Joey Wahler (Host): It causes indigestion and discomfort, so we're discussing heartburn. Our guest, Dr. Rudolf Schilli. He's an Internal Medicine physician and gastroenterologist with Beebe Healthcare. This is the Beebe Healthcare Podcast. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Schilli. Welcome.

Rudolph Schilli, MD: Hello, hello.

Host: So first, your education and certifications were in the Chicago area, right? Tell us about that if you would.

Rudolph Schilli, MD: Correct. My undergraduate training was at the University of Illinois. And after that, I went to Northwestern University Medical School. And after four years of medical school, I had five years of postgraduate training in Internal Medicine and Gastroenterology.

Host: And so, how long have you been with Beebe and what brought you there?

Rudolph Schilli, MD: I've been with Beebe now five and a half years and what brought me here was that I was kind of done with my practice in Pennsylvania. And since my wife and I built a house here, I wanted to stay in Medicine so that's why I got employed by Beebe.

Host: Great. So, we've heard the term, but what exactly is heartburn because it can manifest itself in different ways, right?

Rudolph Schilli, MD: Correct. But what heartburn is, it's a disagreeable sensation, usually of burning in the chest area. And associated with heartburn, quite often patients feel reflux or stomach juices, you know, that come up and can reflux all the way into their mouth. Now, besides these typical symptoms, sometimes there's atypical manifestations of this kind of reflux, mainly chest pain, cough, even wheezing.

Host: So obviously, this is someone that can greatly adversely affect someone's quality of life.

Rudolph Schilli, MD: Absolutely. At its very worst, these patients are tormented. They wake up at night with really a hot feeling at the back of their throat, coughing and sputtering. And all through the day, they have continued disagreeable sensations of reflux and heartburn. For some people, it can be a living hell.

Host: So speaking of which, what services are offered at Beebe Healthcare's Heartburn Center in order to address all this?

Rudolph Schilli, MD: We recently got new technology, which was new for Beebe, but not necessarily new overall. And the purpose of this new technology is to really distinguish those patients who need laparoscopic surgery to fix their reflux. And let me just explain further, like when we get patients who have reflux that does not respond to the standard medication, then we wonder, are they really candidates for laparoscopic fundoplication, which is not really that big a deal because it's laparoscopic, but it can really be a godsend for those patients who suffer.

So, what we do, and one of the items of technology is called the Bravo pH Monitoring system, where the patients come for endoscopy, they get sedated, and we pass the scope, and we measure off where the end of the esophagus is. And then, we have a catheter with a capsule at the end of the catheter, and we affix it to the esophagus, and it's really a marvel of technology because it sends wirelessly data to a recorder that you wear on your waist that actually measures the exact acid level of your lower esophagus every minute for 96 hours.

So in that context, then, we identify patients who have abnormal reflux. Then, if they have abnormal reflux and their symptoms can't be cured with simple medicine, they have another test called high-resolution esophageal manometry, which is a big term for determining the motility or pressure characteristics in their esophagus. And this we do in the office, and it determines for the surgeon what type of wrap he is to do surgically. So, it has very valuable data for the surgeon.

And that's kind of the two things that we have now that we did not have a year ago. And the reason that's important is because I've seen patients in the office who were convinced they had reflux. I was convinced that they had reflux. Then, we do the Bravo test and we show no reflux. So obviously, you shouldn't be sending them for surgery when they don't have reflux.

Host: So, when you have this new technology at hand, what's that like for you and the people you work with at Beebe to be able to offer this now?

Rudolph Schilli, MD: It offers us a whole dimension of care that we did not have before. And let me just go backwards in time a little bit. When I had my practice in Western Pennsylvania, I had a really big practice and most of our practice was open referral for scoping. In other words, family doctors would just send patients for upper endoscopy or colonoscopy. And I got tired of seeing these poor souls who had such horrible symptoms of reflux. And I would tell the family doctor, "Go ahead and give them another proton pump inhibitor." And then, they would send them again in a year because they didn't get better. And so, I thought they're wandering around, you know, like the Lost Tribe of Israel looking for the promised land, and we weren't giving it to them. So, that's where I got interested in these other techniques, and that's what started me on this.

