Bill Klaproth (Host): So, let's talk about acid reflux. You know, that burning sensation in your chest, that sour or bitter taste in the back of your mouth. It is not fun. So, let's explore its causes, symptoms, and the various ways to manage this common yet very uncomfortable condition. Hopefully, we can help you soothe the burn. Let's talk with Dr. Nathan Allison, a bariatric and general surgeon, and Dr. Xiaosong Song, a gastroenterologist, both with Health First.

This is Putting Your Health First, the podcast from Health First. I'm Bill Klaproth. Dr. Song and Dr. Allison, welcome.

Dr. Xiaosong Song: Hey, Bill. Thanks for having us. Glad to be here.

Dr. Nathan Allison: Thanks, Bill.

Host: Absolutely. Dr. Song and Dr. Allison, we certainly appreciate your time. Dr. Song, let me start with you. So, heartburn is a common condition most people experience at some point in their lives. Is heartburn the same thing as acid reflux?

Dr. Xiaosong Song: It's not. Heartburn is a symptom people present with, and it's a common symptom of acid reflux, but heartburn does not necessarily mean that a patient has a reflux disease.

Host: Okay. So, heartburn is just a symptom of acid reflux.

Dr. Xiaosong Song: Right.

Host: Okay, got it. So then, what exactly is acid reflux?

Dr. Xiaosong Song: Acid reflux is an excessive acid exposure in the esophagus, which can cause different kinds of symptoms like heartburns, chest pains, and regurgitations.

Host: So, it's an excessive exposure to acid. Okay. So then, I see the TV commercials all the time. This seems to be pretty common among the public, is that right?

Dr. Xiaosong Song: Absolutely. It's one of the most common GI tract diseases.

Host: And then, what causes this?

Dr. Xiaosong Song: It's really caused by excessive acid into the esophagus and sometimes because of anatomical reasons like hiatal hernia, but sometimes just that patient for whatever reason has excessive acid going to the esophagus

Host: So, does this generally happen later in life or can this affect anyone at any age?

Dr. Xiaosong Song: Acid reflux can happen anytime in your lifetime. It happens in the pediatric population as well. It can happen anytime. I can't usually associate it with different reasons, for example, the dietary changes, the weight gains, and the stress, and also anatomical reasons, like if a patient, for whatever reason, starts developing a hiatal hernia. So, it could be multifactorial.

Host: Okay. So, several different reasons. You mentioned dietary change, weight gain, stress, other things as well. So then, what are the typical signs and symptoms then of acid reflux?

Dr. Xiaosong Song: Acid reflux, the common symptom of people presenting is usually a heartburn, meaning a burning sensation in the middle of the chest, and you also can experience pain in the middle of the chest. Sometimes the patient is regurgitating foothey'rehey actually having the sensation of food coming up to their esophagus. There are also atypical symptoms. Sometimes people can feel a lump in their throat, and sometimes they can't have change of their voices.

Host: And are there different types of acid reflux?

Dr. Xiaosong Song: Well, we don't really typically divide it into different types, rather than the severity of the symptoms. So, people can have very mild symptoms, sometimes people can have severe symptoms, and sometimes people actually have acid reflux, and they don't have any symptoms. We call this type of patient a silent reflux.

Host: So, Dr. Song, when thinking about this, are there certain foods or lifestyle behaviors that can trigger acid reflux?

Dr. Xiaosong Song: Absolutely. As one of the common GI tract diseases, food intake has a lot to do with acid reflux symptoms. Acidic food can trigger the symptoms, and food can produce acid productions like chocolate. Caffeine also can trigger reflux symptoms. And also, lifestyles, for example, people eat very late at night or they drink a lot of water before they go to bed, it also can trigger acid reflux symptoms.

Host: So, it seems like through lifestyle modifications, people can start to address this on their own by watching what they eat, addressing stress levels, not eating late at night, those types of things, over-the-counter medications. If those things don't work for someone, what are the next steps of treatment?

Dr. Xiaosong Song: Absolutely. So, as you said, Bill, you're exactly right, we always start with the basic. We want people to realize that since this condition has a lot to do with your diet and their lifestyle, we always want to modify that, especially when the patient comes in with mild to moderate symptoms and they just started the symptoms.

