Heartburn and Barrett's oesophagus

Heartburn is a very common complaint and is the discomfort, or burning sensation often felt behind the chest bone. Other terms used for the same condition include indigestion and acid reflux. Heartburn / Barrett's oesophagus symptoms typically occur after food and in particular fatty foods and irritating foods such as citrus fruit, vinegar and alcohol.

This article on heartburn & Barrett's oesophagus is written by Matthew Banks, Consultant Gastroenterologist, UCLH, London.

At least one in three of the population suffers from mild heartburn at some stage of their lives, however for a few the condition can be debilitating and ruin lives. Occasionally, people can suffer from symptoms affecting the throat including a hoarse voice, constant mucous throat clearing and a persistent dry cough.

What are the causes?

Heartburn results from the reflux of the stomach contents up into the gullet (oesophagus). The stomach is very acidic and the acid causes damage and irritation to the lower gullet, which can sometimes be severe resulting in inflammation, ulcers and scarring with narrowing.

Do I need any tests?

Normally, unless there are other symptoms such as difficulty in swallowing, vomiting, a loss of appetite or unintentional weight loss, heartburn does not need any further tests. Sometimes an endoscopy is necessary and special physiology tests measuring the muscles in the gullet and the amount of acid refluxing from the stomach into the oesophagus.

How do I treat it?

Firstly, lifestyle changes can be quite effective. These include reducing the fat in your diet and not eating large meals late at night, particularly because the acid reflux is more likely when lying down. Stopping smoking may help, as will losing weight. Placing a book underneath the head of the bed may reduce nighttime reflux. The next step is to try antacid medication which both reduces the acid in the stomach temporarily but also creates a protective barrier to reduce acid exposure to the gullet. If heartburn is still bothersome, then medications to stop the acid production may be necessary. These include ranitidine, cimetidine, and proton pump inhibitors such as omeprazole.

If you suffer from longstanding heartburn you may develop Barrett's Oesophagus. This condition may lead to oesophageal cancer, but regular endoscopy and treatment can prevent this cancer developing.

What is Barrett's oesophagus?

This is caused by the oesophagus being regularly exposed to regurgitating stomach acid. The damage causes the normal lining (squamous cell pattern) to be replaced by an intestinal-type (columnar pattern.) Barrett's oesophagus increases the risk of adenocarcinoma (cancer originating in glandular tissue) of the oesophagus, which is increasing in prevalence throughout the world. In view of its pre-malignant potential, Barrett's oesophagus warrants regular surveillance with upper endoscopy to ensure the pre-malignant changes are not progressing.

How common is it?

It is estimated that up to 3% of the population may have Barrett's and up to 40% of whom do not have any symptoms. In those people who have heartburn, up to 10% of people have Barrett's oesophagus.

How do you diagnose it?

Barrett's oesophagus is diagnosed by looking at the oesophagus through an endoscope, whereby a tube with a video is inserted through the mouth. This is called a gastroscopy. The diagnosis is verified by taking samples from the oesophagus.

How is it treated?

Most people with Barrett's do not need to be treated apart from reducing the amount of acid in the oesophagus. This is achieved by acid inhibiting drugs such as omeprazole in the same way that acid reflux is treated. Barrett's does need monitoring. This is done by regular gastroscopy, normally every 2 years. Samples of the oesophagus are taken, and providing these do not show any pre-cancerous changes, no specific treatment is required.

If the cells in the Barrett's change to become dysplastic (pre-cancerous), then recent studies have shown that removal of the cells can prevent a cancer developing. This treatment is called Radiofrequency ablation, otherwise known as the BarrX 'Halo' method. Dr Banks at University College London Hospital (UCLH) is currently involved in cutting edge research looking at early detection of pre-cancerous change in Barrett's and different treatments. The National BarrX Halo Research Registry is based at UCLH.

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Heartburn and Barrett's oesophagus