Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Joining me today is Dr. Bashar Qumseya. He's an associate professor of medicine and the chief of endoscopy at UF Health Shands Hospital. He's also the chair of the Standards of Practice Committee of the American Society of Gastrointestinal Endoscopy. He's here to highlight gerd for us. Dr. Qumseya, it's a pleasure to have you join us. This is such a huge problem in this country, and we're learning more it seems just all the time. Speak a little bit about gerd. What do we know about it now that maybe we did not know 10 years ago?

Dr Bashar Qumseya: Thank you Melanie, and thank you for having me today. I'm happy to be here today to talk about, a very important topic that is near and dear to my heart because I've been researching Barretts which is a condition that relates specifically to acid reflux disease. So acid reflux happens when you have stomach content that reflux up through the, GE junction into the esophagus. It is a very common condition and most people, including many of our physicians would have experienced personally acid reflux. The vast majority of the US population have experienced acid reflux, and about 30, even 40% have it on a frequent basis more than once a week.

And so this is a very prevalent condition that affects people's lives very significantly, and it is also very costly condition. The most common kind of medication that are used over the counter to treat acid reflux called PPIs are used on a daily basis by millions of Americans, and we spent billions of dollars. Annually in the US in treatment of acid reflux disease. So what we now know, to go back to your question, Melanie, that we didn't know before, we now have a better understanding of the mechanism of the flap valve and the GE junction that helps prevent acid reflux normally. And how disruption in that mechanism can result in acid reflux.

And furthermore, and most importantly, we now have some non-invasive ways in which we can reconstruct that mechanism of the flap valve to prevent acid reflux and make patients feel a lot better, decrease their dependency on PPIs and decrease regurgitation and some of the sequela of having acid reflux.

Melanie Cole (Host): Now you've mentioned a few. Dr. Qumseya, Barretts, so I'd like you to explain a little bit about some of the complications of untreated reflux, but also the presentation both typical and atypical, because sometimes this is silent. Sometimes people do not know that they have it. It's not always that feeling of heartburn or burping. It's not always those things. So I'd like you to speak a little bit about how it most commonly presents what you see, and if it's left untreated because it might be silent. What are some of those complications?

Dr Bashar Qumseya: So when you have acid reflux, it triggers pain nerves in your esophagus. So you end up having pain and most people refer to that as heartburn. And they present to their primary care providers, usually who is the first, person to see this, with this acid reflux, they might already have gone over the counter and taken medication. So this is the most common presentation. Now what happens is your body does not like to be in pain. So over time, if you have acid reflux, you may develop this change in the lining of the esophagus called Barrett's esophagus.

So Barrett's esophagus, as we all know, is a change from the squamous, kilometer, epithelium of the esophagus, into an intestinal metaplasia. So intestinal metaplasia is where you have a change in the lining of the esophagus. And this change in the lining of the esophagus is actually protective of pain. So patients who have better esophagus experience, less heartburn than patients who don't have it, and that's why people have it, is because your body does not like to have pain.

The problem with Barrett's Esophagus is that it is a risk factor for esophageal adenocarcinoma. So we have looked at the data and for example, the one Florida database, and we've seen that the prevalence of Barrett's esophagus has been increasing dramatically in recent years. And national data showed the same that the incidence of Barrett's Esophagus and esophageal adenocarcinoma have been increasing dramatically over the last 50 years, although most recent data is showing a plateau.

So we may have peaked at this point, but for the last four or five decades we've seen dramatic increases in Barrett Esophagus incidents and prevalence, and in esophageal adenocarcinoma incidents and prevalence. And this may be related to the epidemic of obesity that we have and how obesity is linked to people having Barrett esophagus and acid reflux as well. So that lot of patients who have silent acid reflux may have in fact Barrett's esophagus, and that's why they do not feel the acid reflux. So it's important to know about this.

Now, there are atypical presentations, as you said, of acid reflux. For example, not everybody feels heartburn, but some people may present with cough. Some people may present with chest pain, which is atypical chest pain. They have a chest pain. They feel like they're having a heart attack. They go, they have cardiac workup. They may get a stress test. they may even present to the emergency department for this, and they tell them, no, it's your acid reflux. They may have hoarseness, so they go and see the ENT and they do a procedure or they look at their, vocal cords and they say, yep, you need to see a gastroenterologist.

