Meet Alexander Y. Coe, MD, MEd, a new attending physician with the Division of Gastroenterology, Hepatology and Nutrition at Children’s Hospital of Philadelphia (CHOP).
Dr. Coe is one of three pediatric gastroenterologists on staff at CHOP who performs advanced endoscopic procedures – both diagnostic and therapeutic – for pediatric patients at the hospital. CHOP is one of the very few pediatric hospitals in the nation with this high level of endoscopic support for patients with GI, pancreatic and nutritional concerns.
Before joining the staff at CHOP, Dr. Coe previously spent a year as an advanced fellow in advanced endoscopy at the University of Pennsylvania School of Medicine and 3 years as a gastroenterology fellow at CHOP. He earned his medical degree and masters of education in curriculum and instruction from the University of Nevada and completed an internship and residency in pediatrics at Cincinnati Children’s Hospital Medical Center in Ohio.
Dr. Coe recently sat down for an informal Q&A to talk about his background, why he chose his GI specialty and how he hopes to use endoscopy to improve the health of pediatric patients in his care at CHOP.
Q: Can you share a bit about your background and training?
A: In medical school, I wasn’t sure if I was going to do something surgical or other procedure-based specialty, but I knew I wanted to help children. I completed my pediatric residency training at Cincinnati Children’s where I was exposed to gastroenterology on a deeper level.
When I started my GI fellowship at CHOP, I became hooked by endoscopy early on because of the immediate ability to help diagnose patients or provide minimally invasive interventions. I loved the fact that it was a skillset that could be practiced and could lead to appreciable improvement in a patient’s condition.
Petar Mamula, MD, (pediatric gastroenterologist and Director of the Kohl’s GI Nutrition and Diagnostic Center at CHOP) was – and continues to be – a huge influence on me. He provided most of my exposure to the world of advanced and therapeutic endoscopy and opened many doors to allow me to be where I am today.
After completing my pediatric GI fellowship, I was accepted to be one of the two advanced endoscopy fellows at the University of Pennsylvania. During that year, I trained under true legends within the field of endoscopy – Michael L. Kochman, MD, and Gregory G. Ginsberg, MD, along with several other phenomenal, advanced endoscopy faculty. This was an intensive year where I spent the vast majority of time at the adult hospital getting a high-volume of experience in advanced endoscopic procedures including: ERCP (endoscopic retrograde cholangiopancreatography), EUS (endoscopic ultrasound), enteroscopy, luminal access (dilation, stenting and trans-luminal access), and complex polyp resection techniques.
EUS is one of the new services I have introduced since starting at CHOP.
Q: What excites you most about joining CHOP’s GI Division and working in a pediatric setting?
A: The best part is the ability to continue to collaborate with my mentors that trained me – along with colleagues in other divisions at CHOP, such as interventional radiology, ENT, pulmonology, and surgery – whom I have developed great working relationships with. Being able to expand the repertoire of endoscopic procedures and interventions at CHOP excites me, as it will enhance our ability to provide cutting-edge care that is truly limited to only an extremely small number of pediatric centers. By remaining at CHOP, I can continue the collaborative clinical and academic efforts through the relationships I’ve been able to build with mentors at CHOP and Penn.
Q: Can you explain what “advanced GI endoscopy” includes and how it differs from standard procedures?
A: Advanced GI endoscopy refers to a variety of procedures that are more technically challenging, and often therapeutic in nature. These procedures include ERCP, which utilizes a specialized endoscope where the camera is on the side (like driving a car looking out the side window). This allows for more direct visualization of the opening (major papilla), where we can access the bile duct or pancreatic duct using a series of wires, catheters, balloons and X-ray contrast dye to diagnose and treat disorders of the pancreaticobiliary system. This can be used for disorders such as choledocholithiasis, biliary and pancreatic duct strictures, bile duct leaks, cholangitis, pancreatic stones, strictures or trauma. ERCP is a technically challenging procedure that requires fine control of the instruments and devices, along with an ability to interpret radiographic imaging.
Endoscopic ultrasound is a procedure that utilizes a different specialized endoscope where an ultrasound transducer is mounted to the tip of the scope. This allows the endoscopist to image structures and organs within the mediastinal, abdominal and pelvic areas with high resolution since the endoscope is sitting within the lumen of the digestive tract.
