Recorded Sept. 8, 2022
Navigating GERD and Acid Reflux
Dr. Jeffrey Yenchar (Guest), Dr. Tyrone Galbreath (Host)
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Dr. Tyrone Galbreath 00:00
Well, I’m Dr. Galbreath. I’m a cardiothoracic surgeon here at Fairfield Medical Center. And I’m very pleased today to be joined by Dr. Yenchar, who is going to walk us through patients having GERD, what the normal workup is and how it’s treated. So, with that: Welcome, Dr. Yenchar.
Dr. Jeffrey Yenchar 00:18
Thanks for having me.
Dr. Tyrone Galbreath 00:20
Tell us a little bit about your background.
Dr. Jeffrey Yenchar 00:23
So, I am the medical director of the Heartburn Center, and I have been since about 2016. I’m a general surgeon, and I have been – I’m starting my 24th year here at Fairfield Medical Center. I did my residency at Ohio State. And a big part of my practice has been acid reflux. And so that’s what we’re here for today.
Dr. Tyrone Galbreath 00:47
Great. Thank you for joining us. So maybe we’ll go ahead and start in with what is GERD? And are there things that predispose different patients or people?
Dr. Jeffrey Yenchar 00:59
So, GERD – or what a lot of people call acid reflux or gastroesophageal reflux disease – it’s actually a really, really common condition in the United States. Up to 30 million people have acid reflux symptoms, and a lot of them are self-medicating.
It’s actually one of the fastest growing diseases worldwide. And it probably has a lot to do with the American diet or kind of our western culture and how we eat. So that’s really a big risk factor for acid reflux. It also is one of the most – esophageal cancer is one of the fastest rising cancers. And the main contributor to esophageal cancer is actually acid reflux. And so that’s where our Heartburn Center, you know, comes in in helping diagnose and treat this.
Some of the risk factors for acid reflux: Obesity is certainly one of them. Alcohol and tobacco use, certain medications, diet, lifestyle issues, and even medications – those are the main ones. Hiatal hernias are another issue that we see.
Dr. Tyrone Galbreath 02:16
Okay. And so, the patient on the outside – you may not notice they look a certain way. They tend to be obese, they tend not to be – it can be anybody.
Dr. Jeffrey Yenchar 02:26
It can be anybody. Yeah, it really doesn’t choose. Young, old, overweight, underweight: Yeah, it can, it can be anybody.
Dr. Tyrone Galbreath 02:35
Great. Well, and what are some of the symptoms that people classically, when they come to you, they talk about having?
Dr. Jeffrey Yenchar 02:41
The most common symptom that people talk about is heartburn. I mean, that’s going to be in most people, it’s usually after they eat, especially if they overeat. So that tends to be really the first symptom that people see. As the acid reflux gets a little bit more advanced, patients may actually what we call regurgitate or bring up acid sometimes into their throat; they get that bitter taste in their mouth, or they can have a sore throat when they wake up.
Some people also start to have a little bit of trouble swallowing, just because of the swelling, where the inflammation is from the acid reflux. And then patients can also come in with what we call upper respiratory type symptoms, which you wouldn’t even think would be related to acid reflux, but things like a chronic cough, especially after they eat or waking up at night with a cough, or, you know, feeling like there’s something in their throat all the time, or waking up with a sore throat, or even waking up at night with a cough or choking. You know, so some acid reflux symptoms you wouldn’t even think about because they don’t even involve the stomach or the esophagus.
Dr. Tyrone Galbreath 03:48
Interesting. And so some of the atypical symptoms are kind of upper respiratory at times, are there any other atypical symptoms that people should consider?
Dr. Jeffrey Yenchar 03:56
Yeah, the other one can be chest pain, which it’s interesting: There was a study done that showed about 50% of patients who come into the emergency room with chest pain, it’s actually acid reflux and not their heart. So, you know, of course, they’re going to look at the heart first, because that, you know, can be life-threatening. But, you know, that actually can be a presenting symptom, what we call atypical chest pain.
Dr. Tyrone Galbreath 04:19
Interesting. So, say I’m a person – or a person out in the community – and I’m noticing that I have a few symptoms that I’m kind of concerned about or have questions about: Where would I start in terms of, if I came in to you, what would our workup look like?
Dr. Jeffrey Yenchar 04:37
So, there’s a couple of different ways to start the process. I mean, we have our Heartburn Center here at Fairfield Medical Center with our nurse clinician, and she’s a great resource just to even start the process. Your primary care physicians can make referrals directly to a Heartburn Center physician.
We – when we started the Heartburn Center – one of our main goals was really to try to diagnose acid reflux early, because one of the things that we noticed is that we were seeing, we were detecting more esophageal cancer – but unfortunately it was all later stage. So, our goal with the heartburn center is to actually get people evaluated before they get abnormal cells or before that risk for esophageal cancer goes up.
