Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we're discussing GERD. Joining me is Autumn Ward. She's a Nurse Practitioner who specializes in Digestive Health at the Carle Foundation Hospital. Autumn, I'm so glad to have you with us. What a prevalent problem this is. Tell us a little bit about GERD and how common it is.

Autumn Ward, NP (Guest): Thank you for having me. So, GERD or gastroesophageal reflux disease is definitely one of the most common and chronic gastrointestinal diseases and is thought that up to at least 20% of the US population has a diagnosis of GERD. It definitely can have an impact on an individual's life, including physical activity, social functioning, disturbing sleep patterns, which then in turn can affect anyone's daily activities, productivity at work.

So, it definitely is a very common problem. GERD is caused by the flow of gastric or stomach contents upwards into the esophagus that results in both symptoms and possible complications. The most common symptoms of GERD are heartburn, which is the burning sensation in the chest behind the breastbone and regurgitation, which is the feeling of fluid or food coming up into the chest. Many people can experience both of these symptoms, but some people can have one without the other.

Host: That's interesting. And I'm glad you pointed that out because many people assume that heartburn is GERD, which sometimes we can get periodic heartburn that doesn't necessarily reflect gastroesophageal reflux disease. So, tell us a little bit about when it's important to diagnose this issue and talk about diagnostics for us Autumn, because we get our colonoscopies for the lower ends of our body, really, as a screening. But the screening situation for GERD is definitely not the same. So speak about diagnostics, a little for us.

Autumn: Yeah. Well, first of all, a big question, acid reflux, GERD, and heartburn are typically used interchangeably. But they have different meanings. Heartburn is a symptom of GERD. GERD itself is a diagnosis, defined as regular symptoms, which occur two or more times a week caused by the flow of gastric contents into the esophagus. And then acid reflux is the reason why patients have GERD. A diagnosis of GERD typically can be done based on physical and history alone.

However, when talking to your primary doctor or your gastroenterologist, there are times where we need to evaluate these symptoms a little bit further, especially if you are having heartburn two or more times a week, you're taking over the counter medications and symptoms are not improving. We want to also use diagnostics, not only if you are having heartburn and not improving with medications, but if you ever have trouble swallowing, dysphasia, bleeding or choking episodes. So some of the studies that we can do is an upper GI series, and that's where a patient would be asked to swallow a liquid barium mixture.

And then the radiologist takes a series of pictures and videos to watch the barium travel into the esophagus. An upper endoscopy, which is probably the most common study that most providers would send patients to us for, would be passing the lighted flexible tube into the mouth, into the esophagus and stomach to examine for abnormalities. And this test is done with the aid of sedatives. And there is also pH testing, which measures the amount of acid or fluid refluxing into the esophagus and can be helpful with the diagnosis and treatment of GERD. We do use a Bravo pH monitoring test here. It does take some coordination with scheduling because it is placed endoscopicaly. But it is a capsule that is placed into the esophagus and can measure the amount of acid being refluxed into the esophagus. There is also esophageal manometry testing that is measuring the contractions of the esophagus.

Host: Well, thank you for the comprehensive list of the testing that you're doing at Carle Foundation Hospital. And before we get into some more of the medical therapies, tell us about your team, Autumn, the people that work around you that are doing the endoscopy's and the barium swallows and everything you just discussed.

Autumn: So we are a team of eight gastroenterologists. I believe we have about 10 Advanced Practice Providers, which include Nurse Practitioners and Physician's Assistants. The gastroenterologists are the ones who will do all the endoscopy's. And then we also have nurses that will do the pH testing and manometry testing, working with the gastroenterologist physician.

Host: Very multidisciplinary team. You know, that's the approach that we need when these GI issues arise. Tell us a little bit about some of the updated medical therapies. What are you doing for people after the diagnostic tests and you've ruled that they do have GERD, then what? What are some of the treatments available today?

