Help for Your Heartburn with Dr. Scott Gabbard

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef, and you're listening to Health Essentials Podcast by Cleveland Clinic. Today, we're broadcasting from Cleveland Clinic Main Campus here in Cleveland, Ohio, and we're here with Dr. Scott Gabbard. Thank you so much for being here.

Scott Gabbard: Yeah, thanks for having me.

Nada Youssef:   Dr. Gabbard is a gastroenterologist in the center for esophageal and swallowing disorders; and today, we are talking about acid reflux. Please remember this is for informational purposes only, and it's not intended to replace your own physician's advice.

All right. So before we start, I wanted to ask you, so you work for the Center for Esophageal and Swallowing Disorder, and we're talking about acid reflux. Is that a swallowing disorder?

Scott Gabbard: Yeah, so acid reflux ... It's a great question. Acid reflux is very common. What happens is the esophagus is a tubal muscle. Now, it's made up of smooth muscle predominantly, so not the muscles of your biceps and leg muscles, but muscles like your heart and arteries. That's smooth muscle. So the esophagus extends from the throat down through the chest cavity through the diaphragm muscle, which is a sheet of muscle that separates the chest and abdomen. Once the esophagus gets below the abdomen, it joins up with the stomach.

When you swallow, the esophagus opens, and then squeezes food down. The valve at the very bottom that separates the esophagus and stomach is a ring of muscle. It should be nice and closed. When you swallow, it opens, food passes through, and then it closes. Reflux is a disorder when that valve opens when it's not supposed to, stomach contents, which contain a lot of acid, digestive juices, enzymes, the food you eat, can flow backwards from the stomach into the esophagus and cause symptoms.

Now interestingly, when they've done testing on normal individuals who have no complaints of reflux symptoms, they've actually found that normal individuals can have up to an hour of reflux per day and not feel it. So up to an hour of reflux is actually considered within normal limits. But, patients who are having symptoms, if we do testing on them and find they have two hours, three hours or more, they have problematic reflux that needs to be addressed. Obviously we'll talk about our diagnostic tests later on, but for now, know that it's not abnormal to have a little bit of reflux throughout the day.

So the symptoms of reflux, so the typical symptoms of reflux are heartburn, so burning below the sternum, sort of mid-chest burning, especially after meals or at night when you lay down. Or, regurgitation, the sense of stomach contents either with acid or just volume of fluid and food, flowing back up through the chest into the throat and mouth. So the major symptoms are burning, heartburn, and the regurgitation.

Nada Youssef:   Okay, so when you say it's normal to have acid reflux about an hour a day, is it normal to have it right after you eat? Is it normal to have it just throughout the day? When is it?

Scott Gabbard: Yeah, that's a good question. When we looked at normal individuals, you can have up to about 40 minutes of reflux during the day, and about 15 to 20 minutes of reflux at night, give or take; but most people don't feel it. You can have acid in your esophagus and most people don't feel it. Certainly if you start to feel this commonly, or it becomes problematic, it becomes very bothersome, painful, that's when you have a problem.

Nada Youssef:   Sure. So heartburn is a symptom of acid reflux, right?

Scott Gabbard: Yeah, absolutely.

Nada Youssef:   Okay. What about GERD?

Scott Gabbard: Yeah, so GERD stands Gastro Esophageal Reflux Disease. That's when that stomach contents flowing back up through the valve becomes problematic. GERD is actually having the stomach contents reflux back up into the esophagus. Interestingly, you mentioned the symptom of heartburn. So heartburn just means burning in the middle of the chest. Now interestingly, acid reflux is not the only cause of heartburn. There are other causes, so not all burning is due to acid. You can get damage from certain medications. Different pain medicines like non-steroidal anti-inflammatory medicines, and even some antibiotics, can cause ulcers in the esophagus, which can give you burning. Different infections, like some viruses, rarely can cause burning in the chest.

