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So in conclusion, gastroesophageal disease is a relatively common disorder. It’s characterized by heartburn, which is oftentimes triggered by consuming certain substances, fatty foods, alcoholic beverages, peppermints, chocolate, can be triggered if you bend over to tie your shoes or pick up an object. And for the most part, everyone experiences some degree of acid reflux throughout the day and it doesn’t necessarily represent a problem. When gastroesophageal reflux is referred to as a disease. It’s because it begins to alter your daily routine. It makes you feel uncomfortable and you experience symptoms of heartburn multiple times a week and you find that you feel better when you’re taking antacid medications and avoiding some substances that trigger it. If you notice that you have these symptoms and you don’t have any red flag symptoms such as fever, severe pain, weight loss of greater than 10% of your normal body weight, if this has been going on for two weeks or greater, you should definitely bring it to the attention of your physician if not sooner. They are very simple treatments that we’ve talked about, the medications we’ve talked about when certain procedures such as endoscopy to check whether you have injury to your esophagus and/or stomach. We talked about the role of medications and the role of surgery is only in severe cases for the most part. And the bottom line is if you take your medications, avoid gaining excess weight, pay attention to your diet, you should do quite well. This is Eugene Trowers from the University of Arizona and Gi Department. Thank you so much. Have a great day.
Symptoms of gastroesophageal reflux primarily our concern with heartburn, a burning sensation in the middle of the chest, oftentimes precipitated by certain foods, fatty foods in particular, alcoholic beverages. Certain medications can trigger a heartburn or reflux type symptoms. For example, if you consume medications, commonly referred to as NSAIDs, nonsteroidal antiinflammatory drugs, now these would be medications such as aspirin, Ibuprofen, Naprosyn. These types of things can cause injury to your lower esophageal sphincter, and that’s the sphincter muscle that helps protect your esophagus from the reflux of gastric acid.
So now we talked about the use of laparoscopic or minimally relatively minimally invasive techniques to reinforce your lower esophageal sphincter muscle, but some new things on the horizon concern and endoscopic treatment for gastroesophageal reflux disease where a physician will place an endoscope through your mouth and either suture in place some beads or install some devices which can be used to tighten your sphincter from an external source. Minimally invasive types of procedures and these are ideal for individuals who either have significant health issues such that surgery may be a somewhat challenging for them, or there may be folks who really are interested in invasive surgical procedures. This type of an approach may offer some opportunities for relief beyond the dietary and medical types of therapies we’ve talked about.
As far as testing, the upper endoscopy that we talked about earlier will help the physicians determine if you have any injury because of your reflux disease. That is a separate test, which is more of a gold standard for reflux and that’s called a Ph test with impedance. Impedance just means that you can tell which direction the refluxate is going. The way that Ph test is done, a small catheter is placed through your nose passed down to your esophagus, a fair distance almost to the end of your esophagus. All right, and you walk around with this catheter in place for 24 hours. Now you’ll have a little walkman type device or on your belt, and if you feel heartburn, you press one button. If you take your medications, you press a different button. If you eat a meal, you press a different button. If you recline like you’re going asleep, press a different button and duration of acid reflux will be recorded over 24 hour period of time. There’s a particular score called the DeMeester score and it has to be less than close to 15 to be within a normal range. If your DeMeester score is greater than, let’s say 15 then that’s compatible with acid reflux disease.
Now you might wonder, so how does one confirm a diagnosis of gastroesophageal reflux disease? Well, it depends. Technically your grandmother could make a diagnosis in an uncomplicated case. In other words, you consume a particular substance. It triggers this burning sensation, or if you bend over, tie your shoes, or pick up an object and this reproducibly causes the heartburn, then that’s a pretty good index that you do have gastroesophageal reflux disease. However, the mere fact that individuals have reflux doesn’t necessarily mean that they have a disease or a serious condition. That determination one would arrive at because of the fact that it’s altering your normal activities. It’s making you feel uncomfortable. It’s causing you to experience sensations that you don’t want at times where it’s not convenient for you to feel these things. That’s when the diagnosis begins to firm up.
Hello, this is Eugene Trowers from the University of Arizona Department of Medicine Division at Gi. I graduated from the New York University School of Medicine. I graduated from my Residency Program, Columbia Service at Harlem Hospital in New York. I completed my NIH Gi training at the University of Washington in Seattle. Currently I’m a professor of medicine and the Division of Gi and I’m the director of Gi services, at the University of Arizona South campus facility. I also serve as director of internal medicine residency program at the South campus. In Gi, my area of interest, I see patients who have swallowing disorders and I perform high resolution manometry studies to help diagnose and guide the treatment of these individuals. One project I’m very interested in is patient medical education. Currently I’m writing a book with Dr. Marc Tishler and Karen Spear Ellingwood concerning the empowerment of patients when they visit their doctor, such that they can better follow along in the doctor patient dialogue and be better partners when time for decision making, testing and management arise.
