Acid Reflux

Primary Care Knowledge Boost Podcast One, Acid Reflex. Hello and welcome to Primary Care Knowledge Boost. I'm Dr. Sarah McDermott. And I'm Dr. Lisa Adams. And today we're going to be talking to consultant gastroenterologist Dr. Bliss. All right, so we've got Dr Bliss here today to talk to us about all things gastroenterology. Would you mind just introducing yourself, Dr Bliss, for the listeners? Hi, I'm Phil Bliss. I'm a consultant gastroenterologist here at...

Wigan. I've been a consultant gastroenterologist since 2000, spending most of my career here in Wigan but also a bit of time in Liverpool and I'm currently the clinical director for gastroenterology and scheduled care here at WWL.

Fantastic. So you've got a lot on your plate with all of that by the sounds of things. Well, thank you for taking time out today to come and talk to us about a couple of different things. So we're going to be speaking about acid reflux. And then in a follow-up podcast, we'll be speaking about IBS and abnormal LFTs.

Okay. So were these particular areas that you've identified that were of interest for primary care? Yeah, these are probably the three commonest conditions we get referred to in outpatient clinic. I did a clinic yesterday afternoon. I saw patients with reflux, some with IBS and abnormal liver function tests. So that's probably the bulk of the work that we do in outpatients. Okay, so very relevant for us then.

So if we're starting with acid reflux and talking through that, I think there's a lot of different terminology out there about the different things that people say, dyspepsia, acid reflux, gourd. Would you mind taking us through what you come across, what each of them means and if it matters really?

Well, hopefully it helps. I mean, dyspepsia is the sort of general term that we apply to symptoms related to the stomach, or some people call it the foregut, the esophagus, the stomach, and the ugedenum. And it's sort of indigestion. abdominal discomfort, nausea, bloating and I think it helps if you try and split dyspepsia up into different types of dyspepsia. And there's sort of reflux type dyspepsia, there's abdominal pain type dyspepsia, and there's bloating type dyspepsia.

The sort of pain and dyspepture that you used to get with gastric and duodenal ulceration is far less these days because of the advent of helicobacter test and treat strategies. So we don't get that much patients with... judy and ulcer and gastric ulcer anymore the bulk of the work we get is reflux and most people understand reflux as heartburn and indigestion and In terms of most of the dyspeptic patients we see, that's by far and away the bulk of the work. Now, the difference between...

reflux type dyspepsia and sort of pain and bloating type dyspepsia and Judy and Ulcer disease is that reflux isn't really associated with helicobacter. So we're not going to solve the problem of reflux by eradicating helicobacter. We get a lot of them, the instance of reflux is probably lifestyle changes. Most people tend to be a bit overweight these days, you know, so we get a lot more reflux than Judy and Ulster disease in 2018, 2019.

Reflux, heartburn, indigestion, worse at night, worse laying flat, burping, nearly always responds to a proton pump inhibitor. And most of these patients...

could probably safely be managed in primary care and don't necessarily need to come to see us in secondary care. When you initially see somebody with dyspepsia, what red flags would you worry about? Nice guidelines on... cancer referral are quite clear that sort of new onset dyspepsia over

50 or 55 or another should be a worrying symptom. Patients who have difficulty swallowing, patients who are losing weight, patients who are anaemic, those red flag signs that we all know about and they should be referred.

for endoscopy now the younger patients who don't have any of those symptoms probably don't need endoscopy and we do get a lot of patients referred who don't really fulfil the red flag criteria and what often happens is patients get treated with a proton pump inhibitor, their symptoms get better, the GP says we have to stop your proton pump inhibitor and

symptoms come back and then they get referred and probably the best thing to do would just be to restart the proton pump inhibitor I know there's pressure on on practices to reduce their prescribing quantities of PPIs but the cost of a outpatient gastroenterology appointment is significant and the cost of a repeat prescription for a generic omeprazole isn't quite significant and when you do the health economic calculation you've got really are you getting good value for your money from your

300 pound outpatient appointment for the 25 year old a slightly overweight patient who gets heartburn on a saturday night after they've gone out for six pints and a curry you know that definitely makes sense um and when you talk about

getting referred for the endoscopy there for those red flags. In the Wigan area are we thinking about the direct access endoscopy or are we thinking the two-week pathway? We've got direct access endoscopy and the two-week pathway. If they've got red flag symptoms they should be referred on the two-week pathway.

quite robust systems for triaging those patients and getting them scoped quickly and I think we hit all those targets on a consistent basis despite a steady increase year on year of the number of suspected cancer referrals that come through the system. The other thing to say about reflux disease is it's a chronic condition. You know, most patients with reflux disease...