So after doing that, if the patient has persistent symptoms and we're going to try to use medication to help with controlling the symptoms. And the medication we use are different types of medications. For example, we call it H2 blockers. That's available over-the-counter like famotidine. And also, there are over-the-counter proton pump inhibitors like omeprazole, Nexium, and Protonix. You can try from your primary care doctor's office or just over-the-counter buy that medication if you start having the symptoms without any, we call, alarming signs.

And so, this is very important. We don't want anybody to treat by themselves for a long period of time without being evaluated, especially if you're presenting with alarming signs. And the alarming signs include difficulty swallowing. You're feeling that when you swallow, food get caught and going slow, or you have pain while swallowing, or you're losing weight for no other reasons. This is the time that you should be evaluated by a gastroenterologist to figure out what was the cause of the problem. But if you don't have any of them, especially if you're a young person and just started to have periodic heartburns, despite of lifestyle and diet changes, you still have the symptom, it's reasonable to try over-the-counter or empirical either the famotidine or any of the PPIs.

Host: So, for someone who is struggling to try to manage this on their own, when is the time to see the doctor?

Dr. Xiaosong Song: That's a great question, Bill. So, usually, we tell the patient to try the empirical therapy for about six weeks, four to six weeks. If your symptom does not improve or completely resolve, it's the time you should see a gastroenterologist.

Host: And then, what happens if acid reflux is left untreated?

Dr. Xiaosong Song: So, very important that people need to understand that acid reflux does cause consequences. And it can cause stricture or inflammation in the esophagus and eventually can cause difficulty swallowing. And also, left untreated for a long period of time, it can develop Barrett's esophagus and eventually can develop esophageal cancer.

Host: Oh, boy. Okay. That's not good. So, let me ask you this then. I also hear the term GERD a lot. Where does GERD play into this? How is GERD different from acid reflux?

Dr. Xiaosong Song: So, GERD is actually called gastroesophageal reflux disease. Usually, we use esophageal reflux as a short form for GERD. So, this is interchangeable.

Host: Okay. Interesting. It's not something separate or something different. It's basically a shorter term for acid reflux. And Dr. Allison, I want to bring you in. Thank you so much for your time today. So, we just heard what happens if GERD is left untreated. Some really serious complications can happen. This is not anything you want to fool around with. So, if the lifestyle modifications don't work, if the medications don't work, it sounds like it's going to end up on your doorstep. Can you tell us about the surgical interventions and the next level of treatment then?

Dr. Nathan Allison: The GERD on a continuum, it's a progressive disease. So, no matter what age you are first diagnosed with it, you're going to have that disease the rest of your life. It's how you manage it the rest of your life that's important. And so, like Dr. Song mentioned, you can have this disease process start at any age. Most of the time, people will develop this disease process later on in their life. That's the typical presentation. However, I have 21-year-old patients that have had reflux their whole life, and I've had 90-year-old patients that just got reflux, so there's a continuum.

But once you're diagnosed with GERD, either your primary care or your gastroenterologist will manage that for a time. And then, there will be an inflection point or a break point where you just say, you know, "This isn't working. And that's when I get involved. Now, most of the time when a person is coming to my office, we tried the usual H2 blockers, PPIs. And I usually tell folks when you're escalating dosages to control symptoms and they're still not controlled, or if you have the term is odynophagia, but it's pain with swallowing, or if you're having trouble swallowing, like Dr. Song mentioned, if you're having those symptoms in addition to your GERD, despite being on medicine, it's time to be evaluated and make sure we know exactly what's going on.

And that's when I typically will get involved. A lot of times, for example, with Dr. Song, he's done the workup. He sends me the patient, and he knows when to appropriately refer the patient over. However, you know, everyone is listening to this, not just other GIs. And so, a primary care physician or a dentist or an Ear, Nose and Throat, or a Pulmonary doctor, those are referring doctors that we see quite often that are sending to us for the diagnosis confirmation, and then a treatment.

