Okay, we've had a couple of questions about pregnant patients, so we'll just pair those up. So the first goes to you, Erica. How do you test for listeria in pregnant patients? Yeah, this can be challenging, as I wrote in the Q&A box there. So it takes a cluster of symptoms, and when you first start the workup, of course, you're ruling out any obvious infections, you're doing stool studies. If they're febrile, you're doing the blood cultures. If there's really high suspicion in that they've likely had a contaminated food, and there's high risk for listeria, or it's in the community, then a prompt discussion with the OB-GYN about empiric treatment is a good idea. So like I said, we still rule out all of the traditional kind of stool studies, infections, like I said, blood culture, and then discussing with OB-GYN if you should treat. Okay, thank you. And we'll take the next one over to Drs. Meiberg and Martin. Which anti-reflux medications are safe for pregnancy and breastfeeding when failed Tums and Pepcid? That's a great question. You know, I think great, or category B for most of them, I'm going to think maybe Omeprazole is C. Kerofate could be an option. That can certainly be used after meals, crushed up, dissolved in some water, and taken as a slurry. But it's a tough one, not a lot of options. Yeah, for those, I always recommend that they discuss it with their OB as well. A lot of times they will use PPIs, they'll agree with PPIs. I've even heard some of them say, well, as a pediatrician, we give babies PPIs when needed. But I think super important to have them discuss with their OB and make sure that we have that multidisciplinary collaboration for that. That's a good point. Thank you. So there was a question that I wanted to bring up that I saw come through about pink retic fecal elastase and having falsely low values. Erica, do you mind just commenting on that? Yes, yes. I'm sorry, you can probably answer this question, because I know you're in the pink retic field. So the fecal elastase is our really only test we have for EPI. It's not amazing. There is a high chance of false positives, actually, because it is dilutional. So if the patient picks up the stool sample with some urine that's in the hat, or say they get extra water, toilet water in their specimen, and then they turn it in, it's going to look as though it's a low value because it's dilutional. It's kind of like acute pancreatitis. You can't just go off the lipase. A lipase may be elevated, but if they don't have imaging and they don't have abdominal pain, then you can't just go off the lab values. So when you have a fecal elastase that's low and you're suspicious of severe pancreatic insufficiency, you need to follow this up with looking for fecal fat, if that's positive, going to a 72-hour. Do they have risk factors for pancreatic insufficiency? Do they have chronic pancreatitis, a pancreatic cancer? Have they had a lipple? Do they have cystic fibrosis? Or have they had other procedures like a gastric urine Y or other kind of small bowel diseases that make it so the pancreatic enzymes aren't secreted by the duodenum nor absorbed? So there needs to be more follow-up into just acting on one test. Thank you. Absolutely. Another one that I saw come through in a couple of different ways is how we have discussions with our patients who have concerns about PPIs and those potential side effects. Maybe we can just go to Saural and Dr. Martin and then Erika, if you have any comment on that as well, just to give our audience some examples of conversations that we have with our patients. I try to address what's their main concern and really say to them, well, we don't have concrete evidence that these are really causing these potential side effects. But again, it's a medication. There's certainly a possibility for side effects. If I have, for example, a patient with ferrets or high-grade dysplasia and I tell them, your condition that you have outweighs the potential risk of these PPIs. And I do monitor, do some laboratory monitoring in my practice on patients with long-term PPI. I talk to them about other options. Well, can I use H2 blockers or carafe? So it can be a difficult conversation, but just based on what they have for the condition and if it outweighs the potential risk of these PPIs. And usually they have a good grasp on that and they understand. Yeah. I think there's some context that I think is oftentimes helpful to offer the patient because I think many times they come in saying, hey, I'm of a demographic where the likelihood that I'll develop osteoporosis is higher, for example, or I'm worried about the possibility of renal disease or whatever the potential adverse, putative adverse effect is. Uh, but they come in assuming that you'll have something else equally efficacious to treat them with if they stop the PPI. Um, but then if you explain to them, well, you know, I'm going to have to put you on a weaker medication, or we're going to have to consider an invasive procedure of some sort. And that invasive procedure may not get you off of PPIs. You may need to take PPIs on top of the Nissen or what have you. Then that changes the context of the conversation somewhat. Do you find that to be