Then, we're finding more and more that many patients who feel heartburn, yet when we do testing, they have normal levels of acid in their esophagus, actually have a condition called Functional Heartburn, which essentially is nerve confusion in the esophagus. They feel like there's acid in the esophagus, but when we do testing, there's no acid present. It actually is the nerves being confused, sending a signal to their brain saying something's burning when in fact, it's not acid present.

Nada Youssef:   It's the nerves.

Scott Gabbard: It's the nerve confusion, yeah. Here at the Cleveland Clinic Main Campus, generally we see the patients who don't get better with the acid medicines, which we'll discuss later, so they're driving from multiple states away because they can't figure out why they're not getting better. At an academic institution, studies have shown about 75% of the time when a patient comes to us with labeled as GERD, having heartburn that's not getting better with acid medicine, 75% of the time, it's actually this nerve confusion disorder called functional heartburn.

The testing we have available can allow us to differentiate, is this truly due to reflux, due to acid coming back, or is this a different condition? That's why it's so helpful to come to a place like the Cleveland Clinic that has so many different testing modalities we can really figure this out better for many patients who've been frustrated for years.

Nada Youssef:   Excellent, thank you. Now, are there other symptoms of acid reflux associated with heartburn?

Scott Gabbard: Yeah, so that's a great question. So like I mentioned, the typical symptoms are heartburn and regurgitation, feeling things coming back. There are also atypical symptoms. You can get cough from acid reflux. You can get throat burning from acid reflux. You can get a symptom called globus, which is very interesting. It's a sensation of feeling like there's a lump in the back of your throat, but then with all testing, there's no abnormality found; but acid reflux can actually cause that symptom as well.

Now with cough, with throat burning, with this globus sensation, there are many other causes. So reflux is not the only cause. We often find patients who've had cough for years labeled as reflux, but they're not getting better with reflux medicine. We do our testing, and we can also find that it's actually nerve confusion causing their cough; same's true with globus. So reflux can cause these disorders, but it's not the only cause. That's where testing, if you're not getting better with the typical medicines used, is so important.

Nada Youssef:   So you say globus is the feeling of a lump on the back of your throat?

Scott Gabbard: Yeah, it feels like there's a lump in the back of your throat, or a fullness, or a tightness in your throat. It's actually common. About 10% of the population can get this at one time or another. Many of these patients go through test after test, after test, and their doctors can't figure out why. Then they actually come to us and we find it's a nerve confusion disorder, or due to acid reflux. Again, there are many different symptoms of reflux, but these symptoms are fairly non-specific. There are many causes for these symptoms. Reflux certainly can cause all the symptoms I mentioned, but many other things can as well. It can be a little tricky to diagnose.

Nada Youssef:   Sure.

Scott Gabbard: We see patients who have been going through test after test, after test for years until they come to us, and we can better understand why they're having their symptoms.

Nada Youssef:   Going back to that lump, it does present itself anywhere in the esophagus, or is it only the back of the throat?

Scott Gabbard: Yeah, so at least in terms of globus, by definition it's a throat symptom.

Nada Youssef:   Okay.

Scott Gabbard: That said, there are many other nerve confusion disorders. You can have a disorder where it feels like you've having difficulty swallowing. You feel like food gets stuck in the chest. Yet on all the testing, everything looks normal. That's called Functional Dysphagia. That's a nerve confusion disorder where the esophagus gets confused; even though everything's working fine, you feel like things are getting stuck. That would be sort of the nerve confusion disorder when it's in the chest as opposed to in the throat.

Nada Youssef:   Very good to know, thank you for that. We talked about acid in the stomach that comes up with acid reflux.

Scott Gabbard: Mm-hmm (affirmative).

Nada Youssef:   So let's talk about why is there acid in the stomach to begin with?

Scott Gabbard: Yeah, it's a great question. Our stomach should have very, very acidic contents to help us digest our food. In fact, the acid level of the stomach should be up to 1,000 times greater than the acid level of orange juice. It should be very, very acidic in the stomach. That's normal. That helps us to digest our food. In the stomach, it's totally fine. In the stomach, you should have high levels acid, and it's no problem. If that highly acidic contents flows backwards into the esophagus, that can cause the burning, the regurgitation that can be so problematic. In patients where they're having high levels of this reflux, they will get the symptoms that I mentioned.

