DOCTORS AND RESEARCHERS are making annual breakthroughs in studying the digestive system and the potentially drastic consequences of chronic imbalances, such as untreated acid reflux and irritable bowel. With an eye to prevention, treatment and advocacy, SRQ sat down with a pair of Sarasota professionals to learn how to listen to your gut. 

SRQ: When it comes to digestive health, is it at all a useful dichotomy to say you deal with patients on one hand who need medical intervention and patients on the other hand who need a lifestyle change, but may not have an underlying condition? Isaac Kalvaria, M.D., Sarasota Digestive Health Specialists and Sarasota Memorial Hospital: That’s the way we deal with patients, especially because a lot of patients ask about what they should eat and lifestyle changes, and more and more people are shying away from trying medications because they’re scared about side effects. So we have to be very open to discussions about diet and lifestyle, perhaps more so than a decade ago. So we are shying a bit away from medications, although we have access now to wonderful new medications for almost every disease that we treat. But certainly the dietary aspect has become very big, particularly in the last five or six years. F. Scott Corbett, M.D., Gastroenterology Associates of Sarasota and Sarasota Memorial Hospital: In certain ways, diet doesn’t always do what people would hope it would do. If we look at things like reflux disease, many of the behavior modifications that we learned about 40 or 50 years ago really make very small differences for patients with serious reflux these days. Typical measures like avoiding caffeinated coffee and chocolate and peppermint, these are things that would relax the lower esophageal sphincter muscle and it was shown in research in the past. And we find that traditional behavioral modifications that we taught in the past made very little difference with the exception of a few things like raising the head of the bed if someone has a lot of regurgitant symptoms or losing weight. Those are probably the two modifications that make the most difference for patients, whereas using acid suppressing agents makes a huge difference. Kalvaria: In the rest of the digestive tract, a lot of people get into dietary fads. For example people going gluten-free. People become very focused on a lot of stuff that goes through the internet. In relation to irritable bowel syndrome, which is a very common disorder, there are a lot of misconceptions, and a lot of this stuff just doesn’t work. Sometimes it works because a patient may be sensitive to a particular food item removed from their diet and you can’t argue with success, but there is a tremendous amount of misconception out there about diet, certainly from the acid reflux point of view, and inflammatory bowel disease as well. Corbett: And with diverticular disease, which are little pockets and out-pouches of the bowel. We really weren’t sure what the cause of complications in that disease was, one of which is infection. We used to think that things got caught in the diverticulum, so we told patients to avoid things like popcorn, corn and nuts. Studies now have shown that there’s really no particular diet that prevents or provokes complications in diverticular disease. So people following traditional methods are avoiding many things that are very healthy for them and not really following what is scientific. 

What are the most common health problems that you treat in the Sarasota area? Kalvaria: Acid reflux is one of the more common reasons for people to present to us. Part of the increase in acid reflux is because there’s an increase in obesity and there’s a certain association between weight and acid reflux. We’ve become a very obese nation and acid reflux has increased, plus complications associated with acid reflux. 

What’s happening in the body when you experience acid reflux? Kalvaria: It’s acid from the stomach coming up north instead of going south. There is a sphincter muscle, it’s kind of a flapper valve, at the bottom of the esophagus and that is supposed to protect the esophagus from acid that’s coming backwards. The valve opens when you eat and should close when you finish the meal to prevent things going backward. People that have issues with that sphincter or valve, or people who are obese —obesity around the abdomen tends to push things upwards instead of downwards—tend to get acid reflux. 

With such a patient would you aim to treat with medication or would you push for a lifestyle change? Kalvaria: As Dr. Corbett points out, lifestyle changes don’t often work, unless we have people who are caffeine addicts. When you identify that in the history, you can often make that change. That’s probably the only dietary issue that can positively affect reflux. Corbett: But Isaac’s right, the issue of central obesity is a very important aspect that contributes to acid reflux disease and when the acid comes up into the esophagus it can cause erosions and ulcerations. When somebody develops that type of issue, lifestyle changes really are not going to make a difference. We have to consider other therapies, which are usually medical therapies using powerful medications that suppress acid. 

