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The Burning Questions below were originally produced for Barrett's Wessex some years ago.

Isn't Heartburn normal?

Nearly everyone gets heartburn occasionally: the burning feeling in the chest that's not the heart burning but the oesophagus (the pipe that takes the food from the throat to the stomach).

It's estimated 1 in 10 of us gets heartburn on average about once a week and perhaps blame the hot, spicy meal we've eaten.

In reality, heartburn can be caused by eating or drinking nearly anything. It's most usual when we've eaten too much or too quickly without letting our food move naturally through the stomach before cramming more in.

The stomach reacts to food (and the expectation of food) by making a strong acid to start dissolving it as a major part of the digestive process. The stomach and the intestine leading away from the stomach have a layer of specially adapted cells that prevent them from being attacked by the acid.

Between the oesophagus and the stomach is a valve (called the lower oesophageal sphincter, or LOS for short) to prevent acid splashing back up the oesophagus. However, if the valve doesn't close properly, that's precisely what does happen: acid splashes up the unprotected oesophagus attacking it.

That's heartburn.

Sometimes the top (“fundus”) of the stomach can get trapped in the hole (“hiatus”) in the diaphragm the oesophagus passes through. This is called an hiatus hernia and can lead to an ineffective Lower Oesophageal Sphincter.

Unfortunately, our modern lifestyle may be to blame for increasingly common attacks of heartburn.

We eat too quickly so food isn't given enough time to leave the stomach normally.

An overfull stomach may be the reason the LOS hasn't closed properly but there are other causes.

Fatty foods are slower to dissolve so take longer to clear the stomach.

Smoking and alcohol relax the muscles that control the LOS so it doesn't do its job properly.

Stress restricts the digestive process (to enable “flight or fight” response) which may result in a residue of excess acid.

If you get heartburn frequently, you should see your doctor: It just could be the beginning of a road that leads to cancer!

What is reflux?

Normal digestion is a one way street:

  1. Food is chewed and mixed with saliva in the mouth.

  2. Swallowing moves the food into the throat through the “Upper Oesophageal Sphincter” (or UOS).

  3. Gravity and contracting muscles (a process known as “peristalsis”) moves it down the oesophagus, through the Lower Oesophageal Sphincter (LOS) into the stomach.

  4. In the stomach, acids and enzymes break the food into a liquid (called “chyme”).

  5. The food passes through another sphincter, the Pyloric Sphincter, into the duodenum where it mixes with bile to help digest fats.

  6. Peristalsis continues to propel food into the intestine where the nutrients are extracted from the chyme.

Sphincters are valves supposed to control the direction of flow. Reflux is the term used when matter travels backwards through a sphincter for some reason. Some back-flow is normal: releasing gas build up or vomiting – the body's mechanism to expel potential poisons.

Gastro-oesophageal reflux, through the LOS, is that most commonly referred to. When it's acidic, it can cause heartburn.

Most people get heartburn occasionally but if you get it frequently, you need to see a doctor. Frequent acid attacks on the oesophagus can result in oesophagitis where the lining is burned red raw. Continuing attacks can change the cells (called “metaplasia”) resulting in Barrett's Oesophagus.

Frequent reflux is given the name, “Gastro-Oesophageal Reflux Disorder” (or GORD).

Reflux through the UOS is called “Larygo-Pharyngeal Reflux” (or LPR). Matter refluxing may enter the lungs resulting in heavy coughing to remove it (like a smoker's cough). Or it may remain in the throat providing a constant tickle or a choking sensation. If it is acidic, it can cause a sore throat and it may attack the voice box making the voice hoarse.

Bile reflux occurs when bile refluxes through the pyloric sphincter into the stomach and thence up the oesophagus along with the acid.

Although the stomach is protected against acid, it is not protected against bile. Bile attacking the stomach lining will cause abdominal pain which could develop into gastritis. Other symptoms, however, are similar to acid reflux: heartburn, cough, hoarseness but it has a particularly nasty taste and green colour.