Today, I’d like to talk to you briefly about a fairly common problem. It’s referred to as GERD. Gastroesophageal reflux disease. Now you may wonder, well, what is GERD exactly? Or many of us have experienced heartburn, a burning warm sensation in the chest. Oftentimes it’s precipitated by certain foods, fatty foods, greasy foods in particular. Sometimes if you consume an alcoholic beverage, that might do it. Or perhaps you happen to bend over to tie your shoes or to pick up an object, and this may recreate the sensation of a burning in the middle of your chest. And that’s commonly referred as gastroesophageal reflux disease.
One thing that’s important to keep in mind is that you normally have a sphincter muscle, separates the swallowing tube from the stomach. Now, when this sphincter muscle is doing its job, you have much less likelihood of reflux. But suppose it relaxes or suppose it’s permanently weakened. Well then you could imagine you’ll get frequent heartburn or reflux. Now the next question would be, well, gee, how can I determine if I have a problem with this? Normally, if you take an antacid medication, it could be a liquid acid. It could be what we refer to as a proton pump inhibitor, provisac, or some other similar types of medication. Those medicines will block the effect of acid. So now if you reflux gastric content, you won’t get that injury or inflammation or irritation from the acid. What else could you do? Well, if you elevate the head of your bed at least 30 to 45 degrees when you’re reclined, this will help the reflux acid drain by gravity. If you avoid eating a large snack or meal within two hours of going to bed, that can help. What about if you consume a smaller volume of food? Well naturally a smaller volume will stimulate a smaller volume of acid, and so even if you have reflux, you’ll reflux a smaller amount.
What else can cause heartburn symptoms? Well, in pregnant ladies, for example, hormones can affect the lower esophageal sphincter. It can compromise its degree of contraction, and so then the likelihood of reflux occurring is more common. Increased weight. And you can imagine if you have increased fat cells or enlarged organs in your abdomen, this will cause pressure on your lower esophageal sphincter and that will facilitate acid reflux. So these are some of the common symptoms. Now, what are some of the warning signs, things that you really would want to be concerned about? Well, if you notice that your appetite has dropped off significantly. If you’ve lost 10% of your body weight over a relatively short period of time and you’re not on a diet, that should really get your attention. If you have pain upon swallowing or if you have difficulty swallowing, these are warning signs of more severe conditions or complicated gastroesophageal reflux disease.
So, you’ve answered the questions and it seems that yes, gastroesophageal reflux disease is a distinct consideration in your case. So what about it? Well, let’s assume that you’re less than 40 years of age, this has been going on for a relatively short period of time. All things being equal, you have no warning signs. Those things about severe weight loss, difficulty swallowing, etc. Physician will probably give you a trial of an antacid medication and ask you to take it and see how you do for about two weeks. Now, if you still have problems and you’ve avoided the medications, the food substances, you know you’ve quit smoking and you still have symptoms, then it may be a consideration that you go for an upper endoscopy. Now an upper endoscopy, actually the formal term is, it’s kind of fancy esophagogastroduodenoscopy. And basically what happens when you arrive at the Gi facility, they’ll explain to you in great detail what you can expect. The night before you would have had only clear liquids and then once you go to sleep don’t consume anything else. If you have certain types of medications, let’s say for high blood pressure, you may take that several hours before your scheduled exam with a very small amount of water, and when you arrive, you should notify the nurses and physicians that this is what you’ve done. And this would have been on the direction of your physician.
Time for the test. The physician will go through what we’ve referred to as an informed consent. They’ll tell you that this upper endoscopy is a fairly safe test. And normally what takes place is that the physicians will give you medication to help you relax. You’ll be laying on your left side. Okay. You’ll probably have some supplemental oxygen to help you maintain your breathing throughout the test. And then while you’re in a form of twilight sleep, they’ll introduce the scope through a bite block. Okay. Which is used to protect your teeth and to protect the scope. And they’ll ask you to gently swallow the scope. Now, under direct vision, they’ll look at the lining of your esophagus and they can see if you have any inflammation or ulcerations. An ulcer is like a break or a sore in the lining of the esophagus. They’ll examine your esophagus. They’ll examine your stomach and the first part of your small intestine. Now this entire process takes place anywhere from about 10 to 15 minutes.
