Second Opinion; 404; Gerd

Oh. Major funding for second opinion is provided by the Blue Cross and Blue Shield Association an association of independent locally owned and community based Blue Cross Blue Shield plans committed to better knowledge for healthier lives. OK. Welcome to second opinion we're each week we solve a real medical mystery. When we close this file

in half an hour from now you'll not only know the outcome of this week's case but you'll be better able to take charge of your own health care. I'm your host Dr. Peter Sellers when you've already met our special guests who are joining our cast of regulars of course primary care physician Dr. Lou papa and communications expert Kathy Cole Kelley. Now no one on this team has ever seen this case cases here. I've seen it and I get to tell them all about it. This week's case concerns a patient named Paul. Paul is a 52 year old woman. She's in her primary care physicians office Lou and she's complaining of chest pain. Specifically she's complaining about spasmodic chest pains for no apparent reason. What you want to know about it. It's a black box. I mean chest pain can be so many different things going a lot more information on exactly when she's getting it and what she means by spasmodic tests the pains last for about 10 minutes and they go away. She's of course wondering if she asks you could this pain be a heart attack. It could be heart disease and if it's necessary a heart attack but you know chest pain things you worry about is heart disease is the big concern.

But you need to lie. To get more information related some relating factor and I can give you some of the numbers. It's mostly numbers over here. She is 5 foot 2 inches tall weighs 170 pounds with a BMI of about 31. Her blood pressure is 140 over 80. Her LDL cholesterol 260 actually her total cholesterol is well over 200. She smokes and she's on vitamins B and C and occasional over-the-counter arthritis. Medication I think he writes here that she's on some Aleve that help you at all well not really I mean it's a lot of information but it doesn't really it tells us she has some chronic respect if she is obese. She smokes she's hypertensive she has a high LDL So it gives us information. Because I mean I got it but I mean but it is bad but it doesn't help. I mean it's bad for her respect profile I'm not sure if NSA helps us with the Goss or just an example of it's an example of I think you've actually said this before to us. The labs mean nothing without the history. Absolutely I mean it's great to have that information may be more useful more once I have more information about her chest pain so they think I'd be interested whether we have it or not as you know is it related to exertion you know is it

related to meals. It doesn't hurt when she breathes. There's some things like that might even be important there's none of this history here so I'll tell you what her primary care doctor does. Since you're off to a cardiologist we happen to have one here so you don't go out of 5. And you heard said already. Oh yes his bad the spasmodic nature of their of the symptoms. You had a clearly defined that night Louis set but it could be a heart it could be a threatening heart attack in the cardiologist office now what's going to happen to Paul. Well what's going to happen is we're going to dwell into the history first. We're going to do well into that part that Louis was saying you know is so important. Is there any other work up that you would do other than history. I would probably do is challenge functional tests. What's our challenge functional That would be a stress that is sort of on a treadmill and then I walk and see if yes yes yes. And most likely most likely she'll end up with either a regular test or an imaging modality. You're making pictures of her heart taking pictures and I get to use a doctor's phrase here all this workout was

negative in detail. The one thing that I think is important for the viewers to realize is garbage in garbage out. You know this is the history that we've got is it leads us down this very murky trail of somebody who has some sort of chest pain and what where where basically chasing a chief complaint and we don't have much more information there's an interesting paradigm that's going on here that's different than the G.I. tract as you would perform diagnostic studies before you give or an empiric trial of medications. Probably because these are no symptoms history no history chest pain ruled out because you could die from this. The functional aspects of any test depends on your pre test probability. Absolutely right Her goal is not low. Hers how do we know. Well she's a small car she's boss made of balsa. And what I didn't hear was family history no family history on the carpet loom going to let me put you on the spot in the absence of this history. You get nothing else right. Would you not have done what I did and other words if this someone who came into the emergency room and that's the most immediate patient unconscious then yes that you would do but I think I don't want the point to be lost that. You get a symptom and you just go through this like this and this is where the DM is a scary symptom I think right I