If you're refluxing in your 20s and 30s, you're going to be refluxing in your 40s and 50s. You're going to be refluxing in your 60s and 70s. And we do get an awful lot of patients who get referred back. on a cyclical basis for their two or three yearly gastroscopy, which... doesn't show any different than the previous ones. And I accept it's difficult to know when patients keep coming back to see you with the same symptoms, when to refer back for investigations. I think...

Going back to your warning signs, anything that's changed, have they got dysphagia, are they having difficulty swallowing now, are they losing weight, are they becoming anemic? I think those patients... you know it's appropriate to refer back but somebody who's got chronic stable dyspepsia who stable on ameprazole but it comes back when they stop ameprazole they don't necessarily need to come back and so if we've got somebody who has presented for that first appointment with

simple dyspepsia they've got no red flags you're not really worried about anything and are there any particular tests that you would do at that stage before starting medication well if if it's if it's reflux then probably not really you just check a full blood count to check they're not anemic The relevance of helicobacter is much less in reflux disease. If it's more epigastric pain...

where you might think they could possibly have an ulcer, then obviously you can do a helicobacter test for those patients. But for the reflux patients, I probably wouldn't bother checking for helicobacter.

Okay, so the full blood count would be means just to make sure they're not anemic. And then as a GP, if we see these patients, they've got reflux. It's quite straightforward. There's no red flags. And we start them on a course of... a proton pump inhibitor they respond okay what goes after that really in terms of the next step well i mean a good strategy i suspect most patients do this

already it's called on-demand strategy so if they've got symptoms they take the proton pump inhibitor on those days and if they've not got symptoms they don't take the tablets and we sort of advise that although as i said i think a lot of patients I think I would if I had heartburn, I'd take my tablets till my heartburn went and if it came back.

I'd start taking the tablets again. So intermittent pulse therapy, on-demand strategy can be useful and can reduce your prescription frequency and reduce the drug cost, I suppose. And a good general principle is always to be on the lowest dose. of the drug that keeps your symptoms at bay. And you might argue that you can put people on a lower dose.

But if you're putting someone on a low-dose treatment and it's not being effective, I would argue that's a bigger waste of money than keeping someone on a slightly higher dose that is having an effect on a patient's symptoms. Okay. And kind of thinking if we talk about the prescriptions and things like that.

at the minute so first choice would be a proton pump inhibitor yeah what kind of things should we be counselling patients about when we're starting them on a proton pump inhibitor so thinking about side effects risks things like that i had a patient yesterday who came to see him in clinic who uh first came to clinic in 2000 with

heartburn and had an endoscopy in 2000, which was normal. She was stable on Omeprazole for years and years and years, went on holiday to Spain and read this article that proton pump inhibitors were associated with all sorts of symptoms and therefore she stopped taking care. omeprazole and their symptoms came back. So she fed back up to clinic and she started their omeprazole again and her symptoms have gotten better. In general, proto-bomb inhibitors are very safe drugs. They've got a very

good safety profile. There's hundreds of millions if not billions of people around the world who are taking proton pump inhibitors and the side effect profile from those drugs is is very good if all our drugs were safe as proton pump inhibitors then i think that the world would be a much better place so

I wouldn't be overly concerned regarding side effects of proton pump inhibitors. And thinking about the other ones, so if we're unable to use a proton pump inhibitor for some reason, would you choose something like a ranitidine? I mean, H2 receptor antagonists... predate proton pump inhibitors and some patients can't tolerate the proton inhibitors for a variety of reasons or they don't find them effective and H2 receptor antagonist is a

a perfectly acceptable alternative it probably isn't as an effective in terms of acid suppression uh taken on a population basis but we're individuals aren't we and some patients will not respond to a ppi when there's whereas they will respond to a

H2 receptor antagonist. The other thing to consider I suppose is not all reflux is acid reflux. You can have biliary reflux and obviously... bilir reflux isn't going to respond to acid suppression and they're the patients who will need to have the sort of the alginate therapy the barrier therapies gaviscon sucral fate those type of things to just to provide a barrier effect from the the bile reflux

And that's a clue if you've got someone who you think has got typical reflux, but it doesn't get better with a proton pump inhibitor. Is it bile reflux? Because I was going to ask, is there a role for things like your Gaviscon and your alginate therapies in simple reflux as well? Yeah, and most patients, I would imagine... patients who respond to Gaviscon probably don't come to see me in secondary care. They may not even come to see somebody in primary care. Okay.

When you're prescribing, for example, if somebody's got reflux where they're on a proton pump inhibitor and they're also using Gaviscon, generally it's not recommended to use them at the same time, is it? Yeah, I think you tend to take...

