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GERD (transcript)
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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.


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(heart beat)


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(Dr. Peter Salgo) 
Welcome to Second Opinion where 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 Salgo, and 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-Kelly.  Now no one on this team has ever seen this case.  The case is here, I've seen it and I get to tell them all about it.  This week's case concerns a patient named Paula.  Paula is a 52 year old woman.  She's in her primary care physician's office, Lou, and she's complaining of chest pain.  Specifically she's complaining of spasmodic chest pains for no apparent reason.  What do you want to know about it?

(Dr. Lou Papa)  
Well, that's a black box.  Chest pain can be so many different things.  I'm going to need a lot more information on exactly when she's getting it and what she means by spasmodic chest pains.

(Peter) 
Well, the pains last for about ten minutes and then they go away.  She's, of course, wondering and she asks you could this pain be a heart attack.

(Lou)  
It could be heart disease.  I don't know if it's necessarily a heart attack, but chest pains the things you worry about is heart disease as the big concern, but you need to get more information, some relating factors.

(Peter) 
I can give you some of the numbers.  It's mostly numbers over here.  She is five foot two inches tall, weighs a hundred seventy pounds with a BMI of about 31.  Her blood pressure is 140/80.  Her LDL cholesterol is 160.  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 on occasion.  Does that help you at all?

(Lou)  
Well, not really.  I mean it's a lot of information.  It tells us she has some risk factors.  She's obese, she smokes, she has hypertension, she has a high LDL so it's gives us information.

(Dr. Gladys Velarde) 
That's bad.

(Lou)  
But it is bad but it doesn't help - I mean it's bad for her risk factor profile.  I'm not sure if it necessarily helps us with regards to her chest pain-

(Peter) 
Do you know what that's an example of?  You've actually said this before to us.  The labs mean nothing without the history.

(Lou)
Absolutely. It's great to have that information.  Once I have more information about her chest pain - so, the things I'd be interested in - whether we have it or not is it related to exertion?  Is it related to meals?  Does it hurt when she breathes?  There are some things like that.

(Peter) 
Right, but there's none of this history here.  So I'll tell you what her primary care doctor does.  He sends her off to a cardiologist.  We happen to have one here. How are you doing Gladys?

(Gladys) 
I'm fine.  Thank you for having me.

(Peter) 
And you were upset already.

(Gladys) 
Oh, yes, it's bad.  The spasmodic nature of the symptoms, you've got to clearly find out like Lou said, but it could be heart attack, it could be a threatening heart attack.

(Dr. Peter Salgo) 
In the cardiologist's office now what's going to happen to Paula?

(Gladys) 
Well, what's going to happen is we're going to dwell into the history first.  We're going to dwell into that part that Louie was saying is so important.

(Peter) 
Is there any other workup that you would do other than a history?

(Gladys) 
I would probably do a challenge functional test.

(Peter) 
What's a challenge functional test?

(Dr. Gladys Velarde) 
That would be a stress test -

(Peter) 
Put her on a treadmill, make her walk and see if she has chest pains.

(Gladys) 
Yes and most likely, most likely, she'll end up with either a regular test or an imaging modality.

(Peter) 
You're making pictures of her heart.

(Gladys) 
Taking pictures of her heart.

(Peter) 
Now I get to use a doctor's phrase here.  All this workup was negative in detail.

(laughter)

(Lou)  
One thing I think it's important for the viewers to realize is garbage in, garbage out.  This history that I look at it leads us down this very murky trail of somebody who has some sort of chest pain and we're basically chasing a chief complaint and we don't have much more information.

(Dr. Jeffrey Peters) 
There's an interesting paradigm that's going on here that's different than the GI tract is you would perform diagnostic studies before you'd give her an empiric trial of medications.

(Gladys) 
Probably because these are new symptoms.

(Dr. Peter Salgo) 
History, no history.  Chest pain, rule it out because you could die from this.

(Dr. Lou Papa)  
But the functional aspects of any test depends on your pre-test probability.

(Gladys) 
Absolutely and hers is not low.

(Lou)  
How do we know?

(Gladys) 
Well, she's a smoker.  She post-menopausal and I did not hear any family history.

(Peter) 
No family history on the chart, but Lou, let me put you on the spot.  In the absence of this history - you get nothing else.  Would you not have done what Gladys wanted you to do?

(Lou)  
So, in other words, if there's someone who came into the emergency room and that's the most you can get when the patient unconscious then yes, that's what we do, but I don't want the point to be lost that you get a symptom and you just go through -

(Susan Pirrozzolo) 
The symptom is a scary symptom.  I think I'm having a heart attack.  Will you please check that first?

