Managing Chronic Acid Reflux (or GERD)

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, colorectal surgeon and the president of Main Campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, I'm very pleased to welcome Dr. Jeff Steiner, a gastroenterologist at the Digestive Disease Institute at Cleveland Clinic, Florida. Jeff, welcome to Butts and Guts.

Dr. Jeff Steiner: Thank you, Scott. Thanks for having me today.

Dr. Scott Steele: Before we talk about exploring gastroesophageal reflux disease or GERD, acid reflux as it's known, we'd like to hear a little bit more about you. So, can you tell us a little bit more about your background, where you're from, where did you train, and how did it come to the point that you're at Cleveland Clinic, Florida?

Dr. Jeff Steiner: Sure. Well, if you can't tell by my accent, I am a New Yorker. I grew up on Long Island. I did all my formal training in internal medicine and gastroenterology at NYU. And about 30 years ago I moved to South Florida and I've been in private practice in South Florida until about six months ago when I had the opportunity to join Cleveland Clinic, Florida. I've been here for about six months and really enjoying the experience.

Dr. Scott Steele: That's fantastic. And as I said, today we're going to talk a little bit about GERD or gastroesophageal reflux disease, more commonly known as acid reflux and explain to our listeners what that is.

Dr. Jeff Steiner: Sure. I think the best way to understand gastroesophageal reflux is to have a little bit of basic anatomy and physiology. Basically, the esophagus is the tube that leads from the mouth to the stomach. It's more than just a passageway, but basically, it is a passageway down into the stomach. And what's important at the bottom of the esophagus joining into the stomach is the lower esophageal sphincter. And simplistically, when someone swallows and food goes from the esophagus into the stomach, the sphincter relaxes and food goes in and then it closes tightly. And this is important because the lining of the esophagus is very sensitive to acid. The lining of the stomach obviously is not the stomach is where food begins digestion, there's stomach acid. And basically, that's the view of gastroesophageal reflux disease. GERD, as we call it, basically is an incompetency of the lower esophageal sphincter, which allows acid to reflux onto the esophagus, and this causes various symptoms such as heartburn, discomfort, pain, and other various symptoms.

Dr. Scott Steele: Truth or myth, acid reflux can begin at any age.

Dr. Jeff Steiner: Most definitely. Infants sometimes are born and have acid reflux and grow out of it over time, and anybody at any age can develop acid reflux. What's interesting is that numbers like 30% of people in Western countries have acid reflux. So, this is something that is very prevalent and very serious because I'm sure we'll get into it a little bit later, but some of the sequela of acid reflux can lead to severe medical problems.

Dr. Scott Steele: We talk about acid reflux and everything, but what are the signs and symptoms of GERD?

Dr. Jeff Steiner: Basically, if someone has burning pain in their chest, very often people have this occasionally, but if you have it more than twice a week and it becomes problematic, this is gastroesophageal reflux. Other symptoms can be, I have patients come in and see me and tell me they dentist and the dentist is telling them the enamel is coming off of their teeth or people that have recurrent ear infections or a sore throat or a changing their voice. These are some of the symptoms you can have with acid reflux. But the most common one, the basic one that we know about is the burning in the chest. You can also have what's called globus, which is a sensation that you have, a ball in your throat that just doesn't go away or more seriously, you could have trouble swallowing or pain when you're swallowing. All of these can be symptoms of acid reflux.

Dr. Scott Steele: Sounds like some of these symptoms can actually be mistaken for heart disease.

Dr. Jeff Steiner: Most definitely, and that's very important. Traditionally, a heart attack or cardiac pain is more of a squeezing type of a pain. Very often someone develops a sweaty feeling or a diaphoresis, we call it, the pain in the chest can travel down to their arm, usually their left arm, which is more characteristic of the heart. But it's very, very important, especially in women because women are under diagnosed with heart disease, especially with women, they begin to develop symptoms that they think are acid reflux. It's very important to take a good history and make sure that there's any question that it could be related to the heart to make sure that the patient winds up seeing a cardiologist just to rule that out as a possibility.

