If you take an ant acid more than twice a week, this next hour is for you. Okay.

Oops. There you go. Okay. Heartburn isn't a disease. It's a warning light. And most people have learned to cover it with tape. So, heartburn gets treated with ant acids and and proton pump inhibitors uh to decrease the amount of acid that we're producing. and that's great for reflux. Um, but there are other disease processes that cause heartburn or chest pain. Uh, and we're just pretending, you know, that we're treating them when we're really not. So, there are six different things in in total, and we'll talk about, we're going to get into all of them. Um, but, uh, you know, for some of them, we're treating it. For one of them, we're treating it and the rest we're not. We're just kind of playing around. You know, [gasps] right now, this is a big deal. It's about one in five adults in the US are suffering from reflux. So 20%. Um, and more than half of the people that are taking an a daily acid reducer are still having symptoms. So it's it's not that it resolves it for for everybody. Most of the people are still having problems. And so we're just pretending that we're treating the problem when it's actually just still there. Uh, and people are still suffering even though they're maxed out or they're trying it or they're trying the new ones, the the latest one and trying the best one to see if they can get a better result. So, by the end of the hour, you're going to know the difference between ordinary heartburn and the five conditions that mimic it. Uh, we're going to talk about the five warning signs that mean stop taking the pills and start getting checked out and get scoped and looked at and see what's going on. Uh, we're going to look at what's actually causing the reflux and whether it's something a pill can fix or you need something else and what to ask your doctor at the next appointment. Okay, this is important because uh over the last 40 years there's been a five-fold increase in the diagnosis of esophageal cancer and esophageal cancer is a big deal and a big problem. Um most of the people that get it aren't alive at 5 years. It only has about a 20% 5year survival. So so by the time it gets found it's usually very late and there's there isn't that much we can do big operations chemotherapy. Uh but even still with that most people don't end up surviving long. Yes ma'am. What's the main cause of that? We're gonna talk about it. We're gonna talk about it. So in the past most of the esophageal cancers uh that were found in the world were called squamus cells. It's a type of cell that's a cell that's normally found in the esophagus. In the last 40 years all of a sudden it's become adenocarcinoma which is the cell found in the stomach. And the reason that that's happening is because we're having such increases in reflux, such increases in obesity that all of that stuff is is going refluxing up into the esophagus, causing changes and and causing increases in that new type of cancer that we weren't seeing before. Okay. So, I want to talk to you about a a patient of mine. Uh I'm going to call him Dave. He was 52 years old. Big guy. He was worked as a trucker. Um he carried his uh roll of Tums in the in the car in the glove compartment. So he always had it with him in case he had an attack in the daytime. And at night he was taking his his PPI, his acid reducer uh was in the medicine cabinet at home. And he took them religiously for 11 years. Uh you know, he go back, see the doctors, get refilled, go back, you know, and and he was doing pretty well with it. um until all of a sudden he couldn't tolerate the chicken was getting stuck in his throat and then it was bread and then it was rice and when by the fin the time they someone finally take took a look in there they found a cancer at the bottom of the esophagus right at the top of the the stomach. Um and that was blocking the the food pipe from emptying and not allowing him to eat. Um so major resection major you know chemotherapy afterwards a big deal and like I said a very low chance of fiveyear survival for him. Um, and it's not that anyone made a mistake. Everyone for for those 11 years, three different doctors saw him. They kept refilling his medicines. And at every visit, the decision process was correct. But it's just that no one looked at the overall picture and saw that the risk was increasing increasing over time and decided to take a look and see, you know, could there be anything else besides regular reflux that was a problem. Um, and so, so this is what I want to try to avoid and that's why I want to tell you a little bit about him and and what what uh gets to that point. So, where where are we going to go? We're going to talk about what reflux is, what it isn't, where it comes from, you know, why people get it. We're going to talk about what a hyal hernia is, okay? And and how do you get it and what it means and how it actually causes reflux. We're going to talk about the five warning signs that I mentioned earlier and what what you should be concerned about if you're if you're sensing any of these things and and go talk to your doctor about let them know. We're going to talk about the pills and the different medicines that there are and how they work and what they do and what they don't do. Um and that way everybody gets in a better idea of what's going on with that. And then we'll talk about the different procedures for the patients that do require procedures for this for this uh disease. Um what there is out there that we can do. And then we're going to talk about the imposters. We're going to talk about the five other issues. Uh really that we'll break it down into four, but the other issues that can that can seem like reflux that aren't necessarily reflux and might have other treatments that have to get done. Okay, so let's get started. So you have two valves at the bottom of your esophagus, not just one. Um the the blue valve there is the lower esophageal sphincter. That's a ring of muscle that goes around the bottom of the esophagus. kind of squeezes down and prevents the acid from just coming up into your chest all the time. Then you then the one that people don't recognize is that the diaphragm itself is a muscle and where that esophagus crosses through the diaphragm, the muscles squeeze of the muscles of the diaphragm squeeze on that esophagus and provide like an extra clamp on the outside kind of like a hand on a garden hose. So, it's it's two muscles, two rings around each other, and that's the what provides the valve so that all the acid dust doesn't come up into your throat and into your mouth and nose and all that when you when you lay down or when you bend over. Um, so it's a disruption in this that's going to be a problem that we'll talk about. So, there are three ways that that door opens. The first one is naturally it pops open on its own. When you swallow, at the end of the swallow, it opens up to allow the food to go through. And sometimes it just gets opened on, you know, when it gets weakened, when the muscle ring gets weakened and it just allows the stuff to come up. Also, when when you burp and the pressure goes up, it will open up, allow the air to come back out so that you can feel the release relief of the burp or when you vomit, the same thing. And then the last one is the two valves get pulled apart. And we're going to talk about that in a little bit. And that's what a hyo hernia is. So when the two valves the neither valve is very strong and the only way they work is when they're together. When they get separated neither one are strong enough to overcome the pressures that happen in the belly and prevent the acid from coming up in the chest.

