Well, welcome to our webinar today. We’re going to talk about gastroesophageal reflux disease, and we’re going to talk about evaluation and treatment of acid reflux. So, my name is Lisa Lin. I’m one of the Clinical Instructors at the UCLA Division of Digestive Diseases, and we’re gonna dive right into our talk. So, just to give you a brief overview of what we’re talking about today, gastroesophageal reflux disease–we also call it GERD for short– and we’re going to go through some of these common questions. So, what is acid reflux? Why does reflux disease happen? How common is it? What are the symptoms of reflux disease? How do I know if I have reflux disease? You know, why should I treat it? And how do I treat it? So, here–this image here. This is a picture of the esophagus. So that’s the tube that connects our mouth to our stomach, and this is the stomach, and this is the first part of the small intestine. So, we’re going to focus on this area here, where the esophagus connects to the stomach, and as you can see here, there’s a lower esophageal sphincter here, and you can think of that as kind of a little gate between the esophagus and the stomach, and in this, our stomach produces acid, so we have a certain amount of acid in our stomach, and sometimes this acid can come up into the esophagus. So that’s what we call acid reflux, right? It’s when the stomach acid flows back up into the esophagus, which is that tube that connects between your mouth and your stomach. But we all have, at one point in our lives, experienced some episode of acid reflux, right? If we’re eat a really heavy meal, you know, that can happen occasionally, and that doesn’t mean we have reflux disease. So what do we mean when we talk about GERD, or reflux disease? What we really mean are, you know, chronic and frequent reflux events that actually causes bothersome symptoms and complications of chronic reflux disease. So, why does reflux disease happen? So, here, again, on this image, you see pictures of the esophagus connected to the stomach, and again, here is that lower esophageal sphincter that we talked about earlier. So, any issue that happens with any part of this can predispose you to reflux disease and its symptoms and complications. So, you know, esophageal dysmotility– so if your esophagus is not pushing liquids or food through down to the stomach as well, that can, you know, make things stay in the esophagus longer, or acids stay in the esophagus longer, and that can cause symptoms of ulcerations in the esophagus and symptoms of reflux. You can have an ineffective barrier between the esophagus and the stomach, so, you know, for example, if you have a hiatal hernia, which is where you have a little part of your stomach that herniates up into the chest, so that’s, as you know, for a hiatal hernia, when you have that, again, this barrier between the esophagus and stomach gets compromised. So, again, predisposes you to reflux disease. You can occasionally get transient relaxation of this gate, of this lower esophageal sphincter, so that’s what we call transient lower esophageal sphincter relaxation, and sometimes in some people, that happens more frequently than normal, and the more times that gate opens, then of course there are more opportunities for acid to come up into the esophagus. You can also have abnormalities with your stomach. So for example, you know, in obesity, we have more, you know, if you have more central obesity, you have more pressure on the stomach, right? So it’s all about a pressure gradient. if you have more external pressure on the stomach, again, that allows you to overcome the pressure on the esophagus more easily and allow more reflux to happen. Sleep apnea, you know, if you wear a device at night that kind of is blowing air in, you can get more air into the stomach and increases the air in the stomach, and again, that can also predispose to more reflux. Sometimes you can have gastroparesis or what we call delayed–you know, it’s delayed emptying of the stomach. So with any delayed emptying, you have more stuff sitting in the stomach for a longer period of time, so again, you know, more likely for that stuff to come back up into the esophagus from the stomach. And very rarely, you can have acid hypersecretion, which is where your stomach kind of secretes too much acid, and that causes some damage to lining of the esophagus or reflux symptoms. So, how common is reflux disease? And you know, the answer is that reflux is very common. 