[Music] good evening and welcome to doctors on call i'm dr peter nelen professor and department head of family medicine and biobehavioral health associate dean for rural medicine and co-leader of the duluth campus of the university of minnesota medical school i'm your host for our program tonight on upper gi problems the success of this program is very dependent on you the viewer so please call in your questions or email them to ask at wdse.org the telephone numbers can be found at the bottom of your screen our panelists this evening include dr victoria herron a family medicine physician with cmh rater family clinic in cloquet and dr john reich a gastroenterologist with essentia health our medical students answering the phones tonight are sophie brow from fairmount minnesota luke lemire from deerwood minnesota and anna schue from new alm minnesota and now on to tonight's program on upper gi problems dr herron what is hiatal hernia and is it normal a hail hernia is an unusual hernia and people think of it as something on the outside but it's on the inside it's when part of your stomach kind of comes up through your diaphragm and into the space where your lung usually is it happens a lot it would not be considered normal but it happens an awful lot and it's not permanent it can be a sliding hiatal hernia that goes up and down up and down up and down so it's always on the inside and it is part of your upper gi tract wow that's that's interesting dr reich how far into the body does an upper endoscopy reach so an upper endoscopy is one of the more common procedures we do in gi evaluating for upper gi problems ulcers heartburn things like that but typically the the scope will go into someone's in the patient's mouth and down through their swallowing tube called the esophagus into their stomach and typically into about a foot or so into their small intestine called the duodenum or druidenum and so in total it would go in about three feet into the person uh however i will say that the entire gi tract uh is somewhere between 15 and 20 feet long and so you know we certainly don't get close to observing the entire thing but most much of the pathology in upper gi problems that people have is where we look with those endoscopies thank you dr herron what is barrett's esophagus and why does it matter barrett's esophagus is the name somebody put to some changes that can happen in the esophagus in the swallowing tube that goes from your mouth down to your stomach where the normal lining that's usually supposed to be like the inside of your mouth undergoes changes usually from repeated exposure to acid reflux and the lining changes to something that isn't nice and smooth and shiny it's more rough and it does have some potential not a lot but some potential to turn into cancer and that is why it can be important and why it needs follow-up thank you dr reich how might reflux and coughing be related good question so reflux so sometimes some of the more common symptoms that people have with reflux include the textbook heartburn burning discomfort in the upper abdomen lower chest often after eating or when laying down changing positions eating caffeine spicy food drinking caffeine eating spicy foods things like that but sometimes people have atypical symptoms of reflux as well and one of the somewhat atypical symptoms of reflux is that if some of that stomach acid or stomach contents at least are refluxing not just to the lower part of that esophagus or food tube but all the way even up sometimes into the back of the mouth or the throat it can irritate the the upper airway and even the vocal cord area and sometimes leads trigger that cough uh response and so yeah so we not infrequently get uh referrals or questions or questions asked to see folks with a chronic cough to evaluate for reflux because that can be one of the symptoms thank you dr herron what is abdominal migraine that's a very good question abdominal migraine is what it sounds like it is it is a migraine that is pain that is in your stomach area that really is not from your stomach but is from the same mechanism that would give somebody else a headache with the vascular changes in neuro changes but it ended up with the way somebody's body worked in their stomach it's actually more common in children to have that kind of manifestation it can come with the same kind of nausea that migraines also come with it you have to kind of tease it out by the history as far as why somebody's stomach hurts on a regular basis like that very interesting thank you dr reich why are antibiotics involved in the treatment of ulcers and most ulcers in the stomach or the first part of the small intestine that duodenum that we mentioned earlier are are not don't require antibiotics to treat most ulcers that we find in the stomach are from taking medications like ibuprofen and aleve aspirin especially in higher doses these medications called nsaids these pain relievers but occasionally it's not as common in our area but we do see it folks will get a bacteria called h pylori bacteria that lives in the stomach and when folks have h pylori in their stomach it does depending on what part of the stomach it can increase acid production or at least decrease the safety barrier uh that the stomach creates from acid to to cause ulcers and so if we do an endoscopy and take biopsies and we find that there's this little squiggly bacteria called h pylori there and there's other tests you can check stool forward breath test other ways of diagnosing as well but if they if you have this bacteria then the recommendations to both heal the ulcer and prevent potential other complications potentially even stomach cancer although very rare we use antibiotics to treat if we find that particular infection but in general we don't usually need antibiotics for ulcers thank you dr herron how might exercise help or make worse upper gi problems interesting thought exercise could make upper gi problems worse if you're doing something with a rather full stomach to increase your reflux if you're doing sit-ups with a full stomach and squishing your stomach and causing the reflux to come up that isn't good if you've got a lot of acid in your stomach and you're trying to do push-ups or something where you're prone also you can get more reflux um anything where you tighten your abdominal muscles a lot can kind of push that acid up probably more if you have a fuller stomach if you're exercising and losing weight weight loss in general is good for decreasing reflux just because there's less pressure on the stomach and in general people who lose weight experience less in the way of acid reflux so in the long run it's good just to be careful what you're doing in the short term dr wright what are esophageal viruses so esophageal varices are essentially varicose veins that occur in that esophagus which sits right above your stomach