Host: Now, switching gears a bit, over-the-counter medication is also a treatment option for heartburn. So, how should someone decide if that's the way to go?

Rudolph Schilli, MD: Well, heartburn is a very common symptom in the United States. Something like 20% of all people will have the symptom once a week. And now, those patients who only have it once a week aren't really the serious ones that we really want to treat and fix. But the main thing is when somebody has reflux, they should, number one, assess where they're at with their body, their lifestyle. And if they're overweight, they should lose weight. If they're more sedentary, they should exercise. And quite often, just weight loss, control of diabetes, and exercise will make the heartburn go away without an over-the-counter medicine. But if they do need an over-the-counter medicine, there's a whole variety for them to pick from. And really, I think it's okay if that is not a frequent encounter. In other words, if they use it just sparingly and don't have to do it every day, they're okay in my opinion.

Host: If they're more at the low end of the spectrum there, so to speak.

Rudolph Schilli, MD: Right. Now on the other hand, if patients have been on a more powerful drug like Nexium or Protonix, then we look at, has this been over years? And then, in those kinds of situations, we wonder about the development of Barrett's esophagus, which is a premalignant condition of the esophagus. And under those circumstances, we would want to then endoscope them to see whether or not they had Barrett's esophagus, which is a separate issue from the acid measurements that we're talking about.

Host: Gotcha. So, a couple of the things you referred to there, doctor, the improved lifestyle importance in terms of exercise and diet, and also figuring out whether you're in a category where you should try some over-the-counter medication first, as opposed to something more serious, I would imagine, obviously, these are some of the things you're going to go over with a patient in initially diagnosing them.

Rudolph Schilli, MD: Well, absolutely. You see, patients that we see are the worst of the worst. Somebody who has just casual heartburn that quickly resolves on its own, they don't need to come see a gastroenterologist. But the ones that we see tend to be more complicated patients, and I go over everything with them. You know, we don't want them to have these tests if they're not committed to further improvement of their own care. You know, if somebody says, "There's no way I'm going to have this surgery," well, then there's no reason to do the studies, you know, in that circumstance.

Host: Gotcha. One more on over-the-counter meds for heartburn. You mentioned these are commonly used, of course. Any frequent misconceptions about those that you can clear up for people?

Rudolph Schilli, MD: Not so much the standard antacid treatments that people get like Tums and Rolaids. But when we talk about proton pump inhibitors, I've had patients who've refused to take them because of the erroneous literature that they've read on the internet, or really the erroneous things that they see on TV.

Most of these studies linking these drugs with osteoporosis and various other conditions really don't prove to be reliable. In other words, somebody publishes a paper, then it's on the NBC news, people watch the news and they don't realize that the paper is really a bogus paper and not that scientific to begin with. So as a consequence, misconceptions get perpetuated to the point where I had a woman in Pennsylvania who've had a major bleed from a gastric ulcer, and I had to put five clips on the ulcer to stop the bleeding. She stopped taking the drug because she thought it might make her demented. Now, she was 86 and sharp as a tack, so I don't really know what she was worried about. And I told her, "What I'm worried about is you bleeding to death, not you developing dementia when you're 110."

Host: Absolutely. Now, how about examples, doctor, of foods that can trigger heartburn? And can you offer some alternative suggestions for more of a heartburn-friendly diet here?

Rudolph Schilli, MD: Well, you know, this is something that there's a lot of foods that can trigger this, namely spicy foods, chocolate, red wine. The patients can go on the internet, they can see a whole list of things. My philosophy is we want to create the best situation we can for the patient. I've kind of shied away from being very rigorous about the diet because they're not going to follow it anyway. You know, over the years, they're just not going to do it. So the best thing, it's like golf, you have to play it where it lies. And I try to make the patients have a lifestyle that they can accept without making too many intrusions on my part. So, that's really the overriding philosophy.

