There’s a disease that American doctors are absolutely terrible at diagnosing. It’s estimated that three million Americans have celiac disease and only a small percentage of them know it. In celiac disease, a component of wheat, rye, and barley called gluten sets off an immune reaction that attacks the intestine and can affect the entire body. Read more »
If you’re from a Western country, there’s a 10-20 percent chance that you suffer from classic symptoms of acid reflux: chronic heartburn and/or acid regurgitation.
But if you don’t have those classic symptoms you may still have acid bubbling up from the stomach into the esophagus, a condition called “gastro-esophageal reflux disease” (GERD). Over the past decade, research has suggested that acid reflux can cause atypical symptoms such as cough, hoarseness, sore throat, asthma, and even chronic sinusitis. GERD can also cause chest pain, especially if the acid causes the muscle in the esophagus to go into spasm.
As an internist and gastroenterologist, I’ve seen patients who have suffered for years with atypical symptoms of GERD get better with treatment. Although I usually prescribe acid-reducing medication, I try to avoid an approach that relies exclusively on “better living through chemistry.” In fact, my goal is to treat the symptoms with life-style adjustments alone if possible. Smoking and obesity both increase acid reflux and must be addressed. I tell my patients to limit alcohol, caffeine, chocolate, peppermint, and fatty foods (I know, basically anything that gives them even an iota of pleasure in life). I also suggest keeping a food diary to try to identify culprits such as tomato-based products or certain spicy foods. If their symptoms resolve then they can try to reintroduce the things they miss the most. Elevating the head of the bed can sometimes help.
The most serious consequence of chronic acid reflux is esophageal cancer. About ten percent of patients with long-standing acid reflux develop changes in the swallowing tube that increase the risk of developing adenocarcinoma, a deadly cancer with a 5-year survival rate of less than fifteen percent. The condition is called “Barrett’s esophagus. “Fortunately, only about one in 200 patients with Barrett’s esophagus develops cancer each year. And over the last year a treatment called “radiofrequency ablation” has been found to be extremely effective in treating Barrett’s esophagus that is starting to show signs that it may turn into cancer.
It’s estimated that almost 15,000 Americans will die from esophageal cancer this year. Fifty years ago, more than 95% of esophageal cancers were “squamous cell” – the kind caused by smoking and excess alcohol use. As smoking has declined, the incidence of squamous cell carcinoma has dropped. But for reasons that are not clear, esophageal adenocarcinoma – the kind linked to acid reflux (and smoking) – has dramatically increased over the past forty years and now accounts for about half the cases of esophageal cancer. From 1975 to 2001 there was a 600 percent rise in esophageal adenocarcinoma. The obesity epidemic may well be playing a role by increasing the number of adults with acid reflux.
Gastroenterologists can diagnose acid reflux by slipping a thin, flexible instrument (endoscope) through the mouth and down the esophagus. It’s a lot easier than it sounds. Patients are usually given sedation and the back of the throat is sprayed with numbing medicine to avoid gagging. There’s no problem breathing because the tube doesn’t go into the breathing tube (the trachea). Biopsies can be taken from the last part of the esophagus to look for microscopic evidence of Barrett’s and inflammation (esophagitis) caused by acid reflux.
There is currently a controversy about who should be endoscopically screened to look for evidence of Barrett’s esophagus. Only a fraction of the millions of patients with chronic reflux will ever develop Barrett’s. And many patients with Barrett’s have no symptoms at all. In a study in Sweden, 1.6% of the population had Barrett’s but only about 40% had heartburn. And only about half of esophageal adenocarcinoma is estimated to be a result of reflux.
The American College of Gastroenterology recommends against screening the entire population but says it may be appropriate in certain populations at higher risk – such as Caucasian males over 50 with longstanding heartburn. That would be me. So for this week’s episode of CBS Doc Dot Com, I underwent an upper endoscopy, explained and performed expertly by Dr. Mark B. Pochapin, director of The Jay Monahan Center for Gastrointestinal Health at New York-Presbyterian Hospital/Weill Cornell Medical Center. For more information about the Jay Monahan Center, click here.
For information about GERD from the American Society for Gastrointestinal Endoscopy, click here.
To watch my upper endoscopy, click here:
Last night, President Obama made a pitch for preventive care in his address to a joint session of Congress on health care:
“And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies – because there’s no reason we shouldn’t be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.”
