Transcript
Alyssa Paschke: Hi and welcome to our November Live Q & A. Today, we are talking with Dr. Jeffrey King from National Jewish Health and Dr. Emily Speer from our clinical partner St. Joseph Hospital. Today, we're going to learn about GERD.
Alyssa Paschke: GERD stands for gastroesophageal reflux disease. It happens when the stomach contents flow, backflow back into the esophagus. Our doctors are going to explain what GERD is, how it's treated, and how it can be prevented.
Alyssa Paschke: As we go along, we are going to take some audience questions, so if you have a question, feel free to type it into the comment section and we'll try to get to as many as possible.
Alyssa Paschke: Thanks for joining us today. We really appreciate your time. Dr. King, I wanted to start off with you. Could you explain what GERD is and is it a disease or a condition?
Dr. King: Sure. GERD, as you mentioned, stands for gastroesophageal reflux disease. Gastro means stomach, esophageal means esophagus, so it's reflux of contents coming from the stomach up into the esophagus. That's a normal phenomenon that we all experienced during the day, usually a very few number of times and usually to the point that it doesn't cause any problems.
Alyssa Paschke: Okay.
Dr. King: Where the D comes in, the disease comes in is when that reflux ends up causing symptoms, or inflammation, or problems either within the esophagus, or if it's coming up high enough above the esophagus in the throat or lungs.
Alyssa Paschke: Okay, so it's a little bit more than just the everyday, type of reflux.
Dr. King: That's right, yeah. The disease part of the nomenclature really is more discussing symptoms and complications of reflux, but reflux by itself can be a normal phenomenon.
Alyssa Paschke: Okay, great. Dr. Speer, I wanted to ask you, can you talk about what causes GERD and is it hereditary?
Dr. Speer: Yeah. Our bodies are really pretty miraculous in that we have a lot of backup mechanisms to prevent pathologic gastroesophageal reflux disease. We have our esophagus that squeezes food down and helps prevent reflux from coming back up. We have a little sphincter at the bottom of our esophagus called the lower esophageal sphincter that's closed most of the time to help prevent reflux from coming up. We have a little valve that helps prevent reflux from coming up. We have the way that our stomach empties food and gastric contents downstream that helps prevent it. We have our diaphragm that helps prevent it as well.
Dr. Speer: So, GERD occurs when one of those things breaks down and you have a pathologic amount of that reflux coming up. It's only through testing that you figure out what exactly has broken down.
Alyssa Paschke: That makes sense. It sounds like there is a lot of different factors that it could be, so you don't know.
Dr. Speer: Exactly.
Alyssa Paschke: ... definitely have the testing to figure out the specifics.
Alyssa Paschke: Dr. King, what are the signs and symptoms of GERD that are beyond just the normal reflux people might experience?
Dr. King: Sure. Most people think of reflux as heartburn or indigestion. The two most typical symptoms of reflux are heartburn or regurgitation, tasting stuff actually or feeling it come back up into your upper chest, or up into your mouth.
Dr. King: Now, there are a lot of other potential symptoms of GERD that people don't necessarily think of as being due to reflux. And as I mentioned, sometimes that reflux can come above the esophagus, can get onto the throat or even down to the lungs. It can cause a number of symptoms including loss of voice, hoarse voice, throat clearing, chronic cough, lung infections, sinus infections, even dental problems. And so, when we're talking about the signs and symptoms of GERD, it really is determined by where that reflux is getting to and where it's damaging.
Alyssa Paschke: Okay, that makes sense.
Alyssa Paschke: Dr. Speer, what are some of your recommended treatments for GERD?
Dr. Speer: There are a lot of different ways to treat GERD and it really depends on what your predominant symptom is. For heartburn, for instance, we often start with antacid medications such as PPIs like omeprazole, and even H2 blockers. There are a lot of different medications that can really effectively treat GERD, so that's usually the first thing that we go to.
