The Smartest Pill You’ll Ever Swallow​

The Smartest Pill You’ll Ever Swallow. 

There’s a breakthrough brewing in the world of medicine – smart pills. This time, Brendan will help make this mind-blowing micro technology “easier to swallow” with the help of Dr. Peyton Berookim of the Gastroenterology Clinic of Southern California. Smart pills help medical teams capture and unlock mountains of additional data about what’s going on in largely unexplored intestinal tracts. Listen in as Brendan and Dr. Berookim discuss the implications of the smart pill technology and how going from reactive to proactive & preventive care is key to the future health of all humans.

Transcript

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Hello everyone, and welcome to. That's understandable. I'm your host, Brendan McEvoy, US head of External Communications at AstraZeneca. If this podcast has been enjoyable and informative for you, take a moment to like and follow on your favorite streaming service. And if you know anyone else interested in today's topic, be sure to share, because our goal is to help everyone to better understand what science can do when we all work together. It's a common theme in children's education shows. The main character is learning about the digestive system when they suddenly shrink down, small enough to investigate inside the body. During their trip, they discover a blockage in the esophagus or learn about a condition in the small intestine, gaining a new, deeper understanding of the inner workings of the human body. Before exiting and sharing what they've learned with the audience. Sounds farfetched right? But with advances in technology, this fantastic journey is actually very real. No, I'm not talking about shrinking doctors, but thanks to ingestible cameras, healthcare providers can now view the inner workings of the human body without an invasive procedure through the use of what is known as smart pills. Smart pills are a class of digital health tools that travel through the gastrointestinal or GI tract to help health care providers and diagnosis, treatment, and even surgery, providing real time, detailed information on a patient's GI tract health. That's a lot to digest, but fortunately, here to help us is our guest, Doctor Peyton Berookim, a gastroenterologist with the Gastroenterology Clinic of Southern California. With nearly 20 years of experience in diagnosing and treating conditions of the GI tract and liver. Welcome to. That's understandable, Doctor Berookim, Brendan, thank you for having me. Absolutely. So we've got quite the topic to talk about, so I'm not going to waste any time. I shared in the upfront there that the title of today's episode is The Smartest Pill You'll Ever Swallow, and it comes from something you said in an earlier conversation we had, making you the perfect person to ask, what makes these pills so smart, and how do they even work these smart pill capsules are truly the smartest pill you're ever swallow. There are various capsules designed for examining the, different aspects of the gastrointestinal tract. We have one capsule that's designed for the esophagus and the stomach. there's another capsule for the, small intestine, and we have a different one for the large intestine, also known as the colon. And depending on which capsule we use, the recording times vary anywhere from 30 minutes to 8 hours, depending on which capsule they're swallowing, the esophagus being the shortest and the colon being the longest. Study. so typically patients would come to the office first thing in the morning. We, have them wear a recording device. they swallow one of these pills. they leave the office, they come back about eight hours later, and they give back the recording device to us. That needs to be downloaded. And as these capsules traverse through the small bowel, they're taking multiple images for a second. So after the eight hour period, there's approximately 15,000 pictures or so, for me to review in hopes of maybe answering some of the medical questions we're looking for. the good news is, these are one time capsules, so they do not have to be retrieved. they pass naturally and get flushed away. now, over the years, with the advancement of technology, the smart pills have become even smarter. So think about the smart phone you had 15 years ago. Now think about the smartphone that you have today. How everything is better, smaller, faster. it's a completely different device. Similarly, the pictures of the smart pills, become sharper, clearer. they have improved the camera angles. so they're now a little wider, allowing more surface area visualization and, decreasing the chance of possibly missing something. and the software has become more advanced. So, as I mentioned, the capsule is traveling through the small bowel is taking multiple pictures per second. So if it gets delayed in an area, there's going to be a lot of, repetitive photos. but now the software is able to remove those repetitive photos, shortening the video. So when we go to review it, it's more of a condensed, more efficient study. to read. They've been great before