What are the Long Term Consequences of Untreated Heartburn?

An empty operating room. (Hemera)
An empty operating room. (Hemera)

A case of hiatus hernia with severe reflux esophagitis - inflammation and ulcerations.
A case of hiatus hernia with severe reflux esophagitis – inflammation and ulcerations.

Heartburn is a symptom of gastroesophageal reflux disease (GERD). That means there is reflux of acid and bile from the stomach and duodenum into the esophagus. This irritates the esophagus and causes symptoms in the short term and damages the esophagus in the long run. Reflux may be associated with or without a hiatus hernia.

Children and adults are affected by this condition. Today, we will talk about adults with heartburn.

The most common symptoms of GERD are: heartburn, regurgitation and trouble swallowing. Less common symptoms are: pain with swallowing, increased salivation (also known as water brash), nausea and chest pain.

A person can have several other atypical symptoms associated with GERD. These symptoms are: chronic cough, laryngitis (hoarseness, throat clearing), asthma, erosion of dental enamel, dentine hypersensitivity, sinusitis, damaged teeth and pharyngitis.

If GERD remains untreated then there are serious consequences leading to injury of the esophagus. You don’t want that to happen to the only organ which carries food from your mouth to the stomach.

The damage starts with the condition called reflux esophagitis (see attached picture). Gastric acid and bile are toxic to the lining of the esophagus (epithelium) causing ulcers near the junction of the stomach and esophagus. This eventually leads to esophageal strictures – the persistent narrowing of the esophagus. It becomes difficult to swallow solid food and sometimes liquids if it is too narrow.

The next change occurs in the form of Barrett’s esophagus called intestinal metaplasia (changes of the epithelial cells from squamous to intestinal columnar epithelium) of the distal esophagus. This is a premalignant condition. The final chapter in this ongoing saga is headlined with that ugly word – cancer. What starts with a simple symptom of heartburn can transform into cancer. The progression is slow but can be persistent if heartburn is not treated.

Heartburn is a very common condition. Four to nine percent adults have heartburn daily, and another 10 to 15 percent have heartburn at least once a week. That means about 20 percent of the adults have heartburn on a weekly basis. Diagnosis is based mainly on symptoms.

Endoscopy is required if complications of GERD are suspected. Barium studies are also indicated in some instances.

Heartburn can be prevented by change in lifestyle: lose weight, change eating habits, avoid bending or straining, sleep with the head of the bed elevated (maximum damage to the esophagus occurs at night), no smoking, no alcohol, and take appropriate medications to neutralize or reduce acid in the stomach. Surgery is also an option in patients with intractable problems or complications of reflux.

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Heartburn, Barrett’s Esophagus, and Cancer

Dear Dr. B: I have chronic heartburn. I have been told I have Barrett’s esophagus. I believe this is a pre-malignant condition. Should I be having scope tests every year as a method for surveillance and early detection of cancer of the esophagus?

Dear reader: Answer to this question depends on the type of changes seen in the esophagus. There are many unresolved controversies regarding the surveillance and management of this condition. Let us briefly look at the whole subject of Barrett’s esophagus and the current recommendations.

All experts agree that Barrett’s esophagus is a complication of long lasting and usually severe gastro-esophageal reflux disease (GERD) – commonly known as heartburn. This may or may not be associated with a hiatus hernia.

The condition was first described in 1950 by Sir Norman Barrett. His original description has been revised few times. Currently, Barrett’s esophagus implies change in the lining of the esophagus (of any length) from a squamous type to columnar type. This change is only recognized at the time of endoscopy and confirmed by biopsy.

Barrett’s esophagus affects mainly white men, with an average age of 55 years. It occurs in only a small percentage of people with GERD – approximately five to15 percent of patients with inflamed esophagus due to reflux. There is a small but definite increased risk of cancer of the esophagus in people with Barrett’s esophagus.

About 10 percent of patients with Barrett’s esophagus at the time of the initial endoscopic examination have coexistent esophageal cancer. Unfortunately, the 5 year survival rate for patients with esophageal cancer is only 11 percent.

Is it possible to do something to prevent Barrett’s esophagus from turning into esophageal cancer?

Regular endoscopic surveillance and biopsy is recommended for patients with Barrett’s esophagus despite the high cost and inconvenience and the lack of proof that it prolongs survival. Biopsies are done to look for dysplasia.