Autumn: Well, certainly the number one discussion is lifestyle modifications. Patients can have certain foods, and there are known certain foods and beverages that can trigger reflux; chocolate, coffee, peppermint, greasy, or spicy foods, tomato products. Alcohol can also lower the lower esophageal sphincter pressure and can contribute to acid reflux. If you are a smoker, the number one discussion that we will have with patients is to stop smoking. Tobacco can result in acid reflux and is one of the biggest risk factors for esophageal cancer. Weight loss is also encouraged if overweight. Excessive abdominal fat is one of the biggest risk factors for heartburn. Waiting at least two or three hours after eating before laying down, is also recommended. Gravity is one of our biggest protections against acid reflux. So, keeping the head of the bed elevated at an angle is also very helpful for nighttime symptoms. There are numerous over the counter medications that we can use for the treatment of occasional heartburn. These medications help to neutralize the acid in the stomach. So medications such as Tum's and Mylanta.

And these can provide quick release, but alone do not heal an inflamed esophagus. So, then you'll also have the medications, the H-2 blockers and PPI therapy. H-2 blockers have been around since the mid seventies in the treatment of GERD or reflux disease and these help improve symptoms of heartburn and regurgitation. We know them commonly as ranitidine or famotidine. And H-2 blockers are generally a little less expensive than proton pump inhibitors or the PPIs, but can serve definitely as initial treatment or maintenance therapies in reflux disease with mild symptoms.

So then we also have the PPIs, our proton pump inhibitors, omeprazole, pantoprazole. And these are stronger acid blockers than the H-2. They allow time for damage of esophageal tissue to heal. This medication is designed to decrease the amount of acid in the stomach, and is better at healing ulcers in the esophagus and stomach as well.

And they are typically required to achieve effective long-term maintenance therapy in a significant number of patients with heartburn and reflux disease. Both of the H-2 blockers and PPI's are available over the counter at a lower dose. Many patients will need higher dosage, which is a prescription. Those are our standard treatments, that many people know about. I'm not sure if this will come to fruition or you know, where it will be, but there is a new medication potassium-competitive acid blockers, or P-CABs that are being used in the Asian countries, I think since about 2015. Vonoprazan is the name of the medication and it's a more potent, longer acting than traditional PPI's. And they, it has been used for the treatment of gastric and duodenal ulcers, healing reflux esophogitis and prevention of relapse. However, it is unclear if this will be an appropriate and safe long-term, lifelong treatment. And so I think there's more to come with this medication.

Host: What about surgical interventions Autumn? Just briefly touch on some of the ones that your team is doing at the Carle Foundation Hospital.

Autumn: So there are surgical options available for patients who just don't respond to medical therapy and have had adverse reactions. Fundoplication is a surgical intervention that can be done. There is also the LINX device, which is a ring of tiny magnets that can wrap around the junction of the stomach and esophagus and that magnetic attraction is strong enough to keep the junction closed for prevention of reflux, but weak enough to allow food to pass through. With any surgical intervention, there's definitely going to be additional testing that's required. Definitely an upper endoscopy, pH testing, manometry likely. So it's very important, for our collaborative process with the gastroenterologist and the surgery team before pursuing a surgical intervention.

Host: That's great information. So wrap it up for us. What would you like listeners, other providers to know about gastroesophageal reflux disease and what you are doing at the Carle Foundation Hospital?

Autumn: I think very important. Heartburn is common, but it is not a trivial condition. If you are experiencing heartburn two or three times a week, that could be reflux disease and definitely should not be ignored. If left untreated, longstanding, severe chronic heartburn, reflux disease can be associated with pre-cancerous changes such as Barrett's esophagus and esophageal cancer. So, it definitely should not be ignored. And if there's any concern, primary care physicians can refer patients to GI for evaluation. Can also order upper endoscopy's for us to proceed with that for an evaluation as well. So, definitely very important, to not ignore these symptoms in these patients.

Host: Thank you so much, Autumn for joining us today. For more information, and to get connected with one of our providers, you can visit carle.org or for a listing of Carle providers, and to view Carle's sponsored educational activities, please visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.