Mirella Falcone

Good evening, everyone, I hope you're well and welcome to our webinar treatment for indigestion and bloating. My name is Mirella and I'll be your host for this evening. Our expert presenter for this evening is consultant Gastroenterologist, Dr Hanumantharaya.

The presentation will be followed by a Q&A session, if you'd like to ask a question during or after the presentation please do so via the Q&A icon which is on the bottom of your screen, this can be done with or without giving your name. If you do give your name, we will be able to follow up with your questions after the webinar if we haven't been able to answer your question during the webinar itself.

If you would like to book a consultation, we have Chelsea Dann from the Private Patients team on hand to take any phone calls after the webinar and we'll provide the telephone number at the end of this session. Please note the webinar is being recorded.

I'll hand it over now to Dr Hanumantharaya and you'll hear from me again shortly.

Dr Hanumantharaya

Thank you, Mirella, for your kind introduction, my name is Dr Hanumantharaya, I'm a consultant Gastroenterologist and I've been working at Benenden Hospital for the last six years or so. I predominantly practice general gastroenterology here at Benenden Hospital but have some special interests in the liver, pancreas, and wild diseases as well.

So, what I said that we will briefly discuss indigestion and its causes and gastroesophageal reflux and briefly on both bloating and its causes and then finally I would like to touch upon some myths and confusions around the medications such as proton pump inhibitors which are used to treat indigestion and the importance of diet in the management of indigestion and bloating.

Finally, we will give time to ask questions, so intuition is a very common symptom and in my practice about 40 of the patients I see either they come with symptoms of indigestion or are blotting and about 20 per cent of the general population do suffer from these symptoms of indigestion but approximately about only five per cent present to the GPs for help.

The symptoms are very varied, sometimes patients might be just having burping and belching and some abdominal pains but as such one should have at least three months of symptoms of upper abdominal pain and fullness after eating and early satiety, and they are the typical symptoms of indigestion.

Many times, the symptoms of gallbladder diseases, pancreas and some motility disorders with the gut itself may overlap with the symptoms of indigestion, although many of these patients are benign conditions, you know there's no doubt that indigestion and bloating is a cause of psychological distress and poor quality of life.

As I said earlier, I think that most of these patients have benign conditions, and you would be surprised to know that cancers are identified only in about less than two per cent of these patients and the acid-related symptoms and diseases are seen in about 25 per cent of the patients that could be ulcers and severe inflammation in the gullet or helicobacter calorie induced ulcers.

I think approximately about 10 per cent of the patients do suffer from sinister symptoms which need urgent investigations, and those symptoms could be someone who has had an injection for the first time after 50 years of age and if you had lost weight or suffered any difficulty in swallowing or vomiting. I think those are the symptoms I think you should consult your GP or perhaps come out to us for investigations.

Now, this is the group of patients we would like to help, and you have had your endoscopy but that was negative what to do further? You’re still having symptoms and you know we would like to help this group of patients although most of these patients are functional some other diseases could be causing similar symptoms like indigestion symptoms such as motility disorders and bladder issues and perhaps celiac disease.

Interestingly, I would like to see in two ways these groups of patients who have normal endoscopy still have symptoms and are associated with some sinister symptoms and there is clear evidence that approximately about six to seven per cent of these patients might be having some other cancers.

Cancers of the pancreas, gallbladder or perhaps lymph node cancer I think those patients need further thorough investigations to rule out any cancers in those patients and other groups of patients might be still having symptoms of gallbladder disease and they certainly would like to know what causes the symptoms and you know, if possible, they want to get treated and get on with their life.

If you have a mild symptom, perhaps you know your GP might just do a test for helicobacter quality and treat you with antibiotics. If you're positive and that might resolve your symptoms and or it might just simply give you some empirical treatment with acid suppression for about two to three weeks and your symptoms might disappear. If you had any small ulcers or inflammation in the balance but they might also send you for an endoscopy.

