Monday, October 31, 2011

Irritable Bowel Syndrome

I was working in the gastrointestinal clinic at the county hospital when I went into see a new patient referral.  I’ll call her Jane.  She was in her mid-30s. 
“Hi, I’m Sharon and I’m a PA in the clinic.  How can I help you?”
“I’m Jane and my physician referred me due to my having gassy abdominal pain with constipation that won’t go away.”
“Okay, what work-up have you had so far for it?”
“My physician has done an x-ray of my abdomen which just showed that I had a lot of stool present.  He’s also told me to take a lot of fiber, which just made my bloating worse.”
“Okay, well let’s start with your family history then, any history of cancer in any of your relatives?”
“No, none.”
“Any history of cancer in yourself?”
“No.”
“Have you had any rectal bleeding?”
“No.”
“How about any other symptoms related to your abdomen, such as acid reflux, diarrhea, a feeling of fullness, etc?”
“Sometimes I get diarrhea, it only last for 2-3 days, then it’s gone and my constipation is back.  I also have occasional reflux, which I take some over the counter zantac for, which relieves it.”
“How long have you had these symptoms?”
“For about a year or so.”
“What medications are you on?”
“I take a blood pressure medication, lisinopril.  My occasional zantac for my acid reflux.  And then I take over the counter miralax when my constipation gets really bad and I feel all bloated up.”
“Does the miralax work for you?”
“Yes, I usually have to take two doses though before I get relief.”
“Okay, once the miralax works, is your abdominal pain gone, or is it still there?”
“No, once the miralax works, I have relief of my gassy pain and bloating.  But then the cycle just starts all over again.  A couple of days later I’m all constipated again, with lots of gas and bloating.”
“So when you have constipation, are you able to pass any bowel movement or do you just feel plugged up?”
“I can pass a small amount, but I have to really push to get it out, and then it’s only a small amount.”
“Does your symptoms ever wake you up at night?”
“No.”
“Okay, well then how about any drug allergies?”
“None.”
“Any weight loss?”
“No.”
I quickly scanned through her patient chart and saw that her blood counts were normal as was her electrolytes. 
“Okay, I see that your labs are normal which your primary care physician drew on you a while back. So
then let me listen to your chest, feel your abdomen and I’ll go over what we’ll do for you.”
The patient’s physical exam was normal which included her abdominal exam which did not show any tenderness to palpation.

At this point the most likely diagnosis for this patient was irritable bowel syndrome (IBS).  This is a clinical diagnosis.  The patient did not have any ‘red flags’ i.e. rectal bleeding, pain awakening her at night, weight loss, abnormal blood counts and she had the typical constellation of alternating diarrhea with constipation history.  She also complained of gassy pain with a feeling of bloating which was relieved with passage of her stool.  If the patient had any ‘red flags’ then this would have necessitated her receiving a more complete work-up which could consist of having a flexible sigmoidoscopy (a procedure where a scope is put up the patient’s rectum and the inside walls of the patient’s lower colon is inspected). 
If the patient had mostly diarrhea alternating with some constipation then the work-up would have consisted of doing stool studies (to rule out infectious diarrhea) and/or studies to make sure she didn’t have celiac disease (a gluten sensitivity). 

“Okay, what I want you to try first is to increase your their water/fluid intake to at least 72-84 fluid ounces a day.  I also want you to stop all diet soda intake which has an artificial sweetner that most people don’t handle very well and gives patients gas.  You can try a lactose free and ‘gas-free’ diet.  Lactose is found in milk products and can cause gas in patients who are lactose intolerant.  There are many foods (mostly vegtables and some fruits) which can cause gas formation, I’ll give you a list before you leave the clinic.”
“Okay, now about the fiber supplement.  You probably tried taking the fiber too fast.  Fiber helps move food along the GI tract in a smooth fashion.  But for those patients who have IBS we tell them to increase their fiber intake very slowly so as to not cause additional gas.  Generally we advise patients  to begin with taking 1 teaspoon every day for 3 days, then increase by ½ teaspoon every 3 days until they are at 1 tablespoon 3 times a day.  Then you can switch over to the fiber tablets or cubes every day.  I want you to get your fiber intake up to 30 grams a day and stay there.   With the additional fiber intake and fluid intake this helps to relieve the constipation symptoms by allowing the system to regulate itself.”
“Are you with me so far?”
“I think so, are you going to write this all down for me?”
“Sure.  I’m going to give you information on the foods that can cause gas, as well as our fiber schedule to take home with you.” 
“Exercise is another benefit for patients.  Exercise helps to increase the motility of the GI tract, which then helps with proper regulation.  So I want you to try to walk 30 minutes 3 times a week.  Can you do this?” I asked.
“I can try.”