think I mean I want to tell you please write her test and he's coming and going. What I would like to know is that she have a when she moves is a funny lady with activity. That's why I'm putting her on the treadmill I see or is she get it when she eats or does she get when she takes a deep breath is rivaling answer history drying in the here was my number one thing. Well I will tell you what happens next. They put her on an ACE inhibitor which is a high blood pressure drug among other things they put on a beta blocker and they put her on a staten. Good idea not a good idea everybody buy into this I think it's a great as you know not just what about us but they don't put her on aspirin is she still having chest pain right. I mean I think you're putting her in a cocktail that she probably should have been on for some time and it's fine to treat that. But what about her symptoms. She goes back to her peacekeeping and what she says to her primary care physician is ok my cardiologist that you sent me to said I'm not dying this minute. The problem is I'm still having pain.

Now she's forthcoming maybe she's not quite as afraid that she's going to die and she's willing to share more with you. She says this pain is what she's calling her hunger pains. That's how she describes it. And she says that she eats to make the pain go away. She has the pain here which she calls her solar plexus and this pain is occurring pretty much every day. And she wants you to tell her what's going on I've got this pain. No one makes me more concerned about a gastro or a gastric issue it issues specifically and the typical symptoms that she had that may have been what triggered it. Also disease. Susan you've had some of these symptoms what is it like. With me it was all of a sudden I felt like I just drank a glass a soda it was just I couldn't and I couldn't describe it I couldn't pinpoint when it happened. What made it happen or anything. What did you do to try to control your pain. With me it happened it wasn't new it happened over a long period of time. And I did go see a doctor who immediately put me on medication and sent me to a gastroenterologist. So what did you take over-the-counter medications. I tried to many years ago it didn't help me.

But I will tell you when I realized that most of all was in periods of stress. It's actually not uncommon for these symptoms to come out when you're under stress because it's that time where your brain is taking all of the signals from your body and not really able to filter them out. So you so you're feeling things that normally are probably going on in your body but now you're feeling them at a heightened response So wait let me put a word to this. Let me put a tag on this. You have heartburn. Yes. All right. That being said I want somebody to define heartburn and rather than ask the internal medicine side I'm going ask a surgeon to do it as they generally do it in words of one syllable that most people can understand what's harder. First let me say that the one person's heartburn is another person's chest pain. And they thought they could be difficult to set apart for heartburn is classically a sub sternal low sub sternal burning sensation that's precipitated by meals and often relieved by antacids. They will tell you a little bit more about Paula. She smokes and she says the word she uses my diet stinks. That that's a

phrase from the chart she's American with that this pain wakes her up from sleep several times a week. She has tried over-the-counter medications for heartburn sometimes four times the recommended dose and she doesn't feel any better she stopped them because they weren't working. After all she says doesn't everybody have heartburn. So a point there one is that it's unusual to not find some relief and heartburn with today's over-the-counter medications. I'm not a gastroenterologist but I would say that it is so common that I think maybe we can ask take a ball here. How many of us have had heartburn. I mean women when they're pregnant I've had had 60 percent of the American public suffers heartburn. All I want he says 90 60 percent in install in polls 60 percent and 20 percent on a weekly basis. Could Paula's pain be heartburn. I'm going to take the negative side to that.

I would say her pain is not heartburn houseroom her pain may be related to gastroesophageal reflux disease. But I don't consider her pain as heartburn. Why not the. The heartburn is really a burning that rises as as Jeff was saying rises up in behind the chest and it usually rises from the upper part of the stomach up towards the neck and she isn't describing it that way so I would call it and in my chart I would exactly classify it the way she is telling me it's chest pain. At this point it's non cardiac chest pain. In other words if I if I hear you correctly what you're saying is you're withholding your diagnostic. Opinion because you want to keep your mind open because you don't want to miss That's exactly right. If I call her heartburn or GERD and remember those are they are they are actually two different things. Heartburn is the pain that GERD can cause. That's exactly right. And Ryan what are you going to tell the patient so. So usually what I tell them is it's very likely that it's related to a gastrointestinal illness or it's related to GERD. We have to consider some other things.