Are there serious health risks involved with acid reflux or is it mostly discomfort? Corbett: Those patients are susceptible to a pre-cancerous condition in the esophagus that we call Barrett’s Esophagus, which can actually affect as many as 15 percent of patients who have reflux disease. Part of our problem with this is that we are not detecting many patients who have Barrett’s. In fact, we’re probably only detecting about 4 percent, because most patients are unaware. When the body’s own stem cells repair the damage of the acid in the esophagus, in patients who are genetically predisposed those stem cells will replace it with intestinal lining, which is more tolerant of acid. So many times their symptoms go away—this is a protective mechanism and one that has probably served the human race well for hundreds of thousands of years. The problem is that when that change takes place, there’s a genetic message to those cells. And it’s the accumulation of genetic changes in those cells over time that predisposes patients to developing esophageal cancer. This did not really become much of a problem until the average life expectancy reached the age of 45 in 1900. In that point in time we start seeing an incredible increase in the incidence of intestinal-like cancer in the esophagus related to Barrett’s Esophagus. And over the last three decades we’ve seen a tremendous rise in incidence and we can parallel this with the rise of obesity in the population. 

So patients will have real intestinal tissue in their throats? Is there anything you can do to remove or reverse? Corbett: It’s what we call an intestinal metaplasia, which is an intestinal-like lining that repopulates the esophageal lining. There is treatment now, with the use of radio frequency. We have a variety of things we can do for this depending on the circumstances. There are surgical techniques and cryotherapy, but one of the more reliable methods we’re seeing is radio frequency. 

How should people know whether what they’re having is a systemic problem in need of an expert and when they’re just having a rough few days? Kalvaria: If you have persistent heartburn, that’s usually something that will bring them to the primary care physician, and primary care physicians are very tuned in to Barrett’s Esophagus now and will often refer patients to us as gastroenterologists to undergo endoscopy, which is how we make the diagnosis. As Dr. Corbett points out, quite often once you’ve developed a complication like Barrett’s Esophagus the warning signs go away, so these patients are quite oblivious to the fact that they’re developing a problem. Unfortunately, some of these people present for the first time with esophageal cancer, and when you examine the esophagus you see evidence that they’ve had Barrett’s Esophagus for a number of years and were not aware of it because the reflux went away. So one of the groups of patients we always get worried about is the patient who says, “I had acid reflux for many years when I was younger, but it all went away and I’m fine.” Those are the people who are warning flags for us. Corbett: The fact that average human life expectancy is increasing at a substantial geometric rate has resulted in us seeing things medically that were not seen very often in the 19th century or so. There is a subset of patients with the potential for Barrett’s who should be looked at—anybody who has a family history of Barrett’s and anybody who has a history of intestinal-like cancer in the esophagus. These are risk factors that are very serious and families should be screened. Caucasian males have a very high risk. Smokers too. Unfortunately, we’re only finding about 4 percent of patients who have Barrett’s. We’re actively trying to develop screening. Kalvaria: If you look at cancer incidence over the last 30 years, almost every cancer is completely flat and the only cancer that shows a steady increase is adenocarcinoma of the esophagus. It’s really a major public health problem. 

What is irritable bowel syndrome (IBS)? Is it an easily defined syndrome or is it more of a default diagnosis? Kalvaria: We’ve gotten much better at diagnosing it. It used to be the diagnosis of exclusion, meaning that you would have patients presenting with typical symptoms, which are abdominal pain and changes in their bowels, particularly in young females, and you would rule out all the other causes of that and label them as having irritable bowel. We now have better criteria for diagnosing it and we can identify based on history and using what is called Rome criteria. These are criteria defined by a group of experts that meet in Rome on a regular basis and produce a book that updates the criteria for the diagnosis of several diseases like irritable bowel. They’re called functional diseases, meaning that in many of these conditions you can’t see anything by putting a scope in or doing an X-ray, you have to make the diagnosis based on the patient’s history. But with irritable bowel syndrome, the typical symptoms are abdominal cramps and either diarrhea, constipation or even a mixed picture. The typical person is a young female —this is much more common in women than men by a ratio of probably eight or ten to one. And it’s probably increasing in incidence to some degree. We live in a lot more anxiety-ridden society and this is often precipitated by stress and life changes. Fortunately we have treatment available now; we have more medications available that are very effective and we have lifestyle modifications. There’s a diet called the FODMAP diet that’s become quite in vogue. So there are some modifications that sometimes work. But it’s usually, like everything else in medicine, a combination of lifestyle changes, dietary changes, medication and sometimes even psychological therapies. 