and, have become even better. Awesome. Thanks. Thanks for that. that explanation and kind of setting us up. I know where it's an audio only podcast. but can you give us a sense of the size? So, like, you know, in comparison to maybe pills that were familiar with taking, how would you describe sort of the size of the different pills? So they're all similar in size. They're approximately the size of a multivitamin, maybe about an inch in height and a little narrower and width. They're round, they're smooth. They're very easy, to swallow. so we haven't had any issues. So in your, in your practice, how often are you using something like this? Well, I've been using this technology in my practice for over 15 years and I actually use it frequently. for example, our traditional upper endoscopy can only see approximately the first six inches of the small bowel, and a traditional colonoscopy can evaluate the last six inches of the small bowel. But the small bowel is about 21ft in length. So, the small pill is the perfect tool to evaluate the remaining 20ft, as a possible side of blood loss or whatever we're looking for. also, you know, at times patients may not be a good candidate for sedation, where anesthesia may be a risk. And for these patients, the pill cam again would be a, great alternative if, many patients happen to be on blood thinners. And when undergoing the traditional upper endoscopy or colonoscopy, these medications need to be discontinued, because of the potential increase in, bleeding. And these patients are on these medications because they may have had a prior history of blood clots, or they may have an irregular heartbeat. And stopping them, can put them at risk of developing a new clot. And again, the pill cam would be a good choice for patients in that situation. And what sort of reactions do you get from a patient when you tell them that they're they're going to swallow a camera, if you will? Are they, you know, apprehensive or what sort of the typical reaction? So when I explain the procedure to them, I usually show them a sample. it's a pretty, jaw drop in reaction. it's very futuristic. they're very excited. And at the same time, they're also very relieved when I let them know that the capsule is and have to be retrieved. So, but patients are always willing to do it when they're excited to do it. And I guess, you know, you know, you shared just a few minutes ago, you know, some of the benefits in, in using this is smart pill over some other diagnostic tools in terms of being able to, obviously get more capture, more information, than traditional the traditional, tools, if you will. But, are there any, you know, drawbacks or concerns in, in using this type of technology in comparison to others? Sure. I think the may main drawback is that the capsule cannot obtain any buffs. Since this is a video recording. there's also a higher chance of the camera missing a pull, potential pathology over your traditional procedures. When you're doing an endoscopy, you can bring the scope, you know, back and forth, change the angle. this is a video. So if the capsule passes an area, there's no way of really, you know, when you're rewinding the capsule to reexamine an area that it missed. It's also important to know that the smart pills should not be used in anyone suspecting any narrowing or stricture of their digestive track, because the camera can get stuck. These capsules do contain batteries. so if they do get stuck, they do have to be removed non surgically. This might not be, you know, super relevant, but in that scenario, you know, if you if you sort of see something or like, you know capture something but you're not quite sure with the next step be to do you know, do it the more traditional and just copy or would it be to like would you have the, the patient swallow another, smart pill? Good question. So if we identify something on the smart pill, if it's in the esophagus, you do your traditional endoscopy. If it's the colon, they do the traditional colonoscopy. It's the small bowel. It's a little trickier. So depending on if it's an upper half of the small bile or the lower half, there is a procedure called a double balloon. So it's a different technique. It takes several hours to do. It's not as simple as and endoscopy or colonoscopy. So we go either from up top and try to reach that lesion and then try to take a biopsy to see if it's malignant. and if so then we schedule patients for surgery to have that area resected. So either going from up top with a double balloon or doing a retrograde double balloon from below, you can, try to reach where the pathology is and then confirm if it's something that needs to be removed or not. Okay. Are there any limitations on the frequency in which a patient could, you know, I'm thinking like, is this something that a patient could could smart swallow a smart, smart pill on a yearly basis as a, you know, tool? Or is there any sort of limitations in the in that frequency, I guess is what what I'm getting at. We we do run into patients with obscure GI bleeding and we do an upper endoscopy. We do a call and ask if we can't find