Transcription:
Heartburn, Acid Reflux and GERD

Melanie Cole (Host): Welcome. In this panel discussion today, we're talking about GERD and there is a lot to discuss. My guests are Dr. Jamii St. Julien, he's a General Surgeon with a Fellowship in Minimally Invasive Surgery and Dr. Abhi Patil, he's a Gastroenterologist and they are both with BayCare. Dr. Patil, I'd like to start with you. Tell us a little bit GERD, the prevalence and how it impacts the daily health of individuals with GERD.

Abhitabh Patil, MD (Guest): GERD is a very common symptom in the United States. There are several million patients that suffer from GERD. Many patients don't need medications; however, many patients do end up on medicine and a lot of patients continue these medicines, often for life.

Host: Explain a little bit about what it is Dr. Patil.

Dr. Patil: Well GERD refers to two major symptoms and the most common symptom is heartburn. The second symptom is regurgitation. Both of which are classified as GERD which stands for gastroesophageal reflux disease.

Host: Dr. St. Julien, do we know what causes GERD in some people and other people do not have that? And divide it up for us. Are there different levels of it?

Jamii St. Julien, MD, MPH (Guest): Our natural body's anatomy has certain mechanisms that prevent the reflux of acid from the stomach up into the esophagus. And in some people, that barrier is compromised. There are actually a number of reasons that I could go into but ultimately, it's usually a weakness of the what we call the sphincter of the lower part of the esophagus that also has to do with where it passes through the diaphragm and the anti-reflux mechanism is broken.

And so then acid that normally should just stay in the stomach refluxes up into the esophagus more than usual and causes GERD. Other things like obesity, pregnancy, anything that increases the abdominal pressure can also cause GERD as you can imagine, pushing that acid up into the esophagus. Long answer, sort of the gist of it.

Host: Well Dr. St. Julien, sticking with you for just a second. Who is most at risk? You mentioned obesity, so I'd like to just expand on the risk factors and who would be more subject to it and while you are talking about that, people wonder if spicy food is the culprit or any of these other comorbid conditions. Speak about who is at risk.

Dr. St. Julien: So, I would say the prevalence of GERD has been on the rise in the setting of the increasing obesity epidemic. The number one risk factor in my mind is going to be obesity. Outside of that, there is going to be a genetic component. Some people think of it as a connective tissue disease.

So, every now and again, you'll have young people with reflux who are not obese. And so there's no great answer as far as who specifically is at risk, but we do know that certain populations such as obese patients often premature infants, the prevalence increases with age as well as our tissues get a little bit more lax. Overall, obesity is really the biggest risk factor.

And then diet, spicy foods, acidic foods definitely play a role. Overeating is a very big culprit. Which is common in America. Large portion sizes and eating until we are full and stuffed.

Host: Dr. Patil, how is it diagnosed? If somebody feels that heartburn. And as I've had an endoscopy before, it's a pretty simple procedure. Tell us a little bit about the ways that you can diagnose reflux or GERD, and also do you see endoscopy becoming like colonoscopy where it's something that we might use as a standard screening test that might even be covered by well-visits and prevention.

Dr. Patil: The role of endoscopy is not necessarily to diagnose GERD, although it can be used. It's important to know that 80% of patients who have GERD will have a normal endoscopy. Going back to making the diagnosis, the diagnosis is made by typical symptoms and if patients have a response to medication; that alone is enough to make the diagnosis of GERD. And so most patients do not require additional testing. The role of the endoscopy is if you are trying to quantify how bad the GERD is and if they are surgical candidate then it's useful or if you are using the endoscopy to sort out other conditions such as esophagitis or Barrett's esophagus or other problems of the esophagus. That is the main role for endoscopy.

Host: Well then Dr. Patil, continue on with that thought. You mentioned Barrett's esophagus and the listeners don't know what that is. Is GERD a precursor for cancer? And tell the listeners what Barrett's esophagus really is.

Dr. Patil: So, Barrett's esophagus is a precancerous condition of the esophagus believed to be related to chronic acid exposure. Now if you take the entire United States population, only 7-10% of patients actually have Barrett's esophagus. And out of the 7-8% of people that have Barrett's esophagus, only about one or two percent will go on to form esophageal cancer.

So, it's a subset of patients who have GERD who have Barrett's esophagus who then go on to develop esophageal cancer who are really at risk. So the vast majority of patients who have GERD will not get esophageal cancer or even Barrett's.

Dr. St. Julien: Dr. Patil is right. It's overall a low prevalence. However, I will say that it's still very important. What we used to see with esophageal cancer is a certain type of cancer that was typically caused by alcohol and smoking, usually found in the upper esophagus. But now, again, with the obesity epidemic; we've seen a shift to the most common type of esophageal cancer being in the lower esophagus secondary to Barrett's which is ultimately secondary to reflux.

So, while the overall prevalence is low, we are still seeing a shift towards increased cancer ultimately secondary to long-term, long-standing untreated reflux which is why we pay so much attention to it and we like to stay on top of it in addition to helping people with their quality of life.

Host: Well it's so important and before we talk about some surgical options, Dr. Patil, tell us about some nonsurgical options. Are medications primarily used to control the symptoms, but they don't necessarily cure the issue?

Dr. Patil: Medications are used to neutralize acid in the stomach so that what splashes up into the esophagus is not acidic and therefore does not cause a corrosive damage in the esophagus or lead to Barrett's esophagus. Medications also have a slight anti-inflammatory effect, but this is still an area for the research. But medications certainly do have a powerful effect in controlling GERD and GERD-related symptoms and they are commonly used today.