Patients can also be given anti-spasmotics if they are complaining of spastic abdominal pain.  If the patient’s IBS is severe then these patients can also be given anti-depressants which work on the nerve endings in the GI tract and decrease the pain sensations.   An alternative to prescription medication is for patients to try taking peppermint oil 187 mgs 3 times a day and this has shown symptoms improvement in more than 50% of patients.

“Okay, well it’s going to take you a couple of weeks to get your fiber intake up to the full dose of 30 grams a day.  It will also take you some time to see whether going on a lactose free and gas-free diet makes any difference in your symptoms.  So I want you to take the miralax only if you absolutely have to, otherwise stay with the plan regarding the change in your diet and exercise.  Schedule yourself to come back in and be seen by the GI clinic in 6-8 weeks and we’ll see how you are then.”
“Okay.”
I retrieved the information on the necessary food changes as well as the fiber schedule and gave them to her. 

Two months later Jane was back in clinic.  I went into see her.
“Hi, Jane how are you?”
“I’m better.  I stopped all of my diet soda intake and that helped.  Stopping all of my milk products didn’t do anything for me.  I found one or two of the vegtables caused me a problem such as broccoli and cauliflower, so I don’t eat them anymore.  And I followed your instructions on fluid intake and also about the fiber intake.  I slowly worked up to 30 grams of fiber after 6 weeks and I’ve noticed that has helped.  I’ve only had to take one dose of miralax in the last two weeks since I’ve been on the full dose of fiber intake.  And I’m trying to walk several times a week.”
“Sounds great.  How’s your pain and gas symptoms?”
“Almost gone. “
“Alright, I’m glad to hear it.  Well it sounds as though you’re finally on the right track.  I don’t think we need to see you again then.  Keep up the good work.  If you by chance find that you need some additional help you can also take some peppermint oil three times a day, which comes over the counter and that has been shown to be effective in over 50% of the patients who take it.   I’m glad to see you’re doing so well.”
“Thanks.”


       

Thursday, October 27, 2011

A Newborn with a Heart Murmur

Every once in a while as I worked in the newborn nursery at the county hospital I helped staff, a newborn would be admitted to the unit who had a congenital defect.  Many of them were simple, they were what we considered minor malformations.  These were easy to take care of such as a partially formed sixth digit (which we would tie off, the extra digit would eventually fall off) or they would have somewhat of a loopy earlobe (what was called lop ear deformity).
Then there were the major congenital malformations, which could affect the child as they grew up, and for which they could need corrective surgery.  It was these infants that were generally referred over to the pediatric specialist services, based on what congential defect the infant had. 
 Just such an infant was admitted to the newborn nursery while I was on duty.  She was a cute little 7 lb. newborn of hispanic ethnicity.  Looking at her you wouldn’t think anything was wrong, she was breastfeeding just fine, was not jaundiced (yellow tinge to her skin) and was on schedule to be discharged home with her mom at 30 hours post delivery. 
I went in to do her first physical exam at 15 hours of life (she had been born the night before and spent the night with her mom in her bassinet next to her mom’s bed).  So she was a newborn that we needed to check, make sure she had received her first immunization of hepatitis B and check her bilirubin level as well as do her PKU test (heel stick test to acquire blood).

There are a few things that are done to newborns born in a hospital setting.  These include checking the newborn’s bilirubin level (to make sure that they are not going to need any intervention such as phototherapy), checking the newborn for PKU (a genetic disease that can affect the child’s mental development) and take care of any congenital abnormalities we find.  If a major abnormality is found these newborns are connected up with the pediatric specialty clinic which will follow them. 
 
As I listened to the newborn’s chest I heard a holosystolic murmur (murmur heard throughout all of systole) at her left lower sternal border.  We grade murmurs on the loudness of the murmur as well as how long they last through systole or diastole.  I graded the murmur as being a 3/6.  I didn’t pick anything else up on her physical exam.  But because she had a heart murmur I had to call the pediatric cardiology service.  They would have to bring their mobile echocardiogram machine with them (an ultrasound machine that bounces sound waves off of the organ being looked at, which is then picked up by the machine and reflected in pictures on the ultrasound screen). 
The little newborn probably had a VSD, or ventricular septal defect.  This is an opening in the septal wall between the patient’s two lower ventricles.  When patients have such defects their blood flow goes from their left ventricle to the right ventricle.  Having a VSD is the most common congenital heart defect that is found. 

