Don’t Spurn the Burn
Heartburn.
That deep, irritating sensation that creeps from your stomach toward your neck, creating pressure and leaving a nasty acid taste in the back of your throat.
More than 60 million Americans report paying the price for overindulging in fatty or spicy food with heartburn symptoms at least once a month. Most don’t give it much thought.
But chronic heartburn, of the day-after-day, year-after-year variety, can be a potent warning of bigger medical problems, including esophageal cancer, which is deadly if not caught early.
When does heartburn merit professional attention?
Sometimes it’s hard to tell. We’re all conditioned to take care of it ourselves.
Medicine-cabinet remedies are ingrained in popular culture: the fizzy sound of Alka Seltzer or the soothing pink bottles of Pepto-Bismol. Then there’s the protection promised by popping some Pepcid AC or Zantac pills before a heavy, fat-laden meal sure to set your belly burping.
And the world of alternative medicine offers another raft of remedies: from simple chamomile tea to Chinese herbs and homeopathic preparations.
All may help the occasional bout of indigestion. But some doctors worry that Madison Avenue’s message of quick and easy relief has convinced the public that heartburn is nothing to worry about.
Indeed, some surveys have found that 40% to 50% of patients don’t even mention heartburn to their doctor because they don’t think it’s a medical problem. That’s a notion that Dr. Joel Richter, a professor of medicine at the Cleveland Clinic Foundation in Ohio, would like to dispel.
“The issue is a simple one: Heartburn is something to take seriously,” he says. “Americans think heartburn is a nuisance, not worth mentioning to their doctors because of these doggone ads.”
Richter has seen patients who have spent more than a decade chewing their way through four or five rolls of antacid tablets daily. Other doctors say busy executives sometimes view heartburn as a badge of honor, part of the price they pay for success.
They’re wrong.
Anyone who experiences heartburn more than twice a week should see a specialist for endoscopy. It’s a 15-minute diagnostic procedure, done with light sedation, that involves inserting a flexible, lighted tube into the esophagus to check for signs of cell damage, precancerous changes or outright tumors. It’s especially important for people who experience any “alarm symptoms,” including difficult or painful swallowing, weight loss, anemia, blood in the stool or vomiting blood.
Valve Problem Results in Reflux
Heartburn is caused by a malfunction in the lower esophageal sphincter, a valve that opens to let food pass into the stomach. When it’s healthy, it should close to prevent acid from backing up. Even in healthy people, it may get forced open once in a while by an overfilled stomach, when you feel “stuffed.”
But in some people, the valve opens too easily and subjects them to reflux--the repeated splashing of digestive juices into the esophagus. Erosive acids then bathe the lining of the digestive passageway that is supposed to be a one-way route to the stomach.
There are two basic methods of dealing with it: with antacid pills or liquids that neutralize the acids, or with medications that interfere with acid production and cut off the acid pipeline.
Doctors don’t really know why there is more heartburn these days.
But it could be that in winning the war against ulcers, which are often caused by an infection with the bacteria Helicobacter pylori, doctors are losing ground against heartburn. H. pylori inflames the stomach, which in turn reduces acid production. But in eradicating the bug with better sanitation and antibiotics, “the acid-secreting cells now are rebounding,” says Richter. That means there’s more acid to kick back.
The acid kickback, called gastroesophageal reflux disease, or GERD, can be treated with a combination of medications and lifestyle changes, such as cutting out late-night eating, limiting caffeinated drinks and foods that promote acid production, giving up carbonated beverages that push acid into the esophagus, and raising the head of the bed by 6 inches to keep acid from backing up at night.
Dr. Ken DeVault, of the Mayo Clinic in Jacksonville, Fla., says those with GERD do well with powerful prescription drugs, like Prilosec and Prevacid, that block acid production and give irritated digestive tissues a break. Among GERD sufferers who have used Prilosec is President Clinton, according to details from his annual physicals. A weaker class of drugs, called histamine blockers, include Pepcid, Zantac and Tagamet, which are available in nonprescription form.