So, our standard, our standard workup really consists of three main tests. The first is an upper scope, where we put a lighted camera down the throat. And that really lets us see, is there any evidence of damage to the esophagus? Is there any abnormal cells that might increase the risk for esophageal cancer? We look for hiatal hernias, and we’re actually looking to see if patients really do have reflux.
The second thing that we do is we do acid testing. We’ve got a little capsule, it’s about the size of a vitamin, that we can clip to the inside of the esophagus. And for 48-hour period, I can tell a patient how many times they reflux, when they reflux, what symptoms go with it, and really get an idea of the pattern of their reflux, maybe some of the causative issues so we can make some lifestyle changes and things like that.
And then the third test we do is called esophageal manometry. And this is really a test that’s going to tell us why do they reflux? Most people reflux because of one of three reasons, and they may have all three of these, but there’s a valve at the bottom of the esophagus called the lower esophageal sphincter. And so, on reflux patients, either that valve is too weak, or it’s too short, or the third reason is they developed what’s called a hiatal hernia, which moves that valve up into their chest. And if it’s up there, even if it’s normal, it doesn’t work. So, our workup is really looking at getting an idea of why the patient refluxes, and then that opens up a bunch of treatment options to figure out how can we better control their symptoms.
Dr. Tyrone Galbreath 06:53
Okay. So, the first step would probably be just coming in for an appointment and speaking with the nurse navigator, and then eventually talking more. Now, if I’m a patient that’s been on, say, I’ve been on Protonix or I’ve been on something in the community, when should I think about starting to be more aggressive? Is it just that I’ve been on it for 10 years? Is it that if I have breakthrough symptoms, when would I want to be more aggressive?
Dr. Jeffrey Yenchar 07:17
Yeah, there’s, there’s a lot of different philosophies on this. And it’s really changed over the years, just because, you know, a few years ago, there were all the concerns about being on proton pump inhibitors long term. And, you know, now we found out that probably a lot of that there’s not a lot of scientific backed evidence to support those what was in the media.
But one of our beliefs to the Heartburn Center is if somebody has been on an acid blocker for at least a year, they – at a minimum – should have a baseline upper scope, you know. Now, that doesn’t mean you have to come off your medicine, and staying on the medicine for 5-10 years is fine. But you need to at least need to have a baseline and we’re looking for that, what’s called Barrett’s esophagus, or that precancerous lesion.
The other patients we see most often are the patients with the larger hiatal hernias, because their symptoms aren’t always just reflux related. They can be shortness of breath, or trouble swallowing, you know those kinds of symptoms. But also the bigger the hernia gets, the medicine just doesn’t help.
Another group that we see are actually people who don’t want to be on medication long term, you know, they’ve been on Prevacid for five years, they want to come off it. So, we do a little more detailed evaluation to see if maybe there are some other treatment options.
And then the main group, of course, is those who have been on acid blockers, it controlled their symptoms for a few years, but now they’re starting to get some acid coming up, or they’re starting to wake up at night. They’re taking, you know, five, six Tums a day and it’s just not helping. And so, once they start to regurgitate acid, the medicines just aren’t going to work – because I think the important thing to remember is, is that medication doesn’t stop your acid reflux. All it does is decrease how much acid your stomach makes. So, you’re still refluxing, you just don’t feel it as much. But when people start to regurgitate, that’s when the medicines just not going to fix that.
Dr. Tyrone Galbreath 09:11
Okay. Interesting. So, you had mentioned an upper scope. What is that – a detailed procedure? Is it outpatient? What does that entail?
Dr. Jeffrey Yenchar 09:21
Yeah, it’s an outpatient procedure. It’s usually done under sedation or can be done under full anesthetic. And it’s basically a lighted tube that has a camera on the end, it goes through the throat, allows us to look at the inside of the esophagus, the inside of the stomach, and the first part of the small intestine. Biopsies can be taken from it. The procedure itself takes about 10- 15 minutes. And it’s – you have a little bit of sore throat for 24 hours, but you’re back to normal the next day. The upper scope is also, if we’re going to do the acid testing with this small capsule, it can be put in at the same time.
Dr. Tyrone Galbreath 09:57
Great, great. So, say that I go down that road, and we find out that I do have acid reflux. And I’m either one of those patients that doesn’t want to be on medication forever, or I’m having problems with it. What are the options out there for more aggressive measures?
