This is the fourth and final part of my interview series with Dr. Mark Noar about the link between gastric motility and acid reflux.
In the previous parts we discussed some foundational factors: gastric motility, gastroparesis, and pyloric outlet obstruction.
Now we will discuss how all those things paint a complete picture of a patient’s reflux, and how to use this information to treat it effectively.
Interview On Causes Of Acid Reflux
What is wrong with how most physicians currently approach reflux?
The academic community tends to focus on the esophagus, and the esophagus only, when they talk about reflux.
In reality, reflux is a complication resulting from compromised stomach motility.
It usually takes 10 to 20 years for a new concept to get attention in the medical community. Now, finally, they’re slowly but surely beginning to wake up to the fact that gastric motility has a strong influence on reflux disease.
Can you share an example of a patient with GERD you treated, to give me an understanding of what your treatment process looks like?
I’ll give you a perfect example I had to deal with this morning.
A patient contacted me after he’d had a reflux-corrective procedure. His reflux got better, but now he was having terrible symptoms of gastroparesis, which means his stomach was emptying too slowly.
This patient was never correctly evaluated before having the reflux corrected.
He already had gastroparesis before the surgery. However, the symptoms of gastroparesis were less pronounced. The lower esophageal sphincter was malfunctioning, which meant that the pressure in the stomach was allowed to vent into the esophagus. As a result, the patient’s main symptom was reflux.
The surgery closed off the lower esophageal sphincter so that pressure couldn’t be released. However, the stomach is still blocked, which means the gastroparesis is accentuated and now shows stronger symptoms.
All that could be avoided if we looked at all influential factors for gastric motility, in addition to reflux.
I get many emails from readers. Something that I find interesting is that most only get a basic check-up by their physician. They might get a gastroscopy, manometry and pH test. Even if their symptoms persist, most can’t find a doctor to do additional tests that might find the causes of their acid reflux. How many people could get better, if physicians looked at things like gastric motility and gastroparesis more often?
Let’s look at the statistics. I think you’d be shocked to hear that 40 to 45% of patients already have gastroparesis at the time they are diagnosed with reflux disease. However, most are not diagnosed with gastroparesis, just reflux.
It’s not unusual for GERD patients to undergo an anti-reflux procedure, like the Stretta procedure, or a Nissen Fundoplication. However, if the gastric motility is abnormal and has not been treated, then the reflux procedure is eventually going to fail.
You mean the reflux symptoms will come back if the gastric motility issue is not treated?
Correct.
After ten years, 65% of Nissen patients are symptomatic and taking medication again. It isn’t necessarily due to the Nissen procedure failing. It’s often because the gastric motility was never addressed.
I frequently see patients who have had a Stretta procedure. They might feel worse again despite the fact it’s only been a year since the procedure.
Often, I find out that the motility was the driving issue. I fix the gastric motility, and their reflux is corrected once again.
It’s all about what is causing reflux, not just studying the end result of the disease.
Do you have some more examples of typical reflux patients?
Let’s use a couple of real-world examples. Someone comes to me with reflux symptoms.
They’ve been seeing another doctor, and the doctor does the usual reflux testing. The pH test shows that the patient has reflux. The patient has a normal lower esophageal sphincter pressure on an LES motility test.
Nothing is done for this patient because the sphincter pressure is normal based on the statistics that define normal.
Why does this patient have reflux despite his normal sphincter pressure? The answer is that the LES pressure is just not “normal” enough. Normal is simply defined by the sphincter pressure of people who don’t have reflux symptoms.
However, what matters is the sphincter pressure compared to a person’s stomach pressure.
If the LES pressure is in the normal range of about 35, and the stomach pressure is only 20, that person will not reflux.
However, if your LES pressure is 35, but your gastric pressure is 40, you’re always going to reflux, even though you have a “normal” LES pressure.
The patient’s LES pressure might be “normal,” but that is not normal enough for that person’s unique physiology. We have to look at all of this together, not at each value individually.
Can you share another example of a patient you treated?
Here is another example of a patient who has been diagnosed with reflux. This patient has “normal” LES pressure as well.
However, in this case, the patient’s gastric emptying test shows gastroparesis, and their electrogastrogram shows they have pyloric dysfunction.
If the gastric motility is abnormal and we see that the cause is a pyloric malfunction, we fix the pylorus, and the reflux goes away. Why? Because the root cause wasn’t the esophageal sphincter, it was the pyloric sphincter elevating gastric pressures and then compromising the LES.
This is where we all need to be in order to truly understand the disease. We need to stop looking at the end result, which is the symptoms, and trying to fix them. Instead, we need to look at, and address, the causes of reflux, and then the symptoms may go away by themselves.
We’ve talked about many procedures to fix the causes of acid reflux. How many patients would get better just by improving their diet?
Before you move on to a procedure, you do everything you can to help control your symptoms and therefore keep your reflux limited.
I have reflux myself. My disease is LPR — laryngopharyngeal reflux. I don’t have esophageal reflux symptoms. I have respiratory symptoms.
I lost 50 pounds and my LPR improved by 90%.
But the question is why did my weight loss have that effect? It’s because, by reducing the size of my abdomen, I decreased the pressure on my stomach, the gastric pressure, and now the normal pressure of my lower esophageal sphincter is not compromised by the increased abdominal pressure caused by being obese or overweight.
