Transcription:
Avoid the Burn: Heartburn That Is

Melanie Cole, MS: Many people occasionally experience gastroesophageal reflux or GERD. However, if your symptoms persist, it may be time to see a specialist to help with that reflux. My guest today is Dr. Clint Semrau. He’s a general surgeon with Aspirus Healthcare. Dr. Semrau, what is GERD? People have heard about heartburn, they’ve heard about reflux. What exactly is GERD?

Clint Semrau, DO: GERD effects around 80 million people in our country. It’s a very common issue to see. Sometimes ranging from some discomfort or a burning sensation in the chest. Some people actually have regurgitation where food comes back into their mouth or issues with chronic coughs associated with it. So, it’s kind of a spectrum of the disease. An underlying issue is that the valve that keeps food in the stomach essentially is being compromised and not working properly any longer.

Melanie: Do we know why that is? Do we know what causes it?

Dr. Semrau: Several different things usually contribute to it. Hiatal hernia is very common where you get a natural weakness. That’s very common to see, but over time it gets to the point where the body can't compensate for that anymore. Some people have a weakness in the muscle itself in the lower esophagus. Sometimes things such as obesity, pregnancy, those sorts of things increase your abdominal pressure. There’s about five/six different pathways that we control reflux. We can tolerate having a couple of those different pathways interrupted, but we eventually get to the point where we compensate anymore and that’s where we become symptomatic.

Melanie: Can it be silent? Do people always know that they have it?

Dr. Semrau: No. People with GERD who present in my practice with more advanced symptoms such as swallowing disorders usually don’t have any heartburn symptoms because they either had it when they were younger and basically outgrew it, or just never had those nerve areas develop properly down there. So, you don’t have the pain sensation that other people have in that area. So, some people call non-erosive reflux disease, but it’s also called silent GERD at times. It usually presents later because you don’t eat tacos or something and say I have heartburn, I shouldn’t eat that anymore. Instead that damage is occurring over years. So, you'll present with swallowing disorders or scar tissue with form in the esophagus or you'll have some call it stricture. So, the silent people are usually the ones who have more progressive symptoms when they present.

Melanie: While you mention tacos and such, one of the myths is that this is caused by spicy food. Is that true?

Dr. Semrau: My recommendation for people is if spicy food bothers, don’t eat it. In reality, I think it really depends on your situation. Spicy foods and anything that comprises that lower sphincter. Onions is one that will relax the lower esophageal muscle there. So, anything that’s compromising that barrier can increase it. The spicy foods used to be felt that everybody that should avoid spicy foods and caffeine. I find definitely some groups of patients that holds true in, but a lot of times it’s just more acidic or spicy foods are just increasing something that’s underlying there.

Melanie: Let’s talk about diagnosis then. We know that a colonoscopy is a great screening for colon issues and polyps. People hear about endoscopy. Is that the screening that you would use to determine whether or not someone has GERD or even something that might be further along like Barrett’s esophagus?

Dr. Semrau: Yeah, EGG would probably be our gold standard way to work that up. When we look at colonoscopy, we have very strict screening guidelines. Whereas other countries, like Japan, don’t. Japan has gastric cancer, so everybody gets EGG there and hardly anybody gets colonoscopies. So, looking at our population here, if we do have somebody who’s high risk or they’ve been on an antacid medicine for a number or years or they have breakthrough symptoms despite an acid medicine or actual ulcer like symptoms or family history. Those higher risk people are the ones who usually get into a screening group of some sort. Depending on your situation, we have different recommendations. To do a screen, we either look at doing an upper endoscopy, which is the EDG, or a barium swallow is another good screening which you don’t have to be sedated for. But you don’t have a good look and you don’t have tissue biopsy for things like Barrett’s and precancerous type regions. So, you don’t always pick up with just a screening like an upper GI.

Melanie: Is GERD a precursor for cancer doctor?

Dr. Semrau: People with untreated GERD have a higher risk of cancer. Anywhere from two to eight fold increased. If you have somebody with Barrett’s or more advanced influx issues, it’s about an eight fold increase. If somebody’s just untreated reflux symptoms on a daily to weekly basis, they have about a two to four-fold increase. Luckily, esophageal cancer is rare in our country for most people. If you double or quadruple something, you're still talking about a 3%-10% lifetime risk if somebody’s untreated reflux symptoms.

Melanie: So, what’s the first line of treatment? As you mentioned, people try medications. There’s proton-pump inhibitors, which people hesitate because they’ve heard in the media that there’s side effects to those. Some people just pop Tums every time or try not eating spicy food. What are some of the treatment options available? Speak a little bit about antacids versus proton-pump inhibitors. When does it become a prescription?

Dr. Semrau: Sure. Initially starting out, a Tums takes care of it once in a little while. That’s a good regiment to start with. If it gets to be that you're using them daily or several times a day, that’s probably when you need to move on to a better acid control option. All that the Tums type medication’s doing is just neutralizing that acid. So once that occurs, you get [rebow ph?] acid. A lot of times you'll find it’s a scenario where you're eating Tums throughout the day, which have some side effects with calcium and magnesium issues over time. When you neutralize that acid, your body responds by saying I don’t have enough acid. So as the medicine wears off, your body’s making more. So, you'll get worse acid, so you get this kind of chain reaction going that feeds into itself.