And I'll say one other thing about GERD, you know, we try all of the different lifestyle and behavioral modifications, all the way up to and including medicine. But typically, I give patients an option when they get to my table, by the time they're getting to me, they're pretty fed up with a lot of different things. And so if you're a younger person, and remember this is a progressive disease, if you're a younger person, we're going to say, "You know what? We might want to do something earlier," because otherwise you're going to be on this medicine for 50 or 60 years versus if you're someone that's 85 and you're just getting this. We're not going to rush to do anything dramatic. We're going to manage this the way Dr. Song was mentioning.

Host: So through this process then of managing it, if it does land on your doorstep and surgical intervention is needed, can you correct the condition or do you provide long-term relief? For someone listening, that's got to be a very big question.

Dr. Nathan Allison: I like to always answer that question by just a very simplified way of saying what GERD is in terms of the physics of it, so then you can understand how I'm going to approach it. So, what's happening in its most basic form is the pressure inside the stomach is higher than the pressure of the lower esophageal sphincter. Some people call it the sphincter, some people call it a valve, but the very bottom of the esophagus has a intrinsic resting pressure that's tight. Think of it like a grip or a handshake that you're holding something. And so, you're gripping this thing. And so, that intrinsic pressure, that pressure that is always there keeps food from coming up, keeps acid from coming up. And so when that pressure in the stomach, for whatever reason, you gained weight, you ate a big meal, a whole host of reasons, but whenever you drink a carbonated beverage, whenever you increase the pressure in your stomach such that it's consistently higher than the lower esophagus sphincter pressure, then you're going to have a reflux, okay? So if you think about it in terms of physics, the esophagus squeeze is pretty strong. This valve at the end of the esophagus has a normal tone or a normal resting pressure. We call that the lower esophageal sphincter resting pressure. And then, we have the stomach or intra-abdominal pressure.

So, most people have a stomach that is squeezing at 8 to 10. If you're AM obese or morbidly obese person, it might be 10 to 12 or 12 to 14. The valve pressure is supposed to be around 15. And then, the esophagus is usually in the neighborhood of 35 to 100, maybe 110. And so, you want the numbers to go from the esophagus down. The numbers in the esophagus are big. The numbers in the lower esophageal sphincter are between that number and then the stomach being the lowest number. So, if you have that going from a high to a low number, everything is going to flow in one direction. What happens is, because of anatomical considerations like Dr. Song was saying, hiatal hernia, or increased weight, or the valve is weakened, now you get an inverse relationship. When you think about this, it's just plumbing and it's just physics. when the pressure is higher in the stomach than it is in the valve, stuff's going to come up. And so, when you think about it that way, there's two ways that you can fix reflux in its most general form.

You can either, A, tighten the pressure of the lower esophagus sphincter, so you're increasing the resistance to open and let stuff come up, or you can decrease the pressure below the valve. In this basic form, those are the two easiest ways to think about fixing reflux. And so, we have all of those options at our disposal here to be able to fix incorrect reflux.

Now, as I said earlier, reflux is a progressive disease. And so, in addition to being progressive, it's a lifelong disease process that's going to require lifelong management. I hate to use the word cure, because as soon as you cure something, something else happens, and then you kind of go down that rabbit hole. So, it's a management process. But if you mean cure is the patient's not on medication, they're not having the symptoms anymore, and all of their numbers and their laboratory values and their endoscopies look normal, if you consider that a cure, then that's great. But I will say, you know, "Let's see what it looks like in five years," "Let's see what it looks like in 10 years."

And so when you think about this process, it really depends on your workup. Dr. Song will do a workup that includes an endoscopy, a swallow evaluation, also possibly what's called a Bravo pH test that looks at what is my true acid score? For example, if I said to you, "Hey, how bad's your reflux?" You're going to say, "Oh, it's pretty bad." But I don't know what that means objectively, I just know that subjectively you think that it's really bad. It could be very severe, or it could be very minor in terms of the score that we talk about. So, we have to get that objective data. And then, we apply that data to what we know to be things to fix it.

So, we think of fixing this reflux problem in two ways, tightening the pressure on the valve or lowering the pressure below the valve. And so, when you think about tightening the pressure, that's the most common thing people think about. "Doc, I want you to fix my valve." And so, we have endoscopic treatment options where we go in just like the normal endoscopy that we diagnose reflux with and we can tighten or hypertrophy the muscles at the bottom of the esophagus, so they are not so willing to open up and let stuff come up. Then we also have surgical options, which we do quite frequently here. And those options are minimally invasive, usually in the 30 to 40-minute range where we're going in and we're tightening that valve, and then allowing that valve to stay tight, and we have lots of options for that.

