Loma Linda University Medical Center

About Loma Linda University Medical Center

The Loma Linda University Medical Center is an academic Level 1 Trauma and Tertiary-Care Medical Center.  There are more than 21,000 admissions annually and 500,000 outpatient visits.  The division of gastroenterology and hepatology offers robust clinical services including all general gastroenterology procedures and advanced diagnostics and therapeutics.  Our small bowel program (video capsule endoscopy, double balloon enteroscopy) is the only one in the region. We have multiple experts in gastrointestinal motility and routinely perform anorectal manometry, esophageal manometry, EndoFLIP, BRAVO, wireless motility capsule, 24 hr pH impedance testing, and biofeedback.  Our therapeutic endoscopists perform a wide range of procedures including complex ERCP, endoluminal stenting, lumen-apposing metal stent placement, EUS, radiofrequency ablation and endoscopic mucosal resection of Barrett’s esophagus, ESD, POEM, and endoscopic full thickness resection. Our Liver Transplant program is one of the largest in California and performs >100 liver transplants annually.

Inpatient General GI Consult

The general GI consult service offers comprehensive consultative care to inpatients at the LLUMC, LLUMC East Campus, and LLUMC Surgical Hospitals.  The service is comprised of an attending physician, one first year fellow, rotating internal medicine and surgery residents, and medical students.  While on this service, fellows oversee the team of trainees and perform inpatient procedures along with the consult attending.  Fellows assist in teaching and ensuring high quality consultative service.  Consultations involve general gastroenterology, gastrointestinal bleeding, refractory clostridium difficile, and many other conditions.  Fellows are trained in a variety of advanced hemostasis techniques, diagnostic endoscopy and colonoscopy, percutaneous endoscopic gastrostomy and gastrojejunostomy tube placements, endoscopic dilation, foreign body removal, colonic decompression, fecal microbiota transplant, and other techniques on this rotation. 

Inpatient Hepatology Consult

The Hepatology consult service offers comprehensive consultative care to inpatients at the LLUMC, LLUMC East Campus, and LLUMC Surgical Hospitals.  The service is comprised of an attending physician, one first year fellow, rotating internal medicine residents, and medical students.  While on this service, fellows oversee the team of trainees and perform inpatient procedures along with the consult attending.  Fellows assist in teaching and ensuring high quality consultative service.  Consultations involve general hepatology, acute liver failure evaluation, cirrhosis complications, pre-transplant and post-transplant management.  Fellows are trained in a variety of advanced hemostasis techniques, diagnostic endoscopy and colonoscopy, Minnesota tube placement, and liver biopsy interpretation on this rotation.  Fellows will have the opportunity to participate in multidisciplinary conferences including Liver Case Conference, pathology conference, and Liver Transplant Selection Committee.

Inpatient Advanced Endoscopy Consult

The advanced endoscopy consult service offers comprehensive consultative care to inpatients at the LLUMC, LLUMC East Campus, and LLUMC Surgical Hospitals.  The service is comprised of an attending physician and one second or third-year gastroenterology fellow.  While on this service, fellows perform inpatient consultations and advanced procedures along with the consult attending.  Consultations involve complex pancreaticobiliary diseases, gastrointestinal luminal obstructions, gastrointestinal perforations.  Fellows are trained in a variety of ERCP techniques, fluoroscopy, endoluminal stenting, lumen-apposing metal stent placement, and other advanced techniques.  Fellows also gain exposure to endoscopic suturing and endoscopic ultrasound while on this service.

VA Loma Linda Healthcare System

About the VA Loma Linda Healthcare System

The VA Loma Linda Healthcare System serves more than 76,000 Veterans with a catchment area including towns more than 100 miles away. The Gastroenterology section is a diverse team that provides comprehensive care across all subspecialties. Unique procedures that fellows have the opportunity to get involved with include cyanoacrylate injection of bleeding gastric varices, EndoFLIP ®, endomicroscopy, in-office hemorrhoid ligation, endoluminal stenting, ERCP, in-office PEG tube exchange, radiofrequency ablation of Barrett’s esophagus and radiation proctitis, single balloon enteroscopy, vibration-controlled transient elastography and wireless motility capsule. There is a fully equipped motility lab and an endoscopic ultrasound specialist.

Inpatient Rotation

The inpatient Gastroenterology service is consult only, with a team comprised of an attending physician, one first-year fellow, Internal Medicine residents and occasionally medical students. Primary learning objectives include providing specialist-level insight on diagnostic workup and management of all luminal, hepatology, and pancreatobiliary problems, performing careful pre-procedural assessments, developing endoscopic skills, reviewing inpatient small bowel capsule studies and completing electronic consults.