(Dr. Gladys Velarde) 
And it's right in the chest and it's coming and going.  What I would like to know is does she have it when she moves? 

(Lou)
Right, right

(Gladys)
Is it related with activity?  That's why I'm putting her on the treadmill.

(Lou)  
Does she get it when she eats or does she get it when she takes a deep breath?  There's other things.

(Gladys) 
That's right and that's the history.  Dwelling in the history was my number one thing.

(Peter)
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 her on a beta blocker and they put her on a Statin.  Good idea?  Not a good idea?  Everybody buy into this?

(Lou)  
I think it's a great idea.

(Ryan) 
What about aspirin?

(Peter) 
They don't put her on aspirin.

(Lou)  
Is she still having chest pain?

(Gladys) 
Right.  You're putting her on a cocktail that she probably should have been on for some time and it's fine to treat that, but what about her symptoms?

(Peter) 
She goes back to her PC and what she says to her primary care physician is okay, 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.  Now what?

(Dr. Lou Papa)  
That makes me more concerned about a gastrointestinal... a gastric issue.  Specifically, the atypical symptoms that she has. That may have been what triggered it, but ulcer disease. 

(Peter) 
Susan, you had some of these things.  What is it like?

(Susan) 
With me, it was all of a sudden. It felt like I just drank a glass of soda and I couldn't describe it.  I couldn't pinpoint when it happened, what made it happen or anything.

(Dr. Peter Salgo) 
What did you do to try to control your pain?

(Susan) 
With me it wasn't new.  It happened over a long period of time and I did go see a doctor who immediately put me on a medication and sent me to a gastroenterologist. 

(Peter) 
Did you take over the counter medications?

(Susan) 
I tried to many years ago.  It didn't help me at all, but I will tell you when I realized it most of all was in periods of stress.

(Dr. Ryan Madanick) 
It's actually not uncommon for the 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're feeling things that normally are probably going on in your body, but now you're feeling them at a heightened response.

(Peter) 
Let me put a word to this.  Let me put a tag on this.  You had heartburn.

(Susan)
Yes.

(Peter) 
All right.  That being said, I want somebody to define heartburn and rather than ask the internal medicine side I'm going to ask the surgeon to do it because they generally do it in words of one syllable that most people can understand.  What's heartburn?

(Jeffrey) 
First of all, let me say that one person's heartburn is another person's chest pain and they can be difficult to set apart, but heartburn is classically a low substernal burning sensation that's precipitated by meals and often relieved by antacids.

(Peter) 
I'll tell you a little bit more about Paula.  She smokes and the word she uses is my diet stinks.  That's a phrase from the chart.

(Ryan) 
She's American, right?

(Dr. Peter Salgo) 
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 all she says, "Doesn't everybody have heartburn?"

(Jeffrey) 
Several points there.  One is that it's unusual to not find some relief in heartburn with today's over the counter medications.

(Gladys) 
I'm not a gastroenterologist, but I would say that it is so common that I think maybe we can take a poll here.  How many of us have had heartburn?  I mean women when they're pregnant, I've had heartburn.

(Ryan) 
Sixty percent of the American public suffers heartburn.

(Gladys) 
Oh, I would say ninety.

(Ryan) 
In polls.  Sixty percent and twenty percent on a weekly basis.

(Peter) 
Could Paula's pain be heartburn?  Is that fair?

(Ryan) 
I'm going to take the negative side of that.  I would say her pain is not heartburn.

(Peter) 
How so?

(Ryan) 
Her pain may be related to gastroesophageal reflux disease, but I don't consider her pain as heartburn.

(Peter) 
Why not?

(Dr. Ryan Madanick)
The heartburn is really a burning that rises, as Jeff was saying, rises up 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.

(Peter) 
In other words, 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 things.

(Ryan)  
That's exactly right.  If I call her heartburn or GERD and remember they are actually two different things.

(Peter) 
Heartburn is the pain that GERD can cause.

(Ryan) 
That's exactly right.

(Kathy Cole-Kelly) 
And Ryan, what are you going to tell the patient?

(Ryan) 
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.

(Dr. Peter Salgo) 
Before we go any further  because we are going to get deep into GERD territory. Can we define it?

(Ryan)
GERD, G-E-R-D...its an acronym, it stands for gastroesopogeal reflux disease. It is a condition when the contents of a stomach reflux up into the esophagus and causes either damage or complications and/or significantly interfere with someone's quality of life.

