**Episode Title: EP57: Second Interview With Senior Gastroenterologist Gautam Ramnath**
**Dr. Warwick Bishop:** Welcome to Dr. Warwick's podcast channel. Warwick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warwick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love.
Hi, my name's Dr. Warwick Bishop, and I'd like to welcome you to my consulting room. Today I've got a return visitor. Today I have the opportunity to talk with and interview Dr. Gautham Ramnath, who's a senior gastroenterologist based in Brisbane. Gautham has worked predominantly in private practice in gastroenterology for over a decade in Brisbane, but also has been well trained in geriatrics and pharmacology. He's been a previous guest on this podcast show, and I'm absolutely delighted to have him back again today. Welcome back, Gautham.
**Dr. Gautham Ramnath:** Hello, Warwick. Thank you for having me back.
**Dr. Warwick Bishop:** Today, Gautham, I'd really like to cover chest pain, reflux, and how gastroenterologists and cardiologists approach that difficult problem. So why don't I get the ball rolling and ask you, what sort of patients do you commonly see with chest pains that you follow up and investigate and think are predominantly likely to be reflux-related or gastrointestinal-related as opposed to cardiac-related? It's a common problem that we both share; patients don't weigh that much. There are many people who have chest pain, and it's sometimes easier, and the basic starting point for all these patients is to actually listen to the description of pain.
So if someone's describing an acid burning sensation coming from the stomach heading up into the chest, or if they can actually taste their food when that happens, that's a very good marker that it's what we call esophageal reflux disease. That gets contents from the stomach, which are very acidic or bile-containing, to come up into the very sensitive gullet and irritate it, sometimes damaging it.
The flip side to that, as I'm sure you agree, is if it's not such a clear-cut story, and sometimes even if it is a clear-cut story, if there's a high risk of heart disease, we always, as doctors, treat all chest pain as cardiac in origin, even if I give the patient a diagnosis of a gastrointestinal problem. And that's because of the potential consequences. So I think that's the two competing elements I deal with when I see patients with chest pain. One is actually making sure I've got the right description. And that description is the nature, the associated symptoms. Do you taste your food? Is it just a straight pain in the chest? And what other factors would make me consider other diseases, heart disease, but equally in some individuals, disease of what they call the biliary tree, gallbladder, or the pancreas? They can sometimes mimic similar problems.
So one of the difficulties, I think, Gautham, is that they're fairly common bedfellows. Patients that may be predisposed to having reflux problems may also be the very same patients who are predisposed to having heart-related problems. Would you agree?
**Dr. Gautham Ramnath:** Absolutely. And that's why we do have this interplay between gastroenterologists and cardiologists, and sometimes with occasional humorous bits of conflict between the two about where the pain is coming from. It relates to the way the body perceives pain; there is a certain lack of precision about how it tells you where the pain is coming from. The body tells us in little bands across the chest. Imagine tying a string around your chest. That's the way the nerves are distributed into the spinal cord. And we tend to see pain in segments.
Both in gastroenterology and in cardiology, when you have pain in a segment, we look at the structures underneath and on either side of the segment. So if it's anything in your chest, it is ever so hard to say it's not your heart. But if your risks of heart disease are low, if there's a lot of reflux, if there are swallowing problems, if there's a known issue in the background, like a large heart or dyspnea, if you wake up coughing and choking with food in your mouth, that would make me veer more towards urgent assessment for gastrointestinal issues.
So certainly, I tend to agree with you fully that the starting point is the history from the patient and getting a clear description of exactly when the discomfort's occurring. One of the things that I think helps me is obviously whether the pain comes or is associated with exertion, physical exertion, whether it's climbing stairs or walking or whatever that activity may be.
Certainly from a cardiologist perspective, having discomfort occurring with exertion fits more in our diagnostic inclination that it's going to be related to the heart. Though I certainly do see some patients who get reflux, which is gastrointestinal-related pain, with exertion as well. So it's not always that clear-cut, is it?