So your body has its own cleaning crew. Uh you know getting acid in your esophagus is actually normal uh and physiologic. So we all get acid in our esophagus all the time because the pressures in our abdomen are higher. it pushes a little acid up. Well, that the the esophagus senses it and starts cleaning it up. So, number one is swallowing. Just by swallowing that that produces a paristalsis or muscular flow that pushes everything back down into the stomach. So, that gets rid of the majority of the acid that gets up into the esophagus. Then you have a saliva. saliva itself, it doesn't really dilute the acid with the water in it, but the bicarbonate and the phosphate in the saliva will actually um neutralize the acid and and make it feel better. So, that's why if you drink water, it doesn't necessarily make your heartburn get any better. Uh but the saliva itself is is doing that for us all the time. And I put up a bonus tip. If you're suffering from reflux, if you chew sugar-free gum after all your meals for about 20 30 minutes, you produce extra saliva, extra by carb gets sent down into your esophagus and helps kind of neutralize the acid a little bit. May not it may not take care of all of it, especially if you have a overwhelming amount of reflux, but it'll help with a little bit of of the physiologic reflux, so the acid doesn't sit there as much. Um, and then the lining itself also protects itself. It has a muc mucus barrier that helps protect itself from acid. It also produces about 25% of the bicarbonate that's in the esophagus comes from the lining itself. Uh so it works to to protect itself and when that lining kind of gets weak and and permeable then that increases the risk of of sensing the amount of acid that's in that esophagus. Yes. What would the make the lining become weaker? So what can make the lining become weaker? A bunch of different things can do it. Uh it can be an autoimmune disease. It can be pills. So certain antibiotics can really irritate that esophagus. Uh iron pills also irritate the esophagus. Um several other medicines can do it as well. Um and chronic reflux will irritate the esophagus and wear down that lining to make it weaker and then make it more sensitive to acid as it comes back up. Yeah. It's a cycle that gets worse and worse. It's like a snowball rolling downhill, you know. So a normal endoscopy for those of you that have had it doesn't mean you have reflux. I mean it doesn't mean you don't have reflux. So some people think oh my scope was normal I'm I'm cool I got nothing. No about 60 to 70% or six out of 10 pe patients who have normal endoscopies really have reflux. Uh it's just that the endoscopy only looks for damage from the reflux and a lot of the patients don't have dam visible damage that you can tell. Um, and then three out of 10 will have visible irritation either with with some gastritis, but mainly is we're looking at esophagitis or inflammation of the esophagus that uh we see in about 30% of patients. And about one in 10 or a little bit less than that will actually have damage to the lining or changed lining where the cells change from that squamus cell, the squamus epithelial cell to an adenomous cell. they just it changes the shape and it changes the function and those adenoma cells are different and those are precancerous cells up in the esophagus. Okay, so camera's a good way to find damage but it's not a great way to diagnose reflux. So if you think, oh, I just need a scope to see if I have it. No, it's not great for that. It's look to see it's good to see if you're moving on to the next steps of of damage. So and reflux isn't just heartburn. a a significant percent probably 25 30% of patients who have reflux do not have heartburn. Okay, they call it silent reflux sometimes if they don't have any significant symptoms but it can show up with a lot of other types of symptoms. So the two classic heart two classic reflux symptoms are heartburn and regurgitation and regurgitation is a sensation of fluid going up into the chest or esophagus. And some people feel that when they bend over and they tell me, "Oh my god, it comes out my nose." Uh or when they're laying down at night and you don't have gravity to kind of keep it down. Um they feel it coming up into the esophagus and chest. Uh so that's those are the two classic symptoms for reflux. Then we talk about the atypical symptoms of and and chest pain. I'm sorry that isn't from the heart. That's part of the heartburn type symptoms. And then we go into the atypical symptoms of reflux that happen a little bit less commonly. things like chronic cough, horse horarsseness of the throat, especially in the morning after a night of the acid bathing the vocal cords, uh worsening asthma because sometimes acid will get up into the lungs and irritate the bronchial tree and cause asthma. And then the enamel wearing off the teeth just from having acid in your mouth overnight. Yes. And how do you know the enamel is wearing off the teeth? The dentist, how do you know the enamel's wearing off the teeth? The dentist will tell you, you know, dentist is going to say, "Wow, you have to ask the dentist." You may have to ask, but I would assume that most of them are going to tell you, "Hey, your teeth aren't looking good. They're looking weak. The enamel is not looking good." Um, so it it would be the sort of thing if you haven't heard it from your dentist and you're good about going to the dentist, probably not going on with you. Probably not an issue, but you can ask them the next time you go for a cleaning and see what you see what they say. Okay. Um, and then possibly linked, but a lot of times it's something else. So, so we can't always say it's from reflux is sinus trouble, sore throat, ear symptoms, constant throat clearing and lung scarring. Actually, when I was at the university, we were doing a lot of uh surgery, reflux surgery for patients that had lung scarring and they were moving towards uh lung transplants because they at nighttime they were getting so much aspiration of fluid from the esophagus up into their lungs that it was causing scarring in the lungs and they were having difficulty breathing. And the lung and the lung quality was getting worse and worse. Yes, ma'am. And how do you how do you detect scaring the scaring of the lungs? You have to go see a good pulmonologist to to detect the scarring of the lungs. And it's going to be the sort of thing you're having shortness of breath. Uh and then they'll do they'll do X-rays, they'll do CAT scans, they'll do pulmonary function tests to look at that. Yeah. Okay. So, some people have all the damage and don't have the any of the burning. So, remember burning doesn't happen to everybody. [snorts] So it's not, you know, some people think, did I do this to myself? They ask me concerned, you know, is this something I did? Well, there are some things that people do that that cause reflux and there are a lot of things that you you can't affect that cause reflux. So, you know, your genetics, um, some people just have genes. Your it's known to run in the family. So, if your mom and your aunt and your cousin all have reflux, you have a higher chance of having reflux. Uh, age, as you get older, people tend to develop more reflux. Okay. I'm starting to get heartburn where I never used to get it before and it's horrible but uh but age is a is a risk factor for developing reflux. Uh gender females tend to get more reflux than men. Don't know why. Um and congenital defect. Some people are born with hyal hernas and some young babies unfortunately have to have surgery at the beginning because they have such bad reflux uh from their big hyal hernia that that they need to get operated on in order to to thrive because they can't eat when they're little kids. So those you can't fix. But the ones you can fix reducing belly fat. So losing weight and reducing belly fat which puts pressure on the on the chest on the abdomen which push pushes up on the chest that does help decrease your your risk of reflux. And any significant weight loss actually can decrease your risk of reflux by almost 40%. So it's a big it's a big this is the biggest thing you could do to help reduce your reflux is lose some lose some weight. Stop smoking is another one. Smokers do have more reflux. Um, it's known that that you get irritation of the of the lining of the esophagus in the stomach, but in addition to that, the mus the muscles of the bottom of the esophagus tend to be a little bit weaker in smokers than people that are non-smokers. So, the smoking tends to let that esophagus open up more. Uh, regulating your meal times. So, having large late meals also increases your risk of reflux because then you go to bed and you have that big the high pressure inside the stomach that's pushing and it's more likely to go up into the chest. um managing your your caffeine intake. Caffeine also causes relaxation of the of the sphincter. And so more than two cups a day has increased the the risk of reflux. Okay. So decreasing caffeine, increasing physical activity. It's known that that also helps the decrease in improves muscle tone. It also helps with gastric emptying. So it gets your stomach emptier so there's less pressure pushing up. And medication management, you know, um some of the medicines that can cause reflux sometimes need to be changed around for that. So in the one large study, you know, five habits accounted for about four out of 10 cases. And so the first five