(Peter)
If you had had more of this history, that it was pain which came on at night, woke her up, seemed to be relieved by food, that she thought she had heartburn, could you have skipped the visit to the cardiologist's office and simply said ah, it's heartburn?

(Lou)
Why not? Those are pretty good...

(Ryan) 
Could I?  That's exactly right.

(Gladys) 
I would go back to the new - are these new symptoms all of a sudden?  If they were new all of a sudden I would probably err on the side of having her seen by a cardiologist.

(Lou)  
I disagree.  In primary care that would not happen.

(Peter) 
You said what?  That you could skip it or you couldn't skip it?  You said you would go to the cardiologist anyway.

(Jeffrey) 
I think you should.  Absolutely.

(Kathy) 
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 going to be the key.

(Lou)  
That's a separate issue.

(Dr. Gladys Velarde) 
No, it's the patient. It's a patient issue.  I think it's the same issue.  It's all of the patient's issue.

(Lou)  
No, it's not the same.

(Ryan) 
It's always about the patient.

(Lou)  
If I had a patient that came in and said - wait a minute.

(Gladys) 
But when you come to your conclusion it is one issue. 

(Dr. Lou Papa)  
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, I get it.  After a big meal I get it and when I'm fatty I get it.  Then they tell me I'm really worried about heart disease.  I'm going to take that into account.  That's not a concern in my mind I know they're going to be thinking about heart disease but that's reflux disease.

(Peter) 
Let me pause for just a second.  I know you guys are duking it out.  Go back to your respective corners, talk to your sidemen and let's sum up what we've talked about already.  This is getting good already and normally it's the surgeons that mix it up.

(Lou)  
No, it's always Gladys.

(Peter) 
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.  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 ischemic 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.  If you're having heartburn and doesn't everybody have heartburn?  You gave me some numbers.

(Ryan) 
Most people have heartburn.  Intermittent heartburn occurs, however, if it's occurring on a regular basis, if it's occurring a couple times a week it's interfering with her life.  Then it's not normal.

(Peter) 
You had symptoms, right, Susan?

(Susan Pirrozzolo) 
Yes.

(Peter) 
What were the symptoms that brought you to the doctor?

(Susan) 
I started feeling heartburn three hours after I ate.  I didn't lay down after I ate.  That plus reading things saying if you don't get it fixed - people saying if you don't get it checked you might cause damage to your esophagus.  That's what brought me to the doctor.

(Dr. Peter Salgo) 
So that's what you were referring to.  Did they test you?

(Susan) 
I went to a gastroenterologist.  He did an endoscopy.

(Peter) 
Hey guys, a new word.  What's an endoscopy?  I'm going to go to this side.

(Ryan) 
An endoscopy is when a gastroenterologist or a surgeon or some physician, practitioner, takes a look into the intestinal tract with a camera.  It's usually a long tube with a light and a camera at the end of it to visualize the inner lining of the intestinal tract.

(Peter) 
I can hear people at home cringing.  Oh, my goodness, he's putting a tube in my mouth, down my esophagus, into my stomach.

(Dr. Ryan Madanick) 
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.

(Peter) 
When you had it done did you remember anything about it afterwards?

(Susan) 
I didn't, although they did tell me if you gag go ahead and gag is what they said, but I slept through the whole thing.

(Peter) 
I can tell you what they did for Paula.  She had an endoscopy. 

(Ryan)
It doesn't surprise me.

(Peter)
This woman is getting tested invasively in this particular case and guess what they found? 

(Ryan) 
Nothing.

(Peter) 
Nothing.  How did you know that?

(Ryan) 
Because that's what most people find.

(Dr. Peter Salgo) 
But she's having all these symptoms.

(Ryan) 
It doesn't matter.  Actually, this is a very important point.  If it finds nothing it doesn't rule out reflux as the cause of the symptoms.  Over fifty percent of patients are going to have negative endoscopy.

(Jeffrey) 
Only about fifty-five percent, though, so there's a reasonable chance.  You don't want to get the audience thinking that it's ninety percent chance of finding nothing.  It's about half and half.

(Peter) 
Well, I can give you a little more history.  She has had gallbladder surgery in the past.  She doesn't have a gallbladder.  She's had a hysterectomy so she doesn't have a uterus and she has no evidence of an ulcer.  Paula's doctor recommended six weeks of intensive PPI therapy.  What's that and should it work in her case?

(Ryan) 
So PPI therapy.  PPI stands for proton pump inhibiter.  These are the most potent anti-acid medicines.  They're called antisecretory medicines.  They're the most potent that are out there right now.  They've been out for about fifteen to twenty years in the United States and they control acid secretion in the stomach like no other medicine has.

