Joey Wahler (Host): It can cause much pain or discomfort and produce further health issues. So, we're discussing gastroesophageal reflux disease, commonly called GERD. Our guests, both from Southeast Georgia Health System, are Dr. Will Tsai. He's a general and bariatric surgeon. We're also joined by Romaine Hanson. She's a General and Vascular Surgery dietitian.

 This is Health Matters from Southeast Georgia Health System. Thanks for joining us. I'm Joey Wahler. Hi there, Doctor and Romaine. Welcome to you both.

Romaine Hanson: Thank you.

William Tsai, MD: Hey.

Host: Great to have you aboard. So first, I'm curious about what brought each of you to not only the healthcare industry, but to your particular field, and of course, to Southeast Georgia Health System as well. How about you, Dr. Tsai?

William Tsai, MD: Medicine, to me, I grew up with a long passion for service and making meaningful progress in life where you can help people. And I feel it as a calling. And so, that's how I got into Medicine. Why this area? This is just a beautiful geography, and it's got a great hospital, a great community. And so, a pleasure to be out here and to serve this local community.

Host: All right. How about you, Romaine?

Romaine Hanson: I think with my name, I think I was destined to do this, Romaine. Yes. So, growing up, I was just exposed to real, whole, natural foods all my life. Growing up in Guyana, that's just the kind of foods we ate. So, knowing that, and actually when I started school, I wanted to be in Food Science. But for me, Food Science was more what I thought food science was preparing foods and that part of it. But when I entered college, coming from Guyana to here, that's not what food science actually was. It was more the science of food. And that's how I actually got into Dietetics.

And I also, like Dr. Tsai, have a passion for community and helping people. And food is, for me, vehicle that I can do that with, and I love food. I'm passionate about food. So to blend the two, that's just how it ended up.

Host: And as you touched on, Romaine, with that name, you kind of have to eat healthy, right?

Romaine Hanson: You just do, you just do.

Host: Absolutely. Dr. Tsai, back to you. Many people, of course, suffer from heartburn. But what are some perhaps lesser known or maybe surprising symptoms of GERD that people don't recognize right away? And when should someone consider that they may have it?

William Tsai, MD: GERD is one of the most common diseases. You're not going to find essentially any adult who's not previously had a GERD symptom before. Usually, well managed either with over-the-counter medications or with romaine diet modification. It's where you have persistent chronic symptoms of chest pain. An atypical symptom would be-- well, not atypical, but what patients may find is not usual from reflux is hoarseness from their voice, chronic cough, even goes as far as aspiration pneumonia. And so they might have gone a long time with a chronic cough or what they thought of maybe as asthma or hoarseness and pneumonia from a cold, where it really was just very poorly controlled chronic reflux disease.

Host: And so, as you point out, people typically, at some point or other, have these symptoms, but I guess at times they don't realize how serious they can be. So, what are the potential complications if you let this go too long, which can include a risk of cancer, correct?

William Tsai, MD: Yeah, that's right. So if you have very poorly managed reflux disease, you can have the things that we just talked about. You can have vocal cord polyps and changes. You can have aspiration pneumonia, and that's from the pulmonary side. From the GI side, the chronic acid damage to your distal esophagus can cause a condition called Barrett's esophagus. Barrett's esophagus is actually a precursor to esophageal cancer. And so, one thing to note is that if you have poorly controlled reflux disease, that it can lead to later on in life a risk of esophageal cancer.

Host: Back to you, Romaine. And diet, of course, can play a huge role in triggering GERD symptoms. So, how does diet affect our system in that regard? And what are some of the main types of foods people with GERD should avoid?

Romaine Hanson: Well, first off, most people get up and what's the first thing they reach for? Their coffee. So, coffee is one of those foods or beverages, if you will, that can trigger GERD as well. It's along with tomatoes and citrus foods, carbonated beverages, chocolate. Some people's favorite, chocolate. Those types of foods can actually trigger GERD.

Host: Things that are acidy, right?

Romaine Hanson: And what it does, it relaxes the lower esophageal sphincter causing that reflux to happen. That food can come back up.

Host: Gotcha. How about types of foods that promote good health in this area?

