If I suffer from heartburn, when should I see a doctor?

If you are suffering from heartburn more than once a week and having to use any medication including those medicines bought over the counter, then you should be checked out by your GP. It may well be necessary to get an endoscopy to ensure that all is well and you do not have Barrett's oesophagus or any inflammation or ulcers as a result of the heartburn.

Will I get cancer?

There is a connection between heartburn, Barrett's oesophagus and cancer although the vast majority of patients with these very common symptoms will never develop either Barrett's oesophagus or cancer of the oesophagus. A rough estimate is that 10% of people with heartburn will develop Barrett's oesophagus and approximately 7% of those may go on to get cancer over their lifetime. The idea behind monitoring individuals with Barrett's oesophagus and investigating people with heartburn is to detect any cancer occurring at a very early and curable stage.

How should I alter my diet?

There are no precise dietary recommendations for patients with Barrett's oesophagus. However, you should avoid foods that are known to make reflux or heartburn worse. For example, alcohol, coffee, chocolate and citrus fruits all fall into this category. Fatty foods also tend to take longer to leave the stomach and this can make patients feel uncomfortable. If you find that large meals irritate your Barrett's, then eating smaller amounts more often might suit you better. Overall, eat foods that suit you and enjoy all things in moderation! Tablets to stop acid reflux which causes heartburn are very effective and once on these medications, patients often find they can eat a normal diet. You may also find helpful an article that appeared in the Daily Mail in March 2008, which gives sensible advice to people with acid reflux, link below:

http://www.dailymail.co.uk/debate/columnists/article-537768/Sit-straight-eat-small-meals-beat-acid-reflux.html

Is Barrett's oesophagus or cancer of the oesophagus hereditary?

Usually these conditions develop in patients who have no family history. However, like most cancers, they are likely to occur as a result of lifestyle factors for example, whether or not we are overweight, whether we exercise, what kind of diet we eat as well as inherited factors from our parents. Any inherited factors or genes are likely to each confer a very low risk individually but when the effect of several genes are combined and added to lifestyle the risk may increase sufficiently to lead to cancer. At the moment we do not know of any genes like the BRCA genes which lead to breast cancer. However, there are some rare families in which several family members have been affected with Barrett's oesophagus and cancer and it is possible that in these cases, there are some equivalent of BRCA genes still to be discovered.

Does being overweight lead to Barrett's oesophagus and cancer?

Being overweight does increase the likelihood of having heartburn because it can lead to a hiatus hernia and alter the normal anatomy between the stomach and the oesophagus. There is also recent evidence to suggest that being overweight might increase the risk of cancer slightly although the reasons underlying this are still being elucidated.

Is there a connection between the reflux and hernia and Barrett's oesophagus and would surgery to fix the reflux stop the Barrett's oesophagus from progressing?

Reflux of acid and bile is a main risk factor for Barrett's oesophagus. There are a number of reasons why people tend to have reflux and one of the commonest causes is a hiatus hernia which is also more likely in people who are overweight. A hiatus hernia means that the top most part of the stomach has slipped above the diaphragm into the chest.

Normally the diaphragm acts with the small muscle or sphincter at the lower end of the oesophagus and start of the stomach to prevent reflux coming up. Once the stomach has slipped up the diaphragm is no longer in the same place as the lower oesophageal sphincter muscle and therefore acid and bile are more likely to slosh up from the top of the stomach into the lower oesophagus.

An operation can be performed to correct a hiatus hernia normally called a Nissan Fundoplication and this can be performed as a keyhole operation (laparoscopy). This can be very successful at reducing reflux; however, although we know that acid and bile are important causes of Barrett's and there is some laboratory evidence that these components may cause the cells to behave in a more cancerous way, we don't fully understand all the factors that cause Barrett's to progress from cancer. There are a number of studies looking at whether an anti-reflux operation reduces the progression to cancer but there are conflicting results from these studies and overall there is not enough evidence to suggest that this operation is likely to reduce cancer and therefore we do not recommend it purely for this purpose. In other words we recommend the operation to stop the symptoms of heartburn but we cannot guarantee to patients that this would reduce the risk of cancer progression. One problem is that there has not been a controlled trial comparing patients treated with an operation compared to patients treated with tablets in a randomised fashion and it would probably be unethical to do this.