Host: You have to play it where it lies. That's a great analogy, huh?

Rudolph Schilli, MD: Yes.

Host: So, you've basically found that by building in the likelihood that there are certain things people aren't going to follow, as you just pointed out, you've got to kind of take them in a different direction then?

Rudolph Schilli, MD: Yes. I tell them about the dietary factors. But, you know, I think that avoiding certain trigger foods is less important than stopping smoking, getting your diabetes under control, losing weight, and exercising.

Host: Well, again, you mentioned exercise there. Any other lifestyle changes people can make to try and help prevent or lessen heartburn and are there any surprising habits that might be contributing it to surprise people that may not be aware of?

Rudolph Schilli, MD: I think I'll turn that question on its head a little bit. There are symptoms that they might have that they don't recognize as being reflux. And we had a phrase in Internal Medicine, everything that wheezes is not asthma. Because somebody who has bonafide asthma may have worsening of their asthma by acid reflux, and they may not even be aware of the acid reflux as opposed to being aware of their asthma.

Host: Understood. So for heartburn sufferers, any potential underlying conditions that might need to be addressed?

Rudolph Schilli, MD: Absolutely. Patients who have continued heartburn that's very severe, we have to worry about Barrett's esophagus being present, and that's a premalignant condition of the esophagus that can lead to esophageal cancer. And a lot of gastroenterologists feel that Barrett's esophagus is the vehicle for which we've been seeing increases in esophageal cancer in this country. And esophageal cancer is really a desperately bad kind of situation for patients. So, whatever we can do to forestall its development is going to be very useful for their lives. So, that's one thing. The other thing we look for is sometimes esophageal cancer in and of itself can produce symptoms that make the patient think that they have ordinary heartburn, when in fact it's not the case.

Now, the warning signal we look for in patients with heartburn is difficulty in swallowing because these are the types of patients who may have esophageal cancer or may merely have a complication of reflux, which is esophageal stricture, which is a narrowing or scarring of the esophagus.

Host: A couple of other things. You mentioned earlier some of this new technology that's available now. And when you talk about that, what would you say, generally speaking, would be the chances of most people being able to successfully address heartburn with these options now available?

Rudolph Schilli, MD: Well, that's interesting. You know, one of my patients in Western Pennsylvania asked me when we discussed the laparoscopic surgical approach to it, asked me, "Well, what are the results?" And I said, "Well, maybe I've referred maybe a thousand patients for this and almost none of them come back."

Host: Well, those are some eye-opening statistics, right?

Rudolph Schilli, MD: Yes.

Host: No repeat offenders, so to speak.

Rudolph Schilli, MD: Hardly any. Hardly any.

Host: Hardly any. That's a tough batting average to beat. Those sound like Hall of Fame numbers, right?

Rudolph Schilli, MD: Very much Hall of Fame numbers.

Host: And finally, to visit Beebe Healthcare's Heartburn Center, doctor, do patients need a referral?

Rudolph Schilli, MD: As far as I know, they do not. They can call on their own and and schedule an appointment for a consultation. And I think that it's important for them to be able to do this independently rather than through their doctor because some of the problem is that some doctors might not be as attentive to the patient's symptoms as other doctors, and this is one way for them to find satisfaction in their health care.

Host: And then, finally, you mentioned once again, you have to play it where it lies. I saved the most important question for last, doc. How's your golf game these days?

Rudolph Schilli, MD: My golf game's pretty terrible. My game in Gastroenterology is a lot better.

Host: I was just going to say those numbers for you on the golf course, not quite up to snuff with your numbers at successfully treating patients, but that's a good thing, right?

Rudolph Schilli, MD: Yes, I agree.

Host: Well, folks, we trust you're now more familiar with Beebe Healthcare's Heartburn Center. Dr. Rudolph Schilli, a pleasure. Keep up the great work and thanks so much again. And for more information, please visit beebehealthcare.org. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for being part of the Beebe Healthcare Podcast.