Dr. Speer: When people have a lot of regurgitation-type symptoms, or they have problems with their lungs from chronic aspiration, that reflux coming up and then spilling over into the lungs, then sometimes that will require more of a anatomic attack on fixing the GERD, which would be surgery, and there are a lot of different ways to tackle that. There is laparoscopic surgeries that we do with the small incisions, there is endoscopic surgeries, and there are stimulators, all sorts of different options.
Alyssa Paschke: Gotcha. It's definitely a wide variety of treatments available out there. I wanted to stop and take a moment to see if any questions have come in from the audience so far.
Speaker 4: Sure. A viewer is asking if GERD can be confused with bronchitis?
Dr. King: As I talked about before, that the symptoms of GERD really are determined by where that reflux, those contents are getting to. And if they are getting above the lungs and getting onto the airways, a lot of people may not feel that reflux from an esophagus standpoint. They may not be getting much heartburn or actually feeling it come up, and the only symptom may be something like a bronchitis, a chronic cough, if they had an episode of pneumonia or something like that.
Dr. King: And so, it is not uncommon for us to see people who come in and they say, "I get bronchitis a few times a year and it just keeps happening every single year." These recurrent symptoms that don't necessarily behave or respond to the typical treatments are... You should start taking a step back and thinking about other causes such as reflux.
Alyssa Paschke: Great. Anything else?
Speaker 4: Yes. Corin B. is asking if it's safe to take over the counter, like Zantac or there were some recalls and just curious, what is safe to be taking?
Dr. King: Do you want to take that?
Dr. Speer: Yeah, sure. Generally, we say that if you're having very typical heartburn and reflux symptoms without any alarm symptoms, alarm symptoms would be things like difficulty swallowing food, rapid weight loss, things like that that make us concerned that there could be malignancy or I'm sorry, a cancer in the esophagus or something else going on other than straightforward heartburn, then obviously if you don't have those alarm symptoms, it's okay to take an over the counter medication.
Dr. Speer: If you continue to have heartburn and reflux for say, over five years or so, or your reflux is not controlled on those medications, then certainly you need to talk to your PCP about considering referral to a gastroenterologist, like Dr. King to get an endoscopy to make sure that there is not anything more serious going on.
Dr. King: And then I think possibly part, the other part of that question is the recent recall on ranitidine in Zantac. And so the FDA, I think their most recent update to what they put out was last week. Right now, the recalls are generally, they're leaving it up to the individual manufacturers of those compounds. The FDA is leaving it up to the physician and the patient to have that conversation and decide, weighing risks and benefits.
Dr. King: But suffice it to say, that there are other alternatives that are not undergoing FDA investigation right now that are available either over the counter or by prescription. So, if there is a concern about a possible long-term risk of taking those medications there are certainly alternatives that are easy, easily accessible.
Alyssa Paschke: Great. Anything else?
Speaker 4: Yes. Lindsey M. is asking, when would you treat a patient surgically? What level would you get to that you need to act?
Dr. Speer: Yeah. Typically, when I see patients here at National Jewish Hospital, they've tried maximal medical therapy. Their symptoms are somewhat controlled, but not well controlled on the antacid medications. So, those people are typically very interested in pursuing surgery.
Dr. Speer: When patients have predominantly regurgitation-type symptoms that also aren't controlled on medications, and when people have lung disease associated with GERD, then they are typically interested in pursuing surgery.
Dr. Speer: We see a lot of people with lung disease, obviously here at National Jewish Hospital and one of those lung diseases is called interstitial pulmonary fibrosis. And we know that about 87% of those people have GERD, but over 50% of them are asymptomatic. So, when we have patients who have stronger indications for surgery, that's usually when they seek the advice of a surgeon.
Speaker 4: Joan B. is asking about silent GERD. What is silent GERD?
Dr. King: Silent GERD, in a way, is almost a little bit of a misnomer. As I said, the typical symptoms of GERD are generally heartburn and regurgitation or the feeling or tasting of stuff come back up. If you don't have those symptoms, but testing, whether it's a barium test or formal reflux testing does show evidence of reflux, then we call that silent reflux because you don't have the heartburn, you don't have the regurgitation.
