[Music] good evening and welcome to doctors on call I'm Dr Ray Christensen faculty member from the Department of Family Medicine and biobehavioral health at the University of Minnesota medical school I also am a family physician at Gateway Family Health Clinic in Moose Lake Minnesota I'm your host for our program tonight on upper GI problems and please remember the success of this program is very dependent on your questions of the audience so please call in your questions tonight or send them in email to our address at ask pbsn north.org the telephone numbers can also be found at the bottom of your screen our panelists this evening includes Dr John Reich a gastroenterologist with Essentia Health Dr Omar sadiki an internal medicine specialist with St Luke's Internal Medicine Associates and Dr Jason wall a family medicine physician with the duth Family Medicine Residency program our medical students answering the phones tonight are Alex Higgins Stewartville Minnesota Andre midn Lowry Minnesota and Shawn Morris from Maple Grove Minnesota and now on to tonight's program on upper GI problems I'd like to start out I think probably just letting you guys introduce yourselves Jason you want to tell us just a little bit about your work at the residency and what you do sure thanks Dr Christian uh when you complete medical school you have to choose your specialty Pediatrics um Internal Medicine surgery obstetrics uh if residents if uh students choose uh family medicine they come to our program here in duth for three years where we work at both hospitals uh and they learn how to take care of basically people from Cradle to grave so we do pediatrics adult Med medicine deliver babies and take kind of its continuity so we take care of people in the hospital outside the hospital um and uh we try to be the proverbial uh general practitioner good old zp yeah it's where I started Dr sadiki yourself uh I'm um I'm an internist uh at St Luke's Internal Medicine but I also do addiction medicine um I'm board certified in that and I recently just passed my boards on Obesity medicine so kind of do uh that now as well and Dr ik yeah I'm a a gastroenterologist at essenti Health uh focusing on all kinds of GI issues but upper GI reflux Crohn's disease alcera of colitis several different things I did my medical SK School here in duth and uh happy to be back it's a great place Dr Wall I think we'll start with the we've already kind of talked about some of the things that Dr Reich does so let's talk about the esophagus and reflux and some of the medications we talked about the ppis earlier uh fill us in a little bit sure thanks I find that you know in the course of a day we become used to a certain vocabulary we throw around all these terms EGD PPI you know nid uh and these are you know uh PPI stands for a proton pump inhibitor n said stands for a non-al anti-inflammatory drug and EGD is an as safo gastroscopy it's a camera down the throat so where these all come together is that uh you know if you have a problem in your stomach such as uh an ulcer or too much acid production reflux uh a proton pump inhibitor is a class of medication that can affect the parietal cell which is a cell in the lineing of the stomach that um exchanges potassium and hydrogen and makes your stomach acidic acidic stomach is the normal state uh prevents uh you know it starts the digestive process the proton pump inhibitor will stop the um secretion of acid into the stomach pretty effectively almost you know completely we use that for people with ulcers and people with conditions that could lead to bleeding where the acid could irritate that and cause bleeding and so it's a very effective medication there are many uh out there both over the- counter and prescription and you probably know many of them from the the tv ads but very effective medication and kind of a main stay of our treatment for gastro asapo reflux and other conditions so Dr Reich do you want to add to that one of the questions that just came in is are there alternatives to the ppis to treat gird also there there are and this question comes up in my practice nearly daily and the question one of the questions has been the safety of these PPI medications especially longterm and we can talk about that too but as far as far as Alternatives there are are less potent acid reducing medicines um they're called H2 blockers that they don't turn off the acid quite as much but they work fairly quickly and for most people are fairly effective um fam Modine is the most commonly used over-the-counter version of that um we do talk a lot to people especially if heartb burner reflux is their main symptom about Lifestyle Changes such as weight loss uh some folks need to have their torso elevated a little bit at night so that gravity keeps acid down a lot of this is because the sphincter muscle that controls acid reflux in a lot of people is a little looser than it's supposed to be or they may have a small hernia inside that allows for more acid to come up but so sometimes lifestyle modifications can be quite helpful uh these H2 blockers I I've been talking to some people about even a a supplement called DGL it's called dcer resonated licorice it's a black licorice supplement that seems to help Soo the stomach sometimes if people are very opposed to to taking those proton pump inhibitors I will say that I feel in general they're fairly safe to take and in the long run uh if folks are getting enough vitamins and minerals whether it's through multivitamins or Diet calcium and vitamin D generally there's very minimal risk to taking them but there are some Alternatives Dr sadiki do you want to add into that any I think that's pretty much covered most of it so the question to go along with that is drinking hot drinks regular bad for your throat drinking hot drinks regularly bad for your throat I mean I don't I don't think it has should shouldn't be bad as long as not colding hot but fig