are the big ones. But like I said, losing weight seems to be the the biggest risk factor and the biggest thing that you can do for helping the reflux. So what's a hyal hernia? A hyal hernia is when the two valves get separated. So we talked about it already. There are two valves there at the bottom of the esophagus. When they get pulled apart, that's a that's by definition a hyal hernia. So you see up here, let me see. That doesn't work. Yeah, there it is. No. Uh, that that blue valve gets pushed up, the bottom of the esophagus gets pushed up and you get a little bit of stomach uh up into the chest and that separation is what causes the hyal hernia. Okay. Uh, and that or that's I'm sorry, not what causes that's what is a hyal hernia. And then so I'm going to show you Oh, good. You go you don't have lunch yet because I'm going to show you some gross some gross pictures. So I didn't want to gross you out if you already had lunch. But u this is what a hyo hernia this is what it looks like in in real in x-rays. So this is a normal esophag where but the patient swallowed some contrast and you see the esophagus filling all the way down to the diaphragm here where it starts getting dark because this is the belly and this is the stomach bubble of air and there's nothing above the diaphragm of stomach. All the stomach is down below the diaphragm. This is one of my patients who had a humongous hyal hernia. [snorts] And what it is is that this is all stomach here. The diaphragm is this white line down here. So all of this stuff is not supposed to be here. The the bottom of the esophagus is way up here and the stomach is kind of smooshed way all up here. Um, so this is a huge hyal hernia and you can see the contrast kind of getting stuck up above the diaphragm because it can't empty well when when a pouch is stuck up there. But don't you eat less because of that? Um, some Yeah, people a lot of times have have a hard time with huge hyalo hernas. They eat less because they get full quicker. U, but it's not a positive thing. They also get shortness of breath because when that stomach distends, it squeezes on the squeezes on the lungs so they can't breathe as well either. uh and they get a lot of reflux because the valve is all messed up. And in her case, she had come into the emergency room because her stomach had flipped on itself and was obstructed um and could have died. So, this is one of the long-term complications of huge hyo hernias is a gastric vvulus where the stomach flips over and gets obstructed and then the blood supply gets cut off and the stomach can actually die. It becomes a surgical emergency. Okay. So, I So, you had to operate those? I operated it on her. Yeah. Yeah. Actually, I saw her in clinic uh recently and she looked great. She was so h she came in all happy and smiley, saying she was eating better uh and feeling a lot better and more energetic. Wow. Yeah. Okay. So, I'm going to show you what it looks like endoscopically. So, this is on the inside when we put a scammer camera in here. We're doing a Uturn. We're turning the camera back so we're seeing the camera. There's a U at the bottom and we're looking back up towards the GE junction or the bottom of the of the esophagus, top of the stomach. And so this is the fundus or the very top of the stomach. We're going to talk about the fundus in a little while. And then this is the valve there. You see how it's nice and tight around that esophagus? How there's no opening? How everything is nice and tight there. So you can imagine that that works well to squeeze down and prevent acid from going up. This is a patient with a hyo hernia. So you can see that the esophagus is wide open. The hole is right beside here. You can look way on up into the chest into the esophagus and you see the esophagus tissue actually actually looks different. Looks whiter than the than the peachish uh color of the the uh yeah the peach color of the of the stomach. Um that's squamus epithelium versus adenoma cells. Okay. So this is a woman with a significant hydro hernia. It's not the same patient but a woman with a significant hydro hernia uh where her esoph was so wide it wasn't squeezing around the esophagus. So the esophagus just got big and dilated and floppy and allowed the acid to go up and down through into the esophagus. Okay, I'm going to show you now a surgical picture. And unfortunately, because I had forgotten to look for it, I didn't find the one of a normal one. But this is what a hyal hernia looks like laparoscopically. Okay, this is a diaphragm right here. This is the diaphragm. The liver is right here in the corner. We're lifting it up with this instrument with this stick kind of getting it out of the way because the liver is really in the way here. And then down here is the stomach. Well, where the stomach should be sitting down in the belly. This opening here is a humongous hyal hernia. And half the stomach is up into the chest here. Normally, this is closed. The whole thing here looks like just like this. And there's a tiny little opening where the esophagus is and the entire stomach is down here. But in this case, half the stomach herniated up into the chest. And what we're actually looking at, so you get an idea, when we do surgery, we have to bring all this stuff down back here. This is the bottom of the heart. Um, because the heart is anterior to the area where you get a hyo hernia. So everything is very close. And then on the sides, you can't see it here, but on the side here and on the side on this side, on the back side of the diaphragm are where the right and the left lung are. Okay. Did I gross you out enough? Was it good? Was it good you weren't eating yet? Yes, ma'am. What was that yellow card? Fat. This is all fat. This is momentum. This is what we call the body's policeman. Okay. This is the abdominal policeman. The the This is the fat inside our abdomen, which is normal to have some fat. You don't want to have a huge amount, but to have some is normal. And if there's ever any infection or any inflammation in the abdomen, that that fat will kind of work its way over and sit on top of it and kind of hold it down like a bouncer at a bar until the infection goes away. It kind of surrounds it and the inflammatory tissues kind of surround it and it forms an an inflammatory ball uh so that it just doesn't spread through the whole abdomen. So it's it's the body's policeman. Okay. All right. So it gets a little bit more complicated. I mean there are four types of hyotal hernas. Okay. 95% of them are type one which is basically where the two valves get separated usually by a few centimeters. Um and and the top part of the stomach kind of sneaks on up into the chest. So the GE junction which was normally down here at the diaphragm gets pulled on up and you get a little bit of stomach up above. So this is a sliding hyo hernia and like I said that's about 95% of the hernas that are found. The other 5% are the types 2, three and four. Type two is a parasoph they're all these are parasophageal hernas and par esophageal around esophagus. So in the type two the esophagus is all the way it goes all the way to the abdomen. So the GE junction is in the right place but a little piece of stomach snuck through the hole where the esophagus was supposed to come out of behind it or around it and went up into the chest. Okay. So that c that causes problems because that food gets stuck there and the patient feels the pain, discomfort. It can cause ulcers and bleeding and and issues there and may may require surgery. Then type three is a mixed hyalo hernia which has both a sliding component and the parasophageal component with the top of the stomach getting up in there. And type four is a giant complex one which is all of it's a type three plus another piece of organ. So, I've I've operated on people that have had uh the whole stomach up there plus part of the colon or plus part of the small intestine. Um there reports of the spleen getting up in there a little bit. Um so, part of the pancreas can get up there. So, a bunch of different things can get pulled up into that space if it's big enough and chronic enough and has been there long enough. Yes, ma'am. Once you do surgery, it will repeat itself because will it recur? Will it recur? Good question, and I'll tell you in a few minutes. [laughter] We're going to get to it [sighs] this way. I keep you paying attention. All right. So, why does a hernia cause reflux? Okay. I mean, we've kind of talked about it a little bit. The two valves get separated and when the valves get separated, they're both weaker than than they were together. So, that so the fluid goes through much easier than it did before. In addition, you have a little pouch of stomach up above that's kind of obstructed. So the acid kind of gets up there, stays up there, and then the the valve is messed up. So then it just goes here and goes up and come down and gets stuck here and goes up and comes down and gets stuck and goes up. So it just kind of goes through that little circle and keeps increasing the amount of acid that goes up there. So So having that pouch up there makes a difference. And then every time you swallow, it just opens right up and goes right on up because it's it's separated away. Oh, and then same thing. This is why, and I talked about it, this is why your big meals are worse because you lay down right afterwards, your stomach is full full of pressure and it pushes everything up into the chest. Okay?