It's a bit like your asthma treatment. You know, you have your preventers and your relievers, so your omeprazole is what you'd take or your PPI would take on a regular basis. And then if you get breakthrough symptoms, a cup full or a spoonful of Gaviscon is often helpful on top of that. That's a nice way to go.

think about it you could have a mixture of acid and bile reflux and if you suppress the acid then maybe the bile reflux becomes more prevalent and prominent and you might need the gaviscon just to to keep on top of that yeah that makes sense one question that we were really keen to ask as well was we've got access to the direct access endoscopy yeah we know that if people have got red flags it should be a two-week wait pathway

When would you recommend using the direct access endoscopy pathway? It's difficult, isn't it? You might have somebody in their 40s who don't quite hit the 50 trigger for the nice two weeks.

guidance and you might want to send them for a an open access endoscopy and it is tricky to know i think i think the concern would be that everybody could get referred through the direct access endoscopy that doesn't necessarily need an endoscopy but it's useful to know that perhaps those ones that were thinking oh they really need a scope but they're not hitting that too weak to send them through that way.

And then just in terms of management for those people, you mentioned some lifestyle changes before. Do you mind just hitting on some of the things that you would normally advise patients? I mean, obviously weight loss helps reflux. Smoking can help reflux. Avoiding large meals late at night will help you reflux. Avoiding the obvious triggers, spicy foods, too much alcohol. People talk about propping the head of the bed up.

Now, they have limited effects. I think they do have some effects, and I think we should be encouraging patients to adopt those. Sometimes they might work on their own, but I think as an adjunct to the pharmacological therapy, we should be suggesting lifestyle changes. Yeah, brilliant. So we've asked about lifestyle and then we've also talked about general long term management and that on demand or pulse therapy. Do you think we should be following people up?

long-term who were on proton pump inhibitors or alginate therapies? I would imagine that patients will... self-select and if they're having ongoing symptoms and they get him warning signs and in terms of repeat prescriptions I think if patients you'll be able to see how many

times the patients have come in for a repeat prescription of omeprazole and they're not needing them as regularly then you know you could call them in and say should we stop prescribing it but i mean it's a workload doesn't it can you see everybody can you follow up all the patients it's what what value you're going to get from that review of a patient with a chronic benign dyspeptic condition as opposed to

Seeing patients with acute problems and new problems in the clinic, that's a question for individual practice, as I imagine. We don't do it in secondary care. We obviously can't do it. And you'd have to rely on the patients to... come back if there was a problem yeah yeah so as long as they're well safety netted it's generally reasonably safe to leave them be yeah and you know just reassure patients you know

it's just heartburn. It's not going to shorten your life in any way. It's a bit of a nuisance. You might well have it. You'll have good times with it and bad times with it. And I think we've got to a bit of a paradox in medicine that you'll have a patient... who's got advanced cancer or advanced degenerative neurological disease will resign to the fact that we can say to them there's not much more we can do for you this is this is what's going to happen but with patients with

chronic long-standing benign conditions we feel very uncomfortable to sort of to say this is it you've got heartburn this is your treatment you don't need to worry about it anymore and we keep sending back for more and more tests and the second and third and fourth opinions but maybe we should just say You've got heartburn. It's not going to kill you. Don't worry about it. Carry on.

And for those patients that, for example, we have started on a proton pumping monitor for quite simple reflux symptoms, that may not have worked or if they've tried the elevated therapy and that might not have worked. For those patients then who've just... got seemingly unresponsive symptoms what do you think we should be doing next well anti-reflux surgery is an option for patients with reflux disease but a lot of patients with resistant symptoms

the symptoms may not necessarily be due to acid reflux, may be due to other factors, maybe functional, maybe other things going on in there. their life. And I would worry about a patient who you know has got acid reflux, who doesn't respond to proton permit therapy, they may not necessarily, if you speak to a surgeon

They'll be worried about doing antireflux surgery for those people because it might be dysmotility, very functional elements to their symptoms, and they worry about operating on those. But then that is the final treatment for this condition. We investigate those with 24-hour pH studies to confirm that it is acid reflux.

bile reflux and we always check for motility disorders because if you do an anti-reflux procedure in somebody who's got a esophageal motility disorder you're probably going to make them worse rather than better yeah so in those patients that we've

that have come back to us and say we've tried increasing the ppi they're not really getting better would those be candidates to refer on probably for an opinion for possible anti-reflux surgery but it can be a bit of a minefield and you you do stand the chance of making patients worse rather than better as i've said is what essentially a benign

disease yeah and in terms you mentioned it might be some other things going on if they're not responding to acid reflux treatment you mentioned about kind of dysmotility and all those things are there any other intra-abdominal causes that we should be worried about or thinking about if someone has kind of indigestion

but they're not responding. I'm thinking of non-organic problems, really, rather than organic problems. I mean, obviously, patients who have delayed gastric emptying can have reflux, so patients who've got... Diabetes with gastroparesis, they can get reflux. The stomach doesn't empty properly, so you're more likely to get reflux. But I think if there's anything more going on intra-abdominally...