hot tea and coffee should be okay for your throat I can even help soothe a sore throat if you have one family doc anything you want to add into that I think it's benign and you know uh unless you have some other uh irritants such as as you know chewing tobacco and other things that can cause chronic inflammation in the mouth it's pretty harmless acid reflux seems to get worse for this person lying down at night are there other than and you've already done this some of this John in discussing this are there other habits like eating earlier that might be helpful great great question and again yeah we talk about this quite a bit but uh we we feel that having food in your stomach when you lay down at night is a fairly significant risk factor for reflux and most of the reflux that occurs in in people are when times when often you don't feel it when you're laying down or sleeping at night and so I generally recommend people try to avoid eating even just little snacks within a couple of hours of laying down you know one of the other things that I tell people about that isn't super expensive not like buying a big adjustable bed is you can take uh 2x4s or bricks or some cinder blocks and actually put them on the floor under the bed post raise it up about 4 to 6 in and that way your whole bed is at a little gentle slope but you can still roll around if you're like me you're always moving at night when you're trying to sleep but then you still sort of have a somewhat natural position but that gravity does help keep things down Dr sadiki does gird which is gastro esophageal reflux disease I thought we probably say what gird is is that a risk for esophageal cancer I mean it can be again as we discussed the lower saag spinter maybe Lucifer some people and if that does kind of consistently over time the it gets into into the esophagus it can lead to changes in the lining of the esophagus which can eventually if not going untreated could lead to cancer John do you want to follow us through with that um so I imagine EGD is where we go with that and how often few couple minutes on that yep so the the EGD or sophical gastrosoph as Dr Wall pointed out uh is a small camera about the diameter of a a pen that you write with in your mouth and down into your stomach and your small intestine and one of the main reasons we do this is for people who have reflux and to to add on to Dr siki's Point chronic reflux can change the lining of the esophagus it can actually adapt and mutate and turn into this thing we call barretts esophagus in which the esophagus actually almost turns into stomach lining and because it it's trying to adapt to that acid environment that it's not supposed to see but over time that bars esophagus those cells can continue to mutate and potentially turn into precancerous and cancerous cells and so one of the reasons we do the endoscopy is to screen people for that check for that and uh and try to identify why potentially they are having the The Reflex issues and also too lot this comes up a lot in our Clinic is that it once you've been diagnosed with that barits I think there's a pretty regular followup where they want to do egds um is like every one year three years something you know to to make sure sure that we're surveilling that it's not progressing it's true we do keep an eye on that depending on how much there is and what the cells look like under the microscope typically anywhere between one and five years that we keep an eye on that Dr sadiki one of the questions that's come in is Foods food getting stuck in the throat uh and this person it was after nights of heavy drink uh dad has the same thing wondering if it's genetic so this is the sun writing in and asking or if it's related to alcohol and is there something about something they can do about home prevent pre prevention of this and I think just push into that move into maybe some symptoms of esophagal cancer we'll mix that in too I guess symptoms of esophagal cancer would be I'm thinking difficulty swallowing difficulty swallowing that could be one cause another cause it's commonly seems like acalasia where the muscles and the Esopus that kind of help the food contract and go down they don't the the nerves don't contract the way they should and the food can get stuck typically solids um that then that can be treated can there's different things they can do dilations and other procedures that may help with that but EGD is what would be helpful in diagnosing any kind of narrowing or those kind of things that you would see I don't know the answer is is this do you guys know is it genetic is there a genetic pre predisposition here um I I I don't think so I think that so so alcohol relaxes that muscle it also can actually be directly a little bit irritating to the esophagus similar to acid and so the combination of alcohol food and and and and the acid and the loose sphincter what I see in a story like what I'm hearing here is that over time the irritation from these episodes actually causes can cause narrowing and scarring of the esophagus called a stricture that usually is benign but if you're getting food stuck that is something that we probably need to look into and probably need to take a look with the camera just to be sure there's nothing more going on but most of the time it's it's really just sort of direct irritation from the alcohol and the acid and this questions come up several times about the feeling that something is stuck in your throat or difficulty swallowing and what you're really saying at some point along the way that should be evaluated go see your family doc and probably a GI and have a look in there Jason you want to add into that appreciate when the um GI Physicians do an EGD because it's a pretty quick and simple test and it gives a lot of information especially if you know um a picture is worth a thousand words when somebody's saying that they just have the Sensation that food's getting caught