GERD: What is Barrett’s Esophagus?



Barrett’s Esophagus is a condition where the lining of the esophagus has been repeatedly damaged by exposure to stomach acid and the body repairs the damage using a different type of tissue.  So instead of replacing the damaged cells with cells that would be found in the esophagus the cells are replaced with cells similar to those found in the intestine and because of this the process is known as intestinal metaplasia.

Barrett’s Esophagus does not give the sufferer any symptoms so it can only be diagnosed by visual examination using an endoscope.

The cells that line the esophagus and those that line the stomach are different types of cells which have different functions and there is a defined line which marks the border between the two.  This defined line and the fact that the two types of cells also look very different make it easy for the physician to see the abnormal cells which have developed and to diagnose Barrett’s Esophagus.

There is no treatment to reverse this condition so the best possible treatment strategy is to prevent it occurring in the first place and this is why preventing acid reflux is so important.  If you have never heard of Barrett’s Esophagus you might wonder why you would need to prevent a condition that causes no symptoms.  The reason is that in a small percentage of cases the condition can progress to esophageal cancer.

As you cannot reverse the condition surgery or other alternative procedures will be recommended if a biopsy shows severe or high-grade dysplasia in the cells.  Surgery can be used to remove the abnormal lining or laser or high energy treatment can be used to destroy the precancerous cells in situ.

The Linx Device: A Magnetic Bracelet to Prevent Heartburn



The Linx Device is a medical device which is fitted by a surgical procedure and it is designed to prevent heartburn arising and thereby treat GERD.

0 The Linx Device: A Magnetic Bracelet to Prevent Heartburn

The Linx is a flexible bracelet made from twelve interlinked titanium beads each of which contain a tiny magnet and it works by supporting the function of the LES (Lower esophageal sphincter).   The device  is fitted around the lower esophagus using keyhole surgery and once fitted the twelve magnets pull together preventing stomach acid from leaking out of the stomach up into the esophagus, helping prevent the occurrence of heartburn.

The device opens when swallowing occurs as swallowing exerts higher pressures and this allows the food and drink to pass normally into the stomach for digestion.  It also allows you to belch and vomit as normal.

The Linx device is manufactured in the US by Torax Medical of Shoreview Minnesota but the device has yet to receive FDA approval allowing its use in the US.but it has received approval for use in some European countries.  However it does look likely that FDA approval will not be too far away following the unanimous approval in January 2012 by of the FDA advisory committees that the Linx was safe and effective for preventing heartburn in patients suffering from GERD where their heartburn does not respond to medication.

Surgical intervention is of course always the treatment of last resort due to the risks and complications that surgery can have.  However this surgical procedure which takes around an hour to perform does have benefits over other types of surgical procedures for GERD as it is both reversible and it has a very short recovery period.   Patients can return to a normal diet the next day and resume normal activities within a week.

 

Heartburn and Acid Reflux Becoming More Common



The results of a study published in the medical journal GUT on 21 December 2011 are showing a worrying increase in the frequency with which symptoms of heartburn or acid reflux are suffered.

The research which was carried out in Norway collected health information by questionnaires over two periods from almost 30,000 people.  The first period covered 1995 to 1997 and the second period covered 2006 to 2009.  The questionnaire asked the participants whether they experienced the symptoms of heartburn or acid reflux and if so how severe these symptoms were.  Some of the participants were also questioned about the frequency with which these symptoms were suffered.

The main points coming out of this study which was conducted by researchers from Norway, Sweden and King’s College London are that:-

  • the incidence of all heartburn/acid reflux symptoms rose 30% over the two review periods
  •  the incidence of  severe symptoms rose by 24%
  • the numbers experiencing  heartburn/acid reflux symptoms at least least once a week increased by 47%
  • Women under 40 were least likely to experience the symptoms and were more likely to have the symptoms disappear without treatment
  •  Those aged 60 to 69 were the most likely to have severe symptoms, with women experiencing this symptoms more frequently than men
  • Age did not increase the likelihood of a man suffering  heartburn/acid reflux symptoms.

Possible explanations for the increases proposed include:-

  • Excessive weight – over the period of the study there has been a large increase in the numbers of the population who are overweight or obese.
  • The use of HRT (Hormone Replacement Therapy).
A more detailed article on this topic can be found here.

 

Stretta® Therapy in the News

On 22 November 2011  the American Journal of Gastroenterology gave advance online publication to the findings of a study to evaluate the application of radiofrequency energy (Stretta® therapy) in the treatment of GERD.  The data which came from the double blind, sham controlled study confirmed that Stretta® therapy improves the physiology of the LES (lower esophageal sphincter) and that this was the likely cause of the improvement in GERD symptoms.

There have been several studies which have reported relief from the symptoms of GERD following Stretta treatment at the gastro-esophageal junction (GEJ), but these studies did not identify how this improvement was achieved.  This study was set up to test the hypothesis that the Stretta therapy alters GEJ resistance.

