HEART ON FIRE
Heartburn and acid indigestion often signal the presence of gastroesophageal reflux disease, which can have serious consequences.
by Jon Nalick
For decades, Charles Stucken devoured antacids and prescription drugs to control the painful chronic heartburn that robbed him of sleep and soured his enjoyment of daily activities.
The problem became so severe that he could not lie down without stomach acid boiling up his throat. Over time it ravaged his throat lining, causing pre-cancerous growths to form.
"I thought that was the way my life was going to be," says Stucken, a 46-year-old dentist from Long Beach, Calif. "Fortunately, I was wrong."
In 1993, he underwent a three-hour procedure at USC University Hospital that finally cured him and transformed his life in the process.
"The difference was night and day after the operation. I immediately felt better. It's amazing that a simple procedure can have such a positive effect on your life," Stucken says.>
Stucken suffered from gastroesophageal reflux disease, (GERD). This condition involves malfunction of the valve that prevents fluids from backing up out of the stomach into the esophagus. As a result, powerful stomach acid can back up, or "reflux," into the esophagus, causing potentially serious injury.
Jeffrey Peters, M.D., associate professor of surgery and chief of the division of general surgery at USC University Hospital, says that heartburn is the most common symptom of GERD. Also called acid indigestion, heartburn is typically described as a burning chest pain beginning behind the breastbone and moving upward to the throat. The pain can be severe and is sometimes mistaken for a heart attack.
Other major symptoms of GERD include regurgitation of food into the throat, sore throats, hoarse speech, asthma and recurrent bronchitis. More than 60 million American adults experience heartburn at least once a month, and about 20 million suffer from it daily.
Peters emphasizes that although most people perceive chronic heartburn as a relatively benign illness, the truth is that it often signals the presence of GERD, which can have potentially fatal consequences.
Persistent reflux of food and acid into the throat can trigger bleeding, scarring, Barrett's esophagus-a precursor for aggressive malignant esophageal tumors-and also can destroy the lungs.
Peters recalls two recent cases where the disease was caught too late. Both patients required lung transplants because of GERD-related symptoms. One patient survived, the other died.
"Chronic heartburn can be as important a warning as a breast lump or blood in the stool," says Peters.
USC University Hospital is one of a few dozen nationwide that specializes in GERD treatment, and also has "a reputation as one of the best centers for esophageal surgery in the world," Peters says, crediting Tom R. De Meester, M.D., professor and chair, Department of Surgery, for that reputation "because of his history in esophageal research and surgery. He's assembled an excellent team here."
Michael Kline, M.D., USC assistant professor of clinical medicine, says GERD usually results when the lower esophageal sphincter, which normally relaxes during swallowing to allow food into the stomach, relaxes too much or at the wrong time. Alternatively, the valve may simply lose strength and become incapable of properly sealing the stomach, Kline says.
The disease is an equal-opportunity illness, affecting people of all ethnic groups and ages, including infants. The prevalence of severe GERD increases over the age of 50.
Treatments for GERD range from simple behavior modification to medicines, and in severe cases, surgery.
Behavior modification can include having patients avoid fatty foods, alcohol, caffeine and citrus fruits, all of which can cause heartburn. It may also require patients to sleep with their heads elevated. Quitting smoking may also help, Kline says.
He notes that food does not cause GERD, although certain foods do seem to exacerbate symptoms in some people. Wearing tight clothing, eating large meals and lying down following meals can also exacerbate GERD symptoms.
Foods, in general, can trigger symptoms because they fill the stomach and can cause sporadic relaxation of the lower esophageal sphincter. In addition, all meals stimulate acid production in the stomach to aid digestion and can increase reflux into the esophagus in GERD sufferers.
Medical treatments include antacids, drugs such as Tagamet and Zantac and the new powerful drugs Preclosec and Prevacid that decrease the stomach's production of acid. Other medications increase the ability of the esophagus to squeeze tighter to seal the stomach properly.
Often, to diagnose the illness, physicians use a procedure called endoscopy to examine the esophagus for damage. During endoscopy, the patient swallows a thin, flexible tube tipped with a video camera that permits the physician to directly inspect the lining of the upper gastrointestinal tract, Kline says.
The procedure can be used to identify complications of GERD and to take small tissue samples for analysis. GERD patients who have certain symptoms, such as difficulty in swallowing or painful swallowing, are usually considered for endoscopy, as are patients who fail to respond to medical therapy. Some physicians advocate endoscopy for all patients with long-standing GERD.
As many as 5 million people are believed to have severe cases that would make them potential candidates for surgery. During surgery, physicians attempt to repair the sphincter's ability to close off the stomach by wrapping the top of the stomach around the esophagus, where it acts like a new valve.
In 1951, Swiss surgeon Rudolph Nissen performed the first such operation to aid a patient who had a hole in the esophageal sphincter. Nissen discovered that the operation, called fundoplication, had the unintended and unanticipated side effect of completely curing the patient's chronic heartburn.
In the decades that followed, physicians performed the operation infrequently partially because it required opening the patient's abdomen and other fairly invasive techniques to accomplish. The fact that GERD was not considered a serious illness was also a factor, Peters says.
In 1991, physicians experimented with a new minimally invasive surgical technique that dramatically reduced the length, cost, pain and scarring. Using miniature laparoscopic tools, surgeons now perform the procedure through five holes in the abdomen, all no more than a half-inch.
As a result, hospital stays are usually two days or less, with patients able to resume normal activities within a week or two. Typically, it is also less expensive to have the surgery than pay for years of prescription medicine to control the illness.
"When performed expertly, the operation is successful as often as 90 to 95 percent of the time-patients no longer need medication or any other kind of treatment and it dramatically improves their quality of life," Peters says.
"Anyone who has had the disease and has been on medication for more than six months should see a physician to determine if they are good candidates for the operation," Peters advises. "There's a lot of people out there who need this treatment who aren't getting it."