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Got GERD? Find Out If You’re At Risk For Esophageal Cancer

September 25th, 2009 by Jon LaPook, M.D. in Better Health Network, Health Tips, Video
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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:

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Physicians And The H1N1 Flu

May 2nd, 2009 by Jon LaPook, M.D. in Better Health Network, Video
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Yesterday I visited the Centers for Disease Control in Atlanta and was taken inside the command center, where almost 100 staffers have been working around the clock to monitor and stem the current outbreak of flu.

I first spoke to Toby Crafton, the manager of the command center, who oversees the day-to-day operations. He and his team have been preparing for a possible pandemic of flu or another infectious illness for years. I also spoke to Michael Shaw, PhD, who heads up the virology labs that are studying the H1N1 virus causing the current outbreak. He’s spent a career learning the laboratory techniques that are so urgently needed right now. The third person I spoke to was Dr. Richard Besser, Acting Director of the CDC, who has been working at the agency for 13 years and is an extensively published expert in infectious diseases.

I mentioned that last week I had received an email notification from the New York City Department of Health (NYCDOH) about how I should be managing my patients with flu-like symptoms. The advice was actually not intuitively obvious to me. For example, the Department of Health said that for patients with mild illness, treatment with anti-viral meds like Tamiflu and Relenza was only recommended for patients who also had underlying conditions that increased their risk for complications due to influenza. Dr. Besser pointed out that it was especially important right now for physicians to stay up to date with the recommendations being made by public health officials. Doctors can contact their local department of health and sign up for the same type of email notification that I received.

This brings us to the main point of today’s blog post. Many of us – patients and physicians alike – have been thinking about the influenza virus for about a week. Public health officials like the teams at the CDC and the NYCDOH have been thinking about it for years. Physicians, me included, are used to practicing medicine based on “clinical judgment.” We understand that medicine is an art and not a science, that there are many different ways to approach a problem, that there’s often no clear “right” or “wrong.” We are also used to doing things “our way”, whatever that way is. But this is not a time for doing things “our way” if it’s at significant odds with strong recommendations being made by public health officials. There are recommendations that may seem logical – like prescribing medication for somebody with mild flu symptoms “just in case” that nevertheless go against the judgment of people who have trained for years to think about how to deal with an epidemic.

What if you’re a physician who strongly disagrees with a suggestion of public officials? Then challenge that recommendation publicly. Bring the discussion to light; maybe you’re right. While this is no time to go rogue, doctors have an obligation to think carefully and independently and to challenge recommendations that seem illogical. But don’t silently do things your own way.

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