Heart murmurs are graded on a scale of 1 to 6.  A 1 means that the murmur is barely heard with a stetoscope.  A 6 means that you can hear the murmur without a stetoscope.  Murmurs can be heard in systole (when the heart beats) or in diastole (when the heart is at rest).  If a murmur is heard in diastole this is generally thought of as being pathologic, i.e. a bad murmur.  If a murmur is heard in systole is can foreshadow something good or bad. 

Then we listen for the length of the murmur.  Does the murmur last for the length of systole or diastole?  Does the murmur only show up half way through systole?  In other words, when does the murmur show up and how long does it last?  This gives us some additional information on the murmur and where it might originate from. 

A few hours later the pediatric cardiology service showed up.  The cardiology fellow had the mobile echocardiogram machine with him.  The pediatric cardiology service liked to bring the mobile unit with them when assessing the newborns, seeing that they could acquire quite a bit of solid clinical information from it. 
I went in along with the cardiology fellow when she went into the nursery to see the newborn in question.  After listening to the newborn herself with her stetoscope, she agreed with me about the grade of the murmur and that it was holosystolic.  Then the cardiology fellow put some warmed gel on the transducer of the echocardiogram machine and put it on the newborn’s left chest and slowly moved it around.  As she did this, on her screen appeared the newborn’s heart.  On the bottom of the screen, the newborn’s electrocardiogram appeared (electrical activity of the heart). 
The echocardiogram showed the newborn’s atriums (upper chambers of the heart) were normal, as well as her aorta.  As the cardiology fellow moved the transducer down the newborn’s chest various views of her ventricles (lower chambers of the heart) came into view.  And there you could see a small opening between the two lower ventricles that was patent.  The blue color (showing blood moving away from the transducer) not only went up through the aortic valve (which is normal) but a small amount of it also moved off to the left, through the small septal defect and into the right ventricle.  So indeed the newborn had a ventricular septal defect.  Thankfully though it was on the smaller size, as defects go, so she probably would not need to have surgery.

With any of the cardiac congenital defects, many of them also have changes that are seen on the patient’s electrocardiogram, i.e. electrical activity of the heart.  Seeing that this little newborn only had a small defect in her septum separating her two lower ventricles, it wasn’t enough to bring about a change in her electrical activity in her heart.  Had she had a larger septal defect, changes in her electrical activity would have been seen. 
 
After the pediatric cardiology fellow finished with the echocardiogram, she wiped off the transducer gel from the newborn’s chest and walked out of the nursery to go find her mother on the post-partum OB floor.  The newborn would have to be followed in the pediatric cardiology clinic.  This little newborn would most likely do very well, and she had the potential of the septal defect closing on its own.  If it had been any larger she would have been facing some right sided heart damage as well as possibly some pulmonary damage.  Pediatric patients who have large septal defects usually end up with some sort of corrective open heart surgery to seal off the defect.       
The following morning the newborn was discharged with her mom home.  She had an appointment to be seen in the pediatric cardiology clinic in 6 weeks at which point in time she would have most likely have a full echocardiogram done. 

