Transcription:

Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole. We have a panel for you today with Dr. James Callaway. He's an assistant professor in gastroenterology and Dr. Kristen Wong. She's an assistant professor and general surgeon. They're both at UAB Medicine and they're here to highlight Gastroesophageal Reflux Disease or GERD for us. Doctors, thank you so much for joining us. I would like to start with Dr. Callaway. Can you please tell us the scope of the situation that we're talking about today? The impact on the daily health of individuals? Really the scope of the issue of GERD and the prevalence?

Dr. James Callaway: Sure. Thanks so much for having us today. Gastroesophageal reflux a quite prevalent condition. It affects almost all of us to some degree over our lifetime, we may have some troublesome heartburn symptoms. Reflux disease is primarily defined as either pyrosis or heartburn, kind of the burning sensation in our chest or regurgitation, where you may actually feel food, contents, or acid kind of going up into the chest and potentially in the back of the throat. But those symptoms may occur after routine meals, but it being a troublesome symptom and becoming a prevalent happening more than a few times per week is considered pathologic and quite troublesome.

And that's what many patients are referred to our GI clinics or our surgical colleagues for when symptoms are prevalent or they're not responding to typical medical therapy. The prevalence though is actually, it's quite prevalent. Up to 40% of Americans will have troublesome heartburn symptoms at some time during their life. And at any given time, about 20% of patients actually are on heartburn medications, either over the counter or prescription medications at some point during their adult life.

Melanie Cole: Dr. Callaway, do we know why? Why is it becoming more and more prevalent? Is it because we're seeing this obesity epidemic? Is it our food choices? Is it sedentary lifestyle? All of those things. Why are you seeing an.

Dr. James Callaway: I do think obesity is the number one risk factor that we are running into, and that it's becoming increasingly prevalent over the last 20 to 30 years. And that's probably the biggest risk factor that continues to push the GERD needle forward. We are becoming more due to diagnosing it and also many of the reflux medications are becoming over the counter at this point, and so patients are self-treating as well. So I think the actual prevalence is probably under-recognized as patients try to treat their reflux symptoms at home without actually seeking medical professionals too.

Melanie Cole: So Dr. Wong, don't worry, I'm not forgetting about you, but Dr. Callaway sticking with you for just a minute. As we speak about diagnoses, tell us a little bit about how you come to a definitive diagnosis of GERD. If you're doing endoscopy, do you feel that this is something that, that people should be screened for, like colonoscopy? Is it something that you see happening in the future? Speak just a little bit about diagnoses and all of the different things and available tools that we have today.

Dr. James Callaway: Sure, great question. Reflux disease is, as we mentioned, common and it is actually difficult to define in some ways. We know just by definition, it's refluxing of gastric contents into the esophagus. That can just be clinical symptoms. As I mentioned, there's some heartburn that someone may happen to have after a meal. But eventually it may become pathologic. And in that situation it can cause troublesome symptoms that actually cause changes in someone's quality of life. It can cause damage to the esophagus and the setting of inflammation or what we call errosive esophagitis, and it can lead to further types of problems as well.

LIke Barrett Esophagus or even potentially esophageal adenocarcinoma. So it's a diagnosis that we don't want to miss because if left untreated it could have potential long-term implications including something as dredded as cancer. To diagnosis this though, primarily it's done either by clinical history where we talk to our patients about their symptoms and we may actually even use medications as an empiric trial to see if their symptoms do respond. Many times that's actually how the reflux diagnosis is. In gastroenterology, or if you're seeing a gastroenterologist, we are much more apt to actually perform objective testing.

We may use an endoscopy, as you mentioned, which is a flexible camera scope to go down into the esophagus and look for damage from reflux disease. Or we may use things like ambulatory pH testing, which is where we can objectively quantify how much reflux a patient is having, whether they're having five episodes a day or 500 episodes a day. We have different mechanisms where we can actually quantify that amount of reflux and then prognosticate someone on how frequently their symptoms may occur. Or maybe best treatment options based on how much reflux that they are actually having.

Melanie Cole: You mentioned earlier Dr. Callaway medications and people are self medicating at home. I'd like you to speak about the medications that are available now, whether over the counter or by prescription. And there have been so many studies that have come out raising concern for medications that are used to treat GERD, but these studies really only have demonstrated an association, not this cause and effect relationship. So I'd like you to speak about that just a little bit as you're telling us about what you would try as your first line defense.