Romaine Hanson: So, it would be more vegetables, quite the opposite of what we just discussed. So, things like your fatty foods and spicy foods, you would want to avoid foods like that. Something else that can actually help promote some ease, if you will. Being able to sit up when you eat, not being reclined. Exercise, that helps as well. Managing your weight actually can actually help with reducing GERD as well.

Host: How about, and this is a complicated area naturally, but if you had to try to break it down to simplify it for our purposes, what's your best advice for those that struggle with altering their diet toward doing some of the things you're talking about? It's not easy.

Romaine Hanson: definitely isn't. So maybe picking one thing and starting there. So, let's say coffee, for instance, in the morning, if you're a three-cup person, maybe just cut back to maybe one cup the morning or every other day or something like that, just modifying what it is you're already doing and reducing that to help affect that change. And we can't ask you to do everything all at once because we know it won't happen. So, just baby steps.

Host: Baby steps. Good advice indeed. Dr. Tsai, recent advancements in diagnostic tools have significantly improved the assessment of GERD. Let me ask you about some things where that's concerned. First, what does an EGD do? And I'll have you tell us what that acronym stands for.

William Tsai, MD: Yeah, EGD is the primary first step in figuring out whether you have significant reflux or anatomical problems that could lead to reflux. An EGD stands for esophagogastroduodenoscopy. And it's like a colonoscopy, but it's a flexible scope with a camera. We go down your esophagus, we go into your stomach, and we go to the first portion of your small bowel, which is called your duodenum. And then, we slowly back out and we take a look at some of the anatomy there. Do you have something called bile reflux? That can actually cause a very bad case of gastroesophageal reflux. Then, we look at the stomach, make sure that there's not any abnormalities there. And then, for my part of looking at the reflux, I actually turn the scope back at itself, and that's called retroflexion. And that's just a technical term for looking back at the scope.

And from there, I'm looking for something called a hiatal hernia. Hiatal hernia is one of the main anatomical issues that can cause reflux. A hiatal hernia is a gap in your diaphragm. And if the diaphragm where the esophagus goes into your abdominal cavity is too big, you get a hiatal hernia. And how is that relevant is that there is a valve at the bottom of your esophagus called your lower esophageal sphincter. If you have a hiatal hernia, the top part of your stomach tends to try to go up towards your head into this cavity called the mediastinum, and that's where your heart and chest have anatomy, and it keeps that lower esophageal sphincter stented open. And so, the juices that you make when you're eating or even when you're not can easily reflux into your esophagus. And that is what causes the symptoms and the burning. And if you can imagine gastric juices are very acidic for the purposes of breaking down your food so your body can digest it. It's meant only to stay within the confines of the stomach and not reflux into the esophagus or further. So if it refluxes in the esophagus, now you have that heartburn, the chest pain, the water brash, which is kind of the acidy taste in your mouth. And worse, if you get acid to the back of your throat, it could go the other way and burn your vocal cords or give you aspiration pneumonia.

Finally, the scope, we go into your esophagus. And I'm looking to see how does the bottom of your esophagus look? Is there esophagitis? We mentioned earlier this condition is called Barrett's esophagus, which is precancer. So if it looks bad, I'll take some biopsies that area, make sure that you do or don't have Barrett's esophagus. And then finally, there could be strictures at the bottom of your esophagus. Sometimes a hiatal hernia will make the bottom of your esophagus also twist, and that's called a volvulus. So, we're really taking a good look at the anatomy at the bottom of your esophagus. We look at the rest of your esophagus and then we come out. Typically, an EGD is about five to 10 minutes long. So, not super long and under sedation from an anesthesiologist.

Host: Gotcha. How about a Bravo probe?