Friday, October 21, 2011

Medical Providers, and The Importance of Patient Education

I was seeing one of my end-stage liver disease patients for his first follow-up appointment with me, the other day.  I was going through my usual patient educational information on how to adhere to a low salt, high protein, high potassium diet.  I asked him whether he was staying on this diet as well as asking him whether he was staying on his nutritional supplements (multi-vitamin, Vitamin E and omega 3). Before he could reply, his wife spoke up and said:  “You know the first time he saw you, he came home and told me that you were ‘mean’ and he didn’t want to come back and see you again.  He also told me that you had advised him to start on the nutritional supplements.   So I went out and got them for him.  He told me that he wasn’t going to take them.  I told him a couple of vitamins a day wasn’t going to hurt him, and if they helped like you said they would, then great, maybe he’d start feeling better.  And I’m here to tell you he does.”
I looked at my patient and he told me, “I’m feeling so much better, I finally have some energy and I’m sleeping at night.” 
I replied, “Glad to hear it.”  “How’s your salt intake?” 
As the clinic visit progressed I could tell that he was compiling with his diet, his ascites was gone, although he still had some pedal edema.  His bilirubin was also down, nearing normal.  At the end of the visit I told him he could decrease his diurectics and to come back and see me in a month.
Patient education, that’s what we’re supposed to be all about.  The physicians don’t have time to spend with the patient, explaining things to them, demonstrating how to take care of their cellulitis, or how to stay hydrated when they have a case of diarrhea.  But we should take the time, we’re the ones who can speak to our patients in a language they can understand.  Many times our physicians speak on too high of an intellectual level that they don’t even comprehend how much the patient didn’t understand them. 
I used to work for a hematologist who specialized in leukemia.  He told me repeatedly that the reason he looked upon me as his ‘right hand man’ was that I could translate his scientific jargon into a language the patients could understand.  He honestly didn’t feel as though he could see patients without my help.  He’d talk about cytogenetic changes and chromosomal deletions and the patients would immediately become lost in what he was trying to say.  So I ended up putting together a very visual patient educational portfolio explaining everything about the various forms of leukemia in it.  I would then use this portfolio with every new patient we saw.  Numerous times, as I was going through the 45 minutes teaching session, patients would just start crying.  They would tell me, “no one ever took the time to explain my disease to me like you just did.  Now, I finally understand what’s wrong with my bone marrow.” 
If we’re not educating our patients on how to take care of themselves, how to stop smoking, or how to exercise, decrease their salt intake, whatever it may be, we’re doing them a disservice.    We can’t expect our patients to be compliant with their medical treatment program unless we are able to speak in a language they understand, and show empathy towards their struggle in getting healthy.  They need to know we are on their side. 
Sometimes this involves being tough on our patients, telling them the truth  (whether they like it or not, many times it ends up being the ‘or not’ scenario).   Patients can’t get well until they have faced the truth about themselves.  As with my patient at the beginning of this essay, I had to get tough with him (he saw it as being mean) regarding the fact that alcohol had given him a cirrhotic liver.  I told him he had a choice to make, he could either continue to drink and eventually die of his liver disease, or he could quit drinking and hopefully live.  Thankfully, he chose the latter. 
     

The Power of One

I've put this real story on my blog to help you, my reader understand how even 1 person, yourself can go out and change your world for the better.  You can change your circumstances, your lifestyle, you can indeed become a better person, a stronger patient advocate, let nothing get in your way!  Become empowered!

Sandy, had been a PA for 18 years and was working in an academic medical center in the department of medicine, where she ran several out-patient clinics as well as taught at the medical school, precepted NP and PA students, and did clinical research.  Her research results had been presented several times at national physician meetings.  Her writing skills were such that she had been involved in writing NIH funded training grants as well as other grants.  She was also the author of more than 50 published articles in the commercial and medical journal arena. 

Over the years of working in the department of medicine she had come up against numerous MDs who didn’t like the idea that the institution employed mid-levels.  She was aware that this attitude came from the very top down, it even included the CEO, who had expressed adamant beliefs that mid-levels didn’t belong within the institution.  This belief even extended to the daughter of the CEO (a MD) who had worked with Sandy and had told her mother that she wanted to go to school to become a PA.  Upon hearing this, the CEO told her daughter that she wouldn’t pay for her schooling unless she went to college with the intention of going to medical school. 

The second in command under the CEO (just prior to being promoted to his current  position) had been head of the community health clinics (10 of them).  His mission (we shall call him Dr. P ) for the past 4 years had been to get rid of mid-levels within the community clinics.  He had been partially successful, he had gotten rid of 8 of them, and replaced all of them with MDs.  

The mid-levels (NPs and PAs) ‘ran scared’ of him.  They dared not cross him, he was biased, preferring to believe the mid-levels didn’t know what they were doing, and choosing not to listen to their concerns. 

Then came the time for the leadership retreat, all department heads and higher executives were told to attend.  During the retreat the CEO told everyone in attendance that she was going to implement group patient clinic appts, much like what Kaiser Permanente was doing.  Sandy had already begun to initiate a similar idea in her clinics, especially when her RN had to show patients how to do their injections. 

Then it came time for the Department of Medicine head (Sandy’s boss’ boss) as well as the Division of Orthopedics to do their presentation on the usage of mid-levels within their respective areas.  There were 5 ortho PAs and the surgeon told the audience that they were very useful as surgical first assistants.  He went on to show how financially his division couldn’t handle all of the multiple trauma cases they had without the PAs on board. 

Then the Department of Medicine Chief got up and did his presentation.  Sandy was the only mid-level within his department.  He explained to the audience (which included the CEO and Dr. P) that he had been so impressed with what Sandy had accomplished that he was hiring three other mid-levels in his department within the next 3 months.  He went on to explain how financially she had brought in payer sources as well as had the highest rate of remission (compared to the national levels) in the patients she treated. 

He raved so much about what Sandy had accomplished that two MDs the following Monday caught Sandy in the hallways and told her that they had heard about her work and that there had been quite a bit of talk about her.  Having no knowledge of what they referring to, she just said ‘thank you’ and went on about her work.  Little did she know that both of these MDs had been at the leadership retreat and heard her boss’ boss speak just the prior week. 