Dr. Jeffrey Yenchar 10:15
Yeah, so, if lifestyle modifications aren’t working and the medicines aren’t working, certainly then surgery is usually the next step. And through our Heartburn Center, we have several different types of procedures – actually, we have three. We have what’s called the LINX device, which is a band of magnets that we can place around the lower esophagus to stop reflux. We have the standard Nissen operation, which is where we wrap the upper stomach around the lower esophagus to make a new one inch valve. And then we also have a modification of that Nissen called a partial or a Toupet, and that’s where we go 180 degrees. All of those procedures can be combined with a hiatal hernia repair. Because the key was surgery is surgery is actually going to fix the reason you reflux: We’re going to fix any hiatal hernia that we find. But we’re also going to lengthen and strengthen that vowel with the lower part of the esophagus to stop the reflux.
Dr. Tyrone Galbreath 11:18
Great, good to know. And is there a downside? You know, you’d mentioned esophageal cancer as being a concern. If I was to let this go and not get something done, are there other things that I should worry about? Or that would be a risk to me as a patient?
Dr. Jeffrey Yenchar 11:32
Yeah, one of the things that can happen, particularly with people with very severe acid reflux, is they can start to get some pretty significant scarring in their esophagus, what we call a stricture. And that area becomes very narrow, and it can become very difficult to swallow. And there becomes a point when if they if it gets narrow enough, we’re kind of limited in what we can do. So obviously, we don’t want patients to get to that point.
The other thing that we can see is especially in some of these patients with really large hiatal hernias. And I think in the past, people felt that you couldn’t fix these hernias. But now with the new technologies we have, new mesh, using the robot, things like that – we can take patients who have 50-60% of their stomach in their chest and restore everything back to where it needs to be. A pretty rare complication of having a large amount of stomach in your chest as it can actually twist; it’s called a volvulus. And that’s life-threatening, I mean, people can die from that. So, it’s one of the things that we really want to identify these patients with the large hiatal hernias, and at least give them the option to maybe consider getting that repaired. So, that’s some of the other issues that can happen when you have either long-term reflux or big hiatal hernias.
Dr. Tyrone Galbreath 12:51
Okay. And so, when we talked about going down that surgical route that you had mentioned – when you do those three procedures, is that an open surgery? Is that a laparoscopic? Robotic? Is there a way to choose that?
Dr. Jeffrey Yenchar 13:04
Yeah, yeah. Me personally, I do all of my acid reflux, hiatal hernia surgeries, all robotic now. We have the technology here at Fairfield Medical Center, and it really – in my mind – is the best way to do these procedures. We also do them laparoscopically, which again, is a good operation. It’s pretty rare nowadays that we do these open – maybe in an emergency setting or in someone who’s had to have the surgery done several times – but even in that setting, robotic or laparoscopically is better.
I think the reasons are that it just – especially robotic – the visualization is so much clearer and better. The mobility you get with the wrist of the instrument allows us to get in places that we can’t really always get to in an open operation or laparoscopically. And it just – patients seem to recover faster, they seem to have less pain and get back to normal activity sooner.
Dr. Tyrone Galbreath 14:05
So generally, after a procedure like this, what is the amount of time that maybe I’d spend in the hospital? and maybe when an average patient might go back to work?
Dr. Jeffrey Yenchar 14:13
So, with the LINX device, most of those patients go home same day. They do not have to stay in the hospital. Standard hospitalization for either the partial fundoplication or the Nissen fundoplication is typically just overnight. The larger hiatal hernia patients can go home anywhere between one and three days after surgery. S, hospitalization time isn’t too long. And most of these patients will go home on some sort of a special diet depending on the procedure. Patients who don’t really have much of a hiatal hernia can be back to normal activities, including lifting, in about two weeks. Patients with the bigger hernias, it’s usually a 6-8 week lifting restriction. So, I have – a lot of patients will be back to work, you know, within 10-14 days.
Dr. Tyrone Galbreath 15:02
Wow, that’s great. Well, I guess as far as questions go, that really kind of concludes what I have. Maybe you can kind of do a finishing touch on how patients will get in touch with you or the Heartburn Center and we can go from there.
Dr. Jeffrey Yenchar 16:59
So, we do have, like I said, the Heartburn Center here at Fairfield Medical Center. Our nurse clinician is Heather Littrell, and you can arrange for a free consult – if you if you were just, say, interested in learning more about acid reflux and deciding if you wanted to at least have baseline studies, or even do the full, you know, acid workup – she has all the educational material and can just do a really good evaluation and just help guide patients, you know, what the next steps are.
If you’re someone who’s been having your upper scopes all along, and you want to learn more directly from, you know, the surgeons or members of the Heartburn Center, we do have eight different physicians in our Heartburn Center. And certainly, you can be either self-referred or have your primary care physician or even specialists refer to them to get the process going.
Dr. Tyrone Galbreath 17:55
Great. Well, thank you very much for coming. And thank you, and we will look forward to seeing our audience again on the next show, but we appreciate everybody’s viewing.
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