The study was carried out in a tertiary care center using consecutive GERD patients.  All participants in the study underwent two upper gastrointestinal endoscopies at 3 monthly intervals, during which either active or sham radiofrequency treatment was performed in a randomized double-blind manner.   Each patient undertook a symptom assessment, endoscopy, manometry, 24 hour esophageal pH monitoring, and a distensibility test of the GEJ both before the start of the study and after 3 months.

The results were measured using a Barostat distensibility test of the GEJ before and after administration of the relaxant sildenafil.  Twenty two patients took part in the study with eleven in each group.  After three months the sham treatment produce no impact on any of the measures used but the Stretta therapy produced improved symptom score and decreased GEJ compliance.  After the administration of sildenafil, GEJ compliance returned again to pre-Stretta level, thereby establishing that GEJ fibrosisis was not causing the improvement.

Mederi Therapeutics who manufacture Stretta are of course delighted by the results of this study and Will Rutan their CEO said,

“These results add to the significant body of research on Stretta. The treatment works exceptionally well to reduce or eliminate symptoms in sufferers of GERD, but exactly how it works is now more clearly understood , with 67 publications supporting Stretta as a safe, effective, and durable treatment, Stretta offers an excellent alternative to invasive surgery.”

The Side Effects of Proton Pump Inhibitors (PPIs)




Proton Pump Inhibitors (PPIs) are an important type of medication that can help to treat heartburn and ulcers but like all medications they do carry certain risks and side effects.  If you have been prescribed any of these medications and have concerns you should discuss these concerns with your medical practitioner but don’t stop taking any prescribed PPI medication without discussing the matter first with your doctor.  Most people tolerate the use of PPIs very well so short term, low dose use of these drugs only usually causes minor side effects if any, such as diarrhea, headaches, rashes, constipation, dry mouth, nausea or abdominal pain.  These drugs can however interact with other medication either directly or indirectly. PPIs are designed to reduce stomach acid and altering the acid levels can reduce or increase the absorption of certain drugs

  • Ketoconazole (Nizoral or Sebizole)

PPIs can reduce the absorption of Ketoconazole, an antifungal drug which is often prescribed for those with compromised immune systems to prevent or treat fungal skin infections. It also has the effect of reducing testosterone levels and surpressing glucocorticoid synthesis and can therefore be used to treat other health conditions.

  • Digoxin (Lanoxin, Digitek, and Lanoxicaps)

PPIs can increase the absorption of Digoxin a drug which is extracted from the foxglove plant. Digoxin is used to treat heart conditions that cannot be controlled using other treatments. The combination digoxin with a PPI can also cause low magnesium.

  • Diazepam (Valium), Warfarin, (Coumadin) and Phenytoin (Dilantin)

PPIs can reduce the breakdown of these drugs in the liver increasing the concentration of the drug in the bloodstream.
Long term use or higher doses may bring more serious side effects so this is why any treatment should be at the lowest dose possible for the shortest time.

  • Increased risk of osteoporosis and bone fracture

Studies have shown an increased risk of fracture amongst those using PPIs when compared to those not taking them. It is thought that the reduced stomach acid interferes with the absorption of calcium which then leads to an increased risk of fracture or osteoporosis.

  • Higher risk of pneumonia

Researchers believe that the decrease in stomach acid allows the bacteria which cause pneumonia to multiply and spread.

  • Infection with clostridium difficile (c difficile)

There was a study in 2010 which showed that hospitalized patients taking PPIs were at increased risk of infection with c.difficile. Infection with c. difficile infection can lead to dysentery, long standing colon problems or possibly death.

  • Other Stomach problems

As bacteria which would normally have been destroyed by the stomach acid pass into the intestines they multiply. This bacterial growth can cause contagious diarrhea or colitis.

  • Vitamin B12 deficiencies

Vitamin B12 deficiencies, especially in the elderly, can be very serious as they already have a decreased ability to absorb this vitamin. PPIs appear to affect the absorption of Vitamin B12 in the same way as calcium. B12 is vital to the correct functioning of the nervous system, metabolism and brain function. A deficiency can cause irreversible nerve damage, dementia, depression anemia or fatigue.

  • Low Magnesium levels (Hypomagnesemia)

Using PPIs for as little as three months can cause the depletion of magnesium levels. Magnesium is a very important mineral to help in the prevention and treatment of heart disease. Low levels of magnesium may cause kidney disease, high blood pressure, severe muscle spasms, seizures, tremors or irregular heartbeat.

  • Severe Rebound Acid Secretion 
This is a side effect with a difference as you only notice it when you stop using the PPIs.  Although the PPIs are very good at neutralizing the stomach acid they also appear to stimulate acid production.  This means that for an initial period while this increased acid production is returning to normal, heartburn or acid reflux symptoms can recur and could be worse than before.