(Peter) 
Protons are what make acid.

(Ryan) 
Protons are acid.  Hydrogen is a proton.

(Peter) 
Do we all agree that just putting her right now for a brief period of time on a PPI, proton pump inhibitor, is a good idea.
(Jeffrey)  
It's the most common scenario.

(Peter) 
But that's not what I asked.

(LAUGHTER)

(Dr. Jeffrey Peters) 
I would have a conversation with her about whether she wanted to enter into a diagnostic algorithm for GERD now or a trial of PPI therapy had I seen her initially.

(Peter) 
What did you have?  Did they put you on a PPI?

(Susan) 
Yes.

(Dr. Peter Salgo) 
And what did your endoscopy show, by the way?

(Susan Pirrozzolo) 
No damage but very red.

(Peter) 
So there was inflammation?

(Susan) 
Yes.

(Peter) 
And you were on a PPI and what happened?

(Susan) 
It worked.

(LAUGHTER)

(Peter) 
Can we go home now?

(Susan) 
Well, no, because it came back.  It came back.

(Dr. Ryan Madanick) 
Came back on medicine?  While you were taking it?

(Susan) 
Yes, but first he asked me when you're on it six months go off it and see what happens, so I did.  Two days later it was worse than it had ever been so I went right back on it.

(Peter) 
Paula comes back on her PPIs for a period of time.  Anybody want to bet what happened?  Did it work or not?

(Ryan) 
It probably didn't work.

(Dr. Peter Salgo) 
Why do you say that?

(Ryan) 
Surprisingly, in people who have normal endoscopies more commonly than not it doesn't work.

(Peter) 
It didn't work.  Now she's wondering whether she needs more diagnostic tests.  You alluded to the fact that there might be some more tests for her out there.  What tests would those be?

(Jeffrey) 
The key test is an acid study, a pH study that 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.

(Peter) 
When you mentioned put something down into your stomach and walk around with it for a day her eyes almost bugged out of her head.  Why did that strike you?

(Lou)
This is why, in primary care, we do an empirical trial?

(Susan Pirrozzolo) 
Would you have asked her to change her diet at this point?

(Ryan) 
I provide my patients with a handout.  Most of my patients when I have the handouts available - we have a handout that goes over diet, it goes over lifestyle modifications, although if you just do those things in most people they're not going to work.
 
(Kathy) 
As noble as your intentions are of providing this information we know that for instance the smoking cessation, asking for patients to change diets, if we don't understand the readiness for this change we're just talking our talk and we have no idea if they're pre-contemplative, they're not thinking yet about it or they're ready or they're on the fence.

(Gladys) 
But it's critical because the lady is obese and on top of that she does drink I think you said and she smokes.

(Peter) 
I'm not sure we have a significant drinking history, but she smokes and she's large, she's hypertensive.

(Lou)  
And then the other issue is do they take the drug consistently?

(Ryan) 
And appropriately.

(Peter) 
I'll tell you what she did.  She fired her gastroenterologist and hired a new one and this new gastroenterologist said I'm going to do some tests.  She said oh, good.  I like tests I think.  He wanted to do some manometry.  He wanted to do a gastroscopy.  He wanted to do a 24 hour acid study.  Is that reasonable?  I gather it's reasonable for you.  Would everybody else have done that?

(Dr. Ryan Madanick) 
Although she had the gastroscopy already.

(Peter) 
Right.

(Lou)  
I guess it depends on what she wants to do with that information.

(Dr. Peter Salgo) 
This chart is replete with numbers if not history. And I can tell you that about 10.1% of the time the pH of her esophagus was less than 5.  She had fifty-eight reflux events during the study.  Fifteen were non-acid. 

(Jeffrey)
She has GERD.

(Peter)
Her sphincter pressure was 6.  Her peak pressure was 100.  Her peristalsis showed that ten out of ten swallows were normal and her fifty percent gastric emptying time in two hours.  In other words, it took two hours to fifty percent empty her stomach.  That's slow, right?

(Jeffrey) 
It is slow.

(Peter) 
I heard the magic word over here.  Does that make the diagnosis for you?

(Jeffrey) 
She has two and a half times the amount of acid in her esophagus of the upper limit of normal on that acid test.

(Peter) 
So?

(Jeffrey) 
So that defines GERD.

(Peter) 
So now what?  Do we know anything more than we knew before?

(Ryan)  
It defines GERD in a way, but there are totally normal people who do have that amount of acid.

(Peter) 
Oh thanks.

(Jeffrey) 
But they have GERD.