There'd be additional, there'd be other warning symptoms. There'd be vomiting, I'd be losing weight, and you'd usually get blood test abnormalities. Yeah, fine. So we'll be alerted to that for some other reason if it's happening. In general practice, if we're starting somebody on anti-inflammatories...

they're using them for longer than two weeks i would start somebody on a ppi to protect the stomach if somebody's already got pre-existing reflux is that much of a problem that you encounter in in secondary care yeah it's risk benefits but i think nice guidance are quite clear aren't they if someone's going to be on a

a non-steroidal anti-inflammatory drug, we should be co-prescribing proton pump inhibitor therapy. Yeah, definitely. And I tend to do that as well, Sarah, if they're going to be on it long term. I think it's hard when you've got somebody who's already on a PPI that you think they'd really benefit from an anti-inflammatory for their osteoarthritis.

the knee and you think oh they've got previous reflux history are we going to make it worse but they're already on a ppi to help them with that i think it's again an individual case by case and you would you'd say to the patient i'm going to try this medication it might make your indigestion worse. If it does, then we'll stop and think again. If it doesn't, carry on. And if they're already on a PPI, then hopefully that should provide some gastroprotective effect. Brilliant. Thank you.

So in terms of reflux, if you think about kind of summing that up, are there any kind of salient points that you kind of want GPs to take away from today that might help them a bit better for preventing referrals into secondary care? Obviously, warning signs, you know, don't ignore them. Uncomplicated reflux isn't usually a symptom of cancer. Difficulty swallowing, weight loss, vomiting, anemia, they're much more concerning. But obviously you need to be aware of the red flag signs.

PPIs are very good drugs, they're very safe drugs, and if someone's having good relief from them, I wouldn't necessarily want to stop them without good reason and a good discussion with the patient, you know, say that if the symptoms do come back. just restart and i think if someone's symptoms come back after stopping a ppi that shouldn't necessarily mean another referral back to to secondary care yeah that makes sense thank you

So thanks very much, Dr Bliss, for joining us today. We're going to have you back with us again to talk about abnormal LFTs and IBS. So we'll speak to you then. Thank you. Look forward to it. So thank you to Dr Bliss for that really interesting talk. It was really useful to...

think about dyspepsia in terms of different types of dyspepsia and to think of it as a chronic condition and to be able to reassure patients about this and think about the fact that often your symptoms will come back when you stop PPIs. Yeah, that's true. And I think it was useful for me to know that not all reflux is acid reflux and to think about biliary reflux as a reason if they're not responding and try the alginate therapy in that case.

and also that surgery isn't really for everybody and even though it's a last case resort a lot of people won't actually get any benefit from it yeah that's right yeah one of the things that we wanted to talk about which we didn't was about when to stop medications for if you're wanting to do a h pylori test do you want to tell us a bit more about that lisa yes that's right so i went away and had a little look at the nice guidance about

it and it seemed to be that if you're doing the urea breath test or the stool antigen test then you need to stop a ppi two weeks before doing the test if you're doing the blood test you don't need to do anything and stop any medications or anything like that and

for antibiotics they need to have not had any in the past four weeks right yeah i know and for the ht antagonist it's only a day before that you need to stop it right okay and one thing that we should have pointed out earlier is there is a gastro advice and guidance now so for questions that you have that you might not need a referral for it's really useful to ask there.

if you've got a patient that you needed a bit of advice about exactly and that's accessed through the same choosing book system so all the secretaries should know how to do that for our primary care health professionals out there brilliant

And I guess the only thing else for us to say is that obviously this is our first podcast and we're trying things out and doing different bits and pieces. So we've got a survey that we'd be really grateful if you could fill in. It's in the description of the podcast. It'll take about five minutes. any useful feedback would be great we'd really really appreciate it and it means that we'll be able to make this a bit more tailored and for everyone right there

Brilliant. Yeah. And we have different ways that you can contact us as well. We've set up a Twitter account, which is primary care knowledge boost podcasts, which is PCKB podcasts. And we have an email, which is.

primarycarepodcasts at gmail.com yep exactly and we'll appreciate any contact or communication through those to give us again some feedback so we look forward to seeing you next time we've got dr bliss back again to talk to us about abnormal liver function tests which should be a really good podcast and we'll get in touch with everybody when that's out and available to listen to so yeah for now thanks for listening and we'll see you next time on primary care knowledge boost thank you