I think if you have a severe or any sinister symptom, I think you should seek early help because picking up any cancers at an early stage has a better prognosis the most the indigestion patients or actually, they're suffering from functional dyspepsia and this is very common in patients who've got anxiety and depression and it might be that there is a disordered cut brain access the cause of their symptoms. They're often quite difficult to treat these patients but in my practise what I've seen is that meticulous dietary modifications would certainly help and treat treating them with neuro modulators to calm down their gut-brain axis such as antidepressants and certainly help these patients.

Now the gastrointestinal reflux, you know reflux is a very common thing and it's quite physiological and, but you know if you're really getting more frequently and more often during the night-time and that is probably is what is called as a gastroesophageal reflux disorder, and you might be having very typical symptoms of heartburn and regurgitation and others might be having atypical symptoms such as wheeze and some dry cough and hoarseness of voice.

A majority of these mild gastric could be treated with a course of medications. However, there are a group of patients who would be having very refractory symptoms of gastroesophageal reflux and the reason in them could be due to insufficient acid suppression and there's only about 25 per cent of the patients would you know get rid of their symptoms by once daily and passive separation medications may be that we need to optimize that treatment increasing the medications to twice daily maximum doses to treat their symptoms and there are also other conditions could be the cause of their refractory gastroesophageal reflux and sometimes we see a lot of younger patients allergic individuals presenting to us similar symptoms like gastroesophageal reflux and but they might be having inflammation in the college due to allergy mediated not acid-related those patients typically need endoscopy and biopsies from the galactic to confirm this disabled and, as I said earlier, I think there could be other causes such as you know motility disorders of the collect or a moderate resource of the stomach could be causing their refractory symptoms.

I would say that everyone who has got what is some reflux benefits from having a gastroscopy, the reason behind that is that if you know what we are dealing with we could plan your management better. For example, if you have a balanced oesophagus, you probably need your acid suppression medications for a lifetime whereas if you have no structural damage inflammation or ulcers, perhaps just take a short duration of acid suppression medications with the lowest dose possible.

I think most of the mild symptoms of gastroenteritis could be treated just by lifestyle modifications and perhaps taking medications as and when required and some of the lifestyle modifications such as elevating the rear of the bed and providing some of the foods which cause relaxation of the lower especially sphincter would be useful, such as spicy food, chocolate, and fizzy drinks.

Smoking and heavy alcohol consumption have implications for the relaxation of that lower sufficient sphincter and avoiding these smoking and alcohol would certainly help them as well. But, if you have a severe symptom, I think you should see us, and we can investigate you thoroughly to look for any damage to the gullet and to pick up any other causes of symptoms mimicking gastrointestinal reflux and of course severe and refractory symptoms of gaseous reflux and there are surgical interventions and endoscopic treatments are available.

Now I have to say that the proton prop inhibitors what we call this land lansoprazole or omeprazole and these medications are for the last  30-40 years and ever since I qualified and I've seen these medications are wonderful drugs which saved lots of lives and in the past when a patient presented with the severe bleeding or ulcerations in the stomach they would strike go to the surgery, but nowadays we can successfully treat these patients with proton pp inhibitors and to be very effective these medications have to be taken 30 minutes to one hour before the first meal of the day and the reason is that proton PPS that secrete the acid are maximally expressed when you're in an empty stomach and the asset suppression medications are more helpful to block these PPS and decrease the asset suppression and there are some safety concerns with the long-term usage of proton from cannabinoid and some side effects such as infections clustered in this cell and salmonella are quite common in in these patients and some other male absorption of magnesium and calcium and iron is also seen in patients.

There are some concerns about the long-term use of these medications recently whether or not they are associated with kidney disease and I think most of them are more the case reports and but very controversial probably need more proposed studies to confirm this and also dementia patients and studies conducted so far two studies they said long-term use of inhibitors is associated with memory loss but two other studies have rejected this but the bottom line is that if you need these medications it is very helpful and but  they are being misused and they have been prescribed for unindicated and indicated diseases I think that should stop.