and it could be something as simple as a stricture that from reflux but it could also be cancer and so um the sooner we know about that the better the other thing thing we can do on an endoscopy is actually stretch things out a little bit we can do what's called a dilation to actually help that food go down and and we're seeing that lots of young people who actually have an allergy type condition and I want everyone at home to memorize this phrase It's called eosinophilic esophagitis but it it's actually an long-term kind of chronic allergy where the esophagus gets narrow and people get food stuck and that's a a symptom that or a disease that it's not doesn't shorten anyone's life but it does need to be addressed people generally need to change their diet or be on different medicines and have these things called dilations so getting getting food stuck and things not going down is definitely something we we take seriously nisson fundoplication is this a helpful treatment for gird and uh any ideas on the long term is that have to be redone or looked at again and I don't have an answer this is a question John I look at you I don't you know so Nissen funcation is a surgery in which the top of the stomach is actually taken and wrapped around the lower part of the esophagus to tighten that lower sphincter muscle so reflux can occur It's very effective um the numbers are not perfect as far as about half a people maybe after five or 10 years maybe need to be back on an acid blocker there are some downsides to any surgery often times people can't vomit after they have this surgery which is fairly bothersome for people sometimes you feel a little more bloated with it um in general it's effective but it is surgery and there are there's Al all kinds of new techniques actually coming out even one that you can do through a scope there's a little magnetic device that can be placed surgically that goes around the bottom of the esophagus to tighten that sphincter a little bit that can be removed if it doesn't work and so while Nissen is still a fairly common surgery there are some sort of Alternatives that we're sort of moving toward um that are a little a little bit sort of less invasive and not don't change your Anatomy as much thank you Jason what might cause someone uh when they're eating let's go back through this they difficulty swalling something get stuck on the throat uh they can't swallow they can't breathe talk about that situation just a little bit the heck certainly excellent question so you know having um uh obstruction uh that's conceivably where you know food has gone down you know the the the trachea and is no long you know they people can't ventilate so they can't you know move air in and out it's a medical emergency and uh you know the the heick is a you know forceful blow um right in the uh subid region to create you know intrathoracic pressure to expel that uh material from the airway um um so yeah it's it's a it's a medical emergency and uh um another important thing to do is uh you know with your finger you know sweep the sweep the person's back of their throat for anything um and that can be it can be done standing it can also be done with the person laying on the ground and uh a strong uh application of pressure right in the subid region uh I've never seen it done um I don't know if any of my colleagues here have but uh uh I think the the important thing with choking is to recognize it and to um to to get help and the heick would be a firstline maneuver and when you're an old person cut your meat up and eat small Ms and all of chew better better I've only ever seen it in movies y yeah Dr sadiki could you talk about stomach pull-ups just a little bit stomach pups that's growth of the stomach lining that can be precancerous again we would be from increased acid production if you have um um you different things like gastritis elor B different bacteria different causes of stomach Pops that you would could be precancerous if not caught early enough so that's when you would be noted on an EGD which would go in biopsy and see where what that shows and Jason because this kind of Falls in our a little bit gastric ulcers hpylori s so there there's a bacteria that can invade the lining of the stomach and you know when somebody comes to us with chronic burning pain you know the our list of possible diagnoses would be you know ulcer uh infection with this helicobactor pylori uh and then of course you know some uh other conditions due to medication use uh commonly people take a lot of um ibuprofen non-steroidal anti-inflammatory drugs those can uh lead to uh some irritation of the stomach lining poor nutrition can lead to some breakdown of the stomach lining uh uh along with uh some uh tobacco use and other things can cause further irritation but as far as the helicobactor when we're going through and uh trying to figure out what might be causing this pain if there are other risk factors the person's not consuming alcohol they're not using a bunch of ibuprofen um uh at that point we often refer to our colleagues in gastron neurology and um there are some tests that you can do to look for helico pylori they're they're not perfect um we'll do those tests if they come back then we'll go ahead it's a cocktail of medications you take take for a couple weeks um to treat uh but if that doesn't then the gastroenterologist can go in and take a biopsy to the stomach lining too and when you look at that with the microscope they can identify these organisms in the lining too and it's very endemic common in certain parts of the world but I see it you know on a regular basis in our practice here too does H pylori and this is for all of you does hpylori increase the risk of stomach cancer it it does and in fact it has been implicated potentially as the so stomach cancer worldwide is the second or third leading cause of cancer death and it's because hpylori partially because H pylori is