So there's a lot of atypical presentations. Sometimes patients can present with asthma and acid reflux or silent acid reflux has also been linked to cases of, pulmonary fibrosis where patients actually end up having to undergo lung trans. Because they have undetected acid reflux that needs to be treated. So there are a lot of ways that, acid reflux can present and patients who have acid reflux need to be treated to prevent these, downstream sequela that we've been talking about.

Melanie Cole (Host): So you mentioned PPIs as one of the first line treatments and how many millions of people are on them, and studies have come out that have always, for a while raised concern about these medications. I'd like you to speak about that briefly. And then for gerd, that's refractory to medications, some of the surgical indication treatment options that are out there because it really is such a huge problem. And even do you think Dr. Qumseya, as we speak about screening diagnosis for colonoscopy, should this be treated that way as well? Should there be a screening option that's done for people that might be more at risk?

Dr Bashar Qumseya: So let's start with the PPI adverse events. These have gained a lot of national attention. PPIs are very safe medications and we have been using them for many, many years. They work really, really good. However, they are not risk free. And the main risk factors of taking long-term PPIs, meaning patients. They come to you in their twenties, in their thirties, in their forties, and they're gonna live for another 20, 30, 40 years. So you cannot keep them on PPIs forever because what we're doing is, we are suppressing the acid, obviously in the stomach, and you need the acid in the stomach for a lot of stuff, including for digestion, absorption of various, vitamins.

So a lot of patients who are on long-term PPIs can have vitamin D deficiency. They can have osteoporosis, which is probably one of the most important risk factors from chronic PPI use. The acid in the stomach works as a first line to prevent infection. So, For example, studies have linked acid suppression by PPIs to maybe increased covid infections, increased risk of, pneumonias, increased risk of c diff infections. And there are a lot of other adverse events. There are a lot of studies that looked at the prevalence of these adverse events in PPIs.

And overall, they're very, very low. But more importantly, also, a lot of patients do not wanna be on these medications forever because they come to me and they say like, if I miss the medication once, I'm gonna be miserable. And I don't, you know, I'm young, I'm 40, I'm 50. I do not wanna do this the rest of my life. Be dependent on a medication that I also know is not great for me in the long term. PPIs are very effective. By treating patients on them for many, many years is probably not the right choice. However, we'd have had surgical options for patients with acid reflux.

They're called fundoplications and they come in various forms, this fundoplication, dual fundoplication to pay. And there are different forms of fundoplication where the surgeon, perhaps the fundus of the stomach, are on esophagus and fixes a hernia. Now, this is an invasive procedure. Many patients do not want to have it, and a lot of patients who had the Procedure had experienced adverse events, mainly they cannot burp, they cannot throw up, which is very bothersome. Many patients who come to me are aware of people who've had these procedures and had adverse events from that.

So a very small minority of patients with acid reflux have in fact gotten fundoplication, but until recently we really didn't have anything else to offer them. More recently, now we are starting to, provide this procedure called transoral Ingenless fundoplication, which is a good option that is less invasive than having surgery and works good. and we can talk about that a little bit more. But I do wanna address your other question before we talk about the tif, which is screening for patients who have acid reflux. In fact, there are already guidelines on this.

I was actually the first author on the guideline by the American Society of the Gastrointestinal Endoscopy, and we looked at the evidence for this extensively. There's clear evidence that if you have multiple risk factors, acid reflux for Barrett's esophagus, then screening by various methods. Most commonly endoscopy is indicated and there are recommendations from all major GI societies within the US and outside of the US recommending screening for Barrett's Esophagus and esophageal cancer in patients who have multiple risk. However, compliance with these guidelines is minimal.

We see, for example, I looked at this data in the One Florida database, which has over 9 million patients in this state of Florida, and we found that most patients who have four or more risk factors for esophageal cancer, they have reflux, they have obesity. They are white traits, they are male gender, they smoke, and go on. These patients, only about 20 to 30% ever had an endoscopy in their life. So we're talking about patients who have many risk factors. And they are getting colonoscopies, but they're not getting endoscopies. So we're trying to raise awareness about this, and I'm glad you brought this up.