and the most of the time we see esophageal berries in folks who have liver problems or what we call cirrhosis of the liver and the reason you see that is because all of the blood that is in and around your intestines after you eat meals and you are digesting your food all of that digested food and the nutrients and things that come out of your intestines go into your liver to sort of be detoxified and proteins are made and various things but in in what if the liver is is sick if it's scarred and that blood can't flow through the liver very well it kind of backs up and becomes congested in your in and around your intestines and one of the places that becomes most congested is there at the lower part of that esophagus and so you get these big veins and it's it's can be problematic those big veins those varices can cause life-threatening bleeding sometimes so in folks who have known liver disease or cirrhosis of the liver we do check for those and make sure because there are some treatments that can decrease that risk thank you dr herron for heartburn what is some of the first lines of your advice to relieve heartburn there's a lot of things that you can do did just mention that working for weight loss though not easy is something to strive for there's a lot of dietary changes that you can look into spicy foods greasy foods can often aggravate it so if you avoid those specific foods alcohol and caffeine can be bad chocolate i'm kind of going down the list of all the good things aren't i peppermint even onion tomato and people have their individual things that they know make their heart burn worse but kind of watching what you eat not eating very large meals if you think about it the more you extend your stomach the more likely the pressure in there is to push acid up not eating a lot before you lay down you fill up your stomach and you get more horizontal you're going to get more acid coming up so just a lot of lifestyle things that you can do in terms of discretionary eating can really help great great advice for our patients doctor what conditions relate to abdominal pain after eating well there's there's a lot a lot of conditions that you know you can have after you eat and interestingly talking about ulcers earlier often in folks who have ulcers their pain seems to actually get a little bit better when they eat but things that can potentially make abdominal pain worse when you eat so sometimes folks who have issues with their gallbladder gallstones when you eat food drink mostly greasy meals as sort of the textbook sort of thing but the the gallbladder tries to squeeze and put this special bile into the intestines to help you digest the food and if there's a stone blocking or if it's sick that can cause pain after you eat sometimes it's not real common but sometimes if people have narrowing of their arteries that go into their intestines and they eat food that can cause pain certainly there's a very common condition called irritable bowel syndrome that tends to be associated sometimes when people eat they feel bloated and have some discomfort pain sometimes that gets better with the bowel movement but some of those are some of the more common reasons maybe that people would get pain after they eat food thank you dr herron what might contribute to excess gas in the stomach excess gas in the stomach and there's a lot of things that can do that some people end up swallowing air if they're chewing gum if they're just holding a toothpick in their mouth swallowing air gets you a lot of gas in your stomach some foods are notorious for getting metabolized in your gut by your own bacteria to gas and that's an individual thing everybody has their own gut biome their own collection of bacteria that lives in your gut you're supposed to you need them they digest your food for you and given the right food they digest beautifully given food that doesn't quite digest well you end up with a lot of gas thank you dr reich how are strictures in the esophagus stretched there's there's a couple methods for that and in the esophageal strictures are not terribly common but of course i see a fair amount of them in what i do on a daily basis and most of the time i would say these strictures are from chronic reflux can actually cause some scarring in the esophagus and cause it to be narrow and there's an allergic condition that we see once in a while that can do this as well but essentially most gastroenterologists i would say have their own way almost of doing it but there's you can use a balloon if a stricture is just one narrow little ring in one spot in the esophagus you can actually take a catheter right through your camera and be watching and inflate a balloon full of water to stretch that narrowing out break up that scar tissue and open that stricture up i actually prefer to use a method that seems kind of brutalistic actually if you were to watch what i did but we take a long dilator it almost looks like someone is a sword swallower when we do it but when you're nice and sedated we take a long dilator and we first run a wire down into the stomach and we put this dilator over the wire and in the mouth and all the way down and it stretches the whole esophagus out and is very effective for opening up these strictures great dr herron how common is it that reflux is associated with asthma exacerbations how common is it relatively common not all the time there's a ton of things that can make asthma worse acid reflux is just one of them but it definitely is one of them if somebody has bad acid reflux their asthma is going to get worse so if somebody's struggling with their asthma one of the things to do is definitely consider working them up for sometimes you can have acid reflux and not even know it it can be totally asymptomatic that means you can have it and not have any symptoms but that can make your asthma worse so it's definitely something to consider along with a whole lot of other things dr reich you mentioned gallstones are gallstones always removed not not always so one of the reasons that they aren't always removed is that there was a big article i believe it was at harvard medical school where they just took a whole bunch of faculty at this at the college and they did ultrasounds to see how many had gallstones and then they followed those folks over many over years to see how many were going to have problems and actually a very small percentage of people with gallstones eventually had issues with those so routinely if you see gallstones and you're doing a scan for other reasons you don't have to have your gallbladder out however if you have things like pain after you eat or there's other complications that sometimes we see such as if the pancreas becomes involved if if one of these stones falls out and blocks the pancreas and someone gets pancreatitis of course then that gallbladder needs to come out they used