10%-20% of people in the US have at least weekly symptoms, and 40% of people have intermittent symptoms. So it’s extremely common. I’m sure you all know someone who has symptoms of reflux disease. And what are some of those symptoms? So, reflux disease can present in a variety of symptoms, but really, the typical classic symptoms of reflux disease is heartburn and regurgitation. There are other atypical symptoms, so like chest pain, belching, nausea, epigastric pain, bloating, or laryngeal symptoms, which are, you know, symptoms in the throat area, and reflux disease can also cause symptoms outside of the esophagus, or outside of the throat area. So, you know, you can have globus, which is where you have this sense of discomfort or pressure in the throat area, you can have coughing. It can cause more ear, nose, and throat symptoms, like inflammation in the back of the throat, Inflammation in your sinus tracts, and also recurrent infection or inflammation of the ears. It can also affect your teeth, causing dental erosions, and it can also affect your airway, so it can, you know, worsen asthma. Or, if you have a lot of reflux, a lot of stuff coming up from the stomach into the esophagus, and, you know, sometimes you may aspirate a little bit of that into your lungs, you know, over time they can cause some scarring of the airways or scarring of the lungs. So, what symptoms are truly concerning? You know, we have some symptoms that we call alarm symptoms, and those symptoms include dysphasia, which is a symptom where you feel like food, either liquid or solid, is getting stuck in the chest when you swallow, weight loss that’s not intentional, as an alarm symptom, and also anemia, which is a low blood count, is also an alarm symptom because that can indicate that, you know, maybe there’s a chronic, slow process of bleeding from the intestinal tract that’s happening. So, how do you know if you have reflux disease? So, you know, I put on this picture because, you know, we talked a lot about proton pump inhibitors. Proton pump inhibitors is a class of acid suppressing medication that we commonly use as a first-line treatment for reflux disease, and basically, you ingest the pill, it gets absorbed from the bloodstream, and then that goes back to suppress these acid producing pumps in the stomach. So the first thing, usually, that we do in clinic is, if you have typical symptoms of reflux disease, you know, we put you on a good acid suppressing medication, and if that resolves your symptoms, then that tells us that your symptoms was probably related to acid or due to reflux disease. So, you know, that’s one simple way that you can know if you have an acid issue or not. Other things other than trying a proton pump inhibitor, sometimes we can do an endoscopy. So that’s where we, you know, you’re put to sleep, we use a camera, it’s a scope, and there’s a camera and light at the end, and we put that into the mouth to take a look at the esophagus, stomach, and first part of the small intestine, and usually we do an endoscopy if there are any of those alarm symptoms that we talked about earlier or if you have some high risk factors. So if you are at risk for developing Barrett’s esophagus, which we’ll talk about in a couple of slides, if you have chest pain that’s thought not to be due to your heart, or if you’ve tried the medications like proton pump inhibitors and your symptoms are not any better. So on an endoscopy, through the camera what we can see is, you know, any ulceration or inflammation of the esophagus or any signs of permanent changes to the lining of the esophagus, something called Barrett’s esophagus. Other tests that we can do to investigate whether you have true reflux disease or not are what we call ambulatory reflux monitoring, or pH testing. So, one test that we frequently do is called the Bravo study, or Bravo pH test, and this has to be done during the time of an endoscopy. So as you can see on this picture here, this is the little Bravo pH capsule. It’s very small. It’s about the, you know, tip of this pencil eraser. And what we do is, during the time of an endoscopy, we basically clip this low pH capsule onto the end of your esophagus, close to where your esophagus connects to the stomach, and, you know, for the next two to four days, you would wear this recorder that looks like this, and basically, this pH capsule will detect how much acid is coming up into your esophagus from your stomach and transmit that information wirelessly to this recorder that you’re wearing, and after about five days on average, this pH capsule will fall off on its own, passing in your stool. You don’t have to retrieve it, and you just return this recorder for us, and we can review that information. So usually, we want you to do a Bravo study or, you know, this sort of pH testing for a couple reasons. One is if you are planning to get some sort of surgery to treat reflux, you know, I think it makes sense that before you undergo surgery, you want to do some definitive test to tell you for sure that you actually have true acid reflux. Or if you have symptoms of reflux that’s really just not improving or resolving completely on proton pump inhibitors, those acid medication that we were talking about, or if you’re just, you know, sort of, clinically we’re just not sure if you have reflux or not that’s causing your symptoms, and we want to make sure. So as I said before, this Bravo study is usually a 2-4 day test. The other type of pH testing that we do is a catheter-based pH test. So as you can see in this picture here, we basically put in this–there’s a thin wire here, and this thin wire has sensors that can detect the acid in the esophagus, and