And before we go any further because we're going to get deep into GERD territory can we define it. Gerd G-III RDA it's an acronym stands for gastroesophageal reflux disease. It is a condition when the contents of the stomach or reflux up into the esophagus and cause either damage or complications and or significantly interfere with someone's quality of life. If you would had more of this history that it was pain which came out at night seemed to be relieved by food that she thought she had heartburn could you have skipped the visit to the cardiologist office and simply said ah it's heartburn why not I mean that's a that's a pretty damn good with those risks that could I as exactly right. But I would go back to the new I have these new symptoms. If there were no all of a sudden I was probably probably err on the side of having her seen by a cardiologist and timer that would not happen. You said what.

That you could skip or you couldn't skip it you said you would go to the cardiologist and he should. Absolutely I don't want him going to the other thing is being patient centered and listening to what the patient wants the patient is saying that she's scared that that's what's going on. So that's why I wanted to see everybody. That's a separate issue because that patient is a Belgian issue I think is the same issue. That's all it is not it's not the same so if I had if I had a patient I came in and said wait a minute I had a question you came an illusion it is one it is but if you have a patient that comes in and says I have this pain in my chest it's spasmodic I lie down again after a big meal I get it and when I'm fatty I get it and they tell me I'm really worried about heart disease. I'm going to take up this saying I'm. That's not a concern in my mind. I know they can be think about heart disease but that's that's reflux disease. If you're one of us or just the second I know you guys are duking it out. Go back to your respective corners. Talk to your side then and let's sum up what we've talked about already this is getting good already and you know not only is the surgeons that mix it up you know it's always glad to get support. Chest pain is a symptom it is not a diagnosis and heart disease always needs

to be ruled out if you're suspicious about it unless you are certain. I'm going to set an accurate diagnosis to determine what is causing your symptoms is important even if you have to rule something out to be sure that you get to that diagnosis. Can we all agree based on the exclusion of the ski make or life threatening heart attack threatening cardiac pain. We can agree on heartburn as a diagnosis or as a symptom. I can tell you that heartburn is what they were working with from this point forward and you're telling me if I hear you all correctly that heartburn is not normal and if you're having heartburn to me but doesn't everybody have heartburn you gave me some numbers most people have heartburn intermittent heartburn occurs. However if it's occurring on a regular basis it's coming a couple times a week. It's interfering with her life. Then it's not normal and you had symptoms right. Yes. What were the symptoms that brought you to the doctor. I started feeling that heartburn three hours after I ate I didn't lay down after I ate that.

That plus reading thing saying if you don't get a fake people saying if you know get it checked you might cause damage here's something else. That's aggressive that's what you're referring to. I mean do they test you for any. I went to my Generac went to a gastroenterologist he didn't and asked me for you guys a new word. What's an endoscopy. It's going to go to the side. So an endoscopy is when a gastroenterologist or surgeon or some physician practitioner takes a look into the intestinal tract with a camera. It's usually a long tube with a light in a camera at the end of it to visualize the inner lining of the intestinal tract I can hear people at home cringing Oh my goodness he's putting a tube in my mouth down my esophagus into my stomach it's not that bad. Most people at least in America have sedation when they get it. You won't remember very much of it if anything at all. You're going to have it done. Did you remember anything about it afterwards. I didn't know they did tell me if you gag. Go ahead Jack here's what he said but I I thought the whole thing. Well I can tell you what they did for Paula. OK.

She had an endoscopy. That doesn't surprise me. This woman is getting tested invasively in this particular case. And guess what they found nothing. How did you know that. Because that's what most people find is that what she's having all these symptoms and that's why actually this is a very important point. If it finds nothing it doesn't rule out. Reflux as the cause of the symptoms. Over 50 percent of patients are going to have negative endoscopy only about 55 percent though so it's not there's there's a reasonable chance. Now I get the audience thinking that it's 90 percent chance of finding nothing about it's about half and half. Well I can give you a little more history. She has had gallbladder surgery in the past. She doesn't have a gallbladder common. She's had a hysterectomy so she does have a uterus and she has no evidence of an ulcer. Paula's doctor recommended six weeks of intensive peepee eye therapy. What's that. And should it work in her case. So Peepy I therapy people I stand for proton pump inhibitor.