Organs such as the pancreas, liver, bile duct, spleen and lymph nodes are often only a few millimeters to centimeters away from the tip of the scope when positioned in various areas of the esophagus, stomach or duodenum. This allows for high-resolution images that are not obstructed due to patient size, or air in the bowels which can impair the quality of standard transabdominal ultrasounds.
In addition to diagnostic capability from ultrasound imaging, there are many other diagnostic and therapeutic things we can do with EUS. For example: minimally invasive sampling or a biopsy of focal lesions within an organ, such as a liver or pancreas, can be done with a fine needle under ultrasound guidance quite safely. Furthermore, when patients have complex fluid collections or infections, it is possible to provide internal drainage from the collection through the digestive tract by creating a port using a plastic or metal-mesh stent that can be deployed under endoscopic ultrasound guidance. The most common examples of this type of intervention are pancreatic fluid collections.
Q: What types of complex cases or conditions are best suited for advanced endoscopic care?
A: Diseases or disorders of the bile duct and liver can often be treated with ERCP, which can spare patients from more invasive surgery or external drains that can be uncomfortable and inconvenient for patients.
Endoscopic ultrasound has a wide variety of clinical applications including, but not limited to:
- Evaluating submucosal tumors or lesions
- Sampling enlarged lymph nodes
- Treating gastric varices with coil embolization
- Evaluating subtle parenchymal and ductal changes in chronic pancreatitis
- Draining fluid collections
- Assessing for perianal fistula and collections
- Endoscopic ultrasound-guided liver biopsy
- Portal pressure gradient measurements.
Q: CHOP’s GI Division is proud to be the only pediatric hospital in the country with three advanced endoscopists on staff. From your perspective, what does that mean for referring providers and patients?
A: Ultimately, having three advanced therapeutic endoscopists – including Dr. Mamula, Michael A. Manfredi, MD, and myself – allows the entire array of endoscopic procedures (both diagnostic and therapeutic) to be offered.
Referring providers should feel confident and comfortable sending patients to us with any type of challenging or complex case that may benefit from procedures like ERCP, EUS, enteroscopy (push, single-balloon, double-balloon), complex polyp resection, endoscopic suturing, or per-oral endoscopic myotomy (POEM).
Q: How does advanced endoscopy help patients avoid more invasive surgical interventions?
A: The major benefit to patients with advanced endoscopic procedures is that it provides alternative therapy that is less invasive than surgery, and often interventional radiology. There are no external incisions, drains or tubes. Everything is done using the natural orifices of the body.
Advanced endoscopy can also help us partner with our surgical colleagues to make surgical planning easier and safer. For example, when a patient had a suspected neuroendocrine tumor in the pancreas – that could not be seen by MRI, CT or PET scans – endoscopic ultrasound was able to identify the size and location of the tumor, allowing for a more precise resection of the tumor. This spared the patient from enduring a larger resection of their pancreas or surrounding structures.
Q: What are some of the most impactful ways your role will expand the scope of care CHOP can offer to children and families?
A: I truly believe that being able to start – and eventually grow – our endoscopic ultrasound capabilities at CHOP will provide patients with a variety of major benefits:
- All their care can remain at CHOP, rather than be transferred elsewhere for a specific procedure – such as an adult hospital.
- Endoscopic ultrasound can, in certain situations, provide more of a “one-stop-shop” so patients don’t have to endure multiple trips for diagnostic tests, procedures or interventions. For example, patients with metabolic dysfunction-associated steatotic liver disease (MASLD) or abnormal liver enzymes can undergo an endoscopic ultrasound procedure that performs sheer-wave elastography (to assess the stiffness of the liver), takes a liver biopsy under EUS guidance, measures direct portal pressure, and provides a genera endoscopy assessment of the upper gastrointestinal tract (especially for pre-bariatric procedure planning). This can be done in one procedure, as opposed to the patient making multiple trips for diagnostic radiology/ultrasound, interventional radiology and GI endoscopy.