basically, we put that film wire in through the nose, and it goes into your esophagus, and at the same time you’re also going to wear a recorder, you know, for 24 hours, and the sensors from this wire will then transmit that information to the recorder, and at the end of the test, you just take the catheter out. So usually, we do this type of testing, again, for similar indications as the Bravo test, you know, if your symptoms are not getting better on the acid suppressing medication, or if we’re just not sure if your symptoms are due to reflux or not, or if it’s before surgery. The other indication is if, for example, if you’re on a chronic blood thinner, and you can’t get the Bravo placed endoscopically, then this would be another good option, and again, this is a 24-hour test. So, why should you worry about reflux disease, and why should you bother to treat it? Well, you know, chronic exposure of the esophagus to acid can actually cause inflammation of the esophagus, can cause symptoms, and can cause long-term damage. So, you know, this is a picture, an endoscopic picture. So this is through that endoscopy test, and as you can see here, there are these ulcerations in the esophagus. So this is a picture of the esophagus, and you can see those ulcerations. So that’s what we call esophagitis. And when we see that, that’s usually due to a sign of chronic reflux disease, and, you know, chronic inflammation of the esophagus can cause several complications. So, one is it can cause a stricture, and the stricture is basically a narrowing of the esophagus. So, if you imagine like scratching your skin the same spot over and over again, usually our body heals by trying to form a scar, right? So that same process can happen with our esophagus, where, you know, you have chronic inflammation and damage to the lining of the esophagus from the acid exposure, and our body tries to heal by making scar tissue, and over time, you know, this scars down that part of the esophagus and causes this narrowing, and when it gets too narrow, it can cause symptoms like trouble swallowing food or liquids. The other complication that can happen from chronic reflux disease is what we call Barrett’s esophagus. So as you can see here on these endoscopic images, basically this salmon colored or pink colored tissue that looks different from the tissue above, so this pink colored tissue is actually what we call Barrett’s esophagus, and it’s basically just, over time the lining of the esophagus starts to look like the lining of your stomach, and it’s our body’s response to chronic acid exposure. The issue with Barrett’s esophagus is, you know, it does increase your risk of developing esophageal cancer, so that’s why we want to avoid it. And lastly, this is the complication that no one wants, and that’s esophageal cancer. So, how do we treat reflux disease? So, there are, you know, many different treatment options. We always, you know, recommend starting off with lifestyle changes. That never hurts. So, some things that you can do is, especially if you’re overweight or if you’ve had a recent weight gain that kind of predisposed you to having reflux disease symptoms, weight loss is helpful. And we don’t ask you to lose like, you know, 30 pounds, 50 pounds, right? Just a few pounds can make a big difference. So, you know, we always aim for kind of the 5 to 10 pound range to start off with, and then, you know, oftentimes for some people reflux symptoms are worse when they lie down because when you lie flat, you’re taking away the help from gravity, so things are more likely to come up from the stomach. So, one thing that can be very helpful is head of bed elevation, when you lie flat or when you’re lying in bed. So, you know, you can usually purchase a wedge pillow like this online or in stores, and the point of this is that it elevates the torso of your body. So basically, it allows you to achieve this little bit of an incline and to gain that help from gravity so things are draining better from the esophagus. You want to avoid eating late, so avoid eating a meal or heavy meal 2-3 hours before you lie flat. And there are certain foods that can trigger symptoms, so, you know, some classic acid reflux foods that people talk about is like caffeine, alcohol, because those foods are thought to relax that lower esophageal sphincter more often. You know, what we really talk about is, if you have food that trigger your reflux disease symptoms, then definitely you should avoid them, but if they don’t clearly trigger your symptoms, you don’t have to avoid, you know, that whole long list of classic acid reflux foods. So the other, you know, common way that we treat reflux disease is through the acid suppressing medication that we talked about earlier. So there are two classes that we often use. There’s the proton pump inhibitor, and there’s the H2 blocker, and these are just different types of proton pump inhibitors and different types of the H2 blockers. Most of these are all over-the-counter. Now, you know, the proton pump inhibitors is really kind of the best medication that we