true too? That's true. Right. Yeah. So providing them with some understanding that there isn't some ideal other solution, that there's not going to be any medication as effective for their severe GERD as, as a PPI. So if they're going to quit, quit at lock, stock and barrel, they might have to deal with worsening symptoms of their reflux or risk with their Barrett's or undergo surgery or endoscopy or laparoscopy. I would have to agree. And I also, you know, just let them know that we do need more data. You know, some of this is associational in respects of, we have no kind of black and white data showing that these kind of questionable adverse reactions. And then with the osteoporosis, I agree, assessing the risk factors for sure. Yeah. I think the only other thing that I add is when we talk about, especially osteoporosis, there's so many risk factors for osteoporosis and PPIs are probably one of the lower ones. And so the things that we can change are particularly our females. And if they're postmenopausal, those are much higher risk factors. What can we do to help either with calcium and vitamin D supplementation or, you know, routine DEXA scans, and I think just validating their concerns, letting them know what we have literature wise. And like Dr. Martin was saying, you know, there aren't any other great alternatives. So particularly somebody with Barrett's esophagus, you can really go through that risk benefit scenario. You know, do we have other questions? Oh, we do. Oh, do we have other questions? We sure do. And anything we don't get through in the live session, just like yesterday, the faculty will write them up and staff is looking at a way to be able to create a document that'll give you all the questions and answers from the course. So you can look forward to that as well. There's a few folks wondering here about the difference between a swallow study and with liquid or a pill. So is esophagram different from barium swallow? When ordering barium swallow, what's the difference between a single versus a double contrast? So, you know, that's a really good question, because when push comes to shove, if you're thinking about, say, the workup of dysphagia, you're concerned not only about the possibility of a fixed mechanical obstruction, which the barium column can be very effective in demonstrating, but you also want some understanding of motility. And you can get both, but you get more out of the actual fluoroscopy, which is the movie x-ray, as opposed to just spot images, which is just a few static pictures, right? So the x-ray is basically done with these barium column studies as a movie. So they're shooting the movie anyway. And at many institutions, including ours, they're going to give you both. They're going to give you the higher definition static images, the shots, the independent four or five or six pictures, but they're also going to give you the movie reel so that you can actually watch the bolus transit through the esophagus. And so at our institution, if the indication is dysphagia, the radiologist is going to know that you want both. And that's going to happen automatically. My opinion is, if you work with a radiology group that's not automatically going to give you fluoroscopy for you to view as the provider, you ought to ask specifically for a video esophagogram. Does that make sense? Do you agree with that, Sorel? Yeah. And I want to mention too that endoscopy doesn't take the place of a barium esophagogram video or otherwise in the workup of dysphagia, because I want you to picture this. Let's say you have a distal esophageal ring, a Schottky's ring. So you have a narrowing point to some degree that's circumferential in the distal esophagus where food's hanging up. If you're looking directly down the tunnel like you are with an endoscope, you're getting the view from the driver's seat of the subway train. And there are things that you're not going to see very well as the driver adds on the sidewall of the subway tunnel or some slight narrowing of the tunnel in front of you. You can't see that real well. But if you get a side view with a barium swallow, you're going to see something like a Schottky's ring or an esophageal web very, very clearly, just like the passenger is going to see the ad on the sidewall of the subway from the passenger seat in the subway ultra well, that sort of thing. So it provides different visual perspectives on the disease process. Both are important. Okay, our next question is, is nausea and vomiting considered an additional red flag for GERD? It can certainly be associated with GERD. It depends on the vomiting, if it's, if it's effortless, if it's tasting like food, but certainly we see some patients with nausea that it certainly could be GERD. A red flag, I guess it depends on how much they're vomiting, what are the symptoms are associated with that, but it certainly would be worth investigating. So, Sorelle, you were, you were schooling me earlier on how rumination, which causes causes regurgitation can lead to GERD and GERD complications. Can you go over that for a second? So rumination is usually effortless. It's a primitive brainstem reflux and people, patients will have effortless regurgitation after