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IN THIS ARTICLE Barrett's esophagus and cancer   
Problems swallowing solid food and weight loss may be a sign of cancer of the esophagus. more...  OTHER TOPICS Exercise, nutrition and health |
More than a Little Heartburn: Gastro-esophageal Reflux Disease (GERD) Gary M. Gray, M.D. Most people suffer now and then from heartburn. Heartburn has nothing at all to do with the heart. It occurs when acid from the stomach regurgitates, or backs up into, the lower esophagus, the tube connecting your mouth and stomach. Most people describe it as ranging from a sour taste in the back of the mouth to a powerful burning sensation in the mid or lower chest and throat. Normally, this regurgitation is prevented by the esophageal sphincter, a sort of one-way valve that allows food and drink to pass down the esophagus to the stomach while preventing gastric acid and other stomach contents from traveling in the opposite direction. Heartburn often comes after you lie down with a full stomach, for instance in bed after a large or late dinner, or after exposing the esophagus to tobacco smoke, alcohol, coffee or other substances that tend to increase stomach acid or to relax the esophageal sphincter. Heartburn is much more common than it is serious. If the symptoms are only occasional and they go away when you take an over-the-counter antacid, it is usually nothing to worry about. If, on the other hand, you have chronic problems that are not helped by over-the-counter medicines, you should talk to your doctor. You may have Gastro-Esophageal Reflux Disease or GERD. What is GERD? Like heartburn, GERD is caused by stomach acid moving the wrong way through the esophageal sphincter into the throat. Unlike garden-variety heartburn, however, GERD can be a serious long-term health problem. It can also lead to esophagitis, an inflammation of the esophagus caused by regular reflux of stomach acid back into the esophagus. Some patients with GERD develop a condition called Barrett's esophagus, in which the esophagus undergoes unhealthy changes that may increase the risk of a change to so-called dysplasia. Cells that have developed dysplasia have an increased risk of developing into a cancer. Long-term exposure to stomach acid caused by GERD can cause a variety of problems that are grouped under the term esophagitis. These include loss of the esophagus's protective mucus layer, at times with the development of sores or ulcers. Over a prolonged period, such ulcers may produce scarring, leading to narrowing of the esophageal tube and consequent resistance to passage. Although the effects of GERD are most often felt after going to bed, daytime regurgitation problems are not uncommon. As esophagitis worsens and becomes chronic, producing a narrowing of the esophagus, in addition to heartburn-like symptoms, such as a sour taste in the mouth or a feeling of pressure in the chest area, sufferers may feel pain when swallowing food (odynophagia) and experience the sensation that swallowed food has become stuck (dysphagia). About three-fourths of those with the disease have persistent and disturbing symptoms over many years. At least half of these experience heartburn on a daily basis and one-third need to take an anti-heartburn drug at least once a day.1 Treatment In the past, esophagitis sufferers were told to raise the position of their head while sleeping and were given alkali antacids to neutralize the acid or other medicines that reduce stomach acid production, such as H2-receptor antagonists. While these can still be effective treatments, they do not work for everyone. Fortunately, today's doctors have a whole range of other types of drugs to choose from, including the very effective proton pump inhibitors (PPIs) (omeprazole or Prilosec®; lansoprazole or Prevacid®). In the many cases where esophagitis is not helped by antacids or H2-receptor antagonists, a single capsule per day of omeprazole or lansoprazole provides relief from heartburn and sour regurgitation, and promotes healing of sores and lesions within four weeks in the vast majority of patients.2,3 Many of these new drugs also have the added advantage of being more convenient and less expensive.4,5 Barrett's Esophagus Left untreated, chronic regurgitation of gastric contents can set in motion a process that may end in the development of cancer, or adenocarcinoma, of the lower esophagus. The process works like this: the body tries to protect the esophagus from the damaging effects of stomach acid by bringing tissue to the esophagus from the lining of the upper stomach, an area of the body that is able to