anything. We do a capsule, we can't find anything. And unfortunately, sometimes these patients go through numerous procedures, including numerous capsules. to figure out where the source is. Because sometimes if you're not doing the capsule at the time of the bleeding, you're going to miss it because a lot of times these are lesions that bleed temporarily and then they stop. So when we go in there we don't see it. And then they resurface the bleed. And then patients end up in the emergency room again. And we do endoscopy. Call an alcove. It's normal. Do another capsule. So I've seen patients go to a several rounds of these and sometimes we still can't find the source. Believe it or not. It was interesting to hear the advantages and limitations this technology presented in a practice like Doctor Berookim’s, he mentioned there were benefits to the patient and provider, and I wanted to know specifically how this technology helped patients. One of the things, as you were talking about benefits earlier, I had, and when we were chatting in sort of the pre, you know, our pre meeting, if you up to this, I believe you were also talking about some benefits from a medication adherence or maybe the ability to, to determine could you just shed a little bit more light on on that benefit. Sure. So the the smart pill plays an important role in like monitoring patients, response to therapy. For example, I've diagnosed numerous patients with, Crohn's disease or inflammatory bowel disease. by using this camera, they swallowed the camera. you know, their upper endoscopy, your colonoscopy, the normal were suspecting something's going on in a small bowel where they swallow the video camera, and the camera identifies ulcers in the lining of the small bowel. And it gives us our diagnosis of Crohn's disease. we then start patients on the appropriate medications many times they're doing well. Sometimes patients may still, clinically have symptoms. And, we have them repeat the capsule. Maybe 6 or 7 months later, to go back and review and see, you know, confirms to also seven resolves. Have they improved? So it lets us know that therapy is working. so we don't just rely on their symptoms, but we also confirm mucosal healing, which is very important. Okay. One of the questions that, you know, oftentimes with any sort of health care procedure or anything like that is, is obviously, maybe it's the topic of cost. Right? So is there it does it is there any sort of significant differentiator? you know, putting aside the potential better benefit of or, you know, the more information captured, is there in terms of a patient perspective? And, you know, I know it varies based on, you know, insurance and coverage and things like that. But is there a significant difference in cost for the, in using a smart pill versus a more traditional or sort of less intelligent diagnostic tool? Well, the standard endoscopy is a very intelligent, you know, but when we do endoscopy and colonoscopy, you got to keep in mind these are not done in the office and done at the surgery center. So that has the cost of the surgery center, cost of anesthesia. so it can actually be more expensive if you consider all that. but patients have to be aware sometimes insurance doesn't cover these capsules. They may have to pay out of pocket. And then keep in mind, if they do a capsule again it's a video. So if it identifies something then they need to go and do the traditional endoscopy to maybe take a biopsy to sample it to see is it cancer. so they may end up having to do both procedures. But there's definitely an important role where these capsules, you know, play a role for patients, not for everyone. Okay. And and you know, I was thinking to put it in sort of practical terms that it actually what you just shared there because I wasn't thinking about sort of a having to go to a surgical center for, you know, a traditional diagnostic procedure versus using the smart pill. So if we, if we think about it, comparisons to maybe the traditional colonoscopy versus something like this, do I know oftentimes the a lot of people say the hardest part of a colonoscopy is the prep work and things like that. Would a patient still undergo, you know, some sort of prep work prior to using the smart pill? Great question. absolutely. So yeah, the colon has to be super clean. So we can see, because this is a video, the colon cleanse is actually a little bit more aggressive because we need to make sure that it is clean as a whistle. during a colon housekeeping, we're able to flush and wash and rinse, where we can't do that with this. I mean, I want to be clear. The colonoscopy is still the gold standard for colorectal cancer screening. but for, you know, patients who are maybe apprehensive of having the procedure done for whatever reason, whether it's the stigma of it, whether they don't want to be sedated. the colon asked that the colon Powell would be, you know, a viable option. But the colonoscopy is the gold standard. and yes, patients have to still fast and get cleaned out, like a typical colonoscopy. Okay. And this might be a silly question, but how