So, people always think it's the size of the hernia. Oh, I don't need to do anything because my hernia is small or oh my gosh, I need surgery because my hernia is big. You know, they told me and said the size really doesn't have much to do with it at all. Uh, it has a little bit to do with recurrences. Okay? If a hernia is greater than five centimeters in size, the chance of it coming back is about 354%. If the ch if it's less than 5 centimeters in size, the chance of it coming back is about 5 to 10%. Okay? So has to do with recurrences, but not for not for deciding necessarily who gets surgery, who doesn't get surgery. So a small hernia that's causing a bunch of symptoms and the medicines haven't helped, we talk about surgery. So you could have a 1 ccimeter hernia, you could have no hernia and still need surgery because you're having a lot of reflux symptoms. So you don't need to have a hyo hernia. So the size doesn't matter. If you have a decent size hernia, but your pH test is normal, you're not having symptoms. Most of the times I'm going to probably leave it alone. There's there's there's other indications to operate on a hyal hernia, but for reflux, it's it's not an indication. Can't you push down and make it go back? Can you push the hernia back down? Just like you do in the groin and the belly, right? And the belly button. You can do all that. Where are you going to push to push your esophagus back down, though? There's no place because it's surrounded by the ribs. So, you can't there's no way to get it back down. What helps is standing, you know, walking because gravity pulls everything down. Okay? You're not going to be able to push it, but gravity will pull it a little bit. But if it really gets stuck and it's really big, it may not it's probably not going to reduce completely. You'll probably just get a little bit of a reduction. And I see that when I put patients in the operating room, when they're laying down, they're flat um and we lift up the liver, they may have a whole bunch of stuff stuck up in there, and when I get the anesthesiologist to stand them up as we do these operations kind of standing, a lot of the stuff starts falling out. Not everybody, not everything because a lot of the stuff is stuck in there with the scarring, but a the extra stuff tends to start coming on out. You do the surgery with the person standing pretty much. I tell anesthesia, stand them up like if they're walking out of here. So, we do it probably on the table on on the table. They're probably at about 21 22 degrees. So, we put footboards on so they don't slide down. We put straps. We have them all tied down. But it's easier because it gets the part of operating laparoscopically is you need to use gravity to help you so you get space and by mo by using gravity and sliding everything down we get a little bit just an extra inch or two but that extra inch or two makes a world of difference and gives us the space we need to operate. Yeah. All right. So and then you have to actually prove that it's reflux. I in the old days and and there's still I'll tell you honestly there's still some surgeons who operate on patients for reflux without proving that it's reflux and I hate it because sometimes they're going to operate on things that aren't reflux and at um you know in my previous uh job and here now since I've been doing a lot of reflux surgery I get a lot of patients that had surgery that did it didn't make them better and it's because they probably didn't have reflux to begin with and they went on the symptom of heartburn and again the imposters kind of surprised them and got them. So I test everybody to make sure that it really is reflux before you get surgery because I I always tell you you know I always tell patients I want to make you better not make you worse because with any surgery you have a chance of making somebody worse. You have a chance of a complication. So we want it to be to work out well and so we try to stack the deck in our in our favor before we ever operate. Okay. All right. So who who actually needs surgery for reflux kind of these you know I try to tick these three boxes. one, are they having symptoms? Is it real, ongoing, and affecting your life? Um, I tell my patients, my best patient is a miserable patient. The one who comes in and says, "Doctor, I'm miserable. I I can't live. I can't sleep at night because everything's coming up. I have heartburn all the time. I'm scared to miss a medicine because if I miss it, I'm the symptoms are going to be horrible. So, I, you know, when I go on a trip, I'm scared I'm going to forget my pills." Um, you know, those are awesome patients because the next day when I walk in to see them in the morning, they're all smiles. They're like, "Oh my god, I was able to sleep last night. I didn't have burning coming up last night. I This is This is the first time I've slept in 20 years like this." So, those are the best. The ones that are the worst are the ones that we're operating on that have little or no symptoms because how am I going to make you feel better? It's going to be hard and I have a chance of making you feel worse. Okay? So, we'll talk about some of the stuff that can happen. Um, so symptoms is important. Proof, I already told you proof is super important. I think I think everybody needs proof before they operate especially nowadays when it's easy to get proof and then that the medications failed that's the first step for most people is you try the medicines and if the medicines are doing well um there is indication to operate on people even there are several indications operate on people even if the medicines are doing well but usually it's because they don't want to take the medicines you know they're they're scared of complications of the medicines that we'll talk about they're scared of taking them long term uh or they've had allergic reactions or or they have other reasons They just don't want to take them for life. Yes, ma'am. I'm sorry. Maybe you said it. I missed it. What is the test you do for the proof that you have the You guys are You guys are anxious. You're getting You're getting ahead of me. I promise I'll get there. That's a good question. And I and I'll get there. I'll get there. Yes. Is there a relationship between people that have gastritis and reflux? Is there a relationship between people have gastritis and reflux? They Yes. they there is a relationship but not necessarily causal. Um and it may just be that they have because you do not have to have excess acid to have reflux. Okay? It's just reflux. It's stuff coming up. So you may have a normal amount of acid. Um but you can have reflux symptoms, heartburn, and it be esophagitis and not necessarily be a lot of reflux. And a lot of those are associated with gastritis because sometimes the meds that cause inflammation of the esophagus also cause inflammation of the stomach. Some of the autoimmune diseases can cause inflammation of the esophagus and the stomach. So they're kind of associated but they're not the same. And so when patients tell me, "Oh, I've had gastritis for years and I'm taking my, you know, acid reducer." Well, great. But the, you know, is it affecting your heartburn or not? Because I don't I count it as a different disease process. And you didn't mention as a cause. Yeah. Stress. Is that a factor? Yeah, stress [snorts] is a big factor for for people. Um the the brain stress, anxiety, all of those things, depression, they all affect the GI tract. The way it functions, the way it empties, uh the way it squeezes, the amount of acid that you produce, all of that is is affected and hard to quantify though. It is hard to quantify. And so, but it does play a role. And and there are certain disease processes with reflux or heartburn that we treat with meditation and behavioral behavioral modification and anxolytics and things like that even anti-depressants because it makes them better. So yeah, some of some of them it is related. And can't you have silent reflux? And that's even more serious. You can uh so silent reflux can happen about 25% of the time. And why is it more serious? Because you don't know it. Because you don't know it. And you're getting the damage without even knowing it. Without knowing. Yeah. So that's that's how people show up first time with not being able to swallow because things get stuck. Yes, ma'am. What is gastritis? Gastritis is