Nada Youssef:   Does the stomach have a lining that's then protecting it from the acid, that maybe-

Scott Gabbard: Absolutely, yeah. When you look at it under a microscope, they're completely different types of cells that line the esophagus and stomach. The stomach is lined with a particular set of cells that do not register when acid's present. Under the microscope, the esophagus actually looks kind of similar to skin. So you can imagine pouring acid on your skin, you're going to feel it. Same's true in the esophagus. When acid comes back up, the esophagus does sense that, and then patients get the symptoms that I mentioned.

Nada Youssef:   Great, thank you. What lifestyle factors contributes to acid reflux?

Scott Gabbard: That's a great question. Like I said, normal individuals can get up to an hour of reflux per day, but there are clearly some risk factors for developing more reflux. In particular, abdominal obesity has been shown to actually cause that bottom valve to open more when it's not supposed to. With the obesity crisis in the US, we're seeing much more acid reflux.

Other conditions, smoking, cigarette smoking's been shown to again, effect the valve to allow the valve to open when it's not supposed to. So smoking's a risk factor. Diet, so diet is really interesting. A lot of things get attributed to diet. Doctors mention all sorts of things, don't eat this, don't eat that when you have reflux. Very little of it has been shown to have an effect.

Nada Youssef:   Really?

Scott Gabbard: Interestingly, there was a study that did suggest that eating more than 15 to 20 grams of fat and eating more than 500 calories at a meal did result in more reflux after that meal; but most other things that doctors have mentioned, avoiding acidic foods, avoiding spicy foods, avoiding mint, avoiding chocolate, avoiding caffeine, none of that's been shown to really make a big different. Believe it or not. My patients love me.

I tell them, "No, you can drink coffee as long as it doesn't cause problems." They love me for that. So yeah, so. Interestingly, it may be more of a volume and fat issue, but all the classic things that doctors have mentioned didn't really make a difference when they've studied it; for what it's worth.

Nada Youssef:   Wow, I'm surprised about the spicy.

Scott Gabbard: Yeah. Well, it doesn't cause more reflux. You feel it more because you sense that capsaicin, so you feel it more but it doesn't actually result in more reflux. It's just you get the same amount of things coming back up, it's just you're feeling it more because there's a lot of that capsaicin, that spice in there. That's actually where it causes more symptoms, not so much it causes more acid to come up.

Nada Youssef:   Right.

Scott Gabbard: But for pregnancy, certainly anyone who's been pregnant, I've been told generally develops reflux, especially in that third trimester. It's a few factors. One, the hormones do cause the lower valve to open more. Then two, increased intra-abdominal pressure from the baby actually pushes up and actually results in more reflux. So actually reflux is very, very common in pregnancy.

Nada Youssef:   Okay.

Scott Gabbard: Lastly, there is an anatomic disorder called a hiatal hernia. So I mentioned that the esophagus travels through the diaphragm, the sheet of muscle that separates the chest and abdomen, and joins the stomach under the diaphragm. Now, if the stomach comes up above the diaphragm, that is a hiatal hernia. When part of the stomach is displaced and actually is in the chest cavity. Interestingly, studies have shown that up to 50, 55% of US adults have a small hiatal hernia. A small hiatal hernia in and of itself doesn't mean you're going to get reflux. It's very common. But a large hiatal hernia, and we're talking about when three centimeters or more of the stomach is up in the chest cavity, does increase the risk of having acid reflux or GERD.

Nada Youssef:   How do you know if you have the hiatal hernia? Because that can cause the acid reflux, but is there a feeling? Is there something that can present itself?