(Peter) 
Let me stop right now before we make it even more complicated, which we will in a moment I suspect and sum up what we've been discussing for the past few minutes.  You may think that heartburn is simple.  Not any more.  It is not.  There are lots of causes and getting a professional diagnostic workup will result probably in better treatment.  We now have all these measurements, we have Paula who is symptomatic, we have Paula who failed an empiric trial of proton pump inhibitors. What are her options now?

(Lou)  
As a primary care doc I would sit down with her again just like Kathy said because we're at a branch point then, what we're going to do here.  Did she really have an adequate trial in the PPIs?  That's going to be important.  Was it the proper dose?  Was she taking it correctly?  Did she really stick to the diet and I need to make the pointer - where are the branch point.  Whether you're going to go down that route or if I'm going to send you to Dr. Peters.  That's why I asked what is she going to do with the information?  I would have found that a pH study would be much more useful if it was negative.

(Gladys) 
I'm curious.  Before you go on, you said well, if it was negative it would be easier.  I think it would be more -

(Lou)  
No, not easier.  I'm saying that's how the test would be very helpful to me.

(Gladys) 
Can you have it negative and the symptoms have GERD?

(Ryan) 
Yes.

(Dr. Jeffrey Peters) 
Now the key is to try to put the two together.  The symptoms and the fact that we found abnormal acid in her esophagus.  What unfortunately happens many times, Lou, is that surgeons see these patients; acid is not the cause of the symptoms.  They get an operation and they still have their symptoms.  Then they go back into his office and he says, see, this is a bad operation.

(Ryan) 
That was why I was saying the first time it doesn't mean that just because she has acid reflux that these symptoms are related to acid reflux.

(Dr. Peter Salgo) 
Paula's doctor said I think you probably need surgery.  Should they have done that?

(Jeffrey) 
We've got a challenge now to try to figure out what's causing her symptoms.  It's like an abnormal x-ray.  Is it the cause of the problem or is it the underlying problem?  You have a clear abnormality that you've identified with a test.  You can fix that abnormality with an operation, no doubt about it, but is the patient going to get better and that's a very difficult judgment at times.

(Dr. Lou Papa)  
From the primary care perspective what kinds of things help enhance the possibility that surgery for her would be successful?

(Jeffrey) 
Three predicting factors for success with surgery and you could take surgery as stopping reflux.  One is a positive pH test.  Two is a typical symptom of reflux - heartburn, a cough or hoarseness and three is a good response to medicine.

(Peter) 
What kind of surgery are we talking about?

(Jeffrey) 
It's an anti-reflux operation.

(Peter) 
Got that part.

(Jeffrey) 
And what it does is it rolls the stomach around the lower esophagus sort of like putting a bun around a hot dog for about two inches.

(Peter) 
A fundoplication.

(Jeffrey) 
A fundoplication.  It's the fundus of the stomach and we plicate it.

(Peter) 
Or wrap it.

(Dr. Jeffrey Peters) 
Wrap it.  These days it can be done laproscopically like we do gallbladder surgery with a telescope and television camera and in the right circumstances it's an excellent operation.

(Peter) 
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?

(Jeffrey) 
On average about ninety percent of the time.

(Dr. Peter Salgo) 
That's a good success rate.

(Ryan) 
It's going to basically cure reflux.  It doesn't always cure symptoms and that's what Jeff is saying.  It cures reflux for all intents and purposes.

(Peter) 
Is Paula the extreme end of the patient spectrum here?  How many patients with GERD wind up actually having surgery?

(Jeffrey) 
A very small percentage.  Probably eighty thousand anti-reflux operations in the United States.  There's eighty million people with GERD so less than one percent.

(Peter) 
So let me tell you what happened with Paula.  Paula had a Nissan fundoplication and it worked. And it worked!

(laughter)

(Ryan)
I'm happy too.

(Peter)
But be that as it may, she's off of her PPIs.  She stopped smoking and she's losing weight 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 Paula?

(Ryan)
I would probably retest her at that point and maybe do some additional testing.  At this point 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 to address some other issues.

(Peter) 
Let's pause for a minute and 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?

(Susan) 
Better but it's creeping back in lately.  I went to my doctor last week.  I'm on two pills.  He said take one in the morning, one in the evening.  I'm trying that.

(Peter) 
Well, I want to thank you for being here and sharing your problem with us.

(Susan) 
Thank you.

(Dr. Peter Salgo) 
All you guys, just a terrific discussion.  Wonderful fight, by the way.

(LAUGHTER)

(Peter) 
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 workup 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 Salgo and I'll see you next time for another Second Opinion.  This was a great show.


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