inflammation of your stomach lining. Same thing as esophagitis is of the esophagus lining. And it it's not necessarily from acid. It's not necessarily from acid. It can be it can be from a weakness of the lining for multiple reasons. Uh it can be a genetic weakness. It can be a weakness uh from disease process causing a weak uh decrease in the mucus production of the stomach which protect pro protects the lining. Uh it could be autoimmune changes to the lining. Um it could be it can be the pills that you're taking. It could be H. pylori is a huge cause. So bacterial infection is a huge cause. So it could be a lot of different things but it's not necessarily acid. acid. It can cause the inflammation, but but it's not the cause of the gastritis. It's not what happens. There had to have been a weakness in that lining wall for the acid to affect it because the stomach is made to have acid in it and not made to have a ton of acid in it and not get affected. Okay. All right. So, if a hernia is found, what do we do? You know, type one hernia, are there symptoms? No. Leave it alone. If there's symptoms, you got to prove if it's reflux off medicine. If it's not reflux off medicine, look for another cause. If it is reflux and PPI's failed, surgery. If it hasn't failed, probably just sit on it and not do anything. Okay? So, there are there are ways type ones get to surgery, but you have to like have proven it and medicine failed to get there. There's otherwise there's no reason. Whoops. There we go. Um, types two, three, and four, it depends on the anatomic type. Type four we normally repair because things can get stuck. You can get incarceration and strangulation of tissues stuck up in that big hernia. Um types two and three if there are symptoms. Yeah, you repair them all. Okay. If there are no symptoms, the experts disagree. There's a little bit of to disagree here. Some people say they should be fixed because they can progress to type four. Uh but the progression to type four is actually 1 to 2% a year. So it's pretty, you know, or having a major complication is pretty low. Uh but uh so some people say, "Yeah, you should fix it." Others say you don't. There's no big consensus on the on the major societies as to what to do. Okay. All right. The part that nobody puts in the brochure when they when they're when they're selling you the uh beachside condo. Um you know, it's the hernas can come back. So we talked about it already. You know, if they're over 5 centimeters, it can be over, you know, almost about a 50% comeback over uh over time. And if they're under five, it's pretty rare. You know, le less than one in four. uh really you know it's it's about 10% at at 3 years and then um most of the times when they come back it's not necessarily that you have to go back to surgery. Most of them can don't have any symptoms. Occasionally they do have symptoms and you can treat it medically and you don't need to do anything else but about 6% will need to be reoperated on. Um so it's pretty uncommon. Um, unfortunately that's been a pro a big part of my practice is operating on people who've had surgery before sometimes multiple times uh that for that have had complications or issues or recurrences of their symptoms. Um, but then you you know talk to the surgeon before the surgery not after so you're not surprised and so you understand other things that can happen bloating. People get more bloated after surgery because the gas can't come out as easily as it did before. while when when when you had the valve that was open, it was easy to burp and get everything out. Um, also difficulty vomiting after some of these surgeries is hard to vomit. Some patients will develop diarrhea uh because of injury to the nerves around the esophagus. It can cause the the rest of the intestines to function a little bit weird and cause a little bit of diarrhea in a small percentage of patients and even pancreatic issues. You can have pancreatic insufficiency in some patients for some of the nerve supply changes after surgery. So, a lot of different things can happen and it's a trade-off that you have to make, you know, then that's why you don't operate on every single person just because they have a hernia. You know, you have to see are you willing to trade some some, you know, the heartburn and regurgitation for potentially having some of these other side effects postoperatively. And that's why I said I, you know, I I'm more hesitant to operate on people that feel great because I have a good chance of causing something with them. So, five red flags and this is, you know, something that you guys need to know. Um, one, food sticking or trouble swallowing. If it's never happened to you, you would think like, "Wow, yeah, if that ever happened to me, I'd freak out." But if it's happened to you, people normalize it. And there are people that have had food sticking in their throat or difficulty swallowing for years and they never do anything about it. They just kind of like, "Yeah, this is the way I am." And I drink a little bit of water, I get up, I hit myself in the chest or whatever. Um, and so, but it's not normal. Okay? It's not normal. So, you just know that. uh weight loss you didn't try for. So, you know, if you're losing weight and you didn't mean to be losing weight and you don't know why, that's something you got to look at. Vomiting blood or black tar stools. So, any blood in the GI tract is an issue uh that you got to be careful for and you got to look out for. Okay. Ongoing vomiting. So, if you start throwing up and continue throwing up and having difficulties, of course, you got to get into the emergency room or get to the doctor and be seen right away. And then heartburn that suddenly gets better after all the years without changing anything. Uh that's one of the things I didn't mention when I was talking about Dave, you know, uh before he got diagnosed, he'd lost like 14 pounds and he was happy. He thought it was the walking that he'd been doing. Um and also for the last year or two before he got diagnosed, his heartburn actually got a little bit better. And you know, he didn't know he thought it was the meds just working better than it had been before. But what can happen is when you get the change in the cells those those um adenoma the the u adnocarcinoma or adno cells that aren't squamous cells are less sensitive to acid. So you feel the acid less than you did before. So heartburn that's getting better and you haven't changed anything is a concerning factor and should get should get checked out and that's one people miss all the time. So what what does a normal starting point look like? I mean, heartburn is so common. Not everybody jumps into surgery or jumps into, you know, everything. But what do you do? Well, if you have classic heartburn and no red flags, normally the recommendations start eight weeks of a of a proton pump inhibitor, an acid reducer every day. Okay? One of the things that I learned a long time ago, people take these medicines wrong all the time. So, three big classes of medicines, actually now there are four classes of medicines, but the the three that everybody knows about ant acid like a TMS and a rolates, right? um the the the histamine blockers, the H2 blockers like Tagamet uh and uh Zantac that used to be they got rid of Zantac but Tagamett and then the third one is PPIs or proton pump inhibitors like omerazol, pantopresol, esomerazole. There's a bunch of different ones there's like about six or seven that I know about. Um and those those are daily those are and they they work at decreasing they significantly decrease acid production of the stomach. So the ant acids work like this. You take them and it's like a chemical reaction in a chemistry lab in a beaker. You're pouring something on the acid that helps neutralize it. So if you're feeling heartburn, what should you take? An acid. I love gavascon. The gavascon is is the only one that will sit on the top layer of the stomach and kind of coat to prevent the acid from coming up. Uh so it works even better than Tums. So gavascon works great, but Tums you can also chew and and get the Tums in. Um, and uh, so that's that's immediate effect, short lasting, goes away because it's a chemical reaction, goes away when you're done. The histamine blockers work in about two hours. Okay? So if you're taking your tag and you think that it's helping you