Scott Gabbard: That's a great question. You cannot feel a hiatal hernia in and of itself. That's something that would be found on a test, either an endoscopy, when we stick a camera down to look at the lining of the esophagus and stomach. You can see it on different radiologic tests like a barium swallow, where a patient would drink liquid barium, and it would coat the esophagus. You can see the anatomy. Or, something like a CAT scan can actually show a hiatal hernia. But I do have to mention again, having a small hiatal hernia is very common. For all of our listeners, if you've been told you have a small hiatal hernia, that's nothing worrisome. Certainly a large hiatal hernia can result in reflux, but hiatal hernias are very common. So just having a small one doesn't mean you're going to get reflux. It doesn't mean it has to be fixed with surgery. The vast, vast majority of patients with hiatal hernia have no symptoms, don't need surgery to fix it. It's very common.

Nada Youssef:   All right. I want to talk about things that people can do to avoid acid reflux, maybe preventable measures besides stopping all the risks.

Scott Gabbard: Yeah.

Nada Youssef:   The obesity, smoking, and all the stuff. What other things could we do to avoid that?

Scott Gabbard: Yeah, so it's interesting. Again, going back to what doctors tell patients, very little of it has actually been shown to work in real studies. The things that have been shown to work, if you're obese, so if you have a BMI greater than 30, losing say around 3 points on your BMI has been shown to help with reflux. If you're a smoker, quitting smoking's been shown to help with reflux. Then, if you have symptoms at night when you lay down and you have symptoms at night, elevating the head of the bed, and we'll get to sleeping on the left side, has been shown to help. Essentially everything else, lifestyle factors, has not been shown in studies. Like I mentioned, avoiding caffeine, avoiding chocolate, avoiding soda, acidic foods, unfortunately hasn't been shown to help. Yeah.

Nada Youssef:   How about when you say when sleeping, I know a lot of people, acid reflux, the symptoms come up when you're sleeping the most.

Scott Gabbard: Yeah.

Nada Youssef:   I hear that sleeping on your left side helps. Can we talk about why sleeping on the left side helps?

Scott Gabbard: Yeah, absolutely. When you lay flat, you lose the function of gravity, right? When you're upright, you have gravity working for you so that if things come back up, they fall right back down quickly back into the stomach. When you lay flat, you lose gravity. Now interestingly, if you lay flat and you're just on your back or if you're on your right side, the valve is submerged. The valve is underneath where everything pools in the stomach. If the valve opens, everything rushes into the esophagus. When you sleep on your left side, your valve is positioned such that it is on top of where everything pools, so there's a layer of air that separates where everything pools from the stomach so if the valve opens, only air comes up back.

Interestingly, there was a physician who was here at the Cleveland Clinic back in the 90s who did some very interesting studies, a couple studies, that actually demonstrated the benefit of being on your left side for reflux. His name was Dr. Steve Shay, and he retired from here about five years ago. He was one of the pioneers in positioning at night. Now what's interesting is I talked to Dr. Shay all the time, and he struggled with trying to figure out how to get patients to remain on their left side.

Here at the Cleveland Clinic, we're actually lucky enough to be part of a study where a pillow was developed that actually locks you on your left side. It was shown in some very prelim studies to reduce reflux by about 80, 85%. When we looked at it in our patients with heartburn and regurgitation, we actually found that it helped symptoms at night by about 70% or so. We expanded that, and we used it in pregnant women, and we got the same results. It was about 70% symptom improvement at night, which is huge for pregnancy, helping them without giving them medications. We've even used it in our lung transplant patients now, because acid reflux can damage the lung transplant. If acid gets into a lung transplant, it can actually put the patient at risk for rejection. So we're using this pillow that locks you in place on your left side for all of our patients who get a lung transplant and have reflux, and we're looking to see what effect that has on their survival. We know that it reduces their reflux by about 70% at night. We've been very excited about that study.

Nada Youssef:   That's great, because even I remember when I was pregnant, the doctor always told me to try to sleep on my left side. It's the organs. It's the positioning of your body, right?

Scott Gabbard: Absolutely. Absolutely. Yes, you want to make sure that valve is separated from where things layer in the stomach, so that when it opens, only air comes back up. Yeah.

Nada Youssef:   Then also, don't eat late at night. Is that a thing, or?

Scott Gabbard: Yeah, absolutely.

