good evening and welcome to doctors on call I'm Dr Ray Christensen a faculty member from the Department of Family Medicine and biobehavioral health at the University of Minnesota Medical School Duluth campus and I'm a family physician with Gateway Family Health Clinic in Moose Lake I am your host for our program tonight on upper GI problems the success of doctors on call is very very dependent on you the viewer so please call in your questions tonight or email them to ask wdse.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Robert Erickson a gastroenterologist with Essentia Health Dr Victoria Herron a family medicine physician with CMH Raider clinic in Cloquet and Dr Brad Irwin a gastroenterologist with St Luke's Gastroenterology Associates our medical students answering the phones tonight are Barrett bukowic from Warroad Minnesota Nika freeberg from katumbin Tanzania and Tommy gentle from Barrett Minnesota and now on to tonight's program an upper GI program problems ah I would like to start out just trying to define the territory a little bit Dr Herron what do we mean by upper GI for GI generally refers to your upper GI tract that's the part of you that goes from the back of your throat down to about the bottom of your stomach and the first part of your upper intestine it includes your esophagus your stomach the first part of your upper intestine your duodenum and some people will throw in the gallbladder as well in that territory so we start out in the in the mouth or the back of the mouth so let's talk a little bit about esophagus Dr Irwin can you talk tell us a little bit about the esophagus what it does and what we should think about yeah the esophagus is it's a muscular tube uh its main job is to transport food that we've swallowed once food enters the upper esophagus it's basically propelled down towards the stomach that's its main function really it's comprised of a mucosa that's the inner layer and then it has a muscular layer and the interesting thing about the esophagus it's innervated with a combination of skeletal as well as smooth muscle but the Lion's Share the functions involuntary meaning that once the food is down into the esophagus you have no control of that propulsion but that's what it does Dr Erickson maybe just to finish off the upper GI part talk about the stomach a little bit so the stomach is a receptor from the from the esophagus and it it acts uh to to grind the food so you eat a steak and it's a big piece and a big piece of meat and it has to grind it into smaller pieces to introduce it into the small intestine to be able to digest that further to absorb it it also makes acid it's involved in in B12 absorption so there's more to it than just just being a sac and a grinder it has other physiologic functions Victoria I know you love this subject what is GERD gerd gerd is the problem where you have acid which normally lives in the stomach that migrates up the esophagus and causes problems um it can happen for a variety of reasons some people have it more than others it can cause a variety of symptoms some people get that really bad heartburn in their chest other people can just get a cough that acid reflux can be the cause of a chronic cough it can be really annoying especially if people eat close to bedtime and then lay down they can get that heartburn that can keep them up at night or a cough at night it can be worse with certain foods it can be detrimental to the lining of the esophagus normally your esophagus has a nice smooth lining but if it gets saturated and acid it can eat away at the lining resulting in ulcerations and possibly pre-cancerous or even cancers changes um that chronic acid reflux can do bad things but it can be difficult to pin down because the intensity of the symptoms doesn't always relate to the intensity of the acid reflux very good thank you Brad you look down a lot of these both of you guys you look down quite a bit what are some of the diseases the esophagus is kind of a muscular tube so we have Gerd are there other things that happen in the esophagus that we should think about yeah in the range of diseases is quite broad Dr Herron mentioned you know acid reflux that's probably one of the most common things we see unfortunately we can get cancer in the esophagus and that can kind of come in different forms as well there are infiltrating diseases that can affect the esophagus and and then the motility of the esophagus if you have severe reflux you can then develop the ulcers that Dr Herron mentioned and have bleeding from that uh manifestations of chronic liver disease can be seen in the esophagus in the form of varices so there is quite a broad variety of things that we can see or find when we do upper endoscopy and then have to manage Bob those in the last year or so maybe it's two years I've seen a lot on eosinophilic esophagitis and all of a sudden it's a new player on the market or on in front of us what is that what do we do for it well you know it's almost like asthma the esophagus is what I mentioned the patients it's the esophagus mucosa reacting to to antigens in our food in our diet you know often it's it's wheat milk products seafood and eggs that patients are allergic to the lining of the esophagus actually gets infiltrated with allergic type cells called eosinophils and when that occurs there's chronic inflammation and it doesn't can cause narrowing and stenosis so the common scenario is a and it's often in younger males it's a 32 year old male with intermittent problem swallowing and then he eats some venison it's certainly deer hunting season and Dr Irwin or I need to go out and take the venison out of the esophagus uh you know when