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When heartburn becomes a serious problem

13 September 2015

Heartburn is a very common condition, affecting one in five people every week.

An attack is often triggered by eating certain foods, particularly spicy foods, alcohol, coffee, citrus fruits, carbonated drinks or high-fat foods. Symptoms include regurgitation, burning chest pain, discomfort when eating and, rarely, cough or voice changes.

For most people these symptoms are uncommon and can be managed with over- the-counter antacids. In some, however, these symptoms persist for more than a few weeks or happen daily, and represent an on-going health problem known as chronic Gastro-Oesophageal Reflux Disease (GORD).

Around one in ten of patients with GORD - 600,000 people in the UK - will have an underlying condition called Barrett’s Oesophagus, a pre-cancerous cell change in the lining of the gullet caused by chronic acid exposure.

Men are much more likely to develop this condition than women – men account for around 80 per cent of cases – and it is more common in people who are obese, Caucasian and middle aged (average age at diagnosis is 55). The condition can run in families.

For the vast majority of sufferers, these cell changes will never progress any further. In a few, however, approximately one in 20 men and one in 33 women, cancer of the oesophagus will develop at some point in their life.

‘Barrett’s Oesophagus is caused by a chronic accumulation of acid and bile from the stomach which causes damage to the lower third of the gullet,’ explains Dr Jason Dunn, a Consultant Gastroenterologist at London Bridge Hospital.

‘It is a pre-cancerous condition which means some people diagnosed with Barrett’s Oesophagus will go on to develop oesophageal cancer, although the risk is low and it is difficult to predict. One problem is that patients often present late and may not be able to be offered a chance of a cure. Cases of the disease are increasing in the Western population as more people become obese.

‘The challenge is identifying patients with Barrett’s Oesophagus early and intervening in those at highest risk, before they develop cancer.’

The UK has the highest rate of oesophageal cancer in both men and women in the European Union. Such is the concern about the rise in cases that Public Health England earlier this year launched a campaign to raise awareness of the link between acid reflux and oesophageal cancer.

Yet research by Public Health England shows that almost two thirds of people don’t know that heartburn could be a sign of cancer. In fact, a recent awareness campaign in North East England revealed that the majority do not know what or where the oesophagus is.

‘If you have acid reflux for more than three weeks, you should consult your doctor – particularly if you are over 55,’ says Dr Dunn, who also works at Guy’s and St Thomas’ NHS Foundation Trust in London. Barrett’s Oesophagus is diagnosed by having an endoscopy – where a long, thin flexible tube with a light and tiny high-definition camera at one end, is passed down the throat into the oesophagus. This can be under sedation or with local anaesthetic spray.

Images and cell samples taken during the procedure are used to identify subtle changes in the lining of the oesophagus. If Barrett’s Oesophagus is confirmed, treatment depends on its severity. If there are normal cell changes of Barrett’s Oesophagus then, typically, a repeat procedure is undertaken in two to five years depending on the length of the affected area.

If abnormal cell changes are present, called dysplasia, then treatment is based on the severity. Low grade changes are only treated if they are persistent, so more intensive surveillance is usually required. If high- grade changes are present, however, then treatment is recommended immediately as there is a 60 per cent chance of cancer developing over the next five years. In about 15 per cent of cases, dysplasia is diagnosed at the very first endoscopy.

For years, the only treatment for patients with Barrett’s Oesophagus was major surgery to remove the affected area, often followed by chemotherapy.

‘Surgery involves removing the entire oesophagus and pulling up the stomach into the chest to make a new one,’ explains Dr Dunn. ‘It is a major operation, involves at least two days in intensive care and patients need chest drains and feeding tubes, although almost all with dysplasia do recover. Around a third of patients suffer problems with eating afterwards.’

A new minimally-invasive treatment is now available at London Bridge Hospital which can save patients from undergoing major surgery.

Using special instruments which are fed through an endoscope, specialists first cut away the affected area which is often raised or depressed – a procedure known as Endoscopic Mucosal Resection. Patients are then given two or three sessions of radio-frequency ablation – using endoscopic devices that deliver high doses of radiowaves which destroy the pre-cancerous lining of the oesophagus, allowing a healthy lining to grow back.

Numerous studies have shown that radio- frequency ablation is both safe and successful in completely eradicating Barrett’s Oesophagus, and preventing the disease developing into cancer. ‘Radio-frequency ablation salvages the oesophagus,’ says Dr Dunn. ‘There is a slight risk of narrowing of the oesophagus but what you are left with is an intact oesophagus, and that is a great benefit to patients.

‘The procedure can be carried out under sedation and patients are sent home the same day.’

Once patients have completed their course of treatments, they have follow-up appointments every six months for two years, and then annually after that.

Dr Dunn urges anyone with either persistent acid reflux or a family history of Barrett’s Oesophagus or oesophageal cancer to go to their GP as they may need an endoscopy.

Treatment of Barrett’s Oesophagus is now very effective, he says, while if you are diagnosed with oesophageal cancer, there is just a 15 per cent chance of surviving five years.

‘It is great that we can now offer this minimally- invasive technology for patients with Barrett’s Oesophagus, essentially turning the clock back and removing the risk of it developing further,’ says Dr Dunn.

To book an appointment at London Bridge Hospital, please call 020 7234 2009.