But, what was most important was that both MD presentations on mid-levels and their usage, turned the heart of the CEO.  At the end of the leadership retreat, she told everyone in attendance (including Dr. P) that the attitude and emphasis in this academic medical center would henceforth not only be friendly towards mid-levels but that they were to be hired and kept.  Not only were they needed for financial reasons but two of them could be hired for every MD on board.  Therefore twice the amount of patients could be seen for every MD hired. 

With this change of heart, the mid-levels in the community health clinics could breath again, relax and go about doing what they did best.  So not only did Sandy’s work affect her immediate division within the department of medicine, but it also affected patients having access to healthcare out in the community.  Mid-levels would once more be hired to fill the empty clinical positions in the clinics. 

So if any of you ever think that you don’t have an impact on others, or on what is going on around you, think again.  You, as an individual can indeed bring about change, change in how you communicate with your physicians, change in how you deal with life issues. 

The Power of One is a significant force.  Go make that change, you’ll be glad you did!

Thursday, October 20, 2011

Skin Cancer, Easily Treated, Easily Cured

I had seen a 60ish year old Caucasian patient in my hepatitis clinic numerous times as I was the clinician who treated him as he went through his 11 month treatment program successfully.  Six months after finishing his treatment his blood levels still showed no evidence of a return of his hepatitis C virus, so I had dismissed him from any necessary follow-up. 
So I was surprised to see him scheduled back on my clinic schedule.  I walked into the exam room with a quizzical look on my face as I asked, “what brings you back into my clinic?”
“I don’t have a primary care physician, you’re the only one I’ve seen for the past couple of years.  So I needed to ask you what you thought about this thing on my forehead.” Earl stated.  With that he moved his second finger back and forth over his left forehead. 
“Okay, let me grab a light and I’ll take a better look at it,” I replied. 
I grabbed a hold of the wall mounted welch allyn otoscope light and shined it on Earl’s forehead.   With the light shining over his left forehead, I used my finger to feel the skin he was questioning.  He had a small raised and flat lesion in the center of his left forehead which was pearly white in color.   It wasn’t very large, about ½ inch in diameter.  The lesion’s border were irregular. 
“Earl, I think you have skin cancer.  It looks to be a basal cell cancer, which is the most common form of skin cancer.  It’s easy to remove, but I’ll have to send you over to the dermatology (skin) clinic to have them remove it.  So I’ll make you out a referral and you’ll have to call and make an appointment with them in 3 days, which is typically how long it takes for the referral to go through to them.  Is that okay?”
“Yeah, just give me the number to call in 3 days and I’ll be happy to get this thing taken care of,” stated Earl.
“Okay, I’ll be right back, I have to get the clinic number for dermatology for you to call and a referral form,” I stated.
I came back and gave Earl the number he needed to call and his copy of the referral form. 
“Nice to see you again, Earl.  Don’t forget to call okay?”
“I won’t. “
With that I excused myself and went to go see another waiting patient. 

Skin cancer is one of the most common forms of cancer there is.  It is estimated that there are over 1 million patients per year who will have skin cancer.  80% of these skin cancers are of basal cell origin.  The other forms of skin cancer are squamous cell cancer and melanoma. 

Basal cell cancer is very common in Caucasian patients who have had years upon years of exposure to sun and its UV radition.  A person has a 30% risk of having cancer over their lifetime. 

Basal cell typically has 5 different appearances: 1) it can be red, raised, nodular in appearance, or 2) smooth, flat, glistening, pearl colored, or  3) a chronic non-healing ulcer, or  4) superficial, flat red colored lesion or 5) dark pigmented raised lesion.

About two weeks later I was walking out of clinic as Earl was just leaving the dermatology procedure room and he saw me.
“Sharon,  thanks for sending me to the derm clinic.  I did have basal cell cancer like you thought.  Do you like my bandage?” Earl asked as he pointed to his 1 x 1” bandage on his forehead. 
“You look cute.  How did they remove the lesion?”
“I told them to go ahead and cut it out.  So they numbed up my skin and removed it, then they put some stitches in.  I have to come back in a week for them to remove the stitiches and they’ll tell me at that time whether they got it all out.  Something about my needing clean margins which they won’t know until they get the pathology report back.  They also told me that I have to be seen by them every year from now on to be checked for any further evidence of skin cancer.”
“Well, at least if any of your friends ask about your bandage you’ll have a good story to tell them.  I’m glad you got it taken care of.”
“So am I.”