did you know? And you talked about sort of the obviously the different types of pills based on, you know, where they're trying to, you so capture information from is it and this is where my, you know, lack of knowledge in the human body is, is it in the pill? I guess essentially, regardless of the pill, it's it follows the same track, if you will, through the body and the longevity of the pill. And it's is is how it the amount of information it's able to capture. Right. It's not that like the pills is finding its way to, you know, a specific part of the body. Is that accurate. So you're right, the pill has to go through the same track. They swallow it, it goes down the esophagus in for looking for pathology in the esophagus. Those pills have two cameras one on each. And so you're getting more pictures because it's a shorter track. We need those images. and they pass through the stomach. And, usually that's what we're looking for. The technology is different with each pill. The small bile pill is really designed for looking at inflammation in the small intestine. So obviously, in order to get to the small intestine, it has to pass the esophagus in the stomach. So we do get images, but not to the detailed extent that an esophageal pill would give us. And then the colon pill is a little different. The battery life has to be longer because it has to reach the colon, and then you have to, you know, it has to be viable enough to get excrete treated, that sometimes patients have to take certain medications to help push the capsule further down to speed up the transit time. So it doesn't give you a great picture for the small bowel. So every capsule does go down the same track, but they're functions a little bit differently. Had to obtain that data to provide us better data okay. And is there certain are there certain patient populations where where this maybe isn't preferred or maybe is preferred over traditional measures? Yeah. Then I guess there are certain cultures and the the stigma of doing a colonoscopy are greater. But I think over the years the education, showing the importance of undergoing a screening. All I'm asking for you, I think the message is finally getting through where, everybody understands that it's an important screening. and I'd like to point out, because I get this asked often, sometimes my female patients ask me, the woman need to do a colonoscopy. And the answer is absolutely yes. if you have a colon, you are at risk of developing colon cancer. I think it's the, idea because the cameras go into the rectum and they think rectal prostate exam. So patients get confused. But every male and female over the age of 45 should undergo some sort of screening for colorectal cancer. Listening to Doctor Berookim’s answers. I could tell how important it is for him to give patients an alternative to more invasive techniques, and just how valuable smart pills are to his practice. With that in mind, I wanted to see how he thought this technology could continue to improve. There was a study by the University of California that showed, an AI algorithm could predict inflammatory bowel disease development in 86% of cases using data from smart pills. Do you think AI and smart pill data could be used to proactively screen for other conditions? Absolutely. one or more common uses of the smart pill is actually for the diagnosis and monitoring. inflammatory bowel disease. As I mentioned earlier, the software is getting, smarter. So currently, when the capsule goes through the software, me mark off certain pictures and it thinks it's a normal and we do get a lot of false returns, false negatives. And I think adding I can probably, better identify any real pathology to market, including colon cancer. So the doctors still have to review it. But if you have another AI AI to see, you know, for better charges reviewing this. So after we read this study, we go back and see if there is something they suggest. and I think that's in the works. so, you know, the colon pill right now is in the market and can be used for colon cancer screening. And the purpose of the colon pill is to identify the presence or absence of polyps, polyps or abnormal growths that typically turn into cancer. So, this is a way of identifying if there are polyps present. again, this is just a video. So if a polyp is identified, the patient will need to undergo a traditional colonoscopy to have it reviewed. But absolutely these smart pills are always used for inflammatory bowel disease or available for colon cancer screening and other things as well. And we're talking a lot about the, sort of in diagnosis as a diagnosis or diagnostic tool. Are there applications in actually treating GI disorders as well? So you mean what we're looking for? I mean, a lot of patients, they may have unexplained blood loss from their digestive tract. Right. So they undergo maybe a traditional upper endoscopy and a colonoscopy. and, we don't see anything. And then the small bowel, the smart pills can help us in identifying maybe the cause of the various medical issues. I've had numerous patients with unexplained blood loss, and these