Dr. Scott Steele: What are some of the common triggers that can aggravate acid reflux symptoms, and then how do you really diagnose it and make sure it's acid reflux?

Dr. Jeff Steiner: Acid reflux is caused by an incompetency of the lower esophageal sphincter. The sphincter that's closed tightly until you swallow and then food goes down and then it closes again. People that tend to overeat eat, eat large meals, people that have obesity, people that are eating certain foods such as spicy or acidy foods, fatty foods, cigarette smoke, alcohol, all these things can be triggers for acid reflux. Generally, we basically say that acid reflux is probably more prevalent in men, although women can get it also because if you have an increase in the pressure in the abdomen, this makes it easier for acid to reflux beyond that sphincter. The dietary things that I mentioned cause a incompetency or a relaxation of the sphincter at the bottom of the esophagus, and this is what causes the reflux. Other issues is a lot of people have what's called a hiatal hernia. What a hiatal hernia is the top part of the stomach where the esophagus joins is pushed up above the level of the diaphragm, and that further allows the sphincter to become incompetent and allows the acid reflux.

Dr. Scott Steele: That's so interesting. So, what does treatment look like for it?

Dr. Jeff Steiner: Well, the first thing we speak to patients about is the obvious dietary changes and possibly weight loss, if that's the case. Avoid the foods that cause acid reflux, try not to overeat. It's especially important to make sure a patient doesn't eat before they go to sleep at night because you need at least an hour or probably more than that to clear the stomach. If you go to sleep on a full stomach, gravity does not work in your favor. So, it's easier for the acid and the stomach contents to reflux into your esophagus. And we're talking about nonmedical treatments first. I tell patients that they can raise the head of their bed, they can put a wedge underneath the mattress to raise the head of the bed. Sleeping on two pillows isn't good enough during the course of the night. The pillows probably move side to side and you don't get that benefit.

I also have patients that put small blocks of wood underneath the head of their bed to raise the bed up also so that gravity helps them. Now, in terms of medical treatment, there are various medical treatments, most of which are over the counter, but of course, we have prescriptions and that's been a little bit problematic also. When I first trained and first started practicing, we had medications called H2 blockers. Tagamet and Zantac and Pepcid are some of the common names. Those were prescription. They ultimately became over the counter. And then the second line, the stronger line of medications we have are called proton pump inhibitor medications, Nexium, Omeprazole, pantoprazole or Protonix, the brand name. And these medications a number of years ago went over the counter also. And the problem is they do such a good job of blocking the acid that if a patient takes them on their own for a long term, they could be some of the symptoms that as gastroenterologists, we really want to see the patient for to prevent some of the sequela of acid reflux.

That's very important. That's why the disclaimer on most of the medications over the counter are if you still have symptoms after taking the medication for two weeks, or if you've stopped it after two weeks and the symptoms come back, you should see the gastroenterologist. And this is really very important.

Dr. Scott Steele: Yeah, that's incredibly important. Can you talk a little bit more about changes in nutrition and lifestyle modifications can help?

Dr. Jeff Steiner: Sure. Well, obviously, weight loss is the first thing because people that tend to be obese or overweight have increased pressure in their lower abdomen that allows reflux to recur. Avoiding overeating, and also avoiding fatty foods and spicy foods, alcohol, because these cause a relaxation of the lower esophageal sphincter. What's interesting is very often someone goes out to a meal and they eat, and as you walk out, they have peppermints on the counter as you leave and someone eats a meal, they feel pretty well, they pop a few peppermints in their mouth and then 10, 50 minutes later they're having heartburn. And peppermint actually is a big offender. Peppermint relaxes the lower esophageal sphincter and allows reflux. So, it may not be the meal or the food the patient ate, it may just be the peppermint they took afterwards.

Dr. Scott Steele: Are there any advancements on the horizon when it comes to diagnosis or treatment of GERD? And then maybe before that too, can you prevent GERD from happening in the first place?