  Basal cell cancer always needs to be addressed.  It can become aggressive and spread locally.  There are various ways of removing basal cell cancers.  These methods include:
1)      Surgical excision, which is where the lesion is removed by cutting it out
2)      Mohs micrographic surgery, which is a surgical procedure where the dermatologist checks the skin edges of the lesion under the microscope to make sure they got it all removed (what we call histology)
3)      Cryosurgery, which is a freezing technique
4)      Radiation
5)      Chemotherapy, topical application of 5 FU and imiquimod

The method by which the basal cell cancer is removed is based upon where the lesion is located, the likelihood of it’s re-occurrence, and the patient’s preference.  So if you have any suspicious skin lesions, please make an appointment to be seen by a dermatologist (physician who specializes in skin diseases) to have it checked, or have your primary care physician check it out for you. 

Drug Allergy

I was working in an urgent care clinic when I walked into one of the exam rooms to see a new patient. 
“So what brings you into be seen?” I asked.
“I’m having a problem with my tongue and lips.  They seem to be swelling somewhat,” Curt said. 
“Okay, anything else?”
“No, just this weird feeling in my lips and tongue, it’s feels as though its tingling,” Curt stated as he sat on the exam table. 
“Are you by chance on a blood pressure medication?”
“Yes, I take a medicine I believe it’s called enalapril, “ replied Curt. 
“How long have you taken it?”
“My doctor put me on it about two weeks ago.”
“Well it sounds as though you’re having a side effect to your blood pressure medication, you’re on what we call an ACE inhibitor.  One of it’s side effects is it can cause swelling of the face, more specifically the mouth, lips, throat, nose area.  We call it angioedema.”
“Are you on any other medications?”
“No, just that one.”
I quickly finished taking Curt’s personal medical history, his family history and did not find anything else that would have caused his problem.  His physical exam was normal except some mild swelling of his lips which were a little redder than normal and possibly some mild swelling of his tongue, seeing that his tongue edges were beginning to encroach upon his bottom teeth. 
“Okay, Curt you need to stop taking your blood pressure medication, you’re allergic to it.  I need you to call your primary care physician in the morning and advise him that you have had an episode of angioedema due to your enalapril.  He’ll have to start you on a different blood pressure medication.  In the meantime, I need you to start taking some zyrtec, which comes over the counter once a day for the next 3 days.  That should be enough anti-histamine to make your mild amount of swelling go away.  Any questions?”
“Nope, I think I got it.  Do I just ask the pharmacist for some zyrtec?”
“You can, or you’ll find it in with other allergy medications, it should be in a green container, it’s a 10 mg. dose.  Got that?”
“Yep, thanks for you help.”
“Not a problem, enjoy the rest of your week.”

  Angioedema can be caused by many things, cold temperatures, drugs, allergies to shellfish, hereditary (family gene), and vibrations.  It causes swelling of the skin layers: subcutaneous and dermal layers, usually due to histamine release.  Typically patients are treated with anti-histamines (to block the histamine release), and/or steroids.  If it’s a severe case (such as life threatening, patient’s airway is potentially threatened from the swelling) then they are given epinephrine sub-cutaneously and are treated in an emergency room. 

Wednesday, October 19, 2011

Dealing with Acid Reflux

I’ve seen numerous patients who have acid reflux, or what we in medicine call GERD, which stands for gastrointestinal reflux disease.  One patient stands out though and that was a 49 year old male patient who I saw in the GI clinic I was working in one morning. 
I knocked on the exam door and walked in to be greeted with the patient, whom I’ll call Dan and his wife. 
“So, what brings you into see us in the GI clinic, Dan?” I asked.
Angrily he stated, “the ER sent me.  I’m tired of this pain, but I’m really fed up with having to have waited three weeks for this visit!  No one wants to explain what’s wrong with me, all they want to do is give me meds and send me on my way.” 
“I see.  So where is your pain?” I asked.
Dan pointed to his upper portion of the abdomen over his midline. 
“Okay, how long has the pain been there?” I asked. 
“Months, maybe years,” Dan replied still angry. 
“What  medications have you taken for the pain?” I tried to ask calmly. 
“Too many.  The ER gave me some Nexium to try, prior to that I had been on Prilosec and Zantac.  But, the pain never goes away.  I want it gone!” Dan stated adamently. 
“Have any of the medications you’ve been on helped your pain?”
“The Nexium helped some, so I’ve been taking that.  The others didn’t do much of anything,” stated Dan. 