Dr. King: The reason why I said it's a misnomer is because oftentimes that reflux is causing symptoms, but just not symptoms that you think of as being reflux.
Alyssa Paschke: Right.
Dr. King: For instance, throat clearing, chronic cough. I've had people come in who are singers who said, "I just can't sing in church anymore. I used to be in a band and I just can't sing anymore." They've never had any reflux once in their life, or the typical reflux symptoms, heartburn, regurgitation, once in their life. And when we put them through testing, we actually find out that they're having quite a bit of reflux that they weren't aware of. So, silent reflux basically just means you don't have heartburn or those regurgitation symptoms.
Alyssa Paschke: Got it. I guess along those lines, what suggestions do you have for living with or preventing GERD if you've been diagnosed with it? I'll let you answer, Dr. Speer.
Dr. Speer: Sure, yeah. The top thing that you can do as a patient is you can follow different lifestyle modifications to help minimize the amount of GERD that you have. Those are things like sleeping with the head of your bed at a 30 degree incline, things like avoiding spicy foods, avoiding caffeine, alcohol, eating late at night, all those types of things.
Dr. Speer: As far as your personal symptoms, it's always a good idea to keep a food diary and try to figure out what your triggers are and avoid those triggers.
Alyssa Paschke: Great. Dr. King, I read that about 70% of people with asthma also have GERD. Could you explain why that might be?
Dr. King: Sure. Dr. Speer alluded to it earlier. That there are a lot of mechanisms that we have in our body to prevent gastric or stomach contents from going back up in the esophagus, and one of those is the diaphragm, which is the muscle that sits underneath the lung. It moves up and down and that's why our lungs inflate and deflate. And the diaphragm sort of pinches the esophagus at the bottom of it, and that's one of the mechanisms we have to keep that area tight and keep stuff from coming back up.
Dr. King: When people have asthma or other lung conditions, it often changes pressures within the lungs. It changes the effort they need to give to be able to breathe, inhale and exhale. And that can change the dynamics, the pressures in the lungs, where that diaphragm is sitting, how tight it is, is it low, is it high, how it's pressing on the esophagus. As the diaphragm lowers, it actually increases pressure in the stomach. And so, that combination of increased pressure in the stomach or the abdomen, decreased pressure up in the chest cavity, things are going to move in the path of least resistance. And so, there are a lot of lung conditions that the mixture of things together is such that it promotes that, the movement of stomach contents in the wrong direction.
Alyssa Paschke: Oh, that's really interesting.
Dr. King: The other thing I'll add is that oftentimes asthma patients are taking beta agonist, so a type of inhaler, or a rescue inhaler, and there is evidence to show that that can loosen up the lower esophageal sphincter that was discussed before. And the looser that muscle is, the more at risk you are of having reflux. So, there are a couple of things that go together in asthma patients.
Alyssa Paschke: Wow! Yeah, I definitely didn't know that, so very good information. You alluded to this, other lung conditions, but are there other conditions that are affected by GERD in addition to lung conditions, or really the lung conditions go hand-in-hand with this in certain instances?
Dr. King: I can start and you can add on. Again, when we talk about what parts of the body may be affected by GERD, it's really everyone has generally heard about the esophageal complications of it, irritation, pre-cancerous conditions, difficulty swallowing. But it's really, once you get above the esophagus into the airway that there is a number of things that can be associated with it and other conditions.
Dr. King: Again, I've seen patients with chronic sinus infections and that's their only chronic symptom where once we put them through the evaluation, it really comes down to the fact that they probably have GERD contributing to that.
Dr. King: There can be, again, dental problems. People that have had cavities and have had all their teeth... I've seen patients who have had most of their teeth having to be pulled out that once we put them through an evaluation, we find out they have a lot of reflux.
Dr. King: So, there is a number of things above the esophagus, whether it's within the lungs themselves or it's within the other throat and sinus cavities that can be involved.