with the heartburn, it's really not. What it's doing, your heartburn is just going away with over time. Um, so the tag works better. You can take it in the evening time if you get evening symptoms frequently. Uh the problem is if you take these every day, you get what's called tacifilaxis where they stop working well. So so you have to kind of take them kind of intermittently for them to have any effect in the long term. Okay? So your body has to get off of them sometimes. But the other ones, the PPIs, and I love this because I hear it every day in clinic. Oh, when I get heartburn symptoms, every once in a while I'll take a a pepsid. I mean, I'll take an amezol and it gets rid of my heartburn. And I'm like, no, it doesn't. A merazole takes 24 hours to work. So, and it significantly cuts out your acid production, but in 24 hours, your heartburn's gone on its own. Okay? So, if you get if you're the Omerazol is not a pill that you take as a as an ad needed thing. So, if you notice when they sell it even without prescription now, they sell it as a twoeek course of 14 pills or 28 pills or something like that. And you're not supposed to take it uh you're not supposed to take it one and every once in a while because it doesn't do anything. Okay. If you have recurrent heartburn more than two or three times a week, you should be on one of these pills to help control it. If you're having occasional heartburn, ant acids are the best way to go, okay? Uh because it'll work a lot better, a lot quicker for you, and a lot more reliably. Um so, you try an 8week trial of a daily acid reducer and then a real attempt to come off of it and see what happens. If you if it was just episodic, maybe it was a bad stress time, maybe you developed some esophagitis from something that had that had upset your stomach, uh you get over it and you're done. You're done. Um and oh, the yeah, you got to time the medicine. Take it 30 to 60 minutes before a meal and not at bedtime. Some people take it twice a day, which is okay if you have to go to twice a day, but the best time is in the morning before your meals. Okay. Before breakfast. And then a barerium swallow is not the right test to diagnose reflux on its own. I hardly ever send anyone for an upper GI series, but all the medical guys do. I don't know why. They love it and even a bunch of surgeons do. Reflux is horribly diagnosed on on an upper GI series. They diagnose almost everybody with reflux and I'm finding that it's not correlated to symptoms at all. So, I I never use it. I use other tests. Okay. I'll use an upper GI series to look at hyo hernia to see how big it is or to get some other ideas of anatomy, but not for reflux. So, when do you need to get scoped? You need to get scoped if you have any red flags. If you've had reflux for years and have never been scoped, uh because the risk of complications goes up with more years of reflux, okay? And as you get older, if you're over 50 with new or worsening symptoms because again, age we talked about being one of the risk factors. So, any change in someone who's a little bit older needs to be checked out. Your reflux isn't controlled after a proper 4 to 8 week trial. So, if it didn't get better, you know, the PPIs are really darn strong medicines and they do get rid of the acid. So, if your if your reflux isn't better, then you got to look to see what was really causing it. And then if your doctor's considering a procedure or surgery, you you got to get scope because we have to look at the anatomy and see what's going on. Okay. All right. What do what do I ask for in the reports? You know, were biopsies taken? If not, why not? Was I on my acid reducer during it? You got to think about that. Did you see a hyo hernia? How big is it? but also what type is it? You want to know that whether any irritation, ulcers or narrowing and what does the valve look like and where the tube meets the stomach. So all of that helps the surgeon or anybody who's going to plan a procedure to get a better idea as to what's going on. Okay. Yes. As a patient, yeah, we don't know who's a good doctor and who's not. And you mentioned several times that other doctors use for diagnosis or for treatment things that you don't like, you don't recommend. So, I'm a pain I'm a pain about this, but normally you go to somebody who's a specialist. So, most of the gastronurologists are better than the primary cares. They understand it better. Unless you have a primary care who's really done a lot of of learning on the topic, they're they're not going to know as well. So, if you've had issues, go see a gastronurologist and start there. So, so specialists will do the right thing. The most of the specialists will do the right thing. Yeah. But the great majority of PPIs are not prescribed by specialists. They're prescribed by primary care. And you get a second opinion and a third. Yeah. And you guys look around. Look around. Okay. All right. I'm gonna I'm going to rush because I'm actually way behind. I'm realizing that we've been we've been talking a lot and I've been talking way too much. So, the other two tests, we do acid acid monitoring and pressure testing, motility or monometry. Okay. I always apologize to my patients when I send them for these because they're uncomfortable tests. They have to put a catheter down your nose and have you swallow some water while while the catheter is there to look to see how it works. But without this, we haven't proven you actually have reflux and we don't know how well your esophagus works. Okay. All right. So, what actually works? You know, I you hear a lot of things online and everybody talks about things and they tell you to do all these uh cleanses and all that stuff. None of that stuff really works. Okay, this is the stuff that works. Losing weight, number one, like I said, that's the strongest thing on the list. Number two, not eating anything for two to three hours before you lay down. Number three, raise the head of the bed six to eight inches. And laying on your left side actually helps decrease the acid that goes up into the esophagus as well. Laying on the right side increases the acid that goes up into the esophagus. Okay. Um it's raising the head of the bed with blocks or a wedge pillow. Putting extra pillows behind your neck, all it does is bend your head forward and doesn't help raise your chest. So wedges or blocks under the bed. And then quitting smoking. It's another big one. And then avoid your own trigger foods. your trigger foods. You have to find out what they are. There's a big long list. You caffeine, chocolate, wine, uh alcohol, tomatoes, pizza, all all that stuff. If it doesn't trigger you, it doesn't trigger you. If it does, it does. You know, no need no reason to sacrifice everything. Um just you try it out and see what what effects it has on you. Yeah. And this is this is what it is that you have to find what the trigger food is. Too many patients are really restricted in their diet and avoiding foods that do not trigger them. So, you got to find out what triggers you. So, what the medications do, we went into it already. I'm not going to spend more time. And the goal is the lowest dose that works for the shortest amount of time that works. It's not to stay on this forever. Um, but occasionally some people have to, but that's not that's the goal is to get you off. Are they dangerous? How many of you guys have read stuff online or or read the articles about omerazol being linked to heart attack being linked to bone disease? Well, bone disease, kidney disease, dementia, early death, you know, all that stuff. So, most of it is not proven. This is a relationship seen in big epidemiologic studies. They haven't shown any causation at all. The only ones that look like there might be something to it are certain intestinal infections like uh claustrdium deficil infections of the colon um low magnesium levels a specific nephritis or kidney inflammation and uh osteoporosis or or some bone some bone weakness. So those things can be affected. U but even though they are you do not the recommendations right now are in general unless you have symptoms you don't need these tests. You don't need bone density scans. You don't need B12 testing. You don't need routine kidney monitoring because you're on a PPI. Should you get them for other reasons? Sure. It's not telling you not to do them, but because you're on the PPI