Heartburn, also known as GERD or Acid Reflux
Heartburn is a well-known condition defined as excessive relux of stomach contents into the esophagus causing injury, inflammation, pain, and sometimes coughing and choking. GERD is the medical term for heartburn and stands for Gastro Esophageal Reflux Disease. It is estimated that perhaps 20% of the US population experiences GERD on a regular basis. In contrast, GERD occurs in only 5% of the population in Asian countries. It appears that the incidence of acid reflux correlates strongly with obesity, sedentary lifestyle and rich diet. It has been observed that as more countries adopt a western diet and lifestyle westernized, heartburn rates are increasing.
GERD is further defined by the appearance of the esophagus during an upper endoscopic exam. An upper endoscopy utilizes a fiberoptic, lighted scope to directly visualize the esophageal lining. If obvious erosions and erythema are present within the esophagus, we call that “GERD with erosive esophagitis”. If the esophagus looks pretty normal, we call that “non erosive GERD” or “NERD”.
GERD can cause a wide range of symptoms – the classic symptoms being burning in the chest after eating, bitter juices refluxing into the mouth, and waking up at night with coughing and choking, and nausea in the morning. However, many patients do not experience “classic GERD” and will report different symptoms. For example, they may experience atypical GERD symptoms such as, a non-specific discomfort in the chest but no burning, or they might develop a chronic cough, sinus and ear problems, and shortness of breath.
In severe cases of GERD, asthma and other respiratory problems as a result of gastric juices refluxing into the lungs. This is called aspiration. Many of these patients may start off with their ENT or pulmonary specialist looking into causes of their breathing issues,only to find they are being referred to a gastroenterologist to investigate for GERD.
How Is Heartburn Managed?
In most patients with typical or atrypical GERD, a careful medical history can identify factors known to be associated with heartburn. This history will include diet, lifestyle, medication use, alcohol and tobacco use, family history, and prior surgeries to the intestinal tract. Other medical conditions might also be contributing to GERD such as, low thyroid, obesity, delayed stomach emptying, diabetes and many more. Once we have a good understanding of the heartburn history, a management plan can be outlined.
The typical work up for GERD would include basic labs, possibly an abdominal and chest Xray, a referral to a dietitian for counseling and possibly a weight management program. Individuals that appear to be at high risk for esophageal damage, will undergo an upper endoscopy to identify signs of inflammation, as well as precancerous or cancerous changes.
Is Heartburn Dangerous?
For a very long time, the medical community did not believe that heartburn was a concerning issue. Heartburn sufferers were recommended antacid therapy, along with diet and lifestyle changes. Patients would often self-medicate with TUMs, Rolaids and other over the counter meds. However, we now know that heartburn is a serious condition and needs to be managed properly.
Unfortunately, GERD can stimulate changes in the lower esophagus that may lead to cancer. In the US population, esophageal cancer has been on the rise at an alarming rate. Approximately 18, 000 people die each year from esophageal cancer and this is primarily related to poorly controlled GERD. However, to keep perspective, most patients with GERD will not develop esophageal cancer and with a diagnostic procedure known as upper endoscopy, we can determine very clearly your risk of cancer in the future. The individuals with the highest risk of esophageal cancer have a condition known as Barrett’s esophagus.
Barrett’s Esophagus (BE)
Barrett’s esophagus (BE) is an abnormal lining that develops in the lining of the lower esophagus after years of acid and bile reflux. Barrett’s is not cancer, but it is thought to be the first step towards developing a cancer. It has been shown in the laboratory that chronic pulses of acid into the esophagus stimulate molecular changes in the DNA of cells lining the esophagus. Over time, these DNA changes accumulate and can eventually lead to a Barrett’s and esophageal cancer. Barrett’s esophagus can be identified easily on an upper endoscopy and is usually characterized as “salmon colored” mucosa. The normal esophageal lining appears whitish, while the abnormal Barrett’s tissue will literally look like salmon colored tissue growing up into the esophagus. The technical term for Barrett’s is “intestinal metaplasia“. The term metaplasia means a new lining has formed in a location where it does not normally occur. In the case of Barrett’s, the salmon colored tissue more consistent with small bowel mucosa, should not be seen in the esophagus. The pathologist in the laboratory is able to confirm Barrett’s changes after looking at samples of the esophageal lining under the microscope. The presence of Barrett’s esophagus indicates significant reflux has been occurring over the years. Interestingly, many patients with BE will deny significant heartburn or perhaps they experienced heartburn years ago. To add to our confusion, Barrett’s esophagus may actually make heartburn symptoms disappear. The Barrett’s tissue in some ways, is more resistant to the effects of acid reflux and may be the body’s way of protecting the esophagus form further injury. For that reason, our center is interested in individuals with typical and atypical GERD even if it occurred years ago. They may still need further evaluation to rule out the presence of Barrett’s esophagus.
How Is Barrett’s Esophagus Managed?
Fortunately, most individuals with Barrett’s esophagus will not develop esophageal cancer. There are several factors which make a Barrett’s patient higher risk including the following: a long segment of Barrett’s – over 3 cm in length, dysplasia on the microscopic exam, nodules within the Barrett’s lining that may be harboring more aggressive cell changes, and then other factors like age over 50, obesity, poor diet, untreated GERD, and sedentary lifestyle.
The typical patient who is referred to our center for Barrett’s esophagus will have an upper endoscopy and repeat biopsy of the esophageal lining, possibly molecular/DNA analysis of the Barrett’s tissue, a measurement of Barrett’s length, identification of dysplasia on biopsy, and assessment for any nodules or thickened areas within the Barrett’s tissue. Following the endoscopic assessment, a risk score will be given based on our findings. Risk Categories include high risk, intermediate and low risk.
Patients who have high and intermediate risk will be referred for endoscopic therapy as a way to non-surgically eradicate the Barrett’s tissue. Current treatments for eradicating Barrett’s includes – Radiofrequency ablation (RFA), Endoscopic Mucosal Resection (EMR), Cryotherapy – freeze spray, and other technologies.
Low risk Barrett’s patients will typically have a short segment of abnormal tissue – measured during the endoscopy, no dysplasia in cells analyzed under the microscope, and no nodules or thickened areas seen on the endoscopic exam. These individuals need to be followed periodically but do not need endoscopic treatment.
In our center, all patients with Barrett’s esophagus, high and low risk, are recommended a nutrition consult to discuss diet, foods to avoid, and anticancer strategies. Patients who are overweight are referred to our weight management program. Losing weight has a profound effect on both heartburn activity and cancer risk. We also monitor patients closely to ensure acid reflux is controlled. We often use pH probes to confirm reflux is no longer occurring and in patients who fail to respond, we refer for expert surgical evaluation to consider ways to decrease acid reflux. We like new technologies and will try to stay abreast of new surgical and non-surgical methods of treating heartburn and Barrett’s.