At our hospital, we have a very dedicated endoscopy unit, and we can offer you comprehensive gastroscopy and surveillance and taking biopsies and let's follow his tests and we can also investigate you with all the radiological investigations and

there's also 24-hour PH monitoring to confirm the acid reflux available here as well and some of the tests are not available here but we could certainly outsource these tests to the nearer hospitals and if further treatments required for your refractory gastroesophageal, we could put you in in the right hands to get treated. Also want to tell you that surgical intervention such as laparoscopic quantification is also available here at Benenden Hospital.

Bloating is again a quite common symptom which is probably population suffer from bloating and it's more common in patients with functional diseases such as IBS and functional constipation patient typically present with increased pressure fullness and symptoms of gas trapping.

It is not known why and how one would get the symptoms of bloating which is quite a complex pathology, however, some reasons such as increased gas production due to complex and digestible carbohydrates in the cut could be of course and I think there's a lot of evidence coming out and that change in the gut microbiota could well be the cause of some of the functional symptoms such as bloating and digestion and somewhat very common in patients with stress and anxiety as well there's certainly some organic causes which cause bloating as well such as selective disease and some pancreatic cancer deficiencies and respond to some bacterial overgrowth very rarely and some cancers could be causing obstruction and gas trapping as well and it's quite common in patients who underwent previous fund application and other surgical procedures certainly we would like to investigate for all these organic causes and treatable causes to help you with.

So going to see a doctor when you have bloating if you have diarrhoea, bloody stools and pale greasy stools that could be due to some more absorption such as celiac disease or pancreatic enzyme insufficiency, I think you certainly need to see the doctor and if you're experiencing severe abdominal pains and unintended weight loss of more than 5 per cent you should really see the doctors and the treatment is mainly very much individualized if you have any severe symptoms then we would like to investigate it thoroughly to rule out any treatable causes or any wave cancers and if your symptoms of predominantly due to is used I think you will probably benefit from a dietary intervention such as a low FODMAP diet and perhaps taking some probiotics to regenerate a good bacteria in your gut and if your symptoms of bloating are predominantly due to psychological issues you might benefit from some neuromodulator medications and some behavioural therapy as well.

So, at Benenden hospital, we could certainly investigate you for all the organic causes, we can offer breath tests to diagnose any possibility of a small intestinal bacterial or growth and we also have dedicated dietitians who could help you with some exclusion diet and low FODMAP diets.

Finally, you may have heard about this low FODMAP diet, this was caused by an Australian researcher more than it's quite popular among the world and it is quite intense and boring as well and these are the feet with the high fodmaps and you should be really avoiding, and I've listed here some fruits which would help. These are low fodmap diets I think we would not recommend our patients to practice low fodmap diets on their own there is an increasing chance of fallout from the program because it is quite intense and boring, and some patients tend to develop some nutritional deficiencies adhering strictly to this. So, I would advise that if you are intending to practice a low FODMAP diet I think we should see a dietitian get the help they can advise you on the exclusion of the diet and then reintroduction of the FODMAP and they can desire you on a modified and low FODMAP diet which suits you better.

Mirella Falcone

Thank you very much, many thanks for that. Now we'll take some questions that have been answered, that have been asked sorry. So, if I start with the first one. I'm 34 and suffer quite badly with bloating particularly after eating I have tried changing my diet and not drinking fizzy drinks it is uncomfortable but not painful should I still get this checked?

Dr Hanumantharaya

I think yes, I would suggest that at least we should do some basic investigations in your case to rule out some malabsorption conditions and once they are ruled out and if you have any worrying symptoms, I think perhaps you should see a dietitian for a dedicated dietary modification.

Mirella Falcone

Thank you, next question. I recently saw my doctor about my regular stomach pain and discomfort after eating they suggested a gastroscopy, but I am worried about this would I be awake for this, and would I need to stay overnight in the hospital?

