Caitlin Whyte: Heartburn is such a frustrating and painful condition to deal with, especially if it's chronic. So today, we're talking about heartburn, what it is, the best treatments and outcomes if you don't take care of it. Joining us for this chat is Dr. Igor Brichkov, This is Maimo Med Talk. I'm your host, Caitlin Whyte. Well, doctor, thank you for being with us today. Can you define heartburn and describe the common symptoms to start us off?

Dr. Igor Brichkov: Okay. So heartburn is basically, actually just one of the symptoms of a bigger disease, which we call GERD, gastroesophageal reflux disease. Heartburn is the most common symptom of that. And it's basically the sensation of a burning or a pain, typically in the middle lower part of your chest. Sometimes people feel it in the back. But it's basically an unpleasant sensation that some people get with gastroesophageal reflux disease that's not controlled.

Caitlin Whyte: So tell us more about the kinds of people that are affected by heartburn. I know for me personally, it didn't start until I was a bit older, but I know some people who've have had it much earlier.  

Dr. Igor Brichkov: Gastroesophageal reflux disease typically can actually affect infants.  there are some infants who are born with it to the point where some kind of surgical procedure to correct that has to be performed early on in life. However, that's sort of a different cause and something more congenital. In terms of adults with heartburn, typically, it has a lot to do with our diet and the way we eat and the way we live our lives and the way we incorporate our meals in our lives. We see about 10% to 20% of the Western world has gastroesophageal reflux disease, you know, and heartburn being the most common symptom. It, you know, typically peaks in onset in middle age, you know, 40s to 60s. But people get it as young as teenage years and most people who are in their 60s and 70s, some of them have it and don't even know they have it. And when they get their first endoscopy, there's evidence of some acid damage to the lower part of the food pipe.

The typical folks that get it, we typically see it in people who eat high fat diets, high typically greasy foods, not spicy foods. Spicy foods is a common myth. Spice does not necessarily cause heartburn, but it's the kind of foods that we eat with our spicy meals. Because if you're going to be eating chicken wings, hot chicken wings, buffalo wings, for instance, it's not the spice that's going to be giving you the heartburn after that. It's the greasy oil that it has been fried in that will do it. And then, we just naturally assume that it's going to be something spicy that's causing it.

Caitlin Whyte: Gotcha. Okay. So when is it time, would you say, to consult a physician? How do we know when our GERD or heartburn has reached a level that needs that medical attention rather than just, you know, running to the local grocery store or drug store for relief?

Dr. Igor Brichkov: Well, I mean, I think that if it happens to you on occasion, based on certain types of foods that you eat and you eat them once in a blue moon, you may not need necessarily to consult a physician for it. But we're talking about people who have this, you know, every day, almost every day or have symptoms with every meal or it doesn't matter what they eat and they're just getting symptoms. Or people with atypical symptoms, which is not always heartburn. So what we call atypical symptoms, symptoms that signal gastroesophageal reflux disease, but don't necessarily mean that it's heartburn itself. Some people wake up in the morning with that brash acid taste in the back of their throats. Some people wake up in the morning coughing, things like that, they're not typical, but they are fairly common symptoms of gastroesophageal reflux disease. If people are having that, if they're waking up every morning with those kinds of things, then they should probably consult a physician.

Caitlin Whyte: Well, let's talk about our relief options. Can you talk about treatment?

Dr. Igor Brichkov: Typically, the first treatment for any kind of gastroesophageal reflux disease is not medicine or surgery or anything like that, it's just modifying your lifestyle. So your typical patient is someone who lives a busy life. They have meetings all day or working all day long. They don't really necessarily have time to sit down and eat a proper healthy meal. And what they're doing is they're skipping lunch, they're skipping breakfast. They come home after all their workday is done and they scarf down a large meal very quickly. Then they're exhausted, they lay down afterward. And all of those things are going to be causing that heartburn sensation because you're going to fill up your stomach and then you're going to lay down and gravity is going to allow that acid that you've just stimulated your stomach to make by eating a meal, to just come right back up into your food pipe.