My consultant once told me not to eat oranges or drink red wine. Is there a comprehensive
list of items 'verboten'?


Oranges and red wine are both quite acidic and acidic things can make reflux worse. There are a number of foods which can aggravate reflux but there is also a lot of individual patient variation. Some foods upset some people but these same foods may be well tolerated by others. It is therefore difficult to produce a comprehensive list of items which should be avoided. Our dietician recommends that you avoid foods which upset you and in general, caution might be advised for acidic, spicy food and too much caffeine. In general, as always, a good healthy balanced diet is recommended.

Is there an increased incidence of IBS in people diagnosed with Barrett's Oesophagus?

Some patients with irritable bowel syndrome also get indigestion type symptoms. However there is no direct link and no increase in Barrett's oesophagus with people with irritable bowel syndrome.

I have found over the years that Nexium Ò works best for me, however because of the cost, the Doctors always try to get me to take a cheaper alternative. When all the new changes come in, will they be able to insist on me taking a cheaper drug?

There are a number of different brands of proton-pump inhibitors and some are off-licence and therefore the generic version is cheaper. However, we know that some patients require particular brands and doses to get good control of their symptoms and consultants are very happy to liaise with GPs and recommend specific brands and doses for patients when necessary. Of course doctors will always need to try to prescribe in the most cost-effective way.

How corrosive to the oesophagus is bile?

Bile is very corrosive to the oesophagus. We know this from animal studies and studies in Barrett's patients where the pH (acid) and the bile constituents of the oesophagus have been recorded. It is likely that a combination of acid and bile are responsible for causing Barrett's oesophagus. Medication to reduce acid reflux also reduces the overall volume of reflux and therefore reduces the bile to some extent. Unfortunately there is no specific medication to reduce bile reflux.

Has the sponge-test been trialled sufficiently yet to draw conclusions on its benefits to
early diagnosis (at GP level) of Barrett's?


The results from the first sponge test (cytosponge) performed in the Cambridgeshire area on over 500 patients are very encouraging. This has now been published in the British Medical Journal, however it takes a number of studies before conclusions can be drawn and before such tests become nationally recommended in screening programmes. We are now in the process of our second trial called BEST2 (http://www.cptu.org.uk/trials/BEST2.php) which will see whether we can not only diagnose Barrett's oesophagus with the sponge but also divide patients into low and high risk. We hope that all this will gradually pave the way to show its benefits and see whether it is indicated at GP level on a national basis.

I am taking part in the AspECT trial and am on high dose acid suppression (two 40mg tablets daily) and high dose aspirin (300mg daily). I have read* that 'there is a small risk that high dose acid suppression could increase the risk of cancer progression and this is being tested in the [trial'. Why might there be a link between high dose acid suppression and increased risk of cancer progression? *Oesophageal Cancer - UK, July 2005, Janusz Jankowski, Cancer Research UK.

The AspECT trial is a chemoprevention trial to see whether acid suppression and aspirin reduce the risk to cancer. Patients taking highest dose of acid suppression and highest dose of aspirin should presumably be at the lowest risk of progression to cancer. Since prescriptions for proton pump inhibitors have increased over a similar time period as this type of cancer one might ask whether one is causing the other. However, when studies have been done to look at whether there is a direct link no direct evidence has been found. Therefore, although of course we will have to see what the results from this trial show, it would be surprising if the high dose acid suppression was shown to cause cancer.

Are there any concerns regarding long-term use of PPIs?

There have been concerns about whether these drugs could increase the risk of osteoporosis and gastrointestinal infections because of the reduction in acid. There have been two large studies looking at the risk of PPIs and osteoporosis which showed opposite results. Therefore, there does not seem to be a major concern about osteoporosis from these medications as far as we can tell. Some patients do have side effects from these drugs and some patients do get more gastrointestinal infections but on the whole they are very well tolerated and have been used now for over 20 years and as far as we can see they are very safe.

Until I was diagnosed with Barrett's oesophagus I spent many years having uncomfortable evening and other meals, food seeming to stick half way down. My family kept telling me to go to the doctors, but I kept telling them I was just eating too fast. If I had gone, could I have prevented Barrett's or just saved myself years of discomfort?