Now, if they see areas of abnormality, ulceration, significant inflammation, or growth, then they may pass a small instrument through the scope, obtain a sample of the tissue, which they will send to the lab. Pathologists will look at it under a microscope and see exactly what’s going on. Do you have significant inflammation? Do you have some other disease process which has infiltrated the lining of your esophagus? Or do you have a tumor? Based upon the information gleaned from the followup tests, your physician will be in a better position to make certain recommendations as to future treatments and evaluations.
Now you may ask, does gastroesophageal reflux disease cause any other significant issues or is it associated with other diseases? Now we mentioned the fact that cigarette smoking, which can be associated with chronic lung disease, obviously can potentiate acid reflux disease. But there’s a particular condition called Barrett’s esophagus. This is a condition which is a precancerous condition, and it’s intimately associated with gastroesophageal reflux disease. Now, Barrett’s Esophagus is a relatively rare condition, but we’ve noticed that the incidence of Barrett’s esophagus has increased significantly over the last 20 to 30 years. We’ve also noted that in Caucasian males, especially those who are at least 30 years of age, and who have had gastroesophageal reflux disease for at least three years, the likelihood of them develop Barrett’s esophagus increases significantly. So if a patient has gastroesophageal reflux disease, the significant heartburn that occurs multiple times a week, and that they pretty much need to take antacid medications quite frequently in order to keep their reflux under control. And this has been going on for three years. Those individuals, all things being equal, are primary candidates for a screening upper endoscopy to see if they have Barrett’s esophagus.
Now, let’s assume that you’ve had reflux symptoms, which had been fairly bothersome. They’ve been occurring the majority times during a week. Let’s say more than three to four times a week. They’re altering your daily activities. Hence, they become somewhat problematic. And this has been going on at least for two weeks. Well, as an adult, this may mean that you’re having some issues with gastroesophageal reflux disease, and so it would then probably appropriate to make an appointment with your primary care physician to find out exactly what’s going on. So now you’re in the doctor’s office. You relay your heartburn symptoms, you tell them how long this has been going on. What makes it better? What makes it worse? What have you tried to do to alleviate the symptoms? The physician may ask, well, have you taken certain types of antacid medications? Have you had any relief from that? When you would recline in bed, were your symptoms worse? if you bent over to tie your shoes, was this problematic?
Now what is Barrett’s Esophagus? Well, we talked about gastroesophageal reflux. The acid refluxes from the stomach into the esophagus, and the acid irritates the esophageal lining. And if this goes on for a period of time, months, years in particular, then the lining of the esophagus begins to change. And it changes in a way where it begins to look like the lining of the stomach. Now remind you, the stomach was designed to produce acid. It can tolerate a fair amount of acid. The esophagus does not tolerate acid as well. So you reflux acid over a period of time. This chronic inflammation and injury to the esophagus causes the esophageal tissue to change such that it begins to look like the lining of the esophagus. And in Layman’s terms, that’s what Barrett’s Esophagus is all about.
What’s important, let’s say you go to your doctor and they say you have Barrett’s esophagus. Well, what’s the significance of that? It may become a precancerous condition. But what’s important to know is whether you have what’s called Barrett’s esophagus with dysplasia, because the dysplasia means that you have these abnormal cells present. Now, if a patient, let’s say, has Barrett’s Esophagus and their symptoms remain the same, then you should probably repeat their upper endoscopy in three years to see if the Barrett’s has changed. Has it progressed? Now, let’s have another scenario. Patient has Barrett’s esophagus with low grade dysplasia, so there is some change in the cells, but it’s relatively low grade. That patient, again, is at some risks for possibly developing cancers. It’s small risk, so you should repeat the screening endoscopy in a year.
What happens if you scope a patient and you notice that the patient has Barrett’s Esophagus? And you get the biopsy sample back and it says Barrett’s esophagus with high grade dysplasia. Now you could think of that as one step before cancer. So what should take place? Well, that patient should undergo a repeat endoscopy relatively soon with biopsies. If the results come back again, Barrett’s esophagus with high grade dysplasia, then that patient should be referred for therapy to eradicate that high grade dysplasia. And that’s done by several different means. Basically, what would happen is patient endoscoped, and a thermal or heat type device is used to actually cook or destroy the abnormal tissue. If the patient has high grade dysplasia and some focus of early cancer, then that patient needs to be referred for surgical treatment.