handle contact with stomach acid safely. Unfortunately, however, moving to a new environment puts the stomach lining tissue under great stress. This stress causes a series of changes in the new tissue that can eventually lead to the development of cancer. These changes are called Barrett's esophagus. How likely are you to develop this condition? Your risk of developing Barrett's esophagus is significantly greater if you have a history of regular GERD symptoms, if you are over 50 years old, or if your doctor finds esophageal inflammation caused by acid reflux.6,7,8 Barrett's esophagus is far from rare, found in 10% of patients whose persistent symptoms of GERD lead to a "scoping" of their esophagus by a physician. Not all Barrett's esophagus sufferers develop cancer, but their cancer risk is 30 to 125 times greater than that of someone without Barrett's changes.9 Recent studies suggest that there has been a dramatic increase in incidence in recent years, to the point that Barrett's esophagus now results in the most common type of upper gastrointestinal tract malignancy, especially among white men.10,11,12,13,14,15,16,17,18,19 Drugs, Monitoring and Surgery Because Barrett's is more or less a severe form of esophagitis, the first treatment doctors use is to try to reduce stomach acid secretion using the proton pump inhibitors (PPIs) such as omeprazole and lansoprazole. When esophagitis is very severe, double doses of PPI therapy are often necessary to eliminate symptoms of GERD. Unfortunately, these treatments do not always reverse Barrett's. At increased risk for cancer, Barrett's esophagus sufferers must be closely and regularly monitored. Typically, this means an endoscopy, or visual examination of the esophagus using a special instrument, and biopsy, or removal of tissue samples for analysis, of the lower esophagus every 24 to 36 months. Depending on the results of these tests, the doctor may recommend either more frequent monitoring or, perhaps, surgery.20 Laser Surgery A new, relatively untested way to treat Barrett's esophagus is to remove damaged tissue from the esophagus using laser surgery, which can be less invasive than conventional surgery.21 However, the jury is still out on its effectiveness and you may wish to discuss with your own doctor whether this is something you should consider.22 Preventing GERD Symptoms Although those who have changes in the structure of the normal valve mechanism at the lower esophagus will experience reflux of acid and the consequent symptoms of heartburn and a sour taste, there are ways to minimize the regurgitation. Reflux is often more likely to occur after retiring at night because the esophagus loses the advantage of gravity due to its position above the acid-producing stomach. Thus, it is important to eat relatively early meals, several hours before bedtime. It is also important to eat a meal that is relatively low in fat. A dinner high in fat content will slow the rate of stomach emptying, thereby leaving both some residual meal and the added acid produced in response to the meal. Keeping the fat content of the dinner meal to a minimum encourages the stomach to empty the meal and secrete acid long before bedtime. Certain foods will either stimulate stomach acid production or serve to relax the valve at the junction of the esophagus and stomach. To prevent symptoms, therefore, it is important to avoid these foods, particularly late in the day. Coffee, tea and hot chocolate will increase the quantity of stomach acid. Concentrated chocolate and alcohol (particularly in the so-called after-dinner liqueurs) relax the normal esophagus-stomach junction barrier. Hence, simply eating small meals relatively free of fat several hours before bedtime and avoiding chocolate-enriched desserts and liqueurs may be sufficient to greatly decrease for many people nighttime heartburn and regurgitation. Guidelines for Treating GERD
The Future for GERD and Barrett's GERD is a very common condition that often leads doctors to discover Barrett's esophagus and other esophageal problems. What we do not know, however, is how many people may have Barrett's but are unaware of it because they have little or no GERD symptoms. At present, the usual advice is to have anyone with Barrett's undergo an endoscopy every 12-24 months, especially if they are over 50. This represents quite a large and expensive task, even without adding those who may have Barrett's without significant symptoms. In the near future, we hope that non-invasive, efficient methods of diagnosing Barrett's, even in those with mild symptoms, well before it evolves into cancer, will be developed.