Dr. James Callaway: Sure, absolutely. Well, we do encourage lifestyle modifications for patients with minimal symptoms of reflux disease or intermittent symptoms of reflux disease. That includes weight loss for those that obese or overweight. Potentially avoiding the times of day that they're actually eating, trying to avoid late night meals and things of that nature. When it comes to medical therapy, proton pump inhibitors have been around for over 30 years now, and those are the most effective medical treatment for reflux disease. There are other types of medications out there including histamine receptor blockers.

Which also have been used for short term relief of heartburn and GERD symptoms, and those are typically used for kind of short durations. Typically are not used chronically, but either proton pump I inhibitors or H2 receptor antagonist are our primary medical treatments. You mentioned about the potential association with adverse conditions and there have been numerous studies, especially in the last 10 years, which have identified associations with long term use of PPIs and a development of these types of conditions.

Most of those studies have numerous flaws, as you mentioned, and are not really considered definitive, and they really haven't established a true kind of cause and effect relationship between PPIs and those adverse conditions. High quality studies have not found that PPIs significantly increased the risk of many of the things that have been reported, including stomach cancer, osteoporosis related bone fractures, chronic kidney disease. We do think that there is an increased risk of intestinal infections.

But that being said we do think that PPIs are still, the benefits of them really outweigh the, the risk, the theoretical risks of the associations that many of these epidemiologic studies have brought up over the last 10 years. So in general, we still think PPIs are safe but we do want to use the lowest effective dose in all of our patients that we are treating. And if symptoms are not responding appropriately, we should investigate that or we should definitely. engage our surgical colleagues to, to think about other potential treatment options that do not include medicines. Kristen will get you involved here shortly.

Dr. Kristen Wong: Okay. No, I could listen to you. Go on. Keep going.

Dr. James Callaway: All the medical side so far.

Dr. Kristen Wong: Yeah, no, that's fine with me.

Melanie Cole: Dr. Wong. We did not forget about you. So as Dr. Callaway just alluded to, for GERD, that's refractory to medications, please discuss some of the surgical indications and treatment options that are available?

Dr. Kristen Wong: Sure. Thank you for having me. I could listen to Dr. Calloway talk all day, so, you know, but yeah, so there's a couple of traditional treatments, surgical treatments for reflux. And there's a couple of non-traditional treatments for reflux that are kind of this new techniques that we are just now developing. So, the first tried and true technique for people that have either maximized their medical therapy, those are. The people that are on two PPIs already, they're taking tums as needed. So they're really just unhappy and their symptoms aren't well controlled. Or the people that don't wanna take their PPIs because of these reported side effects.

So those are the people that we bring in and we talk to. And the first thing that we would discuss with them is probably the tried and true surgery approach, which is a gastric fundation. So that is started in the 1950s and it's basically a wrap. And it has initial success rates of greater than 90% at high volume centers. And the idea behind the wrap is that it kind of recreates the pressure of the lower esophageal sphincter and prevents that reflux from coming back up from the stomach into the esophagus. For implications, I think they get a bad wrap because I think in the surgical community there's a highly variable techniques.

And so you have a lot of Results and the different kinds of results and the range of outcomes are very different amongst surgeons. Overall, I think is it technically difficult? It does require an overnight or inpatients day. But the good news is that over 90% of patients that undergo an anti-reflux surgery. IE a fund implication, do see symptom improvement and get off of their medications. What are the downsides of a fund implication? There are a couple different poor, you know, bad outcomes that we wanna look for. The biggest things that I think a lot of people who refer to their surgeons are worried about are gas bloat syndrome and dysphasia.

So that range is in the 20% of people postoperatively after a fund application. And we can go into the different types of fund implications as well. the nissen is the, probably the most well known fund implication, and that's a 360 degree wrap. So when we go in. We, we usually do these all laparoscopically nowadays. And we wrap the stomach 360 degrees around the GE junction. That's compared to several other options we have called partial wraps, which is a two pay fund implication or a door fund implication. And those are generally either a posterior or an anterior wrap, approximately 180 to 270 degrees. So a little bit of a gentler wrap.