There are guidelines about this. People should be getting screening if they have risk factors. So I encourage primary providers all the time. If you have patients that meet these criteria and they're due for a colonoscopy, this would be a perfect time to have an endoscopy. At the same time, if they have these other risk factors that I was talking about.

Melanie Cole (Host): Wow, that is so interesting that you are one of the people that started this initiative because I've been wondering for so long about that. And so before we wrap up, Dr. Qumseya, I'd like you to just speak about some of those advances briefly that are, available now and these procedures for GERD that are really helping to increase the quality of life and decrease some of the sequela of GERD.

Dr Bashar Qumseya: Exactly. So this is what we started talking about. One of the procedures that we're very excited about offering here at the University of Florida Health Shands Hospital is called the Transoral Ingenless Fundoplication. So in this procedure, a patient, goes endoscopy and after, we've done workup before to make sure that they're the right candidate. Mainly that we confirm that they have acid reflux by pH testing, and we also do a motility test to make sure they don't have an issue with the movement of the esophagus. And then we check for the size of a hiatal hernia.

That's key because if they have more than two centimeters of varial hernia. We cannot do this procedure alone, we'll have to do it alongside the surgery. So for patients who have confirmed acid reflux and do not have a large hiatal hernia, the stiff procedure is an excellent option. We bring the patient in, this is done under general anesthesia, but again is incisionless. So we go through the esophagus with this device, and we create a fundoplication. Without making any incisions, the patients go home the same day.

It is an outpatient procedure. We keep them on a diet for about five to six weeks and then they can go back to the regular diet. And about 80% of them are able to get off of the PPIs, and 80 to 90% of them have excellent results in terms of decrease in their regurgit. And decrease in acid reflux. And we confirm these results. There is a lot of trials on this, but here at our center we confirm the acid improvement by doing a pH test before and a pH test after to make sure they have responded well. These patients who have this procedure and about 80 to 90% of the time, it is very successful.

They come to me, and we have changed their life dramatically. They can now eat the kind of foods that they like. They can have a pizza, they can go to a restaurant, they can lay flat in the bed without having to be propped up because they're having to regurgitate all their, food, overnight or stomach juices. So they have excellent improvement in their quality of life, and they're very satisfied and they are off of the PPIs. So this was not an option maybe 10 years ago. More and more this is becoming an option. Now for patients who have a hernia as well, which is also a lot of patients with reflux have a hiatal hernia.

We also do this procedure alongside with the surgeon, so we have partnered with one of our excellent surgeons here, Dr. Masio Mansour, and he sees them in the clinic as well. After I have assessed the patients and then we take them to the OR where he does the hernia repair, I then come in and do. Transoral incision, less fundoplications. We admit the patient overnight and we send them home and they also do very well because we fix the hernia and now we fix the acid reflux and they do amazingly well. Our patients also have excellent, profile in terms of adverse events for this procedure.

Most patients never have any dysphagia. Or difficulty swallowing because the TIF procedure that we use is a rather big device. It's 60 French, which is as big as you can get in the esophagus. And so dysphagia is not an issue for our patients, which used to be an issue for other patients who have the surgical approach. And gas bloat is not an issue. Up to 70% of patients who have the surgical approach can have something called gas bloat, or they feel bloated and they can't burp. But with the TIF population, the studies have shown this to be less than 3%, which is amazing.

So overall, a very successful procedure for the right candidate. If somebody has acid reflux that either of you do not wanna be on PPIs forever, or they are still symptomatic, despite being on PPIs, referring them to us, will do the full workup for them and we will offer them the best treatment option and they can do very, very.

Melanie Cole (Host): Thank you so much. What an informative episode This was Dr. Qumseya. Thank you for joining us and really sharing your incredible expertise. To learn more about this in other healthcare topics at UF Health Shands Hospital, please visit innovation.Ufhealth.org or to refer your patient or to listen to more podcasts from our experts, please visit UFhealth.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.