got for suppressing acid, and, you know, as you can notice and as you can see here, anything that ends in -prazole is a proton pump inhibitor, and anything that ends in tidine is an H2 blocker, okay? So, these are some of the medications that you may hear from your doctors for suppressing your acid and treating your reflux disease. And I just want to, you know, spend a minute to talk about–proton pump inhibitor safety because, you know, there’s been a lot of news about this, recently a lot of controversy. So, proton pump inhibitors are generally very safe, and we’ve been using it for a long time, you know, since 1988, and really, the sort of evidence on the potential adverse effect of proton pump inhibitors, you know, from a scientific perspective, they are low quality studies. They’re retrospective studies. A lot of them were not initially designed to answer or study that particular question, and a lot of things, like the relationship between dementia and proton pump pump inhibitors, have really been debunked through better quality studies. So–and I would say even if you assume worst case scenario, even if you assume that these potential risks are actually real, you know– the absolute risk that’s been reported in the data is extremely small. It’s about 0.03% to 0.5% per patient per year. So I think the big picture is that, you know, the quality of evidence on benefit of long-term proton pump inhibitor use on these indications of reflux disease, Barrett’s esophagus, stricture, you know, the quality of these evidence are moderate quality to very high quality, and really, I think if you have a true indication that warns proton pump inhibitor use, the benefit of long term proton pump inhibitor use far outweighs the small potential risk. So, other ways that we can use to to treat reflux disease. So, there are surgical therapies. So, you know, one surgical therapy is what we call fundoplication. As you can see in this image here, it’s where the surgeon basically takes the first part of the stomach, the top part of the stomach, and wraps that around the end of the esophagus to form a better barrier between the esophagus and the stomach. And then there are some newer surgical therapies that are out and is available here at UCLA as well. So, something called the LINX procedure, and this is done by a surgeon, and basically, they place a ring of magnetic beads where the esophagus connects to the stomach, and, again, it forms a more effective barrier. And then this bead–when you swallow, like to eat food– this ring of bead will be able to expand to allow passage of food. So, there are endoscopic therapies out as well, now. So, one endoscopic therapy that we do here is TIF, and it’s short for a transoral incisionless fundoplication. So the concept is, you know, you do it through an endoscopic procedure, so through that camera procedure, and you’ll be asleep during the procedure, but basically it creates a partial wrap, kind of similar to what they do during surgery, but basically through the endoscopic camera instead. And I think this is important to note, is that before you undergo any surgical treatment or non-medical treatment for reflux disease, you really do need these two type of tests. So, one is a pH test off of acid suppression, and that’s really to make sure you truly have acid reflux disease, you know, that warrants surgical therapy or non-medical therapy, and this is assuming that you don’t have obvious ulcerations in the esophagus and if you have no Barrett’s esophagus. The other tests that you need is the esophageal manometry, and this is where we place a thin catheter through the nose, there are pressure sensors all over this catheter, and we have you do some swallows of liquids and jello-like substance, and really, this test is to test your esophageal motor function, how well your esophagus works in pushing down fluid or food into the stomach, and, you know, before we put any sort of intervention to tighten up that sphincter, we want to make sure that your esophagus actually works well and is able to push things down effectively. So, some take-home points–reflux disease is very, very common, and classic reflux symptoms are heartburn and regurgitation, but reflux disease can present with other symptoms as well, and if acid suppressing medications like proton pump inhibitors do not resolve your symptoms, you really should undergo some sort of definitive pH testing off of acid suppression to answer the question “do you have truly have acid reflux or not?” And, you know, again, the suppressing medications like proton pump inhibitors are absolutely safe for long-term use, and, you know, if you really need it to control your symptoms or to treat any of those complications that we talked about, the benefit definitely outweigh risks. And again, we have a lot of treatment options now for treating reflux disease. Those treatment options include medications, endoscopic therapy, and surgery as well. So, I just want to thank you all for joining us in this webinar. I hope that was informative for you, and let us know if you have any questions.