And typically, just modifying people's habits is the first treatment, and it works very well. Teach people, just a little bit of patient education in terms of teaching people how to take the time in their day, to eat a small meal, eat a snack when they need to eat smaller meals more frequently. Don't gorge on large meals when you finally have the chance to eat. And do it right, stay upright as much as possible after eating meals. Don't eat a meal right before you go sleep, right before you lay down. Don't lay down on the couch. Don't eat laying down, a lot of people do that. That's a no-brainer one. You know, they're eating their chips and oily and greasy foods while they're laying down, watching TV on the couch. All you have to do is just not do that and,

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Dr. Igor Brichkov: magically, your symptoms will start getting better. So that's the first step.

After that, once we try dietary modifications, once we try, you know, coaching people into a slightly more healthy eating habits, eating lifestyle, then if you continue to have symptoms, then typically the next step is some form of antacid pill. So antacid medications, there's a large variety of them. I mean, the earlier generation of antacid, which were the simple ones, the Pepto-Bismol, things like Zantac or Tagamet, what we call H2 blockers. Those are medications that came out a little bit earlier and a lot of people were on those and they typically work, not as well as the newer generation of medications, what we call PPIs, proton pump inhibitors, basically a fancy name for something that blocks the acid-producing cells in your stomach from producing as much acid. Those pills came out around in the '90s and those were godsends when they came out because we loved them. All of a sudden, all these people who were suffering with chronic reflux, but didn't want to necessarily have any kind of invasive surgical procedures to correct it, were all of a sudden getting symptomatic relief and those pills work very well, those proton pump inhibitors. And those are the ones that you hear about advertised on TV, Nexium, Protonix, to name a couple of them, the little purple pill, the Nexium. Those are pills that work very well to control gastroesophageal reflux disease. And there are many, many patients who we've put those on.

Typically, we see a lot of patients with gastroesophageal reflux disease who are on those pills or their primary doctor has put them on them. They're not getting any relief from them and there's a trick to taking them correctly. And the trick is, and I think, you know, people who are on those pills should probably know this, is that you have to take it with meals. So if you're taking a pill that blocks your acid pump in your stomach, that pill is not going to work unless that acid pump is actually on. So if that acid pump is off currently, if your cells aren't actively trying to produce acid in your stomach, then taking a pill to block them will not actually work, will not actually do anything. So typically, you want to take those pills with meals, because a meal will trigger the acid response and will trigger those cells in your stomach to start making acid and the proton pump to do its thing. And that's when those pills will have the ideal effect. All the acid that will be generated during that meal will be somewhat blocked and attenuated to the point where you'll make just enough acid to do its job with digestion of the meal you just ate. And then, there's no excess acid made. And that won't go back up into your esophagus and cause any heartburn sensation.

Caitlin Whyte: Wonderful. Well, I'd also like to know what happens if a patient leaves this condition untreated? I mean, it is so easy to kind of brush off, but what are some long-term effects?

Dr. Igor Brichkov: The long-term effects. Some people have no long-term effects at all. We don't know who those people are or why they just don't feel it. After a while, they think that they're okay. And those are actually the people in potentially the worst situation because they don't have any symptoms to tell them to go seek medical attention and they just leave it alone. And those are the people who are unmonitored, unwatched and, one day, they show up with potential real side effect of having reflux, but they just never knew about it because they just didn't feel it or their symptoms were mild.

The people who you leave alone, untreated, the most common group is people who are just miserable. They try to modify their diet. They avoid foods and long-term, they start losing weight, they're unhappy. They have some psychological effects from this. They don't like to go out with their peers. They're not very social and so on and so forth. From the medical standpoint, long-term side effects include chronic acid damage to the lower or even the entire food pipe.

So the middle or the inner lining of the food pipe is made up of a certain type of cell that exists only in that portion of the digestive tract. The stomach is made up of an entire different lining, and so are the intestinal cells. And what happens when you have chronic long-term damage to the inner lining of the esophagus is, as a defense mechanism, the inner lining of the esophagus sometimes changes and it changes to a different kind of cell. Under a microscope, it looks like the inner lining of an intestinal cell. And we call that intestinal metaplasia. So that's basically a fancy word for a named disease that was named Barrett's esophagus. When you look up Barrett's esophagus, Barrett's esophagus just means an abnormal change in the lining of the lower part of the esophagus.