Dr. Jeff Steiner: Well, I think we need to talk about one of the modalities that we have, which is endoscopy. An endoscopy is a procedure performed by gastroenterologists where the patient is sedated and mild sedation, and then the tube is placed in the patient's mouth and we're able to look down in esophagus in the patient's stomach. When a patient comes to see me, and they have either failed medical therapy, as I mentioned before or they've got what we call alarm symptoms. Someone has a new onset of difficulty swallowing, usually over the age of 50 or 60, or they've got evidence of bleeding, they've got a black stool, or suddenly they become anemic, they're losing weight, they're having difficulty swallowing or pain when they swallow, they're having persistent vomiting. Or if they have a relative, a first-degree relative, mother, father, sister, brother who has had esophageal cancer. These are reasons why an endoscopy might be performed. Based on the findings on the endoscopy, at that point, further treatments could be recommended.

Along the same lines, if I can continue, some of the things that we look for and we worry about is going back again to the anatomy and the physiology that I mentioned earlier, because the lining of the esophagus is exquisitely sensitive to acid, basically the body tries to defend itself against acid. So, if you've had acid reflux for a long period of time, the lining of the esophagus becomes irritated. And in some cases, you can have what's called a stricture. It narrows down the lining fibrosis, and this can be a problem long term. The other issue that we worry about more so is something called Barrett's esophagus. Barrett's esophagus is a change in the lining of the esophagus that begins to mutate and the end stage of this could be cancer. So, in patients that have had long-standing reflux or any of these symptoms, it's very important for us to do an endoscopy to make sure they don't have this condition Barrett's esophagus. And if they do, we need to screen them over a longer period of time to make sure there isn't any change toward cancer.

Dr. Scott Steele: Yeah, absolutely. It's amazing how these complications from something as simple as acid reflux can lead to long-term, death type events. So, great to hear that we have some things out there. Now it's time for a quick hitter. It's a chance to get to know you a little bit better. So, first of all, what was your favorite car?

Dr. Jeff Steiner: My favorite car. In my younger days I drove a BMW and now I'm driving a Tesla. So, I guess I've gotten older and I've gotten more environmentally careful I guess, so to speak.

Dr. Scott Steele: Fantastic. What's your favorite food?

Dr. Jeff Steiner: Unfortunately, you're catching me here. I'm a gastroenterologist and I'm supposed to tell you that I eat a Mediterranean diet and I'm very careful, but I'm a meat and potatoes guy. I like steak.

Dr. Scott Steele: Nothing wrong with that. Is there a trip out there that was your favorite trip or one that you would like to go on?

Dr. Jeff Steiner: My wife and I last month went to Amsterdam. I'd never been there before and we had a great time like nowhere else we've been. That was my most recent trip and in recent memory of my most enjoyable.

Dr. Scott Steele: Fantastic. Do you have a hidden talent or one that maybe many people don't know about?

Dr. Jeff Steiner: Well, my wife and I are now empty nesters and we recently got a English bulldog that we're raising. I don't know if it's a hidden talent, but it's a talent that I'm trying to express in terms of becoming a dog trainer. My wife and I are now dog trainers.

Dr. Scott Steele: Can you wrap all this up and give a final take-home message for our listeners regarding gastroesophageal reflux disease?

Dr. Jeff Steiner: Yeah, what I would say is that if once in a while you overeat or once in a while you have heartburn and it goes away and it's not bothersome to you over a period of time, that's nothing to worry about. But if you have heartburn that occurs more than twice a week and is really bothersome to you, and maybe you've tried over the counter medications that I mentioned earlier, it's time to speak to your internal medicine doctor and maybe get a referral to a gastroenterologist so you can look further into this because like we mentioned, there are issues that can occur down the road. It's more than just feeling well, it's preventing something that can be a problem for you.

Dr. Scott Steele: Fantastic and great advice. For more information on the Digestive Disease Institute at the Cleveland Clinic Florida, please call 877.463.2010. That's 877.463.2010. You can also visit clevelandclinicflorida.org/digestive for more information. That's clevelandclinicflorida.org/digestive. Jeff, thanks so much for joining us here on Butts & Guts.

Dr. Jeff Steiner: Thank you for having me, Scott.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.