GERD, or gastrointestinal reflux disease is a very common disorder.  Many patients have it,  from those who are pregnant, to those who are obese, to those who have hiatal hernia (an outpouching of the bottom portion of the esophagus).  Typically patients take medications for it to suppress the acid formation in the stomach.  There are typically two forms of medications, one is called histamine blockers, such as Zantac, Tagamet, Pepcid, and the other one is a proton pump inhibitor, these go under the name of Prilosec, Nexium, Prevacid, etc. 

Thankfully as we continued to talk, Dan was beginning to calm down.  Maybe it was because he saw that I wasn’t dismissing him out of hand and sending him on his way. 
I took his medical history and social history and found out that he had two major risk factors for acid reflux and those were he was a 2 pack a day smoker and also drank a fair amount of alcohol every day. 
After doing his physical exam and only finding that he was tender over his upper midline of his abdomen, I asked him whether anyone had ever explained what acid reflux was all about. 
Much calmer now, Dan replied, ‘no.’
“Okay, well let me go get some pictures of what acid reflux is all about and come back in and go over them with you,” I stated.
I left the exam room, retrieved the GI teaching materials out of the conference room and returned to Dan. 
“Okay, Dan here’s some pictures for you to look at as I explain to you what’s going on inside of you.”
“No one has ever explained any of this to me, why are you doing it?” Dan asked.
“Well, because for you to understand what is going on with your acid reflux you need to understand where it came from and how to treat it.  You also need to understand why we are going to do an endoscopy on you, in other words we are going to put a scope down your swallowing tube, what we call your esophagus and take a look at it as well as your stomach.  So I need to explain all of this to you, so that you will comply with your medication regimen as well as show up for your scope procedure. “
“Okay, what’s this?” Dan asked as he pointed to the teaching picture of a patient’s esophagus and stomach.
“Okay,” as I pointed out the mouth, esophagus and then stomach in the pictorial, this is a picture of your mouth.  When you swallow your food goes into your esophagus and is then deposited into your stomach.  In your stomach you have acid which is meant to break down food products.  But sometimes acid is able to get into your esophagus, which as you see by this picture means it is going upstream.  When the acid gets into your esophagus you feel this as pain, typically right where you pointed with your finger at the beginning of this appointment.  Acid does not belong in your esophagus, because over time, it begins to break down the tissue that is there, and your esophagus’ response is to form a protective barrier of cells which are squamous cells (named squamous due to their cube shape).  And over time these cells can become dysfunctional and start to change into cancer cells.  So when you have your endoscopy we will be looking at this area right at the tail end of your esophagus and the beginning of your stomach.  If we see sometime suspicious we will biopsy it and let the pathologist tell us what it is.  If your endoscopy shows that you have Barrett’s esophagitis, which means that you have the changes which are reflective of the beginning of cancer cells, then we will be scheduling you for a regular follow-up scope procedures so that we can keep an eye on it and biopsy any further changes.  Barrett’s is the beginning of cancer, but it doesn’t mean that it has to change into cancer.”
“Do you follow all of that?” I asked.

There are many risk factors for Barrett’s esophagitis.  They include:
1)      Chronic longstanding GERD
2)      Age, mean age of diagnosis is 55
3)      Male sex
4)      Caucasian race
5)      Abdominal obesity.
Now of these risk factors there are only two which are amendable to change.  They include the patient’s weight, especially their weight around their waist line and whether they have GERD.  Risk factors for GERD include:
1)      Alcohol intake
2)      Smoking
3)      Abdominal obesity
4)      Pregnancy
5)      Fat intake 

