Tag: GERD

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Asthma and Reflux

Dear Dr. B: I have asthma and my doctor thinks it is caused by gastro-esophageal reflux disease although I have no history of heartburn. Can you please explain this to me?

Answer: Heartburn and regurgitation are classical symptoms of gastro-esophageal reflux disease (GERD). But GERD may present in atypical ways. Atypical presentation may be in the form of diseases of the lungs, ear, nose and throat or in some other ways. In atypical presentation, majority of the patients do not have classical heartburn or acid regurgitation.

Asthma, chronic bronchitis, aspiration pneumonia, bronchiectasis and pulmonary fibrosis may be some of the lung problems a person may have with atypical GERD.

Atypical GERD may affect ear, nose and throat in the form of chronic cough, laryngitis, hoarseness, pharyngitis and sinusitis.

Non-cardiac chest pain, dental erosions and sleep apnea are other conditions related to atypical presentation of GERD.

These patients are suspected to have atypical presentation of GERD when they fail to respond to conventional therapy for their medical condition. For example, all patients with non-allergic asthma in which wheezing is poorly controlled should be evaluated for GERD.

Studies have shown that 30 per cent or more patients undergoing cardiac angiogram for chest pain will have normal findings. Of these 40 to 50 per cent will have abnormal findings in the esophagus on endoscopy and pH monitoring.

Finding a cause for various conditions mentioned here can be frustrating. Heartburn is often absent. Endoscopy is often negative. It may be worth trying gastric acid suppression therapy using proton pump inhibitors (PPI) to see if the symptoms affecting the lungs, ear, nose and throat and other conditions are relieved by these medications. Trial of medications twice a day for two to three months may be effective.

If the patient does not respond to this therapy then the next line of investigation would be 24-hour pH study while on PPI.

So, it is not easy to come to a diagnostic conclusion when investigating patients who are suspected to have atypical presentation of gastro-esophageal reflux disease. I presume you have had thorough investigation and your doctor has made a diagnosis after taking into consideration all the results.

*****

Are you worried about getting old? Here is a joke I received from a friend:

“Sixty is the worst age to be,” said a 60-year-old man. “You always feel like you have to pee and most of the time you stand there and nothing comes out.”

“Ah, that’s nothing,” said a 70-year-old. “When you’re 70, you don’t have a bowel movement any more. You take laxatives, eat bran and sit on the toilet all day and nothing comes out.”

“Actually,” said the 80-year -old, “Eighty is the worst age of all.”

“Do you have trouble peeing, too?” asked the 60-year old.

“No, I pee every morning at 6:00. I pee like a racehorse on a flat rock, no problem at all.”

“So, do you have a problem with your bowel movement?”

“No, I have one every morning at 6:30.”

Exasperated, the 60-year-old said, “You pee every morning at 6:00 and have a bowel movement every morning at 6:30. So what’s so bad about being 80?”

“I don’t wake up until 7:00,” said the 80-year-old.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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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

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Heart Burn

Heartburn is a common condition and people often ask me: Dr. B, why do I have heartburn? What can I do about it?

“Heartburn is a serious symptom that merits more attention from patients and physicians,” says an editorial in the New England Journal of Medicine (NEJM).

The editorial says that heartburn is the hallmark of reflux from stomach to esophagus, a disorder that may lead to esophagitis (inflammation of the gullet), progressing in some patients to cancer of the esophagus. The cancer is preceded by a condition called Barrett’s esophagus.

Heartburn (also known as GERD or gastro-esophageal reflux disease) is a condition in which an individual experiences a sensation of burning from the stomach to the throat. This is due to the reflux of acid, sometimes mixed with bile and food. This is accompanied by bitter taste in the throat and the mouth. Sometimes coughing spells follow the reflux as the acid spills over into the wind pipe. This may also result in pneumonia.

Normally, below the diaphragm and in the abdominal cavity, there is a functional valve at the junction of the esophagus and the stomach (gastro-esophageal junction). This valve allows saliva and food to travel one way from mouth and esophagus to stomach. When the valve becomes incompetent, stomach contents reflux into the esophagus – resulting in heartburn.

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.

Why does the valve become incompetent?

The valve loses its tone. The exact reason for this is not known. It may be associated with some medical condition, obesity or hiatus hernia – a condition in which gastro-esophageal junction slides between the chest and the abdomen through the opening in the diaphragm – a sliding hiatus hernia. Hiatus hernia may or may not be associated with reflux and vice versa.

