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In this episode, we delve into the serious consequences of fecal impaction and chronic constipation on patients’ well-being and health care costs. Our guest, Mahesh Moolani, an internal medicine physician and author of Tough Decisions In Care Of Elderly Loved Ones, sheds light on the pulsed irrigation evacuation (PIE) device. Discover how this device provides relief for patients with neurogenic bowel disorders and recurrent impactions when traditional treatments fail. Join us as we explore the safety, efficacy, and potential impact of the PIE device in improving patient outcomes.

Mahesh Moolani is an internal medicine physician and author of Tough Decisions In Care Of Elderly Loved Ones (A guide for caregivers).

He discusses his KevinMD article, “A unique method for managing chronic bowel conditions, treating fecal impaction, and preparing for colonoscopy procedures.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Mahesh Moolani. He’s an internal medicine physician, and we’re going to talk about the KevinMD article “A unique method for managing chronic bowel conditions, treating fecal impaction, and preparing for colonoscopy procedures.” Mahesh, welcome back to the show.

Mahesh Moolani: Thank you, thank you, Kevin. Thanks for having me.

Kevin Pho: So we were talking offline. I think you were on almost when the podcast started, three-plus years ago, so it’s great to have you back on again. For those who didn’t listen to our first episode together, just briefly share your story and journey to where you are today.

Mahesh Moolani: I’m an internal medicine physician. I do traditional medicine; in fact, I quit going to the hospital three years ago, so I just do primary care, and I see patients in nursing homes. I came to know about the pulsed irrigation device a couple of years ago through someone. It was invented by Mr. Roy Abel, who passed away about 10 years ago. He was himself a quadriplegic. In fact, he had a little bit of power in the right hand, but otherwise he became quadriplegic while he was in college. Some disease affected him, a polio-type disease, and then he became quadriplegic, and he was suffering with neurogenic bowel.

He was an amazing gentleman. He was enterprising; he created a few businesses while being quadriplegic, and one of them was to find relief for his fecal impaction. He had a few people who made this machine, and he did multiple studies in multiple centers across the country. But I think he had marketing challenges, because he was limited in mobility, so he couldn’t travel.

If you’re lying in the bed and you can’t poop, then that’s a pretty miserable condition. So those who are using it love it. Many say that it saved their life. It is not life-changing, according to them; it was a life-saving thing for them. One person told me, “My daughter would have died without it,” because she was having recurrent fecal impaction and fecal incontinence. So we acquired the company about two years ago, once we heard these stories: that we can make some changes for humans, for some of the people around the world.

Kevin Pho: So before we get into the device itself, you’re an internal medicine physician, and you see a lot of geriatric patients, as I do. Tell us about chronic constipation and the scope of chronic constipation. Just give us some context before we talk about the device.

Mahesh Moolani: I would say this is more for people who have paraplegia, quadriplegia, or spinal cord injury-related things, any reason which causes neurogenic bowel. With chronic constipation, there is a huge number of patients who have chronic constipation. Let me give you fecal impaction data. There was a study published in 2011 in the Journal of Clinical Gastroenterology. It says that yearly, patients were admitted or went to the ER for fecal impaction, and the cost for each fecal impaction is about $3,000-plus. That was 2011, and as you know, the cost of everything has gone up tremendously. If you are admitted with fecal impaction, your mortality is very high. We never think fecal impaction can cause mortality, but most of those people have associated disorders, and fecal impaction is associated with huge mortality.

So 42,000 patients are getting admitted, and we can prevent those hospitalizations and ER visits with the machine, because our data, which over the years is proven data and published data, proves that for patients, hospitalization can be prevented, and hospitalization length can be shortened. If patients are getting admitted for three days or five days, you can treat them within a day and send them back.

As for chronic constipation, I’m in touch with a lot of gastroenterologists nowadays, and they say that there are patients who take Linzess and Amitiza, and still they have such bad constipation that they use enemas and they use suppositories all the time, and still they don’t have a good quality of life. They have a tremendously bad quality of life.

I’ll just give you an example. I had a patient who had a stroke about three years ago. Now she’s in a wheelchair because of left hemiplegia, and she came to visit me. I was curious. I was not that curious about fecal impaction before, three years ago, but now, because of my company, I’m always thinking about fecal impaction. Does it affect her? I asked her, “How often do you move your bowels?” and the caregiver gave me the answer: once every week or once every two weeks. And she was on Linzess. I was like, “OK.” I never thought that people are suffering like that, and they have just taken their suffering for granted. They say, “OK, this is part of life.” But this should not be part of life, if there are things available. She uses enemas also, but an enema makes a mess in the bed, because she cannot be transferred. So this machine, I think, will help, because it can be done in the bed without making a mess.

Kevin Pho: So tell us a little bit more about this device. This is what’s called a pulsed irrigation evacuation device. So what exactly is that?

Mahesh Moolani: Basically, it consists of two big jars. One is filled with water, tap water, but at body temperature. We keep it a little higher so that the body temperature doesn’t drop, because we’re pulsing a lot of fluid into the colon and the rectum. Water is pulsed through the speculum into the rectum, and that pulsed water makes the colon do peristaltic movement, and the peristalsis causes the fecal material to dissolve. The same speculum has two parts: One is to pass the water, and another is to carry the fecal material out, which is collected in another container. So there are two containers. One is to pulse the clear water, and another is to hold the fecal material when it is coming out.