it's stuck and that's sometimes the manifestation there are medications that treat it to reduce that inflammation so Brad what do you do for it um it depends there's a couple of approaches with the eosinophilic esophagitis you can start simply by placing people on ppis or acid reducers so there's a subset that are will respond to that in other words their swallowing will improve just with the PPI so ppi is like Omeprazole like Omeprazole exactly then as Bob mentioned this is kind of an allergy of the esophagus to a food antigen so the next logical step is do elimination diets picking the common foods that trigger eoe and eliminating from your diet for a while and see if it responds to that um Next Step would be in wait I generally practice if I need to I'll start adding steroids steroids in a slurry typically something like budesonide mixed with a thick liquid or make it into a slurry and swallow it the old days we did inhalers and have people swallow them uh treating asthma right like you're treating asthma of the esophagus and that can be a challenge for folks because you try to swallow that gas a lot of it comes out your nose and doesn't really get down there so and there's a couple newer medicines out now that gained acceptance or approval for this as well Bob I'm going to pull you back to the stomach a little bit tell us about ulcer so we can kind of pull some of the questions together oh sure so ulcers is a defect in the lining of the the stomach so you see a canker sore in your mouth that's what ulcers look like in your stomach uh they're in the stomach or right after the stomach and we'll call the duodenal bulb and you know it causes ulcers number one taking agents such as Motrin or Naprosyn what we call NSAIDs but H pylori has been determined to be a cause of ulcer it's probably one of the more significant advancements in medicine is the detection of H pylori and treating that in the past people who used to get surgeries taken half their stomach taken out for what was an infectious disease so since that's been discovered we can treat this bacteria with antibiotics to reduce the need for surgeries and complications can you give us a real short story of how that was determined uh Marshall and Warren so the one was a pathologist I can't remember what the other one was but one actually drank a slurry of of H pylori and had had an endoscopy done and saw the infections so they they satisfied Coke's postulate which is proving that a bacteria can cause a disease this bacteria had been seen in the early 1900s but as a lot lot of things are recycled ideas and and then they took off with it then a lot of people didn't want to believe it this was in the early 90s but it he won the norbel priest or Peace Prize for that warned it yep he did how do you treat that Victoria have you or should we let these guys talk about treatment um once you've determined that somebody does have H pylori and they can do it on biopsy if they're looking down into your stomach take biopsies of ulcers to make sure they're not cancer because some ulcers are cancer some are not I really hope yours is not if they do find the H pylori bacteria there that's one way to diagnose it you can also diagnose it with a breath test because the bacteria are active they're metabolizing and if you can put a certain radioisotope very safe for you but you can measure it into the stomach and then measure what comes back out you can prove that you have a bacteria down there you can also do it comes out the bottom end as well stool samples to prove that you have H pylori there is a blood test but the blood test is more useful to prove you don't have it because once it's positive it's positive that moves you forever forever uh so that's how you can prove that you have it discussion beyond that no she gave it very yeah that was great yep so the other place that we're circling around a little bit is the hiatus hernia now so Brad hiatus hernia really nothing more than a portion of the stomach rising up above the diaphragm and when that occurs a couple things happen the the natural barrier to reflux is the lower esophageal sphincter in the diaphragm and uh in the normal situation these would line up and prevent acid reflux if you have a common sliding hiatal hernia that simply means that part of the stomach rises above the diaphragm it kind of pushes up and the barrier to reflux isn't as robust as it used to be so surgery for this the majority large majority of people do not need surgery for their Hiatal hernias and most people if they've been told they have a hiatal hernia they won't forget it but most Hiatal hernias are asymptomatic but if you do have a hiatal hernia and reflux the reflux is worse but there are surgeries of people who have a lot of regurgitation there are surgeries where you can pull the pull the hernia down and do and perform a wrap of the stomach around there to repair it so your family doc Victoria what what do you have what would you have me do without all of for hiatus hernia for a headline or maybe even for GERD for and they're related a lot of people with Hiatal hernias do have the GERD weight loss can help not filling your stomach too full will help not laying down right after eating will help there are certain foods that actually make reflux worse and unfortunately there are foods that people like a lot and we eat a lot of tomato onion chocolate peppermint caffeine makes things worse alcohol makes things worse you can not eat a lot of the foods that make reflux worse and if you watch yourself and don't overeat and don't lay down right after eating you can make life a lot more pleasant and smaller meals probably that's not overeating does