they eat and depending on what social situation they are, if they are in at the restaurant, they obviously will try to keep it down, but at home, they'll spit that out. That sometimes is confused with the regurgitation and GERD. And some of those patients with the ongoing regurgitation, they eventually can get acid up and they can go have a reflux, esophagitis. Most of those patients will not have nausea. It's just this effortless regurgitation and sometimes difficult to diagnose unless you ask the right question about what does the regurgitation taste like? Is it just like the food? How long have you had it? And does it just come up without nausea? That's more rumination than GERD. Our next question is how do you treat the gas bloat symptoms after Nissen? It can be difficult. I would say over-the-counter gas products, really strict diet modifications, no straws, no hard candy, no gum, eating slowly. As in a patient swallow a lot of air, they fast, eaters. Those are probably the things I would, I would focus on, but it can be a very uncomfortable symptom for them. This person writes, I have heard a TIF can still be performed on a failed or weakened Nissen. Is that true? Certainly, it can be an option at all. It depends on what you find on subsequent pH studies and how the patient's symptoms are. It really depends on how big the hiatal hernia is. It's also going to depend on what the operator performing the TIF endoscopy is, or end-illuminal procedure is going to be willing to do. The results may be different. Understand that TIFs haven't been performed on a routine basis for very long. In fact, at a lot of centers, it's not done routinely. As a result, the data is lacking and the existing data tends to be inconsistent and dirty. So it's hard to make predictions. The other thing is there aren't a lot of operators that are willing to do the TIF endoscopy. There aren't a lot of operators that have done lots of TIFs repeatedly. Because they don't tend to do TIFs for all comers, but they only do them in patients with no or small hiatal hernias, for example, it really depends on how scrutinizing you are in sort of segregating out who you actually aren't going to do TIFs on and who you're willing to do them in. I know that sounds like a cop-out of an answer, but it's the reality. If a patient presents with oropharyngeal dysphagia and EGD and speech therapy are normal, what do you recommend next? I would probably work them up for myasthenia gravis. Think about, you know, that's a difficult one. Sometimes reflux can cause higher dysphagia. The history there is really determining, are you having trouble with getting the bolus out of your mouth after you chew it, or is it sticking in the high neck? But yeah, workup can include myasthenia gravis labs. Have you have anything else to add to that? Well, yeah, I do have a question for you there. You know, there may be situations, particularly, you know, someone like yourself who's going to go through the patient's past medical history in excruciating detail, which I know you do, that there may be a subset of patients who you may need to do some sort of neuropsychiatric testing or something to try to ferret out any contribution from that spectrum of disorder. Can you offer, say, a profile of a patient who might benefit from that? Like, who do you segment out to send for something like that? Yeah, that's difficult. It all depends on, you know, for example, I've seen one male patient here that in the office, he wasn't able to swallow liquids. And we did the whole workup on him, video swallow, esophagram, everything came back unremarkable. And we end up sending him to GI psych and really help him overcome that fear initiating that swallow. And over a few months to a year, he was able to get back to swallowing. So like you said, neuropsych, GI psych is helpful. You know, I just want to highlight a point here and the conversations that Sorel and I have, which is that, you know, I perform a lot of procedures and Sorel sees a lot of patients way more than I do. And so he has very different insights into things than I'm able to ferret out. And so, you know, what we ask and answer each other here is real day to day stuff. This is how our practice works. Wonderful. So we're coming to the close. And I want to throw a question over to Erica before we close out this Q&A session. Erica, you had mentioned osmotic gap of greater than 100, but this person's been running their practice with a gap of greater than 50. She's new to this field and wondering if it's better to practice, if it is better practice to wait until the gap is larger. Yeah, so the 50 to 100 is a little bit of a gray zone. Generally, you know, I would go down to 75. I think if you're right at 50, you have to determine the risk factors. And like I said, is this really secretory diarrhea? So like I said, I would maybe go to 75. I don't know if I'd make my cut off at 50. Waiting, you know, I guess you could wait and repeat it. Maybe there was can be some changes in a couple weeks. I don't know if that's entirely necessary, but I would be okay with 75.

pregnant patients

testing for listeria

safe anti-reflux medications

pink retic fecal elastase tests

discussions with patients