Nada Youssef:   Okay.

Scott Gabbard: So again, it hasn't been shown in studies, but physiologically, it takes the stomach about four to six hours to empty fully after a meal. You can imagine if you go and you go to a fast food place, and you get a burger and fries, and a big drink, and then lay down, you're going to get a significant amount of reflux because it's going to take your stomach a few hours to empty. We generally tell our patients if you have a lot of symptoms at night, try not to eat within three or four hours of laying down because that's how long it takes your stomach to digest the food. That's how long it takes for that meal to empty fully from the stomach.

Nada Youssef:   That's good information, thank you.

Scott Gabbard: Yeah.

Nada Youssef:   Now I want to talk about some of the treatments, maybe the over-the-counter medications. I know like Tums and all these antacids, are those safe to take regularly?

Scott Gabbard: Yeah, so that's a great question. If you have very infrequent symptoms, so you're talking less than once a week. Say Thanksgiving's coming up, say you know you get symptoms after Thanksgiving dinner. Certainly something like an antacid would be great. Antacids neutralize stomach acid, so they work pretty well if you have infrequent symptoms. One alternative to antacids is that some of them actually contain a chemical called alginate. Alginate's very interesting. It's derived from seaweed, believe it or not. It floats on top of all the acid in the stomach. There's the food that you eat, and then there's a layer of acid that floats on top of the food called the acid pocket. Antacids that contain alginate actually float on top of that acid pocket and form a mechanical barrier to cover the acid so that what comes back up is more the alginate than actually acid. If the regular antacids aren't working for a patient, one nice step up therapy is looking for an antacid that contains alginate.

Nada Youssef:   Okay.

Scott Gabbard: Now, those medicines neutralize acid. They treat the acid that's already there. If you have more frequent symptoms than once per week, we start talking about treating with a medicine that prevents the stomach from making acid. Right now in the US, there are two major types of medications that prevent the stomach from making acid. One category that's been around since the 70s is called the histamine 2 receptor antagonist, or an H2 blocker. Now, these are the types of medicines, ranitidine, famotidine, that are available now over the counter and they do stop the stomach from making acid; but a few caveats to using them.

This category of medications actually stop working within a week or two. Your body gets used to it and you get a condition called tachyphylaxis, which means it stops working. They're good for short term use, like if you know that again, the holidays are coming up and you know you're going to have a few days where you're going to parties. You can take them for a few days, but long term, they often don't work because your body gets used to them. Stomach acid levels go right back to baseline.

One other thing that has been in the news lately is ranitidine, one of those H2 blockers, they've actually found levels of NDMA; which is a possible carcinogen. A lot of ranitidine the past few weeks has been pulled from pharmacy shelves. We've gotten a lot of calls from patients. So certainly, if you've been on ranitidine, we recommend talking to your physician about alternatives. If you want to switch to a different medicine in that same category like famotidine.

But many of my patients who have been on the H2 blockers come to me and say they're not working, and I say, "Well, yeah. We know that your body gets used to them after a couple weeks, so they don't work well long term." That's where we step up patients to another category of medicine called a proton pump inhibitors, which now have been around for about 30 years. They were introduced in the US in the late 80s, and those stop the stomach from making acid not fully, but they cut acid levels down considerably. They continue to work so your body doesn't get used to them, and so they work long term. These are in the category of medicines, proton pump inhibitors, or PPIs. There had been some news a few years ago questioning if PPIs were related to conditions like kidney disease, dementia, or bone fractures. There were fears that having too little acid in the stomach would lead to not absorbing nutrients well, and things like kidney disease, dementia, or bone fractures.

What I tell patients, because we talk about these a lot in the gastroenterology community. These studies that were done four or five years ago were retrospective, so they looked backwards; which you have a lot of risk for error when you look backwards because there's a lot of different factors you can't control for. How often does the patient go out to fast food, restaurants? Do they exercise? What other medical conditions do they have? You can only control for a few of those. So it showed a very, very weak association between proton pump inhibitors and these things like kidney disease or dementia. Scared a lot of doctors into taking their patients off the acid medicines.