- Liver biopsies performed under EUS guidance have an excellent safety profile, without sacrificing the quality of the diagnostic specimens obtained for pathology. These patients generally experience less pain because the needle does not go through the abdominal wall. Patients can eat and move about, as opposed to being required to lay flat for several hours post-procedure, which is the case for traditional percutaneous liver biopsies.
Q: How do you anticipate collaborating with referring physicians and other specialties to deliver comprehensive care to patients?
A: I look forward to being able to share what we are building at CHOP with advanced endoscopy at other institutions. I intend to arrange visits to speak with various institutions so we can help educate more clinicians about the role, benefit and capabilities of advanced endoscopic procedures and how we can help them and their patients now.
Open communication and continued collaboration between our group and referring centers will be key. Our goal is to help as many patients and referring providers as we can reach.
Q: What advances or innovations in endoscopy do you see shaping pediatric GI care in the years ahead?
A: One of the pillars of advanced endoscopy is to be able to provide a diagnostic or therapeutic intervention that can be done just as well – or better – than alternative procedures with more efficacy, less invasiveness and less morbidity.
Obesity and metabolic liver disease will likely continue to be significant health concerns within pediatrics. By working with Dr. Manfredi, our MASLD physicians, surgeons, dietitians and exercise therapists, I see a growing need to be able to provide truly comprehensive diagnostic and therapeutic endoscopic services to help improve the health of children with obesity and metabolic liver disease.
CHOP is one of the leaders in pediatric IBD care, and I anticipate we can utilize EUS to provide goal-directed care for patients with complex IBD. No other pediatric center is using EUS for this clinical indication. We will be able to be at the forefront of this in our clinical applications and research because of this novel use of EUS.
Lastly – using eosinophilic esophagitis and stricture disorders of the esophagus as a framework – we can design studies to evaluate the role of EUS in better diagnosing, monitoring and potentially caring for these disorders.
Q: What opportunities exist for CHOP’s division to lead in this space nationally?
A: I fully believe CHOP will be the leader in pediatric endoscopy through our ability to offer the full spectrum of endoscopic care; a renewed focus on dedicated endoscopy education of our trainees; by hosting regional (potentially national) hands-on training courses; and by spear-heading novel clinical trials.
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Meet Alexander Y. Coe, MD, MEd, a new attending physician with the Division of Gastroenterology, Hepatology and Nutrition at Children’s Hospital of Philadelphia (CHOP).
Dr. Coe is one of three pediatric gastroenterologists on staff at CHOP who performs advanced endoscopic procedures – both diagnostic and therapeutic – for pediatric patients at the hospital. CHOP is one of the very few pediatric hospitals in the nation with this high level of endoscopic support for patients with GI, pancreatic and nutritional concerns.
Before joining the staff at CHOP, Dr. Coe previously spent a year as an advanced fellow in advanced endoscopy at the University of Pennsylvania School of Medicine and 3 years as a gastroenterology fellow at CHOP. He earned his medical degree and masters of education in curriculum and instruction from the University of Nevada and completed an internship and residency in pediatrics at Cincinnati Children’s Hospital Medical Center in Ohio.
Dr. Coe recently sat down for an informal Q&A to talk about his background, why he chose his GI specialty and how he hopes to use endoscopy to improve the health of pediatric patients in his care at CHOP.
Q: Can you share a bit about your background and training?
A: In medical school, I wasn’t sure if I was going to do something surgical or other procedure-based specialty, but I knew I wanted to help children. I completed my pediatric residency training at Cincinnati Children’s where I was exposed to gastroenterology on a deeper level.
When I started my GI fellowship at CHOP, I became hooked by endoscopy early on because of the immediate ability to help diagnose patients or provide minimally invasive interventions. I loved the fact that it was a skillset that could be practiced and could lead to appreciable improvement in a patient’s condition.
Petar Mamula, MD, (pediatric gastroenterologist and Director of the Kohl’s GI Nutrition and Diagnostic Center at CHOP) was – and continues to be – a huge influence on me. He provided most of my exposure to the world of advanced and therapeutic endoscopy and opened many doors to allow me to be where I am today.