so um endemic in particular southeast Asia where stomach cancer is very common they have very strict screening programs and things for it and so it is something that even sometimes if we find it incidentally in the stomach maybe it's not causing you any symptoms often we will we we it is recommended to treat it because it is consider considered a carcinogen we talked earlier and I think we need to just go back these long-term medications when I was in medical school we worried about bleeding obstruction perforation and and pain for ulcers and then Tagamet came and the world has changed from that point so I'm really old so the long-term use of these medications in the beginning it was three week three weeks or a month or whatever and there was always a break now we're perpetually on them does ppis do ppis and these other medications increase the risk for Alzheimer's or other illnesses or not and these are the questions that are floating in here right now it's for the panel you can all jump in I I I I you I get the question so much but the the studies on this the population studies I don't want to bore anybody too much but there always conflicting data one study will say there's a slight increased risk of dementia and then a larger Maybe maybe better quality study will say that no that's not true and then one other another one will say maybe there is a little bit of a link and we don't really understand if these drugs do cause that what the reason that that would be is um and so my general approach really with any medicine is if we can find Alternatives use the lowest effective dose possible that like like we talked about lifestyle modifications or less intense medications sometimes surgery if it's heartburn or reflux or things like that but in general it's it's a risk benefit with any medicine and the risk from what I can tell from reading the studies is that the risk is extremely low if there is a true link to those two things and so we always have the discussion but um usually if someone really needs to be on these medications it's to help their quality of life and prevent cancer and it's usually we feel like the benefits of these do do outweigh the risk I I agree fact the more the more immediate effect of their day-to-day discomfort with you know eating quality of life enjoyment of their life in general kind of gets impacted uh gets they get benefit from taking the ppis or pepid or whatever they're taking where Alzheimer's there's a no confirmed risk I feel like the the immediate risks uh wa benefits outweigh the risks in the long run a followup are there any vitamins or supplements or foods that are beneficial for upper GI Health great question a plant-based diet is going to be beneficial Mediterranean yeah stuff that's more like easier to break down obviously if you're eating more complicated food a lot of meats that are harder to break down you're stomach's going to make more acid to break down set those things which could increase you know the stomach upset and stomach pain anything with the higher like you know nitrate you know some of the Smoked Meats and um you know and certainly just from a functional like you know I I enjoy spicy food but you know if you have a diet of chronic you know very spicy food that can be harmful too you know just can lead to some chronic irritation um is that true because the argument is is that the spice or the the the peppers are good for you I don't have an answer I'm just here you guys sit the the some the uh um great call it's cayenne pepper there there is there I saw a study not too long ago that suggested that maybe some spices have a little pro-inflammatory effect although most foods that have Spice in them you know we're not talking about spicy Doritos and things like this but like actual peppers and real true food plants and things that are naturally spicy generally the health benefits of those things are going to outweigh the the potential risks of having some spice in your diet now the spice spy foods do tend to increase symptoms of heartburn and reflux and potentially could loosen that sphincter a little bit um it's not entirely clear and so like everything in moderation but I don't I would certainly wouldn't say the spicy foods are unhealthy but like Dr well said you know in moderation definitely Jason the public health EPC talk about it we're going to deliver Dr Christensen I feel when when I've been on this show I always take this opportunity you uh years ago we had you know complicated um modestly effective treatment for hepc there is a lot of Heep SE in our community both Urban in Twin Cities and in have one minute 40% of uh the hepi in Minnesota is an outstate you know small towns and so we have drugs now in eight weeks they're you know greater than 98% effective to treat hepc and so hepc can lead deliver failure death and a lot of um Downstream health things so you know uh as Physicians we're aggressively screening people for FC we have safe effective treatment and so if you think you're at risk for hepc you know see a health care provider and uh we have a great treatment for you your painter wants to know if artificial intelligence will solve some of these problems uh artificial in like everything in life uh it's a double-edged sword and yes it will because um our minds are fallible and the machines are a little more consistent so they're going to pick up things combination just the other day you know you'll see something with one lab here a lab here you weren't connecting it but the machine is going to I want to thank our panelists this was a great discussion Dr John Wright Dr Omar sadiki and Dr Jason walf and our medical student volunteers Alex Higgins Andrew mittendorf and Sean Morris please join me again next week for a program program on lower GI problems when my panelists will be Dr Jonathan Gap Dr Paul Sanford and Dr Addie vorio thank you again thank you again for watching have a great [Music] night [Music]