Without treatment, excessive acid can create an inflammation of the esophagus called esophagitis. Eventually, it may cause a worrisome condition called Barrett’s esophagus, in which patches of the esophageal lining resemble the cells that line the small intestine. About 10% of GERD sufferers have Barrett’s, which requires close monitoring because the intestinal-type cells are at higher risk of turning cancerous.
Barrett’s yields an odd paradox, Richter says. Barrett’s patients often report that their heartburn symptoms have improved. But sometimes that’s because changes in the cells have desensitized them to the acid, while at the same time increased the risk of their becoming cancerous.
Doctors variously estimate that anywhere from 0.5% to 5% of Barrett’s cases can develop into esophageal cancer, which can spread with terrifying speed to the lymph nodes and other organs.
The risk factors are continued reflux, smoking and drinking alcohol. Smoking is more closely associated with adenocarcinoma of the lower esophagus, which is most often seen in white men. Alcohol is more linked with squamous cell carcinoma of the upper and middle esophagus, which tends to strike more Asians and African Americans, says Dr. Sassan Soltani, a gastroenterologist in private practice in Pasadena.
Although the overall number of cases of esophageal cancer may be low--about 12,000 new cases a year--the disease kills 10,000 each year. Esophageal cancer is one of only two cancers--the other is the skin cancer known as melanoma--in which the incidence of the disease is rising.
“It’s potentially a preventable disease,” says DeVault. “More of the problem is people who just suffer [from GERD] and don’t need to.”
Depending on the patient’s age, overall health and preference, doctors may operate to tighten up the malfunctioning valve in GERD patients by taking some of the stomach and wrapping it around the lower esophagus. The surgery can be done in a minimally invasive way, leaving only tiny incisions.
That’s what finally made life easier for Calvin Murphy II of Monrovia.
Hiatal Hernia Caused Him Grief
Murphy, a 45-year-old telemarketer, was diagnosed more than a decade ago with a hiatal hernia, a condition in which some of the stomach bulges up into the esophagus and acts as a receptacle for acid. The acid reflux ruled his life. He was using up a 96-pill bottle of antacids every 10 days. He couldn’t bend over during the day lest the acid come back up.
At night, he says, “I got to where I was sleeping on a mountain of pillows so my stomach contents would stay in my stomach . . . instead of rolling up my throat.”
Last year, after hearing that a friend’s reflux-plagued boss developed cancer and learning from a television report that hiatal hernias raise esophageal cancer risk, he underwent endoscopy. Soltani found some cell changes that could turn precancerous if left untreated.
Murphy began taking Prevacid and underwent surgery to close up the hernia and repair the faulty valve.
Today, he says, “I can eat habanero peppers. I make my own salsa. Nothing upsets my stomach now.”
Periodic news reports have sent others scrambling for doctors’ appointments. In March, a Swedish study that appeared in the New England Journal of Medicine looked at GERD as a risk factor for cancer. It produced a rash of calls to gastroenterologists. The American College of Gastroenterology also logged more hits on its Web site and more requests for information at its hotline, (800) 478-2876.
But DeVault says he doesn’t want the public to panic and run half-cocked to specialists. There are ways to determine whether heartburn merits aggressive response.
“If you’re over 40 and you’ve had bad reflux a long time, your chances of developing esophageal cancer are higher than for someone who has never had reflux,” DeVault says, “but your comparative risk is still fairly low.”
The question is, what’s the threshold for worrying? Some specialists say weekly bouts of heartburn. Others, like Richter, say twice weekly or more. But duration is just as important. Even mild heartburn year after year should be checked with endoscopy.
For the most part, Richter says, health plans will pick up the $300 to $500 tab for endoscopy.
“The biggest problem we have with insurance companies now is the more powerful medicines give more powerful relief, but the insurance companies want us to prescribe the weaker medications,” Richter said. Prilosec or Prevacid cost $2.50 to $3 per pill, but the histamine blockers cost only 50 cents to $1.
Richter is looking ahead to 2002, when cheaper, generic forms of Prilosec will become available.