is not a reason enough just to get them. Okay. The problem with staying on the pills long term is not that it's dangerous, is that it's may just may not be enough. It may not be stopping the damage that's going on underneath while you're just putting the tape over the the engine check engine light. So the good news is it's not just pills anymore. Um it's uh and it's not just pills or major surgery anymore. There are different options and I'm going to talk to you about an endoscopic option that's also available. Endoscopy is going through the mouth. So there are some things that we can do through the mouth uh to de to diminish the invasiveness of the procedure in certain patients. So repair through the mouth and this is from Merit Medical. This is something called the the TIFF procedure. with a trans transoral incisionless fundation. And this device is put into the mouth. It looks like a long endoscope. This is the tip of it. And the tip does a U-turn. And the U-turn fires these little tacks and it recreates the valve in certain patients. So what you do is you insert it into the stomach. You look back at the at the top here where there's no valve. You pinch it and recreate the valve with these little tacks. So that makes the valve a little bit stronger than it was before. the outcomes actually look pretty good in a subset of patients that had no or very very small hernas um and that did not have significant uh that wasn't that didn't have complicated reflux. So regular reflux it seems to work relatively well and so that's an option. What we've been doing more often is combining this with uh a laparoscopic repair of the hyal hernia because there almost everyone does have a hyalo hernia and when you combine the laparoscopic repair uh it's a little less invasive than doing the fundation um but it uh but it gives you better re better return on of investment of your time in the risk because it a much better chance of having resolution of the reflux symptoms and the regurgitation symptoms. So keyhole surgery is a funation. We do it all laparoscopically, but basically what we're doing is getting the top part of the stomach, which normally sits over here. We wrap it around behind the esophagus and either do a complete wrap like this one where we suture it all the way around and and create a uh a valve down here or a partial wrap where we go partly part of the way around. And we choose that based on esophageal strength because um a a real a weak esophagus is not going to take a full wrap very well. It's going to be a little too tight for it. So you're going to cause more problems. But so a lot in a lot of patients if we're finding a little bit of weakness in the esophagus, we're doing partial wraps to help with that. Okay. And then there's also the magnetic ring or the lynx device. Uh this is a foreign body that you have to put inside around the esophagus. Um, but what it does is the each of these are little magnets that stick to each other, but they pop open when there's higher pressure. So you stick it right around the bottom of the esophagus here. It recreates a valve and when food so it doesn't allow the acid to come up from the pressure of the belly, but when you swallow the bolus pushes and opens up the valve to allow the food to go through. Works pretty well. works just about as well as a Nissen, the fundations, uh, with a little less uh, problems with food sticking in the first six months. After six months, they're both about equal in terms of patient comfort and and satisfaction. Um, this is newer. It's been done for about the last 15, maybe 18 years. I've been doing it for about seven or eight years. Um, and it works pretty well. Sometimes it doesn't, but it works pretty well. Uh, and some people have asked for this. Okay. So which repair fits me? You know, first you confirm reflux and medication is not enough. If it's a hernia 2 centimeters or smaller, maybe you can do it through the mouth. If it's a bigger hernia uh or you know or has other issues, then either combined repair or laparoscopic surgery or the ring are different options. Okay.

All right. We'll get it to the end here, but the five conditions that mimic reflux or that give you heartburn type symptoms and how to recognize them. Number one is the changed lining barit esophagus. So found in about three out of three to 14 out of every hundred adults with reflux who get scoped. So we find it. It's not completely abnormal. And this is the precancerous change. The good news is if you get this, it doesn't mean you're going to get esophageal cancer. It just means your risk is higher. But the risk is like an uh it's about 14 times higher than normal but it's still only about one and a half percent a year depending on the exactly on the type of of uh barretts that you have. Sometimes higher, sometimes lower. Um and then this is from years of acid causing changes and like I said earlier it may cause actually an improvement in the heartburn symptoms in the in the time that you have it because it's not as sensitive to heartburn. Okay. So who should be checked about it? If you're a man, if you have reflux, long-standing reflux, plus you're a man, should get looked at because increased risk of esophageal cancer. If you're over 50, white, former smoker, former smoker, uh, carry your weight around the middle, and if anyone in your family has a history of Barretts or cancer of the esophagus. So, all of these are increased risk factors of esophageal cancer that someone that has this should consider getting scoped at earlier uh, and more frequently. Just keep track on top of it. The second one is eosinophilic eosinaphilic esophagitis. This is something that's found a lot of times when patients have heartburn and have pain in the chest. Um and it's an allergic inflammation of the swallowing tube and it can be caused by foods. It can be caused by autoimmune disease. It can be caused by u uh pills or medicines. And what we see on endoscopy is this is a normal esophagus kind of you know a muscular tube going down. And here you see one that's ringed. It looks like has a bunch of little rings in it and it can get to the point of scarring down and even stenosis or or tightening of the esophagus. So, this can only be shown on biopsy. Sometimes it's normal. It looks normal. Uh but only a biopsy of the esophagus can tell you if you have it and the treatment's a little different. Ant acids can cure about 50 30 to 50% of it, but uh most people will may require steroids on top of it. Sometimes oral, sometimes topical stuff that that they drink to coat the linings. the muscle one or achillesia. So the thing that I always tell my patients is heartburn can be caused because your the bottom of your esophagus is too loose or because it's too tight. So imagine yours is the one that is too tight. And what do we do with anti-relux surgery? We make it tighter. Right? I really could mess somebody up unless I really look into this. And akalasia can present as heartburn about 25 to 30% of the time because they have a lot they have reflux. And I've had some patients never getting food getting stuck, which is the classic symptom for achillesia, food getting stuck and not being able to tolerate food progressing to liquids. Um but uh but having only reflux as their symptom. So the foul the valve doesn't open and um we treat this not with a true funalation, but we actually have to cut the muscles of that sphincter to let it open up. It can be done one of two ways. either endoscopically for something called a poem or laparoscopically with a procedure called the helermyottomy. Okay, both work very well and they help to relieve the emptying of the esophagus so people can swallow and eat better. Harper reflux that isn't reflux. So functional heartburn or uh acid hypersensitivity. So this is when you feel symptoms and you you're you know it really bothers you but their studies are all normal and it happens in some people and there sometimes you know the nerves are just hyperactive uh sometimes it's other issues it could be stress or anxiety things like that um so these are patients probably 25 to 30% of patients who are treated for reflux or heartburn that don't get better on the PPIs have this okay and so we need to look at other causes but unless you look for it and do the test to see if they have reflux or heartburn or not. You're never going to think about doing this other stuff.