So, once you get to the point where you're needing Tums on a daily basis or several times a day, then getting into either an H2 blocker like a Zantac medication, which is the ranitidine, famotidine. The dine families when you're looking over the counter at the medications on the boxes of the generics. Versus a proton-pump inhibitor, which is like a Nexium or an omeprazole. They're going to be zole class medications: pantoprazole, omeprazole, esomeprazole. Add zole to generic ending to kind of differentiate the two.

The H2 blockers are our first go-to medication for this, and it does a really good job of controlling acid symptoms. The PPI class, or the proton-pump inhibitors, they're the newer medication. They're much more aggressive at controlling the symptoms. Whereas the H2 blocker classes work really well for people for a period of time over usually two to five years. You start to need escalating doses and your body becomes non-responsive to H2 class medicines where you don’t see it with the PPIs. So, first line, either one’s a good choice. Kind of downfall to PPI class is some of the side effects you'll see in literature nowadays where it effects bone absorption. There’s some association with Alzheimer’s and other malabsorption type related issues with it. In that case, that’s why if you don’t have an indication like Barrett’s or some actual precancerous changes where we want to be really aggressive, it’s nice to try at least initially with that H2 blocker class. Those side effects don’t seem to be as predominant.

Melanie: So, if medications don’t work—And we don’t have a lot of time doctor but speak about some procedural interventions that you might explore if somebody is still having problems with GERD.

Dr. Semrau: Well, the first key is to make sure it is just GERD alone. It is very common to see somebody has an underlying food allergy. Gallbladder issues a lot of times will present as a GERD. Once you really focus on the GERD diagnosis, usually correcting the way that valve functions is what we need to be doing. So that involves first a test to make sure that the esophagus is squeezing properly, and the stomach is emptying properly. If that’s all functioning the way it should, then we can go in and repair a hiatal hernia if we see one or recreate that valve if needed. As far as the valve piece, that’s where we have some variances.

There’s something called a LINX, which is a little magnetic bead ring that has been pretty promising. It’s starting to be used in community hospitals. I've held off on it because I have some concerns about what its going to be doing 10 years down the road. So, I've held off on it personally. The Nissen is kind of our gold standard reflux surgery. It’s the most aggressive reflux surgery we have. It has a lot of side effects long term though such as bloating issues and sometimes even swallowing issues with it because it’s so aggressive of a wrap.

The one I do a lot of times though is kind of a nice happy medium. It’s a TIF procedure where we come in from the mouth and we recreate that valve. It’s not as aggressive as the Nissen is, but the side effect profile is much more favorable. There’s some other opportunities for things like Roux-en-Y, which is a gastric bypass. Toupets and fundoplication, which are more just variations of the Nissen or other surgical approaches depending on a patient’s situation. Each patient is a little different in how the best way to handle that is.

Melanie: What about lifestyle doctor? What would you like people to know about things that they might try? Whether it’s late night eating or spicy food or exercise or how they sleep or any of these things that might help prevent GERD in the first place.

Dr. Semrau: Sure. The diet and exercise are really big factors with all medicine, but especially with this situation. Maintaining weight or losing, particularly what we call centripetal obesity or obesity around your abdominal area increases your intrabdominal pressure. So, addressing weight alone helps. If you have underlying medical issues like diabetes, controlling those. Diabetes, for example, and certain medications such as seizure disorders will affect the way things empty in the stomach. So, kind of just getting that under control.

Dietary wise, people usually do better if they avoid eating a couple of hours before they go to bed. Their symptoms during the day are usually a little more manageable because you're standing up and gravity is keeping things in your stomach. When you lay flat, you'll find that stuff’s regurgitating back because now we took out the gravity assistance. Things get the opportunity to come back up easier. Other strategies that are popular are keeping the head of the bed elevated a little bit. Some people actually prop themselves up on pillows or sleep in chairs. Kind of try and take out that gravity equation. Those are kind of some of the basic starting points for managing symptoms.

Melanie: Wrap it up for us then. Tell the listeners what you would like them to know about when they experience bouts of heartburn or GERD and when you think it’s important that they come in and see somebody.

Dr. Semrau: Yeah. I’d say once you find that you're using a Tums more than once a week, it’s probably time to at least bring it up to your family doctor. We have a lot of options beyond lifestyle modifications, we have a lot of surgical options, we have a lot of medication options to address things. It does have some long term, you know cancer risk is very real with it in addition to the quality of life that comes with it. So, I definitely say that at the point it’s once a week, it’s time to get with your family doctor. From there, it might be a simple tweaking a few things in your other medications or some lifestyle modifications that they can identify and can improve upon to starting you on a medication class.

By the time I see people, they're a little more advanced. Maybe 1% of people end up getting any sort of real surgical evaluation with these after seeing their family doctor. So, it’s not automatic you have heartburn and you need surgery type of a thing, but it’s just making sure you're not ignoring those symptoms.

Melanie: Thank you so much for being with us today and explaining and sharing your expertise about GERD. Something that so many people suffer from the uncomfortable symptoms of heartburn. Thank you again for joining us. This is Aspirus Healthtalk. For more information, please visit aspirus.org. That’s aspirus.org. I’m Melanie Cole. Thanks so much for listening.