“Yeah, but how does the acid get back up into my esophagus?” Dan asked.
“One of the ways it gets there is when you are sleeping, you sleep prone and therefore acid can easily get into your esophagus then, because it does not have to go against gravity.  Another way it can gain access is through eating fatty foods.  Fat has an affect on the gastro-esophageal sphinctor (GE junction, which is the separation between the stomach and esophagus, it is a small piece of tissue that blocks acid access back into the esophagus) .  Fat allows the GE junction to relax and therefore acid can take advantage of this and acquire entry to the esophagus.  Another way that acid can get into your esophagus is if you were obese, which you are not.  But if you were, the additional weight patients carry on their abdomen tends to pull the GE junction apart, which allows the acid access.  In addition you have two major risk factors for acid reflux and possible Barrett’s esophagitis due to your alcohol and smoking history.  Both of these work together to cause cellular changes in your lower esophagus.  And over time these changes can become cancerous.  So it’s for these reasons that we need to do what we call an endoscopy.   Okay?”
Dan nodded his head in agreement. 
“Now as far as your taking medications to prevent acid reflux that’s what the Nexium is for.  It prevents the acid from being formed by your proton pump cells which are in the lining of the stomach.  Seeing that you have told me that Nexium worked to some degree, what I’m going to do is increase your Nexium medication to twice a day dosing.  I want you to take the Nexium just prior to breakfast and dinner.  This way it will have time to get into your system, it will then be primed to turn off your proton pumps which are wanting to turn on when you present food into your stomach.  You can also take some Zantac on top of this at night if you have any symptoms.  You can take Zantac whenever, it won’t matter whether you take them with food or not.  If you have to take Zantac, you should notice a difference in your discomfort within 30 minutes.  Also I would like for you to stop off and see the clinic social worker.  Ask her for information on Alchoholics Anonymous and how to contact the local American Lung Association to quit smoking.  You need to do both of these, but try doing it one at a time.   Any questions?”
“No, I think you explained it all to me.  When am I going to be scoped?” asked Dan.
“I’ll send the nurse into schedule the procedure and she will give you the instructions on what you can have the day before the procedure and how long the procedure will take.  Here’s your new script for the  Nexium twice a day and here’s a script for the Zantac if you need it.  Here is your return to clinic appointment slip, make an appointment to come back in and see us within a few weeks of your endoscopy, okay?”  I asked.
“Okay,” Dan replied.
I walked out of the exam room, and looked at my watch.  I had ended up spending 1 ½ hours with him explaining everything and calming Dan down.  Hopefully it had been worth it, only time would tell. 

Medications which are used for GERD consist of two drug families.  The first drug family is called histamine blockers.  Most people are aware of  histamine blockers because they take one for their allergies, such as Claritin or Zyrtec.  These are classified as histamine type 1 blockers.  The histamine blockers we use for GERD are classified as histamine type 2 blockers.  These medications commonly go by the name of Tagament, Pepcid, or Zantac.  It doesn’t matter when you take these medications, they are able to get into the system and turn off the histamine releasing cells in the stomach which helps form acid.  Most patients who have acid reflux are able to take these drugs and they work just fine for them. 

Then there are those patients who have symptoms that are not totally controlled or controlled at all with a histamine type 2 blocker.  These patients need to be put on a proton pump inhibitor.  This class of drugs inhibits  the proton pump, which is located in the wall of the stomach.  The proton pump is responsible for forming the majority of the acid in the stomach, which is responsible for the initial breakdown of food products.

Proton pump inhibitor medications go by the name of Nexium, Prilosec, Prevacid, and others.  This class of drugs have to be taken either just prior to a meal or with your meal.  Taking them in this manner is the best way to make them the most effective.  They are then able to get into the system and are then primed to turn off the proton pumps which are trying to turn on when food is presented to the stomach.  These medications will not turn off the proton pumps if they are not trying to turn on. 
    
A couple of weeks later Dan was back on the GI clinic schedule to be seen.  I checked his endoscopy results and found that he had been diagnosed with Barrett’s esophagitis and would need a repeat endoscopy in 6 months.  I went in to see him.
“Hi, Dan how it’s going?”
“I’m better, my acid reflux is much better, I rarely have to take the Zantac, my Nexium is working like it should.”
“Glad to hear it.  Did they explain to you after your procedure that you do indeed have Barrett’s esophagitis?”
“I vaguely remember the GI physician telling me he thought I had it based on what he saw when he scoped me.” 
“Well, your pathology of all of the biopsies done shows that you do have it, you have what is called dysplastic cells, which could change over into cancer.  So we are going to have to put you on a regular schedule to scope you every 6 months for the foreseeable future. “
“Why do you do that?” Dan asked.
“We want to hopefully be able to prevent you from having cancer of your esophagus.  So with your staying on your medications for your acid reflux and your not having any more symptoms, hopefully you won’t transform into frank cancer.  But if you do, we’ll be on top of it and get you seen by a surgeon who can remove that portion of your swallowing tube.  Understood?”
“Yeah, I think so.”
“Now, what about your smoking and your alcohol intake.  Have you been able to make any progress with either one of those as far as quitting?”
“Pam, the social worker gave me info on Alcoholics Anonymous.  I’ve started to attend the weekly meetings in my area.  But it’s hard.  I don’t know whether I’m going to be able to do it.”
“Well, keep trying, it’s important for your health.”

Six months and one year later Dan had his repeat endoscopies.  His one year report showed that his Barrett’s esophagitis was regressing somewhat and beginning to return back towards normal cells again.  That was encouraging.  I saw him in clinic after that and he was happy with his response, his twice daily Nexium was still working and he had been alcohol free for 10 months with the help of Alcoholics Anonymous.  I could only hope that he would continue to improve.