In the GI community, when our statistical experts looked at those studies, they actually found boy, this really looks more like statistical abnormality, but not a real cause and effect. So interestingly just a couple months ago, they released the results of a very large 17,000 patient study that showed no increased risk of dementia, kidney disease, bone fracture, heart attack, stroke, death, pneumonia. It was a well done. It was done forwards, prospective. So now obviously if the patients need the proton pump inhibitors, we discuss the risk and benefit. We do think these medicines are safe for the right patient. They work very, very well at controlling acid. If you have ulcers in the esophagus from acid reflux, the proton pump inhibitors are the only medicines that have been shown to reliably heal ulcers from acid reflux, so they are very helpful. But again, if you're going to be on them long term, I think you should discuss with your physician the risks and benefits; but they are safe to take in the majority of patients.

Nada Youssef:   I want to go back to the NDMA.

Scott Gabbard: Yeah.

Nada Youssef:   You mentioned it could be cancer causing, or it is. Are there any other medications out there that are being recalled from pharmacies that our audience should know about?

Scott Gabbard: Yeah. I know that one of the blood pressure medicines was recently recalled.

Nada Youssef:   Yeah.

Scott Gabbard: Because of low levels of NDMA.

Nada Youssef:   That also is present.

Scott Gabbard: Absolutely. So again, pay attention to the news. We're getting more and more reports of this. Now, it is ... NDMA, it's still controversial, the absolute risk of cancer. So it's not like everyone who took ranitidine is going to develop stomach cancer from this, but there were very low levels. Again, the risk in different studies has been questioned. What is the true risk? But certainly if you're on a medicine that has been linked to levels of NDMA, you should certainly talk to your physician about what is the risk, and are there any alternatives that don't have that chemical. Yeah, very good question.

Nada Youssef:   Great. Now, I know you mentioned acid reflux does happen to many pregnant women. Are these medications safe for pregnant women?

Scott Gabbard: Yeah, that's a great question. We do think that the proton pump inhibitors are safe. Most of them are in a category of for pregnancy that they've found to be safe. That said, most OBGYN, and most gastroenterology physicians try to limit their use, even though they are safe. Many of us will use antacids for pregnant women. The H2 blockers have been used, and the proton pump inhibitors, if needed, can be used. Then like I said, sleep positioning. We've found 70% improvement in symptoms in pregnant patients, so using those lifestyle things may help as well.

Nada Youssef:   I'm sorry, for without treatments for patients that don't go see their doctor, that don't go see doctors much.

Scott Gabbard: Mm-hmm (affirmative), yeah.

Nada Youssef:   Can this lead to more complications?

Scott Gabbard: Absolutely, absolutely. The vast majority of patients who have reflux will not develop these worrisome complications. That said, reflux can lead to ulcers at the bottom of the esophagus from acid, and over time, those can bleed, so that you can get bleeding from them. They can cause scarring and cause narrowing of the esophagus, which can cause difficulty swallowing. That's called a stricture, and that would need to be treated by a gastroenterologist with a scope to stretch out the esophagus to help with swallowing.

But the most worrisome condition that is associated with reflux is esophageal cancer, esophageal adenocarcinoma. So over the past 20, 30 years, we've seen an uprise in the amount of esophageal adenocarcinoma that goes along with the obesity crisis, the metabolic syndrome in the US. So more and more patients are getting reflux, and we're seeing higher levels of esophageal adenocarcinoma over the past few years.

Now, cancer of the esophagus, adenocarcinoma, generally comes from a precursor called Barrett's Esophagus. So we mentioned the two different types of lining, the stomach lining and the esophagus lining. Rarely, patients who have chronic reflux, the lining of the esophagus begins to change. It looks more like intestine, so it goes away from looking more like skin, and it starts to look more like intestine. That's due to repeated insult from acid injury, plus genetics play a role. That, if you have Barrett's, it's essentially when we're looking inside the esophagus on a scope, but the lining looks more like stomach than it does esophagus. We take biopsies, and the pathologist can confirm that.