Remember, I have LPR, which is primarily a disease of pepsin, a stomach enzyme. Pepsin is always coming up, I can’t do anything to change that unless I have a procedure. However, if I avoid acidic foods, then I don’t reactivate the pepsin, and I don’t experience symptoms.
The last point is, if you have chronic reflux and you choose natural methods to control your symptoms, you must have regular examinations. Let’s say every five years, to make sure you’re not developing cancer. Every five years I have an endoscopy, whether I want to or not.
What about the diagnostic tests to find the causes of GERD? Who should do them and when?
The only reason for doing all that testing is if you plan on fixing the problem permanently.
If you are happy just feeling better, and don’t care if you have to take a pill, then you don’t need to do any detailed diagnostic testing. You just have to take a pill.
Also, there are many people who have mild reflux and simply control their diet, and they feel wonderful. There’s nothing wrong with that.
In fact, that’s the first thing you should do before you see a doctor. Try to control it yourself. Change your dietary habits. Lose some weight. Don’t eat within four hours of bedtime. Avoid trigger foods.
Know the difference between esophageal reflux and LPR type reflux, so you can make sure that the things you do regarding avoidance will make a difference.
However, if you want to permanently fix the issue, you need to get the testing done to fully understand your disease. Only that way will you know what to fix.
Okay. Let me sum up which tests there are. Most gastroenterologists will do gastroscopy, manometry and pH monitoring. Then there are the tests for gastric motility and gastroparesis that we talked about in our other interviews, the electrogastrography, short EGG, and the gastric emptying scan. Those are all tests, right, or have I forgotten any?
That would be the full complement of testing needed.
If we had a really easy way of measuring gastric pressure that people would tolerate, I would say that might be the only test we need to do. However, there is no good test for that.
Last question. The EGG, where can I have that test? I had it done in your office. However, it seems that not many physicians offer the test, or have even heard of it.
There are a number of centers around the world.
It’s a small number, but that number is growing. It will continue to grow, as the appreciation for the need to understand gastric motility increases.
You are very active in the field of reflux, particularly when it comes to educating both physicians and patients, also in Facebook groups. Why are you doing that?
The medical community is not great at communicating its knowledge and helping patients understand their disease.
That’s the reason I educate on reflux.
Although sometimes criticized for my work on Facebook by the medical community, I think one of the reasons I persevere is because I teach patients how to understand their disease and communicate with their doctors. Then those patients go to their physicians and demand proper diagnosis and treatment.
I want people to understand what their disease is, and how should it be properly diagnosed and treated.
Once they know that, they can take that knowledge to their physician. They can make their own doctor more knowledgeable on reflux. The physician can then start being more proactive in doing what needs to be done about reflux.
How should patients confront their physician with knowledge they got on the internet?
First and foremost, learn about your disease. Learn about all the options and what should be done to diagnose your disease.
Then go back to your physician and don’t take “No” for an answer.
Take your knowledge and educate the doctor. He or she may initially be very resistant to this. For instance, I know physicians say all the time, “Oh, my god, you’re going to come in here and talk to me about something you learned from Dr. Google.”
This reaction happens so often that my own patients sometimes say things like, “Listen, I know you’re going to be upset with me because I got this from Dr. Google.” But my answer to this is just, “No, I think it’s wonderful.”
It’s wonderful that they’ve learned something on their own and they’re bringing it to me.
One of the most interesting things I have found with Facebook groups is that it’s like having thousands of people who are my research assistants. They go out and do all sorts of incredible research and find little-known articles that I don’t usually get a chance to see. They bring them forward so that we can review them and criticize them and benefit from their information.
It’s phenomenal for me because I have become a better physician, just because people have brought me knowledge I didn’t have access to.
Physicians are busy. They don’t always have time to read. They can’t read everything. There are thousands and thousands of new articles every year. I can’t read them all. Yet, my team of researchers across the social network world bring me that research.
Knowledge is power, and then teaching that knowledge to your own physician is powerful. This way, everyone becomes better. Slowly but surely, everyone’s knowledge base increases so that everyone will have access to a physician who is competent on reflux.
When I go to a physician and mention that I have reflux, they nearly always want to put me on proton-pump inhibitors. I know that they don’t work for me at all. I’ve tried them. Many studies prove that PPIs are not good for the treatment of respiratory reflux, which is the type of reflux I have. Still, even after explaining that, some physicians still want to prescribe me PPIs, even if I’m seeing them for something completely unrelated to GERD. That makes me wonder. How do I, as a patient, know whether what a physician recommends is good advice or not?
This gets to the root problem you have when you go to a physician.
Physicians are taught to react to symptoms. If someone comes in with heartburn and you put them on PPIs, most of the time their symptoms will go away. Many patients are quite happy to take a pill if it makes them symptom-free. They don’t want to know what the root cause is.
If the physician recommends a pill, you must research that pill yourself. The resources that exist today on the internet are unparalleled to what was available in the past. Now you can evaluate any recommended treatment yourself.
Everyone must answer for themselves: Am I happy fixing my symptoms knowing my disease continues, or do I want the disease itself to go away, so I don’t have to treat my symptoms?
Ask the doctor, “Are you treating my symptoms or are you going to fix the disease?”
That’s a really good question to ask. I like that. These were all my questions. Thank you very much for your time.
This is the last part of the interview series with Dr. Mark Noar.
If you want to read up on the first three parts, here are the links: gastric motility, gastroparesis, gastric outlet obstruction.