Can IBS be cured or is it something that needs to be managed as you go through life? Corbett: IBS is something that is typically present early in life and it will potentially plague somebody throughout their life. It seems to die down a little bit as patients get older, but not always. Kalvaria: It affects people in the productive and reproductive years of their lives, so if you look at the costs both in dollars and in productivity, it’s right up there with many diseases people regard as much more serious, like diabetes, asthma and hypertension. Think of a young woman who’s trying to raise a family and holding down a job and she has to constantly rush to the bathroom. It’s really a major problem affecting people in their productive years. 

Are there general lifestyle changes that people can make to improve their gastrointestinal health? Kalvaria: Probably the most important factor is control of weight. Fatty liver disease is becoming an epidemic as well and there’s a lot of association between weight and gastrointestinal disorders. So control of weight is very important. So just being sensible with control of calorie intake. And there are food fads—the paleo diet has become very in vogue - and it’s a big controversy right now whether you restrict fat or whether you restrict carbohydrates. We’ve gone round and round over the years and the truth is probably somewhere in the middle. A very high fat diet isn’t good for the heart and a very high carbohydrate diet isn’t good for weight. So calorie control is probably the most important thing. Corbett: The most sensible diet is probably Newton’s diet—calories in, calories out. If you’re taking more calories in than you’re burning up, you’re going to gain weight. If the opposite, you’re going to lose weight. It’s not quite that simple, but it’s a good rule of thumb. One of the ways of helping with weight control or encouraging patients to eat a balanced diet is portion control. When people start restricting their intake and following food fads they’re going to doom themselves to failure, because they will ultimately go back to doing what they were previously. It’s usually better advice to tell them to eat a balanced diet and eat less of it. 

How related are cardiovascular and gastrointestinal health? Will living an active lifestyle have benefits aside from weight loss? Kalvaria: It’s very therapeutic. It’s therapeutic in maintaining people’s weight and also in other ways that we can’t fully understand. You have the endorphins that are released when you exercise and these are your feel-good hormones. It’s really useful for a lot of different disorders, particularly the functional disorders like irritable bowel. When patients have severe irritable bowel syndrome and they’re focused on diet, we try to also focus them on other issues like exercise, socialization and leading a balanced life. In effect, when you look at what’s recommended for a lot of disorders you ultimately come down to a few basic things, which are watch your calorie intake, balanced diet, exercise, socialize and enjoy life. Even the recommendations for staving off or maybe delaying dementia are the same recommendations as they are for controlling heart disease or controlling bowel disorders. It’s very interesting when you look at a lot of opinions about all these disorders and how similar they are. 

Some doctors have posited that the microbiome in our digestive tracts—the microbiota—has been greatly reduced in terms of variety and it could have negative effects. Are you seeing these effects? Kalvaria: An interesting statistic is that we have a 100 trillion cells in our body and 90 trillion are bacteria. They are a tremendous influence on general body health, because of bacteria that may not be friendly. So changing the microbiome, which has also become very much in vogue, can certainly affect a lot of different disorders. Corbett: We’re really just scratching the surface about our knowledge of this fascinating world of how bacteria influence our health. We’re learning certain diseases have a tremendous bearing on bacteria in our body and we’re not just talking about our gastrointestinal tract but our whole bodies. It’s been shown that certain colonizations of bacteria can actually influence or cause diabetes, arthritis, IBS. There are many ways in which bacteria in our system influence our health and we are affecting that tremendously by what we do. We have to be cautious about our use of antibiotics and what we do afterward. Talking about irritable bowel, a subset of patients are felt to have a condition called post-infectious irritable bowel, where they’ve had an infection that influences the bacterial content in their system or they received an antibiotic that destroys normal gut bacteria and allows for repopulation by bacteria that may not be so kind. We’re starting to learn certain ways of influencing that. One way is using antibiotics that are safe for the body, that actually don’t get absorbed into the system but just act within the gut itself, and then attempting to repopulate the gut with bacteria that can promote a healthy environment. But we’re just scratching the surface, we really don’t understand it completely.

