Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, M.D.
 19 January 2005

THE PROBLEM OF “HEARTBURN”

            A gentleman recently came to the clinic for help with heartburn.  He was a 52 year old executive who had his three cups of coffee for breakfast every morning.  Over the years, he had learned that this would cause heartburn and he would take several Tums to combat the problem.  He felt that he needed the coffee and simply wasn’t willing to consider stopping that all together, although he knew it caused the heartburn.  Recently, the problem had become more prominent and he was having increasing difficulty swallowing.

            His physical examination from the outside was unremarkable.  He had lost approximately 5 pounds in the last several months through no effort of his own and he was not inordinately overweight to begin with.  Examination of his esophagus by an endoscope demonstrated that he had a cancer of the esophagus.  The condition appeared to be substantially far advanced.

            After staging his condition and finding that there were no metastases to other areas, he underwent a surgical procedure to resect the carcinoma of the esophagus.  The bottom half of his esophagus was surgically removed and a new tube was constructed out of a piece of intestine to connect his remaining esophagus to the stomach.  His surgery was done approximately six months ago and his weight has dropped slightly further since then.  He has difficulty with eating  and relearning how to swallow.  All of his food has to be very carefully chewed and liquified in order to get it down to the stomach.  Peanut butter and dry meat just don’t work.  At this time, there does not appear to be a recurrence of his tumor but six months is a little early to be sure what his long term prognosis will be.  He and his wife and his son were all very frustrated and wondered what happened.  Why did he get cancer of the esophagus?

Heartburn is the slang term applied to those people who have acid from their stomach back up into the swallowing pipe (esophagus) causing a burning sensation.  The term is quite appropriate as the acid does actually “burn” the esophagus.  The problem begins with a faulty valve.  The esophagus runs from the person’s mouth to their stomach and carries food and water down to the stomach.  The lining of the esophagus is the same tissue as in the mouth;  the esophagus is not made for corrosive or irritating substances.  One of the quirks of nature is the relationship between the stomach and the esophagus.  Specifically, the stomach has a huge amount of acid present and the esophagus is not made to deal with much more than lemonade or at most, a little bit of vinegar.  When too much acid gets into the esophagus, the acid virtually burns it.  A person can get a very unpleasant sensation of “heartburn” simply from swallowing a spoonful of vinegar.  There is a thousand times more acid in vinegar than there is in the saliva in your mouth.  Well, imagine what a thousand times more acid than vinegar could do to the bottom of your esophagus.  This is where the problem resides.  There is a purse-string like valve at the bottom of the esophagus that is designed to open and let food go from the esophagus into the stomach.  This valve then closes back up again so that acid doesn’t come back up from the stomach into the esophagus.  But approximately half of the population over age 40 has a valve that is incompetent.  Specifically, the esophagus-stomach valve allows material to bubble back into the esophagus causing heartburn.  This valve is made less competent by (of all things) smoking, alcohol and coffee.  Some people learn early that these three agents make their heartburn worse and they stop using them to a significant advantage.  Others are sort of slow learners.

            After the person has experienced heartburn over an extended period of time, the irritation at the bottom end of the esophagus takes on a new problem.  This is called “Barrett’s esophagitis”.  This condition occurs after years of heartburn and bubbling acid back into the esophagus.  Barrett’s esophagitis is very dangerous because approximately 1 in 20 people who have it develop cancer of the esophagus.  When a malignant cancer such as this occurs in the esophagus, the condition is very unlikely to be cured through surgical intervention.  Instead radiation and chemotherapy or perhaps some type of palliative surgical procedure might be done but the condition is very serious and has only a 6-10% two year survival.

            Thus, as it is often brought out in these columns, the answer to the problem is prevention.  Step one involves recognizing that Tums, Maalox, Mylanta, or other antacids are not an answer to this problem.  It may turn off the heartburn for a brief period of time but if a person is having symptomatic heartburn, there are many other times of the day when acid is coming back out of the stomach, irritating the esophagus and thereby causing an irritating burn to the bottom of the esophagus.  There is early evidence suggesting that those people who use a family of drugs called a proton pump inhibitors (Prilosec OTC, Nexium, Prevacid, Aciphex, Protonix) can neutralize the stomach acid and thereby prevent the burns that occur when stomach contents bubble back into the esophagus.  The use of Axid, Pepcid, Zantac, and Tagamet is better than nothing but these drugs are not as effective in controlling stomach acid as are the proton pump inhibitors mentioned above.  The proton pump inhibitor family of drugs has been out since the late 1980’s and to this time appear to be remarkably safe drugs.

            A second step in dealing with heartburn is to be checked if the problem has been present for several years.  Barrett’s esophagitis develops after years of irritation to the esophagus.  Those people who have had heartburn for 10-15 years will benefit from having a examination of the esophagus to insure that there is not a preliminary changes suggestive of a cancer coming or alternatively of actually having an early cancer that can be corrected.  The problem with cancer of the esophagus is that it is usually far, far advanced by the time it is discovered because cancer of the esophagus causes so few symptoms in the early stages of the condition.  If the Barrett’s esophagitis is detected early, more vigorous preventive treatment can be instituted although complete resolution of the problem is unusual.  Once a person is seen to have Barrett’s esophagitis, surveillance re-examinations periodically are a special warranted step.

            It almost sounds like an alarmist message stating that heartburn can be so dangerous.  But the incidence of adenocarcinoma of the esophagus has been increasing dramatically in the past three decades in the United States.  At least part of this problem relates to the high coffee consumption in this country.  For those that have had heartburn for 10-15 years that they have dealt with symptomatically, a visit to your local clinic is worthwhile to screen for the potential that a more dangerous problem might be waiting.  The procedure to look for abnormalities in the esophagus is relatively simple and can be done as an outpatient.