How is it diagnosed?

Diagnosis is based on classical symptoms of heartburn. Difficulty swallowing food, liquids or even saliva signifies narrowing of the esophagus due to inflammation, scarring or cancer. Barium x-rays have a limited value in the assessment of esophagitis (inflammation of the esophagus) or Barrett’s esophagus. Endoscopy (gastroscopy) and biopsy is the best way to assess the lining of the esophagus for inflammation or pre-malignant Barrett’s changes.

Every person with heartburn does not require gastroscopy. The NEJM editorial says that there is no precise protocol to say when gastroscopy is warranted in patients with heartburn. The usual indication is when heartburn is severe enough to be the main symptom for which medical evaluation sought, and in patient who presents with difficult swallowing.

Heartburn can be prevented by change in life-style: lose weight, change eating habits, avoid bending or straining, sleep with head end 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.

Remember, heartburn should not be ignored and must be given respect!

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Indigestion

Individuals, health care institutions and Alberta Blue Cross spend millions of dollars for the use and “abuse” of pills for indigestion, heartburn and the treatment of peptic ulcer disease. Is there a sensible way of using these pills?

Recently, this subject was discussed in the DUE (drug use in the elderly) Quarterly.

Dyspepsia (indigestion) affects 29 percent of the adult population and accounts for seven percent of visits to family physicians.

Most widely prescribed and used acid suppressing agents are:

-Proton pump inhibitors (PPI)- accounts for 90 percent of Alberta Blue Cross Group (ABCG) 66’s cost of acid suppression agents (examples-Losec, Prevacid, Pantaloc)

-H2 antagonists –accounts for 10 percent of the ABCG 66’s cost of acid suppression agents (examples-Zantac, Pepcid, Axid and their generic versions)

Why would one need these pills?

-For eradication of Helicobacter pylori organism from the stomach. A protocol requires that any patient with H. pylori infection, in the presence of an ulcer, should receive one week of “triple therapy” – two antibiotics and PPI. In the absence of an ulcer, the use of “triple therapy” is controversial.

-For gastroesophageal reflux disease (heart burn) – four to eight weeks of treatment with PPI or H2 antagonist is indicated with life-style changes.

-For functional dyspepsia, also known as non-ulcer dyspepsia or indigestion. In this condition, an individual has all the symptoms of an ulcer but no ulcer is found on investigations. A difficult condition to treat satisfactorily. A person may end up using the pills for prolonged period of time for symptomatic relief.

-For NSAID-related dyspepsia – individuals who are on non-steroid anti-inflammatory drugs (NSAID) are prone to peptic ulcer disease or indigestion. These individuals are on long-term use of stomach pills.

Losec should be taken half an hour before any meal, while Pantaloc and Prevacid should be taken before breakfast. These pills should be taken whole, not broken or chewed.
The Quarterly says that PPI have been recognized to be efficient and safe in what they do. And there is not much difference in the clinical use of the three PPIs except for the cost.

The cost comparison of PPIs in Alberta shows that Losec 20mg once daily costs $66.00 per month, Pantaloc 40mg once daily costs $61.26 per month and Prevacid 30mg once daily is the cheapest at $60.00 per month.

The largest group of patients on PPI are the ones with heartburn and gastroesophageal reflux disease. Many of these patients can be treated with life style changes and over the counter medications and/or cheaper H2 receptor antagonists like Zantac, Pepcid, or Axid. Those who do not respond to these measures can be stepped up to a PPI. These patients also require investigations to assess the degree of damage to the lining of the oesophagus by gastric and biliary juices.

The next large group on PPI is one with indigestion due to NSAID use. Patients who have peptic ulcer due NSAID therapy are best treated with PPI. NSAID patients are usually on another drug called misoprostal, which offers protection against development of ulcers.

Patients with non-ulcer dyspepsia should not be on long term PPI therapy without trial of other therapies, which are cheaper, and with minimal side effects. Prolonged acid suppression in the stomach without good reason may lead to atrophy of stomach glands and deficiency of vitamin B12. Plus the cost to the patient and other institutions that pay for the prescriptions.

So, if you are on any of the pills mentioned here on long term basis then ask your doctor: Do I really need it? Is there anything cheaper? Is there anything else you can do to relieve your symptoms?

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