Dr Hanumantharaya

I think it is not a painful procedure the gastroscopy and we can give you sedation and sedation would not necessarily just knock you out during the procedure, but it will keep you comfortable itself it takes about 10 minutes to do and most of the patients are you know could go home excuse me now we're after the procedure and we don't normally keep the patients in the hospitals after the first year.

Mirella Falcone

Thank you, next question. I'm quite an active person and cycle to work most days my GP suggested exercise can help to bloat but after eating breakfast I feel so bloated that I don't enjoy cycling, should I avoid exercise so soon after eating?

Dr Hanumantharaya

I think I think you should try and take a light exercise perhaps a casual walk after your dinner or after lunch, certainly, I wouldn't advise you cycling which probably can cause more discomfort and I would be just to know what kind of investigations you had so far and occasionally I think there might be, as mentioned earlier, and there might be some issues with

motility disorders and it's worth checking to make sure that your gut is working well.

Mirella Falcone

Thank you, next question. I don't suffer floating pains, but I feel that my tummy rumbles and makes noises so regularly that it can be embarrassing it even makes noises when I'm not hungry at all. Should I see a gastroenterologist? Sorry didn't pronounce that correctly.

Dr Hanumantharaya

I think you know this is the most of the patients it is just the perception that you know there is the content in their gastrointestinal tract is quite a lot and they're producing a lot of gas this is just a false perception but yes I think there might be the reason that you are probably eating a lot of complex carbohydrates which is drawing a lot of water into your gut as well and perhaps I think you know you would certainly benefit from some dietary modifications such as low FODMAP diet to decrease the osmotic load in your gut.

Mirella Falcone

Thank you, next question. I struggle to sleep at night due to acid reflux and sometimes wake up because of it I have stopped drinking tea and sleep more upright. Are there any other solutions I can try?

Dr Hanumantharaya

Well certainly I think as I mentioned in my talk I think you know elevating the editing of the bed at least six to eight inches would help you and I think you might be having inadequate acid suppression and I think it will be useful that you know if you could you know to swap your or you can if you could take an extra acid suppression medication an hour before your evening main certainly would help some of the patients.

Mirella Falcone

Thank you, next question. I suffer quite badly from heartburn and bloating after eating, I have tried changing my diet. Are there any natural remedies I can try before resorting to an endoscopy?

Dr Hanumantharaya

I think that we have advised patients to take peppermint capsules which are quite good, and some patients would benefit from charcoal tablets as well I think there's a lot of information on the website of the natural medicine as well you could have a look at that.

Mirella Falcone

Thank you, next question. What does modulation of the brain-gut axis mean? Now I think that's a good question and basically, like any part of our body our gut is heavily innovative with the nerve endings and in some patients especially patients who are very anxious and these nerve endings get criteria and this is sensed very easily by our gut and our brain as well and so modulating this what we call as a visual hypersensitivity or irritation using some of the lotus anticipate is clearly shown to be a benefit in those patients with a disordered gut-brain access.

Mirella Falcone

Last question. Is chicory root fibre good or bad for a FODMAP diet?

Dr Hanumantharaya

I really don't know about that, and I think you know we'll probably ask our dietitian, and I will we'll get back to you on that.

Mirella Falcone

Thank you, so thank you to everybody that asked the questions. If you've provided your name, we'll be able to answer any other questions after the webinar. If you'd like to book your consultation, please contact us on the number on your screen until eight o'clock tonight or between eight am and six pm Monday to Friday. You'll receive a short survey, and we would be grateful if you could spare a few minutes to let us have your feedback on today's webinar.

Our next webinar is on the 30th of June with consultant Gynaecologists, Rowan Connell and Ana Zakaryan who will be discussing the MonaLisa Touch and female health services including HRT and menopause. So, on behalf of Dr Hanumantharaya, myself, and the team at Benenden Hospital, I'd like to say thank you very much for joining us today and we look forward to you joining us again on another webinar very soon. Thank you.

Dr Hanumantharaya

Thank you very much.