Dr. Miller: Heartburn, when does that become a concern, next on The Scope Radio.
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Dr. Miller: Hi, this is Tom Miller, and I'm here with Dr. Kathleen Boynton, and she is a doctor in the Department of Medicine and she is a gastroenterologist, a specialist in gut disorders. And she is also an associate professor. She is here today to talk about heartburn.
Kathleen, when is heartburn... everybody gets heartburn, right? I mean, you have that big chili cook-off and a couple of hours later you're really resenting that and you're reaching for the sodium bicarbonate, or you're going for Tums. How often would one have heartburn and not be worried about it? Or conversely, when should somebody worry that they're having heartburn too often?
Dr. Boynton: Well the truth is nobody has ever done the study where they say this frequency equals a severe disease. But generally I tell people, if you're having it two to three times a week that's probably enough to see your physician. The other concern of course is if you come from a family with a history of esophageal cancer, perhaps any degree of heartburn is enough to see somebody.
Dr. Miller: I know a lot of patients will have heartburn maybe three times a week, and then they just have gone to the store and they've bought several different kinds of antacids. If that works, do you still think they need to see a physician?
Dr. Boynton: I think that they do, because we know that the way you feel doesn't necessarily match what's going on inside your gut. And your concern is to prevent the complications that are irreversible, that are related to heartburn.
Dr. Miller: Long-term heartburn, what are those complications?
Dr. Boynton: You can get scar tissue in the esophagus. The esophagus is made to be elastic, so if you inadvertently swallow a big piece of food it can still distend, stretch the esophagus and pass down into the stomach. If you get scar tissue it cannot pass, and we see obstructions all the time when we're on call, where somebody has a piece of meat, say, that's stuck in the esophagus and won't pass.
Dr. Miller: Then long-term heartburn can lead to scarring of the esophagus, the narrowing of the esophagus so that you can't pass food and is a dangerous situation.
Dr. Boynton: Right.
Dr. Miller: Now what about this term called Barrett's esophagus? Some patients will come in and they've read about it on the Internet or heard it on TV shows about Barrett's esophagus and its relationship to heartburn.
Dr. Boynton: Yes. Barrett's is a concerning change in the tissue and it develops as a result of exposure to acid, which causes inflammation. Inflammation means that the tissue has to regrow. And sometimes the tissue makes a mistake and it grows to look more like the tissue we see in the stomach, and then duodenum. And the problem with that is a small percentage of those people that have that Barrett's tissue will go on to develop esophageal cancer. So our question is when we see a patient with heartburn, are they somebody that may have Barrett's? How do we decide whether or not to investigate that?
Dr. Miller: Now there are age cutoffs I think; the older a person is the more likely a physician is likely to recommend diagnostics. Can you talk a little bit about that and when you decide as a gastroenterologist that a patient might in fact need a study, or a look down to see what that tissue looks like, to see if they have Barrett's esophagus?
Dr. Boynton: In medicine we have what are called guidelines, and they are in part based on associations, because we want to be efficient and not do unnecessary testing on patients. The recommendation is that in a white male over the age of 40 who has a history of heartburn that we do an endoscopy, and the endoscopy helps us. We can see the Barrett's tissue; it looks different from normal tissue.
Dr. Miller: Now the endoscopy, can we just clear that up for some people. That's a tube that goes down with a light on the end of the scope and they can actually see the tissue in the esophagus. They could even take biopsies.
Dr. Boynton: Right. And based on those biopsies we can tell someone whether or not they have Barrett's disease. If they have Barrett's then we recommend that they be monitored with endoscopy and the frequency can be in a year, or it could be every three years, depending on the profile.
Dr. Miller: Now the physician might also decide there's treatment, and are there effective treatments for heartburn that can make it better?
Dr. Boynton: Absolutely. And they are even available over the counter. The most effective are what we call the proton pump inhibitors, and there is a whole bunch of those. But the one that's over the counter is omeprazole, or Prilosec, and that's probably the most frequently used drug.
Dr. Miller: When you go you grab the omeprazole and it's probably cheaper, right?
Dr. Boynton: Yes.
Dr. Miller: And taking that daily, I think, is pretty much what's prescribed for people who have heartburn three or more times a week. And I've found most patients do very well with that; it's very effective.
Dr. Boynton: Yes.
Dr. Miller: And it stops heartburn in its tracks.
Dr. Boynton: Yes, that's correct.
Dr. Miller: Now what happens if a person is taking one of these medications and they're breaking through?
Dr. Boynton: Well in the doctor's brain, when they see those patients, what they are wondering is first of all do I have the diagnosis correct. Is this still acid? But assuming that it is still acid, we will increase their medication. If that doesn't work there is even surgery that will fix the underlying mechanical problem that causes reflux.
Dr. Miller: Now how often in your experience would a patient not respond to medication to reduce or to eliminate heartburn and need to go on to surgery? How often does that happen?
Dr. Boynton: I don't have exact numbers, but it's under 10% of patients. Sometimes patients will elect to have the surgery for lifestyle reasons. They just don't want to be on a medication long term, and that's a valid consideration.
Dr. Miller: So it sounds like the take-home points are; one, if you're having heartburn more than three times a week, you should probably see your physician and have him decide if additional diagnostic studies should be done; or if they would just go ahead and prescribe a medication, such as omeprazole that would eliminate the heartburn. And if you're having heartburn and you're taking a medication for heartburn, you really should probably see your physician about it for additional diagnostic studies.
Dr. Boynton: Right.
Dr. Miller: Thank you very much.
Dr. Boynton: You're welcome.
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