These are the most potent anti acid medicines. They're called anti secretory medicines. They're the most potent that are out there right now. If they've been out for about 15 to 20 years in the United States and they control acid secretion in the stomach like no other medicine has in protons are what make acid protons are acid proton the hydrogen is a proton. So do we all agree that just putting her right now for a brief period of time on API proton pump inhibitor is a good idea. It's the most common scenario but that's not what I asked. Yeah I would ask I would have a conversation with her about whether she wanted to enter into a diagnostic algorithm for GERD now or a trial of PPA I therapy. Had I seen her initially what did you have did they put you in a PPO Yes. And what is your endoscopy show by the way. No damage but very rad. OK so there was a type of inflammation. Yes and you were on a PPO and what happened. It worked. Can we go home now or will be great when I actually came back and came back on medicine. He while you were

taking. Yes but he first he asked me to. When you're at six months go off it and see what happened so I did it two days later it was worse than it had ever been so I went right back on it but now it comes back on her PPR for a period of time. Anybody want to bet what happened to work or not. Probably didn't work. Why do you say that. Surprisingly in people who have normal endoscopy more commonly than not it doesn't work it didn't work. Now she's wondering whether she needs more diagnostic tests. What test with those being the key test as it is an acid study a ph study. OK it can now be done by either implanting a sensor in the esophagus or by dropping a little tube in the nose and walking around with it for a day or two. Right when you mentioned put something down in your stomach and walk around with a pro-am for a day. Her eyes always bugged out and this is why we do in primary care in a pair of trial which is it. Why why why why didn't you hear that. I'm sorry would you have asked her to change her diet at that I provide my patients with a handout. Most of my patients when I have the handouts available with a handout that

goes over diet it goes over lifestyle modifications and it's very important all these little good stuff. Although if you just do those things in most people they're not going to work is noble if your intentions are of providing this information. We know that for instance a smoking cessation asking for patients to change diet if we don't understand their readiness for this change. We're just talking our talk and we have no idea if they're pretty contemplate of they're not thinking yet about it or they're ready or they're on the fence. That is critical because the lady and she has and she on top of that she does drink I think and she smokes. I'm not sure we have a significant drinking history but she smokes and she's large. She's hypertensive and then the other issue is do they take the drug consistently and appropriately. I'll tell you what she did. She fired a gastroenterologist and hired a new one. But this new guest joiner all just said I am going to do some tests. She said Oh good I like tests I think and he wanted to do some

Manami tree you want to do a gastroscopy. He wanted to do a 24 hour acid study is that reasonable. I gather it's reasonable for you what everybody else has done. I guess although she had the gastroscopy already right I guess it depends what you want to do with that information. Lou's chart is replete with numbers if not with history and I can tell you that about ten point one of the percent of the time the pH of herself I guess was less than 5. She had fifty eight reflux events during the study 15 were non acid. I just heard her pressure was 6 her peak pressure was 100. Her pursed also showed that 10 out of 10 swallows were normal and her 50 percent gastric emptying time in two hours. In other words it took 2 hours to 50 percent empty her stomach. That's slow right. It is slow and slow. So I heard the magic word over here is that make a diagnosis for you. She has two and a half times the amount of acid in her soft against that of the upper limit of normal on that acid test. So to that that defines zines GERD. OK so now what do we know anything more than we knew before that it defines GERD in a way. But they were totally

asymptomatic totally normal people who do have that amount of acid. Oh thanks yes. OK then let me stop right now before we make it even more complicated which we will in a moment I suspect and sort of sum up what we've been discussing for the past few minutes. You may think that heartburn a simple not anymore. It is not there are lots of causes and getting a professional diagnostic work up will result probably in better treatment. We now have all these measurements we have Paula who symptomatic. We have Paula who failed an empiric trial of proton pump inhibitors. What are her options now. Well as a primary care doc I would sit down with her again just like Kathy said because we are at a branch point and what we're going to do here. Did she really have an adequate trial in the US. I mean that's that's going to be important was it was the proper dose. Was she taken correctly did she really stick to the diet I need to make the point to here's where the branch point where are you going to go down that route. Or if I'm going to send you to Dr. Peter that's why I asked What is she going to do with the information I would have found that Ph.D. which would be much more useful if it was negative.