capsule has identified maybe cancers of the small bowel, ulcers in the stomach, ulcers in the small bowel. a really interesting story. Several years ago, I had a 90 plus year old, patient she's brought to my office by, her daughter. She wasn't really eating like she used to. She's had significant weight loss. Daughter was concerned. Something's going on. her doctors just told her. You know, your mom's old or older, so obviously she's not going to eat as much as she normally would. so, you know, I talked to this patient. She's previously healthy, so it didn't make any sense to me that this is an age related issue. I asked a patient if she has pain with swallowing, and, she said yes, so that let me know that there's some sort of problem with the esophagus. I scheduled her, had a swallow, one of the esophageal pills, and it showed that she had, candida or fungus throughout her entire esophagus. I treat her with a short course of antifungals. Her discomfort resolved. She started eating again, you know, gained most of her weight back, and, everything was back to normal. You know, this is a patient that I would be risky for me to sedate in the office. so this technology allowed me to come up with the right diagnosis and, it was so gratifying to see her do well. And, I'm still receiving holiday cards from her daughter, so. That's nice. it's very cool. Yeah, it. You know, we talked about, you know, some of the different, you know, potential conditions that that the smart pill can help, you know, identify or help diagnose. And we, you know, you shared about sort of the, colonoscopies and sort of the, the recommended guidelines of I believe you said over 45. Yeah. We obviously are always trying to bring useful information. In addition to, of course, informing people about smart pills and, and how that technology is, is sort of unlocking additional insights. Are there other sort of, useful information or like screening tips that you would suggest or, like what would be the most common or regular reason why a, a patient may come in for some sort of screening or diagnosis beyond? I guess I'd say beyond sort of a colonoscopy. So in my field, the most common call, indication of screening is colon cancer screening. So it used to be 50 years of age. Now it's 45. we don't know why there has been an increased risk of, or I should say increased incidence of colorectal cancer in, people aged 45 to 50. So for that reason, they've lowered the, guidelines of 45. fortunately, I don't diagnose myself too many young patients with colon cancer. But I do hear, about a lot of cases where a patient may come to my office, say, you know, my colleague, my boss, my cousin, my best friend just got diagnosed with stage four colon cancer and sometimes are under the age of 40. So it's very frightening. so we the society, we encourage everyone to get screened and I think we're doing a better job of doing that. and then I also try to see patients have, like, a family history of, other cancers that may warrant having them do, genetic testing, you know, to see if they're a carrier for any particular cancers. So that's important. We do a lot of upper endoscopy for different reasons. Patients with chronic heartburn are at risk of developing, esophageal cancer. So if they've had heartburn, heartburn for 15 plus years, having an upper endoscopy is important to screen for esophageal cancer. patients obviously have symptoms of unexplained abdominal pain, trouble swallowing. We do. And asking you to make sure, it's not cancer or something that can be treated. So we have a lot of ways of diagnosing things. And, you know, these, smart pills just add to our arsenal. When you think about your your practice in this space, maybe, you know, prior to the smart co being introduced to now to maybe even what you envision for the future. Tell me a little bit about like how you know, as you've as you evolve from sort of free smart pills to now like what what like what is change for you or like, as you think about, you know, what what sort of new information, new insights have or unlocked that you think might even be taking to the next level as, as this technology evolves even further. So I was introduced to the smart pill during my training. So ever since I've been in practice, it's been available. But I know before the smart pill to for example, to validate the small intestines, patients would have had to undergone surgery. So now we're eliminating unnecessary surgeries by having them swallow a video camera. but medicine is evolving. You know, we're learning more about different, disease entities. And, you know, whether it's a blood test, genetic testing to figure out where the problem was, the and allow us to kind of focus on that screening, to rule in or rule out a specific illness. Before we wrap up our conversation. So I just want to go back and again give you the opportunity. If there's anything that you think would be helpful. Anything that we missed out in this conversation around the smart pill or anything like that, I just want to make sure that you have the opportunity to to share it with, with the audience. Yeah, I just