Dr. Speer: Yeah, I'd second that. I think Dr. King is describing the extra esophageal manifestations of GERD. So, a lot of data and research has gone into the esophageal manifestations, the heartburn and the reflux-type symptoms and then eventual lead to Barrett's esophagus that can progress to esophageal cancer. But, there are so many different extra esophageal or outside of the esophagus conditions that can arise and be contributed or even caused by GERD. So, that's one of the things that we specialize here in at National Jewish Hospital is those extra esophageal manifestations.
Alyssa Paschke: Yeah. It sounds like really the best way would be if you're experiencing some of these symptoms to really come in and be seen by either your primary care physician or a gastroenterologist because there is so many different factors and you really want to be able to pin point the specific cause.
Dr. Speer: Absolutely.
Alyssa Paschke: Dr. Speer, would you, what should you do if you have symptoms of GERD? Would you see a specialist right away? Would you recommend people go to their primary care, along those lines of what we were just discussing?
Dr. Speer: Yeah. Most people do start with their primary care physician. They're usually the most easily accessible physicians.
Alyssa Paschke: Sure.
Dr. Speer: And then also a lot of insurance companies require a referral to a specialist such as Dr. King or myself after seeing their PCP. But, if you have any of the alarm symptoms you should, which are difficulty swallowing, weight loss, blood, things like that, then absolutely you should see your PCP to get a referral to a gastroenterologists right away. If you have straightforward heartburn then, it's perfectly fine to start with your PCP.
Alyssa Paschke: What kind of testing do you do at St. Joe's or at National Jewish when somebody does come to see you?
Dr. King: The first part of the evaluation really starts with a very good history where you talk with the patient and you really try to get to the heart of what symptoms you're really evaluating. Is it really an esophageal problem, or is it more of an airway problem, or outside of the esophagus because that helps determine next phases for testing.
Dr. King: We haven't gotten really into this part of things, but there are different types of reflux, acid reflux, which most people have heard of for which all those medications that were discussed earlier are used to treat, the acid reducers.
Alyssa Paschke: Right.
Dr. King: And then there is another type of reflux called non-acid reflux, which is other stomach contents that are not acidic that can also come back up and cause problems. And depending on what symptoms you're evaluating and what type of reflux you're most concerned about, you can choose, which reflux testing is best.
Dr. King: There are different tests. There are certain tests that measure just acid reflux. There are other tests that measure acid and non-acid reflux. There are tests, again depending on where in the esophagus you're trying to measure.
Alyssa Paschke: Right.
Dr. King: So, there is a lot of nuances that go into deciding what the proper test is. But I think first and foremost, you really have to take a good history from the patient and know exactly what type of symptoms or manifestations you're investigating first. And that's where sometimes some, a specialist perspective can be very helpful.
Alyssa Paschke: That definitely makes sense. I wanted to take one more pause here and see if any other questions have come in from the audience?
Speaker 4: Yes. Ben K. is asking about stress and heartburn and GERD and ulcers. Are they connected?
Dr. King: Do you want to take this one?
Dr. Speer: I'll let you.
Dr. King: You'll hear that a lot from people who have said, "Oh, in the past I had an, my doctor told me I had an ulcer. It was during a time where I was very stressed out and there wasn't necessarily any testing done to prove that." There has been some literature over the past few years that has actually looked at this and there is, there actually is some evidence behind that to show that people that are just very stressed out, or anxious, or have a history of significant stress do tend to be more at risk of having ulcers and why that is, it's a little bit unclear.
Dr. King: But I think in my clinical experience, the people who have said that they have an ulcer because of stress, when we actually do the testing, it's very uncommon to actually see a physical ulcer there. But suffice it to say is, there actually are a couple of papers out there that have looked at this and have actually found increased incidents of ulcer, stomach ulcers in patients who, with significant stress or anxiety.
Speaker 4: Okay. We have a couple patients that are asking you about specific other illnesses going along. Darren B. is asking about gastroparesis.
Dr. King: Gastroparesis yes, so, it's slow emptying stomach, yeah.