And so when people come in and they want, we wanna talk about Fund implications there's a lot of different variables that go into how we decide which wrap someone will get. And I will state that generally most four gut surgeons across the country have moved away from the classic 360 degree fund nissan implication. Because between the Nissan and the two pay, actually they've had similar rates of getting people off their PPIs, similar rates of symptom improvement, but the two pay is actually known to be a gentler wrap and therefore has less dysphasia and gas bloat syndrome. So a lot of surgeons are now moving just to offering people the two pay and consider the Nissan full 360 degree wrap a thing of the past.

The next thing we might consider for patients is the links device or the Magnetic Sync Augmentation device. And this is something that developed in the early two thousands, and we have at least 10 year data on this now. It's a device made up of interconnected magnets, each of which is encased in a titanium bead, forming a ring, sort of like a bracelet. And we place these circumferentially around the esophagus, near the gastro esophageal junction. And so the idea is at risk, the magnetic force will hold the beads close together to prevent reflux from occurring, and they can separate in response to a food bolus.

And so, it does allow normal physiologic function and it does have very good results. So they've done a couple of trials comparing the links to the Fund implication device, and it's been shown to be equivalent in terms of symptom relief and getting patients off their PPIs. Now there are couple of relative contraindications in one absolute contraindication to placing the links. The relative contraindications would be an existing esophageal motility disorder. Things like the presence of another electrical implant, or a patient that might require MRIs in the future greater than 1.5 Teslas.

And the only absolute contraindication to a links device is an allergy to titanium or nickel, which is what the device is made of. So you know, The links is a good option. And I think for patients who have typical reflux symptoms who don't have a really large hiatal hernia and don't meet any of the other relative contraindications, I would absolutely offer a links to those patients. It's the literature's out there and again, but I do make the caveat that we only have 10 years worth of data on the links versus the fund implication, which we've has been around for 70 years.

Melanie Cole: Isn't it fascinating for both of you in your field? What an exciting time. And before we get ready to wrap up, and again, thank you Dr. Wong, for that comprehensive overview of the procedures that are available. I'd like to give you each a chance for a final thought as you're speaking to other providers and the importance of this multidisciplinary approach and this combined clinic where you represent different specialties, but work so very well together. Dr. Wong, starting with you, I'd like you to speak to other providers and what you would like them to know when they're referring their patients, getting to that next step where surgery might be indicated. When would you like them to do that? When is it important to refer?

Dr. Kristen Wong: Sure. I think. If you have patients that are un unhappy with their current medical therapy, either they don't want to take PPIs any longer, or they still have symptoms despite being on maximal medication therapy, I think that's when you need to definitely refer to the surgery side of the team. And again, like I said, we have several good options and more options are coming down the pipeline. More with more technology being introduced for reflux.

Melanie Cole: And Dr. Calalway last word to you, as you're speaking to primary care providers and even patients that listen to these, what would you like them to know as they counsel their patients on those lifestyle behaviors and those conservative measures that we try before we get into the PPIs and the medication intervention and onward. What would you like them to know as they are counseling their patients on the increasing prevalence of GERD in the community?

Dr. James Callaway: Absolutely. I really would encourage weight loss as the initial treatment for many patients that have ref not only reflux, but other types of metabolic conditions that, that we know obesity contributes to and can have long term poor outcomes with. So that is always the first thing that we will recommend if patients are having persistent symptoms on PPIs. The first thing I do like to make sure is make sure that we are dealing with classic reflux disease. Our most recent guidelines have really stressed the importance of really objectifying reflux and actually quantifying it earlier in the treatment.

So patients are not on long-term PPIs for many, many years, treating some type of reflux symptoms, which may or may not actually be reflux disease. So, I would like to engage either the surgeons or the gastroenterologist early on if we are unclear about exactly what's going on, so we can help define is this persistent reflux? Is this refractory GERD? And then we can really help try to figure out what's the best therapy for them, whether it's additional medical treatment. Whether it's injunctive medical treatment, whether it's lifestyle changes or whether or not we really should engage our surgeons.

Because there are certain types of symptoms, especially regurgitation, that PPIs are just not very good at treating and engaging our surgical colleagues can be really life altering for our patients to try to help with that symptom in particular but reflux in general.

Melanie Cole: Thank you both so much for joining us and sharing your incredible expertise with this very prevalent condition. So thank you again, and a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole.