Joey Wahler (Host): It can cause great discomfort and possibly lead to other medical issues. So we're discussing gastroesophageal reflux disease, commonly called GERD. Our guest, Dr. Rameez Alasadi. He's a Gastroenterologist with Silver Cross Hospital. This is Silver Cross Hospital's I Matter Health Podcast, where medical experts bring you the latest information on health topics that matter most to you and your family.

Thanks for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome.

Rameez Alasadi, MD: Hi, thank you for having me. Appreciate it.

Host: Great to have you aboard. So first, for those unfamiliar, what exactly is GERD and what are its most common symptoms?

Rameez Alasadi, MD: GERD is basically what we refer to as gastroesophageal reflux disease. It is a condition where the acid in the stomach or stomach content will flow back into the esophagus. The esophagus is the pipe that connects the mouth with the stomach. So, stomach content going up into the esophagus, irritating the esophagus causing symptoms is what we refer to as gastroesophageal reflux disease.

However, the problem that happens is due to an ineffective valve or an incompetent valve or a sphincter. So, in the bottom of the esophagus, there is a valve or a sphincter formed by a circular group of muscles that would allow the food to go down from the esophagus into the stomach, the valve will relax as soon as the food reaches the bottom of the esophagus, allow it to go into the stomach, minimizing stomach content from going back up by tightening the valve right after you eat.

Now, it's not a one way valve, so it would allow us to vent the stomach content, that's why we're able to belch, that's why we're able to vomit, but if the valve is incompetent and relaxed for multiple reasons, then the stomach content will go up into the esophagus, leading to irritation of the esophageal lining, leading up to symptoms that we will be talking about later.

So, that's why we describe as gastroesophageal reflux disease. It's a chronic condition related to a mechanical problem in the valve in the bottom of the esophagus, the upper part of the stomach, right at the junction.

Host: Gotcha. And as you just touched on, many are familiar with the term heartburn, which is a symptom of GERD, correct?

Rameez Alasadi, MD: Correct.

Host: And so what is that exactly, heartburn? We hear it,what does it mean?

Rameez Alasadi, MD: Yeah, so, the lining of the esophagus is not made to handle acid for a long period of time. Now remember, we produce acid in our stomach, but we don't feel it. So the lining of the stomach is more of an acid resistant, can handle acid for a long period of time. No issues because of the special lining, special membrane in the stomach.

The esophageal lining is completely different. So we can handle a little bit of acid going up into the esophagus, but acid is something that will irritate the lining of the esophagus and cause burning sensation. So, it's a burning sensation behind the chest bone. People will feel and describe it as a heart burn.

Host: So how common is this condition?

Rameez Alasadi, MD: Well, it's not uncommon. More than 20 percent of the adult in the United States will experience GERD.

Host: Wow, that's a big number, yes?

Rameez Alasadi, MD: It is. It is very big. And it's actually, on the rise as well, too.

Host: And so if someone thinks they may have GERD, at what point should the symptoms move them to see a doctor like yourself?

Rameez Alasadi, MD: That's a very good question. So, there are things that we call them alarming signs. And alarming signs would be problem with food going down in the esophagus. People will feel that the food is not going down. I feel like it is getting stuck in the esophagus. So that's a concerning symptom and they should be seeing the physician right away and a gastroenterologist who specializes in gastrointestinal problems to be evaluated.

So people who, we call them anemic, they have a low blood count, by losing blood, people who vomit blood, or they have tarry stool, black tarry stool, or losing weight, unintentional weight loss. Those are alarming signs and they need to be addressed right away. Now that's for something more alarming, but if there are patients who have reflux for many years, even if it's controlled, they may want to talk to the physician about different options in terms of treatment of reflux, one. Two, they may need to be screened for an underlying condition or precancerous condition that can develop from having reflux for a long period of time. Talk about side effects, talk about what are the options we have available for patients in terms of treating and addressing the root cause of reflux itself.

So, alarming signs, they need to see the physician right away. They want to talk about options, that's another reason to go and see the physician, and also for screening for potential precancerous condition that can develop from reflux called Barrett's esophagus, that's something that could be developed in certain percentage of people who have reflux for a long period of time. So those are important things to be discussed.

Host: Absolutely, and so that being said, if someone comes to you suspecting they may have GERD, how do you go about diagnosing whether in fact they have it?

Rameez Alasadi, MD: We actually, by obtaining the history and knowing that they have heartburn or something called regurgitation, where the food come back into their esophagus, maybe even to the point where it reaches the mouth as well too. So that's also another sign of reflux. So people that have symptoms like this, they would be treated for maybe a couple of months with acid suppressing medicine and the response to treatment points towards the diagnosis.

Now, there are other ways of making the diagnosis, less invasively, where people will have an endoscopic procedure. It's a flexible tube that has a camera at the tip of it. Under light sedation, we pass a flexible tube through the mouth into the esophagus, looking for damages in the lining of the esophagus.

We refer to it as esophagitis. So if we see something like this endoscopically at the time of upper endoscopy, that's an indication for reflux, and that can make it a diagnosis right there and then. If we see the precancerous condition that we just alluded to, called Barrett's esophagus, that's another indication that they, we make a diagnosis of reflux.

Now there are probes or sensors that we can place and attach to the wall of the esophagus that senses the acidity in the esophagus, that coming from the stomach, sends a signal wirelessly to a receiver that patients will carry with them for about four days or so. The probe will sense the acid level in the esophagus, sends a signal to the receiver that recording the data, patients will be doing thing they do. They eat normally, they sleep, they are off acid suppressing medication, they are on it, we ask them to stop it to know what's going on in their esophagus. So, by looking at the recording, we can make the diagnosis of reflux and, and confirm that. There are also tests, there is a little tiny catheter that we can place through the nose into the esophagus, where also again the catheter is connected to a recorder, and the recorder will be looked at after 24 hours.

 We look at the recording, we'll see what's going on in the esophagus. The patient reflux when they're laying down, that they reflux when they're sitting up, they have even heartburn at what certain time of the day, because they can press a button and that marks the time when they felt the symptoms, and we can correlate this with the changes in the acidity in the esophagus based on the recording.

So there are different ways of documenting this and also making a diagnosis of reflux.

Host: Interesting. That sounds very high tech indeed. So, who Doctor is most at risk for GERD, and what can people do on their own to try to help prevent it lifestyle wise concerning diet, etc.?

Rameez Alasadi, MD: Anybody can have GERD, in general. We all have some reflux that we clear up right after we eat, and that's not GERD. But the chronic condition that we refer to as GERD, it's more seen with increased weight because developing an abdominal fat that can push on the stomach. And by doing this, would lead to stomach content of refluxing, so people who are overweight, or obesity, those are, people who are obese, they are at higher risk for developing GERD. During pregnancy the patients might experience reflux as well. But most likely we see this with increasing weight.

Host: And how about, when we talk about treatment, what are the most common remedies for GERD?

Rameez Alasadi, MD: If we talk about treatment, we have different options. Obviously, medication is one of them, and then you get to the treatments that can address the mechanical problem with reflux, which is fixing the incompetent valve. So, in terms of medication, it could be as simple as using antacids like Tums, Maalox, Mylanta.

Those medication will give you an immediate relief of symptoms, but not long lasting. And then you get the, what we call them H2 blockers, things that start to block the acid development in the stomach. And H2 blockers like Pepcid, fametidine, Zantac that suppresses the acid production. And then to a higher level, we have what we call them proton pump inhibitors.

Those are medication that suppresses the acid pumps in the stomach and blocks it. So those are potent medication that can control symptoms very well, and they can heal the inflammation of the esophagus that we call the esophagitis with, high percentage. So that's from a medical standpoint. Now, all patients we discuss with them what we call lifestyle modification, meaning we address weight loss, avoiding late meals and snacks, so we ask patients to avoid at least having anything to eat or drink for about three to four hours before they go to bed. So remember when people are sleeping and laying down, the esophagus and the stomach are in the same level. So gravity is not their friend anymore.

So the stomach content will easily back up into the esophagus. So, avoiding late meals and snacks will help minimizing this, minimizing caffeine intake, cigarette smoking, alcohol, citrus food, tomato based food, peppermint. Those are things that we discuss with the patients around their diet. Now, elevation of the head of the bed can help minimizing symptoms as well, and then you go to the other which is whether surgical or endoscopic techniques that could be done to augment the valve or reconstruct the valve that we talked about early on, which is the root problem of this issue.

The GERD is a mechanical problem. We have a valve between the esophagus and the stomach that's not working well, incompetent, leaky, if you will, so we need to reconstruct the valve. So, one of the approaches would be on the invasive side is surgery, although that could be done less invasively with robotic or laparoscopic approach with just a few holes in the stomach, which means quicker recovery, fixing the valve, fixing what we call the hiatal hernia, and reconstructing the valve.

Or could be done endoscopically in selected group of patients where they are a candidate for this approach, something called TIF procedure or transoral incisionless fundoplication, which basically is an endoscopic procedure done where patients are asleep. We pass a flexible tube through their mouth with a device that allows us to put fasteners at the upper part of the stomach, the lower part of the esophagus, and wrap the upper part of the stomach around the lower part of the esophagus, creating more of a high pressure zone and reconstructing the valve. So preventing acid from traveling back up into the esophagus.

So I know I've given you a long answer, but there are different ways of treating reflux and it's not a one size fits all. We have to look at what patients want and what procedure is suitable for them. Some patients don't want to take medication for a long period of time. Some patients have side effects from the medicine. So remember, medication will address the acid level, but not the mechanical component of reflux, which is the root of the problem.

Host: Understood. We appreciate the comprehensive approach on your part, Doc. So, a few other things. One being, can GERD lead to cancer in the esophagus?

Rameez Alasadi, MD: Yes, it can. And that's one of the concerns that we have about reflux. Although when we manage reflux, we want to control the symptoms, right? So that's the number one thing, and we just talked about different ways of doing this. But the main concern is the development of precancerous condition from reflux.

So the good news is not everybody who has reflux will end up having this precancerous condition that we refer to it as Barrett's, and not everybody with this precancerous condition will go on and develop cancer, but we don't know who has the Barrett's esophagus in pre cancerous condition. We want to prevent this from developing.

So, a small percentage of people with reflux will develop Barrett's esophagus, small percentage of people that have Barrett's esophagus which is the pre cancerous condition, go on and develop cancer. Now, this happens because of the new lining that develops in the esophagus from long exposure to acid. So, remember the stomach, it's kind of, it's the area where the acid is being produced, but the lining of it and the intestinal lining is protective lining.

So when the esophagus get exposed to acid over a long period of time, this is when the changes happen. The body kind of want to protect itself, so it develops a lining that's more protective, and resistant to acid, referred to as Barrett's esophagus. Sounds like a good thing, but this acid resistant lining does not belong there, and it's a pre cancerous lining.

And, the way of finding out about it by doing an endoscopy, looking down with a camera when patients are sedated. It's a flexible tube the size of my pinky, has a little light at the tip of it, which allow us to inspect the esophagus and see the lining and take biopsies and determine what's the level of pre cancerous changes in the esophagus that we're encountering here.

Host: If untreated, what other issues medically can GERD lead to?

Rameez Alasadi, MD: The inflammation in the esophagus, if it developed, can lead to scarring. So what we call esophagitis, it's actually a condition where it describes inflammation or developing even ulceration in the esophagus. So scarring can develop from ulceration and that can lead to narrowing in the esophageal opening, a lumen, we call it stricture, and that will prevent food from going down and the food will get stuck, the food will stuck in the esophagus and does not make it into the stomach, so that's something that can develop beside the pre cancerous condition we talked about and the cancer that can develop there too. And bleeding is one of the other issues too, so if the ulceration is severe, patients can either have what we call acute GI bleed. They lose blood profoundly, or they lose blood over time and they become anemic and that leads to low blood count and the complication that developed from that as well too.

Host: In summary here, Doctor, generally speaking, what are the chances of effectively addressing GERD in a patient?

Rameez Alasadi, MD: Or that could be uh, easily addressed and managed; whether with medication, lifestyle modification, depending on the degree of reflux that the patient have. And if they're not responding to medication or lifestyle modification which we talked about, then we have less invasive approaches whether surgical or endoscopic approach or even combined procedures.

Many times we collaborate with our colleagues in surgery and they will address the issue of what we call the hiatal hernia, which part of the stomach kind of slides up in the chest. They fix it robotically or laparoscopically and then endoscopically we'll go down with the scope, with the device we talked about and do what we call the TIF procedure and reconstruct the valve.

So we can effectively, with high success rate, control the symptoms very well. But obviously every patient, needs a specific type of treatment based on multiple factors that we assess once we see them in the office and discuss all the options with them.

Host: Understood. Well, folks, we trust you're now more familiar with GERD and how it's addressed. Dr. Rameez Alasadi, very comprehensive indeed. Thanks so much again.

Rameez Alasadi, MD: Thank you. Thank you for having me. I appreciate your time. Thank you.

Host: Same here. And for more information, please do visit silvercross.org/GERD, G-E-R-D. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. And thanks so much again for being part of Silver Cross Hospital's I Matter Health podcast.