**Dr. Gautham Ramnath:** No, it's not. Again, I can tell you a personal story that I had the world's worst reflux, and I promptly went along and saw my cardiologist. I'm sorry, Warwick, you weren't in town at that time, and I live a few thousand kilometers from you. Don't blame someone else. But I had my whole extensive workup, as you would as a person in their mid-40s who has a terrible family history of heart disease. I then had to find a colleague who had to do the endoscopy, which showed me my nasty reflux.
**Dr. Warwick Bishop:** Absolutely right. Because it's the same nerves that supply both the esophagus and the heart, it is absolutely possible sometimes to tell them apart based only on their history. So if you have troubles telling them apart, what sort of investigations do you use as your initial investigations to try and get more information, Gautam?
**Dr. Gautham Ramnath:** There are what we call alarm features in the history, and I'll go back to history for a moment because people often come in and what they assume is reflux may not be. So I always drive back to tell me exactly what you feel and sense to break down rather than go on what their descriptive diagnosis starts with. From there, if it's pain lower down in the chest, I'd consider problems with the biliary tree. So you'd look at liver function tests, markers for the pancreas, an ultrasound of the gallbladder, and the upper abdomen.
As you go higher up, you have other alarm features, one in particular called dysphagia, which is where a sense of food's sticking. That's a very good marker. There's something wrong with either the mechanics of the way the gullet is working or with the inner surface. Dysphagia for us is a very important sign because it's one that we don't want to delay endoscopy. It can lead to early diagnosis, especially of esophageal cancer, which thankfully in our community remains rare. So that's a fairly important point I might just highlight for the people listening. Changes in swallowing is a very important symptom to follow up with your doctor straight away. Is that what you're saying?
**Dr. Gautham Ramnath:** Absolutely. It's the gastroenterologist's equivalent of crushing chest pain when you walk upstairs.
**Dr. Warwick Bishop:** Yep, yep. Okay, I get that. So if you had any trouble swallowing, if you had a sense of acid in your mouth or waking up with food in your mouth, or if you are anemic or iron deficient, as a gastroenterologist, there are features that would make me want to evaluate endoscopically, which is a little flexible tube with a camera, to look down the throat as early as possible.
**Dr. Gautham Ramnath:** Sorry, Kerry?
**Dr. Warwick Bishop:** I was just going to say, the reason being, in most cases, happily, it's something simple enough that I can treat. But we certainly don't want to lose any time in more sinister cases.
So one of the things I was going to ask you is whether you ever use drug treatment for reflux as a diagnostic therapeutic trial. So if you really thought someone had a simple case of reflux, would you put them on an antacid therapy and bring them back in a week or two and see how they've gone?
**Dr. Gautham Ramnath:** I do, in fact. And again, it comes back to the individual you're dealing with. So a 20-year-old who's just come back from school who's got nasty reflux and they feel acid coming up into their chest, sometimes taking a topical antacid, even Gaviscon, Myelanta, if it soothes the symptoms very quickly, that's a good sign that it's something local associated with the top of the gastrointestinal tract.
And whether I tend not to use tablets like the more potent acid-suppressing agents, we have a category of tablets called proton pump inhibitors. I tend to reserve that until I'm a bit more satisfied because I don't like patients going on drug trials open-ended. If they can convince me and they come back and say, "Hey, listen, when I eat four hours after eating, I get this burning pain, it comes up, I took my lantern, it went away." That's a good correlation that says it's acid-related. Then if they tell me it happens all the time, I'm getting it five, six times a week, that's frequent enough to make me reach for a script pad.
**Dr. Warwick Bishop:** Yeah. There is still some controversy about who do you not have a look in. A younger, fit person, perhaps not. But if you have added factors like a smoker, excess alcohol, someone 40 plus, you definitely are going to tend more to having a look endoscopically. And obviously, an endoscope is a tube or a telescope that goes down into the gullet and looks at the top end of the gullet.
That's a fairly simple and easy procedure. That's my understanding of it. As a gastroenterologist, you don't see that as a particularly invasive procedure or do you see it as a simple procedure?