We’ve done all those things. You’ve lost weight exercise, you have adhere to an appropriate diet, you’re taking medications to the maximum extent and you still have problems. Well then you may need to go for testing to see if number one, you have an ulcer present or growth present in your upper GI tract. But let’s say you’ve done that and there are no obvious lesions found. Then you may need to go for a different type of test. You may need to go for manometry, That’s a fancy word, but basically they’ll place a probe through your nose, down into your esophagus and the computer will determine to what degree do you have contractions in your esophageal muscles and relaxation? To what extent does that sphincter muscle that separates your esophagus from your stomach? To what degree does it contract and relax appropriately? Okay, because let’s say for example, if a patient refluxes acid but their esophagus doesn’t contract appropriately, then acid may sit there for an extended period of time. Cause more damage. Or let’s say your lower esophageal sphincter is relatively weak, the likelihood of reflux occurring is greater. Or let’s imagine you have a hiatus hernia. Now, hiatus hernia means that you have a portion of your stomach has popped up into your chest and it’s sitting there like a cup. Okay, so now when you reflux acid into this cup, the acid is sitting in this cup for a prolonged period of time. Therefore, the likelihood of the acid causing injury is greater because it can’t reflux up and come back down. It’s sitting in a cup. Alright, so these are some considerations.
So you’ve done all the medical therapies and your symptoms are still bothersome. You’ve gone through the appropriate testing. We know that your esophagus clears appropriately, but let’s say your lower esophageal sphincter pressure, that muscle that separates the stomach from the esophagus is kind of weak. Then you are a physician after doing the appropriate tests of the muscles, the menomatries, the Ph studies may refer you to a surgeon for evaluation for what we call a fundoplication. Fancy term. But basically what it means is that they’ll use a laparoscope, make some small incisions in the area, and then surgically reinforce the muscle in the lower part of your esophagus, that sphincter. So now your sphincter has better tone. So when you reflux stomach acid, your sphincter is stronger. The likelihood of an acid bolus injuring your esophagus is reduced, and that can drastically improve your symptoms. Now, naturally, you still have to do some things to help yourself exercise, eat smart, and lose weight when appropriate.
First place to go would be chat with your physician and ask questions. You should feel empowered to ask if physicians about anything. Now, beyond that, there’s certain information that you can obtain from the website. The NIDDK, which is an agency from the National Institutes of Health and their digestive disease and kidney site, has information for patients. You could also go to sites such as UpToDate. UpToDate has inflammation naturally for healthcare practitioners, but they also have a wealth of information for patients, and this information is updated regularly, and so you’ll get the latest guidelines.
You may wonder, are there any kind of hereditary or genetic components to GERD? In general, no. In some rare instances, patients may have conditions which can affect swallowing and so forth, but oftentimes gastroesophageal reflux disease is acquired and there may be many reasons for it. Some of the more common ones are increased weight, the effects of hormones, either from birth control pills and/or pregnancy. Cigarette smoking can lower the sphincter pressure in that valve that protects your esophagus from the reflux of acid. What else? If you have certain connective tissue disorders such as Lupus, which is an inflammation in the lining of certain tissues, or if you have Scleroderma, which is a condition where the lining of your esophagus becomes very hard and fibrotic. That can compromise your sphincter and exacerbate the effects of reflux. So there are a number of possible causes or etiologies for gastroesophageal reflux disease.
You’re in your doctor’s office. They informed me that you have gastroesophageal reflux disease. So if you reflect upon some of the things that we’ve talked about, what are some baseline treatments? Well, we always ask the patient to do some lifestyle modifications. Do some things for yourself. So exercise, watch the amount of food that you consume and the types of food that you consume. You might want to avoid greasy or fatty foods, alcoholic beverages. It’s always a good thing to avoid a cigarette smoking. I would suggest that you not consume a large snack or a meal within two hours of going to bed or assuming a reclining position. Antacid medications, which will minimize, to a great extent, the amount of acid present in your stomach. Therefore, if you happen to have an episode of reflux, the likelihood of you experiencing heartburn and or some injurious effect to your esophagus will be greatly minimized.
Now certain costs. Obviously, I’m sure everybody is concerned about costs. And fortunately a number of the very potent antacid medicines we refer to them as PPOs, Proton pump inhibitors, you can think of them as smart bombs. They really hit the acid producing sites in the stomach. They’re very effective at markedly reducing acid. And a number of these agents have become available over the counter. And so you don’t need a prescription. You can purchase these still, I would use them under the advice of your physician. Those types of things are relatively inexpensive. Now, if you want a good source for bargains so to speak, and you try to work with your insurance company, a good site is GoodRx. If you go to GoodRx, you can see the types of pharmacies in your community, in your zip code area, and you can see relative prices for a particular medication. In this case, an antacid medication, get a coupon and along with your insurance, you may experience some significant savings and we recommend this to all of our patients. There are also some formularies. One comes to mind, Walmarts, and there are others which offer inexpensive generics. Walmart has a $4 generic. If your physician prescribes a generic form of this antacid medicine, you may be able to get a month supply for $4. It’s a great bargain.
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