it does it help to spread your meals out over the day too a little bit yes we used to talk I used to tell everybody to elevate the head of the bed is that still something that we do yeah gravity is cheap yes it is yes it is if you can get a bed that you can do that with so that brings us around to Omeprazole is that a safe drug you know so I'm really old when I went to when I was in medical school we were taught was it bop for the treatment of ulcers bleeding obstruction pain and perforation that was the reasons all we heard about was surgery and then Tagamet came along but you're going to use that for three weeks and then we've gone on to where we are today so tell me about Omeprazole can we take that forever or what's the story and who wants to grab that one well it's a real interesting story when we came out in training right um we could only use it for for two months because it is supposedly caused a carcinoid tumor in a rat but it's been the only medication I've seen go from a black box warning to over-the-counter use so over this 25-year period of time there was a lot of Omeprazole and other ppis we call Prevacid is another one Protonix is another one there's five of them um and what they do is they block the acid pump so you need to take it 30 minutes before you eat so this this pump is blocked and then when you eat it tries to stimulate the acid so the acid can't come out if it's blocked so that's what supposedly caused these bumps and these carcinoid tumors in the rats but hasn't been proven uh to be the case now since then there's a lot of associations that have developed uh osteoporosis chronic kidney disease they even attributed dementia and early death to toomeprazole now they just dispelled the early death issue but all those are really associations there's maybe two of them infections of the GI tract and osteoporosis maybe maybe our cause and effect yeah but they're very effective medications and if patients need that for their heartburn it's really a risk benefit analysis and if if that's if their life is better on the medication then it's worth taking so I'll Channel Ben Owens a little bit because we talked about Ben earlier but Ben would say something to the effect of uh you've got to make a decision is the medicine worth do you really need that medicine and how do you handle the risks how do you do that doctor he'd probably look at one of the Specialists not at Victoria so Brad how do we make that decision well you know I think Bob did a great job explaining the safety of Omeprazole it's probably one of the most studied drugs ever developed and there's been millions and millions of prescriptions for this drug for a long time with that said most people don't want to take a pill if they don't have to and I'd rather not give them a prescription if they don't need it so it you know typically in a case of just heartburn we would probably use it temporarily in our cases of Barrett's esophagus the recommendation is still to use it indefinitely indefinitely yes so so Victoria are there some non-pharmacologic ways to treat heartburn kind of a lot of what we talked about I think you're pretty much I did want to mention one thing about you know taking the Omeprazole for a bit and then going off of it it's the rebound acid that you can get if you've been on it for a while and then stop it if you've been suppressing the acid pumps for a while and then stop suppressing you can get kind of a rebound acid upswing for a bit so some people stop it and go oh my goodness my heartburn is horrible but if you give it a week or two that actually will settle down so if you use say Pepcid if you take some Tums if you really watch your diet and give it a little bit you may get over that rebound acid that's really good advice I agree one thing to add to that is it's really it's one of the shared decision making that patients need to make with their Physicians and their primary physicians and their gastroenterologists you know have a conversation about these potential side effects and you know the goal is to minimize medications but if if you need a medication again it's it's a risk benefit analysis and I I just want to reiterate in my all my years of working with the GI people there's always been a good relationship back and forth and sharing uh is as to how we would handle patients and we really appreciate that from our specialty people we've already kind of touched on this but how much of a role does gravity play in the upper GI for it's an interesting question for reduction of heartburn you mean or just leave it open that's that's the question well the interesting part about it is um there is I've seen um in a particular it was a band where the guy was was said to would do a headstand and swallow water so um so it can be done you can you can swallow water anti-reflance but that doesn't happen very often and um imparted you know I guess I guess gravity would be related to keeping acid down to emptying the stomach probably best to sit up when you're eating it is yeah yes you don't want to do a headstand that's right how does uh how does dysphagia mimic COPD symptoms and is it a related to interthoracic stomachs so I suspect we're talking hiatus hernia again with that so dysphagia or difficulty swelling does that mimic COPD um I'm I'm foggy on that one I don't think it does but you're all shaking your hips yeah I'm trying to reach for that Bob I don't know maybe they see you you can feel a fullness in your chest COPD yeah dysphagia I mean if you swallow and something gets stuck you actually usually have hyper salivation yeah so maybe that's one way of telling the two apart what causes increased flemons and coughing from