Creighton University

 
5/21/2007
By: Julie Anderson

Joe Kavan started out like many of us, suffering through the occasional bout of heartburn.
 
Over time, the bouts became more frequent.
 
Then the heartburn was always there, even when he was on prescription medication.
 
If he dined out late, he'd stay up several hours before going to bed. Sometimes he'd sleep in a chair. Other times he'd wake up in the middle of the night and cough for hours after the same stomach acids that caused the heartburn also got into his lungs.
 
Years after the heartburn started, tests indicated the Omaha attorney had Barrett's esophagus, a change in the lining of the esophagus associated with gastroesophageal reflux disease. Barrett's, in turn, can lead to esophageal cancer.
 
"That's when I very much became concerned," said Kavan, who had surgery to prevent the reflux.
 
Some doctors are advising keeping a closer eye on chronic heartburn symptoms that can signal the reflux disease, known by the acronym GERD. The incidence of the related esophageal cancer has been increasing over the past 25 years at a rate greater than that of any other major cancer.
 
"People simply shouldn't be ignoring some of the alarm symptoms," said Dr. Sumeet Mittal, an assistant professor and director of the Esophageal Center at Creighton University Medical Center.
 
Doctors aren't sure exactly what's causing the increase in the still relatively rare cancer, known formally as esophageal adenocarcinoma. Nor are they sure when to check for Barrett's esophagus in people with the reflux disease.
 
There are no commonly accepted guidelines for who should be screened for Barrett's  --  or when. The American College of Gastroenterology recommends that patients with chronic reflux disease undergo screening endoscopy. Mittal typically recommends screening for those with more than five years of reflux. Patients with Barrett's are checked more often.
 
The endoscopy  --  done by snaking a fiber-optic scope down the esophagus  --  costs about $1,000, although the price varies. Insurance typically covers it. Some places, including Creighton, also offer a capsule camera that people can swallow, known as a PillCam.
 
"The difficulty is (determining) what is a cost-effective way to screen out those candidates who have the highest risk," said Dr. Tim McCashland, a gastroenterologist and associate professor of medicine at the University of Nebraska Medical Center. "That hasn't been studied to the point where we can classify patients as high risk or low risk."
 
Lots of us, in fact, get heartburn occasionally. It's that burning pain in the chest or in the throat that strikes when stomach juices  --  acids, bile and digestive enzymes  --  bubble up into the esophagus.
 
Those with frequent heartburn often have the reflux disease, which occurs when the valve at the bottom of the esophagus doesn't close properly. One estimate is that 60 million Americans suffer from the disease.
 
Of those, about 10 percent develop Barrett's esophagus, and fewer than 1 percent of people with Barrett's each year progress to cancer.
 
But doctors don't know which ones will make that progression. Making things murkier, 40 percent of people who develop esophageal cancer have no history of GERD or Barrett's, according to one report.
 
The reflux disease typically is treated with lifestyle changes and acid-suppression drugs, including the purple pills (Nexium and Prilosec) and other proton pump inhibitors.
 
Mittal said some theorize, however, that acid-suppression drugs, some of which now are available over the counter, may be playing a role in the rise in esophageal cancer. They cut the acid and the pain associated with it, but there's concern that bile, an alkaline substance, might be left to do damage. While the pills can help heal erosions, the cellular damage may remain.
 
"Even if you're happy with the medicines, you should get screened," Mittal said.
 
Other suspected culprits in the cancer increase: More people are overweight, which is linked to heartburn and the reflux disease, and dietary habits have changed to include more fried, fatty foods and eating on the run. Smoking also has been considered a cause.
 
But Dr. Doug Brouillette, chairman of the gastroenterology department at Bergan Mercy Medical Center, which recently opened a new Digestive Health Center, noted that theories about bile reflux still need testing.
 
Acid-suppression drugs prevent damage to the esophagus and aspiration into the lungs  --  "it still is the best thing out there for treating acid reflux," said Brouillette, who also is with Midwest GI Associates.
 
Surgery is another option for treating reflux disease. Kavan, the attorney with the long-running heartburn, underwent the standard procedure, which involves wrapping the top of the stomach around the valve at the bottom of the esophagus to strengthen it.
 
The surgery doesn't eliminate the risk, and newer methods of treating Barrett's with tissue heating or freezing are available or under study.
 
Kavan went back last fall for his first endoscopy since his October 2005 surgery. The Barrett's was still there, but there was no indication it had gotten worse.
 
The reflux, though, is gone. That's a good thing. Kavan loves French cooking and recently made sushi.
 
And what's even better, "I can eat the meals that I cook." 
 

Heartburn 
WHAT: Burning sensation in throat or chest when stomach acid backs up and touches the lining of the esophagus.
MAY OCCUR AFTER: Eating a large meal, lying down after a meal, eating foods that tend to trigger heartburn, such as chocolate, coffee, alcohol, carbonated beverages and tomato-based sauces.
TREATMENT: Lifestyle changes, such as avoiding certain foods; medications; surgery.
CAN BE SYMPTOM OF: Gastroesophageal reflux disease, or GERD.
 

GERD
WHAT: Occurs when the lower esophageal sphincter -- a ring of muscle that acts as a valve at the bottom of the esophagus -- doesn't close properly, allowing stomach contents to regularly leak back into the esophagus. An estimated 60 million Americans have it.
CAN LEAD TO: The start, or worsening, of asthma and chronic cough.
COMPLICATIONS: Can cause bleeding, ulcers, scarring or Barrett's esophagus, a change in cells in the esophageal lining that, over time, can lead to cancer.

Treating GERD
Lifestyle changes, medications or surgery. The common surgical procedure, fundoplication, involves wrapping the upper part of the stomach around the valve to strenghten it. Typically, it's done laparoscopically, requiring only tiny incisions in the abdomen.

Reprinted with permission from the Omaha World-Herald. 

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