Our GI experts discuss why upper GI/esophageal conditions may go unrecognized, how to detect them and when to take action.
Some 25 million Americans are believed to suffer on a daily basis from gastroesophageal reflux disease (GERD) – better known as heartburn – and as much as 40% of the adult U.S. population are estimated to experience it less frequently. Some of these patients also suffer from a hiatal hernia, which is typically asymptomatic. For most patients, these conditions are a serious nuisance, but not a serious health hazard. The challenge for physicians lies in determining how to treat these common disorders before they become dangerous, without subjecting patients to unnecessary treatment.
The rise in GERD, believed related to the epidemic of obesity and other lifestyle factors, is associated with an increase in esophageal adenocarcinoma. This cancer has grown six-fold in the past 30 years, while squamous cell carcinoma (often associated with smoking and alcohol use) has declined. Given its former obscurity, physicians trained several decades ago may be less likely to recognize the potential for chronic GERD to turn cancerous.
To manage GERD, patients should avoid alcohol, greasy foods, sodas, mints, licorice, chocolate and smoking. They should eat smaller, more frequent meals and avoid a large meal within a few hours of bedtime. Losing weight is also helpful. “Modest weight loss and a prudent diet are often sufficient to manage symptoms,” notes A. Steven Fleisher, M.D., chief, Division of Gastroenterology; and director, Interventional Gastroenterology Program at Medstar Franklin Square Medical Center.
If chronic use of over-the-counter antacids is necessary, patients should consult their primary care physician. In turn, primary care doctors should refer patients to a gastroenterologist if reflux continues for several years. While GERD medications are generally safe and effective, chronic use not only may indicate the need for further evaluation, but also may lead to osteoporosis and an increased risk of infections such as clostridium-difficile (C. diff). “Make sure the patient’s vitamin D levels are adequate so they can absorb calcium,” Dr. Fleisher advises.
Compounding the issue is the fact that patients’ heartburn symptoms may decline or disappear not only with medication but also as their disease progresses. Chronic reflux can cause the esophageal lining to be damaged so significantly that it resembles stomach lining and causes discomfort to abate at the same time that the risk of cancer increases. This condition, called Barrett’s esophagus, is a strong risk factor for esophageal adenocarcinoma. The normal progression is from the initial stage of metaplasia to low grade dysplasia, high grade dysplasia and cancer; however, a Danish study published in the October 13, 2011 issue of the New England Journal of Medicine found that the annual risk of this cancer was only 0.12%, lower than the previously assumed risk of 0.5%.
In the December 2, 2012, issue of the Annals of Internal Medicine, the American College of Physicians published guidelines for using upper endoscopy in GERD patients, as well as guidelines for screening for Barett’s (see sidebar). Patients with GERD should receive endoscopy if they also experience dysphagia, bleeding, weight loss or recurrent vomiting, or if they have not responded to medication after several months.
If Barrett’s is found, Dr. Fleisher advises endoscopy surveillance at least every three years for patients who have Barrett’s without dysplasia and as often as every six months for those with dysplasia.
Treatment: EMR and Ablation
Gastroenterologists often perform endoscopy to evaluate the mucosa of the esophagus for strictures and the presence of Barrett’s. Until 2007, when the Prague C & M (circumference and maximal extent) criteria were developed, consistent assessment criteria were lacking.
Dr. Fleisher says, “Our practice uses the Prague Criteria, which is becoming the accepted classification for endoscopically-suspected Barrett’s. In non-dysplastic Barrett’s, four quadrant biopsies should be obtained every two centimeters in the involved esophageal segment. Barrett’s is suspected endoscopically when the normal pearl-pink mucosal lining is replaced with a salmon-pink appearing mucosa. We also often see associated hiatal hernias. The length of the Barrett’s segment correlates with more significant cancer risk. While it’s unusual, some patients have one third to one half of their esophagus affected.”
“If any nodular components are present,” he continues, “we perform an endoscopic mucosal resection (EMR). EMR can be a cure for very early stage Adenocarcinoma and it can be performed at the time of initial endoscopy, but often isn’t. Endoscopic ultrasound is often performed to assess for depth of invasion, and local lymphadenopathy prior to resection of sub-centimeter lesions. If the pathology shows disease limited to the lamina propria or muscularis mucosae, in the absence of lymph node metastases, lymphovascular invasion, or poor differentiation EMR provides definitive therapy. Nevertheless, these patient need close short term endoscopic surveillance.”