As a doctor who has held the hands of patients dying from totally preventable illnesses, I couldn’t agree more. The largest number of deaths in the United States are caused by two preventable causes – tobacco smoking and
high blood pressure – killing an estimated 467,000 and 395,000 people respectively in 2005. The list goes on and on, including obesity, physical inactivity, and poor diet.
When I was working in the emergency room as a medical resident, it was heartbreaking to see a patient with poor routine medical care roll into the emergency room with a devastating stroke that could have easily been averted with regular office visits and blood pressure medication – both relatively inexpensive compared to the cost of caring for the stricken patient.
We’re not preventing enough deaths by the types of cancer screening tests mentioned by President Obama. One reason is the technology is still not good enough. We need to develop better screening tests that pick up problems early but don’t lead to an unacceptable number of unnecessary biopsies, procedures, and further tests. And
not enough patients are screened. Only about about 60 percent of women get mammograms and about 50 percent of men and women get routine colonoscopies.
Lack of insurance coverage is certainly a big reason why some patients don’t undergo screening. Another reason is patient fear and misunderstanding. In order to educate the public about the risks of colon cancer and the benefits of screening exams, Katie Couric underwent a colonoscopy on national television in March, 2000. Three years later, researchers at the University of Michigan found that colonoscopy rates jumped by 20 percent across the country following Katie’s procedure, calling the rise the
“Katie Couric Effect.”
It’s almost 10 years later and we’re still not screening enough patients. Although the death rate from colon cancer has dropped in recent years – likely mostly because of screening efforts – colorectal cancer still strikes almost 150,000 Americans every year and kills about 50,000.
As a gastroenterologist, I have seen patients’ lives saved by the removal of polyps and early cancers found by colonoscopy. I have also taken care of patients whose colon cancers were found too late to save them. Over the years, I must have heard every excuse for ducking a colonoscopy. The top four (and my answers):
And even if you have a tough night, it sure beats chemotherapy.)For this week’s CBS Doc Dot Com, I follow Katie’s lead and undergo a colonoscopy with cameras rolling in an attempt to remind people that a screening colonoscopy can save your life. I had the benefit of a house call the night before by my office nurse, Debbie Fitzpatrick, who held the video camera and offered advice and encouragement as I had a taste of my own medicine: the colon cleanout solution. The colonoscopy was performed expertly by Dr. Mark B. Pochapin, director of The Jay Monahan Center for Gastrointestinal Health at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.
For more information about the Jay Monahan Center,click here.
Today an elderly physician friend of mine woke up with some very mild abdominal pain. He is a stoic man, and never complains about anything – not even the pain associated with a dislocated/shattered hip and multiple bone fractures from a car accident (he was very nonchalant about that event 2 years ago).
So when I heard that he was going to see a doctor about his belly pain – I knew that something serious was afoot. His doctor ordered an abdominal x-ray series, noted a tumor, and sent him to the O.R. within the hour.
In the O.R. the surgeons found a perforated colon (it must have ruptured minutes to an hour or two prior) without signs of peritonitis. There was a cancerous mass (without metastases) that they were able to remove completely. They washed his peritoneal cavity extensively to remove all fecal matter and potential cancer cells and transferred him to the ICU for observation overnight and IV antibiotics.
So far it seems that my friend will make a full recovery – and there is no evidence of remaining cancer, though we’ll need to be vigilant with follow up.
I can’t get over how lucky he was to have discovered the perforated colon within hours of it occurring, that the surgeons took care of him immediately, and that the cancer seems to have been contained and removed. I don’t know if his “luck” was partially due to his physician’s intuition about his own body, professional courtesy extended to him by peers, or that the Canadian healthcare system is not as burdened in his part of the country (Nova Scotia) as it is in others where there may be longer wait times.
All I can say is that my friend is one lucky Canadian!
I hope you can read the print on this.
It’s a hoot!
Apparently, the Vacuum Tympan cures the most “desperate causes” of hoarseness and sore throat, massages vocal cords and gives immediate flexibility (to what?). Oh, and after it brings relief, “a permanent cure soon follows”.
Maybe it sucks out the phlegm. (Ewww…just writing that made me gag.)
It sort of looks like the old incentive spirometers we’d use for post-op patients.
Or maybe it’s a type of nebulizer.
