As we watch television, read magazines, or speak with friends and family, we are constantly reminded about heartburn and reflux, also known as GERD (Gastroesophageal Reflux Disease). There are multiple over-the-counter remedies to treat this common symptom, but have we ever thought about the potential dangers of chronic gastric acid exposure? Today, I would like to discuss the definition of gastroesophageal disease and the possible risks of developing Barrett’s esophagus and esophageal adenocarcinoma.
One must first realize that some reflux is normal. This symptom occurs when the stomach acid content travels backward from the stomach up into the esophagus. It rarely occurs during sleep or evening hours. Pathologic reflux is associated with symptoms as a burning, at times painful, sensation in the center of one’s chest usually experienced after meals. Difficulty swallowing or dysphagia can occur with longstanding heartburn. One develops ulcerations or possibly a stricture with extended exposure to gastric acid.
The term Gastroesophageal Reflux Disease (GERD) describes patients with symptoms suggestive of reflux or complications from reflux. It has been described that patients with untreated GERD can develop esophagitis in 50 percent of cases when an endoscopy is performed. An endoscopy is an examination of the stomach, esophagus, and small intestine. A flexible instrument is gently placed in the mouth and advanced to the esophagus, stomach, and small intestine while the patient is sedated.
GERD has been found to occur in approximately 22 percent of the entire U.S. population. The most common symptoms of GERD are heartburn, regurgitation, and dysphagia. One can also present with atypical symptoms as chronic cough, laryngitis, and chest pain. GERD-related chest pain may mimic angina pectoris or a heart attack. The symptom is described as a burning, squeezing sensation located in the center of the chest with radiation to the jaw, back, and arms, usually lasting minutes to hours and resolving spontaneously or with antacids. These symptoms usually occur after meals, worsened by emotional stress, and can awaken one from sleep.
Most people try over-the-counter remedies as antacids or proton pump inhibitors as omeprazole, Nexium, or pantoprazole with limited results. Very often, patients do not take these medications appropriately. Most proton pump inhibitors need to be taken 30 minutes before breakfast or supper to maximize acid inhibition. The newest proton pump inhibitor, Dexilant, can be taken with or without food.
GERD may result in many complications that involve the esophagus. Barrett’s esophagus occurs when columnar epithelium replaces the squamous epithelium that normally lines the lower esophagus. This change is secondary to chronic GERD and predisposes people to adenocarcinoma of the esophagus. Unfortunately, this change does not cause any specific symptoms.
The risk of developing esophageal cancer is increased at least 30-fold above that of the general population. The term dysplasia, meaning change, must first occur on the Barrett’s esophagus in order for adenocarcinoma to occur. These changes range from low-grade dysplasia to high-grade dysplasia. The estimate of the risk of progression of low-grade dysplasia Barrett’s esophagus to esophageal adenocarcinoma ranges from 0.2 percent in low-grade to 14 percent per year in high-grade dysplasia.
We treat virtually all patients with Barrett’s esophagus indefinitely with a proton pump inhibitor. The thought process is that by aggressively suppressing acid reflux, we may prevent esophageal cancer. Anti-reflux surgery is an option for highly selected patients who do not respond to acid suppression.
A new mode of therapy called radiofrequency ablation uses radiofrequency energy delivered by a balloon to ablate, or destroy, the Barrett’s mucosa. Patients with documented Barrett’s esophagus with at least low-grade dysplasia are candidates for therapy. Studies have shown reduction in the rate of transformation to adenocarcinoma with RFA therapy.
To summarize, chronic GERD needs to be evaluated appropriately, especially for people with risk factors such as age greater than fifty, history of GERD greater than five years, obesity, and males who are at a definitive higher risk for developing Barrett’s esophagus and adenocarcinoma of the esophagus. I strongly suggest that anyone having reflux for an extended period of time with the above risk factors to contact their medical provider or myself to determine if further studies are required to diagnose Barrett’s esophagus and potentially prevent esophageal carcinoma with appropriate treatment and surveillance. This common symptom known as heartburn can be the first warning sign for possible developing Barrett’s esophagus and possible adenocarcinoma.
Dr. Glenn S. Pfitzner practices at Rockford Digestive Health Specialists, PA, in Mount Airy.