You see all sorts of probiotic supplements in the stores. Are those effective? Kalvaria: How do you know which bacteria to repopulate and how do you know the source of what you’re buying? It’s an unregulated industry and a lot of what people are buying as probiotics aren’t effective for their particular situation, or maybe they’re buying something that has no bacteria. It’s lost its potency. There are a few probiotics that have been studied and are reasonably effective, but again you don’t know what the correct probiotic is for your individual situation. Yogurts are a type of probiotic that contain good bacteria and I tell my patients that they should probably be having a serving of yogurt every day. It certainly helps, but we’re just scratching the surface. If we had this conversation in five years, we’d be able to say this probiotic works for this disease and different probiotics for different diseases, but right now it’s hit and miss. Corbett: There are very few probiotics that have actually stood up in controlled trials. Part of it happens to be the potency. Many things that you see out there on the shelf just don’t have what’s on the label anymore. Many of the probiotics that have performed very well in randomized controlled trials are ones that have to be refrigerated to maintain their potency. And for pharmacies and health food stores to carry something like that creates a burden economically, so what you typically see out on the shelf is not going to be effective for the patient. We are finding some interesting things with these probiotics, things you never think would happen. It turns out that the yeast of one or another certain probiotic has been effective in preventing the gut problems that occur when a patient receives radiation therapy for cancer. Then one that has no effect is very therapeutic in other diseases. It’s a very interesting field of research that we’ll find over the next decade is a very important aspect of our health in general. Kalvaria: Another issue with intestinal bacteria that’s become quite interesting is the concept of fecal transplantation. In certain conditions like clostridium difficile, the infection that happens after antibiotics wipe out your bacteria, you can actually cure people by giving them a fecal transplant. You give them somebody else’s stool, either infused into the colon or produced as capsules. Again, you’re basically rebooting your computer—you’re driving out the bacteria that are injurious to you and repopulating your gut with bacteria from a healthy individual. It’s often a family member but it doesn’t have to be because now they’ve established fecal transplant banks. It’s not a subject one likes to address, but for recurrent clostridium difficile it is incredibly effective and we’ve done a lot at this hospital with probably a 95 percent success rate.

Clostridium difficile? Corbett: Approximately 15 percent of the population harbors clostridium difficile in their gut all the time and it’s kept in check by the normal microflora of the gut. This bacteria secretes a toxin and that toxin is generally at very low levels in the healthy individual, but if someone receives broad-spectrum antibiotics it can kill the normal bacteria. This bacteria is very resistant, so what happens after an illness is that this bacteria will flourish and then the bulk of the toxin that it is secreting causes a colitis and that colitis can become life-threatening. We do have antibiotics than can kill the bacteria, but often this bacteria can become highly resistant. There are seven states where there are particularly resistant strains of this bacteria and Florida happens to be one. It is becoming increasingly difficult for us to kill the bacteria once it’s established, so we recommend prevention by using probiotics and repopulating. But sometimes that fails and one of the newer methods is the fecal transplant. SRQ­

F. Scott Corbett, M.D.
Dr. Corbett received his medical degree from New York University School of Medicine before completing an internship with University of Miami Affiliated Hospitals and the Miami Veterans Administration Hospital, where he also completed his fellowship. Board-certified in gastroenterology and internal medicine, Corbett has been annually ranked as one of “America’s Top Doctors” by Castle Connolly since 2006.

Isaac Kalvaria, M.D.
Dr. Kalvaria attended medical school at Godfrey Huggins School of Medicine in then Rhodesia, today Zimbabwe. A member of the Royal College of Physicians and the Royal College of Surgeons, Kalvaria completed his residency and gastroenterology research fellowship at Groote Schuur Hospital, South Africa. Kalvaria has also previously served as Assistant Professor of Medicine at the University of Florida.