Dr. Michael Saunders received his medical degree in 1993 from the Medical College of Wisconsin in Milwaukee. Since 1999, he has been Clinical Assistant Professor of Medicine and Attending Physician in the Division of Gastroenterology at the University of Washington in Seattle. In 2003, he was named Outstanding Specialty Clinician in the Internal Medicine Clinic at the University.
Reflux 1: What attracted you to gastroenterology?
Dr. Saunders: My father is a gastroenterologist. There’s that saying about diarrhea being hereditary – it runs in your genes.
Actually, one of the first things you decide when you go through medical school is whether you’re going to be in medicine or surgery and it was pretty clear that I was more on the medical side of it, but the prospect of doing primary care wasn’t appealing to me. I wanted to do something that offered some procedural aspects. Gastroenterology to me is the most diverse of the medical subspecialties. Each organ that we deal with, the esophagus, colon, the pancreas, they’re all different. So I think it’s the diversity of diseases as well as the ability to do some procedures.
Reflux1: What is the biggest challenge about the job?
Dr. Saunders: That’s a good question. I think our knowledge about some of the diseases that are common – such as irritable bowel syndrome or gastroesophageal reflux disease – even though we’re smarter than we were 20 years ago, there’s still a lot we need to know. And any time you don’t understand the pathophysiology of a disease, you’re treatment and ability to help patients lags behind. So I think that’s our biggest challenge.
Reflux1: What are some of the biggest gaps in knowledge about reflux?
Dr. Saunders: We don’t really understand why people get heartburn. Some people can have severe esophagitis, Barrett’s Esophagus, and yet have minimal systems. And on the other end, there are some people who have horrible burning chest pain that doesn’t respond to our best medications. Maybe they have non-erosive reflux disease or what we call “functional chest pain.” But it’s still not clear why some people experience symptoms and some don’t.
Reflux1: What percentage of your patients come to see you about reflux, and what’s the range of severity that you see with your reflux patients?
Dr. Saunders: I’d say about a third of our patients are reflux patients. As far as the range of severity, we see some patients who have very severe reflux disease with complications like Barett’s Esophagus, or esophageal strictures, and we see some people who have pronounced symptoms with minimal damage. There’s a whole range.
Reflux1: If you’re seeing a patient with reflux for the first time, what do you do? Can you talk about the steps you go through to diagnose and treat reflux?
Dr. Saunders: Sure. Reflux is a clinical diagnosis, so you very much rely on a medical history and a description of symptoms. A variety of symptoms have been attributed to reflux including cough and sore throat and all sorts of unusual things, but the only two that have been predictive of abnormal acid exposure in the esophagus are the classic heartburn and feeling of regurgitation.
If a patient has those two main symptoms, you’ll often give them a trial of a proton pump inhibitor. These medications have really changed the way we approach acid peptic disease because they are so good at suppressing acid, that we can use them as a diagnostic test of GERD. If a patient responds completely to it within two to four weeks, then it’s reflux. If not, it’s probably not reflux.
Reflux1: What might it be if they don’t respond to the PPI?
Dr. Saunders: It could be refractory or severe reflux disease although that’s very unlikely if they really haven’t responded to a good trial of a PPI. More likely, patients may have “functional chest pain,” or “esophageal hypersensitivity,” where they experience pain presumably related to the esophagus, and yet the trigger or mechanism for the pain is not clear. These patients often do not respond to acid suppression suggesting that gastro-esophageal acid reflux disease is not the cause.
Reflux1: What are some options for a patient with functional chest pain?
Dr. Saunders: There are not many good options. Sometimes one uses medications that can modulate the pain response, such as tricyclics, with varying results.
Reflux1: What percentage of your patients would you say have functional chest pain?
Dr. Saunders: On the whole of people with reflux disease, it’s probably 10 to 15 percent. With patients who are referred to me with “refractory reflux,” that percentage is much higher, maybe 60 percent.
Reflux1: What are some of the lifestyle factors that contribute to reflux?
Dr. Saunders: Sure. A smart patient might say, well, “Why do I have reflux?” And the main mechanism of reflux, for most people, is transient lower esophageal sphincter relaxation, which occurs mainly when the stomach is distended. So anything that stretches or distends the stomach can contribute to reflux. So the main lifestyle or dietary thing is really to avoid overeating. It’s not necessarily to avoid caffeine, or chocolate, or spicy foods, it’s to avoid all of that at once. Our tendency as a society is to have big meals. So, avoiding large meals is the first thing to do.
Coffee and alcohol certainly can weaken the esophageal sphincter as well. I had one patient who was drinking a case of Mountain Dew a day. We stopped that and his reflux dramatically improved. But one cup of coffee really shouldn’t cause reflux.
Patients with nighttime symptoms want to avoid eating at night, and elevate the head of the bed with blocks. At night, gravity is no longer working for us. We have less saliva to buffer acid and we swallow less while asleep which decreases the clearance of the esophagus.
Patients who have reflux and are overweight, should attempt weight loss. That won’t guarantee that it will get better, but it often can.
Reflux1: If you could recommend one thing to doctors who treat reflux, what would it be?
Dr. Saunders: My first point would be that it’s a clinical diagnosis, and not everything that burns in the upper half of the esophagus is reflux, so doctors shouldn’t attribute every symptom someone has to reflux. The second point is that reflux is a serious condition, and it should be treated aggressively – and maintained aggressively. My analogy is to high blood pressure. You treat someone’s blood pressure, when it’s elevated, until it’s normal. But then you continue the treatment once it’s normal, to prevent complications. The same is true for reflux.
Reflux1: What questions do your patients commonly ask about reflux?
Dr. Saunders: The first question is why do they have it, and we talk about some of the mechanisms that cause reflux. The people who have significant reflux almost always have anatomic factors that predispose them to reflux, the main one being a hiatal hernia. It’s the size of the hiatal hernia that correlates most with the severity of one’s reflux.
The second question is, “Is this going to affect me for the rest of my life?” The answer is that unless there’s some major reversible factor, like if the patient is grossly overweight or is drinking a case of Mountain Dew a day, most of these patients, particularly if they have the anatomic abnormalities, are going to need indefinite therapy.
Secondly, are the medications are safe, and whether there are alternatives to medications? They are safe. We now have 20 year data for the PPI therapy, and they are effective and well tolerated in the majority of patients. We do now have some other modalities, such as ant-reflux surgery and endoscopic treatments. The surgery can be very effective, but the long-term durability is uncertain and there are some side effects. But for patients who don’t tolerate the medications, or for young patients, surgery is certainly an option.
There are several endoscopic reflux procedures available. Enteryx is an option for patients with mild to moderate reflux that responds to medication. If the patient is responding well to medication but just doesn’t want to take medication for the rest of his life, then Enteryx is an option.
Reflux1: Can you talk about how the medications work?
Dr. Saunders: Sure. There are several different types of anti-acid medications. An acid producing cell has a pump that pumps out acid into the stomach. Topical antacids work on the acid that has already been pumped out, and that’s why they are only transiently effective, and not very successful.
Medications like Zantac and Pepcid are H2 receptor antagonists, and they block the Histamine 2 receptor, which is on the stomach cell. Histamine is one of three main stimulants of gastric acid production. The H2 blockers can work quickly, but they’re not very potent because there are other stimulants of gastric acid secretion that can overcome the blocking of the H2 receptor.
The Proton Pump Inhibitors or PPIs block the actual pump that is responding to all the stimulants of gastric acid secretion, so that explains why they are very effective. They often take three to five days to reach their peak effect, so they work better when taken every day. Their long-term efficacy remains very good.
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