References General Review Goyal RK et al. Columnar Lined (Barrett's) Esophagus. Clinician 17 (6):1-30, 1999. 1. McDougall NI; Johnston BT; Kee F, et al: Natural history of reflux oesophagitis: a 10 year follow up of its effect on patient symptomatology and quality of life. Gut 38:481, 1996. return 2. Bate CM, Keeling PW, O'Morain C, Wilkinson SP, Foster DN, Mountford RA, Temperley JM, Harvey RF,Thompson DG, Davis M: Comparison of omeprazole and cimetidine in reflux oesophagitis: symptomatic, endoscopic, and histological evaluations. Gut 31:968, 1990. return 3. Porro GB, Pace F, Peracchia A, Bonavina L, Vigneri S, Scialabba A, Franceschi M: Short-term treatment of refractory reflux esophagitis with different doses of omeprazole or ranitidine. Journal of Clinical Gastroenterology 15:192,1992. return 4. Bloom BS: Cost and quality effects of treating erosive oesophagitis. A re-evaluation. Pharmacoeconomics 8:139, 1995. return 5. Castell DO; Richter JE; Robinson M et al: Efficacy and safety of lansoprazole in the treatment of erosive reflux esophagitis. The Lansoprazole Group. American Journal of Gastroenterology 91:1749, 1996. return 6. Oberg S, DeMeester TR, Peters JH, Hagen JA, Nigro JJ, DeMeester SR, Theisen J, Campos GM, Crookes PF The extent of Barrett's esophagus depends on the status of the lower esophageal sphincter and the degree of esophageal acid exposure. J Thorac Cardiovasc Surg 117:572-80, 1999. return 7. Chalasani N, Wo JM, Hunter JG, Waring JP: Significance of intestinal metaplasia in different areas of esophagus includingesophagogastric junction. Dig Dis Sci 42:603-7, 1997. return 8. Nandurkar S, Talley NJ, Martin CJ, Ng TH, Adams S: Short segment Barrett's oesophagus: prevalence, diagnosis and associations. Gut 40:710-5, 1997. return 9. Gonzalez-Correa CA, Brown BH, Smallwood RH, Kalia N, Stoddard CJ, Stephenson TJ, Haggie SJ, Slater DN, Bardhan KD: Virtual biopsies in Barrett's esophagus using an impedance probe. Ann N Y Acad Sci 873:313-21, 1999. return 10. Gulizia JM, Wang H, Antonioli D, Spechler SJ, Zeroogian J, Goyal R, Shahsafaei A, Chen YY, Odze RD: Proliferative characteristics of intestinalized mucosa in the distal esophagus and gastroesophageal junction (short-segment Barrett's esophagus): a case control study. Hum Pathol 1999 30:412-8, 1999. return 11. Morales TG, Sampliner RE, Bhattacharyya A: Intestinal metaplasia of the gastric cardia. Am J Gastroenterol 92:414-8, 1997. return 12. Spechler SJ: Short and ultrashort Barrett's esophagus--what does it mean? Semin Gastrointest Dis 8:59-67, 1997. return 13. Eloubeidi MA, Provenzale D: Does this patient have Barrett's esophagus? The utility of predicting Barrett'sesophagus at the index endoscopy. Am J Gastroenterol 94:937-43, 1999. return 14. Canto MI, Setrakian S, Petras RE, Blades E, Chak A, Sivak MV Jr: Methylene blue selectively stains intestinal metaplasia in Barrett's esophagus. Gastrointest Endosc 44:1-7, 1996. return 15. MacLennan AJ, Orringer MB, Beer DG: Identification of intestinal-type Barrett's metaplasia by using the intestine-specific protein villin and esophageal brush cytology. Mol Carcinog 24:137-43, 1999. return 16. Ormsby AH, Goldblum JR, Rice TW, Richter JE, Falk GW, Vaezi MF, Gramlich TL: Cytokeratin subsets can reliably distinguish Barrett's esophagus from intestinal metaplasia of the stomach. Hum Pathol 30:288-94, 1999. return 17. Voutilainen M, Farkkila M, Juhola M, Nuorva K, Mauranen K, Mantynen T, Kunnamo I, Mecklin JP, Sipponen P: Specialized columnar epithelium of the esophagogastric junction: prevalence and associations. The Central Finland Endoscopy Study Group. Am J Gastroenterol 94:913-8, 1999. return 18. Morales TG, Bhattacharyya A, Johnson C, Sampliner RE: Is Barrett's esophagus associated with intestinal metaplasia of the gastric cardia? Am J Gastroenterol 92:1818-22, 1997. return 19. Goldblum JR, Vicari JJ, Falk GW, Rice TW, Peek RM, Easley K, Richter JE: Inflammation and intestinal metaplasia of the gastric cardia: the role of gastroesophageal reflux and H. pylori infection. Gastroenterology 114:633-9, 1998. return 20. Oberg S, Clark GW, DeMeester TR: Barrett's esophagus. Update of pathophysiology and management. Hepatogastroenterology 45:1348-56, 1998. return 21. Overholt BF, Panjehpour M, Haydek JM: Photodynamic therapy for Barrett's esophagus: follow-up in 100 patients. Gastrointest Endosc 49:1-7, 1999. return 22. Gossner L, May A, Stolte M, Seitz G, Hahn EG, Ell C: KTP laser destruction of dysplasia and early cancer in columnar-lined Barrett's esophagus. Gastrointest Endosc 49:8-12, 1999. return |
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