Dysplasia is a cellular process that occurs in the lining of the Barrett’s esophagus. Presence of dysplasia indicates increased risk of cancer. It is not a foregone conclusion that patients with dysplasia will develop cancer but dysplasia remains the best indicator of cancer risk.

How often one should have scope tests and biopsies? It depends on the presence of dysplasia in the Barrett’s esophagus:
If the patient has no dysplasia: The frequency for endoscopic biopsy surveillance is annually twice, and then, if no dysplasia is found, every 3 to 5 years. Risk of subsequently developing cancer is quite low.
If the patient has low grade dysplasia: A surveillance endoscopy with biopsies at six months, one year, and then yearly is recommended.
If the patient has high grade dysplasia: The management of high grade dysplasia involves repeating the biopsies right after the high grade is discovered to rule out an accompanying cancer. Esophagectomy (surgical removal of the esophagus) is the gold standard of therapy for high grade dysplasia and cancer, but experimental procedures are available.

The treatment for Barrett’s esophagus is, in general, essentially the same as for GERD and heartburn. It is either medical (acid-suppression drugs) or surgical (fundoplication). There is no guarantee that either treatment will result in the disappearance of Barrett’s esophagus or in a reduced cancer risk.

Thought for the week:
“Nothing can be created out of nothing.”
-Lucretius 99-95 BC

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Esophageal Cancer

Cancer of the esophagus (gullet) is relatively uncommon condition. But because of its poor prognosis, it ranks among the 10 leading causes of cancer death in Canadian men 45 years of age and older

Dave’s uncle Bill finds out about it when he has difficulty swallowing food.

Bill starts to lose weight. He tries bland and pureed (liquid) diet. But he continues to lose weight. Except for saliva, nothing goes down.

Bill lives alone. He does not like to complain or bother other people.

One day, Dave runs into Bill at a shopping mall. Dave is surprised to see how much weight Bill has lost. Dave invites Bill to come over for a good home cooked meal.

Dave’s wife Susan cooks roast beef. Bill is hungry and takes the first bite. He chokes. The food is stuck in the esophagus. He is unable to swallow saliva. He is rushed to the Emergency Department.

Bill undergoes emergency gastroscopy (a flexible long instrument with light and camera at the tip) to check and remove the food bolus from the esophagus. The physician also finds the cause of the blockage – a tumour. He takes biopsies and within few days the result shows cancer.

Bill undergoes more tests to see if the cancer has spread. These tests are chest x-ray, blood tests, ultrasound of the liver, and CAT scan of the chest. Unfortunately, the results show that the cancer has advanced.

Bill is shocked. So is Dave. Naturally, their first question is – now what? They want to know everything about the cancer.

In an adult, esophagus is a long straight tube, 40 cm. long. It starts in the throat, travels through the chest cavity, behind the heart and the big vessels (aorta), passes through the diaphragm and joins the stomach. About 4 cm. of the esophagus is below the diaphragm.

Esophagus connects the mouth to the stomach. What a journey our food has to take before it gets to the stomach!

The esophagus is kept lubricated by saliva we swallow and the mucous secreted by the esophageal glands.

Esophageal cancer is slightly more common in males than females. Some of the possible causes of this cancer are alcohol, tobacco, chronic inflammation of the esophagus, and previous lye-induced injury.

Esophageal cancer occurs either in the upper, middle, or lower part of the gullet. Since the gullet is fairly small in diameter, the symptoms of blockage occur early. But it does not help improve prognosis. In approximately 95 per cent of cases, surgical cure is impossible by the time diagnoses is made.

Hence treatment options are very limited. Besides surgery, radiotherapy has shown promising results in some cases. But 5 year survival rate for surgery, radiotherapy or the combination of the two is poor (5 to 15 percent).

In most cases, the only treatment option is palliative in nature. This may include chemotherapy to treat the systemic disease (cancer spread), dilatation, stent or laser therapy to keep the esophageal lumen open.

Unfortunately, Bill’s tumor has already spread to lungs and liver. Therefore, he has very limited treatment options. And the prognosis remains poor.

Bill and his family need emotional support in this trying time. Pain control is very important for comfort and to keep the moral up. Therefore, he is referred to Cancer Clinic, Pain Clinic and Palliative Care Program.

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

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