It's no secret that reflux, irritable bowel syndrome and inflammatory bowel disease have reached epidemic proportions in America. We asked some of Nashville's top GI specialists to break down the latest news and myths on some of the most common diagnoses.
Gastroesophageal reflux disease is a condition in which the stomach contents leak backwards from the stomach into the esophagus, irritating the esophagus and causing heartburn. While reflux hits nearly everyone on occasion, experiencing symptoms more than twice a week for a few weeks could lead to more serious complications.
"GERD is a common problem and can affect 10 percent of the population at any given time," said Saint Thomas Medical Partners Gastroenterologist Neil Price, MD. For many, occasional episodes can be treated with antacids and simple lifestyle changes like elevating the head of the bed at night.
Price said GERD has been a tremendous focus for researchers over the past 30 years. "Until the 1970s, antacids were the main treatment for GERD, and then we saw H2 blockers which are more effective than antacids at turning off acids for longer," Price said.
Twenty years ago Americans flocked to a newer drug class called proton pump inhibitors, proven to be more effective for severe symptoms. In fact, the now over-the-counter class represents the third most prescribed medication in the world. But Price said there are new concerns about the long-term use of proton pump inhibitors. That's because patients with severe heartburn are likely to stay on the drug for life, increasing the otherwise minimal risk of damage to kidneys, bones and other systems.
"Overall it's a very safe class of drugs, but it's certainly something patients need to have a conversation about with their provider," Price said. "We try to balance the benefits with potential long-term risks."
For many, weight loss and dietary changes are effective ways to control heartburn long term. Pamela Duncan, MS, RD, LDN, Dietitian III at the Vanderbilt Nutrition Clinic, said patients often underestimate the role simple lifestyle changes can make in GERD treatment.
"I don't look at diet as a cure but in combination with medical therapy," Duncan said. Patients should avoid acidic foods like coffee, tea, sodas, tomatoes, juice and alcohol. And while many eat mint to calm the stomach, Duncan said the herb could actually open up the lower esophageal sphincter and make symptoms worse. Exercise also can help, in part because it encourages weight loss and improves overall health. However, Duncan warns against vigorous exercise in patients with GERD and other digestive disorders and urges patients trying to lose weight to talk to their providers.
Irritable Bowel Syndrome
IBS is a chronic functional disorder of the gastrointestinal system. Patients experience abdominal pain and altered bowel habits, with predominantly diarrhea (IBS-D), constipation (IBS-C) or both (IBS-M). According to the National Institutes of Health, IBS affects approximately 11 percent of the population, although less than 30 percent of that group seeks professional help. It affects more women than men, and absence of a definitive biomarker has led many to classify it as a symptom of psychological difficulty like anxiety.
"What's interesting now is that research shows a link between IBS and a number of people with intolerance to different kinds of foods and the inability to digest certain fruit sugars," Price said. "We now believe it's a mixture of causes."
Since many IBS patients carry high levels of bacteria in their small intestine, Price said patients often respond well to dietary and antibiotic therapies. Duncan cautions providers against taking a "one size fits all" approach to treating IBS patients - a mistake she commonly sees in her work with GI patients.
"Each patient is an individual," she said. "Fiber is variable and doesn't just thicken stool so patients will react differently depending on whether they have chronic diarrhea or constipation." She urges providers to refer patients to dietitians who specialize in gastroenterology. "It's very difficult and overwhelming for a patient to be handed a sheet with 'do's' and 'don'ts," said Duncan, who works exclusively with gastrointestinal disease patients.
Inflammatory Bowel Disease
Inflammatory Bowel Disease is a broad term that describes conditions with chronic or recurring immune response and inflammation of the gastrointestinal tract. The two most common inflammatory bowel diseases are ulcerative colitis and Crohn's disease. Inflammation affects the entire digestive tract in Crohn's disease and only the colon in ulcerative colitis. Both illnesses are characterized by an abnormal response to the body's immune system.
"Crohn's and ulcerative colitis are markedly different diseases," said Sara Horst, MD, gastroenterologist at the Vanderbilt Digestive Disease Center. She works exclusively with IBD patients at the Nashville specialty center, which has more than 2,500 patient visits annually.
Anti-TNF drugs like infliximab have been effective at achieving remission, although up to 70 percent of Crohn's patients require abdominal surgery within 30 years of diagnosis. However, surgery is becoming less common thanks to breakthroughs in immunosuppresants. And in 2014 a new drug called vedolizumab was approved for treatment of both diseases.
While most IBD patients are well informed, Horst said the prevalence of new medications could make it tough for providers to choose the best therapy.
"Successful treatment involves good patient-provider relationships," Horst said. "Patients should be involved in those decisions and be aware of benefits and risks of each medication."
Horst, whose research interest includes the role of stress, anxiety and depression in IBD patients, urges providers to treat the patient as a whole. That means ensuring patients are up-to-date on vaccinations and health screenings and checking for nutritional deficiencies, as certain therapies can increase risk of bone loss and certain cancers.
"Gastroenterologists need to have the tools to make sure they're dealing with everything together," she said. "It can take a long time to help patients find right medications, but we're here to help with that."