After completing my pediatric GI fellowship, I was accepted to be one of the two advanced endoscopy fellows at the University of Pennsylvania. During that year, I trained under true legends within the field of endoscopy – Michael L. Kochman, MD, and Gregory G. Ginsberg, MD, along with several other phenomenal, advanced endoscopy faculty. This was an intensive year where I spent the vast majority of time at the adult hospital getting a high-volume of experience in advanced endoscopic procedures including: ERCP (endoscopic retrograde cholangiopancreatography), EUS (endoscopic ultrasound), enteroscopy, luminal access (dilation, stenting and trans-luminal access), and complex polyp resection techniques.
EUS is one of the new services I have introduced since starting at CHOP.
Q: What excites you most about joining CHOP’s GI Division and working in a pediatric setting?
A: The best part is the ability to continue to collaborate with my mentors that trained me – along with colleagues in other divisions at CHOP, such as interventional radiology, ENT, pulmonology, and surgery – whom I have developed great working relationships with. Being able to expand the repertoire of endoscopic procedures and interventions at CHOP excites me, as it will enhance our ability to provide cutting-edge care that is truly limited to only an extremely small number of pediatric centers. By remaining at CHOP, I can continue the collaborative clinical and academic efforts through the relationships I’ve been able to build with mentors at CHOP and Penn.
Q: Can you explain what “advanced GI endoscopy” includes and how it differs from standard procedures?
A: Advanced GI endoscopy refers to a variety of procedures that are more technically challenging, and often therapeutic in nature. These procedures include ERCP, which utilizes a specialized endoscope where the camera is on the side (like driving a car looking out the side window). This allows for more direct visualization of the opening (major papilla), where we can access the bile duct or pancreatic duct using a series of wires, catheters, balloons and X-ray contrast dye to diagnose and treat disorders of the pancreaticobiliary system. This can be used for disorders such as choledocholithiasis, biliary and pancreatic duct strictures, bile duct leaks, cholangitis, pancreatic stones, strictures or trauma. ERCP is a technically challenging procedure that requires fine control of the instruments and devices, along with an ability to interpret radiographic imaging.
Endoscopic ultrasound is a procedure that utilizes a different specialized endoscope where an ultrasound transducer is mounted to the tip of the scope. This allows the endoscopist to image structures and organs within the mediastinal, abdominal and pelvic areas with high resolution since the endoscope is sitting within the lumen of the digestive tract.
Organs such as the pancreas, liver, bile duct, spleen and lymph nodes are often only a few millimeters to centimeters away from the tip of the scope when positioned in various areas of the esophagus, stomach or duodenum. This allows for high-resolution images that are not obstructed due to patient size, or air in the bowels which can impair the quality of standard transabdominal ultrasounds.
In addition to diagnostic capability from ultrasound imaging, there are many other diagnostic and therapeutic things we can do with EUS. For example: minimally invasive sampling or a biopsy of focal lesions within an organ, such as a liver or pancreas, can be done with a fine needle under ultrasound guidance quite safely. Furthermore, when patients have complex fluid collections or infections, it is possible to provide internal drainage from the collection through the digestive tract by creating a port using a plastic or metal-mesh stent that can be deployed under endoscopic ultrasound guidance. The most common examples of this type of intervention are pancreatic fluid collections.
Q: What types of complex cases or conditions are best suited for advanced endoscopic care?
A: Diseases or disorders of the bile duct and liver can often be treated with ERCP, which can spare patients from more invasive surgery or external drains that can be uncomfortable and inconvenient for patients.
Endoscopic ultrasound has a wide variety of clinical applications including, but not limited to:
- Evaluating submucosal tumors or lesions
- Sampling enlarged lymph nodes
- Treating gastric varices with coil embolization
- Evaluating subtle parenchymal and ductal changes in chronic pancreatitis
- Draining fluid collections
- Assessing for perianal fistula and collections
- Endoscopic ultrasound-guided liver biopsy
- Portal pressure gradient measurements.
Q: CHOP’s GI Division is proud to be the only pediatric hospital in the country with three advanced endoscopists on staff. From your perspective, what does that mean for referring providers and patients?
A: Ultimately, having three advanced therapeutic endoscopists – including Dr. Mamula, Michael A. Manfredi, MD, and myself – allows the entire array of endoscopic procedures (both diagnostic and therapeutic) to be offered.