Because bile reflux often occurs with acid reflux, it is frequently overlooked.

Should I see a doctor?

If you suffer occasional heartburn which is readily controlled by an over-the-counter antacid, there's probably no need to visit your doctor.

Over-the-counter antacids are usually chalky tablets flavoured with peppermint or citrus f ruits to be chewed or sucked, or thick white liquid flavoured with aniseed or peppermint. However, if you find you are turning to these frequently (perhaps twice a week, every week), you need to ask yourself why. If there's no obvious answer, you need to ask your doctor.

Chest pains may be caused by acid indigestion but could also be signs of a heart attack. They should always be investigated.

A persistent cough may be due to a chest infection but could also be due to reflux. You may need to get it checked out.

If you have swallowing difficulties or find certain foods difficult to swallow, see your doctor.

Your doctor may refer you to a gastroenterologist or organise an endscopy.

During this procedure, you will normally be sedated and an endosocpe (a camera in a flexible tube) is passed through your mouth (or nose) and down your throat permitting the doctor to examine the lining of your oesophagus. He will also, usually, take biopsies (small samples of cells) painlessly during the procedure which can be examined for signs of Barrett's Oesophagus or cancer.

The whole procedure takes about 20 minutes.

Persistent acid reflux can cause the condition known as Barrett's Oesophagus which in a few cases can undergo changes (called “dysplasia”) which can lead to cancer.

Not everyone who develops Barrett's Oesophagus, experiences heartburn; this is known as “Silent Reflux” but can be potentially as damaging.

How is acid reflux treated?

Acid refluxing from the stomach through a weak Lower Oesophageal Sphincter (LOS), attacks the cells lining the oesophagus which can lead to Barrett's Oesophagus and possibly cancer. So what can we do about it?

There are two approaches: we can tackle the reflux or we can tackle the acid.

Tackling the acid is often the easiest. For a quick remedy, we can neutralise the acid by taking an antacid, usually based on calcium carbonate (chalk), or an alginate (usually an aniseed-flavoured, creamy liquid that floats on top of the acid lake in the stomach).

Longer lasting medicines work by reducing acid production by the parietal cells in the stomach.

“H2 antagonists” (eg. Ranitidine) work by stopping histamine triggering the production of the acid.

Proton Pump Inhibitors” (eg. Omeprazole) work by blocking the “proton pumps” that produce the acid.

Medicines cannot prevent reflux. However, patients are often prescribed anti-emetics or pro-kinetics which help peristalsis – the muscular contractions that move the food down the oesophagus.

Lifestyle changes can help prevent reflux.

Whilst the stomach is full, keeping the throat higher than the stomach ensures gravity will prevent the contents flowing uphill. Likewise, avoiding actions that would squeeze the stomach will prevent the contents being squeezed back.

Don't overfill your stomach – eat little and often. Don't eat for three hours before going to bed. Raise the head of your bed 6-8 inches on blocks. Avoid bending, or exercise that constricts the stomach, after eating. Avoid tight fitting clothing.

There is evidence to suggest smoking and excess alcohol will relax the Lower Oesophageal Sphincter facilitating reflux.

A surgical procedure to prevent reflux is the fundoplication where the fundus (top part) of the stomach is wrapped around the LOS and stitched to form a constriction. This is usually performed laparoscopically (“keyhole” surgery) and normally requires one night in hospital and a “sloppy” diet for a few days but after a few weeks the patient can perform and eat quite normally.

What is Barrett's Oesophagus?

The stomach produces strong acid to start dissolving the food at the beginning of the digestive process. The duodenum and small intestine are lined with special cells that are resistant to acid erosion but the oesophagus isn't – as it's not supposed to carry acid.

The normal lining of the oesophagus is soft and pink and known as squamous tissue.

