When heartburn turns serious

Heartburn troubles most of us occasionally and is just an irritating inconvenience. It often comes from eating too much, eating spicy goods or even wearing tight-fitting clothes. But chronic heartburn, which flares up one or two times a week, can lead to serious problems if not recognized and treated. Regularly occurring pain behind the breastbone, usually after meals or on reclining can be a sign that need to seek medical attention.

What exactly is heartburn? Heartburn is the most common symptom of gastroesophageal reflux disease (GERD). Forty percent of adults (72 million people) are affected at least once a month, 20 percent (36 million people) at least once a week, seven to 10 percent (12 to 18 million) once a day. Heartburn occurs in males three to four times more than in females for reasons unknown, and it occurs in white males more often than others. Other lifestyle factors that complete the heartburn profile include smoking, drinking and obesity. Heartburn occurs when digestive juices in the stomach essentially go the wrong way, that is, up into the esophagus rather than down into your stomach and into the intestines. In heartburn sufferers, the valve at the base of the esophagus, called the lower esophageal sphincter (LES), has difficulty staying closed.

As a result, the LES fails to do its normal job of keeping stomach acid and contents out of the esophagus and in the stomach. These corrosive juices can damage the tissues, which in turn causes the burning sensation. Regurgitated acid results in a sour taste in the mount and bad breath, swallowing difficulties, chronic coughing, choking, hoarse voice, chest pain and worsening of asthma symptoms. If GERD goes untreated, the stomach acid can cause esophagitis, a more severe irritation of the lower esophagus. Left long enough, esophagitis leads to bleeding, ulcers or permanent scarring. In some cases, these symptoms cause a potentially dangerous condition called Barrett’s esophagus and increase the chances of esophageal cancer. Other potentially serious complications include sleep disturbances, sore throat, scarring of the vocal cords and dental problems. Eight out of 10 heartburn sufferers have nighttime symptoms to severe that they interfere with work and essential everyday tasks.

Heart pain vs. heartburn. Despite its name, heartburn has nothing to do with the heart. Some patients understandably confuse heartburn with heart pain, but making the opposite mistake can have deadly results. Further complicating the issue is the fact that the sensation of heartburn can vary from person to person. One major difference between the two is that heartburn generally is not associated with physical activity, while exercise can increase the pain resulting from heart disease or the beginning of a heart attack, and rest may temporarily relieve the pain. Sometimes, chest pain resulting from GERD or an esophageal spasm may be extremely difficult to distinguish from cardiac chest pain. The symptoms of pain, spreading from below the breastbone to the neck, jaw and arms, can mimic the symptoms of coronary artery disease.

This situation is complicated by the fact that those who have both heart disease and reflux may experience acid reflux, which increases the workload of the heart and can trigger angina, a spasmodic, choking or suffocating pain in the chest. The only sure way to get peace of mind about your chest pain is to have a complete medical evaluation.

Heartburn and asthma. Although no hard empirical evidence exists, these does seem to be an association between heartburn and asthma. There are two possible ways that reflux can affect the airways and make asthma worse. First, the stomach acid tracks up the esophagus, particularly when one lies down. Small amounts of acid trickle into the airways, causing them to spasm, which creates shortness of breath and wheezing. Alternatively, acid reaches the lower part of the esophagus and stimulates nerve endings. This causes the smooth muscle in the airways to contract and consequently narrows the breathing tubes. Patients perceive this sensation as shortness of breath. There are some particular symptoms that may indicate that you have GERD-induced asthma. They include;

1. Asthma symptoms becoming worse after eating a high-fat meal, coffee, chocolate or alcohol:

2. Wheezing and shortness of breath while also experiencing heartburn symptoms such as a burning, acid taste in the mouth

3. Persistent cough, particularly when lying down. Empiric treatment with acid-suppressing medication can help in diagnosing reflux-induced asthma. The esophageal Ph testing also can be useful in monitoring the effectiveness of ant reflux therapy.

An estimated 80 percent of asthma sufferers have acid reflux. According to Professor of Medicine and Physiology at Tulane University Health Sciences Center, some studies suggest that when acid reflux is treated aggressively, asthma improves. Asthma can get worse, however, even in those who don’t have GERD. So the question exists as to whether one influences the other. It may be necessary for some patients to take medications that treat both diseases. Also, some patients may benefit from a surgical procedure known as fundoplication, in which the LES is strengthened by wrapping tissue from the stomach around it. The same lifestyle advice applies to patients with and without asthma symptoms: lose weight if necessary, eat a low-fat diet, elevate the head of the bed; avoid certain foods known to worsen reflux, such as coffee, alcohol and caffeine; and avoid large meals late at night.

Other lung problems can develop when reflux causes acid to overflow into the lungs. This typically occurs when the person is lying down and is serious in that it can lead to bronchitis and pneumonia. If you are experiencing any breathing difficulty, seek the advice of a physician to avoid serious consequences.

Heartburn as a risk factor for Barrett’s and cancer. Before a 1999 article in The New England Journal of Medicine, heartburn was mostly looked at as a nuisance to the sufferer. But that study reported a link between heartburn and esophageal cancer by demonstrating that patients with regular heartburn were 43 times more likely to develop esophageal cancer than the general population. The risk was greater the longer; the more severe and the more frequent the heartburn. In addition, a recent study published in The New England Journal of Medicine reports that those who suffer nighttime symptoms of heartburn are more likely to develop cancer than those who do not.