So, three things to do this week. If you've been on an acid reducer for more than eight weeks, book an appointment and ask one question. You know, there think about this. Was my diagnosis ever actually confirmed or was it just the assumption that it's heartburn? Because ah, everybody gets heartburn, you know. Um, if you've been told you have a hydro hernia, figure out the size it is. And remember the size it is two years ago isn't necessarily the size it is now. They tend to get bigger like every other hernia over time. Uh and also find out um if think about if you have symptoms because that's going to make a huge difference. Do you have any symptoms? Do you have reflux symptoms? You know do you have other hyalo hernia symptoms which I haven't gone into things like anemia because sometimes they develop ulcers in that stomach because of the hernia and and they show up as anemia or blood even a little bit of blood in the stools. Um, do you have shortness of breath when you eat or do you have food getting stuck when you eat? Those are other indications to operate for hydro hernia besides reflux. Okay? Or or like the woman that I showed you earlier, the whole stomach was up in the chest and it was flipping and it was at risking of obstruction. Okay? And then if you have any of the five red flags, please don't fill your prescription. Go and get scoped right away. All right. Um, you can take if you want take a picture of this, take it to your appointment, but those are the questions you need to know if you have reflux symptoms and you're taking and you're taking pills. Same things I showed you earlier. But it's something that you want to keep track of and you want to know and make sure that your doctors are thinking about. And if you're catching them by surprise, maybe go see a specialist uh to see. And and the funny part is I'm a surgeon. I'm not a gastronurologist, but I do so so much GI surgery that I do most of my own scopes. Um, so I will send some of the stuff out to the gastronurologist, long-term treatment of eocinic esophagitis and some of the other stuff I send out, but most of the reflux stuff and and and the other things I take care of myself, even doing the endoscopies and the diagnostic stuff because I do so much with my surgery in the surgery there. And we are um a little Mercy plug. Um we've recruited a doctor to come join me uh and he's starting in the next month or two at Mercy um who is a gastronurologist who who works on functional GI or motility and he does a whole GI tract motility. But uh with me the biggest thing is esophageal motility. Um and uh so so we're looking at all the things even gastroparesis which is another disease process that we're not talking about today. So, we're going to be developing a full esophageal center uh to treat all these all these issues here, which we had he was with me before when we were at the university and we had that center at the university. We're putting it back together. So, the band's getting back together again uh here here on closer to you guys. So, going back to Dave, remember the guy was he was a soldier. He did what he was told. He went to his doctor's appointments. He refilled his meds. He felt he got he was getting better, you know, he thought he was getting better and then he got the big surprise. So, just keep that in mind. Don't don't forget about this just because the pill is kind of taking care of things. Stay on top of it. Get checked and and uh so that you don't get into any issues. All right. Any questions? Yes, sir. I was told I have a Shadski ring. Yes. Can you explain what that is? So a shaskky's ring is is so those rings that I showed you of esophage eocinophilic esophagitis they can they can start shrinking down more and more and more and usually from but not from ee but from reflux where the chronic bathing of the acid up there causes scarring in that in the line inner lining. So it starts shrinking shrinking shrinking and getting tighter and tighter and it's a shatzkis ring. It looks like a little ring on X-ray in the middle of the esophagus. And those oftentimes have to be dilated mult and sometimes multiple times um to to try to prevent them from going back down and letting you swallow because you can develop dysphasia or food getting stuck because that's too tight. And it's actually, you know, a lot of people feel it and I feel that's a an indication for anti-relux surgery because it's that continuous reflux that's causing the the complication. And usually complications of reflux are treated with surgery uh in addition to medicines. Okay. Yes, ma'am. Does bloating have any relation at all? So, does bloating have any relationship to any of this? Yeah, it it really does. Um, so I mentioned gastroparesis a minute ago and gastroparesis is when the stomach does not empty well. So for we we I've how many times have I talked about the pressure inside the abdomen, right? That so that plays a role on pushing things up in the chest. If your stomach doesn't empty well, that raises the pressure inside the stomach and that pushes everything back up into the chest. And constant bloating is increased pressure and probably a a functional disorder of the stomach emptying and can cause the issue with that coming up. Um so patients that that's some of the questions we ask the patients when they come they always fill out for me different questionnaires. Some of them are heartburn and reflux questionnaires. Some of them are gastroparesis questionnaires because they're interrelated. And if you have severe gastroparesis your chances of an anti-relux operation working are less because you fixed the in but you didn't fix the out. So sometimes you have to fix it in and out in order for everything to flow. What is a gastroparesis? Gastroparesis is a disease process caused by multiple different things. Most most of the times it's from diabetes but mo multiple different things. No, gastro is stomach. Paresis is paralysis. So the stomach is paralyzed. It's not moving or emptying well. Okay. Yes, ma'am. Out of curiosity, that [clears throat] magnetic ring you talked about, that ring at the airport, will the magnetic ring ring at the airport? No. But it's a good question. People ask that all the time. Um, the only limitation with that ring is that you have to when you get an MRI, it has to be a a special MRI. It can't be the latest strongest MRI because those magnets are too strong and they'll break the ring. They actually make it they demagnetize the magnets so they stop working. Yeah. All right. Any other questions? Well, thank you very much, guys. You've been wonderful and it's pleasure seeing [applause] you.

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