It appears that, in a response to frequent acid attack, the epithelium (lining) cells of the oesophagus undergo a change to resemble those found in the intestine. This is sometimes referred to as “Intestinal Metaplasia” and commonly known after the doctor who first noted it, as Barrett's Oesophagus, or just Barrett's.

Through an endoscope (small camera attached to a flexible hose used to examine the oeosphagus), Barrett's shows as redder areas on the surface.

Biopsies, small cell samples, taken with the endoscope, examined in the laboratory show the structure of the cells.

Squamous cells are usually fairly flat whereas the darker Barrett's cells are columnar in structure. Atypically, however, the abnormal cells may continue to change in size and shape - a process known as dysplasia, which can be categorised as Low Grade or High Grade depending upon the extent of the dysplastic changes.

High Grade Dysplasia is known as pre-malignancy as it can continue to mutate to become oesophageal adenocarcinoma (cancer).

Fewer than 1% of Barrett's patients a year will develop cancer but to be sure, patients diagnosed with Barrett's receive regular screening by endoscopy every two or three years looking for signs of dysplasia whence surgical intervention may be offered to remove all traces of Barrett's and prevent cancer from developing.

How is Barrett's Oesophagus treated?

Although Barrett's has no symptoms, patients may still experience problems from acid reflux which are normally manageable with medication. Regular surveillance ensures those with Barrett's will not get cancer so no other action is usually considered.

If the pre-malignant condition, High Grade Dysplasia, is discovered however, there are surgical interventions that may undertaken to eradicate the dysplastic cells.

Because all surgery carries risk, surgical intervention is unlikely to be offered for anything less than Low Grade Dysplasia.

The most extreme treatment is Oesophagectomy when the oesophagus is removed, attaching the stomach directly to the throat, drawing it up into the chest. This is major surgery but does ensure all pre-cancerous cells are removed.

Less radical treatments attempt to destroy the dysplastic and pre-malignant cells whilst leaving the rest of the oesophagus intact.

Endoluminal Mucosal Resection (EMR), uses an endoscopic technique to cut away the affected area of the oesophagus, where this is possible.

One of the newest techniques that has become the treatment of choice for many gastro-enterologists is Radio Frequency Ablation (RFA).

This uses a special balloon head on an endoscope, wrapped with fine electric wires that deliver a short burst of high energy radiation that burns away a precise depth of the top (mucosal) layer of the surface of the oesophagus. Delivered as out patient treatment, two or three such treatments may be required after which the destroyed cells are replaced naturally by the body as healthy squamous tissue.

Will I get Cancer?

In the UK, there are probably about 2,500,000 with Barrett’s Oesophagus of whom about 7,700 will die each year – meaning nearly 2 million of us won’t!

Only about 100,000 know they have the condition.

We are the lucky ones. We’ll get medication and regular surveillance scopes to look for any pre-cancerous signs (dysplasia).

It’s those who don’t know they have this who may not realise there’s something wrong until it’s too late.

Typically, they’ll continue taking over-the-counter antacids until they get swallowing difficulties which send them to their doctor for help.

There are many reasons for swallowing difficulties. One of them is a tumour. If it’s discovered at that stage, typical prognosis is just 6 weeks.

Risks of progression at the different stages are estimated as 0.25% p.a. for non dyslastic ("ordinary") Barrett's, 1% p.a. for Low Grade Dysplasia and 6% p.a. for High Grade Dysplasia/

If signs of dysplasia are seen, the Barrett’s can be ablated to prevent further possible progression to cancer.

Because Barrett’s without dysplasia has such a low risk of progression, it is usually left alone. It may even be thought of as a friend that stops our body digesting itself. But if strong acid is constantly thrown at it, there’s just that very small chance that it could turn nasty – which is why we have regular surveillance.

The Burning Questions factsheets are a few years old. They preceded the Down With Acid encylopaedia which has been described as the definitive resource. It has its own website, from where copies may be downloaded or ask us to send you a free printed copy.