We don't know how long Barrett's takes to develop and generally when we endoscope patients it is either present or not, we don't see it in the developing stages. This suggests that it probably develops quite rapidly over a period of weeks. We think that it is very important that patients with persistent heartburn symptoms see their GP and are investigated early to ensure that if there is Barrett's we find it. Once diagnosed we can then do our best through surveillance to prevent cancer developing, or detect it at a very early stage. However, we do not currently have any evidence to say that endoscoping people earlier or prescribing acid suppressants will actually stop the Barrett's from developing.

What are 'safe' drinks?

There are no safe or unsafe drinks patients should drink. Too much caffeine is not a good idea and too many acidic drinks can be upsetting for reflux. However, with very successful proton pump inhibitor therapy it is likely that you can drink anything.

Can you tell us about a new technique performed at Spire Hospital Manchester and West Midlands? They have developed a flexible magnetic bracelet that is fitted around the oesophagus.

This flexible magnetic bracelet is called 'LINX'. There have been a number of procedures developed to try and prevent reflux. The idea is that this magnetic bracelet pinches the lower end of the oesophagus and stops reflux coming up, but when you eat the magnets are weak enough that they then come apart. It is very early days to know how successful this is. In general the techniques in the past have all looked promising initially but have then run into problems. For example, the Angelchik device where a number of these had to be removed because they eroded through the oesophagus. It is too early to know whether this is going to be useful or not. We would not recommend that patients have these procedures unless undertaken as part of a research protocol.

What percentage of patients with this condition go on to contract cancer and how successful can surgery be?

The risk of developing cancer in Barrett's oesophagus is low at approx. 1 in 200 patients per year. However, because this is higher than the general population we do recommend surveillance or monitoring. When patients develop dysplasia then the risk increases further. Surgery to remove the oesophagus can cure the condition. However with the use of better endoscopic techniques such as endoscopic mucosal resection (removing a large area like a big biopsy) or radiofrequency ablation surgery does not have to be done when the disease is at a very early stage, in other words cancer confined to the very superficial layers or high grade dysplasia.

I am lucky as I taste refluxate often enough to monitor it but have you any hints as to how a patient with silent reflux may be more aware of their acid/bile levels?

Reflux which doesn't cause symptoms is a problem because patients will not know they have it. We know that there are a significant proportion of people out there with silent reflux. One of the interesting questions is whether a screening programme should be for all individuals above a certain age in the population to try and also diagnose people with silent reflux who have Barrett's.

At a previous Barrett's Evening, mention was made of a technique used in America to burn
off (please forgive the less than medical description) the Barrett's cells but this was not thought appropriate at the time. Has opinion changed?


There are a number of techniques to burn off the lining. The most recent is called radio frequency ablation or HALO which uses radio frequency energy delivered through a balloon to get rid of the Barrett's lining. This seems to be very successful and there is a large study published in the New England Journal of Medicine in 2009. Generally this treatment is recommended and reserved for patients with dysplasia and Barrett's oesophagus until more long-term follow-up information is available but the results so far are very encouraging. Previous techniques included photo-dynamic therapy. These were also fairly successful but had more side effects, in particular being sensitive to the light and therefore this has generally fallen out of favour and people are now using radio frequency ablation.

How do I know if I develop this condition, ie. what signs and symptoms differentiate it from
'ordinary' long-term oesophagitis? Should I be tested again in the future?


Unfortunately, heartburn is the common symptom for reflux. It may cause no damage to the oesophagus, or oesophagitis or in some patients Barrett's oesophagus. Therefore there is no way of distinguishing between them from the symptoms alone. In general if the reflux symptoms are getting worse or persisting over a long period of time, then an endoscopy is recommended.

Is the keyhole surgery, wrapping stomach around oesophagus, appropriate for curing a persistent cough caused by reflux?

Persistent reflux can cause a cough and if this is the cause then medication or surgery to stop the reflux can stop the cough. However, it is very important to be sure that this is the cause of the cough and to rule out other lung or respiratory causes.

What lifestyle changes can I make to stop the condition deteriorating?

Of course living a healthy lifestyle is always better. We advise patients to take regular exercise,
to avoid being overweight and to avoid eating late at night. In the past, advice has been given to elevate the head of the bed to try and prevent reflux but this is rather anti-social and in general the medications used to stop reflux are very successful but this is not usually needed.


 


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