Now once that lining changes, that lining can potentially start growing and going haywire, meaning some of the cells in that lining, which are chronically damaged, continue to try to replenish themselves. And every time there's a damaged cell, it'll slough off, a new cell will take its place and so on and so forth. And the more you trigger cells to keep dividing in that area under hostile conditions, and what I mean by hostile conditions, it's just acid exposed in that area, which shouldn't be in that spot.

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Dr. Igor Brichkov: And every time you trigger a cell to divide, occasionally something can go wrong and the cells can start growing abnormally. And that will lead to something what we call dysplasia, which is a precursor or the early first step to turning into cancer. The kind of cancer it forms, which is very, very common in the Western world is an adenocarcinoma.

Typically, we see most of the patients that we see in the Western world have a type of cancer known as adenocarcinoma of the esophagus. And most of those patients have it because of reflux disease. That is the worst thing that can happen with chronically untreated reflux disease. Basically, it's a very difficult to treat cancer and patients don't have good survival, don't have good outcomes once that cancer is diagnosed, just because it's usually diagnosed and it's already at a late stage.

The lesser long-term complications of chronic untreated reflex disease is basically anything that happens from chronic esophageal damage to the inner lining of the esophagus. So besides cancer, sometimes just damaging the inner lining of the esophagus is kind of like damaging your skin. If you damage your skin in one area, you know, if you scrape your knee or cut yourself, you'll get a little scar there. So in the same way, a scar can form on the inside of the esophagus. And that scar will be of a certain type of tissue, scar tissue, that's it's not normal tissue, meaning that it's a lot more rigid, it's a lot more fixed. When you have scarring of the inner lining of esophagus, it causes something called a stricture. And a stricture basically is a very tough tissue on the inner lining of the esophagus and it swells towards the inside and it doesn't allow food to pass easily. So a lot of people with strictures have difficulty swallowing and that develops over a long period of time of chronic acid exposure.

Other forms of it, there's something called a Schatzki ring, which is just another fancy name for a type of stricture that happens right at the lower part of the food pipe. And it has a distinct appearance when we look at it with a camera. Those are really the majority of the long-term untreated effects of reflux disease.

Caitlin Whyte: Gotcha. Well, thank you for listing all those out. Doctor, as we wrap up here, why would a patient choose Maimonides Health for treatment? What makes your treatment different?

Dr. Igor Brichkov: At Maimonides, we offer the full gamut of treatments for reflux disease. And these include both medical in terms of giving the appropriate medications, designing the medication regimen on a tailored basis for the patients. We offer the ability to test for reflux in a more advanced way. Conventional testing for reflux disease, most often in a primary doctor's office isn't done. And typically, when patients are sent to a gastroenterologist for for their first workup, most private gastroenterology offices or centers will look at a patient, do an endoscopy, based on the symptoms just prescribed medications.

We actually look at the patients, test them appropriately for reflux, with more advanced testing that we have available at our institution. And we can tailor our treatment and design treatments tailored specifically to that patient and their disease and the cause of their disease. So for instance, some patients have chronic reflux disease, but their symptoms aren't heartburn. And those are the patients who typically fall by the wayside because they're not really being addressed. Because they're not having a heartburn, but they're having some form of symptoms, either waking up with a cough, chronic deterioration in their lung function, they might be silently aspirating while they're sleeping at night, but they're not feeling heartburn. So their primary doctors won't prescribe them necessarily any treatment. And they'll be bouncing back and forth seeking medical advice from other physicians. And typically, they go to five or six doctors before finally someone says, "You know, you have reflux disease that's causing all this and let's treat it." And once they get treatment, then they start getting better.

So at our institution, we're able to diagnose that fairly early in the experience. We have ways of testing for reflux that's not acid related and the solution for it is not necessarily taking an antacid pill, but maybe something that requires surgery to correct. If there's an anatomical problem, such as a hiatal hernia that may be causing it, that we can correct. We can do it all under one roof. And we all work together and we have specialists who actually specialize in treatment of gastroesophageal reflux disease. Since it is so common in the Western world, we make sure that we have somebody both from the surgical side and from the gastroenterology side that knows how to test for it, knows how to treat it all under one roof.

Caitlin Whyte: Well, doctor, thank you so much for your work in this field. I know personally many are thankful for your work. For more information, you can visit maimo.org. And to make an appointment with Dr. Brichkov, please call 718-283-8471. This has been Maimo Med Talk. I'm your host, Caitlin Whyte. Stay well.