to make astronauts have their gallbladders come out if they had gallstones because you don't want to have an attack in space but in general not asymptomatic gallstones just really don't need to to be removed okay good to know thank you dr herron how about jaundice what is it and what causes it oh my the what is it is easy jaundice is when you start turning yellow the worse it is the more yellow you turn it starts maybe with just the whites of your eyes getting a tinge of yellow and somebody can turn pretty much yellow all over in a very very severe case it is from a buildup of a compound in your body bilirubin and it's often associated with liver disease bad acute liver disease can make you turn jaundiced because that compound is usually metabolized in your liver and if the liver isn't doing well it just builds up the thing is anything that can really affect your liver can make you turn jaundiced if it's a disease if it's a parasite if it's a toxin you have to sort out what is affecting the liver you know where it's coming from but you don't know why it's coming thank you dr reich a patient might have acid reflux affecting the vocal cords to be irritated is this condition permanent that's a tough question because oftentimes in my specialty in the gi specialty we interact with the ear nose and throat specialist on this and sometimes we go a little bit back and forth and sometimes one of us will say it's not from reflux and sometimes we say it will but basically so the thought there is that if you have acid irritating your vocal cords that it probably is not permanent but sometimes if you put someone on an acid reducer like a pilot or a prilosec or over the counter acid reducer and the problem continues usually it's either not from reflux or maybe the there are things coming back up that are not acid that sometimes people would need surgery to take care of now that's pretty rare uh but in general to answer the question is it permanent usually not permanent if you can reduce how much exposure to the acid or the reflux is happening thank you dr herron what makes pancreatitis such a serious illness oh pancreatitis can be not too bad or you can die from it you need your pancreas to digest your food every time you eat your pancreas kicks in with enzymes to help your stomach digest your food so you can use it if your pancreas gets ill gets inflamed if you get pancreatitis which is pancreas plus itis inflammation of your pancreas you can't eat so that's one two because when it's inflamed it leaks these enzymes you start digesting yourself um and that's a bad thing to have happen your pancreas is destroying itself and when your body has that happening there's a cascade kind of a domino effect that can happen and one system after another in your body can start shutting down you can get really really really sick with pancreatitis you can die from pancreatitis it just depends on how bad it is it's never good thank you for explaining that dr reich how can stomach polyps lead to cancer so stomach stomach polyps are fairly common and stomach cancer at least in our part of the world is very rare and and there are a variety of kinds of stomach polyps and probably the most common kind of stomach polyp that we see is the kind that's actually associated with acid blocker medicines and these polyps are actually completely benign and and just don't ever become cancer but there are some types of polyps and you know without kind of boring everyone there's there's a type called an adenoma there's one called a hyperplastic polyp but so these polyps can be pre-cancerous polyps and the way that works basically is that you get a little mutation in the lining of the stomach probably from some insult maybe it's medication maybe it's acid maybe it's that h pylori bacteria that i was talking about earlier and that mutation causes the lining of the stomach to grow faster than everything around it and it causes these bulges or polyps and if you leave those alone potentially you can get more mutations and eventually it can become a cancerous growth and so it's a similar mechanism or same way that sort of works with colon polyps and colon cancer but as far as it's which is much more rare than than colon issues thank you dr herron for someone with acid stomach symptoms and medication is not helping what else can be done that's a very good question hopefully that person can have a good talk with their doctor because if they have acid stomach symptoms and they're not getting better maybe they need a really good look to see if it actually is acid in their stomach causing the problem if i may i remember one case of a lady who complained and complained and complained about her horrible acid until they took out the most horrendous gallbladder that the surgeon had seen in a long long time she felt it right in the middle it was horrible it was her gallbladder her insides just weren't quite wired correctly so even if it feels right where the acid reflux would be maybe it's not acid reflux if the acid medicine isn't helping go back and take another look it sounds like that persistence of symptoms needs further evaluation each time yep if what you're doing isn't working go back and take another look and dr reich are there symptoms or conditions of not enough acid there are some well so if you intentionally block acid with medications that that stop acid production generally people don't have a lot of problems from that specifically but if you completely block acid from the stomach you can see issues with with digestion absorption of certain things such as iron vitamin b12 sometimes can lead to loss of protein occasionally diarrhea if there's not enough acid and probably the most common but also insanely rare condition is called autoimmune gastritis or there's another one called minetriers disease but honestly this is like one in a million kind of thing but but not enough acid in the stomach is is quite rare and if someone has a condition with that or if they're on one of these acid blockers for extended periods of time we do make sure intermittently that they have enough iron that they're you know they're getting enough calcium and vitamin d and things so it can uh it can kind of impair some digestion of nutrients thank you and dr herron a quick question who needs screening for hepatitis c children or adults adults are the people recommended by the cdc to be screened if they were born between 1945 and 1965. originally there was a high risk group to be tested now it's just everybody thank you well i want to thank our panelists dr victoria herron and dr john reich and our medical student volunteers sophie brow luke lemire and anna shu please join us next week for a special mental health program on anxiety and depression hosted by dina klabaugh the founder and ceo of insight counseling thank you for watching good night [Music] [Music] [Music] [Music] you