If you have Barrett's Esophagus, you're at slight increased risk of having esophagus cancer. The risk is low. So if you just have Barrett's Esophagus, the risk of it turning it into esophagus cancer is one in 400 per year; so it's pretty low. That said, it's higher than the general population. If you have Barrett's Esophagus, the general recommendations are to get an endoscopy every three to five years to make sure it's not progressing towards cancer, and that progression is called dysplasia. So your gastroenterologist will take biopsies of the esophagus.

One interesting thing is there were a few studies that were recently released that did actually demonstrate that those proton pump inhibitor medicines that I mentioned before do decrease the risk of Barrett's Esophagus turning to cancer by about 70%. It's a no brainer that when we're taking care of a patient who has ulcers in their esophagus, that tightening called a stricture, or Barrett's Esophagus, those patients absolutely need to be on a proton pump inhibitor indefinitely; because in Barrett's Esophagus, it reduces the risk of that turning to cancer. In ulcers, it heals the ulcers. If you have a tight area called a stricture after you dilate it, being on those proton pump inhibitors reduces the risk of it coming back. Those are conditions that absolutely patients need to be on those proton pump inhibitors long term.

Nada Youssef:   A lot of us freak out when we Google our symptoms.

Scott Gabbard: Yeah.

Nada Youssef:   Esophageal cancer sounds terrifying. Are there symptoms that once you see this ... Now, you said blood.

Scott Gabbard: Yeah.

Nada Youssef:   Would there be blood in urine? Would that be blood in stool? Would that be throwing up blood? What would you see?

Scott Gabbard: Yeah. It's a great question. There are definitely some alarm symptoms that we worry about. If you just have heartburn, regurgitation, a couple of time ... once a week or a couple times a week, that's not an alarm symptom. But, if you have evidence of bleeding, so that can be vomiting blood. That can be turning your stools from brown to dark, so black stools is a worrisome thing. That's a sign of bleeding in the upper gastrointestinal tract. Any difficulty swallowing. We term that dysphasia. If you feel solids or liquids getting stuck as they go down through the chest, that's a worrisome sign.

That's something that you definitely should discuss with your physician because the general recommendation is if you have signs of bleeding, if you have dysphagia, if you feel things getting stuck as you swallow, those patients should get an endoscopy. That's a scope with a camera on the end of it where a gastroenterologist or a surgeon would go down and take a look, and look for those things I mentioned: ulcers, a tight area called a stricture, make sure you don't have Barrett's, and nothing that would increase your risk of turning to cancer.

That said, having esophageal cancer is still pretty rare in the US; but certainly any patient who has those alarm symptoms, we recommend discussing with your physician right way because most cases we would want to perform an endoscopy to figure out what's going on.

Nada Youssef:   Sure. All right, one more question for you.

Scott Gabbard: Yeah.

Nada Youssef:   When you say "Difficulty swallowing," you're pointing from your throat all the way down to your chest.

Scott Gabbard: Mm-hmm (affirmative), yup.

Nada Youssef:   When I think of swallowing, I'm thinking of the back of my throat swallowing. You're saying it could be anywhere in the esophageal area that you could feel something getting stuck.

Scott Gabbard: Absolutely.

Nada Youssef:   It's not just the back.

Scott Gabbard: Yeah, absolutely. Like I said, the esophagus extends from the throat down to the bottom of the chest. You can have things get stuck anywhere along that path. Now, what's really interesting is that the esophagus is very stupid; not just our patients', but everyone's. We get called in the middle of the night to pull out a piece of chicken or steak from someone's esophagus. They'll point.

They'll point to their throat and say, "I feel it right now." We go down with the scope and it's actually down at the very bottom of the esophagus. Your brain can't localize where things are getting stuck. That makes our job a little bit more difficult because patients will feel like things are getting stuck way up high. We go down and the problem is way down low. Again, that's where the nerves travel. Where someone is feeling something doesn't actually mean that that's where the problem is. That's where again, talking to your physician and if you need testing, that's where it's really important.

