some within a single 30-minute session. Many say biofeedback has been a miracle.

"We had an 18-year-old girl, very pretty, who had not been continent a day in her life," says Schuster. "Her doctors were thinking of doing a colostomy, a surgical procedure in which a permanent opening is made to the colon through the abdomen, where a bag is attached to collect waste. "Within one session with us, she was continent, and she's been fine since then." -- MH