Dr. Speer: Exactly.
Dr. King: Do you want to answer this?
Dr. Speer: Gastroparesis is basically a failure of one of those parts of the esophagus and the diaphragm, and the stomach, and the valve and all of those things that I was mentioning before. So, when your stomach empties slowly, that's called gastroparesis or gastro meaning stomach and paresis meaning kind of paralyzed, partially paralyzed.
Dr. Speer: There are a lot of different ways to treat gastroparesis. We start with the gastroparesis diet, which is small, frequent, low-fiber, low-fat meals to try to keep the stomach as empty as possible. And then there are also medications to help the stomach empty a little bit more rapidly as well. And then if those things fail, then there are also a surgical and endoscopic options that we can try to help the stomach empty.
Dr. Speer: One thing that we do know is that there are at least a couple of types of gastroparesis, one is idiopathic. We don't really know what causes it. And the second one is diabetes induced, so if a patient has diabetes, one of the first things that you need to do is get that glucose under control.
Alyssa Paschke: Great. Any other questions?
Speaker 4: Yes. Joan is asking about osteoporosis and G-E-R-D, and how would you treat that combination?
Dr. King: I think the, at least in my clinical practice, the times that that discussion has really come up is when we're talking about using acid reducing medications, particularly PPIs or proton pump inhibitors. Those are medicines like Prilosec, Nexium, Protonix that people may be on.
Dr. King: There is some suggestion, or conflicting evidence whether or not they affect the absorption of calcium changing the acidity in the stomach, and the intestine may change how calcium is absorbed through the intestine, which may contribute to poor bone health. And so, that discussion will often come up if a patient's been diagnosed with osteoporosis and we're talking about starting these medications, or if they've been on these medications for a while and they're working and they want to continue on the medications. A lot of patients will bring up the fact that they may have read somewhere or heard from their primary care physician that it may contribute to bone health issues.
Dr. King: In general, people who are going to be on long-term PPIs, I will often, if there is that concern on the patient's behalf, we'll do periodic bone density testing to look for evidence of osteoporosis, or if they come in with a baseline of osteoporosis, we'll recheck their bone density after they've been on the medication for a little while just to make sure that nothing is changing. Obviously if things are worsening, then we have a conversation about the risks and the benefits of staying on the medication.
Alyssa Paschke: Great. So, to wrap up here, I wanted to ask each of you, could you share your top tip for managing GERD symptoms?
Dr. Speer: My top tip would be that heartburn and reflux and GERD-type symptoms are a little bit different for every person. So, find your trigger, try to avoid that trigger, and any alarm symptoms, see your doctor right away.
Dr. King: Yeah. I just want to reiterate the fact that you really need to pay attention to what it is, what your symptom of reflux really is. And if it is that typical esophageal symptom of heartburn or indigestion, then certainly avoiding spicy acidic foods, being on an acid reducer may be very helpful.
Dr. King: If on the other hand, it's more of a lung symptom, a throat symptom, then that may be insufficient. You may need to do something that actually stops the reflux from happening. And at that point, I think that's where getting in to see a doctor can be very helpful.
Dr. King: One of the best things you can do that almost all the literature on reflux says is, is weight loss. If you are overweight or obese, certainly weight loss is one of the best things you can do to decrease that pressure that you have on your stomach and hopefully keep stuff from being pushed back up.
Alyssa Paschke: Great. Well, I wanted to thank you both for speaking with us this afternoon. I think it was really informative for me and hopefully for all of you out there in the audience and we hope you learned something new about GERD. And if we didn't get to your question, we will follow up with you in the comments, so not to worry there.
Alyssa Paschke: Feel free to like our Facebook page, National Jewish Health and St. Joseph Hospital and share this video with your friends and family. And for more information about National Jewish Health and St. Joseph Hospital, you can visit working together.org and that includes a lot of our joint programs and treatment programs between both hospitals. Thank you so much.
Dr. Speer: Thank you.
Dr. King: Thanks.
