Posted October 7, 2013
Miami Herald
By Howard Cohen, The Miami Herald
Heartburn is a hot topic.
Tune in to television and lay off the DVR’s fast-forward button during the commercial breaks. We’re talking heartburn and acid reflux problems, which are on the rise.
“The problem is half the people in this country experience reflux. It’s very common and a lot of that may have to do with obesity,” said Dr. Michael Sternthal, medical director of the Endoscopy Center at Baptist Hospital in Coral Springs. “People are gaining weight and that’s certainly a big risk factor. Some of that is due to more awareness. We used to have the old [Pepto Bismol] commercial — ‘plop-plop, fizz-fizz’ — now we are inundated with the [Nexium] ‘purple pill’ and you go to the drug store and see lines of pill bottles.”
Some of the reflux can be relatively harmless. Most everybody can relate to that roiling, boiling sensation that bubbles up from the stomach to the throat after a big or spicy meal. Often, the symptoms are traceable to that second helping of nachos and are not regular occurrences.
Changes in diet and exercise to control weight gain, avoiding alcohol and smoking, and listening to mom’s admonishment — “Don’t lie down after dinner!” — can quench the fire. When that doesn’t work, over-the-counter medications, primarily proton pump inhibitors (PPI) like Prevacid and Prilosec that block acid production, can alleviate the symptoms.
But gastroesophageal reflux disease, or GERD, can be more serious. GERD, which affects an estimated 25 percent of the U.S. population , or about 50 million Americans, can make swallowing difficult and lead to chronic throat and chest pain. Left untreated, GERD eats away at the lining of the esophagus, a 10-inch tube with which we swallow food and drink, and renders the esophageal sphincter flap, which keeps stomach acid, bile and other contents, out of the throat, relatively ineffective. Cancer of the esophagus can result, though it is not as prevalent as colon cancer, which is the second-leading cause of cancer death behind lung cancer.
“The alarms are if you are losing weight, food is getting stuck when you swallow, or you vomit blood or have a dark stool then you should see your doctor,” Sternthal said.
Obesity can increase pressure in the abdominal area and push the stomach into the chest, known as a hiatal hernia, which leads to a higher chance of acid spilling into the esophagus, said Dr. Baharak Moshiree, an associate professor of medicine and director of motility at the University of Miami Miller School of Medicine.
Raising the head of the bed by six to eight inches with a block, not just pillows, and not eating late at night or within three hours of bedtime can alleviate symptoms or reduce the risk of reflux.
“Acid reflux-inducing foods like Hispanics love, cafe con leche, because of the caffeine which is hard to tell patients to avoid, causes inflammation of the stomach and causes impairment of the muscles in the lower esophageal sphincter,” Moshiree said. “Caffeine weakens the muscles which predisposes us to more reflux. Same with chocolate and alcohol. Peppermint, fatty and fried foods does the same thing. Smoking neutralizes the saliva in our mouth and saliva can neutralize acid so this can cause more symptoms.”
Chewing gum, Moshiree said, can be helpful because it stimulates saliva production.
Barrett syndrome is a more serious complication of prolonged acid reflux, lasting 10 or more years. The lining of the esophagus, worn by acid, changes to a tissue similar to the intestinal lining. The process is referred to as intestinal metaplasia. Individuals with Barrett’s esophagus are at increased risk for a rare type of cancer called esophageal adenocarcinoma. A preventative procedure, radial frequency ablation, scoops out damaged tissue from the esophagus and can help avert or treat Barrett’s.
Once diagnosed with Barrett’s, which affects about 10 percent of adults with reflux, according to Dr. Barry Migicovsky, a gastroenterologist with Memorial Regional Hospital, an individual will usually undergo surgery to remove the abnormal cells and then is put on meds indefinitely.
Vanessa Gonzalez, 36, a reflux patient of Moshiree, never figured she could have GERD despite a persistent cough that lasted for five months at a time.
“I never felt any heartburn or symptoms that would tell you you have acid reflux,” she said. A gastroenterologist who examined Gonzalez, who works as an administrator in the cardiology department at the University of Miami, suggested her problem sounded like GERD.
“I said, ‘Oh, you must be out of your mind.’ Just because I had this cough I thought everyone was crazy telling me I had GERD. But then a few months ago I got this really bad, crushing pain in my chest. I didn’t have the cough but had this pain and got scared. Every time I’d lean forward or lay down it was really painful and the first thing you think is you are having a heart attack. I finally went to Dr. Moshiree and she did an endoscopy and the results came back that I had symptoms of GERD.”
Gonzalez was put on Zantac, a histamine blocker, and said she hasn’t had symptoms since.
“My whole experience triggered my husband to go see her as well. He gets a lot of heartburn and had similar symptoms but he has reflux, not GERD. He eats a lot of spicy foods.”
Richard Kearns, a patient of Migicovsky’s at Memorial and a former CEO of Spice World, a major supplier of garlic to the nation’s supermarkets, had Barrett’s.
“Being a layman, I thought it was heartburn. There was a time if I ate too close to bedtime, which I would do a lot when going out with colleagues and having a glass or two of wine, I felt like someone put a blowtorch in my esophagus. I realized this was not normal,” he said from his home in Deerfield Beach.
Kearns underwent the ablation procedure about 2-1/2 years ago. “There was some pain involved, nothing I couldn’t live with. I didn’t love the soft diet for a week afterward,” he said, chuckling.
Last week an endoscopy revealed his system was clear. “I’m feeling pretty darned good.”
Screenings can detect esophageal problems before they become too serious or lead to cancer.
High resolution esophageal and three-dimensional anorectal manometry uses color topography to measure the areas of the esophagus as they contract. Probes measure the acidity in the esophagus and how often a patient has reflux episodes. For this test, a patient wears a catheter for 24 hours and is assessed by the doctor after returning the following day.
A Bravo sensor capsule, lowered into the esophagus through the mouth where it can attach to the esophagus wall, transmits radio frequency to a computer for a doctor’s analysis. This test is popular with younger patients and the capsule is excreted via the GI tract in about 48 hours.
When reflux or GERD is diagnosed, proton pump inhibitors like Nexium are effective but long term use can increase chances for osteoporosis because the meds can interfere with the absorption of calcium and vitamin B12. Rather, it’s better to change your diet and lifestyle, doctors say.
If one has Barrett’s and treatments like ablation do not work, or if there is cancer and it isn’t caught early enough, the best option is surgery, said Dr. Mark Block, chief of the division of thoracic surgery at Memorial Healthcare System in Broward.
One type of surgery, done through laparoscopy, sews the upper part of the stomach around the lower part of the esophagus to shore up the sphincter muscle. Robotic, three-dimensional visualization, or video-assisted thoracic surgery, is minimally invasive and makes little incisions.
“This can make a big difference in recovery time and the complication rate after surgery,” Block said. “In the last year or so I’ve done probably half a dozen, and the recovery is much better than the traditional open approach.”
The most common complication of the surgery is pneumonia and breathing problems. Patients are kept in the hospital for a minimum of a week and drink liquids during the healing process.
“Most can come back to the same sort of diet before they became ill but they have to eat smaller meals more regularly because they don’t have a functioning esophagus so they have to be careful not to lay down after they eat,” Block said. “If you catch these cancers early, the operation is curative.”
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