About 20 to 30 liters of water is pulsed into the colon, and for those who are using it, the procedure usually takes one to two hours. Basically, it helps the colon do the peristaltic movement, and that helps. With an enema, you pulse it once, and you get whatever comes out. But here, the fluid keeps on pulsating every 15 seconds, 30 seconds, 45 seconds, so the fecal material gets dissolved and it comes out.

Kevin Pho: So you mentioned that the typical patient for a device like this would be those with neurogenic colon, right, or neurogenic bowel. So tell us about other indications for the use of this device.

Mahesh Moolani: One is 100 percent neurogenic bowel. Many people do not know this term. Even as physicians, we do not use the word “neurogenic bowel” as much. We use “neurogenic bladder” a lot; we have seen patients with Foley catheters. But neurogenic bowel, even in our diagnoses, we do not write it. Neurogenic bowel can be due to any reason: spinal cord injury, spina bifida, Parkinson’s disease, MS. So it is a huge number of diseases. Basically, any neurological disorder which affects the whole body can cause neurogenic bowel. So that is one of the things.

Another thing is colon prep. We were studied in the Houston VA hospital for colon prep, because there are so many people who are admitted to the hospital who either cannot drink GoLYTELY, or they refuse to drink it, or they vomit, and we have to do a colonoscopy. Nowadays, the number of inpatient colonoscopies has decreased tremendously, but still there are patients who need a colonoscopy, and they cannot be discharged without the colonoscopy. So we were studied for that, and the device was found to be equal or better. In fact, other VA hospitals are getting in touch with us, because they want to do the procedure and they want to have the device so that they can do the colon prep real quick.

One doctor told me, “If the colonoscopy is scheduled for the next day, they have to prepare today, and if it is not clean, then they have to wait another day.” So basically, sometimes they have to wait two or three days before they can do a colonoscopy, and with this device, they can do it within four hours: “OK, just get the patient prepped, and we will do the colonoscopy.” You make the decision in the morning, and the patient goes home in the evening. So for colon prep also, it can be really good.

Kevin Pho: So tell me about the cost of something like this. Is it normally covered by insurance? Is it expensive? Give us an idea of the costs for a device like this.

Mahesh Moolani: For hospitals, it is not a big deal whenever I talk to a hospital, because they have huge budgets. For individuals, the cost is about $15,000 or $16,000, and some insurances are covering it. The VA covers it, and some others cover it. There are a few Medicare Advantage plans which are covering it, because they want to prevent patients from going to the hospital ER, because the ER will cost them too much. If you have recurrent fecal impaction, that can cause major issues, especially cost-wise, and it will reduce the cost tremendously. It will improve the quality of life. So it’s $16,000, or $15,000 or $16,000, per device, for institutions as well as individuals. But many individuals want it to be rented. There are people who are paying out of their pocket if the insurance doesn’t cover it. But many insurance plans, once the patient is already willing to fight, cover it.

Patients, you can sell anything to a patient very easily. But we physicians, all of us, have a barrier: “Wait a minute, this is too costly.” We make the decision based on cost so much: “OK, this may not be good for you,” without reviewing the literature, without seeing how the fecal impaction or neurogenic bowel is affecting that patient. So that is very important for us to realize, that the patient is already suffering, especially with neurogenic bowel and recurrent fecal impaction. They are suffering big time. There are kids with spina bifida; they are suffering big time. There are kids with Hirschsprung disease; they are suffering big time. With this, at least that part, that misery, is gone. There are other miseries already going on, but you can take care of that portion of their life. Just imagine you’re not constipated. You feel so good; at least you feel light.

Kevin Pho: We’re talking about Mahesh Moolani. He’s an internal medicine physician. We’re talking about his KevinMD article “A unique method for managing chronic bowel conditions, treating fecal impaction, and preparing for colonoscopy procedures.” Mahesh, for those physicians who may be listening to this, just again give us an idea of typical cases that would make them think, hey, maybe they should consider the pulsed irrigation evacuation.

Mahesh Moolani: Yeah, paraplegic patients, quadriplegic patients, 100 percent. Patients with severe Parkinson’s disease, MS, or patients with severe idiopathic constipation. To make it very simple, any patient who is using enemas, this is the device for them. They’ll be feeling good for three days. We recommend doing the procedure two times a week; some are doing it three times a week. Your colon gets clean, and it is not just a small part; the whole colon gets cleaned. So any patient who’s using an enema, simple as that. If you are writing an enema for a patient multiple times a week, this will be a very clean procedure for them. It will improve their quality of life tremendously.

Kevin Pho: Final question: Tell us some of your take-home messages that you want to leave with the KevinMD audience.

Mahesh Moolani: For any physician who manages neurogenic bowel or quadriplegic patients, and rehab centers, especially now, the rehab centers are interested. We are being used in Craig Hospital in Denver, because we have patients, especially with spinal cord injury, who are having a miserable condition. With the bowel clean, they feel so good. There are patients who are into sports, wheelchair sports, and if your bowel is cleaned, your efficiency in sport is going to be tremendously high. Even if it gives you 20 to 30 percent more energy: “Oh my God, I’m feeling good. I can play today.” So if you are managing those patients, paraplegic and quadriplegic, just think about their quality of life and how you can improve their quality of life by prescribing this device.

Kevin Pho: All right, Mahesh, thank you so much for sharing your time and insight, and thanks again for being on the show.

Mahesh Moolani: Thank you, Kevin.