Host: Well thank you for clearing that up for the listeners. Dr. St. Julien, tell us about some surgical indications for GERD.

Dr. St. Julien: Patients that we generally consider for anti-reflux surgery are going to be those who have reflux and are taking medicine but it's not working.

So, essentially poorly controlled on medication. Or, patients who take medication, it is working, but they don't want to take medicine every day for the rest of their life. We are seeing more of that recently because of the concern about the TPIs and then lastly, patients who have long-standing reflux who have some sort of complication of reflux. And that's going to be Barrett's esophagus, or severe esophagitis, or a narrowing or scarring of the esophagus secondary to all that acid exposure.

So, those are generally the patients we would discuss surgery with.

Also, reflux is often associated with something called a hiatal hernia which is where a portion of the patients who have large hiatal hernia that's causing symptoms who have those types of reflux symptoms that I just discussed are usually the most typical patients that we consider for surgery.

Host: Dr. St. Julien, sticking with you for just a minute. Tell us what a patient can expect if they are going to undergo anti-reflux surgery, do they still need meds afterwards? Tell us just a little bit briefly what that surgery looks like.

Dr. St. Julien: Of course. Dr. Patil mentioned the upper endoscopy where they look directly in the stomach. We also have to do pH test which is a test that we use to confirm that there is actually an abnormal amount of acid that's passing up into the esophagus. Most patients will need something called a barium swallow where they swallow a certain type of contrast and x-rays are taken and that gives us a good sense of the anatomy and any evidence of any hiatal hernia. And then lastly, esophageal manometry which is a test that tests the function of the esophagus that helps us decide which type of operation they would be a candidate for.

And as far at the surgeries go, so any anti-reflux surgery is going to be minimally invasive. So, laparoscopic. There are some surgeons who are using the robot. But for the most part, laparoscopic surgery is the standard of care. It usually has two components. If there is any hiatal hernia, the first portion of the operation is to fix the hiatal hernia and that just means closing that defect in the diaphragm that's gotten too big and has allowed the stomach to pass up there.

You pull the stomach back into the abdomen and you fix the diaphragm.

And then the second portion is what we call the anti-reflux component and that's either going to be a fundoplication also know as a stomach wrap which is kind of the historical gold standard and the newer option for that is the LINX magnetic sphincter augmentation device. So and it generally takes about an hour or so to do. Patients can sometimes go home the same day, sometimes stay overnight.

And then depending on the procedure, we will put them on a certain type of diet in the weeks following surgery. But for the most part, patients are very satisfied. They are up walking the same day of surgery and as far as reflux control; 80 or even 90% of patients can expect to either decrease or completely stop their antacid medications.

Host: And about things that they can do to hopefully prevent it in the first place but that if they are somebody who has questions about surgery, they don't want to be on medications; what would you like them to ask their surgeons about LINX and fundoplication and all of these different procedures you mentioned?

Dr. St. Julien: A lot of people out there have a fear of surgery. I think they feel that they have reflux, their doctor just gives them their medication and even though they are struggling with it, that's just going to be their life. So, I want people to know that you don't have to struggle with reflux. If the medications are not working, there are very good options and yes, it's a surgery, but it's a very effective and minimally invasive surgery with excellent outcomes.

So, if someone is considering surgery, because their medicine aren't working or if they don't want to take the medicines out of concern for long-term effects or any reason that they may be considering surgery; I think that should be brought up with their primary doctor or their gastroenterologist and ask to see a surgeon. Here at St. Anthony's we have a Heartburn and Swallow Center which is a great place to start. There's a phone number that can be called and there's a nurse navigator that can really guide them through the entire process.

Host: Well that's great information. Dr. Patil, last word to you. What would you like listeners to know about things they can do at home to help control their own symptoms, whether it is we have talked about obesity or diet, alcohol, exercise, sleep any of these things, please – you know to deal with our GERD symptoms.

Dr. Patil: I think the most important thing to do is if patients are overweight or obese is to start a weightloss program including diet, exercise with the goal of losing weight. Oftentimes, this can have a profound effect on patients' symptoms. The second thing is I think in terms of medications over-the-counter medications are very great in controlling these symptoms. Medicines such as Pepcid, previously Zantac which has now been pulled off the market, Tums. These medication are very effective and can be taken as needed. And many prescription drugs have now become over-the-counter and are very effective in controlling these symptoms.

I think when it comes to treatments for GERD, I think medical treatments such as diet, exercise, or even medications are very effective in healing a lot of patients' symptoms and I look at medications and surgery as kind of like what we do for eyesight. You can wear glasses for the rest of your life, that is taking medicines for the rest of your life or you can get LASIKS surgery and fix it once and for all. So, I do think that surgery has a role and I think there are patients who are candidates for that. But I think the most important thing is that when the symptoms are not responding to medications to seek help and seek evaluation by a gastroenterologist because not all symptoms of heartburn is GERD and sometimes you do need an endoscopy to exclude other conditions that might be masquerading as GERD.

Host: Well thank you both so much for joining us today and sharing your expertise and explaining to the listeners what they can do to help themselves if they do have GERD and what their options for treatment are. That wraps up this episode of BayCare HealthChat. To learn more about BayCare's gastroenterology services head on over to our website at www.baycare.org for more information and to get connected with one of our providers. If you found this podcast informative, please share. We all know somebody with GERD. So please share on you social media, share with friends and family and be sure not to miss all the other interesting podcasts in our library. Until next time, I'm Melanie Cole.