Liver Rotation

One second- or third-year fellow is typically on the Liver Rotation, which is mainly focused on outpatient Hepatology. Primary learning objectives include thorough investigation of liver failure, viral hepatitis and cholestatic liver disease, providing comprehensive care of chronic liver disease including the transplant evaluation process, engaging a multidisciplinary team that includes Mental Health, Surgical Oncology, Medical Oncology and Radiology providers, and familiarization with non-invasive methods of staging liver fibrosis. MR, ultrasound, and vibration-controlled transient elastography (VCTE) are all performed routinely. Fellows can learn to perform and interpret VCTE during this rotation. When not in clinic, the fellow on Liver Rotation is responsible for outpatient endoscopy cases and should also attend the weekly Tumor Board conference.

Procedure Rotation

One second- or third-year fellow is typically on the Procedure Rotation, which is focused on outpatient endoscopy and inpatient and outpatient advanced endoscopy. The fellow on the Procedure Rotation is assigned to the endoscopy board with the other attendings and can choose to be involved with any specific case. The Procedure Rotation fellow is responsible for evaluating any patient requiring a fluoroscopy-guided procedure (ERCP, jejunostomy tube placement, endoluminal stent) and assisting with the procedure.

Riverside University Health System Medical Center

About Riverside University Health System Medical Center

The Riverside University Health System (RUHS) Medical Center in Moreno Valley is an academic medical center that has provided care to patients in Riverside County for over one hundred years.  At this designated county hospital fellows are exposed to a vast amount of complex pathology and are privileged to deliver care to an underserved population.  The GI faculty at LLUMC rotate at RUHS and provide care in both the inpatient and outpatient settings.  A wide variety of gastrointestinal procedures are performed including upper endoscopy, colonoscopy, ERCP, and endoluminal stenting.

Inpatient Consult

The inpatient consult service offers comprehensive consultative care to inpatients at the RUHS Medical Center.  The service is comprised of an attending physician, one second or third year fellow and rotating surgery residents.  While on this service, fellows oversee the team of trainees and perform inpatient procedures along with the consult attending.  Fellows assist in teaching and ensuring high quality consultative service.  Consultations involve general gastroenterology, gastrointestinal bleeding, general hepatology, cirrhosis complications, complex pancreaticobiliary diseases, gastrointestinal luminal obstructions, and gastrointestinal perforations.  Fellows are trained in a variety of advanced hemostasis techniques, diagnostic endoscopy and colonoscopy, percutaneous endoscopic gastrostomy and gastrojejunostomy tube placements, endoscopic dilation, foreign body removal, colonic decompression, ERCP and other techniques on this rotation

Electives

Motility

During this 4 week elective fellows work directly with motility specialists at LLUMC and the VA.  Fellows begin the rotation with web based modules and didactics for general introduction to anorectal manometry, esophageal manometry, BRAVO, and 24 hr pH impedance equipment and interpretation.  During the rotation fellows work with faculty and learn advanced interpretation of motility and pH testing.  Fellows work with nurses in the LLUMC GI lab to learn the nuances of placement of catheters and testing protocols.  Fellows also observe treatments in our biofeedback program.  There are dedicated periods for outpatient endoscopic procedure training as well as for completing assigned reading on advanced topics in motility.

Small Bowel

During this 4 week elective fellows work directly with small bowel specialists at LLUMC and the VA.  Fellows begin the rotation with web based modules and didactics for general introduction to video capsule endoscopy.  During the rotation fellows work with faculty and independently to refine skills in interpretation of video capsule endoscopy.  Fellows will evaluate all inpatient video capsule endoscopies performed during this rotation in addition to evaluating outpatient examinations.  Fellows will gain exposure to double balloon enteroscopy at LLUMC and single balloon enteroscopy at the VA.  There are dedicated periods for outpatient endoscopic procedure training as well as for completing assigned reading on advanced topics in small bowel. 

Inflammatory Bowel Disease

During this 4 week elective fellows work directly with inflammatory bowel disease specialists at LLUMC and the VA.  Fellows will participate in IBD clinics at both sites with multiple providers including gastroenterologists and surgeons. There will be exposure to complex inflammatory bowel disease where fellows will learn principles of medical and surgical management. Fellows will spend ½ day per week in the radiology department advancing their skills at interpreting diagnostic gastrointestinal imaging studies as well.  There are dedicated periods for outpatient endoscopic procedure training as well as for completing assigned reading on advanced topics in inflammatory bowel disease. 

Continuity Clinics

SAC Health

Fellows will manage their own panel of clinic patients at the Loma Linda University Health SAC Health during their first year of fellowship.  SAC Health is a Federally Qualified Health Center that provides care to underserved populations.  Fellows see 4-5 patients in this weekly clinic, which allows for ample time for teaching.  A weekly “mini-journal club” introduces fellows to seminal articles in general gastroenterology as they are taught evidence-based outpatient gastroenterology care.  Fellows encounter a wide range of general gastrointestinal illnesses including functional disorders, motility disorders, and inflammatory bowel disease

Loma Linda VA Ambulatory Care Center

During the last 2 years of fellowship fellows will manage their own panel of clinic patients at the Loma Linda VA Ambulatory Care Center. Fellows encounter a wide range of general gastrointestinal illnesses including functional disorders, motility disorders, and inflammatory bowel disease.