William Tsai, MD: A Bravo probe is very good technology because when I do the EGD, I'm looking for a hiatal hernia, right? But if you have a small, hiatal hernia, you may have bad reflux or you may not have bad reflux. It usually correlates with the severity of reflux, but not always. And so, Bravo has really been very helpful technology in the last 10 years that we've been dealing with this. So, at the end of my EGD, I actually place a little probe that's pinned in place with a little needle in the bottom of your esophagus. You don't feel it, it's done while you're sedated during this procedure for your EGD, and you won't actually feel it afterwards either. And this probe has a pH sensor probe on it. So, the test lasts four days. And it is measuring pH levels constantly through that time. It wirelessly communicates with a box and a receiver that you're going to wear on your hip. And it's going to measure the pH. And it's got actually buttons that you can press that relate to symptoms. So, there's three buttons. There's one that's chest pain, there's one that's regurgitation, and there's one that is like more upper esophageal symptoms. And you press those buttons and that receiver actually is trying to correlate, "Hey, when I press the chest pain button, am I refluxing at this moment?" And so, it can give a really good data back to the patient saying, "Hey, you're refluxing 20% of the time. When you reflux, how long are each episode of reflux? And when you have chest pain, is it correlated with actual reflux?" And so, you can really sit down with a patient and give them really good detailed information about their symptomatology.

Host: And you go home with that, yeah?

William Tsai, MD: Yeah. So, you go home with a box. It's with you for four days. You can take it to work. It's going to be by your side when you sleep. And then, after those four days, when that study's done, you return the receiver back to us. We retrieve that data, the probe is programmed to release after four days, and it comes off, and it goes down the GI track.

Host: Gotcha. How about an EndoFLIP?

William Tsai, MD: EndoFLIP is reasonably new. So, we have to make sure that you are swallowing effectively before we want to plan for any surgery. So, this test is mainly a diagnostic study to make sure that you are a good candidate for surgery. So, one, do you have normal antegrade, which means from your mouth to your stomach contractions? Do you have any muscular issues in your esophagus that can mimic reflux disease? Because we don't really want to do reflux surgery if your pain is not from reflux, right? So, we can take a look if you're having tertiary contractions. And finally, we want to make sure that that valve that we're talking about relaxes appropriately. And that's called LES relaxation. So, it's a technical term just to say that, "Is the bottom of your esophagus relaxing appropriately?" If it's not, it can actually be reasonably harmful to do the surgery in the setting of poor LES relaxation.

Now, what did we used to do? We used to do something called high-resolution manometry, and that's actually performed still in America at a lot of institutions. The difference with high-resolution manometry and EndoFLIP is EndoFLIP, I will, when I do your EGD, place your BRAVO pH probe, so you're sedated. The manometry was a study that was done aside from the gastroenterologist or a general surgeon, where a nurse would place a balloon that patients would have to swallow to get the same results. And it was just very poorly tolerated because patients just obviously having a balloon down your throat through your nose is just reasonably uncomfortable. So, this kind of has allowed us to do more of these diagnostic studies without the discomfort from the original manometry.

Host: Okay. And then, how about in terms of treatment, doctor? Who's a candidate for medication and how effective is that versus a candidate for surgery, often nowadays, robotic surgery? And what is the key to that effectiveness in that procedure?

William Tsai, MD: So, like we said, there are so many people have reflux. And certainly, you do not want to do the surgery on 75% of Americans. And so, you're going to take a look at their symptomatology, and we send you to Romaine and work on diet modification. That's the first thing is, you know, try to do diet modifications. If you're doing diet modifications and it's working and you can get by with just an occasional PPI or H2 blocker, which are common over-the-counter medications, then that sounds very reasonable.

What we typically see are from patients who want the workup for surgery and, eventually, surgery is folks that are in the very chronic portion. They know all the reflux precautions like eating smaller meals, not eating before bed, not being recumbent. They've been through dietary modifications and they've done the best they could with that. They have tried to lose weight. They've been taking medicines for decades. You know, originally, PPIs, such as Nexium and Protonix, they were not invented to be taken for the rest of your life. So, that's what's happened to a lot of Americans, is that there is this medicine that came out decades ago, and it's very helpful, but not intended to take from when you're 30 or 40 to the end of your life. And so, those are the type of people that surgery can be very effective where you say, look, let's work you up for a hiatal hernia because a PPI or H2 blocker or even diet modification can't fix a large hiatal hernia. And if you're having reflux from a hiatal hernia, then it's time to consider maybe surgery to fix that. And so, that you can be off your medications and you can kind of have a better quality of life with reduced risk factors for Barrett's esophagus.