Dr. Fleisher adds, “EMR involves using an endoscope with tools to suction up the affected tissue. A band is deployed around the lesion, which is then removed with a snare and electrocautery. We may inject submucosal saline to lift the lesion away to facilitate banding. When the sub mucosa is involved, medically fit patients will need esophagectomy. More extensive disease may need chemotherapy and radiation before or after surgical resection.“
Following EMR, the remaining affected tissue is ablated, typically using radiofrequency (RF) ablation. A study published in the September 2012 issue of Gastroenterology found that initial RF ablation might not be cost effective for patients with Barrett’s in the absence of dysplasia, but may be appropriate for confirmed and stable low grade dysplasia, and is superior to endoscopic surveillance in high grade dysplasia.
Dr. Fleisher notes, “RF ablation is recommended along with photodynamic therapy and EMR for eradication of Barrett’s esophagus according to a March 2011 position statement on the management of Barrett’s esophagus by the American Gastroenterological Association (AGA). In selected cases, we also perform cryoablation, a technique that is still investigational for the management of dysplasia in Barrett’s esophagus. Prospective studies that demonstrate its comparable effectiveness are not yet completed. Cryotherapy freezes the involved tissue using liquid CO2 or liquid nitrogen. We use the latter, applying it for about 20 seconds in two to three applications. Patients appear to tolerate the procedure well other than some chest discomfort.”
When to Treat Hiatal Hernias Surgically
Hiatal hernia, the most common diaphragmatic hernia, is a broad term that that covers a variety of conditions in which an anatomical structure pierces the membrane of the diaphragm. While the cause is often unclear, these hernias occur more often in women, those who are overweight, and those over age 50. Because a hiatal hernia may not create symptoms until there is an emergent situation, it is often discovered incidentally.
Hiatal hernias are classified as Type I through Type IV, with Type I denoting a sliding hiatal hernia (roughly 80% of hiatal hernias) where the gastro-esophageal (GE) junction followed by the body of the stomach protrudes through the esophageal hiatus and above the diaphragm. In the less common paraesophageal hernias (Types II – IV), the fundus is displaced into the mediastinum above the GE junction. Type IV denotes a large defect in the phrenoesophageal membrane that allows other organs, including the colon or spleen, to slip up into the chest.
Adrian E. Park, M.D., MIS/GI surgeon and department chair of Surgery at Anne Arundel Medical Center, explains, “Most hiatal hernias develop over a long period of time. Patients may have had GERD 10 to 15 years ago but then their symptoms subsided. However, if they get full quickly when they eat and have shortness of breath, they may have a hiatal hernia. The danger is that the hernia can twist suddenly and strangle the stomach, requiring urgent surgical intervention.”
“Only 1 to 2% of these hernias need surgery,” continues Dr. Park, “but it’s a challenge to determine when surgery is necessary. Data shows that if we plan surgery electively, the mortality and morbidity rate is 1/5th to 1/20th that of emergency surgery. As a result, we’ve learned to err on the side of being aggressive. The great judgment required is when to intervene with patients who are not highly symptomatic. The way I approach it is to talk with the family members about the patient’s eating habits, their activities of daily living and whether they’re losing weight.”
Dr. Park notes that many patients have lost their exercise tolerance and can’t walk around the mall or grocery store. “It happens so insidiously and slowly that patients often are worked up first for cardiac and pulmonary issues,” he comments. “Once it is determined that they have a large or paraesophageal hiatal hernia, surgery often allows them to improve their pulmonary function and, as a result, their exercise tolerance.”
Laparoscopic surgery has greatly improved surgical outcomes for hiatal hernia repair. Dr. Park declares, “If you can prevail laparoscopically, you should; patients get up much more quickly and that makes all the difference. While 98% of patients are elderly, they can go home within two days and usually spend less than two hours in the OR.”
Though not a fan of GI robotic surgery, Dr. Park says, “The camera systems and instruments used in the laparoscopic procedure are continuously improving. The interest in a single incision approach has waned and four to five incisions of 5mm are more the norm.”
Dr. Park advises, “When seeking a surgeon, referring physicians should look for a surgeon who does at least several procedures per month with good pre and peri-op education and a nurse and nutritionist on the team. Some of these procedures are extremely complex and should be concentrated in select centers. The mortality rate should be under 1% and the complication rate less than 6%.”
Unless patients are willing to make long-term adjustments to their lifestyle, the surgery may not be worthwhile. Dr. Park comments, “I tell patients that if they can’t commit to lifestyle and dietary changes, which in fact constitute a healthier way to eat and live, such as eating smaller and more frequent meals daily and chewing their food well, deep breathing and core/aerobic exercises, then they shouldn’t undergo surgery and we’ll part as friends.”
Adrian E. Park, M.D., general surgeon and department chair, Surgery, Anne Arundel Medical Center
A. Steven Fleisher, M.D., general and interventional gastroenterologist; chief, Division of Gastroenterology; and director, Interventional Gastroenterology Program at Medstar Franklin Square Medical Center.