Referring providers should feel confident and comfortable sending patients to us with any type of challenging or complex case that may benefit from procedures like ERCP, EUS, enteroscopy (push, single-balloon, double-balloon), complex polyp resection, endoscopic suturing, or per-oral endoscopic myotomy (POEM).
Q: How does advanced endoscopy help patients avoid more invasive surgical interventions?
A: The major benefit to patients with advanced endoscopic procedures is that it provides alternative therapy that is less invasive than surgery, and often interventional radiology. There are no external incisions, drains or tubes. Everything is done using the natural orifices of the body.
Advanced endoscopy can also help us partner with our surgical colleagues to make surgical planning easier and safer. For example, when a patient had a suspected neuroendocrine tumor in the pancreas – that could not be seen by MRI, CT or PET scans – endoscopic ultrasound was able to identify the size and location of the tumor, allowing for a more precise resection of the tumor. This spared the patient from enduring a larger resection of their pancreas or surrounding structures.
Q: What are some of the most impactful ways your role will expand the scope of care CHOP can offer to children and families?
A: I truly believe that being able to start – and eventually grow – our endoscopic ultrasound capabilities at CHOP will provide patients with a variety of major benefits:
- All their care can remain at CHOP, rather than be transferred elsewhere for a specific procedure – such as an adult hospital.
- Endoscopic ultrasound can, in certain situations, provide more of a “one-stop-shop” so patients don’t have to endure multiple trips for diagnostic tests, procedures or interventions. For example, patients with metabolic dysfunction-associated steatotic liver disease (MASLD) or abnormal liver enzymes can undergo an endoscopic ultrasound procedure that performs sheer-wave elastography (to assess the stiffness of the liver), takes a liver biopsy under EUS guidance, measures direct portal pressure, and provides a genera endoscopy assessment of the upper gastrointestinal tract (especially for pre-bariatric procedure planning). This can be done in one procedure, as opposed to the patient making multiple trips for diagnostic radiology/ultrasound, interventional radiology and GI endoscopy.
- Liver biopsies performed under EUS guidance have an excellent safety profile, without sacrificing the quality of the diagnostic specimens obtained for pathology. These patients generally experience less pain because the needle does not go through the abdominal wall. Patients can eat and move about, as opposed to being required to lay flat for several hours post-procedure, which is the case for traditional percutaneous liver biopsies.
Q: How do you anticipate collaborating with referring physicians and other specialties to deliver comprehensive care to patients?
A: I look forward to being able to share what we are building at CHOP with advanced endoscopy at other institutions. I intend to arrange visits to speak with various institutions so we can help educate more clinicians about the role, benefit and capabilities of advanced endoscopic procedures and how we can help them and their patients now.
Open communication and continued collaboration between our group and referring centers will be key. Our goal is to help as many patients and referring providers as we can reach.
Q: What advances or innovations in endoscopy do you see shaping pediatric GI care in the years ahead?
A: One of the pillars of advanced endoscopy is to be able to provide a diagnostic or therapeutic intervention that can be done just as well – or better – than alternative procedures with more efficacy, less invasiveness and less morbidity.
Obesity and metabolic liver disease will likely continue to be significant health concerns within pediatrics. By working with Dr. Manfredi, our MASLD physicians, surgeons, dietitians and exercise therapists, I see a growing need to be able to provide truly comprehensive diagnostic and therapeutic endoscopic services to help improve the health of children with obesity and metabolic liver disease.
CHOP is one of the leaders in pediatric IBD care, and I anticipate we can utilize EUS to provide goal-directed care for patients with complex IBD. No other pediatric center is using EUS for this clinical indication. We will be able to be at the forefront of this in our clinical applications and research because of this novel use of EUS.
Lastly – using eosinophilic esophagitis and stricture disorders of the esophagus as a framework – we can design studies to evaluate the role of EUS in better diagnosing, monitoring and potentially caring for these disorders.
Q: What opportunities exist for CHOP’s division to lead in this space nationally?
A: I fully believe CHOP will be the leader in pediatric endoscopy through our ability to offer the full spectrum of endoscopic care; a renewed focus on dedicated endoscopy education of our trainees; by hosting regional (potentially national) hands-on training courses; and by spear-heading novel clinical trials.
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