In addition to being the current Secretary of the Board of Trustees of the American College of Gastroenterology and Chief of Gastroenterology at Eastern Virginia Medical School, Dr. Johnson has lectured extensively both in the US and world wide on a variety of topics, in particular the subject of gastroesophageal reflux disease. He is an editor or associate editor of 3 GI journals and reviewer for another 11 journals. Dr. Johnson has published over 250 articles, abstracts, book chapters and review articles in the field of gastroenterology.
Dr. Johnson speaks to Reflux1 about the latest and greatest endoscopic treatments for reflux disease.
Reflux1: Dr. Johnson, could you please tell us how you got started in gastroenterology?
Dr. Johnson: I started in internal medicine and got excited by being around people that were always dynamic, looking forward and asking provocative questions. In particular, a couple of people in medical school were tremendous role models in gastroenterology; they planted the seed that continued to cultivate as I advanced in internal medicine. Doctors Alvin Zfass, Ed Cattau, Don Costell, and Joel Richter; these are people that continue to play a big role in my career as a gastroenterologist.
Reflux1: Could you explain to our users the difference between heartburn and GERD, as they are often confused?
Dr. Johnson: Heartburn and GERD can be, to the patient, the same diagnosis. Heartburn is a symptom, while gastroesophageal reflux disease, or GERD, is a clinical syndrome, or an event (reflux) manifested or indicated by a symptom, be it heartburn or regurgitation.
Heartburn is best defined as a burning sensation that radiates from the stomach up into the chest; it is frequently associated as happening after meals or while lying down. Regurgitation is the fluid sensation that comes up when people either lay down or bend over, sometimes after a meal.
Gastroesophageal Reflux Disease, or GERD, means that you have an event that is the reflux described above. A lot of normal people that have GERD have never manifested symptoms. But eventually there come symptoms that patients recognize. So they now recognize either the burning sensation or the regurgitative volume sensation. Those symptoms indicate a disease.
Reflux1: What gaps currently exist in patient education for reflux disease?
Dr. Johnson: Well, number one: that the control of symptoms is something that really is available to everybody. You don’t have to suffer because you have a disease. Case in point, a patient I saw a few months ago (the father of another physician) was sent to me for colon screening. I asked him to lie down as I was taking his cardiac history prior to making him sleepy with sedation for colonoscopy. I asked him how he slept and he said he didn’t sleep well. He couldn’t really lie down at night and was very concerned because he thought it might be his heart. I investigated further and learned that he was sleeping in a recliner. He is 75 years old and he’s been sleeping that way for 5 years because that’s the way he thought getting old was supposed to be!
So it’s an understanding from the patient perspective to ask the appropriate question, "is this symptom something that I have to put up with?" There are a lot of options, both endoscopic and pharmacologic - and even surgical - for the treatment of reflux disease.
Reflux1: What are the biggest trends in the development of new technologies for treating reflux disease?
Dr. Johnson: The biggest trend is putting in perspective where we’ve been. We’ve gone from surgical interventions, which have really been the mainstay for the last 30-35 years, and moved on to pharmaceutical interventions. These started with the introduction to the histamine receptor antagonist, and from 1989 on, moved to the proton pump inhibitors.
Recently, there’s been a tremendous interest in endoscopic interventions. I look at these as something that are the horizon. These endoscopic therapies are not an absolute "one shoe fits all," but an alternative to surgery and pharmaceutical interventions. I put this in perspective by calling this "baking, sewing and stuffing."
To treat reflux disease you can bake the esophagus with a radiofrequency ablation therapy called Stretta®, you can sew the esophagus with a number of sewing technologies, and more recently, the introduction of injectable technologies allows us to "stuff" the esophagus. I call this the Home Economics approach to treating reflux disease: baking, sewing and stuffing.
Reflux1: Can you tell us more about these endoscopic technologies that you’re mentioning?
Dr. Johnson: The Stretta® procedure, or radiofrequency (RF) ablation, is a technology that has been around for quite some time. Actually, physicians and patients may be familiar with this technology. Cardiologists and electrotherapists have been using it for years to obliterate aberrant cardiac conduction pathways in the electrophysiology labs. Orthopedic specialists have gotten into it recently, using it to deliver this energy to tighten up joint laxity.
Gastroenterologists have now become more interested in using this intervention to "tighten up" the lower esophagus and perhaps change the compliance, or the tensile strength, of the distal esophagus. That interest has led to the whole radiofrequency ablation technique. It seems to work and has been shown to be effective in both randomized and unrandomized sham-controlled studies. As a result, there have been a lot of technological advances with RF approaches.
On the injection side there have been a variety of efforts. These include the use of Plexiglas in Greece a couple of years ago. Dating further back to the mid 1980s, gastroenterologists inspired by Dr. Glen Lehman were injecting bovine (cow) collagen - and even Teflon paste - into the lower esophagus. It actually worked to control reflux disease, however it just didn’t last.
More recently, the technique has been refined with the introduction of a new procedure called Enteryx®. This is a bio-inert polymer, which is injected as a liquid, but it solidifies to more of a sponge material. The idea is to change the lower esophagus. Basically what Enteryx® does is build out the resistance of relaxation to distention. As the stomach distends, there is a relaxation of the esophagus and stomach junction, which thereby allows the acid to move up into the esophagus. This is altered in response to this Enteryx® procedure. The Enteryx® procedure has been studied now in both 6- and 12-month extended trials and in some centers in 24-month trials. It has proven to be effective and very safe, and was recently approved by the FDA for release in the United States.
Reflux1: If I’m a patient with reflux disease, where do I find more information?
Dr. Johnson: Well I think you need to see a gastroenterologist. If you go to a surgeon, you get surgery. If you go to someone who can offer the full menu, as gastroenterologists do, I think they will tell you about the best options for YOU as a patient. There is no one treatment that is best for every patient- no "one shoe for all sizes". So it’s critical that you see someone who is going to listen to you, talk to you about your symptoms, and then really give you the best therapeutic options based on your symptoms. It’s not that any one procedure is for somebody that doesn’t respond to one particular therapy; however, the worst patient to ever select for any of these interventional procedures is somebody that doesn’t respond to medical therapy.
The best successes we have with surgery or endoscopic therapies are with people whose symptoms are successfully controlled with a medical therapy. So start with a physician who knows all avenues, from pharmacology and endoscopy to surgery. I think it’s best to start with a GI that has got their finger on the pulse of all three areas.