a GI standpoint I was going to say well if you're coughing up phlegm it's probably not from your stomach you know it's more your chest or your chronic bronchitis or or whatnot but I mean in Victoria mentioned this Bob mentioned this you can have regurgitation of stomach fluid and that that might be what they're referring to yeah yeah we didn't touch on the fact that if you have bad enough acid reflux you can actually get enough inflammation and your esophagus that some Scar Tissue will form and it can form like a ring that's actually blocks food from going down and can obstruct food to the point that you are throwing up your food and you will be coughing up and regurgitating your food and saliva and stuff because you have a ring of scar tissue preventing things from going down and that requires the services of one of our Specialists to go down there and get the blockages out and stretch out the ring there is one thing is that sometimes people or patients have a hard time telling sinus drainage from from reflux especially when they're having problem swelling right here at the sternal Lodge so um that that's one issue too where maybe it's coming from sinuses well I was always taught that a quarter day goes down the back here throw it from the top so I don't know what you guys that's right where I come from that's what I was told well it's leaders of intestinal secretion per day you know so we had an email come in a patient with intense stomach pains in the middle of the night lasted about an hour she was ready to see I'm assuming she but it might have been he was ready to call an ambulance but decided to wait and went back to sleep didn't feel well for the next couple of days recently had a CBC and her doctor said she was fine could this be gallbladder should she have further testing still some dull pain thoughts it can be a variety of things family doctors that's a good thing did she actually go see the doctor where where is the pain if it's still there I guess there's a lot of information that that's missing that's missing in order to make a good call on that one yeah no physical yeah a little non-specific what if it persists you know persistence and we don't know age we don't know a lot of things on this one yeah but he's right if it's persisting a little bit more work up would probably be in order um why doesn't the stomach valve open to pass food into the small intestine I not sure where this comes from um I I think generally it does but I know that diabetics and others sometimes there's delay in emptying sure it's spread you want to jump in uh I I'm assuming they're talking about the pylorus yes nothing more than basically the the muscle that opens and closes and allows food to Transit into the small bowel a lot of reasons you can have dysfunction there you can have ulcers form and that can form scar tissue and stricturing the pylorus there is pyloric stenosis and infants that need surgery to correct um you can have you mentioned essentially gastroparesis which is delayed gastric emptying and diabetics and people with other neuropathies and there's a subset that are idiopathic as well which simply means that there's a delay in stomach emptying as well um so yeah it could range the gamut from malignancies to ulcers Etc in other folks one of the questions that also comes up is taking higher doses of ppis does that have any effect on possibly catching covet does that make you more susceptible and I honestly have no idea myself and you guys don't either I don't think we have any information in my knowledge it does not because that's to the best of our knowledge I think it floated around there for a while early on yeah yeah but I don't think there was anything proven about it right right this is an interesting question after two years of reflux I'm having trouble swallowing is this serious yes go get checked correct yes for probably an agreement on that is there any way to prevent and we've talked about this Barrett's esophagitis and uh reflux hiatus hernia number one I need to lose weight right so weight's a factor and any other thoughts I think everything everything we've said we've covered it okay is GERD seasonal oh that's a good one yeah it is a good one I know there's ulcers have said to be seasonal but I suppose you could maybe think about Foods being seasonal and this one this the question is late fallen and late spring that's related to ulcers more I know I've forgotten that yes it is seasonal um peppermint gels are they helpful for heartburn generally not they could be helpful for swallowing they can actually precipitate more reflux hiccups what causes hiccups don't sit there silent it's a rhythmatic contraction of the diaphragm and you know as you know sometimes it takes various measures to try to get that to stop and you've got 15 or 20 seconds so what would you do uh one thing you do is hold your breath and yeah I think I've heard that but I don't know of a good reason that they've been around for a long time and I don't know for sure what causes them um does why does prednisone cause my severe hiccups was a question where it started out so does prednisone do that or not well apparently for that person it does that doesn't that's a good answer and with that thank you so much I want to thank our panelists Dr Robert Erickson Dr Victoria Herron and Dr Brad Irwin and our medical student volunteers Barrett bukowic Nika freeberg and Tommy gentle next week please join host Dina claybaugh for a program on child and a Child and Adolescent mental health when her guests will include therapist Anne Meehan and psychotherapist Mary Morehouse I want to thank you so much for watching us have a great night foreign