Heartburn and Barrett’s Esophagus: Approximately 10 to 15 percent of heartburn sufferers develop a condition known as Barrett’s esophagus, which implies the presence in the esophagus of a specialized intestinal type of epithelium (tissue lining). This tissue becomes unstable in part because of its high turnover rate and so increases the risk of becoming cancerous. Barrett’s develops because acid and digestive enzymes reflux into the esophagus needs to regenerate after the cells are destroyed to create a new barrier lining. This prevents gastric juice from further damaging the wall and causing heartburn and ulcers or bleeding. In Barrett’s the cells that form the new lining are abnormal and precancerous tissue.

This new lining grows very rapidly and does not disappear or regress on its own. Much scientific evidence suggests that Barrett’s is a precursor to esophageal cancer. Early screening of heartburn patients fro Barrett’s can prevent further complications. Associate Professor of Medicine says that screening reveals cancer at earlier and far more treatable stages in patients known to have Barrett’s than in those not screened with serial endoscopies.

Diagnosis of Barrett’s: Barrett’s doesn’t have its own set of symptoms, so it is difficult to diagnose. It is usually found when heartburn patients seek medical attention. Unfortunately, these patients are only the tip of the iceberg. And it make it even more confounding, many people who have Barrett’s don’t have heartburn, so when, how or why they get the disease is unknown. What’s interesting to note is that if everyone in the population were screened, about one percent would have Barrett’s , and many of those (about 50 percent) would not have heartburn.

Precursor to cancer. The problem with missing a diagnosis of Barrett’s is that this condition is recognized as a precursor to cancer. But if we don’t know a person has Barrett’s, then how can we screen for cancer? This is where a new strategy will have to come into play: finding Barrett’s in those with no heartburn history. Doctor notes that they really need to determine how to find those Barrett’s sufferers who don’t have heartburn symptoms because most who get cancer come from this group. They point out that the risk of cancer in a patients with heartburn alone (that is, without Barrett’s) is possible but very infrequent. However, if Bret’s is present, cancer risk goes up; this is true especially in cases in which high-grade dysplasia, 59 percent progressed to cancer. Based on cancer rates, the risk of developing cancer over the course of any given year for a patient with heartburn once a month is one in 10,000, whereas for a patient who experiences heartburn once a day, the risk is one in 2,500. And in Barrett’s patients, the overall risk increases to one in 200 per year.

Monitoring and treatment. Doctors usually recommend that patients with Barrett’s be monitored with upper GI endoscopy and biopsies. Studies are underway to develop tests that will help pathologists and physicians better determine which Barrett’s patients are likely to go on to develop cancer and which will not. The bottom line is that although you have an increased risk of cancer and should always seek medical treatment for heartburn that occurs at least once per week, there is no need for immediate panic. Even if you do have Barrett’s monitoring is usually effective. Closer monitoring is called for in cases in which low-grade dysplasia is diagnosed.

In cases of high-grade dysplasia, surgery is generally necessary. Esophagectomy, removal of the esophagus, is typically reserved for patients who have high-grade dysplasia or cancer and is not recommended for patients who have Barrett’s esophagus alone. It is important to recognize that frequent heartburn is a disease, not just a lifestyle inconvenience. So don’t ignore it. When you seek medical attention for your heartburn, you will, at a minimum, improve your quality of life and may very likely help your doctor recommend further screening to prevent progression of the disease. Doctors can prescribe antacids, H2 blockers, or proton-pump inhibitors for healing lessons. There is no cure, but with these treatments and some simple lifestyle changes, you can keep your symptoms in check.

In addition, some people with severe GERD have significant regurgitation that doesn’t respond to lifestyle changes and common medication treatments. In this cases or when the cost and inconvenience of lifelong medication is not wanted, anti-reflux surgery, e.g., a "Nissen wrap, can be performed. In this procedure, the surgeon tighten the area around the lower esophageal sphincter muscle, which protects against reflux. This procedure provides a long-term solution to GERD in the majority of patients, but about one-third will require medication again later on. Hospital stay time is minimal for this procedure.

Controlling your symptoms through lifestyle changes. Although lifestyle changes rarely provide a complete cure for chronic heartburn there are things that you can do to control your symptoms. They include wearing loose clothing, eating smaller meals, avoiding lying down for three hours after a meal, losing weight and avoiding fried or fatty foods, citrus fruits, tomatoes, chocolate, coffee, carbonated drinks and alcoholic beverages. Also, elevating the head of your bed can assist in reducing symptoms. Smoking can cause the LES to weaken, so it’s important to quit.

When to seek treatment. There are no set guidelines as to when heartburn deserves treatment. They think the key is the chronicity of the heartburn. Heartburn more than three times per week for longer that one year in someone over the age of 40 concerns. Any person with heartburn and trouble or pain on swallowing should seek an evaluation. Other ‘alarm’ signs also include anemia and weight loss. Specific symptoms for GERD that should generate a physician visit include weight loss, poor appetite, vomiting, difficulty swallowing and persistent weakness, suggesting possible anemia. Other symptoms such as hoarseness, wheezing and chronic cough also should be attended to be a physician and may reflect underlying GERD.

Stay tuned for new Barrett’s and cancer therapies. Some interesting new therapies are now available for heartburn and Barrett’s esophagus. Two such therapies, the endo-CinchTM and the StrettaTM procedure, are endoscopic procedures that involve tightening the area around the LES to block the reflux. Although interest is keen for both because they are less invasive than other therapies, more long-term studies are need to establish their safety and efficacy. A new therapy under investigation is ablation therapy for Barrett’s esophagus in which the Barrett’s lining is destroyed. Much about heartburn and its consequences still needs to be learned, but with each new study, our knowledge advances. Heartburn symptoms can be controlled and managed. The bottom line is that chronic heartburn should never be ignored. Seek medical attention to control your symptoms and improve your quality of life, and you may even head off more serious complications.