Robotics. Robotics is definitely a game changer for anti-reflux surgery, not just for anti-reflux for foregut surgery, for bariatrics, for general surgery. It just has made the surgery recovery times better, it's more precise, the outcomes are better. And so, the surgery is not fundamentally different, it's just performed in a much better way.

Host: Understood. Romaine, how about the recovery time for that surgery? And are there any food restrictions afterwards? What can people expect post-operation?

Romaine Hanson: Sure. Well, as far as the recovery goes, correct me if I'm wrong, Dr. Tsai, pretty much, probably about up to two weeks and you should be fine. However, soft diets are very helpful. Again, diets that are going to help with reducing that reflux, so reducing your coffee, your caffeine intake, reducing your carbonation, things with carbonation in them, your fatty foods, fried foods, spicy foods; again, your chocolates, citrus. So, all of those types of foods, being mindful even after surgery that you're still paying attention to that and trying to reduce or eliminate that as much as possible, so that you actually shorten that recovery time.

Host: And, Doctor, picking up on that, what steps can patients take to manage their GERD symptoms, aside from maybe diet, and to enhance their overall well-being going forward?

William Tsai, MD: After surgery, what Romaine says is definitely spot on, is be mindful of the things that set you off for reflux. The other thing is many times reflux is associated with obesity. So, a lot of counseling on managing your weight post anti-reflux surgery. And so, folks that are on the borderline of morbid obesity, I've recommended them heavily careful with your weight. Make sure that you're keeping that down. Not only for reflux in general. Morbid obesity increases intra-abdominal pressure, which is one of the main causes of reflux. But also for the longevity of your hiatal hernia repair. So, the risk factor of reoccurrence is morbid obesity for having a recurrence of your hernia. So very mindful, spend a lot of time counseling on maintaining a good BMI postoperatively.

Host: And, Doctor, I'm sure you have many, is there a particular patient success story you can share in this area?

William Tsai, MD: Yeah. Just in general, that's one of my favorite things with anti-reflux surgery is not one person in particular, but almost all of them is that they come. And they sit in the office and I said that the first, one of the first few questions after how you're doing or having an issue is, "How's your reflux?" And "It's gone." And I said, "Hallelujah. And what about the meds? Are you on them?" "Nope. I stopped taking them. They're on the counter. And so, that is the very satisfying part of it, is almost immediately, in fact, I'll see them the next day after I operate before I see them in follow up in office. And they said the reflux is gone. The pain that I was having, the chest pain, all that is disappeared. And so, that is really the kind of the great part of this job and the surgery in particular is seeing folks that they're having decades of reflux and now, it's gone.

Host: That's awesome. And speaking of which, Dr. Tsai, for each of you, in summary here, I'm wondering how rewarding is it, how beneficial is it to your understanding of GERD to be treating patients suffering from it? How about you, Romaine? What's the best part of this?

Romaine Hanson: Just seeing people's life become that much better. We all enjoy eating, right? And having to feel that discomfort every time you eat. I mean, that's not pleasurable at all. So, being able to enjoy, just enjoy life, period, where that's concerned, I mean, is rewarding. And knowing that you can play a part in that is incredible.

Host: How about you, doctor?

William Tsai, MD: Yeah, exactly. This job is hard, but this is the best part is that when you get to see folks that can change your life fundamentally. And there's folks that they're having to sleep with their head of the bed elevated on cinder blocks. They're waking up in the middle of the night with chest pain. Folks that can't work out because when they go for a run, it causes reflux. It's nice to be able to fix that for them. And that is definitely one of the most rewarding parts of this job, is to help folks out.

Host: Indeed. Some of the things you mentioned there, I'm sure, are parts of life that many unfortunately take for granted until it becomes difficult, right? Well, folks, we trust you're now more familiar with GERD and its treatment, Dr. Tsai, Romaine, love the name, thanks so much again.

Romaine Hanson: Thank you.

William Tsai, MD: Thank you.

Host: And for more information, please visit sghs.org/services/gastroenterolog/gerd-treatment. Now, if you found this podcast helpful, please do share it on your social media and thanks again for being part of Health Matters from Southeast Georgia Health System.