And you said well if it was negative he would be easier. I think of the marque complex all would be much cooler. No I mean I didn't say that easy I'm saying that's how the test would be very helpful to me. If it was that you know can you have it can you have it negative feel with these symptoms have a scar. Now the key is to try to put the two together. Yes the symptoms and the and the fact that we found abnormal acid or softness. What unfortunately happens many times Lou is a surgeon see these patients. Acid is not the cause of the symptoms. They get an operation and they still have their sympathy exactly right then they go back and if that means I think I can see this is a bad option that was why I was saying in the first time. It doesn't mean that just because she has acid reflux that these symptoms are related to acid reflux. Paula's doctor said I think you probably need surgery should they have done that. We've got a challenge now to try to figure out what's causing our symptoms. It's like an abnormal x ray is that the proper cause of the problem or is it the underlying problem either have a clear abnormality that you've identified with the test you can fix that abnormality with an operation no doubt about it. But if that is the patient going to get better

and that's a that's a very difficult judgment at times. So what kind of things are you know from a primary care perspective what kind of things help enhance the possibility that surgery for her would be successful. The three predicting factors for success with surgery which in a can just take surgery is stopping reflux. One is a positive pH test. Two as a typical symptom of reflux heartburn. Unlike cough for hoarseness and three is a good response to medicine. What kind of surgery are we talking about over here. This is an it's an anti reflux operation. Got that part and were it what it does is it. It rolls the stomach around the lower esophagus sort of like putting a bun around a hot dog for about two inches a fundoplication fundoplication it's the fundus of the stomach and we placate it was around this rabbit. These days it can be done laparoscopically like we do gallbladder surgery with a telescope and television camera and in the right circumstances it's an excellent operation. I can tell you that Paula had

this fundoplication by the way before I tell you whether it worked for Paula how often does it work. On average about 90 percent of the time that's a good success rate. It's going to basically cure reflux. Correct. It doesn't always cure symptoms and that's what it's up and that's what I was saying that it cures reflux for all intents and purposes Paula the extreme end of the patient spectrum here. How many patients with GERD wind up actually having surgery. Very small percentage are probably 80000 anti reflex operations United States there's 80 million people with GERD so less than 1 percent. So let me tell you what happened with Paula Paula had a Nissen fundoplication and it worked. All of her symptoms were. Yeah. You know it's not easy to be that as it may. She's off of her peepee eyes. She stopped smoking and she's losing weight right. And she says she's losing weight because she doesn't have to eat to stop the pain. Now supposing the surgery hadn't worked then what would have happened

to Paul. I would probably retest her at that point and maybe do some additional testing. What I'm hoping to do is tell her that her symptoms that the current symptoms she has are not related to ongoing reflux. And even though the surgery worked you're still having symptoms we have we have to address some other issues like the pauses for a minute and sort of summarize what we've discussed. Left untreated GERD can lead to serious trouble as you pointed out sometimes irreversible damage to the esophagus you mentioned that too. Treatment However as we all pointed out can be very effective and most of the time the treatment does work. How are you doing better but it's creeping back again lately. Is that right. I would say that might actually last week. I'm and two pills he said take one in the morning one in the evening. Trying that. Well I want to thank you for being here and sharing your problem with us. All you guys just a terrific discussion wonderful fight by the way this is this. Tune in for round two we covered a lot of ground.

It's important to remember that chest pain is a symptom remember this all began with chest pain. It is not a diagnosis though and heart disease always needs to be ruled out. You need an accurate diagnosis to determine what is causing your symptoms. You may think that heartburn is simple but it is not. There are multiple causes and getting a professional diagnostic work up will result in better treatment left untreated GERD can lead to serious perhaps irreversible damage. Treatment that can be very effective is available. So you need to be seen need to be worked up and need to get the treatment. And of course our final message is this taking charge of your health means having informed and quality communication with your doctor. I'm Dr. Peter salvo and I'll see you next time for another second opinion. Search for health information and learn more about doctor patient communication on the second opinion website. The address is PBS dot org. Yeah.

Major funding for second opinion is provided by the Blue Cross and Blue Shield Association an association of independent locally owned and community based Blue Cross Blue Shield plans committed to better knowledge for healthier lives. Yes.