Nada Youssef:   That sounds like that could also be like the nerve confusion that you mentioned earlier as well.

Scott Gabbard: Absolutely. Yeah. Yeah, absolutely. Generally we mentioned the treatment, the proton pump inhibitors. They work for the vast majority of patients who truly have reflux, but there is a sub category of patients where they've been through antacids. They've been through the H2 blockers. They've been through proton pump inhibitors. None of it helped.

All the time I see patients who say, "I've been on this medicine, and I take this medicine four times a day." You're only supposed to take it twice a day. They say, "It's just not working." That's where we talk about doing testing to figure out what is truly the problem. So a scope can look, and like I said, it can find if you have ulcers, if you've got a tight area called a stricture, make sure you don't have anything that could turn to cancer.

A scope doesn't tell you how much reflux you have, or if reflux is truly the cause of your symptoms. It just tells you if there's damage. What we use is a test called a pH Probe. There are a few different types of pH probes. There's one that's a string that goes through your nose, and it dangles in your esophagus for 24 hours. It gets taped to your face and patients wear it for 24 hours. There's also a wireless capsule, which can be placed during an endoscopy, that sucks on the lining of your esophagus. It just is attached to your esophagus. It stays there for about a week. It'll fall off and you pass it in your stool, but it sends a WiFi signal to a receiver you wear for 48 to 96 hours. It tells us the amount of acid in your esophagus.

So for all those patients who aren't getting better with the acid medicines, often will do the next step, be an endoscopy and a pH probe to figure out is it truly reflux? Like I said, 75% of the time, when a patient comes to us and says they're not getting better with the acid medicines, we do this pH test and we actually find it's not acid. It's nerve confusion, that functional heartburn. Those patients are treated very differently. Their problem isn't reflux. Their problem is nerve confusion, so different therapies that address nerve confusion. There are different medicines, believe it or not, some old antidepressants have been shown to help; not because these patients are crazy or anxious, but it's because those medicines work by the chemicals serotonin and norepinephrine, which are involved in anxiety and depression. They're also involved in nerve transmission of the gut. In fact, 95% of the body's serotonin is made in the gut. Medicines that modulate serotonin, and many of them are antidepressants, have been shown to help with nerve confusion in the gut.

Many centers offer behavioral therapy, so cognitive behavioral therapy, diaphragmatic breathing, relaxation training, even hypnotherapy to treat this nerve confusion with great success; 70 to 90% symptom improvement. Here at the Cleveland Clinic, we do have a behavioral therapist who's excellent and offers many of these therapies for our patients. She's very used to dealing with patients who have functional heartburn with great success. It's wonderful.

We also, believe it or not, one of my colleagues has trained in acupuncture. Acupuncture has been shown to help this nerve confusion. It works amazingly well. She has started offering acupuncture here. We are studying with one of my fellows, transcutaneous electroacupuncture. This is when you put small electrodes that stick to the skin, so there's no needles. They actually take an electrical current through some of the acupoints. We're studying that for the use in this functional heartburn. There are a lot of treatments we can offer to these patients who've been through years of acid medicines with no improvement. Once we diagnose them correctly, we can offer them completely different therapies, which are highly, highly effective.

Nada Youssef:   Great.

Scott Gabbard: Yeah.

Nada Youssef:   Thank you so much. It's been a pleasure. A lot of good information.

Scott Gabbard: Yeah.

Nada Youssef:   Thank you so much. For our listeners or viewers, to learn more about acid reflux or treatment options, or to make an appointment, make sure you go to ClevelandClinic.org/SwallowingCenter and thank you again so much for being here today. It's been a pleasure.

Scott Gabbard: Yeah, thank you for having me.

Nada Youssef:   Thank you. To listen to more of our Health Essentials Podcast from our Cleveland Clinic experts, make sure you go to ClevelandClinic.org/HEPodcast. For more health tips, news and information from Cleveland Clinic, don't forget to follow us on Facebook, Twitter, and Instagram at Cleveland Clinic, just one word. Thank you. We'll see you again next time.