Frankly, it looks like a bong.
********************
I’m at that age where certain tests involving scopes and colons are recommended, so I did my duty as the good custodian of my health and scheduled the pre-test appointment.
(Don’t worry, this will not be a case of “TMI”.)
I’m sitting there with the GI doc going over my health history, when he notices I’m on Protonix. Based on this fact (and the fact that my upper abdomen is sore on palpation – well, duh, you’re pushing on it!) he says “Well, you are going to be out anyway, I might as well take a look down there, too!”.
Say what? I’m here for a tube up one end and you want to put a tube down the other end, too?
I swear to (insert-your-own-deity-here), my first thought was “dude, you’re just trying to add a procedure to crank up the income.”
I’m not proud that was my first thought, but I’m being honest here. “Sure!” he said. It might be a structural problem, we can make sure you don’t have Barrett’s Esophagus (note to self: look that up) and basically just know what we are dealing with.
Well, okay. But I don’t have indigestion/heartburn when I’m on Protonix; I’m rather asymtomatic, actually.
“What kind of anesthesia would you prefer? We can use Versed/Fentanyl or if you want, we can use proprofol.
Propofol? Dude, you can stick a tube anywhere you want. Go for it!
*****
Easiest thing I’ve ever done. I have no idea why I waited so long. When I fell asleep Shania Twain was feeling like a woman and when I woke up, the Eagles were takin’ it easy and I wondered when the hell they were going to start!
I was done.
The procedure went well, the biopsies were taken (routine) and I would get my results by mail within two weeks.
*****
My colon rocks. No problems except divertiulosis and I can live without nuts and seeds.
It was the endoscopy that I almost refused that showed the problem.
The biopsies showed acid-induced esophageal and gastric inflammation.
What??? How??? I thought the Protonix was taking care of that!
*****
And then came the “treatment” boxes checked off.
“Keep taking your medicine for the next three months, then stop.”
Okay…if I have this inflammation now, why would I stop the medication? Won’t it get worse if I do?
“Please avoid Aspirin, Naprosyn, and Motrin. Tylenol is okay.”
Aw man, Motrin is my best friend, my right hand! It’s gotten me through many a rough shift; 12 hours in the ER can make you ache. Tylenol isn’t worth the powder it is printed on.
I took a swig of my Diet Pepsi.
“Avoid fatty foods…”
Okay, doing that already with ol’ Richard Simmons’ plan.
“…chocolate, peppermint, spearmint and smoking”
Bah – I don’t smoke and I can live without chocolate and who wants spearmint anyway?
Took another swig of Diet Pepsi.
“…alcohol…”
No biggie, I only have two Bud Lights a month, during Nascar races, and that’s only to support Kasey Kahne’s sponsor (and I know you all just doubled that to four per month…).
“Avoid caffeinated beverages…”
Uh oh.
Took a tiny swig of Diet Pepsi.
“Decaffeinated coffee…”
That…means…ohh nooooo…
*****
Oh HELL no.
I will NOT give up Starbucks.
Damn it!
I don’t smoke, I barely drink, I don’t do drugs, my diet has more fiber that corrugated cardboard, I’ve lost close to 30 pounds and I’m working on the other 25.
My only “vice” is a total addiction to Starbucks and the goal of someday mainlining Diet Pepsi.
It will be a cold day in hell before I give those up.
*****
I’m giving them up.
I know the effects of chronic esophageal and gastric inflammation can lead to bigger problems.
And in the scheme of things, given the impact a diagnosis can make on a life, this borders on laughable.
But we all talk about how the patient has to take responsibility for their health. I could keep on downing Starbucks twice a day and Diet Pepsi in my sleep and then whine because my Protonix isn’t working.
Or I can make the changes suggested and see if they will make a difference.
But how ironic that the main problem was found in a test I didn’t even know I needed; and how scary that I was essentially asymptomatic, but the inflammation was still there!
Kudos to the doc for being interested enough to find out why I had needed to be on Protonix to begin with.
I shudder to think what things would have looked like had I been on no medication.
*****
Who knows?
Maybe I can go off Protonix if these changes work.
And I can still go to Starbucks, only my new drink will be a Grande Skinny Vanilla Steamed Milk.
With a little cinammon on top.
Hey, a girl’s gotta have something to look forward to…
*This blog post was originally published at Emergiblog*
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