**Dr. Gautham Ramnath:** The gastroenterologist, that's my perspective, will always say if only it wasn't for the gag reflex, we could do it as part of our initial consultation. And that's absolutely true. The complications, because it can be uncomfortable as the scope goes just past the top of the throat, we tend to give people a light sedation. So it can be a little bit time-consuming. It takes about three to four hours, typically. We want people to fasten their stomachs completely empty. And it is very well tolerated. So it's a very common procedure. It's performed frequently. It's usually safe.
I always take my time to tell my patients, life is never risk-free, but major life-threatening complications, major complications in endoscopy are very, very infrequent, far less than 1 in 2,000, 1 in 3,000.
**Dr. Warwick Bishop:** Yeah, so it's a pretty safe, widely used, safe procedure.
**Dr. Gautham Ramnath:** Yeah, pretty safe and widely used. And obviously, if you get to look, if you actually get to look at the esophagus and at the stomach, you can make a direct visual appraisal of what's going on and figure out what the diagnosis is. So obviously a very powerful diagnostic tool as well.
**Dr. Warwick Bishop:** It's very useful. And its main utility is it tells me the severity of damage. It tells me about precancerous changes. It also helps identify where the problem's coming from. Sometimes the problem is more the stomach than the esophagus. Many times everything looks quite normal, and a lot of interpretations are needed to make sure we have the right diagnosis. So in terms of identifying surface damage or precancerous changes or other processes, it's invaluable. We unfortunately don't have a replacement for that.
**Dr. Gautham Ramnath:** Yeah.
**Dr. Warwick Bishop:** Look, one of the other things I was going to ask you is when you're first evaluating a patient with reflux, are there any drugs that that patient may be taking that would get your attention or make you focus more on reflux being more likely or drugs that would make you think it's less likely?
**Dr. Gautham Ramnath:** Intriguingly, when I look at people who come in with what sounds like reflux, I take a bigger step back, Warwick. The body has a limited number of ways of expressing an underlying disease. So what we often refer to as reflux is simply an inflamed or irritated gullet or esophagus. And the first thing I do is actually try and look at what other potential causes of inflammation you can get to the gullet.
And society-wide, one of the bigger causes, unfortunately, which can impede our free time, is alcohol. Alcohol is very caustic, very irritant. And if you have severe ulceration in either the esophagus, which is the gullet, or the stomach, it's very difficult to get that ulceration to resolve while you're still on the alcohol. So if you talk about drugs, that's my first pick.
**Dr. Warwick Bishop:** Yeah.
**Dr. Gautham Ramnath:** There are particular agents that are caustic. So there are antibiotics that are irritant that can sometimes get stuck halfway and cause a focal ulcer where it just eats its way in. One called doxycycline. So that's part of the reason why we always tell people to have a large glass of water with their antibiotics. Intriguingly, asthma patients. The inhaler sometimes causes candida or thrush, a fungal infection. It's very common and presents exactly like reflux.
A lot of my patients will tell me, "I've tried everything, it's not going away." And then when you take a history and say, "Yes, I've taken my inhaler, I've got terrible asthma," many of them will have candida or thrush infection. Identifying it allows us to treat it ever so simply. There is a remnant population that when we say we've got a symptom, what we're actually saying is our nerves are telling us there's a problem. And sometimes the nerves can misfire. That's what we call a functional disorder. We do see that from time to time.
Did you mention the non-steroidal anti-inflammatory drugs like Voltaren or Indosid? Do you think they've got a big role in reflux?
**Dr. Gautham Ramnath:** Interesting thing. I am not... If they get stuck halfway, if someone, for whatever reason, they have a blockage in their food tube in the chest that goes to the esophagus, yes, it can cause a local irritant effect. But it is such a distinct organ from the stomach and the small bowel, which is where the anti-inflammatories cause more trouble. So I don't see that they cause trouble in the esophagus. It's starting to cause trouble more in the stomach.
It sounds like I'm splitting hairs there, but from a patient and gastroenterology perspective, even though they are connected, problems in the stomach tend to be very distinct from problems in the esophagus. So I have patients with large hiatal hernias, which is where some of the stomach comes up into the chest, makes it easier to reflux. Perhaps a few of them, because there's so much free food, tablets, everything washing back and forth, may have slightly more problems with the esophagus. But that category of tablets, the Voltaren and Indosid, is more the stomach and small bowel is what we see.
**Dr. Warwick Bishop:** Okay. Well, look, in the interest of time, I'm going to start to wrap up. But there is some really interesting interplay that I want to share with you and see what your comments are on. And that's that you know very clearly that the esophagus runs right down to the back of the heart and really approximates to the left atrium so that these things literally touch each other.
And obviously, as cardiologists, we take advantage of that because we put a tube down the esophagus with an ultrasound probe so we can look into the heart very closely. But what I see, I think, over and over is people who describe refluxy type symptoms or unsettled gastroenterological problems, but they report palpitations as well. Do you want to talk to that? Because I find it absolutely fascinating, and I've got a funny feeling there's something really going on there, and we just don't understand it well.
**Dr. Gautham Ramnath:** You know, it's really interesting you brought that up, Warwick, because I do have a few patients who will tell me very clearly, "I get reflux, my heart's doing something funny." And there's a couple of different mechanisms where it can do that. The fundamental issue, as I said earlier, is the nerve ending to the heart; it travels the same nerve bundle as the nerve endings to the esophagus. So it's quite likely that they're sensing the heart, but the body's misreporting it as right next door.
I think we may have both at one point been at Flinders Medical Center, and we had an esteemed professor of cardiology whose reflux disappeared after he had his bypass surgery. We have quite a few of those patients as well. So with medicine, with individuals, there is a certain unfortunate imprecision to how nerve endings work. And absolutely, yes, I think that there is something there. Whether I can accurately tell you just on the history alone, I'm sorry, I can't. I've never been able to do that. I have had many interesting conversations with cardiac and gastric colleagues to say maybe we should look sideways.
We know that if it's an abnormal rhythm and the heart's not pumping effectively, some of the chambers get a bit bigger under stress and that pushes into the esophagus. That's another potential way to do that as well. But, yeah, I agree with you. There certainly is an interplay, and I do see that.
**Dr. Warwick Bishop:** Yeah. Well, look, I mean, from my own anecdotal perspective, I've had a few patients with irregular heartbeats, what we would call ectopic beats, so extra beats, particularly atrial or ventricular; it doesn't matter, but they've also described a history of worsening reflux at the same time. And to my surprise, when I've given them a little bit of proton pump inhibitor to carry them over till they see their gastroenterologist, they come back and say, "I didn't go and see them because my tummy settled down and the palpitations went away." So it's fascinating, absolutely fascinating.
Let me spin it around to you another way, because there's an interesting body of data coming out now that patients with very large hiatal hernias, where part of the stomach pops up into the chest, there's not a lot of space there. There just isn't. So the stomach can sometimes push on the heart a little bit. There's a body of data that says that is associated with cardiac issues as well.
**Dr. Gautham Ramnath:** Don't you go stealing all my punter.
**Dr. Warwick Bishop:** Well, before we get too much reflux or cause heartburn, we might wrap that up there. Gautham, it's been an absolute delight talking to you. I know that both of us are constantly confronted by the interesting intricacies of clinical medicine and the challenges that it brings. Reflux is no different. Constant. It's a very common entity, but so commonly does it present uncommonly. So it's been an absolute delight talking with you. Thank you so much for sharing today on the podcast. Take care.
**Dr. Gautham Ramnath:** So thank you. Say goodbye to everyone.
**Dr. Warwick Bishop:** Indeed. Thank you for having me back on your podcast, and as someone who keeps yours, support mechanisms for the gut, otherwise commonly known as the heart, and good health for my patients. I appreciate that. But lovely hat. See you again, Laura.
**Dr. Warwick Bishop:** Thanks, Gautham. And to the podcast listeners, thank you for joining us. And until next time, I wish you the very best. Goodbye.
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