I think patients should be well educated with what's going on. it's important to rely on your physicians, but I think patients need to be their own advocate and know about what's available in different fields. So, sometimes you have to get a second opinion. if your guts telling you something is wrong and that you're told everything is normal, you have to get a second opinion and see if there are other technologies, methods of identifying if something is going going on. So I think, with the internet today, there's information available to everybody at our fingertips. So it allows us more than ever to self educate and know what the next step may be. Yeah. Now that's a that's a great reminder about the importance of being your own advocate seeking the information. I think you're right. There might be some some patients might be or, you know, hesitant to, you know, seek multiple opinions, you know, or, you know, obviously some cults sometimes even that there's a fear or discomfort and even seeking one opinion. So it's a great it's a great it's a great reminder to really be your advocate. Take the information you need to get the get the questions that you have answered. What about, I guess sort of my, my final question would be, you know. Yeah, I'm sure there you have peers out there that maybe haven't, you know, peer physicians out there who haven't incorporated smart pills into their practice, maybe have some apprehensions. Is there anything or any anything you'd say to them that you know from your perspective? If they haven't, that maybe they should? Can you know, any reasons why? or advice or, thoughts on and why they should consider incorporating smart pills into their practice? I mean, I personally think it's important for every physician, to be up to date with the latest and greatest technology in whatever field they specialize in it. the smart pills are an absolute necessity for any GI practice. And I think physicians who are not trained to perform or read these studies, they should at least refer their patients to a facility that does perform this. Who's comfortable with doing this? you know, my nine year old patient that I just mentioned, if I didn't have this tool, she'd be at high risk for doing an endoscopy. I mean, I and, I don't know what I would do. but, I was able to diagnose her in my office without having to sedate or taking her surgery center. so I think it's necessary. you know, I'll give you another perfect example why GI should incorporate this technology. few years back, I had a gentleman who came to my office for a colon capsule, study rather than doing the traditional colonoscopy. And, you know, with every patient, I explained the pros and cons of every procedure. I reminded him, hey, you know, the colonoscopy is still the gold standard, and, that's what I recommend. well, this patient happened to be a former I.V. drug user. You know, he'd been clean for over 30 years, and he was afraid of getting any form of narcotic medication, you know, for sedation, fearing it may trigger his former, addiction. So he had a valid point. And we proceeded with the smart pill. And thankfully, it was, normal. So you didn't have to undergo the traditional colonoscopy. again, I think these smart pills are, you know, an important arsenal for any GI practice. And if someone's not familiar with it, it's never too late to educate yourself. And, if there's any apprehension, know that they're available and refer them to a colleague who has these technologies, available for their patients. Thank you. Doctor Berookim. to put sort of a fine point on this episode, I can tell how beneficial this smart pill technology is not just to a health care provider like yourself, but to patients as well, from those who can't undergo anesthesia for health or personal reasons. To those who are maybe nervous about more traditional methods, these smart pills can really give you another tool that can achieve the scientific and medical process you need while keeping patients at ease and ultimately as healthy as possible. Yeah, we're just here to, you know, offer help. So, whatever extra tools we've got makes our job easier. Yeah. Fantastic. Well, Doctor Berookim, thank you so much for your time. This has been really insightful to, you know, to learn about smart pills, this technology, how it's being used. So, yeah, again, thank you. I'm. I know this will it's helpful to me. Informative. So I'm sure it will be helpful and informative to our audience as well. My pleasure. Thank you. The potential of these devices seems incredible and it can be a lot for us to take in. I'm grateful for experts like you and others who can share their experience and expertise to help us break down barriers to our understanding of technologies like this one, and equip us to be more active participants in our own health care journeys. You certainly helped us learn more about the benefits and made us a little smarter about smart pills. Thanks again for joining us. On That's Understandable. For more information about today's episode, be sure to check the show notes. Until next time, be well, be healthy, Be understanding.