But there's one other important point that Dr. Song made, which was the anatomical part, which is what are we doing about this person if they have a hiatal hernia? And a hiatal hernia is a hole in the diaphragm that allows the stomach to slide up into the chest, and it puts an abnormal amount of pressure on that valve. So, for those of you that don't know this, the chest is a negative pressure environment. And the abdomen is a positive pressure environment. So whenever you have a hole in a, think of it like a doorway separating those two things, everything is going to want to go up into the chest. And so, the stomach will slide up into the chest and now you've got a little bit, or in some people, a moderate or even a lot of stomach above that diaphragm in a place where it's not supposed to be. And so then, you get this kind of siphoning effect. If you've ever seen those old timey water siphons, where you pull the handle and water comes up out of the ground, it works very similar to that. So, you're getting this refluxing type of event because of the anatomy there. And so, that's what we try to fix, is we try to correct the anatomy and then tighten the valve.

Host: When you know what the problem is, you understand what the fix is. So for someone who has hit this inflection point, as you mentioned earlier, Dr. Allison, and now they are having acid reflux, Dr. Song, let me ask you, what is the first step then?

Dr. Xiaosong Song: In general, we are looking at the patient's age. You know, if you're younger than 50, you don't have any alarming signs, which we referred to early on, like difficulty swallowing, pain with swallowing, and unintentional weight loss, you can try an empirical treatment for four to six weeks. If your symptom does not completely resolve, then you should come to see a gastroenterologist.

If your symptoms resolve, then the next step is actually you're going to start tapering the medication, see whether you're able to taper them. Some people cannot. If you are able to taper the medication and use as needed, and I think that you probably do not need to see a gastroenterologist, but if you cannot taper off the medication for 12 months, according to the American Gastroenterology Association recommendations, we need to do further testing to see why you cannot get off it. But if you do not respond in four to six weeks of a therapy, you also should see a gastroenterologist at that time.

Host: Well, that makes it very easy to understand. If the lifestyle modifications and medications aren't working after a year or you can't taper off the medications within a year, it sounds like that's when you're going to need to go to this higher level of intervention. That's where Dr. Allison comes in.

Dr. Xiaosong Song: Absolutely.

Host: Well, this has really been fascinating. I know this affects a lot of people, so I want to thank you both very much for your time today.

Before we wrap up, if I could just get final thoughts from each of you, I would appreciate that. Dr. Song, let me start with you. Anything you'd like to add?

Dr. Xiaosong Song: GERD is a very common GI tract symptom, but don't take it for granted. If you don't respond to medical therapy or you have prolonged symptoms, come to see us. And then, we should work it out to figure out what's the problem, and then we'll move on.

Host: Absolutely. Very well said. And Dr. Allison, final thoughts from you?

Dr. Nathan Allison: Yeah. So, I agree with Dr. Song. It's a disease process that can largely go ignored until it's kind of too late. And so, my take-home message would be, if you're having symptoms despite your medication, you might be a candidate for some of the options that we talked about briefly about the procedures to fix this problem. So, you can either, A, come off your medication or, B, be better controlled.

I say to people all the time, 20 minutes can change your life for the better in terms of this process. And so, if you think about that in terms of how much time we've been talking for about 20 minutes and, in 20 minutes, we could change a person's life forever in the trajectory of their reflux. So, I think we have a lot of options to offer people in 2024.

Host: Well, that's a great optimistic note to wrap this up. There are a lot of options to offer people in 2024. This has really been educational and informative. Dr. Song and Dr. Allison, thank you so much for your time today. We appreciate it.

Dr. Xiaosong Song: Thank you, Bill.

Dr. Nathan Allison: Thanks Bill. Have a great day.

Host: And once again, that's Dr. Xiaosong Song and Dr. Nathan Allison. For more information, please visit hf.org/reflux. And thank you for listening to Putting Your Health First. And if you enjoyed this episode, please be sure to tell a friend, share on social media, and check out our entire podcast library. We look forward to you joining us again.