Meet AGA’s Future President: Passionate about AGA and the Renaissance in Gastroenterology
Michael Camilleri, MD, AGAF
Vice President, AGA Institute; Mayo Clinic College of Medicine, Rochester, MN
I make no apology in claiming that the focus of my passion, clinical work and research is neither trendy, nor easy, nor popular among fellows and gastroenterologists. Yet, functional GI and motility disorders are arguably one of the most relevant groups of disorders bringing patients to gastroenterologists. Some estimate that they account for 50 percent of consultations to gastroenterologists and 25 percent of visits to primary care physicians. There is unmet clinical need, large indirect costs, absenteeism or presenteeism for patients, as well as a “heart sinking” feeling for doctors encountering these patients. Progress in this field has been difficult, and the speed bumps have included focus on symptom-based diagnosis rather than understanding of patho-physiological mechanisms, excessive regulatory focus on patient response outcomes, and lack of funding.
However, I perceive that my own experience has paved the way to shape how clinicians diagnose and care for patients with gastroparesis, dyspepsia, IBS, chronic constipation and diarrhea, and has helped to develop the drugs that are used widely in practice today.
AGA Research Funding Enables Renaissance in IBS Understanding
With research funding from the AGA Research Foundation, my team at the Mayo Clinic has made significant strides in applied, patient-oriented gastroenterology research. In 1992, I received a grant from the AGA Research Foundation and used those resources to develop noninvasive imaging methods to study patho-physiology and to understand mechanisms that modify motor functions of the stomach, small bowel and colon. With these crucial validation studies, our research and diagnostic tests in the field of motility no longer depended on the passage of tubes down the throat, which was uncomfortable, invasive and sometimes so stressful that the observed changes might have been attributable to the psycho-sensory perturbation rather than the disease state.
We introduced these gamma scintigraphic methods into clinical practice and used these measurements as biomarkers of disease and response to therapies in development for colonic motility disorders or IBS. We predicted correctly (current count 12 for 12) which drugs would go on to regulatory approval and marketing, and those which did not make the grade in clinical trials. The approved drugs are: LOTRONEX®, Zelnorm®, Amitiza, LINZESS™ and RESOLOR®.
Subsequently, a method was developed and validated to measure gastric volumes noninvasively, and we introduced these tests into clinical practice to assess symptoms of dyspepsia and gastroparesis.
With these validated measurements, I was fortunate to receive funding from NIH to study adrenergic and genetic mechanisms in the control of motor, sensory and autonomic functions in IBS, and the genetic control of gastric motor functions and satiation in obesity.
I was then at a crossroads in my career: I wanted to start to understand the intraluminal and mucosal factors involved in IBS. Fortunately, I received the AGA-Miles & Shirley Fiterman Foundation Joseph B. Kirsner Award for Distinguished Achievement in Clinical Research in Gastroenterology. I was deeply honored to receive this award in the presence of Dr. Kirsner, arguably one of the giants of patient-oriented research in the last century. This award allowed us to investigate intraluminal content (initially bile acids and, more recently, short chain fatty acids and the microbiome) and mucosal barrier and immune functions in order to complement the studies of motility and sensation and comprehensively explore the peripheral functions that could be altered in IBS. As an integrative physiologist, I believe that understanding the inter-relationships of these diverse quantitative traits is essential if we are to have an impact on the diseases that we are trying to cure sometimes, to relieve often and to comfort always.
The work of many groups around the world has demonstrated that there are other peripheral mechanisms that can be targeted to improve current treatment outcomes, including permeability, immune activation, hypersensitivity, bile acids and the microbiome. Just as fecal microbial transplants are having dramatic effects on colonic infections, it is conceivable that the restoration of balance among these intraluminal mechanisms may pave the way for significant advances in patient care.
As gastroenterologists, we are heading for a time when there will be less emphasis on the procedural, and more on the “cognitive” practice. If we are to preserve our place as the preferred caregivers for gastroenterological disorders, we need to make sure that we can offer patients more than another negative colonoscopy.
My Involvement with AGA
As I prepare to become president of the AGA Institute in 2015, it’s a great time to reflect on how AGA has impacted my career, in addition to providing research funding at critical points in my career.
I first came to the U.S. in 1983; I was completing my clinical and research training in London, England, and my mentors thought that to complete my training, it would be a great idea to have a BTA sticker; BTA stands for “been to America.” Through contacts between my mentor, Vint Chadwick at Hammersmith Hospital (now Imperial College), London, and Drs. Sid Phillips and Juan-Ramon Malagelada at Mayo Clinic, I interviewed and it was decided that I would work with Juan. This was my second research fellowship and it was a blast! I was exposed to great mentors, research facilities to conduct patient-oriented research (for which I was passionate), and a great group of research fellows who have continued to have significant impact on their respective fields: Fernando Azpiroz, Greg Gores, John Kellow, Fermin Mearin, Robin Spiller, Vincenzo Stanghellini to name a few (guys the order is alphabetical!). In 1984 and 1985, I attended DDW® and presented my research. All the educational opportunities, state-of-the-art symposia, one-on-one interactions at the posters and the question-and-answer sessions at the end of my research presentations made me realize: AGA (and DDW) was my academic home away from home.
Through meetings at DDW, serving on the AGA Institute Council as the Neurogastroenterology & Motility Section representative (paired with basic scientists, Michael Gershon and Helen Cooke), and election to the governing board, I continued to benefit from mentoring outside my first academic home. The most formative of these mentoring experiences was with Daniel K. Podolsky, who included me as an associate editor of Gastroenterology. Editing then really caught my interest: an ability to support colleagues not only at one’s own institution, to bring the best out of their papers and to help form the vision of our specialty. Not surprisingly, I threw my hat in the ring when the AGA announced it would launch a clinical practice journal to complement the prestigious Gastroenterology. I am so proud of Clinical Gastroenterology and Hepatology (CGH), and of the continued success of Hashem el-Serag and his teams of editors. The partnership of David Brenner as editor of Gastroenterology during the term of the Mayo Clinic editors of CGH was critical, and we all recognize and respect the way the University of North Carolina-based editors helped us build CGH into a first-rate journal.
It is now my turn to give and support the renaissance in cognitive gastroenterology. On my first travel to a research meeting in Europe in 1978, my first mentor advised, “Make sure you give to academic gastroenterology at least as much as you take from it.” I am now fortunate to be a servant leader of AGA, and I invite you to join me in supporting the AGA Research Foundation, which plays an important role in mentoring and academic development of young investigators. I am confident this effort will jump-start other gastroenterology trainees’ careers, whether they come from a Mediterranean island (as I do) or somewhere else in the U.S. or the world.
Dr. Camilleri is a paid consultant for AstraZeneca and Novartis AG and receives research support from Salix Pharmaceuticals Ltd., SK Life Sciences Inc., Rhythm Pharmaceuticals, and Second Gemone, Inc. He is also a member of the American College of Gastroenterology, American Neurogastroenterology and Motility Society and the American College of Physicians.